January/February 2018

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

GENERAL AND TRAUMA SURGERY

Celebrating the Profession in San Francisco and Marin

VOL.91 NO.1 January / February 2018

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE January / February 2018 Volume 91 Number 1

General and Trauma Surgery Celebrating the Profession in San Francisco and Marin FEATURE ARTICLES

MONTHLY COLUMNS

9 A Proud Tradition in Surgery: The UCSF Naffziger Surgical Society

Wen T. Shen, MD, MA

10 Trauma Prevention and Care: The ACS Level 3 Trauma Surgery Program at Marin General Hospital

Ed Alfrey, MD; Meaghan Carroll, MSN, RN, CEN, CNL, TCRN 12 UCSF General Surgery: A Mission of Excellence in Care, Education, and Research

Hobart W. Harris, MD 14 Gender-Affirming Surgery: Meeting the Needs of a Diverse Population Ryan Guinness, MD; Erica Metz, MD; Ali Salim, MD; and Winnie Tong, MD

16 Operation Access: Partners in Donating Surgery for the Bay Area’s Uninsured

Kevin R. Hiler, MD, and Amanda Kohlbrenner, MD

17 Whole Person Care: An Innovative Initiative Boosts Marin Public Health Matt Willis, MD, MPH 19 From Classroom to Voting Floor: The Role for Medical

Students in Health Policy Sarah Rosenberg-Wohl, MPH

20 Medicine and Leadership: Q&A with David Klein, MD, MBA Man-Kit Leung, MD, and John Maa, MD

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Membership Matters

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President’s Message John Maa, MD

26 Medical Community News 27 Classified Ads 27 Upcoming Events

OF INTEREST 6

Introducing John Maa, MD

21 Welcome New Members 23 Health Policy Update: Zika Karen Smith, MD, MPH

24 In Memoriam: Rolland C. Lowe, MD Randall Low, MD 25 Touching Hands Project Edward Diao, MD

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

A NOTE FROM SFMMS PRESIDENT JOHN MAA, MD On behalf of Gala Committee Chair Robert Margolin, I would like to invite you to attend the SFMMS 150th Anniversary Gala on March 15 at the St. Francis Yacht Club. We will celebrate the entire history of SFMMS as one of the oldest component medical societies in California. The Gala theme will be "Celebrating 150 years of Advocating for Physicians and Patients" and will feature former SF Department of Public Health Officers Mitch Katz and Sandra Hernandez as speakers. Please RSVP early, as I anticipate that the event will be sold out, and also let us know if you would like to be a featured sponsor of the evening.

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMMS Members Anthem Still Not Complying with AB 72 Interim Payment Rules, Physicians Report

Don’t Miss the SFMMS 150th Anniversary Celebration & Gala!

In 2018, the San Francisco Marin Medical Society (SFMMS) is celebrating its 150th anniversary, and we are planning an extraordinary Anniversary Celebration & Gala to recognize this important milestone in our organization’s history. Come together with many of the Bay Area’s most influential stakeholders in the medical community and network with colleagues, SFMMS leaders, and local dignitaries. We hope you will join us for an evening of festivities as we celebrate our rich history, our members, and their contributions to the local medical community. Visit www.sfmms.org/Events.aspx for more information or to purchase tickets.

The CMA has continued to receive reports from physician offices that Anthem Blue Cross is not paying the "interim payment" as required under California’s new law (AB 72) limiting out-ofnetwork billing for covered, non-emergent services performed at in-network facilities. CMA has also received reports that Anthem representatives have advised some physicians that its Covered California EPO products are not subject to AB 72, which is incorrect. If your practice has received incorrect payments or denied claims from Anthem, or any other payor, related to the new law, CMA wants to hear from you. Practices can contact CMA at (888) 401-5911 or economicservices@cmanet.org. For more information, visit www.cmanet.org/ab-72.

DMHC Fines Anthem $5 Million for Failing to Address Consumer Grievances

The California Department of Managed Health Care (DMHC) recently took enforcement action—including a $5 million fine— against Anthem Blue Cross for a systemic failure to resolve consumer grievances in a timely manner. This enforcement action is the result of deficiencies identified in medical surveys conducted

by DMHC, as well as 245 specific grievance system violations identified by the DMHC Help Center during the investigation of consumer complaints from 2013 through 2016. Frustrations expressed by consumers echo the experiences of physicians who have submitted appeals. Like the grievance process available to patients, physicians can submit written appeals to the plans when services are denied. Plans are required to have fast, fair, and cost-effective dispute resolution processes to resolve physician disputes. Many physicians, however, report that when they submit appeals to Anthem, the dispute process is simply a rubber stamp to uphold the initial denials, without effective resolution, resulting in unresolved complaints that delay needed care.

Are Your Prescriptions Pads Compliant with the Law?

Members Mingle at SFMMS Mixers SFMMS teamed up again with Arc Galleries and the IBC Artist Studios in Sausalito for a mixer and art gallery tour. Three local artists and representatives from a Marin gallery spoke with attendees about their approaches to creating and collecting art.

SFMMS was also pleased to co-host a holiday mixer with the Northern California chapter of the Medical Group Management Association (MGMA) at the South Beach Yacht Club in San Francisco. It was a great opportunity for physicians and practice management staff to network and share in holiday festivities.

We hope to see you at our next event!

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California law requires 14 elements that must appear on California security prescription forms, including "check boxes that shall be printed on the form so that the prescriber may indicate the number of refills ordered." Security forms that lack the check boxes, even if they indicate refills in a different way, are deemed noncompliant. This requirement took effect in 2007. The California Board of Pharmacy recently reminded licensees that it will cite and fine pharmacists and pharmacies that dispense controlled drugs with noncompliant forms.

For more information on the California security prescription form requirements and exceptions, see CMA On-Call document #3201, "Controlled Substances: Prescribing." CMA On-Call documents are available free to members in CMA’s online health law library at www.cmanet.org/cma-on-call. Nonmembers can purchase documents at $2 per page. CMA members also receive 15% off all orders of compliant California security prescription pads and electronic health record printer paper from RxSecurity.

SAN FRANCISCO MARIN MEDICINE JANUARY/FEBRUARY 2018 WWW.SFMMS.ORG

Time to Verify Your Patients’ Eligibility and Benefits For 2018 The beginning of a new year also means that both calendar year deductibles and visit frequency limitations reset. And, with open enrollment, patients may be covered by a new payor. The new year also brings a host of other challenges that could affect your ability to be paid: • On January 1, 2018, Health Net Federal Services (HNFS) will begin providing managed care services to 2.9 million TRICARE beneficiaries in the 21 western states, including California. HNFS will take over the contract previously held by UnitedHealthcare Military and Veterans Services.

• The Covered California open enrollment period began November 1 and runs through January 31, 2018. While Covered California will maintain its relationship with all 11 health plans that participated in the California exchange in 2017, Anthem Blue Cross is exiting the exchange market in all but three regions in 2018, citing market instability. This will impact more than 150,000 enrollees.

Do your homework before the patient arrives by obtaining updated insurance information and verifying eligibility at the time of scheduling, if possible, and by making copies of the insurance card at the time of the visit.

Online Worker’s Compensation Education Offered

The Division of Workers’ Compensation (DWC) recently launched a free online physician education course recommended for qualified medical evaluators (QME) participating in California’s workers’ compensation system. The online education will cover how to prepare for an evaluation and outline the components of a quality report, how to properly identify and apply the complexity factors in the medical-legal fee schedule to ensure accurate billing, and the administrative regulations for staying in compliance as a QME. Access to the physician education module can be found at www.dir.ca.gov/dwc/CaliforniaDWCCME.htm.

Change in Pain Assessment Requirement

Effective January 1, 2018, California hospitals and other health facilities will no longer be required to assess a patient’s pain when collecting other vital signs. This new policy (http://bit.ly/2BYbGOT) is in accordance with AB 1048.

A patient’s pain must still be assessed, but now facilities may create their own policies as to when pain assessment and management will take place, consistent with clinical practice.

Are You Reporting Communicable Diseases and Conditions as Required?

It has been brought to the attention of the Medical Board of California (MBC) that some physicians and surgeons are not reporting certain communicable diseases and conditions to authorities within specific time frames, as legally required. Failure to report or delayed reporting can result in the unnecessary spread of disease and preventable illness. It can also result in discipline for physicians. Information about which diseases and conditions are reportable, when to report, and how to report is available on the CDPH website at http:// bit.ly/2kVjpT7.

CMA Practice Management Tip: Did You Know That Anthem Blue Cross Plans to Slash Reimbursement on E/M with Modifier -25?

Anthem recently announced that effective January 1, 2018, it plans to cut reimbursement of evaluation and management (E/M) services billed with modifier -25. CMA has developed a Modifier -25 Financial Impact Worksheet that will help practices calculate the net financial impact to their practice resulting from this change. To download the worksheet and learn what CMA is doing to fight this unfair payment policy, visit www.cmanet.org/tips.

January/February 2018 Volume 91, Number 1

Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Spring Forth Studio EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Erica Goode, MD, MPH Michel Accad, MD Shieva Khayam-Bashi, MD Stephen Askin, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD Linda Hawes Clever, MD David Pating, MD SFMMS OFFICERS President John Maa, MD President-Elect Kimberly L. Newell Green, MD Secretary Benjamin Franc, MD, MS, MBA Treasurer Brian Grady, MD Immediate Past President Man-Kit Leung, MD SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Executive Assistant/Office Manager Maria Vega Membership Coordinator Mina Yoo SFMMS BOARD OF DIRECTORS Charles E. Binkley, MD Peter N. Bretan, Jr., MD Alice Hm Chen, MD Irina S.C. deFischer, MD Nida F. Degesys, MD Robert A. Harvey, MD Imran Junaid, MD Naveen N. Kumar, MD Michael K. Kwok, MD Raymond Liu, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo. MD Rayshad Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD Michael Scahill, MD, MBA Monique D. Schaulis, MD Michael C. Schrader , MD, PhD, FACP Dennis Song, MD Jeffrey L. Stevenson, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo , MD Albert Y. Yu, MD, MPH, MBA CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

(continued on page 27)

WWW.SFMMS.ORG

JANUARY/FEBRUARY 2018 SAN FRANCISCO MARIN MEDICINE

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Introducing John Maa, MD

The 2018 President of the San Francisco Marin Medical Society Why did you choose a career in medicine?

One of the key inspirations for my career in medicine was my mother. She valued the professional skills and dedication of physicians and stimulated my interest through high school and college through the extracurricular activities and other opportunities she created for me. I wrote a tribute to her in the New England Journal of Medicine in 2011 entitled “The Waits That Matter” (http://www.nejm.org/doi/full/10.1056/ NEJMp1101882#t=article).

How did you choose your medical specialty?

When I applied to medical school, I thought all doctors performed surgery, delivered babies, took care of children, and delivered primary care in clinic. This was because Marcus Welby, M.D. was a popular television show when I was growing up, and Dr. Welby did all of the above. So for me the question was which type of surgeon I would be. General surgery, with the breadth of procedures performed and many professional pathways, appealed the most to me.

Why are you a member of SFMMS?

I became an AMA member as a medical student at Harvard and was part of the Massachusetts Medical Society. As a general surgery resident at UCSF, I was a member of the CMA/ SFMS, and when I began practice at San Mateo Medical Center after finishing residency, I joined the San Mateo County Medical Association. In 2004 I attended the AMA Campaign School, and after returning to UCSF Medical Center in 2005 I rejoined SFMS. It was after completing a yearlong sabbatical in Washington, D.C., in 2010 that I fully recognized political advocacy as the driving force behind public policy. I then ran for the SFMS Board of Directors and have continued since as an SFMS/SFMMS member to advance the health of the public through physician advocacy on topics including sugary drink taxes, tobacco control, firearm safety, and health care reform.

How is being a part of organized medicine important for your patient care philosophy?

I believe that participating in physician advocacy and leadership is an important complement to delivering highquality patient care. One needs to be aware of the larger political, financial, and social forces in Washington, Sacramento, and City Hall that will impact the care you deliver. Conversely, real-world experience in caring for patients is essential to being an effective policy advocate and enlightening the conversation on Capitol Hill, in Legislatures, and at City Hall with what you witness firsthand clinically.

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Can you tell us about any goal(s) you hope to accomplish during your term as SFMMS President?

My primary objectives will be to strengthen the foundation built by the previous past presidents, and to continue SFMMS’ presence as a leading public health advocacy organization in San Francisco and Marin. The hallmarks will be to continue the wonderful increase in SFMMS membership to modern highs, expanding the outreach of San Francisco Marin Medicine magazine, and expanding the presence of SFMMS in the public health advocacy arena. Specific goals will be to uphold the menthol ban passed by SF City Hall in 2017, raise awareness of the health hazards of recreational marijuana use and sugary drinks, promote firearm safety, and assist in the health reform conversation nationally.

What are some of the biggest opportunities or challenges you see in health care within the next year, and within the next three to five years?

Federal health reform will return to the national conversation in early 2018, probably by February. It will open a window to move the health reforms that remain unfulfilled by the Affordable Care Act to be contemplated once again. The next step of the ACA had been to catalyze meaningful delivery system reform, but this was derailed by the midterm elections in 2010 and the Supreme Court challenge in 2012. Understanding the true costs of medical care and how medical prices are determined will help inform conversations about universal health care, single payor, and payment reform.

Any advice for new physicians transitioning into practice from residency?

To the graduating residents—congratulations and best wishes for an amazing career. The first year in practice is an incredible period of growth. There are so many wonderful possibilities from a career in medicine, and the next major step in your career is to establish yourself and identify the professional endeavor in which you will excel. I hope that you soon find that personal area of professional focus for which you will be recognized by the community. Along the way, I would recommend mastering leadership and political skills that will further advance your career.

If you weren’t a physician, what profession would you most like to try?

One of my favorite hobbies is sailing, and racing sailboats professionally in competitions worldwide has always been a dream.

SAN FRANCISCO MARIN MEDICINE JANUARY/FEBRUARY 2018 WWW.SFMMS.ORG

PRESIDENT’S MESSAGE John Maa, MD

A Legacy of Leadership The Past Paves the Way for a New Era for Medical Policy and SFMMS It is a distinct honor and privilege to follow in a line of distinguished SFMMS Presidents— most recently Drs. Shannon Udovic-Constant, Lawrence Cheung, Roger Eng, Dick Podolin, and Man-Kit Leung. The start of 2018 marks a period of growth and opportunity for the organization, with the election of Dr. Udovic-Constant as Vice-Chair of the CMA Board of Trustees and Dr. Peter Bretan’s candidacy to become the next CMA President.

I’d like to begin by thanking immediate Past Presidents Man-Kit Leung and Peter Bretan, along with Executive Director Mary Lou Licwinko, for navigating SFMS and MMS through a successful merger. SFMMS membership is at a modern high for the joint organization, with medical student and resident membership also at recent highs. This provides the core foundation to build upon by strengthening our financial position and our journal, San Francisco Marin Medicine, under the leadership of Gordon Fung.

This issue highlights the contributions of general and trauma surgeons, who play a key role in addressing the emergency care crisis. Over the upcoming year, I plan to focus efforts to support the training and education of medical students and residents and reduce their loan indebtedness. Trainee educational debt is an important and rarely discussed reason why comparing the U.S. health care system to the single-payor systems of other nations is of limited benefit. In those countries, medical education is either free or inexpensive due to significant government support, which makes it easier for students in those nations to pursue careers in primary and emergency care.

In each of the President’s Messages this year, I will provide an update about advocacy and legislation and offer insights to better understand the public policy and advocacy processes. To highlight some advocacy issues that will be prioritized in 2018: Locally, SFMMS advocacy will focus on defending the ban on the sales of menthol and flavored tobacco products that was introduced by Supervisor Malia Cohen, passed unanimously by the San Francisco Board of Supervisors, and signed into law by the late Mayor Lee. The lifesaving measure is being challenged

by Big Tobacco through a referendum on the June 2018 SF ballot.

SFMMS was a key early endorser of the legislation and, to preserve Mayor Lee’s intent, will work to defend against the repeal being funded primarily by RJReynolds. We will also continue efforts to encourage the utilization of safe injection sites in SF and decrease the number of discarded syringes in the streets.

In Sacramento, two key legislative priorities will be (1) the ongoing efforts to expand optometric scope of practice, which must be balanced with patient safety and appropriate supervision, and (2) the single payor legislation SB 562 that was a focus at the HOD. We will also carefully evaluate the public health impacts of the extended alcohol service hours bill introduced

by Senator Scott Wiener. We welcome your comments on these topics in particular.

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At the federal level, Senator Feinstein has introduced legislation to promote firearm safety, and the CMA issued a recent report chaired by Dr. Udovic-Constant to reduce the epidemic of firearm violence in our state. The debate over health care reform should likely reignite in 2018. It is my hope that SFMMS can be a leader to enlighten the health care reform debate both in Sacramento and on Capitol Hill. I believe that SFMMS can be the convener of a national conversation about health reform and be recognized as a leading resource and advocate for patients and physicians. As I survey the membership of SFMMS, the expertise and intelligence of the accomplished cadre of clinicians and health care leaders, across all specialties, is readily apparent.

As I reflect over the past two decades, it has been a very challenging era for the practice of medicine. Many changes have been catalyzed during this rebuilding phase, and I believe the time has now arrived for a renaissance in medicine, to optimize the quality and safety of patient care nationally and implement constructive change. The overarching vision now is of opportunities through new collaborations, such as the UCSF-Marin General Hospital partnership; the new relationships with Marin Health and Human Services and the SF Department of Public Health; and the rebuild of CPMC, Kaiser San Rafael, and ZSFGH. Finally, thank you for the wonderful opportunity to serve as SFMMS President, and thank you to everyone on the front line of clinical care. We should be very proud of what is done collaboratively by our membership across Marin and San Francisco to meet the needs of the citizens of both counties.

Most important, SFMMS is your professional society—please let the leadership know what you believe should be a priority for the organization. Best wishes to all for a spectacular 2018.

Let’s work together to bring the organization to new heights!

Dr. Maa attended U.C. Berkeley and then graduated from Harvard Medical School in 1994. He served as a captain in the U.S. Army for eight years, and completed his general surgery residency at UCSF in 2002. He is currently chief of the Division of General and Acute Care Surgery at Marin General Hospital and is on the medical staff of Dignity Health - St. Francis. He can be reached at jmaa@sfmms.org.

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The San Francisco Marin Medical Society

1868 2018

Anniversary Celebration &

Advancing the Art & Science of Medicine:

Celebrating

150 Years of Advocating for Physicians and Patients

March 15, 2018 5:30–9:00 pm ST. FRANCIS YACHT CLUB 700 MARINA BOULEVARD, SAN FRANCISCO, CA 94123

In 2018, the San Francisco Marin Medical Society (SFMMS) is celebrating its 150th anniversary.

Please join us at the SFMMS 150th Anniversary Celebration & Gala as we recognize this important milestone in our organization’s history. Guests will be treated to a lively reception, followed by a formal seated dining experience, exciting presentation, and brief documentary highlighting the medical society’s achievements in its 150 years of leadership.

We hope you will join us for an evening of festivities as we celebrate our rich history, our members, and their contributions to the local medical community.

• Black tie optional. RSVP required. • TICKET PRICES

Early Bird .

. . . . . .

$125.00

(RSVP by 2/9/18)

Regular

. . . . . . . .

$150.00

(RSVP by 3/9/18)

For more information, or to purchase tickets, go to www.sfmms.org/Events/150thAnniversaryGala or contact SFMMS at (415) 561-0850 x200

General and Trauma Surgery

A PROUD TRADITION IN SURGERY The UCSF Naffziger Surgical Society Wen T. Shen, MD, MA Howard C. Naffizger was the first chair of the Department of Surgery at the University of California, San Francisco. In his first year as Chair of Surgery, 1929, he

also served as President of the SFMS. Born and raised in the Sierra foothills, Naffziger was educated at U.C. Berkeley and UCSF and received his surgical training at Johns Hopkins. At Hopkins, he was a favorite resident of Harvey Cushing, one of the founding figures in the nascent field of neurosurgery. Naffziger returned to UCSF in 1912 and quickly became the leading neurosurgeon on the West Coast. In 1929 he was selected to become the first chair of the UCSF Department of Surgery, and over the next two decades he built the program into one of the premier institutions for surgical training and research in the country. In 1947, the UCSF Department of Neurosurgery was established as a separate entity from the remainder of the Department of Surgery, and Naffziger became its first chair. Shortly thereafter, in 1949, the UCSF Department of Surgery formed an alumni organization called the Howard C. Naffziger Society, composed of graduates of its surgical residency training program. More recently, the organization was renamed the UCSF Naffziger Surgical Society.

Surgeons eligible for membership in the Naffziger Society include graduates of the UCSF surgical residency training program as well as those who have undergone fellowship training at UCSF. In addition, UCSF Department of Surgery faculty members can become associate members after three years on faculty. Each year, the UCSF graduating chief residents in general surgery are inducted into the Naffziger Society at an end-of-year dinner. With the induction of the 2018 graduating class, the Naffziger Society will have more than 400 members.

The Naffziger Society has met annually for the past several decades. Naffziger reunion events have served as an outstanding opportunity for former UCSF surgical trainees and faculty members to gather and reminisce, and also to meet and spend time with current UCSF surgery residents and faculty. While many UCSF Department of Surgery graduates have remained in the Bay Area, a large number have moved on to other medical centers across the country, and many have become national and international leaders in surgery. The roster of UCSF Department of Surgery alumni who have returned to address the Naffziger Society throughout the years have included Tom Russell (executive director of the American College of Surgeons, 2000–2010), Frank Lewis (executive director of the American Board of Surgery, 2002–2017), Richard Carmona (U.S. Surgeon General, 2002–2006), Carlos Pellegrini (chair, University of Washington Department of Surgery, 1993–2016), William Jarnagin (chief, Hepatobiliarypancreatic Surgery, Memorial Sloan-Kettering Cancer Center), and Gerard Doherty (chair, Brigham and Women’s Hospital Department of Surgery).

In addition to holding an annual reunion event, the Naffziger WWW.SFMMS.ORG

UCSF Naffziger Surgical Society Day, May 19, 2017 (Photo courtesy of Lawrence W. Way) The 2018 UCSF Naffziger Surgical Society Day will take place on Friday, May 11, 2018, at the UCSF/Mission Bay campus. There will be an all-day symposium followed by a reception and reunion dinner. Please go to naffzigersociety.com for further details and information.

Society also provides financial support for current UCSF Department of Surgery residents. This has included funding for mid-level residents in their research years, contributions toward purchase of operating loupes for rising second-year residents, and support for purchase of textbooks and subscriptions. This past year, Edward Chen (2000 UCSF Department of Surgery graduate, current professor of Surgery, Emory University) generously provided funding for special chairs for each of the seven graduating UCSF chief residents on behalf of the Naffziger Society.

On May 19, 2017, the UCSF Naffziger Surgical Society held a one-day symposium on the past, present, and future of surgical training and practice. This event was held at the Oberndorf Auditorium at the UCSF/Mission campus and brought together several generations of UCSF surgeons. Presentations included Technical and Mental Training for Surgeons, Critical Thinking and EvidenceBased Practice, Mentorship and Role Modeling, Surviving and Thriving after Residency, and Reflections on Retirement. An allstar roster of 14 former and current UCSF surgeons gave a series of wonderful talks and participated in panel discussions on these and other topics. Speakers included Karen Deveney (Oregon Health Sciences University), Diana Farmer (chair, University of California, Davis), Brent Eastman (93rd president, American College of Surgeons), William Schecter (Professor Emeritus, UCSF), and Lawrence Way (Professor Emeritus, UCSF).

Wen T. Shen, MD, MA, is associate professor of Clinical Surgery with the Division of General Surgery, University of California, San Francisco Department of Surgery.

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General and Trauma Surgery

TRAUMA PREVENTION AND CARE The ACS Level 3 Trauma Surgery Program at Marin General Hospital Ed Alfrey, MD; Meaghan Carroll, MSN, RN, CEN, CNL, TCRN The residents of Marin County are protected by a dedicated trauma system anchored by Marin General Hospital’s Level III American College of Surgeons trauma program, one of 46 Trauma Centers in California and the only Trauma Center in Marin County.

The partnership in trauma is affiliated with both the Kaiser San Rafael Emergency Department, and the partner in the northern part of the county, Novato Community Hospital. In collaboration with the county first responders that cover the nearly 261,000 inhabitants residing in the 520-square mile area, the EMS system cares for an average of several hundred trauma patients every year.

Of patients evaluated, 20.5% are under 18 years of age and 20.6% are over 65 years of age.

When patients arrive in the MGH Emergency Department, they are evaluated by a comprehensive team of health care providers based upon the acuity level of their injuries, including the Emergency Department physician, an anesthesiologist, and a trauma surgeon, along with Emergency Department nurses and medical assistants, radiology, laboratory, and the operating room staff.

All of the Emergency Department physicians are certified by the American Board of Emergency Physicians. In addition to being certified by the American Board of Surgery, the trauma surgeons have all completed the Advanced Trauma Life Support training program.

One quality reporting group has consistently rated the Marin General Trauma Program as the number-one program in the Bay Area, and number four in California based upon quality and outcomes.

Over the last few years, the Trauma Program at MGH has averaged more than 700 trauma patients each year, with 768 patients in calendar year 2016. The majority of these patients (95%), are more than 18 years of age. Although Marin General Hospital does not have a pediatric trauma unit, pediatric trauma patients are evaluated, and those needing hospital admission for continuing care are then transferred to either Children’s Hospital of Oakland or the Lucille Packard Children’s Hospital at Stanford. More than 50% of the patients treated by the Trauma Program at MGH are injured from falls, about one-quarter of the patients have been involved in motor vehicle crashes, and about 10% are from our active bicycle community. MGH is also the site where patients who have fallen from the Golden Gate Bridge are brought for resuscitation.

In addition to the active care system in place for the injured patients, the Trauma Program also proactively educates the residents of Marin County in areas of injury prevention. This is particularly important for our elderly patients, who comprise a significant proportion of our patients at risk for injury. Despite the progress in the development of trauma systems and the care of injured patients, injury remains the leading cause of lives lost and lost work productivity, and every year it leaves many citizens chronically dis10

abled. The greatest challenge for every trauma center is that injury is largely preventable. As shown in our database, falls are the most common reason for traumatic injury in Marin County. We chose “A Matter of Balance” as our falls prevention program. A Matter of Balance is an evidence-based falls and injury prevention program for older adults designed to reduce the fear of falling and increase activity levels among older adults, and it has been implemented in other trauma centers across the country. The program’s goals are to reduce fear of falling, stop the fear of falling cycle, and increase activity levels among community-dwelling older adults. The program includes eight two-hour sessions for small groups (8 to 12 participants) led by two trained facilitators.To assist with this undertaking, a falls prevention coordinator for A Matter of Balance was recruited to assist in teaching 24 courses and to enable participants to complete their first A Matter of Balance class.

A new program, “Stop the Bleed,” championed by the American College of Surgeons, has also been initiated at Marin General Hospital— one of the first trauma programs in the Bay Area to initiate the program locally. Stop the Bleed is a nationwide campaign from Homeland Security to empower individuals to act quickly and save lives. What has been learned from several of the recent tragic and horrific mass shooting tragedies is that many patients died from bleeding that could have been stopped before the arrival of first responders. There have also been lessons from the military theater that have demonstrated that as many as 7% of combat casualties are preventable by stopping extremity bleeding. Soldiers now routinely carry tourniquets on their equipment belts and are instructed on proper use. This single advance has decreased preventable deaths from 7% to 2% during the latest part of the Gulf War conflict. In civilian circumstances, no matter how rapid the arrival of professional emergency first responders, bystanders will always be first on the scene. A person who is bleeding can die from blood loss within five minutes; therefore it is important to quickly stop blood loss.

Meaghan Carroll, the MGH Trauma Program Manager, has taught more than 550 Marin County residents “Stop the Bleed” techniques, such as proper application of tourniquets and hemorrhage control.

On a national level, there have been initiatives to require all new automobiles to be equipped with tourniquets in the glove box. Some T-shirt manufactures have started including labels that show how the shirt can be used to save a life by stopping bleeding. Recently the MGH Trauma Committee comprised of trauma, orthopedic, emergency medicine, and neurosurgical physicians all completed a Stop the Bleed instructor course. Further plans to incorporate a routine Stop the Bleed course across Marin County are in progress.

Injury will always be a part of our lives, whether we live in Marin County or rural parts of Monterey County. The ability to prevent death and limit disability depends in large part upon the avail-

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ability of first responders and trauma systems, and also of our residents to assist in preventing injury and death. Identifying elderly at-risk persons is a responsibility that we all share. Educating every citizen on how to assist injured patients before the arrival of professional medical personnel, and how to access the emergency system, will always be at the forefront of a successful trauma system. At Marin General Hospital, we have developed an aggressive trauma program that encompasses all aspects of trauma care, including educating the public and constantly improving our hospital-based Trauma Program.

Ed Alfrey, MD, is chief of Trauma Surgery and chair of the Marin General Hospital Department of Surgery.

Meaghan Carroll MSN, RN, CEN, CNL, TCRN, is the Trauma Program Manager at Marin General Hospital.

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General and Trauma Surgery

UCSF GENERAL SURGERY A Mission of Excellence in Care, Education, and Research Hobart W. Harris, MD The Division of General Surgery at the University of California, San Francisco, has a long and proud tradition of excellence in clinical care, surgical education, and research. Building on a foundation of outstanding

achievement, we have entered the twenty-first century with 41 full-time academic and 64 clinical faculty members. Our academic enterprise extends over five principal teaching hospitals and two affiliated institutions, certifying the breadth and depth of our commitment to public service, dedication to training future leaders in surgery, and tireless pursuit of knowledge.

UCSF has a well-established and deserved reputation for preeminent patient care services, much of which is anchored in our division’s world-class programs in surgery of the liver, biliary system, pancreas, colon and rectum, thyroid and parathyroids, and breast, as well as programs in melanoma, obesity, and the management and prevention of acute traumatic injuries.

For well over a century, a parade of remarkable men and women have labored to enlighten, educate, and, perhaps most importantly, comfort where there was suffering. Our faculty continues to make seminal contributions to the treatment of surgical diseases, from pioneering minimally invasive surgical techniques to treat diseases of the esophagus to introducing revolutionary approaches to delivering comprehensive care to women with breast cancer. The tradition of innovative clinical care remains vibrant and central to our mission. Please join me as we briefly review several of our exciting clinical programs.

Carol Franc Buck Breast Care Center

The Breast Care Center continues on its path to innovation in the screening, treatment, and prevention of breast cancer. For example, since not all breast cancers are the same, and some are considerably less dangerous than others, as more women are screened for breast cancer we have increased the chance of finding “ultra–low risk” tumors. Until very recently, we could not say for sure which tumors were ultra–low risk and which were not.

A recent publication from the Breast Care Center (JAMA Oncology, November 2017) describes how the use of a specific genetic test can accurately identify patients whose long-term outcome is expected to be excellent with minimal or even no systemic treatment. This novel test can help our breast care specialists safely predict which women with a new diagnosis of breast cancer will do well with less treatment than previously recommended. Another example of the Breast Care Center’s innovative approach is the WISDOM study (Women Informed to Screen Depending on Measures of Risk). This is a large, statewide effort involving most of the UCSF Breast Care Center team members, along with collaborators across California and elsewhere in the country.

The goal is to improve breast cancer screening by testing and 12

comparing the safety and efficacy of a personalized screening strategy, informed by each woman’s breast cancer risk. Women can elect to be randomly assigned or, if they have a strong preference, to choose which type of screening to get (annual versus personalized based on their personal risk). Importantly, every woman aged 40–74 who has not had breast cancer is eligible to participate! Help us find the best strategy for screening—join the WISDOM study (wisdomstudy.org).

Bariatric and Metabolic Surgery

Our program is unique among bariatric surgery programs in the Bay Area and nationwide. As a nationally accredited comprehensive program, we provide excellence in bariatric care in a multidisciplinary manner for a variety of patient populations, including those with general bariatric and metabolic surgery needs and uncomplicated obesity, those with associated medical problems from being overweight, and those with complicated medical problems such as severe liver or kidney disease. Furthermore, our highly skilled surgeons treat patients who need repeat or revisions of prior bariatric surgical procedures to correct problems stemming from their prior operation. Beyond providing excellent surgical care, we have an active research program with multiple innovative studies, including those with a focus on the effectiveness of bariatric surgery in transplant patients, bone health following obesity surgery, gut microbiome and fatty liver disease (NASH), and endoscopic treatment of weight regain following gastric bypass.

Surgical Oncology

February 2015 marked the official opening of the UCSF Mission Bay Hospital, where we have a concentrated effort focused on the surgical care of patients with cancer through our section of Surgical Oncology. Multidisciplinary programs that are dedicated to treating two rare cancers and that should be highlighted are the Soft Tissue Sarcoma and Neuroendocrine Tumor Programs. These rare cancers are best diagnosed and treated by a team of providers, including surgical and medical oncologists, dedicated pathologists, and diagnostic and interventional radiologists. All new patients are thoroughly evaluated by this team of specialists in order to optimize and individualize each patient’s care. By working very closely with other clinicians at all stages of care, we are best able to determine when to operate, the potential value of pre-, intra- and post-operative therapies, and how to identify candidates for experimental treatments.

Center for Global Surgical Studies

UCSF is “advancing health worldwide.” Nowhere is this effort more evident than through the activities of the Center for

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Global Surgical Studies (https://global.surgery.ucsf.edu). Did you know that if you get in an automobile accident in Cameroon, no ambulance is coming to get you? And, if you make it to a hospital, you may or may not get the lifesaving care you need.

This scenario is far too common: Worldwide, 90% of deaths due to injuries occur in developing countries. Despite this enormous public health problem, surgical care is rarely a priority in most resource-limited regions. Consequently, these inadequacies have devastating consequences: Globally, more people die from surgical diseases, including traumatic accidents, than from HIV, tuberculosis, and malaria combined. Thus, the UCSF Center for Global Surgical Studies collaborates with partners in sub-Saharan Africa on research and education projects to improve access and quality of surgical care. Every project features graduate students from the United States and developing country partners, thereby building future leaders in global surgery. In Cameroon, our Center is working with the Ministry of Public Health to research ways to prevent injuries and improve trauma care with minimal resources. In Uganda, we are working with local surgeons in regional hospitals to improve the availability of resources such as blood transfusions and to evaluate the cost-effectiveness of surgical care. Long-term goals include finding solutions that make sense for each health system and that increase access to surgical care in developing countries.

As academicians, no jewel in the UCSF School of Medicine crown shines more brightly than our students and residents.

These accomplished and immensely capable young people infuse the institution with a blend of enthusiasm and intellectual curiosity that is as electric as it is infectious. Our faculty relishes opportunities to share their excitement about surgery with eager and open-minded medical students. Similarly, we strive to train the next generation of leaders in surgery. General surgery residents at UCSF are selected for their demonstrated academic prowess, dedication to public service, and declared desire to make important and positive contributions to the future of the profession. While we fully acknowledge that the process of selecting future leaders is at best imperfect, we simultaneously celebrate our past and present achievements. Over the last 25 years, our ranks have produced 14 past or current department chairs, two past executive directors of the American College of Surgeons, the former chair of the American Board of Surgery, and a Surgeon General of the United States. We believe that our intellectually rigorous and clinically demanding academic setting yields a fertile environment for nurturing leadership skills and ambitions.

As a public, land grant institution, no aspect of our collective mission is greater than our quest for new knowledge. From our students and trainees to our colleagues to society at large, we all share the expectation that considerable efforts will be directed at creative academic pursuits. The seriousness with which we take this responsibility is reflected in the Division’s four full-time scientists, dozens of research fellows, ten independently funded research programs, and a research budget in excess of 3.5 million dollars per year. From local chalk talks to international presentations, from peer-review manuscripts to textbooks, our faculty is actively immersed in the discovery and dissemination of new information. For example, take the story of Dr. Tammy T. Chang, a general surgeon who has a PhD in immuWWW.SFMMS.ORG

nology. Dr. Chang initially thought that she wanted to become a transplant surgeon and do research on transplant immune rejection. However, she learned that the most pressing problem in treating organ failure is not that transplanted organs are being rejected but that there are not enough donor organs for all the people who need them. “There is a critical need for an alternative to transplantation,” Dr. Chang explains. To develop a different treatment, her research aims to understand the key factors that keep cells functioning properly, in order to recreate that environment and generate tissue-engineered organs. Her lab is working on understanding how cells lose function during fibrosis, a process of scarring in diseased organs. She is also using three-dimensional cell culture to produce “organoids” and to develop surgical strategies to introduce them into patients with liver failure. “I was at a meeting where people were discussing how to advance tissue engineering,” Dr. Chang recalled.

“One scientist asked, ‘Where are the surgeons? We need them to tell us how anything we come up with can be put into people.’

Then and there, I knew I was in the right field.”

We are exceptionally fortunate to live and work in Northern California, a vibrant region of the country known for its physical beauty, independent spirit, and cultural diversity. The Division of General Surgery at UCSF continues to reflect these qualities as we pursue our mission to be an innovative academic and global resource providing the highest standard of patient care, research, and education. Accordingly, we value compassion, professionalism, intellectual generosity, and the lifelong pursuit of knowledge and excellence.

Dr. Hobart W. Harris, J. Englebert Dunphy Endowed Chair in Surgery and chief of General Surgery at the University of California, San Francisco (UCSF), is a physician-scientist with interests in the human response to infection and acute injury, diseases of the liver and pancreas, and complex ventral hernias. After earning a combined MD/MPH at Harvard Medical School and Harvard School of Public Health, he completed his surgical training at UCSF. Since joining the faculty at UCSF in 1994, Dr. Harris has directed an NIH-funded research laboratory for more than 20 years; authored over 185 original articles, abstracts, and book chapters; served on numerous federal scientific review committees; and currently chairs the Research Advisory Board for the Shriners Hospitals and the FDA’s General and Plastic Surgery Devices Advisory Committee (CDRH). In addition, he maintains a busy clinical practice that focuses on the management of inflammatory and neoplastic diseases of the pancreas, diseases of the liver and biliary system, abdominal catastrophes (e.g., enterocutaneous fistulas, abdominal sepsis, open abdomens), and complex ventral hernias.

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General and Trauma Surgery

GENDER-AFFIRMING SURGERY Meeting the Needs of a Diverse Population Ryan Guinness, MD; Erica Metz, MD; Ali Salim, MD; and Winnie Tong, MD The term gender dysphoria describes the distress caused by a discrepancy between a person’s gender identity and the sex they were assigned at birth.1 While not all transgender individuals experience gen-

der dysphoria, those who do may seek transition to the gender with which they identify, and this may or may not include surgery. In recent years, there have been significant advances in the health management of transgender individuals.2 These developments encompass psychological, medical, and surgical approaches to help alleviate gender dysphoria. Moreover, social and political developments during this time have brought more attention to the health needs of this underserved and diverse patient population.

In an effort to provide the highest standards of care for transgender individuals, the World Professional Association for Transgender Health (WPATH) has developed guidelines that serve as a framework for health professionals caring for this patient population.3 These standards of care include criteria for not only hormone therapy but also for various gender-affirming surgical procedures. Such procedures allow an individual with gender dysphoria to finally experience harmony between their body and self-identity.

When it comes to gender-affirming surgeries, it is important to acknowledge that there is a broad range of gender identities among patients. Moreover, each surgical plan must be tailored to the individual patient, as not every patient necessarily wants or requires all procedures. In addition, individual procedures and timing may vary based on the patient’s comorbid medical conditions and previous surgical history.4

Feminization Procedures

Gender-affirming surgical techniques for patients on the transfeminine spectrum include facial feminization surgery, feminizing mammoplasty, and genital surgery.

Facial Feminization Surgery Surgical approaches to develop more feminine facial features include various bony and soft tissue procedures such as brow lifts, rhinoplasty, cheek implantation, chin and jaw contouring, and lip augmentation. Chondrolaryngoplasty (tracheal shave) may be requested to reduce the appearance of the prominent thyroid cartilage. Most of these procedures are done on an outpatient basis.

Feminizing Mammoplasty For some patients along the transfeminine spectrum, feminizing mammoplasty greatly increases subjective feelings of femininity and social comfort. While hormone therapy can lead 14

to some breast development, the response can vary among patients, and many transgender women and transfeminine spectrum patients are not satisfied with the result and seek feminizing mammoplasty. Augmentation can be achieved with saline or silicone implants as well as fat grafting as an adjunct to make the implant less visible and palpable, or to help narrow the wide cleavage between the breasts. This procedure is usually done on an outpatient basis.

Genital Surgery The most common genital surgery among transgender women and transfeminine spectrum patients is vaginoplasty with some variation of the penile inversion procedure. In this technique, a neovaginal cavity is created between the rectum and the urethra, and the vaginal lining is created from penile skin. An orchiectomy is also performed, with the labia created from scrotal skin and a neoclitoris created from a portion of the glans penis. The prostate is left in place to avoid complications such as incontinence and urethral strictures. Patients may need preparation before surgery, such as genital hair removal.

Length of hospital stay can be up to one week, and the procedure may require multiple stages to complete.

Masculinization Procedures

Gender-affirming surgical techniques for patients on the transmasculine spectrum include chest reconstruction, hysterectomy, salpingo-oophorectomy, metoidioplasty and phalloplasty procedures.

Chest Reconstruction Often referred to as “top surgery,” chest reconstruction consists of creating a flatter and more masculine-appearing chest. There are several techniques to achieve this, including subcutaneous mastectomy or reduction mammoplasty. Most patients will have repositioning of the nipple-areola complex. Occasionally liposuction can be done in an attempt to contour the chest or axillary rolls. The complexity of the surgery is increased with prior surgery to the chest or the degree of ptosis. The incision type will depend partly on chest volume, position of the nippleareola complex, and degree of skin laxity. This procedure is typically done on an outpatient basis.

Genital Surgery The goal of genital surgery for transgender men and transmasculine spectrum patients requires individualization. Surgery may range from a metoidioplasty to a phalloplasty. The former refers to lengthening of the hormonally hypertrophied clitoris, usually done in a single procedure. Phalloplasty involves the

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creation of a neophallus using a flap from a donor site, typically a free flap from the forearm or a pedicle flap from the thigh, and placement of an erectile device. Phalloplasty is typically staged in two to three surgeries, spaced several months apart, with length of hospitalization ranging from one day to one week. Metoidioplasty and phalloplasty can include vaginectomy (removal of the vaginal canal), scrotoplasty (creation of a scrotum from labia skin), and urethral lengthening (creation of a neourethra from skin or mucosal tissue through the phallus to achieve the ability to urinate while standing). Hysterectomy may also be completed at the same time and is necessary if vaginectomy is elected. Patients may retain ovaries or elect to have an oophorectomy. Typically, a team of plastic, gynecologic, and urologic surgeons will perform these procedures.

The Costs of Care

In tandem with the growing visibility of transgender people in the United States, there has been an increase in health insurance coverage for gender-affirming surgeries. However, the extent of coverage will vary widely based on the individual’s health insurance plan and the type of surgical procedure being covered.

California is one of only a handful of states that actually has antidiscrimination laws requiring health insurance companies to provide coverage for gender-affirming surgeries. Many other states have no protections whatsoever. Yet even in a state with these protections, there is room for improvement. Not all types of procedures may be covered, and many insurers are still making distinctions between what constitutes a “medically necessary” versus a “cosmetic” procedure.

A Model for Gender-Affirming Health Care

Providing these kinds of gender-affirming surgeries is no simple task. A truly integrated and comprehensive program consists of general medical care, hormone therapy, and behavioral health services in addition to subspecialized surgical services.

At Kaiser Permanente, the sustained commitment to developing the components of a comprehensive program in a collaborative, multidisciplinary, and culturally competent fashion is the hallmark of how the organization has come together to respond to serving this patient population.5 Both the Multi-Specialty Transitions Clinic (MST) in Oakland and the Gender Pathways Clinic in San Francisco represent Kaiser’s commitment to offer comprehensive transgender health services under the guidelines from WPATH, which outlines services recommended for transgender patients.

The transgender patient care settings at Kaiser Permanente take a common approach to ensure coordinated care, reflecting the organization’s integrated care model. For those patients considering gender-affirming surgery, their primary care physician will first send a referral to either the MST or Gender Pathways Clinic. Shortly thereafter, a nurse care manager will contact the patient to discuss their treatment plans and help coordinate the presurgical evaluation process. This includes (1) meeting with a mental health gender therapist; (2) taking the opportunity to attend a class to learn about the surgical options, the risks and benefits of each option, and how to prepare for surgery; and finally (3) having a consultation with a surgeon. A multidisciplinary team of nurses, medical social workers, mental health providers, and physicians staff the clinic. Such a model allows all WWW.SFMMS.ORG

providers to collaborate with one another throughout the patient’s gender transition, which allows for more efficiency and better outcomes.

Conclusion

Ongoing advances in psychological, medical, and surgical care have led to improved access to care for transgender patients. Gender-affirming surgery presents one facet of a multidisciplinary approach to help these patients receive the care they need. Moreover, each surgical plan must be tailored to the individual patient, as not every patient necessarily wants or requires all procedures. Collaboration between the surgeon, medical provider, and mental health professional in the framework provided by the WPATH guidelines is integral to providing quality care to this patient population. Furthermore, continued research and innovation within this field will foster improvement in surgical technique and overall outcomes.

Ryan Guinness, MD, is a third-year resident in the combined Internal & Preventive Medicine Residency Program at Kaiser San Francisco and University of California, San Francisco.

Erica Metz, MD, is the medical director of Gender Pathways at Kaiser San Francisco and is the regional medical director for Transgender Health at Kaiser Northern California.

Ali Salim, MD, is the chief of Plastic & Reconstructive Surgery at Kaiser San Francisco.

Winnie Tong, MD, is a plastic surgeon at Kaiser San Francisco, specializing in gender-affirming surgery, reconstructive surgery, and microsurgery.

Thank you to Dr. Sand Chang; Dr. James Constant; Carlos Hojila, RN, MSN; Terri Hupfer, RN, NP; Dr. Michelle Morrill; Dr. Susanne Watson; Dr. Erica Weiss; and Dr. Eve Zaritsky for their contributions to this article.

References: 1. Brown, G. A review of clinical approaches to gender dysphoria. Journal of Clinical Psychiatry. 1990; 51:57-64.

2. Berli J, Knudson G, Fraser L, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: A review. JAMA Surgery. 2017; 152(4):394-400.

3. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 2011. Available at http://www.wpath.org/site_page.cfm?pk_association_webpage_ menu=1351&pk_association_webpage=3926. Accessed November 26, 2017.

4. Colebunders B, Brondeel S, Salvatore D, et al. An update on the surgical treatment for transgender patients. Sexual Medicine Reviews. 2017; 5:103-109.

5. Seto B. Helping patients navigate through transitioning and total health. Permanente Medicine. Available at https:// permanente.org/coordinated-transgender-person-care-pathway/. Accessed November 26, 2017.

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OPERATION ACCESS Partners in Donating Surgery for the Bay Area’s Uninsured Kevin R. Hiler, MD, and Amanda Kohlbrenner, MD As physicians, we have all said at some point that we went into medicine to help people, and in many ways, as either employed physicians or private practitioners, we do so every day. However, often those

need help the most in our current health care climate are forgotten. With large corporations dominating the health care scene, it can be difficult to find ways to provide care for the uninsured and undocumented who genuinely need our support. As we find ourselves surrounded by bills and mountains of paperwork, struggling to meet overhead, maintain case volumes, or meet RVU requirements, the goal of truly making a difference for the uninsured population can feel unattainable.

Fortunately, there is Operation Access (OA). A San Francisco–based nonprofit founded in 1993 with the mission of connecting uninsured patients with specialty physicians who want to donate care, OA enables physicians like us to engage in medical volunteerism right in our own community. Their network spans all nine Bay Area counties, with more than 100 participating physicians in San Francisco and Marin alone.

Hospital partners in these two counties provide more than 500 donated outpatient surgical and specialty procedures per year. Through strong partnerships with hospitals and medical groups throughout the region, OA’s program bridges the health care gap while acting as a crucial resource for specialty care for uninsured patients.

Importantly, OA facilitates a seamless and straightforward volunteer experience. Local community clinics refer patients in need of specialty care to OA, and OA screens the patients for eligibility for their program. Patients are then referred to physicians’ practices, and OA’s team of bilingual case managers coordinates appointments, liaises with hospital and medical group partners, hires interpreters, and maintains an open line of communication for the patients. There is no added paperwork, no huge time expenditure, and no weeks on trips to underserved areas overseas. All that is required is seeing the patient in your office and setting up their procedure as you would for any insured patient.

By being both patient centered and volunteer driven, OA allows volunteering to become part of your routine. As a specialty physician volunteer with OA, you literally can help on a daily, weekly, or monthly basis, depending on your availability.

For us, working with OA has been enjoyable. Our practice is small, with just two surgeons, one who has been in practice for more than thirty years and one new to practice, giving us a unique viewpoint. As a longtime physician who has supported OA from the beginning, it has been a no-brainer. Back in 1998, I was actually chair of Surgery at CPMC, and I presented the program to the hospital administration, who embraced it in a way that allowed the patients to come in like any insured patient.

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The support services of anesthesia, pathology, and lab graciously threw in their support gratis and we all became early adopters of the program. We never looked back, and it has been very gratifying to help those who need it most. For my daughter, volunteering through OA has been a great source of cases and has facilitated her ability to serve a community that was integral to her training in the Central Valley. In her words, "I feel privileged to begin my practice already contributing in this way."

From a public health standpoint, OA’s program also allows for upstream interventions that prioritize both the patient and the allocation of hospital resources. As general surgeons, we commonly see that patients referred to us have already been to the ER. By coordinating planned surgeries, these patients can be treated in a timely and safe manner, thus bypassing additional costly ER visits and the complications that arise from letting problems fester. The process has the potential to not only help the patient but also the bottom line.

Ultimately for us, however, it’s about the patients. It is highly rewarding to serve a patient population that is so grateful for the help. The experience of volunteering with OA fosters the kind of patient-doctor relationship that is often lost in the modern electronic era of medicine, while allowing us to fulfill the trademark statement that passed through most of our lips during those med school interviews and that, while a cliché, is still true. We went into medicine to help people, and the uninsured are the people who need it the most.

To learn more about Operation Access, visit www.operationaccess.org. To get involved as a medical volunteer, reach out to Program Director Ali Balick at ali@operationaccess.org.

Kevin R. Hiler, MD, is a board-certified general surgeon who has been practicing for more than 30 years. He served as the chairman of the Department Surgery at CPMC from 1998 to 2013 and has donated 126 surgical procedures for uninsured patients since he began volunteering with Operation Access in 2001.

Amanda Kohlbrenner, MD, Dr. Hiler’s daughter, is also a general surgeon. She has donated seven surgical procedures for uninsured patients since she began volunteering with Operation Access in 2016. Both physicians frequently perform surgery together and are based in San Francisco.

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General and Trauma Surgery

WHOLE PERSON CARE An Innovative Initiative Boosts Marin Public Health Matt Willis, MD, MPH Frequent flyers. Super-utilizers. Hotspotters. Whatever term we use, the data is clear: In every community, a small fraction of patients accounts for a large portion of health care spending. This is especially true in

the Medicaid population, where 5 percent of enrollees account for 48 percent of program expenditures. Our emergency department physicians often know these patients by name and can recite their problem lists. We also know, as we manage their latest medical crises, that we’re not effectively addressing the factors that inevitably lead them back into our EDs again and again.

Both San Francisco and Marin are tackling this problem through a new, federally funded initiative called Whole Person Care. Funded by the Centers for Medicare and Medicaid Services and the California Department of Health Care Services (DHCS), the three-year pilot is aimed at building more robust local supports for Medi-Cal clients with complex medical, social, and mental health needs. The primary outcomes are reduced emergency department visits and hospitalizations among those Medi-Cal clients who contribute most to avoidable health care spending.

According to DHCS, “The overarching goal of the WPC pilots is the coordination of health, behavioral health, and social services in a patient-centered manner, with the goals of improved beneficiary health and well-being through more efficient and effective use of resources.”

In Marin, what gives us hope that we can be successful is the scale and scope of supports not previously available to super-utilizers, outside of conventional medical care coordination or case management.

In Marin, we started enrolling patients into our WPC pilot in November 2017. Individuals are identified primarily based on health care system use and EMS transport data. Analysis of 911 calls reveals the same skewed distribution toward a subset of frequent utilizers who use the majority of services.

A common feature among Medi-Cal clients with the highest utilization rates is housing instability or homelessness. Recognizing that housing and health are inseparable, we have started to case manage and house the county’s most vulnerable chronically homeless through the WPC pilot. As of December 13, 10 WPC enrollees in Marin were experiencing homelessness. Three of these are newly housed since enrolling, and three more have nearfuture move-in dates. Our short-term goal is to enroll 75 clients in housing-based case management by April 2018.

While these numbers seem modest, they reflect a promising new level of coordination between medical and social services agencies. This success is built on the coordinated efforts of the county’s several homeless service providers, who now pull from a single master list of prioritized candidates. The ranking method for placement into available housing is informed by patient-specific health WWW.SFMMS.ORG

care utilization patterns. This way, homeless patients with repeat avoidable ED visits are now identified and prioritized for housing.

Enhanced coordination between social services and health care providers is supported by a shared, HIPAA-compliant, cloud-based tracking system with patient-level health and benefits information. A lead case manager assigned to each enrollee has access to timely status updates in a single tool for all their clients. The Marin County Department of Health and Human Services, Behavioral Health and Recovery Services, Partnership HealthPlan (Marin’s managed Medi-Cal plan), and other partners share information that was previously siloed in separate databases. Information includes client-specific status for important services such as Medi-Cal, Social Security, Veterans Services, Employment, Housing, CalFresh (food stamps), and General Assistance.

In addition to a focus on housing and enhanced information sharing between sectors, WPC is facilitating expanded scope of services among key partners. For example, WPC funds will support a pilot program for Emergency Medical Services (EMS) providers to perform new activities to prevent avoidable 911 calls, ED visits, and hospital bounce-backs. Under the pilot, select EMS providers will conduct post-discharge follow-ups, as nonemergency visits, for WPC clients in their homes. This form of “community paramedicine” will support recovery at home by providing alternative and timely medical resources to vulnerable clients at risk for readmission.

The WPC pilot in Marin has just begun, and it is being refined and modified as it grows. Physicians can anticipate benefits of enhanced care coordination, especially in preventing avoidable and costly visits and in facilitating safe discharge dispositions.

The WPC pilot is an exciting and overdue measure to align providers into a single support system. However, from a public health standpoint, WPC still exists to support individuals after they’ve developed complex illness. The other side of the health care utilization equation is this: The healthiest 50 percent of all Medicaid enrollees account for only 2.7 percent of expenditures.

At a population level, the most cost-effective strategy is maintaining health. In Marin, we will continue to pursue the dual path of disease prevention and health care system innovation to reduce health disparities across the county.

Matt Willis, MD, MPH, has been the Marin County Public Health Officer since 2013. He calls on experiences as an internal medicine physician, epidemiologist, and member of the Marin community to guide public health strategy.

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General and Trauma Surgery

FROM CLASSROOM TO VOTING FLOOR The Role for Medical Students in Health Policy Sarah Rosenberg-Wohl, MPH In October, I joined medical students from across California at the annual California Medical Association (CMA) House of Delegates (HOD). It was my sec-

ond time participating; I’d first attended HOD in October of my first year of medical school, the month in which I was finally beginning to emerge from anatomy lab and lecture and could take part in an arena I’d always wanted to engage in—health policy.

HOD is the annual meeting at which members of the CMA debate and vote on policy recommendations, covering topics affecting health policy, public health, and medical practice. It’s a major way in which physicians and trainees can affect health care beyond the scope of their immediate clinical practice.

HOD takes place in an enormous convention center hall; I remember sitting in the rows of chairs to the left of the tables where hundreds of delegates sat. There are medical students from across California at HOD, organized as the Medical Student Section (MSS). In the months leading up to HOD, the MSS discusses, debates, and votes on its stances toward the various CMA policy recommendations under discussion, so that the medical student delegates—one from each medical school in California—can vote on the floor of the house on behalf of the MSS. Even as a nonvoting observer last year, I found the process exhilarating. We had all read the major issue reports in detail before arriving, but as new amendments were proposed and discussed in rapid succession, we who were new benefited enormously from the knowledge of more seasoned students, who provided us with relevant background and information on our group message thread about how CMA has previously addressed similar issues. It was fast-paced: As each new item was raised for discussion, our eyes moved back and forth between the overhead screens on which text was projected, the people speaking at the microphones, and the discussion on our group message thread.

Our opportunities to learn about health policy in medical school are limited. In our first and second years, we have a few lectures on the history of American health policy, comparative analysis between our health care system and those of other countries, and a basic introduction to health insurance and health economics. These lectures are excellent, but classes about health policy must inevitably compete with other subjects for space in the curriculum.

I left last year’s HOD inspired to find new ways to engage in shaping health policy outside of the classroom. I joined forces with other interested students, and we set up phone banks against the proposed ACA repeal; organized protests, letter campaigns, and phone calls on behalf of our classmates and colleagues who benefit from DACA; brought in a lunchtime lecture series on various aspects of health policy; and led discussions WWW.SFMMS.ORG

on local health-related ballot measures. With the SFMMS, we attended the annual CMA Legislative Advocacy Day, where we spoke with our representatives in Sacramento about protecting funding for primary care and increasing access to MediCal. I have been grateful for the mentorship of other students, who have been generous with their time and advice as I learn how to become a more informed thinker and better advocate.

And as I have begun working with physicians in the SFMMS, I have benefited from mentorship from those who have been doing this work for their careers.

Much of the debate at HOD centers around the year’s major issue reports, which address topics selected as those that are most relevant to health policy, public health, and the practice of medicine. The issues discussed at this year’s HOD were national health care reform, California health care reform, mental health, and physician workforce development. Much of the work is done before the meeting, to generate a report on each issue, but voting on those reports and on new amendments occurs during the meeting itself. Particularly exciting moments on the voting floor this year included the strengthening of the CMA’s position on inclusion of a public option in state health care reform and the adoption of language to address mental health stigma—both of which were in part the result of work done by the MSS—as well as strengthening support for DACA recipients.

At HOD this year, I was honored to serve as UCSF’s delegate to the MSS, where I had the chance to vote on policy, address the voting body on behalf of the MSS, learn from medical students and physicians, and introduce first-year students to this difficult but rewarding work on behalf of our patients. In our classroom lectures, we learn about the basics of health policy; this work allows us to engage in shaping it.

Sarah Rosenberg-Wohl, MPH, is a second-year medical student at UCSF. She is the vice chair of Legislative Affairs for the CMA-MSS and sits on the CMA’s Subcommittee on Medicare.

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General and Trauma Surgery

MEDICINE AND LEADERSHIP Q&A with David Klein, MD, MBA Man-Kit Leung, MD, and John Maa, MD What and when was your first impetus to become active in hospital leadership—did this start in your training, or after?

I became interested in hospital leadership early in my career.

This interest stemmed from working in various settings and observing strong administrators who were successful and inspiring (from my vantage point) as well as those who had opportunities for improvement. The contrast inspired me to make a difference for the better. I simultaneously became active in statewide organized medicine and in a number of leadership positions, including medical staff governance roles. About 10 years into my surgical practice, a door opened that allowed me to get actively involved with the building of a de novo hospital in my community and gave me a hands-on opportunity to work alongside a national company in a leadership role to operationalize the facility.

Who were particularly influential mentors and why?

I have had many mentors in my career and luckily still do!

From a hospital administration standpoint, there were three standout mentors who impacted me the most and led me toward a positive career transition. The first was the CEO of a national hospital company who was a visionary leader and possessed the unique ability to communicate and inspire trust. He focused on quality and safety rather than earnings. He treated physicians as valuable partners in any decision that was essential to achieving success. The second mentor was the chief medical officer of the same company. I was able to work closely with him and learn about the importance and value of physician executives and the range of roles available to them. Lastly, I was directly mentored by an experienced hospital CEO, who spent endless hours of his time helping me understand the complexities of running a hospital and thereby "lighting the fire" that inevitably redirected my career.

Many, if not most, physicians are trained to and wish to focus on clinical care and research, and they don't feel prepared for a career as a hospital leader. What is your advice to them, and how has your career path been most rewarding?

I strongly believe that more physicians should be involved in hospital leadership and other physician executive roles. There is no substitute for clinical knowledge and understanding the intricacies of patient care that so easily translate into hospital leadership. Most physicians actually know much more than they admit about management, given their daily responsibility of running their own practices and sole accountability for their P &Ls. While business education is minimal during medical training, the attributes of strong communication, managing daily challenges, 20

marketing, leadership, strategy development, and putting the patient at the center of all decisions are often a part of a physician’s armamentarium. Some of the more detailed business skills, such as financial accounting, budgets, and projections, can be developed, particularly if one pursues an advanced degree. While this is not an absolute requirement, it is respected and well received in administrative settings.

What were some of the more memorable events, accomplishments, and lessons learned in your career?

As a practicing general surgeon, there were so many memorable and rewarding events. The ability to make a difference in someone’s life, or be an actual “lifesaver” is the greatest reward of all. Nothing quite matches the gratitude heard from a patient and family at this pivotal moment. The rewards are less apparent as an administrator, since people do not often share personal praise. What I do find the most rewarding, however, is the ability to impact health care in a global sense and change lives on a much broader scale, not necessarily one life at a time. Specific to administration, I am very proud of building a greenfield hospital from the ground up in Texas. Starting as the first (and only) employee, helping with design and construction oversight, selecting the equipment, hiring the first leadership team followed by the general staff, recruiting a brand-new medical staff, putting operations into place, traveling through the community to introduce the facility, and ultimately opening the doors—this was truly a once-in-a-lifetime experience!

What suggestions/tips might you have for students and residents who are considering becoming hospital systems leaders? Is there a career path they should pursue or an additional degree, like an MHA?

First and foremost, it is beneficial to get a few years of clinical practice under your belt so you can bring that experience to the table of becoming a physician executive. One should get involved in organized medicine and hospital or group leadership, perhaps starting as a department chair or vice chair, or even a committee member. One should take advantage of any and all leadership programs offered by hospitals, as they are constantly seeking doctors who have an interest in leadership and often offer physician leadership courses. Spend time with the administrative team whenever possible, setting time aside to “pick the brain” of the CEO, CMO, and COO. Observe leaders in various positions, identifying skills that are successful and resonate with you. Make sure to also pinpoint elements that do not work well and can be improved. Find a physician executive mentor who is willing to spend time with you

SAN FRANCISCO MARIN MEDICINE JANUARY/FEBRUARY 2018 WWW.SFMMS.ORG

to explore your interest and coach you. Be involved in the medical society in your community and in other organizations, such as ACPE or ACHE, both of which offer CMEs and courses in leadership. Lastly, I believe a master’s degree is extremely beneficial, such as an MBA, MHA, MMM, or MPH. A degree not only propels your business skills but ultimately gets you a seat at the table, empowers your business sense and credibility, and then equips you with the vocabulary needed to compete in the business world with historically few physicians. It also demonstrates commitment to the various hospital companies, many of which will require a master’s degree for higherlevel leadership positions. Equally important is to decide early on just how active you want to remain in the practice of medicine, if at all. If you get this far, then you still have to decide whether to stay on the clinical side, in a role such as a medical director, VPMA, or CMO, or opt for more focus in operations (less common with doctors but the role I chose). This includes seeking the position of COO, CEO, and hospital president. Definitely lots to think about!

What were the highlights of your career as a general surgeon?

I had the privilege of having a richly rewarding career as a general surgeon and sometimes still miss being in the operating room . . . some days more than others! As much as I loved operating, it ultimately provided me the relationship to get to know my patients and their families and in some way make a positive difference in their lives—and also be available to them when outcomes were less positive and the relationship became a privilege in a different way. It would be difficult to list just a few highlights, as I feel so fortunate to have been able to do something that I loved and found so gratifying.

The roles of clinician and medical administrator can sometimes seem to be in conflict, at least in terms of financial incentives—i.e., reducing costs vs. providing the best possible care regardless of costs. Do you ever feel this kind of tension in your work?

There are times when decisions can seem conflicting, but I always lean toward patient quality and safety. When this is the case, the decision is crystal clear. My goal is to always put the patient at the center of any decision I make (clearly sometimes easier said than done) and to try to do the right thing for the right reason. I have also learned that when you really dig down deep, you can usually meet your financial goals without sacrificing patient care. As most people know, high-quality care is actually less expensive to provide in the long run than inadequate care. In today’s health care climate, it is all about value, which is quality/cost, so health care administrators are constantly seeking the highest quality at the lowest cost.

Having a clinical background has clearly helped me to make some of these important decisions and succeed in the process.

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David Klein, MD, MBA, has served as president and CEO of Saint Francis Memorial Hospital/Dignity Health in San Francisco since March 2016. Dr. Klein is a member of the Hospital Council of Northern/Central California and the San Francisco Medical Society. He serves on the board of directors of the Saint Francis Foundation Board and is a board member for the Hacienda Surgery Center. He is a Fellow of the American College of Surgeons.

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HEALTH POLICY UPDATE ZIKA Important message from the California Department of Public Health (CDPH) Karen Smith, MD, MPH Here in California, the Zika virus remains a serious public health concern. Californians, particularly pregnant women residing in the state, are at risk of contracting the Zika virus, which could have devastating impacts on a developing baby. As of December

1, 2017, there have been 619 cases in California—10 in that month alone. So far in California, Zika virus infections have been documented only in people who were infected while traveling to areas with ongoing Zika transmission, through sexual contact with an infected traveler, or through maternal-fetal transmission during pregnancy.

While the species of mosquito that carries the Zika virus, Aedes aegypti, is not native to California, it has been detected in an increasing number of counties throughout the state, including the California-Baja and California-border region (San Diego and Imperial Counties).

We recently released a PSA on the subject; you can view it here by visiting zikafreeCA.com.

Here are a few things we want you to know.

Zika is mosquito-borne virus that can infect both men and women. Most concerning of all, the virus can have detrimental effects on pregnant women and their unborn babies. This is why it is up to all of us to be vigilant.

There are three main ways to contract the virus: 1. From mosquitoes in infected areas, 2. Through unprotected sex, and 3. From an infected mother to her developing baby.

WWW.SFMMS.ORG

First and foremost, the CDPH advises men and women of childbearing age to not go to areas with Zika. As you make travel plans, you can find out where Zika is present by visiting the following site: https://wwwnc.cdc.gov/travel/page/zika-information.

If you or your partner must travel to an area with Zika presence, it is important to note that the virus is spread through sexual intercourse and can live in men for up to six months; in women, eight weeks. The only way to avoid the virus entirely is to abstain from sex entirely. Otherwise, safe sex should always be practiced.

Couples planning pregnancy when either has been exposed to the Zika virus should speak with their health care provider about a safe time to try to get pregnant.

Otherwise, when traveling, be sure to use EPA-registered insect repellent for three weeks after you return to prevent the spread of Zika back home. See your doctor right away if you have Zika symptoms such as fever, rash, red eyes, or joint pain.

For more information, visit ZikafreeCA.com.

Karen Smith, MD, MPH, is director of the California Department of Public Health and a state public health officer. Dr. Smith is a physician specializing in infectious disease and public health.

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IN MEMORIAM: ROLLAND C. LOWE, MD A Personal Tribute to a Role Model from the Community Randall Low, MD

Editor’s Note: Our esteemed colleague Rolland Lowe, MD, passed away in November. Last issue we ran a brief obituary (Nov/Dec 2017), and this month we offer a reflection from his friend and fellow physician Randall Low, MD. I first met Dr. Rolland C. Lowe in the late 1960s, while he was making hospital rounds. I was in college at Berkeley and visiting my future wife, whom he had just operated on. His manner was professional, competent, caring, and personable. I had no idea that this young doctor was to become a dear friend, colleague, role model, and even a father figure to me.

San Francisco’s Chinatown was isolated and insular. To the outsider it was exotic, mysterious, and in many ways left to its own devices. There was a health and dental clinic and the largest elementary school in the city in the community, all allegedly self-governed by the Chinese Six Companies. It was against this backdrop that Dr. Lowe started in general practice and general surgery. Raised in Oakland, he was a prodigy, attending U.C. Berkeley and graduating from UCSF at 22 years old. After serving as a GMO in Korea, he came back to UCSF and trained as a surgeon specializing in vascular procedures. Fulfilling half the dreams of his father, he became a physician; but he didn’t practice in China, the other half of his father’s dream. Instead, he made San Francisco’s Chinatown his community.

The office was on Jackson Street, across the street from Chinese Hospital, a small community-based facility originally established as a dispensary at the turn of the twentieth century. He brought his surgical cases there and later became chief of staff and president of the board. He was legendary for seeing patients after surgical cases and staying to 10:00 or 11:00 p.m. He was always available. He treated all comers, the monolingual, the uninsured. He was a dedicated doctor who was well respected and well loved.

The 1960s in Chinatown were a tumultuous time. While 24

the rest of the city was dealing with the “counterculture,” this community was dealing with an influx of immigrants from Asia and refugees from Southeast Asia. The changing demographics brought new problems and challenges in housing, education, and the “gang” problems in Chinatown. Interestingly, Dr. Lowe, being an outsider from Oakland and actually having ties to the Mainland Chinese government, established himself with the political infrastructure of Chinatown. He was involved with his family association and was in its leadership. Outside the community, the headlines were of the Golden Dragon Massacre and the evictions of the International Hotel. Dr. Lowe was a friend to those who were evicted, many of whom he cared for gratis as patients, and he served on the committee to rebuild the hotel, which now stands on Kearney and Jackson. He was also involved with the founding of the Chinatown Youth Organization, which still serves the youth of the community. During this time Dr. Lowe was formative in countless service efforts, including the institution of English as a second language in SFUSD schools and working with the Newcomer Program, Self-Help for the Elderly, On Lok Health Services, the Chinatown Development Center, and much more.

Dr. Lowe always described himself as a consensus builder.

He would identify a situation, gather those concerned, and mediate a possible solution and a strategy to obtain the goals. He was successful in many of his endeavors because he was pragmatic and realized some of his own limitations.

All these accomplishments were not unnoticed outside the Chinatown community. Mayor Dianne Feinstein appointed Dr. Lowe to the Civic Service Commission. At that time, few from the community were asked to participate in local government. He was slated to become chair but opted to rededicate his energies to medicine. And, of course, that resulted in his becoming the first Chinese president of both the San Francisco Medical Society and then the California Medical Association.

Returning to the community in 1981 after my own medical training, I found the health care landscape had changed. The community now had a dynamic hospital with a well-trained and active medical staff, and besides the public health clinic, Northeast Medical Services (NEMS) was established. Northeast Mental Health Services, along with Richmond Area Medical Services (RAMS) and a unit psychiatric ward, was established at SF General for Chinese-speaking patients; On Lok Health Services and Self-Help for the Elderly were providing care for older residents.

Dr. Lowe was not alone in bringing about this transformation, but he was the instrumental catalyst.

The big challenge of the 1980s in health in his community was the uninsured. There were many working poor in the community, and the challenge in medicine was to cut costs and to

SAN FRANCISCO MARIN MEDICINE JANUARY/FEBRUARY 2018 WWW.SFMMS.ORG

make access to medicine more affordable to the underserved.

Dr. Lowe was a leader who convinced physicians to organize the Chinese Community Health Care Association (CCHCA), a nonprofit IPA that was dedicated to serve this community. This prompted Chinese Hospital to form the Chinese Community Health Plan, which offered affordable health insurance to the working poor and small businesses.

At SFMS, Dr. Lowe was learning how to thrive and make a contribution to a bigger stage. He always acknowledged the guidance given him by the leaders of the SFMS, such as Brad Cohn, Sidney Foster, and others, to get him up to speed. He was proud to be the president of the SFMS, and during his time he advocated that the society become more inclusive in recognizing other modes of practicing medicine.

There was much excitement in our community with Dr. Lowe’s ascension to the presidency of the CMA. I saw him continuing to learn and trying to build consensus to improve conditions. I saw him put in the hours to travel the state and learn of the issues facing doctors in rural California. Again, his message was that of inclusiveness and dialogue.

After his presidency, Dr. Lowe and another former president of the CMA, Dr. Frank Staggers, set the structure for the Network of Ethnic Physicians with the CMA Foundation. This organization was created to provide a forum for all ethnic physicians to share their special problems.

In retirement from the practice of medicine, Dr. Lowe continued to build consensus. He helped found the Asian American Health Forum and the Chinese American Community Foundation, and he continued to support Chinese for Affirmative Action. Over the 50 years I knew Dr. Lowe, his touchstone was his wife, Kathy. An elegant woman, she supported him in his many endeavors and kept his feet on the ground, unfailing in her support but not afraid to offer her thoughts and opinions. They raised three children and had three grandchildren.

I always blamed Rolland and Kathy for spoiling me. He was a wine enthusiast and shared his knowledge and fine wines with his friends. Proud members of the Medical Friends of Wine, they traveled the world together and enjoyed fine dining.

I was fortunate to join the Lowes on a cuisine tour of China. It was an experience of a lifetime, and my countless wonderful memories include our smuggling in eight cases of California wine in attempts to match the magnificent food.

Throughout his career, Dr. Rolland Lowe met and affected many people. I wish that even more could have made his acquaintance, because for many knowing him truly was a lifechanging experience.

Cardiologist Randall Low, MD, attended U.C. Berkeley, and the U.C. Davis School of Medicine. A former SFMS board member and CMA delegate, he is also a previous president of the Chinese Community Health Care Association.

WWW.SFMMS.ORG

Touching Hands Project Edward Diao, MD On November 11, the San Francisco Surgery Center (SFSC) hosted a day of reconstructive surgery for underinsured and uninsured patients from the greater San Francisco Bay area.

The facility, anesthesia, surgery, and ancillary services were all donated at no cost to the patients. Surgical equipment and implants were donated by the Stryker Corporation.

The Touching Hands Project is an outreach program of philanthropy sponsored by the American Society for Surgery of the Hand (ASSH) and the American Foundation for Surgery of the Hand (AFSH). Dr. Edward Diao was the team leader for the San Francisco site, which was joined by Atlanta, Georgia; Philadelphia, Pennsylvania; and, earlier in the year, Nashville, Tennessee, as the other sites for this nationwide initiative.

The surgeries performed included:

• The conversion of a fused wrist with no motion in 25 years in a 59-year-old male to a mobile artificial wrist by reconstruction with a Total Wrist implant of metal and polyethylene (Stryker ReMotion System) • The lengthening of a congenitally shortened fifth finger in a 33-year-old female by a sliding oblique metacarpal bone osteotomy with fixation using plates, screws, and pins (Stryker VariAx System) • The exploration of a chronic nerve injury leading to thumb and wrist paralysis six months after a fall in a 37-year-old male by exploration and excision of damaged muscle causing nerve compression

• A carpal tunnel release with limited incision techniques in a 60-year-old female via an endoscopic surgical tool (MicroAire tool and Stryker Video Tower System) • The practice manager for Dr. Edward Diao, Shayne Connelly, observed, “… it was a great event. Spirits were high among the volunteers because the patients were so grateful. This was a special way to give back to the community. People are looking forward to doing it again and encouraging others to join in.”

Dr. Diao is Professor Emeritus of Orthopaedic Surgery and Neurosurgery at University of California, San Francisco. He serves as chief of Hand Surgery at California Pacific Medical Center, founder and managing partner of the SFSC, and vice president of the American Foundation for Surgery of the Hand. He is also a staff physician at St. Francis Square Hospital, St. Mary’s Medical Center, and Summit Alta Bates Medical Center in Berkeley.

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MEDICAL COMMUNITY NEWS CPMC

Robert Margolin, MD

Kaiser Permanente Maria Ansari, MD

SFMH and SMMC

Robert Harvey MD, MBA, CPE and Carl Bricca, DO Congratulations to our recently elected medical staff officers: Dr. Robert Margolin (Chief of Staff), Dr. Oded Herbsman (Vice Chief of Staff), Dr. Nobl Barazangi (Secretary), and Dr. Thomas Peitz (Treasurer). The Officers will serve their first terms in these positions from January 1, 2018, to December 31, 2019. A special thank-you to our former Chief of Staff Dr. Edward Eisler for his outstanding leadership and support of the medical staff. The following physicians were also elected to serve as Medical Executive Committee Members-at-Large for the 2018–2019 term: Drs. George Horng, Andrea Yeung, and Robert Klett. Members-atLarge represent the interests of the medical staff as a whole as they participate in the resolution of Medical Executive Committee issues and serve on medical staff committees as part of their leadership roles.

Dr. Brian Andrews has been reappointed as chair of the Department of Neurosciences for a third and final term (2018–2022). The Department’s clinical programs include the Forbes-Norris ALS-Neuromuscular program; the neuro-oncology endonasal skull-base program; the Brain Health Center; services for epilepsy, cerebrovascular/neurointernventional, neurospinal (in collaboration with orthopaedics), neuroconsults, movement disorders, and headaches and migraines; pediatric neurosurgical collaborations with Stanford Children’s Health; and collaborations with Acute Rehabilitation and Microsurgery at the Davies Campus.

Recognized for achievements in patient safety and quality, The Leapfrog Group® named CPMC to its list of Top Hospitals in 2017.

The Leapfrog Top Hospital award is widely acknowledged as one of the most competitive honors American hospitals can receive. Performance across many areas of hospital care is considered in establishing the qualifications for the Top Hospital award, including infection rates, maternity care, and the hospital’s capacity to prevent medication errors. The selection of Top Hospitals 2017 is based on surveys from nearly 1,900 hospitals.

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After piloting our Enhanced Recovery After Surgery (ERAS) program in 2014 for elective colorectal and orthopedic surgery, Kaiser Permanente San Francisco (KPSF) is expanding our ERAS program to all inpatient surgery.

ERAS is a key way to provide patients with an improved experience and quality outcome, as well as to reduce health care costs. ERAS began in Europe in the 1990s and is now being used in hospitals across the United States, with many working on innovative approaches to the concept. Over 800 hospitals in the United States, including every Northern California Kaiser Permanente hospital, participate in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). Participation in NSQIP provides hospitals with standardized and audited risk-adjusted outcome data, which guides surgical process improvements such as ERAS. KPSF is Kaiser Permanente’s regional referral center of excellence for many advanced surgical programs, including cardiovascular, hepatobiliary, colorectal, gynecologic, total joint, ocular oncologic, gender reassignment, and robotic surgery. Our ERAS program, known simply as Enhanced Recovery, reduces the catabolic and inflammatory surgical stress response as compared with traditional postsurgical care. The Enhanced Recovery program targets complications, such as infection and pain, through three key elements: improved patient nutrition, early ambulation, and improved pain management. It works in tandem with our hardwired surgical site infection reduction systems. Of course, quality improvement is a multidisciplinary process, and Enhanced Recovery requires continuous modification of preop, intra-op, and post-op processes. Additionally, the program takes significant patient education, made possible by an integrated and advanced technology system that amplifies the connection to our patients and allows us to standardize systemwide change in a compacted time frame. In the end, it pays off: A study published on July 19, 2017, in JAMA Surgery describes 15,849 patients in 20 Kaiser Permanente medical centers with decreased complications, including mortality, and improved discharge.

Dignity Health and UCSF Health have formed an affiliation that will integrate community-based care with the best of academic medicine and create a stronger physician network throughout the Bay Area.

The agreement builds upon an already robust relationship between Dignity Health and UCSF Health—two health systems known for their clinical excellence and missions to provide quality, affordable care to all, including the underserved. In the past, Dignity Health and UCSF Health have collaborated in several areas, including pediatric burn care, acute rehabilitation, and cardiac arrhythmia, among others.

The first part of the agreement allows UCSF specialists to care for patients at three Dignity Health Bay Area hospitals: Saint Francis Memorial Hospital, St. Mary’s Medical Center, and Sequoia Hospital. This care extension will enable more patients to receive specialty care sooner and in more places, including in their own community hospitals.

Additionally, the Bay Area Dignity Health hospitals have joined the Canopy Health accountable care network. Canopy Health contracts with a broad range of health plans to provide patients with wide access to care providers, from primary care to specialists, enabling patients to access the care they need close to their home, school, or work. The affiliation also forges a new relationship between UCSF physicians and Dignity Health Medical Group physicians based in San Francisco and San Mateo County. Collaboration between our medical groups and UCSF’s clinical network will allow us to share best practices and improve access, quality, efficiency, and coordination of care for shared patients.

This affiliation is the first of its kind for Dignity Health, and we are enthusiastic about the opportunities that this agreement provides for the communities we serve. UCSF is an excellent partner in the Bay Area, and we look forward to expanding our relationship on behalf of our patients.

SAN FRANCISCO MARIN MEDICINE JANUARY/FEBRUARY 2018 WWW.SFMMS.ORG

UPCOMING EVENTS 2018 AMA National Advocacy Conference February 12–14, 2018 | Grand Hyatt Washington, Washington, D.C. The American Medical Association will host the 2018 AMA National Advocacy Conference on February 12–14, 2018, in Washington, D.C. This year’s conference features a terrific lineup of guest speakers and a variety of activities and opportunities that will leave you better informed and empowered to advocate for patients, the medical profession, and the future of health care. For more information, or to register, visit https://www. ama-assn.org/national-advocacy-conference.

Stepping up to Leadership: IMQ/PACE Platinum Training Program for Physician Leaders February 22–23, 2018 | Paradise Point Hotel & Spa, San Diego, CA This program provides the tools and knowledge physicians need to succeed in leadership roles by combining IMQ’s expertise in medical staff matters with PACE’s expertise in communication and assessment. This course is offered every two years to provide new leadership teams the opportunity to learn and train together.

Visit www.physician-leadership.org for more information.

UCSF Conference on Medical Care of Vulnerable and Underserved Populations March 1–3, 2018 | Holiday Inn Golden Gateway, San Francisco, CA Topics include updates on a broad range of diseases disproportionately affecting vulnerable patients, including diabetes, depression, PTSD, and more. Register now at http://bit.ly/2BwGabe.

Activities and Actions of Interest

(continued from page 4, Membership Matters)

Support for Hospital Opioid Use Treatment (SHOUT) This program (http://bit.ly/2kV4sk1), developed by UCSF addiction medicine specialists, provides clinical leaders in hospital settings with tools to start and maintain patients on buprenorphine or methadone during hospitalization for any condition.

Participants have access to a suite of resources: coaching, toolkits, protocols, monographs for pharmacy and therapeutics committees, and webinars (including two listed below). California Health Care Foundation is proud to support this work.

JOIN OR RENEW YOUR MEMBERSHIP TODAY!

Don’t Let Your SFMMS Membership Expire on 3/1 Make sure you continue to receive the benefits of SFMMS and CMA membership by renewing before the March 1 drop date. Mail/fax your completed renewal form when you receive it in the mail, renew online at www.sfmms.org with your credit card, or call us at (415) 561-0850 x200.

CLASSIFIED ADS Office space available. Seeking physician, either internal medicine or specialist, to either join our practice or share office space and staff. We are a small private practice. Multispecialty group with a prime location and available space. Will consider full or part time physician. Michael Schrader, MD, at 415 921 8210 or schradermd@gmail.com

SFMMS 150th Anniversary Celebration & Gala

March 15, 2018 | 5:30–9:00 p.m.

St. Francis Yacht Club, San Francisco, CA In 2018, SFMMS is celebrating its 150th Anniversary. Please join us on March 15, 2018, at the St. Francis Yacht Club in San Francisco to celebrate 150 years of advocating for physicians and patients. Visit www.sfmms.org/ events/150thAnniversaryGala for more information, to purchase tickets, or to learn about sponsorship opportunities.

WWW.SFMMS.ORG

JANUARY/FEBRUARY 2018 SAN FRANCISCO MARIN MEDICINE

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