October 2006

VOL.79 NO.7 OCTOBER 2006 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

The Changing Face of Medicine

CONTENTS SAN FRANCISCO MEDICINE October 2006 Volume 79, Number 7 The Changing Face of Medicine

FEATURE ARTICLES

MONTHLY COLUMNS

10 The Changing Health Care Workforce: Q&A with Marilyn Moats Kennedy Amanda Denz

4 On Your Behalf 5 Upcoming SFMS Events

12 No Stone Left Unturned: Two Tales of Clinical Advocacy Mark Renneker, MD, and Gwendolyn Stritter, MD 14 Offering a Third Option Jordan Shlain, MD

7 President’s Message Gordon Fung, MD, MPH 9 Editorial Mike Denney, MD, PhD

16 LOONY, and Loving It! The Joys of a Low Overhead and Out of Network Practice Daphne Miller, MD

34 Hospital News 20 Classified Ads

18 Do More Good Bonita Ford Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129

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20 In My Opinion: The Death of the Urban Pediatrician Stephen Kaufman, MD

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21 SFMS Assessment Survey Results: Preparing for the Future Thomas H. Lee, MD 33 SFMS Takes Positions on Two State Ballot Initiatives

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23 2006 Slate of Candidates 24 SFMS Officer Candidate Statements

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How Does This Issue of SFM Look?

We are trying a few new things at San Francisco Medicine Magazine and would appreciate your feedback. If you have any comments on the look, style, or printing quality of this issue, please let us know! All comments should be directed to Amanda Denz, our managing editor, by calling (415) 561-0850 extension 261 or sending an e-mail to adenz@sfms.org. october 2006 San Francisco Medicine

ON YOUR BEHALF

September 2006 Volume 79, Number 7

A sampling of activities and actions of interest to SFMS members

Editor Mike Denney, MD, PhD Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artist Amanda Denz Cover Model Kendy Pinkerton-Cockmeyer

Notes from the Membership Department

Editorial Board Chairman Mike Denney

SFMS Night at the Symphony

Obituarist Nancy Thomson

The next Membership event on the horizon is the SFMS Night at the San Francisco Symphony. Mark your calendars for Thursday, November 30! Enjoy a preconcert reception in the Davies Green Room with hors d’oeuvres and beverages, followed by a vibrant program of Rachmaninoff and Tchaikovsky, conducted by Vladimir Ashkenazy. Orchestra seats are $77, first tier are $67. For more information, or to order tickets, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Stephen Askin

Gretchen Gooding Judith Mates

Wade Aubry

Samuel Kao

Toni Brayer

Thomas Lee

Corey Maas

Arthur Lyons

Ricki Pollycove

Jordan Shlain Leonard Shlain

Jerome Fishgold Rita Melkonian

David Smith

Alan Greenwald Kathleen Unger

Leo van der Reis

Erica Goode

Kenneth Maybury Stephen Walsh

SFMS Officers President Gordon L. Fung President-Elect Stephen E. Follansbee Secretary Charles J. Wibbelsman Treasurer Stephen H. Fugaro Editor Mike Denney

Coming Soon!

Immediate Past President Alan Greenwald

Something new and different: Arrangements are in the works for a SFMS Tennis Mixer at the San Francisco Tennis Club. This event will be a fun and relaxing introduction to the courts and amenities of this top-notch club, followed by a Margarita Mixer with light appetizers. More information will be available soon.

The Membership Department and the physician members of the Membership Committee are actively exploring future events and services to benefit SFMS members. The next several months are sure to proving exciting! As always, member input and suggestions are appreciated.

Please feel free to contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms. org with any ideas!

SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Director of Public Health & Education Steve L. Heilig, MPH Director of Administration Posi Lyon Director of Membership Therese Porter Board of Directors Mei-Ling E. Fong, MD

John W. Pierce, MD

Thomas H. Lee, MD

Daniel M. Raybin, MD

Carolyn D. Mar, MD

Michael H. Siu, MD

Rodman S. Rogers, MD

Richard L. Caplin, MD

John B. Sikorski, MD

Lucy S. Crain, MD

Peter W. Sullivan, MD

Jane M. Hightower, MD

John I. Umekubo, MD

Brian J. Lewis, MD

Gary L. Chan, MD

Michael Rokeach, MD

George A. Fouras, MD

Jordan Shlain, MD

Jeffrey Newman, MD

Alan M. Teitelbaum, MD

Thomas J. Peitz, MD CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate Judith L. Mates, AMA’s Women Physicians Congress Governing Committee

PacAdvantage to Shut Down December 31; CMA Partner Can Help Affected Physician Practices Find Other Coverage Pacific Health Advantage (PacAdvantage), a nonprofit health insurance purchasing alliance for small businesses, will cease operations at year-end because too many

San Francisco Medicine october 2006

insurance providers have withdrawn from the voluntary program. The latest insurer to announce its departure was Blue Shield of California, which said earlier this year that it would withdraw from the program on December 31. Blue Shield was the eighth insurer to quit since the program was created in 1992.

PacAdvantage was created by the state so that small businesses with two to fifty employees could band together and negotiate lower health insurance premiums.

PacAdvantage currently provides health insurance for 6,200 small businesses representing 116,000 people across California, who now have four months to find other coverage.

CMA’s partner, Marsh Affinity Group, can help affected member physicians find alternative insurance options. Contact Marsh at (800) 842-3761 or cmacounty. insurance@marsh.com.

Tell Your Member of Congress to Stop the Payment Cut and Give Physicians a 2.8 Percent Increase Physicians, CMA needs you to turn up the heat on your members of Congress and motivate them to fix the Medicare payment problems before Congress adjourns in September. As you know, CMA has been fighting for years for a long-term fix to Medicare’s flawed sustainable growth rate (SGR) formula.

If Congress fails to act before the end of the year, physician rates will be cut 5 percent on January 1 of next year, and rates will be cut by a total of 35 percent during the next six years. The cuts are an unintended consequence of a formula established under laws passed in 1989 and 1997, which was supposed to establish a “sustainable growth rate” for spending on doctors’ services. The formula allows Medicare spending on physician services to grow at the rate of the gross domestic product (GDP)—but it actually penalizes physicians, because the costs of www.sfms.org

physician services rise more rapidly than does the GDP. Reimbursement for all other Medicare providers is calculated using the Medicare Economic Index (MEI), which is a market index of actual medical practice costs.

Health plans, hospitals, and nursing homes are all seeing payment increases, while physician payments are being slashed.

The inequities are glaring: 2007 Medicare Provider Payment Updates

Upcoming Events October 13, 2006 CME Program: Environmental Medicine and Health UCSF Laurel Heights Auditorium, 9a.m.– 5p.m. For more information, contact Steve Heilig, heilig@sfms.org or (415) 561-0850 extension 270.

October 27, 2006 CMA Organized Medical Staff Section Annual Assembly Sacramento Sheraton Grand 8 a.m.–5 p.m.

All medical staff representatives are encouraged to attend. Topics include Medical Staff Bylaws, EMTALA & ER Call, and Medical Staff Role in Quality Initiatives.

October 22–25, 2006 Education for Physicians on End-of-Life Care (EPEC) Near Yosemite National Park. Physicians can fulfill their 12-unit requirement in Pain/End of Life. Geriatric CME credits also apply. A combination of presentations and workshops designed to teach physicians to better assess and treat pain, use effective communication skills with patients and families, and more. For more information, see the FAQ pages at www.surveymonkey. com/s.asp?u=37122157023.

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Health Plans: + 7 percent Hospitals: + 3.6 percent Nursing Homes: + 3.5 percent Physicians: – 5 percent Congressional leaders have hinted that they may only be able to freeze payments at 2005 levels. With practice costs increasing at a rate of 4 to 6 percent a year, a payment freeze would essentially be a pay cut.

Tell your members of Congress that a payment freeze is unacceptable, and urge them to dump the flawed SGR physician

October 25, 2006 Beyond Zero Tolerance: New Directions in Drug Education and School Discipline Fort Mason Conference Center in San Francisco, 8a.m.–4p.m. Landmark Building A Cosponsored by the Drug Policy Alliance, San Francisco Medical Society, Office of the Mayor, City and County of San Francisco with Mayor Gavin Newsom providing opening remarks, San Francisco Department of Public Health. For more information, call (916) 608-8686.

November 29, 2006 Universal Health Care Access in San Francisco: Reality or Dream?

California Pacific Medical Center 5:30 p.m.–7:70p.m. SFMS and CPMC’s Program in Health and Human Values will present a forum on the ongoing effort to provide access to health care for every San Franciscan. For information and to RSVP, contact Steve Heilig at the SFMS, (415) 561-0850 extension 270 or heilig@sfms.org.

November 30, 2006 SFMS Night at the Symphony To order tickets, or for more information, contact Therese Porter in the Membership Department at (415) 561-0850, extension 268 or tporter@sfms.org.

payment formula and replace it with a new formula based on the MEI, which would increase physician payments by 2.8 percent in 2007. Tell them that failure to reform the Medicare payment formula will make it more difficult for seniors to find a physician and further jeopardize access to care.

Visit the CMA website, www.cmanet. org, for more information, including talking points and sample letters.

For more information, contact Elizabeth McNeil at (415) 882-3376 or emcneil@cmanet.org.

November 8, 2006 Taking Charge: Contract Analysis and Preparing for Negotiations San Francisco location to be announced, 10:30a.m.–3:30p.m. Topics Include: Evaluating current and proposed payor contracts; Essential clauses to leave in and/or take out; Determining specific payor’s value to your practice; Targeting payors for contract termination, negotiation or renegotiation; Preparing for contract negotiations; Monitoring payor compliance with payor terms; “Silent PPOs” and their implications; and Legal implications of contracts. Contact Posi Lyon for more information, or to RSVP, (415) 561-0850 extension 260, plyon@sfms.org.

January 28–30, 2007 UCSF-CHE Summit on Environmental Challenges to Reproductive Health and Fertility Mission Bay Conference Center, UCSF, San Francsico. This summit will provide overviews by leading researchers of science and environmental contaminant impacts on reproductive health and fertility, among other topics. Contact Mary Wade for more information, (415) 476-2563 or wadem@ obgyn.ucsf.edu.

october 2006 San Francisco Medicine

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president’s Message Gordon Fung, MD, MPH

Strength in Numbers

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his month’s San Francisco Medicine is a critical one to the membership of the San Francisco Medical Society, as it contains the candidate information for possible officers and directors of the 2007 board as well as delegates to the California Medical Association. Why is this information so important?

Because these are the volunteers who have committed their time and energy to making San Francisco and California a better place to practice medicine. These are the physicians who have stepped up to the plate and dedicated precious hours serving the needs of all San Francisco physicians and advancing the health of our patients and our community. They are our peers who have executed the mission statement of SFMS. Each candidate has, in reality, already offered his or her expertise and skills in helping to shape the practice of medicine in San Francisco. They are running for office based on a foundation of committed service and a vision that is consistent with the mission of SFMS. Each one has submitted a short bio and a platform upon which he or she is seeking election. As your president, I urge you to review these statements and vote on your choice of officers, directors, and delegates. This is one of the best ways to keep in step with the medical society that represents you in city and state government.

It is also important to keep in touch with the officers and directors once they are elected. Bring them the issues that affect your practice. Bring them your thoughts on critical matters in health care. Bring to their attention anything that will help resolve issues of racial disparities, health care access, overcrowding in the hospitals, diversions in the emergency departments, unreasonable

regulations on our practices put in place by the state and federal governments, and inadequate reimbursements for services. The medical society is more effective as your voice in government when you give your input.

Last month I was a panel member at UCSF Primary Medicine Grand Rounds. The topic was, “What Can Organized Medicine Do for You?” I discussed the history of medical societies, first in the United States generally, then specifically in San Francisco.

Although SFMS had a rough and stuttering start, we have grown to become one of the premier medical societies in California. We have a significant influence on health policy, in California through our delegates to the CMA, and nationally through our delegates to the AMA. We have also experienced success working with city government, and we strive to be part of the solution rather than another problem. We had representation on the Universal Healthcare Council for San Francisco and continue to be represented in the implementation committee, called the Healthcare Access Program, which has a program activation date of July 2007. We are also providing input into the city’s emergency response plans, the coordinated efforts to improve emergency psychiatry services, and the citywide 5150 response. At bimonthly SFMS board meetings, we receive reports from the major hospitals in the city as well as the San Francisco Department of Public Health, and we give our input to the leaders of those agencies.

We’ve certainly come a long way, and we don’t plan to disappear any time soon. So I encourage every physician, member or nonmember, to become involved in SFMS—first through your vote and then through a continued dialogue with elected leaders.

SFMS TAKES POSITIONS ON TWO STATE BALLOT INITIATIVES The SFMS Board of Directors has taken positions on two ballot initiatives to appear on the California November ballot: Proposition 85: Parental Consent for Abortion: OPPOSE Proposition 86: Tobacco Tax: SUPPORT

Please see page 33 for more information about these positions www.sfms.org

october 2006 San Francisco Medicine

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DEPARTMENT TITLE HERE Editorial Mike Denney, MD, PhD

The Trickster in Medical Practice

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he trickster character is ubiquitous in mythology. In indigenous American stories, coyote eats the bait but escapes the trap and then howls to teach humans how to sing. In African lore, Esru wears a cap that is red on one side and blue on the other so as to provoke arguments among those on opposite sides, thus, by creating paradox, helping humans cross boundaries to be with the gods. In Chinese myth, monkey travels with the pilgrim Tripitaka on his journey to India to seek the Buddhist scriptures, and through his screeching, flitting through trees, and ingenious nonsense, monkey distracts adversaries and shows the way. European traditions include leprechauns, elves, trolls, kobolds, dwarfs, brownies, and fairies that sometimes guard hidden treasure and, if caught, can escape by becoming invisible, creating diversions, or performing other monkey business. Tricksters in general are mischievous nonconformers who are not content with the status quo, but by confronting conflict with paradox, they are essential to the creative development and denouement of any story, adventure, or innovation.

The classical trickster in Western mythology is the Greek god Hermes. Even as a little baby, he left his crib and “slipped sideways through the keyhole, like fog on an autumn breeze.” Later Hermes stretched some cowgut strings across a turtle shell and invented a lyre that, when strummed, would emit celestial music. He stole fifty of Apollo’s cattle and hid them away; when later confronted about the theft, Hermes played the lyre so that Apollo was spellbound as “the delightful sound of the divine music penetrated his senses.” Zeus then gave Hermes winged sandals and made him god of travelers and messenger of the gods.

In his captivating book Trickster Makes This World, art scholar Lewis Hyde points out that tricksters are boundary crossers who at times may be bothersome, but who are indispensable to the wellbeing of any culture. Hyde posits that the trickster is the captive who can escape, the adventurer who can set new boundaries at effective distances, the persistent traveler often without a home base, and, above all, an adaptor to the environment who can devise innovative ways to play old games. Hyde says, “In spite of all their

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disruptive behavior, tricksters are regularly honored as the creators of culture. . . [they] have gone on and helped shape this world so as to make it a hospitable place for human life.”

In this issue of San Francisco Medicine, we find trickster tales of innovations in medical practice. Daphne Miller, MD, tells how, feeling trapped within the vicissitudes of managed care, she escaped to form her novel “storefront” operation in which she can successfully tend to her patients, earn a living, and enjoy her private life.

Mark Renneker, MD, and Gwendolyn Stritter, MD, report crossing boundaries, like messengers of the gods, to practice as advocates for patients who are caught in the morass of medical information and decision making. Jordan Shlain, MD, describes his group of physicians who, like the god of travelers Hermes, practice beyond a home base to make house calls and hotel calls. And Bonita Ford, MA, Integrative Health Consultant, shows how physicians can adapt to the environment to make their office practices ecologically friendly. These medical tricksters are adventurers who can create culture and make the medical world more hospitable—which, to needy patients, can sound like delightful celestial music.

And so it is that from all of this we can conclude . . . well, once upon a time there was the little train that could—twinkle, twinkle, little star—four score and seven years ago—had we but world enough and time—avast, you buccaneers—the cow jumped over the moon—hold the phone—and the monkey wrapped his tail around the flagpole— (Aha, the reader is glancing away, wondering what the words are about. While the reader is distracted by nonsense, the trickster is disappearing, escaping without an ending to his tale. The trickster has crossed the boundaries to reveal paradox once more. His words are performative—they speak not only about the trick, they become the trick. Trickster Editor has other roads to travel, other mischief with which to propel future stories in San Francisco Medicine, other messages to bring and games to play. The reader may feel uneasy, in need of denouement, but our paradox also offers delight with the enchanting possibility that in medical practice, as in the culture, trickster makes this world. Wheeeeee.)

october 2006 San Francisco Medicine

the changing face of medicine

The Changing Health Care Workforce Q&A with Marilyn Moats Kennedy Amanda Denz

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his month SFM had the opportunity book him/herself solid for a few months and will upset many older physicians, but that to speak with Marilyn Moats Ken- then take a break. is where the money will come from. nedy about the changing face of medical practice. Kennedy is an author, speaker, and consultant who studies workforce trends and Figure 1 management strategies in a variety Pre-Boomer Boomer Cusper Buster Netster of fields, including health care. In 1934–1945 1946–1959 1960–1968 1969–1978 1979–1988 her work, she examines how the values of different generations Work first Work first Some of both Lifestyle first Lifestyle first affect the workplace. In Figure 1, Loyal to employer Loyal to employer Some of both Loyal to skills Loyal to skills excerpted from a chart Kennedy Independent but Care deeply what Some of both Don’t care what Care little uses during presentations, she conventional others think others think about what others think breaks down the characteristics Value working Want others to Want others to Prefer to work Will tolerate of five generations currently ocwell with others work with them work with them alone small groups cupying the workplace. According Strong chain of Chain of Either way Individual first Individual first to Kennedy, these characteristics, command command along with other trends related to © Marilyn Moats Kennedy 2005 these generations, are changing the way medicine is practiced and ushering in a new norm for health care.

SFM: Do you think the aging of the Baby- SFM: How do you think the differing values Boomer generation will affect health care in of the various generations will affect the health SFM: What changes do you see on the horizon other ways as well? care workplace? in regard to the way medicine is practiced?

Kennedy: In twenty years, the Boomers Kennedy: Boomers got into medicine Kennedy: There is a third type of work will need cardiovascular care and cancer because of the prestige. Netsters and Bustemerging right now—along with part-time treatments, so that is where the focus will ers did it because they wanted to make a and full-time, the number of people doing go. But right now they are at an age where difference, they wanted that personal satis“episodic” work is on the rise. Across the most of them are just opting for elective faction, and they thought that career would board, people are starting to prefer work- surgeries. All of the things people used to support their lifestyle—having a family and ing 24/7 for six months and then taking live with—sagging skin, baldness, etc.—the whatnot. the next six months off. I predict that we new generation of medicine will say they To Netsters and Busters, making time will see a rise in seasonal jobs in health don’t have to put up with. In the next ten for family is very important. Their fathers care. Not in primary care, but in some of years, Lasik, teeth-whitening, face-lifts, hair didn’t parent, they put career first. The the subspecialties, particularly in cosmetic replacement, Botox—all of these things will Netsters and Busters plan to parent whether surgery. As the Boomers age, the number be in high demand. As a result, hospitals are their kids like it or not. Don’t forget—for of elective surgeries that people will have going to realize that much of their bottom every action there is a reaction, so Boomers is going to go up. These types of procedures line will depend on people who are not didn’t father, and now the next generation can be done at any time; they do not need “sick” in the way that the term has previ- places family ahead of career. to be done immediately, so a surgeon can ously been defined. This change of focus 10 San Francisco Medicine october 2006

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SFM: How do you see these younger generations making their careers work while also making time to parent and have families?

Kennedy: Many young physicians want to be hospitalists so they can also coach soccer and pick the kids up from school some days.

It is more of a priority. The Chief of Staff, however, who is probably a Boomer, may look at the young physician who takes so much time away from work and think he’s lazy. But in order for hospitals to attract young, talented physicians, they have to accommodate this lifestyle.

What the Netsters and Busters have that the Boomers don’t is the power of scarcity. They come from much smaller generations and therefore face less competition and are more in demand—and they also have security in knowing they’ll inherit from their Boomer parents.

Right now the Boomers have power in numbers and therefore still hold a lot of control in the workplace, but the Busters and Netsters will eventually inherit that

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control. And since the birth rate is still going down, future generations will also hold the power of scarcity.

To learn more about Marilyn Moats Kennedy, please visit her website, www.moatskennedy.com.

Congratulations Dr. Margolin!

SFMS would like to congratulate Past-President Robert Margolin, MD, on taking first place in this year’s CMA Foundation Golf Classic. As a result of his success, Dr. Margolin’s name will be engraved on the CMA Foundation Golf Classic trophy, which is prominently displayed in the CMA Foundation office!

SFMS Symphony Night Mark Your Calendars for Thursday, November 30th!

Enjoy a pre-concert reception in the Davies Symphony Hall Green Room featuring hors d’ouevres and beverages followed by a vibrant program of Rachmaninoff and Tchaikovsky conducted

by Vladimir Ashkenazy. Orchestra seats are $77.00, 1st tier are $67.00, inclusive of the reception. Tickets are limited, so we must have your RSVP and payment no later than Tuesday, November 7th.

To order tickets, or for more information, contact Therese Porter in the Membership Department at (415) 561-0850, extension 268 or tporter@sfms.org.

october 2006 San Francisco Medicine 11

the changing face of medicine

No Stone Left Unturned Two Tales of Clinical Advocacy

The Medical Equalizer Mark Renneker, MD

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or one week in 1988, I ran a classified ad in the San Francisco Chronicle that read, “Trapped in a Medical Nightmare and Need Help? Call THE MEDICAL EQUALIZER, a physician specializing in advocating for you, resolving unsolvable cases, and in-a-jam second opinions.” I gave only a phone number for contact information.

I did this as a quasi-experimental measure of what I was beginning to observe all around me: patients increasingly dissatisfied and struggling with the health care system, whether they were rich or poor. I’d come to realize that, for whatever reason, I was good at getting such patients “unstuck,” and I wondered if I might forge a practice doing just that. The ad, then, was targeting patients whose medical problems were so difficult and complex, or their experiences with the medical system so disastrous, that they had hit the wall and were now so desperate that they would actually answer such an ad.

The calls began coming in, and my clinical advocacy practice was born. From the start, my position with those initial patients was (and remains) that I would not provide treatment, only advocacy and casespecific research, education, and guidance.

What I quickly learned is that an entirely different clinical strength came from tying my hands as a treating physician, and that it resulted in something more lasting and sustaining for patients. I also learned that, though my stated goal was advocacy, this work rarely required confrontation with the patient’s doctors. In other words, there are in fact very few bad doctors, but many

doctors with too little time.

Intriguingly, I also discovered several other things: First, people were entirely willing to pay out-of-pocket for my services on a time-spent basis, as they would pay a lawyer (I worked out a sliding scale and wouldn’t take insurance; my billing-to-reimbursement rate is about 99 percent). Second,

most of the work with the actual patients was easiest and perhaps best done over the phone during evening appointments, when my clients were comfortably settled at home and out-of-town family members could readily be conferenced in. Third, the work required an inordinate amount of time—I might spend ten to twenty hours in a week on just one case. And finally, some of the calls I received came from people living elsewhere in the country, indicating a pervasive need for a physician willing to go to bat for patients.

With essentially no further advertising, just word of mouth, my practice as a clinical advocate quickly grew. After all, doesn’t practically everyone know someone in a medical struggle, whose case would likely benefit from a thorough going-over? When I describe my work to other physicians, at first they are puzzled; but they understand instantly when I say, “It is all those extra things that you—being a physician—might do for someone really close to you, such as a family member: making calls to the treat-

12 San Francisco Medicine october 2006

ing doctors, checking the records, looking through the medical literature, identifying all possible experimental protocols, calling experts and biotech companies around the country, making sure that everything possible is being looked at and done and that no stone is left unturned.”

In the early 1990s, being a surfer and realizing that I didn’t need to rent a typical medical office, I instead rented a house at Ocean Beach, in which I could work and gain quicker and easier access to the waves. I needed little in the way of staff, hiring only an office manager (who still works for me). I also subcontracted with a medical research expert (who also still works for me), who searches for medical information in actual medical libraries, by phone, and online.

I took an all-comers approach, even if, for instance, I’d never heard of a given patients’ disease. In a sense, I can approach each case with the awe and interest of a third-year medical student. My promise to patients isn’t that I am expert in every disease, but that I am expert in finding, evaluating, and accessing specialists, research, and ideas about any disease. It helps being a family physician, since I feel comfortable with virtually every kind of patient—pediatric, adolescent, adult, obstetric, geriatric, hospice. It also helps to trust oneself to be able to deal with problems from any specialty.

Also, my training as a generalist had been inherently based in patient advocacy; I had learned never to leave patients to fend for themselves with specialists or a hospital.

From the start, I’ve had more cases than available time. Only a third of the cases are from the Bay Area; a third are from elsewhere in California, and the final third are from elsewhere in the country or the world. One-third are for fellow physiwww.sfms.org

cians, other health professionals, lawyers, or PhDs—people who know when they aren’t getting optimal care. Half are cancer cases, and many involve pain and neurological conditions, endocrinology, rheumatology, and immunology.

To avoid becoming like so many toobusy doctors, who don’t have enough time for each patient, I established an inviolable “lifeboat” rule: I would take on no more than one new case per week. Only a minority of cases involve a single consultation (scheduled for one to two hours); most then require a significant amount of time in the first week or two, with periodic follow-up appointments. Now, some fifteen years later, I have worked with hundreds of patients and families, spanning an immense variety of medical problems and advocacy issues.

A Different Path Gwendolyn Stritter, MD

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n the summer of 1994, my father was diagnosed with metastatic cancer. As an anesthesiologist certified in pain management, I had little training in cancer medicine and trusted the local oncologists to do their best with him. However, it soon became clear that my father needed a medically savvy advocate.

His oncologist had not researched treatments for his unusual cancer, nor given him any real details (or choices) about what treatments he was being given. There were long delays in returning phone calls and responding to abnormal lab reports.

Belatedly, I realized the oncologist meant well, but he had a large caseload and busy office hours. It was clear that if I didn’t step up and become my father’s clinical advocate—educate him about his cancer, guide him through the health care maze, and “watch his back”—then there would be calamities ahead. Since he lived across the country, in North Carolina, it led to my first experience with telephone-based clinical advocacy. Although he eventually died, I take comfort in the fact that I helped him enormously. My experiences with his physicians over the last year of his life strongly shaped my commitment to practice www.sfms.org

patient-centered medicine.

Fortunately, I was a member of the Permanente Medical Group in San Jose, which tried hard to follow this same patientcentered philosophy. But in the mid-1990s, a shift in California health care economics, precipitated by the move of large for-profit HMOs into the state, forced my group to cut resources in order to stay in business.

I compensated by spending extra, unpaid time to meet the needs of my patients.

But as the health care economic crisis deepened and the patient load increased, my practice style proved unsustainable. It soon became clear that I could no longer work in that type of medical system.

I decided to start a new kind of medical practice—one based on advocacy and intensive case research. My goal was to provide the highest level of medical information to all. In the summer of 2000, I resigned my group practice position to design and implement such a practice.

In January 2001, I learned that Mark Renneker, in San Francisco, was engaged in exactly this type of practice. Over the next eleven months, Dr. Renneker took me under his wing and taught me what he had learned in his ten years of high-level clinical advocacy. In this, I followed about thirty other physicians who had sought him out, all with serious interest in becoming patient advocates. My training largely consisted of spending several days per month at his office, listening in on his consultations, performing the many necessary research activities for each case (searching the literature, making phone calls, etc.), and gradually taking on cases under his supervision. Since about half of his cases involve oncology, he guided me in undertaking intensive readings of oncology textbooks and journals, and in attending numerous oncology conferences. Now, some five years later, I have a full-time clinical advocacy practice with a special focus on women with breast cancer.

Mark Renneker, MD, is a graduate of the UCSF School of Medicine (1975–79) and the UCSF/SFGH Family Practice Residency Program (1980–84); Associate Clinical Professor, Department of Family and Community Medicine, UCSF; Attending Physician, Laguna Honda Hospital (since 1983); and Founder and President, Surfer’s Medical Association.

Gwendolyn Stritter, MD (pictured in her office on the right), is a graduate of Stanford University School of Medicine (1979– 84) and Anesthesiology Residency Program (1985–89); board-certified in Anesthesiology with a subspeciality certification in pain medicine; the former Director, Pain Management Unit, Kaiser San Jose (Santa Teresa Community Hospital); and the Founder of Stritter Medical Consulting, Portola Valley, California.

Editor’s Note: Patient advocacy is a burgeoning field; the first comprehensive book on the subject is due out next year, by Jones and Bartlett Publishing (edited by JoAnne Earp and Elizabeth French). This article is adapted from a chapter in that book.

Confidential Help Available Concerned about a colleague, yourself, or a family member who may have an alcoholic, chemical-dependent, or mental or behavioral problem? CMA/CDA offers the Confidential Assistance Line, a 24-hour voluntary phone service for physicians, dentists, medical students, residents, and their families and colleagues. This service is completely confidential and using it will not result in any form of disciplinary action or referral to any disciplinary body. The goal is treatment, not discipline.

In Northern California, please call (650) 756-7787. In Southern California, please call (213) 383-2691. For more information, contact Kathleen de Fabrique, (415) 882-5107 or kdefabrique@cmanet.org.

october 2006 San Francisco Medicine 13

the changing face of medicine

Offering a Third Option Jordan Shlain, MD North America, 9400 B.C. The wife of a sick man travels through the night to find the village shaman. After a description of the ailment, the shaman comes to the home of the ill, intones incantations, and advises the sick man’s wife to prepare a poultice comprised of herbal medicines, some of which are efficacious and some of which are worthless. The shaman returns regularly until the man is well.

The woman gives the shaman fresh corn as thanks.

New York, 1782 The father of a sick child seeks out a doctor at the newly opened New York Hospital. The physician travels to the home, examines the infant, and talks to the parents. He advises rest and quarantine. He returns in one week and admits the patient to King George Hospital, where he manages the case until the child is discharged.

The government of King George picks up the bill.

Germany, 1895 Wilhelm Conrad Röntgen discovers the X ray.

London, 1928 Dr. Alexander Fleming discovers penicillin.

Florida, 1977 The Emergency Medicine residency program graduates its first ER doctor.

Corporate boardrooms across the U.S., 1984 Doctors become “providers.”

San Francisco, 1994 Dr. Robert Wachter of UCSF coins the term “hospitalist.”

San Francisco, 1995 A sixty-three-year-old man dials 911 after failing to get a timely appointment with his primary care “gatekeeper” for progressive malaise. Sirens wailing, he is rushed to the emergency room, where he gets a chest x-ray, complete blood counts, chemistries, and urine tests. Then he waits.

He is ultimately admitted to the hospital with lobar pneumonia, where he is managed by a team of hospitalists. He is never seen by his primary care doctor while in the hospital. He is “efficiently” discharged to a skilled nursing facility in two days and is cared for by another team of hospitalists for eight days before being discharged and sent home. His total bill is $75,000. His “health plan” has a $5,000 deductible and a 20 percent coinsurance payment. The man’s out-of-pocket expenses add up to almost $20,000—and he has insurance.

San Francisco CPMC resident clinic, 1996 Joyce Hansen, CPMC Residents Clinic Director, asks if someone will make a house call on a barely ambulatory little old lady in the outer Richmond. I volunteer. When I arrive at her home, I spend an hour with her—I dip urine, diagnose a UTI, and give her oral ciprofloxacin. We are unhurried, she is very relaxed in her favorite chair, and hypertension is nonexistent. I walk through her apartment and notice a forty-foot phone cord winding all over the floor—a major fall risk. I promptly instruct her daughter to buy a cordless phone.

14 San Francisco Medicine october 2006

San Francisco, 1999 The Internet becomes mass media.

Wall Street, 21st century Aetna Acquires US Healthcare, Anthem acquires WellPoint, Coventry acquires FirstHealth, United Health Care acquires PacifiCare, Cogent rolls out a nationwide hospitalist network.

San Francisco, 2006 A forty-four-year-old man develops a severe cough and teeth-chattering chills. He does an Internet search and finds San Francisco On Call Medical, a twenty-four-hour house-call service. He books a same-day appointment online. The doctor calls him and visits his home within two hours. His pulse ox is 93%, pulse 111, temperature 103° F. with egophony. The doctor also notes decreased breath sounds and makes a clinical diagnosis of pneumonia. He prescribes two grams of IM ceftriaxone, a seven-day course of moxifloxicin, and codeine cough syrup.

The patient gladly pays with pretax dollars in his health savings account, using a VISA card. The physician instructs his staff to call this patient daily until the problem resolves.

The man is back to work in two days. Total cost: $495, paid by HSA and applied to his insurance deductible.

§§§ At a recent medical staff meeting, I discussed the way our group, San Francisco On Call Medical, works. “Sounds like a gimmick,” said a high-ranking hospital physician. My eyes nearly popped out of my head. “Gimmick,” I thought, “wow … talk about a guy being so inside the box that he doesn’t even know he’s in a box!” www.sfms.org

Up until thirty years ago, house calls were a mainstay of medicine. Now a hospital administrator—and a doctor, no less—feels comfortable calling them a “gimmick”?

Has the corporate HMO-ization of society corrupted the collective memory of generations?

The sad truth is that patients are finding it more and more difficult to access care.

Most doctors, covering for large practices on evenings and weekends, give their patients two options: First, go to the nearest emergency room; or second, wait until you can see your primary care physician at the next available appointment.

Imagine you have any one of the following conditions: explosive diarrhea and fever; a severe 9/10 migraine with vomiting; a back sprain rendering you immobile; difficulty ambulating (you are ninety-four years old); hypertension, hypothyroid, and a painful, cellulitic toe (you weigh 434 pounds and have diabetes). I would venture to guess that no one reading this article would find our two options above to be adequate in any of these scenarios. But the truth is that these were the only two options—until now.

I like to think that our group is thinking outside the box and making small innovations in the overall health care system. We are reinventing a third, albeit old-fashioned, option—the immediate house call. We do not replace the ER, nor do we usurp the role of the primary doctor; rather, we take pressure off the burdened system and act as a functional after-hours extension of the primary medical office. We now do as many house calls during regular hours as we do after hours, proving that some people are too inconvenienced to move when they are sick. Much as the hospitalist is a novel new specialty defined by geography, we too are defined by geography—our practice is defined by the address of the patient.

The winds of change in medicine are constantly being upgraded to a higher-category storm. Drugstore chains are offering healthcare clinics staffed by nurse practitioners—CVS pharmacy paid $170 million for MinuteClinic. Health savings accounts are exploding (from $600,000 to more than $3 million in eighteen months). Electronic medical records will be mandatory by 2014.

There are now pay-for-performance report www.sfms.org

cards for health providers. Eleven percent of doctors have opted out of Medicare, up from 5 percent in 2000. Fee-for-service practices are doubling every year. There is an American Association of Concierge Medicine. There is a Center for Consumer Driven Health Care at the Galen Institute.

The cost of pharmaceuticals increased eightfold from 1990 to 2000.

I think it is important to uncouple the notion of health care into two discreet components: physician-patient and medical-industrial complex. The former is rooted in care and the latter is rooted in profits and shareholders.

The current climate of fee-for-service practices and other financial arrangements between doctors and patients is the first seri-

“I like to think that our group is thinking outside the box and making small innovations in the overall health care system.” ous attempt in the last fifty years to create a genuine marketplace in medicine. Physicians spend an inordinate amount of time (and money) attempting to satisfy the needs of insurance companies, at the expense of satisfying patients. Doctors who do spend extra time with patients are paid the same as those who herd them through like cattle.

If our services are not provided within the framework of a market environment, they will be expensive, poorly administered, rarely updated, and eventually rationed as the cost of the system spirals out of control.

The current system based on a medical-industrial complex provides the wrong incentives, leading to rapid inflation, patient and physician dissatisfaction, slow uptake of new technology, and roadblocks to innovation and improvement.

Our great nation has been deluded into believing that health insurance is health care. It is not. Health insurance is simply a promise to pay for some portion of the cost of care. Insurance, as a management

vehicle for care, is severely impaired. Since the invention of HMOs, fewer people have access to health care—in fact, in 2006 there is less access than at any time since the end of World War II. Physicians are not a spoke in the health care “wheel.” We are the axle. We are the collective wisdom that enables the wheel both to turn and to exist. Health care has always been two people—a doctor and a patient—sitting in a room talking. What physicians must do is to take back the dignity that is rightfully earned in the pursuit of our great profession! We take this back by being passionate, proactive, progressive, and creative.

In 2006, it is patients, not doctors, who are taking the lead in modeling a system that works for them, and it’s called consumer-driven health care. If physicians do not “sense and respond” to the needs of patients but continue to operate under the rubric of “make and sell,” we will essentially be repeating the mistake GM made when Honda entered the market. That is, Honda listened to the customer and made small, economical cars, while GM insisted they knew best what was good for the car buyer—if GM made it, people would buy it.

I truly enjoy making house calls, even at 3 a.m. When I founded SF On Call Medical Group, I was on call twenty-four hours every day. Now our group is comprised of five physicians boarded in pediatrics, family medicine, and internal medicine. Our tiny goal is not to change the entire system, but rather to make a small, local contribution by helping patients get access to care and by relieving the load in doctors’ offices.

I believe that more and more physicians covering for large groups, or those who are unable to see office drop-ins, will soon recognize the benefits of offering patients this third option. Why would we not, as compassionate professionals, offer all afterhours patients the option of a convenient house call?

The current spasm in health care is viewed by many as a looming problem. The 2006 CMA Leadership Conference stated clearly that this train will come off the tracks in less than six years—unless we recognize that we must make changes, individually Continued on page 22...

october 2006 San Francisco Medicine 15

the changing face of medicine

LOONY, and Loving It! The Joys of a Low Overhead and Out of Network (LOON) Practice Daphne Miller, MD

I

am beginning to suspect that there is a small revolution afoot in the house of medicine. It all started several years ago with the occasional phone call from colleagues, mainly specialists, in San Francisco and other big cities. They were thinking of leaving their large group practices and severing their dozens of insurance contracts in order to start their own little clinical enterprises. They had heard about my small practice, which operates outside the purview of the medical insurance industry, and were seeking some logistical advice.

Then, one day, I noticed that it was no longer just the specialists calling. Primary care colleagues were starting to make breakfast and lunch dates to talk about their ventures into “uncontracted” or “unassigned” solo, fee-for-service practice. On a regular basis, someone would furtively pull me aside in the halls of the hospital and, in a whisper, tell me about their plan for “getting out.” Weekly phone calls started to come in, not just from the big urban centers, but from places like Yuba City: “Do you have any advice for a gynecologist who has had enough?” or “I am ready to take the plunge, because I cannot spend another day seeing four patients an hour.” All of these doctors, regardless of specialty and location, seem to have two main goals: They want to spend more time with each patient, and more free time without any patients.

When I first left academia in 2000 to open my six-hundred-square-foot “storefront” family practice, more time was my motivational mantra. I was terrified, especially given the fact that I had just turned down five years of guaranteed research funding in order to sign a $35,000 small-business loan. Most of my colleagues were truly puzzled by my bizarre behavior. Leaving

academia was one thing, but saying no to insurance contracts and to a large-practice setting was just not the thing to do. They would come up to me exuding that blend of sympathy and concern that we usually reserve for our patients who have just been diagnosed with an incurable disease. They would ask how things were going, in a tone that suggested that we all knew that death was imminent.

Now, heading into my seventh year at that very same street corner, I can safely say that things are going well. Not just well, but darn well. (Superstitious as I am, I am spitting twice over my right shoulder and knocking wood as I write this.) In 2003, I was joined by an intrepid family-practice colleague, Avril Swan. As side-by-side solos, we enjoy the “more time” and “less hassle” practice that we both fantasized about before we became disillusioned by the real world of medicine. Of course, on those days when our one shared employee is sick, or the door to our tiny bathroom has come off its hinges, or the burglar alarm won’t shut off, we don’t feel quite so self-congratulatory. But we remind ourselves that developing side skills as carpenters or electricians, or scheduling our own appointments for a day, far outweighs hours of hassles with insurance companies.

We are just happy that we are in control of our own schedules and that our professional lives are not spent running from room to room in order to see our quota of patients.

On a good day, which happens more often than not, we find ourselves spending thirty to ninety minutes with each patient—with ample time to perform home visits and teach a steady flow of UCSF medical students. On balance, we both seem to get a morning gym or yoga workout, as well as some daylight hours of quality time with

16 San Francisco Medicine october 2006

our school-aged kids and our spouses.

How did I get here? During those advice-seeking phone calls and luncheon dates, all my colleagues seem to have the same set of questions about the nuts and bolts of venturing out solo. While it would take more than a brief article to address them in detail, here are the highlights: Can you really make a living?

One particular colleague, who is very unhappy in his big-practice setting, always seems to be a bit irked that I am still smiling.

He recently asked me whether I was “independently wealthy,” implying that I was the Marie Antoinette of medicine, just dabbling in clinical practice for fun. As much as I wish this were true, I actually do need to work for a living. As it turns out, the low-overhead, no-insurance model, while being far from a get-rich-quick scheme, is a very respectable way for a physician to make a living. When I look at the FTE salaries earned by most family physicians in California, I do indeed feel fortunate, as I seem to make at least 20 percent more than the average.

Does it only work if you take care of the very wealthy?

It is easy to dismiss our practice model by calling it a rarified boutique practice for the very wealthy. The best way to dispel this idea is to spend some time in our waiting room. On any given day, you will see everyone from Pacific Heights matrons to dot-commers to Rainbow Foods employees to monolingual Spanish families to SRO dwellers from the Tenderloin. My mission, from the outset, was to offer care to patients from a range of socioeconomic backgrounds, and I have assiduously avoided becoming a boutique practice by keeping my fees www.sfms.org

affordable and by instituting a generous sliding scale. This is easily accomplished by maintaining a low overhead and giving patients the handsome discounts that most doctors give (unwillingly) to their contracting insurance companies. Most of my patients have figured out that they do not get their money’s worth out of the exorbitantly priced designer PPO insurance plans and have converted to large-deductible major medical plans with a health savings account (HSA). Since most of their office visits are out-of pocket anyway, they actually find our practice to be more affordable than many insurance-contracted ones.

Can you do this if you have no business background?

Prior to opening my practice, my only business experience was a front-lawn lemonade stand in the second grade. I had never managed any budget other than my household expenses, much less written a business plan. At first I saw this as a big deterrent to venturing out solo. Then I visited chiropractors and acupuncturists in the neighborhood and realized that they had not had an ounce more business training and were doing just fine. If you follow the KISS principle (keep it simple, stupid) and make sure to institute, from day one, systems that are user-friendly, such as QuickBooks, electronic records, and an uncomplicated office management software, then you should be just fine.

How do you keep a low overhead?

The quick-and-dirty answer is to pare down the most expensive line items: staff and space. While malpractice insurance may be a third item on this list in most states, MICRA has made premiums in California affordable for most specialties. If you do not contract with insurance companies and you do have patients pay their bills at the time of the visit, then you do not need hordes of administrative staff to process claims and track down payments. A lower patient volume allows you to do without medical assistants or nursing staff to take vitals or give shots—services that I actually take great pleasure in doing myself, which patients seem to appreciate. In addition, a leisurely pace means that you do not need a row of exam rooms in which to stash waiting, www.sfms.org

undressed, paper-gowned patients. Instead, they can lounge calmly in the waiting area, sipping their mineral water and waiting for you to cheerily invite them into your oneand-only exam room—almost as if they were guests coming over for tea.

Some of the solo doctors I have spoken to recently are taking even more daring steps to cut overhead. They are not hiring assistants and are simply getting an on-line

Daphne Miller’s Office

scheduling system and using a one-room office with a door code, so that patients can let themselves into the waiting room. Others are doing home visits only, thus eliminating the need for an office altogether.

Is it hard to attract patients? Do you need to advertise?

After all these years, I can tell you with assurance that a satisfied patient begets more patients. When I started my practice, I simply hung up a shingle and waited to see who would walk in the door. Those two people each told ten people, and so on. By my third month in practice, I was in the black; by the end of my first year, I had paid off my loan. I did do some public speaking at neighborhood community centers and parenting centers, and that seemed to be an effective way to attract patients. As my practice grew, it caught the attention of local papers, TV, and magazines. However thrilling it might have been to see my name in print, I do not believe that this had much of an effect on growing my practice, however. Most patients choose their doctor not based on the opinion of the media, but on the recommendation of another physician or a referral from a trusted friend.

Is being on-call too demanding?

Spending more time with patients during the day means that they call much less at night. Dr. Swan and I trade off months on call, and neither of us has found it to be too onerous. On average, we might receive four or five after-hours pages per week, and rarely do they come in the dead of night. In general, patients are reluctant to disturb us.

I also think it helps us to know that if we do work after hours, we will be paid for it.

After being in practice for this long, I have a rather extensive support network of specialist and primary care colleagues with similar modes of practice. As a matter of fact, I was recently inspired to invent an acronym to describe this model: LOON, for LowOverhead, Out of Network. The description seemed apt—not only because one has to be a bit loony to embark on such a venture but, as it turns out, the loon is excellent at diving headfirst into things. For family doctors, there is now a national list serve and advice website run by the Rochester, New York-based LOON guru, Gordon Moore, MD. In the Bay Area, LOON specialists and generalists are meeting quarterly to support each other at the office of Mill Valley orthopedist Catherine Jasan, MD. Almost every week, small LOON practices around the state are opening their doors.

Just to be clear, this practice model is in no way the definitive answer for our wounded and beleaguered medical system. Clearly, such a complicated problem requires a multipronged solution. Also, many doctors (and patients) do continue to survive and thrive in large community clinics or insurance-contracted, private practice settings.

But after six good years spent on my sunny street corner, I can say with assurance that being a LOON is a viable option for doctors who love to practice medicine but have yet to find their professional nirvana.

Daphne Miller has been a LOON family practitioner in San Francisco since 2000. She trained at Harvard Medical School and did a family practice residency and fellowship at UCSF. She currently sees patients part-time and dedicates the other half to cooking, yoga, writing about food and nutrition, or spending time with her architect husband and two children (pictured on opposing page).

october 2006 San Francisco Medicine 17

the changing face of medicine

Do More Good An Integral Approach to Health Care that Benefits Patients, Physicians, Communities, and the Environment Bonita Ford

T

COLLECTIVEPLURAL

INDIVIDUALSINGULAR

he standard handed down by Hip- government officials and physicians, helped and the environment. A broader perspective pocrates, “First do no harm,” is close an industrial yeast plant, which was might be useful. a central value in contemporary the largest fixed source of air pollution in medicine. Given the enormous challenges the area. From West Oakland, we learn An Integral Approach in the field today, we are often called upon that alliances across disciplines enable Integral theory offers a view “from ten to take it one step further and “do more broader-reaching health initiatives in a thousand feet up.” According to philosopher good.” Can we do more good? What more community.

Ken Wilber, there are four factors that are is necessary?

Finally, hospital administrators, plan- essential to integration: the individual and The current medical system inadver- ners, and builders are joining the revolution- the collective experience, each in their retently contributes to the deterioration of ary wave in medicine, creating a new gen- spective objective and subjective capacities the global environment. Hospitals generate eration of “green” hospitals. This trend is led (see Figure 1 below). significant amounts of mercury and PVC by Health Care without Harm and Hospitals To place these four quadrants within a plastic waste. A 2005 study by Pat Hem- for a Healthy Environment, which address medical framework, consider a woman who minger, reported in Environmental Health the reduction or elimination of dangerous has breast cancer and is also low-income, Perspectives, finds our waterways contami- hospital wastes such as mercury and PVC an immigrant, and a single mother. The nated with approximately 100 pharmaceuti- plastics, and which facilitate hospital designs objective-individual quadrant (upper right) cal drugs. Additionally, illnesses related to that keep in mind fewer toxic materials and considers the woman’s body, the cancer, and the environment are becoming a greater the occupants’ well-being. Green hospitals may include her genetic predisposition and issue. One recent Breast Cancer Fund study show great potential, with participation poor nutrition. The subjective-individual attributed 40 percent of deaths in the world growing in the U.S. and internationally. quadrant (upper left) focuses on her perto environmental pollution and degradaAll of these advances promise an sonal experience and psychological factors, tion. Cancer and infectious disease are two improved medical system. However, none such as her extreme stress and anxiety. The prime examples of risks that have grown or offer a totally comprehensive approach that exterior-collective quadrant (lower right) are expected to grow dramatically. benefits patients, physicians, communities, The physician, who endeavors to meet the need for adequate care within an ailing 1: The Four Quadrants Figure 1: The Four Figure Quadrants of Health and Diseaseof Health and Disease system, is often forgotten. In a now-familiar study by the Policy Forum of the American Medical Association, Mamta Gautam SUBJECTIVE-INTERIOR OBJECTIVE-EXTERIOR found that 46 percent of doctors suffer from advanced burnout. Perhaps an ethic of “do more good” should include this aspect of I IT health and emotional well-being.

Cross-disciplinary dialogue is touching Personal experience The body, the disease experts in environmental medicine and public health, as well as citizen groups. A case in point is West Oakland, where a child WE ITS is seven times more likely to be hospitalized for asthma and there are ninety times more Cultural experience, norms Physical environment, social and values structures diesel particulates per square mile than in the rest of the entire state. Recently, a collaboration of local constituencies, including 18 San Francisco Medicine october 2006

www.sfms.org

considers social factors, such as her lack of access to medical care and her exposure to chemical toxicity in her work and home environments. Finally, the interior-collective quadrant (lower left) includes her cultural experience, such as a norm that prescribes her role in caring for others before taking care of her own health.

In this framework, would we say that this woman’s disease is the result of genetics, psychological factors, chemical toxicity, or cultural self-neglect? As we view her in relationship to her environment, we can see that her disease potentially results from many or all of these factors. An integral approach distinguishes itself by considering all quadrants: the body, the person’s mental and emotional well-being, the cultural influences on health and disease, and the social structures and environmental factors contributing to health and disease. An integral approach offers potential interventions in all four quadrants and, in this example, would recommend chemotherapy, counseling, support groups, and the reduction of environmental toxicity as appropriate measures.

In greening the workplace, a doctor makes the office, clinic, or hospital a healthier place for people. By reducing resource consumption, decreasing waste, and making the building less toxic, the doctor fosters an environment that is conducive to good health. In becoming an environmental health advocate, a physician is invited to make a commitment to environmental stewardship. In providing sustainable medical care, physicians emphasize medicine that is cleaner, less polluting, more renewable, safer, and more accessible to patients. This practice of ecologically sustainable medicine is good for people and the environment, offering a new set of ethical values and principles within our medical system.

The green health care model includes the body and psyche of the patient, the physician-patient relationship, the physician him/herself, the type of medical treatments used, the physician’s office or the hospital, and the natural environment. It is founded on the understanding that all these elements contribute to health and healing. Unique to this model is its understanding that a healthy system of medicine must serve the

health of the patient while also protecting the health of the physician, the community, and the environment. By expanding the scope of our care as physicians and healers, we can not only do no harm—we can do more good.

A physician may act as a powerful instrument of change by expanding his or her own perspectives of health and healing, by educating patients and colleagues on how to promote health on a broader scale, and by changing his or her relationship to the very practice of medicine—to do more good. In a time when medicine is facing so many challenges, doing more good is essential. i

Bonita Ford has an MA in Holistic Health Education from John F. Kennedy University and a BS in Biochemistry from Queen’s University. She is the Associate Director at the Teleosis Institute, a nonprofit organization in Berkeley promoting sustainable medical practices that are good for people and the environment. To learn more about the Teleosis Green Health Care Program, visit www.teleosis.org.

The Green Health Care Model Green health care is an integrally-based model that includes the contributions of its predecessors while addressing all four quadrants of health and healing. It emphasizes three areas that are often neglected in current approaches—the physician, the practice of medicine itself, and the connection between personal and ecological health.

The Teleosis Institute, which developed the green health care model, sees the physician as uniquely empowered to influence change in both patients and the medical system. (Teleosis addresses the culture of medicine and medical treatments themselves as part of promoting a healthier system of medicine.) Green health care also emphasizes ecological literacy—an understanding of the connections and processes in nature—as relevant to medicine, because its efforts to promote health are impaired by the reality of living in a toxic environment.

Green health care includes three components: greening the workplace, becoming an environmental health advocate, and providing sustainable medical care. www.sfms.org

october 2006 San Francisco Medicine 19

in my opinion Stephen Kaufman, MD

The Death of the Urban Pediatrician

A

s the nature of health care in urban centers has radically changed, the role of physicians is undergoing a major reorganization. Pediatrics, especially in its function of changing the emphasis from disease treatment to prevention, has contributed a great deal to the well-being of children. Sadly, the private practice of urban pediatrics is not viable, and I am a mourner at its grave.

Hospitalists have been hired to diagnose and treat hospitalized children. The primary care pediatrician is welcomed only as a visitor, provided he doesn’t dictate care or charge for services. Neonatologists attend all cesarean sections and care for all babies admitted to the intensive care nursery. Advice for breast-feeding is given by the lactation service, and patients who arrive in the emergency room are treated by an ER doctor. The pediatrician has no significant part to play within the hospital other than to refer patients. He is confined to office practice.

What happens in the office? Children with complex diseases are referred to subspecialists and multispecialist teams for ongoing care. Practice consists mainly of well-baby care, treatment of minor ailments, and immunizations. These can be accomplished by a nurse practitioner at a lower cost than that charged by the pediatrician.

Supervision of the nurse practitioner and coordination of care of complex diseases treated by multiple subspecialists is neither satisfying nor economically viable for the pediatrician.

General pediatrics will remain a viable specialty in rural areas for the foreseeable future. In urban communities, however, with their multiplicity of subspecialists and tertiary care hospitals, there is little opportunity to use the myriad skills developed in a residency program. Administration coordination and supervision is not a satisfactory substitute for the responsibility of practicing medicine.

Speaking personally, when I entered pediatrics I sewed lacerations, did exchange transfusions, read EKGs, started IVs, drew blood from femoral and internal jugular veins, attended cesarean sections and intubated newborns, performed spinal taps, and had primary responsibility for the children I admitted to the hospital. Over the years, I have lost these skills through attrition.

Parents develop a loyalty to their childrens’ pediatrician.

Because of the families and the children that I see, practice is still pleasurable for me. However, I cannot recommend that newly trained pediatricians enter the private practice of urban pediatrics, either for economic or for medical gratification.

Dr. Stephen Kaufman has been in Pediatrics and Pediatric Endocrinology practice for the past forty years. He is a clinical professor of Pediatrics at UCSF, active on the staff at CPMC, and a member of the Lawson Wilkins Pediatric Endocrine Society.

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www.sfms.org

sfms assessment survey results Thomas H. Lee, MD

Preparing for the Future It goes without saying that the practice of medicine is experiencing dramatic change and that many physicians are struggling to adjust to increasingly difficult pressures. This past winter, the SFMS Board of Directors met to discuss and prepare for the future of the society and its members. In addition to reevaluating the San Francisco Medical Society’s mission and objectives, the meeting participants felt that more information was needed to better understand the concerns of current and future members.

The result of this discussion was the development and launch of the SFMS Assessment Survey, conducted from May through July of this year. The survey was developed based on input from SFMS committee members and was distributed in online and print format to member and nonmember physicians throughout San Francisco.

Overall, 299 responses came in, one-third of which were obtained online and two-thirds via paper. Survey respondent characteristics included the following: • 27% SFMS members, actively involved • 56% SFMS members, not actively involved • 7% former SFMS members • 6% never members of SFMS • 50% in solo/small-group practice (>10 MDs) • 3% in large-group practice (10–20 MDs) • 11% in very large-group/integrated delivery/HMO systems (20+ MDs) • 8% in academic medical centers • 2% in community clinics • 6% in medical schools Of those who were never members of SFMS, 73% did not know what the benefits of membership were, and 60% did not know what SFMS does. Nonmembers were much more likely to be female. By contrast, active members of SFMS were more likely to be males practicing in solo/small-group practice, large-group practice, or community clinics.

The primary goal of the survey was to better understand the concerns and needs of physicians in San Francisco today. The results demonstrated the following: www.sfms.org

• 38% of respondents—significantly or very significantly concerned about staying on top of relevant legal/health policy issues and/or influencing policy • 33% of respondents—significantly or very significantly concerned about preventing burnout • 33% of respondents—significantly or very significantly concerned about whether they could make enough money in their profession Less significant concerns—getting involved with local public health initiatives and keeping professional life stimulating • Only 4%—significantly or very significantly concerned about whether they were in the right profession In general, active SFMS members tended to have more significant concerns about influencing and shaping legal/policy issues and about making an income. Less-active SFMS members were more interested in improving professional networks and contacts, running a better practice, and preventing burnout. Former members had few concerns. And nonmembers were more concerned about preventing burnout and serving as advocates for their patients.

When asked which of SFMS's services would be most valuable: • 54%—state and federal legislative advocacy regarding the practice of medicine was very or most valuable • 44%—local health-related issues specific to San Francisco were very or most valuable • 38%—state and federal legislative advocacy affecting health policy issues was very or most valuable • 38%—the SFMS membership directory was very or most valuable • 36%—timely communication on late-breaking information on legislative issues was very or most valuable Active SFMS members were more interested in issues around the practice of medicine and local advocacy. Less-active members were more interested in the SFMS membership directory. Former members were more interested in local advocacy issues. And nonmembers were more interested in health policy issues, timely Continued on page 22... october 2006 San Francisco Medicine 21

Preparing for the Future: Continued from page 21... communication, and patient referral services.

Overall, the survey results appear to show that SFMS is doing work important to its members—specifically, it serves as an advocate for physicians and the patients they serve. Though there appears to be some variation among the different subgroups, advocacy and the timely communication of key legislative updates are universally viewed as important. Other services, such as the SFMS directory, magazine, and special forums, are more or less valuable to different subgroups, but not to the masses. And lastly, there appear to be opportunities to reach out to female physicians; to those working in large, integrated health care systems; and to younger physicians in practice.

One limitation of the survey was the fact that fewer than 10 percent of respondents were nonmembers. Given that this was not reflective of the local physician population, a greater subset of non-SFMS physicians would have been preferred. Nevertheless, the information gleaned from this survey will help the Medical Society better plan activities and events for its members and encourage it to continue to seek new ways to reach out and meet the needs of future members. The practice of medicine is under increasing pressure to change and adjust to difficult economic and operational realities. The more that physicians can be represented

by SFMS, the more likely it is that we can all be effective in shaping the dialogue and direction of medicine’s future.

in my opinion

22 San Francisco Medicine october 2006

Offering a Third Option: Continued from page 15... and collectively. We would do well to remember that the Chinese ideogram for crisis is the symbol for danger combined with the one for opportunity.

Dr. Shlain is Founder and Medical Director of San Francisco On Call Medical Group, a primary and urgent care practice that specializes in house calls. After graduating from U.C. Berkeley, he joined Harvard’s WorldTeach and spent a year teaching high school in Kenya. He attended Georgetown Medical School and completed his Internal Medicine Residency in San Francisco. Dr. Shlain currently lectures at U.C. Berkeley on the micro- and macroeconomic trends in medicine and is at the forefront of the development of consumeroriented health care models. He sits on the Board of Directors and Executive Committee of the San Francisco Medical Society and is an assistant clinical professor at the UCSF Medical Center. He also sits on advisory boards for several start-up health care delivery companies.

www.sfms.org

sfms election 2007

2006 Slate of Candidates Pursuant to the SFMS Bylaws Article X Section 2–Nominations, the Nominations Committee renders in writing the following slate of candidates for the 2006 SFMS election. This slate was announced at the September 11, 2006, General Meeting, at which time the SFMS President called for additional nominations from the floor. The following are this year’s candidates:

2007 Officers—for one-year term: For the office of President-Elect, Secretary, Tresurer, and Editor only one candidate may be selected for each individual office.

For President-Elect: Steven H. Fugaro For Secretary: Michael Rokeach For Treasurer: Charles J. Wibbelsman For Editor: Mike Denney (Incumbent)

SFMS Board of Directors Three-year term 2007-2009: The seven candidates receiving the highest number of votes will serve as directors on the SFMS Board.

Brian T. Andrews Lucy S. Crain * Jane M. Hightower * Donald C. Kitt Corey S. Maas William A. Miller Jordan Shlain * Paul M. Silvestre Lily M. Tan Shannon Udovic-Constant *Incumbent Director

Nominations Committee Two-year term 2007-2008: The candidates receiving the highest number of votes will serve as members of this committee.

Eileen G. Aicardi Mei-Ling E. Fong Keith E. Loring William A. Miller

Solo/Small Group Practice Forum Delegate Two-year term 2007-2008: Eric Tabas

Solo/Small Group Practice Forum Alternate Delegate Two-year term 2007-2008: Gary L. Chan

Delegates to the CMA House of Delegates Two-year term 2007-2008: The four candidates receiving the highest number of votes will serve as delegates. The President-Elect automatically becomes the fifth delegate. The next four will be alternate delegates.

Taissa Cherry ** George A. Fouras Gordon L. Fung * Thomas H. Lee ** E. Ann Myers * Joshua H. Rassen * Shannon Udovic-Constant H. Hugh Vincent * *Incumbent Delegate

**Incumbent Alternate NOTES:

• 2006 President-Elect Stephen E. Follansbee automatically succeeds to the office of President.

• 2006 President Gordon L. Fung automatically succeeds to the office of Immediate Past President.

• Ballots will be mailed to all SFMS members in late October. Upon receipt, please mark your ballot and return it immediately to SFMS, 1003A O’Reilly Ave. San Francisco, CA 94129.

• Ballots must arrive by 5 p.m. on Monday, November 13, 2006. The name of the SFMS member (not the corporation name) must be printed legibly or typed on the return envelope.

www.sfms.org

october 2006 San Francisco Medicine 23

sfms election 2007

SFMS Officer Candidate Statements FOR PRESIDENT-ELECT

Steven H. Fugaro Specialty: Internal Medicine Membership: SFMS/CMA 1986 SFMS: Treasurer 2006; Director 2003–05 SFMS Committee Appointments: Executive 2006; Finance Chair 2006; SFMS PAC Board 2005–06; Information Technology 2006; Nominations 2004 Related Medical Affiliations: American College of Physicians, Society of General Internal Medicine Medical School: Yale University 1981 Hospital Affiliation: UCSF, Mt. Zion Teaching Appointments: Associate Clinical Professor of Medicine, UCSF Policy Statement: I have practiced privately, full-time, in internal/primary care medicine for the last sixteen years and before that was employed by UCSF for eight years as a general internist and clinician-educator. This varied employment background enables me to appreciate both the vast changes that have occurred in medicine in the previous two decades as well as the varied challenges confronting physicians today in academic medicine, managed care, and private practice. I have become increasingly aware of the critical role played by the San Francisco Medical Society in influencing medical care and medical policy at the local, state, and national levels. The Medical Society has been able to accomplish this via its CMA Delegation and its recognized role as the leader of organized medicine in our city. There are a number of important issues that we as a Medical Society will need to confront over the next year—issues such as

primary care physician shortages, fair billing for noncontracted physicians in the ER setting, and the relationship between managed care entities such as Brown & Toland with various IPAs and specialty groups in San Francisco. I welcome the opportunity to serve the San Francisco Medical community as SFMS President-Elect in the coming year and to work closely with Dr. Stephen Follansbee, the President of SFMS for 2006.

FOR SECRETARY

MICHAEL ROKEACH Specialty: Emergency Medicine Membership: SFMS/CMA 1990 SFMS: Director 2001–06 SFMS Committee Appointments: PAC Board 2002–06 (Chair 2003–06); Executive 2006; Medical Review and Advisory 2000–06; Nominations 2003 CMA: Alternate 2002–03 Related Medical Affiliations: Vice Chief of Staff, CPMC 2006; Medical Staff Treasurer, CPMC 2004–05; Medical Executive Committee, CPMC 1992–2004; Chair, MEC Nominating Committee 1997–2000; Chair, Risk Management Committee, CPMC 1990– 1998; Quality Performance and Improvement Committee, CPMC 1992–present; Executive Committee, San Francisco Emergency Physicians Association, Ambulatory Services PI Committee, CPMC 1998–present; Chair, Sutter Emergency Department Directors Group 2003; Representative, EMS Clinical Advisory Committee 1990–2002; National and California Chapter American College of Emergency Physicians Medical School: University of Miami 1973

24 San Francisco Medicine october 2006

Hospital Affiliation: Active: CPMC Policy Statement: It has been an honor and a pleasure serving on the San Francisco Medical Society Board of Directors and as chair of its PAC. I believe I represent the best interests of the practicing physicians in our community with regards to social, political, and governmental issues. The Medical Society must continue to confront the many issues challenging our ability to meet the needs of our patients and our own families. Organized medicine is the most effective vehicle to protect the values of our practices. I am excited about the future of our Medical Society, and I would like to continue being a part of the Society’s leadership. I am offering my candidacy for secretary of SFMS, and I hope you will support me. I look forward to serving the interests of all physicians in San Francisco.

FOR TREASURER

CHARLES J. WIBBELSMAN Specialty: Pediatrics/Adolescent Medicine Membership: SFMS/CMA 1985 SFMS: Director 2003–06 CMA: Very Large-Group Practice Forum Delegate 2001–06; VLGPF Alternate 1996– 97/1999–2000; SFMS Alternate Delegate to the CMA 1996–97 Related Medical Affiliations: President of Professional Staff, Kaiser Foundation Hospital, San Francisco 2002–04; Vice President of Professional Staff, Kaiser Foundation Hospital, San Francisco 2001–02; Board of Directors, the Society for Adolescent Medicine 1997–99/2002–05; President, Northern California Chapter of The Society for Adolescent www.sfms.org

sfms election 2007 Medicine 1989–97; Board of Directors, USF Center for Child Development 1999–2001; Medical Guest Host, KRON Morning Show 2002–03; Member, American Federation of Television and Radio Artists 2002–06; North American Society for Pediatric and Adolescent Gynecology 1999–2006; Committee on Adolescence, The American Academy of Pediatrics 2003–present Medical School: University of Cincinnati 1970 Hospital Affiliation: Kaiser Foundation, San Francisco Teaching Appointments: Clinical Professor of Pediatrics, UCSF Policy Statement: As a physician practicing medicine in San Francisco since 1976, I have had the opportunity to observe health care delivery from two very different perspectives: initially as a physician with the Public Health Department; and, for the past 27 years, as a pediatrician in a very large-group model HMO. In both spheres of practice, quality of medical practice, access to care, and culturally competent care to diverse patient populations are high priorities. The San Francisco Medical Society has the unique role of providing leadership and guidance in achieving these goals of practice through its delegation to the CMA and its status as recognized leader of organized medicine in San Francisco. As a spokesperson for physicians in San Francisco, SFMS helps maintain a high level of professionalism in medicine and serves as an advocate for physician wellness in these turbulent times of change. Our Medical Society also is and will continue to be a key conduit of information to physicians regarding legislative issues on the local, state, and national levels as these issues affect our daily practice of medicine. I would be proud to carry on this tradition of leadership and community recognition.

FOR EDITOR

Myron K. (Mike) Denney (Incumbent Editor) Specialty: Psychosomatics/General Surgery Membership: SFMS/CMA 2002 SFMS: Editor 2006 SFMS Committee Appointments: Executive 2006; Editorial Board 2002–06 Medical School: University of Michigan 1959 Teaching Appointments: Adjunct Faculty, Holistic Health Education, John F. Kennedy University; Integrative Health and Healing, California Institute of Integral Studies; Depth Psychology, Pacifica Graduate Institute Policy Statement: I am honored to be nominated for another term as Editor of the Journal of the San Francisco Medical Society. It has been a pleasure serving this past year. As this Journal is an advocate for physicians and patients, my editorials have focused on underlying meanings and transcendent dynamics of economic, political, scientific, ethical, and personal issues that confront both healers and the afflicted. I will dedicate myself to the ongoing quality of our publication as it continues to explore new and deeper perspectives of the art and science of medicine.

FOR BOARD OF DIRECTORS

BRIAN T. ANDREWS Specialty: Neurological Surgery Membership: SFMS/CMA 1988; AMA 1988 www.sfms.org

Related Medical Affiliations: Medical Executive, CPMC 2003–05/2006–07; Chief of Neurological Surgery/Vice Chair Neurosciences, CPMC 2000–present Medical School: University of California, San Francisco 1981 Hospital Affiliation: Active: CPMC, St. Mary’s, St. Luke’s; Courtesy: St. Francis, Seton Teaching Appointments: UCSF Clinical Faculty in Neurological Surgery 1988–present Policy Statement: As a practicing neurological surgeon in the city and county of San Francisco for the past eighteen years, I am aware of the difficulties with access to proper subspecialty care through the emergency departments of our major hospitals. I am also closely involved in the development of a Neurosciences Center at the California Pacific Medical Center in San Francisco. I believe SFMS can, and should, identify difficulties with, and shape policy for, access to subspecialty care in San Francisco. I believe SFMS can unify the goals of subspecialties practicing in both the university systems and the private hospitals in San Francisco.

I am very interested in contributing my time to these important matters as they are addressed by the San Francisco Medical Society.

LUCY S. CRAIN (Incumbent Director) Specialty: Pediatrics Membership: SFMS/CMA 1972; AMA 1992 SFMS: Director 2004–06; Treasurer 2003; Director 2001–02 SFMS Committee Appointments: Finance 2002–06 (Chair 2003); SFMS Services Board 2003–06 (Secretary-Treasurer 2004–06); SFMS PAC Board 2002–06; Nominations 2002–03/2006; Information Technology

october 2006 San Francisco Medicine 25

sfms election 2007 2006; Executive 2002–03 CMA: Alternate Delegate 2004–07 CMA Committee Appointments: Council on Legislation 2004–06; Technical Advisory Committee for Medi-Cal Reimbursement Related Medical Affiliations: First Five San Francisco Commissioner 2003–present (Chair 2004–present); Chair, AAP-CA Task Force on Children with Special Health Care Needs 2000–present; Member, AAP-CA Board of Directors; Chair, Health Committee of San Francisco Commission on Children and Families (SFCFC/Proposition 10 Commission) 2002; County Commissioner SFCFC 1999–present; Immediate Past Chair, American Academy of Pediatrics, California; and member of Board of Directors, National AAP 1997–2000 Medical School: University of Kentucky 1965; MPH­, UCB 1971; Fellowship in Health Policy, UCSF Institute for Health Policy Studies 2001 Hospital Affiliation: Active: UCSF, Lucile Packard Children’s Hospital at Stanford Teaching Appointments: Clinical Instructor, LCPH at Stanford Department of Pediatrics; Clinical Professor, emeritus, UCSF Department of Pediatrics Policy Statement: Practicing physicians are uniquely qualified to advocate for quality improvement and standards of health care and education and to partner with consumers, patients, and community leaders in demanding accountability regarding health issues from legislators and others. SFMS is crucial in facilitating these partnerships to address the health issues of our community, and in promoting educational opportunities for our members and future physicians and leaders within medicine. The CMA House of Delegates offers SFMS a visible presence in the prioritization of health care concerns, as well as opportunities to recommend solutions. The impact of politics on health policy and practice, and on the future health of our community, state, and nation both today and in the future, underscores the strategic role to be played by our Medical Society and our profession.

JANE M. HIGHTOWER (Incumbent Director) Specialty: Internal Medicine Membership: SFMS/CMA 1991; AMA 1984 SFMS: Director 2004–06 SFMS Committee Appointments: Membership 1996–98; Credentials 1996 Medical School: University of Illinois 1988 Hospital Affiliation: Active: CPMC; Courtesy: St. Mary’s Policy Statement: I have been a member of the Medical Society Board from 2004 to 2006. I have been very pleased that there are so many physicians who are active advocates for physicians and patients. My research, which involves mercury and fish, has allowed me to learn about how the government, nongovernmental agencies, industry, and public and private health care sectors work together in order to set policy. In working with these groups, I have learned that clinical physicians are often not included in discussions when it comes to environmental and public health issues. As a Board Member of SFMS, I will continue to bring balance to the voices and encourage involvement of clinicians in issues that affect us, our own health, and the health of our patients.

DONALD C. KITT Specialty: Neurology Membership: SFMS/CMA 1988; AMA 1988 SFMS: UCSF/ACF Consultant to the Board 1999

26 San Francisco Medicine october 2006

SFMS Committee Appointments: Tripartite 2000 Related Medical Affiliations: Chief, Neurology Section, Department of Medicine, St. Mary’s 1998–present; Fellow, American Academy of Neurology 2004–present; President, Association of Clinical Faulty, UCSF 1998–99; President, San Francisco Neurological Society 2001; Board of Directors/Executive Council, San Francisco Neurological Society 1998–present; American College of Physicians 1985–present; Executive Council of the Association of Clinical Faculty, UCSF from 1995–99; Hastings Center for Bioethics 1976–present Medical School: University of Southern California 1982 Hospital Affiliation: Active: CPMC, St. Mary’s; Courtesy: Chinese, St. Francis Teaching Appointments: Associate Clinical Professor, Department of Neurology, UCSF 2003–present; Assistant Clinical Professor, Department of Neurology, UCSF 1990–2003 Policy Statement: For generations, SFMS has been a stalwart leader in bringing awareness of health care issues to institutions and to the practicing physician. My hope is that SFMS can unite physicians in a cohesive participatory community to maintain the integrity of our profession in San Francisco. We also need to increase membership through incentives and rates reasonable for physicians entering practice.

As a native San Franciscan, my dream became true in practice and in teaching neurology for 18 years. We cannot predict what issues may arise, but I promise that I will provide thoughtful judgment, counsel, and new ideas.

COREY S. MAAS Specialty: Facial Plastic Surgery/Otolaryngology www.sfms.org

sfms election 2007 Membership: SFMS/CMA 1993; AMA 1981 SFMS: Editor 2004–05 SFMS Committee Appointments: Executive 2004–05; Editorial Board 2003–06; Insurance Mediation Committee CMA Committee Appointments: Ambulatory Care Committee AMA: Young Physicians Representative, Facial Plastic Surgery Medical School: University of Florida 1986 Hospital Affiliation: Active: CPMC, Moffitt-Long, UCSF; Courtesy: SFGH, Tahoe Forest Hospital Policy Statement: I am honored to be nominated to serve again on our Board of Directors. The service and time commitment to our organization has been very rewarding, since the San Francisco Medical Society provides so much for our medical community and the community at large.

We have many issues facing us, and over the next three years I would remain committed to contributing to the fine efforts of our Society.

WILLIAM A. MILLER ALSO CANDIDATE FOR NOMINATIONS COMMITTEE Specialty: Internal Medicine Membership: SFMS/CMA 2002 SFMS: St. Luke’s Medical Staff Liaison 2006 Related Medical Affiliations: St. Luke’s Hospital Chief Medical Executive and Immediate Past Chair, Department of Medicine; Associate Professor, Touro University Medical School: University of Arizona College of Medicine 1991 Hospital Affiliation: St. Luke’s Policy Statement: Health care is undergoing a new era of dynamic changes that may well lead to a major restructuring of how care is delivered and paid for. There www.sfms.org

are many national initiatives surrounding quality of care, patient safety, and the way physicians and hospitals are paid based on their ability to adapt to these new expectations. I wish to serve on the Board in order to play a leadership role in making sure that physicians are at the table to have input in these changes, so that we can improve the care that we provide to our patients while at the same time ensuring that new physician-compensation structures are fair and appropriate.

Jordan Shlain (Incumbent Director) Specialty: Internal Medicine Membership: SFMS/CMA 1997 SFMS: Director 2003–06 SFMS Committee Appointments: Editorial Board 1998–2006; Information Technology 2006; Web Page Oversight 2002–05 (Chair 2003–05); Executive 2004–05; Physician Membership Services 2001–03; QOM 2001–2003; Managed Care 1998–2002 CMA: YPS Delegate 2006–07 (Alternate Delegate 2004–05) Medical School: Georgetown 1994 Hospital Affiliation: Active: CPMC, Mt. Zion Teaching Appointments: UCSF Associate Clinical Professor, School of Nursing Policy Statement: As a native San Franciscan and a second-generation Society member, I am eager to assist and serve on the board. I believe our Society has significant clout in shaping policy and could benefit from the perspective and experience of a physician brought up in the environment of managed care. As a member of the Editorial Board, I have worked closely with many of our outstanding leaders and understand the challenges that face the health of our society and our city over the next decade.

PAUL M. SILVESTRE Specialty: Pediatrics Membership: SFMS/CMA 1999 Medical School: UCSF 1994 Other: MPH (Maternal and Child Health) from U.C. Berkeley Hospital Affiliation: Active: CPMC, UCSF/SFGH; Courtesy: Seton, Mills-Peninsula Teaching Appointments: UCSF Department of Pediatrics Clinical Instructor Policy Statement: This is a difficult time for our changing health care system. It is clear that our role goes beyond individual patient interactions to include education, policy, and advocacy for our community.

SFMS is the perfect organization to initiate the changes needed to improve patient access and reduce physician roadblocks to providing quality care. As a pediatrician, I would be a strong advocate for our children’s health needs. Working as a newborn hospitalist—a supervising attendant at a county clinic—as well as working in private practice, I have broad exposure to our current health care delivery system and would provide a valuable perspective.

LILY Meiyu TAN Specialty: Ob/Gyn Membership: SFMS/CMA 1999–present CMA: Young Physicians Section Alternate Delegate 2006–07 Related Medical Affiliations: CPMC Gynecology Quality Improvement Committee 2002–2005; Chinese Hospital Pharmacy Committee 2001–2002; Physician Representa-

october 2006 San Francisco Medicine 27

sfms election 2007 tive for OB/GYN Nurse Practitioner Training Committee 2006 Medical School: Albany Medical College 1995 Hospital Affiliation: Active: Kaiser Permanente San Francisco Teaching Appointments: CPMC Nursing Staff Educator 2002–2005; Kaiser Staff Educator for Residents and Medical Students 2006 Policy Statement: With the recent explosion in scientific technology, the future of medicine has become increasingly enmeshed with politics. Advances in the science of medicine and challenges in the organization of health care delivery have made the politics of medicine more complex than ever before. As a Board Member, I hope to infuse new energy into the San Francisco Medical Society, providing a fresh perspective and a voice for our newer members, and urging them to play active roles as the future leaders of organized medicine.

SHANNON UDOVIC-CONSTANT ALSO CANDIDATE FOR DELEGATION Specialty: Pediatrics Membership: SFMS/CMA 2001 SFMS Committee Appointments: SFMS PAC 2006; Medical Review and Advisory 2002–present CMA Committee Appointments: Young Physicians Section Executive Committee, AtLarge Member 2003–2005 Related Medical Affiliations: AAP State Government Affairs Chapter Representative; AAP Chapter Board, Alternate Member-atLarge 2003 Medical School: U.C. Berkeley/UCSF Joint Medical Program, MS 1996, MD 1998 Hospital Affiliation: Active: Kaiser Permanente Teaching Appointments: Assistant Clinical

Professor, UCSF Department of Pediatrics Policy Statement: As individual physicians in San Francisco, we can directly affect the health and well-being of our own patients.

The power of organized medicine is that physicians across all specialties can have one voice to address the broader health care issues facing patients and their physicians through improved access to care, appropriate reimbursements, public health programs, and effective health care legislation. Combining my work with the CMA Young Physicians Section and my experience with lobbying and health policy, I would welcome the opportunity to serve SFMS to increase membership and involve our members in advocacy on behalf of San Francisco physicians and patients.

FOR NOMINATIONS COMMITTEE

EILEEN G. AICARDI Specialty: Pediatrics Membership: SFMS/CMA 1979 Related Medical Affiliations: Northern California Chapter of the American Academy of Pediatrics Medical School: UCSF 1974 Hospital Affiliation: Active: CPMC; Courtesy: UCSF Teaching Appointments: Clinical Professor, UCSF Department of Pediatrics Policy Statement: I have been a general pediatrician in private practice in San Francisco and Marin since 1978. I have seen many changes take place in the delivery of medical care in my office. I have been very active at UCSF and in the Northern California Chapter of the American Academy of Pediatrics, but to date I have not done much with SFMS. I am willing to serve if elected on the Nominations Committee for the Medical Society in order to represent the

28 San Francisco Medicine october 2006

general practitioner on the Committee.

Mei-Ling E. Fong ALSO CANDIDATE FOR DELEGATION Specialty: Internal Medicine Membership: SFMS/CMA 2000 SFMS: Director 2003–06 SFMS Committee Appointments: Physician Membership Services 2006; Executive 2005; Nominations 2004–05 CMA: Alternate Delegate 2003–06 Related Medical Affiliations: Associate Member, American College of Physicians; Member, California Medical Association; Member, UCSF Association of the Clinical Faculty Medical School: University of Oklahoma 1994 Hospital Affiliation: UCSF, Marin General Hospital, CPMC, St. Mary’s Hospital Teaching Appointments: Assistant Clinical Professor of Medicine, UCSF Policy Statement: As medicine continues to undergo dramatic changes, it is important that efforts be made to preserve accessible, quality health care for patients and to remove obstacles that physicians encounter in the delivery of that care. I feel that the San Francisco Medical Society serves this purpose. By serving as a Board Member for the past three years, I have been able to see how the Medical Society educates physicians about important health care issues and organizes us into a powerful group that can effect change. I seek your support in my reelection as an SFMS Delegate.

www.sfms.org

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sfms election 2007 “For Director.”

FOR SOLO/SMALL GROUP PRACTICE FORUM DELEGATE KEITH E. LORING Specialty: Emergency Medicine Membership: SFMS/CMA 2003 Related Medical Affiliations: Chair, Department of Emergency Medicine, St. Mary’s Medical Center Medical School: Johns Hopkins University School of Medicine 1991 Hospital Affiliations: Active: St. Mary’s; Courtesy: SFGH Teaching Appointments: Assistant Clinical Professor, USCF Policy Statement: It is an honor to be considered for a position on the SFMS Nominations Committee. Wise stewardship of our profession requires our direct, passionate, and constant involvement. If we are to truly flourish, we must maintain a keen awareness of the world outside our practices, our medical groups, and our medical centers. We must be able to stand alone as the strongest advocates for what is right for our patients as well as what is right for us to receive in compensation for our efforts.

My candidacy for this committee marks my first real attempt to put these words into action and become involved in something greater than my own practice of emergency medicine at St. Mary’s and San Francisco General Hospitals. If we are to stem the tide that continues to erode our profession, it is critical that we continue to identify the brightest among us who have the integrity and energy necessary to stretch beyond their day-to-day clinical practices and make our voices heard in the local, state, and national health care dialogue. I would be honored, willing, and able to help in that endeavor if elected to this committee.

ERIC TABAS Specialty: Obstetrics and Gynecology Membership: SFMS/CMA 1987 SFMS: Treasurer 2000; Director 1995–99 SFMS Committee Appointments: Finance Committee 1999–2004 (Chair 2000); SFMS Services, Inc., Board 1997–2001 (Secretary/ Treasurer 1999); Executive 1998–2000; Nominations 1997; Legislative 1988–92 Medical School: Northwestern 1980 Hospital Affiliation: Active: CPMC, Saint Mary’s, Saint Francis; Courtesy: Davies, Mount Zion, UCSF Teaching Appointments: Assistant Clinical Professor of Obstetrics/Gynecology, UCSF Policy Statement: I want to continue to serve San Francisco physicians by becoming the SFMS delegate to CMA’s Solo/SmallGroup Practice Forum. I believe that SFMS is the only organization in San Francisco that is accessible to all San Francisco physicians. It provides us a community beyond our individual situations. The society is the principal voice of medicine for our community, our patients, the world of politics, and the media. Through SFMS, we have the potential to lead and shape medicine and the issues pertinent to our physicians and our patients. In particular, I look forward to representing the ideas and issues of solo and small-group practices in San Francisco to the CMA, as I have been in solo practice for eighteen years.

WILLIAM A. MILLER ALSO CANDIDATE FOR DIRECTOR See biography and policy statement under 30 San Francisco Medicine october 2006

FOR SOLO/SMALL GROUP PRACTICE FORUM ALTERNATE DELEGATE

GARY L. CHAN Specialty: Internal Medicine Membership: SFMS/CMA 1981 SFMS: Director 2002–06; St. Francis Memorial Hospital Medical Staff Liaison SFMS Committee Appointments: Executive 2006; Information Technology 2006; Health Care Foundation of San Francisco Board 2005–06 Related Medical Affiliations: Assistant Medical Director, Brown & Toland 1990–present; Utilization Management Advisor, Blue Shield 1984–99 Medical School: Tufts University 1976 Hospital Affiliation: Active: Saint Francis, CPMC, Saint Mary’s Teaching Appointments: Clinical Associate, UCSF Policy Statement: I have been active on the SFMS Board for the past three years. I am currently on the HealthCare Foundation Board as well. I would be pleased to serve as a delegate from San Francisco to the CMA and to be more involved. Thank you for offering me that opportunity. I have been practicing internal medicine here in San Francisco for the past twenty years and have witnessed vast changes in medicine. I have firsthand knowledge of how the managed care system has evolved and the pressures placed on the system by providers, insurers, employers, and, lastly, consumers. There has been a large disconnect between the goals and wishes of all parties concerned. There needs to be more active education on how the current system works or doesn’t work. Only then can we begin to lay the groundwork to fix it for the benefit of both physicians and patients, who have been mostly afterthoughts. Through our organized voice, physicians can play a www.sfms.org

sfms election 2007 role in changing our current system for the better. SFMS provides a forum for getting our voices heard. There still needs to be more public education on the evolving changes in health care. We all are paying a lot more for less. I hope to represent these concerns in the coming years. Thank you for your vote.

FOR CMA DELEGATION

TAISSA CHERRY (Incumbent Alternate) Specialty: Pain Management Membership: SFMS/CMA 2003 SFMS Committee Appointments: SFMS PAC 2005–06 CMA: Alternate Delegate 2005–06; Resident Delegate 1993–94 Related Medical Affiliations: American Academy of Pain Medicine, International Association for the Study of Pain Medical School: Emory University 1991 Hospital Affiliation: Kaiser Permanente San Francisco Policy Statement: I’ve enjoyed serving as an alternate delegate on the San Francisco Medical Society Delegation to the CMA House for the past two years. It’s been gratifying to see many of the resolutions introduced by the SFMS Delegation go on to become national and state law. I have always been interested in public health policy making and have been involved in various campaigns for legislative bills by means of writing letters, speaking with our California legislators, and serving on the SFMS PAC. I’m very interested in continuing to be part of that process as your delegate.

www.sfms.org

GEORGE A. FOURAS Specialty: Child and Adolescent Psychiatry Membership: SFMS/CMA 1996; AMA 1987–90/1995–present SFMS: Director 2003–06 SFMS Committee Appointments: Executive 2003–06; Psychiatric Services 1996–2006; SFMS PAC 2004–06; Physician Membership Services 2003–06; Fellowship/Wellness 2006 CMA: Alternate Delegate 2000–02; California Psychiatry Association Specialty Delegate to Young Physicians Section CMA 1996–99 Related Medical Affiliations: President, Northern California Regional Organization of Child and Adolescent Psychiatry 2000 (President-Elect 1999); Chair, California Psychiatric Association Child and Adolescent Committee 2000–present; Medical Director, Foster Care Mental Health Program, City and County of San Francisco 1995–present Other: Board-Certified in General Adult Psychiatry 1999 Medical School: Ohio State University 1990 Hospital Affiliation: Courtesy: SFGH Policy Statement: I am honored to be nominated for a position on the CMA Delegation. I have enjoyed representing you at the House of Delegates in the past and on the Board of Directors currently, and I hope to continue to serve our Medical Society. As a physician working in the San Francisco DPH, I am keenly aware of how state policies, especially regarding Medi-Cal, affect our patients, both public and private.

In addition, it is likely that more scope-ofpractice issues will be introduced in the next legislative session. I will work hard to bring these issues to SFMS and to ensure that our views are carried to CMA. It is my firm belief that we must work together, regardless of specialty, to present a united message regarding patient care and our ability to practice medicine.

GORDON L. FUNG (Incumbent Delegate) Specialty: Cardiovascular Diseases Membership: SFMS/CMA 1985 SFMS: President 2006; President-Elect 2005; Director 1999–2000/2002–2004; Secretary 2001 SFMS Committee/Board Appointments: Executive 2000–06; SFMS Finance/Investment 1998–2006; PAC 2005–06; Professional Relations and Ethics 1997–2006; Judicial 2005–06; Services, Inc., Board 1995–2005 (President 1999–2005; Secretary/Treasurer 1996–98); Nominations Committee 2000–01; Editorial Board 1995; Insurance and Managed Care Mediation 1995–96 CMA: SFMS Delegate 2005–06; Specialty Society (Cardiology) Delegate 2002–06; Alternate 2001; Delegate 2001 CMA Committee Appointments: Medical Staff Survey Steering Committee 1998; Medical Staff Survey 1995 Related Medical Affiliations: American College of Cardiology, California Chapter, Vice President and Governor 2006; Chair, Membership Committee 2002–06; Member, National Board of Directors, American Heart Association 1999–2001; President, California Affiliate, American Heart Association 1996–98; Medical Director, ECG Lab, UCSF 2001–present; Director of Cardiac Services, UCSF Medical Center at Mount Zion 2001– present; President, San Francisco Division, American Heart Association 2004–06 Medical School: UCSF School of Medicine 1979 Hospital Affiliation: Active: UCSF, CPMC; Associate: Chinese Hospital and Saint Francis Memorial Hospital Teaching Appointments: Clinical Professor of Medicine, UCSF 2006–present; Associate Clinical Professor of Medicine 1998–2006 Policy Statement: I am honored to be nominated for the SFMS Delegation to the CMA

october 2006 San Francisco Medicine 31

sfms election 2007 House of Delegates. Over the past several years, the challenges of practicing medicine in San Francisco and California have caused many physicians to consider early retirement and leave the field entirely. Regardless of hospital affiliation, mode of practice, or specialty, this organization pulls together the energy and expertise of all physicians to support physicians and quality health care for all San Franciscans. I strongly believe that all physicians need to be a part of this team effort to support each other in an organized manner. Only by volunteering to be part of the solution can we hope to succeed in medicine. I look forward to working with you and for you.

THOMAS H. LEE (Incumbent Alternate) Specialty: Internal Medicine Membership: SFMS/CMA 2002; AMA 1994 SFMS: Director 2006–08; Young Physician Representative to Board 2003–05 SFMS Committee Appointments: Executive 2006; SFMS PAC Board 2003–06 (Vice Chair 2005–06); Information Technology (Chair 2006); Editorial Board 2003–06; Web Page Oversight 2004–05 CMA: Alternate Delegate 2005–06 Medical School: University of Washington 1994 Hospital Affiliation: Active: CPMC, Saint Mary’s Teaching Appointments: UCSF Policy Statement: As a younger physician interested in improving care delivery systems, I believe that SFMS plays an important role in bridging policy with the practice of medicine. Clinical practice can, at times, be isolating, and it is rewarding to share a common passion for improving the care of our patients outside the exam room. I believe that SFMS best serves the

community as a unified voice for patient and physician advocacy. To that end, I would like to continue efforts in membership recruitment and retention, forums for education and discussion, and the development of solutions that support improved regional coordination of care.

E. ANN MYERS (Incumbent Delegate) Specialty: Endocrinology Membership: SFMS/CMA 1989; AMA 1980 SFMS: Consultant 2006; Immediate Past President 2005; President 2004; PresidentElect 2003; Secretary 2002; Director 1998– 2001; Saint Mary’s Medical Staff Liaison 1999–2001 SFMS Committee Appointments: Executive 2002–05 (Consultant 2006); SFMS PAC 2003–06; Judicial 2003–06; Local Health 1995–2006; Physician Membership Services 2003–06 (Chair 2003); Fellowship/Wellness 2006; Finance 2004; Chiefs of Staff 2003–04; Nominations 1999/2001–02/2005 CMA: Delegate 2001–06; Alternate Delegate 1999–2000 Related Medical Affiliations: Board, American Diabetes Association, Golden Gate Chapter 1989, California Affiliate 1996–97 Medical School: Creighton University 1976 Hospital Affiliations: Active: CPMC, Saint Mary’s Policy Statement: We need to continue to serve the public through the education and advocacy programs of SFMS while alerting community leaders and the public to the impending crisis as San Francisco’s medical infrastructure erodes. Physicians must defend our vital tradition, protecting the health of both individual patients and the public. We must unite to demand that payers reimburse hospitals and health professionals so that closures, program cutbacks, and personnel

32 San Francisco Medicine october 2006

and physician shortages stop. I will foster the growing public and political awareness so that physicians, patients, and the public can work together to strengthen our future health. If elected, I will work with you on behalf of our patients and medicine.

JOSHUA H. RASSEN (Incumbent Delegate) Specialty: Internal Medicine Membership: SFMS/CMA 1976; AMA 1987 SFMS: Board Consultant 1996–2006; Immediate Past President 1995; President 1994; President-Elect 1993; Secretary 1992; Director 1987–91 SFMS Committee Appointments: Physician Membership Services 1994–2006 (Chair 1995–96); Judicial 1995–2006; Executive 1989–95 (Consultant 1996–2004); SFMS PAC Board 1995–99 (Chair 1997–99/Consultant 2000–04); Finance/Investment 1998– 2003; Local Health 1995–2000; Insurance and Managed Care Mediation 1996; Nominations (Chair) 1995–96; Professional Relations and Ethics 1985–91 (Chair 1986–91) CMA: Delegate 1993–2006 (Chair 2004–05; Vice Chair 1997–98); Alternate Delegate 1987–92 CMA Committee Appointments: Professional Liability 1998–2005; Medical Staff Survey 1977–95; Council on Judicial Affairs 1994; Judicial Review 1991–92 Related Medical Affiliations: CPMC, Chief of Division of General Internal Medicine 1993–2002; CPMC, Executive Committee 1993–2001; Children’s Hospital Medical Staff Treasurer 1989–92; Executive Committee 1989–92; Bylaws Committee (Chair) 1989–92; Merger Task Force Bylaws Committee (Co-chair) 1991–92; Children’s IPA (President) 1990–92 Medical School: Washington University 1973 www.sfms.org

sfms election 2007 Hospital Affiliations: CPMC, Saint Mary’s Policy Statement: Thank you for the opportunity to serve on the San Francisco Delegation to the CMA House of Delegates for more than fifteen years, including a two-year term as Delegation Chair. The role of CMA in overseeing physician and patient interests at the state level is truly vital to our welfare as physicians. We need to continue to advance the great ideas of the San Francisco Delegation. In addition, we need to support CMA in proactive efforts to shape medical policy, as well as in its vital role in “damage control” from legislative and judicial assaults. I would appreciate the opportunity to continue to actively participate in the CMA Delegation.

SHANNON UDOVIC-CONSTANT ALSO CANDIDATE FOR DIRECTOR See biography and policy statement under “For Board of Directors.”

Delegate 1985–90 CMA Board Committees: Nominations 1997–2003; Medical Services 1997–2002; Finance 1999–2003; Bylaws 2001–03 CMA Committee Appointments: Council on Legislation 1996–97; Speaker’s Advisory 1993–96; Rules 1994–95 (Chair 1995); Solo Practice TAC 1993–94 (Chair); Governance TAC 1994; CALPAC Board of Directors 1995–2001 (Executive Committee 1999–2001) AMA: Delegate 1996–2005 (Vice Chair 2000–04; Chair 2004–08); Alternate Delegate 1994–95; House Select Oversight Committee 2001; Reference Committee C: A-95, I-95, A-01; Cal-C Committee Chair 1995–96; Resolutions Committee 1995–2000 Related Medical Affiliations: Saint Francis Physicians Medical Group/CHW Bay Area Physicians Medical Group 1995–2000 (President/CEO); Saint Francis Memorial Hospital Board of Trustees 1990–96/2000–06 (Secretary 1994–95; Chair 2001–03; Ex-

ecutive Committee 1992–2007); Catholic HealthCare West Bay Area Board of Directors 1996–2001; CHW Strategic Planning Committee 2001–05 Medical School: UCSF 1968 Hospital Affiliation: Active: Saint Francis Policy Statement: My purpose in medical politics is to further the agenda and goals of California physicians. As a delegate to our CMA House, I am able to take part in the debate on those issues that will go for national action. As Chair of the California Delegation to the AMA for the past three years, it is my responsibility to shepherd California resolutions through that process.

Our Delegation has been remarkably successful—a particular honor for me because so many of the resolutions adopted nationally emanated from our own San Francisco Medical Society. I ask for your continued support and particularly for your input on issues important to California physicians.

SFMS TAKES POSITIONS ON TWO STATE BALLOT INITIATIVES

H. HUGH VINCENT (Incumbent Delegate) Specialty: Anesthesiology Membership: SFMS/CMA/AMA 1972 SFMS: Board Consultant 1993–present; Immediate Past President 1993; President 1992; President-Elect 1991; Director 1982–90 SFMS Committee Appointments: Medical Review and Advisory 1975–present; SFMSPAC Board 1991–96 (Chair 1995–96/ Consultant 1997–present); Health Care Foundation of San Francisco Board 1999– 2004; Managed Care 1998–2001; Physician Membership Services/Membership 1986– 89/1994–2001 (Chair 1994–95); Nominations 1994–95/2000–01 (Chair 1994–95); Judicial 1993–99; Anesthesia Section Chair 1975–90 CMA: Trustee 1997–2003; Delegate 1991– 97/2003–06 (Chair 1993–96); Alternate www.sfms.org

The SFMS Board of Directors has adopted the following two positions on ballot initiatives to appear on the California November ballot: Proposition 85: Parental Consent for Abortion OPPOSE The SFMS joins the CMA; the state societies of pediatrics, family practice, obstetrics and gynecology, nurses, and teachers; and many other organizations in opposition to Proposition 85. Such measures have not been shown either to reduce abortions or increase healthy communication among families. However, they have resulted in later-term abortions, and they can put adolescents with dysfunctional families at greater risk. Abortions have been declining substantially for the past decade, and parental consent laws have not been a factor in that positive trend.

Proposition 86: Tobacco Tax SUPPORT The SFMS again joins a long list of medical and health associations and organizations, including the CMA and the Heart, Lung, and Cancer Societies, in supporting the proposed tobacco tax. Although this initiative has provoked some controversy within medicine regarding incidental issues, the SFMS board agrees with the CMA Board of Trustees that the positive health gains in terms of funding, education, and training will far outweigh any negative consequences.

There are a dozen more ballot initiatives to appear on the November ballot. SFMS and CMA have not taken any positions other than those described above.

october 2006 San Francisco Medicine 33

hospital News Chinese

Fred Hom, MD

Drs. Edward Chow and Justin Quock from the Chinese Community Health Care Association (CCHCA) are working with Drs. Tung Nguyen and Elisa Tong from U.C. San Francisco to conduct a National Cancer Institute-funded research study to understand how to increase colorectal cancer screening rates among Chinese Americans. The project involves the Asian American Network for Cancer Awareness and Research Training (AANCART), the Chinese Council, and its Community Networks Program with UCSF. Dr. Chow, executive director of CCHCA, is the Principal Investigator, while Dr. Quock is an active medical oncologist in the community. As part of the physician training, Dr. James Yan, gastroenterologist, spoke on screening for colorectal cancer, and recently surgeons Yanek Chiu and Laurence Yee discussed surgical treatments. For questions, Dr. Chow can be contacted at (415) 397-3190 extension 212.

The medical staff is reminded that Dr. Quock also heads the Chinese Hospital Palliative Care Committee. Hematologist Dr. Harry Lee founded the committee and joins chaplain services, social services, and case management.

The committee can assist physicians not only with end-of-life care, but also with discussions with family regarding clarification of “code status” and pain and palliative chronic disease management. Such issues are often challenging in the Chinese culture, where longevity is so highly valued.

CPMC

Damian Augustyn, MD

California Pacific Regional Rehabilitation Center is proud to sponsor its fifth annual conference for rehabilitation professionals. “Mild Traumatic Brian Injury: Theory, Assessment, and Practice” is a one-day event exploring contemporary theories, controversies, diagnostic models, assessment tools, therapeutic interventions, and community resources in the treatment of individuals with mild traumatic brain injury. This program is designed

for rehabilitation professionals including physical/speech/occupational/recreational therapists, nurses, neuropsychologists, physicians, case managers, and attorneys. Attendees may report up to six hours of Category 1 credit. For more information about this educational opportunity, see the program brochure at www.cpmc.org/services/rehab or contact Catherine Filippone at filippc@sutterhealth.org. California Pacific Medical Center was recently named “Best Hospital in San Francisco” by Jewish News Weekly readers for the second consecutive year.

Seton

Julius Zsigmond, MD

Dr. Lisa Capaldini was voted Best Doctor in the Bay Area by the readers of the San Francisco Bay Guardian: “With more than fifteen years of experience dealing with HIV and other medical issues, Dr. Lisa Capaldini is our readers’ go-to doc for all their health needs.”

“Where experience counts” reflects the unwavering dedication and outstanding work of our physicians, clinicians, and support staff.

As we move forward to expand our treatment of cardiovascular disease, we are excited to provide a new electrophysiology service and a new electrophysiology (EP) laboratory at Seton Medical Center. The EP lab, dedicated to the study of the conduction system of the heart, will be one of a few EP labs in the area equipped for biplane, flat detector imaging. This sophisticated digital technology will allow electrophysiologists to perform very precise diagnostic tests from two different directions simultaneously. They will be able to provide comprehensive diagnostic and treatment options—from medications to ablation therapy—for patients with irregular heartbeats and congestive heart failure. Care can be provided for people with abnormally rapid heartbeats (atrial flutter, atrial fibrillation, ventricular tachycardia, supraventricular tachycardia, ventricular fibrillation), as well as for those with abnormally slow heartbeats (bradycardia). As part of these electrophysiology

services, the program will also offer such state-ofthe-art procedures as intracardiac mapping and echo and cardiac ablations to cure specific forms of abnormal heart rhythms.

An electrophysiology study is a procedure

34 San Francisco Medicine october 2006

that examines the heart’s electrical activity and pathways and is performed for the following reasons: complete electrophysiology testing of the electrical conduction system of the heart; diagnose the source of abnormally slow heart rhythms, bradycardias; diagnose the source of abnormally fast heart rhythms, called tachycardias; provoke and diagnose abnormal heart rhythms, called arrhythmias, that occur infrequently; reveal and pinpoint suspected arrhythmias; evaluate a person’s risk for sudden death.

An electrophysiology study may also be helpful in assessing symptoms of unknown cause, including chest pain, shortness of breath, fatigue, and dizziness or fainting (syncope).

Treatment services include implantation of defibrillators, devices that bring the heart back into normal rhythm using electric shocks; implantation of cardiac resynchronization devices, such as pacemakers, which restore the heart’s normal rhythm with electrical impulses; ablation of diseased heart tissue through a catheter to treat such arrhythmias as ventricular tachycardia, supraventricular tachycardia, and atrial fibrillation.

An electrophysiology study may also be done to assess your response to antiarrhythmic drug therapy, or your need for a pacemaker or implantable cardiac defibrillator (an ICD).

The Electrophysiology, Arrhythmia, and Pacemaker Program team includes board-certified electrophysiologists, certified technicians, and registered nurses.

St. Luke’s

Jerome Franz, MD

While St. Luke’s cannot ignore the delay in our merger with CPMC, we will not stop making progress as we integrate our management. We are seeing increased surgical volume and a rise in patient satisfaction scores and employee morale. Change can be threatening, but it can also lead to new growth.

On the outpatient side, an ambulatory care center is being built about one block from the main campus. It is the vision of CEO Martin Brotman, and its goal is to meet the needs of our community’s underserved, multicultural population and high prevalence of chronic diseases. www.sfms.org

hospital News Brotman used a personal connection to the Skirball Foundation of New York to obtain seed money of $1.5 million, which will be matched in a donor campaign by the St. Luke’s Hospital Foundation.

The Skirball Center will provide affordable health care. It will feature a comprehensive care model with extensive use of nonphysician providers having cultural competence appropriate for our community. Patients’ chronic diseases will be managed with the help of electronic health records. Desiree Arretz, MD, will be the medical director, bringing the knowledge she has gained in her years as the primary internist for the Health Care Center. The Health Care Center will continue to operate as the major source of pediatric, obstretric, and orthopedic care in our community.

St. Mary’s

Kenneth Mills, MD

Philanthropy has long had an intricate and essential relationship with health care.

The hospitals of Catholic Healthcare West, and specifically St. Mary’s Medical Center, exemplify the best of this relationship, benefiting from the business community, grateful patients, physicians, and other friends. The St. Mary’s Medical Center Foundation organizes and directs all the giving for the hospital. Under the capable leadership of Margine Sako, the foundation works through its seventeen-member board of directors. Mr. Doug Dillard is the president of the board, and physician members include Dr. Robert Dietz, Dr. Stanley Yarnell, and myself.

There are currently four areas of priority for the foundation: comprehensive cancer services, McAuley Mental Health Services, acute rehabilitation services, and the charity care endowment. An additional special project this year is building out the vascular suite.

The Annual Spring Gala was held at the new St. Regis Hotel in May. The event honored retiring orthopedic surgeon and director of the orthopedic residency program Dr. Gar Wynne.

The St. Mary’s Auxiliary was also recognized.

The sold-out event raised nearly $200,000 for the hospital. www.sfms.org

Our other annual event occurred just a few weeks ago. The Golf and Tennis Classic is always a favorite for the friends of St. Mary’s; this was its twenty-seventh year. The daylong event is held at the Olympic Club and the weather always seems to cooperate. This event raised $250,000, earmarked for our Sister Mary Philippa Clinic serving the poor.

These events are the visible highlights of our foundation, but much more goes on behind the scenes. Dedicated physicians and grateful patients regularly remember St. Mary’s in their annual giving and in their estate planning. Without all of this, we would not be able to reach out so fully to the communities we serve.

UCSF

Ronald Miller, MD

UCSF has established a Pediatric Brain Tumor Institute devoted to understanding and developing new treatments for childhood brain tumors. The Institute’s research will focus on the biology of pediatric brain tumors, which is not as well understood as that of adult brain tumors, and new therapies have been slow to develop, according to Dr. Mitchel Berger.

Berger, a neurosurgeon at UCSF Medical Center, chair of the Neurological Surgery Department, and Kathleen M. Plant Distinguished Professor, will head the Institute.

Childhood brain tumors are rare, but the mortality rate associated with them has surpassed acute lymphoblastic leukemia, and brain tumors are now the most common cause of cancer deaths among children. While about 60 percent of children with brain tumors survive at least five years, this figure has improved only slightly in the past quarter century.

The institute is funded by a $300,000 grant over three years from the Pediatric Brain Tumor Foundation of the United States, with matching funds from the UCSF Department of Neurological Surgery.

The Institute will focus initially on five main pediatric brain tumor projects, with emphasis on pediatric brainstem glioma and medulloblastoma, led by Berger as principal investigator.

Investigators in the UCSF Neurological Surgery department will collaborate with other institu-

tions, including the Pediatric Brain Tumor Foundation Institute at Duke University.

In 1999, UCSF was chosen to join the Pediatric Brain Tumor Consortium, funded by the National Cancer Institute. The UCSF team is committed to rapidly moving promising research into clinical trials and to creating an environment that focuses on the specific needs of the children and families who suffer from the effects of this devastating disease.

Veterans

Diana Nicoll, MD, PhD, MPA

Senator Dianne Feinstein visited the San Francisco V.A. Medical Center (SFVAMC) and toured the Center for the Imaging of Neurodegenerative Diseases on August 23, 2006. Senator Feinstein is the ranking member of the Senate Appropriations Subcommittee on Military Construction and Veterans Affairs. The Center for the Imaging of Neurodegenerative Diseases is funded by the V.A., NIH, and the Department of Defense, and its mission is the early detection and subsequent monitoring of chronic and neurodegenerative brain diseases. Researchers obtain brain images by scanning with a 4.0 Tesla MRI magnet. Disorders under study include Gulf War illness, posttraumatic stress disorder (PTSD), Alzheimer’s disease, Parkinson’s disease, epilepsy, and HIV dementia.

Senator Feinstein was given an overview of medical center programs and construction projects, and physician specialists briefed her on their clinical and research work in Parkinson’s disease, PTSD, and advanced brain imaging. Patients involved in these research projects described their experiences to her. She also met veteran patients and family members and spoke to a large audience of SFVAMC staff, affirming her commitment to America’s veterans. She commented on the high quality of clinical care and extensive research conducted at SFVAMC and promised to continue to support clinical care, medical research, and capital improvements at the site.

Her visit concluded with the presentation of the Military Order of the Purple Heart to two injured Iraq War veterans from California.

october 2006 San Francisco Medicine 35

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