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

ADVOCACY IN ACTION PHYSICIANS OUT FRONT CMA and AMA Policy Precedents Reproductive Health Rights vs Wrongs Practicing in the Pain Pendulum Countering Childhood Trauma The Vaping Wars

Plus: Report from the SFMMS Addiction Conference An AMA Presidential First Volume 92, Number 4 | July / August 2019


SAN FRANCISCO MARIN MEDICINE

IN THIS ISSUE

July/August 2019 Volume 92, Number 4

ADVOCACY IN ACTION FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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President’s Message: Some Shining Lights in the Darkness Kimberly L. Newell Green, MD

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Report from the AMA Annual Meeting Man-Kit Leung, MD

Practicing in the Pain Pendulum: A Visit with Robert Brody, MD Steve Heilig, MPH

10 The David E. Smith/SFMMS Addiction Symposium Toni Brayer, MD 11 Never Seen, Never Heard: The Health of a Homeless Man Michael Schrader, MD, PhD

13 Hard Lessons From Patients: The Good That Can Come When We Stop Seeing Cancer As A “Battle” Sunita Puri, MD 14 Medical Policymaking Can Be Fun—Honest! Michael Schrader, MD

15 Drug Education and Marijuana Legalization: Safety First Marsha Rosenbaum, PhD 17 Reproductive Health Rights; Now More Than Ever Pratima Gupta, MD, MPH

18 Meet AMA’s New President: Patrice Harris, MD on the Opioid Epidemic, Health Equity and More Shannon Firth

20 Let’s Move “Back from the Brink” of Nuclear Apocalypse Robert M. Gould, MD 23 The Stealth Superbug Epidemic: 162,000 Annual Deaths from Antibiotic Resistant Infections, Say New Estimates David Wallinga, MD

24 California Surgeon General Puts Spotlight on Childhood Trauma: An Interview with Nadine Burke Harris, MD Rob Waters 26 Ageism in Medicine: A Talk with Louise Aronson, MD Judith Graham 30 The Juul Delusion: We Don’t Get Fooled Again Steve Heilig, MPH

36 Upcoming Events

COMMUNITY NEWS 32 Marin General Hospital Embarks on New Phase of a Long, Proud History Jon Friedenberg 32 The MERI Center for Education in Palliative Care at UCSF/ Mount Zion Michael Rabow, MD and Redwing Keyssar, RN 33 Saint Francis Memorial Holds Inaugural Transgender Health Conference 33 Cancer and Genetics Maria Ansari, MD, Kaiser Permanente

OF INTEREST

12 A New Battle Against Soda Brews in California 27 CDPH Releases 2018 Data on the End of Life Option Act Coalition for Compassionate Care in California 28 In Memoriam: Erica T. Goode, MD, MPH 36 Welcome New SFMMS/ CMA Members 36 Advertiser Index

Save the Date! SFMMS General Membership Meeting

September 9, 2019, 5:00pm Golden Gate Yacht Club, San Francisco, CA

31 California Takes Historic Step Toward Universal Coverage Sandra Hernandez, MD SAN FRANCISCO

MARIN MEDICAL SOCIETY

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


MEMBERSHIP MATTERS CalHealthCares to Pay $58.6M in Loans for 247 Physicians Who Commit to Serve Medi-Cal Patients Nearly 1,300 health care providers applied to the CalHealthCares loan repayment program, which pays up to $300,000 in debt relief in exchange for meeting certain criteria such as maintaining a patient caseload of at least 30% Medi-Cal patients, being in good standing with state licensing boards and other service time obligations. The awards are intended to improve access to care for low-income patients by creating economic incentives for physicians and dentists to provide care to MediCal beneficiaries. The awardees will be providing services to Medi-Cal patients in 39 counties throughout California. They represent 40 specialty areas of medicine including pediatrics, psychiatry and OB/GYN. Additionally, the awardees vary in different practice settings including academic, community clinic or Federally Qualified Health Centers (FQHCs), government, group practice, hospital and private practice. A total of $340 million has been allocated to the CalHealthCares program from Proposition 56 revenue. The recent announcement of awardees is the first of at least five rounds of funding. For more information, visit www. calhealthcares.org.

Well Physician California Announces New Executive Leadership Team

Well Physician California recently announced its new executive leadership team, including Dave Logan, Ph.D, as Chief Executive Officer and Emily Coriale, PharmD as the company’s Chief Operating Officer. Well Physician California is a joint effort from the California Medical Association (CMA) and Stanford University to target physician wellness and reduce burnout and attrition from the profession. Well Physician California aims to be the most comprehensive program in the country to increase physician wellness and ultimately improve the quality of care for patients.“We are seeing an alarming increase in burnout rates in our profession,” said David H. Aizuss, M.D., president of the California Medical Association. “Dave and Emily have the skills and experience to help oversee the creation and implementation of a program that will help doctors and patients address the growing demands and pressures physicians face.” For more information, go to https://www.cmadocs.org/wellness.

Final MIPS Scores For 2020 Medicare Payments Now Available

If you participated in the Medicare Merit-Based Incentive Payment System (MIPS) in 2018, your MIPS final score and performance feedback are available now on the Quality Payment Program (QPP) website, https://qpp.cms.gov/. The payment adjustment you will receive in 2020 is based on this final score. A positive, negative or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished under the Medicare physician fee schedule in 2020. Read more at http://bit.ly/2y5bv0u..

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Advocacy on Recent Anthem Modifier 25 Policy Continues The CMA, along with the American Medical Association (AMA) and other state and specialty societies continue to voice concerns with the recent implementation of the Anthem Blue Cross policy denying certain evaluation and management (E/M) services submitted with modifier 25. The new Anthem policy will deny an E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record for the same provider (or a provider with the same specialty within the same group TIN). CMA remains very concerned with the adverse impacts of this new policy upon our physician members and is continuing the dialogue with Anthem regarding our concerns. Read more at http://bit.ly/2OaRMYj..

DHCS Instructs Plans on 2018/19 Supplemental Prop 56 Managed Care Payments

On June 13, 2019, the California Department of Health Care Services (DHCS) issued instructions for Medi-Cal managed care plan distribution of the supplemental payments for FY 20182019. While DHCS released funds to the managed care plans in its March capitation payments, it was not until recently that it provided guidance to the plans on the distribution of funds to physicians. The supplemental payments – made possible by the Proposition 56 tobacco tax funding – increase payments on 23 CPT codes, including 10 new preventive codes. More information and a full list of the eligible CPT codes may be found at http:// bit.ly/2M9BEn9.

What Is The Proper Way To Terminate The Physician-Patient Relationship?

There are numerous reasons why a physician may terminate the physician-patient relationship. Physicians, however, should be aware of potential liability, including for patient abandonment, if the relationship is not properly terminated. While physicians do have discretion as to whether to provide services to any particular person, they should be aware that there are legal and ethical constraints on the scope of that discretion such as contractual obligations and non-discrimination laws. For more information about terminating the Physician-Patient Relationship, see CMA health law library document #3503, “Termination of the Physician-Patient Relationship.” This document, as well as the rest of the CMA online health law library, is available free to members at www.cmadocs.org/health-law-library. Nonmembers can purchase documents for $2 per page. Contact: CMA Legal Information Line, (800) 786-4262 or legalinfo@ cmadocs.org..

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Featured Member Benefits: Student Loan Refinancing and PatientPop Technology Solution

July/August 2019

CMA has partnered with SoFi, a leader in marketplace lending, to provide members with a variety of student loan refinancing options, including low-variable and fixed rates with terms ranging from five to 20 years. Visit http://bit. ly/30LgTSI for more information. CMA has recently partnered with PatientPop, the leader in practice growth technology, to help physicians improve their online presence and attract more patients. PatientPop offers an all-in-one technology solution that’s proven to help physicians thrive in the digital age, including online reputation management, social media marketing and search engine optimization. PatientPop will provide CMA members with a free audit to evaluate the competitiveness of their digital profile and a free one-hour consultation to learn how PatientPop can help them promote their practices online, attract new patients and retain them for life. In addition to deeply discounted service fees, CMA members save 50% off their implementation fee. For more information about this exciting new member benefit, visit http://compare.patientpop.com/cma.

Be on the Lookout for the 2019-2020 SFMMS Membership Desktop Reference

SFMMS’ annual member pictorial directory includes San Francisco and Marin physician members with practice information. The directory also includes a physician list by specialty as well as a reference list of local health organizations and services. With a circulation of 1,400 and used by many physicians and office staff on a daily basis, the directory provides a great opportunity for physician members to receive referrals and grow their network. One free copy of the directory is mailed to all member physicians. Additional copies are available for purchase at http://bit.ly/2YhW4Rv.

Volume 92, Number 3 Editor Gordon L. Fung, MD, PhD, FACC, FACP Interim Editor Irina deFischer, MD Managing Editor Steve Heilig, MPH Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Shieva Khayam-Bashi, MD Arthur Lyons, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Kimberly L. Newell Green, MD President-Elect Brian Grady, MD Secretary Monique Schaulis, MD, MPH Treasurer Michael Schrader, MD, MPH, PhD, FACP Immediate Past President John Maa, MD Editor Gordon L. Fung, MD, PhD, FACC, FACP SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Executive Assistant/Office Manager Ian Knox 2019 SFMMS BOARD OF DIRECTORS Peter N. Bretan, Jr., MD Alice Hm Chen, MD Anne Cummings, MD Nida F. Degesys, MD Robert A. Harvey, MD Naveen N. Kumar, MD Michael K. Kwok, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD William T. Prey, MD Justin P. Quock, M Sarita Satpathy, MD Dennis Song, MD, DDS Kristen Swann, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo, MD

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PRESIDENT’S MESSAGE Kimberly L. Newell Green, MD

SOME SHINING LIGHTS IN THE DARKNESS In this moment I could not be more grateful to be surrounded by a community of warriors: Vocal advocates for life, for health, for the families of this nation. It is with a heavy heart that I sit and listen to news stories of

yet more deadly attacks on our citizens, because as a nation we are unable to do what it takes to stop gun violence. The victims are not just citizens: They are sons and daughters, mothers and fathers, brothers and sisters, best friends. I am devastated that the bright lights of their spirits have been extinguished, and my heart goes out to the families of victims all over our country. In this moment I could not be more grateful to be surrounded by a community of warriors: Vocal advocates for life, for health, for the families of this nation. I admit that I sometimes struggle to keep my faith in the power of advocacy as the mass shootings continue unabated; as I continue to hear stories of children removed from their families at the borders of our country; as I read of appalling conditions for all immigrants at our borders. And then I hear the news that companies like Juul are portraying themselves as “public health companies“ when the data is clear: recent studies show that many more e-cigarette users become new nicotine users than quit smoking (on the order of 80 new nicotine users, most of who are youth, for every 1 “quitter”). The powerful and dishonest tactics that have been used by Big Tobacco for years are now contributing to massive youth addiction. Who are the perpetrators of this crime against our youth, I wonder, and how do they sleep at night? And then my distress and cynicism is countered as I read in this issue of San Francisco Marin Medicine about the work of the astounding physicians whose passion and commitment to reversing these tragedies is evident every day. We hear from doctors who fight tirelessly to preserve womens’ right to make their own reproductive choices. We hear from doctors on the front line of treating pain, of finding solutions to homelessness, and of helping youth to make healthy choices in a time of legalized recreational marijuana. When look at the data about improved vaccine rates in Marin county and beyond: as a pediatrician I am so grateful to Senator Richard Pan, MD, who transitioned from a medical office full of children straight into the lion’s den, where as a state Senator he tirelessly pushes to protect our most vulnerable citizens from preventable diseases in the face of massive disinformation campaigns about vaccine safety. Marin County’s numbers demonstrate the power of this brave act and also the tireless work of many public health officials and physicians in the county. WWW.SFMMS.ORG

I am so excited as Governor Newsom and Secretary Dr. Mark Ghaly expand their team and their solidify their plans for the health of Californians, and we are honored to have an interview with California’s Surgeon General, Dr. Nadine Burke-Harris, as she helps the state think about how to identify, prevent and remediate early childhood trauma. There is much more good work going on, and you can read about some of that here, but finally, we would like to dedicate this issue to another tireless physician advocate: Dr. Erica Goode, the “doctor every patient wanted.” A beloved clinician and favorite clinician educator, she was also deeply interested and active in health policy and in nutrition, wrote often for this journal, and herself served as our "obituarist". One of the physicians-in-training who wrote an essay for this journal last fall, Yun Rose Li, wrote: “Life and death are not for a man to decide, but the choice to live life to the fullest is. It is a lesson a physician should never forget.” I trust that the remembrance we include here will not only convince you that Dr. Goode did just that, but also that we should all strive for the same. At SFMMS we continue to build relationships with local and state stakeholders in political, academic, and public health arenas in order to do the important work of advocating for health: The health of all of the citizens of San Francisco, Marin, California, and our country. We are grateful for all of you who are on this journey with us, and hope that many more physicians will join in this vital work. Kimberly L. Newell Green MD is a pediatrician in San Francisco and Assistant Clinical Professor at UCSF. She is the former Chief of Healthcare Innovation and Chief of Physician Health and Wellness at Kaiser Permanente in San Francisco where she practiced as a general pediatrician for over a decade and was a member of the senior leadership team. A graduate of Princeton University, she completed a Fulbright Fellowship in India and produced a documentary film about cross-cultural healthcare at the Harvard School of Public Health.

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REPORT FROM THE AMA ANNUAL MEETING: Man-Kit Leung, MD This past June, I had the opportunity to attend my first AMA House of Delegates (HOD). Along with fellow San Francisco Marin Medical Society (SFMMS) members Dr. Peter Bretan (CMA President-elect), Dr. Lawrence Cheung, and Dr. George Fouras, I sat with medical students and physicians from all modes of practice, from all specialties, from all corners of the country, and from all career stages to discuss AMA policy on a wide range of health-related topics. Although debate was often contentious (at times reminiscent of my home life with two young children), policy was advanced on a number of important issues. Here are some highlights: SFMMS Resolutions This year, SFMMS carried two resolutions via the CMA to the AMA HOD. The first was entitled “Holding the Pharmaceutical Industry Accountable for Opioid-related Costs" and the other “Gun Violence-Compensation for Healthcare Expenditures.” Both resolutions were generally well-received, and final versions with amendments were adopted by the HOD as follows: 1) HOLDING THE PHARMACEUTICAL INDUSTRY ACCOUNTABLE FOR OPIOID-RELATED COSTS

RESOLVED That our American Medical Association advocate that any monies paid to the states, received as a result of a settlement or judgment, or other financial arrangement or agreement as a result of litigation against pharmaceutical manufacturers, distributors, or other entities alleged to have engaged in unethical and deceptive misbranding, marketing, and advocacy of opioids, be used exclusively for research, education, prevention, and treatment of overdose, opioid use disorder, and pain. 2) FIREARM VIOLENCE PREVENTION: SAFETY FEATURES

RESOLVED That our American Medical Association advocate for firearm gun safety features, including but not limited to mechanical or smart technology, to reduce accidental discharge of a firearm or misappropriation of the weapon by a non-registered user; and support legislation and regulation to standardize the use of these firearm gun safety features on weapons sold for nonmilitary and non-peace officer use within the U.S.; with the aim of establishing manufacturer liability for the absence of safety features on newly manufactured firearms guns. I cannot overstate how extremely impressed and proud I am to have witnessed the ideas spawned at our local SFMMS delegation meetings mature to become national policy. Kudos to the authors including Drs. Gordon Fung, Keith Loring, Rob Margolin, David Smith, Shannon Udovic-Constant, John Maa, and, of course, Steve Heilig!

Single Payer Probably the most contentious issue debated at this year’s HOD dealt with single payer. Analogous to SFMMS’ past efforts at the CMA to remove opposition to—but not endorse— a possible single payer system, a resolution was introduced to remove AMA opposition to the concept of single payer. The ejection of protesters who avoided security into the House shouting “Medicare-for-all” preluded the heated discussion. After much debate, the House narrowly voted—47% vs. 53%—to defeat the resolution, thereby sustaining AMA’s current position of “oppose.” What was clear from the discussion, though, was near uniform agreement in support of universal access to quality health care, but how we get there continues to be a controversial subject. 6

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New AMA President–Many firsts Sworn in as AMA’s 174th President during this past HOD, Dr. Patrice Harris is the first African-American woman and first child and adolescent psychiatrist to hold the association’s highest office. Notably, for the first time in history, the Immediate Past President, the President, and the President-Elect of AMA are all women.

State Senator Dr. Richard Pan and U.S. Surgeon General Dr. Jerome Adams Providing testimony alongside California State Senator Dr. Richard Pan and U.S. Surgeon General Dr. Jerome Adams was one of the brightest highlights for me. Dr. Pan testified on the importance of limiting non-medical exemptions for immunizations, a resolution that ultimately passed the AMA HOD and is consistent with CMA policy. Meanwhile, Dr. Adams provided testimony on a multitude of topics including addressing the vaping crisis among youths in America as well as encouraging AMA to study and report back on the health consequences of legalization of cannabis, which could help guide evidence-based federal policy. Address by Seema Verma, head administrator for CMS Verma discussed several topics including the need to reduce administrative burden for physicians, to innovate alternative payment models that emphasize value and quality, to improve interoperability of electronic health records, and to support health plan competition which would conceptually allow increased choice and access to affordable health care. Dr. Hugh Vincent’s Generosity Dr. Hugh Vincent (past President of SFMMS and former chair of the CMA delegation to the AMA) made a surprise visit to the HOD and announced a challenge to the delegates to raise money for the AMA Foundation. He offered a dollar-for-dollar match up to $190,000.

As a result of his amazing generosity, the foundation raised approximately $665,000. As many delegates can attest, participating at an HOD at any level can be a process painful to both the mind and body (especially the buttock). At least for me, however, it can also reinvigorate the soul and renew hope. Despite differences in viewpoints and politics, over 600 dedicated and passionate medical students and physicians sacrificed time away from their livelihoods and families to craft national policy for a healthier America. It truly was a privilege to work among them. Moreover, although parliamentary procedure can be slow and frustrating, I witnessed first-hand how it is the most democratic way to give opportunity for every voice to be heard. In fact, now that I’m back, I might try out parliamentarian rules at home. A good place to start might be addressing my wife as “Madam Speaker.” Man-Kit Leung MD is an SFMMS past-president and representative to the AMA, a graduate of UCSF, and an otolaryngologist and head and neck surgeon in San Francisco.

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Advocacy in Action

PRACTICING IN THE PAIN PENDULUM A Visit With Robert Brody, MD Steve Heilig, MPH As a primary care physician, how did you first get interested in pain management? Right before we saw the first AIDS patient in the early 80’s, I was involved with setting up the first inpatient hospice unit in the UCSF system at SFGH. I later became the medical director of the City-funded AIDS and hospice home care teams, which is where I learned a lot about pain management. Then, in the mid-1980s, SFGH clinicians would come up to our inpatient team - to me, our oncologist, hospice nurse and pharmacist - and say "my patient isn't dying, but he has a lot of pain, can you help us?" Because there wasn't anybody else - the anesthesiologists and neurologists were busy elsewhere and not doing pain management, and because the Laguna Honda hospice unit just opened - our hospice nurse and hospice pharmacist underwent the transition to pain nurse and pain pharmacist. Then in the early’90’s, the surgeons were calling us to come see their post-discharge patients in clinic for pain management. So we said, Let's have an actual pain clinic to do outpatient care too, instead of just inpatient. Soon we were joined by a clinical psychologist trained in pain management, which added immensely to how we understood pain and what we could do for patients. But we were only there 1/2 day per week, so our wait times were months long. It’s only in the last couple years that there are anesthesiologists, physiatrists, and nurse practitioners on board to help with the patient load. What were you seeing most often in pain patients? We see all kinds of pain - somatic, neuropathic, spasm, trauma-related, cancer pain - sorting that out is relatively straightforward. It does take time to listen carefully to understand the patient’s experience of pain. But these various pains come in complicated people, people with substance use disorders, mental health issues, homelessness, incarceration, poverty, psychological and sexual abuse, all of which affect how they respond to their pain and how we need to respond to them. What kind of patient volume do you see? The clinical pharmacist alone on our team sees between 180200 new inpatients a month, and we see more in the clinic. We see some outpatients a couple times and some people for years. Our aim is to stabilize the patient and turn them back over to their primary providers for ongoing management.

There has been much attention paid to undertreated pain, then a focus on the opioid abuse epidemic, and now some swing back to undertreated pain, and many clinicians feel caught in the middle of this. Is that an issue for you? Yes. My career has coincided with these swings of the pendulum. When I was a medical student, the only patients who got opioids were dying of cancer or were immediately post-surgery. 8

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And then, partly through hospice, there was demonstration of how these meds could be used effectively to help patients and use increased to control pain – pain became a problem we could actually do something about, not just in end-of-life patients but in others. The VA had a campaign to make pain a vital sign, and that spread. And we did think that opioids were safe and nobody who got them medically was using them recreationally, but that turned out not to be the case, triggering a huge reaction. So we’re almost back to only dying patients and immediately post surgery patients getting opioids. But the epidemic of chronic pain has not gone away, and in some ways has gotten worse. The patients who were treated with significant doses of opioids, when that was accepted medical practice, and whose function improved on those meds have now been caught when their longtime providers retire or move away or they change insurance and they face new providers who say “No, I’m not going to do that” and they are left with their chronic pain and “substance use disorder.”

Why do you put quotation marks there? Are you saying it’s an iatrogenic condition? Not necessarily, but yes, that’s a question. If you get cut off suddenly from your longtime opioids you are twice as likely to go get them on the streets, and more likely to die from that. And now the loudest voices on the appropriate use of opioids are not the pain physicians but the addiction doctors. There is a big abuse problem, no question, but the regulators have overreacted and a lot of doctors have been scared off.

Are you referring to the overdose death investigations of physicians? Yes, connecting death certificates from overdoses with physicians who prescribed opioids. And what provider in her right mind would prescribe these drugs to a patient who has any hint of going out onto the street for pain relief out of desperation? So we have patients who were functioning on stable doses of opioids for years and their provider leaves, and they are sent back to us. And all we can do is explain the regulatory environment to them, which doesn’t help their pain.

But it’s undeniable that the opioid abuse epidemic and ODs have blown up, and now we have fentanyl in the mix to exacerbated it. So it seems there is an effort both clinically and politically to find a middle path here. Yes, to “thread the needle”. But many of those people never had issues with overdoses and other problems before now. There’s really no easy way to sort this out.

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Right, and even the FDA just admitted they can’t come up with rational dosage limits. How about the current CDC guidelines on prescribing opioids? They’ve made things even worse. Setting a limit to the number of morphine equivalents that can be prescribed is arbitrary. And the guidelines have been interpreted by insurance companies in terms of public safety, but limiting opioids also happens to save them a lot of money.

Do you think a lot of your colleagues have been scared away from prescribing what they might otherwise think as clinically appropriate? Well, I think they’re saying this is what is appropriate now, following the guidelines, when they would have done something different just a few years ago. The effect on the patient is not considered enough. Following these guidelines can be the right thing to do professionally, but the guidelines are so constraining that patients suffer for it. Is this an ethical dilemma for physicians who might know people are being harmed? It’s not seen that way by many providers. Physicians can point to data that shows that if you have nonmalignant pain, opioids don’t help. But individual patients say they don’t care what the data shows, these medicines help them function in the world by decreasing their pain and without them they can’t work, socialize, take care of themselves. And when confronted with data that shows that higher doses are dangerous, patients say that they’ve been taking these doses for years and they are willing to take the risk: the frequent tension of beneficence and non-maleficence vs patient autonomy.

Where do you think this pendulum is going now? We have begun to see a bit of a swing back. Some doctors are saying “Wait a minute, patients are being harmed by these guidelines.” I don’t know how far that will go. There is a backlash against Big Pharma too, regarding all their marketing efforts. Yes, and from what I saw, it certainly was greed, particularly around Oxycontin. And by the way, we don’t even use that preparation any longer, as the reformulation to prevent abuse doesn’t work well as an analgesic and causes more side effects. Are there new developments in pharmacology that make you more optimistic? Absolutely. I am told there are analgesic molecules on the horizon that don’t trigger addiction issues, and more targeted medications coming. There’s reason for hope.

How about the CURES program? Useful or just a hassle? The recent requirement to repeatedly check CURES means it has become another barrier, causing providers to say “Why require me to waste my time going to this website unnecessarily rather than allowing me to use my judgment when I need to see what the patient has been prescribed?” It’s a good tool when needed, but to require it frequent use just makes physicians that much more reluctant to prescribe. WWW.SFMMS.ORG

Do you think it should be optional then? It has been underfunded and difficult to use for many. Right, it should be available as a tool when needed. Even if it worked perfectly administratively, it’s unhelpful and unnecessary unless needed.

What do you think of using cannabis for pain? It’s clear that anxiety increases pain, and anything that reduces anxiety can help with pain. And a lot of people use cannabis for sleep, which is also necessary for pain control. So indirectly, cannabis is useful for managing pain. Whether it has direct impacts is still an open question.

How about pain contracts with patients, are those helpful? “Contract” is the wrong word. A contract is something negotiated between parties, but with these, the provider has all the power to cut somebody off, the patient has none. I think they make it easier for the provider to stop prescribing when there is a violation of the prescribing rules, which is what these are.

There aren’t that many pain specialists and a mixed perception of some of them. The American Pain Society has just declared bankruptcy. They took money from Big Pharma and are being sued and don’t have the money to defend themselves. But they were otherwise a legitimate organization. There has been a mandated CME program for pain, and physicians had mixed experiences with that. Given how central pain is to practicing medicine, do you favor such a mandate of any kind? For one thing, I’d worry about whose voices would be heard – the pain doctors, the proceduralists, the addiction doctors, the palliative care providers? Mandating CME is probably not what needs to happen. Cognitive behavioral therapy and focused psychological services for pain management need to be available, meaning paid for. There needs to be a lot more money put into training, from medical school onward. When there are good resources for treating pain for physicians to use, they will use it. We just need to provide it.

Dr. Robert Brody is a veteran of the everchallenging and shifting problem of treating pain, especially chronic pain, in perhaps the most diverse patient population possible. A clinical professor of medicine and family & community medicine at UCSF, he has practiced for 41 years at San Francisco General Hospital, where he is the founding clinician in the pain consult service and the pain clinic and was longtime chair of the ethics committee there.

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Advocacy in Action

THE DAVID E. SMITH/SFMMS ADDICTION SYMPOSIUM

Toni Brayer, MD

and experiences using psychoacWhat do you get when you combine a healthcare icon, tive substances to treat depreshundreds of passionate parsion, PTSD, end of life, anxiety, addiction and trauma. Smith ticipants, a resurgence of remarked that, for him, this history and cutting edge sciwork had come ‘full circle’ with ence? “You get The Annual all the new grants and research. David E. Smith Symposium – His own studies with psychoacthis year titled “Psychedelic M e d i c i n e , Te c h n o l o g y a n d tive drugs was shut down in the 1960s when the media attenConscious Recovery.” The June conference was standing room tion exploded and all research only at UCSF Mission Bay, hosted was stopped. The new edition by Dr. David Smith and SFMMS’ of the Journal of Psychoactive own Steve Heilig. Drugs, guest-edited by Doblin Drs. Tomas Aragon and Toni Brayer with conference Dr. David Smith, a long time and started by Dr. Smith and also co-chairs David Smith and Steve Heilig SFMMS member (he received in its 52nd year, has “Psychedelic his 50-year member pin last year), started the Haight-Ashbury Research Today” as a theme and was handed out to all attendees. Free Clinic in 1967, when he was a recent UCSF graduate and The lunch break featured a striking presentation by “Rock to witnessed the huge influx of young seekers, soon to be labeled Recovery,” wherein participants of all backgrounds participated “hippies,” in the neighborhood. During the “Summer of Love,” this onstage in the creation of a moving, self-affirming song. For this clinic became a national model for compassionate care, as well particular performance, the “band’ was christened “David Smith as a training site for UCSF medical students. The Haight Ashbury and the Psychedelics.” Clinic provided care for tens of thousands of people during the The afternoon panels were on the “conscious recovery” counterculture of the 60’s and 70’s, providing substance abuse theme, also with a slant on how new technologies developed in treatment, mental health services and medical attention in a safe Silicon Valley and beyond are being applied in the drug treatment and professional environment. field. All seemed in agreement that with this particular disease In subsequent decades it evolved into a San Francisco instituor syndrome, a holistic, multidisciplinary approach is always indicated. Even with striking improvements in therapy, there’s tion, with millions of patient visits. In the same era, Rock Medino “magic bullet” in healing addictions. cine was started by the doctors that staffed the clinic and has The closing speaker was UCSF School of Medicine Dean of Eduprovided care for thousands of concert-goers ever since. Fiftytwo years later, the clinic still operates as part of Healthright 360, cation Catherine Lucey, MD, who gave a moving account of being and the Symposium is an outgrowth of the decades of research spurred into action on this problem by the overdose deaths of both and knowledge gained. a medical student and a member of her own family – both in their Public Health Officer for San Francisco, discussing how San twenties. She outlined the many longstanding deficiencies in care Francisco has responded to substance abuse trends. He highand training in medicine, and UCSF’s new efforts to remedy them. lighted the need for more buprenorphine treatment for opiate The participants sitting in chairs lining the walls stayed till the users, and a more aggressive approach to minimizing the harms end and the breaks were filled with networking and sharing of associated with marijuana use, especially in young people. ideas. I appreciated the chance to hear these experts and witness For the session on the resurgence of mainstream research on the beginning of a new age of pharmacology and more. Judging psychedelic medications, he was followed by keynote speaker Dr. from this year’s turnout they better get a bigger venue for next Rick Doblin, founder of the Multidisciplinary Association for Psyyear’s symposium! chedelic Studies (MAPS). Dr. Doblin is a true pioneer in the field of psychoactive substances and their use in treating a number Toni Brayer, MD, a past-president of the of disorders, and has spearheaded the re- starting of approved SFMMS, is a practicing internist and has studies in many sites for many substances. After decades of clanbeen Chief Medical Officer for Sutter Health's destine use and inability to legally study these medicines, we West Bay Region. She is past CEO of the are now entering “Psychoactive Age 3.0” with research being Sutter Pacific Medical Foundation and on conducted around the world. the board of the Medical Insurance Exchange On a following panel discussion moderated by Heilig, other of California. experts, including from UCSF and Stanford, reviewed their studies 10

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NEVER SEEN, NEVER HEARD: THE HEALTH OF A HOMELESS MAN Michael Schrader, MD, PhD Ron lives in the woods in San Francisco near where the Golden Gate becomes the Pacific. “He has been chronically homeless for 30 years. He has been my patient for almost 18 years. During that time I have treated him for acute and chronic conditions complicated by homelessness. And he is my neighbor: I often stop to talk with him on the street when I am out running or walking the dog. Ron may be a little different from the homeless we see sprawled on the sidewalks of San Francisco. He does not use drugs or alcohol and is a seasoned outdoorsman. He dresses neatly in camouflage and carries his belongings in a rucksack. He has a semi-permanent campsite that he moves only when he has to. He has shown me pictures: he keeps a clean camp. He is affable and intelligent and speaks with a Southern accent. He lives somewhere off the Lands End Trail in the Golden Gate National Recreation Area, a beautiful park on the crumbling cliffs overlooking the outflow of the San Francisco Bay to the Pacific. Foggy and cool for most of the summer, it is storm-whipped, cold, windy, and wet in the winter. The trails can be slick and bushwhacking can be perilous. When I first met Ron he had been referred to me for a preoperative evaluation for a lumbar laminectomy. He was 46 years old. At that time he was being treated for PTSD that resulted from a terrible accident in Georgia where his wife and children were killed by a runaway truck. Ron had worked as a truck driver himself but was disabled from PTSD. He was taking medications and receiving counseling from an outpatient public mental health clinic. He was a smoker and overweight but healthy enough to be at minimal risk for cardiopulmonary complication from surgery. His problem was after surgery care—he couldn’t go back to sleeping on the ground in a tent perched on a ledge on a steep hillside. He had arranged temporary housing after surgery in a single room occupancy hotel through public assistance. But Ron hated those places with their constant noise and drug-dealing neighbors. It wasn’t restful, but it was inside. The laminectomy was successful and Ron returned to his camp in the woods. I saw him regularly for routine healthcare maintenance. He continued to smoke, but of course got regular exercise clambering in and out of his hidden camp to get his food and supplies. One day Ron came to see me after falling on a muddy slope. He had contusions and abrasions but no fracture or sprain. I dressed his wounds and arranged a follow up WWW.SFMMS.ORG

appointment. Several days later he returned with a recurring fever. The source was not immediately evident so I ordered blood tests and cultures. He was hemodynamically stable and I thought him well enough to return to his camp. Two days later both blood cultures grew Gram-positive cocci. I tried to reach Ron on his cell phone but there was no answer. The next day the final identification from the cultures was S. aureus. Besides his cell phone I had no other way of reaching Ron: He had no emergency contacts and I had no idea where exactly his camp was. I was very concerned but could think of no way to find him. A day later Ron returned my call and I sent him to the emergency room to be admitted to the hospital. He had a psoas muscle abscess requiring surgical debridement and a six-week course of antibiotics. He finished the course of antibiotics in a hospital-based skilled nursing facility. He was happy to be inside during those several weeks as it was winter and his camp was whipped by rain and strong winds. I may have extended his stay an extra weekend partly so he could watch the Super Bowl. I believe the source of the S. aureus to be from recurrent suppurative hidradenitis of the groin probably made worse by limited access to bathing. Ron was treated with numerous courses of antibiotics over several years and had surgical debridement of them on several occasions. Ron’s PPD test converted to positive fourteen years ago and he was treated with a nine-month course of isoniazide. He tolerated the treatment well and has had no evidence of active tuberculosis. Over the years he has had his right hip replaced, an inguinal hernia repair, several additional back surgeries, and bilateral cataract surgeries. Over the years Ron has developed Type 2 diabetes. Initially he was managed with diet but that was problematic. He of course has no refrigerator which limits his ability to store fresh food. He has a limited ability to cook on a camp stove. His food must be carried in to his camp and stowed safely from animals. Consequently his diet is high in carbohydrates, salt, and fat. His diabetes has worsened and become poorly controlled. He had acute pancreatitis probably as a side effect of metformin. He lost considerable weight and developed chronic pancreatitis for which he takes replacement enzymes. He is insulin-dependent but is unable to refrigerate the insulin. Recently Ron started using a mail order pharmacy that refused to send his diabetic supplies continued on page 12

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Advocacy in Action and medications to his post office box. I suggested he have it mailed to my office instead. I believe he has switched back to a local pharmacy despite the higher cost. Two years ago Ron came to my office without an appointment because he had been assaulted and robbed during the night. He had been hit on the head and been unconscious for an undetermined amount of time. I determined that he was neurologically intact and sent him to Saint Francis for a CT scan of the head to rule out subdural hematoma. Since the attack occurred in the Golden Gate National Recreation Area I contacted GGNRA Park Police who sent an officer to my office to take his statement. Ron believed that his assailants, two men and a woman accompanied by a dog, were users of methamphetamine who were looking for cash that homeless often carry. The area Ron lives in has a number of homeless that Ron knows are chronic methamphetamine users. Ron had symptoms of post concussion syndrome for several months but has now recovered. He moved his camp to a more inaccessible location. His chronic ongoing medical problems include diabetes, chronic pancreatitis, and hyperlipidemia. He has quit smoking and restarted, but his level of smoking has greatly decreased. Through these 18 years Ron has had insurance through Medicare and has received good medical care. He will be 65 this year and finds that living in the wind and the rain is getting harder. He would like to move inside. His friend Cal died several years ago after decades of living in the outer Richmond and the GGNRA. Cal would not even use the tarp Ron gave him to stay dry when it rained. He was known as the Birdman because he fed the birds from the bag of chips he always carried. Cal was obese and a veteran. Ron found him obtunded on the ground and called paramedics who took him to San Francisco General. Ron asked me to help him find out Cal’s condition. I told him that would be a HIPAA violation, and he didn’t know Cal’s last name anyway. He later heard Cal had died in the hospital.

Ron’s health history is emblematic of the problems that the homeless face: exposure to violence, exposure to the elements, exposure to infectious disease, insufficient hygiene, unhealthy diet, the collateral effects of drug abuse, and social isolation. The mortality rate for unsheltered homeless is 10 times that of the general population.1 He has applied for housing and has been waiting for years. San Francisco assigns housing priority for those with drug and alcohol problems, the mentally ill, and those with HIV/AIDS. But not for him. I obtained records from the psychiatric clinic where he used to be seen, and I wrote a letter stating that he still had PTSD despite no longer being on medications. He is still waiting. I recently asked Ron what he thought the most important services homeless people need. He said: housing, supportive services, mental health care, and medical care. What every member of our community needs. Ron may not be a typical homeless person, but there may be no such thing. Each homeless person has a unique narrative of his or her misfortune. Michael Schrader, MD, PhD, is a longtime internist in private practice in San Francisco, on the board and treasurer of the SFMMS, vice-chair of the SFMMS delegation to the CMA, and a clinical professor at UCSF.

References 1. Roncarati JS, Baggett TP, O’Connell JJ, et al. Mortality Among Unsheltered Homeless Adults in Boston, Massachusetts, 2000-2009. JAMA Intern Med. 2018;178(9):1242–1248. doi:10.1001/jamainternmed.2018.2924

A New Battle Against Soda Brews in California Zaidee Stavely

Doctors, dentists and public health advocates are gearing up for another battle with the soda industry. Several organizations, including the American Heart Association, the California Medical Association and the California Dental Association, among others, announced Wednesday that they are joining forces to push for a statewide tax on sugar-sweetened beverages.

It’s the latest in a long war against soda in California. First, a handful of cities, starting with Berkeley in 2014, passed local taxes on sugar-sweetened beverages. Then, last year, the soda industry fought back by pushing for, and eventually achieving, a 13-year ban on more local soda taxes. The new coalition, Californians for Less Soda, aims to either push for passage of AB 138, or to organize to put a measure on the 2020 ballot to impose a statewide tax on soda and other sugarsweetened beverages. Dr. John Maa, chairman of the American Heart Association’s California Advocacy Committee, said over the past decade the country has witnessed an explosion of obesity and Type 2 diabetes, 12

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including among children. Type 2 diabetes used to be seen almost exclusively in adults, which is why it is also called “adult-onset diabetes,” but Maa said pediatricians are increasingly diagnosing children with this type of diabetes. He said 1-in-3 children born in the year 2000 are expected to develop Type 2 diabetes in their lifetime. In the African-American and Latino communities, he said the rate is even higher — 1 in 2. “Part of the reason is that kids on average drink up to a bath tub of sugary drinks per year. That’s 30 gallons per year,” Maa said. “This could be the first generation where our kids live shorter lives than their parents in our history. That’s why it’s so urgent to act.” A statewide tax of 2 cents per ounce could reduce consumption of sugary drinks by 15 to 35 percent, according to the Legislative Analyst’s Office and could reap an estimated $4 billion a year. The coalition says at least half of the funds should go toward promoting health among children and youth and toward reducing health disparities between different communities. From Edsource.org

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HARD LESSONS FROM PATIENTS: The Good That Can Come When We Stop Seeing Cancer As A "Battle" Sunita Puri, MD W h e n A l ex Tr e b e k , t h e longtime “Jeopardy” host, revealed to the world that he’d been diagnosed with Stage 4 pancreatic cancer this spring, his statement echoed the words of many patients I’ve treated. “I’m going to fight this,” Trebek promised. “I plan to beat the low survival statistics for this disease.” Though I mourned his diagnosis, I also winced at his use of the familiar language of “fighting” and “beating” cancer. As a palliative care physician, I know patients can find it empowering to describe their approach to illness as a battle. But others have shown me that the language of “fighting” a disease or “giving up” is a toxic binary. It divides the sick into winners and losers — those who beat cancer and those whom cancer beats. This militaristic approach to sickness is perhaps rooted in the notion that our personal outlook on disease can change our biological outcomes. But in my experience, these words just as often stand in the way of honest, vulnerable conversations about fear and anxiety, and the peace and dignity most people want as an illness worsens. For some, fighting words are armor that doubles as a veil. What they mask is what interests me. One of my patients, a woman in her 50s named Janey, recently declared that she wasn’t about to “wave the white flag.” Diagnosed two years earlier with stomach cancer that had spread to her liver and bones, Janey came to the hospital with severe pneumonia. Once a personal trainer, she had lost so much weight that I could wrap my fingers around her upper arm. Surgery and multiple rounds of chemotherapy hadn’t kept her cancer from growing. But knowing this didn’t stop Janey from asking about the next surgery or medication she could have. “I might look weak, but I want to keep fighting,” she told me, squeezing her husband’s hand. I asked her to help me understand what that meant to her. Could it be freeing rather than disempowering to understand that the body — born of nature and subject to its laws — has its limits? Had I met Janey seven years ago, when I was still a medical resident, I wouldn’t have had the courage to probe for a deeper explanation. When I didn’t know any better, I performed CPR on WWW.SFMMS.ORG

dying patients because they’d told me they wanted “to fight till the last breath.” Using ventilators and dialysis, I prolonged the deaths of patients who told me they wanted “everything” done. I thought I was honoring their wishes. I see now that I didn’t actually know their wishes; I’d projected on to them my own notion of what fighting disease meant — maintaining life even at the cost of its quality. I couldn’t see that although a patient might call herself a fighter, perhaps her body simply couldn’t battle anymore. When I sat down next to Janey and asked her to define “fighting,” she cried. “I feel like if I don’t do every single treatment possible, it’ll be like giving up on my family,” she said. “But being here in the hospital keeps me away from them.” Getting chemotherapy and going to the hospital had begun to make her increasingly anxious. Blood tests hurt more and more as her veins became harder to find. She hyperventilated during an MRI, fearing the results. When she became dizzy and passed out in the hospital, she’d wanted to ask her oncologist if she was dying, but she couldn’t bring herself to project anything other than a positive outlook. “I’m not a quitter,” she told me, “but I think fighting this is killing me.” “Keep the faith and we will win,” Trebek said in his statement. It’s a sentiment that patients and doctors alike cling to when an illness advances despite our best efforts to restrain it. But could it be freeing rather than disempowering to understand that the body — born of nature and subject to its laws — has its limits? That no matter how strong our determination to live, our bodies will eventually die? If the language we use reflects our cultural attitudes, then our perspective on illness and death, and the metaphors we use to discuss them, must evolve together. Maybe cancer and heart disease and organ failure aren’t battles to win or lose, but illnesses that we strive to treat. Maybe a patient living with cancer isn’t a warrior, but simply a human being struggling to live well and survive while contending with her mortality. Our bodies and lives are infinitely more than battlegrounds. continued on page 14

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Advocacy in Action Janey couldn’t loosen her grip on the terms “fighting” and “giving up,” but she came to realize that her focus on outsmarting cancer had compromised her sources of joy. After two more hospitalizations for pneumonia, Janey enrolled in hospice. She told me that fighting for her comfort — being at home, lucid and free of pain — mattered more to her than pursuing the clinical trial her oncologist had mentioned. However limiting it may be, I know I will continue to hear the language of war from my patients. And like an accidental linguist, I will keep examining it for its true meaning. The fight for our lives shouldn’t result in the loss of the lives we want to lead. Challenging and even resisting such fighting language might help us to see more clearly that one person’s choice for hospice can be just as courageous as another’s choice to enroll in a clinical trial. Janey, back at home, sent me a photo of her family gathered around their dinner table, another of her daughter’s perfect

report card. She emailed, wondering whether patients who step away from the fight die sooner than those who soldier on. Her husband called one month later to tell me that she had died in her sleep, alert and clear-minded until the end. “I think she came to see that letting go and giving up aren’t the same thing,” he wrote to me. I keep his card taped to my desk.

Sunita Puri, MD is a graduate of UCSF and the medical director of palliative medicine and supportive care at Keck Hospital and Norris Comprehensive Cancer Center of USC. She is the author of “That Good Night: Life and Medicine in the Eleventh Hour.” The original version of this piece appeared in the Los Angeles Times.

MEDICAL POLICYMAKING CAN BE FUN – HONEST!

Michael Schrader, MD

Did you ever want to help form healthcare policy but didn’t quite know where to start? Maybe you want to correct a problem or just have a new idea that could change the world. The resolution process is a good place to start and easier than you might think. I was at a social function discussing SFMMS resolutions with a longtime member and he asked whether writing a resolution was like writing a term paper. I told him it was more like writing the outline for a term paper and then having other people do the research for you. The format for a resolution is simple: several “whereas” clauses to frame the problem with background and evidence, followed be “resolved” clauses to suggest a course of action the CMA should take if the resolution is adopted. Generally these are concise with a length of about one page. They may include footnote references. Once finished these are reviewed by the SFMMS delegation and if approved, submitted by the SFMMS to the CMA. The CMA has a quarterly review process and year round adoption of resolutions. Resolutions are analyzed by CMA staff for background information and financial impact. Resolutions are then presented on the CMA website for commentary by delegations and individual physicians statewide. The next step is evaluation by CMA committees and subcom-

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mittees. Once online testimony closes, all testimony is gathered and presented to the respective council members. The recommendation is then presented to the delegates again for further testimony before being sent to the Board of Trustees for final review. Actions are made to refer resolutions to the CMA Board of Trustees for adoption as official CMA policy. The Board of Trustees can adopt the Council’s recommendation or to revise it. In addition some resolutions are submitted to the AMA for consideration as AMA policy. Resolutions that are adopted as CMA policy and have a clause that is to be “referred for national action.” The California resolutions committee chair, Dr. Lawrence Cheung, works with staff to refine the resolution and submits it to the AMA HOD for consideration. He will also work with other delegations to gain support for CMA resolutions. Many great resolutions have started with the SFMMS and have gone on to become state and national policy – not only at the CMA and AMA but in governmental legislation and law. Take a look at the two-page “Tradition of Advocacy” list of issues at the end of this journal – almost all of those topics were first addressed as SFMMS policy resolutions. If you are interested in writing a resolution and need some guidance, please contact one of us for help. We don’t want ANY good ideas for a resolution wasted. WWW.SFMMS.ORG


DRUG EDUCATION AND MARIJUANA LEGALIZATION: SAFETY FIRST Marsha Rosenbaum, PhD Like many parents, when my children entered high school, I wished “the drug thing” would magically disappear and my kids would simply abstain. Yet as a researcher supported by the National Institute on Drug Abuse, a drug policy expert, and a resident of the San Francisco Bay Area, I knew this wish to be a fantasy. Today, as a parent and now a grandparent, my worries center around two hot button issues: drug education and marijuana legalization. My concerns about drug education began during my tenure as a research sociologist, when I interviewed hundreds of men and women who were addicted to heroin or in medically assistant treatment, mostly methadone maintenance. Many talked about the so-called drug education they had received in high school. They had been told that marijuana would automatically lead to hard drugs and inevitable addiction. Yet in the real world, they saw that most marijuana use did not, in fact, lead to such dire outcomes. Consequently, too many dismissed all the anti-drug messages they heard, opening the door to experimentation with opioids. These troubling stories about counterproductive drug education struck me, so I joined the Drug Policy Alliance, and my research shifted from opioid addiction to drug education. What I learned upon further investigation of drug education was deeply troubling. With abstinence as the goal, teenagers were being told, like the heroin addicts I’d interviewed, that marijuana would lead (among other problems) to harder drugs, lung cancer, and brain damage. The ultimate, and only message was the simplistic “just say no.” Most programs have been aimed solely at preventing drug use, and after instructions to abstain, the lessons end. No information is provided about how to avoid problems or prevent abuse, for those who do experiment. Abstinence is treated as the sole measure of success, and the only acceptable teaching option. As a realistic parent, I believed, and continue to believe, that abstinence is a noble goal, and the best choice for teenagers. But this approach is clearly not enough. Instead, what’s needed is a fallback strategy that, like the modern sexuality approach, includes comprehensive education that puts safety first. That's why, back in 1999, an effort to help other parents navigate the “drug thing,” I wrote Safety First: A Reality-Based Approach to Teens and Drugs. Since its original publication, this 40-page resource been distributed, in print and online to WWW.SFMMS.ORG

over half a million parents and educators, including PTAs, government agencies, and schools all over the world. The 7th edition of the booklet was updated in May of 2019, and is free and available, online or in print, through the Drug Policy Alliance or the California State PTA. Legalization of marijuana is another area of concern. Since 2012, eleven states have legalized marijuana for recreational use, and over half have decriminalized possession of small amounts and/or legalized for medical purposes. These laws apply to people over the age of 21, with very limited exceptions for young people with a clear medical need. Voters passed these initiatives not as an endorsement of marijuana per se, but as an effort to undo the damage done by its criminalization: out-of-control youth access, massive numbers of arrests, and the crime, corruption and violence that comes with a multi-billion dollar illicit market. Tax revenues derived from sales had the potential to provide local and state governments with badly needed funds for education and other critical services. Today, the end of marijuana prohibition increasingly seems inevitable, with a majority (66%) of Americans favoring legalization, and three-fourths believing marijuana will eventually be legal nationwide. Since protecting youth has been acknowledged as a top priority, each of these new laws clearly specifies that legalization applies to adults only and contains built-in safeguards that restrict sales to minors. Still, many worry that legalization might "send the wrong message," leading to an escalation in teenage use. Recent data about post-legalization teenage marijuana, fortunately, is encouraging. The annual Monitoring the Future survey of high school students' drug use found recently that a majority of teens say that even if marijuana was legal, they would not try it. Recently, numerous researchers have looked at teen marijuana use in states that have legalized. Their findings clearly indicate that marijuana legalization has not led to any increase in teen marijuana use, and in some cases, use has actually decreased. Here’s where quality drug education and marijuana legalization come together, and we have an opportunity, indeed an obligation to re-think our approach to drug abuse prevention and education — both in school and at home. Let’s face it. Teenagers have used marijuana, along with alcohol, pharmaceuticals, and a host of other intoxicants, for decades. continued on page 16

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Advocacy in Action Parents and educators have consistently advocated abstinence, but despite our admonitions and advice, significant numbers of teenagers have continued to "experiment." Legalization presents just one more challenge, as marijuana becomes a normal part of the adult world, akin to alcohol. It's time to get realistic, devise and advocate for innovative, pragmatic strategies for dealing with teens and marijuana and other drugs in this new era. The drug education model I recommend is Safety First: Real Drug Education for Teens—a new, “harm reduction” curriculum for high schools that provides honest, science-based information on the range of substances available to teens today. This approach, devised by educators, delivered in health classes and consistent with National Health Education Standards, advocates abstinence, but encourages moderation, if experimentation persists, as well as an understanding of the legal and social consequences of drug use. Classes take an especially close look at marijuana, legalization, and vaping. An added benefit for teachers is that schools have a unique opportunity to use legalization to enhance civics lessons, in real time, about the process by which laws are made and how and why they are changed. Surely this will capture students' attention. They must understand that legalization applies only to adults, and the significant legal and social consequences of marijuana use remain mostly unchanged for them until they reach the age of 21.

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Many parents today have direct experience with marijuana and are in a quandary about how much to reveal to their kids about their past or present use, fearing honest admissions might open the door to their teen's experimentation. In states where it's legal, some wonder whether it's appropriate to consume marijuana openly, modeling responsible behavior, as they would with alcohol. As a mother myself, I know that there are no easy, simple answers to these questions. Ultimately, sound science, education, openness, loving communication, and most important, safety, should guide our approach to teens, marijuana, and other drug use—whether these substances are legal for adults or not.

Marsha Rosenbaum, PhD, is a former National Institute on Drug Abuse researcher with extensive expertise about drug use, abuse and treatment and Director Emerita of the San Francisco Office of the Drug Policy Alliance. She is the author of numerous books, scholarly articles, opinion pieces, and most recently, Safety First: A Reality-Based Approach to Teens and Drugs.

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REPRODUCTIVE HEALTH RIGHTS; NOW MORE THAN EVER

Pratima Gupta, MD, MPH

When our patients come to us, do you think they are expecting our comprehensive medical expertise or lies and limited options? It shouldn’t be up to ideological politicians to make decisions about our health care. That’s a decision someone should make with their family and a health care provider like us. In February, the Trump administration posted destructive changes to the Title X national family planning program. Often referred to as the Title X Gag rule, it would make it illegal for doctors, nurses, hospitals, community health centers, and any other provider in the Title X program to tell patients how they can safely and legally access abortion and limit birth control options. At the end of April, a federal judge in San Francisco granted a request for a preliminary injunction, to halt implementation of these harmful regulations in California. The 9th U.S. Circuit Court of Appeals in July lifted those injunctions, and the same court rejected emergency bids to overturn that decision. That allowed the restrictions to go back into effect while court challenges proceed. Let’s be clear- this Gag rule is yet another attempt to take away women’s basic rights. The result of this Gag rule is that people will not get the health care they need. Internationally this has long been demonstrated to be true, and a recent Lancet study confirmed that such a policy actually decreased contraceptive use and increased abortions, many of them unsafe, by 40% in Africa – accomplishing the exact opposite of what proponents say they desire. We can expect similar results in the United States. Physicians practice medicine. Politicians should not. Recently, I saw a young white woman who got pregnant since she was unable to refill her birth control prescription. I was able to counsel her about all her options and after consultation with her partner and her mother, she decided to terminate the pregnancy. I performed her abortion - we should proud of this care in California since this is how it should work. Abortion bans are also rampant and this year- at least 15 states have introduced a variety like Alabama's and Georgia’s. These bills are part of the anti-abortion movement’s coordinated strategy to eliminate abortion, criminalize pregnancy, and exert control over the reproductive autonomy of people nationwide. Everyone, regardless of their race, of their income, or where they live, deserves the best medical care and information available. Under this rule, they won’t get it. When we stand against these sham laws we are standing up for women who have the least access to care. We need to ensure that ALL women, no matter what their zip code, have access to the care they need and deserve. Thankfully, California officials and health professionals reject this gag rule, alongside the medical community, lawmakers and public health experts. Here are some things you can do now: • Follow and donate to the groups who are on the ground in Alabama and Georgia: The P.O.W.E.R. House, SisterSong, the WWW.SFMMS.ORG

Yellowhammer Fund, and the Feminist Women's Health Center. We need to listen and learn from them about what they need. • Support national reproductive rights organizations such as Planned Parenthood and the National Abortion Rights Action League. • Consider authoring op-eds and letters in your local media and beyond, and post on social media so that folks know what is happening and what the stakes are. • Use your medical knowledge and authority to educate others and speak out on these issues wherever possible. • Join Physicians for Reproductive Choice and Health (PRCH), a physician-led national advocacy organization. • Vote, with reproductive health positions and evidence in mind since health care is indeed political. Pratima Gupta, MD MPH is an OB/Gyn, abortion provider, Third Vice Chair of the San Francisco Democratic Party, and Legislative Chair of the Women's Caucus of the California Democratic Party.

Toward An Evidence-Based Reproductive Bill of Rights and Health Steve Heilig, MPH and Pratima Gupta, MD

• Include the right to reproductive choice in every State Constitution; • Make insurance coverage of all FDA approved contraception mandatory as in the ACA, without religious exemptions; • Make medical abortion fully covered and as widely available as possible, including at University clinics and OTC where appropriate; • Mandate evidence-based sexual health education in every school, public or private, with information on all real medical and counseling services available; • Include education on the need for and provision of abortion in every medical school curriculum • Oppose and do not comply with any “gag rule” restricting free and confidential discussion of all medical options between physicians and their patients. • Support real financial and other support for pregnant women and new mothers in poverty and otherwise vulnerable to making healthcare decisions they might not otherwise want. JULY/AUGUST 2019

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Advocacy in Action

MEET AMA’S NEW PRESIDENT: Patrice Harris, MD on the opioid epidemic, health equity, and more Shannon Firth Patrice Harris, MD, became the 174th president of the American Medical Association (AMA) during the House of Delegates annual meeting in June. She is the first African-American woman to assume the presidency. Harris is an Atlanta-based child psychiatrist who has held leadership positions in the American Psychiatric Association, Georgia's Psychiatric Physicians Association, and the Medical Association of Georgia's Council on Legislation. She has been on the AMA's Board of Trustees since 2011.

Diversity — obviously, it's a big deal that you were elected the first African-American female president of the AMA. You're turning the tide on some of the beliefs about the AMA; still, the faces of medicine don't match the faces of your patients, as you said in your inaugural speech. Harris: I am privileged to be tangible evidence to girls and boys from communities of color that, yes, you can aspire to be a physician, and you can aspire to even be the president of the AMA. I consider that an honor.

But an organization should never rest on its laurels. There will always be opportunity to improve. Harris: We always want to strive to increase the diversity of the physician workforce because we know that has an impact on health equity. For instance, we've had some studies that show that African-American men are more likely to listen to their physicians if their physicians look like them. We certainly need to do a lot of work, and by we, I mean just more than the AMA. We need medical schools, and the business community, and all of the partners to make sure we start earlier, looking at pipeline issues. In my speech, I specifically mentioned African-American men; we are seeing just an unacceptably low number of African-American men who are entering and graduating from medical school. I highlighted that [in the AMA speech] because we need to make that a key point, but it is by no means the only area where we need to increase the diversity of the workforce. It's workforce and leadership. Women have been hovering a little over 50% of the medical school class over the last couple years. Diversity and inclusion is not just about numbers, and it's not just about bringing folks into the door. It's about making sure they stay there and then also they aspire to leadership positions. One of the goals you mentioned in your speech was to see an end to the opioid epidemic "on the horizon" a year from now. What are the challenges to making that happen? Harris: Too many people are dying from this epidemic — dying preventable deaths. We really need to eliminate the barri18

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ers to treatment for those who have a substance abuse disorder. We've seen a reduction in the number of prescriptions, and physicians are enhancing their education, but again, the epidemic has evolved and now we are at a critical juncture. We're making sure that everyone, no matter what the opioid, has access to medication-assisted treatment; right now, we're two in 10. We need to get that to 10 out of 10 people who need and want treatment for an opioid-use disorder. We need to make sure 10 out of 10 get it at the right time.

The AMA Opioid Task Force, which you lead, has helped some states to eliminate burdensome requirements (prior authorization) for medication assisted treatment. Can you speak about those advances, and other efforts that you think will make a difference? Harris: When physicians have to pick up the phone and call for authorization to treat someone with an evidence-based treatment, that delays care and could mean death. We've been been able to have success in Pennsylvania, and several other states, to eliminate the need for prior authorization. We need that in all 50 states, and that's what I'd like to see next. The other big issue is parity, ensuring equal coverage for behavioral and physical health services. Parity laws have been federal law for 10 years and some states have their own parity laws. Still, many states have not even completed the evaluation to see where their payers are. We are working with all the partners to make sure states' insurance commissioners are evaluating the payers in their state. Once they identify who is, who's not, what the barriers are, what the problems are, they can work towards solving those problems. WWW.SFMMS.ORG


The AMA House of Delegates approved a resolution related to the access and privacy of substance use records, related to a provision known as 42 CFR Part 2. How do you think making these behavioral health records more easily available to doctors will affect patients, and physicians' care of those patients? Harris: The goal of that resolution was to eliminate the silos, because 42 CFR Part 2 did require some data to be separate. There was a reason for that. That was because there were some issues with stigma and discrimination associated with having a substance-use disorder. Now, we know that we have made progress since then, and so the authors of that resolution want to make sure that there's better coordination of data, and the data is integrated while protecting policy. The policy making is the start. The next step is working together to implement that policy. The implementation is still to be determined but, of course, the goal is to better coordinate the data while making sure that privacy protections and confidentiality are maintained.

There was a protest on the House floor at the start of the AMA meeting by "Medicare for All" advocates. How can the AMA stay in the conversation around healthcare while it continues its opposition to this and other single-payer plans? Harris: The AMA is always willing to look at ideas. We just have our own metrics by which we will evaluate specific proposals. You could probably ask 10 people how they define single payer, and you might get 10 different answers. You could ask 10 people what they mean by "Medicare for all" or a public option, and you will get 10 different answers. The key is the AMA is focused on patients and principles. Just because "Medicare for All" may not be our preferred policy does not mean we won't have a conversation. In fact, I think our House of Delegates is a solid demonstration that we are always willing to have a fair-minded, evidence-based policy debate about different proposals. Shannon Firth is Washington Correspondent , MedPage Today, where the original version of this interview first appeard.

The issue of health equity came up several times during the meeting; How do you plan to move the needle on health equity? Harris: Last year, the House [of Delegates] passed recommendations from the task force on health equity, and one of the main recommendations was to create a Center on Health Equity, and have that center be the lynchpin to move our work -- and our commitment to that work -- forward with a clear understanding that health equity and issues around diversity and inclusion need to be embedded into the DNA of our organization, in all of our work that we do.

As a child psychiatrist in a large city with a diverse population, where do you see these inequities, and how would you like to see that change? Harris: I recently testified before Congress regarding maternal morbidity and mortality. We know that African-American women are dying at increased numbers in up to a year after childbirth, even African-American women who are well educated and who have insurance. African Americans also get diagnosed with colon cancer later. In so many health issues in our country, people from communities of color live sicker and die younger because of lack of access to health, or because of other determinants of health, such as lack of transportation in rural areas. Going back to maternal morbidity and mortality, if there's not an option for you to get prenatal care that's close by and you don't have transportation, it would be difficult for you to get that care. When you don't get the prenatal care, you're more likely to have adverse outcomes. In regards to mental illness, we know people who have serious and persistent mental illnesses also die younger. Now, there are many causes of that. One is smoking and tobacco use. We then have to look at why is that particular community dying 25 years earlier? Those are what I mean by health inequities that I see in Atlanta, and across this country.

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Advocacy in Action

LET’S MOVE “BACK FROM THE BRINK” OF NUCLEAR APOCALYPSE Robert M. Gould, MD A s h e a l t h p ro f e s s i o n a l s increasingly focus on addressing the present unfolding dangers of global warming, we have a related and equally urgent need to speak out about the accelerating threats of civilizationending nuclear weapons. It seems like eons have passed since President Obama pledged our country’s “commitment to seek the peace and security of a world without nuclear weapons” in his famous 2009 address in Prague that paved the way for his Nobel Peace Prize. Following this, the prospects for nuclear disarmament seemed auspicious with the 2010 signing of the “New START” Treaty by the U.S. and Russia that called for further reductions in strategic nuclear weapons. However, this achievement was soon undermined by increased geopolitical contention between the two largest superpowers, and the related drive to develop new, and more “usable” nuclear weapons, such as those with smaller, and more accurate payloads. The current U.S. program to “modernize” our nuclear arsenal, initiated under the Obama Administration and now overseen by President Trump, is projected to cost up to $1.7 trillion, after inflation, over the next 30 years. The U.S. program has been matched by similar modernization programs of Russia, China, and other nuclear weapons states (NWS), creating a new nuclear arms race that clearly violates the letter and intent of the Nuclear Non-Proliferation Treaty of 1968 under which the NWS pledged to eliminate their nuclear arsenals as expeditiously as possible. This steadfast refusal of the U.S. and the other NWS to fulfill their disarmament obligations informed the founding of the International Campaign to Abolish Nuclear Weapons (ICAN), which led the effort to pass the Treaty on the Prohibition of Nuclear Weapons1, adopted by the vote of 122 nations at the UN in July 2017, for which ICAN was awarded the Nobel Peace Prize. The Treaty, which explicitly bans the possession and use of nuclear weapons, and the programs that develop them, is now in the process of seeking entry into force, with 23 of the 50 nations needed having ratified it, all facing the concerted and powerful opposition of the NWS. The imperative for ratification of the Treaty is underscored by recent heightened contention between the U.S. and Russia. In February, President Trump announced that the U.S. would withdraw from the Intermediate Nuclear Forces (INF) Treaty and 20

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subsequently President Putin announced reciprocal Russian intent to withdraw. The INF Treaty, negotiated and signed by Presidents Reagan and Gorbachev in the late 1980s, has tamped-down the dangers of nuclear war, and withdrawal from this treaty leaves our planet highly vulnerable to increased perils of regional and global nuclear weapons proliferation and war. Exemplifying these dangers are the continued nuclear flashpoints in South Asia and Korea, and the recent threats of a U.S. war on Iran, which have accelerated in the wake of the Trump Administration’s unilateral 2017 withdrawal from the 2015 Iran Nuclear Deal that limited Iran’s nuclear program in return for relief from international financial and oil sanctions. Adding to this combustible mix are nascent offensive global programs to develop and deploy new hypersonic missiles that could initiate a nuclear, or very powerful conventional attack on targets across the globe on the order of 15 minutes, defying any possible “defense.”2 Of equal concern are the greatly increased global capabilities of cyberwarfare exemplified by the recent revelation of a U.S. program, active since 2012, that inserted cyberweapons into the Russian power grid.3 These actions, mirrored by Russian and other active state programs, threaten all critical infrastructure, including industrial facilities such as chemical plants and oil refineries that could lead to devastating impacts on public and environmental health. Equally vulnerable are the hundreds of global nuclear power plants that could be remotely sabotaged to provide the dread equivalent of a nuclear terror attack or meltdown.

Back From the Brink

In recognition of this panoply of these mutually reinforcing threats to human existence, Physicians for Social Responsibility has joined with partners such as the Union of Concerned Scientists, Federation of American Scientists, 350.org, and numerous other organizations in developing a national, grassroots “Back from the Brink” (BftB) campaign.(1) This campaign, subsuming many of the goals of the 2017 Treaty to Prohibit Nuclear Weapons, calls on our government to initiate negotiations with all other NWS (Russia, China, Great Britain, France, India, Pakistan, Israel and North Korea) to achieve a verifiable, enforceable and timebound accord to eliminate all nuclear arsenals. continued on page 22

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Advocacy in Action In line with this over-arching disarmament goal, BftB calls for a number of concrete steps within the U.S. that could immediately begin to reduce the dangers of nuclear war, many of which now are connected with specific Congressional initiatives that aim for bipartisan support: • Ending the sole, unchecked authority of any President to initiate a nuclear attack. While increased attention has been focused on this issue since the start of the Trump Admin istration, this has been a dangerous option through all U.S. governments since the dawn of the nuclear age. Current legislation that would limit presidential authority has been introduced in the Senate (S. 200) by Edward Markey (D-MA), and in the House (H.R. 669) by Ted Lieu (D-CA). •

Having the U.S adopt a No First Use policy, to make it clear to NWS and all other nations that our government will never start a nuclear war. Legislation towards this end has been introduced in the Senate (S. 272) by Elizabeth Warren, (D-MA), and in the House (H.R. 921) by Adam Smith (D-WA).

Cancelling the U.S. plan for modernizing its nuclear weapons arsenal, that in addition to making weapons more accurate and usable, encourages nuclear weapons proliferation around the globe. There are now a number of relevant spending bills aimed at limiting this program pending in the House (H.R. 1086, H.R. 1231, H.R. 1249), and in the Senate (S. 312, S. 401)

Taking the U.S. nuclear arsenal off hair-trigger alert, that would reduce dangers of nuclear launches due to accidents, communication breakdowns, unauthorized or impulsive decisions, and currently heightened by developments in global cyberwar capacity.

In addition to these specific legislative initiatives, a comprehensive resolution “Embracing the Goals and Provisions of the Treaty on the Prohibition of Nuclear Weapons “(H.R. 302) has been drafted by Representatives Jim McGovern (D-MA) and Earl Blumenauer (D-OR), which contains all of the distinct goals of the various aforementioned legislative efforts. Such Congressional actions have been complemented by a robust grassroots movement working within towns, cities and states throughout the nation to pass local resolutions in support of the of the BftB campaign. On June 11, 2018, the U.S. Council of Mayors unanimously adopted the Resolution “Calling on the Administration and Congress to Step Back From the Brink and Exercise Global Leadership in Preventing Nuclear War.” Subsequently, BftB was endorsed unanimously by the City Councils of Baltimore, Washington D.C. and Los Angeles. In August 2018, Assembly Joint Resolution 33 “Treaty on the Prohibition of Nuclear Weapons” was overwhelmingly passed by the California Legislature,” with California Senate Majority Leader Bill Monning introducing the measure: As the former Executive Director of the International Physicians for the Prevention of Nuclear War, which won the 1985 Nobel Peace Prize, I am pleased to urge passage of AJR 33 which urges leaders in our nation to embrace the United Nations Treaty on the Prohibition of Nuclear Weapons and spear a global effort to prevent nuclear 22

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war. This resolution also calls upon our leaders to end anyone's sole authority to launch a nuclear weapon. Since the height of the Cold War, the United States and Russia have dismantled more than 50,000 nuclear warheads, but 15,000 of these weapons still exist and pose a risk to human survival. Cities across California have passed similar resolutions, and California has long led the nation on important policies like this, and we must do so again, this time on the critical issue of nuclear weapons. Members, I've had the honor of visiting Hiroshima and Nagasaki where the survivors’ mantra is 'Never Again.' There are no winners in a nuclear war. Amen. It is the fervent hope of those of us working within BftB and allied efforts within the global movement for nuclear abolition that we will witness similar victories regarding pending initiatives within the state legislatures of Maine, Massachusetts, New Jersey, Oregon, Vermont and Washington. In addition, we hope to make sure that questions exploring the dangers of nuclear weapons (as with global warming) will be raised in the various Presidential candidate forums this coming year. As with the increasing engagement of physicians and other health professionals around the health impacts of climate change, our voices opposing the real and present dangers of nuclear war are critically needed, and reinforced by longstanding policies within the California and American Medical Associations calling for the elimination of nuclear weapons. Your active participation in this movement can make a real difference for human survival. Robert M. Gould, MD, is an Associate Adjunct Professor in the Program on Reproductive Health and the Environment at University of California, San Francisco School of Medicine. He is a Past-President of National Physicians for Social Responsibility (PSR), and President of SF-Bay Area PSR, and a longtime delegate to the CMA House of Delegates.

References 1. Back from the Brink. The Call to Prevent Nuclear War. Available at: https://www.preventnuclearwar.org Accessed June 25, 2019. 2. Smith RJ. Hypersonic Missiles Are Unstoppable. And They’re Starting a New Global Arms Race. New York Times. June 19, 2019. Available at: https://www.nytimes.com/2019/06/19/magazine/hypersonic-missiles. html?searchResultPosition=1 . Accessed June 25, 2019. 3. Nechepurenko I. Kremlin Warns of Cyberwar After Report of U.S. Hacking Into Russian Power Grid. New York Times. June 15, 2019. Available at: https://www.nytimes. com/2019/06/15/us/politics/trump-cyber-russia-grid. html?searchResultPosition=1 Accessed June 25, 2019.

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THE STEALTH SUPERBUG EPIDEMIC 162,000 Annual Deaths from Antibiotic Resistant Infections, Say New Estimates

David Wallinga, MD My 95 year-old dad is on his life’s last leg. He lives in a memory unit, under hospice, with a terminal diagnosis of dementia. Something will kill him, eventually. In hospice programs and nursing homes, it’s often a superbug infection. Superbug is the colloquial term for a disease-causing bacteria that’s ‘resistant to’— i.e. immune to treatment with—multiple antibiotics. Technically, superbug infections are known as multi-drug resistant infections. One example are MRSA infections, which are caused by a super-resistant strain of staphylococcus bacteria. The World Health Organization, the Centers for Disease Control and Prevention (CDC), and others consider the global epidemic of antibiotic resistance to be one of our biggest health threats. Superbugs sicken, disable and kill lots of Americans every year. Until recently, the most used figure was at least 23,000 annual deaths, along with 2 million infections. And yet those are considered “low-ball” numbers by just about everyone, including the CDC which derived them. The CDC figure only includes deaths in hospitals, ignoring deaths among folks like my dad who might die from MRSA or another superbug infection at their homes or in a senior facility. Counting the latter, Reuters reported in 2016 that there actually could be tens of thousands more superbug-related deaths each year, over and above the 23,000 or more deaths in hospitals. In a bold move, the Infectious Diseases Society of America (IDSA), which represents physicians who specialize in infectious diseases, recently decided to move away from relying on CDC’s estimates, and instead uses a figure of up to 162,044 deaths annually, or more than 7 times higher. The latter comes from an estimate of annual deaths published recently by a team from Washington University School of Medicine in the journal, Infection Control & Hospital Epidemiology. Thinking big picture, the revised estimate makes multidrug-resistant infections the 3rd leading cause of deaths in the United States, after heart disease and cancer. The revised figure amounts to more deaths than are caused by all accidents, and more than double the number of opioid deaths.

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Having good numbers can be important for setting national research or campaign priorities to combat antibiotic resistance. Regardless of whether the annual death toll is 23,000 or 160,000, however, we already know that cutting overall antibiotic use of antibiotics has to be a top priority if we’re going to maintain their effectiveness into the future. At the most basic level, use and overuse of these drugs drives bacteria to become resistant to them. Pork and beef production remain two of the largest sources of unnecessary antibiotic use in the U.S.. Medically important medicines are routinely and intensively fed to herds of pigs and cows that aren’t sick, ostensibly to ward off problems created by the crowded, often unsanitary, conditions under which those animals are being raised. Europe has legislated non-antibiotic approaches to these problems, such as cleaner farms, better nutrition, and less crowding. Until the situation changes in the U.S., we fear that other efforts to curb superbug infections and deaths will never be as successful as they could or should be.

David Wallinga is a physician with the Natural Resources Defense Council. He has more than 20 years of experience in writing, policy, and advocacy at the intersection of food, nutrition, sustainability, and public health. He completed his medical school education at the University of Minnesota; he also holds a bachelor’s degree in political science from Dartmouth College and a master’s degree in public affairs from Princeton University. He is based in San Francisco.

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Advocacy in Action

CALIFORNIA SURGEON GENERAL PUTS SPOTLIGHT ON CHILDHOOD TRAUMA Rob Waters In January, two weeks after taking office, Governor Gavin Newsom appointed pediatrician Nadine Burke Harris, MD, MPH, as California’s first surgeon general. Burke Harris is known nationally for her work serving the Bayview-Hunters Point neighborhood of San Francisco, a historically Black community with high rates of poverty and violence, and advocating for children exposed to trauma. In 2012, she founded the Center for Youth Wellness, a national organization that raises awareness about the lifelong impact of adverse childhood experiences (ACEs) and trauma on the health and mental health of children. The concept of ACEs first emerged from a 1998 study that found that children exposed to abuse, neglect, and other negative experiences had an increased lifelong risk of many common chronic health conditions. Burke Harris has pioneered the development of screening tools to assess children’s exposure to ACEs and to treat them. Her TED talk on the effect of trauma on children has been viewed more than 5 million times. Her book, The Deepest Well: Healing the Long-Term Effects of Childhood Adversity, was published last year.

How do you and the governor define your new role? It’s a wonderful opportunity for me to be a partner and adviser to the governor and a health champion. I work in partnership with the secretary of Health and Human Services [Mark Ghaly, MD], and my role is to get out there, work across systems, engage with ordinary Californians and with the medical community, and advance the health of Californians.

How do you want to use this bully pulpit, and what are the big messages you want to communicate to the state’s health care workforce and policymakers? The [US] surgeons general in the past who have been impactful have been able to move the needle on specific public health threats. I don’t see this as a role of doing a little bit of everything. Governor Newsom has a strong focus on health and the health and well-being of children. That’s part of the reason we see a pediatrician in this role — along with my background in adverse childhood experiences and toxic stress. I believe strongly that adverse childhood experiences and toxic stress constitute the major public health issue of our time. Toxic stress is essentially the germ theory of the 21st century, and we implemented everything from vaccines to pasteurization of milk to sanitation of our water supply in response to germ theory. Childhood adversity leads to long-term changes in the structure and function of our brains and bodies, and those changes can subsequently impact educational attainment and risk of violence or incarceration. They dramatically affect health, with significant risks for the leading causes of death in California, including heart disease, stroke, cancer, and Alzheimer’s disease. 24

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For many of us, there’s medical care and there’s mental health, and they’re totally separate. But the body does not make that distinction. A public health response requires not just early identification, such as routine screenings and early intervention within the health care space. It also requires that we look at how we’re doing our work in the educational field and in our justice system. I intend to do a deep dive on toxic stress and how it impacts health, and what we can do across systems, particularly from a health equity standpoint. For the health care workforce, a big part of my effort right now is supporting implementation of AB340 — the law that requires all individuals on Medicaid, children and adults, to be screened for adverse childhood experiences. We’ll be implementing AB 340 next January. We’re moving forward pretty quickly, and the Newsom administration has allocated $45 million in the proposed budget to reimburse providers screening for ACEs. There’ll be a billing code so they’ll be able to get a supplemental payment on top of whatever they would already have gotten for that visit.

Are you seeing any concern or hesitation from the pediatric community? The thing that’s most surprising to me is how welcome this change is. But there are hesitations. Providers worry they don’t have adequate resources when they face a positive ACEs screen. It indicates a need for provider training. Part of the reason for moving toward universal screening is that for so many children and adults, the history of ACEs is not recognized. Every provider can understand that the health condition in front of them — whether it’s headaches or abdominal pain — may be stress-related. An ACEs score reminds a provider to help their patient understand how stress impacts his or her health and what to do about it. WWW.SFMMS.ORG


I’m guessing one hesitation may be: “Well, even if that’s so, where am I going to send these patients?” That’s a really common question. There’s a lot we need to do to support our systems and make them more robust. When Vincent Felitti, the co-principal investigator of the ACE study, began screening for ACEs, he did a trial where he implemented the ACE question into the intake at Kaiser for 110,000 patients. They didn’t make any changes to their mental health or social work infrastructure, yet there was a significant drop in ER visits and in outpatient sick visit use. For many patients, it’s just having a medical professional make that connection and say, “Your history of adversity may be impacting your health.” We need to strengthen linkages between our mental and behavioral health systems, to improve access and coverage. For many patients, it’s just having a medical professional make that connection and say, “Your history of adversity may be impacting your health.” We need to strengthen linkages between our mental and behavioral health systems, to improve access and coverage. So how do you break down the silos and integrate those services? Access and the ability to share information between primary and behavioral health care providers are key, but it also requires a fundamental frame shift. For many of us, there’s medical care and there’s mental health, and they’re totally separate. But the body does not make that distinction. Many places are moving toward integrated primary care and behavioral health and teambased care. California has been leading the effort to improve maternal health and in the last few years has cut in half the rate of women dying in childbirth. But there’s still a huge disparity, especially with Black women. The work on maternal mortality has been admirable, and it shows what happens when we systematically tackle a preventable health problem. But as we look at disparities that persist, I’m asking: Is this another place where toxic stress plays a significant role? How does cumulative adversity over the lifetime affect perinatal outcomes? We know women with higher ACEs have greater risk of chronic health problems — cardiovascular disease, diabetes, mental health concerns, greater risk of depression before you get pregnant, higher likelihood of being in unsafe relationships, being victimized, and experiencing physical or emotional abuse. Women with higher ACEs have increased risk of preeclampsia. The experience of discrimination can also contribute to the toxic stress response. Combine that with the different quality of care sometimes provided for communities of color, and there is a tremendous opportunity to view maternal mortality, particularly in the African American community, through the lens of toxic stress and to address some of the root causes.

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What is your strategy for ensuring you have the greatest impact as surgeon general? Surgeons general who have been successful have really focused on moving forward one issue at a time. Classically, it’s C. Everett Koop and the work he did on tobacco in the 1980s during the Reagan administration. It took a lot of moral courage to do the work he did, to get people to really grasp the health risk around cigarettes. That was a big deal, and there was a lot of resistance. So coming into this role, my first surgeon general’s report will be on ACEs and toxic stress in California. When will that come? I hope to have it out in 2020. Being the first surgeon general in the state of California, there is some basic infrastructure stuff that needs to happen first. Like, I don’t have a printer. Literally, right now I’m printing at home. Some time after I get a printer, we’ll have a surgeon general’s report.

Final question. What’s your overarching message to policymakers and folks in California health care? I believe a public health-scale intervention around adverse childhood experiences and toxic stress is going to be the biggest public health advancement of our time. I want folks to be educated about this issue and to support the implementation of routine screening, early detection, and early intervention, because the evidence shows that’s key. A lot of people have the sense of: “How can we screen? It’s so difficult and expensive to treat. We don’t have sufficient resources. We’re going to overwhelm the system.” Right now, our system is only set up to detect toxic stress when it’s the equivalent to stage four. With breast cancer, stage four comes with a much lower survival rate than stage one. Treatment is more expensive, more intensive, and much more costly. The answer to many conditions is to move detection to stage one. The survival rate for stage one breast cancer is greater than 90%. Screening is not the thing you don’t do because you fear being overwhelmed. It’s the thing you have to do so you can intervene early and prevent the development of stage four. Actually do prevention instead of mopping up later. Which is far more costly, and there’s a lower success rate. So let’s do it early on. – From the California Health Care Foundation

Nadine Burke Harris graduated from UC Berkeley and earned a medical degree from UC Davis. After earning a master’s degree in public health from the Harvard T.H. Chan School of Public Health, she completed a residency at Stanford University. She lives in San Francisco with her husband and their four boys.

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Advocacy in Action

AGEISM IN MEDICINE A Talk with Louise Aronson, MD

Judith Graham Society gives short shrift to older age. Society gives short shrift to older age. This distinct phase of life doesn’t get the same attention that’s devoted to childhood. And the special characteristics of people in their 60s, 70s, 80s and beyond are poorly understood. Medicine reflects this narrowmindedness. In medical school, physicians learn that people in the prime of life are “normal” and scant time is spent studying aging. In practice, doctors too often fail to appreciate older adults’ unique needs or to tailor treatments appropriately. Imagine a better way. Older adults would be seen as “different than,” not “less than.” The phases of later life would be mapped and expertise in aging would be valued, not discounted. With the growth of the elder population, it’s time for this to happen, argues Dr. Louise Aronson, a geriatrician and professor of medicine at the University of California-San Francisco, in her new book “Elderhood” It’s an in-depth, unusually frank exploration of biases that distort society’s view of old age and that shape dysfunctional health policies and medical practices. In an interview, Aronson elaborated on these themes. How do you define ”elderhood”? Elderhood is the third major phase of life, which follows childhood and adulthood and lasts for 20 to 40 years, depending on how long we live. Medicine pretends that this part of life isn’t really different from young adulthood or middle age. But it is. And that needs a lot more recognition than it currently gets.

Does elderhood have distinct stages? It’s not like the stages of child development — being a baby, a toddler, school-age, a teenager — which occur in a predictable sequence at about the same age for almost everybody. People age differently — in different ways and at different rates. Sometimes people skip stages. Or they move from an earlier stage to a later stage but then move back again. Let’s say someone in their 70s with cancer gets really aggressive treatment for a year. Before, this person was vital and robust. Now, he’s gaunt and frail. But say the treatment works and this man starts eating healthily, exercising and getting lots of help from a supportive social network. In another year, he may feel and look much better, as if time had rolled backwards. What might the stages of elderhood look like for a healthy older person? In their 60s and 70s, people’s joints may start to give them trouble. Their skin changes. Their hearing and eyesight dete26

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riorate. They begin to lose muscle mass. Your brain still works, but your processing speed is slower. In your 80s and above, you start to develop more stiffness. You’re more likely to fall or have trouble with continence or sleeping or cognition — the so-called geriatric syndromes. You begin to change how you do what you do to compensate. Because bodies alter with aging, your response to treatment changes. Take a common disease like diabetes. The risks of tight blood sugar control become higher and the benefits become lower as people move into this “old old” stage. But many doctors aren’t aware of the evidence or don’t follow it.

You’ve launched an elderhood clinic at UCSF. What do you do there? I see anyone over age 60 in every stage of health. Last week, my youngest patient was 62 and my oldest was 102. I’ve been focusing on what I call the five P’s. First, the whole person — not the disease — is my foremost concern. Prevention comes next. Evidence shows that you can increase the strength and decrease the frailty of people through age 100. The more unfit you are, the greater the benefits from even a small amount of exercise. And yet, doctors don’t routinely prescribe exercise. I do that. It’s really clear that purpose, the third P, makes a huge difference in health and wellness. So, I ask people, “What are your goals and values? What makes you happy? What is it you are doing that you like best or you wish you were doing that you’re not doing anymore?” And then I try to help them make that happen. Many people haven’t established priorities, the fourth P. Recently, I saw a man in his 70s who’s had HIV/AIDS for a long time and who assumed he would die decades ago. He had never planned for growing older or done advance care planning. It terrified him. But now he’s thinking about what it means to be an old man and what his priorities are, something he’s finally willing to let me help him with. Perspective is the fifth P. When I work on this with people, I ask, “Let’s figure out a way for you to keep doing the things that are important to you. Do you need new skills? Do you need to change your environment? Do you need to do a bit of both?” Perspective is about how people see themselves in older age. Are you willing to adapt and compensate for some of the ways you’ve changed? This isn’t easy by any means, but I think most people can get there if we give them the right support. Q: You’re very forthright in the book about ageism in medicine. How common is that? Do you know the famous anecdote about the 97-year-old man with the painful left knee? He goes to a doctor who takes a history and does an exam. There’s no sign of trauma, and the doctor says, “Hey, the knee is 97 years old. What do you expect?” And the patient says, “But my right knee is 97 and it doesn’t hurt a bit.” WWW.SFMMS.ORG


That’s ageism: dismissing an older person’s concerns simply because the person is old. It happens all the time. On the research side, traditionally, older adults have been excluded from clinical trials, although that’s changing. In medical education, only a tiny part of the curriculum is devoted to older adults, although in hospitals and outpatient clinics they account for a very significant share of patients. The consequence is that most physicians have little or no specific training in the anatomy, physiology, pharmacology and special conditions and circumstances of old age — though we know that old people are the ones most likely to be harmed by hospital care and medications.

What does ageism look like on the ground? Recently, a distressed geriatrician colleague told me a story about grand rounds at a major medical center where the case of a very complex older patient brought in from a nursing home was presented. [Grand rounds are meetings where doctors discuss interesting or difficult cases.] When it was time for comments, one of the leaders of the medical service stood up and said, “I have a solution to this case. We just need to have nursing homes be 100 miles away from our hospitals.” And the crowd laughed. Basically, he was saying: We don’t want to see old people; they’re a waste of our time and money. If someone had said this about women or people of color or LGBTQ people, there would have been outrage. In this case, there was none. It makes you want to cry.

What can people do if they encounter this from a doctor? If you put someone on the defensive, you won’t get anywhere. You have to say in the gentlest, friendliest way possible, “I picked you for my physician because I know you’re a wonderful doctor. But I have to admit, I’m pretty disappointed by what you just said, because it felt to me that you were discounting me. I’d really like a different approach.” Doctors are human beings, and we live in a super ageist society. They may have unconscious biases, but they may not be malicious. So, give them some time to think about what you said. If after some time they don’t respond, you should definitely change doctors.

Do you see signs of positive change? Absolutely. There’s a much larger social conversation around aging than there was five years ago. And that is making its way to the health system. Surgeons are thinking more and more about evaluating and preparing older adults before surgery and the different kind of care they need after. Anesthesiologists are thinking more about delirium, which has short-term and long-term impact on older adults’ brains. And neurologists are thinking more about the experience of illness as well as the pathophysiology and imaging of it. Then you have the age-friendly health system movement, which is unquestionably a step in the right direction. And a whole host of startups that could make various types of care more convenient and that could, if they succeed, end up benefiting older people. This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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CDPH Releases 2018 Data on the End of Life Option Act The California Department of Public Health (CDPH) released the 2018 Data Report on the End of Life Option Act (EoLOA). This latest report on the End of Life Option Act covers the period from January 1, 2018, to December 31, 2018, and reflects information on individuals who were prescribed aid-in-dying drugs and died in 2018, as well as cumulative counts for the period commencing January 1, 2016. New in the report this year are four data points which were not previously reported: 1. Patient informed family of decision: 87% reported informing family; 3% did not inform family; 2% had no family to inform, and for 8% it was unknown. 2. Class of drugs prescribed: 37% of patients were prescribed a sedative; 35% a Cardiotonic/Opioid/ Sedative; 18% other; and 10% unknown. 3. 4.

Physician or trained healthcare provider present at the time of ingestion: 54% had a physician or trained healthcare provider present; 25% did not; and for 21% it was unknown. Place of death (setting and/or location): 92% of patients died in a private home; 4% in an assisted living residence; 2% in a nursing home and 2% in an in-patient hospice residence.

The report also includes cumulative data: Between June 9, 2016, when the law came into effect, and December 31, 2018, prescriptions have been written for a total of 1,108 people under the Act and 807 individuals (72.8 percent) have died from ingesting the medications. The 2018 data indicates that 452 individuals received prescriptions under the End of Life Option Act in that year. That figure appears to be down from a total of 577 individuals who received prescriptions under the Act in 2017. Other key 2018 data points include: Of the 452 individual who received prescriptions, 337 died following their ingestion of the prescribed medications, including 23 individuals who received prescriptions prior to 2018. Of those who died, 88.7 percent were 60 years of age or older, 94.4 percent had health insurance and 88.1 percent were receiving hospice and/or palliative care. For general information on the EoLOA law, visit CCCC’s EoLOA page here. To view and download the 2016 and 2017 EoLOA Data Reports and access provider and patient reporting forms, visit CDPH’s EoLOA page here: https://www.cdph.ca.gov/ Programs/CHSI/Pages/End-of-Life-Option-Act-.aspx?mc_ cid=f7b24b211b&mc_eid=56ee03c5d7

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IN MEMORIUM Erica T. Goode, MD, MPH March 25, 1940 - June 15, 2019 All knew her as a brilliant but modest, optimistic, good-humored, gentle woman who was an example of the best of what a human being could be. Erica discovered early in life that she was happiest helping others, which is how she spent her vibrant, optimistic, exceptionally well-lived life. So she was beloved by family, friends, colleagues and devoted patients, who now mourn her passing. She was born March 25, 1940 to Ed and Mary Lou Sweeting and proved to be a perfect blend of her father's focused intelligence and iron will and her mother's sweet, gentle manner. Her parents named her Judith Raymond Erica Sweeting, but her father called her "Ockie" for reasons known best to him. When she entered school, she rejected most of that and chose to use the name Erica, which is how we all knew her. It was an early demonstration of her gentle decisiveness. At the age of eight, while playing by Strawberry Creek, she decided she wanted to go to UC Berkeley, and, characteristically, that is exactly what she did, receiving three degrees from that University: an undergraduate degree in nutrition (1962), a Masters of Public Health (1967), and a medical degree (1977). Professionally, she was the doctor every patient wanted. After finishing her internship and residency at Children's Hospital in San Francisco - where she was co-chief resident - she opened her own private practice, which was quickly filled; although she always found it all but impossible to turn away someone who needed her help. She cared for each patient and took the time necessary to listen to and heal them. Even after she retired, some patients said, "you are going to be my doctor until one of us dies." In 1999 she joined the Institute for Health and Healing at California Pacific Medical Center, where she was able to work with others to provide integrative care. Although Erica practiced traditional western medicine at the highest level, she was always open to learning about alternative treatments. She was a mainstay of the medical community. Drawing on her deep knowledge of nutrition, she developed one of the first eating disorder programs in San Francisco. For 26 years she served as an associate clinical professor of medicine at UCSF, teaching the Introduction to Clinical Medicine program, to hundreds of medical students. During that same period, she gave a series of lectures on nutrition each year to the medical residents at Children's Hospital and California Pacific Medical Center. She developed comprehensive, collaborative protocols for nutri28

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tional, psychosocial, and medical management for bariatric patients at St. Mary's Hospital. She served on the CPMC Ethics Committee continuously from 1984 to her retirement; grappling with difficult and sensitive issues. Erica also was an active member of the San Francisco Medical Society and worked on the editorial board of its monthly publication, writing many articles and guest editing a special edition on nutrition in medicine. She also wrote obituaries of Society members – delegating to her husband the job of scouring the back pages of the newspaper every day to make sure no one was missed. Erica served (often as chair) her UCSF Medical School Class reunion (i.e. fundraising) committee every five years – but always insisted that the money raised be used for scholarships for needy students. Deeply interested in effecting change in health policy and community care issues, Erica served for several years on the California Commission on Aging and was a delegate to the White House Conference on Aging in 1996 and again in 2006. She joined the board of the Richmond Community Foundation in 2009. For more than a decade Erica also was part of the Prison Visitation and Support program, driving each month to Dublin, California to visit with two imprisoned women. Of course, she had her share of accolades. For her practice she was routinely listed in "The Best Doctors in San Francisco," for her teaching and dedication to the art of healing she was made a member of the Alpha Omega Alpha Honor Medical Society, and for her devotion to her patients she was given the Institute for Health and Healing's Compassionate Caregiver award. At her retirement party she was feted with speeches and given a bouquet of broccoli. But her real joy was in the relationships she had with her husband, sons, extended family, friends, colleagues and patients. All knew her as a brilliant but modest, optimistic, good-humored, gentle woman who was an example of the best of what a human being could be.

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Advocacy in Action

THE JUUL DELUSION: We Don’t Get Fooled Again Steve Heilig, MPH TIME magazine's annual "100 most influential people" list features luminaries from around the world who are doing something good. Thus it was surprising to see the co-founders of JUUL vaping company included as "smoking the competition,” for JUUL is fast becoming one of the more vilified companies anywhere, the target of a class action suit, bans on its products, and more. What gives? The United States surgeon general called youth vaping an “epidemic,” and so have many other medical and health authorities, as well as San Francisco’s current city attorney, who notes “E-cigarettes are a product that, by law, are not allowed on the market without FDA review. For some reason, the FDA has so far refused to follow the law.” San Francisco Board of Supervisors thus unanimously voted to ban the sale of e-cigarettes in city limits if they are not approved by the FDA, and there is now a court-ordered ten-month deadline for the FDA to conduct that review – thanks to the American Academy of Pediatrics and the Cancer, Heart, and Lung Associations, among others. The key issue, dividing some experts, is “harm reduction.” The SFMMS has long been a vocal proponent of harm reduction in various settings, but calculations of benefits vs. harms are central. E-cig marketers hold that vaping is primarily a way to quit smoking tobacco. There’s no denying that does work for some smokers. But the far bigger impact is negative: Beyond the unhealthy components in vaping products and the risks of nicotine addiction itself, recent Dartmouth School of Medicine research, something of a ‘smoking gun” in this debate, indicates that for every adult who successfully uses vaping to quit cigarette smoking, 80 young people will become tobacco smokers after initiating vaping. Back in 2011, the SFMMS brought policy to the CMA stating “CMA supports prohibition of the use of electronic cigarettes and other nicotine delivery devices not approved by the FDA as smoking cessation aids in those places where smoking is prohibited by law.” In 2014, we further convinced CMA to support a ban on e-cig advertising, regulation consistent with tobacco products, and taxation to offset health costs of e-cig use. JUUL’s CEO has said he’s “sorry” for the epidemic of youth vaping, as their marketing was heavily youth-oriented early on. His company is now flooding the media with expensive ads saying how much they do to discourage teen use. But they are also fighting San Francisco’s moratorium on sales, and using 30

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virtually every tool in the “Big Tobacco” playbook to keep selling their products – unsurprisingly, given that vaping and tobacco industries are now very intertwined in both ownership and aims. UCSF anti-tobacco authority Dr. Stan Glantz recently noted that the e-cig companies “are, like their big brothers at Philip Morris, trying to bury San Francisco voters in a huge pile of money to keep selling their products without restriction, including overturning the ban on flavored e-cigs 58% of voters just upheld in the face of a massive industry campaign against it.” For a clear diagnosis of the issue, here is what a former San Francisco City Attorney recently wrote in the San Francisco Chronicle. Listen to one who knows:

Juul’s SF ballot measure typical of Big Tobacco’s disingenuous tactics

Louise Renne, San Francisco Chronicle, July 10, 2019 As San Francisco’s city attorney, I sued the tobacco industry and won $500 million in damages for the massive harm caused by cigarettes. I also learned one big thing about Big Tobacco: Don’t believe a word they say. That’s why I was disturbed to learn that 20,000 San Franciscans were somehow persuaded to sign petitions for a November ballot measure that was written by the tobacco industry’s lawyers. This supposedly pro-health measure is sponsored by the San Franciscobased electronic-cigarette firm Juul Labs, of which Altria, the maker of Marlboro and other tobacco products, is a minority owner. Juul claims its proposal will protect children, but I have examined the ballot measure, and it does exactly the opposite. Juul’s initiative would repeal anti-smoking laws that were enacted to keep e-cigarettes out of the mouths of children. It would also gut city officials’ authority to regulate e-Cigarettes in the future. Second, Juul’s initiative would repeal the law that prohibits e-cigarette sales to anyone under the age of 21 and replace it with an unenforceable restriction on “knowingly” selling to minors. Juul’s provision would therefore require the city to prove that an e-cigarette seller knew a buyer was under the age of 21 to enforce the restriction, which would be virtually impossible. That suggests that if a youth who buys vaping products simply claims or appears to be at least 21, the retailer is off the hook. That’s like having no age limit at all. Finally, Juul’s initiative contains a so-called poison pill designed to kill any ballot measure imposing stricter regulation of e-cigarettes, and it permanently prevents city officials from regulating the products without going back to the ballot. Juul calls its ballot measure “An Act to Prevent Youth Use of Vapor Projects,” but that is not at all what it would do. Big Tobacco undoubtedly hopes that slick packaging, clever marketing and lavish spending on political ads will trick voters into passing this deceptive measure. That is how the industry hooks kids and harms the public. Here is the warning label I would attach to this measure: Don’t be fooled by Juul.

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CALIFORNIA TAKES HISTORIC STEP TOWARD UNIVERSAL COVERAGE Sandra Hernandez, MD California has taken a historic step toward universal coverage by making sure all young people with low incomes are eligible for Medi-Cal and by making it easier for many Californians who purchase their own insurance to afford coverage. On June 13, the California Legislature voted on a budget that would allow all low-income Californians under the age of 26 to enroll in Medi-Cal — the state’s Medicaid program — regardless of immigration status. It would also raise the income eligibility threshold for seniors and people with disabilities seeking to enroll in Medi-Cal; offer new financial help to low- and middle-income Californians who purchase coverage on the state’s health insurance marketplace; and reestablish an individual mandate to buy insurance or pay a fee — an Affordable Care Act provision until Congress removed it in 2018. At a time when the federal administration continues to erode health coverage for Americans and threaten hardworking immigrants, California is showing a different path is possible. With the latest budget, California becomes the only state in the country to open its Medicaid program to all low-income residents, regardless of immigration status, under the age of 26. The state also closed a small but important coverage gap by raising Medi-Cal’s income eligibility level for seniors and people with disabilities to align with that of most adults under age 65. These bold actions speak to our state’s values of inclusion. Californians recognize that our future prosperity depends on the health and well-being of all our residents. Californians recognize that our future prosperity depends on the health and well-being of all our residents. California leaders have also recognized the challenges that too many of our residents and small businesses face in trying to afford

health insurance on their own. The budget adds protection for those with the lowest incomes who struggle to purchase their own insurance, and it recognizes that, in a state with a high cost of living, Californians with moderate incomes also need help. Reestablishing the individual mandate penalty will encourage more Californians to maintain health coverage, which benefits all of us. While these decisions are surely worth celebrating, we must acknowledge the work ahead. We must find a way to cover all Californians, including the low-income undocumented adults and seniors who remain ineligible for Medi-Cal. We must rein in the cost of coverage for consumers. And we must protect access to care in the face of harmful federal actions, including the federal administration’s proposed changes to the public charge rule. We are still a long way from a health care system that works for all Californians, but the state budget shows that progress is possible. Step by step, staying true to our values, we will get there.

Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016. Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.

CLASSIFIED ADS Internal Medicine Practice For Sale - Napa County. Concierge medical practice with revenues averaging $600,000 seeing 8-10 patients per day. Seller's net income is near the 90-percentile for IM. Long established in the area, moved to newly renovated 1440 sq. ft. location in 2015; great proximity to hospital. EMR in place. Photos and third-party appraisal available. Offered at only $497,000. Contact Medical Practices USA for more information. 925-820 6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com. Ophthalmology Practice For Sale - Marin County. Revenue $700,000 with one owner-doctor and well-trained staff. 1350 square feet in medical building with good parking. Strong potential for both revenue growth and efficiency improvements with more surgical time, development of a website, and addition of optometry and optical services and products. Third-party appraisal available. Offered at only $285,000. Contact Medical Practices USA for more information. 925-820-6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com OFFICE for rent, SF Chinatown, near several MUNI lines. 3 exam rooms, office, wait room, reception, staff room, private bathroom, 788sqft, BO (415) 921-2097

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COMMUNITY MEDICAL NEWS Marin General Hospital Embarks on New Phase of a long, Proud History Jon Friedenberg, President & Chief Operating Officer, MarinHealth Medical Center Next year, Marin General Hospital will celebrate the opening of its new, stateof-the-art, earthquake-safe hospital replacement. Construction will be finished by the end of 2019 and a grand opening planned for the summer of 2020. A day that the hospital and our community have been planning for more than four years and eagerly anticipating. The new hospital will include a four-story, 260,000-squarefoot building with 114 private rooms, an expanded emergency department and six new advanced operating/procedural suites. Special amenities and eco-friendly features, such as rooftop gardens, balconies, and natural light in every patient room, will support a healing environment for patients and families. The need for new hospital facilities was clear. Marin has seen a five-fold population increase since we first opened our doors and our community counts on us, now more than ever. As the only provider of many important services and programs, we feature Marin’s only Designated Trauma Center, specializing in providing state-of-the-art trauma care 24/7; Labor and Delivery Hospital Services – Offering private birthing rooms and a Level II neonatal intensive care unit (NICU); A Full-Service Cancer Care Program with survival rates that exceed the National Cancer Data Base (NCDB) rates for breast and prostate cancers; Comprehensive Heart and Vascular Care plus sophisticated care for A-fib and other complex issues: Accredited Chest Pain Center – Lifesaving treatment for heart attack victims in half the time of the national average; Inpatient Pediatric Care Program – 24/7 board-certified pediatricians available for inpatient and emergency care; Spine & Brain Program – comprehensive spine and brain care, including emergency and elective brain and spine surgery; Certified Primary Stroke Center that Can Treat Both Ischemic and Hemorrhagic Stroke; and Acute Inpatient Psychiatric Services tailored to meet specific patient needs. Beginning July 30, under the umbrella name MarinHealth, the hospital will become MarinHealth Medical Center. An expanded, comprehensive strategic alliance with UCSF Health means residents of the community and referring physicians will have additional, specialized care available right here in the North Bay. Our focus continues to be maintaining attracting and retaining the best physicians and staff, state of the art technology and facilities, providing our patients with a healing environment, financial stability and the agility to respond to the healthcare challenges of the future.

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The MERI Center for Education in Palliative Care at UCSF/Mount Zion A new and innovative program in Palliative Care Education at UCSF Michael Rabow, MD, and Redwing Keyssar, RN Merijane Block was a patient at UCSF, living with metastatic breast cancer for 26 years. She insisted on being seen as a whole human being—as a strong, smart, creative woman with years of experience in the world and a woman with a powerful spirit and open heart. She also demanded that all of her clinicians and caregivers show up and be fully present—unafraid of showing their humanity in the midst of a clinic visit or difficult new diagnosis. It is in this spirit of honoring our humanity, as care-givers and care-receivers, that we offer the MERI Center to our community. To build a healing community at Mount Zion and beyond, the MERI Center works to support patients facing serious illness, to train family and volunteer caregivers, to promote the competence and humanity of professional health care teams, and to bring an openness to how our community sees death via the core domains of adult education—imparting knowledge, developing skills, and fostering healthy attitudes. Funded in 2018 by the Mount Zion Health Fund and two private donors, the MERI Center seeks to promote “primary palliative care” within the Mount Zion community, bringing symptom management, advance care planning, and compassionate care to those facing serious illness. Existing MERI programs are designed to promote a culture of primary palliative care within the context of routine health care at UCSF/Mount Zion. With the direction of MERI Palliative Care Champions selected from each of the 12 major clinical programs on the UCSF/Mount Zion campus, patients, families, and clinicians are supported with training and systems for: • Advance Care Planning education and training, with the “What Matters Most Workshops” for patients, families, and staff • Symptom Management, with a national palliative care education web-based clearinghouse and pain management physician order sets • Resiliency Promotion, with support groups as well as in-person and online courses Programs in development include:

• Family Caregiver and End-of-Life Doula Trainings • Connecting clinicians to meaning in their work through programs in creative expression such as poetry, art, drama, and music • Educating the public by bringing end-of-life awareness and care into the public square For more information please contact Dr. Michael Rabow , Mike.Rabow@ucsf.edu or Redwing Keyssar, RN, judithredwing. keyssar@ucsf.edu WWW.SFMMS.ORG


Saint Francis Memorial Hospital Holds Inaugural Transgender Health Conference

KAISER PERMANENTE Maria Ansari, MD

Co-Hosted by World Professional Association for Transgender Health (“WPATH”) Event Marks Public Launch of Saint Francis Memorial Hospital’s Gender Institute Dignity Health Saint Francis Memorial Hospital hosted San Francisco’s first medical conference on transgender health— marking the public launch of its Gender Institute. “Discussions on Gender Affirmation: Surgery and Beyond,” was held May 30-June 1 at the Hotel Kabuki in San Francisco and co-hosted by the World Professional Association for Transgender Health (“WPATH”). “While Saint Francis Memorial Hospital has been supporting the health needs of transgender patients for decades, this area of medicine is rapidly evolving and the Gender Institute wanted to provide a venue to discuss and deliberate on best care,” said Kathleen Jordan, MD, chief medical officer at Saint Francis Memorial Hospital. “The conference hosted health care professionals sharing and learning best practices in addressing the health care of persons of all gender identities, and brought together true pioneers in their fields.” The conference aimed to help health care providers address the ethical and practice-related concerns of serving individuals who are considering surgery. Topics covered included: • An ethical framework for navigating challenges in gender care • Counseling patients/clients regarding surgery options • Physical preparation for surgery • Discussions on complications of gender surgeries • Masculinizing and feminizing surgical procedures • Nonbinary surgery requests • Ethical issues in adolescent treatment • How to be a well-informed health care advocate • Facial feminization and voice surgery The goal of the Saint Francis Memorial Hospital Gender Institute, launched two years ago, is to deliver compassionate, highquality, and affordable health services to transgender patients and their families. Led by a council of experts, the Gender Institute is committed to providing patients with the respectful environment that they deserve. The Gender Institute’s multidisciplinary professionals together provide a comprehensive continuum of care to the Hospital’s patients and their families throughout the pre-operative process, including a positive and supportive environment for transgender patients to seek care, counseling services, and referrals to related resources and services. Saint Francis also includes cultural training for its staff to ensure a welcoming and healing environment for persons of all gender identities. For more information about the Gender Institute at Saint Francis, and the recent conference, visit https://www.dignityhealth.org/bayarea/locations/saintfrancis/services/genderinstitute. WWW.SFMMS.ORG

Cancer and Genetics The role of genetics in the diagnosis and treatment of cancer has become increasingly important in recent years. National data indicates that burnout rate among physicians is more than 50 percent and the suicide is also higher for physicians than for other professions. In the United States, we’re losing one doctor a day to suicide which is a national tragedy. One change has come with the recognition that certain malignancies, such as pancreatic cancer, have more inheritable components than previously realized. These can be identified through germline DNA sequencing, which tests healthy cells for inherited, or germline, mutations that increase the risk of certain cancers and can also influence treatments decisions. In addition, family members can be alerted that they may be at risk. Another frontier is precision oncology, in which we perform next-generation sequencing (NGS) of the tumor DNA itself, looking to see if there are alterations unique to a specific individual’s tumor that might make them candidates for novel medications targeting that particular mutation. NGS has enabled rapid, comprehensive sequencing of tumor DNA and revolutionized the practice of oncology. At Kaiser Permanente, we offer NGS to all of our patients who have advanced cancer. Every case is reviewed by a genomic oncology tumor board, which looks through the full range of standard treatments and potential clinical trial opportunities and makes recommendations to the treating physicians. Because of our large patient population and integrated system for data collection and analysis, we are able to identify the most promising precision oncology trials for our patients and offer them access to cutting edge therapeutics not otherwise widely available. We are now one of the largest enrollees of patients to clinical trials of any health care system in the country and are continuously looking to expand the portfolio of trials available to our members. The role of cancer genetics is continuously evolving, and Kaiser Permanente is at the forefront of this evolution, ensuring our patients have access to the latest technologies to reduce the burden of cancer in our communities.

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UPCOMING EVENTS 2019 NEPO Summit August 23-24, 2019 | Pasadena, CA

2019 CMA House of Delegates October 26-27, 2019| Disneyland Hotel, Anaheim, CA

The 2019 Network of Ethnic Physician Organizations (NEPO) will be held August23-24 in Pasadena. This year’s theme is Standing Up for Health Care in California. The twoday summit is an innovative educational event for physicians, public health professionals, advocates and community leaders that offers policy and best practices for reducing health disparities, building diversity in the workforce and increasing cultural competency in clinical care. See more information at http://bit.ly/2LNh25v.

The House of Delegates convenes annually to debate and act on resolutions and reports dealing with myriad medical practice, public health and CMA governance issues. Policies adopted by the House are implemented by the Board of Trustees, which also deals with the many interim policy issues that arise between annual sessions. Visit https://www.cmadocs. org/hodfor more information.

CMA Presidential Gala October 26, 2019| Disneyland Hotel, Anaheim, CA

Each year, the CMA hosts a Gala torecognize and celebrate the incoming CMA President. This year’s Presidential Gala will honor Dr. Peter Bretan Jr., and will take place on Saturday, October 26th, at the Disneyland Hotel in Anaheim. Guests willenjoy a cocktail reception, dinner andentertainment. This year’s Gala features the magic and excitement of live theater with A Night on Broadway. More details and ticket information will be available soon at www.cmadocs.org.

SAVE THE DATE – 2020 SFMMS Annual Gala Friday, January 31, 2020, 5:30-9:30pm | Green Room at the SF War Memorial, San Francisco

The 2020 SFMMS Annual Gala will be held on Friday, January 31, 2020at the Green Room at the San Francisco War Memorial. President-Elect, Brian Grady, MD will be installed as the 2020SFMMSPresident. More information and registration willbe available soon at www.sfmms.org/events.aspx. Sponsorship opportunities are available –contact Erin Henke at ehenke@sfmms.orgor (415) 561-0850 x268.

SFMMS General Membership Meeting September 9, 2019, 5:00pm | Golden Gate Yacht Club, San Francisco, CA Calling all SFMMS members! Join SFMMS at our General Membership Meeting to meet SFMMS and CMA leadership and to learn firsthand the issues that SFMMS and CMA are advocating for on behalf of physicians and their patients in San Francisco, Marin, and California. The slate of candidates running for SFMMS elected positions will be read during the meeting. Special guests include: CMA President David Aizuss, MD; SFMMSPresident Kimberly Newell Green, MD; San Francisco Mayor London Breed; and San Francisco Department of Public Health Director Grant Colfax, MD.

Advertiser Index Cooperative of American Physicians, Inc. . . . . . . . . . . . . . . . . . . . . Inside Back Cover Doctor’s Company. . . . . . . . . . . . . . . . . 4 First Republic Bank. . . . . . . . . . . . . . . 29 Mechanics Bank. . . . . . . . . . . . . . . . . 21

WELCOME TO OUR NEW SFMMS/CMA MEMBERS: Linday Raleigh, MD | Anesthesiology Van Nye Selby, MD | Internal Medicine Yen-Trang Vo, MD | Family Medicine

MIEC. . . . . . . . . . . . . . . . . . Inside Cover Norcal Group. . . . . . . . . . . . . . . . . . . . 7 Tracy Zweig Associates. . . . . . . . . . . . . 19 Sutter Health CPMC. . . . . . . . . . . . . . . 16 Sutter Health NCH. . . . . . . . . . Back Cover 36

SAN FRANCISCO MARIN MEDICINE JULY/AUGUST 2019

WWW.SFMMS.ORG


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

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PAID

San Dimas, CA Permit No. 410

Profile for San Francisco Marin Medical Society

July/August 2019  

San Francisco Marin Medicine, Vol 92, No. 4, July/August 2019

July/August 2019  

San Francisco Marin Medicine, Vol 92, No. 4, July/August 2019

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