October 2011

VOL. 84 NO. 8 October 2011

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

Medicine for the Stages of Life

Medicine for Midlife The evolution of ADHD: Social Context Matters Group Prenatal Care: A New Model Drinking Trends in Adulthood

The “Million Hearts” initiative Exploring the Gluten-Free Diet Craze CALPAC Update, News from the SFMS, and More

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

October 2011 · Volume 84, Number 8

Medicine for Midlife FEATURE ARTICLES

MONTHLY COLUMNS

10 The Odyssey Years: A Healing Journey into Adulthood Katherine Sulzer

4 Membership Matters

11 On the Eve of Graduation: Stepping into the Post-Medical School World Eisha Zaid 13 Drinking Trends in Adulthood: The Battle of the College Binge- Drinking Bulge David Pating, MD 15 Motherhood: A Reflection Toni Brayer, MD

7 President’s Message George Fouras, MD 9 Editorial Gordon Fung, MD, PhD 29 Classified Ads 40 Hospital News

OF INTEREST

16 Group Prenatal Care: A Community Health Center Offers a New Model for Care Sara Johnson, MD 18 Feelings of Loss Postpartum: A Physician and Mother Reflects on the First Weeks Martina Scholtens, MD, CCFP 19 Chronic Sorrow: A Landscape of Parental Loss Nancy Iverson, MD

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Public Health Update: San Francisco Sobering Center Shannon Smith-Bernardin, RN, MSN, CNL, and Michelle Schneidermann, MD

29 CALPAC Update: CALPAC Is Fighting for You Richard Thorp, MD

21 The Evolution of ADHD: Social Context Matters Dan Eisenberg, PhD, and Benjamin Campbell

30 SFMS Health Policy Report: Medical and Public Health Policy Making for California and Beyond Stephen Follansbee, MD, and Steve Heilig, MPH

23 The Gluten-Free Diet Craze: Shortfalls of a Restriction Diet Peter J. Curran, MD

41 In the News: New “Graphic” Tobacco Labels Draw Fire

24 Simplify Your Diet: Promoting the Anti-Inflammatory Mediterranean Diet Carol Ceresa, MHSL, RD

42 Back Page News

26 The “Million Hearts” Initiative: Preventing Heart Attachs and Strokes Thomas R. Frieden, MD, MPH, and Donald M. Berwick, MD, MPP

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

SFMS ELECTION 31 Slate of Candidates 32 Candidate Statements

MEMBERSHIP MATTERS A Sampling of Activities and Actions of Interest to SFMS Members

Coming Soon to an Inbox Near You: Dues Renewal 2012 membership renewals are right around the corner! Make sure you continue to receive the benefits of SFMS and CMA by renewing your membership beginning in October.

There are three easy ways to renew your dues this year: • Mail/fax in your completed renewal form when you receive it in the mail.

• Renew online using your credit card.

• Enroll in the EasyPay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or membership@sfms.org.

Don’t forget the benefits membership brings, including: • Staying up to date on vital health care issues that affect San Francisco physicians with the San Francisco Medicine journal, SFMS News e-Newsletter, and SFMS blog.

• Connecting with physicians through SFMS social events and our online communities on Facebook, Twitter, and the member-only LinkedIn group.

• Accessing customized practice management resources to help you navigate the ever-changing health care environment in California.

• Protecting your interests as a physician and preventing reimbursement cuts, through the advocacy you get from SFMS/CMA on monumental topics such as Medicare physician payments and MICRA. 2011 membership expires after December 31.

SFMS Night at the Symphony–October 28 Join SFMS on Friday, October 28, for an evening at the SF Symphony! Reserve your seat to see Alan Gilbert of the New York Philharmonic conduct Beethoven and Hayden. The package includes access to the Green Room with complimentary drinks and hors d’oeuvres and a discount ticket in the Orchestra section. For more details or to RSVP, contact SFMS at (415) 5610850 or membership@sfms.org.

CMS Pushes Back Deadline for E-Rx Exemption

Centers for Medicare and Medicaid (CMS) released the final regulation on the 2012 Medicare e-prescribing penalty program in September. The final rule includes provides more flexibility under the exemption categories so that more phy4 5

San Francisco Medicine October 2011

sicians can be eligible for an exemption to avoid the 2012 eprescribing penalty. Physicians can also apply for more than one exemption category if a combination of categories apply to their particular hardship. In addition, CMS extended the deadline to apply for an exemption to November 1, 2011. Details of the final 2012 Medicare e-prescribing can be found at http://wp.me/pBDEx-l3.

Medicare Revalidation Requirement for Providers

All providers and suppliers who enrolled in the Medicare program prior to March 25, 2011, will be required to revalidate their enrollment by March 25, 2012, under new risk-screening criteria required by the Affordable Care Act (section 6401a).

Newly enrolling and revalidating providers and suppliers are placed in one of three screening categories representing the level of risk to the Medicare program. The three categories—limited, moderate, or high—determine the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application.

Palmetto GBA will begin notifying physicians and entities to revalidate in September. Their plan is to start with those physicians and other organizations who are enrolled in Medicare but do not yet have complete profiles in PECOS (Provider Enrollment, Chain, and Ownership System). They will also send revalidation letters to all Independent Diagnostic Testing Facilities (IDTF). The remainder of the physicians and providers will receive letters over the next nineteen months, in an order still to be determined. Upon receipt of the revalidation letter, physicians and organizations will have sixty days to respond.

Here are a few items to remember during the initial startup of this effort: • This applies to any individual or organization that enrolled or revalidated prior to March 25, 2011.

• Do not do anything until you get a letter instructing you to revalidate. (This is important in order to ensure an orderly enrollment process.)

• CMS is working on simplifying this process on the Internet-based PECOS system, hopefully for January 2012.

• Palmetto is working with CMS to establish a schedule that will accomplish the regulatory requirement and avoid any disruption in payment to physicians.

• Physicians who are making changes (moving, closing practice, etc.) should continue to submit their changes as usual. www.sfms.org

SFMS On-Site Seminars October 14: Creating a “Director of First Impressions”—Customer Service, Patient Relations, and Telephone Techniques This half-day practice management seminar provides valuable training for both front- and back-office staff to handle patients and tasks both efficiently and professionally using superlative customer service skills.

This seminar will provide your staff with the tools necessary for positive patient relations. 9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast). $95 for SFMS/CMA members and their staff ($85 each for additional attendees from the same office); $150 each for nonmembers. Contact Jen Suh, jsuh@sfms.org or (415) 561-0850 extension 200, for more information.

October 28: “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. This seminar teaches the core business elements of managing a practice, which physicians don’t receive in medical school training. 9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast). $225 for SFMS/CMA members and their staff ($200 each for additional attendees from same office); $325 for nonmembers. Contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260, for more information.

CMA Webinars

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events.

• October 19: EOB Analysis—Successful Claims Appeal • 12:15 p.m. to 1:15 p.m.

• October 26: Key Financial Ratios to Increase Profitability • 12:15 p.m. to 1:15 p.m. and 6:15 p.m. to 7:15 p.m.

• November 2: EMR/EHR Update • 12:15 p.m. to 1:15 p.m.

• November 9: EHR Meaning Use • 12:15 p.m. to 1:15 p.m. and 6: 15 p.m. to 7:15 p.m.

SFMS Spotlights Advocacy and Community Health Efforts at General Meeting

A wonderful time was had by all at the SFMS General Meeting on September 12 at the Golden Gate Yacht Club. With warm enthusiasm, SFMS President George Fouras, MD, welcomed sixty residents and physicians—a quarter of whom were first-time attendees!—to the annual event. Featured speaker CMA President James Hinsdale, MD, delivered an informative presentation about CMA’s legislative efforts to preserve MICRA, prevent further reimbursement cuts from Medicare and MediCal, and maintain the economic viability of physicians.

Event participants appreciated the chance to exchange new knowledge, gain insights into organized medicine, and foster networking. Members gave us positive feedback and showed interest in becoming actively involved in future events, including upcoming mixers and the SFMS Night at the Symphony scheduled for October 28. www.sfms.org

October 2011 Volume 84, Number 8 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 Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Jennifer Suh

BOARD OF DIRECTORS Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD

Term: Jan 2009-Dec 2011 Jeffrey Beane, MD Andrew F. Calman, MD Lawrence Cheung, MD Roger Eng, MD Thomas H. Lee, MD Richard A. Podolin, MD Rodman S. Rogers, MD

Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Shannon UdovicConstant, MD Joseph Woo, MD CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

October 2011 San Francisco Medicine

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San Francisco Medicine October 2011

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PRESIDENT’S MESSAGE George Fouras, MD

Recent Happenings at the SFMS The end of summer is always a busy time for the San Francisco Medical Society. This year has been no exception. As one of the founding stakeholders for HealthShare Bay Area (our health information exchange), we participated in demonstration interviews by two vendors that were selected via the RFP process.

In addition to the original stakeholders, several potential new partners participated in the interviews, which were conducted using a structured scoring mechanism. The demo scripts covered a broad range of critical areas that would be required for a robust HIE, such as the patient consent process, viewing an aggregate patient record, tools for communication among providers and/or the patient, and medication management and reconciliation among providers.

We anticipate that a vendor will be selected by late October or early November, and HealthShare Bay Area should be able to go live by the end of 2011 or early 2012. Both vendors demonstrated impressive platforms that will provide easy-touse virtual health records accessible to the stakeholders using a variety of current EHR applications.

The general membership meeting of the San Francisco Medical Society was held again this year the Golden Gate Yacht Club, with the background of spectacular views of the bay. I was delighted to see how many members came for the first time. Dr. Hinsdale, the current president of the California Medical Association, spoke to our members regarding several current topics. He discussed the current situation with the SGR fix and possible scenarios that Congress may embark on.

In addition, he discussed his thoughts on changing aspects of CMA leadership processes that would encourage our younger members to become more involved earlier. This was welcome news, as the SFMS has actively supported the concept of promoting more involvement by younger physicians, as demonstrated in our current slate of candidates.

One other task that occurs at this meeting is the presentation of the upcoming year’s slate of candidates by the nominations committee, which was chaired by Immediate Past President Mickey Rokeach. We are once again in a strong position for success based on the excellent candidates who are running for office. Please take a moment to review the candidate statements found in this issue of SF Medicine, and be sure to return your ballots promptly. My thanks to the nominating committee for its excellent work, and best wishes to the candidates.

Finally, one of the major tasks of the San Francisco Medical Society is to participate in the CMA House of Delegates, which this year will be held at the Disneyland Resort in Anaheim, California, in mid-October. The delegation is chaired www.sfms.org

by Steve Follansbee, who follows in a long line of exceptional people to take on this task. I will also refer you to the article by Steve Heilig and Steve Follansbee, in this issue, which will go into further details regarding the resolutions that our medical society has submitted for consideration by the House.

We have participated in a joint meeting in preparation for the House of Delegates with the ACCMA in order to coordinate positions on resolutions of mutual interest. Historically, the San Francisco Medical Society has been seen as the “liberal” county medical society by the House of Medicine. However, when you look at our accomplishments, I think I can safely say that we are one of the more moderate voices in the house and, in fact, tend to be trailblazers when it comes to public health and policy issues. For example, we have introduced or changed CMA policy regarding the care of patients with HIV, the sugar content of foods that are available in schools, physician aid in dying, and more recently the formation of a TAC regarding the legalization and regularization of marijuana.

Many of the resolutions that we have introduced have gone on to be considered by the AMA House and ultimately have had an impact on national health policy.

October 2011 San Francisco Medicine

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EDITORIAL Gordon Fung, MD, PhD

Medicine for the Phases of Life: Midlife This month we continue our phases-of-life series by exploring topics specific to the middle years. In medicine, midlife as a phase is a relatively new phenomenon. In 1940, the life expectancy for Americans of both sexes and all ethnicities was 62.9 years. By 1950, it was 68.2 years, and life expectancy has continued to rise to the 2011 age of 78 years and 2 months (specifically, 80.5 years for women and 75.5 years for men).

In the 1940s there were only two fields of medicine that were age-related: pediatrics and adult medicine, with the transition falling between 18 and 21 years. This was based more on legal and political definitions of adulthood (18 being the age of eligibility for military service and 21 being the drinking age) than on anything to do with the normal transitions of the human body. Based around this definition of adulthood, all clinical specialties divided their training and practice into these two major categories.

Over the last several decades, however, we have begun to recognize additional definable phases of life. In response to rising life expectancy, the American Geriatric Society was founded in 1942. It received formal recognition with board certification in 1982 and the designation as a subspecialty of medicine. This formalized the division of medical care into three age phases, with the largest group being those in midlife—roughly from ages 18 to 65. Now we’re seeing midlife, or adulthood, being divided into new subphases. In our opening article, Katherine Sulzer explores the idea of the “odyssey years,” or the relatively new phase that marks the transition from youth to adulthood and that may extend through the twenties, when people engage in self-exploration rather than “settling down” immediately after college. Eisha Zaid writes about her feelings on the eve of graduation from medical school, another decidedly momentous step into adulthood.

Another action that marks the entrance into adulthood for many is becoming a parent. We explore preparing for parenthood, defining motherhood, postpartum feelings, dealing with the loss of a child, and other topics surrounding being a parent.

For some of us, and for many of our patients, dealing with a lifelong disease or disorder is a reality. In their article on ADHD, Dr. Eisenberg and coauthor Campbell explore a perspective that may give adults who have the disorder another way to view it. In addition to discussing possible evolutionary benefits, they note that the incidence of adult ADHD is roughly half of that among children, and they cite as one possible reason the fact that adults can choose roles suitable to the way they operate and can manage symptoms by building lives that support how they naturally function. www.sfms.org

In addition to building a life that supports who you are, building a life that supports the future you desire is also a part of the middle years. A necessary part of planning for the next stage of life is learning to care for your body by taking preventive measures in this stage of life. One recommendation by the National Cholesterol Education Project is that, by age 21, everyone should know their cholesterol level, and ideally it should be less than 200. The Department of Health and Human Services recently established the Million Hearts Campaign, which you can also read about in this issue. Its goal is to save 1,000,000 lives from heart attacks and strokes over the next five years, using evidence-based guidelines for riskfactor management. Considering that cardiovascular disease remains the number-one killer of adults, addressing cardiovascular health as early as possible should be a cornerstone of preventive care in adulthood. In addition to exercise, diet is important. In this issue we address both the gluten-free fad that’s sweeping the nation as well as the Mediterranean diet.

Just as the middle phase has no exact beginning, it has a vague end. The next issue of San Francisco Medicine will explore the later years of life, another stage that the baby boomers are rapidly redefining as they begin to enter it. Until then, enjoy reading the selection of articles we’ve chosen on adulthood—a broad and multifaceted phase of life that encompasses many changes, stages, and ages.

October 2011 San Francisco Medicine

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Medicine for Midlife

The Odyssey Years A Healing Journey into Adulthood Katherine Sulzer

Gazing out a windowpane, where my eyes met the convergence of sky and ocean, I imagined a magnolia flower in the azure of this union. I closed

my eyes, departing from the blue of the day to enter the blushing white image of succulent fibers in soft fabrics that appeared to make up this flower. The fabrics bound and interlaced to one another, creating separate petals of seamless structures that, together, shaped a provocative blossom. It was rapturous in its nature. I felt at home in its balmy presence.

I was thirty miles from the coast of Massachusetts that day, on Nantucket Island, where I had spent my childhood. In 2008, I graduated from college and chose to return to my home, where I once again lived with my parents. Throughout this period, I clasped onto the image of this magnolia, as I had learned to use self-guided imagery and visualizations as one way of healing connections within. In Japanese culture, the magnolia flower is often gifted to new parents after a child is born, symbolizing life force and a love of nature, perhaps to silently articulate the innate reciprocity that transitions us through the phases of life.

In an op-ed article entitled “The Odyssey Years” (New York Times, October 9, 2007), David Brooks writes of a new phase in life; a transition between adolescence and adulthood. He describes the odyssey years as “the decade of wandering that frequently occurs between adolescence and adulthood. Old success recipes don’t apply, new norms have not been established, and everything seems to give way to a less permanent version of itself.” Brooks references a “spirit of fluidity,” as our connection to traditional social institutions is severed, leaving young people to create their own meaning.

In the ancient story, Odysseus faces tangential paths and multiple tribulations along a decade-long journey home after the fall of Troy. The impediments he encounters create new pathways, leading Odysseus in unknown directions. This wandering provides opportunities for growth and healing—possibly 10 San 11 SanFrancisco FranciscoMedicine Medicine October October2011 2011

through times of pain and crisis, or even love and amity.

The return to Nantucket felt like a retraction from a path I had once envisioned, as I claimed new territory in nostalgia.

I thought my growth into an adult was lost in the familiarity of past lives on this island that reverberated with memories from childhood and adolescence.

My personal odyssey began when I was sexually assaulted a few months before I attended my first year of college. Thereafter I suffered from symptoms of posttraumatic stress disorder (PTSD). I became hypervigilant and extremely sensitive to my surroundings. Then, three days before leaving Nantucket for college, the unexpected death of a family member exacerbated the intensity of these symptoms. Throughout college, I felt a lack of desire to participate in the multiple activities and hobbies that had, for many years, brought me joy.

This healing journey demanded a presence in hardships while time continued to move me forward. I experienced an expansion of perception by seeing the world in a greater context than the narrow experience of the present moment, by way of travel and living abroad, and also through accumulating practices that helped me slow an overly active mind and connect with my body through guided imagery and yoga. In my wandering home, I discovered an unabashed love for nature and a different interface with the fourteen miles of land on Nantucket I once thought I had known so well.

Five years into my odyssey, I visited my father’s parents— for the first time in eleven years—when I was twenty-three years old. It was June in Maryland, and the wetlands on their property hovered in a translucent mist. We decided to go on a walk.

I slowly weaved down a path, traversing embedded roots, and supporting my grandmother, who had symptoms of fatigue and pain from living with shingles.

We fell silent upon arriving at a clearing on this path. I could barely believe what my eyes saw. Hidden on this land, where my grandfather’s workshop sat, stood a large magnolia tree that was in full bloom. It held what looked like hundreds of fully matured blossoms. The mist had suspended the blossoms in the air, eating away the green of their leaves, revealing perfectly sculpted crowns of whiteness. I closed my eyes and basked in their luxurious scent, remembering the image of the magnolia I had seen that day on Nantucket, when I felt the life force through which I had begun my healing odyssey. I knew I had arrived home that day; I had become an adult.

Katherine Sulzer attends the California Institute of Integral Studies (CIIS), where she is a candidate for a master’s degree in integrative health studies. She has worked in public health in various capacities, from testing and counseling individuals for HIV/AIDS to program development. She is also a medical writer. www.sfms.org

Medicine for Midlife

On the Eve of Graduation Stepping into the Post-Medical School World Eisha Zaid ahead. I look forward to finally being able to take care of patients and practicing medicine. With a higher level of responsibility, I know the learning curve will be steep and that I will be unprepared.

To help guide us through the unknown and nebulousness that has come to define internship, our faculty members have peppered advice into our concluding lectures. If there is one unifying theme, it would have to be that we must remember what we do not know and to ask for help.

“If you do not know, just say, ‘I do not know.’” This line was repeated to us multiple times by our faculty. It seems simple enough.

The following is a small sample of some of the advice passed on to us (listed in no particular order). I include this list as a reference to myself and as a way to calm my nerves right before I am gowned and don the title of “doctor” tomorrow morning—a designation I still feel I need to earn.

Advice from My Faculty

“Open your eyes. School is done.”

The voice of our faculty member echoed through the lecture hall as he culminated our medical school training with one final session. Earlier, he had lead us through a period of meditation in the last moments of class, guiding us through reflecting over our time as students and thinking about the individuals who have impacted our growth as physicians and humans.

I found myself thinking back to my first experiences as a medical student—the first moment I stepped foot on the UCSF campus during my interview, my first day of medical school in the same lecture hall, my first patient interview in Moffitt Hospital, my first time teaching an MSP session, my first clinical clerkship, my first surgery, my first delivery, and my first residency interview. As these memories whirled in my mind, I felt an overwhelming sense of gratitude to the people in my life—my family, friends, teachers, mentors, and patients— who have been the foundation of my education and identity.

On the eve of graduation, I am overcome with a myriad of emotions. It’s a confusing mix of excitement, anxiety, nostalgia, and fear.

As I leave behind four years of medical school, some amazing friends, and an incredible city, I embrace the opportunity www.sfms.org

1. Absolute honesty is a must.

2. When working with patients and their families, remember their vulnerabilities.

3. You are the intern; therefore you are at the bottom (again).

Just remember that.

4. There needs to be a free flow of information up and down the chain of command, similar to that in a military hierarchy.

5. Take the time to know yourself—the core you—not influenced by being a doctor.

6. Realize your limited competence.

7. Do not take things personally.

8. Learn from your patient’s stories.

9. Look like a doctor. And that means that men need to grow their beards on vacation.

10. No comment on the women’s dress.

11. Remember why you went into medicine in the first place— to help people.

12. Find balance in your life and take care of yourself.

And tomorrow, we graduate.

Eisha Zaid, a regular contributor to San Francisco Medicine, graduated from UCSF Medical School in May 2011. This fall she started her residency at the University of Michigan in Obstetrics and Gynecology. She shares her experiences in medicine and life on her blog, http://eishazinnerworld. blogspot.com/.

October 2011 San Francisco Medicine

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San Francisco Medicine October 2011

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Medicine for Midlife

Drinking Trends in Adulthood The Battle of the College Binge-Drinking Bulge David Pating, MD I recently agreed to be interviewed by ABC TV about youth drinking, thinking I would make a public service announcement about emerging drug trends. Instead, I was surprised to be asked to com-

ment on YouTube clips showing drunken college co-eds who were photographed while passed out in compromising and vulnerably suggestive positions: slumped over toilets, half-dressed, lipstick smeared on stomachs, as if pranked by sorority mates.

This piece received the headline “Girls Gone Wild.” As for my opinion: “Hmmm,” I said, “This is not good. I’m glad this is not my daughter!” So much for my career as a TV expert.

The real backstory is this: We are riding a bulging epidemic of alcohol abuse on college campuses (see table on next page).

Fifty percent of college-age young adults binge drink (five or more drinks for men, four or more for women) at levels that put them at risk for health and social consequences; 20 percent drink at levels that meet the definition of alcoholism. This epidemic is rampant and ubiquitous, affecting large universities and small private colleges alike. Within days of opening the University of California’s newest campus in Merced, for instance, one student fell out of a second-story dorm window, drunk and intoxicated, and another died from acute alcohol poisoning. Have all these college students gone wild? (Source: National Household Survey on Drug Abuse, 2009) The concern on college campuses is major. The problem is that our public policies about drinking do not line up with what we know about the effects of alcohol on the developing brain.

The brain matures (myelinates) from the back to the front, from the cerebellum (age 12–14) to the limbic cortex (14–16) to the frontal lobe (18–24). Frontal lobe maturation is not complete until 25 years, resulting (on average) in less impulse control and poorer judgment in young adults than in those in mid-life. Actuarially, the car rental industry has known this for some time, as reflected in their nonnegotiable minimum-age requirement of 25 years. They know that auto accident rates peak at age 19 years and do not decline until age 25. Those that do rent to

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younger drivers charge a heavy surcharge. Those in car rentals avoid the problems of young adults driving recklessly or while intoxicated in a way that college campuses have been unable to avoid. While college deans adamantly encourage young adults to make safe and healthy choices, young adults may be more susceptible to social pressures to drink recklessly and less capable of thinking through the consequences.

Fortunately, college health centers have been unanimous in trying to head off the pending disasters related to student binge drinking. Disasters can range from life-threatening injury or accidents to date rape, assault, and arrest. Over time, it can lead to school failure and dropping out (see sidebar on next page). UCLA has led efforts to bring the National Institutes of Health (NIH) alcohol and drug screening toolkit to California to combat excessive college drinking. For clinicians working with young collegeage adults in an office setting, I offer this advice: The pressures on college students are enormous. They are not only at risk for alcohol abuse but also for drug and tobacco use, including marijuana, and for depression and unsafe sex. We confront and challenge student expectations about alcohol and other risky behaviors while screening for binge drinking and providing motivational counseling for those at risk.

Continued on the following page . . .

October 2011 San Francisco Medicine

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Current Binge and Heavy Alcohol Use among Persons Aged 12 and Older (2009)

A Snapshot of Annual High-Risk College Drinking Consequences The consequences of excessive and underage drinking affect virtually all college campuses, college communities, and college students, whether they choose to drink or not.

Death: 1,825 college students between the ages of 18 and 24 die from alcohol-related unintentional injuries, including motor vehicle crashes.1

Injury: 599,000 students between the ages of 18 and 24 are unintentionally injured under the influence of alcohol.1

Assault: 696,000 students between the ages of 18 and 24 are assaulted by another student who has been drinking.1

Sexual Abuse: 97,000 students between the ages of 18 and 24

For college administrators, NIH evidence suggests that college drinking can be reduced through coordinated efforts to implement prevention education, alter student norms, enhance screening, and promote zero-tolerance campus rules. A full description of these evidence-based recommendations is available at http://www.collegedrinkingprevention.gov. The bottom line is that there is a better way. First, involve individuals, students as a whole, and the surrounding community in efforts to counter norms with facts: Problem drinking is everyone’s responsibility! Second, administrative, health, and police actions should be aimed toward keeping students healthy and in school. The following is a list of commonsense campus policies that appear capable of reducing high-risk alcohol use: reinstating Friday classes and exams to reduce Thursday-night partying; possibly scheduling Saturday morning classes; implementing alcohol-free, expanded late-night student activities; eliminating keg parties on campus where underage drinking is prevalent; establishing alcohol-free dormitories; employing older, salaried resident assistants or hiring adults to monitor such dormitories; further controlling or eliminating alcohol at sports events and prohibiting tailgating parties that model heavy alcohol use; refusing sponsorship gifts from the alcohol industry to avoid any perception that underage drinking is acceptable; banning alcohol on campus, including at faculty and alumni events.

As a closing blessing, there is a ray of hope in this story.

While many young adults drink excessively—and a large proportion make a serious habit of it—half of them will “age out” by reducing their drinking significantly or stopping drinking, even if alcohol dependent. Aging out is a poorly researched phenomenon and difficult to predict. It is hypothesized to be linked to brain maturation, altered social context, or increased social responsibilities experienced upon graduation, marriage, or starting a family. Regardless, it is encouraging to know that with respect to excessive drinking among young adults, past behavior is not destiny. For college kids “gone wild,” of course, this assumes they live through their college heydays long enough to tell about them. Let’s hope enough sanity survives in our college health centers and deans’ offices to keep them safe.

David Pating, MD, is an addiction medicine specialist.

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San Francisco Medicine October 2011

are victims of alcohol-related sexual assault or date rape.1

Unsafe Sex: 400,000 students between the ages of 18 and 24 had unprotected sex and more than 100,000 students between the ages of 18 and 24 report having been too intoxicated to know if they consented to having sex.2

Academic Problems: About 25 percent of college students

report academic consequences of their drinking, including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall.3

Health Problems/Suicide Attempts: More than 150,000 students develop an alcohol-related health problem,2 and between 1.2 and 1.5 percent of students indicate that they tried to commit suicide within the past year due to drinking or drug use.4

Drunk Driving: 3,360,000 students between the ages of 18 and 24 drive under the influence of alcohol. 1 Vandalism: About 11 percent of college student drinkers report they have damaged property while under the influence of alcohol.5

Property Damage: More than 25 percent of administrators from schools with relatively low drinking levels and over 50 percent from schools with high drinking levels say their campuses have a “moderate” or “major” problem with alcohol-related property damage.6 Police Involvement: About 5 percent of four-year college stu-

dents are involved with the police or campus security as a result of their drinking,6 and 110,000 students between the ages of 18 and 24 are arrested for an alcohol-related violation such as public drunkenness or driving under the influence.2

Alcohol Abuse and Dependence: 31 percent of college students met criteria for a diagnosis of alcohol abuse and 6 percent for a diagnosis of alcohol dependence in the past 12 months, according to questionnaire-based self-reports about their drinking.7

1. Hingson et al 2009. 2. Hingson et al 2002. 3. Engs et al 1996 and Presley et al 1996a, 1996b; 4. Presley et al 1998. 5. Wechsler et al 2002. 6. Wechsler et al 1995. 7. Knight et al 2002.

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Medicine for Midlife

Motherhood A Reflection Toni Brayer, MD

They say the only time your children are really all yours is when they are in the womb. At the time of

birth, they begin their own life journey and you are there as a guide. For a few years you are guiding all the time, and their journey is mapped out by you. It doesn’t take long to realize that you can set the course, but the child will take her own path that has nothing to do with where you thought she was going.

Eighteen years go by in a flash.

You don’t even realize that Mommy and Me at Gymboree has ended. The wonderful spirituality of breast-feeding is over.

That first lost tooth led to others and then there were no more.

Those endless pageants and recitals just ended. You clutched your heart hoping he wouldn’t miss the fly ball, and then he began catching them all, and then there was no more Little League. The piano lessons faded into science projects and those faded into SAT practice. The weird music and clothes www.sfms.org

and text messaging that was “oh, so secret” just seemed to fade away and then . . . you’re alone with the memories. Our little ones are launched and all we can do is hope all of the stories, bedtime tuck-ins, advice, school project help, and prayers will be enough to sustain that sweet child into adulthood.

“The mother-child relationship is paradoxical and, in a sense, tragic. It requires the most intense love on the mother’s side, yet this very love must help the child grow away from the mother and to become fully independent.”—Erich Fromm At the end of the day, all we can do is give our best love to our children as they grow, and enjoy the love that returns to us.

Toni Brayer, MD, a longtime member and past president of the SFMS, has practiced internal medicine in the Bay Area for more than twenty years. She writes about everything health and beyond on her blog, www.everythinghealth.net. She is also a member of the San Francisco Medicine editorial board.

October 2011 San Francisco Medicine

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Medicine for Midlife

Group Prenatal Care A Community Health Center Offers a New Model for Care Sara Johnson, MD Thumbing through charts of the morning’s patients, I felt excited and a little apprehensive, unusual for a Friday morning in clinic.

Instead of coming in for individual appointments, my patients would all be here at once, for the first meeting of my CenteringPregnancy group. For these eight Spanish-speaking women in early pregnancy, all with similar due dates, prenatal care would consist of a series of ten twohour group visits.

They would have the same individual health assessments as in usual prenatal visits, but we would integrate these with group discussions and education on topics related to pregnancy, general health, and parenting.

Our clinic conference room had been rearranged to the order of the day, with plants demarcating a corner area for individual assessments, an area for vital signs and charting, a circle of chairs for discussion.

Another table was laid out with name tags and food, and there was music playing. It felt more like a meet-and-greet or party than a clinic. I even had a mild case of hostess anxiety.

This type of group prenatal care (CenteringPregnancy, Cheshire, Connecticut) has been implemented in more than 100 clinical practices in the United States and abroad since 1995. It shares the basic aims of traditional individual prenatal care for promoting maternal, child, and family health, with additional important benefits. Expectant mothers spend less time waiting and instead are able to connect with each other, forming a peer group that is a key resource for learning and support. With the group, providers have more time for shar16

San Francisco Medicine October 2011

ing information and getting to know their patients, and they don’t have to repeat the same information multiple times. The structure of the groups reflects the value of patient-centered care: patients assess and record their own vital signs; the provider provides an overall framework for discussion but is the facilitator of discussions, rather than the director. Problems— and solutions—emerge from the group; the provider stimulates discussion and fills in gaps in knowledge.

Research supports the efficacy of group prenatal care. A matched cohort study showed improvements in prematurity-related outcomes, with centering patients delivering infants with significantly greater birth weights and gestational ages.

In a randomized controlled trial, participants in group care had higher satisfaction with the care, greater prenatal knowledge and rates of attendance, and greater readiness for labor and for baby care compared to patients in the traditional model, with no differences in antenatal or delivery costs.

Evidence aside, for our practice this was a new model, and the departure presented a few challenges. I would be scaling back in my role as expert and relinquishing the control that it afforded my type-A physician personality. And the grand idea of creating a healthy community was a bit daunting. Would we really be able to provide a space where the tired waiting room expressions of my patients, many of whom are socially isolated as new immigrants, were replaced with looks of engagement and connection? This community was as at the heart of why we had embarked on the program, but I wasn’t sure how we would get there.

The World Health Organization defines health as “a state of complete mental, physical, and social well-being, and not merely the absence of disease or infirmity.” As physicians—as people—we may understand this intuitively, and this broad definition of health is part of the foundation of community medicine. But looking at the structure of medicine as a whole, and how services are allocated and delivered, it’s not always easy to see the connection between health and health care.

What we have is an extremely sophisticated disease management system.

In a fifteen-minute visit it’s hard to find room for the totality of the mental, physical, and social aspects of the patient, and the aim of a visit is usually is to establish the presence or absence of disease. Preventive efforts often take the form of a one-way flow of information from physician to patient: www.sfms.org

“Smoking increases your risk of abruption and preterm birth.”

“If you don’t lose weight you’re likely to develop diabetes.”

This information aims at changes in behavior that are crucial to prevention and health in the context of the twenty-firstcentury scourges of obesity, diabetes, and heart disease, but it won’t suffice. The health psychology literature from the last twenty years highlights an intuitive truth: Information alone does not change behavior. We now know that motivation, selfefficacy, and relevant skills are keys to behavior change. But these are elements that most physicians do not have the training—let alone the time—to develop.

Groups, on the other hand, can naturally promote health and behavior change. Peer pressure can discourage negative behaviors, and peers provide models for positive behavior that patients may be more inclined to follow than directives from a health care provider.

Also, participation in groups is directly related to mental and social well-being: Research confirms that membership in a group that meets regularly increases measures of happiness, satisfaction, and confidence.

By addressing these multiple dimensions of health—physical, mental, and social—and providing natural avenues for behavior change, care in a group offers a kind of congruence of health and health care that makes sense. This is especially true for reproductive-aged women, a segment of the popula-

tion whose life stage brings them into contact with the health care system at a time when they are largely disease-free. They are prime targets for prevention. Pregnant women in particular have a heightened motivation for health, and transient diseases of pregnancy reveal vulnerabilities, for example hypertension and diabetes, that can be managed through behavior change.

We must seize this tremendous opportunity for prevention by embracing a broad definition of health.

There are no fireworks, but as the centering group moves through its weeks, the nebulous notions about the power of the group take form in small gestures: A woman teaches the stretches we learned for back pain to her coworkers at the night shift of a chocolate packing factory. A patient who develops gestational diabetes shares her story and, in response, another expectant mother stops eating fast food, her weight gain normalizing. A story about a past experience with a member of the hospital staff prompts discussion of how to advocate for the care you need, whether by hitting the call button, asking for a translator, or filing a complaint. It’s a discussion I can’t imagine having in a one-on-one prenatal visit, but for this group it seems crucial. Many of the women decide to continue to meet after they deliver, in a walking group for new mothers.

The group has clicked, and my hostess anxiety has given way to an enjoyment unmatched in most of my clinical encounters. It’s true: The patients are their own best resources for their health, broadly defined. We just need to provide the space.

Sara Johnson, MD, is an obstetrician-gynecologist at La Clinica de la Raza in Oakland. She completed her residency at Kaiser Hospital in San Francisco.

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8/31/11 11:31 October 2011 San Francisco Medicine 17AM

Medicine for Midlife

Feelings of Loss Postpartum A Physician and Mother Reflects on the First Weeks Martina Scholtens, MD, CCFP

When Ilia was a few weeks old, Pete asked, and said it so casually from the couch where he was reading after dinner, “Do you miss our old life?”

What a relief to hear it said. I did. I missed the old routine, driving in to Vancouver in the mornings with four-year-old Ariana in the back seat, CBC on the radio, and a day at the clinic ahead of me. Yes, there will be a similar routine in a few months, with an infant in the car and a graduated return to work, but those other days, the particular way they were, are done.

“I guess you’ll never have another son-baby, hey, Mom?” asked my six-year-old son cheerfully as he ate his afterschool-snack the next week. I could have cried. I saved all my kids’ clothes in anticipation of this possible fourth, and now that she’s here I have boxes of corduroy pants, sneakers, little ball caps to set afloat. Somehow my daughters’ infancies seem preserved through Ilia wearing their hand-me-downs, but I can’t kid myself: My son’s baby days are over.

And then I overheard Ariana greeting her little sister.

“Good morning, Ilia,” she said seriously. “It’s your mediumsized sister.” Saskia’s still the oldest, and Leif’s still the only boy, but the crown of youngest child has been passed from Ariana to Ilia, by my choice. Then, after church an elderly woman tugged on my arm, admired the baby and confided, “Mothers have a very special relationship with their youngest daughter.” At that moment Ariana came into view: long dark pigtails, thin legs in purple boots making their way across the room to the gardens outside. There she was, the daughter with whom I would have had that extra-special relationship— except I’d taken that from us and given it to this newest baby.

Those first two months, I missed my bodies. The one before this last pregnancy. The one before I had ever been pregnant at all. The pregnant one, even, that at least looked 18 19

San Francisco Medicine October 2011

purposeful. A week post-partum, sitting at the breakfast table, Leif gestured at my paunch with his spoon and asked, “You know why that looks like that? Because all the equipment is still in there.”

Most of all, I’ve struggled with the temporary loss of my identity as physician. At the little good-bye party over cake in the chart room in February, I asked the clinic to please just stagnate until I returned. Of course they will forge ahead and do all sorts of interesting things while I’m away, and I hate to not be a part of it. Some of my patients requested six-month supplies of medications to tide them over until my return. I didn’t comply, but I understood. I’m grateful for my locum, but I’m jealous of her, too. I miss the collegiality of the clinic, the focus on others’ lives, the escape from my own head, the sense of contributing to the community, the academic stimulation.

I’m back to work in the fall, but in the meantime, I feel a little unmoored.

How I love this little face. I marvel that someone I couldn’t have imagined months ago could feel so inevitable, could have an entire family happily orbiting around her.

Don’t mistake this for ingratitude. It’s simply an acknowledgment that for this new mother, mixed in with the bliss of those first six to eight weeks, were feelings of loss and grief.

Surely I’m not the only one.

Dr. Scholtens recently returned to work as a family physician and medical coordinator at Bridge Refugee Clinic in Vancouver, BC, following a seven-month maternity leave for her fourth baby. She currently enjoys a blend of clinic days in the city and at-home days in the seaside village of Deep Cove. She also spends time teaching and writing. Dr. Scholtens feels privileged to have close views of people’s lives—as a physician and as a mother.

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Medicine for Midlife

Chronic Sorrow A Landscape of Parental Loss Nancy Iverson, MD “Imagine your heart being taken from your chest and opened up as if it were a pouch with a zipper on it. Take the insides out and set them on a concrete slab and blow it up with a stick of dynamite. Scrape up all the fragments you can find, put them back into the now empty heart, zip it up, put it back, and go on with your life. This is now the heart I must learn to live with.”—Jane Otell, Compassionate Friends, March/April 2009

One mother, who had joined our Living with Loss parents’ support group shortly after the death of her second son, shared this piece with the group just months after the death of her third son. I’d

known her through the group for years, had spent hours in the hospital with her, her husband, and their boy as he was dying, and was struck by her reading of Jane Otell’s compelling description. I found myself wondering if anyone can truly imagine the enormity of facing their child’s death. How would the devastation feel at first—with, say, the heartbreak of learning of a distressing diagnosis? And a second time—say, with a setback in chemotherapy—or a third time—perhaps discontinuing aggressive interventions—and then again— with the death of a child—and perhaps again—with another death of a child—and again—a birthday party that “should” have had one more guest, and the graduation ceremony that is one member short, and the family who will always be missing the groom or the bride for the wedding party.

In the gathering that night of parents who were anticipating or had lived through the deaths of their children, no one knew the author and no one among the group had experienced the exact same events, but all could resonate with the profound nature of the demands of their losses. In my years of pediatric practice, as a consultant with Comfort for Kids, and in facilitating this parents’ support group, I’ve learned there are as many story lines and ways of living with childhood illness and death as there are parents for whom these sagas have become their life narratives. In fact, I’ve learned there are more, as a parent’s perspective in the days to months after the death of a child may transform almost unrecognizably years and even decades later. Yet through these disparities I notice that universal threads appear.

Loss’s immediacy and sorrow’s relentlessness are key players in the unfolding story line. When a child is diagnosed with a life-threatening condition, grieving begins. Families seek to find their way through a bewildering maze of decisions, adjustments, and changes. A “new normal” develops, with ongoing challenges that are often confusing and overwhelming, and chronic sorrow emerges. Struggling to navigate at the intersection of grief and hope, parents tread www.sfms.org

through the shards of broken dreams and mourn new and continuing losses. Rumi’s poem “The Guest House” evokes the emotional landscape: This being human is a guest house Every morning a new arrival.

A joy, a depression, a meanness, some momentary awareness comes as an unexpected visitor.

Welcome and entertain them all!

Even if they are a crowd of sorrows, who violently sweep your house empty of its furniture.

—The Essential Rumi, version by Coleman Barks

The brutal “crowd of sorrows” that encroaches on a family navigating a child’s end of life is immense. With the first whisper of worry that a child’s life may end much sooner than imagined, a journey begins that continues on beyond diagnoses, interventions, memorial services, and regroupings—a journey that mandates traveling through terrifying terrain to an unnamable destination. It may seem that sorrow is the sole guest, the one who threatens to crowd out all others and stay forever.

What happens after a child dies? One mother refuses to ever speak her child’s name again, while another sets an extra place at the table for years. One father starts a second family as quickly as possible, while another retreats into professional life and virtually disappears from his family.

Parents often doubt that they themselves will survive as they grapple with navigating their transformation into a new—and nameless—identity. Dr. Sukie Miller writes, “When your husband dies, you become a widow. When your wife dies, a widower. Children who lose their parents are called orphans.

But we have no name for the parent who loses a child, nor for the brothers and sisters of a child who dies, nor for the others—aunts, uncles, cousins, grandparents, even the friends, contemporaries, and adults—who experience the loss of a child they love.” (From Finding Hope When a Child Dies: What Other Cultures Can Teach Us) Professionals, family members, friends, and caregivers, while longing to help ease the despair and suffering for grieving parents, may feel powerless. Theories and strategies don’t fit many of the situations we encounter; we fail to catalyze the outcomes we may have learned to identify as successful. We may even wonder if we are contributing to distress.

Understandings of chronic sorrow and shattered dreams

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October 2011 San Francisco Medicine

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Chronic Sorrow Continued from the previous page . . . can be helpful to parents and professionals who wonder if they will survive these experiences.

It is one thing to struggle with grieving; it is another to receive acknowledgment that chronic sorrow and shattered dreams are normative and to begin to reconfigure a healing journey.

We cannot prevent parents having to face the enormous crises they do, but by exploring ways to connect, share stories, cultivate resources, and sustain community, we can help guide parents through their challenges and ease their pain.

In 2000, the staff of Support for Families of Children with Disabilities asked me to run a workshop about grief and loss for parents. During the introductions in the first session, we all realized that no parent attending had had a child die— yet—but all had children with complex or life-limiting medical conditions and were no strangers to ongoing challenges and sorrows. That day those parents asked to start an ongoing support group, and Living with Loss has continued to meet since. Some parents discovered our group through a medical referral shortly after a child’s diagnosis, some through hospice recommendations, and some through the social worker with Support for Families of Children with Disabilities. Occasionally a conversation in a coffee shop or some other unlikely setting initiates the connection. No matter how parents find this group, where they are on the journey of their child’s illness and their grieving, and how long they participate (some for one or two sessions and some for years), they each have a home in this community.

Parents come together to hear and to share their stories, insights, and longings. They are able to relate their experiences in a way that helps others, and they describe their own sense of unburdening as they express their heartaches, triumphs, and frustrations with the group. Relief can be palpable as deadlines for completing the “stages of grief” are dismissed. Expectations for resuming former lives, hopes, and dreams are accepted as impossible, and parents offer solace and mourn together. As chronic sorrow commands its place in the circle, integrity and courage arise as well. Parents begin to find their way in the unfamiliar landscape and befriend old feelings in a new way. Carol Dolaghan, whose daughter Caitlin died at the age of nineteen, wrote this about joy: “Joy isn’t happiness. She isn’t everything going swimmingly. Joy comes from truth and hope and knowing you are loved. Joy wakes up early in the morning, goes outside and listens to the birds in the morning quiet, and then has the strength to go on and look into the face of tragedy and suffering.”

We can count on mothers and fathers to be a trustworthy resource when we explore ways to best serve parents in times of profound loss. As they teach and learn from one another, we may learn from them, too. As we witness them as they encounter despair, disappointment, and sorrow, we can cultivate our own capacity to patiently be present with raw pain at 20 San 21 SanFrancisco FranciscoMedicine Medicine October October2011 2011

the same time that we remain open to the seeds of hope and comfort. While we may never stop wishing that we could protect a family from a “crowd of sorrows,” we can develop and inspire the practice of meeting all the moments that life offers us with grace. We can return to Rumi’s “The Guest House” and encourage ourselves and the families we encounter to still treat each guest honorably.

He may be clearing you out for some new delight.

The dark thought, the shame, the malice, meet them at the door laughing, and invite them in.

Be grateful for whoever comes, because each has been sent as a guide from beyond.

Nancy Iverson, MD, is a pediatrician who works both in the San Francisco Bay Area and at the Pine Ridge Indian Reservation in her home state of South Dakota. She has served as a board member and as a member of the advisory committee of Support for Families of Children with Disabilities. She founded and facilitates the organization’s Living With Loss Support group for parents of children with life-threatening illnesses. She also developed a similar group at the Institute for Health and Healing at CPMC and was a pediatric consultant for Comfort for Kids, a Bay Area in-home pediatric palliative care and hospice organization. When she’s not taking care of families, she’s swimming in the San Francisco Bay. She was the first woman to participate in the eleven-mile Bay to Breakers Swim and has completed 130 Alcatraz swims, including four round-trips. She founded and directs PATHSTAR (www.pathstar.org) and is the producer/director of From the Badlands to Alcatraz, a documentary about this program.

www.sfms.org

Medicine for Midlife

The Evolution of ADHD Social Context Matters Dan Eisenberg, PhD, and Benjamin Campbell Attention-deficit hyperactivity disorder (ADHD) affects an estimated 8 percent of children (12 percent of boys) and 4.4 percent of adults in the U.S. ADHD has a large heritable component (around 70 percent), suggesting that genes play a role in its etiology and that it can be modified by natural selection.

Thus, ADHD’s high prevalence begs the question: Why hasn’t natural selection removed the genes that underlie ADHD from the human population? To begin to answer this question, and to better understand the phenomenon of ADHD, we must consider our current social environment, and the likely past environments that we have experienced over our evolutionary history, alongside genetic and molecular evidence.

We live in different social and ecological contexts than our ancestors. Widespread formal schooling and formal teaching are recent inventions of the past few hundred years. Before about 10,000 years ago, all humans were nomadic hunter-gatherers, without agriculture or domesticated animals. While our ancestors faced social pressures and needed to focus their attention to learn and practice complex foraging and hunting skills, the nature of the social and educational demands were qualitatively different from those we now face. While today we specialize in narrowly defined skills, hunter-gatherers were likely generalists, needing to acquire and practice a broad variety of subsistence and social skills.

From studies of modern hunter-gatherers, we can surmise that learning took place through play, observation, and informal instruction, rather than through the highly regimented classrooms almost all of us have experienced. It is no surprise that ADHD is usually diagnosed in children who have trouble focusing “properly” in school, and it continues to be a problem for adults when their work or lifestyle requires focusing in particular, regimented ways. There is good reason to believe that in our evolutionary past, ADHD was often not much of a problem and was perhaps even an asset.

Some intriguing evidence for this hypothesis comes from work on the genetics of ADHD. One gene associated with ADHD is called dopamine receptor D4 (DRD4), alleles of which change the sensitivity of a subtype of dopamine receptors that are expressed in the prefrontal cortex. ADHD is a complex trait (regulated by many genes), and the ADHD-associated allele in the DRD4 gene (called DRD4 7R) only accounts for a small portion of the cases of ADHD. Nonetheless, a variation of the DRD4 gene provides a window into the evolutionary forces that shaped our brain.

The 7R (ADHD-associated) allele of the DRD4 gene is peculiar in that it seems to have originated about 45,000 years ago and was then positively selected for. That is, the 7R allele www.sfms.org

conveyed some advantage to those who carried it—it increased their “fitness.” We can infer this based on patterns of “linkage disequilibrium” in the DRD4 gene. Linkage disequilibrium is a well-established technique in genetics that compares the rate of recombination (crossing over) that is expected to occur by chance with that which is actually observed. The deviation in DNA sequences in the population from chance expectations gives evidence about the nature of natural selection that occurred.

Based on these linkage disequilibrium patterns, we have good reason to believe that the DRD4 7R allele was selected for in past environments and therefore likely was evolutionarily advantageous. But the story gets more interesting. The frequency of the 7R allele varies dramatically across populations, from less than 1 percent in some populations to more than 70 percent in others.

In a study conducted by Chuansheng Chen and colleagues, many of these differences across groups were explained by aspects of the groups’ histories. Populations with longer histories of migrating tended to have a greater frequency of DRD4 7R alleles.

While we can’t be sure why the 7R allele is more prevalent in more migratory populations, it might be that people with behavioral traits related to ADHD were more likely to want to migrate away from their homes. Or perhaps people with this allele were better at adapting to the new environments they found themselves in once they did migrate. Entering an unfamiliar environment can be overwhelming, and it takes time to learn what is most critical to pay attention to. Perhaps those with what we would now recognize as ADHD were better able to adapt to these new environment by learning different methods of hunting and gathering or negotiating new social and/or cultural norms.

Additionally, Chen and colleagues reported that populations that currently practiced a nomadic lifestyle tend to have higher frequencies of the 7R (ADHD-associated) allele than sedentary populations. We have extended Chen’s work with evidence gathered from work with a group of pastoralists of Kenya known as the Ariaal. The Ariaal are traditionally herders of camels, cattle, sheep, and goats. They traditionally live in the desert and don’t stay in one place for long, because they must keep finding food and water for their herds. While many Ariaal continue to practice this traditional lifestyle, more recently a subgroup of Ariaal have become less nomadic, settling in one location. This settled group practices more agriculture, sells more goods on the market, and their children go to school.

We analyzed the DRD4 genotypes of about 150 adult Ariaal men, about half from the nomadic group and half from the settled group. Specifically, we looked to see if we could correlate the presence of the 7R allele with a measure of health (as determined by men being less underweight) of the Ariaal men. We found that

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October 2011 San Francisco Medicine

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Photo of Ariaal men by Peter Gray

The Evolution of ADHD Continued from the previous page . . . the nomadic men who had the 7R ADHD-associated allele were less underweight than the nomadic men who didn’t have the ADHD allele. But among the settled men, the reverse was true: The settled men with the ADHD-associated allele were slightly more underweight than the men without the ADHD allele.

These results are concordant with the previous findings associating DRD4 with migration patterns. Given the association of the DRD4 7R allele with ADHD more generally, these results suggest that there is something about the nomadic context that allows people with ADHD-like behaviors to be more successful in an evolutionary sense. Perhaps nomadic Ariaal with a more diffuse attention better scan their dynamic environments, noticing the status of their herd, the signs of water or food or raiders sneaking up. This different attention span might serve less well for settled Ariaal, who must focus on schooling, growing crops, and selling goods at market.

Altogether, there are multiple lines of evidence suggesting that the ADHD-associated allele of the DRD4 gene promotes behavioral/psychological traits that are helpful in some social and ecological contexts but detrimental in others. The direct clinical importance of these findings is limited. However, they should push us to consider the role of social context in ADHD in our own society. Are there areas in our society where children and adults with ADHD might better use their traits?

There is good reason to believe that ADHD in children is primarily a problem of not being able to adjust to the demands of school. In our society, schooling is compulsory, generally dictates to children how they should learn, and employs an essentially uniform pedagogical approach—no matter the varied circumstances of the children. Although formal studies are lacking, there is good anecdotal evidence, compiled by psychologist Peter Gray, that children who are given more freedom to direct their own education and lives no longer need ADHD medications, can 22 23

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better use their behaviors/psychology as an asset, and are able to lead more productive and healthy lives. This is not to say that ADHD medications don’t have a valuable role to play. However, it would probably be better to view such medications not as a cure for a disease but as a stop-gap measure to help a person cope with the demands of a society we should be working to make more inclusive.

It is interesting to note that the adult incidence of ADHD is about half that of children. As adults, we generally have more freedom than children to choose roles that fit our strengths and to use medications strategically. Such freedom allows adults with ADHD to select jobs where they are not disabled by their different attention patterns. In fact, adults may be able to find niches where their ADHD is a clear benefit. Individuals with ADHD have been described as paying attention to what is interesting rather than what is “important.” But what is “important” is often a reflection of particular social values. In some fields, like the arts or sciences, what is interesting is what is important. If individuals with ADHD can sustain their attention by paying attention to what is interesting, their often tremendous energy can lead to productive careers in these creative fields.

Children and adults with ADHD are often made to believe that their ADHD is strictly a disability. Instead of understanding that their ADHD can be a strength, they are often given the message that it is a flaw that must be solved through medication.

We hope that increased attention to social context and understanding of our evolutionary legacies will help those with ADHD pursue their interests in a way that is more productive for themselves and for society.

Dan Eisenberg is a PhD candidate in biological anthropology at Northwestern University. His research focuses on using evolutionary biology and cross-cultural comparisons to better understand human health, disease, and behavior. He does fieldwork in the Bolivian Amazon. His current primary research focus is on telomere biology and the evolution of aging. Eisenberg’s CV and publications can be found at http://www.dtae.net.

Benjamin Campbell is associate professor of anthropology at University of Wisconsin-Milwaukee. He has been studying pastoral nomads in East Africa for fifteen years. More recently he has begun to focus on neuroanthropology, the study of the brain as both producer and product of culture. His specific research interests include embodiment and ritual as well as the role of the dopaminergic reward system in human brain evolution.

Further Reading Eisenberg DTA, Campbell B, Gray PB, Sorenson MD. Dopamine receptor genetic polymorphisms and body composition in undernourished pastoralists: An exploration of nutrition indices among nomadic and recently settled Ariaal men of northern Kenya. BMC Evolutionary Biology. 2008; 8(173). http://www. biomedcentral.com/1471-2148/8/173/abstract. http://evolution.binghamton.edu/evos/seminars/fall2009/ogray/. http://www.psychologytoday.com/blog/freedomlearn/201009/experiences-adhd-labeled-kids-who-switch-conventional-schooling-homeschool. www.sfms.org

Medicine for Midlife

The Gluten-Free Diet Craze Shortfalls of a Restriction Diet Peter J. Curran, MD “In the matter of diet I have been persistently strict in sticking to the things which didn’t agree with me until one or the other of us got the best of it.”—Mark Twain

Novak Djokovic’s advantage goes beyond his 57-2 tennis record and two grand-slam victories leading up to the U.S. Open this year. He also has adhered

to a gluten-free diet since his nutritionist tested him for the allergy last year. Besides all that winning, he claims that he has more energy and has lost some extra weight. One thing the diet could not do was save him recently from a shoulder injury in Cincinnati that forced him to retire in the finals against Andy Murray.

Gluten allergy in its most severe form, celiac disease, has been around for centuries. It manifests as an autoimmune disease causing diarrhea, anemia, and osteoporosis; it’s triggered by dietary gluten peptides generally found in wheat, barley, and rye. The British pediatrician Samuel Gee recognized that children with celiac disease had an intolerance to milk and starchy foods. One of his patients seemed to respond well to a diet consisting of a daily quart of Dutch mussels, which the child tolerated for exactly “one season.”(1) Another British physician, John Paulley, made the connection between the disease and changes to the intestinal lining due to the protein gluten. The discovery of gluten-induced autoimmune disease made celiac disease treatable by dietary restriction in affected children, and it is believed to have significantly reduced the mortality rate in children.

Celiac disease affects approximately three million people in the United States. Although the prevalence of the disease has increased somewhat, the current gluten-free diet craze and estimated $1.7 billion related industry are driven by a much larger population that is believed to suffer from gluten sensitivity or gluten intolerance. A potential screening test measures serology titers of antibodies to anti-transglutaminase (ATA or anti-tTG) with 3 percent of primary care patients with typical gastroenterology complaints thought to have high titers of anti-tTG. However, other conditions, such as diabetes, irritable bowel syndrome, and arthritis, are associated with elevated titers of the antibodies, and there is little evidence that finding cases by screening results in improved morbidity or mortality. In fact, one study in Cambridge suggested improved cardiovascular mortality in patients with celiac disease.(2) General-population screening is not recommended.

Beyond the athlete, other celebrities have taken up the cause touting the dangers of gluten. Jenny McCarthy’s wellpublicized crusade against childhood vaccines had a controversial angle related to the treatment of autistic children with www.sfms.org

a gluten-free diet. It’s hard to argue against a parent’s attempt to find solutions for a disorder as difficult and mysterious as autism. McCarthy generated criticism with her views because of the ways that vaccine avoidance and dietary restriction may affect the health of the general population.

A problem with the popular gluten-free diet may be an incorrect concept of dieting. The definition of diet is the deliberate selection of food to control body weight or nutrition intake. William Banting, a nineteenth-century English undertaker who is credited with being the father of dieting, wrote a booklet entitled Letter on Corpulence Addressed to the Public, receiving his inspiration on food selection from Dr. William Harvey, who treated diabetics with what was essentially a low-carbohydrate diet. Banting initiated his new diet at age 65, when he weighed 202 pounds at a height of 5’5’’. He lost about 60 pounds and lived another sixteen years, enjoying four meals a day with meat and wine—hardly a sacrifice compared to foods available to the wealthy of that time. Perhaps what made Banting’s diet so successful, and kept his booklet in print for a long time, was the sustainability of the diet compared with the habits of society.

Another way of looking at food selection is through Charles Darwin’s idea of evolution.

His famous theory of natural selection or survival of the fittest essentially eliminates the outliers on both ends and moves toward the mean.

It does not imply that there will not be outliers; the Djokovics in society will follow a restriction diet such as gluten-free and continue to defeat their opponents. The celiac patient, by default of diet or death, will benefit from the gluten-free restriction diet. But unless fast food becomes an accepted health diet, any fad diet is counter to the Darwinian principle of society’s evolution toward the mean for sustainability. Society dictates that we eat what is readily available to us. Public health policy must change before food selection (or diet) will change in a sustainable way.

This concept of societal evolution allowed the Dutch pediatrician Dr. Willem Karel Dicke, working in the 1940s, to discover the link between wheat and celiac disease.(3) During the Dutch famine of 1944, his patients’ conditions improved during the scarcity of flour and became worse again when the famine ended. It took a famine to restrict wheat from the general population, which will gravitate to the mean and eat

Continued on page 25 . . .

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Medicine for Midlife

Simplify Your Diet Promoting the Anti-Inflammatory Mediterranean Diet Carol Ceresa, MHSL, RD As physician, you are aware of the strong role of nutrition in both health and illness. Your patients

look to you for guidance in healthy living and often have questions about the abundant and sometimes questionable nutrition information found both on the Internet and in newspapers and magazines. More and more, research supports what our grandmothers already knew—foods can both protect and help reduce risk for many common medical conditions, including excessive weight, cardiovascular disease, cancer, memory/cognition, and even pain. One of the most important verbal interactions with your patient can be to discuss simple ways to eat delicious and healthful food, for maximum good health impact.

Eating a Mediterranean-type diet has already been linked to lower risk of mortality, cardiovascular disease, and Alzheimer’s disease, and recently this eating style has been shown to reduce risk of disability. At the same time, Americans are eating far fewer fruits and vegetables than recommended. According to the CDC’s 2009 Behavioral Risk Factor Surveillance System, in California only 27.7 percent of adults consumed fruit five or more times a day, and 71.3 percent are overweight or obese (35.8 percent overweight, BMI 25.0-29.9; 25.5 percent obese, BMI 30.0+). Distilling healthy eating advice into a few words can be a challenge.

The good news is that the Mediterranean style diet can be a visually beautiful, delicious way to eat for health. It is rich in antioxidants, omega-3 fatty acids, and highly beneficial phytochemicals (plant substances responsible for the colors, textures, smells, and taste) that protect beyond vitamins and minerals. The emphasis on whole grains, vegetables, fruits, nuts and olive oil, and fish promotes a healthy weight (decrease in body mass index), decreases blood pressure, decreases blood leukocyte count, and increases high-density lipoprotein levels and baseline brachial artery diameter. Additionally, omega-3 fatty acids (found in fish oils, flaxseed, and walnuts) have been associated with improved brain health and aging.

Spices have received more recent attention for protective, healing properties. Research shows that curcumin may help treat a range of health problems, including heart disease, Alzheimer’s disease, arthritis, prostate problems, inflammatory bowel disease, and various cancers. Dr. Bharat Aggarwal, professor of the Department of Experimental Therapeutics at the University of Texas M.D. Anderson Cancer Center, is looking at the powerful molecular and biochemical effect of many spices, especially curcumin, the active ingredient of turmeric.

Curcumin is a powerful antioxidant that has been shown to be effective in reducing inflammation and pain, as well as acting as an anticancer agent (inhibiting the activation of genes that trigger cancer, inhibiting the proliferation of tumor cells, inhibiting 24 25

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the transformation of a normal cell into cancer, shrinking tumor cells, enhancing the cancer-destroying effects of chemotherapy and radiation). Researchers have also found that curcumin has the strength to inhibit the toxicity of polycyclic aromatic hydrocarbons (PAHs), cancer-causing chemicals in the environment; that it inhibits damage caused by ionizing radiation, such as radiation from the sun, X-rays, and other medical tests; and that it prevents the formation of suspected cancer-causing compounds found in processed and cured foods. (For example, PAHs form on meat, poultry, and fish when they are grilled or fried at temperatures exceeding 352 degrees.)

How does this science translate into food advice? Refer to your local nutrition expert, the RD or registered dietitian, for more details about a healthy diet and for your patient who needs medical nutrition therapy for chronic or acute disease/ medical conditions that are affected by diet.

All medical insurances, including Medicare and Medicaid as well as private insurances, cover nutrition therapy when referred by a physician as an intervention for a specific medical diagnosis.

Foods in the Mediterranean Diet Fish 2-3 or servings/week (1 serv = 4 ounces), salmon, sardines, mackerel, anchovies, tuna, mussels, cod, talapia. Good protein, rich in omega-3 anti-inflammatory fatty acids.

Other Protein Poultry, lean meat, reduced or nonfat yogurt, milk, eggs (0-4/week), 2-3 times/week. 1 serv = 3 ounces, skinless chicken, turkey. Daily/weekly: source of calcium, vit D, beneficial bacteria for gut.

Whole Grains 3-5 servings/day (1 serv = ½ cup cooked), brown rice, quinoa, barley, steel-cut oats, buckwheat, whole grain pasta, bulgur, coarse polenta.

Vegetables 4-5 servings/day (1 serv = 1 cup raw or ½ cup cooked), dark leafy greens, cruciferous vegetables (broccoli, cabbage, Brussels sprouts, kale, bok choy, cauliflower), winter squash, onions, peas. www.sfms.org

Legumes Dried beans, 1-2 servings/day (1 serv = ½ cup cooked)— use in place of meat, edamame, black beans, chickpeas, red beans, white beans, split peas, lentils.

Fruits 3-4 servings/day, 1 serv = 1 med-size fresh fruit, ½ cup chopped fruit or juice, or ¼ cup dried fruit. Berries, pomegranate juice, apples, cherries, pears, melon, grapes (fruits in season).

Nuts and Seeds Walnuts, almonds, flaxseeds, pumpkin seeds, pine nuts, pistachios. Add to salads, use as snacks. Flaxseed and walnuts are rich in omega-3 fatty acids.

Healthy Fats Olive oil, grapeseed oil, avocado, flaxseed, walnut oil. 2 Tbsp/day. Use for in place of butter or margarine; use in salad dressing, as an ingredient in recipes.

Spices Turmeric, cinnamon, oregano, cumin, black pepper, basil, rosemary, ginger, paprika, fennel seeds. 1 tsp/day. Vegetable curries, add to soups, use in salad dressings.

Others Antiaging, antioxidant, and resveratrol-rich foods/beverages, red grapes, red wine, pomegranate juice, blueberries, peanuts, cocoa. Choose chocolate that is >60% cacao.

Carol Ceresa, MHSL, RD, is the clinical nutrition section chief for the San Francisco VA Medical Center.

The Gluten-Free Diet Craze Continued from page 23 . . . wheat when it becomes readily available. This idea is contrary to contemporary preventative screening: testing the whole population to find outliers (subjects with disease). Is it any wonder that several of our sacred screening tests, such as prostate-specific antigen and mammography, have come under scrutiny? Or why is it that physicians continue to universally test cholesterol despite the fact that most heart attack patients have average cholesterol? An attempt to follow a restriction diet will likely have the success of a New Year’s resolution; it probably won’t hurt you, but, more importantly, it won’t succeed. Gravitating toward the mean is sustainability.

Dr. Pete Curran is a physician in private practice in San Francisco and president-elect of the San Francisco Medical Society.

References Gee SJ. On the coeliac affection. St. Bartholomew’s Hospital Report. 1888; 24:17-20. http://web2.bium.univ-paris5.fr/ livanc/?cote=epo0466&p=1&do=page.

Van Heel D, West J. Recent advances in coeliac disease.

Gut. 2006; 55(7):1037-46.

Dicke WK. Coeliakie: Een onderzoek naar de nadelige invloed van sommige graansoorten op de lijder aan coeliakie (PhD thesis in Dutch). Utrecht, the Netherlands: University of Utrecht.

Tracy Zweig Associates INC.

Recommended Reading Nutrition Guide for Clinicians, Second Edition, Physicians Committee for Responsible Medicine, www.pcrm.org, pcrm@ pcrm.org. No charge when ordered for training residents, medical students. http:/ aaps.nccd.cdc.gov.

• www.ChooseMyPlate.gov, for the basics.

• Healing Spices, Bharat B. Aggarwal, PhD, and Debora Yost. Sterling Publishing, Inc. 2011.

• What Color Is Your Diet? David Heber, MD, PHD, with Susan Bowerman, MS, RD. HarperCollins Publishers, 2002.

• The Mediterranean Prescription, Angelo Acquista, MD, with Laurie Anne Vandermolen. Ballantine Books, 2006.

• A Recipe for Life by the Doctor’s Dietitian, Susan Dopart, MS, RD, with Jeffrey M. Batchelor. SGJ Publishing, 2009.

• The New American Plate Cookbook, American Institute for Cancer Research, 2005.

See a full list of references at www. sfms.org/archives. www.sfms.org

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tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m October 2011 San Francisco Medicine

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Medicine for Midlife

The “Million Hearts” Initiative Preventing Heart Attacks and Strokes Thomas R. Frieden, MD, MPH, and Donald M. Berwick, MD, MPP Each year, more than 2 million Americans have a heart attack or stroke, and more than 800,000 of them die. Cardiovascular disease is the leading cause of

death in the United States and the largest cause of lower life expectancy among blacks. Related medical costs and productivity losses approach $450 billion annually, and inflationadjusted direct medical costs are projected to triple over the next two decades if present trends continue.1 To reduce this burden, the Department of Health and Human Services (DHHS); other federal, state, and local government agencies; and a broad range of private-sector partners are today launching a “Million Hearts” initiative to prevent 1 million heart attacks and strokes over the next five years by implementing proven, effective, inexpensive interventions.

Cardiovascular prevention works in two realms: the clinic and the community. Clinical and community interventions each contributed about equally to the 50-percent reduction in U.S. mortality due to heart attacks between 1980 and 2000.2 If used consistently, proven interventions could prevent more than half of heart attacks and strokes. It’s time to take the next big step.

In the clinical realm, Million Hearts will improve management of the “ABCS”—aspirin for high-risk patients, bloodpressure control, cholesterol management, and smoking cessation. As for community-based prevention, the initiative will encourage efforts to reduce smoking, improve nutrition, and reduce blood pressure. It will implement the cardiovascular disease prevention priorities of the National Quality and National Prevention Strategies and help meet targets set

by Healthy People 2020.

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Improving management of the ABCS can prevent more deaths than other clinical preventive services.3 Patients reduce their risk of heart attack or stroke by taking aspirin as appropriate. Treating high blood pressure and high cholesterol substantially and quickly reduces mortality among highrisk patients. Even brief smoking-cessation advice from clinicians doubles the likelihood of a successful quit attempt, and the use of medications increases quit rates further.

Currently, less than half of people with ischemic heart disease take daily aspirin or another antiplatelet agent; less than half with hypertension have it adequately controlled; only a third with hyperlipidemia have adequate treatment; and less than a quarter of smokers who try to quit get counseling or medications. As a result, more than 100 million people—half of American adults—smoke or have uncontrolled high blood pressure or cholesterol; many have more than one of these cardiovascular risk factors. Increasing use of these simple interventions could save more than 100,000 lives a year.3 Measuring and monitoring can encourage providers to improve preventive care.4 Improving care is particularly critical in light of increases in the prevalence of obesity and diabetes. Obesity and physical activity are currently being addressed by complementary efforts designed to improve understanding, implement pilot or community-based programs, and evaluate outcomes. The First Lady’s “Let’s Move” campaign is a comprehensive initiative with the goal of ending childhood obesity—a precursor to cardiovascular disease—within a generation by fostering environments that support increased physical activity and improved nutrition for children and families. And public and private partners are working to expand the Diabetes Prevention Program, which promotes weight loss, improved nutrition, and increased physical activity among people at highest risk.

The Affordable Care Act (ACA) provides a strong foundation for Million Hearts by increasing coverage and facilitating improved care. It waives patient cost sharing for preventive services, including blood-pressure and cholesterol screening and smokingcessation counseling and treatment, for enrollees in new private insurance plans. The new annual wellness visit for Medicare beneficiaries will help physicians focus www.sfms.org

on reducing cardiovascular risk and target interventions appropriately. Eliminating Medicare’s “doughnut hole” in prescription-drug coverage will increase access to cholesterol-lowering, smoking-cessation, and blood pressure medications. Covering 32 million currently uninsured Americans will reduce financial barriers to preventive care, and expanding community health centers will increase access to care and reduce health disparities. In addition, electronic health records (EHRs) will support improved clinical decision making.

Additional means of increasing control of the ABCS include reducing or eliminating co-payments for medications, once-a-day dosing, team-based care approaches, stepwise care management, and new forms of payment and delivery for higher-quality, higher-value, and coordinated care, such as those envisioned for accountable care organizations.

Expanding use of prevention-oriented EHRs will enable providers and health systems to track and improve management of the ABCS. Incorporating core ABCS-related quality measures and decision-support tools into the 2013–2014 criteria for “meaningful use” of information technology and providing technical assistance through quality-improvement organizations in all states, the sixty-two Health Information Technology Regional Extension Centers (which reach nearly 100,000 primary care doctors) and Beacon Communities will reach more than 100 million patients within the next few years.

Million Hearts will work to standardize core ABCS indicators across medical practices, insurers, institutional providers, and systems in public and nonpublic settings. Standardization will facilitate public reporting and identification and diffusion of best practices and will reduce providers’ burden by streamlining quality measurement and improvement. The initiative will be linked to quality-recognition programs (e.g., the Physician Quality Reporting System and star ratings for Medicare Part D and Medicare Advantage plans) and may eventually support approaches in which providers are paid more for better preventive care.

Community-based prevention works by facilitating healthy choices. Important community-based prevention initiatives include those funded by the American Recovery and Reinvestment Act’s Communities Putting Prevention to Work program and programs supported by the ACA’s Prevention and Public Health Fund, including Community Transformation Grants; initiatives for tobacco control and chronic-disease prevention and control; many National Prevention Strategy initiatives; and state and local actions addressing tobacco use, nutrition, and the linkage between clinical and communitybased prevention.

Reductions in smoking, sodium consumption, and trans fat consumption can substantially and rapidly improve cardiovascular health. Warning people about the harms of tobacco use through mass media and other measures, as well as www.sfms.org

package labeling as enabled by the Family Smoking Prevention and Tobacco Control Act and creating smoke-free public places and workplaces as detailed in the National Prevention Strategy and facilitated through ACA-funded community grants, should further reduce smoking rates by discouraging smoking initiation and encouraging cessation.

Reducing sodium intake, another key National Prevention Strategy intervention, reduces risks of hypertension and cardiovascular disease. Because most dietary sodium comes from processed and restaurant foods, it’s difficult for Americans to limit their sodium consumption. Procurement guidelines from the DHHS and the General Services Administration and proposed school-food standards from the Department of Agriculture include a focus on sodium reduction. Menu-labeling requirements in chain restaurants will help people make more informed choices. The Centers for Disease Control and Prevention (CDC) is increasing public and professional education regarding sodium, and the CDC’s National Health and Nutrition Examination Survey (NHANES) will begin collecting information on sodium consumption.

Consumption of artificial trans fat increases the risk of cardiovascular disease by raising low-density lipoprotein (LDL) cholesterol levels and lowering high-density lipoprotein (HDL) cholesterol levels. Replacing artificial trans fat with heart-healthy oils is feasible and does not increase the cost or change the flavor or texture of foods. Since the Food and Drug Administration began requiring listing of trans fat content on food labels, the industry has voluntarily reformulated foods, and according to CDC data, Americans’ trans fat consumption has decreased by at least half. Elimination of such consumption could prevent 50,000 deaths per year.5 Million Hearts will leverage, focus, and align existing investments and generally not require new public spending.

Voluntary initiatives will simplify, harmonize, and automate clinicians’ reporting requirements; decrease administrative burden; improve the quality of prevention and care; and inform the public more fully. Improvements in control of the ABCS, nutrition, and smoking are projected to prevent more than a million heart attacks and strokes over the initiative’s first five years. By focusing our initial efforts where they will save the most lives, we aim to make progress toward a health system that will serve Americans’ needs in the twenty-first century.

Thomas R. Frieden, MD, MPH, is director of the Center for Disease Control and Prevention (CDC). Donald M. Berwick, MD, MPP, is the administrator of the Centers for Medicare and Medicaid Services (CMS). This article originally appeared in the New England Journal of Medicine. It has been reprinted here with permission. Disclosure forms provided by the authors and the full list of references are available with the full text of this article at NEJM.org.

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Public Health Update Shannon Smith-Bernardin, RN, MSN, CNL, and Michelle Schneidermann, MD

San Francisco Sobering Center Providing care to the acutely intoxicated is a challenging endeavor. Working with those commonly labeled “chronic inebriate” can be even more demanding. This population overuses emergency services and their care is costly and fragmented. Additionally, their health outcomes are much worse than those of the general population.

History In 2003, after examining the impact of chronic inebriates on both public resources and individual health, the San Francisco Department of Public Health partnered with the nonprofit Community Awareness and Treatment Services (CATS) to design a pilot program addressing the needs of persons found intoxicated in public. The McMillan Stabilization Program, now known as the Sobering Center, engaged clients with alcohol dependence with the objectives to decrease the number of alcohol-only related admissions to the emergency department, decrease the number of alcohol-only related ambulance transports, and increase the health and well-being of chronic inebriates.

Target Population

The Sobering Center receives intoxicated clients from the streets and emergency departments by ambulance, police, and MAP (Mobile Assistance Patrol, a division of CATS) van services.

Clients who self-present cannot be accommodated at this time and are referred to a program or drop-in center for assistance.

Clinical Practice

Following comprehensive nursing protocols, clients are assessed by registered nurses and medical assistants upon intake and monitored throughout their stays for any medical or psychiatric complications. Nurse practitioners and physician’s assistants from the adjacent Medical Respite program complement clinical services by providing urgent care and detoxification referrals. If a client is too acute for sobering services, the nurses will coordinate transfer to an emergency department for further evaluation. Throughout the client’s stay, which is typically six to eight hours, staff endeavors to engage the client in discussion regarding their health and well-being, focusing on alcohol use, housing status, and acute medical needs. Prior to discharge, clients are offered referrals to detoxification services, treatment programs, and case management.

Impact

The numbers of those using sobering services has been substantial. Since opening, the Sobering Center has provided sobering services to more than 7,500 individual clients, with 26,000 total encounters. Ranging from 900 to 1,600 distinct clients for more than 3,000 encounters annually, nearly 80 percent of these clients have had one to two encounters during the eight years

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that the program has been operating. Meanwhile, the top 5 percent of clients have greater than ten visits, with a smaller number using services more than 100 times. Significantly, more than 80 percent have a history of homelessness.

Currently, over 40 percent of client encounters are referred via ambulance, diverting ER admissions, with an additional 35 to 40 percent from the street via MAP van. More than 1,500 encounters—approximately 6 percent—have transferred from emergency departments. Police, clinics, case management programs, and street outreach refer 10 percent of total client encounters. A majority of clients—nearly 90 percent—safely sober and discharge to either self-care or a substance abuse facility. To date, the percentage of clients requiring a higher level of care—with referrals to medical or psychiatric emergency departments—remains at 4 percent overall. Clients referred from EMS or ER bounce back to the ER at a rate of less than 3 percent annually. To date, there have been two deaths out of 26,000 total encounters in eight years.

Conclusion

By focusing on those with chronic public intoxication and offering a refuge from the streets, the Sobering Center has been able to form ongoing relationships with frequent users. Engendering trust, in the best of cases, leads to decreased alcohol use or abstinence. The need is still great, and the Sobering Center continues to assist hundreds of clients monthly. Recent studies (Katcher et al; Lewin Group) indicate that alcohol has a substantially negative impact on health in San Francisco. Ten of the seventeen leading causes of preventable mortality are related to alcohol, and up to 10 percent of premature mortality is due to alcohol. Additionally, a review of San Francisco’s 2006–2008 indicator for age-adjusted emergency room visits due to acute or chronic alcohol abuse demonstrated a rate of 43.1/10,000 population—far above the goal of 21.3/10,000 (Health Communities Institute). Work is ongoing to develop solutions for long-term chronic inebriation and, until then, the Sobering Center will continue to provide an alternative to emergency care.

Michelle Schneidermann, MD, is a UCSF associate clinical professor of medicine in the Division of Hospital Medicine at SFGH. She is also the medical director for the San Francisco Medical Respite and Sobering Center. Shannon Smith-Bernardin, RN, MSN, CLR, is a registered nurse with the SFDPH and is the coordinator of the SF Sobering Center and Intake Coordinator of the Medical Respite Program. www.sfms.org

CALPAC Update Richard Thorp, MD

CALPAC Is Fighting for You! As chair of CALPAC (California Medical Association Political Action Committee), I want to give you an update on how CALPAC has been fighting for you in the political arena.

CALPAC supports candidates and elected officials who are friendly to the House of Medicine.

There have already been four special elections throughout the state this year:

Assembly District 4 (North of Sacramento)

CALPAC supported Beth Gaines, a Republican businesswoman from Roseville. Gaines handily won the election over Democrat Dennis Campanale.

Senate District 17 (Antelope Valley)

CALPAC supported former Assembly Member Sharon Runner, a Republican businesswoman from Antelope Valley.

Runner also handily won the election over Darren Parker.

Senate District 28 (Los Angeles)

CALPAC supported former Democratic Assembly Member Ted Lieu. Lieu defeated Republican James Thompson and moved to the upper house.

Congressional District 36 (Los Angeles)

CALPAC was instrumental in AMA’s Political Action Committee supporting Democratic Los Angeles Council Member Janice Hahn. Hahn defeated Republican Craig Huey in the high-profile race.

I can say that these members will now be strong advocates on our behalf.

Despite our successes, we still face many challenges. Trial attorneys have already started a fight to overturn MICRA, California’s landmark Medical Injury Compensation Reform Act; there are ongoing efforts to erode the prohibition on the corporate practice of medicine; and there are continuous efforts to challenge your scope of practice. Your support is needed to build on our successes and ensure that we have the necessary resources to prepare for the 2011–2012 election cycle.

These elections are going to be transformational for the California Legislative. The Citizen’s Redistricting Commission has finalized congressional, state senate, state assembly, and Board of Equalization districts. The perceptions of the commission’s decisions, good and bad, are likely to shape a national trend. These newly drawn districts, coupled with California’s open primary system, will result in a number of contentious races. CALPAC has extensively studied the new districts and is www.sfms.org

preparing for these high-profile races on your behalf.

The bottom line is this: We must be stronger than ever to defend against increased challenges to physicians, both in the legislature and in the upcoming elections.

That is why I am asking for your support. I have believed for some time that donating to CALPAC is one of the most important contributions that I make, because it ensures that medicine has direct access to the policy makers who have the potential to come between me and my patients. Personally, I have been a President’s Circle member for nine years by donating $1,000 every year.

By making a contribution today, you will ensure that we continue to have the most active political affairs operation in California. 2012 is going to be a challenging year with many more high-profile elections for us to be involved in than ever before.

Please visit www.calpac.org to donate today!

I look forward to working with all of you on behalf of our patients and our profession.

Richard Thorp, MD, is chair of the CALPAC.

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Evaluate, diagnose, and treat student patients with a broad range of primary care problems, injuries, or illnesses, including medical, psychological, and gynecological conditions. Provide specialized treatment to SFSU student athletes and act as sports team physician. Full position description is at: http://www.sfsu.edu/~hrwww/Employment_HRMS/employment/jobs.html. This position is a full-time, benefited position. For further information, please call Juliet Olson at (415) 338-2313 or write to Juliet_@sfsu.edu. SF State is Equal Opportunity/Americans with Disabilities Act employer and has a strong commitment to the principles of diversity. EEO/ADA October 2011 San Francisco Medicine

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SFMS Health Policy Report Stephen Follansbee, MD, and Steve Heilig, MPH

Medical and Public Health Policy Making for California and Beyond The California Medical Association can be a formidable force in Sacramento health policy making. The CMA House of Delegations meeting, scheduled for October this year, is an opportunity for physicians to guide the CMA on important issues and set the priority for these efforts.

Your elected SFMS delegates have introduced a roster of policy resolutions for debate at the meeting. As your representatives, we thought you might like to see what we will be addressing— along with the many other resolutions introduced from other delegations throughout the state. The SFMS is a relatively small but relatively “loud” presence each year, with a good track record of successful policies; here is our list. Next month we will have a scorecard on what we were able to get adopted, and then the real work will begin in the halls of politics, translating these words into something that benefits patients, the public, and physicians all over our state—and beyond, as some of these would then be referred on to the AMA.

SFMS Proposed Policies for 2011 (Authors in Parenthesis)

Reduction of Subsidies of Tobacco in Films (Fung)

Did you know that the movie industry gets big tax credits for filming, including when they portray tobacco use? UCSF researchers have shown this is true—that taxpayers subsidize tobacco marketing, in effect—and we hope to stop that.

Unethical Rebates from Pharmaceutical Companies (Susens) Some drug makers still offer money to doctors who

with unwarranted cost and safety implications; we hope to stop that.

Healthy Food Marketing for Children (Desai, Schickedanz, Udovic-Constant ) The obesity epidemic too often starts in childhood, and better “selling” of healthy food is indicated; this would encourage that on various fronts.

Opposing Legal Prohibition of Circumcision (Tabas)

This intrusion was blocked from the state ballot but will likely be back, and we want the CMA and AMA on record in opposition for next time.

Firearms and Censorship (Follansbee) Another intrusion, courtesy of the gun lobby, prohibits Florida physicians from even talking with patients about the risk of guns in the home. We hope to stop this there and before it spreads.

Contraception as a Fully Covered Health Insurance Benefit (Silverman, Desai, Myers) This has now been adopted as

national policy, but attempts to overturn it are already promised. We want the CMA and AMA on record in support of full coverage.

Increasing Organ Donation via Presumed Consent

(Follansbee/Margolin) The waiting lines for organs get longer, and more people die while waiting. It is time for some changes in organ policy, and we are asking the CMA to weigh in, based on evidence, ethics, and the examples of some other nations.

Clinical Sense and Costs at the FDA; Generic v. Brand Medications (Susens) When a generic medication mysteriously

prescribe their products. Some doctors take that money. This is against ethical codes, and we hope to stop that.

goes back to “brand” and the price skyrockets, that seems wrong, and we think the FDA should take a closer look.

(Lopato) As reported in the San Francisco Chronicle, certain “clinics”

Too much pediatric poor vision is missed, and schools may be a good place to screen for that and refer to early intervention.

Deceptive Pregnancy “Crisis/Counseling” Centers

are in fact “pro-life” centers that use misinformation and fear tactics to divert women from considering abortion. We would require full disclosure of what is and is not offered at such places.

Regulation of Electronic Cigarettes (Fouras, Aragon)

These nicotine delivery devices may have their place as harm reduction, but they need more regulation for both users and the public, and this resolution would require that.

Supporting the California Cancer Research Act

(Margolin) The CCRA will be on the ballot, increasing tobacco taxes

for cancer research, and we ask the CMA to join the full-court press to help it pass in this “no new taxes” era.

Clinical Research: Banning “Seeding” and Similar Marketing Trials (Susens) Pharmaceutical companies do mar-

keting in the guise of “research” even after the medication is approved, 30 San 31 SanFrancisco FranciscoMedicine Medicine October October2011 2011

Vision Screening for School-Aged Children (Leung) Emergency Department Overcrowding

(Maa/Curran) When emergency departments get too crowded, some hospitals have “triaged” based on financial considerations. That’s not good; there must be better ways, and we’ll ask the CMA to try to find them.

As you can see, it’s a full and diverse roster. As already mentioned, there will be much more from other delegates around the state; any CMA member can propose a resolution, and perhaps we can help you bring good ideas forward next year. As for this year, stay tuned.

Stephen Follansbee is past-president of the SFMS, chairs the SFMS delegation to the CMA, is an infectious disease specialist at Kaiser San Francisco, and is a clinical professor at UCSF. Steve Heilig is Associate Executive Director of the SFMS. www.sfms.org

SFMS Election

Slate of Candidates 2012 Officers Term: 2012 For President-Elect: Shannon Udovic-Constant, MD For Secretary: Jeffrey Beane, MD For Treasurer: Lawrence Cheung, MD For Editor: Gordon L. Fung, MD For SFMS Board of Directors Term: 2012–2014 Seven candidates to be elected to the Board of Directors: Andrew F. Calman, MD * Arti D. Desai, MD Roger S. Eng, MD * Jennifer Gunter, MD John Maa, MD Richard A. Podolin, MD * Elizabeth K. Ziemann, MD * Incumbent Director

For Nominations Committee Term: 2012–2013 Four candidates to be elected to the Nominations Committee: Diana I. Bojorquez, MD Chunbo C. Cai, MD Wan Chung Chi, MD Jill M. Guelich, MD Yi Brenda Shue, MD For Young Physicians Section Delegate Term 2012–2013 Arti D. Desai, MD (Incumbent Alternate)

For Young Physicians Section Alternate Delegate Term 2012–2013 Mason Spain Turner, MD

For AMA Delegate Term 2012–2013 H. Hugh Vincent, MD (Incumbent Delegate)

For AMA Alternate Delegate Term 2012–2013 Robert J. Margolin, MD (Incumbent Alternate)

For SFMS Delegation to the CMA House of Delegates Term 2012–2013 The four candidates receiving the highest number of votes will serve as delegates. The President-Elect automatically becomes the fifth delegate. The next five will be alternate delegates.

William S. Andereck, MD ** Andrew F. Calman, MD ** Gary L. Chan, MD * Roger S. Eng, MD ** Stephen E. Follansbee, MD *** George A. Fouras, MD * Jennifer Gunter, MD Katherine E. Herz, MD Robert I. Liner, MD ** Leslie M. Lopato, MD ** Keith E. Loring, MD ** George P. Susens, MD * * Incumbent Delegate ** Incumbent Alternate *** Incumbent Delegate/Chair

NOTES 2011 President-Elect, Peter J. Curran, MD, automatically succeeds to the office of President.

2011 President, George A. Fouras, MD, automatically succeeds to the office of Immediate Past-President.

This year members will be able to vote online if we have their e-mail addresses in our database. Please look for a special e-mail from SFMS on October 24 with detailed information regarding the online voting process as well as the link to the online ballot.

This is the last year we will mail paper ballots to voting members, so please provide us with your e-mail address. Bal-

lots will be mailed in late October only to SFMS members for whom we have no e-mail address on file. Upon receipt, please mark your ballot and return it immediately in the special envelope provided. All other members please vote online.

Ballots MUST arrive at the SFMS offices by 5 p.m., Monday, November 14, 2011, whether by mail or electronic means.

If mailed, the name of the SFMS member (not the corporation’s name) must be printed legibly or typed on the return envelope.

Please see candidate biographies and statements on the following pages. www.sfms.org

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SFMS Election FOR PRESIDENT-ELECT SHANNON UDOVIC-CONSTANT Specialty: Pediatrics Membership: SFMS and CMA 2001 SFMS: Treasurer 2011; Director 2007–10 SFMS Committee Appointments: SFMS PAC 2006– 11 (Chair 2009–10, Secretary/Treasurer 2007–08), Executive 2007–11; Medical Review and Advisory 2002–present; Bylaws 2007 CMA: Delegate 2010–11; Alternate Delegate 2008–09 CMA Committee Appointments: Young Physicians Section Executive Committee, AtLarge Member 2003–2005 Related Medical Affiliations: AAP-CA State Government Affairs, Cochair 2008–present; AAP Chapter Board, Alternate Member-atLarge 2003 Medical School: U.C. Berkeley/UCSF Joint Medical Program, MS 1996, MD 1998 Hospital Affiliation: Active: Kaiser Permanente Teaching Appointments: Assistant Clinical Professor, UCSF Department of Pediatrics Policy Statement: As individual physicians in San Francisco, we can directly affect the health and well-being of our own patients.

The power of organized medicine is that physicians across all specialties can have one voice to address the health care issues facing patients and their physicians. This is even more important as we implement health care reform. Physicians must help shape the future of how health care is delivered and financed. SFMS can be a leader locally by requiring accountability that these changes will support the best care of our patients. I would welcome the opportunity to continue to serve SFMS.

FOR SECRETARY JEFFREY BEANE

Specialty: Geriatrics, Hospice, and Palliative Medicine Membership: SFMS/CMA 1998 SFMS: Director 2009–11 SFMS Committee Appointments: Executive 2011,

Well-Being 2010–11 Related Medical Affiliations: American Ge32 33

Candidate Statements

riatrics Society, American College of Physicians, and American Academy of Hospice and Palliative Medicine; Member, Ethics Committee and Physicians’ Well-Being Committee at Kaiser Permanente Medical School: U.C. Davis 1981 Hospital Affiliation: Active: TPMG Policy Statement: Our profession needs an organized, unified voice in order to exert physician leadership in health care policy. I have a particular interest in health care delivery for frail, chronically ill patients. I am excited by the opportunity to improve endof-life care in our community as provided by the recent passage of AB 3000 (Wolk), which establishes the POLST form (Physician Orders for Life-Sustaining Treatment) as the equivalent of a prehospital DNR, and I look forward to SFMS providing leadership in establishing the POLST form as the standard of care across all settings in San Francisco.

FOR TREASURER

LAWRENCE CHEUNG Specialty: Dermatology Membership: SFMS/ CMA 2005; AMA 2005 SFMS: Secretary 2011; Director 2009–10 SFMS Committee Appointments: Executive 2010–11; SFMS PAC Board 2007–11 (Vice Chair 2010); Membership Services Committee 2006–11 CMA: Alternate Delegate 2009–12; YPS Alternate 2008 Related Medical Affiliations: Fellow, American Academy of Dermatology; Fellow, American Society for Dermatologic Surgery; Member, Society of Investigative Dermatology Medical School: Columbia University College of Physicians and Surgeons 1998 Hospital Affiliation: Active: St. Mary’s, Chinese Hospital Teaching Appointments: Assistant Clinical Professor of Dermatology, UCSF Policy Statement: As a recent graduate who started my own solo practice in the city five years ago, I have gained a deep appreciation for the San Francisco Medical Society. Beyond the camaraderie of colleagues, the Society has provided a wealth of resources to me as a practicing physician. I soon became active in the Society because I wanted to ensure

San Francisco Medicine October 2011

that it remains a valuable resource for other physicians. I joined the Membership Committee because I felt that a robust membership base is critical for the Society on many levels.

From the number of delegates at the CMA to the legitimacy of representing San Francisco physicians in areas of patient advocacy and health care policy, membership is the backbone of the Society. I also became active in the Political Action Committee because I feel that California is a pioneer in many areas of health initiatives, and San Francisco is one of the cities leading these changes. I believe that only by actively engaging in the political process can we ensure positive outcomes for both our patients and our profession. I am truly honored to have been nominated to serve as the Treasurer of the Society.

FOR EDITOR

GORDON L. FUNG (Incumbent Editor) Specialty: Cardiovascular Diseases Membership: SFMS/CMA 1985 SFMS: Editor 2011; Consultant 2008–2010; Immediate Past-President 2007; President 2006; PresidentElect 2005; Director 1999–2000/2002–04; Secretary 2001 SFMS Committee/Board Appointments: Editorial Board 2007–11/1995 (Chair 2011); Executive 2011/2000–07; PAC 2005–10 (Consultant 2011); Professional Relations and Ethics 1997–2011; Judicial 2005–08; Bylaws 2007; SFMS Finance/Investment 1998–2006; Services, Inc., Board 1995–2005 (President 1999– 2005; Secretary/Treasurer 1996–98); Nominations Committee 2007/2000–01; Insurance and Managed Care Mediation 1995–96 CMA: SFMS Delegate 2005–12; Specialty Society (Cardiology) Delegate 2002–06; Alternate 2001; Delegate 2001 CMA Committee Appointments: Medical Staff Survey Steering Committee 1998; Medical Staff Survey 1995; Council on Scientific and Clinical Affairs 2008–present Related Medical Affiliations: American College of Cardiology, California Chapter, President and Governor 2006–09; Chair, Membership Committee 2002–06; Member, National Board of Directors, American Heart Association 1999–2001; President, California Affiliwww.sfms.org

ate, American Heart Association 1996–98; Member, Executive Committee, Council on Clinical Cardiology, AHA 2005–09; Medical Director, ECG Lab, UCSF 2001–present; Director of Cardiac Services, UCSF Medical Center at Mount Zion 2001–present; President, San Francisco Division, American Heart Association 2004–06 Medical School: UCSF School of Medicine 1979 Hospital Affiliation: Active: UCSF; Associate: Chinese Hospital, Saint Francis Memorial Hospital, St. Mary’s Hospital, CPMC Teaching Appointments: Clinical Professor of Medicine, UCSF 2006–present; Associate Clinical Professor of Medicine, 1998–2006 Policy Statement: I am honored to be nominated for the SFMS Delegation to the CMA House of Delegates. Over the past several years, the challenges of practicing medicine in San Francisco and California have caused many physicians to consider early retirement and/or leaving the field entirely. Regardless of hospital affiliation, mode of practice, or specialty, this organization pulls together the energy and expertise of all physicians to support physicians and quality health care for all San Franciscans. I strongly believe that all physicians need to be a part of this team effort to support each other in an organized manner.

Only by volunteering to be part of the solution can we succeed in medicine. I look forward to working with you and for you.

FOR BOARD OF DIRECTORS ANDREW F. CALMAN

(Incumbent Director) ALSO CANDIDATE FOR DELEGATION Specialty: Ophthalmology Membership: SFMS 1993; CMA 1982; AMA 1982 SFMS: Director 2009–11 SFMS Committee Appointments: Executive 2011, PAC 2009–2011 (Chair 2011) CMA: Alternate 2011; Ophthalmology Subspecialty Delegate 2002–10, House of Delegates Insurance & Reimbursement Reference Committee D 2004–07 (Chair 2007) Related Medical Affiliations: Associate Examiner, American Board of Ophthalmology; Medical Expert, Medical Board of California; St. Luke’s IRB 1996–2003 Other: American Academy of Ophthalmology Executive Council 2003–08; Health Policy www.sfms.org

Committee 2004–08; Legislative Key Contact 2000–08; California Academy of Ophthalmology (President 2010; VP 1998–99, 2005–06; and CFO 2004–05); California Medicare Carrier Advisory Committee 1996–2004; Chair, Prevent Blindness Northern California 2011 Medical School: UCSF 1989 (MD-PhD) Hospital Affiliation: Active: CPMC-St. Luke’s, UCSF, SFGH; Courtesy: CPMC, St. Mary’s, Seton Teaching Appointments: UCSF, Associate Clinical Professor of Ophthalmology and Family & Community Medicine Policy Statement: For me, advocacy has been a natural outgrowth of fifteen years of practicing in a low-income area. I authored successful CMA and AMA resolutions to allow drug importation from Canada and to direct Medicare negotiations with pharmaceutical companies (reversing AMA policy), and to improve early detection of childhood disabilities. I recently helped organize physicians in a successful effort to resist the closure of CPMC-St. Luke’s Hospital and completed my term as president of my state specialty society. I have also worked for many years on Medicare reimbursement policy at the state and national levels.

In these difficult economic times, I will be a tireless advocate for fair payments to physicians and for access to health care for our most vulnerable citizens.

ARTI D. DESAI

ALSO CANDIDATE FOR NOMINATIONS COMMITTEE Specialty: Pediatrics Membership: SFMS/CMA 2011 SFMS Committee Appointments: SFMS PAC Board 2011 Related Medical Affiliations: American Academy of Pediatrics San Francisco Alternate Delegate (Chapter 1) 2011–13; Chapter 1 Advocacy Committee 2006–11 Medical School: Wayne State University School of Medicine 2006 Hospital Affiliation: Active: CPMC Policy Statement: Making a positive impact on the health of a community requires both upstream and grassroots change. As a hospitalist, I have the honor of serving children and families on a grassroots level. However, my work would not be complete without

the ability to impact the community on a population level through policy change. The San Francisco Medical Society, alongside the California Medical Association and the American Academy of Pediatrics, provides an important vehicle to influence health policy for children. Encouraging and supporting young physicians, in particular, to engage in legislative advocacy will sustain our efforts to strengthen the physician voice in our political climate.

ROGER S. ENG

(Incumbent Director) ALSO CANDIDATE FOR DELEGATION Specialty: Radiology Membership: SFMS 2003, CMA 1995, AMA 1995 SFMS: Director 2009–11 SFMS Committee Appointments: Executive 2010–11, PAC 2011; Nominations 2011 CMA: Alternate Delegate 2008–2011; Board of Trustees 1997–98, 2003–07; Delegate/Alternate Delegate 1995–present; Young Physicians Section, Chair 2001–02 CMA Appointments: Committee on Nominations 1997–98, 2003–07; IT Committee, Chair 2004–08; Radiologic Technology Certification Committee 2004–present; Long-Range Planning Committee 2003–07; Chair, CMA Website Taskforce Subcommittee 2006–07; Health Care Finance Technical Advisory Committee 2004; Committee on Medical Service 1998–99 AMA Offices: AMA Delegate 1996–97; AMARPS Delegate 1995–97; AMA-YPS Delegate 1998–99 (Vice Chair, CMA YPS delegation) Related Medical Affiliations: Chief of Radiology, Chinese Hospital 2003–present; President, Golden Gate Radiology Medical Group 2006–present; Treasurer, California Radiological Society 2010–2011; Treasurer, San Francisco Bay Radiological Society 2010– 2011; Chinese Community Health Care Association Information System Physician Advisory Committee 2006–present; Carestream Healthcare Information System Physician Advisory Board 2005–present; American College of Radiology, Councilor 2008–present; California Radiological Society, Executive Committee 2008–present; Chinese Hospital, Medical Executive Committee 2004–2010 Medical School: George Washington University 1991

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SFMS Election Hospital Affiliation: Active: Chinese Policy Statement: As a native San Franciscan, I am honored to be renominated to the SFMS Board of Directors. It is vital for organized medicine to take a lead role in the changes affecting our health care delivery system. If reelected I will continue to work hard on making our medical society an ever-stronger voice for our patients and community.

JENNIFER GUNTER

ALSO CANDIDATE FOR DELEGATION Specialty: OB/GYN and Pain Medicine Membership: SFMS/CMA 2011 Medical School: University of Manitoba Faculty of Medicine 1990 Hospital Affiliation: Active: Kaiser-Permanente San Francisco Teaching Appointments: Associate Professor University of Colorado 2005; Assistant Professor University of Colorado 2001–2004; Assistant Professor University of Kansas 1996–2001 Related Medical Affiliations: Director, Center of Pelvic Pain and Vulvovaginal Disorders, Kaiser Northern California; Member of the Joint Practice Committee Kaiser San Francisco (2007–present); Infectious Diseases Subcommittee of the Joint Practice Committee Kaiser San Francisco (2007–present) Policy Statement: I am honored to be nominated as a candidate for the SFMS Board of Directors. I am deeply committed to the mission of advocating for both physicians and patients. As an OB/GYN who became board certified in pain medicine later in my career, I bring insight into the experiences of both primary care physicians and specialists. I have more than fifteen years’ experience serving on national and local committees. I am a strong communicator and will listen to your ideas and concerns and work well with our stakeholders to advance our common goals.

Thank you for your consideration.

34 35

Candidate Statements

JOHN MAA Specialty: General Surgery Membership: SFMS/CMA 2004; AMA 1991 Related Medical Affiliations: Board of Directors and Western States Affiliate Advocacy Taskforce Member, American Heart Association; Secretary-Treasurer of the Northern California Chapter of the American College of Surgeons; one of the “Top 20 people making a difference in health care in America—2009” Medical School: Harvard Medical School 1994 Hospital Affiliation: Active: UCSF Teaching Appointments: Assistant Professor in Residence and Associate Clerkship Director in Surgery, UCSF School of Medicine; UCSF CODA Course Director 2006–2009; 2010 recipient of the Kaiser Excellence in Teaching Award Policy Statement: During my past year in Washington, D.C., watching health care reform unfold firsthand, I was struck by the absence of balance in the debate. A discussion of the amazing successes in American health care has been missing, and my concern is that in the rush to pass ACA, the true problems were framed incorrectly. The challenges in medicine are likely a mirror of what needs to be reformed in law, finance, government, and societal expectations. As a member of the SFMS Board, I will seek to empower physicians to restore balance on Capitol Hill and identify better health care solutions for America.

RICHARD A. PODOLIN

(Incumbent Director) Specialty: Cardiovascular Diseases Membership: SFMS/CMA 1991 SFMS: Director 2009–11 Related Medical Affiliations: Immediate PastPresident of the Medical Staff, St. Mary’s Medical Center; Specialty Society Delegate to the CMA, California Chapter of the American College of Cardiology; Associate Chief, Department of Cardiovascular Medicine and Interventional Cardiology, SMMC Medical School: Stanford University 1979 Hospital Affiliation: Active: St. Mary’s

San Francisco Medicine October 2011

Policy Statement: We are in a period of rapid and yet uncharted change in the practice of medicine. Both social policies and economic realities are requiring physicians to align more closely with hospital systems and other health care organizations, and this structural integration has the potential to improve quality and efficiency. Still, it is critical that physicians maintain a strong, independent voice.

We need to align to improve efficiency and access, but we also need to maintain our position as the stewards of medical quality. If we wish to maintain high-quality care in this community, we need to safeguard reimbursements and provide a practice environment that will attract and sustain excellent physicians in both primary and specialty practices.

As a member of the SFMS Board, I will work to promote these goals.

ELIZABETH K. ZIEMANN

Specialty: Family Medicine Membership: SFMS/CMA 2010–present; AMA 2006– present; AAFP 2002–present SFMS: SFMS Medical Staff Liaison to St. Luke’s Hospital Related Medical Affiliations: St Luke’s Committee for Interdisciplinary Practice 2010– present Medical School: University of Iowa Carver College of Medicine 2007 Hospital Affiliation: Active: St. Luke’s, CPMC Teaching Appointments: I serve as an Epic Care Center Implementation Expert, which involves developing clinical content for our electronic medical record and teaching physicians and staff how to use the system.

Policy Statement: I have accepted the position as liaison between St. Luke’s and the SFMS and would be honored to be a member of the board. Throughout my residency I was an active advocate for primary care and underserved populations, through my involvement with the Iowa Medical Society, Iowa Family Medicine Residents’ Council, and Iowa City Free Medical Clinic. Here in San Francisco I have also become active within the medical community, seeing outpatients at our clinic in Potrero Hill as well as inpatients at St Luke’s, and I look forward to continuing my efforts to reduce health care disparities through my work with the SFMS. www.sfms.org

fOr NOMINATIONS COMMITTEE DIANA I. BOJORQUEZ Specialty: Pediatrics Membership: SFMS/CMA 2006 Medical School: Yale University School of Medicine 2002 Hospital Affiliation: Active: Kaiser Permanente, San Francisco Teaching Appointments: UCSF Assistant Clinical Professor, Department of Pediatrics Policy Statement: I am honored to be considered for a position on the Nominations Committee. I will nominate leaders who will continue to uphold the traditions of this society, advocating for physicians in San Francisco.

As we move into an era marked by unprecedented changes in our health care industry, I look forward to becoming more involved at the local level and helping shape the future by identifying future leaders of the SFMS.

CHUNBO C. CAI

Specialty: Physical Medicine & Rehabilitation Membership: SFMS/CMA 2008 Other: Massachusetts Medical Assn. Young Physicians Committee/Global Medicine Committee 2000–07; Environmental Medicine Committee 2000–2006 Medical School: Fudan University, Shanghai Medical College 1984 Hospital Affiliation: Kaiser Permanente Teaching Appointments: Boston University, Tufts Medical School 2002–07 Policy Statement: I am honored to be nominated to join the nomination committee at San Francisco Medical Society. In the current economic turmoil, health care is facing the biggest challenge that we ever had before.

We need strong leadership bringing us together to walk through this tough period of time. It would be my privilege to work with other committee members in selecting the outstanding individuals with vision and devotion to this course.

www.sfms.org

WAN CHUNG CHI Specialty: Physical Medicine & Rehabilitation Membership: SFMS/CMA 2011 Related Medical Affiliations: American Academy of Physical Medicine & Rehabilitation; California Society of Physical Medicine & Rehabilitation Medical School: Northwestern University Medical School 2000 Hospital Affiliation: Active: St. Francis Memorial Hospital; St. Mary’s Medical Center; Kentfield Rehabilitation & Specialty Hospital Policy Statement: With the changing landscape in medicine, I have been encouraged by my colleagues to become active in SFMS in order to influence the practice of medicine for the future. I feel honored to have been nominated. I look forward to interacting with colleagues who share my passion for the practice of medicine, and I hope to find new young physician leaders to join as part of the Nominations Committee.

JILL M. GUELICH

Specialty: Obstetrics & Gynecology Membership: SFMS/ CMA 2011; ACOG 2005 Medical School: Vanderbilt University School of Medicine Hospital Affiliation: Active: California Pacific Medical Center; Saint Francis Hospital Teaching Appointments: UCSF Volunteer Clinical Faculty Policy Statement: I am happy to be considered for the Nominations Committee of the San Francisco Medical Society.

YI BRENDA SHUE

Specialty: Endocrinology Medical School: Texas A&M Medical School 2003 Hospital Affiliation: Active: St. Mary’s Medical Center Teaching Appointments: St. Mary’s Medical Center

2009–present Policy Statement: I am honored to be nomi-

nated to serve on the SFMS Nominations Committee. It would be my privilege to be able to work together with my mentors and friends at SFMS to help select future leaders for this great organization.

fOr YOUNG PHYSICIANS SECTION DELEGATE ARTI D. DESAI

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

fOr YOUNG PHYSICIANS SECTION ALTErNATE DELEGATE MASON SPAIN TURNER

Specialty: Psychiatry Membership: SFMS/CMA 2004 AMA 1995–2003 (not currently active) AMA Offices: Delegate and Member, Credentials Committee; Residents and Fellows Section; AMA 2001 Related Medical Affiliations: At-Large Member, Executive Council 2007–2009 CA Society of Addiction Medicine ; Chair, Conference Planning Committee for Addiction Medicine Review Course 2010, CA Society of Addiction Medicine; Chief, Department of Psychiatry, Kaiser Permanente San Francisco Medical Center; Assistant Director, Outpatient Services, Regional Mental Health and Chemical Dependency; Kaiser Permanente Northern CA; Diversion Evaluation Committee Member (Fresno), Board of Registered Nursing; Department of Consumer Affairs, State of CA 2011–2015; Chair, Conference Planning Committee, Kaiser Permanente Northern CA Regional Psych/Chemical Dependency Conference; Vice President of Board of Directors and Cochair of Public Policy Committee, Mental Health Association of San Francisco; Clinical Co-Lead, Depression Leadership Team, Kaiser Permanente Northern CA Medical School: University of Texas Southwestern School of Medicine 1999 Hospital Affiliation: Active: Kaiser Permanente San Francisco Teaching Appointments: Assistant Professor, UCSF Policy Statement: I am honored to be considered for the position of SFMS Alternate Del-

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SFMS Election egate, Young Physician’s Section, to the CMA House of Delegates. Many challenges and opportunities present themselves to us as physicians, whether in individual or in large group and HMO practices, and our collective voices must be heard as the landscape of medical care provision changes over the next few years. Barriers between disciplines and better integration of primary care, specialty, and subspecialty care will lead our field forward and ensure that we not only weather the challenges ahead but emerge as a stronger and more unified profession. As a local and regional administrator in mental health for Kaiser Permanente Northern California, I am experienced in the intricate and delicate nature of health care policy and patient advocacy as well as implementation of complex operational initiatives with the goal and purpose of advancing our ability to provide the highest-quality care to our patients and create a positive practice environment for ourselves as physicians. Together, we can present a strong and unified presence for the advancement of physician practice in California.

FOR AMA DELEGATE

H. HUGH VINCENT (Incumbent Delegate) Specialty: Anesthesiology Membership: SFMS/ CMA/AMA 1972 SFMS: Board Consultant 1993–present; Immediate Past-President 1993; President 1992; President-Elect 1991; Director 1982–1990 SFMS Committee Appointments: Medical Review and Advisory 1975–present; PAC Board 1991–96 (Chair 1995–96/Consultant 1997–present); Health Care Foundation of San Francisco Board 1999–2004; Managed Care 1998–2001; Physician Membership Services/Membership 1994–2001/1986– 89 (Chair 1994–95); Nominations 2000– 01/1994–95 (Chair 1994–95); Judicial 1993–99; Anesthesia Section Chair 1975–90 CMA: Trustee 1997–2003; Delegate 1991– 97/2003–present (Chair 1993–96); Alternate Delegate 1985–90 CMA Board Committees: Nominations 1997–2003; Medical Services 1997–2002; Finance 1999–2003; Bylaws 2001–03 CMA Committee Appointments: Council on Legislation 1996–97; Speaker’s Advisory 36 37

Candidate Statements

1993–96; Rules 1994–95 (Chair 1995); Solo Practice TAC 1993–94 (Chair); Governance 10–94 TAC 1994; CALPAC Board of Directors 1995–2001 (Executive Committee 1999– 2001) AMA: Delegate 1996–present (Vice Chair 2000–04, Chair 2004–08); Alternate Delegate 1994–95; House Select Oversight Committee 2001; Council on Long Range Planning and Development 2008–12 (Chair-Elect 2011–13); Reference Committee C: A-95, I-95, A-01; Cal-C Committee Chair 1995–96; Resolutions Committee 1995–2000 Related Medical Affiliations: Saint Francis Physicians Medical Group/CHW Bay Area Physicians Medical Group 1995–2000 (President/CEO); Saint Francis Memorial Hospital Board of Trustees 1990–96/2000– 10 (Secretary 1994–95, Chair 2001–03, Executive Committee 1992–2007); Catholic HealthCare West Bay Area Board of Directors 1996–01; CHW Strategic Planning Committee 2001–05 Medical School: UCSF 1968 Hospital Affiliation: Saint Francis Policy Statement: As always, my purpose in medical politics is to further the agenda and goals of California physicians. As ChairElect of the Council on Long-Range Planning and Development, I will work to make our AMA more accessible and responsive to your needs. Of course I ask for your vote and support, but I also ask for your input (hhmdsfcma@msn.com) on issues important to you.

FOR AMA ALTERNATE DELEGATE ROBERT J. MARGOLIN

(Incumbent Alternate) Specialty: Internal Medicine Membership: SFMS/CMA 1987; AMA 1992 SFMS: Board Consultant 2000–present; Immediate Past-President 1999; President 1998; President-Elect 1997; Director 1992–96 SFMS Committee/Board Appointments: Executive 1993–99 (Consultant 2000–present); SFMSPAC Board 2009–11/1995–2001 (Consultant 2003–08/Vice Chair 2000–01); Judicial 1997–2011; Physician Membership Services/Membership 1995–2006 (Consultant 2011); HCFSF Board 1995–2005;

San Francisco Medicine October 2011

Finance/Investment 1998–2002; Managed Care 1998–2002 (Chair 2000–02/Cochair 1999); 130th Anniversary Celebration 1998; Nominations 1999–2000/1995–97 CMA: CMA Trustee 2003–11; Delegate 1997– 2002 (Chair 2001–03/Vice Chair 1998–2000) CMA Committee Appointments: Committee on Nominations 2003–2010; Chair Audit Committee 2009–11; AB 3686 TAC 2004–05; Long-Range Planning 2004–present; eCommerce TAC 2003; Council on Legislation 2001–02; CALPAC Board of Directors 2004– present; Treasurer 2008–present AMA: Alternate Delegate 2008–11 Related Medical Affiliations: Medical Director, Integrated Practice Group 1995–97; Medical Board, Mt. Zion, 1992–95; President, Physician’s Medical Group at Mt. Zion (IPA) 1993–present; Board of Directors, Medical Insurance Exchange of California 2007 Medical School: Tufts University 1981 Hospital Affiliations: Active: CPMC, UCSF Teaching Appointments: Associate Clinical Professor, UCSF Policy Statement: I have greatly enjoyed serving on the SFMS Board of Directors and as SFMS President, chairing our delegation to the CMA House, and serving as your trustee of the CMA Board of Trustees for the past eight years. I have been your alternate delegate to the AMA House of Delegates for the past four years. I have enjoyed advocating for physicians locally, throughout California and nationally. Now more than ever, it is vital to have physician leadership that is dynamic, experienced, and sensitive to the needs of physicians and their patients. I ask for your support in allowing me to continue our work on the implementation of health care reform, MICRA preservation, financial advocacy, and many other vital issues.

FOR CMA DELEGATION WILLIAM S. ANDERECK

(Incumbent Alternate) Specialty: Internal Medicine Membership: SFMS/CMA 1979; AMA 1995 SFMS: Editor 1995–96; Director 1990–2002 SFMS Committee Appointments: Bioethics 1997–99/1988–94; Editorial Board 1995– 98; SFMS PAC Board 1997–98; Nominations www.sfms.org

1996; Professional Relations and Ethics 1983–94 CMA: Trustee 2004–2010; Solo and Small Group Practice Forum; Founding Chair, Solo and Small Group Practice Forum 1996–2001; President 2002–2004; SFMS Delegate 1993– 95; SFMS Alternate Delegate 1986–92 CMA Committee Appointments: Council on Ethical Affairs 1998–2003; Ad Hoc Health Care Financing TAC 2000–03; Evolving Trends 1990–96; Council on Ethical Affairs, Consultant 2003–2012; TAC to Reevaluate the Board of Trustees 2000; RICO TAC 2001–2003 Related Medical Affiliations: Program in Medicine and Human Values, California Pacific Medical Center, Medical Director; Editor, Hotline physician newsletter; Board of Directors, California Pacific Medical Associates; Chair, Ethics Committee, CPMC; Board of Directors, SF Zoo; Executive Committee Member at Large CPMC 1998–2001 Medical School: University of Tennessee 1974 Hospital Affiliations: Active: CPMC Teaching Appointments: UC Berkeley; CPMC Policy Statement: I have been honored to serve as the SFMS’s representative to the Solo and Small Group Practice Forum for fourteen years. In 1996, I was asked to assume a role in the development of the mode of practice forums and became the founding chair of the SSGPF. I served the more than 10,000 initial members of that forum as its chair, president, and finally, CMA trustee for six years. Now it is time to return to the Delegation I cut my teeth on in 1986, in San Francisco. I have gained invaluable experience working with the current leadership of the CMA and, more importantly, have forged close relationships with individuals in every delegation. It would be an honor to be able to continue my career with the CMA helping to advance the marvelous ideas and policies that originate from the San Francisco Medical Society.

ANDREW F. CALMAN

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

www.sfms.org

GARY L. CHAN

ROGER S. ENG

(Incumbent Delegate) Specialty: Internal Medicine Membership: SFMS/CMA 1981 SFMS: Director 2010–11 / 2002–07; Treasurer 2009; Secretary 2008; St. Francis Memorial Hospital Medical Staff Liaison 2005–2011 SFMS Committee Appointments: Executive 2006–10; Finance 2009–2011 (Chair 2009); Nominations 2007; Information Technology 2006; Health Care Foundation of San Francisco Board 2005–06 CMA: Delegate 2010–11; Alternate Delegate 2008–09; Solo/Small Group Practice Forum Alternate 2006–07 CMA Committee Appointments: Committee on Medical Services 2009–11 Related Medical Affiliations: Medical Director, Brown & Toland 1990–present; Utilization Management Advisor, Blue Shield 1984–99 Medical School: Tufts University 1976 Hospital Affiliation: Active: St. Francis, CPMC; Courtesy: St. Mary’s Teaching Appointments: Clinical Associate, UCSF Policy Statement: I have been active with the SFMS Board for nine years and on the Delegation for the last six years. I would be pleased to continue serving as a delegate to the CMA and thank you for offering me this opportunity. I have been practicing internal medicine here in San Francisco for close to twenty-eight years and I am amazed at the vast changes in medicine. Going forward with EHR and health reform in general will change the landscape of American medicine. We as physicians must be at the table to control this process as much as we can. At the state level there are always forces trying to impact our practice whether we practice alone or in small, medium, or large groups.

Having been a CMA delegate before has given me an awareness of our vulnerability at the state level. Hospital groups and insurers constantly try to chip away at the corporate bar and reimbursements and to straitjacket our practice of medicine. Only through our organized voice can physicians play a role in limiting these regulations. We must remain vigilant for ourselves and for future physicians. I hope to continue to represent these concerns. Thank you for your vote.

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

Policy Statement: I am honored to be renominated to serve on the SFMS Delegation to the CMA House of Delegates. I look forward to working with the rest of our delegation to advance the policies of our SFMS within CMA.

STEPHEN E. FOLLANSBEE

(Incumbent Chair) Specialty: Infectious Diseases Membership: SFMS/CMA 1982 SFMS: Board consultant 2009–present; Immediate Past-President 2008; President 2007; President-Elect 2006; Director 1999–2005 SFMS Committee Appointments: Judicial 2006–11; Executive 2001/2004–07 (Consultant 2008–09); PAC 2006–08; Disaster Planning (Cochair 2002–10); Nominations 2003–04 (Chair 2008); Medical Review and Advisory Consultant 1993–2002; Chiefs of Staff 1996–97 CMA: Delegate 2004–11 (Chair 2008–11) Related Medical Affiliations: Attending physician, Kaiser Permanente Medical Group; Director of HIV Services, Associate Director of Clinical Trials Unit (1998–present), and Director of Adult Travel Medicine Services (2008–present), Kaiser San Francisco; Assistant Director, Bay Area Consortium of AIDS Providers, 1990–present; Medical Director, Institute for HIV Research and Treatment, Davies Medical Center, 1988–1998; attending physician, Ward 86, SFGH Medical Center, 1983–1998; Chief of Staff, Davies Medical Center, 1996–1997 Medical School: University of Colorado 1977 Hospital Affiliation: Active: Kaiser Permanente Medical Center, San Francisco Teaching Appointments: Clinical Professor of Medicine, UCSF 2009–present Policy Statement: It is an honor to have been part of the San Francisco Medical community since 1977, working in the university, research, public, and fee-for-service practice sectors. I am proud to be a member of the SFMS and to serve as a CMA delegate and now chair of the delegation. I have witnessed outstanding leadership in the SFMS, which remains not just reactive but also proactive, advocating for the health of our community

October 2011 San Francisco Medicine

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SFMS Election and the well-being of our profession. We have seen challenges and opportunities for improvement in health care delivery and financing over the last several years. The importance of physicians and our delegation in helping to guide those changes and the successes we have had in the past cannot be overstated. I look forward to the continuing opportunity to serve our important organization and our profession.

GEORGE A. FOURAS

(Incumbent Delegate) Specialty: Child and Adolescent Psychiatry Membership: SFMS/CMA 1996; AMA 1987–90/1995– present SFMS: President 2011; President-Elect 2010; Secretary 2009; Director 2003–08 SFMS Committee Appointments: Executive 2003–11; SFMS PAC 2004–11 (Chair 2007– 08); Physician Membership Services 2003– 11; Nominations 2008; Psychiatric Services 1996–2006; Fellowship/Wellness 2006 CMA: Delegate 2010–11; Alternate Delegate 2007–09/2000–02; California Psychiatry Association Specialty Delegate to Young Physicians Section, CMA 1996–99 Related Medical Affiliations: President, Northern California Regional Organization of Child and Adolescent Psychiatry 2000 (President-Elect 1999); Chair, California Psychiatric Association Child and Adolescent Committee 2000–present; Medical Director, Foster Care Mental Health Program, City and County of San Francisco 1995–present Other: Board-Certified in General Adult Psychiatry 1999, recertified 2009 Medical School: Ohio State University 1990 Policy Statement: Thank you for the honor of being nominated to the SFMS delegation to the CMA House of Delegates. Over the course of my membership in the SFMS, I have been impressed by the broad diversity of our membership and the strong advocacy we have had for our patients and our profession. Many of our policy ideas have gone onward from the CMA to the AMA. I am proud to have been a member of the delegation in the past, present, and—with your support—the future.

JENNIFER GUNTER

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

38 39

Candidate Statements

Policy Statement: I am honored to be nominated for the Delegation to the CMA Board of Delegates. I have worked in California since 2006 and am highly motivated to represent San Francisco physicians. I have a thorough understanding of public health issues, the political nuances of health care, and more than eleven years’ experience serving on national and local committees. I will convey our interests and concerns to the CMA and work with other delegates to achieve our goals of advancing health care for Californians. I will continue the tradition of strong representation that San Francisco physicians expect.

Thank you for your consideration.

KATHERINE E. HERZ

Specialty: Pediatrics Membership: SFMS/CMA 2011 Medical School: UCSF 2001 Hospital Affiliation: Active: Kaiser Permanente San Francisco/Redwood City Policy Statement: I have been living and working in the Bay Area for fifteen years. After completing medical school and residency training in pediatrics, I pursued a fellowship in health care research and policy. I have long-standing interest in both clinical care and health policy and have been fortunate to combine these pursuits in diverse settings, both in the U.S. and overseas. Rapid changes in medicine and insurance will demand flexibility and ingenuity along with commitment to best possible care for all. It would be an honor to serve as a San Francisco Medical Society Delegate to the CMA House of Delegates.

ROBERT I. LINER

(Incumbent Alternate) Specialty: Obstetrics and Gynecology Membership: SFMS/CMA 2004 CMA: Alternate Delegate 2008–11; Reference Committee E 2008/2009 Related Medical Affiliations: Diplomat, ACOG; American Institute of Ultrasound in Medicine Medical School: University of Rochester 1970 Hospital Affiliation: Associate Physician

San Francisco Medicine October 2011

Diplomat, UCSF Dept. of Ob, Gyn., & Reproductive Sciences Teaching Appointments: Associate Physician Diplomat, UCSF Dept. Ob, Gyn., & Reproductive Sciences; Clinical Faculty and Temporary Director, OB/GYN at Mt. Zion Hospital (retired) Current Practice (1988–present): Formerly in private practice in prenatal diagnosis, diagnostic ultrasound (obstetrical and gynecologic), and genetic amniocentesis and certified by the Fetal Medicine Foundation to perform ultrasound genetic screening at eleven to fourteen weeks. Currently providing the same services for UCSF’s Prenatal Diagnostic Center.

Policy Statement: I became a member of the SFMS/CMA in order to join others who want to do their part to make a difference in the way physicians use their individual and collective influence to improve the health and well-being of patients. This is both idealistic and self-serving, since professional improvement enhances the quality of our own working lives and also because, eventually, we all become patients. Impressed with the personalities of the members of the SFMS and with the diligent work expended by its delegation at the HOD meetings, I wanted to be a participant as well as an observer at those meetings. As something of a student of the history of medicine on the Pacific Coast, I know that it can take time for wise policies to evolve.

Best evidence-based practice can only evolve with dedicated leadership. I’m pleased and feel honored to be able to join the SFMS delegation, working toward wise policy and best practice.

LESLIE M. LOPATO

(Incumbent Alternate) Specialty: Psychiatry Membership: SFMS/CMA 1989 CMA: Alternate Delegate 2010–11 Medical School: Stanford University 1978 Internship and Residency: Mount Zion Medical Center of UCSF Internship in Internal Medicine, Internship and Residency in Psychiatry Hospital Affiliation: Active: Kaiser Permanente Committees: Chair, Hospital Ethics Committee, Kaiser Medical Center, San Francisco 1987–2011; Member, Physician Wellness Committee, Kaiser Medical Center, San Francisco 2005–2011 Policy Statement: As a child of the sixties, I www.sfms.org

had, in my youth, regarded organized medicine as a hidebound collection of doctors trying “manfully” (usually literally so) to maintain the status quo. In actuality, the CMA House of Delegates is democracy-in-action in organized medicine. It offers a unique opportunity for any California physician to seek support and action from the CMA on any issue that he or she feels is vital to the ethical practice of medicine. I would be honored to serve again as your delegate and hope you will allow me to bring your visions and concerns to this dynamic process.

KEITH E. LORING

(Incumbent Alternate) Specialty: Emergency Medicine Membership: SFMS/CMA 2003 SFMS: Director 2011– 2013/2009; Treasurer 2010 SFMS Committee Appointments: Executive 2009–11; Finance and Investment 2010–11 (Chair 2010); Nominations 2007–08 CMA: Alternate Delegate 2011 CMA Committee Appointments: Council on Legislation 2010 Related Medical Affiliations: Attending Emergency Physician, St. Mary’s Medical Center; Attending Emergency Physician, St. Francis Memorial Hospital; Full Partner, California Emergency Physicians Medical School: Johns Hopkins University School of Medicine 1991 Hospital Affiliations: Active: St. Mary’s, St. Francis Policy Statement: It has been an honor and a privilege to serve as Board Member, Treasurer, and appointed CMA Alternate Delegate of the SFMS, especially during this past year of deep personal crisis. Wise stewardship of our profession requires us to each to do our best, no matter our individual circumstances, to be passionate yet consistent and thoughtful advocates for our patients and our practices. If we are to truly flourish, we must maintain a keen awareness of the world outside our practices, our medical groups, and our medical centers. We must be able to stand together to advocate for what is right for our patients as well as what is right for us to receive in compensation for our efforts. My candidacy for CMA Alternate Delegate is part of an ongoing commitment to put these words into action and become involved in something greater than my own practice of emergency medicine at St. Mary’s and St. Franwww.sfms.org

cis Hospitals. If we are to stem the tide that continues to erode our profession and place our patients in harm’s way, it is critical that we nurture the brightest among us who have the passion, patience, and energy necessary to stretch beyond day-to-day clinical practices and make our voices heard in the local, state, and national health care dialogue. Proactive involvement in the deliberations of the CMA House of Delegates is critical for this organization to be able to continue advocating for our patients and practices in San Francisco, especially in a time of exceptional financial uncertainty and likely upheaval of our health care system. I would be honored, willing, and able continue in helping serve this need if elected.

GEORGE P. SUSENS

(Incumbent Delegate) Specialty: Internal Medicine Membership: SFMS/CMA 1982 SFMS: Consultant 2003– present; Immediate PastPresident 2002; President 2001;President-Elect 2000; Director 1996–99; Medical Staff Liaison to

TPMG 1996–99 SFMS Committee Appointments: Finance/ Investment 2001–09; Executive Committee 1997–2002 (Consultant 2003–06); Disaster Planning 2002–06; Nominations 2002/1994– 95; SFMSPAC Board 1997–2002; Judicial 2000–02; Chiefs of Staff 2001; Bioethics 1986– 87; Legislative 1990–95 CMA: Delegate 2000–11/1996–97; Alternate Delegate 1998–99/1993–95 Related Medical Affiliations: Chair, Credentials and Privileges Committee of Kaiser Foundation Hospital 1996–present; Vice Chair, Board of Directors, Northern California Permanente Medical Group 1993–96 Medical School: Northwestern 1962 Hospital Affiliation: Active: Kaiser Permanente Policy Statement: It has been a privilege to serve the San Francisco Medical Society as a delegate to the California Medical Association’s annual meeting. I would like to continue my efforts to influence the CMA’s responses to the hostile environment in which we find ourselves. The SFMS’s influence on the CMA and AMA is remarkable for our small size. As I said when I was elected President of the SFMS, “I feel we are the conscience of CMA.” Physician advocacy is effective.

Peter J. Panagotacos, MD Board Certified Dermatologist Specializing in

Hair Restoration

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Member of SFMS and CMA for over 30 years AMA Lifetime Member • Fellow of the American Academy of Dermatology Member of Advisory Council of American Society of Hair Restoration Member of International Society of Hair Restoration Surgery Member of International Society of Dermatologic Surgery October 2011 San Francisco Medicine

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HOSPITAL NEWS KAISER

Saint Francis

CPMC

Robert Mithun, MD

Patricia Galamba, MD

Michael Rokeach, MD

Women go through many changes during their lives from adolescence through menopause. During a woman’s reproductive years (menarche through menopause), there are many side effects of hormone fluctuations that a woman may experience.

Some of these changes relate to menstruation. Following adolescence, a woman’s menstrual cycle may become more regular as her “hormonal axis” matures. In the few years leading up to menopause, her periods may again become irregular.

As a woman ages, her fertility also changes, with the most fertile time being under the age of thirty. Fertility declines most significantly during the late thirties and becomes quite low in the forties. That said, during the reproductive years a woman can become pregnant at any age, so using effective birth control throughout this time is important.

Menopause is a unique journey for each woman. Women may learn of ways to support their symptoms through nonpharmacologic approaches, although some women require medications to manage the “change of life.”

This is also an important time to talk to women about other mid-life health risks that can accompany menopause, such as osteoporosis, heart disease, or increased cancer risk.

As health care providers, it is essential that we understand and support women through the many changes they undergo during their adult years. Depending on the population a particular provider treats, there are cultural, religious, and psychosocial determinants to be considered. In some cases it is most useful to use a team approach when helping women through the various stages, depending on the particular cultural context.

Working in partnership with our female patients through their adult years, using members of their care teams, is an optimal way to guide women through their reproductive years. This includes coordinated inperson evaluation by providers as well as health education through classes and online resources at www.kp.org/mydoctor.

Saint Francis has gotten off to a busy start this fall. In September we hosted several OR private screenings for the San Francisco surgical community and our neighbors on Nob Hill. We aren’t done yet, as we still have one more opening for VIP donors and dignitaries. That event is on October 12 from 5:00 to 7:00 p.m., and members of the Medical Society are welcome to attend. The Surgical Department remodel really takes Saint Francis into the future, and it’s certainly worth a peek. Please be my guest.

The hospital has been involved with community activities, including support of the Susan G. Komen Race for the Cure, the American Heart Association Walk, the American Cancer Association’s Making Strides Walk, and the San Francisco Giants’ half-marathon race held in late August. Our ER physician Joanne Sun, MD, was on hand for any emergent care, as was one of our new orthopedists, Rob Purchase, MD, who cared for race-related sports injuries.

On the topic of midlife medicine, the Women Physicians’ Dialogue Group hosted a dinner on September 21 with guest speakers from the California Safe Cosmetics Program, the California Department of Public Health. and the California Healthy Nail Salon Collaborative. The topic of discussion was “Health Concerns and Potential Health Effects of Cosmeceuticals.” It was a lively and informative discussion.

And, finally, let me extend kudos to orthopedist and sports guru Jim Garrick, MD, for a great prerace interview on KFOG about the Bridge-to-Bridge race scheduled for October 2. Additional kudos go to Dr. Tom Haddad for his on-camera interview with KCBS’s Nancy Snyderman, MD, on the topic of acid reflux, and Selina Shah for her KCBS interview on Zumba dance injuries—which, if you are in your midlife phase, can happen pretty easily if you aren’t careful.

40 San 41 SanFrancisco FranciscoMedicine Medicine October October2011 2011

CPMC has just been named as a Gold Medal-winning Family Favorite in Bay Area Parent magazine’s annual Best of the Best reader survey. Not only were we named a Top Hospital and Birthing Center but, because we have won a Gold Medal three years in a row, we have also been inducted into the Bay Area Parent 2011 Hall of Fame. Congratulations and thanks go out to all employees and medical staff for making CPMC such a great place for families to receive care.

Stewart Cooper, MD, has received a 2011 Health Care Hero Award from the San Francisco Business Times. Cooper, director of the CPMC Liver Immunology Laboratory, was honored with the top award in the category of research and development. The award recognizes excellence and unsung heroes who enrich the lives of those they serve. Cooper was cited for his transformative liver disease research related to the hepatitis B and C viruses and for his work in caring for patients and promoting early diagnosis and treatment of liver cancer.

CPMC Food and Nutrition Services’ Bernie Brown was recently awarded the Unsung Hero award from the San Francisco Business Times. Although Bernie is known for making great milk shakes and smoothies for patients who often have difficulty eating, he received the award because he touches people’s lives with his caring and compassionate demeanor and because he always goes the extra mile to bring comfort and a smile to the patients he is caring for. The difference Bernie makes in people’s lives is evident not only by the award he has received but also by the numerous positive comments he has been receiving in post-discharge patient surveys from those he has cared for.

www.sfms.org

IN THE NEWS New “Graphic” Tobacco Labels Draw Fire The Food and Drug Administration is requiring new, more graphic photographic labels on tobacco, depicting some real-life disease impacts of smoking. The tobacco industry is fighting this requirement—which would seem to indicate that such explicit labeling could have a positive impact on discouraging smoking—especially among young people, which is when most smokers become addicted. Surveys of adult smokers show that most wish they had never started.

Quitting is possible. For resources, see: RX for Change A UCSF site for clinicians: http://www.rxforchange.ucsf.edu/ UCSF Center for Tobacco Control Patient-oriented resources: http://tobacco.ucsf.edu/resources/9 American Heart Association http://www.heart.org/ American Lung Association’s Online Program http://www.ffsonline.org/

www.sfms.org

October 2011 San Francisco Medicine

41

BACK PAGE SFMS Career Fair a Success The SFMS’ second annual Career Fair enjoyed a great turnout. On September 27, over seventy residents and fellows from local residency programs connected with recruiters from nineteen exhibiting organizations representing variety of practice types and settings based in San Francisco Bay Area. Many residents felt this was a wonderful opportunity to become acquainted with practice position opportuniPhoto by Dr. Paul Abramson ties and choices available in their specialty in San Francisco Bay Area, and highlight small clinics and groups that may have been overlooked by regional or national job search events.

One event attendee commented, “Thank you for organizing an event that showcases the Bay Area’s local community clinics. This event is unlike any other because of the emphasis on San Francisco Bay Area job opportunities.”

For those that missed the career fair, SFMS will be publishing a list of available positions and recruiter contact information in our November member-only eNewsletter.

SFMS is already planning for next year’s event, tentatively scheduled for September 2012 at St. Mary’s Medical Center.

SFMS would like to thank the California Pacific Medical Center for providing the venue for this event. We would also like to recognize our participating exhibitors and staff at the graduate medical departments of CPMC, UCSF, St. Mary’s, and Kaiser Permanente for their generosity and support.

EXHIBITORS

42

Asian Health Services Brown & Toland Cardiovascular Medical Group Chinese Hospital CHW Medical Foundation CPMC/Sutter Health Haight-Ashbury Free Clinics – Walden House La Clinica de La Raza Malin, Aubry, Gores, Wang, Haddad, and Sankaran Marin Hospitalist Medical Group/Marin General Hospital My Doctor Medical Group Native American Health Center NorthEast Medical Services (NEMS) One Medical Group The Permanente Medical Group/Kaiser Permanente San Francisco Community Clinic Consortium San Francisco Department of Public Health Sonora Regional Medical Center San Francisco Medicine October 2011

SFMS Past-President’s Environmental Health Research

William Goodson, MD, breast cancer specialist and a past president of the SFMS, has been toiling on innovative research for more than a decade. His publication of some results were featured in a cover story in the San Francisco Chronicle in September, with the title “Study: BPA, methylparaben block breast cancer drugs.”

Goodson, a senior clinical research scientist at California Pacific Medical Center Research Institute and lead author of the study published in the journal Carcinogenesis, noted that BPA and methylparaben not only mimic estrogen’s ability to drive cancer but appear to be even better than the natural hormone in bypassing the ability of drugs to treat it.

Goodson notes that his interest in this field developed during meetings at the SFMS and through editorials he wrote in San Francisco Medicine while SFMS president in 1999. He served as faculty at early meetings of the Collaborative on Health and the Environment, founded at the SFMS in 2002. As for the chemical he studied for this paper, as he concluded in the Chronicle, “It’s used so much.

We kind of swim in it.” Goodson plans to continue with more research in this arena.—Steve Heilig, MPH

The Carcinogenesis article: http://carcin.oxfordjournals.org/content/early/2011/09/01/ carcin.bgr196.abstract?sid=ed031383-0b51-49c1-b76802b7b5b80054 The San Francisco Chronicle story: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/09/12/ MN2U1L2ERJ.DTL#ixzz1Y44FJeEu The Collaborative on Health and the Environment: http://www.healthandenvironment.org

Letter to the Editor

The More Things Change, the More They Stay the Same In the June 2011 issue of San Francisco Medicine, George Fouras expresses his surprise about the reaction of some panel members at a recent Future of Healthcare Leadership Summit. George’s reaction rang a bell. Almost fifty years ago (I believe it was 1970) the then-new editor of the journal removed me from the editorial board because of reportage on foreign health care systems that I had written at the request of the previous editor. The reason for the dismissal (I remember it well): “We (the San Francisco Medical Society) do not want to promote socialism.” To me, the editor’s reasoning was startling.

In today’s debate on the health care system, some interests employ scare tactics. These tactics adversely affect the process that leads to the best possible outcome for the country’s health care delivery system. In fact, all groups and interests—patients, providers, institutions, and manufacturers—will be best served if everyone, with no one excepted, recognizes the benefits of a truly national health care delivery system. — Leo van der Reis, MD www.sfms.org

The San Francisco Medical Society and CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000!

Now is the time to take a good look at the SFMS/CMA plan if: • It has been more than one year since you last reviewed your life insurance protection • You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your financial planning no longer seem as secure as they once did Endorsed by:

• You think you may be paying too much • The amount of coverage provided by your medical group isn’t enough and you can’t take it with you if you leave

Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance!

Underwritten by:

Administered by:

Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.

*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice.

51423 (6/11) ©Seabury & Smith Insurance Program Management 2011 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

CA Ins. Lic. #0633005 • AR Ins. Lic. #245544

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