October 2007

VOL.80 NO.8 October 2007 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

DISASTER! A COMPREHENSIVE GUIDE FOR DOCTORS

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CONTENTS Disaster! A Comprehensive Guide for Doctors October 2007 Volume 80, Number 8

Features

Monthly Columns

10 Staying Close to Home Mary Ellen Carroll

4 On Your Behalf

11 How to Get Involved Ahead of Time Rebekah Varela

7 President’s Message

12 Alternative Care Centers John Brown, MD 13 The Emergency Physician Eric Isaacs, MD, FACEP, FAAEM

Stephen Follansbee, MD

9 Editorial

Mike Denney, MD, PhD

15 New Disaster Planning Aids Michael Petrie 16 In Case of Emergency John Brown, MD Editorial and Advertising Offices

19 Infectious Disease Response Susan Fernyak, MD

1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261

21 Preparing for the Inevitable William Schecter, MD, FACS, and Lann Wilder, EMT-P 22 Advice from Our City’s Planner John Brown, MD

Fax: 415.561.0833

Email: adenz@sfms.org Web: www.sfms.org/magazine Subscriptions:

Disaster Preparedness Resources

$45 per year; $5 per issue

5 San Francisco Emergency Response District Map

website, www.sfms.org/advertising, or can

23 How to Be Prepared: An Essential Guide for Physicians

Advertising information is available on our be sent upon request.

Printing: Sundance Press

24 Disaster Preparedness in Each Hospital

P.O. Box 26605 Tuscon, AZ 85726-6605

Special Section: SFMS Elections and Bylaws 27 Slate 28 SFMS Officer Candidate Statements 36 SFMS Bylaw Updates

To see San Francisco Medicine Magazine online, please visit our website:

www.sfms.org/magazine

The Editors of San Francisco Medicine would like to extend a special thanks to John Brown, MD, and the San Francisco Department of Public Health for their assistance in putting together this comprehensive guide on disaster preparedness.

San Francisco Medicine october 2007

www.sfms.org

ON YOUR BEHALF

October 2007 Volume 80, Number 8

A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artist Amanda Denz Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Arthur Lyons

Toni Brayer

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

Shieva Khayam-Bashi SFMS Officers President Stephen E. Follansbee President-Elect Stephen H. Fugaro Secretary Michael Rokeach Treasurer Charles J. Wibbelsman Editor Mike Denney Immediate Past-President Gordon L. Fung

Save the Date! SFMS Nutcracker Night Coming Soon Mark your calendars for an exciting NEW member event, the San Francisco Medical Society Nutcracker Night at the San Francisco Ballet, on Saturday, December 29. This fun, “family-friendly” event will also feature a festive reception at 6:00 p.m. followed by the performance at 7:00 p.m..

Details—including pricing and seating locations—to follow, but if you have any questions please contact Therese Porter in the Membership Department, (415) 561-0850 extension 268 or tporter@sfms.org.

Also on the horizon is the return of the popular SFMS Tennis Mixer at the San Francisco Tennis Club in January.

Remember—nonmembers are welcome at SFMS membership social/cultural events, which is a great way for them to get to know SFMS and its membership better.

SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Donald C. Kitt

Term:

Jordan Shlain

Jan 2005-Dec 2007

Lily M. Tan

Gary L. Chan

Shannon Udovic-

George A. Fouras

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

John W. Pierce

Mei-Ling E. Fong

Daniel M. Raybin

Thomas H. Lee

Michael H. Siu

CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate

Promoting Membership Just Got Easier Did you know that your physician peers can now join the San Francisco Medical Society online? Prospective members can go to www.sfms.org and click “Join SFMS” on the top of the home page. It’s quick and easy, and new members get a 50 percent discount on their first year’s dues!

Thank you to our members who have already referred their fellow physicians— physicians talking to physicians remains the strongest and best way for the Medical Society to grow its ranks and help shape the future of medicine.

ing their NPI included in their Membership Directory listing. You can respond by fax, e-mail, or the postage-paid return envelope included in the mailing. If you haven’t received your update packet, or you have any changes in your contact information, please contact Therese Porter, Director of Membership, at (415) 561-0850, extension 268 or tporter@sfms.org.

Solo Incorporated Practitioners May Have to Reenroll in Medicare Changes in the Medicare enrollment process over the years have caused some differences between the NPI and Medicare identification number assignment process.

This may require some physicians to complete a new Medicare enrollment form so that their NPI and Medicare “provider types” match. Particularly affected are solo incorporated practices, which must obtain both an organizational NPI and an individual NPI. If you have two NPIs but only one Medicare provider number, a new CMS 855 application may be necessary.

Contact Frank Navarro at (916) 5512046 or gfonseca@cmanet.org for more information.

CMA/UCSD Pain Management CME Program Available on DVD

CMA and University of California at San Diego have collaborated on a unique case-based CME program on DVD, which physicians can use to receive their statemandated twelve hours of Category I CME in pain medicine and end-of-life care. The program, Pain Management: A Case-Based Have You Returned Your Records CME Program for Physicians, provides Update Form Yet? specific information on the most common We recently sent out letters to our pain syndromes. The price, including CME membership requesting updates on phone testing and credits, is $150 for members, number, e-mail address and NPI number. $200 for nonmembers.

Each year we update our records so that our For more information, visit http://www. members are kept up to date. We are espe- ab487.com. cially focusing on adding our members’ NPI numbers to their membership files, and in 2008 members will have the option of hav-

San Francisco Medicine october 2007

www.sfms.org

This map shows San Francisco’s emergency response districts and disaster response hubs.

For more details please see the article on page 10.

www.sfms.org

october 2007 San Francisco Medicine

Richard E. Anderson, MD, FACP Chairman and CEO, The Doctors Company

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly introduce the Tribute Plan. We go way beyond dividends. We reward years spent practicing good medicine.

We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company.

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You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.”

Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our professional liability program, including the Tribute Plan, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293. You can also visit us online at www.doctorsagency.com.

© 2007. The Doctors Company. All rights reserved.

President’s Message Stephen Follansbee, MD

Disaster Preparedness

H

urricane Katrina passed through New Orleans on August 29, 2005. The fallout from the hurricane and the flooding that followed will probably persist for years. There are lessons to be learned from Hurricane Katrina for all of us, not only as physicians, but also as citizens. The events at Memorial Hospital in New Orleans are particularly poignant.

The hospital was flooded with ten feet of water after the levees collapsed. There was no electricity, no running water, no sanitation, and no evident evacuation plan for the sickest of patients.

Staff tried to commandeer boats to evacuate some of the less ill.

One physician and two nurses attended to the needs of very ill patients on the floor. They attempted to provide compassionate and professional care for four days in a setting of hopelessness. Later they were charged with the murder of at least four patients by the Louisiana State Attorney General. They were subsequently cleared of all criminal charges. However, accusations and civil suits against these health care workers persist.

What are the rules of care when supplies are exhausted and there is no apparent chance of rescue? Each worker who remained at Memorial Hospital and voluntarily took care of patients is a hero.

They had their own lives, families, and needs to think about, yet they stayed. How can we be critical of decisions that these individuals made when we, as their physician colleagues, were not there offering assistance or advice?

As members of the medical community of San Francisco, we need to ask ourselves if we are in fact ready for our own disaster. The city has suffered major earthquakes, fires, cholera epidemics, threats of epidemics such as SARS, gas line explosions, and international threats of terrorism. These incidences have taught us physicians a lot. However, I suspect that this issue of San Francisco Medicine will teach us even more.

One lesson from New Orleans is that help is not necessarily “on the way.” There is the expectation that government agencies will be ready and able to provide necessary medications, antidotes, vaccinations, equipment, and expertise in the event of a disaster. But even the best preparation does not ensure there will be personnel, landing strips, vehicle access, or capacity to deal with a disaster. As a city, we will need to be prepared to take care of ourselves. The “Essential Guide for Physicians” on page 23 will provide you with www.sfms.org

a variety of resources to keep in mind in the event of a disaster as well as information about what to have on hand.

As physicians, we are used to being in charge. We expect to use our medical expertise and not to be asked to do tasks that may appear trivial or outside of our specialty. In a disaster that may not be possible or appropriate. In the first seventy-two hours of a disaster, my infectious diseases expertise may not be needed at all, for example. That doesn’t matter. What matters is that I will be willing to recognize what is necessary and act accordingly. In addition, we may not be able to get to our own offices or medical centers. Like the physicians and nurses and pharmacists and other staff at Memorial Hospital in New Orleans, we may be asked not only to put our expertise aside to accomplish more immediately urgent tasks, but also to fill those needs in unfamiliar surroundings, with people we do not know at all.

A final lesson is that denying that an impending disaster exists is not appropriate. Denial can be a powerful and personally useful coping mechanism. However, in the face of disaster, denial is foolhardy. Whether what comes is an earthquake, act of terrorism, nuclear accident, or weather event caused by global warming, we need to be ready.

Finding out in advance what your medical center or office’s plan is, what response units will be set up in your neighborhood, or what the city’s overall plan will be in terms of disaster medical care could save that precious time of trying to figure it out after your cell phone and Internet have gone down. Reading this issue of San Francisco Medicine and getting involved in some of the programs mentioned is a great step toward preparation.

october 2007 San Francisco Medicine

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Editorial Mike Denney, MD, PhD

Baghdad by the Bay

T

he late beloved humorist and columnist Herb Caen often referred to San Francisco as “Baghdad by the Bay.” He was speaking of the exotic beauty, deep mysteries, exciting adventures, tantalizing intrigues, and sensual pleasures of San Francisco, which he deemed to be as magical as Baghdad, that historic city located between the Tigris and Euphrates rivers in the Biblical land of Ur in Mesopotamia, home of ancient Babylon and the cradle of civilization.

The “exoticism” of Caen’s Baghdad had become instilled in the minds of Westerners through the many stories of the Arabian Nights, adventure tales that were derived from ancient folklore and mythology of Egypt, India, Persia, and the Arab world, stories that include Sinbad the Sailor, Ali Baba and the Forty Thieves, and Aladdin. The “sensuality” of Caen’s Baghdad lay in the stories that often depicted the joys of food and flesh. And the “magic” of Caen’s Baghdad derived from the genies in lamps, winged horses, and flying carpets that could grant wishes, transform reality, and transport the reader to the depths of the sea, the world above the clouds, and the citadel of the moon.

Outside of the world of magic, however, we know that Baghdad was also a city of disasters. The current city, founded in 732 A.D. by Caliph al-Mansur, was probably built upon the ruins of a destroyed earlier settlement. The city prospered and by 900 A.D. was a hub of learning and commerce, the time that is the setting of most of the stories of the Arabian Nights. Soon, however, the city experienced a series of calamities. In 1258, Baghdad was sacked by the Mongols; the inhabitants were massacred and the culture disintegrated. In 1534, disaster struck again when the city was destroyed by the Ottoman Turks. British control and dominance lasted from 1921 to 1946, and the more recent prosperity through petroleum also is marked by the destruction of most of the city’s infrastructure, due to the Iran-Iraq war, the Persian Gulf War, and the current Iraq war.

Of course, Baghdad by the Bay also had its disasters, though smaller in scope. Most famous of these is the great San Francisco earthquake and fire of 1906. Before that, during the Gold Rush, the city had undergone its period of “Barbary Coast” lawlessness, which required organized vigilantes to take up arms. The powerful San Andreas fault, the images of the destructive force of tsunamis, the ongoing story of New Orleans, and the rising threat of terrorism continually remind www.sfms.org

us that San Francisco may be vulnerable to disaster.

When such a disaster strikes, what story will be told? Will it be of mass destruction or of a disaster that was contained by careful preparedness? Are we prepared? Can Baghdad by the Bay learn something in this regard from the old exotic city of Baghdad and its stories of Arabian Nights?

We might remember that the tales in the Arabian Nights were stories within a story—the encompassing tale of which was A Thousand and One Nights, about a young woman named Scheherezade who, in a curious way, may offer a lesson about disaster preparedness.

In this overarching story, King Shahryar had developed the bad habit of marrying young maidens, then killing them the morning after their one nuptial conjugation on their wedding night. Scheherezade was going to be King Shahryar’s next wife, but she was prepared for disaster—she had a plan.

On their wedding night and each night thereafter, Scheherezade told King Shahyar fascinating stories, all of those exotic tales in Arabian Nights, many of which begged for denouement. The king, fascinated by the tales and unwilling to kill Scheherazade because he wanted to know the endings, listened carefully for a thousand and one nights, and then was so intrigued that he wanted to be with her forever. Scheherezade had escaped disaster.

This issue of San Francisco Medicine, with the generous guidance of John Brown, MD, Director of Emergency Medical Services for the city and county of San Francisco, provides many stories about our state of disaster preparedness. Dr. Brown has emphasized that interlocking departments, hospitals, and medical personnel must coordinate their activities, because the failure of one department could cause the whole system to break down like a house of cards.

Paradoxically, in the opening sentence in his book Baghdad by the Bay (Comstock Editions, 1951), Herb Caen says, “San Francisco, to me, is like a house of cards, postcards in glowing colors stacked against the hills.” Obviously, Caen was talking about this colorful, exotic, and romantic city and was unaware of the implications of a “house of cards” concept in disaster preparedness. And so it may be that we can liken our task to that of Scheherezade—we have the opportunity to tell the ultimate story of disaster preparedness in San Francisco, hopefully to preserve Herb Caen’s romantic dream of “Baghdad by the Bay.” october 2007 San Francisco Medicine

Disaster! A Comprehensive Guide for Doctors

Staying Close to Home San Francisco Develops a Response Hub in Each of the City’s Neighborhoods Mary Ellen Carroll

F

or the City and County of San Francisco, the question of another big earthquake is not if but when.

In fact, an earthquake is only one of many potential disasters, both man-made and natural, that San Francisco faces. Disasters worldwide, including Hurricane Katrina, have shown that these events will test a community well beyond its everyday ability to respond. In San Francisco, we have a newly conceived plan for community disaster response that takes an innovative approach to planning for and responding to a disaster.

Our city must be prepared to deal with the effects of a disaster without any outside aid for at least the first seventy-two hours.

Any event that results in mass casualties will quickly overwhelm the City’s traditional emergency medical responders, such as ambulance providers and hospitals. With this in mind, the Department of Public Health (DPH) planners began looking at how to better incorporate community medical and mental health services immediately after a disaster.

In early 2007, individuals from the DPH, the Fire Department, the Human Services Agency, the Department of Emergency Management (DEM), and the American Red Cross convened to develop a plan. This group, lead by DPH and DEM, analyzed existing community disasterresponse plans and created a template for a community response plan that could be applied to each community within San Francisco, taking into account the unique hazards, needs, and response capabilities of those individual communities. The result of these meetings was to create the concept of operation for Community DisasterResponse Hubs.

10

Community Disaster-Response Hubs are tasked with keeping communities “whole” in the immediate aftermath of large disasters, when it may take a minimum of seventy-two hours for the City to mobilize itself and for outside resources to be channeled into affected communities. During this initial stage, communities will be limited to their own existing resources. The Community Hubs will provide an incident command structure at the field or district level to achieve the following community disaster-response objectives: medical and mental health support; shelter support; food and water distribution; support for vulnerable populations; information dissemination and coordination.

From the very first meeting of the community disaster-response work group, DPH had the goal of mitigating the impact on hospitals so that they would be able to provide needed acute care in an emergency.

By dealing with the basic medical, mental health, and care and shelter needs at the community level, there will be less impact of the “worried well,” minor casualties and those seeking basic care and shelter in acute care facilities.

The Hubs will operate out of DPH clinics and will be staffed with DPH and other CCSF disaster service workers (DSWs). The Hubs will collect and disseminate information by providing the City’s Emergency Operations Centers with field-level data on the overall status of the community, both during response and into recovery. This will enable integration of the response and relief effort of the community with the larger local government response, and it will provide the community with a means for requesting resources from local government.

The plan uses existing Emergency

San Francisco Medicine october 2007

Response Districts (ERDs) to divide the City (see map on page 5). Within each ERD, there will be a minimum of one Hub. The locations of the Hubs will be based on certain criteria, including consideration of liquefaction and high-intensity earthquake shake zones, proximity to open space, population density, vulnerable populations, and NERT staging areas.

The first phase of the Community Response Hub planning is complete. A concept of operations has been distributed to internal stakeholders for comment. The next phase will include a pilot implementation of the plan that will take place in one ERD. Community stakeholders from that district will be invited to participate, including community-based organizations, faith-based organizations, the business community, schools, and neighborhood groups. After the six-month pilot, a Citywide rollout of the plan will take place. The goal is to have operational plans, training, equipment, and supplies in every ERD in San Francisco by the end of 2008. The result will be a City that is prepared to deal with whatever disaster occurs with what resources are available within all communities in San Francisco.

Mary Ellen Carroll is a Senior Health Program Planner with the Office of Policy and Planning in the Department of Public Health.

She has been at the DPH for three years and previously worked in nonprofit sector, specifically in the area of health and housing for special-needs populations in San Francisco. She has a master’s degree in Urban Affairs from Virgina Tech.

www.sfms.org

Disaster! A Comprehensive Guide for Doctors

How to Get Involved ahead of Time Disaster Response Opportunities for Medical Professionals Rebekah Varela

I

n the event of a disaster, having an adequate number of trained health care providers available to pitch in can mean the difference between a successful response and a system overwhelmed by acute patient need. As a physician, there are several ways you can become involved with public health disaster preparedness and response, ranging from local to national opportunities. Choosing the level of response that is right for you depends on the amount of time you are willing and able to give to preparedness training, your ability to travel on short notice, and your own personal and family preparedness plans and obligations.

Medical Reserve Corps (MRC) MRC units are community-based and function as a way to locally organize and use volunteers who want to donate their time and expertise to prepare for and respond to emergencies. MRC volunteers supplement existing emergency and public health resources and are, first and foremost, a local asset. Founded in 2002, the Medical Reserve Corps is housed in the Office of the Surgeon General. Currently, there are 695 MRC units across the nation and 126,060 individual volunteers. MRC volunteers include medical and public health professionals such as physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists.

MRC volunteers can choose to support communities in need nationwide.

During the 2004 hurricane season, MRC volunteers filled in at local hospitals, assisted at local shelters, and provided first aid.

During this two-month period, more than thirty MRC units joined the relief efforts.

Local plans for a Medical Reserve Corps are underway as a joint project of the San Francisco Department of Public Health www.sfms.org

and the San Francisco Fire Department.

Considerations in planning for a successful MRC include integrating with hospital human resources systems for precredentialing medical volunteers, planning for emergency communications needs and deployment protocols, and providing ongoing training for MRC participants. Bay Area Health care providers will receive information in the mail regarding the San Francisco Medical Reserve Corps when the program is officially launched.

For more information, please visit www.medicalreservecorps.gov.

Emergency System for the Advance Registration of Volunteer Health Professionals A central challenge to using medical volunteers in times of a disaster is the ability to confirm the credentials and identity of the volunteer. Attention to this problem was raised during the events of September 11, 2001, and the anthrax attacks that followed.

In response, Congress authorized the funding and creation of the Emergency System for the Advance Registration of Volunteer Health Professionals (ESAR-VHP) in 2002.

Administered at the state level, each system includes readily available, verifiable, up-todate information regarding the volunteer’s identity, licensing, credentialing, accreditation, and privileging in hospitals or other medical facilities. The State of California ESAR-VHP is a standardized volunteer registration system aimed at identifying health care providers willing to respond during a declared disaster at both the local and state levels.

For more information, or to participate in the ESAR-VHP system, please visit https://medicalvolunteer.ca.gov/.

California Medical Assistance Team/Federal Disaster Medical Assistance Team Nationally, the federal government has the Federal Disaster Medical Assistance Team (DMAT) program as part of the National Disaster Medical System (NDMS).

During a disaster, the DMATs provides essential medical care at the disaster site as well as triage and medical care at staging and reception sites and they prepare patients for evacuation. Six of the fifty federal DMATs are located in California. These teams are comprised of approximately 120 personnel each with the ability to treat up to a thousand patients per day. The federal DMATs are activated solely by NDMS, at their discretion.

California Medical Assistance Teams are state-organized and -funded groups of professional and paraprofessional clinical personnel, supported by a cadre of logistical and administrative staff, designed to provide medical care during a disaster or other event. Developed on the model of the federal Disaster Medical Assistance Teams, with a more rapid deployment profile, a CalMAT provides response personnel and equipment capable of rendering care under austere conditions. The CalMAT program is funded by, overseen by, and exists within the auspices of the Emergency Medical Services Authority.

For more information on the Federal DMAT based out of San Francisco, please visit www.dmatca6.org/. For more information on the CalMAT, please contact the State of California Emergency Medical Services Authority at (916) 322-4336.

Rebekah Varela is a Health Planner with the Office of Policy and Planning in the San Francisco Department of Public Health.

october 2007 San Francisco Medicine

11

Disaster! A Comprehensive Guide for Doctors

Alternative Care Centers Where Will Medical Care Be Offered in the Event of a Disaster?

John Brown, MD

A

lternative Care Centers (Field Care Clinics, Casualty Collection Points, Alternative Treatment Sites, and Disaster Medical Assistance Teams) are extensions of the physician’s ability to provide medical care in a disaster environment.

They fit into the armamentarium somewhere between a physician’s office and an urgent care center. Flexibility in their placement is key; it’s important to recognize that this is not a one-size-fits-all tool. An ACS can be a small operation with a doctor and some other health care professionals working as a clinic at a shelter, or a full medical staff providing trauma stabilization and evacuation as a part of a larger disaster patient care and evacuation site. The common theme is that the providers will be taking some basic building blocks and using them to provide the best structure possible for patient care in any given situation.

Let’s consider some potential uses of such a facility. A Field Care Clinic can be established indoors if sufficient space is available, or outdoors in several tents with utility services. Its mission would be the routine care of patients unable to access doctor’s offices, clinics, or urgent care centers following a disaster. It can also be used as additional, or surge, capability for a fixed facility such as a hospital, skilled nursing facility, or outpatient center. Designed with a twenty-bed patient capability, it is likely to be used to care for patients with primarycare conditions, with rapid turnaround times for these patients. Optimum staffing levels would depend on patient load and supplies, but at least two to four physicians or physician extenders and twice that number of nurses and nursing assistants would be needed to keep patient turnover high. An example would be the FCC’s used by the 12

San Francisco Department of Public Health for the Millennium events of 1999–2000, the Halloween in the Castro gatherings, or this year’s All-Star Game.

A Casualty Collection Point is usually found within a larger entity that is an evacuation point for individuals following a disaster, either in need of shelter or in need of staging prior to transferring out of the area. Casualty Collection Points may be set up in tents or preexisting nonmedical facilities, and they may have to deal with large numbers of patients arriving rapidly, providing a triage and stabilization function as opposed to definitive care. CCPs are routinely used in rapidly evolving natural disasters and during wartime with refugee populations. A recent example is the use of Casualty Collection Points in the Madrid Train bombings of 2005.

An Alternate Treatment Site is a facility that is normally used to provide nonemergency medical care and is now being enhanced to provide disaster medical services. The treatment capability of an alternate treatment site would vary depending on the capabilities of its daily use.

An outpatient clinic, for instance, would be able to provide the depth and breadth of treatment needed for routine medical conditions, but it would have potential limits on its ability to care for a rapid influx of patients (depending on its design). A convention center turned into an alternate treatment site would be able to accept a large and rapid influx of patients, but its ability to provide care would be limited to the supplies and medications brought with the treating personnel. Examples of Alternate Treatment Sites were found in many locations after Hurricane Katrina in 2005, as rural clinics were returned to service

San Francisco Medicine october 2007

by out-of-state volunteers.

A Disaster Medical Assistance Team provides the most flexibility of any available Alternate Care Center. The team consists of thirty-five providers, with representation from the physician, physician extender, nursing, EMS, communication, logistics, pharmacy, and administration professionals. The DMAT facility is self-contained, serviced regularly, and its team members are required to train and exercise together annually. The DMAT system is part of the National Disaster Medical System and has resource support from the Federal Government. DMATs have provided a variety of care services, from running extensions of Emergency Departments at Hurricane Katrina response missions to providing specialty services (pediatrics inpatient capacity, specialty care EMS transport, mass prophylaxis, and immunization, to name a few) depending on need. The difficulty with using this resource in a disaster is the time needed to bring it on-site—from six to twelve hours at a minimum.

San Francisco physicians of all specialties and experience would be important providers for Alternate Care Sites that would be established after any disaster in our City. In the hours immediately following a disaster, staff may not be able to access their normal hospital or outpatient care setting, and a nearby ACC would be a better option to be providing care once the physician had assured his or her family’s safety. Some hospitals may be damaged in a disaster, and normal care there would not be possible, so the use of an ACC at or near the damaged facility would provide some level of service for patients seeking care.

Finally, the orderly movement of patients

Continued on Page 18... www.sfms.org

Disaster! A Comprehensive Guide for Doctors

The Emergency Physician What Role Will These Docs Play During a Large-Scale Emergency?

Eric Isaacs, MD, FACEP, FAAEM The best emergency physician is an excellent diagnostician, a skilled air traffic controller, a complex symphony conductor, and a hospitable maitre d’. In addition to their direct patient care duties, emergency physicians are prioritizing and moving patients through the health care system, coordinating specialist care, and ensuring that patients are comfortable and satisfied with their experience in the hospital. The role of the emergency physician during disaster operations is merely a magnification of their duties during a routine shift. The ability to multitask, to juggle multiple patients, to demonstrate procedural skill with EKG readings and radiology “first reads,” and to demonstrate comfort with patients across the spectrum of age, gender, and chief complaint are particularly valuable qualities when resources are scarce.

As the health care safety net, and the only health care provider open twenty-four hours a day, seven days a week, and 365 days a year, the city’s emergency departments are on the front lines of receiving patients affected by disaster. Interestingly, there is a misconception by the public and health care providers regarding the manner in which patients will arrive in a large-scale disaster.

Every day, we rely on the emergency medical system (EMS) to pick up our patients and deliver them to the hospital of their choice.

In the case of locally contained emergencies that might overwhelm a single hospital, like a bus crash, systems are in place so that patients who enter the health care system through EMS will be spread around to other community hospitals for stabilization, including those suffering trauma, burns, and poisonings. Our own country’s history has shown that, in natural disasters and manmade ones (such as the 9/11 attacks and the www.sfms.org

anthrax incidents in 2001), most victims bypass ambulance transport. More than 80 percent of patients involved in these events go to the nearest emergency department by

“The role of the emergency physician during disaster operations is merely a magnification of their duties during a routine shift.” foot or private vehicle. And a large number of patients are the so-called “worried well.”

These are the patients who may not have been exposed but present concern about disease without signs of illness. After the Sarin gas attack on the Tokyo subway in 1995, more than 5,000 patients sought care in local hospitals. The “worried well” outnumbered patients actually exposed by more than four to one. These patients will occupy scarce resources, but they need an initial medical evaluation and subsequent follow-up. The care of these patients should fall to the broader medical community who can respond to such a disaster.

While every member of the medical community is familiar with the principles of triage, the ability to triage patients rapidly and effectively results from training and practice. With a few exceptions, it is emergency physicians who are most practiced at the art and skill of triage. While many emergency planners recognize the necessity to integrate the larger hospital community in disaster drills, it does not happen enough.

The emergency department is involved in hospital disaster drills at least twice a year, and even then, only the staff on duty is

involved in the drills. More training and practice are needed for all of us. Decisions must be made to benefit the greatest number of potential survivors. Right now, our triage is based on severity, channeling resources to those who need them most. In biologic disasters, for example, triage point of contact decisions may be based on exposure and infectiousness.

Triage processes and decisions will differ depending on the scope and nature of the disaster being faced. San Francisco is one of the few cities in the United States to face such a variety of as potential disasters.

We are constantly reminded that a major earthquake will strike San Francisco again in the future. We have direct contact with two bridges (one under construction), subject to collapse from an industrial accident or terrorist event. We are a densely populated city, with trucks carrying hazardous materials moving along the freeway traversing our neighborhoods. We are a high-visibility tourist destination with a subway system, making us a desirable target for terrorist attacks involving explosives or chemical or biological weapons. The SARS outbreak reminded us of our vulnerability to entities such as pandemic influenza, given that we serve as a major port of entry to the United States from countries around the world. Most emergency departments in San Francisco are struggling to meet the demands for day-to-day emergencies, let alone respond to disasters involving large numbers of patients. An organized response from the medical community, locally and on a national level, is necessary to impact this problem.

Emergency physicians should play a number of roles in disaster planning and

Continued on Page 18...

october 2007 San Francisco Medicine

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Disaster! A Comprehensive Guide for Doctors

New Disaster Planning Aids New Standards to Be Unveiled in San Francisco Michael Petrie

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hroughout California, medical disaster plans are being revised to reflect the reality of the post-9/11 world. When implemented, these plans will materially improve the ability of local, regional, and statewide EMS organizations to respond to natural and man-made disasters.

In California, a partnership of EMS Administrators, the California EMS Authority, and Regional Disaster Medical Health Specialists (RDMHS) are working to complete the state’s first medical operations disaster manual, the California Disaster Medical Operations Manual (on CD-ROM).

This manual will prescribe standards and operations in the most critical functions of medical disaster management—alerting and communications; incident and medical resource assessment; requesting, deploying, receiving, and integrating medical mutual aid; EMS field operations; and distribution of patients across geopolitical boundaries.

There were challenges in creating a statewide medical disaster capability. In some instances, structures and processes used in urban EMS systems differ greatly from those used by rural systems. However, those involved understand that common practices are necessary for successful emergency operations among numerous organizations, and that local preferences must be deferred to develop a single statewide system.

The CD-ROM will be released this month. Local EMS agencies, such as the San Francisco EMS Agency, will incorporate the standardized structures, processes, and practices from the CD-ROM into their policies. Additionally, soon after its release, the CD-ROM will be revised to incorporate public health operations, using the stanwww.sfms.org

dardized structures and processes already developed. This iteration will rely heavily on collaboration with our colleagues from the CCLHO and the California Department of Public Health.

Within San Francisco, a parallel process is occurring. For approximately the past year, the San Francisco EMS Agency has coordinated the first material revision of the Multi-Casualty Incident (MCI) Policy since it was developed in 2003. This revision expands the MCI policy to a comprehensive MCI and Mass Casualty Event (MCE) Plan.

This plan will incorporate best medical disaster practices from other EMS systems, implement the standardized structures and processes identified in the California Disaster Medical Operations Manual, and consider the unique characteristics of the San Francisco EMS system, which includes seven EMS dispatch centers, the San Francisco Fire Department, seven EMT or paramedic ambulance providers, and twelve ambulance-receiving hospitals.

Development of the San Francisco MCI and MCE Plan has relied heavily on scenario-based planning. EMS, public health hospital, clinic, law enforcement, ambulance, security, National Guard, Department of Homeland Security, emergency management, and fire service representatives participated in discussion-based exercises to determine doctrine and priorities when responding to disasters.

The MCI and MCE Plan will reflect the reality of EMS preparedness in the post9/11 world. The plan describes responses to a range of critical incidents, including EMS system overloads, which are rapid increases in emergency medical calls that overwhelm resources. The plan considers whether ambulances should transport patients to

hospitals or alternate treatment sites when hospitals are overwhelmed. The plan describes enhanced roles and responsibilities for all EMS stakeholder organizations, including communication centers, first responders, ambulance providers, hospitals, the Department of Public Health, and the EMS Agency. In total, the MCI and MCE Plan will define organizational structures, processes, and standards that will better prepare San Francisco’s EMS system to provide patient care following an MCI or disaster.

In addition to creating a new MCI plan, the San Francisco EMS system will be one of the first in the nation to attempt to deploy an electronic patient tracking system. This patient care tool is necessary to track patients from multiple simultaneous MCI sites to multiple treatment areas, ambulances, and hospitals or other destinations. The EMS Agency is working to develop and implement this system by the spring of 2008.

However, plans are not capabilities, and they do not, on their own, improve preparedness. Following completion of the MCI and MCE Plan, training materials will be developed, and those expected to follow the plan will be trained and properly equipped. Following training, stakeholders will be evaluated through exercises and deficiencies identified in those exercises will be corrected, resulting in a San Francisco that is better prepared to respond to and recover from an emergency.

Michael Petrie is the administrator of the San Francisco EMS Agency and sits on the executive board of the EMS Administrators Association of California. He is also on faculty at the Center for Homeland Defense and Security at the Naval Postgraduate School.

october 2007 San Francisco Medicine

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Disaster! A Comprehensive Guide for Doctors

The DMAT Team set up shop at the All Star Game in San Francisco

In Case of Emergency The Disaster Medical Assistance Team is Ready John Brown, MD

I

n the arena of disaster preparedness and response, the conversation has changed dramatically since the one-two punch delivered to the American psyche by the World Trade Center Disaster and Hurricane Katrina. Although 9/11 served to codify the fear of terrorist threat, it did not truly tax our medical response system. Katrina, on the other hand, highlighted the medical issues at play during a catastrophic event, as well as the failings of our local, state, and federal health care resources.

Preparedness and response begin in the affected community. Communities typically become overwhelmed during a disaster for a variety of reasons including inadequate resources, inadequate surge capacity, communications breakdown, and destruction and/or inadequacy of local government and private infrastructure.

One of the resources available to a community during a disaster is the Disaster Medical Assistance Team (DMAT).

What Is DMAT? A DMAT is a multidisciplinary team designed to provide medical care during a disaster or other catastrophic event. It deploys to disaster sites with sufficient supplies and equipment to sustain itself for a period of seventy-two hours while providing medical care at a fixed or temporary medical care site. It is one of a number of specialty teams overseen by the National Disaster Medical System (NDMS) under the U.S. Department of Health and Human Services (HHS).

The mission of NDMS includes providing medical response to a disaster area in the form of teams, supplies, and equipment; moving patients from the disaster site to unaffected areas of the nation; and providing definitive medical care at participating 16

hospitals in unaffected areas.

NDMS teams that support these functions include the Disaster Medical Assistance Team (DMAT), Disaster Mortuary Operational Response Teams (DMORT), Disaster Veterinary Response Team (DVRT), National Nurse Response Team (NNRT), and the National Pharmacy Response Team (NPRT).

DMAT Structure and Function By virtue of being multidisciplinary and self-sufficient, DMATs are somewhat complex. For this reason, teams are typed by their ability to deploy to various situations, with type 1 teams being the most self-sufficient. Of the more than forty DMATs in the country, only a handful are type 1 teams.

A deployed team consists of about forty people at all levels: medical providers, logistics folks, communications and IT personnel, and command staff. The medical providers include physicians, midlevel providers, nurses, and prehospital providers.

From an operational perspective, DMATs need to be capable of providing care that spans the gamut of prehospital care to urgent care to emergency care to primary care. As such, providers from all backgrounds have a role to play.

However, providers who have broad experience are particularly valuable. This is true for all levels of providers. Indeed, one of the most enjoyable aspects of being on a DMAT team is being able to practice alongside people whose knowledge, experience, and abilities often transcend the scope of their specific degree or licensure. It also serves as a source of comfort for those primary medical providers who may feel that they are being called upon to push the limits of their comfort zone.

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Typical examples of physician specialties represented on a DMAT include emergency medicine, orthopedics, pediatrics, anesthesiology, ophthalmology, and family medicine. Family medicine physicians are particularly well-suited to the diverse experience that DMAT offers. With a rich training curriculum, however, most providers of all licensure can learn the “tools of the trade” to keep them functional and comfortable serving the team.

DMATs typically deploy for two weeks at a time, although they are on call for shortnotice deployability for a month at a time.

Although team members can decide up to the time of deployment if they are willing and able to deploy, this arrangement can be very challenging for health care professionals. For traditionally employed folks, the Uniformed Services Employment and Reemployment Rights Act (USERRA) protects them from retaliation or loss of job.

For health care professionals not employed in the same fashion, especially physicians, USERRA does not really help. Generally, we rely on the goodwill of our professional groups and colleagues to help us with this commitment. However, this is one reason why physicians are particularly hard to recruit and tend to be the most understaffed and limiting component in staffing a deployable team.

DMAT California 6 San Francisco is well known for drawing bright, interesting, and diverse health care workers and professionals. The same can be said of the San Francisco Bay Area’s Disaster Medical Assistance Team, DMAT CA-6. Although CA-6 is really a regional team, which draws from parts north, south, and east of the City, the team lives up to that www.sfms.org

expectation. Indeed, of the more than forty such teams within the National Disaster Medical System (NDMS), CA-6 is among the most experienced and is helping drive ongoing improvements in this system.

DMAT CA-6 Experience The World Trade Center Disaster Although 9/11 was the bookend to this new era of disaster awareness, from the medical communities’ perspective it was not what one might have expected. The World Trade Center Disaster was one of only two events that have led to the activation of all deployable DMAT teams. However, because there were few survivors, the DMAT mission was to support the recovery workers on site. CA-6 rotated through the site about one month after the disaster and stayed for two weeks.

During that deployment, we stayed in hotels and worked standard eight-hour shifts onsite. We functioned as an onsite urgent care clinic working out of two treatment tents on either side of the WTC site. During our stay, the patient census was about twenty to thirty patients per shift. Peak injuries and patient visits occurred around two weeks after the disaster, when the relief effort got into full swing. At that time there were five medical tents and the census reflected that allocation of resources.

The injuries seen and treated included burns, lacerations, sprains, and foreign bodies. The medical problems seen most often included respiratory infections, asthma, dehydration, and chest pain. Being so close to definitive care, there was a low threshold to transfer patients out. However, because of the extreme level of motivation on behalf of the workers, it was often difficult to get complete histories and compliance with recommendations because of the fear

the workers had of being taken off their assignment.

Hurricane Katrina Deployment Katrina represents the other extreme for a DMAT deployment. This was a unique situation in which every deployable DMAT team in the country was predeployed to the Gulf Coast prior to landfall. Despite this initial effort, the devastation of the Hurricane and the inadequacies of the other components of the response led to the excessively tragic outcome of this disaster.

CA-6 deployed two full teams for Hurricane Katrina relief. The first involved prepositioning in Texas before the storm struck the Gulf Coast, then subsequent deployment to the Superdome in New Orleans, the LSU Campus in Baton Rouge, and the Louis Armstrong Airport in New Orleans. During this two-week period, the team’s primary function was triage and stabilization in a very austere and chaotic environment. A five-member “strike team” was also deployed to the morgue facility in St. Gabriel, outside of Baton Rouge, to support the DMORT (Disaster Mortuary Operational Response Team) mission to perform medical forensics and identification on the recovered dead.

The second deployment occurred approximately five weeks after the storm and involved medical augmentation missions.

The primary mission was the provision of emergency department level care to the population served by the West Jefferson Hospital just south of New Orleans. This included running a high acuity treatment tent for ten days outside of a damaged hospital helping to care for the 100 to 150 patients per day.

Secondary missions involved providing medical strike teams (small groups of five providers) to staff a medical clinic in a decimated small community on the coast, and to provide immunization services to New Orleans residents. The team provided a total of more than four weeks of service to thousands of patients during the relief efforts.

Nonfederal Resources In addition to the federal resources provided by NDMS, many states have or www.sfms.org

are currently building state medical response resources, and there are local and nonprofit resources as well.

CalMAT Recognizing the difficulties of relying too heavily on the federal government for assistance during a disaster, California has been developing a system for disaster medical response called CalMAT. Though still in its development stage, significant resources have been purchased for this system, including three 200-bed Mobile Field Hospitals and three large regional caches of equipment and supplies that can quickly be moved into place to support a disaster medical response.

CalMAT teams are envisioned to be similar in structure and function to DMATs, but with a less stringent application process and a more flexible time frame for deployment. Although there will be a number of sources of personnel for these, at this time it appears that DMAT team members will have an advantage in terms of training and dual-roster deployability. The nonprofit San Francisco Bay Area DMAT is helping develop the personnel component of the CAL-MAT concept. There will, however, be other participant organizations, including the Medical Reserve Corp, which is a less well-defined organization of medical personnel who wish to be of service to the state during a time of need.

The experiences of 9/11 and Hurricane Katrina have provided valuable lessons and have given us cause to examine our preparedness to meet the medical needs of our communities during a disaster.

San Francisco suffers from much of the same inadequacies facing all communities throughout the country. However, with its rich and capable medical community, there is room for optimism. There are many ways that all of us, both medical and nonmedical providers, can contribute to the effort to improve preparedness and adequacy of our community medical system. Of course, the folks who belong to DMAT CA-6 and your local San Francisco Bay Area DMAT would like to recruit you. There are, however, many other ways to be involved that balance one’s means and desires, including the evolving CalMAT and Medical Reserve Corp systems. Stay tuned.

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Alternative Care Centers Continued from Page 12...

Emergency Physician Continued from Page 13...

from disaster site to definitive care (if that level of care were needed and not available at the site) would be dependent on adequate resuscitation and stabilization of patients, as well as accurate triage of those with the best chance of responding to treatment to be evacuated. In addition, quality palliative care for those not likely to survive and not being evacuated for further care would become of equal importance to these patients and their families.

To learn more about providing care at Alternative Care Sites, visit the EMS Agency website at www.sanfranciscoems.org and the State of California EMS Authority at www.emsa.ca.gov.

John Brown, MD, has been the Medical Director of the San Francisco EMS Agency since 1996. A graduate of Holy Cross College and the University of Connecticut Medical School, he completed a residency in Emergency Medicine at the Naval Hospital San Diego and an EMS Fellowship at the University of Arizona. He is currently a faculty member of the UCSF/SFGH Emergency Medicine Residency Program and a Medical Officer for the Disaster Medical Assistance Team Bay Area CA-6. He practices emergency medicine at San Francisco General Hospital.

response. First, they need to take personal responsibility for being prepared. They may be on duty when disaster strikes and will be expected to respond in order to relieve their colleagues for long-lasting events.

Participation and feedback during disaster drills is crucial for personal and system improvement. In this time of planning for hospital rebuilds, emergency physicians should take an active role to ensure that adequate space and attention are given to the needs of emergency patients and to disaster operations. San Francisco emergency physicians currently act as directors of the city’s emergency communications center and San Francisco Fire Department EMS division.

What can the community of medicine do to prepare for a disaster? A recent survey showed that many physicians feel underprepared to respond to an emergency, with only one in five primary care physicians feeling prepared to play a role in responding to a bioterror attack. Physician training in emergency response is available and effective. Physicians, if prepared, are extremely valuable in reducing morbidity and mortal-

ity during a disaster response. Physicians can effectively care for others only if reasonably confident of their own safety. An important focus of training is personal and family preparedness. Create an emergency kit for the home and office with a supply of food and water, clothing, and first-aid supplies. A family emergency plan should also include a defined meeting place and clear communication strategies. Review and practice the plan regularly.

The San Francisco Emergency Physicians Association (SFEPA) is a dues-free organization that holds monthly meetings of physicians advocating for the improved care of all emergency patients in San Francisco.

The SFEPA strives to make sure that we are prepared as a community, and to bring back to our hospitals innovative ideas that can be implemented in our own systems.

Dr. Eric Isaacs is the current President of the San Francisco Emergency Physicians Association. Dr. Isaacs was the Assistant EMS Medical Director for the San Francisco Fire Department from 1995 until 2000. He has been practicing emergency medicine at San Francisco General Hospital for thirteen years and is currently a Clinical Professor of Medicine at UCSF.

Welcome New Members!

The San Francisco Medical Society would like to welcome the following new members:

Howard A. Grossman, MD Student Members from the UCSF Class of 2011 Lisa Ashbrook Shannon Bell Diana Chaves MaryAnn Dakkak Edward Durant

Stephanie Garcia Jennifer Hsiao Amanda Johnson Tiffany Lu Devon McGee

Jonathan Ostrem Ehsan Saadat Erica Sanford Alison Silvis Mia Smucny

Brian Toy Orlando Zepeda

interested in sponsoring a new member?

SFMS has embarked on a New-Member Sponsorship program. Upon approval by the Board or Executive Committee, each new member is assigned a sponsor, an established SFMS member whose primary responsibility is to help the new member become better acquainted with the Society and its benefits. Sponsors are expected to connect at least once with the new member socially (over breakfast or coffee, for example) and to invite the member to at least one SFMS event (such as the Annual Dinner, Legislative Day, Candidate’s Night, or a Mixer) during the course of their first year of membership. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org for more information or to volunteer.

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Disaster! A Comprehensive Guide for Doctors

Infectious Disease Response How the San Francisco Department of Public Health Would Respond Susan Fernyak, MD

A

n infectious disease emergency (IDE) could impact San Francisco in numerous ways. The most likely scenario is a naturally occurring event such as pandemic influenza, SARS, or a particularly virulent strain of N. meningitidis.

A less likely scenario could occur though the planned release of a bacteria, virus, or toxin such as B. anthracis, F. tularensis, Brucella species, Y. pestis, smallpox, botulinum toxin, or riacin.

Regardless of the scenario, an IDE would have an enormous impact on both the health of San Franciscans and our social infrastructure. Depending on the specifics, there would likely be panic, an increased demand on our health care facilities by both the ill and the worried well, some disruption of essential services, and behaviors driven by rumors and misinformation. On a daily basis, we respond to small outbreaks using current staffing and infrastructure. However, responding to a large-scale outbreak will require additional staff, equipment, support, and an enhanced infrastructure. To plan for such a large-scale event, we have developed on IDE Response Plan. This plan guides the “scaling up” of epidemiology and surveillance, containment measures (mass prophylaxis, isolation and quarantine, and infection control), and communication with clinicians, hospitals, and the public.

Epidemiology and Surveillance An infectious disease emergency may not be as readily detected as other types of disasters, such as earthquakes, fires, or chemical releases. In the early stages of an outbreak, cases may be dispersed among several health care providers and facilities.

Or, for emerging diseases such as avian influenza A H5N1, diagnostic tests would www.sfms.org

not be commercially available, so recognition and identification of the threat could be delayed.

The most effective outbreak detection system is comprised of clinicians making early reports to SFDPH. Clinicians are legally required to report more than ninety diseases to Public Health (find the list at www.sfdph.org/cdcp). You may give public health investigators the critical clue to detecting or preventing an outbreak—if you call us: (415) 554-2830 is the number, twenty-four hours a day, 365 days a year, when you suspect a single case or an outbreak of a communicable disease that is unusual, severe, or highly infectious.

Two recent health emergencies were detected by observant clinicians reporting an unusual pattern to public health authorities: reports of several encephalitis cases in combination with wild bird die-offs in New York City led to the detection of West Nile Virus in North America in 1999; and the report of possible anthrax meningitis in Florida uncovered the anthrax outbreaks of 2001. Please call us as soon as you suspect a case or potential outbreak of an urgent and severe communicable disease. HIPAA does not require you to obtain patient consent to disclose information to health authorities conducting a public health investigation.

Once SFDPH receives a report of an outbreak or case of communicable disease, it will be investigated by SFDPH’s multidisciplinary team of disease control investigators, health workers, epidemiologists, and clinicians. Investigators will call the health care provider to confirm the diagnosis and gather specific data on symptoms, signs, diagnostic tests, treatment, and known contacts to the patient. They will interview patients or their proxies to determine exposures and

risk factors for acquiring the infection, their occupation, and their contacts. For emerging and bioterrorism threat diseases, we may request specimens for confirmatory testing by the public health laboratory network as an epidemiologic tool for outbreak identification and management. In an infectious disease emergency, multiple teams will be activated to find and interview cases and contacts by phone, in the community, and in health care facilities. SFDPH will request assistance from clinicians and health care facilities to identify all persons needing follow-up by public health for investigation and interventions according to criteria that will be disseminated at the time of the emergency.

Mass Dispensing of Antibiotics and Vaccines In the extremely unlikely event of an infectious disease emergency that requires dispensing of antibiotics on a massive scale, San Francisco is prepared. We have identified twenty large dispensing sites throughout the city, and we have purchased twenty trailers that are storing all of the equipment and supplies necessary to rapidly activate a Point of Dispensing or “POD” site. In April 2007, in collaboration with Charles Schwab, we exercised our ability to dispense antibiotics to individuals picking up for both themselves and others. Data from this exercise suggest that we can dispense nearly 7,000 courses of antibiotics per hour per POD. This would allow us to provide antibiotics to our daytime population of 1.2 million people in less than nine hours, exceeding the federal standard of thirty-six hours.

Plans are also underway to reach vul-

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nerable populations (e.g., the homebound or culturally or linguistically isolated) via the organizations that serve them. Mass prophylaxis plans also include models and protocols for administering immunizations.

Supplies of antibiotics or immunizations would come from the federally managed Strategic National Stockpile. The overall mass prophylaxis planning effort is also regional via monthly Bay Area planning meetings, so that screening standards and dispensing methodologies remain consistent across county lines. Plans for additional enhancements include web-based screening for antibiotics, testing of drive-through vaccination clinics, and creation of triage and dispensing protocols for all bioterrorism agents.

Pandemic Influenza Planning Planning for an influenza pandemic presents unique challenges in emergency planning, as there are several characteristics of an influenza pandemic that differentiate it from other public health emergencies.

Unlike other natural disasters, a pandemic has the potential to cause illness in a large number of people, overwhelm the health care system, and jeopardize services by causing high levels of absenteeism in the workforce. Basic services, such as health care, law enforcement, fire, emergency response, communications, transportation, and utilities could be disrupted during a pandemic.

Finally, the pandemic, unlike many other emergency events, could last many months and affect many areas throughout the world simultaneously.

In order to respond effectively and efficiently to pandemic flu, the health department has been meeting with partner agencies and updating their infectious disease emergency response plans. In 2005, an Avian/Pandemic Influenza Task Force of city agencies was formed to identify weaknesses in planning and to strengthen interagency collaboration. A key finding was the need to strengthen continuity of operations plans to deal with high levels of absenteeism that could result from workers becoming ill, staying home to care for children or family members, or refusing to go to work.

In addition, city agencies felt that absenteeism could be mitigated with training. First 20

responders would feel comfortable coming to work if they better understood what a pandemic influenza was and how to protect themselves and their families. To meet the training needs of 27,000 city employees, the health department is developing avian and pandemic influenza materials and training videos.

San Francisco businesses have also been particularly aware of the need to plan for pandemic influenza and have requested information and planning support. To assist the business community, we have conducted three forums, developed a template to assist them in continuity planning, and posted fact sheets and policy documents.

Despite these efforts, there is still much to do. This fall, the Health Department plans to launch a one-year pandemic influenza outreach project targeting the general public, businesses, emergency responders, and clinicians. Focus groups will be held to assess our citizen’s knowledge of pandemic influenza, how to best prepare for a pandemic, and when to seek medical care. With the results, we will identify and develop appropriate materials and activities to assist the general public to plan for an influenza pandemic.

As a Clinician, How Can I Help?

The most important contribution you can make as a practicing physician is to report to SFDPH suspected or confirmed cases and outbreaks of diseases that are unusual, severe, or highly infectious. Once SFDPH receives a communicable disease report, we can investigate and act on it as necessary.

In addition, review your office emergency response plans. Consider how your office will respond if phone call volume and drop-in rates increase five- to tenfold.

Consider implementing infection control practices for patients with a cough and fever.

Guidelines for infection control during a pandemic are available at our website at www.sfcdcp.org. These simple recommendations (such as posting signs, providing masks to patients with a cough, and isolating patients you suspect may be infectious) should be implemented now to decrease the transmission of seasonal influenza in the office setting. In addition, they provide training for both staff and patients in the

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event of a pandemic.

Finally, encourage your staff to implement family emergency plans. A link to suggested contents can be found at www.72hours.org. Staff who feel confident that their families are safe will be more likely to come to work.

Dr. Susan Fernyak is Deputy Health Officer for San Francisco and Director of the Department of Public Health’s Communicable Disease Control and Prevention Section.

Her Section is responsible for epidemiology, surveillance and disease control, immunization programs, and bioterrorism preparedness and response. She managed San Francisco’s Smallpox Vaccination Program and the City and County’s response to SARS. Her current focus is on the development of an Infectious Disease Emergency Response Plan that can be used to respond to many different diseases, including pandemic flu, anthrax, smallpox, and other infectious disease threats. Dr. Fernyak is a practicing internist, did a fellowship at UCSF in AIDS Prevention, and has worked as a consultant for WHO and UNAIDS.

For news, local events, CME opportunities, and to view San Francisco Medicine Magazine online, please visit our website:

www.sfms.org

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Disaster! A Comprehensive Guide for Doctors

Preparing for the Inevitable Notes from the San Francisco General Hospital Disaster Committee William Schecter, MD, FACS, and Lann Wilder, EMT-P

S

an Francisco hospitals will one day be challenged by mass casualties caused by an earthquake, an industrial or transportation accident, or an attack involving either conventional or nonconventional weapons.

The Role of the Individual Hospital in the Emergency Medical Response The hospital is a part of the systemic response to the incident. Hospitals must interact and communicate with prehospital emergency medical personnel; the police; fire officials; city, state and federal disaster officials; and the press. Previously competing hospitals must now communicate with each other, share resources, and perhaps transfer patients between institutions. Participation in Municipal and Regional Disaster Committees is essential in order to establish close relationships among all of these institutions before a mass casualty event occurs.

The Role of a Level 1 Trauma Center in the Emergency Medical Response to a Mass Casualty Event Level 1 Trauma Centers cease to function as such once the number of critically ill patients they receive exceeds the resources necessary to care for these patients as individuals. The goal of prehospital care is to convert a mass casualty event in the field to a multiple casualty event for each receiving hospital. Therefore, all hospitals must be prepared to receive victims of the event, some of whom will be critically ill.

The primary role of the Level 1 Trauma Center is to help the system prepare for the Mass Casualty Event before it occurs.

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The Response of the Individual Hospital to a Mass Casualty Event Administrative Response A command post should be established, staffed by key administrators providing communication with external agencies and coordination of the response of all hospital departments. Hospitals will likely be faced with large numbers of family members seeking information who will require supervision and support. A senior administrator should be assigned to assist the Clinical Incident Commander in order to rapidly mobilize the resources of the hospital to effect the clinical decisions.

Clinical Response The hospital should be locked down so that entrance is limited to the Emergency Room. In the event of a biological or chemical attack, decontamination should be performed prior to entrance to the hospital. The initial triage of patients to “walking wounded� and stretcher cases should take place outside of the Emergency Department. Stretcher cases undergo a rapid secondary triage to either Immediate Care or Delayed Care after entry to the ER. The goal of immediate care is airway control, control of external hemorrhage, vascular access, and rapid transport to either the OR or the ICU. In a true mass casualty event or disaster, some patients may require so many resources that their care may adversely affect the survival of other patients with more salvageable injuries. These expectant care patients initially receive comfort care only.

Most will not survive. Dead patients are triaged to the morgue. If the field triage is performed skillfully, very few dead patients

will arrive at the hospital. The CT scanner is the major bottleneck to the orderly rapid flow of patients through the intrahospital diagnostic and therapeutic triage cascade.

Incident Command System The Hospital Incident Command System (HICS) is implemented to effectively manage a mass casualty event and facilitate logistical and administrative support for the response, while maintaining the safety of existing patients, visitors, and staff. No one reports to more than one person, and one person is responsible for no more than three to seven subordinates, thus ensuring rapid and effective communication throughout the Incident Management Team. During a mass casualty event, responding clinicians must leave their egos at the door. They must perform their assigned tasks and respect the decisions of the Incident Commander.

Hospital response to a Mass Casualty Event is a complex process requiring careful planning by the Hospital Disaster Committee, active involvement of physicians, and close coordination with all agencies and institutions involved in the Emergency Response System.

William P. Schecter, MD, FACS, is Professor of Clinical Surgery and Vice-Chair of Surgery at UCSF and Chief of Surgery at San Francisco General Hospital. Dr. Schecter spent time studying civilian hospital response to mass casualty events and caring for casualties from the Lebanon war in Israel.

Dr. Schecter currently serves as Co-Chair of the SFGH Disaster Committee.

Lann Wilder, EMT-P, has been a field Emergency Medical Technician and Paramedic since 1986. She has been Emergency Management Coordinator for SFGH Medical Center since 2004. For a full list of references, please see our website at www.sfms.org.

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Disaster! A Comprehensive Guide for Doctors

Advice from Our City’s Planner Becoming a Disaster-Capable Physician in a Disaster-Capable City John Brown, MD

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hen I became a physician in June of 1982, one of my chief concerns was that I would be perceived as incompetent by a patient, family member, or a medical colleague if I did not master any area of medical knowledge—that I would betray the trust that these people placed in me. I anticipated that the rigorous educational process of medical school, residency, and fellowship would help me learn all that I needed to know in my chosen area of specialization, so that I would respond professionally and with maximum effectiveness to any situation in which I found myself. I assumed that my situation would be very different based on my choice of specialty and practice environment, and that I could obtain lots of feedback on my progress. I would have time to prepare and improve my skills, and my practice of medicine would reflect this effort.

When I faced my first community disaster, I found that the experience challenged all of these assumptions about my preparedness, as disasters on a societal level always challenge the health care system.

There is no rigorous process in place for disaster training and evaluation of the degree of readiness of physicians, despite the need that all practitioners, regardless of specialty or office setting, have for being prepared.

In previous disasters, medical professional response has run the gamut from heroic and well organized to inadequate, ineffective, and even inappropriate. Feedback on the level of disaster training or preparedness of individual physicians is rare, and outside of certain specialty training programs, such training may be difficult to obtain. A disaster can strike at any time, and delay in preparation results only in increased vulnerability.

In light of this situation, what can 22

we, as physicians, do to become disastercapable? Specifics will vary from practice to practice, but there are a few overarching principles to guide our responses. We should be proactive, not complacent. No outside expert or disaster specialist is going to do this for us, so we must find or develop the tools we need and use them. Details matter, even the small, irritating ones. It is necessary to have a home and office disaster kit that is stocked appropriately for what we and our families will need—a kit that we update on a regular basis. We should each train now for the leadership role that we’ll have in a future disaster setting. Physicians provide leadership in daily practice; this expectation will only be magnified in a disaster. Each of us must know, today, our specific, most effective role in a disaster. It’s always a bad idea to open our hospital’s disaster plan for the first time on the day of the disaster itself. Finally, we must demand organizational competence in disaster response. Our hospital medical staff, our practice partners, our nursing and ancillary staff, and our local and specialty medical societies all need to play a role in disaster response and train their members accordingly.

Finally, what can we do as a community to become a disaster-capable city?

Certainly allotting adequate resources for disaster preparedness is important and often very difficult to achieve. Maintenance of a disaster capability is costly, time-consuming and difficult to track across city departments and community organizations, while parameters of success are hard to interpret. Simple and effective steps would include participation in hospital or city disaster exercises; requesting disaster preparation updates at staff meetings; contacting government representatives and expressing support for

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programs, organizations, or initiatives that are described in this issue; volunteering on committees or for organizations that are working to improve response; and updating personal, family, and worksite response plans. Don’t wait for some future day—today is the perfect time to take a step forward and become competent and prepared for medical disaster management.

Dr. Brown has been the Medical Director of the San Francisco EMS Agency since 1996.

A graduate of Holy Cross College and the University of Connecticut Medical School, he completed a residency in Emergency Medicine at the Naval Hospital San Diego and an EMS Fellowship at the University of Arizona. He is currently a faculty member of the UCSF/ SFGH Emergency Medicine Residency Program and a Medical Officer for the Disaster Medical Assistance Team Bay Area CA-6. He practices emergency medicine at San Francisco General Hospital.

Dr. Brown pictured in front of the field hospital while participating in a disaster preparedness exercise

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Disaster! A Comprehensive Guide for Doctors

How to Be Prepared An Essential Guide for Physicians

I

n addition to being personally prepared, there are a number of things physicians must do to become professionally prepared. Once you have assembled your personal disaster preparedness kit you can use the following resources to be sure you are able to offer your services as a medical professional in the event of a disaster.

Physician Disaster Preparedness Necessities Have Professional Diagnostic Equipment: Bring items such as portable ophthalmoscopes, otoscopes, stethoscopes, penlights, and BP cuffs when responding to a disaster.

Make Copies of Identification Materials: Keep photocopies of your current medical license, driver’s license, and any hospital identification cards in an accessible place.

Your medical license and drivers’ license will be necessary to practice in an EMS/prehospital setting if that is where you are needed immediately following a disaster.

Get on the List: The San Francisco Department of Public Health maintains a Health Alert Notification Database (HAND). The HAND is a confidential database used only to send out important and timely health information. If you are a

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clinician working or living in San Francisco and would like to sign up to receive Health Alerts, go to www.sfdph.org/cdcp and click on “Health Alerts”, and then “Sign up to receive Health Alerts”. You can then either complete an on-line registration OR download and fax a completed form to 415-554-2848.

Sign Up in Advance: Read the article entitled “How to Get Involved Ahead of Time” on page 11 to find out what organizations you can get involved with now.

Have an Office Disaster Plan: Every office should have a plan. Make sure your office or clinic has a cache of food, water, a battery-powered radio, flashlights, extra clothing and blankets for employees. Also be sure your office has a cache of professional diagnostic or treatment equipment commonly used, e.g. vaginal speculums, wound care supplies, pediatric antipyretic medications, or whatever else is appropriate for your practice setting.

Make a Phone Tree: Having a calldown list of employees, if appropriate, is also a good idea. Checking in with each employee to be sure they each have personal disaster plan is also a responsible move as an employer.

Know Your Building Safety or Escape

Plan: Office-based practices should develop and inform employees of their safety or escape plans, including things like getting under tables or desks during the active phase of an earthquake, how to evacuate the building in case of emergency, establishing a reassembly point outside the building where the staff can meet to check and be sure everyone is safely evacuated, teaching staff how to use a fire extinguisher, and so forth.

Educate Your Patients: Leave educational materials in the office waiting room about disaster preparedness. Make sure patients—especially those who are caregivers, if appropriate—are educated on preparedness during routine office visits.

Learn More Online: • www.sfms.org/disaster—for a lengthy list of resources regarding disaster preparedness visit our website.

• www.72hours.org—a comprehensive site developed specifically for San Francisco residents.

• www.bepreparedcalifornia.ca.gov.— This new state site includes information on personal disaster readiness as well as covering professional preparedness topics such as handling a bioterrorism event or a health care surge.

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Disaster Preparedness in Each Hospital Chinese Joseph Woo, MD

Thanks to CEO Brenda Yee, Board Member Rose Pak, and Dr. Stuart Fong, Chinese Hospital has taken the lead in developing, refining, and implementing the Chinatown Disaster Response plan. Any disaster can be catastrophic, especially in a community, such as ours, that is densely populated, has numerous unreinforced masonry buildings and non-English-speaking residents, and is a mecca for tourists.

Training and preparedness has been the mantra. With HRSA (Homeland Security) grants, fifteen nurses were sent to a trauma course to learn to care for patients in the event of a disaster. Seven staff members have trained in hazardous decontamination procedures. Five staff members attended Hospital Incident Command System Training to learn to function as incident commanders. Stuart Fong is working on ways to engage the community, including staging a “disaster fair� and spreading information through the Chinese newspapers.

The Chinatown Disaster Command Center will be located at Portsmouth Square, which will serve as the assembly point for residents, coordination center for NERT, and communication point with city government. Seriously injured patients will be sent to Chinese Hospital. First aid will occur on-site or patients will be sent to the Chinatown Public Health Center or North East Medical Services (NEMS).

At Chinese Hospital, we are also rethinking our supply situation, since hospitals should be self-sustaining for ninety-six hours. We are working on a pan-influenza plan in the event of an epidemic. Chinese Hospital is also an active participant in the semiannual citywide emergency drills.

CPMC Damian Agustyn, MD

California Pacific Medical Center (CPMC) is one of the largest private, not-for-profit teaching medical centers in Northern California.

The safety and security of our patients, visitors, and staff is paramount. CPMC participates in monthly meetings with San Francisco hospitals 24

and local authorities to coordinate our disaster preparedness and planning activities to ensure that we are ready to meet community needs in the event of a disaster.

As a part of preparation, CPMC has purchased a surge tent (for additional patient capacity); decontamination tents for all of our hospital locations; personal protective equipment, including respirators and protective clothing for mass decontamination activities; two-way radios and satellite radios to enhance communications; and laptop computers and printers for the hospital command centers.

Last year, we trained and certified ninetyone staff members at the First Receiver Operational (FRO) level with a hazardous materials or weapons of mass destruction event in mind. The training teaches staff self-protection from contamination, how to recognize contaminated patients, how to decontaminate patients, and how to understand the Hospital Incident Command System (HICS). This year, our goal is to train and certify an additional sixty staff members.

CPMC conducts at least two disaster training exercises annually in conjunction with the city of San Francisco and other local hospitals.

We view the drills as training opportunities and require all staff to participate. We also encourage physicians to participate and learn to understand reporting structure within the organization. At least one of the yearly drills tests our ability to effectively handle an influx of patients. Each exercise is followed by a critique with areas for improvement identified.

The next hospital drill will be in coordination with the statewide disaster exercise to be held on October 25, 2007. The San Francisco scenario will focus on a pandemic.

Kaiser Robert Mithun, MD

Emergency preparedness is vital to every medical center and is, ideally, an integral part of daily operations. At the Kaiser Permanente San Francisco Medical Center, we are focusing on optimal ways to incorporate emergency preparation into our everyday roles and tasks. With designated teams, plans, and structures in process, we are building a system to help ensure safety

San Francisco Medicine october 2007

not only for our patients, members, physicians, and staff but also for those in the surrounding community.

Critical for our medical center during an emergency is a coordinated response among the multiple sites that comprise our campus, so that everyone knows how to respond during an event. Some of the ways in which we are building our emergency preparedness infrastructure and systematizing our efforts include extensive leadership training, building our inventory of critical supplies and equipment, and enhancing emergency response plans and protocols.

Clear incident command roles for medical center leaders are critical for being prepared in a crisis, where each designated person understands the scope and breadth of his or her responsibility.

By cross-training leaders and managers, we are reinforcing crucial knowledge of the Incident Command System and preparing staff for a variety of possible events. Focusing specific training and education efforts on key hospital employee groups, including Operator Services, Security, and select nursing units, enhances their ability to perform such functions as patient evacuation and cross-campus communications. The importance of clear and frequent internal communications cannot be overstated and is a priority in our overall planning.

While it is essential that physicians and employees be ready to perform their functions at the medical center, we are also providing Employee Home Preparedness training, with the goal of stressing the importance of home preparation. We understand that in an emergency, the first priority of our physicians and employees will be ensuring their families safety.

If physicians and employees have home disaster plans in place, then they are better able to focus their attention on patient and community needs during an event.

We have an ongoing commitment to serve the greater community, which does not begin or end with an emergency event. However, building partnerships to help in disaster preparation and response with the local community, as well as with other San Francisco area hospitals, facilitates our ability to care for our patients and those who call upon us during a crisis. An important way we foster these relationships is by www.sfms.org

Disaster Preparedness in Each Hospital participating with other San Francisco hospitals in the monthly Hospital Council Emergency Preparedness Task Force, which addresses critical disaster planning issues as well as how hospitals might coordinate our services in a crisis.

In all our efforts to be fully prepared during an emergency event, we hope to integrate and acknowledge the many components that constitute a well-designed plan. It is essential that our medical center, and all others, be prepared for any type of emergency so that we are able to provide the necessary services to ensure the safety of our patients, those with whom we work, and our families at home.

Saint Francis Wade Aubrey, MD

Saint Francis Memorial Hospital recognizes its integral role in the event of a local disaster.

Because of our central location in San Francisco’s downtown, we are often a first responder in local emergencies. In 1989 we treated a high volume of earthquake victims from downtown office buildings, expanding our emergency department by using the surgery recovery room and calling in medical staff members (including myself) to see patients during the evening and night hours after the Loma Prieta earthquake. In 2001 we treated patients from nearby office buildings for potential anthrax exposure.

Our managers have recently been trained in SEMS, NIMS, and HICS. This allows us to “speak the same language” in our work with local emergency response agencies. We participate in all city and statewide emergency programs and drills. In October we will join in the Statewide Medical and Health Disaster Exercise for pneumonic plague. In San Francisco, we’ll be testing our preparedness for pandemic flu.

Our Emergency Management Committee meets monthly to plan disaster drills, coordinate training sessions, and ensure that we can provide the services, equipment, and supplies necessary in an emergency. To encourage our employees’ disaster preparedness at home, especially for earthquakes, training is provided to new employees during orientation and is reiterated annually.

We’ll also be hosting an Employee Personal Preparedness Fair this fall. www.sfms.org

We are especially aware of the critical role our Bothin Burn Center might serve in the wake of a catastrophic event. At a time when financial concerns are forcing many burn centers to close, Saint Francis is expanding its burn unit capacity.

Our ten-bed, multidisciplinary burn unit will add up to four new beds to meet community demand.

This bucks the national trend toward closure of these much-needed facilities. Recently the Associated Press reported that burn centers are closing across the nation due to costs, leaving communities unprepared to handle widespread burn casualties resulting from possible terrorist attacks or other major disasters. However, these services are crucial in a disaster, and Saint Francis is committed to keeping them available.

St. Luke’s Jerry Franz, MD

Are we at St. Luke’s ready for disaster? Trying to find the answer to that question led me to Milo Fanene, who is responsible for safety activities at all four CPNC campuses. He is enthusiastic about his work, part of which is coordinating disaster drills. At St. Luke’s, he is taking steps to see that all buildings and areas are included, even those that do not have overhead page. A phone tree has been set up with a backup runner system if the phone doesn’t work or no one answers in a particular area.

Our emergency codes will be changed in the near future to match those at the other campuses, increasing from nine to fourteen. Some of the homegrown flavor will be lost in the transition; for example, “code 77” for a combative person becomes “code gray,” and “Dr. Dangerfield” for a weapon becomes “code silver.” One that does not change, and which we have to prepare for but hope never to hear, is “code triage” for disaster.

The question looming before us is the planned closure of acute care services in 2010. How will this affect city and regional capacity in the event of a major disaster? I have not heard a convincing answer from the Public Health Department. This is one more reason why the doctors and employees at St. Luke’s are committed to keeping our hospital open. Many are expected to testify on October 11 at the Board of Supervisors committee hearing on the future of our hospital.

St. Mary’s Richard Podolin, MD

As physicians in health care, we face the everyday traumas of life. Occasionally, we are called upon to face larger, sometimes catastrophic, situations such as the aftermath of a major disaster. As Californians, and particularly as San Franciscans, we live with the prospect of a major earthquake, fire, or possible act of terrorism.

The only real choice or control we have is to be prepared. The Sisters of Mercy, who founded St. Mary’s Medical Center 150 years ago this year, have a long and distinguished history of responding to disasters, from the cholera, smallpox, and influenza epidemics of the 19th and early 20th centuries to the 1906 earthquake.

Their resourcefulness and determination aided the survival of the afflicted and ensured the survival of this institution. The Sisters of Mercy, Catholic Healthcare West, and St. Mary’s Medical Center are equally determined to be prepared for future challenges.

More recent events, such as 9/11 and Hurricane Katrina, have provided recent, though unfortunate, learning experiences for government agencies and disaster-response institutions.

The message has been clear: hospitals are now considered an integral part of the community response. St. Mary’s Medical Center works collaboratively with all other hospitals in the city and with the S.F. Department of Emergency Services and Department of Public Health on the Hospital Emergency Preparedness Task Force. Together, we all participate in annual statewide disaster drills and, likewise, have all adopted the National Incident Management System (NIMS), which provides for a common command structure.

NIMS further facilitates first-responders in “speaking the same language,” ensuring clear communication. “Many of St. Mary’s key leaders recently attended a two-day training on implementing a newly revised, health care-based Incident Command System (HICS) that will allow us to interface well with our community in disaster response. St. Mary’s looks forward to participating in the October 25 citywide Pandemic Flu Exercise,” says Debi Simon, CHW Safety Manager, St. Mary’s Chair of Emergency

october 2007 San Francisco Medicine

25

Disaster Preparedness in Each Hospital Preparedness Committee.

St. Mary’s Medical Center has also partnered with other hospitals in San Francisco to create memoranda of understanding between the institutions to plan for sharing of professional staff, medical supplies, and basic needs such as fuel. In the aftermath of a disaster, this cooperation should allow for expedited transactions and smoother transitions between facilities to lessen confusion and speed community recovery.

Standards effective January 1, 2008, require hospitals to be self-sufficient and able to stand alone in terms of food and supplies for a minimum of ninety-six hours. St. Mary’s Medical Center has these supplies: water, fuel, bedding, medicine, and decontamination and first-aid supplies stored in an accessible area outside of the main facility.

Several redundant communication systems, including satellite phones, two-way radios, and ham radio, have been installed to ensure communication in the event of disaster.

As physicians, it is our responsibility not only to care for the ill but to contribute to a healthy and whole community; disaster planning is part of that responsibility. It is the goal of everyone at St. Mary’s Medical Center to continue to be a resource and refuge for the community that we have been a part of for 150 years.

and to ensure continual improvement in these response systems,” says Hunn.

More than 120 staff members have been trained in “first receiver training” that will enable the Medical Center to respond safely to a chemical or other bioterrorism event. Additional trainings during the past year included building evacuation, triaging and preparing patients for pandemic flu response, surge planning, and communications.

The Medical Center has a surge plan to accommodate up to at least seventy disaster victims at Parnassus and to transport less injured patients to UCSF Mount Zion.

The Medical Center meets monthly with San Francisco DPH and the nine other “receiving” hospitals in San Francisco as part of the Hospital Council of Northern California effort to coordinate response activities, discuss distribution of grant monies and equipment, and share best practices. This coordination resulted in a draft MOU that could be used among hospitals should they need to share resources. The Medical Center employs the Hospital Incident Command System (HICS) to ensure that a structured organizational response is in place to respond properly and safely to an event.

UCSF

Diana Nicoll, MD, PhD, MPA

Veterans

direction of activities.

In the event of an emergency, the SFVAMC has the ability to notify employees within minutes, per our emergency preparedness plans, through a Send Word Now program. Send Word Now is a service that sends a single message to multiple voice and text devices and allows us to contact staff in an emergency and find out who can respond.

Should a hazardous material incident occur, the SFVAMC will activate its decontamination team, which is trained to remove or isolate hazardous materials. The SFVAMC is reviewing and updating emergency plans on an ongoing basis and educating staff to prepare for an emergency.

Planning is done in coordination with city and state, and the SFVAMC was recently awarded funds by the City of San Francisco to upgrade its emergency communication equipment.

SFMS Seminar!

Please contact Posi Lyon (plyon@sfms.org or (415) 561-0850 extension 260) to register for this seminar.

Space is limited; advance registration is required.

Ronald Miller, MD

UCSF Medical Center works in collaboration with the UCSF campus on an emergency management program in four key areas: emergency preparedness, emergency response, mitigation, and recovery. If there is a need for emergency response, all services are integrated into a joint Emergency Operations Center.

The Medical Center has employed an all-hazards approach for developing a comprehensive emergency management program, with risks identified though a vulnerability analysis, according to Medical Center Safety Officer Robert Hunn. The program is tested through full disaster drills held at least twice a year, which include all staff. More frequent, focused tabletop drills also test the program. “Emergency preparedness drills are the best way to test any system’s ability to safely respond to a disaster

During the Gulf Coast disaster of 2005, the Department of Veterans Affairs’ ability to safely evacuate hundreds of patients and employees was remarkable. In addition, the ability to access electronic medical records enabled doctors and nurses to provide ongoing care to veterans. The V.A. was recognized for its efforts and praised for its ability to respond to the emergency.

As part of its disaster readiness, the San Francisco V.A. Medical Center (SFVAMC) has adopted the Hospital Incident Command System (HICS), an emergency management system that employs a logical management structure, defined responsibilities, clear reporting channels, and a common nomenclature to help hospitals communicate with emergency responders. HICS was designed to minimize the confusion that can exist during a disaster and allows management to respond quickly with structure and a focused

November 9, 2007 “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management.

9:00 a.m.–5:00 p.m. (8:40 a.m. registration/continental breakfast), $250 for SFMS or CMA members/$225 for second attendee from same office/$325 for nonmembers.

2007 Slate of Candidates

Pursuant to the SFMS Bylaws Article X Section 2–Nominations, the Nominations Committee renders in writing the following slate of candidates for the 2007 SFMS election. This slate was announced at the September 10, 2007, General Meeting, at which time the SFMS President called for additional nominations from the floor. The following are this year’s candidates:

2008 Officers—for one-year term: For the office of President-Elect, Secretary, Tresurer, and Editor only one candidate may be selected for each individual office.

For President-Elect: Charles J. Wibbelsman For Secretary: Gary L. Chan For Treasurer: Michael Rokeach For Editor: Mike Denney (Incumbent)

SFMS Board of Directors Three-year term 2008-2010:

Young Physician Section Delegate Two-year term 2008-2009:

The seven candidates receiving the highest number of votes will serve as directors on the SFMS Board.

Lily M. Tan (Incumbent Alternate Delegate)

Lawrence Cheung Jennifer H. Do George A. Fouras * Shieva C. Khayam-Bashi Keith Loring William A. Miller * Jeffrey Newman * Thomas J. Peitz * Daniel M. Raybin* Michael H. Siu * *Incumbent Director

Nominations Committee Two-year term 2008-2009: Four candidates will be elected to the Nominations Committee.

Mark A. Alderdice Donald C. Kitt Richard B. Ward Angela Wong

AMA Delegate Two-year term 2008-2009: H. Hugh Vincent (Incumbent)

Young Physician Section Alternate Delegate Two-year term 2008-2009: Lawrence Cheung

Delegates to the CMA House of Delegates Two-year term 2008-2009: The four candidates receiving the highest number of votes will serve as delegates. The President-Elect automatically becomes the fifth delegate. The next five will be alternate delegates.

Gary L. Chan, MD Stephen E. Follansbee, MD * Brian J. Lewis, MD *** Rita Melkonian, MD ** William A. Miller, MD Rodman S. Rogers, MD Jordan Shlain, MD Rachel H.C. Shu, MD ** Peter W. Sullivan, MD ** George P. Susens, MD * John I. Umekubo, MD ** *Incumbent Delegate **Incumbent Alternate ***2007 Delegation Chair

AMA Alternate Delegate Two-year term 2008-2009: Robert J. Margolin NOTES: • 2007 President-Elect Steven H. Fugaro automatically succeeds to the office of President.

• 2007 President Stephen E. Follansbee automatically succeeds to the office of Immediate Past President.

• Ballots will be mailed to all SFMS members in late October. Upon receipt, please mark your ballot and return it immediately to SFMS, 1003A O’Reilly Ave. San Francisco, CA 94129.

• Ballots must arrive by 5 p.m. on Tuesday, November 13, 2007. The name of the SFMS member (not the corporation name) must be printed legibly or typed on the return envelope. www.sfms.org

october 2007 San Francisco Medicine

27

SFMS OFFICER CANDIDATE STATMENTS FOR PRESIDENT-ELECT

maintain a high level of professionalism in medicine

education on how the current system works or doesn’t

and serves as an advocate for physician wellness in

work. Only then can we begin to lay the groundwork

these turbulent times of change. Our medical society

to fix it for the benefit of both physicians and patients,

also is, and will continue to serve as, a key conduit of

who have been mostly afterthoughts. There is a major

information to physicians regarding legislative issues

crisis in health care today. The costs are going through

on the local, state, and national levels as these issues

the roof as the benefits and reimbursements diminish.

affect our daily practice of medicine. In this leadership

Only through our organized voices can physicians play

role, I will follow the role of my predecessors in speak-

a role in changing our current system for the better.

ing on behalf of our medical society and representing

SFMS must provide a forum for getting our voices

our medical society in a leadership capacity in local

heard. I hope to represent these concerns in the coming

and state issues and events. I will be very proud to

years. Thank you for your vote.

carry on this tradition of leadership and community CHARLES J. WIBBELSMAN

recognition.

FOR TREASURER

Specialty: Pediatrics/Adolescent Medicine Membership: SFMS/CMA 1985

FOR SECRETARY

SFMS: Treasurer 2007, Secretary 2006, Director 2003–05 SFMS Committee Appointments: Executive 2006–07, Nominations 2006–07, Finance/Investment 2007, Physician Membership Services 2006–07 CMA: Very Large Group Practice Forum Delegate 2001–07, VLGPF Alternate 1996–97/1999–2000, SFMS Alternate Delegate to the CMA 1996–97

MICHAEL ROKEACH

Related Medical Affiliations: President of Professional

Specialty: Emergency Medicine

Staff, Kaiser Foundation Hospital, San Francisco 2002–

Membership: SFMS/CMA 1990

04; Vice President of Professional Staff, Kaiser Foundation

GARY L. CHAN

SFMS: Secretary 2007, Director 2001–06

Hospital, San Francisco 2001–02; Board of Directors,

ALSO CANDIDATE FOR DELEGATION

SFMS Committee Appointments: PAC Board

the Society for Adolescent Medicine 2002–05/1997–99;

Specialty: Internal Medicine

2002–07 (Chair 2003–06), Executive 2006–07, Medical

President, Northern California Chapter of the Society for

Membership: SFMS/CMA 1981

Review and Advisory 2000–07, Nominations 2003

Adolescent Medicine 1989–1997; Board of Directors, USF

SFMS: Director 2002–07, St. Francis Memorial Hospital

CMA: Alternate 2002–03

Center for Child Development 1999–2001; medical guest

Medical Staff Liaison 2005–06

Related Medical Affiliations: Vice Chief of Staff, CPMC

host, KRON Morning Show 2002–03; member, American

SFMS Committee; Appointments: Executive 2006–07,

2006–07; Medical Staff Treasurer, CPMC 2004–05;

Federation of Television and Radio Artists 2002–07; North

Nominations 2007, Information Technology 2006, Health

Medical Executive Committee, CPMC 1992–2004;

American Society for Pediatric and Adolescent Gynecology

Care Foundation of San Francisco Board 2005–06

Chair, MEC Nominating Committee 1997–2000; Chair,

1999–2006; Committee on Adolescence, the American

CMA: Solo/Small Group Practice Forum Alternate

Risk Management Committee, CPMC 1990–1998; Qual-

Academy of Pediatrics 2003–present

2006–07

ity Performance and Improvement Committee, CPMC

Medical School: University of Cincinnati 1970

Related Medical Affiliations: Assistant Medical Direc-

1992–present; Executive Committee, San Francisco

Hospital Affiliation: Kaiser Foundation, San Francisco

tor, Brown & Toland 1990–present; Utilization Manage-

Emergency Physicians Association, Ambulatory Services

Teaching Appointments: Clinical Professor of Pedi-

ment Advisor, Blue Shield 1984–1999

PI Committee, CPMC 1998–present; Chair, Sutter Emer-

atrics, UCSF

Medical School: Tufts University 1976

gency Department Directors Group 2003; Representative,

Policy Statement: As a physician practicing medicine

Hospital Affiliation: Active: St. Francis, CPMC, St.

EMS Clinical Advisory Committee 1990–2002; National

in San Francisco since 1976, I have had the opportunity

Mary’s

and California Chapters, American College of Emergency

to observe health care delivery from two very different

Teaching Appointments: Clinical Associate, UCSF

Physicians 1988–2007

perspectives: initially as a physician with the Public

Policy Statement: I have been active on the SFMS

Medical School: University of Miami 1973

Health Department; and, for the past twenty-eight

Board for the past five years. I would be pleased to serve

Hospital Affiliation: Active: CPMC

years, as a pediatrician in a very large group model

as a delegate from San Francisco to the CMA and to

Policy Statement: It has been an honor and a pleasure

HMO. In both spheres of practice, quality of medical

serve as your Secretary. Thank you for offering me that

serving on the San Francisco Medical Society Board of

practice, access to care, and culturally competent care

opportunity. I have been practicing internal medicine

Directors and as chair of the PAC. I wish to continue

to diverse patient populations are high priorities. The

here in San Francisco for the past twenty years and have

as an officer in the role of Treasurer in 2008. I sincerely

San Francisco Medical Society has the unique role of

witnessed vast changes in medicine. I have firsthand

believe I represent the best interests of practicing phy-

providing leadership and guidance in achieving these

knowledge of how the managed care system has evolved

sicians in our community. The Medical Society must

goals of practice through its delegation to the CMA

and the pressures placed on the system by providers,

continue addressing the many issues challenging our

and as a recognized leader of organized medicine in

insurers, employers, and, lastly, consumers. There has

ability to meet the needs of our patients and our own

San Francisco. As a spokesperson for physicians in San

been a large disconnect between the goals and wishes

families. Organized medicine remains the most ef-

Francisco, the San Francisco Medical Society helps

of all parties concerned. There needs to be more active

fective vehicle to protect the values of our medical

28

San Francisco Medicine october 2007

www.sfms.org

practices. I am excited about the future of SFMS, and

SFMS Committee Appointments: SFMS PAC

serve on the Board of Directors. As a second-generation

I would like to continue being a part of the Society’s

Board 2007, Physician Membership Services Committee

SFMS member, I have nurtured a great appreciation

leadership. I am offering my candidacy for Treasurer,

2006–07

for the integral role the Society plays in advocating

and I ask for your support once again.

Related Medical Affiliations: Fellow American

for patients and physicians and in formulating health

Academy of Dermatology, Fellow American Society for

policy. I will remain committed to these values as I

Dermatologic Surgery, Member Society of Investigative

strive to improve the health and well-being of the

Dermatology

children and families in our community. I look forward

Medical School: Columbia University College of Physi-

to working with and incorporating the voices of each

cians and Surgeons 1998

member to strengthen our Society.

FOR EDITOR

Hospital Affiliation: Active: St. Mary’s, Chinese Hospital Teaching Appointments: Assistant Clinical Professor of Dermatology, UCSF Policy Statement: As a recent graduate who started MYRON K. (MIKE) DENNEY

my own solo practice in the city two years ago, I have

(Incumbent Editor)

gained a deep appreciation for the San Francisco

Specialty: Psychosomatics/General Surgery

Medical Society. Beyond the camaraderie of colleagues,

Membership: SFMS/CMA 2002, American College of

the Society has provided a wealth of resources to me

GEORGE A. FOURAS (Incumbent Director)

Surgeons 1967

as a practicing physician. I soon became active in the

Specialty: Child and Adolescent Psychiatry

SFMS: Editor 2006–07

Society because I wanted to ensure that it remains a

Membership: SFMS/CMA 1996, AMA 1987–

SFMS Committee Appointments: Executive 2006–07,

valuable resource for other physicians. I joined the

90/1995–present

Editorial Board 2002–07

Membership Committee because I felt that a robust

SFMS: Director 2003–07

Medical School: University of Michigan 1959

membership base is critical for the Society on many

SFMS Committee Appointments: Executive 2003–07,

Teaching Appointments: Adjunct Faculty, Holistic

levels. From the number of delegates at the CMA to

SFMS PAC 2004–07 (Chair 2007), Physician Member-

Health Education, John F. Kennedy University; Integrative

the legitimacy of representing San Francisco physi-

ship Services 2003–07, Psychiatric Services 1996–2006,

Health and Healing, California Institute of Integral Studies;

cians in areas of patient advocacy and health care

Fellowship/Wellness 2006

Depth Psychology, Pacifica Graduate Institute

policy, membership is the backbone of the Society. I

CMA: Alternate Delegate 2007–08/2000–02; California

Policy Statement: I am honored to be nominated

also became active in the political action committee

Psychiatry Association Specialty Delegate to Young Physi-

for another term as Editor of the Journal of the San

because I feel that California is a pioneer in many areas

cians Section, CMA 1996–99

Francisco Medical Society. It has been pleasurable

of health initiatives, and San Francisco is one of the cit-

Related Medical Affiliations: President, Northern

and rewarding to serve for the past two years. As this

ies leading these changes. I believe that only by actively

California Regional Organization of Child and Adoles-

Journal is an advocate for physicians and patients, my

engaging in the political process can we ensure positive

cent Psychiatry 2000 (President-Elect 1999); Chair,

editorials have focused upon underlying meanings

outcomes for both our patients and our profession. I am

California Psychiatric Association Child and Adolescent

and transcendent dynamics of economic, political,

truly honored to have been nominated to run for the

Committee 2000–present; Medical Director, Foster Care

scientific, ethical, spiritual, and personal issues that

Board of Directors and the Young Physicians Section

Mental Health Program, City and County of San Francisco

confront both healers and the afflicted. I will dedicate

Alternate, and I hope to be able to serve the Society

1995–present

myself to the ongoing quality of our publication as it

in those capacities.

Other: Board-Certified in General Adult Psychiatry 1999

continues to explore new and deeper perspectives of

Medical School: Ohio State University 1990

the art and science of medicine.

Hospital Affiliation: Courtesy: SFGH Policy Statement: I am honored to be renominated for

FOR BOARD OF DIRECTORS

a position on the Board of Directors. I have enjoyed representing you at the House of Delegates in the past and on the Board of Directors currently, and I hope to continue to serve the SFMS. As a physician working in the San Francisco Department of Public Health, I am JENNIFER H. DO

keenly aware of how state policies, especially regarding

Specialty: Pediatrics

MediCal/Medicare, affect our patients, both public and

Membership: SFMS/CMA 2006

private. In addition, it is likely that further scope-of-

SFMS Committee Appointments: Physician Member-

practice issues will be introduced in the next legislative

LAWRENCE CHEUNG

ship Services Committee 2007

session. I will work hard to bring these issues to SFMS

ALSO CANDIDATE FOR YOUNG PHYSICIANS SEC-

Medical School: Saint Louis University School of

and to ensure that our views are carried to CMA. It is

TION ALTERNATE

Medicine 2002

my firm belief that we must work together, regardless of

Specialty: Dermatology

Hospital Affiliation: Active: CPMC

specialty, to present a united message regarding patient

Membership: SFMS/CMA 2005, AMA 2005

Policy Statement: I am honored to be nominated to

care and our ability to practice medicine.

www.sfms.org

october 2007 San Francisco Medicine

29

Emergency Medicine, St. Mary’s Medical Center

cians must grapple with as the way that health care

Medical School: Johns Hopkins University School of

is delivered and paid for in America is redesigned. It

Medicine 1991

is crucial that we physicians have a seat at the table.

Hospital Affiliations: Active: St. Mary’s; Courtesy:

Pretending that these changes will not happen will

SFGH

only lead to us failing to have a voice in the process.

Teaching Appointments: Assistant Clinical Professor,

Local medical societies like ours are the cornerstones

USCF

upon which larger groups, such as the CMA and AMA,

SHIEVA C. KHAYAM-BASHI

Policy Statement: It is an honor to be nominated as

draw their strength in representing our interests during

Specialty: Family Medicine

a candidate for the SFMS Board of Directors. Wise

this crucial time. As a member of the SFMS Board, I

Membership: SFMS/CMA 2006, AMA 2006

stewardship of our profession requires our direct, pas-

have played and will continue to play an active role

SFMS Committee Appointments: Editorial Board

sionate, and constant involvement. If we are to truly

in advancing our cause.

2005–07

flourish, we must maintain a keen awareness of the

Related Medical Affiliations: American Academy of

world outside our practices, our medical groups, and

Family Physicians, Society of Teachers of Family Medicine

our medical centers. We must be able to stand together

Medical School: University of California, Davis 1993

to advocate for what is right for our patients as well

Hospital Affiliation: San Francisco General Hospital

as what is right for us to receive in compensation for

Teaching Appointments: Associate Clinical Professor,

our efforts. My candidacy for the Board is part of an

Department of Family and Community Medicine, Univer-

ongoing commitment to put these words into action

sity of California, San Francisco

and become involved in something greater than my

Policy Statement: I have been practicing and teach-

own practice of emergency medicine at St. Mary’s, St.

JEFFREY NEWMAN (Incumbent Director)

ing medicine at San Francisco General Hospital for

Francis, and San Francisco General Hospitals. If we

Specialty: Preventive and Internal Medicine

the last nine years. I am a native San Franciscan and

are to stem the tide that continues to erode our profes-

Membership: SFMS/CMA 1995

feel committed to serving the underserved population

sion and place our patients in harm’s way, it is critical

SFMS: Director 2005–07

of our county with compassion and excellent medical

that we nurture the brightest among us who have the

SFMS Committee Appointments: Information Tech-

care. My areas of interest include integrative medicine,

integrity and energy necessary to stretch beyond their

nology 2006

patient advocacy, teaching compassion and humanism

day-to-day clinical practices and make our voices heard

CMA Committee Appointments: Represented CMRI

in medical education, promoting interdisciplinary team

in the local, state, and national health care dialogue.

at Quality Improvement Committee meetings

models of care, improving end-of-life care, spirituality

I would be honored, willing, and able to help in that

Related Medical Affiliations: Director, Sutter Health

in medicine, care of underserved populations, and

endeavor if elected as a Board Member.

Institute for Research and Education

international health/humanitarian medical relief.

Medical School: Tufts University 1972

I have enjoyed serving on the Editorial Board for

Hospital Affiliation: In process: CPMC, St. Luke’s

the last two years. I wish to serve on the Board of

Campus

Directors to bring a perspective from the care of the

Teaching Appointments: Adjunct Professor, Institute

county/underserved population, and to help shape

for Health and Aging, UCSF

policy in our community to enhance patient care and

Policy Statement: Reimbursement policies and other

access as well as physician satisfaction and well-being.

incentives for quality medical services need to be im-

I hope to offer a balanced perspective with thoughtful

proved, especially for prevention and end-of-life care.

ideas on challenging issues affecting our community’s

WILLIAM A. MILLER (Incumbent Director)

We need better information systems to provide more

patients and physicians.

ALSO CANDIDATE FOR DELEGATION

efficient and effective services. SFMS collaborations in

Specialty: Internal Medicine

community health projects should be expanded.

Membership: SFMS/CMA 2002 SFMS: Director 2007, St. Luke’s Medical Staff Liaison 2006–2007 SFMS Committee Appointments: Nominations 2007–08 Related Medical Affiliations: St. Luke’s Hospital Chief Medical Executive and Immediate Past Chair, Department KEITH E. LORING

of Medicine; Associate Professor, Touro University

Specialty: Emergency Medicine

Medical School: University of Arizona College of

THOMAS J. PEITZ (Incumbent Director)

Membership: SFMS/CMA 2003

Medicine 1991

Specialty: Emergency Medicine

SFMS Committee Appointments: Nominations

Hospital Affiliation: St. Luke’s

Membership: SFMS/CMA 1998

2007–08

Policy Statement: Decreasing physician reimburse-

SFMS: Director 2005–07; Secretary 2003–04; Director

Related Medical Affiliations: Vice Chief of Staff, St.

ment, pay-for-performance, core measures for doctors

2000–2002; Appointee, Board of Supervisors ER Diver-

Mary’s Medical Center; Assistant Chief, Department of

… these are just a few of the challenges that physi-

sion Task Force 2003

30

San Francisco Medicine october 2007

www.sfms.org

SFMS Committee Appointments: Disaster Planning

Related Medical Affiliations: Chair, Department of

to care for each other. 2) Would you like to see SFMS

2002–06, Physician Membership Services 1998–2006,

Medicine and Medical Director, Intensive Care Unit, St.

presidents serve more effectively into a second year? 3)

Nominations 2006/2002, Executive 2001–05

Mary’s Hospital

We need more visible benefits for members to lower

CMA: Filled in as Young Physicians Section Delegate 2001

Policy Statement: I am honored to be nominated

attrition rates. I would like your feedback. Please fax

Related Medical Affiliations: President, San Francisco

for a second term on the SFMS Board of Directors.

your yes/no answers to (415) 753-1123 for all points

Emergency Physicians Association, 1992–1995; American

The SFMS should be an effective unified voice for all

listed. Thank you for your confidence.

College of Emergency Physicians

physicians in the San Francisco community, including

Medical School: University of California, Los Angeles

those in group practices such as the Permanente Medi-

1990

cal Group, institutions such as UCSF and SFGH, and

Hospital Affiliations: Active: CPMC

physicians in private practice. I am in private practice

Policy Statement: The practice of medicine is under-

specializing in pulmonary diseases and critical care.

going tremendous change. There are capacity issues,

Previously I practiced at the Palo Alto V.A. hospital.

resource issues, and the increasing expectations of

My wife has been a Kaiser physician for more than

our patients. We all must provide care in a setting of

twenty-five years. Current problems we physicians

limited or even decreasing resources. This reality has

need to address include more reasonable paperwork

placed a tremendous strain on the health care system

requirements for physicians, adequate compensation

and on us as physicians. Through my involvement with

for subspecialty Emergency Department coverage, and

MARK A. ALDERDICE

the medical society as a Board Member and an Execu-

affordable health care insurance coverage for all of our

Specialty: Emergency Medicine

tive Committee Member, I have come to realize how

patients. SFMS needs to continue to be in partnership

Membership: SFMS/CMA 2003

important the SFMS is in the eyes of the community

with the city government and the state legislature

Related Medical Affiliations: Regional Medical Director,

and among policy makers. It allows us to speak with one

to achieve our goals. We should play an active role

SF Region, California Emergency Physicians 2001–present;

clear voice to ensure that our message is heard as we

in setting CMA policy and action, and support the

Assistant Medical Director, California Emergency Physi-

advocate for our patients and our profession. My goal

efforts of the CMA and the IMQ in advocating for

cians, Doctors Medical Center Modesto 1999–2001

as a Board Member is to reach out to physicians in the

patient safety.

Medical School: University of California, Davis 1986

FOR NOMINATIONS COMMITTEE

community by extolling the benefits of membership on

Hospital Affiliation: Active: St. Francis, St. Mary’s,

both a professional and a social level. I look forward

Seton

to continued participation with SFMS and appreciate

Teaching Appointments: Associate Clinical Professor,

your support as we continue to advocate for our patients

UC Davis 1998–present; Associate Clinical Professor,

and practices.

UCSF 1992–98 Policy Statement: I am pleased to have this opportunity to participate in the elections process of the San Francisco Medical Society. Our willingness to MICHAEL SIU (Incumbent Director)

be active members of our local society as well as our

Specialty: Family Practice

statewide organizations is essential if we are to maintain

Membership: SFMS/CMA 1998

our ability to have a concerted and effective voice in

SFMS: Director 2005–07

influencing the policies that ultimately affect all of

SFMS Committee Appointments: SFMS Services, Inc.

our practices.

DANIEL M. RAYBIN (Incumbent Director)

Board 2000–06; Political Advocacy 2006

Specialty: Pulmonary Diseases and Critical Care

Related Medical Affiliations: CPMC Adult Quality

Membership: SFMS/CMA 1982

Care and Improvement Committee 1996–present, United

SFMS: Director 2005–07

Healthcare Quality Assurance Committee 1998–2000

SFMS Committee Appointments: Nominations

Medical School: University of Santo Thomas 1979

2006–07, Medical Review and Advisory Committee

Hospital Affiliation: Active: CPMC; Courtesy: St.

(cochair 2003–07)

Mary’s Hospital

Medical School: Stanford University 1973

Teaching Appointments: Assistant Clinical Professor,

Hospital Affiliations: Active: St. Mary’s; Courtesy: St.

Department of Family and Community Medicine, UCSF

DONALD C. KITT

Francis, CPMC; Consultant: San Francisco and Palo Alto

2002; American Academy of Family Physicians, active

Specialty: Neurology

V.A. Health Science Centers

teacher in Family Medicine 2002

Membership: SFMS/CMA 1988, AMA 1988

Teaching Appointments: Adjunct Clinical Profes-

Policy Statement: Thank you for the opportunity

SFMS: Director 2007–09, UCSF/ACF Consultant to

sor, Medicine, Stanford University; Clinical Professor,

to have served you on the Board of Directors for the

the Board 1999

Medicine, UCSF; Clinical Associate Professor, Medicine,

last three years. If reelected, I would focus on several

SFMS Committee Appointments: Tripartite 2000

Creighton University; also part of the core faculty in the

issues: 1) A house-call program for all active or retired

Related Medical Affiliations: Chief, Neurology Sec-

Internal Medicine Residency Training Program at St.

members. As doctors, we spend our time devoted to

tion, Department of Medicine, St. Mary’s 1998–present;

Mary’s

the care of others. This program would be for doctors

Fellow, American Academy of Neurology 2004–present;

www.sfms.org

october 2007 San Francisco Medicine

31

President, Association of Clinical Faulty, UCSF 1998–

Membership: SFMS/CMA 2005

2004–08); Alternate Delegate 1994–95; House Select

1999; President, San Francisco Neurological Society 2001;

Related Medical Affiliations: Northern California

Oversight Committee 2001; Reference Committee C:

Board of Directors/Executive Council, San Francisco

Chapter of the American Academy of Pediatrics

A-95, I-95, A-01; Cal-C Committee Chair 1995–96;

Neurological Society 1998–present; American College of

Medical School: Washington University School of Medi-

Resolutions Committee 1995–2000

Physicians 1985–present; Executive Council of the As-

cine Class of 1999

Related Medical Affiliations: St. Francis Physicians

sociation of Clinical Faculty, UCSF from 1995–1999;

Hospital Affiliations: Active: Kaiser Permanente

Medical Group/CHW Bay Area Physicians Medical

Hastings Center for Bioethics 1976–present

Teaching Appointments: Assistant Clinical Professor,

Group 1995–2000 (President/CEO), St. Francis Memo-

Medical School: University of Southern California

UCSF Department of Pediatrics

rial Hospital Board of Trustees 1990–96/2000–08 (Secre-

1982

Policy Statement: I have been a practicing general

tary 1994–95, Chair 2001–03), Catholic Healthcare West

Hospital Affiliation: Active: CPMC, St. Mary’s;

pediatrician in the San Francisco Bay Area since 2005.

Bay Area Board of Directors 1996–01, CHW Strategic

Courtesy: Chinese, St. Francis

Prior to that, I worked as an academic hospitalist at St.

Planning Committee 2001–05

Teaching Appointments: Associate Clinical Profes-

Louis Children’s Hospital. As a pediatrician, I believe

Medical School: UCSF 1968

sor, Department of Neurology, UCSF 2003–present;

that patient advocacy requires involvement on a

Hospital Affiliation: Active: St. Francis Memorial Hospital

Assistant Clinical Professor, Department of Neurology,

broader level to shape health care policy. I have been

Policy Statement: As always, my primary purpose in

UCSF 1990–2003

active with San Francisco Medical Society because of

medical politics is to further the agenda and goals of

Policy Statement: The SFMS has been a stalwart

its role in advocating for both patients and physicians.

California physicians at the national level. As chair

leader in bringing awareness of health care issues to

I would be honored to contribute to the SFMS as a

of the California Delegation for the past four years,

institutions and the practicing physician for genera-

member of the Nominations Committee.

I have worked to build a broad coalition to achieve

tions. My hope is that the SFMS can unite physicians in a cohesive participatory community to maintain the

consensus on and support for our resolutions. In that

FOR AMA DELEGATE

time, our delegation has been remarkably successful.

integrity of our profession in San Francisco. The Nomi-

I have been nominated for a position on AMA’s

nations Committee provides a unique opportunity to

Council on Long-Range Planning and Development.

represent the SFMS membership and help continue a

If successful, I hope to be able to help effect positive

legacy of accountable leadership pursuant to the bylaws.

change for AMA’s future. I ask for your continued sup-

I would be honored by your support.

port and particularly for your input on issues important to California physicians.

FOR AMA ALTERNATE DELEGATE H. HUGH VINCENT (Incumbent Delegate) Specialty: Anesthesiology Membership: SFMS, CMA, AMA 1972 SFMS: Board Consultant 1993–present, Immediate Past President 1993, President 1992, President-Elect 1991, RICHARD B. WARD

Director 1982–1990

Specialty: Internal Medicine

SFMS Committee Appointments: Medical Review

Membership: SFMS/CMA 1989

and Advisory 1975–present, SFMSPAC Board 1991–96

Related Medical Affiliations: Chair, Department

(Chair 1995–96/Consultant 1997–present), Health Care

ROBERT J. MARGOLIN

of Medicine, St. Francis 2000–06; St. Francis Board,

Foundation of San Francisco Board 1999–2004, Managed

Specialty: Internal Medicine

dates unknown; Board, Hill Physicians Medical Group

Care 1998–2001, Physician Membership Services/Mem-

Membership: SFMS/CMA 1987, AMA 1992

1995–present

bership 1994–2001/1986–89 (Chair 1994–95), Nomi-

SFMS: Board Consultant 2000–present, Immediate Past

Medical School: New York Medical College 1986

nations 2000–01/1994–95 (Chair 1994–95), Judicial

President 1999, President 1998, President-Elect 1997,

Hospital Affiliation: Active: St. Francis, St. Mary’s

1993–99, Anesthesia Section Chair 1975–90

Director 1992–96

Teaching Appointments: Creighton, dates unknown

CMA: Trustee 1997–2003, Delegate 1991–97, 2003–08

SFMS Committee/Board Appointments: Ex-

Policy Statement: Not Available

(Chair 1993–96), Alternate Delegate 1985–90

ecutive 1993–99 (Consultant 2000–07), HCFSF Board

CMA Board Committees: Nominations 1997–2003,

1995–2005, Judicial 1997–2007, SFMSPAC Board

Medical Services 1997–2002, Finance 1999–2003,

1995–2001 (Consultant 2003–07/Vice Chair 2000–01),

Bylaws 2001–03

Physician Membership Services/Membership 1995–2006,

CMA Committee Appointments: Council on Leg-

Finance/Investment 1998–2002, Managed Care 1998–

islation 1996–97, Speaker’s Advisory 1993–96, Rules

2002 (Chair 2000–02/Cochair 1999), 130th Anniversary

1994–95 (Chair 1995), Solo Practice TAC 1993–94

Celebration 1998, Nominations 1999–2000/1995–97

(Chair), Governance 10-94 TAC 1994, CALPAC

CMA: CMA Trustee 2003–07, Delegate 1997–2002

Board of Directors 1995–2001 (Executive Committee

(Chair 2001–03/Vice Chair 1998–2000)

ANGELA WONG

1999–2001)

CMA Committee Appointments: Committee on Nomi-

Specialty: Pediatrics

AMA: Delegate 1996–2007 (Vice Chair 2000–04; Chair

nations 2003–present, AB 3686 TAC 2004–05, Long-

32

San Francisco Medicine october 2007

www.sfms.org

Range Planning 2004–present, eCommerce TAC 2003,

medical students 2005–07; courtesy Staff Educator for

Chief of Staff, Davies Medical Center, 1996–1997

Council on Legislation 2001–02, CALPAC Board of

UCSF medical students 2005–07

Medical School: University of Colorado 1977

Directors 2004–present

Policy Statement: With the recent explosion in sci-

Hospital Affiliation: Active: Kaiser Permanente Medical

Related Medical Affiliations: Medical Director, In-

entific technology, the future of medicine has become

Center, San Francisco

tegrated Practice Group 1995–97; Medical Board, Mt.

increasingly enmeshed with politics. Advances in the

Teaching Appointments: Associate Clinical Professor,

Zion, 1992–95; President, Physician’s Medical Group at

science of medicine and challenges in the organiza-

UCSF 2005–present/1996–1998

Mt. Zion (IPA) 1993–present; Board of Directors, Medical

tion of health care delivery have made the politics

Policy Statement: It is an honor to have been part

Insurance Exchange of California 2007

of medicine more complex than ever before. As the

of the San Francisco Medical community since 1977,

Medical School: Tufts University 1981

young physician section delegate, I hope to infuse

working in the university, research, public, and pri-

Hospital Affiliations: Active: CPMC, UCSF

new energy into the San Francisco Medical Society

vate practice sectors. I am proud to be a member of

Teaching Appointments: Associate Clinical Professor,

and California Medical Association, providing a fresh

the SFMS and to serve as a CMA delegate. I have

UCSF

perspective and a voice for our newer members, and

witnessed outstanding leadership in the SFMS, which

Policy Statement: I have greatly enjoyed serving on

urging them to play active roles as the future leaders

remains not just reactive but also proactive, advocating

the SFMS Board of Directors for eight years and serving

of organized medicine.

for the health of our community and the well-being of

as its President in 1998. During the past several years, I have increased my involvement with the CMA. In addition to chairing our delegation to the CMA House

our members. SFMS faces continued financial chal-

FOR YOUNG PHYSICIANS SECTION ALTERNATE DELEGATE

for three years, I have also served on CMA’s Council

lenges, but that should not undermine our mission.

I look forward to continuing to serve our important organization.

of Legislation and the CALPAC Board of Directors.

LAWRENCE CHEUNG

During the past five years, I have served as your Trustee

ALSO CANDIDATE FOR BOARD. See biography under

to the CMA Board. I have enjoyed advocating for

“For Board of Directors.”

physicians both locally and throughout California and now wish to apply my energy and experience to

FOR CMA DELEGATION

the national arena. I ask for your support in allowing me to continue our work on health insurance reform,

GARY L. CHAN

MICRA preservation, financial advocacy, and many

ALSO CANDIDATE FOR SECRETARY. See biography

other issues vital to physicians and our patients.

under “For Secretary.”

BRIAN J. LEWIS (Incumbent Chair) Specialty: Medical Oncology

FOR YOUNG PHYSICIAN SECTION DELEGATE

Membership: SFMS/CMA 1989, AMA 1997 SFMS: Consultant 2007, Director 1999–2006 SFMS Committee Appointments: Physician Membership Services 2006, HCFSF Board 2005–06, Nominations 2005, Executive 2001, Education Chair 1996 CMA: Delegate 2006–07 (Chair 2006–07), Alternate Delegate 2000–05 and 1996 (Vice Chair 2004–05), Very STEPHEN E. FOLLANSBEE (Incumbent Delegate)

Large Group Practice Forum Delegate 1999, VLGPF

Specialty: Infectious Diseases

Alternate Delegate 1997–98

Membership: SFMS/CMA 1982

Medical School: Harvard 1969

LILY MEIYU TAN (Incumbent Alternate)

SFMS: President 2007, President-Elect 2006, Director

Hospital Affiliation: Active: Kaiser Permanente

Specialty: Ob/Gyn

1999–2005

Teaching Appointments: Clinical Professor, UCSF

Membership: SFMS/CMA 1999–present

SFMS Committee Appointments: Executive

Policy Statement: The CMA House of Delegates is

SFMS: Director 2007–09

2001/2004–07, Judicial 2006–07, PAC 2006–07, Disas-

the voice that communicates the concerns of Califor-

SFMS Committee Appointments: Information Tech-

ter Planning (cochair 2002–07), Nominations 2003–04,

nia physicians to the AMA, to government, and to

nology 2006

Medical Review and Advisory Consultant 1993–2002,

the media. The craft and compassion shown by the

CMA: Young Physicians Section Alternate Delegate

Chiefs of Staff 1996–97

delegates in framing resolutions and the camaraderie

2006–07

CMA: Delegate 2004–07

manifested in the debates foster a wonderful sense of

Related Medical Affiliations: CPMC Gynecology

Related Medical Affiliations: Attending physician, Kai-

common purpose and fellowship. In years past, I have

Quality Improvement Committee 2002–2005, Chinese

ser Permanente Medical Group, 1998–present; Director

been fortunate to help represent the SFMS, and I will

Hospital Pharmacy Committee 2001–2002

of HIV Services and Module Chief, Adult Primary Care,

again run for chair in the upcoming delegation. I would

Medical School: Albany Medical College 1995

Kaiser San Francisco, 2000–present; Assistant Director,

be grateful for your support.

Hospital Affiliation: Active: Kaiser Permanente San

Bay Area Consortium of AIDS Providers, 1990–present;

Francisco

Medical Director, Institute for HIV Research and Treat-

Teaching Appointments: CPMC nursing staff educator

ment, Davies Medical Center, 1988–1998; attending

2002–05; Kaiser Ob/Gyn staff, teaching residents and

physician, Ward 86, SFGH Medical Center, 1983–1998;

www.sfms.org

october 2007 San Francisco Medicine

33

Hospital Affiliation: Active: CPMC, Mt. Zion, UCSF, Stanford Teaching Appointments: UCSF Associate Clinical Professor, School of Nursing Policy Statement: As a native San Franciscan and a second-generation society member, I am eager to assist and serve on the Board. I believe our society has RITA MELKONIAN (Incumbent Alternate Delegate)

RODMAN SHELTON ROGERS

significant clout in shaping policy and could benefit

Specialty: Gynecology, Female Urology

Specialty: Urology

from the perspective and experience of a physician

Membership: SFMS/CMA 1991

Membership: SFMS/CMA 2000

brought up in the environment of managed care. As a

SFMS: Consultant 2005–07, Immediate Past President

SFMS: Director 2006–08

member of the Editorial Board, I have worked closely

2004, President 2003, President-Elect 2002, Editor 2001,

SFMS Committee Appointments: Nominations 2007

with many of our outstanding leaders and understand

Director 1996–2000

CMA: Solo/Small Practice Forum Alternate Delegate

the challenges that face the health of our society and

SFMS Committee Appointments: Executive 1998–

2005

our city over the next decade. Health care is chang-

2004 (Consultant 2005–07), Physician Membership

Related Medical Affiliations: American Urological

ing rapidly and physicians need to take back control

Services 1998–2007, Judicial 2002–07, Editorial Board

Association

of their profession. We are at an “inflection” point

2001–06, Finance 2003–04, SFMS PAC Board

Medical School: University of Oklahoma 1995

in health care delivery and financing. It is here and

1999–2004, Nominations 2004/2001/1997, Managed

Hospital Affiliation: Active: CPMC, St. Mary’s

now that we need to be creative, build consensus, and

Care 1998–2001, Insurance Mediation 1993–96

Policy Statement: Like many physicians, I entered

make bold moves.

CMA: Delegate 2002–05, Alternate Delegate 2006–

medicine wanting to contribute to the health of indi-

07/1998–2001

vidual patients as well as to make advancements in my

CMA Committee Appointments: Council on Legisla-

discipline. Accomplishing this certainly requires hard

tion 2004–07

work and high standards on a personal level. However,

Medical School: National University 1977

it has become clear to me that clinical excellence is in-

Hospital Affiliation: Active: St. Francis

sufficient to ensure the best long-term health outcomes

Teaching Appointments: Assistant Clinical Professor,

for our patients in our current political, insurance, and

Stanford University

medico-legal environment. I believe that organized

Policy Statement: I have greatly enjoyed serving SFMS

medicine is the best way to learn about and hopefully

RACHEL HUI-CHUNG SHU (Incumbent Alternate

in different levels over the past few years, especially

influence this environment, for the benefit of patients

Delegate)

serving as an alternate delegate and delegate to the

primarily and physicians secondarily. If chosen to be a

Specialty: Ob-Gyn

CMA for the past six years. In these challenging times,

delegate, I would vigorously advocate to protect both

Membership: SFMS/CMA 1992, AMA 1986

when the practice of medicine is so deeply influenced

the independence of the relationship between doctors

SFMS Committee Appointments: Credentials

by insurance companies, legislation, and governmental

and patients and the quality of medical care delivered

1994–2007, Physician Membership Services 1994–2002,

regulations, it is crucial for us as physicians to play ac-

in California.

Nominations 2001–02, Leadership Development 1995

tive roles in reforming our vastly imperfect health care

CMA: Alternate Delegate 2001–07

system. The CMA is our advocate and our voice in the

Related Medical Affiliations: Chinese Hospital Medi-

legislation arena, and being active in CMA is the only

cal Executive Committee (MEC) 1999–present, CPMC

way to reform the troubled health care system. It will

OB/GYN MEC 1998–present, CPMC Perinatal Quality

be a great honor for me to continue as a delegate to

Assurance Committee 1994–present, CPMC Joint Health

the CMA House of Delegates, and I appreciate your

Committee 2001–present, GYN New Technology Com-

continued support.

mittee 1997–present Medical School: University of Missouri 1986

WILLIAM A. MILLER

JORDAN SHLAIN

Hospital Affiliation: Active: CPMC, Chinese; Cour-

ALSO CANDIDATE FOR BOARD. See biography under

Specialty: Internal Medicine

tesy: St. Francis

“For Board of Directors.”

Membership: SFMS/CMA 1997

Teaching Appointments: Clinical teaching staff, UCSF

Policy Statement: We all know that health care policy

SFMS: Director 2003–09

1992–present

is of major interest at both the state and national levels.

SFMS Committee Appointments: Editorial Board

Policy Statement: I am honored to be a candidate for

In the efforts to reduce health care spending and the

1998–2006, Information Technology 2006, Web Page

the CMA delegation again. We are in a time of change,

subsequent battle to divide up the shrinking health

Oversight 2002–05 (Chair 2003–05), Executive 2004–

as so many issues are facing practicing physicians

care dollar, it is crucial that physicians have dynamic

05, Physician Membership Services 2001–03, QOM

today. These issues include patient advocacy, rising

representation in the government process. I desire to

2001–2003, Managed Care 1998–2002

malpractice premiums, PPOs, boutique medicine, and

serve the local community of doctors by representing

CMA: YPS Delegate 2006–07 (Alternate Delegate

new technology, to name a few. Practicing physicians

us at the state level through the California Medical

2004–05)

also face the reality of the electronic age and must be

Association’s House of Delegates.

Medical School: Georgetown 1994

knowledgeable in using electronic medical records,

34

San Francisco Medicine october 2007

www.sfms.org

ihealthrecords, and HIPAA, plus advances in technol-

SFMS: Consultant 2003–07, Immediate Past President

Teaching Appointments: Clinical instructor and

ogy, minimally invasive procedures, and privacy issues.

2002, President 2001, President-Elect 2000, Director

member of teaching faculty, St. Mary’s Medical Center

CMA gives each one of us a voice in this complex

1996–99, Medical Staff Liaison to TPMG 1996–99

1980–present

world. If elected, I hope to make a difference.

SFMS Committee Appointments: Finance/Investment

Policy Statement: The San Francisco Medical Society

2001–07, Executive Committee 1997–2002 (Consultant

offers many benefits to its members; but in this con-

2003–06), Disaster Planning 2002–06, Nominations

stantly changing medical environment, the Society

2002/1994–95, SFMSPAC Board 1997–2002, Judicial

must also change to meet the challenges. As your

2000–02, Chiefs of Staff 2001, Bioethics 1986–87,

representative on the delegation to the CMA House,

Legislative 1990–95

my goal is to ensure that the needs of all practicing

CMA: Delegate 2000–07/1996–97, Alternate Delegate

physicians are heard and considered. While there are

1998–99/1993–95

many opportunities, what really matters is your daily

Related Medical Affiliations: Chair, Credentials and

practice, and that is what we need to focus on. My

PETER W. SULLIVAN (Incumbent Alternate Delegate)

Privileges Committee of Kaiser Foundation Hospital

hope is to be able to contribute as a practicing physi-

Specialty: Emergency Medicine

1996–present; Vice Chair, Board of Directors, Northern

cian and as your Representative, in order to allow your

Membership: SFMS/CMA 1990

California Permanente Medical Group 1993–96

practice to be sustainable and allow you to provide the

SFMS: Director 2003–07, Treasurer 2002, Director

Medical School: Northwestern 1962

highest quality of care to patients. In order to fulfill

1996–2000, Medical Staff Liaison CPMC 1999–2004

Hospital Affiliation: Active: Kaiser Permanente

our mission, we need the collective strength of all

SFMS Committee Appointments: Finance/Investment

Policy Statement: It has been a privilege to serve the

physicians practicing in San Francisco to join the SF

2000–07 (Chair 2001–02); Local Health Affairs Chair

San Francisco Medical Society as a delegate to the

Medical Society.

2000–06; Executive 2000–04; Nominations 2002–03;

California Medical Association’s annual meeting.

SFMS Services, Inc., Board 2001–02; Physician Member-

I would like to continue my efforts to influence the

ship Services/Membership 1996–2002; Medical Review &

CMA’s responses to the hostile environment in which

Advisory 1995–2000; Managed Care Task Force 1994

we find ourselves. The SFMS’s influence on the CMA

CMA: Alternate Delegate 2002–07

and AMA is remarkable for our small size. As I said

Related Medical Affiliations: Vice Chair, Emer-

when I was elected President of the SFMS, “I feel we

gency Medicine, CPMC; Physician Information Officer,

are the conscience of CMA.” Physician advocacy is

CPMC; Group Manager, San Francisco Emergency

effective.

Medical Associates; Medical Director, Utilization Review, SFGH 1978–94; Finance Committee and Board, SFIPA; Specialist for Credentials and Utilization Review Committees, CPMC Medical School: UCSF 1971 Hospital Affiliation: Active: CPMC Policy Statement: I am honored to be nominated to serve on the SFMS Delegation to the CMA House of Delegates. I have enjoyed the opportunity over the last

JOHN I. UMEKUBO (Incumbent Alternate Delegate)

six years to meet with my SFMS colleagues and address

Specialty: Internal Medicine

the hot issues facing physicians statewide. I continue

Membership: SFMS/CMA 1980

to sit on the SFMS Finance Committee and Board,

SFMS: Director 2003–07, St. Mary’s Medical Staff

where many of the issues of interest to San Francisco

Liaison 2003–07

physicians are discussed. It would give me great pride

SFMS Committee Appointments: Executive 2006–07;

and pleasure, if I am reelected, to represent the physi-

Physician Membership Services 2007; Fellowship/Wellness

cians of San Francisco at the CMA level.

2006; Nominations Committee 2004–05, 1999–2000;

Save the Date!

SFMS Nutcracker Night A NEW member event—the San Francisco Medical Society Nutcracker Night, on Saturday, December 29. This fun, “familyfriendly” event will also feature a festive reception at 6:00 p.m. followed by a performance of the San Francisco Ballet’s glorious new production of the Nutcracker at 7:00 p.m. Watch for more information, including seating locations and pricing. If you have any questions please contact Therese Porter in the Membership Department. A perfect way to unwind after the holidays!

Executive 2003; Chiefs of Staff 2000–02 CMA: Alternate Delegate 2006–07, 1999–2000 Related Medical Affiliations: Chief of Staff, St. Mary’s Medical Center, 1999–2003 (Executive Committee Member 1992–2004); San Francisco County Health Commission 1999–2007; Medical Director of San Francisco Community Convalescent Hospital 1989–2007; member of Board Development Committee, Catholic Healthcare GEORGE P. SUSENS (Incumbent Delegate)

West Bay Area Region

Specialty: Internal Medicine

Medical School: St. Louis University

Membership: SFMS/CMA 1982

Hospital Affiliation: St. Mary’s Medical Center

www.sfms.org

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Proposed bylaws amendment Pursuant to Article XVI of the SFMS bylaws, the Board of Directors at its September 10, 2007 meeting voted unanimously to recommend that the membership ratify fairly substantial bylaws amendments. The proposed changes follow the candidate bios and policy statements. Please note: new language is underlined, language to be deleted is in strikethrough text.

Bylaws of the San Francisco Medical Society (Draft August 2007)

ARTICLE I ‑ NAME AND OBJECTS Section 1 ‑ Name The name of this organization shall be THE SAN FRANCISCO MEDICAL SOCIETY. Section 2 ‑ Purposes The objects of this Society shall be to promote and develop the science and art of medicine, to conserve and protect the public health, to promote the betterment of the medical profession, to cooperate with organizations of like purposes, and to unite with similar societies of other counties of the State to form the California Medical Association.

ARTICLE II ‑ MEMBERSHIP Section 1 ‑ Classes of Membership The members of this Society shall consist of Active (Regular, Resident Physician, Medical Student), Associate, Affiliate, Retired, Inactive, Non-resident and Honorary. and shall also be members of the California Medical Association.

Section 2 – Regular Active Membership 2.1 Qualifications. To be eligible for election to regular active membership in the Society, an applicant must be a physician holding an unrevoked and unsuspended license to practice medicine and surgery issued to the physician by the State of California.

The applicant must be of good moral and professional character and must not support, nor practice, nor claim to practice, any exclusive or sectarian system of medicine. The applicant must subscribe to the principles of medical ethics of the American Medical Association and to such as may from time to time be adopted by the California Medical Association, and shall recognize the authorized officers and judicial bodies of the Society and the California Medical Association as the proper authorities to interpret any doubtful points of ethics.

A physician may apply for regular active membership in this Society if the physician’s professional practice or residence is located in San Francisco.

2.2 Rights. An Regular active members shall have the right to vote and shall be eligible for any office or honor within the gift of the Society.

Section 5 3‑ House Officer Affiliate Resident Physician Active Membership 5.1 3.1 Qualifications. To be eligible as a house officer affiliate resident physician active member in this Society, an applicant must be an intern, resident or fellow and member of the CMA Resident and Fellow Section., and continue to be throughout the term of his/her membership, a member in good standing of the House Officers Medical Society of the California Medical Association. House officer affiliate Resident physician active membership will terminate on conclusion of the period of appointment as an intern, resident or fellow. A six‑months’ extension of membership may be granted, upon the request of the member, at the discretion of the Board of Directors.

5.2 3.2 Rights. House officer affiliate Resident physician active members shall not have the right to vote and shall be eligible for any office or honor within the gift of the Society. or the right to hold any elective office, or have any right or title to any property of this Society. They shall pay dues as prescribed by the Board of Directors.

Section 6 4 – Medical Student Affiliate Active Membership 6.1 4.1 Qualifications. To be eligible for election to medical student affiliate active membership in this Society, an applicant must be and continue to be throughout the term of his/her membership a medical student active member of the California Medical Association at the University of California San Francisco or a school of medicine acceptable to the Board of Directors. Medical student affiliate active membership will terminate on conclusion of the period of training. A six‑months’ extension of membership may be granted, upon the request of the member, at the discretion of the Board of Directors.

6.2 4.2 Rights. Medical student affiliate active members shall not have the right to vote, or the right to hold any elective office, or have any right or title to any property of the Society. and shall be eligible for any office or honor within the gift of the Society.

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Section 3 5 ‑ Associate Membership 3.1 5.1 Qualifications. A physician residing or working in San Francisco, not engaged in the private practice of medicine but in teaching or research work, or holding a position in government service, shall be eligible to election to associate membership in this Society. The physician need not hold a license to practice medicine or surgery granted by the State of California.

3.2 5.2 Rights. Associate members shall have all the rights and privileges of active members except the right to vote or hold any elective office in the Society, and they shall have no right or title to any property of this Society.

Section 4 6 – Nonresident Affiliate Membership 4.1 6.1 Qualifications. An active member of another county medical society who desires to affiliate with this Society shall be eligible to nonresident membership provided he/she has his/her major office for the practice of medicine outside of the City and County of San Francisco.

4.2 6.2 Rights. Nonresident affiliate members shall have such rights and privileges as may be determined by the Board of Directors, except the right to vote or to hold any elective office. They shall have no right or title to any property of this Society.

Section 5 ‑ House Officer Affiliate Membership 5.1 Qualifications. To be eligible as a house officer affiliate member in this Society, an applicant must be, and continue to be throughout the term of his/her membership, a member in good standing of the House Officers Medical Society of the California Medical Association. House officer affiliate membership will terminate on conclusion of the period of appointment. A six‑months’ extension of membership may be granted, upon the request of the member, at the discretion of the Board of Directors.

5.2 Rights. House officer affiliate members shall not have the right to vote, or the right to hold any elective office, or have any right or title to any property of this Society. They shall pay dues as prescribed by the Board of Directors.

Section 6 ‑ Student Affiliate Membership 6.1 Qualifications. To be eligible for election to student affiliate membership in this Society, an applicant must be and continue to be throughout the term of his/her membership a medical student active member of the California Medical Association at the University of California San Francisco or a school of medicine acceptable to the Board of Directors. Student affiliate membership will terminate on conclusion of the period of training. A six‑months’ extension of membership may be granted, upon the request of the member, at the discretion of the Board of Directors.

6.2 Rights. Student affiliate members shall not have the right to vote, or the right to hold any elective office, or have any right or title to any property of the Society.

Section 7 ‑ Retired Membership 7.1 Qualifications. The Board of Directors may grant retired membership to those active and associate members who have ceased the practice of medicine to the extent and for reasons satisfactory to the Board. Retired membership shall endure as long as the retired member does not engage in the practice of medicine; but in the event that a member classified as retired resumes the practice of medicine, such resumption shall automatically terminate retired membership and reestablish active membership after payment of dues. Upon resumption of the practice of medicine by any retired member, the Secretary shall transfer such member from the retired classification to the active classification.

7.2 Rights. Retired members shall not have the right to vote, or the right to hold any elective office, or any right or title to any property of the Society. They shall be privileged to attend any meetings of the Society or its sections which are open to active members.

Section 8 ‑ Inactive Membership Leave of Absence 8.1 Qualifications. The Board of Directors may elect as inactive to grant a leave of absence to any member in good standing who leaves his/her practice for a period of six or more months to engage in bona fide postgraduate study, or who leaves his/her practice by reason of protracted illness and/or for whom payment of dues would be a hardship. Any member applying for status as an inactive member a leave of absence or for reduction of dues must satisfactorily show he/she will not be engaged in the

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private practice of medicine and surgery for such period applied for; he/she must show adequate reasons deemed sufficient by the Board of Directors for the granting of such inactive status or reduction of dues. Such leave may not exceed one year, but shall be subject to renewal upon request.

8.2 Rights. Inactive Members granted leave of absence status shall not have the right to vote, or to hold any elective office, or, if holding an office during the period away from practice, shall relinquish such office. Inactive Such members shall have no right or title to any property of this Society.

Section 9 ‑ Honorary Membership 9.1 Qualifications. A person distinguished for his/her services or attainments as a Doctor of Medicine or in the field of public health, or in research, or other specific work, or other endeavors contributing to medicine, may be elected to honorary membership in this Society.

9.2 Rights. Honorary members shall not have the right to vote, or the right to hold any elective office, or any right or title to any property of the Society.

9.3 Persons qualified for honorary membership may be elected by an affirmative vote of not less than two‑thirds (2/3) of the members of the Board of Directors, but no person shall be elected to honorary membership unless his/her nomination has been considered at two consecutive regular meetings of said Board.

Section 10 ‑ Standards of Qualifications This Society shall be the sole judge of the moral, ethical, and professional qualifications requisite for admission to or continuation of any kind of membership in this Society.

Section 11 ‑ Method of Admission to Membership 11.1 Any person who desires to become a member of this Society shall fulfill the following provisions: application blanks provided by the Society shall be filled out, signed, and submitted with two recent pictures of the applicant, of designated size, to the membership department. Secretary of the Society. The application blanks shall contain, in addition to any other matter, at least the following: “The undersigned applicant certifies that he/she has read the Bylaws of the San Francisco Medical Society, and agrees, in case of his/her election, that his/her membership in said Society shall be conditional upon his/her compliance with the Bylaws of said Society, as well as the Constitution and Bylaws of the California Medical Association; the undersigned further agrees that he/she will recognize the authorized officers of the said Society and said Association as the proper authorities to interpret any doubtful points in professional conduct and will at all times abide by and be governed by their interpretation.”

The application shall be endorsed by two active members and shall also contain thereon the following: “Any active member of this Society in good standing may endorse this application. Each endorser shall be fully conversant with the applicant’s moral, ethical, and professional qualifications, and by such endorsement agrees to appear, upon request, before the Credentials Committee to testify with respect to the applicant’s qualifications.”

11.2 The review of applications for membership and credentialling procedure shall be conducted by the Credentials Committee membership department pursuant to policies as established by the Board of Directors or Executive Committee from time to time.

11.3 The affirmative vote of a majority of members of the Board of Directors or Executive Committee entitled to vote shall be necessary to elect.

11.4 In the event of an adverse recommendation by the Credentials Committee or an objection to membership voiced before the Board of Directors or Executive Committee, the procedures specified by the Bylaws of the California Medical Association shall apply.

11.5 The names of those elected shall be published in the issue of the bulletin next succeeding their election and payment of dues.

11.6 An applicant who has received a final adverse decision regarding admission or who withdraws the application for membership following a proposed rejection shall not be eligible to reapply for Society membership for a period of three (3) years from the date of the final decision or withdrawal of the application. Any such reapplication shall be processed as an initial application and the applicant shall submit such additional information as may be required to demonstrate that the basis for

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the earlier adverse decision no longer exists.

11.7 When an applicant fails to fulfill the requirements within one year of the date of receipt of his/her application by the Society, without showing adequate cause to the Credentials Committee, Board of Directors, the application shall be null and void.

11.8 Applicants for active and associate, and affiliate membership, including transfers, shall not be eligible to election until completion of all requirements for admission.

11.9 Applicants for affiliate membership shall complete and submit appropriate application blanks provided by the Society, and any additional information deemed necessary by the Credentials Committee for its consideration. The recommendation of the Credentials Committee may be acted upon by the Board of Directors or Executive Committee, upon receipt, notwithstanding any other provisions of these Bylaws, except insofar as the Bylaws of the California Medical Association may provide.

Section 12 ‑ Change of Status, Termination of Membership, and Discipline 12.1 When a change in qualifications requires a membership status change, the member must request that change of the Secretary in writing within ninety days of the change in qualifications. If an affiliate associate member wishes to change to active status, the requirements for active membership must be met at that time. The Board of Directors may at its discretion initiate proceedings designed to clarify the appropriate status of any member.

12.2 Any member in good standing may resign by filing with the Secretary a written resignation which may be accepted by the Board of Directors or Executive Committee, only after all indebtedness of said member to the Society has been paid to the date of filing his/her resignation. Dues of this Society will be refunded on a pro rata basis in the event of disabling illness or death.

12.3 Any member whose license to practice medicine and surgery in the State of California is revoked shall thereupon cease to be a member of this Society.

12.4 Membership shall cease automatically thirty days after notice of delinquency if any dues or assessments remain upon as of the due date established pursuant to these Bylaws or the Bylaws of the California Medical Association.

12.5 Any member who has been adjudged guilty of a criminal offense involving moral turpitude, or who has been adjudged guilty by this Society of gross misconduct as a physician or citizen, or who practices medicine in a manner not commensurate with the standards of the medical profession of this community, or who violates any of the provisions of the Bylaws of this Society, shall be liable to censure, suspension, expulsion or other discipline.

12.6 The procedure to be followed by this Society with respect to censure, suspension, or expulsion or other discipline of a member shall be governed by the provisions of the Bylaws of the California Medical Association. To that end, the Bylaws of the California Medical Association, together with any future amendments, modifications, or replacements thereof, are hereby incorporated herein by reference and made a part of these Bylaws.

12.7 Any person whose membership has been terminated in this Society may apply for membership after the expiration of five (5) years from the date of expulsion from membership or three (3) years from the date the member resigns following issuance of formal charges. Such application shall be considered in the same manner as a new application for membership, provided that members who have resigned in good standing or who have been dropped for nonpayment of dues or assessments may be reelected at any time by a majority of the Board of Directors or Executive Committee upon the payment of all dues and assessments in arrears.

12.8 Whenever a former member’s license to practice medicine is reinstated by the Medical Board of California or the Board of Osteopathic Examiners following a revocation, that former member may reapply after one (1) year from the date of reinstatement in the same manner as a new applicant.

Section 13 ‑ Transfer from Other County Society A physician presenting a transfer certificate or transfer card from another component county society of the California Medical Association must accompany such transfer certificate or card with a regular form of application for membership, properly filled out.

The Board of Directors or Executive Committee shall act upon such application as upon all other applications for membership, except that such active membership in another component society of the California Medical Association may be accepted as evidence of qualification for membership in this Society.

Section 14 ‑ Transfer to Other County Society A member in good standing, against whom no charges are pending, wishing to be transferred to another county society, shall be granted a transfer certificate or card without cost, subject to the provisions of the Constitution and Bylaws of the California

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Medical Association. This certificate shall state the class of membership, the date on which the member was admitted to membership, and the date of issuance of the certificate, and shall be signed by the Secretary.

ARTICLE III ‑ BOARD OF DIRECTORS Section 1 ‑ Composition and Term 1.1 The Board of Directors shall consist of the officers and twenty‑one elected directors.

1.2 Directors shall be elected to three‑year terms, to commence January 1 of the year following their election.

1.3 A director who has served two consecutive full terms of office as a director shall not be eligible to such office again until one year has elapsed from the date of termination of said second consecutive term.

1.4 The office of any Director who is absent from more than one-half of the regularly scheduled meetings of the Board in any calendar year shall be declared vacant by the Board at its next regular meeting.

1.5 The Board may excuse the absence of any director at any meeting for a bona fide reason acceptable to the Board of Directors.

Section 2 ‑ Powers of the Board 2.1 Subject to the provisions of these Bylaws, the Board of Directors shall be vested with full and complete power and authority to manage, control, use, invest, reinvest, lease, transfer, mortgage, convey in trust, sell or otherwise dispose of all property and assets of whatever kind or nature owned by the Society, and shall also be vested with full and complete power and authority to do and perform all acts, and to conduct, manage, control, and transact all the affairs and business of and for and on behalf of the Society, and to manage and conduct all the work and activities of the Society in fulfilling the purposes thereof.

2.2 An abstract of the proceedings of each meeting of the Board of Directors shall be published to the general membership in the bulletin of the Society as soon as practicable after the date of each meeting of the Board.

2.2 2.3 In addition to the powers and duties specified elsewhere in these Bylaws, the Board of Directors may investigate and consider any matter that may be of any concern to the Society.

2.3 2.4 The Board of Directors may formulate rules governing the expenditure of moneys to meet the necessary expenses and fixed charges of the Society.

2.4 2.5 The Board of Directors shall consider and approve a budget for the forthcoming fiscal year.

Section 3 ‑ Meetings of the Board 3.1 The Board of Directors shall hold a regular meeting at least once each quarter at the office of the Society. a location specified by the Board. Due notice of the time and place of such meeting shall be sent by the Secretary to each director. Any member of the Society in good standing may attend any regular meeting of the Board as an observer.

3.2 Special meetings of the Board of Directors may be called at any time by the President, or shall be called by the President on the written request of any five directors and filed with the Secretary. At least three days’ notice of the time and place of all such meetings shall be given by the Secretary to each director, and such notice shall state the nature of the business to be considered at that meeting.

3.3 All regular meetings of the Board shall be held within the City and County of San Francisco.

3.4 The President shall preside at all of the meetings of the Board, and in the President’s absence the President‑Elect shall preside. The Chair shall have the privilege of voting on all matters coming before the Board.

3.5 Directors may participate in and act at any meeting of the board of Directors through use of a conference telephone or other communications equipment by means of which all persons participating in the meeting can communicate with each other.

Such participation shall constitute attendance and presence at the meeting. Any action which may be taken at any regular or special meeting of the Board of Directors may be taken without a meeting if a consent in writing set forth the section so taken shall be signed by all of the directors entitled to vote with respect to the subject matter thereof.

3.6 The Board may excuse the absence of any director at any meeting for bona fide illness of the director, urgent patient care matter, out of town business or other bona fide reason acceptable to the Board of Directors.

Section 4 ‑ Quorum and Order of Business 4.1 The presence of a majority or fourteen members of the Board of Directors in regular or special meeting shall constitute a quorum.

4.2 The order of business of the Board of Directors shall be established by the presiding officers prior to the meeting.

4.3 All acts and proceedings of the Board of Directors shall be recorded by the Secretary or his or her designee in a minute book and shall be submitted to the Board for approval at its next regular meeting.

ARTICLE IV ‑ OFFICERS Section 1 ‑ Offices and Terms 1.1 Designation of Officers. The officers of this Society shall be a President, a President‑Elect, an Immediate Past President, a Secretary, a Treasurer, and an Editor.

1.2 Method of Election. The officers shall be elected in the manner provided by these Bylaws at the regular annual election of the society.

1.3 Term of Office. All elected officers shall serve for a term of one year, or until their successors shall qualify.

1.4 The officers shall be elected by majority vote of members voting for that office. In the event that two or more candidates receive an equal number of votes, election shall be determined by lot in such manner as the Board of Directors shall determine.

Section 2 ‑ Duties of President The President shall be the chief elected officer of the Society, and as such shall carry out the expressed will of the Board of Directors and of the Society in all matters not in conflict with these Bylaws. The President shall preside at all meetings of the Board of Directors, the Executive Committee, and the general meetings of the Society; the President shall appoint all committees, with the approval of the Board of Directors. The President shall be a member ex‑officio of all committees, except committees primarily engaged in individual peer review or which are exclusively judicial in function, and the Nominations Committee, where the President will appear at the first meeting, and thereafter only by invitation.

The President shall perform such other duties as custom and parliamentary usage may require or the Board of Directors may direct.

Section 3 ‑ Duties of President‑Elect The President‑Elect shall act for the President in his/her absence or disability. If the office of President becomes vacant, the President‑Elect shall then succeed to the presidency to serve as president for such unexpired term. The President‑Elect shall then succeed to the presidency for his/her regularly elected term of office. The President‑Elect shall be an ex‑officio member of all committees of the Society, except the Nominations Committee and committees primarily engaged in individual peer review or which are exclusively judicial in function.

No person shall be eligible to election as President‑Elect who will not have served for at least three years as an officer and/or a member of the Board of Directors prior to assuming said office.

Section 4 ‑ Duties of Secretary 4.1 Minutes. The Secretary shall attend the Board of Directors, Executive Committee and any other official business meetings and cause to be kept minutes of their respective proceedings.

4.2 Records and Seal. The Secretary shall cause to be kept the seal and official records and papers of the Society.

4.3 Membership Roll. The Secretary shall cause to be kept an accurate roll of all members of the Society.

4.4 Administrative Duties. The Secretary shall cause to be carried on, under the direction of the President, the Board of Directors, and the Executive Committee, all of the business and correspondence of the Society, as provided in these Bylaws, and any other duties as the Board of Directors may direct.

Section 5 ‑ Duties of Treasurer 5.1 Funds. The Treasurer shall cause the funds of the Society to be properly kept and shall cause to be kept account of the same.

The Treasurer shall cause to be received all funds due to the Society. The Treasurer shall cause to be received all bequests and donations made to the Society and shall ensure disposition of them as directed by the Board of Directors. The Treasurer shall cause to be deposited the funds of the Society in such commercial or savings bank as shall be designated by the Board of Directors as depositories of the Society, or oversee such other disposition of the funds as shall be ordered by the Board. The Treasurer shall cause the authorized expenses of the Society to be paid. The Treasurer shall cause to be remitted to the California Medical Association the proper portion of the annual assessment of dues to that Association then due from all members, new members, or members in arrears from whom payment has been received.

The Treasurer shall cause accounts to be submitted to such examination as may be required by the Board of Directors, and at least once a year, the books and accounts of the Society shall be examined by a certified public accountant selected by the Board and a formal audit shall be conducted every five years.

5.2 Checks. The Treasurer’s signature shall appear on all checks except as the Board by resolution may provide.

5.3 Reports. The Treasurer shall cause financial reports to be made to the Board of Directors and Executive Committee at each regular meeting.

5.4 Bond. The Board of Directors shall require that all persons disbursing Society moneys be covered by insurance adequate to protect the Society’s assets.

Section 6 ‑ Duties of Editor and Editorial Board 6.1 The Editor chairs the Editorial Board and oversees its

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work., and works closely with the Managing Editor to ensure that publications are in accordance with SFMS policy and guidelines.

6.2 The Editor and the Editorial Board shall ensure that all advertisements that appear in Society publications shall meet the official advertising rules and regulations of the Society.

The Editor works closely with the Managing Editor on all aspects of SFMS publications.

6.3 The Editor and the Editorial Board shall compile and prepare for the archives of the Society and for publications, suitable article on the history of the Society and obituaries of deceased members. The Editor works closely with the Managing Editor, Editorial Board and SFMS staff to ensure that publications are in accordance with SFMS policy and guidelines.

6.4 The Editor and the Editorial Board shall ensure that all advertisements that appear in Society publications shall meet the official advertising rules and regulations of the Society.

6.5 The Editor and the Editorial Board shall publish obituaries of deceased members.

Section 7 ‑ Duties of Executive Director The duties of the Executive Director shall be such as delegated by the Board of Directors and specified in the Executive Director’s contract.

7.1 The Board of Directors shall appoint and fix the salary of the Executive Director.

7.2 The Board of Directors shall require that the Executive Director be covered by insurance adequate to protect the Society’s assets.

ARTICLE V ‑ EXECUTIVE COMMITTEE Section 1 ‑ Members 1.1 The Executive Committee of the Board of Directors shall consist of the President, President‑Elect, Immediate Past President, Secretary, Treasurer, Editor, and five members of the Board of Directors, appointed by the President with the approval of the Board to hold office for one year.

1.2 Any appointed member may be removed from the Executive Committee by the President with the approval of the Board of Directors.

1.3 The President shall be the Chair of the Executive Committee and the Secretary shall be the Secretary thereof. In the absence of the President or the Secretary, the President‑Elect shall fulfill the duties of the absent member.

Section 2 ‑ Meetings 2.1 The Executive Committee shall meet on call of the President, or in the President’s absence, on call of the President‑Elect.

2.2 Five members thereof shall constitute a quorum, provided one of the appointed members of the Board is present.

Section 3 ‑ Duties The Executive Committee shall act for and on behalf of the Board of Directors in the transaction of the business of the Society in the intervals between the meetings of the Board of Directors. It shall have such advisory powers and such other duties as the Board of Directors shall from time to time determine. The Executive Committee shall seek the ratification of the Board of Directors except in matters of great urgency when action by the Executive Committee is required.

The decision of any committee directly pertaining to any member, other than a matter pending before or determined by the Judicial Committee, may be appealed to the Executive Committee.

Section 4 ‑ Records All the acts and proceedings of the Executive Committee shall be recorded by the Secretary or his or her designee and shall require the ratification or approval of the Board of Directors except as Section 3 provides.

ARTICLE VI ‑ TRUSTEES Section 1 ‑ Election The members shall elect those district trustees of the California Medical Association to which the Society is entitled. No person shall be elected as trustee except by majority vote of the members voting.

Section 2 - Duties The duties of a district trustee shall be as prescribed by the Bylaws of the California Medical Association. Trustees elected by the members shall be privileged to attend all meetings of the Board of Directors and the Executive Committee.

ARTICLE VII ‑ DELEGATES Section 1 ‑ Delegates to the California Medical Association 1.1 The members shall annually elect a sufficient number of persons to fill the expiring and vacant terms of delegates and alternates to the California Medical Association.

1.2 The person elected as President‑Elect shall be deemed

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elected simultaneously as a delegate. The remaining delegate positions shall be filled by the persons nominated for the office of delegate, according to the number of votes received, in descending order. Alternates shall be the persons receiving the next highest number of votes, in descending order. In the event that two or more persons receive an equal number of votes for a single available position, election shall be determined by lot in a manner selected by the Board of Directors.

1.3 The term of a delegate or alternate shall be two years, except that the initial term of any new office which the Society is entitled to elect shall be one year whenever such shorter term will more nearly provide for the election of one‑half of said delegates or alternates in any year.

1.4 The delegates to the California Medical Association shall represent this Society in the House of Delegates of the California Medical Association. Alternates shall act for and in place of absent delegates and shall be selected to so act in the order of votes received at the election, beginning with the alternate receiving the higher number of votes in the year of his/her election.

Section 2 ‑ Delegates to the American Medical Association 2.1 Those members of this Society entitled to vote who are also members of the American Medical Association shall be entitled to nominate or be nominated for and to elect any delegate or alternate to the American Medical Association which this Society is entitled to elect. Such election shall be by majority vote.

2.2 The term and duties of any person elected as a delegate or alternate to the American Medical Association shall be as the Bylaws of the American Medical Association and California Medical Association respectively provide.

2.3 Vacancies in the office of delegate or alternate to the American Medical Association shall be filled by a majority vote of those members of the Board of Directors. who are members of the American Medical Association.

Section 3 - Young Physicians Section 1.1 The members shall annually elect a sufficient number of persons to fill the expiring and vacant terms of delegates and alternates to the Young Physicians Section of the California Medical Association. Eligibility shall be determined by the California Medical Association.

1.2 Delegate positions shall be filled by persons nominated for the office of delegate, according to the number of votes received, in descending order. Alternates shall be the persons receiving the next highest number of votes, in descending order. In the event that two or more persons receive an equal number of votes for a single available position, elections shall be determined by lot in a manner selected by the Board of Directors.

1.3 The term of a delegate or alternate shall be two (2) years, except that the initial term of any new office which the Society is entitled to elect shall be one (1) year whenever such shorter term will more nearly provide for the election of one-half of said delegates or alternates in any year.

1.4 The delegates to the Young Physicians Section to the California Medical Association shall represent this Society in the meetings of the Young Physicians Sections of the California Medical Association. Alternates shall act for and in place of absent delegates and shall be selected to so act in the order of votes received at the election, beginning with the alternate receiving the higher number of votes in the year of his/her election.

ARTICLE VIII ‑ VACANCIES IN OFFICE Section 1 ‑ How Filled 1.1 In the event of death, resignation or removal of the President, the President‑Elect immediately shall become President for the unexpired term and for the succeeding term to which he/she was originally elected. The other officers shall retain the offices to which they were elected.

1.2 In the event of the death, resignation or removal of the President‑Elect, the Board of Directors shall appoint an Interim President‑Elect for the unexpired term. At the next regular election, a President and President‑Elect shall be elected.

1.3 The Board of Directors shall appoint to the vacancy for the unexpired term of any director, the unsuccessful candidate for the office of director who received, at the annual election at which the retiring, disqualified, or deceased director was elected, the highest number of votes among the unsuccessful candidates for said office.

1.4 The Board of Directors, by appointment, shall fill any vacancy in office not otherwise provided for in these Bylaws, which occurs during the term of office. Such appointee shall fill the unexpired term.

ARTICLE IX ‑ MEETINGS Section 1 ‑ Rules of Order All meetings of the Society shall be governed by the parliamentary rules and usages contained in the current edition of Sturgis Standard Code of Parliamentary Procedure, when not in conflict

with these Bylaws.

Section 2 ‑ General Meetings The Society shall hold at least one general meeting per year.

Notice of all general meetings shall be published in the bulletin of the Society. The President of the Society shall preside at all general meetings. At least one general meeting shall be held in September.

Section 3 ‑ Special Meetings Special meetings of the Society may be called at any time by the President, and shall be called by the President on the request of a majority of the directors, or on the written request of at least ten percent of the members of the Society entitled to vote. At least seven days’ written notice of all special meetings called shall be given by the Secretary to each member of the Society. Such notice shall state the time, place, and purpose of the special meetings, and no other matters shall be considered or acted upon.

Section 4 ‑ Suspension of Procedure Rules of order or the agenda may be suspended only on the affirmative vote of three‑fourths of the voting members present.

Section 5 ‑ Roll Call Vote by roll call shall be held upon demand of any member.

ARTICLE X ‑ ELECTIONS Section 1 ‑ Conduct of Election The Board of Directors shall conduct all elections, both regular and special, and shall have charge of all matters pertaining thereto, except the election of section officers, as provided for in these Bylaws.

Section 2 ‑ Nominations 2.1 The Nominations Committee shall nominate a ticket, rendered in writing, at least two weeks prior to the September General Meeting, and such report shall be available to any member of the Society, containing one or more names each for President‑Elect, Secretary, Treasurer, and Editor, and shall nominate the number of persons at least equivalent to the number of vacancies which exist or which are about to exist among the delegates and alternates to the California Medical Association and to the American Medical Association, and one or more names for any vacancy which exists or which is about to exist in the respective offices of trustees to the California Medical Association. Further, the Nominations Committee shall nominate at least seven (7) members for the office of Director, as well as at least four (4) members for the Nominations Committee.

2.2 The October issue of the bulletin will list the names of all nominees and their biographical data.

2.3 At the September General Meeting the names of nominees will be read. The President shall call for additional nominees from the floor for all offices. Nominations from the floor shall be in writing and shall be accompanied by the written consent of the nominee.

2.4 Any nominee declining the nomination shall do so in writing.

Section 3 ‑ Date of Election The annual election shall be held on the second Monday in November unless this is a federal holiday, in which case it shall be the following day.

Section 4 ‑ Official Ballot There shall be no other ballot than the official ballot as provided by the Secretary.

On each ballot shall be printed, in order chosen by lot, the names of the nominees for each office to be voted upon by the Society.

After the name of each nominee, as printed in the official ballot, shall be placed a square in which the voter shall mark a cross opposite the nominee for whom he/she wishes to vote. Each ballot will provide instructions for marking the ballot. Any ballot marked for more nominees for an office than there are places to be filled shall not be counted for any of the nominees for the office thus marked.

Section 5 ‑ Procedure of Voting and Counting Votes 5.1 The Secretary shall mail distribute one official ballot with instructions and official for return envelopes to each qualified voter not more than twenty‑one days or less than fourteen days prior to the election.

5.2 The Board of Directors shall establish reasonable procedures for preparation, dissemination, collection and counting of ballots.

5.3 No ballot other than the ballot originally mailed distributed shall be provided to any member except upon his/her application to the offices of the Society.

ARTICLE XI ‑ SECTIONS Section 1 ‑ Purpose and Formation Sections may be formed in the Society for the presentation, discussion, and study of subjects pertaining to the science and art of medicine or for such other purposes and in such manner as the Board of Directors may determine. New sections may be created or existing sections discontinued by the Board of Direc-

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tors. All acts and proceedings of the sections shall be subject to the approval of the Board of Directors.

Section 2 ‑ Officers of Sections Each section shall elect its own chairperson and secretary for a term of one year. Section officers shall serve no more than two consecutive terms. The officers of each section shall be responsible for the proper keeping of the records of the section meetings, and establishment of proper meeting dates.

Section 3 ‑ Funds of Sections A section shall not have the right or power to levy any dues or compulsory assessments on its members, but contributions may be made or received at any time that the members may elect, for any purpose not in conflict with these Bylaws. No section shall incur any expense to the Society without the consent of the Board of Directors.

Section 4 ‑ Attendance at Section Meetings Any member of the Society in good standing may attend any meeting of any section thereof. Any section may require, as a record of attendance, the signatures of all members attending its meetings. Any section may restrict the right to vote in its meetings and affairs on any basis of attendance, which it may determine, subject to the approval of the Board of Directors.

ARTICLE XII ‑ COMMITTEES Section 1 ‑ General 1.1 The Society shall have such standing and special committees as the Board of Directors shall approve subject to these Bylaws.

1.2 Unless specified otherwise in these Bylaws, the President shall appoint, with the approval of the Board of Directors, chairpersons and members of all committees. Vacancies shall be filled by the President with the approval of the Board of Directors.

1.3 Committees shall report orally or in writing to the Board of Directors unless otherwise expressly provided in these Bylaws.

Section 2 ‑ Peer Review Committees 2.1 Standing Peer Review Committees shall be composed of at least nine members, appointed to three‑year terms subject to confirmation by the Board of Directors at the end of the first year.

The President, with confirmation by the Board of Directors, shall appoint a chairperson, who must have served one prior term on the same committee.

2.2 Standing Peer Review Committees include, but are not limited to, committees to perform the following functions: (a) Professional Relations: To investigate, mediate or arbitrate, and otherwise seek to resolve issues or disputes between members of the medical profession and members of the public or other professions, or between members of the Society. (b) Third‑Party Mediation: To investigate and seek the resolution, upon written request, of all matters of dispute or controversy from patients, third‑party payors, or members in matters concerning prepaid care or benefits, and to investigate and seek the resolution of dispute or controversy upon the written request of patients, members, or government agencies responsible for the administration of government‑financed health care in any matter pertinent thereto related to quality or appropriateness of care, benefits, or administration.

Section 3 ‑ Bylaws Committee This committee shall be constituted on an as needed basis to consider or recommend amendments to these Bylaws., reviewing The Committee shall review the Bylaws at least every five years.

Section 4 ‑ Credentials Committee The Credentials Committee is composed of at least nine members, with three appointments each year, each appointment for a three‑year term. In addition to other duties specified in these Bylaws, this committee shall investigate the credentials, records, and qualifications of all applicants for all types of membership. It shall provide orientation and information for new members, and shall make its written recommendation thereon to the Board of Directors or Executive Committee.

Section 4 5 ‑ Nominations Committee The Nominations Committee shall consist of eleven members.

Eight members are to be elected by the general membership.

The term of office shall be two years, with four members elected each year at the annual election. The outgoing Immediate-Past President plus two members shall be elected by the Board of Directors from its membership for a one‑year term at the no later than the second Board meeting of the year. This committee shall elect its own chairperson. The Immediate-Past President shall serve as chairperson of this committee. A period of one year shall elapse before reelection to this committee.

Section 5 6 ‑ Editorial Board 56.1 The President, with the assistance of in consultation with the Editor, and the approval of the Board, shall appoint members of an Editorial Board, of which the Editor shall be chairperson.

5.2 The committee Editorial Board will be composed consist of at least three members, one appointed each year to a three‑year term. from eight to 15 members.

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5.3 The Editorial Board will act shall serve in an advisory capacity to the Editor of the bulletin and the Managing Editor. It will publish the Directory and other Society publications.

5.46.2 Policy of Society publications shall be consistent with Society policy as outlined by the Board of Directors and the Editor shall be assisted by the Editorial Board in carrying out such policy. The Editorial Board shall work with the Editor to ensure that all content of the SFMS publications meet with the policies, rules and regulations of the SFMS. 5.5 Any dispute as to the propriety or content of material intended for publication shall be resolved by the Editorial Board or at the request of the President or the Editor, the Executive Committee. Issues that, for any reason including expediency in the publishing process, cannot be resolved within the Editorial Board shall be referred by the Editor to the President and the Executive Director.

Section 67 ‑ Judicial Committee A Judicial Committee will be established as prescribed in the Bylaws of the California Medical Association and will consist of at least five members to include the President or President‑Elect, the Immediate past President, and three active members. Its function will be to discharge such responsibilities as the Bylaws of the California Medical Association may require. In the event that any member of the Judicial Committee for any reason cannot hear any matter coming before the Judicial Committee, the Board of Directors shall appoint another member to sit in the matter. No member of any peer review committee shall be a member of the Judicial Committee.

ARTICLE XIII ‑ FUNDS, DUES AND ASSESSMENTS Section 1 ‑ Annual Assessment of Dues 1.1 Funds shall be raised by annual per capita assessment of dues upon members of the Society.

1.2 Dues for all classes of members for the ensuing year, including any reductions or waivers of annual dues applicable to any category of members meeting specified criteria, shall be fixed by the Board of Directors each year. The total annual dues for members shall be due and payable on January 1 of each year and must be paid on or before the date fixed by the Board of Directors for the payment thereof or on or before the dates fixed by the Board for the payments of installments thereon.

Any member who becomes delinquent shall be notified by First Class Mail at the member’s last known address by the Treasurer that the member is no longer in good standing or entitled to the rights, privileges or benefits of membership in the Society.

The delinquency date for the Society dues shall not precede the California Medical Association delinquency date.

1.3 Any member presently in the armed forces on a temporary basis may have his/her annual dues reduced or waived by the Board of Directors at his/her request.

1.4 The Board of Directors shall have authority to fix at a lesser rate than the regular dues, the annual dues of members who are just beginning practice or members for whom full payment would constitute a hardship.

Section 2 ‑ Special Assessment Funds may be raised by special assessment, or in any other manner approved by a majority vote by mail, of members entitled to vote.

Section 3 ‑ Right, Title, or Interest in Society Property No person other than an active member in good standing shall have any right, title, or interest in the property of the Society and the interest of any active member therein shall cease when the active member ceases to be an active member in good standing of the Society.

If any active member shall resign or otherwise cease to be a member, all of his/her interest in and to all property and funds of the Society shall terminate, and such termination of membership shall operate as a release and assignment to the Society of all right, title, and interest of such member in and to all property and funds of the Society.

such question, matter, or proposition.

1.2 A referendum shall be directed by the Board of Directors at the first meeting thereof, following the filing with the Secretary of a written request therefore, signed by at least ten percent of the members of the Society entitled to vote.

Section 2 ‑ Procedure of Voting and Counting Votes The Board of Directors shall prescribe, fix, and determine the form of the question, matter, or proposition so referred to the voting members and the time within which such vote shall be cast.

The vote shall be by secret ballot. Each vote must be in writing and the same must be placed in a sealed envelope, enclosed in a sealed envelope bearing on the corner thereof the printed or typewritten name of the voter. The envelope shall be mailed or delivered to the Secretary’s office at Society headquarters.

The canvass thereof shall be made under the direction of the Board of Directors.

The Board of Directors shall establish reasonable procedures for preparation, dissemination, collection and counting of ballots.

Section 3 ‑ Recall The Board of Directors at any regular or special meeting may, by the affirmative vote of at least eighteen directors, remove any person elected pursuant to these Bylaws from office, provided that the action of the Board shall not take effect unless ratified by the vote of the members of the Society entitled to vote. The submission to the members for ratification shall be conducted as a referendum, and the provisions of Sections 1 and 2 of this Article (XV), insofar as applicable, shall govern. If a majority of the votes cast are in favor of sustaining the action of the Board, then, in such event, the removal from office shall immediately become effective.

ARTICLE XVI ‑ AMENDMENTS Section 1 ‑ Procedure 1.1 These Bylaws and any chapters or sections thereof or any part of any thereof may be amended or repealed or new Bylaws adopted by an affirmative vote of a majority of the members of the Society entitled to vote and voting thereon.

1.2 Any amendment or amendments, or the repeal of any chapter or chapters, section or sections thereof, or any part of any thereof, may be proposed by resolution of the Board of Directors adopted by the affirmative vote of not less than a majority of the members thereof, or may be proposed in writing, signed by not less than ten percent of the members of the Society entitled to vote, which written proposal shall be filed with the Secretary.

1.3 After the adoption of any such resolution by the Board of Directors, or the filing with the Secretary of such written proposal signed by at least ten percent of the members of the Society entitled to vote, providing for any such amendment or amendments, or the repeal of any chapter or chapters, or section or sections of these Bylaws or a part thereof, or for the adoption of any new Bylaw or Bylaws, the Board of Directors shall cause a summary of said proposed amendment or amendments or repeal, or any new Bylaw or Bylaws to be published in the official bulletin of the Society.

The proposed amendment or amendments, or repeal, or any new Bylaw or Bylaws, shall be submitted by mail ballot to the members of the Society entitled to vote, and if a majority of the votes cast are in favor of the adoption of any such amendment or amendments or new Bylaw or Bylaws or of such repeal, these Bylaws shall thereupon be amended accordingly.

ARTICLE XIV ‑ INCORPORATION Section 1 ‑ Incorporation of Society The Society shall have the power and authority, by vote of the active members, either by mail ballots or by written assents, to authorize, empower, and direct the Board of Directors to incorporate the Society as a California nonprofit corporation.

ARTICLE XV ‑ REFERENDUM AND RECALL Section 1 ‑ Referendum 1.1 The Board of Directors at any meeting thereof may, by a majority vote of all its members, submit by mail any question, matter or proposition to the members of the Society entitled to vote, and a majority of the votes cast by mail by the members of the Society entitled to vote shall be final and bind and govern the Society upon the question, matter, or proposition so submitted to the membership, provided, however, that no less than one‑third of the members entitled to vote, vote upon

october 2007 San Francisco Medicine

39

The Value of SFMS Membership in 2007 How many benefits did you take advantage of this year?

While the practice of medicine continues to change, we want to

remind you that one of the important benefits of San Francisco Medical Society membership hasn’t…the services of Marsh to help you with your insurance needs. For example, in the past year we have helped SFMS members: ◆ Obtain a $1,500 per month guaranteed issue disability insurance benefit ◆ Be eligible to make a $5,650 contribution to a health savings account ◆ Save 5% on medical insurance premiums (and even more with HDHPs) ◆ Obtain a $50,000 term life insurance benefit on a guaranteed issue basis ◆ Save 5% on Long Term Care insurance premiums ◆ Participate in a Dental Program Open Enrollment ◆ Receive a $20 deposit to help open their new health savings account ◆ Save significantly on their workers’ compensation premiums ◆ Protect their practice from employment liability claims

Can’t wait until ’08!

For more information* on the benefits available to you as a SFMS member, call a Client Service Representative at 800-842-3761 or e-mail CMACounty.Insurance@marsh.com.

Sponsored by:

Underwritten by: Hartford Life and Accident Insurance Company** – Term Life, LTD UMB Bank – Health Savings Accounts Blue Shield of California – Medical Insurance Metropolitan Life Insurance Company – Long Term Care John Hancock – Long Term Care Guardian Life Insurance Company of America – Dental Fireman’s Fund Insurance Company – Workers’ Compensation

Administered by:

* Including costs, exclusions, limitations and terms of coverage. **Hartford Life and Accident Insurance Company, Simsbury, CT 06089

© 2007 Seabury & Smith Insurance Program Management • CA License #0633005 • CMA1-721 • 9/07 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer Human Resource Consulting (including Mercer Health & Benefits, Mercer HR Services, Mercer Investment Consulting, and Mercer Global Investments), and Mercer specialty consulting businesses (including Mercer Management Consulting, Mercer Oliver Wyman, Mercer Delta Organizational Consulting, NERA Economic Consulting, and Lippincott Mercer).