AN RANCISCO EDICINE S F M VOL.84 NO.3 April 2011
JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY
The History of Medicine in San Francisco
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In This Issue SAN FRANCISCO MEDICINE April 2011 Volume 84, Number 3 The History of Medicine in San Francisco
FEATURE ARTICLES
12 Medical Ethics in San Francisco: A History of the Oath in Action Albert Jonsen, PhD 13 Health Care in the Chinese Community: The Evolution of a San Francisco Community Collin P. Quock, MD, FACP, FACC 15 How Stanford Came and Went: A San Francisco Story Arthur Lyons, MD
16 The National Free Clinic Movement: San Francisco Roots and the Involvement of the SFMS David E. Smith, MD, FASAM, FAACT
18 Thirty Years of HIV/AIDS: The Medical Community and the SFMS in the Early Years of the Epidemic Stephen Follansbee, MD, and Steve Heilig, MPH
MONTHLY COLUMNS
4 Membership Matters 5 Classified Ad 7 Executive Memo Mary Lou Licwinko, JD, MHSA 9 President’s Message George Fouras, MD
10 Editorial Gordon Fung, MD, PhD 36 Hospital News
Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261
20 Where Have All Our Hospitals Gone? A Historical Perspective on the Development of San Francisco’s Hospitals Paul Scholten, MD
About the Cover Image
24 The History of the Blood Bank: Large-Scale Blood Banking in San Francisco and Beyond Erica Goode, MD
The San Francisco Medical Society has a collection of historical medical supplies, photos, and other documents chronicling the history of medicine in San Francisco. The vials are a part of a surgical kit we believe was produced in the early to mid 1900’s. To see more photos of historical medical equipment see page 35.
22 Women in Medical History: Pioneers Who Shaped Medicine in San Francisco Nancy Thomson, MD
26 Operation Access: Plugging the Hole in the Surgical Safety Net William P. Schecter, MD; Douglas P. Grey, MD; Paul B. Hofmann, PhD
e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.
28 A History of Disaster Response: Physician Involvement in Response to Past, Present, and Future Disasters Stephen La Plante, Mary Mercer, and John Brown
29 The Barbary Plague: An Unfortunate Event in San Francisco Medical History Erica Goode, MD 30 Healthy San Francisco: Making History in Health Care Tangerine Brigham
32 MICRA: A Victory of the Past, a Struggle of the Present Robert Margolin, MD
33 Welcoming the Japanese Physicians: The Eighteenth Bicentennial Medical Mission John Umekubo, MD www.sfms.org
April 2011 San Francisco Medicine 3
Membership Matters April 2011 A Sampling of Activities and Actions of Interest to SFMS Members
Volume 84, Number 3 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay
Editorial Board Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD
Erica Goode, MD, MPH
Toni Brayer, MD
Shieva Khayam-Bashi, MD
Linda Hawes Clever, MD
Arthur Lyons, MD
Peter J. Curran, MD
Stephen Walsh, MD
SFMS Officers President George A. Fouras, MD President-Elect Peter J. Curran, MD Secretary Lawrence Cheung, MD Treasurer Shannon Udovic-Constant, MD Immediate Past President Michael Rokeach, MD SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Director of Administration Posi Lyon Director of Communications Amanda Denz, MA Director of Marketing and Membership Jonathan Kyle Board of Directors Term: Jan 2011-Dec 2013
Lily M. Tan, MD
Jennifer H. Do, MD
Shannon Udovic-
Benjamin C.K. Lau, MD
Constant, MD
Man-Kit Leung, MD
Joseph Woo, MD
Keith E. Loring, MD Terri-Diann Pickering, MD
Term: Jan 2009-Dec 2011
Marc D. Rothman, MD
Jeffrey Beane, MD
Rachel H.C. Shu, MD
Andrew F. Calman, MD Lawrence Cheung, MD
Term: Jan 2010-Dec 2012
Roger Eng, MD
Gary L. Chan, MD
Thomas H. Lee, MD
Donald C. Kitt, MD
Richard A. Podolin, MD
Cynthia A. Point, MD
Rodman S. Rogers, MD
Adam Rosenblatt, MD CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate
4 San Francisco Medicine April 2011
Young Physicians Mixer Will Take Place June 16! The San Francisco Medical Society’s annual Young Physicians Mixer has been rescheduled and will now be held on June 16, 2011, from 6:30 p.m to 8:00 p.m. This is an excellent opportunity for physicians who are new in their practice, or new to the area, to meet other local physicians and build upon their professional network. The event will be held at the SFMS offices in the Presidio and complimentary refreshments will be provided. Residents and nonmembers are encouraged to attend. To RSVP, please contact Jonathan Kyle at (415) 561-0850 extension 240, or jkyle@ sfms.org.
CMA Webinar Calendar
CMA is offering a number of excellent webinars this year that are free to SFMS members. Register at www.cmanet.org/ calendar. • May 4: Dealing with Sensitive Personnel Issues | Debra Phairas • 12:15 p.m. to 1:15 p.m. & 6:00 p.m. to 7:00 p.m. • May 18: A Guide to CMA’s Amazing Legal Library | Samantha Pellon, CMA • 12:15 p.m. to 1:15 p.m. • June 1: ICD-10 | Practice Management Institute • 12:15 p.m. to 1:15 p.m. • June 15: Best Practices for Accounts Receivables | Mary Jean Sage • 12:15 p.m. to 1:15 p.m. & 6:00 p.m. to 7:00 p.m.
SFMS Webinars
The SFMS will offer the following webinars in partnership with ACCMA. Visit our website, www.sfms.org/events, for full details or to register. Contact Posi Lyon with any questions, plyon@sfms.org or (415) 561-0850 extension 260. • Billing & Coding Bootcamp (a five-part series) • April 29: Live Session: Basic Training | 9:00 a.m. to 4:00 p.m. • May 6: Webinar #1: Surgery Coding | 10:00 a.m. to 12:00 p.m. • May 20: Webinar #2: Procedures,
Services, and Modifiers | 10:00 a.m. to 12:00 p.m. • June 3: Webinar #3: Managing & Preventing Claims Denials | 10:00 a.m. to 12:00 p.m. • June 17: Webinar #4: Understanding Insurance Guidelines and Maximizing Payout | 10:00 a.m. to 12:00 p.m. • May 11: It’s Not Magic, It’s Good Management: Tips, Strategies, and Legal Issues for Medical Managers |12:30 p.m. to 1:45 p.m. • June 7: Can You Hear Me Now? Physician-Patient Communication to Promote Outcomes and Reduce Liability |12:30 p.m. to 1:45 p.m. • June 22: Managing Your Managers (for Physicians) |12:30 p.m. to 1:45 p.m. • July 13: CalOSHA Training for the Medical Practice |12:30 p.m. to 1:45 p.m.
Medical Staffs’ Relationship with Hospital Boards Subject of New Medical-Legal Document
With more and more pressures on hospitals to improve quality and control costs, the California Medical Association (CMA) has received an increasing number of questions concerning how much authority that hospitals may lawfully have over hospital medical staffs. California has a long legal history of safeguarding the self-governance right of hospital medical staffs. However, there are also laws that provide hospital boards with oversight authority over the medical staff. But those laws are limited. To assist physicians and their medical staffs in understanding the complexities of these laws and the proper boundaries between the parties, CMA has recently created CMA On-Call medical-legal document #1279, “Medical Staff Relationship with Hospital Board.” The document outlines the general principles of medical staff/hospital board interaction and when and under what circumstances hospital involvement is www.sfms.org
permissible. Areas of such interaction discussed in the new document include, among others: peer review, bylaws amendment, contracts, codes of conduct, access to peer review files, and the role of the chief medical officer. This resource is free to members at CMA’s members-only website. Contact Samantha Pellon, (916) 551-2872 or spellon@cmanet.org, or visit www.cmanet. org to view the document.
in 2012. Physicians must also submit electronic prescriptions at least 25 times by the end of 2011 to avoid a penalty in 2013. A group practice participating in eRx GPRO I or GPRO II must also submit a minimum number electronically, but the number required will vary by the size of the group. Physicians can also avoid the reduction if they have fewer than 100 cases containing an encounter code in the measures denominator (outpatient E&M codes) for the Act Now to Avoid E-Prescribing period January 1 to June 30, 2011. Further exemptions are described by the Centers Penalties in 2012 A change in Medicare law will penal- for Medicare & Medicaid Services (CMS) ize physicians beginning in 2012 if they in the educational article “2011 Electronic don’t e-prescribe in the first six months of Prescribing (eRx) Incentive Program Up2011. The new rules require physicians in date—Future Payment Adjustments.” individual practices to submit at least ten It should be noted, however, that a Medicare Part B claims with the electronic February 17 report by the Government Acmeasure code eRx G8553 and an eligible countability Office criticized CMS for failing encounter code by June 30, 2011, or face to coordinate the e-prescribing program a claims payment reduction of 1 percent with the federal electronic health record (EHR) incentive program, which provides financial incentives to phy3575 Geary Blvd. San Francisco, CA 94118 sicians who demonstrate “meanCommunity-Based Palliative Care ingful use” of an CARE Recommendations and Best Practices EHR system. Each program requires Join us for this full day educational conference different technolexploring the many aspects of Palliative Care. ogy and each has Hear from experts on topics including: different reporting • Compassion Fatigue criteria. • POLST: Choices and Values The Ameri• Special Considerations for Community-Based can Medical AssoCare Facilities ciation and other Wednesday, May 11, 2011 at the Event Center, medical organizaSaint Mary’s Cathedral, 1111 Gough St., San Francisco tions wrote a letter Your attendance at two Booster Funded in part by: to the U.S. DepartSessions is required in order to Health Resources and receive 9.75 credits, otherwise only ment of Health and Services Administration/Bureau 6.75 continuing education credits will be of Health Professions Human Services in issued. Visit www.IOAging.org/education (HRSA/BHPr) Grant Number for complete details. December 2010, UB4HP19046 urging changes in Register early for a discount! Visit www.IOAging.org/education the e-prescribing Call 415-750-4140 x223 or email program, but CMS education@ioaging.org with any In-Kind Sponsors: has not yet requestions. sponded. Contact CMA’s reimbursement
www.sfms.org
help line, (888) 401-5911, or economicservices@cmanet.org.
Congratulations Dr. Sanghvi
Suketu Sanghvi, MD, former SFMS Board Member, was recently appointed Associate Executive Director of The Permanente Medical Group. In this capacity, he will be working to improve the care of 3.2 million Kaiser members throughout Northern California. He will continue to practice medicine at the Kaiser Permanente San Francisco medical center.
Community-Based Palliative C a r e C o n f e r e n c e : C A RE Recommendations and Best Practices This event, hosted by the Institute on Aging and cosponsored by the SFMS, will take place on Wednesday, May 11, 2011, from 8:30 a.m. to 5:00 p.m. Visit http://education.ioaging.org/ educational_programs.html to register or contact the Institute on Aging at (415) 750-4140 extension 223.
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April 2011 San Francisco Medicine 5
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Practices affiliated with Hill Physicians Medical Group retain their independence while enjoying the support of a large, well-integrated network of providers. Hill’s advantages include: • Fast, accurate claims payments • Free eReferrals, ePrescribing and online doctor-patient communications • Experienced RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions to help you meet the federal mandate • Easy preventive care and disease management reminders for patients • Extensive health resources that boost patient engagement • High consumer awareness that builds practice volume That’s why 3,600 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians one of the nation’s leading Independent Physician Associations. Get more for your practice and your patients by affiliating with Hill Physicians Medical Group. Get more information at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com
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Executive Memo Mary Lou Licwinko, JD, MHSA
A Brief History of IT
W
hen I became executive director of the San Francisco Medical Society in November of 1998, the staff computers were not linked together, so we couldn’t e-mail each other within the office. One of my first acts was to set up an interoffice e-mail system. In terms of recent advancements in information technology, connecting the office staff through e-mail seems pretty mundane, and it emphasizes how far and how fast IT has advanced in the last thirteen years. In 2011 SFMS, in conjunction with the San Francisco health and medical community, is embarked on a mission to try to link the entire health care community of San Francisco together via a health information exchange. Presently, there is no unified, digital medical-records system in San Francisco. When patients switch doctors, transfer between health care providers, or receive emergency care away from their medical home, the predominant method of sharing health data is via courier, fax, or U.S. mail. Clinicians and staff can spend significant time securing patient records, which are often housed in multiple locations. Not infrequently, records are misplaced. Inevitably, vital information about the patient is unavailable to the provider at the point of care. This has an adverse impact on provider efficiency, overall costs, and, most importantly, patient care. The San Francisco Health Information Exchange (SFHEX)— working under the auspices of the San Francisco Medical Society Community Service Foundation and guided by a diverse board of San Francisco health care industry professionals—will provide the infrastructure for a unified electronic health-record system for San Francisco. This service will allow providers to have access to secure community-wide patient data when and where they need it. It will also permit patients to gain a complete view of their medical record, irrespective of where individual records may reside. Health information exchange has received generous support and funding through the Health Information Technology for Economic and Clinical Health (HITECH) Act, contained within the federal American Recovery and Reinvestment Act (2009). California received approximately $38.8m in funding, which is being distributed through the state-designated entity for health information exchange, Cal eConnect.
www.sfms.org
SFHEX Steering Committee Arieh Rosenbaum, MD (Chair) – SFMS CSF Board Amy Berlin, MD (Vice Chair) – SFMS CSF Board Paul Abramson, MD – At-large independent physician Helen Lee (IT Manager) – Chinese Hospital Association Alan Fox (CFO, St. Francis) – Catholic Healthcare West Craig Vercruysse (CIO, West Bay Region) – Sutter Health (CPMC) Peti Arunamata (Area Information Officer) – SF Kaiser Permanente Center Larry Lotenero (CIO) – UCSF/Mt. Zion Medical Center David Lown, MD – SF Community Clinic Consortium Adrian Rawlinson, MD – Brown and Toland IPA Alan Fink (eSolutions) – Hill Physicians IPA David Counter (CIO) – Department of Public Health Kate Howard (Budget Office) – SF Mayor’s Office Craig Newmark (Craigslist founder) – Health Services Consumer Rep Jon Kolenda (ACTCM) – Licensed Alternative Medicine Provider
April 2011 San Francisco Medicine 7
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President’s Message George Fouras, MD
The Role of the SFMS in History
T
he role of organized medicine may take on many faces, dependent on the needs of the society, its members, and the state. The SFMS was first founded in the Gold Rush era and then revived in 1868, but the tasks and challenges that existed at our founding have obviously evolved over the decades. Some would say that the chief role of the SFMS is to provide legislative advocacy. In most situations, we work collaboratively along with the California Medical Association and others. In the recent past we have worked with such stakeholders as the San Francisco Department of Public Health, locally, to introduce legislation in banning the sale of tobacco products in pharmacies. We also filed an amicus brief, along with the CMA, when big retailers such as Walgreen’s fought the legislation in court. We have provided testimony to the public health commission regarding the Campos ordinance, which created a health care master plan in the City and County of San Francisco. We have worked with the mayoral task force to develop and support the Healthy San Francisco Program and participated in the lawsuit to preserve the program. In addition, we have worked on legislation to allow minors to receive vaccines in order to prevent STIs. Many of us have worked or trained at San Francisco General Hospital and still work at or support services and training there. The SFMS was active with the mayoral task force when the issue of building a seismically stable hospital arose, taking on a leadership role for where and how that would occur. We were also an active participant in the campaign for Prop A, which would provide funding for the rebuild. Finally, our members often meet with our local supervisors and state legislators to discuss issues regarding patient care and the practice of medicine in our county. We sponsor a “candidate’s night” biennially, hosted by the SFMS Political Action Committee, where our members may participate in interviews of candidates for the Board of Supervisors. Over the last two years, SFMS, through its Community Service Foundation, has joined with other members of the San Francisco health care community to develop the San Francisco Health Information Exchange. The Exchange will provide the platform for interconnectivity of electronic health records within San Francisco. The Exchange is being funded through contributions from the Exchange’s members as well as community grants. SFMS also has received a grant from CalHIPSO to assist physicians in choosing and implementing electronic medical
www.sfms.org
records and assisting them in demonstrating “meaningful use.” The SFMS has also been a significant influence on the policy of CMA. Once a year, we have sent our delegation to the CMA’s annual meeting. Many of our resolutions have gone on the AMA for consideration and national action. Despite the reputation of San Francisco being a bastion of liberalism (the “land of fruits and nuts” as some say), we are often seen in the HOD as a force for moderation, providing thoughtful, fair, and balanced views regarding the issues that present themselves. For example, we have submitted resolutions in the CMA House of Delegates regarding such debates as children’s nutrition in public schools or the forced repatriation of patients to their home countries by health care systems when funding for their care has disappeared. We have attempted to initiate dialogue regarding the physician’s role in the dying process. Furthermore, we have successfully advocated for the CMA to take a look at the role of marijuana in health care delivery and declare the current substance abuse policy to have failed, leading to the formation of TAC, of which a few of us from SFMS will be members. Another role that is just as important is that of the SFMS in providing collegiality for all members, future, present, and past. Recently, the SFMS hosted our annual Symphony Night at Davies Symphony Hall. Thirty members and spouses gathered in the green room for an hour of social contact prior to a wonderful performance of collected works of Bach and Shubert. In the past, we have sponsored an “Evening at the Nutcracker” for members and their families, along with a social mixer at the DeYoung Museum. We will continue to host social mixers, sponsored by the Membership Committee, for young physicians and medical students. In the past, these have been well received and have allowed younger physicians and physicians-to-be a view of who we are and what we can accomplish.
April 2011 San Francisco Medicine 9
Editorial Gordon Fung, MD, PhD
Local Medical History
T
he usual axiom “Those who do not study history are doomed to repeat it” is actually a misquotation of the original text written by George Santayana, who, in his The Life of Reason, Vol.1, Reason in Common Sense, wrote, “Those who cannot remember the past are condemned to repeat it.” This is a quote from someone who believed that history is a factual depiction of events that can lend itself to further study to discover the reasoning behind past actions and guide the deliberations and directions of future actions. It does not appear that he considered anonymous sentiments of authors of the past: “Historians, it is said, fall into one of three categories: Those who lie. Those who are mistaken. Those who do not know.” I tend to look at history in the way that R. G. Collingwood did; he said, “The value of history is that it teaches us what man has done and thus what man is.” This month’s theme, the History of Medicine in San Francisco, highlights the widespread involvement of medicine that we experience in San Francisco, from the very beginnings of a physician’s life in medical school and training to health care delivery to diverse communities to the health care response to natural disasters and man-made tragedies years after the initial insult to current issues in health care reform. Throughout the entire history of San Francisco (which doesn’t go back that far), the health care field has come together to overcome adversity in providing medical care to every segment of society, as you will read in Dr. Collin Quock’s compelling article on the history of Chinese Hospital and health care in the Chinese community. A little-known fact to the younger generation is that Stanford University Hospital had its origins in San Francisco at the Pacific Presbyterian Hospital, which was to later become the California Pacific Medical Center. Dr. Arthur Lyons recounts the controversies among the faculty and institutions surrounding that move, which separated the two major teaching hospitals by forty-five miles. San Francisco Medical Society was just a fledgling organization at that time. And even though the numbers of the physician members remained limited, it grew to become one of the strongest voices in organized medicine for quality medical care; a stalwart advocate for public health issues; and a leader in health care policy reform for the city of San Francisco, the state of California, and the nation through its delegations to the California Medical Association and the American Medical Association. SFMS was
10 San Francisco Medicine April 2011
the support for Operation Access, which coordinated volunteer physicians and hospitals to provide needed surgeries to the poor. We also were involved with the Blood Bank of the Pacific at its very start, and we continue to have its medical director on our board of directors as a consultant, because of the strong working relationships needed for quality care and emergency preparedness with the blood bank and physicians and hospitals. One of our past presidents, Dr. Laurens White, was a true visionary during his tenure, predicting the current predicament of San Francisco hospitals. In the 1970s, malpractice premiums were rising at an unsustainable rate. As in many other states now, practicing physicians were either deciding not to set up practice here or were moving out altogether, due to the prohibitive cost of practice. Although many physicians were involved with the full backing of the CMA, there was a notable leader in the movement to limit liability premiums through the MICRA bill. Dr. Robert Margolin, our current CMA trustee, gives his account of the heroes of that movement that still stands successfully today, after more than thirty years. Even though there have been many challenges to limit its scope and increase the amounts allowed on noneconomic suffering, the CMA and its membership fully recognize the impact that this success has brought to the practice of medicine in San Francisco and the state, and they continue to thwart any new attempts to weaken it. Living in San Francisco has not been without the anxiety of dealing with the specter of earthquake, one of the worst natural disasters that can hit this geographical area. San Francisco’s citizenry and physicians have been the first responders and most sustaining force in the major quakes that have hit the city. SFMS has worked closely with the EMS in developing preparedness plans and getting the word out to educate the public about what to do when the next “big one” comes. Although the HIV/ AIDS epidemic did not crash on San Francisco like an earthquake, we were among the first to recognize the epidemic and have remained in the forefront of efforts to diagnose, treat, and prevent the spread of this devastating disease. When it comes to taking on the thorny issues of medicine, SF physicians have worked collaboratively with others to find solutions to problems. Several of those movements are highlighted in this month’s issue: an accounting of the beginning of the Haight Ashbury Free Clinic movement, a history of Healthy San Francisco, a history of medical ethics, and a history of women www.sfms.org
in medicine. There is always much more to write about than we have space for. At UCSF, there are significant changes in medical education that are making history now. The changes are so major that, as a practicing physician, one might not even recognize the newer settings and curricula of medical education in the twenty-first century. San Francisco is one of the foremost areas of development in the biotechnology industry, with the new research triangle and the QB3 at UCSF’s new Mission Bay campus. These are topics for a future issue on the history of medicine in San Francisco—history that is being created as we live today. I hope that you will be as encouraged as I was while reading through these histories, which demonstrate what past and present San Francisco physicians have been capable of and have done through the groundbreaking and sound actions of their time and ours.
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April 2011 San Francisco Medicine 11
The History of Medicine in San Francisco
Medical Ethics in San Francisco A History of the Oath in Action
Albert Jonsen, PhD
T
he concept of medical ethics has been in San Francisco as long as medicine has been. The practice of medicine in the Western world has been guided by the Hippocratic ethic. At the same time, San Francisco medicine, like every other practice venue, has its stories of practitioners who were venal, unscrupulous, and dangerous. Some of our earliest politicians came to our city as doctors! Most of those early practitioners were, we can presume, men (and, rarely, women) of integrity and dedication. My uncle, Dr. Charles Sweigert (1902–1990) was one of them. He was greatly puzzled when I was appointed professor of medical ethics at UCSF in 1972. What need to teach ethics to medical students? Who was I—a philosopher, not a physician—to teach doctors? Medical ethics was, in his view, something natural to the gentlemen who practiced medicine. It had been taught to him not by an ethics professor but by the example of his academic and clinical teachers. The great Arthur Bloomfield, his professor of medicine (who remembers the day when there was one professor of medicine?) at Stanford, taught him not only how to diagnose disease and occasionally provide treatment but to behave toward patients and colleagues with the decorum of a gentleman physician. The ethics of the gentleman physician had been articulated by the Englishman Dr. Thomas Percival in his 1802 volume Medical Ethics: “The physician must unite tenderness with steadiness, and condescension with authority, as to inspire the minds of their patients with gratitude, respect, and confidence.” In 1927, two years before my uncle Charles graduated from Stanford Medical School, Dr. Chauncey Leake,
12 San Francisco Medicine April 2011
professor of pharmacology at U.C. Medical School, published Percival’s work with commentary. Leake preferred to identify its teachings as medical etiquette rather than medical ethics, for he saw its precepts, as did my Uncles Charles, as the natural decorum that marked a physician’s dealings with those who sought his help. Percival was not, in Leake’s view, proposing an ethic properly speaking, those basic principles that gave structure to the moral life. However, it was becoming clear in the 1960s that this etiquette was insufficient. Something more like a real ethic was needed. The first dramatic, indeed shocking, revelation that a more solid foundation must be built was the degrading, inhumane behavior of Nazi physicians who experimented on the most vulnerable patients and upon concentration camp detainees. Another San Francisco physician, Dr. Otto Guttentag, professor of philosophy of Medicine at UCSF, was a pioneer in rethinking the ethics of medicine. In 1951, he organized a symposium entitled “The Problem of Experimentation on Human Beings.” The papers of that event were published in Science. Only a few years later, the need for ethics in experimentation was demonstrated to the public when a temporary employee of the Public Health Service office in San Francisco, Peter Buxton, discovered the records of the Tuskegee syphilis experiments in the PHS San Francisco office and reported it to the press. Unethical behavior by medical researchers who were not Nazis but officers of the Public Health Service demanded a renewal of medical ethics. In 1972, Dr. Philip Lee, Chancellor of UCSF, invited me to teach medical ethics. Both Dr. Leake and Dr. Guttentag were on the faculty when I arrived. They accepted this
strange newcomer graciously and taught me much about the ideals of medicine. Dr. William Tooley, chief of neonatology, a new field filled with ethical quandaries, invited me into the newborn intensive care nursery for regular rounds where saving very premature babies was balanced against the threat of lifelong debility. We held the first national conference on the subject and published “The Ethics of Newborn Intensive Care” in 1974. Dr. J. Engleburt Dunphy, chief of surgery, insisted that medical students be shown how their daily work as internists, surgeons, or psychiatrists demanded deep reflection on the nature and extent of their duties toward patients. He and I designed a course that the curriculum committee and the dean, Dr. Julius Krevans, made required for graduation. Dr. Dunphy died before we taught that course. Yet it went on for many years and served as an early model of how medical ethics could be taught. Courses, however, cannot convey the essence of ethics, which lies not in concepts but in commitment. Another dramatic episode enforced that truth: the AIDS epidemic. Again, a San Francisco physician stood among those who showed how this devastating disease summoned physicians to an ethic beyond etiquette. One day in 1982, Dr. Marcus Conant casually mentioned in a doctors’ dining room conversation that he (a dermatologist) had seen an unusual number of young men with a rare skin cancer, Kaposi’s sarcoma, traditionally seen only in elderly Eastern European men. Within a short time, that symptom was linked to a rare pneumonia and the earliest characterization of Acquired Immune Deficiency Syndrome appeared. San Francisco was one of the epicenContinued on page 14 . . . www.sfms.org
The History of Medicine in San Francisco
Health Care in the Chinese Community The Evolution of a San Francisco Community
Collin P. Quock, MD, FACP, FACC
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here were a number of reasons they came: social unrest and a poor economy at home, the lure of paying jobs, the thrill of sailing abroad, and carving out a new life, and even the prospect of gold. These were some of the causes for the vigorous influx of Chinese into California during the second half of the nineteenth century. At one time there were more than 100,000 in California. Chinese enclaves sprouted from Marysville and Weaverville to Oakland and San Francisco. They followed the railroads north into Oregon and Washington and south to Texas and Mississippi. It was mainly a bachelor society. Most never really expected to stay here. The general plan was to work, save up, and retire back to their homes in China. Even if they were to get sick and die here, they expected their tongs to send their bones back home. They worked as day laborers, cooks, and laundrymen. A second layer of shops, restaurants, and services grew up to support them. Among these were herbalists and traditional healers. They were the health care providers. But they were no match for the poor sanitation and infectious diseases of the day. The Chinese community was looked upon by the mainstream as a source of pestilence. Their unwelcome competition in the job market was capped by the Chinese Exclusion Act passed by Congress in 1882. A few occupations were exempted: Both immigrants and those Chinese already here needed a place to house their contagious and their dying members. Thus in San Francisco the Tung Wah Dispensary was born. It opened in 1900 at 828 Sacramento Street. It was a place where friends brought in food and laundry; it was essentially a www.sfms.org
death house. It was visited by the traditional healers and three Western doctors whose names resonate in our history: Drs. B. C. Atterbury, George L. Fitch, and Lydea I. Wickoff. Other medical facilities in the City seldom took in the Chinese; only a few went to the distant county hospital. This little hostel was completely destroyed by the San Francisco Earthquake of 1906, but because of the need, it was promptly reopened in Trenton Alley. Earlier attempts by Chinatown leadership to build a hospital had been blocked by various groups downtown. But now there was no stopping the adroit maneuvering of our leaders. A fund-raising campaign brought in contributions even from London, New York, and Asia, totaling more than $200,000. My father served as internal auditor on the campaign committee. A blackand-white photograph hangs over my desk, depicting a crowd of dignitaries celebrating the opening of a state-of-the-art, sparkling new Chinese Hospital. It was April 18, 1925, the anniversary of the Great Quake. What a proud day that must have been! In the front row of that photograph stands a little boy, fourth from the right, behind a taller girl. He grew up to become Chinatown’s first internist/hematologist, Dr. Jonah Li. My dad stands way up on the steps, leaning to his left. The head nurse scurrying around inside was Mae Tom, later wife of Dr. Joseph Lee, one of the first generation of Chinese-Americans trained in Western medicine to attend at this hospital. The others were Drs. Margaret Chung, James Hall, Wong Him, and Rose Goong Wong, who delivered me at Chinese Hospital. In the time that has elapsed, both our
community and our medical staff have grown dramatically. When I started practice in 1971, many physicians of the second wave were still around to tell their stories. Dr. Henry B. Woo, the first trained surgeon, brought such luminaries as Drs. Alson Kilgore and Francis Sooy to scrub in our operating rooms. Dr. Collin H. Dong had achieved fame as the author of a popular book that advocated elements of the Cantonese diet for the successful treatment of arthritis. His patients included Horace Stoneham, owner of the San Francisco Giants, and one of team’s stars, Willie McCovey. Drs. Edwin Owyang and George D. Fung served as presidents of the San Francisco Tuberculosis and Lung Association. George and his brother, Dr. Paul Fung, were awarded honorary doctorates by University of the Pacific for their scholarly work in Buddhism. Paul was the father of our own esteemed colleagues Gordon, Gregory, and Lenora Fung. Gordon and Dr. Dexter Louie have presided over our medical society, and Gordon has also been president of both the California Chapter of the American College of Cardiology and the Western States Affiliate of the American Heart Association. Dr. Stanley Louie was the first trained pediatrician to join our staff. Dr. Thomas Hum, a Harvardtrained obstetrician, was the driving force behind the founding of Northeast Medical Services, part of the neighborhood clinic network established by Kennedy-Johnson legislation. Tom also opened a prenatal clinic at Chinese Hospital. Dr. Jack Jew rose to the rank of brigadier general in the United States Army Reserve Medical Corps while conducting a private practice in general and thoracic surgery in Chinatown. Continued on following page . . . April 2011 San Francisco Medicine 13
Health Care in the Chinese Community Continued from previous page . . . Today, his brother, Dr. Larry Jew, still works actively in his general practice with his son, Jerome Nicholas, and links us to our earlier experiences. But it was for the next generation to construct a new hospital that opened next to the old one in 1979. The lead was taken by Dr. Rolland C. Lowe, who recruited Jonah Li to chair the fund-raising within the medical staff. Rolland would go on to become president of this medical society and, later, the president and chair of the California Medical Association. Dr. Harry Lee became the first medical director of On Lok Senior Health and helped found the Medical Insurance Exchange of California. Dr. Edward A. Chow succeeded to the presidency of the society and is the longest-serving health commissioner in San Francisco, having starting with the very inception of that body. But his biggest single achievement is the nurturing of the Chinese Community Health Plan and the Chinese Community Health Care Association, our independent practice association. These entities have become national models for health care delivery and are integral parts of the local health care system, with Chinese Hospital as its core. Nearly every one of the physicians mentioned above is or has been a member of this medical society. The medical staff has sprouted other wings. In 1973 the Continuing Medical Education Committee gave birth to a longrunning series of Annual Award Lectures honoring nationally known figures who have contributed to the health of the community. That was an event started to counter the lingering suspicion in the City’s medical community that some sort of Asian witchcraft was practiced within its walls. In 1982, that same CME committee produced what is now named the Conference on Health Care of the Chinese in North America. Held every other year since, this conference has brought together clinicians and researchers to explore common problems and solutions concerning Chinese patients. It has subsequently given rise to the Federation of Chinese American and Chinese Canadian Medical Societies, weaving together some 3,000 providers
14 San Francisco Medicine April 2011
located in urban areas with large Chinese colonies, interested in serving their medical needs. Dr. Randall Low is the international executive vice-president. In 1984, the same Conference took place in Los Angeles and gave birth to the Asian American Health Forum, which later included Pacific Islanders as well. This organization celebrates its twenty-fifth anniversary this year as the acknowledged voice for the health of all Asians and Pacific Islanders in America. It is its work that led directly to the signing of federal legislation recognizing and addressing the health disparities suffered by these ethnicities. But the hospital itself has not stood still. Although statistics did not allow the hospital to maintain the traditional obstetrical and nursery units where actor Bruce Lee was born, those units were not closed but were transferred entirely to California Pacific Medical Center. Last year Chinese Hospital had a total of 1,942 in-patient discharges and 421 observation cases. In addition to the current campus on Jackson Street, there are outreach clinics providing culturally sensitive care to the Chinese populations in the Sunset, the Excelsior, and Daly City. Systemwide, the total number of out-patient visits, tests, and procedures in 2010 was 478,860. The hospital consistently scores high in media comparison with other hospitals. Every survey of Chinese Hospital by the Joint Commission on Accreditation of Health Care Organizations results in scores in the high nineties. The highly competent nursing staff is a model of dedication, kindness, and sensitivity. Ancillary staffs in all departments are equally dedicated to quality customer service. With both the health plan and the hospital under the singular, inspired leadership of Chief Executive Officer Brenda Yee, the entire system functions seamlessly. The ledger runs on the positive side year after year. This allows our Board of Trustees, led by the capable former deputy mayor of San Francisco, James Ho, to stay on schedule with its plans for a new seven-story hospital. This year we will see the retirement of the grand old lady that has been our home since 1925. In the near future we will see a repeat of the joy of that earlier opening day; it might even be on another April 18th.
Collin P. Quock, MD, FACP, FACC, spent thirty-seven years in the solo practice of internal medicine and cardiology in Chinatown. He is a past chief of staff and former historian of the medical staff at Chinese Hospital. Dr. Quock left clinical practice two years ago and now works on various projects in health care. He continues to volunteer with the American Heart Association and is clinical professor of medicine emeritus at UCSF.
Medical Ethics in San Francisco Continued from page 12 . . . ters of AIDS. Our physicians quickly learned that they might be at risk by treating AIDS patients, since the mode of transmission was poorly understood. The ethical duty to treat patients even at risk to oneself was continuously debated. This debate demands a most serious examination of the basic principles of medicine, “Benefit your patient and do them no harm.” Conant, together with Paul Volberding and Molly Cooke, husband-and-wife physicians at San Francisco General, became exemplars of this ethical maxim. The UCSF Division of Medical Ethics sponsored an early conference on “The Meaning of AIDS” that explored this question, resulting in an early exposition of the ethics of the epidemic, The Meaning of AIDS (1989). It might be said that this traumatic event gave the strongest impetus to the reexamination of traditional medical ethics that now bears the name bioethics. San Francisco medicine has been at the forefront of this new medical ethics. UCSF maintains a strong academic program in medical ethics under Bernard Lo, MD. CPMC’s program in Medicine and Human Values, founded by Bill Andereck, MD, endeavors to bring contemporary ethical developments into the practicing community. If he were here today, I think my uncle Charles would appreciate that history. Albert Jonsen, PhD, is codirector of the Program in Medicine and Human Values at CPMC and was the original chief of medical ethics at UCSF. He is the only nonMD honorary member of the SFMS and is winner of the 2011 SFMS Perlman Award for Excellence in Medical Journalism. www.sfms.org
The History of Medicine in San Francisco
How Stanford Came and Went A San Francisco Story
Arthur Lyons, MD
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n the southeast corner of Pacific Avenue and Division Street in San Francisco stands a large, beautifully preserved wooden Victorian mansion, replete with turrets, its own water supply on the top floor, and large windows looking out on perhaps the most expensive real estate in the City. Few who drive by as they cross Pacific Heights know that it belonged to perhaps the most hated doctor who ever lived in San Francisco. His name was Charles N. Ellinwood. His story is an interesting one. Dr. Ellinwood was president of and professor of physiology at Cooper Medical College, and he was treasurer of its hospital, located at Clay and Webster Streets, at the time of the great San Francisco earthquake in 1906. He was the sole legatee of the past owner of the school, the successful and wealthy surgeon Dr. Levi Cooper Lane, who had died some years earlier, followed soon afterward by his wife. They were childless. Ellinwood was left exclusive control of the school’s endowment with the full expectation that he would continue the wise and successful administration that characterized Dr. Lane’s long tenure. Lane himself had inherited the proprietary school from his pioneer uncle Dr. Samuel Elias Cooper and had made it highly respected, perhaps the most prestigious medical school in the western United States. Lane was entrepreneurial and used his wealth to build the Lane Hospital, the most modern hospital of its time, and to form and endow the famous Lane Medical Library. It was and remains the largest library of its kind in the West. He gathered around him the finest skilled medical faculty in San Francisco to teach and manage the hospital’s wards and clinics. www.sfms.org
Lane and his hospital competed successfully with the University of California School of Medicine, then under the direction of Lane’s archrival and one-time AMA President, Dr. Beverly Cole. The Toland Medical College, another proprietary institution, had been given gratuitously to the Regents of the fledgling Berkeley University in 1873 by its founder, 49er physician Dr. Hugh Toland. U.C. migrated from its Stockton origins to Parnassus in 1895, thanks to Mayor Sutro’s beneficence, where it later built its own hospital. The Lane Hospital, an imposing brick structure with a large auditorium, remained in use on Sacramento and Webster Streets until 1970, with its founder’s heart remaining, at his request, in an urn in a prominent place near the podium. In April 1906, most of the City was destroyed by fire and earthquake, and the Cooper College was severely damaged. The Trustees requested funds from Ellinwood to effect repairs. In a contentious meeting in June 1906, Treasurer Ellinwood, whose relations with Dean Dr. Henry Gibbons, Jr., were not the best, simply refused to release any money to the school. As can be imagined, the trustees were frustrated and furious, but Ellinwood stood firm, declaring that the quality of the school did not warrant the expenditure of any funds. The trustees ultimately resorted to court action, but the court, considering the terms of Lane and Mrs. Lane’s wills, could not see any way to break Ellinwood’s absolute control over the endowment. The faculty, which was all-volunteer in the days before outside funding, and the Lane Medical School, which they staffed, were left high and dry. Ellinwood kept the money. In desperation, Dean Gibbons, with the approval of the trustees, approached
Stanford University and proposed giving up control of the school if the Palo Alto institution would maintain it in the City and keep its clinical faculty. Thus began the Stanford University Medical School in San Francisco. Stanford maintained its presence in San Francisco for more than fifty years, graduating a succession of successful doctors and maintaining a prestigious, worldclass faculty. It used the Lane buildings and added to them. It also ran a division of the San Francisco General Hospital with distinction until 1959, when consolidation occurred with the building of the new Stanford Hospital on the campus in Palo Alto. At that point the local Stanford Clinical faculty again was faced with a crisis, as most of them had no intention of leaving their San Francisco practices for the hinterland. At the same time, they wanted desperately to maintain the hospital where they put their patients. For the next several years, the hospital-sans-medical school continued under various iterations and sponsorships until it was rebuilt and became what it is today: California Pacific Medical Center, a prominent and successful San Francisco institution, part of the Sutter Health System. The origins of CPMC and its hectic history are largely unknown today. Mercifully, Dr. Ellinwood has also been forgotten, except by his descendants who continue to occupy the mansion he built on Pacific Avenue. The Lane name persists in what has become a most fabulous medical library, as does the annual Lane lectureship, held in the world-class medical school at Stanford some thirty miles away from where they all originated. Arthur Lyons, MD, is a retired neurosurgeon. He is a past-president of the SFMS and a member of the Editorial Board. April 2011 San Francisco Medicine 15
The History of Medicine in San Francisco
The National Free Clinic Movement San Francisco Roots and the Involvement of the SFMS
David E. Smith, MD, FASAM, FAACT
R
ecently I’ve been volunteering at the Common Ground Health Clinic in Algiers, Louisiana, which serves the uninsured in an impoverished area of New Orleans. Formed in the days after Hurricane Katrina, when it became quickly apparent that the city’s medical infrastructure lay in ruins, Common Ground has seen the need for its services continue to grow while New Orleans struggles to rebuild. Other free clinic activities in New Orleans include a weekend clinic at the Redeemer Presbyterian Church, staffed by Tulane medical students and faculty. They are sponsored by the Christian Medical & Dental Associations (www.cmda.org), which organizes free clinics near medical schools around the country as part of its campus ministry. In San Francisco, Glide Memorial Methodist Church has started a free clinic staffed by UCSF faculty, funded by a mix of church and Healthy San Francisco funding. These clinics provide an important response to the problems of the uninsured while government debates what its response will become after the political wars on health care reform are settled. A Common Ground staff member shared with me that her mother had worked at the Haight Ashbury Free Medical Clinic in the 1960s. She was raised with the Free Clinic spirit of nonjudgmentally helping the uninsured, and she stressed that she heard “health care is a right, not a privilege” so many times that it’s second nature to her. To many politicians this concept is unconstitutional and un-American. The seed for the Free Clinic movement was born during the Summer of Love. When we opened the Haight Ash-
16 San Francisco Medicine April 17 San Francisco Medicine April 2011 2011
bury Free Medical Clinic (HAFMC) in June 1967, in the first 24 hours we saw more than 250 patients, presenting primarily with various public health maladies (Smith & Luce 1971). Of course there were charity and government clinics then, but “free” was a philosophical term, not just an economic concept. It encompassed nonjudgmental care aimed at those outside the system, whether they were hippies, drug addicts, gays, poor people of color, or others demonized by the dominant culture. And San Francisco’s public health department was then actively denying the need for medical care in the Haight. “Free” threatened the mainstream medical system, and when John Luce (later chief of staff at San Francisco General Hospital, after graduating from UCSF) published an article about HAFMC, my malpractice insurance carrier canceled my policy, saying, “I didn’t know you were treating those weirdos.” As the Clinic was operating as my medical practice at that time, this could have killed the Free Clinic seed, but Steve Walsh (who later became President of San Francisco Medical Society) recommended that I contact SFMS for help reinstating my insurance, which it provided. This early support not only helped the Clinic survive but led to the establishment of five other free clinics by the end of 1967. Twenty-eight opened in 1968. By 1970, there were more than seventy free clinics in North America, with about a third of them in California (Fletcher 1982, Seymour & Smith 1986). In late 1968, we created the National Free Clinic Council (NFCC) to provide organizational support and a network
for information exchange (Smith et al. 1971), organizing two symposia, in 1969 and 1970. The NFCC adopted the slogan “Health care is a right, not a privilege” and convened in 1972 at the Shoreham Hotel in Washington, D.C., with the twin goals of sharing service delivery strategies and gaining government support for the rapidly grooving free clinic movement. As this was during the peak of the Vietnam war and antigovernment protests, these goals produced great internal conflict in the NFCC, including a protest at the conference by the SDS—they cavorted naked on the stage while I was speaking. However, out of this conference came an annual million-dollar grant from Special Action Office on Drug Abuse Prevention, which helped support free clinics across the country (Nebelkopf 1973, Fletcher 1982). More than 300 free clinic workers attended the 1970 conference, and the proceedings were fortuitously printed in The Free Clinic: A Community Approach to Health Care and Drug Abuse (Smith et al. 1971) the following year. Sadly, the first lines of its Introduction report: “The National Advisory Commission on health manpower stated in its report in 1967 that the national health care apparatus is more mishmash than system, a collection of bits and pieces characterized by overlapping, duplication, great gaps, high costs, and wasted effort. “As far back as 1932, a national committee, examining the high costs of medical care, published a detailed and comprehensive report describing the ways that the health care delivery system has totally failed throughout America.” The greatest challenge for the free www.sfms.org
clinics was funding. There was never enough, yet representatives of the various clinics could never agree whether it was OK to accept government funding—this was a time of great mistrust of institutions by young people, and it was, for the most part, young people who had the passion to open these clinics. The NFCC limped along for a few more years and produced two additional conferences. However, in 1977 internal political dissent led it to turn down an offer of federal funds for administrative support, and the NFCC soon self-destructed (Fletcher 1982, Seymour & Smith 1986). This history was reinforced to me a few years ago when I was asked to give a keynote lecture to the National Association of Free Clinics (NAFC), representing more than 1,200 free clinics nationwide, and I was introduced as the father of the national free clinic movement. As I looked over the audience, I thought, “What a long strange trip it’s been,” because many of the new free clinics are church-based, with retired community physicians sitting next to young health care activists with hair of varying lengths—including no hair at all—but united in a common purpose in serving the poor of all colors, ethnicities, and socioeconomic statuses. The common denominator in their patient population is no health insurance and no other access to primary care. Since 2001, the NAFC has taken up the challenge of providing a voice for the free clinic movement. It focuses on the issues facing free clinics today in the United States—still primarily their lack of funding—and have garnered media attention for the need for universal health care by sponsoring one-day health care events in several cities, often in conjunction with local health care providers, as they did in New Orleans in 2010 (www. FreeClinics.us). A survey of free clinics in 2005–2006 reports that 1,007 free clinics offered a health care safety net in forty-nine states and the District of Columbia. Annually, they provided medical and dental care for 1.8 million individuals, with a mean operating budget of under $300,000; 58.7 percent received no government
www.sfms.org
funding. The clinics were open a mean of eighteen hours per week and typically provided chronic disease management, physical examinations, urgent/acute care, and medications (Darnell, 2010). Over 80 percent of the clinics surveyed opened in the 1990s and 2000s, indicating the ongoing need for medical and dental services beyond government-funded and private insurance. Almost a third of the clinics were associated with a hospital; over a quarter had a church affiliation (Darnell, 2010). The NAFC estimates that the number of patients seen by free clinics reached nearly 9 million in 2009. They report an average of five calls a week from organizations and individuals interested in starting a free clinic (DePaul 2010). Darnell’s survey also reveals that free clinic patients were largely uninsured (92 percent), and primarily adults. Half were white, and the income of 97 percent fell under 200 percent of the poverty level ($19,140 for a single person in 2005). The homeless and immigrants comprised about 81 percent of the clinic population, and those with substance abuse disorder represented just under 20 percent. Those with HIV/AIDS comprised another 9.5 percent (Darnell 2010). Just as the Haight Ashbury Free Medical Clinic opened to meet the needs of its neighborhood population, San Francisco recently saw the start of its newest free clinic, Clinic by the Bay, serving exclusively the uninsured working poor of its Excelsior and nearby Daly City neighborhoods. Like the clinics surveyed by Darnell (2010), Clinic by the Bay relies on volunteer clinicians (primarily retired), and operates without government funding. Hillary Clinton wrote, “It takes a village. . . .” and the SFMS is certainly part of the village that takes care of its own in San Francisco. President Obama has written that “past history is not dead and buried and it is not even past”—his struggle, the latest in a series of attempts to provide affordable access to health care, confirms that this history is not dead at all. In fact, it will continue to haunt us unless political and public attitudes change in a major way toward health care reform.
David E. Smith, MD, FASAM, FAACT, is the founder of the Haight Ashbury Free Medical Clinic and a past president of the National Free Clinic Council.
References Christian Medical & Dental Associations. www.cmda.org. Darnell JS. Free clinics in the United States: A nationwide survey. Arch Internal Medicine. 2010; 170(11); 946:953. http:// www.wafreeclinics.org/admin/mod-cms/ viewattachment.php?id=498, http:// www.wafreeclinics.org/admin/mod-cms/ viewattachment.php?id=499. DePaul J. Free health clinics: America’s best-kept secret? The Fiscal Times. May 3, 2010. Fletcher DJ. The free clinic movement in America. 1982. Thesis, masters in Public Health, University of California, Berkeley. National Association of Free Clinics. www.FreeClinics.us. Nebelkopf E. White Bird flies to Phoenix: Confessions of a free clinic burn out. 1973; Eugene, OR: West Eugene Bozo Association. Seymour RB, Smith DE. The Haight Ashbury Free Medical Clinics: Still free after all these years, 1967–1987. 1986; San Francisco: Partisan Press and Haight Ashbury Publications. Smith DE, Bentel DJ, Schwartz JL. The free clinic: A community approach to health care and drug abuse. 1971; Beloit WI: Stash Press. Smith DE, Luce J. Love needs care: San Francisco’s Haight-Ashbury Free Medical Clinic and its pioneer role in treating drug-abuse problems. 1971; Boston: Little, Brown & Co.
April 2011 San Francisco Medicine 17
The History of Medicine in San Francisco
Thirty Years of HIV/AIDS The Medical Community and the SFMS in the Early Years of the Epidemic
Stephen Follansbee, MD, and Steve Heilig, MPH
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he first inpatients with pneumocystis pneumonia, an opportunistic infection complicating what would come to be known as AIDS, were seen in several hospitals in San Francisco in the summer and fall of 1981. Kaposi’s sarcoma was also being seen by a few dermatologists at the same time. Individuals with these unexplained problems were seen throughout the medical community, at private hospitals and doctors’ offices as well as at San Francisco General Hospital and the University of California Medical Center. San Francisco quickly became identified as an epicenter of the HIV epidemic. The SFMS was drawn to respond from the start. The infectious agent was not even identified yet, and controversies were myriad: How was it spread? Was aerosolized transmission occurring? Were mosquitoes or other vectors at work? Were health workers at risk? Could we interrupt transmission with education, condoms, clean needles, closing gay bathhouses, coercion, or something else? There was sometimes an underlying sense of panic in the early years, due to fears of personal risk, a sense of futility or impotence in terms of saving patients’ lives, and more general uncertainty about what to do, in a preventive sense, to minimize the epidemic. It was a time of crisis unlike any in most memories. “I haven’t felt like this since I was on a battlefield,” said one veteran physician. Because the epidemic impacted all parts of the medical community, the SFMS formed a citywide AIDS committee with all hospitals, the health department, and community physicians represented. The committee served as a critical component
19 San Francisco Medicine April 2011 18 San Francisco Medicine April 2011
in a citywide response and was soon joined by other organizations, including the newly formed Bay Area Community Consortium of HIV providers and the Bay Area Physicians for Human Rights (BAPHR). One of the first landmark efforts was a national conference presented at the SFMS headquarters on Masonic Avenue in 1985. The faculty was composed of most of the key figures in early research, treatment, prevention, and policy, including Paul Volberding, Mervyn Silverman, Jay Levy, Warren Winkelstein, Constance Wofsy, Michael Gottlieb, Samuel Broder, and many others. People came from around the nation to attend this early AIDS conference, where the virus was still referred to as HTLV-III. Amid the professionalism, tempers sometime flared Beyond providing clinical education, the SFMS AIDS committee was the locus of heated debates on many topics. It presented HIV rounds at every local hospital, featuring other leading figures such as Marcus Conant and Donald Abrams; set up an AIDS referral panel; and presented policy recommendations on AIDS testing, contact tracing, blood banking policies, and more. State propositions surfaced proposing ill-advised and punitive AIDS policies, and the SFMS group advocated strongly and successfully against these. Similar proposals and struggles arose at the annual CMA meetings, with rational, evidence-based approaches prevailing in most cases, although only after protracted debates. The contentious issue of occupational risk arose after a mysterious case of a dentist infecting multiple patients, and SFMS advice regarding universal precautions and testing was adopted citywide and beyond. The SFMS needle-exchange
policy became a model nationwide. Public education campaigns were designed in partnership with the health department and AIDS Foundation. Through it all, well into the 1990s, the SFMS journal featured a monthly AIDS Update column with multiple authors, which was read far beyond our city’s borders even before the era of the Internet. The impact of this epidemic in San Francisco was not predicted at the time of those first few cases in the 1980s. The physicians who were beginning to see those patients, and those at risk for HIV/ AIDS, were not prepared for the psychological impact that this disease would have on their own lives, both professional and personal. The existence of the SFMS AIDS committee, along with other organizations such as BAPHR and the Community Consortium, gave clinicians a chance to find support and acknowledgment of their efforts and concerns. It gave them a forum and opportunity to express concerns over policy and access to care and insurance reimbursement. Clearly the San Francisco Medical Society’s response to HIV/AIDS demonstrates again the importance of a professional organization that links physicians across practice locations and links physicians with a broad range of professional expertise. No single organization or practice site could have handled the volume of patients that were to present in the late 1980s and 1990s with HIV/AIDS. This link provided by the SFMS facilitated the rapid acknowledgment of this new problem and was critical in the formulation of policies, treatment and screening guidelines, and education that became nationally recognized and implemented.
www.sfms.org www.sfms.org
In retrospect, although the many functions of the SFMS AIDS committee were soon taken up by others as more was learned and expertise disseminated, clearly the many physicians who volunteered their time then deserve the lasting gratitude of our community. It is safe to say that many lives were bettered, even saved, by their contributions. If any of those physicians, in addition to those already mentioned, who were so involved are reading this, you know who you are—and on behalf of many, we express our gratitude. Stephen Follansbee, MD, is an infectious disease specialist at Kaiser Permanente San Francisco and is past president of the SFMS. Steve Heilig, MPH, is the assistant executive director of the SFMS.
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April 2011 San Francisco Medicine 19
The History of Medicine in San Francisco
Where Have All Our Hospitals Gone? A Historical Perspective on the Development of San Francisco’s Hospitals
Paul Scholten, MD Editor’s Note: A previous version of this first appeared in San Francisco Medicine in March 2003. The late Dr. Scholten was SFMS President in 1971 and a dedicated student of medical history and official SFMS Historian. As many may not know the background of their own and other local hospitals, we thought we’d reprint this piece, with some updates—although there is much more to be said, of course.
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n 1960, a regional medical planning agency organized a series of meetings in San Francisco of medical society and hospital staff and executive board members in an attempt to establish an orderly plan for hospital care and building in the city. San Francisco has traditionally been the medical center for Northern California, and in some specialties, for the entire state. Newspapers of the time featured stories of wild ambulance rides to San Francisco from distant places. But times had changed and excellent hospitals, medical centers, and medical schools had sprung up in Los Angeles, San Jose, San Diego, and up and down the great Central Valley. By 1960 it was obvious that San Francisco had twice as many hospital beds as were really needed; some estimated three beds for every one that could be regularly filled. The obvious answer was to consolidate services and close some hospitals. Obstetrics was the proposed starting point, with consolidation of all maternity services into two, perhaps three, centers. Pediatrics would be next. Almost all who attended the meetings were in agreement but no one was in favor of closing or even curtailing their own hospital’s services. Since not one hospital would sacrifice its own interests, nothing concrete came from the meetings.
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At that time, 1960, there were twenty-six full-scale hospitals in San Francisco.
“Preszionchild”
In July 1979, Laurens P. White, then president of the San Francisco Medical Society, wrote a mind-boggling President’s Message column, entitled “Welcome Preszionchild,” in San Francisco Medicine that addressed the problem of hospital underutilization and inflamed the local medical community. He wrote, “It can be done, it should be done, and let us do it. We must combine three small, good hospitals into one excellent behemoth. The prize for all of us, if we have the vision to do it, will be in excellence, efficiency, broader services, and lower costs because of better utilization.” In this message, he proposed combining Presbyterian, Mt. Zion, and Children’s Hospitals into one big unit for greater efficiency and the good of the city. He also proposed moving the obstetrical and pediatric programs from SFGH to St. Luke’s and establishing one big central laboratory service for the whole city, connected to the various hospitals by computer terminals. The reaction was both predictable and immediate. There were angry letters demanding that White be either fired as president or encouraged to “do the right thing” and resign. The most incensed wanted to start heating up the tar and making a feather pillow. Actually, there was little that could be done, or needed to be done, about the offending President’s Message. Laurie White was entirely within his rights in making the proposal, and now, decades later, the proposed consolidation has come to pass and “Preszionchild” is a reality, although not quite in the proposed combination. In January 1990, San Francisco Medi-
cine used for its cover story an article entitled “Where Have All Our Hospitals Gone?” that harked back to the 1960 meeting. That story noted that of the twenty-six hospitals listed in 1960, only fourteen survived in 1990. Since then, Letterman and Shriner’s have closed and most of the remaining hospitals have formed combinations among themselves or with groups outside of San Francisco. For the historical record, it should be interesting to describe what happened to the city’s hospitals in the past half century. Chinese Hospital, although still small and crowded, has rebuilt itself once and now embarks on a major rebuild again, and it continues to serve the special needs of the Chinese community. In 1960, after Stanford Medical School moved to Palo Alto, its hospital metamorphosed into Presbyterian Medical Center (PMC). Later, after a titular merger with Stockton’s University of the Pacific, PMC acquired a dental school, the old Physicians and Surgeons College, and became Pacific Presbyterian Medical Center. It then completely rebuilt and replaced the nineteenth- and early-twentieth-century building that it inherited from the old Stanford Hospital. In time it became California Pacific Medical Center (CPMC) and began to establish partnerships with other local institutions, including Children’s Hospital and Davies Medical Center. It also joined the Sutter Health chain and is now proposing a major rebuild on Van Ness, with revamping of the other Sutter campuses at Davies, Children’s, and St. Luke’s as well. Davies Medical Center, which started life as the German Hospital and found it prudent to change its name to Franklin Hospital when the U.S. entered World War www.sfms.org
I, in time changed its name to Ralph K. Davies, after a benefactor, and became part of CPMC. It is situated on quite a nice piece of land, much of it vacant, and it is rumored that CPMC might erect a tall structure on the back of the property and concentrate much of the group’s acute care at the site. Children’s Hospital was completely rebuilt in the 1980s and expanded by capturing beds vacated when St. Joseph’s Hospital closed. Joining with CPMC, many of its acute care functions were cut back. It operates as the California Campus of CPMC. Mount Zion Medical Center has continued its century-long tradition of service but became part of UCSF, and it is still the site of clinical care, research, and other functions. St. Luke’s Hospital, the only nongovernment hospital serving the southern half of San Francisco, also became part of Sutter and has been the focus of considerable efforts to maintain needed services there. It is part of the proposed rebuild and revamp for Sutter facilities in San Francisco. The Veteran’s Administration Medical Center at Forty-fourth Avenue and Clement Street continues to care for the veterans of our various wars and is a full teaching arm of UCSF as far as house staff and instruction are concerned. The University of California San Francisco has expanded since 1960 from a very fine regional hospital into one of the world’s top medical centers. It receives more research funding than any other research institute anywhere. UCSF purchased the former Fireman’s Fund Insurance Building and transformed it into its Laurel Heights Campus. It has absorbed Mount Zion Medical Center and is in the extended process of creating an entirely new Mission Bay campus in the old railroad yards in the South of Market District. San Francisco General Hospital continues to function as the “County Hospital,” is the site of our local trauma center, and became the premier AIDS treatment and research center in the world. Formerly, its patient care was split between Stanford and University of California medical schools, but today it serves as one of UCSF’s primary teaching hospitals. It is currently being rebuilt onsite, a staggeringly complex
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project. Saint Mary’s Medical Center is the oldest hospital in town, operating continuously since 1857. It is the surviving Catholic Hospital in San Francisco; formerly St. Joseph’s and Mary’s Help shared that distinction. It is now a part of Catholic Healthcare West. The local Catholic Healthcare West Bay Area Region includes seven member hospitals: St. Mary’s, Seton, St. Francis, and Half Moon Bay as well as Sequoia, O’Connor, and St. Louise in the South Bay. Kaiser-Permanente Medical Center has almost completely rebuilt and renovated itself in the past decade and absorbed the old French Hospital farther out Geary Street as an annex. Saint Francis Memorial Hospital, after ninety-five years as an independent, joined the Catholic Healthcare West group.
Gone but Not Forgotten
What of the institutions that have vanished since 1960? French Hospital, founded in Gold Rush days, met disastrously declining occupancy and was sold to a hospital corporation about 1987. Unable to improve the census, they sold the hospital to Kaiser-Permanent in late 1989. Garden Hospital on Geary Boulevard merged with CPMC and became the Garden-Sullivan campus of CPMC. Golden Gate Hospital, a small proprietary facility at Sutter and Larkin, fell on slack times and closed in 1974. Green’s Eye Hospital, at one time a thriving ophthalmological center, became San Francisco Eye and Ear Hospital, then Cathedral Hill Medical Center, and then downgraded to a clinic. The U.S. Public Health Service Hospital on Lake Street, known as the “Marine Hospital” since 1850, was closed in 1980 as a government economy measure. Mary’s Help Hospital, on Guerrero at Fourteenth Street, faced rebuilding and decided to relocate in Daly City, where San Francisco’s surplus beds were acutely needed. In time, it has become Seton Medical Center. Notre Dame Hospital, at Van Ness and Broadway, was built by the Italian community as Dante Hospital. Taken over by the Army as an annex to Letter-
man Hospital during World War II, it resumed life as Notre Dame, a convalescent hospital, and closed in the late 1970s. It now houses senior citizens. Polyclinic Hospital, another small proprietary hospital at 1055 Pine Street, became Callison Memorial Hospital in 1966. It was the victim of declining occupancy and closed in 1972. St. Joseph’s Hospital, founded by the Franciscan Sisters in 1889, fell victim to low patient loads and the lack of young ladies who felt a vocation in sisterhood, and it locked the doors in 1980. Children’s Hospital bought title to the beds; the building is now senior housing. Hahnemann Hospital, founded as a homeopathic institution in the late 1800s, renamed itself Marshal Hale Hospital after a benefactor in 1974 and, plagued by underuse, was absorbed by its next-door neighbor, Children’s Hospital, now part of CPMC. Southern Pacific Hospital, at Fell and Baker Streets, was built by the Southern Pacific Railroad and used as the major medical center for its seriously ill or injured employees from all over the West. With the rise in health plans, health insurance, and better hospitals in smaller cities, it proved uneconomical and was sold to a Dr. Upjohn of the pharmaceutical family in 1968. He renamed it Harkness Hospital but had to close it after several years of large losses; it is now senior housing. Sutter Towers was built across the street from Mount Zion and was intended as a specialized care annex but never really got off the ground. It later became Unity Hospital but was closed as such in 1975. Shriner’s Hospital for Crippled Children, on Nineteenth Avenue, needed revamping but rather than rebuild here decided to build a whole new facility in Sacramento, in close association with U.C. Davis. Letterman Army Hospital closed after a hundred years when the Army moved out and turned the property over to the Golden Gate National Recreation Area. The SFMS is now headquartered just across the street from the hospital site, in a building once used for housing Letterman medical officers. April 2011 San Francisco Medicine 21
The History of Medicine in San Francisco
Women in Medical History Pioneers Who Shaped Medicine in San Francisco
Nancy Thomson, MD “Women should not be expected to write or fight or build or compose scores. She does all by inspiring men to do all.” —Ralph Waldo Emerson (1802–1882)
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n 1948, when I started college at Stanford University, my physician-father discouraged me from preparing for medical school, saying that I would take a man’s place, then marry and never practice. Lois Scully, MD, a San Francisco internist, Stanford graduate, and 1979 president of the American Women’s Medical Association, ran into the same bias at about the same time when the Stanford physician who interviewed her told her to go home, marry, and have five children. In the early nineteenth century, Lucy Stone (1818–1893) wanted a good education, but the only college in the world that accepted women at that time was in Brazil. Luckily, Oberlin University was founded in 1835 in Ohio, the first U.S. college to accept both women and African-American students. Stone enrolled and graduated in 1847. However, when it came time to seek a profession, the only field open to women was teaching. In 1849 (the year Elizabeth Blackwell graduated from Geneva Medical College in New York), Lucy Stone wrote, “We believe that if the system of educating females for physicians be generally adopted, a great amount of suffering and death will be saved.” In fact, the number of female medical school graduates rose steadily from 1849 to 1900. By 1900 in Boston, women represented 18 percent of practicing physicians. However, by 1903 women’s participation in medicine began to decline, as most of the women’s medical schools established in the previous fifty years were closed or
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merged with male-dominated schools, which continued to reject women applicants. This situation generally prevailed until the 1970s, when the feminist movement and antibias legislation brought about an increase in women attending medical schools. In 1970, female admissions to medical schools were at 9.2 percent; in 1980 they had risen to 27.9 percent, and they are at almost 50 percent today. The decline in economic potential for physicians (which was historically one of the foremost motivations for male medical students) is given comparatively little importance by female students, who cite longtime interest in medicine and science, the desire to help others, and dissatisfaction with other types of work among their reasons for choosing medicine. The following time line highlights women’s place in the medical history of San Francisco.
Historical Time Line
1620 From the time of landing at Plymouth Rock, women as well as men practice medicine in New England, often after an apprenticeship with a practicing physician. However, when American medical schools are established, they follow the European pattern of barring women from seeking medical degrees. 1863 Elizabeth Pfeifer Stone, the first woman to practice medicine in California, settles in San Francisco. Probably German-born and -trained, she previously practiced in New York.
1873 The University of California acquires Toland Medical School in San Francisco, and since U.C. is already coeducational, Lucy Maria Field Wanzer, a thirtythree-year-old teacher, is accepted as its first female medical student. However, the dean suggests to her fellow students that they “make it so uncomfortable for her that she cannot stay.” 1874 Charlotte Blake Brown applies to the San Francisco Medical Society for admission. Some members of the Membership Committee feel strongly that females are mentally, physically, and morally unfit to study medicine, let alone practice the profession. On advice of mentors, Brown withdraws her application. 1875 Following the model of Elizabeth Blackwell’s New York Infirmary for Indigent Women, Pacific Dispensary for Women and Children is founded by three women, all educated on the East Coast: Charlotte Blake Brown, Martha Bucknall, and Sarah E. Browne. This outpatient clinic, initially located at 510 Taylor Street, is intended to provide opportunities for women physicians to obtain internship experience. 1876 San Francisco Medical College of the Pacific accepts its first female student, Alice Boyle Higgins, who graduates in 1877. 1877 Having been admitted to the California Medical Society along with four other women in 1876, Lucy Wanzer www.sfms.org www.sfms.org
becomes the first female member of the San Francisco Medical Society.
1880 Founders of Pacific Dispensary create the first nursing school west of the Rockies. Its one-year course becomes a two-year curriculum in 1882.
1887 The Pacific Dispensary moves to a new two-story building at California and Maple Streets and becomes Children’s Hospital. Interns and residents can be either male or female, but there are no men allowed on the medical staff. 1895 Citizens of San Francisco raise money to build the Little Jim Building for pediatrics at Children’s Hospital.
1896 One year after X-rays are discovered, Elizabeth Fleischmann-Aschheim, an engineer, opens the first X-ray laboratory in California, at 611 Sutter Street.
1896 William Randolph Hearst leads the campaign for the Eye and Ear Pavilion at Children’s Hospital.
1904 Dr. Charlotte Blake Brown dies at age fifty-eight. Her daughter, Adelaide Brown, MD (1868–1933), carries on her mother’s work at Children’s Hospital but also serves on the Stanford faculty at Lane Hospital. She fights locally and nationally for clean milk, sanitary garbage disposal, maternal and child welfare, visiting nurse services, and clinics offering cardiac care and birth control. 1906 The San Francisco earthquake forces the demolition of the 1887 Children’s Hospital building. 1911 A new, four-story brick Children’s Hospital building opens at California and Cherry Streets.
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1912 The Contagious Disease Pavilion opens at Children’s Hospital, with money donated by William Randolph Hearst, to care for patients with diphtheria, scarlet fever, measles, TB, and, later, polio.
1915 Children’s Hospital affiliates with the University of California for the teaching of medical students. 1915 The American Medical Association admits its first female member. 1916 Henries Hagar Duggan, MD, becomes a pioneering medical anesthesiologist. She works at various hospitals but settles at Children’s for twenty-five years, retiring after the end of World War II. 1938 UCSF pediatricians Mary Olney and Ellen Simpson found summer camps for children with diabetes.
1946 Marian Yueh Mei Li arrives in San Francisco, having completed medical school in Shanghai. She eventually opens a private practice and becomes the first Chinese female ophthalmologist to practice in Chinatown. 1952 Pediatrician Hulda Thelander establishes the Child Development Center at Children’s Hospital for children with cerebral palsy, developmental delays, and congenital defects. 1960 Internist Roberta Fenlon, MD, becomes the first female president of the San Francisco Medical Society. 1971 Dr. Roberta Fenlon becomes the first female president of the California Medical Association.
1977 Linda Hawes Clever, MD, MPH, founds (and chairs) the Department of Occupational Health at California Pacific Medical Center. She is also the first female editor of the Western Journal of Medicine and is the founder of RENEW, an organization to help fight professional exhaustion and dissatisfaction. 1980 Children’s Hospital acquires St. Joseph’s Hospital.
1988 Marshall Hale Hospital, formerly Hahnemann Homeopathic Hospital, merges with Children’s Hospital. 1991 Children’s Hospital and Pacific-Presbyterian Medical Center merge to create California Pacific Medical Center (CPMC). CPMC joins the Sutter Health chain. 1995 Judith M. Mates, MD (ob-gyn), becomes the second female president of the San Francisco Medical Society. 1996 Toni J. Brayer, MD (internist), becomes third female president of SFMS and, in 1990, the first female chief of staff at California Pacific Medical Center.
2003 Rita Melkonian, MD, FACOG (obgyn), becomes the fourth female president of the San Francisco Medical Society, with E. Ann Myers, MD (endocrinology), as the president-elect.
In closing, it’s interesting to note that in 1868, while debating the admission of women, the American Medical Association recorded this statement by Dr. Alfred Stille, prominent teacher of pathology: “Another disease has become epidemic. The woman question in relation to medicine is only one of the forms in which the pestis mulieribus vexes the world. In Continued on page 31 . . . April 2011 San Francisco Medicine 23
The History of Medicine in San Francisco
The History of the Blood Bank Large-Scale Blood Banking in San Francisco and Beyond
Erica Goode, MD
D
eWitt Burnham (1904–1991), the fourth of five children, was born in San Francisco at his family’s home on Divisadero, between Turk and Eddy Streets.2,4 His father, Clark Burnham, MD, and mother, Alice Kinne, left that home after the San Francisco earthquake and fire, due to lack of water, electricity, and gas, and ultimately moved to Berkeley, where the children grew up. DeWitt attended Andover, thinking he would major in geology, but while home for the summer, his father pressed him to consider medicine. He discovered, while chatting with shopkeepers and the local pharmacist, that Dad had begun to brag that DeWitt, the younger of two sons, was planning on becoming a physician, entering the world of medicine with him and DeWitt’s older brother Clark. That, DeWitt felt, sealed it, and he entered U.C. Berkeley with that goal, graduating in 1926. (This was not the era of teen rebellion, apparently). Medical School was at Stanford, Lane Hospital, long before the move to Palo Alto; he began his practice in internal medicine at 384 Post St., now the Saks Fifth Avenue building, on Union Square.1,2,4 As a bachelor internist, he was in significant demand by patients and women alike, and he was well regarded throughout his career as an astute diagnostician.2,4,5 He didn’t marry until 1950, at age forty-six. His bride, Betty, twenty-six, was a dietitian at St. Luke’s working in the Diabetes Education program; she also worked part-time in his office.2 I knew Dr. Burnham during my internship and residency at Children’s Hospital, now known as CPMC, California Campus. He was intrigued by my interest in nutrition, and when I began a weight
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control clinic, he provided my first caliper for measuring fat-pad thickness. (He also requested that I assume his practice, which I declined due to its 490 location.) Patients revered him, his peers regarded him with utmost respect, and he took a lively interest in everything. He was an energetic gentleman, who unfortunately developed a thrombotic stroke at age seventy-nine while undergoing hip replacement.5 He lived for the next eight years, compromised but able to use an early Apple computer, which allowed him to complete three booklets of recollections and archival information.2 For example, his writings relate that the Irwin Memorial Blood Bank began as follows: “One day early in 1940, I was going up the stairs of Stanford Hospital on Clay St. when I met Yank Chandler, dean of Stanford Medical School and a great surgeon. He looked very tired, and he said, ‘I just lost a 27-year-old man in surgery, from a bleeding ulcer, because he had a rare blood type and we could not get enough blood to save him. DeWitt, I want you to start a blood bank for this hospital right away.”1 As he tells it, Dr. Burnham then visited the biggest blood bank in town at S.F. County Hospital (now SFGH); found that the A, B, O, AB blood types had been identified in 1909; and heard the complaint that it was difficult to obtain enough donors for adequate supplies. (This preceded 1942 and the beginning of the use of Rh typing, never mind more subtle subtypes of blood cell markers.) He learned that since AB, the rarest, was seen in only 5 percent of the population, obtaining only 25 units would require 500 donors. It seemed unlikely that each hospital could garner that volume of regular donors, given the number of
hospitals in San Francisco, never mind the wider Bay Area. Indeed, when he called Cook County Hospital in Chicago, known to be the largest blood bank in the country, even they had difficulty finding enough B (with 10 percent prevalence) and AB donors. He first thought Stanford might be the repository, but knowing of various turf wars between institutions, he settled on the San Francisco Medical Society, with a goal of service to all San Francisco hospitals. Their initial response, “This is the craziest thing we’ve ever heard of, but here’s a committee; see what you can do with it as chairman.”1 The proposed site, while donated at no cost by the SFMS, was suboptimal initially, since it was to be located in the basement level of their elaborate, fourstory brownstone mansion at 2190 Washington St. While the space was huge and elegant (with twin Carrera marble lions in front, marble fireplaces, and brocade and gold-leaf walls), the lower level (with its ballroom, kitchen, servant’s quarters, and wine cellar) was dusty, cobwebbed, and sorely in need of renovation and paint. Coincidentally, the builder of that 1904 mansion was William. C. Irwin, whose wealth derived from the Hilo Sugar Company, which included six plantations. He was able to buy Lanai Island for one dollar.1,3,6 Fortuitously, DeWitt learned that while he used his Post St. office in the morning, Dr. John Upton, an ob-gyn physician, practiced there in the afternoon—and that, as a West Coast Canadian, Upton was funded by the British government and the William Irwin Foundation to develop a system of drying blood plasma. The powdered plasma would be shipped to Singapore, Hong Kong, and other areas of wartime www.sfms.org
engagement where British forces were amassing. The fledgling SFMS Blood Bank Committee was chaired by Dr. Burnham and consisted of twelve members, including Dr. Upton, other physicians, pathologists, the director of the San Francisco County Hospital Blood Bank, and department heads representing the various San Francisco hospitals. “We met each Sunday morning for coffee and Danish,” as stated by DeWitt, with the goal of becoming the world’s largest and first community blood bank.1 The donors would be served in the ballroom, brought from downtown by special bus or adapted cable car. The wine cellar could be adapted as storage for glass bottles; the kitchen, for serving donors alcohol, coffee, and cookies. Servants’ quarters were developed into office space or labs, housing autoclave, refrigeration units, and supplies. Major assistance in developing bottles, tubing, and other supplies came from Cutter Labs in Emeryville. They were essential to the process, creating a centrifuge that gently separated blood products without cell damage.1,3 Refrigerated trucks were purchased to transport blood; the charge for each unit delivered to hospitals was replacement banking plus $7.50.3 The Blood Bank was developed as a nonprofit entity, with ongoing donations from the City, Red Cross, and foundations, plus massive amounts of volunteer time. Merchants paid for large downtown billboards exhorting people to donate to the war effort. By far the most reliable and steady stream of funding came from the Irwin Family Foundation, and, during the war, the British War Relief.1,3 Since these dedicated Committee members were pioneers in this process, they found themselves repeatedly improvising and working out many early problems as they went. Oddities and missteps included the following: The freezer unit came without doors on its shelves; as the main door was opened, freezing, dense air flooded out the bottom and blew women’s skirts above their heads. Doors were added, shelf by shelf.1 The Desi-Vac plasma drying unit was designed to freeze-dry prefrozen
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plasma; to accomplish this, each bottle of plasma was placed sideways in a bath of alcohol and dry ice, allowing it to evenly coat the inside of the bottles to a depth of about a quarter of an inch. The bottles were kept frozen until twelve had been collected, connected to the Desi-Vac, and dried for sixteen hours. As DeWitt noted, “The whole business looked like a sow with her piglets.”2 The powdered plasma was then shipped to British bases in the Pacific theater, at no cost, each with the needed equipment and sterile saline for reconstitution in the field.1 Many times Dr. Burnham found Dr. Upton up at midnight, scrutinizing his Desi-Vac machine while still dressed in his tuxedo from the evening’s events.3 Without disposable materials, many volunteers were called upon to autoclave metal and glass and to reclean and sterilize the rubber tubing. Occasional inevitable mismatches occurred in the local hospitals; Drs. Burnham or Upton, or Dr. Curtis Smith, a surgeon, cofounder, and the third-most active member of the Committee, chased down each problem. In one instance, an intern who knew nothing of how to warm whole blood prior to transfusing it into a patient, asked the student nurse to give it. The blood “could not be given.” The Blood Bank technician was asked to investigate; he found that whoever was warming the blood at that hospital was heating it over a gas flame on a kitchen stove! The RBCs were being fried, and they clumped. More training was provided.1 In June 1941, just six months before Pearl Harbor and the U.S. entry into World War II, the Blood Bank formally opened. Five symbolic units of blood were collected that day, one donor being the wife of the Stanford Hospital chief of surgery and another, Templeton Crocker, the son-in-law of and an heir to William Irwin’s fortune. By the end of 1941, production had risen to more than 443 units per month. The Blood Bank quickly began sharing its methods for processing and shipping whole blood and products to local hospitals and overseas. Enquiries were endless; visitors came from Australia, Peru, England, India, and elsewhere, taking the knowledge to their areas in order to develop their own blood bank
systems. San Mateo and the East Bay soon had their own blood bank networks.1,3 Dr. Smith’s wife Virginia became the tireless head of Volunteer Services; and since no disposable dishware was available, donors received their alcohol (whiskey for men, sherry for women) and snacks on lovely china and glassware, served and washed by volunteers. Later, Bernice Hemphill, an amazingly capable bioanalyst, was recruited from Honolulu, where she was living in December 1941. On December 7, she had rushed to Queen’s Hospital to assist following the attack on Pearl Harbor. She became the supervising technologist there, serving to collect, process, and distribute blood for several years after 1941. She came to the Irwin Memorial Blood Bank in 1944 and served there for decades.3 On December 8, 1941, DeWitt received orders to report in two weeks to his Naval Reservist Medical Unit. Upton left for military service in 1942. The expanding Blood Bank was thus left in the capable hands of Dr. Smith until 1946, when the other two mustered out of the military. By then they took less-active roles. Dr. Burnham, a naval reservist in the Medical Corps, was first detailed to areas in California to discuss blood bank development with civilian groups; but after military training and several deployments, he ended up, in March 1943, as Chief Medical Officer of Espiritu Santo in the New Hebrides Island chain of the South Pacific. The entire unit was under the command of a naval captain. As men began developing a few cases of dengue fever, DeWitt urged the captain to allow a “sanitation day” to close all operations so his crew could search out and eliminate all standing water. This was denied, and one-third of the large base population fell ill with dengue, which is much more debilitating than malaria. From then on, sanitation days were his purview. Over the next two years, many units of plasma were provided for both troops and natives living on the island. Burnham found this most gratifying, knowing the number of deaths they were preventing through this use of blood.1 At the end of the war, Burnham and Continued on page 27 . . . April 2011 San Francisco Medicine 25
The History of Medicine in San Francisco
Operation Access Plugging the Hole in the Surgical Safety Net
William P. Schecter, MD; Douglas P. Grey, MD; Paul B. Hofmann, PhD
O
peration Access is a 501(c)(3) nonprofit organization that has provided low-risk outpatient surgery, diagnostic, and specialty procedures to uninsured patients in the Bay Area since 1994.
The Germ of an Idea
Provision of surgical care to the uninsured was discussed at a meeting of the Northern California Chapter of the American College of Surgeons in 1992. After the meeting, Drs. William Schecter and Douglas Grey continued the discussion at weekly meetings. We decided that provision of care to all patients in need was part of our professional responsibility, and we noted that it was easier to volunteer overseas than in our own community. We needed a structure to connect patients in need with volunteer surgical teams. We met with the San Francisco section of the West Bay Hospital Conference to propose that hospitals provide operating rooms and surgical equipment on a rotating basis so that volunteer doctors and nurses could provide low-risk outpatient surgery to patients in need. The CEOs at the meeting agreed with the concept in principle, although both they and we doubted that anything would come of the proposal.
Building the Organization
We reached out to various groups for help and learned of a hospital CEO, Paul Hofmann, who was teaching a graduate course at the U.C. Berkeley School of Public Health. During an early discussion, the need became apparent for a formal business plan, articles of incorporation, bylaws, a board of directors, and state as well as federal tax exemption. With funding
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provided by a small grant from the CEO of the Kaiser Permanente San Francisco Hospital (KPSF), two MPH students, Donna Elder and Cindy Caldwell, were recruited to assist in creating the business plan. We were off and running with professionals who understood project design, management, timelines, market surveys, and the like. We then expanded our working group to include Joanne Burik, an outstanding nurse administrator at San Francisco General Hospital, as well as Paul Neumann, an attorney at Weissberg and Aaronson, who provided pro bono legal services, including filing articles of incorporation as a 501(c)(3) nonprofit corporation, applying for state and federal tax exemption and preparing bylaws. Later, Nathan Nayman, the Executive Director of the San Francisco section of the West Bay Hospital Conference, joined our group to represent the hospitals.
The Structure of Care
We spent hundreds of hours outlining the process of care. Caldwell and Elder performed a market survey, contacting the many San Francisco Free Clinics to estimate the number of patients needing our services. We initially thought we would be caring only for medically indigent patients, but we soon realized that these patients could receive care at San Francisco General Hospital. Insured patients had access to nonprofit hospitals. Our patients would come from low-income, uninsured workers and the self-employed who fell through the cracks of our health care system. We set up an administrative structure to screen patients from our referring clinics for financial eligibility and medical comorbidities and connect these
patients with surgeons and hospitals. We solved the problems of credentialing, liability, and quality assurance by limiting the volunteers’ service to their own hospitals. The hospital credentialing and quality assurance programs were already in place and the doctors provided their own malpractice insurance. This arrangement also obviated the need for the clinical volunteers to become oriented to different policies, procedures, facilities, and staff.
Piloting the Program
“Every plan is good until the first shot is fired.” We decided to select one hospital to pilot the plan and work out the kinks. The hospitals were understandingly concerned about excessive cost if a complication occurred that required long-term hospitalization. Frank Alvarez, the CEO of KPSF, along with Philip Madvig, MD, physician in chief of the hospital, agreed to pilot the program and Richard Cordova, the CEO of San Francisco General Hospital, agreed to admit any patient who required hospitalization for a complication. We initially limited the cases to operations well within the competence of the surgeons on the Board (Schecter and Grey) and chose the initial volunteers from among our friends. Any complication would have probably killed the infant program. We identified a number of unanticipated logistical issues, but the Kaiser Permanente administration understood that this was a pilot program and we quickly solved the initial problems. Claude Organ, editor of Archives of Surgery and chief of surgery at Highland Hospital in Oakland, published the results of our first twenty-nine cases and wrote a supportive accompanying editorial. (1,2) www.sfms.org
Funding and Expanding the Program We received a $10,000 start-up grant from the San Francisco Foundation and a few small donations. Another Foundation program officer, while supportive of the concept, declined to fund us because he thought the expected passage of a universal health care act would make our organization unnecessary! The San Francisco Medical Society generously provided temporary office space without charge. Then we learned of the Robert Wood Johnson Reach Out program to encourage physician volunteerism. We were the only surgical program to apply and eventually received a three-year grant for $300,000. With this money we were able hire Caldwell on a half-time basis as our first executive director, and the program rapidly expanded. We had to balance demand and capacity. If we recruited hospitals and volunteers and no patients came, the volunteers might lose enthusiasm. If we promised services to referring clinics but could not provide them due to inadequate capacity, we would lose referrals. We first expanded our program within San Francisco and then the East Bay. We identified surgeon and anesthesia leaders in each hospital before approaching the administration with the concept. We continually “marketed” our services to referring primary care clinics serving the uninsured. As we continued our geographic expansion, we also expanded the spectrum of operative procedures and surgical specialties. Receiving referrals from more than eight-nine community clinics, we currently provide services in thirty-three hospitals and medical centers in six Bay Area Counties, relying on more than a thousand medical volunteers. We have also greatly expanded the number and variety of procedures we provide. For the first decade of operation, we were living hand to mouth. We realized we would have to develop a fund-raising program to support our activities once the Robert Wood Johnson grant ended. Fortunately, our community has been generous in supporting Operation Access. Without this support, we would be unable to serve our patients. Major ongoing www.sfms.org
financial assistance has been provided by Kaiser Permanente, Sutter Health, and the John Muir/Mt. Diablo Community Health Fund. We have also received funding from the San Francisco Foundation, the S. D. Bechtel, Jr. Foundation, the Blue Shield of California Foundation, and the Grey Family Foundation.
Accomplishments and Future Plans
The details of our program have been recently published. Our volunteers have evaluated 6,935 patients and performed 4,943 procedures since the program began in 1994. The estimated value of donated surgical services is $47 million. Very few complications (18) have occurred requiring hospitalization. Most of the complications were urinary retention and minor wound infections. There have been no major complications. The number of procedures has expanded rapidly in recent years. The OA Program continues to grow and expand in the Bay Area. Each year, the number of referrals increases, along with the number of medical volunteers and participating hospitals. We have developed a “tool kit” to assist other communities in developing Operation Access programs, and with the encouragement of the American College of Surgeons and Kaiser Permanente, our Board established the Operation Access Institute in 2010 to facilitate the replication of our model in other parts of the country. The Orange County Medical Society now runs a similar program called Access OC. We are hopeful that the Affordable Care Act of 2010 will reduce the need for our services, but we recall the reluctance to fund our program in the early 1990s because of “impending health care reform.” As long as the need continues, Operation Access will be here to help plug the hole in the surgical safety net. Visit www.sfms.org/archives for a list of references.
The History of the Blood Bank Continued from page 25 . . . Upton returned to their respective practices. By 1954, the original Washington St. building was deemed hopelessly outdated, and with extensive fund-raising, Irwin Memorial and the SFMS built a new home for the Blood Bank at Masonic and Turk. Since its inception, virtually all methods of recruiting donors, providing technical aspects of blood sorting, and banking have changed. But since 1948, the Irwin Memorial Blood Bank has been cited by the CMA as being a model for blood banks everywhere, due to its volunteerism, donor clubs, and low-cost method of operation. In 1971, it saw the last of paid donors,3 who represented a practice that was always fraught with issues of infection and higher risks of transmission of “donation hepatitis,” now known to be hepatitis C, which was untestable until 1989. It is due to the tireless work of these three physicians, and thousands of paid and volunteer monthly hours, that San Francisco’s Blood Centers of the Pacific (formerly Irwin Memorial Blood Bank) continues to be the standard by which all others are measured. Erica Goode, MD, recently retired from practicing general medicine at the CPMC Institute for Health and Healing. She is an associate clinical professor at UCSF. A longtime SFMS member, Dr. Goode is also a member of the SFMS editorial Board.
References Burnham DK, MD. Turns and Returns, unpublished collection of papers, letters. 1988. Burnham, E. Oral history as related to E. Goode. March 8, 2011. San Francisco. Forrest S. Promises to Keep: History of the First Four Decades of the Irwin Memorial Blood Bank of the San Francisco Medical Society. Cutter Labsoratories, San Francisco, 1982. Burnham D. My Brother Clark. Unpublished collection, history, genealogy. 1989. Personal knowledge of Dr. Burnham. Bloomfield, A and A. Gables and Fables. Heyday Books, Berkeley, pp. 226-7. April 2011 San Francisco Medicine 27
The History of Medicine in San Francisco
A History of Disaster Response Physician Involvement in Response to Past, Present, and Future Disasters
Stephen La Plante, Mary Mercer, MD, and John Brown, MD
S
an Francisco physicians have a long history of involvement in disaster response in the City, starting with the development of the public emergency hospital system, deploying ten small emergency hospitals geographically throughout the City, and continuing with the medical response by the Department of Public Health to the refugee camps that were established following the 1906 earthquake. With a combination of citizen initiative and the U.S. 6th Army at the Presidio, twenty-six camps were set up throughout the City to house those displaced by the quake. The Department of Public Health selected sixteen of them to provide daily clinics for the next year and a half. Examining a bound ledger entitled “Pay Roll Log, 1906–1907,” DPH sent teams of varying sizes to these camps as follows: surgeons, nurses, horse-and-wagon teamsters, foremen and laborers, pharmacists, and night watchmen. In August 1906, emergency sanitary surgeons were sent, paid $100 per month. By January 1907, camp surgeons were added at $150 per month. It is likely that these emergency sanitary surgeons were closer to the modern health inspector. Because of infectious disease issues, such as plague, the role of assistant bacteriologist was added in September 1907. These camps operated for several years, until the last of the twenty-six was dismantled in April 1910. Currently the Department of Public Health has participated, along with the Hospital Council of Northern California’s Emergency Preparedness Partnership, in several initiatives to improve postdisaster medical care. Among these are an Emergency Operations Plan dealing with natural and man-made disasters, an Infectious Dis-
28 San Francisco Medicine April 2011
ease Response Plan dealing with biological hazards, and a Multi-Casualty Incident Plan for the Emergency Medical Services System. Many of these responses involve physicians as key responders, but the current state of disaster preparedness on the personal and hospital level, a crucial factor in the success of any response, is unknown. Research currently being conducted at UCSF and the San Francisco Department of Emergency Management is investigating the existing barriers to personal preparedness among physicians and frontline hospital staff, as well as identifying specific training needs for disaster medical response. Further efforts across the city and state are looking to help physicians and medical personnel develop the skills necessary for providing effective medical care in a disaster. At the first annual Disaster Research Symposium, hosted by the San Francisco Medical Society in December, physicians from several different specialties highlighted ongoing research projects on topics ranging from disaster simulation to ultrasound in austere environments. This spring and summer, as a specific outreach to physicians, the Emergency Preparedness Partnership will be hosting a series of Disaster Grand Rounds lectures at hospitals throughout the city, beginning with Saint Francis and St. Mary’s Hospitals. These are important first steps to making our hospitals, clinics, and individual providers better prepared to function in a disaster. However, this is only the beginning. What is the optimal scenario for the future of physician involvement in disaster response? In our view, physicians who are prepared for disaster duty will recover rapidly from the first shock of any disaster. They will be informed quickly by various commu-
nications modalities—social media, pagers, fax, and Internet-compatible devices—and they will secure the safety of their families and homes and then will interrogate one of many sources for current information on the status of emergency medical response: dedicated websites such as sfdem.org, neighborhood information sources such as disaster hubs located at the public library and neighborhood clinics, media outlets such as radio or streaming internet sources. And they will report to duty where they are most needed. They will arrive at a variety of facilities that are impacted by the disaster but are still functioning. These will include: (1) Hospitals that have survived the incident and are fully functional, employing the Hospital Incident Command System to handle the large increase in demand for multiple medical services. (2) Clinics using emergency supplies cached by their sponsoring organizations and maintained by designated disaster personnel at each facility, able to provide basic medical and injury services. (3) Alternate care sites, such as the City’s Field Care Clinics, deployed to assist patients sent to staging areas for transport to unaffected out-of-City facilities, and in the hardest-hit neighborhoods where normal medical facilities are not functional. Physicians will be directing other health care providers in techniques of austere care, using medical diagnostic and therapeutic skills that are modified for the low-tech and high-volume demands of a postdisaster environment. Volunteer medical personnel that are in San Francisco by circumstance will be rapidly credentialed to provide care to the level of their training and competence. Medical facilities will be Continued on page 31 . . . www.sfms.org
The History of Medicine in San Francisco
Barbary Plague An Unfortunate Event in San Francisco Medical History
Erica Goode, MD The Barbary Plague:The Black Death in Victorian San Francisco, by Marilyn Chase, Random House, NY, 2003
M
arilyn Chase, a Wall Street Journal reporter (who is, incidentally, married to Randy Chase, MD, a well-known San Francisco internist and SFMS member), has written a fascinating, evocative, and carefully researched reconstruction of the evolving epidemic of bubonic plague (caused by immigrant rats carrying Yersinia pestis) in a young, entrepreneurial San Francisco of the 1880s and beyond. The book focuses on the years from 1899 through the Fire/Earthquake of 1906. The players included politicians and the businessmen who had arrived to support miners with services and products of all types, as well as to provide to the myriad needs of a burgeoning city. Shipbuilders arrived to outfit the Spanish-American war in the Philippines. The “Big Four” orchestrated the laying of track for the Southern Pacific Railroad. Boatloads of Chinese laborers arrived in San Francisco to do the grueling work of building that railroad. Prior to the Gold Rush, Yerba Buena contained 700 souls. It barely acquired the name San Francisco, in 1848, before exploding with men from all parts of the American and European continents, all in pursuit of gold. Only later came a trickle of women, beginning with prostitutes and, later, Asian women or girls sold into slavery before departing for San Francisco. Eventually, more churches and schools were built, concurrent with the arrival of teachers, ministers, priests, nuns, and the wives and children of the founders. A tiny handful of physicians were among those new arrivals. A quarantine station was established on www.sfms.org
Angel Island, for greater or lesser scrutiny of newly arriving ships and immigrants. For that half century, the growing city welcomed all comers, from entrepreneurial Brahmins to working-class American men including Jews, Catholics, Protestants, Hispanics, and the occasional African American. While a level of prejudicial thinking smoldered, only as Asians began showing up was societal discrimination and public abuse condoned by the populace. This was not merely a language issue, since alliances between Spanish and English speakers, while occasionally rocky, were not systematically condemned. Only those Asians who could adapt to the language and desires of Caucasian businesses or families were hired as drivers, gardeners, maids, and houseboys. Even those with college degrees from U.C. Berkeley and elsewhere had bleak possibilities beyond those positions. Meanwhile, in 1899, the U.S. Public Health Service, aligned with the National Hygienic Laboratory in Washington, D.C., became aware of and concerned about a new wave of bubonic plague in China. So did the surgeon general of the Marine Hospital Service, Walter Wyman. His service was charged with insuring that incoming ships and their personnel were free of communicable disease. A rising star in that Service was a young microbiologist, Dr. Joseph Kinyoun, who was dispatched from Washington to the quarantine station at Hospital Cove, Angel Island, in 1899. Kinyoun had learned Louis Pasteur’s microbial techniques from the Pasteur Institute in Paris; he had also traveled to Germany, where he was able to replicate Robert Koch’s postulates in confirming bacterial cause and effect. While in Europe, he also learned to produce horse serum
diptheria antitoxin, imprecise and rugged though this is now known to have been. Despite Dr. Kinyoun’s medical expertise, he lacked both persuasive abilities and political clout. He denigrated what he perceived as the Jewish businessmen who chose to ignore his concerns about plague and other epidemics threatening to wash ashore from Manila and the Far East. Indeed, the entire business community was quick to dismiss his messages to them and to the Public Health Service in Washington, D.C. His response was to bully people; this further undermined people’s perceptions of the seriousness of his alarm. Dismissive poems in the press were the response to his initial revelations of disease. The standoff came to a head in March 1900, when a San Francisco bacteriologist, Wilfred Kellogg, brought in a vial of blood from the corpse of a Chinese gentleman, Wong Chut King, who had lived in Chinatown. As Dr. Kinyoun viewed the gramnegative rods, he and Kellogg sent word that plague might be the diagnosis. This led to several days’ quarantine of Chinatown, until Koch’s postulates confirmed the problem. The Chinese community was under siege. There were many reported instances of Chinese people dying alone, their peers horrified at the disease, or fleeing to remote spots in the city, again dying alone but infecting others as they traveled. Isolated cases began to appear in the wider community. Politicians became alarmed at fewer passengers arriving by train from the East Coast, and embargoes began with Canada and Mexico refusing goods from California. Merchants swarmed into City Hall, demanding that Mayor Phelan do something. He Continued on page 31 . . . April 2011 San Francisco Medicine 29
The History of Medicine in San Francisco
Healthy San Francisco Making History in Health Care
Tangerine Brigham
A
lmost five years ago, San Francisco’s health care community joined forces with then-Mayor Gavin Newsom and then-Supervisor Tom Ammiano to improve access to care for uninsured adult residents. This public-private partnership resulted in the development of Healthy San Francisco (HSF). HSF was the City and County of San Francisco’s foray into health care reform before national health reform was enacted in March 2010. HSF is a program of the San Francisco Department of Public Health. HSF provides comprehensive, affordable health care to uninsured San Francisco adult residents irrespective of each person’s employment status, immigration status, or preexisting medical conditions. It restructures the often fragmented health care safety-net system into an organized delivery system for those seeking care. San Francisco is home to an estimated 64,000 uninsured adults, according to the 2009 California Health Interview Survey. HSF currently serves approximately 54,500 uninsured adults, or 85 percent of the estimated population.
Services
Uninsured adult residents enrolled in HSF have access to a range of comprehensive services across a continuum, including primary care, prevention, specialty, diagnostic, ancillary, pharmacy, emergency, hospital, behavioral health (mental health services and substance abuse treatment), and durable medical equipment services.
Non-Health Insurance Medical Home Model Healthy San Francisco provides access to care outside the insurance model. HSF
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is not a health insurance program. Rather, it is based on the notion that by providing uninsured residents with a primary care medical home (i.e., a clinic), they can receive comprehensive health services across the continuum. Medical homes can help improve treatment outcomes and reduce the likelihood of costly emergency-room visits and duplication of care.
Provider Network
Currently, there are more than thirtyfive primary care medical homes in HSF, along with other key providers in the HSF network: • Fifteen public primary care medical homes through the Department of Public Health • Seventeen private nonprofit medical home sites through various nonprofit clinics • Four medical home sites offered through two private physician groups • One nonprofit health plan (Kaiser Permanente) • One public hospital (San Francisco General Hospital Medical Center) • Five nonprofit hospitals: California Pacific Medical Center (CPMC), Chinese Hospital, Saint Francis Hospital, St. Mary’s Medical Center, UCSF Medical Center
Results to Date
At its core, HSF strives to expand access to care, promote appropriate use of services, and ensure participant satisfaction. Since its launch in July 2007, the Department has gleaned important findings in these areas to helpful assess the effectiveness of the program. In the area of expanded access to care, the number of uninsured enrolled in the program and the number of participating
providers increased. HSF ended the first year with 24,000 enrollees and the third year with 53,000; it now serves roughly 54,500. From its launch till now, the number of providers willing to serve the uninsured and participate in the program has increased. HSF started with twenty-seven primary care medical homes and now has thirty-six. In addition, the number of participating hospital systems increased from one public hospital to six hospital systems. In terms of health services use, a review of clinical data over the last two years suggests that HSF is contributing to appropriate levels of care: 76 percent of HSF participants continuously enrolled for a twelve-month period received primary care services; there is a low rate of avoidable emergency department visits, at 9 percent. Our proudest accomplishment is that an independent survey conducted by Kaiser Family Foundation found that 94 percent were satisfied with HSF and 90 percent indicated improvements in health needs being met after enrolling in HSF. Eighty-six percent (86%) of HSF participants report having a usual source of care.
Impact of Federal Health Reform on HSF
Passage and implementation of federal health reform will not dismantle Healthy San Francisco. The City will continue to have this program, because federal health reform does not cover all uninsured persons. The current estimate is that 60 percent of HSF participants will leave the program and be eligible for and enroll in Medicaid or receive subsidized health insurance through the California Health Benefits Exchange beginning in January 2014. The health care safety net is still needed. www.sfms.org
Applying for HSF Together, the City and County have taken great strides to improve health access and outcomes for uninsured residents. As providers, we can each do our individual part in helping move this effort forward by letting uninsured patients know where they can enroll in the program. If one of your patients inquires about Healthy San Francisco, please refer them to the City’s 3-1-1 Call Center, www.healthysanfrancisco. org, or (415) 615-4500. Tangerine M. Brigham is the Deputy Director of Health for the SFDPH and the Director of Healthy San Francisco. Barbary Plague Continued from page 29 . . . sent telegrams, not entirely against his will, to forty cities, denying that the plague had been found in more than the initial case. The San Francisco Call newspaper declared the plague threat a complete sham. The denial, including improper diagnoses by physicians believing they were watching patients succumb to typhoid or pneumonia rather than to generalized or pneumonic forms of the plague, was made worse by the San Francisco Health Department’s limited staff and lack of training in basic epidemiological techniques. Furthermore, though Surgeon General Wyman sent a dispatch to Dr. Kinyoun urging those essentials of quarantining the area, extreme scrutiny of incoming ships and people, and the essential step of finding and exterminating rats, even he had no clear evidence that rats (known to spread pestilence among animals), were the vectors for fleas as the essential transmitters of plague bacilli. This lack of emphasis, and Dr. Kinyoun’s persuasive limitations, meant that efficient quarantine of Chinatown was further undermined. The city instead simply stopped flow of food and goods into and out of Chinatown, meaning that nobody was cooperative with these partial efforts. Fortunately for San Francisco, the politically inept Dr. Kinyoun was replaced in 1901 by Rupert Blue, MD. Blue was, until 1909, a doggedly single-minded, compulsive sleuth, resentful of all less driven public health officials, as he scrutinized every possible vector and case. Prior to his tenure in
www.sfms.org
A History of Disaster Response Continued from page 28 . . . communicating with, and supported by, the Department of Public Health’s Department Operations Center, using the Incident Com-
the City, Blue had seen cases in Italy, and he held prescient views on the dangers of the plague known to have developed in 1894 in China. At that time, the French scientist Alexandre Yersin first diagnosed it in Hong Kong, using the simple Gram stain method developed in 1884 by the Danish scientist Hans Gram. Later physicians thought like true epidemiologists, rounded up rats, conducted experiments on rats and fleas, and made an amazing discovery (which I never heard about in medical school, and I suspect many of you haven’t either). It turns out that one flea, Pulex cheopis, and another, Ceratophyllus fasciatus, have an essential difference in their digestive systems and the degree to which they disgorge remnants of a prior blood meal into the skin of the next victim. While both types are capable of transmitting bubonic plague, “our” San Francisco plague fleas were primarily of the Ceratophyllus type, with much less disgorging capability than the Pulex strain. Plague transmitted via P. cheopis could easily have devastated the entire community. This book teaches us volumes about the scoundrels and survivors, well-meaning obfuscators, and dedicated investigators that peopled the City between 1900 and 1909. Here I have merely set the stage for this remarkable, medically intricate story of the survival of our city. But as a hint about the preservation of Chinatown and the Chinese community as we know it today, there was one major and unlikely savior. While the local Chinese Consul, a colorful and articulate gentleman, did his part, the key to exonerating the Chinese of San Francisco was a woman. For more about her, you will need to read this book. Without her, Chinatown would have been swept off into a swampy, undeveloped area south of our current beloved ballpark. Fortunately, with all that a century behind us, our City today is one of the most egalitarian in the country. Hopefully, that legacy will remain.
mand System that all residents learn during their primary training. Leaders in the medical response will be found among those who have completed additional special training, such as the newly ACGME-certified Fellowship in Emergency Medical Services, in partnership with disaster planners and response personnel certified in multiple disciplines. The overall medical response will have many glitches and issues, but in the end will be shown by thorough evaluation of the data collected to have prevented excess morbidity and mortality, and research of the response will point to even better future techniques and training. The historical facts are clear. The current response is being implemented. The future is in your hands as a San Francisco physician. We encourage you to develop, train on, and fully implement your personal, medical practice or hospital, and neighborhood response plan before the next disaster strikes. The future of disaster response in our City can be a bright one, and it demands your action today. Steven LaPlante is the current EMS agency administrator for San Francisco. Mary Mercer, MD, is an EMS/disaster fellow at the University of California/SF General Hospital. John Brown, MD, is the medical director of the San Francisco EMS Agency. Women in Medical History Continued from page 23 . . . other shapes it attacks the bar, wriggles in the jury box, and clearly means to mount upon the bench; it strives thus far in vain to serve at the altar and thunder from the pulpit; it raves at political meetings, harangues in the lecture room, infects the masses with its poison, and even pierces the triple brass that surrounds the politician.” If only Dr. Stille could see us today. We’ve sure come a long way. Nancy Thomson, MD, was a practicing anesthesiologist at Children’s Hospital from 1963 to 1985. In 1988 she received her master’s in public health from the University of California at Berkeley. From 1991 to 2000 she worked as the infectious disease officer and staff physician at San Quentin State Prison. Dr. Thomson remains actively involved in SFMS on the editorial board and as the obituarist. April 2011 San Francisco Medicine 31
The History of Medicine in San Francisco
MICRA A Victory of the Past, a Struggle of the Present
Robert Margolin, MD
W
e are all too aware of the many crises facing physicians and patients today. Now is the time for organized medicine to come together and take bold steps to advocate for physicians and their patients. This difficult time is reminiscent of 1975, when California physicians engaged in a legislative battle for their professional existence. They faced a malpractice insurance crisis and fought for the passage of MICRA reform. Many unfortunate events led to this dire situation, but unity, hard work, visionary thinking, and boldness helped resolve it. In the late 1960s, the number and size of medical liability lawsuits had begun to rise dramatically. From 1968 to 1974, lawsuits rose from 12 per 100 California physicians to 26 per 100. During the same period, million-dollar cases rose from two to ten per year. By 1975 the number of insurance carriers in California had dropped from thirty to three, and every casualty insurance company in the United States was on the edge of insolvency due to huge underwriting losses and the poor performance of the stock market. Sadly, one of the carriers that left the market in 1973 was American Mutual, a program that was sponsored by local medical societies and one that had insured most of the physicians in Northern California for the prior twenty-five years. The crisis culminated in a notice sent by Argonaut Insurance Company to its insured on January 31, 1975. It stated that the Northern California group policy was to be canceled in three months and that physicians would have to buy individual policies with a rate increase of 384 percent. Other carriers, including Traveler’s Insurance Company, sent similar notices to physicians throughout the state.
32 San Francisco Medicine April 2011
For many years the CMA had been working on legislative solutions but had been thwarted by the Assembly’s Judicial Committee, which was controlled by trial attorneys. CMA members responded by convening three special meetings of its House of Delegates. There they developed a legislative and public relations strategy to solve the problem. They would save physicians’ practices by promoting the passage of a law that would lead to significant tort reform. Major disruptions in patient care began to occur. Northern California anesthesiologists withdrew their services to protest the drastic rate increases. Similar actions by surgeons spread throughout the state. Only “urgent and “emergency” surgery was available for the next month. On May 1, a group of physicians’ spouses, led by the CMA’s Auxiliary, traveled to Sacramento and camped out in the governor’s reception room. They threatened to stay there until the crisis was resolved. Soon other states joined in the strike, attracting national media attention to this issue that was now sweeping the nation. CMA’s massive media campaign was gaining public support for tort reform. On May 6, Governor Jerry Brown was forced to call an extraordinary session of the legislature to solve the problem. Assemblyman Barry Keen introduced the bill later known as MICRA during the special session. The battle was heated and lasted for months. Finally, the bill passed the Assembly (60 to 19) and the Senate (43 to 4) and became law on December 17, 1975. For the next nine years, trial lawyers fought the constitutionality of the law. Eventually, the Supreme Court upheld the law in 1985. MICRA could now be applied widely to medical malpractice claims. Physicians were not done finding solutions
to this problem. Successful tort reform was essential, but without reasonably priced liability insurance, physicians would be unable to practice medicine. Our San Francisco Medical Society, along with six other Northern California medical societies, created the Medical Insurance Exchange of California. This became the first of several physicianowned professional liability carriers in California. A bold and risky venture at the time, it has been extremely successful and beneficial to physicians. It has maintained its goals of working to reduce the incidence and severity of lawsuits, rigorously defending physicians who get sued, keeping premiums as low as possible, and returning all profits back to physician owners. MICRA still serves today as the gold standard for tort reform. Its two most important provisions, a cap of $250,00 on noneconomic damage and limits on plaintive attorneys’ contingency fees, have been crucial in keeping premiums low enough for physicians to continue practicing in our state. Recently, trial lawyers have again issued a threat to attack and dismantle MICRA. If they succeed, our malpractice premiums will double or triple overnight. CMA needs your support to continue the long battle to preserve this sacred law. We hope all of you will join in this effort. Robert Margolin, MD, has practiced primary care medicine in San Francisco for the past twenty-seven years. He has devoted much of his career to advocating for physicians and their patients. He was president of the SFMS in 1998, Chair of our CMA Delegation to the CMA for three years, and has been our Trustee in the CMA Board of Trustees for the past eight years. He is an alternate delegate to the AMA and is a CALPAC officer He is an officer of the medical staff at CPMC. www.sfms.org
The History of Medicine in San Francisco
Welcoming the Japanese Physicians The Eighteenth Bicentennial Hiroshima Medical Mission
John Umekubo, MD
A
team of physicians led by Dr. Jiro Yanagia, specializing in radiation effects from Hiroshima, Japan, will arrive in San Francisco to conduct the eighteenth biennial medical examinations of Americans of Japanese and Korean ancestry who survived the atomic bombings of Hiroshima and Nagasaki during World War II nearly sixty-six years ago. It will consist of a comprehensive medical examination and follow-up evaluation on July 16 and 17, 2011, at the Sister Mary Philippa Health Center at St. Mary’s Medical Center. Since 1977, the Hiroshima Prefectural Medical Association has sponsored the official biennial medical mission for the benefit of the American survivors living in the United States who, due to their exposure to radiation in the 1945 bombings, face continuing medical problems. The medical mission this year is divided into two teams. The first will conduct medical examinations in Los Angeles and Hawaii, and the second will travel to San Francisco and Seattle. This year’s medical mission is also supported by the Japanese Ministry of Health, Labor, and Welfare; the Radiation Effects Research Foundation; A-bomb Casualty Council of Hiroshima; Hiroshima prefectural and city offices; and local medical organizations and representatives from the prefecture and city of Nagasaki. According to a spokesperson regarding the medical examinations, “These biennial Japanese medical visits are the only ongoing opportunity for American hibakusha—survivors of the atomic bombings—to receive thorough examinations for long-term effects of their radiation exposure from the atomic bombings.” According to previous examiwww.sfms.org
nation results, “it is very meaningful for the survivors to consult with and listen to the explanations on the conditions of their disease, the treatment that they were receiving, or the advice on the effects of lifestyles from Japanese medical specialists conducting the medical examinations.” For many of the first-generation hibakusha, the health of their children and future generations are also of great concern. The health examinations cover clinical examinations for internal diseases and surgical and gynecological physical examinations and consultations. Included in the examinations are the following: general hematology tests; urinalysis; biochemical testing such as liver function tests; diabetes screening; thyroid gland function testing; serum cholesterol screenings; and screenings for colorectal cancer, liver cancer, multiple myeloma, breast cancer, and uterine cancer. More than 200,000 people died in the atomic bombings of Hiroshima and Nagasaki or shortly thereafter as the result of acute injuries. By 1950, the figure had risen to 340,000 people. Today, among the living hibakusha, there are an estimated 1,120 Americans. Many of the American hibakusha are citizens by birth who were either visiting relatives or attending school in Japan and were stranded and could not return to the United States when the war started. Others became naturalized citizens of permanent residents after World War II. The Japanese medical mission receives volunteer support from dedicated groups and individuals throughout the United States. The biennial medical examinations are conducted through the
support of the local medical associations affiliated within the cities in which the medical examinations are conducted. It is this spirit of cooperation and the humanitarian efforts expressed by all involved in the biennial medical visits that help make them a truly worthy and meaningful endeavor. Supporting organizations and institutions for the San Francisco medical mission include the following: The San Francisco Medical Society has had a sister relationship with the Hiroshima Prefectural Medical Association since 1981 and provides the local affiliation necessary to conduct the medical examinations in San Francisco. The Sister Mary Philippa Health Center at St. Mary’s Medical Center has been involved with the biennial medical mission since 1995. Previous supporting institutions for the medical mission have included the UCSF Ambulatory Care Center and California Pacific Medical Center. The Committee of Atomic Bomb Survivors in the United States was established in 1971 as a support group for atomic bomb survivors residing in the United States. The Friends of Hibakusha is a volunteer organization formed in 1981 to provide support services for the atomic bomb survivors, and it provides volunteer support for the medical examinations. Volunteer support is also provided by the consulate general of Japan in San Francisco as well as by other Bay Area organizations and individuals. John Umekubo, MD, practices internal medicine in San Francisco and is a longtime member of the SFMS.
April 2011 San Francisco Medicine 33
Donate Blood. Save Lives. To make an appointment, call us at 1-888-393-4483 or visit www.bloodcenters.org
35 San Francisco Medicine April 2011
www.sfms.org
The History of Medicine in San Francisco
T
he San Francisco Medical Society is home to many boxes of historical medical supply kits, photos, and other documents chronicling the history of medicine in San Francisco. Here are images of two favorites. Since our previous historian, Dr. Paul Scholten, passed away we have yet to find someone interested in replacing him. If you have an interest in local medical history and would like to take on the job of learning about SFMS history and acting as our historian please contact Amanda Denz, adenz@sfms.org or (415) 5610850 extension 261.
The SFMS Mansion Covered in Snow in 1882
On December 31, 1882, this photo was taken of the mansion that housed the medical society for over a century. Sold in 2005, this mansion still stands today (boxed in by buildings on all sides) at 1409 Sutter Street in San Francisco.
Nervous? Crank Handle and Hold on Tight! Although we are unsure of what year this device was manufactured, the SFMS staff has verified that it no longer works. Here are the instructions as per the operating label inside the lid:
The Improved Magneto Electric Machine for Nervous Disease Manufactured by S. Maw & Son, 11 Aldersgate Street, London, E.C. Directions for Use.—Connect the two metallic chords with the sockets at the end of this box, and apply the handles attached to the same, to the part desired to be subjected to the electric current, the strength of which can be regulated by the speed at which the handle is turned. If it is desired greatly to increase power, the brass knob at the end of the box should be pulled out, so as to disconnect the keeper from the magnet. If a piece of wet sponge is placed in each handle, it will obviate the pricking sensation which at times is an annoyance to the patient. These sponges must not be put away in the box damp as they will rust the apparatus. The bearings and spring should be occasionally oiled.
www.sfms.org
April 2011 San Francisco Medicine 35
Hospital News Kaiser
Robert Mithun, MD
Providing excellent health care for the residents of San Francisco, and those who come to the city from other parts of the Bay Area, has long been a tradition of the Kaiser Permanente San Francisco Medical Center. Built nine years after the founding of Kaiser Permanente in 1945, the San Francisco Medical Center was dubbed a “dream hospital” by the San Francisco Chronicle when it opened in 1954. Founding Kaiser Permanente physician Sidney R. Garfield included such innovations in the San Francisco hospital as the “Baby-in-the-Drawer” service for new mothers and the ability for newborns to “room-in” with their mothers. The Baby-in-a-Drawer was one of the first steps toward mothers learning to care for their infants in the hospital without relying exclusively on the nursery staff. During the 1960s, San Francisco became one of the Kaiser Permanente sites to include the “Total Health Care Project,” which provided patients and their physicians a comprehensive overview of health status. As an organization focused on prevention, the health assessments enabled providers and patients to create goals and strategies for better health outcomes. Since the construction of the initial hospital, the San Francisco Medical Center has expanded to include more than fifteen buildings comprising the urban campus. Currently, the medical center includes the only hospital in San Francisco to meet the California Hospital Facilities Seismic Safety Act requirements for 2030. Remaining responsive to the needs of our San Francisco membership, we have created several culturally competent care modules within the Department of Medicine, including Bilingual Chinese and Spanish clinics, as well as one devoted to the needs of our HIV patients. All of these specialty clinics have celebrated their tenth anniversaries and been recognized as models of care for the populations they serve. At this point, we provide services to over 20 percent of San Francisco’s population and, since 2009, have participated in the city’s health care program, Healthy San Francisco.
36 San Francisco Medicine April 2011
CPMC
Michael Rokeach, MD
The American Academy of Orthopaedic Surgeons (AAOS) presented its 2011 Humanitarian Award to Taylor K. Smith, MD, during a ceremony at its 2011 annual meeting. The Humanitarian Award honors members of the Academy who have distinguished themselves through outstanding musculoskeletal-related humanitarian activities in the United States or abroad. This award also recognizes those orthopaedic surgeons who help to improve the human condition by alleviating suffering and supporting and contributing to the basic human dignity of those in need. Congratulations, Dr. Smith. Drs. Kevin Hiler, Susan Day, and John Moretto were recently reappointed as department chairs for Surgery, Ophthalmology, and Pathology, respectively. Dr. Hiler will serve as chair of the Department of Surgery through 2012, Dr. Day will serve as chair of the Department of Ophthalmology through 2014, and Dr. Moretto will serve as chair of the Department of Pathology through 2015. CPMC’s program in Medicine and Human Values will host its Summer Workshop in Ethics: Interface between Palliative Care and Ethics on Saturday, June 11, 2011, at the University of San Francisco’s Fromm Institute. The workshop will explore the options available at the end of life and the ways in which the medical aspects relate to the ethical aspects of deciding to withdraw or withhold lifesustaining treatment. For more information, contact Antonio Kruger at (415) 600-1647. The Department of Pediatrics will host Pediatric Liver Disease Update on Saturday, May 21, 2011, at the St. Regis Hotel in San Francisco. This half-day conference will focus on new advancements in the diagnosis and understanding of pediatric liver disease. For more information, contact Sophia Hall at (415) 600-7450.
UCSF
David Eisele, MD
“If an ‘impossible’ scientific experiment results in failure 98 percent of the time, ask not why the experiment failed but why it succeeded at all. It’s how a once-impossible dream became the cochlear implant.” These were the words that Robert A. Schindler, MD, professor and chairman emeritus of the Department of Otolaryngology, Head and Neck Surgery at UCSF, chose to close a recent lecture he presented on the development of the cochlear implant, a breakthrough in which he played a pivotal role. Fifty years ago, cochlear implantation was indeed considered an impossibility. Prevailing thought in hearing science was that the inner ear was sacrosanct—the cochlea could never be invaded without destroying delicate hair cells, thus resulting in permanent deafness. It was otologic surgeons who came to recognize that the cochlea could survive a stapedectomy, a revolutionary procedure that became the surgery standard for more than a decade. These findings were largely dismissed by the scientific community who continued to assert that implanting the cochlea could never been done successfully. In 1971, however, visionary UCSF neuroscientist Robin Michelson, MD, presented promising findings in his paper “The Results of Electrical Stimulation of the Cochlea in Human Sensory Deafness” and debuted the first cochlear implant system, a system that shares features with every cochlear implant device developed since. Reaction from the hearing science community remained skeptical. Michelson’s findings were in “direct conflict with existing knowledge.” Michelson, however, found a believer in Francis A. Sooy, MD, chairman of the UCSF Department of Otolaryngology and incoming UCSF chancellor. Sooy recruited Michael Merzenich, PhD, and Schindler, who, with Michelson, pioneered the development of the multichannel cochlear implant. Today, the cochlear implant remains the most technologically sophisticated neuroprosthesis ever created. To view Dr. Schindler’s lecture, visit http:// ohns.ucsf.edu/sl. www.sfms.org
Hospital News Saint Francis
Patricia Galamba, MD
Saint Francis has a long history of serving the health care needs of the community. In 1905, five prominent physicians at Southern Pacific Hospital decided to open a private hospital for their patients. Southern Pacific Hospital provided care for the railroad workers and their family members. The original “St. Francis Hospital” (we changed our name in 1951) was destroyed by the Great Earthquake of 1906, and in 1911 a new 100-bed hospital was opened on the corner of Hyde and Bush, our current location. Our Board of Trustees still maintains a prominence of physician members; one other hospital in California has a similar board structure. Over these 105-plus years, Saint Francis has enjoyed being part of the history of medicine. We were the first hospital west of the Rockies to open an acute burn center, which still thrives today as the Bothin Burn Center. For forty-eight years the hospital maintained a residency program in plastic and reconstructive surgery—it was the first of its kind in San Francisco. In 1963 Saint Francis opened the first psychiatric unit in a private hospital. The hospital opened one of the first occupational health programs, the Franciscan Treatment Room, more than thirty-five years ago to serve the workers of the City and County of San Francisco. Saint Francis established the first pulmonary rehabilitation program and the first hyperbaric oxygen program. Among our other firsts are the Centers for Sports Medicine with three locations San Francisco, Walnut Creek, and Corte Madera. Our physicians have been pioneers in sports medicine, artificial disc replacement, computer navigation joint replacement, and hip arthroscopy. Not bad for a small community hospital.
www.sfms.org
St. Mary’s
Frank Charlton, MD
In 1857, an intrepid group of Sisters of Mercy from Ireland saw a lack in San Francisco. A cholera epidemic had broken out, and suddenly an entire city found itself in need of health care. Unfortunately, this Gold Rush, boom-town, port city had no hospital. These courageous Sisters stepped forward in a time of crisis, and they did not only administer to the sick and dying. They also pooled all their resources and any others they could muster and opened San Francisco’s first hospital: St. Mary’s. More than 150 years later, we’re still here fulfilling the original mission of those Sisters: providing health care to the sick and indigent of San Francisco. After the great earthquake and fire of 1906, St. Mary’s had to rebuild itself anew at its current location at Hayes and Stanyan, while continuing as the teaching hospital where many of the physicians who subsequently founded UCSF and Stanford medical schools were trained. St. Mary’s has long been at the forefront of medical progress, noted for our many firsts: first free clinic in SF, first total hip arthroplasty in California; first coronary angioplasty in the U.S.; first inpatient AIDS/ dementia unit on the West Coast; first multidisciplinary Spine Center and back school in the U.S. (where Drs. Zucherman and Hsu invented the revolutionary treatment for spinal stenosis known as the X-Stop in 2005); first U.S. center, along with UCSF, to offer percutaneous atrial appendage ligation for nonvalvular atrial fibrillation. We just opened the CHW Cancer Center at St. Mary’s, along with our new, state-of-the-art outpatient infusion center. As we have done for one-and-a-half centuries, we continue to educate the next generation of doctors and nurses, so that they will carry on the mission of those brave Sisters to make a Healthy San Francisco a reality.
Veteran’s Diana Nicoll, MD, PhD, MPA
Patients newly diagnosed with Alzheimer’s disease or other dementias, and their families, need better guidance from their physicians on how to plan for the progressive loss of ability to handle finances, according to a study led by a physician at the San Francisco VA Medical Center. “When a patient is diagnosed with Alzheimer’s disease or dementia, the chance that their physician will discuss advance planning for finances is miniscule,” said lead author Eric Widera, MD. “And yet when family members and caregivers are asked what’s important to them, finances are near the top of the list.” Writing in the February 16, 2011, issue of the Journal of the American Medical Association, the authors use a case study of an Alzheimer’s patient who progressively lost the ability to handle finances as a springboard for a review of medical literature on the topic of dementia and financial impairment. “The literature tells us that financial incapacity occurs early and very rapidly in Alzheimer’s disease and other dementias,” said Widera. This rapid progression of financial incapacity makes it essential that physicians proactively counsel patients and their families on financial planning early in the disease, while the patient still has the capacity to make decisions. As a first step, the authors recommend that early in the course of the disease, the patient sign a durable power of attorney authorizing a family member or caregiver to make financial decisions on the patient’s behalf. Also, the patient and caregiver may want to open joint financial accounts. “This can protect the patient’s autonomy while giving the caregiver a bit of oversight, and provide an early warning system as the disease progresses,” noted Widera. “This is about giving patients with dementia a choice, respecting them as individuals, and working to maintain their autonomy even beyond the point where they can’t make decisions anymore,” Widera said.
April 2011 San Francisco Medicine 37
No Pressure, Just Savings!
Spending more than you have to for workers’ compensation insurance doesn’t make sense. Workers’ Compensation premiums are on the rise again, right at a time when reducing practice expenses is a priority for every physician.
The San Francisco Medical Society-endorsed Workers’ Compensation program, with its 5% member discount (15% depending upon where you place your group health insurance), will be even more important to members this year. When you place your coverage with Employers Compensation Insurance Company, the endorsed program insurer, chances are your savings will exceed the 5% program discount. Rather than guess what your savings can be, take a moment to contact Marsh and let us show you
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Please call a Client Service Representative at 800-842-3761 today. The process is simple and fast.
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