November/December 2017

SAN FRANCISCO MARIN MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M A R I N M E D I CA L S O C I E T Y

MENTAL HEALTH 5150 Mental Health and Substance Use in SF

Political Psychiatry Adult ADHD Resident Burnout Child Psychiatry

PLUS: ANNUAL CMA MEETING REPORT

VOL.90 NO.9 November/December 2017

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE November / December 2017 Volume 90, Number 9

Mental Health FEATURE ARTICLES

MONTHLY COLUMNS

10 5150: Notes From An Urban Psychiatry Department

Mel Blaustein, MD

11 Public-Academic Partnership: Mental Health and Substance

Use in San Francisco

James Dilley, MD 16 Political Psychiatry: Goldwater and Beyond

Steven Reidbord, MD

18 Adult ADHD: The Societal and Personal Costs, Treatment, and Self-Management Mason Turner, MD, and Evelyn Miccio, PsyD 20 Behavioral Health: Emergency Department Task Force Report

Hospital Council of Northern and Central California,

San Francisco Section

23 Diagnosis: Resident Burnout: Finding A Prescription for Wellness Ryan Guinness, MD, and Lisa Chui, MD 24 Child Psychiatry: An Update Regarding Youth Involved with Child

Welfare and Probation George Fouras, MD 26 A Pause Does Refresh—and More Linda Hawes Clever, MD, MACP

27 Book Review: Leary in the Lab with Doctors Steve Heilig, MPH

SAN FRANCISCO

MARIN MEDICAL SOCIETY

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

SAVE THE DATE: SFMMS 150th Anniversary Celebration & Gala March 15, 2018 | St. Francis Yacht Club, San Francisco, CA In 2018, SFMMS will celebrate its 150th Anniversary. Save the date for a celebration not to be missed! More information and registration will be available soon at https://www.sfmms.org/ events.aspx. Sponsorship opportunities available—contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

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Membership Matters

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President’s Message Man-Kit Leung, MD

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Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

32 Medical Community News 34 Upcoming Events 34 Classified Ads

OF INTEREST 27 SFMMS and CMA Mourn the Loss of Former

CMA President, Rolland Lowe, MD 27 Responding to the Fires: Thank You!

Man-Kit Leung, MD

28 House of Delegates: Mental Health Report/

CMA Council on Science and Public Health

Donald Lyman, MD, MPH, Chair

29 California Medical Association Report/2017

Annual Meeting

Lawrence Cheung, MD

30 Leadership Profile: An Interview with SFMMS

member UCSF Dean Dr. Bruce Wintroub, MD

John Maa, MD, and Lawrence Cheung, MD 31 From Heat Emergencies to Mass Shootings:

Physicians Need to Take the Lead

John F. Brown, MD 33 In Memoriam: George Lee, MD

Erica Goode, MD 34 SFMMS Election Results

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMMS Members the wake of the accident, classmates of the victims worked with Assemblywoman Fletcher and CMA to develop legislation that would better equip servers and bartenders to identify signs of overconsumption and intervene before tragedy strikes. California is now the 19th state, along with the District of Columbia, to require that bartenders and servers receive mandatory training on alcohol responsibility. Oregon mandated responsible beverage service training three years ago and estimated a 23 percent decrease in fatal single-vehicle nighttime crashes.

Act Now, Avoid 4 Percent Medicare Penalty In 2019 SFMMS Featured Member: Mike Scahill, MD, MBA Dr. Mike Scahill is a pediatrician and Medical Director with the Virta Clinic (www.virtahealth.com). He was raised in Scranton, Pennsylvania, and studied biochemistry and history at Boston College before getting his MD and MBA from Stanford. Dr. Scahill completed his residency locally at UCSF’s Pediatric Leadership for the Underserved program. His formative experiences included working from the Dominican Republic through Kenya and Mozambique to India, which fostered an interest in global health and a passion for market based solutions to thorny problems of population health. These experiences led him to his current role with the Virta Clinic. SFMMS is pleased to welcome Dr. Scahill as our Featured Member! Read more about Dr. Scahill at www.sfmms.org/About/FeaturedMember.aspx.

Supporting Physicians Impacted By California Wildfires More than two dozen SFMMS members answered the call for volunteers to help staff a Marin evacuation site during the recent devastating wildfires in the North Bay. The California Medical Association (CMA) has identified dozens of physician members who have lost their homes or medical practices, and the CMA remains in close contact with county medical societies in the impacted counties. The Sonoma County Medical Association Alliance Foundation (SCMAAF) announced that half of its board members have lost their homes, and they have created a fire relief fund: SCMAA.org/Relief. The California Medical Association Foundation has also launched a donation portal at thecmafoundation.org/Cal-Fires and will work directly with county medical societies to ensure the funds reach those with the most urgent needs.

Gov. Brown Signs CMA-Sponsored Responsible Beverage Service Training Bill

Governor Jerry Brown recently signed a bill sponsored by the CMA and introduced by Assemblywoman Lorena Gonzalez Fletcher, requiring individuals who sell or serve alcoholic beverages to undergo responsible beverage service training.

The bill (AB 1221) is the result of a tragic drunk-driving accident that killed two UC San Diego medical students in 2015. In 4

This is the first year physicians need to report on quality measures under the new Quality Payment Program (QPP) from the Centers for Medicare and Medicaid Services (CMS). Eligible professionals who fail to report in 2017 face a 4 percent payment penalty in 2019. During the 2017 transition year, CMS will allow physicians to select one of three "pick your pace" participation options. Participating at any level in 2017 will ensure that you will not be hit with the 4 percent pay cut in 2019. The American Medical Association (AMA) has published a video, "One patient, one measure, no penalty: How to avoid a Medicare payment penalty with basic reporting," (https://www.ama-assn.org/qpp-reporting) with step-by-step instructions on how to report to avoid a negative 4 percent payment adjustment in 2019. The CMA has also published a MACRA resource page at www.cmanet.org/macra to help physicians understand the new payment reforms and what they can do now to start preparing for the transition.

Still No CHIP Funding Resolution in Sight

Federal funding for the Children’s Health Insurance Program (CHIP) expired on September 30, 2017. Although the successful twenty-year-old program has historically had bipartisan support, Congress was consumed by efforts to repeal and replace the Affordable Care Act (ACA) and missed the deadline to extend the program and its funding without interruption. Since its inception, CHIP has successfully provided children of low-income, working families access to comprehensive coverage, mental health services and essential preventive services, such as immunizations and developmental screenings, to prevent more serious illnesses and disease. California is one of five states that have already received emergency funding from Medicaid to keep their programs running. It is unclear, however, how long that funding will last.

The CMA continues to pressure Congress to act quickly to renew this critical, cost-effective program. CMA has urged Congress to reauthorize the program for at least five years at current funding levels to give states the stability to engage in long-term planning and innovation.

State Sees Marked Increase in Applications for Primary Care Residency Program Funding

The California Office of Statewide Health Planning and Development received a record number of applications for family medicine and primary care residency funding through the Song

SAN FRANCISCO MARIN MEDICINE NOVEMBER/DECEMBER 2017 WWW.SFMMS.ORG

Brown Healthcare Workforce Training Program (https://www.oshpd.ca.gov/ HWDD/Song-Brown-Program.html). In 2016, the California legislature passed a budget that committed $100 million over three years ($33 million each year) in health care workforce funding. Although Governor Brown proposed to eliminate these funds in his 2017-2018 budget, CMA and SFMMS fought to maintain this important funding, which is critical as we work to address California’s primary care physician shortage. Inadequate funding for residency programs exacerbates access problems—every year, hundreds of graduating medical students don’t find a residency slot in California to continue their training, forcing talented young doctors who want to stay and practice in California to other states and communities. Data shows that most physicians set down roots in the areas where they train and remain there after their training to care for their communities.

FSMB Releases Free Online Education Modules for Medical Students and Residents

The Federation of State Medical Boards (FSMB) has released a free online education module for medical students and residents who are interested in learning about the medical licensing process. The new module, “Understanding and Navigating the Medical Licensing Process,”(http://bit.ly/2yg3HvD) is designed to help medical students and residents familiarize themselves with the licensing process before they apply with their state medical board. This is the second module in a series of online educational offerings developed by the FSMB Workgroup on Education for Medical Regulation. The workgroup is currently working on future modules focused on the medical disciplinary process and dealing with physician health and impairment.

JOIN OR RENEW YOUR MEMBERSHIP TODAY!

When you join the San Francisco Marin Medical Society, you join more than 2,000 members in San Francisco and Marin who are actively protecting the practice of medicine and defending public health. Working together with you, SFMMS unites physicians to champion health care initiatives and innovation, advocate for patients, and serve our local medical community, including physicians of all specialties and practice modes. We cannot do this alone.

Join SFMMS/CMA Today to Receive 15 Months of Membership for the Price of 12 - Starting October 1, 2017, new members who join paying full 2018 dues, will receive the remaining months of 2017 membership for free.

Join today to start receiving your benefits. Visit www.sfmms.org/membership for more information about SFMMS membership and benefits, or to join online.

Renew Your Commitment to Medicine; Renew Your SFMMS Membership Today - Make sure you continue to receive the benefits of SFMMS and CMA membership by renewing today. Full dues-paying members enjoy a 5% Early Bird Discount* if your renewal is received by December 15, 2017. There are three easy ways to renew your dues: 1. Mail/fax your completed renewal form when you receive it in the mail; 2. Renew online at www.sfmms.org with your credit card; or 3. Enroll in Easy Pay Automatic Dues Renewal Plan** (quarterly installments) by contacting SFMMS at (415) 561-0850 or membership@sfmms.org.

*5% Early Bird Discount applies to 2017 full dues-paying members only who are renewing at the same level for 2018; renewal form and payment must be received by December 15, 2017. **Easy Pay Automatic Dues Renewal Plan (quarterly installments) is available to full dues-paying members only; renewing members receiving the Early Bird Discount are not eligible for Easy Pay.

WWW.SFMMS.ORG

November/December 2017 Volume 90, Number 9

Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Toni Brayer, MD Arthur Lyons, MD Chunbo Cai, MD John Maa, MD Linda Hawes Clever, MD David Pating, MD SFMS OFFICERS President Man-Kit Leung, MD President-Elect John Maa, MD Secretary Brian Grady, MD Treasurer Kimberly L. Newell, MD Immediate Past President Richard A. Podolin, MD MMS Officers President Peter Bretan, MD President-Elect Michael Kwok, MD Secretary/Treasurer Naveen Kumar, MD Immediate Past President Jeffrey Stevenson, MD SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Executive Assistant/Office Manager Maria Vega Membership Coordinator Mina Yoo SFMMS BOARD OF DIRECTORS Larry Bedard, MD Charles E. Binkley, MD Peter Bretan, MD Irina deFischer, MD Nida Degesys, MD David T. Duong, MD Benjamin L. Franc, MD Steven H. Fugaro, MD Robert A. Harvey, MD Imran Junaid, MD Naveen Kumar, MD Michael Kwok, MD Raymond Liu, MD Todd A. May, MD Jason Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Ray Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD

Monique D. Schaulis, MD Michael C. Schrader, MD Lori Selleck, MD Dennis Song, MD Jeff Stevenson, MD Winnie Tong, MD Matt Willis, MD Joseph W. Woo, MD Albert Y. Yu, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

NOVEMBER/DECEMBER 2017 SAN FRANCISCO MARIN MEDICINE

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We are HONORED to take care of Marin. Literally.

Enhanced by the transformative combination of medical expertise and the healing power of nature, Marin has been one of the longstanding healthiest counties in California. And, Marin General Hospital delivers an efficient, technologically advanced workplace where physicians and other clinicians can do their best work to keep our community in good health. We work hard to provide a top-notch medical hub where all of Marin’s healthcare providers can confidently send their patients.

Recently, Marin General Hospital earned Top Hospital designation from The Leapfrog Group, an award that honors only the most elite performers (top 3%) dedicated to providing the highest level of patient care. We are proud to collaborate with the outstanding physicians in our area to have attained this recognition.

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PRESIDENT’S MESSAGE Man-Kit Leung, MD

The Year in Review Every holiday season for me is a time of introspection and reflection. I was born on Christmas Day (much to the delight of frugal relatives who could cover two occasions with one gift), and like many others around my age, every birthday now comes with a self-assessment. Am I who I want to be? How can I be better? What can I do to be happier? I expect to face the same questions this holiday season as I reflect on how I spent this past year starting a new decade of life.

The highlight of 2017 for me no doubt will be presiding over this society. At the beginning of the year, the leadership of this organization pledged to advocate for our profession’s higher goals. These include the needs to expand access to healthcare and medications, to improve health outcomes through evidence-based science, and to provide medical care without undue administrative burden. The society also recognized the importance of social determinants of health, such as socioeconomic status, education, employment, social support networks, and access to health care, in driving health outcomes.

Consequently this past year, we advocated for legislation that extended parental leave protection for employees of smaller companies; that placed health warning labels on sugar-sweetened beverages; that supported supervised safe injection sites; that allowed blood transportation vehicles to use highoccupancy vehicle lanes; that prohibited tobacco retailers from selling flavored tobacco products in the city; that supported large grocery chains to report antibiotic use policies associated with meat products in their stores; that opposed extension of alcohol service hours; and that reformed outdated human immunodeficiency virus (HIV) criminalization laws. A considerable amount of effort this year was especially made to successfully win back funding to improve access for Medi-Cal patients. All the while, working with the California Medical Association (CMA) and the American Medical Association, we defended against repeated attempts at the federal level to undo progress made which extended health care coverage to millions of Americans.

Internally, our organization continued to grow bigger and stronger. This past year, the San Francisco Medical Society merged with the Marin Medical Society to form the San Francisco Marin Medical Society (SFMMS). This merger increased our total membership, decreased administrative inefficiencies, and augmented our sphere of influence. Our CMA Trustee, Dr. Shannon Udovic-Constant, won election to become the Vice-Chair of the CMA Board, and student member Rachel Ekaireb was elected the Medical Student Section CMA Trustee.

Dr. Pratima Gupta, SFMMS Political Action Committee Board member and delegate to the CMA House of Delegates, won the WWW.SFMMS.ORG

prestigious CMA Compassionate Service Award. Finally, current SFMMS Board member Dr. Peter Bretan announced his candidacy for 2018 CMA President-elect and delivered an eloquent and heart-warming candidate’s statement.

Above all, we have stayed true to our core values. These values include the beliefs that every life has worth, that everyone deserves to be healthy, and that everyone—regardless of religious creed, gender, gender identity, sexual orientation, ethnicity, and immigration status—deserves to be treated with dignity. Consistent with these values, this past year, we marched for women, for science, and for Pride. We supported our neighbors devastated by the Northern California wildfires through volunteerism and charity. We publicly decried policies that discriminated against Muslims, women, immigrants, and Dreamers, while denouncing racism, fascism, misogyny, and xenophobia in all forms whether subtle or overt. We continued to take a stand against the tolerance of intolerance, the permission of prejudice, and the indulgence of inequality.

It has been the privilege of my career thus far to serve this membership in my capacity this year. I am proud of who we are, what we do, and what we believe in. Thank you for being part of this society, for sustaining this organization of dedicated doctors, and for practicing and upholding the core values of our profession.

On its 150th birthday next year, the medical society will no doubt feel fully gratified by its identity and its achievements. I hope that on a distant Christmas Day in the future, I too will be able to attain the same level of fulfillment. Happy holidays to you and all!

Man-Kit Leung, MD, is an otolaryngologist—head and neck surgeon in private practice and the 2017 President of the San Francisco Marin Medical Society. He welcomes correspondence at mleung@sfmms.org.

NOVEMBER/DECEMBER 2017 SAN FRANCISCO MARIN MEDICINE

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EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

MENTAL, PROFESSIONAL, AND POLITICAL HEALTH In his 2015 TedMed talk, internist and former United States Surgeon General Vivek Murthy, MD, talks about his "prescription for happiness." Happiness has many benefits, it seems, both psychological and physiological, not to mention extending lifespan. But he notes that unhappiness was the most common factor he saw in many years of practice.

He cites a school in San Francisco's Visitacion Valley plagued by violence, stress, poverty, absenteeism, and all that comes with those problems. An innovative insertion of a secular meditation practice during school hours reduced many maladies schoolwide, he reports, as one student puts it, transforming a place of fear into one of hope. It's inspiring and hopeful as a sort of "prevention intervention," and clearly not enough, for clearly much more than meditation, or medication, is needed to address our nation's mental health maladies.

During his tenure as Surgeon General, Murthy continually spoke on mental health issues, including such issues less likely to be featured in the DSM like chronic stress and loneliness, and produced a landmark report on addiction, including the opioid crisis (see our September issue for reports from our conference on addiction issues). In his work he repeatedly lamented that very small percentages, perhaps 10 percent, of such problems are adequately diagnosed and treated. There are many reasons for that; the stigma of mental health problems and addiction, a dearth of personnel and resources leading to poor access to care, outright discrimination, dismal reimbursement, and yes, denial among the afflicted and those professionals and policymakers who might be seen as qualified and obligated to help them.

What is the result? We see it in our streets, our emergency departments, our budgets, our media, sometimes in our own families. And we see it in the increasingly common tragedies of gun violence, such as the recent mass shooting in Las Vegas. This is a complex issue, as "mental health" can be used as a scapegoat and diversion—not all, or even most, people with mental health problems are violent, and "improving mental health" would not fix the gun violence issue. UC Davis emergency physician Garen Wintemute, MD, is a leading gun policy researcher. We asked him about this seeming dichotomy, and he replied, "It’s a false choice. We need to improve mental health care because doing so will have many benefits, going well beyond firearm violence.

But only 4 to 5 percent of interpersonal violence is primarily attributable to mental illness. We need to address firearm violence in ways beyond improving mental health care."

At this year’s CMA House of Delegates, one of the three major topics for the organization was mental health. With the dedicated review of Council of Science and Public Health and input from experts in the field, the House discussed and resolved to establish policy to address the major gaps in inteWWW.SFMMS.ORG

grating mental and general medical health, increasing access, fostering high quality care through teams of providers, and continuing to monitor for gaps in care or losing patients in the cracks. The medical student section made significant refinements in the resolutions to make this effort more comprehensive and practical while maintaining the steps to improve the access and service.

So the battle is on many fronts. In this issue of our journal we are pleased to present an eclectic menu of contributions, from a report on how psychiatry looks on the frontlines of an urban hospital to how it is wrestling with "diagnosis" of a prominent politician. Current policy issues, both local and statewide, are presented in reports from our hospital association and CMA. Perspectives on training and physician well-being, foster children, suicide prevention, and more are presented. Our authors are dedicated experts. They tell of much good work. Yet for us as readers and editors, there remains a feeling of so much more to be done. Too much of the etiology, or at least the lack of sufficient response, of and to our chronic mental health crises is, for lack of a better term, political.

Surgeon General Murthy was reported to lose his post after the last Presidential election at least in part due to his speaking out so forcefully on such issues as gun violence and control, which he aptly labeled a public health issue. He paid a political price; given his expertise and wisdom, one might say our nation did too. This was political science, not the other kind. But Murthy seems to have emerged undaunted and still committed.

At his 2017 UCSF medical school commencement address, Murthy told the new physicians, "The world needs you to embrace your role as a moral leader in society. Being a moral leader leads by example, means standing up for truth, reason, and science. It means speaking out for the most vulnerable among us. It means holding elected leaders responsible for meeting the needs and upholding the values of our communities.

Historically, many of us have been reluctant to take on such a role. We've been told we should shy away from wading into controversies or appearing political. But your obligation from now on is to stand up for the vulnerable and the voiceless. And if that means engaging in controversy, or being labeled as political, then do it anyway. Because principles are only worth having if you have the courage to act on them."

Which certainly sounds like a healthy message to us.

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Mental Health

5150 Notes From An Urban Psychiatry Department Mel Blaustein, MD The third floor at Saint Francis Memorial Hospital is a twenty-four-bed acute inner-city unit with an average stay of three to seven days. Two thirds of the pa-

tients come to us from the Tenderloin where drugs are endemic as is homelessness, violence, and shattered lives. Three quarters of all admissions are suicidal or claim to be. More than half the patients are abusing street drugs and I don’t mean marijuana, which is as common as water. The bulk of our population come directly from our own emergency department (ED) but another third come from other EDs as far away as Los Angeles to Eureka to Sacramento. We have three psychiatrists, over twenty-five nurses, psychiatric techs, five social workers, therapists ,chaplains and security police. The unit is the second largest in the city handling a population comparable and as sick as that at San Francisco General.

All the patients are admitted on seventy-two-hour observation (5150) as suicidal, violent, or gravely disabled (too psychotic to provide food, clothing, or shelter). A superior court judge comes to the unit every Monday and Thursday for those patients who want to contest an extension of their original three-day hold taken out by the treating psychiatrist. Patients are also allowed to contest the ordering of medications against their will (Riese hearing).

Some sample admissions to the units: twenty-year-old single Filipino female dancing naked in the streets; sixty-fiveyear-old single white female believing men are breaking into her apartment and raping her; thirty-year-old Asian American male taken by the Highway Patrol from the Golden gate Bridge; fiftyyear-old single white male threatened to hit his mother with a baseball bat; thirty-four-year-old single Latino on cocaine believing that the mafia is after him.

Day-to-day operations on the unit are never predictable.

We might have a manic patient running up and down the halls, a depressed patient holed up in his room, or a self-destructive patient banging her head against the wall. Safety is a priority for patients and staff. We rarely have to involuntarily medicate and/ or seclude and restrain out-of-control patients. The turnover is quick and disposition is a priority from day one. Rounds are conducted daily with the treatment team. Groups are held regularly: art, process, yoga, exercise, and patio breaks.

atric admissions, no guns at home. A former government worker with three kids; owns his home, living with a friend. Diagnosis: major depression. Issue number one: assessing his suicide risk. Danger signs: elderly male (highest group); Asian (much shame, language problems); severe losses (wife, health, work); serious attempt. Positive signs: No prior attempts (number one indicator of suicidality); children (most protective factor); housing; friends. Also: no drugs, no alcohol. Monitored closely initially and then less so. Started on antidepressants (Remeron for sleep and appetite stimulation and/or Elavil, good for sleep but anti-cholingeric) plus anxiolytics Klonopin or Ativan (anxiety a dangerous indicator of suicide). On the unit for two weeks. Improved, attended groups, one to one meetings, plus medication.

Discharged to the community senior programs, follow-up care.

Note that suicide is the number ten cause of U.S. mortality.

Case 2. A twenty-two-year-old single white male abusing meth-

amphetamine with command auditory hallucinations to suicide.

Living in a tenderloin flat with four recent admits and parents burned out. Left animated, not hallucinating, to a halfway house.

Did not follow up. Suicided from the Golden Gate Bridge three months later. Mother called thanking me and saying he’s finally at peace. What may have happened: the continuation of auditory hallucinations, relapse on methamphetamine, and medication non-compliance. But surprisingly suicide is rare in this population from the inner city with so much depravation and drug abuse—a testament to the human spirit.

Mel Blaustein, MD, is the Medical Director of the Psychiatry Department at Saint Francis Memorial Hospital.

Two Case Studies

Case 1. A seventy-six-year-old widowed Asian male lacerated his

wrist after his wife of fifty years died two months earlier. Multiple medical comorbidities: coronary artery disease, hypertension, renal disease. On admission: poor sleep, weight loss, crying spells, hopelessness. No prior suicide attempts, no prior psychi10

SAN FRANCISCO MARIN MEDICINE NOVEMBER/DECEMBER 2017 WWW.SFMMS.ORG

Mental Health

PUBLIC-ACADEMIC PARTNERSHIP Mental Health and Substance Use in San Francisco James Dilley, MD Mental health and substance use problems are among the most common health issues facing health care systems around the world. For example, the World

Health Organization published data in 2015 suggesting that behavioral health disorders and drug and alcohol use disorders continue to grow and are expected to be in the next few years, the second highest among all medical conditions resulting in the inability to work. Not surprisingly, discharge data from Zuckerberg San Francisco General Hospital (ZSFG) is consistent with the impact of these kinds of disorders: three of the top ten discharge diagnoses in 2015 included: Schizophrenia/Psychosis, Medical Conditions related directly to drug and/or alcohol use, and Depressive Disorder.

Zuckerberg San Francisco General Hospital and Trauma Center

ZSFG is the city’s public hospital that serves over one hundred thousand patients per year. Owned and operated by the City and County of San Francisco’s Department of Public Health, ZSFG is also one of the nation’s top academic institutions, partnering with the University of California, San Francisco (UCSF) School of Medicine for more than 140 years. As such, physicians at ZSFG are faculty of UCSF and provide not only the most up-todate patient care, but also conduct research and clinical training of the next generation of physicians and a host of other alliedhealth professionals.

This article will focus on the activities of the UCSF Department of Psychiatry at ZSFG in the three areas of clinical care, teaching, and research that mark the primary missions of the University.

UCSF Department of Psychiatry at Zuckerberg San Francisco General Hospital and Trauma Center

The Department of Psychiatry at ZSFG was established in the early 1970s and developed a free-standing psychiatric residency program that focused on attracting young physicians committed to the idea of community psychiatry. Community psychiatry is an approach to understanding mental illness, care and treatment that highlights the importance of social factors in their impact on mental health and on developing services to address the needs of identifiable populations either with or at risk for mental health disorders/disabilities.

In the early 1980s, the program was incorporated into the department of psychiatry at UCSF and brought this perspective to the training of residents and medical students at the University.

Since that time, the department at ZSFG has retained its emphasis on community psychiatry, working closely with the City and CounWWW.SFMMS.ORG

ty’s Department of Behavioral Health Services. Funded primarily by the city and county of San Francisco, the faculty and staff in our department also successfully bid on state and local contracts and grants to develop new programs. As a result, the Department has grown steadily, creating new programs in response to the various needs of the city and county and remains an outstanding example of a public-academic partnership that works together to best serve the needs of the citizens of San Francisco. Some examples of these kinds of programs will be mentioned in the discussion of clinical services below.

UCSF Department of Psychiatry at ZSFG: Clinical Services

Our department is dedicated to providing culturally competent, evidence-based services to the diverse patient population we serve. With a commitment to the recovery model of care and emphasizing a commitment to the least restrictive environment possible, we provide care to thousands of patients each year. The Department is comprised of seven Divisions aimed at improving the lives of all we serve: Division of Acute and Emergency Services

Psychiatric Emergency Services (PES): San Francisco’s only 24/7 dedicated psychiatric emergency room that accepts adults placed on Emergency Detention Holds, that allows the police and mental health professionals with specific training to bring people to the hospital against their will for evaluation, treatment, and follow up care. Sixty percent of the eight thousand clients PES evaluates annually are on these holds. PES also provides consultation services to the ZSFG Medical Emergency Room and the city’s Child Crisis Services, and serves as the primary entry point to our acute inpatient beds for those in need of acute inpatient hospitalization.

Inpatient Care: Serving adults eighteen years and older and accounting for almost half of the locked inpatient beds in San Francisco, our inpatient units total forty-four community beds and an eleven-bed Forensic Unit that caresfor inmates too psychiatrically ill to be managed in the jail.

Consultation/Liaison Services (C/L): Helping our medical colleagues manage medical patients with co-occurring psychiatric disease, our C/L psychiatrists work to help such hospitalized medical and surgical patients manage their mental health disorders while recuperating from their medical illness.

Electroconvulsive Therapy Service: Administers this specialty intervention to patients both hospitalized at ZSFG as well as others in need of the service from the San Francisco Health Network.

Continued on the following page . . .

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Continued from the previous page Public-Academic Partnership Division of HIV/LGBT Services: Known as the Alliance Health Project (AHP), AHP is dedicated to providing human immunodeficiency virus (HIV) prevention services, including HIV counseling and testing, selected sexually transmitted disease diagnoses and treatment; and a range of mental health and substance abuse services to the city’s low-income LGBTQ and HIV-affected communities. These services include psychiatric medication evaluation and monitoring, individual and group psychotherapy, case management, and psychiatric crisis services. Serving some sixty-five hundred clients annually, AHP is dedicated to improving the well-being of the city’s LGBTQ community. Developed in 1984, AHP is one of the community psychiatry programs developed in response to a critical city need: providing mental health and behavioral health services to those affected by the devastation of the AIDS epidemic.

Division of Behavioral Health and Neuropsychology: Includes the Neuropsychology Service and the Primary Care Behavioral Health Team. Provides support to the physicians and patients of primary care the Family Health Center and the General Internal Medicine outpatient clinics. Serves forty-two hundred patients annually. Team members provide psychiatric consultation, crisis intervention and short-term treatment of mild-moderate common mental health conditions like depression and anxiety.

Division of Citywide Case Management: Provides assertive case management services (delivering medications to those in their hotels, providing lunch and other services at their facility downtown, helping negotiate disagreements with hotel managers and the like) to nearly one thousand of the most seriously mental ill patients in the city, as well as the city’s forensic mental health patients. Also includes the Emergency Department Case Management Program which provides long-term integrative care for 110 under served medically and psychiatrically fragile individuals who are high users of acute care at ZSFG. Division of Infant, Child and Adolescent Psychiatry: Provides a range of psychiatric care, and general mental health services to over three hundred children and their families from birth to twenty-four years of age annually at ZSFG, as well as child focused consultations to a number of community organizations and the San Francisco School District.

Division of Substance Abuse and Addiction Medicine: Provides opiate replacement therapies and other services, including HIV and Hepatitis C services focused services, to more than eight hundred people each day, both on-site and in the community via mobile methadone vans.

Division of Trauma Recovery Services: Another program developed to address a particular social need, this division provides multidisciplinary care to 750 victims of trauma and violence annually through the following programs: the Child and Adolescent Support Advocacy and Resource Center (CASARC) with a specific focus on sexual assault, this program provides forensic interviews and collection of forensic evidence for the San Francisco Police and District Attorney’s office as well as ongoing mental health care for the victims of assault; the Trauma Recovery Center (TRC), which provides mental health care and case management to victims of interpersonal violence; the Rape 12

Treatment Center (RTC), which provides analogous services to those provided by CASARC for adult victims of sexual assault; Survivors International (SI), which is focused on recent immigrants who have suffered torture and are seeking asylum status; and the Neurotrauma Outreach Program (NTOP), which provides care to those with traumatic brain injuries.

UCSF Department of Psychiatry at ZSFG: Clinical Teaching

Our department plays a critical role in the education and training of the next generations of psychiatrists at UCSF. We provide a range of innovative training experiences for all sixtyfour residents in the UCSF Department of Psychiatry Residency Training Program over all four years of their training. A large number of UCSF medical students also receive training in interviewing techniques and an introduction to psychiatric patients and common disorders.

Resident Training: Each UCSF psychiatry resident spends four intensive months in their first year of training on our inpatient units. Residents work closely with an on-unit attending psychiatric hospitalist and a clinical care team that includes nurses, social workers, and occupational therapists. Goals include: interviewing patients in various states of distress and obtaining historical information, formulating a differential diagnosis and initial treatment planning with an emphasis on psychopharmacologic interventions and beginning to understand the system of lower levels of care, and the strengths and contributions of allied health professionals.

All sixty-four residents also spend one month in their first year in our psychiatric emergency room, providing care for acutely ill patients, many of whom are brought in by the San Francisco Police against their will for evaluation and treatment.

Residents learn to triage patients, manage acute agitation, assess those actively suicidal or homicidal, and learn how to determine the most appropriate discharge and follow up care, based on the patient’s presentation and history. In their second year, half of the residency class rotates through our Consult-Liaison service for three-month blocks, learning to assist other services in the care of patients with comorbid psychiatric illness and medical/surgical conditions. In subsequent years, many senior residents choose to partake in our unique, advanced, specialty clinical experiences in the High Risk Obstetrics Clinic, the Infant Parent Program, and Childand Adolescent Psychiatry Clinics.

Fellowship Training: UCSF-ZSFG’s Public Psychiatry Fellowship: In 2011, we partnered with the San Francisco Department of Public Health (SFDPH) Behavioral Health Services to develop this one-year fellowship. Fellows are committed to the role of psychiatrists as physicians caring for people with severe mental illness. As such, these post-graduate psychiatrists spend four days a week delivering clinical care within a community mental health program in San Francisco County. One day a week, the fellows meet with the Fellowship Directors for didactics, case-based learning seminars, and supervision at ZSFG. During these Wednesday didactics, fellows learn about the history and organizational structure of public psychiatry, recovery, evidence-based psychosocial rehabilitation models, management, forensic topics, integration of care, homelessness, and advocacy.

A unique aspect of the Fellowship that separates it from

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others across the country is a focus on developing quality improvement projects to address some aspect of care at their clinical care site.

Now in its sixth year, the program has grown to five fellows annually, incorporates San Mateo and Alameda counties, and has been a successful recruiting tool attracting psychiatrists interested in the public psychiatry from all over the country.

UCSF Department of Psychiatry at ZSFG: Research

Consistent with our history and areas of interest, the Department of Psychiatry conducts a range of research at ZSFG, including projects focusing on: • Mental Health Services Research • HIV and Mental Health Care; HIV prevention/LGBT mental health • Substance use disorders and treatment • Integration of Mental Health and Primary Care • Reducing healthcare disparities for minorities with Serious Mental Illness • Prevention of Depression/Smoking Cessation/Worldwide Massive Open Online Interventions • HIV/AIDS and Hepatitis C virus (HCV) prevention and treatment/Health interventions • Perinatal Mental Health and Health Disparities • Health Disparities among Juvenile Justice Youth/Behavioral Health for Juvenile Justice Girls

The Future: In line with our commitment to serving the underserved and vulnerable populations in our city, we are constantly on the look out to develop new programs to address social needs. For example, in 2017, we are expanding our forensic services by providing psychiatric care in the city and county’s jail system.

In addition, under a new contract with the city’s Adult Probation Program we will be providing behavioral health and re-entry services for those on probation who suffer from mental illness, and we have applied for a similar program targeting adolescents involved with the juvenile justice system. We are also hopeful that our inpatient units will be remodeled and our emergency room expanded as psychiatry did not move into the new hospital that opened in 2016.

In sum, ours is a dynamic department dedicated to the ongoing care of the underserved and advancing knowledge about best practices in the different areas in which we work. We are grateful for this opportunity and appreciate the support provided by our partners at the San Francisco Department of Public Health.

Golden Gate Bridge Suicide Barrier Moves Forward Mel Blaustein, MD

I was invited to attend a recent briefing on the progress of the construction of the barrier on the Golden Gate Bridge. Attendees including family members Manuel

and Kimberly Gamboa, Dana Wittmer, and David Hull, who is also the President of the Bridge Rail Foundation. John Vadari represented San Francisco Suicide Prevention. Our hosts were Priya Clemens, Director of Public Affairs; Ewa Bauer, Chief Engineer; Lisa Locati, Bridge Patrol Captain; and Steve Miller, Bridge Deputy General Manager.

Driving across the bridge, you will notice fencing to protect the workers below, but attesting to the fact that something is happening. Construction is due to be completed January 2021, but it will not be until next summer that on the Western span of the bridge construction will be obvious.

At present, staging for the materials will be on Lincoln Blvd, with headquarter at the Bay Model in Sausalito. Constructing a barrier on both sides on this 1.7-mile-long structure is no mean task, but one that is important to complete. Already in 2017, at the time of this writing, we have had twenty-seven suicides, not far from last year’s thirty-one. This year, the bridge has been able to hire five new officers. They have already made 210 interventions.

The most positive part of the meeting was clearly the mood of the bridge staff and their appreciation of the urgency to complete the work. I’ll spare the readers the details regarding the scaffolding, the salt water maintenance, sources of the metals, the wind studies, and the fabrication of the steel nets. But let me just assure you that we are moving forward.

James W. Dilley, MD, is Professor of Clinical Psychiatry and Vice-Chair, UCSF Department of Psychiatry, Chief of Psychiatry at Zuckerberg San Francisco General Hospital and Trauma Center, and Executive Director of the UCSF Alliance Health Project. For more information, see psych.ucsf.edu/zsfg.

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POLITICAL PSYCHIATRY Goldwater and Beyond Steven Reidbord, MD The candidacy and election of Donald Trump has triggered a fierce debate in psychiatry over the “Goldwater rule.” This ethical standard of the American Psy-

chiatric Association (APA) prohibits its members from offering professional opinions about public figures such as politicians.

Largely uncontroversial for the past four decades, it is now under attack as a “gag rule” that blocks psychiatrists’ “duty to warn” the public about an allegedly impaired leader.

The Goldwater rule was a response to events preceding the 1964 presidential election. Magazine publisher and provocateur Ralph Ginzburg mailed a survey to over twelve thousand U.S. psychiatrists, asking whether the Republican candidate, Senator Barry Goldwater of Arizona, was psychologically fit to serve as president. The APA learned of this survey beforehand and warned Ginzburg not to report psychiatric opinions that lacked the usual clinical standards, i.e., a private doctor-patient relationship and careful evaluation. But Ginzburg knew the result he wanted and ignored this advice. Although only twenty percent of the psychiatrists responded, and only half (ten percent of those surveyed) said anything negative, Ginzburg devoted an entire sixty-page issue of Fact magazine to Goldwater’s purported mental instability. The front cover proclaimed: “1,189 Psychiatrists Say Goldwater is Psychologically Unfit to be President!”

Nothing was said about the silent majority. The issue included a lengthy psychological hit piece by Ginzburg, who had no mental health training, then dozens of pages of mostly negative material submitted by the surveyed psychiatrists. These comments included various alleged diagnoses of Goldwater, from personality disorders to paranoia, even schizophrenia.

After losing the election, Goldwater successfully sued Ginzburg and his magazine for defamation. In 1973, nearly a decade later, the APA published its first ethical code. It was based on the ethical code of the American Medical Association, “with annotations especially applicable to psychiatry.” The APA annotated section 7, regarding the profession’s interaction with the public, with language nicknamed the Goldwater rule. It remains unchanged to the present day:

“On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

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The APA argues that professional opinions about an individual, including but not limited to diagnosis, are only valid when derived from clinical interviews and other personal data. Media impressions are insufficient. The APA also believes that informal published opinions erode public confidence in psychiatry, indirectly discouraging patients from getting the help they need.

Finally, there is a danger of stigmatizing psychiatric language by equating having a diagnosis with unworthiness or unfitness.

Many individuals are unsuited for leadership even without a formal diagnosis. Conversely, a number of revered leaders, e.g., Abraham Lincoln and Winston Churchill, likely did suffer from emotional disorders. The APA has long cautioned against using specific diagnoses as proxies for employability or fitness for duty.

Since the rise of Trump, however, the Goldwater rule has been called into question. Some mental health professionals argue it is indeed possible to diagnose a politician based on public statements and behavior. Pointing to decades of video and reportage, these critics claim more is known about Trump’s character than about the character of any relatively new patient.

(Ralph Ginzburg said something similar about Senator Goldwater back in 1964.) They say many diagnostic criteria are simple observations that require no special expertise or interpretive skill. They say Trump’s narcissism is so blatant it is apparent for anyone to see. And they imply that establishing a diagnosis for Trump is tantamount to declaring him unfit.

Allen Frances disagrees. As former chair of the APA’s DSMIV task force, he authored the diagnostic criteria for narcissistic personality disorder. He says Trump is a classic narcissist, but does not qualify for a psychiatric diagnosis because he does not suffer from social or occupational impairment due to his narcissism. This claim, too, is hotly debated. (Note that Frances himself violates the Goldwater rule by offering this opinion.) He also argues that labeling Trump “mad not bad” obscures Trump’s real shortcomings. If the president is relieved of duty, it will be by impeachment for political reasons, not by the 25th amendment for psychiatric ones.

Critics of the Goldwater rule also claim a countervailing ethical duty to warn the public about a mentally unstable or dangerous leader. “Duty to warn” derives from the 1974 ruling in Tarasoff, in which the California Supreme Court held that mental health professionals have a duty to warn individuals who are threatened with bodily harm by a patient. (The court revised its ruling in 1976 to a more flexible “duty to protect.”) Critics argue that if psychiatrists must warn one member of the public, surely they must warn the whole populace when similarly threatened.

The APA counters that Tarasoff compels the release of private information, not already-public information such as a politician’s

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behavior. The court also expressly limited Tarasoff to the “special relationship” between doctor and patient; there is no such duty otherwise. Considering that mental health professionals widely argued against the original Tarasoff ruling, citing a duty to their patients, not to the public at large, this newfound “duty” regarding Trump seems more rooted in politics than professional ethics.

The Goldwater rule is an ethical stance of the APA, the world’s largest association of psychiatrists. Nonetheless, as a voluntary membership organization its rules carry no weight for non-APA psychiatrists, nor for other mental health professionals (although the analogous organization for psychologists, the American Psychological Association, similarly considers it unethical to diagnose a person who has not been examined). The worst penalty for violating the Goldwater rule is loss of APA membership—in theory, as it has never happened!—belying overheated rhetoric about censorship and gag rules.

For non-members of the APA who are worried about the sanity of our leaders, the Goldwater rule is, at most, a powerful symbol. The public has long used the language of craziness and foolishness to describe disliked political figures and viewpoints. Perhaps the real turning point of 1964 was the democratization of psychiatric jargon, i.e., the popular use of actual diagnostic labels instead of “nutty” or “bonkers.” As mental health professionals enter the political fray armed with diagnoses and learned opinions, they would be well-served to consider a paradox. On the one hand, psychiatry enjoys no privileged status in political discourse. Its views are as easily waved off as any other partisan critique. Warnings about Trump’s mental health are met with nods from his critics, dismissal by his base, and little else. The president’s supporters have been almost as quick to suggest damning diagnoses for Hillary Clinton and Nancy Pelosi. On the other hand, the former Soviet Union teaches us that alleged psychiatric incapacity can be a vicious weapon when wielded by those in power.

The introduction of psychiatric disqualification into American politics may be a Pandora’s box we someday regret having opened.

Steven Reidbord, MD, is a psychiatrist in private practice in San Francisco. Viewing his role as a mental health educator, he chairs the Continuing Medical Education (CME) committee at California Pacific Medical Center, teaches psychotherapy, clinical evaluation, and psychiatric ethics to residents, and writes about psychiatry and medicine for the public.

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Mental Health

ADULT ADHD The Societal and Personal Costs / Treatment and Self-Management Mason Turner, MD, and Evelyn Miccio, PsyD ADHD is a chronic neurobehavioral disorder that impacts individuals across the lifespan. The disorder

is comprised of a total of eighteen attentional and hyperactive symptoms that can wreak havoc on an individual’s life.1 Research studies on ADHD have identified difficulties in familial interactions, academic and employment arenas, social activities, interpersonal and intimate relationships, general day to day activities as well as the individual’s overall quality of life.2,3,4 The burden of compromised functioning due to ADHD has significant personal, occupational and health consequences that can be remedied with appropriate identification and treatment of the disorder.5

Cultural and Societal Interpretations

ADHD is often under-recognized and underdiagnosed, especially in adulthood, which may be due, in large part, to the initial conceptualizations of the disorder. Historically, it was viewed as a childhood disorder that individuals “outgrew.” However, it has become increasingly clear that this is not the case; it is simply presented differently in adulthood. Efforts were made to incorporate this awareness with the latest revision of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM5), with an adjustment to the diagnostic criteria in adulthood. Unfortunately, the DSM5 criteria have never been validated in adults, and does not include developmentally appropriate symptoms and thresholds for adults, and fail to identify some significantly impaired adults who are likely to benefit from treatment. Additionally, strong parental involvement assists children in managing behavior and compensating for attentional deficits. As individuals mature into adulthood and become more independent, symptoms can have a more profound impact and become more readily apparent.

Many individuals with ADHD have learned to compensate for their cognitive and interpersonal challenges, while failing to fully appreciate the full impact it has on their lives. Similarly, those around the individual with ADHD may wonder why there is a pattern of inconsistent performance across life domains, and may attribute these inconsistencies to a fundamental character flaw, such as being “lazy” or “unreliable” and “forgetful” to name a few less than favorable adjectives. A closer analysis reveals, someone with “ADHD may appear to function well; however they may expend excessive amounts of energy to overcome impairments; and they may be distressed by ongoing symptoms such as restlessness, mood instability and low self-esteem.” These life stressors associated with ADHD also result in, “increased accidents, medical resource utilization, antisocial behavior and drug/alcohol abuse”.6 16

The Consequences of ADHD Although the diagnostic criteria provide a conceptualization of the condition, and an operational professional definition of the disorder, it sorely underestimates the cumulative challenges of life with ADHD. For example, while not part of the DSM5 diagnostic criteria, problems with activation, consistent motivation, reliable productivity, harnessing cognitive resources to function on demand, and understanding the subtleties of social interactions, are common hourly challenges for an individual with ADHD. Novel situations, locations, duties and demands can instantly dismantle, or derail, the ability to function effectively, if the individual lacks solid compensatory strategies, or robust problem-solving tools. Given the insecurity of this clinical picture, many individuals with ADHD struggle with low self-esteem, hopelessness, anxiety, depression, relationship difficulties and employ unhealthy self-medicating substance abuse habits.

Brod et al. conducted a qualitative study across seven countries, with 108 participants, regarding the “Burden of Illness for Adults with ADHD” with focus groups “designed to elicit narratives of the experience of ADHD in key domains of symptoms, daily life and social relationships,” offering a sobering perspective on the reality of life with ADHD. The data collected also suggested, “the relevance of the diagnostic category for adults is not necessarily limited to certain countries and sociocultural milieus.”7

Importance of Assessment, Treatment, and Peer Support

ADHD is a dynamic condition with systemic problems, versus simply a checklist of inattentive and hyperactive symptoms.

In light of the evolution of ADHD as an adult diagnosis, adequate training for health providers is critical. Etiological heterogeneity can result in inconsistent presentations that may be overlooked, or missed as in fact, ADHD. Differences in methodological assessment of ADHD can also impact identification of the disorder. The characteristics, traits and clinical presentations of adult ADHD need further research and development in an effort to offer sound training, which would ultimately provide astute clinicians who can identify individuals with the condition. In the interim, if clinicians were to focus on an individual’s ability to plan, organize, self-motivate, and effectively manage themselves in relation to time, they are more likely to identify core challenges associated with ADHD.8 Healthcare resource utilization is high among the ADHD population, with higher rates of comorbid depression, sleep difficulties, headaches and anxiety creating undue distress and financial burden to individuals, couples, families, health care organizations, and society as a whole.9

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The treatment of ADHD is most effective when a combination approach is applied, specifically, pharmacotherapy intervention, psychotherapy, and peer support. Given the low self-esteem and stigma associated with ADHD, peer support is crucial, in that it provides a unique perspective that is both validating and reassuring for the individual struggling with ADHD, a bona fide condition, that they are not alone, nor simply “lazy” or “unreliable” and “forgetful.”

Pharmacotherapy has historically been the primary treatment of ADHD, however, cognitive behavior therapy (CBT) is the second evidenced supported treatment for ADHD and can also be highly effective in managing co-morbidities, including substance misuse and abuse. According to Dr. Ramsay, the cofounder and co-Director of the Adult ADHD Treatment and Research Program at the University of Pennsylvania Perelman School of Medicine, “CBT targets procrastination, disorganization, poor time management” by way of skills-based behavior change and skills performance. Ramsay highlights the “relevance of cognitive distortions in the conceptualization and treatment of adult ADHD.”10 Although the treatment focuses on cognitive thought processes, the emphasis in adult ADHD treatment is on the behavioral changes needed to improve overall functioning. A central problem of ADHD is poor self-regulation. The behavioral challenge is initiating behaviors towards desired actions, or a future goal. Dr. Ramsay further identified the importance of “behavioral engagement, bridging from intention to action” as a way to assist in facilitating goal completion, and a sense of accomplishment, versus frustration.

Treatment Strategies

Effective and empirically supported treatment packages combine individual and group interventions, which target various symptoms. Psychoeducation is an important initial intervention, as many individuals are unclear about the diagnostic criteria and how it applies to them personally. Simultaneous medication and peer support interventions are also recommended. Each individual with ADHD will have a different constellation of challenges, and may lack the insight to itemize their concerns, or recognize them as being associated with ADHD. Psychoeducation can also provide an avenue for creating a self-inventory of their individual challenges, which will serve as a template for their unique treatment and intervention approach. Peer support classes or psychotherapy groups can provide a venue for working on concrete skills, and establishing accountability partners that can assist with the daily maintenance of the newly learned strategies. One challenge in treatment effectiveness, is the recollection of the “homework” or work to be completed in between meetings with a provider. One strategy to combat this tendency to forget, or accurately recall the intervention, and feel hopeless, is the use of acronyms. For example, a comprehensive word tool was created by Dr. Miccio for the ADHD individual to quickly recollect how best to minimize, or “LESSON©” the impact of the symptoms of ADHD. The acronym “LESSON©” was devised to create a sense of agency regarding the daily impact of ADHD

See chart about LESSON

Although this tool may seem foolish, or inherently obvious to many, it has been utilized with adults with ADHD, and has been found to be effective, as well as reassuring that they can WWW.SFMMS.ORG

employ a quick and easy tool to improve their functioning, at will. Establishing goals, a plan and timeline will help provide the structure to succeed and manage the goals daily, weekly and monthly.10 This will also simultaneously combat negative thoughts, and low self-esteem. For clinicians, recognizing ADHD and treating the co-morbidities associated with the illness will result in improvement in social and occupational functioning, as well as enhance the quality of life for individuals who suffer with the disorder. As one of the most common psychiatric disorders, all psychiatric, addiction medicine and primary care clinicians should be familiar with the presenting symptoms and array of deficits that may result from the illness. With adequate and comprehensive treatment, patients with ADHD can manage their illness very effectively.

Mason Turner, MD, is board certified in Psychiatry and Addiction Medicine and serves as the Director of Outpatient Mental Health and Addiction Medicine for Kaiser Permanente, Northern California. He is also Assistant Clinical Professor of Psychiatry at the University of California, San Francisco. One of his primary clinical interests is management of co-morbid ADHD and substance use disorders, and he lectures extensively on this topic as well as other current issues in addiction medicine and psychiatry.

Evelyn Miccio, PsyD, in a licensed clinical neuropsychologist, and the Director of Neuropsychological Services and Resident Training at Kaiser Permanente Medical Center in San Francisco.

Dr. Miccio has worked at the medical center for eighteen years, specializing in adult ADHD. Dr. Miccio offers staff trainings on the disorder throughout the Northern California Region, and has created intermediate and advanced adult ADHD classes for adult members.

A full list of references can be found at www.sfmms.org.

Self-Care: How will you LESSON the symptoms?

Less screen, more green Exercise Socialize

Sleep

Organize

Nutrition

Example Goals:

I will turn off electronics one hour before going to bed, and I will spend ten minutes outside each day.

I will walk fifteen minutes today.

I will make one social engagement this week.

I will go to sleep and wake up within the same hour every day.

I will sort through laundry, mail, or wash dishes for fifteen minutes.

I will eat by 12:00pm today, with the assistance of an auditory alarm.

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BEHAVIORAL HEALTH Emergency Department Task Force Report Hospital Council of Northern and Central California, San Francisco Section The City’s emergency departments are a vital resource—designed, organized and staffed to provide core emergency services. That resource is under strain,

causing EDs to divert ambulances to other hospitals. At any given moment, at least one hospital (often two or more) is unable to accept patients. Yet, “diversion” is symptom of a larger challenge—the demand for services outpaces supply.

To understand the root causes, in 2016, the San Francisco Section of the Hospital Council of Northern and Central California (Hospital Council) commissioned a report (“Protecting San Francisco Emergency Services: Diagnosing and Addressing the Challenges of San Francisco’s EDs”) providing a detailed analysis of current ED utilization and diversion, a range of national case studies, and a comprehensive set of recommendations.

The report recommended the establishment of a Behavioral Health Emergency Task Force (ED Task Force) to identify the type, quantity, location, and funding of additional behavioral health and mental health capacity to relieve the strain on EDs and the over-reliance for psychiatric emergency services in the public and private sectors, an area of focus in the report. This is a shortened summary version of the Task Force’s preliminary report and recommendations.

Research indicates that ED crowding can have causes that reside far beyond the four walls of the ED. Upstream from the ED, ambulance routing and availability of alternatives can heavily influence the demand. Downstream from the ED, availability of acute, post-acute, and community-based capacity can prevent a timely discharge from the ED. The task force encourages the Hospital Council to plan for sufficient downstream capacity and continue optimizing the efficiency and safety of transfers, admissions, and discharges.

Having said that, inpatient boarding represents a unique challenge that would be difficult to address or even measure at the Hospital Council or the City level. During the initial data gathering, there was no consistent way across all emergency rooms to determine whether a patient was in the emergency room due to inpatient boarding and to assess the frequency and impact of this issue.

Even if such data were available, different hospitals adopt different clinical, operational, and administrative policies around transfers and capacity management, thus identifying one optimal approach that is right for all is challenging.

Recommendations

These preliminary recommendations, still to be finalized by the task force, are complementary rather than mutually exclusive and taken together constitute a balanced approach that addresses both the burning need and its underlying cause.

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Relieve ED strain by expanding the capacity of lower acuity psychiatric facilities like PES (Psychiatric Emergency Services).

Immediate relief through increases in locked psychiatric beds and PES-type services, coupled with interventions known to reduce strain (crisis stabilization, short-term crisis residential, etc.).

• Prioritize locked psychiatric beds. Also, support lower acuity settings such as: • Crisis Stabilization (less than 24 hours) • Short-term crisis residential, Acute Diversion Units, Urgent Care Services (2-21 days) • Transitional Residential (30 days to one year) • Respite (5 hours to 2 weeks)

Reduce ED utilization by increasing community based options that intervene in a developing crisis before acute intervention by the ED.

Preventative health services (focused on behavioral health) and social support options for homeless and at-risk individuals that address the root causes of issues leading to ED visits.

• Endorse support options that intervene in a developing crisis to prevent ED use.

• Systematic improvements. Invest in patient navigation, identification/tracking, and resource coordination; coordinate the collection of data—arrival, length of stay, and discharge information—for a subset of patients to inform policy decisions on the type of interventions and services needed.

• Invest in patient navigation, identification/tracking, and improve resource coordination among providers.

• Coordinate the collection of data (arrival, length of stay, and discharge information) for a subset of patients to inform policy decisions on the type of interventions and services needed, noted in above two recommendations.

Current Efforts

It is important to acknowledge the multiple efforts across the public and private sector to add more capacity, create programs and alternate destinations, and more. Yet, such efforts may not be sufficient with demand continuing to outpace supply as San Francisco can expect 305,000 to 340,000 ED visits by 2020 with the current growth rates, but they are a step in the right direction and will provide some assistance in balancing the demand and supply equation for ED services.

Notes on Recommendations Locked psychiatric beds. The ED Task Force discussed

adding locked psychiatric beds to provide more immediate relief

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to ED overcrowding. The general understanding is the central factor contributing to overcrowding was that locked psychiatric beds remain occupied with patients exhibiting behavioral health and/or intoxication symptoms who wait on an ED gurney for prolonged times (from hours to days) until those beds become available. By adding locked psychiatric beds, staffed with skilled nurses and potentially hold patients for up to several months; increasing the capacity in the ED. Members rated this option as having a high potential impact on overcrowding.

Adult Day Health Center. Task Force members proposed providing preventative health services (focused on behavioral health) for homeless and at-risk individuals to address the root causes that lead to ED visits, such as acute and severe mental illness coupled with methamphetamine use. The task force specifically focused on utilizing an existing space(s) (preferably in the Tenderloin or Bayview areas) to establish an Adult Day Health Center. A public-private partnership model is possible. This initiative would also fit within the broader eco-system of resources for the mentally ill including crisis hotlines and night shelters.

The task force also referred to the Rafiki Coalition and successful Adult Day Health Centers in Los Angeles and Alameda County as models to explore. It is important to note that the use of such services would be to be accessible 24/7 since those that can benefit arrive after hours in the ED. Members specifically proposed improving management and tracking of emergency department processes and operations (including patient inflows and outflows). This opportunity includes enhancing current patient navigation and care coordination as well as connecting behavioral health patients with already available resources in the City and more appropriate care and care settings.

Increase use of lower acuity care settings. The ED Task

Force found that a driver of ED overcrowding was a lack of alternative lower acuity care settings. A shortage of post-acute psych beds has created a “backflow” of patients.

The ED Task Force found there is a shortage of beds for PES to discharge their patients to, thus, PES has to hold patients longer than appropriate causing a tripling of their diversion rate in five years. Because of increased PES diversion, acutely ill and agitated psychiatric patients that need PES wait on an ED gurney for prolonged times, displacing acute medical patients in the waiting room.

Expand existing PES. The task force members confirmed that there is infrastructure in place and room to expand the existing PES, a plan already being explored and therefore is not a priority for the task force.

New facility for psychiatric emergencies. This report

notes the value of expanding PES type services and related efforts, but the ED Task Force did not endorse building a new facility like the current Alameda County PES (John George) due to the financial cost. The ED Task Force noted the challenges in PES, such as creating silos and limiting integration.

New community triage clinic. Task force members proposed establishing a new community (or converting an existing) WWW.SFMMS.ORG

clinic in a neighborhood with a high rate of mental illness-related arrests and jail detentions to provide access to behavioral health services and to reduce mental health arrests. This clinic could also serve as a triage center (similar to models in Cook County, Chicago). Members expressed concerns, however, that establishing this type of center could stigmatize a neighborhood.

Sobering Center. A successful public-private partnership

that treats intoxicated patients in the proper setting while reducing the strain on the City’s ED is the Sobering Center. Since July 2003, the Sobering Center has provided care for 14,000 individuals for a total of 48,000 encounters. Nearly 40% of the clients arrive via ambulance with another 10% from emergency department referrals. Those arriving by ambulance are direct diversions from emergency departments, providing relief to overcrowding and unnecessary admissions. Of note, the percentage of clients requiring a higher level of care—with referrals to medical or psychiatric emergency departments—remains at less than 4 percent overall. The Sobering Center has been able to form ongoing relationships with frequent users and provide the support necessary when they are ready for positive change.

Again, these are preliminary recommendations that will require final approval by the Task Force, and then consideration for implementation.

Behavioral Health Emergency Department Task Force: Brett Andrews Positive Resource Center John R. McQuaid, PhD San Francisco VA Healthcare System/ Langley Porter UCSF Steve Fields, MPA Progress Foundation Alan W. Newman, MD California Pacific Medical Center Victor Garcia, RN California Pacific Medical Center David Pating, MD Kaiser San Francisco Medical Center Kavoos Ghane Bassiri SFDPH Behavioral Health Services Maria C. Raven, MD, MPH, MSC UCSF School of Medicine Susan Lambe, MD UCSF Medical Center Jeffrey Schmidt, RN, MPH Zuckerberg San Francisco General Hospital and Trauma Center Mark Leary, MD Director of PES at ZSFGH Abbie Yant, RN Saint Francis Memorial Hospital Daniel R. Ruth The Jewish Senior Living Group

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Mental Health

DIAGNOSIS: RESIDENT BURNOUT Finding A Prescription for Wellness Ryan Guinness, MD, and Lisa Chui, MD An altruistic medical student is about to enter residency training. They are excited about becoming a doctor and

the prospect of caring for patients. What follows in the coming years, however, is a decline in the very same compassion that motivated them to pursue a career in medicine. Empathy is eroded as they experience time-constrained patient interactions in the clinic, on the wards, or in the operating room. They also practice alongside faculty with increasing workloads and pressure to generate greater clinical revenue for the same medical center where the teaching program resides. Nonetheless, residents are expected to manage their emotions and achieve the best possible outcomes without making mistakes, because there’s little room for error.

The Problem

Barriers to seeking help are widespread in training culture.

Arguably, residency is a setup for burnout due to a culture of perfectionism, high levels of stress from heavy workloads and long hours, the challenging nature of working with people who are sick, and life changes that happen to young physicians. The statistics are sobering. In a recent article published in The Journal of Graduate Medical Education, resident wellness was found to be significantly lower compared to the general population in seven of eight studies that were included as part of a recent systematic review of wellbeing in residency.1 Moreover, in a cross-sectional study comparing residents across postgraduate year, PGY-1 residents reported significantly less satisfaction with lifestyle than PGY-2 and PGY-3 residents.2 This was even more pronounced for female residents compared to their male counterparts.3 Clearly the rigors of training have been shown to affect the wellness of resident physicians. The important question is what can be done to respond.

Previous Attempts to Address the Issue

In 2003, national limitations on resident work hours were introduced by the Accreditation Council for Graduate Medical Education (ACGME) with the intent of improving resident wellness, education, and patient care. These limitations were followed by more aggressive recommendations put forth by the Institute of Medicine in a 2008 report.4 Yet, are limitations on work hours effective in preventing burnout? So far, studies conducted under reformed duty hour guidelines have yielded mixed results. In addition, the majority of surveyed faculty members report a negative effect on resident patient care and education since duty hour limitations began. These regulations have also resulted in little or no improvement in inpatient mortality or patient safety.5 Thus, despite good intentions, duty hour limitations have produced little concrete benefit in effectively tackling this issue.

Seeking More Effective Solutions

In responding to this epidemic of resident physician burn-

WWW.SFMMS.ORG

out, some have suggested to look beyond duty hour regulations in seeking solutions. A new hope is the implementation of formal wellness curricula into resident training programs. Not only can they provide an arena for support, but wellness programs can be flexible and initiatives tailored to different resident populations.

For instance, at Kaiser Permanente San Francisco’s Internal Medicine Residency Program, residents worked to implement a series of wellness interventions that included forums to discuss emotionally difficult patient cases, small group mindfulness and meditation sessions, wellness conferences, and pet therapy sessions to name a few.

There was a shared understanding among residents and faculty that incorporating these interventions into graduate medical education curriculum could help residents deal more successfully with the stress of training while developing important techniques to help his or her career. The overarching goal was to set a precedent that wellness is an integral part of their residency program now, and moving forward.

Time to Act

Fortunately, the dialogue in academic medicine is slowly changing from documenting the problem of burnout to searching for ways to enhance the learning environment for the benefit of residents throughout their careers and their patients alike. The ACGME recently put out new requirements that speak directly to re-thinking institutional culture. They set out a clear imperative for training programs to create a learning environment with a culture of respect and accountability for physician well-being, recognizing that this is crucial to the ability of those working in it to deliver the safest, best possible care to patients. In the wake of the controversy surrounding duty hour reform, this approach represents a new hope in the solution to the long-debated issue of burnout and wellness during residency training.

Conclusion

The journey through residency will never be an easy venture, but there are new approaches to make the road a little better to command. Making meaningful changes to improve the learning environment, to identify and address burnout in residents, and to provide systems to support wellness will protect trainees. Perhaps, while training residents to become good doctors, we can also teach them to thrive in the process.

Dr. Ryan Guinness is a third-year resident in the combined Internal and Preventive Medicine Residency Program at Kaiser San Francisco and University of California, San Francisco. Dr. Lisa Chui is an internal medicine physician who also serves as Program Director for Physician Health and Wellness and Assistant Chief of Adult and Family Medicine at Kaiser Permanente San Francisco Medical Center. A full list of references can be found at www.sfmms.org NOVEMBER/DECEMBER 2017 SAN FRANCISCO MARIN MEDICINE

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Mental Health

CHILD PSYCHIATRY An update regarding youth involved with child welfare and probation.

George Fouras, MD Over the last ten years, greater attention has been paid to the condition of those youth who are involved with child welfare (foster care) and/or probation. Not only have the number and quantity of psychotro-

pic medications caused concern, but also the youth who were not reunited with family, spending their childhoods in foster homes or congregate care.

In June of 2016, it was reported that as of September 30, 2015, 427,910 American youth were in out of home care (foster care).1 Based on data from California compiled by U.C, Berkeley, as of July 1, 2017 the state had 53,382 youth in care, with Los Angeles having 18,755 and San Francisco 638.2 Not included in this statistic, but just as important, were the number of youth who were booked into juvenile hall in San Francisco, 743, representing a 19.6% drop from 2012.5 Prior to 2010, a few studies were conducted by Bonnie Zima, MD and Julie Zito, MD indicating that foster youth were being prescribed medications at high rates, based on Medicaid claims data.8 However, this was greatly clarified in the summer of 2010 with two reports being published. The first was by Laurel Leslie from Tufts looking at psychotropic medication oversight programs of forty-seven states.4 In general, state programs were not as robust in providing oversight of psychotropic medications for youth in foster care. In comparison, San Francisco County began a psychotropic medication oversight program in 1996, well ahead of the state and the country. As a result of SB 543 in 1999, the State of California passed the first rules for medication oversight, referred to as the JV-220. This was a significant change in that the courts were given jurisdiction of consent for medication over parents or legal guardians. At first, it applied only to youth in foster care, with youth in probation being optional. This was changed in 2012 with the oversight of psychotropic medication authorization for probation youth now falling under the JV-220 process. The second, was a study from Rutgers looking at atypical antipsychotic use in sixteen states.6 They noted that this class of medication was used up to nine times more often in youth in foster care versus the general Medicaid population. In addition, they noted that youth under the age of five were also being prescribed these medications, along with evidence of poly-pharmacy in the primary study population of five to seventeen (inclusive).

These studies then prompted the Government Accountability Office (GAO) to conduct a report, which was presented as testimony to Congress in December of 2011.7 Five states were selected for audit and review using 2008 data. One of the key findings was that of the five states selected for review, California not included, the psychotropic medication oversight programs fell short of the American Academy of Child and Adolescent Psychiatry (AACAP) “Position Statement on Oversight of Psychotro22

pic Medication Use for Children in State Custody.” Other significant findings were that foster youth were prescribed medication 2.7 to 4.5 times more often than non-foster youth. In addition, a significant number of children were prescribed five or more psychotropic medications at a time, while others were prescribed doses in excess of Food and Drug Administration (FDA) guidelines. Finally, there were several cases of children less than one year of age being prescribed medication.

Concurrent with these investigations, in a project that took over ten years, in June 2015, AACAP published the first, ever, “Practice Parameter for the Assessment and Management of Youth Involved with the Child Welfare System.” Part of the challenge of this paper was the esoteric nature of foster care, which varies greatly from state to state, versus a disease process or illness.

Shortly after the publication of the GAO report, the California Department of Social Services (CDSS) and the Department of Health Care Services (DHCS) entered into a joint quality improvement project with three workgroups (Clinical, Data, and Youth/Family) tasked with creating deliverables that were reviewed by an expert panel prior to release or publication. The clinical workgroup drafted “California Guidelines for the use of Psychotropic Medication with Children and Youth in Foster Care”, which is accompanied by five appendices.3 Unlike most public documents of this kind, it is the intention of these two state agencies to review and update these guidelines yearly.

While not mandatory, it is hoped that counties will voluntarily utilize these guidelines as best practices for youth in foster care (or probation) in California.

Since the publication of these reports, several pieces of legislation have been enacted related to the care provided to youth in foster care and probation. Ostensibly, youth are being removed from the care of their parents and family, because of concerns about safety, abuse, or neglect or the commission of offenses against the laws of society. However, there was a growing realization that having social services as the “parent” for a child often resulted in worse outcomes with almost no support available once the youth reached the age of majority, or “aged out,” of the system. Many youth, especially teenagers, would end up being placed in group homes, in many cases until reaching the age of eighteen. Placement in a group home was based on a Residential Care Level (RCL) model with the averagegroup home a “10”, while “residential treatment” was considered levels 12-14.

The level was not strictly defined, and was based on the services provided by the home. While the youth was to receive treatment and then be stepped down to a less restrictive setting, in reality, many stayed in these homes for years. Adoption of AB 403 “Foster Youth: Continuum of Care Reform” completely changed

SAN FRANCISCO MARIN MEDICINE NOVEMBER/DECEMBER 2017 WWW.SFMMS.ORG

this system. Gone were RCL levels and group homes, replaced

by Short Term Residential Therapeutic Placements (STRTP), which were designed to be a short term (six months or less) placement, and where intensive assessments and treatment would occur. This would also include medical care and psychiatric treatment and therapy. While it is possible for a youth to stay longer than six months, the goal would be for the youth to be stepped down to placement at home or with a “resource family” (i.e. foster home). The overall treatment plan would be guided by the Child Family Team meeting (CFT) which included the youth and family in treatment and placement decisions.

Another concept that began to be discussed by child psychiatrists in 2015 was the concept of “deprescribing,” first identified in the adult literature based on the degree of polypharmacy for geriatric patients (not just psychiatric medication). A literature search for deprescribing in children yielded no published papers. As a result, a proposal was put forth for the AACAP to develop a “clinical guideline”(formerly called a practice parameter) on desprescribing to be developed by the Adoption and Foster Care committee of the AACAP Deprescribing is not synonymous with the discontinuation of medication, but is rather the evaluation and identification of medications to be optimized as part of a treatment regimen with a structured approach to minimizing or discontinuing identified medications for which the risk outweighs the benefit. In addition, reliance on evidence based practices, including prescribing, is to be emphasized.

In the last legislative session, a bill was passed that allowed the Medical Board of California to investigate physicians for “repeated acts of clearly excessive prescribing” to youth involved with the child welfare system. This is being accomplished by

DHCS forwarding records to the Medical Board of California (MBC) based on Medi-Cal billings and/or the atypical antipsychotic Treatment Authorization Request (TAR) process that is supervised by them. In addition, there is language that the MBC may act if a youth is prescribed three or more medications for ninety or more days. However, the criteria that the MBC employs for making this determination is unknown. For example, if a physician writes a prescription for Benadryl or melatonin so that the foster parent does not have to pay out of pocket, it is unclear whether that counts toward the three medications.

The overall practice of child psychiatry is changing dramatically as new research and discoveries are made. The standard of care is being shaped not only by current research and best practices, but also by legislation, often by well meaning groups and agencies, but for which there are often unintended consequences. As a result, it is important that we as medical providers of care focus not only on the hard science of biological processes, but also on the more esoteric nature of public health that occurs in our State and Federal legislative bodies.

Dr. Fouras is a child psychiatrist with the Los Angeles County Department of Mental Health. He was formerly a child psychiatric consultant to the San Francisco Human Services Agency, and was a past President of the SFMMS. He currently co-chairs the Adoption and Foster Care committee for the AACAP. A full list of references can be found at www.sfmms.org.

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5/2/17 12:23 PM

Mental Health

A PAUSE DOES REFRESH And More Linda Hawes Clever, MD, MACP A colleague mused awhile back, “I wasn’t sick, but I was out of sorts. With the spin and whirl all around, I realized

that my body was operating as if everything was 911. It came to me that this is not 911. You know, very few things are 911.”

Now there is a refreshing insight!

Besides developing such a sound philosophical perspective, what can we do to contend with all the clanging busyness that annoys or threatens to submerge us? Taking a pause is one way; taking a moment—just a moment—to move aside from blaring and incessant demands.

In order to take that pause that refreshes, it helps to reflect a bit about why so many of us have our pedals to the metal. Briefly, why are you in overdrive? Is it DNA, culture, fears, dreams, debt, opportunities, obligations, habits, more—more—more, and electronic health records (EHRs)? (It’s not all EHRs! Ask your family and patients how much peace and calm they are having these days. There is a great deal of clangor everywhere.)

Next, consider why you might want to stop your scurry-andscramble. Check appropriate boxes: You aren’t savoring much? That’s sad. You’re missing some subtleties and joy. Also, savoring helps return your tense shoulders to horizontal from being wrapped up around your ears.

You haven’t had a brilliant idea lately? No down time to think or plan?

You’ve lost touch with some dear, important people? You’ll regret that. I do.

You are so tired that you fall asleep while watching TV in bed and roll over on your Triscuits-n-cheese? Hmmm: messy and itchy.

You don’t like being grumpy—and others don’t like you being grumpy, either.

List your own theories about why you should take a pause that refreshes.

How can you pause?

The first step is to be aware of what the fuss is all about and why you are in it. Make a list. It could be short or long. See paragraph three for prompts. Be frank; tell the truth.

Next, how might you take a break, just a breather? Around 500 BCE, Pythagoras, who blended his theorems with his gift for music, said of silence, “Be silent or let thy words be worth more than silence.” The mystic medieval nun, Hildegard of Bingen, picked up his theme 1600 years later when she transformed his ideas into prayer, music—and silence. (Give yourself a beautiful moment and listen to her music in concert or on CD—the Sequentia Ensemble releases on DHM are reputed to be truest to her times.) One of the basic survival questions that cultural anthropologist Angeles Arrien asked was, “When did you last enjoy 24

the sweet territory of silence?” For more quiet times, search the web for Martin Boroson. He takes only a minute to introduce an intriguing concept: “one-moment-mediation.” Try it, for silence is one way to pause.

You have heard about other ways to pause: take a few deep breaths, get some exercise, enjoy the luxury of a good night’s sleep, play (with friends and family; indoors, outdoors; even poker!).

It is a relief tome that science is starting to explain ancient practices that some label woo-woo. For example, we are learning about centers in the brain that, in response to slow breathing (as in yoga), settles the amygdala’s penchant for agitation. We know that being out in Nature—or even looking at a picture of it—increases blood flow to the anterior angulate and insular cortex, where empathy and altruism reside, and decreases blood flow to the prefrontal cortex area associated with depression.

Now comes the delicious step, finding incentives that can spawn plans and actions to take a pause. I don’t want to suggest anything that would frighten the horses or shock your delicate sensibilities. After all, this is about a pause, not a revolution. Why don’t we think together?

If you—and I—paused, what might happen?

• We might savor a song or a sip of homemade soup, a sea salted caramel, a moment of a memory, a story or a laugh or a hug.

• We might clear the cobwebs and really focus on the conversation we’re having or really find a solution. Focus brings bright light, clarity, intensity.

• We could open up. We could listen instead of judge or rush on. A tide of new ideas could fill a pause.

• We could get inspired instead of tired.

• We could register and remember a delight, such as when our then-3.5-year-old grandtwin Mila mused while her mother drove her to a birthday party, “If we are on an adventure, Mom, does that mean we are lost again?”Or her brother Graham’s observation, “Doughnuts are better than flu shots.”

• Shhhh. We could enjoy the silence with Pythagoras, Hildegard, et al.

• We might find that a pause eases tensions and allows some harmony and peace.

Wait a minute! Just a minute! Maybe this is the revolution.

Linda Hawes Clever, MD, is a Clinical Professor of Medicine at UCSF, member of the National Academy of Medicine, and a former editor of the Western Journal of Medicine. She founded the not-for-profit RENEW twenty years ago, and is author of The Fatigue Prescription: Four Steps to Renewing Your Energy Health and Life.

SAN FRANCISCO MARIN MEDICINE NOVEMBER/DECEMBER 2017 WWW.SFMMS.ORG

Mental Health

LEARY IN THE LAB WITH DOCTORS A Book Review Steve Heilig, MPH The Ketamine Papers: Science, Therapy, and Transformation Philip Wolfson, MD and Glenn Hartelius, PhD, Editors | MAPS Books, 2017 Changing Our Minds: Psychedelics and the New Therapy Don Lattin | Synergistic Press, 2017

It's often said that history repeats itself, and that's certainly true with respect to clinical use of illegal drugs. Over half a century ago, Harvard researchers with

names like Leary and Alpert became overly optimistic about the therapeutic potentials of lysergic acid diethylamide (LSD), "magic mushrooms," and other substances, and their "research" soon exploded into so much public experimentation that such substances were soon illegal even for researchers (and President Nixon called Leary "the most dangerous man in America"). The backlash forced such experiments underground for decades, although bans never fully eliminated use.

We're now years into a new era of optimism about such long-taboo substances. Medical use of marijuana, scientifically supported or not, is now fully out of the bag, with endorsements from some seemingly unlikely sources. "MDMA, or ecstasy, is emerging as one of the most promising treatments for intractable post-traumatic stress disorder," noted the staid Wall Street Journal recently, reporting that Phase 3 trials have been approved by the Food and Drug Administration (FDA). The American Psychiatric Association also reported favorably on this move, noting, "Given the challenges of effective psychopharmacological psychotherapy for post-traumatic stress disorder (PTSD), the possibility of any new agent that may improve clinical outcomes is welcome."

A Northern California organization, the Multidisciplinary Association for Psychedelic Studies (MAPS), has doggedly pursued the "mainstreaming" of clinical trials of a number of substances via established researchers and institutions, helping gain governmental approval. As summarized on Wikipedia, "Included in MAPS’ research efforts are 3,4-Methylenedioxymethamphetamine (MDMA) for the treatment of post-traumatic stress disorder; LSD and psilocybin for the treatment of anxiety, cluster headaches, and depression associated with end-of-life issues; ibogaine for the treatment of opiate addiction; ayahuasca for the treatment of drug addiction and PTSD; medical marijuana for PTSD . . . " Note that most of the applications being researched fall into the broad category of mental health problems; also the irony of the potential for treating addictions. Many people can provide anecdotal tales of efficacy, but that is not enough, and two new books detail how research is being rebooted. Veteran journalist WWW.SFMMS.ORG

Don Lattin's Changing Our Minds is called "an experiential tour through a social, spiritual, and scientific revolution that is redefining our culture’s often confusing relationship with psychoactive substances." Lattin, long a religion reporter for the San Francisco Chronicle, wrote two earlier best sellers on the history of psychedelics, and now mixes his own story of self-experimentation with the details of the research resurgence. Long afflicted with depression and addiction, he tries a range of remedies, legal or not. His story is a worthy read from a sophisticated perspective, both skeptical and open to new perspectives and approaches. He does seem to find some relief, and his book is compelling.

But what are an interested, if not desperate, patient and physicians to know and do regarding actually using such substances?

Such clinical guidelines and criteria are coming along too. Perhaps one of the more surprising drugs "in the pipeline" in this regard is ketamine—yes, the "dissociative anesthetic" used most commonly by veterinarians and in severely injured people, primarily in emergency medicine, and illicitly as a "party drug" in the club scene. But new research has shown promise for depression, addiction, PTSD, and more.

Marin psychiatrist Philip Wolfson is on the leading edge of ketamine use, and has compiled a thick compendium of articles on all aspects of its clinical use. He sees it as "a potential savior in the psychiatric medicine bag that is generally recognized as having gone stale," providing "a break with troubled usual mind and the possibility of relief and positive transformation." Savior is a strong word, and some might hear echoes of Leary and the ill-fated psychedelic optimism of the 1960s. But Wolfson and his colleagues marshal vast references and anecdotal evidence to support that ketamine, properly applied, can be a breakthrough medication, and more. His five-hundred-page tome should now be the standard, state-of-the-art-and-science volume on this topic.

Many search for, and claim to find, "magic bullets" for what ails us. Most don't quite pan out. Some even prove more dangerous than helpful—but not all. This is serious work, and proponents know very well it requires expertise, credentials, diligent adherence to research protocols—and something more. MDMA researcher Charles Grob, MD, professor of psychiatry and pediatrics at the University of California, Los Angeles School of Medicine, cautions “We have a great opportunity here. We have to learn the lesson of the 1960s and not repeat the mistakes we made way back then. I would emphasize very strong ethical standards— that’s going to be key moving forward.”

Steve Heilig, MPH, is associate executive director for public health and education at the SFMMS and a member of the editorial board. He is also co-editor of the Cambridge Quarterly for Healthcare Ethics and occasional editor for the Journal of Psychoactive Drugs.

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SFMMS and CMA Mourn the Loss of Former CMA President Rolland Lowe, MD Former SFMS and CMA President Rolland C. Lowe, MD, passed away on Saturday, November 4, at the age of eighty-five.

Dr. Lowe was well known for a lifetime of service to the community in San Francisco, working to provide immigrants with high-quality health care. He also had a long history of service in organized medicine, and regularly used his leadership positions to get physicians more involved in their communities.

During more than five decades in organized medicine, Dr. Lowe held many distinguished roles, including serving as the first Asian American president of CMA, the first Asian American president of the San Francisco Medical Society and as chair of the CMA Board of Trustees and the CMA Foundation Board of Directors.

Dr. Lowe grew up in a low-income community in Oakland at a time when tacit discrimination against Asians was commonplace. Though faced with adversity during his youth, he graduated from UC Berkeley at eighteen and went on to be one of just five Asian students accepted into UC San Francisco’s medical school class of 1955, where he trained to become a vascular surgeon.

Responding to the Fires: Thank You! A Message from: Man-Kit Leung, MD, SFMMS President

By one week after the fires erupted, the SFMMS had forty-eight people respond to the call for volunteers, including thirty-six physicians, plus nurses, physician assistants, and interpreters.

Healthcare professionals at their finest!

Our thoughts are with those affected by the devastating North Bay wildfires. We applaud the tireless and heroic efforts of the emergency personnel and medical professionals, including many of our member physicians, who are helping those who have been injured and displaced by this disaster.

In addition to helping coordinate physician volunteers to assist the Marin County Department of Health & Human Services staff at the Marin Civic Center Evacuation Center, SFMMS has put together a list of ways to contribute to relief efforts. Please consider making a financial contribution—it's the most efficient and effective way to maximize your donation's impact, does more to stimulate local economies which may be suffering, and decreases the environmental impacts associated with waste from surplus goods and goods transportation.

Here are some local, on-the-ground funds that will go directly to victims when it's time to rebuild: The CMA Foundation has a wildfire fund: http://www. thecmafoundation.org/Cal-Fires The California Academy of Family Physicians (CAFP) Foundation also has a fund: http://www.familydocs.org/firerelief.

Their president-elect is a Santa Rosa physician who will coordinate use of the funds, with one hundred percent to be granted (no overhead).

North Bay Fire Relief Fund Redwood Credit Union (RCU), in partnership with the RCU Community Fund, Inc., The Press WWW.SFMMS.ORG

After completing his surgical residency at UCSF, Dr. Lowe was highly sought after by prestigious clinics across the Bay Area, but instead dedicated himself to serving patients in the underserved Chinatown community.

During Dr. Lowe’s fifty-four years of membership in CMA and the San Francisco Medical Society, he was well-known for his role in the reorganization of the CMA Foundation. Dr. Lowe was also involved in the creation of CMA’s Ethnic Medical Organization Section, which was established in 1995. He received numerous awards for his philanthropy, including recognition at the White House Conference on Philanthropy.

He leaves his wife of sixty years, Kathy; his sons Larry (and his wife Jeanne) and Randy; his daughter Yvonne (and her husband Bob); and grandchildren Brennan, Laura and Marnie.

A further tribute will appear in our next issue.

Democrat, and Senator Mike McGuire, is now accepting financial donations to assist fire victims and aid relief efforts. One hundred percent of your tax-deductible donations will go directly to support those affected. When you donate, you can choose to support any of the four counties affected: Sonoma, Napa, Mendocino, or Lake. You may also designate "all" and your funds will be equally distributed among all four counties.

Sonoma County Resilience Fund The Community Foundation Sonoma County has launched the Sonoma County Resilience Fund to address the mid to long-term needs of our community.

Napa Valley Community Foundation (NVCF) Disaster Relief Fund Through financial contributions, Napa Valley Community Foundation and its nonprofit partners providing relief services on the ground can do more good for more people, with greater speed and sensitivity than with material donations.

Cash donations provide medical and other services now and can help rebuild infrastructure later.

OTHER OPPORTUNITIES TO HELP Adopt a Family - Housing Email: SHAREfire@petalumapeople.org You will be contacted and screened to match you up with a family/person in need of temporary housing. A background check will be conducted.

Center for Volunteer and Nonprofit Leadership Register to volunteer, or make a donation. CVNL was activated as an Emergency Volunteer Center (EVC), overseeing volunteers and donations for Napa and Marin Counties.

Thank you for supporting our neighbors to the north who have been devastated by these wildfires.

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HOUSE OF DELEGATES MENTAL HEALTH REPORT / CMA COUNCIL ON SCIENCE AND PUBLIC HEALTH Donald Lyman, MD, MPH, Chair RECOMMENDATION 1: That CMA develop a strategic and implementation plan for advancing CMA’s mental health delivery priorities. The plan shall include, but not be limited to actions as follows: 1) Support legislative and regulatory measures to: a) Advance the integration of mental and physical health care. b) Amend the Lanterman-Petris-Short Act to expand the definition of "grave disability" to include individuals with mental health disorders who are unable to care for their own health and safety due to their mental illness. c) Protect the confidentiality and privacy rights of patients receiving care for psychiatric and substance use disorder conditions, while allowing appropriate data-sharing among clinical professionals caring for the same patients and information sharing with family in defined situations when essential for patient care. d) Support innovative alternatives in crisis care, such as Psychiatric Emergency Services and Crisis Residential Programs. e) Work with the California Department of Corrections and Rehabilitation (CDCR) and local government agencies that oversee jails to support the diversion of individuals with mental illnesses away from correctional facilities and toward appropriate treatment settings. CDCR and local agencies should ensure follow-up community treatment and establish insurance eligibility for individuals who are being released from jail or prison with mental health or substance use disorders. f) Target mental health service outreach and access to evidence-based treatment for particularly vulnerable populations including individuals with substance use disorder and/or dual diagnosis, LGBT individuals, foster youth, the homeless, etc.

2) Continue to expand and support the behavioral health workforce, including: a) Training and expanding financial incentives, including loan repayment programs, for behavioral health providers who demonstrate a commitment to practice in under served areas and communities. b) Support voluntary education and training opportunities for primary care providers to provide behavioral health services, while seeking to reduce the systemic administrative and financial barriers that have impacted their ability to deliver mental health services in the primary care setting (see 3b). c) Support crisis intervention training programs for law enforcement and other first responders. d) Creating more training opportunities within public educational institutions, such as the University of California and California State University systems, for mental health clinicians at all levels (e.g., Master’s level professionals including Licensed Clinical Social Workers, Licensed Marriage and Family Therapists, Licensed Professional Clinical Counselor, Psychologists, NPs, PAs, MDs).

3) Facilitate streamlined financing and payments for mental health services through: a) Support for measures that would expand funding and the number of available adult and pediatric beds for inpatient psychiatric care, in28

cluding hospital rehabilitation, acute crisis stabilization settings and residential care. This includes increasing the Medi-Cal budget for mental health, thus facilitating increased inpatient and residential bed availability, and outpatient services. b) Reducing the administrative and financial barriers which have impacted the mental health service delivery in the primary care setting (e.g., allowing simultaneous billing for the management of chronic physical conditions and management of psychiatric and mental health conditions, and ensuring physicians have adequate time to treat patients in a more holistic manner and address both their physical and mental health care needs). c) Legislative and regulatory measures that facilitate streamlined payment and greater flexibility for counties to use Mental Health Services Act (MHSA) and federal Medicaid funding, allowing their use for needed services, such as innovative programs and supported housing for homeless mentally ill patients and expanding the use of Assisted Outpatient Treatment (Laura’s Law) for individuals lacking capacity to understand their need for treatment. State government should maintain oversight over county-administered programs and ensure that all counties follow standardized rule for provision of services when mental health patients present across county lines (e.g., when one county’s resident who needs mental health care is seen in an emergency department located in another county). d) Increase regulatory assessments of whether health plans are providing parity care for mental health and substance use disorders and meeting regulatory access standards, and assisting health plans to come into compliance with parity laws and access standards when they are found to be deficient. Penalties can be considered if assessment shows that plans demonstrate a willful pattern of non-compliance with current laws and standards. e) Promote integrated care for mental health and substance use disorders in Medi-Cal rather than the current bifurcated system that fragments care.

4) Support further research and evaluation of mental health delivery models, including but not limited to: a) Creating a comprehensive data infrastructure to better measure mental health outcomes on a state/population level. b) Developing universally accepted quality measures for mental health care. c) Funding and creating greater access to medical research opportunities that further the cause of mental health, including during residency training and throughout continuing medical education.

5) Support actions to reduce social stigma surrounding mental health issues by: a) Promoting public awareness of the prevalence and treatability of mental health issues. b) Addressing providers' attitudes toward recovery for individuals with mental disorders.

This report was approved at the 2017 meeting of the CMA House of Delegates, to be finalized and approved for action.

SAN FRANCISCO MARIN MEDICINE NOVEMBER/DECEMBER 2017 WWW.SFMMS.ORG

CALIFORNIA MEDICAL ASSOCIATION REPORT / 2017 ANNUAL MEETING Lawrence Cheung, MD This year, the House of Delegates of the California Medical Association convened at the Disneyland Resort in Anaheim in October. Over twenty San Francisco

Marin Medical Society members (with a record number of medical students!) formed our delegation. Over the two days, the Delegates were given in-depth presentations on four major subjects: Federal Health Care Reform, Single Payer and Public Options in Health Care, Health Care Workforce in California, and Mental Health in California.

The House also voted on numerous key recommendations on each of these four areas. These recommendations will form the core policies that will help guide the CMA. All final reports and recommendations will be available soon on the CMA website, CMAnet.org.

Featured speakers and panelists included AMA President Dr. David Barbe, U.S. Congressman and House Majority Leader Kevin McCarthy, U.S. Congressman Raul Ruiz, as well as several prominent San Francisco physicians including University of California, San Francisco (UCSF) Professor Dr. Andrew Bindman and former head of San Francisco Department of Public Health and now Chief Executive Officer of the California Health Care Foundation, Dr. Sandra Hernandez.

Our very own Dr. Pratima Gupta was honored with the Compassionate Service Award. The award honors a CMA member physician who best illustrates the association’s commitment to community and charity care. Dr. Gupta was recognized for her volunteer work at

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the St. James Infirmary, a clinic that serves female transgender and male sex workers in San Francisco. Dr. Gupta has been working at the clinic since 2005 and currently serves as its volunteer medical director.

On a very exciting note, our very own Dr. Shannon Udovic-Constant was elected as the Vice-Chair for the CMA Board of Trustees.

Dr. Udovic-Constant has been our elected CMA Trustee representing our district at the Board of Trustees for the past several years. The delegation is thrilled that Dr. Udovic-Constant will continue to represent our district in this new role. Also, our student delegate Rachel Ekaireb of UCSF was elected as student representative to the CMA Board of Trustees.

Ending on a high note, the House of Delegates has officially ratified the merger between San Francisco Medical Society (SFMS) and Marin Medical Society (MMS) to form the new San Francisco Marin Medical Society (SFMMS). Dr. Peter Bretan, past president of MMS and current Executive Committee member of the SFMMS has announced his candidacy for the position of CMA President-Elect and that election will take place at the 2018 CMA House of Delegates.

Lawrence Cheung, a dermatologist, is a former SFMMS President and the incoming chair of the SFMMS delegation to the CMA, succeeding Dr. Gordon Fung after many years of leadership.

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LEADERSHIP PROFILE An Interview with SFMMS member UCSF Dean Dr. Bruce Wintroub, MD John Maa, MD, and Lawrence Cheung, MD What do you love most about dermatology and what was your secret to becoming a Chair of the Department of Dermatology and the longest serving Chairman at University of California, San Francisco (UCSF) of thirty-two years?

Being the Chair of the Department of Dermatology was and still is my “dream job.” For me, the ideal position is to be a leader in my field. Dr. Rudi Schmid was the Dean of the Medical School when I became Chair. He once shared, “Bruce, remember this. I am not going to evaluate you on what you do, I will measure your success by the success of those around you.” At that moment, I realized that my career would be in the “people business,” and that the success of being the Chair is that not only do I need to listen, but I need to help each of my faculty grow and to achieve their dream. I also realized that I needed to create a financially successful clinical department so that we could invest in our talented faculty and support teaching and investigative and scientific work. Dr. Rudi Schmid’s advice was right on point, and he was my life long mentor and friend until his death.

After becoming the Chair of the Department of Dermatology, you were given larger roles at UCSF. What were the highlights?

During the Clinton years of health care reform, the early 1990s, I was responsible for creating an internal UCSF physician group called the Integrated Practice Group. We distributed capitation payments to physicians and compensated physicians in return for value. The project enabled UCSF to set the stage for the merger with California Pacific Medical Group to form Brown and Toland Group.

I was the Executive Vice Dean at the time as we worked Dr. Michael Abel to execute formation of the new organization. (Editor’s note: Brown and Toland is now one of the largest and most successful Independent Practice Associations (IPAs) serving the Bay Area).

After the creation of Brown and Toland, where did your work take you next?

After Brown and Toland, I worked with Dean Haile Debas as we attempted UCSF/Stanford merger. I learned that things do not always succeed, and that if you take risks, sometimes you fail. I was the Executive Vice President after the merger went live in 1997. It lasted two years before it was dissolved. This was a time when mergers were happening all over the country, such as Massachusetts General Hospital (MGH) with the Brigham and Women’s Hospital to form Partners, as well as Columbia and Cornell among others.

We looked into successful mergers such as Partners at Harvard where the hospital system merged, but not the physicians. We thought we could do better, and we decided to form an integrated health system merging both the hospital system and physicians from the two medical schools. That was a mistake. We should have left the physicians out of the deal, and let them run their groups as they wanted. We should have just merged the hospital system. This was the biggest failure in my career. Afterwards I returned to being the Chair of Dermatology. However, I learned how medical centers 30

work, how health systems are formed and managed, and just how difficult it can be to lead physicians through jarring change.

Reflecting back on your leadership roles at UCSF, what might be your suggestions to young physicians and trainees who aspire to a similar career path? How did you learn?

I learned on the job. If I were to do this today, I would have gone the route of MD/PhD, and then obtained an MBA. When I was a trainee, you could become a scientist without a PhD. There are a lot of other skills that are helpful for physician leaders today that are not taught in medical school. I think an MBA is extremely valuable in learning management skills and financial skills. If I were a trainee today, I would obtain an MBA with a health emphasis, though there are only a few of those offered. I believe the secret to a good leader is to realize when you don’t understand and to listen.

Do you have any recommendations on the type of research that young physicians should engage in order to enter the leadership track?

Basic science was the favored pathway available in my time.

New areas of research such as translational research, and outcomes/health services research were areas that had not developed yet. I recommend that you should choose the area that for which you have a passion and pursue that route; it really doesn’t matter where you start. What matters is that you choose something that you enjoy.

If you have the leadership skill sets, they will manifest themselves.

What was your most formative experience as Dean of UCSF Medical School?

As Dean, I learned to say “yes” and “no” in a nice way, and to always make the reasons for each answer clear. My most memorable experience was when the medical students held a demonstration “White Coats for Black Lives” in December 2014. I have always been supportive of diversity but I never fully grappled with the concept until that day. The medical students organized a very public demonstration of which I was unaware. It brought back memories from the Vietnam era, when actions and words at a college campus could end up on the front page of the newspaper. Remember, this was the early time of Black Lives Matter, Staten Island and Ferguson. This was a very real event that happened at our doorstep and was not something that I experienced by watching the news. This was the news.

Afterwards, we ensured that the right message went to the press, and we held a retreat to understand what students were telling us. We learned that there our committed students led this event and had nucleated similar demonstrations at over eighty other medical schools. Many students had very real life experiences, either directly as medical students or through experiences of close family members. Some examples: The Medical Center was providing free breakfast, but several medical students of color in line were pulled aside by security asking them what they were doing in line.

Comments that faculty would make to minority students that were

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sometimes insensitive, such as “Great talk, I wasn’t expecting that of you.” Several students had family financial hardship and were sending scholarship money home causing them to end the month without enough money for food. So, we examined ourselves and have made many changes to support our students. This inspired me to discuss the lack of diversity in my own specialty at a plenary session of the American Academy of Dermatology. I believe that UCSF’s response demonstrated that students CAN have an impact.

To me this was the moment of my term as Medical School Dean that was most memorable.

MENTAL HEALTH SERVICES ACT IN SAN FRANCISCO

A State program designed to address unmet mental health needs of the community Imo Momoh In November 2004, California voters approved Proposition 63, now known as the Mental Health Services Act (MHSA), intended to expand and transform community mental health services throughout California. MHSA funding, revenue from a 1 percent tax on any personal income in excess of $1 million, is distributed to respective county mental health systems under a formula developed by the State.

The MHSA called upon local counties to transform their public mental health systems to achieve the goals of raising awareness, promoting the early identification of mental health problems, making access to treatment easier, improving the effectiveness of services, reducing the use of out-of-home and institutional care, and eliminating stigma toward those with severe mental illness or serious emotional disturbance.

In San Francisco, MHSA funding has allowed for expanded access to intensive treatment services, housing, employment services and peer support services for thousands of individuals with mental illness. Promising outcomes from MHSA investments include declines in arrests, mental and physical health emergencies, school suspensions and expulsions, and the number of days in residential treatment.

The greatest promise of the MHSA is a vision of outreach and engagement, a philosophy of recovery and wellness, a belief in the strength and resiliency of each person with mental illness, and recognition that they are to be embraced as equal members of our community. Recovery from mental illness is not only possible, it is to be expected. The Mental Health Services Act program in San Francisco is part of the Behavioral Health Services Division of the San Francisco Department of Public Health.

For more information visit: www.sfdph.org/mhsa WWW.SFMMS.ORG

FROM HEAT EMERGENCIES TO MASS SHOOTINGS: Physicians Need to Take the Lead

John F. Brown, MD This past Labor Day weekend, San Francisco experienced record-breaking temperatures and record-breaking demands for emergency medical care. We are all aware the rewards of living in the Bay Area also demand a disaster readiness based on emergencies that have affected us in the past: earthquakes, small scale epidemics, fires, and aircraft crashes. We should learn from our experience on Labor Day weekend 2017 the need for true all-hazard preparation and develop innovative approaches to health and safety threats, from heat stress to mass shootings.

The unique features involved are the inadequate notice, rapid increase, and unpredictable peak of emergency medical care needs. During the busiest days of the recent heat wave, we dealt effectively with historic high Emergency Medical Services (EMS) call volumes and emergency departments stretched well beyond capacities, coupled with physical plant failures associated with heat. By staged escalation of resources including mutual aid from surrounding counties (thank you!) and frequent hospital communication and resource assistance, we stayed ahead of the need. Similarly, in recent mass shooting events we see demands for trauma and mental health care as well as facility and personal safety issues that quickly overwhelm normal capabilities.

We as physician leaders in the community can take concrete steps to be better prepared: • Visit SF72.org to ensure personal and family preparedness • Sign up for Alert SF to be prepared in your neighborhood • Learn your role in your hospital’s disaster plan and advocate practicing it regularly • Discuss ways you can expand treatment capacity in your scope of practice rapidly with minimal notice • Join the SFMMS in advocating study and implementation of effective preventive strategies • Educate your patients whenever possible • Advocate for a strong EMS Agency and EMS System

We all have a tendency to pass this preparedness burden on; instead let’s make it a core part of all of our practices.

John Brown, MD, MPA, is the Medical Director of the San Francisco EMS Agency and a practicing Emergency Physician at Zuckerberg San Francisco General Hospital. He is also a Medical Officer for the National Disaster Medical Assistance Team California-6.

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MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

Kaiser Permanente

SFDPH

Alice Chen, MD

Maria Ansari, MD

Burnout and job dissatisfaction among U.S. physicians appears to be a significant problem and more common than other U.S. workers. In 2012, a survey of 27,276 physicians found 45.8 percent reported at least one symptom of burnout, with the highest rates of burnout among providers on the front lines (family medicine, internal medicine, and emergency medicine). There is also evidence that the problem may be getting worse. Just three years later, a 2015 study by the same authors found the number of U.S. physicians reporting at least one symptom of burnout had increased to 54.4 percent.

While mental health has gained more attention in recent years, mental health challenges remain vastly under-recognized and under-treated, especially for healthcare professionals. Physicians have among the highest suicide rates in the nation. More than four hundred doctors die by suicide each year.

Sutter Health is building a suicide safer community by partnering with Living Works, an internationally renowned suicide prevention training program, to respond early, effectively, and compassionately for team members who may be at risk of suicide. Resources are available 24/7 if you or someone you care about is struggling to cope with life stressors, losses, or other circumstances that can produce painful thoughts or feelings.

Sutter Health Employee Assistance Program (EAP) provides free, confidential assistance, including referrals to licensed counseling professionals: 1-800-477-2258. Other resources include the California Pacific Medical Center Physician Wellness Committee Confidential Message Line: (415) 600-5849, National Suicide Prevention Lifeline: 1-800273-8255, and Crisis Text Line, from anywhere in the U.S. with a trained Crisis Counselor: Text 741741.

Following the violent events in Las Vegas and recent catastrophic flooding, webinars were also conducted for Sutter Health employees where strategies were shared on how to cope with tragedy and manage your feelings.

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In order to address some of the most pressing behavioral health issues facing the San Francisco community, Kaiser Permanente has developed a Community Benefit implementation strategy to be rolled out over the next three years. These strategies aim to serve low-income individuals, reduce geographic, financial, and cultural barriers to accessing health services, and advance increased general knowledge through education or research that benefits the public.

Ultimately, Kaiser Permanente’s goal is to ensure that community members experience social/emotional health and wellbeing, and have access to high-quality behavioral health care services when needed. Other goals include expanding prevention and support services for mild to moderate behavioral health conditions; decreasing stigma associated with seeking behavioral health services among vulnerable and diverse populations; developing a diverse, well-trained behavioral health care workforce that provides culturally sensitive behavioral health care; and increasing access to culturally and linguistically appropriate behavioral health services for vulnerable and low-income populations.

Strategies for accomplishing these goals are categorized as prevention, destigmatization, workforce, and access to high-quality and integrated behavioral health care. Once enacted, the expected outcomes of these various strategies include increased participation in drug and alcohol prevention programs; a greater number of people from underrepresented groups enrolling in education and job training programs; and better integration of care between primary and behavioral health care, among others.

Up to this point, Kaiser Permanente has provided several Community Benefit grants to San Francisco organizations, such as Boys & Girls Club of SF, Larkin Street Youth Services, and Volunteers in Medicine – Clinic by the Bay. Notably, the organization has renewed a second, threeyear commitment to its neighborhood Thriving School, John Muir Elementary School, to provide behavioral health services to an underserved population within the school community.

In November 2004, California voters approved Proposition 63, now known as the Mental Health Services Act (MHSA), intended to expand and transform community mental health services throughout California. MHSA funding, revenue from a one percent tax on any personal income in excess of one million dollars, is distributed to respective county mental health systems under a formula developed by the State.

The MHSA called upon local counties to transform their public mental health systems to achieve the goals of raising awareness, promoting the early identification of mental health problems, making access to treatment easier, improving the effectiveness of services, reducing the use of out-of-home and institutional care, and eliminating stigma toward those with severe mental illness or serious emotional disturbance.

In San Francisco, MHSA funding has allowed for expanded access to intensive treatment services, housing, employment services, and peer support services for thousands of individuals with mental illness. Promising outcomes from MHSA investments include declines in arrests, mental and physical health emergencies, school suspensions and expulsions, and the number of days in residential treatment.

The greatest promise of the MHSA is a vision of outreach and engagement, a philosophy of recovery and wellness, a belief in the strength and resiliency of each person with mental illness, and recognition that they are to be embraced as equal members of our community. Recovery from mental illness is not only possible, it is to be expected.

The Mental Health Services Act program in San Francisco is part of the Behavioral Health Services Division of the San Francisco Department of Public Health.

For more information visit: www.sfdph. org/mhsa

SAN FRANCISCO MARIN MEDICINE NOVEMBER/DECEMBER 2017 WWW.SFMMS.ORG

IN MEMORIAM ZSFG

Christopher Colwell, MD

Anyone involved in healthcare today knows there is a crisis in this country regarding insufficient resources for psychiatric care. At least one result of this deficit is a steadily increasing burden on emergency departments of having to care for patients suffering from psychiatric disease. The Emergency Department (ED) at ZSFG is no exception. Patients with underlying psychiatric disease represent the fastest growing population we see in the ED. In response to this growing need, we are making a number of improvements. The Psychiatric Emergency Services center (PES) is undergoing a renovation over the next year and a half that will increase its capacity from 18 to 20 beds and provide a more optimal environment for caring for our patients. We are planning to designate PES as an ambulance receiving center and, while this has proven to be challenging, we are still hopeful this will become an option to safely expedite care for appropriate patients. We have also worked with PES staff to ensure the right patient is cared for in the right place. Many of our patients with psychiatric disease also suffer significant medical problems as well and we in the ED are responsible for medically stabilizing patients prior to any transfer to the PES. While some of these patients can be quite complicated, we have identified a group of patients that can safely be expedited to the PES without needing an extended stay in the ED. This process has shown early success: in the first 3 months 200 such patients have been evaluated and discharged from PES with zero bouncebacks. While this effort is still in the initial stages, this early success is promising and is due in large part to a simplified process for redirection if any concerns are identified. Despite these new initiatives to reduce the demands on the ED, there is still a far greater demand than there are resources to meet that demand. Until there is greater access to outpatient and transitional services for patients suffering from psychiatric illness in San Francisco, the impact will continue to be felt in emergency departments across this city.

Dr. Colwell is chief of emergency services at ZSFGH. WWW.SFMMS.ORG

George Lee, MD Dr. Lee was an astonishingly accomplished and active physician, who passed away abruptly on September 26, 2017 after a very short illness, at his home in Yountville, California. He was a man of passion for medicine, medical care, patients, families, colleagues, and friends. This was a lifelong quality; as a child, born in Brooklyn, NY on 3/1/41, and during his school years.

In High School he was not only an Honor student, receiving the New York State Regents’ Scholarship, but also the star quarterback and captain of the baseball team, earning the title of Most Valuable Player (MVP) as a senior.

Amazingly, he began college at the Mater Christi Seminary in New York.

However (good for the thousands he treated medically and otherwise affected), he quickly switched schools and later graduated from the Albany Medical College of Union University in Albany, NY, in 1968 with Honors for Best Bedside Manner. He was a Captain in the U.S. Army Medical Reserves.

George married his wife Kiton August 24, 1963. They had two daughters, Barbara and Kelly, and a son, Douglas. The family moved to San Francisco in 1969 for an Ob-Gyn residency at University of California, San Francisco (UCSF).

After only one year in private practice, George was named Chairman of the Obstetrics and Gynecology Department at Pacific Presbyterian Medical Center, and served in that role for twenty-five years.

He then served as vice chief of staff and Director of the California Pacific Medical Center (CPMC) Women’s Health Center. He taught, as Associate Clinical Professor in Ob-Gyn at UCSF. Further, he created the Family Birth Place at Pacific Presbyterian Medical Center (PPMC), providing a much more homelike, large space for a woman in labor, allowing for a delivery on site, with ample room for sleeping, as needed, for her husband or partner.

As it became clear that surfeit of older hospitals in SF existed, he engineered much of the merger of four prior hospitals; then called CPMC, after which he held numerous leadership positions at CPMC. He helped forge the Program in Medicine in Philosophy into its current iteration as the Institute for Health and Healing.

George served as a member of both the CPMC Board of Directors and the Board of Trustees of the Foundation. For thirty-eight years he was financial director on the Board of Pan-Med. Ltd. and as President and Chief Executive Officer for the Physician’s Reimbursement Fund, Inc. George helped the U.S. Congress Draft the EMTALA Emergency Medical Treatment and Labor Act. He established a cooperative self-insurance model for physicians in San Francisco (somewhat akin to that offered to retired AMA member MDs).

He championed a better patient-centered approach to improve patient care outcomes.

In 1977, he and Kit began building their Ranch in Yorkville, CA. They both loved that home, and spent many happy times building and living there.

He established the Mendocino Wine Growers Inc. Guild, and served on their board of Directors. He was also on the Anderson Valley School Board, and Health Center, respectively.

George had hundreds of friends, family, and colleagues. The sheer force of his accomplishments will always bean inspiration to those who knew him. He was very kind to those who pulled their weight; I was fortunately a beneficiary of that trait. George will be deeply missed for who he was, a compassionate, wonderful friend and colleague —Erica Goode, MD NOVEMBER/DECEMBER 2017 SAN FRANCISCO MARIN MEDICINE

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

SAVE THE DATE SFMMS 150th Anniversary Celebration & Gala

March 15, 2018 | St. Francis Yacht Club San Francisco, CA In 2018, SFMMS will celebrate its 150th Anniversary. Save the date for a celebration not to be missed! More information and registration will be available soon at https://www. sfmms.org/events.aspx. Sponsorship opportunities available—contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

CLASSIFIED ADS Medical and dental space

2,000 sf and up in newly upgraded Pacific Vision Foundation building at 711 Van Ness Ave, SF. Ford Griswold, Bayside Realty Partners, 415-990-7004 or fgriswold@baysiderp.com.

For Sale: ENT/Derm Equipment

Otic, Nasal & Oral Instruments, Mirror Warmers, Stapedectomy Set, Lighted. Surgical Loupes, Power table, Mayo Stands, Small Oxygen Tank, Laryngoscope, Over 40 Lipsuction Cannulas, IV Stands, Defibrillator, Instrument Trays, New Tulip Liposuction Set. Call Dr. Parnell (415) 271-1720.

Medical Office

250 sf medical office at 350 Bon Air Road with reception area and ample parking. $1400. Anne-Marie 415-955-7050 599 Sir Francis Drake, window office with high ceilings, 2 exam rooms, private restroom and reception area. $2450. Anne-Marie 415-955-7050

Medical Office

Newly remodeled turnkey medical office space in San Francisco (Union Square) and Greenbrae (one block from MGH) for sublease.

Part time or full time, short or long term available. Have FlouroXray and Ultrasound. Some staffing assistance available. Contact Nicholas Colyvas MD at 415 999-8646 or nickcolyvas@gmail.com 34

SFMMS Election Results 2018 Officers (one-year term) President-Elect: Kimberly L. Newell Green, MD Secretary: Benjamin L. Franc, MD, MS, MBA Treasurer: Brian Grady, MD Editor: Gordon L. Fung, MD, PhD, FACC, FACP

2017 President-Elect, John Maa, MD, automatically succeeds to the office of President.

2017 President, Man-Kit Leung, MD, automatically succeeds to the office of Immediate Past President.

Board of Directors (seven elected for three-year term 2018-2020) Alice Hm Chen, MD, MPH Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD, PhD, FACP Eric C. Wang, MD Matthew D. Willis, MD Albert Y. Yu, MD, MPH, MBA

Nominations Committee (four elected for two-year term 2018-2019) James L. Chen, MD Diana Coupard, MD Michael Kwok, MD Todd A. May, MD

American Medical Association Delegate (two-year term 2018-2019) Robert J. Margolin, MD

American Medical Association Alternate (two-year term 2018-2019) Gordon L. Fung, MD, PhD, FACC, FACP CMA Trustee (one elected for three-year term Oct. 2018 – Oct. 2021) Shannon Udovic-Constant, MD, FAAP Young Physicians Section Delegate (two-year term 2018-2019) Jaclyn Taub, DO

Young Physicians Section Alternate (two-year term 2018-2019) Priyanka Wali, MD Current Delegation to the CMA House of Delegates (completing two year term in 2018) Delegates Lawrence Cheung, MD, FAAD, FASD Gordon L. Fung, MD, PhD, FACC, FACP Pratima Gupta, MD John Maa, MD Richard A. Podolin, MD, FACC Andrea M. Wagner, MD Alternates Mihal L. Emberton, MD, MPH, MS John Landefeld, MD, MS (Resident) Robert J. Margolin, MD Amy E. Whittle, MD

Delegation to the CMA House of Delegates (two-year term 2018-2019):

Delegates Kimberly L. Newell Green, MD (automatically serves in capacity as SFMMS President-Elect) Ameena T. Ahmed, MD, MPH Naveen N. Kumar, MD Man-Kit Leung, MD Joann E. Moschella, DO Alternates Roger S. Eng, MD, MPH, FACR George Fouras, MD, DFAPA Michael Kwok, MD L. Alison McInnes, MD, MS Stephanie Oltmann, MD

SAN FRANCISCO MARIN MEDICINE NOVEMBER/DECEMBER 2017 WWW.SFMMS.ORG

Welcome New Members!

ACTIVE REGULAR MEMBERS Sona Lee Aggarwal, MD | Internal Medicine Danielle Alkov, MD Oliver Michael Bacon, MD Benjamin Bailey Barreras, MD Karen Joanne Bos, MD Carl E Bricca, DO | Internal Medicine Diana Lynne Coupard, MD | Internal Medicine Teresita Yee Degamo, MD | Internal Medicine David Wade English, MD Joanna Jenks Eveland, MD Matthew Ian Fellows, MD | Family Medicine Richard Feng, MD Anna Fiskin, MD Michelle Renee Fleurat, MD | Emergency Medicine Alan M Gelb, MD | Emergency Medicine Andrea Michelle Grosz, MD Marsha Ann Haller, MD | Family Medicine Alexandra Mei Jen, MD | Obstetrics and Gynecology Se Young Ju, MD | Internal Medicine Simrun Jeet Kalra, MD | Psychiatry Daniela Young Wan Kim, MD Marc Franklin Kurtzman, MD | Hospitalist Clifford Shih Lau, MD | Family Medicine Stephanie Y Le, MD Connie May Lee, MD Phyu Phyu Lim, MD Ruth Jujung Lin, MD | Clinical Genetics and Genomics (MD) Janice Kimberly Louie, MD | Internal Medicine Nikhil Daniel Majumdar, MD | Psychiatry Arbella Helen Malik, MD | Family Medicine Ben Harris Meisel, MD | Pediatrics Paul Jude Moralejo, MD | Family Medicine Rita Phi Nguyen, MD Abena Akufo Opoku, MD | Occupational and Western Medicine Vishal Yogesh Patel, MD | Hospitalist Kenneth Cesar Payan, MD Mayumi Qin Pierce, MD Robin Ricardo Randall, MD | Psychiatry Carmelo Lim Roco, MD | Internal Medicine Kelly S Rue, MD | Ophthalmology Seema Sharma, MD | Internal Medicine Candace Wan-ping Shavit, MD | Anesthesiology Linda Wan-Lin Shiue, MD | Internal Medicine Sareena Singh, MD Vibeke Strand, MD | Immunology Tilak Kumar Sundaresan, MD | Internal Medicine Jana Svetlichnaya, MD | Internal Medicine David Tran, MD Kiana Vala, DO | Family Medicine Emily Rebecca Wistar, MD STUDENTS Alyssa Baccarella Hannah Michelle Borowsky Mayra Cruz Austin Lee Maria de Fatima Reyes Christina Wang

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HOUSE OFFICERS Pilar Abascal, MD | Psychiatry Christine Anastasion, MD | Rheumatology Sonjay Belari, MD | Anesthesiology Danielle Binler, MD | Anesthesiology Danial Syed Bokhari, MD | Pediatric Radiology Lucas Broster, MD | Psychiatry Robert Burky, MD | Surgical Critical Care (Surgery) Meng Chen, MD | Allergy and Immunology Leon Gordon Clark, Jr., MD | Internal Medicine Ken Coelho, MD | Internal Medicine Hayley Crossman, MD | Internal Medicine Nicole Tatsui D'Arcy, MD | Emergency Medicine Brittany Dashevsky, MD | Radiology Claire Debolt, MD | Internal Medicine August Reich Dietrich, MD | Hematology Oncology Annie Do, MD | Plastic Surgery Safa Doost Renee Drolet, MD | Psychiatry Vera Goldberg, MD | Pediatrics Jill Goslinga, MD | Neurology Katryana Mary Pulver Hanley-Knutson, MD | Radiology M. Earth Hasassri, MD | Psychiatry Omar Hassan, MD | Radiology Brandon Holmes, MD | Neurology Ian Holmes, MD | Gastroenterology Dru Aaron Imrie, MD | Neonatal-Perinatal Medicine Bhavika Kaul, MD | Pulmonary Critical Care Medicine Jessica Kim, MD David Alan Klein, MD Jessica Koenig, MD | Psychiatry Priya Menon Krishnarao, MD | Radiology Taylor LaFlam, MD | Pediatrics Courtney Lane-Donovan, MD | Neurology Stephanie Le, MD Pearlene Lee, MD | Occupational Medicine Yalin Lin, MD | Pediatric Cardiology Milan Manchandia, MD | Radiology Anne Mardy, MD | Maternal and Fetal Medicine Pierre Martin, MD | Neurology Ryan Mattie, MD Jacob Mayfield, MD | Internal Medicine Dana L McDermott Nehali Mehta, MD | Pediatric Nephrology Diana Melo, MD | Internal Medicine Armaiti Parvez Mody, MD | Pediatric Endocrinology Saundra Nguyen, MD Kristin Nguyen, MD | Psychiatry Rachel Ochotuy, MD | Pediatric Cardiology Rebecca Olveda, MD | Pediatrics Philip Pauerstein, MD | Pediatrics Yue Peng, MD | Pathology Pamela Peters, MD | Obstetrics and Gynecology Bryan Robins, MD | Surgical Critical Care (Surgery) William Rubenstein, MD Elliot Schwartz, MD | Anesthesiology Veronica Searles Quick, MD | Psychiatry Priya Shankar, MD | Pediatrics Michael Smith, MD | Pediatrics April Stey, MD | Surgical Critical Care (Surgery) Martin Thelin | Pediatrics Drew Thompson, MD | Internal Medicine Erinma Ukoha, MD | Obstetrics and Gynecology Matthew Joseph Vengalil, MD Alana Wade, MD | Interventional Cardiology Ho-Hui Wang, MD | Psychiatry Jennifer Susan Woo, MD | Pathology Jennifer Anne Zabinsky, MD | Pediatric Endocrinology Beth Shoshana Zha, MD | Pulmonary Critical Care Medicine

NOVEMBER/DECEMBER 2017 SAN FRANCISCO MARIN MEDICINE

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

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REASONS TO JOIN CMA AND YOUR COUNTY MEDICAL SOCIETY

TOGETHER WE ARE STRONGER

HEAD SEAT AT POLICY TABLE

California Medial Association (CMA) and its county

Through aggressive political and regulatory

medical societies have represented California’s

advocacy, CMA and its county medical societies

physicians for 160 years as the recognized voice

are positioned as one of the most influential

of the house of medicine. Together we stand taller

stakeholders in the development and implementation

and stronger as we fight to protect patients and

of health policy.

improve the health of our communities. We are a we do wouldn’t be possible without the support of

COLLABORATE WITH COLLEAGUES

members like you.

CMA and its county medical societies bring together

dominant force in health care – but all the great work

SHAPE THE FUTURE OF MEDICINE Members receive direct access to our state and

physicians from all regions, specialties and modes of practice through leadership, collaboration, social and educational events, and community service.

national legislative leaders to influence how medical

PROMOTE PUBLIC HEALTH

care is provide today and in the future.

From tobacco use and obesity to prescription drug

PROTECT THE PROFESSION Your membership affirms your commitment to the medical profession and ensures physicians remain in control of the practice of medicine.

GET PAID

abuse and vaccinations, your membership dollars support forward-thinking public health advocacy to improve the health of Californians.

PROTECT MICRA CMA staunchly defends the landmark Medical Injury Compensation Reform Act (MICRA) year after

Members receive one-on-one assistance from CMA’s

year, saving each California physician an average of

reimbursement experts, who have recouped $13

$75,000 per year in professional liability insurance

million from payors on behalf of CMA physicians in

premiums.

the past seven years.

LEAD BY EXAMPLE

STAY IN THE KNOW CMA and its county medical societies produce

CMA and its county medical societies provide many

publications to keep you up to date on the latest

opportunities to get involved, including opportunities

health care news and information affecting the

to volunteer, serve on a committee, council or board,

practice of medicine in California.

and shape the future of the medical profession.

Join or renew your membership today! www.cmanet.org/join Questions? Contact our Member Service Center at (800) 786-4262 or memberservice@cmanet.org.