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Evolving Specialties in Medicine

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In This Issue

SAN FRANCISCO MEDICINE October 2010 Volume 83, Number 10 Evolving Specialties in Medicine FEATURE ARTICLES

10 HIV/AIDS Medicine: Nearing Its Third Decade Stephen E. Follansbee, MD, and Jason Flamm, MD

12 Pain Management: Total Patient Care for the Treatment of Painful Conditions George W. Pasvankas, MD, and Mark A. Schumacher, PhD, MD 14 Physical Medicine and Rehabilitation: Demystifying the Modern-Day Physiatrist Benjamin C. K. Lau, MD

16 Medical Genetics: What Is Medical Genetics and What Do Medical Geneticists Do? Robert L. Nussbaum, MD, FACP, FACMG


4 Membership Matters 5 SFMS Advocacy Update 7 President’s Message Michael Rokeach, MD

9 Editorial Gordon Fung, MD, PhD 32 Hospital News 33 Classified Ads

18 Choosing a Specialty: Factors that Influence a Student’s Choice Mary K. Kelly, MD 2010 SFMS ELECTION INFORMATION 22 Slate of Candidates

22 Candidate Biographies

On page 00 of this issue you will find a poster from the Blood Centers of the Pacific. We created this insert so you could detach it and display it, either on a wall or in a frame, to alert your patients to the importance of donating blood.

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261 e-mail: Web: Advertising information is available by request.

October 2010 San Francisco Medicine 3

Membership Matters October 2010 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 83, Number 10 Guest Editor Gordon Fung Managing Editor Amanda Denz

SFMS Resident & Fellows Job Fair

Copy Editor Mary VanClay

Mark your calendars! The San Francisco Medical Society will be holding its first Resident/Fellow Career Fair at the Millberry Union on the UCSF campus Thursday, November 18. The event will run from 5:00 p.m. until 7:30 p.m. and is free to any resident or fellow who is a member of SFMS, or who joins at the event. Nonmembers will be charged $5 for admission. The event will be an excellent opportunity for physicians looking to practice in the Bay Area to network with representatives from a variety of local practice types and sizes and enjoy free wine and cheese. As part of an effort to make participation accessible to all, the pricing structure for hosting a table at the event will be tiered. Large-group practices (150 or more physicians) will pay $250, medium-group practices (5 to 150 physicians) will pay $100, and solo and small-group practices (1 to 4 physicians) will be able to host a table free of charge. If you have any questions about the event, or would like to inquire about reserving a table, please contact the Membership Department at (415) 561-0850 extension 240, or email We look forward to seeing you there!

Editorial Board Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes Clever

Ricki Pollycove

Gordon Fung

Stephen Walsh

Erica Goode SFMS Officers President Michael Rokeach President-Elect George A. Fouras Secretary Peter J. Curran Treasurer Keith E. Loring Immediate Past President Charles J. Wibbelsman SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Communications Amanda Denz Marketing Specialist and Membership Development Associate Jonathan Kyle Board of Directors Term: Jan 2010-Dec 2012

Roger Eng

Gary L. Chan

Thomas H. Lee

Donald C. Kitt

Richard A. Podolin

Cynthia A. Point

Rodman S. Rogers

Adam Rosenblatt Lily M. Tan

Term: Jan 2008-Dec 2010

Shannon Udovic-

Jennifer H. Do


Shieva Khayam-Bashi

Joseph Woo

William A. Miller Jeffrey Newman

Term: Jan 2009-Dec 2011

Thomas J. Peitz

Jeffrey Beane

Daniel M. Raybin

Andrew F. Calman

Michael H. Siu

Lawrence Cheung CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate

SFMS Announces New Dues Incentive Plan

Peer-to-peer communication remains the single most effective recruitment and retention strategy for any organization, but especially those involving physicians. If you ask a fellow member why he or she joined SFMS and CMA, the answer is most likely to be that a colleague suggested it. Increased membership numbers translate to a more diverse and robust membership, greater resources, and a stronger voice of advocacy for the profession and for patients. Given this, SFMS has developed an incentive program to encourage recruitment of new members that also interfaces with

4 San Francisco Medicine October 2010

the CMA’s “Member Rewards” program. Beginning now, any new member you recruit for the 2011 dues year will discount your 2012 SFMS dues and, depending on the total number of members you recruit, give you the opportunity to receive free or discounted CMA dues as well.

SFMS Dues Incentive Program Details Recruit 1 member - receive $100 off your 2012 SFMS dues. Recruit 2 members - receive $200 off your 2012 SFMS dues Recruit 3 members - receive $300 off your 2012 SFMS dues Recruit 4 members - receive $400 off your 2012 SFMS dues Recruit 5 or more members - receive FREE SFMS dues TPMG physicians: Recruit 4 or more members (TPMG or non-TPMG) - receive two free tickets to the Annual Dinner

CMA “Member Rewards” Dues Incentive Program Details Recruit 3 to 4 members – receive 50 percent off CMA dues Recruit 5 or more members - receive FREE CMA dues There is no CMA incentive component for TPMG physicians. Talking points and other materials, as well as support from the Membership Department, will be made available to assist members in recruitment. Please contact Jonathan Kyle, Assistant Director of Marketing and Membership, with questions at (415) 561-0850, extension 240, or at .

CMA Foundation’s Carol A. Lee, Esq., Receives Hispanic Health Leadership Award

Carol A. Lee, Esq., CMA Foundation’s President and CEO, was named one of the recipients of the 2010 Hispanic Health Leadership Award. The award was presented by the National Hispanic Medical Association (NHMA) during its Resident

Leadership Program Reception held on August 23 at the Sheraton Grand Hotel in Sacramento. Ms. Lee received the award for her active role in improving health care issues for the Hispanic community.

Clinic by the Bay Is Looking for Practicing and Retired Physician Volunteers!

Clinic by the Bay is a new, volunteerpowered, free health clinic for the working uninsured. Based upon the successful Volunteers in Medicine (VIM) model that engages retired health care professionals and community volunteers to provide high-quality health care, we are located in the Excelsior neighborhood of San Francisco. Clinic by the Bay is the 82nd VIM clinic in the country. We have begun providing primary care services on Tuesdays 4:00 to 8:00 p.m. and Thursdays 2:00 to 6:00 p.m. For more information, please contact Dr. Mary Ann Miner, Medical Director, at or visit our website at

SFMS S e m i n a r : “ MBA ” f o r Physicians and Office Managers

Friday, October 29, 2010: This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. The seminar teaches the core business elements of managing a practice—this includes critical information that physicians don’t necessarily receive in medical school training. 9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast). $225 for SFMS/CMA members and their staff ($200 each for additional attendees from same office); $325 for nonmembers Contact Posi Lyon at or (415) 561-0850 extension 260 for more information or to register. Advance registration is required.

SFMS ADVOCACY UPDATE Advocacy for Physicians, Patients, and Our Community On behalf of all SFMS physicians, the San Francisco Medical Society continues its commitment to the following agenda: • Preserving the health care safety net and public health programs in times of severe budget cuts. Fighting cuts in Medi-Cal and other reimbursement programs important to our neediest residents. Serving on the Mayoral Task Force on health care reform and its impact on the local safety net. • Strong support of antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies. With the California Medical Association, submitting an amicus brief opposing lawsuit to overturn the ban. Tightening existing restrictions on smoking in public places. • Developing and sponsoring the San Francisco Health Information Exchange to electronically link health records of institutions and physicians in San Francisco. With the Local Extension Center, assisting physicians in adopting electronic medical records and reaching meaningful use in order to receive federal funding. • Working with Mayoral Task Force to develop and support the Healthy San Francisco program and participating in lawsuit to preserve the program. • Providing physicians for medical consultation for the San Francisco Unified School District. • Participating as a partner in the Hepatitis B Free program in San Francisco and educating physicians and patients on prevention and treatment of hepatitis B.

Other Ongoing SFMS Community Health Activities

ACCESS TO CARE: SFMS leaders have long advocated that every San Franciscan should have access to quality medical care, and our representatives served on the Mayoral Task Force that designed the Healthy San Francisco program. SFMS joined in the lawsuits to preserve that program as well. SFMS members advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s. ANTI-TOBACCO ADVOCACY: SFMS advocates were in leadership roles in the banning of tobacco smoking in San Francisco restaurants, ahead of the rest of the state and nation; we advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and more. SFMS signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies. HIV PREVENTION AND TREATMENT: The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more. SCHOOLS AND TEEN HEALTH: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and worked on improving school nutritional standards; it provides ongoing medical consultation to the SFUSD school health service. In addition, SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent. ENVIRONMENTAL HEALTH: SFMS’s many environmental health efforts include establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures. REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and national leader in advocating for women’s reproductive health and choice, including access to all medically indicated services. PUBLICATIONS: The SFMS’ award-winning journal, San Francisco Medicine, has long been recognized as one of the very best local medical publications; many nationally known authors write for us, including medical leaders both locally and beyond; The journal goes not only to virtually every practicing physician in San Francisco but to local political and other leaders as well. For more information, see or call (415) 561-0850. October 2010 San Francisco Medicine 5

Independent But Not Alone.

James Yoss, M.D. Hill Physicians provider since 1994. Uses Hill inSite and RelayHealth services for ePrescribing, eReferrals and secure online communications with patients.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.

Get more information about Hill Physicians at or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Sacramento area: Doug Robertson, regional director, (916) 286-7048, San Joaquin area: Paula Friend, regional director, (209) 762-5002, Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

President’s Message Michael Rokeach, MD

Evolving Specialties in Medicine


s we come to the end of what can only be described as a true Mark Twain summer in San Francisco, we can take solace in the change of season—whatever that represents in Northern California. Schools are back in session, leaves are starting to turn color, and, lo and behold, it’s election time again. The Medical Society will be choosing next year’s leaders, and the important mid-term congressional and statewide offices elections will be held on November 2. Beginning next year, we will be initiating electronic voting for our own elections at the San Francisco Medical Society, as well we should. Paperless is definitely in and green. But for now, when you receive your ballot in the mail, please fill it out and return it. Your vote counts. The theme for this, our October issue of San Francisco Medicine, is “Evolving Specialties in Medicine.” Our esteemed contributors will touch upon a number of medical specialties that did not even exist as recently as fifteen years ago. This issue is a poignant reminder of my own practice of emergency medicine, which was not a recognized specialty when I entered the profession in 1976. Fresh out of an internal medicine residency, I decided to try my hand at a shift work specialty, and I became what is commonly referred to as an E.R. doc. My initial plan was to practice at Presbyterian Hospital in San Francisco for only a few years then open an office as an internist and primary care physician. Back then, we were collectively known as “moonlighters,” a term that now seems somewhat pejorative. For reasons that are still unclear, I was smitten by the variety of patients who paraded through the emergency department, as well as the lifestyle this type of practice allowed. Working twenty-four hours straight didn’t faze me, and the long stretches of time off were intoxicating. At the start of my career, I was board eligible in internal medicine, but there were no boards in emergency medicine. It wasn’t even recognized as a specialty until 1978. There were no residency training programs at the time, until the University of Cincinnati started the first emergency medicine residency program in 1971. So I took my internal medicine boards in 1977 and continued working at Presbyterian Hospital and then Mt. Zion Hospital, the first two hospitals in San Francisco to contract with a physician group to provide twenty-four-hour coverage of their emergency rooms. I was deemed eligible to

sit for emergency medicine boards once I accumulated 7,000 hours in the emergency department, and I took the written board exam in 1985 and the oral exam in 1986. This was known as the “practice track,” which was eventually eliminated, and I was grandfathered in to the specialty. Today there are around 120 emergency medicine residencies in the U.S. and it’s one of the more highly sought-after post-medical school specialty training programs. In this issue you will read about the newer medical specialties, such as pain management, physical medicine and rehabilitation, hospitalist medicine, genetics and stem cell, and HIV medicine. The inpatient or hospitalists specialty has spread over the country like a tsunami, and it started right here in San Francisco. It has changed the face of medicine forever. Most primary care doctors no longer admit and care for their own patients when hospitalization is required. The original impetus for creating this group of specialists was several-fold: to reduce hospital lengths of stay by applying more uniform care to inpatients and to provide 24/7 coverage for hospitalized and often very ill patients. It has, I believe, met and exceeded those expectations. Inpatient medicine has established a standard for most if not all U.S. hospitals and has unquestionably improved the care our patients receive. And finally, we hear from one of our medical students on how and why new doctors choose a particular specialty. I would think the decision is more difficult than ever, given the greater array of choices. Having said that, I would still do exactly what I did thirty-five years ago and become an emergency medicine specialist. I hope and believe the thousands of patients whose lives I was fortunate enough to touch would agree with my decision. Enjoy our October issue of San Francisco Medicine, and, as always, your comments and suggestions are appreciated.

October 2010 San Francisco Medicine 7

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The Development of Specialties


istorically, the development of medical specialties began with the establishment of specialty institutes as the centers of excellence of that field. The first documented specialty center was an orthopedic institute in 1780, dedicated to the treatment of children’s skeletal deformities. The first physician specialty organization was the American Academy of Ophthalmology and Otolaryngology, established in 1896. In the early 1900s, specialism in medicine was regarded as a means of promoting public trust through a system of certification inside the framework of national specialty medicine organizations. Until the development of this “specialty board movement,” each physician had been the sole assessor of his/ her own qualifications to practice a given specialty. The concept of a specialty board for the purpose of establishing qualifications for specialists was first proposed in 1908 by Derrick T. Vail Sr., MD, in his presidential address to the American Academy of Ophthalmology and Otolaryngology. In 1932, a Committee on Specialists of the National Board of Medical Examiners established guidelines to define who would be competent to practice in a given specialty. The committee set up a system that encouraged one national qualifying board per specialty, organized by representatives from various societies in that specialty. It also kept each national specialty qualifying board separate from all others, while encouraging these boards to disseminate professional information about their members. The goal of specialty examining boards was to maintain the standards of specialty practice. There are currently twenty-four approved member boards of the American Board of Medical Specialties (originally the Advisory Board of Medical Specialties), with four founding members in dermatology (1932), obstetrics and gynecology (1930), ophthalmology (1930), otolaryngology (1924), and the newest board, medical genetics (1991). In 1948, the Liaison Committee for Specialty Boards established the criteria for the approval of new examining boards: The differentiation of a new specialty must be based on major new concepts in medical science and represent a distinct and well-defined field of medical practice; a single standard of preparation for and evaluation of expertise in each specialty must be recognized by only one medical specialty board for each specialty; the training needed to meet certification requirements by the applicant must be distinct from that required for certification by approved ABMS member boards so that it is not included in established training programs leading to certification by approved ABMS boards; a medical specialty board

must demonstrate that candidates for certification will acquire, and it diplomats will maintain, capability in a defined area of medicine and demonstrate special knowledge and competencies in that field; evidence must be presented that the new board will establish defined standards for training and that there is a system for evaluation of educational program quality; the applicant medical specialty board must demonstrate support from the relevant field of medical practice and broad professional support. After World War II, there was an explosion of new medical knowledge and technologies, resulting in increasing numbers of specialties and specialists and, hence, a decline in the number of physicians choosing careers in general practice. The trend toward excessive specialization was of particular concern, leading ABMS to establish the Committee on Certification, Subcertification, and Recertification (COCERT) to avoid the fragmentation of the primary specialty and to use the terms “Added Qualifications” or “Special Qualifications.” As of today, the member boards can certify in more than 145 specialties and subspecialties. After the establishment of certifying boards and the Advisory Board for Medical Specialties, the physician leaders of these organizations, appreciating their public accountability in issuing specialty certifications, considered best methods for ensuring the continued competence of a board-certified practitioner. The first recorded discussions of recertification began in 1935 and evolved into the Maintenance of Certification program to evaluate all the facets of practice believed to be necessary and sufficient for certified physicians to have and maintain throughout a professional career, with eventual focus on education and assessment to encourage continuous quality improvement. This is known as the “competency movement.” Today, about 65 percent of the American physician workforce is primarily made of specialists, subspecialists, and super-subspecialists, compared to 35 percent primary care physicians. The primary care provider not only has to keep up to date with the management of primary care issues but also to keep abreast of the explosion of medical knowledge and new specialties and subspecialties to adequately triage and appropriately refer patients and their families who need specialty or subspecialty management. This issue of San Francisco Medicine highlights a few of the newest specialties, with guidelines on when and how to refer to them for their special expertise. October 2010 San Francisco Medicine 9

Evolving Specialties in Medicine

HIV/AIDS Medicine Nearing Its Third Decade

Stephen E. Follansbee, MD, and Jason Flamm, MD


e are nearly approaching the completion of the third decade of HIV/AIDS medicine. Arguably, no other area of medicine has developed so rapidly and been associated with such dramatically increasing complexity and pandemic implications as HIV/ AIDS. The field of HIV/AIDS has moved the science and practice of virology and immunology at a lightening pace. It has had a profound impact on the processes of drug development, drug and device testing, research accountability, and medication licensing and pricing. HIV/AIDS has helped focus the local, national, and global issues of universal access to health care as well as human rights, particularly women’s rights, onto the agenda for health care delivery. In 2010, who could argue that HIV/AIDS is not an important and emerging specialty within medicine and health care, not only in the United States but also worldwide?

A Little History

On June 5, 1981, the Centers for Disease Control first reported in Morbidity and Mortality Weekly Report a number of cases of Kaposi’s sarcoma and pneumocystis pneumonia in homosexual men in New York City and Los Angeles. In early 1983, Luc Montagnier and colleagues in Paris, followed quickly by Robert Gallo and colleagues at the National Institutes of Health, reported the association of an apparently novel retrovirus with the newly recognized syndrome of generalized lymphadenopathy and severe immunodeficiency. This virus was eventually named HIV-1. In 1985, in vitro testing showed that the drug zidovudine had anti-HIV activity. Zidovudine had previously been shelved

as an ineffective anti-cancer drug. Phase I/II clinical trials were rapidly completed. Within twenty-two months, on March 19, 1985, zidovudine was licensed in the United States as the first treatment for AIDS. In 1996, Drs. Kitahara and Koepsell published in the New England Journal of Medicine evidence that physician experience in treating HIV/AIDS improved survival in adults. Evidence has continued to emerge that provider experience in treating HIV/AIDS improves outcomes, not only in developed countries but also in resource-limited communities. On December 1, 1998, the first World AIDS Day was organized under the leadership of the World Health Organization. This was intended to recognize the pandemic nature of this disease and the necessity of unifying the many practitioners and workers in the field and to establish a universal agenda. In 2000, two professional organizations were founded to further the recognition that HIV medicine had evolved into a specialty field of its own. AAHIVM (the American Academy of HIV Medicine) provides not only education and credentialing for health care professionals in HIV care but also advocacy for persons with HIV and health care professionals alike. HIVMA (HIV Medicine Association) is affiliated with the Infectious Diseases Society of America (IDSA) and also provides a forum for education, research, and scientific publication of developments in the field, through the publications of IDSA. In 2010, there are six classes of HIV medications licensed in the United States. There are complex tests looking at viral resistance to these medications. There is a marked increase in information on HIV-

11 San Francisco Medicine October 2010 10 San Francisco Medicine october 2010

related drug-drug interactions, pharmocodynamic considerations, pharmacogenetic risks for individual differences in drug metabolism and risk for hypersensitivity reaction, and toxicity issues. Survival in the U.S. and other developed countries has improved remarkably. Actuarial tables suggest that a person in his or her early thirties diagnosed in 2008–2009 with HIV can expect more than thirty years of additional life. Recognizing this, many states, including California, now have legislation mandating that health plans provide unimpeded access to expert HIV care for all their enrollees. Is there a continued need for HIV specialty care? The answer is clearly yes. Does that mean that some physicians do not need to know HIV medicine? The answer is clearly no. Although many of our colleagues in other specialties have seen the practice of HIV care evolve during their careers, there is no doubt that our patients with HIV/AIDS still have many comorbidities and complications of HIV that span over each and every specialty. A few examples may suffice. Though there is only the rare case of CMV retinitis seen today, cases of optic neuritis and posterior uveitis due to syphilis or anterior uveitis due to rising CD4 counts rise still require prompt attention by an ophthalmologist. Orthopedic surgeons may see fewer cases of avascular necrosis of the hip, but they are seeing more osteoporosis and fractures as a result of aging and possibly HIV therapies. Neurologists today see fewer cases of HIV-associated progressive multifocal leukoencephalopathy, but they still are called upon to evaluate the variety of neuropathies and cognitive decline we too often witness. The plastic surgeons are

dealing with HIV-associated facial lipoatrophy and fat accumulation with injectable therapies or liposuction techniques. We expect and continue to need the expertise of all our specialty colleagues to help us provide ongoing comprehensive HIV/AIDS care. There are no exceptions. Is there one HIV specialty? Of course there is not. We practice in urban and suburban environments in relatively rich resource settings. However, some of our HIV specialty colleagues practice in very rural settings. HIV is no longer just an urban disease, limited to the few cities that first witnessed the disease’s emergence in the early 1980s. Likewise, the literature is expanding on the care of HIV patients in resource-poor countries throughout the world, evaluating the need and extent for the routine laboratory monitoring that we have grown accustomed to in the United States. In a world where a number of agencies and programs, including PEPFAR (the President’s Emergency Plan for AIDS Relief), the Gates Foundation, and the William F. Clinton Foundation, to name a few, have increased access to HIV medications for millions of infected children and adults around the world, the choice of medications remains limited and the practitioners managing these therapies need specialized training to assure appropriate care. HIV prevention is another specialized field that needs to coordinate and implement ongoing research, outreach, education and drug and device development, as well as potential new vaccines in order to reduce the estimated 2.3 million new annual infections around the world. So how does any physician practice HIV medicine? With or without additional certification, practitioners are faced with an ever-evolving knowledge base and changing treatment options. As in other fields, practitioners treating HIV/AIDS are also increasingly addressing information and sometimes misinformation that their patients have gathered from a multitude of sources. Of the 100,000 general internists in the U.S., it is estimated that 95 percent do not practice HIV medicine at all. It is known that about 4,000 U.S. physicians write prescriptions for antiretroviral agents. The number of HIV-specialized

practitioners in San Francisco, the Bay Area, and throughout California remains relatively small. We educate each other and stay abreast of current knowledge and practice through discussions, communitybased provider organizations (in San Francisco it is the Bay Area Consortium of HIV providers), several annual meetings such as CROI (Conference on Retroviruses and Opportunistic Infections), and the professional organizations mentioned earlier. In addition, we have access to information in journals and online resources that are free of commercial bias. Examples include,,, and www.hivinsite.ucsf. edu, to name a few. The nearly thirty years of HIV medicine have provided us with many challenges but also great excitement and hope. We doubt that the next thirty years will be any less challenging or complex. We expect that the specialty of HIV medicine will continue to grow from its adolescence to a more mature and well-recognized specialty worldwide. For all of us it has been a privilege to contribute to and witness the marked changes in HIV medicine. We are thrilled by the unity that providers of HIV care feel worldwide as we move to eradicate this disease. At the same time, we are saddened by each loss of a patient to HIV/ AIDS. We are frustrated by the barriers to access, compassion, and knowledgeable HIV/AIDS care that sometimes still exist both locally and internationally. We remain optimistic. We urge all of us to “be there for the cure.” Dr. Stephen E. Follansbee is the Director of HIV Services, Director of Travel Medicine, and Associate Director of the Clinical Trials Unit at Kaiser Permanente Medical Center, San Francisco. He is also a professor of clinical medicine at UCSF and a past-president of the SFMS. Dr. Jason A Flamm is the Director of HIV Clinical Care and Research at Kaiser Permanente Medical Center, Sacramento, and Chair of the Northern California Kaiser Permanente Regional HIV P&T Committee. He is also an assistant professor of clinical medicine at the UC Davis. He is a founding member of the AAHIVM and remains active in the California/Hawaii chapter.

Welcome New Members! The SFMS would like to welcome the following new members: From the Permanente Medical Group • Jerry Arellano, MD Cardiac Electrophysiology Referred by Maria Ansari, MD • Rima Ash, MD Neurology • Holly Deng, MD Internal Medicine • Yael Moss, DO Internal Medicine • Marc Rothman, MD Internal Medicine • Danny Wu, MD Obstetrics & Gynecology • Brita Zaia, MD Emergency Medicine From CPMC • Jason Dimsdale, MD Obstetrics & Gynecology Referred by Jane Fang, MD • Ziv Peled, MD Plastic Surgery • Manish Varma, MD Internal Medicine Referred by Peter Curran, MD From St. Mary’s • Victor Chin, MD Ophthalmology

From VAMC • James Brown, MD Internal Medicine

From SFGH • Robert McClellan, MD Orthopedic Trauma

HOUSE OFFICERS - UCSF Naomi Anker Amaya Basta Nancy Benedetti Steve Braunstein Anand Patel

October 2010 San Francisco Medicine 11

Evolving Specialties in Medicine

Pain Management Total Patient Care for the Treatment of Painful Conditions

George W. Pasvankas, MD, and Mark A. Schumacher, PhD, MD


he battle against pain and suffering is as old as humankind itself—taking center stage in everything from ancient cave paintings depicting childbirth to the millennia of religious and philosophical thought. Throughout the long and rich history of medicine, there have been many practitioners of the healing arts who have contributed to the amelioration of pain. Yet somehow, the development of a discipline in modern medicine solely devoted to the scientific advancement of the understanding of pain and the diagnosis and treatment of painful conditions has taken form only within the past few decades. The idea to provide “total” patient care for the treatment of complex painful conditions through multidisciplinary, multimodal pain management was championed by Dr. John Bonica, a World War II-era anesthesiologist who proposed the concept out of his experience caring for injured soldiers. The extensive training and experience with analgesic pharmacology and regional-neuraxial anesthesia made for a natural extension from the broader practice of anesthesiology to an exquisite focus on pain management. Although the backgrounds of individual pain practitioners may vary greatly, their common ultimate goal is to establish a pain-relief strategy that is diagnosis driven and multimodal in practice, maximizing the number of therapeutic options for the patient. Sometimes, despite the best efforts of all involved, patients may suffer from challenging pain states of unclear or multifactorial etiology, defying focal and/or diagnosis-driven care. Nevertheless, the growing practice of pain medicine provides patients with a

complementary repertoire of therapies aimed to reduce pain and suffering while improving quality of life and function. Such strategies attempt to balance the need to provide compassionate care to seemingly hopeless clinical situations with the limitations of rational, scientifically verified interventions. Not surprisingly, referring physicians may stare aimlessly at the growing list of services provided by an individual practitioner or “pain clinic” and wonder when, how, and where to best refer when “conservative” pain management is inadequate or has failed outright. Some conditions may be temporally limited and prove to be amenable to a focused pain consultation and/ or interventional approach (for example, an inpatient admission for multiple rib fractures resulting in respiratory failure). For other painful conditions, the discipline of pain medicine seeks to provide a broader multidisciplinary approach to recognize and treat acute conditions suspected to be progressing toward chronic conditions, or chronic complex pain conditions that have been refractory to previous strategies. To effectively manage painful conditions, pain practitioners must consider both the focus of the referral and the broader clinical and psychosocial situation, when appropriate. Consider on the one hand a previously healthy patient referred for acute onset of lower back pain with or without radiculopathy that has persisted for longer than three months. In contrast, another patient may present with lower back pain in the setting of metastatic cancer with involvement of the lower pelvis/sacrum for three years, having noted escalation of pain and home

12 San Francisco Medicine october 2010

opioid analgesics. In each case, the pain practitioner must provide a focused set of diagnostic tools from history, physical exam, and, when indicated, imaging and functional studies. Although many referrals like those above arise from outpatient clinical encounters, many others arise from within the inpatient setting. In the latter case, pain specialist consultations are often triggered by either insufficient analgesia or intolerable side effects despite high-dose opioid analgesics. The goal in such scenarios will often be guidance on proper opioid analgesic management and the possible use of adjunctive medications known to limit opioid dose escalation and improve analgesia. However, a more difficult task for the pain consultant in some scenarios is to help broach the difficult subject of when to reconsider the propriety of continued aggressive opioid titration. Given recent evidence that escalating doses of opioid analgesics may at times actually drive pain, hyperalgesia, and side effects without improvement of the patient’s symptoms, the pain specialist may consider opioid rotation as part of a revised analgesic strategy. Therefore, pain medicine consultations can provide a reassessment of alternate therapies under conditions of either acute pain, acute chronic pain, or chronic nonmalignant pain linked to comorbid conditions. In addition, in the inpatient and outpatient setting, they often serve as an invaluable part of the team that provides end-of-life care. Under these settings, pain management physicians commonly manage the following painful conditions: Neck and back pain: Outcome studies have supported the use of

guided epidural steroid injections to serve as a “conservative” measure prior to spinal surgery. However, pain consultations are of value first and foremost to ensure that the proper diagnosis has been made and the treatment plan is supported by evidence-based medicine. Within this context, neck and/or back pain with radiculopathy is evaluated and treated. Cancer pain: Half of all patients receiving treatment for solid tumors experience chronic pain, as do the majority of cancer patients with advanced disease. Following revision of the National Comprehensive Cancer Network in 2005, pain-relief strategies should be more diagnosis driven and multimodal, encouraging all patients to be screened for pain. In this case, the physician works with the patient to achieve his or her personal goals for pain relief, which may result in the removal of rigid estimates of life expectancy in regard to interventional therapies. Moreover, optimization of pain-management pharmacology, including the use of adjuvant medications (COX-2 inhibitors, TCA, SNRIs, sustainedrelease opioid analgesics) versus judicious use of neurologic blocks, can help limit the dosing requirements and side effects of these medications. Neurogenic-neuropathic (nerve) pain: These include painful diabetic peripheral neuropathy, HIV/HAARTassociated neuropathy, chemotherapy/ radiation therapy-induced neuropathies, post-herpetic neuralgia, complex regional pain syndromes with or without sympathetic components, nerve root compression, spinal cord compression, peripheral nerve injury/inflammation, phantom-limb pain, infection, neoplasms, and post-stroke central pain. Nonmalignant pain conditions: These include soft tissue pain, fibromyalgia, myofascial pain, cervical strain, musculoskeletal/rheumatologic pain, postinjury or surgical pain, post-avulsion, as well as chronic inflammatory conditions such as inflammatory bowel, pancreatitis, and pelvic pain. Management of these conditions often encompasses a number of responsibilities. The pain medicine physician

often provides oversight to the broader pain management plan, helping to ensure that all appropriate avenues of care are pursued and that appropriate disciplines are involved. Further, depending on the practitioner, setting, and patient, the pain medicine physician is often primarily responsible for the pharmacologic and interventional management of these disorders. Depending on the situation, pharmacologic management may make use of such modalities as topical/local therapies, neuropathic pain medications (including antidepressants and anticonvulsants), nonopioid and opioid analgesics, and muscle relaxants. Pain management may also include (when appropriate) such interventional treatment options as: • Image-guided injections for the cervical and lumbar spine (including epidural steroid injections, transforaminal injections/selective nerve root blocks, facet injections or facet/medial branch blocks, sacroiliac joint injections, etc.) • Radiofrequency ablation/denervation/rhizotomy • Intradiscal procedures, including provocative discography, functional anesthetic discography, and intradiscal therapeutic procedures (intradiscal electrothermal therapy, percutaneous discectomy/nucleoplasty/disc decompression, etc.) • Somatic/peripheral nerve blocks (such as occipital nerve blocks, lateral femoral cutaneous nerve blocks, etc.) • Visceral nerve blocks, including neurolysis (such as celiac/splanchnic, hypogastric, etc.) • Sympathetic blockade (including stellate ganglion block, lumbar sympathetic block) • Trial and implantation of neuromodulation devices such as spinal cord simulators and spinal drug delivery systems • Trigger point injections • Injections of a peripheral joint or bursa Over time, many other specialties have become involved in the academic and clinical missions of pain medicine. Today, the American Board of Medical

Specialties designates pain medicine as a recognized subspecialty not only of the American Board of Anesthesiology but also of the American Board of Physical Medicine and Rehabilitation and of the American Board of Psychiatry and Neurology. While the individual disciplines have historically had particular skill sets and/or foci of interest within pain medicine, the specialty continues to grow more interdisciplinary in its training and practice. As a result, progressive blurring of traditional lines of care has led to improved coordination between physician and nonphysician care providers such as psychologists, acupuncturists, and physical therapists. Taken together, these developments have brought us closer to Dr. Bonica’s vision of providing “total” care to our patients suffering from a wide range of painful conditions. Dr. George W. Pasvankas is an Assistant Clinical Professor in the Department of Anesthesiology, and the Interim Medical Director at the UCSF Pain Management Center. Dr. Mark A. Schumacher is an Associate Professor at UCSF School of Medicine Department of Anesthesia and Perioperative Care.

October 2010 San Francisco Medicine 13

Evolving Specialties in Medicine

Physical Medicine and Rehabilitation Demistifying the Modern-Day Physiatrist

Benjamin C. K. Lau, MD


hysiatry tends to be one of those specialties that many patients are unfamiliar with, and even some physicians aren’t sure what to make of it. So I’d like to remove the mystery hovering over my chosen specialty and give you some insight into the workings of a modern-day physiatrist.

A Little History

The role of the physiatrist has changed significantly over the years. The first Department of Physical Medicine was founded in 1936 at the Mayo Clinic by Frank Krusen, MD. He himself had developed tuberculosis; inspired by his road to recovery, he initiated a program in physical therapy at Temple University and subsequently moved on to the Mayo Clinic. Two years later, Dr. Krusen coined the term physiatrist and worked alongside several other physicians to establish a specialty that is now known as Physical Medicine and Rehabilitation, or PM&R. A traditional PM&R residency involves general, neurological, pediatric, spinal cord, electrodiagnostic, and brain injury rehabilitation training modules. By the time I did my residency at U.C. Irvine in the 1990s, the program also encompassed musculoskeletal medicine, pain medicine, and outpatient training. Furthermore, current PM&R programs also include training in musculoskeletal ultrasonography for diagnostic and therapeutic purposes.

Inpatient Physiatry

In my own practice, I have covered both the inpatient and outpatient sides of my specialty. On the inpatient side, I have practiced at St. Francis Memorial Hospital

as a private attending for nearly a decade and served as the medical director of the Acute Rehabilitation Unit. During those years, particularly as a director, I witnessed significant changes in the practice of inpatient rehabilitation. Most notable of these changes is the development of more subspecialty certifications that include traumatic brain injury, spinal cord injury, pediatric rehabilitation, neuro-rehabilitation, pain medicine, and, of course, electrodiagnostic medicine. Regardless of the subspecialty program, the practice environment witnessed significant changes, which surpassed the traditional demand on a physiatrist. In the past, a physiatrist’s responsibilities would include physical therapy protocol, occupational therapy, speech therapy, recreational therapy, and general medical issues. Such duties would be on par with what you’d expect from the types of patients deemed ready for rehabilitative services. But nowadays, most of the patients admitted to the Acute Rehabilitation Unit suffer from severe medical complications, and they are much sicker and more debilitated than previous PM&R patients. This is true even after a consult in which we have determined that the patient is able to participate in three hours of an intensive inpatient rehabilitative program. We admit some rather sick patients to the floor. For example, a typical new admission could be a hemorrhagic stroke patient who has Parkinson’s disease, a post-fibrillator implant, and is on Coumadin. Another example would be a heart and lung transplant patient who is post stroke with hip fracture, on multiple medications, with no family member tak-

15 San Francisco Medicine October 2010 14 San Francisco Medicine october 2010

ing care of him. “What’s the reason for this?” you may ask. According to Medicare regulations, a patient must be sick enough to demand daily physician rounding and skilled nursing care to be admitted to a rehab service. So the situation is somewhat of an oxymoron, in that a patient should be strong enough to withstand the rigors of an effective rehab program yet still sick enough to qualify being seen by doctors and a staff in a hospital on a daily basis. As a result, a physiatrist has to strike a balance among many aspects of the patient’s care. First, the physiatrist has to treat multiple medical conditions, prescribing therapy and arranging for hospital discharge and follow-up for the patients. Second, these cannot be accomplished without assistance from hospitalists, internists, and many other specialists available in the hospital to give us medical support. Hence a physiatrist’s role also includes team management and coordination of higher medical care needs among specialists and even between hospitals and/or primary care physicians. It’s a tough balancing act that can be risky at times, as Medicare may do retrospective chart review at any time and determine that the patient did not meet their criteria to receive inpatient rehabilitation. Fortunately, PM&R units have an entire staff of rehab nurses, therapists, social workers, and doctors to assist in meeting the needs of rehab patients. The unit may include RNs (specially trained in PM&R), occupational therapists, physical therapists, speech pathologists, recreational therapists, a well-trained social worker, clinical psychologists, a program outreach manager and program director (administrative), and a medical director

who is a physiatrist. The staffs are well versed on the insurance environment and, in particular, Medicare requirements and regulations. These considerations will be given to each and every single admission and discharge. For patients who are unable to meet the minimum requirements to be admitted, we will recommend alternative placement. This may include a skilled nursing facility, board and care, family supportive care-at-home, in-home supportive service, a hospice program, or, in certain situations, a very short stay in the rehab program for some family training and then discharge to home. And like the rest of the medical community, PM&R has been hit by insurance cuts, challenging Medicare/Medicaid changes, and the Obama Health Care Reform bill; all have made acute rehabilitation admission, discharge, and overall care more challenging. This has forced us to turn away patients who are in need of services due to insurance restrictions. Because only three inpatient acute rehabilitation programs exist in San Francisco, there are very few physiatrists in inpatient services. The rest of my colleagues are in outpatient practices, skilled nursing programs, or long-term acute care programs (LTACs). LTACs are special rehabilitation units where they would admit patients with such conditions as severe traumatic brain injury, neuromeningitis (with severe cognitive changes), comatose patients, and severely medically incapacitated patients who need long-term rehabilitation care. A typical example will be a paraplegic patient with spinal osteomyelitis and deconditioning requiring long-term intravenous antibiotic treatment and therapeutic exercises. Unfortunately, those are the very sick patients who would need acute medical management and assistance, but, by law, LTACs cannot exist within an acute care hospital.

Outpatient Physiatry

The flip side of my practice involves outpatient rehabilitation and pain management. The scope of conditions treated in this specialty includes any

functional problem caused by a muscle, nerve, or neurological ailment. These include everything from back and joint pain to spinal cord injuries, post-stroke treatment, and spasticity management. Physiatrists are also well versed in pain medications, their usage, FDA regulations, and protocols, and they order regular toxicity screenings. As a result, they receive many referrals from primary care for management of patients’ drugs. Common treatments in a physiatrist’s office may include but are not limited to modalities therapy (by PT or PTA), medications, injections with cortisone or hyaluronic acid for knees, nerve root blocks, Botox injections for pain, and acupuncture. In addition, diagnostic nerve conduction studies and electromyography tests may be offered in some offices. In many cases, the main goal of an outpatient PM&R musculoskeletal practice is to help the patient avoid surgery. Rehabilitation physicians often have broad practices, but some concentrate on one area. For example, pediatric physiatrists have their own niche and are usually found in institutions or teaching hospitals, for the simple fact that they are generally reimbursed by state-run insurance. Other physiatrists may practice in a large spine group or pain clinic and focus their practice on spine disorders, myofascial pain, fibromyalgia, and joint pain. Some may choose to focus on geriatric rehabilitation, chronic pain management, sports medicine or brain injury, just to name a few. There are fewer solo practices around, but they still do exist, and I am one of them. In regard to practice load, a physiatrist’s outpatient may consist of approximately 50 to 60 percent industrialinjury patients, with the remaining spread among Medicare and Medicaid, private insurance, and HMOs, depending on the individual practice. Because worker’s compensation is a large part of many outpatient physiatrists, we do a significant amount of medical-legal work, which often involves attorneys. This includes performing qualified medical evaluations, agreed medical evaluations, and independent medical evaluations, or assuming the role

of primary treating doctor for the injured workers. These services entail specialty consultations, answering specific questions pertaining to individual cases, and resolving disputes between injured workers and insurance companies, as well as providing services in depositions and occasionally in court.

Physiatry and Its Far-Reaching Scope In summary, physical medicine and rehabilitation is a useful specialty, particularly in light of the fact that we have a large group of aging baby boomers. Physiatrists treat nerve, bone, and muscle problems that impair movement and function. Our goal is to decrease pain and enhance function or ease of care by a caretaker. I have seen the “physical therapy physician” evolve from general rehabilitation to multiple subspecialty training with both inpatient and outpatient practice preference. To be sure, PM&R is an integral part of the current health care environment. And no matter how the Medicare environment requirements change, physiatry will continue to have a definitive role in our society. Benjamin C. K. Lau, MD, graduated from Albert Einstein College of Medicine and finished a surgery internship at Montefiore Medical Center in New York. Thereafter, he finished his PM&R residency at U.C. Irvine. He is currently a solo private practitioner in San Francisco. He practices outpatient rehab and emphasizes in chronic pain management, acupuncture, general rehab issues, disability, and workers’ compensation cases. He is also a QME and does IME and AME. He is on hiatus from his inpatient practice right now.

October 2010 San Francisco Medicine 15

Evolving Specialties in Medicine

Medical Genetics What Is Medical Genetics and What Do Medical Geneticists Do?

Robert L. Nussbaum, MD, FACP, FACMG


edical genetics is the field of medicine dedicated to the diagnosis, prevention, management, and therapy of hereditary diseases. For many years, most medical geneticists were physicians who first went through internal medicine, pediatrics, ob/gyn, or other residencies and then undertook informal fellowships where they received additional subspecialty training in hereditary diseases. In 1982, medical genetics as a subspecialty was formalized for the first time by examinations given by the newly formed American Board of Medical Genetics (ABMG). Nine years later, medical genetics was invited to become a freestanding medical specialty in its own right by the American Board of Medical Specialties (ABMS) and the Council on Medical Education of the American Medical Association. As a result, training programs in medical genetics were reconstituted as residencies that are evaluated and accredited by a residency review committee of the Accreditation Council for Graduate Medical Education (ACGME). Although medical students may apply through the National Resident Matching Program directly to medical genetics residencies, most medical geneticists still do a medical genetics residency after a residency in medicine, pediatrics, ob/gyn, or family medicine. As a result, the great majority of medical geneticists are double boarded in internal medicine/medical genetics, pediatrics/medical genetics, or maternal fetal medicine/medical genetics. Generalists and specialist physicians all have patients with heritable disorders in their practices. Indeed, medical geneticists cannot possibly provide all the care required by every patient with a heritable disease since they cannot possibly have

all the specialized knowledge and skills required to provide all necessary medical or surgical management for all the manifestations of every genetic disease. They do, however, bring a particular set of skills and a fund of knowledge concerning the entire spectrum of manifestations of hereditary diseases in patients and their families that typically go beyond that of most physicians. What, then, is the particular, distinctive role of the medical geneticist? First, it should be stressed that medical geneticists consider not just the patient but the patient’s relatives as well. With this in mind, a medical geneticist must (1) carry out a careful assessment of the pattern of disease occurrence in a family to identify modes of inheritance; (2) obtain a detailed history and perform a specialized physical examination to uncover even subtle symptoms and physical anomalies; (3) have excellent communication skills to convey complex information about rare disorders to patients, their families, and their professional colleagues; (4) know the pleiotropic manifestations of genetic disease so he/she can arrange and coordinate comprehensive ongoing surveillance for what are often cryptic or age-dependent signs and symptoms; (5) make sophisticated choices of which genetic tests to obtain and know how to interpret them; (6) have authoritative knowledge of highly specialized and complex treatment regimens; and (7) make sure that relatives at risk receive counseling and care. We will examine, in more detail, the four areas of medical genetics practice: diagnosis, prevention, management, and therapy of hereditary diseases. Diagnosis. Many patients are referred to medical geneticists for a diagnosis. For example, the geneticist may be asked if

17 San Francisco Medicine October 2010 16 San Francisco Medicine october 2010

there is an underlying genetic explanation for a child born with complex birth defects, such as cleft palate or congenital heart malformation, or for an infant with delayed cognitive development, such as a chromosome imbalance or fragile X syndrome. They may be asked to assess if an unusually tall, thin patient has Marfan syndrome, or to evaluate a patient with an unusual family history of renal cancer for a hereditary cancer syndrome such as the von HippelLindau syndrome. Although the number of disorders that can be diagnosed by directly testing the relevant gene or genes for mutations continues to increase, many hereditary diseases still must be diagnosed on clinical grounds alone, i.e., from history, physical exam, and routine laboratory testing. In these cases, the signs may be subtle and require an experienced observer. Even if the genes in which mutations may cause a particular hereditary disorder or birth defect are known and can be evaluated in a clinical molecular diagnostic laboratory, there can be of number of such genes. Hereditary pheochromocytoma, for example, may be caused by a mutation in any one of eight different genes, and careful evaluation of the patient and family is necessary to assess the likely diagnoses and prioritize what can be expensive clinical testing. Once DNA analysis is completed, medical geneticists often need to interpret and explain test results to other professionals and to the family. Prevention. With a diagnosis in hand, disease prevention becomes a major role for medical geneticists. Often the patient will seek a genetics consultation to learn about the risk of inheriting or developing a hereditary condition in himself or in a family member, particularly a child. The medical geneticist provides information on

the options available to avoid passing on the disease or to prevent particular manifestations. Other times, it is the geneticist who recognizes that a risk exists and, following the requirements of “duty to warn,” will work with the patient to alert other family members of their risk. Finally, obstetricians with specialized medical genetics training can provide prenatal diagnosis of many hereditary conditions, giving parents the option to avoid a pregnancy affected by a serious birth defect or hereditary disorder. Management. The care of patients with hereditary disease is a shared enterprise among many subspecialists across many branches of medicine and surgery. Geneticists often serve to coordinate that care. For example, a woman carrying a deleterious mutation in BRCA1 will need to work with oncologists, breast surgeons, and gynecologists to receive the care designed to prevent breast or ovarian malignancy or to catch it early if possible before metastatic disease occurs. Similarly, a child with a constellation of birth defects may need reconstructive surgery from numerous surgical specialists as well as physical or speech therapy. By coordinating the care of such patients and their families, medical geneticists often function as “general practitioners” for rare disorders. Finally, geneticists are called upon to provide highly specialized care for patients with rare biochemical disorders. Many of these diseases, such as phenylketonuria or glycogen storage diseases, require careful biochemical monitoring and the use of exacting dietary and/or pharmaceutical treatments. This work is often carried out in partnership with clinical dieticians with specialized training in the dietary treatment of such individuals. Most medical geneticists work on a team along with genetic counselors. Genetic counselors are professionals trained to obtain and assess family history, interpret genetic test results, perform outreach to at-risk family members, provide patients and their families with assessments of disease risk, and discuss various options for management and prevention. When appropriate, they also can provide shortterm psychological counseling and support to patients and their families coping with a

serious or fatal disease in themselves or in their relatives. Genetic counselors usually hold a master’s degree in genetic counseling—the American Board of Genetic Counseling accredits all training programs, of which there are currently thirty-two in the United States, and oversees the examinations the graduates of these programs must take to become certified genetic counselors. Until recently, medical geneticists and genetic counselors have focused primarily on diagnosis, prevention, management, and treatment of disorders that were inherited according to recognized Mendelian patterns. Such diseases are generally rare and usually caused by gene mutations that produce a large increase in disease risk. Technologies such as whole-genome scanning for DNA variants or even whole-genome sequencing are becoming more widespread and affordable. As the genetic contributions to more common, complex diseases are elucidated, medical genetics professionals are being asked to interpret the results of such testing and are, therefore, becoming more involved in the care of patients with complex sets of genetic changes that alter

disease susceptibility in subtle ways. In summary, the specialty of medical genetics rests on a highly technical, scientific foundation of molecular genetics and biochemistry and yet, at the same time, requires a high degree of psychological competence and awareness. Although medical genetics is itself highly specialized, the fact that we consider the entire family to be our patient and that we must often refer our patients to a variety of different specialists for highly specialized care means that the field also has elements in common with general practice or family medicine. It has been my great pleasure to be involved in the practice of medical genetics for more than thirty years, and I look forward to what future advances in genetics and genomics will bring to the care of my patients in the years to come. Dr. Robert L. Nussbaum, an internist and medical geneticist, specializes in the care of adults with hereditary disorders. He is chief of Medical Genetics at UCSF Medical Center and codirector of the Program in Cardiovascular Genetics at the UCSF Heart and Vascular Center.

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Evolving Specialties in Medicine

Choosing a Specialty Factors that Influence Medical Students’ Choices

Mary K. Kelly, MD


he selection of a medical specialty is one of the most important choices that a medical students faces. Ironically, students are asked to make this profound decision while in the midst of busy rotations and intense academic study, and also with proportionally little experience of what will be their daily clinical or scientific practice. Furthermore, this choice is complicated by the multitude of options that the diverse and evolving practice of medicine offers. This includes disciplines and lifestyles as varied as surgery, psychiatry, internal medicine, and radiology, all of which branch out into increasingly specialized practices such as pediatric cardiac electrophysiology and adult addiction psychiatry. How does this life-altering decision process take place? This article aims to answer the question by beginning broadly, briefly reviewing the current literature and then narrowing to focus on individual perspectives of recent UCSF graduates as well as UCSF faculty currently serving as medical student mentors. The motives and influences on medical student career choice are numerous. A common theme found throughout the current literature is that specialty choice is likely related to an individual’s different attributes, motivations, and personality traits. Specifically, Baron et al 2007 found that variables as diverse as student academic standing and achievement in medical school, religious preference, family medical traditions, medical school curriculum, strong faculty mentors, and lifestyle considerations may play important roles in determining specialty choice. Pawełczyk et al 2007 further delineated among such factors by simultaneously

analyzing several predictors of specialty choice among residents from varying medical disciplines and extracting significant variables. Predictors included demographics, academic performance, income, personality attributes, social status, and intellectual content. Pawełczyk et al found that internal medicine residents are more likely to be introverted, attentive, have deeper intellectual curiosity with higher aspiration levels, and highly value mental stimulation and problem solving. In contrast, surgical residents are more likely to be assertive, extroverted, and interested in emerging technology, prestige, and higher income potential. Primary care residents are more likely to be patientcentered and people-oriented, highly value serving society, and enjoy seeing diverse patients and health problems. As many factors may potentially influence one’s specialty choice, recent graduates of UCSF were interviewed to provide insight on how this decision is made on a case-by-case basis. Susannah Graves, MD, is a 2010 UCSF SOM graduate and is currently a categorical internal medicine intern at UCSD. When recently faced with choosing a specialty, she decided by reflecting on her perception of how the different specialties pursue medical inquiry, her personal experience with disease, and the benefit of a lasting patient-doctor relationship. “I enjoy the detective work of diagnosis that internists use to navigate the often subtle nuances of therapy choice. Reading about the latest developments in the field of medicine can be exciting, and I relish discovery in the lab. Tackling unanswered clinical questions makes me feel like I am making a difference for my patients in giv-

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ing them more reason to hope. For people like my cousin, afflicted with diseases with no known cure, research into innovative treatments can mean life. Another factor that drew me to internal medicine is the uniquely longitudinal relationships internists share with their patients. We can engage patients in thorough workups and provide thoughtful treatments, then see the results over time. This is very satisfying to me.” Another recent graduate of UCSF School of Medicine, Brian Molenhoff, MD, is a psychiatry resident at UCSF. Although many of the typical factors went into his decision, he realized one was most important to him: what he truly enjoyed learning about in his spare time. “There were a lot of things to consider, but what it really came down to in the end was what I tended to spend my time reading about. I realized that I would be reading about psychiatry no matter what specialty I went into. I always look forward to reading journals and books—and this makes it really fulfilling to try to be the kind of evidence-based, thoughtful doctor that I strive to be.” UCSF faculty who serve as medical student mentors and have stellar student reviews were asked how they help medical students make their specialty decisions. Their answers focus on strategies that promote self-discovery and an understanding of the characteristics of a given medical field that are important to each individual. Here are a few excerpts on what they had to share: Amin Azzam, MD, MA, is an associate clinical professor and faculty chief for Trainee Professional Development at the UCSF Department of Psychiatry,

director of the Problem-Based Learning curriculum at the UC Berkeley-UCSF Joint Medical Program, and codirector of the Foundations of Patient Care course and the Health Professions Education Pathway to Discovery Program at the UCSF School of Medicine. “I think the key in advising students about all the complexities that go into making a big choice such as this one is to listen first. Do your best to understand where the challenges and blind spots lie for each individual trainee, and then help them see those relative weak spots from a new vantage point. “Of course, I’m not giving them specific answers to the choices—I don’t say, ‘You should go into psychiatry.’ Instead, it’s more about pointing out the dilemma that the student may not quite fully understand him- or herself: ‘It seems to me you’re struggling between a lifestyle choice and something you seem really passionate about.’ From there, as it’s ultimately the student’s life to live, I leave it in their own hands to decide what seems right. “Lastly, I offer a general piece of advice that was once given to me when I was applying to residencies. You know how animals have their fight-or-flight instincts? Like gazelles on the plains of Africa whose ears perk up when they sense danger because a lion is lurking nearby in the grass? As humans, we too have that same paleocortex of our brains—we just tend to suppress it under the guise of intellectual superiority. But it’s there for a reason, and we should not ignore it. When deciding a specialty choice or getting on the interview trail, you’ll get those gut instincts that tell you that a certain career or place just isn’t right for you. Even better, you’ll get that gut instinct telling you that you know you’d be happy. Trust those instincts—they’re your heart talking instead of your head. And we in medicine tend to make the error of following our heads and ignoring our hearts far more than we should!” Calvin Chou, MD, PhD, FAACH, is an associate professor of clinical medicine at UCSF, the codirector of the Foundations of Patient Care course and the director of the V.A.-based Longitudinal Rotations

(VALOR) program at the UCSF School of Medicine. “There are a couple of important principles that I hope students hear and try to remember: “First, career choice occurs in the context of your entire life. Don’t oversacrifice your life for your career—few people in the twilight of their lives say, ‘I wish I’d worked more.’ But at the same time, don’t fritter away your life in front of the TV when you can gain such fulfillment out of the work of medicine. Unlike many other professions, we are extremely lucky that the basis of our work is to help others through some of the most trying periods of their lives. “Second, identify your passion—your vocation—as well as possible, and let that lead you through your entire career. I know it’s kind of touchy-feely to say to always know your true north, but it is completely true. I can say this as the poster child for someone who changed career paths: I was an MD/PhD student with a thesis in molecular immunology, and along the line I was brutally honest with myself and realized that running a lab and thinking about molecular biology—while fun—was not my true passion. I am interested in how people talk to each other and want to facilitate deeper understanding between people, be that patients and doctors, learners and teachers, colleagues, etc. Always remembering that keeps me on track for my career. I know people that I’ve advised in the past who let other considerations get in the way of their passions, and they become unhappy or jaded. Life’s too short for that. Why not make work a passionate experience?” Tim Kelly, MD, is an HS clinical professor, vice-chair for Education as well as the director of Advanced Clerkships and Intern Selection at the UCSF Department of Pediatrics. “I often counsel students to think not just about the patients that they will take care of but also about the people they’ll be surrounded by in the discipline or specialty. For instance, I loved my OB mothers—delivering kids, miracle of life, spiritual moments for sure—and found it very rewarding. However, I found the OB nurses to be a bit pushy and cranky out

of sheer necessity to get the job done, I think, and they were clearly better than competent. “But when I got to pediatrics, it just felt like home. These were my ‘peeps.’ They were funny, caring, casual, lighthearted, deeply passionate about kids. My colleagues-to-be weren’t afraid to sit on the floor with a kid to make a connection or get peed on by a baby with great aim (and then just laugh about it—almost like it was a privilege—and not get ticked off about it!). They were sort of how I saw myself, or at the very least what I wanted to be and aspire to in my professional life. I usually have students reflect on what moved them and spoke to them at a broader, higher level than just the actual focused work—like the environment and the people surrounding them. “I also have students imagine what it would be like at the worst (or most challenging) time in a career: It’s 4 a.m., you’re tired, stressed, asleep in your warm bed on a cold, rainy, blustery San Franciso night and you get called to come in to the hospital for something that is undeniably essential—no wiggling out of this one. You drag your sorry butt out of bed and you shuffle over to the mirror to get dressed and you look at your reflection and say, ‘I am going into the hospital to see . . . fill in the blank.’ What do you get? How does that sit? Are you ticked off and hypercritical, nasty even? Or are you able to be (somewhat) compassionate and (somewhat) excited by what you are about to do? If so, then that is the specialty for you. This exercise is imagined in the future, when you are done training and not a resident—what your life might be like for decades. I can honestly say that for me, when I say, ‘I am going to see a sick (abused) (in pain) (scared) (specialneeds) kid’ in those darker moments, I am as thrilled today to contribute and to heal and to make a difference in their little lives as I have always been.” Perhaps what is most important to remember in choosing a medical specialty is that career decisions can happen many times over the course of one’s life, spanning work and nonwork domains. Thus, Continued on page 21 . . .

October 2010 San Francisco Medicine 19

Continued from page 19 . . . while specialty choice is considerably important, it does not have to determine one’s entire career, and it can simply be the foundation of one’s future. Additionally, one of the greatest aspects of the field of medicine is that it constantly evolves. As time passes, more opportunities open up as new jobs and niches are created. Every doctor can and deserves to have his or her niche, to be “thrilled” at the start of each new day to get up and do what he or she chose to do in medicine. Dr. Kelly graduated from UCSF in 2009, completed internship at Alameda County Medical Center 2010, and is currently an anesthesia resident at Massachusetts General Hospital. A full list of references is available on

David E. Smith, MD Honored by California Medical Association At the recent annual meeting of the CMA, longtime SFMS member David Smith MD was honored by the CMA Foundation with its Sparks Leadership Achievement award, which “honors an individual or a group that has shown outstanding concern for the health of communities.” Dr. Smith, a 1964 UCSF graduate, founded the Haight-Ashbury Free Medical Clinics in 1967 to care for the masses arriving here in the “Summer of Love.” He headed the Clinics for four decades, during which there were over two million patient visits and pioneering modes of treatment developed. He is a pioneer in the medical treatment of drug abuse, and has been President of the American Society of Addiction Medicine. Some years after founding the clinics, he was told by a former UCSF professor “you were so promising - where did you go wrong?” Much more recently, he received the UCSF Medal, the highest honor bestowed by the University. Smith was nominated for the award by the SFMS, in a letter signed by Philip R. Lee, former UCSF Chancellor, and SFMS staff member Steve Heilig, who introduced Smith at the CMA meeting and is a previous recipient of the Sparks award, which was founded by Robert D. Sparks, MD, a longtime leader in medicine and public health. For more information on the award, see:

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2010 SFMS Election Information 2010 Slate of Candidates Pursuant to the San Francisco Medical Society Bylaws Article X Section 2 - Nominations, the Nominations Committee renders in writing the following slate of candidates for the 2010 SFMS election. This slate was read at the September 13, 2010, General Meeting. SFMS President, Dr. Michael Rokeach, called for additional nominations from the floor; none were forthcoming. The following are this year’s candidates: 2011 Officers, Term: 2011 For President-Elect: Peter J. Curran, MD For Secretary: Lawrence Cheung, MD For Treasurer: Shannon Udovic-Constant, MD For Editor: Gordon L. Fung, MD

For SFMS Board of Directors Term: 2011–2013 Seven candidates will be elected to the Board of Directors: Jennifer H. Do, MD * Benjamin C.K. Lau, MD * Man-Kit Leung, MD Keith E. Loring, MD ** Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel Hui-Chung Shu, MD * Incumbent Director ** Outgoing Officer

For Nominations Committee Term: 2011–2012 Four candidates will be elected to the Nominations Committee: Luis A. Bonilla, MD Jason Dimsdale, MD Lisa W. Tang, MD Andrew Wang, MD For Young Physicians Section Alternate Delegate Term: 2011 Thomas K. Haddad, MD NOTES

For Solo/Small-Group Practice Forum Delegate Term: 2011–2012 Eric Tabas, MD (Incumbent)

For Solo/Small-Group Practice Forum Alternate Delegate Term: 2011–2012 Eric H. Denys, MD (Incumbent)

For Delegates and Alternates to CMA House of Delegates Term: 2011–2012 The four candidates receiving the highest number of votes will serve as delegates. The President-Elect automatically becomes the fifth delegate. The next five will be alternate delegates. Elizabeth A. Andrews, MD Lawrence Cheung, MD ** Roger Eng ** Steven H. Fugaro, MD * Gordon L. Fung, MD * Man-Kit Leung, MD** Robert I. Liner, MD ** Michael Rokeach, MD * Shannon Udovic-Constant, MD * H. Hugh Vincent, MD * Andrea M. Wagner ** * Incumbent Delegate ** Incumbent Alternate

• 2010 President-Elect, George A. Fouras, MD, automatically succeeds to the office of President. • 2010 President, Michael Rokeach, MD, 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 in the special envelope provided. • Ballots MUST arrive at the SFMS offices by 5:00 p.m., Monday, November 8, 2010. The NAME of the SFMS member (NOT the corporation’s name) must be printed legibly or typed on the return envelope. Next year we plan to move to online elections. Please make sure we have your e-mail address on file. We must have your e-mail address for the online voting process. 22 San Francisco Medicine October 2010 23 San Francisco Medicine October





Specialty: Cardiology Membership: SFMS 2007, CMA 2005 SFMS: Secretary 2010; Director 2009 SFMS Committee Appointments: Executive 2009–10, SFMS PAC Board 2009–10 (Secretary/Treasurer 2009), Membership Services 2008–10; Medical Review and Advisory 2009–10 CMA: Alternate Delegate 2009–10 CMA Committee Appointments: Young Physician Section Representative on Council on Legislation 2009–10 Related Medical Affiliations: Director of Cardiac Rehabilitation, St. Mary’s Medical Center; St. Mary’s Executive Committee (Secretary/Treasurer) 2011 Medical School: Loma Linda University 1994 Hospital Affiliation: Active: St. Mary’s, Saint Francis Policy Statement: I appreciate being selected by the SFMS Nominations Committee as a candidate for President-Elect and SFMS Delegate to the 2011–2012 CMA House of Delegates. Our Medical Society is focused this year on meeting the needs and supporting the common interests of San Francisco physicians. Thank you for your continued support of local organized medicine.

ALSO CANDIDATE FOR DELEGATION Specialty: Dermatology Membership: SFMS/CMA 2005, AMA 2005 SFMS: Director 2009–10 SFMS Committee Appointments: Executive 2010; SFMS PAC Board 2007–10 (Vice Chair 2010), Membership Services Committee 2006–10 CMA: Alternate Delegate 2009–10; YPS Alternate 2008 Related Medical Affiliations: Fellow, American Academy of Dermatology; Fellow, American Society for Dermatologic Surgery; Member, Society of Investigative Dermatology Medical School: Columbia University College of Physicians and Surgeons 1998 Hospital Affiliation: Active: St. Mary’s, Chinese Hospital Teaching Appointments: Assistant Clinical Professor of Dermatology, UCSF Policy Statement: As a recent graduate who started my own solo practice in the City five years ago, I have gained a deep appreciation for the San Francisco Medical Society. Beyond the camaraderie of colleagues, the Society has provided a wealth of resources to me as a practicing physician. I soon became active in the Society because I wanted to ensure that it remains a valuable resource for other physicians. I joined the Membership Committee because I felt that a robust membership base is critical for the Society on many levels. From the number of delegates at the CMA to the legitimacy of representing San Francisco physicians in areas of patient advocacy and health care policy, membership is the backbone of the Society. I also became active in the Political Action Committee because I feel

that California is a pioneer in many areas of health initiatives, and San Francisco is one of the cities leading these changes. I believe that only by actively engaging in the political process can we ensure positive outcomes for both our patients and our profession. I am truly honored to have been nominated to run for Secretary of the Society and to serve again as a member of the CMA Delegation.



(Incumbent Director) ALSO CANDIDATE FOR DELEGATION Specialty: Pediatrics Membership: SFMS/CMA 2001 SFMS: Director 2007–10 SFMS Committee Appointments: SFMS PAC 2006–10 (Chair 2009–10; Secretary/ Treasurer 2007), Executive 2007–10, Medical Review and Advisory 2002–present; Bylaws 2007 CMA: Delegate 2010; Alternate Delegate 2008–09 CMA Committee Appointments: Young Physicians Section Executive Committee, At-Large Member 2003–2005 Related Medical Affiliations: AAP-CA State Government Affairs, Co-Chair 2008– present; AAP chapter Board, Alternate Member-at-Large 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

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medicine is that physicians across all specialties can have one voice to address the health care issues facing patients and their physicians. After my participation in the membership retreat this year, I look forward to advancing the great work of SFMS. I would develop public health collaboration and lectures on organized medicine for the next generation. I would welcome the opportunity to continue to serve SFMS as the Treasurer to enhance the financial health of our organization.



ALSO CANDIDATE FOR DELEGATION Specialty: Cardiovascular Diseases Membership: SFMS/CMA 1985 SFMS: Consultant 2008–present, Immediate Past President 2007, President 2006, President-Elect 2005, Director 1999–2000/2002–04, Secretary 2001 SFMS Committee/Board Appointments: Editorial Board 2007–10/1995; PAC 2005–10; Professional Relations and Ethics 1997–2010; Executive 2000–07; Judicial 2005–08; Bylaws 2007; SFMS Finance/Investment 1998–2006; Services, Inc., Board 1995–2005 (President 1999–2005; Secretary/Treasurer 1996– 98); Nominations Committee 2000–01; Insurance and Managed Care Mediation 1995–96 CMA: SFMS Delegate 2005–10, Specialty Society (Cardiology) Delegate 2002–06, Alternate 2001, Delegate 2001 CMA Committee Appointments: Medical Staff Survey Steering Committee 1998, Medical Staff Survey 1995, Council on Scientific and Clinical Affairs 2008 to present Related Medical Affiliations: American College of Cardiology, California Chapter, President and Governor 2006–09; Chair, Membership Committee 2002–06; Mem-

ber, National Board of Directors, American Heart Association 1999–2001; President, California Affiliate, American Heart Association 1996–98; Member, Executive Committee, Council on Clinical Cardiology, AHA 2005–09; Medical Director, ECG Lab, UCSF 2001–present; Director of Cardiac Services, UCSF Medical Center at Mount Zion 2001–present; President, San Francisco Division, American Heart Association 2004–06 Medical School: UCSF School of Medicine 1979 Hospital Affiliation: Active: UCSF; Associate: Chinese Hospital, Saint Francis Memorial Hospital, St. Mary’s Hospital, CPMC Teaching Appointments: Clinical Professor of Medicine, UCSF 2006–present; Associate Clinical Professor of Medicine 1998–2006 Policy Statement: I am honored to be nominated for the SFMS Delegation to the CMA House of Delegates. Over the past several years, the challenges of practicing medicine in San Francisco and California have caused many physicians to consider early retirement and/or leaving the field entirely. Regardless of hospital affiliation, mode of practice, or specialty, this organization pulls together the energy and expertise of all physicians to support physicians and quality health care for all San Franciscans. I strongly believe that all physicians need to be a part of this team effort to support each other in an organized manner. Only by volunteering to be part of the solution can we succeed in medicine. I look forward to working with you and for you.


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(Incumbent Director) Specialty: Pediatrics Membership: SFMS/CMA 2006 SFMS: Director 2009–10 SFMS Committee Appointments: Physician Membership Services Committee 2007–10, PAC Board 2008 Medical School: Saint Louis University School of Medicine 2002 Hospital Affiliation: CPMC Policy Statement: I am honored to be nominated for the Board of Directors. I was raised in San Francisco, and, like my father, I am a primary care physician in the City. My practice focuses on general pediatrics, and a large part of being a pediatrician is learning to effectively advocate on behalf of my patients. It is this belief in advocacy that has inspired me to seek a second term on the Board of Directors. I recognize that all physicians—subspecialists and primary practitioners alike—face many challenges in today’s environment. My active participation in the Medical Society has solidified my passion to protect the integrity of our profession. I am committed to the Medical Society and its efforts to support a strong, cohesive voice for physicians of all specialties. BENJAMIN C.K. LAU

(Incumbent Director) Specialty: Physical Medicine and Rehabilitation Membership: SFMS/CMA 1999 SFMS: Director 2010 Related Medical Affiliations: American Board of PM&R, American Academy of PM&R Medical School: Albert Einstein 1993 Hospital Affiliation: Active: St. Francis; Courtesy: Chinese Hospital and St. Mary’s Policy Statement: The practice of medicine is an art, yet the running of medical

administration is more complicated than ever before, requiring a dedicated team of administrators, physicians, legal specialists, and politicians to provide and secure top-of-the-line, fair treatment to our people. It is an honor and a great learning experience to work among this group of dedicated people to service our city. MAN-KIT LEUNG

ALSO CANDIDATE FOR DELEGATION Specialty: Otolaryngology, Head and Neck Surgery Membership: SFMS/CMA2009 SFMS: Medical Staff Liaison to Chinese Hospital 2010 CMA: Alternate Delegate 2010 Medical School: UCSF School of Medicine 2003 Hospital Affiliation: Active: Saint Francis, CPMC; Courtesy: Chinese, St. Mary’s Teaching Appointments: Adjunct Clinical Instructor, Stanford University School of Medicine 2009–2011 Policy Statement: Solo and small-group practices are critical to the comprehensive delivery of health care. Unfortunately, many of these practices are struggling to survive. As a physician in a small-group practice that serves immigrant populations in San Francisco, I endorse policies that encourage community practices to thrive and that improve access to health care, especially for the underserved. On this board, I intend to vigorously support SFMS’s efforts to advocate for the well-being of community physicians and to develop innovative community health programs that improve access and quality of care for all San Francisco residents.


(Outgoing Officer) Specialty: Emergency Medicine Membership: SFMS/CMA 2003 SFMS: Treasurer 2010, Director 2009 SFMS Committee Appointments: Executive 2009–10, Finance and Investment (Chair 2010); Nominations 2007–08 CMA Committee Appointments: Council on Legislation 2010 Related Medical Affiliations: Vice Chief of Staff, St. Mary’s Medical Center; Regional Medical Director, San Francisco Peninsula Region, California Emergency Physicians Medical School: Johns Hopkins University School of Medicine 1991 Hospital Affiliations: Active: St. Mary’s, St. Francis; Courtesy: SFGH Teaching Appointments: Assistant Clinical Professor, USCF Policy Statement: It has been an honor to serve as Board Member and Treasurer of the SFMS. 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 together to advocate for what is right for our patients as well as what is right for us to receive in compensation for our efforts. My candidacy for Treasurer is part of an ongoing commitment to put these words into action and become involved in something greater than my own practice of emergency medicine at St. Mary’s, St. Francis, and San Francisco General Hospitals. If we are to stem the tide that continues to erode our profession and place our patients in harm’s way, it is critical that we nurture the brightest among us who have the integrity and energy neces-

sary to stretch beyond day-to-day clinical practices and make our voices heard in the local, state, and national health care dialogue. Prudent financial stewardship is critical for this organization to be able to continue advocating for our patients and our professional interests, especially in a time of exceptional financial uncertainty and likely upheaval of our health care system. I would be honored, willing, and able continue in helping serve this need if re-elected. TERRI-DIANN PICKERING

Specialty: Ophthalmology Membership: SFMS/CMA 2000 SFMS Committee/Board Appointments: Editorial Board 2007–09 Related Medical Affiliations: St. Mary’s Medical Center Chair, Department of Ophthalmology 2004–06; Eye Surgery Center of SF Medical Director 2010; Blue Shield of California Credentialing Committee 2000–present Medical School: Harvard Medical School 1994 Hospital Affiliation: Active: St. Mary’s, Eye Surgery Center of SF; Courtesy: CPMC, Highland (Oakland) Teaching Appointments: Clinical Instructor, Department of Ophthalmology, CPMC 2000–present Policy Statement: I’m honored to be nominated for the SFMS Board of Directors. Since arriving in San Francisco in 1994, I’ve observed the collegiality and acceptance shown by the doctors in this city. The spirit of embracing diversity, putting patients first, and volunteerism shown by the doctors here is inspirational. This is a wonderful environment in which to practice medicine, and I will work to maintain that environment and to give back to the community that wel-

October 2010 San Francisco Medicine 25

comed me so many years ago. We must all work together to ensure that it remains an honor to practice medicine—an act of compassion, not an act of drudgery. The future brings challenges and SFMS will fight the good fight for our patients’ sake, and uphold the honor of our profession. Thank you. MARC D. ROTHMAN

Specialty: Internal Medicine Membership: SFMS/CMA 2010 Medical School: New York University 2002 Hospital Affiliation: Kaiser Permanente Policy Statement: Though new to San Francisco, I have been active in both the AMA and the American Geriatrics Society over many years. In medical school I served for two years on the board of directors for both the New York State and County Medical Societies, and I was a delegate or alternate to several annual meetings. I led the fellows section of the AGS and also served on its Education Committee for three years. I look forward to assisting the SFMS in its mission to advocate on behalf of all physicians in our great city.

CMA: Alternate Delegate 2001–09 Related Medical Affiliations: Chinese Hospital Medical Executive Committee (MEC) 1999–2008, CPMC OB/GYN MEC 1998–present, CPMC Perinatal Quality Assurance Committee 1994–present, CPMC Joint Health Committee 2001–present, GYN New Technology Committee 1997–present, CCHCA Board Member 2007–present Medical School: University of Missouri 1986 Hospital Affiliation: Active: CPMC, Chinese; Courtesy: Saint Francis Teaching Appointments: Clinical teaching staff, UCSF 1992–present; Dartmouth Medical School 2009–present Policy Statement: I am happy to be a candidate for the SFMS board position. We are in a time of change, as many issues are facing practicing physicians today. These issues include patient advocacy, the new health care initiatives and health care reforms that are coming, rising malpractice premiums, PPOs, boutique medicine, and new technology, to name a few. Practicing physicians also face the reality of the electronic age and must be knowledgeable in using electronic medical records, e-prescriptions, advances in technology, minimally invasive procedures, and privacy issues. SFMS gives each one of us a voice in this complex world. If elected, I hope to make a difference.

Hospital Affiliation: St. Luke’s, Seton Teaching Appointments: Toro University Adjunct Clinical Instructor of Family Practice Policy Statement: I am honored to be nominated to serve on the SFMS Nominations Committee. It is my goal to help find the physician leaders of the future who will continue the high mission of the San Francisco Medical Society—to advocate for the patients and physicians of San Francisco. JASON DIMSDALE

Specialty: Obstetrics and Gynecology Membership: SFMS/CMA 2010 Medical School: Duke University School of Medicine 1993 Hospital Affiliation: CPMC Teaching Appointments: Clinical Instructor, University of Pittsburgh School of Medicine (Magee-Womens’ Hospital) 1997–2001; Director, Ob-Gyn Clinical Teaching Programs 1998–1999 LISA W. TANG



Specialty: Ob-Gyn Membership: SFMS/CMA 1992, AMA 1986 SFMS Committee Appointments: Credentials 1994–2007

Specialty: General Practice Membership: SFMS/CMA1988 Related Medical Affiliations: Salvadoran American Medical Society Medical School: University of El Salvador 1982

26 San Francisco Medicine October 2010 27 San Francisco Medicine October

Specialty: Family Medicine Membership: SFMS/CMA 2007 Medical School: UC San Diego 2004 Hospital Affiliation: Kaiser Permanente, San Francisco Teaching Appointments: UCSF Clinical Professor, Department of Family and Community Medicine 2009–present Policy Statement: Having grown up in San Francisco, it would be my privilege

to serve my hometown by participating in the Nominations Committee. Through this role, I will select the future leaders of the SFMS. At a time when our country is confronted with the challenge of implementing the recently passed health care reform, the SFMS has a pivotal role to play. My vision is to nominate leaders who will be champions for both patients and physicians at this critical juncture. Subsequently, San Francisco will become the model city in the delivery of universal health care, as evidenced by Healthy San Francisco. ANDREW WANG

Specialty: Internal Medicine Membership: SFMS/CMA 2010 Medical School: Georgetown University 1997 Hospital Affiliation: Saint Francis Policy Statement: I am honored to be considered for a position on the Nominations Committee. Having practiced internal medicine for ten years in San Francisco, I have experienced both the joys and frustrations of caring for our patients. The landscape of health care is changing rapidly. I hope to positively influence the future of medicine by participating in the process of selecting outstanding physician leaders for the SFMS.

Specialty: Gastroenterology Membership: SFMS/CMA 2010 Medical School: George Washington University School of Medicine Hospital Affiliation: Saint Francis Teaching Appointments: UCSF Assistant Clinical Professor of Medicine Policy Statement: I am honored to be nominated to serve as an alternate on the delegation to the CMA House of Delegates. I have been practicing internal medicine and gastroenterology in San Francisco since 2006. I was encouraged to join SFMS and the CMA by many of my mentors and I am excited to be a part of the organization. The health policy decisions that are made now will affect our patients and our practices for many years to come. Organizations like SFMS allow physicians to have a voice in this crucial process. I look forward to working with my colleagues to better medicine for both California physicians and the patients we serve.





(Incumbent Delegate) Specialty: Obstetrics and Gynecology Membership: SFMS/CMA 1987 SFMS: Treasurer 2000, Director 1995–99 SFMS Committee Appointments: FOR YOUNG PHYSICIANS SECTION Finance/Investment Committee 1999– 2010 (Chair 2000); SFMS Services, Inc., ALTERNATE DELEGATE Board 1997–2001 (Secretary/Treasurer 1999); Executive 1998–2000; NominaTHOMAS K. HADDAD tions 1997; Legislative 1988–92 CMA: Solo/Small-Group Practice Forum Delegate 2006–10 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 as SFMS Delegate to CMA’s Solo/Small-Group Practice Forum. I believe that SFMS is the only organization in San Francisco that is accessible to all San Francisco physicians. It provides us with 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. As I have been in solo practice for twentyfive years, I particularly look forward to representing the ideas and issues of San Francisco solo and small-group practices to the CMA.

Specialty: Neurology Membership: SFMS/CMA 1976 SFMS: UCSF Association of Clinical Faculty Consultant 2000 SFMS Committee Appointments: Tripartite 1999–2001 CMA: Solo/Small Practice Group Forum Alternate 2009–10 CMA Committee Appointments: Council on Scientific Affairs 2007; Specialty Advisor, Cal Advantage 1996; Scientific Advisory Panel on Neurology 1992–94 (Chair 1994) Related Medical Affiliations: Secretary/ Treasurer, Association of California Neurologists 2006–present; President, San

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Francisco Neurological Society 2001–02; President, Association of Clinical Faculty, UCSF 2000; Member, Ethics Committee, CPMC 1986–present Medical School: University of Leuven, Belgium 1966 Hospital Affiliation: Active: CPMC; Courtesy: UCSF, Mt. Zion Teaching Appointments: Associate Clinical Professor in neurology, UCSF Policy Statement: I have accepted the invitation to become Alternate Delegate for the Solo/Small Practice Forum. I may not seem the most likely candidate because I am at the end, not the beginning, of my career after thirty-two years in San Francisco. However, all these years, and my involvement in both local and national organizations, have given me a perspective on how changes in health care have affected individual and small-group practices. Since 1980 I have been involved in numerous capacities in the American Association of Electrodiagnostic Medicine, and I was President of the Association of the Clinical Faculty at UCSF and of the San Francisco Neurological Society. Individual practitioners are facing enormous challenges because of the power the for-profit health insurance companies are wielding. Small groups will only survive if they can find a form of practice that sets them apart from large groups. It will be a challenge. There can be no divisiveness among us. I will need your input in order to chart the course for you. I look forward to your collaboration.

Chief, Pharmacy and Therapeutics 2007– present; Co-Chair, Medication Safety Committee 2007–present; Inpatient Core Lead MD, KP Health Connect 2009–present; Assistant Chief, Department Hospital Medicine 1993–2003; Medical Director, Medical Surgical Units 1999–2003 Medical School: University of Texas, Southwestern 1993 Hospital Affiliation: Kaiser Permanente Policy Statement: I have been practicing as a hospitalist in San Francisco since 1997 in a group-model HMO. While taking care of patients, I have also worked to improve the delivery of care, whether by helping run medical surgical units or my own department. More recently my interests have been with medication safety, electronic health records, and informatics. The San Francisco Medical Society has a proud tradition of outstanding legislative advocacy for physicians and patients. It would be a privilege to contribute to that tradition by serving as an SFMS delegate to the California Medical Association’s annual meeting. LAWRENCE CHEUNG (Incumbent Alternate) ALSO CANDIDATE FOR SECRETARY. See biography under “For Secretary.” ROGER S. ENG




Specialty: Internal Medicine, Hospitalist Membership: SFMS/CMA 1997 Related Medical Affiliations: Assistant

CMA Appointments: Health Information Technology EHR Evaluation Committee, 2009–present; Committee on Nominations 1997–98, 2003–07; IT Committee, Chair 2004–08; Radiologic Technology Certification Committee 2004–present; Long-Range Planning Committee 2003– 07; CMA Website Taskforce Subcommittee, Chair 2006–07; Health Care Finance Technical Advisory Committee 2004; Committee on Medical Service 1998–99 AMA Offices: AMA Delegate 1996–97, AMA-RPS Delegate 1995–97, AMA-YPS Delegate 1998–99 (Vice Chair, CMA YPS delegation) Related Medical Affiliations: Chief of Radiology, Chinese Hospital 2003–present; President, Golden Gate Radiology Medical Group 2006–present; President, Kona Healthcare 2009–present; Chinese Hospital, Medical Executive Committee 2004–present; Chinese Community Health Care Association Information System Physician Advisory Committee 2006–present; Chinese Hospital, Chair, Nominations Committee 2007–present; Carestream Health Physician Advisory Board 2005–present; American College of Radiology, Councilor 2008–present; California Radiological Society, Executive Committee 2008–present Medical School: George Washington University 1991 Hospital Affiliation: Chinese Policy Statement: Thank you for the opportunity to serve on the SFMS Delegation. I look forward to working with the rest of our delegation to advance the policies of our SFMS within CMA.

(Incumbent Alternate) Specialty: Radiology Membership: SFMS 2003, CMA 1995, AMA 1995 SFMS: Director 2010–11 SFMS Committee Appointments: Executive 2010 CMA: Alternate Delegate 2008–10; Board of Trustees 1997–98, 2003–07; Delegate/ Alternate Delegate 1995–present; Young Physicians Section, Chair 2001–02

28 San Francisco Medicine October 2010 29 San Francisco Medicine October

(Incumbent Delegate) Specialty: Internal Medicine Membership: SFMS/CMA 1986

SFMS: Consultant 2010, Immediate Past President 2009, President 2008, President-Elect 2007, Treasurer 2006, Director 2003–05 SFMS Committee Appointments: Medical Review and Advisory 2009–10 (Co-Chair 2010), Finance 2006–10 (Chair 2006), SFMS PAC Board 2005–10, Executive 2006–09, Information Technology 2006, Nominations 2009 (Chair)/2004, Membership Committee 2006–2010 CMA: SFMS Delegate 2007–10 Related Medical Affiliations: American College of Physicians, Society of General Internal Medicine, American Medical Association, Board Member San Francisco Health Plan (SFMS representative) Medical School: Yale University 1981 Hospital Affiliation: UCSF, Mt. Zion, CPMC Teaching Appointments: Associate Clinical Professor of Medicine, UCSF Policy Statement: I have practiced privately, full-time, in internal/primary care medicine for the last seventeen 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 various challenges confronting physicians today in academic medicine, managed care, and private practice. As the past President of SFMS, I have become acutely 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. This has never been so evident as in the last two years, with the far-reaching federal reforms in medicine that affect all of us. 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 continue to be critical legislative battles involving Medicare, MediCal, SGR, GPCI, the corporate bar in medicine, and the scope of medical practice. There are in addition numerous important local 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, EHR implementation, and provider involvement with Healthy San Francisco. I welcome the opportunity to serve the San Francisco medical community as a Delegate to the California Medical Association from SFMS and to work closely with Dr. Stephen Follansbee, the head of the SFMS Delegation for 2010. GORDON L. FUNG (Incumbent Delegate) ALSO CANDIDATE FOR EDITOR. See biography under “For Editor.”

MAN-KIT LEUNG (Incumbent Alternate) ALSO CANDIDATE FOR BOARD. See biography under “For Board of Directors.” ROBERT I. LINER

diagnostic ultrasound (obstetrical and gynecologic), and genetic amniocentesis; certified to perform ultrasound screening at eleven to fourteen weeks, Fetal Medicine Foundation Policy Statement: I became a member of the SFMS/CMA in order to join others who want to do their part to make a difference in the way physicians use their individual and collective influence to improve the health and well-being of patients. This is both idealistic and self-serving, since professional improvement enhances the quality of our own working lives and also because, eventually, we all become patients. Impressed with the personalities of the members of the SFMS and with the diligent work expended by its delegation at the HOD meetings, I wanted to be a participant as well as an observer at those meetings. As something of a student of the history of medicine on the Pacific Coast, I know that it can take time for wise policies to evolve. Best evidence-based practice can only evolve with dedicated leadership. I’m pleased and feel honored to be able to join the SFMS delegation, working toward our perceptions of wise policy and best practice. MICHAEL ROKEACH

(Incumbent Alternate) Specialty: Obstetrics and Gynecology Membership: SFMS/CMA 2004 CMA: Alternate Delegate 2008–10, Attendee House of Delegates 2006–07, Reference Committee E 2008–2009 Related Medical Affiliations: Diplomat, ACOG; American Institute of Ultrasound in Medicine Medical School: University of Rochester 1970 Hospital Affiliation: Retired Teaching Appointments: Clinical Faculty and Temporary Director, OB/GYN at Mt. Zion Hospital (retired); Assistant Clinical Professor (temporary), UCSF at Highland General Hospital (retired) Current Practice (1988–present): Private practice in prenatal diagnosis,

(Incumbent Delegate) Specialty: Emergency Medicine Membership: SFMS/CMA 1990 SFMS: President 2010, President-Eelect 2009, Treasurer 2008, Secretary 2007, Director 2001–06, CPMC Medical Staff Liaison 2006–08 SFMS Committee Appointments: Executive 2006–10, PAC Board 2009– 10/2002–08 (Chair 2003–08, Consultant 2008), Medical Review and Advisory 2000–08, Nominations 2003 CMA: Delegate 2009–10, Alternate Del-

October 2010 San Francisco Medicine 29

egate 2002–03 Related Medical Affiliations: Chief of Staff, CPMC 2010–2011;Vice Chief of Staff, CPMC 2006–10; Medical Staff Treasurer, CPMC 2004–05; Medical Executive Committee, CPMC 1992–2004; Chair, MEC Nominating Committee 1997–2000; Chair, Risk Management Committee, CPMC 1990–98; 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, EMSA Clinical Advisory Committee 1990–2010; National and California Chapters, American College of Emergency Physicians 1988–2010 Medical School: University of Miami 1973 Hospital Affiliation: CPMC Policy Statement: It has been an honor and a pleasure serving as San Francisco Medical Society President this year. I wish to continue my service to the medical society and the CMA by being chosen as a representative to the House of Delegates this year. By representing the organized San Francisco medical community at the CMA, I hope to further the great efforts of past delegates to this august body. To that end, I will represent the best interests of all practicing physicians in San Francisco and California and, most importantly, of our patients and communities. SHANNON UDOVIC-CONSTANT (Incumbent Delegate) ALSO CANDIDATE FOR TREASURER. See biography under “For Treasurer.” H. HUGH VINCENT

(Incumbent Delegate)

Specialty: Anesthesiology Membership: SFMS/CMA/AMA 1972 SFMS: Board Consultant 1993–present, Immediate Past President 1993, President 1992, President-Elect 1991, Director 1982–1990 SFMS Committee Appointments: Medical Review and Advisory 1975–present, 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 1994–2001/1986–89 (Chair 1994–95), Nominations 2000–01/1994– 95 (Chair 1994–95), Judicial 1993–99, Anesthesia Section Chair 1975–90 CMA: Trustee 1997–2003, Delegate 1991–97/2003–06 (Chair 1993–96), Alternate Delegate 1985–90 CMA Board Committees: Nominations 1997–2003, Medical Services 1997–2002, Finance 1999–2003, Bylaws 2001–03 CMA Committee Appointments: Council on Legislation 1996–97, Speaker’s Advisory 1993–96, Rules 1994–95 (Chair 1995), Solo Practice TAC 1993–94 (Chair), Governance 10–94 TAC 1994, CALPAC Board of Directors 1995–2001 (Executive Committee 1999–2001) AMA: Delegate 1996–present (Vice Chair 2000–04, Chair 2004–08); Alternate Delegate 1994–95; House Select Oversight Committee 2001; Council on Long-Range Planning and Development 2008–12; Reference Committee C: A-95, I-95, A-01; Cal-C Committee Chair 1995–96; Resolutions Committee 1995–2000 Related Medical Affiliations: Saint Francis Physicians Medical Group/CHW Bay Area Physicians Medical Group 1995–2000 (President/CEO), Saint Francis Memorial Hospital Board of Trustees 1990–96/2000–10 (Secretary 1994–95, Chair 2001–03, Executive Committee 1992–2007), Catholic HealthCare West Bay Area Board of Directors 1996–01, CHW Strategic Planning Committee 2001–05 Medical School: UCSF 1968 Hospital Affiliation: Saint Francis Policy Statement: My purpose in medical

31 San Francisco Medicine October 2010 30 San Francisco Medicine october 2010

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 and development of those issues that we will take for national action at AMA. I ask for your continued support and particularly for your input on issues important to California physicians. ANDREA M. WAGNER

(Incumbent Alternate) Specialty: Emergency Medicine Membership: SFMS/CMA 1983 Related Medical Affiliations: Medical Director, Northern California Kaiser Permanente EPRP (Emergency Prospective Review Program); Practicing Emergency Physician in the Emergency Department at Kaiser San Francisco Medical School: Tufts University 1978 Hospital Affiliation: Kaiser Permanente Other: Board of Directors, California Chapter American College of Emergency Physicians 2006–present; Vice Chair, EMREF (Emergency Medical Research and Education Foundation); Chair, Injury Prevention Subcommittee Policy Statement: I am proud to have been a member of the CMA and the SMFS since 1983. In 2006, I was appointed to the CAL/ACEP Board of Directors. Since then I have been elected representative to the Board of the California Chapter of my specialty. I am the Vice Chairman of EMREF (Emergency Medical Research and Education Foundation). I also serve as the Chairman of the Injury Prevention Sub-Committee. I attend National American College of Emergency Physicians meetings yearly and act as a councillor to the delegation. I would be honored to be chosen as a representative to the CMA House of Delegates. Thank you.

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Hospital News Saint Francis


Patricia Galamba, MD

Robert Mithun, MD

When the term “hospitalist” was first coined in 1996, fewer than 1,000 internists limited their practice solely to the hospital. That soon changed. Between 2002 and 2007, the field grew from approximately 10,000 to 20,000 practicing hospitalists, and the number is now currently estimated to be nearing 30,000 in the United States. When Kaiser Permanente San Francisco hired its first hospitalists in 1997, they originally worked within the Department of Medicine. Soon after, the Department of Hospital Medicine (HM) became the first free-standing department of its kind within the Kaiser Permanente NCAL Region. Today, the Hospital Medicine Department has grown to include 21 providers and two full-time “nocturnists,” whose practice is based solely on overnight care. Moving forward with expanding the specialty, there will be more direct integration of providers into the Emergency Department and potentially a greater sharing of responsibility for general surgery patients with complex medical issues. Similarly, agreements with the Ob/Gyn Department are also expected in the coming year. Currently, in addition to staffing the traditional resident-teaching services, the Hospital Medicine Department has specific service agreements with many of the surgical departments. These include Head and Neck Surgery, Orthopedics, Urology, and Cardiovascular Surgery, as well as medical subspecialties such as oncology and cardiology. Encouraging hospitalists to assume various leadership roles within the administrative structure of the medical center has evolved naturally. Several physicians currently hold medical director positions and are leading quality-improvement projects and patientsafety initiatives. So, while hospital medicine is not the newest of specialties in the field, it is one that is adapting and expanding its scope in order to provide excellent patientcentered care.

Who says you can’t teach an old dog new tricks? In anticipation of the coming of age of electronic medical record (EMR) technology, here at Saint Francis we’re working with our practitioners to keep everyone in the loop. I don’t think the role of the Medical Informaticist has become a subspecialty yet, but the need for electronic competency is more pressing than ever. To that end, SFMH is hosting an information technology fair for the medical staff in October. We will have the opportunity to meet different EMR vendors and view the latest tech gadgets for physicians. Clearly we are all headed in the direction of EMRs, and the future will require that we get on board in order meet federal payer expectations. Members of the Medical Society are welcome to stop by on October 7 between 8:00 a.m. and 2:00 p.m. (second floor, Doctors’ Dining Room). Enjoying ourselves further still as we bravely move forward into the EMR era, Saint Francis Memorial Hospital will host a fun social event—the annual Saint Francis Day on Wednesday, October 6. This is a longstanding tradition of more than fifty years. It’s an afternoon of camaraderie including golf, bicycling, running, and walking, followed by en evening of fine food, dancing, and awards at the Olympic Club. I’ll report next time about all the goings-on. On November 1, Saint Francis becomes a fully nonsmoking campus. No one will be allowed to smoke inside any hospital buildings or any of its contiguous sidewalks. As an institution dedicated to improving the health of our patients and community, we must “walk the walk” and show our commitment and leadership in tangible ways. All CHW hospitals will be smoke free by January 1, 2011.

32 San Francisco Medicine October 2010 33 San Francisco Medicine October


David Eisele, MD

For more than 100 years, UCSF Medical Center has fostered clinical innovations that have brought about dramatic advances in patient care. One such contribution is the hospitalist field, a specialty pioneered here nearly fifteen years ago. Hospitalists—a term coined in 1996 by Dr. Robert Wachter, chief of the Division of Hospital Medicine at UCSF, and Dr. Lee Goldman—are physicians who help comanage internal medicine patients, overseeing emergencies, anticipating and preventing problems, and providing early response treatment when necessary. Hospitalists play a critical role in reducing lengths of stay and rates of readmission and costs, while greatly improving patient safety and quality of care. In 2006, we looked at other patient populations who would benefit from the enhanced quality and safety of care that these physicians provide, and that led us to become one of the first medical centers to implement a “neurohospitalist” service. UCSF’s neurohospitalist program, the only one of its kind in the Bay Area, treats common neurological problems that require urgent treatment, rare or complex disorders that are difficult to diagnose, and neurological conditions that arise from other inpatient conditions such as delirium or confusion. Neurological disorders are diverse, complex, and common, affecting nearly 50 million Americans and costing more than $600 billion each year. Neurology patients in particular tend to have higher rates of complications, and as our population ages, more and more of us will find ourselves in the emergency room in a neurological crisis. The need for more specialized testing, diagnosis, and treatment is imperative. The success of neurohospitalist services such as ours has spawned a national movement to develop similar programs across the country and has played a key role in not only providing superior care to individual patients but also in helping hospital systems run more efficiently.

Hospital News Veteran’s

C. Diana Nicoll, MD, PhD, MPA

Measuring Health Progress in San Francisco A coalition of health organizations has launched a new effort to track and prioritize health improvements in San Francisco. SFMS leaders attended the launch meeting, hosted by the Mayor and Hospital Council.

COMMUNITY VITAL SIGNS Specialists in geriatric medicine at the San Francisco V.A. Medical Center call the traditional approach of advance care planning “fundamentally flawed” and propose a new paradigm. Their proposal is published in the August 17, 2010, edition of the Annals of Internal Medicine. Rebecca Sudore, MD, a SFVAMC physician, notes a number of problems with traditional advance care planning, including the difficulty people have predicting future preferences for medical treatment, the likelihood that preferences and values will change, and the difficulties that clinicians and surrogate decision makers often encounter in attempting to interpret and carry out a patient’s advance care directives. “Up to 76 percent of people will have to have someone else make medical decisions for them at the end of life,” notes Sudore. “We don’t prepare patients and their families to deal with this situation, and it’s difficult for them to know what to do.” Sudore calls for patients and surrogate decision makers to work with clinicians well in advance of any anticipated medical crisis to lay the groundwork to make the best possible in-the-moment medical decisions at the time that end-of-life care choices actually need to be made. She proposes three key steps in preparing patients and surrogate decision makers for making medical decisions at the end of life. The first step for the patient is to choose an appropriate surrogate decision maker and to ensure he or she understands the role. As a second step, patients should start clarifying their end-of-life goals, while realizing that there may be changes in those goals and values over time. Third, patients should give surrogate decision makers permission to work with physicians to make decisions near the end of the patient’s life even if they contradict prior written instructions. This flexibility relieves the stress felt by surrogates and helps them to make better “in-the-moment” decisions on the patient’s behalf.

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

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

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

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*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice. 49813 (5/10) ©Seabury & Smith Insurance Program Management 2010 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • •

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October 2010  
October 2010  

San Francisco Medicine, October 2010. Evolving Specialties in Medicine.