August 2006

V O L . 7 9 N O. 5 A U G U S T 2 0 0 6 $ 5 . 0 0

San Francisco Medicine August 2006

www.sfms.org

CONTENTS SAN FRANCISCO MEDICINE August 2006 Volume 79, Number 5 Medicine and Creativity FEATURE ARTICLES 8 The Backstory of a Physician Turned Writer Leonard Shlain, MD

MONTHLY COLUMNS

10 Creativity in Retirement Larry Lurie, MD 12 A Creative Collaboration Between Doctor and Patient Robert Markison, MD

4 On Your Behalf 6 President’s Message Gordon Fung, MD, MPH 7 Editorial Mike Denney, MD, PhD 28 Hospital News

14 Painting Memories: Art Therapy for Alzheimer’s Patients Diana Reynolds Roome 17 Art as a Gateway for Physical, Social, and Spiritual Well-Being Elizabeth Agnese 19 Puppetry in Medicine: The Inclusive Art Lee Armstrong

30 In Memoriam Nancy Thomson, MD 30 Classified Ads 31 Announcements 31 Upcoming SFMS Events

20 Artistry in Plastic Surgery Roger Friedenthal, MD 22 Physician, Balance Thyself Erica Goode, MD 25 A Creative Approach to Prevention Diana Amodia, MD; Jeff Draisin, MD; and Sharon Meyer, CNC OF INTEREST

Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833

27 Public Health Update: New Developments in HIV Prevention Jeffery Klausner, MD, MPH

Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue

How Does this Issue of SFM Look?

We are trying a few new things at San Francisco Medicine Magazine and would appreciate your feedback. If you have any comments on the look, style, or printing quality of this issue please let us know! All comments should be directed to Amanda Denz, our managing editor, by calling (415) 561-0850 extension 261 or sending an email to adenz@sfms.org www.sfms.org

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

august 2006 San Francisco Medicine

ON YOUR BEHALF

August 2006 Volume 79, Number 5

A sampling of activities and actions of interest to SFMS members Editor Mike Denney, MD, PhD Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artists Amanda Denz and Brian DeSimone Editorial Board

The SFMS Physician Referral • Another Chance to Participate Service is Being Updated in RENEW •

Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Gretchen Gooding Judith Mates

Wade Aubry

Samuel Kao

Toni Brayer

Thomas Lee

Corey Maas

Arthur Lyons

Ricki Pollycove

Jordan Shlain Leonard Shlain

Jerome Fishgold Rita Melkonian

David Smith

Alan Greenwald Kathleen Unger

Leo van der Reis

Erica Goode

Kenneth Maybury Stephen Walsh

SFMS Officers President Gordon L. Fung President-Elect Stephen E. Follansbee Secretary Charles J. Wibbelsman Treasurer Stephen H. Fugaro Editor Mike Denney Immediate Past President Alan Greenwald SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Director of Public Health & Education Steve L. Heilig, MPH Director of Administration Posi Lyon Director of Membership Therese Porter Board of Directors Mei-Ling E. Fong, MD

John W. Pierce, MD

Thomas H. Lee, MD

Daniel M. Raybin, MD

Carolyn D. Mar, MD

Michael H. Siu, MD

Rodman S. Rogers, MD

Richard L. Caplin, MD

John B. Sikorski, MD

Lucy S. Crain, MD

Peter W. Sullivan, MD

Jane M. Hightower, MD

John I. Umekubo, MD

Brian J. Lewis, MD

Gary L. Chan, MD

Michael Rokeach, MD

George A. Fouras, MD

Jordan Shlain, MD

Jeffrey Newman, MD

Alan M. Teitelbaum, MD

Thomas J. Peitz, MD CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate Judith L. Mates, AMA’s Women Physicians Congress Governing Committee

Notes from the Membership Department

San Francisco Medicine August 2006

One of the most valuable aspects of membership in the San Francisco Medical Society is the opportunity to participate in the Physician Referral Program. more than 6,000 referrals per year are made to member physicians on the basis of specialty, geographic location, foreign language fluency, and other factors.

We are in the process of updating our Physician Referral Service databank. A mailing of the appropriate forms recently went out to the active membership. We are in particular need of physicians who will accept new Medi-Cal and Medicare patients, and members are encouraged to check the Medi-Cal/Medicare boxes on the referral agreement form. We look forward to the robust participation of our members in this valuable service.

If you have any questions about the services or the agreement, please contact Therese Porter, Director of Membership, at (415) 561-0850, extension 268, or tporter@ sfms.org.

Dr. Linda Hawes Clever will be presenting one more pilot session of the RENEW program for the members of the San Francisco Medical Society on August 16 at 5:30 at the SFMS Presidio offices. This session is complimentary. If you are interested in attending, contact Therese Porter or Keven Chriss in Dr Clevers’s office, (415) 459-7398 or keven@linex.com.

RENEW is based on Dr. Clever’s 25 years experience in internal medicine and occupational health. RENEW helps physicians and others who juggle work, family, and community commitments sustain, or regain, their enthusiasm, effectiveness, and purpose. Competing demands can be treacherous, so RENEW helps people explore and reaffirm values, then tap into deep sources of energy, motivation, and talent so they can move ahead. The idea is to build or reclaim optimism, vitality, joy, and fulfillment in our work and lives.

For more information about RENEW ,visit www.renewnow.org.

The SFMS Membership Mixer Is Coming!

•It’s YOUR Society The San Francisco Medical Society is always looking for ways to make membership more meaningful and valuable. Your feedback is appreciated. Feel free to contact Therese Porter, Director of Membership, at (415) 561-0850, extension 268 or tporter@ sfms.org with questions, comments, and suggestions.

•

Thursday, August 24 from 6:00 to 8:00 p.m. at the Togonon Gallery, www.

TogononGallery.com, located at 77 Geary Street, 2nd floor. It will be a wonderful opportunity for SFMS members to meet each other and mingle at an exciting exhibit of art from Myanmar (formerly Burma) with beverages, hors d’ouevres, collegiality, and live jazz! New members are especially encouraged to attend.

In order to get an accurate catering count, we encourage you to RSVP by August 11 to Therese Porter, Director of Membership, at (415) 561-0850, extension 268, or tporter@sfms.org.

• Visit Our Website, www.sfms.org,

for Current News and Events!

The SFMS website is now updated on a regular basis to include the most recent On Your Behalf, Action News, and local events of interest, including many events that offer CME credits. www.sfms.org. www.sfms.org

Physicians Must Complete Pain CME by End of Year; Next Presentation of CMA’s Pain Management Conference Is Sept. 8-9 in San Francisco California law (AB 487) requires physicians to complete twelve hours of continuing medical education (CME) in pain management and the care of terminally ill and dying patients. Physicians have until December 31, 2006, to satisfy this requirement. Doctors licensed in California after 2002 (when the law was enacted) have four years from the date of licensure to complete the CME requirement.

One way to fulfill this requirement is by attending CMA’s pain management conference, “Pain, Palliation, & Politics: Pain Management and End-of-Life Care in California’s Regulatory Environment.”

This practical two-day CME program will be offtered September 8-9 at the San Francisco Marriott Hotel and again December 1-2 at the Disneyland Hotel in Anaheim. CMA tailored this program to meet the needs of physicians who do not specialize in pain medicine. Offering 14 hours of Category I CME, this program completely fulfills California’s AB 487 mandate.

CMA members pay $335 (nonmembers $600). Register early and get $40 off the registration fee.

For More information, contact CMA’s pain management seminar hotline, (415) 882-3330 or kdefabrique@cmanet.org.

CMA Encourages Physicians to Opt Out of Inadequate Concentra Settlement Most California physicians recently received a notice about a class-action settlement with Concentra, a company that provides PPO networks, medical bill review, and other cost-containment services to insurance companies.

The lawsuit, brought by a Pennsylvania orthopedic medical practice, alleged that Concentra engaged in “silent PPO” activity and used biased repricing methods to unfairly reduce payments to physicians. CMA urges physicians to opt out of this inadequate www.sfms.org

settlement agreement, which provides very little real relief to physicians. The deadline to do so is September 12.

The nationwide settlement applies to any physician in the country who has had a workers’ compensation or auto accident bill repriced by Concentra or one of its subsidiaries. The vast majority of physicians in California are covered by this settlement.

CMA, AMA, and a number of other state medical societies believe the defendants’ promised changes are illusory and inadequate to redress the damages incurred by physicians as a result of defendants’ alleged activities. AMA filed formal objections to this settlement before its preliminary court approval. AMA intends to object again at the formal fairness hearing, currently scheduled for October 19 in Philadelphia.

For more information, contact the CMA’s legal information line, (415) 8825144 or legalinfo@cmanet.org.

for vaccines covered by the federal vaccine program. Unfortunately, although the FDA approved the shot for females age 9 to 26, is it likely that most payers will only cover the vaccine for 11- to 12-year-olds, as would be required by law. The vaccine costs $360 (three shots at $120 each).

For more information, contact Robin Flagg, (415) 882-5110 or rflagg@cmanet. org.

A Reminder for Providers and Physicians Who Bill Medicare Contractors

CDC Recommends New Human Papilloma Virus Vaccine for Pre-adolescents The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) is urging that 11- and 12-year-old girls be routinely vaccinated against human papilloma virus (HPV), the sexually transmitted virus that causes cervical cancer. The committee also said the shots can be administered to girls as young as 9, at the discretion of their physicians.

This recommendation follows the June approval of Gardasil, the first vaccine specifically designed and approved by the Federal Food and Drug Administration (FDA) to prevent cancer in females ages 9 to 26. Vaccine proponents believe that the vaccine could dramatically reduce the nearly 4,000 cervical cancer deaths in the United States each year.

With ACIP approval, it is likely that federal officials will also vote to add the HPV vaccine to the federal Vaccines for Children program, which pays for immunizations for the poor. A CMA-sponsored law also requires California health plans to pay

A brief hold will be placed on Medicare payments for all claims during the last nine days of the Federal fiscal year (September 22 through September 30, 2006). These payment delays are mandated by section 5203 of the Deficit Reduction Act of 2005. No interest will be accrued and no late penalties will be paid to an entity or individual by reason of this one time hold on payments. All claims held during this time will be paid on October 2, 2006.

This policy only applies to claims subject to payment. It does not apply to full denials, no-pay claims, and other non claim payments such as periodic interim payments, home health requests for anticipated payments, and cost report settlements.

Please note that payments will not be staggered and no advance payments will be allowed during this nine day hold.

For more information please view the “MLN Matters” article at www.cms.hhs.gov/MLNMattersArticles/downloads/MM5047.pdf.

CMA Celebrates 150th with Historical Exhibit August 11 through September 4 at the state fair, Cal Expo in Sacramento, the CMA will have an 800-square foot exhibit of CMA “then and now”. The exhibit will feature artifacts including an old physician’s office, old-time doctor bags, surgery tools used on the pioneer trails to California, and more. For information contact CMA Communication Center, (916) 551-2072, or visit the CMA website, www.cmanet.org/150/, or Cal Expo website, www.calexpo.com.

august 2006 San Francisco Medicine

president’s Message Gordon Fung, MD, MPH

Creativity: An Integral Part of Medical Practice

I

s creativity an inborn talent, or is it something cultivated through practice? We know that people who maintain creative and interactive activities can slow the onset and severity of dementia. Being creative is also one of the most satisfying and pleasurable activities one can participate in. So what does it take to be creative? In the current era of experts and consultants, a creative person is one who spends the majority of his or her time professionally doing creative activities—creating new art, new songs, or new approaches to mundane problems. But the definition of a creative person can stretch beyond professional artists to physicians who are, by nature, creative people.

Remember that exceptional feeling when you were finally able, by trying a brand-new approach, to reach a patient who was recalcitrant and refusing to comply with a treatment plan? Creativity is an attitude or characteristic of constantly reviewing or being aware of what is ongoing and thinking of ways to change and improve it. But creativity is also something, in the current era of quality improvement, that seems to be discouraged so as to have all providers offer the same measurable, efficient quality and quantity of service.

However, creativity is one of the identifiable characteristics that distinguish candidates for medical school. One of the qualitative evaluations of admissions to medical school is what types of activities candidates have been involved in. Some candidates have excelled in the arts or are accomplished musicians. Some have

gone to volunteer in health care settings in third world countries or with the Peace Corps. Others have gone to minority clinics or into research laboratories.

Creativity is a necessary part of the profession, and the medical schools recognize this. Physicians are usually thinking of new ways to help people, whether it is by learning more about their profession through discovery and research, or by putting the new information into practice by creating new ways to work with patients. If one approach doesn’t work, then physicians find another way that does.

Additionally, physicians are fairly creative time managers since they must respond to one clinical situation to the next without much advance knowledge of what each day may bring. Patients and staff are usually caught in a bind, not being aware of all the demands of their physicians. But physicians definitely keep the patients and staff in mind when they make decisions regarding change and when responding to emergencies and unexpected clinical situations.

Aside from the usual creativity of constantly learning new things and dealing with the unexpected, there are physicians and providers who have been able to add creativity to their practice in unusual ways. This edition of the SFM is devoted to those physicians and providers who have been able to add their own special brand of creativity to their practice in service to patients.

Annual General Meeting of the San Francisco Medical Society Hold the date! The SFMS General Meeting will take place on Monday, September 11th, 2006, from 6:00 to 7:30 pm. Tentative guest speakers include Mayor Gavin Newsom and CMA President Michael J. Sexton, MD. The nominations committee will be presented. Members are also invited to attend the regular board meeting which will immediately follow the general meeting. This presents a good opportunity to meet with SFMS leadership and learn firsthand what SFMS and the CMA are involved in on behalf of San Francisco’s physicians.

If you plan to attend please RSVP by August 28 to Posi Lyon, plyon@sfms.org or (415) 561-0850 extention 260.

San Francisco Medicine August 2006

www.sfms.org

DEPARTMENT TITLE HERE Editorial Mike Denney, MD, PhD

Cure and Creativity

I

n her book Creation Myths, the Swiss analytical psychologist Marie-Louise von Franz describes how ancient creation stories of various cultures have acted as mirrors of the innate patterns of creativity and artistic expressions of human beings. For example, von Franz points out that in Egyptian cosmology, the god Ptah creates the whole world using a potter’s wheel and thenceforth becomes the essence of every work of art made by human hands.

The Chinese mythical creator, P’an Ku, is depicted as having a chisel with which he sculpts the mountains and carves out the sky.

The Iroquois legends describe a Sky Mother who takes mud from the mouth of Little Toad and paints it onto the back of Big Turtle, whence it spreads to create the earth. In a Hindu creation story, the Goddess of Nature weaves the universe upon a divine loom, and in African lore, the gods Mwile and Kolombo mold human beings from clay.

Reflecting this ubiquitous creative urge, human art has always depicted stories of divine beginnings, which can be seen in such wonders as Hindu and Buddhist paintings and sculptures, the mosaics of Islamic mosques, the Torah of Jewish temples, the ceiling of the Sistine Chapel, and innumerable other renderings of nature and the sacred in art and literature.

From that perspective, perhaps it’s not surprising that nowadays the internet bookseller Amazon.com offers 3,350 titles on creativity. There are books with names such as Inspiring Creativity, Understanding Creativity, Stimulating Creativity, and Managing Creativity. There are tomes called Group Creativity, Corporate Creativity, Breakthrough Creativity, Visual Creativity, and Serious Creativity. We can read The Yoga of Creativity, The Zen of Creativity, The Tao of Creativity, The Ethics of Creativity, and The Rape of Creativity. Still other treatises associate creativity with madness, attention deficit disorder, autism, dissociation, and depression. And, of course, there is the obligatory title Creative Cooking and its inevitable counterpart, Creative Dieting.

As in this issue of San Francisco Medicine we explore the theme of creativity and healing, might we discover some ways that physicians and others who have chosen a primarily remedial career can find a way to express their own inborn creativity? Can both doctors and patients transcend a paradigm of pathology and cure so that healing can actually become a creative process? Could it be that www.sfms.org

a mythological figure as creator of the universe might be depicted as holding a scalpel, stethoscope, and reflex hammer as creative instruments with which to express the curative art of medicine and surgery?

To satisfy their innate creative urge while working within an essentially remedial profession, many physicians participate in research so as to discover new understandings of disease and to create innovative healing techniques. Some of us find renewal and inspiration for our work through avocations in music, painting, sculpting, writing, and other artistic expressions. Others gain that same kind of gratification by collecting, tending, and promoting the arts. Interestingly, in this issue Roger Friedenthal, MD, observes in his own specialty that cure and creativity are actually united in the art and science of plastic and reconstructive surgery.

It may be that cure and creativity have an even more intimate relationship than that expressed within the practice of doctors. In his book Creativity and Disease, Philip Sandblom, MD, PhD, tells the stories of 140 famous authors, artists, and composers—from Chekhov to Beethoven to Frida Kahlo—and explicates how their ailments directly inspired their artistic genius. Completing the reciprocal nature of disease and creativity, others have turned this reality upon itself by using literature, music, and art as curative methodologies with which to treat disease.

As we engage this cycle of disease, cure, and creativity, we might recall the intimate connection between divine creation stories and human art and then notice some book titles not yet mentioned here: Creativity and Spirituality; Art, Creativity, and the Sacred; Creativity and Divine Surprise; Chaos, Creativity, and Cosmic Consciousness; Creativity, Spirituality, and Transcendence; and The Soul of Creativity.

Perhaps it is here, with Marie-Louise von Franz and Amazon. com, that we may realize our remedial healing work as being creative. Certainly, after recovering from serious illnesses, many patients feel a sense of rebirth, as though the divine had played a creative hand in their cure. Reciprocally, we physicians might find that cure and creativity have their most fundamental union within the reality that medicine is, indeed, an art—and that each act of healing is like a little creation story, an expression of the divine.

August 2006 San Francisco Medicine

medicine and Creativity

The Backstory of a Physician Turned Writer Leonard Shlain, MD

M

y career as a writer emerged from the single worst experience of my life. At age thirty-seven, my wife and I had three young and lively children, Kimberly, Jordan, and Tiffany.

We had just moved into a new house in the suburbs, and I was busy building my surgical practice. My life was going exactly according to plan. And then, in a single instant, everything changed. I found myself sitting on the edge of a hospital bed dressed in the half-gown of a postsurgical patient, being informed by my surgeon that my biopsy had tested malignant.

Frightened and anxious, I asked him to predict my chances of surviving. His reply devastated me. He repeated a line I had only heard in old B movies, one I would never employ when discussing a serious diagnosis with my own patients. He gravely intoned, “If I were you, I would get my affairs in order.”

After he left the room, I began to weep.

At that moment, my close friend Fred Miller arrived. I told him that I had just been told I would probably die, and soon. Being the good friend that he was, he tried to calm me with reassurance. He said, “Lenny, something good is going to come of this.” I paused in my wallow of self-pity to reproach him for his clumsy attempt to cheer me up.

“Are you out of your mind?” I retorted. “This guy just told me I am going to die and you’re telling me that something good is going to come from having cancer!”

After a year of radical therapy and its complications, I felt well enough to fully resume my surgical practice. Sobered and more compassionate, I had now experienced two distinct medical educations—my formal one through training, and my informal one through being a patient.

San Francisco Medicine August 2006

This was 1974. In the random dartboard game of life, this particular dart landed on my bull’s-eye in a watershed year in American history that was dominated

by Watergate and Vietnam. America was experiencing a pervasive sense of lost innocence. Amid this national despair, Elisabeth Kübler-Ross published her book On Death and Dying. A national sensation, it spawned numerous self-reflective seminars concerning the meaning of life and the preparations necessary for confronting one’s mortality. An organizer of one of these workshops thought it would be provocative to have a surgeon provide his perspective from both sides of the scalpel.

At first I was hesitant, as I knew I would have to reveal a great deal of personal material about myself and my fears. But my year from hell had been a transformative experience, and I wanted to share it.

Judging from the audience’s reaction, my presentation resonated profoundly. Afterward, a man approached me and asked if I had a written version of my speech. I answered that I had made some notes but, no, I had not formally committed it to paper. Charlie Garfield introduced himself and informed me that he was editing a book entitled Stress and Survival: The Realities of a Serious Illness. Having lined up Linus Pauling, Norman Cousins, Karl Menniger, and Hans Selye, he invited me to join the other contributors by writing down what I had just said, and he would include it as a

chapter.

Initially, I wasn’t sure I was up to such a task. I had taken only freshman English at the University of Michigan. There was little in my background that would even vaguely intimate that I had what it took to become a graceful wordsmith.

For the previous ten years, my creative writing outlet had been the daily entry of progress notes concerning my patients’ status. Intended only for doctors and nurses to read, these purely passive-voice, objective, emotionally detached descriptions filled with jargon, acronyms, eponyms, and lab values never qualified for any literary awards. Innovative phrasing was actually discouraged, as flowery writing tended to obfuscate; “Just the facts, Ma’am,” as TV’s Jack Webb used to deadpan.

Nevertheless, I believed it would be therapeutic for my soul to recount the lost year of my life, and since I was still very much concerned that I might soon die, I thought of it as a legacy for my children.

After the publication of the book, I began to receive letters and phone calls from people who, in similar straits, had been touched by my chapter. I learned that the Stanford Radiation Department had copied it and was handing it out to all patients entering its program. “Humpf,” I mused, at first unable to believe that something I had written had made a significant impact.

L’affair cancer greatly boosted my confidence concerning my writing ability.

“My career as a writer emerged from the single worst experience of my life.

My life was going exactly according to plan. And then, in a single instant, everything changed.”

www.sfms.org

In the midst of my recovery, my oldest daughter, Kimberly, who was twelve at the time, and I planned a visit to see New York’s great legacies of Western Civilization. Kimberly manifested budding artistic capabilities, so father and daughter set out on a cultural vacation. The idea at the root of Art & Physics, my first book (William Morrow and Co., 1991), began to take shape on this trip. I perceived similarities between modern art and twentieth-century physics and became convinced that there was a fundamental link between the two.

At the time, I was also performing carotid endarterectomies, which held a special fascination for me. Early in my medical education, I had toyed with becoming a psychiatrist. Although I ultimately chose surgery, I did not relinquish my interest in how the brain works. Operating on carotid arteries required that I understand this. One feature especially intrigued me: Right brains were decidedly different from left brains.

Ruminations concerning the puzzle of consciousness, the right/left split, and the connections between cubism and relativity tumbled like clothes in my mental dryer.

One day, while driving to work with an unfocused mind, the buzzer on the dryer sounded, informing me that the clothes were done. I suddenly realized that all these different subjects were interrelated, and voila! I began the grand adventure of writing a book.

I approached the art of writing as I had approached the acquisition of the skills necessary to become a surgeon. I knew that proficiency begins with considerable practice and close attention to emulating experts. Reams of foolscap disappeared into the wastebasket as I tried to capture the elusive qualities of grace and elegance that lie in a narrow band on the long continuum anchored by ponderous and turgid writing at one extreme and precious and hyperbolic writing on the other.

When I attended social functions, people would ask in a good-natured way, “What are you up to?” I would tell them I was writing a book. “About surgery?” they would prompt. “No,” I would reply, “about art and physics.” This would usually be a conversation-stopper. I could witness their eyes glaze over as I tried to explain my www.sfms.org

theses over the clink of glasses and cocktail chitchat. Politely pointing out to me that I was neither an art historian nor a physicist, they would often suggest, “Perhaps you should try to get a magazine to publish an article first.”

Undaunted, I kept plodding along, justifying my effort to myself as something

“Integrating the yang life of a busy surgeon with the yin life of a contemplative writer has been an exciting and unexpected turn of events in my life’s trajectory.” of a harmless hobby that could occupy me in the dotage of my retirement. Yet, in my heart of hearts, I was convinced I was on to something.

One night, after I had given a lecture to a small group called the Mill Valley Literary Society, a man approached me and asked if I had a text that complemented my presentation. Robert Stricker informed me that he was a new literary agent, and that he was intrigued by my ideas. When I told him I was writing a book about the subject, he asked if he could read something I had written. Flattered, I gave him drafts of a few chapters and was elated when he phoned me a few days later to inform me that he thought this could be a very successful book.

He offered to represent me.

Stricker said he was off to New York and that he wanted to show my work to some publishers. Despite his kudos, I had serious doubts about the quality of my writing and did not think it was polished enough to show to a major publisher. He convinced me to let him take one chapter to show to one publisher, just to see what the response would be.

When he left for New York, he promised that I would hear from him in a few days. After a week passed, I became convinced that his mission was a failure and that he was too embarrassed to call me. Ten days

later, Stricker phoned. He apologized for not following our original plan. He explained that the first publisher was so enthusiastic about the single chapter and outline that he decided to shop the book to others.

After a expectant pause, he went on to say that eight major publishers were interested in my work! There are only a few times in life when one has to hold the phone away from one’s ear to stare at it and make sure the device has not malfunctioned.

After I recovered, I asked him what the next step in this process would be, and he told me that the publishers wanted to read the rest of the book. Stunned, I replied that I hadn’t yet written the rest. Stricker then told me, “Write it!” For the next year, I was a man possessed. I wrote early in the morning before surgery. I wrote on vacations, on weekends, and while waiting for cases to begin in the surgery suite. Finally, Art & Physics debuted and, much to my delight, received many (but not all) over-the-top reviews.

Integrating the yang life of a busy surgeon with the yin life of a contemplative writer has been an exciting and unexpected turn of events in my life’s trajectory. In a way, it nicely balanced the sharp deviation from course that resulted from the earlier non-Hodgkin’s. A coda: I recently received a literary award held at a dinner function.

My old friend Fred Miller was in the audience. After I told this story, I looked at him and said, “You were right, Fred. Something good did result from having been diagnosed with cancer.”

august 2006 San Francisco Medicine

medicine and Creativity

Creativity in Retirement Larry Lurie, MD

I

s pent my adult life as a practicing psychiatrist, first as an advocate for Community Mental Health and then as a full-time, private practitioner with two offices in San Francisco. I considered creativity part of the art of my psychotherapy practice, but hands-on art was far from my mind as I worked with the emotionally troubled seeking my professional skills.

I dabbled in sketching and watercolors during my residency, taking courses with my wife—but that was more about our shared interests than about art. For the next thirty years, I didn’t pick up a charcoal, pencil, paintbrush, or piece of clay. During that time, I treated a number of patients who had retired or were about to retire. A number of them suffered from clinical depression. All had devoted their energies to work and career and were adrift as they faced mandatory retirement. They had no visions or plans about what to do next. That scared me, since I was approaching sixty and knew I was in exactly the same position. So, as I worked with my patients in finding alternatives (which usually had to do with creating or collecting), I began to ask myself what I wanted to do in my own retirement.

The Bay Area has a wonderful institution called “Open Studios,” which is held every October and allows the general public to visit the studios of working artists. I went one year and was enticed by the sculptures of Harriet Moore, who had a studio near my 10

home. I liked the idea of playing with clay, and I remembered how I used to make plaster models of teeth for my father, who was a dentist. After that Open Studios visit, I did nothing about proceeding aside from telling my annual men’s backpack group that I was thinking of taking up sculpture when I retired. Every year for four years, I said the same thing. Finally, in the fifth year, one of my friends brought in an advertisement from an adult education organization called the Learning Annex, which described sculpture classes given by Harriet Moore. The group essentially said, “Don’t tell us again about what you are going to do in the future. Do it now.”

With that message as a motivation, I started taking classes every Saturday morning. I liked the tactile, sensuous qualities of clay, and I enjoyed forming and molding it.

It was so different from my profession, whose ethics admonish, “Don’t touch.” I especially enjoyed making figurative faces and busts.

Perhaps viewing and “reading” faces for forty years made the subject intriguing to me.

I retired from private practice three years ago, and my involvement with clay increased to five days a week. At that point, I wanted to learn how to glaze my pieces, so I took a ceramics course at San Francisco

San Francisco Medicine August 2006

City College. However, before they taught glazing, they insisted that I learn hand building and throwing on a wheel, and that I gain knowledge about the chemistry of clay. As a ceramics novice, I found that throwing was a complete challenge. I am not a “natural.”

Determined to learn, I am persisting, but I have a long way to go. Along the way, with the encouragement of my professor, I had the idea that I could combine my sculptures with the bowls I had been making. Didn’t the ancient Greeks, Etruscans, and Romans do that?

That’s where I am now. My days fly by, and during the hours I’m actually creating, I don’t ever think of eating or using the bathroom. Retirement has been very fulfilling for me, as it turns out. Now, perhaps reflecting the cycles of life, I am exhibiting my own work in “Open Studios.”

Some of the most recent research about creativity and aging, as reported by Andrea Sherman in Generations, suggests that to maintain healthy cognitive function with age, people must maintain physical activity, mental activity, and social engagement.

Dancing is reported to be the best physical activity. Crossword puzzles and Scrabble challenge the mind.

However, the arts raise the venture to another level, because they use what Howard Gardner calls “multiple intelligences” in solving problems or creating projects. www.sfms.org

Gene D. Cohen, MD, a geriatric psychiatrist also writing in Generations, discusses the time between ages fifty and seventy as the period of “liberation.” There is a mounting sense of personal freedom to speak one’s mind and a feeling of having time to experiment with something different.

Cohen feels that older people in particular are healthier when they experience a sense of mastery. This sense can influence their subsequent behavior. People who perform well in something they had not realized they could master are then able to master other activities that had previously seemed impossible. The arts provide some of the best opportunities to experience a new sense of control or mastery. Cohen says, “In the arts, opportunities to create something new and beautiful are endless and offer an enormous sense of satisfaction and empowerment.”

George Vaillant, MD, recently completed a study, reported in the April 2006 issue of The American Journal of Psychiatry, about what gives satisfaction in retirement.

He concludes that creative activities and those that give a sense of purpose (also referred to as “pro-social” activities, such as watching one’s grandchildren), provide the most satisfaction. He adds, “Perhaps the most important adjunct to happy retirement, besides a sense of purpose and a good marriage, was learning how to play again.

Play is defined as behaviors that are highly gratifying to the individual and that do not injure the social order, do not contribute to the gross national product, and do not necessarily evoke societal praise or encouragement. Unlike the world of work and love, in the world of play, the people in the outside world need not respond.“ Satisfactions come less from others’ responses than from the enjoyment inherent in the activities themselves. When receiving the Purpose Prize, Judea Pearl, father of the slain reporter Daniel Pearl, said, “People over 60 have more talents and more energy than they realize. Younger people constantly worry what their boss or their family might think.

At my age, I’m free of constraints.”

In my own experience, the roots of the creative were present, though I never consciously wanted to be an artist. These roots were properly watered by friends, by my own recognition of the inevitability www.sfms.org

of retirement and aging, and by access to schools and teachers. The pleasure I feel comes from using my eyes, arms, and hands to put my perceptions into tangible form.

Since I have already had a successful professional career, the results of my play with clay have less importance than if I were younger and seeking an identity. There are other ways to retire and grow old, but for now, I am enjoying this way. Perhaps the noted aging ceramist Eva Zeisel put art in the best perspective when she said, “It’s very difficult to know exactly whether to live for an ideology or even to live for doing good. But there cannot be anything wrong in making a pot, I’ll tell you. When making a pot, you can’t bring any evil into the world.”

Upcoming Conference Announcements Environmental Medicine and Health: Cardiology, Oncology, and More—Science, Medicine, Prevention, and Policy Friday, October 13, 2006, 8:30 a.m to 6 p.m. at the UCSF Laurel Heights Conference Center, San Francisco, CA. Co-Sponsored by the San Francisco Medical Society, the Collaborative on Health and the Environment, California Academy of Family Physicians, American Academy of Pediatrics, California (AAP-CA), The Permanente Medical Group. CME available. The registration fee is $100.

Co-chairs for this event will be Philip R. Lee, MD, Professor of Medicine at Stanford University and Chancellor Emeritus at UCSF; Gordon Fung, MD, MPH, Chairman for the Collaborative on Health and the Environment, President of the San Francisco Medical Society and of the American Heart Association in San Francisco; and Brian Lewis, MD, of The Permanente Medical Group.

For more information please contact Steve Heilig, (415) 561-0850 extension 270 or heilig@sfms.org, or see the website, www.healthandenvironment.org.

Beyond Zero Tolerance: New Directions In Drug Education and School Discipline Wednesday, October 25, 2006, 8:30 a.m. to 4 p.m., Fort Mason, San Francisco. This event is co-sponsored by the SFMS, The Drug Policy Alliance, Mayor Gavin Newsom, and the San Francisco and Marin Departments of Public Health. The registration fee is $100.

For more information please call (415) 921-4987 or visit www.BeyondZeroTolerance.org.

august 2006 San Francisco Medicine

11

medicine and Creativity

A Creative Collaboration between Doctor and Patient Robert Markison, MD

P

atients come to a doctor’s office seeking expertise and hope. Expertise is know-how based upon skill, current knowledge, contribution to the field, and reliably good results over the long haul.

Hope comes from an abiding love of people and an abiding trust that the creative process is accessible to all of us. Hope is bound up in optimism, and optimism rests on the solid belief that thoughts, feelings, and raw materials are more workable than fixed.

Algorithms have their place in medicine, but many patients require something outside of cookbooks. Patients do best when they understand that medical care is a creative collaboration between patient and doctor, and remedies maybe obvious or unobvious. Creativity itself is best defined as the bridging of apparently disparate domains, yielding fresh and reproducible new ideas or new objects. In my own practice of hand surgery, I enjoy nongeneric problem solving, and I have seen patients benefit from creative collaboration in a number of cases.

Each of my patients leaves my office with a hand-rendered anatomical drawing explaining the diagnosis and treatment. I find that patients are more confidently engaged in the treatment process when the diagnosis has been visually rendered. And in my personal life, I undergo ongoing “creative cross training” through various endeavors in order to hone my skills.

ous study of various fields for the refreshment of our teaching skills. In my own career, I wanted to learn about the rapid time frames of trauma care, so I did a full general surgery residency at UCSF, followed by a hand surgery fellowship, and then spent much of

my time between 1975–89 working on the trauma team and other surgical teams at San Francisco General Hospital. In 1984, I cofounded the UCSF health program for performing artists in order to gain a greater understanding of cumulative trauma within longer time frames among creative people.

This also gave me a chance to “give back to my own,” since I have been a serious musician for nearly fifty years. At the same time, I went back to school for deep study of the overlapping body systems. I remain a surgical “tissue mechanic,” but my heart is in creative cross training for the enhancement of patient care.

Creative cross training The Oxford English dictionary defines doctor as teacher, and indeed, much of our time is spent teaching. This entails continu-

Temporal cross training The daily practice of music seems to benefit the practice of medicine. Music composition, arrangement, performance,

recording, and production are all a part of my routine. I try to compose and record a new piece of music each morning to set the groove for the day. Each composition serves a practical purpose. Moving a frequency spectrum of sound over metronomic time seems to set the stage for one fine day after another. Dizzy Gillespie was right when he said, “Rhythm is king,” and Duke Ellington was surely correct when he proclaimed that “It Don’t Mean a Thing If It Ain’t Got That Swing.”

Here are the details of morning’s sixty-minute temporal/musical “workout”: Step One Track 1: Brushes on a snare drum with subtle hi-hat cymbal punctuation, meter of 120.

Track 2: Acoustic rhythm guitar, simple Django Reinhardt-style gypsy chord voicings.

Track 3: Bass clarinet (rather than string bass), as a nice harmonic complement to rhythm guitar.

Track 4: First clarinet part, minor mode, cycle of fifths alternating with cycle of fourths.

Track 5: Second clarinet part, minor mode, cycle of fifths alternating with cycle of fourths, counterpoint against the first clarinet part.

Track 6: Muted trumpet on second counterpoint line.

Step Two Sound editing/engineering: Balancing track volume levels, equalizing each track for proper placement in the sound-frequency spectrum, reverb, compression, mix-down to disc.

Step Three

12

San Francisco Medicine August 2006

Conversion of the stereo 24-bit audio file to a monophonic MP3 file, upload to the cell phone wireless system, followed by download to my cell phone for use as a cell phone ring tone. Cell www.sfms.org

phone ring tones should be no longer than 11–12 seconds, and the remaining music is archived for use in a forthcoming audiovisual suite about (biological) cellular rhythms, entitled Ribosomal Rhythm. Morning workouts are seldom wasted.

The creative process in music and medicine calls forth all sorts of nested clocks: metronomic time, circadian rhythms, brainhand neuromuscular clocks, and the parallel clocks of counterpoint.

The clinical interaction in and out of the operating room consists of point, counterpoint, Angled flute head joint theme, and variations; these are also essential musical values. Everything that happens musically finds its complement in medical practice.

Music embodies the graceful movement of time, providing a helpful counterbalance to the sometimes gloomy nature of medical time. Music is just one example of temporal cross training, and any endeavor which improves a practitioner’s appreciation of workable time is of great value. I think Sir Isaac Newton explained medicine as well as anyone when he published Principia Mathematica in 1687, clearly describing the first and second derivatives of differential calculus: Rate of change (dxdt) and rate of rate of change (ddxdt). After all, physicians are time-tinkerers engaged in the lifelong study of tissue calculus.

the brain nimble, and I thank master artist Vincent Perez for teaching me about this.

Spatial cross training through art and craft has also expanded my hands-on knowledge of a variety of trades, definitely enhancing the care of similarly engaged patients.

Here are the details of yesterday morning’s ninety-minute spatial cross training: Step One Fire up the glass fusing kiln to 1450°F, then set a sheet of clear glass on top of a milled steel form. Melt the glass around the form.

Step Two Carve a drawing into the concave side of the glass, serving as an internal negative-

Custom cast sax keys space microsculpture viewed properly from the convex side of the glass.

Step Three Pulverize some colored glass (from a root beer bottle), wash it several times, mix the glass with gum Arabic, and paint/fill the microsculpture under a dissecting microscope.

Step Four Second firing, this time to 1380° in order to melt the colored glass into the clear glass without melting the clear glass.

Step Five Spatial cross training Art and craft are my own pillars of spatial cross training. Art stops time just as surely and gracefully as music moves time. The daily production of art and craft has direct relevance to medical practice by pushing imagery to logical visible and tangible conclusions. Since I have been redesigning musical instruments for forty years, I have often delighted in the transfer of these manual skills to the clinical setting.

When I do small-joint work in the hand or design/redesign surgical instruments, I’m using skills that come from decades of musical instrument redesign. Ambidextrous rendering in art and craft seems to keep www.sfms.org

and John Coltrane in the same discussion.

He stressed the value of playing at any tempo in any key, the necessity of original composition, and constant memorization of repertoire; and he encouraged me to learn as many instruments as I possibly could.

A remarkable number of musical prodigies can reproduce note-perfect Chopin but cannot improvise. They are glad for advice about linking improvisation and health.

Patients often come to my office in order to learn how to “improvise their way out of trouble” when nothing else is working.

Create a sterling silver background with soldered bezel, mount the glass/micro sculpture piece, add the attachment for leather cords and the cord tips, and the bola is complete. I wear handcrafted bolas or hand-painted neckties to work, and their presence seems to spark therapeutic discussion of the creative process with my patients.

Improvisation Before presenting a handful of cases, I should mention the value of improvisation.

I was fortunate to obtain classical and jazz clarinet training from Peter Ferrara, who often described the improvisational skills of Bach, Beethoven, Schubert, Charlie Parker,

Illustrative Cases 1) Symphony cellist with bilateral thumbs carpometacarpal joint osteoarthritis and carpal tunnel syndrome, plus hypothyroidism. Rx: Tighter control of TSH from 5.0 down to 3.0, substantially decreasing the carpal tunnel syndrome symptoms and joint pain; reworking of the bridge of the cello without compromise of sound, in order to decrease finger pressure/thumb counterpressure on the back of the neck of the instrument; gradual switch from French to German Hand bow cast and machined in order hand to retractor avoid sustained pinching with the right thumb. This combination of remedies afforded the patient ten years of musical comfort. He retired gracefully, and required a left thumb carpometacarpal joint arthroplasty two years later. He is one of more than a thousand musicians whose careers I have followed for more than twenty years.

2) Data-entry worker with bilateral wrists flexor tenosynovitis. Rx: Dragon Naturally Speaking software, with my training session videotaped for patient reference later on.

3) Oil painter with progressively disabling scleroderma, diffuse small-joint arthritis in the hands. Rx: I taught her to do the under painting with monochromatic airbrushed acrylics, and the final layer of Continued on page 24...

august 2006 San Francisco Medicine

13

medicine and Creativity

Painting Memories: Art Therapy for Alzheimer’s Patients Diana Reynolds Roome Editor’s Note: The following article was originally published March 11, 2005 in the Mountain View Voice.

I

n a sunny alcove with cherry and apple blossoms outside the window, Joan is copying a calendar photo of a tropical beach. She has painted wide swathes of turquoise and blue on the top half of the paper laid out before her. Every week, she makes a picture of water. Now she’s resting and smiling, content to look at what she’s done.

Opposite her at the table, Peter bends over a design that he makes up as he goes along. His brush leaves a trail of multicolored squiggly lines as he dips it rapidly into the paints and on to the paper. When asked what it depicts, he replies, “Totally abstract,” then “trees, forest. It’s a mess,” but he smiles as he dips his brush back into the pan of green watercolor.

Just down the hall, one of Peter’s framed paintings hangs on the wall. It shows a number of buildings and other structures, most of them labeled in a careful script with the names of colors or words like “Junk,” which he has written three times. His painting is also signed, like all the other pictures hanging here. Peter was an engineer in his younger days, and Joan was a journalist.

Now they both live in the assisted care living facility for those with Alzheimer’s and dementia, at Palo Alto Commons.

The paintings on the wall and the art class in progress are the result of the Memories in the Making, a therapeutic art program run by the Alzheimer’s Association. It is designed for patients with no art background and at almost any stage of Alzheimer’s.

Alzheimer’s and dementia can rob their victims’ worlds of color and detail.

14

Painting is a powerful way to retrieve those things— both for the artists and their loved ones.

Six residents attend today, chosen according to their level of energy and expressed interest. They sit around a table, absorbed in the images they are creating.

Bea, in a wheelchair, drops off to sleep from time to time, then wakes up to resume the

“When a person has lost their cognitive abilities, they may still have a wealth of creative material inside. Painting is a way for it to come out. Sometimes whole pieces of people’s history come back” task of copying the petals from a print of a deep purple clematis. So far, she has dabbed two arcs in the lower right corner of her paper. Lauren Schwartz, the volunteer group facilitator, and Erika Mendoza, a staff activity leader, remind her to pick up the brush and try a new color, offering suggestions and encouragement.

“Some people will come down the hall and don’t know what they’re going to.

Then all of a sudden, they’re engaged,” said Schwartz, who has been running the weekly class for a year and a half, and is finishing a master’s degree in transformative arts.

“This seems to bring out some individuality, because it’s so totally expressive and personal. Some don’t talk much, but this activates their imagination and takes them

San Francisco Medicine August 2006

to another place. It seems to tap into their spiritual side.”

Memories in the Making classes are held at 15 sites from San Francisco to San Jose, and more classes are being added. The program is designed to offer a vehicle for communication, self-expression and rediscovery. It also helps replace some of the skills that dementia takes away, said Toni Morley, an art and family therapist and coordinator of the program.

“Watercolor is a very fluid medium that taps into memories from the past, and brings up pieces of people’s past history,” said Morley. She tells how one man, who didn’t communicate verbally, chose a picture of a fish from images on the table, and meticulously copied it for over an hour.

When his wife saw what he had done she wept, explaining that he had once collected tropical fish.

“Painting often provides a way for the family to communicate,” said Morley.

“When a person has lost their cognitive abilities, they may still have a wealth of creative material inside. Painting is a way for it to come out. Sometimes whole pieces of people’s history come back.”

In a recent exhibition put on by Memories in the Making program, one painting depicted a memory of a drive home from Yosemite, with mustard fields and prune trees in the rain. While painting an abundance of multicolored leaves, a retired rancher told stories of family life on the ranch. A frail woman who carried a baby doll and hadn’t spoken in class repeatedly painted squares, with different colored squares inside. When asked about them one day, she suddenly said, “Yes, I used to make quilts.”

Painting is a boost to self-esteem, as creations are held up and admired, and www.sfms.org

later often framed, hung and exhibited. It also helps people connect to their previous accomplishments, said Stephanie Fielden, who facilitates the Memories in the Making class at the Avenidas Senior Day Health Center in Mountain View.

“When people lose all kinds of skills and abilities, here’s a chance they have to be creative again,” said Fielden. One man who doesn’t speak, for example, is “very good at painting and one of the least hesitant with the brush. He always initials his work, and there’s a pride in that. [Others] may not remember their work, but we confirm that it’s theirs and encourage them to continue.”

At Palo Alto Commons, Peggy applies several shades of color to a large pink orchid, and adds yellow for the center.

“I feel I should dress it up a bit,” she says, “but I’ll ruin it.” Her neighbor at the table, who is drawing the outline of a flower in pencil, turns and admires the pink orchid.

“It’s beautiful,” she says. When Peggy continues to criticize her own work, Peter tells her she can strengthen her talent by doing more art. Schwartz finds a picture Peggy did last week, of a flame-colored tulip, and holds it up for all to see.

www.sfms.org

“I did that?” she asks, delighted. “Now I’m looking at it, I realize it looks a lot better than when I first did it.”

The art classes stir up conversation and build a special camaraderie, said Lenora Park, director of the center. “It’s comfortable, familiar, and quiet. People who don’t normally sit for a period will be engaged for 45 minutes.”

Some people paint fairly quickly and boldly, while others continue working on a piece for weeks, Fielden explained. Her role is to provide inspirational pictures, art materials and ideas, and sometimes step-bystep instruction, especially if a participant becomes fixated on stirring the brush in the water or repeatedly going over the same area of paper. However, she never puts anything on the paper itself. Facilitators, who are given brief training and are always accompanied by a member of the care staff, do not need to have an art background though Fielden, for example, has a degree in graphic design.

A research study, Emotion in Dementia Patients: Effects of a Fine Arts Group on Well-Being, Dupart, Krisztal, Long & Morley, 2003, demonstrates that people engaged in the art activity are less depressed,

more focused, more social, and experience less anger, sadness and apathy than those participating in a current events program.

“One of the challenges [of Alzheimer’s and dementia] is the loss of connectivity—memories, the past and activities.

The art helps people reconnect to the past and to parts of themselves, emotionally and socially,” said William Fisher, director of the Alzheimer’s Association Northern California branch, headquartered in Mountain View.

The Memories in the Making program holds an annual exhibit and auction of participants’ work. The art is also on display at several sites where classes are held. see www.alznorcal.org or call (650) 962-8111 for more information on the auction or to find out about volunteering opportunities. *Names of patients with Alzheimer’s or dementia have been changed to preserve anonymity.

Reprinted with permission from the Mountain View Voice

august 2006 San Francisco Medicine

15

Aon Physician Alliance: Protecting the Assets of Physicians and Surgeons As a leading independent insurance broker, Aon Physician Alliance is dedicated to serving the medical malpractice insurance needs of physicians and surgeons.

Aon Physician Alliance is the solution to your professional liability insurance needs: • We are part of Aon Corporation, one of the world's largest insurance brokers, and a Fortune 250 company.

• We have established professional relationships with most of the nation's top medical malpractice insurers to provide you with the choices you need.

• We also have the experience and knowledge of the medical professional liability market to ensure that you are getting the most value for your insurance dollar.

• We provide professional liability solutions to 1,000,000 Healthcare Providers Now that the professional liability market is becoming more competitive, the time is now to compare your coverage.

Call Aon Physician Alliance at 1-866-815-5776 to get us working for you.

Helping you protect your practice against the unexpected.

Insurance coverage available for your new or existing medical spa/anti-aging clinic or similar required coverage.

www.aonphysicianalliance.com

Your Source For Professional Liability Insurance Solutions

Aon Physician Alliance is a division of Affinity Insurance Services, Inc.; in NY and NH, AIS Affinity Insurance Agency; in MN and OK, AIS Affinity Insurance Agency, Inc.; and in CA, AIS Affinity Insurance Agency, Inc. dba Aon Direct Insurance Administrators License # 0795465. © 2006 Affinity Insurance Services

MD-Pro-806-SF

medicine and Creativity

Art as a Gateway for Physicial, Social, and Spiritual Well-Being Elizabeth Agnese

H

appiness might be defined as the blossoming of our unique creative talents—individually and collectively. This creativity, as applied to healing, is not just an individual matter. Author Lynn S. Chancer, author of Sadomasochism in Everyday Life (Rutgers University Press, 1992), says, “It is through mutual recognition that we have the opportunity to develop as humans in all domains: physical, mental, social, and spiritual. It is from this mutual space of recognition that healing takes place for all people, regardless of age, cultural background, or life circumstances.”

My direct experience with families from all socioeconomic backgrounds and cultures consistently shows that when people engage in interrelated arts, the dynamics within the family shift. Unhealthy relationships are modified, old wounds heal, and new collaborative patterns develop. This shift takes place within the framework of respect for one another through the development of each individual’s talent.

I develop creativity salons, handson music, and art experiences for people of all ages and cultures, inspiring direct experiences that stem from each person’s own choices. The interrelated performing, visual, and culinary arts, along with classic literature, form the foundation upon which individuals and members of their families create healthier relationships. This type of engagement creates the vital opportunity to bring meaning and value into each person’s life, and these integrated experiences are mentally, physically, and socially transformative.

My typical day involves going into the living space of the client to teach interrelated arts. My background as a professional opera singer and my degree in psychology, www.sfms.org

with specialization in applied community psychology, give me the tools to teach piano and voice while responding to each individual as they go through the learning process. All other subjects become easier to learn, because the arts inspire the client’s mental, physical, and social capabilities while building selfesteem. I continually hear, “Wow, I really can play the piano.

Wow, I can really sing.” Others are heard to say, “Can’t she sing beautifully.” The study of a specific art bolsters each client’s confidence and builds his or her understanding and compassion for all cultures. Each student has the capacity to transform his or her life through the healing qualities of the interrelated arts.

Research suggests the potent value of children’s self-discovery through their direct experiences in the interrelated arts.

These important breakthroughs in human development are being recognized by crossdisciplinary professionals, such as anthropologists, sociologists, and archeologists, who realize the arts’ potential in the bigger picture of human development. Within a self-paced process of discovery, each person evolves to create what gives meaning in his or her life. This enrichment fosters the contributions each of us makes to the well-being of others, which is a healing in itself.

When we are fulfilled from the inside, we live a life filled with vitality. It is this vitality that is found within new research of teens’ brains and their cognitive developmental processes. Author Barbara Strauch,

in her book The Primal Teen (Anchor 2004), illustrates how the brain is positively impacted by creative practice in developing teens.

Instead of risk-taking in activities that would be harmful, such as drug and alcohol use, the arts provide the risk-taking element in a positive manner, adding to the development of self-esteem within the learner.

The interrelated arts develop the brain in many ways by embracing cognitive thinking skills, which overlap into other disciplines of learning. For example, learning to play the piano engages fine motor skills and spatial conceptual thinking similar to what is involved in learning math skills. Learning music is like learning a new language. The elements of brain function engage the senses through the music’s rhythm, pitch, melody, harmony, and dynamics—thus engaging the whole person.

Victor E. Frankl, author of Man’s Search for Meaning (Beacon Press, 2006), says that we have a choice of our attitude in each moment in time. During his time in concentration camps during World War II, he chose his attitude and what to think about. He consciously chose what gave him meaning in one of the worst times for all of humanity—to focus on the writing of his book. This gave him meaning and the will to live.

Direct experience within the interrelated arts expands our vision of self and others. We learn how to be human. Giving the self the gift of a slower pace, through the Continued on page 27...

“The interrelated arts develop the brain in many ways by embracing cognitive thinking skills, which overlap into other disciplines of learning.”

August 2006 San Francisco Medicine

17

medicine and Creativity

Puppetry in Medicine: The Inclusive Art Lee Armstrong

F

rom explaining a medical procedure to a child to asking a child to recount a story from his or her life in a therapy setting, physicians may find the art of puppetry useful in a number of situations. Puppetry is also a creative outlet that can provide a source of joy to physicians who deal with life and the preservation of life on a daily basis—an endeavor that is often rewarding but physically demanding and emotionally draining.

A puppet can help a young child understand a medical procedure and the steps the patient and his medical team must take to help him get well.

A simple puppet routine can cover this information and allay fears. Most importantly, it takes the information from a “lecture” structure to a memorable experience the child has participated in and will more likely remember.

Puppetry is very effective in medical DVDs. Puppets can bring humor and warmth to a difficult subject. Many hospital libraries have puppet videos on health and safety issues for child and family viewing.

Sesame Street Visits the Hospital shows a positive experience for Big Bird. As he gets a blood test and an X ray, he realizes that the hospital staff is there to make him feel better again.

I’m Still Me! by the Leukemia Society of America is a video for young school-aged children. It features Susan Linn and her puppets talking about childhood leukemia and the fears and concerns of classmates of the child. Uplifting, silly, and fun—yet full of good information for young children—it is an excellent starting point for discussions at home or at school.

18

Puppet DVDs are also excellent in explaining lengthy medical procedures. Young children often may not understand the scope of the treatment and how important it is to work with their medical teams over an extended period. However, children will view a DVD multiple times, if it’s engaging,

takes turns as storytellers, puppeteers, and audience. The group brings to life a variety of puppets and objects to tell stories from each individual’s life. This approach can be very therapeutic, providing moments of heartfelt laughter as well as education.

As the book’s coeditor, Matthew Bernier, MCAT, ATR-BC, states, “Puppets serve as animated symbols. Symbols carry meaning and have emotions connected to them. Symbols help us to make sense of our world. They connect us to our pasts and guide our present and steps into the future. ” Puppetry is a tool for healing and an adventure into a world of imagination. Put a puppet on your hand … give it a deep breath … have it look around you … and discover the magic of puppetry.

Puppetry 101 and thus gradually learn the information they need.

Experts agree that puppets are also powerful tools in therapy and healing.

“Sharing fundamentals of communication and transformation, puppets and therapy are well matched…. Puppets empower by offering the motivation and the means to make feelings known,” says Mickey Aronoff, the therapy consultant for Puppeteers of America. Children in a hospital setting may have difficulty expressing their fears. A puppet can be an effective spokesperson for the child, giving voice to unasked questions.

Puppetry in Education and Therapy (Authorhouse 2005) has excellent examples of the uses of puppetry for children and adults, including a therapy called Puppet Playback Theater. In this process, a therapy group

San Francisco Medicine August 2006

Puppetry incorporates many arts, from puppet crafting to writing to acting. You can even stage-manage the “actors.” It’s also a liberating experience.

You don’t have to look a certain way to play the lead role. In fact, you can play them all—hero, villain, dragon, or alien. As a bonus, you can use your puppetry skills in medical education and therapy and healing for both children and adults.

To get started in the puppetry arts, you’ll need—not surprisingly—a puppet.

There are many places to buy puppets, or you can make your own. The first puppet that Jim Henson made was fabricated from his mother’s old coat. There are numerous books and many websites that can help you start building puppets (check the Resources section). The most important point is to use a puppet that fits your hand and feels good www.sfms.org

to operate.

For the same reason that an artist doesn’t use a house paintbrush to paint a portrait, you’ll want to find the appropriate puppet for your needs. Make sure you have an affinity for the puppet you’ve selected.

Perhaps the character has an engaging smile, a twinkle in its eye, or a friendly way of breathing smoke. Imagine its past life.

Give it a great personality and a unique (but comfortable) voice. Miss Piggy was only an extra in the crowd until Frank Oz made some definite personality choices and created a frog-lovin’ pig. Give your puppet a passion. A love of cookies transformed one monster.

You can incorporate years of medical training in “Super Doctor,” with his or her X-ray vision, or in “Nurse Kitty,” who loves his or her purrfect patients. Over time, your puppet will develop a life of its own that will be more than the sum of its parts.

If your puppet hobby takes off and you want to learn more, join your local Puppet Guild and the national Puppeteers of America. Attend a puppet festival. These offer workshops and shows all day and night and provide a great opportunity to mingle with people who impart the joy of life into their art.

Puppet Manipulation Good puppet manipulation creates the illusion of life in an inanimate object. In general, try to keep the wrist, fingers, and arm as relaxed and fluid as possible.

Looking Eye contact is one of the most important things you can do to make a puppet connect with an audience. To give the illusion of life, a puppet’s eyes need to focus on what it’s supposed to be looking at. Be aware of where the eyes are on the puppet.

The puppet’s pupils don’t move. Therefore, the puppet’s head needs to turn as the puppet makes eye contact. With your own eyes, look from side to side, up, down, and behind you. Notice how that feels, then practice it with the puppet. Repeat this exercise www.sfms.org

with your own eyes, but at different speeds.

Notice the difference between a long, slow look and a quick glance. Repeat this with a puppet. A puppet that gives a long, slow look toward a cookie, for example, can speak volumes without saying a word.

Breathing A simple breath gives the illusion of life to a puppet. In a mouth puppet (one whose mouth is primarily what you’re manipulating), the breath comes from the palm of the hand and wrist. See what happens to your body when you give a small sigh or a big yawn. Try this with your puppet. Try a cough, a sneeze, a burp … there are endless possibilities!

Talking In a mouth puppet, usually the thumb goes inside the lower jaw and the rest of the hand is above the puppet’s upper mouth.

The tendency with a mouth puppet is to open the whole hand to make the mouth move. However, if the top of the hand moves a lot, it is difficult for the puppet to have good eye focus. Observe that when you talk, your lower jaw drops. Try dropping just the thumb when you open the puppet’s mouth. Practice counting, opening once for each syllable. At the end of each syllable, the thumb and the fingers should touch.

The top of the hand will move but be can be reserved for emphasis, as when you use a wide-open mouth for a dynamic, surprised expression.

Putting It All Together Have your puppet sing its favorite song. Have the puppet start by looking at the audience, clearing its throat, taking a breath, then singing the first part of the song tentatively. Concentrate on lowering the thumb. As the puppet becomes more involved in the song, play with the expressiveness of the mouth area. Remember to have the puppet “look” at the audience. At the end, have the puppet take a bow and walk nicely off the stage.

Resources • Puppeteers of America website, www. puppeteers.org. Information on festivals, local puppet guilds, puppetry stores, and puppet-related services, including puppets to buy. Membership includes the excellent Puppetry Journal, use of the group’s A/V library, and more.

• The San Francisco Bay Area Puppeteers Guild,www.sfbapg.org. Bringing together people who are interested in the art of puppetry.

• Puppetry in Education and Therapy: Unlocking Doors to the Mind and Heart, edited by Matthew Bernier and Judith O’Hare (Authorhouse, 2005).

• Folkmanis, 1219 Park Ave., Emeryville, CA 94608, (510) 658-7677,www. folkmanis.com. Puppet store; try out secondhand puppets at great prices.

• Puppets on the Pier, Pier 39, San Francisco, CA 94133,(800) 443-4463, www. puppetdream.com. Puppets and supplies of all types.

Lee Armstrong is a co-owner of Images in Motion, Inc., a company that specializes in puppetry for TV. She is currently producing videos at IIM and puppeteering on a new PBS series called “Mustard Pancakes.” Her additional credits include a variety of programs, from Jim Henson’s “Fraggle Rock” to the Baby Leap DVDs. She is the video consultant for Puppeteers of America and is active in the local San Francisco Puppeteers Guild.

Images in Motion, based in Sonoma, California, is a developer of puppetry and animation for TV and film.The company provides a full range of services, from pre to post production, including a shooting studio and a crew experienced with the needs of TV puppetry. Clients include the National Marrow Donor Program, the USDA Forest Service, Leapfrog Toys, Cartoon Network, Genentech, and more.

Additional information can be found at www. imagesmedia.com.

august 2006 San Francisco Medicine

19

medicine and Creativity

Artistry in Plastic Surgery Roger Friedenthal, MD There is no excellent beauty that hath not some strangeness in the proportion.

—Of Beauty, Sir Francis Bacon, 1627

C

reativity in plastic surgery generally involves artistry, since plastic surgery is an art form as well as a craft.

Creativity can clearly evolve after competence has been achieved, but this creativity exists within sharply delimited rules dictated by the laws of healing and of blood supply.

In reconstruction, we value artistry mainly in the way it contributes to form and function, while in aesthetic surgery, we value its contribution to naturalness and beauty.

If you asked a fish about its universe, the last thing it would tell you about is the water.

Plastic surgeons rarely think about the artistry involved in their work, even though it is omnipresent. Plastic surgery is a unique field of surgery in the complexity of the end result. There are more shades of judgment applied to the results of a rhinoplasty than to those of an inguinal herniorrhaphy. The results of most other surgical procedures are judged primarily by whether the organ operated on works afterward or does not, although a good scar is always a plus. If that organ functions better after surgery, or at least does not malfunction, the result is generally considered satisfactory. Plastic surgery, by contrast, allows for a greater spectrum in how a result is judged and valued. A nose is not just “done.” As a matter of fact, if it looks

done, it has not been done very well.

An injured hand demands the utmost delicacy and precision in repair to allow the restoration of anything like natural function. Fine surgical technique in a bloodless field with a surgical tourniquet, followed up with physical therapy, can result in a hand that works again. The creativity is revealed in the degree of function which can be achieved. The structures of the hand may be restored to an exact cosmetic appearance, or they may not.

The artistry does not lie primarily in the appearance, which may still be imperfect. It lies in the function, which in itself can be a thing of beauty.

A repair of a cleft lip shows another side of plastic surgical reconstruction. Muscular tissue within the lip must be repaired so that there is completely natural spontaneous lip movement, but natural cosmetic appearance is paramount.

The superficial structures need to be lined up exactly. The artistry lies in the meticulous attention to detail. Both the nasal and lip tissues on a tiny baby’s face are incised and rotated in different directions so that each moves into a normal position. Fine landmarks are exactly lined up and exactly repaired. The precision needed is amplified by the knowledge that any error or inexactness will be magnified by the baby’s natural growth into adulthood. Artistry here can be close to invisible.

A TRAM breast reconstruction, by contrast, is all appearance and no func-

“Plastic surgery is a unique field of surgery in the complexity of the end result. There are more shades of judgment applied to the results of a rhinoplasty than to those of an inguinal herniorrhaphy.”

20

San Francisco Medicine August 2006

tion. It is unfortunate but true that a breast lost from cancer cannot be replaced with a new breast. Plastic surgery can assist with the replacement of the missing breast by creating a new breast mound and a nipple by performing areolar reconstruction that is close enough to natural that psychological and emotional healing are significantly enhanced. While an implant or tissue expander can often give a pleasing replacement, a more exact and softer reconstruction can be obtained by replacement of the missing tissue with other tissue. Plastic surgery does best when it replaces like with like.

Soft-tissue reconstruction of the breast is most often performed with abdominal tissue. The procedures have acronyms such as TRAM and DIEP, which are abbreviations for rather long and clumsy nomenclature.

In all of these cases, a large, undifferentiated mass of abdominal skin and fat is transferred a long distance, with its vital blood supply either preserved or restored. If the blood supply is preserved, this large mass of tissue is transferred by leaving a long vascular leash running through a transposed rectus abdominus muscle. If the blood supply is restored, a small nourishing artery and vein are isolated and divided in the lower abdomen. Then they are connected to a new artery and vein near the breast, using extremely fine sutures placed with the assistance of a surgical microscope. Whether the plastic surgeon chooses to preserve or restore the blood supply is just the start of the task: This mass of abdominal tissue then needs to be shaped into a copy of the opposite breast. To move the tissue while preserving its blood supply is a tremendous surgical challenge. To shape that tissue into a graceful anatomic shape demands artistry.

The area of plastic surgery in which creativity and artistry particularly come to www.sfms.org

the forefront is cosmetic surgery. As with reconstructive surgery, surgical proficiency requires acknowledgment of blood supply and tissue tolerance. While a cookie-cutter approach can be appropriate and competent, true excellence requires an appreciation of beauty.

Beauty is complex and difficult to define.

It is certainly at least partially in the eye of the beholder. Without question, beauty has its base in a particular culture, and our own culture has its own standards. A case can be made (and certainly has been made) that beauty is arbitrary and defined by mass media. Whatever the truth or half-truth of that point of view, I suggest that we put it aside for the present. From a practical standpoint, we live in a culture in which beauty is judged the way that it is. It is my personal opinion that you might as well argue with the weather.

This is not to say that beauty is necessarily attainable with plastic surgery. In most cases, attractive, approachable, handsome, or cute are reasonable goals. (Another physician once told me that “you can go a long way on cute.”) There is certainly an “inner beauty” that can shine through, but the plastic surgeon can hardly work on this directly. From personal observation, I can state with assurance that an inner glow certainly seems to shine when a person feels good about how they look.

It has been proposed from ancient times that ideal proportions might define beauty. I have a book called Proportions of the Aesthetic Face that attempts to do just that for facial beauty. While the diagrams are certainly useful, I have not found them to be helpful in other than a general sense.

Writing On Beauty more than 350 years ago, Sir Francis Bacon proposed that “one [could] make a personage by geometrical proportions [or] by taking the best parts out of diverse faces, to make one excellent. Such personages, I think, would please nobody, but the painter that made them.”

Some individuals actually had a chance to effectively study his proposal about “tak-

ing the best parts out of diverse faces” in a computer study. They attempted to combine the faces of generally acknowledged beautiful individuals on a computer in an effort to create an ideally beautiful face. What they came out with was, in their judgment, not beautiful but “average.”

That seemed surprising and counterintuitive.

Their conclusion was that beauty was average—a conclusion that, I think, says more about the errors of extrapolating meaning from data than it does about the nature of beauty itself. It is probably closer to the truth to state that their study showed that an average perfect face could be bland. Beauty actually needs to be imperfect. The thoughts of Sir Francis Bacon continue to be insightful: “There is no excellent beauty that hath not some strangeness in the proportion.”

We take advantage of that “strangeness in … proportion” to create an aesthetic balance. A person’s eyes, for example, are often the most fundamentally attractive facial feature. They are the feature on which other people fix their own eyes. The eyes can be either enhanced to draw attention or be freed from the distraction of other prominent features. A large nose or a receding chin can easily divert attention away from the eyes, and nasal or chin alteration can allow the eyes to finally reveal themselves. In facial aging, by contrast, the eyes themselves remain unchanged, while the eyelid, cheek, and brow tissues around them show the changes of age. Precise rejuvenation in this area is one of the most powerful corrections that can be made.

While the plastic surgeon uses these principles of proportion and balance as a general guide, they do not help further.

What is to be done to make the result as beautiful or handsome as possible? That is, of course, where artistry and creativity come in. That is what draws students to plastic surgery and continues to challenge practitioners in the field.

“While a cookiecutter approach can be appropriate and competent, true excellence requires an appreciation of beauty.”

www.sfms.org

SFMS is now accepting nominations for David Perlman Award for Excellence in Medical and Health Reporting.

The San Francisco Medical Society presents the “David Perlman Award for Excellence in Medical/Health Reporting.” each January at the SFMS Annual Dinner to recognize the good work of California reporters from television, radio, newspapers, and magazines.

David Perlman is the veteran Science Editor of the San Francisco Chronicle who has won numerous awards for his reporting of science, technology, and medicine for more than thirty-five years.

A prestigious panel of SFMS journalists, physicians, and community leaders will judge the selections received. SFMS will announce the award recipient in November 2006.

The winning report will be well researched, written, and produced between September 1, 2004 and September 1, 2006, by a print or broadcast media headquartered in the state of California.

All entries must have been designed to improve the public understanding of health, health care, and/or medicine and/or contributed to significant improvement in the quality of care.

If you have recently read, seen, or heard a piece of journalism that you think should be nominated, please either alert Amanda Denz (see contact information below), or contact the news organization and suggest that they nominate the piece.

The deadline for nominations is September 30, 2006, for the 2007 award.

All entried must be submitted by the news organization’s editor and entries must include 5 copies of the piece along with a letter explaining why the piece is being nominated.

Entries may be submitted to the San Francisco Medical Society, 1003A O’Reilly Ave, San Francisco CA 94129.

For further information please contact Amanda Denz, SFMS Communications Director, at (415) 561-0850, extension 261 or adenz@sfms.org.

august 2006 San Francisco Medicine

21

medicine and Creativity

Physician, Balance Thyself Multifaceted means to honing and healing yourself, your patients, and the globe Erica Goode, MD

W

illiam Stewart’s recently published book, Deep Medicine, is designed as a collaborative reflection of mind, body, and spirit-enhancing practices that an individual—physician or not—may use to promote balance in life. As Dr. Stewart points out in various ways that one does not just “become balanced.” Each individual’s qualities should, under best circumstances, provide the insight, energy, and social and familial circumstances that allow that person to discern and quest for his best-suited endeavors.

Stewart reflects upon the age-related aspect of this unfolding, quoting George and Gisela O’Neil, both students of Rudolf Steiner, who sort the human process into groups. They call birth to age twenty maturation, age twenty to age forty the evolution of emotional and psychological stability, and forty and beyond the development of individual and spiritual maturity. (All of this assumes a reasonably stable circumstantial base; that is, familial and social norms that are workable for that developing individual).

Dr. Stewart has been practicing medicine for about twenty-five years. Before becoming the founder and director of the Institute for Health and Healing at CPMC, he served as CPMC’s Chief of Opthalmology, where his path lead him toward a set of principles that defines medicine as healing in the broadest sense.

His book provides examples, stories,

and poetry, showing that health and vigor must begin with some element of familial strength and love. Next, and throughout life, there must be reasonably consistent provision of what the sociologist Maslow termed the Hierarchy of Needs; food, shelter, and clothing being the most basic.

Without these, one’s health of mind, body, and spirit is unsustainable.

I first heard of this concept during my MPH nutrition training at UC Berkeley, before working as a public health nutritionist and then entering medical training.

It saved me the trouble of restating the metaphor for medical care as a battlefield, or a marketplace (think health insurance companies listed on the stock exchange), but rather as ecological metaphor, which an MPH graduate invariably takes from that experience. Dr. Stewart’s line of reasoning in the book develops this idea with care, as did Fritz of Kapra thirty-five years ago, in his book, The Tao of Physics.

As one of my anatomy professors put it in l973, to our table of four women at UCSF, “Kids, you have to know the forest and the trees in here; and how the trees fit with everything else, after you finish this course.”

Dr. Stewart notes that James Hutton, an l8th-century physician and geologist, took this concept even further, stating that we need to consider ourselves in juxtaposition to our entire planetary surroundings to fully diagnose or treat an illness. Dr.

“Stewart’s book is designed as a collaborative reflection of mind, body, and spiritenhancing practices which an individual— physician or not— may use to promote balance in life.”

22

San Francisco Medicine August 2006

Stewart cites the UC Berkeley Center for Ecoliteracy as detailing the key principles of ecology as: Evolution (we are in a constant state of flow and change); Interdependence (our existence is part of a larger web of life); Limits (we have definite, finite resources, and must seek a point of sustainability); Diversity (each part of the whole is unique and essential); and Cyclical(our existence is in the context of nature’s larger, cyclical patterns).

Dr. Stewart provides multiple pertinent quotes; the two that best exemplify the evolving human as helper and healer are the following: “See the world as yourself, have faith in the way things are.

Love the world as yourself, then you can care for all things.” ­—Lao Tzu, the Tao te Ching “If you want to change the world, first change yourself. And when you are changed, truly changed, every thing around you will be changed.”

—Sri Aurobindo and The Mother, Pondicherry Deep Medicine is a remarkable book, one that invites, entreats, and encourages everyone to move toward inner and outer awareness of who they are and what they exist for, before illness brings them to their knees and forces its own self-assessment.

All physicians have worked with and for patients who understand that changes must occur, often when it is almost too late. The Institute for Health and Healing sees a high concentration of such individuals—individuals who are confronted with the dangerous possibility that they must www.sfms.org

change or face permanent affliction, and perhaps an untimely death.

It might be the l,000 cuts of bodily discomfort via metabolic syndrome; the awareness of a job or a marriage that must be changed for the soul to survive; or the need to stop smoking, everywhere! My husband and I were in Glasgow, Scotland, recently.

The governing city council had just passed an ordinance that banned smoking anywhere, indoors or out, and the populace was slowly moving toward compliance—but the occasional shopkeeper would still furtively hover in a back alley, smoking a few puffs before carrying the butts away. Balance takes time.

And as Dr. Stewart points out, balance, whether in the larger ecological sense or personally, is not possible moment to moment—as everyone going through a medical internship knows. Even here, adjustments to lunacy occur. A 1984 study in JAMA concluded that a medical resident, sleepless for twenty-four hours, makes multiple mistakes interpreting a reasonably straightforward EKG tracing. But it took a patient death in New York City, due to oversight by a harried, exhausted medical intern, to finally provide U.S. medical residents with an eighty-hour workweek. And the balance is again elusive, since attendings, out of practice in the insertion of lines, or just because they lived through those years of imbalance themselves, are now finding their schedules compromised by the need to resume some of the workload.

One shining example of creative life force influencing medicine is that of a dear friend and colleague of Dr. Stewart—Govindappa Venkataswamy, MD (Dr. V) of Southern India. Dr. V is a frail eightyseven-year-old ophthalmologist. Despite rheumatoid arthritis, which he developed in his youth, he was a deft, gifted eye surgeon.

At age fifty-nine, with the vision, energy, and persuasiveness of ten humans, he left the military in India with a wellspring of concern for the millions of Indians who developed cataracts at early ages. In India, an individual who cannot work represents an extra mouth to feed, and a burden to his or her entire village.

Dr. V began with the “McDonald’s” concept of careful, standardized, mass prowww.sfms.org

duction. He built one, two, and finally five large eye hospitals in Southern India. He convinced family members, most of whom trained in Europe and America, to enter the field of ophthalmology. Others were urged to become hospital administrators.

All work for less pay than they would earn elsewhere in India.

Now they meditate each morning, prior to serving their patients; their needs for childcare, household care, and food preparation are done by others; they live adjacent to airy, lovely buildings—each of which has a large golden lotus blossom at the courtyard level that can be seen from each level breezeway above. In meeting these physicians, pharmacists, and young nurses recruited from villages, and their children, Dr. Stewart noted that all seem very happy with their lives. Patients seldom have transportation, and hence are screened in villages, bused to and from the hospitals, checked medically for any diseases that might interfere with their productiveness at home, and treated for these problems as well.

Since doctor means teacher, these hospitals offer their surgical experience to ophthalmology residents from Europe and the US. One fourth-year resident from Massachusetts General Hospital in Boston was thrilled to be there. Since a cataract operation at these Madurai hospitals takes six minutes he had done more surgery in one month there than in his entire residency in Boston.

Dr. V simply felt this was his duty to the world. He is a modest, simply dressed, small gentleman, who took his inspiration from Ghandi, Sri Aurobindo, and his own spiritual force for change.

This is a shining example of deep medicine. Dr. Stewart’s book provides many inspirational options for moving oneself toward that purposeful quest for one’s best endeavors and self-awareness. A message that rings throughout the book is that each person’s path will surely be unique.

William B. Stewart, MD, is the cofounder and Medical Director of the Institute for Health and Healing at the California Pacific Medical Center in San Francisco. He is a nationally renowned oculoplastic surgeon and a former chairman of California Pacific’s Department of Ophthalmology. He has received the “Best Doctors in America” recognition every year for more than ten years and is a frequent, inspiring guest lecturer around the world, dedicated to changing the way we understand health and healing. His self-published book, Deep Medicine, will soon be available on Amazon.com. Copies may also be obtained through the Health and Healing Center, (415) 600-HEAL, or by e-mailing Rennie Lindner at lindner@sutterhealth.org.

Erica Goode is an Internist, practicing since l999 in the 5-physician IHH Medical Clinic with Dr. Stewart. She teaches Nutrition to CPMC Medical Residents, and is on the Clinical Faculty at UCSF.

SFMS Symphony Night Returning this fall!

More information— including the date for this SFMS Membership favorite— will be available soon.

august 2006 San Francisco Medicine

23

A Creative Collaboration, continued from Page 13... oils was done with far less hand strain. Percutaneous IP joint arthrolyses under local anesthesia returned sufficient thumb, index, and long-finger range of motion to facilitate comfortable brush handling.

4) Jazz guitarist who has lost his left ring and little fingers during his carpentry day job. Rx: Reeducation of both hands based upon the jazz technique of Django Reinhardt, who lost function of all but the left thumb, index, and long fingers as a result of a very serious hand burn. As the patient learned righthanded use of a 3.5 mm (Wegen) pick and finger-friendly gypsy chord voicings, his musical opportunities expanded.

5) Flutist with mild-moderate bilateral shoulder impingement, fearful of surgery. Rx: 88° flute head joint, thumb rest, appropriate key extensions to permit vertical flute playing, along with instruction in playing the EWI4000S wind MIDI controller, which contains a built-in analogue synthesizer in order to expand musical horizons and opportunities.

Creativity and health are interwoven, and this applies equally to doctors and patients.

Constant temporal and spatial cross training keeps a doctor’s mind active while enhancing patient care. Improvisational skills benefit doctor and patient equally. Every patient seeks expertise and hope. Continuous expansion of the “creative palette” generates virtuous cycles beyond simple cures.

Dr. Markison is a solo practice hand surgeon in San Francisco. He is also an Associate Clinical Professor of Surgery at UCSF. He studied music composition at Juilliard while majoring in biology at Columbia University. He has studied the human fossil record under the guidance of paleoanthropologist Donald Johanson for the purpose of designing “hand-friendly” musical instruments and other tools. His book entitled Creativity and Health should be available within the next six to twelve months.

Attention San Francisco Physicians: SF Medicine Magazine Seeks Your Creativity!

We want to publish poetry, short anecdotal stories, photography, drawings, collages, and photographs of paintings or sculptures created by SF Physicians. Please don’t be shy, submit your artwork! Send all material to Amanda Denz, 1003A O’Reilly Ave. San Francisco, CA 94129, or by e-mail, adenz@sfms.org.

24

San Francisco Medicine August 2006

www.sfms.org

medicine and Creativity

A Creative Approach to Prevention Diana Amodia, MD; Jeff Draisin, MD; and Sharon Meyer, CNC

C

reativity can mean many things.

At California Pacific Medical Center’s Therapeutic Lifestyle Change Program (TLC), they use poetry, art interpretation, and personal story telling as part of an in-depth prevention program.

TLC blends creativity and the healing arts with nutritional and lifestyle approaches to address many common risk factors.

National clinical guidelines have described “therapeutic lifestyle change” as “the first line of therapy” and as a “standard of care” in the management of risk factors related to cardiovascular disease, stroke, diabetes, metabolic syndrome, and cancer.

Lifestyle changes associated with better health outcomes include improved nutrition, weight reduction, physical activity, and stress management.

The TLC Program, which we offer at the Health and Healing Center in San Francisco, is a ten-week group program available to people who are working with a primary care physician. The group starts with a brief reading to set the tone. Then they do a grounding meditation, have a check-in so everyone is fully present no matter how they are feeling, and participate in an experiential exercise such as yoga or expressive arts. Then the physicians begin the lecture and discussion portion.

Lab tests can be helpful, and everyone gets a full nutritional evaluation and individualized nutrition plan, but lasting lifestyle changes occur from the inside out.

The experiential and creative exercises are the key to this program, because they help with overcoming challenge, handling stress, finding inspiration and support, and listening to your heart. For instance, in the first week, patients evaluate their personal resources by listing their individual gifts www.sfms.org

and talents, character qualities, time usage, love and relationships, and so forth. Often something is discovered that will help the person a lot more than healthy recipes, though we include those as well.

In another exercise, participants are shown a wide variety of artistic photos from the Smithsonian Institute and asked to chose one that represents “how I see myself” as well as one that depicts “how others see me.” In a safe and supportive group, the answers often stimulate the participants to better understand themselves in new ways.

For instance, a participant who eats while “hardly noticing what I put in my mouth” is likely to overeat—regardless of the diet— unless he learns new skills, such as mindful eating. A few other examples of useful personal insights gained through this simple exercise include: harsh self-judgment, giving to others at your own expense, and being so controlling that relaxing is difficult.

Turning insights into healthy lifestyle changes is best supported by a well-thought out progression of education, skill building, and group support. The program is also designed to try and achieve results that leave people feeling better within the first month as a way of building commitment. The tenweek time commitment is long enough to be effective and condensed enough to fit into busy schedules. A group format limits the cost to participants and facilitates creativity and support.

TLC originated as a program developed by a group of scientists and practitioners who created a nutritional approach for dealing with metabolic syndrome. It further evolved when Dr. William B. Stewart to put much more emphasis on creativity and self-discovery as key aspects of supporting behavioral change. Combining self-discov-

ery with practical lifestyle approaches allows us to connect our inner search with our outer circumstances in a way that sustains healthy change. This program offers a new way for physicians to help patients reduce risk factors before they get a life-altering disease. Common risk factors addressed are: hypertension; abdominal obesity; elevated triglycerides, fasting blood glucose, and total cholesterol; low HDL cholesterol; physical inactivity; cigarette smoking; and a family history of heart disease.

Diana Amodia, MD, is a board-certified internist practicing at the Health and Healing Center with twenty years of experience treating people with complex chronic medical conditions and multiple diagnoses.

Jeff Draisin, MD, is the Lead Physician at the Health and Healing Center’s clinic at California Pacific Medical Center. He is a board-certified family physician who has been practicing integrative medicine for more than fifteen years.

Sharon Meyer, CNC, is a certified nutritionist and a Cordon Bleu chef whose expertise includes designing practical, customized approaches to nutrition.

The Health and Healing Center is an integrative medicine program at California Pacific Medical Center, http://myhealthandhealing.org.

A free introductory class of the TLC Program will be offered on September 19.

The ten-week class begins Tuesday, October 3, from 6:30-8:00 p.m.: www.cpmc.org/ihh/ hhc/support/selfcare.html.

August 2006 San Francisco Medicine

25

‘‘A former employee is suing me for wrongful termination. Does my insurance cover that?”

It does if you have

Employment Practices Liability Insurance.

Why is Employment Practices Liability Insurance needed?* • Statistics show an employer is more likely to have an employment claim than a property or general liability claim.

• The average amount paid for out-of-court settlement is $40,000.

• Defense of the average EPLI case, through trial, costs over $45,000.

• The median compensatory award in EPLI cases is $218,000.

• 67% of all employment cases that litigate result in a judgment for the plaintiff.

• 10% of awards in cases involving discrimination and wrongful termination are in excess of $1,000,000.

• Six out of ten employers have faced employee lawsuits within the last five years.

Employment related suits usually involve one or more of the following: discrimination, sexual harassment, wrongful termination or workplace torts. The purpose of the SFMS program is to provide members with the needed tools and protection generally missing from other insurance policies.

SFMS’s claims made program provides members with significant benefits: • Web based training for members, office managers and employees to help minimize exposure to employment practices lawsuits.

• Access to a legal information hotline staffed by employment practices attorneys.

• Review of employee handbooks and employment applications.

• Economically priced Employment Practices Liability Insurance** that provides for defense costs and losses an insured becomes legally obligated to pay as a result of a covered claim.

• Choice of policy limits of $250,000, $500,000 or $1,000,000.

• Low minimum premiums.

• Low per claim deductibles.

• 60 day extended reporting endorsement included.

For more information on the Special First Time Buyers Program or to receive a brochure and application, call a Marsh Client Service Representative at 800-842-3761 or e-mail CMACounty.Insurance@marsh.com.

Sponsored by:

Administered by:

Affinity Group Services * Society for Human Resource Management – 2002

** Coverage provided by a carrier rated A by AM Best

© 2006 Seabury & Smith Insurance Program Management • CA License #SL0633005

777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 •CMACounty.Insurance@marsh.com • www.MarshAffinity.com • 6/06

public health update

New Developments in HIV Prevention Jeffrey Klausner, MD, MPH

R

ecent changes have occurred in STD/HIV-prevention efforts in San Francisco. In June, the new “Buck Syphilis” campaign was launched to address the continued transmission of syphilis among men who have sex with men. This campaign uses empowering images of men to remind those at risk to get regular syphilis testing. As part of that campaign, SFDPH will work with medical providers to offer frequent routine sexual health assessments and STD screening to men in the targeted group.

SFDPH recommends syphilis testing every three to six months for sexually active men who have sex with men with multiple partners (more than one partner in the past year). Many HIV care providers obtain that syphilis test with every CD4 T-cell count. We are also working with hospitals and private laboratories to make nucleic acid amplification tests (NAATs) available for gonorrhea and chlamydia testing in rectal and pharyngeal specimens. We have learned that most rectal infections occur without symptoms and can explain up to 10% of the risk for new HIV infections. Thus timely identification and treatment of rectal infections can reduce the risk for HIV infection.

Effective control of gonorrhea and chlamydia in all persons requires regular screening, timely treatment, treatment of exposed sex partners (any sex partner within the past sixty days) and retesting at three months to rule out reinfection. Internet-based tools are available to make partner notification and treatment easier for patients—see www.InSpot.org—as is regularly updated sexual health information at www.SFCityClinic.org.

With the FDA approval of the human papillomavirus (HPV) vaccine for the prevention of cervical cancer, SFDPH will be work-

ing to educate medical providers and at-risk women to promote the use of the vaccine. Current recommendations are that young women routinely receive the three-dose vaccination series starting at eleven to twelve years of age and that catch-up vaccination be offered to women younger than twenty-six years of age. The vaccine is targeted to prevent infection from the four HPV types (6, 11, 16, and 18) that are the major causes of genital warts and cervical cancer.

In April 2006, the State of California made HIV reporting by name mandatory. Since the early 1980s, AIDS reporting has been a names-based reporting system. The expansion of name reporting to include those with HIV infection but without AIDS (defined by the presence of opportunistic infection of CD4 T-cell count < 200 cells/mm3) will help prevention experts measure the population burden of HIV infection in California. Patients undergoing HIV testing should make a fully informed decision knowing the risks, benefits, and consequences of and the alternatives to testing. To that end, it is critical that patients who undergo HIV testing are made aware of that new state law requiring that the names of patients with HIV infection be reported to the local health jurisdiction and then to the state in a manner similar to the reporting of other communicable diseases. In addition, patients who undergo HIV testing should be informed that anonymous testing is available. Finally, patients should be reminded that the results of several HIV tests and those tests related to HIV infection, including HIV viral-load tests and CD4 T-cell counts, may be reported with the patient’s name to the local health jurisdiction.

Art as a Gateway for Well-Being, continued from page 17...

In his book The Path to Tranquility (Penguin 2002), the Dalai Lama says, “Today our knowledge has expanded greatly with the help of science and technology; however, knowledge regarding our own mind, our deep nature, is limited.” Creative expression within a safe environment opens us to fully experience our choice of attitude while learning from the challenges inherent in an art form.

Perhaps this is how the arts heal. They invite a process for being fully present in the moment. This is the gift of human development for all, and its glow is far-reaching. Let the music begin.

the study of the arts and the discipline and focus it takes to learn, takes persistence, and this persistence requires quality time. But when we respond to the self and to other people with destruction instead of enhancement, we become part of the fabric that diminishes the self and others.

My direct experiences in the performing arts as a professional opera singer have given me great gifts to recognize how universally connecting music is, regardless of life circumstances. Direct experience within the interrelated arts creates balance in one’s life. I see proof of this every day in my work, mirrored in the glow and vitality of my students. www.sfms.org

Elizabeth Agnese is a professional opera singer and an art therapist with a master’s degree in psychology who uses cross-generational programming through the arts to work with families.

August 2006 San Francisco Medicine

27

hospital News Chinese

Fred Hom, MD

The Chinese Hospital Memory Center is up and running as a collaboration between Chinese Hospital, the UCSF Memory and Aging Center, and the Chinese community of San Francisco. Its goal is to improve the cognitive health of Chinese in San Francisco through patient evaluation and treatment, as well as through communitybased educational efforts. The clinic will provide early diagnosis, earlier start to treatment, and additional access to caregiver-support services.

The model for the Memory Center is the existing clinical collaborations of both Self-Help for the Elderly and Chinatown Public Health Center with the UCSF Memory and Aging Center. Doctors or families may refer individuals for evaluation of complaints or symptoms of dementia. Symptoms can be in the areas of memory, language, visual-spatial function, executive function, motor function, or behavior.

Dr. Craig Hou, neurologist at UCSF, will evaluate individuals at the two clinics. The comprehensive evaluation will include history, physical examination, and cognitive testing conducted in Cantonese or Mandarin. The memory clinic will prove to be an invaluable service for the Chinese community.

28

CPMC

Damian Augustyn, MD

“Frontiers in Pediatric Hospitalist Medicine,” presented by the CPMC Pediatric Hospitalist Division, will take place on Friday, October 6, 2006, at the W Hotel in San Francisco. This one-day course is designed for pediatric and neonatal hospitalists, pediatricians, family practice physicians, and allied health professionals who participate in the care and management of sick children and neonates. For more information, please contact Carmel O’Connell at (415) 600-2722.

The CPMC Department of Orthopedic Surgery is proud to present “Knee Arthritis following Sports Injury: Current Concepts,” September 29–30, 2006, at the Cathedral Hill Hotel in San Francisco. This two-day conference will cover such topics the early detection of knee arthritis following sports injury, bone cartilage paste to treat knee defects, and minimal surgical intervention for knee arthritis following sports injury. The second day of the conference will feature a dry lab with demonstrations of a variety of surgical techniques, including meniscus transplantation, the Illizarov Technique for HTO salvage, and tibial tubercle transfer and patellofemoral replacement techniques. For more information, please contact Beverly Hoover at (415) 600-6484.

San Francisco Medicine August 2006

Saint Francis

Guido Gores, MD

In recent months, Saint Francis Memorial Hospital has seen several changes in its Board of Trustees and departmental leadership. I’d like to take this opportunity to acknowledge my colleagues for all their hard work.

Nominations for department chairs were held recently, and we’re pleased to announce the new appointments. The new Department of Medicine Chair will be Internist Amy Bossen, MD. Plastic and Reconstructive Surgeon Robert Harvey, MD, will chair the Department of Surgery. The Psychiatry Department Chair will remain David Ogami, MD. Radiologist Jon Shanser, MD, will continue as Department of Special Services Chair. We’re very thankful to all for their service.

In July, two members of the Board of Trustees left after their terms ended. They are Orthopedic Surgeon James Garrick, MD, and Ophthalmologist Gary Aguilar, MD. We are grateful for their many contributions. Their positions will be filled by Orthopedic Spine Surgeon Clement Jones, MD, and Plastic and Reconstructive Surgeon Issa Eshima, MD. We are delighted to welcome them to the Board.

Next on our agenda is the opening of our new, improved, and expanded Emergency Department. Scheduled to open in October, the new unit will feature eighteen beds and will return to its original location on the first floor, with an entrance on Bush Street. The state-of-the-art facility will be the first ED in San Francisco to meet the new seismic design standards. We will be hosting open-house events and welcome the entire medical community to come preview our advanced new facilities. Look for more news next month on this exciting development.

www.sfms.org

hospital News St. Luke’s

Jerome Franz, MD

Summer is upon us, and many physicians have plans for travel. One among us is preparing for more than the usual vacation. Joe Blumenthal, beloved cardiologist at St. Luke’s for more than thirty-five years, bicycled 1,000 miles this July from Victoria, Canada, to Point Reyes Station. He did it for pleasure and to raise money for the American Heart Association. Experienced at long rides, he trains by riding regularly from his home in Inverness to St. Luke’s.

We congratulate Marc Snyder, Chair of the Emergency Department, on his election to the Board of Directors of the American College of Emergency Physicians, California chapter. Marc is also an accomplished saxophonist, playing for many years with the Dr. Jazz quartet. His group entertains every year at the Auxiliary’s Musée de Noel.

Once more, the St. Luke’s Labor and Delivery Program has won Sutter Health’s award for best overall performance in first pregnancy and delivery, for the third time in four years. Laura Norrell, Chair of the OB/GYN Department, gives much of the credit to the hardworking maternity staff, but her excellent group of physicians and midwives also deserve all the praise bestowed upon them.

www.sfms.org

UCSF

St. Mary’s

Ronald Miller, MD

Kenneth Mills, MD

Out with the old and in with the new! Well, they’re certainly not old, but it is the time of year to say good-bye and good luck to our graduating residents as they move on to the next step in their careers. Our graduating interns and residents in medicine, orthopedics, and podiatry are all making us proud. Private practice and hospitalist positions await several of our graduates, and many of them will be remaining in the area. Others are going on to residencies and fellowships in oncology, gastroenterology, radiology, anesthesiology, and ophthalmology.

At the same time, we welcome our incoming interns and residents. We have residents graduating from prestigious medical schools throughout the U.S. as well as from China, Iran, India, and England. We also welcome Terrie Mendelson, MD, as our new Associate Program Director for Internal Medicine.

We have held our annual Resident Faculty Retreat, which provides an opportunity for key faculty members to meet with the new chief residents and house-staff leadership. Themes of this year’s retreat included faculty expansion and development, house-staff and faculty morale, and mentoring and advising. There was consensus that St. Mary’s strength is that we are a faithbased community hospital with a clinic and a teaching program.

The Medical Executive Committee continues to take a strong interest in the teaching program and how it relates to the broader medical staff and quality within a medical center. It has been noted that we received full accreditation for five years, with commendation, from the ACCGME. Our board passage rate is 88 percent, fellowship placement is impressive, and our goal of post-graduate retention continues to be a challenge in this highly competitive field.

In the first effort of its kind in the United States, researchers at UCSF have launched a study to determine whether giving active probiotic supplements to infants can delay or prevent asthma.

The intervention is a novel method for the primary prevention of asthma with enormous potential to have a public health impact, said Michael Cabana, MD, chief of the Division of General Pediatrics at UCSF Children’s Hospital and principal investigator for the study. According to Cabana, there currently are no known ways to prevent asthma.

Probiotics are microorganisms administered in adequate amounts to confer beneficial health effects. They typically are chosen from bacteria that normally inhabit the gastrointestinal system and are therefore known to be safe.

Asthma is one of the most common chronic diseases of childhood and the most common cause of school absenteeism. Called the Trial of Infant Probiotic Supplementation to Prevent Asthma, or TIPS, the study is based on the “hygiene hypothesis,” which holds that little or no exposure to bacteria and viruses during a critical period of infancy can lead to an imbalance in the immune system and result in diseases such as asthma. This is thought to be especially true for high-risk groups, such as children with parents who have asthma.

The three-year study will include about 280 healthy, full-term babies who have either a mother or a father with asthma. The study is being supported through a grant from the National Institutes of Health.

The TIPS study is currently recruiting women who are pregnant and have a history of asthma, or a partner with asthma, to participate in the study. To find out more about the study, visit www.tipsasthmaresearch.org, call (866) 913-TIPS, or e-mail TIPS@ucsf.edu.

august 2006 San Francisco Medicine

29

hospital News in memoriam Veterans

Diana Nicoll, MD, PhD, MPA

Mary Whooley, MD, staff physician and researcher at the San Francisco V.A. Medical Center, was recently interviewed for the JAMA Report regarding her article published in JAMA’s June 28 issue, “Depression and Cardiovascular Disease: Healing the Brokenhearted.” Dr. Whooley’s research is focused on understanding how psychological factors, particularly depression, influence the onset and progression of heart disease. Dr. Whooley is Principal Investigator of the Heart and Soul Study, a ten-year study of more than 1,000 patients with coronary heart disease. She designed the study to understand how psychosocial factors affect cardiovascular outcomes. In publications resulting from the Heart and Soul Study, Dr. Whooley and her colleagues have demonstrated that depressive symptoms more strongly predict health-related quality of life than do measures of cardiac function, including left ventricular ejection fraction and inducible ischemia. They have also found that depression is associated with biological factors, such as increased levels of cortisol and norepinephrine, and behavioral factors, such as medication nonadherence and lack of exercise, all of which may increase risk for heart disease.

The medication nonadherence study raises the possibility that “because they’re depressed, patients simply aren’t doing what they’re supposed to do to take care of themselves, and this in turn implies a potential treatment,” according to Dr. Whooley. “If you get rid of the depression, you might get rid of the nonadherence.” Dr. Whooley notes that the norepinephrine study, on the other hand, suggests that depression could make heart disease patients “more vulnerable to the ill effects of elevated stress hormones.” Dr. Whooley and her colleagues are now studying which of these behavioral or biological factors, or which combination of them, may account for the increased risk of heart disease associated with depression.

30

San Francisco Medicine August 2006

Nancy Thomson, SFM Obituarist

Phillip M. Beglin, MD Phillip M. Beglin, MD, passed away April 20th, 2006, at the age of 82. He was born October 29, 1923, in Santiago, Chili. He graduated from Seattle University School of Engineering and then served as an officer in the U.S. Navy during World War II. After the war, he received his MD from St. Louis University Medical School. After his residency in Urology, he came to San Francisco, where he was in private practice for more than forty years—joining the San Francisco Medical Society in 1957. He was on staff at St. Francis Memorial Hospital and served as Chief of Urology at St. Mary’s Medical Center He enjoyed spending his free time rooting for his beloved 49ers, playing handball, socializing with his Olympic Club friends, traveling, relaxing, and entertaining at his family home in Napa. Phil and his family were longtime members of St. Stephen’s Church in San Francisco. He leaves behind his devoted wife of fifty-three years, Joan, having demonstrated his constant love and support throughout her continuing battle with Alzheimer’s disease. They were fortunate to spend

the last year together at the Irene Swindell Residential Care Facility.

He is also survived by his seven children, Mary Henrichs, Michael Beglin, Shannon Reggio, Mark Beglin, Sheila Nishioki, Frank Beglin, and Felicia Rundquist, and their 16 grandchildren.

Janice Mae McGowan, MD Janice Mae McGowan, MD, a member of the San Francisco Medical Society since 1970, passed away June 7, 2006, at age 77. Born in Chicago on October 22, 1928, to Dominick and Helen McGowan, she received her BA and MD from University of Illinois, graduating with the latter in 1960. She returned to Cook County for a residency in Internal Medicine in 1980. She recertified as a diplomat of the American Board of Family Practice 1991–98. She practiced in California for thirty years in student health at San Francisco State College and at Kaiser in San Rafael. She retired in 1999. Dr. McGowan never married, and her two brothers, Roger McGowan and Joseph McGee, predeceased her. She is survived by four nieces and two nephews and her good friend, Lee Rosenthal, a lab technician at Kaiser.

Classified Ads Send Electronic Claims Using Your Own Software!

Save time and money! FREE trial offer!

Call Signature Claims toll free (877) 744-2561 Electrolysis—Permanent Hair Removal Renee Yates, R.E., L.E. 2355 Ocean Avenue San Francisco, CA 94127 (near Stonestown) (415) 333-2444

CET Cancer Center-High Dose Rate Brachytherapy Specialists Providing Treatment and Care for Prostate, Gynecological, Breast, Head & Neck, and Other Localized Tumors. Offering High Quality Care Exceptional Survival and Tumor Control Results. Call (877) 238-1437 or E-mail info@cetmc.com P (510) 986-0690 F (510) 986-0159 www.cetmc.com/

www.sfms.org

announcements SFMS Members Will Have the Chance to View Exhibit “The Quiet Wind: Contemporary Art from Myanmar” During August Mixer The exhibit “The Quiet Wind: Con- been exhibitions of Burmese art in other temporary Art from Myanmar” will be on Asian countries, but few to date in the display during the SFMS membership mixer Western world. on Thursday, August 24 from 6:00 to 8:00 “The Quiet Wind” focuses on subp.m. at the Togonon Gallery. jects taken from Myanmar’s rich cultural Shown for the first time on the and religious heritage and the country’s West Coast, this beguiling collection of largely unspoiled physical beauty. Icons twenty-five paintings and symbols of Budshowcases the work dhism, seen everyof Nann Nann, Nay where in Burma, Myo Say, Khin Zaw predominate this Latt, Soe Moe, and Zaw show. By necessity, Win Pe—all leading most Myanmar artartists from Myanmar ists remain cautious (formerly Burma). in their choice of The West knows subject, generally avoiding themes little about this beautiful but troubled counthat might be contry of fifty-five million strued as overtly people, sandwiched political or critical between China and of the regime. But India, governed by a these restrictions reclusive military dichave a surprising tatorship that has held upside: In focusing power for more than on what they see forty years. There have “Off For Breakfast” by Soe Moe, a featured artist around them, the

artists capture a purity and spirituality that is often absent in the art of emerging nations, where the portrayal of conflict is often to the fore.

The membership mixer will be a wonderful opportunity for SFMS members to meet each other and mingle while enjoying this exciting exhibit. Beverages and hors d’oeuvres will be served as members listen to music from a live jazz band! New members are especially encouraged to attend.

In order to get an accurate catering count, we encourage you to RSVP by August 11t to Therese Porter, Director of Membership, at (415) 561-0850, extension 268, or tporter@sfms.org. Togonon Gallery, www.TogononGallery.com, is located at 77 Geary Street on the 2nd floor.

Upcoming SFMS Events August 16, 2006 RENEW at the San Francisco Medical Society RENEW helps physicians and others who juggle work, family, and community commitments sustain, or regain, their enthusiasm, effectiveness, and purpose. RSVP to Therese Porter, tporter@sfms.org or (415) 561-0850 extension 268.

August 24th, 2006 SFMS Membership Mixer From 6:00 p.m. to 8:00 p.m. Thursday, August 24 at the Togonon Gallery in San Francisco. RSVP to Therese Porter, tporter@ sfms.org or (415) 561-0850 extension 268.

See information on gallery above

www.sfms.org

September 11, 2006 SFMS General Meeting 6:00 p.m. to 7:30 p.m.

Tentative Guest Speakers include Gavin Newsom, Mayor of San Francisco, and Michael J. Sexton, MD, CMA President.

Members are also invited to attend the regular meeting of the Board which immediately follows the General Meeting.

RSVP by August 28 to Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260.

October 13, 2006 CME Program: Environmental Medicine and Health UCSF Laurel Heights Auditorium, 9am-5pm For more information contact Steve Heilig, heilig@sfms.org or (415) 561-0850 extension 270.

august 2006 San Francisco Medicine

31

Does it feel like the world is closing in on you?

Let MIEC take care of the malpractice pressures so you can focus on your practice.

The doctors that formed this company established a business structure and philosophy that means you never have to ask yourself if you are insured with the right company.

■ ■ ■ ■

■

We have a ZERO profit motive MIEC is 100% owned and governed by the doctors it insures 31 years of continuous service to California doctors Claims Expertise. We have now resolved over 24,000 malpractice claims and lawsuits reported by our policyholders over the past 31 years.

Nearly 90% are closed without payment.

We carry one of the highest security ratings of A- {excellent} issued by AM Best’s

Next Steps: For more information or download an application: Go to www.miec.com "Applications & Forms" to download an application or click on “Why MIEC” to better understand our philosophy and structure.

Call us: at 800-227-4527. Ask for Phanelia Hill (phaneliah@miec.com) our California underwriter or Diane Major (dianem@miec.com) / Lauren Kielian (laurenk@miec.com) our Underwriting Managers.

6250 Claremont Avenue, Oakland, California 94618 • 800-227-4527 • www.miec.com SFmedSoc_ad_05.06

MIEC Owned By The Doctors It Protects.