May 2014

SAN FRANCISCO 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 E D I CA L S O C I E T Y

GLOBAL MEDICINE Preventing Blindness in Nepal The Local Roots of the Global Free Clinic and Addiction Medicine Movements

Philanthropy: Converting Money into Impact

Plus: Highlights from Legislative Leadership Day Kids, Diseases, Vaccinations—and Parental Peer Pressure

VOL.87 NO.4 May 2014

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IN THIS ISSUE

SAN FRANCISCO MEDICINE May 2014 Volume 87, Number 4

Global Medicine FEATURE ARTICLES

MONTHLY COLUMNS

12 Stumbling into Philanthropy: Turning a Lot of Money into a

Lot of Impact

Kevin Starr, MD

4

Membership Matters

9

President’s Message Lawrence Cheung, MD, FAAD, FASDS

14 Preventing Blindness: A Mycotic Ulcer Treatment Trial

in Rural Nepal

Kieran O’Brien, MPH, and Nisha R. Acharya, MD, MS

16 Global Orthopaedics: Collaborative Partnerships for the Future

Saam Morshed, MD, PhD, MPH 20 Made in San Francisco: The Local Roots of the Free Clinic and

Addiction Medicine Movements

David E. Smith, MD, FASAM, FAACT 22 Reversely Innovative: Experiences from Rural Kenya

Megan Mahoney, MD

24 Teaching the Teachers: Initiative from the International

Council of Ophthalmology

Bruce Spivey, MD, MS, MEd

11 Editorial

Gordon Fung, MD, PhD

28 Medical Community News 31 Public Health Perspective: Kids, Diseases,

Vaccinations—and Parental Peer Pressure

Steve Heilig, MPH 33 Ten Questions: Interview with Andrew

Snyder, MD, FAAP 34 In Memoriam 34 Upcoming Events 34 Classified Ads

OF INTEREST

6 2014 Legislative Leadership Day

Welcome New Members The SFMS welcomes the following members: ACTIVE REGULAR MEMBERS Merik Spiers Gross, MD | Internal Medicine Hali Hammer, MD | Family Medicine Seif Sleiman, MD | Hospitalist Carlos Quintana, MD | Neurology Shoshana Ungerleider, MD | Internal Medicine

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

STUDENTS Brian Shaw

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members Physicians Champion Bills to Increase Access to Care at Legislative Leadership Day More than 400 physicians, including thirty SFMS members, participated in CMA’s Legislative Leadership Day on April 22 at the State Capitol. The SFMS group, represented by leadership as well as at-large members, met with Senator Mark Leno, Assemblymember Phil Ting, and a legislative aide for Assemblymember Tom Ammiano.The group advocated heavily in support of AB 1805 (reversing the 10 percent cut to Medi-Cal provider rates), AB 1771 (reimbursement for telephone/electronic patient management), and AB 2771 (all products clauses). All three bills will assist in maintaining patient access to adequate physician networks. Photos and details from the event can be found on page 6.

FDA to Regulate E-Cigarettes; Physicians Urge to Comment on Proposed Rule

The Food and Drug Administration (FDA) released a proposed rule that would give the agency authority to regulate alternative tobacco products, including e-cigarettes. Aimed at preventing tobacco-related diseases and deaths, the proposed rule leaves room for additional needed improvements, including banning flavors for e-cigarettes and cigars, which can contribute to their

appeal for young people. FDA is accepting physician comments on the proposed rule on e-cigarette regulation until July 9, 2014. Physicians are urged to submit clinical research, data, and other information at http://1.usa.gov/1mM8w2J. SFMS has long advocated for regulation of e-cigarettes, including endorsement of Supervisor Eric Mar’s proposed legislation this year and of the San Francisco Department of Public Health’s Resolution No. 7-11 in 2011.

Meaningful Use Relief

Additional relief for eligible providers participating in the meaningful use program has arrived in two forms—expanded exemptions and expanded assistance. Expanded Exemptions: Providers who are eligible for the Medicare EHR Incentive Program and have been unable to successfully demonstrate meaningful use for either the 2013 or 2014 reporting year due to circumstances beyond their control may apply for a hardship exemption. The deadline to apply is July 1, 2014. Visit the CMS Payment Adjustment and Hardship Exemption webpage (http://www.cms.gov/ Regulations-and-Guidance/Legislation/EHRIncentivePrograms/ PaymentAdj_Hardship.html) for downloadable tip sheets that detail the qualifications of each hardship exemption. Expanded Assistance: Eligible professionals may still seek subsidized assis-

New CMS 1500 Implementation Reference Guide

SFMS/CMA surveyed the major payors in California to learn about each payor’s requirement for submitting the new CMS 1500 (2/12 version) for submission after April 1, 2014. With ICD-10 implementation delayed until October 2015, SFMS/CMA is awaiting additional information from CMS on whether there will be any changes to the new CMS-1500 form. Until that time, we recommend that providers continue to follow the previous guidance issued and implement as required.

Payor Name Require new Additional Information CMS 1500 form effective 4/1/2014* No

Will allow practices to submit either CMS 1500 (version 08-05 or 02-12) after April 1, 2014. Aetna will require the new CMS form (02-12) beginning October 1, 2014.

Blue Shield No of California

Will allow practices to submit either CMS 1500 (08-05 or 02-12) after April 1, 2014. Blue Shield will notify providers at a later date as to when they will require use of the new CMS 1500 form (02-12).

Aetna

Anthem Blue Cross

Yes

Cigna

No

Humana

Yes

Health Net Medi-Cal

Medicare

United Healthcare

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No

Yes Yes Yes

Require practices to submit new CMS 1500 (02-12) effective April 1, 2014. Any claims submitted on the old CMS 1500 form (08-05) will be rejected.

Will allow practices to submit either CMS 1500 (08-05 or 02-12) after April 1, 2014. Cigna will notify providers at a later date as to when they will require use of the new CMS 1500 form (02-12).

Will allow practices to submit either CMS 1500 (08-05 or 02-12) until October 1, 2015.**

Requires practices to submit the new CMS 1500 (02-12) on April 1, 2014. Any claims submitted on the old CMS 1500 form (08-05) will be rejected.

Effective April 1, 2014, DHCS will require practices to submit the new CMS 1500 form (02-12). Any claims submitted on the old CMS 1500 form (08-05) will be rejected.

Effective April 1, 2014, requires practices to submit the new CMS 1500 form (02-12). Any claims submitted on the old CMS 1500 form (08-05) will be rejected.

Requires practices to submit the new CMS 1500 form (02-12) on April 1, 2014. Any claims submitted on the old CMS form (08-05) will be rejected.

Notes: *Information current as of March 19, 2014. **May be delayed until October 1, 2015 with new ICD-10 postponement. Please confirm with payor.

SAN FRANCISCO MEDICINE MAY 2014 WWW.SFMS.ORG

tance from CalHIPSO to meet meaningful use in 2014. CalHIPSO is the federally funded regional extension center serving clinicians in all California counties except Orange and LA. CalHIPSO is continuing to provide technical services through December 31, 2014, to both current and new members. However, there is limited availability for new enrollments. Contact CalHIPSO for more information at (510) 302-3364 or e-mail organization name, contact info, zip code, and NPIs to info@calhipso.org.

United Healthcare to Roll out Premium Designation Program in California

United Healthcare recently announced it would begin implementation of its Premium Designation program in California in the coming months. Under the program, physicians will be ranked on both national and specialty-specific measures for quality and various cost-efficiency benchmarks. Under the program, physicians achieving United’s criteria for quality and cost thresholds will receive a Premium Designation on their physician profile, marketed to United members through the United online physician directory. In addition, employers may choose to offer health benefit programs (e.g., reduced costsharing or tiered benefit programs) that provide benefit incentives for members to use only physicians with the United Healthcare Premium Designation.

United expects to fully implement the program by the end of 2014. For more information, visit UnitedHealthcareOnline.com.

Noridian Begins Next Round of Medicare Revalidation Process

Medicare Administrative Contractors (MACs) have been requiring physicians to revalidate their Medicare enrollments as mandated by the Affordable Care Act (ACA). Noridian, California’s MAC, recently sent another round of revalidation letters. This revalidation effort applies to providers and suppliers that were enrolled prior to March 25, 2011.

Physicians who receive a request for revalidation must respond to that request within 60 days or face the possibility of being deactivated. Do not do anything until you get a letter instructing you to revalidate. Physicians who are making changes (moving, closing practice, etc.) should continue to submit their changes as usual. A list of providers who have been sent revalidation requests can be downloaded at http://go.cms.gov/1hRqFEC. If you are listed and have not received the request, please contact Noridian at (855) 609-9960.

Free Risk Assessment Tool to Ensure HIPAA Compliance

Physicians in small to mid-sized practices can conduct their own risk assessments using a free tool newly available from the U.S. Department of Health and Human Services. The security risk assessment (SRA) tool is designed to help practices conduct and document a risk assessment to evaluate potential security risks in their organizations under the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. Conducting an SRA also is a core requirement for physicians seeking payment through the federal meaningful use program for electronic health records.

New Anthem Blue Cross Exchange Addendum: What Physicians Need to Know

Anthem Blue Cross recently notified more than 11,000 practices who are currently participating in its individual/exchange network of a contract addendum that will become effective July 1, 2014. The amendment only applies to physicians who are currently participating in the Anthem Blue Cross individual/exchange network. According to the notice, the addendum contains new regulatory requirements. While many provisions are requirements of Covered California, SFMS/CMA has concerns with certain provisions that appear to be beyond the scope of regulatory requirements. To view the notice and opt-out information, visit http://bit.ly/1f3m1Dj. WWW.SFMS.ORG

May 2014 Volume 87, Number 4 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD John Maa, MD Chunbo Cai, MD

SFMS OFFICERS President Lawrence Cheung, MD President-Elect Roger S. Eng, MD Secretary Richard A. Podolin, MD Treasurer Man-Kit Leung, MD Immediate Past President Shannon UdovicConstant, MD SFMS 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 Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Ariel Young BOARD OF DIRECTORS Term: Jan 2014-Dec 2016 Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Adam Schickedanz, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2012-Dec 2014 William J. Black, MD Andrew F. Calman, MD John Maa, MD Todd A. May, MD Kimberly L. Newell, MD William T. Prey, MD Steven H. Fugaro, MD

Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD

MAY 2014 SAN FRANCISCO MEDICINE

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LEGISLATIVE LEADERSHIP DAY SFMS Physicians Gather in Sacramento to Advocate for a Package of Bills to Increase Access to Health Care

CMA press conference. Photo Credit: David Flatter.

A dedicated group of thirty SFMS physicians and medical students joined more than 400 of their colleagues on April 22 to bring the voice of medicine to legislators. During CMA’s fortieth annual Legislative Leadership Conference, SFMS members had the opportunity to lobby legislative leaders as champions for medicine and their patients. Among the issues discussed were Medi-Cal reimbursement rates, access to care, and the local soda tax effort. Below is a sampling of CMA-sponsored bills and opposed legislation.

SFMS/CMA-Sponsored Legislation

AB 1805 (Skinner & Pan) reverses a 10 percent cut made to California’s Medicaid program (Medi-Cal) in 2011. Medi-Cal reimbursement rates are among the lowest in the nation, often reimbursing providers below the cost of care. Many Medi-Cal patients have difficulty finding providers able to care for them. As millions of new patients enter the health care delivery system, reimbursement rates must be sustainable so that patients have real access to care. The bill was unanimously approved by the Assembly Committee on Health.

AB 1759 (Pan) extends through 2015 and beyond the re-

imbursement increase for certain Medi-Cal primary care providers, currently mandated under the Affordable Care Act but set to expire on December 31, 2014.

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AB 1771 (V. Manuel Perez) increases access to care, especially in underserved areas, by requiring health insurance companies licensed in the State of California to pay contracted physicians for telephone and electronic patient management telehealth services.

AB 2400 (Ridley-Thomas) improves health plan network integrity and reduces consumer confusion by giving providers more control when negotiating material changes to their health plan contracts. The bill prohibits contracts issued, amended, or renewed by health service plans and health insurers after January 1, 2015, from including provisions that terminate provider contracts if they exercise their right to negotiate or refuse a material change to the contract. It also prohibits contracts that are amended or renewed after that date from containing provisions that require participation in unspecified current and future products or product networks, unless the plan discloses the reimbursement rate, method of payment, and any other contract terms that are materially different from those of the underlying agreement.

SB 1000 (Monning) helps consumers make more informed

decisions about purchasing and drinking sugar-sweetened beverages (SSBs) by requiring SSBs to be sold with a safety warning label.

SAN FRANCISCO MEDICINE MAY 2014 WWW.SFMS.ORG

SFMS/CMA-Opposed Legislation SB 1215 (Hernandez) eliminates the in-office exception to the self-referral law for advanced imaging, anatomic pathology, radiation therapy, and physical therapy. The bill was defeated in the Senate Business, Professions, and Economic Development Committee after receiving just one vote. This bill would have been a major blow to the integrated care model, resulting in increased costs as these services would have been driven toward the more expensive hospital setting and would have inhibited the development of practices that integrate and coordinate care.

SFMS leaders meet with Wendy Hill, legislative aide to Assemblymember Tom Ammiano.

A PHYSICIAN’S REPORT FROM THE GROUND Amanda Posner, MD UCSF student Brian Shaw illustrates the positive impact of AB 2400 on physicians to Senator Mark Leno.

SFMS members ask for Assemblymember Phil Ting’s support of AB 1805 to reverse the 10% Medi-Cal provider rate cut and prevent further erosion to the health safety net system.

CMA president Richard Thorp, MD provides testimony at the Assembly Committee on Health. Photo Credit: David Flatter.

WWW.SFMS.ORG

“This bill is a real job killer. And I only have five minutes.

You can speak to my staff after that.” Thankfully, this wasn’t an actual legislator but a fictional representative that I was addressing in my advocacy class at UCSF. Our class was divided into small groups, and each group was assigned a bill to defend. We had to research our bill and defend it to a “legislator,” usually a classmate or a lecturer. This advocacy class was part of our preparation for a subsequent visit to the state capital, acting in conjunction with the San Francisco Medical Society (SFMS).

As part of the commitment to educating the modern physician, the medicine, family medicine, and pediatrics residency participate in advocacy rotations. During these rotations, clinical duties are kept to a minimum while we learn about the issues our patients face around access, social justice, and health literacy. We then learn how to address these same issues at the city, county, and state levels.

We also learn how a bill goes from an idea to a proposition to a law (think Schoolhouse Rock with more hierarchy diagrams) and how to lobby at the legislature. We learn what government makes decisions relating to health care, who oversees programs for children, who distributes funds for public insurance, and some of the with intricacies and interplay between these governmental groups.

It is confusing, to say the least.

Whereas physicians our parents’ age had little use for these types of classes in their formal training, UCSF recognizes that it is not enough for their residency programs to create pure clinicians anymore. In this day and age, we must be trained in business and technology, entrepreneurship, and, moreover, in ability to maneuver within the legislature.

As it turns out, the advocacy program was an excellent introduction to our trip to Sacramento. We arrived the night

Continued on the following page . . .

MAY 2014 SAN FRANCISCO MEDICINE

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The SFMS group pictured with Assemblymember Phil Ting.

A Physcian’s Report from the Ground Continued from previous page . . . before the legislative hearings were to take place, eager to discuss our personal positions on the bills we were familiar with among our coresidents. We woke early to meet with the San Francisco Medical Society, to whom I am extremely grateful for teaching us the ropes and giving us a guide of do’s and don’ts (i.e., do arrive on time, don’t discuss campaign contributions). We were given an itinerary and split into groups so that we might meet with as many legislators as possible. We then left for the Capitol building.

It was incredible to see just how many people were filing through the hallways of the Capitol building. Different affinity and lobbying groups—schoolchildren, migrant workers, lawyers—were all scurrying about, trying to find Room 402 or Conference room A. Each legislator we met with was thoughtful and cared about our presence, though some of it was eerily like our practice sessions at UCSF. Limited time was a theme among all our meetings, and we struggled to say as many of our points as we could in ten- to fifteen-minute sessions. This was a challenge for the complicated issues that we felt passionate about. Out SFMS leaders were excellent guides to parsing down our anecdotes and positions into salient points. It was important for us to see, as residents, that our position mattered and our presence was appreciated.

The most memorable experience for me as a first-time spectator in committee hearings was when Dr. Richard Pan, a fellow pediatrician and assemblyman, turned to look at the audience and said, “I know there are many of you here to support this bill who are not able to speak individually today.

Please stand up if you are here in support of AB 1759.”

Watching the entire mezzanine stand up with me made me realize that, as physicians, we do have a say, and our collective voice is extremely important.

It is our duty to advocate on behalf of our patients—if not in Sacramento, then as best we can on a county, community, or institutional level. It made me feel hopeful for myself, future physicians, and our patients.

Amanda Posner, MD, is a second-year pediatrics resident at UCSF. She is originally from New York and is hoping to pursue a fellowship in pediatric gastroenterology.

Keynote speaker and Speaker-Elect of the California Assembly, Toni Atkins. Photo Credit: David Flatter.

PRESIDENT’S MESSAGE Lawrence Cheung, MD, FAAD, FASDS

Avoiding Overdose: A Drug Against Fatal Drug Abuse I recently learned about a collaborative project between the general medicine and family practice clinics at San Francisco General Hospital (SFGH) and the San Francisco Department of Public Health (SFDPH) on tracking the percentages of pain management registry participants prescribed intranasal naloxone.

These clinics offer intranasal naloxone to all patients receiving chronic opioid therapy for pain and any other patients that may be at risk. I think this an excellent public health policy.

A report from the Centers for Disease Control and Prevention (CDC), “Drug Poisoning Deaths in the United States, 1980-2008,” helps put this topic into perspective.

1) In 2008, poisoning became the leading cause of injury death in the U.S. (surpassing motor vehicle traffic deaths), and nearly 9 out of 10 poisoning deaths are caused by drugs.

2) During the past three decades, the number of drug poisoning deaths increased sixfold from about 6,100 in 1980 to 36,500 in 2008.

3) During the most recent decade, the number of drug poisoning deaths involving opioid analgesics more than tripled from about 4,000 in 1999 to 14,800 in 2008.

4) Opioid analgesics were involved in more than 40% of all drug poisoning deaths in 2008, up from about 25% in 1999.

This problem has continued to worsen and, according to another CDC report, more than 22,000 deaths occurred from prescription drug overdose in 2010, and 75% of these involved opioid pain relievers or prescription painkillers.

As we all know, naloxone is an opioid antagonist that can reverse the potentially fatal respiratory depression caused by opioid overdose. It has virtually no side effect except for the potentiating withdrawal symptoms to those already with opioids in their system. Naloxone is currently available in three forms: syringe, intranasal, and, most recently, the FDA approved an auto-inject pen (Enzio) that uses audible instruction to guide a layperson through the process. The cost of the syringe or intranasal form ranges $15-25 while the cost of the new auto-inject pen will be substantially higher.

Aside from the cost barrier, there is a psychological barrier associated with naloxone prescription. Some patients, particularly chronic pain patients, are worried that a naloxone prescription signals a lack of trust from their health care provider and that it could lead to a decrease in the medication dosing. Health care providers are concerned that a naloxone prescription may induce the patients into more risky behaviors, a similar argument used against the HPV vaccines.

As a result, since 1996, many community groups have been formed to distribute naloxone in hopes of early intervention to prevent death from opioid overdose. A report from WWW.SFMS.ORG

February 2012 from the CDC showed that from 1996 to 2010, 188 community programs distributed a total of 52,032 vials of naloxone that reversed 10,171 opioid overdoses. This report demonstrates that community distribution of naloxone can have a substantial impact in preventing numerous deaths from opioid overdoses.

From a legal perspective, the California state legislature has been fairly progressive in enacting laws that have gradually allowed greater distribution and use of naloxone. Our very own Assemblyman Tom Ammiano authored AB 635, the Overdose Treatment Act, which became law in 2014. This act is significant in that it explicitly allows health care providers to prescribe an opioid antagonist to a patient or anyone who is able to assist the patient in case of an opiod overdose. In addition, it offers health care providers protection from civil and criminal liability relating to the prescription and use of opioid antagonists. Lastly, it provides protection from civil and criminal liability for administering an opioid antagonist in an emergency. This effectively breaks down the legal barriers to the prescription and use of opioid antagonists.

This approach fits in the ever-growing recognition that “harm reduction” approaches—needle exchange to prevent infectious disease transmission being a now-established example—can not only be effective preventive strategies but can also garner trust and cooperation among drug users and even lead to treatment of the underlying addiction problem.

One we get past any initial judgment that such efforts must be “enabling” substance abuse, we can devise healthy, even lifesaving, interventions and programs.

Indeed, CMA has official policy on this issue:

1) That CMA support physician prescription of naloxone explicitly for potential future opiate overdose.

2) That CMA support first responders being trained and equipped to administer naloxone.

I applaud the general medicine/family practice clinics at the SFGH and the SFDPH for their work in promoting the practice of offering naloxone to their pain management patients. I hope that this practice will continue to gain momentum and support.

Further Information and Resources www.prescribetoprevent.org www.harmreduction.org

MAY 2014 SAN FRANCISCO MEDICINE

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EDITORIAL Gordon Fung, MD, PhD

Global Medicine There was a time when global medicine was the elective rotation for adventurous medical students or residents who spent four to twelve weeks in a foreign exchange program.

Many of these programs were established through the visionary leadership of certain medical schools and health institutions to create networks with international sites. Some trainees would have premedical international exposure through the Peace Corps.

Over the years, the number of programs offering such exposure to international volunteerism has grown, and there are specific program associations—e.g., the IVPA (International Volunteer Program Association), made up of seven full-member organizations: AYUDA (American Youth Understanding Diabetes Abroad), AMIGOS (Amigos de las Americas), CrossCultural Solutions, Global Citizens Network, Global Services Corps, Globe Aware, and Service for Peace. Formal programs have been established for fully trained physicians who want to take time off from their practices, have sabbaticals abroad, or transition after retirement into offering their expertise and services. There are also catastrophe relief efforts, for which volunteer medical teams travel to countries in need through the Red Cross and other ad hoc organizations.

Over the past few years, health care institutions and universities have developed programs of Global Health Sciences with the specific purpose of improving health and reducing the burden of disease in the world’s most vulnerable populations.

UCSF Global Health Sciences integrates UCSF expertise in all of the health, social, and biological sciences and focuses that expertise on pressing issues in global health. As with all institutions, GHS works with partners in countries throughout the world to achieve those aims. The institutions train students and early-career professionals with master’s degrees that prepare them for careers in research, policy, organizational leadership, program management and evaluation, and academia. One of the unique aspects of the UCSF program is a ten-week opportunity for students to focus on their particular area of interest, often in a hands-on setting or country of interest.

Many of the current practitioners in global medicine are the pioneers who worked in the field and developed their expertise as these academic programs were being developed. In this month’s issue we have the unique opportunity to learn from them. We begin with Kevin Starr, who describes his experiences in “Stumbling into Philanthropy.” In trying to make an impact on the burden of disease in developing countries, donors are looking for results. There is increasing awareness that just throwing money at a problem does little to solve it—and may do more harm than good. Even large philanthropic organizations, such as the Robin Hood Foundation, have learned that training and instituting organizational infrastructure are key to getting the results and delivering the measurable results that donors want to support.

WWW.SFMS.ORG

Providing expert, direct service is another crucial cog in global medicine. Many volunteer organizations are specialty and disease specific and can bring much-needed teaching and services directly to underserved communities. Kieran O’Brien and Nisha Acharya, Saam Morshed, and Megan Mahoney write about their experiences in specific medical missionary work in their fields.

Although global medicine focuses on the world’s most vulnerable populations, many in the U.S. feel that there are domestic communities that can meet those same criteria, and we should be aware that we can volunteer locally with the same energy and objectives. David Smith, a frequent contributor to San Francisco Medicine, recounts his experiences in San Francisco and the city’s impact on the field of addiction medicine—a growing medical problem locally and abroad.

Another level of assistance to any vulnerable population is working within the community to find local leaders or providers who can pass the mantle of training to others, expanding the reach of needed services throughout the community.

This follows the Chinese proverb, “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.” In that vein, Bruce Spivey’s article “Teaching the Teachers: Initiative from the International Council of Ophthalmology” discusses efforts to provide assistance to the community for a lifetime.

Finally, as editor, I want to mark the passing of one of our longest-standing members of the Editorial Board, Dr. Nancy Thomson. I am sure you read about her in the April issue.

She was passionate and energetic, always contributing to San Francisco Medicine through brainstorming ideas and writing articles, book reviews, and obituaries; she helped make San Francisco Medicine the award-winning journal it is today. She is sorely missed. Thank you, Nancy, for all you have done.

MAY 2014 SAN FRANCISCO MEDICINE

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Global Health

STUMBLING INTO PHILANTHROPY Turning a Lot of Money into a Lot of Impact Kevin Starr, MD I wasn’t looking for this job. My friend and mentor, Rainer Arnhold, MD, died while we were working together in the mountains of Bolivia. His family, bankers for generations, wanted to establish a foundation to carry on Rainer’s life’s work, and they invited me to be part of it.

I was an ER doctor. I didn’t know anything about philanthropy, the foundation world, or how international aid works.

I did know something of science and health, and I had a working knowledge of places where people are poor, and my job gave me time to travel. And so I traveled like crazy, visiting a lot of projects and organizations in a lot of sweaty places, trying to figure out what works—or what that even means.

In those early years, I’d go to philanthropy and development conferences, and it seemed as though there was some secret code—a code that, once broken, would allow even a rookie like me to embark on a glorious voyage of change. As an outsider, I was a little intimidated but figured that I needed to pay my dues.

After a lot of time in the field, I realized that there was no secret code. There were savvy people who could tell you what didn’t work, but only a few who seemed to know what did. It was disappointing, but liberating. At least I wouldn’t have to go to all those conferences.

Instead, I learned by doing—finding great mentors, making some painful mistakes, sucking the lessons from successes, and generally paying attention. And for better or worse, what we do now at Mulago came in response to what seemed to be missing in the sector. Here are the big things that were in short supply: Impact

Yes, impact. Inputs, outputs, activities, effort, money— nothing matters if you don’t create real impact, but in those early days, few seemed to be paying much attention to it. The doers weren’t measuring it, and the donors weren’t asking for it. Too often there didn’t seem to be much of it.

A single-minded focus on impact changed everything for us. It helped make sense of complicated projects and chaotic institutions. It drove the development of a lean, systematic approach to evaluation. Mulago was transformed from a traditional foundation into something that more closely resembled a venture capital firm—but a firm that sought impact in place of profit and measured its return on investment as the cost per unit of impact. That shift resonated with the bankers on our board and allowed us to work that much more closely together. We don’t fund anyone who doesn’t measure impact in a meaningful way, and we never will.

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Design By and large, the work of organizations didn’t seem designed. The norm was a loose collection of accumulated activities driven by a hazy central theme, with a big dose of “it seemed like a good idea at the time.” I thought there was a cool opportunity to develop a new approach to design for impact, and in 2005 we launched the Rainer Arnhold Fellows program to refine and deliver an iterative design process. In short, we now design by identifying exactly the impact an organization wants to have and figuring out how to drive the behaviors needed to make that happen (in fact, we’ve come to view Mulago as a bunch of money trying to change behavior). These days, design-for-scalable-impact occupies at least as much of our time as evaluation and portfolio administration.

A Businesslike Approach

I went to a hippie college with a business-is-bad culture, and a medical school where we all believed (not unreasonably) that Big Pharma and corporate health care are at the root of all evil. It took a me a long time to understand that business, at its core, is about getting stuff done, and that all organizations need to be run in a businesslike way. Once I got it, I realized that I needed a very smart grown-up around, so I hired Laura Hattendorf (over the course of a lunch), who has a Stanford MBA and an impressive track record in both the commercial and social sectors. She transformed the way we run the portfolio and, as working partners, we can focus on business and impact models equally and simultaneously. Our board has been very generous and has built the endowment considerably; I think that Laura did a lot to give them confidence that we—and the organizations we fund—are serious about how we do business.

Where we’ve ended up is this: Mulago’s mission is to meet the basic needs of the very poor. We fund organizations that 1) reach that target population, 2) have a solution designed to be scalable, and 3) can deliver it in a businesslike way. We give only unrestricted funding, and we continue funding as long as there is good progress toward impact at big scale. There are more than forty organizations in our current portfolio, and we’ve got a great bunch of cofunding colleagues.

Measuring impact, designing for impact, and applying business methods toward impact: These are not always easy, but they’re almost always doable and eventually make things a lot easier. It doesn’t make sense to sink dough into an organization that doesn’t measure its impact any more than it would to invest in a business that doesn’t measure profit and loss; designing together for impact gives you an understand-

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ing of what an organization really does and how the people there think; and the application of business methods and tools drives a whole new level of clarity and efficiency to the delivery of impact.

And here’s the best part: The people who run social sector organizations—the doers—are among the most inspiring and generally coolest people on earth, but when there is an asymmetrical relationship with us—the donors—that is focused on money, our relationships with them can get strained and weird.

A mutual obsession with impact can transform doers and donors into genuine, interdependent partners, and the clarity that it brings can—finally—make it possible to be friends.

Kevin Starr, MD, directs the Mulago Foundation and the Rainer Arnhold Fellows Program. A graduate of UCSF’s Family Medicine program, he practiced emergency and primary care for more than two decades before devoting himself full-time to philanthropy, both international and domestic.

Further Information and Resources For more on this topic, see the author’s previous piece in the SFMS journal: Starr K, Heilig S, 2013: “Hippocratic Philanthropy: Lessons from International Health” San Francisco Medicine, v.82 (2)19-20. Also see the following websites: • Mulago Foundation: mulagofoundation.org • Rainer Arnhold Foundation: rainer-fellows.org

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MAY 2014 SAN FRANCISCO MEDICINE

13

Global Health

PREVENTING BLINDNESS A Mycotic Ulcer Treatment Trial in Rural Nepal Kieran O’Brien, MPH, and Nisha R. Acharya, MD, MS

As the morning fog begins to lift, the dark, lush foothills beneath the white-tipped, jagged peaks of the Himalayas become visible beyond the bright green rice paddies. Mysterious and beautiful,

this scene not only sets the stage for daily life in the agricultural Terai region of Nepal but depicts an environment rife with opportunity to injure and infect the cornea.

Despite recent declines in infectious ocular diseases worldwide, corneal opacities remain among the leading causes of blindness globally. Corneal ulcers disproportionately affect the developing world, at rates up to ten times those seen in the United States. In general, antimicrobial treatment of corneal ulcers is effective at eradicating infection, but “successful” treatment is not always associated with good visual outcomes. The scarring that accompanies the elimination of infection leaves many eyes blind. In collaboration with our partners in the United States, India, and Nepal, researchers at the UCSF F.I. Proctor Foundation are working to reduce blindness through innovative studies on the treatment and prevention of corneal ulcers.

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Treatment Bacteria are common causes of infectious keratitis in both the United States and the developing world. Though antibiotics facilitate the resolution of the infection, they have no direct effect on the inflammatory sequelae that can impair vision. Some advocate the use of adjunctive corticosteroids to help inhibit the inflammatory process, but others worry about the potential for exacerbation of infection, corneal thinning, perforation, or increased intraocular pressure. The debate over the potential for corticosteroids in treating bacterial corneal ulcers has raged for decades.

In the Steroids for Corneal Ulcers Trial (SCUT), we aimed to provide additional evidence to guide optimal treatment practices for bacterial corneal ulcers.1 We partnered with the Dartmouth-Hitchcock Medical Center and the Aravind Eye Care System in South India for this study. Aravind is the largest eye care provider in the world and operates under a hybrid model in which nearly two-thirds of patients are treated free of cost. In a part of the world with exceptionally high rates of corneal ulcers, Aravind’s Cornea Clinic sees 2,000–2,500 ulcers each year.

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We enrolled 500 subjects with bacterial keratitis in SCUT and randomized them to receive adjunctive corticosteroids or a placebo. Overall, we found no difference in visual acuity or scar size between treatment groups after three months. However, there was some evidence that corticosteroids could improve outcomes in certain cases, such as among more severe ulcers or if provided earlier in the course of treatment.

Though rarer than bacterial ulcers in temperate regions, fungal corneal ulcers can be more difficult to treat and often have worse outcomes. Fungal ulcers account for nearly half of all corneal ulcers in tropical regions. Although corneal specialists believe existing treatments for fungal ulcers are only moderately effective, topical natamycin remains the only antifungal approved by the U.S. Food and Drug Administration for topical ophthalmic use. The newer topical voriconazole showed promising results in vitro, and in the past many specialists indicated they would have preferred to use topical voriconazole had it been available.

Working again with the Aravind Eye Care System, we conducted the first Mycotic Ulcer Treatment Trial (MUTT I).2 Here we compared the standard treatment with topical natamycin to the newer topical voriconazole. We found that natamycin was associated with better visual acuity at three months compared to voriconazole, with the improved results due to differences seen in a subset of ulcers caused by Fusarium species. In fact, this trial showed that topical voriconazole should not be used alone in the treatment of filamentous fungal keratitis, and the previously accepted, “moderately effective” treatment remains the standard of care.

Prevention

All in all, it has proven difficult to discern a difference between antimicrobials in randomized controlled trials of corneal ulcers. In fact, MUTT I was the only corneal ulcer trial we know of that found such a difference. Moreover, treatment may not always prevent poor visual outcomes after infection. Given the limitations seen with treatment, prevention may be our best opportunity to reduce the vision loss associated with corneal ulceration. In the United States, corneal ulcers are associated with contact lens wear, but in developing countries like India and Nepal, corneal ulceration most commonly affects individuals who have experienced ocular trauma. Such trauma is often experienced by agricultural workers, who can go on to develop a corneal abrasion and ultimately a corneal ulcer. Corneal ulcer patients in these countries may also experience worse outcomes related to delays in presentation, the inability to afford or procure medicines, or the lack of suitable donor material for corneal transplants.

Several prevention studies in Nepal, Myanmar, Bhutan, and South India have suggested that antimicrobial ointment applied promptly after a corneal abrasion could dramatically lower the incidence of ulcers.3 These projects also showed that it was possible to train village-level health workers to diagnose corneal abrasions and provide preventative care.

In the NIH-funded Village Integrated Eye Worker trial (VIEW), a collaboration with Aravind and the Seva Foundation, we hope to provide definitive evidence of the effectiveness of a village health worker program to prevent corneal ulcers. For WWW.SFMS.ORG

this community randomized trial in rural Nepal, we are working within an existing network of government-trained Female Community Health Volunteers (FCHV). These women currently provide basic health education and family planning services for their communities and are well respected throughout the country as local health care workers.

The VIEW research team is working in two districts with large populations of agricultural workers in the plains region of Nepal. FCHVs located in intervention villages will be trained to diagnose corneal abrasions using simple tools and to provide antimicrobial ointments to those villagers who present to them with abrasions. FCHVs in control villages will receive no additional training. Through an annual population-based census, we will identify villagers suspected of having a corneal ulcer in order to determine the incidence of ulceration in intervention and control villages.

Historically, the incidence of corneal ulcers has been difficult to determine. Modern technologies and unique innovations have facilitated our estimate of the incidence of ulcers in our study area in Nepal. We are using a custom mobile application on Google Nexus 5 smartphones to collect the census data, and a specially-designed Ocular CellScope photography attachment to take corneal photographs of villagers with suspected ulcers.

These tools have enabled us to easily collect an unprecedented amount of data and photos, which we hope to use to more accurately describe the corneal ulcer landscape in rural Nepal.

As we continue to explore treatment options through studies like our ongoing MUTT II trial, which examines the addition of oral voriconazole to topical treatment for fungal corneal ulcers, we are also looking ahead for opportunities for prevention.

While traditional infectious causes of vision loss like trachoma continue to decline around the globe, corneal ulcers remain among the top five causes of blindness today. But infectious keratitis is both treatable and potentially preventable, and we hope, with increased awareness of options for treatment and prevention, that we can add corneal ulcers to the growing list of historical causes of blindness.

Kieran O’Brien, MPH, is a research coordinator at the UCSF F.I. Proctor Foundation who works primarily with the International Program’s corneal ulcer studies in South Asia. Nisha R. Acharya, MD, MS, is director of the Uveitis Service at the F.I. Proctor Foundation and associate professor in the Departments of Ophthalmology and Epidemiology and Biostatistics at the University of California, San Francisco. Dr. Acharya’s research interests include designing and implementing clinical trials and epidemiologic studies in the field of ocular infection and inflammation.

References 1. Srinivasan M, Mascarenhas J, Rajaraman R. et al. Corticosteroids for bacterial keratitis: The Steroids for Corneal Ulcers Trial (SCUT). Arch. Ophthalmol. Feb 2012; 130(2):143-150.

2. Prajna NV, Krishnan T, Mascarenhas J. et al. The Mycotic Ulcer Treatment Trial: A randomized trial comparing natamycin vs voriconazole. Arch. Ophthalmol. Dec 10 2012; 1-8.

3. Upadhyay MP, Srinivasan M, Whitcher JP. Microbial keratitis in the developing world: Does prevention work? Int. Ophthalmol. Clin. Summer 2007; 47(3):17-25.

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Global Health

GLOBAL ORTHOPAEDICS Collaborative Partnerships for the Future Saam Morshed, MD, PhD, MPH

The impact of injury and musculoskeletal disease on global health continues to grow. The 2010 Global

Burden of Disease study11 estimates that injury accounts for 11 percent of disability-adjusted life years globally, with the majority occurring in low- and middle-income countries as a result of road traffic injuries. There are an estimated 1.2 million deaths and an additional 20 to 50 million nonfatal injuries from road traffic injuries.14 Appropriately, the WHO declared 2011 to 2020 a Decade of Action for road traffic safety.8 This public health effort to promote injury prevention is likely to have an enormous long-term impact. However, while awaiting effective policy and infrastructure changes, orthopaedic surgeons in low- and middle-income countries are managing an overwhelming volume of musculoskeletal injuries with limited resources.

The broad disparity in resources includes inadequate or nonexistent emergency medical systems, workforce deficiencies, and a dearth of material resources.10 Further, large gaps exist for education and research. Inadequate trauma care leads to profound human suffering unrecognized by the 16

general public. However, the need for improved musculoskeletal care in developing countries is not novel information to surgeons. There is a rich history of humanitarianism within the surgical specialties. Early efforts focused primarily on volunteerism through surgical missions providing direct patient care and surgery. Organizations such as Orthopaedics Overseas in the United States, World Orthopaedic Concern in the United Kingdom, and others have established numerous sites to facilitate clinical care and educational activities through volunteerism.4 Professional societies, such as the Société Internationale de Chirurgie Orthopédique et de Traumatologie (Society for Orthopaedic Surgery and Traumatology; SICOT), support conferences to share research, education, and networking opportunities.9 SIGN Fracture Care International, a nongovernmental organization, uniquely addressed the lack of orthopaedic implants by manufacturing and donating intramedullary nails designed for low-resource environments and by training local surgeons in their use.15 Another avenue with immense potential to reduce disability and improve orthopaedic care is collaborative partnership between resource-rich

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and resource-poor centers.

While this is not a new concept, particularly in nonorthopaedic specialties, we believe there is great potential for a comprehensive model of partnership that addresses clinical support, education, and clinical research.13 This type of institutional partnership supports low and middle-income countries’ centers in a longitudinal and sustainable manner. Support for local or regional conferences, exchange of residents and faculty, and mentorship provide connections for additional training through fellowships and observerships. The Internet provides a powerful tool that allows for instant communication, information exchange, and educational opportunities.6 An emphasis on exchange rather than a one-way flow of knowledge is crucial. By working with local leaders and educators at academic centers, there is a powerful multiplier effect as knowledge passes to future generations of surgeons through existing training programs.

Less emphasized but equally important is support for clinical research. Examples range from individual longitudinal mentorship for proposals and manuscripts to large-scale collaborative research studies. A qualitative investigation of orthopaedic surgeons in academic centers in sub-Saharan Africa highlighted an almost universal interest in participating in research studies.3 Surgeons cited academic advancement and research requirements for trainees as incentives to participation in research, highlighting the fact that academic models are actually quite similar. The dearth of resources and training in research methodology and inundations with clinical responsibility were cited as major impediments to progress. Despite scarce resources, we believe research represents a critical element in the development of academic institutions in low- and middle-income countries. Research addresses locally relevant clinical questions, creates a culture of intellectual curiosity, and promotes critical quality improvement.

Additionally, research may effectively advocate for greater resources from both local government and outside funders in order to affect crucial policy improvements.

As an example, we at the University of California San Francisco (UCSF) developed a partnership with the Muhimbili Orthopaedic Institute (MOI), an academic training center in Dar es Salaam, Tanzania. This began with an exchange of faculty and trainees for clinical observerships and conferences. After surgeons from MOI participated in a research course held in San Francisco, we embarked on a collaborative effort to design a prospective study evaluating outcomes of operatively treated femur fractures. UCSF assisted in developing a robust WWW.SFMS.ORG

research protocol, securing peer-reviewed funding, ethical approval, and providing inexpensive technologic aids such as small laptop computers and mobile phones for data collection as well as access to a free Web-based data collection system.

The day-to-day study activities are carried out entirely by the surgeons and staff at MOI, which is aided greatly by very modest funding for two local research coordinators. In addition to biweekly Web-based conferencing, biannual site visits have allowed UCSF investigators to continue to mentor the MOI research team, as well as trainees from both institutions, in the conduct of clinical research. To date, the study has enrolled more than 300 patients and achieved greater than 75 prercent follow-up at six months.

One cannot tout the successes of overseas involvement without also acknowledging that opportunity costs exist, such as the loss of revenue, burden to practice partners, absence from academic or administrative responsibilities, and time away from home. Nonetheless, many persevere in private practice and academia because the work is important; the question is, will it be valued by those in a position to support it? Its value to those who do the work is obvious (most everyone who has done this work confirms this), and the beneficiaries of the efforts nearly always are appreciative, but these are insufficient for sustainable programs. The support of one’s partners and family is critical. In the academic context, political will among department leadership is crucial to the longterm success of collaboration. At the University of California, the political will on the part of department chairs and division chiefs has been vital to the development of an overseas elective for residents that is more than a decade old.5 In 2006, the University of California established the Institute for Global Orthopaedics and Traumatology with the support of leadership, faculty, and residents. The institute’s mission is to promote global orthopaedic academic partnership.

Continued on page 19 . . .

MAY 2014 SAN FRANCISCO MEDICINE

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Global Orthopaedics Continued from page 17 . . .

The financial challenges of initiating global academic collaboration are significant. However, the well-documented epidemic of trauma outlined above should serve as a foundation and impetus to begin advocating for support from the governmental down to the departmental levels. There is precedent for success on the part of our professional organizations rising to face such acute challenges. The American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and the Orthopaedic Research Society速 have advocated successfully for unprecedented funding of vital skeletal trauma research to treat conditions faced by our wounded warriors as a result of recent conflicts.12 The time has come to focus our collective will to address the growing burden of orthopaedic conditions globally, or miss the opportunity.

For those who see this spate of musculoskeletal afflictions as a foreign problem not worthy of our attention, we would ask them to reconsider. In our increasingly interconnected world, problems of this magnitude have global repercussions.

In the United States, we are in the midst of a health care crisis caused by skyrocketing costs and indiscriminate obsession with unproven technologies and practices rather than value.1,2 While the outcome of the debate on this crisis remains uncertain, few would deny its critical importance not only to the health of our nation but to that of our economy, which itself affects the economies of many other nations.

Orthopaedic surgeons must similarly acknowledge this predicament and open themselves to the possibility that the answers will come from many places, not just from the surgeons of one country. Over time, most developed democratic nations and institutions have understood the folly of entrusting their welfare to a limited few of particular gender or ethnicity. Similarly, the possibilities of innovations that will transform orthopaedic care worldwide should not be limited by geographic boundaries. Any orthopaedic surgeon who had the opportunity to visit fellow surgeons practicing in developing nations and austere environments would attest to their remarkable creativity in addressing difficult problems with low-tech and affordable solutions. The SIGN intramedullary nail system, which was originally developed for use as an interlocking tibial nail in the absence of C-arm, was successfully adapted for use in the femur and humerus by innovative surgeons in developing countries out of necessity.

There are now centers in the U.S. under financial constraint who may begin using the SIGN nail as a low-cost alternative to more expensive implant manufacturers. This model allows cost savings for U.S. hospitals while simultaneously providing revenue for SIGN to continue donating implants in lowresource environments. By developing global networks and empowering leaders who may not otherwise benefit from the same resources that we have, we make a vital investment in the collective brain trust that will ultimately secure all of our futures.

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Another reason the orthopaedic community should embrace global involvement with an emphasis on academic and clinical partnerships is the remarkable interest in teaching and service that is rising within our community. The aforementioned efforts of numerous organizations are a testament to the commitment that our colleagues are willing to make in order to serve. Those who have not yet left our borders to participate but pride themselves on education in regional or national teaching activities will be inspired by the enthusiasm of learners from underdeveloped nations. One of the most promising phenomena has been the increasing number of domestic orthopaedic training programs that have developed overseas electives.7 These aspiring surgeons will fill our ranks with globally minded leaders. Just as our professional organizations have recognized the importance of developing a cadre of basic and clinical researchers to ensure that orthopaedic surgery will not be left behind, we must recognize the opportunity presented and secure career pathways and funding for those talented young surgeons looking to pursue global orthopaedics. Investing in career development awards through orthopaedic professional organizations, as well as governmental sources, will pay dividends.

We believe that orthopaedic surgeons should be proud of their embrace of volunteerism and educational activities, both locally and globally. Individuals and institutions should increasingly partner with academic institutions in low-resource environments to foster the development of clinical, educational, and research activities. This evolution of outreach will confirm our commitment to mutually beneficial exchange programs and the development of self-sustaining systems for improving orthopedic health care around the world.

Dr. Morshed is an attending orthopaedic trauma surgeon and director of the Clinical Research Center at the UCSF/San Francisco General Hospital Orthopaedic Trauma Institute (OTI). He is an executive member of the Institute for Global Orthopaedics and Traumatology, whose mission is to improve care of underserved populations affected by skeletal injuries through academic collaborations. His clinical practice is focused on skeletal trauma, surgery of the pelvis and acetabulum, and problem fractures including mal-unions and non-unions. A full list of references is available online at www.sfms.org.

Dear Abby at End-of-Life Care Event SFMS staffer Steve Heilig with the real Dear Abby, who has more than 110 million readers, at the annual lunch for Compassion and Choices, a leading advocate for better end-oflife care and policy.

Photo by SFMS member Robert Liner, MD.

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Global Health

MADE IN SAN FRANCISCO The Local Roots of the Free Clinic and Addiction Medicine Movements David E. Smith, MD, FASAM, FAACT In the early 2000s, I traveled to China as part of a WHO delegation. I helped facilitate the first Narcotics

Anonymous (NA) group in China in response to the nation’s rapidly growing methamphetamine and heroin problems, and I attended an Alcoholics Anonymous (AA) meeting in Beijing (Smith, 2004).

In 2007, the government minister in charge of addiction for Vietnam told me that the country’s growing economy was promoting the use of amphetamines and heroin, leading to increases in HIV disease and prostitution. Vietnam had no addiction treatment programs, nor were they aware of any AA/NA groups. In a subsequent e-mail, however, Peter Banys, MD, of UCSF/VA, described Vietnam’s intention to open pilot methadone maintenance/HIV treatment centers in Ho Chi Minh City.

UCLA physician/researcher Walter Ling has worked in Thailand to develop addiction treatment using methadone to treat addicts, as well as an adapted version of Matrix. More recent reports indicate that drug users in Southeast Asia and China are held in detention camps and may be subject to forced labor (Human Rights Watch, 2012).

Recent articles indicate that while addicts in Russia are not criminalized, treatment is strictly voluntary, with severe penalties for dealing and trafficking. The head of the country’s Federal Drug Control Service questions the effectiveness of methadone and does not plan to allow its use for treatment of heroin addicts. Distribution of clean syringes is also not supported (RT.com, 2014).

Where is all this activity on addiction coming from? First, it’s obviously a longtime, worldwide problem. But it can also be said that at least some of the attention, expertise, and action originated here in the San Francisco Bay Area. People here played a significant role in launching the concepts of free medical care and the disease model of addiction.

While most industrialized nations provide universal health care, obviating the need for free clinics, other nations have some access to free health care through charitable organizations. Programs for treatment of addictive disease are increasing throughout the world, supported by the efforts of the International Society of Addiction Medicine.

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“Better Living through Chemistry”?

San Francisco was the locus of a major sociocultural revolution that shook the world to its very foundation in the 1960s. Large numbers of young people flocked to the Haight Ashbury with a philosophy of “Better Living through Chemistry,” peaking in 1967 with the Summer of Love media frenzy, which generated worldwide attention (Brokaw, 2007). I was studying psychopharmacology at the University of California, San Francisco (UCSF), including psychedelic drugs such as LSD. When I walked down the hill, leaving my lab rats behind, I found myself in the midst of thousands of young people who were also taking the drug, most of them enjoying its effects.

What changed as the decade progressed? The dream became a nightmare with the beginning of the “speed epidemic” and its offspring, such as meth, ice, bath salts, and krocodil, which destroyed the Haight Ashbury in 1968 and continue to devastate urban and rural communities across the country (Edwards, 2011; Owen, 2007a, 2007b; Smith, 1969; Smith & Luce, 1971).

The history of this turbulent period is still being written; an excellent recent report is David Talbot’s Season of the Witch. In San Francisco and the Santa Clara Valley during the late 1960s, various cultural currents flowed together to create a fusion of flower and processor power—the nascent hacker subculture, the quasi-academics researching the effects of LSD on expanding human potential, and the Merry Pranksters celebrating LSD with music and light shows. In the Haight Ashbury there was the hippie movement, and in Berkeley there was the anti-war free speech movement. Illicit drugs opened “doors of perception,” and abuse closed them (Brand et al, 1995).

The Free Clinic Movement

One of the many social movements that came out of that psychedelic era was the Free Clinic Movement, beginning with the founding of the Haight Ashbury Free Medical Clinic on June 7, 1967, at the start of the Summer of Love. Founded on the philosophy that “health care is a right, not a privilege,” its organizers were motivated by the same liberation and civil rights principles as the other progressive, counter-establishment movements of the time. The Clinic was also a response to the growing drug epidemic, which began with pot and LSD, then devolved to speed and on through heroin (today we’re seeing the misuse of prescription opioids). Part of the original Clinic philosophy was that addiction is a disease and the addict deserves the right to treatment (Wesson, 2011). This was the beginning of the medical specialty of addiction medicine, now a board-certified specialty.

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In late 1968, we organized the National Free Clinic Council (NFCC) to provide organizational support and a network for information exchange (Smith et al, 1971). Currently, the National Association of Free Clinics (NAFC) has taken up the challenge of providing a centralized body for the free clinic movement. The association focuses on the issues facing free clinics today in the United States and has garnered media attention for the need for universal health care by sponsoring one- or two-day health care events in several cities during the past few years, often in conjunction with local health care providers (www.FreeClinics.us).

A 2005–2006 survey of free clinics reports that 1,007 free clinics offered a health care safety net in 49 states and the District of Columbia, providing medical and dental care for 1.8 million individuals annually. Their mean operating budget was under $300,000, and 58.7 percent received no government funding. The clinics typically provided chronic disease management, physical examinations, urgent/acute care, and medications. Over 80 percent of the clinics surveyed opened in the 1990s and 2000s, indicating the ongoing need for medical and dental services beyond government-funded Medicare and Medicaid and employer-funded private insurance. Almost a third of the clinics were associated with a hospital; over a quarter had a church affiliation (Darnell, 2010).

Free clinic patients were uninsured (92 percent), and over 80 percent were adults ages 18–64. Fifty percent were white, and the income of 97 percent fell below 200 percent of the poverty level ($19,140 for a single person in 2015). Those with substance abuse disorder made up just under 20 percent of the clinic population. Those with HIV/AIDS comprised another 9.5 percent of those seen (Darnell, 2010). In recent years, the Free Clinic Movement has spread across the U.S., with many faith-based organizations sponsoring new programs (Schmitt, 2011).

Overseas, WHO reports that most of Europe (including Russia), Australia, Canada, a few countries in South America, and the Gulf states provide universal health care to their populations (Stuckler et al, 2010). Nongovernmental organizations, churches, and universities have established permanent and short-term missions for primary and specialized care, such as HIV prevention and treatment, vision, dental, and surgery, in locations in Africa, Asia, and Central and South America.

Haight Ashbury Free Clinics in 2014

The Haight Ashbury Free Clinics and Walden House, two iconic 1960s San Francisco nonprofit health care agencies, merged into a single organization in July 2011 to provide primary medical care and addiction treatment services to the most vulnerable members of society. The combined organization’s leader, Dr. Vitka Eisen, CEO of the new HealthRIGHT 360, emphasized, “We now have the expanded capacity to provide comprehensive medical, substance abuse, and mental health care to the community we serve.” The combined organizations (incorporating Asian American Recovery Services in 2013 and Women’s Recovery Association in 2014) now create one of the largest private nonprofit health care and addiction treatment facilities in the United States (GarWWW.SFMS.ORG

cia, 2011), serving almost 24,000 individuals annually in their residential and outpatient facilities.

The Spread of Addiction Medicine

HealthRIGHT 360 serves as a model for integrating the medical culture and the addiction treatment culture in order to provide improved services in the era of health care reform (Roy & Miller, 2010). Its growth and assimilation of drug treatment and primary care programs reaffirm that San Francisco remains on the leading edge of innovation and integration of medical substance abuse and mental health services.

Studies indicate that for every $1 spent on substance abuse treatment, $7 is saved that would otherwise be spent on health and social costs (Parthasarathy et al, 2001).

Here in California, we’re well aware of the astronomical costs of incarceration, precipitating Governor Brown’s realignment of a segment of the prison population to local counties (Henry, 2011).

Internationally, the International Society of Addiction Medicine (ISAM), founded in 1998 with input from Bay Area addiction specialists, educates and develops guidelines for international physicians while providing avenues for collaboration through its annual meetings and the Internet. A major project has been the compilation of articles from almost 200 authors, including myself, in The Textbook of Addiction Treatment: International Perspectives, currently in press.

David E. Smith, MD, FASAM, FAACT, was honored with the 2013 Peter E. Haas Public Service Award from the University of California, Berkeley, on April 12, 2014 (photo below). The program included the chancellor’s remarks, a lecture by Dr. Smith on the importance of public education for public service, and a video prepared by the University (http://www.youtube. com/watch?v=Q8glI6dC1q4&feature=youtu.be, or search David Smith MD + Haas Award). The Peter E. Haas Public Service Award recognizes an alumnus or alumna of the University who, through his or her personal efforts, has made a significant public contribution within the boundaries of the United States. The award is intended to recognize activity at the grassroots level and to illustrate the impact that an individual can have on society through creative social change. A full list of references is availble online at www.sfms.org.

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Global Health

REVERSELY INNOVATIVE Experiences from Rural Kenya Megan Mahoney, MD Imagine you are a twenty-six-year-old doctor, working in a subdistrict hospital in rural Kenya.

You share the responsibility of seeing patients in this rural facility with only one other doctor, who doubles as the medical superintendent. And when he is gone, you are the one doing the budgeting, ordering supplies and medicines, and overseeing the staffing of the hospital. In addition, you were posted by the Ministry to work in Maasai land, and you do not speak Maasai and had to quickly learn the entrenched customs that influence health and health behavior. Overnight you become a resident in family medicine at a private tertiary care hospital in Nairobi. You adapt quickly to the way of practicing medicine in this new environment with a paying clientele, long list of available medications, and patients from all over the world.

The nimbleness of mind to be able to take in these varied novel clinical situations and make context-specific management decisions is supported by the executive function. Executive function is the set of mental processes that help us connect past experience with solving a problem or task at hand.

Whether we are working in a busy clinic, labor room, or emergency room, executive function keeps us focused on what is relevant and helps us problem solve when necessary, while ignoring distractions.

Physicians rely on executive function to adeptly make management decisions; troubleshoot given a medical, cultural, or administrative uncertainty; respond to novel situations; and perform technically difficult tasks. From my perspective after two years as residency director of a family medicine residency program in Nairobi, Kenyan doctors have an advantage in handling these situations.

This advantage starts from childhood. Executive function develops from early childhood until early adulthood, and our ability usually peaks in our mid-twenties. From an early age, most Kenyan doctors learn to speak at least two languages, Swahili and English. And most speak a third, their tribal language or “mother tongue.” Evidence supports the strong association between bilingualism and trilingualism and the development of executive function in childhood (and the delayed onset of Alzheimer’s disease), the so-called “bilingual advantage.”1 Through neuroimaging, it appears that bilingual people 22

use a different cognitive network to tackle a completely nonverbal problem, compared to their monolingual counterparts.

The link between multiculturalism and creativity in the workplace is well documented.2 By early adulthood, young Kenyan doctors are placed in new and authentic roles in the health care system in various geographic locations in the country. The usual course after graduating from medical school at the age of twenty-four is a year of internship, which can occur in eligible hospitals in the country that could serve one or two of the culturally distinct ethnic groups. After their internship, doctors are again posted by the Ministry in a different geographic and cultural district area with tremendous clinical and administrative responsibilities. Kenya incorporates incredible ethnic diversity, with almost seventy distinct languages spoken and dozens of culturally distinct African and non-African groups (Arabs, Asians, and Europeans)— with no group representing more than one-fifth of the population.3 These novel cultural and clinical experiences in early adulthood stimulate the executive system. As a result, doctors have an exemplary capacity for creative problem solving depending on the unique clinical and cultural situation of the patient, along with significant health care management experience, by the time they enter a residency program.

The prevailing and emerging family medicine residency programs in Kenya follow the directive of the Ministry of Health’s Family Medicine Strategy that “the Family Physician is the most appropriate person to respond to the challenges of the Kenyan health service delivery system” and build upon existing skills with curricula in health care management, adult education, community-oriented primary care, interprofessionalism, ethics, and continuous quality improvement. When family medicine residents embark on their master’s thesis, research that involves health system and population health and relates to health system improvement is particularly encouraged.

In the family medicine residency program at Aga Khan University, East Africa, in Nairobi, we have embedded authentic experiences in health systems improvement. First-year residents spend two months in a rural coastal area where most households live on much less than a dollar a day, with among the highest malnutrition and maternal mortality rates in the country. Residents not only work with government partners to provide quality care at the district hospital and affiliated health centers in an interprofessional team but they also conduct a home visit with community health workers and implement a health fair for 1,000 villagers. Secondyear family medicine residents work in the large network of urban-based primary care clinics affiliated with Aga Khan

SAN FRANCISCO MEDICINE MAY 2014 WWW.SFMS.ORG

Megan Mahoney (second from right) with family medicine residents and epidemiologist at the Integrated Primary Health Care Program in Kaloleni, Kenya.

University Hospital, Nairobi. The clinics are staffed by general practitioners who do not have specialty training. Along with offering a weekly family medicine clinic in these outreach centers, they are designing and rolling out clinical guidelines, providing on-the-job mentoring to the clinic staff, and learning other elements of quality improvement and quality assurance programs.

Third- and fourth-year residents work across a sub-county health care system. Through these experiences, they learn social determinants of health, health systems strengthening, principles of adult learning, population health, rural and urban medicine, quality assurance and improvement, and community engagement.

Across the globe, educational programs in the health professions are being called upon to respond to an increasingly complex health care landscape by including early exposure to health systems and population health.4 American undergraduate universities often offer international exchange programs, but there are few examples in health professions schools.

Health professions student exchanges can foster cross-fertilization among students from different countries and expose them to significant cultural and health care organization diversity.5 They can prepare students to practice in their own country with its diverse practice settings, cultural backgrounds, clinical manifestations, and resource levels, and further develop their innovative capabilities to tackle domestic health systems dilemmas. Obviously, future doctors would benefit from a global network of colleagues. The adaptability and creativity gained from an international health professions student exchange program could prepare future doctors to innovate in and improve on an ever-changing health care system at home.

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Megan Mahoney, MD, is associate clinical professor at the UCSF Department of Family and Community Medicine, and Family Medicine Residency program director and visiting associate professor at Aga Khan University, East Africa. She serves as lead of the Integrated Primary Health Care Program, a public-private partnership between UCSF, Aga Khan University, Kenya Ministry of Health, and the community to further primary health care system improvement in rural Kenya. She is the inaugural director of the UCSF East Africa Office supported by the U.C. San Francisco-Gladstone Center for AIDS Research, which promotes collaboration among UCSF and local researchers and educators throughout the region.

References 1. Marian V, Shook A. The cognitive benefits of being bilingual. Cerebrum. 2012 Sep-Oct; 2012:13.

2. Leung AK, Maddux WW, Galinsky AD, Chiu CY. Multicultural experience enhances creativity: The when and how. Am Psychol. 2008 Apr; 63(3):169-81.

3. Simons and Fennig (eds.). Ethnologue: Languages of the World, seventeenth edition. 2013. Dallas, Texas: SIL International. Online version: http://www.ethnologue.com. Accessed April 1, 2014.

4. Frenk et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet. 2010 Dec 4; 376(9756):192358.

5. Finkel ML, Fein O. Teaching medical students about different health care systems: An international exchange program. Acad Med. 2006 Apr; 81(4):388-90.

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Global Health

TEACHING THE TEACHERS Initiative from the International Council of Ophthalmology Bruce Spivey, MD, MS, MEd The International Council of Ophthalmology (ICO) is likely best known for its World Ophthalmology Congresses; the ICO examinations offered throughout the world

to help ophthalmologists evaluate their knowledge; and the ICO fellowships organized to help promising young ophthalmologists from developing countries improve their practical skills and broaden their perspectives of ophthalmology. In its global efforts to “Build a World Alliance for Sight,” the ICO is seeking to improve ophthalmic education by “Teaching the Teachers,” offering conferences, courses, curricula, and online resources to anyone involved in ophthalmic education, with the ultimate goal of raising the level of patient care. Components that helped shape this valuable initiative are numerous.

For example, in Mexico City, Mexico, in 2004, the first Residency Program Directors course was held. Course organizers Drs. Enrique Graue and Karl Golnik received an enthusiastic response from the residency program directors and ophthalmic educators in attendance, who were eager to further expand their teaching capabilities—reinforcing that more courses of this type were needed.

In Hong Kong, China, in 2008, more than 100 speakers participated in eighteen symposia on global educational initiatives at the ICO’s first World Ophthalmic Education Colloquium. In the keynote address, “Direction and Development of Ophthalmic Education in the Coming Decade,” I presented the ICO’s proposal on refocusing ophthalmic education. The talk’s main thrust was to rethink and redefine how we teach ophthalmologists and others to provide eye care.

In 2010, Kathleen Miller, now ICO executive director, interviewed educators to learn how the ICO could better help them become more effective teachers. Identifying teaching limited by static textbooks and resources that were either not translatable or regionally relevant, the educators actively supported the ICO’s focus on teaching teachers. Respondents emphasized the need for the ICO to either distribute or facilitate easy access to adaptable curricula and to online tools, information, and resources.

With this affirmation of need, the ICO advanced the Teaching the Teachers initiative by following three guiding principles:

Duplicate Nothing • Collect what is good • Adapt and translate

Create What Is Necessary • International curricula • Inperson educator courses and conferences • Web-based teaching course • Webinar network • Technology blog Share and Collaborate • Supranational societies • National societies • Regional subspecialty societies 24

Through Teaching the Teachers, educators develop relationships with other educators in their region; learn more about modern educational theory, methods, and tools; and are better supported in their efforts to raise the level of patient care.

Great Challenge, Real Opportunity

According to the World Health Organization, approximately 39 million people worldwide are blind and 246 million have moderate or severe visual impairment. The great tragedy is that 80 percent of this vision loss is avoidable. Though prevention and treatment options exist, many regions of the world are not learning about or implementing effective new ophthalmic techniques and best practices. A critical cause is the lack of effective training and continuing professional development for ophthalmologists and other eye health personnel.

The ICO, in partnership with its 130 national and multinational ophthalmologic member societies, aims to improve ophthalmic education through Teaching the Teachers. This global initiative helps ophthalmic educators become better teachers by providing customizable electronic tools and enhanced training tailored to local resources and needs. The intended result is more effective educational programs and better-trained ophthalmologists and eye care professionals worldwide, with improved patient care as the ultimate outcome.

Through funding support of the ICO Foundation and others, Teaching the Teachers programs include: Residency Program Directors Courses

Led by Dr. Karl Golnik, ICO director for Education, Residency Program Directors (RPD) courses focus on promoting resident education in ophthalmology by offering methods of instruction, assessment, and competency measurement. Trainers are provided with good practices from existing teaching models and offered modern educational theory, methods, and tools. Supported in part by the Allergan Foundation, the courses provide opportunities for educators to network and, ultimately, to raise the level of eye care in their part of the world. Since 2004, the ICO has conducted twenty-six RPD courses in eighteen countries/nations, impacting more than 1,100 program directors.

Regional Conferences for Ophthalmic Educators

The ICO Regional Conferences for Ophthalmic Educators support educators of all ophthalmic professionals and facilitate networking within the region. Workshops and special-interest group discussions are developed based on registrants’ interests to better ensure that the needs of that particular region are addressed.

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The World Ophthalmic Education Colloquium (WOEC)

Webinar Network

Open to all members of the ophthalmic community, the WOEC presents symposia on wide-ranging topics, including developing successful webinars, program and faculty evaluation, the teaching of ethics, and how to increase the quality of residency training through accreditation. The colloquium is integrated into the scientific program of the World Ophthalmology Congress® of the International Council of Ophthalmology and historically draws at least 300 attendees.

The Ophthalmology Webinar Network is a resource for sharing live lectures and archives of lectures from residency programs around the world. The network is the result of the combined efforts of supranational, regional, and national ophthalmologic societies and others.

World Ophthalmology Congress

Of all the educational offerings of the ICO, the World Ophthalmology Congress has the widest scope and broadest impact. In partnership with national and supranational societies, the global event is held biennially in different regions and provides ophthalmologists and educators with a scientific program addressing all subspecialties and interests in ophthalmology. The 2014 Congress in Tokyo, Japan, attracted more than 16,000 individuals from 129 countries.

ICO Residency Curriculum and Subspecialty Fellowship Curricula

A keystone of the ICO’s strategic plan for education has been developing educational curricula, most recently an expansive update of the ICO Residency Curriculum and creation of new, subspecialty fellowship curricula. Under the direction of Dr. Andrew G. Lee, project chair, and with the effort of international committees of subspecialty experts recruited from the four major geographic regions, the curricula offer a consensus on what should be taught and provide a standardized content outline for ophthalmic training.

Delivered online, the curricula are intended to be translated and adapted, with the precise local detail for implementation left to each region’s educators.

Attendees at ICO courses have overwhelmingly stated that they expect to improve their teaching effectiveness based on what they have learned. A lack of funding, experience, time, administrative support, and resources were listed by attendees as possible barriers to implanting these changes, but they noted that these barriers could be overcome if the ICO provided access to more resources and additional training opportunities.

There is growing interest in global health and increasing desire for equity in care, and extensive and avoidable visual impairment and blindness throughout the world compels a global commitment.

Knowledge, skill, and opportunity exist today to transform eye care, and the potential to have a multiplying and self-sustaining impact from Teaching the Teachers is great. Respected experts are poised to lead and execute a worldwide reform of ophthalmic education to preserve and enhance sight throughout the world.

Bruce Spivey, MD, MS, MEd, is president of the International Council of Ophthalmology. To learn more, go to www.icoph.org. Find tools, resources, and programs for Teaching the Teachers and sign up for the monthly Educators Letter at the ICO’s Center for Ophthalmic Educators at educators.icoph.org.

SFMS Letter Appears in San Francisco Chronicle Regarding Antbiotic Resistance

Center for Ophthalmic Educators

Scary news about overuse of antibiotics

The Center for Ophthalmic Educators empowers teachers of all groups to become even stronger educators by providing a vast array of resources and tools, including those used at ICO-sponsored courses. Developed by Dr. Eduardo Mayorga, ICO director for ELearning, and Dr. Gabriela Palis, the Center’s editor in chief, educators are offered an easily defined learning management system, with courses such as How to Teach, What to Teach, What to Teach With, What to Assess, and What to Assess With. The Center also offers news, events, blogs, and online discussions, and it includes online courses and workshops, including the following examples.

Editor: The Chronicle on May 1 featured two stories on the same topic with a frightening outcome.

First was “Drug resistance found worldwide,” noting that the World Health Organization found deadly bacteria to be harder to treat all the time and calling this “as big a threat as terrorism.”

The second story noted that a California bill to restrict antibiotic use in agriculture had failed because of “strong poultry and beef lobbies (“Antibiotics ban sought amid human resistance”).

The San Francisco Medical Society hosted a conference on this crucial threat a decade ago, when the evidence that mass feeding of antibiotics to livestock contributed to bacterial resistance was already strong. Such evidence has only grown stronger, and we persuaded the California and American Medical Associations to also oppose such routine use—as do many other medical and public health organizations. But still, politics impedes good policy, and thus we are left with what your story aptly terms a “ticking time bomb.” When might science and sense guide our policy on this issue?

Lawrence Cheung and Steve Heilig San Francisco Medical Society

Web-Based Teaching Courses

Three Web-Based Teaching Courses workshops have been presented to help teachers enter the Web-based teaching setting and enhance their effectiveness in both Web-based settings and in faceto-face encounters.

ICO Webinar Workshop

In 2013, the ICO began offering the Webinar Workshop: How to Broadcast Lectures and Live Courses Online, providing participants with the inspiration, tools, knowledge, and skills that allow them to develop webinars and greatly expand their teaching activities.

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MAY 2014 SAN FRANCISCO MEDICINE

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Protect Access to Quality Health Care and Patient Privacy OPPOSE THE MICRA MEASURE Here’s why a broad coalition of doctors, community health clinics, hospitals, local governments, public safety, business and labor opposes the proposed November ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals:

YOU MAY BE AWARE OF A TRIAL ATTORNEY-SPONSORED BALLOT MEASURE THAT WOULD UNDERMINE THE PROTECTIONS AFFORDED TO PATIENTS ACROSS CALIFORNIA AS PART OF THE MEDICAL INJURY COMPENSATION REFORM ACT (MICRA).

THIS NOVEMBER, these trial attorneys will ask voters to weigh

THE CALIFORNIA MEDICAL ASSOCIATION (CMA) has joined a

in on “The Troy and Alana Pack Patient Safety Act,” which

broad coalition of doctors, community health clinics, hospitals,

would make it easier and more profitable for lawyers to sue

local governments, public safety, business and labor to oppose

doctors and hospitals. This measure, according to California’s

the proposed November ballot proposition. Visit www.cmanet.

independent Legislative Analyst, could increase state and local

org/micra for more information about what CMA is doing in this

government malpractice and health care costs by “hundreds

fight and how to get involved.

of millions of dollars annually,” ultimately placing the burden of this additional cost on all of us.

AS IT STANDS NOW, county and state hospitals have to pay medical malpractice awards out of the budgets they receive from

Community health care clinics, like Planned Parenthood, say this measure will raise insurance costs that will cause specialists, like OB/GYN’s to reduce or eliminate services to their patients.

taxpayers. If medical malpractice awards increase, government costs will increase too.

Somebody has to pay, and that will be taxpayers through higher taxes and California citizens through higher health care costs.

NOT ONLY WOULD THIS MEASURE COST patients across the state, it’s a misleading measure intended to fool voters.

ADDITIONALLY, this measure would vastly increase the number

Written by trial attorneys, the measure makes it easier and

of lawsuits filed in California. That’s why the independent

more profitable for lawyers to sue doctors and hospitals —

Legislative Analyst says that county and state hospitals will see

even if that means higher health costs for the rest of us. Our

costs of tens of millions of dollars that taxpayers will have to

health laws should protect access to care and control costs for

pay.

everyone, not increase lawsuits and payouts for lawyers.

YOU’LL HEAR A LOT OF RHETORIC

support the measure. ‘It’s the ultimate

COMMUNITY HEALTH CARE CLINICS,

from the proponents of the measure

sweetener.’”

like Planned Parenthood, say this

but really, this is another example of

measure will raise insurance costs that

special interest legislation trying to

THIS MEASURE also requires a

will cause specialists, like OB/GYN’s

fool the voters into thinking this about

government database with personal

to reduce or eliminate services to their

something that it’s not. The authors

information on patients’ prescription drug

patients. Finding doctors to deliver

of this proposal purposely threw in

history. Hackers have already managed

children in rural areas and community

non- MICRA provisions, like drug

to access personal information from

clinics is already difficult and reducing

testing doctors, to disguise the real

millions of Target customers and even

services will make a bad situation worse.

intent, which is to increase the limits

the Pentagon, and another big database

on medical malpractice awards so that

will only make our information more

trial lawyers make even more money.

vulnerable.

OVER 1,000 GROUPS have joined

The main proponent of the measure was

together in support of MICRA and in

recently quoted in the LA Times, saying,

PHYSICIANS TAKE AN OATH to protect

opposition to this dangerous, costly

“The drug rules are in the initiative

patients – and this dangerous initiative

measure. Be part of the effort to protect

because they poll well, and the backers

would put patients at risk of losing

patients by visiting

figure that’s the way to get the public to

access to quality medical care.

www.cmanet.org/micra today!

savings of $ over 95,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s trial lawyers have launched an attack to undermine MICRA and its protections, and we need your help.

Membership has never been so valuable!

WAYS SFMS-CMA IS WORKING FOR YOU! 2012 SAN FRANCISCO MICRA SAVINGS CHART General Surgery

Internal Medicine

OB/GYN

Average

(Non-invasive)

San Francisco

$26,612

$7,392

$36,964

$23,656

Miami & Dade Counties, FL

$190,088

$46,372

$201,808

$146,089

Nassau & Suffolk Counties, NY

$127,233

$34,032

$204,684

$121,983

Wayne County, MI

$121,321

$35,139

$108,020

$88,160

FL-NY-MI Average

$146,214

$38,514

$171,504

$118,744

MICRA Savings

$119,602

$31,122

$134,540

$95,088

* Medical Liability Monitor - Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.

CMA_MicraCharts_SFMS_7.5x4.75_2013.indd 1

San Francisco Medical Society 1003 A O’Reilly Avenue San Francisco, CA 94129 Phone: (415)561-0850 Fax: (415)561-0833 5/24/13 10:23 AM

MEDICAL COMMUNITY NEWS KAISER

Robert Mithun, MD

SFVAMC

Diana Nicoll, MD, PhD, MPA

SUTTER PACIFIC MEDICAL FOUNDATION Bill Black, MD, PhD

Recognizing truth in the 1997 Institute of Medicine’s report “America’s Vital Interest in Global Health,” which states, “The direct interest of the American people is best served when the United States acts decisively to promote health around the world,” Kaiser Permanente is committed to global health. Kaiser Permanente International is a nonprofit subsidiary of the health care organization. Its goal is to improve health care systems around the world by sharing its knowledge and experience with governments, health plans, health care providers, and other organizations. Kaiser Permanente physicians and staff provide the education for these programs. In 2007, Kaiser Permanente developed its Global Health program, which aims to provide global health experiences to our physicians and residents.

Physicians and residents are given the opportunity to volunteer in underserved communities around the world, in a safe and organized manner. Programs are developed and maintained to assure that they provide adequate graduate and continuing medical education for participants. In addition, the program allows Kaiser Permanente to build relationships with existing international health care programs, medical facilities, and medical schools. Currently, there are programs in eight countries, and in the past five years, sixty-five residents and more than 120 physicians have participated. Kaiser Permanente has also partnered with nongovernmental organizations to provide disaster medical relief, including working with Doctors Without Borders. Kaiser Permanente has provided physicians to participate in ten emergency Doctors Without Borders missions to countries such as Syria, Afghanistan, Kenya, Sri Lanka, and Nigeria. Working with Relief International, Kaiser Permanente has provided disaster medical relief to missions in Haiti, Pakistan, and Peru, deploying more than 100 Kaiser Permanente volunteers. Kaiser Permanente empowers its staff to appreciate global issues and to bring this knowledge back to their local practices, making them more effective health care providers.

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In the Bay Area, many hospitals have noted increased incidence and severity of Clostridium difficile infections since 2009, due to the emergence of a new, virulent strain that is associated with a high complication rate and that disproportionately affects the elderly. In addition, hospitals across the country have been increasingly affected by infections due to multidrug-resistant organisms, which are associated with prolonged hospitalization plus increased morbidity, mortality, and cost. A recently described organism, Klebsiella-producing carbapenemase, has caused outbreaks in urban medical centers in the Eastern U.S. and is beginning to appear in Bay Area hospitals; treatment options for these organisms are limited. New strategies are needed to prevent the spread of such organisms.

On a national level, there is a new mandate to develop an antibiotic stewardship team consisting of infectious disease physicians, pharmacists, and infection control practitioners at each VA Medical Center. The goals of a multidisciplinary antibiotic stewardship program are to reduce cost and complications of antimicrobial therapy and to prevent the development of antibiotic resistance. The focus of the San Francisco VA antibiotic stewardship program has been judicious antimicrobial use in the hospital. This has led to sustained decreases in Clostridium difficile infections at our medical center.

Recent studies have suggested novel approaches to infection prevention in the hospital. In a recent report, the use of probiotics in hospitalized patients receiving antibiotics was reported to decrease the incidence of Clostridium difficile infection and antibiotic-associated diarrhea (Johnston, Ann Intern Med 2012). Another study showed the use of daily chlorhexidine wipes in ICU patients led to significant reductions in hospital-acquired infections (Climo, N Engl J Med 2013). These studies have led to new initiatives in our medical center to promote use of probiotics in selected inpatients receiving antibiotics and to perform daily chlorhexidine bathing for ICU patients.

Doctors at Sutter Pacific Medical Foundation have contributed to the health of populations in developing countries a variety of ways, from assisting after disasters to providing aid and support that makes a difference in the long term. Their work is truly impressive, and it also dramatically impacts the quality of life and medical care for those populations.

Recently, internal medicine physician Robert Napoles was in the area ravaged by the typhoon that hit the Philippines. The Filipino culture is in his blood, he says, as he treats many Filipinos in his practice, and he worked in that country as a Peace Corps volunteer. “The devastation is overwhelming. You use your experience to do whatever you can,” he said.

SPMF CEO Toni Brayer, MD, organized Sutter Health doctors and nurses to donate critical medical care in Haiti after the earthquake. They took twenty suitcases of medical supplies and provided hospital, pediatric, orthopedic, and ICU care. “Being able to provide care at the most basic level and connect with humankind is my reward,” she said. “I’m particularly proud my skills were put to use by Sutter Health to organize a massive relief effort.’’

Denise and Elliott Main, SPMF doctors practicing maternal fetal medicine, provide ongoing critical help for HIV/AIDs cases in Honduras, including widespread outreach to high-risk populations. The couple helped start three AIDs clinics, after learning about the plight of people with AIDS while doing relief work in the wake of Hurricane Mitch. The clinics, part of Siempre Unidos, were early providers of antiretroviral drugs. “It’s hard to walk away from this,’’ said Dr. Denise Main. “We wanted to develop infrastructure locally that we could support remotely.’’

The couple had to cut back on trips to Honduras due to escalating crime there, but they spend countless hours fund-raising.

At SPMF, we are pleased to support clinicians as they provide care and alleviate suffering globally.

SAN FRANCISCO MEDICINE MAY 2014 WWW.SFMS.ORG

CPMC

Edward Eisler, MD

New research by CPMC’s stroke team was presented earlier this month at the American Heart Association’s International Stroke Congress in San Diego. Results by Dr. Nobl Barazangi, Dr. David Tong, Sigrid Sorenson, and their colleagues showed that expanding the use of the S.M.A.R.T. approach to include more remote rural and community hospitals in addition to comprehensive stroke care centers can increase the number of AIS patients being treated, with positive patient outcomes at discharge and low mortality rates.

CPMCRI will soon be home to the latest technology in DNA sequencing, advancing our leadership in translational research and ultimately benefiting patients with illnesses ranging from cancer to age-related conditions. This month, new funding from the CPMC Foundation supported the purchase of an Illumina MiSeq®, a “next-generation” DNA sequencer that will enable our investigators to explore genetic variation underlying complex illnesses.

Congratulations to Grant Davies, CEO of Sutter North Bay Hospitals and executive vice president of CPMC, for his appointment to the board of commissioners for the Joint Commission. The Joint Commission works to improve the safety and quality of health care through education, publications, and consultation and evaluation services. Congratulations also go out to Abe Dosi, vice president, Administrative Services at CPMC, for being selected as one of the forty honorees in this year’s San Francisco Business Times publication 40 under 40.

A grand opening ceremony was held this past February to celebrate the opening of CPMC’s Bayview Child Health Center, the Center for Youth Wellness, and the Children’s Advocacy Center, a program of the San Francisco Child Abuse Prevention Center, at 3450 Third Street in the Bayview. The event, attended by California Attorney General Kamala D. Harris, Mayor Edwin Lee, San Francisco Supervisor Malia Cohen, City Attorney Dennis Herrera, District Attorney George Gascón, and Dr. Warren Browner, highlighted the colocation of the three service delivery partners.

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ST. MARY’S

Robert Weber, MD

St. Mary’s is looking forward to one of the most exciting events on our calendar each year: the Asian Heritage Street Celebration.

The annual event takes place this year on Saturday, May 17, from 11 a.m. to 6 p.m. near Civic Center Plaza, and organizers expect nearly 80,000 people to attend.

The St. Mary’s booth will be located near the main stage on Larkin Street (near Fulton Street), and it will be coordinated by our Asian Physicians Advisory Committee (APAC), which has served our community for more than twenty years. APAC offers more than 150 doctors, many of whom are bilingual in a variety of languages, to help serve the needs of our Asian patients. This is particularly important at St. Mary’s, where 30 percent of our patient population is Asian.

APAC’s services at the Celebration include providing free health screenings, answering questions Fair attendees may have, and even offering free ten-minute lectures in the Hill Physician tent next door. This truly is a fun and special event in our community, and I invite all of my fellow physicians to attend.

The St. Mary’s Primary Care Council asks that you mark Tuesday, June 3, on your calendar. That’s the date of the next Primary Care Symposium, and it will take place from 5:30 to 7:30 p.m. in Morrissey Hall (2250 Hayes Street) on the St. Mary’s campus.

The focus of this symposium will be weight loss surgery, and expert presenters are currently being scheduled. We anticipate this being an informative event, and CMEs will be offered. For more information, please contact Lydia Lee at (415) 750-5868 or Lydia.

Lee@dignityhealth.org.

SAINT FRANCIS Robert Harvey, MD, MBA

Saint Francis Memorial Hospital is happy to announce that we are one of the local agencies playing a vital role in a new initiative called the San Francisco Transitional Care Program. This is a citywide, four-to-six week hospital-to-home program that helps coach skills to build one’s confidence and ability to manage one’s own care in the home. It will help bridge the gap between a discharge and a strong recovery.

San Francisco’s Department of Aging and Adult Services is collaborating with City hospitals on this initiative, with Saint Francis providing community-based transitional care. With Saint Francis’ help, patients who are sixty-five and older (or adults with disabilities who are aged eighteen to sixty-four) will have increased access to our staff as well as to a system that integrates and coordinates community-based transitional care with admission and discharge processes to optimize the appropriate use of care.

These services will have an emphasis on nutrition, transportation, and care at home. The end goal of the program is to improve transitions of care, improve quality and safety, reduce avoidable hospital readmissions, and generate a savings to the Medicare program.

The San Francisco Transitional Care Program is another way Saint Francis is striving to increase health care access to an underserved population of our community. In fact, just last month my column touched on the 110,000 in grants we awarded to local nonprofit organizations that work to benefit the Tenderloin, which shares a neighborhood with our hospital.

As health care professionals, we have the profound ability to make our community a better, safer place. As our chief of staff, I’m proud that our staff accepts this responsibility wholeheartedly and constantly seeks ways to lend a supportive hand.

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www.thedoctors.com/TDCIS

PUBLIC HEALTH PERSPECTIVE Steve Heilig, MPH

Kids, Diseases, Vaccinations—and Parental Peer Pressure Vaccination is one of history’s most significant health advances. But California has had outbreaks of measles and pertussis in the past year. California also has a rising number of children not vaccinated for such diseases. Unsurprisingly, experts say these trends are linked—and such trends are worsening.

Some kids are not vaccinated because their parents can’t afford the vaccine—which has too often been poorly reimbursed or not covered by insurance at all. Some might not have easy access to health care. Some feel it is against their religion—the reason for an available exemption to mandated vaccination requirements for entering school. A recent CMA-sponsored and SFMS-supported state law requires that parents be told about vaccines by a health professional before not having their kid vaccinated. But the primary factor in the more recent increase in parents’ not having their kids vaccinated seems to be fears about risks of vaccines—especially increased autism. While that and other fears have been discredited in the scientific world, misinformation still spreads widely via the Internet and in social settings. Among die-hard anti-vaccine activists, no amount of evidence suffices to change their minds and actions.

There is a long and well-documented history of anti-vaccine sentiment going back over a century, with conspiracy theories and mistrust as common themes—in our time, those providing vaccines are even being murdered in some nations. Health professionals have struggled to develop effective, convincing messages to counter anti-vaccine sentiment.

Much of the mistrust and misinformation about vaccines is spread among parents (and, interestingly enough, both the most and least affluent families are often most prone to antivaccine propaganda). Parental peer pressure is powerful.

When head lice are found in a school, alerts to parents can be an effective tool in battling the problem. For this more serious issue, health professionals could do more to harness that power in favor of vaccines. The large majority of parents still do trust their pediatricians and other doctors and do vaccinate their kids. Not enough know that the decision by a minority of parents not to vaccinate can put all kids at risk—especially when the percentage of kids vaccinated falls beneath that needed for what is called “herd immunity.”

Thus, this modest proposal: At any school where unvaccinated children are enrolled, parents could be warned—and urged to take action by urging the parents of those children to heed both science and public responsibility and have their kids vaccinated. A poster with information such as that on the right could be posted at schools, parent/teacher meetings, and mailed to parents. It just might help. And even if this might be construed by some as “public shaming,” isn’t that sometimes justified when behavior can justifiably be called shameful?

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Sample Notice WARNING TO PARENTS Your child is now attending school with some students who are not vaccinated against serious diseases.

When a significant percentage of children are unvaccinated, that can put not only those children but also your own child at increased risks for such diseases.

Please talk to other parents about this important problem, both at school and before playdates and other such gatherings outside of school settings. This is doubly important if you have younger children at home, especially infants or other preschool children who could be exposed.

Three important facts:

1. The numbers of unvaccinated children are increasing, after decades of vaccines lowering disease among children. In many areas, some of this drop in vaccination is due to parental choice.

2. This increases outbreaks of communicable diseases, with more sick and even dying children than before. This is a more serious problem than alerts about head lice parents receive and respond to.

3. Vaccines do not cause diseases, including autism or other such conditions. Pediatricians and other doctors love their own children too—and have them vaccinated.

For the safety and health of all—please have your children vaccinated, and urge other parents to do the same! For more information on vaccinations from doctors, see the American Academy of Pediatrics: http:// www2.aap.org/immunization/

Steve Heilig is a public health advocate and medical ethicist with the San Francisco Medical Society and other health care organizations and is coeditor of the Cambridge Quarterly of Healthcare Ethics. A version of this piece appeared in the San Francisco Chronicle. A full list of references is available online at www.sfms.org or http://bit.ly/1iMDtwa.

MAY 2014 SAN FRANCISCO MEDICINE

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A N o r c A l G r o u p c o m pA N y

TEN QUESTIONS SFMS Member Profile: Andrew Snyder, MD, FAAP The San Francisco Medical Society is launching a new member spotlight column to feature profiles of leading stakeholders from the medical community and to get their personal views on medicine.

We hope to showcase members from across the SFMS spectrum to reflect the rich tapestry of our membership and help highlight some of the great work of our community.

1. What’s the biggest barrier to practicing medicine today? Complexity and burdens of the regulatory and reporting

requirements unlike those of any other developed country worldwide. Further, the frenetic pace required to succeed under today’s misaligned and varying reimbursement methodologies make it extremely difficult to provide comprehensive, caring, and coordinated care. One of the things we do at Brown & Toland is try to simplify reimbursement for independent physicians as much as possible, so they can do what they do best, practice medicine.

7. What is the most memorable research published since you became a physician and why? AIDS research

has been a remarkable success story that unfolded in the past decade.

Going forward, I believe the research that resulted in the Human Genome Project will eventually change medicine as we know it.

8. What is your advice to other physicians on how to avoid burnout? It is funny that we find it difficult to remember

how we practiced before mobile technology, even though it wasn’t that long ago. My best advice is find time every week to truly unplug!

9. Do you have a favorite hospital-based TV show? The first season of ER was pretty good, after that, I realized living medicine during the day and watching at night was not conducive to my mental health. House as a comedy has had some great episodes with some innuendos that only physicians could truly appreciate.

2. If you could change or eliminate something about the health care system, what would it be? Politics. The

10. If you weren’t a physician, what profession would you like to try? That depends; does my fantasy profession also

3. Why are you a SFMS member? Physician engagement has never been more important than during this time of rapid system reform. Physician education on the social-political issues affecting the practice of medicine and organized advocacy is critical for our professional success.

Professional Biography

overregulated oversight is an enormous administrative burden and an incredibly costly layer of our system that has not been shown to provide or promote higher quality or more efficient care. In fact, it has had the opposite effect. Partisanship and health care should not be in the same sentence.

4. What advice would you give to a medical student or resident just starting out today? Learn the business and

public policy of health care, in addition to learning medicine itself.

Further, truly understand Health Information Technology. Physicians are at a competitive disadvantage if they are not learning how to incorporate quickly evolving technologies into the practice of medicine and how they deliver care.

5. What’s the best piece of advice you’ve gotten in your career so far? Follow your passion, a career is a long time!

There is a lot of distractive noise in the system of care. Focus on what you love and make your area of interest a better place to practice through advocacy and leadership. Get involved; this is our business to make better.

6. What is the most rewarding aspect of being a doctor? Rhetoric aside, helping people, both as a clinician as well as at a

system level. We have much to improve upon in our delivery system to improve physician and patient satisfaction. Level heads must prevail.

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have to support my family and pay the bills? If I had more talent, being a professional musician would be very fun; and there are some days becoming a barista seems satisfying enough. Really though, if we as an industry better managed the administrative burdens causing stress and angst, there is no other profession that I would prefer.

Andrew Snyder, MD, is the Senior Vice President and Chief Medical Officer of Brown & Toland Physicians IPA, where he oversees all clinical programs including Care Management, Quality Improvement, and Utilization Management across all products and ACOs. A boardcertified pediatrician providing primary care and specializing in children with special healthcare needs and chronic disease, Dr. Snyder has a very broad background in healthcare. Prior to his position with Brown & Toland, he was the founder, president, and chief executive officer of Stamford Health Integrated Practices (SHIP), of Stamford, CT, where he managed the clinical and corporate operations. He also was vice president of Ambulatory Physician Network Development at Stamford, served as the physician officer at Lifespan and Rhode Island Hospital, and was the senior medical director at Lifespan/Physicians Physician Service Organization.

Dr. Snyder also served as medical director of Outpatient Services and vice chairman at Hasbro Children’s Hospital in Providence, Rhode Island. In addition to his professional experience, Dr. Snyder has held faculty positions with Brown Medical School. He is a graduate of the University of Connecticut Medical School.

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IN MEMORIAM

UPCOMING EVENTS

Ron Smith

5/20: San Francisco Physician Investment Group Meeting | 6:30 p.m. | St. Francis Memorial Hospital Ever wonder why Warren Buffet is so successful? Want to know how to choose equities, options, and mutual funds? Interested in becoming a better investor for retirement or to supplement your income? Local physicians are starting up a new discussion group in which doctors help doctors achieve their financial goals. Come join your colleagues for a stimulating evening. Novices to experienced investors are welcome!

Dinner will be provided. For more information, please contact George Fouras, MD, at geofou@sbcglobal.net. Please note: The views of investment group members are their own and do not necessarily represent the views of SFMS or have its endorsement.

Ron Smith, a leading local health advocate known to many SFMS members, died in March at the age of seventy-one. A longtime executive with the Hospital Council of Northern California, Ron played an important role in many issues of note, working with physicians all over town and beyond—and did so with not just expertise but humor and energy. His contributions are too many to list here—his San Francisco Chronicle obituary is easily found online - but we at the SFMS just wanted to express our sorrow at his passing and our gratitude for his presence. He was an esteemed and trusted friend and colleague to many at the SFMS.

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Sutter Health’s Institute for Health & Healing (IHH) is Recruiting Highly Skilled, Board-Certified Integrative Primary Care Physicians

We seek passionate, experienced physicians who employ a holistic approach to patient care and want to contribute to an innovative model of ambulatory health care transformation. IHH physicians and allied providers use evidence-based integrative modalities to address physical, mental, and spiritual health.

Physicians who join the Institute for Health and Healing clinics practice as part of Physician Foundation Medical Associates (PFMA).

PFMA is a multispecialty medical group exclusively associated with Sutter Pacific Medical Foundation, made up of over 160 physicians.

Sutter Health is a multibillion-dollar health care company with hospitals, foundations, and affiliated medical groups from Modesto to the Oregon border and is the second largest health care system in Northern California. EOE Interested parties should send a CV and letter of interest to mckinnk@sutterhealth.org. For more information about the IHH, please visit our website at www.myhealthandhealing.org.

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5/22 Webinar: Revenue Recovery—Effective Strategies to Maximize Collections | 12:30 p.m. to 1:45 p.m.

Collections have always been a challenging area for many practices, and they will be even more challenging with Covered California’s increased cost-sharing requirements. This webinar will present an overview of the various ways a patient becomes responsible for paying for services rendered, how long an account may be pursued, and the various methods used for revenue recovery. The webinar is free to all SFMS members and is $199 for nonmembers. Register at http://bit.ly/1iDLbh0.

5/30-31: Latino Health Conference | Santa Clara Convention Center This two-day statewide program will provide evidence‐based strategies for delivering more effective care to Latino patients. For more information or to register, please visit http://events.signup4.com/ LatinoHealthConference or e-mail Latino-Health-Conference@kp.org.

6/3: Primary Care Symposium | 5:30 p.m. to 7:30 p.m. | Morrissey Hall, St. Mary’s Hospital Hosted by the St. Mary’s Primary Care Council. For more information, please contact Lydia Lee at (415) 750-5868 or Lydia.Lee@dignityhealth. org.

6/5: California Preferred Medical Associates Annual Meeting | 6:00 pm to 8:00 pm Bothin Auditorium, CPMC California Campus Hosted by CPMA, the annual meeting features a CMA/SFMS presentation on Covered California contracting and reimbursement issues for providers. The event is open to all physicians. For more information, please contact MOverbay@pacifichealthalliance.com

6/4-5 Webinar: ICD-10 Documentation | June 4, 12:15 pm to 1:45 pm for Primary Care Physicians | June 5, 12:15 pm to 1:45 pm for Specialists Effective October 1, 2015, the U.S. government is mandating the shift from the existing ICD-9 code system to ICD-10, expanding the number of codes to more than 155,000 from 20,000. The June 4 webinar will focus on ICD-10 documentation for primary care providers, and June 5 webinar for specialists. Both webinars are free to all SFMS members and at $299 for non-members. Register at http://www.accma.org/ PracticeTools/ICD10.aspx or contact (510) 654-5383.

SAN FRANCISCO MEDICINE MAY 2014 WWW.SFMS.ORG

You have to pay for workers’ compensation insurance. But...

YOU DON’T HAVE TO In California, rates for workers’ compensation insurance are soaring.

In the second half of 2013, rates increased by an average of 8.7%.1 That’s after a 10% increase in the first half of 2013.2 Source: Workers Compensation Insurance Rating Bureau of California, http://www.wcirb.com/sites/default/files/documents/132023_010114_ amended_ppr_filing_complete.pdf

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SFMS members, call 800-842-3761 to see if you can save!

Are you paying too much for your workers’ compensation coverage?

Finding out is easy. Just call 800-842-3761 to compare your current policy with workers’ compensation insurance available through the San Francisco Medical Society.

This members-only program is available through Mercer. As the world’s leading insurance broker, Mercer can provide the outstanding service and expertise you deserve.

Call Mercer at 800-842-3761 today to get your free, no-obligation quote.

2 Source: Business Insurance, https://www.businessinsurance.com/ article/20130925/NEWS08/130929901

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Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 67125 (5/14) Copyright 2014 Mercer LLC. All rights reserved.

777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com

Robert W. Osorio, M.D., FACS, Chairman, Department of Transplantation

Surpassing national expectations is how we help you surpass yours.

At Sutter Health, we believe healthcare is better when patients come rst.

And now we have proof. A third-party report just found that our adult liver and kidney transplant programs at California Pacic Medical Center in San Francisco were unmatched by any other in the country.* So we’d like to congratulate CPMC’s transplant staff and thank our patients for putting their trust in us. Together, we’re making healthcare better. That’s how you plus us and we plus you.

Learn more at CPMC.org *Based on risk-adjusted survival rates published annually by the Scientic Registry of Transplant Recipients, CPMC was the only transplant program in the U.S. with better than expected survival following both liver and kidney transplants in adults.