October 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

THE 2018 SFMMS ELECTION EDITION

POLITICS AND MEDICINE:

Essential Issues, Uneasy choices Health Reform Single-Payer Gun Control Immigration

SFMMS CANDIDATES SLATE .....

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Volume 91, Number 7 | October 2018

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SAN FRANCISCO MARIN MEDICINE

IN THIS ISSUE

October 2018 Volume 91, Number 7

POLITICS AND MEDICINE FEATURE ARTICLES

MONTHLY COLUMNS

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2

Membership Matters

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President’s Message: Guns and the Health of a Nation John Maa, MD

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The Democrats’ Approaching Dilemma: What Should They Do about Health Reform?

Caroline Poplin, MD, JD

Firearm Injuries and Violence Prevention: The Potential Power of a Surgeon General’s Report John Maa, MD, and Ara Darzi, MD Reprinted from the New England Journal of Medicine

11 Immigration, Children and Healthcare: Standing Up Together to Do What’s Right

Sandra R. Hernández, MD

13 Single-Payer Healthcare Is the Only Solution

Chris Cai, Isabel Ostrer and Jackson Runte

OF INTEREST 15 Marin General Hospital and UCSF Health Form Alliance 31 Extending San Francisco’s Ban On CandyFlavored Tobacco Products Into Marin

John Maa, MD, Matt Willis, MD, and Steve Heilig, MPH

29 Upcoming Events 30 Classified Ads

32 Community News: Kaiser Permanente

Maria Ansari, MD 32 Advertiser Index

ELECTION 2018: 16-17 CMA President-Elect: SFMMS Candidates’

Statements 18-29 SFMMS 2018 Leadership Election

Information

1868 2018

Anniversary

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 CELEBRATING 150 YEARS OF SFMMS HISTORY

Drs. Xavier Barrios and Rolland Lowe.

SFMMS AND ITS MEMBERS PAVED THE WAY to many

notable accomplishments and positions of distinction. In 1960, Dr. Roberta Fenlon was elected as the first woman president of the medical society. Dr. Xavier Barrios was elected as the first Hispanic president of a medical society in California in 1972, and Dr. Rolland Lowe was elected as the first Asian American president of the medical society in 1982, and of the California Medical Association in 1997.

Drs. J. Michael Bishop and Harold E. Varmus.

Dr. Stanley B. Prusiner.

SFMMS is proud to count among its past members many esteemed leaders in the profession, including three recipients of the Nobel Prize in Medicine. In 1989, Dr. Harold E. Varmus and Dr. J. Michael Bishop received the award for innovations in cancer research, and in 1997, Dr. Stanley B. Prusiner received the award for his discovery of prions and their relationship to neurological diseases.

SFMMS Featured Member: Sarita Satpathy, MD, MPH, CPE

Dr. Sarita Satpathy was born in Orissa, India, but has lived in many states within the U.S., as well as Spain, England and the West Indies. She studied biological psychology and zoology as an undergraduate student at the University of Texas in Austin, Texas. She then received her master’s in public health with a focus on community health education at San Jose State University. She went to medical school at St. George’s University in Grenada, Wisconsin. She completed her residency in

internal medicine at St. Michael’s Medical Center/Seton Hall in Newark, New Jersey. She has been working both as a hospitalist and in the outpatient setting in the Bay Area since completing her residency. She has held leadership roles as both a medical director and a regional medical director in the hospitalist setting.

Her interests include medical volunteering work, international travel, cycling and yoga.

SFMMS is pleased to welcome Dr. Satpathy as our Featured Member! Read more about Dr. Satpathy at www.sfmms.org/ About/Featured Member.aspx.

SFMMS General Membership Meeting

SFMMS Co-Hosts Luncheon with Special Guest, Mayor London Breed

Irene Sung, MD, receives J. Elliot Royer Award in Psychiatry.

Dr. Rolland Lowe’s son and daughter receive the 2018 SFMMS Community Service Foundation’s Public Service Award, given in memoriam of their father’s many accomplishments.

More than 90 SFMMS members attended the General Membership Meeting held at the Golden Gate Yacht Club in San Francisco on September 12, 2018. The SFMMS Community Service Foundation’s Public Service Award was given in memory of Rolland Lowe, MD, and was presented to Dr. Lowe’s family. SFMMS was pleased to present the J. Elliot Royer Award in Psychiatry to Irene Sung, MD. Featured speakers included CMA President Dr. Ted Mazer and Assemblymember David Chiu.

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Mayor London Breed recently addressed SFMMS physician members from the San Francisco Department of Public Health (SFDPH) and the San Francisco Health Network (SFHN) at a luncheon co-hosted by SFMMS, SFDPH and SFHN. The Mayor shared her health priorities, including wraparound healthcare support for the homeless, Mayor London Breed speaks to physicians at a luncheon safe injection sites, supportive co-hosted by SFMMS, SFDPH housing, and public health fundand SFHN. ing. She also acknowledged the i m p o r t a n c e o f S F M M S ’ c o l l a b o ra t i o n a n d t h e p o s i tive impact that it has on public policy in San Francisco.

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

A panel of SFMMS/SFDPH leaders also discussed our collective policy priorities for the coming year, including addressing the opioid epidemic, sugar-sweetened beverage taxes, firearm safety, menthol and flavored tobacco products ban, and more.

SFMMS leaders participate in a panel discussion with physicians from SFDPH and SFHN.

Physicians for a Healthy California to Administer $40 million GME Fund Thanks to Prop. 56, the California Legislature created a $40 million graduate medical education (GME) fund for the University of California (UC) to sustain, retain and expand GME programs, with the goal of increasing the number of primary care and emergency physicians in California. This program will be administered by CMA’s foundation—Physicians for a Healthy California (PHC)—on behalf of the UC and in coordination with a five-member executive board and 15-member Advisory Council. PHC expects to release these funds to GME programs in the current fiscal year. Read more at http://bit.ly/2Ni9t7y.

Health Information Exchange and CURES: What Physicians Need to Know

This spring, a coalition led by the CMA and the California Health Information Partnership & Services Organization (CalHIPSO) secured a $5 million expenditure for health information exchange (HIE) in the 2018-19 state budget. This funding will be used as the match to draw down $45 million in federal HITECH funds, creating a $50 million investment in HIE. Once federal approval is secured, funds will flow to HIEs to help onboard physicians in their communities. In general, this involves all the technical and support services needed to connect physician practices to an HIE and help them integrate data exchange into their practice workflows. A portion of the funding for this project is being set aside to help HIEs connect directly to the Controlled Substance Utilization Review and Evaluation System (CURES) database. Read more at http://bit.ly/2xdKJmR.

Marin General Hospital and UCSF Health Form Alliance

Marin General Hospital (MGH) and UCSF Health have formed a strategic alliance to expand clinical collaborations in Marin County, with the goal of improving patient care and strengthening physician practices for the local community. The agreement is the highest level of integration to date between the two institutions and will provide a number of opportunities for collaborative projects well into the future, including new and expanded care sites with MGH and UCSF providers and specialists throughout Marin County. UCSF also will have the right to nominate two directors to the MGH board. Read more at http://bit.ly/2xfz3Pz.

SAVE THE DATE: 2019 SFMMS Annual Gala

The 2019 SFMMS Annual Gala will be held on Friday, January 25, 2019, at Cavallo Point in Sausalito. President-Elect, Kimberly Newell Green, MD, will be installed as the 2019 SFMMS President. Watch for your invitation to arrive in the mail. More information and registration will be available soon at www.sfmms. org/events.aspx. Sponsorship opportunities are available—contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

WWW.SFMMS.ORG

October 2018 Volume 91, Number 7

Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production 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 Anne Cummings, MD Irina deFischer, 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 Anne Cummings, MD Nida F. Degesys, MD Robert A. Harvey, MD Naveen 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

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PRESIDENT’S MESSAGE John Maa, MD

GUNS AND THE HEALTH OF A NATION This July, the San Francisco Marin Medical Society was featured in a New England Journal of Medicine “Perspectives” article that I co-authored, calling for the United States Surgeon General to report on the problem of firearm injuries and violence in America.

A landmark in tobacco control was the 1964 report by U.S. Surgeon General Luther Terry on smoking and health. This publication served as the starting point of nearly 40 subsequent U.S. Surgeon General’s reports on smoking. Over the decades, these reports have characterized the impact of smoking on children, minorities, and women, and the dangers of secondhand smoke, nicotine addiction, workplace smoking, and of electronic cigarettes. A new Surgeon General’s report on firearm injuries might similarly stimulate new ways of thinking and unexpected answers. In 1999, the Institute of Medicine report “To Err is Human” catalyzed change in medicine by raising societal awareness of the rates of medical error. Perhaps a deeper understanding of the impact of firearms falling into the hands of the wrong individuals will help move the conversation forward.

A similar report on firearm violence prevention could be modeled after the 2017 CMA report chaired by CMA Board Vice Chair Shannon Udovic-Constant, summarizing the existing CMA and new AMA policies around the public health crisis of gun violence in America. The AMA recently passed numerous resolutions that supplement an already strong policy position on gun violence prevention, ranging from banning “bump stocks” to opposing concealed-carry reciprocity legislation. In the aftermath of the Parkland High School mass shooting on Valentine’s Day 2018, Congresswoman Robin Kelly introduced H.R. 5161 on Capitol Hill that would require the U.S. Surgeon General to submit a report annually to Congress about the effects of gun violence on public health. Our U.S. Congressman from Marin, Jared Huffman, is a co-sponsor of that legislation. In July, SFMMS also sent a letter to the Chief Medical Officer of the U.S. Department of Health and Human Services (HHS) asking the agency to explore the recommendation further. If control of the U.S. House of Representatives changes in November of 2018, the opportunity to convene Congressional hearings in 2019 to move this concept forward will be greatly enhanced.

Locally, a slate of firearm safety bills have passed the Legislature and were sent to the Governor for signature. The SFMMS endorsed SB 221, co-authored by Senators Scott Wiener and Jerry Hill and Assemblymembers David Chiu, Phil Ting and Kevin Mullin to limit the sale of firearms and ammunition at the Cow Palace. The CMA and Northern California Chapter of the AmeriWWW.SFMMS.ORG

can College of Surgeons have also endorsed SB 1100 by Senators Anthony Portantino and Scott Wiener, which seeks to close existing loopholes and raise the minimum age to purchase firearms to 21 in California. (Update Oct. 1: Governor Brown vetoed SB 221 but signed SB 1100.) Before becoming SF Supervisor of District 2, Catherine Stefani served as a spokewoman for Moms Demand Action for Gun Sense in America, which aims to reform gun laws. Supervisor Stefani will continue to be an ideal partner for SFMMS and CMA in firearm safety efforts into the future.

The SFMMS has also authored two resolutions that will be considered by the CMA House of Delegates, the first to encourage health-related organizations to divest their financial resources from any holdings in the gun and ammunition industries, and the second to hold the firearm industry financially responsible for the healthcare and other economic costs related to their marketing of and advocacy for guns sold in our nation.

A gun violence restraining order (GVRO) option was signed

by Governor Brown in 2014 after the Isla Vista mass shooting to allow law enforcement and family to petition a judge to temporarily remove firearms from an at-risk individual who may commit gun violence. However, the law has only been activated a handful of times in San Francisco since then. Physicians are not allowed to apply for a GVRO directly, but may contact the local sheriff, police department, or advise a patient’s family member about the process.

These and other strategies may help to incorporate the principles of responsibility and safety in firearm ownership to ensure a safer future for America. But in any event, ultimately, ending the epidemic of firearm violence in America will require sustained leadership extending beyond legislation, to change social norms and reduce the level of gun violence portrayed in Hollywood and video games viewed by children, to curb the daily tragedy of accidental pediatric injury from unsafe storage of firearms, and to reduce straw firearm purchases that allow weapons to fall into the wrong hands. It will be a long, concerted effort and process to change our gun culture for the better, and SFMMS will continue to lead the way.

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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SAN FRANCISCO

MARIN MEDICAL SOCIETY

JOIN OR RENEW TODAY When you join the San Francisco Marin Medical Society, you join more than 2,000 members in San Francisco and Marin who are actively protecting the practice of medicine and defending public health.

Working together with you, SFMMS unites physicians to champion healthcare initiatives and innovation, advocate for patients, and serve our local medical community, including physicians of all specialties and practice modes. We cannot do this alone.

Join SFMMS/CMA Today to Receive 15 Months of Membership for the Price of 12 Starting October 1, 2018, new members who join paying full 2019 dues, will receive the remaining months of 2018 membership for free. Join today to start receiving your benefits. Visit www.sfmms. org/membership for more information about SFMMS membership and benefits, or to join online.

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Renew Your Commitment to Medicine; Renew Your SFMMS Membership Today Make sure you continue to receive the benefits of SFMMS and CMA membership by renewing today. Full dues-paying members enjoy a 5% Early Bird Discount* if your renewal is received

by December 15, 2018. Renewing is easy: 1. Mail/fax your completed renewal form when you receive it in the mail; or 2. Renew online at www.sfmms.org with a credit card. *5% Early Bird Discount applies to 2018 full duespaying members only who are renewing at the same level for 2019; renewal form and payment must be received by December 15, 2018.

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

Politics and Medicine

The Democrats’ Approaching Dilemma: What should they do about health reform?

Caroline Poplin, MD, JD

If the Democrats begin to retake control of the federal government in November—for example, by flipping the House—they should start thinking about their next moves on health reform.

They will have plenty of time for contemplation: President

Trump and his minions will, if anything, redouble their attack on the Affordable Care Act (ACA) for the next two years, and the Senate (unless also flipped) will do what it can to help. Even if they regain control, all House Democrats can do, especially if the Senate doesn’t flip, is block bad bills from getting to President Trump’s desk. There is no compromise with this man.

The Choice

But in 2020 the Democrats will be at a fork in the road, and they will need to answer an important question: Should they restore and improve whatever survives of the ACA, based on 10 years of real-world experience, or should they respond to rising calls for “Medicare for All,” for part or all of the under-65 population?

Now Is the Time to Start Thinking.

The debate to date is not evenly balanced. As you would expect, supporting the ACA are the large (and growing) industries that benefit—for-profit insurance companies, large forprofit hospital chains, pharmaceutical manufacturers and so forth. (Indeed, the ACA was designed precisely to garner their support, or at least buy their silence.) In addition, though, over the last 30 years, an extensive and powerful “policy” community of academics, consultants, economists, and highly regarded think tanks (likely some with industry funding) have developed an elaborate intellectual infrastructure to support market-based commercial healthcare.

On the “Medicare for All” side, we have Physicians for a National Health Program (that should tell you something); Gerald Friedman, PhD, an economist at UMass Amherst; and recently, some advocacy organizations. No leading think tanks that I am aware of.

Since Democrats now have a choice, perhaps instead of starting from where we have been—the same thinking that led to the ACA—perhaps we should start with where we want to arrive.

We should have two principal goals. First, everyone needs to get the care they need at a price they can afford—that is to say, the objective is care, not coverage. Second, we need to get WWW.SFMMS.ORG

the total cost of the system down. That hasn’t happened despite strenuous efforts on many sides, possibly because the policy community has been ignoring some important costs as it bears down on what we pay clinicians (of which, full disclosure, I am one).

Important Cost #1: The Sickest Patients

One of the best opportunities to reduce cost—often overlooked in this context—is the sick patient. In general, 5% of a population is responsible for 50% of its total health care cost.

Treating these patients, who have multiple problems including depression, functional and cognitive impairment, as well as, often, limited social support or financial resources, is expensive, yes. But secondary and tertiary prevention, close follow-up, and improving patients’ social determinants of health saves the system money—mostly by keeping these patients out of emergency rooms, hospitals, in-patient rehabilitation and nursing homes—and improves patients’ quality of life.

Commercial health insurers and risk-bearing accountable care organizations (ACOs) want no part of the sickest patients— the way to make money is to insure and/or care for the healthy.

Low costs, excellent outcomes and numerous healthy patients mean high profits. Insurers and ACOs also seek reinsurance from the federal government, the states, high-risk pools and other programs to which to transfer the costly 5%. These maneuvers allow insurers to keep their profits and socialize the losses.

Important Cost #2: Administrative Costs

The good news is, from 1990 to 2012, the U.S. healthcare workforce grew by 75%. The bad news? Ninety-five percent of that growth was in administrative staff, not physicians. By 2012, there were 16 non-doctors for every doctor. Worse, only six of the 16 were involved in patient care.

So how much value do the 10 non-clinicians contribute to patient care? Drs. Jiwani, Himmelstein, Woolhandler and Kahn extensively analyzed the data for 2012 and determined that expenses related to billing and insurance in our multi-payer system totaled almost 18% of U.S. healthcare expenditures that year, far more than in any other OECD country. In 2014, in The OCTOBER 2018

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New York Times, Elisabeth Rosenthal estimated administrative costs at 20% to 30% of the total. Today, the ratio of administrators to clinicians is probably higher and accounts for a larger percentage of U.S. healthcare costs. Why? First, as politicians and the policy community have pushed a market-based system, U.S. healthcare has become a very profitable business, with many participants answering to Wall Street.

To stay in business, prosper and expand (those latter two are often linked), businesses need managers, and the above-mentioned consultants, to supervise marketing, identify profit and cost centers, and extract maximum productivity from the work force. Frequent negotiations between insurers and providers over prices also require businesspeople (and generate huge transaction costs).

Managers do not come cheap: John Commins points out that in 2005, CEOs made three times as much as orthopedic surgeons (the physician heavy hitters); 10 years later, five times as much. Indeed, physician compensation represented only 8.6% of total healthcare expenditures in 2012. We know how orthopedic surgeons help patients—CEOs, not so much.

Second, hospitals, insurers, and health systems are consolidating ever more quickly, sometimes for survival, often for increased leverage with one another, and for increased profit.

Consolidation of multiple hospitals or businesses requires additional administrators to manage the administrators of local systems. Or as Cathy Shoen, a senior expert at the Commonwealth Fund, put it,”[At] large hospitals there are senior VPs, VPs of this, that and the other.” Whether consolidation improves quality and reduces cost, it does move important decisions further and further from the bedside.

And finally, all these managers as well as the policy community and, alas, Congress, have an unshakable faith in the ability of health information technology to “transform” U.S. healthcare, reduce costs, and improve quality by collecting and analyzing vast amounts of data about everything.

Indeed, their faith was such that in 2009 Congress promulgated the so-called HITECH Act, “encouraging” all hospitals and doctors (first with carrots, then with sticks) who received payments from Medicare to buy electronic medical records systems so that they could send their outcomes data to CMS and other interested parties, who would presumably use them to improve care and reduce cost. Under the Medicare Access and CHIP Reauthorization Act (MACRA), passed in 2015, these required reports became even longer and more complicated.

It doesn’t appear that anyone has done a credible analysis of how much top-heavy management and its high-tech tools cost our system—my guess it’s become a significant percentage of the total. We need to reassess this before we design the system of the future. From my vantage point at the sharp end of the stick, expensive managers and HIT are not merely useless—they are counterproductive and wasteful.

And quality? At least one analyst crunched the numbers and concluded that “as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers.”

What’s the answer? The cost of healthcare in the U.S. continues to rise in an unsustainable manner, particularly if we insist, as we should, that in a country as rich as this, everyone who 8

needs medical care should get it. In 2009, the Democrats went with market-based reform, based partly on what seemed politically most feasible. Truly. Not only did it undo them politically, but it did not save money. In 2020, with a little luck, they will get another chance.

The way to reduce costs, maintain quality and cover all is to treat the sick, simplify and decentralize through Medicare for all. Providers must be nonprofit. Now is the time to work out the details.

Caroline Poplin, MD, JD, is an attorney and internist in Bethesda, Maryland. She is a former staff internist for the National Naval Medical Center, and currently practices medicine part-time at the Arlington Free Clinic in Virginia. She also consults for law firms on Medicare and Medicaid fraud.

Reprinted with permission from MedPage, August 23, 2018. Original story with links to references: https://tinyurl.com/y8u7enn2 https://bit.ly/2xGVjSH

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

Politics and Medicine

Firearm Injuries and Violence Prevention: The Potential Power of a Surgeon General’s Report John Maa, MD, and Ara Darzi, MD

IN THE AFTERMATH of the shooting at a social services center

in San Bernardino, California, in 2015, President Barack Obama suggested that the relationship between firearm ownership and gun injuries might be as strong as the connection between cigarette smoking and lung cancer. The full extent of the burden of firearm injuries is incompletely understood because of historical restrictions on federal funding for research on firearm violence by the Centers for Disease Control and Prevention (CDC). But recent increases in the frequency and lethality of mass shootings in the United States—and the approximately 90 gun deaths that occur each day—argue for efforts to reframe the national debate about firearms as a public health issue.

The five-year anniversary of the Newtown, Connecticut, school shooting arrived in the shadow of mass shootings in Las Vegas and Sutherland Springs, Texas, in 2017, and shootings in Parkland, Florida, and Santa Fe, Texas, served as additional reminders of the risks for children attending school. As the United States came to understand a different set of health hazards—those associated with cigarette smoking—and the burden of smoking-related diseases on the healthcare system, a major step was the 1964 Surgeon General’s report on smoking and health.¹ This publication was the first of several Surgeon General’s reports on tobacco control, and similar reports on AIDS, mental health, and substance use disorders have influenced national discussions. A powerful step now would be a Surgeon General’s report to fully characterize the complex problem of firearm injuries and violence in the United States and sharpen efforts to identify new solutions by revealing how the country got to its current state.

Objective data on the history, epidemiology, health effects, and financial costs of firearm violence, as well as the factors that contribute to it, could inform this discussion by conveying the full scope of the problem. The nearly 20,000 annual gun suicides in the United States and estimated 760 gun-related domestic violence fatalities each year would be worthy areas of focus for such a report, given the programs that the CDC and other federal agencies already support aimed at preventing suicide and intimate-partner violence. A definitive statement could also summarize the overwhelming scientific evidence that having WWW.SFMMS.ORG

a firearm in the home increases the risk of suicide. The report could serve as an urgent call to action for professional medical organizations and federal authorities. International leaders could help by describing the changes in both gun laws and social norms that have reduced firearm violence in their countries.

A study of World Health Organization (WHO) mortality data found that Americans are 25 times more likely to be victims of a gun-related murder and eight times more likely to die by firearm suicide than people in other developed countries.² Japan, on the other hand, has among the lowest per-capita rates of firearm ownership, the lowest rates of gun murders, and the highest life expectancies in the world as ranked by the WHO in 2015.

The U.S. healthcare system is often blamed for the country’s 2015 WHO ranking as 31st worldwide in life expectancy. But the complex and incompletely understood problem of firearm violence cuts across legal, political, educational, and financial systems. The new Surgeon General’s report could begin to tease apart entangled issues in these systems. The consequence of such system failures is enormous: beyond the deaths caused by gun violence, survivors often have lifelong physical and psychological problems including disability, depression, and substance abuse.

The increasing burden from mass-casualty incidents on the country’s emergency rooms, healthcare system, and lawenforcement agencies has highlighted the urgent need for action. After the mass shooting in Las Vegas, patient needs rapidly overwhelmed the capacity of emergency responders and paramedics. Miscommunications led to patients being taken to the closest hospitals, rather than to trauma hospitals that were best equipped to treat them. But a surge of nearly 600 gunshot victims—many transported by private vehicles—is a nightmare that is nearly impossible for any institution or city to prepare for without the assistance of state or federal agencies. The coordinated and effective medical response to the November 2015 mass-casualty event in Paris can be partially attributed to a master plan developed 20 years earlier but never activated until that day.³ In the United States, a joint federal and state collaboration spearheaded by the Department of Health and Human Services could coordinate county-wide emergency responses to OCTOBER 2018

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mass shootings. Strengthening the Bureau of Alcohol, Tobacco, Firearms and Explosives and potentially dividing it into two separate agencies could also help address gun-related threats.

As we further elucidate the problem of firearm violence, new solutions may present themselves, including ones that involve the legal system. The National Rifle Association (NRA) and gun-rights advocates have used the law to protect their Second Amendment rights through litigation (such as Heller v District of Columbia) to strike down existing gun control laws. The challenge for firearm-safety advocates is to develop an equally effective legal strategy to protect public health. Wide variability in state laws related to firearm ownership complicates this mission. California implemented an assault-weapons ban in 1989, and Governor Jerry Brown signed the first “gun violence restraining order” in 2014 to allow family members and lawenforcement officers to petition the court to disarm a person who makes threats of firearm violence.⁴ The Surgeon General’s report could catalogue these and other legislative efforts and help standardize firearm laws throughout the country.

The report might also stimulate new ways of thinking, shifts in societal norms, and development of new social programs related to firearm safety. The person behind the Sutherland Springs shooting had served time in prison for domestic violence and escaped from a mental health facility but was still able to acquire firearms. The Parkland shooting occurred despite repeated notifications to the Federal Bureau of Investigation and law enforcement about the threat posed by a student who had stated his violent intent on social media. Breakdowns in communication, straw purchases (buying a gun for another person who may be prohibited from purchasing one), the portrayal of gun violence in movies, limitations of background checks, lost and stolen firearms, and fragmented accountability in the chain of reporting of dangerous persons reflect larger societal challenges. A deeper understanding of the legal and administrative errors that result in firearms falling into the wrong hands could help move this discussion forward.

The United States has a long history of prioritizing the rights of gun owners over public safety. In 1992, after leaving the Office of Surgeon General, C. Everett Koop wrote an editorial addressing violence as a public health issue.⁵ He focused on firearm injuries and proposed that anyone owning or operating a firearm be required to meet specific criteria, such as being monitored in the firearm’s use. The recommendations were never implemented.

During his Senate confirmation hearings to become Surgeon General in 2014, Vivek Murthy characterized the problems surrounding firearm violence in the United States as public health concerns. His support for gun control led to his appointment’s being delayed for several months. After Murthy’s confirmation, the political climate limited his office’s ability to champion firearm safety. A 2011 Florida law sought to prevent physicians from discussing firearm ownership with their patients; the ban was struck down by the 11th Circuit Court of Appeals in 2017.

In the aftermath of the Las Vegas and Parkland shootings, however, the tone of the conversation has changed. Parkland students started a national movement by sharing the horror they witnessed. Perhaps the time has arrived to commission the first Surgeon General’s report on firearm injuries and violence prevention to stress the importance of collecting and disseminating data on the true nature of the public health problem we 10

are facing. The United States could then begin using a public health approach to incorporate the principles of responsible and safe firearm ownership into the legal interpretation of the Second Amendment to ensure a safer future.

This article was published on June 27, 2018, at NEJM.org.

Disclosure forms provided by the authors are available at NEJM.org.

Author affiliations: John Maa, MD, is with the Division of General and Acute Care Surgery, Marin General Hospital, Larkspur, California, and the San Francisco Marin Medical Society, San Francisco. Ara Darzi, MD, is with the Department of Surgery, Imperial College London—St. Mary’s Hospital, London.

References 1. U.S. Public Health Service. Smoking and health: Report of the advisory committee to the Surgeon General of the Public Health Service. Washington, D.C.: U.S. Department of Health, Education and Welfare, 1964.

2. Grinshteyn E, Hemenway D. Violent death rates: the U.S. compared with other high-income OECD countries, 2010.

Am J Med 2016;129:266-73.

3. Hirsch M, Carli P, Nizard R, et al. The medical response to multisite terrorist attacks in Paris. Lancet 2015;386:2535-8.

4. Vernick JS, Alcorn T, Horwitz J. Background checks for all gun buyers and gun violence restraining orders: state efforts to keep guns from high-risk persons. J Law Med Ethics 2017;45(1_suppl):98-102.

5. Koop CE, Lundberg GB. Violence in America: a public health emergency. Time to bite the bullet back. JAMA 1992;267:3075-6

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

Politics and Medicine

Immigration, Children and HealthCare: Standing Up Together to Do What’s Right

Sandra R. Hernández, MD

The U.S. has long been a refuge for people yearning for a better and safer life. As a nation, it enhances our communities and strengthens our moral standing around the world.

IN THE LAST FEW MONTHS, we have seen those cherished

values turned on their head. Our hearts broke as we watched the federal government separate parents from their children, bringing direct and avoidable harm to families who came to this country out of desperation. The cruelty and chaos created by that policy have been soundly rebuked by leaders and ordinary citizens across the political spectrum.

Under pressure from the courts and the public, the Trump administration in June directed the Department of Health and Human Services to reunite families while continuing to pursue policies that would allow the government to detain them together indefinitely. Many parents and children remain apart.

Those who have been reunited have undoubtedly been scarred by the experience, particularly children, for whom these events are dangerously traumatic. And most of these families remain in a perilous legal limbo, with no safe place to call home.

The government’s treatment of these families speaks directly to who we are as a nation. We all have a role to play in making the situation right.

There are many philanthropies around the U.S. and in California with a long history of supporting just and humane immigration policies and providing help for those fleeing violence. They include the Annie E. Casey Foundation, California Community Foundation, Casey Family Programs, Evelyn and Walter Haas, Jr. Fund, The New York Community Trust, Open Society Foundations, Rosenberg Foundation, The San Francisco Foundation, The California Endowment, the Irvine Foundation and many others. In times like these, we are reminded of how important their work is. Many have responded to this crisis with increased support and grantmaking.

While the broadest areas of need right now do not fall squarely in the California Health Care Foundation’s areas of focus or expertise, our board and staff felt that it was important for us to contribute to this larger effort, particularly to help families in our state.

We owe a great debt to many partner organizations who have helped us figure out how to craft meaningful and timely contributions. With the benefit of their knowledge and their grantmaking leadership, CHCF will be making up to $1 million in emergency grants to groups that support separated children and detained families.

If you are interested in helping separated children, detained families or immigrants seeking asylum in California or beyond, I recommend these resources: WWW.SFMMS.ORG

Grantmakers Concerned with Immigrants and Refugees has been a go-to resource for foundations on the issue of family separation and detention. It produced a helpful guide for grantmaking strategies. It is also keeping track of foundation statements and funding commitments.

California Community Foundation has created its own LA for All Fund and maintains a list of organizations in Los Angeles County and across the country that seek to protect, heal and reunify families.

Latino Community Foundation has compiled a list of organizations accepting support, as well as links for information about foster care and clothing donation sites.

CHCF has drawn inspiration and knowledge from these

organizations, and I am grateful for their commitment. Working together, we can protect the U.S.’s role as a beacon of humanity, freedom and opportunity in a harsh world. Those are powerful values, but they do not sustain themselves. It is our job—all of us—to defend and nurture them.

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 for 16 years. She previously served as Director of Public Health for the City and County of San Francisco. Sandra is an assistant clinical professor at the University of California, San Francisco, School of Medicine. She practiced at San Francisco General Hospital in the AIDS clinic from 1984 to 2016. She is a member of the SFMMS. Note: The SFMMS is a participant in a new CHCF-funded project, coordinated by the California Academy of Family Physicians, to develop information and advocacy resources for both clinicians and patients. Stay tuned.

OCTOBER 2018

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Politics and Medicine

Single-Payer Healthcare Is the Only Solution Chris Cai, Isabel Ostrer and Jackson Runte

We are a group of UCSF medical students who firmly

believe that a single-payer system is the only sustainable solution to our nation’s out-of-control healthcare spending and growing disparities in healthcare access. California and Bay Area physicians have the opportunity to lead the way on developing truly equitable and affordable healthcare reform. We define single-payer as a unified, government-run healthcare system, with streamlined administration, minimal cost-sharing and universal coverage. Evidence shows that a single-payer system will benefit physicians, generate substantial cost savings and vastly improve healthcare equity.

Single-Payer Benefits Physicians

Physicians stand to gain from a single-payer system due to administrative simplification and decreased malpractice rates.

Over half of all practicing physicians in the United States experience burnout, which is often linked to excessive administrative burden and inefficiency. Currently, half of physicians’ time is consumed by these responsibilities.¹ As the government becomes the sole payer, providers are relieved of the burdens of multiple payers and made less vulnerable to uncompensated care.

In addition, malpractice rates are likely to go down under a single-payer system. Roughly half of malpractice fees are designated for future medical payments so patients can pay for care to manage complications from improper treatment. In a single-payer system with minimal cost-sharing, the need for these fees will be eliminated, reducing the financial incentive to initiate malpractice suits. While more research needs to be conducted on this subject, evidence from other countries is promising. For example, the proportion of healthcare spending dedicated to malpractice in the U.S. is nearly double that in Canada.² Finally, a single-payer system has the potential to create a unified health record and vastly streamline information distribution and access, thereby improving provider communication and quality of patient care. A unified payer system is the first step toward a unified EHR. A common concern among providers is that physician compensation will decrease under a single-payer system. However, with expanded coverage and minimal cost-sharing, total utilization of provider services increases. At the same time, providers’ billable hours increase due to decreased administrative load.³

Single-Payer Is Cost-Effective

The United States has the most expensive healthcare system in the world. Compared to other developed countries, the U.S. WWW.SFMMS.ORG

spends nearly twice as much on medical care while performing worse on health outcomes, including life expectancy. The U.S. spent 17.8% of its gross domestic product on healthcare, while spending in other developed countries ranges from 9.6–12.4%.4 Furthermore, healthcare spending is projected to grow at an average annual rate of 5.6% through 2025, expanding to nearly 20% of GDP.⁵ Moving to a single-payer system would save the U.S. money.

Even as more people gain health insurance coverage and more services become covered, health spending is projected to decrease under a single-payer system. A cost analysis of the most recent single-payer legislation in California, Senate Bill 562, projected that the state would generate over 10% savings in the first year of implementation, equal to $37.1 billion in healthcare spending.³ The largest contributor to these cost savings is administrative simplification achieved by a single-payer system. The most-cited study on U.S. healthcare administrative expenditures, published in the New England Journal of Medicine, estimated that administrative costs accounted for 31% of healthcare spending in the U.S. compared to 16.7% in Canada. Across the board, single-payer analyses show that savings would be realized from lower administrative costs. The policy think-tank, RAND, performed an analysis of the New York Health Act, a single-payer bill currently in the state legislature, which shows that the state would spend $11.6 billion more on patient care, but $13.9 billion less on administration, generating savings of $2.3 billion.⁶ Many single-payer projections also show that bulk purchasing of medications and durable medical equipment would lead to significant savings. A recent study published in JAMA comparing U.S. healthcare spending to that of 10 other high-income countries showed that pharmaceutical spending was vastly higher in the U.S. Per capita spending for pharmaceuticals in the U.S. was $1,443 compared to between $466 and $939 in other countries.⁴ Single-payer cost analyses consistently project savings on pharmaceuticals and medical equipment in the range of 1.8–4% of total healthcare spending.7,8 A streamlined, single-payer system would allow the U.S. to realize savings while covering more Americans and increasing the amount of money actually going toward healthcare.

Single-Payer Improves Healthcare Equity

As we prepare to enter the healthcare workforce, we are deeply concerned by persisting barriers to healthcare that disproportionately harm the patients most in need. The most glaring OCTOBER 2018

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of these is insurance coverage: While the ACA improved uninsurance rates nationwide from 16.7% to 10.3% between 2013 and 2016, many remain uninsured, with 3 million left in California alone.9,10 Nearly half of this population cite the high cost of insurance as the main reason they remain uninsured.⁹ But when it comes to healthcare access, the challenges are far more complex than insurance coverage alone.

Rapidly expanding cost-sharing requirements are affecting all types of health insurance policies in the U.S., which means that being insured does not guarantee affordable access to care.

Among individuals insured by large employers, deductibles have increased nearly 170% over the past 10 years with cost-sharing by patients increasing at a faster rate than insurer payments.11 Underinsurance is also a growing problem, with 24% of those with employer plans and 44% with individual or marketplace plans meeting the criteria in 2016. This is primarily due to high deductibles and out-of-pocket costs, according to the Commonwealth Fund.12 Underinsurance is problematic because individuals with high levels of cost-sharing have been shown to reduce use of care for both minor and serious symptoms.13 In addition, large and concerning increases in high-severity emergency department visit expenditures and hospitalization days have been documented among underinsured low-income groups.14 When underinsured patients are forced to use healthcare services financial losses can be astronomical. Upon implementation, a single-payer system would completely eliminate uninsurance and underinsurance in the U.S. Even more troubling are the amplified effects of increased cost-sharing on specific patient populations. Racial minorities have incomes and savings that are just fractions of whites’, which severely impacts affordability of healthcare in our for-profit insurance system. For example, according to the most recent U.S. census data, average net worth and income for black households are 8% and 65% of white households, respectively.15 Consider an average black family, with a net worth of $9,211, insured by an ACA bronze plan: With a family deductible of over $12,000, this family could be bankrupted by a single high-cost encounter with the healthcare system—an encounter a higherearning family would be able to withstand far more easily. The disproportionate effects of cost-sharing on minorities should be considered a form of structural racism—that is, our health system is itself a structural force that perpetuates racial group inequity on the societal level.

Other distinct patient groups are being victimized by unequal healthcare distribution and costs. For example, while the ACA outlawed denial of coverage due to pre-existing conditions, insurers are finding new ways to deny coverage to high-cost patients. “Adverse tiering,” or the structuring of drug formularies to place entire drug classes in a high cost-sharing tier, has been documented across insurance plans for several high-cost chronic diseases such as mental illness, cancer, diabetes, rheumatoid arthritis and HIV. This effectively deters these patients from enrolling in their plans.16 Simplifying our insurance system to a single, public payer would vastly reduce the capacity of healthcare financing to systematically oppress specific patient groups in the U.S. The principle of distributive justice, an ideal we acknowledge under oath in our earliest days of medical school, tells that all patients should be valued equally. If we truly care about justice

14

in our healthcare system, it is essential that clinicians examine how for-profit insurance systems incentivize discriminatory behavior in our own clinical and business practices. If access to our services continues to be determined by reimbursement size, we allow for the persistence of a healthcare system that preferentially serves wealthier, healthier individuals. The value of our work is not dependent on any aspect of the individual patient sitting in front of us in the exam room. Just imagine a healthcare system that empowers providers to treat any and all individuals with equal care regardless of income, health status, disability, race or citizenship!

Actions San Francisco Marin Medical Society Can Take

As the organized voice of physicians, medical societies play a major role in advocating for and advancing health reform. The current political and social climates present an opportunity for organized medicine to take a leadership role in transforming healthcare. We urge SFMMS to advance single-payer through formal advocacy at the state and national levels. Single-payer healthcare is the only viable model for improving physician work quality and generating significant cost savings while also creating a more just healthcare system.

Chris Cai is an MS2 at UCSF. He is active in Students for a National Health Program (SNaHP) and Students for Organized Medicine (SFOM). Isabel Ostrer is an MS2 at UCSF. Before attending medical school she spent several years doing health policy research at Harvard Medical School focused on disparities in healthcare access for vulnerable populations. She is active in Student for a National Health Program (SNaHP). Jackson Runte is an MS2 at UCSF. A California native, he has witnessed the harmful effects of the insurance industry on healthcare access and physician practice in both rural and urban settings across the Golden State.

References 1. Sinsky C, Colligan L, Li L, et al, “Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties,” Ann Intern Med, 165(11):753-760 (2016).

2. Anderson GF, Hussey PS, Frogner BK, Waters HR, “Health spending in the United States and the rest of the industrialized world,” Health Affairs, 24(4), 903-914 (2005).

3. Pollin R, Heintz J, Arno P, Wicks-Lim J, “Economic analysis of the Healthy California single-payer health care proposal (SB-562),” Political Economy Research Institute, University of Massachusetts (2017).

4. Papanicolas I, Woskie LR, Jha AK, “Health care spending in the United States and other high-income countries,” JAMA, 319(10), 1024-1039 (2018).

5. Keehan SP, Stone DA, Poisal JA, Cuckler GA, Sisko AM, Smith SD, et al, “National health expenditure projections, 2016–25: price increases, aging push sector to 20 percent of economy,” Health Affairs, 36(3), 553-563 (2017).

6. Liu JL, White C, Nowak SA, Wilks A, Ryan J, Eibner C, “An assessment of the New York Health Act: A Single-Payer Option for New York State,” RAND Corporation, Santa Monica, CA (2018).

7. Sheils J, Cole M, “Cost and economic impact analysis of a single-payer plan in Minnesota, 2012” (2013).

8. The Lewin Group, “Cost and coverage analysis of nine proposals to expand health insurance coverage in California” (2002).

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

MARIN GENERAL HOSPITAL and UCSF HEALTH FORM ALLIANCE MARIN GENERAL HOSPITAL (MGH) AND UCSF HEALTH have formed a strategic alliance to expand clinical collaborations in Marin County, with the goal of improving patient care and strengthening physician practices for the local community.

According to Lee Domanico, Chief Executive Officer of Marin General Hospital, while mergers and acquisitions are a growing trend in healthcare, Marin General Hospital has been able to keep high-quality care local by forging strategic partnerships with physicians and other community healthcare providers.

“This strategic alliance with UCSF will allow us not only to remain independent, but also to be able to provide the North Bay community with rich access to a wide range of high-quality, specialized medical services right here in Marin County,” said Domanico. “With UCSF and our community partners, we will engage in multi-year planning to further enrich those services with new programs and technologies.”

“We have a long history of collaboration for specialty care with Marin General Hospital, and I am so pleased we are now able to expand on that history of serving residents in Marin and throughout the North Bay,” said Mark Laret, President and CEO of UCSF Health. “This will make a tremendous difference for patients who need the specialty care of UCSF, but also want the convenience of seeing our specialists close to home.”

This alliance builds upon decades of collaboration between

the two hospitals. Over the past seven years alone, MGH and UCSF Health have entered into four key relationships that have greatly benefitted patients:

Neo-Natal Intensive Care Unit (NICU)

UCSF Benioff Children’s Hospitals physicians provide support at the MGH NICU.

Neurosurgery

UCSF’s Department of Neurosurgery provides trauma, inpatient and outpatient services at MGH.

Pediatric Care

MGH’s Braden Diabetes Center offers physician services for pediatric diabetes through the UCSF Madison Clinic. UCSF pediatric surgeons and anesthesiologists perform procedures at MGH so pediatric patients and their families can stay close to home.

Cardiac Surgery

UCSF’s Department of Cardiac Surgery provides MGH call coverage and elective services.

In addition, MGH and UCSF Health are both part of Canopy Health, a growing accountable care network that partners with insurance companies to bring greater and more affordable access to the Bay Area’s highest-quality physicians, hospitals and other providers, while enabling patients to receive in-network care close to home.

MARIN WEIGHT LOSS & WELLNESS 9. Kaiser Family Foundation, “Key facts about the uninsured population” (2016).

10. Kaiser Family Foundation, “Health insurance coverage of the total population” (2017).

11. Claxton G, Levitt L, Rae M, Sawyer B., Kaiser Family Foundation, “Increases in cost-sharing payments continue to outpace wage growth” (2015).

12. Commonwealth Fund, “Underinsured rate increased sharply in 2016; more than two of five marketplace enrollees and a quarter of people with employer health insurance plans are now underinsured” (2017).

13. Wong MD, Andersen R, Sherbourne CD, Hays RD, Shapiro MF, “Effects of cost sharing on care seeking and health status: results from the Medical Outcomes Study,” AJ Public Health, 91(11), 1889-1894 (2001).

14. Wharam JF, Zhang F, Eggleston EM, Lu CY, Soumerai SB, RossDegnan D, “Effect of high-deductible insurance on high-acuity outcomes in diabetes: a Natural Experiment for Translation in Diabetes (NEXT-D) Study,” Diabetes Care, dc171183 (2018).

15. U.S census data retrieved from https://www.census.gov/data. html.

16. Pearson C, “Avalere analysis: exchange benefit designs increasingly place all medications for some conditions on specialty drug tier,” Avalere Health An Innovation Company (2016).

WWW.SFMMS.ORG

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OCTOBER 2018

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election

2018

SFMMS CANDIDATE for CMA PRESIDENT-ELECT peter N. bretan, jr., md, facs

I’m Peter Bretan, a laparoscopic uro-

logic and kidney transplant surgeon. I work in Marin, Sonoma and Santa Cruz counties. My main hospital serves Kaiser, the Palo Alto Medical Foundation and the County Alliance Medi-Cal with a large under- and uninsured population. Thus my practice is as inclusive as possible, and interacts with all modes of practice.

In CMA I’ve been a past Trustee, President’s Forum Chair, current District X AMA Delegate, and CMA Small and Solo Group Practice Forum Delegate. I’ve served as President of my component medical society three separate times, and also bring extensive leadership experience in medicine outside of the CMA. I’ve previously directed Transplant Programs at the Cleveland Clinic Foundation, UCLA and St. Joseph’s in Santa Rosa, and was an Associate Professor at UCSF. I continue to teach students as an immunology lecturer at UC Berkeley. My academic accomplishments include over 200 scientific publications, two medical patents, and service as a current reviewer for five medical journals. I completed a PhD curriculum in basic science that provides a solid foundation in medical science that can help our profession in healthcare policy-making.

As a professor at Touro Medical School in Clinical Urology, I have taught a healthcare policy class for the past 15 years. This course for students and practicing physicians has been important for our profession in California to educate legislators—not only about what it takes for doctors to save lives, but that all lives are precious, not just to the families they are part of, but to society as a whole. That is why I continue to teach a healthcare policy course, as it is important to our profession especially in these times of great change.

Today we need this type of cooperation, as we are faced with a complex and rapidly changing environment that threatens the foundation of all medicine, especially the doctor-patient relationship. We need a strong partnership with not just our current legislative allies, but to expand this base with a similar course offered statewide.

I am the Western Section Healthcare Representative for the American Urological Association (AUA). As the current President of the California Urological Association (CUA), I have tackled important medical practice issues such as physician burnout 16

Candidate Statement

from burdensome factors such as MOC, inefficient EMR, and unsustainable office overheads. I have a direct interest in this issue as the field of urology several years ago had one of the highest burnout rates, approaching 65%. Now after much effort addressing the roots of burnout, the rate has decreased by 20%. The American Board of Urology, in response to the AUA and CUA, has eliminated MOC, and replaced it with a CME program named Life Long Learning. This new program has been much better received by our membership, and I am proud to have been part of changing this process that is so vital to our specialty.

I served for 28 years in the USPHS Reserves, attaining the naval rank of Captain (O-6). I was deployed for the care of Cuban refugees in 1980, and to those displaced from Hurricane Katrina in 2005, leading the rebuilding of hospital medical staffs in New Orleans afterwards. Thus I have a deep understanding of the need for a concerted Public Health response to disasters.

While my career has given me in-depth medical knowledge, with rich and varied leadership experiences, the accomplishment I cherish the most is being the Founder and CEO of LifePlant International. LifePlant is a charitable organization that furnishes life-saving transplants in developing countries, for which I was recognized by the AMA with the Benjamin Rush Award for Citizenship and Community Service.

My greatest motivation is in service to give back to society for my good fortune. I grew up as a child farm laborer, and I know what it is to be without adequate healthcare. Because of this I will fight for all physicians to be adequately represented, trained and heard too, so that they are adequately compensated for care of their patients. Universal coverage is an important goal of both the CMA and AMA, and must be sustainable for all physicians and their patients to succeed. With my broad and in-depth leadership experiences, I can help CMA accomplish this aim in a time where a rapid understanding of complex issues is necessary. That is why I am running to be your next CMA President.

I am very proud and grateful to have been endorsed by the SFMMS for this position. I humbly ask for your vote and support to lead our CMA as President-Elect this upcoming year.

—Peter N. Bretan, Jr., MD, FACS

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

election

2018

SFMMS CANDIDATE for CMA PRESIDENT-ELECT kenneth S. blumenfeld, md, faans

Every position or office I’ve held

in organized medicine has been a call to service. My decision to run for President-Elect is no different. It comes from requests and encouragement of those around me combined with a sincere desire to represent and lead our CMA. Being president of an organization like CMA requires dedication, determination, and sacrifice. It has to be a labor of love. Ideally being the President of CMA should not be a goal or aspiration but rather a position you are chosen to fill for the good of the organization.

For my qualifications I would refer you to the Declaration of Candidacy below. Notwithstanding the credentials of my fellow candidates, I would distinguish myself as being most prepared to perform the duties and responsibilities of the President of CMA. Doctors, and their patients, need advocacy and representation. Regulatory burden, physician burnout, narrow networks, workforce shortages, drug costs, healthcare disparity, inadequate GME funding, encroachment of scope of practice, attacks on medical staff autonomy, and attempts to repeal MICRA are just some of the issues we will be facing.

Many of our challenges are brought upon us by others. Consider Prop 46, the governor’s attempt to supplant Prop 56 funds, SB 562, and AB 3087 to name a few. Other challenges and opportunities we champion based on emerging policy and politics.

We will be working with a new administration and the prospect of universal access. We will be asked how to control the costs of healthcare. We will be stewarding a ballot measure on sugar-sweetened beverages. There will be continued debate on opioid abuse and gun violence. We will be working to enhance physician wellness. As always, efforts will be made to increase the number of medical school and residency positions in California. Diversity in our organization, leadership and workforce will remain a priority. Lastly, we must address how to provide care to the mentally ill and underserved.

Campaigning for President-Elect, I have listened more than I have spoken. I hear your concerns and struggles. I want to assure you that your issues will be my issues. Our CMA, not the CNA or SEIU, is and must remain, the premier medical organization in California, the go to on healthcare policy, and the mouthpiece for patient advocacy.

WWW.SFMMS.ORG

Candidate Statement

Representation, education, and advocacy are what CMA must do and what I am about. Let me represent you as the next President-Elect of our great CMA. I will not disappoint. I ask for your vote.

Thank you.

—Kenneth S. Blumenfeld, MD, FAANS

DECLARATION OF CANDIDACY

Kenneth S. Blumenfeld, MD, is a board certified neurosurgeon practicing in San Jose, California. He was in solo practice from 1992 to 2016. Since 2016 he has been with the Palo Alto Foundation Medical Group as a full-time neurosurgeon and Tier 1 administrator. Dr. Blumenfeld has worked at, as well as served on the medical executive committees of multiple hospitals north and south of the Golden Gate. He is a past Chief of Staff at Good Samaritan Hospital in San Jose and an UCSF Adjunct Clinical Professor. He is currently a member of the medical staffs of Regional Medical Center of San Jose, El Camino Hospital of Los Gatos and Mountain View, O’Connor Hospital of San Jose, and Dominican Hospital of Santa Cruz. He has helped build and establish several Level II Trauma Centers as well as Comprehensive Stroke Centers. Dr. Blumenfeld obtained his medical degree from the Johns Hopkins School of Medicine in 1986 and completed his neurosurgical residency at the University of Pennsylvania in 1992. He obtained his board certification in 1995 and remains a diplomat and Fellow of the American Association of Neurological Surgery.

Dr. Blumenfeld has a long history of service in organized medicine, having joined the Santa Clara County Medical Association and California Medical Association in 1993. Within SCCMA he has served as a delegate for both the SSGPF and his district.

He has been a VP of External Affairs, SACPAC Chair, and is currently the President. His activities within CMA have included being Vice Chair and Chair of the Council on Legislation. He has been a CALPAC board member and currently serves as a Trustee from District VII. Dr. Blumenfeld is a member of numerous specialty societies including the California Association of Neurological Surgery (CANS), American Association of Neurological Surgery, Western Neurosurgery Society, and Council of State Neurological Societies.

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SAN FRANCISCO

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MARIN MEDICAL SOCIETY

Pursuant to the San Francisco Marin Medical Society Bylaws “Article X Section 2—Nominations,” the Nominations Committee renders in writing the following slate of candidates for the 2018 SFMMS election. This slate was read at the September 12, 2018, General Membership Meeting, at which time the SFMMS President called for additional nominations from the floor.

2019 Officers – Term 2019

For SFMMS President-Elect: Brian Grady, MD For SFMMS Secretary: Monique Schaulis, MD, MPH For SFMMS Treasurer: Michael Schrader, MD, PhD, FACP For SFMMS Editor: Gordon L. Fung, MD, PhD, FACC, FACP (Incumbent Editor) For SFMMS Board of Directors Term: 2019-2021 Seven candidates to be elected to the SFMMS Board of Directors: Nida Degesys, MD (Incumbent Director) Zarah Iqbal, MD Michael Kwok, MD (Incumbent Director) Heyman Oo, MD, MPH (Incumbent Director) Sarita Satpathy, MD, MPH, CPE Jeffrey Stevenson, MD (Incumbent Director) Kristen Swann, MD Winnie Tong, MD (Incumbent Director)

For SFMMS Nominations Committee Term: 2019-2020 Four candidates to be elected to the SFMMS Nominations Committee: Tracy Hessel, MD Kenneth Katz, MD, MSc, MSCE Susan Nguyen, MD Kenneth Tai, MD

For SFMMS Delegation to the California Medical Association House of Delegates Term: 2019-2020 The candidates receiving the highest number of votes will serve as Delegates; the rest will be Alternate Delegates or on the wait list.

The President-Elect automatically becomes one of the Delegates according to the SFMMS Bylaws: Lawrence Cheung, MD, FAAD, FASDS (Incumbent Delegate) Gordon L. Fung, MD, PhD, FACC, FACP (Incumbent Delegate) Beth Griffiths, MD (Incumbent Alternate Delegate) Ryan Guinness, MD Pratima Gupta, MD (Incumbent Delegate) Keith Loring, MD (Incumbent Alternate Delegate) John Maa, MD (Incumbent Delegate) Robert Margolin, MD (Incumbent Delegate) Heyman Oo, MD, MPH David Pating, MD (Incumbent Alternate Delegate) Richard Podolin, MD, FACC (Incumbent Delegate) Sarita Satpathy, MD, MPH, CPE Jeffrey Stevenson, MD (Incumbent Alternate Delegate) Andrea Wagner, MD (Incumbent Delegate) Matt Willis, MD (Incumbent Alternate Delegate)

NOTES 2018 President-Elect Kimberly Newell Green, MD, automatically succeeds to President.

2018 President John Maa, MD, automatically succeeds to Immediate Past President.

Member voting will take place ONLINE ONLY. In order to place your vote, we must have your email address in our database. Please provide us with your email address if we don’t already have it. Paper ballots are NO LONGER MAILED. Please look for a special email from SFMMS on October 23 with detailed information regarding the online voting process, as well as the link to the online ballot.

Your electronic vote must be cast by 5 p.m. on Monday, November 12, 2018.

Please see candidate biographies and statements on the following pages.

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SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

CANDIDATE BIOGRAPHIES President-Elect BRIAN GRADY, MD

Urology

Treasurer

Secretary

MICHAEL C. SCHRADER, MD, PHD, FACP

MONIQUE D. SCHAULIS, MD, MPH

Emergency, Hospice and Palliative Medicine

Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations

Urologist, Golden Gate Urology; active medical staff member at CPMC and CPMC/MissionBernal, St. Mary’s Medical Center, St. Francis Memorial Hospital and Seton Medical Center.

Senior Physician, Emergency Department, Kaiser San Francisco; Senior Physician, Palliative Medicine, Kaiser San Francisco/South San Francisco; Vital Talk Senior Associate, Bay Area Hub Faculty; teach UCSF Emergency and Kaiser Internal Medicine residents.

Private practice, internal medicine; Fellow, American College of Physicians; Clinical Professor of Medicine, UCSF Volunteer Clinical Faculty; Instructor, Inpatient Medicine CPMC 2000-11; Instructor, UCSF medical student office preceptor 1998-present.

SFMMS Board of Directors Liaison from St. Luke’s Medical Staff to the SFMMS; member of the Executive Committee, past Secretary, current Treasurer.

SFMMS Board Member; SFMMS Executive Committee Member.

SFMMS Board of Directors 2015-2018, SFMMS Executive Committee 2017-2018, Treasurer SFMMS PAC 2018, Vice-Chair SFMMS CMA Delegation 2018.

Chief of Staff-elect at Seton Medical Center; former president of the CMA Resident Physicians Section; delegate to the AMA HOD and CMA HOD, Resident and Student Sections.

Treasurer, Kaiser SF Emergency Department; Opioid Champion, Kaiser SF Emergency Department.

I trained to be a physician-scientist but decided my passion was clinical medicine. I have always participated in teaching the next generation of physicians. I currently serve on the UCSF Volunteer Clinical Advisory Board. I am CEO of an independent physician practice, a small business. I am concerned about the health of people in the community and have served on the Community Action Committee at Saint Francis Memorial Hospital for the past two years. I have experience in clinical practice quality and served previously on the Subcommittee on Congestive Heart Failure Outcomes and the Atrial Fibrillation Clinical Pathway Committee at UCSF/Mt. Zion.

Medical Society Experience

Additional Relevant Experience

Why Are You Interested in Serving?

I have been in private practice at many of the hospitals in San Francisco for the past 18 years. I was fortunate to train at our great local university, UCSF, which included experience at Kaiser, SFGH and the VAMC. I hope to continue the great work done by SFMMS and its past leaders in championing the role of physicians in healthcare.

WWW.SFMMS.ORG

Over the past four years I have been active on the SFMMS Board of Directors and have found it to be a powerful forum for leading public health policy. The office of the treasurer is integral to this mission: the financial health of the society is necessary to promote the SFMMS agendas. As the CEO and previously the treasurer of a small business, I have experience with accounting, budgeting, tax preparation, asset management and auditing. I will use these skills to manage SFMMS finances.

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CANDIDATE BIOGRAPHIES SFMMS Board of Directors

Editor GORDON L. FUNG, MD, PHD, FACC, FACP

NIDA F. DEGESYS, MD

Incumbent Editor

Incumbent Director

ZARAH IQBAL, MD

ALSO CANDIDATE FOR CMA DELEGATE

Cardiovascular Diseases

Emergency Medicine

Pediatrics

Current Job Positions and Hospital and Teaching Affiliations

Clinical Professor of Medicine, UCSF Medical Center; Director of Cardiac Services at UCSF Medical Center at Mount Zion; Director of Asian Heart & Vascular Center; Director of Electrocardiography Laboratory at MoffittLong Hospital.

Resident Physician, UCSF/San Francisco General Hospital.

SFMMS: Editor 2011 to present, Executive Committee 2011-present; Past President; CMA: Delegate since 2000 (past chair), Member of Council of Scientific Affairs 2004-present, IMQ Surveyor since 1994.

SFMMS Board of Directors.

Medical Society Experience

Additional Relevant Experience

Why Are You Interested in Serving?

Over the past six years I have learned much more about the topics and issues facing clinicians and our community. Working with the SFMMS staff, Editorial Board and Executive Committee has been one of the highlights of my involvement with SFMMS. In a sense, San Francisco Marin Medicine, our award-winning journal, is one of the oldest still-viable forms of social media used by the physician community serving the San Francisco Bay Area. I truly cherish my time on the board and look forward to serving as your editor for 2019.

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I am the only resident member of the SFMMS Board of Directors. I serve as National Resident Representative to the American College of Emergency Physicians Board of Directors and have also served as National Speaker and Vice Speaker of the Emergency Medicine Residents’ Association. I served as National President of the American Medical Student Association and chaired its board of trustees. In medical school, Ohio’s governor appointed me student trustee on the Northeast Ohio Medical University Board of Trustees.

Over the past two years I have been committed to advocating on topics important to Bay Area residents and fellows including sugary beverage taxes, safe injection sites and tobacco legislation. Bay Area public health legislation victories help move the AMA and our country in the right direction for our patients. It would be an honor to serve a full term on the board and continue representing physicians in training.

I’m currently a PGY-2 resident at UCSF in the Pediatric Leaders Advancing Health Equity (PLUS) program. My program mission is to train pediatric residents to advance health equity for children and families, and includes training in leadership, community health and health policy in addition to excellent clinical training.

CMA Council on Legislation (2017 – current); CMA Delegation to AMA (2014 – 2017); member, CMA CMS Medi-Cal Subcommittee (2015 – 2016); CMA-MSS Vice Chair for Policy (2014).

I have been very active at the local (SFMMS), state (CMA), specialty (AAP) and national (AMA) level, advocating a broad range of issues related to health equity, public health and social justice. In my two years on the California delegation to the AMA, I created and implemented an electronic system to track resolutions and reports that amplified our voice and effectiveness.

I fundamentally believe that advocacy is a core part of our profession. I’m proud to call SFMMS my home in organized medicine, with its history of challenging the status quo and pushing our systems to do the right thing for our patients and our profession.

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

MICHAEL K. KWOK, MD

HEYMAN OO, MD, MPH

SARITA SATPATHY, MD, MPH, CPE

Incumbent Director

Incumbent Director

ALSO CANDIDATE FOR CMA DELEGATE

ALSO CANDIDATE FOR CMA DELEGATE

Internal Medicine

Internal Medicine — Hospitalist and Outpatient Internal Medicine

Pediatrics

Current Job Positions and Hospital and Teaching Affiliations

Internal Medicine private practice, both inpatient and outpatient (Kwok Internal Medicine, Inc.); active Medical Staff, Marin General Hospital; Courtesy Medical Staff, Novato Community Hospital.

General Pediatrician, Marin Community Clinics; Associate Physician & Clinical Instructor, General Pediatrics Department, Zuckerberg San Francisco General and UCSF Benioff Children’s Hospital.

Hospitalist, St. Francis Memorial Hospital; Hospitalist, Kentfield LTAC both Marin and SF; Outpatient Internal Medicine at Crossover Facebook Campus.

Member of MMS/SFMMS continuously since 1992; Board of Directors Marin Medical Society, 1994–1996, 2012–5/2017; Secretary/Treasurer MMS, 2013–2015 & President-Elect, 2016– May 2017; Executive Committee of SFMMS, 5/2017–present; Board of Directors SFMMS, 5/2017–present; Alternate Delegate to CMA HOD, 2014–present.

SFMMS Board of Directors; Marin Committee member.

I have been active on the Membership Committee for the last few years, committed to engaging physicians to get involved with SFMMS. Together, physicians can bring positive change and a more cohesive sense of community to the overall health and well-being of our patients. I wish to continue cultivating this environment within our community.

Marin General Hospital Strategic Planning Committee, 2015–present; Marin General Hospital Medical Executive Committee, 2018 & 2019; Novato Community Hospital Board of Directors, 1998–2006 (Finance Committee, Nominations Committee, Executive Committee; Secretary of the Board); NCH Medical Staff: Vice Chief of Staff 1997, Secretary/Treasurer 1995-1996 & 2005-2011; Chairman Pharmacy & Therapeutics Committee 1993-1996; Quality Review Committee 1992-2011 & Medical Committee 1992-2011, Medical Executive Committee for 11 years; Marin Physician Hospital Organization Board of Directors 1997-1999; chaired Marin PHO Committee on Physician Recruitment & Retention.

As a medical student, I served on the Board of San Diego County’s Medical Society for three years, and since graduating residency from UCSF, I have served on the SFMMS Board for the last year. I have also been an active member of the American Academy of Pediatrics Chapter 1 Advocacy Committee for the last four years and currently serve as one of its Co-Chairs.

I helped establish Cogent Health Care’s hospitalist program, served as Hospitalist Medical Director, then as one of eight Regional Medical Directors for Cogent’s California hospitalist programs. My work in varied hospital settings, including Acute, Subacute, LTAC and outpatient, has helped me better understand healthcare delivery issues and enriched my ability to network with other providers. Having recently chaired the St. Francis Foundation Wine Women and Shoes charity event, I know the impact physicians can have as leaders in charity and volunteer work for needy communities.

Because of my experience in medical staff leadership/governance, hospital governance, county medical society leadership & independent medical practice, I have very broad interests/ perspective on the practice of medicine. I hope to bring this experience and perspective to the Board of Directors to advocate for the profession of medicine and care of patients.

Over the last year, I have been privileged to represent SFMMS on a variety of critical issues ranging from gun violence prevention to banning flavored tobacco products. I would be honored to continue working on these and other healthcare policy issues by serving another term as a Board Member and as a Delegate to CMA.

Medical Society Experience

Additional Relevant Experience

Why Are You Interested in Serving?

WWW.SFMMS.ORG

I wish to be politically active in healthcare to foster a better, stronger, healthier community.

I want to connect with physicians of varied backgrounds—ethnically and culturally diverse, younger physicians new to the community, and to inspire women leaders. Together, physician leaders can combat major issues by networking, increasing awareness and being present at varied levels of our community. My experiences and interest in networking and advocacy, and my passion for health-related issues will help me represent our collective voice through the Medical Society and CMA.

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CANDIDATE BIOGRAPHIES SFMMS Board of Directors JEFFREY L. STEVENSON, MD

KRISTEN SWANN, MD

WINNIE TONG, MD Incumbent Director

Incumbent Director

General Practice, Primary Care

Emergency Medicine

Plastic surgery

Current Job Positions and Hospital and Teaching Affiliations

Private practice, solo practice, medical staff Marin General, Novato Community Mills-Peninsula Hospitals.

Kaiser San Rafael Emergency Medicine Physician; Pediatric and Sepsis Leader for the department.

I am currently a plastic surgeon at Kaiser Permanente Medical Center in San Francisco and have mentored medical students and residents in surgery rotation and research.

Immediate Past President Marin Medical Society 2017; SFMMS Board of Directors and Executive Committee 2017; PAC 2017; currently Alternate Delegate; former CMA Work Comp Technical Advisory Committee (TAC).

Marin Committee member.

I have served on the SFMMS Board (2016– 2019). I am involved in the Finance Committee (2018) and Membership Committee (2018).

Working with legislators, professional groups, CMA, private. MEDICAID-MEDI CAL (GOALS): 1.Taxpayer’s default healthcare. 2. Eligibility: remove penalties for working. 3. Efficiencyinfrastructure improvements; expedite qualifying, treatment, payment. EHR IMPROVEMENTS (Goals): 1. Physician intuitive, expedited. 2.

CURES intuitive. 3. Interoperability resolution with CMA leadership; revoke EHR certification if fails interoperability tests like “I need a patient record CD, now.” 4. Time of service authorization. 5. Secure core medical data. End proprietary “ransom.” WORKERS COMP: 1. SB 563-1160 (Pan-CMA); payor MD responsible for utilization review. Goal: medical director board seat. 2. Improve efficiency; 28:1 Premium: Paid Medical. OTHER: 1. Lobbied extra time reimbursement: 99358 Bill It!

Took on various EMRA committee leadership roles during residency; also Chief Resident.

Now, as Kaiser’s Emergency Dept. pediatric and sepsis leader, I work to coordinate and improve sepsis and pediatric care in the ED and regionally. On the Concussion Smart Marin Committee, I’ve been working over the past year to coordinate and standardize pediatric concussion care and follow-up among all Marin County EDs, sports teams, public and private schools. I’ve been involved heavily in ACEP since residency. I was resident board member for Virginia ACEP for three years and was on the state legislative ACEP committee.

I completed a health policy mini fellowship with ACEP, working in DC headquarters and lobbying for Emergency Medicine daily on Capitol Hill.

I have served on the Women Plastic Surgeons Steering Committee and the Government Affairs Committee for the American Society of Plastic Surgeons (ASPS). My prior involvement in the ASPS Young Plastic Surgeon Steering Committee provided insight into concerns of new surgeons.

Quality of care, practice survivability.

Born and raised in Marin, I am excited to be back here practicing medicine. Although relatively new to SFMMS, sitting on the Marin Committee this past year has broadened my health policy horizons and instilled a desire to get more involved in helping protect and improve healthcare overall in the Bay Area.

Medical Society Experience

Additional Relevant Experience

Why Are You Interested in Serving?

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I’ve enjoyed serving on the SFMMS Board.

SFMMS actively advocated for patients and community on important public health issues, including soda tax, flavored nicotine products, safe injection sites. I strongly believe in continuous education/improvement; the SFMMS Board can provide the platform to launch improvements. I can provide energy, enthusiasm and leadership in programs for orienting physicians to an environment demanding high-quality care and continuous education.

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

SFMMS Nominations Committee TRACEY HESSEL, MD

Pediatrics

KENNETH KATZ, MD, MSC, MSCE

Dermatology

SUSAN NGUYEN, MD

Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations

Lead Pediatrician at the Marin Community Clinics, a Federally Qualified Health Center; Volunteer Clinical Faculty, UCSF School of Medicine and UCSF School of Nursing; Preceptor for Dominican University Physician Assistant Program.

Dermatologist, Kaiser Permanente San Francisco; Chief, Outpatient Pharmacy & Therapeutics, Kaiser Permanente San Francisco Medical Center; Volunteer Attending, Dermatology, San Francisco General Hospital.

Hospitalist, Marin General Hospital and Sutter Alta Bates Hospital.

Medical Society Experience

Previous: San Mateo Medical Association Board member, Current: Marin Committee.

Additional Relevant Experience

Trained at UCSF for medical school and residency; Champion Provider Fellow, UCSF; Marin County Healthy Eating Active Living Steering Committee; Marin County Oral Health Steering Committee; Head Start Medical Advisory Committee; Board Member, HeadsUp San Rafael City Schools Foundation.

Member, FDA Dermatologic and Ophthalmic Drugs Advisory Committee; Associate Editor, JAMA Dermatology; Co-chair, American Academy of Dermatology Expert Resource Group on LGBT/Sexual and Gender Minority Health; Member, Board of Directors, Bay Area Physicians for Human Rights.

I had the privilege to be on the board of the San Mateo Medical Association at a time when we were unified as a group to defend MICRA in 2014 and won.

With healthcare costs increasing and political challenges persisting, we must advocate more than ever before on behalf of physicians and ALL of our patients. I would be honored to help nominate colleagues to serve the society who are committed to it and the physicians and patients it serves.

Many physicians don’t know how much their medical society fights on their behalf. It is my goal to do all that I can to get myself and others involved. It would be an honor to have your support to serve on the Nominations Committee.

Why Are You Interested in Serving?

In my current position, I have advocated for our local underserved patient population and partnered with other organizations to strengthen our local safety net. I am inspired by the work being done by the SFMMS to effect change on a larger scale and hope to be able to help encourage other local physicians to participate in the efforts to promote the health of our greater community.

WWW.SFMMS.ORG

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CANDIDATE BIOGRAPHIES SFMMS Nominations Committee

SFMMS Delegation to the California Medical Association House of Delegates

KENNETH TAI, MD

LAWRENCE CHEUNG, MD, FAAD, FASDS

GORDON L. FUNG, MD, PHD, FACC, FACP

Incumbent Delegate and Chair of the Delegation

Incumbent Delegate ALSO CANDIDATE FOR EDITOR

Medicine/Pediatrics

Dermatology

Cardiovascular Diseases

Current Job Positions and Hospital and Teaching Affiliations

Chief Medical Officer at North East Medical Services.

Solo private practice with volunteer teaching responsibility at UCSF, St. Mary’s Medical Center and CPMC.

See bio under Editor.

Medical Society Experience

Additional Relevant Experience

San Mateo Health Commissioner; Physician Advisory and Quality Improvement Member for Health Plan of San Mateo and San Francisco Health Plan; California Health Care Foundation Leadership Fellow, 2009-2011; Vice Chair of Medicine Department at Chinese Hospital, 2014-2015.

SFMMS: Board Consultant 2016, Immediate Past President 2015, President 2014, President-Elect, Treasurer, Secretary, Board of Directors, Political Action Committee, Membership Committee; CMA: House of Delegates serving as Delegation Chair as well as member of CMA Council on Science and Public Health; At-Large CMA delegate to AMA House of Delegates.

I have been very active at the both the local (SFMMS), state (CMA), and national (AMA) levels. My role in the CMA delegation to the AMA is that of the California Resolutions Committee Chair. I have the responsibility of shepherding CMA policy into AMA policy.

Why Are You Interested in Serving?

I have worked in San Francisco in a safety net clinic for the last 14 years with colleagues at CPMC, Chinese and Zuckerberg hospitals.

I have promoted healthcare initiatives such as Soda Tax and Ban on Flavored Tobacco. It would be an honor to join the Nominations Committee to ensure that physicians’ voices are heard at the local and state levels.

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I am honored to have served in the delegation for the past several years. I have seen a number of progressive public health policies that originated in our delegation become state and federal policy. SFMMS leads the way in crafting policies that protect/promote medicine and our patients. I humbly request your support for re-election.

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

BETH GRIFFITHS, MD

RYAN GUINNESS, MD

PRATIMA GUPTA, MD

Incumbent Alternate Delegate

Internal Medicine

Incumbent Delegate

Internal and Preventive Medicine

Obstetrics and Gynecology

Current Job Positions and Hospital and Teaching Affiliations

Assistant Clinical Professor, Division of General Internal Medicine, UCSF.

Internal Medicine Resident, Kaiser Permanente; Preventive Medicine Resident, UCSF.

Kaiser Permanente Senior Physician; Volunteer Assistant Professor at UCSF; Medical Director, St. James Infirmary (free clinic in SF for sex workers and transgender individuals).

Member, CMA Health Reform Technical Advisory Committee; Member, CMA Council on Legislation; Delegate, CMA House of Delegates; Vice Chair, CMA Resident & Fellow Section; Chair, CMA Medical Student Section; Vice Chair, Legislative Affairs, CMA Medical Student Section; Council Member, AMA Council on Medical Education; Delegate, AMA House of Delegates.

I have contributed several articles to San Francisco Marin Medicine over the past year, including on topics such as Zika virus, resident burnout and mental health, and genderaffirming healthcare.

SFMS PAC 2016; Delegate to CMA House of Delegates.

Prior to medical school, I worked in the U.S. House of Representatives and the California State Legislature. Since, I have used this experience to advocate for a better, more equitable healthcare system, primarily through organized medicine. Currently, I serve as Director of Health Care Advocacy for the Division of General Internal Medicine at UCSF, where I develop curricula in health policy and advocacy and collaborate with faculty to expand the impact of their work.

I have served as a resident representative on several committees at Kaiser Permanente, including the Physician Health & Wellness Committee, Diversity Committee and the Medical Assistant Physician Partnership Work Group. I am also a member of the Bay Area Physicians for Human Rights.

American College of OB/Gyn Legislative Committee member, Board of Directors of California Family Health Council, Member of San Francisco Mayor’s Anti-Human Trafficking Taskforce, former member of Board of Directors for Physicians for Reproductive Choice and Health.

In my seven years as a CMA Delegate, I have continually been so impressed with CMA’s impact, from expanding residency funding to increasing Medi-Cal reimbursement rates. I would be honored to continue to serve with such an incredible group of physicians, and to continue to focus on our patients’ health.

Serving as a SFMMS Delegate would allow me to represent the resident experience and help bridge a connection between the medical society and resident trainees. I hope to use this position to advocate for issues that pertain to SFMMS, residents and the medical community at large.

Medical care and service extends beyond the doors of my clinic. Physician advocacy is an important part of my medical philosophy, as I consistently use my voice as a physician to fight to ensure reproductive rights for all men and women in the U.S. and abroad.

Medical Society Experience

Additional Relevant Experience

Why Are You Interested in Serving?

WWW.SFMMS.ORG

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CANDIDATE BIOGRAPHIES SFMMS Delegation to the California Medical Association House of Delegates KEITH LORING, MD

JOHN MAA, MD

Incumbent Alternate Delegate

Incumbent Delegate

Addiction Medicine and Emergency Medicine

ROBERT MARGOLIN, MD Incumbent Delegate

General Surgery

Internal Medicine and Geriatrics

Current Job Positions and Hospital and Teaching Affiliations

Addiction Medicine at HealthRIGHT360’s Integrated Care Clinic (The Haight-Ashbury Free Clinic and Walden House Recovery Centers).

Medical Society Experience

SFMS/SFMMS Board of Directors 2009–2015; Executive Committee 2009–2011; Treasurer 2010; Finance Committee 2010–2013; Alternate Delegate to CMA HOD 2011–2013 and 2018; Delegate to the CMA HOD 2014–2015; Membership Committee 2018.

Additional Relevant Experience

Why Are You Interested in Serving?

I want to help respond to the evolving challenges posed by the Trump administration, opioid and other substance use epidemic, and other public health issues. SFMMS’ contribution to difficult issues over the years has been substantial and promises to remain so. I would value greatly a renewed opportunity to serve as a delegate.

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1) Immediate Past Chair, UC Office of the President Tobacco Related Disease Research Program; 2) Chief, Division of General and Acute Care Surgery, Marin General Hospital; 3) Immediate Past Chair, American Heart Association Western States Affiliate Advocacy Committee; 4) Medical Staff, Dignity Health – St. Francis; selected as (415) Top Doctor by Marin Magazine and as a San Francisco SuperDoctor.

Primary care practice in Internal Medicine; Chief of Staff of the Medical Staff at CPMC; Chair of the Credentials Committee, CPMC; Board of Directors, Medical Insurance Exchange of California; Associate Clinical Professor, UCSF.

President 2018; Secretary 2016; Board of Directors 2012–2015; Executive Committee 2014–16/2012-13; AMA 1991–present; CMA Specialty Society Delegate, Northern California Chapter American College of Surgeons (ACS); Awarded SFMS David Perlman Award for Excellence in Medical Journalism in 2013; San Francisco Marin Medicine magazine Editorial Board 2012–present.

AMA: Delegate to the House of Delegates; CMA: Past Member of the Board of Trustees, Past Chair of the Audit Committee, Chair of CALPAC; SFMMS: Past President, Past Chair of the CMA Delegation.

Past President, ACS Northern California Chapter; Recipient of 2013 ACS Ellenberger Award for Excellence in State Advocacy; Nominated for White House “Champion of Change for Prevention and Public Health” 2013; Named one of “Top 20 People Making a Difference in Healthcare in America” 2009; Current Member, American Heart Association Board of Directors, and Past President, San Mateo Division 2004–2005; Commendation for Tobacco Control Advocacy by SF Board of Supervisors 2014; American Heart Association Physician Volunteer of the Year 2016.

I have spent much of the past 25 years in leadership roles in our medical society and the CMA.

As SFMMS President, I have sought to expand programs for members and advocate on behalf of quality patient care in Sacramento. I would be honored to continue to help SFMMS lead efforts to strengthen the future practice of medicine and improve the health of San Francisco through the CMA Delegation.

I have greatly enjoyed my role as your CMA delegate for the past 20 years. I believe I have the experience, perspective, energy and desire to continue to advocate for physicians and their patients and thus ask that you re-elect me to serve as your CMA delegate.

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

HEYMAN OO, MD, MPH

DAVID R. PATING, MD Incumbent Alternate Delegate

ALSO CANDIDATE FOR DIRECTOR

Pediatrics

RICHARD A. PODOLIN, MD, FACC

Psychiatry/Addiction Medicine

Incumbent Delegate

Cardiology

Current Job Positions and Hospital and Teaching Affiliations

See bio under Board of Directors.

Staff Psychiatrist, Kaiser San Francisco Medical Center; Associate Clinical Professor, Dept. of Psychiatry, UCSF.

I am in private practice with one partner (Remo Morelli, MD) and affiliated with St. Mary’s Medical Center.

SFMS/SFMMS: Board of Directors 2013–2018, Psychiatry Committee (chair), Journal Guest Editor and Contributor, Daniel Perlman Journalism Award (2011); CMA: Delegate 2014–2015, Marijuana Regulation TAC (2011), CMA Gary Nye Award for Physician Health and Well-Being (2011), Committee on the Medical Board (2009).

SFMS: [Note: I let “SFMS” stand as none of what’s listed took place after Marin joined].

President 2016; President-Elect 2015; Secretary 2014, Board of Directors 2009-13, Executive Committee 2012-16; Nominations Committee 2009; Delegate to CMA House 2015-16; Alternate Delegate 2014. Additionally, for many years I served as delegate to the CMA from the California Chapter of the American College of Cardiology.

Medical Society Experience

Additional Relevant Experience

Why Are You Interested in Serving?

Health Commissioner and Vice President, San Francisco Dept. of Public Health (2014–2018); State Commissioner and Vice Chair, California Mental Health Oversight and Accountability Commission (Prop. 63) (2007–14); Chair, California Coalition on Whole Health (MH/SUD coalition on implementation of CA Health Exchange); Board Memberships: CHA Behavioral Health Board, CPA Government Affairs, CSAM/ ASAM Executive Councils, CPPPH Board, National Quality Forum-Behavioral Health Committee; Past Advisor to Medical Board of California, Diversion Program.

SFMMS is Northern California’s most vibrant influential health policy leader. Through its far-reaching journal, collaborations with SF and Marin DPH, and progressive CMA resolutions promoting healthcare reform, SFMMS affects us all. As a recipient of so many SFMMS offerings, I wish to humbly “give back” to our amazing SFMMS family.

WWW.SFMMS.ORG

I served as Chairman of the Quality Committee at St. Mary’s Medical Center for four years, and then as Chief of Staff for four years. I have been President of the San Francisco Heart Association and a District Councilor for the California Chapter of the American College of Cardiology. Currently I serve as Vice Chairman of the Community Board of St. Mary’s Medical Center and Board Chairman of the St. Mary’s Medical Center Foundation.

In this period of fundamental change in our healthcare system, physicians need to align to advocate for their profession, their patients and their community. The strength of the SFMMS and the CMA will directly affect the viability of medical practice and the vitality of healthcare in San Francisco.

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CANDIDATE BIOGRAPHIES SFMMS Delegation to the California Medical Association House of Delegates SARITA SATPATHY, MD, MPH, CPE

JEFFREY L. STEVENSON, MD

ANDREA M. WAGNER, MD

ALSO CANDIDATE FOR DIRECTOR

Incumbent Alternate Delegate

Incumbent Delegate

ALSO CANDIDATE FOR DIRECTOR

Internal Medicine — Hospitalist and Outpatient Internal Medicine

General Practice, Primary Care

Emergency Medicine

Current Job Positions and Hospital and Teaching Affiliations

See bio under Board of Directors.

See bio under Board of Directors.

Director of Outside Hospital & Emergency Operations and EPRP for Northern California; Staff Physician, Emergency Medicine, Kaiser Foundation Hospital, San Francisco.

Medical Society Experience

Delegate to CMA House 2015-18; Alternate Delegate 2012-14.

Additional Relevant Experience

Board of Directors, California Chapter of the American College of Emergency Medicine, June 2006–June 2012; Counselor, American College Emergency Physicians, 2006-14; Committee Member, Government Affairs Committee California ACEP, 2006-14.

Why Are You Interested in Serving?

I would like to continue in my role in the SFMMS delegation to the CMA House of Delegates. We play a critical role for our Medical Society in crafting and promoting policy resolutions. Thank you for your support.

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SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

MATT WILLIS, MD Incumbent Alternate Delegate

UPCOMING EVENTS Clinic by the Bay

Volunteer Physician Info Breakfast Public Health Current Job Positions and Hospital and Teaching Affiliations

Public Health Officer, County of Marin; Guest Researcher, U.S. Centers for Disease Control and Prevention; Adjunct Professor in Public Health, Dominican University of California.

Medical Society Experience

Marin Medical Society Board Member (2015-17); regular contributor to Marin Medicine magazine; SFMMS Board of Directors; Marin Committee; Alternate Delegate to the CMA House of Delegates.

Additional Relevant Experience

California Conference of Local Health Officers (CCLHO) Executive Board; Health Officers Association of California Legislative Committee; CCLHO Health Equity Committee Co-chair; State of California Opioid Workgroup.

Why Are You Interested in Serving?

The SFMMS can lead the way in supporting health and well-being for all in our region.

I’m excited to add my voice as a health officer, physician and epidemiologist to make sure public dialogue and policies are grounded in evidence and informed by the firsthand experience of physicians.

WWW.SFMMS.ORG

October 25, 2018, 7:45-9:00 a.m. | Credo Restaurant, San Francisco

(2 blocks from Montgomery BART)

“Practice the art of medicine, not the business of healthcare.”

Come learn about volunteer opportunities with Clinic by the Bay to serve low-income, uninsured adults. RSVP to info@clinicbythebay.org. (RSVP

by October 18 appreciated!)

2018 West Coast Minority Women Professionals (MWP) Conference October 27, 2018 | Oakland Asian Cultural Center This year’s theme is “We Are Family,” and the one-day seminar will focus on providing attendees with the tools for success and showcasing endurance from prominent women of color or other disadvantage. Visit http:// bit.ly/2LsuNlE for more information.

2018 AMPAC Campaign School December 6-9, 2018 | AMA Office, Washington, D.C.

The 2018 AMPAC Campaign School is targeted to AMA members, their spouses, residents, medical students and medical society staff who want to become more involved in the campaign process. Visit http://www.ampaconline.org/political-education/ampac-campaign-school/ for more information.

SAVE THE DATE: 2019 SFMMS Annual Gala Friday, January 25, 2019 Cavallo Point, Sausalito

Mark your calendar for the 2019 SFMMS Annual Gala! PresidentElect, Kimberly Newell Green, MD, will be installed as the 2019 SFMMS President. Watch for your invitation to arrive in the mail. More information and registration will be available soon at www.sfmms.org/ events.aspx. Sponsorship opportunities are available—contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

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welcome new SFMMS members!

Active Regular Members Benedict Tien Chou, MD | General Medicine Brandi Pauline Wright, MD | General Medicine Brian Su, MD | Orthopaedic Surgery Carlos Manuel Angeles San Mateo, MD | Surgery Edward Alfrey, MD | Surgery Edward Lee, MD | Otolaryngology Shanti Lila Gooden, MD | Psychiatry Thuy D Vu, MD | Physical Medicine

Residents and Fellows Abhisake Kole, MD | Hospital Medicine Ahmed Sami Ali Abuzaid, MD | Neurology Albert Fu-Ding Yen, MD | Anesthesiology Andrew Ikhyun Kim, MD | Internal Medicine Arian Mashhood, MD | Neuroradiology Belinda Wang, MD | Psychiatry Chelsea Xu, MD | Internal Medicine Chidinma Enyima, MD | Nephrology Christina Homer, MD | Internal Medicine Cory Johnson, MD | Family Medicine Crister Brady, MD | Family Medicine Danny Sullivan, MD | Pathology Destiny Roseman, MD | Internal Medicine Erica Evans, MD | Pediatrics Fay Gao, MD | Neurology | Cardiac Electrophysiology Gabriel Espinoza, MD | Emergency Medicine Greg Goldgof, MD | Lab Medicine Harrison Hines, MD | Neurology Hope Caughion, MD | Internal Medicine Isaac Lopez, MD | Internal Medicine Jack Wilkinson, MD | Psychiatry Jared Scott Mahan, MD | Neuroradiology Jayme Leigh Congdon, MD | Pediatrics Jeannette Mathien, MD | Radiology Jeffrey Ferrell, MD | Pediatrics Jennifer Davis, MD | Internal Medicine Jesse Ikeme, MD | Internal Medicine

Jonathan Butts, MD | Surgery Jonathan Gerard Amatruda, MD | Nephrology Joseph Cleveland, MD | Internal Medicine Justin Rossi, MD | Psychiatry Karen Hauser, MD | Internal Medicine Karl Soderland, MD | Neuroradiology Lauren Len Spiegel, MD | Neurology Marissa Ashleigh Boeck, MD | Surgery Meera Subash, MD | Internal Medicine Michael Wang, MD | Dermapathology Michael Waul, MD | Dermatology Michelle Lough, MD | Family Medicine | Family Community Medicine Mohammad Kazem Fallahzadeh Abarghouei, MD | Nephrology Nicolas Derr-Reyes, MD | Family Medicine Nicole Moore, MD | Emergency Medicine Noriko Anderson, MD | Neurology Paul Ehlers, MD | Emergency Medicine Rahul Banerjee, MD | HMON/ONCO Samuel Schnittman, MD | Internal Medicine Scott Brandon, MD | Internal Medicine Sepehr Aziz, DO | Child/Adult Psychology Shuaib Raza, MD | Emergency Medicine Sojung Yi, MD | Emergency Medicine Sumi Sinha, MD | Radiation Oncology Susan Yuan Shen, MD | Psychiatry Tyler Paul Jankowski, DO | Pathology William Smith, MD | Psychiatry Yongtian Tina Tan, MD | Pediatrics

Students Arman Mosenia Brandon W. Yan Christopher Johnson Cora Ormseth Juan Vasquez Kevin Chu Michael Olvera Miguel Nunez

CLASSIFIED ads North East Medical Services is one of the largest

community health centers in the United States targeting the medically underserved Asian population in San Francisco. They are searching for an Associate Medical Director with at least two years clinical and leadership experience. Candidate must be Board Certified/Board Eligible Family Medicine or Internal Medicine. Cantonese and/or Mandarin language skills preferred. This position is approximately 50% clinic, 50% administrative. For more information please contact Galen Roberts, groberts@jordansc.com or 636542-8310.

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Newly remodeled medical office for lease near Chinese Hospital, 818 Jackson St., San Francisco. 788 sq. ft., $2,400 per month. 415-921-2097.

Beautiful, sunny doctor’s office space in Novato.

Rooms include waiting, exam, office, kitchen, bathroom.

Two days a week. $800 per month. 415-506-4907.

Medical office for lease adjacent to Marin General Hospital at 599 Sir Francis Drake Blvd. ±1,150 sq. ft., $6,996 per month. Parking. 415-464-6414, SVN|QAV.

SAN FRANCISCO MARIN MEDICINE OCTOBER 2018 WWW.SFMMS.ORG

Politics and Medicine

EXTENDING SAN FRANCISCO’S BAN ON CANDY-FLAVORED TOBACCO PRODUCTS INTO MARIN John Maa, MD, Matt Willis, MD, and Steve Heilig, MPH

“Vaping” and electronic cigarettes are relatively new, but the ways they are being marketed to young people are not. Back in the 1970s, an R. J. Reynolds executive wrote, “If our company is to survive and prosper, over the long term we must get our share of the youth market.” The sales team at Lorillard echoed, “The base of our business is the high school student.” Over the following decades, the tobacco industry created Joe Camel, marketed heavily around high schools, and created candy-flavored tobacco products that target kids. This last tactic is still being aimed at our youth, especially with menthol cigarettes and flavored vaping liquids. The American Lung Association states, “Youth are routinely bombarded with advertising for flavored tobacco and e-cigarettes every time they walk into a neighborhood convenience store. It’s clear that these products with candy themes and colorful packaging are geared towards teens.”

In June, San Francisco voters upheld a new tobacco law by a 68 to 32 margin to ban the sale of all flavorings, including menthol, in tobacco products (including electronic cigarettes). The Marin County Board of Supervisors will soon vote on a Marin menthol and flavored tobacco ban modeled after the San Francisco legislation. San Francisco and Marin, both ranked among California’s healthiest counties, have long histories of leading the way in progressive health policy. The two counties approved the 2012 and 2016 statewide tobacco taxes by the widest margins across our state. Bans on the sale of flavored tobacco products have already passed in Fairfax, Novato, and Sausalito.

The new Marin legislation addresses a troubling increase in e-cigarette use among youth. The California Healthy Kids Survey found that 39 percent of Marin County eleventh graders had tried an e-cigarette. The total cost of smoking to Marin residents is over $138 million annually. A study funded by the National Institutes of Health suggests that teens who use e-cigarettes are more likely to smoke conventional cigarettes. According to research in the journal Pediatrics, vaping exposes teens to toxic, cancer-causing chemicals. A UCSF report indicated the heart attack risk doubles for daily e-cigarette users risk, and some teens are adding marijuana to their vaping products.

WWW.SFMMS.ORG

In 2011, an FDA Advisory Committee concluded that “removal of menthol cigarettes from the marketplace would benefit public health in the United States.” But as with any public health legislation that impacts corporate profits, resistance from Big Tobacco is likely. Fears about possible criminalization and arrests for tobacco sale or use may be raised, but the only penalty will be for retailers to surrender their tobacco sales licenses if they violate the ban. Opponents may say the ban will drive small businesses out of Marin, which was said back when cities banned smoking in restaurants—and that didn’t prove true either.

Smoking remains the leading cause of preventable death in the United States, claiming up to 500,000 lives annually.

Protecting our youth from products that increase the risk of life-long smoking addiction and the associated health risks is sound public health policy. The vast majority of smokers start while young. We must do all we can to stop the alarming trend of addictive e-cigarette and kid-friendly flavored tobacco products that are reversing decades of progress toward raising a tobacco-free generation. Our youth deserve the chance at a healthy start in their adult lives and to a future that is free from addiction. We all share the responsibility to make sure that they get this chance. Please ask your Supervisor to vote yes, and join the San Francisco Marin Medical Society, Marin County Office of Education, American Heart Association, California Medical Association, American Cancer Society, parents, and teachers among many others in this important public health legislation.

John Maa is President of the San Francisco Marin Medical Society and the Chief of General and Acute Care Surgery at Marin General Hospital. Matt Willis is the Marin County Public Health Officer.

Steve Heilig is Public Health Director for the SFMMS and senior staff at Commonweal in Bolinas.

This op-ed was published in the Marin Independent Journal.

OCTOBER 2018

SAN FRANCISCO MARIN MEDICINE

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COMMUNITY NEWS KAISER PERMANENTE Both nationally and locally here in Northern California,

Kaiser Permanente recognizes that the opiate epidemic is a major public health problem, one that is driven in large part by physician prescriptions. We have been at the forefront of efforts nationwide to find solutions at both the policy and practice level, with a broad, systemic approach focused on physician education and support, pharmacy-level checks, patient safety, and patient and family education.

Our integrated system offers a unique advantage in allowing everyone involved in a patient’s care to see a record of all medications prescribed and the dates of refills. This enables full communication and coordination between physicians and pharmacists.

Our concern for patient safety extends to the use of naloxone treatment in the case of a drug overdose. Our pharmacies distribute naloxone kits as a covered benefit, a policy we instituted in coordination with the implementation of changes in California law. In recent years, we have also increased efforts to raise awareness of the overdose risk associated with benzodiazepines, particularly in regard to the interactions with opiates and alcohol.

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Maria Ansari, MD Kaiser Permanente is also a leader in the world of addiction treatment. Since 2005 we have offered buprenorphine-based treatment for opiate use disorder and currently offer the full complement of medical treatment options including naltrexone and methadone. We work within the law to coordinate care between addiction treatment providers and prescribers of opioids, to the greatest extent possible.

Kaiser Permanente physicians both in San Francisco and elsewhere in the country take active roles in policy setting and advisement, serving as representatives to the American Society for Addiction Medicine and sitting on the executive board of the California Society of Addiction Medicine.

As a result of these efforts, Kaiser Permanente achieved a nearly 40 percent reduction nationwide in Kaiser Permanente patients on 90 morphine milligram equivalents or more per month between 2014 and 2017.

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THE STRENGTH TO HEAL

and the opportunity to practice on the leading edge.

As a preventive medicine physician on the U.S. Army Health Care Team, you’ll work with a leader in research, health education and disease prevention. We’ll give you challenging responsibilities and immerse you in the latest research — because our Soldiers deserve your very best.

You may also earn many financial benefits, including a $220,000 signing bonus and student loan repayment.

To learn more, call us at 602 - 253 - 0371 or visit: healthcare.goarmy.com/kw82.

©2011. Paid for by the United States Army. All rights reserved.

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

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