November 2009

VOL.82 NO.9 November 2009 $5.00

SAN FRANCISCO MEDICINEJ O U R N A L O F T H E S A N F R A N C I S C O M E D I C A L S O C I E T Y

Diversity in Medicine

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SAN FRANCISCO MEDICINE November2009volume82,Number9diversityinmedicine

FEATURE ARTICLES

10 Improving Quality and Equality: Eliminating Racial and Ethnic Disparities in Health Care Joseph R. Betancourt, MD, MPH

11 Diversity in Medicine: A Student’s Perspective Tonantzin Rodriguez, MPH

13 Minority Doctors in Short Supply: A Report on California Elizabeth Fernandez

14 Ethic Physician Leadership Summit Satinder Swaroop, MD

16 Politics 101: Highlights from the Ethnic Physician Leadership Summit Politics 101 Workshop Randal Pham, MD, FACS

17 Ethnic Minorities in Clinical Trials: An Important Consideration Owen Garrick, MD

19 Diversity at UCSF: Addressing Current and Future Health Disparities J. Renee Navarro, Pharm D, MD

OF INTEREST

24Policy and Progress at the CMA Stephen Follansbee, MD, and Steve Heilig, MPH

25Health Policy Perspective: Still Sick Steve Heilig, MPH

MONTHLY COLUMNS

4 Membership Matters

7 President’s Message Charles J. Wibbelsman, MD

9 Editorial Mike Denney, MD, PhD

21 Hospital News

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In This Issue

4saNfraNciscomediciNeNovember2009 www.sfms.org

November2009volume82,Number9

Editor Mike DenneyManaging Editor Amanda DenzCopy Editor Mary VanClay

EDITORIAl BOARD

Chairman Mike DenneyObituarist Nancy Thomson

SFMS OFFICERS

President Charles J. WibbelsmanPresident-Elect Michael RokeachSecretary George A. FourasTreasurer Gary L. ChanEditor Mike DenneyImmediate Past President Steven H. Fugaro

SFMS Executive Staff

Executive Director Mary Lou LicwinkoDirector of Public Health & Education Steve HeiligDirector of Administration Posi LyonDirector of Membership Therese PorterDirector of Communications Amanda Denz

CMA Trustee Robert J. MargolinAMA Representatives

H. Hugh Vincent, DelegateRobert J. Margolin, Alternate Delegate

sfmsmembers:saveThedatefortheannualdinner

Next year’s annual dinner will take place at the Concordia-Argonaut Club Thursday, January 21, 2010. President-Elect Michael Rokeach, MD, will be in-stalled as 2010 SFMS President. SFMS Members will receive an invitation to the 2010 SFMS Annual Dinner in December. Please return the RSVP card promptly. Contact Posi Lyon (415) 561-0850, exten-sion 260, with questions.

doweHaveYourcorrectcontactinformation?

Most importantly, do we have your e-mail address? Don’t miss out on important information from SFMS and CMA!

You can update your records online or by contacting the Membership Depart-ment at (415) 561-0850 extension 268 or [email protected].

NewwaystoPayYourdues!The 2010 dues statements have gone

out. This year SFMS has added a new op-tion to make paying your dues easy, safe, and convenient: You may now elect to pay your dues via credit card installments. Details and an authorization form have been included in your dues statements. As always, you may also use the online dues payment system on our website or you can pay by check or credit card via fax or U.S. mail. If you have any questions, please contact the Membership Depart-ment at (415) 561-0850 extension 268 or [email protected].

inviteYourPeerstoJoinandgetabreakonYoursfmsdues!

Members of the San Francisco Medi-cal Society/California Medical Association know that participation in organized medicine benefits both physicians and their patients. SFMS members have been helping shape the future of medicine for nearly 150 years.

If each member of the San Francisco Medical Society/California Medical Asso-

A SAmpling of ActivitieS And ActionS of intereSt to SfmS memberS

ciation encouraged just one new physician from among their peers to become a mem-ber, SFMS/CMA would become an even more powerful force in the legislature, the courts, the media, and on the local level. All it takes is each SFMS/CMA member recruiting just one new member to make a significant effect on membership. With SFMS’ “Connect the Docs” referral pro-gram, you can help grow membership in SFMS and CMA and give yourself a break on your SFMS dues, all at the same time.

If you are a dues-paying member of SFMS/CMA:

Recruit four or more new members to the San Francisco Medical Society/Califor-nia Medical Association and receive a free SFMS membeship for the 2010 dues year.

TPMG members’ dues are paid by Kaiser, but if a TPMG physician refers five or more members (TPMG or not), he or she will receive two free tickets to the SFMS Annual Dinner.

Be sure the new member completes the “referred by” information so that you receive appropriate credit.

Joining has never been easier, with our online application system. All a prospec-tive member has to do is visit www.sfms.com and click on the “JOIN SFMS” button in the upper right-hand corner. If the new member has never been a member of CMA before, they may be eligible for a 50 percent discount on their first-year dues.

You—or the prospective member—can also contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or [email protected] with questions or to have a membership information packet sent.

Upcoming event: amixer forresidentsandYoungPhysicians

Thursday, November 19, 6:00–7:30 p.m. Residents and young physicians are invited to a mixer at the San Francisco Medical Society’s offices in the Presidio of San Francisco. Enjoy appetizers and wine in a comfortable, informal atmosphere while connecting with your young physi-

Membership Matters

Stephen Askin Toni BrayerLinda Hawes-CleverGordon Fung Erica Goode Gretchen Gooding

Shieva Khayam-BashiArthur LyonsTerri Pickering Ricki Pollycove Stephen Walsh

Board of Directors

Term: Jan 2009-Dec 2010Jeffery BeaneAndrew F. CalmanLawrence CheungPeter J. CurranThomas H. LeeRichard A. PodolinRodman S. RogersTerm: Jan 2008-Dec 2010Jennifer H. DoKeith E. LoringWilliam A. Miller

Jeffrey NewmanThomas J. PeitzDaniel M. RaybinMichael H. SiuTerm: Jan 2007-Dec 2009Brian T. Andrews Lucy S. CrainJane M. HightowerDonald C. KittJordan ShlainLily M. TanShannon Udovic-Constant

www.sfms.org November2009saNfraNciscomediciNe54saNfraNciscomediciNeNovember2009 www.sfms.org

it makes sense to cancel a payor contract; how to make sense of your revenue stream; how to improve the patient experi-ence; and much more. The Best Practices tool kit, available free to all physicians, is organized into nine chapters that can be read sequentially or on an as-needed basis. Download the tool kit today. Contact CMA’s reimbursement helpline at (888) 401-5911 or [email protected].

webinarscheduleCMA offers a wide variety of webinars,

both live and recorded, to help you address crucial health care issues and mange your practice. Registration is free for members and their staff. Space is limited, so register soon. Visit the CMA calendar at www.cmanet.org/calendar/ for more information. Most webinars are available for on-demand playback shortly following the live presentations in the webinar archives at CMA’s members-only website.

For more information, contact Shan-non Navarra-Lujan at the CMA at (800) 786-4CMA or [email protected] .

medicare reimbursementassistance

Palmetto is offering helpful webinars on Medicare reimbursement. Go to www.palmettogba.com/j1 and then click on Learning & Education in the tool bar for a choice of workshops, contractor teleconferences, and more.

Membership Matters

cian peers and members of the San Fran-cisco Medical Society.

Let us know you’re coming! Please rsvp by Tuesday, November 17.

Contact Therese Porter in the Mem-bership Department at (415) 561-0850 ext. 268 or [email protected] to RSVP or learn more.

bestPractices:PerforminganeHrNeedsassessment

Selecting and implementing an elec-tronic health record (EHR) system is one of the most complex and resource-intensive activities a medical practice can under-take. Before taking on this challenge, it is important for you to assess your EHR needs, with an eye for what will work best for your specialty, the size of your practice, the stage in your career, and your comfort level with technology.

Chapter 7 of CMA’s Best Practices tool kit will show physicians how to perform an EHR needs assessment and create a road map for the EHR selection and implementation process. CMA published the 140-page Best Practices tool kit with generous support from the Physicians’ Foundation to help physicians improve the efficiency, and in turn the quality, of their practices. In addition to helping you learn how to perform an EHR needs assessment, the tool kit will teach you how to find and keep qualified staff; how to build a defensible fee schedule; when

report from the sfms HealthinformationTechnologymeeting

On October 22 the San Francisco Medical Society hosted an informational session on Health Information Technol-ogy at CPMC. Dr. Paul Tang addressed a very full, attentive crowd from all over the city. Dr. Tang is chief medical information officer for the Palo Alto Medical Founda-tion, vice chair of the Federal HIT Policy Committee, and co-chair of the California HIE Advisory Board. In addition, Dr. Tang is a Board Certified Internist, an associate professor at Stanford University, and an electrical engineer. He explained to the room that the United States spends more on health care ($6,102 per person) than Canada ($3,165) or Japan ($2,249) and that our mortality is greater than all other countries except Finland (due to their high suicide rate). With many of the “baby boomers” reaching sixty-five by 2011, Medicare will likely be bankrupt by 2017. This over sixty-five population will double by 2030. In February President Obama mandated that to achieve improved out-comes all patient health records must be electronic (EHR) by 2014 with penalties in payments to non-compliant eligible professionals by 2015. The National pri-orities of this system are to improve the quality and safety of patient care, to en-gage patients and their family by provid-ing access to specific health information with progress notes for each encounter, to improve care coordination and public health of the population—all this within a framework of privacy and security protection. There ARE $39 million dollars available to get the systems installed in California. The vendors of EHR systems, their fees and ongoing support, are a key issues. The San Francisco Medical Society is working with the California Medical Association on these issues. In addition the SFMS is working with local hospitals, clinics, medical groups, the public health department and physicians to develop a Health Information Exchange (SFHEX)as a means of securely exchanging health care data across disparate entities.

—Nancy Thomson, MD

2009-10 SFMS Directory and Desk Reference Available Now!

This important and trusted healthcare resource contains a comprehensive listing of SFMS Members with their specialties and contact information. It is also packed with helpful resources that no medical o�ce should be without!

SFMS Members receive one copy free as a membership bene�t; additional copies are only $45 each. Nonmembers pay $75 per copy.

Order your copy today! Contact Carol Nolan at (415) 561-0850 ext. 0 or [email protected]. SFMS

Interested in advertising in next year’s Directory? For more information contact Jonathan Kyle at (415) 561-0850 ext. 240 or [email protected].

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Charles J. Wibbelsman

President’s Message

A s you will see in the following pages of our journal this month, there are many well-written articles submitted from the 2009 Ethnic Physician Leadership Summit

recently convened in September in Santa Clara by the California Medical Association (CMA) Foundation and the Network of Ethnic Physician Organizations.

When one considers the topic of diversity in medicine, there are many different levels of thought that come to mind. Often, as a physician, one first contemplates the diversity in race, ethnicity, and cultural backgrounds that our physician colleagues bring to their own unique practice of medicine. Indeed, the San Francisco Medical Society, in our 140-year history, reflects the diversity of our city and county in our membership and the leadership of our elected Board of Directors, our Executive Board, and past presidents.

I am honored to follow such outstanding previous presidents as Rolland Lowe, MD, who was born in San Francisco’s Chinatown and not only served as the first Asian American president of the SFMS in 1982 but also joined the California Medical Association’s Board of Trustees, and then was elected president of the CMA in 1997. During his tenure as CMA president, Dr. Lowe gave minority physicians a place at the table, creating a voting section for ethnic physicians with the CMA. He later helped start the Network of Ethnic Physician Organizations to address disparities in health care.

Another former president, Xavier Barrios, MD, not only headed up the SFMS in 1972 but today is still in practice at St. Luke’s Hos-pital and is a strong advocate for Hispanic patients. We also have had many women take the helm of leadership in this Medical So-ciety. In 1960 Roberta Fenlon, MD, was our first woman president; Judith Mates became our first Chinese American female president in 1995. Some of most recent presidents include Ann Myers, MD, in 2004 and Rita Melkonian, MD, in 2003—both of whom have inspired me and been my mentors. Our diversity has also embraced sexual orientation, including openly gay and lesbian members of our Board of Directors, some of whom have served and are now serving as presidents.

Yet not only as president this year but as an active member of the Medical Society for the past fifteen years, I am acutely aware that, in many ways, our organization could reach out to more members. Long gone are the Board of Directors meetings where everyone was a white, heterosexual male in a suit and striped tie;

still, as president, I would like to realize and welcome more African American physicians, more physicians with diverse Hispanic back-grounds, and other members of differing cultural and ethnic back-grounds into the Medical Society and on our Board of Directors.

Diversity in medicine also means, poignantly, the diversity of the patient population whom we care for in our everyday practices and how we relate to patients of the same race and ethnicity and, in particular, those patients of a different race and ethnicity who speak another primary language than our own. Communicating with and understanding the culture of these patients from a differ-ent background presents us with many challenges in our practice of medicine. San Francisco, as a city and county offering medical care, does a yeoman’s task of reaching out to and offering cultur-ally competent and language-specific services to our patients. In the past ten years, many of our health care delivery systems in this city and county have developed patient education materials now printed in Spanish, Chinese, and other languages so that our patients can understand their own health just as well as a white English-speaking patient can. Many hospitals and medical offices in San Francisco have on-duty interpreters and now telephone access to interpreter services for all languages. Being president of the San Francisco Medical Society has given me an opportunity to represent the Medical Society in many different forums. Most recently, last year’s president, Steve Fugaro, MD, and I were invited to attend a focus group of health care providers by the Hepatitis B Free Coalition. After the session was well underway, I became acutely aware that many physicians and health care providers in San Francisco are not routinely screening patients born in China for the hepatitis B surface antigen. I became aware that we as physi-cians must embrace the diversity of our patient populations, their needs, and what screening and preventative medicine they deserve. As a physician in adolescent medicine, I routinely perform a urine screen for chlamydia on all sexually active adolescents. I truly wish that all of my colleagues who care for adolescent patients would also embrace the diversity of sexual activity among teens.

We, as physicians, have a long way to go to fully meet the challenges that diversity presents among us, and in meeting the diversity issues of our patients; but we have made some giant leaps thus far. We need to do continue to take big steps in the future, in order for all of us to be better doctors.


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Editorial

Dharma, Genius, and Diversity

Mike Denney, MD, PhD

program in Culture and Medicine and holds regular sessions in Perspectives of Difference. In government, the U.S. Depart-ment of Health and Human Services now has Minority Health Resource Centers serving indigenous Americans, and private entities such as the Transcultural Nursing Society and National Medical Association promote equality in healing for various groups. These and a host of other organizations across the country are devoted to fairness, equality, and excellence in medical care.

In this issue of San Francisco Medicine, we offer some of the ideas presented at a recent gathering of the forty groups in the Network of Ethnic Physician Organizations in California, a project of the California Medical Association Foundation that addresses health disparities of diverse populations, diversity in the workplace, access to medical care, and cultural competency at the local community and state levels.

If we focus again upon the individual, we may find an even more compelling reason to honor diversity in medicine. We may notice that in myths and fairy tales it is often the different “other” who provides the essential wisdom for the fulfillment of the story. The Little Prince brought his wisdom from another planet. Humpty Dumpty introduced new language to Alice inside her looking glass, Jack and his extraordinary bean stalk led us to a world of giants and magic harps, and the cackling wise crones always showed the lost children the way out of the deep, dark forest.

Yes, if we value our differences and tend diversity in medi-cine we may not only achieve affirmation, equal opportunity, and better health care for all, but our hospitals, clinics, offices, and, indeed, our communities can become enriched by the unique gift brought by each human being, no matter how “different” she or he may seem.

In his book I and Thou, the twentieth-century philosopher and mystic Martin Buber put it this way: “We gaze toward the train of the eternal You; in each we perceive a breath of it; in every You we address the eternal You.” Thus we may offer the ultimate expression of diversity when we cherish and honor the dharma, genius, and divine child in each and every one of us.

A mong some Eastern African peoples, an ancient ritual around childbirth was practiced. When a pregnant woman came near to term, the members of the com-

munity gathered around her to celebrate. After fires were lit, dances were performed, and the ancestors were called in, the elders encircled the woman to welcome the unique gift that this child would bring to enhance the future of the tribe.

This image of the divine child has manifested itself in cul-tures throughout the world. In Buddhism, the idea of dharma signifies that each individual is born with inimitable talents that, with the right practice, can be actualized during a lifetime; and in ancient Greece the word genius applied not only to those whose life work coincided perfectly with their god-given talents but meant that every single human being had a unique genius and thereby brought a distinctive offering to the world.

As in this issue of San Francisco Medicine we explore the notion of diversity in healing, as we pay attention to the special needs and qualities of both caregivers and patients in a diverse population, might these concepts of dharma, genius, and the divine child offer deeper meaning?

The idea of diversity has evolved naturally in the United States, this land of immigrants and opportunity. The twenti-eth century brought sweeping new ethics, politics, and social changes through affirmative action and equal opportunity em-ployment, which resulted in a democratic culture more inclusive of all diverse people regardless of ethnic, racial, gender, age, sexual-orientation, religious, physical, and mental differences. Today, at all levels of government, business, and education, di-versity programs promote the rights, privileges, and talents of a diverse population by educating managers and implementing the high ideals of liberty and justice for all.

In medicine, the variables in diversity seem even more important since they are pertinent not only to equality among disparate populations but, indeed, are essential to health and well-being, even life and death, of individuals. Research centers such as the Center for Cross-Cultural Health at the University of Minnesota and the Center for the Study of Race and Ethnicity in Medicine at the University of Wisconsin are actively assembling data that are essential to understanding the special health needs of various groups.

The University of California at San Francisco has an active


Joseph R. Betancourt, MD, MPH

Eliminating Racial and Ethnic Disparities in Health Care

I n the latter half of the twentieth cen-tury, this country has witnessed dra-matic improvements in health due to

initiatives in health promotion and disease prevention. Our ability to detect and treat medical conditions in their early stages has been the hallmark of this progress and has allowed us to prevent premature and costly morbidity and mortality. Despite interventions that have improved the overall health of the majority of Ameri-cans, racial and ethnic minorities have benefited less from these advances. Data from the National Center for Health Sta-tistics has consistently shown that racial and ethnic minorities suffer worse health outcomes from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others. There is no doubt that these disparities in minority communities are linked to the adverse impact of social determinants—such as lower levels of education, poor housing, unemployment, and overall low socioeconomic status—on health outcomes. Similarly, lack of insur-ance or access to medical care clearly contributes to poorer health status.

However, evidence suggests there are the racial/ethnic disparities in qual-ity of care for those with access to the medical system. These disparities have been shown to exist in the use of cardiac diagnostic and therapeutic procedures; prescription of analgesia for pain control; surgical treatment of lung cancer; referral to renal transplantation; treatment of HIV, pneumonia, and congestive heart failure; and the use of general services covered by Medicare (such as immunizations and mammograms). Countless studies have documented racial/ethnic disparities in

the diagnosis and treatment of various conditions, even when controlling for socioeconomic status, insurance status, site of care, stage of disease, comorbidity, and age, among other potential confound-ers. In fact, some seven years ago now the prestigious Institute of Medicine (IOM) released its landmark report, Unequal Treatment: Confronting Racial/Ethnic Disparities in Healthcare, cementing this issue into the health care community’s consciousness.

Since this time, we have also been able to understand the impact of dis-parities on quality, safety, and cost. For instance, research has shown that mi-norities and patients with limited English proficiency suffer from more medical errors with greater clinical consequences while hospitalized than do their white counterparts, have longer lengths of stay for the same clinical condition, are more likely to have preventable hospitalizations, and are more frequently readmitted for chronic conditions (such as congestive heart failure) than their white peers. Just last month the Joint Center on Political and Economic Studies, a Washington think tank, in collaboration with Johns Hopkins University and the University of Maryland, released a report highlighting that racial inequalities in health care access and quality added more than $50 billion a year in direct U.S. health care costs over a four-year period. Furthermore, they found that more than 30 percent of direct medi-cal expenditures for African Americans, Asian Americans, and Hispanics were excess costs linked to health inequalities. Between 2003 and 2006, these excess costs were $229.4 billion, and the indirect costs of racial inequalities associated with

illness and premature death amounted to more than a trillion dollars over the same time period. Similarly, the Urban Institute calculated that if African Americans and Hispanics suffered from diabetes, hyper-tension, stroke, renal disease, and other ailments at the same rate as whites, the U.S. health care system could save $23.9 billion this year. Over a ten-year span, health disparities will cost Medicare, Medicaid, private insurance companies, and individuals $337.4 billion.

What does this mean for health care? Clearly, the IOM report Unequal Treatment has had and will continue to have a great impact on how we adapt our health care systems to assure that we deliver the highest quality of care to any patient we encounter, regardless of race, ethnicity, culture, class, or language proficiency. The key lesson is that eliminating racial and ethnic disparities shouldn’t be an “add-on” to the long list of competing interests we face every day. On the contrary, efforts to eliminate disparities are central to quality improvement and should be integrated into all such endeavors. This includes activities to promote efficiency, effective-ness, patient safety, patient-centeredness, timeliness, and equity—the pillars of quality health care laid out by another influential IOM report, Crossing the Quality Chasm. We can invest now and integrate this work into the quality portfolio, or pay dearly later.

Ultimately, having a greater under-standing of the root causes of disparities should allow us to intervene accordingly, whether in our roles as executives, ad-ministrators, managers, opinion leaders, teachers, or caregivers. In the clinical

improvingQualityandequality


Continued on page 12 . . .



A migrant farmworker spends all day picking fruits and veg-etables to feed our nation, but he

lacks food security to feed his own family. An elderly Hmong grandfather sacrificed his homeland to protect our nation but cannot speak to his own doctor due to the lack of an interpreter. A black professor teaches our nation’s college students but waits years longer than his white coun-terpart for a kidney transplant.

Our country prospers on the hard work and dedication of our rich cultures and diverse traditions. However, our current system discriminates against citizens based on education, race, ethnic-ity, geography, and socioeconomic status. For a country that values progress and innovation for the future, millions of its citizens lack access to basic preven-tive and primary health care services. Health disparities are a reality in the United States. As doctors, we can make a difference in addressing these health disparities through advocacy, community involvement, and cultural competency. Health disparities must be addressed in medical schools by increasing diversity within the student body and by educating medical students regarding health care disparities. Through my experience, I have learned about health care disparities and the importance of diversity in medi-cal school.

How can we improve care among high-risk populations, such as migrant farmworkers? Since 2000, I have volun-teered at a student-run free clinic called Clinica Tepati. For more than thirty years, Clinica Tepati has provided care for un-insured patients from the Sacramento area. Mexican-American undocumented

immigrants make up the majority of our patient population. We provide culturally sensitive medical services, such as inter-preters and health education workshops in Spanish with culturally modified physi-cal activity and diet suggestions. When we see overweight diabetic patients, telling them to exercise is not enough. What if the patient can’t afford a gym membership, does not live in a “walkable” neighborhood, or doesn’t believe that being overweight is unhealthy? Telling the patient to eat healthier foods is not enough. What if the patient doesn’t cook for the family, can’t afford fresh fruit and vegetables, or prefers traditional cultural foods? Telling the patient to comply with treatment is not enough. What if the pa-tient has no insurance or is underinsured to pay for prescriptions and procedures, prefers alternative healing methods, or doesn’t understand the purpose of the medications? Getting to know your pa-tients, their beliefs, their lifestyles, and their resources serves as an important asset in providing quality health care for underserved communities. On a com-munity level, physicians can advocate for healthy school lunches, sidewalks in low-income neighborhoods, safe playgrounds, affordable fruits and vegetables in local supermarkets, healthy cooking prepara-tion for cultural foods, and traditional healers as partners in care.

How can health care disparities be addressed? Prior to medical school, I con-ducted a research project in Fresno among diabetic patients. I met an elderly African American patient who was a professor. He had been on dialysis for more than ten years due to diabetic nephropathy and was waiting for a kidney transplant. In a

literature review, I learned about racism and discrimination in medical care from the publication Unequal Treatment from the Institute of Medicine. When educa-tion and socioeconomic status were con-trolled, significant differences between racial/ethnic groups existed in the quality of medical care. My own patient is one of many African American patients waiting longer for organ transplants compared to whites with similar socioeconomic back-grounds. Does it matter that your patient has insurance? Yes. Does it matter that your patient has a college degree? Yes. Does the race/ethnicity of your patient matter? Yes. In the United States, your patients’ racial/ethnic background influ-ences the quality of care that they receive. Through racial/ethnic bias competency workshops and educational programs, physicians ensure the highest quality of medical care for patients, regardless of their skin color.

How can physician diversity improve health care disparities among under-served populations, such as the Hmong community? During my summer precep-torship, I had the opportunity to work with primary care providers in a feder-ally qualified health center. My preceptor shared a friendly, caring relationship with his patients and their families. But in ad-dition to cultural differences, a language barrier further distanced me from my pa-tient. With non-English speaking Hmong patients, we used the telephone language interpreters due to the lack of any other kind—although sometimes we were able to call on another family member to serve as the interpreter. A diverse, professional workforce is needed to provide qual-

diversityinmedicine

Tonantzin Rodriguez, MPH

A Student’s Perspective


Continued on the following page . . .


ity communication and medical care for patients. Most medically underserved areas in the United States have diverse communities. In the medical field, many populations are underrepresented, in-cluding the Hmong, Mexican-Americans, African Americans, and Native Americans.

How do we increase diversity in the health field? Disparities among under-served populations are not limited to health care but also extend to education. Latinos consist of nearly 40 percent of the population in California. However, only 13 percent graduate from college. During an outreach experience for the Latino Medical Student Association, we visited my hometown to talk to students about college. Ella Elementary School consists of predominantly Mexican and Hmong low-income students. On the first visit, we asked, “What do you want to be when you grow up?” Nearly all the girls said, “A mommy.” The students didn’t know anyone who went to college. More than 60 percent of the population has not graduated high school. The teach-ers face limited financial resources and language and cultural barriers when dealing with students’ families. The high school offers few advanced placement courses and guidance counselors encour-age vocational work more than college admissions. Most students have at least one part-time job to help contribute to the family’s expenses. This community re-flects the adversity of low-income, diverse students. These students must compete with students from well-resourced school districts, highly educated families, and ac-cess to many advanced placement college preparatory courses. Increasing diversity in medical school means increasing diver-sity at the college level. Diverse students from low-income communities are not on equal playing ground academically, when compared with students from higher socioeconomic classes. The pipeline of mentorship must begin at the elementary school level. After our yearlong outreach activity, we asked the students again, “What do you want to be when you grow up?” This time, they said, “A doctor.”

How do we address diversity in medical school? Though cultural sensitiv-ity and patient communication classes exist, these workshops hold significantly less priority than the core medical sci-ence courses. Sessions are sporadically held at the end of a busy school day. At U.C. Davis, the Family and Community Medicine Department strongly supports educating students on underserved popu-lations. Lunchtime electives are offered on underserved communities, or students may enroll in a clinical elective to spend time at the free clinics on weekends. In addition, weekend conferences and eve-ning seminars provide an opportunity for students to learn more about diversity and disparities. However, most activities are optional and only attract interested students. Others continue their medical career with a strong emphasis in diagno-sis and treatment instead of communica-tion and advocacy.

Through medical school, I have learned about health care disparities and the importance of diversity. The status quo is not good enough. As doctors, we can make a difference in addressing these health disparities through advocacy, com-munity involvement, cultural competency, and diversity. Health care disparities will cease to exist when the migrant farm-worker has access to healthful food, the Hmong grandfather can speak to his doc-tor, and the African American professor receives a kidney transplant.

Tonantzin Rodriguez, MPH, is a sec-ond-year medical student at U.C. Davis Medical School and participated in the medical student panel during the 2009 Ethnic Physician Leadership Summit.

encounter, for example, Unequal Treat-ment tells us that poor cross-cultural communication between provider and patient (including due to language barri-ers), stereotyping of patients by provid-ers, and patient mistrust all contribute to racial/ethnic disparities and lower quality care. Needless to say, disentangling and addressing the multifactorial and com-plex causes underlying racial and ethnic disparities is extremely challenging. The literature is expansive but, as one might expect, imperfect, given how difficult it is to study these issues in a clear and simple fashion. Actors within the health care system hold steadfast to their specific perspectives on the causes of disparities and strategies to eliminate them. Yet all agree that something must be done to ad-dress this national problem. Measurement of our progress to eliminate disparities is equally difficult and challenging, yet absolutely required if we are to chart our movement and document our successes. If true quality improvement in health care is our goal, the elimination of racial and ethnic disparities will surely follow.

In this time of great debate about health care reform, we need to consider how we can make our health care system more equitable. Not only do we need to increase access to health care and provide stability to those who have health care coverage, but we also need to assure that everyone benefits equally from what we have to offer—thus truly achieving equity in health care. This is certainly no easy task, but as we approach this historic mo-ment, we have the opportunity to rewire our health care system so that is respon-sive to the needs of all patients and truly delivers on its promise of quality. As health care providers, we can certainly make a difference through our words, activism, action, and deeds, helping create a new, equitable, efficient, and effective health care system for the next century.

Joseph R. Betancourt, MD, MPH, is director of the Disparities Solutions Center at Massachusetts General Hospital and is assistant professor of medicine at Harvard Medical School.

Improving Quality and EqualityContinued from page 10 . . .

Diversity in MedicineContinued from the previous page . . .



A Report on California

Elizabeth Fernandez

A study on physicians in California shows a glaring gap between the number of doctors of color com-

pared with the state’s ethnically diverse population, especially among African Americans and Latinos.

At the same time, the state has a disproportionate number of Asian and white doctors, according to the UCSF study, which focuses on doctor ethnicity and language fluency.

It found that out of nearly 62,000 practicing doctors in California, only 5 percent are Latino even though Latinos comprise a third of the state’s total popu-lation. Only 3 percent of doctors in Califor-nia are African American, compared with 7 percent of the state’s overall African American population. While Latinos and African Americans make up about 40 per-cent of the state’s residents, fewer than 10 percent of California’s doctors are African American or Latino.

The disparity is particularly alarming because minority physicians are far more likely to practice primary care medicine and work with poor or uninsured pa-tients in rural areas, inner cities, or other communities with a chronic shortage of physicians.

“This is a critical public health issue,” said Dr. Kevin Grumbach, director of the UCSF Center for California Health Work-force Studies, which released the report Wednesday. “These patterns are real. The problem is even worse than we thought.”

In a state with more than 35 million people, fewer than 3,300 Latino and only about 2,000 African American physi-cians are in “active patient care,” said Grumbach.

“It brings the numbers home in a

concrete and stark way,” he said.The health profession has long

bemoaned the poor representation of minorities among physician ranks, a dis-parity wrought in part by a lamentable legacy of discrimination that included segregated educational practices. But this report is the first to analyze the phy-sician workforce in California based on data compiled by the California Medical Board. The data was mandated by a 2001 state law requiring the board to gather information based on factors including doctor specialties, ethnicity, and lan-guages spoken.

The report found that whites make up 61 percent of the state’s doctors while the white population is just under 48 percent. Asian and Pacific Islander doctors comprise 26 percent of the phy-sician workforce while the state’s Asian population is about 11 percent. That category includes doctors who say they are Chinese, Indian, or Filipino.

“It is cultural,” said Dr. Satinder Swa-roop, chair of the California Medical As-sociation Foundation’s Network of Ethnic Physician Organizations, during a news conference Wednesday at the U.C. Davis School of Medicine.

“Asian families push their children,” said Swaroop, who practices in Southern California. “Five people in my family are doctors. Part of it is we feel it is the field to go to.”

Yet within the Asian-doctor category, there is a troubling shortage of Samoan, Cambodian, and Hmong doctors, the re-port found, decrying the overall pool of doctors statewide as inadequate.

The ethnic gap is just as acute in the Bay Area, where a fifth of the general population is Latino, compared with less than 4 percent of the doctor popula-tion. The Bay Area’s African American population is just over 7 percent while the number of African American doctors is just under 3 percent.

Besides English, Spanish is the lan-guage most commonly spoken by Cali-fornia’s doctors—about 18 percent said they speak Spanish fluently.

Medical experts at the news confer-ence stressed that ethnic diversity is directly tied to better access and quality of health care for disadvantaged patients.

Dr. Henry Watson didn’t attend the session, but he has long known the lesson. A second-generation African American physician in Oakland, he has been an anomaly much of his life. So, too, was his father, James, who was refused medical privileges at some local hospitals when he first hung his shingle in Oakland in the mid-1950s.

“I crawled on the floor of my father’s medical office when I was a baby,” said Watson. “It was my life’s dream to become a doctor and work with my father.”

After graduating from medical school and completing his residency at UCSF,

minoritydoctorsinshortsupply


“The disparity is alarming because minority physicians are far more likely to practice primary care medicine and work with poor or uninsured patients . . .”

Continued on page 15 . . .



Satinder Swaroop, MD

2009 Summit Focused on Health Care Reform and Strategies for Change

H ealth disparities and health policy, impact on quality care of health IT and the stimulus pack-

age, and inspiring messages of hope and determination from medical students. These are just some of the highlights from the California Medical Association (CMA) Foundation and Network of Ethnic Physician Organizations (NEPO) 2009 Ethnic Physician Leadership Summit, held September 26–27 in Santa Clara. In attendance were medical students, community health advocates, health care professionals, and policymakers such as Congressman Mike Honda of the Fifteenth Congressional District and Assembly-woman Fiona Ma of the Twelfth Assembly District of California.

Joseph R. Betancourt, MD, MPH, di-rector of the Disparities Solutions Center at Massachusetts General Hospital and as-sistant professor of medicine at Harvard Medical School, kicked off the summit by presenting an overview of the health disparities in minority populations in the United States. Dr. Betancourt stated, “My goal every day is to figure out how I can get everybody to take one step forward on this issue, to assure we can achieve equity in the health care system.”

An Unprecedented Opportunity: Federal Stimulus Funds Advancing Health IT in California was presented by Mark Smith, MD, MBA, chief executive officer of the California Healthcare Foundation. Diversity in Clinical Trials addressed the gap that exists with communities of color in clinical trials, while Politics 101 reminded ethnic physicians about the importance of participating in public health policy efforts.

Dr. Guillermo Valenzuela, MD, was

presented the 2009 Ethnic Physician Leadership Award for his outstanding leadership in efforts to send Inland Em-pire students to college. “I am so honored to receive this award,” said Valenzuela, chair of Women’s Health at Arrowhead Regional Medical Center in Colton. “It is my hope that this will bring attention to the need for greater investment in the futures of students across the state.”

The California Medical Association Foundation, in conjunction with the Net-work of Ethnic Physician Organizations (NEPO), designed the Ethnic Physician Leadership Summit program to serve as a vehicle to continue the organizational development and strategic planning for NEPO; establish a process and structure for public policy advocacy for NEPO (in-clusive of the development of the capac-ity to identify, analyze, track, and reach consensus on key public policy issues); to work with partner advocates, policy makers, and other coalitions; to serve as

an information clearinghouse and com-munications conduit on policy issues for ethnic physicians and their organizations; and to facilitate the collaboration of ethnic physicians across projects within NEPO.

The 2009 Ethnic Physician Leader-ship Summit is sponsored by the Califor-nia Wellness Foundation, the California Endowment, United Health Foundation, Genentech, the Doctors Company Foun-dation, P&G, Pfizer, the Office of Minority Health, HealthNet, California Smoker’s Helpline, the Health Professions Educa-tion Foundation, and Fluency, Inc.

A project of the CMA Foundation, NEPO is a coalition of more than forty-one ethnic physician organizations through-out California. As these leaders from the Chinese, Peruvian, Vietnamese, Latino, East Indian, Filipino, Korean, and African American medical associations coalesced around a unified message, the creation of NEPO was set in motion. No longer would ethnic physicians allow critical decisions

ethnicPhysicianLeadershipsummit



Watson achieved that dream, joining his father’s North Oakland practice in 1985. The elder Watson died last year, but his son continues his mission of providing quality medical care to many of Oakland’s poor residents. For a decade, he has trav-eled with a mobile clinic.

“There are higher incidences of cer-tain diseases in people of color,” he said. “Doctors of color work hard to screen for those kinds of diseases.”

In two weeks, he plans to launch a special, county-sponsored program—on Fridays he’ll treat only indigent patients.

“It took me twenty years to get it,” he said ruefully. “I could be in a high-rent district, but I believe in working in the community that needs me, in the com-munity that brought me up. This is what I live for.”

that impact the health of their communi-ties to be made without ethnic physicians at the table. The project, established in 2002, is designed to identify strategies for building the capacity of ethnic physi-cian organizations. As a result, physicians are able to reduce health disparities and improve access to health care for their communities through increased col-laboration with community organizations and through policy advocacy in both the public sector and in organized medicine, as well as addressing cultural competency and diversity in the health care workforce. For more information about NEPO or the Ethnic Physician Leadership Summit, visit www.ethnicphysicians.org or contact [email protected].

Satinder Swaroop, MD, is the steering committee chair of the Network of Ethnic Physician Organizations.

report’srecommendationsThe UCSF report included the fol-

lowing recommendations for solving the ethnicity gap among doctors:

• Invest in the educational pipeline preparing minority and disadvantaged students for careers in medicine and other health professions.

• Promote diversity as a key part of expanding California medical education.

• Hold health professions schools accountable for an institutional culture and environment that promotes diversity, recruitment, and retention of underrep-resented minorities.

• Increase incentives for physicians to work in underserved communities in California.

Elizabeth Fernandez is a staff writer for the San Francisco Chronicle. This ar-ticle, from April 2008, is reprinted with per-mission from the San Francisco Chronicle.

Minority Doctors in Short SupplyContinued from page 13 . . .

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Randal Pham, MD, FACS

Highlights from the Ethnic Physician Leadership Summit Politics 101 Workshop

D uring the Politics 101 work-shop at the Ethnic Physician Leadership Summit, physician

attendees were asked to sit back and think of themselves as patients sitting in a doctor’s office. What would they want from their doctors? How would they want to be treated? What would they expect from their health providers as they are empowered with the tools to effect health care reforms? It was within this framework that I defined public policy and discussed how they can participate in the public policy process.

The results of a 2009 public policy survey conducted by the Network of Eth-nic Physician Organizations, a consortium of forty-one ethnic physician organiza-tions, was presented. One hundred and one physicians responded to the survey. The survey revealed that access to health care is the number-one concern to both ethnic and nonethnic physicians. Health care reform was ranked second by the ethnic physicians, whereas health and health care disparities were second for the nonethnic physicians. Other issues of concern were cultural and linguistic competency, workforce diversity, obe-sity prevention, and physician work-force. Most responders came from two counties in California, Alameda and Los Angeles, but every county in California was represented. This survey was used to help prioritize public policies that are pertinent to physicians of color.

I introduced the audience to the Eth-nic Medical Organization Section (EMOS) of the CMA. In 1997, the California Medical Association established EMOS as a section to represent the ethnic physicians who are members of CMA. EMOS is dedicated

to representing the unique perspective of physicians of color and to facilitating com-munication and participation between physicians of the diverse ethnic groups in California. EMOS also provides a forum with CMA through which to resolve the unique concerns facing communities of color, promote nondiscrimination at all levels of medicine, and promote qual-ity and culturally sensitive medical care. EMOS as an organization is represented in both the CMA House of Delegates and the CMA Board of Trustees to effect change within the house of medicine that benefits physicians of color.

During the workshop I also described the process through which an issue of concern to ethnic physicians can be con-ceived and turned into concrete change in the form of legislation or legal action, as in the case of the injunction by a federal judge to stop the 10 percent MediCal cut in 2008. I urged ethnic physicians and nonethnic physicians who are interested in serving the ethnic communities to join EMOS and participate in the Annual Legislative Briefing, the CMA Legislative Day, and the NEPO/EMOS Legislative Day.

Tom Riley, director of Government Relations of the California Academy of Family Physicians, also pointed out that we are living in a very exciting time. He stated that in his twenty-seven years as a lobbyist, he has never before encountered an opportunity to effect change in health care of this magnitude. Mr. Riley reported that, based on a survey he conducted, the public perceives the U.S. health care system as an automobile that is “very ad-vanced,” “very expensive,” “not everybody can use it,” with “lots of moving parts,” and “if you get in a wreck, you die.” According

to the public, the U.S. health care system is inaccessible, unsustainable, and of dubious quality. These are the reasons used by various groups in Washington to justify sweeping reforms of the health care system.

Given the size and complexity of HR 3200, Mr. Riley suggested that the attend-ees pick three things from HR 3200 that they think that are of utmost importance and use advocacy strategies to voice their concerns. Mr. Riley highlighted the CMA’s support for coverage expansions, insur-ance market reforms, nearly $400 billion in physician payment fixes, and elimina-tion of the current sustainable growth rate formula and MediCal rate increase. He also reasserted the CMA’s opposition to reduced payment for imaging services, the ban on physician-owned hospitals, provisions allowing nurse practitioners to run medical homes, and regulations forcing physicians to accept a public plan.

Attendees were urged to be actively involved by contacting and maintaining relations with their senators and repre-sentatives in Congress.

Randal Pham, MD, FACS is an oculo-plastic surgeon practicing in San Jose and is the chair of the Ethnic Medical Organi-zation Section (EMOS) of the California Medical Association. He is also a member of the Vietnamese Physician Association of Northern California.

Politics101

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Owen Garrick, MD

An Important Consideration

P harmaceutical and biotech com-panies are facing more stringent requirements surrounding effi-

cacy and safety on new drug applications, particularly as they relate to minority populations and women. African Ameri-cans and Hispanics represent the largest minority subgroups in the United States, and they are disproportionately and more severely affected by disorders such as cardiovascular disease, diabetes, hyper-lipidemia, HIV/AIDS, asthma, obesity, and cerebrovascular disease. Comply-ing with the FDA guidelines regarding proportional inclusion of minorities and women in clinical trials has the potential for significant financial gain to pharma-ceutical companies as new products re-ceive quicker approval and are brought to market sooner. Further, the Center of Drug Evaluation and Research (CDER) notes that 4 percent or fewer of the participants in 2,500 clinical trials conducted between 1995 and 1999 were African American. This trend continues today, even though it has been well established that certain drugs are metabolized differently in Afri-can Americans and women. Thus, minor-ity inclusion in clinical trials also serves to improve health care for all Americans.

briefHistoryThe randomized clinical trial has

generally been accepted as the gold stan-dard to test new clinical interventions. For many years, the predominant participant in clinical trials was an adult, Caucasian male. Over the years there has been a growing body of evidence demonstrating the need to include minorities and women in clinical trial research studies. During the Clinton administrations of the 1990s

we saw the development of inclusion guidelines in clinical trials:

In 1993, the NIH Revitalization Act established guidelines for inclusion of women and minorities in NIH-sponsored clinical research, and the FDA allowed a “Refusal to File” if clinical trial analyses on gender and race were not included.

In 1997, the FDA Modernization Act directed development of gender and minority guidance.

In 1998, the FDA amended its regula-tions for New Drug Applications (NDAs) to require that sponsors present efficacy and safety data on subpopulations based on race and gender.

In 1999, population pharmacoki-netic (PK) guidance recommended the collection of population PK data to help assess safety in minority populations and suggested that industry conduct clinical studies in subjects representative of the population to be treated by the drug.

Interestingly, with a close read, one observes that there are actually diver-gent federal policies about the level of participation of racial and ethnic groups in government- and industry-sponsored clinical trials. The NIH guidelines have “teeth,” while the FDA policies are more suggestions for industry.

racial/ethnic differences indisease

Clinical trials have demonstrated ra-cial and ethnic differences in the pharma-cokinetics of certain drugs. Lim showed in 1996 the pharmacokinetic reasons for diversity of trials by examining the racial and ethnic variations in bioavailability for drugs that undergo gut or hepatic first-pass metabolism. Different ethnic and

racial groups have variations in protein binding, volume of distribution, hepatic metabolism, and renal tubular secretion.

These differences can also determine the biologic course of certain diseases in the face of active treatment programs. In other words, diverse patient groups receiving the same and recommended treatment protocol could have vastly dif-ferent health outcomes.

Additionally, it has been well estab-lished that environmental factors lead to increased severity of disease at time of diagnosis as well as increased predisposi-tion. These are underestimated contribu-tors to differences in outcomes.

From a policy perspective, one can choose to support either the environmen-tal or genetic determinants of drug treat-ment outcomes. From a matter of course, what is relevant to your patients is that drugs work for them and their families.

barrierstoovercomeIt has also been determined that a

major barrier to successful drug devel-opment has been finding appropriately trained and experienced clinical investi-gators who have access to specific patient populations required to adequately test a drug’s efficacy and safety. In this regard, African-American and Hispanic physi-cians represent an important source of new clinical investigators that have ready access to this highly valued clinical population.

There is significant data that points to the strong connection between the principal investigator and the patient. Multiple published reports show that mi-nority physicians are more likely to care

ethnicminoritiesinclinicalTrials

Continued on the following page . . .


in clinical trials. As that happens, we will have a true sense of drug efficacy that may impact dosing regimens and potentially improve health outcomes for all of our patients.

referencesCenters for Disease Control. MMWR

Morb Mortal Wkly Rep. 2004; 53:121-125.Gray B et al. Patient-physician pair-

ing: Does racial and ethnic congruity influence selection of a regular physician? J Comm Health. 1997; 22(4):247-59.

Johnson JA. Influence of race or ethnicity on pharmacokinetics of certain drugs. J Pharm Sci. 1997; 86:1328-33.

Kalow W. Interethnic variation of drug metabolism. Trends Pharmacol Sci. 1991; 12:102-107.

Komaroumy M et al. The role of black and Hispanic physicians in providing healthcare for underserved populations. N Engl J Med. 1996; 334(20):1305-10.

Lin KM et al. The evolving science of pharmacogenetics: Clinical and ethnic

for minority patients. Additionally, minor-ity physicians provide a disproportionate amount of care to minorities, the poor, and Medicaid recipients. Nonetheless, recruiting ethnic populations can be suc-cessfully achieved by all physicians, just as all physicians are capable of providing care to all ethnicities.

There have been many issues studied as to why ethnic minority patients have not participated more in clinical trials. From a practical perspective, I have found that the top two reasons that diverse patient populations do not participate in clinical trials are: They were not asked; They were not asked by their doctor.

That is not to say that issues of mis-trust, language, and economic constraints should be ignored. But the 80/20 rule likely applies in recruiting ethnic minority patients. I would surmise that the main reasons that most patients of any ethnic-ity participate in a study is that they were asked to in an appropriate way by the physician that they trust.

Note: While your practice may not have a large minority patient population, partnering with ethnic minority physi-cians is a means to gain access to those targeted ethnic patients for clinical stud-ies. I would not approach a colleague after you have received funding for a study to ask him or her to refer patients but rather would pursue a subinvestigator relation-ship that is more collaborative and begins in the early stages of study design or protocol review.

Basic statistical concepts will show that underrepresentation of racial and ethnic minorities in clinical research limits the applicability of trial results to diverse subpopulations. Yet the phar-maceutical industry, policy makers, and providers continue to operate in a system that produces the disparity in clinical trial participation. There are proven ways to gain access to diverse patient popula-tions. While it may not be as simple as the famous quote from the movie Field of Dreams, “If you build it, [they] will come,” with some effort and persistence more ethnic minorities will participate

perspectives. Psychopharmacol Bull. 1996; 32:205-17.

National Vital Statistics System—Mortality (retrieved from DATA2010 at http://wonder.cdc.gov/data2010).

NIDDK. Weight-Control Information Network. 2008.

Saha S et al. Do patients choose physicians of their own race? Health Aff (Millwood) 2000; 19(4):76-83.

Surveillance, Epidemiology, and End Results (SEER) Data. National Cancer Institute 2004.

Thom T et al. Heart disease and stroke statistics: 2006 update. Circulation. Feb. 14, 2006; 113(6):e85–e151

Healing Our Village (HOV) Clinical Research has established a network of lo-cal clinical research alliances that provide training and support to investigators as they successfully deliver patients to drug company sponsors in clinical trials. For more information, contact [email protected].

Ethnic Minorities in Clinical TrialsContinued from the previous page . . .

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J. Renee Navarro, Pharm D, MD

Addressing Current and Future Health Disparities

diversityatUcsf

T he University of California, San Fran-cisco, sits at the center of one of the most densely populated and diverse

U.S. cities. We are both a medical center and health sciences campus, so to effect true change in disparities in health care, we understand the importance of promoting diversity among faculty and staff who have direct patient contact as well as among our current and future scientists, clinical investigators, and educators. A diverse pool of scientists, for example, will provide perspectives that may increase our under-standing of health and disease patterns in communities defined by race, ethnicity, gender, sexual orientation, or age. They also may facilitate more diverse participation in clinical trials and research.

campus-widecommitmentWhile there has been a history of sup-

porting diversity at UCSF since the 1960s, leadership realized that establishing a culture of diversity must be embedded in every initiative across the campus, and it must start from the top. Nurturing diver-sity was adopted in 2007 as one of seven strategic directions outlined in the UCSF Strategic Plan, the product of extensive in-put from the campus community and com-munity partners. The plan specifically calls on UCSF to “continue to improve diversity of faculty, staff, students, and trainees to effectively establish a culture of diversity on the UCSF campus.”

The plan’s diversity goals include cre-ating a more diverse campus community, ensuring that UCSF continues to attract the best and most diverse candidates for all educational programs, and improving diversity among senior leadership. In ad-dition, UCSF’s newly appointed chancellor,

Susan Desmond-Hellmann, has stated her ongoing commitment to perpetuating a climate that welcomes and respects the contributions of all faculty, staff, students, and trainees.

In just two years, we’ve taken huge steps toward reaching our strategic goal. One major achievement has been em-powering someone to lead and oversee initiatives to enhance diversity among faculty, students, and trainees; ensure the advancement and timely completion of academically related diversity activities; and coordinate with relevant system-wide committees. My position as director of Academic Diversity was created in 2007. Its other activities include:

• Developing an academic database to track faculty searches, applicant pool demographics, national availability data, and current trends about existing faculty.

• Introducing a leadership develop-ment program for staff in management positions to build the pipeline for future UCSF leaders.

• Conducting an inventory of existing campus outreach programs designed to increase the pool of students, postdoc-toral scholars, and faculty from diverse backgrounds.

• Recommending improvements to UCSF outreach endeavors.

• Launching a diversity website with information and video profiles to help fos-ter appreciation for individual differences.

We embrace an inclusive definition of diversity—one that refers to the variety of personal experiences, values, and world views that arises from differences in cul-ture and individual circumstance. While UCSF reports on the number of women

and underrepresented minorities, the uni-versity and medical center are committed to increasing participation among all un-derrecognized groups irrespective of age, religion, language, abilities/disabilities, sexual orientation, socioeconomic status, and geographic origin.

cultivatingfutureLeadersIn addition to efforts focused on cur-

rent faculty, students, trainees, and staff, we’ve also charged each school at UCSF—the Schools of Dentistry, Medicine, Nursing, and Pharmacy—as well as the Graduate Division and UCSF Medical Center with identifying leaders who are responsible for addressing diversity opportunities unique to their schools while coordinating activi-ties with the director of Academic Diversity.

Each has developed outreach pro-grams designed to expose potential stu-dents from diverse backgrounds to their specialties and to help them consider medical or research careers. The results have been measureable: an increase in the number of underrepresented minorities in the schools’ classes and improved account-ability across the campus. In addition, pro-grams such as the Medical Center’s School at Work focus on professional development for employees who are part of the UCSF community and encourage them to con-sider careers as allied health professionals.

The long-term commitment of UCSF to enhancing, appreciating, and cel-ebrating the diversity of our campus community is thriving. A diverse health care workforce is a significant part of the solution to ending health and health care disparities, and we are prepared to continue to lead this effort.


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We are very fortunate at Chinese Hospital to have signed a couple of our number-one draft choices. Joining our staff this fall are oto-laryngologist Dr. Man-Kit Leung and urologist Dr. Wenwu Jin.

In addition to being a skilled surgeon, Dr. Man-Kit Leung is also the son of our own renowned Dr. Martin Leung. He comes to us with incredible credentials, including gradu-ating summa cum laude at Harvard College, a doctor of medicine from UCSF, ENT training at Stanford, and a rhinology and sinus surgery fellowship at Harvard Medical School. He will be splitting time in Chinatown and at his of-fice near St. Francis Hospital. He is joining the practice of Drs. Dexter Louie and Clifford Chew.

Dr. Wenwu Jin is another all-world physician. He holds a PhD in biophysics and bioengineering from Case Western University, where he also received his doctor of medi-cine. He completed his residency in urology at Baylor College of Medicine in Houston. His interests cover all major fields of adult urology, with special interests in minimally invasive laparoscopic and robotic surgeries. He is taking over the practice of Dr. Raymond Fay. Truly, “everything is bigger in Texas” ap-plies to Dr. Jin.

ClearVision mask changes the face of patient care, literally: When Jeanne Hahne, RN, began working in a burn unit, she was frustrated because patients would come in badly burned and in need of treatment and comfort. But because they were dressed in cap, gown, and mask, she found it hard to create an emotional bond with patients, because the mask obscured the face and created a distance. So she invented the ClearVision mask. It’s made of clear plastic and works just like a regular mask but with several important advantages: Improved com-munication. Patients can see your lips as you talk, and see facial gestures more readily. Health. The mask could also prove to be a better barrier. Patient safety. Communication problems are the number-one cause of medical errors in hospitals. Patient anxiety. Being in the hospital is already scary enough.

Health First, our specialized, multicultural health resource center at St. Luke’s, is being hon-ored for its health education work. San Francisco Health Plan presented Health First with the Award for Dedication to Health Care Service Delivery during a ceremony at Fort Mason on October 29. Health First is an ambulatory health resource center that serves as a hub of preven-tion, education, and care coordination activities in the neighborhoods surrounding St. Luke’s. San Francisco Health Plan is a city-sponsored health plan providing health insurance to more than 55,000 low-income San Franciscans.

Thanks to a generous sponsorship by CPMC Foundation, our Davies campus is now a member of Practice Greenhealth—a non-profit organization dedicated to reducing the ecological footprint of the health care industry. Membership will give CPMC access to education, networking, support, and technical assistance, helping us improve our environmental steward-ship. These services will be applied to all of our facilities as we work to “green” CPMC through initiatives such as waste minimization, reduction of toxic chemicals, and resource conservation.

Saint Francis Memorial Hospital can be de-scribed as a place where “cultures connect.” Our downtown location affords us the opportunity to serve every demographic, from the affluent on Nob Hill to the uninsured in the Tenderloin to the newly immigrated in Chinatown and Little Saigon. Our Emergency Department is often the first place an international tourist will turn to for medical care. When we opened our new ER in fall 2006, we made certain that patient rooms were predominantly private and that each room or bedside was installed with a CyraCom phone system so that we would have 24/7 translation services at our fingertips. We serve everyone side by side in our ER.

It is striking to see how over the past sev-eral decades our workforce (doctors and hos-pital staff) have become as culturally diverse as our patient population. We rely heavily on our certified translators and our interdisciplinary team to assess cultural issues as they are related to the patient’s medical care, especially issues at end of life. Some challenges result from cultural differences between the patient’s beliefs and values and the practice of Western medicine. As practitioners we are wise to be aware of our own assumptions, beliefs, and values and know that they can impede our understanding of the patient’s needs. The most effective way to provide integrated care is to set aside our assumptions, seek to understand the patient, and meet them where they can understand the care that we can provide. We are fortunate to have the support of our Spiritual Care, Pal-liative Care, and Bioethics Departments in the accommodation of our beliefs and practices. On October 21, we happily celebrated the thirtieth anniversary of our Centers for Sports Medicine. At the celebration we unveiled the dedication of the Centers to honor sports pioneer and Medi-cal Director Dr. James Garrick. The program is now called the James G. Garrick Centers for Sports Medicine. Congratulations to Dr. Garrick and his outstanding sports medicine team.

Hospital News

cPmcDamian Augustyn, MD

chineseJoseph Woo, MD

saintfrancisPatricia Galamba, MD


It is important for every physician to recognize the signs of abuse. Primary care physicians are often the first professionals with an opportunity to identify victims of vio-lence. Patients who are abused may hide the cause of their injuries or emotional distress, and the physician must appreciate patients’ hesitancy in sharing this very private informa-tion. These patients may have been isolated by their abuser, and they may have told that no one but the abuser will love or help them. Patients may share their stories of abuse with their primary care physician but fear taking steps toward help. Furthermore, reporting abuse can have significant consequences in patients’ lives. It may affect their finances, their familes, and their children. As doctors, it is our duty to understand the anxieties our patients may encounter and then help empower them to make positive changes.

When a physician is confronted with a possible case of violence or abuse, the first priority must be the patient’s safety. What resources are needed? Does this situation require counseling, social workers, police pro-tection, or all of these? Psychiatric consultation can be invaluable, but unfortunately it may be necessary to help patients overcome barriers before they can receive this help. There is a common stigma associated with seeing a psy-chiatrist, and this may be particularly strong in some age groups and cultures. Once consulted, the psychiatrist can perform a risk assessment and can serve as a resource for primary care physicians, emergency physicians, and even the police, assessing a patient’s proximity to danger and helping patients help themselves.

As physicians, we can be the bridge to community resources available to abuse vic-tims. We need to be cognizant of the reporting requirements in some circumstances. First, however, we must be sensitive to the whole patient and see beyond the immediate pre-senting problem.

On September 14 the SFVAMC celebrated its seventy-fifth anniversary. A ceremony was held for patients and staff with Marvin Sleisen-ger, MD, distinguished physician and former chief of medicine; and Lloyd “Holly” Smith, professor emeritus, UCSF, providing remarks. Both are responsible for the establishment of the affiliation between the V.A. and UCSF. Also attending was Margaret Handlery, the great-granddaughter of Lt. Colonel John D. Miley, the man for whom the V.A. property is named. Construction of the hospital began in 1933 on land known as Fort Miley, formerly used as a defense battery. The original plans called for twenty-one buildings and a 500-bed hospital. It was architecturally designed in a California-Spanish-Mayan style at a cost of $1.25 million. The hospital opened in 1934 with twenty-five staff doctors and a distinguished group of con-sultants. In 1941, the Japanese attack on Pearl Harbor on December 7 led to immediate reac-tivation of the Fort Miley batteries. More than 300 veterans were evacuated from the V.A. hospital due to the possibility of an air attack against San Francisco. Patients were returned to the hospital after the batteries were decom-missioned and the hospital reopened in 1946. The Medical Center has a long history of being in the forefront of medical innovation and cutting-edge research. A fifty-year affili-ation with the UCSF, has allowed the Medical Center to recruit outstanding clinicians, teachers, and researchers. This successful col-laboration has facilitated advances in medicine and research and is the cornerstone of the Medical Center’s reputation for excellence. Today, the SFVAMC serves more than 50,000 veterans and provides ,more than 400,000 outpatient visits in fiscal year 2008. More than 700 UCSF trainees from thirty-four programs rotate through the Medical Center each year. It also has the number-one V.A. research program in the nation, with more than $77 million in expenditures in 2008.

This issue includes an article describing UCSF’s efforts to promote a culture of diversity among faculty, staff, and students. Nurturing di-versity is a university and medical center prior-ity and one of the seven goals of UCSF’s strategic plan. These efforts are critically important; we also understand they are not an end in them-selves. To improve care for all patients, respect for others’ differences must turn into actions that demonstrate appreciation of a group’s sensitivities, beliefs, or communication styles. One way to achieve that is by identifying local or global partners. UCSF launched a clinical trial to test culturally specific interventions for type II diabetes in Chinese immigrants. A study in Diabetes Care shows disease rates are 1.6 to 3 times higher for Chinese Americans than for European Americans. “Many standard recom-mendations for diabetes self-management don’t consider Asian orientations to health, including concerns for balance, or offer treat-ments sensitive to traditional Asian diets or ex-ercise preferences,” said Catherine Chesla, RN, DNSc, principal investigator and School of Nurs-ing professor. Chesla and UCSF researchers are collaborating with two respected Chinatown agencies, Donaldina Cameron House and North East Medical Services, in all research aspects. Study participants receive culturally specific training in managing complex social situations that arise during diabetes self-care, including tips on talking to doctors. Mt. Zion hospital historically has facilitated access to care for Russian-speaking people. The hospital began offering interpreters in the 1980s to address Jewish-Russian immigrants arriving in the city. Today, UCSF provides three full-time Russian-speaking interpreters and approximately 15,000 Russian interpretations annually. “Many Russian-speaking patients are elderly and need help with cancer, cardiology, or diabetes care,” said Tatyana Latushkin, interpreting services manager for Mt. Zion and Parnassus Medical Centers. The service offers 150 languages.

Hospital News

veteransDiana Nicoll, MD,

PhD, MPA

st.mary’sRichard Podolin, MD

UcsfElena Gates, MD


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24saNfraNciscomediciNeNovember2009 www.sfms.org25saNfraNciscomediciNeNovember2009 www.sfms.org

Policy and Progress at the CMA

D emocracy is the worst form of government other than all the rest, or so the saying goes. The 300-plus elected physicians who constitute the House of Delegates (HOD)

of the California Medical Association’s prove the point. Gather-ing annually, this year in the sometimes surreal environs of the Disneyland “resort” in Anaheim, the unwieldy group follows parliamentary procedure in arguing out dozens of policy pro-posals covering virtually all aspects of medical practice, science, regulation, ethics, finance, and more.

It’s no mere academic exercise. The CMA’s political advocacy in Sacramento and elsewhere has a very good scorecard, and this is where the positions and priorities are set. Beyond that, some CMA policies are argued and adopted nationally by the AMA. And many of those, through the years, began here in San Francisco.

The SFMS delegation, although relatively small, has by wide acclaim had an outsized impact on many issues throughout the years. Some have even called our group the “conscience” of the CMA, due perhaps to our continued focus on public health and ethical issues. This year was no exception. After three pre-HOD meetings locally, we brought a solid roster of resolutions to the meeting—and had virtually all of them adopted in some form. Some highlights, courtesy of your SFMS delegation (with names appended where special credit is due):

Sugar taxes: CMA will now support increased taxes on sodas and other relevant sugar-sweetened beverages, with the revenues to be used for public health education efforts. (Shannon Udovic-Constant, MD)

Pharmaceutical safety: CMA will advocate that the FDA be funded and staffed to adequately inspect and ensure the safety of all pharmaceuticals, including over-the-counter products, con-sumed in the United States, and that the FDA require labeling of all pharmaceuticals with their ingredients and their respective countries of origin. (Ann Myers, MD)

Endocrine-disrupting chemicals: CMA will urge further collaboration among medical and scientific groups to identify ways to decrease exposure to endocrine-disrupting chemicals and that policy regarding EDCs be based on comprehensive data cov-ering both low-level and high-level exposures. (Ann Myers, MD)

Medical practice guidelines and conflicts of interest: CMA now holds that members of practice guideline develop-ment committees must disclose any possible conflict of interest; that medical and specialty associations should not receive from drug, device, or equipment manufacturers any money for prac-tice guidelines; and that guidelines should be peer-reviewed by

independent reviewers. (George Susens, MD) “Smart growth” and air pollution reduction: CMA sup-

ports regional targets for local governments to reduce greenhouse gas emissions and support land use and transportation strategies to meet those targets. (Thomas Addison, MD)

Alcohol taxes: CMA now supports increased alcohol taxes and will advocate that any measure to increase alcohol taxes should allocate money to alcohol-related education, outreach, prevention, and treatment programs. (Gordon Fung, MD)

Health system reform and palliative care: CMA will seek to improve access, training, discussion, and/or provision of good palliative care in any setting and respond to the scare tactics of those who distort the intent and impact of proposals to improve palliative care. (William Andereck, MD)

These were just a few highlights. There were many more debates, including the annual one over “physician-assisted dying” (delegates Robert Liner and Follansbee strove to get CMA to take a ‘neutral” position but could not prevail). Your SFMS delegates even revised another delegation’s proposal and was able to get the CMA to now “consider the criminalization of marijuana to be a failed public health policy” (George Fouras, MD). For more information, visit the CMA website at CMAnet.org.

sfmsrePreseNTaTivesTocma

Report from the 2009 CMA Annual Meeting

Stephen Follansbee, MD, and Steve Heilig, MPH

Stephen E. Follans-bee (Chair)Gordon L. FungRachel Shu E. Ann MyersPeter W. Sullivan Michael RokeachGeorge P. Susens Shannon Udovic-Constant

John I. Umekubo H. Hugh VincentRobert I. Liner Lawrence CheungRita Melkonian Peter J. CurranRodman S. Rogers Roger Eng George A. FourasRobert J. Margolin

William S. AndereckRichard A. Podolin Richard BohannonCraig H. KligerAndrew F. CalmanTimothy Hamill Thomas E. Addison Eric TabasEric DenysSuketu Sanghvi

24saNfraNciscomediciNeNovember2009 www.sfms.org www.sfms.org November2009saNfraNciscomediciNe2525saNfraNciscomediciNeNovember2009 www.sfms.org

Health Policy Perspective

Still SickSteve Heilig, MPH

competition on price alone.” Or, as Cohn observes, “When they’re not dealing with large groups of employees, insurers have no desire to protect those who most need protection.” In effect, Cohn concludes, “managed care hadn’t so much altered the evolution of American health insurance as reinforced it, moving toward a system that left the most medically vulnerable at even greater risk than before.”

Cohn strives to be fair, giving some of the perspective of those charged with controlling costs as well. But it’s hard to reconcile a $500 million payout to HMO chiefs with the suffering some insured people endure—or cannot. And now even man-aged care is less viable than ever; Cohn notes that public and private insurance is faltering, and safety-net charitable clinics and emergency rooms and public hospitals are strained to the breaking point. “Sooner or later, something was going to give,” he writes.

As in a newer and somewhat similar popular book, The Healing of America by T.R. Reid, Cohn sees solutions out there, sometimes in other nations. But neither author seems to feel that such “healing” is forthcoming anytime soon. So, with this depressing diagnosis, what is the cure? We now have a one-year-old federal administration that has focused mightily on health care “reform.” Multiple bills are grinding through committees in Washington, with the outcome unknown at press time. In his book, Cohn views previous attempts at reform under Presidents Clinton and Bush as largely political failures in the former or giveaways to powerful insurance and pharmaceutical interests in the latter. Massive lobbying and “donations” in recent months – on the order of $1million daily - are striving to repeat some version of those precedents. The much-discussed “public op-tion” has been euthanized, then resuscitated, with the prognosis unknown, Other “reforms” are also being watered down,

Yet in addition to whatever expanded coverage of uninsured people results from this round of reform, some progress might also be achieved in the form of restrictions on some of the in-surance industry abuses Cohn documents. Limits on denial of coverage, including that for “preexisting conditions,” would be one major improvement. Such regulations will be far from the sweeping reform being proposed earlier this year,, but a worthy step along the way to a more humane health care “system.” Even with such incremental reforms, perhaps our national health care picture may not be quite so “sick.”

And remember, as countless sports teams have been re-minded—there’s always next season.

A s happens every generation or so, health care “reform” has become, at least in political terms, sexy. Tradition-ally seeing it as a “third rail” of policy making that few

dared touch, officials, pundits, and experts of all stripes have been proposing remedies to the chronic issues of the cost, qual-ity, and, especially, lack of access to care. Not since the Clintons’ well-intended but unsuccessful 1994 attempt at sweeping reform has the issue been so prominently discussed.

In 2007, I reviewed for the San Francisco Chronicle a then-new book titled Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price, by Jonathan Cohn, a se-nior editor at the New Republic. His book is now out in paperback and, unfortunately, as much or even more relevant than when it was first published. Perhaps the most notable aspect of Cohn’s book was that he focused less on the uninsured, and more on the majority who are ostensibly “covered.” Cohn illustrates his research with many real-life stories, albeit invariably sad ones. Consider Steven and Elizabeth Hilsabeck of Texas, whose son was born with cerebral palsy. Physical therapy is indicated to help people with this incurable condition, but the family’s insur-ers suddenly stop paying for it. A clerk informs them wrongly that they are only covered for sixty visits per lifetime; and then asks them “When is he getting over the cerebral palsy?” The couple considers divorce just so Elizabeth might become poor enough to qualify for Medicaid. Instead, they sell their home and move into a cramped trailer to afford care for their kids. Other unfortunate “insured” people profiled here wind up in other trailers, and some of their lives end with suicide, brought on by the despair of never getting the care they need.

As should now be clear, even the insured often struggle with hassles, obstruction, misinformation, and worse from their “partners” in the health insurance industry. Cohn details how health insurance has evolved from well-meaning nonprofit ef-forts to large profitable companies and “managed care” in the 1990s, and how each step has brought more complaints. In President Obama’s August address on healthcare, he focused on insurance industry abuses more than any other problem, and Senator Dianne Feinstein has more recently added that the industry “has no moral compass.”

The underlying dynamic, of course, is that so much of the health care industry remains a for-profit business. Even the founding figure of managed care, Paul Elwood, MD, came to la-ment it: “The idea was to have health care organizations compete on price and quality. The form it took, driven by employers, is



Independent But Not Alone.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians.

• Fast, accurate claims payments

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• Preventive care and disease management reminders for patients

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That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.

Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, [email protected]

Sacramento area: Doug Robertson, regional director, (916) 286-7048, [email protected] San Joaquin: Paula Schmit, regional director, (209) 762-5002, [email protected]

Richard Ward, M.D.Hill Physicians provider since 1994. Uses Ascender preventive health reminders and RelayHealth online communications for patient care and ePrescribing solutions.


SF Medical Society Dr. Richard Ward.indd 1 3/16/09 4:36:05 PM


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Independent But Not Alone.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians.

• Fast, accurate claims payments

• Free electronic communication capabilities via RelayHealth

• RN case management for complex, time-intensive cases

• Preventive care and disease management reminders for patients

• Deep discounts on EMR and EPM solutions

That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.

Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, [email protected]

Sacramento area: Doug Robertson, regional director, (916) 286-7048, [email protected] San Joaquin: Paula Schmit, regional director, (209) 762-5002, [email protected]

Richard Ward, M.D.Hill Physicians provider since 1994. Uses Ascender preventive health reminders and RelayHealth online communications for patient care and ePrescribing solutions.


SF Medical Society Dr. Richard Ward.indd 1 3/16/09 4:36:05 PM

I’m Dr Dan Nathanson, Endovascular Surgery Director at the Vascular Institute at California Pacific Medical Center, a unique program with specialists from four areas— interventional radi-ology, cardiology, vascular surgery and neuro-surgery — working together to provide the most sophisticated array of treatment options for all aspects of vascular disease.

With the minimally-invasive endovascular repair of abdominal aortic aneurysms, long incisions and lengthy hospital stays are no longer neces-sary. Patients are ambulating one day post-op and discharged the second day. Over 350 endovascular AAA repairs have been performed at the California Pacific Vascular Institute. This remarkably success-ful technique requires a high level of experience and technical expertise.

I’d like to make an appointment to see you in your office. Why? I’d like to take just a few minutes to familiarize you with our facilities, equipment, staff — and discuss treatment options for your next aneurysm patient.

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When was the last time a doctor came to YOU?

November 2009

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