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SAN FRANCISCO MEDICINE / OCTOBER 2005
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IN THIS ISSUE Prescriptions or Prisons? Experienced physicians know that few serious medical problems are wholly “fixable” with only medical intervention. The patient’s habits, social setting and lifestyle, and so on often must be addressed and bettered for that person’s health to have lasting improvement. This is especially true when difficult factors like addiction, mental illness, homelessness, and attendant legal problems are involved. In such cases, a bigger picture is needed. In this issue, our authors address such problems with (often) encouraging views on how medicine and law can work together for the benefit of some of our most troubled patients. Outdated criminal “justice” approaches and priorities are challenged; better, less rigid and more medically-oriented models are described. When such new perspectives are not only more effective in bettering health but also more humane and cost-effective, everybody benefits. This theme issue is dedicated to our late lamented leader Robert Lull, MD. His open mind and dedication made him a champion of just these kinds of forward-looking approaches. He was a scientist and physician who was compassionate almost to a fault, and we know there are many people in our city and beyond who miss him deeply. Send your letters and comments to Managing Editor Edare Carroll at ecarroll@sfms.org.
October 2005, Vol. 78, No. 8
Medicine and Law: Walking the Thin Line Between Care and Punishment 13 Addiction Medicine: New Answers for Old Problems John N. Chappel, MD 15 Methamphetamine Addiction and HIV Disease: A Concurrent Spread of Two Epidemics David E. Smith, MD 19 Harm Reduction in San Francisco Jails Sheriff Michael Hennessey 21 Beyond the Twinkie Defense: Criminal Culpability and Mental Illness John R. Chamberlain, MD 24 San Francisco’s Behavioral Health Court: On the Cutting Edge Honorable Herbert Donaldson and Jennifer Johnson 27 When Mental Illness Meets the Criminal Justice System Jo Robinson, MFT 29 Tom Waddell Health Center: Health Care for the Homeless Barry Zevin, MD 31 Perspective—Medical Marijuana: Curtailing Abuse Steve Heilig, MPH, and Stephen Follansbee, MD 32 Guest Editorial: Female Physicians Express Frustration with the Profession Leo van der Reis, MD
MONTHLY COLUMNS
Of Interest 9
Commentary Sandra Hernandez, MD, and Steve Heilig, MPH
12 Report from the SFDPH John Brown, MD
7
President’s Message Alan G. Greenwald, MD
10 Editorial Corey S. Maas, MD 44 Hospital News
33 2005 SFMS Slate of Candidates
Nominations Report This issue features the SFMS Slate of Candidates running for office as your medical society leaders. Please see page 33. Ballots will be mailed in late October.
http://www.sfms.org
42 Proposition 36 Revisited
MEMBER SERVICES 4
On Your Behalf
43 Member Benefits Page 47 Calendar of Events
OCTOBER 2005 / SAN FRANCISCO MEDICINE
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ON YOUR BEHALF
October 2005, Volume 78, Number 8 Editor
A sample of legislation and advocacy activities SFMS/CMA provide for you
Corey S. Maas, MD
Managing Editor Edare K. Carroll
Copy Editor Cynthia Rubin
Cover Artist Alex Rothwell
Editorial Board Corey S. Maas, Chairman Nancy Thomson, Obituarist Stephen Askin Wade Aubry Toni Brayer Mike Denney Jaqueline Dolev Jerome Fishgold Alan Greenwald Erica Goode Gretchen Gooding Samuel Kao Thomas Lee Arthur Lyons Alan Maloney Rita Melkonian Kenneth Maybury Judith Mates Ricki Pollycove Jordan Shlain Leonard Shlain David Smith Kathleen Unger Leo van der Reis Stephen Walsh Shieva Khayam-Bashi
SFMS Officers Alan G. Greenwald President Gordon L. Fung, President-Elect Stephen E. Follansbee, Secretary Randall Low, Treasurer Corey S. Maas, Editor E. Ann Myers, Immediate Past President
SFMS Executive Staff Mary Lou Licwinko, JD, MHSA, Executive Director Steve L. Heilig, MPH, Director of Public Health & Education Edare Carroll, Director of Communications/Managing Editor Posi Lyon, Director of Administration Thomas Young, Director of Membership
Board of Directors 2004-2006 Lucy S. Crain Stephen E. Follansbee Brian J. Lewis Jordan Shlain
Richard L. Caplin Jane M. Hightower Michael Rokeach
2001-2005 Mei-Ling E. Fong William J. Kapla John B. Sikorski John I. Umekubo
Steve H. Fugaro Charles A. Moser Peter W. Sullivan
2002-2004 Thomas E. Addison James A. Davis Jerome A. Franz Charles J. Wibbelsman
Gary L. Chan George A. Fouras Gordon L. Fung
CMA Trustee Robert J. Margolin
AMA Representatives H. Hugh Vincent—Delegate Judith L. Mates—Alternate Delegate Judith L. Mates—AMA’s Women Physicians Congress Governing Committee
Editorial and Advertising Offices 1409 Sutter Street, San Francisco, CA 94109 Phone 415/561-0850, ext. 261; Fax 415/561-0833 E-mail: ecarroll@sfms.org, web: http://www.sfms.org San Francisco Medicine reserves the right to edit all reader contributions for brevity, clarify and length as well as to reject any subject material submitted. All expressions of opinions and statements of supposed facts are published on the authority of the author over whose signature they appear and cannot be regarded as expressing the view of the SFMS, unless previously adopted by the society. Acceptance of advertising in this publication in no way constitutes approval or endorsement of products or services by the SFMS. Subscriptions: $45 per year; $5 per issue. Advertising rates and information sent upon request.
Printing Sundance Press P.O. Box 26605, Tucson, AZ 85726-6605
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DHS EXPEDITES MEDI-CAL ENROLLMENT PROCESS FOR HURRICANE EVACUEES
The California Department of Health Services (DHS) last week approved an expedited Medi-Cal enrollment process for Hurricane Katrina survivors evacuated to California. The expedited process allows same-day eligibility determinations and minimizes red tape so that patients can get immediate care. Evacuees will be treated as California residents and will be immediately eligible to receive assistance even if they do not plan to make California their permanent home. While evacuees must still meet MediCal’s financial eligibility requirements, any federal disaster assistance does not count toward income and property limits. DHS has also waived its “proof of financial eligibility” requirements, recognizing that many hurricane survivors will not have pay stubs or other paperwork to show that their incomes are low enough to qualify for Medi-Cal. For more information, contact CMA’s Robin Flagg at (415) 8825110 or at rflagg@cmanet.org. HHS SCHEDULING PHYSICIAN VOLUNTEERS FOR SHORT-TERM AND LONG-TERM GULF COAST ASSIGNMENTS THROUGH DECEMBER
Many physicians have contacted CMA to find out how they can assist in Hurricane Katrina relief work. CMA has formed a task force that is in direct touch with the five Gulf Coast state medical societies to learn how physician volunteers can best help alleviate the suffering caused by Katrina. Currently, licensed physicians who can commit to short-term, long-term, or rotating coverage are urgently needed in Louisiana, Mississippi, Alabama, Florida, and Texas. The best way to volunteer is through the U.S. Department of Health and Human Services (HHS), which is managing a
SAN FRANCISCO MEDICINE / OCTOBER 2005
national medical relief effort. Physicians can volunteer at the HHS Health Care Professionals and Relief Personnel Volunteer page at https://volunteer.ccrf.hhs.gov or call its hotline at (866) 5286334. HHS is currently scheduling physician volunteers for short-term and long-term assignments through December via its website and hotline. Relief workers will be nonpaid temporary federal employees, and will therefore be eligible as HHS employees for Workers’ Compensation and also for liability coverage under the Federal Tort Claims Act. Although there will not be any salary, travel and per diem will be paid. Assignments may last 14 days or longer. All physician volunteers must bring their medical license, valid photo ID, DEA license, and prescription pads. PRINTING ERROR NOTED IN AUGUST SAN FRANCISCO MEDICINE
Any member who received a defective copy of the August edition of San Francisco Medicine, on “The Gift of Healing—Physicians Serving the Needy,” should contact Managing Editor Edare Carroll at (415) 561-0850, ext. 261, or by email at ecarroll@sfms.org. Our new printer, Sundance Press, inadvertently deleted pages 7, 8 and 9 and doubleprinted pages 11, 12, 13 and 14. Sundance is reprinting this issue and will mail members a corrected copy. CMA REACHES DEAL WITH GOVERNOR TO PROTECT MEDICAL PHYSICIAN REIMBURSEMENT
CMA recently reached a firm agreement with the Schwarzenegger administration not to cut Medi-Cal physician reimbursement rates this year, despite a court ruling that would have allowed those cuts. The governor also
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agreed to work with CMA to prevent Medi-Cal rate cuts in future years. In 2003, CMA won a federal court injunction blocking the 5 percent MediCal rate cut that was passed as part of the 2003-04 budget. Unfortunately, that injunction was overturned in August when a panel of the U.S. 9th Circuit Court of Appeals in San Francisco found that “neither Medicaid recipients nor providers have a private right to challenge California’s compliance with Medicaid.” The court ruling, which CMA is appealing, opened the door for the administration to cut Medi-Cal reimbursement rates by 5 percent. To prevent such cuts, CMA is sponsoring a bill (AB 1735) that would keep the administration from cutting rates in the current budget year and harming California’s Medi-Cal patients. With overwhelming support of physicians throughout California, the bill attracted wide bipartisan support in both houses of the legislature. Governor Schwarzenegger on Thursday told CMA officials that he will support the bill and that he will work cooperatively with CMA to avoid cuts in the future. California already ranks near the bottom of all states when it comes to physician reimbursement. Physicians are paid $22.80 for the average patient visit. Inadequate reimbursement has already forced many physicians out of the MediCal program, and additional cuts would worsen the problem. Patients unable to find care when they are ill will be forced into emergency rooms, where the cost of care—and eventual cost to the state—is multiplied three or four times. For more information contact David Ford at (866) 462-2819 or dford@cmanet.org. UCSF ONLINE POSTGRADUATE CERTIFICATE IN PAIN MANAGEMENT
The University of California San Francisco Postgraduate Certificate in Pain Management Online Program provides postgraduate education in pain management to students around the world. The program is offered through a
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collaboration between the University of California, San Francisco; the University of Sydney; and the University of Edinburgh. The course may be completed entirely online. For more information call Laurie Snyder at (415) 885-7269, (United States) or visit the website at: http:// mountzion.ucsfmedical-center.org/ pain_management/cert_index.html. SFMS MEMBERSHIP BENEFIT
SFMS Membership Director Thomas Young is pleased to announce the new member benefit of a Wells Fargo credit card and Wells Fargo financial services. The credit card offers cash back at the end of each year based on a percentage of total expenses. It is impossible to list specific pricing here with regard to financial services, because of the breadth of services available, but members are urged to call Karen at (866) 489-1555 to set up a financial interview. Wells Fargo offers exclusive pricing for SFMS members on all of its products and has a dedicated team looking out for your best financial interests. This benefit may be extended to your family and office staff too! In addition, Shred It, the security shredding service used by the SFMS, will soon be offering substantial discounts to members only. Office managers can call Thomas Young at (415) 561-0850, ext. 268, for more information. CMA DEFEATS DEPRESSION CME, ADVERSE DRUG REPORTING MANDATES
A grassroots campaign by CMA physicians and lobbyists led to the defeat of two CMA-opposed bills, one that would have created a new CME mandate and another that would have required physicians to report all adverse drug events to the FDA. In response to CMA’s calls to action, physicians throughout California contacted their legislators and asked them to vote against both of these bills. A big thanks to all CMA physicians who contacted their legislators on these bills.
As reported in the September 1 CMA Alert, the CME bill (SB 524) would have required all physicians who treat patients for depression to complete mandatory CME on the subject. CMA opposes mandatory CME. While CMA does not question the importance of properly diagnosing and treating depression, we believe strongly that CME requirements must remain flexible. The other defeated bill (SB 380) would have required physicians to report all adverse drug events to the FDA’s MedWatch. Physicians already voluntarily report adverse events. CMA told legislators that the cause of adverse events is not always apparent and this bill would force doctors to make a report regardless of the degree of certainty on the cause of the adverse event. This would lead to incorrect data that will not help us better understand and treat our patients. Although both bills have been granted reconsideration by the Assembly, it is unlikely that they will come up for discussion again this year. For more information contact Dave Ford at (916) 444-5532 or dford@cmanet.org. NEW SFMS / CMA HEALTH SAVINGS ACCOUNT PROGRAM NOW AVAILABLE!
The new San Francisco Medical Society / CMA-sponsored Health Savings Account program is now available to members regardless of which qualified high deductible health plan you are enrolled in. The Health Savings Account enables you to make federally tax deductible contributions to the account, earn interest on a federally tax free basis and withdraw funds without penalty for qualified medical, dental and vision expenses. For more information on this new member benefit, call Marsh Affinity Group Services at (800) 842-3761. sfm
Continued in next column
OCTOBER 2005 / SAN FRANCISCO MEDICINE
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Thomas Addison, MD, Receives National Lung Association Award Dr. Thomas Addison, longtime member of SFMS, recently received the American Lung Association’s Michael Stulbarg Memorial California Medal. The California Medal was established more than 40 years ago and was renamed the Michael Stulbarg Memorial California Medal last year in honor of the California Thoracic Society President and amazing volunteer who died in April 2004. Dr. Addison is a respected clinician, teacher and advocate for better access and care for people with lung disease. As the California Thoracic Society delegate to the California Medical Association House of Delegates, he has left a lasting legacy in this state by encouraging his colleagues to support important public polices that protect lung health. He is both a compassionate physician and inspirational teacher. He currently serves as staff pulmonologist at the Permanente Medical Group in San Francisco and clinical professor of medicine in the department of medicine at the University of California, San Francisco. Beginning in 1975, Dr. Addison has served on every California Thoracic Society committee and a variety of American Lung Association committees at both the state and local levels. He served as president of the California Thoracic Society in 1993. He is a strong supporter of policies to reduce tobacco use and was instrumental in convincing the California Medical Association to change its position and support using the funds for tobacco education and control as the voters had intended. Dr. Addison has been recognized for his outstanding efforts over the years and in 2003 was named as one of the “Best Doctors in San Francisco.” In 1999, he won the UCSF Mt. Zion Teaching Award and in 2002, he was awarded Outstanding Inpatient Teacher by Kaiser Permanente San Francisco. He has authored or coauthored more than 20 journal articles and papers on the cause, prevention and treatment of lung disease. He has also volunteered his time and expertise to a variety of medical organizations over the years including the American Medical Association and the National Association for Medical Direction of Respiratory Care. He recently served as president of the California Chapter of American College Chest Physicians and is an immediate past member of the Board of Directors of the San Francisco Medical Society. sfm
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SAN FRANCISCO MEDICINE / OCTOBER 2005
http://www.sfms.org
Alan G. Greenwald, MD President
President’s Message Disaster Readiness
T
his country’s worst natural disaster occurring in Mississippi and Louisiana this past month must serve to force us to assess our own vulnerabilities. We understand natural disasters by living in the land of earthquakes, mudslides and wild land fires. What we have seen in New Orleans is that a strategic disaster in a place of high population density can disrupt the infrastructure indefinitely. What can we possibly do to ready ourselves for the next natural or man-made crisis? Recent terrorism experiences in New York and various European cities have put us on a constant level of alertness. Being prepared for man-made weapons has some bearing on being prepared for other types of emergencies. To that end, our local public safety infrastructure is continually undergoing upgrades regarding communication technology, equipment and training. A large portion of the city budget is spent on safety and disaster readiness. Fortunately we have also been helped by federal Homeland Security grants and other federal organizations. San Francisco, being a city and county, has set up a coordination of government, public safety, hospitals and various clinics. The local government has control of the field through its fire and police stations. The EMS system, as first responders, and the San Francisco General Hospital are under the direction of the local government. They have prepared extensive disaster planning and coordination efforts. But what about the next level of care? Are we all on the same team? The remaining hospitals are independent entities and have their own agenda and priorities, which may be at odds with the local government at times. The local hospital council and organization of emergency physicians meet regularly to coordinate their efforts. We would hope that in a true emergency, institutional and political differences will be put aside. One issue of contention between government and local hospitals and physicians is the ambulance diversion program. The San Francisco Director of Emergency Medical Services of the Department of Public Health, John Brown, MD, has a serious concern about the city’s ability to handle large-scale emergency with its ambulance system. I encourage you to read his Report from the SFDPH on page 12. The current hospital diversion policy allows hospitals to use diversion as an economic mechanism to http://www.sfms.org
manage staffing and patient flow. I believe that his planned policy of ultimately eliminating diversion is on target and would best serve the citizens of San Francisco. In metropolitan areas that have eliminated diversion, hospitals and emergency physician have actually experienced economic benefits from the increased flow of insured patients. Changing the current diversion policy would require hospitals to reorganize their flow of elective services such as cardiac and transplant surgery, which utilize intensive care beds. Some creative management of hospital staff and services could put us on a better footing regarding disaster readiness. San Francisco has its particular geographic difficulties as a peninsula. A large-scale evacuation would generally push everyone south in the event of losses of the Bay Bridge and Golden Gate Bridge. It does not take much imagination to figure out the impossibility of efficient egress when regular rush hours cause backups. It would be unlikely that enough boats would be available to move many people away by water even with the Coast Guard and mutual aid from neighboring counties. The likelihood that people would be stranded in the city is great and their numbers would probably overwhelm any first response effort. The federal government has extensive disaster plans, but as seen in New Orleans, we are probably going to be on our own for at least 72 hours. So here is what we should do. First prepare your own family for 72 hours of self-sufficiency with regard to power, medical supplies, light, food, water, and shelter. Organize a means to find each other in the event of separation and plan on a location to meet if forced out of your residence. Now that we appreciate the potential to lose valuable documents and information, have copies of important materials and records of possessions in a safe remote site. Let your family members in other parts of the country know how to find you in the event of an evacuation. Check out the city preparedness link: www.72hours.org. Prepare your office or clinic for the possibility of providing care during and following a disaster. Participate in hospital readiness and disaster planning by serving on disaster committees and exercising in drills. Know where to show up and what documentation and tools you will need to be able to serve. For information on communicable disease prevention and control, biological events and terrorism, go to: www.sfcdcp.org. OCTOBER 2005 / SAN FRANCISCO MEDICINE
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SAN FRANCISCO MEDICINE / OCTOBER 2005
© 2005 Seabury & Smith Insurance Program Management CA License #0633005 777 South Figueroa Street, Los Angeles, CA 90017 • (800) 842-3761 CMACounty.Insurance@marsh.com • www.MarshAffinity.com • 10/05 http://www.sfms.org
Commentary Sandra Hernandez, MD, and Steve Heilig, MPH
Proposition 73: Dangerous Medicine
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teenage girl sits in her doctor’s office, very upset. “I haven’t had my period for two months,” she says, looking at the floor. “Well, if you have been sexually active, you could be pregnant,” the doctor says. And, after testing, it turns out she is indeed pregnant. Now what? A detailed conversation ensues and she is adamant that she is too young and not ready for motherhood, and wants an abortion. “Have you talked to your parents?” the doctor asks. “Could they help you with this problem?” “They’d kill me!” the girl interrupts. And therein lies a major flaw of Proposition 73, the latest attempt to require “parental notification” for teens seeking abortion. The proposition was put onto the ballot by a wealthy businessman who not only opposes abortion, but also the use of contraception. Such laws have already been struck down in California as an intrusion into the privacy of young women and their doctors, but now he seeks to change our state’s constitution. What could be wrong with requiring parents to be involved? Ideally, nothing. Any parent would likely want to know, and counsel his or her daughter, about an unwanted pregnancy. And in fact most teens would talk to one or both parents—if they could. But not all families are intact, and not all teens have open and healthy relationships with their parents. What about those who are estranged from one or both parents, who have never talked with their parents about sex and their own sexual activity and are afraid, too, who may even be victims of abuse? Embarrassment, denial, cultural taboos, and fear—on the part of not only teens but of parents—often prevent such discussions. Such girls may try to self-abort or seek unsafe abortions, and history tells us how dangerous that can be. The consequence of a teen seeking an illegal abortion in order to conceal her pregnancy from her parents can be catastrophic. The tragic case of Becky Bell, an Indiana adolescent who died from an illegal abortion after such a notification/consent law was instituted in her state, is only one such case. Her parents supported parental consent laws before their loss, but now speak out nationwide against such restrictions. Many other girls and young women have been harmed as well. Good family communication and trust cannot be mandated by government. http://www.sfms.org
The American Academy of Pediatrics opposes parental notification laws, noting that “mandating parental notification does not achieve the intended benefit of promoting family communication, but it does increase the risk of harm to the adolescent by delaying access to appropriate care.” The American Academy of Family Physicians and the American College of Obstetricians and Gynecologists also cite the risk to teens’ health in opposing these laws. The board of directors of the San Francisco Medical Society, composed of leading physicians of all specialties, unanimously opposes Proposition 73. Nurses also know that such laws are flawed and thus the California Nurses Association also agrees Proposition 73 is a bad idea. The United States still has one of the highest rates of unintended pregnancy among teen girls in the developed world. Everyone’s goal should be to reduce these pregnancies, but we have not yet agreed on how to do that. A few abortion opponents think we’ll achieve it by forcing girls to talk with their parents first. There is no evidence to support that assertion. Proponents of Proposition 73 even admit that tragedies such as the East Bay case where a girl died after taking the “abortion pill” would probably not have been prevented by a parental notification law. But still they seek to use frightened teens as pawns in their single-minded efforts to ban abortion. The truth is that the only way to prevent abortions is to prevent unwanted pregnancies. That takes solid sexual education, access to good contraception when a teen does become sexually active, and access to good health care at every point in a teen’s development. All the parental laws, well-intended or not, will not replace the need for these services; in fact, it will drive some girls away from their doctors—and from their parents. Let’s not further punish some of our most vulnerable young women with a law that could deny them their opportunity for a healthy future. Dr. Sandra Hernandez is a practicing physician, CEO of the San Francisco Foundation, and former director of public health for San Francisco. Steve Heilig is with the San Francisco Medical Society, founding coeditor of the Cambridge Quarterly of Healthcare Ethics, and a former sex educator with Planned Parenthood and public and private schools.sfm OCTOBER 2005 / SAN FRANCISCO MEDICINE
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Corey S. Maas, MD Editor
Editorial Commemorating the Life of Robert Lull, MD We lost a good friend and colleague in May—Dr. Robert Lull. His tragic death was highlighted in the media but the profound impact this loss has had on those who worked with him at the medical society, and within the greater community of physicians in San Francisco, cannot be overstated. Anyone who attended the standing-room only memorial service at the SFMS headquarters in June can attest to the outpouring of grief at his absence and expression of gratefulness for having known him at all. Bob was a very intelligent, genuine and likable person. Despite his already having served in my position as editor of San Francisco Medicine, he nearly always found time to attend our editorial board meetings. He provided thoughtful input and yet was humble and self-effacing in his suggestions. He was a real team player. The SFMS Editorial Board was moved to devote this special issue of San Francisco Medicine to attempt to come to terms with his tragic passing and offer some light on the fact that the mentally ill and criminally insane will never be rehabilitated in a criminal justice sytem. As most of you know, Bob also served as the President of our SFMS in 2002 and was very active in all aspects of our SFMS activities. His kindness, sincerity and generosity were always noted and appreciated by our medical society staff and colleagues. Death is part of medicine and I think we are all reminded, certainly in some specialties more than others, how short a lifetime is and how the measure of our lives is the impact that we have on others. It is beyond the scope of this tribute to discuss all the ways that Bob Lull made an impact on those around him, but they say a photo is worth a thousand words. For Dr. Robert Lull, a quote in remembrance: “When it’s all over, it’s not who you were. It’s whether you made a difference.” Bob made a difference. May he rest in peace.
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We miss you, Bob. Thanks for the memories. http://www.sfms.org
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John Brown, MD Director, Emergency Medical Services
Report from the SFDPH Ambulance Diversion: It’s Time for a Change
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mbulance diversion—the practice of allowing hospital emergency departments to close temporarily to ambulance traffic without affecting other ways patients arrive to be treated in emergency departments—has caused problems for patients, physicians, paramedics, and disaster preparedness since it was initiated in the early 1980s. Patients dislike diversion because it keeps them from reaching their hospital of choice by ambulance. To circumvent the ambulance diversion system, some patients inappropriately drive or walk in to the Emergency Department, placing themselves and others at unnecessary risk. Physicians practicing general medicine and specialty care dislike diversion because it impedes their ability to transfer patients via ambulance from home or their doctor’s office to a hospital where the physician has admitting privileges. Emergency physicians dislike diversion because it makes emergency department overcrowding the emergency department’s problem, not the hospital’s. Paramedics dislike diversion because it complicates the triage and destination decision process. Paramedics also dislike ambulance diversion because it prevents them from definitively informing family where their relative will be transported. Finally, ambulance diversion is detrimental to disaster preparedness because it allows hospitals to respond to temporary patient surges by “pushing back” patients into the EMS system, instead of “pushing forward” with rapidly deployable patient care surge capacity, which is necessary in serious multicasualty incidents or disasters. Although many may dislike diversion, it is best viewed as an imperfect solution to the problem of emergency department overcrowding. None of us wants a critically ill patient to receive substandard care because the emergency department is overwhelmed with other patients. This is especially regretable if other hospital emergency departments are empty. Unfortunately, with the decrease in the number of emergency departments in San Francisco, coupled with increased need for emergency services, diversion has gone from being a safety valve for rare hospital events to being used regularly to manage variations in patient flow and chronic staff shortages.
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In order to control the overuse of diversion, the Emergency Medical Services Agency has made a number of reforms in diversion policy. First, we simplified the diversion policy from two tiers (critical care and emergency department) to one (total diversion). Second, we decreased the maximum number of hospital facilities that have to be on diversion for diversion to be suspended (once too many hospitals are on diversion, diversion no longer serves any purpose). Now we are working to implement EMS system fleet management methods that eliminate potential geographic or provider bias for ambulance crews (e.g., the practice of taking patients to the facility nearest their station despite patient or physician wishes). The next step in diversion reform is to revise the ambulance destination policy to incorporate recent evidence-based changes in medical therapy for patients suffering from acute coronary syndrome and stroke. We will be evaluating the recent medical literature and involving clinicians with expertise in the inpatient and follow-up management of these conditions, in addition to informing our EMS and emergency medical providers, in setting new ambulance destination policy. This policy would acknowledge the development of stroke center and acute chest pain center designations as well as diagnostic and therapeutic options for field personnel. When patient medical need is better matched to hospital capability, we hope to see less time- and resource-consuming patient transfers and less use of diversion. The EMS Agency will be revising ambulance destination and diversion policies during the coming year, and we invite input from the San Francisco Medical Society and system health care providers. Visit our website at www.sanfranciscoems.org, and look for these policies to be put up for public comment and discussed at our EMS Advisory Committee meetings this winter and spring. Help us to assure that the new policies are the best possible for patients, physicians, EMS providers, and preparedness. Comments about these policies can be sent to John.Brown@sfdph.org.sfm
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MEDICINE & LAW
Addiction Medicine: New Answers for Old Problems John N. Chappel, MD
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very physician has had experience with alcoholics and drug addicts. All too often that experience is negative, resulting in frustration and pessimism. A colleague once asked me, “Why do you try to treat alcoholics and drug addicts? I’ve never known any to get better.” Even my psychoanalyst, an otherwise fair person, has asked me why I choose to work with “the dregs of society.” The short answer to these questions is that addiction medicine is both challenging and fascinating. The reward comes when our alcoholic or other addicted patients get into stable recovery. When this occurs, usually through working in a 12-step program of recovery in Alcholics Anonymous (AA) or NA (Narcotics Anonymous), the formerly hopeless case may become “weller than well.” Addiction medicine has developed slowly as a subspecialty in medicine. In 1804 Benjamin Rush, MD—a cosigner of the Declaration of Independence and the father of American psychiatry—described alcoholism as a disease for which the treatment was abstinence. For over a century medical treatment of chronic alcoholics consisted in lengthy stays in “insane asylums.” The results were so poor that a moralistic view replaced the medical view. With the advent of
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Prohibition (1919-1933) several physicians were arrested and incarcerated for trying to treat opioid addiction with pharmaceutical opiates. The result was a surgical excision of addiction treatment from medical education. We were advised to leave alcoholics and other drug addicts to religion or the criminal justice system. In my medical school in the 1950s, we had one hour on alcoholism. That hour was taught by a visiting expert, not by one of our faculty role models. The separate developments of AA (1935), prison hospitals for the treatment of addiction (1930s to 1950s), and methadone maintenance (1963), combined with the unusual action of the AMA in declaring that alcoholism was a disease, culminated in 1970 with the passing of the Controlled Substance Act and the establishment of the National Institute for Alcoholism and Alcohol Abuse (NIAAA) and the National Institute of Drug Abuse (NIDA). These institutes cosponsored the Career Teacher Program in Alcohol and Drug Abuse, which in its first decade resulted in a sixfold increase in curriculum hours in the medical schools that had career teachers (about 50 percent). Residency training was almost untouched by these developments. In 1972 the California Society for the
Treatment of Alcohol and Other Drug Dependencies was the first medical organization to formally classify doctors who treated alcoholics in the same category as doctors who treated other drug addictions. The development of the Minnesota model of residential treatment for alcoholics also created a role for physicians on the treatment teams. Further stimulus was provided by a number of physicians who had finally received good treatment for their own addictions, and left their original medical specialties to work in addiction medicine. In 1983, the California society developed the first certification exam in addiction medicine. This move was stimulated by the growing insistence of health insurance companies and legislators that we know what we are doing. In 1986 the first national medical organization was formed under the cumbersome name of the American Medical Society on Alcohol and Other Drug Dependencies (AMSAODD). The California society gave the certification exam it had developed to this national organization and became one of its state associations. In 1989, the AMSAODD became the American Society of Addiction Medicine (ASAM), the California society became CSAM, and the AMA recognized addiction medicine as a subspecialty of medicine (ADM).
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Addiction Medicine Continued from page 13 ASAM then developed a textbook to complement the certification exam.1 Psychiatry, in the meantime, had been developing its own interest and competence in addiction treatment. In 1980 the Diagnostic and Statistical Manual (DSM III), for the first time, included a chapter on Substance Use Disorders. The American Academy of Addiction Psychiatry (AAAP) was formed. In 1989 the Residency Review Committee (RRC) for psychiatry began requiring a structured experience in alcohol and drug dependence treatment. In 1993 the first American Board of Medical Specialties (ABMS)–approved examination was given for a Certificate of Added Qualification (CAQ) in Addiction Psychiatry. Since 1998 a one-year fellowship in addiction psychiatry has been required before being eligible to take this exam. In the meantime the development of residency training in addiction medicine has been slowly developing. A national study of 1,831 residency directors from family medicine (n=448), psychiatry (n=192), internal medicine (n=406), pediatrics (n=212), obstetrics and gynecology (n=261), emergency medicine (n=113), and osteopathic medicine (n=199) was conducted in 1999 by M. F. Fleming and his colleagues. A wide variation was found. Psychiatry reported the highest rate of required curriculum (96 percent) with a median of 10 hours. Family medicine was second, with 75 percent and a median of eight hours.2 The other specialties reported that 55 percent or less had a required curriculum and the median hours ranged from three to five. Of greater concern was the fact that less than 10 percent of the faculty performed clinical work in alcohol and drug treatment programs. Twelve percent of the faculty responsible for teaching addiction medicine were certified by 14
ASAM and 7 percent had the CAQ in addiction psychiatry. While medicine has been slowly developing its response to addiction disorders and shifting from an acute-care emergency-room response to the more accurate chronic care reality,3 the picture in our jails and prisons is much worse. The addictive disorders, which affect about 75 percent of the developed world’s largest incarcerated population, are, with a few exceptions, ignored. The judiciary has begun to respond to this massive problem by developing drug courts. The success of these courts has led to the development of mental health and co-occurring disorders courts. The judges who come to the National Judicial College for courses in the new field of Therapeutic Jurisprudence express frustration at the difficulty they encounter in finding physicians who have interests and skills in these areas. CSAM, (415) 927-5730, offers a three-day course each year in October designed to help physicians add to their knowledge base and get started in developing their clinical skills in addiction medicine. These courses alternate between a Review Course, which focuses on the fundamentals, and a State of the Art Course, which brings the most recent research and new developments in ADM to physicians who attend. Buprenorphine (Suboxone) and acamprosate (Campral) are two of the new medications that primary care and other physicians can use in treating their alcohol- and other drug-dependent patients. The combination of knowledgeable prescribing, interest in helping addicted patients, and skill at referring to and supporting 12-step participation can change a formerly frustrating professional experience into one that is satisfying and rewarding. Born in Alberta, Canada, Dr. Chappel received his MD degree from the University
SAN FRANCISCO MEDICINE / OCTOBER 2005
of Alberta in 1960. Following an internship and general practice in Alberta and Malaysia, he received an MPH from the Harvard School of Public Health in 1965. During a psychiatric residency at the University of Chicago from 1965 to 1968, and then as a faculty member, he began working with alcoholics and heroin addicts in the Illinois Drug Abuse Program. In 1974 he came to the University of Nevada as a career teacher in Alcohol and Drug Abuse and established the current training in addiction medicine at the medical school. From 1989 to 1998 he was a nonalcoholic trustee on the General Service Board of Alcoholics Anonymous. This experience stimulated a major interest in the nature of recovery from addiction, including the roles of spirituality and working with a 12-step program of recovery. He is certified by the American Society of Addiction Medicine and helped develop both the certification exams and review courses given by that organization. He also obtained, by examination, the Certificate of Added Qualification in Addiction Psychiatry of the American Board of Psychiatry and Neurology.
REFERENCES
1. Graham AW, Schultz TK, MayoSmith MF, Ries RK, Wilford BB (Eds). Principles of Addiction Medicine, Third Edition. ASAM Inc., Chevy Chase, MD 2003. 2. Fleming MF, Manwell LB, Kraus M, et al. Who teaches residents about the prevention and treatment of substance use disorders? A National Survey. J Fam Practice, 48(a): 725-729, 1999. 3. McLellan AT, Lewis DC, O’Brien CP. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA, 284 (13): 1689-1695, 2000. sfm
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MEDICINE & LAW
Methamphetamine Addiction and HIV Disease: A Concurrent Spread of Two Epidemics David E. Smith, MD
O
ur California Senator Dianne Feinstein, in her decade-long effort to help the government crack down on the nation’s growing methamphetamine epidemic, introduced a bill to limit an individual’s purchases of drugs containing pseudoephedrine to 7.5 grams a month from about 250 capsules. Similarly, retailers would be required to send computer records of purchases to state databases to ensure that no individual exceeds the purchase limit. The bill also sets up a national methamphetamine treatment center to research the best ways of helping addicts kick their habits. Senator Feinstein has described the methamphetamine epidemic as the single worst drug threat that any of us has faced in our lifetime. She cites national data showing that the number of meth labs raided jumped to 15,994 in 2004, from 7,438 in 1998. She also says that in San Francisco the use of methamphetamine, with its associated compulsive sexuality, has led to a spike in sexually transmitted diseases, including a resurgence of HIV disease among gay men. This was demonstrated by the increase of new infections of HIV (which are resistant to current medications) in gay men using methamphetamine and participating in high-risk sex. Thus emerge the twin epidemics of methamphetamine addiction and HIV disease. They coalesce to spread drug-
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resistant strains of the virus. Dr. Martin Fensterscheib, Santa Clara County Public Health Officer, confirmed the increased likelihood of multiple strains of new HIV infection with the increased probability of a drug-resistant strain of the HIV virus. The epidemic of methamphetamine and HIV was eloquently described in the addiction medicine publication New Times by Mark Gillard in an article entitled “Methamphetamine and HIV.” He described the typical pattern of abuse of methamphetamine in association with high-risk sexual practice, followed by the comedown or crash, in which the individual feels depressed while attempting to lead a normal life outside of the South of Market “gay speed scene” in San Francisco. In a major Los Angeles study this last year, nearly one in three gay and bisexual men who tested positive for HIV acknowledged using crystal methamphetamine. This is almost triple the rate of methamphetamine use in HIV-positive men in 2001. Officials at the Los Angeles Gay and Lesbian Center presented data based on 19,300 tests over four years at the National HIV Prevention Conference. The general agreement is that the methamphetamine problem is a growing threat to gay and bisexual men. Dr. Jeffrey Klausner, director of sexually preventive disease control in San Francisco, likewise emphasizes how serious this growing problem is. Quentin
O’Brien, the Gay and Lesbian Center’s Director of Health and Mental Health Services, calls the increase “startling,” believes it is now inching upward, and says it is uncertain when the peak will occur. The likelihood of unprotected sex has long been associated with methamphetamine abuse by increasing arousal and reducing inhibitions, the drug often also prompts users to seek sex with multiple partners, thus heightening the risk of contracting HIV. Increasing high-dose methamphetamine abuse is associated with increase in sexual fantasies, but as noted in our 1980 study titled “High-Dose Methamphetamine Adult Sexual Dysfunction,” the result has been not just sexual enhancement but also erectile dysfunction. Consequently, many gay men are combining methamphetamine and Viagra. In fact, a recent presentation indicated that the highest per-capita sales of Viagra were in the Castro district of San Francisco. A recent Robert Woods Johnson project was commissioned to study the growing misuse of Viagra in young gay males abusing methamphetamine because of the public health concerns over this drug combination and its relationship to the spread of HIV/ AIDS. However, when these drugs are mixed to overcome the sexual dysfunction effects of methamphetamine, safe sex is
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Methamphetamine Addiction and HIV Continued from page 15 often left by the wayside. And as Gillard describes, the rectal chafing from compulsive sexuality increases the likelihood of viral transmission, and combining the drugs also raises the incidence of heart attacks and stroke. “We’re losing people to the effects of multiple methamphetamine drug use as well as to HIV disease,” he writes. There is also an increase in serious cardiovascular disease with this younger population abusing methamphetamine. Dr. Terry Neill of the UCSF department of neurology recently reported methamphetamine-induced strokes in 30- to 40year-old males and females that were longlasting and difficult to treat because of the associated toxic periarteritis. A GLOBAL PROBLEM
The twin epidemic of speed and AIDS is not confined to the United States, but is now global in nature. Walter Ling and Richard Rawson of UCLA, leaders in methamphetamine research and treatment, have described a rapidly increasing methamphetamine epidemic in Thailand and other Southeast Asian countries. There methamphetamine addiction has fueled both IV drug abuse and unsafe sexual practices, including widespread prostitution relating much more to heterosexual activity and also contributing to the rapid spread of HIV disease. JVR Prasoda Rao, regional director of the United Nations AIDS Support team for Asia and the Pacific, posted the second highest increase in HIV/AIDS rates in a region home to more than one half the world’s population. At the 2005 Seventh International Congress on AIDS in Asia and the Pacific, he described this epidemic surge as the “silent tsunami,” potentially killing many more people than the thunderous December 2004 disaster in southeast Asia.
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TREATMENT OPTIONS
The development of specialized treatment, including research into new medications, is crucial for dealing with this methamphetamine epidemic. Kathy Jett, at the 38th Anniversary Conference of our Haight Ashbury Free Clinics, indicated that Proposition 36, the Diversion to Treatment in the Criminal Justice System program, placed more than 30,000 drug offenders in treatment during the first year—more than half of them being treated for the first time. Jett indicated that although specialized treatment is needed for methamphetamine addiction, effective treatment can be quite successful as demonstrated by many of the recovering methamphetamine abusers who attended our Haight Ashbury Free Clinics Conference and are participating in our stimulant recovery groups.1 Cathy Reback, a researcher and director of prevention at the Van Ness Recovery House in Hollywood, stressed that in the past, addiction recovery and HIV treatment programs did not collaborate, but that now there’s a big move toward expanding collaboration between them—an integration that’s long been emphasized at programs like the Haight Ashbury Free Clinics. To be effective, specialized treatment for methamphetamine addiction must deal with the methamphetamine-related sexual issues, including sexually transmitted diseases as well as comorbid psychiatric disorders. It is hoped that the national specialized methamphetamine treatment center proposed by Senator Feinstein will emphasize the integration of treatment for methamphetamine addiction with comorbid medical and psychiatric disorders. Gabrielle Antolovich, editor of New Times, has published a list of specialized treatment programs for methamphetamine abuse, including Gateway House in the San Jose area, (800) 488-9919. Information also can be obtained from the National Council on Alcoholism and Drug Dependence’s Information Clearinghouse at 1415 Koll Circle, Suite
101, San Jose, CA 95112. The Haight Ashbury Free Clinics offer specialized methamphetamine recovery group programs as well as inpatient and outpatient treatment, focusing on some of the special needs of methamphetamine abusers. MISPLACED PRIORITIES
We in addiction medicine applaud Senator Feinstein’s heroic leadership in dealing with the methamphetamine epidemic, including reduction of the availability of pseudoephedrine (which is well known for being converted into methamphetamine) and the development of a national specialized methamphetamine treatment center. The question is why the current administration’s White House Office on Drug Abuse Policy hasn’t paid more attention to the surging methamphetamine epidemic and its association with the growing HIV problem. At a recent White House Office on National Drug Control Policy (ONDCP) visit to the state of California, we posed that question to representatives of the ONDCP. They persisted in putting their emphasis on the issues of medical marijuana as a higher priority. While medical marijuana may be a political and ideological priority for this administration, and is a significant medical practice issue (which has been thoroughly reviewed by the American Medical Association), it is far from being the number-one drug problem in the United States and pales in comparison to the methamphetamine epidemic in terms of urgency.2 I posed a similar question to a congressional representative at a meeting in Washington, D.C., recently and he stated that the methamphetamine problem, which started in California and spread to the rural areas of the United States, is considered a “fly-over zone” problem in the Beltway. He explained that rural middle America is called the “fly over zone” by our leaders in the Notheast corridor and that until the methamphetamine epidemic hits the Beltway, it will not be a priority for this administration.
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Methamphetamine Addiction and HIV
The Second Annual Phoenix WellCare Conference
Continued from page 17 In a recent article by the Center for Substance Abuse Research, the headline read, “Methamphetamine Named Top Problem by Majority of County Law Enforcement Agencies in western U.S.—Will the East Follow?” The article states that more than one-half of 500 county law enforcement agencies in the U.S. report that methamphetamine is their primary drug problem, according to a recent survey conducted by the National Association of Counties. Three-fourths of law enforcement agencies in the Northwest and Southwest regions reported that, based on drug-related arrests in the last year, methamphetamine was the biggest problem in their county. More than one-half of responding agencies in the upper Midwest (67 percent) and lower Midwest (57 percent) reported the same. In contrast, around one fourth of agencies in the Southeast and only 4 percent of those in the Northeast reported methamphetamine as their number-one drug problem. While these findings support previous research indicating that the West and Midwest have been hit hardest by methamphetamine use, they also suggest that the eastern U.S. should be vigilant for any increase in methamphetamine-related problems. Until the methamphetamine epidemic hits the Northeast and becomes a political priority for members of this current administration, they will continue to be out of touch with the nation’s addiction priorities and therefore will provide an ineffective response to this current epidemic. It is hoped that Senator Feinstein’s leadership can redirect national priorities to the true public health and safety needs of our country, including targeting the serious twin public health epidemics of methamphetamine addiction and HIV disease. We in the medical community have a responsibility to support political leaders like Senator Feinstein, who base their policies on scientific fact and public health priorities, rather than on political ideology.
21st Century
Nutrition
Focus on nutrition,
&
Environmental Health
immunity and longevity issues
November 5, 2005 at the historic Fairmont Sonoma Mission Inn and Spa, Sonoma, CA For those who wish to serve as resources for patients interested in complementary medicine, alternative therapies and healthy living practices. This activity has been approved for Category 1 AMA/PRA Credit. Visit phoenixwellcare.com for registration information, or call us at 707.255.2818. Morning Keynotes Eleanor Hynote, MD; Advanced Clinical Nutrition Update David Brady, ND, DC; Innovative Testing for Integrative Practices Connie Grauds, RPh; Jungle Medicine: Ancient Wisdom, Modern Science Afternoon Workshops, Exhibits, Demonstrations Gourmet, Organic Lunch; Organic Beverage Reception, Overnight Spa Special
Dr. Smith is the founder, president and medical director of the Haight Ashbury Free Clinics, Inc. He is also past president of the American Society of Addiction Medicine and associate clinical professor at UCSF and medical director for CA State Drug and Alcohol Programs. REFERENCES
1. Smith, D & Heilig, S. Addiction as a brain disease: Methamphetamine as a case study. San Francisco Medicine, Volume 77 (5 ), pp. 13–15, May, 2004. 2. Smith DE, Heilig S, Editors. Marijuana at the millenium: medical and social implications. Journal of Psychoactive Drugs, Volume 30(2), 1998. 18
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MEDICINE & LAW
Harm Reduction in San Francisco Jails Sheriff Michael Hennessey
I
n the San Francisco Sheriff ’s Department, the concept of harm reduction is employed in the administration of the county jails in three distinct fashions: providing freedom from physical harm for people in custody; providing rehabilitative programs for prisoners that address addiction, violent behavior and educational deficiencies; and providing post-release employment and educational opportunities for those released from our jails. We believe that by thinking in terms of harm reduction inside the jails, we are also reducing harm to the community, as the ex-offenders who return to live in the community are less likely to commit new crimes. San Francisco has one of the largest county jail systems in the country. Our daily prisoner population is about 2,000, but we have over 45,000 admissions per year. One of the most difficult tasks facing the department is keeping people safe from harm while they are in our custody. Key to this goal is a sophisticated prisoner classification system, which begins the minute an arrestee enters our system. Each new admission receives personal interviews from both medical personnel and deputy sheriffs. The information gleaned in these interviews is augmented by computerized criminal justice record checks. Among the important factors considered: prior prison experience or lack thereof; suicide attempts or other mental health issues; matters of
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physical health or disability; any history of escape or escape attempts; current or past charges of violence; and issues of sexual identity that could lead to vulnerability. After we distill this information, a housing or placement decision is made with the goal of grouping prisoners with similar levels of sophistication or special housing needs. Ideally, the jail system would have sufficient single-cell housing to allow the classification system to work to its maximum potential. While our jails lack sufficient single-cell housing, our classification system has resulted in our jails being far below the national average in incidence of prisoner assaults, suicides and sexual batteries. Even though the state of California has only this year added the word “rehabilitation” to the title of its prison system, now calling it the California Department of Corrections and Rehabilitation, the San Francisco Sheriff’s Department has for the past 30 years consistently emphasized rehabilitation programs as the goal of incarceration. While our focus has traditionally been on incustody programs, we have recently greatly expanded our post-release programs by opening an innovative and unique charter high school for prisoners and ex-offenders. The demographics of the county jail are the demographics of poverty and addiction. It should be of no surprise to learn that most people in the San Francisco jails are substance abusers. For more than 45
percent of the prisoner population, the most serious criminal charge faced is a drug charge. Many other prisoners are in custody for theft crimes, such as burglary, auto theft, petty theft, etc., which are related to their drug and alcohol dependencies. And about one fourth of the jail population faces serious felony charges for crimes of violence. The overwhelming majority of our local prisoners were unemployed for a significant period prior to arrest, did not graduate from high school and, although they have a bail amount set that could secure their immediate release, have no money or assets for bail. They also share one other very important factor in common: Within a matter of weeks or months, they will all be getting out and coming back into our community. The programs offered by the Sheriff’s Department focus on substance abuse, education, family reunification, and employment preparation. Over the years we have been fortunate to receive start-up grants from the federal government as well as from local and national foundations. We also benefit from a wealth of area agencies that provide services in the jails and that are available to provide services to prisoners upon release. One of the most effective forms of treatment in custody is an approximation of a “therapeutic community model” within the jail. We began using this approach in
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Harm Reduction in SF Jails Continued from page 19 1993 with a challenge grant from the U.S. Department of Health and Human Services to create a women’s drug treatment therapeutic community within our jail. In this model, known as the Sister Program, a group of 40 to 50 women live in a selfcontained housing unit and participate all day in drug counseling, parenting classes, basic education, life skills training, and other efforts to mirror the experience of living in a halfway house environment. Our partner in this program is Walden House, one of the nation’s most respected drug treatment programs. In fact, many of the women enter the Walden House residential program upon release from jail. A 2003 study showed significant success with this approach: Sister participants had a 28 percent recidivism rate compared to a 60 percent rate for a nontreatment control group. After seeing the potential of the women’s drug treatment program, we expanded our efforts in 1995 to create a parallel program for men, called Roads to Recovery. Our 2003 survey of this program also shows a significant reduction in recidivism: 48 percent recidivism, compared to 60 percent in a control group, which is encouraging, but not as dramatic as with the women offenders. In 1996 we decided to press the limits of the therapeutic community model in a jail setting and dedicate a housing unit to a program specifically for violent prisoners. This program, called Resolve to Stop the Violence Project, or RSVP, is based on the restorative justice principle that crime hurts victims, communities and offenders and that justice should include an attempt to repair the harm that crime causes. RSVP places 60 men charged with violent crimes, or with a history of violence, in a dormitory setting where they are immersed in an intense, peer-based self-evaluation process that examines what causes a man to use violence as a form of control and communication. We emphasize three main
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components: offender accountability, victim restoration and community involvement. RSVP’s motto is: Violence is learned; It can be unlearned. With the prisoners, this is achieved through five basic steps: by raising awareness of social, cultural and personal belief systems that promote violence; teaching that one has a choice as an alternative to violence; improving communication skills; creating empathy for
❝ Our most recent effort to change the lives of those in custody is the creation of Five Keys Charter High School, the nation’s first injail charter high school. Recognizing that fewer than half of the prisoners we release have a high school disploma, we looked for a way to get them back on the education track.❞
victims and their families; and emphasizing the need to make positive contributions to the community upon release. Survivors of violent crime play a key role in the program, too. They were part of the planning group that created the curriculum, they participate in frank dialogue with offenders every week in a session we call Victim Impact, and they receive services at a community resource center dedicated to providing direct assistance and counseling to the victims of the offenders in our program. RSVP has become one of the most studied jail programs in the country. Dr. James Gilligan, director of the Center for the Study and Prevention of Violence at the University of Pennsylvania, has been engaged in an evaluation of this program for the past eight years and the results are
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more amazing than we could have predicted. For a violent offender who participates in the program for four months, there is an 80 percent lower likelihood that he will be rearrested for a violent act when compared to a control group of similar offenders. A violent offender who spends three months in the program is 51 percent less likely to be rearrested for a violent act. The uniqueness and success of this program was recently recognized with the 2004 Innovations in Government award by the Ash Institute at Harvard University and the Council for Excellence in Government. Our most recent effort to change the lives of those in our custody is the creation of Five Keys Charter High School, the nation’s first in-jail charter high school. Recognizing that fewer than one half of the prisoners we release from jail have a high school diploma, we looked for a way to get them back onto the education track and to improve their chances of obtaining gainful employment. With the support of the San Francisco Unified School District and the San Francisco Board of Education, we created a certified charter high school that must meet the same educational standards required of every California high school. By creating a charter school, we became eligible for state funding based on our ability to maintain a stable population of prisoner-students who spend a minimum of six hours per day in approved classes. Now beginning our third school year, we have 11 full-time teachers, a principal, a registrar, a small support staff and 225 students per day. We have had 19 students graduate with full high school diplomas and hundreds more gain credits toward their graduation requirements. Recognizing that most county jail terms are relatively brief, we have also entered into a long-term lease of a building near San Francisco’s Hall of Justice and have renovated it into a post-release continuation high school and resource center for ex-offenders. Our goal is not only to provide them with educational opportunities, but also to offer the other forms of guidance and counseling that may serve to keep them out of jail in the future.
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MEDICINE & LAW
Beyond the Twinkie Defense: Criminal Culpability and Mental Illness John R. Chamberlain, MD
M
r. A lives alone in an apartment and attends a local college. Recently, neighbors have complained Mr. A has begun to play loud music late at night and shout—although they have not noted any visitors. One day, Mr. A confronts a neighbor, Mr. B, and accuses Mr. B of working against him and for the “politburo.” He tells Mr. B to stop these “activities” at once. Later in the week, Mr. A walks up to Mr. B, says he warned Mr. B to “desist,” produces a knife, and repeatedly stabs Mr. B. The police arrive and take Mr. A into custody. He is muttering about having “stopped them” and having “got the bastard.” Defense counsel raises a question about Mr. A’s sanity. Looking at the above vignette, the reader might have one of several reactions. Is Mr. A “crazy”? Did Mr. A have some vendetta against Mr. B? Was Mr. A using some substance and intoxicated at the time of the attack? Does Mr. A have some physical or neurological condition that could explain his behavior? Is Mr. A “faking” being ill to get away with his behavior? The behavior described above is aberrant, violent and socially unacceptable. This is a case where most health professionals would expect the legal system to solicit assistance from the medical profession to help determine what was happening prior to and during the attack.
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Let us assume that appropriate professionals are consulted to evaluate Mr. A. Their investigation, as well as that of the authorities, reveals Mr. A stopped attending classes six weeks earlier and had
❝ While the question of whether he is malingering remains, there does seem to be evidence of a psychiatric problem affecting Mr. A. However, in the legal system the presence of a mental illness is not the ultimate issue in a case involving the insanity defense.❞
withdrawn from most social contacts two to three months before. He and Mr. B had never had any significant interactions or conflicts. Mr. A occasionally smoked marijuana but toxicology tests were completely negative. Physical and neurological examinations were normal.
He had a family history of schizophrenia. In light of the above information, some of the questions initially posed have been answered. Mr. A had no known vendetta against the victim, he was not intoxicated, he had no evidence of a physical or neurological disorder to explain the behavior. Further, he had a history of behavioral changes over a significant period of time before the attack. While the question of whether he is malingering remains, there does seem to be evidence of a psychiatric problem affecting Mr. A. However, in the legal system the presence of a mental illness is not the ultimate issue in a case involving the insanity defense. Although mental illness is a matter of importance in legal settings, especially criminal cases, insanity is a purely legal construct. This issue is recognized in the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. The introduction reads, “The purpose of DSM-IV is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders. It is to be understood that inclusion here, for clinical and research purposes, of a diagnostic category . . . does not imply that the condition meets legal or other nonmedical criteria
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Beyond the Twinkie Defense Continued from page 21 for what constitutes mental disease, mental disorder, or mental disability.”1 Further, it is important to realize that different standards are used to define “insanity” in different jurisdictions. As a result, a defendant may be considered insane in one jurisdiction but not in another even though she or he performed the same action with the same mental condition. An important concept in the American legal system is that of criminal responsibility. An individual is criminally responsible if the prosecution can prove beyond a reasonable doubt that his or her behavior satisfies the criteria for all elements of the crime and no defense of justification or excuse can be demonstrated.2 In the American legal system, a crime consists of an actus reus (the guilty act) and a mens rea (the guilty mind). The presence of these factors must be proved beyond a reasonable doubt by the prosecution for the defendant to be convicted of a crime. In the above example, there is little doubt that an actus reus was present—a man was stabbed. Further, a mens rea appears to have been present as well—the perpetrator threatened the victim, obtained a weapon, and confronted the victim again before making an attack. However, the question must be asked, What is the impact of the defendant’s mental state on these issues? The concept of criminal responsibility is based on the fact that each person is considered responsible for his or her behavior unless she or he falls into certain groupings of people; those categories include children and those unable to understand the need to behave responsibly.3 In the 17th century, Sir Edward Coke cited the principle “actus non facit reum nisi mens sit rea,” or “an act does not make a person guilty of a crime unless that person’s mind be also guilty.”4 In the sixth century under the Emperor
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Justinian’s codification of law it was determined that “[an] infant or a madman who kills a man is not liable under the lex cornelia—the one being protected by the innocence of his intent, the other excused by the misfortune of his condition.”4 When we review these standards, it is apparent that legal rules do not identify which of the described mental disorders constitute a “mental disease” or “mental defect” for the purposes of the legal system. Rather, these standards identify the effects that must result from the disorder to meet the criteria for insanity. 5 This characteristic has persisted to the present.
❝ According to California Penal Code Section25.5, ‘in any criminal proceeding in which a plea of not guilty by reason of insanity is entered, this defense shall not be found by the trier of fact solely on the basis of a personality or adjustment disorder, a seizure disorder, or an addiction to, or abuse of, intoxicating substances.’ ”❞
For example, one of the commonly used standards for determining the presence of legal insanity is the M’Naghten standard from the 19th century. According to this standard, “every man is presumed to be sane, and to possess a sufficient degree of reason to be responsible for his crimes, until the contrary be proved to [the court’s] satisfaction.” To establish a defense on the grounds of insanity, it must be clearly proved that at the time of committing the act, the party accused was laboring under such a defect of reason, from disease of the mind, as not to know
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the nature and quality of the act he was doing, or as not to know that what he was doing was wrong.”6 Therefore, as pointed out by S.J. Morse in 1999, mental illness is not an exemption from criminal responsibility, but may give rise to conditions that either produce excusing conditions or negate the required mens rea.2 In California, the legislature has addressed the issue of insanity with modifications to the M’Naghten standard. According to California Penal Code Section 25 (b), “in any criminal proceeding . . . in which a plea of not guilty by reason of insanity is entered, this defense shall be found by the trier of fact only when the accused person proves by a preponderance of the evidence that he or she was incapable of knowing or understanding the nature and quality of his or her act and of distinguishing right from wrong at the time of the commission of the offense.” 7 In other words, the defendant must prove to the jury (the trier of fact) that at the time of the alleged offense, it was more likely than not (by “preponderance of the evidence”) that she or he met this standard. Further, according to California Penal Code Section 25.5, “in any criminal proceeding in which a plea of not guilty by reason of insanity is entered, this defense shall not be found by the trier of fact solely on the basis of a personality or adjustment disorder, a seizure disorder, or an addiction to, or abuse of, intoxicating substances.”7 These standards raise a number of questions about the insanity defense. First, a defendant’s appearance or conduct in the courtroom is irrelevant to the issue of insanity at the time of the offense.3 The relevant issue in insanity evaluations is the individual’s mental state at the time of the alleged offense. As a consequence, while interviewing the defendant is important in these assessments, collateral information is a key component of such evaluations. The evaluating clinician must determine what the likely mental state of the defendant was at the time of
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the offense using accounts of friends, family members, witnesses and the police. To be found not guilty by reason of insanity, the defendant must have a mental disease—more precisely one of those not specifically excluded by statute as the sole basis for the plea. Further, to be found not guilty by reason of insanity, the defendant must show that at the time of the alleged offense a mental disease was present. Finally, to be found not guilty by reason of insanity, the defendant must show that at the time of the alleged offense the mental disease identified met the standard for insanity applicable to the jurisdiction where he or she is being tried. A note must be made about substance use and abuse in these cases. Voluntary intoxication has not generally been viewed as a basis for a criminal defense. Rather, it has been seen as an aggravating factor in sentencing. Regardless of the test used for insanity, voluntary intoxication could not traditionally be the basis of an insanity defense. The cognitive or volitional impairment implicit in these standards must be the product of a “mental disease or defect.” Intoxication has not been felt to meet that definition.8 Many people wonder what happens to the individual found not guilty by reason of insanity. The concern is that such acquittees simply “get off.” There is a perception that people found insane are simply released to the street to endanger society again. However, these individuals are often confined in prison or in mental health facilities for longer periods than if they were found guilty of the offense as charged. In fact, this sometimes results in defendants declining to invoke the defense because they realize they may never be released.3 The insanity defense is raised in less than 4 percent of cases. Thus, it is not commonly used, despite the perception it is readily utilized by dangerous individuals to escape responsibility for their actions. The defense is successful in less than 1 percent of those cases. In the case of Mr. A, the defense will need to consider whether to raise the insanity defense. However, even if Mr. A
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is found to have a mental illness, the defense’s task is not complete. The defense will need to find evidence Mr. A met the strict standard of insanity utilized in California. Finally, the defense will have to face the prospect that Mr. A might not be sent to prison if the defense is successful, but he may never be released from the forensic hospital setting. Dr. Chamberlain is an assistant clinical professor of psychiatry at the University of California San Francisco. After graduating from the University of California San Diego, he completed three years of general surgery residency at the University of Michigan Medical Center before transferring to UCSF for a residency in adult psychiatry. He next completed a fellowship in forensic psychiatry at UCSF and then joined the faculty in the Department of Psychiatry and later became director of the Adult Consultation Liaison Service. In July 2004 he joined the UCSF Psychiatry and the Law program as the assistant director. REFERENCES
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. 2. Morse SJ. Craziness and criminal responsibility. Behav Sci Law, 17: 147 – 164, 1999. 3. Gutheil TG. A confusion of tongues: competence, insanity, psychiatry and the law. Psychiatric Services, 50: 767 – 773, 1999 4. McSherry B. Voluntariness, intention, and the defense of mental disorder: toward a rational approach. Behav Sci Law, 17: 581 – 599, 2003. 5. Slovenko R. The mental disability requirement in the insanity defense. Behav Sci Law, 17: 165 – 180, 1999. 6. M’Naghten case, 8 Eng. Rep. 718, 722 (1843). 7. http://www.leginfo.ca.gov 8. Marlowe DB, Lambert JB, Thompson RG. Voluntary intoxication and criminal responsibility. Behav Sci Law, 17: 195 – 217, 1999. sfm
Harm Reduction in SF Jails Continued from page 19 The very name of the school, the Five Keys Charter High School, sums up our holistic approach to this form of harm reduction services. The term Five Keys is a constant reminder to our students of the areas of their lives they must address in order to stay out of the criminal justice system and build better lives for themselves: recovery, education, employment, family and community. The Sheriff’s Department has other innovative and successful prisoner programs, such as the Garden Project, Prisoner Legal Services, mentoring, and family reunification, and the department works with local organizations, such as Goodwill, the Family Services Agency and local churches, to provide other services to prisoners and their families. With the number of prisoners we see, there are never enough services to meet the needs. But at a time when prisons and jails are seen primarily as a place for punishment and retribution, this department takes a longer view and believes that government can do better than blindly releasing thousands of drug addicts and violent men back into society, knowing that new victims await their return. And, as we think about the limitations of our criminal justice system, we must be willing to acknowledge that when a government imprisons, a government cannot abdicate its responsibility to run safe and humane prisons. And, in fact, as we have seen here in San Francisco, it can do so much more. Michael Hennessey has been the elected sheriff of San Francisco since 1980.sfm
Watch for SFMS election ballots being mailed out to all members in late October. They must be filled out and returned to the SFMS office by November 14th.
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MEDICINE & LAW
San Francisco’s Behavioral Health Court: On the Cutting Edge Honorable Herbert Donaldson, Judge of the Superior Court, and Jennifer Johnson, Deputy Public Defender
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hen Behavioral Health THE NATIONAL TREND together. In dealings with mentally ill The problem of mentally ill offenders in offenders, there is a surprising unity of voice Court was featured in San Francisco Medicine jails and prisons throughout the United States among prosecutors, defense attorneys, police, magazine in June/July of 2004, it was a fledgling is well known. Studies indicate that the rate sheriffs, judges and mental health providers. effort by the Superior Court to stem the flow of serious mental illness among the jail The concept of Mental Health Courts is a of mentally ill offenders into the criminal population in the United States is at least three logical outgrowth of this collaboration, and justice system. The creation of a mental health to four times higher than the rate of serious court dockets dedicated to dealing with court at the Hall of Justice was an mentally ill offenders are growing innovative experiment designed to rapidly. redirect mentally ill clients into the WHY SAN FRANCISCO IS community mental health system. In A LEADER the summer of 2004, the court had been Although San Francisco’s in operation for only 18 months. Policy Behavioral Health Court was created makers in the city were scarcely aware without looking to any national model, of the collaborative effort of the criminal there are common themes among justice and mental health communities mental health courts across the country. to address a crisis that has steadily Most judges and lawyers in a mental become the responsibility of the health court work closely with mental criminal justice system. health providers who offer intensive In this past year, Behavioral Health case management services and access Court has become part of the to medication. The court setting vocabulary of the city of San Francisco. provides structure, accountability, and The concept has garnered support from a supportive atmosphere for clients. the San Francisco Medical Society, local Attorney Cynthia Johns, Judge Herbert Donaldson and psychologists and psychiatrists, Attorney Jennifer Johnson of the Behavioral Health Court. While San Francisco mirrors other jurisdictions in these areas, the vision community behavioral health, the 1 Mayor’s Disability Council, local law mental illness in the general population. of the players involved and the personality of enforcement and the Superior Court bench. Although the issue has received some national the city have shaped a court with some What started as a pilot project is now viewed attention, little funding is available for important differences. by many in the justice system as a necessary innovative programs designed to address the component of the city’s approach to some of overrepresentation of mentally ill offenders in BEHAVIORAL HEALTH COURT IS A PRE-PLEA COURT its most vulnerable citizens. San Francisco is the system. Unlike most mental health courts, San Out of necessity, local communities have on the forefront of what may well turn out to be the biggest trend in criminal justice since responded by streamlining limited resources Francisco’s court does not require clients to and forging relationships between enter a guilty plea to criminal charges in order the advent of drug courts in the 1990s. organizations that traditionally do not work
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to participate in treatment. In the community of mental health court practitioners, this is known as a “pre-plea” court. The key reason for this approach is that the court recognizes its own limitations in treating this population of offenders. Most clients in our court have fallen through the cracks of a decimated mental health system. Many have never had any mental health treatment at all. To complicate matters, a large percentage of them are dually diagnosed with a substance abuse problem. Failure rate is understandably high and relapse is common for this population. The court does not ask clients who have never been offered the option of participating in mental health treatment to give up basic constitutional rights in order to have the opportunity to participate. Instead, the team learns about the client first, observes how the client responds to treatment, and sets expectations accordingly. COURT FOCUSES ON DIAGNOSIS RATHER THAN CHARGES
A second difference that stands out visa-vis San Francisco and other jurisdictions is that our court does not maintain a rigid set of standards about which criminal charges will be accepted into the court. Rather than focusing on the criminal charges, Behavioral Health Court looks to the client’s mental health diagnosis, and to the connection between the mental illness and the behavior that led to the client’s arrest. There is a presumption in Behavioral Health Court that certain charges such as sex offenses, domestic violence, and crimes involving serious bodily injury will be excluded from consideration. In certain cases, the court will consider extenuating circumstances such as the client’s long-term mental health history, willingness to participate in treatment, family and social support, and prior criminal history as factors in the eligibility decision. Since ours is not an adversarial process, the consent of the district attorney’s office is necessary for these exceptions. LEGAL OUTCOME IS RELATED TO MENTAL HEALTH OUTCOME
Finally, our court is unique in that there is no set standard for what it means to “graduate.” Each case is looked at individually,
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and success is defined differently for each client. The court operates on the premise that a client can always exceed our highest expectations. In Behavioral Health Court, the better the mental health outcome, the better the corresponding legal outcome. Clients are rewarded for success in treatment by having felony charges reduced to misdemeanors, grants of probation terminated early, and criminal charges dismissed. A PROMISING FUTURE
San Francisco’s Behavioral Health Court has received positive publicity and national attention over the last year. Along with articles in three local newspapers, our court was featured in a newsletter for the United States Interagency Council on Homelessness after a visit by President Bush’s homelessness czar, Philip Mangano. In one of the most significant developments this year, we were invited to participate in the first comprehensive study of mental health courts. After a lengthy interview process, San Francisco’s Behavioral Health Court was selected from more than 100 jurisdictions across the country. Funded by the MacArthur Foundation, the study will look at the outcome data of four courts over a period of three years, comparing clients who have participated in mental health courts to other, similar clients who were not offered the option of treatment. The researchers will look carefully at how incentives, sanctions and the court atmosphere contribute to success in mental health treatment and how these factors influence legal outcomes and rates of recidivism. In addition to receiving the honor of being chosen for the MacArthur Mental Health Court Study, Behavioral Health Court has assisted in crafting national policy in the area of mental health courts. In June of this year, the staff of the court attended a conference hosted by the U.S. Department of Justice and attended by more than 400 people from mental health courts across the country. Behavioral Health Court participated in a special forum where 15 mental health court practitioners were asked to evaluate and edit a document entitled “The Essential Elements of a Mental Health Court.” This document will be published by the Bureau of Justice Assistance, a division of the U.S. Department
of Justice, and the Council of State Governments. It is likely that the clients in Behavioral Health Court would not be in the criminal justice system at all if our mental health system had not crumbled under decades of neglect and targeted budget cuts. While San Francisco is not alone in confronting an unprecedented influx of mentally ill offenders into the criminal justice system, the city is showing leadership in finding a solution. Without any funding at all, Behavioral Health Court has found a way to maximize existing resources, protect public safety, decrease homelessness and treat clients with respect and dignity. Our sincere hope is that this court can realize its full potential in the months and years to come. Jennifer Johnson, a deputy public defender in San Francisco, represents the majority of indigent defendants in Behavioral Health Court. She has been working with the court since the planning stages and is actively involved in promoting the concept of mental health courts. She can be reached at Jennifer.Johnson@-sfgov.org. Judge Herbert Donaldson graduated from Stanford Law School 49 years ago and was appointed to the bench January 1, 1983, by Gov. Jerry Brown. Judge Donaldson has served in almost every department of the San Francisco Superior Court, primarily within the criminal courts. Prior to being appointed to the bench, he was chief counsel at a poverty law office and also a sole legal practitioner specializing in criminal law. He retired in 1999 but continues to serve the court. His extensive experience and interest in rehabilitation for mentally ill nonviolent offenders make him well suited to head the Behavioral Health Court, which he has done since 2003. REFERENCES
1. Criminal Justice/Mental Health Consensus Project, Council of State Governments, June 2002, introduction, p. xii. sfm
Dues statements were mailed out to all members this month. If you haven’t already done so, please mail in your 2006 dues today to assure your good standing.
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MEDICINE & LAW
When Mental Illness Meets The Criminal Justice System Jo Robinson, MFT
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hen President John F. Kennedy signed the Federal Community Mental Health Centers Act in 1963, he promised that, “…if we launch a brand new mental health program now, it will be possible within a decade or two to reduce the number of patients now under custodial care by 50 percent or more.” He further assured that “…the reliance on the cold mercy of custodial isolation would be supplanted by the open warmth of community concern and capability.” Forty-two years later, one wonders what John Kennedy would think if he were to walk the streets of San Francisco to learn that the San Francisco Police Department and law enforcement all across the country have, by default, become the mental health providers of the marginalized mentally ill in our communities. If he were to enter America’s jails today he would see these institutions of criminal justice are now holding more mentally ill people than our psychiatric hospitals. President Kennedy’s idealism and today’s reality are polarized. A different type of custodial isolation, one of jails and prisons, has supplanted the custodial isolation of hospital care. For example, in Santa Clara County, when Agnews State Hospital closed its doors to the mentally ill, Santa Clara’s county jail population arrest rate increased by a staggering 300 percent. 1 Inadvertently, criminal justice is tending to the
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disease of mental illness. According to the National GAINS Center, approximately 804,000 inmates with serious mental disorders are admitted to U.S. jails each year—70 percent are incarcerated for nonviolent crimes. Roughly 8 percent of the nation’s jail population has a diagnosis of schizophrenia, bipolar or major depression; in San Francisco that statistic is 10 percent. Jails and prisons are stressful places; they can be traumatic for those with mental illness. Because of the extreme conditions of incarceration and the consequential stress, many mentally ill people’s condition worsens during detention. Additionally, some psychiatric medications cloud thinking, making an already vulnerable population even more vulnerable. Many individuals with a serious mental health disorders have their first contact with a mental health professional while in the criminal justice system. This happens because a previously undiagnosed mental illness is identified or the first psychotic break occurs during incarceration. Criminalizing the mentally ill is not the right answer. As a state and as a nation, we have a system that is broken. When possible, the goal of our community should be preventing the incarceration of mentally ill individuals. The ideal is to provide adequate mental health treatment that is well received by mentally ill individuals in the appropriate, least
restrictive settings. This takes a userfriendly, flexible system that subscribes to a belief that any door to treatment is the right door. Nevertheless, when a person with mental illness does come into contact with law enforcement, appropriate programs and systems in criminal justice must be in place. These systemic programs should consist of diversion from jail; treatment while incarcerated; and discharge planning from jail into community treatment. DIVERSION
Jail diversion’s2 aim is to reduce or eliminate the time a mentally ill person spends in jail by moving him or her toward treatment in the Community Behavioral Health Service (CBHS) system. Diversion programs are designed to enhance public safety by making jails and prison space available for violent offenders and providing judges with alternative dispositions for mentally ill individuals who would be better served outside the criminal justice system.3 Diversion from the criminal justice system can take place at the point of contact with the police officer. Many cities and counties are providing Crisis Intervention Team (CIT) training to law enforcement officers. This specialized training teaches officers how to respond to calls involving people with a mental illness. It is hoped that this type of training
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When Mental Illness Meets Criminal Justice Continued from page 27 will decrease bad outcomes from police encounters with mentally ill individuals and reduce the number of arrests of the mentally ill. In San Francisco, the CIT classes began in 2001. The class is 40 hours of training consisting of didactic experiential visits to treatment centers and conversations with consumers of mental health services and family members. The class is co-taught by mental health and law enforcement professionals. SFPD has completed its 14th class, graduating approximately 400 officers. An emerging and innovative practice for jail diversion is Mental Health Courts. Mental health courts are therapeutic courts using the court’s authority and a multidisciplinary team approach in working toward getting the defendant out of jail and into community treatment. Once again San Francisco has proven to be a leader in the field of mental health and criminal justice. San Francisco began its version of mental health court (known as Behavioral Health Court) almost two years ago. TREATMENT WHILE IN CUSTODY
All inmates must be screened at booking for mental heath problems. In addition, in-custody mental health programs must provide crisis intervention and management of acute psychiatric episodes; offer stabilization and treatment of mental disorders; and provide medication support services. Any mentally disordered inmate who appears to be a danger to oneself or others, or to be gravely disordered, must be transferred for further evaluation and treatment to a designated LPS treatment facility (a place designated to receive people placed on 5150 WIC holds) unless the jail contains such a facility. These are all minimum jail standards governed by state law and monitored by the Corrections Standards 28
Authority. In San Francisco’s jail, the medical/mental health services are accredited by the Institute for Medical Quality (a subsidiary of the CMA). One of the goals of this accreditation is to assure the jail medical/mental health care meets the community standard of care and not just minimum jail standards. We recognize that jail inmates are part of the San Francisco community. They return to our neighborhoods influencing the health of all of us. San Francisco’s Jail Psychiatric Services (JPS) saw over 5,300 incarcerated individuals last year and hospitalized at SFGH approximately 750 mentally ill individuals who met the criteria for involuntary treatment. JPS is considered to be a model program working closely with the San Francisco Sheriff’s Department, CBHS, and the courts to treat, stabilize, and refer mentally ill offenders into community treatment programs.
mental illness in jails and prisons is equal to or less than that of the free population, there is work to be done. The tending of the marginalized mentally ill needs to be removed from the profession of law enforcement and returned to the health care community. We, the health care providers, cannot afford to sit back and take a passive stance. We must advocate for change in the system and demand public policy that treats mental illness as a disease, not a crime, in appropriate settings with evidence-based and emerging practices. Perhaps, then, JFK’s promise can become a reality. Jo Robinson, MFT, is the program director of San Francisco’s Jail Psychiatric Services. She was appointed to a six-year term on the California’s Council on Mentally Ill Offenders in 2002. She serves on the board of directors for the Forensic Mental Health Association of California and is a surveyor for the Institute for Medical Quality’s Corrections and Detentions and Healthcare.
DISCHARGE PLANNING
Whenever possible, the planning for the release of a mentally ill inmate needs to begin at the start of their incarceration. As always, clients’ needs and input should help drive the plan; however, if a court case is pending or the person is on probation or parole, the criminal justice system will have input into the treatment and the discharge plan. A recently released report confirmed that intensive case management is effective in addressing the needs of the mentally ill offender population that have been ignored for years.3 In San Francisco, we have developed an intensive case management team that has a forensic focus, UCSF’s Citywide Case Management. This program works closely with JPS and the Behavioral Health Court taking challenging clients and stabilizing them in community treatment. While San Francisco is making progress with diversion, treatment and planning for people with mental health diseases who come into contact with the criminal justice system, we still have a long way to go. Until the rate of serious
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REFERENCES 1. Teplin LA (1984). The criminalization of the mentally ill: Speculation in search of data. Psychological Bulletin, 5467. 2. For additional examples of diversions, refer to the TAPA website: http:// gainscenter.samhsa.gov/html/tapa/ jail%20diversion/background.asp). 3. Massaro J. (2004). Working with People with Mental Illness Involved in the Criminal Justice System: What Mental Health Service Providers Need to Know (Second Edition). Delmar, NY: Technical Assistance and Policy Analysis Center for Jail Diversion, 6. 4. Mentally Ill Offender Crime Reduction Grant Program, Legislative Report (2004), California Board of Corrections, 20.sfm
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MEDICINE & LAW
Tom Waddell Health Center: Health Care for the Homeless Barry Zevin, MD
J.T., a 52-year-old man, presented to the Tom Waddell Health Center (TWHC) urgent care clinic complaining of weight loss, abdominal pain, and feelings that he was going to die soon. He reported living in a friend’s garage for several years after his wife died, and he lost work after the dot-com bust. He made several visits to our urgent care center in which the following problems were identified: gastritis, alcoholism, depression, COPD, and others. He was referred to our general medical primary care clinic and saw a physician and social worker. He was treated with an outpatient alcohol detox regimen, which required very close follow-up with the nursing staff to manage his moderately severe alcohol withdrawal. This was successful, but he remained severely depressed, and his primary care physician started him on antidepressant medication and his social worker referred him for psychotherapy. (Over a period of months he worked with the social worker until a good match could be found to provide him with psychotherapy that was culturally appropriate for his homelessness and other psychosocial factors.) As his depression lifted and he became more active, the severity of his COPD became clearer and spirometry provided by the COPD/ asthma nurse on site showed severe obstructive disease. His physician was able to prepare a comprehensive letter documenting his health status and documenting his functional disabilities, and he was able to get Medi-Cal and SSI. This allowed him to obtain housing as well as more specialized medical care. He
has not required hospitalization and is extremely grateful for the services he has received. He has given public testimony to the San Francisco Health Commission expressing his certainty that he would have died had the services of TWHC not been available. Providing health care for homeless people in San Francisco presents many challenges. This year marks the 20th anniversary of Health Care for the Homeless (HCH) nationally and in San Francisco. The Tom Waddell Health Center (TWHC) was one of the original sites that received grant funding for HCH and is the largest provider of homeless health services in San Francisco. The core concept of the Health Care for the Homeless model is integrated multidisciplinary teams working doing outreach to engage with and provide ongoing health care for homeless people who need it. Research and clinical experience show that homeless people have worse health and more medical problems than housed people— even those with comparable levels of poverty. An important secondary aim of the HCH model is reducing acute and long-term care by addressing primary care and prevention needs in the outpatient setting. The extent of the needs of homeless people in San Francisco is reflected in the fact that Tom Waddell Health Center has the largest staff and the largest number of visits of any of the DPH Community Oriented Primary Care (COPC) clinics. Over a period of years TWHC has developed a bio-psycho-socialspiritual paradigm of care that has proven very
effective. The services are provided at the central clinic at 50 Ivy Street in the Civic Center area and at more than 25 community sites where homeless people congregate or receive services. Each year 14,000 to 15,000 individuals are seen for a total of more than 50,000 encounters. The staff numbers over 130 employees. The medical problems seen reflect the nature of the population: skin and soft tissue infections, HIV disease, hepatitis C, cirrhosis, and COPD along with other common diseases of adults, often in advanced states reflecting years of neglect. The large majority of patients seen have substance use disorders and mental health disorders. Most of the patients seen are alienated from their families and other supportive social structures although very few are completely isolated. Many have had poor experience in medical settings in the past. Although they live in extremely challenging circumstances, many display uncanny survival skills and cling tenaciously to their independence and integrity. There is a great deal of hopelessness and homelessness is tremendously demoralizing and dehumanizing. Recognition that restoration of meaning and hope is essential to health is considered the spiritual aspect of care. Staff treat each person with respect and dignity with the aim to restore selfrespect and self-efficacy. The medical staff at TWHC consists of 11 physicians and 11 nurse practitioners with another dozen or so per-diem medical staff.
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Health Care for the Homeless Continued from page 29
Remarkably, for an organization of this kind, retention of staff has been superb, with most of the medical staff having 10 or more years of service in the organization. A high level of collegiality and a sense of shared purpose and mission likely account for this. Frustrations arise around lack of resources and systems of care that don’t work or that create competition between needy groups for scarce resources. There are few managed care hassles working with a population that is greater than 60 percent unsponsored and indigent, with the rest having Medi-Cal or Medi-Cal/Medicare, but access to diagnostic and specialty services is often very limited. Constant budget scares and erosion of the infrastructure have reduced morale in recent years but the staff continues to embody a very strong sense of advocacy for patients. TWHC is quite expansive in its aim to meet the needs of homeless people in San Francisco. The following summaries are examples of some of the projects under way and services offered: PRIMARY CARE
The primary care clinics at TWHC are divided into clinics run by specialized multidisciplinary teams. These teams usually work both in a primary care clinic and in one or more community sites to facilitate outreach and engagement. The teams include a women’s team serving homeless women; Clinica Latina, serving homeless monolingual Spanish-speaking people; a transgender clinic, serving transgendered people, an HIV Team; and a GMC team serving homeless adults. The primary care clinics follow approximately 3,000 people per year. This year TWHC is one of seven clinics statewide to have received grant funding to redesign primary care operations to decrease wait time, increase productivity and increase patient satisfaction. The greatest pressure on the clinic is to increase primary care capacity. Therefore the program has developed the High Access Primary Care Pilot. This is an effort to deliver comprehensive
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primary care at four community sites that have previously only offered psychosocial services or episodic care. These sites include two mental health centers that treat large numbers of homeless people who are in severe need of primary care but who previously have not accessed primary care. MCMILLAN DROP-IN CENTER
The McMillan stabilization project is now two years old and sees about 350 visits per month. This project allows patients to be brought to a community-based facility rather than an emergency room for sobering. This is of great benefit to patients as they are offered an array of services and follow-up that are not available to them in an emergency department setting. It also serves an important role in reducing unnecessary emergency room use and decreasing emergency room diversion. A summary of outcomes of the project is available online at www.sfdph.org/reports/McMillan/6MonIntRpt.pdf . A recent innovation is the establishment of McMillan as a site for the high-access primary care pilot described above.
the evening, a team comes to the shelter and sees all comers for episodic medical care, prevention services such as TB screening and immunization, and gradual trust-building that will ultimately help enable many of those patients to participate in primary care. Lengthy experience shows that people form a trusting relationship with one provider and the transition to primary care works best if they are able to see the same person at the clinic as they have seen in the shelter. FAMILY TEAM
Family homelessness has been underrecognized locally and nationally. The TWHC family team is a collaboration with UCSF Family and Community Medicine to serve homeless families. The model, again, is outreach to shelters and service agencies on a regular and reliable schedule; engagement and trust building; and connection to primary care. Since children are not seen at the TWHC central clinic, the primary care connections are made with the Family Health Center at SFGH.
HIV CENTER OF EXCELLENCE
CHALLENGES FOR THE FUTURE
TWHC has received funding to establish the Tenderloin Area Center of Excellence in HIV care (TACoE). TWHC was a pioneer nationally in recognizing that HIV/AIDS disproportionately affects homeless and marginal populations. The model of care is based on the clinic’s 18 years of experience in delivering state-of-the-art HIV care to patients affected by homelessness, mental illness and addiction. The funding also exemplifies efforts to expand multidisciplinary services by partnering with community-based organizations. TACoE partners include TARC, Asian Pacific Islander Wellness Center, and Harm Reduction Therapy Center. TWHC provides HIV primary care for over 600 patients a year and reaches twice that number in providing outreach and urgent care.
The needs of homeless people in San Francisco are very dynamic, and they change based on multiple factors in the political, economic, and physical situation in the city. A major effort will be made in 2006 to close one of the major gaps in homeless services in San Francisco—availability of appropriate medical respite facilities for patients being discharged from hospitals and those who could avoid admission if they had a stable living situation. Funding is always a challenge and even small donations can make a difference. (Donations to TWHC can be made through the San Francisco Public Health Foundation c/o TWHC, 50 Ivy St., San Francisco, CA 94102; or go to www.sfpublichealthfoundation.org.) Health Care for the Homeless work can also be a very satisfying volunteer opportunity for physicians. Inquiries regarding volunteering can go to Barry Zevin, MD, medical director at Barry_Zevin@sfdph.org. Dr. Zevin is the medical director for homeless and community services at the Tom Waddell Health Center, San Francisco Department of Public Health.sfm
SHELTER SITES
The archetypal Health Care for the Homeless service is providing outreach and on-site medical care at homeless shelters. TWHC has clinics at eight homeless shelters in San Francisco. Each clinic works on a similar model. One or more days a week, usually in
SAN FRANCISCO MEDICINE / OCTOBER 2005
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Perspective Medical Marijuana: Curtailing Abuse Current Practices Mock the Will of California Voters and Doctors Steve Heilig, MPH, and Stephen Follansbee, MD
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he San Francisco Medical Society was the only medical association to endorse Proposition 215, which the voters passed in 1996 to allow legitimate use of cannabis by patients. We did so after hearing from many local doctors, particularly specialists in cancer and AIDS, that marijuana had been helpful in easing some patients symptoms— and even after the then-federal “drug czar” visited to request that we not endorse the proposition. Since then the SFMS has also joined in lawsuits to protect patients and physicians who feel that cannabis can alleviate some symptoms, and has presented several professional and public forums related to medical and other uses of cannabis. Numerous authorities, including the Institute of Medicine of the National Academy of Sciences, have confirmed many local physicians’ conviction that cannabis can be helpful in some circumstances. The ongoing local debate about “cannabis clubs” and the recent Supreme Court decision allowing for federal crackdown on medical-marijuana-related activities does highlight some of our concerns with how Proposition 215 has been implemented. We spoke out on behalf of physicians and patients almost a decade ago and feel we should do so again. We still believe that no patient should be denied safe, legal, and affordable access to whatever therapy that patient and his or her physician deem to be helpful. Research on how cannabis best helps patients, and how to best administer it—which seems likely not via smoking—is ongoing and promising and should be supported without undue restrictions. It would be logical for the results of such research to be incorporated into drug policy. That said, it should also be said that Proposition 215 should not be a license for abuse of either cannabis or patients, via profiteering. An informed and objective look at the current “system” of numerous cannabis clubs reveals that a small number of physicians, marijuana farmers, and dispensaries are taking advantage of the goodwill of California voters and lack of regulations for their own financial gain. Privately, some insiders from all of these categories have confided that this is so, and that only a small percentage of what is currently called “medicinal” cannabis use could be deemed legitimate by any objective measure. However, in Northern California at least, it seems politically incorrect to say so.
http://www.sfms.org
Federal authorities are now raiding some marijuana clubs. Perhaps we should be upset by this, but it’s hard to conjure much sympathy for those who, by abusing the (non)system, are bringing more scrutiny upon San Francisco and could jeopardize legitimate access. There is no way our city needs dozens of such clubs. The numbers of patients and the amount of cannabis being sold just does not add up. There is recent evidence that organized crime has become involved—and organized crime only seems to gravitate to where big money is to be made. Thus the valid call for a moratorium on new clubs, and for better regulation and supervision of those that do operate. Those efforts should be enacted. One likely-to-be-unpopular proposal might make it mandatory that any dispensary be run as a nonprofit, which sells only reasonable amounts to legitimate patients—at cost. At a forum the SFMS cosponsored a couple of years ago, some dispensary operators advocated such cost controls and assured that the prices would be far lower than any club currently offers. Not only would this provide access for the most needy, but also it would likely dissuade profiteers from continuing their operations or starting new ones. We fully endorse local efforts to regulate cannabis clubs. True quality and financial control are essential aspects of providing the best possible access and least risk of political interference. This will require the close involvement of city authorities and a willingness to eliminate the hypocritical profiteers. Physicians who seem to be offering recommendations for cannabis use without a legitimate medical evaluation should not be immune from such scrutiny. Whether people should be arrested at all for cannabis possession and use is a larger, complex societal question for another day. Marijuana is not harmless, especially to children and teens, and researchers are divided on the best policies to minimize that harm. But hypocrisy in the guise of compassion and medicine is unacceptable, especially when it is a front for profiteering. It’s time to make the legitimate medical use of cannabis a more mainstream process. There’s already more than enough abuse of California voters’ good intentions.sfm
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Guest Editorial Female Physicians Express Frustration with the Profession Leon van derReis, MD
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n spite of progress during the past two to three decades, gender-related issues continue to be of considerable concern to female physicians. From interviews with individual and groups of female physicians, conducted in connection with another study, it became apparent that a level playing field remains a distant goal. It also became obvious to many female physicians that the public’s attention to gender-related matters seems to have waned, and articles and projects related to gender issues are infrequent and inadequate. Understandably, however, these issues continue to be important in the minds of most female physicians. Michelle Caughey, the new president of the San Mateo County Medical Association, referred to her personal experiences in the July/August issue of that organization’s Bulletin. Studies that have attempted to assess opinions of women in medicine have primarily depended on face-to-face encounters. Invariably the opinions expressed in these encounters are influenced by personal and extraneous factors. In order to obtain genuine personal opinions, we undertook to assess the attitudes and perceptions of 200 randomly selected female physicians. To insure maximum confidentiality, the 12-question questionnaire was anonymous. The questions reflected the most frequently raised issues during interviews. In an attempt to assess the influence of different cultural and political conditions, 100 of the participants were practicing California physicians, and the other 100 were practicing female physicians in the Netherlands. (Dutch physicians were selected since their medical sophistication is comparable to U.S. levels, and the population as well as the number of physicians of California is just about double that of the Netherlands, making numerical extrapolations fairly simple.) Of the 200 survey forms mailed via regular postal channels, 91 usable replies were analyzed. The age distribution of the physicians was similar in both groups, most belonging to the 31to-40 and 41-to-50 age groups, with lesser representation for the 30-and-below and above-60 age groups. The resulting data show one striking difference between the two groups, namely the ratio of full- versus part-time practice. While 65 percent of the U.S. physicians were in full-time practice, the reverse was true in the Netherlands, where 66.67 percent were in part-time practice. The vast majority in both groups (about 80 percent) opined that problems exist concerning the attitude of their male colleagues, while at least 70 percent knew of a case of sexual harassment. Sixty-five percent considered that they themselves had been subjected to sexual harassment. Even though all stated that they
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were fully aware of the increase in the number of female medical students, close to two thirds felt that the increase in female faculty is lagging. Persistent negative attitudes among some of the male colleagues were considered to influence promotion, specialty selection and obtaining residencies. In a recent Dutch study, aside from the promotion issue, a determination was made that even though women are fairly well represented on academic committees that deal with scientific matters, males predominate on committees that control administrative and policy matters. Most respondents appeared to be aware that the compensation of female faculty is less than that of their male counterparts. Eighty percent of the U.S. physicians and 90 percent of the Dutch physicians expressed the opinion that generally male colleagues disapprove of women working part time. The fact that in the Netherlands two thirds of the female physicians work part-time suggests that a regulatory safety net, protecting social and economic benefits, plays a major role in the professional and personal lives of women in medicine. Over 80 percent of California physicians and about 90 percent of Dutch physicians stated that those women who aspire to reach high positions in academic medicine ought not to have children, and should have a partner who can attend to the chores of daily personal life. It is noteworthy that in spite of some of the negative attitudes and perceptions, 85 percent of U.S. physicians and 92 percent of Dutch physicians believed that the standing of women in medicine has benefited from the increase in women who have entered the profession. Although it is true that the number of individuals surveyed is not very large, the replies and the similarity of responses to every question (in both groups) that ask for an opinion can be accepted as an indicator of the attitudes and perceptions vis-a-vis women in medicine and to be a true reflection of the opinions of the respondents. There is a very real need for further integration of women in all sectors and levels of medicine. Given the increasing number and role of women in medicine, greater attention should be paid to rectifying some of the “traditional” attitudes of some male physicians, facilitating the option of part-time practice, breaking the glass ceiling and eliminating discriminatory practices such as unequal compensation and barriers to promotion. Dr. van der Reis is an adjunct professor in Health Care Management and Clinical Professor of Community and Rural Medicine with the University of Alabama. He is also the director of the Quincy Foundation for Medical Research and a long-standing member of the San Francisco Medical Society and SFMS Editorial Board.sfm http://www.sfms.org
2005 SFMS Slate of Candidates
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ursuant to the SFMS Bylaws Article X Section 2 Nominations, the Nominations Committee renders in writing the following slate of candidates for the 2005 SFMS election. This slate was announced at the September 12, 2005 General Meeting, at which time the SFMS President called for additional nominations from the floor. The following are this year’s candidates: OFFICERS
Term 2006 For the office of President-Elect, Secretary, Treasurer and Editor, only one candidate may be selected for each individual office. President-Elect: Stephen E. Follansbee Secretary: Charles J. Wibbelsman Treasurer: Steven H. Fugaro Editor: Mike K. Denney BOARD OF DIRECTORS
Term 2006-2008 The seven candidates receiving the hightest number of votes will serve as directors on the SFMS Board: Mei-Ling E. Fong* Thomas H. Lee Carolyn D. Mar Amir Matityahu William A. Miller Rodman S. Rogers John B. Sikorski* Peter W. Sullivan* John I. Umekubo* * Incumbent Director
NOMINATIONS COMMITTEE
Term 2006-2007 The candidates receiving the highest number of votes will serve as members of this committee: Kenneth J. Hammerman Daniel M. Raybin Richard M. Naidus Charles J. Wibbelsman AMA DELEGATE
Term 2006-2007 H. Hugh Vincent (Incumbent) AMA ALTERNATE DELEGATE
Term 2006-2007 Judith L. Mates (Incumbent)
Gary L. Chan Lucy S. Crain ** George A. Fouras Alan G. Greenwald * Brian J. Lewis *** Dexter Louie * Carolyn D. Mar Judith L. Mates * Rita Melkonian * Rachel Hui-Chung Shu ** Peter W. Sullivan ** George P. Susens * John I. Umekubo * Incumbent Delegate ** Incumbent Alternate *** 2006 Delegation Chair NOTES:
CMA TRUSTEE
Term 2006-2008 Robert J. Margolin (Incumbent) YOUNG PHYSICIAN SECTION DELEGATE
2005 President-Elect Gordon L. Fung automatically succeeds to the office of President. 2005 President Alan G. Greenwald automatically succeeds to the office of Immediate Past President.
Term 2006-2007 Jordan Shlain (Incumbent) YOUNG PHYSICIAN SECTION ALTERNATE DELEGATE
Term 2006-2007: Lily M. Tan DELEGATES TO THE CMA HOUSE OF DELEGATES
Two-year term 2006-2007 The four or five candidates receiving the highest number of votes will serve as delegates. The next five or six will be alternate delegates. Note: President-Elect automatically becomes the fifth or sixth delegate.
Ballots will be mailed to all SFMS members in late October. Upon receipt, please mark your ballot and return it immediately to: SFMS, 1409 Sutter Street, San Francisco, CA 94109. Ballots must arrive by 5 p.m., Monday, November 14, 2005. The name of the SFMS member (not the corporation name) must be printed legibly or typed on the return envelope.
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ALSO CANDIDATE FOR NOMINATIONS Specialty: Pediatrics/ Adolescent Medicine Membership: SFMS/ CMA 1985 SFMS: Director 2003-
SFMS Officer Candidate Statements Continued from page 33
FOR PRESIDENTELECT:
STEPHEN E. FOLLANSBEE Specialty: Infectious Diseases Membership: SFMS/CMA 1982 SFMS: Director 1999-2005 SFMS Committee Appointments: Executive 2001/2004-05; Nominations 2003-04; Disaster Planning (co-chair 2002-05); Medical Review and Advisory Consultant 1993-2002; Chiefs of Staff 1996-97 CMA: Delegate 2004-05 Related Medical Affiliations: Attending physician, Kaiser Permanente Medical Group, 1998-present; Director of HIV Services and Module Chief, Adult Primary Care, Kaiser San Francisco, 2000-present; Assistant Director, Bay Area Consortium of AIDS Providers, 1990-present; Medical Director, Institute for HIV Research and Treatment, Davies Medical Center, 1988-1998; attending physician, Ward 86, SFGH Medical Center, 1983-1998; Chief of Staff, Davies Medical Center, 1996-1997 Medical School: University of Colorado 1977 Hospital Affiliation: Active: Kaiser Permanente Medical Center, San Francisco Teaching Appointments: Associate Clinical Professor, UCSF 1996-1998 Policy Statement: It is an honor to have been part of the San Francisco medical community since 1977, working in the university, research, public, and private-practice sectors. I am proud to be a member of the SFMS and to serve as a CMA delegate. I have witnessed outstanding leadership in the SFMS, which remains not just reactive but also proactive, advocating for the health of our community and the wellbeing of our members. SFMS faces continued financial challenges, but it should not undermine our mission. I look forward to continuing to serve our important organization. FOR SECRETARY:
CHARLES J. WIBBELSMAN
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05 CMA: Very Large Group Practice Forum Delegate 2001–05; VLGPF Alternate 199697/1999-2000; SFMS Alternate Delegate to the CMA 1996-97 Related Medical Affiliations: President of Professional Staff, Kaiser Foundation Hospital, San Francisco 2002-04; Vice President of Professional Staff, Kaiser Foundation Hospital, San Francisco 2001-02; Board of Directors, the Society for Adolescent Medicine 2002-05/ 1997-99; President, Northern Caifornia Chapter of the Society for Adolescent Medicine 1989-1997; Board of Directors, USF Center for Child Development 1999-2001; Medical guest host, KRON Morning Show 2002-03; member, American Federation of Television and Radio Artists, 2002-05; Committee on Adolescence, the American Academy of Pediatrics, 2003 to present Medical School: University of Cincinnati 1970 Hospital Affiliation: Kaiser Foundation, San Francisco Teaching Appointments: Clinical Professor of Pediatrics, UCSF Policy Statement: As a physician practicing medicine in San Francisco since 1976, I have had the opportunity to observe health care delivery from two very different perspectives: initially as a physician with the Public Health Department and for the past 25 years as a pediatrician in a very-large-group-model HMO. In both spheres of practice, quality of medical practice, access to care, and culturally competent care for diverse patient populations are high priorities. The San Francisco Medical Society has the unique role of providing leadership and guidance in achieving these goals of practice through its delegation to the CMA and as a recognized leader of organized medicine in San Francisco. As a spokesperson for physicians in San Francisco, the Medical Society helps maintain a high level of professionalism in medicine and serves as an advocate for physician wellness in these turbulent times of change. I would be proud to carry on this tradition of leadership and community recognition.
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FOR TREASURER:
STEVEN H. FUGARO Specialty: Internal Medicine Membership: SFMS/ CMA 1986 SFMS: Director 2003-05 SFMS Committee Appointments: SFMS PAC Board 2005; Nominations 2004 Related Medical Affiliations: American College of Physicians, Society of General Internal Medicine Medical School: Yale University 1981 Hospital Affiliation: UCSF, Mt. Zion Teaching Appointments: Associate Clinical Professor of Medicine, UCSF Policy Statement: I have practiced privately, full time, in internal/primary care medicine for the last 15 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 and the varied challenges confronting physicians today in academic medicine and private practice. I have become increasingly aware of the critical role played by the San Francisco Medical Society in influencing medical care and medical policy, at the local, state, and national level. The Medical Society is able to accomplish this via its CMA delegation and its recognized role as the leader of organized medicine in our city. I welcome the opportunity to serve the San Francisco medical community as SFMS Treasurer and Director in the coming years. FOR EDITOR:
MYRON K. (MIKE) DENNEY Specialty: Psychosomatics/General Surgery Membership: SFMS/ CMA 2002 SFMS Committee Appointments: Editorial Board 2002-05 Medical School: University of Michigan 1959 Teaching Appointments: Adjunct Faculty, Holistic Health Education, John F. Kennedy University; Integrative Health and Healing, California Institute of Integral Studies; Depth
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Psychology, Pacifica Graduate Institute Policy Statement: I am honored to be nominated for Editor of the journal of the San Francisco Medical Society, after having served on the Editorial Board for the past three years. As this journal is an advocate for physicians and patients, my articles and Perspective editorials have focused upon underlying meanings and transcendent dynamics of economic, political, scientific, ethical and personal issues that confront both healers and the afflicted. I will dedicate myself to the ongoing quality of our publication as it continues to explore new and deeper perspectives on the art and science of medicine.
FOR BOARD OF DIRECTORS:
MEI-LING E. FONG (Incumbent Director) Specialty: Internal Medicine Membership: SFMS/CMA 2000 SFMS: Director 2003-05 SFMS Committee Appointments: Executive 2005; Nominations 2004-05 CMA: Alternate Delegate 2003-06 Related Medical Affiliations: Associate Member, American College of Physicians; Member, California Medical Association; Member, UCSF Association of the Clinical Faculty Medical School: University of Oklahoma 1994 Hospital Affiliation: UCSF, Marin General Hospital, CPMC, St. Mary’s Hospital Teaching Appointments: Assistant Clinical Professor of Medicine, UCSF Policy Statement: As medicine continues to undergo dramatic changes, it is important that efforts be made to preserve accessible, quality health care for patients and to remove obstacles that physicians encounter in the delivery of that care. I feel that the San Francisco Medical Society serves this purpose. By serving as a board member for the past three years, I have been able to see how the Medical Society educates us physicians about important health care issues and organizes us into a powerful group that can effect change. I seek your support in my reelection as an SFMS Delegate. THOMAS H. LEE Specialty: Internal Medicine
Membership: SFMS/CMA 2002; AMA 1994 SFMS: Young Physician Representative to Board 2003-05 SFMS Committee Appointments: SFMS PAC Board 2003-05; Editorial Board 2003-05; Website Committee 2004-05 Medical School: University of Washington 1994 Hospital Affiliation: Active: CPMC, Saint Mary’s Teaching Appointments: UCSF Policy Statement: As a younger physician interested in improving care delivery systems, I believe that the SFMS plays an important role in bridging between policy and the practice of medicine. Clinical practice can, at times, be isolating, and it is rewarding to share a common passion for improving the care of our patients outside the exam room. I believe that the SFMS best serves the community as a unified voice for patient and physician advocacy. To that end, I would like to continue efforts in membership recruitment and retention, forums for education and discussion, and the development of solutions that support improved regional coordination of care. CAROLYN D. MAR ALSO CANDIDATE FOR DELEGATION Specialty: Internal Medicine Membership: SFMS/ CMA 1999 Related Medical Affiliations: Chief of Service, Kaiser Medical School: University of California San Francisco 1996 Hospital Affiliation: Active: Kaiser Permanente; Courtesy: UCSF Clinical Training Faculty Teaching Appointments: UCSF Policy Statement: I am honored to be nominated to the Board of Directors of the SFMS and to represent the interests of physicians in the CMA House of Delegates. As an internist, I am acutely sensitive to the changes in the health care system over the past few decades and feel that it is imperative that physicians play a larger role in determining the shape of an increasingly chaotic and fragmented system that benefits neither patients nor physicians. Unfortunately,
physicians have passively allowed others to determine our current situation. By working together with policy makers, we front-line care providers can provide a crucial voice in designing a future health care system that is fair, high quality, affordable and accessible. AMIR MATITYAHU Specialty: Orthopedic Trauma Surgery Membership: SFMS/ CMA 2003 SFMS Committee Appointments: Finance/Investment Committee Related Medical Affiliations: UCSF Academic Search Committee; SFGH Trauma Performance Improvement System Committee; SFGH Multidisciplinary Trauma Peer Review Committee; UCSF Department of Orthopedics Resident Selection Committee; UCSF Department of Orthopedics Education Committee Medical School: Hahnemann University Medical Center, 2002 Hospital Affiliation: UCSF, SFGH Teaching Appointments: Assistant Professor, UCSF Policy Statement: It is an honor to be nominated to the SFMS Board of Directors. I am committed to working with the SFMS on issues that affect the San Francisco–based population. Specifically, I have been working on a personal level within SFGH to decrease the cost of health care and increase patient access to a high level of care. I am looking forward to contributing my time to this essential cause and other ones within our community. WILLIAM A. MILLER Specialty: Internal Medicine Membership: SFMS/ CMA 2005 Related Medical Affiliations: Chair, Department of Medicine and Chief Medical Executive, and director of St. Hospitalist Service, St. Luke’s Hospital; Associate Professor, Touro University Medical School: Univ. of Arizona College of Medicine 1991 Hospital Affiliation: St. Luke’s Policy Statement: San Francisco is the
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birthplace of many innovations that have greatly affected health care delivery throughout the world. Examples include the hospitalist movement, Kaiser and managed care. Ironically, there are notable deficiencies in the health care provided within San Francisco itself. St. Luke’s Hospital is one of many entities that struggle to provide care to the under- or uninsured within a national health care delivery system that does not adequately provide for the cost of that care. My goal is to develop ways of making our institutions, such as St. Luke’s, financially viable so that this important work may continue. R O D M A N S H E LT O N ROGERS Specialty: Urology Membership: SFMS/ CMA 2000 CMA: Solo/Small Practice Forum Alternate Delegate 2005-06 Related Medical Affiliations: American Urological Association Medical School: University of Oklahoma 1995 Hospital Affiliation: Active: CPMC, Saint Mary’s Hospital Policy Statement: I am honored to be nominated as alternate delegate to the Solo/ Small Group Practice Forum. Like most young people, I entered medicine wanting to contribute to the health of individual patients, as well as make scientific advancements in my discipline. Accomplishing this requires more than the action of one individual. It is dependent upon the culture of those who provide care and conduct research, as well as the choices made by the individuals and institutions paying for such care. I believe that the San Francisco Medical Society is a good way to participate in the community for both patient and physician advocacy so that we may influence the choices of the other partners in health care. JOHN B. SIKORSKI (Incumbent Director) Specialty: Psychiatry Membership: SFMS/CMA 1970 SFMS: Director 2003-05 SFMS Committee Appointments: Chair, Psychiatric Services Committee, 36
1989-present; MRAC 1990-present Related Medical Affiliations: Adjunct Secretary, International Association for Child and Adolescent Psychiatry and Allied Professions, 1994-present; past co-chair, Children’s Rights and Legal Issues Committee, American Academy of Child and Adolescent Psychiatry Medical School: University of Michigan 1962 Teaching Appointments: Clinical Professor, Department of Psychiatry, the Children’s Service at Langley Porter and the Psychiatry and the Law program, UCSF Policy Statement: I have had a long-standing interest in psychiatric and mental health education and service at both the professional and public health levels. As chair of the SFMS Psychiatric Services Committee, I have advocated for expanding mental-healthrelated services within the broader framework of medical practice and public health. In this context, I would work with the leadership of the SFMS to continue to reflect and respond to the ever-changing needs, challenges and opportunities of our members, our patients, and the community in which we live and practice our profession. PETER W. SULLIVAN (Incumbent Director) ALSO CANDIDATE FOR DELEGATION Specialty: Emergency Medicine Membership: SFMS/CMA 1990 SFMS: Director 2003-05; Treasurer 2002; Director 19962000; Medical Staff Liaison CPMC 1999-2004 SFMS Committee Appointments: Finance/ Investment 2000-05 (Chair 2001-02); Local Health Affairs Chair 2000-05; Executive 2000-04; Nominations 2002-03; SFMS Services, Inc., Board 2001-02; Physician Membership Services/Membership 19962002; Medical Review & Advisory 1995-2000; Managed Care Task Force 1994 CMA: Alternate Delegate 2002-05 Related Medical Affiliations: Chair, Emergency Medicine, CPMC; Physician Information Officer, CPMC; Group Manager, San Francisco Emergency Medical Associates; Medical Director, Utilization Review, SFGH 1978-94; Finance Committee and Board, SFIPA; Specialist for Credentials and Utilization Review Committees, CPMC
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Medical School: UCSF 1971 Hospital Affiliation: Active: CPMC Policy Statement: I am honored to be nominated again to the Board of Directors. It has been a pleasure to serve on the Finance Committee these last three years as well, despite the difficult decisions we’ve had to make. We physicians continue to face enormous issues that can be resolved only through organized medicine—hence my continuing membership in and support of SFMS, CMA, Cal-ACEP and ACEP. Medicare is still on a downward path of payments while our practice expenses continue upward, Medi-Cal is a disgrace and probably going to get worse, the uninsured problem is unchanged, ED on call is still an issue, and the assault on MICRA continues. We in organized medicine must speak out, and only in large numbers will we be heard. We need to continue to fight for control of our practices, or give up and let the bureaucracy take over. I advocate physician involvement and education in the selection and implementation of the electronic health record. I pledge to continue with the improvements we have made. Our common goal is a happy doctor providing best-practices medicine to satisfied patients. I would be proud to represent San Francisco physicians on our Medical society board. JOHN I. UMEKUBO (Incumbent Director) ALSO CANDIDATE FOR DELEGATION Specialty: Internal Medicine Membership: SFMS/ CMA 1980 SFMS: Director 200305; St. Mary’s Medical Staff Liaison 2003-05 SFMS Committee Appointments: Nominations Committee 2004-05, 19992000: Executive 2003; Chiefs of Staff 200002 CMA: Alternate Delegate 1999-2000 Related Medical Affiliations: Chief of Staff, St. Mary’s Medical Center, 1999-present (Executive Committee Member 1992present); San Francisco County Health Commission 1999-present; Medical Director of San Francisco Community Convalescent Hospital 1989-present; Health Commission 1999-present; Catholic Healthcare West Bay Area Region, member of Board Development Committee
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Medical School: St. Louis University Hospital Affiliations: St. Mary’s, CPMC Teaching Appointments: Clinical instructor and member of teaching faculty, St. Mary’s Medical Center 1980-present Policy Statement: The San Francisco Medical Society offers many benefits to its members but in this constantly changing medical environment, it could do more. As your representative on the Board of Directors, my goal is to ensure that your needs as a practicing physician are fulfilled. While there are many opportunities, what really matters is your daily practice and that is what we need to focus on. My hope is to be able to contribute as a practicing physician and as your representative, in order to enhance your practice and allow you to provide the best medical care to patients.
Membership: SFMS/ CMA 1982 SFMS: Director 200507 SFMS Committee Appointments: Medical Review and Advisory Committee
KENNETH J. HAMMERMAN Specialty: Gastroenterology Membership: SFMS/CMA/AMA 1978 Medical School: New York University 1969 Hospital Affiliation: Active: St. Francis, CPMC; Courtesy: UCSF T e a c h i n g Appointments: Associate Clinical Professor of Medicine, UCSF Related Medical Affiliations: Chief of Staff, Saint Francis Memorial Hospital; Saint Francis Board of Trustees, member (four terms); Catholic Healthcare West Bay Area Region, Member of West Bay Regional Board Policy Statement: I have been active in the San Francisco medical community for 27 years and have experienced and adjusted to the many challenges that our practices and hospitals have gone through. Our Medical Society has enabled us to advocate on behalf of our patients and profession at the local and state levels, and it is of utmost importance that this mission continue. I seek the opportunity to continue this process by serving on the Nominations Committee to ensure that we are represented by our most effective physicians.
(co-chair 2003-05) CMA Committee Appointments: IMQ Surveyor Medical School: Stanford University 1973 Hospital Affiliations: Active: Saint Mary’s; Courtesy: Saint Francis, CPMC; Consultant: San Francisco and Palo Alto VA Health Science Centers Teaching Appointments: Adjunct Clinical Professor, Medicine, Stanford University; Clinical Professor, Medicine, UCSF; Clinical Associate Professor, Medicine, Creighton University; also part of the core faculty in the Internal Medicine Residency Training Program at Saint Mary’s Related Medical Affiliations: Chair, Department of Medicine and Medical Director, Intensive Care Unit, Saint Mary’s Hospital Policy Statement: I am honored to be nominated for a position on the SFMS Nominations Committee. The SFMS should be an effective unified voice for all physicians in the San Francisco community, including those in group practices such as the Permanente Medical Group, institutions such as UCSF and SFGH, and physicians in private practice. I am in private practice specializing in pulmonary diseases and critical care. Previously I practiced at the Palo Alto VA hospital. My wife has been a Kaiser physician for over 20 years. Current problems we physicians need to address include more reasonable paperwork requirements for physicians, adequate compensation for subspecialty Emergency Department coverage, and affordable health care insurance coverage for all of our patients. SFMS needs to continue to be in partnership with the city government and the state legislature to achieve our goals. We should play an active role in setting CMA policy and action, and support the efforts of the CMA and the IMQ in advocating for patient safety.
DANIEL M. RAYBIN Specialty: Pulmonary Diseases and Critical Care
RICHARD M. NAIDUS Specialty: Emergency Medicine Membership: SFMS/CMA 1986 Medical School: University of Rochester 1972 Hospital Affiliations: Active: St. Francis;
FOR NOMINATIONS COMMITTEE:
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Courtesy: Seton Policy Statement: I am happy to support the valuable work of the society using my experience of 30 years of emergency medicine practice in San Francisco and having been active in medical leadership at Saint Francis Memorial Hospital for most of that period. CHARLES J. WIBBELSMAN ALSO CANDIDATE FOR SECRETARY. See biography under “For Secretary.” Policy Statement: As a delegate to the CMA’s House of Delegates since 1995, I have had the opportunity to observe representation and advocacy in the practice of medicine in the state of California. Indeed, just as the House of Delegates is diverse in representation from individual and group practice, as well as primary, specialty and subspecialty care, the San Francisco Medical Society needs to also have such diverse representation. Cultural and ethnic diversity has always been a unique strength of our Medical Society. As a member of the Nominations Committee, I would be honored to continue to ensure that our Medical Society continues to have the diversity that it has always embraced along with the injection of new and younger members of our society into elected offices and leadership roles. As a member of a very large group practice in San Francisco, I have had the opportunity to network with over 200 physicians with whom I share the practice of medicine. Also, having been on the Board of Directors of the San Francisco Medical Society for the past three years, a member of the American Academy of Pediatrics’ District IX, a clinical professor in Pediatrics at UCSF, and a delegate to the CMA, I have had the opportunity to meet and network with many physicians here in San Francisco. I would like to bring this experience of networking to our Nominations Committee. FOR AMA DELEGATE:
H. HUGH VINCENT (Incumbent Delegate) Specialty: Anesthesiology Membership: SFMS/CMA/AMA 1972
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SFMS: Board Consultant 1993-present; Immediate Past President 1993; President 1992; PresidentElect 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 199495); 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 1996-2005 (Vice Chair 200004; Chair 2004-06); Alternate Delegate 199495; House Select Oversight Committee 2001; Reference Committee C: A-95, I-95, A-01; Cal-C Committee Chair 1995-96; Resolutions Committee 1995-2000 Related Medical Affiliations: Saint Francis Physicians Medical Group/CHW Bay Area Physicians Medical Group 1995-2000 (President/CEO); Saint Francis Memorial Hospital Board of Trustees 1990-96/2000-06 (Secretary 1994-95, Chair 2001-03); Catholic Healthcare West Bay Area Board of Directors 1996-01; CHW Strategic Planning Committee 2001-05 Medical School: UCSF 1968 Hospital Affiliation: Active: Saint Francis Policy Statement: As before, my primary purpose in medical politics is to further the agenda and goals of California physicians at the national level. As chair of the California Delegation for the past three sessions, I have had the responsibility of shepherding our resolutions through that process. In that time, our delegation has been remarkably successful, and it has been a particular honor for me because so many of those resolutions adopted 38
nationally emanated from our own San Francisco Medical Society. I ask for your continued support and particularly for your input on issues important to California physicians. FOR AMA ALTERNATE DELEGATE:
JUDITH L. MATES (Incumbent Alternate Delegate) ALSO CANDIDATE FOR DELEGATION Specialty: Obstetrics & Gynecology Membership: SFMS/ CMA/AMA 1976 SFMS: Board Consultant 1997present; Immediate Past President 1996; President 1995; President-Elect 1994; Secretary 1993; Editor 1992; Director 198891 SFMS Committee/Board Appointments: SFMSPAC 1994-99 (Consultant 2000present); Editorial Board 1992-present; Executive 1992-96 (Consultant 1997present); Nominations 2000-01/1996-97/ 1994; Local Health Affairs 1995-2005 (Chair 1995-98); Judicial 1995-2005; Web Page Oversight 1996-2005; Medical Review and Advisory 2002; Physician Membership Services/Membership 1996-2002; HCFSF Board 1996-99; Heads of IPAs Task Force 1994-99; Insurance Mediation 1983-91 CMA: Delegate 1992-2005 (Chair 19972000/Vice-chair 1995-96); Committee on the Well-Being of Physicians 2004-05 (Chair 2005); President’s Forum (Chair 1995); Reference Committee G 1992-94 (Chair 1994); Consultant, Medical Managed Care Task Force AMA: Alternate Delegate 1998-present; Women Physicians Congress, Governing Council: 2000-2005, Vice Chair, WPC 200305 Related Medical Affiliations: CPMC Board of Directors, 1994-95 Medical School: Tufts University 1969 Teaching Appointments: Assistant Clinical Professor, UCSF Policy Statement: My years in private practice in San Francisco and my activities in the SFMS, CMA and AMA have given me a broad knowledge of the advocacy work that must be done for the good of physicians and patients. We are experiencing a continuation of the health care crisis that has now become
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a chronic illness in our society. Currently, some states are undergoing a liability crisis reminiscent of the one we had in 1975. California’s resulting MICRA legislation is now the gold standard for the rest of the nation and we need to support this legislation entirely, advocating the same standards for other states. This issue is but a beginning step in rethinking health care policies for our state and for our nation. I am still optimistic in thinking that physicians must actively participate in our SFMS, CMA and AMA at this time of crisis and change, and I am willing to devote my time and efforts to continue this battle. Please re-elect me as your representative to the CMA and AMA. FOR CMA TRUSTEE:
ROBERT J. MARGOLIN (Incumbent Trustee) Specialty: Internal Medicine Membership: SFMS/ CMA 1987, AMA 1992 SFMS: Board Consultant 2000-05; Immediate Past President 1999; President 1998; President-Elect 1997; Director 1992-96 SFMS Committee/Board Appointments: Executive 1993-99 (Consultant 2000-05); HCFSF Board 1995-2005; Judicial 1997-2005; SFMSPAC Board 1995-2001 (Consultant 2003-04/Vice Chair 2000-01); Finance/ Investment 1998-2002; Physician Membership Services/Membership 19952002; Managed Care 1998-2002 (Chair 200002/Co-chair 1999); 130th Anniversary Celebration 1998; Nominations 1999-2000/ 1995-97 CMA: CMA Trustee 2003-05; Delegate 19972002 (Chair 2001-03/Vice Chair 1998-2000) CMA Committee Appointments: Committee on Nominations 2003-05; AB 3686 TAC 2004-05; Long-Range Planning 2004-05; eCommerce TAC 2003; Council on Legislation 2001-02; CALPAC Board of Directors Related Medical Affiliations: Medical Director, Integrated Practice Group 1995-97; Medical Board, Mt. Zion, 1992-95; President, Physician’s Medical Group at Mt. Zion (IPA) 1993-present Medical School: Tufts University 1981 Hospital Affiliations: Active: CPMC, UCSF Teaching Appointments: Associate Clinical Professor, UCSF
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Policy Statement: I have greatly enjoyed serving on the SFMS Board of Directors for eight years and serving as its president in 1998. During the past several years, I have increased my involvement with the CMA. In addition to chairing our Delegation to the CMA House for three years, I have also served on CMA’s Council of Legislation and the CALPAC Board of Directors. During the past three years, I have served as your Trustee to the CMA Board. I have enjoyed advocating for physicians both locally and throughout California. I ask for your support in allowing me to continue our work on health insurance reform, MICRA preservation, financial advocacy and many other issues vital to physicians and their patients. FOR YOUNG PHYSICIANS SECTION DELEGATE:
JORDAN SHLAIN (Incumbent Alternate Delegate) Specialty: Internal Medicine Membership: SFMS/ CMA 1997 SFMS: Director 2003-06 SFMS Committee Appointments: Executive 2004-05; Website Committee 2002-05 (Chair 200305); Editorial Board 1998-2005; SFMS PAC 2004; Nominations 2003; Physician Membership Services 2001-02; QOM 20012003; Managed Care 1998-2002 CMA: Young Physicians Section Alternate Delegate 2004-05 Medical School: Georgetown 1994 Hospital Affiliation: Active: CPMC, Mt. Zion Teaching Appointments: UCSF Associate Clinical Professor, School of Nursing Policy Statement: As a native San Franciscan and a second-generation society member, I am eager to assist and serve on the board. I believe our society has significant influence in shaping policy and could benefit from the perspective and experience of a physician brought up in the environment of managed care. I have recently initiated a forum for the newer members of our society, called QOM, to voice their issues and foster a sense of community. As a member of the editorial board, I have worked closely with many of our outstanding leaders and understand the challenges regarding the health of our society and our city for the next decade.
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FOR YOUNG PHYSICIANS SECTION ALTERNATE DELEGATE:
LILY M. TAN Specialty: Ob/Gyn Membership: SFMS/ CMA 1999 Medical School: Albany Medical College 1995 Hospital Affiliation: Active: CPMC, St. Francis Teaching Appointments: CPMC nursing staff educator 2002-present. Related Medical Affiliations: CPMC Gyn Quality Improvement Committee 2002present; Chinese Hospital Pharmacy Committee 2002-2001. Policy Statement: With the recent explosion in scientific technology, the future of medicine has become increasingly enmeshed with politics. Stem cell research, advanced assisted reproductive techniques and human cloning among other advances, have served not only to greatly expand our capabilities, but to raise novel ethical concerns—concerns which have made the politics of medicine more complex than ever before. As the young physician delegate, I hope to infuse new energy into the San Francisco Medical Society, provide a fresh perspective and a voice for our newer members, and urge them to play an active role as future leaders of organized medicine. FOR CMA DELEGATION:
GARY L. CHAN Specialty: Internal Medicine Membership: SFMS/ CMA 1981 SFMS: Director 200205 SFMS Committee Appointments: Health Care Foundation of San Francisco Board 2005 Related Medical Affiliations: Assistant Medical Director, Brown & Toland 1990present; Utilization Management Advisor, Blue Shield 1984-99 Medical School: Tufts University 1976 Hospital Affiliation: Active: Saint Francis, CPMC, Saint Mary’s Teaching Appointments: Clinical Associate, UCSF Policy Statement: I have been active on the SFMS Board for the past three years. I am
currently on the HealthCare Foundation board as well. I would be pleased to serve as a delegate from San Francisco to the CMA and to be more involved. Thank you for offering me that opportunity. I have been practicing internal medicine here in San Francisco for the past 20 years and have witnessed the vast changes in medicine. I have firsthand knowledge of how the managed care system has evolved and the pressures placed on the system by providers, insurers, employers and lastly consumers. There has been a large disconnect between the goals and wishes of all parties concerned. There needs to be more active education on how the current system works or doesn’t work. Only then can we begin to lay the groundwork to fix it for the benefit of physicians and patients who have been mostly afterthoughts. Through our organized voice, physicians can play a role in changing our current system for the better. SFMS provides a forum for getting our voices heard. There still needs to be more public education on the evolving changes in health care. We all are paying a lot more for less. I hope to represent these concerns in the coming years. Thank you for your vote. LUCY S. CRAIN (Incumbent Alternate Delegate) Specialty: Pediatrics Membership: SFMS/ CMA 1972; AMA 1992 SFMS: Director 2004-06; Treasurer 2003; Director 2001-02 SFMS Committee Appointments: Finance 2002-05 (Chair 2003); SFMS Services Board 2003-05 (Secretary-Treasurer 2004-05); SFMS PAC Board 2002-05; Executive 2002-03; Nominations 2002-03 CMA: Alternate Delegate 2004-05 CMA Committee Appointments: Council on Legislation 2004-05; Technical Advisory Committee for Medi-Cal Reimbursement Related Medical Affiliations: First Five San Francisco Commissioner 2003-present (Chair 2004-present); Chair, AAP-CA Task Force on Children with Special Health Care Needs 2000-present; Member, AAP-CA Board of Directors; Chair, Health Committee of San Francisco Commission on Children and Families (SFCFC/Proposition 10 Commission) 2002; County Commissioner
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SFCFC 1999-present; Immediate Past Chair, American Academy of Pediatrics, California; and member of Board of Directors, national AAP 1997-2000 Medical School: University of Kentucky 1965; MPH, UCB 1971; Fellowship in Health Policy, UCSF Institute for Health Policy Studies 2001 Hospital Affiliation: Active clinical faculty: UCSF and Lucile Packard Children’s Hospital at Stanford Teaching Appointments: Clinical Instructor, LCPH at Stanford Department of Pediatrics and Clinical Professor, emeritus, UCSF Department of Pediatrics Policy Statement: Practicing physicians are uniquely qualified to advocate for quality improvement and standards of health care and education and to partner with consumers, patients and community leaders in demanding accountability regarding health issues from legislators and others. SFMS is crucial in facilitating these partnerships to address the health issues of our community, and in promoting educational opportunities for our members and future physicians and leaders within medicine. The CMA House of Delegates offers SFMS a visible presence in the prioritization of health care concerns, as well as opportunities to recommend solutions. Understanding the impact of politics on health policy and practice today and the future health of our community, state and nation underscores the strategic role to be played by our Medical Society and our profession. GEORGE A. FOURAS Specialty: Child and Adolescent Psychiatry Membership: SFMS/ CMA 1996, AMA 1987-90, 1995-present SFMS: Director 200305 SFMS Committee Appointments: Executive 2003-05; Psychiatric Services 1996-2005, SFMS PAC 2004-05; Physician Membership Services 2003-05 CMA: Alternate Delegate 2000-02; California Psychiatry Association Specialty Delegate to Young Physicians Section CMA 1996-99 Related Medical Affiliations: President, Northern California Regional Organization of Child and Adolescent Psychiatry 2000 (President-Elect 1999); Chair, California Psychiatric Association Child and Adolescent 40
Committee 2000-present; Medical Director, Foster Care Mental Health Program, City and County of San Francisco, 1995-present Other: Board Certified in General Adult Psychiatry 1999 Medical School: Ohio State University 1990 Hospital Affiliation: Courtesy: SFGH Policy Statement: I am honored to be nominated for a position on the CMA delegation. I have enjoyed representing you at the House of Delegates in the past and on the Board of Directors currently, and hope to continue to serve our Medical Society. As a physician working in the San Francisco DPH, I am keenly aware of how state policies, especially regarding medical, affect our patients, both public and private. In addition, it is likely that more scope-of-practice issues will be introduced in the next legislative session. I will work hard to bring these issues to SFMS, and to ensure that our views are carried to CMA. It is my firm belief that we must work together among all specialties to present a united message regarding patient care and our ability to practice medicine. ALAN G. GREENWALD (Incumbent Delegate) Specialty: Orthopedic Surgery Membership: SFMS/ CMA 1984; AMA 1984 SFMS: President 2005; President-Elect 2004; Editor 2003; Director 1989-96 SFMS Committee Appointments: Executive 2003-05; Editorial 2000-05; Physician Membership Services 2003-05 (Chair 2004); Judicial 2004-05; Chiefs of Staff 2004-05; SFMS PAC Board 2004-05/1999/1995 (Consultant 1996-98); HCFSF Board 19972001; Nominations 1996 and 1999-2000 CMA: Delegate 2004-05 Medical School: University of Pittsburgh 1977 Hospital Affiliations: Active: CPMC; Courtesy: St. Francis, St. Mary’s, St. Luke’s, UCSF Mt. Zion, Marin General Teaching Appointments: Clinical Instructor, UCSF Department of Orthopedics Policy Statement: Thank you for your nomination for the CMA delegation. I look forward to continuing my commitment to the delegation. It is an important process for our society to advance and support the democracy of organized medicine. We have provided substantial influence in the state and national political process and I am proud to be involved.
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BRIAN J. LEWIS (Incumbent Vice Chair) Specialty: Medical Oncology Membership: SFMS/ CMA 1989, AMA 1997 SFMS: Director 1999-2006 SFMS Committee Appointments: Nominations 2005; HCFSF Board 2005; Executive 2001; Education Chair 1996 CMA: Alternate Delegate 2000-05 and 1996 (Vice Chair 2004-05); Very Large Group Practice Forum Delegate 1999; VLGPF Alternate Delegate 1997-98 Medical School: Harvard 1969 Hospital Affiliation: Active: Kaiser Permanente Teaching Appointments: Clinical Professor, UCSF Policy Statement: The CMA House of Delegates is the voice that communicates the concerns of California physicians to the AMA, to government, and to the media. The craft and compassion shown by the delegates in framing resolutions and the camaraderie manifested in the debates foster a wonderful sense of common purpose and fellowship. In years past, I have been fortunate to help represent the SFMS, and I have been asked to serve as chair in the upcoming delegation. I would be grateful for your support. DEXTER LOUIE (Incumbent Delegate) Specialty: Otolaryngology Membership: SFMS/ CMA 1978 SFMS: Board Consultant 1999-2005; Immediate Past President 1998; President 1997; President-Elect 1996; Secretary 1995, Director 1992-94; Chinese Hospital Medical Staff Liaison 199596 SFMS Committee Appointments: Executive 1994-98 (Consultant 1999-2005); Judicial 1996-2005; PAC Board 1996 (Consultant 1997-2005); Finance/Investment 1998-99; Bioethics 1997-99; Medi-Cal Managed Care Advisory Committee 1997-99; Nominations 1998-99; 1994-95 CMA: Delegate 1994-2005; Alternate Delegate 1992-93
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CMA Committee Appointments: Medical Services 1998-2001; Medical Staff Survey 1990-94 Related Medical Affiliations: JD/MPA, Golden Gate University; Associate Medical Director, CCHP Medical School: Tulane University 1969 Hospital Affiliations: Active: CPMC, Chinese Hospital, Saint Francis Policy Statement: Physicians, as patient advocates, are faced with many challenges. We must protect our patients, many of whom have no or inadequate insurance coverage. We must protect and improve access. We must protect MICRA, attempts by nonphysicinas to practice medicine, and unrealistic and inappropriate regulation of the practice of medicine. There are many other issues. We have much to do. CAROLYN D. MAR ALSO CANDIDATE FOR BOARD. See biography and policy statement under “For Board of Directors.” JUDITH L. MATES (Incumbent Delegate) ALSO CANDIDATE FOR AMA ALTERNATE DELEGATE. See biography and policy statement under “For AMA Alternate Delegate.” RITA MELKONIAN (Incumbent Delegate) Specialty: Gynecology, Female Urology Membership: SFMS/ CMA 1991 SFMS: Consultant 2005; Immediate Past President 2004; President 2003; Presidentelect 2002; Editor 2001; Director 1996-2000 SFMS Committee Appointments: Executive 1998-2004 (Consultant 2005); Editorial Board 2001-05; Judicial 2002-05; Physician Membership Services 1998-2005; Finance 2003-04; SFMS PAC Board 1999-2004; Nominations 2004/2001/1997; Managed Care 1998-2001; Insurance Mediation 1993-96 CMA: Delegate 2002-05; Alternate Delegate 1998-2001 CMA Committee Appointments: Council on Legislation 2004-05 Medical School: National University 1977 Hospital Affiliation: Active: St. Francis Teaching Appointments: Assistant Clinical Professor, Stanford University http://www.sfms.org
Policy Statement: I have greatly enjoyed serving SFMS in different levels over the past few years, especially serving as an alternate delegate and delegate to the CMA for the past six years. In these challenging times when the practice of medicine is so deeply influenced by insurance companies, legislation and governmental regulations, it is crucial for us physicians to play active roles in reforming our vastly imperfect health care systems. The CMA is our advocate and our voice in the legislation arena and being active in CMA is the only way to reform the troubled health care system. It will be a great honor for me to continue as a delegate to the CMA House of Delegates and I appreciate your continued support. RACHEL HU I-CHUNG SHU (Incumbent Alternate Delegate) Specialty: Ob-Gyn Membership: SFMS/CMA 1992, AMA 1986 SFMS Committee Appointments: Credentials 19942005; Physician Membership Services 1994-2002; Nominations 2001-02; Leadership Development 1995 CMA: Alternate Delegate 2001-05 Related Medical Affiliations: Chinese Hospital Medical Executive Committee (MEC) 1999-present; CPMC OB/GYN MEC 1998-present; CPMC Perinatal Quality Assurance Committee 1994-present; CPMC Joint Health Committee 2001-present Medical School: University of Missouri 1986 Hospital Affiliation: Active: CPMC, Chinese; Courtesy: Saint Francis Teaching Appointments: Clinical teaching staff, UCSF 1992-present Policy Statement: I am honored to be a candidate for the CMA delegation again. We are in a time of change, as so many issues are facing practicing physicians today. These issues include patient advocacy, rising malpractice premiums, PPOs, and boutique medicine, to name a few. Practicing physicians also face the reality of the electronic age, and must be knowledgeable in electronic medical records, ihealthrecords and HIPAA—advances in technology and privacy issues that are here to stay. CMA gives each one of us a voice in this complex world. If elected, I hope to help form
policy and make a difference on behalf of my colleagues. PETER W. SULLIVAN (Incumbent Alternate Delegate) ALSO CANDIDATE FOR BOARD. See biography and policy statement under “For Board of Directors.” Policy Statement: I am honored to be nominated to serve on the SFMS Delegation to the CMA House of Delegates. I have enjoyed the opportunity over the last six years to meet with my SFMS colleagues and address the hot issues facing physicians statewide. I continue to sit on the SFMS Finance Committee and Board, where many of the issues of interest to San Francisco physicians are discussed. It would give me great pride and pleasure, if I am re-elected, to represent the physicians of San Francisco at the CMA level. GEORGE P. SUSENS (Incumbent Delegate) Specialty: Internal Medicine Membership: SFMS/ CMA 1982 SFMS: Consultant 2003-05; Immediate Past President 2002; President 2001; PresidentElect 2000; Director 1996-99; Medical Staff Liaison to TPMG 1996-99 SFMS Committee Appointments: Executive Committee 1997-2002 (Consultant 2003-05); Finance/Investment 2001-05; Disaster Planning 2002-05; Nominations 2002/199495; SFMSPAC Board 1997-2002; Judicial 2000-02; Chiefs of Staff 2001; Bioethics 198687; Legislative 1990-95 CMA: Delegate: 2000-05/1996-97; Alternate Delegate 1998-99/1993-95 Related Medical Affiliations: Chair, Credentials and Privileges Committee of Kaiser Foundation Hospital 1996-present; Vice Chair, Board of Directors, Northern California Permanente Medical Group 1993-96 Medical School: Northwestern 1962 Hospital Affiliations: Active: Kaiser Permanente Policy Statement: It has been a privilege to serve the San Francisco Medical Society as a delegate to the California Medical Association’s annual meeting. I would like to continue my efforts to influence the CMA’s responses to the hostile environment in which we find ourselves. The SFMS’s influence on
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Proposition 36 Revisited The Substance Abuse and Crime Prevention Act, also known as Proposition 36, was passed by 61 percent of California voters on November 7, 2000. This initiative allows first and second time nonviolent, simple drug possession offenders the opportunity to receive substance abuse treatment instead of incarceration. Proposition 36 allocated $120 million annually for five and one-half years to pay for treatment services. However, due to the large disparity between incarceration and treatment costs, it was estimated that the initiative will save California taxpayers $1.5 billion over the five-year period. The allocation of funds for treatment expires in fiscal 20052006. A number of bills have been introduced in the legislature to refund Proposition 36. However, not all of the bills so far introduced are driven by a desire to further the mission of Proposition 36. Some legislation, backed by law enforcement, aim to turn back Proposition 36 and return to a crime and punishment mentality in dealing with substance abuse. The California Society of Addiction Medicine (CSAM) has been very vocal in support of Proposition 36. CSAM’s President (at the time of the initiative) Peter Banys, MD, wrote a statement on behalf of CSAM that appeared in the voters’ handbook. Gary Jaeger, MD, Chair of CSAM’s Committee on Public Policy appeared on television spots for the initiative. In approving Proposition 36, the majority of California voters defined drug abuse as a medical and public health problem deserving of medical responses. As physicians we cannot agree to restore the failed criminal justice approaches inherent in the three decade long “war on Drugs.” “Jail is a blunt and expensive instrument. If you are a hammer, everything looks like a nail. Clinicians have a broader range of tools in their toolboxes,” Dr. Banys recently wrote in a letter to the chair of the Senate Committee on Health.
receive what UCLA researchers call a standard dose of treatment, in this case meaning they spend the same amount of time in treatment as people who complete treatment. This is a respectable mix of outcomes that shows treatment dollars are being well-spent. Remember, a month of incarceration is far more expensive to California than a month of even the most intensive treatment. Proposition 36 compares well with other systems linking treatment and criminal justice. The Proposition’s 34.4 percent completion rate is virtually the same as the rate for all other criminal-justice referrals. Drug courts had a 41.8 percent completion rate statewide—albeit with a much smaller, handpicked group of drug offenders. Data show that Proposition 36 clients are more severely addicted than those in drug court. Most importantly, Proposition 36 has saved many human lives. “Before I entered Prop 36 I never saw my family during the holidays,” said Gary, 47, a Prop 36 graduate who had used drugs for 30 years. “Yesterday I bought toys for my grandchildren. I am now a productive member of society.” There is clearly a role for incarceration in drug policy. However, incarceration is not treatment. As CSAM member Diana Sylvestre, MD, wrote, “I went through 4 years of medical school, 2 years of residency, and 5 years of fellowship, all at top locations. In all those years, and with all of those lectures, I did not receive a single lecture on jail. That is because jail is not treatment, it is punishment. I could get my fat patients to lose weight if I locked them in a cage. Would you call that a treatment for obesity?” This article first appeared on the California Society of Addiction Medicine website at http://www.csam-asam.org/prop36article.vp.html.
PROPOSITION 36 IS WORKING
According to a study of Proposition 36 by UCLA, about half of clients in the program’s first two years were entering treatment for the first time in their lives. In the most recent year, first-time clients were more commonly Hispanics, male, younger drug users (over half were 35 years of age or younger) and methamphetamine users. Many first-time clients have a drug use history of 10 years or more. Nearly three out of four clients entering Proposition 36 treatment make substantial progress and reach positive outcomes. Just over a third (34.4 percent) complete their treatment. Another 8 percent are discharged from treatment with a rating of satisfactory progress. Almost a third more (29.8 percent)
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(From L to R) SFMS President Alan Greenwald, MD, Mayor Gavin Newsom, CMA President Michael Sexton, MD, and SFMS President-elect Gordon Fung, MD, pose for a photo following the September 12 annual general meeting of the San Francisco Medical Society. Both Mayor Newsom and Dr. Sexton were the Society’s featured speakers that evening. The dinner meeting was open to all SFMS members.
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HOSPITAL NEWS ■ Chinese
■ CPMC
■ Kaiser
Fred Hom, MD
Damian Augustyn, MD
Bruce Blumberg, MD
Chinese Hospital brought home the gold medal in the “B” Division at the 10th Annual San Francisco International Dragon Boat Festival on August 27 at Treasure Island. Our fine athletes were able to ward off teams from the Marines/Coast Guard and four other organizations in the finals race.
Dr. Michael Black, chief of Pediatric Cardiac Surgery and the surgical director of Pediatric and Adult Congenital Heart program, performed a historic surgery last Wednesday on a young woman with a congenital abnormality of a coronary artery. Dr. Black used the daVinci robot to completely correct her defect. The machine allowed for very sensitive micro-maneuvering critical for this procedure. The surgery was quite involved and required tying off an abnormal blood vessel communication in the patient’s heart. Rather than a chest incision, the young woman has only three small holes or ports where the robotic instruments were introduced. She had her breathing tube removed in the operating room, stayed in ICU about six hours before going to the floor, and was discharged home two days later (instead of a day in ICU and four to five days in hospital). The case was a fabulous success, and we are pleased to offer our patients the benefits of less invasive surgery. California Pacific Medical Center’s Kenneth Binmoeller, MD, and Ann Chen, MD, are now performing double balloon enteroscopy, a non-surgical procedure that goes beyond the capabilities of capsule endoscopy by allowing more precise examination and enabling treatment of the entire small intestine, the most difficult organ to access in the gastrointestinal (GI) tract. The small intestine remains the most common site of obscure bleeding when a source cannot be identified by upper endoscopy or colonoscopy. “Upper endoscopy and colonoscopy allow us to see only the two extreme ends of the gastrointestinal tract. The small intestine, which is around 25 feet long, has been the ‘blind spot’ beyond our reach,” says Dr. Binmoeller. Double balloon enteroscopy now changes that. sfm
At Kaiser Permanente, we believe alcoholism and drug use disorders are chronic medical illnesses, which deserve our highest medical attention. Patients with these disorders suffer painful and costly consequences on par with diabetes, asthma and hypertension—their families suffer as well. At Kaiser, we commit to providing high quality medical treatment to meet the needs of our addicted patients and their families. Treatment works! Our San Francisco Chemical Dependency Recovery Program provides state of the art treatment for 2000 patients annually. Our services include outpatient medical detoxification, day hospital, intensive outpatient, family and co-dependency treatment. We also contract with an extensive network of residential substance abuse treatment programs. Staffed by board certified addiction medicine physicians, psychiatrists, psychologists, therapists and certified drug and alcohol abuse counselors—our staff expertly provides individualized multidisciplinary treatment for all ages. Having fully embraced parity-level treatment, it is hard to imagine providing service any other way. Incarceration is not treatment; mandated treatments might be treatment. At Kaiser, we are not newcomers to the strengths and weaknesses of mandated treatment. Working extensively with EAPs and Substance Abuse Professionals (SAPs), who oversee patients in safety sensitive jobs, we routinely support our patient’s recovery and facilitate compliance with their return-to-work mandates. In our experience, the best treatment is integrated collaborative treatment. When families, employers, courts and treatment providers collaborate, all the best resources can be brought to facilitate the medical recovery from addiction. sfm
Medical staff rowers were: Shu-Wing Chan and his daughter, Mei-Sai Chan; Arthur Chin, Edward Chan, Vernon Fong and Randall Low. Hospital staff participants were Simmy Lee, Elena Wong and Jiong Jiang from respiratory, Stuart Fong, infection control and risk management, Wayne Dong, radiology manager, Jackie Won, social services, Alice Louie, physical therapy, and Tasha Yuen, Jennifer Hong and Cesar Trinidad of nursing. Also, an honorary gold should go to the number one cheerleader, Sally Lee, RN. The Chinese Community Healthcare Association noted congratulations to Dr. Dexter Louie for being elected to the board of the CMA Foundation and to Dr. Edward Chow for being honored for his service to the Chinese and Asian community by the Asian Perinatal Advocates. Finally, the JCAHO reminder of the month: remember to perform and document the “Pre-op Time-Out” prior to all procedures and surgeries that require an informed consent. sfm
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HOSPITAL NEWS ■ Saint Francis
■ St. Luke’s
■ St. Mary’s
Guido Gores, MD
Ernesto J. Puletti, MD
Kenneth Mills, MD
Saint Francis’ Centennial Year is turning out to be quite an auspicious one. In June, our Bothin Burn Center received its official reverification from the American Burn Association/American College of Surgeons. The verification for both adult and pediatric patients also commended Saint Francis for “its continued commitment to excellence, and its commitment to provide quality burn care to its patients.” The Bothin Burn Center is the only verified burn center in San Francisco. There are over 100 burn centers in the country, but only 40 are verified. In July, Saint Francis invited the American College of Surgeons, Commission on Cancer, to survey our CancerCare Program. The hospital received a full three-year Accreditation with Commendation. The commission commended the program in nine survey focus areas. In August, we hosted the Joint Commission for the Accreditation of Healthcare Organizations at our hospital for an intensive five-day survey. We received full accreditation for the hospital and satellite clinics. These accreditations are a true testament to the hard work of our staff and physicians and their commitment to excellence and quality care. Since it is our centennial year, pardon me if I blow our horn a little louder. Early in August, San Francisco Supervisors Jake McGoldrick and Board President Aaron Peskin introduced a board resolution commending Saint Francis Memorial Hospital, along with our sister hospital, St. Mary’s Medical Center, and Catholic Healthcare West (CHW) “for the promotion of public-private partnerships whose goals is to enhance and to protect health care services, particularly for the medically undeserved.” It has been a very good year. sfm
Dr. William Miller has been selected to fill the new position of chief medical executive for St. Luke’s, an office intended to strengthen ties between the medical staff and the administration and to increase physician input into the planning process. Too often the Medical Executive Committee has been informed after the fact of substantive changes within the hospital. Now we have a strong voice within the administration. He will also head the physician development process, in which he has already shown initiative by the creation of Project Turning Point, which was discussed in a previous column. Dr. Miller says he is, “committed to improving the financial viability and future of St. Luke’s Hospital.” Dr. Miller was an internist and oncologist in Arizona before moving here in 2000 to become medical director of the hospitalist service. For the last year he has also been chair of medicine. He was a physician leader in JCAHO recertification and has participated in many quality improvement efforts. He cochairs the Information Technology Steering Committee, which will oversee the implementation of an electronic health record over the next five years. We admire the energy he brings to our hospital. In June, Dr. David Haskin retired from his pediatric practice after more than 50 years at St. Luke’s. He attended a retirement party in his honor. He has been chair of pediatrics, vice-chief of staff (twice), and chief of staff. He was much loved by his patients, many of whom continued to see him well into adulthood. He will be missed in the Doctors’ Dining Room, where he was a fixture for many years and a thorn in the side of the previous administration.sfm
It’s always a relief to have the Joint Commission Survey completed, especially when full accreditation is the outcome. Once again, St. Mary’s demonstrated it’s sound quality improvement processes, organizational culture of safety and dedicated medical staff. The same week we had an unannounced survey of our Skilled Nursing Facility by the Center for Medicare and Mediciad Services. That result was also favorable. As we all know, the challenge for the future is being prepared. All JCAHO surveys will be spontaneous and unannounced!
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St. Mary’s continues to look to the future and the future is our doctors and our patients. We have had our first meeting with the architect to develop a long-term master site plan. Over the last four years, we have recruited 37 doctors to our campus. We are running out of space. Part of the plan will be for a new medical office building on campus, as well as building out more space for outpatient services. This will be an exciting process for strategic collaboration with administration, the board of directors, and the medical staff. Finally, we are all shocked and saddened by the recent events with Hurricane Katrina and her havoc on the Gulf coast. Just the enormity of the impact on hospitals and other health care facilities and their patients is horrid. Catholic Healthcare West, St. Mary’s as well as our medical staffs and nursing staffs have all offered assistance and volunteered. As San Franciscans, this should serve as a reminder to the need for our own preparedness. Disaster planning is not a useless and futile exercise. We will need it and it will serve us well. sfm
OCTOBER 2005 / SAN FRANCISCO MEDICINE
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HOSPITAL NEWS ■ Seton
■ UCSF
■ Veterans
Stephen Conrad, MD
Linda M. Reilly, MD
Diana Nicoll, MD, PhD
Seton rises through the unremitting fog of Daly City—a beacon of hope for motorcyclists on the Northern Peninsula. From our hospital, we see San Bruno Mountain where the struggle between the developers and environmentalists continues. (The developers are winning). We can also see the cemeteries of Colma where some of our less fortunate patients lie in eternal repose.
Lisa Hornberger, MD, is out to change routine prenatal ultrasound exams. More than 90 percent of major structural heart defects can be detected in the fetus via ultrasound screening. Currently, however, physicians who do routine prenatal screening find less than 20 percent to 25 percent of these defects. “That means the screening ultrasound given to the majority of pregnant women is not sufficient,” says Hornberger, director of the Fetal Cardiovascular Program at UCSF Children’s Hospital. “One percent of newborns have a heart defect and 20 to 30 percent of these babies have a serious heart defect,” she says. “Improving the detection of most major structural heart defects is extremely important because we know that prenatal detection improves perinatal and neonatal outcome, and it’s obviously critical for preparing families who are going to have an affected baby.” In addition, she says, UCSF and a few other U.S. hospitals have the capability to intervene prenatally with the possibility of preventing certain defects from developing into serious abnormalities. In training sessions for obstetricians and radiologists throughout Northern California, Hornberger is showing practitioners how to screen fetuses for heart defects at 16 to 20 weeks. She also is working to develop techniques for reliably detecting cardiac defects in the fetus as early as 10 to 14 weeks, work that she has been involved in since 1992. One of the characteristics that may appear at this early gestational age is nuchal (at the neck) thickening, a characteristic that can be one indicator of Down’s syndrome. Researchers also now know that nuchal thickening is associated with cardiac defects even in the absence of chromosomal defects like those that cause Down’s syndrome.sfm
The focus of this issue of San Francisco Medicine is on the decriminalization of medicine. At Seton, we no longer have an inpatient psychiatric service, but we do have mental illness. Our psychiatrists are busy, however the emphasis is on outpatient care rather than inpatient treatment. John Roumasset, MD, has developed an outpatient hospitalization program in which patients meet on a regular basis and receive therapy—both group and individual. They also learn coping and living skills while their medications are monitored. The program has proven successful and the majority of patients remain productive and capable of independent living. Both Seton and Seton Coastside prevailed as we just completed a successful JCAHO survey. Our reviewers focused on conscious sedation, time outs and medication management. One surveyor was fixated upon oxygen tank storage. We were prepared and prevailed in all areas. We intend to maintain a high level of readiness in order to cope with future surveys which will be unannounced.sfm
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SAN FRANCISCO MEDICINE / OCTOBER 2005
The San Francisco VA Medical Center (SFVAMC) cares for veterans with various forms of mental health and substance abuse conditions and helps them to return to as normal a life as possible. The mental health and substance abuse providers use innovative approaches to treatment and are in the vanguard of research into these conditions. SFVAMC also provides outpatient mental health treatment at all of its sites in San Francisco, San Bruno, Santa Rosa, Ukiah and Eureka. The Substance Abuse Day Hospital (SADH) is an intensive outpatient treatment program with a mission to provide short-term and cost-effective care as an alternative to inpatient drug and alcohol treatment. It is an option to stabilize veterans who have returned from military combat in Afghanistan or Iraq, who are unable to initiate abstinence in less intensive outpatient settings. The SADH is also used to intensify outpatient treatment and/ or structure for veterans who relapse in less intensive outpatient settings. Since 1992, the Substance Use/ Posttraumatic Stress Disorder Team (SUPT) has provided state-of-the-art treatment for veterans who have a diagnosis of Posttraumatic Stress Disorder (PTSD) having served in a combat environment and have one or more addictions. SUPT maintains the dual mission of helping veterans (of whom Iraq War veterans are the latest) to achieve and/or maintain abstinence from drugs and alcohol and to work through some of the issues related to their combat experience. To achieve this SUPT provides an integrated program that focuses on relapse prevention, PTSD symptom management (using both pharmacologic and behavioral interventions), anger management, and a general improvement in coping and relationship skills. sfm http://www.sfms.org
Classified Ads The San Francisco Medical Society does not investigate offers made in classified advertising and assumes no liability concerning them. Publication of any advertisement should not be deemed an endorsement of the products or services advertised. To place a classified advertisement, call (415)561-0850, ext. 261, and request an order form via fax or mail, or email ecarroll@sfms.org; fax: (415)561-0833.
OFFICE SPACE AVAILABLE Medical Office for lease: 78 sq. ft. at 2186 Geary Street. Corner office w/ view of SF skyline. Plenty of parking on site. Contact Greg Smith, agent, at (415) 931-5630, ext. 2, or by email at greg@palladin.net.
VOLUNTEERS NEEDED VOLUNTEER PHYSICIANS NEEDED for Doctors of the Worlds’ Human Rights Clinic to assist torture survivors. Tasks: Provide physical exam and documentation. Commitment: 1-2 days/month. Required: state licensed, board eligible, compassionate, culturally sensitive. Call (619) 278-2405, fax: (619) 294-9281.
VOLUNTEERS NEEDED FOR PROJECT HOMELESS VOLUNTEER PHYSICIANS NEEDED for the San Francisco Department of Public Health’s Project Homeless Connect to reach out and supply medical and other services to homeless individuals in San Francisco. If you would like to participate as a volunteer, please contact SFMS Executive Director Mary Lou Licwinko, at (415) 561-0850, ext. 237, or by email at mll@sfms.org. This is an opportunity for SFMS members to work with Mayor Newsom to assist the homeless in our beloved city. Please consider becoming involved with other medical society members in this most worthwhile mission.
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Calendar of Events UCSF OBSTETRICS AND GYNECOLOGY UPDATE: WHAT DOES THE EVIDENCE TELL US? OCTOBER 19 TO 22
Grand Hyatt Union Square Call (415) 476-4251. RECLAIMING THE HEART AND SOUL OF MEDICINE: THE PATH OF SERVICE OCT. 21 - 22
A CME workshop for health professionals with Rachel Naomi Remen, MD The Acqua Hotel, Mill Valley, California $425 physicians; $250 residents (707) 575-6801. ADDICTION MEDICINE: STATE OF THE ART 2005 FROM THE BRAIN TO THE COMMUNITY OCTOBER 19 TO 22
Hyatt Regency, Long Beach California Society of Addiction Medicine Contact csam@compuserve.com. (415) 927-5730; www.scam-asam.org. SFMS’S “MBA” FOR PHYSICIANS AND OFFICE MANAGERS: FINANCE THURSDAY, NOVEMBER 3
1409 Sutter Street 9 a.m. to 12 noon (8:40 a.m. breakfast/ registration)
Call Posi Lyon at (415) 561-0850, ext. 260. SFMS’S “MBA” FOR PHYSICIANS AND OFFICE MANAGERS: OPERATIONS THURSDAY, NOVEMBER 10
1409 Sutter Street 9 a.m. to 12 noon (8:40 a.m. breakfast/ registration) Call Posi Lyon at (415) 561-0850, ext. 260. SFMS’S “MBA” FOR PHYSICIANS AND OFFICE MANAGERS: PERSONNEL THURSDAY, NOVEMBER 17
1409 Sutter Street 9 a.m. to 12 noon (8:40 a.m. breakfast/ registration) Call Posi Lyon at (415) 561-0850, ext. 260.
2005 SFMS Slate of Continued from page 41 the CMA and AMA is remarkable for our small size. As I said when I was elected president of the SFMS, “I feel we are the conscience of CMA.” Physician advocacy is effective. JOHN I. UMEKUBO ALSO CANDIDATE FOR BOARD. See biography and policy statement under “For Board of Directors.”
Dr. Tom Lee accepts a certificate of appreciation from President Alan Greenwald at the September 12th SFMS Annual General Meeting for his work steering and developing the soonto-be-launched new website for the Society. OCTOBER 2005 / SAN FRANCISCO MEDICINE
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