September 2015

VOL.88 NO.7 September 2015

SAN FRANCISCO MEDICINEJOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

FORTY-NINESQUARE MILES OF INNOVATIONLOCAL BREAKTHROUGHS IN MEDICINE AND PUBLIC HEALTH

Service and ValueMIEC takes pride in both. For over 35 years, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services, we’ve partnered with policyholders to keep premiums low.

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* (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

“ As your MIEC Claims Representative, I will serve

your professional liability needs with both

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Senior Claims Representative Michael Anderson

MIEC Belongs to Our Policyholders!

Toni Brayer, MDBoard of Governors, Internal Medicine

Keeping true to our mission MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For 40 years, MIEC has been steadfast in our protection of California physicians with conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services; we’ve partnered with policyholders to keep premiums low.

Added value: n No profit motive and low overhead n Dividends for an average savings of 25% on 2015 premiums for California

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* On premiums at $1/3 million limits. Future dividends cannot be guaranteed.

MIEC 6250 Claremont Avenue, Oakland, California 94618

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MIECOwned by the policyholders we protect.

SFmedSoc_ad_02.13.15.indd 1 2/19/15 4:07 PM

IN THIS ISSUE SAN FRANCISCO MEDICINE September 2015 Volume 88, Number 7

FORTY-NINE SQUARE MILES OF INNOVATION

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850Web: www.sfms.org

MONTHLY COLUMNS

4 Membership Matters

9 Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

16 Welcome New Members

28 Medical Community News

30 Upcoming Events

29 Classified Ad

OF INTEREST

24 CMS Update Ashby Wolfe, MD, MPP, MPH

26 Public Health Update: Mandatory Influenza Vaccination or Masking of Health Care Workers During Influenza Season Tomás J. Aragón, MD, DrPH

27 Health Policy Perspective—Physician-Assisted Dying: Honest Choices Donald Abrams, MD, and Steve Heilig, MPH

ADVOCACY UPDATE

23 September SFMS Advocacy Update John Maa, MD, FACS

FEATURE ARTICLES

9 Identifying HIV: The First Step to Hope in the AIDS Crisis Paul Volberding, MD 11 Linking HIV with AIDS: A Breakthrough in Understanding Stephen E. Follansbee, MD

13 One Medical: Redefining the Primary Care Model Thomas Lee, MD 15 San Francisco Values: Health Care Is a Right, Not a Privilege David E. Smith, MD, and Steve Heilig, MPH

17 Universal Health Coverage: Healthy San Francisco Provided Access to Residents Steve Heilig, MPH

18 Optogenetics: Taking Neuroscience by Storm Bruce Goldman

20 A Neurological First: A Piece of San Francisco Medical History Arthur E. Lyons, MD

21 A Cardiovascular First: Catheter Ablation of the AV Junction Melvin Scheinman, MD

4 SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG

Activities and Actions of Interest to SFMS Members

MEMBERSHIP MATTERS

other key contacts. SFMS members can download the profiles for free as part of their member benefits at http://bit.ly/1JRuj4d.

SFDPH Releases Health Advisory on Opioid Overdose

The San Francisco Department of Public Health has issued an advisory after noting an increase in opioid overdose cases reported to the SF Drug Overdose Prevention and Education (DOPE) Project, with more than 75 cases in July 2015 (versus 25 in July 2014). Most have occurred in the Civic Center area and involved a fine white powder found to be pure fentanyl. Multiple doses of naloxone have often been required to reverse the overdose. There has not been a corresponding rise in overdose-related ambulance calls or deaths from opioid overdose, suggesting that programs designed to avert mortality by supplying naloxone to users and their close contacts have so far been effective. Health care providers should continue to promote appropriate provision of naloxone.

Naloxone can be distributed and prescribed to lay persons in San Francisco who may experience or witness an opioid overdose. It is covered by Medi-Cal, Healthy SF, and most health plans and can also be furnished by pharmacists registered to do so without a pre-scription. Naloxone is also available at no cost from the DOPE Proj-ect, targeting drug users and their friends and family via syringe exchange sites. These means of naloxone provision and use are protected by California law (AB635 and AB1535). Visit http://bit.ly/1PnXr3h for additional resources for substance use treatment and naloxone.

CDC Vaccine Schedule App for Clinicians and Other Immunization Providers

The Centers for Disease Control and Prevention (CDC) has launched a vaccine schedule app for clinicians’ use on smartphone and tablets. Health care professionals who recommend or admin-ister vaccines can immediately access all CDC-recommended im-munization schedules and footnotes using the CDC Vaccine Sched-ules app. Optimized for tablets and useful on smartphones, the app shows the child, adolescent, and adult vaccines recommended by the Advisory Committee on Immunization Practices.

The app visually mimics the printed schedules, which are re-viewed and published annually. Users can identify correct vaccine, dosage, and timing with two or three clicks. Any changes in the schedules will be released through app updates. For more informa-tion, visit http://bit.ly/1UzvSqo.

Covered California Health Plan Network Directory Accuracy

Last November, the California Department of Managed Health Care (DMHC) released the results of an audit of the Anthem Blue Cross and Blue Shield Covered California networks.

Among other things, the audit found that 12.8% of the phy-sicians listed on Anthem’s network were not accepting Covered

2015–2016 Membership Desktop Reference

The 2015–2016 SFMS Membership Directory and Physician Desk Reference has been mailed out to all active physician mem-bers. The annual Directory is one of the most valued benefits of membership and is the only pictorial directory of physicians in San Francisco. This resource is complimentary to all SFMS physician members currently practicing medicine and is used throughout the year by physicians and their staff. For questions or information about the Directory, please contact Ariel Young at (415) 561-0850 extension 200 or [email protected].

SFMS Members Receive Complimentary Access to Payor Profiles

The California Medical Association has published updated profiles on each of the major payors in California, including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, United Healthcare, Medicare/Noridian, and Medi-Cal. Each pro-file includes key information on health plan market penetration, a description of the plan’s dispute resolution process, and the name and contact numbers for medical directors, provider relations, and

4 SAN FRANCISCO MEDICINE SEPTEMBER 2015 WWW.SFMS.ORG WWW.SFMS.ORG SEPTEMBER 2015 SAN FRANCISCO MEDICINE 5

September 2015

Editor Gordon Fung, MD, PhD

Managing Editor Amanda Denz, MA

Copy Editor Mary VanClay

EDITORIAL BOARDEditor Gordon Fung, MD, PhD

Obituarist Erica Goode, MD, MPH

SFMS OFFICERSPresident Roger S. Eng, MD

President-Elect Richard A. Podolin, MD

Secretary Kimberly L. Newell, MD

Treasurer Man-Kit Leung, MD

Immediate Past President Lawrence Cheung, MD

SFMS STAFFExecutive Director and CEO Mary Lou

Licwinko, JD, MHSA

Associate Executive Director, Public Health and

Education Steve Heilig, MPH

Associate Executive Director, Membership and

Marketing Jessica Kuo, MBA

Director of Administration Posi Lyon

Membership Coordinator Ariel Young

CMA Trustee Shannon Udovic-Constant, MD

AMA Delegate Robert J. Margolin, MD

AMA Alternate Gordon L. Fung, MD, PhD

Michel Accad, MD

Stephen Askin, MD

Payal Bhandari, MD

Toni Brayer, MD

Chunbo Cai, MD

Linda Hawes Clever, MD

Erica Goode, MD, MPH

Shieva Khayam-Bashi, MD

Arthur Lyons, MD

John Maa, MD

David Pating, MD

BOARD OF DIRECTORSTerm: Jan 2015-Dec 2017

Steven H. Fugaro, MD

Brian Grady, MD

John Maa, MD

Todd A. May, MD

Stephanie Oltmann, MD

William T. Prey, MD

Michael C. Schrader, MD

Term: Jan 2014-Dec 2016

William J. Black, MD

Benjamin C.K. Lau, MD

Ingrid T. Lim, MD

Keith E. Loring, MD

Ryan Padrez, MD

Rachel H.C. Shu, MD

Paul J. Turek, MD

Term: Jan 2013-Dec 2015

Charles E. Binkley, MD

Gary L. Chan, MD

Katherine E. Herz, MD

David R. Pating, MD

Cynthia A. Point, MD

Lisa W. Tang, MD

Joseph Woo, MD

Volume 88, Number 7

California patients, while 12.5% were not in practice at the location listed in Anthem’s directory. The audit also found that only 56.7% of the physicians list-ed in Blue Shield’s Covered California directory could be verified as accepting Covered California patients.

DMHC will be conducting a follow-up of its audit this fall to determine whether the health plans have resolved their inaccurate network directories. SFMS physicians who are misidentified as participating in a network by An-them or Blue Shield when in fact they are not, or whose information in a net-work directory is inaccurate, are urged to contact CMA’s Center for Economic Services at (888) 401-5911 or [email protected].

JAMA Study Shows E-Cigarettes Could Serve as Gateway to Traditional Tobacco Products; SFMS and CMA Participate in Save Lives CA Lobby Day and Endorsement of Tobacco Legislation Package

The Journal of the American Medical Association published a new study that showed that high school students who use electronic cigarettes are more than twice as likely to progress to smoking conventional tobacco products.

Students who used e-cigarettes were about twice as likely over the course of the study to report smoking cigarettes, three times as likely to report smok-ing hookah, and five times as likely to report smoking cigars.

The study comes as lawmakers, during a special session, reintroduced SB 151, which would raise the smoking age in the state to twenty-one years old, and SB 140, which would regulate e-cigarettes in the same way as other to-bacco products.

SFMS and CMA join our Save Lives California coalition partners to applaud California legislators spearheading legislation to keep tobacco out of the hands of our youth and to increase the overall health and wellness of Californians. Several San Francisco physicians participated in the August 26 coalition lobby day (coverage on p. 25). The passage of this package of bills will have an im-mediate, life-saving impact by reducing the number-one preventable cause of premature death and disability.

Noridian Announces New AuditsNoridian, California’s Medicare administrative contractor, has announced

that it will be conducting service-specific targeted audits of procedure codes 99205 and 99233 when rendered by providers with specific specialties (99205 performed by cardiology and pulmonary; 99233 performed by internal medi-cine and hematology/oncology).

These reviews are conducted on a pre-payment basis, meaning Noridian will notify physicians selected for claim audits through the additional docu-mentation request (ADR) process before payment is made. Upon receipt of a request for information, practices must submit all applicable documentation for each claim with a copy of the ADR as a cover sheet. Records should be mailed (hard copy or CD) or faxed to Noridian within 45 days of receipt, or a claim de-nial will result. More information on the ADR process can be found at https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/ads-submissions.

CMS Clarifies ICD-10 Grace Period GuidanceIn early July, the Centers for Medicare & Medicaid Services (CMS) an-

nounced that for a period of one year, it will allow for flexibility in claims pay-ment, auditing, and quality reporting processes. CMS specifically clarified its statement that during the 12 months after ICD-10 implementation, contractors would not deny claims based solely on the specificity of the ICD-10 diagnosis code. However, claims will be rejected if they do not contain a valid ICD-10 code. CMS further defined a “valid code” as one that is coded to the maximum level of specificity. Claims will not, however, be rejected or audited simply because they contain the wrong code—as long as it is a valid code from the right family. The ICD-10 implementation date of October 1, 2015, has not changed.

Success.

Protect Your Online Reputation With CAP’s Free Physician’s Action Guide!

Since 1977, the Cooperative of American Physicians

(CAP) has provided superior medical professional

liability coverage and valuable risk and practice

management programs to California’s finest

physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand

the realities of running a medical practice, and

are committed to supporting you with a range of

value-added programs and services. These include

a 24-hour adverse outcomes hotline, HR support,

EHR consultation, a group purchasing program,

and payment and reimbursement education and

support, to name a few.

It’s what California’s finest physicians strive for. . .and what CAP can help you achieve.

The Physician’s Online Reputation Action Guide can

help you build a strong and positive reputation.

Learn how to:

• Encourage patients to post positive reviews.

• Appropriately respond to negative reviews.

• Optimize social media to establish your credibility.

Request your free electronic or hard copy today!

800-356-5672 | CAPphysicians.com/ReputationPro

WWW.SFMS.ORG SEPTEMBER 2015 SAN FRANCISCO MEDICINE 7

San Francisco has been called many things: the most beau-tiful city in the nation; the place where all the brightest, craziest, most desperate, and/or most good-looking people end up; “49 square miles, surrounded by reality”; and much more. Many trends start here, like them or not—“San Fran-cisco Values” has been a slogan of either pride or revul-sion, depending upon one’s perspective. Many people pass through our transient city, many of them changed forever for the experience.

One such visitor was the late Oliver Sacks, MD, whom the New York Times named “the poet laureate of medicine,” who died at press time after a long career as a neurologist and best-selling author. On his very long and impressive CV is this: Mt. Zion Hospital, San Francisco, 1960-1961: Research Assistant, Parkinsonism Unit; 1961-1962: rotating internship.

Sacks later noted that he was drawn here not only by top-notch medical training but by San Francisco’s reputa-tion as a hotbed of poetry and nascent “countercultural” ele-ments—such as beatniks—and that this is where he began writing in earnest, not only about science and medicine but about “colorful” local characters and scenes. True to form, he hitchhiked to get here for his internship as well, and for a time rode motorcycles with the local Hell’s Angels (and sur-vived). His books such as Awakenings and The Man Who Mis-took His Wife for a Hat, among many others, remain classics of medical literature.

Nowadays the most dominant “rebels” in the Bay Area might be said to be the technologically-inclined denizens of Silicon Valley (and now of our city as well). They are seek-ing to reinvent much of our economy and society (and, it should be acknowledged, seeking to get rich in the process). In medicine, most of this new biotech innovation remains one of vast potential with practical applications still in the future. But, barring some huge disaster or the dreaded se-vere economic “correction”, it can be wagered that striking innovations centered here will continue and accelerate. What manner of diagnostic tools, treatment options, devices, and preventative strategies are already in the pipeline? What new care delivery options? What innovations we cannot yet even categorize?

In this issue of our journal we feature just a few from our recent and distant past.

The most “vintage” breakthrough is a neurological dis-

covery dating from the 1800s and is chronicled by our edi-torial board member, SFMS past-president, and local medical historian and neurosurgeon Arthur Lyons, MD. The devasta-tion of the early HIV epidemic with San Francisco as a ground zero resulted in some of the most rapid medical science prog-ress in history. It’s explored in pieces by two of the leaders in that response—Paul Volberding, MD, and Stephen Follansbee, MD. The “free clinic” movement dates from 1960s San Fran-cisco and is told here by Haight-Ashbury Clinic founder David Smith, MD, with the more recent effort to move towards uni-versal coverage (Healthy San Francisco) also described. Mel-vin Scheinman, MD, describes a cardiological first.

If space were unlimited we could cover the abundance of other advances made locally—with the presence of major teaching hospitals, UCSF, and the biotech industry there are many. Genentech, the discovery of prions, the discovery of telomeres, the discovery of oncogene viruses, the first fetal surgery, the development of precise recombinant DNA tech-niques that led to the Hepatitis B vaccine, and so on have all been written about extensively. And again, there are many more to come.

Despite what breakthroughs may occur in the future, the human element of medicine will remain paramount. Regard-less of what some believe or dream, “tech” will never fully re-place a thinking, feeling, trained physician. In fact, Dr. Oliver Sacks seemed to feel this way regarding his own practice and even his writing. When asked what he might like to be most known for a century from now Sacks replied, “I would like it to be thought that I had listened carefully to what patients and others have told me,” he said, “that I’ve tried to imagine what it was like for them, and that I tried to convey this.”

No one taught me more about how to be a doctor than Oli-ver Sacks,” reflected another renowned physician/author, Atul Gawande, MD, in The New Yorker, “He wanted to see humanity in its many variants—face to face, over time, away from our burgeoning apparatus of computers and algorithms. He cap-tured both the medical and the human drama of illness, and the task of the clinician observing it.”

We like to think he learned at least some of that during his relatively brief stay in here in San Francisco, but regardless, it’s one more reminder that, despite whatever progress comes from the concentration of innovation in our area and beyond, medicine will always be more about people than procedures.

EDITORIALSuccess.

Protect Your Online Reputation With CAP’s Free Physician’s Action Guide!

Since 1977, the Cooperative of American Physicians

(CAP) has provided superior medical professional

liability coverage and valuable risk and practice

management programs to California’s finest

physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand

the realities of running a medical practice, and

are committed to supporting you with a range of

value-added programs and services. These include

a 24-hour adverse outcomes hotline, HR support,

EHR consultation, a group purchasing program,

and payment and reimbursement education and

support, to name a few.

It’s what California’s finest physicians strive for. . .and what CAP can help you achieve.

The Physician’s Online Reputation Action Guide can

help you build a strong and positive reputation.

Learn how to:

• Encourage patients to post positive reviews.

• Appropriately respond to negative reviews.

• Optimize social media to establish your credibility.

Request your free electronic or hard copy today!

800-356-5672 | CAPphysicians.com/ReputationPro

Forty-Nine Square Miles of Innovation

Gordon Fung, MD, PhD, and Steve Heilig, MPH

“I cannot pretend I am without fear, but my predominant feeling is one of gratitude. I have loved and been loved; I have been given much and I have given something in return; I have read and traveled and thought and written. I have had an intercourse with the world, the special intercourse of writers and readers.”

-Oliver Sacks, MD, 1933-2015, a few months before dying of cancer in August


FOR $3 A DAY, SFMS/CMA MEMBERS RECEIVE MORE THAN $6,000 A YEAR IN SAVINGS AND SERVICES, INCLUDING:

SFMS/CMA Member Benefit Value

Patient referral service via SFMS’ phone referral line and online physician finder tool . . . . . . . . . . . . . . . . . . . . . . . . . $200

Access to exclusive physician networking events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150

Personal physician webpage for practice promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100

Subscriptions to San Francisco Medicine and SFMS Membership Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100

One-on-one assistance with practice management experts from Center for Economic Services on . . . . . . . . . . . . . *$150reimbursement and practice operation issues . *value hourly rate with a practice management consultant

Access to objective written analyses of major health plan contracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200

Discounted employment contract review service with a contract attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500

Special member rate for AAPC’s ICD-10 training seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200/session

Discounted registration for the Western Leadership Academy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300

CME tracking and credentialing service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20

HIPAA-compliant communication via DocBookMD, enabling physicians to instantly exchange patient information . . . . $100with other physicians at the point of care

15% off temper-resistant security prescription pads and printer paper with Rx Security . . . . . . . . . . . . . . . . . . . . $162 .75

30% off your current bill for medical waste management and disposal services through EnviroMerica . . . . . . . . . .*$1,000*based on average savings

30% off on Epocrates products, including Epocrates Essentials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50

Up to 10% discount on life insurance through Mercer Health & Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $100

Member-only savings on office supplies and magazine subscriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500

Access to webinars and seminars ranging from business essentials for physicians, EHR adoption best practices, . . . $400and effective coding/billing strategies, including our exclusive value-based payment model workshop with CMS Region IX Administrator in May 2015 .

For a list of full member benefits, visit http://www.sfms.org/membership/membership-benefits/full-member-benefits.aspx.

SFMS_3DollarsADay_FlyerAd_2015.indd 1 4/27/15 12:35 PM



The early wave of HIV infection in San Francisco was swift but unrecognized. In 1980 I was working part-time in the walk-in side of the San Francisco General Hospital Emergency Room and recall many gay men presenting with severe “flu.” I have no way to prove it, but I believe many were quite likely suffering from acute primary HIV infection. My wife, Molly Cooke, was a medicine chief resident at SFGH dur-ing the same time and began to note gay men being admitted with very unusual infections seldom before seen in young and “healthy” adults. Following the first publications about what soon was called AIDS, San Francisco saw a horrifying, rapid in-crease in cases and, soon, deaths from this utterly mysterious new disease.

With Art Ammann’s report of AIDS in an infant following blood transfusion in 1982, the reality of AIDS as an infectious disease became inescapable. The public’s anxiety (and that of my own, as a caregiver) climbed quickly, as we knew noth-ing about either the transmissibility of whatever was causing AIDS or its natural history. And, of course, we had no therapy to prevent certain death for everyone with advanced AIDS. In retrospect, of course, while we were asking all those questions, the virus was continuing to spread, infecting tens of thousands before we had any tools to confront the epidemic.

The first step to hope required the identification of this new infection. Fortunately, the scientific community became mobilized. After a delay, the NIH made research funding avail-able for AIDS. My own first grant was submitted in 1982 and funded in 1983, and during 1983 and 1984, only several years after the first recognition of AIDS, the cause was revealed. Al-though much is made of the dispute between Luc Montanier in Paris and Bob Gallo in the United States, fewer than should do so actually appreciate that here at UCSF Jay Levy also discov-ered the virus and was undoubtedly independent in doing so. As a side note, Jay’s discovery was a personal one for me, as I had moved to San Francisco in 1978 specifically to work in his laboratory, leaving the day before seeing my first Kaposi’s sar-coma patient as I started a position at SFGH.

The early reaction to the recognition that a human retro-virus was the cause of AIDS is well chronicled in Randy Shilts’s pivotal book And the Band Played On. Personalities of the cast of characters in HIV discovery were large, and competition was fierce and less than polite. I recall first hearing of the French discovery at a scientific meeting in Park City, probably in 1983. Reaction from the Americans at the meeting was dismissive, and the fight over assigning credit for the discovery continued for years. Even the name of the virus generated discord, which continued until HIV was chosen as a neutral term, not favoring any of the independent discoverers.

Once the virus was identified, scientists including Jay Levy found antibodies in the blood that could be used to identify those who had been exposed. I recall volunteering for one of the first tests of Jay’s HIV detection assay and was hugely relieved to be negative. By then I’d cared for hundreds of AIDS patients, many before the concept of “body substance precautions” came into vogue, and I was privately terrified that I had been infect-ed. Knowing that I was not was of course good news to me, but, more important, it allowed me to be fully assured in reassuring the public that HIV was clearly not easily transmitted by non-sexual means.

Having identified the virus and an antibody assay allowed us to clarify HIV transmission, but we more gradually learned a shocking lesson. With essentially all other viruses, a positive antibody test means that one has been exposed to the virus and typically that one has overcome that brief infection and become immune. With the HIV antibody test, we found a great number of persons testing positive. Some had AIDS, but many more were either completely asymptomatic (“healthy seropositive” was a popular term) or complaining of a variety of signs and symptoms less striking than AIDS. We began to worry that these “milder” cases might be at risk of progressing to AIDS. A leader in this research, Donald Abrams, published a key paper asking whether this condition was an endpoint or a prodrome to AIDS. Unfortu-nately it certainly was, but as we followed all this, it gradually be-came clear that all the seropositives were progressing and that none had developed immunity, and that the untreated mortality of HIV infection was close to 100 percent.

HIV is now a chronic disease. Treatments can suppress the virus in the vast majority of individuals able to take the drugs regularly, and new regimens of combination therapy are con-tained in a single daily pill, most with few side effects. Treatment may well allow a normal life span and also prevents transmis-sion. Efforts here and elsewhere aimed at “Getting to Zero” are moving us toward community-wide HIV control, while others are working to find a cure or an effective vaccine. But none of this amazing progress could have started without first finding the virus itself. The San Francisco medical community has con-tributed mightily to success in the HIV epidemic, but at its heart it is all based on finding the agent that has changed our world.

Dr. Volberding is an oncologist by training who has special-ized in HIV since the epidemic was first recognized in 1981. He is now the director of the UCSF AIDS Research Institute, codirector of the UCSF-Gladstone Center for AIDS Research and director of research for UCSF Global Health Sciences. He lives in San Francisco with his wife, Molly Cooke, also an academic physician at UCSF. He is a longtime member of the SFMS.

Paul Volberding, MD

The First Step to Hope in the AIDS CrisisIDENTIFYING HIV

Morrissey Hall, St. Mary’s Medical Center2250 Hayes Street, San FranciscoRefreshments and hors d’oeuvres provided by the SFMS

For detailed event information, including a list of confirmed exhibitors, please visit http://www.sfms.org/Membership/StudentResidents.aspx

EVENT OPEN TO ALL UCSF, CPMC, ST. MARY’S, AND KAISER PERMANENTE SF RESIDENTS AND FELLOWS

LOCAL

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Featuring San Francis

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A Breakthrough in Understanding LINKING HIV AND AIDS

What was the discovery? AIDS is the end product of infec-tion due to HIV, a retrovirus. In the spring of 1981, unexplained clusters of an unusual malignancy called Kaposi’s sarcoma and lung infection caused by Pneumocystis carinii (now P. jiroveci) were noted. San Francisco, along with New York City and Los Angeles, was identified quickly as an epicenter for this new syn-drome, associated with severe immune deficiency and death. By July 1982 there were more than 414 cases in the U.S. and 155 deaths reported. Theories as to causality were plentiful. Evidence that AIDS was due to an infectious agent was presented at a meet-ing sponsored by the New York City Department of Health in June 1982. However, a virus causing lymphadenopathy syndrome (LAN) was not presented until June 1983. HTLV-3 (to become HIV) was announced as the cause of AIDS in April 1984.

How was this news first received, with hesitation or enthusiasm? For many of us, the identification of a virus caus-ing AIDS was expected, and accepted. Although less than thirty-six months seems like a rapid time to identification of a viral etiology, health care systems and providers had to react more quickly to the possibility of other causes and modes of transmission. In retrospect, we were seeing patients admitted with the acute retrovi-ral syndrome in 1977. The first inpatients with AIDS in San Francisco hospitals occurred during the summer of 1981, when there were no spe-cific infection prevention precautions for AIDS in place. The epidemiology rapidly pointed to an infectious agent, even before the June 1982 meeting. In April 1982, UCSF initiated precau-tions based on guidelines for cytomegalovirus infection. CDC guidelines in November 1982 sug-gested infection prevention precautions should follow those for preventing hepatitis B trans-mission in the workplace. Identification of HIV as the cause validated the infection prevention plans that had been imple-mented in Bay Area hospitals more than a year before.

At the initial NIH press confer-ence in April 1984, when HTLV-3 (HIV) was presented to the public as the cause of AIDS, it was sug-gested there would be a blood test for HIV. After the first blood test was licensed in early 1985, blood banks quickly adopted the screening test. At the same time

they instituted a policy of not releasing the result to donors for a waiting period of several weeks, to discourage people at risk for HIV from donating blood just to access the test. By the end of 1985, there were more than 800 publicly funded HIV test sites and nearly 80,000 people had been tested in the U.S. Over the next several years, additional tests, such as the Western Blot (1987), p24 antigen test (1989), and HIV viral load test (1999) became available. At the same time, the HIV denialists were still arguing that HIV was an innocuous virus, that the tests monitor-ing infection and the state of viral replication were useless.

Even in 2014 there were articles offering alternative expla-nations for the cause of AIDS, denying that this is a viral infec-tion. Arguments for other causes of AIDS include speculation that AIDS is a U.S. government experiment at genocide gone awry, is related to immune overload from other concurrent in-fections, is the toxic result of recreational drug use or chemicals, is due to malnutrition, is related to the wrath of a God, is an ac-cidental lab event allowing a fairly innocuous infection in other

primates to enter the human species, or is due to contami-nated vaccine against polio, just to name a few.

Fueled by these unfounded speculations of other causes, in San Francisco and elsewhere, there was a

minority of people with HIV who refused antiretro-viral treatment when the first medication became available in 1987. This minority has continued to decline, now twenty-eight years since the intro-duction of the first antiviral medication against HIV and nearly twenty years since the introduc-tion of combination medication therapy that has radically changed the course of HIV disease.

What has the long-term impact been? In 2015, some of the tests monitoring the status

of HIV infection, particularly plasma HIV viral load testing, as well as genotypic and pheno-

typic assays of HIV to assess for the emer-gence of drug resistance, have become

the standard of care in HIV medicine. These tests have been used to short-

en the time course of introduction of new anti-HIV medications in North America and Europe. They have also been used to help guide patient management using the in-creasing number of medications licensed to treat HIV in the U.S.

This finding has also enhanced

Stephen E. Follansbee, MD

Continued on the following page . . .


the evaluation of strategies to prevent HIV. A blood test now al-lows fairly rapid assessment of prevention strategies, including the use of chemoprophylaxis (so-called PrEP) for vulnerable indi-viduals. While there are still important questions to be answered, such as what aspects of human immunity are necessary for effec-tive control of this virus, as well as how to develop a vaccine for prevention of HIV, for many the identification of HIV as the cause of AIDS has removed the stigma and fear of HIV as being the con-sequence of other causes.

How did it impact you and your practice? I made the decision to enter the subspeciality of infectious diseases in 1980 because I naively thought that this offered me an unusual op-portunity within internal medicine to cure patients. For several years, patients presenting with AIDS lived an average of nine months, despite our best efforts to treat the opportunistic con-ditions and support nutrition and healthy lifestyles. The identi-fication of HIV as the cause of AIDS allowed for the rapid test-ing and availability of newer medications. It allowed for more complete assessment of strategies of HIV management, leading to the current recommendation to test and treat at even the ear-liest stage of infection. It allowed for development of successful yet still imperfect strategies for prevention of HIV infection. It has moved this infection from its nearly universally fatal course to one that is manageable for people who have access to testing, treatment, and monitoring. Lastly, this discovery still holds the promise of new findings to come, including advances that will provide a vaccine for prevention and a cure for those infected.

There is a lot to be learned from questions that are seemingly well answered scientifi-cally yet continue to generate controversy. The current paranoid, unscientific public opposition to accept-ing the benefits and efficacy of routine preventive vaccination for common childhood viral and bacterial infections is an ex-ample. It is simplistic to think there is one explanation to un-derstand the motivation of individuals or groups who deny that HIV is the cause of AIDS, or deny the tremendous benefits that have occurred as a result of this important scientific finding. Our responsibility to ourselves as scientists and healers, to our patients and to our communities, is to continue to understand the truths of what is known and to strive for better answers and solutions to legitimate questions that remain. The science and medicine of HIV treatment and prevention is no exception.

Stephen E. Follansbee, MD, is a retired HIV and infectious dis-eases specialist in San Francisco. Since completing his postgradu-ate training at UCSF, he practiced for sixteen years with the Infec-tious Diseases Associates Medical Group and then another sixteen years with Kaiser Permanente in San Francisco. He is a clinical professor of medicine at UCSF and longtime member and past-president of the SFMS. Since retirement his main activities have been to say “no” to most requests for new responsibilities and to say “yes” to becoming certified in scuba diving.

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Linking HIV and AIDSContinued from the previous page . . .



During my years of medical training, I was lucky enough to practice in a wide variety of clinical en-vironments, from small, rural family practice and communi-ty health centers to large, urban academic medical centers and staff-model HMOs. And no matter the environment in which I cared for patients, the common thread among them was that good people were frustrated and demoralized from working in a broken delivery system—a system that was more than past due for an overhaul.

Physicians and patients alike shared my frustration with what seemed to be an irrational delivery model. For all the talk about quality patient care, the system appeared to prevent (if not suppress) thoughtful, patient-centered medi-cal care. It was this disconnect that sparked a personal mission for me to explore and ultimately start a radically new model of primary care—one that would eventually become One Medical.

I decided to focus on primary care because I felt it was one of the most undervalued and broken parts of the delivery mod-el. Poor reimbursement, complex work flow, high overhead, and declining morale were just some of the problems that pri-mary care physicians faced.

Primary care, if done well, can offer a more holistic per-spective for patients (rather than being just the sum of several organ systems). In an era of hyper-specialization and microni-zation, I felt that an integrated primary care model could pro-vide unique insight and guidance to patients as complete indi-viduals. Lastly, I felt that a strengthened primary care model would help reduce downstream specialty and hospital costs, resulting in more affordable and accessible health care for all.

When starting One Medical, we were able to look at what was happening in San Francisco and Silicon Valley as inspira-tion for what was possible in health care. Iterative prototyping was a common design methodology used by many high-growth tech companies; could the same be applied to health care?

In that spirit, we opened a small, single prototype office in downtown San Francisco in early 2003 with just one doctor—me. We started without any preconceived notions about what “needed” to be done. Thinking expansively around the patient, we designed a model that could care for patients thoughtfully at both small and large scales. We reorganized work flow and used technology to support new processes. Instead of asking for more from payors, we looked internally to see how we could improve our administrative overhead. Much of what we did wasn’t neces-sarily new or unknown per se. We just applied solid organization management against some well-known and important principles.

One of the key learnings from our rapid prototyping was that lots of small changes can really add up. As an example, by using email instead of phone for many simple administrative tasks, we could more effectively respond to and document patient needs on a consistent basis, saving time and money. Though email may seem trivial, it was (and still is) uncommon for medical offices to incorporate email on a broad-scale basis.

Of course, we hit a variety of obstacles along the way, and progress wasn’t always a straight line forward. We had to grapple with the complexity of varying health care regulations, particularly as we grew and began operating in multiple states. We also had to learn how to serve differing de-mographics from a variety of neighborhoods. What appealed to patients in the Financial District did not necessarily appeal equally in Noe Valley, often due to differing demographic and clinical needs.

Initially, we didn’t know if our higher-quality, higher-touch model could garner enough efficiency to be economically sus-tainable. But after iterating on multiple ideas in our first proto-type, it became pretty clear that we were able to deliver high-er-quality care and service while also operating at much lower overhead than a traditional primary care practice. We knew we were headed down the right track.

Today, One Medical includes about forty offices in seven markets. We care for prenatal mothers, kids, adults, and seniors in a wide variety of neighborhoods and communities. Employ-ers now sponsor One Medical as a benefit. And we’re starting to make some investments in 24/7 video and phone-based ser-vices. Though we’re always iterating and improving the model, the fundamental pillars of our practice remain strong: a com-mitment to delivering high-quality primary care in an affordable manner for all.

My hope is that this practice style—using thoughtful design and technology to operate more effectively and efficiently—will become more the norm than the exception. Our model enables primary care providers to spend more time with patients and engage in thoughtful decision making rather than managing pa-perwork. This is the kind of environment that attracts medical students and residents into careers in primary care.

Amazingly enough, it’s still very early days for what’s pos-sible in primary care and at One Medical. We’re excited about what the future may hold.

Thomas Lee, MD, is the founder and CEO of One Medical Group. He has served on the SFMS board of directors.

Thomas Lee, MD

Redefining the Primary Care Model ONE MEDICAL


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When the Supreme Court ruled in favor of the Af-fordable Care Act, or “Obamacare,” in June, top White House and federal health officials held a meeting to reflect on what that meant. One striking thing they noted was that this decision confirmed that “health care is a right, not a privilege.” And why was this so notable? That was the founding slogan of the Haight-Ashbury Free Medical Clinic in June 1967.

That fabled “summer of love” was a long time ago, but some of the values of that era do not seem so radical now as they did then. Health care should not be available only to those who can pay for it. The environment needs protection from us. Women are equal to men and should have control over their reproductive and other health needs. Racism is an outdated scourge. Our diets matter, and the less meat we eat, the bet-ter for all concerned. Drug abuse is and should be addressed as a public health and medical issue more than a legal one. Marijuana in particular is not something that should lead to prison. Some illegal drugs might even, if judiciously used, help people. War is bad, meaning peace is good. Communal living may yet be a necessary movement as our population ages. And while “All You Need Is Love” might be stretching things, as the second momentous Supreme Court decision regarding mar-riage equality showed, real love should not be prohibited but encouraged. As even the Pope has noted, who are we to judge? We are not blind ’60s apologists—there were many problems then. But the mainstreaming of worthy ideas from that era continues.

The free clinic movement was ignited here and spread nationwide. The ACA is far from perfect, but “the perfect is the enemy of the good.” Getting it adopted involved many compromises. But mil-lions of Americans now have access to care, and there are many good new ACA elements—mandated contraception, constraints on discriminatory and predatory practices, expanded addiction treatment and preventive services, and more. Overall health costs appear to be less than they would be without the ACA. Implementing and fine-tuning it is a hugely complex, ongoing task—as has been true with Medicare and Medicaid, health pro-grams established in the ’60s out of the spirit of solidarity with those most in need.

A mentor to us both, Dr. Philip R. Lee, served as U.S. as-sistant secretary of health and chancellor of U.C. San Fran-cisco in the 1960s. Bullets were fired through his window at UCSF while he was seeking to desegregate that campus, then often called “the plantation” by local African-Americans. He

has repeatedly reminded us that progress often takes de-cades, even lifetimes. Phil is now in his nineties, but he re-cently reflected, “We may not always be listened to, or be as influential as we might wish, but we just keep on trying.” “San Francisco values” have been both lauded and reviled through the years. Some people will never agree with them. But compassion and equality are timeless goals enshrined in the founding documents of our nation, revived in many ways in the “City of Saint Francis” a half-century ago. And when even the United States Supreme Court endorses such movements, to us it seems that, yes, in many ways, the hippies indeed got it right.

David E. Smith, MD, is a graduate of UCSF Medical School, founder of the Haight-Ashbury Free Medical Clinic, past president of the American Society of Addiction Medicine, recipient of the U.C. Berkeley Haas Public Service Award, and a lifetime SFMS member. Steve Heilig, MPH, is a longtime staff member of the SFMS, coeditor of The Cambridge Quarterly of Healthcare Ethics, and recipient of the California Medical Association’s Sparks Award for contribu-tions to public health. An earlier version of this piece appeared in the San Francisco Examiner.

David E. Smith, MD, and Steve Heilig, MPH

Health Care Is a Right, Not a Privilege SAN FRANCISCO VALUES

Dr Smith, center, with co-author Heilig and other associates of the Haight-Ashbury Free Medical Clinic and Rock Medicine.


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PHYSICIANSKelly Ann Fung, MD | Internal MedicineThomas Sean Halligan, MD | Family MedicineMeaghan Margaret Lynch, MD | Physical Medicine and RehabilitationCurtis Paul Ross, DO | UrologySarita Satpathy, MD | Internal Medicine Denise Stella Zusman, MD | Psychiatry

HOUSE OFFICERSAudrey Arai, MD | Family Medicine Rahmat Balogun, DO |Internal Medicine Geoffrey Buckle, MD | Internal Medicine Laura Kay Byerly, MD | Geriatric Medicine Mauro Caffarelli, MD | Child Neurology Emily Cedarbaum, MD | Internal Medicine Angela Lin Chang, MD | Pediatric Allergy Molly Chapman, MD | Radiology David Chen, MD | Pediatrics Daniel Chow, MD | Radiology Adam Coy, MD | Radiology Bryan Darger, MD | Emergency Medicine Sarah Schaffer DeRoo, MD | Pediatrics Michael Do, MD | AnesthesiologyRebecca Anne Dumont Walter, MD | Neuroradiology Fanny Mojdeh Elahi, MD | Neurology Robert ElDabaje, MD | Internal MedicineCamila Fabersunne, MD | Pediatrics Joline Fan, MD | Neurology Emily Frank, MD | Pediatrics

Latoya Comer Frolov, MD | Psychiatry Jin Ge, MD | Internal Medicine Boris Getman, MD | Pathology Elizabeth Patricia Griffiths, MD | Internal Medicine Sasha Gupta, MD | Neurology Andrew Hall, MD | Anesthesiology Fatemat Hassan, MD | Pediatric Cardiology Aaron Hayson, MD | General Surgery Matthew Hickey, MD | Internal Medicine Gillian Lee Hsieh, MD | Gynecologic Oncology Kevin Hwang, MD | Orthopaedic Sports Medicine Monica Elizabeth Kaitz, MD | Occupational Medicine Andrew Allen Kao, MD | OphthalmologyBridget Keenan, MD | Internal Medicine Nicole Kim, MD | Internal Medicine Hannah Kirsch, MD | Neurology Yilun Koethe, MD | Radiology Justin Krogue, MD | Orthopaedic Surgery Courtney Lawhn Heath, MD | Radiology Lauren Lederle, MD | Internal Medicine Esther J. Lee, MD | Anesthesiology Julieann Lee, MD | Pathology Janet Y. Lee, MD | Endocrinology, Diabetes and Metabolism Justin Libaw, MD | Anesthesiology Jenny Lu, MD | Radiology Harjot Maan, MD | Dermatology Daiva Mattis, MD | Pathology Kareem Mawad, MD | Radiology SoYoun Min, MD | Oral and Maxillofacial Surgery

Alicia Morehead-Gee, MD | Internal Medicine Tyler Edwards Morrison, MD | PsychiatryKanae Mukai, MD | Cardiovascular Disease Vicky Thi Nguyen, MD | Radiology Arvind Nishtala, MD | Internal Medicine Marci Pepper, MD | Anesthesiology Kenny Pettersen, MD | Internal Medicine Yujie Qiao, MD | Radiology Sandeep Sabhlok, MD | Anesthesiology Shayan Salim, MD | Oral and Maxillofacial Surgery Brian Sauer, MD | Neurology Joshua Shak, MD | Internal Medicine Jun Shoji, MD | Nephrology Elif Sozmen, MD | Neurology Nichole Starr, MD | General Surgery Kenji Taylor, MD | Family Medicine Diana Thiara, MD | Internal Medicine Christina Toutoungi, MD | Psychiatry Kent Truong, MD | Pathology Diana Tsen, MD | Pediatrics Richard Wang, MD | Pulmonary Disease Mia Williams, MD | Internal Medicine Jason Yoo, MD| General Surgery Haining Yu, MD | Psychiatry Sean Dustin Ziegler, MD | Psychiatry

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What was the discovery? The “discovery” was that San Francisco could truly reach universal health care access via a program designed to fill in any gap, funded via mandated em-ployer contributions. A commission, which I served on, was chaired by former San Francisco Public Health Directors Drs. Sandra Hernandez and Mitch Katz to help design it. We called it “Healthy San Francisco” (HSF).

How was it first received, with hesitation or enthu-siasm? Patients loved it, once they sorted out the concept, eligibility, and registration. The medical community had mixed but generally supportive responses once the admittedly limited reimbursements started arriving for services previously do-nated. Certain segments of the business sector were not so im-pressed, and a restaurant association even sued all the way to the Supreme Court to stop it. They lost. A few folks, mostly tour-ists, objected to the small surcharge at restaurants, but as the owner of one popular eatery in my neighborhood put it, “That’s not the type of person we want to serve anyway.”

What has the long-term impact been? First, access to care for upwards of 70,000 San Francisco residents. Then, with the advent of the ACA and enrollment of many of those into Medi-Cal, continued access for approximately 20,000 who did/

do not qualify for any other coverage—mostly undocumented immigrants.

How did it impact you and your practice? My “prac-tice” in this regard was to help design and advocate for HSF and monitor it. Many media questions came in from around the na-tion, asking how it worked and was working and if it was repli-cable elsewhere (usually not). I, along with SFMS Past-President Gordon Fung, served on the commission charged with revising a downsized HSF to fit into the ACA era.

But mostly, I recall this: walking down Divisadero Street, hearing my name called, seeing an old friend for the first time in years. He told me he had just had a knee replacement at SFGH af-ter years of severe pain; that he had considered killing himself at one point due to that unresolved suffering. He said HSF made the surgery possible, and he hugged me and started to cry when I told him I had been part of the program’s start. I’ll never forget that.

Steve Heilig, MPH, is a longtime staff member of the SFMS, co-editor of The Cambridge Quarterly of Healthcare Ethics, and re-cipient of the California Medical Association’s Sparks Award for contributions to public health. An earlier version of this piece ap-peared in The San Francisco Examiner.

Steve Heilig, MPH

Healthy San Francisco Provided Access to ResidentsUNIVERSAL HEALTH COVERAGE



A most marvelous instrument, the brain, compris-es about 100 billion nerve cells, or neurons, each of which may connect to 10,000 other neurons. Pulses of informa-tion in the form of electrical signals race along nerve fibers like sports cars on a speedway. Yet what do you see when you look at a brain? Inscrutability. A shimmering, gelatinous mass of fatty fibers, snaking and threading to who knows where.

What if you could install traffic signals along the neurons threading through a living brain, so that you could start or stop traffic on them and observe the effects? Karl Deisseroth, MD, PhD, an associate professor of bioengi-neering and of psychiatry and behavioral sciences at the Stan-ford University School of Medicine, and his colleagues have cre-ated just such a system. The technology, called optogenetics, mixes optics, genetic engineering, and several other disciplines. It literally uses lights to control the messages zinging along our nerves: The go signal is blue, and the stop signal is yellow. Both are photosensitive proteins called opsins, originally discovered in microbes.

Optogenetics has taken neuroscience by storm. Since De-isseroth published the first paper describing how it works in 2005, thousands of researchers around the world have started using it to define the deficits behind schizophrenia, autism, ad-diction, Parkinson’s disease, and more. And in December 2010, the peer-reviewed Nature Methods named optogenetics the journal’s “method of the year.”

“Optogenetics is the solution to our long-standing problem of lack of precision,” says Anatol Kreitzer, PhD, a UCSF neuro-scientist who recently collaborated with Deisseroth on a study of Parkinson’s disease. “It lets us selectively inhibit or activate exactly the cells we’re interested in. Karl’s work is really revo-lutionary.”

Until now, most brain studies have relied on electrodes or drugs. Electrodes work fast. But they stimulate in a nonpredict-able way, igniting many different nerve-cell types in many dif-ferent circuits. Plus, even though the stimulation is local, nerve fibers innocently passing through can get stimulated and trigger consequences far away. And while electrodes can activate neu-rons, they can’t inhibit them, which is just as critical to studying brain function.

Drugs can selectively activate or inhibit neurons, but not always just the ones you want (that’s one reason they produce side effects). Plus, they ooze everywhere and can’t be mopped up quickly, making them lousy on/off switches. Without precise techniques, how are you ever going to make sense out of 100

billion sentient spaghetti strands winding to and fro like midday traffic in some 3-D Manhattan?

Deisseroth is a practicing psychiatrist as well as a research-er. In 2004, as a new assistant professor at Stanford, he was ea-ger to improve the lives of patients with psychiatric disorders and dissatisfied with brain scientists’ inability to map the mal-functioning nervous circuitry behind those disorders.

“Psychiatry has a long way to go,” he says. “That’s not be-cause psychiatrists are anything but thoughtful, well-trained, and observant. It’s because we’ve lacked the tools to tease apart the component circuits that make up a working brain and exam-ine their functions, one by one.”

So he conjured up a work-around: Neurons transmit elec-trically coded information down long, skinny fibers that project to other neurons near and far. What if you could coat their sur-faces with photosensitive molecules so that when light hit those fibers, it would make them propagate—or resist propagating—impulses on demand? Suppose you could also control which set of neurons would carry those molecules on their surfaces, and you could direct the light to just the place you wanted. Then, at the flick of a switch, you’d be able to turn on or turn off the flow of impulses in the neurons of interest and learn a huge amount about what they’re doing.

Deisseroth knew that photosensitive molecules called op-

Bruce Goldman

Taking Neuroscience by StormOPTOGENETICS


surfaces as hoped, and they bioengineered it further so it would do so more readily. Blue light made selected neurons fire. To test this in live, freely moving, opsin-injected rodents, Deisseroth’s group inserted a customized tube, or cannula, into the rodents’ brains. During experiments, they threaded an ultra-thin opti-cal fiber (outer diameter one-tenth of a millimeter) through the cannula. This way they could, at will, send pulses of laser light through the fiber to exactly the desired brain area. It worked like a charm, eventually.

As for the immune-reaction heebie-jeebies, a tight seal called the blood-brain barrier appeared to exempt experimen-tal animals’ brains from patrol by bulky antibodies and cellular cops. The suspicious molecules apparently went undetected.

The Deisseroth group published their results with the excitatory blue-light opsin in 2005 in Nature Neuroscience. Not long afterward, they got an inhibitory, yellow-light-sensitive opsin, isolated from yet another one-celled organism, to work. Labs around the world are now routinely using both of them.

While the new methodology has terrific potential in psy-chiatric research, it has obvious limitations. Experiments that introduce foreign genes for light-responsive, nerve-impulse-triggering proteins into human beings aren’t safe just yet. That’s where experimental mice come in. But when you’re watching a mouse, it’s a whole lot easier to observe its movements than its mental state. So a nice way to check out optogenetics’ potential for brain research is to examine the animal equivalent of Parkin-son’s disease, a movement disorder.

While Parkinson’s ultimate causes are unknown, the dis-ease clearly involves the loss of a set of neurons located in a structure deep within the brain, whose signals feed directly into two separate circuits crucial to controlling voluntary movement.

Recently Deisseroth, along with UCSF’s Kreitzer and col-leagues, optogenetically unraveled the workings of those two nerve-cell circuits and proved that one of the two facilitates normal movement, while the other inhibits it. Using both the blue-light-responsive, nerve-revving opsin and the yellow-light-responsive, nerve-blocking one, the researchers showed that imbalances in these two circuits’ function can produce Parkin-son’s-like symptoms in mice—and that optogenetic interven-tions can exacerbate or alleviate those symptoms. By stimulat-ing one of the two opposing circuits, they could restore normal movement in mice even after destroying the upstream nervous circuit that normally drives this activity and whose loss is the hallmark of Parkinson’s disease. The results were published last year in Nature.

The finding implies that Parkinson’s patients’ conditions could someday benefit from new drugs that might be able, un-like current treatments, to stimulate the circuit that facilitates movement but not the circuit that inhibits it.

Bruce Goldman covers immunology, infectious disease, neu-rosciences, cellular and molecular physiology, and biochemistry for the Stanford University School of Medicine. This article was reprinted courtesy of Stanford University.

sins had been isolated from microbes such as Chlamydomonas reinhardtii, aka pond scum. Opsins are pore-like proteins that open in response to particular wavelengths of light, allowing currents consisting of electrically charged particles to flow ei-ther in or out (depending on the particular type of opsin) across cell surfaces.

In theory, opsins were made to order for Deisseroth’s ap-proach. In practice, few had tried it and nobody had pulled it off, for plenty of reasons. For one, the opsin molecules would have to show up not just anywhere inside of neurons but on their surfac-es, where all the electronic impulse-passing action is. Proteins go where myriad biochemical imperatives direct them. Whether microbial opsins would really wind up on the surfaces of mam-mals’ neurons—the only place where they could do any good—would be a bit of a crapshoot.

On top of that, proteins are complex and finicky, working well only under the right conditions (heat, acidity, and the company of chemicals called cofactors). Would an opsin molecule work as well in a mammalian neuron as it does in a pond-scum cell? An-other nail-biter: Microbial proteins on mammalian cell surfaces are sitting ducks. If the immune system, which abhors foreign substances, sees them, it just might chew the neurons they’re sit-ting on into shreds, or at least produce profound inflammation. It added up to one risky proposal. But Deisseroth wanted to take a shot at it. He recruited two grad students, Feng Zhang and Ed Boyden. Zhang knew chemistry, molecular biology, and virology. Boyden was adept at electrophysiology. They plunged in.

A researcher at the Max Planck Institute had recently found an algae-derived gene coding for an opsin that, when stimulated by blue light, passed electrical current in a way that, in principle, could cause neurons to fire. Deisseroth got hold of the gene and suggested that Zhang try to fit it into some kind of system that could shuttle it into living mammalian neurons.

Zhang eventually settled on using a defanged virus. Viruses are good at breaking into cells and commandeering their genet-ic machinery. To use a virus as a genetic-engineering tool, you take away its disease-causing weapons and replace them with a gene or genes you’ve taken from somewhere else. Then you in-ject your customized gene shuttle into an experimental animal. When the virus gets inside a cell’s nucleus, it delivers the alien gene into that cell’s own genome.

To ensure that just the right cells would produce the pro-tein, Zhang affixed a kind of bar code to the opsin gene. Typi-cally, genes have short “come hither” sequences of DNA right in front of them that tell cells’ gene-reading machines which genes to perch on and when to make the proteins they specify. These little DNA tags are called promoters, and gene-readers in differ-ent cell types are attracted to different promoters. A gene—say for hemoglobin—with a particular promoter sequence may get hit on all the time by the gene-reading machines in a red blood cell, but never in a skin cell.

Deisseroth’s team surmounted every hurdle. They succeeded in virally delivering opsin-encoding genes into rodents’ nervous tissue. They were able to restrict opsins’ production to neurons, or even just a select type of neuron. The protein popped up on nerve-cell



In the fall of 1884, the news here was that Grover Cleveland, a Democrat from New York, won the first of what would turn out to be his two elections as president of the United States. But in Britain there was a major medical event to be reported. To the consternation of vocal and often violent English antivivisectionists, a neurologically diagnosed brain tumor was successfully diagnosed and operated upon for the first time in history. It was removed from a twenty-five-year-old farmer at the Maida Vale Hospital, London. The case was diagnosed and the tumor localized in the brain based primarily on experimental work on dogs and monkeys carried out over the previous decade by Dr. David Ferrier (1843–1928), aug-mented by the clinical investigations of epileptic seizures by Dr. John Hughlings Jackson (1835–1911).

Although the man’s tumor was highly malignant and the patient did not survive more than a few months, it was hailed as a remarkable achievement and widely reported in the medi-cal as well as the popular press. Cerebral localization was still being argued and prominent investigators continued to hold that the brain acted as a whole and that localization of the vari-ous brain functions was largely a myth. The patient’s physician was Alexander Hughes Bennett, MD (1848–1901), whose fa-ther, also a prominent doctor, had died of a potentially remov-able brain tumor. It was he who made the clinical diagnosis and urged surgery. The reputation of the surgeon, Rickman Godlee (1849–1928), lent legitimacy to the case. He was nephew of the famous Joseph Lister, his office partner, future president of the Royal College of Surgeons, and ultimately knighted by King George. The significance of the Godlee-Bennett case was well appreciated. Beside being an example of the then-recent remarkable advances in surgical technique, it was tangible evi-dence of the concept of brain localization, and it particularly dramatized the value of animal experimentation.

In San Francisco in early 1886, a young man was admit-ted to the Lane Hospital on Clay and Webster Streets, suffer-ing from severe headache and focal epileptic seizures. Joseph Oakland Hirschfelder, MD (1850–1922), the admitting physi-cian, made the diagnosis of brain tumor near the contralateral motor strip. All the tools that we now consider routine in such cases lay far in the future. X-rays, for example, had to wait an-other ten years before Wilhelm Roentgen made their discovery. Hirschfelder had to depend on clinical signs alone. Like Ben-nett in London, he relied on the character of his poor patient’s seizure disorder and his post-ictal palsy. The San Francisco surgeon involved was Hirschfelder’s colleague John F. Morse, MD (1856–1898). The finding of the tumor in their case, after opening the intact skull, again helped vindicate the still-con-troversial concept of cerebral localization. The description of the tumor, soft and infiltrating, was consistent with a glioblas-

toma as fatal now as it was then. Their patient died after three weeks of postoperative infection, a not uncommon outcome at the time in spite of the stifling carbolic acid mist of antiseptic surgery. The Hirschfelder-Morse case was the second success-ful attempt at removal of a nonapparent tumor from the brain, and the first in the United States. It was to become the forerun-ner of many such cases in this country.

Joseph O. Hirschfelder, born in Oakland, was a well-known and highly trained San Francisco doctor. A U.C. graduate, he took his medical training in Germany and was professor of Clinical Medicine at the Cooper Medical College (ultimately to become Stanford after the 1906 earthquake). Among other things, he was one of many investigators who carried out early laboratory experimentation on tuberculin in hopes of finding a cure for the scourge of tuberculosis. He was the first of at least three gen-erations of men who became prominent in American science. He was also a president of the San Francisco Medical Society.

John F. Morse was born in San Francisco, the son of a pio-neer physician. He graduated from the Medical College of the Pacific and from the Friedrich Wilhelm University in Berlin, and he subsequently spent a year in Heidelberg. With that ex-tensive training behind him, he established his surgical practice in San Francisco in 1882. Beside his pioneering brain tumor surgery, he carried out many of the earliest appendectomies here and was the first in this country to successfully operate on abdominal aortic aneurism using copper wire. He was ac-tive in medical politics and he too was a president of the San Francisco Medical Society. Surgery lost a giant when he died suddenly of apoplexy at age forty-one.

Although far from what was considered the medical cen-ters of the world at the time—Philadelphia, New York, London, Paris, and Berlin—San Francisco had a remarkably sophis-ticated medical community in the late nineteenth century. In spite of the presence of many quacks and unlicensed practi-tioners, most doctors had a good education for the time, and many of the physicians had extensive European training. The Hirschfelder-Morse case is a good early example of pioneer-ing skilled medical and surgical practice in San Francisco. The groundbreaking step in the practice of neurosurgery carried out here in 1886 is a case in point.

Arthur E. Lyons MD, is a retired neurosurgeon, medical his-tory buff, and longtime member of the SFMS and the San Fran-cisco Medicine editorial board. He is also a past-president of the SFMS.

Arthur E. Lyons, MD

A Piece of San Francisco Medical HistoryA NEUROSURGICAL FIRST



Prior to the 1980s, patients with very symptom-atic, drug refractory supraventricular arrhythmias were treated with open heart surgery with direct destruction of the AV junction, followed by permanent pacemaker insertion. In March of 1981, after three years of work in the animal labo-ratory, I conceived the idea of using a catheter technique for AV junctional ablation using direct-current energy.

Before applying this approach to people, we studied the effects of direct shocks using canines. These dogs underwent extensive physiologic testing as well as postmortem studies to be certain that the delivered energy was safe in terms of not dis-rupting valve function or producing damage to the myocardium or coronary vessels.

The technique was first applied in March of 1981 to a gentleman with atrial fibrillation, heart failure, and severe co-morbidities, who was judged to be too high-risk for surgery. The procedure turned out to be successful and was followed by insertion of a permanent pacemaker. We subsequently used a similar technique for catheter ablation of a posterior-septal ac-cessory pathway in 1984.

The initial discovery received mixed reviews, as some car-diologists felt it would be used for no more than a very small, select patient group. Others opined that it merely traded one disease (drug-refractory tachycardia) for another (pacemaker-dependent state).

In the late 1980s, radiofrequency energy was substituted for direct current shocks, and this technique rapidly became the treatment of choice for patients with supraventricular tachycar-dia. The technique of a catheter ablation for control or cure of virtually all cardiac arrhythmia is now well accepted throughout the world.

The effect on my life was largely gratification that I have in some small way contributed to the betterment of patients’ lives. It continues to give me great gratification that patients whom I have treated are totally restored to normal lives.

Dr. Melvin Scheinman received his undergraduate degree at Johns Hopkins and his medical degree at the Albert Einstein Col-lege of Medicine. He received his post graduate training in cardiol-ogy at UCSF and established the Cardiac Electrophysiology section at UCSF in 1979. He was the first to apply catheter ablation in hu-mans and was instrumental in in defining mechanisms of arrhyth-mias as well as ablative procedures for complex arrhythmias. He currently holds the Shorenstein Chair in Cardiology and is director of the Comprehensive Genetic Arrhythmia section at UCSF. He has received a number of pioneer and out standing teaching awards from the American College of Cardiology, Heart Rhythm Society, as well as UCSF. In 2014 he was awarded the outstanding scientist award (clinical domain) from the ACC.

Melvin Scheinman, MD

Catheter Ablation of the AV JunctionA CARDIOVASCULAR FIRST

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August was an active month in advocacy for SFMS.

Tobacco RegulationOn August 26, 2015, three SFMS members joined more than

a hundred physicians, health care workers, and patient advo-cates at a daylong rally at the Capitol in Sacramento in support of the six tobacco control bills heard during the special extraor-dinary session on health care convened by Governor Brown. Lo-cal physicians Drs. Laura Davies, Renee Fogelberg, and John Maa represented SFMS at the press conference and legislative meet-ings coordinated by Save Lives California, a coalition with the CMA, American Heart Association, American Lung Association, Planned Parenthood, American Academy of Pediatrics, Califor-nia Dental Association, SEIU, and more. Along with several UCSF medical students, they spoke to members of the Legislature and their staff about the package of bills to regulate electronic ciga-rettes, raise the legal age to buy cigarettes to twenty-one years old, and create new tobacco taxes. SFMS and CMA have endorsed all six bills. The bills had previously won support from the Sen-ate health committee and, with the success of the Legislative Day, are swiftly moving through the Senate and Assembly before the 2015 legislative session concludes in mid-September.

SB X2-5 by State Senator Leno (D-San Francisco) would set up statewide rules for e-cigarettes similar to those governing to-bacco cigarettes, including that they be labeled accurately and not be marketed to children. Other bills in the package include:

SB X2-6 would close loopholes in smoke-free workplace laws by prohibiting smoking in certain environments, such as covered parking lots, gaming clubs, bars, and tobacco shops.

SB X2-7 would raise the minimum legal age to purchase and consume tobacco products from 18 to 21.

SBX2-8 would extend funding eligibility for tobacco educa-tion programs in school districts and require all schools to be tobacco free.

SB X2-9 would authorize local jurisdictions to impose a tax on the distribution of cigarettes and other “tobacco products.”

SBX2-10 would establish an annual Board of Equalization tobacco licensing fee program, which is estimated to raise $12 million.

A separate measure first introduced by Senator Richard Pan at the press conference seeks to impose a $2-per-pack tax hike on cigarettes and is backed by Save Lives California. The tax is projected to raise $1.1 to $1.4 billion annually. The reve-nues would help support state health care and smoking preven-tion entities including the Department of Health Care Services to fund Medi-Cal, the Department of Education to assist school programs for tobacco education, and the University of California to support physician training and its Tobacco-Related Disease Research Program. The coalition has also submitted a ballot initiative for the tax increase in the event that the Legislature

fails to institute the tax and will begin collecting signatures if this occurs. A Field Poll released the day of the press conference revealed that 67 percent of California voters would support the $2 tobacco tax.

After the Legislative Day, Dr. Fogelberg reflected, ”As a pri-mary care physician or subspecialty clinician this is the most important work we can do. Our patients’ lives matter.” Dr. Davies noted, “It was great to be part of an event with such broad sup-port focusing on the health of all Californians.”

End-of-Life Care/POLSTIn another win for SFMS advocacy efforts, on August 18,

Governor Jerry Brown signed AB 637 by Nora Campos (D-San Jose), which authorizes nurse practitioners and physician assis-tants, under the direction of a physician and within their scope of practice, to sign Physician Orders for Life-Sustaining Treat-ment (POLST) forms and make them actionable medical orders.

This new law had been championed to the CMA by SFMS delegation efforts for three consecutive years before the CMA sponsored a bill that Governor Brown has now signed, and it

LOCAL ADVOCACY

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September SFMS Advocacy Update

John Maa, MD, FACS

Continued on page 25 . . .


Proposed Rule Released Update to Physician Fee Schedule (Changes to compensation and reim-bursement rules)

In July, CMS released the first update to the Physician Fee Schedule since the repeal of the Sustainable Growth Rate through the Medicare Access and CHIP Reauthorization Act of 2015 (MA-CRA). The proposal includes a number of provisions focused on person-centered care and continues the Administration’s com-mitment to transform the Medicare program to a system based on quality and healthy outcomes.

In the proposed CY 2016 Physician Fee Schedule rule, CMS is also seeking comment from the public on implementation of certain provisions of the MACRA, including the new Merit-based Incentive payment system (MIPS). This is part of a broader effort at the department to move the Medicare program to a health care system focused on the delivery of quality care and value.

The proposed rule includes updates to payment policies, pro-posals to implement statutory adjustments to physician payments based on misvalued codes, updates to the Physician Quality Re-porting System (PQRS), which measures the quality performance of physicians participating in Medicare, and updates to the Physi-cian Value-Based Payment Modifier (VM), which ties a portion of physician payments to performance on measures of quality and cost. CMS is also seeking comment on the potential expansion of the Comprehensive Primary Care Initiative, a CMS Innovation Center initiative designed to improve the coordination of care for Medicare beneficiaries. The proposed rule also seeks comment on a proposal that supports patient- and family-centered care for seniors and other Medicare beneficiaries by enabling them to discuss advance care planning with their providers. The proposal follows the American Medical Association’s recommendation to make advance care planning services a separately payable service under Medicare.

CMS is accepting public comments on the CY 2016 PFS- proposed rule until September 8, 2015, and will issue the final rule by November 1. More information about the proposed rule can be found at https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-16875.pdf.

The Medicare Access and CHIP Reauthorization Act (MACRA)

MACRA repeals the SGR Medicare payment update formula and updates the Physician Fee Schedule payment for 2015 on-ward. MACRA sunsets existing programs (PQRS, VM, and Mean-ingful Use) by December 31, 2018. In their place, MACRA creates a new Merit-Based Incentive Payment System (MIPS) to measure performance on Quality, Resource Utilization, Clinical Improve-ment, and Electronic Health Records as a way to score eligible providers. MIPS eligible providers get a composite score based on four domains (Quality, Resource Utilization, Clinical Improve-ment, and Electronic Health Records). While the statute establish-es the weights for the different domains, CMS is developing the specifics for what measures will be included in each domain. MA-CRA emphasizes using outcome measures when possible.

Depending on how many measures are available for the cer-tain domains, the statute allows the Secretary to re-weight the domains. The MIPS composite score will determine the MIPS program payment adjustment factor. The MIPS adjustment factor will be 4% in 2019, 5% in 2020, 7% in 2021, and 9% for 2022 onward. MIPS requires the lowest 25% tile (below the perfor-mance threshold) to receive the maximum negative payment adjustment. MIPS also allows an extra payment for exceptional performance; the threshold for exceptional performance is yet to be determined by the Secretary. A scaling factor is applied to the MIPS adjustment factor to ensure that MIPS is budget neutral.

Clinicians who chose to continue to participate in straight fee-for-service Medicare, billing under Part B and the Physician Fee Schedule, will be subject to MIPS. Clinicians who choose to become involved with, or are already participating in, Alternative Payment Models, will be exempt from the MIPS requirements. Al-ternative Payment Models (APMs) include participants in CMMI models, MSSPs, ACOs, and CMS demonstrations, including Patient Centered Medical Homes. Entities can become APMs if they use certified EHR technology, use measures in the MIPS program, and the entity bears significant financial risk. APM guidelines will be developed by a Payment Model Technical Advisory Commit-tee. Eligible Professionals in APMs will have requirements speci-fying that a percentage of their Part B payments will be furnished

CMS UPDATE

Maximum Penalties before MACRA Maximum Penalties and Bonuses After MACRA

2015 4.5%2016 6%2017 9%2018 10%2019 11% or more Maximum penalties and bonuses are 4%2020 Maximum penalties and bonuses are 5%2021 Maximum penalties and bonuses are 7%2022 and beyond Maximum penalties and bonuses are 9%

Ashby Wolfe, MD, MPP, MPH


goes into effect on January 1, 2016. This victory demonstrates that the CMA is open to scope of practice expansions that en-hance the safety and timeliness of patient care, and ensure that patient end-of-life treatment preferenc-es are honored.

The POLST form was introduced in California in 2008 and indicates the types of medical treatment patients desire to-ward the end of their lives. Signed by both a doctor and patient, POLST forms give the seriously-ill patient more control over the care they receive, documenting their wishes in advance should they become unable to further communicate their desires. Six-teen other states allow nurse practitioners and physician assis-tants to sign POLST forms.

Under current law, a POLST form did not become valid un-til signed by 1) the patient or their decision-maker and 2) the treating physician. In situations in which access to a physician is limited, several days might pass between the time a patient or decision-maker completed a POLST form, and the physician reviewed and signed. During such a delay, patients may receive unwanted care or treatment because their POLST is not yet val-id. At SFMS’s urging, CMA collaborated with palliative care spe-cialists and geriatricians to co-sponsor this bill, recognizing the importance of POLST to document end-of-life care preferences with the hope that this new bill could result in increased use of POLST orders.

Sugar-Sweetened Beverage Ordinances UpdateFinally, the American Beverage Association filed opposition

in federal court against two of the sugar-sweetened-beverage bills supported by SFMS and signed by Mayor Lee in July. The City Attorney chose not to oppose the injunction against the ban of soda advertising on city property, but appears poised to defend the warning labels on billboards, buses, transit shelters, sports stadiums and posters that was advanced by Supervisor Scott Wiener. A response from the City Attorney’s office is antici-pated in early September.

John Maa, MD, FACS, is a past president of the Northern Cali-fornia Chapter of the American College of Surgeons, and chair of the University of California Office of the President Tobacco Related Disease Research Program. He is on the medical staff of Marin General Hospital and is a member of the San Francisco Medical Society board of directors and the editorial board for San Fran-cisco Medicine.

Advocacy Update Continued from page 23 . . .

by the APM (25% in 2019 and 2020; 50% 2012 and 2022; 75% 2023 onward).

The timeline for MIPS and APM development is directed by the statute, and CMS is working to meet the statutory mile-stones. MACRA funds CMS to develop quality measures for MIPS. MACRA emphasizes using measures with evidence support and the use of outcome measures. CMS plans to seek stakeholder input for the development of MIPS, APMs, and new measures.

Please consider signing up for the Health Care Payment Learning and Action Network, which is an open listserv, from which members of various workgroups will be solicited for the purposes of implementing the new MACRA legislation. Informa-tion about the network can be found at http://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Net-work/. Register for the listserv at http://innovationgov.force.com/hcplan.

Ashby Wolfe, MD, MPP, MPH, is chief medical officer at Centers for Medicare & Medicaid Services Region IX.

NEW ANTIBIOTIC RESISTANCE RESOURCES

The CMA Foundation’s AWARE (Alliance Working for Antibiotic Resistance Education) offers a free new mobile application providing clinical guidelines for optimal use of antibiotics. It is available for both Android and iOS devices and found in the Google Play or iTunes stores by searching “AWARE Toolkit.” This tool is already being used by clini-cians worldwide.

And if you truly want to see trends in resistance illus-trated, by pathogen (Campylobacter, E. coli O157, Salmo-nella, and Shigella) and state, check this new CDC National Antimicrobial Resistance Monitoring System (NARMS) tool as well: http://wwwn.cdc.gov/narmsnow/

It provides a quick and alarming graphic portrayal of resistance trends.


PUBLIC HEALTH UPDATE

As in previous years, I am issuing a Health Officer order mandating that all hospitals, skilled nursing, and other long term care facilities in the City and County of San Francisco require their health care workers (HCWs) to receive an annual influenza vaccination or, if they decline, to wear a mask in patient care areas during the influenza season.

For other clinical facilities and ambulatory care centers, we strongly recommend implementation of a similar policy.

RationaleInfluenza infection affects 5 to 20 percent of the US popula-

tion every year, leading to an estimated 3.1 million days of hos-pitalization and 31.4 million outpatient visits. HCWs are both at risk for influenza and can transmit the virus to their patients and coworkers. Patients in our health care facilities, especially young children, pregnant women, the elderly, and those with chronic health conditions, are at greater risk for influenza-re-lated hospitalization and death. Healthy People 2020 objectives target a 90 percent seasonal influenza vaccination rate for all health care personnel.

State law requires that general acute care hospitals and cer-tain employers, including skilled nursing and other long term care facilities, offer influenza vaccinations to employees. (Cal. Health & Saf. Code, §1288.7, subd. (a); 8 Cal. Code Regs., § 5199, subd. (c)(6)(D) and (h)(10).) If hospital employees decline vac-cination, they are required to sign a declination statement in lieu of vaccination. (Cal. Health & Saf. Code, §1288.7, subd. (a); 8 Cal. Code Regs., § 5199, subd. (c)(6)(D) and (h)(10).) This order enhances patient protection by requiring unvaccinated HCWs to wear a face mask in patient care areas during the influenza season. Comprehensive mandatory vaccination programs, that include masking for unvaccinated HCWs, have been associated with high HCW vaccination rates (>95%).

Our goal is to protect both health care workers and patients from influenza disease by increasing rates of influenza vacci-nation of HCWs. We expect this policy to reduce employee ab-senteeism during influenza season, and reduce HCW-to-patient transmission of influenza.

Order: I, as the Health Officer of the City and County of San Francisco, am requiring that each and every hospital, skilled nursing, and long term care facility in San Francisco imple-ment a program requiring its health care workers to receive an annual influenza vaccination or, if they decline, to wear a mask for the duration of the influenza season while work-ing in patient care areas.

Duration of OrderThis order is ongoing and applies to each influenza season

unless the order is rescinded. The influenza season is defined as December 15 to March 31 of the following year. In any given year, if influenza surveillance data demonstrate unusually early and/or late peaks, I may extend the period during which the masking program shall apply for that year.

Facilities Subject to the OrderThis order applies to hospitals, skilled nursing, and other

long term care facilities.

Definition of HCWsFor the purposes of this order, “health care workers” or

“HCWs” are persons, paid and unpaid, working in health care settings who have direct patient contact or who work in patient care areas.

I appreciate your help and support in protecting the resi-dents of the City and County of San Francisco. For any additional questions, please contact the SFDPH Immunization Program at 415-554-2955.

Tomás J. Aragón, MD, DrPH, is Health Officer of the City and County of San Francisco, and Director of the Population Health Division at the Department of Public Health. He is a member of the SFMS.

Mandatory Influenza Vaccination or Masking of Health Care Workers During Influenza Season

Tomás J. Aragón, MD, DrPH


HEALTH POLICY PERSPECTIVE

The California End-of-Life Options Act (SB128), which would have legalized physician-assisted dy-ing (PAD), was front-page news and stirred much controver-sy. The bill is now in limbo due to religious opposition, although the multidenominational California Council of Churches sup-ported it. Lawsuits to legalize the practice of PAD (not “suicide,” a term that is not truly relevant here) seem to be failing as well, and a ballot initiative—expensive and even messier than legisla-tion—might be the next step.

One casualty of such emotional debates can be ba-sic truths about the personal, clinical, and policy deci-sions surrounding this issue. Both of us have much expe-rience in these arenas and hope to shed some light here. Approaching the end of their lives, patients most want two things from their doctors: that they have clinical competence and know everything that might be done to help a patient not suffer, and that they will be there for the patient no matter what. Rarely—not often, but not never—that can include hastening the end to some degree, and always at the patient’s own choice. Most of the time such requests are not carried out, but just knowing that one has some added control and choice at the end can actually extend life in some cases—ironic, but true.

The California Medical Association (CMA) opposed PAD for many decades, until this year. This change in position initially was spurred by the SFMS delegation, which three times in re-cent years attempted to get the CMA to reexamine its opposi-tion, for the following reasons: First, accumulating surveys of doctors’ opinions on this topic (more than 30,000 physicians in published surveys thus far) indicate that at least half, and likely more, physicians now support some legal options for PAD. Second, experience in states that have legalized PAD for years shows that the many fears about abuses have not been realized and that, again, the practice is uncommon, and legalizing it can actually lead to improvements in general care at the end of life. Finally, the hallowed medical dictum “Do no harm” is now seen to include the possible harm of keeping patients alive and suf-fering longer than nature or their God intended, or, first and foremost, longer than they might want for themselves.

After the SFMS wrote to CMA leadership stressing these facts, the CMA conducted a survey of its leadership and found that a substantial majority supported legalizing PAD, or at least not opposing it. While still working to ensure that all reasonable safeguards against abuse are in any PAD policy, the CMA then changed to a “neutral” position. This is how a democratic organi-zation, which purports to represent the profession, should work. The one vocal medical group against SB128, the Association of Northern California Oncologists, also conducted a survey of members on this topic. Their survey also came back with a majority supporting PAD legality. But the executive leadership

of the Association felt otherwise and discounted the members’ vote in deciding to continue to oppose SB128. We wish they had had the integrity of the CMA in this regard and, as a result, Dr. Abrams has terminated his membership with the Association.

For those who care for patients coping with end-stage disease, support of PAD, or at least neutrality, increasingly seems a humane option. The PAD issue comes down to an is-sue of patient choice and control toward the end of life, when we are very vulnerable. Many if not most of us will be such patients at some point, and we hope that by that time, we and our doctors will be empowered to make ultimate these choic-es without outside interference. And that our medical asso-ciations will also respect those choices and majority opinion.

Dr. Donald Abrams is chief of oncology at San Francisco Gen-eral Hospital and a professor of medicine at the University of Cali-fornia, San Francisco. He was a pioneer in the response to the AIDS epidemic and is a longtime SFMS member. Steve Heilig is coeditor of The Cambridge Quarterly of Healthcare Ethics, health policy director for the San Francisco Medical Society, and a former hos-pice worker and director. He drafted the original resolution urg-ing the California Medical Association to take a neutral stance on physician-assisted dying.

Physician-Assisted Dying: Honest Choices

Donald Abrams, MD, and Steve Heilig, MPH

SFMS ADVOCATES FOR CHINESE COMMUNITY PHYSICIANS

In a recent, unfortunate conflict between a local health plan and a physician association, SFMS and CMA sent a strong letter of support for physician and patient interests. The Chinese Community Health Care Association (CCHCA) includes many SFMS-member physicians, serving the local community. CCHCA leaders asked for support in a contract-ing conflict with the local health plan, and SFMS responded that “CCHCA is a pillar of the San Francisco community, hav-ing been organized as a nonprofit independent physician organization more than three decades ago to promote social welfare by making health services more accessible to the Chinese community . . . CMA and SFMS are greatly concerned that the Health Plan’s actions interfere with physicians’ abil-ity to serve their patients, while also diminishing the long, proud history of the Chinese Hospital and the close relation-ship generations of physicians and patients in San Francisco have enjoyed.” The conflict is currently unresolved, but the letter concludes, “CMA and SFMS are prepared to support CCHCA and its physicians to continue to achieve their chari-table purposes.”


MEDICAL COMMUNITY NEWS

SPMF physicians advance medical knowledge through research and education. Research increases their awareness—and their colleagues’ awareness—of cutting-edge treatments that can improve patients’ lives. Here are some “breakthroughs” from our physicians and patients:

Historic six-way and nine-way donor and recipient kidney transplant matches took place this year at California Pacific Medi-cal Center (CPMC) and UCSF Medical Center thanks to Matchgrid, an algorithmic program enabling incompatible pairs to be matched. The software was developed by David Jacobs, who came up with the idea after he had a kid-ney transplant at CPMC.

Mohammed Kashani-Sabet, MD, direc-tor of CPMC’s Center for Melanoma Research and Treatment, participated in research with colleagues that sparked FDA approval of nivolumab, a breakthrough drug for melano-ma. Checkpoint inhibitors including nivolum-ab have emerged as promising therapies in slowing and preventing tumor growth.

David King-Stephens, MD, Kenneth Laxer, M.D. and Peter Weber, MD, pioneered new research that was key to FDA approval of the RNS® System (NeuroPace)—a brain stimulator—in treating epileptic seizures. The effectiveness of NeuroPace was shown in a randomized controlled trial at multiple centers in the U.S.

Robert Miller, MD, Jonathan Katz, MD, and colleagues at CPMC’s Forbes Norris MDA/ALS Research and Treatment Center are studying new ways to reduce neuroin-flammation suspected to contribute to the progression of amyotrophic lateral sclerosis (ALS). They are leading a national clinical tri-al of a drug that shows promise in halting ALS progression. They are also leading a national multicenter effort to standardize electronic health records in ALS so basic clinical data can be stored in a single data system.

SPMFBill Black, MD, PhD

Dr. Robert Miller, director of the Forbes Norris MDA/ALS Research and Treatment Center at CPMC, received new funding from the ALS Association and Neuraltus to lead a novel phase II clinical study of the drug NP001, an immune system regulator that has shown promise in halting the progression of amyo-trophic lateral sclerosis (ALS). Dr. Miller will lead a placebo-controlled, six-month treat-ment trial to confirm results observed in a previous study of NP001, the results of which were published in the April 2015 issue of Neu-rology: Neuroimmunology & Neuroinflamma-tion, an official journal of the American Acad-emy of Neurology.

In early May, CPMC launched a collective effort to become a high-reliability organiza-tion. Sepsis is the first of five focus areas tar-geted for improvements in 2015. Subsequent areas of focus will be the Universal Protocol Time Out, handwashing, alarm fatigue reduc-tion, and hand-offs. The Leapfrog Group, which ranks hospital quality and safety nationally, re-cently released its Hospital Safety Score grades for the last six months. The Pacific, California, and St. Luke’s campuses received “A” ratings from this organization, while the Davies Cam-pus received a “B” rating.

CPMC was recognized as being among the best hospitals in California for 2015–2016 by U.S. News & World Report. The annual rank-ings rate top hospitals in the state and in ma-jor metropolitan regions, according to their performance in sixteen adult specialties. Of the 430 hospitals reviewed in California, CPMC was recognized among the best, ranking fifth in the San Francisco metro area and fifteenth in the state. In addition, CPMC received “high performer” recognitions in three specialties: heart bypass surgery, hip replacement, and knee replacement. CPMC also ranked as a “top-50 hospital in the nation” for gynecology. Only 137 of the nearly 5,000 U.S. hospitals evalu-ated received a national ranking in at least one specialty.

CPMCEdward Eisler, MD

Recent advances in technology have led to the development of applications that have expanded the diagnostic and therapeutic roles of endoscopy. Endoscopic ultrasound (EUS) is primarily a diagnostic imaging tech-nique in which an ultrasound probe is built into the tip of the endoscope. EUS allows for the structural evaluation of abnormalities of the gastrointestinal tract, such as esophageal, gastric, and rectal tumors.

Ultrasound imaging can also image structures and organs immediately adjacent to the gastrointestinal tract, such as the pan-creas, common bile duct, gallbladder, and liver. By advancing a small needle via the en-doscope and directing a fine needle aspirate, we can perform a minimally invasive cytol-ogy. EUS has become a standard diagnostic evaluation for the staging of gastrointestinal tract and pancreatic cancers.

By providing access to areas deep within the abdominal cavity, EUS offers therapeutic interventions that would otherwise require surgical or percutaneous radiologic treat-ment. EUS-guided drainage of pancreatic pseudocysts and debridement of pancreatic necrosis has improved the management of highly morbid complications from pancre-atitis. Additionally, EUS-guided celiac plexus nerve block offers an alternate approach to delivering analgesia for cancer patients, and EUS placement of fiducial markers into tu-mors enables focused radiation treatment of pancreatic cancers.

Over the past three years, we expanded our endoscopic mucosal resection (EMR) ser-vice. EMR is the curative removal of large pre-cancerous growths from the gastrointestinal tract that historically required surgical resec-tion. As a result of EMR, hundreds of patients have benefited. Most recently, we have begun to develop services in endoscopic submuco-sal dissection (ESD). ESD is an advancement of EMR practices with the goal of curative treatment of stage IA cancers of the gastroin-testinal tract. Indications for endoscopy have rapidly increased, and as technology evolves, endoscopy will remain at the forefront.

KaiserMaria Ansari, MD


Transcatheter aortic valve replacement (TAVR) has become groundbreaking therapy for treating severe symptomatic aortic steno-sis (AS) in patients that are high risk or inop-erable for surgical aortic valve replacement (SAVR). AS affects 16.5 million Americans over age sixty-five and becomes progressively se-vere with age. When patients develop symp-toms, half will die within two years without treatment. In the past, 40 percent of patients were not offered SAVR due to comorbidities, but now TAVR allows them life-saving therapy. TAVR involves using a catheter to implant a new valve attached to a stent within the pa-tient’s diseased valve. In the majority of cases, TAVR can be performed percutaneously from the groin. TAVR requires specialized, multi-disciplinary expertise in interventional car-diology, cardiac surgery, echocardiography, electrophysiology, anesthesia, radiology, and nursing, among others, for patient-centered care. TAVRs are performed in state-of-the-art, hybrid operating rooms designed to meet the needs of both the operating room and cath-eterization laboratory.

SFVA is one of the leaders in TAVR, be-ing among a handful of nationally approved VA centers. Since 2013, our program has completed more than fifty cases with excel-lent outcomes. We offer valve-in-valve TAVR for patients with degenerated surgical bio-prostheses. We offer both currently available FDA-approved devices from Edwards and Medtronic, with their balloon-expandable and self-expanding valves, respectively. These op-tions increase patient eligibility, decrease mor-bidity, and increase eligibility for percutaneous treatment, since access size requirements are significantly decreased. SFVA team leaders Drs. Elaine Tseng (cardiac surgery) and Ken-drick Shunk (interventional cardiology) are nationally and internationally recognized in clinical and basic science research in TAVR, with continuous funding since 2005. SFVA research predicted crucial valve-in-valve out-comes using benchtop research prior to global registry results.

SFVAMCC. Dianna Nicoll, MD, PhD, MPA

Classified AdFamily Medical Practice for sale. East San Francisco Bay, CA – Multi-discipline practice serving the Asian community. Revenue over $1 million. Multi-language staff; buyer doctor must be fluent in one Chinese dialect. EMR; high profit margin; seller will train buyer in proprietary systems. $682,000. Real estate also available. [email protected]. 800-576-6935. www.PracticeConsultants.com.

Saint Francis and St. Mary’sRobert Harvey, MD, MBAand Robert Weber, MD

Medical advancements are an opportu-nity to improve the processes and tools used in treating and caring for patients. Dignity Health Saint Francis Memorial Hospital and Dignity Health St. Mary’s Medical Center are proud to offer the CyberKnife® Robotic Ra-diosurgery System, an advanced radiation therapy option for patients.

The service is available at San Francisco CyberKnife, a new world-class outpatient cancer treatment center that opened at Saint Francis this summer to serve patients from Saint Francis, St. Mary’s, and Dignity Health Sequoia Hospital in Redwood City. San Fran-cisco CyberKnife is a joint venture between Dignity Health, independent San Francisco-based physicians, and Alliance HealthCare Services, Inc., a national provider of out-sourced health care services.

CyberKnife is a state-of-the-art, noninva-sive alternative to surgery for the treatment of both cancerous and noncancerous tumors, such as those located in the lung, brain, spine, liver, pancreas, and kidney. The treatment delivers beams of high-dose radiation to tu-mors with extreme accuracy in five or fewer outpatient procedures. Compared to tradi-

tional surgical procedures, CyberKnife may also be a more ideal option for patients with inoperable or surgically complex tumors. CyberKnife’s modern mechanism of treat-ing tumors has several benefits for patients, including no anesthesia or hospitalization, minimal radiation exposure to healthy tis-sue, little to no recovery time, and immedi-ate return to daily activities.

Led by John Meyer, MD, medical direc-tor of Radiation Oncology at Saint Francis, and Sara M. Huang, MD, medical director of the Cancer Center at St. Mary’s, San Francis-co CyberKnife offers a dedicated CyberKnife nurse navigator, numerous locations for patient consultation and follow-up care, and a nurse and three physicians on staff who speak Cantonese and Mandarin. The medical staff also includes Lisa Boohar, MD; Barry Chauser, MD; Alexander B. Geng, MD; Meiwen Wu, MD; and C. Dale Young, MD. The addition of CybeKnife to the Saint Francis and St. Mary’s oncology programs means that patients have an innovative, painless alternative to the challenges of traditional surgery.

Save the Date! January 29, 2016 is the SFMS Annual Gala January 29, 6:30 pm to 9:00 pm | Legion of Honor | Celebrate SFMS’ 148 years of physician advocacy and camaraderie with many of San Francisco’s most influential stakeholders in the medical community! The 2016 Annual Gala will be held at the iconic Legion of Honor. Guests are treated to an exquisite reception with elegant hors d’oeuvres and libations. Richard Podolin, MD will be installed as the SFMS President.Network with colleagues, meet SFMS leaders, and enjoy a private viewing of the Legion of Honor’s collection galleries. Please note this is a member-only event. Gala tickets will go on sale November 2015.


9/19: Zero Prostate Cancer Run/Walk | 9:30 a.m., Lake Mer-ced (Skyline and Harding Rd.) | Join SFMS physician members from Golden Gate Urology for the annual Zero Prostate Cancer Run/Walk. This tight-knit community activity brings together athletes, doctors, cancer survivors, and those who care about them to end prostate cancer. Visit http://bit.ly/1EknsZh for more information on how to get involved.

9/22: CMS Webinar on Physician Compare Website and Qual-ity Data | The Centers for Medicare and Medicaid Services (CMS) will host a series of one-hour webinars about public quality reporting and the Physician Compare website. The Physician Compare website was launched on in 2010 as mandated by the Affordable Care Act. It provides contact information, specialties and clinical training, hospital affiliations, and group practice in-formation. Each webinar will offer physicians and other stake-holders an opportunity to ask questions about public reporting on Physician Compare and this year’s thirty-day measure pre-view period. Webinars will be conducted via WebEx on 9/22 at 10 a.m., 9/23 at 1 p.m., and 9/24 at 8 a.m. All sessions will pres-ent the same information. Visit http://bit.ly/1IRwiBf to register for the webinar.

9/25: Special Hope Foundation Conference—Effective Health Care for Adults with Developmental Disabilities | 8:00 a.m.–4:00 p.m., California Endowment Oakland, 1111 Broadway, Oakland | Is California on the right track to provide effective and accessible health care for adults with developmental disabilities? Health care providers, funders, researchers, advocates, policy makers, and other thought leaders will collaboratively look at managed health care for adults with developmental and intellec-tual disabilities at this one-day, information-sharing symposium. For more information or to RSVP, please contact Kathy Bradley at (515) 480-6858 or [email protected].

10/4-7: 2015 Health 2.0 Annual Fall Conference | Santa Clara Convention Center | SFMS members may be eligible to receive complimentary access to the 9th Annual Health 2.0 Fall Confer-ence. This 3-day event will showcase new technologies in health care, examining what has changed in the past year and giving participants a sneak peek at what’s next. Attendees can look forward to live product demos, engaging panel discussions with expert speakers, and days of networking opportunities. Visit http://bit.ly/1LGnWj6 for more information.

10/17: CMA President’s Reception and Awards Gala | 6:00 p.m.–12:00 a.m., Disney’s Grand Californian Hotel & Spa, Ana-heim | The California Medical Association and the CMA Founda-tion invite you to the Nineteenth Annual President’s Reception and Awards Gala. Entertainment for this year’s Gala includes Power Mix, a fifteen-piece band featuring a team of male and fe-male vocalists covering the best-loved songs and dance hits from yesterday and today. Each year, CMA and the CMA Foundation celebrate the extraordinary leadership of individuals and orga-

UPCOMING EVENTSnizations making a difference in the health of Californians. Fes-tivities include a cocktail reception, dinner, an inspiring awards presentation, a live auction, and exciting entertainment. Mark your calendars, as this will be a whimsical night to remember.Additional event information, including ticket sales and RSVP details, is available at www.cmanet.org/gala.

10/29: IMQ Medical Staff Conference | 8:30 a.m.–4:40 p.m., Embassy Suites LAX Hotel, Los Angeles | Effective medical staff leadership is not easy. Patient-care problems can require thought-ful and sometimes difficult communications with colleagues. Join other medical staff leaders in a one-day learning opportunity that provides a foundation of knowledge, techniques, and best prac-tices to help you succeed. In one day, attendees will gain insights to assist them in successfully leading a medical staff and, in doing so, to comply with key accreditation, licensure, and legal require-ments. For more information, visit http://bit.ly/1fseILN or contact Leslie Anne Iacopi at (415) 882-5167 or [email protected].

10/30–31: 2015 Latino Health Conference | Oakland Mar-riott City Center | The 2015 Latino Health Conference seeks to address health disparities in the Latino/Hispanic community by sharing evidence-based practices and clinical research, pro-moting diversity in the health care workforce and creating link-ages between community health organizations and health care providers. Conference participants will receive evidence-based strategies, practice tips, tools, and patient education resources to improve their clinical practice and patient care. Visit http://latinohealthconference.com/lhc/ for program and registration details.

11/5: SFMS Career Fair for Residents/Fellows/Physician Mem-bers | November 17, 5:00 p.m. to 8:00 p.m. | Morrissey Hall at St. Mary’s Medical Center, 2250 Hayes StreetSFMS will be hosting our fifth annual Career Fair on November 17 at Morrissey Hall located on the St. Mary’s Medical Center campus. The event runs from 5:00 p.m. until 8:00 p.m. and is complimentary to residents and fellows from the four San Fran-cisco-based residency programs. This is an excellent opportuni-ty for physicians looking to practice in the Bay Area to network with representatives from a variety of practice types and set-tings, and for employers to connect with physician job seekers.For event details or to inquire about exhibiting, contact the Membership Department at (415) 561-0850 extension 200 or [email protected].

11/9–10: Transforming Health Care—Statewide Stakeholder Summit | Sacramento Convention Center | The California Office of Health Information Integrity (CalOHII) is hosting a two-day conference focusing on the impact of personalized medicine on the future of health care. Presenters include national, state, and local health care leaders and innovators, as well as people on the front lines who will share their challenges and progress. Visit http://bit.ly/1fsh3WN for event and registration details.


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We work to protect you.

YOU WORK TO PROTECT YOUR PATIENTS.

AS A PHYSICIAN, you probably know better than anyone else how quickly a disability can strike and not only delay your dreams, but also leave you unable to provide for your family. Whether it is a heart attack, stroke, car accident or fall off a ladder, any of these things can affect your ability to perform your medical specialty.

That’s why the SFMS/CMA sponsors a Group Long-Term Disability program underwritten by New York Life Insurance Company:

• Benefits not tied to a practice, giving you more flexibility with potential career changes

• Benefit payments that are 100% TAX FREE — when you pay premiums yourself

• High monthly benefits up to $10,000

• Protection in your medical specialty for the first 10 years of disability

With this critical protection, you’ll have one less thing to worry about until your return.

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September 2015

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