October 2009

AN RANCISCO EDICINE S F M VOL.82 NO. October 2009 $5.00

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

The Next Generation of Medicine and sfms election information

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In This Issue

SAN FRANCISCO MEDICINE October 2009 Volume 82, Number 8 The Next Generation of Medicine and SFMS Election Information

FEATURE ARTICLES

10 Technology and the Future: Cost-Effective Medicine John Mongan, MD

12 Tomorrow’s Doctors: A British Perspective on Training for the Future Thomas M. Caparrotta 14 Becoming Real Doctors: Reflections from Medical School Eisha B. Zaid

MONTHLY COLUMNS

4 Membership Matters 7 President’s Message Charles J. Wibbelsman, MD

9 Editorial Mike Denney, MD, PhD 32 Hospital News

16 Entering Medicine Now: Realism and Hope Jennifer Carleton-Nathan

17 The Path to Medical School: Learning to Heal by Caring Isabella Nga Lai

19 The Path Away from Medical School: Biology 101 and Career Counseling Grace Lewellyn 20 Working Together: Turning Generational Differences into Strengths Janet Bickel SFMS ELECTION INFORMATION

22 2010 SFMS Election Slate and Candidate Biographies

Editorial and Advertising Offices

1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue

OF INTEREST

31 San Francisco Medical Society: Advocating for Physicians and Patients

Advertising information is available on our website, www.sfms.org, or can be sent upon request.

Printing: Sundance Press

34 Not So Sweet: Sugar Politics Versus Health Steve Heilig, MPH

www.sfms.org

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

October 2009 San Francisco Medicine 3

Membership Matters October 2009 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 82, Number 8 Editor Mike Denney

Managing Editor Amanda Denz Copy Editor Mary VanClay Editorial Board Chairman Mike Denney

Obituarist Nancy Thomson

Stephen Askin

Shieva Khayam-Bashi

Gordon Fung

Ricki Pollycove

Toni Brayer

Linda Hawes-Clever Erica Goode

Gretchen Gooding

Arthur Lyons

Terri Pickering

Stephen Walsh

SFMS Officers

President Charles J. Wibbelsman

President-Elect Michael Rokeach

Secretary George A. Fouras Treasurer Gary L. Chan Editor Mike Denney

Immediate Past President Steven H. Fugaro SFMS Executive Staff

Executive Director Mary Lou Licwinko

Director ofPublicHealth &Education Steve Heilig

Director of Administration Posi Lyon

Director of Membership Therese Porter

Director of Communications Amanda Denz

Board of Directors Term:

Jeffrey Newman

Andrew F. Calman

Michael H. Siu

Jan 2009-Dec 2010 Jeffery Beane

Lawrence Cheung Peter J. Curran

Thomas H. Lee

Richard A. Podolin Rodman S. Rogers Term:

Jan 2008-Dec 2010 Jennifer H. Do

Keith E. Loring

William A. Miller

Thomas J. Peitz

Daniel M. Raybin Term:

Jan 2007-Dec 2009 Brian T. Andrews Lucy S. Crain

Jane M. Hightower Donald C. Kitt Jordan Shlain Lily M. Tan

Shannon UdovicConstant

CMA Trustee Robert J. Margolin AMA Representatives

H. Hugh Vincent, Delegate

Robert J. Margolin, Alternate Delegate

New Ways to Pay Your Dues!

The 2010 dues statements have gone out. This year SFMS has added a new option: You may now elect to pay your dues via credit card installments. Details and an authorization form were included in your dues statements. It is easy, safe, and convenient.

As always, you may also use the online dues payment system on our website, or pay by check or credit card via U.S. mail or fax. If you have any questions, please contact the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Do We Have Your Correct Contact Information?

Don’t miss out on important information from SFMS and CMA! You can update your records online, or contact the Membership Department at (415) 561-0850 extension 268 or tporter@ sfms.org. There is also a card in the most recent edition of the SFMS Membership Directory that you can use throughout the year.

There has never been a more critical time for health care, and the San Francisco Medical Society wants to ensure that you have the information you need. Increasingly, we will be sending important information to you as quickly as possible through e-mail. If we don’t have your email address, please let us know (SFMS does not share its members’ e-mail addresses).

Also, be sure that you are getting important updates from CMA by visiting the members-only section of www. cmanet.org and signing up for electronic communications of interest and use to members.

Upcoming Event: Mixer for Residents and Young Physicians Residents and young physicians are invited to a mixer at the San Francisco Medical Society’s offices in the Presi-

4 San Francisco Medicine October 2009

dio of San Francisco. Enjoy appetizers and wine in a comfortable, informal atmosphere while connecting with your physician peers. Date in November TBA. Check www.sfms.org or contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org for more information.

Student Mixer a Success!

The SFMS-UCSF Student Mixer on September 24 was a great success. Members of the San Francisco Medical Society mingled with medical students from all four years to network and discuss the medical profession and its future. This annual event is one of the most popular and successful events that SFMS produces.

Many thanks to Epocrates for its gracious sponsorship.

Webinar Schedule

CMA offers a wide variety of webinars, both live and recorded, to help you address crucial health care issues and manage your practice. Registration is free for members and their staff. Space is limited, so register soon. Visit the CMA calendar for more information. Most webinars are available for on-demand playback shortly following the live presentations in the webinar archives at CMA’s members-only website.

For more information, contact: Shannon Navarra-Lujan at CMA at (800) 7864CMA or slujan@cmanet.org.

M e d i c a r e R e i m b u r s e m e n t Assistance

Palmetto is offering helpful webinars on Medicare reimbursement. Go to www. palmettogba.com/j1 and then click on Learning & Education in the tool bar for a choice of workshops, contractor teleconferences, and more.

www.sfms.org

An Exciting New Approach to Underserved and at-Risk Populations in the Bay Area Based on cutting-edge research in neuroscience, the Mind Body Awareness Project has developed an evidence-based mindfulness and emotional intelligence intervention to rehabilitate incarcerated youth that is now being scaled into a new national model and is concurrently being brought into medical contexts to treat adolescents who have been exposed to repeated trauma. An effective, low-cost, experiential intervention, it pays for itself many times over in later health costs avoided. Mind Body Awareness also conducts trainings in self-care, mindfulness, and emotional intelligence for caregivers and health care providers seeking practical tools for self-care, stress reduction, and the cultivation of emotional intelligence in their lives and in relationship to their patients.

You can learn more about the Mind Body Awareness Project’s work at www. mbaproject.org or by contacting Gabriel Kram, director of Consulting Services, at (415) 827-7084.

FTC Delays Enforcement of Red Flags Rule for Another Three Months

The Federal Trade Commission (FTC) recently announced it would again delay enforcement of its new Red Flags Rule, which requires “creditors”—including many physicians—to develop and implement identity theft detection and prevention programs. The new regulations are now scheduled to take effect on November 1, 2009.

For more information on the Red Flags Rule, see CMA’s Red Flags Rule toolkit and webinar, available free to members at the CMA members-only website and in the biweekly SFMS Membership Blast.

Contact Samantha Pellon at (916) 551-2872 or spellon@cmanet.org for more information. www.sfms.org

Membership Matters

2009 SFMS Seminar Schedule All SFMS Seminars require preregistration. Please contact Posi Lyon for more information, plyon@sfms.org or (415) 561-0850, extension 260.

“I was a member of the San Francisco Medical Society for almost fifty years until I retired, and always saw the organization as an important and often progressive voice in organized medicine on many crucial issues.”

—Philip R. Lee, MD, Chancellor Emeritus, UCSF, former United States Assistant Secretary of Health, and Chairman Emeritus, San Francisco Health Commission

November 17, 2009: “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing and personnel management.

This seminar teaches the core business elements of managing a practice that physicians don’t receive in medical school training.

9:00 AM – 5:00 PM (8:40 AM registration/continental breakfast); $250 for SFMS/CMA members and their staff ($225 each for additional attendees from same office); $325 for non-members.

“I have long been a proud San Francisco Medical Society member because the SFMS has been a staunch advocate and supporter of San Francisco General Hospital and public health in general— including pushing influential legislation such as partner testing, funding for AIDS care and prevention, the ban of tobacco at pharmacies, and more.”

—Mitch Katz, MD, San Francisco Director of Health

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President’s Message Charles J. Wibbelsman

The Next Generation

I

n this issue of our journal we gaze into the crystal ball of medicine, peering into the future through the eyes of many of our protégés, residents, and medical students who are making the very memorable transition we have all experienced, from the anatomy laboratory and microscope of pathology to walking into an exam room with a stethoscope.

For many of us, as physicians in clinical or academic practice, teaching medicine is very much a two-way dialogue. While we trust that we can impart some diagnostic clinical pearls to those whom we teach, we also learn the insight that a freshman medical student may have into medicine and the health care delivery system of the twenty-first century. Indeed, the intent that those of us may have had in our undergraduate years of pursuing a scientific profession that offered a position with compensation commensurate with a lifestyle with more than adequate financial security could rarely be the pursuit of those who are our next generation of physicians. Listening to our patients when we take a detailed history often leads us along the right track in making a differential diagnosis. Listening to our medical students and residents can help us understand what medicine in the future may be like. The tradition of wearing a tie and a long white coat with a stethoscope in one pocket while working in a predominately white, male profession is now being eclipsed by the current reality of a diverse group of physicians of all ethnicities and both sexes carrying a Blackberry and an iPhone.

So many times when making a presentation at a grand rounds, when the LCD projector isn’t picking up the signal from the computer that’s holding the flash drive or CD that we have so carefully prepared, and the audience is anxiously awaiting the beginning of our soliloquy, it is the medical student or a resident who comes up, presses some keys or changes a connection and, voilà, the presentation begins. In this next generation of providers are the “techies” who will practice medicine in a very efficient and technical manner. Long gone will be the physician’s scribble that neither patient nor pharmacist is able to decipher.

As president of the San Francisco Medical Society this year, I am honored to have the opportunity to be a player in the major role that our Medical Society will be playing in the San Francisco www.sfms.org

Health Information Exchange (SFHIEX), an effort to coordinate the exchange of electronic medical information among physicians and health care delivery systems at both city and county levels. Indeed, the HIT (Health Information Technology) federal stimulus monies that will be channeled to physicians in California to initiate automated medical records will be a major factor as we transition to the next generation of medicine, again using more technology and instrumentation in our practices.

When one looks at the present generation of medicine and how we practice and have practiced for so many years, we can see a degree of reluctance among some of our fellow physicians to move forward into this new era of high technology. I can personally recall speaking to a colleague of mine, a pediatrician in a large-group multispecialty practice in the midwest, who informed me that a few of his colleagues chose to take early retirement rather than face the challenges of learning to navigate an automated medical record or of even learning to type with more than one finger!

I am delighted that in this issue we can learn and listen to our next generation of physicians, who are already starting to teach us.

October 2009 San Francisco Medicine 7

Strength.

Mark R. Laret, CEO of UCSF Medical Center, Steve McDermott, CEO of Hill Physicians Medical Group, Dr. Sam Hawgood, President of UCSF Medical Group and Interim Dean of UCSF School of Medicine, and Dr. Thomas F. Long, Chief Medical Officer of Hill Physicians Medical Group announce a new affiliation between UCSF and Hill Physicians.

The doctors of UCSF are joining Hill Physicians Medical Group effective January 1, 2010. One of the nation’s best medical centers and one of the nation’s largest physician association are coming together to improve the future of health care in San Francisco.

Independence and strength are not mutually exclusive. Hill Physicians’ providers enjoy autonomy and flexibility while receiving exceptional technological, case management, preventive care and claims processing support. That’s why so many of the best join Hill Physicians.

Your health. It’s our mission.

If you’re a physician in San Francisco, South San Francisco or Daly City and want to know more about joining Hill Physicians, contact: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com or visit www.HillPhysicians.com/Providers.

Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.

Editorial Mike Denney, MD, PhD

Generation Next

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oday, physicians who are retired or approaching the age of retirement belong to a generation of individuals who were born between 1923 and 1943, and who became known as the Silent Generation. Aside from Martin Luther King Jr., Gloria Steinem, Elvis, the Beatles, and the Rolling Stones, it is theorized that most members of this generation were recovering from the great depression and WWII and were busy working hard and tending their lives rather than becoming political activists.

Next came the Baby Boom Generation, people born during the huge post-WWII rise in birth rates between approximately 1944 and 1964. The oldest of these baby boomers are characterized as having become involved in the counterculture of the ’60s, and all of whom seem deeply committed to gender and racial equality and the environment.

Members of Generation X were born in the years after the end of the Vietnam war, approximately 1965 to 1980. The highly educated yet sometimes cynical people of this generation experienced punk rock, the rise of videogames, computers, MTV, and the beginnings of hip hop. They have ambiguous and contradictory attitudes and they are determined not to let the “decadent” baby boomers dictate their values. According to one source, they are committed to “doing the quiet work of keeping America from sucking.”

Generation Y is composed of approximately 60 million people who were born around 1980 to the early 1990s. They are also known as the “Peter Pan” generation because many of them tend to delay adulthood and career, not becoming independent until after the age of 30. These individuals, now between 17 and 39 years of age, have come to be characterized by communication through the Internet, e-mail, texting, and instant messages, not to mention Facebook, MySpace, and Twitter.

Of course, in these various generations certain individuals became or aspired to be physicians, and it is interesting to reflect upon the developments in medicine during each timespan. The Silent Generation witnessed the development of antibiotics, blood transfusion, the Salk vaccine, and the birth control pill. The Baby Boomers experienced the introduction of antiviral medications, beta blockers, and antidepressants, as well as the first organ transplants. Generation X participated in the realization of the AIDS epidemic and treatments such as in vitro fertilization www.sfms.org

and endoscopic surgery, while Generation Y was characterized by the mapping of the human genome, nanotechnology, robot surgery, stem cell research, and fMRI studies of the brain.

In this issue of San Francisco Medicine, we hear from some members of Generation Y as they look forward to careers in medicine. John Mongan, MD, now beginning his radiology residency at UCSF, writes about the application of our rapidly changing technology toward the advanced treatment of large numbers of patients. Thomas Caparrotta, a British fourth-year medical student, is interested in the delivery of health care and believes in a system that provides equal care for all. Eisha Zaid is a third-year medical student at UCSF and speaks about being inspired by her professors to provide the best and most humane care for patients. Jennifer Carleton-Nathan, currently applying to medical schools, including UCSF, recalls an article in the New York Times that described health care as being “in moral distress,” and she aspires to be instrumental in the care of large numbers of patients through advanced technology. Isabella Nga Lai, with a degree in neurobiology from Harvard and currently working in ophthalmology research, is interested in diverse populations and is applying to medical school.

There is one more generation beginning to form. It is Generation Z, beginning with people born around the middle 1990s to the present. And we have one representative from that generation, Grace Lewellyn, currently a first-year student at Berkeley Community College, who recounts her experience in a biology class in which students were required to prick their fingers and then demonstrate their own blood type. After nearly fainting at the sight of blood, she decided that there were other ways to heal besides practicing medicine, and she is pursuing her interests in community and global health care issues, including the ecological crisis of Planet Earth. Grace’s Generation Z is sometimes referred to as Generation Next.

October 2009 San Francisco Medicine 9

The Next Generation of Medicine

Technology and the Future Cost-Effective Medicine

John Mongan, MD

I

am two months into residency, immersed in radiology. Though it sounds cliché, I had planned a career in medicine for most of my life, so going to medical school was more of a progression than a difficult choice. Choosing a specialty, on the other hand, was difficult; my lifelong plans provided me no guidance here. Ultimately, I was attracted to radiology by the proportion of time one is able to spend doing medical work, the ability to be involved in the diagnosis and care of a large number of patients each day, and the opportunity to work with rapidly changing technology.

Starting radiology can be somewhat difficult psychologically. While my peers are now building on their specialty knowledge and skill by taking on leadership roles with teams of interns and medical students, I have exchanged the hard-fought level of at least minimal competency as a physician, which I had achieved by the end of internship, for a new field where my level of knowledge relative to competent practice is essentially zero. This phenomenon, and the mild dysthymia that often accompanies it, is apparently well known in radiology (and described in a publication given to us by one of our attendings, no less). Having been warned about it makes it more tolerable, but it remains uncomfortable. Since the primary role of the radiologist is as a consultant, it can be particularly awkward when I’m asked to “advise” physicians with far more experience than I currently have. I am forever indebted to the attending pulmonologists, many with decades of experience reading chest X-rays, who sat patiently through the ICU radiology conferences I led during my first month,

sometimes politely asking, “Does this Xray maybe show . . . ?” When I reach their level of seniority, I hope I will be as gentle with new trainees.

As I enter the world of radiology, I begin to see some things from a radiologist’s perspective. During my radiology rotations in medical school and at radiology rounds during internship, I had often heard radiologists complain about being given inadequate patient histories.

Now I experience the frustration of trying to put a study into an appropriate clinical context with a one-word history.

I have also seen how subtle findings can become obvious when interpretation is guided by appropriate history, and how the same findings may have completely different interpretation and significance in the setting of different patient histories.

At the same time, I remember the timeconsuming irritation of attempting to concisely summarize a patient’s history in a tiny box on a request form when there are hundreds of other things that need to be done, and I recognize that my own histories were not always models of completeness. Additionally, I’ve realized that it is often not clear to the requesting physician which parts of the history are most relevant, and that it may not even be clear to the radiologist until he or she has seen the images.

This is a conflict I think may soon be solved by technology. Widespread adoption of electronic medical records has at least made patients’ records accessible from the reading room. While this is a great improvement, the delay involved in bringing up each patient’s record generally doesn’t fit well with a busy work flow, so examination of the

10 San Francisco Medicine october 11 San Francisco Medicine October 2009 2009

record is usually limited to complicated cases. Better integration between PACS and electronic medical records would make the electronic record available without disrupting work flow. An ideal system would automatically bring up a summary view of each patient’s electronic medical record alongside their imaging as it is loaded on PACS. The technology for this exists today, but implementation will require coordination between vendors of PACS and electronic medical records.

Such cooperation probably won’t happen rapidly, but when it does I anticipate that it will significantly improve the usefulness of radiology reports, while reducing the number that “recommend clinical correlation.”

The advent of digital radiology and PACS has transformed the practice of radiology and, as with most transformations, there have been unforeseen consequences. One of these is that both images and reports are readily available to clinicians without direct interaction with the radiology department. The natural consequence of this is less contact between radiologists and clinicians requesting studies. This is carried to an extreme by teleradiology companies such as Nighthawk, where studies may be read thousands of miles away, perhaps on a different continent. While these services certainly have their place, I hope that they remain the exception rather than the rule.

I don’t think that patients, clinicians, or radiologists would be well served by radiology becoming a black box where requests go in and reports come out. I think there is value in the improved communication engendered by professional relationships between radiologists and the clinicians www.sfms.org www.sfms.org

they work with. I believe that the onus is on non-teleradiologists to foster these relationships to illustrate that there is added value to local radiology, and this is one of my goals as a new radiologist.

One of the central tenets of medicine is “First, do no harm.” Anyone who has practiced medicine for any period of time recognizes that nearly everything we do carries some risk of harm. In reality, then, we must be sure that the benefit to the patient of each thing that we do outweighs the harm. The oldest and most central tool of radiology, the X-ray, is unfortunately inarguably harmful. Advances of technology have reduced the radiation required for traditional “plain film” studies but have had the opposite effect for CT scans: the increasingly beautiful and useful images from modern multidetector scanners come at a price of increasing radiation dose for patients. As the radiation dose of a single study has increased, so too have the number of studies a single patient is likely to have, since they are faster, less expensive, and more diagnostically useful. In the worst cases (generally chest CTs of young women), some estimates suggest that the additional lifetime risk of cancer from a single study may approach 1 percent. I share the growing concern that as patients’ radiation doses increase, we may sometimes be doing more harm than good; I have recently heard CT scanners described as “the asbestos of the twenty-first century.” I expect that in the coming years good clinicians will be more hesitant to request (and good radiologists more careful in approving) CT scans, especially in young patients where the risk is greatest. I believe there will be increasing use of less inherently harmful modalities such as ultrasound and MR, with CT reserved for situations where the diagnostic benefit to the patient clearly outweighs the risk of the radiation.

From a broader perspective, I think the single most important problem facing medicine as a whole is access to care, and that the central issue of this problem is cost. As I write this, news of a health care crisis and attempts at federal reform dominate the headlines, and it remains unclear how this round www.sfms.org

of efforts will turn out. This is a complex problem, and clearly there are multiple factors that affect the cost of health care.

In my opinion, the greatest contributor to increasing cost is the continual advance and improvement of health care. Many of our greatest successes in medicine are among our primary drivers of cost: Newer, more effective techniques are generally more expensive, as is management of previously lethal conditions such as long-term chronic diseases. Closer to home, I acknowledge that the advances in imaging technology that in part drew me to radiology are a significant contributor to increasing costs. Recognition of technology as a source of cost is important because our ability to innovate in medicine seems to be unlimited, and thus the potential for increase in cost is unlimited.

Meanwhile, the resources available to pay for health care are obviously not unlimited. It seems to me that eliminating waste, tort reform, improved medical records, and other changes that may provide some percentage reduction in costs are at best temporizing measures if they do not address the gap that is opening between the care that could be provided with full use of every available technology and the care that can be provided with the resources that are available. This is an emotionally, ethically, and morally fraught area; particularly so for physicians, because many of us come from a perspective that any limitation on care that might extend or improve a patient’s life is unethical.

Unfortunately, the logical consequence of health care without limit for those with access is what we see today: an ongoing rise in the cost of insurance and decline in the percentage of people with access. Because of this, I think that an increased focus on cost effectiveness, as well as medical effectiveness, of new and current techniques is inevitable. I have heard physicians express the feeling that consideration of cost effectiveness is inappropriate for our profession, and I understand the potential for a slippery slope. I am convinced, though, that this is something that will happen with or without the active participation of the

medical community, and that it will be the greatest single factor affecting my career and the practice of medicine in my lifetime. As such, I feel that it would be an abdication of responsibility to my patients and my profession to avoid engaging in this discussion, and I hope I will not be alone in this conviction.

John Mongan, a Sausalito native, recently returned to the Bay Area after completing an MD/PhD program at U.C. San Diego. After internship in internal medicine at Kaiser Oakland, he is now studying radiology at UCSF. He lives in San Francisco with his wife, Ann.

October 2009 San Francisco Medicine 11

The Next Generation of Medicine

Tomorrow’s Doctors A British Perspective on Training for the Future

Thomas M. Caparrotta

I

decided to become a doctor while crossing Charing Cross pedestrian bridge in London. As we walked, a casual confession to a friend that I’d been mulling the prospect of training in medicine made him exclaim, “Go for it.”

The rest, as they say, is history.

As a graduate into medicine, my route to training was unusual by British standards. Unlike North America, medical degrees in Great Britain are generally pursued by school leavers undertaking five or six years of training; only since the turn of the century have some universities been offering accelerated, funded, fouryear courses for graduates—part of the government drive to widen participation in the medical profession.

And here I am in Swansea, Wales, studying medicine on a graduate course that opened its doors to students in September 2004. Wales, the mother country of the National Health Service (NHS), the vast, staggering, inconceivably expensive beast that is the socialized health care system of the United Kingdom; a holy cow beloved by the British public that offers universal health care to all, free at the point of use and in whose bowels the training of doctors, nurses, and the allied health care professions takes place. A service that, still to this day, is flexible and open-minded enough to fund complementary medicine and cater to the diverse health needs and beliefs of 60 million people.

From the day I set foot in the University’s lecture theater, I realized that the unpredictable nature of the morrow of medicine and society as we know it would make me repeatedly reflect on how I would best be able to serve patients and

their needs in this intractable, meandering stream of change. “Beware,” they said on our first day, as we sat wide-eyed at the bottom of what seemed like an impossibly daunting mountain of medical training.

“Some of what we teach you today will not be what you practice; it will have changed by then.”

The NHS came kicking and screaming into existence during the summer of 1948 as part of a wider agenda on a welfare state to nurse a Britain ravaged by war. Following bitter opposition from the medical community (indeed, the British Medical Association had fought tooth and nail to derail the project), the NHS finally ceased to be only a dream. Aneurin “Nye” Bevan, the Member of Parliament for Ebbw Valley in the Welsh mountains, had lovingly steered the NHS Act through Parliament and finally brought the recalcitrant doctors around by, as he is famously quoted, “stuffing their mouths with gold.”

Be that as it may, sixty years on the Health Service has survived—despite being subjected to the whims of political fancy, to restructuring and reorganization, to the establishment of the internal market, and to devolution of responsibility over health to the constituent nations of the United Kingdom—in a form that still fulfills its founding principles. Professor Williams, our dean of medicine, recently retorted at a careers fair, with stern purpose to his voice, “The NHS was born in the Welsh Valleys, and if it is to die, it is in Wales it will make its last stand”—a good reason I thought to continue working in Wales.

What does the future hold for me and my colleagues? For the future of health care? And the future of the NHS in the U.K.?

13 San Francisco Medicine October 2009 2009 12 San Francisco Medicine october

I have to consider first that cornerstone of medicine, the relationship between doctor and patient. It was Nicholas Jewson, the medical sociologist, who mapped the fluxing relationship between doctor and patient from the bedside in the bedroom, through the hospital, to the laboratory, and now, one imagines, to some scanner or another. Musing on this journey, it seemed to me inevitable that the great schism between body and mind, which widened through the nineteenth and twentieth centuries, should have happened and now come full circle to a reunification of these two, the patient as a whole again. Though perhaps this time we understand that cytokines, hormones, and neurones, to name but a few, connect our various parts into us humans. But to me, certainly, it feels that the sum of these parts is far greater than the elements that make them—for we are more than just a bag of chemicals: We love, we inspire, we think, we create, we become doctors and patients. Not just beings reduced to symptoms demanding treatment. After all, it wasn’t only science that made me choose medicine.

There are, to be sure, vast challenges around the corner for us doctors-to-be, but great successes also. The health problems that our generation will come faceto-face with will indeed be different to those encountered by our predecessors.

(Our increasing life span, girth, and sheer number to name but a few.) However, in my lifetime I also hope behold the control of cancer, the eradication of flu, and the creation of “artificial” blood along with developments that, frankly, seem inconceivable by today’s standards. Britain in particular is going to have to grapple www.sfms.org www.sfms.org

with the increasing financial burden of health care on the public finances, in particular the gargantuan cost required for the research and development of new drugs and the price of new technology along with the increasing expectations of patients. We will have to have a healthy debate about how this fits into the current modus operandi. Not to mention how to deal with that bête noire of government, that much maligned term—health care rationing!—that surely will have to happen worldwide if we are not to spend all our money on health provision and consequently lead medicine by the purse strings to become a victim of its own success.

If I were a betting man, which I am not despite being British, my money would be on the future of medicine being increasingly steeped in genetics and in particular pharmacogenetics. I would conjecture that in years to come, our practice will be informed more by our patients’ DNA blueprint than by the environmental causes of disease, as treatments become tailored to each of our specific makeups. I foresee an already emergent new epoch of medico-legal ethics regard-

ing how this personal genetic information is managed, stored, and communicated, which will be hotly debated over many a dinner table for a good time to come, before giving rise to a shift of paradigm to a world where our genes are stored and accessed in a specific but still to be determined fashion. I suspect that we, as practitioners, will be burdened by an overabundance of biomedical research at our fingertips while being at an uneasy loss as to what to do with it. But it will have to be the public who decide how we move forward into this conjectured new era of medicine. After all, this is an essential political question, not a question to be answered by those involved in health care—those likely to be intimately administering these new ideas.

And what of the NHS—will it still be around in its current form in sixty years to come? Sadly, my crystal ball won’t tell me, but I hope that health care for everyone will remain, regardless of ability to pay; I can’t conceive of the British public allowing otherwise. Whether that means introducing private finance and insurance into the equation, completely reinventing the NHS, or allowing it to continue in

its current form, I shan’t speculate. But I imagine it will be decided in a bloody battle of political wills—with the Welsh, most certainly, wielding their axe at the center of the debate.

The future as a trainee doctor remains one of the most exciting I can imagine, notwithstanding everything it holds, and after all the millennia since the Hippocratic Oath was first uttered, its edicts governing physicians remain ostensibly the same. It equips us to adapt to the changes of the past and will no doubt allow us to do so with those of the future, even when, as doctors and medical students alike, we come into conflict over the avenue that the future of our profession is taking.

Thomas M. Caparrotta, B.Sc. (Hons.), is a penultimate year medical student on the graduate-entry program at the Welsh College of Medicine. He undertook his first degree in Biology at the University of Leeds, graduating with upper-second class honours, and subsequently worked for the Department of Medical Education at St. James’s University Hospital, Leeds, prior to commencing his medical studies.

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October 2009 San Francisco Medicine 13

The Next Generation of Medicine

Becoming Real Doctors Reflections from Medical School

Eisha B. Zaid

H

ello, Mr. Smith. I have a medical student with me. Would it be all right if she comes in with me during your visit?” my preceptor asked a patient during homeless clinic.

“Is she a doctor yet?” the patient asked.

“She’s a doctor-in-training,” my preceptor responded.

“No, she can’t come in. She’s not a doctor yet,” said the patient.

Mr. Smith’s statement has remained ingrained in my mind. His words capture a certain truth about the third year of medical school—you are present, but invisible at the same time. We are merely students, who lack the experience and knowledge to make critical decisions. We never know what to say or how be efficient with our words. We stumble through our longwinded presentations (we have yet to understand the “pertinent positives or negatives”), talk too fast, ask too many questions, and get lost easily.

We are charged with taking care of patients, but we do not yet know how to manage our patients. Despite our shortcomings, we have to start somewhere.

How else do we learn to become doctors?

Third year is all about firsts, starting with our first patients.

We are surrounded by long white coats. We are members of large teams that march around the hospital. Despite being part of this team, we can’t help but feel alone. We stand out in our short, overstuffed white coats. ***** The third year is an interesting time.

One of our professors presented the third year as an opportunity for either great success or paramount failure. In many

ways, the third year sets the trajectory of our professional lives, especially for the students who have not yet differentiated into a particular type of physician (I include myself in this pluripotent group).

Through a series of six- to eight-week rotations, we migrate like nomads from one discipline to another, getting a small taste of each field and its culture. We get to be internists, family physicians, general surgeons, pediatricians, neurologists, psychiatrists, and obstetricians. And at the end of the third year we are expected to differentiate into a specific type of doctor and make a decision about which field we plan to join. The third year is a time of experimentation and immense learning. ***** Generations of doctors started out just like us. They stuttered through the patent interview, fumbled through the physical exam, presented excessively verbose presentations, and ran to keep pace with the team during rounds. We share the same roots in our education. And yet a large chasm separates the student from the educator during the clinical years.

You interact with many inspirational and dedicated physicians, who represent the physician you hope to become one day. They develop patient rapport, demonstrate excellent bedside manner, and take the time to teach students. But you also see other types of physicians. And you remember those physicians, who are jaded and apathetic, making little effort to relate to the patients or the students.

It is always interesting to see how far removed some attending and resident physicians are from students. They simply forget those four years of medical school they spent learning to become a doctor.

15 San Francisco Medicine October 2009 2009 14 San Francisco Medicine october

The same attending or resident, who was a student not so long ago, forgets this when he ignores the medical student, or when he scowls at the new student for not knowing the answer to a question.

The culture of “pimping,” which involves the physician asking students specific questions, emerges as the new mode of teaching during the clinical years.

Oftentimes you lack the right answer and find yourself searching for any words to redeem yourself. It may be better to rename “pimping” to “reading the attending’s mind.”

I have been told by many physicians that with time and practice, the student evolves into the physician. We start by managing our first patients. Otherwise, we would never learn the art of medicine. You have to feel a certain number of abdomens to truly appreciate a soft and nontender abdomen. You have to suture enough incisions before you can approximate the edges perfectly. You need to hear a patient report the same constellation of symptoms over and over again to get better at making a diagnosis.

The more you see and hear, the better you get at differentiating normal from pathologic. You start recognizing patterns as you build on the knowledge you accrued during your preclinical years. And with time, the diagnosis will no longer be just a process of elimination. The diagnosis will come naturally. ***** “You should know everything about your patients, including their favorite colors.”

These were the words from the attending during the first week of inpatient medicine. When I look back to medicine www.sfms.org www.sfms.org

rotation, I remember my patients and their favorite colors—gold, white, yellow, purple, blue, red, orange, gray, black, brown, and pink.

As I look back over the last few months spent on the wards, in community clinics and in the operating room, I am beginning to learn how our third year experiences are so variable, dictated by location and the people we encounter during our rotations. The physicians and residents you work with will determine which patients you see and which diseases you learn about first-hand, as well as what type of teaching you will receive (that is, if you receive any form of teaching at all), along with your final grade.

Third year is about learning. But how do you balance learning with the pressure of being evaluated based on your performance and fund of knowledge? It’s almost like you’re always on a stage, being watched. And the feedback overflows. Constantly being told how you can improve definitely chips away at your sense of security—or makes you more insensitive to any type of feedback.

One thing is for sure: There is no way to prepare for the third year. Presumably the preclinical years give you a foundation to begin diagnosing disease. But humans are more complicated and follow no textbook presentation.

You walk through your third year feeling unprepared, not quite fully grasping the expectations or the full clinical picture of your patient, who has multiple medical and social issues.

There is no way to standardize the third-year medical student experience and education. And perhaps the beauty of third year stems from this very unpredictability. Being a successful third year comes down to one simple rule that has been repeated to me by nearly every attending and resident irrespective of the field: Read and know everything about your patient. But how realistic is such a goal?

No one can prepare you for the first time your patient asks you to help them die, or when the frustrated surgeon screams at you, or when a mother refuses to vaccinate her infant, or when you dewww.sfms.org

liver bad news to your patient with endstage lung cancer, or when your patient looks to you as his doctor. ***** The process of becoming a doctor is a unique experience. More than anything, it is a humbling experience, as you meet patients and families in their times of need, learning the intimate details about your patients’ lives. Some patients open up to you, while others refuse to speak with you. You come to terms with your limitations—the holes in your knowledge base, your lack of experience, and your emotional limits. In many ways, you are like a sponge; you absorb so much information and data. But you lack the time and ability to process what it all means.

You are completely immersed in medicine and sometimes out of touch with your reality, with friends and family.

Despite the inherent challenges of the clinical years, students are privileged to be working directly with patients.

In truth, memories of my patients stay with me; my patients have been the best teachers. In managing their diseases and learning about their lives, I have learned far more than any lecture, physician, or textbook could teach.

From day one, I knew my focus would always be delivering the best care to my patients. At times, I relate more to my patients than to the long white coat I am supposed to become, especially when my patient turns to me for guidance in medical decisions, addressing me as his or her doctor. These small moments of triumph carry me afloat during the tumultuous waves of third year and remind me that we are destined to one day outgrow our short white coats and become real doctors.

Eisha Zaid is a third-year medical student at the University of California, San Francisco.

Welcome New Members!

The San Francisco Medical Society would like to welcome the following new members: Sunny Cheung, MD Referred by Lawrence Cheung, MD David Duong, MD Ryan Farley, MD

Sarah Glavin, MD

Alisha Laborico, MD Jin Lee, MD

Brian Lin, MD

Arieh Rosenbaum, MD Referred by Peter Sullivan, MD Mai-Sie Chan, MD

Man-Kit Leung, MD Referred by Dexter Louie, MD House Officers Rashid E. Panahi (TPMG)

Bao G. Tran (UCSF/SFGH) UCSF Students

Abigail R. Burns

Anna C. Loeb

Larkin Elderon

Justin G. Meyerowitz

Sai-Wing Chan

Amaranta D. Craig Melissa Esparza

Nicole G. Gomez Kathy Hamlin

Noah Hawthorne Alexandra M. Jen Vivian Jiang

Angeline M. Jocson Sirina R. Keesara Kasra Khatibi

Zachary C. Landman Robert Lerrigo

Mala C. Mandyam

Amanda R. Mason Rebecca K. Miller

Paul A. Mittermiller George Ortiz Mary Qiu

Shawn S. Richardson Leslie Sheu

Jennifer A. Stella Vivien K. Sun Amy R. Tao

David Tseng

Wilbur Wang

October 2009 San Francisco Medicine 15

The Next Generation of Medicine

Entering Medicine Now Realism and Hope

Jennifer Carleton-Nathan

D

on’t become a doctor,” said the pediatrician in the emergency department where I was volunteering, “you’ll be paper-pushing for the rest of your life.”

This was not the first word of discouragement I had heard when I announced my intentions to become a physician. I have been treated with horror stories of malpractice suits, reminders that I would have to take the MCAT, the long hours, and of course the fact that I would be in training for the next decade. Even an admissions officer at an information session I attended warned us to think long and hard before applying.

Yet my decision to become a physician had been cemented before this warning. As a “nontraditional” applicant, I had extensively researched the frustrations of the profession. Besides a thorough scouring of blogs, articles, and books documenting real-life accounts of the physician experience, I had also reached out to family friends, to my own doctors, and had contacted and met a few from my University of Chicago alumni network to interview them on their chosen profession. Deep down, I had always known I wanted to be a doctor.

In a way, my research was asking, “What precisely have I decided to get myself into?”

After two years of working in public policy research, I entered a postbaccalaureate pre-med program at Columbia, while working part-time doing clinical research.

When I encountered some red tape as a research coordinator at the hospital where I work, my physician supervisor told me it was good practice for the years to come when I would be “haggling with insurance companies every day” to give my patients the care that they need.

So why do my colleagues and I not heed these warnings and run for the hills?

As one fellow postbaccalaureate student put it, “In any job, you are going to be doing paper-pushing, and you’re not going to like a lot of what you do. Being in the working world taught me that. What matters is the principle behind what you do.”

The number of “nontraditional” applicants who may hold similarly realistic views of what they will encounter in their careers has expanded significantly. The Association of American Medical Colleges reported that in 2008, approximately 40 percent of medical school matriculants were between the ages of twenty-three and twenty-five, meaning that they had taken time off before applying. The greatest factor cited in the decision to enter the field was health-related work experience.

Furthermore, even though the negative images of medical practice that I was bombarded with appear to swirl around in people’s heads, the number of medical school applicants continues to increase every year. Over half a million people applied to U.S. medical schools in 2008. And the competition for these slots is cutthroat.

Unlike many other graduate programs, medical school requires at least four prerequisite courses, a five-hour exam focusing on much of what was learned in those courses, individual essays and interviews for each prospective school, as well as a full yearlong application process.

Beyond being more realistic about the field I am entering, I have also approached each aspect of the application process with a different perspective than I would have had as an undergraduate. Pre-med studies had been described to me by one physician-acquaintance as “something you

16 San Francisco Medicine october 2009

just have to slog through.” But having quit my previous job and put it all on the line for medicine, I approached it with a sense of urgency and enthusiasm. I discovered that the process was teaching me a new way of thinking.

The pre-med classes taught me to think like a physicist, a biologist, and a chemist. Then I hope that the process of studying for the MCATs taught me to begin to think like a physician. The test contains four sections; physical sciences, verbal reasoning, two writing essays, and a biology and organic chemistry section. In the science sections, one is presented with new material and then asked questions about it where one must decide whether to apply what you know or to use information presented in the passage, or both. It is this lightning-fast decision that mirrors clinical practice.

Every patient is a unique case, never replicating textbook examples. You must apply to this patient what you already know and yet be flexible enough to see in front of you what you do not yet understand. In the MCAT verbal section there is a passage, lacking an introduction, conclusion, and transitional sentences, where an author discusses an obscure topic and the examinee must diagnose what they are saying. Even if a patient is rambling on about something, the physician must stay alert, looking for clues and listening deeply in order to understand the whole picture of what is being presented. In this sixty-minute section, one is blasted with one passage after another, practicing deep listening under time pressure. The entire examination seems carefully crafted to test analytic skills under pressure, a mental

Continued on page 18 . . . www.sfms.org

The Next Generation of Medicine

The Path to Medical School Learning to Heal by Caring

Isabella Nga Lai

B

radley! Please stop that!” I pleaded. Not bothered by the red blood trickling down his face, Bradley hit his head repeatedly against the wall.

This was the first time Bradley threw a tantrum, and I did not know what to do. During one summer in high school, I worked at a vocational center for the mentally disabled, where I took care of Bradley. Due to his severe autism, Bradley liked secluding himself and settling in his usual pattern of rocking in his chair and playing with his string. If something disrupted his daily routine, scaring him, he would throw tantrums. His personal caretaker told me Bradley could not show any emotions besides anger and indifference.

At first, Bradley did not like me invading his personal space. However, as he became used to my daily visits, he allowed me to sit next to him. I taught him how to build blocks and shred newspaper. One day I sang “The Itsy, Bitsy Spider” and tried to teach him the hand motions. He laughed. Bradley, who never smiled, was laughing! As Bradley got used to seeing me, he put away his mask of indifference around me. Whenever he saw me, he would grab my hand and make me sit next to him. After my many visits, I became his trusted friend and one of the few people who could ease his tantrums. Whenever he became agitated, I would softly say, “Calm down. No one will hurt you.” Hearing my voice, he would turn to look at me with his deep brown eyes and offer me his treasured string to demonstrate his trust in me.

I was deeply touched that my genuine care for Bradley made such a significant impact on his life. This experience inspired my becoming a counselor for www.sfms.org

Camp Footprints, a camp for children with mental and physical disabilities. At the camp, I cared for many children with Fetal Alcohol Syndrome (FAS) and observed their daily struggles to overcome disabilities ranging from visual problems to heart abnormalities. I saw that their neurodevelopmental problems stunted their abilities and caused their frustrations. I saw children throwing tantrums because they could not understand the lesson, and others sitting in wheelchairs and wistfully longing to run around and play like the rest. I sympathized with their physical pain and empathized with their psychological pain. Though I wanted to do more, I realized my capacity to help them was only as a friend; for that reason, I began aspiring to higher education so that I could provide care to vulnerable individuals.

Through these experiences, I became fascinated with neurological development and human physiology, and I chose to study neurobiology in college. I believed my knowledge would enable me to help children with mental and physical disabilities. Inspired by the scientific advances I learned about in class and by the importance of research, I joined a research project in Dr. John Dowling’s laboratory, analyzing how ophthalmological tools can lead to early identification of Fetal Alcohol Syndrome (FAS). I was drawn to this project because the study of the visual system captivated my academic curiosity; moreover, I strongly believed that my research informed patients and physicians about diagnostic benefits and ultimately contributed to ensuring that FAS children receive timely care to improve their quality of life. Though scientific research

greatly interested me, I also wanted to see the significance of my research and the benefits of providing information about diseases in people’s daily lives.

For that reason, I got involved in promoting healthy practices and teaching about the spread of diseases. I was fortunate to be awarded a fellowship to lead a seminar abroad at the Harvard Summit for Young Leaders of China. In this seminar, I taught adolescents about safe sex practices, the severity of the HIV epidemic, the available cures, and how to prevent the spread of this infection. My experiences in China further cemented my fascination with human health and my desire to play a role in public health.

Through the mentorship of Dr. Jonathan Matsui and Amie Shei, I completed my joint neurobiology and health policy senior thesis. My thesis work familiarized me with scientific research and allowed me to shadow physicians and learn about the clinical environment. I saw HIV-positive patients confiding in infectious diseases specialists, patients asking ophthalmologists endless questions about their vision problems, and worried parents asking physicians about their children’s conditions. One memorable moment for me was seeing a little boy come in with a bleeding cut on his face and the physician’s calm demeanor as he took care of the boy. The boy’s gaze as he looked at the physician reminded me of Bradley’s gaze when he looked at me. It was at that moment, bolstered by other similar experiences in the hospital, that I realized that I wanted to be a doctor: I was truly inspired by the care that physicians provided to patients and the trust that

Continued on the following page . . .

October 2009 San Francisco Medicine 17

The Path to Medical School Continued from previous page . . .

patients had in them.

I know that I want to go into medicine because I want to care for others’ difficulties as the physicians I shadowed did. I want to give people comfort. Moreover, being a physician allows me to fulfill my intellectual curiosity as well as my passion to provide care to others. As a physician, I will be able to continue to study the human body and research methods to ease people’s sufferings. By working with patients, I will have a direct impact on people’s lives and give the vulnerable a sense of security. In addition, a medical degree will give me knowledge and credibility, so that I can work toward improving public health conditions by informing others about diseases and their prevention. I will be able to go on medical missions abroad so that I can be a clinician who provides care not only to local patients but patients all around the world. Ultimately, medicine gives me the capability to improve individuals’ quality of life as well as benefit the community and society at large.

For now, I am only an applicant desiring to enter medical school. Whatever challenges and roadblocks arise, I am sure that medicine is the career for me, and I will work hard to reach my aspiration. I envision my future in medicine as one where I can see all the Bradleys looking at me with those trusting brown eyes, and all the camp children longing to learn and play—but this time, as a physician, I will have the ability and knowledge to lessen their physical and psychological pain.

Isabella Nga Lai is a 2009 graduate from Harvard University with a degree in neurobiology, a certificate in health policy, and a citation in Spanish language and literature. While she is Vietnamese in origin and plays an active role in the Vietnamese community, she also takes pleasure in studying different cultures and in gaining insight into the various ethnographic meaning of diseases. She is currently working in an ophthalmology lab at UCLA for the year and aspires to enter medical school next fall.

Entering Medicine Now Continued from page 16 . . .

approximation of what the examinee will experience in the future as a doctor.

While working on my essays now, articulating my readiness to enter the field, the “secondary” application probes more about me. Beyond why do I want to be a doctor, why would I be a good fit for the school? What do I do in my spare time?

This process prepares me for the many applications and interviews in the future, applying to residencies, jobs, and beyond, where you must wrap your complex self in the box of an essay so that it may be signed, sealed, and delivered.

I know that the road ahead in health care is likely to be a rocky one. And yet, as the generation just entering the field, it is our responsibility and our pleasure to infuse it with hope.

My hope is that the shift will benefit the patient above all else. When the patient benefits, everyone in the field benefits as well. I came across an article a while back in the New York Times citing that health care workers experience “moral distress” in high numbers. The term was defined as a situation where your actions are at odds with your conscience. The more patientcentered the system becomes, the higher the job satisfaction will be for the people who serve them.

Even the fact that such articles are being written in a major news outlet shows that a national discussion is taking place.

It is that discussion that makes me excited to enter the field at this time, when health policy is being reexamined and reevaluated before our eyes. Specifically, the rising costs of emergency procedures may well force us to focus more on preventive care.

I hope I would be prouder to help a patient prevent a triple bypass surgery entirely than I would be to perform one.

As integrative medicine centers begin to open around the country, they represent a model of care that applies evidencebased therapies to a view of the patient as a whole person. In this philosophy, physicians are seen not only as practicing scientists but also as healers. I find it intriguing that some “low-tech” solutions may be reintegrated into patient care, and

18 San Francisco Medicine October 2009

at the same time I am eager to be part of a field where technological innovation happens so rapidly—allowing for less invasive surgeries, shorter recovery times, and more saved lives.

Beyond preparing me academically, the trials and tribulations of this application process are also teaching me perhaps one of the most meaningful lessons of all.

Like the old adage, I am preparing to have the equanimity to accept what I cannot change, the courage to change what I can, and the wisdom to know the difference.

And I can’t wait to get started.

Jennifer Carleton-Nathan graduated from the University of Chicago in 2005. She worked as a public policy researcher for the Seedco Policy Center before completing Columbia University’s Postbaccalaureate Premedical Program in 2009. She is currently applying to medical schools for the fall of 2010 while continuing to work in clinical research at Mount Sinai Medical Center’s department of obstetrics, gynecology, and reproductive sciences.

www.sfms.org

The Next Generation of Medicine

The Path Away from Medical School Biology 101 and Career Counseling

Grace Lewellyn

M

ost little girls go through fantasies of stardom. Mine ranged from classical ballet to international runways; from stage to screen.

Then, of course, the operating room in Grey’s Anatomy and other pop culture influences satisfied my compassionate Libra tendencies and desire to follow my Chinese lineage. I knew at a very young age that I wanted to help people. I wanted to save lives; be the hero, a different kind of star.

Signs began to appear. Freshman year of college required that all students take two lower-division physical science classes to stay on track with graduation requirements. Rumor had it that Biology 101 was an easy A. I quickly went to rateyourprofessor.com and enrolled in the section with the teacher rated “Easiest.”

Sign #1 from the God of Career Counseling: If you are not internally compelled to study the human body, cells, atoms, etc., Stanford Medical School is not awaiting your application.

On day twelve of Biology 101 (I remember the day causing my current self-diagnosis of posttraumatic stress disorder), the assigned lab was to mix a blood sample with both AO and Rh solutions to find the reaction and therefore determine the sampled blood type. While the class waited for the teacher to return with the blood samples, I decided to calm myself by focusing on my curiosity about blood donors and their recipients. Having to see blood to conduct the experiment left me breathing deeply.

Sign #2 from the God of Career Counseling: If the sight of blood makes you queasy, look into professions where sutures, dissections, and simple blood lab www.sfms.org

work are not prerequisites.

I woke up from the serenity of my meditation-induced adventurous mind to dismay that our professor had not been fetching blood samples. She had been on a quest for the needles that would soon catapult into our delicate skin to pinch out our very own, personal blood sample.

Meditation was out of the question now. I began to weigh the idea that this torture wasn’t worth the five possible lab points.

The pride that is supposed to come with being “almost eighteen” was not inhibiting me from bringing my ashen face to the professor and insisting that she prick my finger. I apologized in advance in case I passed out or threw up. I imagined that after going through medical school and her first year of interning, she would be compelled to roll her eyes, mask her intentions with a deceiving smile, and stab the tip of my finger.

Following Murphy’s Law, I nearly fainted, and I left the room. After awkwardly sitting on the ground with my head between my legs, I couldn’t draw enough blood out of my finger to get an accurate sample. However, everyone else in the class seemed to be getting more than enough blood to send me out of the room the second time. I noticed that while the blood rushed from my head, blood was pouring out of the finger of a neighboring student as if it was a broken faucet. While my heart was drawn to comforting him, my stomach was drawn to my throat.

Sign #3 from the God of Career Counseling: If another person is in need and bleeding and you have to leave the room because it makes you faint, you are officially not cut out for any vocation in the medical field. NOT ONE. MOVE ON.

There was no denying that I needed to do exactly that. I made it through the semester, missing the five points for that lab. The following semester I took Geography to fulfill my last physical science requirement.

My calling to heal began to expand beyond allopathic medicine. Geography led the way to languages and religious and cultural studies. I was drawn to study different ethnic groups and their beliefs.

My main interests were the common factors all people share, and why we can’t recognize we are all so similar.

While my fear of blood may hinder me from healing the body, there is no fear stopping me from helping to heal our global culture. Many groups seem to be separated by difference, wars, and trauma. But we can come together and heal these wounds, stitching the global community. I could be the doctor to sew up these cuts. I could be a hero who unifies our many torn cultures to create one global society.

Grace Lewellyn is a seventeen-yearold student at Berkeley City College. She has recently decided to major in cultural anthropology.

October 2009 San Francisco Medicine 19

The Next Generation of Medicine

Working Together Turning Generational Differences into Strengths

Janet Bickel

F

or the first time in history, four generations are now active in the workplace at once. Because the era into which we’re born shapes us in many ways we tend to take for granted, generational tensions are inevitable. Just as fish did not discover water, the characteristics of one’s own generation tend to be no more visible than the air. This is particularly true of the largest generation in U.S. history: Baby Boomers have been known to act as if they were “The Generation” and as if younger generations of professionals must adapt to them.

Certainly, each individual has many influences and characteristics unrelated to the year of birth, and individuals do change as they mature. But people are heavily influenced by societal events and trends during their formative years, and thus a generational lens can help professionals work together more effectively.

Recognizing the need to create highperforming teams and to attract and retain the best people, many businesses have endeavored to become more “crossgenerationally friendly.” Medicine would benefit from a greater focus on this goal as well.

Differences in Expectations About “Balance”

Generation X (most residents and early-career physicians) was the first one in which both parents were likely to work outside the home. Also, parental divorce was twice as prevalent for Generation X and the Millennials (now emerging from medical school) as for the Boomers as children. In part because of these life experiences, Generation Xers and Millennials are less likely than the Veterans (also

called the “Silent Generation”) or Boomers to put work before family, friends, or other interests. Many Generation Xers also witnessed their parents become victims of downsizing in exchange for their loyalty to an organization. So young physicians’ first loyalty tends to be to themselves rather than to any institution. They are therefore less willing to sacrifice than their parents were at that age, less fixated on titles, and less likely to delay “gratifications.”

While not wishing to disappoint their bosses and mentors, young physicians tend to measure success both by their contributions to society and by their ability to maintain personal and professional balance. Since comparatively few have nonworking partners, balance means not just making it home in time for dinner to be served, but full participation in and substantial responsibilities for family life—as well as commitment to personal health and outside interests. This orientation raises thorny questions about what constitutes simultaneous dedication to professional responsibilities. But instead of respectful dialogue on this, too often young physicians encounter negative value judgments such as “selfish” or “slacker”—labels we wouldn’t tolerate if applied to another general category of individuals. As one resident asked, “Why are older physicians so defensive and self-righteous? Could it be that their insistence is more about protecting their own privileges or justifying their own sacrifices?”

Another aspect of the gap to be bridged between junior and senior professionals is that all knowledge and skill domains have become much more complex since senior professionals were getting started. These days, hospitalized

21 San Francisco Medicine October 20 San Francisco Medicine october2009 2009

patients are much sicker, information flow is nonstop, response time is reduced, the regulatory and paperwork burden has tripled; every pressure has been ratcheted up from the previous era. Rising competition for resources such as grants means that career-building is also much more challenging now than during most of the previous half-century. And skills in financial management, collaboration, communication, organizational politics, and negotiation are not optional but critical in order to advance.

D i f f e r e n c e s B e t w e e n t h e Millennials and Gen X

Both the Millennials and Gen X share the expectation of a life outside of work, face steep career-building challenges, and expect to “personalize” their careers.

But substantial differences between these two generations in terms of upbringing have significance for medical educators and physicians. The Millennials had much more protective parents than Generation X did. Because their parents praised and pushed these children, the Millennials expect “trophies for everyone”—or, at least, frequent encouragement and positive feedback. They favor team-based activities, prefer highly interactive educational methods, and seek innovative ways to make a difference. For instance, a group of medical students formed an NPO they named “Right to Sight” and organized a bike-a-thon to raise money to support blindness research; after raising a substantial sum, they tenaciously sought academic credit for this endeavor, testing the goodwill of a number of procedure-defending administrators.

While Boomers and Vets grew up www.sfms.org www.sfms.org

respecting hierarchy, Millennials are comfortable asking “Why?”; they are “evidence-” rather than “eminence”-based.

Younger professionals tend to be more self-confident, direct, and outspoken than their elders. For example, a chair of plastic surgery reported that when he tells residents to do something, they may question the order or simply do not follow it; one told him to “chill out”—responses unimaginable in his generation.

Another shaping influence is electronic: Millennials are digital natives, if not addicts, so they are accustomed to working asynchronously and are fearless in embracing new technology. They fear boredom more than change.

Implications for Educating, Mentoring, and Managing

Because they encourage us to examine what approaches require updating, generational differences can strengthen medicine. For instance, in many ways the traditional one-on-one apprenticeship model of mentoring assumed both a substantial degree of similarity between mentor and protégé and a relatively slow pace of change, with the wise gray-hairs transferring their knowledge to their protégés over a period of years. Given today’s time pressures and heterogeneities, this “parenting” or “grooming” model is unlikely to fits the needs of either senior or junior professionals. Clearly young professionals benefit from exposure to a variety of styles and options, the better to see what stimulates their own development and assists them to take responsibility for their careers.

In addition to individual mentoring relationships and assistance building their networks, young physicians also seek programs that provide a framework for professional development, emotional support, and career planning. For instance, one successful group-mentoring program consisted of sessions one day per month for six months, facilitated by a midcareer professional. Learning outcomes included identification of values-based career goals, development of close collaborative relationships within the group, improved job satisfaction, and skills in areas key to www.sfms.org

advancement. Such updating of mentoring practices also responds to medicine’s need for new models of mutuality and facilitative leadership based on collaboration and shared authority.

Whatever frameworks facilitate senior professionals to effectively share their expertise and stimulate young professionals to take responsibility for their careers deserve consideration. This requires self-awareness and skills at communicating across differences. Rather than depending only on their own experiences, skilled mentors focus feedback, questions, and advice on the young professionals’ learning needs. They aim to foster critical self-awareness—building on students’ emotional engagement, urging them to reflect upon their emerging professional selves, emphasizing the mutuality of their roles in the educational conversation, and modeling respect for multiple viewpoints.

Reflective questions in particular assist young professionals in developing their own visions and taking responsibility for themselves. For instance: How will you develop the necessary expertise? What does success mean to you? What are your goals and timelines?

Let’s agree about the desired outcome, then discuss methods. Tell me more about your understanding of this dilemma. What was the lesson? How can you lock in the learning? What concerns you the most about . . . ? What are you trying to accomplish? Where are you being too hard [or easy] on yourself? How might you be limiting yourself?

While some young professionals may be unfamiliar with this style of coaching, mentors and bosses who keep encouraging such self-awareness and accountability will likely have the most enduring impact.

Such effective and comfortable communication depends on active listening, avoiding assumptions, and combining an optimal balance of support and challenge.

When we accurately attune to others, we enhance insights into the other’s needs, values, and motivations, preventing costly misunderstandings. Active listening also increases our chances of hearing what people are not saying so we uncover sources of resistance and confusion. More-

over, accurate attunement facilitates trust in relationships, which is key to finding common ground.

Other Recommendations

If questions about their commitment to the work arise, link the discussion to outcomes and performance. Offer illustrations linking effort to competency.

Give frequent feedback. Whereas Boomers tend not to seek feedback and demand substantial documentation to support the feedback they get, Millennials expect a lot of feedback, especially praise.

Opening conversations on a positive note paves the way for critical observations.

Create sense of psychological safety so that protégés don’t just “toe the line” but reveal their doubts and hard questions.

Offering more learner-centered mentoring begins from an altruistic motivation to nurture the next generation and from an openness to differences. For instance, if the young professional’s answer to “What’s most important to you right now?” is “Finding competent child care,” then begin there—even if all you can do is suggest someone else to discuss this with.

A generational lens can help bridge inevitable differences among older, middleaged, and young physicians so that each group can best accomplish what society is depending on them for. Becoming more cross-generationally competent also helps an institution compete for the best talent.

Central to this are the capacities of accurately attuning to others and combining an optimal balance of support and challenge—precisely what patients seek in their physicians. Professionals who maintain that they don’t have time for these activities are fooling themselves. Faculty and managers who spend the necessary time with their young professionals, initiating substantive, respectful dialogue about what it means to be a resilient and dedicated physician, will increase their positive impact in the limited time available for coaching, educating, and managing.

Janet Bickel is a career and leadership development coach and consultant. To learn more, visit www.janetbickel.com.

October 2009 San Francisco Medicine 21

2009 SFMS 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 2009 SFMS election. This slate was announced at the September 14, 2009, General Meeting, at which time the SFMS President called for additional nominations from the floor. The following are this year’s candidates.

Officers

Term 2010 One candidate will be elected to each office.

President-Elect: George A. Fouras, MD Secretary: Peter J. Curran, MD Treasurer: Keith E. Loring, MD Editor: No Candidate. The SFMS will have a guest editor for each issue of San Francisco Medicine for the year of 2010.

Board of Directors

AMA Alternate Delegate

Term 2010-2012 The seven candidates receiving the highest number of votes will serve as directors on the SFMS Board.

Gary L. Chan , MD ** Donald C. Kitt, MD * Cynthia A. Point, MD William T. Prey, MD Adam Rosenblatt, MD Lily M. Tan, MD * Shannon Udovic-Constant, MD * Joseph Woo, MD

Term 2010-2011 Robert J. Margolin, MD (Incumbent)

* Incumbent Director ** Outgoing Officer

Nominations Committee Term 2010-2011: Four candidates will be elected to the Nominations Committee.

Jane Fang, MD Robert G. Gish, MD Kimberly L. Newell, MD Mark J. Savant, MD

Young Physicians Section Delegate Term 2010-2011 Dawn L. Rosenberg, MD

CMA Trustee

Term 2009-2012 Robert J. Margolin, MD (Incumbent)

AMA Delegate

Term 2010-2011 H. Hugh Vincent, MD (Incumbent) 22 San Francisco Medicine October 2009

Delegation to the CMA House of Delegates Term 2010-2011 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 *** Robert I. Liner, MD ** Leslie M. Lopato, MD Rodman S. Rogers, MD ** Judy Lynn Silverman, MD Peter W. Sullivan, MD * George P. Susens, MD * John I. Umekubo, MD * Charles J. Wibbelsman, MD * Joseph Woo, MD * Incumbent Delegate ** Incumbent Alternate *** 2009 Incumbent Delegation Chair

NOTES 2009 President-Elect, Michael Rokeach, MD, automatically succeeds to the office of President in 2010. 2009 President, Charles J. Wibbelsman, MD, 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 in the special envelope provided. Ballots MUST arrive at the SFMS offices by 5 PM, Monday, November 9, 2009. The NAME of the SFMS member (NOT the corporation’s name) must be printed legibly or typed on the return envelope. www.sfms.org

FOR PRESIDENT-ELECT GEORGE A. FOURAS Specialty: Child and Adolescent Psychiatry Membership: SFMS/ CMA 1996, AMA 1987– 90/1995–present SFMS: Secretary 2009;

Director 2003–08 SFMS Committee Appointments: Executive 2003–09, SFMS PAC 2004–09 (Chair 2007–08), Physician Membership Services 2003–09, Nominations 2008, Psychiatric Services 1996–2006, Fellowship/Wellness 2006 CMA: Alternate Delegate 2007–09/2000–02; California Psychiatry Association Specialty Delegate to Young Physicians Section, CMA 1996–99 Related Medical Affiliations: President, Northern California Regional Organization of Child and Adolescent Psychiatry 2000 (President-Elect 1999); Chair, California Psychiatric Association Child and Adolescent Committee 2000–present; Medical Director, Foster Care Mental Health Program, City and County of San Francisco 1995–present Other: Board-Certified in General Adult Psychiatry 1999, recertified 2009 Medical School: Ohio State University 1990 Hospital Affiliation: Courtesy: SFGH Policy Statement: Thank you for the honor of being nominated as president-elect. Over the course of my membership in the SFMS, I have been impressed by the broad diversity of our membership and the strong advocacy we have had for our patients and our profession. Many of our policy ideas have gone onward from the CMA to the AMA. I am proud to be a member of our society and look forward to my turn as the steward of our organization.

FOR SECRETARY

PETER J. CURRAN Specialty: Cardiology Membership: SFMS 2007, CMA 2005 SFMS: Director 2009 SFMS Committee Appointments: Executive 2009, SFMS PAC Secretary/ Treasurer 2009, Membership Services 2007–09 CMA: Alternate Delegate 2009–10 www.sfms.org

CMA Committee Appointments: Young Physician Section Representative on Council on Legislation 2009–10 Related Medical Affiliations: Director of Cardiac Rehabilitation, St. Mary’s Medical Center Medical School: Loma Linda University 1994 Hospital Affiliation: Active: St. Mary’s, St. Francis; Courtesy: CPMC Policy Statement: I appreciate being nominated to the SFMS office of Secretary. As a current member of the SFMS Executive Committee and Alternate Delegate to the CMA, I’ve had an exciting year participating in organized medicine at the local and state levels. The SFMS is an effective conduit to letting our legislators know what is important to physicians and being actively involved in developing health policy. We cannot afford to stay on the sidelines in a time of real health care reform. I believe that our society’s leadership is committed to having the collective medical community’s voice heard and, more importantly, committed to having fun doing it.

FOR TREASURER

KEITH E. LORING Specialty: Emergency Medicine Membership: SFMS/CMA 2003 SFMS: Director 2009 SFMS Committee Appointments: Executive 2009, Nominations 2007–08 Related Medical Affiliations: Vice Chief of Staff, St. Mary’s Medical Center; Regional Medical Director, San Francisco Peninsula Region, California Emergency Physicians Medical School: Johns Hopkins University School of Medicine 1991 Hospital Affiliations: Active: St. Mary’s and St. Francis; Courtesy: SFGH Teaching Appointments: Assistant Clinical Professor, USCF Policy Statement: It is an honor to be nominated as a candidate for Treasurer of the SFMS. Wise stewardship of our profession requires our direct, passionate, and constant involvement. If we are to truly flourish, we must maintain a keen awareness of the world outside our practices, our medical groups, and our medical centers. We must be able to stand together to advocate for what is right for our patients as well as what is right for us to receive

in compensation for our efforts. My candidacy for Treasurer is part of an ongoing commitment to put these words into action and become involved in something greater than my own practice of emergency medicine at St. Mary’s, St. Francis, and San Francisco General Hospitals. If we are to stem the tide that continues to erode our profession and place our patients in harm’s way, it is critical that we nurture the brightest among us who have the integrity and energy necessary to stretch beyond day-to-day clinical practices and make our voices heard in the local, state, and national health care dialogue.

Prudent financial stewardship is critical for this organization to be able to continue advocating for our patients and our professional interests, especially in a time of exceptional financial uncertainty and likely upheaval of our health care system. I would be honored, willing, and able help serve this need if elected Treasurer.

FOR BOARD OF DIRECTORS

GARY L. CHAN (Outgoing Officer) ALSO CANDIDATE FOR DELEGATION Specialty: Internal Medicine Membership: SFMS/CMA

1981 SFMS: Treasurer 2009, Secretary 2008, Director 2002–07, St. Francis Memorial Hospital Medical Staff Liaison 2005–09 SFMS Committee Appointments: Executive 2006–09, Finance Chair 2009, Nominations 2007, Information Technology 2006, Health Care Foundation of San Francisco Board 2005–06 CMA: Alternate Delegate 2008–09, Solo/Small Group Practice Forum Alternate 2006–07 CMA Committee Appointments: Committee on Medical Services 2009 Related Medical Affiliations: Assistant Medical Director, Brown & Toland 1990–present; Utilization Management Advisor, Blue Shield 1984–99 Medical School: Tufts University 1976 Hospital Affiliation: Active: St. Francis, CPMC; Courtesy: St. Mary’s Teaching Appointments: Clinical Associate, UCSF Policy Statement: I have been active on the SFMS Board for the past six years. I would be

October 2009 San Francisco Medicine 23

pleased to again serve as a Board Member and a Delegate from San Francisco to the CMA. Thank you for offering me that opportunity. I have been practicing internal medicine here in San Francisco for the past twenty-five years and I am amazed at the vast changes in medicine. We are at a critical juncture with this new administration. Because of my firsthand knowledge of how the managed care system has evolved and of the pressures placed on the system by providers, insurers, and employers, I feel I can represent your concerns. Congress needs to understand how the current system works or doesn’t work for both patients and physicians. There must be clear heads and a more thoughtful discussion. Only then can we begin to lay the groundwork to fix it for the benefit of both physicians and patients. We need to be at the table. Only through our organized voices can physicians play a role in changing our current system for the better. SFMS must provide a forum for getting our voices heard.

I hope to represent these concerns. Thank you for your vote.

DONALD C. KITT (Incumbent Director) Specialty: Neurology Membership: SFMS/CMA 1988, AMA 1988 SFMS: Director: 2007–09; UCSF/ACF Consultant to

the Board 1999 SFMS Committee Appointments: Nominations 2008–09, Tripartite 2000 Related Medical Affiliations: Vice Chair, Neurosciences Department, CPMC 2008–present; Chief, Neurology Division, CPMC 2008–present; Chief, Neurology Section, Department of Medicine, St. Mary’s 1998–present; Fellow, American Academy of Neurology 2004–present; President, Association of Clinical Faulty, UCSF 1998–99; President, San Francisco Neurological Society 2001; Board of Directors/Executive Council, San Francisco Neurological Society 1998–present; American College of Physicians 1985–present; Executive Council of the Association of Clinical Faculty, UCSF 1995–99; Hastings Center for Bioethics 1976–present Medical School: University of Southern California 1982 Hospital Affiliation: Active: CPMC, St. Mary’s; Courtesy: Chinese, St. Francis Teaching Appointments: Associate Clinical

Professor, Department of Neurology, UCSF 2003–present; Assistant Clinical Professor, Department of Neurology, UCSF 1990–2003 Policy Statement: Over the past three years, I have observed the exceptional organization and administration of your San Francisco Medical Society. The Board, Executive Director, and associate administrators are perfectly adept at representing the diversity of ideas that are found in this great city. This grassroots approach has fostered strong legislation at state and national levels. Whether we agree or disagree with CMA or AMA, your opinion is counted and held in high regard because of SFMS. I was initially skeptical but retained some idealism moving onto the Board of Directors.

I invite you to send me your direct questions and concerns and promise to bring them to the Board if you reelect me. cynthia a. point Specialty: Internal Medicine Membership: SFMS/CMA 1988 Related Medical Affiliations: Primary Care Task Force, Saint Mary’s, currently; Board Member, Brown & Toland 1994–2000; Physician Compensation Committee, Brown & Toland and CIPA; Board Member, CIPA late 1980s Medical School: West Virginia University 1985 Hospital Affiliation: Active: CPMC; Provisional: Saint Mary’s Policy Statement: These are challenging times. I know you have heard this before, but it remains true. Also true is that we all want to provide the best care we can for our patients.

The challenges are to do so while keeping our offices and groups solvent and in compliance with the myriad regulations that apply. I have practiced in groups as well as solo offices and have hands-on knowledge of the day-to-day business of an office. If you elect me, I will champion causes that we jointly feel are important.

Please contact me with suggestions.

24 San Francisco Medicine October 2009 25 San Francisco Medicine October

william t. prey Specialty: Psychiatry and Sleep Medicine Membership: SFMS/CMA 1985, AMA 1984 Medical School: Penn State University M.S. Hershey Medical Center 1980 Hospital Affiliation: Active: CPMC Teaching Appointments: Adjunct Faculty, Argosy University, San Francisco campus Policy Statement: I truly appreciate the nomination to the SFMS Board of Directors.

I have practiced in San Francisco since 1985 and have watched our profession adapt, both successfully and unsuccessfully, to the various changes in health care delivery that fate, politics, and the economy have thrust in our path. This nomination gives me an opportunity to have an active voice in helping to guide the SFMS. I have always been an advocate for a free-market approach to health care delivery. Universal coverage does not mean socialized medicine.

High-quality and effective health care can reduce costs. Thank you again.

ADAM ROSENBLATT Specialty: Internal Medicine Membership: SFMS/CMA 1983 Medical School: Harvard University 1973 Hospital Affiliation: Active: CPMC Policy Statement: I have spent my entire postgraduate professional life engaged in the practice of primary care medicine, from 1982 on, in the city of San Francisco. During that time, I have seen primary care go from a highly appreciated discipline of medicine to one that is sadly undervalued and underappreciated.

This is, clearly, to the detriment of medicine as a whole. If elected to the Board, I would hope to bring a strong focus on primary care to the proceedings.

LILY M. TAN (Incumbent Director) Specialty: Ob/Gyn Membership: SFMS/CMA 1999–present SFMS: Director 2007–09 SFMS Committee Appointments: Information Technology 2006 www.sfms.org

CMA: Young Physicians Section Delegate 2008–09, YPS Alternate Delegate 2006–07 Related Medical Affiliations: CPMC Gynecology Quality Improvement Committee 2002–2005, Chinese Hospital Pharmacy Committee 2001– 2002 Medical School: Albany Medical College 1995 Hospital Affiliation: Active: Kaiser Permanente San Francisco Teaching Appointments: CPMC nursing staff educator 2002–05; Kaiser Ob/Gyn staff, teaching residents and medical students 2005–09; UCSF Clinical Faculty, teaching medical students 2005–09 Policy Statement: As an incumbent member of the SFMS Board of Directors, I have enjoyed the responsibility of addressing the health care concerns of our city’s medical providers and patients alike for the past three years. I am running for another term because I have an ever-increasing interest in our city’s health care future, especially given the challenging economic landscape of impending health care reform. As the current Young Physician Delegate to the California Medical Association, I have an active interest in the politics surrounding our future of medicine. Having practiced ob/gyn in both the private practice setting and within the Kaiser Permanente health care system, I have the unique perspective of having actually served as staff for a number of local hospitals, including CPMC, St. Francis Memorial, Chinese Hospital, and Kaiser Permanente, as well as serving currently as clinical faculty for UCSF. My practice experience therefore gives me a personal interest in these different institutions. More importantly, it has given me the perspective of the private practitioner, the HMO provider, and the academician, as well as firsthand knowledge of the many insurance companies that insure the varied patients of San Francisco. I have a very active interest in the future of medicine in San Francisco and hope to contribute more to the San Francisco Medical Society in this upcoming term.

SHANNON UDOVICCONSTANT (Incumbent Director) Specialty: Pediatrics Membership: SFMS/CMA 2001 SFMS: Director 2007–09 SFMS Committee Appointments: SFMS PAC www.sfms.org

2006–09 (Chair 2009), Executive 2009, Medical Review and Advisory 2002–present CMA: Alternate Delegate 2008–10 CMA Committee Appointments: Young Physicians Section Executive Committee, At-Large Member 2003–2005 Related Medical Affiliations: AAP-CA State Government Affairs Co-Chair; AAP chapter Board, Alternate Member-at-Large 2003 Medical School: U.C. Berkeley/UCSF Joint Medical Program, MS 1996, MD 1998 Hospital Affiliation: Active: Kaiser Permanente Teaching Appointments: Assistant Clinical Professor, UCSF Department of Pediatrics Policy Statement: As individual physicians in San Francisco, we can directly affect the health and well-being of our own patients. The power of organized medicine is that physicians across all specialties can have one voice to address the broader health care issues facing patients and their physicians. In my current positions for SFMS, I have furthered our health care advocacy in the community. I have also worked to promote SFMS by leading a summer safety press conference and meeting with San Francisco Supervisors. I would welcome the opportunity to continue to serve SFMS to further the health and well-being of San Francisco physicians and patients.

JOSEPH WOO ALSO CANDIDATE FOR DELEGATION Specialty: Emergency Medicine Membership: SFMS/CMA 2005 SFMS: Chinese Hospital Medical Staff Liaison 2007–09 Related Medical Affiliations: Chinese Hospital Chief of Medical Staff 2005–09, Chinese Community Health Plan Board of Directors 2006–09 Medical School: Medical College of Wisconsin 1991 Hospital Affiliation: Active: Chinese Hospital Policy Statement: I am honored to have this opportunity to participate and serve. I have been an emergency physician for fourteen years and have had the great fortune to be a Chief of Staff and IPA Board Member for the past five years. So much change is upon us . . . medical homes, changing reimbursements.

Throughout my career, I have always tried to

advocate and represent the practicing physician. As Board Liaison, I have learned a great deal about politics and people, but mostly I have been impressed with the passion and idealism that our members still have for this profession.

I hope I have the opportunity to represent you and further our common goals.

FOR NOMINATIONS COMMITTEE

jane fang Specialty: Ob-Gyn Membership: SFMS/CMA 2002 Related Medical Affiliations: Fellow, American College of Obstetricians

and Gynecologists Medical School: Jefferson Medical College 1989 Hospital Affiliation: Active: CPMC Teaching Appointments: Hospital of the University of Pennsylvania 1993–2000, Assistant Professor of Ob/Gyn Policy Statement: Serving on the SFMS Nominations Committee would give me the opportunity to contribute to our medical society by participating in the selection of our current and future leaders.

Robert G. gish Specialty: Internal Medicine Membership: SFMS/CMA 1988–present; AMA 1979– 1980, 1992, 2001–2007 Medical School: Univer-

sity of Kansas 1980 Hospital Affiliation: Active: CPMC; St. Mary’s Teaching Appointments: UCSF, University of Nevada-Reno, University of Nevada-Las Vegas Policy Statement: Health care is, I believe, about to undergo the greatest change in the last fifty years. Under the new Democrat administration (both Congress and presidency) and with the economic changes and broad health care “deficit” in the community, the SFMS is in a key position to effect changes in the San Francisco region. It would be a great honor that, if elected to this position, I would help shape this future through a role and activities on the Nomination Committee for the SFMS.

October 2009 San Francisco Medicine 25

kimberly l. newel Specialty: Pediatrics Membership: SFMS/CMA 2006 Related Medical Affiliations: Fellow, American Academy of Pediatrics Medical School: University of Pennsylvania 2001 Hospital Affiliation: Active: Kaiser Permanente Teaching Appointments: USCF Assistant Clinical Professor Policy Statement: Having trained at UCSF and now being in practice at Kaiser San Francisco, I have had some experience with a range of medical settings and care delivery systems in this city. I am excited to become more involved in the larger medical community via the SFMS and honored to be considered for a position on the SFMS Nominations Committee. Particularly at a time when the economics of health care is tumultuous and the future face of health care delivery in the city, state, and the entire country is being shaped, I believe that it is important to bring committed, effective leaders in medicine together so that we can effectively give voice to the San Francisco’s patients and physicians in these larger debates. I look forward to the opportunity to help nominate the leaders who will frame this debate for the benefit of the entire community.

mark j. savant Specialty: Internal Medicine Membership: SFMS/CMA 2008 Related Medical Affiliations: St. Mary’s Medical Committee; former chair, St. Mary’s Asian Physician Advisory Committee Medical School: Medical College of Wisconsin 1994 Hospital Affiliation: Active: St. Mary’s, St. Francis Teaching Appointments: Creighton (via St. Mary’s); Columbia College of Physicians and Surgeons Policy Statement: Although a member of the San Francisco Medical Society for only a short time, I have been practicing in my hometown for the past nine years and have realized the benefits of the collective wisdom and generous

mentoring of my colleagues as I started my solo practice from scratch eight years ago. As such I am acutely aware of how an organization such as the SFMS can be a leading advocate for patients and the physicians who serve them. It would be an honor to serve on the nominations committee.

FOR young physician section delegate

DAWN L. ROSENBERG Specialty: Pediatrics Membership: SFMS/CMA 2009 Medical School: UCSF School of Medicine 2001 Hospital Affiliation: Active: CPMC; Courtesy: UCSF Teaching Appointments: UCSF Assistant Clinical Professor, Department of Pediatrics 2006–present; Stanford University School of Medicine, Clinical Instructor in Pediatrics 2004–05; Santa Clara Valley Medical Center, Clinical Instructor in Pediatrics 2004–05 Policy Statement: I am honored to become an active member of San Francisco Medical Society. As a young physician, just a few years into private practice, I was excited to learn about SFMS from my experienced colleagues and to be welcomed into its ranks. I hope to encourage membership and participation among other young physicians in our community so that we can contribute our unique perspective and become rising leaders within this important organization.

FOR CMA TRUSTEE

ROBERT J. MARGOLIN (Incumbent Trustee ALSO CANDIDATE FOR AMA ALTERNATE DELEGATE (incumbent) Specialty: Internal Medicine Membership: SFMS/CMA 1987, AMA 1992 SFMS: Board Consultant 2000–present, Immediate Past President 1999, President 1998, President-Elect 1997, Director 1992–96 SFMS Committee/Board Appointments: Executive 1993–99 (Consultant 2000–09), SFMSPAC Board 2009 /1995–2001 (Consultant 2003–08/Vice Chair 2000–01), Judicial

27 San Francisco Medicine October 26 San Francisco Medicine October 26 San Francisco Medicine October2009 2009

1997–2009, Physician Membership Services/ Membership 1995–2006 (Consultant 2009), HCFSF Board 1995–2005, Finance/Investment 1998–2002, Managed Care 1998–2002 (Chair 2000–02/Co-chair 1999), 130th Anniversary Celebration 1998, Nominations 1999–2000/1995–97 CMA: CMA Trustee 2003–09, Delegate 1997– 2002 (Chair 2001–03/Vice Chair 1998–2000) CMA Committee Appointments: Committee on Nominations 2003–present, Chair Audit Committee 2009; AB 3686 TAC 2004–05, LongRange Planning 2004–present, eCommerce TAC 2003, Council on Legislation 2001–02, CALPAC Board of Directors 2004–present, Treasurer 2008–present AMA: Alternate Delegate 2008–09 Related Medical Affiliations: Medical Director, Integrated Practice Group 1995–97; Medical Board, Mt. Zion, 1992–95; President, Physician’s Medical Group at Mt. Zion (IPA) 1993– present; Board of Directors, Medical Insurance Exchange of California 2007 Medical School: Tufts University 1981 Hospital Affiliations: Active: CPMC, UCSF Teaching Appointments: Associate Clinical Professor, UCSF Policy Statement: I greatly enjoyed serving on the SFMS Board of Directors for six years and as its President in 1998. Since then, I have increased my involvement with the CMA. In addition to chairing our delegation to the CMA House for three years, I have also served on CMA’s Council of Legislation and the CALPAC Board of Directors. During the past six years, I have served as your Trustee to the CMA Board.

I have been your alternate delegate to the AMA House of Delegates for the past two years. I have enjoyed advocating for physicians locally, throughout California and nationally. Now more than ever, it is vital to have physician leadership that is dynamic, experienced, and sensitive to the needs of physicians and their patients. I ask for your support in allowing me to continue our work on health insurance reform, MICRA preservation, financial advocacy, and many other vital issues.

www.sfms.org www.sfms.org

FOR AMA DELEGATE: H. HUGH VINCENT (Incumbent Delegate) Specialty: Anesthesiology Membership: SFMS/ CMA/AMA 1972 SFMS: Board Consultant 1993–present, Immediate Past President 1993, President 1992, PresidentElect 1991, Director 1982–1990 SFMS Committee Appointments: Medical Review and Advisory 1975–present, SFMSPAC Board 1991–96 (Chair 1995–96/Consultant 1997–present), Health Care Foundation of San Francisco Board 1999–2004, Managed Care 1998–2001, Physician Membership Services/ Membership 1994–2001/1986–89 (Chair 1994–95), Nominations 2000–01/1994–95 (Chair 1994–95), Judicial 1993–99, Anesthesia Section Chair 1975–90 CMA: Trustee 1997–2003, Delegate 1991–97, 2003–10 (Chair 1993–96), Alternate Delegate 1985–90 CMA Board Committees: Nominations 1997– 2003, Medical Services 1997–2002, Finance 1999–2003, Bylaws 2001–03 CMA Committee Appointments: Council on Legislation 1996–97, Speaker’s Advisory 1993–96, Rules 1994–95 (Chair 1995), Solo Practice TAC 1993–94 (Chair), Governance 10–94 TAC 1994, CALPAC Board of Directors 1995–2001 (Executive Committee 1999–2001) AMA: Delegate 1996–2009 (Vice Chair 2000– 04; Chair 2004–08); Alternate Delegate 1994–95; House Select Oversight Committee 2001; Reference Committee C: A-95, I-95, A-01; Cal-C Committee Chair 1995–96; Resolutions Committee 1995–2000; Council on Long-Range Planning and Development 2008–12 Related Medical Affiliations: Saint Francis Physicians Medical Group/CHW Bay Area Physicians Medical Group 1995–2000 (President/ CEO), Saint Francis Memorial Hospital Board of Trustees 1990–96/2000–10 (Secretary 1994–95, Chair 2001–03), Catholic Healthcare West Bay Area Board of Directors 1996–01, CHW Strategic Planning Committee 2001–05 Medical School: UCSF 1968 Hospital Affiliation: Active: Saint Francis Memorial Hospital Policy Statement: As I have often said, my primary purpose in medical politics is to further the agenda and goals of California physicians www.sfms.org

at the national level. One must build a broad and diverse coalition to achieve consensus and support for our resolutions. I take pride in being a part of that effort. In my new role on AMA’s Council on Long-Range Planning and Development, I hope to be able to effect positive change for AMA’s future. I ask for your continued support and particularly for your input on issues important to California physicians.

FOR AMA alternate DELEGATE

ROBERT J. MARGOLIN (Incumbent Alternate) ALSO CANDIDATE FOR CMA TRUSTEE. See biography under “For CMA Trustee.”

FOR CMA DELEGATION

GARY L. CHAN (Incumbent Alternate) ALSO CANDIDATE FOR BOARD. See biography under “For Board of Directors.”

STEPHEN E. FOLLANSBEE (Incumbent Chair) Specialty: Infectious Diseases Membership: SFMS/CMA 1982 SFMS: Board Consultant 2009, Immediate Past President 2008, President 2007, President-Elect 2006, Director 1999–2005 SFMS Committee Appointments: Executive 2001/2004–07 (Consultant 2008–09), Judicial 2006–09, PAC 2006–08, Disaster Planning (Co-chair 2002–09), Nominations 2003–04 (Chair 2008), Medical Review and Advisory Consultant 1993–2002, Chiefs of Staff 1996–97 CMA: Delegate 2004–09 (Chair 2008–09) Related Medical Affiliations: Attending physician, Kaiser Permanente Medical Group; Director of HIV Services, Associate Director of Clinical Trials Unit (1998–present), and Director of Adult Travel Medicine Services (2008–present), Kaiser San Francisco; Assistant Director, Bay Area Consortium of AIDS Providers, 1990–present; Medical Director, Institute for HIV Research and Treatment, Davies Medical Center, 1988–1998; attending physician, Ward 86, SFGH Medical Center, 1983–1998; Chief of Staff, Davies Medical Center, 1996–1997 Medical School: University of Colorado 1977

Hospital Affiliation: Active: Kaiser Permanente Medical Center, San Francisco Teaching Appointments: Associate Clinical Professor, UCSF 2005–present/1996–1998 Policy Statement: It is an honor to have been part of the San Francisco Medical community since 1977, working in the university, research, public, and private practice sectors. I am proud to be a member of the SFMS and to serve as a CMA delegate. I have witnessed outstanding leadership in the SFMS, which remains not just reactive but also proactive, advocating for the health of our community and the wellbeing of our members. Organized medicine and our profession face continued challenges and opportunities for growth and increased professional satisfaction. I look forward to the opportunity to serve our important organization and our profession.

ROBERT I. LINER (Incumbent Alternate) Specialty: Obstetrics and Gynecology Membership: SFMS/CMA 2004 CMA: Alternate Delegate 2008, Attendee House of Delegates 2006–07 Related Medical Affiliations: Diplomat, ACOG; American Institute of Ultrasound in Medicine Medical School: University Rochester 1970 Hospital Affiliation: Retired from hospital affiliations Teaching Appointments: Clinical Faculty and Temporary Director, OB/GYN at Mt. Zion Hospital (retired); Assistant Clinical Professor (temporary), UCSF at Highland General Hospital (retired) Current Practice (1988–present): Private practice in prenatal diagnosis, diagnostic ultrasound (obstetrical and gynecologic), and genetic amniocentesis. Certified to perform ultrasound screening at eleven to fourteen weeks, Fetal Medicine Foundation.

Policy Statement: I became a member of the SFMS/CMA in order to join others who want to do their part to make a difference in the way physicians use their individual and collective influence to improve the health and well-being of patients. This is both idealistic and self-serving, since professional improvement enhances the quality of our own working lives and also because, eventually, we all become patients. Impressed with the personalities of

October 2009 San Francisco Medicine 27

the members of the SFMS and with the diligent work expended by its delegation at the HOD meetings, I wanted to be a participant as well as an observer at those meetings. As something of a student of the history of medicine on the Pacific Coast, I know that it can take time for wise policies to evolve. Best evidence-based practice can only evolve with dedicated leadership. I’m pleased and feel honored to be able to join the SFMS delegation, working toward our perceptions of wise policy and best practice.

LESLIE M. LOPATO Specialty: Psychiatry Membership: SFMS/CMA 1989 Medical School: Stanford University 1978 Internship and Residency: Mount Zion Medical Center of UCSF Internship in Internal Medicine, Internship and Residency in Psychiatry Hospital Affiliation: Active: Kaiser Permanente Committees: Chair, Hospital Ethics Committee, Kaiser Medical Center, San Francisco; Member, Physician Wellness Committee, Kaiser Medical Center, San Francisco Policy Statement: Delegate (noun): A person sent and empowered to act for another. Delegate (verb): To entrust to another. To carry out the responsibilities of a delegate, I must represent not just my own opinions and interests, but also those of the large and diverse group of physicians who are the members of the Medical Society. This is a time of great change in health care, when the voices of physicians must be heard but when physicians must also demonstrate that we can listen. My years as the Chair of a Hospital Ethics Committee have taught me the importance of listening with respect and careful attention to the thoughts, ideas, and concerns of differing parties, and of helping them to listen to each other. Health care reform is critical, but it cannot be carried in on the backs of physicians, or at the expense of the patient-physician relationship. Organized medicine, through bodies such as the San Francisco Medical Society and the CMA, has obligations to both patients and physicians. For our patients, we want access to the most effective care, provided in an environment of compassion and caring. For ourselves, we want, and need, a sustainable and rewarding professional life, one that can be lived with

integrity and with fidelity to those values that initially brought us to medicine. As a delegate, my job would be to listen, to analyze, to speak, and to communicate, for you and with you.

RODMAN S. ROGERS (Incumbent Alternate) Specialty: Urology Membership: SFMS/CMA 2000 SFMS: Director 2006–09 CMA: Alternate Delegate 2008–09, Solo/SmallPractice Forum Alternate Delegate 2005–06 Related Medical Affiliations: American Urological Association Medical School: University of Oklahoma 1995 Hospital Affiliation: Active: CPMC, Saint Mary’s, Saint Francis Policy Statement: I am honored to be nominated to serve on the delegation to the CMA House of Delegates. Like most young people, I entered medicine wanting to contribute to the health of individual patients as well as to make scientific advancements in my discipline.

Accomplishing this requires more than the action of one individual. It is dependent on the culture of those who provide care and conduct research, as well as the choices made by the individuals and institutions paying for such care. I believe that participating with the CMA and the San Francisco Medical Society are good ways for both patient and physician advocacy so that we may influence the choices of the other partners in health care. Participating in the CMA in previous years has been a fascinating and rewarding experience and reaffirms my confidence in the ability of organized medicine to make positive social contributions.

JUDY LYNN SILVERMAN Specialty: Physical Medicine & Rehabilitation Membership: SFMS/CMA 1995 Medical School: University of Washington 1986 Hospital Affiliation: Ac-

tive: St. Mary’s Policy Statement: We live in interesting times.

There is still a debate as to whether or not access to heath care is a right or privilege. The cost of care continues to escalate, but are we doing as much as we can for improved illness preven-

28 San Francisco Medicine October 2009 29 San Francisco Medicine October

tion? How much change can be initiated in these economic hard times? For better or worse, California has always been on the cutting edge of policy setting and implementation. Trained in physical medicine and rehabilitation, I will bring a perspective for and about patients with chronic diseases—those who need a model of care that allows for disease management when cure is still not a possibility. As a San Francisco delegate, I would hope to add input to the CMA on the debate balancing patient access to care, quality of care, and physician organization. I look forward to your support.

Peter W. Sullivan (Incumbent Delegate) Specialty: Emergency Medicine Membership: SFMS/CMA 1990 SFMS: Director 2003–08, Treasurer 2002, Director 1996–2000, Medical Staff Liaison CPMC 1999–2004 SFMS Committee Appointments: Finance/ Investment 2000–09 (Chair 2001–02); Local Health Affairs Chair 2000–06; Executive 2000– 04; Nominations 2002–03; SFMS Services, Inc., Board 2001–02; Physician Membership Services/Membership 1996–2002; Medical Review and Advisory 1995–2000; Managed Care Task Force 1994 CMA: Delegate 2008–09; Alternate Delegate 2002–07 Related Medical Affiliations: Vice Chair, Emergency Medicine, CPMC; Physician Information Officer, CPMC; Group Manager, San Francisco Emergency 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 again on the SFMS Delegation to the CMA House of Delegates. I have been lucky to meet and confer with my SFMS colleagues over the last eight years to address the multiple issues facing not only SFMS members but health care issues statewide. We still have much to do in organized medicine: MICRA, changes in MediCare, the new Health IT programs, and fair payment come to mind. It would give me great pride and pleasure, if I am reelected, to www.sfms.org

represent the physicians of San Francisco at the CMA House.

GEORGE P. SUSENS (Incumbent Delegate) Specialty: Internal Medicine Membership: SFMS/CMA 1982 SFMS: Consultant 2003– 09, Immediate Past President 2002, President 2001, President-Elect 2000, Director 1996–99, Medical Staff Liaison to TPMG 1996–99 SFMS Committee Appointments: Finance/ Investment 2001–09, Executive Committee 1997–2002 (Consultant 2003–06), Disaster Planning 2002–06, Nominations 2002/1994– 95, SFMSPAC Board 1997–2002, Judicial 2000– 02, Chiefs of Staff 2001, Bioethics 1986–87, Legislative 1990–95 CMA: Delegate 2000–09/1996–97, Alternate Delegate 1998–99/1993–95 Related Medical Affiliations: Chair, Credentials and Privileges Committee of Kaiser Foundation Hospital 1996–present; Vice Chair, Board of Directors, Northern California Permanente Medical Group 1993–96 Medical School: Northwestern 1962 Hospital Affiliation: Active: Kaiser Permanente Policy Statement: It has been a privilege to serve the San Francisco Medical Society as a delegate to the California Medical Association’s annual meeting. I would like to continue my efforts to influence the CMA’s responses to the hostile environment in which we find ourselves.

The SFMS’s influence on the CMA and AMA is remarkable for our small size. As I said when I was elected President of the SFMS, “I feel we are the conscience of CMA.” Physician advocacy is effective.

JOHN I. UMEKUBO (Incumbent Delegate) Specialty: Internal Medicine Membership: SFMS/CMA 1980 SFMS: Director 2003–08, St. Mary’s Medical Staff Liaison 2003–08 SFMS Committee Appointments: Executive 2006–07; Physician Membership Services 2007; Fellowship/Wellness 2006; Nominations Committee 2004–05, 1999–2000; www.sfms.org

Executive 2003; Chiefs[PLURAL CHIEFS?] of Staff 2000–02 CMA: Delegate 2008–09; 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 West Bay Area Region Medical School: St. Louis University Hospital Affiliation: St. Mary’s Medical Center Teaching Appointments: Clinical instructor and member of teaching faculty, St. Mary’s Medical Center 1980–present Policy Statement: The San Francisco Medical Society offers many benefits to its members; but in this constantly changing medical environment, the Society must also change to meet the challenges. As your representative on the delegation to the CMA House, my goal is to ensure that the needs of all practicing physicians are heard and considered. While there are many opportunities, what really matters is your daily practice, and that is what we need to focus on. My hope is to be able to contribute as a practicing physician and as your representative in order to allow your practice to be sustainable and allow you to provide the highest quality of care to patients. In order to fulfill our mission, we need the collective strength of all physicians practicing in San Francisco to join the San Francisco Medical Society.

CHARLES J. WIBBELSMAN (Incumbent Delegate) Specialty: Pediatrics/Adolescent Medicine Membership: SFMS/CMA 1985 SFMS: President 2009; President-Elect 2008; Treasurer 2007, Secretary 2006, Director 2003–05 SFMS Committee Appointments: Executive 2006–09, PAC 2008–09; Finance/Investment 2007–09 (Chair 2007); Physician Membership Services 2006–09 (Chair 2008); Judicial 2008–09; Nominations 2006–07 CMA: Delegate 2008–09; Very Large Group Practice Forum Delegate 2001–07, VLGPF Alternate 1996–97/1999–2000, SFMS Alternate

Delegate to the CMA 1996–97 Related Medical Affiliations: President of Professional Staff, Kaiser Foundation Hospital, San Francisco 2002–04; Vice President of Professional Staff, Kaiser Foundation Hospital, San Francisco 2001–02; Board of Directors, the Society for Adolescent Medicine 2002– 05/1997–99; President, Northern California Chapter of the Society for Adolescent Medicine 1989–1997; Board of Directors, USF Center for Child Development 1999–2001; medical guest host, KRON Morning Show 2002–03; member, American Federation of Television and Radio Artists 2002–07; North American Society for Pediatric and Adolescent Gynecology 1999–2006; Committee on Adolescence, the American Academy of Pediatrics 2003–present Medical School: University of Cincinnati 1970 Hospital Affiliation: Kaiser Foundation, San Francisco Teaching Appointments: Clinical Professor of Pediatrics, UCSF Policy Statement: As a physician practicing medicine in San Francisco since 1976, I have had the opportunity to observe health care delivery from two very different perspectives: initially as a physician with the Public Health Department and, for the past thirty years, as a pediatrician in a group model HMO. In both spheres of practice, quality of medical practice, access to care, and culturally competent care to diverse patient populations are high priorities. The San Francisco Medical Society has the unique role to provide leadership and guidance in achieving these goals of practice through its delegation to the CMA and as a recognized leader of organized medicine in San Francisco.

As a voice for physicians in San Francisco, the Medical Society helps maintain a high level of professionalism in medicine and serves as an advocate for physician wellness in these turbulent times of change. Currently, as President of the Medical Society this year, I have realized the importance and positive results of advocacy in effecting changes in legislation both on a local and state level. I would be proud to carry on this tradition of leadership and community recognition.

JOSEPH WOO ALSO CANDIDATE FOR BOARD. See biography under “For Board of Directors.”

October 2009 San Francisco Medicine 29

Independent But Not Alone.

Richard Ward, M.D. Hill Physicians provider since 1994.

Uses Ascender preventive health reminders and RelayHealth online communications for patient care and ePrescribing solutions.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians.

• Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Preventive care and disease management reminders for patients • Deep discounts on EMR and EPM solutions That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.

Your health. It’s our mission.

Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin: Paula Schmit, regional director, (209) 762-5002, Paula.Schmit@hpmg.com Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.

30 San Francisco Medicine October 31 San Francisco Medicine October 2009

www.sfms.org

The San Francisco Medical Society: Advocating for Physicians and Patients As San Francisco Medical Society members know, since its inception in 1868 SFMS has been an activist organization when it comes to the health of our community. Many projects and activities that have begun in San Francisco have gone on to have implications for the state and the nation. Here are some highlights from the current SFMS community health agenda.

Agenda for 2009 • Preserving the safety net and public health programs in times of severe budget cuts. Opposing Proposition 1D and 1E in special election.

• Testifying in support of antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies. With the California Medical Association, submitting amicus brief opposing lawsuit to overturn the ban.

• Working with Mayoral Task Force to develop and support the Healthy San Francisco program and participating in the lawsuit to preserve the program.

• Providing physicians for medical consultation for the San Francisco Unified School District.

• Working on legislation to allow minors to receive vaccines to prevent STIs without parental consent.

• Participating in the Hep B Free program in San Francisco and educating physicians and patients on prevention and treatment of hepatitis B.

SFMS Community Health Activities

REBUILDING AND PRESERVING SAN FRANCISCO GENERAL HOSPITAL: SFMS spokespersons have taken a lead in advocacy for full funding of the necessary seismically sound rebuild and in acting on the Mayoral committee to advise where and how that would occur. Many of our members and leaders trained and have practiced at SFGH. UNIVERSAL ACCESS TO CARE: SFMS leaders have long advocated that every San Franciscan should have access to quality medical care, and most recently our representatives served on the Mayoral Task Force that designed the Healthy San Francisco program. SFMS joined in the lawsuits to preserve that program as well. SFMS members advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s.

ANTI-TOBACCO ADVOCACY: SFMS advocates were in leadership roles in the banning of tobacco smoking in San Francisco restaurants, ahead of the rest of the state and nation; we advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and more. SFMS recently signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies.

HIV PREVENTION AND TREATMENT: The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more.

SCHOOLS AND TEEN HEALTH: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and worked on improving school nutritional standards; it provides ongoing medical consultation to the SFUSD school health service. In addition, SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent.

ENVIRONMENTAL HEALTH: SFMS’s many environmental health efforts include establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures.

REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and national leader in advocating for women’s reproductive health and choice, including access to all medical-indicated services.

www.sfms.org

October 2009 San Francisco Medicine 31

Hospital News Chinese

Joseph Woo, MD

On September 18th, our medical staff, IPA, hospital and health plan cohosted an event to honor two individuals who have contributed so much to the health and well-being of the Chinese community over the past forty years.

My well-respected friend, Dr. Raymond Fay, will be retiring soon. In fact, he has already turned over the reins of his practice to Dr. Wenwu Jin. Dr. Fay has been in private practice urology in Chinatown since he finished his training. He originally went to medical school here at UCSF, a urology residency at UCLA, and even added fellowships in nephrology and pediatric urology. He is a pioneer in so many areas and was a leader at Children’s Hospital, California Pacific, St. Francis, and was our Chief of Surgery here at Chinese. He is also well known for teaching and research and he strived to be at the forefront of advancements in his field. In fact, he was using and lecturing on electronic medical records more than a decade ago. I will miss his gifted storytelling and his numbingly consistent golf game. I hope he and his wife, Ingrid, will be happy in their new lives on the golf course in Novato. Dr. Collin Quock has long been known for being a gifted cardiologist and a man of the highest ethical standard. His father was a trustee of our hospital and his son, Dr. Justin Quock, continues their dedication in caring for this Chinese community. As most of you would expect, Dr. Quock’s CV reads like a book; however, it is most impressive not for its length but rather the diversity of areas in which he has achieved high honor. He is our past chief of staff, professor emeritus at UCSF, American Heart Association, Chinatown Association leader, even knighted by the Pope!…it goes on and on. Truly, Dr. Quock’s importance to our hospital and community cannot be overstated. However, he stressed to me recently that he is not retiring, only embarking on new endeavors. Sir Collin, thank you for your leadership and I am proud to be your friend and colleague!

CPMC

Damian Augustyn, MD

On September 9, 2009, CPMC launched a new IBD Center to offer an alternative for patients battling Crohn’s disease, ulcerative colitis, IBS, celiac disease, and other GI disorders. It is a “center without walls” in that it is not housed in a single building; instead, it’s a collective grouping of physicians spread throughout CPMC. Patients needing help will be referred to a physician member of the IBD Center for specialist care. In addition to providing highquality medical care, the IBD Center will also offer psychiatric support to help patients cope with the emotional and psychological impact of their diseases; patients can also get expert advice on nutrition and other lifestyle choices that can help them keep their conditions under control. Patients needing more advanced care will also have full access to CPMC’s state-of-the-art interventional endoscopy services. Innovative design combined with world-class medical care are making the new California Pacific Regional Rehabilitation Center one of the most amazing, interactive acute care rehabilitation units in the country. High-tech tools, such as beds that talk in more than 20 different languages, will play a vital role in helping patients recovering from a stroke, brain, or spinal injury. Other tools include a patient lift system that can hold patients weighing up to 1,100 pounds. The lift is part of an overhead rail system that allows patients to move safely from bed to chair, from room to room, even to move around the unit, reducing the risk of injury to themselves and to staff. The lift can also help patients relearn how to walk, taking their weight off their legs as they slowly regain strength, endurance, and self-confidence.

There are low-tech innovations, too. On the corridor floors there are colored tiles every ten feet to help patients see how far they have walked, enabling them and their therapists to chart their progress. Each room has mirrors and mirrored TV screens to help patients practice facial muscle exercises—particularly important for people recovering from a stroke.

32 San Francisco Medicine October 2009 33 San Francisco Medicine October

Saint Francis

Patricia Galamba, MD

Greetings from Saint Francis Memorial Hospital. On July 1, 2009, I assumed responsibilities as Saint Francis’ chief of staff. I am honored to have been selected by my peers for this post. In the short time since my appointment, I can report a growing respect for my predecessors, especially our outgoing Chief of Staff Wade Aubry, MD. On behalf of the entire medical staff, we thank you for your leadership and commitment to Saint Francis.

In keeping with the theme of this issue of San Francisco Medicine, The Next Generation of Medicine, I am happy to report that Saint Francis has been actively recruiting its next generation of physicians. In the past several years we have brought in a significant number of young primary care physicians and specialists. These young men and woman represent the future of our hospital’s medical staff, and we want to encourage them and support them as they build successful practices.

Since 2003, Saint Francis has supported a Women Physicians Dialogue Group, which meets on a quarterly basis in the early evenings. Originally the group was formed to help women physicians connect with their female colleagues. The program has thrived over the past six years and has provided a wonderful way for women to share information on a professional level.

I would be remiss if I did not mention that Saint Francis completed Phase I of its fourphase surgery department remodel in August.

The result is three new, large operating rooms complete with state-of-the-art anesthesia, surgical equipment, computerized imaging, and light booms. Prior to opening the suites for surgical cases, the hospital hosted two openings: one for members of our medical staff and boards and the other for donors and friends of Saint Francis. The operating suites were open for business on August 12. www.sfms.org

Hospital News St. Mary’s

Richard Podolin, MD

San Francisco is recognized around the world as a diverse and cosmopolitan city.

Here at St. Mary’s Medical Center, we reflect the diversity of San Francisco and, more importantly, the diversity of our neighborhood.

Bordered by the Richmond, Haight-Ashbury, Sunset, and Cole Valley, St. Mary’s has been a cornerstone for these neighborhoods. As a community hospital, we understand our integral role in the lives of our neighbors, and we work very hard to serve these communities.

We are Catholic and Protestant and Buddhist and Jewish. St. Mary’s was the first hospital in San Francisco to offer kosher meals. We are male and female, gay and straight. Our physicians speak English, Russian, Spanish, Italian, French, Cantonese, Mandarin, Japanese, Vietnamese, and Hindi. Every room is equipped with a dual-headset telephone with a direct line to a service providing translation for more than 160 languages, from Acholi (spoken in Sudan and Uganda) to Zulu.

But we know that the barriers to communication among people with diverse backgrounds can be more subtle, and far more profound, than those caused by language differences alone. I would urge anyone interested in this to read The Spirit Catches You and You Fall Down, by Anne Fadiman. This eloquent and moving book describes the catastrophic consequences when parents and health care providers from different cultures, motivated to do their best for a child, trying their best to communicate, fail to bridge a cultural divide.

At St. Mary’s we welcome the collaboration of family members and community and spiritual leaders as we strive to understand, and serve, the needs of all our patients. We know that the real key to providing excellent care in a diverse community is the willingness to listen carefully, with a respectful mind and an open heart.

www.sfms.org

Veterans

UCSF

Diana Nicoll, MD, PhD, MPA

Elena Gates, MD

A new study shows that more than onethird of first-time V.A. patients who served in Iraq or Afghanistan have mental health issues.

Among 289,328 veterans of Iraq or Afghanistan who used the V.A. medical system for the first time between April 1, 2002, and April 1, 2008, 37 percent received a diagnosis of a mental health problem, according to a study of national V.A. data conducted by researchers at the San Francisco V.A. Medical Center. Diagnoses included 22 percent with posttraumatic stress disorder, 17 percent with depression, 7 percent with alcohol use disorder, and 3 percent with drug use disorder. “What’s really striking is the dramatic acceleration in mental health diagnoses, particularly PTSD, after the beginning of the conflict in Iraq on March 20, 2003,” says lead author Karen Seal, MD, MPH, a staff physician at SFVAMC. For active-duty personnel, the risk of being diagnosed with PTSD increased by more than four times after the invasion of Iraq, while for National Guard and Reserve members, the risk increased sevenfold. Seal says the study was not able to determine reasons for the increase in mental health problems after the start of the Iraq war, but the authors offer several possible explanations, including “waning public support and lower morale among troops,” as occurred during the Vietnam war era, and “multiple and more lengthy deployments.” The youngest cohort of active-duty veterans—ages 16 to 24 years—were at significantly higher risk for PTSD and alcohol and drug use disorders than active-duty veterans over 40, while, among Guard and Reserve members, those over 40 were at significantly higher risk for PTSD than their colleagues under 25. Women overall were significantly more prone to depression. To prevent what they term a wave of “chronic mental health and social and occupational problems” among veterans, the study authors recommend targeted screening for mental health problems and early interventions.

The flagship program of the Haile T. Debas Academy of Medical Educators is the Teaching Improvement Program, Teaching Observation Program, or “TIP TOP.” Faculty may request an observer assess teaching in a lecture, clinic, or even in the OR. Academy Director and Professor of Medicine Molly Cooke, MD, said the resulting mentor/protégé relationship benefits both sides. “Especially in a research-intensive environment like ours, the teaching mission can become something of a stepchild,” said Cooke. “The role of the Academy is to make sure teachers get the support, recognition, and resources to make teaching the central focus that it should be.”

UCSF’s School of Medicine offers new models for clinical education, pairing students with practicing physicians across specialties for up to one year. These ambulatory preceptorships replace core clerkships, and give students a longitudinal, mentored experience with patients, health care settings, and clinical supervision. Helen Loeser, MD, MSc, associate dean for Curriculum, notes students can learn by authentic engagement in patients’ care, becoming their advocates, and developing skills and mentorship with their physician preceptors. “The student might call a patient to see if he had found a local smoking cessation program, for example, and whether he can get there,” Loeser said. The Pathways to Discovery Program helps learners develop knowledge and skills to contribute to health beyond the care of individual patients. The Program offers five “pathways” of specialization and is available to students from four professional schools, graduate students, residents, and clinical fellows. Participants collaborate with faculty to design mentored projects on topics such as biomedical or clinical investigation, global health, medical education, and the intersection of health and society. “The curricula prepare learners for independent work and leadership to shape healthcare in their future careers,” said Josh Adler, MD, Pathways director and UCSF chief medical officer.

October 2009 San Francisco Medicine 33

Health Policy Perspective

Not So Sweet

Steve Heilig, MPH

Sugar Politics Versus Health

W

hen the San Francisco Chronicle front-page story titled “S.F. looks at fee on soft drinks” hit the streets and Internet in September, a couple of reactions were predictable. First, an outburst of mostly anonymous online comments—more than 1,000 on the first day—with a flavor reminiscent of a group of preschool children who had themselves consumed too much sugar. Second, denunciations by the soda beverage industry and at least one so-called “consumer” group funded by them.

For many of us in the health field, however, there was another reaction to the soda tax/fee proposal: “What has taken so long?”

Ideologies aside, the rise in obesity presents a looming health disaster, but also an economic one. As noted by UCLA and California Center for Public Health Advocacy researchers whose study provoked the latest local proposal, $41 billion is spent treating obesity in our state annually.

There are many reasons for increased weight, but there is no denying that childhood consumption of sugar can play a significant role. Over half of teens drink at least one soda per day, entailing thirty-nine pounds of sugar annually. Overall, soda consumption accounts for almost half of the increased calories Americans eat daily compared to thirty years ago.

At the same time the California study was released, a team of leading figures in food and nutrition published a paper titled, “The Public Health and Economic Benefits of Taxing SugarSweetened Beverages” in the New England Journal of Medicine.

These physicians and other researchers, from Yale, Harvard, and elsewhere, produced a document that should be required reading for anybody interested in this topic—perhaps before they post comments online or send angry letters to newspapers.

The health aspects of overconsumption are now obvious, including not just obesity but diabetes and heart disease, two of our leading and increasing killers. The NEJM paper convincingly outlines “sugar science” but also provides an important look at the financial side of the issue. As has now been learned from long experience with tobacco, by taxing sodas we can not only generate much-needed revenue for health services but also discourage consumption, particularly by children and teens.

Although a majority of states already have a soda tax in some form, the NEJM authors propose a national tax of one cent per ounce, which would generate around $15 billion per year—$1.8 billion in California—and also lead to weight loss among soda drinkers. The revenue should be used for child nutrition and obesity education and treatment programs, they propose. Dental

34 San Francisco Medicine October 2009

care might logically be thrown into the mix as well.

The proposal makes economic sense, even for those who might consider themselves “conservative” in financial policy matters. In fact, Adam Smith, figurehead of free-market economic theory, held that sugar was “an extremely proper subject of taxation.” Modern economists identify some costs of a product or transaction as “externalities” when those costs are borne by third parties. Pollution has long been cited as an example of an externality cost, which is one reason why environmental regulations exist. Obesity and other attendant health costs are externalities of the sugar market. We all pay, or will pay, everincreasing amounts for those costs via tax-funded health care, education, and other expenses—and we even subsidize the production of sugar and its evil twin, high fructose corn syrup, to the tune of $3 billion annually. Why not have the producers and consumers cover more of their fair share?

One answer is that such a tax would likely produce the desired effect of reduced consumption and, thus, the appearance of new beverage-industry lobbying groups such as “Americans Against Food Taxes,” similar to the now-defunct “Tobacco Institute.” So far, expensive lobbying has gutted such tax proposals from public budgetary proposals, including those for health system reform. Proposals to reduce subsidies for sugar have also been killed politically.

Leading nutrition expert Dr. Marion Nestle, author of a number of landmark books on food policy, recently noted that our national sugar policy is “ripe for satire,” and of course she also succinctly advises everyone to “eat less sugar.” That will be a long battle, as with decreasing tobacco smoking, but it will be a worthy one. Recall that tobacco was once a widely subsidized product, and that half of Americans used it. We still have a long way to go there, but we have come a long way as well, sometimes using approaches that seemed extreme when first proposed.

Physicians of almost any specialty are now seeing and lamenting how many of their patients are overweight. Polls show that a majority of Americans support sugar taxes, especially if the revenue is used for related health programs. It’s time to vote with science, economics, and what is increasingly seen as common sense, and increase taxes on sugar, high fructose corn syrup, and sweeteners in whatever guise they are marketed, especially when they are marketed to young people. The alternative is the increasingly bitter status quo.

The SFMS will take a policy resolution in favor of increased sugar taxes and reduced sugar subsidies, codrafted by Jordan Shlain, MD, and Steve Heilig, to the CMA annual meeting this month. www.sfms.org

Now, more than ever.

Becoming disabled could stop your income. Do you have a reliable financial source to help replace it?

Three in ten entering the workforce today will become disabled before retiring1. A disabling injury will sideline one in five Americans for at least a year before they reach age 652; one in seven for five years or more3.

San Francisco Medical Society members can turn to the SFMS-sponsored Long Term Disability Insurance Plan. This plan is designed to provide a monthly benefit of up to $10,000 if you become Totally Disabled.

Members age 50–59 are eligible to apply for up to $6,000 per month.

Visit www.MarshAffinity.com/ cmadownload.html for more information and an enrollment kit.

Administered by:

Please call a Client Service Representative at 800-842-3761 or visit www.MarshAffinity.com/ cmadownload.html to download an enrollment kit.

Let us show you how your membership in the Society can save you money.

Social Security Administration, Fact Sheet January 31, 2007 Life and Health Insurance Foundation for Education, November 2005 3 ”Commissioners Disability Table, 1998,” Health Insurance Association of America, the New York Times, February 2000 1 2

Underwritten by:

Sponsored by:

42612 (9/09) ©Seabury & Smith Insurance Program Management 2009 d/b/a in CA Seabury & Smith Insurance Program Management • CA License #0633005 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 and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

Hartford Life and Accident Insurance Company, Simsbury, CT 06089. The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life and Accident Insurance Company. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. (AGP-5719) • #3-924

When was the last time a doctor came to YOU?

At California Pacific Medical Center’s Atrial Fibrillation and Arrhythmia Center we are com-

mitted to a comprehensive team approach in treating your patient. Whether a patient is having debilitating palpitations, recurrent syncope or severe heart failure, sensitive and difficult challenges await – for them and their family.

We are Andrea Natale, M.D., Steven Hao, M.D. and Richard Hongo, M.D., electrophysiologists who specialize in complex ablation procedures.

In fact, we have the highest atrial fibrillation ablation volume on the West Coast; last year, we performed over 450 procedures. We would

like make an appointment to see you in your office. Why?

We’d like the opportunity to acquaint you with our facilities, staff and equipment – including California Pacific’s new Stereotaxis lab. We’d also like to help familiarize you with referral indicators for your patients with arrhythmias, particularly atrial fibrillation.

The Atrial Fibrillation and Arrhythmia Center offers: •

Board certified, fellowship trained cardiac electro- physiology specialists

•

State of the art technology and facilities for the treatment of arrhythmias

•

Nationally and internationally recognized expertise in complex ablations, providing care for patients and education for physicians throughout the world

•

In 2008, HealthGrades® ranked California Pacific “Best in the San Francisco Area for Cardiology and Overall Cardiac Services”

•

Dedicated arrhythmia nurse and nurse practitioner to provide continuity from the consultation through the procedure to follow ups

Let’s schedule an appointment for a visit to your office: 415-600-7459

www.cpmc.org/services/heart