Transcripts For SFGTV Government Access Programming 20240713

Jurisdiction and does not appear on the agenda. Speakers shall address remarks to the commission as a whole and not to individual commissioners or department personnel. Commissioners are not to enter into debate or discussion with the speaker. Lack every response does not necessarily constitute agreement with or support of statements made during Public Comment. Thank you very much, madam secretary. At this time we will ask for general Public Comment. Any member of the public wishes to give Public Comment, please approach the podium. Seeing none, Public Comment is closed. Item 3 approval of the comments. Discussion and possible action to approve meeting minutes. Minutes from regular meeting on september 25, 2019. Thank you very much, madam secretary. At this item approval of the minutes we will ask for Public Comment. Any member of the public wishes to give Public Comment, please approach the podium. At this point Public Comment is closed. Commissioners. Thank you very familiar. Very thank you very much. We have a motion. We need a second. Thank you very much. Moved and second. Call for the question. In favor say aye. Approved. Thank you very much. Item 4. Update from Department Physician to provide an update and overview of the duties and responsibilities in the Physicians Office. Good morning, raymond terrazas. Welcome to the commission. Good morning commissioners, chief nicholson, invited staff. Could you reflect that the commissioner has joined us for the Commission Meeting this morning. Yes, president. Good morning. Thank you very much for the opportunity to provide this update to you. It is with great pleasure that and with humility that i stand before you here today. So for todays presentation, i will review with you the operations of the office of the department of the physician. Even though i am the one standing before you, please understand there is i do work with a wonderful and very dedicated staff that includes our nursepractitioner and miss Barbara Marino who provides administrative support. She is a fixture in the department and dedicated Civil Service employee. So before i begin my presentation, i think it would be important to review with you the Mission Statement, and also to review the role that the office of the Department Physician plays in the San Francisco Fire Department. Then lastly, i will provide opportunity for questions and answers. I will keep my presentation brief in deference to the chief and command staff so that they can discuss important matters with you. Any Mission Statement begins with a vision. Our vision is very simple. It is to support the mission of the San Francisco Fire Department. Our mission in the office of the Department Physician is plain and simple to protect the health and safety of the members of the department. One of the functions of the office is to guide, direct and advice members of the department concerning their health, fitness and to advise the chief on the individual members suitability for performing the essential functions of the job. In order to accomplish this, we evaluate all candidates for the San Francisco Fire Department in an effort to identify any medical condition that could affect their ability to perform the essential functions of their job and engage in emergency operations. Then we will also inform the chief of the department whether any individual candidate or a current member is medically certified to perform the essential functions of the job. We perform all of the medical examinations for all of the entry level positions in the Fire Department, and we also perform all of the promotional and probation air reexamines. The examination is quite extensive for candidates, not only does it involve ahead to toes examination we perform forensic testing in the office and we will obtain Laboratory Examinations that includes blood tests, ekg, pulmonary function tests, hearing tests, and all of these are geared towards identifying preexisting conditions that may impact an individuals ability to perform the job. We also will perform the commercial drivers exam for the handful of employees in the department who require that for their job, and for current members, we will evaluate the results of their hearing tests and in an effort to make sure that the department is in compliance with oshas Hearing Protection standard. In addition, we certify members for use of respirators as part of the osha protection program. Under the transmissible disease standard for which the Fire Department is a covered entity, we also will review the results of the annual Tuberculosis Testing that we perform for members. And since the standard also encumbers the employer to provide vaccines for transmissible diseases, we provide all of the vaccines that are covered under this standard. The affor mentioned programs in isolation may not appear to be significant, but they are a major component of the Departments Health and safety program. One thing that i would like to mention is that annual testing for tuberculosis is about to undergo a radical change in the United States as it pertains to healthcare workers, and since First Responders are considered to be covered under the healthcare worker, annual Tuberculosis Testing is going to go buy the wayside. Other entities have implemented the recommendations from the cdc, and the only barrier that prevents hospitals in california from making that change and for that matter covered entities, is a change in policy at the level of calosha. That is coming down the road. We also perform all of the return to duty evaluations for members of the department, and a return to duty evaluation is performed whenever a member has been in a period of temporary or partial total disability. The purpose of the return to work evaluation is to facilitate transition to regular duty. Then at the request of the department, we will also perform fitness for duty evaluations, depending on circumstances. The office of the Department Physician assisted with managing the assistance program. We are a liaison between the department and the Workers Compensation department in that role we provide advocacy for the member. We also assist in case management. We facilitate the scheduling of appointments, we facilitate the arrangement and scheduling of needed tests, and then we also serve as the vehicle for transfer of information that the division of Workers Compensation needs in order to adjudicate a claim or to manage a claim. For future opportunities we are always looking to reevaluation or operational activities, and to that end i would like to mention that we are near embarking on a new paradigm for tb and hearing testing in the department. We recognized a while back that the manner and logistics of how tb and hearing testing occurred in the department was logistically cumbersome so we put in place a plan for embarking on a mobile platform for bringing the tb test and hearing test to the station. We wont be able to bring it to every single station, but we will be able to bring the testing to individual battalions. Once we implement the mobile platform, we could also look at leveraging the program for bringing other services on a battalion basis to the members. Any questions . President nakajo thank you very much, doctor. Does that conclude your briefing this morning . Yes, sir. President nakajo all right. We will have members of the public to give Public Comment on the presentation. Any member of the public wishes to give a comment on this physicians report, please approach the podium. Seeing none, Public Comment is closed. We have questions or comments from the commissioners. Thank you very much, Vice President covington. Thank you for being here, doctor raymond terrazas. I have one question related to the performance of the dnz and dot commercial driver exams. Could you tell us more about your involvement in those . The office will perform those examine nations for members that need them. It is only a handful. Is it a physical or eye exam, what kind of exam. Full physical exam mandated by the department of transportation for any commercial driver or anyone who fits the definition of commercial driver, and there are various identifiers and requirements for the examination. So which members of the department would have to what are the titles of the members of the department that would have to come to you for this exam . They are mostly based out of the bureau of equipment. If you are going to drive a vehicle that has more than 12 passengers, you have to be certified by the department of transportation as a commercial driver before you can drive that vehicle. I see. All right. How long have you been head of the office of the department of the physician . 11 years, maam. During your tenure, have you seen any particular trends you would like to share with us in terms of the health of the department . One major change reflects the age breakdown of the department. When i entered the department, we were topheavy, so to speak. Quite a number of members in the department who were chronologically gifted. As younger members have come into the department with increased hiring in the last decade, the age profile of the department has changed, and, consequently, just when ever there is a change in the age profile within an organization, you are going to have a difference in injury rates. You will have a difference in sickness rates, and for that matter career ending injuries. The good news is that we have fewer careerending injuries. We also have many more women in the department now than previously. Have you noticed any particular challenges that women in the Department Face . Not in terms of their ability to perform their job. There is no question there is no difference there. There never was and there shouldnt be, but one has to recognize that the pressures that women face are going to be different than the pressures that men face just because of where our society is today, and that may exert some psychological stress of one degree or another. I am not saying they are more prone or they have more of one or the other, but their position in our society places excess pressures on them in that regard, and in that regard they may face a higher level of stress. But those are psychological as opposed to physical challenges. Are there any physical challenges you noticed . None. Nothing that would be gender specific . Correct. What about the incidents of cancer in the department . Cancer has always been an issue, and more and more because of changes at the division of Workers Compensation, cancer is more readily recognized as being work related. Fewer claims are being denied for cancer. There is an increasing body of evidence that clearly points to the fact that firefighting as a job is a carcinogen, and there is no dispute there. With continued exposure to fire suppression, with continued exposure to the hazards, toxins, chemicals, the cancerous soup that exists at any fire, there is always going to be exposure, and our members will always be at risk. From a medical standpoint, where would your profession, not you individually perhaps, but where would your profession rank firefighters in terms of the most challenging, physically challenging careers . No dispute there, high. Number one, two, three . As far as occupations, it probably is on par with law enforcement. Not as high as military because obviously military is the most, but it is up there. Then if you take into consideration that firefighters dont have access to certain Safety Equipment that may be other industries are able to use, you have to factor in the qualifier that firefights is far more hazardous. Okay. Thank you. You are welcome. President nakajo thank you very much. Commissioner. Good morning, doctor. How do you see your job as far as or the job of the person in this position as far as the eyes of the members are concerned . Let me know if you dont understand my question. Could you clarify, please. Commissioner veronese i am trying to understand. When a member comes into your office, is he coming to get a checkup or concerned about his job . Well, the most common context in which we are going to see a member is in the context of return to duty. You know, 90 to 95 of the time it is going to be an uncomplicated process. The member wants to come back to duty. There is no reason why they cant come back to duty and so we facilitate that. So the percentage of your time is spent on return to duty and what percentage would you call that . Is it 90 of your job is return to duty calls . I would say more like 75, 80 just because of the fact that the end probationary candidate exams occur throughout the year. How much of your job is Preventative Care . Since we are not involved in the actual care of individual members, technically speaking, it is minimal. However, every time we see a member for an examination for a return to duty, we talk about prevention. Why is Preventative Care minimal, using your own words, as part of the job of your office . What i a i am hearing if it is correct you said the health and safety of the members is the primary mission of your office. Why is Preventative Care not a bigger percentage of what you do . Maybe i misunderstand the question. You said Preventative Care is a small percentage of what you do. That is what i understood you said. Your idea of Preventative Care might be different than might be. The rubric that i am coming from is one where we engage the patient on a regular basis for continued followup and logistically in if way the office runs we dont have that opportunity for followup care. We have an opportunity when the member comes to the office to devote a portion of the time that we allocate for the member to prevention, yes. That is my question. Why isnt it a primary . If the mission of your office is to if the core mission of your office is health and safety of members, why isnt Preventative Care a larger portion of that . The structure in which we operate doesnt allow for that, and certainly on a casebycase basis if an individual member wants to come back for followup, that opportunity always exists. For example, in the course of an examination we discover that the members cholesterol level is elevated, we will ask first and foremost they address it with their primary care of course and care physician to address that issue and we invite them to follow up with us to make sure the cholesterol levels are improving. We dont mandate they do that. There is nothing within our structure that allows for that. Again, on a voluntary basis, it does happen from time to time. You said that twice now there is nothing in the structure of your office that provides that. What do you mean by that and why isnt there a structure if the primary mission of your office is to support the health and safety of our members . If there is a deficiency that we need to file structural deficiency to fill there. As a commission we need to know that. Why is it that members are only coming to you for return to work stuff . What that says to me is i am going to the Doctors Office to decide whether the future is strong at the Fire Department. That concerns me. I dont think, in my opinion, your office should be that. It should be what your mission says to promote health and safety of your members. If members are walking into your office thinking am i going to have a job when i walk out of here, that concerns me. I would prefer people are coming to your office saying how do i improve my health . What is it we can do as a Physicians Office to improve the health of the department. What strategies are we impleme implementing to improve the health of the department. What is the structural deficiency you are talking about . It speaks to the fact an individual member has a relationship with their primary care physician. They have entrusted the physician for guidance on those matters. When they have a concern, they will go to their primary care physician and get the advice that they seek. They may give us feedback. They may loop back with us to say, hey, i went to the doctor, they said this was going on. How do i ensure this doesnt impact my ability to do the job, and we will take a look and 99 times out of 100, the primary care physician is doing the right thing. Okay. The structural deficiency you are talking about is more of a protocol set where people are we dont see members of the department for physical health and welfare, they go to their doctor for that. If there is something that determines that they can do the job as opposed to doing what the primary care physician is doing, making sure the preventative measures are there to make sure that member is not contracting posttraumatic stress syndrome or cancer or any of the things we know are incidental and hazardous things that occur in this job . Am i reading that correctly . I would say yes. The member is entrusting their primary care physician for guidance on many of those issues, and again from time to time they may come back to us and say, hey, i went to see my doctor, they found i had this. How do i make sure this doesnt impact my ability to do the job. In that case we will provide consultation. We may even gauge in a conversation, dialogue with their primary care physician, and most of the time the doctor is doing the right thing. Do you think having that mentality as a member, looking at the office of the physician, your office, you and the people that work fo for you, having the mentality this is a meeting that could potentially take my paycheck away from me, do you think that is a productive mentality to have . Do you think it encourages members to come to your office to be open and honest about their Health Issues . I took time to answer that question because that is probably a question best addressed to the members. We dont see every Single Member on a regular basis. There are members who will we will see for a promotional exam and there is no reason for them to come into the office for years because they have not had an injury that required treatment, they have not had illness that introduced prolonged disability, they have been healthy. Without a mandatory periodic examination, there is no reason for them to come in so they are going to most of their medical encounters will occur with their primary care physician. They will always turn to their primary care physician for guidance. If you have a member that, for example, has attorney something in his leg, he is more likely to go to his doctor and talk to his doctor about that and get that fixed through the doctor than to come to you for care, correct . That is very true, yes. Under that circumstance you wont know whether or not that particular member is having that problem that may affect his job . Not at that moment. The only time that we will find out is if the member has been cleared by their doctor to come back to work. That is when we will know about it. If it occurred on the job, yes, we will know about it and we will always be ready for them to come back and request return to duty, but if it happened, you know, while they were on vacation in yosemite, we may not know about it. You know, there have been studies, and i used a broken leg or attorney something in your leg as metaphor for Something Else happening in the Fire Department. They say close to 30 some some level of ptsd or incidents of cancer is on the rise as well. How will you know unless it rises to physically impact their Job Performance or they filed something as a result of their Job Performance they have this particular ailment . We wont unless there is a mandatory periodic examination. Are there any Prevention Strategies that your office has implemented for any particular ailment relating to the health and safety of the department . Well, we have the ongoing respiratory protection program, we have the ongoing Hearing Protection program. Those are the big ones, but beyond that, no, there is no other prevention type program in place. What does the respiratory program aim to detect . First of all, it asks the question is the individual member do they have the ability to wear a respirator . Do they have a medical condition that could impact their ability to wear a respirator. How many of those do you get a year where people are impacted . Is that common . No, because the Overall Health of the department is pretty good. How many respiratory issues have you diagnosed in the last year . Well in the last month, not that we diagnosed but new respiratory diagnoses came to light in the last month. This is a Prevention Program related to respiratory disease. How many in the last year have you diagnosed . Through the respiratory protection program, none have been diagnosed. What was the other program, Hearing Program . Hearing. How many hearing problems have you diagnosed in the last year . Hearing loss will be identified on the hearing exam. I would say roughly about 15, 20 of the time. The good news is that most of the time the hearing loss isnt severe enough to impact the members ability to perform the job. It will be a new hearing loss and we track it to make sure it doesnt cross the threshold where it may impact their ability to perform the job. We seem to be finding results from the hearing Prevention Program and tracking those to make sure the health of that particular member with hearing problems is being treated or if they cant be treated at least tracked so we can see how the health of that member is doing. That is great to hear. In your entire presentation what i didnt hear until commissioner covington brought it up the word cancer or posttraumatic stress system or whatever else is ailing the department. My question is if it is one of your primary goals to implement, primary and secondary Prevention Strategies to the department, why arent we doing that in regards to cancer and in regards to ptsd. Why are we relying on the Cancer Prevention foundation for that stuff . Your question in my opinion goes to the issue of policy. Okay. On the policy issue, even though we have on paper a mandatory examination, it has been on hold for several years now. It has been on hold for several years because of the fact that even though it was mandatory, participation rates were low. Low enough that it was actually costing the department money in order to keep the program going. It was suspended several years ago, and that was one of the few programs that would have allowed identification of problems early enough that they could be addressed and in a timely manner that would not impact the members ability to do the job. So what i heard from you is that the office of the physician is not implementing Prevention Strategies for cancer because that would require somebody to participate in a mandatory way, and when that is done, members arent doing it . Is that right . Yes, but also keep in mind that if we dont have any other policy that mandates that something be done, we cant do anything. We need a policy. Without the policy there is no mandate for doing anything. Okay. Where does that policy come from the commission or the chief or from your office . I would say that it most likely is a collaborative effort. Doctor, here is my issue. Your office one of the primary goals of your office if you look at the job description, the very first duty in there is to develop and implement primary and secondary strategies for the Department Health and safety program. What i am hearing we are tracking hearing and lung capacity but not tracking ptsd or cancer or the unknown what is out there, to the extent that can be done, right . I am also hearing from you one of the primary reasons that a member comes to you is to decide whether or not that member is going to have a job when he comes out of your office because you are determining whether or not he has some sort of physical or mental impairment that will prevent him from doing the job, and i think that is very important. That is the primary reason why the member is coming to your office. I can totally understand why the member would not participate in the mandatory program. Do you understand that . Yes. Do you agree those two things are connectedded . Following your line of reasoning, yes. How do we make changes in this department . Maybe we can save that for a presentation, a future presentation. How do we make changes where we can get the members to come to or see your department as the place where they can get health and safety . Now they are currently looking at your department as a place where they could potentially lose their job. It is hard to see a doctor if they look at doctors as somebody that can take their job away. I know that is an important part that you have to be impartial in what you see and you have to report to the department because ultimately, you know, we are all here to make sure the public is protected and these members can do their job. How do we change that perception where a member looks at your department and says i want to spend as much time in there forever. I want to live as long as possible. I know this job has an incidents of cancer, ptsd and other stuff. And the other stuff with ptsd, alcoholism, addiction and divorces. How do we get your department to be the department that says i want to go there once a quarter because i want to be good at my job, i want to be there for my family past retirement. I want to live forever and be able to enjoy retirement. That is the biggest challenge of your office. It is one of the challenges inherent by the other factor we talked about. It is your job to make sure they can do the job. It is a challenge and needs to be a focus of your office because ultimately we are here to serve the members. The members cant serve the public unless their health and safety is our biggest concern. Now we have a new battalion chief that i am superexcited about that is going to be her daytoday job to think about these things, but to the chief and to you, doctor, this is your biggest challenge. It is something that we need to see some turnaround in the next year. People are now talking about ptsd, cancer. We have seen the cancer tests the urine analysis tests, right, chief . We had people show up for that thing like we have never seen before. We should look at that. Why did people rush to take the urinalysis test . Why are they rushing to do that . We need those policies to be sure they see your office that way, is that true . There is history with regard to the urine test. When the Department First implemented that, and most of the operational logistical and infrastructure was provided by the department, it was viewed as a department test. The participation rates were very low. When all of the infrastructure was transferred to the foundation, participatory rates began to creep up yearoveryear to where they are now. The farther the department was away from that test, the more it was viewed as a positive. What does that tell you, doctor . That ther there are two fact. There is culture within the department, and the need for education. We can provide all of the education we want. That is starting to come. We hope to see that. I am assuming that is happening from your office, too. Nothing prevents you from educating members of the department on best practices to avoid cancer to the extent possible or for that matter ptsd. That education could come from your office. I dont know whether or not it is. It could be and should be. To me what that says, and everybody in here probably has their own opinion about local 798s urinalsis test is successful and the departments isnt. My opinion is that people dont want to give your office their urine because they are afraid of losing their job. How do we mold your program to be as successful as local 798s program so we have people rushing in your office to give urine and blood to make sure their health and safety is being sought after . We have to look at what 798 is doing. Time is changing. I want to believe that members of this department are starting to wake up to these things. The fact that they are rushing to 798s program and afraid of our program for whatever reason is, i think, a lesson to us we need to learn from to try to change the unit to make it more inviting to test. Maybe make things more anonymous. Maybe passing a policy that says whatever results we find here arent going to impact your job unless your personal doctor says it does. Something like that that will not scare people away from wants to give you their results animalsis. We have no analysis. Do you have an idea of the health and wellness of the department, what the incidents of cancer are in the cancer . Do we know what percentage of members have cancer in the department . Off the top of my head, i couldnt give you the exact figure. Is something tracking that . Would you know if they have cancer unless it affects their job . We would know if they file a claim for it. If they dont file a claim we dont know. We dont know which members have performed tsd ptsd unless they have it. Now ptsd is now a workers compable illness so we will know when those workers comp things come in. There is no way of tracking that right now. We dont know what the health and safety of this department is today, and i think that is something we need to work on. Thanks, doctor, for your time. I hope if there are challenges in your department this commission can help with staffing or otherwise that you would bring those to us. Thank you. President nakajo thank you very much. Any other questions or comments with the doctor . Thank you very much, doctor raymond terrazas. I have a few things. In terms of your jurisdiction among the membership, how many of our membership are you responsible for in terms of our department . I would say everyone. Is that 1500 civilians in uniform . Correct. Would it be more than 1500 . Is that a pretty good figure . I believe we are at 18. Close to 18. Thank you, chief nic nichols. 18 total civilians in uniform. All right. In terms of the process and protocol, when a member is on duty and if the member is injured, that members injury is notified to the Physicians Office . Yes. Depending upon circumstance of that member on duty whether or not it is incident or whatever. Does the member report to you because of the incident be or go to their primary . If it happened on duty, if the member reports it as an on duty injury, we will know about it. Some of the time the member will call us following general orders to report their injury. Sometimes we have to reach out to the member to verify that, indeed, they were injured and then facilitate care for them. When a member is injured on duty, it is their duty to report to you at the Physicians Office and they do that on their own initiative . Correct. It doesnt go through the chain of command . It depends. The notice may come from the individual member or may come from their officer or we may have to reach out to the individual member. I am just talking about scenarios. Generally if that member is injured on duty, they report to you, but they report the incident to you but do they report physically to you . They dont have to because if they went to the emergency room for treatment of the injury and from the emergency room they were discharged to home, there is no reason to come back to the department maybe so they wont physically present to the office of the Department Physician. They will call in via phone, and the other reason why they may call in to the office of the Department Physician is because of emergency room didnt give them instructions what to do next, where to go for followup care if followup care is necessary. I am trying to follow this. It is supposed to be simple. I am trying to follow this that is member, he or she, if they are injured on duty, the first requirement or obligation or need is to deal with the injury. I am assuming they go through emergency or go through their physician and they dont necessarily report to you. What is reported to you is the incident report, but you dont see them physically for their injury. Is that pretty accurate . Correct. If they go to emergency and are discharged at home. If they dont call you in, you dont have any idea what happened with that injury, correct . Except for the fact we will review all of the injury reports every morning to see who was injured. We give them a little bit of time to call in and if they dont call in before the end of the day we receive notice, we will reach out to the member and speak to the member individually about the injury. When you say you follow up, meaning you or your nursepractitioner follows up . Correct. That incident of the injury is on the incident report by the command officer or captain or battalion chief, it is recorded, correct . It is recorded in the Department Information management system. If that occurs in the field, that goes to the computer that goes to your system as well . Yes, we have access to that information. If that member is injured or had followup with the physician, i automatic is prime i assume the primary physician, depending upon that injury does that mean that member is able to return to work or what is the protocol between that injury and the incident for being off for temporary work related modified duty or total disability . What is the steps in that. If they are discharged from the emergency room, they may or may not receive instructions from the er physician about what to do about work. Maybe they were but the information that is being thrown as they are leaving the emergency room, that may not be something that they remember. Or for that member it may not be documented in any of the forms, the multitude of forms that they get upon discharge from the emergency room. They might be trying to get back to work, not knowing that they need followup in one of the city and countys medical Provider Network clinics or providers for followup for that injury. They may have to go to one of these providers in order to get a return to duty note, whether return to regular or modified duty. All right. As i am trying to get clarity, i seem to be getting more confused. I will try to struggle through this as well. May i ask what question are you trying to get at. I am trying to figure out and get clarity on process and procedure. I know there are ranges of injuries. I am looking through the degree of injury, if it is severe i assume the member is being followed up. Huish shoes the notification that who would issue the notification to return to work . Also if the injury on duty might be a light juror such. Say the light injury. Say that member goes home. I am okay so i will go back to work. I am trying to find out if those scenarios apply as well . The most common scenario and logistically most simple is an injury that is reported during work hours, during normal business hours. The member is directed to go to one of the medical Provider Network clinics within the city and county of San Francisco. They go to the clinic, are evaluated for the injury. The doctor in the clinic issues the work status report to clearly identify the members work status. They go back to regular duty, placed on modified duty or placed completely offduty. Who is making that recommendation . The physician in the medical Provider Network clinic. Is that at the emergency unit or some other level . It is a clinic. That doctor is making the recommendation whether to return to work or get followup treatment . Correct. They are certified, so to speak, by the city and county of the San Francisco division of Workers Compensation to render medical treatment to that injured employee. If they have a scenario and cannot return to work, what does the member do next, report to the commander and stay home or tell me . There are different avenues that can be taken at that inflection point. The member may call our office to let us know that they were just seen in the clinic and the doctor put them off work. If they havent notified their officer that they were placed off work, then we will notify the Assignments Office to let them know the member has been placed off work. They will be put in off duty status. If the notice goes to the officer, the officer may then notify the battalion chief who may call into the Assignments Office to report that the member is off work. Or it may go to the division chief. I got the point of that. They are now known they cannot return to work until they get certain clearances. When do the members come see you at your office . The bulk of your work is in the report to duty scenario. I am trying to understand differentiation between temporary, total to modified. The members come see you because they have to see you. If they dont get clearance they cant return to work, is that accurate . That is accurate. They dont see you until they are in this category or if they get a shot or education. They come to see you workrelated . Thats correct. Is it in your job discretion you are the one that has authority to sign for them to go back to work or for modification. Our orders speak to that. In your 11 years of doctor, how many have you recommended for total removal is that something you cant answer or is that agria area . If we are, you dont have to answer that. I am curious. I dont believe i it is a h e. P. A. Violation. It has been a handful. They have appeal processes as well . Thats correct. What is the appeal process . If it is for work related injury, the appeal process goes through the states Workers Compensation system, and a independent physician will add e whether there is permanent or not. That is separate from the city and county of San Francisco. The severity in terms of approval going back to work has to do based on the return to duty clearance, is that correct . Can you repeat that . Again, i understand the members have to go to you to get clearance to return to work. Yes. You are the primary person to make that decision in terms of clearance to work . Within the department, yes. In terms of inf