San Francisco Marin Medicine, Vol. 93, No. 4, August/September/October by San Francisco Marin Medical Society

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

Reopening Schools Safely SFMMS/CMA PPE Relief COVID Chronicles and Responses, And more!

ELECTION ISSUE Volume 93, Number 4 | SEPTEMBER/OCTOBER 2020

IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE

FEATURE ARTICLES

MONTHLY COLUMNS

22 COVID Chronicles, or, a Suggested Presidential Speech Robert Wachter, MD

Membership Matters

President's Message: Disinfecting the White House? Brian Grady, MD

24 Reopen Our Schools - for Education and Health: A Personal and Professional Plea Kimberly Newell Green, MD 25 SFMMS Fall Wellness Corner Jessie Mahoney, MD

28 Accountability and Phase II Response to the COVID-19 Pandemic John Brown, MD and Anu Ramachandran, MD 30 COVID Contact Tracing Ellen Weber, MD

31 Hard Lessons: Palliative Care in the COVID Era Monique Schaulis, MD, MPH

32 The Science Underlying Adolescents' Increased Risk from Cannabis Timmen Cermak, MD 34 Extending California's Ban on Flavored Tobacco Products Across America John Maa, MD and Jeffrey Wigand, PhD

September/October 2020 Volume 93, Number 4

6 7

Executive Memo: The Door to Reform is Wide Open Conrad Amenta CMA HOD Report: PPE Relief Jacob Greenstein

COMMUNITY NEWS 36 Kaiser News Maria Ansari, MD

36 Chinese Hospital News Sam Kao, MD

OF INTEREST

26 SFMMS Principles for the Reopening of Schools Closed Due to COVID-19 40 New Nurse Practitioner Independent Practice Law Coming in California 40 Advertiser Index

SPECIAL INTEREST 10 Election 2020: SFMMS Slate of Candidates

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 Welcomes Mayor London Breed, Assemblymember David Chiu, CMA President Dr. Peter Bretan to Annual General Meeting On September 14, SFMMS welcomed members from throughout San Francisco and Marin Counties to connect with one another, hear from physician leaders and special guests, and finalize a slate of candidates for election to SFMMS and CMA officer positions. Members participated in breakout sessions to start the evening. Robust discussions on many issues followed. Our sincere thanks go out to San Francisco Mayor London Breed, State Assemblymember David Chiu, and CMA President Dr. Peter Bretan for joining us for our Annual General Meeting.

SFMMS Urges More Cautious and Staggered Re-Opening of Businesses and Schools

SFMMS Board Supports Resolutions Declaring Racism a Public Health Emergency

The SFMMS wrote to Mayor Breed urging a considered and cautious schedule for opening businesses and schools at similar times, in light of the prospects of a new wave of Covid infections. Our letter follows: Dear Mayor Breed: I am writing on behalf of the physician leadership and more than 3000 physician members of The San Francisco Marin Medical Society. We are so grateful for your hard work to safely reopen some of our San Francisco schools closed due to the COVID-19 pandemic. We firmly believe that this incremental approach with a focus on safety and equity and guided by data and science will demonstrate success and help us understand how to keep all San Francisco children and families healthy during this epidemic. We have noticed that the Timeline for Reopening (https://sf.gov/ step-by-step/reopening-san-francisco) suggests the possibility that some high-risk activities, such as indoor restaurant dining, may resume at approximately the same time as schools are reopening for in-person learning. We strongly urge you to avoid this scenario by maintaining the current timeline to reopen schools but delaying the resumption of highrisk activities as necessary. National data indicates that a fall surge is underway in much of the rest of the country, but thanks to our public health leaders and elected officials like you, San Francisco has been doing well as of late. We hope to keep our numbers down as much as possible. It is vital that we understand the influence of the resumption of routine activities such as indoor dining at restaurants separately from the resumption of essential services like schools on subsequent increases in community spread of COVID-19. Opening both at the same time will make this impossible. Delaying the opening of indoor dining so as not to coincide with school re-openings will enable San Francisco to make evidence-based decisions about closing and opening strategies should a surge occur. It will allow the San Francisco Department of Public Health to collect and analyze vital information about the spread of the COVID-19 virus within these environments in the most informative way possible. It is in the interest of owners of businesses providing indoor dining, in addition to the citizens of San Francisco, to not have schools close again if it is not necessary. Thank you for your careful and evidence-based care of San Francisco’s community in its entirety, including children and other San Franciscans who cannot speak as loudly for themselves. Sincerely, Brian Grady, MD, President

On Monday, July 13th, San Francisco Marin Medical Society (SFMMS) Board members, Consultants and Liaisons convened virtually to discuss, among other topics, racial diversity and justice. The Board heard from expert guests and discussed how to advance diversity and inclusion in our organizations, as well as the principles of racial equity and justice. Later in the meeting, the Board voted to endorse proposed resolutions at the state, and city and county levels declaring systemic racism a public health emergency. These resolutions will be considered at upcoming state and San Francisco Board of Supervisors legislative sessions. The state resolution, entitled California State Resolution to Declare Racism a Public Health Crisis, was introduced by Dr. Richard Pan, and co-authored by Assemblymember David Chiu from San Francisco and "White Coats for Black Lives," a joint initiative of medical students from the UC Berkeley and UCSF medical programs. The San Francisco Board of Supervisors are considering a similar resolution, entitled Declaring Anti-Black Racism as a Human Rights and Public Health Crisis. Physicians in San Francisco and Marin Counties are uniquely situated to observe how racism acts as a social determinant of health. In endorsing both of these resolutions, the San Francisco Marin Medical Society takes an important stand alongside our members and their patients.

SAN FRANCISCO MARIN MEDICINE SEPTEMBER/OCTOBER 2020

Mill Valley Latest to Ban Sale of Flavored Tobacco Products

In September, SFMMS supported the long effort to ban sale of flavored tobacco products in Mill Valley, the latest of Marin communities to do so. The letter we sent to Mill Valley officials is below. Dear Mill Valley Council Members: The San Francisco Marin Medical Society strongly supports the proposal to prohibit the sale of all flavored tobacco products in the City of Mill Valley without exemption. This proposed policy will reduce access to the products that are the tobacco industry’s key strategy for targeting and addicting new smokers, in this case the young people of Mill Valley and the many who visit there. As our county’s medical association with over 3,000 members, we have supported the kind of action this proposal takes for many years, WWW.SFMMS.ORG

and it is now finally bearing healthy fruit. Earlier this month, Governor Newsom signed SB793 to restrict flavored products at the state level. But the tobacco industry has filed to collect signatures to overturn SB793 via the November 2022 ballot. They do not need to win, filing alone will delay implementation for the next two years. Cities must codify their own flavored tobacco policies at the local level. Mill Valley’s youth cannot afford the delay. The tobacco industry is actively and aggressively working to addict new young people, particularly those from communities of color, with flavored tobacco products. They know that flavors like grape, mint (menthol), cotton candy, bubble gum and gummy bears mask the harsh taste of tobacco and are highly appealing to youth. In California, approximately 1 in 10 young adults (18-24 years old) currently use e-cigarettes and mounting evidence shows that young people who start with e-cigarettes are likely to become the addicted cigarette smokers of tomorrow. Cigarette smoking is the leading cause of preventable disease and death in the United States, claiming on average 480,000 lives each year. Ending the sale of all flavored tobacco products will help protect our community from tobacco addiction and is crucial to preventing tobacco-related death and disease. The SFMMS respectfully asks for your support of this vital health policy. Sincerely, Brian Grady, MD President San Francisco Marin Medical Society

SFMMS Addresses Ongoing Concerns Regarding Covid Testing

Continuing a discussion that began at the SFMMS annual meeting, members of the Board, Consultants and Liaisons met on September 23 to discuss the state of COVID testing. Several issues were identified concerning the availability and quality of testing, which are now being summarized to be shared with public officials and health systems. Thanks to Dr. Mike Schrader for Chairing this important discussion.

SFMMS Political Action Committee Interviews Local Supervisorial Candidates

The SFMMS PAC Board on September 3rd met via Zoom with 10 candidates for the San Francisco Board of Supervisors. After interviewing each candidate, our PAC Board members determined our financial contributions to their campaigns. Important connections were made with current and future Supervisors. Dr. Joe Woo chaired this virtual discussion, which lasted over 3 hours.

SFMMS Supports Civic Health Month

Civic Health Month is here! The San Francisco Marin Medical Society is proud to be part of this coalition of over 50 healthcare and voter registration organizations and more than 12,000 frontline providers working to build a healthier and more inclusive American democracy. COVID-19 has drastically affected our communities and created a barrier to voting for millions of Americans. Already, we have seen up to a 70% drop in election-cycle voter registration rates as DMVs remain closed and in-person registration events are impeded by public health guidance. Voting has become a major public health issue, and now more than ever before, we need to give every American a voice in shaping health policy and empower them to do so in a safe and healthy way. Follow Civic Health Month to stay up to date with the latest: •Twitter @Civichealthmon • Instagram @Civichealthmonth

September/October 2020 Volume 93, Number 4 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Shieva Khayam-Bashi, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Brian Grady, MD President-elect Monique Schaulis, MD, MPH Treasurer Michael Schrader, MD, PhD, FACP Immediate Past President Kimberly Newell Green, MD 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 Director of Engagement Molly Baldridge, MPH 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

Cover art: By Cynthia Fletcher www.cynthiafletcherart.com/coronavirus-series “20 Seconds”, 16x20, oil on panel As the pandemic jumped from continent to continent governments around the world told their citizens to wash their hands frequently for at least 20 seconds. Those of us in the west were told that was equivalent to singing the Happy Birthday song twice. The fact that simple soap and water was our best preventative measure is wondrous in its simplicity and at the same time deeply troubling that it was virtually all we had. WWW.SFMMS.ORG

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PRESIDENT’S MESSAGE Brian Grady, MD

DISINFECTING THE WHITE HOUSE? "Our 152-year old medical society does not endorse or oppose specific political figures, but strongly does advocate for sound, evidence-based health and medical policy." Dear Colleagues: We write with a sense of alarmed urgency, in the midst of a terrible pandemic, about the clearly counterproductive messaging, practices, and policies of our current White House, and urge the AMA to speak out forcefully in the interest of the nation’s health. The crisis is now at a point where partisan politics should no longer matter, but medical, scientific, and public health standards and practices still should and do. President Donald Trump’s current Covid infection could provide a learning opportunity for Americans, but instead has been turned into a destructive debacle. He has now advised the nation “Don’t be afraid” of Covid - the opposite of what any responsible message from a leader should be. While not fostering fear or panic, it is imperative that we take this outbreak more seriously than this. It is now clear that he and his inner circle were aware of his infection but still acted in ways that spread the virus, with a growing number of people infected. They are neglecting needed notification and contact tracing as well. The secrecy regarding his status and treatment exceeds confidentiality requirements, especially for any President, whose health and mental status can be crucial to the welfare of so many. This administration’s broader health proposals related to Covid very often run counter to established science, medical standards, and the considered policies of many established medical organizations, including the AMA. He has shunned masks (even mocking another Presidential candidate for wearing one), held and encouraged mass gatherings without protections, advocated unproven and questionable therapies, pushed for unsafe vaccine development and approval timelines, counterproductively meddled in FDA and CDC policymaking in practices, worked to get rid of the ACA (which was endorsed by the AMA), defunded the WHO, pulled out of climate and other important environmental health compacts, and much more, all going against the professional advice and consensus of experts with the most expertise in such matters. Our 152-year old medical society does not endorse or oppose specific political figures, but strongly does advocate for sound, evidence-based health and medical policy. It is undeniable that our current President is very often in conflict with WWW.SFMMS.ORG

such standards. Donald Trump may or may not be president for much longer, but for the time being we are in a crisis of confidence and credibility with respect to his Presidency, and feel strongly that it is certainly time for the AMA, as the leading voice of our nation’s physicians, to forcefully speak out for science, public health, and compassion on these matters, and to make those values known to all of our elected leaders and the public. We respectfully hope for new and strong public statements in the form of media releases and press conferences to counter the harmful impacts of the Trump administration. Thank you for your consideration. Brian Grady, MD President San Francisco Marin Medical Society

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.

At press time, the Editorial Board of the New England Journal of Medicine published an unprecedented editorial on the current situation:

Dying in a Leadership Vacuum The Editors October 8, 2020, N Engl J Med 2020; 383:1479-1480

"Covid-19 has created a crisis throughout the world. This crisis has produced a test of leadership. With no good options to combat a novel pathogen, countries were forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy."

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EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director

THE DOOR TO REFORM IS WIDE OPEN The most esoteric area of health policy in which I’ve been involved has been the digitization of health records. Most agreed that it needed to happen, but nobody wanted to expend political capital, let alone actual capital, to make it happen. It was complicated, difficult, expensive, unsexy, and impossible to claim victory (and credit) with certainty.

Then, in 2008, the world’s financial system melted down, and the United States commandeered what would turn out to be $831 billion via the American Recovery and Reinvestment Act (ARRA) to stave off a recession. A component of the ARRA was the Health Information Technology for Economic and Clinical Health Act, which spurred a “meaningful use” framework designed to motivate the implementation of electronic health records (EHR) by physicians and hospitals in the United States. Adoption of EHRs surged. Today, EHRs, though much-maligned by some, are a fixture in physician offices both ambulatory and hospital-based. What does a financial crisis caused by subprime mortgage lending and derivatives have to do with the digitization of healthcare? Almost nothing. But the crisis they created swung the door to reform wide open: legislators usually reticent to sign off on investments in the arcana of medical workflow and data management were induced to do so by conditions beyond their control. Receptivity to bold ideas increased.

The COVID-19 pandemic has already produced similar conditions. For most of my career, there’s been a debate about whether services provided by a physician over the telephone or by video should be paid for at the same rate as services provided in person. It’s a debate that’s become paralyzed by the ‘what-ifs’: if we pay physicians to provide telemedicine, will it increase access, or will physicians stop providing in-person visits? What price will we pay when it comes to our privacy? Perfect becomes the enemy of good and we wait as, state-by-state, initiatives are piloted, tested, and studied.

In the past months, however, federal and state entities have broadly authorized telemedicine to ensure patients stay at home when seeking medical services. New regulations have established that physicians will be paid for almost all services, at parity with in-person service, on any platform, including privately owned messaging platforms that are not always compliant with federal privacy laws. Penalties for lax privacy practices have been waived. Telemedicine has existed since the 1960s, but the system-wide reforms speculated about for decades took place in mere days. What’s becoming clearer to us every day is that we are in the moment-of-moments, a truly worldwide imposition of perspective. The word crisis comes from the Greek “to separate, decide, judge,” meaning “to keep only what is worthwhile.” And our perception of what is worthwhile tends to change in times of crisis.

If it’s true that the scope of the COVID-19 pandemic will reorder the daily lives of hundreds of millions of people for months or years, that also signifies conditions for change that dwarfs the conditions produced by the financial crisis of 2008, a crisis that nudged medicine toward digitization.

In times of crisis, the incentives and disincentives to which legislators usually respond are outweighed by much larger incentives and disincentives. Risk aversion and economic anxiety are relegated to status as second-order concerns. A government united in purpose, be it of one party or both, should aspire to forge pacts on a societal scale to provide jobs to Americans at a time when they require both work and a renewed sense of mission. It’s a time for the physicians of the San Francisco Marin Medical Society to lean into our values: to be bold, imaginative, and fearless when working with our local legislators in service to our communities and patients. Throughout these pages, you will find examples of the dedication of physicians in San Francisco and Marin. Let’s be inspired by them to recognize and respond to this moment – to walk through the door to reform. Gratefully,

Conrad Amenta

SAN FRANCISCO MARIN MEDICINE SEPTEMBER/OCTOBER 2020

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CMA HOUSE OF DELEGATES (HOD) REPORT:

PPE RELIEF CMA distributes two-month supply of free PPE to more than 40k California physicians Jacob Greenstein Since the onset of the COVID-19 pandemic, lack of personal protective equipment (PPE) has compounded the hardships for medical practices and hindered their ability to provide care for Californians. To alleviate the strain on practices and improve patient access to care, the California Medical Association (CMA) mobilized with its local county medical societies, the state of California and Altais to bring more than 40 million pieces of PPE—including medical-grade masks, gloves and gowns—to physicians free of charge, so that they can safely provide care for California residents. From the beginning, the need was urgent, and the demand was clear. CMA jumped into action, reaching out to California’s Office of Emergency Services to see what it would take to quickly get PPE into the hands of physicians. The result was an unprecedented project— in both scale and complexity— requiring an exceptional level of logistical planning, execution and collaboration between CMA, local county medical societies and several logistical partners. This was an entirely new operation for CMA, setting up a statewide distribution system for essential equipment that the state of California was struggling to get into the hands of physicians who desperately needed it. The CMA team, led by Mike Steenburgh—vice president of membership, marketing and component relations—got to work, rallying county medical societies and reaching out to Pride Industries, a Rosevillebased non-profit that specializes in supply-chain management. Together, they established a statewide distribution network that took materials from state warehouses, repackaged them into individual kits for medical practices and loaded the material on trucks to be distributed at dozens of drive-through events across the state—sponsored by health care services company Altais. The demand for the product was overwhelming. Within days of reaching out to physicians across the state, nearly 10,000 physician practices signed up to secure free PPE. To fulfill these requests, CMA and its component medical societies embarked WWW.SFMMS.ORG

on a three-week-long series of traveling distribution events to put PPE directly into the hands of physicians. On Monday, July 27, 2020, the PPE distribution events kicked off at the Rose Bowl in Pasadena. Staff arrived just after sunrise to scope out, plan and unload the dozens of pallets of PPE and equipment necessary to ensure a safe and effective drive-through event. Soon after, volunteers began to arrive on-site to help complete set up. Hours before the events even began, cars started lining up by the dozens as physicians who had been up against insurmountable supply chain issues could hardly believe there would be enough PPE to fulfill the need. Each box distributed included 1,600 nitrile examination gloves, 320 N95 respirators, 90 isolation gowns, 40 face shields and 800 surgical masks. In addition to a box of PPE, physicians were given a 20-bottle case of 500ml hand sanitizers, when available. Although the thousands of PPE kits will not permanently solve PPE issues for medical practices, the infusion of a roughly two-month supply of masks, gloves and gowns was welcome relief for thousands of physicians who simply could not secure the equipment they needed through traditional channels. Between July 27 and August 13, CMA and county society staff and over 1,000 volunteers from networks of friends, family, and local schools and universities came together to execute a campaign that had a profound impact on physicians and patients across the state. Nearly 10,000 boxes of PPE were handed out at drivethrough distribution events, and more than 6,600 boxes were directly shipped to practices who needed equipment but could not attend their local events. Event teams worked tirelessly in an assembly-line fashion checking reservations, guiding traffic, loading PPE and thanking physicians for their hard work. At roughly 45 lb. for a box of PPE, continued on page 8 SEPTEMBER/OCTOBER 2020

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Responses to COVID volunteers loaded nearly half a million pounds into physicians’ cars over three weeks, sometimes loading for a near full eighthour day in 100+ degree weather. When asked what this means to them, time and time again physicians relayed the hardship of trying to scour the internet for PPE, often paying exorbitant prices for miniscule amounts, if they can even find it, just to keep enough on hand to stay open on a day-to-day basis. “Amazing,” “necessary” and “grateful” were among the words that resounded from event to event. In San Francisco and Marin alone, the SFMMS distributed hundreds of boxes of PPE, reaching hundreds of practices, at no charge to them, to jumpstart and restart efforts to provide care to the residents of the SFMMS community. And we now have many more masks to provide upon request to continue this effort. CMA and its component medical societies continue to advocate for more resources for our state’s physicians. “To say that physicians and health care are essential at this time is an understatement, and PPE is an essential part of their ability to administer care,” said CMA President Peter N. Bretan, Jr., M.D. “CMA and its county medical societies are proud to work with the state to ensure that physicians of California can keep their practices open, and keep themselves and their patients safe.” CMA and its component medical societies remain committed to distributing PPE across the state. Remaining surplus is being shared with medical groups who did not qualify under the parameters of the initial program—which was limited to practices with fewer than 50 providers—and are struggling with securing adequate PPE supplies or experiencing financial hardship because of the increasing costs of PPE. Interested groups can contact CMA at memberservices@cmadocs.org to learn more.

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PPE Relief The California Medical Association and the California Office of Emergency Services distributed more than $80 million worth of personal protective equipment (PPE) free to nearly 15,000 practices in California.*

40,570

36 Events

Physicians Served

Over 15 Days

Boxes Distributed

15,800

in person

PPE Distributed

15 Million

Examination Gloves

40 Million Pieces

by mail

1.4 Million

700,000

Isolation Gowns

Bottles of Sanitizer

6.5 Million

1.5 Million

15 Million

N95 Respirators

Face Shields

Surgical Masks

Value of PPE Distributed

Items per Box 1,600 Nitrile Examination Gloves 800

6,700

9,100

Surgical Masks

320 N95 Respirators 90 Isolation Gowns 40 Face Shields

Practices Reached

15,000

Per Box

$5,000 Total

$80.6 Million Volunteers

Over 1,000

*Distribution is ongoing and these numbers are accurate as of September 1, 2020.

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SAN FRANCISCO

ELECTION 2020

MARIN MEDICAL SOCIETY

2020 Slate of Candidates 2021 Officers â&#x20AC;&#x201C; Term 2021 SFMMS President-Elect: Michael Schrader, MD, PhD, FACP SFMMS Secretary: Dennis Song, MD, DDS SFMMS Treasurer: Heyman Oo, MD, MPH SFMMS Editor: Gordon L. Fung, MD, PhD, FACC, FACP (Incumbent Editor)

SFMMS Board of Directors - Term: 2021-2023 Five (5) candidates to be elected to the SFMMS Board of Directors: Julie Bokser, MD (Incumbent Director) Keith Chamberlin, MD Manal Elkarra, MD Zarah Iqbal, MD (Incumbent Director) Matthew Willis, MD (Incumbent Director) SFMMS Nominations Committee - Term 2021-2022 Four (4) candidates to be elected to the SFMMS Nominations Committee: Leon Clark, MD Beth Griffiths, MD Jessica Duhe, MD Melanie Thompson, DO District VIII California Medical Association (CMA) Trustee - Term Oct. 2021-Oct. 2024 Lawrence Cheung, MD

SFMMS House of Delegates - 2021-2022 The candidates receiving the highest number of votes will serve as Delegates; the rest will be Alternate Delegates or on the wait list. The President-Elect automatically becomes one of the Delegates according to the SFMMS Bylaws: Heyman Oo, MD (Incumbent Alternate) John Maa, MD (Incumbent Delegate) Sarita Satpathy, MD (Incumbent Alternate) Robert Margolin, MD (Incumbent Delegate) Richard Podolin, MD (Incumbent Delegate) Brian Grady, MD (Incumbent Delegate) Gordon Fung, MD (Incumbent Delegate) Keith Loring, MD (Incumbent Alternate) Edward Alfrey, MD Opal Gupta, MD Kenneth Katz, MD Helen Yu, MD Daniel Flis, MD Jessica Duhe, MD

SFMMS Young Physicians Section (YPS) Delegate and Alternate to the California Medical Association House of Delegates Term: 2021-2022 One Delegate to be elected: Megha Garg, MD

NOTES 2020 President-Elect, Monique Schaulis, MD, automatically succeeds to the office of President. 2020 President, Brian Grady, MD, automatically succeeds to the office of Immediate Past President

Member voting will take place ONLINE ONLY. Your electronic vote must be cast by 5:00 p.m. on Tuesday, November 3rd, 2020. 10

Please see candidate biographies and statements on the following pages. SAN FRANCISCO MARIN MEDICINE

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CANDIDATE BIOGRAPHIES President-Elect

Secretary

Treasurer HEYMAN OO, MD, MPH

DENNIS SONG, MD, DDS

MICHAEL C. SCHRADER, MD, PHD, FACP

Also a candidate for SFMMS House of Delegates

Internal Medicine

Oral & Maxillofacial Surgery (ADA)

Pediatrics

Current Job Positions and Hospital and Teaching Affiliations

Oral and Maxillofacial Surgeon, Private Practice Associate Clinical Professor, UOP Department of Diagnostic Sciences Chief, Dental Division, Department of General Surgery, California Pacific Medical Center Active Staff, California Pacific Medical Center Courtesy Staff, St. Mary’s Medical Center

Associate Medical Director, Marin Community Clinics, Novato South Associate Physician/Attending Physician, UCSF & ZSFG Department of Pediatrics

SFMMS Board of Directors 2015-2018, SFMMS Executive Board 2017-2018, Treasurer 2019-2020, Treasurer SFMMS PAC 2018, Alternate delegate/delegate SFMMS CMA Delegation 2017-present, Vice-Chair SFMMS CMA Delegation 2018-present. AMA member (intermittently) since 1986.

Board Member, SFMMS Executive Committee, SFMMS Vice Chair / Board Member, SFMMS PAC Delegate for SFMMS, House of Delegates, CMA

SFMMS Board of Directors Secretary, SFMMS Executive Committee Secretary, CMA Subcommittee on Medi-Cal (member), SFMMS Delegation to CMA House of Delegates (alternate), Marin Commit-tee (member).

I trained to be a physician-scientist but decided my passion was clinical medicine. I have always participated in teaching the next generation of physicians. I currently serve on the UCSF Volunteer Clinical Professor Advisory Board. I am CEO of an independent physician practice, a small business. I am concerned about health of people in the community and currently serve on the Community Action Committee at Saint Francis Memorial Hospital.

President, San Francisco Dental Society Past Chairs of SFDS Membership, New Dentist, Program Development Committees Current/Past Service on SFDS Membership, Legislative, Finance, Community Dental Health, Program Development, Nominating, New Dentist Committees Past Representative to House of Delegates, California Dental Association Board Member, SFDS PAC Member, General Surgery Quality of Care Committee, CPMC Member, Surgery and Operating Room Committee, CPMC

Since medical school, I have been involved in physician advocacy through the medical society in San Diego as well as through CMA. I have served on SFMMS Board of Directors in a number of capacities, most recently as in the office of Secretary. I have also been an active member of the American Academy of Pediatrics (AAP) nationally for the last 6+ years and am currently Co-Chair for the AAP Chapter 1 Advocacy Committee.

In these challenging times, by maintaining broad views to navigate healthcare system, we can invite change to improve the healthcare of our two counties. My background in organized dentistry, medicine, academia, and business bring a different perspective to the board and membership. I would be honored to represent and serve.

As a Board Member/Officer, I’ve had the privilege to use my voice to speak out against flavored tobacco, rally for gun control, and submit resolutions critical to shaping CMA policy around protect-ing immigrant children and families. I would like to take the next step by serving as the Treasurer.

Primary care, internal medicine; Fellow, American College of Physicians; Volunteer Clinical Professor of Medicine, UCSF; Instructor, Inpatient Medicine CPMC 2000-11; Instructor, UCSF medical student office preceptor 1998-present. SFMMS/CMA Committees or Offices

Additional Relevant Experience

Why Are You Interested in Serving?

My focus: COVID-19, health effects of climate change, social determinants, healthcare access, women’s reproductive health, and industries profiting from unhealthful products. We support the profession by defending MICRA, scope of practice, and small group practice. These are enormous problems for one small medical society but we have a tradition of influence beyond our numbers.

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CANDIDATE BIOGRAPHIES SFMMS Board of Directors

Editor

JULIE BOKSER, MD

GORDON FUNG, MD, PHD, FACC, FACP

KEITH CHAMBERLIN, MD

Incumbent Director

Also a candidate for SFMMS House of Delegates

Cardiology

Pediatrics

Cardiac Anesthesiology

Current Job Positions and Hospital and Teaching Affiliations

UCSF Medical Center â&#x20AC;&#x201C; Active Attending; Chinese Hospital â&#x20AC;&#x201C; Associated. UCSF School of Medicine, Clinical Professor of Medicine. Director, Cardiac Services, Asian Heart & Vascular Center, UCSF Medical Center at Mount Zion, Director, ECG Laboratory, UCSF medical Center.

Partner, Tamalpais Pediatrics, a UCSF Affiliate Assistant Clinical Professor, UCSF.

CEO, Prima Medical Group (large primary care and multi-specialty group in Marin County); Co-Chair Operating Room Management Committee; Medical Director, Perioperative Services

Editor, 2011 to present; Executive Committee, 2011 to present; Past President. CMA: Delegate since 2000 (Chair since 2014); Member of Council of Scientific Affairs 2004-2015; Council of Scientific Affairs and Public Health 2015 to present; Council of Delegation Chairs since 2015.

SFMMS current Board Member

SFMMS Delegation

None

I completed my pediatric training at UCSF and served as chief resident at SFGH. Since, I have been working as a hospitalist and primary care pediatrician in Marin. Within my practice, I have taken a leadership role in medical student education, telemedicine, EHR implementation, and COVID preparation.

Secretary, Board of Directors, Meritage Medical Network Past Chair, Practice Management Committee, California Society of Anesthesiologists Co-Chair, Small and Medium-Sized Group Practices, American Society of Anesthesiologists

Serving as a board member of SFMMS is both a privilege and a responsibility. As a board member, I hope to provide a voice for pediatric care in our community. My goals are to better engage pediatric providers and the Marin medical community, raise concerns impacting the health of children and families, and help shape the future of medicine.

Nothing happens in our medical system without physician input. Yet physicians are often left out of the loop. This is a tumultuous time for the House of Medicine and I bring a wide amount of experience and knowledge to encourage physicians and medical networks to see value in each other.

SFMMS/CMA Committees or Offices

Additional Relevant Experience

Why Are You Interested in Serving?

I have been honored to serve as your Editor over the past years.

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MANAL ELKARRA, MD

Family Physician

ZARAH IQBAL, MD

MATTHEW WILLIS, MD

Incumbent Director

Pediatrics

Public Health

Current Job Positions and Hospital and Teaching Affiliations

Family Physician Adult and Family Medicine, Kaiser Permanente San Francisco Mission Bay

SFMMS/CMA Committees or Offices

None

Additional Relevant Experience

Previously I worked as a non-profit Program Director and teacher. I volunteered with various organizations locally and abroad. I have co-organized health conferences, collaborated with different agencies and developed program initiatives. Through these experiences and working in hospitals across the country, I acquired the skills to educate, communicate and advocate.

I’m currently a PGY-2 resident at UCSF in the Pediatric Leaders Advancing Health Equity (PLUS) program. My program mission is to train pediatric residents to advance health equity for children and families, and includes training in leadership, community health, and health policy in addition to excellent clinical training.

Public Health Officer, County of Marin Guest Researcher, U.S. Centers for Disease Control and Prevention Adjunct Professor in Public Health, Dominican University of California

CMA Council on Legislation (2017 – current) CMA Delegation to American Medical Association (2014 – 2017) Member, CMA CMS Medi-Cal subcommittee (2015 – 2016) CMA-MSS Vice Chair for Policy (2014)

Marin Medical Society Board Member (201517); SFMMS Board of Directors 2017-2020

I have been very active at the local (SFMMS), state (CMA), specialty (AAP), and national (AMA) level advocating a broad range of issues related to health equity, public health, and social justice. In my 2 years on the Calfornia delegation to the AMA, I created and implemented an electronic system to track resolutions and reports that amplified our voice and our effectiveness.

California Conference of Local Health Officers (CCLHO) Executive Board Health Officers Association of California Legislative Committee CCLHO Health Equity Committee co-chair State of California Opioid Workgroup

I fundamentally believe that advocacy is a core part of our profession. I’m proud to call SFMMS my home in organized medicine, with its history of challenging the status quo and pushing our systems to do the right thing for our patients and our profession.

The SFMMS can lead the way in supporting health and wellbeing for all in our region. I’m excited to add my voice as a health officer, physician and epidemiologist to make sure public dialogue and policies are grounded in evidence, and informed by the firsthand experience of physicians.

Why Are You Interested in Serving?

I am passionate about the intersection of health and social justice. Through my work with various communities via education, community organizing and empowerment, I have acquired a holistic understanding of health and wellness. I look forward to collaborate, innovate and build with my medical community during this turbulent time. WWW.SFMMS.ORG

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CANDIDATE BIOGRAPHIES SFMMS Nominations Committee BETH GRIFFITHS, MD

LEON CLARK, MD

JESSICA DUHE, MD Also a candidate for SFMMS House of Delegates

Dermatology

Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations

Attending Dermatologist, Alameda Health Systems Assistant Professor of Dermatology, University of California-San Francisco

Assistant Clinical Professor, Division of General Internal Medicine, UCSF

Internist, Department of Adult and Family Medicine, Kaiser San Francisco Medical Center; Volunteer Clinical Associate Professor, UCSF School of Medicine

None

Member, CMA Board of Trustees Chair, CMA Healthy California for All Technical Advisory Committee Alternate Delegate, CMA House of Delegates Member, CMA Council on Legislation Member, CMA Health Reform Technical Advisory Committee

None

Since working in the U.S. House of Representatives and the California Legislature a decade ago, I have used this experience to advocate for a more equitable health care system. Currently, I serve as Director of Health Care Advocacy for the Division of General Internal Medicine and Co-Director of the Community Engagement Rotation at UCSF, where I develop curricula in community engagement and advocacy and collaborate with faculty to expand the impact of their work.

Since joining SFMMS five years ago, I have been so impressed by the organizationâ&#x20AC;&#x2122;s focus on patients and public health. With the new group membership for UCSF physicians to join SFMMS/CMA, I would help the Nominations Committee to identify these new members and consider them for leadership roles.

A global pandemic has highlighted the inequities of care delivery, the importance of physician advocacy and need for collaboration within the medical community. I am interested in recruiting new physicians of diverse backgrounds and experiences into the medical society to shape policy and improve the health of our community.

SFMMS/CMA Committees or Offices

Additional Relevant Experience

During my time in residency at UCSF, I was able to interact with different hospital systems across San Francisco (VA, ZSFG, UCSF) and was also able to gain exposure to a variety of different private practices physicians during that time.

Why Are You Interested in Serving?

I believe that it is important for physicians to participate in the work of solving some of the complex problems in the delivery of quality health care, and I look forward to assisting other physicians in that work. One of the great strengths in this society is the diversity of experience, backgrounds, and viewpoints and I hope to help carry that legacy forward.

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CMA Trustee

CMA Young Physicians Section

LAWRENCE CHEUNG, MD, FAAD, FASDS

MEGHA GARG, MD

MELANIE THOMPSON, DO

District VIII California Medical Association (CMA) Trustee

Family Medicine

Internal Medicine

Dermatology

Current Job Positions and Hospital and Teaching Affiliations

Medical Director, Marin Community Clinics. I currently maintain a patient panel while overseeing the daily medical operations of our San Rafael Campus clinic location. SFMMS/CMA Committees or Offices

SFMMS Physician Wellness Committee

Additional Relevant Experience

I currently serve as a member on the board of the North Bay Chapter of the California Academy of Family Physicians. Over the last two years we have been active at hosting events related to ACA and physician wellness. I have also been an active participant at the CAFP’s annual All Members Advocacy Meeting.

I am a solo private practice dermatologist and the principal investigator of a clinical trials unit that focuses on phase III trials on dermatologic treatments. I also have active volunteer teaching responsibilities at UCSF, St. Mary’s Medical Center, and CPMC.

Associate Chief, Hospital Medicine, San Francisco VA Medical Center; Assistant Professor of Medicine, University of California, San Francisco

SFMMS President (2014), Chair, SFMMS Delegation to CMA (2018 – current), CMA Council on Science and Public Health (2015 - current), Chair, CMA House of Delegates Rules Committee (2020), AMA Delegate At-Large representing the CMA (2015 - current), Chair, California Resolutions Committee of the CMA delegation to the AMA (2018 – current).

American College of Physicians Delegate to the CMA

I have been very active at the local level (SFMMS), state level (CMA) and national level (AMA) on a variety of issues including preserving modes of practice (specifically solo and small group) as well as public health policy (tobacco control, soda, obesity epidemic and health care disparity). I also have the honor of representing SFMMS on the San Francisco Health Plan (SFHP) Board of Governors as an appointed SF County Commissioner since 2015.

I have been active as a physician advocate since I was in residency, and have regularly met with legislative representatives in Washington, DC and Sacramento, including participation in multiple CMA advocacy days. I am a longstanding member of the American College of Physicians California Chapters Health and Public Policy Committee. As an educator at UCSF, I teach medical students about physician advocacy and writing for change.

I’ve been the chair of our SFMMS delegation to the CMA for the past three years and I hope that I can use this experience to serve both SFMMS and CMA well in the capacity as your representative to the CMA Board of Trustees. I humbly ask for your vote.

I believe physicians can change policy, and I am ready to take on a larger role in advocating for our profession. I can offer a unique perspective as a VA doctor and a UCSF educator, and would like to mobilize our young physician community to get more involved in advocacy.

Why Are You Interested in Serving?

Working at a Community Health Center has illuminated the importance of physician voices at the legislative level to shape policy. Whether it’s protecting the doctor-patient relationship from erosion by the barrage of EHR requirements, ensuring that people have access to high-quality care, or addressing physician burnout, it starts with policy change.

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CANDIDATE BIOGRAPHIES SFMMS Delegation to the CMA House of Delegates HEYMAN OO, MD

JOHN MAA, MD

SARITA SATPATHY, MD

Also a candidate for SFMMS Treasurer

Incumbent Delegate

Incumbent Alternate

Pediatrics

General Surgery

Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations

Associate Medical Director, Marin Community Clinics, Novato South Associate Physician/Attending Physician, UCSF & ZSFG Department of Pediatrics SFMMS/CMA Committees or Offices

SFMMS Board of Directors Secretary, SFMMS Executive Committee Secretary, CMA Subcommittee on Medi-Cal (member), SFMMS Delegation to CMA House of Delegates (alternate), Marin Committee (member).

Past-Chair, UC Office of the President Tobacco Related Disease Research Program. 2) Marin General Hospital, General and Trauma Surgery. 3) Chair of the American Heart Association Western States Affiliate Advocacy Committee. 4) Staff Surgeon, Dignity St. Francis. Selected as (415) Top Doctor by Marin Magazine and as a San Francisco SuperDoctor in 2012 and 2013

Hospitalist St Francis Memorial Hospital Hospitalist Kentfield LTAC both Marin and SF Outpatient Internal Medicine at Crossover Facebook Campus

President 2018; Secretary 2016; Board of Directors 2012-2015; Executive Committee 2014-16/2012-13; CMA Council on Legislation 2019-present; AMA 1991 – present; CMA Specialty Society Delegate - Northern California Chapter of the American College of Surgeons (ACS); Awarded SFMS David Perlman Award for Excellence in Medical Journalism in 2013; San Francisco Medicine Magazine Editorial Board 2012 to present

Membership committee, Board of Directors Executive Committee

Member, SF Sugary Drinks Distributor Tax Advisory Committee 2019 – present; Past President, ACS Northern California Chapter; Recipient, 2013 ACS Ellenberger Award for Excellence in State Advocacy; Nominated for the White House “Champion of Change for Prevention and Public Health” 2013; Named one of “Top 20 people making a difference in healthcare in America” 2009; Member, American Heart Association Board of Directors, Past President, San Mateo Division 2004-2005; Commendation, Tobacco Control Advocacy, SF Board of Supervisors, 2014.

I have held a leadership role as a Hospitalist Medical Director at Cogent Health Care where I helped start a Hospitalist program from the ground up. I was later one of 8 Regional Medical Directors for Cogent Health Care where I served both Northern and Southern California Hospitalist programs. I have worked in many hospital settings including Acute, Subacute, LTAC and outpatient arenas which I believe help a physician better understand the medical climate.

The CMA plays an important role in guiding the practice of healthcare forward across California. I would be honored to help SFMMS through our CMA Delegation to lead efforts to strengthen the future practice of medicine, and improve the health of our State.

I am aware of the need to be more politically active in healthcare and the need to actively foster change towards a stronger and healthier community. Interest in connecting the diverse ethnic and cultural members, the younger physicians that are new to the community, as well as inspire women leaders.

Additional Relevant Experience

As a Board Member/Officer, I’ve had the privilege to use my voice to speak out against flavored tobacco, rally for gun control, and submit resolutions critical to shaping CMA policy around protecting immigrant children and families. I would like to take the next step by serving as the Treasurer. 16

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ROBERT MARGOLIN, MD

RICHARD PODOLIN, MD

BRIAN GRADY, MD

Incumbent Delegate

Internal Medicine and Geriatrics

Cardiology

Urology

Why Are You Interested In Serving? Current Job Positions and Hospital and Teaching Affiliations

Primary Care Practice in Internal Medicine; Chief, Chief of Staff of the Medical Staff at CPMC; Board of Directors, Medical Insurance Exchange of California; Associate Clinical Professor, UCSF.

I am in private practice with one partner (Remo Morelli, MD) and affiliated with St. Mary’s Medical Center.

Urologist, Golden Gate Urology; active medical staff member at CPMC and CPMC/ St. Luke’s, St. Mary’s Medical Center, St. Francis Memorial Hospital, and Seton Medical Center

SFMMS: Immediate Past President 2017; President, 2016; President-Elect, 2015; Secretary, 2014; Board of Directors, 20092013; Executive Committee, 2012-2017; Nominations Committee, 2017/2009; Delegate to CMA House, 2015-2017; Alternate Delegate, 2014. Additionally, for many years I served as delegate to the CMA from the California Chapter of the American College of Cardiology.

SFMMS: President, 2020; Secretary 2017; Executive Committee 2015-2019; Board of Directors 2014-2017; Liaison from St. Luke’s Medical Staff to the SFMMS 20132016; CMA Council on Health Professions and Quality of Care, 2016-17.

I served as Chairman of the Quality Committee at St. Mary’s Medical Center for four years, and then as Chief of Staff for four years. I have been President of the San Francisco Heart Association and a District Councilor for the California Chapter of the American College of Cardiology. For two years I served as Chairman of the Board of the St. Mary's Medical Center Foundation.

Currently serving as the Secretary/Treasurer MEC Seton Medical Center; former president of the CMA Resident Physician’s Section.

In this period of fundamental change in our health care system, physicians need to align to advocate for their profession, their patients, and their community. The strength of the SFMMS and the CMA will directly affect the viability of medical practice and the vitality of health care in San Francisco.

I am very grateful to be considered for this position. My colleagues have been such a great support to me in my practice, and I would be honored for the opportunity to repay through service to the SFMMA.

SFMMS/CMA Committees or Offices

Delegate to the House of Delegates; CMA: Past Member of the Board of Trustees, Past Chair of the Audit Committee, Past Chair of CALPAC; SFMMS: Past President, Past Chair of the Delegation.

Additional Relevant Experience

I have spent much of the past twenty years in leadership roles in our medical society and the CMA.

Why Are You Interested in Serving?

I have greatly enjoyed my role as a member of our CMA delegation for many years. I believe I have the experience, perspective, energy, and desire to continue to advocate for physicians and their patients and thus ask that you re-elect me to serve on our delegation. WWW.SFMMS.ORG

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CANDIDATE BIOGRAPHIES SFMMS Delegation to the CMA House of Delegates GORDON FUNG, MD

KEITH LORING, MD

Incumbent Delegate

Incumbent Alternate

EDWARD J. ALFREY MD, FACS

Also a candidate for SFMMS Editor

Cardiovascular Diseases

Addiction & Emergency Medicine

Transplant Surgery, Trauma Surgery, General and Acute Care Surgery

Current Job Positions and Hospital and Teaching Affiliations

UCSF Medical Center – Active Attending; Chinese Hospital – Associated. UCSF School of Medicine, Clinical Professor of Medicine. Director, Cardiac Services, Asian Heart & Vascular Center, UCSF Medical Center at Mount Zion, Director, ECG Laboratory, UCSF medical Center.

Addiction Medicine Physician, HealthRight360 Integrated Care Clinic

1) Department Chair of Surgery, Marin Health Medical Center (MHMC) 2) Medical Director of Trauma Surgery Program, MHMC 3) Adjunct Clinical Professor, Stanford University 4) Chair, Board of Directors, Prima Medical Group, and previous Medical Director of Surgery for the Prima Medical Group 5) Co-Chair, Operating Room Management Committee MHMC

Board of Directors 2011-13 and 2009; SFMS Treasurer 2010; Alternate Delegate to CMA House 2011-20; Finance Committee 201013; Executive Committee 2009-11

SFMMS Board of Directors (current) Marin Committee, San Francisco Marin Medical Society Endorsed by the SFMMS PAC in 2020, candidate for the Marin HealthCare District Board

SF DPH Psychiatric Crisis SOC Committee Member, 2011 to present; SF DPH Dore (Psychiatric) Urgent Care Center Steering Committee, 2007-2011; SF Emergency Physician’s Association President, 2009-2010; Reference Committee Member, CMA House of Delegates, 2011-2012; Vice Chief of Staff at St. Mary’s Medical Center, 2008-2010; Regional Medical Director, California Emergency Physicians, 1/2008 to 8/2010

1) Chair, General Surgery and Residency Program Director, Southern Illinois University 2) Chief, Transplant Surgery, Penn State University 3) Master’s Degree Health Care Management, Harvard University 4) Chair, Marin Health Medical Center Surgical Site Infection Committee 5) Director, Student Clerkship for Surgery, Stanford University 6) Faculty Senate, Stanford University

I want to be a part of the solution involving challenges posed by the impact of the pandemic on our most vulnerable patients who struggle with addiction and mental illness. I value greatly the opportunity to continue serving as part of our delegation to the CMA.

The SFMMS plays a critical role in California Healthcare and as a Delegate to the California Medical Association I can help promote the agenda of the SFMMS. My previous and current leadership experiences will contribute to the mission of the SFMMS and the role of the House of Delegates.

SFMMS/CMA Committees or Offices

Additional Relevant Experience

SFMMS: Editor, 2011 to present; Executive Committee, 2011 to present; Past President. CMA: Delegate since 2000 (Chair since 2014); Member of Council of Scientific Affairs 20042015; Council of Scientific Affairs and Public Health 2015 to present; Council of Delegation Chairs since 2015.

Why Are You Interested in Serving?

I ask your vote to continue in this position.

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OPAL GUPTA, MD

Allergy & Immunology

HELEN YU, MD

KEN KATZ, MD, MSC, MSCE

Dermatology

Child and Adolescent Psychiatry

Why Are You Interested In Serving? Current Job Positions and Hospital and Teaching Affiliations

I am in private practice with San Francisco Allergy, Asthma & Immunology. My current hospital affiliations include UC San Francisco and CPMC hospital systems.

Dermatologist, Kaiser Permanente San Francisco Chief, Outpatient Pharmacy & Therapeutics, Kaiser Permanente San Francisco

I am a child and adolescent psychiatrist at Kaiser Permanente in San Francisco. I completed my training in Child and Adolescent Psychiatry Fellowship at UCSF in 2020. I also received my General Psychiatry Residency training at UCSF.

Nominations Committee, 2018-2020

None

Through my training and practice, I have worked to improve patient care and patient experience by studying the barriers in access to care, the limitations in health care delivery, and the effect of personal characteristics (such as race and socioeconomic status) on disease management. I have mentored fellows, medical students and undergraduates. I currently serve on the Education Services, Data & Technology Committee as part of the American College of Allergy, Asthma, and Immunology.

Chairperson, FDA Dermatologic and Ophthalmic Drugs Advisory Committee Editorial Board member, JAMA Dermatology

As a resident and fellow, I have been involved in various formal and informal leadership positions that have included working on quality improvement projects in my own department, collaborating with trainees from other departments to improve patient care, and developing community partnerships to link patients to needed services.

Physician voices are essential in framing health and social policy. As an allergist treating a wide variety of common conditions, my patient population is diverse in age, ethnicity, and background. I would be honored to help shape and represent healthcare policy locally and statewide as part of the CMA delegation.

California should be a leader in helping physicians provide affordable, patientcentered, culturally appropriate care to all its residents. I would be honored to help SFMMS continue to advocate for policies at the state level that help us achieve that goal.

Our local region is facing many difficult challenges such as homelessness, substance use, and access to mental health care. We need to work across different fields of medicine, and across different organizations. Itâ&#x20AC;&#x2122;s important to bring a diversity of voices to the table in regards to the leadership of SFMMS.

SFMMS/CMA Committees or Offices

SFMMS Nominations Committee

Additional Relevant Experience

Why Are You Interested in Serving?

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CANDIDATE BIOGRAPHIES SFMMS Delegation to the CMA House of Delegates JESSICA DUHE, MD

DANIEL FLIS, MD

Also a candidate for SFMMS Nominations Committee

Otolaryngology

Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations

Otolaryngologist specializing in head and neck surgical oncology; employed by San Francisco Otolaryngology; hospital affiliations include Marin Health Medical Center, University of California San Francisco, California Pacific Medical Center, and Novato Community Hospital.

Internist, Department of Adult and Family Medicine, Kaiser San Francisco Medical Center; Volunteer Clinical Associate Professor, UCSF School of Medicine

None

SFMMS/CMA Committees or Offices

Additional Relevant Experience

Involved with AMA and New Jersey Medical Society during medical school.

Why Are You Interested in Serving?

After several years practicing in the community, I would like to become more involved with the greater medical community and engaged with local health policy that affects medical care in the Bay Area.

SAN FRANCISCO MARIN MEDICINE

During my medical training I served in various leadership roles within the Student National Medical Association (SNMA), including serving as former President of the University of Iowa SNMA, as well as on regional and national committees. My core efforts focused on recruiting and supporting underrepresented students in medicine, addressing health inequities and cultivating socially conscious physicians. Today I look forward to focusing my efforts on physician-patient advocacy in the community that I now serve. A global pandemic has highlighted the inequities of care delivery, the importance of physician advocacy and need for collaboration within the medical community. I am interested in recruiting new physicians of diverse backgrounds and experiences into the medical society to shape policy and improve the health of our community.

SEPTEMBER/OCTOBER 2020

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SEPTEMBER/OCTOBER 2020

SAN FRANCISCO MARIN MEDICINE

Responses to COVID

COVID CHRONICLES, OR, A SUGGESTED PRESIDENTIAL SPEECH Robert Wachter, MD Today, 150 days since I began my Covid tweets, I’m going to do something odd: write the speech that Trump should give. My fellow Americans: It’s been six months since the coronavirus – the virus that causes COVID – first entered our country. In that time, the disease has killed more than 160,000 of our fellow citizens, sickened millions, devastated our economy, & exposed a number of fault lines in our society. The toll – in years unlived, families shattered, people dying alone, healthcare workers and hospitals pushed to the edge, changes to our lives and lifestyles – is unspeakable. We have been attacked by a foe we cannot see, but one that is devastatingly good at what it does. The brutal summer surge that has killed tens of thousands in the South & West shows signs of abating. But the experts tell us that we may be in for another surge, perhaps the worst yet, in the fall. We may have a short window to change course before the next wave hits. In retrospect, faced with a foe like the coronavirus, the right thing to do would have been to recognize our commonality of purpose, and to bring the full measure of American resources – financial, intellectual, communal, and creative – to bear to defeat the virus. But we have not done that. We have instead locked horns in partisan battles that are both unnecessary and unproductive: public health vs. the economy, masks vs. “freedom,” the opening of schools, the closing of borders. As we fought, we lost sight of our common enemy. Our actions should have been dictated by what the best science – which, given the nature of science, evolves over time – told us about how best to defeat the virus and save the most lives. But too often it was not. I take full responsibility for this misguided course. And I vow, in my time left in office, to rectify my mistakes, to bring us together to fight our shared enemy, to focus on saving as many lives as possible – knowing that doing so offers the best chance of bolstering our economy, opening our schools, and unifying our nation. Armed with the hard-earned knowledge that we now have about the virus and the pandemic, I hope you’ll give me an opportunity to change tack, turning to a new path that allows us all 22

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to work as one. Here’s what we need to do: First, the debate about masks must end. By wearing them, we can slash transmission rates & save thousands of lives. Starting today, I am enacting a national mandate: everyone who will come in close contact with others outside their home must wear a mask. I will do so myself. I have instructed the federal government, working with private industry, to begin production of millions of high-quality cloth and surgical masks (along with other needed PPE for healthcare settings). We will make these masks freely available to those who cannot afford them. Additionally, we will launch a major program to rapidly build our COVID testing capacity, with a goal – in the next three months – of deploying hundreds of millions of low-cost, rapid turnaround viral tests that can be used at home or in businesses. I have asked @US_FDA to create a regulatory path to approve such tests if they can reliably identify individuals capable of transmitting the virus. We will also bolster our contact tracing capacity and access to alternative housing for quarantined individuals who need it. To oversee our federal Covid-19 efforts, I am enlisting the help of several outstanding individuals. I am asking @ASlavitt, former head @CMSGov, to assume leadership of the interagency Coronavirus Task Force. Andy will have the full resources of the U.S. govt at his disposal. We desperately need @CDCgov to reestablish its traditional role as the key agency tracking the pandemic and guiding our national prevention activities. Toward that end, I’ve asked @ ashishkjha, head of the Global Health Institute at @HarvardSPH, to become the new CDC director. The CDC will revise its guidelines on school openings, using the best evidence to inform districts when it is safe to resume in-person instruction. We will provide the funding needed for schools to modify their spaces and procedures to make them as safe as possible. I am also creating a new position of Covid Disparities Czar to study the toll of Covid on minority populations and make recommendations about how best to address them. I’m asking @ KBibbinsDomingo, Chair of the Dept. of Epidemiology/Biostat @UCSF, to assume this crucial role. WWW.SFMMS.ORG

I’m proud of our support for vaccine research, manufacturing & distribution. We will redouble this effort, hoping to identify at least 1 safe & effective vaccine by early 2021. I pledge not to interfere w/ FDA’s vaccine approval process – this must be guided by science alone. It’s clear that much of our success in battling Covid will depend on people’s willingness to change behavior: wear masks, avoid crowds, maintain distancing and, ultimately, be vaccinated. To that end, I will ask a group of highly respected “influencers” from diverse fields – including sports, entertainment & social media – to develop a campaign to engage the public in these crucial measures, and increase the public’s trust that following these health guidelines is the best way to save lives, end the scourge of Covid-19, and restore our economy. As a society and a government, we have made mistakes in the past six months. I know I have. I vow to learn from these

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mistakes, to chart a new path, and to unify our country as we pursue our shared goals: ending this pandemic and returning to our normal lives. Thank you for giving me a second chance. I’ve come to understand that we are at a moment in our history that must transcend politics; that the virus doesn’t care about our party or our politics, and – when it comes to our efforts to defeat Covid – neither should we. Thank you, and may God bless the United States of America. (That wasn't so hard, was it?)

Robert M. Wachter, MD is Professor and Chair of the Department of Medicine at UCSF, where he is the Holly Smith Distinguished Professor in Science and Medicine and the Benioff Endowed Chair in Hospital Medicine.

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Responses to COVID

REOPEN OUR SCHOOLS – FOR EDUCATION AND HEALTH A Personal and Professional Plea Kimberly Newell Green, MD As a pediatrician and a mother of two girls, in second and fourth grades respectively, I have direct experience with the profound challenges that forced school closures can bring to the health and welfare of families. As I took on the extra jobs of proctoring my daughters’ education, and providing extra hours of food preparation and household work, the quantity and quality of my other work dramatically suffered. That has been tough. But another result of “distance learning” has been much more worrisome: My husband and I observed my girls’ previous love of school and learning fall apart. At first, my daughters were frustrated with elements of their new iPad-facilitated curriculum that were difficult for them. By the end of the school year, they were resistant to, and threatening to refuse engaging with, anything related to school. In fact we were nearing two crises in our home: Educational and mental health. I fear that if distance learning continues, one or both of them may develop a lifelong aversion to school at a minimum, and potentially also chronic mental and behavioral health issues. This is in addition to their sedentary behavior and the difficulty getting them to engage in physical activity with little coach or teacher or peer influence. And at the age of 7 and 9 my girls have developed patterns of emotional eating: I watch them ask for snacks at the moment that a school lesson becomes difficult or boring. I suddenly see obesity looming. Our children have two highly educated and deeply caring parents who have the financial resources and flexibility to shift some focus from work to school support. They also are enrolled at a wonderful school doing its best to provide a top-notch education, and they have regular access to good internet bandwidth and technology tools with which they can connect to cuttingedge online resources. We are privileged. If closed school is hard for us, it is undoubtedly much more so for families that lack our resources and face additional challenges. When schools are closed, some less-advantaged parents - usually moms - are forced to make one of two bad choices: leave their children without adequate care or help with distance learning, or fail to be able to work enough to provide food and shelter. We all know that COVID-19 is an unprecedented pandemic with untold human consequences. As we work to mitigate 24

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the devastating effects on our public health and economy, it is vital that we also prioritize our children and families’ health and well-being. I believe that among the many failures that our country has committed in the face of COVID-19, failing to work vigorously to prioritize schools is among the greatest. As you will read in the new SFMMS’ Principles for Reopening Schools Closed Due to COVID-19, we believe that schools are the most vital driver of health for children. They are also vital for our working parents, especially women, as evidence mounts that female parents especially are dropping out of the workforce, and precipitously. And they are vital for our economic recovery, because if a parents needs to supervise their children during school hours, holding a job over a long period of time is essentially unsustainable without help. Public health officials in San Francisco have worked tirelessly in the last months to slow the spread of this dreadful virus, and we have had great working relationships with them. In sharing our principles we have been met with gratitude and partnership. Our city has seen lower rates of COVID-19 than many other cities in our state and nation, partly because most of our community adheres to public health standards but also perhaps most significantly because of physician leaders like Grant Colfax, the Director of Public Health in San Francisco, and Tomas Aragon and Matt Willis, the Health Officers of San Francisco and Marin Counties, respectively. All of these incredible public health leaders are members of SFMMS (Drs. Aragon and Willis are currently members of our Board of Directors). More than a dozen Marin schools are opening as I write, and at the time of this writing Dr. Aragon stated that he expects some schools in San Francisco to be able to open by the end of September. We thank all of the health department staff who have been working hard to develop a path to safe and successful reopening. I personally feel that if our society had really taken a step back to think about the long term health and safety of our city and community, we should have focused much more energy and money on creative and innovative solutions to the difficult problem of reopening schools safely (for the entire school community including staff ) and equitably. Unfortunately, due to WWW.SFMMS.ORG

decades of underfunding of our public school system especially in our must vulnerable communities, most public school students in our country will remain at home for their learning at least through January, if not for this year and possibly more. San Francisco public schools are not planning to attempt to reopen at the present and have not committed to a date or a plan. We must do what it takes to reopen schools safely and equitably. And we must do it urgently. That means keeping community rates of COVID low, even if that means slowing the opening of non-essential businesses like bars and restaurants. When we prioritize bars over the education of our children, our society is making a bad choice. In order to do this we will need enormous resources, financial and human. This is the time to invest those resources in the

SFMMS Fall Wellness Corner Jessie Mahoney, MD Chair of SFMMS Physician Wellness Task Force

Mindset Strategies- Psychological PPE for Physicians

While you are “saving” the world, don't forget to take a moment to savor the world. Thank you for your contributions to the world during the last 6 months. It has been an unusual time in medicine. I want to encourage you all to take some time to savor your own life experience. Savoring the beauty of your daily life is critical to your resilience and fortitude. Learning to pause and be present and to be mindful and intentional is protective against burnout and helps you reconnect with your passion, your purpose, and your loved ones. Caring for others, fixing things, and working for change is an integral part of being a healer but we must also not miss out on being, noticing, living, and connecting. When you choose to think that everything is exactly as it should be right here in this moment- all the good and the bad, the covid and the anxiety and the stress- you have much more space, clarity, and energy to simultaneously savor AND save the world. Don’t wait for the circumstances to change to start savoring your life. With intention, start to savor each minute as it is right now and see what happens. The power is in the pause "Practice the pause. Pause before judging. Pause before assuming. Pause before accusing. Pause whenever you are about to react harshly and you'll avoid doing and saying things you will regret." -Lori Deschene Practice the pause. Learn to be present. Choose to be intentional.

Pause and presence change you for the better. Which changes your experience of everything around you for th better. Who doesn't need this right now. WWW.SFMMS.ORG

future of our children, in the future of our economy, in the future of women, in the future of our city. Parents, teachers, pediatricians and child advocates need to make the largest amount of noise over this. Economists and the financial sector should also be making large amounts of noise over this. Reopening schools is an urgent national priority, for all of us. Kimberly Newell Green, MD is a pediatrician and past-president of the SFMMS.

It’s Possible It’s possible to go from struggling to managing to living more easefully to feeling passionate, engaged and connected. Even in 2020. Even as a physician in a pandemic. It’s possible to let go of most of the stress and struggle. To grow. To evolve. To rediscover your passion. It's possible to become more at peace and connected with loved ones. It's possible to be a more content and effective doctor and colleague. It's possible to lessen drama. It's possible to stop wasting time

To struggle less. To decrease worry. To feel at peace. To find ease. To connect better. To feel more compassion. To feel more connected to your purpose.

and energy. To rewrite your story. To make decisions with ease. To prioritize. To constrain. To move forward.

Even in a pandemic. Even with distance learning. Even with partners or colleagues who have their own struggles and aren’t behaving as you think they “should.” It's possible for relationships to strengthen. It's possible to start a new career. To start to feel more content at your job. To find your passion. To find your voice. To be authentically you. It's possible to feel that everything feels manageable and is working out exactly as it is supposed to even when it isn’t all “good.” How? By mindfully managing your mind. Attention and Intention

What if you approached your life with intention as your motivation rather than being driven by guilt, anxiety, or a fear of not measuring up. Guilt is limiting. It drains your energy and narrows your vision. Anxiety and feelings of inadequacy lead to burnout, frustration, and ultimately exhaustion and isolation. Intention involves attention. Intention is the process of identifying and choosing the qualities and energy, you wish to bring into the world. Intention comes from a place of abundance. Rather than moving through the world reacting and numb, what would be different if you chose attention and intention? SEPTEMBER/OCTOBER 2020

SAN FRANCISCO MARIN MEDICINE

SFMMS PRINCIPLES FOR THE REOPENING OF SCHOOLS CLOSED DUE TO COVID-19 Background Re-opening schools safely has become one of the most controversial issues of the COVID-19 pandemic. The question is how to best balance the health and educational needs of students, teachers, parents, and the broader population. As physicians, we believe that such a balance can be obtained via careful, databased procedures and practices. The input of all parties must be obtained and considered in doing so. All of us share the same goals of doing what is best for children, and the San Francisco Marin Medical Society (SFMMS) offers this document of principles in that spirit. It can be difficult to find reliable information about whether and how to reopen schools, as media, policymakers, and organized labor associations issue conflicting statements and guidance. This document is intended to provide clarity on the issue from an evidence-based perspective and with a priority on the health and well-being of children and their communities. SFMMS believes that schools are at least as essential as businesses that have already qualified to resume routine operations and as an essential service, more needs to be done at all levels of state and local government to ensure robust delivery of safe, in person school to our communities. The argument in favor of reopening schools is informed by factors relating to infection/transmission in children, education as a social determinant of health, economic contributions, and the disproportionate effects of school closures on communities of color. • Children are not as susceptible to COVID-19 infection and/or transmission. Data is early but there is generally a consensus that children, as a rule, don’t get as sick, don’t get sick as often, and current evidence suggests that elementary school-aged children (i.e. less than 10) are much less likely to transmit the virus than older youth or adults.

• Being in school is arguably the most important health driver in children in the age of COVID-19. Factors include: o Developmental needs: socialization, adults outside of the household. o Children with special health and educational needs: specialized services provided within the school setting. o Health services: health care services provided within the school setting. 26

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o Reduction of child abuse: Evidence that child abuse and neglect, which in normal times kills more than COVID, increases when kids are not out of the house and in times of economic stress. o Education as a social determinant of health: Educational loss and gaps lead directly to future economic stability and success which trends with health status.

o Educational instruction: Education is a social determinant of health. Educational loss and gaps lead directly to future economic stability and success which trends with health status. o Social and emotional health: schools provide a stable and secure environment for children to develop social skills and peer relationships. The school environment where children feel safe and connected is associated with less depression and anxiety. o Nutrition: Food insecurity: vital meals served at schools. o Children with special health and educational needs: specialized services provided within the school setting. o Health services: health care services provided within the school setting.

o Safety - Reduction of child abuse and decrease in risk taking behaviors: Evidence that child abuse and neglect, which in normal times kills more than COVID, increases when kids are not out of the house and in times of economic stress. In addition, time in school is associated with less sexual activity and substance use. o Physical activity: loss of physical activity associated with school closure can be particularly harmful to children as it is associated with childhood obesity.

• Schools are vital for our current and future economic success:

o The adult supervision of children provided in schools is vital for economic productivity. This especially impacts women of all professions, including physicians and other staff in the health care setting. Educational losses for this entire generation will have a negative ‘ripple effect’ on our local, state, and national economies far into the future. WWW.SFMMS.ORG

o The negative effects of school closures are amplified and worsened for poor and Black and brown children, intensifying the disparities that already exist in our country. Schools in these communities have been historically underfunded and overcrowded and often lack basic materials and services including even soap and paper towels. These are communities in which both adults and children suffer higher rates and worsened outcomes from COVID-19.

SFMMS Principles for the Reopening of In-Person Schools in California

• Reopening schools for in-person instruction when safe is vital for the health of children, families, and the short and long-term economic health of our communities. For these reasons, schools should be considered at least as essential as those businesses that have already qualified to resume operations.

• As an essential service, elected and public health officials should prioritize schools over other types of non-essential businesses when making reopening decisions and allocating funds. • School closures have a negative and disproportionate effect on women and people of color, including but not limited to reduced labor force participation. School attendance is critical to minimizing health and socio economic disparities in our society. • Continued use of stringent control methods to lower community transmission rates so that schools can reopen with an acceptable level of safety should be of utmost priority for public health and other elected officials.

• Decisions regarding school re-openings should be made based on the best evidence available, recognizing that new evidence will emerge over time. During school reopening, robust surveillance, testing and data collection must be supported in order to prioritize student, staff and community safety and to inform future efforts in keeping educational and childcare institutions open. • School districts will require substantial financial support to reopen safely and we urge public officials to prioritize this in their spending plans.

o We urge governments and schools to invest significant resources into making virtual learning as robust and as effective as possible for all students who cannot safely return to school, including ensuring that all students have internet access and access to devices needed to participate in virtual learning.

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o We recognize that extensive additional targeted resources will need to be put into communities that have been historically underfunded and therefore at risk for increased learning gaps and health and educational disparities, including communities of Black and brown children, as well as children with special health care needs.

o Ta c t i c a l g u i d a n c e a n d e n g i n e e r i n g c o n t r o l s developed at the local level are essential for schools as they reopen. Local, county, and state policymakers s h o u l d c o nve n e m u l t i d i s c i p l i n a r y t a s k fo rc e s comprised of experts from the fields of health and education to assist in crafting such guidance. o Adequate types, usage, and quantities of personal protective equipment, including but not limited to N95 respirator-style masks and sanitizing gels and sprays, are essential to resuming the operations of schools.

Additional considerations:

• We urge officials to support research into educational outcomes with a particular focus on minimizing disparities in educational supports and outcomes. Future decisions and work in both in-person and distance learning should continue with the goal of narrowing disparities while holding high educational expectations and standards for all students. • We urge elected and public health officials to engage in specific and nuanced decision-making when mandating how and when schools can open, and to recognize the following:

o Opportunities exist to re-open elementary schools that may not exist for other types of schools because of the low risk of viral infection or transmission by young children.

o The risk for opening schools is different across the state and even within counties. Given the importance of reopening schools, decision-makers should use targeted and nuanced metrics to inform recommen dations around school openings. Local county task forces to include county superintendents, teachers, public health leaders, physicians, and parents can help guide these openings. o An incremental approach to reopening schools has immense value. Starting at the elementary school level may allow policymakers to test policies in a lower-risk environment; refine the template for reopening; gain operational experience and develop best practices; and gather data to inform future opening decisions. What is learned because of incremental school reopening will benefit and accelerate reopening elsewhere.

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Responses to COVID

ACCOUNTABILITY AND PHASE II RESPONSE TO THE COVID 19 PANDEMIC

John Brown, MD and Anu Ramachandran, MD

Our response as physicians and public health providers to the first phase of this pandemic presented a terrifying challenge to modern society and American medicine. As our community journeys into the next phase, we are struck by the parallels between our pandemic “disaster response” and our daily “routine” needs to prevent further disease and care for our patients. This article proposes a simple premise for success in meeting these challenges - increased awareness of and attention to accountability. I am accountable to you and you are accountable to me. As we write this in August 2020, we have navigated the initial response as a community in San Francisco and Marin Counties with enviable success - the lowest rates of COVID-19 infection and mortality of any urban area in the United States. This has been facilitated by a combination of Public Health experience and effort exemplified by the work of our Health Officers–Tomas Aragon, Matt Willis, and their respective Departments of Public Health. The community leadership mobilized rapidly into the Incident Command System structure and enlisted the necessary cooperation of all levels of local government. The partnership of health departments, local mayors and elected representatives spanning many Bay Area Counties removed jurisdictional barriers and helped our multi-county mobile population adopt similar preventive measures simultaneously. Most importantly, the cooperation of the public throughout the region has been the crucial element in this success story. Our collective accountability has shaped the narrative of the Bay Area COVID response, and has allowed us the benefit of time for data collection and resource allocation, a luxury denied to many other areas of the country. Unfortunately, our persistent problems of unequal access to health care, institutionalized racism, economic hardship (worsened by the temporary suspension of crucial economic activity during this period), and our human-nature resistance to change despite evidence of its benefit have continued. While many successful programs and processes exist to address some of these more structural resource deficiencies (such as sobering centers, medical respite shelters, community based recovery and skills training centers) the needs of these programs have increased at a time of diminished government resources. While 28

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some programs were temporarily decreased in order to permit pandemic specific health and welfare processes to be developed, these disparities now must be addressed even more stringently in order to prevent a catastrophic resurgence of the virus. This will not be easy in light of the resources required in a time of economic hardship. To mitigate the spread of virus, we ask everyone to wear a face covering, maintain social distancing in public places and comply with testing recommendations and other public health orders. It is also necessary, as Dr. Fauci from the CDC recently put it in a commencement address for the College of the Holy Cross, for us to “care selflessly about one another”. An open mindedness and sense of inquiry is necessary to look at the results of our social and professional actions, not only our intent. This is one of the pillars of the scientific method—to be honest and transparent, moreover to be prepared to change our initial or usual approach if it is not working. The challenge of infectious diseases to emergency physicians is the longer time scale for the diagnosis and treatment, the patience required in gathering necessary data, and the stunning difference a small change makes in mitigating the number of sick patients entering the emergency care system. Focused attention and perseverance are key. All physicians need to be accountable to our patients, as do the professionals we have the privilege of working with—nurses, specialty care technicians, medical assistants, EMS providers, administrators and insurers. We must be sure to provide the best possible care we can and to protect our health every day in the workplace and at home. Part of this accountability on our behalf is an acknowledgement that this disease is causing disproportionate harm to our Black and Latinx patients, a tangible reminder of the inequities that persist within our healthcare system. We must take lessons from the nationwide conversations about social justice and make daily efforts to better ourselves, our colleagues, and the systems we work within to serve the communities most affected by this disease. Patients need to be accountable to each other and their families, friends and providers by adhering to effective directions and guidelines and taking charge of their health as much as possible in order to not overwhelm the healthcare system. WWW.SFMMS.ORG

Public employees need to be accountable to the public they serve, from small measures, such as providing safe options for public events/services from voting to riding transit, to larger, more difficult measures such as modifying treatment protocols and changing de-escalation strategies to increase safety and prevent harm. They will all count. Politicians need to be accountable to their constituents who are unable to speak for themselves through increased awareness of and support for public health actions/non-pharmaceutical measures to control the pandemic. Political leaders can tackle the status quo and challenge privilege and powerful economic forces responsible for societal stress and emotional confrontation. Assertive and thoughtful actions to change negative behaviors and redistribute resources are difficult but necessary in the era of this pandemic. Business owners and leaders need to be accountable to their employees for their safety and economic well-being. The most important element of a thriving economy is the people that facilitate economic growth. The more death and disability we allow by our actions and inactions, the more damage our economy suffers in the long run. The media can be accountable to the public by verifying new developments in the science around this disease, dispelling rumors and challenging the accuracy of stories amplified by social media that make right action hard to discern. Professional societies such as the SFMSS need to be accountable to their members and to the patients they serve by focusing on changes in current medical practice on all of these fronts— pandemic countermeasures, anti-racist practices and programs, overcoming disparities and difficult access to care. The track record of our society in so many of these arenas has been excellent, from advocacy on increasing health coverage to speaking truth to power on health issues from smoking to healthy eating to addressing behavioral health and gender/race/age related barriers to care. We have partnered with the San Francisco Department of Public Health in these efforts, and with other community and professional organizations such as the San Francisco Emergency Physicians Association to advocate on levels from the organizational to the state levels for medical providers. The path forward now is both sustainment of this effort and an additional awareness of the education and communication needs for resources and expertise to meet the unpredictable challenges of COVID-19 Phase II response. Finally, the authors encourage individual practitioners to become increasingly active towards adapting their practice to meet these changing needs of society. At baseline we can improve our personal and professional disaster preparedness. Reviewing and updating our plans and supplies using the pandemic tools placed on the SF DPH website at https://www.sfdph. org/dph/alerts/coronavirus.asp is a positive, meaningful effort we can make in this time of uncertainty. Please remember that we are approaching the wildfire and heat seasons in Northern California, so we need an all-hazard approach to meeting the challenge of this next phase. Becoming more aware of, educated about and supportive of efforts to diminish the social inequities worsening the effects of this virus is a crucial step to navigating it successfully. Whether that support is by our providing our time, talents or treasure, a less racist, more health-conscious WWW.SFMMS.ORG

and educated patient population will result in more resiliency. This will also result in a more rapid transition to our desired endpoint of phase III response where we have effective medication/vaccination/social controls for COVID 19. Support activities that the authors recommend include volunteer opportunities for physicians which can be found at the City’s COVID 19 Emergency Volunteer site here: https://app.smartsheet.com/b/form/cae0ff0cbe4f417986e817272f527b8b. or by contacting DHR-EVC@sfgov.org. Others are paid opportunities to work at San Francisco’s alternate care facilities as they become available during the surge will be posted here: https:// www.helunahealth.org/ under “Join our Team” and “Current Job Openings”. Finally medical positions to help with the surge response at the state, federal and Community Based Organization levels can be found on the EMS Authority https://emsa. ca.gov/disaster-healthcare-volunteers/ and numerous other websites. As Her Majesty, Queen Elizabeth II said in her speech early in Phase I, “let’s get through this together and we will see each other again.” Let us keep faith in our collective accountability and the power we hold, together, to shape the course of this pandemic. Dr. Ramachandran is a third-year resident in emergency medicine at the UCSF Department of Emergency Medicine with a background in public health and an interest in local and global disaster response.

Dr. Brown is the Medical Health Operations Area Coordinator for the San Francisco Department of Public Health, an emergency physician practicing at San Francisco General Hospital and a Medical Officer on the Disaster Medical Assistance Team CA-6.

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SAN FRANCISCO MARIN MEDICINE

Responses to COVID

COVID CONTACT TRACING: The San Francisco Department of Public Health needs your help to stop COVID-19.

Ellen Weber, MD

The DPH is currently calling all people who test + for COVID-19 in San Francisco. At that time, we determine their ability to isolate and elicit any close contacts. Our contact tracing then calls the contacts to give them quarantine instructions and recommend testing. However, with the current surge, this process is taking too long. COVID-19 is transmitted from person to person. The most infectious period is 2 days before and the first several days of symptoms. Close contacts of these cases must be identified as soon as possible to stop the onward spread of disease. Providers are usually reaching patients with COVID-19 several days before the DPH can. This is an opportunity to slow transmission of the disease down.

What we ask: When you call a patient to disclose results, take a few extra minutes to obtain the names and phone numbers of their household (or other) contacts. Complete the Confidential Morbidity Report (fillable PDF) for COVID-19, then fax or email to DPH. Contacts can also be sent to DPH at https://bit.ly/sfcovidcontacts. If the patient needs help to isolate (food, cleaning supplies or a separate place to stay while in isolation or quarantine), the CMR also contains information on how to provide referrals. For more information, contact ellen.weber@ucsf.edu

San Francisco Department of Public Health

STOP TRANSMISSION OF COVID-19 with D.A.R.T.S.

COVID-19 can rapidly spread •

On average, a patient with COVID-19 will infect 1.5 to 3.5 other people

•

Case isolation with contact tracing reduces transmission by up to 64% 1

•

There is a very narrow window of opportunity to notify contacts of their exposure and recommend quarantine to prevent further transmission. We need providers to help gather this information from patients so public health officials can act sooner.

What providers can do to break the transmission cycle Prior to test, conduct a brief social history Ask the patient how many people live in their household, do they work or go to school, and do they have symptoms.

After a positive result, utilize previously obtained social history to guide case investigation & contact elicitation

Disclose, Advise, Refer, Trace, Support (DARTS) • Disclose test results to the patient. A positive PCR test is highly likely to be a true positive. • Advise isolation. Patients who test positive should isolate for at least 10 full days from the onset of symptoms (or the positive test if they are asymptomatic). They must be fever-free without use of feverreducing medications for 3 days before ending isolation. Isolation is to protect others in the household from getting Isolation means: the virus as well as others in the community. • Do not leave the house Refer: Ask the patient if they are able to isolate. If they cannot isolate from • Separate yourself from others in the household by staying in a room alone others, provider should place a referral for a city-sponsored hotel room at • If possible, use a separate bathroom, or https://covid19isorequest.getcare.com/referral clean the bathroom after every use Trace who else may have been exposed and recommend urgent testing. • Do not share food, utensils, linens or Encourage them to immediately notify their work supervisor or school. Who other items with those in the household • When you have to be around others in lives in their household? Is anyone over 60 or immunocompromised? Obtain the household, wear a face mask and the names and contact information for household contacts & share with SFDPH stay at least 6 feet apart with the COVID-19 CMR. Recommend that all household contacts immediately • Arrange for someone to shop for you, test and quarantine. Remind patients to answer any calls from SFDPH to get and obtain necessary medications free testing, resources and support.

•

Support: Provide ongoing support to safely self-isolate. If the patient needs assistance (food, medications, pet care), refer to a

•

social worker or direct them to call 311. Follow up with the patient for wellness checks as needed.

Don’t forget to complete the COVID-19 CMR form at https://www.sfcdcp.org/covid19cmr 1

MacIntyre CR. Case isolation, contact tracing, and physical distancing are pillars of COVID-19 pandemic control, not optional choices. The Lancet Infectious Diseases. 2020.

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WWW.SFMMS.ORG

HARD LESSONS: PALLIATIVE CARE IN THE COVID ERA

Monique Schaulis, MD, MPH

This spring, while I was working a shift in the ER, my mother-in-law texted me to report that I was mentioned in the San Francisco Chronicle. Surprised, I went to check it out. I found an extensive article on how COVID 19 has affected elders in the Bayview neighborhood. One of the patients profiled was Wilbur Morris, with whom I had worked the month before (in what I now think of as the early COVID era). Mr. Morris was an octogenarian who enjoyed snazzy clothes, parties, and regular jogging, who most likely contracted COVID 19 at a birthday party in early March. I was on the palliative medicine team that consulted during his many week hospital stay. We first became involved when he was intubated in the ICU. Early prognostic data from China and Washington State looked dismal for patients his age on mechanical ventilation, and our palliative team shared this bad news with his family. I worried to myself that his final days on the ventilator might be worse than death. His family and the medical team experienced the uncertainty together, hoping for the best while planning for the worst. Mr. Morris was not my patient in the pre-COVID way; I never touched his body nor held his hand. He would not recognize me. Conservation of PPE and infection control made the experience entirely virtual. Our palliative care team had to quickly find new ways to use technology to connect with families. Ever since I began practicing palliative medicine, the gold standard has been the in-person family meeting. We normally would all gather in a conference room or by the bedside to discuss the road ahead. But COVID 19 created uncharted territory: no visitors for the patients, no family meetings; relatives were often infected or quarantined themselves. As a team, we went into technology overdrive, trying to figure out the best way to bring people together. What would it be like to give bad news by video? What platform would work well, be compliant, and be simple and ubiquitous enough that even technologically unsophisticated people could use it? How would we link in an interpreter if we needed one? We struggled with microphones in the ICU, texting links, and crashing platforms. We went from no telemedicine to all telemedicine in a few weeks. In those early days, we just had to go with what we could get done. The Chronicle journalist wrote about me holding my iphone up to the window of Mr. Morris’ ICU room so the Morris family could see him. As I stood there pressing my phone to the glass, they would pray for him while I silently witnessed these powerful moments. Later, I realized that I was doing what we always try to do in palliative medicine: build connection. After work, I shared with my own family, “the best thing I did at work today was hold up a cell phone.” During normal times, our palliative care team begins most visits with an explanation of what palliative care is. It is rare that people know how we add an extra layer of support for patients and families. But Mr. Morris’ situation really helped drill down to some fundamentals of palliative medicine. While the intensivists and hospitalists kept his WWW.SFMMS.ORG

body alive, palliative care helped take care of his village, talking through hopes, worries, and easing the existential distress that comes from isolation and fear. At the same time, through our conversations with family, we ensured that the grueling treatment he endured was consistent with his personal values. The means by which we did this work was completely different than just a few months prior, and yet the end result was much the same. Though we are in many ways more isolated, wearing masks and face shields and meeting on video, COVID 19 has also brought patients and staff together through an increased collective sense of vulnerability. When I say to families, “I wish things were different,” I share that sentiment in a whole new way. The virus has made it too easy to imagine myself being the daughter on the cell phone, trying to catch a glimpse of her dad in the ICU. And as my patients' families juggle the competing demands of a sick parent, work, and their own children, my own phone chimes with texts from my kids who are managing school at home on Zoom. As a COVID era physician, I have expanded my skills. I have held iPhones at windows for prayers, supported a peri-extubation mariachi performance, and have had to reassure an anxious child that he wasn’t going to accidentally infect and kill his grandparents. In every specialty, we have remade our tools at breakneck speed to fit the times. The professional and the personal have become more intertwined than ever. All of us can’t wait for the COVID pandemic to be behind us. But when it is gone, I wonder what we will take forward? I know that the telemedicine skills we have been forced to develop will forever change the practice of medicine. With a focus on quality, as well as attention to inequities, we will be able to reach many more people, keep our population healthier, and support each other more effectively. No longer will homebound people or those in rural areas be unable to access specialists like palliative teams. On the policy level, reimbursement for telehealth, and nationwide access to wifi will be key to ensuring that this huge advance is sustainable. Finally, my great hope is that COVID 19 will have been a nationwide wake up call to the importance of public health. That the collective trauma we have experienced will yield both emerging leaders in health and in government who will advocate for sound science based policy and an engaged citizenry to support them. That this “lost year” for our schoolchildren will not hold them back but push them to stand up and say that they will never again accept what we have witnessed this year. Monique Schaulis MD, MPH is an emergency and palliative care physician at Kaiser San Francisco, and President-Elect of the SFMMS.

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SAN FRANCISCO MARIN MEDICINE

Responses to COVID

THE SCIENCE UNDERLYING ADOLESCENTS’ INCREASED RISK FROM CANNABIS Timmen Cermak, MD The onset of puberty introduces a period of rapid neurological development characterized by an explosion of synaptic connections, followed by over a decade of pruning, and an increase in axonal efficiency through myelinization. The THC in cannabis interferes with these neurodevelopmental processes by over-activating the brain’s endogenous cannabinoid system (ECS). The ECS is our largest neurotransmitter system. It consists of THC-like neurotransmitters such as anandamide and 2-AG, which are synthesized on demand from postsynaptic cell membrane fatty acids, and cannabinoid receptors (CB1R) that are located presynaptically. The ECS is activated by arrival of a wide variety of neurotransmitters at their postsynaptic receptors. Endocannabinoid neurotransmitters are synthesized in response and then diffuse back across the synaptic space to activate CB1R on the presynaptic neuron. Activation of CB1R produces negative feedback on the presynaptic neuron, decreasing the amount of neurotransmitter released by each axonal firing. This process of tonic negative feedback provides homeostatic regulation of brain chemistry.1 THC activates the brain’s cannabinoid receptors more strongly and longer than anandamide or 2-AG. As a result, CB1R downregulate with the first dose of THC, with CB1R upregulation to normal levels taking sufficient time that too frequent repetition of THC use leads to an accumulation of CB1R downregulation. Two weeks of daily THC downregulates CB1R in rats between 20-60% depending on the brain area.2 MRI demonstrates a 20% reduction in CB1R in the frontal lobes of humans using cannabis regularly that takes a month of abstinence to upregulate to normal levels.3 Chronic use leads to 44% reduction in hippocampal synapses.4 Diffusion Tensor Imaging (DTI) reveals increased anisotropy in the anterior commissure connecting the two hemisphere’s frontal lobes5 as well as in axons within each frontal lobe6, demonstrating disturbances in the flow of intracellular fluid from cell body toward synaptic terminals. These impacts of THC on frontal lobe structure and function are of special relevance to adolescence since the frontal lobes are the last brain region to fully mature. The earlier cannabis use begins, the more profound the impact. This fact is especially well illustrated by the often misinterpreted Dunedin Study.7 A 25-year longitudinal study of 1037 citizens of Dunedin, New Zealand born in 1972/1973 analyzed the long-term cognitive impacts of cannabis. Neurocognitive testing at age 13 established each individual’s baseline frontal lobe functioning, including overall IQ. The level of cannabis use was evaluated at ages 18, 21, 26, 32 and 38, when neurocognitive testing was 32

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repeated. Careful reading of the article reporting this study reveals the following points about reductions in IQ caused by, or associated with, cannabis use: • The more persistently adolescent onset users continue using cannabis during adulthood, the greater is their reduction in IQ at 38.

• Those who began cannabis use earliest and continued throughout adulthood lost an average of 8 IQ points, which is sufficient to alter academic success and job opportunities. •

Stopping cannabis use did not fully restore neuropsychological functioning among adolescent onset former persistent cannabis users. Impairment was still evident for one year or more after cessation of use.

• The only individuals at age 38 who showed a reduction in IQ were those who were using marijuana at least once a week during adolescence. Heavy use during adulthood only did not reduce IQ. Tests measuring IQ are comprised of an aggregate of several subtests. Analysis of the Dunedin data reveals that impairments in early onset persistent users are detected across five areas: Executive Functioning, Processing Speed, Memory, Perceptual Reasoning, and Verbal Comprehension, with the most robust findings being decreased processing speed and impaired executive functions, confirming previous reports.8,9 More specifically, digit symbol testing reveals reduced processing speed, Wisconsin Card Sort reveals increased perseveration and reduced mental flexibility, and Stroop testing reveals increased impulsivity and difficulty ignoring distractions. Participants in the study also identified informants who “knew them well.” These informants reported significantly more everyday life problems with attention and memory among individuals with the most persistent cannabis dependence. This confirms that cognitive deficits caused by cannabis are of more than academic interest. Presenting this data is not intended to demonize cannabis, but rather to establish the inconvenient truth that frequent use is riskier for adolescents than for adults. The Dunedin study also documented that individuals with early onset cannabis use are more likely to be persistent users during adulthood. This finding is consistent with data showing that Cannabis Use Disorder (CUD) occurs more frequently and more quickly in early onset users.10 For example, an 11-year-old who starts using cannabis has over a 17% chance of being addicted by age 13. Starting at 12 has over a 16% chance of addiction by age 14. Starting at 16 runs almost a 13% risk of addiction by 18. Waiting until 18 to WWW.SFMMS.ORG

start cannabis lowers the risk of addiction by age 20 to about 7%. And waiting until 20 brings the risk of developing addiction within two years down to 3% at age 22. The data clearly establish that early onset of marijuana use increases the rate and speed of addiction. A complexity needs to be introduced at this point. For decades the mantra within addiction medicine has been that addiction is a lifelong progressive disease. Physicians have watched millions of lives end in death or insanity from alcohol and other drugs. Abstinence from all mind-altering drugs and a program of recovery are generally considered the only safe escape from this inevitable downward spiral. However, detailed analysis of Dunedin data shows this dire view does not fit the facts when it comes to cannabis dependence. This work also illustrates the potential for misusing statistics to support one’s ideology. In the Dunedin study, 28% of those who started using cannabis at age 13 had met the criteria for addiction by 18. By 21 years old 34% had been addicted; and a full 43% had met the criteria for CUD by age 30. This would be astoundingly bad news except for one fact – at 30 years old only 15% of those who started using marijuana at age 13 were still addicted during the previous year.11 Lifetime rates of dependence can obscure current rates. Clearly, a 15% addiction rate at age 30 for those who started using at 13 is not good. It is highly likely that the course of life for these 15% has been significantly impacted, and equally likely that those who no longer meet criteria for CUD nonetheless suffer lingering consequences of reduced academic performance when addicted at earlier school age.12 But, data show that 2/3 of those who developed addiction at some point after starting cannabis use at 13 were no longer addicted at 30. They had stopped or reduced their marijuana use to levels below the criteria for CUD. Similarly, 25% of those who started cannabis at age 15 met criteria for addiction at some point by age 30, but only 9% still used marijuana addictively during the year prior to age 30. The conclusion must be that cannabis addiction is not inevitably a lifelong disorder. In fact, 82% of those who have used cannabis at least 10 times stop use by age 34, the majority merely losing interest in the drug.13 Cognitive development is not the only task of adolescence. Even when early CUD spontaneously remits soon enough to safeguard persistent frontal lobe damage, disruptions in psychological development can continue. Interlocking developmental tasks such as the establishment of a stable sense of identity and values, peer group affiliation, autonomy and separation, and transcendence and meaning are all issues needing preliminary resolution in order to launch into adulthood. Completing each of these tasks can be delayed or distorted by youthful devotion to cannabis use. Adolescents regularly using cannabis can begin identifying outside traditional adult community norms. While this may contribute to creativity and useful rebellion against unwarranted parental expectations, it may also lead to valuing resistance over accomplishment and opposition to parental values rather than discernment of one’s own. The decision to use cannabis can lead to immediate inclusion in a peer group that demands no more of its members than persistent use. Basing a sense of autonomy on smoking pot does not demand the depth of matuWWW.SFMMS.ORG

rity required to establish a sense of identity that emerges from a deeper awareness of one’s own needs, values and aspirations. And finding meaning in the passive transcendence from routine consciousness offered by cannabis may be interesting in the moment, but ultimately does not usually lead to an accumulation of experience that leads to real world goals. While some overly restrained youth may find cannabis encourages more openness to novel experience and freedom of spirit, this is a lesson that needs to guide one’s life rather than simply be repeated endlessly. In the end, persistent cannabis use is more likely to delay and distort adolescent psychological development than to aid it. Comprehending this fact and using this understanding is made more difficult when frontal lobes are functioning at less than an optimal level.

Timmen Cermak MD is an addiction psychiatrist in Marin, a past-president of the California Society of Addiction Medicine, and author of the new book “From Bud to Brain: A Psychiatrist’s View of Marijuana” (Cambridge University Press).

References 1. Summary of Chapter One, T. Cermak, From Bud to Brain: A Psychitrist’s View of Marijuana, Cambridge University Press, 2020. 2. J. Romero, et al. Time-Course of the Cannabinoid Receptor DownRegulation in the Adult Rat Brain Caused By Repeated Exposure To Delta9-Tetrahydrocannabinol. Synapse, 1998; 30(3): 298–308. 3. J. Hirvonen, et al. Reversible and Regionally Selective Downregulation of Brain Cannabinoid CB1 Receptors in Chronic Daily Cannabis Smokers. Molecular Psychiatry, 2012; 17: 642–9. 4. T. Rubino, et al. Changes in Hippocampal Morphology and Neuroplasticity Induced by Adolescent THC Treatment are Associated With Cognitive Impairment in Adulthood. Hippocampus, 2009; 19(8): 763–72. 5. D. Arnone, et al. Corpus Callosum Damage in Heavy Marijuana Use: Preliminary Evidence from Diffusion Tensor Tractography and TractBased Spatial Statistics. Neuroimage, 2008; 41(3): 1067–74. 6. S. A. Gruber, et al. Why So Impulsive? White Matter Alterations Are Associated With Impulsivity in Chronic Marijuana Smokers. Exp Clin Psychopharmacol, 2011; 19(3): 231–42. 7. M. H. Meier, et al. Persistent Cannabis Users Show Neuropsychological Decline from Childhood to Midlife. Proc Natl Acad Sci USA, 2012; 109(40): E2657–64. 8. M. A. Fontes, et al. Cannabis Use Before Age 15 And Subsequent Executive Functioning. Br J Psychiatry, 2011; 198(6): 442–7. 9. S. A. Gruber, et al. Age of Onset of Marijuana Use and Executive Function. Psychol Addict Behav, 2012; 26(3): 496–506. 10. K. C. Winters and C. Y. Lee. Likelihood of Developing an Alcohol and Cannabis Use Disorder During Youth: Association with Recent Use and Age. Drug and Alcohol Dependence, 2008; 92(1–3): 239–47. 11. Personal communication with John Horwood, University of Otago, re: Christchurch Health and Development Study Data, October 18, 2018. 12. D. M. Fergusson, et al. Cannabis and Educational Achievement. Addiction, 2003; 98(12): 1681–92. 13. K. Chen and D. B. Kandel. The Natural History of Drug Use from Adolescence to the Mid-Thirties in a General Population Sample. Am J Public Health, 1995; 85(1): 41–7.

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SAN FRANCISCO MARIN MEDICINE

Responses to COVID

EXTENDING CALIFORNIA’S BAN ON FLAVORED TOBACCO PRODUCTS ACROSS AMERICA John Maa, MD and Jeffrey Wigand, PhD To increase their profits over the decades, the tobacco industry has specifically targeted two vulnerable populations – Black Americans and our youth - with a variety of flavored tobacco products. Slick marketing campaigns first appeared in Black media and magazines in the 1960’s designed to hook a new generation of young Black Americans on menthol cigarettes. In the 1950s, fewer than 10% of Black Americans who were smokers used menthol cigarettes, but today over 80% of Black Americans who smoke use menthol cigarettes. An estimated 45,000 Black men and women now die as a result of nicotine addiction every year, and menthol cigarette use also carries a heavy toll in the Hispanic and Asian American communities. Unfortunately, this formula for marketing success was repeated years later when the electronic cigarette industry promoted flavored vaping liquids in colorful packaging mimicking candy to target youth, in addition to menthol e-cigarette flavors. The CDC reported that one-third of American high school students used e-cigarettes in 2019. In 2009, the Obama Administration banned the sales of all flavored cigarettes, but exempted menthol. In 2011, the US Food and Drug Administration (FDA) concluded that “removal of menthol cigarettes from the marketplace would benefit public health in the United States.” But the implementation of that FDA recommendation was delayed for years after a lawsuit filed by the tobacco industry, while other nations worldwide including Brazil, Canada, Ethiopia, Turkey, Moldova, the European Union and the United Kingdom all passed national menthol bans. To address this dual public health threat of menthol and flavored vaping liquids, in June of 2017 Mayor Ed Lee signed landmark legislation introduced by then SF Supervisor Malia Cohen to ban the sale of all flavored tobacco products across San Francisco. This proved to be his final public health legacy before his untimely passing later in December 2017. An attempt by RJ Reynolds to overturn Mayor Lee’s legislation was overwhelmingly defeated by San Francisco voters by a 68 to 32 margin in June of 2018, and a repeat attempt by Juul in 2019 to overturn the legislation was defeated once again by SF voters by a 82 34

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to 18 margin. A national movement was catalyzed forward by Supervisor Cohen’s 2017 legislation – much of Marin County in California soon passed legislation identical to SF’s, followed by cities across America including Sacramento in December of 2019, and the entire state of Massachusetts in November of 2019. On August 28th, 2020 the State of California joined Massachusetts when Governor Gavin Newsom signed into law SB 793 by State Senator Jerry Hill, which outlaws the retail sale of most flavored tobacco products in California, after the bill arrived on the Governor’s desk just hours before. Governor Newsom also commented “I have been very expressive in terms of my absolute condemnation of this tobacco industry that continues to find ways to target our youth.” Protecting our youth and the vulnerable from products that result in nicotine addiction and increase smoking rates has been long-standing public health policy. Decades of research have shown that smoking remains a leading cause of preventable death in the United States, claiming nearly 500,000 lives annually. The Covid-19 pandemic has only made the need for strong public health action in tobacco control even more urgent, to offset the healthcare burden to our States already strained by the Covid pandemic. Smoking and vaping have now both been linked in scientific studies to transmission of the virus and worse outcomes from Covid-19, and it is essential for policymakers to implement every effort to curb the spread of Covid-19 and reduce the addictiveness of tobacco products. The Covid pandemic has been a difficult time for Juul. The Federal Trade Commission filed litigation in April of 2020 to end the Juul-Altria partnership as a violation of the Sherman Act, and class action lawsuits went further to allege the Altria-Juul deal was a conspiracy to create an illegal monopoly. Later in April, Juul laid off one-third of their workforce, and announced they were leaving SF and moving to Washington DC. Juul also exited five European markets including France and Spain (Austria, Belgium and Portugal), as well as South Korea. In July of 2020, Juul filed an FDA premarket application to market both Virginia tobacco and menthol flavored electronic cigarettes, amidst calls WWW.SFMMS.ORG

to the FDA from Congressional lawmakers to temporarily clear e-cigarettes from the market during the Covid pandemic. We must do all we can to stop the alarming trend of e-cigarette and flavored tobacco use across America. Given the severity of the Covid pandemic, it is also time to do everything appropriate to curb the spread of the virus. The UK has reported record numbers of adult smokers trying to quit after recognizing the risks posed with Covid-19 and active smoking. In August of 2020, regions of Spain effectively banned smoking in public places over concerns it increases Covid-19 transmission. As we anticipate a second wave of Covid-19 to arrive shortly in the Fall of 2020, strong proactive public health action is necessary to avoid overwhelming our healthcare delivery system this Winter. In July of 2020, the FDA ordered 10 e-cigarette manufacturers to immediately halt sales, after accusing three of illegally marketing their e-cigarettes. Further action now by the White House to follow the lead of California and implement a national menthol and flavored tobacco products ban could help reduce nicotine addiction and the spread of Covid-19. Another strategy would be to restrict the FDA premarket application from Juul to exclude the sale of menthol flavored Juul pods, given the long history of the tobacco industry targeting Black Americans with menthol

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flavors. Around the time of the Spanish Flu in 1918 came important major social changes like womanâ&#x20AC;&#x2122;s suffrage, and perhaps Covid-19 will accelerate stronger public health action towards the Tobacco Endgame, and a future nation free of tobacco and nicotine addiction. John Maa, MD is a general surgeon in San Francisco a former president of the San Francisco-Marin Medical Society, and chair of the California Advocacy Committee for the American Heart Association.

Jeffrey Wigand, PhD is a medical biochemist and former vice president of research and development and environmental affairs at Brown & Williamson Tobacco Corporation who worked on the development of reducedharm cigarettes and in 1996 blew the whistle on tobacco tampering at the company. A version of this piece first appeaerd on The Hill.com.

SEPTEMBER/OCTOBER 2020

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COMMUNITY MEDICAL NEWS Kaiser Permanente

Chinese Hospital

Maria Ansari, MD

Sam Kao, MD

One of the most challenging topics being discussed this fall is how to send children and teachers back to school while protecting them and their families from COVID-19. Schools are essential for children’s development and well-being, going far beyond academics to provide fundamental social and emotional skills, reliable nutrition, mental health support, and opportunities for physical activity. We must also acknowledge that distance learning further propagates the effective social inequities of COVID-19. Data from last spring show that Hispanic and Black children and children of low-income households had significantly lower participation in distance learning. As we support plans to reopen our schools, we must stay cognizant of the incidence of COVID-19 in the community and the degree of community spread; as long as there is widespread community transmission, we risk opening schools only to have to close them again when cases are identified. The countries that have successfully reopened schools have a handle on their COVID-19 incidence, with low rates of community transmission and a robust public infrastructure for testing, contact tracing, and diagnosis. We can follow their guidance in instituting preventative measures including smaller classes, social distancing, staggered recess and lunch times, frequent handwashing and disinfection, and mandated mask wearing. We can recognize teachers and school staff as essential workers and support our state and governor to provide safe plans to reopen, considering local COVID-19 incidence, planning appropriate PPE and social distancing, monitoring for illness symptoms, and promoting mitigation plans when cases arise. We remain optimistic and flexible as we survey the scene of education for our youth. We ultimately look forward to herd immunity created by time and vaccination. We pull from the strength of generations prior who fought against highly transmissible viruses without our present-day level of medical technology to manage, treat, and prevent illness. In the meantime, we applaud and promote the cooperation and adaptability of our medical teams and state government to plan and manage health and safety through this historic pandemic.

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The summer and fall of Covid-19 continues. Our thoughts go to all in our community who have been managing the increased Covid patient admissions. We are all so fortunate that the numbers have stayed down at a manageable level. Chinese Hospital has been happy to help offload some of the non-Covid volume from SF General, to allow them to expand their care of affected patients. At our Hospital, we continue to enjoy a surprising low Covid low census. The Chinatown community is to be commended for their phenomenal adherence to San Francisco’s public health guidelines, and the effectiveness of the Chinese language public service programs. An anonymous survey of facemask compliance found 100% compliance in our area! The Chinese Community Summer Program for medical students, mentioned in our previous column, went off without a hitch. Both medical students performed admirably and were well liked by all. Many thanks to everyone who contributed to this year’s flawless program, both on the inpatient and outpatient sides, giving the students a taste of multiple types of medical practices. Again, we need to thank Dr. Joseph Woo for his incredible energy in resurrecting this fine program, and see it through to the last day. As is always the case, there were adjustments to be made and one-on-one guidance throughout. We look forward to continuing this Program next year, and are definitely eager to see these two students back as practicing physicians in our community! Dr. Woo also served as moderator for the Anti-Hate Speech Rally held at Chinese Hospital June 30, sponsored by the Chinese Community Task Force on COVID-19. We thank all the speakers who helped voice the message condemning divisive rhetoric and emphasizing the promotion of cross-cultural common values to overcome the impact of the COVID-19 pandemic. We also appreciate the robust support by Assemblyman David Chiu and Supervisors Norman Yee and Aaron Peskin. Lastly, we need to thank all of you who are speaking out daily against misinformation, educating your patients about the importance of a scientific approach to combating this virus, and emphasizing the dangers of racism and other rhetoric on our public health. Thank you!

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New Nurse Practitioner Independent Practice Law Coming In California The Governor Has Signed AB 890. Here's What You Need to Know

From the CMA

Background AB 890 authorizes two newly created types of nurse practitioners (NPs) who would be allowed to perform certain functions without standardized procedures. The law specifies the education, training, testing, regulatory and governance requirements for these new NPs, including the circumstances in which an NP must consult with or refer patients to a physician. Key provisions of AB 890 are ambiguous, and will require clarification and guidance from regulators. Though the law will be enacted in the fall of 2020, full implementation and training of these new categories of nurse practitioners will not happen until the required regulations and guidance are approved by state regulators. Implementation of the law now moves to the Board of Registered Nursing, which will be responsible for establishing guidelines for these new categories of nurse practitioners. The Medical Board of California may also have a role to play in the bill’s implementation. The California Medical Association (CMA) will be closely involved in the implementation of AB 890, monitoring and advocating during the regulatory process at the Board of Registered Nursing and at the Medical Board of California, as necessary.

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AB 890 Does Not End Physician Supervision The bill does not prohibit the supervision of NPs – including the two new categories created under AB 890 – or otherwise seek to regulate or modify the operative law regarding the governance of nurse practitioners who do not receive additional training. Current arrangements regarding the practice and supervision of NPs are not regulated or changed by AB 890.

AB 890 Requires Consultation and/or Referral 890 requires “Section 103' NPs to refer cases beyond their training and education to a physician. It also requires “Section 104” NPs, who are practicing in facilities that may not have a physician on site, to consult with and refer patients to a physician in specified circumstances.

AB 890 Explicitly Protects the “Corporate Bar” AB 890 specifies that the corporate bar applies to Section 103 and Section 104 NPs. That means entities including hospitals may not hire, employ or otherwise control the Section 103 and Section 104 NPs unless one of the existing exceptions to the corporate bar applies.

Additional Guidance Is Needed from State Regulators AB 890 does not prohibit physician supervision of nurse practitioners, and implies a continuing role for physicians in the care of patients who are treated by Section 103 or 104 nurse practitioners. Additional guidance from the Board of Registered Nursing and the California Medical Board is necessary to determine what degree of physician involvement is required. Guidance from the Medical Board of California as to how it views the role of physicians under the AB 890 NP structure is necessary to better understand physicians' liability risks created by AB 890. CMA and SFMMS Will Continue to Advocate for the Right of All All Patients to Be Treated by a Physician We have a lot of work to do to ensure AB 890 is implemented in a way that protects patients. The law is clear that AB 890 does not prohibit physician supervision or modify existing arrangements with medical systems or physicians and nurse practitioners, and applies the prohibition on the corporate practice of medicine to these new categories of nurse practitioner. We will continue to advocate for the highest quality health care for all Californians and ensure that medical decisions are made by highly trained medical professionals.

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

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San Dimas, CA Permit No. 410

San Francisco Marin Medicine, Vol. 93, No. 4, August/September/October

Articles inside

Extending California's Ban on Flavored Tobacco Products Across America

The Science Underlying Adolescents' Increased Risk from Cannabis

Hard Lessons: Palliative Care in the COVID Era

COVID Contact Tracing

OF INTEREST

Accountability and Phase II Response to the COVID-19 Pandemic

Election 2020: SFMMS Slate of Candidates

SFMMS Fall Wellness Corner

COVID Chronicles, or, a Suggested Presidential Speech

Executive Memo: The Door to Reform is Wide Open

President's Message: Disinfecting the White House?

Membership Matters