The Interview: Susan Ehrlich: It’s Never Too Late

By Janet Reilly

“Curiosity, humility, perseverance, resilience, being attentive to details … not necessarily the kind of things you would think about when you think ‘hospital CEO,’ but they work for me as a person.” (Josh Edelson)

Walking onto the Zuckerberg San Francisco General Hospital campus in the Mission is like entering a small city. Spread over multiple blocks, teeming with people coming and going, and operating with a budget north of $1 billion, it’s a dynamic place. Every day, more than 5,000 people, including doctors, nurses and City employees, care for San Francisco’s most vulnerable population and run the only Level 1 Trauma Center in San Francisco and northern San Mateo County.

Since 2016, Dr. Susan Ehrlich has been the hospital’s CEO following a seven-year stint as CEO of the San Mateo Medical Center. It’s a position she never imagined occupying when she was working in the City’s public health department and, later, as a medical student at UCSF. “It’s like coming home,” says Ehrlich, with a smile. And, although the challenges of running a complex institution can be daunting, it’s a job she views as the opportunity of a lifetime.

I sat down with Dr. Ehrlich on a recent sunny morning in her office. She is warm, gracious and exudes competence. Our conversation ran the gamut from her unconventional trajectory to the C-suite and tackling the City’s homeless problem to her now not-so-secret Madonna fandom.

You come from a family of health care professionals — your father was acting surgeon general under the Nixon administration as well as a representative for the World Health Organization. Safe to say it’s in your DNA? Yes, in a way it was. My mother also was in health care, just in a slightly different way. She went back to work when my youngest sister was in high school, and she worked in contract management for companies like Marriott and Aramark. She sold services to hospitals, such as food nutrition services, laundry services and environmental services.

Did you always know you’d join the industry? Yes, and no. It was definitely part of my life growing up. My dad, as you know, worked in international health. He was a public servant almost his whole life, as I have been. I started thinking that when I went to college I would just be pre-med. But at Duke University, where I went to school, being pre-med was very intense. I got a little bit disengaged from the intensity of that, and, at the same time, got very engaged in the world of public policy. I went on to major in health policy and did some community work in North Carolina with migrant farm workers.

That’s interesting. After that, I moved out here and went to public policy graduate school at Berkeley. Then I went to Sacramento and worked for the legislative analyst’s office. I studied every health budget the state had, and that’s where I started learning a lot about local health in particular. About five years into that I got hired by [former San Francisco Mayor] Art Agnos and his budget team. So I became the health budget analyst for Art Agnos. This is in 1989. … I did the budget for a few years before I decided to go back to medical school.

“You can’t take care of people’s health issues or behavioral health issues if people are not housed.”

So, you were in your 30s by then, right? I was 35 when I started medical school. My parents thought it was crazy. It was a time in my life when I was really thinking about where I had been and where I was going. I was working with a couple of physician administrators whose jobs and lives seemed so exciting to me. Interestingly, those two people were Sandra Hernandez and Mitch Katz, who, of course, are luminaries. The type of work they did combining the practice of medicine with public policy and health administration just seemed very appealing to me.

Susan Ehrlich leads a staff meeting in her office at Zuckerberg San Francisco General Hospital. (Josh Edelson)

You did your residency in Boston, then moved back to the Bay Area to work at San Mateo Medical Center. What was that like? It was a very different time. It was right after 9/11, and a smallpox vaccination program was one of the big focuses of the health department. Leading that program was one of the first things I did. We got 62 or 63 people vaccinated. That was in anticipation of potential for some kind of …

Outbreak. Outbreak, or intentional outbreak from a foreign power. The SARS [severe acute respiratory syndrome] epidemic was also happening at the time. I did some case investigations, which was really interesting …. About a year into that work, I was asked to open up a senior care clinic. It was a really wonderful experience. I hired every single one of the 15 people who started the clinic — the doctors, the nurses, the nurse practitioners, a psychiatrist, a psychologist, and we started from scratch. It was incredible. That clinic, the Ron Robinson Senior Care Center, is still thriving today.

What are some of the biggest priorities for the hospital today? One of the things that was really important for me when I first got here — and continues to be important — is building the team that leads the hospital. I feel great about where we are. Second, it’s about building our future, which is now mainly about spending the 2016 Health and Safety Bond to renovate this building. The third thing, last but not least, is our enterprisewide electronic health records.

Let’s talk a little bit about your patient population. Approximately 80 percent of your patients receive publicly funded health insurance or have no health insurance at all. I also imagine you care for a fair amount of our city’s homeless population. What specific challenges does that present? First of all, I just want to say, if you ask anybody why they work here — whether they’re Department of Public Health staff or UCSF staff, the vast majority will say they’re here for the patients and for the mission. Our patients have a lot of issues, and they require a very careful focus. We take care of 108,000 people, and those people come in mostly through our clinics — there are 600,000 visits a year in our clinics. If you look at the impact of homelessness, it’s profound. The data that I’m going to cite for you is our official data. I think it probably under-states the issue. Officially, of the 108,000 [patients], about 9 percent of them are homeless. If you go into the E.D. and the inpatient areas, it rises to about 15 percent. In psychiatric emergency, more than 40 percent are homeless, so it’s a big impact.

Do you have that data on what those numbers were five, 10 years ago? I don’t think we kept any very well. It affects everything. I can say that as a primary care doctor. I’m in clinic every Thursday morning, and in every single clinic, I see somewhere around eight to 10 patients. Every clinic has at least one or two people who are homeless, more who are marginally housed. Depression, alcohol abuse, other drugs — just poverty in general, food insecurity. Those problems are just as pronounced as hyper-tension, diabetes, heart disease, chronic kidney disease. We, as an organization, have to be attentive to those things. We can’t take care of the medical problems without taking care of the social issues that patients present with.

And do you believe we have adequate resources in the City to deal with these social issues? That’s a complicated issue. First, I would say that the City and County of San Francisco is incredibly forward-thinking on all of these topics. … We’re incredibly fortunate because we have a lot of places we can send people. We have the Sober Center, the Respite Center. We have supportive housing. There’s lots and lots of resources for people here in the City, and we still have issues, right?

We do. The average person on the street is going to say homelessness and mental illness are the biggest problems in San Francisco. One slight digression I’d like to make on that topic is that I think a lot of what we see on the street that we think is mental illness is actually substance abuse. In particular, methamphetamines are a big deal. I mentioned roughly 50 percent of the people in [Psychiatric Emergency Services] are homeless; 50 percent are also methamphetamine users with or without mental illness.

The truth is, unless you’re very skilled at this you can’t tell the difference between someone who’s psychotic or somebody who’s really high on meth. Methamphetamines are particularly a West Coast problem. Yes, we have issues with opiate abuse, as does the country. The thing about opiates is that we have medication-assisted therapy. You can put someone on methadone or naltrexone or Suboxone. There are options for people with opioid abuse and alcohol abuse, for that matter, but not methamphetamines. So it’s a profound issue. I know the mayor [London Breed] has a task force on methamphetamine, which is going to be really important.You can’t take care of people’s health issues or behavioral health issues if people are not housed. Again, we’ve got a lot of smart people thinking about this problem and trying to build more housing. Until we get really serious about making sure that we increase the number of units of housing, increase the density of housing, it’s going to be very hard to take care of people’s health care problems.

You’re right, but can we build ourselves out of this problem? This housing crisis didn’t happen overnight. It didn’t happen over a decade. It didn’t happen over two decades.I often think about the time when I worked for Mayor Art Agnos. I remember I was in City Hall and looking out at Civic Center Plaza. It was a complete tent city. It’s not a tent city anymore; there’s a playground, which is great, but it’s not as if this is a new problem. I think it’s very exacerbated by the density, all the construction. There’s nowhere to hide in San Francisco anymore. We’re taking away places for people to hide. We’ve got a methamphetamine epidemic that we didn’t have before, so there’s a lot of things that wrap into this.

I think a lot of people look at this, saying, “We’re spending so much money on homelessness, on mental health, how can the problem not be solved?” It’s about how long it’s been building, and it’s really fundamentally an income inequality and a housing crisis [issue].

San Francisco General is a teaching hospital where you train physicians of the future. How is their training different from when you went to medical school? In the first year of medical school, there’s something called The Bridges Project, where you get involved in quality improvement projects at the hospital. Incorporating medical students and residents into the improvement work we do is the biggest difference. And, of course, there are the resident work hour limits, which are really different than when I was training!

Are there more regulations about overworking them? Yes, they’re limited to having 80 hours of work in a week so they aren’t as sleep deprived.

Yours is clearly a complex and stressful job. What do you do for fun? To relax? I know you’re a runner. Yes. That’s a really important part of my life. The two things that I really get engaged with outside of work: number two is running, number one is my family. I have a wife and two kids.

What do you love about San Francisco? Everything. I’ve been living here a long time. The physical beauty, the culture, the fact that I can find new things here all the time. The people. The politics. It’s a great place to be and it’s also a great launching place. I love being a part of this community.

What’s something your staff would be surprised to know about you? I’m not a very surprising person. I’m a pretty authentic person. Most of the things about me, my team knows: My family, my past, what brought me here. Maybe that I love Madonna?

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