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VOL. 84 NO. 10 December 2011

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

The Phases of a Medical Career Preparing Students for Today’s Medical Climate

Changing Specialties Financial Planning Tips For Every Age

Easing into Retirement Motherhood and medicine

Advocacy Throughout Your Career


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IN THIS ISSUE

SAN FRANCISCO MEDICINE

December 2011 · Volume 84, Number 10

The Phases of a Medical Career FEATURE ARTICLES

MONTHLY COLUMNS

10 The Changing Practice of Medicine: Changing Specialties, Roles, and Interests during a Career Linda Hawes Clever, MD

4 Membership Matters

12 The Next Generation: Preparing Students for the Modern Practice of Medicine Catherine Reinis Lucey, MD

7 President’s Message George Fouras, MD 9 Editorial Gordon Fung, MD, PhD

14 The Importance of Mentorship: The UCSF Comprehensive Mentoring Program Jeanette S. Brown, MD 15 Using Your Resident Voice: Effective Advocacy During Early Career Ryan Padrez, MD

32 Hospital News

17 Advocacy During Mid-Career: Going Beyond Establishing a Practice Peter Curran, MD

OF INTEREST

18 Running in the Fast Track: Taking a Career in Phases Tom Madigan

28 Practice Management Tips: Ten Tips to Avoid “Practice Management Hypertension” Debra Phairas

22 Easing into Retirement: The Transition from One Passion to Another Lawrence B. Lurie, MD 24 Balancing Motherhood and Medicine: The Challenge of Creating a Schedule That Benefits All Katherine Chretien, MD 26 Financial Planning: Shifting Priorities Throughout Your Career Deborah Peri

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

33 Classified Ads 34 In Memoriam Nancy Thomson, MD

25 SFMS Election Results

30 In the News: SFMS Members Honored for Volunteer Efforts 31

Health Policy Perspective: Cannabis and California’s Physicians Steve Heilig, MPH; George Fouras, MD; Donald Abrams, MD; and David Pating, MD


MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Medicare Delays Provider Enrollment Revalidation; Revalidation List Now Online The Centers for Medicaid & Medicare Services (CMS) has delayed the requirement that physicians revalidate their Medicare enrollment under the program integrity screening provisions of the Affordable Care Act. According to CMS, the revalidation effort, originally scheduled for March 23, 2013, will be pushed back through 2015. Physicians will be among the last to revalidate. Physicians who have already received revalidation notifications from Palmetto GBA should fill out the form and return it to Palmetto per the instructions in the notice. CMS has posted a listing of providers who have been sent a request to revalidate their Medicare enrollment information. The listing contains the name and national provider identifier (NPI) of each provider sent a letter, as well as the date the letter was sent. To check if you or your practice are on the revalidation list (Phase 1), please visit https://www.cms.gov/ MedicareProviderSupEnroll/11_Revalidations.asp. If you are listed and have not received the request, please contact Palmetto GBA Provider Contact Center at (866) 932-3901.

Physicians Face 27.4 Percent Medicare Payment Cut; Urge Congress to Repeal the Medicare SGR Today!

CMS revised downward a looming cut to physicians, but for the medical community, it will be cold comfort. On January 1, 2012, physicians face a 27.4 percent Medicare Sustainable Growth Rate (SGR) payment cut. The Deficit Committee may be our last chance to eliminate the SGR once and for all. SFMS/CMA believe that stable reimbursement in this program not only protects access to care but also makes economic sense, as physicians are important employers in their communities. Repealing the SGR this year will saves hundreds of billions of dollars and put an end to these last-minute legislative fixes that inevitably delay and increase the problem. SFMS/CMA has strongly opposed the proposed draconian cuts to Medicare physician payment and will continue to advocate for a repeal of the flawed payment formula and for stable and adequate reimbursement for physicians. Please join us in this fight by contacting Congress to ask for a full repeal of the Medicare SGR in the Deficient Committee legislation and let them know the effect the SGR cut will have on your patients and your practice!

Talking Points

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• Failure to stop the SGR cuts will cause physicians to stop

San Francisco Medicine December 2011

taking Medicare patients or to close their doors altogether. • With the baby boom generation fast approaching retirement age, we’re talking about decreased access to care for more than 5 million Californians. • It will cause drastic access problems for seniors and military families who need a doctor. • Repealing the SGR reduces taxpayer costs and the deficit—it is good economics. • Five years ago, the cost to repeal was $48 billion; now it is $300 billion; soon it will be $600 billion. These last-minute stopgaps are increasing Medicare costs to the federal government. We must repeal the SGR once and for all. • Physicians employ more than 500,000 people in California and are substantial contributors to the local, state, and federal tax base. Maintaining appropriate, stable Medicare rates keeps physicians in practice and prevents further unemployment and economic erosion. • Physicians are important businesses and employers crucial to the California economy.

How to Contact Members of Congress

Use the AMA Grassroots Hotline at (800) 833-6354 to call your Representative and Senators Boxer and Feinstein. You will be asked to enter your zip code and select your Representative. Please select your Representative first, then call back to connect with Senator Boxer and Senator Feinstein.

Innovative SFGH Clinic Seeks Volunteers, Funds

Patients’ economic health has everything to do with their physical health. That’s why the residents at the San Francisco General Hospital (SFGH) Pediatric and Family & Community Medicine Departments and the Mission Economic Development Agency created the Financial Fitness Clinic, a medical-financial partnership whose mission is to support and improve the economic and physical health of San Francisco patients and families in financial need. Through individual financial counseling, access to a full array of social services, and personal finance education, the Financial Fitness Clinic provides patients with a resource to address economic determinants of health and the tools to thrive in these tough economic times. Learn more at www. financialfitnessclinic.org. The clinic is currently looking for volunteers from clinical medicine, social work, community development, and financial organizations interested in becoming clinic staff. For more www.sfms.org


December 2011 information, please email Adam.Schickedanz@ucsf.edu or Heather. Bennett@ucsf.edu.

10 Percent Medi-Cal Cuts Will Hinder Access to Care

CMS approved California’s state plan amendment to reduce Medi-Cal reimbursements to clinics, doctors, laboratories, optometrists, pharmacists, and some nursing facilities by 10 percent. Officials with California’s Department of Health Care Services said the cuts are retroactive to June 1, meaning health care providers will have to return money to the state or have the funds subtracted from upcoming payments. CMA has filed a petition with CMS asking that corrective action be taken to address current reimbursement rates and access standards. Califoria’s Medi-Cal reimbursement rates are already the lowest in the nation, and reducing payments will further compromise the safety net for low-income residents. With the new cuts, physicians will be re-

imbursed $11 per Medi-Cal patient visit, when it costs the physician several times that to provide these visits.

Recent data from the California Office of Statewide Health Planning and Development, compiled by the American College of Emergency Physicians, shows a significant increase in emergency room visits since 2005 by Medi-Cal beneficiaries. On average, ER use by Medi-Cal patients increased 30 percent between 2007 and 2009 (most recent reporting period). This demonstrates that Medi-Cal beneficiaries are already being forced to seek necessary care in the ER when they can’t find a physician. The new round of provider payment reductions will ensure overcrowding in emergency rooms and will absolutely mean less access to care for all Californians.

Renew Your Commitment to Medicine and Organized Medicine Today

SFMS would like to thank our 1,400-plus members for their support of the local medical society this year. Because of your support and participation in organized medicine, SFMS continues to be the preeminent physician organization championing the case of physicians and their patients as we face the many challenges of these changing times. Please take a moment to renew your support of SFMS by remitting payment for your 2012 dues today. There are three easy ways to renew your dues again this year: • Mail/fax in your completed renewal form. • Renew online using your credit card at www.cmanet.org. • Enroll in the Easy Pay (quarterly installments) Automatic Dues Renewal Plan by contacting SFMS at (415) 561-0850 or membership@sfms.org.

SAVE THE DATE

SFMS Annual Dinner: January 19, 2012 The 2012 SFMS Annual Dinner will take place on January 19, 2012, at the Concordia-Argonaut Club in San Francisco. Our special guest speaker will be Anthony B. Iton, MD, JD, MPH, senior vice president of the California Endowment’s Building Healthy Communities. Invitations will be mailed to SFMS members in midDecember. RSVP is required. For more information, contact Posi Lyon at plyon@sfms.org or (415) 561-0850 extension 260. www.sfms.org

Volume 84, Number 10 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD

SFMS OFFICERS President George A. Fouras, MD President-Elect Peter J. Curran, MD Secretary Lawrence Cheung, MD Treasurer Shannon Udovic-Constant, MD Immediate Past President Michael Rokeach, MD SFMS EXECUTIVE STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon

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

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

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

December 2011 San Francisco Medicine

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San Francisco Medicine December 2011

www.sfms.org


PRESIDENT’S MESSAGE George Fouras, MD

An “E-ticket” Ride Over the past several weeks, I have been mulling over what I would write about in my closing column as president of the SFMS. The first thing that came to my mind was the reference, as shown in the title. For those of you who have never been to Disneyland (and some of you who are, perhaps, too young to remember or know), an “E ticket” dates back to a time when Disneyland sold coupon books containing “A” through “E” tickets—the best rides, naturally, being the “E” tickets. The easy thing to do would be for me to recount our accomplishments throughout the year. And while we have several to be proud of, I think a better use of this column would be to look toward what lies ahead.

Health care reform. No matter how you feel about the

health care reform bill that was passed, we have embarked on a new journey that will change health care delivery as we know it. Calls for a repeal of this law are dying down as implementation and acceptance proceed. Current suits against the policy, specifically regarding the insurance mandate and the overall constitutionality of the act, are quickly making their way to the U.S. Supreme Court. I don’t think anyone truly believes that the current status of health care reform is even close to what the final product may be. We must, both as individual physicians and as the SFMS, be fully engaged in this process.

The state of the economy. The same phenomenon that

catalyzed the Great Depression of 1929—specifically, overextension of credit—has occurred again, but this time on a global scale. The effects of this recession, and it is not clear that we may be able to avoid a depression, has been worse than any previously seen. I read an article recently in the Motley Fool that compared unemployment during this recession to previous recessions that have occurred since the end of World War II. The data was clear that the degree of unemployment this time is greater than during previous episodes and that it is lasting longer. This does not bode well for the recovery. Why is this important? Because as our governments try to deal with the problems that they have created, our social safety net is eroding. We have three trains all careening toward the same juncture. The number of people relying on Medicaid and public health insurance, as a result of both the economy and health care reform, will increase dramatically in 2014. State governments are attempting to obtain financial relief by limiting funding for these very same programs, which will see an explosion of beneficiaries that they cover. And the final train in our play is being conducted by the federal government: the sustainable growth rate (SGR) fix. What the federal government chooses to do to solve this problem will have a staggerwww.sfms.org

ing impact on our ability to provide  necessary services and on whether physicians will choose to be participants in this program.

The state of politics. Several years ago, Meg Greenfield wrote a column in Newsweek magazine. Her basic premise was this: Fringe groups of any nature, while often annoying or repugnant, are essential to a democratic society. Why? Because these groups, both on the left and the right, help us define what and where the “middle” is, and it is here, in the “middle”, that the foundation of a healthy democracy lives. I mention this because of my concern that the dialogue of the fringe has overshadowed that of the middle, to our peril. Why is this germane to us, the San Francisco Medical Society? It is my belief that anything that affects the well-being of people in general, and by extension our patients, is our business. Getting back to the “E ticket.” One of the strengths that

has impressed me with the San Francisco Medical Society is the balance we have achieved, with some members participating for an extended period of time and thus preserving institutional memory, while also making room for younger members to assume leadership roles. This brings fresh ideas to the house of medicine and also helps younger physicians develop leadership skills. I want to thank the SFMS membership for allowing me to have the privilege to lead this group of people, our colleagues. It has been a fantastic “ride” that I will look back on fondly. In addition, I would like to thank the staff of the SFMS, and so should you all. For it is through their hard work that we stay on top of the current issues facing our profession, get our message out to the public, and ensure successful transitions throughout the years.

December 2011 San Francisco Medicine

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EDITORIAL Gordon Fung, MD, PhD

The Phases of a Medical Career In this edition of San Francisco Medicine, we look at several aspects of physicians’ lives. For the vast majority, the earliest phase begins with medical school. Once one enters the halls of the medical school for the first time as a student, one undergoes mental and attitudinal changes that continue to evolve over a lifetime. Many of us remember when the medical school curriculum introduced us, in lecture halls, to the basic sciences of biochemistry, physiology, and anatomy, allowing limited exposure to patients as we shadowed preceptors in our first year. This was followed by introduction to clinical medicine by organ systems, pathophysiology, histology, and microbiology, with a little more exposure to patients via more shadowing of preceptors. Then there was the third year of clinical clerkships to cover the main clinical rotations of medicine, and then the fourth year of deciding what specialty to pursue via specialty residencies or general internships. There was really no training or education to prepare us for the real world of medical practice—the regulations, the demands of documenting current competency, cultural competency, ethics, and running a practice or running a research laboratory. There was an assumption at that time that physicians would learn the practice of medicine during the postgraduate years or in on-the-job training. At UCSF today, there is more concerted effort to prepare medical students for the current climate, and Dr. Catherine Lucey, vice dean of education of UCSF School of Medicine, shares more about this in her article. Then come the early years of practice, characterized by two significant events: Physicians will finally make decisions without a supervising senior physician or attending and, for those in private practice, physicians will become aware that they are responsible for their livelihoods and practices. If one joins a group, or a very large group or academic setting, the business aspects are a bit more remote, but still one is constantly reminded of the responsibilities of the “business” of medicine. There are numerous issues that one must constantly keep top of mind: new hospital privileges, the responsibility to teach, the responsibility to hire a staff and pay them, and, for some, paying off student loans in addition to starting a family. This phase is variable in duration, since some transition easily into the role of independent physician, while others find it more challenging and may even question whether medicine is indeed the right profession. Eventually, as a young physician, one transitions into an established phase, when more and more of the day is routine: seeing patients in clinic or hospital, getting block-scheduled www.sfms.org

for surgeries, doing on-call activities, and trying to fit one’s personal life into the work schedule. During this time, one becomes much more comfortable making life-and-death decisions for patients and being responsible for the lives of others. Most physicians will also become involved with other activities within their specialty, through committee work within hospitals, membership and volunteerism for their specialty societies, or involvement as a member of a county, state, or national medical society. All the while, physicians try to maintain a balance in their lives to be with family, friends, and their lives “outside” of medicine. It’s important to have other outside interests or hobbies to maintain sanity. But our reimbursements have been routinely cut and lowered with each contract and promise from federal and state governments and insurance companies, forcing physicians to work more hours and see more patients for less compensation. The final phase or transition is as varied as the pool of physicians. Some physicians feel that they have a calling and don’t see a life without being a practicing physician and don’t want to retire. Mentally and emotionally, they see working in medicine as a privilege that allows them to keep helping others. Then there are those who want to retire from medicine to pursue other interests. This decision is simple for some and difficult for others. The current demands on physicians are driving many more to give up their practices rather than just “slow down.” There are some who say that they would rather retire than do EMR. Hopefully, as with other decisions that everyone has to make, every physician makes the right decision to transition through the phases of life thoughtfully and reasonably. We hope you enjoy this issue on the phases of a medical career.

December 2011 San Francisco Medicine

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The Phases of a Medical Career

The Changing Practice of Medicine Changing Specialties, Roles, and Interests during a Career Linda Hawes Clever, MD

If you graduated from medical school more than thirty years ago, AIDS was not part of your lexicon. If you graduated from medical school more than twenty years ago, obesity and gun violence were not considered public health problems. If you graduated from medical school last year, you may have been told, as I was, that one-half of what you learned would be wrong in ten years. We just didn’t know which half. I can remember applying that maxim to the coagulation cascade—and lipid metabolism, too. I decided to wait until some more of the factors and pathways got figured out before I went to the trouble of memorizing them. If diseases, definitions, diagnostic maneuvers, therapies, understanding of the human condition, and health care financing and organization can change, physicians can change, too. In what ways do we change? We may rise to the occasion and learn about leadership, management, respectful team work. We can apply knowledge from different specialties to ours to improve outcomes. (I remember all too well the early heart transplants. I was an infectious diseases fellow before 10 San 11 SanFrancisco FranciscoMedicine Medicine December December2011 2011

immunosuppression was as fine-tuned as it is now. Heart transplantation was a grisly business.) In the career arena, we can recognize the “morale curve,” which was so well described for Peace Corps volunteers. We start with high hopes, then hit reality, and then adjust over months or more. Your morale starts at the max, dips low when the going gets tough, and rebounds to a level slightly lower than your original as you become more informed and develop a more effective modus operandi. Within medicine, you can change specialties as your scientific fascinations shift or as your life and obligations change or as new methods become available (such as stereotactic, micro, and robotic surgery or the recurring acceptability of electroshock therapy). Think about yourself. How many slots have you filled within medicine? I recall a surgeon who covered early expenses by working in ERs, then became a family practitioner, then took more residency training and became a specialist. I think of several physicians who worked in the Department of Occupational Health at CPMC to keep the wolf from their www.sfms.org


doors as they established practices in internal medicine, family practice, and gastroenterology. Within occupational health itself, I know an internist who, intrigued by work and workers, became board certified in occupational medicine. Later, recognizing that many of his patients had unrelenting pain that seemed more related to their psyche and their souls than to structural damage, he got a PhD in psychology and added that to his practice of occupational health. Psychology and patient/doctor communications gradually absorbed all of his professional time. A gifted leader in public health took an additional residency in psychiatry about twenty years into her career, and then practiced psychiatry. A world-class ophthalmologist who specialized in surgery of the orbit found a new spiritual path that became a professional path. Now Bill Stewart heads the Institute for Health and Healing at CPMC. Sometimes physicians become more focused; sometimes they become more general. My husband Jamie loved internal medicine, which is why he took a fellowship in oncology at Stanford with Saul Rosenberg, a superb clinician, as Saul and Henry Kaplan were developing ways to cure Hodgkin’s disease. That training made Jamie an oncologist. Over the years, as circumstances changed (back then, medications were highly toxic, ever more expensive, and not necessarily more effective), Jamie chose to return to his first professional love, internal medicine. In my own life, I followed my interests, mentors, curiosities, and out-of-the-blue opportunities. I started with internal medicine, then took a fellowship in infectious diseases, then a fellowship in community medicine, and, later, another residency in occupational medicine. My scope enlarged to appreciate the vast and dynamic interactions of life, work, and health. Who could have predicted that AIDS would come along and put into urgent service every shred of training I had had? In other instances, internists have become urologists, anesthesiologists have become prison physicians, nurses have become physicians. My mother used to say, often when a person was having difficulties or simply being fractious, “Well, they are just going through a phase.” Phases aren’t easy, including going through the “phases” of a career, yet phases happen to many of us. If you ask a group of ten or more seasoned physicians, it’s likely that three to five to seven are doing things they didn’t do or dream of doing when they started practice—or that maybe didn’t even exist when they finished their medical school or house officer years. When interests and circumstances shift—scientific discoveries, family responsibilities (growing kids and/or aging parents, for example), or the allure of a new field—when that career itch needs to be scratched, it is helpful to have some guideposts to consider:

How do you want to allocate your time to your profession? How important to you are relationships outside your profession, such as family and friends? If time is love, how will you spend your time? Is it possible that your goals might have shifted from being top dog to being a happy dog who is a member of a good pack, yet not in the lead? What facts can you gather about your current situation and other possibilities: location, money, time off (vacation/ sabbatical), the true demand for what you would like to do (that is, will you be busy enough or too busy; do you have the time and energy to build a reputation or a practice)? What are the opinions and energy levels of people you care about, as you consider changes? What about your mentors, allies, family, and friends? If relationships are important to you, who is with you on this adventure? Who is not with you? Have you had those conversations? Are your and their positions negotiable? Do you need some professional help with having those conversations? It’s not embarrassing. It’s always a sign of strength, to get help. If you are thinking about making some changes, what can you do to refresh and renew yourself along the way? What will you do to take good care of yourself during the transition? Transitions take time and energy that need to be replenished. How will you continue getting important exercise? When will you get your flu shots and and invest time in beauty, rest, adventures? Circling back to the meaning in your life and your values, be sure to consult your gut. Your gut is often the seat of your own truth and your own wisdom. The more training we get, the more we may ignore our gut, to our peril and to the peril of our family, friends, and patients. The truth of the matter is, scratch the surface, ask a question, and you will find that many of your colleagues have been through phases or are on the verge of entering one. Whether to become more focused or less focused or to change your focus, going through a phase is an adventure—and you are not alone. Linda Hawes Clever, MD, MACP, founder and president of the not-for-profit RENEW and associate dean for alumni affairs at Stanford University Medical School, received undergraduate and medical degrees from Stanford University. After interning at Stanford, she had several years of medical residency and fellowships at Stanford and the University of California, San Francisco. Dr. Clever is board certified in internal medicine and occupational medicine.

What gives your life meaning? Really, meaning? Is it discovery? Is it comforting someone? Healing? Being a fireman? Saving a life? Saving many lives by working with communities and neighborhoods, regions and countries? www.sfms.org

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The Phases of a Medical Career

The Next Generation Preparing Students for the Modern Practice of Medicine Catherine Reinis Lucey, MD

In 1910, the American educator Abraham Flexner launched a radical change in medical education in the U.S., insisting that medical schools follow a homoge-

neous curriculum with two years of basic science followed by two years of clinical science. One hundred years later, medical education is eerily similar to the educational paradigm embraced by Flexner and his supporters. The educational model is about the only thing that has remained stable in medicine over the past 100 years. In 1910, most disease was acute: Infectious diseases and nutritional deficiencies predominated. If you developed diabetes or hypertension, you simply died. Physicians were expected to interview and examine the patient, perform some simple lab tests, establish a diagnosis, choose from among a small number of effective therapies, tell the patient what to do, and then comfort the dying when the treatments (inevitably) failed. Fast-forward to 2011: Disease is predominantly chronic. Physicians are expected to interview and examine patients; obtain data from genetic profiles, extensive lab tests, and sophisticated imaging studies; carefully review the ever-expanding scientific literature, established clinical pathways, 12 13

San Francisco Medicine December 2011

and practice guidelines; identify the right therapy from among thousands of pharmacologic and procedural options; engage the patient in a discussion about values, insurance coverage, and the risks and benefits of the various options; implement the decision that results from that discussion; coordinate the patient’s complex care with other health professionals; attend to preventive health issues; comfort the suffering and the dying; and repeat this for every chronic disease in each patient. Oh, and enter this complex work into an electronic health record. Phew.

How then, do we educate today’s talented medical students to become physicians capable of navigating this increasingly complex but still wondrously fulfilling career? Changes are in the works for both the process and the outcomes of medical education. www.sfms.org


Students attending medical school today are still expected to embrace the tenets of professionalism and master medical knowledge, patient care skills, and communication strategies. But there are new areas of study that focus on the skills our young physicians will need to succeed in today’s health care environment, a sampling of which are summarized here.

1. Using technology to support clinical work and professional development.

Today’s students are being educated to use technology, such as electronic health records, to proactively identify and reach out to patients who need special interventions to optimize their health, rather than waiting for them to make an appointment on their own. In addition, students are learning how to use clinical decision support tools and Web-based scientific databases to ensure that their decisions are compatible with the most current evidence.

2. Blending personal expertise with systems standardization.

We are teaching students that the judicious use of checklists and guidelines can make care safer and more effective. Students are learning how to judge the quality of guidelines, when and how to follow checklists to ensure the safety of our patients, and, importantly, when to deviate from pathways because of a patient’s unique circumstances.

3. Working within interprofessional teams to get things done.

Students are learning how to assess the capabilities of people on their team, how to delegate wisely and monitor the performance of others, and how to negotiate when disagreements arise within a team of professionals.

4. Adopting a view of continuous quality improvement.

Today’s medical students are being educated to use data to assess their own performance and to measure and compare the outcomes of their patients with national best practices.

Many changes in the process of medical education are also in the wind. Simulation centers, like the new Kanbar Center at UCSF, allow students and residents to practice procedures, communication skills, and complex management strategies in a safe environment. Podcasts allow students to learn factual information at their own pace, while classroom time is dedicated to interactive, small-group discussions of how to apply that information to patients. Longitudinal clerkships imbed students in faculty practices for six months to a year, allowing them to get to know the patients in the practice and to observe the evolution of disease and care processes. Many quandaries about medical education remain. Work hours restrictions on residency challenge us to rethink how we educate residents in the clinical environment so that they not only gain the experience they need in a shortened work week but also learn to be practicing professionals who put the needs of the patient ahead of their own. Medical schools are also asking whether the continuum of medical education, www.sfms.org

from first year of medical school to last year of residency/ fellowship, can be shortened for some talented students and residents. Still other educators wonder if we can leverage our talented students, residents, and faculty to improve the health of our communities in a systematic and sustainable way. UCSF is committed to optimizing medical education so that our graduates become the types of physicians we want to be caring for the people we love and the communities in which we live. I welcome the opportunity to hear your thoughts and ideas. Catherine Reinis Lucey, MD, is the vice dean for education at UCSF.

Welcome New SFMS Members The San Francisco Medical Society welcomes the following new physician members to our family! SFMS New Member as of August 2011:

Sashi Bindu Amara, MD Internal Medicine Althaea Greenstone, MD General Surgery

Jill Marie Guelich, MD Obstetrics and Gynecology Aissatou Haman, MD Internal Medicine Meredith Heller, MD Internal Medicine Katherine Herz, MD Pediatrics Theresa Ann Kemnitz, DO Internal Medicine Alison Carol Lyke, MD Dermatology Edward Melkun, MD Plastic Surgery Karoline Nowillo, MD Plastic Surgery Isabella T. Phan, MD Medical Oncology Robert John Purchase, MD Orthopaedic Surgery Sooji Lee Rugh, MD Internal Medicine Hector Luis Santiesteban, MD Internal Medicine Yi Brenda Shue, MD Endocrinology Ailinh Jessica Tran, MD Internal Medicine Yanling Xu, MD Internal Medicine Pearl Wong Yee, MD Obstetrics and Gynecology

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The Phases of a Medical Career

The Importance of Mentorship The UCSF Comprehensive Mentoring Program Jeanette S. Brown, MD Mentoring is a critical component of career development and success for a clinical translational science research faculty. The University of

California, San Francisco (UCSF) Clinical and Translational Science Institute (CTSI) started a comprehensive mentoring program that began with the Mentor Development Program (MDP) in 2007 in conjunction with the launching of a campuswide faculty mentoring program. The goal of the UCSF Faculty Mentoring Program is aimed at all junior faculty members in all four professional schools, with the goal to pair each with a career mentor to oversee and support their professional development. The Career Mentor is usually in the mentee’s department, should not be their direct supervisor, and is assigned (or approved) by the departmental mentoring facilitator affiliated with the Faculty Mentoring Program. Scheduled meetings take place at least two to three times per year. The director of the Faculty Mentoring Program also serves as the codirector of the CTSI Mentor Development Program.

While mentoring is a critical component of career development in the academic health sciences, particularly for individuals committed to translational research, mentoring skills rarely are taught explicitly.

The CTSI Mentor Development Program’s (MDP) primary goal is to train midcareer and early senior clinical and translational research faculty in the knowledge and art of mentoring so that they can more effectively mentor the next generation of clinical and translational (CT) researchers. The MDP spans the four schools of the university, pooling expertise and resources from nursing, medicine, pharmacy, and dentistry. The MDP includes a combination of skills-based exercises, case discussions, and key information relevant for all CT mentors, such as fiscal and personnel management, IRB procedures, and grant resources. Specifically, the MDP program consists of ten case-based seminars held during monthly half-day meetings over five months. The casebased approach is designed to stimulate discussion about mentoring best practices, such as mentor relationships, fostering independence, challenges to communication, role of the mentor in promoting work-life balance, and mentoring women and members of underrepresented groups. Course faculty include panelists with extensive mentoring experience from within and outside UCSF.

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The monthly schedule includes two seminars each morning and time for mentors in training to network with each other and with senior mentors. While the ultimate goal of the sessions is to provide knowledge and skills for mentoring, the content has the added benefit of directly enhancing the mentors’ research programs through improved understanding of institutional policies and access to resources that strengthen the mentors’ programs as well as the careers of the early career investigators whom they mentor. All MDP materials are on the CTSI website (http://accelerate. ucsf.edu/training/mdp-materials), including mentoring resources, seminar outlines, illustrative mentoring cases, and the opportunity to add observations and comments to the mentoring cases. Since its inception in 2007, nearly sixty mentors in training (MITs) have completed the MDP. Only 15 percent of the MITs reported any previous mentor training. Overall, we found that the MDP had a significant impact on the participants’ assessment of their mentoring skills after completion of the program. Notably, the MITs reported a significantly increased level of confidence in their overall and specific mentoring skills and most reported that they are likely to alter their approach to mentoring as a result of the MDP training. In general, the MDP promotes a mentoring team approach. A team approach to mentoring may be more appropriate for many junior faculty members to fulfill their mentoring/ career goals, particularly those in careers that require significant research/scholarship for advancement. The mentoring team helps to ensure that the mentee is progressing in a timely fashion to fulfill his or her mentoring/career goals. If a mentoring team is assembled, it is important for the junior faculty member to identify a “lead mentor.” The team should also include a career mentor(s) and may include comentor(s), project mentor(s), and additional research/ scholarly mentor(s). (See UCSF mentor definitions at http:// accelerate.ucsf.edu/training/mdp-seminar1-definitions.) Scheduled mentoring team meetings take place at least two times per year.

Important online materials for mentoring:

• MDP case scenarios: http://accelerate.ucsf.edu/training/mdp-cases • Mentoring partnership agreement: http://accelerate. ucsf.edu/training/mdp-seminar1-checklists • Individual/career development plan: http://accelerate.ucsf.edu/training/mdp-seminar1-meeting

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The Phases of a Medical Career

Using Your Resident Voice Effective Advocacy During Early Career Ryan Padrez, MD “Obviously these are some exceptional young people, but what they have in common is that they were ordinary people who cared. They wanted to act, to do something, to make life better for other people—and they have.”—Colorado State Senator Morgan Carroll

This past spring, a small group of pediatric residents from UCSF visited the Capitol in Sacramento to advocate for preventing a legislative proposal to make substantial cuts to California’s Healthy Families program. It was one of many controversial cuts

on the table to our government health programs during the difficult state budget debates of last year. None of the residents in the group were experts in health policy advocacy nor had any of them ever spoken to state legislators. Yet on that day, during their brief trial at advocacy, they discovered something unique and captivating: the power of their resident voice. Dressed in their bright white coats (which had hardly been worn, given that they were pediatricians), they were treated like celebrities and were warmly welcomed by other nonphysician lobbyists when arriving to the Capitol that morning. During the time for in-person public comments to state legislators on the committee, the professional lobbyists in the room advocating for the same issue deferred their time at the microphone to the resident physicians. Everyone wanted to hear what the doctors had to say first. The tenured lobbyists in the room knew that there are few tools more convincing than patient stories from the front lines and articulating how cuts to critical safety net programs will negatively affect access to care. Many residents across the country have had similar moving experiences to the one shared by my pediatric resident colleagues that day in Sacramento, whether it was advocating for an issue at the local level with district supervisors or speaking at the Capitol in Washington, D.C. After such efforts, most are in awe of just how powerful the voice of a resident physician can be in political advocacy. In addition to the awesome responsibility the letters “MD” bring in the hospital or clinic with regards to patient care, there is an equally important social trust the community has for the physician perspective for health and social policy issues. When treated with humility and sincerity, this trust can be an incredible tool for advocacy. The encouraging news is that today’s resident is starting to recognize this opportunity for advocacy not as an option but as a core professional responsibility. More and more medical students now enter residency after previous careers www.sfms.org

in policy, law, education, volunteer corps, nonprofit groups, and even advocacy organizations themselves. Many were thus drawn to a career in medicine not necessarily because of the love for the basic sciences and research but for the opportunity to use their medical degrees to make a difference to their community’s health through patient care and public health activism. Some graduate medical education (GME) programs in all disciplines across the country have started to respond to this growing interest of residents and fellows by building advocacy and health policy material into their curricula. Some GME programs have even taken it a step further and developed formalized tracks that focus on advocacy, health policy, social determinants of health, and leadership skills in addition to the traditional required clinical training. These specialized programs are helping mold the next generation of physicians to be effective advocates and leaders in their specialties as well as their surrounding communities.

With a strong desire to advocate for social change in their communities but with little time available as a resident or fellow, the question becomes how to participate and use our resident voices most effectively. Even with the new duty hour limits, one rarely hears a resident or fellow use the term “free time.” Building on the idea that power in numbers is still an important principle in effective activism, one of the easiest and perhaps most efficient ways to make a difference is through organized medical societies and groups. With the country’s recent focus on federal health care reform and passage of the Affordable Care Act, one of the exciting changes in organized medicine has been the number of new physician organizations and grassroots campaigns that emerged on the national level to help to organize the physician voice. Groups such as Doctors for America and National Physicians Alliance emerged to provide many physicians a refreshing outlet outside of the American Medical Association (AMA). It is exciting to see these new groups continue to thrive, and many young physicians remain involved in their efforts across the country. We are fortunate that, locally, we have an active county medical organization with the San Francisco Medical Society (SFMS). As one who has participated in SFMS since early in medical school at UCSF and now as a resident, it is extremely

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Using Your Resident Voice Continued from the previous page . . .

The Importance of Mentorship Continued from page 14 . . .

gratifying to participate in an organization that is so welcoming to medical students, residents, and fellows. If the goal is to maximize our resident voice in advocacy, then there are a number of good reasons to consider devoting some of our finite free time to SFMS. First, SFMS has proved itself to be refreshingly open to diverse opinions, mirroring the rich diversity in opinions, political preferences, and perspectives found among the people of San Francisco. The advantage of this diversity is that it helps SFMS have rich discussions on issues, and more progressive members are often more willing to be leaders in advocating for more contentious issues well before other medical societies or associations feel comfortable joining the campaign. In addition, SFMS is a well-established organization in the Bay Area that has the ear of elected officials at the local and state levels. Elected officials pay attention to SFMS, and if you are resident with a passion for an idea, policy, or legislative change, working within SFMS is a powerful tool to help advocate for this change with our elected officials. Finally, participating in SFMS brings access to an expansive network of physicians who, despite varying opinions, all share a vested interest in the community of San Francisco. For a physician in training, SFMS provides a great opportunity to meet with physicians across specialties, generations, and practice settings that provide mentorship, important diverse perspectives, and ultimately buy-in to our ideas worth advocating for in the community. Many residents may be hesitant to participate in general organized medical groups such as SFMS due to the lack of time; commitments to their own specialty medical societies; or, perhaps, concern that SFMS does not share the same values, goals, or political views. Unfortunately there is very little that can be done to create more free time during training, but SFMS is working to make it easy to get involved in dialogue by becoming more active with social media such as Facebook, Twitter, and LinkedIn. Given today’s residents’ devotion to advocacy and public health in the community, my hope is that my resident and fellow colleagues will take advantage of SFMS as a welcoming organization to trainees that provides a forum to unify our voices across specialties and the infrastructure and resources to help us advocate for change effectively.

In summary, the combined programs of the CTSI Mentor Development Program and the UCSF Faculty Mentoring Program serve as a model for other institutions to develop the next generation of clinical-translational research mentors.

Ryan Padrez, MD, is a first-year pediatric resident at UCSF in the Pediatric Leadership for the Underserved (PLUS) program. For more information on PLUS, visit http://pediatrics. medschool.ucsf.edu/brochure/pedsplus/.

Jeanette S. Brown, MD, has been a UCSF faculty member in the Department of Obstetrics, Gynecology, and Reproductive Sciences since 1986, with joint appointments in the Departments of Urology and Epidemiology. She is also director of the UCSF CTSI Comprehensive Mentoring Program and director of the UCSF Women’s Health Clinical Research Center. Dr. Brown is an internationally recognized urogynecology clinician and leader in clinical research on lower urinary tract function in women. She has a strong federally and privately funded research program, publishes frequently in peerreviewed journals, and serves as an advisor to the National Institutes of Health (NIH). Reflecting her clinical and research career, Dr. Brown’s teaching activities are focused on mentoring and clinical research training. As director of the UCSF CTSI Comprehensive Mentoring Program, Dr. Brown leads the successful Mentor Development Program (MDP).

Acknowledgments The authors of the two previously published manuscripts where most of this material was developed: Feldman MD, Huang L, Guglielmo J, Jordan R, Kahn J, Creasman JM, Wiener-Kronish JP, Lee KA; Tehrani A, Yaffe K, Brown JS. Training the next generation of research mentors: The University of California, San Francisco, Clinical and Translational Science Institute Mentor Development Program. CTS. 2009;2(3): 216-221. PMC2747761. Johnson MO, Subak LL, Brown JS, Lee K, Feldman M. An innovative program to train health sciences researchers to be effective clinical and translational- research mentors. Academic Medicine. 2010; 85(3): 484-489. PMC2856696. Funding/support: The CTSI Comprehensive Mentoring Program is supported by NIH/NCRR UCSF-CTSI Grant Number UL1 RR024131. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The UCSF Faculty Mentoring Program is supported by the Office of the Vice Provost, Academic Affairs, Faculty Development and Advancement, and is aimed at improving the availability and quality of mentoring for UCSF faculty in all four professional schools.

CMA Physicians’ and Dentists’ Confidential Assistance Line The Physicians’ and Dentists’ Confidential Assistance Line is a phone line service for physicians, dentists, and their family members who request help with problems of alcoholism, drug dependence, or mental illness within their families. This 24-hour phone service provides completely confidential doctor-to-doctor assistance. This service is free and it will not result in any form of disciplinary action or referral to any disciplinary body. There is often an increase in calls to the line during the holiday season and we want to make sure that physicians are aware of this resource. For more information, see the CMA website: http://www.cmanet.org/ resources/confidential-assistance/confidential-assistance. 16 17

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The Phases of a Medical Career

Advocacy During Mid-Career Going Beyond Establishing a Practice Peter Curran, MD Several weeks ago I received a letter from a local surgeon asking if the San Francisco Medical Society would help support a health initiative that had directly impacted his family. We decided to coauthor

a resolution submitted with our delegation to the California Medical Association House of Delegates, which forms health policy for California and often nationally. Last month resolution 610a-11 was approved by the CMA, representing 35,000 physicians in California. The ability to take an idea from the doctor’s dining room to the entire house of medicine is what keeps me an active member of the SFMS. Not that long ago, membership in the local medical society was tied to obtaining hospital privileges and medical malpractice insurance coverage. The days of the draft are over, and today’s membership is completely voluntary.

The intrinsic value of paying dues for membership is perhaps less transparent than in the past. However, a vibrant diversity of members and practice settings have replaced the “old boys’ club” status quo of the past, especially evident at the local level.

As never before, the landscape of health care is changing. CMA President James Hay, MD, sworn in this month in Anaheim as the 144th president, cautions physicians to stop “fighting each other for pieces of a dwindling market.” Over lunch a friend and mentor of mine, who runs a successful solo practice in the Central Valley, said he believes medicine is moving toward a two-tiered system of health care distribution. A less flattering description is the haves versus the havenots in access to health care. Not only is the distribution of health care dollars changing under insurance reform but the physician as an employee rather than small business owner is the prevailing model of practice. Now more than ever, organized medicine is critical to advocate for patients and physicians in San Francisco. A roadblock to medical advocacy is what I call the AMA effect: initial interest at the medical student and resident level, followed by a gradual attrition of members due to the siphoning of membership dues from the specialty societies and other interests. I would argue that community activism and local networking are benefits of membership at SFMS not matched by other organizations. I use the term community activism rather than the almost cliché advocacy because it sugwww.sfms.org

gests the focus of health policy starts in the community. From the office of the city supervisor to the mayor and state representative, your San Francisco Medical Society continually represents all things physician in San Francisco. Recently the immediate past-president of the CMA offhandedly said that he spent much of his time as president trying to block new legislation in Sacramento. Although I understand his intentions against potential threats such as nonphysician scope of practice issues, we cannot forget the power of political dissention to advance best practices. Similarly, the current “Occupy” protests sweeping our cities, despite lacking a common leadership or theme, serve to reinforce the importance of protesting inequality at any level. We must never take for granted the opportunity to fight inequality and social injustice in health care. Networking is more than meeting other like-minded people at a social event. Networking to me means a collective communication that simply cannot be matched working in an individual silo. Active participation in organized medicine fosters service to others and mentorship. Service to others starts in the clinic taking care of patients. We are all foot soldiers in this regard; trained to do our job competently and ethically. Mentorship also starts in the daily practice of medicine, but it goes further in the development of leaders in the profession of medicine. My colleagues at SFMS are leaders in their practices, local hospitals, and even at the state and national level. Organized medicine collectively provides a broader scope and larger impact. Have a passion for end-of-life care or fighting big pharma shortcomings? We have someone for you. How about getting cigarettes out of pharmacies in San Francisco? We’ve worked on that too. Whether you support it ideologically or not, the new CMA policy calling for the legalization and regulation of marijuana in California had a voice from SFMS. Organized medicine is being part of something larger than the individual. It is organizing grassroot campaigns against unfair business practices and raising more than $100,000 for CALPAC this year to put physicians in state office and influence legislation that impacts all of us. It is advancing an honorable profession and leaving a legacy to the next generation. It is being more than a foot soldier in medicine. Pete Curran, MD, is president-elect of the San Francisco Medical Society, delegate of District 8 to the CMA, and a private practice physician in San Francisco.

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The Phases of a Medical Career

Running in the Fast Track Taking a Career in Phases Tom Madigan

On October 1–2, 2011, the Charity Challenge was held at Infineon Raceway in conjunction with the Vintage Racing Classic Car Show. The object was to raise money by offering rides in some fantastic racing machines. Photo: Nancy Freedman Centered in the heart of the Napa Valley, Infineon Raceway was constructed as a cathedral to speed. Infineon is far more modern than its counterpart Laguna Seca, located near Monterey, but not nearly as historic in racing folklore. Infineon plays host to several national events each year, including the NASCAR Save-Mart 300 and the IRL Indy car race, bringing major TV networks and crowds from as far as Southern California. In October of 2011, an event was held at Infineon featuring vintage racing machines as part of a classic car show and a “Charity Challenge” sponsored by the Classic Sports Racing Group. Part of the program included a chance for donors to the charity to ride “shotgun” in a fabulous array of racing machines as a thank-you for their generosity. On the morning of the event, the paddock area was cluttered with vintage racing cars and spectators milling around 18 19

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in anticipation of the coming drama. Striding through the gathering was a slender, athletic figure dressed in a Nomex fireproof driving suit, carrying a crash helmet. As he made his way through the collection of race cars, glances came his way and several cameras were raised in his direction. Which of the thundering machines does he drive? Is he a retired champion here to give out a few thrills? Did he jet over from Europe? His demeanor was intense; he showed what racers call “gun fighter” eyes. Finally a passerby asked, “Which of the cars do you drive?” The answer: “I’m here as a passenger. I’m a doctor.” This was Dr. Eric Freedman, a noted urological surgeon from Sonora, California. The good doctor had come to Infineon Raceway to experience the physical sensations of riding in an all-out racing machine at speeds approaching 200 mph. The connection between author Tom Madigan and Freedman (Madigan is an ex-racer and automotive author) was forged while www.sfms.org


Freedman was treating Madigan for prostate cancer. Their conversation revealed their mutual interest in racing, leading to Freedman’s participation in the October event. Racing, however, is not the only activity that compels Freedman to extend himself mentally and physically. Hockey, climbing, and wilderness exploration are all part of what he calls “life phases.”

This subject of life in general and the phases a doctor experiences throughout his or her career was provoked by a conversation after the Infineon experience. Freedman offers comments on the phases of his career and how today’s physician must make different choices than did those of the past. His comments proved to be extremely interesting, if not slightly controversial. A native of Toronto, Canada, Eric Freedman graduated from the University of Toronto Medical School in 1983. Years of training included pediatrics, urology, and pediatric urology, then a practice in Victoria, British Columbia, from 1994 until 2000. During that period, Freedman became disenchanted with the Canadian health care system and decided to make a move. “Over a period of time, while practicing in British Columbia, I experienced my own personal issues with the Canadian Medical System, a one-pay system controlled by the government,” he says. “I struggled with the many restrictions placed on physicians in terms of trying to get the patient into the system in order to get them treated. These issues caused me incredible frustration because I was trained to help people, and at that time it was difficult if a patient need urgent surgery. It got to the point to where I questioned whether I was in the right occupation. In the year 2000, I talked things over with my wife, Nancy, and we decided to take our two children to the United States, essentially going from a socialist system to a capitalist system. I had a group of colleagues who had gone to the United States and they gave me counsel as to what I might expect.” The Freedmans moved to Buffalo, New York (not too far from relatives in Toronto), where he began a practice. This move punctuated what Freedman calls a “major phase” in his career. For four years in Buffalo, Freedman learned the complexities of the medical care system in the United States. In early 2003, he entered another transitional phase in his life, wanting to strike out on his own. Freedman says, “I remember vividly one night laying out a map of North America, and my wife and I asked the question, ‘Where do we want to go?’” The criteria for this second move included a location with four distinct seasons and a heavy emphasis on the outdoors. Both Freedman and his wife love sailing, hiking, and skiing. Their final choices came down to Oregon, Idaho, New Mexico, and Northern California. As sometimes happens, luck played a hand in his job search. www.sfms.org

Getting ready for his wild ride, Freedman is strapped in place, helmet on and his racing attitude ready. The adventure was part of a charity event held at Infineon Raceway in the wine country of Northern California. Photo: D. Randy Riggs When an inquiry came from Sonora, a small town in the Gold Country of Northern California, Freedman responded and discovered a friend, a fellow Canadian and urologist who practiced in Sonora. Freedman contacted him, paid several visits, and ultimately decided that this was a place he and his family could become attached to. Steeped in the history of the California Gold Rush, Sonora offered rural living, four seasons, and access to outdoor activities and Yosemite National Park. Another feature that puts tiny Sonora on the map is its state-of-the-art hospital, the Sonora Regional Medical Center/ Adventist Health, offering a world-class cancer center. Freedman was given an insider’s tour of the hospital prior to its opening in 2004, which was a contributing factor to his decision. He says, “I suddenly had a vision of this hospital becoming a center of excellence in health care in the middle of a pristine location. I thought, ‘What a great combination, to be able to practice a very high level of medicine yet live in a beautiful environment.’” Now, in 2012, Freedman has become well established with his own practice (advanced urology) and is a leader of the medical staff of Sonora Regional Medical Center. What comes next in the phases of his career? On this subject, Freedman opens up to the new reality of health care. In his words, “The future for a doctor today is much different than it looked

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Running in the Fast Track Continued from the previous page . . . twenty or thirty years ago. Back in the day, the pathway followed by a doctor was set in stone; the health care system was more stable. Things are not so sure anymore. “I think most doctors are worried about the future. What will become of Medicare and the entire health care system? I can remember back when doctors would work until they got to be sixty or so years old, then they looked to ease up their pace and take time to do the things that had been put off. Today, it’s more difficult to plan for any type of retirement; costs are up and the medical profession is in a state of flux. In my view, doctors may end up working years longer than they had planned when they left medical school and started their practice.” On his own future, the doctor says, “I for one have added a new phase in my career: to enjoy some of the activities that I want to do outside of medicine now, while I can afford to expend the energy, the time, and expendable income, rather than wait until I retire, which may not happen so easily as in years past. “Again, as I look at my own life, at this point I can detect the subtle differences that have forced doctors to adjust their thinking about the future. At my age, doctors in the past would have had their practice established, home about paid off, children about to leave the nest, and a few dollars tucked away. They’d be winding down, ready to enjoy life with a little less pressure. All that has changed, and when I look at my own situation I see a lot of instability in the economy. I talk to my patients, some of whom are well into their seventies and even eighties, and some have found that retirement isn’t what it use to be. You know the old saying, ‘You only regret the things you don’t do.’ Because I may have to work in practice much longer than my predecessors did, I have made a conscience decision to try to do some of the more ambitious forms of extracurricular activities—like taking a ride in a racing car.” In conclusion, Freedman condenses his personal reasons for treating the phases in his career as he has and offers his personal opinion on the future as he sees it: “I feel that the future of health care as we know it will go through some adversity and stress. Doctors may find it harder to own a personal practice, and there could be a trend toward working directly for hospitals. Worst case, the 401K you think will be waiting for you when you retire may no longer be guaranteed.

Over the past five years there has been a constant background noise that physician reimbursements may trend downward. Although that has not actually happened yet, one would be foolish to ignore the signs and spend like the government, not worrying about the future. “Again, in my opinion, this trend to spotlight self-preservation is a new phase in my career, one that dims the idea of slowing down and pushes the idea of working for a longer period of time. I propose that the future should be considered a new era in medicine.”

Dr. Eric Freedman loves the challenges in life and has decided that he will enjoy more risky ventures now and not wait until retirement. Photo: Nancy Freedman

AMA Adopts Policies from SFMS Regarding “Crisis Pregnancy Centers” and Other Issues At their interim meeting in November, the American Medical Association (AMA) adopted an SFMS resolution regarding the controversial issue “crisis pregnancy center” and the (lack of) service it provided. This issue has been debated locally and the resolution, authored by SFMS delegate Leslie Lopato, MD, and staff member Steve Heilig, MPH, was adopted by the CMA House of Delegates in October. The AMA policy states: 1. AMA supports regulations that require any entity offering crisis pregnancy services to disclose information onsite, in its advertising, and before any services are provided concerning the medical services, contraception, termination of pregnancy or referral for services, adoption options or referral for such services; and, 2. AMA advocates for any entity providing medical or health services to pregnant women who market medical or any clinical services need to abide by licensing requirements and have the appropriate qualified licensed personnel to do so and abide by federal health information privacy laws. In addition, the AMA also adopted two SFMS’ resolutions: opposing removal of generic medications from the market in favor of more expensive brand name products based solely on a lack of studies of the efficacy of the generic drug, and opposing censorship of physician discussion of firearm risk. For more information, please visit http://www.cmanet.org/news/detail/?article=highlights-from-amas-2011-house-of-delegates0. 20

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The Phases of a Medical Career

Easing into Retirement The Transition from One Passion to Another Lawrence B. Lurie, MD I grew up believing that sixty-five was retirement age. Pensions, Social Security, and (later) Medicare started at

that age. It was a culmination of one’s work life, a well-earned time for relaxation and the pleasures of “owning” your own time. This concept was strengthened further for me when I made a family visit at age sixty and found my younger cousins, many of whom were teachers, already retired at age fifty-five, busy playing golf, bridge, traveling, and tending their gardens.

I reached retirement age and began to face my dilemma seriously. I had enjoyed my practice of psychiatry. I had also treated a number of patients with depression who had developed symptoms after they retired. My advice usually consisted of encouraging them to develop a hobby, such as collecting books, art, maps; or to do something creative, such as returning to piano lessons or taking up painting; or to explore new experiences, such as traveling.

I talked to colleagues when I reached sixty-five and found that many planned to continue working indefinitely. Some reported that the income was important. I personally found that my investment values could fluctuate in one day by more than I could save in six months. My income seemed almost irrelevant. Other colleagues spoke of the pleasure they had in work and the fear of not knowing what else they would do if they retired. My own experience was that practice was a burden (suicidal patients and managed-care authorization requests, for example) as well as an engrossing and challenging profession. San Francisco has had, for about thirty years, a wonderful institution called “Open Studios.” Artists all over the city invite you to their studios to show and sell you their work. Convinced that I better think about what I might do in retirement, I visited a number of artists in my neighborhood. I was particularly attracted by the work of one sculptress, Harriet Moore, and asked if she gave classes. She did, and I began to attend every Saturday morning after the long work week. For a psychiatrist, doing something “hands on” with clay after practicing “hands off” all my work life was a delight. I had limited previous experience in art, which made the Saturday morning classes a pleasure. By now, I had gone three years past my self-imposed retirement age, and after discussion with my wife, I gave my patients 22 23

San Francisco Medicine December 2011

a one-year advance notice that I would be retiring at age sixtynine. My retirement day was July 31, 2003, coming after forty years of practice. Many colleagues retire more gradually, slowing down to work two or three days a week for a while. Since I had a busy practice and many long-standing patients, I found that I did not want to choose which of my patients I would retain, especially if I used an economic basis for my choice. I decided to retire completely, giving patients one years’ notice and arranging referrals for some. Upon retiring, I took up sculpting three days a week. Because I wanted to learn how to glaze my sculptures, I was advised to take a class in ceramics. City College of San Francisco has an outstanding Arts Campus, at Fort Mason, where it’s possible to take credit and noncredit courses for very low fees. I signed up for ceramics, which required me to throw bowls on a wheel. After struggling to learn how to center a bowl, I came to enjoy the new skill. So I have come full circle. Now, every October, I have an Open Studio in the front garden of my home and invite my friends and the public to visit, socialize, and enjoy or even buy my evolving www.sfms.org


sculptures and ceramics. Retirement, I believe, requires a balance of activities (and nonactivities). Volunteer teaching of psychiatric residents at University of California, San Francisco, takes two hours each week. Consultation at an adult day health center is a once-amonth activity. The Fromm Institute, a superb educational institution for older adults located on the University of San Francisco campus, occupies my time several days each week. Retired professors teach courses ranging from the politics of the next election to the teachings of Confucius to the history of musical theater. The Fromm Institute is a place to meet your colleagues and your former patients, and to make new friends over lunch. In retirement, there are many opportunities to serve on boards of directors of nonprofit organizations. They appreciate our experience as practitioners and welcome us to their boards. I chose the San Francisco Senior Center because, professionally, much of my work had been in geriatrics. I became president of the board of the SFSC as it merged with another organization, and I found my skills well used, although I occasionally had the thought, in times of stress, that formerly I had been paid for this kind of work. And then there is travel. I am writing this article as I sit on the deck outside my room on a boat going up the Yangtze River. In thirty minutes, I will be viewing one of the gorges of the Three Gorges Dam. Everybody traveling with me, from all over the United States, is retired. I marvel as they tell me of their previous trips to Egypt, Turkey, Thailand, and other exotic places. Some are inveterate and adventurous travelers, already planning the next trip. I am not in that category. Perhaps one of the hardest questions as we age into our late seventies is where we want to live out the years left to us. One option open to us is moving to an independent-living facility. However, my wife and I have chosen to try to live at home. In San Francisco, there is an organization called San Francisco Village, based on a model started on Boston’s Beacon Hill. By providing for a variety of services ranging from changing your lightbulb to vetting contractors and financial advisors, it makes aging in your own home feasible. My particular interest has been the transition from hospital to home, so that issues including follow-up physician visits, clarity about medications, and being sure there is food in the refrigerator are given proper attention and aid if needed. Establishing communication between hospitals and SF Village has become a project for me and my wife, a gerontologist, to work on together. Finally, relaxation is an important component of retirement. Whether it’s the afternoon naps, reading a book, or watching TV, R&R is a must. Symphony, theater, lectures, ballet, museum-going, and book clubs can serve as relaxation or become work. Personally, I now especially enjoy visiting galleries and museums and find myself looking carefully at the sculptures and ceramics. Keeping one’s personal balance is a key to feeling satisfied. One person’s formula for retirement can be very different from another’s. My medical school roommate lives in Florida, plays golf and bridge and gardens, then goes out to dinner with his golf partners and their wives. It is hard for me to imagine this as a retirement life. He loves it. www.sfms.org

Lawrence B. Lurie, MD, interned at Stanford and was a psychiatric resident at Langley Porter. After serving in the U.S. Public Health Service, he was a fellow in the Community Mental Health Program at UCSF. He was chief of Consultation Services for San Francisco Community Mental Health Services and then founded and directed District V Community Mental Health Services. He was president of the Northern California Psychiatric Society and chair of the American Psychiatric Association’s Committee on Managed Care. His honors include the UCSF Royer Award and the Warren Williams Award from APA. He is currently chair of the board of directors at the San Francisco Senior Center and clinical professor of psychiatry at UCSF. December 2011 San Francisco Medicine

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The Phases of a Medical Career

Balancing Motherhood and Medicine The Challenge of Creating a Schedule That Benefits All Katherine Chretien, MD The Mary Elizabeth Garrett Room lies off a busy corridor on the main floor of Johns Hopkins Hospital. As a medical student and later an internal medicine

practice medicine full-time. She rightly points out that there are limited medical school and residency slots in the face of a growing physician shortage, particularly in the primary care fields that attract women in high numbers. However, Dr. Sibresident at Johns Hopkins, I often treated the small women’s ert’s envisioned ideal would be a great loss to patients and the lounge and adjoining locker room as a sanctuary during my profession, and a major step backward for women in medihectic days and nights of studying and call. Its namesake, a cine. philanthropist who was one of the wealthiest women in the Historically, the practice of medicine required a selfless U.S. in the late 1800s, used her financial power to provide opdevotion to the profession at the cost of personal and family portunities for women to gain independence and autonomy. life. The legendary turn-of-the-nineteenth-century physician She and her friends offered to raise a badly needed $100,000 Sir William Osler is credited with saying, “Medicine is a jealous for the endowment of the Johns Hopkins School of Medicine mistress; she will be satisfied with nothing less.” These roots if the trustees agreed to admit women on the same basis as are evident in the harsh training environment that prevailed men. The rest, for future women in medicine, was history. for so many years, requiring superhuman work hours, rare In her New York Times opinion-editorial “Don’t Quit This days off, and expectations to work through personal illness. Day Job” (June 12, 2011), anesthesiologist Dr. Karen Sibert Slowly, medicine’s professional culture has made progress, reargues that women physicians, who increasingly work partalizing that the care—in all senses of that word—of its memtime or leave clinical medicine altogether to find better balbers helps physicians (men and women) lead more balanced, ance between work and family life, have a moral obligation to healthier, happier lives and helps patients by improving the quality and safety of their health care experience through physician work-hour restrictions. For women physicians, who continue INC. to perform the lion’s share of household duties and child rearing despite society’s A REGISTRY & PLACEMENT FIRM more progressive view of the division of household labor, this has meant the increasing availability of part-time positions, job sharing, and other creative soluNurse Practitioners ~ Physician Assistants tions to allow them to continue practicing medicine while fulfilling commitments at home. Achieving work-life balance means greater satisfaction for one’s career and keeps women (and men) physicians in medicine. Indeed, it is this flexibility possible in certain specialties such as primary care, dermatology, and radiology that makes medicine an attractive career for many women, despite the years of difficult training and medical school debt.

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San Francisco Medicine December 2011

We are, after all, talking about a profession that is built around caregiving, with the parallels between caring for patients and families undeniable. www.sfms.org


Women physicians spend more time with their patients—up to 10 percent more—and have been shown to have a style of doctoring that is distinct from that of their male counterparts: more encouraging, supportive, and patient-centered. The contributions of part-time women physicians are no less in quality to the lives of their patients; shouldn’t such devotion to caregiving at work and home be traits encouraged in physicians?  Invoking the predicted physician work shortage as a reason why women physicians should not work part-time or leave clinical medicine places undue guilt and blame on them. The main factors driving up physician demand are the growth and aging of the U.S. population and health care reform. While women physicians do work fewer patient-care hours compared to men, what kind of profession would we have if women who might decide to work part-time later were denied admission? More reasonable (and humane) answers to the physician shortage lie in lifting the residency training caps to train needed physicians and creating new models to increase efficient use of the existing workforce. Besides, women (and men) who choose to spend a portion of their medical careers working part-time or who take an extended leave may return to full-time work at a later time, for example after their children reach a certain age. Thus there is a need for effective physician-reentry programs that help prepare any previously trained physician to return to the workforce, providing education and retraining as well as portals to reenter medicine. Let’s not forget about men. Besides early- to mid-career women, men approaching retirement age are the other fastest-growing segment choosing to join the part-time physician workforce. Survey data show that today’s medical students and residents, both men and women, say achieving a balance between their work and professional lives will be the most important factor when establishing a fulfilling career in medicine. Medicine mistresses are going out of style all around, much to the dismay of the medical henchmen Burnout, Stress, and Dissatisfaction. www.sfms.org

SFMS 2012 Election Results 2012 Officers for a one-year term President-Elect: Shannon Udovic-Constant, MD Secretary: Jeffrey Beane, MD Treasurer: Lawrence Cheung, MD Editor: Gordon L. Fung, MD

2011 President-Elect, Peter J. Curran, MD, will automatically succeed to the office of President. 2011 President, George A. Fouras, MD, will automatically succeed to the office of Immediate Past President.

Board of Directors

AMA Delegate

Seven elected for three-year term 2012-2014

Andrew F. Calman, MD Arti D. Desai, MD Roger S. Eng, MD Jennifer Gunter, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

AMA Alternate

Two-year term 2012-2013

Robert J. Margolin, MD

Delegates to the CMA House of Delegates

Nominations Committee Four elected for two-year term 2012-2013

Diana I. Bojorquez, MD Chunbo C. Cai, MD Jill M. Guelich, MD Yi Brenda Shue, MD

Two-year term 2012-2013

Mason Spain Turner, MD

Stephen E. Follansbee, MD Jennifer Gunter, MD Leslie M. Lopato, MD George P. Susens, MD

Alternates

Young Physicians Section Alternate Two-year term 2012-2013

First four are delegates; next five are alternates. Shannon Udovic-Constant, MD, President-Elect, will serve as the fifth Delegate according to the SFMS Bylaws. Two-year term 2012-2013

Delegates

Young Physicians Section Delegate Arti D. Desai, MD

Two-year term 2012-2013

H. Hugh Vincent, MD

William S. Andereck, MD Gary L. Chan, MD Roger S. Eng, MD George A. Fouras, MD Katherine E. Herz, MD

To be sure, medicine is a public good. Federal dollars support physician training and, certainly, it is imperative that medical school admissions committees select applicants, male and female, who show a strong commitment to medicine. Yet after training, men as well as women may decide not to practice clinical medicine. Is it more problematic when the reason is because a woman wants to raise a family versus a man who takes a job with a consulting firm? I hope not. These are difficult personal decisions, with an emphasis on personal. Like everyone else, doctors need to make decisions for the health of themselves and their families. Life happens. I am a mother, and I am physician. These two roles are complementary in more ways than they are not. The increase in flexibility for women physicians in recent times has been a boon to those of us who have found a calling in medicine but do not want to sacrifice having a full family life. Isn’t that what Mary Elizabeth Garrett had in mind as well? Independence and autonomy for women to practice what they love, to be empowered by having choices. Katherine Chretien is an associate professor of medicine at George Washington University and chief hospitalist at the Washington, D.C., VA Medical Center. She is founder and editor of the group blog Mothers in Medicine (www.mothersinmedicine.com) and is on the board of contributors at USA TODAY. Reprinted with permission from www. mothersinmedicine.com. December 2011 San Francisco Medicine

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The Phases of a Medical Career

Financial Planning Shifting Priorities Throughout Your Career Deborah Peri Just as a house needs a strong foundation to withstand the elements, you need to have a solid financial foundation. Creating your financial foundation re-

quires that you have the basics covered. Here’s what you need to know.

Design Your Financial Plan

Begin Saving Immediately. Setting aside 10 percent to 15 percent of your income is a healthy amount to give you the best chance of long-term financial security. Make savings your first priority by having funds deducted directly from your paycheck into a retirement plan and savings account. This makes it automatic to adhere to your savings goals and to avoid overspending. In addition to retirement savings, it is always prudent to have six to twelve months’ salary in an emergency savings fund. The first few years are critical to long-term success. Compound growth requires time to work its magic. Consider two young physicians, both of whom wish to retire at age sixty. Doctor A starts saving for retirement straight out of residency at age twenty-nine and contributes $20,000 per year to her retirement plan. At an annual rate of return of 8 percent, she will net $2.47 million in her retirement plan at the end of thirtyone years. Doctor B decides to put off saving for five years and doesn’t make his first retirement plan contribution until age thirty-four. He also contributes $20,000 per year and his annual rate of return is 8 percent. Despite starting only five years later than his colleague, Doctor B ends up with only $1.6 million, a difference of $870,000 dollars, or 35 percent.1 Debt Management. Consider consolidating your student

loans under the Federal Direct Consolidation Loan program. A good strategy is to consolidate loans into the longest period possible, at the lowest interest rate possible, resulting in the lowest currently monthly payment. This will increase your current borrowing power to purchase a home or obtain other business loans and will increase the money available to fund retirement plans. You then have the option to pay the loan off faster if you want to. Visit www.LoanConsolidation.ed.gov. Eliminate or avoid carrying revolving (credit card) debt. Have a couple of credit cards with which to build your FICO score, but pay off all credit cards monthly. Mortgages and student loans are necessary debt; credit card debt incurs high interest rates and is a waste of money.

Plan for Retirement. A retirement projection has many

components: what you think your expenses will be in retirement, what you can expect to receive in the form of pensions or Social Security, and your life expectancy. Work with an invest-

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San Francisco Medicine November 2011

ment advisor or use retirement planning software to determine how much you need to save. A good rule of thumb is to limit the withdrawal of your savings to 3.5 percent to 4 percent per year in retirement. For example, if you need $100,000 per year in retirement income, that could mean accumulating an inflation-adjusted retirement savings of two million dollars or more. (A 4 percent withdrawal rate on two million dollars would be $80,000 per year. Add in Social Security for $100,000 per year.) The good news is that with regular savings and wise investing, accumulating the necessary capital is not nearly as difficult as it might seem. No matter what your debt load, you should start saving for retirement the first year you begin earning income. Compound growth is a powerful ally in building your retirement savings.

Maximize Your Use of Tax Advantaged Retirement Plans. Make full use of pretax contributions. If you contribute

$20,000 to your retirement plan pretax and your marginal tax rate is 35 percent, you save $7,000 in taxes today. In addition to savings on taxes now, your money will grow tax deferred until you take it out of your account in retirement. There are many types of retirement plans available, and your choice will depend on where you work.

Invest Wisely. Your investment strategy needs to segregate funds into those you need for a short-term goal (three to five years) and those you need for the long term. Short-term goals, such as buying a house, should be invested in predictable investments such as money market funds or savings accounts. Long-term goals, such as retirement, require a more sophisticated approach. Diversify your long-term investments among different asset classes, including cash, bonds, domestic stock, foreign stock, real estate investment trusts (REITs), and precious metals. Research thoroughly or work with an investment adviser to determine the right mix of these asset classes for your situation. Rebalance your portfolio periodically, and resist the temptation to try to time the market. Studies have found that while the market has returned 10 percent over the long term, the average investor earns only 4 percent because they move in and out of the market. While you can’t control the markets, you can control your behavior. Family Matters: From Education to Estate Planning

As you establish a solid pattern of saving and made significant progress on paying down your student loans, you may be planning to purchase a home and begin saving for your children’s education. www.sfms.org


Obtaining a Mortgage to Buy a Home. Buying a home is one of the

most expensive decisions you will ever make. Take into account how long you plan to live in the home and understand how much of your income will be consumed by your mortgage. Twenty-five percent of new physicians leave their first job within eighteen months. Rent housing for the first year or two until you are sure you are going to stay in your job, that you like the area, and you know the good school districts for your children. An individual’s ability to qualify for a mortgage will be dependent on income and total debt. While mortgage program guidelines vary, lenders typically require that total debt payments— including principal, interest, p ro p e r t y taxes, and insurance (PITI), and all consumer loan payments—do not exceed 36 percent of gross monthly income.

Saving for College. For your children’s education, 529

plans are a good option as they allow tax free growth and distribution for qualified education expenses. Unlike custodial accounts, the parent is the owner of the account and retains control. If the designated child beneficiary does not use all of the funds, another beneficiary can be named.

Retirement. You should be saving the maximum amount al-

lowed in your retirement plans at this point. For example, the maximum that may be contributed to a SEP IRA for 2011 is $49,000 (provided that all requirements are met).

Life and Disability Insurance. For physicians with depen-

dents, life insurance is a must. Consider buying a twenty-year level term policy. A word of caution: “Permanent” insurance is almost always an expensive product that is not necessary. Permanent insurance has many names, including “whole life” and “universal life.” Stick with term insurance, and invest what you would have spent on permanent insurance instead. Disability is far more likely than death, and protecting yourself and your family with disability insurance is a critical component of any risk management plan.

Estate Planning. It is always important to have a will. As

your assets grow, consult a knowledgeable estate planning www.sfms.org

attorney to set up a trust, will, durable power of attorney, and health care directive. Keep your beneficiaries up to date by reviewing them regularly.

Retirement on the Horizon

Your diligent planning, saving, and regular plan reviews should pay off as you near retirement. Do a comprehensive review of your retirement projections. Make sure you have an accurate understanding of what your expenses will be, including Medicare, other health care expenses, home expenses, and vacations and travel. Take inflation into account for the majority of your expenses and separate out those that are fixed, such as your mortgage. A reasonable rate to use for inflation is 3 percent over the long term. You may find that it will be necessary to work a few more years to reach your goals, or that you would like to work part time initially in retirement to make retirement more secure. With proper planning and diligent saving, you should have the opportunity to decide what is best for you and your family.

5 Takeaway Points

1. Create a financial plan early and start saving. 2. Never sacrifice saving for retirement to meet your other goals. 3. You can’t control the markets, but you can control your behavior and the amount you save. 4. Malpractice, term, and disability insurance are essential. 5. Consult an estate planning attorney for a trust, will, durable power of attorney, and a health care directive. Deborah Peri is a Certified Financial Planner and investment adviser. She focuses on values-based financial planning and investment strategies. She is a vice president at Curran & Lewis Investment Management, Inc. Note: 1. Please note that this is an example for illustration purposes only and more detailed planning is required, as returns will vary from year to year.

December 2011 San Francisco Medicine

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Practice Management Tips Debra Phairas

Ten Tips to Avoid “Practice Management Hypertension” Physicians today are feeling the stress of many aspects of running their practices, and this can lead to forms of “Practice Management Hypertension.” Here are some tips to lower your blood pressure and resultant anxiety to successfully navigate the business side of the practice of medicine. EMR Implementation Hypertension The two most important elements in choosing an EMR are stability/probable longevity of the software company and support services offered. • Research current-year KLAS (an independent rating) EMR rankings for small medical practices. • Redesign your work flow first. • Have your checklist of elements you want and ask each vendor to respond. • Integrate your billing/PM system with EMR for greatest value. • Have a “Super User” at each practice location. • Invest in training: Don’t underestimate the time it takes to learn to use it. • Lighten your schedule when going live and never on Mondays.

Health Care Reform Hypertension • Educate yourself on managed care risk principles (e.g., ACOs, medical homes). • Collect data to analyze costs and track utilization via purchase of relational database software. • Take the time to write handouts to patients explaining managed care and that patients are responsible for knowing their own covered benefits. • Realize the opposite incentives hold; invest time keeping patients healthy. • Remember that everything, including your time, is a cost, and look for ways to reduce costs.

Cash Flow Hypertension

• Learn benchmark A/R, staffing, and line-item overhead expense ratios for your specialty and try to keep expenses within norms by consulting resources such as the Medical Group Management Association (www.mgma.com). • Use your profit-loss report to monitor your practice health. For each line item, actual expense should have a column next to it dividing this into revenue received each month and cumulative year to date, to determine the percent to revenue each line item represents.

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San Francisco Medicine December 2011

• Five days after the end of the month, your office manager should prepare an internal profit and loss statement, accounts receivable report, and collection ratios report. Hold the billing staff, billing service, and office manager accountable for achieving MGMA A/R ratios or better results (see A/R ratio formulas at the end of the article). • Prepare a budget every year by November to project revenue and expense. • Implement cash controls with separation of staff duties involved in the transaction of cash to avoid embezzlement. Never let staff sign checks or have online access to bank accounts.

Malpractice Hypertension

• Attend malpractice insurance carrier loss-prevention courses. • Excellent communication skills and patient rapport are your best prevention mechanisms. Assess your skills and obtain CME in this aspect of your practice. • Prepare lay language versions of written informed consents and patient education materials. • Have lab tracking, referral tracking, and medication flow sheets to assure nothing falls through the cracks with patient results, referrals, and medications. • Document thoroughly and carefully. Purchase EMR/PM software that matches documentation elements with coding or use preprinted forms/chart stamps/checklists to simplify documentation. “If you didn’t chart it, you didn’t do it.”

Personnel and Labor Law Hypertension

• Educate yourself and your office manager on current labor law—particularly with overtime, exempt versus nonexempt, SF sick leave policy, sexual harassment, and wrongful termination prevention. • Prepare a written personnel policy manual and give to all employees. Require a signed statement that they received, read, and understood the policies and place in their personnel file. • Manage staff by following the policies and applying them consistently and fairly. • Prepare a written evaluation review for employees www.sfms.org


yearly. Set performance expectations and incentive programs. • Invest in initial and ongoing training of employees. • Praise and thank employees—“Praise in public, reprimand in private.”

Medicare Fraud and Abuse Hypertension

• Perform internal chart audits for prevention. • Document according to Medicare guidelines. • Prepare a written compliance plan, even if you outsource billing.

OSHA/HIPAA Compliance Hypertension

• Prepare a practice-specific OSHA manual. • Attend a training course and designate an OSHA staff member compliance officer. • All staff must have two hours of documented annual

OSHA training on blood-borne pathogens each year. • Include in the personnel policies that failure to adhere to OSHA regulations is grounds for dismissal. • HIPAA compliance is more than just the form patients sign and should be California specific. CMA PrivaPlan is specific to California.

Mergers, Acquisitions, Foundations, Practice Integration Hypertension

• Don’t merge, join, sell, acquire, or integrate without determining practice and business philosophy, similar values, and compatibility first. • Don’t rush the process. • Seek advisors—legal, accounting, and consultant advice.

IPA/Health Plan Interaction Hypertension

Accounts Receivable Ratios AGING SPREAD RATIO

$ in A/R % to Total A/R

0-30

31-60

61-90

91-120

120+

A/R Balance

$67,500

$32,400

$10,800

$4,050

$20,250

$135,000

50%

24%

8%

3%

15%

100%

The goal is to have less than 15-16% in the 120 days and over category. The practice should hold the billing staff accountable for reducing this amount in the 120 days and over category.

ACCOUNTS RECEIVABLE TURNOVER RATIO Accounts Receivable Ratio = Total $ in A/R 1/12 Annual Charges

Gross Collection % = Collections Charges

Adjusted Collection %

Collections Charges – Adjustments

www.sfms.org

A lower than 1.5 ratio is desirable. This indicates that accounts receivable are turned over or collected at an average of 1.5 months which is good for cash flow to pay expenses and the physician. The gross collection percentage measures collections to charges. This is not a performance measurement because this ratio can be higher or lower depending on where the physician sets fees as a percent to Medicare.

• Get to know the right people within the organization. • Seek ways to obtain power and better rates—merge into integrated groups, specialty IPAs, etc. • Analyze your contracts yearly with top ten CPT codes and top ten payors. Renegotiate or drop the poor payor contracts. • Track claims reimbursement and have staff doggedly follow up and double-check claims. • Ensure staff have time for appeals and denials follow-up. • Don’t be afraid to use the grievance process.

Physician Burnout Hypertension

• Recognize the signs of burnout before it is too late. • Take vacations. • Learn time-management principles. • Learn to say, “No.” • Delegate. • Look for ways to recapture the joy of medicine.

Debra Phairas is president of Practice & Liability Consultants, LLC. This material is Copyrighted 2011 by Debra Phairas.

The adjusted collection percentage directly measures the ability of the staff to collect on monies, which can be expected to be collected after discounts and contractual adjustments. This ratio should always be higher than 95%. Ratios above 100% can either indicate that production or charges are decreasing in this period or it can also mean that additional adjustments are being taken above the norm December 2011 San Francisco Medicine

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In the News SFMS Members Honored for Volunteer Efforts Three SFMS members were recently recognized by Operation Access for their dedication and volunteerism to provide essential surgical and specialty care to Bay Area’s underserved community. Please join SFMS in congratulating our selfless physicians for their contribution to improving access to health care.

Michelle Li, MD is a general surgeon at California Pa-

cific Medical Center (CPMC) who has been volunteering since 2006. She consistently sees one patient per month to provide donated surgeries such as hernia repair and cholecystectomy among an array of other procedures. Pictured above (left) with Pt Namsrai, T.

Elaine Yutan, MD is a general surgeon at Kaiser Permanente San Francisco who has been a volunteer with Operation Access for more than 10 years and continues to play a crucial role in every surgery session we organize at the hospital. In her time with the program, she had provided 86 services. She is pictured above (left) with Charles Jackson, MD. Operation Access is a non-profit that mobilizes a network of medical volunteers, hospitals, and referring community clinics to provide low-income, uninsured people access to donated outpatient surgeries and specialty care that improve their health, ability to work and quality of life. Since 1993, the San Francisco-based organization has coordinated $50 million in charity care and arranged outpatient surgical care and specialty procedures for more than 6,000 patients in the Bay Area. For more information regarding Operation Access, please visit http://www.operationaccess.org/. Eric Denys, MD Receives Honors from UCSF

Heidi Wittenberg, MD (pictured right with Maria Santos) also a CPMC physician, is the only urogynocologist in the Operation Access program. Since she started last year, Heidi has been consistently seeing patients and provides life-changing surgeries to women who had been suffering with these conditions for years.

30 San 31 SanFrancisco FranciscoMedicine Medicine December December2011 2011

SFMS member Eric H. Denys, MD was honored at the UCSF Association of the Clinical Faculty banquet as the 2011 recipient of the Charlotte Baer Memorial Award. Dr. Eric Denys is a neurologist at CPMC and an Associate Clinical Professor in Neurology at UCSF. His major current interests are peripheral nerve disorders, electrodiagnosis, multiple sclerosis, and the treatment of dystonia. Dr. Denys has been involved in the education of physicians specializing in electrodiagnostic medicine for over 25 years. The Dr. Charlotte C. Baer Award is awarded each year to a clinical faculty in recognition of distinguished service to the UCSF School of Medicine, with special emphasis on excellence as a teaching clinician. Please join the SFMS in congratulating Dr. Denys on receiving this prestigious award! www.sfms.org


Health Policy Perspective Steve Heilig, MPH; George Fouras, MD; Donald Abrams, MD; and David Pating, MD

Cannabis and California’s Physicians There has long been a “drug war” surrounding marijuana, not only in terms of the plant’s legal status but also in words. As the California Society of Addiction Medicine observes, “Reasonable dialogue regarding marijuana use has historically proven extraordinarily difficult.” The result is a long-standing stalemate and various symptoms of “reefer madness,” but with a growing consensus that our nation’s marijuana policy has not served us much better than the failed experiment with alcohol prohibition did many decades ago. Most recently, there was this headline: “California Medical Association calls for legalization of marijuana.” It was a cover story in the Sunday Los Angeles Times in October. As the CMA is a large, mainstream medical society, this caused quite a stir. The four authors of this article served as San Francisco’s representatives on the CMA’s Technical Advisory Committee (TAC) tasked with drafting “a comprehensive white paper recommending policy on marijuana legalization and appropriate regulation and taxation.” The TAC was “selected to represent CMA in the areas of science, ethical affairs, public health, addiction medicine, and expertise in the use of cannabis.” We met five times; the deliberations were sometimes contentious but each member agreed sufficiently to endorse a final report to the CMA board of trustees. Our fourteen-page report, “Cannabis and the Regulatory Void,” was submitted to the CMA’s board of trustees and approved, unanimously, in October. Reactions from all sides were immediate. The CMA was called “irresponsible” and at least one opponent used the cliché “What are they smoking?” But there has been much positive response as well, with editorials saying we took “a bold step” toward “a prescription for the medical pot mess” and that the CMA’s “traditionally conservative doctors” are “simply acknowledging the obvious: Our current laws and the resulting war on drugs aren’t working.”   Impact on cannabis use. The primary concern regarding legalization or any lessening of legal penalties regarding cannabis is that it might increase use, particularly among teens. We share such concerns, especially in light of growing evidence regarding negative effects on neurodevelopment. But there is no good evidence that laws have much effect on use; in fact, long evidence is that our punitive approaches have little deterrent effect. Thus we should seek approaches that maximize knowledge about the impacts of cannabis use and that do not worsen the problem by criminalizing otherwise law-abiding people, kicking kids out of schools to no productive end, wasting resources, and hampering research. Evidence-based drug education is difficult but likely to be at least as effective as legal approaches—and likely more so.   Resources and costs. Enforcing largely futile laws is expensive, especially when prison is involved. Appropriate treatwww.sfms.org

ment and education is far more cost effective. While our report recommends an approach closer to that taken toward alcohol, at least for adults, we have no illusion that such an approach is easy or ideal, or that the taxation we endorse will be a simple matter or will yield massive funding. But we are confident that it will be more cost effective than a longtime failed “drug war” or prohibition-type policies. And, very importantly, the funds saved and generated should be directed toward treatment of addiction.   Medical marijuana. We join the many experts and organizations holding that cannabis be placed in a less restrictive category that would facilitate more research. And while we support some legal medical use of cannabis, such as has been allowed since 1996 in California, we note that a decriminalization approach would have the salubrious effect of lessening or even eliminating the need for physicians to serve in the oft-uncomfortable middleman role of “gatekeeper” for medical use of cannabis—and it would allow for more rigorous regulation of questionable practices at “cannabis dispensaries.”  An ever-growing roster of medical, legal, political, and other authorities of all political stripes feel that the time has come for a serious change in our drug laws, especially with respect to cannabis. We have joined them, as has the CMA. Interestingly enough, another new CMA policy was independently adopted this year, which could have served as a preamble to our own report:  MEDICAL VS. LEGAL SOLUTIONS TO DRUG ABUSE: CMA encourages the federal government to reexamine the enforcementbased approach to illicit drug issues (“war on drugs”) and to prioritize and implement policies that treat drug abuse as a public health threat and drug addiction as a preventable and treatable disease.  We agree, and we know that many others do as well. We hope our elected leaders will listen.  Steve Heilig is on the SFMS staff and is editor of the Cambridge Quarterly of Healthcare Ethics. George Fouras is a child and adolescent psychiatrist and president of the SFMS. Donald Abrams is chief of hematology-oncology at SFGH and is a leading medical cannabis researcher at the UCSF. David Pating is an addiction psychiatrist and past-president of the California Society of Addiction Medicine. Their opinions here are their own. December 2011 San Francisco Medicine

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HOSPITAL NEWS KAISER

Saint Francis

CPMC

Janet Stafford, MD

Patricia Galamba, MD

Michael Rokeach, MD

Over the thirty years that I have been a pediatrician for the Permanente Medical Group, I have experienced major changes in the field of medicine. Changes in the patientphysician relationship, in the division between hospital-based and clinic-based medicine, and the predominant use of electronic medical records (EMR) are some of the most significant in my daily practice. The wealth of information on the Internet has resulted in my families being more educated about medicine, giving them the confidence to be more actively involved in decisions regarding their children’s care. This increases my time with them, but the end result is greater satisfaction and compliance. If I can convince the parents to read about diseases like pertussis and measles, and not just blog about vaccines, I may convince them to immunize. The separation of hospital and clinicbased medicine was inevitable as the practice of medicine became more complex. When I was working in shifts on the wards, nursery, and clinic, my learning curve was steep, and I do miss this stimulating environment and diversity of practice. Fortunately, I am able to keep up my knowledge base and skills with the frequent continuing education conferences offered by my medical group. Electronic medical records have resulted in a bedside-communication style change. My keyboard is now part of my physician-patient relationship, as I am able to access information from the recent visit electronically, including the last medication for a condition and missed immunizations. I can print out growth charts and pages of information for everything from eczema to asthma to ankle strains. My ability to care for my patients and to educate them has exponentially increased with this revolutionary new tool. In reflecting on the effect of the above changes to my practice, I realize that my expertise has increased as the patients become more educated and involved, as I focus on outpatient care, and as I use electronic medical records. If only I had more time! 32 33

I am veering away from this month’s theme only because I recently attended the Saint Francis Annual Employee Recognition event and it was one of the highlights of 2011. As I am sure my Medical Society colleagues will agree, we cannot practice medicine without these dedicated individuals who have also chosen a path in health care. The event recognized more than 150 staff members who have given 5, 10, 15, 20, 25, 30, 35, and 40 years of service to the institution. From nurses to housekeepers, the room was packed with smiling and proud faces. This annual event has been hosted at Saint Francis for as long as I have been in practice, and that’s at least 25 years. Administration presents special awards: the CHW Values in Action Award, Employee of the Year, and Shenson Awards for Caring (named after the two brothers, Drs. Ben and A. Jess Shenson, who practiced for more than 100 years combined). It takes a village, and it is heartwarming to see these hardworking individuals rewarded with recognition and praise. I also want to take moment to recognize our hospital for an outstanding press conference in October, with special guests Secretary of the U.S. Department of Health and Human Services Kathleen Sebelius; CHW President Lloyd Dean; CMO Robert Weibe, MD; Hill Physicians CEO Steve McDermott; Blue Shield Executive Vice President/COO Paul Markovich; and Deputy Executive Officer of CalPERS Ann Boynton. The press conference was held to acknowledge the successful ACO (accountable care organization) in the greater Sacramento area. Secretary Sebelius praised CHW, Blue Shield, Hill Physicians, and CalPERS for controlling costs, improving quality, and encouraging physicians, hospitals, and health plans to integrate care. It was an impressive event to remember in 2011. On behalf of my colleagues and all the staff at Saint Francis, we wish the entire Medical Society a happy and healthy New Year.

San Francisco Medicine December 2011

“Wishes for Wellness,” a biannual fundraising event for CPMC’s Women’s and Children’s Services,  recently honored three of its physicians during festivities that included a formal dinner at Bimbo’s 365 Club in San Francisco. This fund-raiser—the largest of its kind at CPMC—recognized Drs. Oded Herbsman, Jordan Horowitz, and Terri Slagle, who have provided outstanding care to patients. This event also raised funds to support a “Wish List” of the Medical Center’s annual funding priorities. The San Francisco Business Times/Silicon Valley Business Journal recently honored CPMC for creating a culture that emphasizes good health practices for staff. CPMC has created a healthy workplace by offering competitive health care plans at low cost to staff, a tuition reimbursement program, and discounted integrative and restorative classes through the Institute for Health and Healing in San Francisco and Marin. CPMC’s Healthy & Green program also provides staff with fresh, locally-grown fruits and vegetables delivered to work. CPMC recently received two distinguished awards from the California Transplant Donor Network (CTDN), a regional organ recovery organization that works with 175 hospitals in Northern and Central California and in Northern Nevada. We received a Top Performing Hospital Bronze Award for exceeding the national standards (75 percent) for the number of organs transplanted for each donor. We also received a Special Award for Tissue Donation for timely referrals to the CTDN. RNs Jack Gallant and Chris Weber are the first at CPMC to complete a new credentialing program to become Certified Clinical Documentation Specialists (CCDS). Only eight California health care professionals passed the rigorous exam between April and June this year, and only about 700 hold the credential nationwide. The program will help CPMC keep accurate inpatient hospital charts and aid in monitoring patients’ health outcomes, such as mortality rates. www.sfms.org


St. Mary’s

Veteran’s

Francis Charlton, MD

Diana Nicoll, MD, PhD, MPA

There is nothing like a career spent in the practice of medicine. Not only is the profession itself unique in nature but our own individual experiences are also unmistakably one of a kind. The extraordinarily intimate relationships our profession requires that we establish and maintain with our patients demand a dizzying array of talents and attributes, many of these different from one specialty to the next. The one common thread that connects us all is a loving desire to care for our fellow human beings. Without this, we would be missing the point of our profession and devaluing our own efforts, no matter how arduous they might be. The rapidly expanding encyclopedia of medical knowledge has outgrown the capacity of any human brain to master it. The electronic health record has become a necessity. There is simply too much information (TMI) to be managed. Concepts such as disease management and preventive medicine guidelines, treatment protocols, and evidence-based best practices have all evolved in the relatively recent past with the goal of standardizing and improving the care that we are able to render to our patients. We are constantly pressured to stick to the formula and follow the cookbook recipe. The not so subtle message is that we need to adhere to the guidelines in order to do right by all of our patients. This is not always true. We must never forget that every one of our patients is an individual with a unique genetic and personal profile. The credo “First, do no harm” appears nowhere in the abovementioned protocols. Potential drug toxicity and treatment complications are an everlurking danger. As physicians, our duty is to educate and collaborate with each patient to do what is best for the individual. We should follow clinical guidelines when appropriate but know when to say, “No.”

www.sfms.org

To prevent the onset of disability in their elderly patients, hospitals should focus on maintaining and restoring patients’ abilities to carry out activities of daily living while they are still inpatients, according to physicians from the San Francisco VA Medical Center. Writing in the October 26 issue of the Journal of the American Medical Association, a team led by Kenneth E. Covinsky, MD, MPH, reviewed the case history of a seventy-yearold patient who lived independently before hospitalization but who became permanently disabled afterward—in part due to common hospital procedures—despite successful treatment of her medical illnesses. “For older people, hospitalization can become an episode of forced dependence,” said Covinsky. “They’re put in bed, their clothes are taken from them, their meals are brought to them, and often, they will not get out of bed for days at a time. This has long-term effects on their ability to function for themselves.” The authors recommend that hospitals adopt treatment models for elderly patients that focus on maintaining function. As an example, Covinsky points to Acute Care for Elders (ACE) units that have been established in some hospitals, including the San Francisco VAMC. “On ACE units, there is emphasis on maintaining and restoring mobility and the ability to carry out activities of daily living,” said Covinsky. “Patients are encouraged to dress and to eat in a common dining room. Also, the discharge planning process is called ‘planning to go home,’ and the emphasis is on what the patient actually needs to continue independent life at home.” The authors acknowledge that some patients will still leave the hospital more disabled than when they arrived, often because of preexisting vulnerabilities such as depression, cognitive disabilities, or advancing age. “Hospitals need to recognize the risk of postdischarge disability and plan for it,” said Covinsky.

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Psychiatrist Needed at Saint Francis Hospital San Francisco Saint Francis Hospital is looking for a psychiatrist to work in the 18 to 24 bed unit at St. Francis Memorial Hospital. Patient population is a mix of inner-city substance users, Medicare/Medical and insurance, plus Kaiser SF contract. 2/3 to 3/4 of referrals come from our emergency department. Our social workers are great asset, and our nurses very accustomed to population. Daily and weekend stipends. Coverage includes a minimum one to two weekends a month. Not a salaried position. Payment is function of per diem rates and patients seen. Annual income approximately $200K + possible private practice. For information contact Dr. David Ogami at (415) 775-0781 or Mel Blaustein, MD, at (415) 928-6100.

December 2011 San Francisco Medicine

33


In Memoriam Nancy Thomson, MD Ronald Chappler, MD

Walter Lee “Skip” Way MD

Dr. Chappler, a native of Missouri, graduated from William Jewell College in Liberty, Missouri before attending Kansas University School of Medicine. He then traveled to Texas where he completed his internship in medicine at the Methodist Hospital in Houston. Following his internship and a two year Navy tour in Florida, he changed directions and arrived in California to pursue a residency at the University of California, San Francisco. Dr. Chappler joined the medical staff at Saint Francis Memorial Hospital as a dermatologist in 1977. Since that very first day, everybody—physicians, patients, and staff enjoyed his special personality. Dr. Chappler had a very down-to-earth approach to dermatology, professional yet friendly and colorful. His office was always happy and cheerful and decorated in a vacation theme. In recent years, Dr. Chappler faced many health challenges, but continued to provide excellent care to his patients. Dr. Chappler was a longtime member of the SFMS, starting in 1988. He is survived by his wife Kim, two adorable twins, and a son.

Dr. Way, widely known as “Skip,” was born in Pittsford, New York, on June 27, 1931. He passed away at home at the age of eighty on July 30, 2011, after a brief illness. His parents, Kenneth and Mary Way, owned and operated the Pittsford Central Pharmacy from 1928 until 1982. It was just two blocks from their home, and he and his younger sister, Adaire, often helped out at the Central Pharmacy. Skip’s interest in pharmacy began there and continued throughout his life. He graduated from Allendale High School in 1949 where he marched in the band playing trombone and was captain of the football team his senior year. Skip studied pharmacy at the University of Buffalo. While there he was introduced, through high school friends, to Elizabeth (Betty) and they married in 1955 while he was at the State University of New York Health Science Center at Syracuse. They returned to Rochester for his internship at Highland Hospital after which the family moved to San Francisco for his residency in Anesthesia at UCSF in the new anesthesia department started in 1958 by Dr.Stuart C.Cullen from Iowa. He received his California license in 1959 and joined the SFMS in 1961. After his residency, Skip continued at UCSF where he taught in the anesthesia department, received his MS in Pharmacology, and then held a joint appointment in both anesthesia and pharmacology. He was Chairman of the Pharmacology and Therapeutics Committee from 1974 to 1984. He retired in 1992, but continued teaching for several years. In 1992 he started editing articles for Prescrber’s Letter, a service which keeps doctors up to date on new developments in drug therapy, and served on the editorial advisory board until his death. The family moved from San Francisco to Ross in 1962 and Skip’s involvement there was extensive. He was a member of the Ross volunteer fire department, served as senior warden on the vestry of St. John’s Epioscopal Church, and he also held positions on the board of the Branson School. Betty and Skip with their family spent many summers at “camp” outside the town of Honeoye in the Finger Lakes Region of New York. Wherever they were they celebrated life with their family and many friends. Skip is survived by his wife, Elizabeth, and their children: Barbara Delpuech and her husband Yann of Los Angeles; Jonathan Walter Way and his wife Joanie and their three children; and Jeffrey Faulker Way and his three children. His sister, Adaire Leps, and her husband Tom live in Kentfield.

Serene C. Low, MD

Dr. Low passed on November 5, 2011, after a brief illness at UCSF Hospital. She was preceded in death by her parents, Dr. & Mrs. C. Y. Low, and her brother, Dr. Ronald B. Low. She is survived by several aunts, uncles, and many cousins whom she was blessed to have. Serene was born in San Francisco at Chinese Hospital with many other Chinese American physicians who served the community. She attended Lowell High School, UC Berkeley, and received her MD at UCSF. She interned at Moffitt Hospital in San Francisco and did her residency at Cincinnati Children’s Hospital in Ohio before joining her father’s pediatrics practice in Chinatown. Dr. Low was board certified in pediatrics in 1967 and practiced with her brother until 2004. She thoroughly enjoyed her work with children and had a calming effect on them when they were being treated. Due to the fact that she was in practice for so long, she even treated some of her patient’s children. Dr. Low also served on the SFMS board of directors from 1976-1978 and was a longtime member. After retirement, Serene and her brother finally had time to travel, joined the Jewish Community Center (to exercise), continued practicing with their volunteer licenses, attended courses in pediatrics, and volunteered their time at St. Anthony’s Foundation. Serene will be sorely missed by her family, friends, colleagues, and patients. Donations in her name may be made to Chinese Hospital, UCSF Foundation, Self Help or St. Anthony’s Foundation.

Haight-Ashbury Free Clinic and Walden House Need Physicians The newly-merged Haight-Ashbury Free Clinics (HAFC) and Walden House are in need of volunteer physicians. The clinics currently need volunteer MDs in the following areas: Pain management (would require commitment to a schedule); Internal medicine, for patients with co-occurring disorders (would require commitment to a schedule); Urgent Care, to relieve our employed staff to focus on chronic care management and follow up. The clinics are also involved in a program to provide a “patient centered medical home” model for patients, to have patients assigned to a specific provider that follows their care over time and has the same ancillary support staff working in tandem to provide education, counseling, medical case management and follow up. If interested, contact Jean Merwin, RN, at jmerwin@hafc-wh.org. 34

San Francisco Medicine December 2011

www.sfms.org


The San Francisco Medical Society and CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000! Now is the time to take a good look at the SFMS/CMA plan if: • It has been more than one year since you last reviewed your life insurance protection • You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your financial planning no longer seem as secure as they once did Endorsed by:

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

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

Administered by:

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

*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice. 51423 (6/11) ©Seabury & Smith Insurance Program Management 2011 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

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


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December 2011  

San Francisco Medicine, December 2011 issue. The Phases of a Medical Career.

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