VOL.81 NO.3 April 2008 $5.00
SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY
Eye to Eye Perceiving the World around Us
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CONTENTS SAN FRANCISCO MEDICINE April 2008 Volume 81, Number 3 Eye to Eye: Perceiving the World around Us
FEATURE ARTICLES
MONTHLY COLUMNS
10 Seeing with the Heart’s Eye Charles Garfield, PhD
4 On Your Behalf 5 Upcoming Events
12 In the Mind’s Eye Shieva Khayam-Bashi, MD 14 The Seeing Tongue Peter Weiss 16 The Feeling of Being Stared At Marilyn Schlitz, PhD 18 The Fear of Looking Steve Walsh, MD
7 President’s Message Steven Fugaro, MD, and Steve Heilig, MPH 9 Editorial Mike Denney, MD, PhD 30 Universal Health Care Update Mitchell H. Katz, MD 32 Hospital News
20 Saving Sight with a Smile Steve Heilig, MPH
34 In Memoriam Nancy Thomson, MD
21 Visual Disabilities in the United States Sunita Radhakrishnan, MD 22 Forever Young Gary L. Aguilar, MD Editorial and Advertising Offices
25 The End of Glasses Daniel Goodman, MD 27 Through a Glass Darkly Susan Kitazawa, RN 29 The Diving Bell and the Butterfly Eisha Zaid
1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon request. Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605
www.sfms.org
April 2008 San Francisco Medicine
ON YOUR BEHALF
April 2008 Volume 81, Number 3
A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay
Notes from the Membership Department
Cover Artist Amanda Denz
Exciting New SFMS Event! Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin
Shieva Khayam-Bashi
Toni Brayer
Arthur Lyons
Linda Hawes-Clever
Terri Pickering
Gordon Fung
Ricki Pollycove
Erica Goode
Kathleen Unger
Gretchen Gooding
Stephen Walsh
SFMS Officers President Steven H. Fugaro President-Elect Charles J. Wibbelsman Secretary Gary L. Chan
Don’t miss the SFMS night at the de Young Museum! Join SFMS members on Friday, May 9 for a reception—catered by Bon Appetit—on the eighth floor of the observation tower from 5:30 to 7:30 p.m., with access to the entirety of this stunning museum until it closes at 8:30 p.m. The cost for this exciting new event is just $20 (includes museum admission) for SFMS members and their guests. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@ sfms.org for more information or to RSVP (deadline is May 5).
Treasurer Michael Rokeach Editor Mike Denney
CME Forms
Immediate Past President Stephen E. Follansbee
Institute for Medical Quality is an important physician resource for CME. You may contact the organization or visit its website for forms and assistance at: The Institute for Medical Quality CME Certification Program 221 Main Street, Suite 210 San Francisco, CA 94105 www.imq.org Contact Paulette Richardson at (415) 8825183 or prichardson@imq.org. SFMS also has CMA forms available.
SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term: Jan 2008-Dec 2010
Jordan Shlain
George A. Fouras
Lily M. Tan
Keith Loring
Shannon Udovic-
William Miller
Constant
Jeffrey Newman
Term:
Thomas J. Peitz
Jan 2006-Dec 2008
Daniel M. Raybin
Mei-Ling E. Fong
Michael H. Siu
Thomas H. Lee
Term:
Carolyn D. Mar
Jan 2007-Dec 2009
Rodman S. Rogers
Brian T. Andrews
John B. Sikorski
Lucy S. Crain
Peter W. Sullivan
Jane M. Hightower
John I. Umekubo
Donald C. Kitt CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate San Francisco Medicine April 2008
40 Percent of Physicians Have Not Yet Registered Their NPI with Medi-Cal If you are among the 40 percent of physicians who have not yet registered their NPIs with Medi-Cal, your claims will be denied. Medi-Cal claims submitted without registered NPIs will not be paid. To ensure uninterrupted claims payment, physicians are encouraged to register their NPIs as soon as possible. Physicians can register their NPI with Medi-Cal using the National Provider Identifier Collection (NPIC) tool available on the Medi-Cal website (www.medi-cal. ca.gov).
Contact the Medi-Cal NPI Helpdesk at (800) 541-5555 (select option 16 and then option 18 for NPI registration).
SFMS Seminar Schedule Advance registration is required for all SFMS seminars. Please contact Posi Lyon at plyon@sfms.org or (415) 561-0850 extension 260 for more information. All seminars take place at the SFMS offices, located in the Presidio in San Francisco. April 18, 2008 Customer Service/Front Office Telephone Techniques 9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast) This half-day practice management seminar will provide valuable staff training to handle phone calls and scheduling professionally and efficiently. $99 for SFMS/CMA members and their staff ($89 each for additional attendees from the same office); $149 each for nonmembers. May 16, 2008 Managing the Team (for office managers and administrators) 9:00 a.m. to 12:00 p.m. (8:40 a.m. registration and continental breakfast) Motivating and Managing Your Office Manager (for physicians) 12:15 to 1:45 p.m. (12:00 p.m. registration and lunch) These two seminars are designed to help physicians and their office managers set expectations, manage change, and design a practice culture that helps the practice thrive. $99 for Managing the Team for SFMS/ CMA members and their staff ($85 each for additional attendees from the same office); $149 each for nonmembers. $69 for Motivating and Managing Your Office Manager for SFMS/CMA members ($59 each for additional attendees from the same office); $109 for nonmembers. www.sfms.org
$150 for both sessions for members; $225 for nonmembers. October 3, 2008 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training to handle phone calls and scheduling professionally and efficiently. 9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast) $99 for SFMS/CMA members and their staff ($89 each for additional attendees from the same office); $149 each for nonmembers.
cardiologists and heart researchers, to aid their understanding and management of coronary artery disease. Conference fee includes an evening banquet with healthylifestyle cooking demonstrations and olive oil tasting, set in the beautiful Monterey Peninsula. For more information, visit www. montereyheart.org.
June 12–15, 2008 Living on the Fault Line: Advances in Occupational Medicine The Claremont Resort and Spa, 41 Tunnel Rd., Berkeley, California 8:00 a.m. to 6:00 p.m. November 4, 2008 The California Society of Industrial Medi“MBA” for Physicians and Office Managers cine and Surgery (CSIMS), in conjunc9:00 a.m. to 5:00 p.m. (8:40 a.m. registra- tion with faculty from UCSF, is offering tion/continental breakfast) a continuing education seminar that will This one-day seminar is designed to provide address cutting-edge concepts regarding critical business skills in the areas of finance, practice, research, and policy in the field of operations, and personnel management. occupational medicine. Visit www.csims. $250 for SFMS/CMA members and their net for more information. staff ($225 each for additional attendees from the same office); $325 for nonmem- June 15–18, 2008 bers. ENDO 08: The Endocrine Society’s 90th Annual Meeting Other Upcoming Events The Moscone Center, San Francisco This meeting offers an unprecedented opMay 2–4, 2008 portunity to learn about the latest advances 2008 CMA Leadership Academy in endocrine research and clinical care Disney’s Grand Californian Hotel in Ana- while networking and collaborating with heim, California more than 7,000 colleagues from around Continuing the Academy’s standard of the world. Discover and evaluate the latest programming excellence, the 11th Annual advances in endocrinology. Hear from leadLeadership Academy looks from the past ers in the field. Choose from among more to the future to assess both broad trends than 200 educational programs, including and specific key developments affecting plenary symposia, updates, debates, and the practice of medicine in California and more. For more information, visit www. beyond. The realities of the present will endo-society.org. also be addressed with a series of practical and powerful workshops designed to help August 10–15, 2008 meet today’s medical practice challenges. Essentials of Primary Care: A Core CurVisit www.cmanet.org/leadership for more riculum for Ambulatory Practice information. Resort at Squaw Creek, North Lake Tahoe This course is designed to provide a compreMay 2–3, 2008 hensive “core curriculum” in adult primary Monterey Bay Regional Heart Symposium care. It will serve as an excellent update and Quail Lodge, Carmel Valley, California review for current primary care physicians Physicians are invited to attend this con- and other primary care professionals, and as ference, featuring nationally recognized an opportunity for specialists to expand their www.sfms.org
primary care knowledge and skills. Particular emphasis will be placed on principles of primary care, office-based preventive medicine, practical management of the most common problems seen in primary care practice, and expanded skills in clinical examination and common office procedures. Emphasis will also be placed on skills in dermatology, psychiatry, gynecology and women’s health, and neurology. For more information, visit www.cme.ucsf.edu.
Stay Up-to-Date with
www.sfms.org! Read the SFMS monthly e-mail bulletin, Action News, read San Francisco Medicine archives, and check the events calendar for upcoming SFMS events and seminars. Visit sfms.org today!
April 2008 San Francisco Medicine
Fantastic Member Events Just one of the many benefits of SFMS membership SFMS Night at the deYoung Museum Don’t miss the SFMS night at the de Young Museum! Join SFMS members on Friday, May 9 for a reception—catered by Bon Appetit—on the eighth floor of the observation tower from 5:30 to 7:30 p.m., with access to the entirety of this stunning museum until it closes at 8:30 p.m. The cost for this exciting new event is just $20 (includes museum admission) for SFMS members and their guests. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org for more information or to RSVP (deadline is May 5).
Also in the Works for 2008: The Togonon Gallery August! Watch for details.
and Jazz Mixer returns this
Another SFMS Night at the Symphony is in the works for October or November. More information will be available soon. In December bring the family to the second annual SFMS
Nutcracker Night!
Visit our website, www.sfms.org, to see more event listings, including seminars, CMA events, and other local events of interest. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org for more information.
SAN FRANCISCO MEDICAL SOCIETY
www.SFMS.org
president’s Message Steven Fugaro, MD, and Steve Heilig, MPH
Smoking Out UC “Until we have a nuclear war, the tobacco industry will continue killing more people than any other man-made cause.”
T
hat was the startling but true statement made by a researcher at a recent UCSF conference titled “It’s about a Billion Lives.” And it’s sadly true, for all the well-established reasons about tobacco being both addictive and lethal and because the tobacco industry has long done whatever it can to get more people smoking, especially young ones, all over the world. Which made it all the more distressing to learn that the University of California, Los Angeles, accepted $6 million from tobacco giant Philip Morris for the otherwise worthy purpose of studying nicotine addiction. This came as part of a Philip Morris research program that, since 2000, has supported 470 research proposals in 60 American medical schools. As part of this effort, in 2006–2007, the University of California received 23 grants for a total of $16 million in Philip Morris funding. UCLA researchers and officials, and even the UC Regents, seem to be participating in a strong bit of willful denial about what this really means. UCLA officials do admit “the idea for the study of teenagers and monkeys originated with Philip Morris.” But then comes this astounding quote, from UCLA’s vice chancellor for research: “I have no idea why Philip Morris decides to fund this antismoking research, but they do. As long as we do not feel that we are interfered with and that the research is done with the highest intentions, what’s in the mind of the funder is irrelevant.” With all due respect, that is scientifically and ethically naïve. Such a statement could have been made with some validity—due to lack of information—a generation or so ago. Now we know, from decades of research and disclosure of tobacco industry documents, and in other fields such as pharmaceutical marketing, that the source of funding and the motives actually make a big difference. The differences come in terms of outcome of the actual research, behavior of clinicians and others who read and are influenced by it, marketing activities of the profit-motivated funders, and more. These influences are found even when there is no outright mention of the funder’s name—that’s one of the little mysteries of human motivation and the altering of it, and the tobacco and other industries seem to know as much or more about that than anyone else. www.sfms.org
This is why, after numerous embarrassments, most leading scientific and medical journals have adopted much stricter “conflict of interest” disclosure policies, with source of funding for research being the main reason for that. It’s also why a rapidly growing number of professional schools and entire universities also have stricter policies, including many banning such funding outright. Philip Morris’s spokesman avers the company has “no intention of using the results or teenagers’ brain scans to develop more addictive cigarettes. We would never do that.” The problem is that they already have, as shown by long and lethal evidence proving otherwise. The tobacco industry’s now-defunct Tobacco Institute was a lobbying arm disguised as a research center, and it finally closed when that became clear to everyone. Now Philip Morris, under similar pressure, has just abandoned the particular research program UCLA participated in, but more such funding is expected from them and other “Big Tobacco” companies. UC researchers and officials should know all this and act accordingly. Saying that they “monitor” such funding carefully, while no doubt true, is not enough. The UC Regents should adopt and adhere to a strict UC-wide policy that does not allow for any tobacco funding of research at this great tax-supported university system. Until that occurs, the evidence will keep showing us that money can buy just about anything, including denial.
April 2008 San Francisco Medicine
Eye to Eye Anatomy: On the left is a 14th century drawing by the anatomist Guido da Vigevano. The dissector looks eye to eye at the corpse in personal relationship, his left hand embracing the body, and his right hand seeming almost reluctantly to use the knife. On the right is the famous 15th century illustration of the famous anatomist Andreas Vesalius. In this picture, the human body is mostly excluded from the scene. The anatomist is not in relationship and looks away from the corpse, holding a dissected arm as a specimen to be viewed with detached observation. Some have noted this to be an artistic illustration of the transition during the Renaissance from a subjective interrelated attitude toward the body to a more detached, objective and scientific way of experiencing the art of medicine.
San Francisco Medicine April 2008
www.sfms.org
Editorial Mike Denney, MD, PhD
An Eye on the Heart
A
t a recent dinner party, a young heart surgeon was asked by a woman from across the table what it felt like actually to look at and touch another living person’s heart. Trying to share his surgical experience objectively, he replied, “Well, let’s see, it looks like pictures you’ve seen in anatomy books, and it feels something like, maybe, holding a piece of sirloin steak in your hands.” As the conversation turned to other topics, most participants seemed unaware of the disappointed look on the woman’s face. When she asked how it “felt” to look at another’s heart, she had wanted to know more about the young surgeon’s subjective feelings—poetically, how his heart felt when he was looking at and touching the heart of another human being. In this issue of San Francisco Medicine, with its theme of the eye and its function, we might notice that the scientific objectivity of this young surgeon, seemingly so essential to modern physicians, may be derived from the etymology of the word object. According to the Oxford English Dictionary, the noun object means that which is thrown, put in the way of, interposed, exposed, or placed before one’s eyes; that which is presented to the view or perception. In regard to this relationship of the eye and objectivity, the philosopher, poet, and psychologist Robert Romanyshyn, in his book Technology as Symptom and Dream (Routledge, 1989), postulates that the foundations of modern scientific thought might have begun around the year 1425, when artists Filippo Brunelleschi and Leon Battista Alberti invented linear perspective vision. In fourteenthcentury paintings, which today we might consider to be distorted, the viewer seems to belong within the landscape or cityscape, with buildings or other objects surrounding the onlooker. However, in fifteenth-century linear perspective vision, with its more “realistic” distant vanishing point, horizon, and ever-decreasing proportions, the viewer is a detached, objective observer. In the medical world, this phenomenon of the eye as isolated observer was expressed in the development of the study of human anatomy. The Dutch psychiatrist and philosopher J. H. van den Berg, in his book Medical Power and Medical Ethics (W. W. Norton, 1978), notes that in the fourteenth-century drawings by the Bolognese anatomist Vigevano, the dissector remains in relationship to the corpse, looking eye to eye, while his left hand holds the body caringly and the right hand performs the dissection. By the year www.sfms.org
1543, the famous woodcut of Vesalius depicts an anatomist who looks not at the corpse but at the viewer, objectively displaying the tendons, nerves, arteries, and veins of a dissected human arm, a specimen to be viewed with detached linear perspective vision. By the year 1628, William Harvey, who studied anatomy at Padua, focused a studied eye upon valves, arteries, and veins, and by mechanically calculating flow demonstrated that the heart is a pump. Before Harvey, the heart was, in the poetic words of psychologist James Hillman, “My love, my feelings, the locus of soul and sense of person . . . and the unfathomable divine.” Within the single vision of science, however, the heart becomes merely a mechanized pump. Throughout history there were those who protested the triumph of the objective eye over the feeling heart. In 1602, the philosopher Giordano Bruno was burned at the stake because of his insistence that philosophy should not be divorced from science. In the early eighteenth century, Giambattista Vico espoused the verum factum principle that truth is not verifiable through science alone. The great poet and scientist Johann Wolfgang Goethe, in his treatise Theory of Colors, challenged Newton’s numerical spectrum of colors and included the subjective experience, saying, “The blue of the sky reveals to us the basic law of color. Search nothing beyond the phenomena.” Perhaps the most succinct yet all-pervasive voice against a purely secular, mechanistic, and scientific view of the universe is the poet William Blake’s protest against the single-vision objectivity of the order of the stars, planets, and the whole universe solely according to the law of gravity, when he said, “May God us keep from single vision and Newton’s Sleep.” And so it seems that we physicians, practicing objective scientific medicine on deeply subjective human beings, have a choice. We can objectify our work with single vision, like the young surgeon at the dinner table, in which case the heart looks like a picture in a book and feels like a sirloin steak. Or we can add to our science our own subjective feelings, and with an eye on the heart acknowledge it as a locus of love and the unfathomable divine.
April 2008 San Francisco Medicine
Eye to Eye
Seeing with the Heart’s Eye Bearing Witness or Remaining a Bystander Charles Garfield, PhD
S
ir Arthur Conan Doyle, a young ophthalmologist in 1887, found himself bored and alone in his consulting room at 2 Upper Wimpole Street, waiting for patients who never came. In a flash of inspiration he created Sherlock Holmes, the detective whose powers of observation would astound the people with whom he came in contact. As we all know, the fictional Holmes possessed an uncanny ability to observe, a cultivated capacity to spot clues. Not really. What is more important is that Conan Doyle, an eye doctor whose work naturally included improving the observational abilities of his patients, heeded an intuitional summons to correct course, to fill empty hours by writing about what he valued most. In so doing, he created the quintessential observer whose capacity to bear witness, to pay attention without prejudice, knew no equal. Conan Doyle’s course correction in the service of his calling is every bit as impressive as the sleuthing of his creation, the amazing Sherlock Holmes. Like many health professionals in our day who have awakened to a willingness to imagine, bear witness, and respond compassionately to the suffering of other human beings and all life, Holmes knew, as the pioneering psychologist Abraham Maslow put it in The Farther Reaches of Human Nature, that “we are not in a position in which we have nothing to work with. We already have a start; we already have capacities, talents, direction, missions, callings.” Today, more and more health professionals are moving beyond the perceptual limitations of mechanistic technological medicine and making themselves available as witnesses to societal suffering and servants to the greater good. Doctors, nurses, mental 10 San Francisco Medicine April 2008
health professionals, and clergy have come to see not only their patients but all living beings, in the words of ecophilosopher Thomas Berry, as “a community of subjects, not a collection of objects.”
“Today, more and more health professionals are moving beyond the perceptual limitations of mechanistic technological medicine and making themselves available as witnesses to societal suffering and servants to the greater good.” Just as Sherlock Holmes was the quintessential observer of clues, more than fifteen thousand Shanti volunteers in San Francisco alone have been quintessential witnesses to suffering. They are men and women who have chosen to move beyond bystander status and to listen, speak, and act from the heart as people with AIDS or cancer shared their experiences and fears openly and honestly. These volunteers, who have provided more than three million hours of service to more than twenty thousand clients, understand that what they do is not psychotherapy but peer support based on compassion, honesty, and consistency—qualities many people possess. But usually, the volunteers’ presence is their most valuable service. They are often the only people to whom clients can truly express the chaos of their present, their anxiety about the future. This acceptance allows Shanti clients to find moments of peace;
for volunteers, moments of grace; often, for both, moments of love and transcendence. Like health professionals who have discovered the therapeutic value of bearing witness to the suffering of others, Shanti volunteers learn the value of cultivating what philosopher Kelly Oliver has called “the loving eye, a critical eye, always on the lookout for the blind spots that close off the possibility of response-ability and openness to otherness and difference”—including all individuals suffering the pain of societal marginalization and discrimination. Oliver points out in her book Witnessing (University of Minnesota Press, 2001) that the “loving eye” sees farther and deeper than mere recognition of an otherness conferred by a dominant group on those who suffer. It sees into a love that “requires a commitment to the advent and nurturing of difference,” an openhearted embracing of difference in otherness. The loving eyes of Shanti volunteers and all health professionals who have moved beyond the status of bystanders to deep suffering are, in the words of Marcel Proust, “new eyes” that see “the universe through the eyes of another, a hundred others” and thereby “the hundred universes that each of them sees.” These are “new eyes” that look at patients not with an objectifying gaze but with a deeply empathic look of both an eyewitness and one who bears witness to the unseen, often inarticulate experiences welling up in the being of another. Oliver also contends that “subjectivity and humanity are the result of witnessing,” and for Shanti clients it is the witnessing of their stories that counts most. For it is only when one can tell his or her story to a compassionate witness that one can articulate one’s inner self and the considerable www.sfms.org
suffering it has endured. In sharing one’s story with such a witness, one simultaneously shares it with one’s self. Whether the story is told by a wealthy woman with cancer to a physician who recognizes the life still left in the patient and helps her find meaning in her final days, or by an errant teenager with AIDS to a volunteer who gently helps him reconnect with his parents, time and again we hear from our patients how much they appreciate those who take the time, as the poet John Milton wrote, to serve as they “only stand and wait.” The willingness to move beyond the bystander, to listen to the stories of those we serve, bear witness to their suffering, and act with compassion, is a core capacity of almost all of us. This is vastly different from what skeptics have believed, that so many people are hopelessly self-absorbed. People will challenge their precious peace of mind to serve others, not because they are prodded to do so but because such caring enhances their own sense of inner peace and well-being. Shanti volunteers never have the satisfaction of saving a life, easing bodily pain, or stopping the spread of disease. Day after day and year after year, they confront the suffering of their clients, at times forming close bonds with people they know will die. Given that the majority of volunteers are under the age of forty, they open themselves to the inner turmoil and perplexing questions that typically accompany a head-on collision with mortality, a self-examination most people try to avoid until the later stages of life, if they engage in such inquiry at all. How much easier it would be, or so it may seem, for these twenty-, thirty-, or fortysomethings to remain bystanders. They could be the men and women actually present to the suffering, neighbors of those afflicted, who choose to remain detached, uninvolved. For years we watched good people remain silent and do nothing as AIDS ravaged the communities of gay people and people of color in epicenter cities across the nation. How much suffering is too much to watch and still remain silent? How long can we say, “I’m too busy” or “It’s not my problem” and retreat quietly to our jobs and homes, not-so-distant witnesses www.sfms.org
to tragedy? Many of us remember how brave community activists and compassionate health professionals and volunteers held up a mirror for all bystanders when they marched in the 1980s and 1990s with banners proclaiming the painful truth, “silence equals death.” Their moral courage showed us the wisdom of Martin Luther King, Jr.’s counsel that “our lives begin to end the day we become silent about things that matter.” How do we make sense of the bystander’s passivity, both our own and that of others? Have we learned to see ourselves as powerless and therefore innocent even in the face of tragedies we know about? No less a figure than Albert Einstein reminded us that “those who have the privilege to know have the duty to act.” How will we choose to view ourselves in these perilous times? As powerless outsiders? Innocent bystanders? Responsible witnesses? Involved citizens? Has the bystander become a twenty-first century archetype gripping us into inaction even in the face of global climate change and planetary devastation? Paul Hawken offers us an antidote in Blessed Unrest (Viking, 2007) when he writes about the more than one million environmental, social justice, and indigenous rights organizations around the world that collectively constitute “humanity’s immune response to toxins like political corruption, economic disease, and ecological degradation.” What happens to us when we observe a steady stream of tragedy and suffering close to home and throughout the world? What happens when we feel an emotional response to such events but are unable or unwilling to respond? What is the cumulative impact of what we’ve become accustomed to? Dr. Richard Hazler, Associate Professor of Counselor Education at Pennsylvania State University, has found that adult and children bystanders who witness repeated abuse inflicted on others may experience both a psychological and physiological stress level that, over time, can equal that of the victim. In his book Bowling Alone (Simon & Schuster, 2000), sociologist Robert Putnam poignantly diagnosed the disintegration of community in America. Shanti and other
volunteer organizations offer a remedy for this national deterioration, demonstrating that in connecting to another human being through a compassionate act, we deepen the connection to ourselves; when we bond with others who serve, we strengthen our community. Volunteering is one of the best therapies in our society. Through active involvement in our own communities we break through the dominant suffering of our era—the loneliness and emptiness we feel in seeing and living life from a protective distance, blind to the view of the loving eye; the sense many people have of losing one’s life while living it. Charles Garfield, PhD, is an author, lecturer, Clinical Professor of Psychology in the Department of Psychiatry at UCSF Medical School, and founder of Shanti, a widely respected AIDS and cancer service organization. He is a Visiting Scholar at the Graduate Theological Union in Berkeley and a founding faculty member at the Metta Institute End-ofLife Counseling program.
Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from full-page, 4-color display ads to classified ads with discounted rates for members. Please contact Ashley Skabar for more information, (415) 561-0850 extension 240 or askabar@sfms.org.
April 2008 San Francisco Medicine 11
Eye to Eye
In the Mind’s Eye “Hysterical Blindness” Examined Shieva Khayam-Bashi, MD “The pain of the Mind is worse than the pain of the Body.”—Publilius Syrus (first century B.C.)
W
hen Ray Charles was around five years old, he watched his younger brother drown in a washtub. He gradually began to lose his vision, and over the following year or two, he ultimately became blind. The cause of his blindness is not certain; it has been surmised that he may have had glaucoma. It has also been surmised that his vision loss might have been a case of “hysterical blindness.” He never recovered his vision. A healthy fifteen-year-old girl had just learned that her boyfriend was cheating on her; she left school early to go home, only to find her mother in bed with a strange man. While running out of the house, she tripped and fell. She did not hit her head or lose consciousness, but when she got up, she realized that she was completely blind. After normal examinations by her primary care doctor, ophthalmologists, and neurologists, and after normal brain MRI and EEG, the diagnosis of visual conversion reaction was made. Several months later, she recovered full vision. Conversion reactions are an ultimate illustration of the mind-body relationship at work. It is a disorder whose hallmark is the appearance of a symptom or loss/ alteration of physical function, suggestive of a neurological or other medical illness, but it is actually an involuntary physical expression of a psychological conflict. The symptom is most commonly motor, sensory, or seizure, and there is no deducible organic pathology or physiologic explanation for the symptoms. Visual conversion reaction, sometimes called “ocular hysteria” or “hysterical blindness,” 12 San Francisco Medicine April 2008
is one type of conversion disorder, which is classified in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV) under Somatoform Disorders. Historically, the diagnosis of conver-
“Conversion reactions are an ultimate illustration of the mind-body relationship at work.” sion disorder has been controversial. In the nineteenth century, conversion disorder was recognized as “hysteria,” a disorder of the mind, which was mainly noted to be an affliction of women, since women were felt to be more susceptible to emotional effects of fear, anger, sexual repression, and overall sensitivity. In the early twentieth century, it was studied further by neurologist JeanMartin Charcot and psychiatrists Pierre Janet and Sigmund Freud. The term “conversion” originates from Freud’s explanation that psychological/emotional distress is repressed and is unconsciously “converted” into a physical condition, thereby relieving the patient of the psychological/emotional distress. It was during World War I that conversion disorders were seen more in men and were referred to as “war neurosis” or “traumatic neurosis.” In fact, conversion reactions were one of the main causes of neuropsychiatric collapse in World War I soldiers. Conversion reactions often occurred after witnessing severely violent incidents, or after traumatic injuries, whether mild or severe. They usually occurred after a soldier reached a place of relative safety,
and could even occur hours, days, weeks, or months after the incident. Persons who experienced conversion reactions very often had no previous history of personality disorder or psychiatric disturbances. It has been estimated that 25 to 70 percent of office visits to primary care doctors involve psychological distress that takes the form of somatic/physical symptoms. This is not news to anyone who practices in primary care, as we often see the physical manifestations of emotional stresses. However, the incidence of actual conversion disorder is much less common, and it is estimated that lifetime prevalence in the general population may range anywhere from 10 to 300 cases per 100,000 people. Estimates are difficult and vary considerably, but conversion disorder may occur in 5 to 15 percent of psychiatric outpatients and may account for about 1 percent of diagnoses in outpatient neurologic practices. Conversion disorders seem to be more common in women, in less educated individuals, and in lower socioeconomic classes. Conversion reactions usually involve neurologic dysfunction, such as disorders of speech, balance, gait, involuntary movements, pseudoseizures, sensation loss in limbs, paralysis, and visual and hearing losses. As such, conversion disorders are often referred to as “pseudoneurologic syndromes” and usually do not include gastrointestinal, genitourinary, cardiac, or pulmonary problems. This disorder is to be differentiated from malingering, somatization disorder, hysterical personality, hypochondriasis, and psychogenic pain. Of conversion disorder symptoms, visual/ocular symptoms are much more rare but do occur. Blindness is the most common presenting symptom in Visual Conversion www.sfms.org
Disorder, sometimes called pseudoneuroophthalmologic syndrome. In the blindness of visual conversion disorder, patients often complain of sudden and complete loss of vision, but it can also be a more gradual process. Other visual symptoms, which are not explained by organic pathology, can include amblyopia, amaurosis, visual field defects, color blindness, diplopia, ptosis, and unilateral gaze paresis. Careful history and physical exams usually help to clarify the diagnosis, and organic pathology must first be ruled out. Often, a careful history can uncover a psychological trauma that preceded the visual change. A thorough ophthalmologic examination, including normal pupillary reactions and funduscopic exam as well as intraocular pressures, should exclude all organic causes, except cortical blindness. Visual conversion disorders are complex and not common enough to be well understood in medicine. Use of alternative names for “conversion,” such as “hysterical,” “psychogenic,” “nonorganic,” and “functional,” seem to propagate a perception of controversy and doubtfulness of a real condition. In this condition, there is a “primary” gain to the patient, in that his/her unconscious “conversion” of a severe psychological stress into a physical one allows for relief from the psychological distress. But there can also be “secondary” gain from the physical loss/symptom, such as financial gains from disability benefits, greater attention from others, and relief from home or work responsibilities. As a result, it is often with a skeptical eye that a physician will approach a patient with conversion disorder, in order to try to distinguish it from feigning or malingering for secondary gains. Several years ago, I volunteered in a small clinic in a very remote village high in the mountains of Guatemala. One night, a knock at the clinic door awoke me, and I found many members of a family holding candles and asking me to go to see the oldest daughter, who had suddenly gone blind. We walked on the dirt paths and through the woods for almost an hour to get to their small family hut, where the young woman was lying calmly on the floor, and family members were anxiously tending to her. I learned that she had had to go to www.sfms.org
the capital city that day, to a government office. This was her first time to leave her village, and she had to ride on buses for hours to get to the city. Upon arrival, she felt overwhelmed and “terrified” by the traffic, clamor, and pandemonium of the city. She felt overwhelming fear for her life, and it was a wonder that she finally found her way back home after dark. Once she arrived safely at her home, she collapsed and fell blind. To my surprise, the young woman did not appear distressed by her sudden bilateral vision loss, though she could not even see my fingers in front of her face. Her pupillary and neurologic exams were normal. Since I had no mydriatic drops, a thorough funduscopic exam was challenging, but it appeared normal as far as I could tell. Her eyes were neither painful nor red, cardiac exam revealed no murmur, and carotid exam was negative for bruit. Her family believed that her blindness was likely due to her severe emotional response to the intense fear of the day’s experiences. Though I really wished for an ophthalmologist to consult, I concurred with the family’s explanation since her exam was normal; I reassured her that she would likely regain her vision by the morning. They thanked me and escorted me back to the clinic, while I prayed endlessly that she would indeed regain her vision and that I was not missing something serious, though I could not come up with many etiologies to explain sudden bilateral vision loss in a healthy young woman. Indeed, by morning she regained full vision; the diagnosis was visual conversion disorder. Her apparent lack of concern for her loss is referred to as “la belle indifference” and is not uncommon in conversion disorders. A family history is also common, and I later learned that her mother had had a similar reaction when going to the city herself many years previously. I also learned of a possible cultural component, in that it is known in this small village that “going to the city” can be a very horrifying experience, one that has caused frightful maladies to other villagers in the past. This experience of visual conversion disorder demonstrates the intimate communication between mind and body. In conversion disorders it could be inferred
that, in certain intense situations, it is more tolerable for the body to experience a physical problem than for the mind to suffer a deeply painful emotional one, so the conversion from emotional to physical seems the only option. In the first century B.C., Publilius Syrus encapsulated the issue this way: “The pain of the Mind is worse than the pain of the Body.” It was in the seventeenth century that the French philosopher and scientist Rene Descartes shared his conclusion that mind and body were separate entities. Descartes was not the first to conceptualize such a distinction, as Plato also outlined this as well. Later scientists and physicians have accepted the model of separatism/dualism, division between mind and body, in an increasingly reductionistic model of practicing medicine. In recent years, however, the dualism model has been challenged by a return to the concepts of integrative medicine and holistic health care, in which mind and body are inseparable. Conversion disorders are one clear example of this connection. Country singer Naomi Judd once said, “Your body hears everything your mind says.” To many of us who appreciate the real principles of holism and integrative medicine, this rings true in all aspects of mental and physical health. It is vividly evident in cases when the mind’s eye goes blind as a result of severe emotional stress. Shieva Khayam-Bashi, MD, is Associate Clinical Professor in the Department of Family and Community Medicine at UCSF and at San Francisco General Hospital, and she is Medical Director of the short-term Skilled Nursing Facility at SFGH.
April 2008 San Francisco Medicine 13
Eye to Eye
The Seeing Tongue In-the-Mouth Electrodes Give Blind People a Feel for Vision Peter Weiss
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lind since birth, Marie-Laure Martin had always thought that candle flames were big balls of fire. The 39-year-old woman couldn’t see the flames themselves, but she could sense the candle’s aura of heat. In October of 2001, she saw a candle flame for the first time. She was stunned by how small it actually was and how it danced. There’s a second marvel here: She saw it all with her tongue. The tongue, an organ of taste and touch, may seem like an unlikely substitute for the eyes. After all, it’s usually hidden inside the mouth, insensitive to light, and not connected to optic nerves. However, a growing body of research indicates that the tongue may in fact be the second-best place on the body for receiving visual information from the world and transmitting it to the brain. Researchers at the University of Wisconsin, Madison, are developing this tongue-stimulating system, which translates images detected by a camera into a pattern of electric pulses that trigger touch receptors. The scientists say that volunteers testing the prototype soon lose awareness of on-thetongue sensations. They then perceive the stimulation as shapes and features in space. Their tongue becomes a surrogate eye. Earlier research had used the skin as a route for images to reach the nervous system. That people can decode nerve pulses as visual information when they come from sources other than the eyes shows how adaptable, or plastic, the brain is, says Wisconsin neuroscientist and physician Paul Bach-y-Rita, one of the device’s inventors. “You don’t see with the eyes. You see with the brain,” he contends. An image, once it reaches an eye’s retina, “becomes 14 San Francisco Medicine April 2008
nerve pulses no different from those from the big toe,” he says. To see, people rely on the brain’s ability to interpret those signals correctly. With that in mind, he and his col-
“A growing body of research indicates that the tongue may in fact be the second-best place on the body for receiving visual information from the world and transmitting it to the brain.” leagues propose that restoring sight is only one of the many trajectories for their research. Restoring stability to those with balance disorders is another. So is bestowing people with brand-new senses, such as the capability to use heat to see in the dark.
Restoring Lost Vision First things first, however, and for the Wisconsin scientists that means restoring lost vision. Swapping the sense of touch for sight is not a new idea. In the 1960s, Bachy-Rita, his colleagues, and other scientists began developing and testing devices that enable the skin of blind people to pick up visual information. For Bach-y-Rita, the experiments also provided insight into the brain’s plasticity. His more general goal has been to find out how well one sense can take the place of another. Until the 1980s, “one of the axioms of neuroscience was that there was no plastic-
ity in the adult central nervous system,” says Edward Taub of the University of Alabama in Birmingham. Today, the field has turned around in response to many studies, including Bach-y-Rita’s. Now, scientists view the brain as almost as malleable in old age as in youth, he adds. The idea of tongue as eye evolved from the earlier skin-as-eye studies. Bach-y-Rita and his coworkers had been placing touchstimulating arrays on areas of people’s skin, such as the back and the abdomen. The scientists used either electrodes or little buzzers to excite nerve endings of the skin in a pattern that corresponded to visual images. They found that after receiving training, blind people using these systems could recognize shapes and track motion. Some subjects could perceive the motion of a ball rolling down an inclined plane and bat it as it rolled off the plane’s edge. Others could carry out an assembly-line task at an electronics plant. It required them to recognize glass tubes lacking solder and then to deposit some solder into those tubes. These results impressed Bach-y-Rita and his colleagues enough to begin trying to apply their basic research toward designing aids for the blind, he says. The researchers’ early systems had the look and feel of what they were—experiments. The buzzers were noisy, heavy, and power hungry. Although electrodes could stimulate nerves quietly and efficiently, high voltages and currents were necessary to drive signals through the skin. That sometimes led to uncomfortable shocks. Because of these drawbacks, Bach-yRita began thinking about the tongue. “We brushed him off,” recalls coworker Kurt A. Kaczmarek, an electrical engineer and perwww.sfms.org
ception researcher, also at the University of Wisconsin. “He tends to be a bit ahead of his day.” In time, however, Kaczmarek was convinced. “One day, I said, ‘Okay, Paul. Let’s go up to the lab and try it.’ It turns out, it worked quite well,” he says. Tongue stimulation, however, isn’t the only way to circumvent blindness. One competing approach, for example, is to implant microchips in the eyes or brain. Another scheme, devised by a Dutch scientist, converts images to what he calls soundscapes, which are piped to a blind person’s ears.
Tongue Stimulation To Bach-y-Rita, his team’s switch from skin to tongue stimulation was crucial. “We now, for the first time, have the possibility of a really practical [touch-based] humanmachine interface,” he declares. He and his coworkers founded the Madison-based company Wicab to exploit the potential. Kaczmarek points out the fledgling company may be in for some competition, since a German inventor already has been granted a U.S. patent for a tongue-vision system. “Using the tongue for seeing is a whole new approach. . . I think it has great promise,” says Michael D. Oberdorfer, program director for visual neuroscience at the National Eye Institute in Bethesda, Maryland. His office has been funding some of the Wisconsin group’s work. The tongue is a better sensor than skin for several reasons, says Bach-y-Rita. For one, it’s coated in saliva—an electrically conductive fluid. So stimulation can be applied with much lower voltage and current than is required for the skin. Also, the tongue is more densely populated with touch-sensitive nerves than most other parts of the body. That opens up the possibility that the tongue can convey higher-resolution data than the skin can. What’s more, the tongue is ordinarily out of sight and out of the way. “With visual aids to the blind, there are cosmetic issues,” says Oberdorfer. “And you’d want something easy to wear that doesn’t interfere with everyday activities.” Currently, the Wisconsin researchers’ tongue-display system begins with a camera www.sfms.org
about the size of a deck of cards. Cables connect it with a toaster-size control box. Extending from the box is another cable made of flat, flexible plastic laced with copper wires. It narrows at the end to form the flat, twelve-by-twelve, gold-plated electrode array the size of a dessert fork. The person lays it like a lollipop on his or her tongue. Stimulation from electrodes produces sensations that subjects describe as tingling or bubbling. The Wisconsin researchers say that the whole apparatus could shrink dramatically, becoming both hidden and easily portable. The camera would vanish into an eyeglass frame. From there, it would wirelessly transmit visual data to a dental retainer in the mouth that would house the signal-translating electronics. The retainer would also hold the electrode against the tongue. The tongue display still has a long way to go in terms of performance, the researchers admit. In the Brain Research (July 13, 2001), Bach-y-Rita and his colleagues Eliana Sampaio and Stéphane Maris, both of the Université Louis Pasteur in Strasbourg, France, report results from the first clinical study of the tongue display. After an initial, brief training period, 12 first-time users—6 sighted but blindfolded and 6 congenitally blind, including Marie-Laure Martin—tried to determine the orientation of the E’s on a standard Snellen eye chart. On average, they scored 20/860 in visual acuity. The cutoff for legal blindness is 20/200 with corrected vision. “It’s not normal sight,” comments Taub. “It’s like very dim shadows. But it’s remarkable. It’s a beginning.” One obstacle to better vision with the device is the low resolution of its 144electrode display. Engineers on the team say they expect to quadruple the array density in the next few years. A more serious problem is the range of contrast that can be replicated on the tongue, Kaczmarek notes. In a typical image, the eye may simultaneously see lighted regions that are 1,000 times brighter than the dimmest ones. But the ratio of strongest to weakest tongue stimulation can only be about 3 to 1. “That’s one of the things we’re struggling with,” Kaczmarek says.
Visual Sensations Exactly how the tongue supplies the brain with images remains a focus of the Wisconsin team’s research. In his 1993 book, The Man Who Tasted Shapes (Putnam), Washington, D.C.-based neurologist Richard E. Cytowic made much of how flavors stimulating the tongue of a friend and, later, an experimental subject would elicit visual sensations. However, that type of involuntary and poorly understood sensory blending, which is known as synesthesia, probably goes beyond what’s needed to explain the operation of the tongue display, Bach-y-Rita says. Instead, there’s plenty of evidence, he says, that even those brain regions devoted almost exclusively to a certain sense actually receive a variety of sensory signals. “We showed many years ago that even in the specialized eye region, auditory and tactile signals also arrive,” he notes. Also, many studies over the past forty years indicate that the brain is capable of massively reorganizing itself in response to loss or injury. When it comes to seeing via the sense of touch, reorganization may involve switching portions of the visual cortex to the processing of touch sensations, Bach-y-Rita says. In that vein, the first clinical study of the tongue device showed that users got better with practice. Of the dozen subjects in the initial evaluation, two went on to receive an additional nine hours each of training. When retested, they had doubled their visual acuity, scoring an average of 20/430. The brain’s apparent ability to shunt data for one sense through the customary pathways of another may enable the Wisconsin researchers to apply their device beyond vision replacement. “It’s not just about vision,” says Mitchell E. Tyler, a biomedical engineer with the group. “That’s the obvious one, but it’s by no means the only game in town.” The team began tests this summer of a modified system that’s intended to assist people who have lost their sense of balance because of injury, disease, or reactions to antibiotics. The unit gathers signals from accelerometers mounted on a person that
Continued on Page 19... April 2008 San Francisco Medicine 15
Eye to Eye
The Feeling of Being Stared At Implications for an Expanded Model of Medicine Marilyn Schlitz, PhD
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ave you ever had the feeling of being stared at, only to discover that someone is in fact looking at you? Surveys suggest that between seventy and ninety percent of the population has reported this experience. The question is, what are you perceiving that gets your attention at just that moment? Is it that you are noticing movement through your peripheral vision, the conventional explanation? Or is there a subtle field of communication that transcends known physical mechanisms? Research into this phenomenon has a long and controversial history. Initial papers on the topic of remote staring were first published around the turn of the nineteenth century. The first experimental investigation (1913) was conducted by a leading psychologist, J. E. Coover, at Stanford University. It involved an experimenter sitting behind participants, either staring directly at their backs or looking away, and then asking them to decide whether they had just been stared at. In more recent times, a similar procedure has been employed with positive results (Sheldrake 2005). Other researchers have developed increasingly sophisticated methodological and statistical procedures. For example, potential experimenter-participant sensory cues have been minimized by employing one-way mirrors and closed-circuit television systems (Braud, Shafer, and Andrews 1993a,b). Researchers have also created a more sensitive-dependent measure of participant’s arousal by recording their electrodermal activity (EDA) rather than asking them to report whether they are being stared at (Schlitz and Laberge 1994). The basic experimental procedure that has evolved includes a “sender” (S) and a “receiver” (R) located in two separate, 16 San Francisco Medicine April 2008
sensory-isolated rooms. A closed-circuit television system feeds a live image of the R to a monitor in the S’s room and, at randomly determined times, the S either stares at this image with intention to physiologi-
“The scientific observations on remote staring suggest an expanded scope for human perception that is worthy of future investigation.” cally arouse R (“stare” trials) or looks away from the monitor and disengages his/her intention (“no-stare” trials). The R’s electrodermal activity (EDA) is continuously recorded during the experiment, and any significant differential effects observed in EDA between “stare” and “no-stare” trials is inferred to reflect the existence of a nonphysical connection between people. Results from a small body of studies are suggestive, though controversial. A metaanalytic review of fifteen experiments using these types of procedures revealed a small but statistically significant overall effect (Schmidt, Schneider, Utts, and Walach 2004). While the experiments do not always work and the results appear to vary with experimenters (Schlitz, Wiseman, and Radin 2005), the methodology has been applied to the field of health care.
How Do Remote Staring and Medicine Meet? The scientific observations on remote staring suggest an expanded scope for human perception that is worthy of future
investigation. They also represent a methodology for exploring the potential role of distant intention in healing. Intention can be defined in a commonsense way as the harnessing of will toward some object or outcome (Schlitz 1995, 1996). There is a component of intention in many healing interventions, including prayer, meditation, and biofield healing. And for many, neither distance nor suggestion makes a difference. A recent survey of adult Americans, conducted by the National Center for Health Statistics, for example, showed that of the top ten complementary and alternative medicine (CAM) healing practices, the most popular was prayer for self and the second was prayer for others (Barnes, Powell-Griner, McFann, Nahin 2004). While the ostensible efficacy of prayer is often explained through reference to psychoneuroimmunological models of self-regulation, there are also suggestions that distant healing intentions may play a role (Schlitz and Braud 1997). Distant Healing Intention (DHI) is sometimes used in the scientific and medical literature to refer to this concept (Schlitz, Radin, Malle, Schmidt, Utts, and Yount 2003). Because the mechanisms underlying postulated DHI effects are unknown, most experiments have been concerned with the straightforward empirical question: Does it work? Some clinical studies suggest that DHI is medically efficacious (Astin, Harkness, and Ernst 2000), but overall the clinical evidence remains uncertain (Benson et al 2006, Krucoff et al 2005). The laboratory evidence may be clearer than the clinical evidence because there are no “competing” intentions to interfere with the test results, such as the prayers of clinical patients’ loved ones, and also bewww.sfms.org
cause tiny physiological fluctuations can be objectively monitored in real time, whereas healing responses may take days or weeks. But the context of laboratory studies is also quite different from that of clinical studies. In the lab, the person assigned to “send” DHI (hereafter called the “sender,” or S) is typically a volunteer who is not especially motivated or trained to provide DHI, and the person assigned to receive DHI (the “receiver,” or R) is often just curious to see what will happen.
A Remote Staring Study Involving Compassionate Intention A recent pilot study illustrates the usefulness of the remote staring testing paradigm for examining DHI in the laboratory (Radin, Stone, Levine, Eskandarnejad, Schlitz, Kozak, Mandel, and Hayssen, in press). Researchers looked at what would happen when the powerful motivations associated with clinical trials of DHI were combined with the controlled context and objective measures offered by laboratory protocols. This laboratory study recruited longterm couples as participants and explored whether training and practice in sending intentions would modulate any measurable effects. It focused on measuring short-term changes in the R’s physiological state as it correlated with the S’s intention. It also measured the correlation between the two; if S was excited, for example, did R show the same state? Participants were assigned to one of three groups. Two of these groups consisted of adult couples, one of whom was healthy and the other of whom was undergoing treatment for cancer. The healthy partners in one of these groups, called the “trained group,” attended an educational program on the cultivation of compassionate intention, defined as the act of directing selfless love and care toward another person. They practiced this intentional meditation for three months before they came to the lab to be tested with their partners. The healthy partners in the “wait group” came to the lab with their partner before taking the training program; and the third group consisted of healthy couples without special training, practice, or motivation other than www.sfms.org
curiosity. When a couple arrived at the lab, the experimenters attached electrodes to each person. The R was asked to relax for 30 minutes in a reclining chair inside a double steel-walled, shielded chamber. R was told that S would be viewing his or her live video image from a distant location for an unspecified length of time, and at random intervals, and that during those periods the sender would make a special intentional effort to mentally connect. Neither S or R knew in advance that the intentional periods were 10 seconds in length, and no one, including the experimenters, knew when the intentional periods would occur because they were randomly determined by a computer. The hypothesis was that S’s intention would cause the distant R’s sympathetic nervous system to become activated. A total of 36 couples participated in the study: 12 in the trained group, 10 in the wait group, and 14 in the control group. Analysis of data combined across all couples showed that R’s skin conductance substantially increased over the course of the average 10-second intentional sending period (p = 0.00009). A half-second after the sender began to direct intention, the receiver’s average skin conductance began to rise. It continued to rise and peaked at the end of the 10-second period, then it began to decline. This was most unexpected because when a person is asked to relax quietly in a shielded room with no external stimuli, their skin conductance normally just declines, indicating relaxation. Comparison of the receivers’ skin conductance across groups revealed that receivers in all three groups responded when their partner began sending intention, but the controls’ response subsided after 4 seconds, the wait group’s response subsided after 5 seconds, and the trained group’s response subsided after 8 seconds. These observations suggest that training plus motivation was more effective than just motivation, and motivation more effective than mere interest. In sum, this study, and many others previously reported, suggests that DHI has a measurable effect on the human body, hopefully one that is perceived as beneficial.
Attempts at Mechanism The effects described in a significant number of remote staring studies are generally considered scientifically doubtful because the “distant” in DHI means shielded from all known causal interactions. Having said that, science is slowly coming to terms with the concept of what Einstein called “spooky action at a distance” within fundamental physics. Research in quantum theory has shown that under certain conditions, particles that interact remain instantaneously connected after they separate, regardless of their separation in time or space. If this property is truly fundamental, then in principle everything in the universe might be entangled (Radin 2006). While everyday objects and humans have not been shown to exhibit such correlations, quantum entanglement begins to offer a possible mechanism for DHI. If this concept does apply to humans, it could explain why entanglements between the minds and bodies of an indifferent, unmotivated couple may be difficult to detect. But in a highly motivated, long-term bonded couple asked to connect mentally, and with the “sender” trained to provide DHI, the underlying correlation might become more evident. As Radin et al (in press) point out, such a relational model is appealing because it does not require anything (force, energy, or signals) to pass between S and R. Instead, it postulates a physical correlation via “nonlocal threads” that may truly weave us together as a seamless whole. For three decades, scientist and anthropologist Marilyn Schlitz, PhD, has pioneered clinical and field-based research in the areas of consciousness, healing, and transformation. She is Vice President for Research and Education at the Institute of Noetic Sciences, Senior Scientist at the California Pacific Medical Center, and Chief Learning Officer for Integral Learning Corporation. Schlitz’s books include Living Deeply: The Art and Science of Transformation in Everyday Life (with Vieten and Amorok) and Consciousness and Healing: Integral Approaches to Mind-Body Medicine (with Amorok and Micozzi). For a full list of references, please visit www.sfms.org/archives.
April 2008 San Francisco Medicine 17
Eye to Eye
The Fear of Looking Notes on Seeing, Showing, and the Creative Process Steve Walsh, MD “I learnt to restrain speculative tendencies and to follow the unforgotten advice of my master, Charcot: to look at the same things again and again until they themselves begin to speak.”—Freud
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recently revisited The Fear of Looking (University of Virginia Press, 1974) by David W. Allen, MD, local psychiatrist, psychoanalyst, and past president of the SFMS. Now well into his ninth decade of life, Dr. Allen retired from practice fifteen years ago and lives with his wife Sallie in San Francisco. His 123-page monograph published thirty-five years ago still offers useful insights relevant to this month’s San Francisco Medicine theme, the eye and visual functioning. Dr. Allen focuses on the psychosocial vicissitudes and conflicts experienced with the pleasurable instinctual desires to see and to look (scopophilia) and to show and to be looked at (exhibitionism). His book brilliantly illustrates the history and importance of scopophilic-exhibitionistic (look-show) factors in clinical psychiatric disorders, in everyday life, and in the treatment situation. Here I want to consider his “implications of look-show factors” for the creative process in art and science, the subject of the book’s concluding chapter. Of related importance is the creative process in our medical clinical work with patients. As physicians, we try our best to see patients and their disordered physical and mental phenomenology just as they are. Robust seeing, looking, listening, and examining are usually followed by showing and display of our findings to ourselves, our patients, and our colleagues in our best creative clinical work. Emotional conflicts in any of those functions can impair that creativity. On another level, Erik Erikson once 18 San Francisco Medicine April 2008
remarked that one of the functions of great intellectual leaders is to model permission to explore new fields. “They give permission to look, to see, to understand the previously forbidden or unknown,” states Dr. Allen. “This is true of Freud, as it is of Darwin, Pasteur, Euclid, and Einstein. And it is probably true of Moses, Jesus, Gandhi, and Malcolm X” (p. 2). Artistic and scientific creativity depend on looking and showing factors in the creators. “From birth to death in any culture, by pervasive attitudes, by repeated examples, by streams of subliminal cues, we all are taught selective inattention,” says Dr. Allen. “We are taught what we must know, what we may investigate; and what we must not question, say, or show. If it is true that the art of being wise is the art of knowing what to overlook, it is equally true that creative genius is the capacity for seeing relationships where others see none. And it is often in observing the commonplace that such insight occurs” (p. 6). Dr. Allen believes that the individual becomes creative only if he possesses “that unintimidated, bounding scopophilia that sees beyond the immediate focus of learn-
ing ... (and is) balanced with an assertive exhibitionism ... challenging us to see things as they are, beyond what authority has previously prescribed or proscribed that we see” (p. 109). Curiosity (derivative from scopophilia) is essential for creativity. The “aggressive pleasure” of creativity depends on “looking and showing cathexes.” Dr. Allen believes that a fundamental first step in the creative process is “the ability to be inwardly curious, to employ self-directed scopophilia without hampering anxiety” (p. 111). He lists several “requirements of creative thinking” (p. 112) gleaned from psychoanalytic work with creative people. These are: 1.) Scopophilia and its derivative curiosity must be ego-syntonic, playful, and insatiable. 2.) Exhibitionism (the pleasurable ability to display) has to be tolerably egosyntonic. 3.) Rebelliousness must be agreeable to the ego. 4.) There must be a tendency to use reversal, to turn things upside down in whole or in part. 5.) Some tendency must exist to use isolation as a mental mechanism “permitting a buildup of tensions that potentiate breakthroughs of observations, feelings, and thoughts into newly experienced combinations.” 6.) There must exist a love of playing with one’s thoughts while delaying actions. 7.) Pleasure in “fondling, taking in, and penetrating” ideas for their own sake must be present. 8.) There is a pleasure in passive observation of the self as well as the external world, as in Shakespeare’s “When to the www.sfms.org
sessions of sweet silent thought I summon up remembrance of things past.” 9.) A capacity for solitary brainstorming is present, without premature criticism and rejection by rationality—as Churchill writes, “No idea is so outlandish that it should not be considered with a searching ... steady eye.” 10.) The ability to enjoy the regressive elements of thought and transient regressive states, “mental messiness or muddleheadedness that may be prerequisite for independent thinking,” is displayed. 11.) There is a capacity for realistic rejection and ordering in final review. 12.) An ability exists to form a multitude of temporary identifications, to shift points of view, angles of vision, to “produce a clearer perception than monocular gazing from a single point of observation.... Repeated shifts ... help to sift out the really relevant from the chaff.” Dr. Allen believes that the creativity of a cultural group or subgroup depends on two sources. One is the “cultural outsider whose sets of selective attention and inattention differ from the group norm,” and the other is the “insider who has become partly an outsider, who ... has escaped or broken the rigid scopophilic-exhibitionistic inhibitions of a sector of his culture ... feeling himself set somewhat apart from the rigid majority.” The person who can “imagine himself in more than one identity and can shift between the identities and fuse them brings us to the creative advantage of the cultural insider-outsider, the semi-outsider, the semi-insider.” There is much more worthy of review in Dr. Allen’s excellent monograph. He has described well a psychoanalytic psychiatrist’s view of visual functioning and its mental and emotional accompaniments. Dr. Steve Walsh is a private-practice psychiatrist in San Francisco and Mill Valley. He is past president of the SFMS, the Northern California Psychiatric Society, and of the UCSF Association of the Clinical Faculty. He is a member of the editorial board and of the psychiatric services committee of the SFMS.
www.sfms.org
The Seeing Tongue Continued from Page 15... indicate when he or she is tilting, and in what direction. By stimulating the tongue with patterns representing the degree and direction of tilt, such a device may act as an artificial vestibular system. Then the person might be able to correct bodily position and avoid falling, Tyler explains. Although the main emphasis of the Wisconsin research has been rehabilitation, the group also foresees using its technology to aid people who don’t have sensory deficits. Interest in enhancement of the senses has come primarily from the military. While Bach-y-Rita and his colleagues were using external skin as a receiver of light-derived images, the Defense Advanced Research Projects Agency in Arlington, Virginia, funded them to develop a sonar-based system to help Navy commandos orient themselves in pitch darkness. The prototype worked, Bach-y-Rita says. Tyler proposes that ground soldiers could also receive data by means of infrared
cameras or other sensors that would alert them, through the tongue, to the presence and positions of enemy troops or tanks. Civilian workers, such as firefighters, might also benefit from such interfaces. That’s pure speculation right now. Martin’s bouts of vision, however, are much more than that. In a new film that aired on Canadian television in June, a smile spreads across Martin’s face as she gets her first glimpse of a candle flame. The film, Touch: The Forgotten Sense, highlights some of the Wisconsin work. Its message is this: Touch works in a thousand ways, often without people even being aware of its roles. By taking this sense into new arenas, such as the tongue display, Bach-y-Rita and his coworkers intend to extend touch’s repertoire even more. For references and further reading please visit our website, www.sfms.org/archives. Reprinted with permission from Science News, copyright 2001.
April 2008 San Francisco Medicine 19
Eye to Eye
Saving Sight with a Smile The Seva Foundation Sets a Standard for Sustainable “Compassion in Action” Steve Heilig, MPH
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hen I was a kid, my friends and I would sometimes pose hypothetical questions such as, “If you could only keep one of your five senses—touch, taste, sight, vision, smell— which would it be?” As I recall, everyone, without exception, chose sight. Much later, I was privileged to assist the Berkeley-based Seva Foundation on blindness projects in the Himalayas. Impaired vision in that region of the world, where there is extreme climate, much poverty, and no roads—can be a death sentence. Blind people, including young patients in their thirties with severe cataract, trachoma, and trauma—become wholly reliant on their families for survival. One such patient was a middle-aged man who had never seen his grandchildren, having become functionally blind years before. The volunteer eye surgeon completed the surgery and the patient wore bandages for a couple days. When the bandages were removed, he gazed upon his family at last. Within minutes, everyone in the area was in tears—including me. It was one of the most moving experiences I’ve ever had. The story of Seva has been widely told: how a seemingly unlikely band of intrepid public health experts and sixties counterculture heroes came together in Asia in the 1970s to choose an intervention with the best chance of having real and lasting impact in alleviating suffering there. More than two million surgeries later, Seva (the name can be translated from Sanskrit roughly as “service with a smile”) has trained multitudes of clinicians, built hospitals and clinics, and provided much direct care and public health support. Patients sometimes walk for weeks to get to an “eye camp” or hospital for services. 20 San Francisco Medicine April 2008
A professed goal of much international health work is that visiting experts and clinicians should train locals to provide the services needed, so that the work in the field does not remain dependent upon visitors and the sponsoring organization. Most international programs do not attain this. But Seva does so, both in Asia and in its other projects in Mexico and with Native Americans. East Bay ophthalmologist and UCSF assistant clinical professor Naveen Chandra, MD, has volunteered his services to Seva at its hospital in Lumbini, in Nepal, partly for that reason. “The most impressive aspect of Seva’s work is that the model aims at making a charitable medical institution selfsufficient,” he says. “When I actually saw the magnitude of what they do, it was just staggering. The energy and passion these doctors and staff bring to their work is so inspiring.” As for his own visits, he explains, “At my last visit to Lumbini, I performed cornea transplantations on good candidates. We did other sophisticated ocular surface disease surgery: corneal limbal autograft, for example. In addition, and more importantly, I proctored their cornea specialist, Manoj Sharma, on cornea transplantation. Lastly, I gave lectures to the doctors on staff and in training on cornea topics.” “I feel like I received more than I gave,” says Chandra. “This is why I went into medicine in the first place: to be able to help at a grassroots level, and to care for people who are so appreciative of the benefits of my work—it makes me re-energized and passionate about being a physician.”
San Francisco ophthalmologist David Heiden, MD, also works with Seva at its new Center for Innovation in Eye Care in Berkeley, California. “CMV retinitis is causing profound blindness in a substantial group of AIDS patients,” he notes. “We’ve launched the AIDS Eye Initiative, and our next step is to figure out how and what to teach overworked doctors on the front lines, learning from what San Francisco ophthalmologists did at the height of our AIDS nightmare. In such places as the slums of Rangoon or rural Africa, how can we teach AIDS doctors with almost no resources to do the crucial parts to prevent AIDS-related blindness? It’s exactly the sort of problem best addressed at a creative place like Seva.” The late David Sachs, MD, an ophthalmologist and SFMS past president, first went to Nepal with Seva in the late 1980s, after I returned from a trip there and told him about Seva’s work. When he returned from that first visit, he reported that “this was the best ‘vacation’ I’ve ever had, and I’m going back.” He did so, repeatedly. There’s just something about Seva that speaks to the best in people. For more information on Seva, see www. seva.org or call (877) 764-7382. www.sfms.org
Eye to Eye
Visual Disabilities in the United States How Loss of Vision Impacts Both Patient and Society Sunita Radhakrishnan, MD
V
isual disability can be defined in several ways. For most patients, the term blindness denotes not being able to see light, but this form of absolute blindness is in fact significantly less common than partial loss of vision. Visual disability is typically defined on the basis of tests that do not accurately represent actual impairment for activities of daily living. For example, patients with some types of macular disease may have a “normal” Snellen visual acuity of 20/20 but still experience severe distortion that precludes meaningful use of this vision. However, for lack of better alternatives, the definition of visual disability continues to be based on two common tests of visual function, namely Snellen visual acuity and visual field measurement. Thus, “legal blindness” is defined as visual acuity with best correction in the better eye worse than or equal to 20/200 or a visual field extent of less than 20 degrees in diameter. “Visual impairment” is defined as having best corrected visual acuity of 20/40 or worse in the better eye. Visual dysfunction is a significant cause of disability among Americans. In the 2004 study by the Eye Diseases Prevalence Research Group reported in the Archives of Ophthalmology, it was estimated that 937,000 Americans older than 40 (0.78 percent) were blind and a further 2.4 million (1.98 percent) had visual impairment. The leading cause of blindness among white persons was age-related macular degeneration (54.4 percent of cases). In contrast, among black persons, cataract and glaucoma accounted for more than 60 percent of blindness. Cataract was the leading cause of visual impairment in white, black, and Hispanic persons. This report also projected a 70 percent increase in blindness and visual impairment by the year 2020, owing largely www.sfms.org
to the aging of the American population. Prevalence estimates in this study were based on best corrected visual acuity, thus visual disability due to uncorrected refractive error was not taken into account.
“Given the considerable impact of visual disability ... it is important to initiate measures to decrease this burden.” The impact of visual disability is multifold and affects the personal as well as the public domain. At the individual level, visual disability can drastically alter the physical, emotional, and economic aspects of a person’s life. From the public health perspective, it results in a significant economic burden that can impact resource allocation for other health-related initiatives. The economic impact of visual impairment was recently described in the 2007 report released by the organization Prevent Blindness America. The findings of this report were based on two studies. The first study by Rein and colleagues was published in 2006 in the Archives of Ophthalmology. The authors estimated the total financial burden due to visual impairment at $35.4 billion, attributed to direct medical costs, indirect costs, and lost productivity. Outpatient and prescription costs formed the major portion of the direct medical costs involved in the treatment of eye disease, while nursing home care accounted for nearly all of the indirect costs. When compared to the general population, the percentage of visually impaired or blind persons requiring nursing home care was significantly higher. The second study by Frick and colleagues re-
ported an annual excess cost of $5.48 billion incurred by individuals with visual impairment, their caregivers, and health care payers. Most of this additional expenditure was spent on home health care. The economic burden of visual impairment is expected to considerably increase in the future, in step with the increasing age and life expectancy of the American population. Given the considerable impact of visual disability on the individual as well as society as a whole, it is important to initiate measures to decrease this burden. One preventive strategy is to improve screening for vision-threatening diseases by programs such as the EyeSmart public awareness campaign, a joint initiative of the American Academy of Ophthalmology (AAO) and EyeCare America. The goal of this campaign is “to limit the impact of eye diseases tomorrow by raising awareness of risk factors today,” and its initial focus will be on five major eye diseases: age-related macular degeneration, cataracts, diabetic retinopathy, dry eye, and glaucoma. The AAO has also issued a new eye-disease screening recommendation, which states that adults with no signs or risk factors for eye disease should get a baseline screening at age 40. A second strategy to reduce the impact of vision loss is to develop more effective treatment modalities. The recent development of antiangiogenesis drugs for the treatment of age-related macular degeneration is a good example. In conclusion, visual impairment and blindness are important causes of disability in the United States. The prevalence of visual disability and its related economic costs are expected to dramatically increase in the next decade, and hence preventive measures must be undertaken today. April 2008 San Francisco Medicine 21
Eye to Eye
Forever Young In the Quest for a Youthful Appearance, the Eyes Remain a Focus Gary L. Aguilar, MD
P
ick up almost any periodical these days, from the staid Wall Street Journal to the National Enquirer, or click through the TV channels anytime, and the odds are good you’ll come across some new development or other that promises to make you look marvelous. There is no mystery why. For as rates of smoking and alcohol use have declined, and as awareness of the benefits of healthier diets and exercise regimens have increased, not only have life expectancies shot up but so also has the desire to look as youthful as possible in all stages of life. To meet that demand, a bewildering array of new goods and services has exploded onto the scene to make us look and feel better. Once virtually the sole province of beauticians, hairdressers, and plastic surgeons, techniques to enhance cosmesis are now practiced by a motley group that includes specially trained ophthalmologists, dermatologists, otolaryngologists, internists, general practitioners, and even dieticians and other nonmedical personnel, such as “estheticians,” personal trainers, even meditation gurus. There have been huge shifts in what is conventionally considered to be beautiful over the years—from the rubicund plumpness favored at the turn of the last century to the gaunt pallor celebrated in high fashion magazines during the last fifty years. But the one thing that hasn’t changed over all that time is that the eyes have a lot to do with beauty. For it is the impact left from first eye contact that leaves the most important and memorable impression. But what is it about the eyes that is beautiful? Is it their color, the distance between them, the fullness and angle of the 22 San Francisco Medicine April 2008
lids, the length of the lashes? Or is it the contour of the brows and nose that frame the eyes? Alas, we are hard pressed to name a feature, whether of eye, brow, or nose, that determines beauty. But we instantly know
“As rates of smoking and alcohol use have declined, and as awareness of the benefits of healthier diets and exercise regimens have increased, not only have life expectancies shot up but so also has the desire to look as youthful as possible in all stages of life.” beautiful eyes when we see them. And yet not all beholders agree. A prior generation swooned at Marlene Dietrich’s high, arching eyebrows. Today, many consider that somewhat freakish, preferring the low, flat eyebrows of a Brooke Shields or a Jennifer Connelly. Then, of course, ethnic and racial differences often explain why some fancy uncreased, flat Asian eyelids and others the rounded, creased “Western” lids. Among the specialists who have been most affected by the vagaries of eye beauty are a relatively new group of specialists, ophthalmic plastic surgeons. A group of ophthalmologists serving during World War II dedicated themselves to the grim, delicate task of reconstructing the shattered eyelids and orbits of those
wounded in war, gaining vast experience given the abundance of material to work with. After the war the lessons learned were put to good use for both functional as well as cosmetic purposes. The most influential papers and textbooks on anatomy and physiology of the eyelids and orbit, as well as functional and cosmetic eyelid surgery, were written by those battle-trained ophthalmologists. In 1969, the group established a new organization, the American Society of Ophthalmic Plastic and Reconstructive Surgery. Through its members and its journal, Ophthalmic Plastic and Reconstructive Surgery, remarkable advances in both the science and art of ophthalmic plastic and reconstructive surgery have been communicated to both members and related medical specialists alike. As an indication of how rapidly things have changed, among the innovations that draw the most public and professional attention today to eliminate age-related wrinkles and hollows from the eyelids are treatments that were scarcely imagined a generation ago. Perhaps the most well known of these is a muscle poison that was first isolated and developed by a San Francisco ophthalmologist, Alan B. Scott—botulinum toxin type A, known popularly as “Botox.” With a remarkable safety record, botulinum toxin provides a nonsurgical way to virtually eliminate crow’s feet, intra-eyebrow frown and worry lines, and even the perioral wrinkles (rhytids) at the edges of the lips. Unfortunately, the treatments are temporary and one must be retreated about every three months to stay wrinkle-free. Recent reports concerning life-threatening risks, while worth noting, should be of little con-
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Continued from the Previous Page... cern to cosmetic patients since the mortal complications principally affected children who were being injected with vastly higher doses of Botox for noncosmetic, muscular disorders. Cosmetic patients, however, are not immune to potential problems. The most common complication of cosmetic Botox occurs when the material migrates away from the injection site, causing a temporary droopy upper eyelid or double vision. Another increasingly popular approach to the problem of wrinkles and hollows is to fill them. The value and popularity of such techniques has followed a sea change in how we perceive the ideal outcome of cosmetic surgery. Whereas it was once believed the surgeon’s goal was to remove as much fat as possible during aesthetic surgery, leaving the hollow-eyed look of an underfed supermodel, it is now recognized that “skeletonizing” the eyelids is no way to restore youth. The presence of some fat is a characteristic of youth. Leaving a bit of it in just the right places accentuates youthful beauty. To achieve the desired effect, it has become common during surgery to transfer the patient’s own fat from a place where it is too abundant—in, say, an upper or lower eyelid or the belly—to a place where there is often an unsightly hollow—in the inferior medial eyelids, just below the bony orbital rim, for example. But sometimes there just isn’t enough fat to go around, and so a substitute for volume enhancement is called for. Injectable collagen, both human-derived and
bovine-derived, is approved for injection by the FDA, and both have been popular choices for augmentation. But their widest use has been in filling small defects, from the depressions associated with scars to crow’s feet, frown lines, and the fine rhytids at the lip margins. Both tend to last no longer than six months, and the less expensive, bovineextracted product requires skin testing for allergy prior to use. During the past five years, a bevy of new products has been added to the filler armamentarium, products that carry none of the few risks that are posed by collagen and products that are capable of doing much more than just filling the small furrows around the lips and lids. While an exhaustive discussion of all the products that are now available on the market is well beyond any reasonable space constraints, a brief overview is in order to prepare members for questions patients might have. The products known as Restylane, Hylaform, and Juvéderm are FDA-approved and are formulated using a product of nature, hyaluronic acid. They can not only fill the small furrows but also much larger depressions, including depressed scars, the hollow depressions underneath the eyes, the so-called nasolabial fold, the creases that run inferiolaterally from the sides of the nostrils toward the bottom of the cheeks, and so on. No skin tests are required to use these products and, except for usually minimal, temporary bruising, there is no downtime associated with these treatments. Depending on the formula, the effect can last from four months to one year, and it is not uncommon
for patients to have large depressions filled while simultaneously receiving Botox treatments to eliminate fine wrinkles. For patients wanting a longer-lasting effect, Radiesse, a compound made from calcium hydroxylapatite, a synthetic form of material found in bone and teeth, and Sculptra, a synthetic poly-L-lactic acid, are available. As with the other new generation of fillers, no skin testing is used and patients experience little or no downtime. Both these products last upwards of one year, and therein lies the most important factor for both patient and physician in considering these products. For whether the effect lasts four months or one year, the effect lasts four months or one year. It is incumbent upon both the patient and physician to know that they are committing to a “certain look” for a long time. In most cases, it’s wise to start off slowly, with shorter-acting products, and then move to longer-duration injections when there is a more complete understanding of the ultimate outcome. The opportunities to maintain a youthful appearance have never been better. But as with all promising innovations, perhaps the most important thing for us, as physicians, to keep in mind is the old saw “do no harm.” The ability to alter someone’s appearance should not be the only reason for doing so. And just because a patient wants a heralded new treatment, that should not be the sole reason we provide it. Gary L. Aguilar, MD, is a Clinical Professor of Ophthalmology at UCSF.
2008-2009 SFMS Member Directory Coming Soon! Directories will be out in June! All SFMS members receive one copy of this valuable resource as part of their memberships. Please watch for your copy in the mail. If you are interested in ordering additional copies please contact Carol Nolan at (415) 561-0850 extension 0 or cnolan@sfms.org for information.
www.sfms.org
April 2008 San Francisco Medicine 23
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whatdrivesyou? A commitment to excellence. A passion for the art of medicine. A basic desire to heal. Whatever it is that sustains you through the daily challenges of your profession, know that you have an ally in NORCAL.
(800) 652-1051 l www.norcalmutual.com 24 San Francisco Medicine April 2008
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Providing San Francisco physicians and surgeons with superior professional liability protection.
Eye to Eye
The End of Glasses The Future of Laser Vision Correction Daniel Goodman, MD
H
ave you ever wondered how a severely nearsighted caveman survived? How did myopic prehistoric man and woman hunt, scan the horizon during their wanderings, or study the stars at night? Or was it the nearsighted individuals who stayed at home in the cave, minded the fire, prepared meals, and tended to the young? Although the first evidence of the use of a corrective lens dates back to the emperor Nero—who was said to watch gladiator games through an emerald—Salvino D’Armate is credited with inventing the wearable spectacle lens in Italy, during the late thirteenth century. Benjamin Franklin is well known as the inventor of bifocal spectacles (1784), which he developed to cure his own combination of myopia and presbyopia. Contact lenses were actually conceived and sketched by Leonardo da Vinci, but the first glass-blown contact lenses were designed by the German glassblower F.A. Muller (1887), and plastic contacts were first introduced by the California optician Kevin Tuohy (1948). The era of laser vision correction began in the late 1980s, with the development of the excimer laser to reshape the corneal surface, and subsequently the flap-making technology to allow LASIK (Laser Assisted In-situ Keratomilieusis). The excimer laser is a 193 nm “cold” ultraviolet laser that, due to its specific absorption characteristics in the cornea, can disrupt intramolecular www.sfms.org
carbon-carbon bonds and thus very precisely reshape the corneal surface, thereby reducing or eliminating refractive disorders of the eye—including nearsightedness, farsightedness, and astigmatism. The excimer laser was approved by the FDA in 1995, and over the past decade it has proven to be a very safe and effective means of correcting refractive errors. A nearsighted (myopic) eye has an elongated axial length, but the refractive error can be neutralized by flattening the
cornea with a central ablation. A farsighted (hyperopic) eye can be similarly corrected with a midperipheral “doughnut-shaped” ablation that effectively steepens the central cornea. Astigmatism is essentially an ovality of the corneal surface, and it can be eliminated by a corresponding elliptical laser ablation pattern that establishes a more normal corneal sphericity. In real estate, it’s “location, location, location,” and in laser vision correction—as in any surgical procedure—it’s “patient selection, patient selection, patient selection” that is of paramount importance. Sophisticated screening tools, including corneal topographers (which measure corneal shape and curvature) and ultrasonic pachymeters (which measure corneal thickness) allow for optimal patient selection. Recent advances in excimer laser ablation include the advent of “wave-front technology,” which allows for more precise measurement of refractive errors and greater precision in the distribution of the laser ablation pattern. As in many medical industries, there is a great deal of marketing hype—both from some manufacturers and some physicians. When the wave-front technology was initially released, the laser manufacturers promoted it as capable of producing “super vision,” allowing patients to routinely see better than 20/20. But in truth, laser vision correction can only allow an eye to see as
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Continued from the Previous Page... well as the concentration of an individual’s retinal photoreceptor rods and cones permits, which is generally their best corrected vision with glasses or contact lenses. Some patients have a “normal” vision of 20/25 (which means they can see at 20 feet what the “normal” person will see at 25 feet), while others have the capacity to see 20/15 or better. (Over the past ten years, for example, I have examined all of the San Francisco Giants baseball players each year in spring training, and the “normal” professional baseball player routinely has visual acuity of 20/10 or better—which means they can see at 20 feet what the “normal” person will see at 10 feet.) Some physicians also promote their diagnostic equipment or laser technology as “better” than others (“my laser is better than your laser” or “my corneal scanner is better than your corneal scanner”), but, in truth, there are no significant differences between the several excimer lasers available; each produces uniformly excellent results in the hands of the thoughtful and careful ophthalmic surgeon.
Depending on the degree of refractive error, between 90 and 98 percent of patients will see 20/20 without spectacle or contact lens correction, following laser vision correction, and more than 99 percent will see 20/40 (the level required by the DMV for a driver’s license). There are potential side effects of laser vision correction. Less than 1 percent of patients still require spectacles or contact lenses for full-time vision correction. When the excimer laser was first developed, nearly 5 percent of patients experienced glare or haloes at night. The chief advantage of wave-front technology, it turns out, is that it has dramatically decreased the incidence of post-op nighttime difficulties, in those patients at a higher risk for these side effects, to less than 1 percent. Some patients experience a period of dryness following laser vision correction, but, in my experience, this is not a permanent condition. Not infrequently, patients have a degree of a dry eye condition prior to LASIK, and afterward they return to their own level of ocular surface “dryness” or health at vary-
ing rates. Though laser vision correction is both safe and effective, it’s not for everyone. Patients with abnormal exams, including abnormally thin or irregular corneas or those patients with an abnormal ocular surface, may not be candidates for LASIK—though they may be candidates for lens implants or other emerging technologies. Certainly our nearsighted prehistoric ancestors would have been thrilled to have had spectacles, and even today, some patients are better served with glasses or contact lenses. Daniel Goodman, MD, is the Medical Director of the Goodman Eye Center and the Eye Surgery Center of San Francisco. He is a Clinical Associate Professor of Ophthalmology at UCSF Medical Center and one of the team doctors for the San Francisco Giants baseball team.
The Best Care -The Best Career Veterans Affairs Medical Center San Francisco
PRIMARY CARE PHYSICIAN/BOARD CERTIFIED INTERNIST The Department of Veterans Affairs is searching for a Primary Care Physician/Board Certified Internist for the Ukiah VA Outpatient Clinic located 100 miles north of SF on Hwy 101. The clinic serves Mendocino and Lake Counties where affordable living meets outstanding recreation with easy access to the spectacular coastline. Responsibilities include: building a manageable panel size across the adult age continuum; some administrative duties, and no call. Great supportive staff and potential for growth await the enthusiastic, self starter who values team spirit and cooperation. Full time position available. Interested candidates please contact Linda Mulligan, MD at (707) 468-7704 and send a CV c/o Ken Browne, Ukiah Outpatient Clinic, 630 Kings Court, Ukiah, CA 95482. Fax (707) 468-7733. US Citizenship required. Selected applicant is subject to random drug testing. Equal Opportunity Employer. 26 San Francisco Medicine April 2008
www.sfms.org
Eye to Eye
Through a Glass Darkly Living with Vision Loss Susan Kitazawa, RN
S
tunned by fresh bad news, sometimes we can manage to utter only an anguished “Oh, no….” Perhaps my optometrist might have found a more measured way to inform me that he was seeing significant cupping of my optic nerve during a routine exam. But, instead, this good man who had been our family optometrist for almost twenty years said at first, from his heart, simply, “Oh, no….” With that, I was welcomed to the world of gradually worsening vision loss. Eight years ago, I had noticed blurring of my distance vision. I was having trouble reading above the 20/80 line as I ran my pediatric patients through the Snellen chart. I myself had worn corrective lenses since first grade, when I had proved unable to see the big E at the top of the chart. With myopia as my longtime companion, I thought then that my recent decreased acuity would be corrected as soon as I found time to go in for a routine refraction and new lenses. Besides, we all know that registered nurses, like doctors, take care of those other people who have health problems. Would that this magical thinking actually protected us from becoming one of those other people! Last week I bought my first white cane, the shorter, lighter “identity” version designed to alert the general public that the bearer has good reason to move so cautiously down the stairs to BART or that her requests for assistance are more than just learned helplessness. Vision rehabilitation staff tell me that, later, I may graduate to a longer “mobility” cane, made of material strong enough to withstand impact with concrete curbs and metal mailboxes. Bit by bit, I’ve had to take leave of things. My driver’s license is gone now (but not those lovely, vivid dreams of driving, www.sfms.org
stick shift). My prior life’s work as a registered nurse has come to an end. The slightest shadows now disguise the once-familiar faces of friends and family. I do many things
“Last week I bought my first white cane, the shorter, lighter ‘identity’ version designed to alert the general public that the bearer has good reason to move so cautiously down the stairs to BART or that her requests for assistance are more than just learned helplessness.” differently now, of necessity, even though I’m still only partway down the path toward legal blindness. When asked to write about vision loss from a patient’s point of view, I quickly agreed to do this—and then wondered what I could say that might make a difference. I know only my own experience of this growing darkness, even though my vision-impaired peers and I often laugh, and sometimes cry, in discovering how much we share even though we live very different lives from one another. I’m humbled by the realization, despite my own patients’ past praise for my empathy for them, that I had so little sense of the depth and complexity of what it is to live with a chronic and worsening medical condition. We fully understand some things only in living them ourselves. Not knowing what it is to be completely blind, nor hav-
ing the experience of a lifelong disability, I report here on that gray zone of vision loss inhabited by those who once could see quite well and who now are lost sometimes even in familiar surroundings. In his honest and insightful book Touching the Rock: An Experience of Blindness (1990), university professor John M. Hull wrote, “It is so hard to be a normal person when one is not a normal person.” With vision loss, many of the mundane tasks of life become arduous and frustrating. Ordinary routine can call for extraordinary and exhausting effort and a need for an unfamiliar patience. Day-to-day social reality changes with significant vision loss. We introduce ourselves to our close friends because we don’t recognize them, or we walk by them, appearing to ignore them, because we don’t see that they’re there. We pour ourselves a glass of 7-Up at a party and completely miss the glass. Requesting help reading the price on an item, we may find the store clerk replying very slowly and loudly, sometimes patting us on the arm in a gesture of comfort. Vision disabled, we find that some others apparently view us as cognitively impaired or as less able to make our own decisions. Geographic boundaries can shrink in toward us. A Sunday drive up to Petaluma or a trip to pick up a few boxes of cat litter now require sometimes complex advance planning, as is true for all without the very American luxury of having both a driver’s license and a car. As vision fades, the range of what we see around us closes in so that, at the end point, the world will seem, at times, to be just our own body and the air around us. Vision loss can challenge one’s sense
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Continued from the Previous Page... of personhood. When we look in the mirror and no one looks back, or perhaps we see only a partial face, missing a nose and half a mouth, we can experience a disconcerting sense of no longer existing as the same solid being that we once were. John Hull writes of the loss of being able to see the friendly smiles or fleeting glances of recognition from others around us, the social acknowledgements that confirm our existence. Sometimes forced to give up former life roles, we seek new ways to be fully engaged members of the community; we may sense the rest of the world rushing past us, possessed with a speed and an efficiency that seem beyond our grasp. For those of us with significant vision loss, where is the good news? What can help? Engaging patients in a give-and-take exchange regarding the many less obvious consequences of vision loss would be of great help to us. Only after a year of experiencing the disconcerting hallucinatory images of what I now know as Charles Bonnet syndrome did I learn that this is a fairly common experience among those with partial vision loss. I first learned about this from my
partially sighted peers. Almost all of us had chosen not to mention this symptom to our doctors, fearing they would think us mad. (The Royal National Institute for the Blind provides an overview of Bonnet’s at www. rnib.org.uk, as well as providing much useful information for those with vision loss.) Providers should offer to give patients specific referral information to local agencies such as the Lighthouse for the Blind and Visually Impaired (www.lighthouse-sf.org). Again, it was a vision-impaired peer who first referred me to this helpful nonprofit agency. The Lighthouse offers a range of classes and activities as well as a store selling adaptive aids. A peer-led vision loss discussion group meets at the Lighthouse twice a month. The Lighthouse also supports people in accessing many other local organizations providing services and advocacy for the blind and vision-impaired. Encouraging and supporting patients in linking with others living successfully with vision loss may be the most worthwhile strategy. I am most grateful for blind and vision-impaired peers who have shared wisdom, humor, and practical resources that help us along this still poorly marked trail. I am grateful for the encouraging insight of
author John M. Hull, who, after musing on the possibility of blindness being a “dark, paradoxical gift,” concluded instead that blindness is more “the wrapping” around a gift than the gift itself, that losing one’s eyesight can be a passageway into a deeper, “more concentrated phase of life.” With the support of others, especially the ongoing support of peers, those of us experiencing vision loss may come to find a deeper understanding and a richer appreciation of life that can balance the difficulties inherent in our seeing through a glass darkly. Susan Kitazawa, RN, enjoys writing, other creative arts, and dancing (mostly Argentine tango). In the past, she worked as a nurse at the University of California, San Francisco, in the San Francisco Department of Public Health, and for the San Francisco public schools. She holds degrees in cultural anthropology, nursing, and education. Reference: Hull, John M. Touching the Rock: An Experience of Blindness. New York: Vintage Books, a division of Random House, 1990.
Continuing mediCal eduCation The California Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The California Medical Association designates this educational activity for a maximum of 19 AMA PRA Category 1 Credits ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.
28 San Francisco Medicine April 2008
www.sfms.org
Eye to Eye
The Diving Bell and the Butterfly A Movie Review Eisha Zaid
W
hen Jean-Dominique Bauby wrote The Diving Bell and the Butterfly, he could not speak or move; he could only blink his left eye. In telling his story, imagination combines with reality and dreams to create a new form of consciousness for Jean-Do, the former French editor of Elle, who becomes imprisoned in his own body after developing “locked-in syndrome” from a cerebrovascular accident at the age of 43. Although physically paralyzed, his brain function, cognition, and senses remain intact. Jean-Do’s memoir was masterfully captured in a critically acclaimed French film that was awarded Golden Globe Awards for best foreign film and best director. The film threads the story of Jean-Do amid the backdrop of his new life in hospital room 119 in the Naval Hospital at Berck-sur-Mer on the French channel coast. This life, characterized by therapists, medical routines, feeding and bronchial tubes, baths, nurses, and reliving memories, is an existence far removed from being a father, son, lover, writer, and member of French society. The creative imagery in the film reflects Jean-Do’s feelings as he becomes physically encased in the heavy shell of his body. He becomes dependent on the nurses, who wash him, change his clothes, move his limbs, clean his feeding and bronchial tubes, and attend to his most basic needs, as if he had regressed to a state of infancy. The resonating image of a diver in a diving bell mirrors Jean-Do’s helplessness as he delves deeper into unknown depths of his own soul to confront his helplessness, fear, confinement, and shame. We see how Jean-Do continues to perceive the entire world through his left eye, while struggling to communicate with those around him and connect with the new reality www.sfms.org
of his life. As he opens his eye from a state of coma, the world slowly comes into focus—a sterile hospital room with white coats bustling around him, with special attention given to the neurologist who delivers the diagnosis
“The film skillfully delivers a poignant message through overlaying powerful visual imagery with Jean Do’s dominating voice as he directly confronts his biggest fear, that of being disconnected from his world.” to a mute and listless Jean-Do. We hear the internal dialogue and frustration that JeanDo expresses as he coherently processes the information being delivered to him by the neurologists, while failing to respond back to the grim news that he has become reduced to a vegetative state. The sight of Jean-Do sitting in his wheel chair with bronchial tubes protruding out of his neck and saliva trickling down his chin as he stares blankly with his left eye evokes feelings of pity and sadness. But his ability to eloquently and powerfully express his voice reminds you that appearances can be deceiving. We hear Jean-Do narrating the film through his ordeal, speaking for himself and echoing his thoughts as we follow him through his preaccident memories, current experiences as a patient, imaginative adventures, and moments of self-reflection. We not only see his life flash on the screen, we gain a deeper understanding of Jean-Do’s character as he
comes to grips with his diagnosis. His vision is not limited to seeing the world; he relives past moments in his life, dreams about his condition, holds steadfastly to imagining life as he would like to live it, and experiences the world through smells, sights, and sounds. We watch how Jean-Do comes to terms with his condition, a transformation that starts with depression and anxiety and thoughts of death, later developing into acceptance of a new life as he regains his ability to communicate using the blink reflex with the assistance of his speech therapist. Through projecting the world through Jean-Do’s eyes, we develop profound empathy for Jean-Do as he works through the adversity in his life. In learning to communicate, JeanDo puts words together, letter by letter, in a process that requires patience, concentration, and practice. Despite the challenges, regaining his communication skills allows Jean-Do to recollect the pieces of his life and discover a way to escape the shackles of the diving bell that had been plunging his spirit deep into an abyss of dread and self-pity. Like the butterfly that reappears throughout the film, he rises above his physical impairment, a classical demonstration of mind over matter. The film skillfully delivers a poignant message through overlaying powerful visual imagery with Jean Do’s dominating voice as he directly confronts his biggest fear, that of being disconnected from his world. Despite the insurmountable challenges he confronts, his physical deterioration does not extinguish his insatiable hunger for life, and his inner voice cannot be silenced. Jean Do serves as an exemplary testament to the human spirit’s ability to overcome the most unimaginable catastrophes. Eisha Zaid is a first-year medical student at UCSF. April 2008 San Francisco Medicine 29
Universal Health Care Update Mitchell H. Katz, MD
Golden Gate to Health Care for All?
I
mpatient with the lack of progress at federal and state levels in reducing the number of uninsured Americans, many counties across the United States are seeking their own solutions to the health care crisis. Unfortunately, local efforts to achieve universal coverage often encounter substantial obstacles, including the high cost of insurance plans, the loss of federal and state revenues that benefit the uninsured, and limited authority to mandate insurance coverage. To broaden access while avoiding these problems, the government of the City and County of San Francisco launched Healthy San Francisco (HSF) in April 2007. Building on the success of an earlier effort to provide health insurance for nearly all the city’s children, HSF is a novel initiative designed to make comprehensive health care available to San Francisco’s 73,000 uninsured residents (13 percent of adults under the age of sixty-five). Currently in the form of a phased start-up, HSF is not an insurance program but rather a restructuring of the county’s health care safety net. Administered by the San Francisco Department of Health, where I am Director of Health, HSF’s universal-access model features key elements of managed care, such as “medical homes,” defined participation and point-of-service fees, and customer service. It provides inpatient and outpatient care, tertiary subspecialty care, prescription coverage, laboratory services, durable medical equipment coverage, and treatment for mental illnesses and substance abuse. (Cosmetic procedures, dental services, fertility treatments, organ transplantation, vision care, and long-term care are excluded.) All uninsured residents between eighteen and sixty-five years of age are eligible to enroll in HSF regardless of income, employment status, immigration status, or preexisting conditions. During an online application process, clients’ eligibility for federal and state programs such as Medicaid is first determined. Those who are eligible can enroll in the appropriate program; those who are not are enrolled in HSF and choose a primary care home from among fourteen county and eight private, nonprofit clinics. (As enrollment grows, we hope to broaden the network of providers.) Participants are given an identification card, a handbook explaining how to obtain services, a list of standard point-of-service charges, and access to multilingual customer assistance. Participation is free for residents whose incomes fall below the federal poverty level. Others pay quarterly participation and point-of-service fees, with total fees for those at or below 500 percent of the federal poverty level amounting to less than 5 percent 30 San Francisco Medicine April 2008
of family income to ensure affordability. HSF provides enrollees with many of the benefits of managed care. Assigning patients to a medical home and primary care provider improves treatment outcomes and reduces the likelihood of costly emergency room visits and duplication of care. The small-fee charge is expected to attract some people who have refrained from seeking care because they considered it unaffordable and refused to accept “charity care.” And the provision of continuous coverage that is not tied to employment gives San Franciscans security even if they change jobs or become unemployed. There are some disadvantages of a non–insurance-based system. Only services provided at a participant’s primary care home and associated hospital are covered (right now, only the county hospital is participating). Emergency care obtained at noncontracted hospitals is not covered. Although emergency care is guaranteed by the federal Emergency Medical Treatment and Active Labor Act, the cost is billable to the patient and can result in a serious financial burden. In addition, unlike insurance, HSF will not pay for care received outside of San Francisco, and enrollees will lose all benefits if they move to another city. Despite these drawbacks, HSF’s universal-access model is a logical option for San Francisco from a cost and financing standpoint. The direct costs of the program are estimated at $198 per person per month—substantially less than the cost of commercial health insurance (though this estimate is admittedly based on the somewhat unfair assumption that there will be no adverse selection—that people with greater health care needs will not be more motivated to join than those with fewer needs). Administrative expenses are expected to be lower than is usual for a health plan—5 percent versus 9 to 14 percent—since HSF does not provide certain services that insurers do (for instance, the program will not be adjudicating out-of-network claims). Assuming a 7 percent inflation rate for the first two years of gradual enrollment, the overall cost of HSF in its third year, when enrollment is expected to be at 60,000 (82 percent of the uninsured), will be approximately $171 million. There are other cost advantages to a universal-access model, including a decreased risk of “crowd-out,” which occurs when insured individuals or businesses drop their coverage to take advantage of a subsidized plan, a practice that can drain subsidy dollars and lead to insufficient program funding. The fact that HSF does not pay claims originating outside the medical home reduces the likelihood www.sfms.org
of crowd-out. Unlike insurance, a universal-access model allows the county to continue receiving certain federal and state revenues, which are critical for maintaining HSF’s fiscal viability. In addition, HSF enrollees will remain qualified for certain federal and state benefits (e.g., the AIDS Drug Assistance Program) that are unavailable to insured patients. Financing for HSF is slated to come primarily from existing county funds for the care of the uninsured, which in 2007 totaled approximately $123 million. An annual $20 million is expected from existing federal and state health programs, and a three-year health care expansion award from the state will add $24 million per year to the budget. It is hoped that since the source of these funds is California’s ongoing hospital waiver, funded through the Centers for Medicare and Medicaid Services, the revenue will be maintained year after year. In addition, a health care spending requirement for employers was enacted under the same ordinance as HSF. Employers with 100 or more employees would be required to spend $1.76 per work hour per employee on health benefits; those with twenty to ninety-nine employees would have to spend $1.17 per hour. Employers could use this money to provide health insurance, create health savings accounts, pay health care claims, or contribute toward employees’ participation in HSF, thereby qualifying employees for free or discounted coverage. The employer spending requirement was legally challenged by a local restaurant association. A U.S. district court ruled in favor of the association, stating that the goals of the program were “laudable” but that the spending mandate was preempted by the Employee Retirement Income Security Act (ERISA) enacted by Congress in 1974. That act was designed to protect employers from having to tailor their benefit plans to a variety of local regulations. However, the city appealed the case to the U.S. Court of Appeals for the Ninth Circuit and asked the court to grant a stay of the district court decision. The Court of Appeals granted the stay, noting that the city has a “strong likelihood” of success in arguing that the employer spending mandate is not preempted by ERISA. Therefore, the spending mandate is in effect pending the appeal of the case. The HSF model is most applicable to counties with multiple safety-net providers. Systematizing the services that county and community clinics, private doctors, and hospitals provide to the uninsured will result in improved care and better data for health care planning. Our experience suggests that, even in counties with a sole charity care provider, offering enrollment identification cards and clear, up-front cost information may comfort people who would otherwise worry about paying for care. In addition, having participants pay prospectively encourages them to seek preventive care. With about 7,400 people enrolled in HSF as of December 2007, it is still too early to tell how successful the program will be; nevertheless, we hope it will inspire more energetic efforts at the state and federal levels. With an estimated 47 million uninsured people in the www.sfms.org
United States, and overwhelming evidence that the uninsured have less access to care and poorer health outcomes than the insured, it is critical that we take action now. This article is a slightly edited version of that which appeared, with references, in the New England Journal of Medicine on January 24, 2008 (NEJM 358:4:327-9). COMMENTARY FROM SFMS REPRESENTATIVES: As representatives of the SFMS who served on the initial Mayor’s panel that drafted plans for the Healthy San Francisco program (with Gordon Fung continuing on the Oversight Advisory Committee for the program’s implementation), we are gratified to see both how well the implementation is proceeding to date and that the legal challenge has been successfully answered so far. Given that federal and state health access plans do not seem to be pending any time soon, despite much debate, San Francisco is providing a unique laboratory for one means of addressing this issue. While no such program will be perfect, we agree with Dr. Katz that this is a worthy effort. And we are aware that people around the nation are watching it with interest. —Gordon Fung, MD, and Steve Heilig, MPH (Note: The SFMS has not taken a formal position to date on the HSF program.)
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hospital news CPMC
Damian Augustyn, MD
Dr. Martin Brotman, CPMC President and CEO, has been chosen to receive the highest award in American gastroenterology, the Julius M. Friedenwald Medal of the American Gastroenterological Association, which is given to the individual who has done the most over a lifetime and a career to influence the field of gastroenterology in the United States. The award will be presented at a special ceremony in San Diego in May 2008. Dr. Brian Andrews was recently appointed Chair of the Department of Neurosciences. Dr. Andrews is a graduate of UCSF School of Medicine and has been a member of the CPMC medical staff since 1988. He has previously served as Chief of Neurosurgery and Vice Chair of Neurosciences at CPMC. CPMC has become the first medical research institution in the world to use a gene silencing therapy to treat Hepatitis B. CPMC teamed up with Pennsylvania-based Nucleonics, Inc., and other investigators worldwide to test an innovative method of helping people suffering from the Hepatitis B virus (HBV). HBV creates strands of genetic material called RNA, which turn the cell into a mini HBV factory, effectively churning out new copies of the virus that spread throughout the liver. In the new RNAi approach, the patient gets an infusion of plasmids, or circular segments of DNA. Once in the liver, these segments produce something called “short interfering RNA” (siRNA), which bind to the HBV RNA. The siRNA then uses a molecular scissor effect to destroy the viral RNA, essentially blocking the virus’s ability to replicate itself in the liver cell. By preventing HBV from multiplying, this method effectively paralyzes the virus and makes it unable to create infectious virus particles. It is hoped that by immobilizing the virus, the patient’s body will be given a chance to fight against it and perhaps even clear HBV from the body completely. 32 San Francisco Medicine April 2008
KPSF
Robert Mithun, MD
Our ongoing effort to improve ocular services to patients takes many forms. For several decades, we have been involved with CPMC in an ophthalmology residency training program, in which a senior resident spends four months at KPSF working closely with our surgeons. All the residents in the CPMC program eventually rotate through our program, and some even choose to begin their medical careers at KP as a result of the experience. Having just one resident at a time enables a close and highly efficient relationship to form between trainers and trainee. In addition, we are a referral center for our sister Kaiser Permanente facilities in a number of ophthalmic subspecialties. Our expertise has grown to include glaucoma, cornea, vitreoretinal, and refractive surgery. Our surgeons are backed by a dedicated team of optometrists and technical staff. By being a referral center, we are able to incorporate new surgical techniques and stay at the cutting edge of ophthalmic surgery practice. Finally, our ophthalmologic services have embraced technology in almost all aspects of the practice, from the examination room to the operating room and beyond. Because ophthalmology is one of the most technologically-based specialties in medicine, we aggressively focus resources and training on the latest technologies as they become available. From microscopes to digital photography to laser scanners, we have incorporated the latest tools available to better serve our patients. At this point the ophthalmologic practice at the medical center is essentially paperless, and our patients are even able to communicate with us electronically from home. With a focus on training, an excellent referral service, and a commitment to using the latest technological tools available, we hope to further improve and streamline our already progressive ophthalmologic practice.
Saint Francis
Wade Aubry, MD
At Saint Francis Memorial Hospital, we’ve been focusing our efforts on combating sepsis. Severe sepsis is the leading cause of death in the noncoronary ICU. About one-third of the 750,000 new cases that occur in the United States each year are fatal. The mortality rates associated with sepsis are extremely high: 30 to 50 percent for severe sepsis and 50 to 60 percent for septic shock. Sepsis places a significant burden on health care resources, accounting for 40 percent of total ICU expenditure. Average cost per individual case is approximately $22,000. Based on these facts, SFMH’s goal for the next three years is to minimize the variation in the care of sepsis patients, following guidelines from the Surviving Sepsis Campaign. Measurable goals include decreasing our current sepsis mortality rate by 20 percent and reducing the cost of care. Pulmonologist Fred Hom, MD, has assumed the role of Physician Champion and will be aided by SFMH’s new Infection Control Manager, Wendy Kaler. I look forward to working with Dr. Hom, Wendy Kaler, our physicians, and the medical community in reducing sepsis mortalities. In other news, we’re pleased to share that SFMH’s Sonia Melara, Executive Director of Rally Family Visitation Services, was recently appointed to the San Francisco Health Commission, the governing and policy-making body of the Department of Health. Sonia will serve as Commission Vice President. The Commission aims to protect and promote the health of all San Franciscans by managing City and County hospitals, regulating and monitoring emergency medical services, and overseeing matters related to the physical and mental health of local residents.
www.sfms.org
St. Luke’s
Jerome Franz, MD
The February 23 issue of the San Francisco Chronicle had a front-page story about our hospital and the ongoing struggle for its future. CPMC has taken a step back from its initial plan to close acute care by 2010 and has responded to community voices expressing the need for these services South of Market. It is participating in a public-private planning process developed under the guidance of Supervisor Michela Alioto-Pier and Dr. Mitchell Katz, Director of Public Health. By the time this article goes to press, a blue ribbon committee will have met several times to develop a plan for both acute care and outpatient services at St. Luke’s. The committee consists of leaders in health, business, community, and labor and will be chaired by Dr. William Shortell, Dean of the School of Public Health at U.C. Berkeley. The vice chair is the Rt. Rev. Marc Andrus, Episcopal Bishop of California. Dr. Ed Kersh will represent the St. Luke’s medical staff, and Dr. Ken Barnes will represent the Save St. Luke’s organization of doctors and hospital employees. Dr. Damian Augustyn will be on the panel, and Dr. Steve Lockhart will act as a community liaison to bring the input of other individuals and groups to the committee. The questions are many. How does a tax-exempt corporation respond to the needs of its community and still maintain financial viability? How does a cash-strapped government continue to provide health care to its poorest citizens? What do the neighborhoods South of Market really need? A report is expected by the end of June.
www.sfms.org
St. Mary’s
Guest Columnist: Steve Chang, MD
In the last few years, extraordinary developments have occurred in the world of ophthalmology. New techniques in the field of cataract and refractive surgery are exciting for both the medical professional and the patient. With recent technological advancements, there are a host of innovations and newly approved procedures. More than eleven million people have undergone LASIK, which has become even safer and more precise with the advent of the femtosecond laser (used to create the corneal flap) in an all-laser “bladeless” experience. However, laser vision-correction is not “one size fits all” anymore. The much-anticipated FDA-approved alternative to laser refractive surgery is now available in the form of the implantable contact lens (ICL). Similar to a standard contact lens, the ICL can correct moderate to high levels of myopia or nearsightedness. Instead of sitting on the surface of the eye as does a typical contact lens, the ICL is delicately placed inside the eye. It provides exceptional visual clarity and is maintenance-free. Significant improvements have been made in the field of intraocular lenses (IOLs) used in cataract and refractive lens exchange surgeries. Aside from the standard single-focus lenses, wavefront optimized versions and astigmatism correcting IOLs now provide the highest possible quality of vision after surgery. Perhaps the most exciting advancement in the IOL field has been the presbyopia-correcting lens. For the first time, lenses are available that have built-in “zoom”—providing simultaneous distance, intermediate and, most of the time, nearvision correction without the need for glasses. Three FDA-approved lenses, ReZoom (AMO), ReSTOR (Alcon), and Crystalens (Eyeonics), now provide a remarkable solution to the presbyopia riddle and an opportunity for millions of baby boomers to get rid of their bifocals and reading glasses forever. For more information, call (415) 668-1000.
UCSF
Ronald Miller, MD
One-year survival rates for patients receiving heart, liver, and lung transplants at UCSF Medical Center are higher than national averages at statistically significant levels, according to recent data compiled by the Scientific Registry of Transplant Recipients. Recognized for tackling the most difficult transplant surgeries, UCSF is the only hospital in the U.S. News & World Report 2007 honor roll of the nation’s top 18 hospitals to exceed national averages or expected survival rates at significant levels in all three programs. The one-year transplant survival rate at UCSF for heart is 100 percent, compared with the expected rate of 87 percent; for liver, 92 percent compared with 88 percent; and for lung, 90 percent compared to 80 percent. Data are collected by the national Organ Procurement and Transplantation Network. A team of volunteers from orthopaedic surgery and sports medicine at UCSF—spearheaded by Kevin Bozic, MD—joined with the American Academy of Orthopaedic Surgeons in March to build a safe and accessible San Francisco playground in one day. AAOS coordinated with local community groups on the project, which took place the day before the beginning of the AAOS annual meeting in downtown San Francisco. The project was part of an ongoing campaign by the academy to build playgrounds throughout the country. The FDA approval process for medical devices needs to change in order to improve health outcomes, according to a recent analysis by UCSF researchers led by Mitchell Feldman, MD, and Jeffrey Tice, MD. In a “Perspectives” piece in the January 2008 issue of the Journal of General Internal Medicine, the team evaluated the federal review process (the method by which devices come to market), how the scientific literature reports on clinical trials involving medical devices, and the effectiveness of independent review boards in improving a technology’s medical benefit to patients. April 2008 San Francisco Medicine 33
Hospital News In Memoriam Nancy Thomson, MD
Veterans
Diana Nicoll, MD, PhD, MPA
The San Francisco V.A. Medical Center recently opened a new high-tech Simulation Center that creates realistic medical scenarios to allow clinicians to improve and refine their medical skills and techniques. The momentum for this program came from the institution’s strong commitment to quality of care and patient safety, with the primary focus being improving the efficiency and effectiveness of the entire health care team. The Simulation Center includes a simulation lab that can be configured as a patient room, an intensive care unit room, or an operating room, as well as a classroom and communication room. Staff participate in handson educational programs specifically designed for physicians, nurses, and other health professionals with a focus on health care team training. The simulator has a full-size SimMan, which is a computer-controlled mannequin whose major body systems have been programmed to respond realistically to the environment, medicines, and other interventions. The mannequin’s responses are manipulated from the control room, and SimMan can be changed to appear to have incisions, broken bones, injuries, or certain diseases. The mannequin may be used to practice a number of physical examination techniques or medical procedures, such as tracheal intubation, cardiopulmonary resuscitation, chest tube insertion, and IV insertion. Other simulator devices train staff in airway management, chest tube placement, and central line placement. There is also an expanding program both to train young surgeons in laparoscopic or “belly button surgery” techniques and to provide advanced surgical training for experienced surgeons to help them enhance their skills. “We’re very excited about the opening of the new Simulation Center,” says Center Director Richard Fidler. “We have created a confidential, nonjudgmental environment where our clinicians can learn better clinical management skills and improve the way we all function as members of a team.” 34 San Francisco Medicine April 2008
John J. Niebauer, MD Dr. John J. Niebauer, a noted hand surgeon who developed one of the first prosthetic joints for the hand, passed away in his Marin County home on December 14, 2007, age 93, after a long illness with Parkinson’s disease. He was born in San Francisco on July 1, 1914. He attended Lick Wilmerding High School, transferring to Tamalpais High School when his family moved to Marin County. He graduated from College of Marin, where his chemistry professor encouraged him to attend Stanford University. He graduated from Stanford School of Medicine in 1942. After his internship and residency in orthopedics, he practiced at Stanford Lane Hospital (which has since become California Pacific Medical Center). He was Chief of Hand Surgery and later Chief of Staff. He taught at UCSF and Stanford and was a consultant in hand surgery to both the U.S. Army and the U.S. Navy. He was instrumental in developing and organizing a program, about which he felt strongly, for the training of orthopedic assistants. He joined the San Francisco Medical Society in 1947 and was affiliated with many other organizations, as well as being a popular lecturer and author of journal articles. Although an innovative leader in hand surgery, he was an old-fashioned physician at heart. He took a loving interest in each of his patients and had a bedside manner that evoked trust and comfort. After retiring, Dr. Niebauer pursued his interest in studying anthropology and many other subjects at College of Marin, including the Paleo-Indian campsites located near his Plumas County cabin. He was an avid outdoorsman, loving walks with his family, friends, and his beloved English Setters. He also enjoyed fly fishing, gardening, painting, reading, and ornithology. He was an enthusiastic sports fan, rooting for the ’49ers, the San Francisco Giants, and the Stanford Cardinal. He is survived by Jean, his wife of sixty-five years; his sons Doug, Pete, and Skip and his wife Janelle and their two sons; and his daughter Pat Hendrickson and her husband Stan and their three children. They will remember him for his joy of storytelling around the campfire and the love and laughter he provided for both his friends and family.
William E. Winn, Jr., MD Dr. William E. Winn, Jr., known as “Ted,” passed away peacefully at his home in San Francisco on December 26, 2007, aged 82. He was born on November 25, 1925, in Beaumont, Texas. He grew up in Dallas, attending Highland Park High School, SMU, and Harvard Medical School with a residency at the Mayo Clinic. Ted practiced ophthalmology in Marin, where he prescribed the only monocle in the county, then at Kaiser San Francisco, for many years. He joined the San Francisco Medical Society in 1972. He was incredibly happy to be a physician and was a strong supporter of universal health care. A Navy veteran of World War II and the Korean War, he was a member of the Alexander Hamilton American Legion Post 448 for many years. He was interviewed for Steve Estes’s book Ask and Tell (University of North Carolina Press, 2007). Ted was very gregarious, enjoying membership in many groups, especially those concerned with food and wine, music, and languages. He loved to sing and belonged to several choral groups, and he played the piano well. He was an enthusiastic attendee and supporter of many musical organizations. He traveled the world from South Africa to Russia, his many trips involving hiking or nature tours as well as seeing churches and pipe organs. He took lots of photographs. He loved languages, especially French and German, and hosted conversation groups. He was invited to many consular events and was never without a foreign dictionary in his pocket in case of meeting a foreign tourist. He was preceded in death by his parents, William Edward and Marjorie Daniel Winn, and by his brother, Robert Daniel Winn. He is survived by his partner of twenty-three years, Alan Nicholson, his sister Marjorie Winn Ford of Dallas, and many nieces and nephews. www.sfms.org
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Where Do You SenD Your Patients with end-Stage heart Disease? California Pacific Medical Center’s Adult Heart Transplant and End Stage Heart Disease Programs offer leading-edge therapies plus quality care and compassion for patients needing: • • • • •
Late stage heart failure diagnosis and therapy Temporary percutaneous total cardiac support Heart transplantation First- and second-generation LVAD devices for bridge-to-transplantation Permanent implantable cardiac support devices
Acute and chronic heart failure, acute myocardial infarction with shock, cardiovascular collapse, heart-based secondary organ failure and post-cardiac surgery acute heart failure are now all selectively treatable with good results using a variety of recent drugs and devices – but timing is crucial. California Pacific is a certified CMS destination therapy center for patients with end-stage heart failure who are ineligible for a transplant due to age, additional health problems or other complications. We go “beyond medicine” by being the only Bay-area hospital to provide a dedicated nursing unit for heart failure, VAD and transplant patients, featuring: • • • • •
Private rooms Beds available 24/7 for your emergency transfers Family room outfitted for patient and family’s use with exercise and video equipment A dedicated, specially-trained nursing staff > 90% patient satisfaction scores
We also go beyond medical care and provide our patients and families with disease counseling, spiritual support and reduced rates for patient and family housing.
heart Transplant outcomes 1 Yr CPMC
1 Yr National
3 Yr CPMC
3 Yr National
Our team Of surgeOns & cardiOlOgists combined
Patient Survival
82.61
85.15
88.24
82.13
Graft Survival
84.00
84.81
89.47
79.28
have over 80 years of heart failure, heart transplant and
Source: SRTR Data released 07/2007 and CPMC internal data
For more information: 888-637-2762 The Adult Heart Transplant and End Stage Heart Disease Program is associated with California Pacific’s Heart and Vascular Center, which offers quality, comprehensive, patient-centered cardiovascular care by a team of pioneering physicians integrating leading-edge technology.
Vad experience:
J. donald Hill, m.d. g. James avery, m.d. Preben Brandenhoff, m.d. ernest Haeusslein, m.d.
www.cpmc.org