Sachin Gupta, MD, and Ranjani Gupta Serve Mission in Rural Western Kenya

Sachin Gupta, MD, is a pulmonary and critical care physician with The Permanente Medical Group at Kaiser Permanente San Francisco Medical Center. He and his wife, Ranjani Akula Gupta, who works in the Integrated Marketing and Communications organization at Kaiser Permanente’s national headquarters in Oakland, returned recently from a mission to Kenya on behalf of the Tiba Foundation. Dr. Gupta provided these observations from their journey and mission.

Aug. 26
What an adventure we are about to embark on! I feel excited and a little anxious going into this trip. This is a unique opportunity to help our fellow human beings through empowerment. I have participated in “set up shop” clinics abroad where a team brings a bunch of medications, supplies, nurses and doctors and comes to an impoverished city to provide service. This is a fulfilling experience; however, its impact is time limited. On this trip I am tasked with empowering the local physicians and clinical officers (effectively Physicians’ Assistants) by teaching them basic bedside ultrasonography. My wife, Ranjani, will be working on innovations, including leading an innovations workshop, as well as providing recommendations to the marketing/patient experience team for the Matibabu Foundation.

The Matibabu Foundation Hospital in Ukwala, rural west Kenya.

The Matibabu Foundation Hospital in Ukwala, rural west Kenya.

With a visit to Africa once before (to Uganda) I’m not as personally worried about the “unknown” of the atmosphere we are entering. Naturally I maintain a healthy fear of having things stolen or getting an infection such as malaria. I have not been to Kenya. However my anxiety is a bit different this time. Traveling with my wife, unlike previously when I traveled alone and met up with colleagues, I concern myself for her health and that she does not have a negative experience in this her first trip to beautiful Africa. I know she is resilient and has tolerated challenging experiences in India so this shouldn’t be too far off.

Well, sitting at the airport and looking forward to disembarking from San Francisco and arriving (at our layover) in Istanbul! It will be a very long journey but well worth it.
___________________________

Aug. 29
The flight to Kenya was fine. It felt pretty fast actually with movies, naps and the ever exciting mealtimes. Being in the Istanbul airport was pretty remarkable, a hodge-podge of various Africans, Middle Easterners, Indians, Asians and Turks. The colors and styles of dress, including extremes of being covered or uncovered, as well as different accents, scents and attitudes was extremely impressive. New York City on the subways, or in Queens at Jackson Heights didn’t hold a candle to this level of diversity. Chatting about geopolitics with a Saudi and later a Somalian was a unique experience.

Arriving at 2:30 a.m. in Kenya was a breeze, as was customs. Dan Ogola, our liaison and head of the Matibabu Foundation, greeted us and we were briskly escorted to our hotel. Dan is a pleasant gentleman who welcomed us with open arms. Perfunctory exchanges of backgrounds and international experiences were made. The car ride was like many other car rides I’ve had in developing countries with the feel of a tropical climate, the smell of burning wood & trash, and the sight of people on motorcycles, bicycle, and small cars scattered throughout the roads. The behemoth highways of the States with large vehicles and high speeds are countered by a population that has outgrown its infrastructure and resources.

20160903_150316

In the hospital, before starting rounds. (Left to right): Dr. Morgan (local physician at Matibabu Foundation), Dr. Susan Jacobson, MD, Sachin Gupta, MD, and Ranjani Gupta (project manager at KP, innovations and marketing consultant to the Matibabu Foundation)

The next day, after meeting with my colleague, Infectious Disease specialist Susan Jacobson, MD, we took a short flight to Kisumu and from there about an hour and a half car ride to Ugunja. We are definitely now in rural west Kenya! I’m excited to see the Matibabu Hospital soon. Sleep, thanks to jet lag, is greeting me early.
_________________________________

Aug. 31
Day one in our small hospital provided a vastly different patient panel than what I see in the States. Generally patients are younger and less burdened by core Western diseases.
Aside from the several cases of malaria that were admitted due to high fevers and dehydration there was a case of diabetic ketoacidosis, related to uncontrolled blood sugars, which is a very uncommon problem here. My insight was actually useful on that case!

IMG_3080

Sachin Gupta, MD, demonstrates point of care ultrasound using a model (local staff member).

There was also a case of decompensated heart failure that portable ultrasound helped us determine was related to severe mitral regurgitation. Possibly from prior rheumatic disease I surmise. The ultrasound device certainly has its uses here. In terms of thoracic testing, the main uses here will be evaluation of consolidation and pleural effusion. I think the cardiac ultrasound will be most useful to evaluate valves, where the physical exam fails, and systolic heart failure. Vascular analyses such as the carotids and internal jugular vein has limited utility; however, IVC analysis should be very helpful in determining volume status. Evaluation of skin lesions and abscesses as well as lymph nodes definitely will also be useful here.

__________________________
Sept. 2
Hospital day 2 was notable for a few interesting cases. One is of a patient with malaria as well as decompensated heart failure. We worked on titrating medications such as an ACE inhibitor and diuretics for her while she’s in the hospital so this way in the future she has fewer long-term complications from heart failure. One key teaching point to the Clinical officer was to not start diuretics when someone is spiking temps to 39C (102.2 degrees Fahrenheit)!
Here in the hospital I feel we are needing to manage things completely with the mindset that follow up maybe an issue and therefore starting someone on heart failure medications in the throes of malaria is a necessity.

Innovations Workshop hosted at the school of nursing & led by Ranjani Gupta -- creativity at full throttle using butcher paper and post-it notes to help spawn ideas.

Innovations Workshop hosted at the school of nursing & led by Ranjani Gupta — creativity at full throttle using Human Centered Design to help spark ideas.

We do have a slew of cases of possible tuberculosis and my own gut instinct is to be pouring over a chest x-ray and we are making the best of the situation by using ultrasound to look at their lungs. It is interesting in one case where I observed a cavity in this man’s lung. We will need to await his AFB Smear result.
(Follow up note: sputum AFB was smear negative; however, we palpated and then performed ultrasound on an enlarged Virchow’s node, then proceeded to perform an FNA that was AFB smear +++)
________________________________-

Sept. 5
While there were many powerful experiences, one story stood out to me.
I was chatting with Ezekiel, our HIV clinical officer after rounds one day. We were discussing the importance of keeping tuberculosis on the differential diagnosis, and the process by which we rule it out in the United States. Really it was a unique opportunity to exchange ideas of practice patterns. He agreed that tuberculosis surveillance needs to be more aggressive in an endemic area like this. He then shared his own personal story of why he is so passionate about this topic. To know Ezekiel’s calm and composed manner is to know how emotional it was for him to share this story with me.

Ezekiel shared, “About one year ago (September 2015) my grandmother was sick with a cough, bringing up sputum and having fevers. She saw a pharmacy-based clinical officer for persistent symptoms. The clinic officer who saw her evaluated her and felt she had pneumonia versus pulmonary tuberculosis based on her symptoms. He gave her some antibiotics and left things alone from there. There were not any tests for pulmonary tuberculosis. She was not assessed by sputum. She did not feel better and her condition worsened. In October, about a month after the initial visit, she went back to the same clinician who evaluated her and felt she had pneumonia versus pulmonary TB again. She looked sick and so she was sent to the hospital for tests. There are they found a large pleural effusion and put in a chest tube until it was drained. They tested her sputum once for TB and the test was smear negative. They told her she did not have tuberculosis.

“My concern was that she had tuberculosis (despite the negative test) and I kept calling and telling my grandmother and mother that I think she needs her doctors the test again for tuberculosis. She and the rest of the family did not believe me and felt I was being paranoid. They only took one sputum and did not run any other test such as Gene- expert on the sputum. I was really worried because she was losing more weight and having drenching night sweats. A few months went by with her deteriorating despite my efforts to push for further testing. She went to the hospital in January with respiratory distress. But it was too late, they could not save her. And she passed away.”

Ezekiel was convinced she passed from undiagnosed and untreated TB and based on his description of his grandmother’s symptoms this was a strong possibility. His voice trembled for a moment as he recollected this story. I had preceded his story by explaining how in the United States our protocol is to test three sputum samples on smear as well as culture. It is likely that her care in a resource-abundant area like the States would have been vastly different and her outcome changed.
For Ezekiel, this experience has taught him the importance of early TB diagnosis and treatment. He is much more aggressive now in excluding TB in his patients. Given he manages a large cohort of patients with HIV, the importance of this cannot be understated. It is sad to me that he had to endure such a tragedy.

Sept. 9
This trip has re-emphasized to me the importance of recognizing each human life as precious. Each human being is with a beautiful narrative of life no matter their upbringing or surroundings. I feel my duty as a physician to recognize the  individual’s narrative and their relationships (not just the disease) was sharpened by this trip. 20160906_124400 Like a dive in cold water, the feeling invigorates you to the core. I recommend this experience to all physicians, to all human beings.

-Sachin Gupta, MD

Dispatch from Pat Courneya, MD: Opening Up to Insights From Cuba

Editor’s note: Patrick Courneya, MD, is executive vice president, Hospitals, Quality and Care Delivery Excellence and chief medical officer, Medicare Advantage, Cost and Prescription Drug Plans,  for Kaiser Permanente. He recently traveled to Cuba with several Kaiser Permanente colleagues to learn more about Cuba’s health care system. He shared his observations in this essay.

 

It has been a very busy time these last two months with a lot of travel, and it is good to have a period now when I am not away from Oakland quite so much.

As a part of my recent travel, I had the privilege to visit Cuba with a team of leaders from Kaiser Permanente. We spent a full week learning about how the Cuban people in a very different system have managed to achieve first world population health results with very limited resources. According to the WHO’s World Health Statistics 2016 Report, Cuban overall life expectancy at birth in 2015 was 79.1 and 79.3 in the United States. In that same report, Cuban healthy life expectancy at birth in 2015 was 69.2 years, compared with 69.1 in the United States. In addition, under age 5 mortality for Cuba in 2013 was 6/1,000 live births (U.S. 7/1,000), immunization percentages are in the high 90s, and 100 percent of women get a get at least four prenatal visits (U.S. 97 percent). They have done this while spending only 11.1 percent of GDP on health in 2014, compared with 17.1 percent for the United States.

Cuban Database IT Entryway CubaThis is not to say they do not have challenges. According to World Bank data in 2015, the maternal mortality ratio in Cuba was 39/100,000 live births, a drop from 58 in 1990, while in the United States the maternal mortality ratio was 14. It is important to note that the baseline rate for the United States in 1990 was 12, showing the United States is going in the wrong direction. Obesity is rising, elevated blood glucose rates are similar to the U.S. and one third of men and nearly 29 percent of women over 25 have elevated blood pressure. They have work to do and they understand that well.

The year 1990, used for baseline in the statistics above, has special meaning for Cuba given the events that hit them soon after. The next year, 1991, the Soviet Union collapsed, and with that momentous and historic change, Cuba lost its biggest customer and most generous patron. The Cuban GDP dropped by 34 percent, as 80 percent of Cuban import and export business evaporated. Coupled with tightened U.S. sanctions in 1992 and 1996, the period of the 1990s became one of the most severe and sustained economic downturns in Cuban history. The Cubans refer to it as the “Special Period,” and it has left a deep mark.

So why is this important for the Cuban health care system, and what did we learn from it during our visit? Faced with the impact of the Special Period, Cuba did not have and could not afford the technology and pharmaceuticals that the developed world takes for granted. In response, they did some remarkable things. They dramatically increased their attention to prevention and doubled down on a system focused on primary care at the neighborhood level.

Transportation CubaThey also built their own pharmaceutical industry that now provides 90 percent of the medications Cubans use, including specialty pharmaceuticals. Like they have with the famous 1950s cars that fill the roadways, Cubans have used remarkable ingenuity to keep their health systems going. The story of how they have done it is complex, and I will share just one example.

Clinica CubaIn Cuba, family physicians lead teams including nurses, vector control specialists, psychologists and other health care workers that take responsibility for a panel of approximately 1,000 patients. Each patient is given a health risk score from I to IV and detailed statistics are reported regularly to the referral district. The risk score is used to guide the efforts of the primary care team. The data include the prevalence and level of control for key chronic diseases such as hypertension, diabetes, and lung disease, as well as immunization rates, other preventive services and maternal child health statistics.

The family physician/nurse team staffs a typical neighborhood clinic, seeing patients both at the clinic and in their homes. The team’s knowledge of the family, their living situation, their behavioral health challenges and other social/non-medical factors is deep, and the ability to respond at the community level is strong. The results are pretty amazing, as the statistics show.

Here is what I found most remarkable, though. Within Cuban health care, they depend on accurate statistics and analysis to guide actions, and their level of transparency is admirable. Each month, for instance, the family doctors serving a given referral region gather together to compare their un-blinded population health statistics, reviewing results and strategizing on how to solve problems revealed by the data.

I must admit I felt as if the results they were getting were too good to be true, so I pressed the question of data accuracy repeatedly during the week I was there. The most compelling response came from a United States journalist who has lived in Cuba for 14 years and is not afraid to say and write what she really thinks. When I asked her how we could be sure that the data was accurate, what she pointed out was profound.

graffitiCuba is on an extremely tight budget and their constitution obligates them to provide care to everyone. In betting on prevention, they have committed to the idea that whatever they do to prevent disease has to work if they are going to be able to afford to provide care. If they make decisions and push interventions based on bad data, they will make expensive mistakes from which they are in no position to recover.

In essence, they have committed the system to the idea that high-quality leads to lower cost and lower burden of morbidity and mortality. With just over 11 million people, with a focus on population health and understanding that they must attend to social/non-medical needs in addition to providing health care, Cuba is getting great results. Affordability and high quality improving the health of the communities they serve. Sound familiar?

Thomas Kaschak, DPM, and Colleagues Return to Vietnam

Editor’s note: Thomas Kaschak, DPM, is a physician at Kaiser Permanente Fresno Medical Center and director of the Viet Nam Medical Project. For the 16th time since 1998, he led a team of clinicians in a medical relief mission in Da Nang, Vietnam, to provide care at the Da Nang Orthopedic and Rehabilitation Center. In 2011 Dr. Kaschak won a David Lawrence Community Service Award, which honors Kaiser Permanente physicians and employees who champion outstanding Community Benefit activities and initiatives demonstrating extraordinary efforts to improve the health of our communities. Dr. Kaschak last blogged from Viet Nam in 2015.

June 22, 2016

Vietnam Medical Project 2016 has proven to be another wonderful venture for both Kaiser Permanente and non-Kaiser Permanente volunteers.  We did have a fabulous team this year!

After a few days of R&R, getting used to the time change, we made it to Da Nang on June 12. We had a wonderful evening dinner with our hosts catching up on old times. It’s always wonderful to see their smiling faces. We have become more family than friends over these 18 years. This is my 16th trip since 1998, and I am so grateful, pleasantly surprised, and flattered that it has become a popular destination for physicians, residents, and students to visit.

Our first day in clinic was Monday, June 13. Quite a busy day! The uncommon is common here, with birth defects, old injuries, new injuries, and effects of years of neglect making up the greatest portion of the pathology that we encounter. Many of the birth defects are quite profound and heartbreaking, particularly when we see them in young children.  On that first day, we evaluated 70 patients and still had to turn 20 away. Throughout the course of our stay, however, we were able to not only see those 20 patients but many more scattered between surgeries and random clinics.

We started surgery on Tuesday, June 14.  Each day, between orthopedic and podiatric procedures, we performed at least 8 to 10 surgeries. It may not seem like a lot, but many of the cases were quite difficult and took 3 to 4 hours! We are challenged by lack of equipment and supplies that we are so used to back home. We try to bring as much of these as we can when we visit, but the weight becomes quite challenging, particularly when checking in for our flights.

Each night, we have the opportunity to visit with our colleagues and their family’s. And, this year, the five wonderful residents from Kaiser Permanente, one from New York,  and four Podiatry students from Pomona, Calif., really made it such a fun and rewarding trip. We all felt that the work was both humbling and rewarding.   Their experiences here, despite the fact that they may never encountered similar pathology at home, still serves well for them to evaluate, determine a plan of action, and implement the action plan for the more difficult situations they will encounter during their practice lifetime. I am so happy that I was able to provide them with the opportunity to gain what I feel is an invaluable professional experience.

Tonight, the eve of our departure from Da Nang, we will have our traditional get together with the entire staff at the “Tulip Lounge”. This has become a wonderful, fun, and touching annual event.  We share the evening with the doctors, nurses, administrators, and others from the Da Nang Orthopedic and Rehabilitation Hospital. We all have such a great time, and it is such a wonderful way to say “Goodbye, and see you next year”!

I truly hope that we can extend the Vietnam medical project to include other hospitals here in Vietnam. We are making inroads at the Da Nang Women’s and Children’s Hospital, and Da Nang General Hospital, but it has been somewhat difficult since my time is typically spend only at the Rehabilitation Hospital. But I am confident that we will be able to offer opportunities to physician, surgeons, residents and students of other specialties so that they can enjoy the gratifying work as well.

I truly hope that our stories  and presentations will inspire others to consider participating. It is my hope as well that some of our “alumni surgeons” can overlap visits with mine, thereby extending the time that we work, and allow a greater number of residents and students as well as attending physicians on their first trip to participate without the anxiety of coming alone.

Anyone who is interested I invite to contact me at Kaiser Permanente Fresno Medical Center. I would love to discuss our work and the possibilities for those who may be interested in participating in the future.

Best wishes to all,

Thomas J Kaschak,  DPM
Kaiser Permanente Fresno Medical Center
Director, Viet Nam Medical Project

Sarah Beekley, MD, Blogs from Guatemala: Seeing First-hand the Value of Health Education

Editor’s note: Sarah Beekley, MD, is a pediatrician at Kaiser Permanente Redwood City (Calif.) Medical Center. She is serving a relief mission in Guatemala for Faith in Practice. She last blogged here from Guatemala in February 2015. She also helped lead Kaiser Permanente’s relief response to the massive earthquake and tsunami in Indonesia in 2004, and was part of a physician team that deployed to Texas to aid victims of Hurricanes Katrina and Rita in 2015.
Greetings from Guatemala
I am in the middle of my week of volunteering with the international health care organization Faith in Practice. Based on the believe that to “whom much is given, much is expected” and that actions speak louder than words,  FIP’s mission is to provide life changing health care to underserved communities in Guatemala.

My team and I (including Cori Glover, MD, and Hilary Bartels, MD, Kaiser Permanente Santa Rosa Medical Center) have treated nearly 1,500 patients in three days of  mobile medical clinics.  Integrating pediatrics, medical, dental, OB-GYN, family practice, optometry, lab, pharmacy, translation, counseling, and referral services, we are blending preventive care with diagnostic, treatment, and referral services.  In addition, we are able to utilize Faith in Practice’s  extensive referral network of Guatemalan and American specialists and surgeons.  This is critical, as I have seen more untreated and under-treated illness while working in Guatemala than in my 30-year career in the United States.

beekley_guatemala_1The most disturbing of these was a previously healthy man who had broken his forearm at work.  A rod had been placed to repair the break, but he was without adequate follow-up care and 2 years ago the rod broke through both the bone and skin.  He presented to the clinic asking for help for his “broken arm”.  Further examination by Dr Glover revealed an infected and essentially useless forearm and hand. Without the social safety nets like workers’ compensation, disability insurance, and health insurance that are so easy to take for granted, he was unemployed and out of options.

beekley_guatemala_2Dr. Glover was able to start him on antibiotics and get him an urgent referral to the orthopedic surgeons in Antigua.   FIP’s extensive network will now work with him to coordinate the 2-3 hour journey to Antigua, his  pre-surgery preparation, and follow up.  Payment is on a sliding scale, and as he is also without a family, I expect  that the majority of his care with be free.

On a positive note, this village proves the value of health education. At our last village clinic, the majority of parents and children had decayed or missing teeth. As fillings are not a realistic option, these teeth need to be removed to prevent deeper and more dangerous infections.  One young patient had the maximum of five teeth pulled, and he needed to return for the remaining 15.

beekley_guatemala_4 In Morazan, however, dental disease was rare.  The parents uniformly and proudly confirmed that they and their children were brushing 2-3 times a day.  I can imagine one teacher, one health provider, or  one community leader a generation ago making dental health his or her mission, with these beautiful smiles being the result.

We ended the day with a record of 107-degree heat….so hot that my stethoscope, plastic chair, and bottled water  were all warm to the touch.   And again, no rain.

***

May 19, 2016

I have never been so grateful to be caught in a rainstorm.  After 107-degree heat and a deadly drought in this area of Guatemala, the downpour last night was a blessing.

I am working with a Faith in Practice multidisciplinary team, providing medical services to underserved communities in El Progresso, Guatemala.  Today was the last of 4 intense days of medical, dental, pediatric, and OB-GYN care at our mobile clinic.  As a pediatrician, I am reminded how important education is, as parents regularly expressed (misplaced ) guilt for their child’s deformity or disability, believing that the “chiles they ate” caused his blindness, or that an argument or “the wind” caused their child to be born with a cleft  palate or club foot.  Though too often we could not fix their child’s disease or disorder, we could help them access resources and prioritize.  We could reassure and compliment them where ever possible, and counter the personal and societal misinformation that was undermining their health.   While doing this work, I was reminded that parents (and gbeekley_guatemala_3randparents) around the world share common hopes and fears for their children.  I was also reminded how a disabled child could consume the resources of a family while binding that family together in the loving care of that child.

Given the prevalence of mosquito-borne illness here, we had anticipated more concern about Zika and malaria.  Instead, the more serious diseases are dengue (with its bleeding and encephalitis) and chikungunya (with relapsing arthritis).  Unfortunately, we saw plenty of the latter.  In pediatrics, we also treated seizures, pneumonia, dehydration,  and trauma (both physical and psychological) among other things. We were able to newly diagnose children with muscular dystrophy (7 years), club feet (2 years), and severe scoliosis (17 years), all of whom received referrals to the specialists with whom Faith in Practice collaborates.  Dr. Bartels even accessed the expertise of one of our own Kaiser Permanente infectious disease specialists to review pictures of a rare, leprosy-like deformity.  In addition to improving the health of these communities, we will return home better for the experience.

Working in an austere medical environment, in another culture and language, is challenging. Yet, this has been an intensely rewarding week, reminding me of the 21 year old who, 37 years ago, decided that she wanted to be a doctor so that she could be of service.  A simple wish, fulfilled this week.

-Sarah Beekley, MD
Kaiser Permanente Redwood City (Calif.) Medical Center

Diane Sklar, MD, and Jean Kayser, MD, Blog from Nicaragua: Care and ‘Consulta’ for Impoverished Women

Editor’s Note: Urogynecologist Diane Sklar, MD,  from San Francisco Medical Center, and OB-GYN Jean Kayser, MD, from Kaiser Permanente Walnut Creek Medical Center, are among several Kaiser Permanente physicians serving a relief mission in Nicaragua to provide women’s health services in impoverished areas there. They provided us with this post.

May 23, 2016

Writing you guys from Nicaragua, where we are 3/4 of way through a 9-day surgical mission trip taking care of the poorest of poor women who need surgery for various gyn issues – mostly related to bladder issues. We’ve been here helping these women who have so little, and who ask for so little.

We saw 130 patients on Sunday lined up on every corridor of the indoor/outdoor clinic. After interviewing every single patient (I learned how much more Spanish I have to study!) we scheduled 25 for surgery – that was a huge challenge in itself. Many came from various living conditions and towns far away. Even if they didn’t need surgery, it was important to give them a “consulta” and hear their concerns.

 

0.1B84

Then, imagine that we operate out of a tiny clinic converted to an operating room/ hospital where there is no automated sterilization- all instruments are dipped in liquid chemical cleansers and remarkably no one gets infections here! Sometimes the air conditioner works in the OR but no one can hardly complain about sweating too much. Remarkably the patients all recover from surgery with the equivalent of ibuprofen and acetaminophen – rarely requiring narcotics – which is unheard of among our patients at home.

 

image2

We take a van to the town where we operate daily – about a 30-minute ride – and the days are long. We start after breakfast and usually leave around 6-7:30 pm to go back to our hotel but somehow the time flies and if they didn’t make us stop to eat lunch, sometimes we would forget. The same sweet woman Anna from years past feeds us daily- the local hot menu of rice, various meats and vegetables.

 

van

It has been incredible bonding with my American colleagues and the local doctors and staff here who are dedicated to helping those who need it most and many of them live in totally humble conditions. The average salary of a doctor here is $800/month and 40 percent are unemployed. Needless to say they are not very fond of the Ortega Dynasty — their president has some ownership in every major business, hospital and utility in the country!

Nearly every morning we meet various members of the surgical crew at 0545 and hike up the hill  behind our hotel to “La Cruz” – approximately 1,000 steps! It takes about 1 hour and 20 minutes – my calves have never been in such good shape!!

stairs
The Kaiser Permanente physicians joining us on this mission are anaesthesiologist Robert Karoukian, MD, Brandon Chen, chief resident, both in the Kaiser Permanente San Francisco Medical Center, and urogynecologist Karen Simpson, MD, in the Kaiser Permanente San Ramon Medical Offices.
 
We miss you all!