June 2018

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

HEALTHCARE ETHICS ENDS AND MEANS: Healthcare Reform as an Ethical Value Preparing Patients for the End Clinical Ethics Consultation Assisted Dying in Practice — and in Limbo Advance Care Planning Shared Decision-Making

PLUS: Guns, Soda, Burnout, CURES, and more Volume 91, Number 4 | June 2018

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE June 2018 Volume 91, Number 4

Healthcare Ethics Ends and Means FEATURE ARTICLES

OF INTEREST

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27 Healthcare Is a Universal Value. It’s Time for a Universal Effort.

Sandra R. Hernández, MD, MPH

I’m a Doctor. Preparing Patients for Death is as Much a Part of My Job as Saving Lives.

Shoshana Ungerleider, MD

10 The History and Ethics of Shared Decision-Making in Healthcare: A Perspective

Lael Conway Duncan, MD

12 Integrating Ethics Within a Healthcare System: A Model Clinical Ethics Consultation Service — and Beyond

Guillermo Palchik, PhD, and William S. Andereck, MD, FACP 14 Advance Care Planning and POLST: Promise and Pitfalls

Karl Steinberg, MD

Physician-Assisted Dying:

28 Your Guns or My Money: Divestment from a Public Health Crisis

Steve Heilig, MPH 29 Soda Tax Starts Paying Off

Nuala Sawyer

30 CMA Urges DOJ to Take Steps to Ensure Smooth Transition to CURES Mandate.

32 SFMMS Spotlights Two Father-Son Physician Duos in Honor of Father’s Day.

The State of Practice, Policy, and Pitfalls 17 Best Practices for Aid in Dying: Recommendations from the Bedside

Lonny Shavelson, MD

34 SFMMS Advocacy Activities: A History of Advocating for Community Health 36 In Case You Missed It: Physician Burnout Costs Up to $17B a Year, Task Force Says.

20 The End of Life Option Act: A Right for the Privileged?

Monique Schaulis, MD, MPH

22 Responding to the End of Life Option Act: Individual, Institutional, and Statewide Perspectives

Lindsay K. Forbes, Cristina Nigro, MS, Barbara A. Koenig, PhD

25 Teaching by Example: Albert R. Jonsen and Bioethics at UCSF

Barbara Koenig, PhD

MONTHLY COLUMNS 2

Membership Matters

5

President’s Message John Maa, MD

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PROPOSITION E VICTORY: San Francisco’s landmark ban on flavored tobacco products was upheld by a 2–1 margin, despite the tobacco industry spending over $11 million to overturn it. The SFMMS favored such a ban since 2010, convinced the CMA to do likewise, and worked hard on this effort. San Francisco again leads in anti-tobacco advocacy!

Editorial: Doing No Harm — In Clinic, Capitol, or Courtroom Gordon Fung, MD, and Steve Heilig, MPH

23 Classified Ad

33 Upcoming Events 35 Community News: Kaiser Permanente

Maria Ansari, MD

SAN FRANCISCO

MARIN MEDICAL SOCIETY

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

MEMBERSHIP MATTERS Recognizing the Contributions of Women Physicians; Marin Medical Society Formed

Marin Medical Society, 1898 Dr. Lucy Wanzer and Dr. Charlotte Brown

Though organized medicine had been slow to rec-

ognize the contributions of female physicians, in 1877, following the leads of the state and national medical societies, the San Francisco Medical Society accepted the first woman into its membership — Dr. Lucy Field Wanzer, who was also the first woman to graduate from UCSF in 1876. The contributions of women physicians further became clear when Dr. Charlotte Blake Brown and Dr. Martha Bucknell and other women members of the medical society, including Dr. Wanzer, joined together to lay the foundation for the Pacific Dispensary for Women & Children, which became the San Francisco Hospital for Children in 1878. It was one of the largest hospitals devoted entirely to women and children patients, with a governing board of women, and an administration and staff largely of women. It was also the first hospital to offer internships and residency training to women physicians in the West.

Thirty years after the San Francisco Medical Society was formed, rural doctors in Marin County joined together to form the Marin Medical Society in 1898. The purpose of the society was to build a healthier Marin County, to encourage quality healthcare and to serve the community.

It wouldn’t be until 1937 that the Marin Medical Society elected its first female president, Dr. Ann Brady, and not until 1960 that the San Francisco Medical Society elected its first woman president, Dr. Roberta Fenlon. Collectively, the San Francisco Marin Medical Society has been led by 14 female presidents.

San Francisco Hospital for Children

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Physicians Converge on Sacramento to Voice Opposition to AB 3087 Twenty SFMMS membersjoined more than 500 phy-

sicians and physicians-in-training throughout California to participate in CMA’s Legislative Advocacy Day in April. SFMMS members met with legislators to share their concerns about AB 3087, a now-defeated bill that would have created a commission of unelected political appointees empowered to arbitrarily cap rates for all healthcare services in all clinics, hospitals and physician practices in California. The bill would have driven physicians out of California or into early retirement. Due in large part to staunch opposition led by CMA, the bill died in the Assembly Appropriations Committee. Key to the bill’s demise was a groundswell of physician opposition, including the actions of our SFMMS members. SFMMS and the CMA applaud the Assembly for recognizing that this deeply flawed legislation would result in enormous costs to the state and restricted access to care for millions. CMA remains fully committed to working with stakeholders on a practical solution that addresses the affordability and accessibility of healthcare in California.

Members of the SFMMS contingent on Legislative Advocacy Day

WWW.SFMMS.ORG

Gun Violence Prevention Advocacy Stories The American Academy of Pediatrics is collecting physician sto-

ries about the impact of gun violence. Senator Feinstein’s office requested stories that can be used in hearings if the assault weapons legislation she wrote with Jeff Flake to raise the minimum age to purchase assault weapons from 18 to 21 moves forward. Please add your own stories/perspectives and invite colleagues in your practice who may want to share their experiences as well. Remember to de-identify patient information so as to comply with HIPAA. Visit http://bit.ly/2wxdb5b to contribute to the Google form.

Physicians Must Check CURES Database Prior to Prescribing Effective October 2, 2018, physicians must consult CURES prior to

prescribing Schedule II, III or IV controlled substances to a patient for the first time and at least once every four months thereafter if that substance remains part of the patient’s treatment. Physicians must consult CURES no earlier than 24 hours or the previous business day prior to the prescribing, ordering, administering or furnishing of a controlled substance to the patient. This law provides, however, that the requirement to consult CURES would not apply if doing so would result in the patient’s inability to obtain a prescription in a timely manner and adversely impact the patient’s conditions so long as the quantity of the controlled substance does not exceed a five-day supply. Read more at http://bit.ly/2KSqikC.

New Coalition Supports Independent Physician Practices in Leading Value-Based Care Movement Recognizing the importance of independent physician practices in

bringing about the movement to value-based healthcare, a group of leading healthcare organizations, including the CMA, have joined together to form the Partnership to Empower Physician-Led Care (PEPC). PEPC will focus on education and advocacy to urge action on four policy priorities: advancing physician-led alternative payment models; ensuring an equitable policy framework that promotes choice and provider competition; creating new opportunities for physicians in commercial markets such as Medicare Advantage; and supporting consumer-directed care. Read more at http://bit.ly/2ry48vB.

All of Us Research Program Launched The All of Us Research Program is a national effort to recruit a

million or more U.S. volunteers to share their health information and inform the research and treatments that will lead to tailored medicine, and better health outcomes for communities — especially those that have been historically underserved. The National Institutes of Health (NIH) is partnering with community and provider groups, including the National Council of Asian Pacific Islander Physicians (NCAPIP), to make sure that the word gets out to Asian American, Native Hawaiian, and Pacific Islander (AANHPI) communities and the providers who serve them. Learn more at http://bit.ly/2IutQLn.

Short-Term Medical Volunteers Needed in Haiti Global Health Teams (GHT) is looking for physicians, mid-level

providers and nurses for one-week primary-care medical clinics in rural Haiti every February, June and October. This is a rewarding opportunity to work with the people of Haiti and provide care in a rural clinic in a medically-underserved area. GHT, an experienced U.S.-based nonprofit operating these clinics since 1998, coordinates all in-country travel and logistics. Visit globalhealthteam.org for more information, or contact Bob Downey at (619) 905-7157 or bob@globalhealthteam.org to apply.

WWW.SFMMS.ORG

June 2018 Volume 91, Number 4 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Linda McLaughlin EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Erica Goode, MD, MPH Shieva Khayam-Bashi, MD Arthur Lyons, MD John Maa, MD David Pating, MD SFMMS OFFICERS President John Maa, MD President-Elect Kimberly L. Newell Green, MD Secretary Benjamin Franc, MD, MS, MBA Treasurer Brian Grady, MD Immediate Past President Man-Kit Leung, MD SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Membership Coordinator Ruben Pambid SFMMS BOARD OF DIRECTORS Charles E. Binkley, MD Peter N. Bretan, Jr., MD Alice Hm Chen, MD Irina S.C. deFischer, MD Nida F. Degesys, MD Robert A. Harvey, MD Imran Junaid, MD Naveen N. Kumar, MD Michael K. Kwok, MD Raymond Liu, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD Michael Scahill, MD, MBA Monique D. Schaulis, MD Michael C. Schrader, MD, PhD, FACP Dennis Song, MD Jeffrey L. Stevenson, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo , MD Albert Y. Yu, MD, MPH, MBA

JUNE 2018

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PRESIDENT’S MESSAGE John Maa, MD

Healthcare Reform: An Ethical Issue Too The eight-year anniversary of the Affordable Care Act arrived in the shadow of successful efforts by the Republican party to repeal the ACA’s core intent — the individual mandate.

As the ACA was stalled, other efforts to reform our healthcare system are accelerating. In 2018 “Single-Payer” is in the air once again, most recently as California Senate Bill 562.

It’s important to dispel myths about these proposals, however. In the frustration with our confusing and expensive system, many physicians want change. But one must also be careful what you ask for. The best answers rest in reframing the healthcare debate through the lens of ethics, with the understanding that healthcare is a public good. Future decisions should be based on what is best for society, and not in response to the most vocal or most powerful.

“We believe that every Californian deserves access to timely, quality healthcare and affordable coverage,” said CMA President Theodore M. Mazer, MD. “Unfortunately, SB 562 would wreak havoc on the market, forcing existing successful models aside while destabilizing the state budget — it’s simply unaffordable and fails to recognize real-world access and market dynamics.”

Now shelved, SB 562 would have eliminated Medi-Cal, Medicare, all private insurance and Covered California for a healthcare insurance product provided by the state, without offering a way to pay for it. The Legislative Analyst’s Office estimated the cost in the low hundreds of billions of dollars with lower funding for schools and community colleges. SB 562 would force healthcare groups to battle public education advocates for state budget dollars, forcing hard choices between funding quality education and quality healthcare.

Single-payer might help rein in some costs, but at what overall cost? Is it odd that such proposals as SB 562, which seek to reduce costs, would cost our state hundreds of billions of dollars? One may wonder why our single-payer systems in the VA and Medicare/Medicaid haven’t already solved the problem with the pricing data at their disposal. Why hasn’t either fixed the drug price and cost containment issues?

Single-payer is just one path to the larger aspirational goal of universal healthcare. The CMA in April announced support for a new package of legislation to achieve universal access by strengthening Medi-Cal, restoring the individual mandate, providing subsidies, insuring undocumented immigrants, among other steps forward. Unfortunately, these efforts were derailed almost instantly.

The real answer is for physicians to lead, to reframe and enlighten the discussion, and to not delegate these important financing decisions to others. The time has arrived for WWW.SFMMS.ORG

physicians to undertake the difficult tasks of both advocating for their patients while acknowledging their personal self interest. Many of the challenges that medicine faces were created by the business sector, and continuing on the path of businessdriven decisions and money-driven medicine would be a mistake. The solutions will come by focusing on principles and values; healthcare that is humane, ethical, equitable, universal, free of fraud and profiteering, and also in recognizing that our society cannot afford to pay for all of the medical care that everyone would wish to receive.

All members involved in healthcare delivery (including patients and administrators) should be held accountable, to protect the framing of healthcare as a public good to be shared for the benefit of all. Our healthcare delivery system is complex, and we need to bring an end to the culture of blaming that has characterized the health debate in the past decades.

Our patients and nation expect us as health professionals to strive towards this higher goal. At its best, America has the finest healthcare delivery system in the world, thanks to the cutting edge research and care provided by physicians across America. More Nobel Prizes in Medicine and Physiology have been awarded to Americans than all of the other nations in the world combined. Forty percent of the world’s medical tourists travel to the US to receive care.

What gives me the greatest hope in the health reform debate in 2018 is the number of physician executives who now hold leadership positions in America’s hospitals. Some of the nation’s leading experts in healthcare reform have recognized that a key limitation with the efforts over the past decade was the inadequate involvement of MDs in crafting the ACA. The most ethical action now would be to remedy that deficiency and invite the physician community as a key stakeholder to the table to lead the effort far forward.

Dr. John Maa attended UC Berkeley and Harvard Medical School, completing his surgery residency at UCSF, and also completed a fellowship at the UCSF Institute of Health Policy Studies and has been president of the Northern California chapter of the American College of Surgeons. He is the chief of the Division of General and Acute Care Surgery at Marin General Hospital and on the medical staff of Dignity-St. Francis Hospital.

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

DOING NO HARM — IN CLINIC, CAPITOL, OR COURTROOM The most durable and succinct medical ethics dictum of all must be “First, Do No Harm.”

While the original Hippocratic Oath itself has widely been amended and sidelined in favor of more modernized codes, doing no harm has endured as an ethical baseline.

Many have wished that more professions had a similar guideline. Lawyers and elected officials, for example: As we went to press with this journal issue, California’s legalization of physician-assisted dying (PAD) had just been overturned, at least in theory, by a lawsuit alleging it was improperly enacted.

It was notable that this action was not taken strictly on procedural issues, not on the legality of the law itself, and glaringly not on any clinical or ethical basis. The lawsuit was filed by a religious group opposed to PAD, using any tactic they could find to overturn the PAD law. One headline read “California court opens world of uncertainty for the dying: While patients worry, lawyers debate the meaning of a single vague and contentious phrase.”

And thus patients and physicians again grapple with arbitrary intrusions. Lonny Shavelson, MD, one of our authors in this issue, has set up a PAD practice, becoming something of a lightning rod in the process. Responding to the legal backtracking, he said, “The patients we see are quite sick, quite close to death — and the last thing they need is a procedural kerfuffle like this.”

Many of our readers are aware the the SFMS — pre-SFMMS — was instrumental in getting PAD legalized in our state. This was done by convincing the CMA to become “neutral” on the issue — CMA opposition had long stopped any effort to legalize PAD. SFMS leadership undertook this decades-long effort based mainly on two bases: That aggregated surveys of over 30,000 physicians — the first such survey having been done by the SFMS — indicated a majority of physicians favored at least some sort of legal option; and that long experience in other states now provided good “laboratory” evidence that PAD could be legalized without negative impacts (and even some positive impacts on more general end-of-life care).

California’s Attorney General promptly filed an appeal, also asking that the PAD law remain in place while the legal process grinds on, writing that “overturning the law immediately would leave healthcare practitioners facing possible criminal prosecution and terminally ill patients who qualify under the law left to “die an excruciating, painful death.” But that appeal was rejected, and the legal battle will continue, with PAD again illegal at this time.

WWW.SFMMS.ORG

So, given this legal limbo, you can find herein a packet of articles detailing how legalized PAD had evolved so far. Shavelson’s clinical outline is something of a landmark, as many physicians have asked many questions about how PAD can be best practiced. SFMMS board member Monique Schaulis, MD, outlines how procedures have been set up at Kaiser Permanente, and Lindsay Forbes and colleagues do likewise from UCSF. One most interesting aspect of reading these reports is how the long, heated controversies tend to fade away once the necessity of informed, compassionate clinical approaches takes precedence.

There is much to consider before and beyond PAD, of course.

Another trio of pieces exploring various aspects of end-of-life care come from Shoshana Ungerleider, MD, Lael Duncan, MD, and Karl Steinberg, MD. Suffice it to say here that these are all leading figures in this realm statewide and beyond. And Gilbert Palchik, PhD, and William Andereck, MD, provide an outline of what CPMC/Sutter’s pioneering clinical ethics consult service does. One notable aspect of this service — witnessed by one of your editors (SH) who has long been a part of the program — is that initially some physicians have viewed it as a possibly threatening intrusion into their practice until they actually utilize it, wherein some have perhaps relied upon it too much. And beyond ethics consults, there is much the CPMC program does to heighten ethics education in the hospital settings, showing what real commitment of expertise and resources can accomplish.

Finally, we must mention Albert Jonsen, recalled herein

by Barbara Koenig of UCSF. Jonsen is a living legend of medical ethics. After a tenure as president of the University of San Francisco, he became a founder of UCSF’s ethical programs and teaching, and then wound up co-directing CPMC’s program. Anyone long active in medical ethics would confirm he is one of the handful of guiding figures in the field. Jonsen is still active, and has received just about every award and recognition possible — but the one we must note is that he is the one non-physician to be elected an Honorary Member of the SFMMS — rarefied company indeed.

We trust you will find much of ethical interest herein.

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Healthcare Ethics

I’M A DOCTOR. PREPARING PATIENTS FOR DEATH IS AS MUCH A PART OF MY JOB AS SAVING LIVES. Shoshana Ungerleider, MD

It wasn’t until just before graduation that we talked about what to do when a patient is dying.

A single three-hour seminar with a group of specialists from the palliative care service; at least it was mandatory.

The presenters were young physicians, and they seemed kind and thoughtful. But I wondered why anyone would devote their medical career to end-of-life care. My classmates and I had spent years of medical school sharpening our history-taking skills, learning to recognize heart murmurs, memorizing the drugs used to treat high blood pressure, diabetes, even cancer.

In the final months of school, I’d worked in the ICU, taking care of critically ill patients who required breathing tubes and lifesustaining machines. I’d learned how to perform intubations and place central lines. I marveled at how much I was able to do to help sick people. Nearly all of us became doctors to keep patients alive, to treat them.

I thought: The ultimate treatment failure is death. I graduated medical school and moved on.

When I was a newly minted doctor, I found myself back in the ICU, no longer a lowly medical student but with real responsibilities.

The patients in an intensive care unit are very sick; they require the highest level of monitoring and intervention that a hospital can provide. This particular unit was lined with patient care bays featuring sliding glass doors, glaring white walls, blinking monitors, and little natural light. Alarm bells dinged constantly, and the smell of bleach disinfectant made my eyes water. I began my rounds each morning at 5:00, checking in on my patients and learning about those who had been admitted overnight.

One morning, I came in to a commotion. There were several nurses scurrying around a new patient’s bed, and the night residents were huddled in a corner, concerned looks on their faces. Before I had a chance to ask what was going on, a loud code blue alarm went off overhead, and the team of doctors descended upon the patient. I peered into the room, and underneath the breathing tube and profusion of lines, I saw an elderly man.

The senior resident called out orders. The intern hopped up on a stool next to the bed and began performing rhythmic chest 8

SAN FRANCISCO MARIN MEDICINE JUNE 2018

compressions that cracked the man’s ribs. The nurses pushed various medications into his IV and watched the heart monitor intently. I stared at the spectacle in front of me. This was my first time seeing a code situation. For 30 minutes I watched strangers in masks and gloves race around an unconscious old man, trying everything they could to keep him alive. But after the heart rhythm monitor fell into a flat line, the team pronounced him dead, removed their protective garb, and walked out of the room.

I later learned that an ambulance had brought in the old man for decompensated heart failure. His heart could no longer effectively pump blood to his organs, and he had been drowning in fluid that backed up into his lungs. On arrival, he was immediately intubated and rushed to the ICU. His family members were out of town, and he had not come with advance directive paperwork, a document stating his wishes.

This was not his first trip to the hospital. He had been admitted five times in the previous six months. During his first hospitalization, his records showed that he was a “full code” and that family had wanted “everything done” to keep him alive.

Despite multiple readmissions, the question was never revisited. I wondered whether they knew what “everything” meant.

I learned that the old man was named Mr. Azarov. He was 88 years old, a widower, originally from Russia, where he had worked as a tailor and musician before coming to the United States. In San Francisco, he’d opened a bakery and had led a simple life. Over the months of his hospitalizations, Mr. Azarov had slowly deteriorated, and each time he became weaker. He battled kidney failure, a stroke, and worsening dementia. Well before he came to us for the last time, he had lost the ability to stand up on his own. His adult children were no longer able to care for him, and several months before he died they’d moved him into a nursing home.

I never knew Mr. Azarov, but I realized then that this man had been dying for a long time. He had a brutal, impersonal end, one he received by default. Who would die that way if they had a choice? Expiring in a hospital room, doctors screaming and scurrying and cracking your ribs, away from your friends and family — I wondered how many opportunities there had been to explain his end-of-life options to him or his family. Did WWW.SFMMS.ORG

they understand his prognosis? I’ll never know. But as he lay there alone in the hospital bed, curtains drawn, still attached to machines, I felt as if we’d failed him.

One day, late in my intern year, while working the emergency room, I met a patient named Mr. Jones. He was a botany professor who lived in an affluent suburb outside San Francisco. He was married, with three grown children, and had the amazing fortune of good health over the whole of a long life. But now he was 72, and he was dying of small cell lung cancer.

Mr. Jones was receiving chemotherapy under the care of a reputable oncologist. He’d come into the ER that night because of severe, worsening shortness of breath that made him unable to walk across the room without collapsing. He told me his family was scared and so was he.

When I came in, I saw that Mr. Jones had once been fit and brawny, although now he was worn and thin. We talked for a while. I asked the customary questions about his symptoms, and got the sense that he was a kind man. I explained to him that fluid had built up in his lungs due to his cancer, and that while we could admit him and remove the fluid with a needle, it would only make him feel better temporarily. I told him I believed his cancer had progressed.

I felt unusually at ease talking to Mr. Jones. After delivering the news, I decided to venture into unusual territory: I asked him what he understood about his diagnosis and his future.

He explained that he had read online how he likely had only months to live, but that his oncologist wanted him to continue chemotherapy for now. Then I asked him what he wanted. To my surprise, he paused. After a moment, he looked up, tears welling in his eyes.

“I’ve had a wonderful life,” he said. “I have an amazing family who loves me, and I want to be at home with them, not here in the hospital.” He started crying. He grabbed my hand. “No one has asked me what I want. Can I please go home? All I want is to be home.”

I was shocked. How could this be? I thought. How had we all failed to take a step back from the diagnoses and treatment options and the lab and imaging results to ask the most important question of all? Mr. Jones did not want to be admitted to the ICU. He didn’t want to be intubated and adorned with the lines we use to sustain the dying. He knew there was no cure for his cancer, and he wanted what all of us hope for in the end: to die comfortably. With the help of the case manager and the social worker, I was able to send Mr. Jones home with hospice care early the next morning. I found out that he died in peace, two days later, surrounded by his beloved family.

As doctors, we dedicate most of our time in medical school to learning about the physical body, how things can go wrong and how modern medicine can fix them.

During residency, we acquire methods for analyzing large amounts of data so that we can accurately assess, down to the minute, what is happening with our patients.

But we spend almost no time at all learning about illness in the context of our patients’ lives, or how to heal people when modern medicine provides no cure. We are rarely schooled in how to break bad news compassionately, or how to sit in silence with a grieving family member, or even how to make recommendations for appropriate end-of-life care.

I have become disheartened by the number of patients who WWW.SFMMS.ORG

received invasive treatment in the final days and hours of life.

So many spend their final moments hooked up to tubes and lines in the ICU, alarms beeping in the background, hidden away from the people who care about them. Modern medicine is always poised to offer another procedure or therapy for prolonging life, but it often does so without considering the quality of that life. How much suffering is five more weeks worth? Or five days, or five hours?

I believe we owe it to our patients to have open, honest conversations about what the future holds. Patients and families need to be informed in order to make decisions that are in line with their values.

My patients have all taught me valuable lessons about what a “good death” might look like. Each one has reminded me that there is more to medicine than placing a line to monitor the heart, or performing an intubation. Sometimes the most powerful healing of all comes through the simple act of sitting and listening to our patients with compassion. If I can help someone live the fullest to the very end, I have practiced the best medicine.

Shoshana Ungerleider, MD, is a hospitalist in San Francisco and founder of End Well: Design for the End of Life Experience. https://www.endwellproject.org/

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Healthcare Ethics

THE HISTORY AND ETHICS OF SHARED DECISION-MAKING IN HEALTHCARE: A PERSPECTIVE Lael Conway Duncan, MD “The two words ‘information’ and ‘communication’ are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through.”

—Sydney Harris “The single biggest problem in communication is the illusion that it has taken place.”

—George Bernard Shaw Since its inception in 1998, the Coalition for Compassionate Care of California (CCCC) has been a champion for respecting the voice and the rights of the patient. Beginning with an original focus on the Patient Self-Determination Act (PSDA), CCCC evolved as the home for the California Physician Orders for Life-Sustaining Treatment (POLST) program and led the state towards a much lauded POLST paradigm model. Our current focus on personcentered care for those facing serious illness or end of life brings together our past work on legislation medical orders and public engagement to support the broad goals of personcentered care and to realize everyone’s right to receive palliative care when seriously ill.

This article examines the legal and ethical groundwork that underlies healthcare decision-making, from the initial conception of informed consent to implementation of the patient selfdetermination and considers the horizon ahead.

We are continuously challenged, these days, to adapt to changing circumstances at rates unprecedented in recorded history. The complexity of daily life increases and we struggle to contend with startling amounts of information, exposure, and choice that the modern world not only offers, but brings to our doorstep in great humming cartloads. The healthcare sector is no exception. Here, we see exponential growth in both the amount and availability of data in its myriad forms. Many argue that healthcare offers a complexity of choices beyond that of other settings1. By its nature, healthcare has always concerned itself with life’s most basic elements: birth, body, mind, health, disease, death. Decisions in this realm that are illconsidered, considered late, or not at all, can result in real and lasting harms. The challenges of managing healthcare information and facilitating decision-making will continue to grow in this tech influenced age of genetics, and to impact the way we experience health, manage disease and face mortality. We ignore these challenges and their impact at our peril.

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The nature of most healthcare decisions is such that individuals are often faced with making choices based on limited information during times of stress. Patients often rely on a provider’s expertise or advice regarding options and potential outcomes. Much has been written about the legal and ethical implications of the patient-provider relationship in matters of information transfer, decisions and consent. Our present understanding of shared decision-making is shaped by the history of informed consent and by those legal and ethical arguments that surround and support it. It bears reflection as we consider the future of this important process.

Early case law focused on a patient’s basic right to consent, not on the right to make an informed decision. A landmark case in 1914 considered narrowly the duty of the provider to disclose information.2 The patient, who was admitted to the hospital with abdominal pain, agreed to undergo an examination, but not surgery, under ether. During the exam, surgery was nonetheless performed to remove a fibroid tumor. Following surgery, the patient developed necrosis in the upper extremity and suffered the amputation of several fingers. The unauthorized procedure was considered battery. The findings of the case ultimately affirmed the patient’s right to consent and selfdetermination. Writing for the Court, Justice Benjamin Cordoza stated, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages.”

It was not until the 1950s that the affirmative obligation to disclose information was joined together with the provider’s traditional duty to secure a patient’s knowing consent, and the legal doctrine of informed consent at last emerged.3 Presently, failure to obtain informed consent is viewed by most states as a variety of medical malpractice, subject to the norms for laws governing negligence. Whether failures of informed consent are considered negligence or battery depends on the state and the actions considered.

Despite clear foundations in law, the practice of informed consent remained more of a theoretical ethical imperative than a normalized medical activity throughout the late 20th century and beyond. In 1982 The President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research produced a report on a mandated study of “the ethical and legal implications of the requirements for informed consent to . . . undergo medical procedures.” The Commission noted WWW.SFMMS.ORG

that the ethical foundation of informed consent was focused on two central values: personal well-being and individual selfdetermination.4 In their summary and recommendations, the Commission described in detail the precepts for upholding the rights of the patient to be an informed participant in their own healthcare journey. Among other things, the Commission held that “ethically valid consent is a process of shared decision-making based upon mutual respect and participation, not a ritual to be equated with reciting the contents of a form detailing the risks of particular treatments.” Furthermore, they stated that “informed consent is rooted in the fundamental recognition that adults are entitled to accept or reject healthcare interventions on the basis of their own personal values and in furtherance of their own personal goals” (provided these choices are medically reasonable). The Commission believed that, “Achieving the Commission’s vision of shared decisionmaking based on mutual respect is ultimately the responsibility of individual healthcare professionals. However, healthcare institutions such as hospitals and professional schools have an important role to play.”

A decade later the Patient Self-Determination Act (PSDA) was passed into law.5 The PSDA was the first federal statute to focus on the advance directive and the right of an individual to refuse life-prolonging treatments they felt were inconsistent with their personal goals and values. The PSDA places burdens on healthcare institutions to provide information to patients describing individuals’ legal rights (in that state) in regard to medical decision-making, to document advance directive information in the medical record, to ensure compliance with state law, and, specifically, to avoid bias or discrimination. Despite decades of effort, action and education, the efficacy, prevalence, availably and utility of the advance directive as a tool for protecting patient self-determination, and as a documents intended to represent the outcome of an informed shared decision-making process, have been called into question time and again.

The advance care planning process with informed shared decision-making as its primary activity, and the use of supporting documents are notably under-utilized even among patients with advanced disease.6–9 So, although the process and practice of shared decisionmaking have been defined and described in detail for more than 36 years the practice is not prevalent enough to ensure that care delivery is based on individual values.10–13 The Institute for Healthcare Improvement (IHI), individual researchers and others have demonstrated that shared decision-making is a low-cost, high-value practice, particularly in serious illness.14–16 The general application of shared decision-making goes a long way to supporting the Triple Aim of improved patient experience, higher quality of care and reduced per capita costs17 and, if used on a daily basis, the practice of shared decision-making enhances provider well-being.18 In California, years of work by the CCCC and others to advance the POLST Paradigm, (a program rooted in shared decision-making for person-centered care) has resulted in concordance of care with patient wishes for many tens of thousands of individuals. Sadly, despite the success of POLST, the extensive culture change required to fully achieve personcentered care and access to shared decision-making for the vast WWW.SFMMS.ORG

majority of patients, remains elusive. Full integration of shared decision-making, and uptake of this practice as an essential provider skill, is long overdue.

Laws and statutes dictating integration of shared decisionmaking in specific settings should not be required. Providers do not want, nor should they accept, the intrusion of the courts into exam rooms to comment on and mandate the nature, style and content of private patient and family conversations. Systematic integration of shared decision-making and normalization of the process across all sectors of healthcare delivery must therefore rely on policy changes and payment reforms that support and incentivize the necessary actions and programs. The implementation of shared decision-making has been an ethical imperative; now it is a necessary and urgently needed remedy for an ailing health system. We must implement this process if care is to be equitable and value-based, no matter how great the challenge. This is a call to action.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

Kuziemsky, C. (2016).

Schloendorff v. Society of New York Hosp. (1914).

Salgo v. Leland Stanford Jr. Univ. Bd. of Trustees. (1957).

Making Health Care Decisions. (1982). https://www.congress.gov/bill/101st-congress/ house-bill/4449 Gamertsfelder, E. M., et al. (2016).

McDonald, J. C., et al. (2017).

Feely, M. A., et al. (2016).

Merchant, F. M., et al. (2017).

Han, P. K., et al. (2013).

Blankenburg, R., et al. (2018).

Amundsen, A., et al. (2018).

Zeuner, R., et al. (2015).

Spatz, E. S., et al. (2017).

Bronner, K. (2018).

Weeks, W. B. (2013).

Elwyn, G., et al. (2016).

Dobler, C. C., et al. (2017).

(For a complete list of references, please contact the author: lduncan@coalitionccc.org.)

Dr. Lael C. Duncan is is the medical director of consulting services for the Coalition for Compassionate Care of California, and a licensed California physician with more than 15 years of clinical practice in internal medicine, infectious disease, and long-term acute care for patients with multi-system disease. After graduating with honors from the University of Washington Medical School in 1991, Dr. Duncan did her residency training at Dartmouth Hitchcock Medical Center. She has been board certified in both internal medicine and infectious diseases and pursued further training in the areas of palliative care, Eastern medicine/acupuncture and community organizing for health initiatives.

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Healthcare Ethics

INTEGRATING ETHICS WITHIN A HEALTHCARE SYSTEM A Model Clinical Ethics Consultation Service — and Beyond Guillermo Palchik, PhD, and William S. Andereck, MD, FACP Who We Are: The Program in Medicine and Human Values (PMHV) at California Pacific Medical Center (CPMC) was founded in 2003. One of the authors of this article, Dr. William Andereck, longtime chair of CPMC’s Ethics Committee, conceived of the Program as a response to the threats posed by an increasingly technical, complex, and costly healthcare system to the values and dignity of individual patients. After a generous grant from a private donor, Dr. Andereck recruited his former mentor Dr. Albert Jonsen, a founder in the field of bioethics, to assist in forming a program of clinical consultation, education, policy, and research for the staff and patients of CPMC. While still based at CPMC, the Program has now expanded and provides Ethics Consultation services to Sutter Health’s healthcare team members, patients and their families, throughout a number of Bay Area hospitals. Our role is to assist in making decisions for the very complex patient situations in the setting of a medical tragedy and crisis. Additionally, we offer education and training in how to work through ethically challenging patient cases, as well as conducting research and promoting scholarship.

Where We’ve Been:

The Program has provided close to 2,000 consults since its inception. PMHV currently serves hospitals in San Francisco, the North Bay, Peninsula, and the East Bay — including CPMC, Novato Community Hospital, Sutter Santa Rosa Regional Hospital, Sutter Lakeside Hospital, Mills Peninsula Hospital, Eden Medical Center, and Sutter Delta Hospital.

With the growth of the Program, the pace of consultations Program Programin inMedicine Medicineand and Human HumanValues Values Yearly YearlyEthics EthicsConsultations Consultations 1985-2017 1985-2017

500 500

has been exponentially increasing and in 2017, we provided service in 411 consults, the highest for the Program so far. This represents an outstanding accomplishment for PMHV, and it showcases the recognition that Sutter Health places in our services to patients and clinicians.

What We Do:

Although anyone involved in a patient’s care (healthcare provider, patient, etc.) can request an ethics consultation, most consultation requests continue to come from physicians (most frequently by the attending physician), and this number has been steadily growing. In 2017, over 60% of our consults were called by doctors in need of assistance in making tough choices for their patients and their families. Social workers and case managers also consistently request ethics consults.

Most of the ethical issues consulted on by PMHV center around patients who, due to their illness, have lost their ability to make their own medical decisions. The challenges of decision making often involves family members in conflict with each other about who best represents the patient’s wishes.

We often assist surrogate decision makers struggling with the harsh realities of their loved one’s hospitalization by working closely with physicians and family members to ensure that the medical decisions made are in the best interest of the patients we serve. The Program sees a significant share of patients who not only have no healthcare decision makers, but we can find no one who can represent their interests. In these cases of unrepresented patients, the hospital policy is utilized to adopt an inter-disciplinary process for decision-making. Another Request Breakdown 2017 60.36% MD 19.52% Social Work/Case Management 9.91% PA, NP, ANP, etc.

5.11% RN 4.00% Administration/Management 0.70% Patient/Family 0.40% Other

# # Consults Consults

400 400 300 300 200 200 100 100 00 1985 1985

1990 1990

1995 1995

2000 2000

2005 2005

2010 2010

2015 2015

Year Year

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WWW.SFMMS.ORG

Primary Diagnosis Group

Primary Ethical Issue 100

# Cases

80 60

2015 2016 2017

40 20 0

Other

Non-Beneficial Treatments

Difficult Patients

Unrepresented Patients

Surrogate Decision Making

Respiratory System Nervous System/Mental Disorders Circulatory System Hepatobilioary System & Pancreas Kidney & Urinary Tract Digestive System Infectious and Parasitic DDs Skin Blood & Immunological Disorders Alcohol/Drug Use Multiple Significant Trauma Injuries, Poison, & Toxic Effect of Drugs Musculoskeletal System Newborn & Other Neonates Ear, Nose, Mouth, & Throat Other

0%

important theme we often come across involves patients and their family members requesting treatments, most often at the end of life, that physicians consider to be medically ineffective.

As such, we are often involved in cases that deal with withdrawing or withholding medically non-beneficial treatments.

These cases are among the most difficult for everyone, as they constitute the realization that the medical team has no more medical options to offer the patient, even in the face of family struggles to accept the reality and finality of the medical illness.

Where We Are Going:

Ethics Consultation Service: PMHV strives to continue to provide a robust standardized service to patients, families, and providers at Sutter Health. We continue to analyze our consultation data to identify trends and patterns for triggers for ethics consultation and involving the service earlier rather than later.

As medical technologies become more advanced, the care of our patients becomes more complex with dilemmas arising every step of the way in terms of the appropriateness of interventions in the setting of life-altering illness.

Sutter-Wide Education: We are increasing our presence Sutter-wide through targeted education for providers in areas where knowledge and skill gaps have been identified. We are using innovative platforms to deliver this education, e.g.

Annual Summer Workshop, noon conferences for medical residents and fellows, regular WebEx sessions on commonly encountered dilemmas, and invited presentations for different departments and hospital services. Ethical Times, our quarterly newsletter, reaches over 1,200 subscribers and provides the community with an overview of the latest issues in the field of bioethics.

Clinical Neuroethics: Many of our consultations have to do with psychiatric and neurological components of the patient’s illness. Therefore, the Program created the Clinical Neuroethics Initiative (CNI), the first endeavor to address issues related to these patients and apply an ethical spotlight to the dilemmas physicians face in the real world of patient care. The objective of CNI is to improve quality care for neurological patients by developing practical solutions and best practices for physicians dealing with the ethical issues that arise when caring for neurologically compromised patients. Even though neuroethics departments and services are becoming increasingly more WWW.SFMMS.ORG

5%

10%

15%

20%

25%

prevalent at academic institutions, and components are being added to the curriculum in law and medical schools, there is currently no other program than ours designed specifically to embed neuroethicists across neurological specialties and work closely with neurological program directors to identify the ethical issues they face in caring for their individual patient populations. This work is now being made possible through a generous grant from the Hearst Foundation.

Organizational Ethics: Many ethical problems in healthcare derive not merely from the perplexing questions facing patients, families, and doctors, but also from the structural features and barriers presented by institutions and their policies.

In the past, we have conducted employee survey polls about ethical culture and behaviors in their hospitals, and provided information on how the institution can best address organizational ethics issues. We continue to recognize these issues and develop solutions to best address them. A recent project of the Program has been recognizing and addressing moral distress of nurses. The Program has also developed major policies on how to address decision-making for unrepresented patients as well as how to respond to requests for non-beneficial treatments that have now been adopted by multiple institutions across Sutter Health.

The Program in Medicine and Human Values continues its upward trajectory in providing ethics consultations and education throughout Sutter Health and beyond, while our professional presentations and contributions to the literature increasingly bring national and international recognition.

Internally, we are developing in-depth assessment tools to better measure our activities, and creating new ways to disseminate what we are learning more widely.

Gil Palchik, PhD, is the Sutter Health Program in Medicine and Human Values’ specialist in neuroethics. Dr. Palchik received both his MSc and PhD in neuroscience from Georgetown University, where he focused on cellular and molecular neuroscience.

William S. Andereck, MD, FACP has practiced internal medicine in San Francisco since 1979. He is program director and senior scholar at the Sutter Health Program in Medicine and Human Values and a former editor of this journal.

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Healthcare Ethics

ADVANCE CARE PLANNING AND POLST: PROMISE AND PITFALLS Karl Steinberg, MD

Much of the work of bioethics committees centers around uncertainty, or disagreements, about end-

of-life care. That’s why it seems like such a no-brainer (brain death pun semi-intended) for people to want to make their wishes known ahead of time, or at least to be sure they designate someone to speak for them legally if they lose decisional capacity in the future. Yet it’s estimated that less than 30% of Californians have an advance healthcare directive (AHCD).

Despite efforts like National Healthcare Decisions Day, The Conversation Project, and the Bay Area’s own Prepare for Your Care (thanks to Rebecca Sudore, MD), even in the chronically and seriously ill population there are many who never discuss their wishes with a physician or even with their family.

Since 2016, the Centers for Medicare and Medicaid Services (CMS) has allowed separate (and additional) billing for advance care planning (ACP) for Medicare beneficiaries, and we are using these codes pretty robustly based on the number of times these codes have been billed (99497 and 99498) over the past year. If you spend 16 minutes or more of a visit discussing ACP or completing forms relating to ACP, there’s no good reason not to bill these codes, which pay about $80. Medical societies including the American Academy of Hospice and Palliative Medicine, the American Geriatrics Society, and AMDA—The Society for Post-Acute and Long-Term Care Medicine, joined the AMA in advocating for adoption of payment for these codes, avoiding the “death panel” controversy this time around. Of course we should be compensated for our time helping patients navigate these complex but critically important issues!

But on the flipside, there’s been a potentially disturbing trend afoot, wherein some organizations are encouraging, or even compensating, their practitioners for completion of ACP documents, including Physician Orders for Life-Sustaining Treatment (POLST) forms, on all Medicare patients. Of course, completing an AHCD is appropriate, and recommended, for everyone 18 and up, so if that can be done in a physician’s office, that’s great. But a POLST form is a different story. According to the National POLST Paradigm, POLST is intended for patients who are seriously ill, medically frail, and for whom the answer to the “surprise question” (would the healthcare provider be surprised if the patient died in the next year?) is No. While anyone can legally complete a POLST in California (assuming they can find a physician, nurse practitioner or 14

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physician assistant to sign it), there are good reasons for the recommended limits on POLST to the seriously ill. The document is designed for people nearing the end of life and for whom the default interventions—where it is assumed that prolongation of life is the goal, within normally accepted parameters—may not be desired because of their medical condition, prognosis, and (self-)perceived quality of life.

Of course, anyone who has strong feelings about their endof-life care, or feeding tubes, can memorialize them in a California POLST form. I know some healthy physicians who have opted to execute POLSTs for themselves specifying DNR/DNAR status, because they just don’t want to be one of those patients they’ve seen who survives CPR. But they are the exception rather than the rule. So why is there a problem with a healthy 66-year-old going to her PCP’s office and having a POLST form shoved under her nose? Well, for one thing, it’s doubtful that a rich conversation will occur in association with this exercise.

We have heard of physicians basically saying to such a patient, whom we’ll call Mrs. P, “If your heart stopped, you’d want it restarted, right?” and proceeding to sign a full-code, full-care POLST form. Worse yet, they then bill a 99497 code as if this conversation took a half hour.

Beyond the obvious impropriety of this, let’s look at the other consequences. The patient may not be asked to formulate an actual AHCD, which is meant to designate her agent if she loses decisional capacity. For someone at Mrs. P’s age in good health, that is a much more important document for which to ensure completion. She may not be encouraged to discuss her more complex care wishes, such as things she would never want (for example, some people are categorically opposed to tube-feeding), with her family. And it creates a false sense of security that Mrs. P won’t have to worry because now she has filled out the appropriate legal forms. It’s true that for a patient who retains decisional capacity, she can change her POLST wishes (or any other directive to physicians) at any time.

Unfortunately, this scenario fails to consider what happens to many people on their journey between good health and death: They lose decisional capacity. Whether due to a sudden catastrophic illness or accident, or caused by the ravages of dementia, a large proportion of patients lose decisional capacity when they are close to death. If that weren’t so, there would be little work for our Bioethics Committees! And then what WWW.SFMMS.ORG

happens? Let’s suppose the unfortunate Mrs. P subsequently develops Alzheimer’s disease and has become nonverbal, no longer even recognizing her own family. Worse yet, now she has been diagnosed with widely metastatic colon cancer. The only document that exists is a full-code POLST form. But a great majority of people would want a loved one to speak for them, knowing their lifelong values, goals and beliefs, if they were facing a serious or terminal illness. So this form could create a conflict for a family member like Mr. P, who knows based on many previous conversations that his wife would not have wanted her life prolonged in such a situation, yet there is a piece of paper (with a doctor’s signature on it) saying she would want it prolonged, up to and including chest compressions, shock, intubation and ventilation. Fortunately, this husband would be able to complete a new POLST on behalf of Mrs. P, assuming he was able to get past potential guilt feelings. At least under current law permitting a “legally recognized decisionmaker”—admittedly a bit of a squishy term, and one that has ethical implications—to formulate a new POLST form for a patient based on changes in medical condition, Mr. P could make his wife a DNAR, comfort-focused treatment, and enroll her in hospice as he knows she would want.

This may all change in the near future. AB 937 (Eggman) is going to be moving in the state Senate after passing the Assembly with little difficulty last year. This law would essentially “lock in” a patient like Mrs. P who completes a POLST form and subsequently loses capacity, to their last personally expressed choices. Unless this person was wise enough to also complete an advance directive naming an agent, which Mrs. P sadly did not do, even their spouse would not be able to change the requests made in that old POLST form, without obtaining a court order. This bill obviously has the potential to cause great suffering.

The stated reason for this bill? Concerns that there are cases where apparently, healthcare professionals are cherry-picking the family member who agrees with their plan, and getting them to sign a new POLST that goes against the family member’s previously expressed wishes. If that has happened, it is not legal under current law, and we really don’t need a new law to address this probably rare concern. Moreover, it invokes a sort of “death panel” conspiracy theory that has no logical basis. Why would we want a patient to get anything other than the care they would have wanted to get? To do otherwise would violate multiple ethical principles, most prominently autonomy.

The CMA has issued a letter of concern about AB 937, but as of the time of writing this article, it has not taken an oppose position. The Coalition for Compassionate Care of California and CALTCM are the only organizations that have, and there’s a good chance they will prove inadequate to defeat this wellintended but ill-advised bill. So, this may become the law of our State. It may cause much unnecessary suffering and take away the ability of loved ones to make medical decisions on behalf of our patients, using either their known expressed wishes (often expressed orally but not memorialized in a document) or substituted judgment based on their current medical status.

While there is a small minority of patients who want the most aggressive medical interventions until the last possible instant of life, there are already ways for these patients to express that and avoid having a family member change it—including WWW.SFMMS.ORG

specifying such wishes on an AHCD or a POLST. But a majority of patients who sign Yes to CPR (full-code) on a POLST—which only applies when the person has no pulse and is not breathing—do not want that to apply ad infinitum. They mean right now if I had a cardiac arrest, I’d want you to try to revive me.

Not 10 years from now when I’ve developed profound dementia and terminal, widely metastatic cancer.

Whether AB 937 passes in its current form or not, it will provide a valuable impetus to those of us who work in this arena. We need to renew our efforts to get everyone to complete an AHCD, so that they aren’t deprived of the ability to have a family member speak on their behalf when they are incapacitated. We will need to educate our colleagues to push AHCDs, which everyone should do, and save POLST forms for those who are nearing the end of life. And we need to get PCPs and nursing homes, among others, to stop pushing non-POLSTappropriate patients to complete POLSTs. Karl Steinberg, MD, is a hospice and skilled nursing facility medical director and chief medical officer in Oceanside. He is past chair of the Coalition for Compassionate Care of California and serves on the National POLST Paradigm's Leadership Council, and serves on the Board of Directors for the San Diego County Medical Society.

Follow or contact Dr. Steinberg on Twitter at @karlsteinberg.

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Physician-Assisted Dying: The State of Practice, Policy, and Pitfalls Editor’s note: As most have likely heard, and can read in our editorial in this issue, as of our press deadline the California End of LIfe Option Act, authorizing physician-assisted dying, is now on hold due to legal challenges. Thus the practice is not legal in California at this time.

This article and the two following describe clinical experience and policy recommendations when the practice was legal here. Please watch for updates in the media; we will provide same as more information becomes available at sfmms.org.

BEST PRACTICES FOR AID IN DYING: RECOMMENDATIONS FROM THE BEDSIDE Lonny Shavelson, MD

On a summer day 21 years ago, the U.S. Supreme Court delivered a unanimous decision denying a constitutional right to what was then called physician assisted suicide (now physician aid in dying). You would think such a rare 9-to-0 agreement of our

most powerful justices would be a death knell to physician aid in dying. But hidden in the justices’ opinions was a conclusion that this debate should continue, even citing a “laboratory of the states”—suggesting that while there was no national constitutional right to aid in dying, individual states could legalize the practice. By the end of that same year, Oregon did just that.

It took California two decades to catch up—but here we are.

Or, as many have been asking with some trepidation as California’s End of Life Option Act approaches two years of clinical practice: “Where are we?”

While California is gathering numbers, those at the bedsides of dying patients want to know how this new law works for individual patients requesting aid in dying, and for the practitioners who receive those requests. Even more so, how does an aid-in-dying request continue to affect patient care after that request?

Our practice is in a unique position to answer many of those questions. We started up at the initiation of the End of Life Option Act on June 9, 2016, to focus solely on patients’ aidin-dying requests and to support practitioners navigating the new law. We have to date been at the bedside of 87 patients as they ingested medications to die—probably the highest number of any single practice in California. We have fielded some 600 requests from across the state, from patients looking for practitioners who will consider their aid-in-dying requests, as well as practitioners hearing their pleas. We started out by feeling our way around clinical practices, as all physicians did soon after the new law was initiated. But along the way we’ve learned some crucial lessons about patient care.

Best practices, The first oral request: A patient with a

less-than-six-month prognosis to live must make a first oral request to the attending physician to initiate the aid-in-dying process, followed by a 15-day waiting period before they are

eligible to take medications to die. Soon after the law started, I took these first oral requests at the time I saw the patients in person, usually 7 to 14 days after their initial contact (our practice makes house calls, since the majority of our patients are too sick to leave their homes).

I soon noticed that about 30% of my patients were either dying during that 15-day waiting period, or losing mental or physical capacity for the required self-administration of the medications. In essence, by waiting a week or two before taking the first oral request, the legislated 15-day waiting period was effectively a three- to four-week waiting period at best, and about 1 of 3 of my patients never made it long enough to die in their desired manner. (One can argue that every patient can’t die in their desired manner and, of course, that’s true. But our practice tries to help as many patients who request aid in dying to achieve their desired route to death.)

We soon adapted our practice to take a patient’s first oral request within 24 to 48 hours of their initial contact. We did this via Telehealth. Using Skype, Facetime or phone, one of our two physicians contacted the patient and explained that a Telehealth conference is, with their permission and understanding, the equivalent of an office visit.1 We would then establish the basic history from the patient and, if appropriate, take their first oral request. That started the 15-day clock ticking. During that 15-day waiting period we would review medical records and visit with the patient in-person at home.

If for any reason they did not qualify for medical aid in dying, the process would stop there—nothing lost by our prompt first-oral request, but everything gained in terms of timing for patients who did qualify. Our rate of patient loss during the 15-day waiting period dropped from 30% to about 16%. Many patients who request aid in dying are quite ill at the point in which they initiate the process, and the longer it takes to get them through the requirements of the law, the sicker they get. (NOTE: If a patient who strongly desires aid in dying as their route to death is at high risk of losing mental and/or physical capacity during the 15-day waiting period, 2 to 6 mg of dexamethasone per day can help them maintain capacity.)

1. Medical Board of California, “Practicing Medicine Through Telehealth Technology.” http://www.mbc.ca.gov/Licensees/Telehealth.aspx WWW.SFMMS.ORG

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Physician-Assisted Dying: The State of Practice, Policy, and Pitfalls Best practices, Delivering aid-in-dying medications: In Oregon’s some 20-year history with aid in dying, about 1/3 of the medications delivered were never taken. In 2016, the time from the patient’s first request to taking the medications to die ranged from 15 days to 1.5 years, with a median of 56 days. A common practice was to prescribe and deliver the medications immediately after the 15-day waiting period—leaving lethal medications in the patient’s house for extended periods.

And for the 30% who never took the medications, the family had to find a safe way to dispose of them. Additionally, these medications have a high abuse potential and were accessible to anyone in the household.

The safety implications of delivering medications soon after day 15 seemed clear to us as we started prescribing for our patients. And the answer was quite simple: Don’t deliver the medications until the patient is clearly ready to take them. By working consistently with one quickly-responsive pharmacist, we were able to deliver the medications one or two days before the patient was ready to take them. Our rate of non-use of delivered medications: Zero. Our time of keeping dangerous medications in the patient’s household: around 1 to 4 days.

Best practices, Continue to follow patients closely as they approach their death: Early delivery of aid-in-dying

medications is often accompanied by the instructions, “take them when you’re ready.” That might be days or months away, during which time the attending physician frequently loses track of the patient’s course toward death. But the patient’s condition can change drastically. One telling example is that of a patient (not in our practice) with colon cancer who received the medications on day 15 with take-them-when-you’re-ready instructions. She later developed a bowel obstruction and decided to take her medications then, leading to a major risk of aid-in-dying failure with dire consequences. Fortunately, an astute hospice nurse stopped the process and averted a crisis.

An axiom: Writing a prescription is a static moment; dying is a dynamic process. As the attending physician for the End of Life Option Act, your terminally ill patient’s care does not end by writing an aid-in-dying prescription.

There are additional benefits of continuing to follow your patients. The patient’s decision about if and when to take aidin-dying medications is a complicated, anxiety-ridden process—and new to the patients and their families. By following patients until death, the attending physician participates in this difficult decision.

I constantly remind patients that taking aid-in-dying medications is not an appropriate response to a bad day, an argument with a family member or an increase in pain. Only by following the patient closely does the attending physician learn why their patient suddenly decides that they’re ready to die “now.” A severe increase in the patient’s pain is not a cause for aid in dying, but for increased palliation of pain. Patients and their families should not be left without physician support to decide if or when to take aid-in-dying medications. Yet we have found it quite common for attending physicians to bow out soon after writing the prescription. Our nurse coined the term prescribe and abandon for this practice.

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Best practices, Work closely with hospice: There is

no reason that a patient requesting aid in dying cannot simultaneously be cared for at home by hospice. In fact, the two go hand-in-hand—excellent hospice and palliative care is the best way to be sure that a patient isn’t requesting aid in dying because of poor medical care or symptom control. If our patients aren’t already in hospice when they start with us, we strongly encourage them to join and/or admit them to hospice.

Additionally, we become the “primary non-hospice physician,” tightly coordinating care with the hospice team in preparation for possible aid in dying. Most hospices have now had many patients make aid-in-dying requests and they are experienced in the unique care these patients require.

Best practices, Use medications that affect brain, respiration, and heart: Many doctors who accept patients’ requests for aid in dying prescribe secobarbital (Seconal). This is a continuation of the “Oregon tradition” where secobarbital was by far the most commonly used medication. But while secobarbital reliably induces sleep and coma, it does not reliably suppress respiration to precipitate death. The Oregon data from 1998 to 2016 show that although the median time to death is 25 minutes, deaths have occurred as long as 4 days after taking secobarbital. Deaths of more than 24 hours were not uncommon.

Our practice considers the ideal time to death as less than 2 hours after taking aid-in-dying medications. Deaths from 2 to 5 hours are common but problematic, those over 5 hours are difficult for the families, and deaths over 24 hours are unacceptable.

We explain to patients that they will not experience the difficulty of prolonged deaths since they will be unconscious, but their families around the bedside might. The longest death in our practice has been 12 hours, an outlier; our average is roughly 2 hours. And there is a reason we haven’t had any deaths over 24 hours: We add medications intended to stop the heart to those intended to stop respiration. (NOTE: The End of Life Option Act requires “self-ingestion” of medications; no injections are permitted.)

1) To put the patient to sleep and then into a deep coma: Secobarbital (10gms) is adequate, but expensive at around $3,500. Instead, we use compounded morphine (15gms) and diazepam (1gm). But while secobarbital or the morphine-diazepam cocktail reliably and rapidly induce coma, neither consistently stops breathing to cause death. In our bedside experience, continued breathing at a low rate and volume (well-tolerated by the heart) is common, delaying death.

2) To induce death if breathing continues: Digitalis (50 to 100mg) and propranolol (2gms).

We combine the sedative, respiratory and cardiac medications into a compounded mixture commonly referred to as DDMP2 , which the patient takes all at once in a 4-ounce suspension ingested within two minutes (longer ingestion times risk the patient falling asleep mid-dose). The morphine and diazepam (M and D of DDMP) rapidly induce coma and, mostly, suppress respiration toward death. If respirations are WWW.SFMMS.ORG

not adequately suppressed, the digitalis and propranolol (D and P of DDMP) stop the heart. The result: We don’t see dayslong deaths.

(NOTE: Patients at higher risk for longer deaths include: a history of extreme athleticism with high cardiopulmonary conditioning; those with gastrointestinal cancers, including pancreatic cancers; gastroparesis; ascites; high doses of anabolic/ anti-inflammatory steroids such as dexamethasone; oddly, cachexia—general wasting includes the gut, and poor gut function means slow absorption of medications.)

While the California Legislature has delineated the legal procedures to comply with aid in dying, establishment of best practices and the community standard of care remains in the realm of practicing physicians on the front lines who not only adapt the legislated requirements to bedside care, but continue to innovate and advance that care. Ongoing conversations among clinicians about implementation of the End of Life Option Act are crucial.

Lonny Shavelson, MD, is a physician, author, radio-journalist and filmmaker. His initial training and practice were in emergency medicine, but he has since worked in a clinic for refugees and immigrants and now as an end of life doctor for terminal patients. His practice is with Bay Area End of Life Options in Berkeley (http:// www.BayAreaEndOfLifeOptions.com).

Best practices: Be present at your patient’s death, or arrange that an experienced aid-in-dying practitioner be there: This one may seem a stretch for those

in busy practices that aren’t, like ours, solely devoted to aid in dying. But think about it. Your patient’s death day is one of the most significant of their life. It’s filled with questions and anxiety; it is ripe with emotion. And, as our practice has learned, aid in dying is a medical procedure of some complexity.

Explaining the medications, how they work, when to expect unconsciousness, the anticipated time to death and more, put both patient and family at ease during an extremely emotional event. Once the patient is unconscious, the family has many questions about what is still happening. By being there, you’ll learn an amazing amount that is essential in working with future patients and families. And, you’re almost guaranteed to find tears of gratitude. Theirs, and yours.

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Physician-Assisted Dying: The State of Practice, Policy, and Pitfalls

THE END OF LIFE OPTION ACT: A RIGHT FOR THE PRIVILEGED? Monique Schaulis, MD, MPH California’s End of Life Option Act has been in place for two years, but the promise of increased control over suffering at the end of life has not yet been realized. The act is meant to compassionately address the suffering of terminal illness and is a step forward for patient autonomy, . But in practice, lack of public discourse and physician education, an inconsistent process, high cost, and a 15-day waiting period all have made access very challenging. These barriers disproportionately affect the disenfranchised, who already experience poor quality end of life care.

Because patient experiences with aid in dying (AID) are not well captured by any dataset, I rely on my experience, as well as cases from local colleagues, to understand the factors that inhibit application of the End of Life Option Act. This anecdotal evidence tells me that public awareness of the law is low. The young Californian Brittany Maynard made headlines in 2014 when she traveled to Oregon to end her life after a terminal brain tumor diagnosis. Since the law was passed, however, we have seen little public attention focused on AID and physician education has lagged.

Doctors generally remain uncomfortable discussing death with patients, and most will discuss AID only if the patient asks. We worry about hastening death and wonder if AID is consistent with our professional standards. But avoiding AID while discussing end of life is akin to not mentioning abortion when counseling on unwanted pregnancy. While doctors know that a discussion of life-limiting illness should include palliative and hospice care, many have minimal training in these challenging conversations. Good communication skills, an open heart, awareness of one’s own biases and fears, and cultural humility are critical to discerning what patients and families value at the end of life. In my experience, merely knowing of the law provides great solace from fears about suffering and death. To work through this complex process, a team approach is needed to support physicians as well as patients and families.

Once patients have decided that they want AID, indecipherable systems can stymie their efforts. Both health systems and individuals can “opt out” of AID and are not obligated to provide referrals, creating delays and confusion. Most terminally ill people do not have the stamina needed to address bureaucratic hurdles and therefore will not get beyond the decision without a strong advocate. Because no lists of participating physicians exist, searching becomes a word of mouth process.

In the Bay Area, Dr. Shavelson has filled in the gap for patients whose system or physician has opted out. For Kaiser members, a patient coordinator serves as a guide through the process, 20

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minimizing additional patient and family stress. But many do not have access to these services.

The mandatory 15-day waiting period also has proved to be too long for many patients. Even at Kaiser, where the process is clear, a substantial minority of those requesting AID die between the required first and second oral requests. A recent patient described the months he had spent considering AID as his cancer progressed. He was certain of his choice but died just a few days after making his first oral request. His family grieved not only losing him, but also having missed the window to help him get the death he wanted.

For those who can find a prescribing doctor and live longer than the required 15 days, the high costs of AID medications are another barrier. AID is not covered by most insurance, including Medi-Cal, Medicare and the VA. Seconal costs about $2,500, and DDAMP2 costs $600. Many patients I see live on a fixed income and chronic illness has devastated their finances.

My first AID conversation was with a physician who chuckled ruefully at his Seconal cost; he understood that in even in death, he was part of the 1%.

Housing also affects ability to access AID because care facilities respond unpredictably to residents’ requests. An 85-yearold patient had been living at a board and care home when he received his terminal cancer diagnosis. His only family was the facility staff and residents. When he asked for AID, the owner said she was morally opposed and would not allow him to take the medication on site. This frail man (for whom walking down the hall was an ordeal) had to leave his residence in order to die as he wished. Eventually, he was assisted by a Compassion and Choices volunteer and died at a hotel. His determination ultimately allowed him to ingest the medications, but every step of his journey was uphill. I feel deeply uncomfortable imagining him dying in an unfamiliar rented room.

Because few California facilities have an accessible preexisting written policy, a predictable response to a patient can not be expected if a patient or family discloses an intent to use AID. One facility requested an extra month’s rent for a private room as a precondition for taking the medication on site. In another case, police unfamiliar with the law cordoned off a patient’s room for investigation, violating the family’s privacy.

On the other end of the spectrum, a local faith-based facility respected a resident’s AID request, and helped him access it despite moral opposition. Laguna Honda has an online policy and protocol. But for the most part, current access to AID outside a private residence is decidedly unpredictable. Negotiating this complex conversation with facilities has been one of the extra stressors patients and families have had to face.

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Despite these difficulties, the Bay Area is better served than many. A colleague told me of a cancer patient who made her first oral request in San Francisco where she was receiving treatment. She needed to return home to be with family in the Central Valley. Unfortunately, despite extensive outreach, her physician was unable to locate any colleagues in Fresno who could provide the mandatory second visit. Ultimately, the patient had to choose between going home and pursuing AID. Even for her physicians, the process proved impossible.

No quick solutions exist to resolve these problems. Statewide implementation of patient-centered processes is key to support the terminally ill. Physicians need training and support to do the work. Health systems that officially “opt out” should have clearer advice for patients than “talk to your doctor or social worker.” Care facilities should make their AID policies transparent so people can choose in accordance with their values. Patients should be able to find physicians who are willing to participate. Researchers should gather high quality data, and using it, strive to make end-of-life medications more reliable and less expensive. We should consider whether the 15-day waiting period serves its purpose. Any barriers to AID should be intentional, meant to provoke contemplation, not byproducts of a dysfunctional system. Ultimately, the perception of aid in dying as a legal right without effective means to obtain it leaves many suffering patients and families stranded. Californians, we must do more.

Tracy Zweig Associates INC.

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REGISTRY

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PLACEMENT

FIRM

Monique Schaulis MD, MPH, practices emergency medicine and home-based palliative care at Kaiser San Francisco.

She graduated from University of Chicago Pritzker School of Medicine and did her emergency medicine residency at Highland Hospital in Oakland. She has done specialized communication training through the Palliative Care Education and Practice Program at Harvard and the Vital Talk program. She serves as a Vital Talk facilitator and is on the board of SFMMS.

CMA URGES CONGRESS AND CMS TO PROVIDE REGULATORY RELIEF TO PHYSICIANS California physicians are overwhelmed with unnecessary, burdensome regulations that take time and resources away from providing quality patient care.

These regulations are a major contributing factor to the disturbing trend in physician burnout. The CMA is urging Congress and the Centers for Medicare and Medicaid Services (CMS) to reduce the regulatory burdens under the Medicare and Medicaid programs. CMA’s recommendations for reform will simplify the Medicare/Medicaid programs, reduce costs, improve quality, increase access to physicians and allow physicians to spend more time with their patients.

CMA’s Top10 Priorities for Regulatory Relief:

~ Physicians ~ Nurse Practitioners Physician Assistants

Voic e : 800-919-9141 o r 805-641-9141 FAX: 805-641-9143 tz weig @tracyzwei g .co m www. tracyzwei g .co m

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1. Reduce the quality and EHR reporting burdens of MACRA. 2. Enforce electronic health record (EHR) vendor compliance and interoperability, and limit add-on fees.

3. Reform the Medicare physician audit programs: Recovery Audit Contractor (RAC) program, and the pre- and postpayment review audits.

4. Require state Medicaid programs and Medicaid-managed care plans to arrange and pay for interpreter services rather than physician offices.

5. Reduce the voluminous Medicare Advantage (MA) health plan medical record requests of physicians related to MA risk-adjustment scores.

6. Further delay and simplify the new Medicare imaging appropriate use criteria program.

7. Remove lab certification requirements for physicians who use waived tests or physician performed microscopy.

8. Rescind the Medicare Two-Midnight/Observation Care rule.

9. Exempt physician in-office drug compounding from the new FDA rule.

10. Change the Stark anti-kickback restrictions to allow more coordinated care alternative payment models.

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Physician-Assisted Dying: The State of Practice, Policy, and Pitfalls

RESPONDING TO THE END OF LIFE OPTION ACT: INDIVIDUAL, INSTITUTIONAL, AND STATEWIDE PERSPECTIVES Lindsay K. Forbes, Cristina Nigro, MS, Barbara A. Koenig, PhD

Introduction June 9, 2018 will mark two years of experience with legalized physician aid in dying (PAD) in California. How are California’s healthcare providers responding to the change in practice? What are the variations in their respective institutions’ policies? What has been the experience of those using physician aid in dying? A team of researchers from the University of California, San Francisco, UC Los Angeles, and the Coalition for Compassionate Care of California is studying these questions and other issues related to the implementation of the legislation. The project entitled “The California End of Life Option Act at One Year: Convening Key Stakeholders” started in the summer of 2017 with the goal of documenting California’s first year of experience.

Many predicted that after California legalized PAD, other states would soon pass similar laws. Colorado, the District of Columbia, and Hawaii have legalized PAD since 2016 meaning 20% of the U.S. population now lives in a locality with access to PAD. This creates a responsibility to monitor and investigate how the law is being implemented and what ethical issues are arising along the way. The lessons learned from California can be informative for states with existing legislation or for states considering legalization.

Background

The project builds on previous work led by the UCSF team and funded by the California Health Care Foundation. Dr. Barbara Koenig and colleagues from the UCSF Program in Bioethics hosted the first “Response Conference” after the EOLOA was signed into law. The conference attendees raised critical questions to consider in preparing to respond to patient requests under the EOLOA [Am J Public Health. 2017 Jun; 107(6): 883888]. One year after legalization, the same team reconvened and expanded their efforts with support from the California Health Care Foundation and the Stupski Foundation to accomplish the following aims: 1. Host a convening of 120 statewide stakeholders to share their experience with policy development, to discuss key issues raised by implementation of the act, and to begin planning research that will allow us to capture the experience of health systems across the state.

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2. Develop and administer a survey to institutional representatives from various practice settings in order to underSAN FRANCISCO MARIN MEDICINE JUNE 2018

stand the degree of implementation statewide, document the range of policy responses, and assess the strengths and challenges of the various policy types.

3. Collect an in-depth narrative account of 20 requests for PAD from the patient, family member, and provider perspective.

Early Lessons

Aim 1: Main Convening The convening took place on September 25 and 26, 2017, in Sacramento, California and included 120 state-wide representatives with diverse backgrounds in health, policy, law, and ethics. Attendees discussed topics such as the nature of suffering, the motivation for PAD requests, the impact on providers, and societal concerns. Attendees outlined challenges they had experienced: the number of steps and requirements involved in the process, finding a willing pharmacist, and the difficulty operating in a large, complex healthcare delivery system. Attendees confirmed that all providers benefit from learning about the law and preparing to respond to inquiries whether or not they anticipate actually writing prescriptions. Attendees highlighted the need for strong collaborations with palliative care and noted the need to call upon that discipline’s skillset to manage difficult conversations at the end of life. As a follow-up to the convening, the conference organizers are working on distilling “best practices” that emerged from the stakeholders experiences and outlining ways to build on the momentum to improve end-of-life care more generally.

Aim 2: Health System Survey The UCLA-based team received responses from 270 healthcare systems. They found that most systems have a policy in place and the ones that have not developed a policy yet are most likely smaller systems in rural settings. Out of the responses received, more than half of the systems opted-out of participating in the law by either prohibiting their providers from serving as attending, consulting, or referring physicians, presenting a challenge for patients seeking access to the EOLOA. Some systems added supplementary safeguards or procedures above and beyond what is required by law. The survey results highlight a disconnect between patient expectations of easy and straightforward access and provider ability to meet those expectations. Healthcare systems also must develop policies enabling coordination with hospices, long-term care facilities, and pharmacies.

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Aim 3: Patient and Family Interviews We have identified and conducted interviews with individuals seeking PAD, including eight patients who shared their own story prior to ingesting the PAD prescription, 20 family members (either before or after their loved one’s passing), and 25 participating healthcare providers. Interviews covered a range of topics including: (1) the story of the patient’s illness, including date of diagnosis, what treatments were offered and received, and experience with symptoms and their management; (2) the timeline and description of their EOLOA process; (3) their reasons for choosing this option in the context of their life experiences, values, and beliefs; and (4) any lessons they wanted to share as a result of their experience with the EOLOA. The interview study confirmed that patients struggled to find willing physicians: some were able to access both attending and consulting physicians within their primary health system; some were able to access the consulting physician from their health system but not the attending; others had to go outside their system for both attending and consulting and a small number had not identified a willing provider. Wait time was stressful and anxiety-provoking for patients. “We had problems with her primary doctor going back and forth saying she was going to do it, not going to do it . . . she says, ‘Okay, we’re going to get this for you and then we’re going to get this figured out,’ and then another two weeks would go by, and then we would call and they wouldn’t return our calls.”

Consistent with key findings from an earlier study [J Gen Intern Med, 2005; 20(3): 234-39], three factors motivate requests for aid in dying: (1) illness-related experiences, such as feeling weak, tired and uncomfortable; (2) a loss of sense of self; and (3) fears about the future. In general, patients wanted to use the law to assert some agency over bodies that were rapidly failing. No one wanted to die but they had endured significant losses related to their illness and treatments and were looking at a future in which they could no longer participate in meaningful activities.

Family members often managed the logistics. Taking the role of “project manager,” they found and contacted willing providers, scheduled and attended patient appointments, picked up the PAD medications, helped patients get their affairs in order, and prepared the medications for ingesting.

For some family members, this meant missing out on precious last moments with their loved one: “I wish I could say it was a special time because I almost feel like I got cheated out of that special time.”

Conclusion

Within the past two years, California has made strides to implement PAD in the largest, most heterogeneous population to date. Our research has identified ethical and practical issues that merit further exploration. Our study team plays an active role in reviewing and refining PAD policies, most recently by testifying at the public hearing on the EOLOA [Hearing before the Select Committee on End of Life Health Care, California State Assembly, Jan 24, 2018] and at the National Academies of Sciences’ workshop “Physician-Assisted Death: Scanning the Landscape and Potential Approaches” WWW.SFMMS.ORG

(http://nationalacademies.org/hmd/Activities/HealthServices/ PADworkshop.aspx). The team is providing recommendations to the California Department of Public Health and the California Medical Board to (1) increase the transparency of data reported annually [CDPH, EOLOA 2016 Data Report] and (2) create a set of common data elements that could be collected across institutions for added understanding of each case and a better aggregate understanding across states where PAD is legal. PAD continues to be a highly contentious topic but with commitment to patient-centered care and continuous learning, we can improve the experience of all patients approaching the end of life.

Acknowledgements

Thank you to the California Health Care Foundation and Stupski Foundation for making this work possible. We also wish to acknowledge the members of our team: Cindy Cain, PhD, Helene Starks, PhD, PMH, Judy Thomas, JD, and Neil Wenger, MD, MPH. We appreciate the input from our steering committee members, conference attendees, and patients and family members for sharing their stories.

To contact the study team, please email TellMyStory@ ucsf.edu or call 415-502-0147. Resources about the End of Life Option Act, including videos of the conferences mentioned in this article, are available on the team’s website at eoloptionacttaskforce.org.

Lindsay Forbes is the bioethics manager at UCSF; she designed an undergraduate major in bioethics at UC Berkeley. Barbara Koenig, a medical anthropologist, is professor and director of the UCSF Program in Bioethics. Cristina Nigro is a doctoral candidate in the History of Health Sciences at UCSF; she served on the research staff for the Obama bioethics commission.

CLASSIFIED Sublease medical office, part-time, Battery & Market, one block from Salesforce Tower. 415-956-8686, Dr. Binstock, jhbmd@ pacbell.net.

INTRODUCING

Our New Production Editor After many years, the SFMMS journal’s excellent production editor Amanda Denz has moved on to greener pastures (namely, Lake Tahoe). Our new staffer is Linda McLaughlin, who brings design experience from several Sonoma and Marin medical society publications, and helped SFMMS with its 150th Anniversary Celebration materials earlier this year.

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Healthcare Ethics

TEACHING BY EXAMPLE Albert R. Jonsen and Bioethics at UCSF

Reflecting on the history of bioethics teaching at UCSF, my

thoughts turn to Albert Jonsen, PhD. While creating a space for bioethics on the campus, Al shaped my career, and the new discipline. In the early 1970s Al was invited by then-chancellor Phil Lee to join the Institute for Health Policy Studies at UCSF, with “ethics” as his remit. I arrived a few years after Al, working first as nurse at UCSF and later a PhD student. One of the first things I did during my initial year of graduate school was to drop by Al’s office in an old house on a steep hill adjacent to the Parnassus Campus.

At UCSF, there wasn’t a bioethics department, there were no formal courses, there wasn’t really a “field” of bioethics then. There was a zone of intense intellectual engagement that centered around Al. We gathered together, read, and talked; the location was Al’s rooftop study above his flat in San Francisco’s Marina district.

It was a very inter-disciplinary group—mostly clinicians. We read papers by philosophers and scientists, teaching each other the new field as we went along. Philosophers explained metaethics; clinicians shared the dilemmas they faced.

Al was the magnet. I was deeply influenced by the circle of people who attended those rooftop seminars. I always felt that I knew the least of anyone present, but I was delighted to be one of the crew. Eventually Al joined my PhD committee. He helped me craft an approach to thinking about the “anthropological study of morality” in particular healing environments. How can we think about the nature of the good? It is a question that continues to consume us all.

Al’s approach to bioethics teaching was to write, to think, and to act. In 1983 he published a “Sounding Board” essay in the New England Journal of Medicine called “Watching the Doctor.”

It was stunningly perceptive. Describing his task as “professing medical ethics,” Al hypothesized that “academic doctor-watching can benefit and improve the relationships between patients and doctors.” He concluded that “a profound moral paradox pervades medicine”: Self-interest vs. altruism.

Al suggested a wide range of sources: I distinctly recall reading the philosopher John Dewey, grappling with the American pragmatists and their keen focus on how broad contextual features influence approaches to leading a moral life. We struggled together with the distinction between ethical and cultural relativism. I was only a student; it was only later that I fully grasp Al’s intellectual contributions.

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Barbara Koenig, PhD

And all the time I was studying, Al was flying back and forth to Washington for his service on the “President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.” I now wonder how he found the time to teach? But it’s funny—I don’t remember his absences—just his presence.

The HIV epidemic was everpresent in those early years. Al had given me a one-sentence assignment to draw up a research agenda after I finished my thesis. He wrote: “Barbara, can you study how doctors learn to care for dying patients?” I designed a study that set out to do so, and walked into the epidemic’s path. During my first year “in the field,” one third of deaths at San Francisco General Hospital were from HIV. Dr. Robert Brody, who was one of the first chairs of the SFGH ethics committee, recalled how Al responded. In the early 1980s, fear of what soon came to be called AIDS was rampant and intense. Professionals refused to provide services or donned space suits. Dr. Brody recalls Al’s visit to the nascent SFGH ethics committee that was grappling with the issue of “refusal of care.” How should we think about professional responsibility during a raging epidemic? Al responded not with a lecture about principles but with a history lesson, arriving with props, including the large beaked mask of the medieval plague doctor. “Altruism vs. self interest” — the paradox built into the heart of healing.

Al taught ethics through those conversations. He also created “ethics rounds,” regularly working with hospital teams, such as UCSF’s pioneering fetal surgery group. As director of UCSF Bioethics, I have the serious challenge of trying to maintain that vivid institutional culture, that intense zone of engagement that brings together scholars and clinicians from throughout the campus.

Al’s work foreshadowed what is now known as “embedded ethics” or the “empirical turn.” He did not reflect from a distance, but was deeply engaged, seeking the “moral archeology” of each specific clinical or research context. As I reflect on the challenges to come, including complex issues like the dominance of the market in healthcare, I feel both challenged, and sustained, by his example.

Barbara Koenig is director of the UCSF Program in Bioethics.

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HEALTHCARE IS A UNIVERSAL VALUE. IT’S TIME FOR A UNIVERSAL EFFORT. Sandra R. Hernández, MD, MPH California is the most diverse place on earth. You

see that diversity in our people, our culture, and our landscape.

Our differences are our strength — but only if we remember the things that bind us together and the values we all share. The belief that everyone should have healthcare is one of those universal values. From the day we are born, healthcare gives people the opportunity to have full lives and the vitality to pursue their dreams. And no one should lack support when illness strikes.

Too many low-income Californians are held back or suffer because it is too hard to get the care they need. California Health Care Foundation’s’s top priority should be to address that problem. Certainly, this undertaking will not be easy, but the good news is that there are clear ways to make healthcare work for low-income Californians. Here are three that are top of mind for us now.

1. All Californians Should Have Health Coverage.

California has made huge gains in recent years under the Affordable Care Act (ACA). We’ve cut our number of uninsured by half. Now we must finish the job and work to ensure everyone has health benefits.

Achieving universal coverage would level the playing field in two key ways. It would allow all Californians to meet basic needs for care, and it would protect all Californians financially from extraordinary healthcare expenses. Today, three million of our friends and neighbors remain uninsured. Most have jobs and are contributing to our economy and communities, but those jobs do not include health insurance. We must also remember that one in three uninsured Californians is an undocumented immigrant. These people are part of the fabric of California’s society; if we allow them to remain vulnerable, all of California will pay the price.

2. Coverage Must Lead to Better Care.

Coverage is not an end in itself — it’s really just the gateway to better health. To deliver on this promise, coverage must lead to better care. Our biggest opportunity to improve care for lowincome Californians is to make sure that California’s approach to coverage for low-income populations — the Medi-Cal program — delivers high-value care. The program covers one in three Californians. And two-thirds of Californians say Medi-Cal is important to them and their families. When we get Medi-Cal right, the impact is broad and deep because of the program’s overall reach and the profound ways in which it improves a person’s prospects for health.

In the last year, we have seen major new federal threats to Medicaid’s fiscal and policy stability. Given the importance of Medi-Cal to California, we must continue working together locally and with other states to protect Medicaid from ill-advised budget and policy changes.

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But it isn’t enough for California to protect the status quo.

There is so much potential for improvement in Medi-Cal, which serves Californians with the greatest health burdens. We can and should make the system easier to navigate and care easier to access. We must modernize the state’s health workforce to make treatment more effective and more cost-effective. And we can and should expect innovation in Medi-Cal to keep pace with the evolution of care in the private sector.

3. Stop Treating Conditions and Start Treating People.

Our healthcare safety net is still organized around the outdated assumption that one person’s body and mind require two or more separate systems of care. Today we know that physical health and mental health are inextricably bound together.

It is past time to update our healthcare system to reflect that understanding.

It is especially important that we better integrate care for low-income Californians who experience mental illness, drug or alcohol addiction, or other complex health conditions. Even though they comprise a relatively small share of the population, they account for half of healthcare spending. Siloed systems of care cause needless and profound suffering.

Healthcare leaders and providers across California have been working harder than ever to address this problem. Innovations in policy, like Medi-Cal’s Whole Person Care and Drug Medi-Cal pilots, are giving communities new opportunities to integrate care. Technology innovations can help providers extend those opportunities to larger and larger numbers of people.

Solutions Are Out There. It’s Time to Put Them to Work Everywhere.

California has the power to accomplish each of these goals.

We boast the world’s sixth largest economy. California is rich in healthcare and innovation talent. But even with those advantages, we cannot succeed without working together across sectors, across professions, and across ideological camps.

Healthcare is a universal value. It will take a universal effort to make sure all Californians can meet their basic need for care.

Dr. Sandra R. Hernández is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. An assistant clinical professor at UCSF, she practiced at San Francisco General Hospital in the AIDS clinic from 1984 to 2016.

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In My Opinion

YOUR GUNS OR MY MONEY Divestment from a Public Health Crisis Steve Heilig, MPH

At the San Francisco “March for Our Lives” rally in March, speakers urged everyone to divest of any investments they might have in the gun and ammunition industries. They detailed how such investments often are buried in many retirement and pension accounts, mutual funds, and more. “Are you unknowingly supporting the gun industry?” one young woman pointedly asked. And I thought, Uh oh, hmmm.

When I first moved to San Francisco decades ago, I went to Wells Fargo to open an account. They have branches in every neighborhood and it just seemed convenient, plus they are based here. Since then I’ve been lucky enough to pile up some cash there, plus a mortgage. I’m no Zuckerberg but they have kinda treated me like one. Even my dog gets the royal welcome, biscuits and all.

Wells Fargo has had some serious scandals but I’ve figured they’d remedy all that. But the words at the rally hit home. We now know all too much of our nation’s tragic and bloody gun violence problem. It’s been designated a “public health crisis” by the AMA. Beyond being reminded by recurrent mass shootings, the ongoing slaughter includes up to 100 people per day, including suicides.

Gun lobbyists argue these are unavoidable, or only “mental health” problems, but the undeniable truth — now known despite suppression of gun-related research — is that where there are more guns, there is more carnage. For most people, having a gun puts you and your loved ones more at risk than any feared and usually imagined intruder. As for fighting off some hypothetical tyrannical evil gun-grabbing government, if you really believe you might do that, it’s proof enough you aren’t rational enough to own guns.

We know that sane restrictions on gun sales, ownership, storage and use can save lives, are constitutional even under the Supreme Court ruling upholding the Second Amendment, and are supported by very strong majorities of Americans, including most gun owners. Most feel that guns and gun owners should be regulated at least as much as, say, cars and drivers. That’s not “gun grabbing” by any stretch. So why the lack of progress? One of the biggest factors in maintaining the tragic status quo is the gun lobby — infamously the radicalized National Rifle Association — which kills almost any effort to further regulate guns.

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The NRA’s work is really about money — for the gun and ammo industries, and for themselves. Thus it seems decreasing their profiteering might be an effective tactic to decrease the slaughter.

Responsible companies refusing to sell weapons or to advertise or accept advertising of them are good steps. Divestment could be another. Movements to remove organizational and individual investments from unhealthy and objectionable industries and practices, such as the tobacco industry and apartheid in South Africa, have gained medical and public health professional support and had positive impact.

So it’s time to practice what I preach. I was dismayed to read in the New York Times recently that “Wells Fargo is the largest financier in the nation of the gun industry and is the main bank for the National Rifle Association.” Further research revealed that Wells Fargo has lent more than $400 million to the gun industry in the past five years — since the slaughter of schoolchildren at Sandy Hook Elementary School — and has remained unapologetic about such practices. Then I read that my bank’s ratio of CEO pay to average worker is the highest in the whole industry — 291–1 ($17.5M to $60,000). That’s capitalism, some will retort, but at some point it becomes obscenity too. So add this to the reasons I can no longer overlook my bank’s partnership with an industry partly responsible for the ongoing gun violence in our nation.

Thus I wish to announce publicly my intent to divest my resources from Wells Fargo. There are resources online to help do this; goodbyegunstocks.com is just one. I have no illusion that losing my relatively paltry funds will outweigh the blood-soaked accounts of the NRA, but one has to start somewhere.

Of course, should Wells Fargo choose to remedy this shameful problem soon, I will gladly reconsider. I sincerely wish my hometown bank would do the right thing. It would be good PR for them at a minimum, and might even gain them some new business. But­ — alas — I won’t hold my breath.

Steve Heilig is public health director for the San Francisco Marin Medical Society, co-editor of the Cambridge Quarterly of Healthcare Ethics, and was certified as an NRA Junior Marksman as an adolescent. This piece is based on an op-ed published in the San Francisco Chronicle.

Gun Violence Prevention Stories?

We at the American Academy of Pediatrics California Chapter 1 Advocacy Committee are collecting stories about patients or other community members affected by gun violence. We plan to share these stories with your elected officials in our gun violence prevention efforts.

Please only submit stories that are HIPAA-compliant and de-identified. Thank you so much for submitting a story!

(Questions? Email: jean.junior@ucsf.edu.)

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SODA TAX STARTS PAYING OFF Nuala Sawyer — SFWeekly, May 29, 2018 Note: SFMMS was instrumental in the prolonged effort to institute a local soda tax, starting with our developing CMA policy in favor of that. Here is a heartening new report on how it is rolling out locally.

Remember the soda tax? In 2016, more than 62 percent of

San Francisco’s residents voted to approve the Soda and Sugary Beverages Tax measure, a controversial proposal that imposed a one cent tax per ounce on sugary beverages like soda to fund health inequity prevention measures citywide. It was a race dominated by large billboards, internet ads, TV commercials, and piles of mailers; all told Big Soda spent tens of millions of dollars, only to lose.

A year and a half later, local government is finally putting its money where its mouth is. On Tuesday, Mayor Mark Farrell and Supervisor Malia Cohen announced that they plan to spend the $10 million a year in soda tax revenue in assisting low-income communities and communities of color. Of that, $4.5 million will go to grants supporting community-based organizations, and the San Francisco Unified School District will get $2.5 million to support healthy meals, water fountain maintenance, and oral care in schools.

The latter, they hope, will end a cycle of obesity and diabetes that disproportionately affects low-income communities.

“The San Francisco Unified School District is uniquely positioned to leverage its scale and role to prevent sugar-sweetened beverage related diseases, such as obesity and Type 2 Diabetes, and to disrupt and reverse health inequities in our community,” said Superintendent Dr. Vincent Matthews. “The Sugar-Sweetened Beverage Tax revenue will increase our capacity to prepare students for learning and to practice healthy habits. This tax revenue will allow us to expand access to nutritious meals made of quality ingredients and locally grown produce, install more

water hydration stations in our schools, increase access to dental care, and establish robust nutrition education and student engagement programs to support healthy choices.”

The funds will also Part of the soda tax will be used to provide healthy eating maintain SFUSD’s water fountains, vouchers to communityoffering kids an alternative to sugary based organizations for beverages. (Courtesy Photo) their members, expand peer programming at HOPE SF housing sites, and support the City’s Peace Parks program and the Healthy Retail program.

The budget decisions were recommended by the Sugary Drinks Distribution Tax Advisory Committee, which began meeting in December 2017 to provide data-based recommendations. While the group has been instrumental in helping direct the funds, Roberto Vargas, co-chair of the committee, says it couldn’t be done without the help of other Bay Area organizations.

“It’s gratifying to see the result of many years of collective effort by UCSF, UC Berkeley, Stanford, San Francisco Public Health Department, S.F. policymakers and local health advocates,” he said. “Mayor Farrell’s budget proposal strongly supports evidence-based approaches, and lives up to San Francisco’s commitment to reinvesting these dollars back into the communities most targeted by the soda industry, and most impacted by disease associated with consuming SPECIALTIES IN sugary drinks.”

All told, this GREATEST is one move NEED voters made that is hard to argue with. Soda mayTODAY cost more, yes, but for some the results of the INCLUDE: tax could be life-changing.

Dermatology

SPECIALTIES IN Family Practice SPECIALTIES IN GREATEST NEEDNEED GREATEST Gastroenterology/Hepatology TODAY INCLUDE: TODAY INCLUDE: Dermatology

Gynecology Dermatology

Family Practice

Infectious Diseases

Family Practice Gastroenterology/Hepatology Internal Medicine’ Neurology

Gynecology Gastroenterology/Hepatology

Be A MAVEN Project Recruitment Ambassador

Oncology

Infectious Diseases

Gynecology Orthopedics Internal Medicine’ Neurology

We need your help as ambassadors of The MAVEN Project to recruit stellar physician volunteers in all specialties including primary care Pediatrics Oncology Infectious Diseases and pediatrics. Please reach to your Project friends and colleagues Ambassador Be Aout MAVEN Recruitment (general and specialty) about MAVEN Project’s flexible, convenient, and meaningful Orthopedics We need your help as ambassadors of The MAVEN Project to recruit Internal Medicine’ Neurology volunteer opportunities. stellar For more information, direct potential physician volunteers in all specialties including primary care Pediatrics physician volunteers to fill outpediatrics. an onlinePlease inquiry form them and colleaguesPulmonology and reach outor to have your friends contact the Director of Physician Engagement, Jill Einstein, MD at about MAVEN Project’s flexible, convenient, and meaningful Oncology(general and specialty) volunteer opportunities.

For more information, direct potential jeinstein@mavenproject.org or 617-641-9743 x713.

Pulmonology physician volunteers to fill out an online inquiry form or have them

Be A MAVEN Project Recruitment Ambassador

Orthopedics

contact the Director of Physician Engagement, Jill Einstein, MD at We need your help as ambassadors of The MAVEN Project to recruit 617-641-9743 x713.

PHYSICIA N VOjeinstein@mavenproject.org LUNTE ER INQ UorIRY FORM stellar physician volunteers in all specialties including primary care WWW.SFMMS.ORG JJUNE 2018 SAN FRANCISCO MARIN MEDICINE Pediatrics and pediatrics. Please reach out to your and colleagues P H YSfriends I C I AN VOLUN TE E R IN QUIRY F OR M

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CMA urges DOJ to take steps to ensure smooth transition to CURES mandate.

The California Department of Justice (DOJ) has certified that as of April 2, 2018, the Controlled Substance Utilization Review and Evaluation System (CURES) — California’s prescription drug monitoring database — is ready for statewide use. The certification starts a six-month implementation period for the duty to consult requirements enacted by the Legislature in SB 482 (Lara, 2016).

Effective October 2, 2018, physicians must con-

sult CURES prior to prescribing Schedule II, III or IV controlled substances to a patient for the first time and at least once every four months thereafter if that substance remains part of the patient’s treatment. Physicians must consult CURES no earlier than 24 hours or the previous business day prior to the prescribing, ordering, administering or furnishing of a controlled substance to the patient.

The California Medical Association is urging DOJ to take a number of steps to ensure a smooth implementation of the new requirement, including the development of educational materials, user outreach and assistance, and the establishment of a provider workgroup or advisory committee that ensures the clinician perspective is taken into consideration as these tools and resources are created for their use. To see the CMA’s detailed letter on this, go to:

http://www.cmanet.org/files/assets/news/2018/05/cma-ltr-to-doj-re-sb482.pdf

Assistant Professor of Physician Assistant Studies Dominican University of California is seeking an Assistant Professor for its developing Master of Science in Physician Assistant Studies (MSPAS) program. The Assistant Professor will be a faculty member within the school of Health and Natural Sciences. The primary responsibilities include teaching and evaluating students.

The Assistant Professor, in conjunction with the Program Director and MSPAS Faculty will participate in the development, implementation, and evaluation of the curriculum that conforms to the Program’s mission, goals, and objectives. Salary and rank are commensurate with applicant’s qualifications and experience.

Qualifications: • • • • •

Current NCCPA certification Master’s degree and eligibility for licensure in the state of California are required A minimum of 3 years of clinical experience and 2 years of teaching experience is preferred Excellent written and oral communication skills required Ability to work collaboratively as a team with other program and University faculty and colleagues

Full position description and application instructions: https://www.dominican.edu/about/employment/jobs Dominican University is a small private university of 1,800 students located in beautiful Northern California, within close proximity to San Francisco, the coast, and the wine country.

For More Information Contact: Dr. Ana Maldonado, Director of Physician Assistant Program Ana.Maldonado@Dominican.edu | (415) 482-1879 30

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Please join the San Francisco Marin Medical Society we gratefully Please Please join the the San San Francisco Francisco Francisco Marin Marin Marin Medical Medical Medical Society Society Society as as aswe we wegratefully gratefully gratefully Pleasejoin join the San Francisco Marin Medical Society as weas gratefully acknowledgethe support of these dedicated partners: acknowledgethe acknowledgethe acknowledgethe support support supportof of ofthese these these dedicated dedicated dedicated partners: partners: partners:

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Saint Francis St. Mary’s Memorial Hospital Medical Center Memorial Memorial Memorial Hospital Hospital Medical Medical Medical Center Center Memorial Hospital Medical Center

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BRONZE SPONSORS BRONZE BRONZE BRONZESPONSORS SPONSORS SPONSORS Actify Neurotherapies Actify Actify Actify Neurotherapies Neurotherapies Neurotherapies A. L. Nella A. A.A.L.L.L.Nella Nella Nella &&Company &Company Company LLP LLP LLP& Company LLP

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Actify Neurotherapies

A. L. Nella & Company LLP

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Sponsors

Medical Student / Resident Sponsors Champion Sponsors Ambassador Sponsors Keystone SponsorsChampion Medical Medical MedicalStudent Student Student //Resident /Resident Resident Sponsors Sponsors Sponsors Champion Sponsors Sponsors Sponsors Ambassador Ambassador AmbassadorSponsors Sponsors Sponsors Keystone Keystone KeystoneSponsors Sponsors Sponsors Michael Kwok, MD Donald Abrams, MD Peter Bretan, Jr., MD Lawrence Cheung, MD Michael MichaelKwok, Kwok, Kwok,MD MD MD Donald Donald Donald Abrams, Abrams, Abrams, MD MD MD Erica Erica Goode, Goode, MD MDMD Erica Goode, MD Erica Goode, Peter PeterBretan, Bretan,Jr., Jr.,MD MD MD Lawrence Lawrence LawrenceCheung, Cheung, Cheung,MD MD MD MDLoring, Jason Nau, MD Roger Roger Roger Eng, Eng, Eng, MD MD MD Roger Eng, Keith Keith Loring, MD MDMD Keith Loring, MD Keith Loring, Eduardo Dolhun, MD Jason Jason Nau, Nau, MD MD MD Eduardo Eduardo Dolhun, Dolhun, MD MD MD Man-Kit Leung, MD Man-Kit Man-Kit Man-KitLeung, Leung, Leung,MD MD MD Stephen Follansbee, MD Kim Stephen Stephen Follansbee, Follansbee, MD MD Kim Kim Newell Newell Green, Green, MD MD Stephen Follansbee, MD Kim Newell Green, MDNewell Green, MD Michael Scahill, MD Steven Fugaro, MD Michael MichaelScahill, Scahill, Scahill,MD MD MD Steven StevenFugaro, Fugaro,MD MD George A. Fouras, MD Michael Scahill, MD John John JohnMaa, Maa, Maa,MD MD MD John Maa, MD George George A. A. Fouras, Fouras, MD MD Michael Michael Scahill, Scahill, MD MD George A. Fouras, MD Michael Scahill, MD Monique MoniqueSchaulis, Schaulis, Schaulis, MD MD MD Schaulis, MD Robert RobertMargolin, Margolin,Robert MD MD MD Margolin, MD Monique MDWibbelsman, Charles Gordon Gordon Fung, Fung, MD MD Charles Charles Wibbelsman, MD MDMD Wibbelsman, MD Gordon Fung, MD Gordon Fung, Charles Wibbelsman, David David David DavidWerdegar, Werdegar, Werdegar, MD MD MD Werdegar, MD Shannon Medical Student / Jeff Stevenson, MD Shannon Udovic-Constant, MD Jeff JeffStevenson, Stevenson, Stevenson, MD MD MD ShannonUdovic-Constant, Udovic-Constant, Udovic-Constant, MD MD Champion Sponsors Ambassador Sponsors Keystone Sponsors Resident Sponsors

Individual

Peter Bretan, Jr., MD Lawrence Cheung, MD Eduardo Dolhun, MD Man-Kit Leung, MD Steven Fugaro, MD John Maa, MD Robert Margolin, MD David Werdegar, MD SFMMS would like to thank Saint Francis Memorial Hospital, SFMMS SFMMS SFMMS would would wouldlike like like to to tothank thank thank Saint Saint Saint Francis Francis Francis Memorial Memorial Memorial Hospital, Hospital, UCSF UCSFUdovic-Constant, Mt. Mt. Mt. Zion, Zion, Zion, UCSF Mt. Zion, Shannon MD

andBay Hospice by the Bay for providing meeting for SFMMS meetings; and and andHospice Hospice Hospiceby by bythe the the Bay Bay for for forproviding providing providing meeting meeting meeting space spacefor for SFMMS SFMMSspace meetings; meetings; meetings; Practice Management & Liability Consultants for providing Practice Practice PracticeManagement Management Management&&&Liability Liability LiabilityConsultants Consultants Consultantsfor forproviding providingaagift giftfor for forour our our a gift for our featured speaker; and Dr. Robert Harvey for making the St. Francis Yacht Club featured featured featuredspeaker; speaker; speaker;and and andDr. Dr. Dr.Robert Robert RobertHarvey Harvey Harveyfor for formaking makingthe theSt. St.Francis FrancisYacht Yacht YachtClub Club Club SFMMS would like to thank Saint Francis Memorial Hospital, available for our 150th Anniversary Celebration & Gala.

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Consultants for providing a gift for our featured speaker; and Dr. Robert Harvey for making the St. Francis Yacht Club

Michael Kwok, MD Donald Abrams, MD Jason Nau, MD Roger Eng, MD Stephen Follansbee, MD Michael Scahill, MD George A. Fouras, MD Monique Schaulis, MD Gordon Fung, MD A veryto special Jeff Stevenson, MD AAAvery very veryspecial special specialthanks thanks thanks toto the the the thanks to the

Erica Goode, MD Keith Loring, MD Mary Lou Licwinko Rob Margolin, Mary MD—Chair Mary Mary Lou Lou Lou Licwinko Licwinko Licwinko Rob Rob RobMargolin, Margolin, Margolin,MD—Chair MD—Chair MD—Chair Kim Newell Green, MD Keith Loring, MD Irina deFischer, MD Loring, Keith Keith Keith Loring, Loring, MD MD MD Irina Irina IrinadeFischer, deFischer, deFischer,MD MD MD Charles Wibbelsman, MD

150th Anniversary Celebration &Committee: Gala Planning Committee: 150th 150th 150thAnniversary Anniversary Anniversary Celebration Celebration Celebration &&&Gala Gala Gala Planning Planning Planning Committee: Committee:

Steve Heilig John John John Maa, Maa, Maa, MD MD MD John Maa, MD Steve Steve SteveHeilig Heilig Heilig Kimberly Newell Green, MD Erin Henke Kimberly Kimberly Kimberly Newell Newell Newell Green, Green, Green, MD MD MD Erin Erin ErinHenke Henke Henke Monique Man-Kit Leung, MD Monique Monique Monique Schaulis, Schaulis, Schaulis, MD MD MD Schaulis, MD Man-Kit Man-Kit Man-KitLeung, Leung, Leung,MD MD MD A very special thanks to the

150th Anniversary Celebration & Gala Planning Committee: Rob Margolin, MD – Chair

Mary Lou Licwinko

PHOTO COURTESY OF FRANK JANG

SFMMS SPOTLIGHTS TWO FATHER-SON PHYSICIAN DUOS IN HONOR OF FATHER’S DAY.

Drs. David and Robert Sperling are father and son cardiologists who work together at Cardiovascular Associates of Marin and San Francisco. Dr. David Sperling joined with another physician to form the practice in 1975, which has now grown to include 17 physicians. He also started the catheterization lab at Marin General Hospital. His son, Dr. Robert Sperling, is now the director of that same cath lab.

Dr. Martin Leung, a Hong Kong native, has been a general practice physician in San Francisco since the 1980s. His son, Dr. Man-Kit Leung, is an otolaryngologist in San Francisco and immediate past-president of SFMMS.

These “partners in medicine” represent two of the many father-child physician pairs serving the communities of San Francisco and Marin. SFMMS sat down with each of them to learn how medicine became a family business and how they have inspired one another.

The Sperlings Why did you decide to become a physician?

David Sperling (father): I was an English and pre-med double major. I took an aptitude test that indicated I would be a good teacher, but I didn’t want to teach. It was an exciting time for cardiology interventions, and I decided to join with another cardiologist in practice.

What are some of your early memories about your dad as a physician?

Robert Sperling (son): I remember my father speaking fondly about one of his patients who had bypass surgery. He talked about him as a person — [the patient] was a captain of a ship and my father would go fishing with him. I remember thinking how remarkable it was for a doctor to have that kind of relationship with a patient.

Robert: I was drawn to the profession through osmosis I guess!

What do you love most about practicing your specialty?

David: Treating patients — I enjoy the relationships I have with them and helping them stay well or get better.

Robert: I think it’s that you can help patients quickly. I enjoy doing angioplasty — it’s very satisfying to see a patient who is having a heart attack feel better quickly and then be able to develop a relationship with them over the years.

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What is it like practicing together?

Robert: It’s one of the most enjoyable things — having spent 15½ years working with my dad, sharing the same field, and consulting about patients. When I got out of training, he would ask me about a procedure; he was genuinely interested in my opinion.

David: We share a consultation room. I find it very stimulating — he’s extraordinarily well-trained, and I love being around the energy of younger physicians. I rely on Robert and on my partners.

How would you describe your dad’s approach to medicine and patients?

Robert: He’s very thorough and dedicated. He explains things to patients and communicates with them often. I learned a lot by listening to him on the phone talking to his patients. As a kid, I remember saying to my mom, “I never want to work that hard.”

I had an understanding about the fact that there were really two qualities my dad possessed as a physician — scientific and humanistic.

What is the best piece of advice you’ve been given throughout your career so far?

Robert: In my training, they emphasized that medicine will demand 110% of you and that you have to set boundaries.

David: Listen to your wife. Pay attention to details. Treat patients the way you’d want to be treated and listen to what they’re saying.

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What are some of the biggest challenges or opportunities you see in healthcare in the next 3–5 years?

David: We are becoming extremely computer-dependent, with no paper records any more. Medicare is requiring many new hoops to go through. Our group’s affiliation with the hospital poses many opportunities in the future.

Robert: I tend to put my head down and try to stay focused on my patients.

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

David: Architecture.

Robert: Teaching high school English or philosophy.

The Leungs Why did you decide to become a physician?

Martin Leung (father): When I was five years old, my mom died from complications of childbirth while delivering my younger brother. Ever since I was a child, I wanted to become a physician.

What are some of your early memories of your dad as a physician?

Man-Kit Leung (son): I remember doing homework in my father’s back office in Chinatown while he was seeing patients on the weekend. I recall thinking Chinatown was so crowded and noisy, and I wondered why my dad wanted to work there.

Later, I did a summer volunteer program at Chinese Hospital and in the process, discovered my cultural inheritance. I learned to appreciate that despite its shortcomings, Chinatown was where the immigrant Chinese felt a sense of comfort and belonging. I never would have imagined that 30 years later, I would have my own office in Chinatown.

When did you decide to follow in your dad’s footsteps and become a physician?

Man-Kit: I’d say late high school and college.

Martin: Man-Kit helped at Chinese Hospital during high school.

He talked with elderly patients in the hospital explaining things in Cantonese. He was very patient with them. He went on to attend Harvard for his undergraduate degree and then to UCSF medical school after graduating college.

Why did you choose your specialty?

Martin: I was going to be an OB/GYN but I had an allergy to latex gloves — we didn’t have alternatives back then. I also wasn’t sure I wanted to be in surgery for many hours at a time.

Man-Kit: Although I planned on specializing in family medicine when I applied to medical school, I became interested in surgery during my training. Of all the surgical sub-specialties, I found ENT was the most diverse in terms of procedures, ranging from fine ear microsurgery to large head and neck oncologic resections, as well as in terms of patients — ranging from newborns to centenarians. I also liked that the head and neck region houses all of the five senses — sight, sound, smell, taste, touch — that we use to interact with others and our environment.

What do you love most about practicing your specialty?

Martin: Well, I liked it a lot more 30 years ago! There was less paperwork and insurance problems to deal with. I liked it when I could have more of a relationship with my patients.

Man-Kit: The diversity of patients and problems that I can care for.

How would you describe each other’s approach to medicine?

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Martin: He’s really caring. I refer patients to him. I’m very confident in his skills.

Man-Kit: Patients really appreciate my dad — he has long-lasting friendships with them. He has a deep concern for their wellbeing not just on a professional level but on a personal level as well. I’ve really learned about the joy of being a doctor from him.

What is the most important thing you learned from each other about the practice of medicine?

Martin: He is much better than I am with medical records. I have a hard time with electronic medical records.

Man-Kit: It’s important to care for the person as a whole — not just the health issue they came to see you for.

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

Man-Kit: Something in public policy or government.

Martin: Taxi driver — I love driving and meeting people.

UPCOMING EVENTS UCSF CME: 46th Annual Advances in Internal Medicine 2018 June 18–22, 2018 | UCSF Parnassus Campus, San Francisco Now in its 46th year, this course reviews the most recent developments and current controversies in the field of internal medicine. Advances in Internal Medicine is presented by the Department of Medicine and is sponsored by the Office of Continuing Medical Education of the University of California, San Francisco School of Medicine. For more information or to register, visit http://bit.ly/2wv1wUw.

ASPC 2018: Congress on Cardiovascular Disease Prevention June 27–29, 2018 | Hyatt Regency Tamaya Resort, New Mexico

The American Society for Preventive Cardiology (ASPC) is holding the 2018 CVD Prevention Congress featuring innovative education, ground-breaking science and interactive discussions with top prevention experts. Attendees will have the opportunity to network with faculty and peers, and will leave with practical and useful information to use in clinical practice. For more information, visit https://www. aspconline.org/congress2018/.

Emergencies in Primary Care and Pharmacology July 6–8, 2018 | Monterey Plaza Hotel and Spa, Monterey

This conference is designed to provide primary care practitioners with up-to-date, evidence-based information commonly encountered in Emergencies in Primary Care and Pharmacology related issues, while suggesting pragmatic approaches to clinical management. The successful completion of this interactive program should improve attendees’ confidence in diagnosing, treating, and prescribing the most effective courses of treatment, with the ultimate goal of improving patient outcomes. Visit http://bit.ly/2IAaRyW for more information or to register.

JUNE 2018

SAN FRANCISCO MARIN MEDICINE

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SFMMS ADVOCACY ACTIVITIES

As the only medical association to represent the entire spectrum of medical specialties, modes of practice and interests of physicians in San Francisco and Marin, the San Francisco Marin Medical Society (SFMMS) has been a champion for community health issues since formation in 1868.Health Our policymaking efforts through A History of Advocating for its Community collaborations with state and national medical societies and political leaders, as well as articles in our awardwinning journal, San Francisco Marin Medicine, have given us a reputation for being influential far beyond the Bay Area.

SFMMS advocacy agenda to continues to focus healthincluding and the drafting following areas:resolutions that would As theThe only medical association represent the on public the 1980s, several entire spectrum of medical specialties, modes of evolve into CMA and AMA policies as well as statewide ballot practice, and interests of physicians in San FranENSURING ACCESS TO CARE: With ongoing vigilant efforts toinitiatives. preserveSFMMS continues to be a partner in the Hep B Free program in San Francisco. cisco and Marin, the San Medical SFMMS leaders programs and prevent cutsFrancisco in Medi-CalMarin reimbursement, Society (SFMMS) has been a champion for access com- to quality medical have long advocated that everyone should have SUGAR-SWEETENED BEVERAGES: SFMMS has long been on munity health issues since its formation in 1868. care. SFMMS joined in the lawsuits to preserve the Healthy San Francisco record combatting overconsumption and marketing of sugar Our policymaking efforts through collaborations with state program, an ultimately successful battle that went all the way tosoda, US especially to young people. To help prevent and and and national medical societies and political leaders, as well SFMMS advocated has provided to, diabetes, heart disease, and other associated battle obesity, asSupreme articles inCourt. our award-winning journal,for, Sanand Francisco Marin assistance community-based organizations including the Haight-Asbury Free diseases, SFMMS endorsed the SF vs. Big Soda coalition and Medicine, have given us a reputation for being influential far Medical Clinics, San Francisco Free Clinic, Marin Community Clinics, supported the landmark local tax on sugar-sweetened beverbeyond the Bay Area. The SFMMS advocacy agenda continues “The SFMMS helped save the Haight free fund clinicprofrom ages, approved by voters, with revenue slated to help toOperation focus on public health the following areas:members have donated Access, andand many others where the start, and I’ve been a loyal member ever since.” grams to prevent or reduce the consequences of consumption medical care and treatment for the uninsured and underserved.

– David Smith, MD, Founder, of sugar-sweetened beverages.

ENSURING ACCESS TO CARE: With ongoing vigilant efforts Haight-Ashbury Free Medical Clinics to preserve programs and prevent cuts in Medi-Cal reimburseANTI-TOBACCO ADVOCACY: SFMMS was a loud voice for cracking ANTIBIOTIC RESISTANCE: SFMMS leaders have presented ment, SFMMS leaders have long advocated that everyone down on tobacco promotion and use, and supported the early 1990s ban on smoking in San Francisco restaurants, at national meetings and contributed to policy on antibiotic should have access to quality medical care. SFMMS joined in a landmark thatthe spread nationwide.

SFMMS has also advocated stronger from secondhand resistance, for including theprotections AMA’s first statement on antibiotic the lawsuits topolicy preserve Healthy San Francisco program, smoke, higher taxes on tobacco products to provide additional funding to Medi-Cal, and the removal of tobacco overuse and agriculture. an ultimately successful battle that went all the way to U.S. products fromSFMMS pharmacies.

In 2017, supported Supreme Court. advocated for, andSFMMS has provided assis- a ban on flavored tobacco products adopted in San SCHOOL AND TEEN HEALTH: SFMMS helped establish and tance to, community-based organizations including thetobacco Haight- industry.

Francisco that is now being hard-fought by the staff a citywide school health education and condom program, Ashbury Free Medical Clinics, San Francisco Free Clinic, Marin removed questionable drug education efforts from high schools, Community Clinics, Operation Access, and many othersB: where HIV PREVENTION AND TREATMENT/HEPATITIS Having been among the first to push for legalized syringe and has worked on improving school nutritional standards. members have donated medical care and treatment for the exchange programs, appropriate tracking and reporting processes for clinical data, optimal funding and more – uninsured and underserved.

SFMMS has been at the center of advocacy for responses to the AIDS epidemic since the 1980’s, including drafting VACCINATION ADVOCACY AND EDUCATION: In several resolutions that would evolve into CMA and AMA policies, as well as statewide ballot SFMMS disresponse to increased outbreaks of initiatives. vaccine-preventable ANTI-TOBACCO ADVOCACY: SFMMS was a loud voice for continues to on be tobacco a partner in the Hep Free in San Francisco. eases in the Bay Area and across the state, the medical society cracking down promotion andBuse andprogram supported emerged as a leader in supporting policy to increase school vacthe early 1990s ban on smoking in San Francisco restaurants, Throughoverconsumption education about theand safety and efficacy aSUGAR-SWEETENED landmark policy that spread nationwide.

SFMMS BEVERAGES: SFMMS hashas longalso been oncination record rates. combatting marketing of vaccines and support of legislation that eliminated personal advocated for stronger protections secondhand of sugar and soda, especially to from young people. Tosmoke, help prevent and battle obesity, diabetes, heart disease and belief exemptions from required childhood vaccines, higher on tobacco products to provide additional othertaxes associated diseases, SFMMS endorsed thefunding SF vs. Big Soda coalition and supported the landmark local taxvaccion nation rates have increased significantly since 2012. SFMMS to Medi-Cal, and the removal of tobacco products from pharsugar-sweetened beverages, approved by voters, with revenue slated to help fund programs to prevent or reduce has authored several resolutions for the CMA, including a resmacies. In 2017, SFMMS supported a ban on flavored tobacco the consequences of consumption of sugar-sweetened beverages. olution allowing minors to receive vaccines to prevent STIs products adopted in San Francisco that is now being fought without parental consent. hard by the tobacco industry.

ANTIBIOTIC RESISTANCE: SFMMS leaders have presented at national meetings and contributed to policy on antibiotic resistance, the AMA’s firstB:statement antibiotic overuse and agriculture.

CARE: SFMMS leaders have developed HIV PREVENTION ANDincluding TREATMENT/HEPATITIS Having on END-OF-LIFE

numerous policies and educational efforts to improve care been among the first to push for legalized syringe exchange toward the end of life, including publishing guidelines on medprograms, tracking and reporting processes for and staff SCHOOL appropriate AND TEEN HEALTH: SFMMS helped establish a citywide school health education and condom ical futility or non-beneficial treatments that have been widely clinical data,removed optimal funding, and more, has been at from high schools, and has worked on improving school program, questionable drugSFMMS education efforts adopted by regional health systems.

SFMMS was one of the the center of advocacy for responses to the AIDS epidemic since nutritional standards.

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SAN FRANCISCO MARIN MEDICINE JUNE 2018

San Francisco Marin Medical Society  415.561.0850  www.sfmms.org

WWW.SFMMS.ORG

early adopters of Physician Orders for Life-Sustaining Treatment (POLST) in California and has been active in the local community coalition to ensure successful use of the form and the important conversation that goes along with completing the medical orders contained on the form. As medical and public opinion evolved, SFMMS became neutral on the option of physician-assisted dying and advocates for physicians and patients to exercise their own judgment as part of the patientphysician relationship.

REPRODUCTIVE HEALTH AND RIGHTS: SFMMS has been

a champion of reproductive choice for women, including supporting the use of RU486 and the medical termination of pregnancy. SFMMS continues to be a state and national leader in advocating for women’s reproductive health and choice, including access to all medical-indicated services.

ENVIRONMENTAL HEALTH: Among SFMMS’s many environ-

mental health efforts are establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for reduced exposure to mercury, lead, and air pollution.

GUN SAFETY/DOMESTIC VIOLENCE INTERVENTION:

SFMMS has contributed to the national debate on gun safety, including ending censorship and allowing physicians to discuss gun safety with their patients. The medical society published guidelines on domestic violence screening and intervention for physicians and other clinicians that were widely distributed and well received by clinicians citywide; the society was cited in the Journal of the American Medical Association as one of the best such resources.

ORGAN DONATION: SFMMS has been the vanguard in

seeking improved donation of organs to decrease waiting lists and deaths due to the shortage of organs through educating the public and proposing new policies regarding consent and incentives for organ donation.

DRUG POLICY AND OPIOID SAFETY: SFMMS has been a

leader in exploring and advocating new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, “treatment on demand” policy that supports immediate entry into drug treatment for those requesting it, and treatment instead of incarceration.

SFMMS was integral in the development of CMA’s landmark report on decriminalization and regulation of cannabis. In collaboration with the public health department, SFMMS has helped develop guidelines for safe opioid prescribing that have been adopted in primary care settings.

PRESERVING PHYSICIAN AUTONOMY: Working together with the CMA, SFMMS advocates for policies that protect physician autonomy and the patient/physician relationship, scope of practice, and reimbursement.

PARTNERSHIPS: SFMMS works closely with many local spe-

cialty and health organizations, such as the Chinese Community Health Care Association, Marin Community Clinics, Marin Department of Health and Human Services, RxSafe Marin, San Francisco Community Clinic Consortium, San Francisco Department of Public Health, San Francisco Emergency Physicians Association, San Francisco Pediatric Council, West Bay Hospital Conference, and others.

COMMUNITY NEWS Maria Ansari, MD

KAISER PERMANENTE Medical ethics in the national healthcare debate is an essential topic, illuminating the way to provide the best care possible to patients and vulnerable populations. Kaiser Permanente plays a leading role in the medical ethics discussion both on the national and local levels, including sponsoring the National Bioethics Symposium, contributing articles on the ethics of ACA repeal, and providing clinical bioethics consultation at the San Francisco Medical Center.

Several key principles to which Kaiser Permanente is committed include affordability of services, quality care, and access to essential benefits. To achieve these and other bioethical goals, we have established a local ethics committee, consisting of physicians, nurses, social workers, physical therapists, other relevant providers, and community members. By providing ethics consultation to patients, family members, and staff, the committee addresses sensitive healthcare issues lacking unclear courses of action. The inclusion of ethics in many discussions allows for patient-centered care and helps reduce moral distress.

WWW.SFMMS.ORG

Since the passage of the End of Life Option Act (ELOA) legislation in California, Kaiser Permanente San Francisco (KPSF) has successfully implemented and operated a program that has assisted all involved with making difficult choices during the most challenging of situations for any patient and family members. The palliative care program at KPSF, besides being an integral part of our multidisciplinary care, also offers further support to patients during this period of life. The complex ethical choices inherent in the program require sensitivity and commitment to the basic principles.

Because personal values at the end of life are not always clear, we have increased our Advance Care Directives and Life Care Planning efforts for all patients. By encouraging everyone to make their choices known in writing, before a life-altering event, we can ethically assist our patients in making plans as active participants in the process.

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IN CASE YOU MISSED IT:

Physician burnout costs up to $17B a year, task force says.

April 30, 2018

In Brief: • Physician burnout is taking a huge financial toll on hospitals and health systems — to the tune of $1.7 billion a year among doctors employed at hospitals, according to the National Taskforce for Humanity in Healthcare, which launched earlier this month.

• When burnout-related turnover among all U.S. physicians is considered, the costs could be as high as $17 billion, according to a paper released by the group, which is made up of doctors, nurses and other healthcare groups.

• Nurse burnout compounds the problem, annually sapping $9 billion from hospitals and $14 billion from the healthcare industry overall.

That burnout is a big problem is well known. In a recent Medscape survey, nearly two-thirds of U.S. doctors said they felt burned out, depressed or both. More troubling still, one-third of respondents said such feelings affected their relations with patients. In another study, one in five doctors reported they’ll reduce clinical hours over the next two years, while one in 50 said they plan to quit medicine for a different career.

According to the task force, burnout results in higher turnover and error rates, as well as poorer outcomes and patient satisfaction leading to lower payments for services.

The paper suggests organizations create a “human-centered” culture and query clinical teams before and after deploying new technologies to see if they eased or increased their workload.

The challenge comes as the U.S. faces a potential doctor shortage in the coming decade. A recent analysis by the Association of American Medical Colleges projects the shortage will reach 121,300 by 2030. Major shortfalls are projected in non-primary care specialties, surgery and psychiatry.

Some organizations are appointing chief wellness officers (CWO) to address these and other workplace issues. For example, the CWO at Southern California Permanente Medical Group (SCPMG) has spearheaded flexible work schedules and peer-topeer support. Specified teams help physicians prioritize administrative tasks and hand off clerical work when possible.

“You have to take a very holistic approach,” Edward Ellison, MD, executive medical director and chairman of SCPMG, told Healthcare Dive in an interview earlier this year. “It starts with culture, but it’s also about the practical, tactical time in your day.”

Others, including Cleveland Clinic, also employ CWOs. And the trend is growing. Last summer, Stanford Medicine became the first academic medical center in the U.S. to designate a CWO. This report further substantiates recommendations made by the University of California, San Francisco report that California should develop a comprehensive strategy to overcome the market forces that discourage physicians and other clinicians from practicing in underserved areas. The report highlights that any successful path to universal healthcare must include measures to improve access to care addressing the issues of physician workforce.

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Below are some highlighted quotations of the report: • “Administrative burdens have increased with the growing availability of electronic health records and is a source for frustration for patients as well as providers.” (Page 14) • “Even if California were to expand health plan competition through a public option in the individual market, additional steps would be needed to overcome physician workforce shortages in underserved areas.” (Page 23) • “To overcome workforce shortages California needs a comprehensive strategy, utilizing incentives to overcome the market forces that discourage physicians and other clinicians from specializing in primary care and practicing in underserved areas. Such an approach could include incentives (1) to ensure that the physician training pipeline includes individuals who are interested and prepared for these roles, (2) to reduce the financial and practice barriers for individuals to enter in these roles, and (3) through physician payment policies which can sustain them in these roles over time.” (Page 23)

Additional Information: CMA Responds to UCSF Universal Access Report (http://www.cmanet.org/news/press-detail/?article=cmaresponds-to-ucsf-universal-coverage-report)

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BE THE PHYSICIAN YOU ALWAYS WANTED TO BE. A PRACTICE WITHOUT BOUNDARIES Diagnosing ailments. Treating injuries. Saving lives. Keeping servicemembers and their families healthy – at home and around the globe. As a Navy Physician, you can pursue your true passion for helping others and do it in ways you’ve never imagined.

Beyond the everyday responsibilities of a doctor, the Navy offers you opportunities to travel the world on humanitarian missions and to contribute to disaster relief efforts in this country and around the world. Wherever you are, you’ll know that you’re bringing life-changing care to those who need it most.

In Navy Medicine, there are opportunities to practice in any of more than 30 specialty and subspecialty areas. And whatever your specialization, you can focus on the finer points of medicine without the business concerns: • • •

Provide truly patient-focused care Earn excellent compensation in an established, thriving practice Operate free of start-up costs, equipment expenses and insurance fees

A DOCTOR AND AN OFFICER As a Navy Physician, you will distinguish yourself with the pride and respect that comes with being a Navy Medical Corps Officer. You’ll not only be a skilled physician, but a leader in your own right: • • • •

Enjoy access to some of the most advanced medical technology on the planet Work at top military medical facilities on shore, at sea and in the field Partner with top health-care professionals on the Navy Health Care team Further your expertise through hands-on experience and Navy-funded advanced training

BENEFITS OF SERVING AS A NAVY PHYSICIAN What else is there to look forward to? A competitive salary with possible supplemental pay and potential bonuses. 30 days’ vacation with pay earned each year. Comprehensive health-care coverage and generous retirement and savings plans. Plus, there are always the fringe benefits, like world travel and tax-free housing, shopping and meals. And more. Beyond that, Navy Physicians enjoy regular hours and manageable patient ratios that provide ample time for family, friends and personal pursuits.

YOU DECIDE HOW YOU SERVE There are different ways that you can commit to practicing medicine in America’s Navy. Active Duty Medical Officers serve full-time. Reserve Medical Officers serve part-time. And the initial service requirement could be as few as two years. A Medical Officer Recruiter can provide more information on your options.

NAVY.COM/HEALTHCARE

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BECOME A NAVY PHYSICIAN For more details, contact your local Navy Medical Officer Recruiter: [Brochure FullAcquisition Name] Navy Medicine Talent Specialist [Brochure Address 1] 546 Vernon Ave Mountain View, CA.2]94043 [Brochure Address 800-345-6289 [Brochure City, State, Zip] kevin.keosibounh@navy.mil [Brochure Phone Number & Extension] [Brochure Email Address]

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Program Administered by Mercer Health & Benefits Insurance Services LLC • CA Insurance License #0G39709 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com