San Francisco Marin Medicine, Vol. 93, No. 5, November/December

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

Volume 93, Number 5 | NOVEMBER/DECEMBER 2020

IN THIS ISSUE

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FEATURE ARTICLES

MONTHLY COLUMNS

18 America's Health was on the Ballot

Sandra R. Hernández, MD, MPH

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Membership Matters

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President's Message/Editorial: The Year of the Fires Brian Grady, MD

19 My First Year of Practice During a Pandemic

Ryan R. Guinness, MD, MPH

22 Know When a Curbside Consult Becomes Patient Care

Gordon Ownby 23 Public Health is Everywhere

Molly Baldridge, MPH

24 Right Time, Right Place: SFMMS Interview with

Donald Abrams, MD

Steve Heilig, MPH

28 The Radical Effects of Discrimination: What Every

Doctor Should Know

Jeff Ritterman, MD

30 Whom Can We Trust? Public Health Officer Strives for Transparency

Matt Willis, MD, MPH 31 Operation Access: Local Medical Volunteerism at Its Finest

Ali Balick

32 Closing a Practice—Essential Tasks­—Especially

Post COVID

Debra Phairas

34 Update on SFMMS Physician Wellness Task Force Efforts

Jessie Mahoney, MD

November/December 2020 Volume 93, Number 5

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Executive Memo: What will 2021 Bring?

Conrad Amenta

CMA HOD Report Michael Schrader, MD, PhD and Steve Heilig, MPH

10 California Medical Association's 2020 Legislative Wrap-Up

COMMUNITY NEWS 36 Kaiser News Maria Ansari, MD

36 Chinese Hospital News Sam Kao, MD

OF INTEREST 8

SFMMS 2020 Election Results

14 Health Advisory- Slowing COVID-19 Community Transmission: The Role of Healthcare Providers 35 In Memoriam: Philip R. Lee, MD and Albert R. Jonsen, PhD 40 Advertiser Index

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 New prescribing and reporting rules for controlled substances coming January 1, 2021

SFMMS on Reopening Schools Safely in San Francisco Chronicle Opinion

On January 1, 2021, all security prescription forms will be required to have a uniquely serialized number, a corresponding barcode and other security features.

California-approved security printers have been issuing these prescription pads since the beginning of 2020. Starting January 1, 2021, except for limited emergency situations, pharmacists will be unable to fill a controlled substances prescription that is not on a compliant form.

Physicians who do not already have these prescription pads should place an order as soon as possible from a Department of Justice-approved security prescription printer to ensure they have compliant prescription pads before the Jan. 1, 2021 effective date. California Medical Association (CMA) security prescription partner, RxSecurity, is already issuing the uniquely serialized prescription forms and has been since 2019.

Implementation of this new requirement was postponed for two years, thanks to CMA-sponsored legislative fix in January 2019. The flawed implementation in 2019 caused mass confusion, left pharmacies unable to fill prescriptions and patients being refused necessary medications.

January 1, 2021 also marks the implementation date of a new law that requires pharmacists and prescribers who dispense controlled substances to report the dispensing of controlled substances to the Controlled Substance Utilization Review and Evaluation System (CURES) within one working day after the medication is released to the patient or the patient’s representative. Previously, pharmacists and prescribers who dispensed had seven days after dispensing. This law requires pharmacists and other prescribers who dispense to report the dispensing of Schedule V drugs, in addition to Schedules II, III, and IV. For more information on CURES and prescription pad requirements, visit the Medical Board of California’s CURES web page: https://www.mbc.ca.gov/Licensees/Prescribing/CURES/

// LETTERS TO THE EDITOR District should focus on reopening schools San Francisco Chronicle Oct. 26, 2020 Regarding “No timeline for opening schools” (Front Page, Oct. 20): We read with a sense of both frustration and urgency about the continued closure and lack of progress in the reopening of San Francisco public schools, despite many medical and public health authorities advising that it is important that children return to schools in a safe manner for all concerned.

The San Francisco Marin Medical Society developed science-based guidelines for such reopening and submitted them to San Francisco Unified School District leadership some time ago, reflecting expert evidence and opinion that in-person education is crucial to children’s education and development, and can be done safely.

Our city and county has just been upgraded to an improved epidemiological status, and we can’t help but agree with Mayor London Breed that getting students back into classrooms seems more urgent at this time than renaming mostly empty schools. On behalf of our physicians, parents, and especially students, we urge that the goal of safely reopening our schools be expedited for all concerned.

Dr. Brian Grady, president,

San Francisco Marin Medical Society

CMA president supports Newsom's regional stay-at-home orderss

SFMMS member and California Medical Association President Peter N. Bretan, Jr., M.D. issued a statement today in response to the governor's announcement on regional stay-at-home orders.

"As COVID-19 rates continue to reach record levels, our health care workers are doing heroic work under increasingly stressful conditions and at increased risk to themselves and their families.

We want to thank the governor for continuing to make hard policy choices based on science and thank all Californians for making necessary sacrifices during these difficult times to keep each other safe, and to protect those that are working overtime to protect the health and well-being of others. We are all tired after nine months of this pandemic, and there is reason to be optimistic about what the year ahead will bring. But we are not there yet. The worst of this pandemic may be yet to come, but with the continued compliance and compassion for our fellow Californians, we can flatten the curve and get through this together.”

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Kevin Nie researches the coronavirus at Burton High School in San Francisco in March, right before the shelter-in-place.

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San Francisco City and County Health Officer and SFMMS Board Member Appointed Director of California Department of Public Health

November/December 2020

On December 7th, Governor Gavin Newsom appointed Dr. Tomás Aragón Director of the California Department of Public Health. Dr. Aragón has been Health Officer for the City and County of San Francisco and Director of the Population Health Division for the San Francisco Department of Public Health since 2011 and is a longtime member of the San Francisco Marin Medical Society's Board of Directors. Dr. Aragón is a tremendous leader, whose vision and dedication has helped mitigate the spread of COVID-19 throughout the Bay Area. Our heartfelt congratulations go out to Dr. Aragón for this recognition of his remarkable leadership.

Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin

Volume 93, Number 5

EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Shieva Khayam-Bashi, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Brian Grady, MD President-elect Monique Schaulis, MD, MPH Treasurer Michael Schrader, MD, PhD, FACP Immediate Past President Kimberly Newell Green, MD Editor Gordon L. Fung, MD, PhD, FACC, FACP SFMMS STAFF Executive Director and CEO Conrad Amenta Associate Executive Director, Public Health and Education Steve Heilig, MPH Director of Operations and Governance Ian Knox Director of Engagement Molly Baldridge, MPH

Cover art: By Cynthia Fletcher https://cynthiafletcherart.blogspot.com/2020/11/gratitude.html “Gratitude,” 12x16 oil on panel

2020 SFMMS BOARD OF DIRECTORS Edward Alfrey, MD Tomás J. Aragón, MD, MPH Ayanna Bennett, MD Julie Bokser, MD Anne Cummings, MD Nida F. Degesys, MD Beth Griffiths, MD Robert A. Harvey, MD Zarah Iqbal, MD Michael K. Kwok, MD Jason R. Nau, MD Stephanie Oltmann, MD William T. Prey, MD Sarita Satpathy, MD Dennis Song, MD, DDS Kristen Swann, MD Kenneth Tai, MD Winnie Tong, MD Matthew D. Willis, MD, MPH Joseph W. Woo, MD Andrea Yeung, MD

Unable to directly thank all those willing to sacrifice their own safety and well being in this global crisis, people found other ways to express themselves.

Home-made signs appeared in windows and on lawns, chalk spelled out thanks on sidewalks, and chain link fences became galleries of grateful messages. Throughout the country and around the world groups of people stood on random corners or in parks and simply held a message of appreciation and gratitude over their head.

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EDITORIAL Brian Grady, MD, and Steve Heilig, MPH

THE YEAR OF THE FIRES This past year began relatively normally in January but already with rumblings of a new pathogen spreading around the world. The rest, as they say, is history, but we are still very much in the midst of it. As we write this what looks to be a bigger surge in infections and hospitalizations than first experienced last spring is building. Our region at least succeeded in heading off the worst of it last time, and we hope that experience repeats.

But there are no guarantees, and our fear is that the influenza pandemic experience of a century ago, when the autumn surge brought far more morbidity and mortality than the first one, might be repeated to at least some degree. Back then, people let down their guards, shunning such relatively simple interventions as masks and distancing, and the results were dire.

Our state has already had far too many Covid cases and deaths; at this point, further mortality largely should be seen as failures of prevention, as we know better about how to avoid transmission. But widespread misinformation, political malpractice in high places, and human stubbornness, to name it politely, has bedeviled our nation’s response with some devastating results. It is something to mourn deeply – and to work to ensure it does not happen again. And here we must acknowledge that even some of our own leaders, who otherwise have done so well, can slip up.

We are confident that lessons are learned and better behavior modeled for all.

That said, our own medical, public health, hospital, and political systems are again mobilized to minimize harms. If there is an upside to this pandemic that we see regularly, it is in how so many have responded so well. By February our local public health leaders were warning of what might be coming and considering hard choices in prevention. Capacity planning at hospitals and health systems was mounted at a crisis pace. Education of clinicians and others about all aspects then known about Covid-19 was quickly underway. And soon shelter-in-place and other community restrictions were enacted that seem to have had a major preventive impact, even though the major economic disruptions cannot be denied. Again, we are very concerned about ICU and staffing capacity here, but hoping and working for the best.

Crucially, two of the most impressive medical responses of modern times are already coming to fruition. Treatment advances, arrived at via necessity and innovation as the first wave hit, have made it so survival rates among those most acutely ill and hospitalized look to be significantly improved. Second, the development of what look like very effective vaccines has occurred at unprecedented speed. These are heartening and inspiring developments, for which we are grateful. We are speaking out so that vaccines get first to those who need them most, including frontline clinicians.

Locally, our SFMMS rapidly presented much COVID-related education and advocacy, often in partnership with other key organizations such as the San Francisco Department of Public Health and UCSF. We have also tried to help in pushing for safe re-opening of schools, and have provided PPE to fill in some gaps. Local phyWWW.SFMMS.ORG

sicians have expressed much gratitude for these efforts, which makes it all worthwhile. But we are acutely and sadly aware that many practices have been severely strained, and even shut down, by the pandemic. We have tried to offer some assistance there, and to provide some “wellness” resources that at least somewhat ameliorate the undeniable stress and burnout this pandemic has only worsened. We will continue those efforts, on everybody’s behalf.

This epidemiological crisis is far from over. The varied responses, depending upon where you look, have been both superb and disgraceful, effective and disastrous. It is not overtly “political” to note, as related in these pages, that healthcare was on the ballot in the recent national elections and that medicine and public health, as professions, now see some hope of much improved national leadership. A pandemic outbreak can be likened to an explosion of fires, requiring all hands on deck to extinguish, and vigilance to prevent further outbreaks.

All first responders and “essential workers” deserve our gratitude and support.

Taking inspiration and solace wherever it might be found, we close with a quote from none other than Gandalf the Wizard, of J.R.R. Tolkien’s Lord of the Rings, named the best British novel of all time by those who know. The actual fires and smoke that enveloped our region this year reminded many of the darkness threatening his imagined Middle Earth. Tolkien himself fought in some of the worst battles of World War I, and then lived through the horrors of WWII. Those experiences no doubt informed his storytelling, wherein he had one reluctant hero lament about war that “I wish it need not have happened in my time.” Gandalf replied, "So do I - and so do all who live to see such times. But that is not for them to decide. All we have to decide is what to do with the time that is given us.” Wise words, and we thank you for all your own contributions, and hope for a healthier, safer future, including whatever holidays you may be able to carve out and enjoy. Our best to all for the coming year. May it be a better one.

SFMMS President Brian Grady, a graduate of UCSF medical school, is a urologist practicing for two decades at CPMC, CPMC/Mission-Bernal, Saint Francis, Saint Mary’s, Chief of Staff at Seton, and has been an SFMMS delegate to the CMA, president of the CMA resident physician section, and a longtime SFMMS board member.

Steve Heilig, MPH is the Director of Public Health and Education for the SFMMS.

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EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director

WHAT WILL 2021 BRING? I distinctly remember late 2019. I was working as the Director of Policy and Strategic Initiatives at the California Academy of Family Physicians, and I had my perspective fixed squarely on the horizon. My colleagues and I were optimistic; the state projected a large budget surplus and Governor Newsom routinely shared his interest in issues related to health and healthcare. New investments in graduate medical education, loan repayment, and Medi-Cal payment rates were coming online. A new prospective Medicare payment model was being tested in California by the Centers for Medicare and Medicaid Services. An initiative led by Covered California, the state’s insurance exchange, explored reducing health disparities among the exchange’s beneficiaries. It felt to me as if California had entered a rare period of investment and reform.

Everything changed in early 2020 with the emergence of the COVID-19 pandemic. Our policy agenda—our hope for care in the new decade—was seemingly wiped clean. The health policy community quickly turned from our aspirational macro-discussions to the nuts-and-bolts issues of personal protective equipment, public health orders, and the availability and quality of testing. I joined the San Francisco Marin Medical Society in May 2020, and had the opportunity to get to know its membership and understand its experiences on the frontlines of this pandemic.

The pandemic unmasked underlying realities about our health care systems, practices, and communities. Economic inequality, disparities in access to care, and political polarization already existed, but the pandemic exacerbated these forces and illustrated how the most vulnerable among us are disproportionately impacted during emergencies. The acceleration of forces was also felt within the profession. Market consolidation, already rampant in California, increased further. The proportion of our membership practicing in medical groups of five or fewer physicians continued to shrink. Small, solo, and independent practitioners, especially in primary care, felt the pressure as the volume of essential and elective procedures alike fell precipitously.

Throughout it all, our physicians shone. While I had never in my life experienced the intensity of the challenges we were facing, I had also never experienced such intense meaningfulness of our work. In the past seven months, I have heard, first-hand, from the emergency room physician who manages a surge of new patients through the hospital doors; from the pediatrician who keeps us focused on the long-term effects of this pandemic on our children; from the primary care physician who reorganizes their entire office workflow to continue to provide full-spectrum care; from the sub-specialist who screens and tests to ensure preventative care doesn’t fall by the wayside; from the public health officer who shares their expertise with the public in full view, without a net, to keep us all safe.

In 2020, physicians inspired us all by rising to this occasion, putting patients first, as their oath demands. Despite the challenges, I’m heartened by physicians’ consistent dedication, integrity, and excellence. This article is titled, “What Will 2021 Bring?” and while I have learned to forgo predictions, I know that the profession will continue to inspire in 2021. My promise to you is that the San Francisco Marin Medical Society will be there for you every step of the way, in the macro and the micro.

Gratefully,

Conrad Amenta

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CMA HOUSE OF DELEGATES (HOD)

REPORT Michael Schrader, MD, PhD and Steve Heilig, MPH CMA policymaking is more than an academic exercise, as it guides our profession’s advocacy in Sacramento and beyond. CMA has a broad agenda of medical and public health interests, and has a solid record of success in proposing, supporting, or fighting legislation and other health-related initiatives. You can read of recent activities elsewhere in this issue of our journal; here is a brief report on the most recent statewide annual meeting – for the first time and for obvious reason, a virtual one.

CMA’s House of Delegates, with representatives from every county in our state, convenes annually to debate the most important issues affecting members, the Association, and the practice of medicine. Reports on those topics, with proposed actions, are presented and debated, and educational speakers are invited to provide additional insight. The HOD also addresses any other issues referred to it by the Board of Trustees, including any changes to the bylaws. During Annual Session, the House elects officers, honors members for their service, and receives important updates about the activities of the Association in the past year. Some important elected officials sometimes join in to update us, this year include the Governor of California.

This year we had two timely major issues, as decided upon last year: “Pandemic Response and Preparedness” and “The Future of Medical Practice Post-Covid.” In addition, a bold amendment to the CMA’s Articles of Incorporation to include health equity and justice as core values was introduced and adopted by the HOD. The format of the HOD was a forum led by Speaker Dr. Tanya Spirtos and Vice-Speaker Dr. Jack Chou. There were inspiring speeches by Governor Gavin Newsom, CMA President Peter Bretan, CMA CEO Dustin Corcoran, and CMA lobbyist Janus Norman. Rather than have in-person testimony and extractions to the major issues, these were done online prior to the HOD. Dr. Peter Bretan from the SFMMS was inaugurated to a second term as CMA President due to the resignation of President-elect Dr. Lee Snook, who made a difficult decision to save his own practice in this crisis period. Dr. Bretan has led us through a tumultuous year and will continue to lead us through the difficult times ahead. The SFMMS’s own Dr. Shannon UdovicConstant was elected as chair of the CMA Board of Trustees, after serving as vice chair for the past three years.

The major issues are meant to be broad policy declarations with specifics filled in through the year-round resolution process. The “Pandemic Response and Preparedness” major issue report addressed supply chain PPE issues, coordination, protection of health officials from threats, protection of the rights of physician trainees, healthcare inequities, and physician volunteer coordination.

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The “Future of Medical Practice Post-Covid" report was a collection of disparate areas related to Covid. The report opened with a call to recognize inequities in health care and social determinants that are a result of systemic racism. It addressed prison health reform and compassionate release.

There was a call for support of financial viability of medical practices. The report advocated for the continuation of telemedicine and addressed the digital divide as well as barriers for patients using technology.

In terms of meeting logistics, many of our delegates, and others, were largely disappointed not to have participated in an in-person conference and felt less engaged than with previous HODs. The delegates recognized that this was probably the best we could do with the current pandemic. On the positive side, without travel and with a much-reduced meeting time—it was five hours—the time commitment this year for delegates was significantly less. But those who had attended in previous years missed the collegiality and even fun this meeting always entails in person.

The CMA HOD is constantly morphing due to our changing profession and now the Covid pandemic. As always, your SFMMS District VIII Delegation strives to represent you. We welcome your ideas and suggestions for resolutions – any issue related to medicine and public health is fair game. For a partial list of some of the topics we have addressed in the past, sometimes with local, state, national and even international impact, please see the advocacy list at the back of this journal. We have a proud tradition and plan to continue that. If you have any thoughts regarding an issue SFMMS and CMA might address, please get in touch with Steve Heilig to start: heilig@sfmms.org Dr. Schrader, an internist now with Dignity Health, is chair of the SFMMS delegation to the CMA.

Steve Heilig, MPH is the Director of Public Health and Education for the SFMMS.

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AMERICA’S HEALTH WAS ON THE BALLOT Sandra R. Hernández, MD, MPH The 2020 election was the the core principles of our democmost consequential election of racy: equal protection under the our time. The well-being of the law, unfettered voting rights, and nation was on the ballot. equal opportunity for all. This Former vice president Joe election’s voting has ended, but Biden appears to have won the the important work of strengthWhite House, though the elecening and protecting our demoction has yet to be officially certiracy must not rest.

What does this mean for fied. Control of the US Senate will California? During the Trump be determined in January. We can administration, we counted only hope that when the dust seton our state to be a leader in tles, America will begin to heal. resisting policies that harmed The COVID-19 pandemic has communities and undermined claimed the lives of more than A Los Angeles resident after voting on November 3. public health. Under the Biden 238,000 Americans — including Photo: Irfan Khan / Los Angeles Times via Getty Images administration, California will almost 18,000 Californians. have the opportunity to work alongside the federal government They were beloved family members, dear friends, neighbors, to achieve common goals. So many health care issues deserve coworkers, and community members. We owe it to those who our leaders’ time and attention, including universal coverage, died to put the country’s health above partisan politics. That health equity, the modernization of Medi-Cal, and how best to starts with crafting a dramatically different federal pandemic meet the health and social service needs of growing numbers response that relies on science and recognizes our collective of people experiencing homelessness. CHCF will double down responsibility to protect community and public health. on its efforts to reshape the health care system so that it works The pandemic makes clear just how interconnected our for all Californians. health is in America. Our federal lawmakers must return to the Regardless of how the rest of the election process plays out, essential work of making health coverage universally available major challenges will remain. The winter months, when temwhile assuring its affordability. They must build on, rather than tear down, the Affordable Care Act (ACA) by making practical peratures drop and Californians are likely to spend more time and meaningful improvements that are widely supported and indoors, will heighten the risks of COVID-19 transmission. The sustainable both fiscally and politically. state is in an economic downturn that dwarfs the Great Reces Much of the work that lies ahead is about making our health sion. The Supreme Court today will hear arguments in a case care system more equitable for those who have endured sysdesigned to overturn the ACA and wreak havoc on a health care system that every one of us depends on. temic racism and blatant discrimination. The Biden administra Just as we have done in every other challenge that has come tion will need to regain the trust of our immigrant families by our way, this state will find ways to move forward, protect reversing the many policies that create obstacles for their full people, and make progress. That is the California way. participation in society, including the Trump administration’s public charge rule. We hope the new administration will take active steps to ensure that our health care system delivers the Sandra R. Hernández, MD, is president and respect, dignity, compassion, and quality that have long been CEO of the California Health Care Foundation. denied to far too many Americans — especially Black people.

Prior to joining CHCF, Sandra was CEO of The We know that there is no health without a healthy democSan Francisco Foundation, which she led for racy. Think of an engaged and informed citizenry as America’s 16 years. She previously served as director of immune system. The more that people participate in civic life, public health for the City and County of San the healthier they are, according to research on civic participaFrancisco. tion conducted in the US and 43 other countries. There may be no more potent public health policy than robust voting rights and easy access to the ballot. Yet those rights are under continuous and direct attack from people who appear not to respect 18

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MY FIRST YEAR OF PRACTICE DURING A PANDEMIC Ryan R. Guinness, MD, MPH I had just become an attending and one of my first tasks was COVID-19.

While I had studied historical pandemics and their epidemiological concepts during medical school and my public health degree, I was now living and practicing during one. It felt like unchartered territory.

Though, as the pandemic advanced, familiar sentiments that I had experienced during the early days of residency began to emerge. It was as if I was an unblemished learner all over again. Just when I had thought my medical training was finally over, little did I know, that it was only the beginning.

As the novel COVID-19 spread across the country, medical centers had to switch their healthcare delivery strategy overnight. The need for innovative measures to provide highquality patient care and manage its spread had become more imperative. I had never used video as a means to connect with a patient during any aspect of my medical training, yet within a few weeks into the pandemic, this was now the norm. I had my initial reservations. From the early days of medical training, I was taught the merit of the physical examination; auscultating the lungs or palpating the abdomen – the importance of ‘touch’ in making a clinical assessment. That same element of physical connection cannot happen in a virtual care model. Instead, I had to quickly adapt to this new kind of clinical encounter. This required learning on the fly, how to try to make the same clinical assessment using other objective measures, all this while trying to maintain some form of ‘webside manner’ with the patient.

Part of this shift involved recognition that the scope of virtual practice has its limitations. A lot of objective data can certainly be gathered during virtual encounters – history of present illness, gross inspection, and/or data that patients can gather themselves with common devices (e.g., glucometers, home blood pressure monitors, thermometers, and weight scales). In contrast, it’s just as important to recognize that there are certain conditions not amenable to virtual care, including any new or significant emergency symptoms.

New workplace safety standards had to be implemented.

These included universal facemasks for all staff and physical distancing, which meant physicians could not be working so closely to one another. Creating staggered physician schedules (e.g., 50% home / virtual care, 50% in-office) helped to facilitate these kinds of standards. With most practices implementing a virtual-care-first strategy, inevitably some patients would need WWW.SFMMS.ORG

an in-person evaluation. Being able to navigate those patients into some form of ‘respiratory’ vs ‘non-respiratory’ status, with accommodating clinic workflows, allowed for lowered risk of exposure for clinic staff. Many more changes are on the horizon as we continue to endure this pandemic and begin flu season. As such, we need to keep adapting quickly.

I find myself constantly learning and adjusting during this pandemic.

Our knowledge of COVID-19 evolves on a weekly, if not daily basis. Articles surrounding COVID-19 continue to be published, as our understanding of the disease changes. Keeping up with the latest information can be daunting, all the while trying to do what is best for the patient in front of you, in-person or on a virtual platform, on any given day. Compounding these difficulties is a strong sense that the federal government and affiliated agencies, have not supplied the sort of clinical leadership that the moment demands. To fill that void, many of us have had to look to high-impact medical journals and academic institutions for guidance, while also relying on more informal networks to get the information and support we need. For instance, some medical centers have sought to provide regular updates through regularly-scheduled Town Halls or even virtual podcasts.

Courage conquers. When others retreat from the lines of danger during a pandemic, healthcare providers run towards it. At the beginning of this experience, it meant taking care of patients despite not having enough Personal Protective Equipment to do the job safely. There was also constant worry that despite every precaution, we could bring the disease home to our loved ones.

Of the many sad realities of this pandemic, most notable is that it has brought to the surface health inequities that have always existed. Black and Brown people are disproportionately affected by COVID-19, as they are by most other chronic conditions in medicine. The Black Lives Matter movement, reignited by the deaths of George Floyd and others at the hands of police brutality, have shed more light on systemic racism and its implications in many facets of our society, healthcare being one of them.

“Put your oxygen mask on first” is a phrase we use to prepare for an impending flight emergency. In a similar realm, we can think about this concept when we describe the importance of self-care among physicians during the pandemic. At times, it can feel as though we’re fighting dual pandemics: COVID-19

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and isolation. Some of us are physically distancing from our own families. Many of us may not have seen a fully unmasked face of a colleague for weeks. No lips, no teeth, no noses, or cheeks. We miss the friendly smiles we used to give one another.

While we may have lost many things during this pandemic, we must remember that our health is our true wealth. Staying grounded in healthy principles during this time will allow us to prosper in our clinical work. Both in life and in crisis, we seek rituals of connection. Taking up forms of exercise, mindfulness practice, or connecting virtually with each other can help us weather this long storm. As time goes by away from friends and family, we find ourselves leaning more on our colleagues who are in this fight with us – providing not just clinical care to our patients but emotional support to one another.

My first year of practice amidst a pandemic has been quite a lesson of a lifetime – a valuable period for personal and professional growth. Yet, it has also been a time of self-reflection.

If anything, this experience has allowed me to feel a deeper connection to my early years of medical training. The same

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drowning sentiments of fear, uncertainty, self-doubt, and even periods of isolation that one experiences during the start of residency – came bubbling to the surface at the start of this pandemic. But it was in these same moments of vulnerability, where I truly began to learn the most about myself; being able to quickly adapt to change, having an openness to new information, and persevering despite the unknown, while maintaining self-care and a sense of gratitude through it all.

Ryan R. Guiness, MD, MPH is an Associate Physician in the Adult & Family Medicine Department at Kaiser Permanente San Francisco Medical Center - Mission Bay. He is board-certified in Internal & Preventive Medicine. He graduated from Dartmouth Medical School, completed a four-year residency in a combined Internal and Preventive Medicine Program at Kaiser and UCSF, and earned a Master’s of Public Health in Epidemiology at the University of California, Berkeley.

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KNOW THE LAW

KNOW WHEN A CURBSIDE CONSULT BECOMES PATIENT CARE Gordon Ownby, General Counsel, Cooperative of American Physicians, Inc. (CAP) If there is a list somewhere of phrases that will spur disagreement among physicians, certainly “curbside consult” would be included.

One case shows how easy access to electronic health records can affect how involved a physician will be perceived in a particular case.

A young mother was on hospital premises with her son, who was being treated for Mast Cell Activation Syndrome. The mother began to experience acute illness and self-injected two doses of epinephrine, which she carried because of her own history of anaphylaxis.

She was then evaluated in the hospital’s emergency room, where she injected herself with a third dose of epinephrine. On evaluation, Dr. ED, the emergency department physician, noted the patient’s history of recurrent unilateral vision loss and a tightening throat. Dr. ED’s initial impression was that the patient’s extreme agitation was not consistent with anaphylaxis.

Dr. ED contacted Dr. N, the neurologist on stroke call that day. Dr. ED and Dr. N discussed the patient’s condition and at one point, Dr. ED asked Dr. N whether she should call a “code stroke” for the patient. Dr. N recommended instead that Dr. ED obtain a brain MRI, which Dr. ED ordered STAT. Dr. ED evaluated the patient again at 6:30 p.m. and noted the patient was more altered, had bitten her tongue, and would need sedation for the upcoming MRI. Though the MRI was degraded by significant patient movement, the radiologist interpreted the study as negative for stroke. Dr. ED admitted the patient to the ICU at 9:30 p.m.

The patient continued to deteriorate and required intubation overnight. A lumbar puncture and an EEG on the patient’s second day were inconclusive and another brain MRI was undertaken on day three. That scan revealed the young woman had suffered an acute infarction of the pons and thalamus. As a result, the patient suffered “locked-in syndrome.”

The patient and her husband sued the hospital and numerous physicians involved in her care over those first three days.

One issue of the multi-faceted litigation was the extent of Dr. N’s responsibility to the patient. Though he was the neurologist on call, Dr. N did not consider his discussion with Dr. ED as making him part of the patient’s “care team,” as he was not called in to see the patient and no stroke code was called prior to his call responsibilities ending at 7 p.m.

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Under these circumstances, a motion for summary judgment seeking Dr. N’s dismissal from the suit would have had significant merit but for activity found in the patient’s electronic health records.

During the discovery phase of the litigation, the plaintiffs’ attorney deposed individuals at the hospital with the most knowledge of the patient’s medical records. That testimony identified Dr. N as logging in to the patient’s EHR not only around the time of his telephone call with Dr. ED, but then again before midnight that evening. Those logs suggested access to the MRI and to the clinical notes, which by that time documented the patient’s continued deterioration.

Though Dr. ED testified that at the time of her discussion with Dr. N she considered him as part of the patient’s care team, there was no evidence Dr. N took any further action or was involved with the patient – other than those EHR logs. With the plaintiff contending that excessive movement rendered the first MRI non-diagnostic, testimony pointing to Dr. N accessing the MRI would put him squarely in the middle of an argument that more should have been done for the patient that first evening.

Dr. N informally resolved the litigation with the plaintiffs, as did several other providers.

With EHR “metadata” able to show virtually every kind of activity involving a medical record, a physician accessing records while claiming no duty will be faced with a difficult question: If the individual is not a patient, what is the justification for reviewing that person’s confidential medical chart?

And while the question of what constitutes a “curbside consult” may be forever debated, electronic proof of a physician’s later review of the medical chart could very well knock the physician off the curb and into the traffic.

As general counsel for the Cooperative of American Physicians, Inc. (CAP) since 1992, Mr. Ownby directs a legal staff and outside counsel to deliver legal solutions to this industry-leading medical professional liability company.

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PUBLIC HEALTH IS EVERYWHERE Molly Baldridge, MPH “ P u b l i c h e a l t h i s eve r ywhere...” These were the first words said to me by my first public health professor on my first day of college. This was before our class dove deeply into the social determinants of health or learned the language used to describe the health inequities existing in our communities.

This was by no means my introduction to public health.

Growing up in Berkeley, California, I was a peer health educator for my high school’s health center. By the time I was 15, I understood how vital access to health and health information is.

As I continued my education as an undergraduate and graduate student, I learned what my role could be in addressing issues of access to public health. In fact, while writing this article, I came across a 2011 paper from one of my graduate courses at San Francisco State University in which I wrote: “Addressing injustice is the underlying theme of the public health work that I do. I have come to understand that the built environment has great impacts on an individual’s and a community’s access to resources that ensure a high quality of life. It is apparent that racism and oppression are woven into the fabric of our built environment. Lewis Thomas wrote, ‘A society can be judged by the way it treats its most disadvantaged. . . As things stand now, we must be judged a poor lot, and it is time to mend our ways.’ The way in which our society is designed requires that there is a disadvantaged portion of the population, in fact its very success relies on this principle, however this principle is not a long lasting one. Basic human rights are being denied and it is my hope that by recognizing these issues and empowering communities will result in meaningful change.”

My undergraduate and graduate degrees informed my work with high school students in Alameda, Oakland, and throughout California. I had the privilege of working with young people to identify where public health was and was not happening in their communities. One memory in particular stands out from this work: we were traversing the streets of downtown Oakland with our camera phones in tow, crisscrossing Broadway and Telegraph, while the young people took pictures of intricately muraled electrical boxes, four way stops, and green spaces.

Every few minutes, while we walked, the same question would come up: “Why does this block look so different from that block?

And, how can we change this?” That was the key, despite frustration when observing inequities - they always asked how change could be made.

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Three months ago, when I joined the San Francisco Marin Medical Society (SFMMS) as its Director of Engagement, I quickly learned that the physicians that I have the privilege of supporting are not only highly engaged in public health issues but understand how public health impacts their ability to provide services to your patients. My narrow view prior to even interviewing with this organization, was that physicians were so entrenched in service providing, seeing back-to-back patients, writing notes, and doing their best to make it home to spend time with loved ones, that they had no time to address, let alone think about systemic public health issues. I now recognize that the physicians of San Francisco and Marin understand the clear connection between what they see among their patients and what is happening in communities: their living conditions, their access to healthy foods, their ability to access public transit, safe outdoor spaces, safe working conditions. All relates to the health conditions you work to treat and enhance in your exam rooms.

Not only do you understand this, you are invested in addressing these inequities at all levels. In the short time I have been with SFMMS, you have written letters to the Governor to protect the rights of inmates at San Quentin Prison, you have created recommendations for safely reopening schools, and you have stood up against hate speech.

Whether it be housing policy or food insecurity, tobacco products or early childhood education, I am so looking forward to continuing this journey with you as your new Director of Community Engagement, where I know you deeply understand that public health is everywhere and we continuously ask: “who has access to that public health and who does not?”

Molly Baldridge, MPH, is the Director of Engagement for SFMMS.

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SFMMS INTERVIEW

RIGHT TIME, RIGHT PLACE Donald Abrams, MD on his career as a pioneer in AIDS care and research, integrative oncology, medical cannabis, the right to die, and more.

Steve Heilig, MPH Donald Abrams, MD finished his hematology/oncology fellowship at the University of California San Francisco just as the AIDS pandemic was exploding in San Francisco. From that challenging, even harrowing start, he went on to do landmark work on HIV itself and then on numerous other controversial medical issues. His papers have appeared in such journals as the New England Journal of Medicine and JAMA. Newly retired, he spent his whole career at “The General” and UCSF, winding up as a full professor of clinical medicine, chair of his division, and a leader in integrative oncology at the UCSF Osher Center for Integrative Medicine. A member of the SFMMS for decades, he looks back at his illustrious career here. This is from a dialogue we did for the New School at Commonweal in Marin. Interviewed by Steve Heilig, MPH. First I’d like to hear a bit about yourself in terms of where you grew up and how you first found your way into medicine.

I was born in New York, and my family moved when I was five to Cleveland. I come from a long line of no doctors. They wanted me to be a rabbi, but I wasn't going to be a rabbi. Medicine, biology interested me and was probably what I was going to do. So I left Cleveland for the first time to go to Brown University where I was initially accepted into a seven-year program that was going to lead to an MD degree. But in the middle of my training, I went to Europe for my first time, came back and said, “Gee, I don't think I want to stay in Providence, Rhode Island for the rest of my life.”

So I dropped out of that program and I tried to apply to medical schools, but everybody said, “Oh, you're not going to get in any place because you don't have any grades” because Brown was very progressive and did away with grades. But I wound up getting into Stanford, so that wasn’t too bad.

And how did you first get an inkling of your chosen specialty?

I really thought I was going to be a psychiatrist. But I spent time at McLean hospital, which is Harvard’s psychiatric hospital, and I was working in the borderline unit, where I was more accepted as a patient than as a medical student. Then I went off to the Maudsley Hospital, which is the psychiatric Institute in London. And I was disturbed that what we called schizophrenia, they called depression. And what we call depression, they called an adjustment reaction. I said, “We're speaking the same language, but, they say this and we say that and I think I need something that's a little bit more definitive or measurable.”

After Stanford, I did my internship and residency at Kaiser in San Francisco and I really bonded to a lot of my patients who had leukemia and cancers who were dying. I think for me, it had to do with my own fear of death that I always say was probably vibrated into me by my parents who lost three of my four grand24

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parents from my birth to my second birthday. My mother was 22 when I was born. She lost both of her parents and I feel that this sense of fear of losing people you love was inculcated into me and I needed to get over that. So by dealing with people who were at that transition, I found a lot of gratification. I first actually wanted to be a hematologist. But I got into my hematology fellowship at UCSF, right as AIDS broke, and AIDS was cancer-Kaposi’s sarcoma and non-Hodgkin's lymphoma. So in the middle of my hematology/oncology fellowship at UCSF, I changed my course a bit and stayed an extra year so I could get my boards in oncology instead of hematology.

And you ended up staying here, in fact, and practicing and working out of San Francisco General, which really became an epicenter for care and research.

Yes. The first year of my hematology/oncology fellowship, I had a young woman die of a very bizarre leukemia. Right after she died, her father, who was in the military, came and showed me his lab report, and he had an even more bizarre leukemia. I said, “Oh, this is weird. This must be viral.” So I did a lecture for the fellows on virally induced malignancy. And in the second year of your fellowship, you're supposed to work in a laboratory and I really had no interest in that. But my mentors invited Harold Varmus to my lecture on virally induced malignancies, and he of course with Mike Bishop later got the Nobel Prize for their work on retroviruses and oncogenesis. This began a conversation between Harold and myself, which ultimately led to me spending the second year of my fellowship trying to work in his retrovirology lab, right at the time that AIDS exploded. I really thought AIDS was a retrovirus, just from what I knew about retroviruses, and I tried to convince some of the 34 postdocs that were in the lab that this disease is caused by a retrovirus, and you should help me look at some of the tissues I'm bringing back from patients that I was seeing in clinic.

And everybody said, “Oh, well, there's really no such thing as a human disease caused by a retrovirus, you’re wasting your time.”

Ultimately, I was really unsuccessful and frustrated in the lab. I was more interested in the syndrome of persistent swollen lymph nodes that I had perceived in gay men at Kaiser. I established a cohort, an observational study, looking at 200 gay men with swollen glands to see if they were going to go on and get the more severe manifestations of what we still weren't calling AIDS yet, but the Kaposi’s sarcoma and the pneumocystis, and that work made me think that “OK, I don't really have time to spend trying to extract DNA and RNA from lymph nodes. So I'm going to go back to the clinic” and that's what I did. That's when I moved from UCSF to San Francisco General. Paul Volberding WWW.SFMMS.ORG

had become the first ever full- time oncologist at San Francisco General and he had seen his first case of Kaposi’s sarcoma, and he came to me and said, knowing that I was a gay man, "You should get involved in this." And ultimately, I got moved over to General where all the action was.

That meant a sudden and big influx of patients with still somewhat mysterious presentations. It seems maybe you were trying to confront mortality as an oncologist and then you get into HIV where, for quite a few years there, everything that was being done was not effective in terms of saving lives. Everybody was dying for quite a while.

Yes, I think I had to get over my fear of losing people I loved. I had four partners from age 25 to 39. And they all died. We had a lot of loss. In fact, Clint, my husband now for 26 years, just pointed out that my career in medicine has now been bookended by pandemics. And I find it very interesting. You know how my reaction to the first was very different from my reaction to the second. In this pandemic, my last two weeks of inpatient medicine attending on the wards at San Francisco General were scheduled to be April fourth to the 17th. And two weeks before that, I said, “You know what, I'm 70. I'm not going to do this.” Whereas in the other pandemic, I jumped in headfirst. They are really very different diseases, very Yin and Yang, as it were, but sort of interesting to me my response to HIV AIDS and my response to COVID-19 being so sort of diametrically opposed.

You're talking basically about both occupational and a more personal risk. That was a big deal in the very beginning of HIV when we didn't even know how it was transmitted, if it might be aerosolized, etc., and that was pretty much universally fatal. A lot of the people on the frontlines were truly heroic there.

Paul Volberding and I spent many a conversation after we got home from work on the telephone saying, Oh, my God, you know, what is this? One day I was working in the emergency room at Kaiser, moonlighting, and I looked at my hand, and I had these three purple spots on my palm. I freaked out, certain I had Kaposi’s sarcoma. So I called Marcus Conant, I think it was a Sunday, and he said, “Come to my office.” Marc was the premier dermatologist working with this new disease. I met him at his office. He arranged to come in and see me on Sunday, and he looked at my hand, and I thought he would reassure me but instead he took pictures of my hand. I said, “Oh my God.” He said, “If it doesn't go away in a week, then I'm going to do a biopsy.” Well, suddenly, I remembered that probably when I was carrying the canister of liquid nitrogen to collect lymph node biopsy specimens, some had splashed onto my hand. And those three purple spots were actually liquid nitrogen burns, and they went away.

You began a community consortium of physicians who were doing research on HIV and we hosted that at the Medical Society.

What do you think are your most significant contributions in this regard to HIV research?

Paul was called to a meeting with Mayor Dianne Feinstein. The goal of the meeting was to make sure that San Francisco General didn't become just an AIDS hospital. Because there was a risk that every patient admitted was going to have HIV AIDS and since we are a teaching hospital, they didn’t want it to be like, if everybody had diabetes, that wouldn't be a very broad spectrum for teaching.

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Paul came back from that meeting and said, “You know, these are all your friends from the gay doctors’ organization. Why don't you start meeting with this group and figure out how we could make sure that we don't get overwhelmed with these patients so that we could triage some of them to their hospitals if we get too many admissions.” We called this group the County Community Consortium, eventually dropping the County because people always got confused as to what the three C’s stood for. Although we started as an educational group, we actually became the first community-based clinical trials group in the country dealing with HIV AIDS. I suppose the Consortium was one of my contributions in that the Consortium planted a seed that then grew into a network that was funded by the American Foundation for AIDS research and, later, the NIH. That's how I became a friend of Tony Fauci because he was ultimately in charge of our network. A lot of gay men and women who went into internal medicine or family practice, thinking that the most severe thing that they would ever treat would be syphilis or gonorrhea but now were dealing with all these young men who were dying. I felt that the Community Consortium brought together people for a group therapy, if you will. We educated each other about this new disease, but we also could come together once a month at the Medical Society, and just be together and share the sadness and share the loss.

The Consortium had a scientific advisory committee and an executive board. This was at the time that ACT UP was becoming popular in San Francisco. NIH wanted to fund “community based” clinical trial programs and we thought it would be a good idea then to bring these community activists into the Consortium. So we established a community advisory board that was made up of patients as well as the activist community. That was another first - Paul and I wrote that up in the Hastings review of medical ethics because it was a new concept to establish a board that included people dealing with the disease, and that's become popular for other conditions as well now too.

We conducted a lot of clinical trials in prevention of opportunistic infections. We did an inhaled pentamidine trial that was one of the first to try to prevent that infection. We tried to prophylax all the infections. I also defined that subset of patients with persistent generalized lymphadenopathy and described them as being a group at risk to develop the more severe manifestations of HIV AIDS. I also was one of the people who contributed specimens to Robert Gallo’s lab at the National Cancer Institute that he used to first describe HTLV-3, or the AIDS retrovirus, back in 1985. I just retired and left my office at Zuckerberg San Francisco General that I've been in for 37 years, and it required packing a lot of boxes which I donated to the university library archivists. But I would look at this stuff that I did in the 80s. And I said, “Wow, I didn't remember that,” and I was pretty impressed.

You were being published in journals like the New England Journal of Medicine and so forth, and on very important topics. And one was medical use of marijuana. How did that come about?

In 1992 “Brownie Mary” Rathbun had gotten arrested baking cannabis brownies for AIDS patients at Zuckerberg San Francisco General. A letter was sent to the AIDS Program suggesting continued on page 26

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that a clinical trial showing the benefit of cannabis should come from Brownie Mary’s “institution,” as if she was our Dean. I said, Okay, I went to college in the 60s and I fought the government to conduct a trial and ultimately succeeded. That began my interest in plants as medicine which ultimately took me to the Telluride Mushroom Festival in Telluride, Colorado a month after I'd done my first ever jury duty, and came home and said, I want to go to law school. But in Telluride, I met Dr. Andrew Weil, who described a two year online distance learning fellowship you could do with his program in Integrative Medicine at the University of Arizona and I said, “I don't want to go to law school, I want to do that.” So I did and when I finished that fellowship, I changed my career direction from HIV AIDS to integrative oncology.

How do you define “integrative” here?

I say integrative oncology is the evidence informed combination of complementary therapies with conventional therapy to benefit the whole person, mind, body and spirit living with cancer.

It is patient centered and relationship based medicine. When I was pursuing my fellowship, I would be reading about nutrition for the first time because we didn't really learn about nutrition at Stanford Medical School when I was there. This has become my passion now - nutrition and cancer. I tell patients that I see at the Osher center that cancer is like a weed and other people are taking care of their weed because I'm not their primary oncologist. I say it's my job to work with the garden, and to make your soil as inhospitable as possible to growth and spread of weed.

And I do that by looking to see how you fertilize the garden. That is, what you eat and what supplements you take. Supplements are also an area of my interest. But physical activity and weight control are also very important. We know that physical activity decreases the risk of a number of malignancies and patients with various cancers who are physically active fare better than those who aren't.

Another big focus is on stress. I see a lot of people when I ask “Tell me your story” who weave a story as if stress caused their cancer. I don't think stress in and of itself causes cancer, but stress which is epinephrine which is lymphocytotoxic and cortisol which is an immunosuppressant. So decreasing stress is important. In the old days (pre-pandemic), when people could be physically close to each other, massage was a good thing to do. Reiki, all of those energy medicine interventions. I like yoga for a stressreducing physical activity. I'm also a huge proponent of traditional Chinese medicine. Traditional Chinese Medicine is all about expelling evil and supporting good. Modern Western medicine really focuses on expelling evil. When people come to see me, I try to support good but when you go to a traditional Chinese medicine practitioner, they do both at the same time, but from a different angle. So they won't say you have stage IV estrogen receptor positive breast cancer, they're going to say “You have decreased spleen qi and increased kidney yang” and they will treat that.

At the end of my questioning the patient before I used to examine them in the old days, I would ask them three questions.

“What brings you joy? What are your hopes? And where does your strength come from?” One husband asked if I was interviewing his wife for Miss America. He said “What is this?” But then I met a woman at a conference who told me that her husband had died a 26

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few years earlier. And she said, “You know, when we came to see you and you asked him those three questions, he realized that even though he was that far along on his path, that he still did have joy, hope and strength, and that really changed the rest of his life.” So that's what I do in integrative oncology. It's not “alternative.” What I do is integrate complementary and conventional care because after all, I am a conventional oncologist.

Have you had a resistance skepticism, obstacles put in your way by the mainstream in medicine, from both your immediate colleagues and otherwise in integrating this?

When I first started, most of the patients who came to see me at the Osher center in 2005 found me on Andrew Weil’s website.

But now 15 years later, my colleagues call and say, gee, can't you see this patient sooner than three months? I believe that even though we can't do a randomized placebo controlled trial of integrative oncology versus mainstream oncology, my colleagues at the Helen Diller Family Comprehensive Cancer Center have come to appreciate that patients that we co-manage may do better than patients that they manage alone. Just like I've come to believe that patients that are seen by a traditional Chinese medicine practitioner do better than patients that just see me and their primary oncologist alone.

Yes, there still are people who are naysayers who think that we're all woo-woo and and charlatans, but now we have an established Society for Integrative Oncology. There are a number of journals that publish integrative cancer care research findings.

I'm one of the editors of the NCI PDQ Integrative Alternative and Complementary Therapies website, which is a very good website. Commonweal also has the valuable Beyond Conventional Cancer Therapies website. So, there are resources available and there is an increasing database. Oncologists are likely the most evidence-demanding of all medical specialists because we deal with a serious disease and we use pretty potent treatments. So we really demand evidence. Andrew Weil has always said that the degree of evidence should be directly proportional to the potential for the intervention to do harm. If I'm going to say, take this new chemotherapy, your hair is going to fall out, you're going to vomit for three days, and your bone marrow is going to be suppressed, you're going to ask where's the evidence that it works? But if I'm going to say, “Why don't you get a massage twice a month and eat more blueberries and broccoli,” how much evidence do I really need? It's very hard to do placebo-controlled blueberries. That's why I say what we do is evidence-informed.

Let's go back to cannabis or marijuana. How did you first encounter this clinically as a treatment or a palliative measure?

I went to school in the sixties, so I have some experience with cannabis and, as an oncologist in San Francisco for 38 years, the number of patients that I've cared for who have not used cannabis is much smaller than the number who have. I think that's why dronabinol (delta nine tetrahydrocannabinol) was licensed and approved in 1985 as a treatment for chemotherapy-induced nausea and vomiting after the National Cancer Institute and a small pharmaceutical company heard that many patients in the 70s were benefiting from using cannabis at a time when we had very few other agents for nausea. But my experience is that THC is not cannabis because the plant has 400 other compounds in it that WWW.SFMMS.ORG

all provide the yin and the yang that balances out the delta-9 THC. When California approved medical marijuana in 1996, I started writing letters for patients to be able to access it. They found that not only is it useful for nausea but sleep, pain, appetite, depression, and anxiety. Whether or not it's useful for treating cancer, again, I've been an oncologist in San Francisco for 37 years. If cannabis cured cancer, I would certainly have a lot more survivors. One of the most painful things I see are people that waited a number of months to see me as a new patient who are treating a potentially curable cancer without conventional care, but with high doses of highly concentrated cannabis products and now they have metastatic disease and can't be cured.

But there have been, at least in vitro, studies that show anticancer activity many attribute mostly to CBD and there’s a big CBD industry now.

I’m not a proponent of CBD, although I tried some last night for sleep, just to see. And it wasn't bad. My patients say that CBD is good for sleep. CBD actually is an antagonist and it changes the shape of the cannabinoid receptor so it no longer could bind THC which is why CBD decreases some of THC’s psychoactivity.

The CB1 receptor is one of the most densely populated receptors in our brain. Manual Guzman, PhD, my friend and colleague in Madrid, has demonstrated that THC complexes with the receptor on these brain tumor cells and leads to programmed cell death. In addition, the cannabinoids decrease vascular endothelial growth factor, which allows new blood vessels to form to feed a growing tumor. They also found that cannabinoids decrease the activity of an enzyme that allows cancer cells to become invasive and metastasize. So that's all very elegant, but it's all in the test tube and in animal models. A small study has now been done with an under the tongue spray whole plant extract, modulated to have a 1:1 ratio of THC:CBD. This drug, nabiximols, is licensed and approved in Canada, the United Kingdom and the European Union for treating spasticity associated with multiple sclerosis. It's not yet approved in the US because none of the studies done here have shown it to be effective for anything. But in this study in 12 patients with recurrent glioblastoma multiforme receiving chemotherapy sprayed the nabiximols under their tongue, and nine sprayed placebo. At one year, 83% of the treated group compared to 53% of the placebo group were alive and that was a statistically significant difference. The fact that it's not yet published in the medical literature after first being reported in 2017 is a little bit disconcerting. The study only involved 21 people which makes it less generalizable. But that's the best evidence that we have so far that any cannabis-based intervention impacts a malignancy.

So when patients ask me, What should I use, particularly brain tumor patients, I recommend a 1:1 ratio of THC:CBD, but I'm not sure that that's correct, because maybe THC alone would have been better than the 1:1 product. I just don't know.

Finally, how did you get into the “right to die” or physicianassisted dying issue? You published some important research on this issue too.

In those early AIDS days, we had all those gay men waste away and it was truly frightening, and people wanted to have a choice.

My colleague Dr. John Stansell called this “orchestrating the good death.” And we figured out that secobarbital with prochlorperaWWW.SFMMS.ORG

zine and alcohol could do it. But I have to say that the number of patients who asked me to do this I could count on two hands. But if you knew what was ahead of you, and didn’t want to burden your partner or family, who were we to deny them, so we would write the prescriptions as requested if it seemed right. Lee Slome, PhD, a psychologist proposed that we survey the Consortium. We provided them with a scenario of a patient requesting assistance and asked “Would you do this?” Then we decided to add “Have you done this?” Those results were published in the New England Journal. We found that the vast majority said they would do it, and over half said they had done so. I didn’t realize at the time that we were ‘outing’ all these colleagues in confessing to a felony.

But on a personal note, my partner who died with me present in 1989 wanted to die at home. His mother came to take care of him one night when I was away, and he fell and she couldn’t pick him up. When I got home she said “He has to go to hospice.” He had the needed medications but had dementia and had forgotten that he had the means. He went to Coming Home Hospice and died there. It was a blessing, and I do believe this is a gift. I am glad we have this option in this state. But dementia is a big issue and currently the way the law is written, dementia disqualifies us from having that right.

At a talk to a large audience not long ago, I asked if dementia patients should still have the right if they have expressed their desires before, and 100% said “yes.”

Well good, that at least means I’m not being so controversial on this topic now! Maybe that’s our next big effort??

You were once President of the national gay and lesbian medical association. How has being a gay man influenced your career in medicine?

Well, I’m not very articulate about this, but I’ve often felt like I was in the right place at the right time in some ways. With AIDS, I was trained in just the right fields when it hit, so what else was I going to do? Even though I think I still have a bit of PTSD from what I experienced in the 1980s and 1990s. Being a gay man in San Francisco wasn’t really an issue – wait, let me say, it took a few times being quoted in the Chronicle about AIDS before I told Randy Shilts that he could say I was gay – and a little tear came down his face. I didn’t have a secure faculty appointment yet so I wasn’t sure my sexual preferences needed to be widely publicized when I was a fellow.

But you wound up a full UCSF professor and chair of a division.

A Professor Emeritus, now, but then again I’ve just been recalled to work part-time in the Osher Center clinic. And I’m really hoping and trying to mentor new people in integrative oncology during this phase of my career.

That, and chasing more total solar eclipses around the planet, right?

Oh yes. But that’s another story.

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THE RADICAL EFFECTS OF DISCRIMINATION:

What Every Doctor Should Know Jeff Ritterman, MD Several months ago, I was seeing medical patients in my office.

Covid19 had not yet changed all of our lives. My focus was on diabetes, hypertension, heart disease, and the other concerns that bring folks to see their primary care doctors. A new patient walked into my office. He was a forty-five year old Black school teacher with elevated blood pressure. He was new to the area and had not been to a doctor for several years. He was not on any medication. The remainder of his history and physical exam were normal, as were his routine lab tests. He was not overweight. He exercised regularly, followed a healthy diet, and had a loving wife and family. I suggested home blood pressure monitoring to make sure that he was not just suffering from white coat hypertension.

He returned to the clinic two weeks later with consistently high ambulatory blood pressure readings. I suggested that he begin taking an anti-hypertensive. When he returned again with elevated blood pressure readings, I added a second antihypertensive medication. This seemed to work for a time, but soon his home blood pressure readings were again high. I added a third medicine. The process repeated itself over the ensuing weeks.

We finally achieved blood pressure control after adding a fourth medication. Sexual dysfunction, dry mouth, leg swelling, cough, and other unpleasant effects may well occur given the medicines which he is taking. But these same medications may be saving his life.

This scenario repeats itself in doctors’ offices all over the country. Why is blood pressure so difficult to control? Why does it stay elevated? Blood pressure is not like temperature which is guarded around a set point of 98.6 degrees. All of our biochemical reactions do better at that temperature. Blood pressure is designed to increase when there is a need and to decrease when we are resting. It’s never a good idea to take the blood pressure of a sleeping patient, as it can be very low. After all, we are horizontal when we sleep, and we have no need for muscle exertion. But when a saber tooth tiger walks into the room our blood pressure rises immediately, allowing us to run for our lives.

The cascade of stress hormones and nerve firings that occur during stress prepares us to respond with “fight or flight.” Our heart increases both the rate of beating and the force of contrac28

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tion, supplying our exercising muscles with the oxygen and the nutrients that are needed. Blood vessels contract to the areas of the body that don’t participate in the stress response and open to those areas that need the extra blood flow. It’s not a time for digestion or sexual arousal. It’s a time for maximal physical effort.

What is the saber-toothed tiger in my patient’s life? It turns out that being mistreated by others and the fear of mistreatment are sadly significant threats.1,2 Scientists call this “everyday discrimination.” Examples include the feeling of being treated with less courtesy than others and the feeling that people act as if one is dishonest. These everyday slights have been called “microaggressions.” They are part of the Black experience in America for many of our patients. In addition to causing blood pressure elevations, these microaggressions can lead to depression, other mental health problems, and even early death. Clearly “micro” is a misnomer.

When our patients fear an attack coming, they get prepared to run or to fight. Hypervigilance is needed. This is an automatic physiological response. The fight or flight response can be lifesaving when we are running from the tiger, but it can wear us down when the response is chronically elicited. Scientists call this “weathering.” It results in excess morbidity and premature death.

Maintaining a hypervigilant state is not healthy, but is certainly understandable when fearing repeated attacks. The vigilance required to avoid these microaggressions is of such a degree that it continues even during sleep. The normal dip in blood pressure that occurs during sleep does not occur in patients who have experienced discrimination during the day. The lack of nocturnal blood pressure dipping is closely related to cardiovascular morbidity and mortality. White patients who are discriminated against will also suffer this lack of blood pressure dipping, but discrimination is much more common in our Black patients. The microaggressions suffered during the day keep our patients on guard even while they sleep. There is no respite, no safe place.

While there are competing theories for the high rate of hypertension in Blacks, at least part of the explanation must be the daily stresses suffered due to aggression, both micro and macro.

There is a terrible mismatch between the body’s stress WWW.SFMMS.ORG

response and the everyday experience of stress. My patient can hardly strike out or run away when he experiences everyday discrimination. Indeed, the experience is often subliminal. Patients are routinely asked to minimize it. Hormones churn and nerves fire. Blood pressure and heart rate both increase, but running and fighting are not acceptable responses. So patients suffer quietly, but not without weathering the stressful physiological storm.

These storms take their toll. They are part of the reason for the Black-white health gap. Experiences of racial discrimination and also the internalization of negative racial bias work together to accelerate the biological aging of Black men. Researchers have studied aging using the length of telomeres, the region at the ends of chromosomes which protect our DNA. The shorter the telomeres, the greater the physiological age of the patient.

Microaggressions shorten telomeres. Patients age more quickly than they would otherwise.3 If smoking causes lung cancer, the most intelligent therapy is prevention. Don’t smoke. If microaggressions and even more overt aggressions are causing excess morbidity and mortality, we need to identify and remove the aggressive behavior. We can prescribe meditation and other therapies to soften the blow of these microaggressions, but a far more effective and just response would be to address and challenge the racism which is at the root of the problem. There is no medicine to shield one against racism.

“Everyday discrimination” is meted out hierarchically. Not all of our patients are treated the same. It is not a hierarchy of talent, or skill, or kindness, or empathy, or compassion. It is a hierarchy of caste!

Every doctor could benefit from reading Isabel Wilkerson’s new book, “Caste: The Origins of Our Discontents.”4 Wilkerson, who won a Pulitzer Prize for her first book, “The Warmth of Other Suns,” has written what will likely become a classic. She compares and contrasts the US caste system (white over Black), the Indian caste system (everyone over the untouchable Dalits), and the Nazi Germany caste system, (Aryan over Jew).

Wilkerson defines caste this way: “Caste is the granting or withholding of respect, status, honor, attention, privileges, resources, benefit of the doubt, and human kindness to someone on the basis of their perceived rank or standing in the hierarchy.”5 This remarkable book helps us to see how race is used in the US to subordinate an entire people based on an arbitrary physical trait and to strip them of their individuality and their humanity. It is swimming in these polluted waters of our caste system that drives up my patient’s blood pressure and makes life unhealthier for all of us.

It’s also the caste system that has allowed some in medicine to betray our most sacred oath of “Do No Harm.” Dr. James Marion Sims, “Father of Gynecology,” practiced and perfected his surgeries on black enslaved women and did so without giving them anesthesia despite its availability. The women had to be forcibly held down as they screamed out while Dr. Sims sliced and sutured their genitalia. Dr. Sims was no rogue doctor. He was elected president of the American Medical Association in 1876.

There is much in the history of medicine and the history of our country that we must learn and face in order to move forward. In Wilkerson’s words: “You cannot solve anything that WWW.SFMMS.ORG

you do not admit exists, which could be why some people do not want to talk about it: it might get solved.”6 Wilkerson gives us a way forward; “radical empathy.” This, like medicine itself, is a moral mission. We do our very best work when we are motivated by our loftiest ideals. Wilkerson explains: “Each time a person reaches across caste and makes a connection it helps break the back of caste…multiplied by millions in a given day it becomes the flap of the butterfly wing that shifts the air and builds to a hurricane across an ocean.”7 Let’s shift the air together!

Jeff Ritterman, MD, retired as chief of cardiology at Kaiser Richmond in 2010, where he had worked since 1981. Dr. Ritterman currently serves as Vice President of the Board of Directors of the San Francisco Bay Area chapter of Physicians for Social Responsibility. Dr. Ritterman served on the City Council of Richmond, CA. Due to his efforts, Richmond’s tobacco prevention ordinances are now models for the state.

References 1 Tomfohr L, Cooper DC, MillsPJ, et al. Everyday Discrimination and Nocturnal Blood Pressure Dipping in Black and White Americans.

Psychosom Med 2010 Apr, 72 (3) 266-272. Online Feb 2, 2010 doi 10.1097/Psy.0b013e3181d0d8b2 2 Nadal KL, Griffin KE, Wong Y, et al. The impact of racial microaggressions on mental health: counseling implications for clients of color.

3 Chae DH, Nuru-Jeter AM, Adler NE, et al. Discrimination, Racial Bias, and Telomere Length in African-American Men. Am J Prev Med. 2014 Feb; 46(2): 103-111 4 Wilkerson, I. Caste. New York, NY. Random House 2020.

5 Caste p. 70 6 Caste p. 385 7 Caste p. 386

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WHOM CAN WE TRUST? PUBLIC HEALTH OFFICER STRIVES FOR TRANSPARENCY Matt Willis, MD, MPH I was asked a specific question by a member of our community at a Marin County Board of Supervisors meeting.

“Whom can we trust, with all the politics swirling around the COVID-19 response?”

The events of the past week have made it even more important to offer a clear answer to that question.

In the past week, the New England Journal of Medicine denounced federal leadership of the COVID-19 pandemic, a leaked letter to the Center for Disease Control and Prevention director revealed the ways that agency may be yielding to outside control, while the president misled the nation about COVID-19 severity and treatment.

The CDC letter echoed my own sentiments on behalf of my former colleagues there, some of the most accomplished public health scientists in the nation, who are being dangerously marginalized.

Doctors and scientists are finding it more challenging to remain outside of politics, or neutral, in their role as stewards of health. And public trust in leadership is wearing thin. A recent Pew Poll showed that 78% percent of Americans believe that politics, more than science, is driving the timing of vaccine availability.

Our community has important decisions facing us in the coming months in our pandemic response, including vaccine strategy, adopting emerging testing and treatment methods, as well as reopening businesses and schools. Trust in public health decision-making will be vital to our success.

I’d like to clarify the ways my team and I navigate these challenges, to guard against the politicization of our COVID-19 response and protect your health.

First, from the beginning of the pandemic, the lack of a national strategy has necessitated strong local responsibility.

Marin residents are partly protected from federal lapses by local, regional and state public health leadership. Through data analysis, literature review and dialogue with experts inside and outside of government agencies, public health leaders are trained and equipped to independently review and scrutinize the science that drives policy.

The California Department of Public Health has taken an increasingly strong role in guiding a coherent statewide response. The pace of reopening in Marin is largely set by the governor’s blueprint for a safer economy, which ties sectorspecific reopenings to local COVID-19 burden.

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Marin is also embedded within a regional community of excellence in health care, medical research and public health. Bay Area experts, including your Marin County doctors, play a vital role in reviewing local data and guiding COVID-19 testing, treatment, outbreak control and vaccine strategies.

Our regional public health network can lead the nation when necessary. On March 17, Bay Area public health officers jointly issued the nation’s first shelter-in-place policy, an action that saved thousands of lives. Our uniquely collaborative public health and academic partnerships provide another buffer against potentially misguided federal strategy.

As another important measure in maintaining trust, Marin Public Health is committed to continuous and open communication with our community. This is reflected in daily pandemic response updates, town hall forums, wide public and media availability, and a web portal (coronavirus.marinhhs.org) that displays daily indicators of local COVID-19 burden.

We also acknowledge that our messages and strategies will change over time. Because SARS-CoV2 is a novel virus, the data that guides our response is evolving.

Our commitment is to provide the best available information, rooted in our current understanding. When messages change it’s a sign we’re paying attention and are adaptive. When “change is the only constant,” a stubborn, fixed response might offer more consistency, but would be more destabilizing in the long run.

The question of whom to trust speaks to uncertainty we all feel about the future of the pandemic during a time of political strife. When we can’t offer certainty, Marin Public Health is committed to offering our community transparent, science-based decision making. We know that trust is inspired more by honesty than false confidence, and more by evidence than authority.

Dr. Matthew Willis is Public Health Officer of Marin County. This commentary appeared originally in the Marin Independent Journal; reprinted with permission.

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OPERATION ACCESS:

LOCAL MEDICAL VOLUNTEERISM AT ITS FINEST Ali Balick Luis had been healthy for most of his life, but began experiencing painful gastrointestinal distress at the age of 47. Originally from Costa Rica, Luis has worked and lived in Marin for many years. Uninsured due to his immigration status, Luis was concerned about the potential cost of care he might need. He visited his local community health center Marin Community Clinics (MCC) in San Rafael for help.

After evaluating Luis’s symptoms and test results, his primary care provider at MCC, Frank Tool, FNP, referred him to Operation Access, a Northern California nonprofit, for a colonoscopy. Luis was so happy when he learned that he qualified and his colonoscopy would be donated.

Operation Access matched Luis with Dr. Natalie Lee from Marin Gastroenterology and the Endoscopy Center of Marin (ECM). As Luis’s procedure day came closer, he experienced a mix of thoughts and emotions. He was ready to get the screening but he was also sad, nervous, and couldn’t stop thinking about his father who had died two years earlier from colon cancer. Luis knew that getting this colonoscopy was very important.

Prior to his procedure, Luis carefully followed the prep instructions and showed up early to ECM with his best friend the morning of his procedure. Dr. Natalie Lee and staff were able to calm his nerves and prepped him for his colonoscopy. During the procedure, Dr. Lee removed two polyps for biopsy. Luis was relieved to learn a short time later that the biopsy did not indicate colon cancer.

Access to surgical and specialty care is vital to the health of our community, but many low-income people either do not qualify for, or cannot afford, health insurance. Operation Access provides a solution by coordinating care for uninsured people who need it. They match medical professionals who donate their time and expertise with patients referred from community clinics. This medical volunteerism works to restore health and prevent emergency room visits, and OA’s culturally sensitive and multilingual staff members provide medical volunteers with efficient logistical support to enable them to provide this care. Operation Access coordinates care in a wide variety of specialties throughout the San Francisco Bay Area and is seeking volunteers as it expands to many other communities in Northern California.

Colonoscopy is the most common procedure coordinated

by Operation Access. Their patients exhibit above-average risk, such as having found blood in the stool from a positive FIT test.

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Colon cancer screening rates across all communities have been impacted

by COVID, but OA staff are working with patients and their volunteer partners to provide a safe environment for screening to continue despite the virus.

While the need for services in Marin County is high, the strain on health care providers posed by the COVID-19 pandemic has temporarily disrupted referral volume to Operation Access as potential patients have deferred nonemergency care. Referrals for 2020 are projected to be 21% lower than 2019. The pandemic has also reduced the service capacity of many specialist volunteers. OA leverages a large and diverse network of partner hospitals and surgery centers to overcome these limitations, but, by year-end, they anticipate service volume will be lower and wait times higher than anticipated at the outset of 2020. Staff are focused on triaging urgent procedures and serving patients at highest risk of colon cancer.

Marin Gastro/ECM specialists Dr. Timothy Sowerby, Dr. Ripple Sharma, Dr. Natalie Lee, Dr. Vikram Malladi, Dr. Christopher Hogan and other staff members have consistently demonstrated their dedication to serving local community members through Operation Access. The ECM team was awarded the All Hands on Deck Award in 2019 for their amazing teamwork and commitment to providing important GI diagnostic screenings throughout the year and during annual Super-GI session events.

In 2019 and 2020, they provided record-breaking numbers of GI screenings in a single day through Operation Access- 22 and 24 total procedures respectively!

Thanks to Dr. Lee and the ECM staff, patients like Luis have access to the care they need. He now feels happy and relieved, no longer worried he has cancer. He knows that in five years he will need another screening due to his family history and symptoms, but now he is less fearful of the future knowing there are programs like Operation Access and people like Dr. Lee who want to help others. Luis stated, "My sincere thanks to all who worked hard to help me. Infinite thanks. May God bless you.

Keep working hard to help those most in need in our community.

Thank you and ‘pura vida’ to all!”

If you are interested in learning more or getting involved with Operation Access, please contact Elise Hilsinger, Marin Program Manager, at elise@operationaccess.org or Dennise Garcia, San Francisco Program Manager, at dennise@operationaccess.org.

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PRACTICAL PRACTICE CORNER

CLOSING A PRACTICE – ESSENTIAL TASKS – ESPECIALLY POST COVID Debra Phairas There may be many reasons why a physician will need to close a practice particularly in light of COVID-19.

Many senior physicians or those with pre-exiting health conditions are reluctant to return to practice. Other reasons include retiring, starting up a new practice, accepting a position elsewhere, selling the practice, divorce, illness, or death. Physicians may be surprised to realize the many unique responsibilities that accompany the decision to close the practice.

There are many people who will be affected by the physician closing a practice. These are your patients, staff, referring physicians, spouses or significant others, heirs, insurance companies, hospitals and vendors.

Death

The most heartbreaking scenario is when a physician dies unexpectedly. The spouse/heirs are grieving yet at the same time, there are many responsibilities for them to complete. The most loving thing a physician can do for the family is to make sure they are fully educated and prepared to close the practice. A living trust is an essential estate planning tool to avoid probate and taxes. Don’t put this off! Please keep a copy of this article with your trust and will. Have your heirs immediately call your local Medical Society. They can assist your spouse, heirs, executor, or estate trustee in many ways. Assure that your heirs can locate passwords, bank accounts, safe deposits, credit cards, income tax reports, lease agreements, malpractice and all health, life, disability insurance policies and staff employment data.

In a physician death, it is wise to have another physician as soon as possible see patients and this can be either a colleague or a locum tenens physician. A spouse can legally run the practice and bill for the deceased physician for six months after death in California. This gives time to either sell or close the practice while still having income flowing in. All the notification tasks outlined when retiring or moving must also be done with death for closing of the practice.

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Moving, Retiring, Selling or Transitioning the Practice If there is enough time, for example more than one year, it is best to try to sell or transition the practice. If you do not either sell or find a custodian of records, the physician or estate will be responsible for retention of the medical records for as long as the malpractice carrier wishes them to be retained. This responsibility also includes release of information requests from the patient to copy or send records to a new physician. This can be 10 or more years and a significant burden! One of the first tasks is finding out from your malpractice carrier their current records retention guidelines. In one practice, the manager shredded all records more than 7 years from date of service and the malpractice carrier guidelines were 10 or more years.

Selling the practice or finding a custodian of records will relieve the physician or estate of maintaining records. In both scenarios, a legal agreement should be written that spells out the responsibilities of the buyer or custodian of records including length of retention, access to the records for departing physician in the case of a professional liability claim and hold harmless agreements for both parties.

The departing physician will need to write a letter to “active” patients to avoid abandonment. A physician can’t just simply put a sign up “retired, gone fishing!” Most malpractice carriers suggest 45 days notice prior to closing the practice. There is no absolute guideline what are “active” patients are but usually the last 2-3 years of patient care is sufficient. Any surgical or cancer follow up patients should receive the letter. If you are selling or engaging a custodian of records, you can combine the notice with an introduction to the purchasing or custodian of records physician. If the patient does not wish to transition to the recommended physician, you can offer a release of information form to transfer the records and also charge the patient for copying records according to California guidelines. These are $4.00 per quarter hour of time plus $.25 per page. Record release requests must be complied within 15 working days.

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Please consider writing a warm thank you to your patients for being entrusted with their healthcare and that you are grateful to have been a part of this patient care for these years. A physician showed me a retirement letter that complained about insurance companies, fear of malpractice and other negative reasons for retiring. This is sour grapes and not recommended!

The patients want to be assured that you loved being a physician and enjoyed taking care of them. It is also a good idea to take out an ad in the local paper announcing your retirement which also proves you did not abandon patients. It is also recommended to send out a letter to your referring physicians in the community as well for notification.

When to tell staff your plans to close the practice also presents a dilemma. It is recommended a few days or week prior to sending out the letter to patients. You may wish to offer a small severance to encourage them to stay until the closing of the practice. You also need to arrange for continued billing and collection work after the close of the practice. Notify 401k or pension administrators regarding rollover for pension/401K plans. You will need to issue the final paycheck with all vacation accruals paid. If you provide health insurance, the brokers will need to be alerted to send out COBRA information to your staff.

Maintain employee files indefinitely.

Medicare, Medi-Cal, insurance payor companies, IPAs and hospital privileging usually require a 90 day notice of closing a practice. Your landlord may require a 30 or 60 day notice. You may be able to extend a lease on a month to month basis until close. Vendors may advance require a notice of discontinuance of services, particularly biohazard waste.

If you have controlled drugs in the practice, you must keep a record of inventory for three years after closing the practice. Also, you should not throw away any drugs, especially controlled drugs into waste receptacles. There are specified companies that will remove controlled drugs. Two times per year, April and October anyone can take controlled drugs to participating police departments free of charge for them to dispose of these drugs. http://www.deadiversion.usdoj.gov/ drug_disposal/takeback If you no longer wish to practice medicine in any capacity you must deactivate your DEA number (AFTER you have disposed of all drugs) and your medical license in California via the California Medical Board. Professionally shred any prescription pads.

Decide where you wish your mail to go and notify the US postal service of the address. Cancel telephone, internet, websites and utilities. Keep your bank account open for practice checks to be deposited for at least a year. Speak with your CPA regarding closing or winding down a corporation.

Creating a checklist of these tasks with a timeline countdown to the actual closing of the practice is recommended as to not forget any of these important tasks to successfully close the practice. © Copyrighted 2019, updated 2020 Debra Phairas, Practice & Liability Consultants.

(415) 764-4800 www.practiceconsultants.net

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SFMMS ADVOCATES FOR MORE AND BETTER PPE Dr. Lee Greenawald NIOSH, 626 Cochrans Mill Road, Building 141, Pittsburgh, PA 15236 Via ppeconcerns@cdc.gov RE:

A National Elastomeric Half Mask Respirator (EHMR) Strategy for Use in Healthcare Settings During an Infectious Disease Outbreak/Pandemic A Notice by the Centers for Disease Control and Prevention

Dear Dr. Greenawald: We respectfully submit this comment from the San Francisco Marin Medical Society, a 152-year old association of approximately 3,000 physicians of all specialties and settings practicing in San Francisco and Marin counties, California.

When Covid-19 first began to appear here early in this year, San Francisco health authorities and clinicians mobilized quickly in response.

But one crucial limiting factor quickly became apparent – as shortage of appropriate PPE, including and especially protective masks. The SFMMS was able to procure a supply from China and distribute to frontline physicians to help fill some of the gap, but critical shortages remained. The San Francisco Emergency Physicians Association conducted a quick survey of members working in emergency departments and received many reports of shortages. The immediate demand for the SFMMS masks from physicians in a wide variety of locales and settings further indicated the problem. We heard many reports also of clinicians re-using masks beyond any likely standard of safety and efficacy. A large distribution of masks and other PPE coordinated by the California Medical Association elicited thousands of requests from medical practices statewide. The need is projected to continue. But ongoing shortages are, candidly, tragic and demoralizing.

Thus, we join the widespread call for more and better PPE, in this case, adopting reusable half-facepiece elastomeric respirators. As noted in a recent NAM report, these are “Commonly used in nuclear power and radiation industries, these respirators can be reused if a rigorous cleaning and disinfection protocol is in place. Elastomeric respirators are well-suited for units that care exclusively for COVID-19 patients. Given postponed elective procedures, central supply employees can be redirected to process and disinfect these respirators.”

There are many reasons to adopt some new standards and products for this type of PPE. These include: Acute shortages of N95 respirators persist, particularly in less-resourced health care settings (skilled nursing, FQHC, correctional facilities, long-term care, EMS); widespread reuse of N95s for prolonged shifts and days, with mixed results of adequate protection; virtually all N 95 decontamination procedures, aimed at re-use, are unreliable, confusing and, most important, unproven; varied adherence to published guidance and unclear efficacy; discomfort and inconvenience of prolonged N95 use; and more.

We are also aware that at least two large health systems have shown that reusable EHMRs, with proper cleaning/disinfection protocols and fit testing, can be safely used in acute care settings, at both the University of Maryland and Allegheny Health System.

For all these reasons, we request and encourage that a new EHMR strategy be adopted, tested, and implemented on a fast-track basis, for the protection of both clinicians and patients in this Covid-19 era.

Thank you for your attention.

Brian Grady, MD, President Steve Heilig, MPH, Director, Public Health and Education SFMMS NOVEMBER/DECEMBER 2020

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UPDATE ON SFMMS PHYSICIAN WELLNESS TASK FORCE EFFORTS Jessica Mahoney, MD As 2020 comes to a close, phrases like physician wellness, physician well-being, professional fulfillment, resilience, and burnout have become all too familiar to physicians.

These are not novel phrases, but as front-line workers, physicians have experienced some of this year’s most trying moments firsthand. As a result, the San Francisco Marin Medical Society (SFMMS) has a renewed dedication to nourishing and sustaining its physician members throughout Marin and San Francisco.

This fall, SFMMS re-established its Physician Wellness efforts, with the goals of healing and supporting physicians in Marin and San Francisco, working towards sustaining physicians in their medical practice, and providing wellness practices and activities beyond social events. With guidance from Dr. Jessie Mahoney, the effort began with a workgroup of fifteen dedicated physicians.

The first task of this group was focused on completing a proposal to CMA Wellness and Sutter Health for physician wellness activities in three categories: social connection, educational programming, and professional services. In November, the group submitted their proposal and are awaiting disbursement of funding to support valuable and well-rounded physician wellness activities to SFMMS members. In the meantime, SFMMS is continuing to convene this monthly Physician Wellness WorkWellness Book Recommendations:

“In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope”

by Dr. Rana Awdish “Together: The Healing Power of Human Connection in a Sometimes Lonely World”

by Vivek H. Murthy, MD “Attending: Medicine, Mindfulness, and Humanity”

by Ronald Epstein, MD “The Inner Work of Racial Justice”

by Rhonda V. Magee

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group, to guide the direction of Physician Wellness efforts, to identify and evaluate the many resources currently available, identify unmet needs in the local physician community, recommend strategies for SFMMS to address those needs and support our local physicians.

Dr. Jessie Mahoney is a pediatrician, a Physician Coach, long-time Physician Wellness Leader, and yoga and mindfulness instructor. She served as a Chief of Physician Health Wellness at TPMG for many years. She is the former Chair of the CMA Subcommittee on Physician Wellness, and the current Chair of the SFMMS Task Force on Physician Wellness.

The Physician Wellness Workgroup is continuing to accept participants until the end of January, and you are invited! If you would like to join this group or for more information please contact Dr. Jessie Mahoney at jessiemahoneymd@gmail.com or Molly Baldridge, MPH at mbaldridge@sfmms.org.

Additional Free Wellness Resources for Physicians: The Mindful Healthcare Collective mindfulhealthcaerecollective.com - A free, physician-led community with the purpose of helping those in healthcare connect, heal and grow. Offers experiential mindfulness and coaching opportunities led by physician experts in the field.

Greater Good Science Center https://greatergood.berkeley.edu/ - A unique resource for both science and wellness practices, including free online trainings, a library of best practices, podcasts, and much more.

The Greater Good Science Center studies the psychology, sociology, and neuroscience of well-being, and teaches skills that foster a thriving, resilient, and compassionate society.

UCSD Center for Mindfulness https://medschool.ucsd.edu/som/ fmph/research/mindfulness/Pages/default.aspx - A resource for online mindfulness activities, guided practices, mindfulness and compassion research, and in-depth trainings.

Spirit Rock Meditation Center https://www.spiritrock.org - Set among 411 acres of serene oak woodlands in the secluded hills of West Marin County, California. Spirit Rock offers a breadth of programs in a variety of formats to fit anyone's schedule, needs and meditation experience — from two-hour, to online, to drop-in classes and daylong events to silent residential retreats lasting from three days to two months and advanced practitioner programs spanning a year or more.

CMA Care4Caregivers Now https://www.cmadocs.org/wellness/ care4caregivers - Free and confidential peer coaching from trained medical practitioners who understand the rigors and emotional stresses of the profession – and who know the value of a safe, confidential and non-judgmental space. Many peer coaches utilize the program and receive ongoing support because of the value they derive from it.

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IN MEMORIAM Philip R. Lee, MD

Dr. Phil Lee, an American health care icon, died October 26 at the age of 96. He was a longtime proud SFMMS member, who played key roles in many crucial medical and public issues, and served as Chancellor of UCSF and twice as national secretary of health.

Born in San Francisco into a family of physicians, Phil did his undergraduate and medical studies at Stanford, where his father had founded the Palo Alto Medical Clinic. He practiced in the Naval Reserve during both World War II and the Korean War, and then at the Mayo Clinic and elsewhere. By the mid-1960s he had been tapped by President Lyndon Johnson as Assistant Secretary of Health, tasked with rolling out the new Medicare and Medicaid programs, including the desegregation of hospitals receiving such funds. At a forum at the old SFMS auditorium on Masonic Avenue at the time, he debated the president of the AMA, who called him a “communist.”

In 1969 Lee was appointed UCSF Chancellor. Told by Black staff there that they referred to the campus as ‘the plantation’ due to lack of promotions, he set about changing things there too, but came to work one morning to find a bullet hole in his office window. “I just moved my desk away from that window and got back to work,” he recalled. When then-California Governor Ronald Reagan made it clear he would hold up UCSF funding due to disagreements with Phil’s policies, Phil arranged to step down to be replaced by a new chancellor “who was a Republican but fully agreed with everything we’d already been doing.”

Phil returned to teaching at both Stanford and UCSF, where the health policy institute became named for him. When AIDS

hit San Francisco in the 1980s, Phil was the first chair of the new San Francisco Health Commission. He was called back to Washington to again serve as Assistant Secretary of Health for President Clinton. He later endorsed President Obama’s ACA, saying “By making Medicare an option for all Americans, the kind of care I receive could be available to everyone.”

One of Phil’s landmark books was titled “Pills, Profits, and Politics” and in 2001 he co-chaired an SFMS conference on antibiotic resistance in the early 1990s, which resulted in stronger AMA and national policy on the issue. He also co-chaired another meeting at the SFMS which launched the Collaborative on Health and the Environment, which continues today. He was an early supporter of the Haight-Ashbury Free Clinic, lending invaluable support to keep it going through lean times.

About the UCSF policy institute bearing his name, Phil reflected that “The most important contribution of our institute are the many people who have been trained there, considering what they’ve gone on to do. We’ve made many important contributions in research, family planning, medical education, pharmacology practice and policy, the health professions, and more. In some areas we haven’t been quite as influential as we might have liked, but we’ve kept trying all along.”

Renowned physician and author Atul Gawande once remarked regarding Phil that “I learned to just keep my mouth shut and listen and learn when he was around.” The late San Francisco Chronicle science editor and journalist David Perlman said “Phil Lee is one of the greatest people I ever encountered — even more so than all the Nobelists I got to interview or schmooze with!” Countless other students, colleagues and others certainly agree.

Phil is survived by his wife Dr. Roz Lasker, and the rest of his family, to whom SFMMS sends sincere condolences.

By Steve Heilig, MPH

Albert R. Jonsen, PhD (Honorary SFMMS member) It is with great sadness that we share the news that Dr. Albert Jonson passed away on October 21st, 2020 at his home in San Francisco. Dr. Jonson was one of the founders of the field of bioethics. In 2003, he co-founded Sutter Health’s Program in Medicine and Human Values with Dr. William S. Andereck at CPMC. At the time of his death, he had finished finalizing the edits to the 9th edition of his seminal book, ‘Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine’. Dr. Jonsen’s work was noted for bringing together theory and practice.

Dr. Jonsen received his doctorate in religious studies from Yale University having previously studied at Santa Clara University (MTh) and Gonzaga University (MA, BA). Prior to his time at Sutter Health, he served as President of the University of San Francisco (1969 - 1972), Professor of Ethics in Medicine and Chief, Division of Medical Ethics at the University of California, San Francisco (1972 - 1987), and Chairman of the Department of Medical History and Ethics at the School of Medicine, University of Washington (1987 - 1999). He served on multiple WWW.SFMMS.ORG

major national commissions that led to the development of guidelines around clinical and research ethics. Other leadership positions included his role as Commissioner on the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1974 - 1978) that led to the writing of the Belmont Report, the statement of ethical principles guiding research ethics.

He also served on The President’s Commission for the Study of Ethical Problems in Medicine (1979 - 1982), which produced the influential definition of death that became the foundation of a model legislation in the United States.

Dr. Jonsen’s teachings and writings created multiple generations of bioethics leaders and his work continues to influence students, academics, and health care professionals throughout the world. He will live on through his work.

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COMMUNITY MEDICAL NEWS Chinese Hospital

Kaiser Permanente

Sam Kao, MD

Maria Ansari, MD

One of the most challenging topics being discussed this fall is how to send children and teachers back to school while protecting them and their families from COVID-19. Schools are essential for children’s development and well-being, going far beyond academics to provide fundamental social and emotional skills, reliable nutrition, mental health support, and opportunities for physical activity. We must also acknowledge that distance learning further propagates the effective social inequities of COVID-19. Data from last spring show that Hispanic and Black children and children of low-income households had significantly lower participation in distance learning.

As we support plans to reopen our schools, we must stay cognizant of the incidence of COVID-19 in the community and the degree of community spread; as long as there is widespread community transmission, we risk opening schools only to have to close them again when cases are identified.

The countries that have successfully reopened schools have a handle on their COVID-19 incidence, with low rates of community transmission and a robust public infrastructure for testing, contact tracing, and diagnosis. We can follow their guidance in instituting preventative measures including smaller classes, social distancing, staggered recess and lunch times, frequent handwashing and disinfection, and mandated mask wearing.

We can recognize teachers and school staff as essential workers and support our state and governor to provide safe plans to reopen, considering local COVID-19 incidence, planning appropriate PPE and social distancing, monitoring for illness symptoms, and promoting mitigation plans when cases arise.

We remain optimistic and flexible as we survey the scene of education for our youth. We ultimately look forward to herd immunity created by time and vaccination. We pull from the strength of generations prior who fought against highly transmissible viruses without our present-day level of medical technology to manage, treat, and prevent illness. In the meantime, we applaud and promote the cooperation and adaptability of our medical teams and state government to plan and manage health and safety through this historic pandemic.

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As I write this column during the Mid-Autumn Moon Festival, I am reminded of timeless rhythms of our agrarian past. Not exclusive to our 3000 year old Chinese tradition, the Harvest Moon is celebrated by most societies around the globe. What a time, every year, to celebrate the bounties of our collective hard work; a time to celebrate the yield from the seeds we have planted.

Of course, not all harvests are the same. This year appears to be one of the leaner years, as we reap the harvest of many years of bad plantings, some bad seeds.

The Chinese Community Summer Program for medical students, mentioned in our previous column, went off without a hitch. Both medical students performed admirably and were well liked by all. Many thanks to everyone who contributed to this year’s flawless program, both on the inpatient and outpatient sides, giving the students a taste of multiple types of medical practices. Again, we need to thank Dr. Joseph Woo for his incredible energy in resurrecting this fine program, and see it through to the last day. As is always the case, there were adjustments to be made and one-on-one guidance throughout. We look forward to continuing this Program next year, and are definitely eager to see these two students back as practicing physicians in our community!

But we must not lose sight of the positives in the midst of overwhelming bad news, as we flow towards the season for our modern Thanksgiving holidays. We need to give thanks to all of you, and your allied health helpers, for the work you have done all year to get our patients, our communities, through illness and pandemic. We should give thanks to the improving air as we have survived another record breaking wildfire season, thanks to the incredible firefighting efforts across our state and throughout the western states. Hopefully the cleansing rains will have started, and the cycle of renewal starts again. We must take a moment to mourn massive losses - of life, property, and our treasured forests. There is still the harvest of our November election to be counted. I hope by the time you are reading this, the yield is indeed as positive as we have hoped and worked towards.

Even within our Chinese healthcare community in San Francisco, we continue to struggle through another bad harvest. The Covid related shutdown has succeeded admirably in flattening our curve here in San Francisco, but has also impacted the financial picture of Chinese Hospital, as it has most hospitals here. The finances have been further exacerbated by unresolved issues between the Hospital and the AAMG physician group that represents the bulk of the Medical Staff at Chinese Hospital. The seeds of distrust planted years ago continue to constrict the health of our medical community. We owe thanks to the efforts of Supervisor Aaron Peskin to try to mediate a peace, and we hope that those efforts will not be in vain.

Ultimately, the daily discussions we have with our patients and our colleagues about health and healthfulness mirror the challenges for health we have in our local community, our broader community and our national community. The habits we encourage for our patients have parallels in the broader view. Truth matters. There are no solutions if our patients are in denial about their problems. The changes they must make to move towards health we hope will be reflected in the measurable improvements in their health; or not, if poorly or not honestly executed. And some problems have festered too long, are too severe, to achieve a lasting recovery.

Let us all hope that we are not too late tackling our collective problems, and that the solutions we pursue, the seeds we plant today, will yield a more bounteous, happy harvest in the years ahead. May you and yours find many reasons for health and hope in the coming Holidays!!!

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