Author: Jonathan Flom

FOR IMMEDIATE RELEASE: February 27, 2023
Statement of Matthew L. Myers, President, Campaign for Tobacco-Free Kids

WASHINGTON, D.C. – The U.S. Supreme Court announced today that it will not hear R.J. Reynolds’ appeal of a lower court ruling upholding Los Angeles County’s law prohibiting the sale of flavored tobacco products. This decision is a tremendous victory for kids and public health. It allows Los Angeles County’s law to remain in effect, while also preserving the authority of states and localities across the country to enact similar lifesaving measures. R.J. Reynolds and other tobacco companies have desperately fought these laws so they can continue to target kids, Black Americans and other communities with flavored products, including flavored e-cigarettes, menthol cigarettes and flavored cigars.

This decision is a rejection of Reynolds’ argument that the Los Angeles County law and similar state and local laws are preempted by the federal Tobacco Control Act. In fact, the Tobacco Control Act includes explicit language preserving the authority of states and localities to regulate the sale of tobacco products within their borders. For this reason, no court has struck down a state or local restriction on the sale of flavored tobacco products as preempted by the Tobacco Control Act. These courts include the First, Second and Ninth Circuit Courts of Appeal. There is simply no legal basis to deprive Los Angeles County, or any other locality or state, of the ability to protect their citizens against the flavored tobacco products that lure kids into a lifetime of nicotine addiction.

Today’s announcement follows the Supreme Court’s decision in December to deny Reynolds’ request for an emergency injunction to block California’s statewide law ending the sale of most flavored tobacco products.

Reynolds’ battle against these laws shows once again that the tobacco companies haven’t changed and are lying when they claim to care about anything other than their bottom line. R.J. Reynolds and other companies will stop at nothing in order to continue targeting children and vulnerable communities with flavored tobacco products. Policy makers at every level must stand up to the tobacco industry’s bullying and take action to protect kids and save lives.

By: Joy Hao, MD, PhD, Conference Committee Chair

For the past three years, we have struggled collectively with an epidemic on top of a pandemic: drug overdose deaths skyrocketed during the first year of the COVID-19 pandemic, predominantly due to synthetic opioids such as fentanyl. In the wake of this fentanyl epidemic, there has been a major shift in public policy in the treatment of opioid use disorder at the same time that the federal Public Health Emergency for COVID-19 comes to an end this year.

For the first time in history, any physician registered with the DEA will be able to prescribe buprenorphine, one of the most effective treatments for opioid use disorder. In December 2022, the United States Congress signed the Consolidated Appropriations Act, thereby eliminating the DATA X-Waiver requirement and ending nearly 20 years of intensive governmental regulation of buprenorphine.

This monumental shift in policy reflects the advocacy efforts of many agencies and organizations over the past decades, including CSAM and ASAM. The mission of CSAM is to promote evidence-based treatment and improve access to high quality addiction treatment for all. As more providers are now able to prescribe buprenorphine, it is even more imperative to promote educational efforts in addiction from medical school through Continuing Medical Education, especially since the DEA now requires all registrants to fulfill mandatory 8-hour substance use disorder training.

CSAM celebrates its 50th anniversary this year. In honor of this momentous occasion, this year’s conference will feature a new approach by combining the traditional review course with panels highlighting cutting edge practices in addiction medicine. We will offer plenary sessions on all major substance use disorders focusing on epidemiology, diagnosis, and treatment, geared towards ABPM Board exam preparation. Furthermore, we will feature multidisciplinary panels for the first time at a CSAM conference, addressing topics as diverse as: treatment of ADHD in substance use disorders, adolescent addiction medicine, frontiers in harm reduction, ketamine and other novel treatments, and alcohol withdrawal management other than benzodiazepines (See schedule here: LINK).

We are excited to present two phenomenal keynote speakers this year: Dr. Dan Ciccarone will speak on the future of fentanyl: supply, use patterns, and public health response. Dr. Anna Lembke will speak on dopamine “fasting” as an early intervention for compulsive overconsumption in the digital age.

The conference will also feature four workshops: Treating Pain and Addiction, Fitness for Duty Evaluation, Bridging the Silos – Arm in Arm for Better Patient Care, and Motivational Interviewing for Busy Clinicians. Lastly, the poster session will return as well.

As we find our footing in a post-pandemic world, I invite you to join us in San Diego this year from August 30th to September 2nd for the opportunity to review, rejuvenate, and reconnect. I hope to see you also at the special CSAM 50th anniversary celebration on Friday evening, September 1st. We look forward to serving you for the next 50 years.

-Joy Hao, MD, PhD

By: Maureen Strohm, MD, FAAFP, DFASAM, MERF Representative

What a banner year this has been and will be going into the 50^th CSAM Annual Conference!  This summer we celebrate CSAM’s 50^th Anniversary.  MERF, the Medical Education and Research Foundation for the Treatment of Addictions, is CSAM’s younger sibling and will mark its 42^th Anniversary at that time.  Over the years, more than 600 residents, medical and psychology faculty, nurse practitioners and physician assistants, as well as new fellows have come through the MERF Scholars programs learning addiction medicine in a unique paradigm – our signature program brings teams of residents and faculty from institutions throughout California and beyond and provides Mentored Learning Experiences with faculty mentors throughout the course and the year that follows. Many of our CSAM and ASAM leaders are MERF graduates!

As our restrictions during the pandemic eased for 2022, we celebrated the chance to come together again with 52 MERF Scholars – residents, fellows, and faculty – participating in person, in small groups to learn strategies of motivational interviewing in the pre-conference workshop, “Motivational Interviewing for Busy Clinicians and Educators”, along with acquiring a myriad of teaching tools to use within the clinic setting once participants returned to their respective institutions.

The small groups continue their work together throughout the conference for case discussions and continued development of their planned projects upon return to their programs. Our quarterly Journal Clubs often continues the camaraderie as the group explores current articles, led by the author(s) of the article under review.

What has changed, and needs your help, is the availability of funding for this long-standing “signature” of MERF. Over the years, the scholarships have been sustained through private donations (including from our own founders and current members) as well as various short-term grants to cover participation expenses. MERF support has evolved from its early stipends mainly covering registration, to our initial MERF Scholars program, then to MERF Champions who came back for follow up training, and then our MATES program supported by state funding to reach out to our colleagues in the FQHCs integrating this important work into their practices.

Since 2022, we have been working to secure new funding and made the decision to support the majority of Scholars last year through our own reserves. At present, outside funding remains uncertain and so we are looking to new strategies to secure a sustainable funding stream that can support MERF scholars for years to come especially at a time when addiction medicine interest is growing and our residents and fellows choosing to specialize in addictions care are expanding.

The opioid epidemic is not going away, and in fact is worsening as it evolves to include stimulant-related deaths, fentanyl and its analogues and now xylazine, maintaining its grip on our patients, friends, families, and communities.

So let’s “pay it forward” – and donate to MERF today!  While $1500 will fund one Scholar this year, we welcome all donations – even larger ones!  If your organization has a charitable foundation, let us know whom to contact with our “ask.”  Better yet, help us get a foot in that door!

Dr. Garrett O’Connor brought his indomitable force in refocusing MERF in 2000 to meet his passionately stated mission: to prevent the harm being done to patients by physicians who lack the knowledge, skill, and training to recognize and treat addiction.  While we have updated that to include all clinicians, we honor his vision.  Stop the harm!  Help us spread the word, the knowledge and experience to all our colleagues!

*Our Mission is to prevent the harm being done to patients by the medical community by bridging the gap in knowledge, skill, and commitment to recognize and treat people with substance use disorders.

By: Jean Marsters, MD, Membership Committee Chair

The membership Committee decided to look at race and ethnicity of our membership in 2022. The results of a Dec 22, 2022 data pull were assembled. It contained race/ethnic identification of all of our members that week. Multi-racial was not offered as a choice at that time, it is in 2023. We wanted to look at all members, and also get a sense if active members in the organization mirror the race/ethnic composition of all members. As a simple proxy for active members, we used all members listed on the CSAM website’s committee list that day. Members on committees were only counted once (people on 2 committees were only counted once). Committees not on the website were not included (such as Nominations Committee). Activities not appearing on the website such as work groups, task forces and the History Project were not included.

We compared our numbers with the California Health Care Foundation’s CA Health Care Almanac: A Quick Reference Guide March 2021¹ which has the racial/ethnic identification of physicians in California in 2019 and 2020 and for the state’s population.

Some of the numbers that break out:

23% of CSAM members “preferred not to answer” or gave no answer to their racial/cultural affiliation. This was a bit less than the 26% of ASAM physicians who answered the same in 2021.

Comparing all CSAM members with those listed on committees:

• White: 44% vs 52%, Asian 12% vs 11%, Hisp/Latino 8% vs 7%, AA 6% vs 2%
• Other 6% vs 3%, AmInd/Alask Nat 1% vs 0%, Nat Hawaii/Other Pac Isl ~ 0.5% vs 0%
• Prefer not to Answer 4% vs 7%

6% of Californians and members are African American, but 2% of committee members listed are.

39% of Californians are Latinx, 8% of members are and 7% of committee members listed are.

32% of CA physicians active in-patient care are AA/PI, 12% of members are Asian and 11% of committee members listed are.

33% of CA physicians active in-patient care are White, 44% of members are White and 52% of committee members listed are.

The authors of the 2022 article in J General Internal Medicine by Garcia et al: Lack of Racial and Ethnic Diversity Among Addiction Medicine Physicians on demographics of Addiction Medicine Physicians call for the development of informed efforts to diversify the addiction workforce. In order to do this, they aptly identify the need to generate accurate numbers so that gaps can be identified and changes through time can be measured.

On behalf of the Membership Committee, I presented this data to the Board on February 11th with the recommendation that the Board reviews this and other data on culture/ethnicity and develop a longitudinal action plan on diversity.

1. https://www.chcf.org/wp-content/uploads/2021/03/PhysiciansAlmanac2021QRG.pdf

By: Chwen-Yuen Angie Chen, MD, FACP, FASAM, Communications Committee Chair

On February 15, 2023 Dr. Caravella McCuistian, PhD presented her findings on the implementation of AB 541 Tobacco Treatment legislation, at the *UCSF Drug Use Research Group meeting (see below for more information on DURG). In attendance were CSAM members Cathy MacDonald, MD (Program Consultant Lifelong Tobacco Treatment Training Program Oakland, CA) and Chwen-Yuen Angie Chen, MD who were instrumental in initiating AB541: https://bit.ly/43cpS0l

Here is a synopsis of Dr. McCuistian‘s presentation:

“California has prioritized smoking cessation among people who use substances through the Tobacco-Free for Recovery Initiative, which includes an intervention aimed at supporting substance use disorder treatment programs in implementing tobacco-free grounds. Dr. McCuistian led an examination of changes in client smoking prevalence, tobacco use behaviors, and receipt of cessation services among the first seven programs participating in the initiative. Program clients completed cross-sectional surveys at the start of the intervention (baseline: n = 249), at an interim timepoint post-baseline (interim: n = 275), and at the end of the intervention 15 months later (post-intervention: n = 219). Over the course of the initiative, 5 of the 7 programs implemented tobacco free grounds. Results indicated that client smoking prevalence decreased from 54.2% to 26.6% from pre to post intervention. Current smokers and those who quit while in treatment also reported an increase in NRT/pharmacotherapy (11.9% vs. 25.2%) from pre to post intervention. These data suggest that an intervention to promote tobacco-free grounds implemented in residential SUD treatment programs was associated with a significant reduction in client smoking and an increase in NRT/pharmacotherapy. These findings directly supported the enactment of California AB 541, which now requires all California substance use treatment programs to assess and treat smoking among patients in these programs. The Tobacco Free for Recovery Initiative serves as a model for how substance use treatment programs may adhere to requirements of AB 541 while addressing smoking prevalence within their programs.”

Here are two resources for additional information:

McCuistian, C., Kapiteni, K., Le, T., Safier, J., Delucchi, K., & Guydish, J. (2022). Reducing tobacco use in substance use treatment: An intervention to promote tobacco-free grounds. Journal of substance abuse treatment, 135, 108640, 1-8.

https://doi.org/10.1016/j.jsat.2021.108640

Campbell, B. K., Le, T., McCuistian, C., Hosakote, S., Kapiteni, K., & Guydish, J. (2022). Implementing tobacco-free policy in residential substance use disorders treatment: Practice changes among staff. Drug and Alcohol Dependence Reports, 2, 100033. https://doi.org/10.1016/j.dadr.2022.100033, 1-8.

*The UCSF Drug Use Research Group (DURG) is a city-wide seminar attended by faculty, postdoctoral fellows, graduate students, and other investigators with a focus on and for persons who use drugs. Started in 2005 after a friendly debate between an epidemiologist and anthropologist on the merits of quantitative versus qualitative research methods, the DURG monthly seminars provide a community platform for new and established investigators to present their work, formulate research questions, and prepare for grant applications, conferences, and publications in a supportive environment. The seminar has been successful in cultivating new collaborations and mentorship and in sustaining interdisciplinary and interprofessional dialogue between those engaged in basic sciences, epidemiology, clinical research, and qualitative methods.  

By: Chwen-Yuen Angie Chen, MD, FACP, FASAM, Communications Committee Chair

In 2025, that’s only two more years from now, the American Board of Preventive Medicine – Addiction Medicine Practice Pathway Certification process will sunset. In 2026, board certification in Addiction Medicine will require ACGME accredited fellowship training.

For your reference, below is the information provided directly from the ABPM website and we hope you plan accordingly if you intend on becoming board certified in addiction medicine through this practice pathway. As part of your preparation resource, CSAM continues to offer their popular annual Board Review Course at their Scientific Meetings, the next one will be held in San Diego from August 30-September 2, 2023. Seating is limited and super early bird registration at a discount is available until April 24: Register for the Annual Review Course Here

Direct from American Board of Preventive Medicine:

“Practice Pathway* (open through 2025)

The practice pathway is the mechanism for physicians to meet eligibility requirements for certification in Addiction Medicine without completing an ACGME-accredited fellowship in Addiction Medicine. Additional requirements include either minimum time in practice or completion of non-ACGME-accredited fellowship training in Addiction Medicine.

Two options are available in the Practice Pathway:

• Time in Practice: Applicants must submit documentation of a minimum of 1,920 hours in which they were engaged in the practice of Addiction Medicine at the subspecialty level; this minimum of 1920 hours must occur over at least 24 of the previous 60 months prior to application. The minimum of 24 months of practice time need not be continuous; however, all practice time must have occurred in the five-year period preceding June 30 of the application year. Practice must consist of broad-based professional activity with significant Addiction Medicine responsibility. Applicants must also demonstrate a minimum of 25% (or 480 hours) as Direct Patient Care. Addiction Medicine practice outside of direct patient care, such as research, administration, and teaching activities, may count for a combined maximum of 75% (or 1440 hours). Only 25% (480 hours) of general practice can count towards the required hours for the Practice Pathway, and the remaining 75% must be specific Addiction Medicine practice. Fellowship activity that is less than 12 months in duration or non-ACGME accredited may be applied toward the practice activity requirement. The actual training must be described for any fellowship activity. Documentation of Addiction Medicine teaching, research and administration activities, as well as clinical care or prevention of, or treatment of, individuals who are at risk for or have a substance use disorder may be considered.

• Non-Accredited Fellowship Training: Credit for completion of training in a non-ACGME-accredited Addiction Medicine fellowship program may be substituted for the Time in Practice option in i) above. The applicant must have successfully completed an Addiction Medicine fellowship of at least 12 months that is acceptable to the American Board of Preventive Medicine. The fellowship training curriculum as well as a description of the actual training experience must also be submitted. Fellowship training of less than 12 months may be applied towards the Time in Practice hour requirements of the Practice Pathway. The non-ACGME-accredited fellowships are those currently accredited through the American College of Academic Addiction Medicine (ACAAM), formerly known as The Addiction Medicine Foundation (TAMF).

Documents and Verifications

• CV/Resume
• Medical License Verification (ABPM will confirm after application)
• Current ABMS Board Certification Verification (ABPM will confirm after application)
• Practice and Training Verification, if using practice activity
• Fellowship Verification, if using credit from a fellowship
• 1 Letter of Reference from a physician who is certified by one of the ABMS Member Boards

*The Addiction Medicine Practice Pathway will expire in 2025. Beginning in 2026, all applicants for certification in Addiction Medicine must successfully complete an ACGME-accredited Addiction Medicine fellowship program. This subspecialty certifying exam will be given annually throughout this period.”

See you this Summer, August 30 – September 2!

By: Randolph P Holmes MD, FAAFP, DFASAM, Government Affairs Committee Chair
with Chwen-Yuen Angie Chen, MD, FACP, FASAM, Communications Committee Chair

CSAM’s Public Policy Committee has a new name, the Government Affairs (GA) Committee. We are early in the legislative session and have been reviewing several bills related to substance use disorders care. There are several bills concerning fentanyl, some of which are more about the old “war on drugs” thinking and do not align with CSAM’s mission. We have several bills that seek to license drug and alcohol counselors and it is likely CSAM will support. Most bills are still in committee so it will be another month or two before the GA Committee will have the final products. CSAM was represented in Sacramento on April 19 for Legislative Day. We will be hearing from our legislators and meeting with staff to elicit support on bills we want to see passed.

When the Section Chief of Special Programs and Utilization Management Branch from the Department of Health Care Services, Steven T. Kmucha, MD JD MMM reached out to CSAM’s President Dr. Karen Miotto with an inquiry for advice and guidance about “best policies” and clinical evidence pertaining to the update of Medi-Cal policies related to Voluntary Inpatient Detoxification (VID), CSAM News Editor and Chair of Communications, Dr. C.Y. Angie Chen connected CSAM Member Dr. Cheryl Ho, Director of Hope Clinic and Co-Founder Valley Homeless Healthcare Program of Santa Clara Valley Health and Hospital System with GA (HPPC) committee for support in crafting a letter, signed by 14 physician-leader colleagues of Dr. Ho who practice addiction medicine within Santa Clara County, outlining the paucity of Medi-Cal funded services for medically supervised withdrawal management in the face of our fentanyl crisis, where ASAM Placement Criteria 3.2 level programs are providing services that would more appropriately fall between 3.2 and 3.7, however, the funding for this level of treatment remains at a level 3.2. We are awaiting a response, and welcome others who are interested in VID reform to reach out to CSAM.

Among the many things that CSAM does as part of our advocacy efforts is submit amicus briefs in support of SUD related legal cases before various courts. CSAM recently signed on to two cases. In the first case (Carpenter), a pregnant woman gave birth and the baby died in San Diego. She is being charged with murder because her urine tested positive for drugs; the submitted brief states why it is wrong to weaponize drug use in pregnancy and the reasoning behind opposing a punitive response to perinatal drug use. In the second case, a man was denied visitation privileges with his child because he tested positive for drugs. Our key arguments include a) substance use, even in high amounts or with high frequency, is not equivalent to a substance use disorder b) The DSM-5-TR distinguishes between substance use and SUDs which should not necessarily be equated c) The frequency, duration, and amount of substance use alone have never been diagnostic criteria in the DSM, because those metrics do not correlate with a lack of control d) A positive drug test alone is not an indicator of a substance use disorder and e) substance use disorders are clinical conditions that should only be diagnosed by trained professionals and not the courts. This latter amicus was filed with CSAM as a lead, with our input on crafting it, and is currently before the State Supreme Court.

CSAM continues to work hard to have our voices heard as the subject matter experts on substance use disorder issues.

JOIN US FOR THIS EXCITING WORKSHOP AUGUST 30, 2023 in San Diego!

with Ingeborg Schafhalter, MD, IASC Committee Chair

How did the idea for CA Bridge come to life?

The idea for CA Bridge began in 2017 when we realized that the emergency department was this incredible 24-7 access point for people in crisis from substance use disorders. The emergency department is the only place in the healthcare system that federal law guarantees access to treatment no matter your insurance or citizenship status, and our patients know that. There is a tremendous amount of trust and reliance on the emergency department particularly by people facing social challenges. It might be busy and loud, but you can trust it. Unfortunately, that’s not true in most other settings in healthcare, even safety net systems often maintain standard workflows that block access to treatment or create onerous eligibility tests and delays.

From an access standpoint the emergency department is ideal, the problem has been that most healthcare leaders both on the medical side and on the administrative side have not considered substance use disorders a legitimate medical condition on par with cardiovascular disease. That means the general treatment expectations have been only the most basic interventions to keep a patient alive with little to no attention paid to the treatment of addiction. As a group, people suffering from substance use disorders have had very little advocacy, their voice is typically just not impactful at the stakeholder tables where large scale decisions around funding and resource allocation are made.

The abject horror of the overdose epidemic has been a catalyst to at least begin the long project of treating people who are suffering from addiction with dignity as any other patient. Through the incredible advocacy and powers of persuasion of people like Dr. Aimee Moulin, Dr. Hannah Snyder and Arianna Sampson, (co-founders of the CA Bridge Program), and support from the California’s Department of Healthcare Services (DHCS: https://www.dhcs.ca.gov/), the CA DPH (https://www.cdph.ca.gov/) and California Hospital Association (https://calhospital.org/) we have been given some space to explore this vision of what if you combined the access capacity of an emergency department with competency in the medical treatment of addiction to provide high-quality care 24-7 for substance use disorders. It’s so simple yet so ambitious, if we can get this done it will save thousands of lives and just become part of healthcare…like strokes, heart attacks, and all the other things we treat in the emergency department every day.

Are there latest findings or practices? 

The big finding is that emergency department staff WANT to do this. The response from clinicians has been incredible. It’s incredibly thrilling to see over 280 hospitals, in California alone, sign on and commit to a fairly rigorous implementation project that up-trains their emergency departments to provide high quality care. With this reach, you start to see population scale impacts that I believe will start to move the needle on overdose deaths–we have seen over 70 thousand emergency department visits for buprenorphine treatment just in the last few years. Many of these people arrived in high-risk crises, either in withdrawal, having overdosed, or just been released from prison. 

How has the program grown? 

CA Bridge began with focus on just getting buprenorphine into standard medical practice at emergency departments in California and grew rapidly to take on all substance use disorders and creating treatment pathways that integrate emergency medical services and hospital inpatient units. Again, nothing we do is particularly innovative, it’s just building out the same care infrastructure that we do for victims of trauma or stroke. For so many reasons leaders in medicine, healthcare, and public policy decided that people suffering from substance use disorders did not merit the same care–the system we have today is very much by design. Hopefully, we can sustain and grow the outrage against this dominant belief and continue to drive progress. 

The future is going to center on deconstructing the current behavioral health system that was conceptualized, designed, funded, and implemented without any serious involvement of medical science. We currently have two largely separate and often oppositional systems–the healthcare system and the behavioral health system. That is a very wasteful and unfortunate situation. The future involves building an integrated system of care from the ground up that applies medical interventions and knowledge in partnership with behavioral health models of care. Cognitive behavioral therapy, contingency management, and medications like buprenorphine should be offered together with social support. Splitting everything up has never made any sense at all. I’m very hopeful we can break through the inertia and special interests and build a commonsense system appropriately scaled to meet the needs of California.

What do you most look forward to presenting at the CSAM WORKSHOP? 

I’m a pharmacology nut, so probably treatment of buprenorphine precipitated withdrawal, but in terms of impact I really think it’s within our grasp to leverage technology to create a statewide network of telehealth enabled Bridge Clinics that provide on-demand treatment (including buprenorphine) that are vertically integrated with 24-7 emergency department care and closely partnered with high-risk touchpoints–jails, syringe services programs, behavioral health residential centers–to create an always available resource. I understand we can’t snap our fingers and fix the overdose epidemic, but we can fix access to medications like buprenorphine, it’s very doable.

Dr. Andrew A Herring graduated from Harvard Medical School and completed his residency in emergency medicine at Highland Hospital—Alameda Health System (AHS) in Oakland, CA where he continues as an attending emergency physician and Director of Research. At AHS he is Division Chief of Addiction Medicine and Medical Director of Substance Use Disorder Treatment and the past Medical Director of the AHS Functional Restoration Pain Clinic. Dr Herring has led national efforts to transform hospital-based care for substance use disorders and his work has been featured in local and national press including the New York Times, Los Angeles Times and National Public Radio. Dr. Herring co-founded and is a PI at CA BRIDGE, one of largest state level efforts to promote access to medication for opioid use disorder in the hospital settings. Dr. Herring’s research has been funded by the National Institutes of Health (NIH) and the Patient-Centered Outcomes Research Institute (PCORI) and has been published in numerous journals including JAMA Open and Annals of Emergency Medicine; his work focuses on treatment of substance use disorders and pain management. He is a co-investigator NIDA CTN 0099 (ED-INNOVATION), and principal investigator for the Public Health Institute CA Bridge Outcomes Study. He has conducted health policy research as a Fulbright Scholar in Central America. Dr. Herring is board-certified in Emergency Medicine, Addiction Medicine, and Pain Medicine, and is Associate Clinical Professor of Emergency Medicine, at UCSF.