December 2008

AN RANCISCO EDICINE S F M VOL.81 NO.10 December 2008 $5.00

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Children and Medicine

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In This Issue

SAN FRANCISCO MEDICINE

December 2008 Volume 81, Number 10 Children and Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 Teaching Tales: Giving Thanks for the Lessons Learned Stephen Kaufman, MD

4 On Your Behalf

11 Learning from Children: Insights from a Pediatrician and Mother Shannon Udovic-Constant, MD

6 CMA House of Delegates Report Stephen Follansbee, MD, and Steve Heilig, MPH

12 The Giddy Triangle: Becoming a Child Again in San Francisco Harry Miles Muheim

7 President’s Message Steven Fugaro, MD

14 A Fall into Terror: A Ten-Year-Old’s Story Nancy Iverson, MD

9 Editorial Mike Denney, MD, PhD

16 One Student Speaks: A Children’s Environmental Organization Makes a Difference Severn Cullis-Suzuki

27 In Memoriam Nancy Thomson, MD

17 Children as Peacemakers: Making Friends Internationally Morton Beebe

28 Hospital News

18 Through the Eyes of a Child: A Case Study Lucy S. Crain, MD, MPH, FAAP

Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129

19 Behind the Curtain: Dealing with the Aftermath of an Emergency Abby Caplin, MD, MA 20 Seeds of Compassion: The Future of Children Alicia F. Lieberman, PhD

Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue

21 What Would You Have Done? Learning from a Child’s Experience George Fouras, MD 22 Children and Justice: San Francisco’s Programs to Help Kids Judge Ina Levin Gyemant 23 No Longer Children: Teenagers and Medicine Charles J. Wibbelsman, MD

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

24 Feeding Problems in Children: An Innovative Approach to Treatment Meeta R. Patel, PhD, BCBA 27 Book Review: Magical Moments of Change Nancy Thomson, MD www.sfms.org

december 2008 San Francisco Medicine

On Your Behalf December 2008

A Sampling of Activities and Actions of Interest to SFMS Members

Volume 81, Number 10 Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artist Amanda Denz Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes-Clever

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

SFMS Officers President Steven H. Fugaro President-Elect Charles J. Wibbelsman Secretary Gary L. Chan Treasurer Michael Rokeach Editor Mike Denney Immediate Past President Stephen E. Follansbee SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term:

Donald C. Kitt

Jan 2008-Dec 2010

Jordan Shlain

George A. Fouras

Lily M. Tan

Keith Loring

Shannon Udovic-

William Miller

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

Daniel M. Raybin

Mei-Ling E. Fong

Michael H. Siu

Thomas H. Lee

Term:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate

Are You Having Medicare Reimbursement Problems?

CMA has been working with SFMS/ CMA members to help them get paid—and getting good results, including significantly reduced wait times. Contact the special CMA Reimbursement Hotline at (800) 786-4262 today to get the help you need!

Please also share this important information with your nonmember colleagues: Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org to join SFMS/CMA and become eligible for this valuable assistance.

SFMS Seeks Cases of Medco Representatives Contacting Patients

At the November meeting of the SFMS Board of Directors, a board member brought a troublesome situation to the attention of the SFMS. According to one of this physician’s patients, an anonymous representative of Medco—the New Jerseybased prescription drug plan—contacted her via telephone to discuss the rationality of discontinuing one of her migraine prevention medications. This patient, along with her physician, had decided to cease using a preventive medication that had undesirable side effects and opted instead to treat migraines as they arose with a drug that costs significantly more money.

The Medco representative initiated a discussion with the patient about that choice and questioned whether or not it was the best plan. After hearing the story from his patient, the physician felt that the discussion was not initiated as a result of safety concerns but rather as an effort to change her medication strategy—a behavior that borders on practicing medicine without a license.

As a result, the SFMS is gathering information about other similar occurrences. If you or any physicians you know have heard similar stories from patients, please contact

San Francisco Medicine december 2008

Steve Heilig at heilig@sfms.org or (415) 561-0850 extension 270.

Influenza and Pneumococcal Vaccines Pricing

The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the Average Wholesale Price (AWP) as reflected in the published compendia, except where the vaccine is furnished in a hospital outpatient department—in which case payment for the vaccine is based on reasonable cost. Annual Part B deductible and coinsurance amounts do not apply to the influenza virus or the pneumococcal vaccinations. All physicians, nonphysician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine. The prices below reflect the payment allowance for the listed CPT codes when the vaccines are furnished outside the hospital outpatient department.

Prices Effective September 1, 2008 CPT 90655: $16.879 CPT 90656: $18.198 CPT 90657: $6.609 CPT 90658: $13.218 CPT 90660: $22.316

Hold the Date! SFMS Annual Dinner

The 2009 SFMS Annual Dinner will be Friday, January 23, 2009, at the Concordia-Argonaut in San Francisco. Watch for your invitation in the mail in late December. RSVP required.

SFMS Nutcracker Night

This fun, family-friendly event returns—offering a terrific way to unwind after the holidays! On Friday, December 26, San Francisco Medical Society members and their guests will enjoy a festive reception at 6:00 p.m., with sweet treats and sparkling beverages, followed by a performance of the San Francisco Ballet’s glorious production www.sfms.org

2009 SFMS Election Results of The Nutcracker at 7:00 p.m. The performance lasts approximately two hours—perfect for postperformance dining in one of the many exciting nearby spots (or getting the young ones home).

Tickets are available in the Orchestra for $85 in advance. Tickets in the Balcony Circle are $70 in advance. The reception is included in the ticket cost. You may mail a check, payable to SFMS, to 1003A O’Reilly Avenue, San Francisco, CA 94129. You may also call or fax the Membership Department with your credit card information. Be sure to specify which section you wish to purchase tickets for.

Space is limited. This event sold out last year, so be sure to buy your tickets early! The deadline to purchase tickets is Thursday, December 18. If you have any questions, please contact Therese Porter in the Membership Department at (415) 5610850 extension 269 or tporter@sfms.org.

SFMS Member Dr. Edward Chow Honored with Award

Dr. Edward Chow received the 2008 Saint Louis University School of Medicine Alumni Merit Award on October 24, 2008. The Alumni Merit Award is given annually, to an alumnus who exemplifies in his/her daily life the mission of Saint Louis University. School of Medicine Dean Philip O. Alderson, MD said, “The Alumni Merit Award recognizes graduates who exemplify the University’s Jesuit ideals of leadership and services to others. Thus, Dr. Chow is honored with this award for being an advocate for the health and well being for the under served communities in the San Francisco Bay Area.” Dr. Chow has been a practicing internist is San Francisco for forty years. In addition to being Executive Director of CCHCA and Medical Director of CCHP, Dr. Chow is also a San Francisco Health Commissioner and also serves on many civic boards and in many leadership capacities nationally. He has been a member of the SFMS since 1967. www.sfms.org

2009 Officers (one-year term) President-Elect: Michael Rokeach Secretary: George A. Fouras Treasurer: Gary L. Chan Editor: Mike Denney 2008 President-Elect Charles J. Wibbelsman, MD, will automatically succeed to the office of President. 2008 President Steven H. Fugaro, MD, will automatically succeed to the office of Immediate Past President.

Board of Directors (seven elected for three-year term, 2009-2011) Jeffrey Beane Andrew F. Calman Lawrence Cheung Peter J. Curran Thomas H. Lee Richard A. Podolin Rodman S. Rogers

Nominations Committee (four elected for two-year term, 2009-2010) Lisa Dana Jerome A. Franz Marybeth Mulcahy Joseph Woo

Solo/Small Group Practice Forum Delegate (two-year term, 2009-2010) Eric Tabas

Solo/Small Group Practice Forum Alternate (two-year term, 2009-2010) Eric H. Denys

Delegates to the CMA House of Delegates (First four are delegates; next five are alternates. Michael Rokeach, President-Elect, will serve as the fifth Delegate according to the SFMS Bylaws. Two-year term, 2009-2010)

Delegates Steven H. Fugaro Gordon L. Fung E. Ann Myers H. Hugh Vincent Alternates Lawrence Cheung Peter J. Curran Roger Eng George A. Fouras Shannon Udovic-Constant december 2008 San Francisco Medicine

Report: 2008 California Medical Association House of Delegates Stephen Follansbee, MD, and Steve Heilig, MPH The annual meeting of the CMA House of Delegates is where the advocacy directions of the CMA are set, in a democratic system where elected physician delegates from regional and specialty groups gather to debate policy proposals ranging from the profound to the puzzling. It’s an intensely busy but very collegial gathering modeled somewhat on the American political system, wherein representatives debate, argue, lobby, strategize, and compromise on issues of importance to medicine and public health in California and beyond. This session was no different in that regard. Important relationships continue to be built by the SFMS and its members, relationships with both other societies and individuals in those societies, including the Medical Student Section.

The bottom line of the myriad of issues under discussion is what is best for patients and medical practice. This imperative was strikingly brought home to all present during a heated debate about a resolution submitted by the SFMS. The resolution noted a trend in some hospitals toward deporting patients who are uninsured nonresidents and held that this is only acceptable with patient consent. Some delegates from other counties argued on behalf of hospitals’ financial interests; CMA past-president Anmol Mahal, MD, forcefully reminded all present that they were in attendance as physicians, not as administrators or those in any other role—a remark that elicited loud applause, followed by an overwhelming vote to accept our proposal.

As is often the case, SFMS resolutions were especially prominent in the “Science and Public Health” section. Noteworthy SFMS resolutions that were adopted included an “emergency” resolution to support bans on tobacco sales in pharmacies, inspired by the San Francisco policy that is already being emulated in other major American cities—and that is now being challenged by the Philip Morris tobacco company. Another SFMS resolution, authored by Eric Tabas, MD, succeeded in having CMA oppose any proposal that would expand the definition of abortion, such as one currently being pushed by the White House. Tabas also authored a successful resolution urging adoption of some accepted protocols for substance abuse screening and care. Drs. William Andereck and H. Hugh Vincent authored

an adopted resolution in support of physicians who invoke nonbeneficial care or “medical futility” policies.

Of course there were numerous debates on resolutions regarding insurance and reimbursement (including balance billing and electronic medical records), HIPAA, vaccines availability, taxing alcoholic beverages to pay for associated care, health care reform, and the current issue of Medicare (Palmetto’s rough transition) and Medi-Cal’s survival. Our own Shannon Udovic-Constant again attempted to get an easier “opt-out” for physicians who do not want the AMA to sell their prescribing data, with mixed success but, we can hope, some progress in acceptance.

For policies with national import, such as many of these, we specify that if the CMA adopts them, that group will in turn advocate for the same position with the AMA. Thus our SFMS resolutions can have national impact, as they have in the past. CMA has already selected some of our new resolutions to take to the AMA meeting this month, and more will likely be added to the list.

Also at the recent CMA delegates’ meeting there was a contested election for CMA President-Elect, with Orange County emergency and family physician Brennan Cassidy the victor.

It’s safe to say that physicians of every specialty and practice setting are impacted in some way by the work of the CMA’s House of Delegates, as it is translated into CMA and AMA advocacy and, where needed, legislation. Whether we actually witness the sometimes messy process of “political” action, it is something that influences our lives and profession.

We are grateful to the many delegates and others who devote their time to making such work as scientifically sound and patient- and physicianfriendly as possible.

SFMS/CMA members can review the resolutions passed and the prioritization given by the delegates by going to the CMA website at www.cmanet.org/member/hod/resolutions.htm.

Dr. Stephen Follansbee is Chairman of the SFMS Delegation to the CMA, and Steve Heilig is the primary staff to the delegation.

SFMS ELECTED REPRESENTATIVES IN ATTENDANCE Stephen Follansbee, MD (Chair) Steven Fugaro, MD Gordon Fung, MD Ann Myers, MD Peter Sullivan, MD George Susens, MD Shannon Udovic-Constant, MD H. Hugh Vincent, MD Charles Wibbelsman, MD George Fouras, MD Rita Melkonian, MD Rachel Shu, MD Roger Eng, MD

William Miller, MD Robert Liner, MD Gary Chan, MD Rodman Rogers, MD Robert Margolin, MD (CMA Trustee) Eric Tabas, MD (solo and small group forum) William Andereck, MD (solo and small group) Suketu Sanghvi, MD (very large group forum) Thomas Addison, MD (specialty delegation) Lily Tan, MD (young physicians) Lawrence Cheung, MD (young physicians) Peter Curran, MD (young physicians) Mary Lou Licwinko, Steve Heilig, SFMS staff

Dr. Robert Margolin was elected Treasure of CALPAC, the CMA’s political action group; Peter Curran, MD, was elected as the Young Physicians Section representative to the CMA Council of Legislation. These are key positions in guiding CMA’s advocacy in Sacramento, and the SFMS became the most substantial association having new substantial contributors to CALPAC.

President’s Message Steven Fugaro, MD

Change Is Possible

I

find it astonishing that this is my final President’s column for San Francisco Medicine and that 2009 beckons, with the San Francisco Medical Society about to welcome Dr. Chuck Wibbelsman as its new leader. As I reflect on the past twelve months, it is tempting, as an outgoing president, to label the time as a “remarkable” year. Yet few among us would disagree that 2008 has proven to be an extraordinary year—politically, economically, and for organized medicine.

No matter what one’s political persuasion, the election of Barack Hussein Obama as United States President is a watershed event in American history. We are all aware of his AfricanAmerican heritage and his “unusual” name. In his speech at the Democratic convention, Obama called himself “a skinny kid with a funny name.” The New Yorker was even more emphatic—“that’s not a name, it’s a catastrophe.” Yet despite enormous demographic and political obstacles, he will be the leader of the free world starting in late January. One of his main campaign promises has been to reform our very disorganized, expensive, and ineffective health care system. I have no doubt that such reform would have been one of his highest priorities—except for the economy.

Except for the economy. That phrase sounds much like the canard, “Aside from that, how was the play, Mrs. Lincoln?” Despite the dramatic and profound implications of the election, it may be dwarfed by the historical nature of the imminent economic recession and possible depression. Our government’s ability to initiate any major programs or reforms will be severely limited by the literally trillions of dollars being spent on stimulus programs and bailouts.

Health care reform does not seem likely any time in the near future.

That is a tragedy for the millions of uninsured and underinsured in the U.S. Despite our frustration over the increasingly dysfunctional nature of health care in this country, 2008 has actually been a year of triumphs, both small and large, for organized medicine in San Francisco and California. Our local pioneering insurance coverage program, Healthy San Francisco, has been a small beacon of light in a very gloomy time. Physicians from our Medical Society played a key role in the design and implementation of this remarkable municipal health insurance program.

On a statewide level, the California Medical Association had one of its finest hours with a successful federal lawsuit to block www.sfms.org

the impending draconian cuts to Medi-Cal provider fees. This budgetary action would have had the effect of further reducing the already small pool of health care providers in Medi-Cal programs, and it would have severely limited their ability to provide anything approaching reasonable care for indigent patients. Federal courts have refused to allow the state to implement these reimbursement reductions, correctly concluding that substantial harm would likely occur as a consequence. This was a victory not just for the CMA but for all those who believe in the justice of providing adequate health care to the indigent of California.

The CMA and the American Medical Association registered a remarkable victory on the national stage this year with their effective opposition to the proposed cuts in Medicare reimbursement rates. Providers all across the nation were facing 10 percent cuts in already meager reimbursement rates for care of our complex elderly population. Organized medicine directly conveyed this message to Congress and reinforced it with targeted advertising to the American people. The result was legislation approving a 1 percent fee increase and enough political muscle to override a Presidential veto with four hours. It is rare for both Senators from the state of a standing President to vote to override a veto—but that was the case in July, when Senators Hutchison and Cornyn of Texas joined with the majority of the Senate. There is no question that more comprehensive Medicare reform is needed, with higher reimbursement rates, but this still represented a very major victory for physicians. This triumph was only possible through the strength in numbers represented by physicians joining together and becoming one voice through the CMA and AMA. The overriding message of the past year was that change is possible, often in remarkable and unpredictable ways. Physicians will never be able to significantly influence policy and governmental programs, either individually or in small groups. However, joining together through the San Francisco Medical Society, the CMA, or indeed the AMA enables us to speak with one strong voice. Only by being unified can all physicians be forceful and effective advocates for our profession, for our patients, and for our future.

december 2008 San Francisco Medicine

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Editorial Mike Denney, MD, PhD

What Would a Child Ask?

W

hen Albert Einstein was asked how, while working in a menial job in the patent office instead of at a university, he was the one who discovered the theory of special relativity, he replied that he always asked the questions that a child would ask. Noting that by the time most people grew to adulthood and became educated about reality they had stopped their childhood imagining about the wonders of space and time, Einstein, who didn’t converse until he was three, said, “I developed so slowly that I began to wonder about space and time only when I was already grown up.”

In Antoine de Saint-Exupéry’s fantasy novel, The Little Prince, after traveling through space and time from asteroids to earth, the Prince says, “Grown-ups never understand anything for themselves, and it is tiresome for children to be always and forever explaining things to them.” In Charlotte’s Web, a magical children’s book by E. B. White, Mr. and Mrs. Arable become concerned about the sanity of their little girl Fern when she seems able to converse with Wilbur the pig, Charlotte the spider, Templeton the rat, the sheep, the lambs, a gander, a goose, and seven goslings—yet Fern and her childlike characters are able to prevent Wilbur’s death and to rejoice in friendship, love, and the miracle of life. In The Wizard of Oz, by L. Frank Baum, Dorothy is whisked through space by a cyclone from Uncle Henry’s and Aunt Em’s farm in Kansas to the wonderful Land of Oz, where, with Scarecrow, Tin Woodman, and Cowardly Lion, she travels the yellow brick road to the Emerald City only to learn that the great Wizard is nothing but a humbug—and she can return home by simply clicking the heels of her magical Silver Shoes.

These stories, and countless other children’s fantasies, fairy tales, and parables, are also cherished by adults. However, scientific and logical thinking separates this “fiction” from “fact,” meticulously relegating it to being “only in one’s imagination” rather than in the “real” world. Still, we cannot help but notice that these childlike and imaginative ways of knowing, as in the case of Einstein and most great innovators, are keys to creativity in the real world.

As we contemplate the theme of Children and Medicine in this issue of San Francisco Medicine, what is it that so intrigues us about these children’s stories? What in them causes us to yearn to express ourselves, to understand the universe, and perhaps even to practice our healing art with spontaneity and imagination that transcend www.sfms.org

ordinary science and often lead to creative thinking?

In his seminal treatise Mundus Imaginalis, the great twentiethcentury French philosopher and theologian Henri Corbin clarified a distinction between the words imaginary and imaginal—the former meaning the unreal world and the latter forming a sort of cognitive imagination, a “real” factor within the mind that can hold both fact and fancy. A more recent expression of this imaginal realm can be found in research using SPECT scans, in which the same area of the brain shows neuronal activity whether the subject objectively sees an apple or subjectively imagines an apple.

In the early twentieth century, Alfred North Whitehead and Bertrand Russell clarified that mathematics and logic are one and the same thought process. A twist was added to this wisdom when, in 1931, the mathematician Kurt Gödel demonstrated that mathematics would always be incomplete, caught in a recursive paradox that offers no definitive answers. This idea was taken up by Douglas Hofstadter, Professor of Cognitive Sciences at the University of Indiana, in his book Gödel, Escher, Bach, in which he demonstrated this recursive paradox in mathematics, art, and music. He called these never-ending paradoxes “strange loops.” In his latest book, I Am a Strange Loop, Hofstadter explains the childlike capacity to imagine in terms of the strange loops of neurons in our brains that can lead to spontaneous discovery. Speaking of Gödel’s 1931 incompleteness theorem, Hofstadter reflects about “this insight of his into the roots of meaning . . . that thanks to a mapping, full-fledged meaning can suddenly appear in a spot where it was entirely unsuspected.”

Perhaps these scientific and logical facts about human cognition can help physicians understand how to be more creative in practice, research, and teaching. However, personally manifesting spontaneous emergence of imaginal and inventive insights may also require a return across space and time to the fiction of children’s stories like The Little Prince, Charlotte’s Web, and The Wizard of Oz. The Prince, Fern, and Dorothy know, in the spirit of Albert Einstein, that the path to spontaneous creative insights is not only through adult scientific inquiry. Einstein simply asked the questions that a child would ask.

december 2008 San Francisco Medicine

Children and Medicine

Teaching Tales Giving Thanks for the Lessons Learned

Stephen Kaufman, MD

W

atch a small child play with a box. He crinkles the paper inside, enjoying the feel and the sound. He places the box on his head as a hat, removes it, then turns it over and beats it as a drum. To him a box is not merely meant to hold things but is an object with a vast number of uses to be explored. He lives in a world full of wonder. If I could emulate him, my life would become richer.

Spending most of my days in the office, I find my patients a major source of gratification and insight. Mary, a precocious two-year-old, curious and energetic, arrives with her mother. Mrs. R appears distraught, complaining that she is perpetually exhausted trying to keep up with Mary. “Tell me about it,” I say.

“When Mary wants to go to the playground, if I say no she nags and nags until I give in. She is so stubborn, I could scream.

She thinks all I have to do is take care of her.

I work, take care of the house, cook meals, and pay the bills.” I become aware that Mrs. R is like a floodlight, diffusing her energy over a wide range of concerns, while Mary is like a laser, focused on a single desire. If I could learn to focus on the task at hand, like Mary, I think I might accomplish more, with less stress. Thank you, Mary.

Josh, an adventurous five-year-old, afraid of nothing, jumps from high places and drives his bike at high speed into immovable objects. Mrs. J has spent more hours in my office and in X-Ray than she can count. She says to me, “I think he is go-

ing to kill himself one of these days. I dread to think what will happen when he gets a driver’s license. We have tried to teach him meditation, get him interested in reading, but nothing seems to work.”

I suggest a karate class. This is rejected: “We are pacifists and teaching violence is unacceptable.” I say, “Then how about a gymnastic class, modern dance, or yoga?”

I explain to Mrs J that “Josh is the kind of kid destined to grow up with an urge to stick knives into people.” (Mrs J looks horrified). I continue, “Your job is to channel him to become a surgeon rather than a hired killer.” I look at my own life and am aware that I was born with a basic personality, and the object is not to change it but to focus on how to use it in the most positive way. Thank you, Josh.

I’ve known John, fifteen years old now, since birth. He was born small for gestational age, had a stormy neonatal course, and ended up with cerebral palsy. From childhood he has been wheelchair-bound, albeit with above average intelligence. He accepts his limitations and uses his abilities well. John is upbeat, does well in school, plays electric guitar, and recently was elected class treasurer.

Most of us would think of him as seriously handicapped, but when I asked John about his quality of life, he answered, “Excellent!” As an older pediatrician who is a step, maybe several, slower on the tennis court and whose energy level is noticeably diminishing, I am learning to appreciate

“Spending most of my days in the office, I find my patients a major source of gratification and insight.”

10 San Francisco Medicine december 2008

those abilities I have left rather than bemoan those I have lost. Thank you, John.

Maya, a bright, sparkly sixteen-year– old, has been getting into trouble in school and with friends. I asked her what was causing her so much grief and she replied, “The other girls start rumors about me, calling me a ho, and goad me until I lose my temper.”

I tell her that she was born with a temper and it is her choice whether to unleash it in a particular circumstance. I asked her, “Why do you want to give up control to somebody else, particularly to someone you don’t like?”

Maya loved the idea of being in control, of being the boss. I would like to add that Maya went on to become class president and started dating the starting quarterback, but suffice it to say that she learned to lessen the number of conflicts in her life. I often think about Maya when I am cut off by an aggressive driver who gives me the finger or I have to deal with bureaucratic robots from insurance companies, and I remember that I will not give up control. Thank you, Maya.

A long time ago, when pediatricians still made house calls, I was asked to see an eight-year-old boy from a family new to the city. I examined David in the hotel where the family was staying. He was lying in bed in toddler-type pajamas with feet, reading a comic book. His parents’ concern, an insect bite on his leg, was trivial, but on further examination I realized David had multiple ecchymoses and hepatosplenomegaly. I advised hospitalization, and a bone marrow biopsy confirmed my suspicion of leukemia.

In those days, this was a fatal diagnosis.

Treatment was started, remission was not

Continued on Page 15... www.sfms.org

Children and Medicine

Learning from Children Insights from a Pediatrician and Mother

Shannon Udovic-Constant, MD

P

erri Klass stated in her book Taking Care of Your Own (1992), “You will be the parent you are in part because you are a doctor, and you will be the doctor you are in part because of your children.” This statement has held true for me. It’s hard to know which has shaped me more—my kids in my home or my kids in my practice. Here are some lessons that I’ve learned along the way.

Slow Down

Often with young children, it’s counterproductive to be in a hurry. I sometimes find myself unsuccessfully trying to get a toddler to cooperate during my exam, and I realize I’m rushing. I take a step back and start playing with the toddler. Suddenly the ear exam I could not accomplish before is easy.

And anyone who has ever tried to get a two-year-old out of the house knows that you cannot rush him or else you will be rewarded with, “No, I do it!” plus a full-on tantrum. Then you aren’t going anywhere—for a long time.

Assume the Best Intentions

One of the hardest things in an outpatient practice is when your first morning appointment is late. You sit there getting more and more anxious, trying to decide if you are going to be late for the next ten patients, when that first patient does finally arrive. In the past I scolded families for showing up late. But then a parent told me, “We are so sorry that we’re late. We were all loaded up in the car when Junior vomited all over everything, including his sister. I had to clean everyone up.”

We all really do the best we can. I was recently reminded of this when I missed www.sfms.org

my son’s kindergarten parent-teacher conference because I wrote it on my calendar for one week later. I sure was glad that the teacher didn’t scold me.

Stop and Smell the Flowers

Children have a way of showing you what you should be paying attention to. I was in the middle of a busy day running errands with my eleven-month-old daughter, whom we had taught some baby sign language. As I hurriedly walked into the drugstore, distracted by the list of things that I needed to buy, she started sniffing the air. This is the sign for flowers. I looked up and realized that I was in the middle of a hundred colorful spring flowers, ready for sale and planting. My baby literally made me stop and smell the flowers.

Choose Honesty

One of the things that I love about kids is that they’re not afraid to tell it like it is. One day after I’d enjoyed a lunchtime burrito, my first afternoon patient was an eleven-year-old boy with a sore throat. I asked him to open his mouth and he said, “Your breath smells.” The mother was horrified, but I was thankful that I could grab a breath mint and keep others from having to experience what he did.

In another situation, I was the one having to provide the honesty. A nine-year-old patient had had high fevers for more than one week, and as part of her workup we needed to perform a lumbar puncture. I helped her with visualization and told her, as best as I could, what she would feel. I told her that it would hurt. The procedure went even better than I could have hoped, and after it was finished she was surprised at how little it had hurt. I still have the thank-you

card she gave me, with “Thank you for doing my lumbar puncture” written across glittercovered construction paper.

Another time I helped a family begin to heal together. I met a mother of two young children for the first time at a checkup for her eight-year-old. The mother was wearing a head covering that I knew was covering up hair loss from chemotherapy, and I could tell that she was sick. I asked about it but realized she didn’t want to talk about it in front of her daughter. I asked the mother if we could speak alone in the hall. This mother had breast cancer and had already been in the hospital for surgery. I explained that she needed to tell her daughter the truth because her daughter already knew something was wrong and probably was thinking the worst.

We told the eight-year-old together, and now—seven years later—the family still comes to see me.

Measure Success over Long Periods of Time

This is something that doctors tend to do pretty well early on in their careers, because our training is so long that we have to delay gratification. Then we start working as physicians, and we get frustrated very easily if we don’t see the results of our treatment quickly. Many of the most rewarding moments of my career thus far have been those times when I needed to be patient and wait for some years to go by before seeing the results of my advice.

One example that stands out in my mind is the teenager who was running away from home. The mother called me to tell me that she had dropped her daughter off at a shelter for teenagers because she didn’t know what else to do. We had already been

Continued on Page 15...

december 2008 San Francisco Medicine 11

Children and Medicine

The Giddy Triangle Becoming a Child Again in San Francisco

Harry Miles Muheim

I

’m a San Franciscan by birth and by breeding, but I’ve been out of town for about ten years now. During this time, I’ve been working, raising a family, trying to pluck an occasional moment of inspiration from the stodgy commonplaces of American life, but mostly answering the question: “Why did you ever leave San Francisco?” I never really do get to answer, because the questioners always go on to tell me about my hometown.

“San Francisco, San Francisco, San Francisco!” they have trumpeted for a decade. “Ah, it’s so charming, shining, historic, wind-whipped, unique, international, crisp, cosmopolitan, cultured, and fog-shrouded!” Then they tell an anecdote about Fisherman’s Wharf.

I got to thinking about these enthusiasts, blathering Friscophiles, on a recent flight home. What was it, I wondered as the great plane shot west from New York, that made the City so special? London is fog-shrouded, Paris is historic, Boston is cultured, New York is cosmopolitan, and Duluth is wind-whipped. But in the matter of persistent accolades, the City beats them all. I determined to find out why.

In three days, I asked fourteen persons to tell me exactly why San Francisco had this underlying magic. Nobody could. I was looking for specifics, but all they could talk about was that elusive pulse beat, that distinctive aura, that unique milieu, that cool grey charm. This was of no help. I’d heard it all in the East.

Learning nothing from my research, I did what many stuck sociologists do: I made up the answer myself. I made it up after a party one night as I prowled back to the hotel along fog-shrouded Filbert Street, listening to the click-click-click of the cable

in the fog-shrouded cable car slot. At the hotel, I looked at a map of the City and confirmed my conclusion. Finally, I knew why there was underlying magic.

This is why: The City of San Francisco tends to make light-headed children out of adults. Let me prove it. It is not all of San Francisco that everybody is crazy about.

Nobody ever talks about quaint old Alemany Boulevard or exotic Bernal Heights.

Nobody ever says that you must not miss the view from the intersection of Twentieth Avenue and Pacheco. All the magic is to be found in a downtown section that I have named “The Giddy Triangle.” At the tips of this triangle stand the Ferry Building, City Hall, and Fisherman’s Wharf. It is only one-twelfth the size of the entire city.

There are interesting places outside the Giddy Triangle, of course, but they are all somewhat square compared to the exciting things inside it. (Golden Gate Park, for example, is a rectangle).

The Giddy Triangle perches raffishly on three of the City’s most famous hills— Nob, Russian, and Telegraph. When you are set down on one of these steep, skewed outcroppings of native schist, you are inevitably off-balance. One foot is always higher than the other, and you simply do not know where you stand. In order to get around in the triangle, you must deal with the vertical dimension. This is something an adult has not done since he was a kid.

As a child, you learn that things can come at you from any direction. You deal with erratic, oblique movements. Your buddy brings his bat down on the top of your head. You bend down to see your new frog, and he jumps up into your eye. Paper darts sail in from anywhere. A gigantic adult head swoops down to let you whisper in the

12 San Francisco Medicine december 2008

big ear on the side. But as you grow up, life and its concomitant actions flatten out and slow up. The change is so gradual that you do not notice the ever-increasing drabness; but by the time your head is six feet from the pavement, you are dealing mostly in level, horizontal, deliberate movements. Gone is the descending baseball bat. Gone is the fine game of spinning around until you’re dizzy.

That now makes you sick. And the simple act of falling to the sidewalk while the crazy world regains its balance—this is out, too. It is undignified for taxpayers to fall down.

The hilly world of the Giddy Triangle, however, is a child’s world. It tilts, it yawns, it is unexpectedly askew. Subtly, it cons you into an attitude of off-balance irresponsibility. It takes you along. The streets are not in stiff-square blocks. They go anywhere.

You walk along a sidewalk that suddenly turns into a staircase, and you follow the staircase up until it dead-ends against a great warm brown rock. Yet the hill soars on up above you, plastered with rickety, precarious houses and great eucalyptus trees. You must go “around” to get up there, and in going around you come to Lombard Street. Here is a stout street, a street that would not give up, a street that makes the grade by snaking back and forth across the face of Russian Hill like an amusement park joke. You must try that! The other quest is forgotten. Down Lombard you go, carefree, weaving. . . .

A block farther on, a car comes down Filbert at you. It swoops at a stupidly steep angle. No car should be upended like that. If he tries to stop, he will tip over frontwards!

For a moment, you think the best way to avoid the car is to jump into the air and let it pass under you. It shoots past before you can try this. You jump anyway. It would have worked beautifully. www.sfms.org

Later, you find yourself at the highperched corner of Powell and California, watching a Powell Street cable car as it comes up over the sharp lip of the hill, pausing for breath on the plateau where the streets meet. It’s amazing. The boxy old car has risen right out of the ground. Its mellow, childish brass bell is ringing a song of victory!

Then, suddenly you have lost your balance. You have fallen and are rolling down Powell toward Pine Street! You roll to a stop at the flat intersection and lie there quietly, hoping no one has noticed. There is no scene. No crowd gathers. Nobody points a finger. A couple of friendly San Franciscans simply step forward, pick you up, dust you off, and send you on your way without a word of reproach. The slogan of San Francisco is, “The City That Knows How.” It is never better demonstrated than in one of those odd moments when a visitor to the Giddy Triangle loses his balance and rolls a couple of blocks.

A funny thing happened to me in San Francisco on this trip. I found the spell of the City, and then, for the first time, I fell under it. This had not happened before because I grew up in the Mission District, which is flat and outside the triangle. I never really got the flavor of the town. But I’ve got it now, and one of these days we’re going to pack up and move back. Yes, we’ll find a rickety little $30,000 house stuck precariously on the face of Telegraph Hill, and we’ll start living it up in a quaint, lighthearted, cockeyed, cosmopolitan, fog-shrouded, childlike way—as only San Franciscans in the Giddy Triangle can do.

This article, written by Harry Miles Muheim, a hearty San Franciscan who died in 2003, first appeared in the San Francisco Chronicle in the 1980s. Harry was an eloquent, award-winning writer of humor, political speeches, television dramas, screenplays, a novel, and innumerable articles in magazines and newspapers. He was a good friend of the late acclaimed and beloved San Francisco pediatricians Carolyn and John Piel. Their daughter, Mary Piel, MD, a member of SFMS, currently practices pediatrics in the City.

www.sfms.org

Children’s Art Decorates Stanford Medical Center

Upon entering the Lucile Packard Children’s Hospital at Stanford Medical Center, visitors are greeted by a column lined with tiles decorated by the pediatric patients. The column is pictured right, with three close up photos below.

december 2008 San Francisco Medicine 13

Children and Medicine

A Fall into Terror A Ten-Year-Old’s Story

Nancy Iverson, MD

“I

s she afraid of me? Is that why she’s screaming? Or is it the shot she’s afraid of?” asked the nurse, poised with a syringe.

The ten-year-old girl’s mother, her face expressing a mix of concern, embarrassment, and bewilderment, answered, “I don’t know. She’s never been like this. She’s our quiet one.”

With a shake of her head, the nurse responded, “Well, it will be better if we just get this done,” stabbed the needle into the girl’s hip, gathered up her supplies, and left the room, the girl still wailing. Neither the nurse nor the shot were the source of distress for the girl. But nobody knew what was, and nobody asked the girl.

That day had started like any other school day in the girl’s fifth-grade life. Just before the morning break, a friend had signaled to her that she could lead the jump-rope game if she was first on the playground. As the stream of students poured out the school door for recess, she was at the front! Until a boy’s leg slammed up against her shin, and she was face down—almost, except her hands had broken the fall. Still determined to keep her jump-rope lead, all she could think about was getting up and running—until she saw her hand. Her right ring finger was pointed off to the side, and her middle finger looked grotesque, almost at right angles to her index finger. And then the pain flooded in, washing out any aspirations of a fun-filled recess, leaving almost no room for even a breath to come and go.

A trip to the school nurse’s office, a phone call to her mother, and, before long, awash in waves of pain, she was in the car with her mother on the way to her pediatrician’s office. From the time they’d first met, Dr. Hanson had fixed any child-

hood ache or pain she’d had—always—and he had unfailingly done so with a wonderful mix of kind words, humor, and expertise. That day, though, he sent her and her mother down to the basement of the medical office building for an X-ray. The girl was worried that her pediatrician had shared no witticisms with her this time and that his face reflected such grave concern. But she knew something was terribly wrong when the X-ray tech talked with Dr. Hanson and, instead of going back upstairs to his familiar, inviting office, the girl and her mother were sent away to another office. She had something so bad that even Dr. Hanson couldn’t fix it.

Aggravated by attempts to flatten her hand for the X-ray, the pain was relentless.

She struggled to find a way to cradle her hand without touching her excruciatingly tender fingers, choking on her hiccups and tears as they entered another medical office building, ominous in its unfamiliarity.

When the exam room door opened, she timidly smiled with recognition and relief at the doctor who entered. She knew who he was! He was her friend Kathy’s dad. But she didn’t know that he was an orthopedist, or even what an orthopedist was. Confusion and pain mingled as he started to examine her hand. He turned to her mother and said, “Looks like we’ll need to realign these fingers under general anesthesia. I’m going to send you out to the hospital right now.” And then the girl’s world came crashing in when, as

14 San Francisco Medicine december 2008

she tuned in and out, she heard him saying, “ … just one night in the hospital and we’ll have her home tomorrow morning….”

She—who had prided herself on perfect attendance at school, whose only stay in a hospital had been as a “normal newborn,” who had never had a broken bone, who was so healthy, who could do just about anything—felt her world irrevocably changing.

Along with her fingers, her perfect records were being shattered.

Off she went with her mother to the hospital, almost numb with the pain in her hand and her emotional distress. A man from their church choir (an anesthesiologist—but how was the girl to know that?) started talking with her mother in the elevator and accompanied them to Room 354, her hospital room. The man talked a bit about “putting her to sleep”—something the girl had recently heard about when her cousin’s dog had died. He nodded to her, shook hands with her mother, and left the room.

And then a nurse came in, probably with a pre-op med, and, as she was standing there ready with the injection, the girl www.sfms.org

focused on the only hospital experience with which she was familiar—that of television.

And she was knew she was embarking on her new reality, where she, too, just like every hospitalized patient in the TV world, would be on the brink of death within moments—always by the second commercial in the TV shows. She knew her time was running out.

In the television world, the precarious patient’s life depended on the right doctor being there at exactly the right moment, and this girl’s right doctor, her wonderful Dr. Hanson, was far away in his office.

Aside from her mother, the only familiar faces she’d even seen since she’d entered this nightmare had been a friend’s dad and someone from their church choir. She didn’t want to be on the brink of death at all, but especially not with Dr. Hanson so far away.

Terror overrode her pain and confusion, her hiccups and sniffles from hours of untreated pain metamorphosed into screams, and she screamed and screamed. No one knew why, and no one gave her the chance to explain. She was terrified about her swiftly impending death. I know. I was that tenyear-old girl.

It was a blur then, saying good-bye to my mother (would this be the last time or would we be reunited by the last commercial?) and being wheeled on a gurney into a large room that looked just like the rooms where surgery happened on TV. There was the man from the choir again, this time saying it looked like they were ready to start.

My thoughts were in turmoil. Should I tell them I wasn’t asleep, or should I close my eyes and pretend to be? I didn’t know what I was supposed to do, but I knew I didn’t want to do anything wrong or be any trouble to anybody.

And then the confusion, the questions, the pain, and the terror all stopped.

I reawakened into a wonderful cushion of softness, a dazzling mound of white (a cast stretching from my elbow to my fingertips) just inches from my eyes. The procedure was done, the pain was gone, and I drifted in and out of a haze softer than any snowdrift I had ever imagined. When I was moved from the recovery room back to Room 354, my mom, dad, and brother were there, and they stayed with me until visiting hours were www.sfms.org

over and came back to take me home the next morning.

And that night nobody knew, or even suspected, that I had a profound sense of relief and appreciation for having escaped near death that afternoon in the hospital.

No one knew how much I suffered that day from the “certainty” of my approaching death. No one knew except for me.

And I remember. I remember every time I see a patient. I remember the enormous expanses and limitations each child faces as he or she grows and develops and reconfigures a world based on experience, imagination, learning, and living. I remember that each child’s life experience—and lack of it—carries meaning. I remember to wonder what’s going on for that child, I remember to ask, and I remember to take the time to listen.

Nancy Iverson, MD, develops and facilitates support groups for families dealing with illness, disability, and death. Currently she facilitates groups through the Institute for Health and Healing at CPMC and through Support for Families of Children with Disabilities. She has taught at Stanford and served as a guest lecturer for Dr. Rachel Naomi Remen’s Course The Healer’s Art at UCSF.

Teaching Tales Continued from Page 10... achieved, and David slowly but inexorably got sicker. One day David turned to me and asked, “Am I going to die?” I struggled for a response and said, “I don’t know. We are doing everything we can. Why do you ask?” He answered, “Because if I die I want my organs given to other children so they can live.” When I am annoyed by the irritations of daily life, I regain my composure and remember, “Don’t sweat the small stuff.”

Thank you, David.

I have changed the names of the children in this article to protect their privacy. Some represent a composite of patients from my practice. My sincerest gratitude to all my children, who have taught me to listen, focus, discard preconceptions, and gain self-acceptance. These lessons have taken me a lifetime to learn, and I intend to put them into practice in my next incarnation.

Learning from Children Continued from Page 11... trying to help this teen for about a year with school and psychological counseling and with medication, but there had been no improvement. I consoled the mom as best I could. Then, a few weeks later, I got a frantic call from the mother because the teen had been raped by an acquaintance. After doing the proper medical procedures and treatment, I spent a lot of time with the teen, discussing her decisions and choices thus far and what her dreams were. Ultimately this teenager transferred to a performing arts school and really blossomed. Some years have passed, and this young woman just sent me a note saying, “You don’t have to worry about me anymore because I am doing really good.”

Remember the Little Things

It is the little things that add up: The mom of a six-month-old baby who had been in my office in tears because she was so exhausted and is now e-mailing to thank me for the sleep training advice that got her baby to sleep through the night. The three-year-old saying thanks for getting the bead out of her ear. Your own two-year-old thanking you for making a “yummy dinner.”

When life gets crazy, it’s easy to remember the annoying things, like the person who cut you off on the freeway or the family that was angry because you were half an hour late to see them because you had an asthmatic with an oxygen saturation of 85 percent. But we have the ability to shape our perception of each day, and I do my best to remember all the little nice things. It makes the day much more rewarding.

Being in the world with kids provides me with innumerable rewards. I tell the young kids in my office, “The trick to being happy is finding something that you love that someone will pay you to do.” I am so thankful that I have done that. There are many lessons that kids teach us, even though, as the adults, we think that we are the teachers. I would like to send out a special thank-you to all of the children in my life for teaching me so many important lessons every day!

Shannon Udovic-Constant, MD, is a pediatrician and member of the SFMS Board of Directors.

december 2008 San Francisco Medicine 15

Children and Medicine

One Student Speaks A Children’s Environmental Organization Makes a Difference

Severn Cullis-Suzuki

C

urrently age twenty-eight, Severn Cullis-Suzuki is a remarkable youth environmental activist, speaker, television host, and author of Tell the World. At the age of nine, with some friends, she formed an organization called the Environmental Children’s Organization.

In 1992, when she was twelve years old, the group raised money to attend the United Nations’ Earth Summit in Rio de Janeiro, where Suzuki received a standing ovation for a speech to the delegates, many of whom were brought to tears. The following are excerpts from her speech: Hello, I am Severn Suzuki, speaking for ECO—the Environmental Children’s Organization. We are a group of twelveand thirteen-year-olds trying to make a difference: Vanessa Suttie, Morgan Geisler, Michelle Quigg, and me. We’ve raised all the money to come here ourselves, to come 5,000 miles to tell you adults you must change your ways.

Coming up here today, I have no hidden agenda. I am fighting for my future. Losing my future is not like losing an election, or a few points on the stock market.

I am here to speak for all generations to come. I am here to speak on behalf of the starving children around the world whose cries go unheard. I am here to speak for the countless animals dying across this planet, because they have nowhere left to go. I am afraid to go out in the sun now, because of the holes in our ozone. I am afraid to breathe the air, because I don’t know what chemicals are in it. I used to go fishing in Vancouver, my home, with my Dad until, just a few years ago, we found a fish full of cancers. And now we hear of animals and plants going extinct every day, vanishing forever. In my life, I

have dreamt of seeing the great herds of wild animals, jungles, and rainforests full of birds and butterflies, but now I wonder if they will even exist for my children to see.

I’m only a child and I don’t have all the solutions, but I want you to realize, neither do you. You don’t know how to fix it, please stop breaking it. Here you may be delegates of your governments, business people, organizers, reporters, or politicians. But, really, you’re mothers and fathers, sisters and brothers, aunts and uncles, and all of you are someone’s child.

I’m only a child, yet I know we are all part of a family, five billion strong, in fact thirty million species strong. And borders and governments will never change that.

I’m only a child, yet I know we are all in this together and should act as one single world towards one single goal.

In my anger I am not blind, and in my fear I am not afraid of telling the world how I feel. At school, even in kindergarten, you teach us how to behave in the world. You teach us to not to fight with others, to work things out, to respect others, and to clean up our mess, not to hurt other creatures, to share, not be greedy.

Then why do you go out and do the things you tell us not to do? Do not forget why you are attending these conferences, who you are doing this for. We are your own children. You are deciding what kind of a world we are growing up in. Parents should be able to comfort their children by saying, “Everything is going to be all right, it’s not the end of the world, and we are doing the best we can.” But I don’t think you can say that to us anymore. Are we even on your list of priorities? My dad always says, “You are what you do, not what you

16 San Francisco Medicine december 2008

say.” Well, what you do makes me cry at night. You grown-ups say you love us. But I challenge you, please, make your actions reflect your words. Thank you.

Editor’s Note: Ten years after delivering that speech, Severn Suzuki admitted that, although her speech was successful and she had attended many more conferences on the environment, her confidence in the people in power and the power of an individual’s voice to reach them has been greatly shaken. She noticed that members of her own generation were becoming increasingly disconnected from the natural world, many of them feeling that they have inherited problems too great to solve. She now emphasizes individual responsibility for the future of the planet.

www.sfms.org

Children and Medicine

Children as Peacemakers Making Friends Internationally

Morton Beebe

I

n 1982, after serving for five years as a columnist for the San Francisco Examiner, philanthropist and humanitarian Patricia Montandon founded Children as the Peacemakers, a nonprofit organization dedicated to making peace in the world through the activities of children in many lands. Since then, thousands of children from numerous countries have acted as “peace ambassadors,” visiting countries that are politically antagonistic.

During the Cold War, one such exchange was experienced by two eleven-yearold girls when Katya Lycheva of Russia came to San Francisco to visit Star Rowe, who had written an essay and created a dance called A Prayer of Peace. The pictures presented here are from Montandon’s book, Making Friends, for which I was the photographer.

The book chronicles the tour of the United States taken together by Katya and Star.

Morton Beebe of San Francisco is an internationally acclaimed photographer and filmmaker.

“If we are ever to have peace in the world, we must begin with our children.”

—Mahatma Ghandi Star and Katya pictured arm in arm in the top photo. The two girls meet Ronald Reagan, lower left, and UN Ambassadors Vernon Walter, United States, and Yuri Dubinin, Soviet Union, lower right. www.sfms.org

december 2008 San Francisco Medicine 17

Children and Medicine

Through the Eyes of a Child A Case Study

Lucy S. Crain, MD, MPH, FAAP

T

he transfer of a seven-day-old infant with multiple craniofacial anomalies and reported choanal atresia and laryngo-, tracheo-, and bronchomalacia from a rural community hospital to the UCSF General Pediatrics In-Patient Service for further evaluation was not unusual.

The child himself was extremely unusual, presenting with kleeblattschädel anomaly (cloverleaf skull), choanal atresia, severe ocular proptosis, broad thumbs and toes, cystic gums, fetal teeth, and a primordial tail. His airway problems were described as progressively worsening by the referring physician, who requested evaluation for tracheostomy. Attempts to intubate the infant at the referring hospital and per transport team had been unsuccessful, and reasons for this were soon evident. With each attempt to intubate or even gently probe his mouth or oropharynx, large bullous cysts erupted at the sites of contact. Intubation at UCSF was successful but resulted in further extension of the unique vesico-bullous lesions down the trachea and into the bronchi.

With the advantage of a wealth of subspecialists at UCSF, pediatric anesthesiologists, otolaryngologists, pediatric surgeons, neurosurgeons, dental surgeons and pathologists, pediatric pulmonologists, geneticists, and neurologists were consulted and stymied by this infant’s challenging problems.

Besides his clinically apparent dysmorphic features, he also had a daunting collection of other problems, including Arnold-Chiari malformation, intestinal malrotation, and multiple skeletal defects. The inability to offer any positive intervention other than palliative care was humbling but realistic.

The most experienced pediatric nurse on a service where we’d seen “everything” agreed that we’d never seen a child like this. Many

staff tended to avoid his bedside, agreeing that he was “hard to look at.”

An ethics team and, per parental request, a chaplain were consulted and joined in a case management conference with the little boy’s parents. It was agreed that the prognosis was grim, but assurance was given that the infant would not be in pain. The geneticists concluded that the diagnosis of atypical Pfeiffer’s Syndrome1 was appropriate, but features of chondroectodermal dysplasia (Ellis-van Creveld Syndrome) were evident. (This was prior to identification of specific gene mutations that could have yielded a more definitive diagnosis.) All the consultants agreed that whatever intervention was offered, the intractable progression of cystic lesions then progressing down the child’s airway and involving his cartilaginous larynx, trachea, and bronchial tree would be fatal. Even if he survived a tracheostomy, his lungs were becoming increasingly noncompliant, and it was recommended that he be extubated.

The parents were obviously overwhelmed. There was no family history of any congenital malformations or birth defects.

Their only other child, a very normal, active four-year-old boy, was back home with his grandparents. He had not yet met his little brother, now miles away in a big hospital where the doctors and nurses were “trying to find a way to make him well.”

The loving parents’ request was simple.

“We need to bring our other son to meet and say ‘Good-bye’ to our baby before disconnecting his breathing tube.” Worries were expressed around the conference table about what impact would be had on the psyche of the four-year-old in viewing his brother’s very abnormal appearance. The parents said, “He will be all right. We’ll prepare him.”

18 San Francisco Medicine december 2008

And they did. The next day, the parents returned and met me and the nurse at the baby’s bedside. His big brother stood beside his incubator, and I asked if he’d like to touch his little brother’s hand. We opened the access port, and he eagerly put his hand inside, inserting his index finger into the grasp of his baby brother. He smiled and said, “He’s got nice fingers.”

Dr. Lucy S. Crain served as Clinical Professor of Pediatrics and was general pediatrics faculty as well as founding director of the UCSF Pediatric Disabilities & Down Syndrome Clinic until her retirement. She now is Clinical Professor of Pediatrics at Stanford University and consults in the Mary L. Johnson Child Development & Behavior Clinic at Lucile Packard Children’s Hospital. She is a member of the Board of Directors of SFMS. Pfeiffer’s Syndrome (Pfeiffer Type Acrocephalosyndactyly) was first described by Pfeiffer in 1964, and many cases have since been reported. Sporadic cases as well as those with autosomal dominant inheritance have been described in Type I. All cases of Types 2 and 3 have been reportedly sporadic, and the syndrome is genetically heterogeneous. Mutations of the fibroblast growth factor receptor 1 (FGFR1) gene, which maps to chromosome 8p11.22-p12, and to the fibroblast growth factor receptor 2 (FGFR2) gene, which maps to chromosome 10q25-q26, have been documented. See K.L. Jones in Smith’s Recognizable Patterns of Human Malformation (sixth edition), Elsevier Saunders, pp. 472-73.

1

www.sfms.org

Children and Medicine

Behind the Curtain Dealing with the Aftermath of an Emergency

Abby Caplin, MD, MA

“N

iño, Niño!” I heard her scream from the hospital room. Hurrying to the doorway, I witnessed a tiny woman frantically pushing on her young son’s chest as he lay sprawled across the bed. His vacant eyes were open and pitched to the left.

Only minutes before, I’d calmly sat with this mother at the bedside, taking her son’s history in my rudimentary Spanish.

She’d been polite, deferential, and clear; I could understand most of what she’d told me. They had traveled to this internationally renowned cancer treatment center from Ecuador, looking for a cure for his cancer. I had observed Jorge as he listened intently to our discussion. He’d been quiet but alert.

The clinic admission note told me he was only nine years old, but he was large and obese, and I would have guessed he was twelve. Upon examination, I was keenly aware of the disconcerting contour of his body, with its doughy lumps of tumor grotesquely protruding from his scalp, chest wall, abdomen, arms, and legs. I’d never seen anything like it.

I knew his attending physician was a gem and would give his right arm to help this boy. As the pediatric resident, I was on board with the plan. So the moment I heard her cries and glanced into the room, the relationship between this tiny mother and her large son went right to my heart: a mother bear desperately fighting to save her cub, her baby, her “Niño.”

My right hand slammed the emergency “Code Blue” button, and my left reached for the resuscitation bag and mask. Within minutes the rescue team arrived. The room quickly filled with men and women in white coats and scrubs, along with their equipment: electrodes, monitors, suction tubes, www.sfms.org

defibrillation paddles, IV poles and fluids.

Shouts of instruction were barked back and forth. Everyone had a job to do and was well rehearsed, focused. But despite their expertise, Jorge proved difficult to intubate.

“Suction!” the frustrated anesthesiologist called. Suctioning was applied, and clear mucus gurgled into the tubing.

Finally the anesthesiologist triumphantly called out, “We’re in!” as he slid the endotracheal tube past Jorge’s vocal cords.

A moment later though, blood violently erupted from the tube, splattering everyone and soaking the bed.

Jorge had suffered a massive pulmonary hemorrhage. In moments it became clear that further efforts would be of no use. All resuscitation maneuvers ceased.

His death was pronounced—“Time: 2:46 p.m.”—and the room emptied as quickly as it had filled.

I stood with two nurses in the now silent room, amid the scene of carnage: Jorge’s body with the endotracheal tube protruding from his open mouth, the useless IVs taped to his skin, the blood that had pooled on the floor, the litter of discarded surgical instruments, gauze, and tape. His mother sobbed in the hallway, attended by others.

At that moment, one of the nurses caught my eye and motioned with her chin in the direction of the curtain, which partially concealed the other bed in the room.

My heart sank when I spotted two spindly little legs with feet covered in oversized blue hospital socks.

Mikey! In the commotion, we had forgotten all about this other little boy. I took a moment to remove my bloodied white coat and toss it onto a chair. Hesitantly, I moved around the curtain.

“Mikey?” I asked gently of the blond

eight-year-old. He was silent; facing the window, pale, staring at nothing. He said nothing. A small teardrop sat on the inner corner of his eye.

“Mikey, are you OK?” I asked, coming around to face him. A silly question, of course, since he’d heard everything. I took his hand, soft and limp, an IV taped to the back of it.

“Mikey, I’m so sorry. It must have been awful for you to have been here the whole time,” I told him.

I waited several minutes, holding his hand, watching his face closely as it remained impassive. Finally he looked directly into my eyes. He spoke with the assurance of someone well beyond his years.

“I’m OK,” he told me. “I just want to be left alone.”

But as I rose to leave, he wouldn’t let go of my hand. That he clung so hard confused me. He’d said he wanted to be left alone.

Insight came swiftly. Of course he needed me to stay. He did want to be alone, he wanted to be left alone. In that moment my heart broke, as I suddenly understood the meaning of his quiet and desperate plea.

Abby Caplin, MD, MA, practices mind-body medicine and counseling in the San Francisco Bay Area. She combines her medical and counseling degrees to specialize in treating women with autoimmune disorders. Her psychological work with patients complements traditional medicine, so physicians can more effectively help their patients.

For more information about her private practice and workshops, go to www.abbycaplinmd.com.

She also helps medical residents reconnect with their passion for medicine through specialized workshops. To find out more about how she can support your medical training program, contact her at (415) 255-9981.

december 2008 San Francisco Medicine 19

Children and Medicine

Seeds of Compassion The Future of Children

Alicia F. Lieberman, PhD In April 2008, the Dalai Lama held an unprecedented conference in Seattle called “Seeds of Compassion.” The meeting was dedicated to the future of the world’s children. Alicia Lieberman, internationally known for her groundbreaking research and work at UCSF and San Francisco General Hospital concerning early intervention for children who have witnessed or experienced psychological trauma, was invited to speak at the conference.

The following is the presentation that she made to the Dalai Lama and all in attendance.

M

y work is about creating a treatment to help babies and very young children whose parents are violent with each other or with the child.

Violence affects every aspect of children’s development: their physical health, the architecture of their brain, their trust in relationships, their capacity for empathy, and their curiosity to explore the environment and learn. There is much violence in our society, and many studies show that children growing up with violence are much more likely than other children to drop out of school, abuse drugs and alcohol, become violent, and go to prison. The personal problem, multiplied by the millions, becomes a social problem.

A turning point in my work occurred many years ago, when I met a three-yearold boy called Alan who was expelled from preschool because he threw a small chair out of the window when his preschool teacher told him to let another child sit on the chair. When the teacher tried to stop him he screamed, “Don’t touch me! I will kill you!”

When I met with Alan and his parents, I found out that Alan had been present a week earlier when his father, who was worried about losing his job, threw a cell phone at the mother and pushed her against the wall, screaming that he would kill her. The

mother yelled, “Don’t hit me!” and the parents pushed and shoved each other before the father left the house and did not return until the next morning. Alan stayed awake crying until well after midnight, but neither parent spoke with him about their fight because they thought he was too little to understand what had happened. The parents also did not notice the connection between Alan’s aggression and their physical fight, although what Alan had done was an almost perfect imitation of his parents’ behavior.

In my work I try to answer the question, “How can we enable children raised in violence to feel loving-kindness for themselves and for others?” The answer I found is, “By helping parents and other adults discover the suffering under the child’s anger.” A very important moment in my work came when I realized that children’s aggression is a cry for help. How to help is what I try to pass on to parents, teachers, and clinicians.

Like all children, Alan loved his parents and turned to them when he needed help.

But in the middle of their fight, the father was too angry and the mother was too scared to pay attention to their child. Alan watched in terror as his parents changed before his eyes from providing care and safety to becoming sudden sources of danger. With his aggression, he was asking, “Do I need to be like my scary parents? Do I need to attack first in order to be safe?”

Young children do not give speeches; they show us what they need. Adults often miss the suffering hidden in the child’s behavior because they are blinded by their own suffering. Aggressive children are saying, “Your anger and my anger scare me, and it is then that I most need your help.” We need to respond to this request. Family violence passes from one generation to the next when

20 San Francisco Medicine december 2008

the parents don’t know that aggression always starts as a defense against feeling weak and helpless. Aggression gives the illusion of being strong, but the fear remains under the surface.

As Alan and his parents met with me to play and talk together about what had happened, it emerged that the fear that Alan’s father felt about losing his job was transformed into aggression toward his wife.

When the father understood this truth, he told his son, “Alan, I am sorry that I hurt your mommy and I am sorry that I scared you. I forgot to use my words.” Alan came very close to him and whispered, “I am scared. I am just a baby.”

Taken aback, his father opened his arms and Alan crawled on his lap. Father and son hugged each other silently as the mother looked on. After this session, Alan’s aggression declined. He and his parents were learning together that compassion begins in the understanding of each other’s needs.

The Hebrew word for compassion, rachamim, shares the same root as the word for womb (rechem), to allude to the origins of empathy for the plight of others in the earliest of human relationships.

Compassion starts in the family but cannot stop there. As a society, we need to become mindful of the plight of those in need and respond to alleviate suffering. This is most urgent when it comes to children, who learn who they are and who they can become from the ways we treat them. Compassion as a state of mind is not enough: It should take the form of action. We must adopt public policies that protect and nurture children’s wellbeing, and we must ensure that government offers parents the tools they need to fulfill the demanding endeavor of raising a child who is healthy in body and mind.

www.sfms.org

Children and Medicine

What Would You Have Done?

Learning from a Child’s Experience

George Fouras, MD

I

have always believed that human beings are, in essence, products of their environments. We are born. We go to school. Make friends. Learn and grow. Most of us in the medical field go into medical school and then residency with the idealistic passion that we are going to cure the world of its ills. Our professors in medical school and residency shape our views as they teach and model themselves for us. Some of us have experienced colleagues who act as mentors.

But the most important mentors we have are our patients. It is they who teach us the limits of our humanity and our art.

For me, it is children in particular who have been my teachers. I have had the experience of marveling at the resiliency of youth in the face of fantastic adversity, from the treatment of cancer to abuse and foster care.

Many years ago, when I was a medical student on my pediatrics rotation at a local children’s hospital, a young girl about nine years old was admitted to my service with a respiratory infection. She’d had several of these infections before, after having survived a near-drowning several years earlier.

The family had gone to a party where there was a pool in the backyard. The mother took the children swimming against the wishes of the father. Some time later, they found the little girl at the bottom of the pool.

Over time, through the miracle of medical science, her brainstem had been rescued but her cerebral cortex had not.

At the time the girl was nonresponsive and was placed on nearly total life support: G-tube feedings, on a respirator. Prior to entering my world, she had coded several times, but in each case, the family insisted that she be resuscitated and have every possible intervention. And she survived to live www.sfms.org

thereafter in a vegetative state.

Now in her hospital room, she is lying in her bed. Antibiotics are being infused.

The respirator is humming along. Vital signs are stable. The smell is typical of a sterile hospital room. The mother rarely leaves her side. She is her greatest advocate. Another child is there, a boy. He is in the room almost as often as the mother. I don’t recall ever meeting the father. What really stunned me was that the boy was often found reading to his comatose little sister or, worse in my opinion, lying in bed with her, holding her.

What do you do when you are a medical student? Here I am watching the pain and the guilt of this mother not only eating her alive but also slowly killing her nearly brain-dead daughter on the installment plan. Each new infection chipping away at her. She recovers from the infection, but slightly more diminished. Meanwhile, I watch the brother being traumatized as the family’s lives are placed on hold, forced to interact with his sister but not in an entirely healthy way. It is like watching a Greek tragedy.

There is nothing harder on a marriage than the loss of a child. I can only imagine the grief and loss that this family endured. I also vividly remember feeling some resentment at them for what they were doing to their healthy son, as well as to the daughter in the bed who had “died” several times. But what also angered me was the behavior and the policies of those in my own profession.

This was a “Terri Schiavo” case that never made the headlines. I saw the hubris of our technology, the idea that we could cheat death. And for every bag of antibiotics that was infused, I wondered how many other children would have to go without a needed vaccination or a well-baby checkup.

I wondered: What was being gained by this?

Were the parents any closer to touching the flame of grief within themselves? Were the medical personnel even trying to facilitate a psychological and spiritual adjustment for the family? Do we as physicians sometimes have to make the hard decisions, even though we know the patient or family does not want to hear them? Will we incur the wrath and the pain of the person to whom we have to say, “This is not an option”?

As we lance a boil, the pain is sharp but brief, and then healing can occur.

Dr. Fouras completed his child and adolescent psychiatry fellowship at Los Angeles County and USC Medical Center in 1995. He is currently the psychiatric consultant for HSA Family and Children’s Services and works with foster children in CBHS. He also serves on the SFMS Board of Directors.

“The most important mentors we have are our patients. It is they who teach us the limits of our humanity and our art.”

december 2008 San Francisco Medicine 21

Children and Medicine

Children and Justice San Francisco’s Programs to Help Kids

Judge Ina Levin Gyemant

R

ecognizing the special needs of children who are affected by the judicial system, San Francisco has three programs that are dedicated to improving the mental and physical health of families, and particularly of children. These services are available for any children who are caught in the adversity of legal actions, and they provide an invaluable resource for referring physicians, attorneys, social workers, and the public.

Kids’ Turn An educational program for children whose parents are separating or divorcing Kids’ Turn provides programs in each of the San Francisco Bay Area counties to ease children (and parents) through the debilitating effects of parental separation or divorce. Fifty percent of all Bay Area children experience parental separation before they reach the age of eighteen, and forty percent of Bay Area fathers do not sleep in the homes where their children reside. These dramatic statistics do not include the increasing number of parents who never live together or never marry.

The dramatic increase in childhood mental and physical health difficulties and risk factors has a tangential relationship with parental separation. The following statistics speak to the urgency of the problem and the need for a comprehensive community response: • Children of divorce are at greater risk of experiencing injury, asthma, headaches, and speech defects than children whose parents have remained married.

• Following divorce, children are fifty percent more likely to develop health problems than children in two-parent families.

• Children experiencing parental sepa-

ration are 65 to 80 percent less physically healthy than children from intact homes.

• Teenagers in single-parent families and in blended families are three times more likely to need psychological help within a given year.

• Compared to children from homes disrupted by death, children from divorced homes have more psychological problems.

The Kids’ Turn program consists of six ninety-minute sessions during which children of the same age are taught how to navigate through the difficult emotions associated with family reconfiguration, and parents are educated on how to support their children. The program is preventive as well as for children experiencing difficulties with actual separation or divorce.

For further information about Kids’ Turn, visit www.kidsturn.org or call (415) 777-9977.

Rally Family Visitation Services of Saint Francis Memorial Hospital Serving families in transition Rosie was two years old when her parents were referred to Rally Family Visitation Services by the San Francisco Unified Family Court for supervised visits with her father. In her first two years of life, she had already witnessed domestic violence and parental substance abuse. The Court believed then, and continues to believe today, that it is in the best interest of children to have a relationship with both parents. While there is increasing evidence of the negative impacts of violence on children, most experts would agree that regardless of the circumstance, children yearn to have an ongoing relationship with both parents. The question is how to make it safe and wholesome.

Rosie, who is now eighteen, continued

22 San Francisco Medicine december 2008

to keep in touch with her father throughout the years, using Rally services. The program staff became a support system, helping her feel safe, connected, and secure while keeping an ongoing relationship with both parents. The time she spent with Rally is unusual, as most families tend to use the services for shorter periods, but the circumstances that led this family to be referred for supervised visitation mirror those faced by most families who are served by the program.

The Rally program provides a safe, neutral environment with professional staff and trained volunteers who supervise visits and monitor exchanges between children and their parents. It is designed for children and adults who may be at risk of emotional or physical harm due to domestic violence, substance abuse, child abuse, or mental health concerns.

Founded in 1991, Rally became a community program of Saint Francis Memorial Hospital in 1997. The hospital provides extensive infrastructure support to the program, which is funded by grants and individual contributions.

Rally is the only program of its kind in San Francisco, serving a diverse population of families. Each year, more than 200 families access program services through the agency. For more information, contact Rally Family Visitation Services of Saint Francis Memorial Hospital at (415) 353-6595.

Youth Treatment and Education Center (YTEC) A juvenile drug treatment program in collaboration with the Superior Court and the San Francisco Unified School District

Continued on Page 30 ... www.sfms.org

Children and Medicine

No Longer Children Teenagers and Medicine

Charles J. Wibbelsman, MD

F

or many clinicians whose practice includes or is exclusively involved in the care of children, the transition from caring for the child who arrives at the office in the arms of his or her parent to providing care for the adolescent who may seek care on his or her own is an everyday challenge.

Adolescence is a time of leaving behind the security blanket of the provisions and care of home and watchful parents and embarking upon a life of many changes, both physical and emotional. This age of rapid change and so much uncertainty must be understood by practicing clinicians, who may need to adapt their own styles of health care delivery to their adolescent patients.

The transition from a pediatric practice to an adolescent medicine practice, in which special office hours are designated for adolescent patients and waiting rooms are complete with signage appropriate for teens, can be beneficial to your practice and most appreciated by teenagers and their parents. Some of us have in fact limited our practices to adolescent medicine and now care exclusively for adolescents and young adults; others, such as general pediatricians and family practitioners, may include adolescents within the scope of their overall practice. Whichever mode of practice one pursues, it is helpful to tailor one’s style of practice to meet the needs of the adolescent.

In addition to having special hours for teens and waiting rooms that can be quickly rearranged with signage on the walls and magazines and educational brochures and handouts specific for teens, adapting one’s practice to focus on adolescents should include understanding the many medical issues unique to this age group, as well as www.sfms.org

being able to offer confidential services to teens when needed.

One of the most difficult transitions for many pediatricians is to perform a “parentectomy.” We can help adolescents only if we can be able to identify if they are involved in risky behavior. The three leading causes of mortality among adolescents—motor vehicle accidents, homicide, and suicide—are all preventable. We must be able to assess these risks. This is accomplished by having a one-on-one, confidential interview alone with the adolescent. Many parents, who have always accompanied their child into the exam room, may not be ready to just wait in the waiting room, and they may not be pleased to be asked to step out of the exam room in order for the doctor to have this special time alone with the adolescent.

Although making this happen may not be an easy task, there are ways to facilitate such a change in your practice. One method is to have the staff member who greets the patient upon arrival be the one to explain to the parent that now that their son or daughter is a teenager who is starting to make some health decisions on his or her

own, the clinician would like to spend some quality time alone with the teen in the exam room to discuss health issues. The staff member can explain that the parent may wish to speak alone with the physician prior to the visit, which makes a good sense since many teens often forget some of the concerns that the parent may have. Another way of spending time alone with the adolescent is to invite the parent in the exam room at the beginning of the visit, during the discussion of nonconfidential aspects of the history, and then request that the parent wait in the waiting room so that you, as the clinician, can spend a little time alone with the teen in order to answer any personal questions that he or she may have. This often is hastened when one begins the physical exam, at which point many adolescents are most grateful to have the parents exit as they disrobe (especially the young men!).

Whatever technique you use, addressing issues of sexual activity, substance use, and sexual orientation can only be accomplished in a confidential setting between you as the clinician and the teen.

Continued on Page 26...

december 2008 San Francisco Medicine 23

Children and Medicine

Feeding Problems in Children An Innovative Approach to Treatment

Meeta R. Patel, PhD, BCBA

F

eeding problems in children, often referred to as pediatric feeding disorders, are identified when a child fails to eat a sufficient quantity or variety of foods or liquids to maintain his weight and grow.

Feeding problems may consist of, but are not limited to, the following: total food/liquid refusal, food selectivity by type (limited diet), food selectivity by texture (eating pureed foods at the age of five), liquid dependence via bottle or breast, and ritualistic eating patterns (only eating French fries from McDonalds; only drinking milk from a baby bottle at an inappropriate age; only eating white foods).

Some children’s feeding problems may be less serious in that they miss a few meals and refuse food on occasion but weight and nutritional status are not compromised.

However, other children may display more serious problems, refusing food or liquid or rejecting certain foods so often that they are at risk for malnutrition, dehydration, impaired development, and/or failure to thrive (FTT). Feeding problems are estimated to occur in 25 to 35 percent of typically developing children and in up to 80 percent of children with developmental delays.

The etiology of feeding problems is complex and may be physiological, environmental, or both. It is hypothesized that feeding problems may develop as a result of medical issues such as gastroesophageal reflux (GER) or food allergies. Although GER

and food allergies may be common in children, some may experience such severe pain while eating that it becomes unpleasant to do so. Children with these types of medical problems may engage in a variety of refusal behaviors (pushing the spoon away, turning the head when food/liquid is presented, crying, emesis) to avoid eating. Although medication or management of the child’s diet may resolve the pain associated with eating, refusal behaviors may persist because of behavioral mismanagement.

A feeding problem may also develop as a result of anatomical abnormalities and/or neuromuscular disorders. The normal development of feeding begins with sucking, swallowing, and biting reflexes.

However, some children who are equipped anatomically to suck, swallow, and bite may also have a specific neuromuscular disorder that renders these mechanisms weak, thus producing more fatigue while eating.

Finally, behavioral mismanagement alone may be another cause for feeding problems. It is likely that children learn to engage in a variety of refusal behaviors associated with eating because of the consequences of those behaviors. Refusal behaviors continue to be strengthened in the child’s repertoire if they lead to a desired outcome (such as not being required to eat). In other words, if a child is not required to eat and the food is removed after engaging in refusal behaviors,

“Feeding problems are estimated to occur in 25 to 35 percent of typically developing children and in up to 80 percent of children with developmental delays.”

24 San Francisco Medicine december 2008

the child will learn to engage in those same behaviors in the future to avoid eating.

Behavioral mismanagement may also be responsible for children failing to transition to more textured foods. It is likely that these children may have had a negative experience (choking, gagging, emesis) when more textured foods were initially introduced and, subsequently, they learned to avoid these textures by engaging in a variety of refusal behaviors. Delayed introduction to solids may also result in texture selectivity. If the child is allowed to avoid these textures, then he may never develop the proper skills necessary to consume regular textured foods.

Therefore, this will eventually lead to oral motor deficits because the child will have not gone though all of the developmental stages necessary to strengthen the proper skills to be a successful eater. In turn, the child may be anxious and fearful when presented with more textured foods.

One possible treatment for children with a diagnosis of a pediatric feeding disorder is to place them on enteral support (such as a nasogastric (NG-) tube or gastrostomy (G-) tube). Generally, children who are FTT or have poor weight gain may need supplemental feedings to meet their nutrition and hydration needs. If tube feedings were not available, these types of feeding problems would be life-threatening. Enteral support may be a good short-term treatment plan for children who consume nothing or very little by mouth. However, long-term dependence on tube feeding can be detrimental to the child’s oral motor skills and may impede speech. In addition, long-term dependency on tube feedings may affect the child’s socialization with his peers.

Treatment at an early age is critical since there is a shorter history of refusal and www.sfms.org

negativity to work against. Once medical issues have been ruled out or treated, the child will be referred to either an occupational or speech therapist for feeding therapy. These services generally are provided once or twice a week and focus on oral motor and sensory issues associated with feeding. However, for more severe cases this therapy model alone may not be effective because of the extensive refusal behaviors.

Since the etiology of feeding problems is heterogeneous, treatment requires the expertise of several professionals. The treatment of choice for more severe feeding problems has been intensive feeding therapy using an interdisciplinary treatment model. The interdisciplinary team may involve a comprehension treatment designed by a physician, nutritionist, occupational/speech therapist, social worker, and behavioral psychologist. All team members are involved in the treatment plan and are under one roof.

Traditionally, the interdisciplinary model is provided in either a clinic or hospital setting (inpatient or day treatment) and intensity may involve a fourto-eight-week all-day program. Generally a trained feeder will conduct meals until an appropriate protocol is developed, and usually during the last few weeks of the child’s admission the family would be trained on

Continued on the Following Page ...

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Feeding Problems in Children Continued from the Previous Page... the final treatment protocol. The social worker may be involved to identify any family issues that may affect the feeding situation and to assist the family in transferring the gains from the clinic or hospital to the home environment. Preliminary data from the Marcus Institute, an eight-week clinic-based program in Atlanta, indicates that more than 87 percent of the goals for treatment were met by the time of discharge and 70 percent of patients met their goals for oral intake.

Most intensive clinic/hospital-based programs provide follow-up care after the four to eight weeks, but this may not be feasible for families who are not local. A more recent and innovative approach to treating feeding problems has been intensive home-based treatment in our mobile Clinic 4 Kidz. Our clinicians travel all over the country providing these services to families and children with feeding problems. Clinic 4 Kidz provides opportunities for families who cannot relocate to receive state-of-theart services in established facilities.

The initial treatment visit is five days for ten to twelve hours per day. Our therapists are in the family’s home from breakfast to dinner. Goals are established during the visit by the clinician and family. A trained feeder generally conducts all meals for the first two to three days, and once an effective protocol is developed, all caregivers are trained on how to implement the protocol in the family’s home environment. In addition, training is provided in restaurants and to school staff. Working with the family in the home environment allows us to determine what is feasible in the family’s everyday life, something that may not be possible in a clinic/hospital-based program. Preliminary data (August 2004 to March 2008; N= 57) from Clinic 4 Kidz initial visits indicates that 93 percent of the goals set during the initial visit were met. In addition, 93 percent of the children increased total oral intake, 85 percent decreased tube feedings, and 91 percent increased the variety of foods/liquids taken.

After the initial five-day visit, the family follows that treatment plan for one

month, and thereafter monthly follow-up visits are scheduled for two to three days per month to ensure that the gains made during the initial visit are maintained and that new skills develop. Follow-up visits continue until the child is an age-typical or developmentally typical eater. Preliminary data from Clinic 4 Kidz follow-up care indicates that 90 percent of patients continue follow-up care and, of those, 100 percent make some level of improvement compared to the initial visit.

Overall, it is clear that more severe feeding problems may require treatment, and that prior to initiating any type of intensive feeding program it is critical that all medical issues are resolved. Both clinic/hospital and home-based intensive programs showed high success rates; however, it is likely that generalization of skills and transfer of control to the family may be easier with the home-based model. Furthermore, the home-based model is more accessible to more people. In conclusion, the caretakers of children who display symptoms of a pediatric feeding disorder should seek help early so that possible enteral support can be avoided and refusal behaviors can be managed.

Meeta R. Patel, PhD, BCBA, works for Clinic 4 Kidz in Novato, California, and can be reached at clinic4kidz@msn.com.

No Longer Children Continued from Page 23...

In my own practice, I may see that a mom who a single parent is most grateful that her son has someone to confide in, as he might otherwise with a father. And many parents comment that they are pleased that there is an adolescent clinic available to help care for their teens.

Adolescents themselves see such a practice as highly beneficial, especially when confidential health matters arise and they are in a quandary about where to seek help. I had such a letter a few months ago from an adolescent patient who is now off to college (see image on page 23).

Often, however, ordering confidential tests on an adolescent can be problematic.

Even sending a confidential urine screen-

26 San Francisco Medicine december 2008

ing test for chlamydia will require having a confidential phone number in order to locate the teen if the test is positive. Luckily many, if not most, teenagers have cell phones, which allows the practitioner to inform the adolescent of a positive result and arrange for treatment and follow-up, all confidentially.

Teenagers constitute a special age group that is often misunderstood, and both parents and clinicians may find it difficult to communicate with them. Tailoring our medical practices to these patients can improve the care that we give teens, enabling us to assess risk behavior and offer preventive health measures and guidance—and to truly save more than one at-risk adolescent’s life.

Charles J. Wibbelsman, MD, is the Chief of Adolescent Medicine for Kaiser Permanente in San Francisco, California. Dr. Wibbelsman has been with the Permanente Medical Group, Inc., for twenty-nine years and serves as Chair of Adolescent Medicine for Kaiser Permanente, Northern California. He is a Clinical Professor of Pediatrics at the University of California, San Francisco, School of Medicine. Prior to his joining the Permanente Medical Group, Dr. Wibbelsman was the Chief of Venereal Disease Control for the City and County of San Francisco. A writer of books for adolescents and their parents, he has coauthored The Teenage Body Book, Growing and Changing, Life Happens, and Crisis-Proof Your Teenager.

Dr. Wibbelsman is a member of the Committee on Adolescence of the American Academy of Pediatrics, and he is President-Elect of the San Francisco Medical Society.

www.sfms.org

Book Review

In Memoriam

Nancy Thomson, MD Magical Moments of Change Magical Moments of Change, by Lenore Terr Norton and Co., 2008 Lenore Terr, MD, Clinical Professor of Psychiatry at the University of California, in San Francisco and in private practice, is a pioneer in the field of childhood trauma. She is the author of three previous books: Too Scared to Cry, Unchained Memories, and Beyond Love and Work. In her new book, Magical Moments of Change, Dr. Terr discusses the case of a twenty-nine-month-old toddler, “Cammie,” who was brought to her office in 1991 as a growling, spitting, “feral” child who had been hideously abused by her parents, even witnessing her baby sister’s murder. The therapeutic relationship has continued for fifteen years, with the foster parents bringing Cammie in for an hour’s treatment once a month. Terr identifies eight moments of dramatic change during those years, moments that not only helped the child but also educated the doctor about what works and what doesn’t in the psychological treatment of young people.

The inspiration for the book began in 2004 with the death of Saul Harrison, one of Terr’s child-psychology teachers, when she was a student and resident at the University of Michigan. This brought together Terr and many of her cohorts from that period. Since Harrison had taught them to attend to the realities of the psychiatrist-patient relationship, no matter how painful or embarrassing it might be for the doctor, the group decided to celebrate Dr. Saul’s life by assembling a group of striking child therapeutic turnarounds that had occurred in their practices. Their goal was to try to understand what happens during these dramatic instances of therapy-induced change. Six colleagues responded to her request for cases, and she added Cammie’s. They were published in Dr. Saul’s honor in the Journal of the American Academy of Child and Adolescent Psychiatry in 2005.

Terr then decided that a book encompassing a collection of such case histories would make the process of childhood change clearer and help not only other professionals but also parents struggling with difficult children. She asked her peers to send her cases, and in three years, thirtythree psychiatrists have written up forty-two vignettes in answer to her question, “Have you ever seen a moment of dramatic change in a child or adolescent during psychotherapy? Describe it and explain its meaning in 500 words.”

Thus, Terr’s new book contains these heartwarming stories of children and adolescents undergoing dramatic psychological change. Her approach is eclectic, emphasizing humor, play, storytelling, and metaphor—the special languages of childhood. The vignettes in the book cover all sorts of disorders, ranging from mild adjustment and developmental problems to severe juvenile delinquency and schizophrenia. There are also cases of posttraumatic stress disorder such as in Terr’s patient Cammie.

These and other techniques described in the book can provide anyone who works with or cares for children with valuable insights and a sensitivity to magical moments that can trigger a transformation in children.

www.sfms.org

Morton J. Thoshinsky, MD Dr. Morton J. Thoshinsky passed away at home on July 22, 2008, age 81, after a short battle with pancreatic cancer. He was born in San Francisco to William and Claudia Thoshinsky on June 10, 1927. He graduated from Washington High School, U.C. Berkeley (Phi Beta Kappa), and UCSF Medical School. He then served two years in Japan in the U.S. Air Force Medical Corps. After completing a surgical residency, Dr. Thoshinksy entered private practice in general and vascular surgery in 1959, joining the San Francisco Medical Society that same year. He served on the hospital staff of Mt. Zion, UCSF, California Pacific Medical Center, Chinese Hospital, and Franklin Hospital. “Dr. T” helped train countless surgical residents over his many years in practice and was proud to have been a three-time recipient of Mt. Zion Hospital’s Award for Outstanding House Staff Teaching. He retired in 1998. Dr. Thoskinsky was preceded in death by his first wife, Marie Calander Thoshinsky, and his eldest son, David. He is survived by his children, Lisa (Paul) Vande Voorde of San Mateo and Peter Thoshinsky of Walnut Creek, and by his two grandchildren; also by his second wife and longtime companion, Angela Tilin Thoshinsky and her two children.

David Dee Rabin, MD Dr. David Dee Rabin, a longtime San Francisco internist and cardiologist, died July 6, 2008, age 77, after a lengthy illness. He was born in Milwaukee on September 12, 1930, and graduated from the University of Wisconsin at Madison in 1952. He completed medical school at Madison in 1955 and moved to San Francisco for an internship and residency in internal medicine at Mt. Zion Hospital. This was interrupted by a twoyear enlistment in the Navy, where he cared for both Navy and Marine personnel at Mare Island and overseas in Japan and Iwo Jima. Following his military service, Dr. Rabin completed his residency at Mt. Zion and was awarded a cardiology fellowship at Michael Reese Hospital in Chicago.

Returning to San Francisco, he entered into private practice, joining the San Francisco Medical Society in 1962 and beginning a nearly forty-year association with Mt. Zion-UCSF Medical Center. He was elected to the medical board of Mt. Zion and eventually assumed the role of associate chief of medicine. He also was an associate clinical professor at UCSF. In addition, Dr. Rabin served as vice chairman of the Meyer Friedman Institute and worked with Dr. Friedman on groundbreaking research that established a correlation between Type A behavior and heart disease.

Perhaps his outstanding achievement, however, was his association with On Lok in Chinatown. Working with its founder, Marie Louise Ansak, Dr. Rabin provided primary care to elderly people who otherwise had no access to doctors. They helped create the model of “total care” that the organization still uses today. Dr. Rabin was a wonderful father, an avid skier, an enthusiastic traveler, a passionate 49ers and Giants fan, a generous and loving friend, and a devoted brother and uncle. He is survived by his former wife, Deborah Rabin of Mill Valley; his son, Joshua Rabin of Long Beach; his daughter and son-in-law, Katherine Rabin and Tim Porter of Corte Madera; his brother, Joel; and numerous nieces and nephews. december 2008 San Francisco Medicine 27

Hospital News Chinese

Joseph Woo, MD

I recently had the pleasure of attending the Fourteenth Conference on Health Care of the Chinese in North America. This meeting was held in Toronto, Canada, this past September.

More than 350 doctors came from around the globe to hear about topics including metabolic syndrome, complimentary medicine, stroke, and asthma, with an emphasis on the uniqueness and differences in caring for the Chinese patient.

This biennial conference has its roots in our own medical staff, as the first conference was held in San Francisco in 1982 with Dr. Edward Chow as Chairperson. These immensely successful meetings eventually evolved into the formation of the Federation of Chinese American and Chinese Canadian Medical Societies (FCMS). The FCMS strives to be an organization that “not only serves as a conduit of camaraderie” but also builds a “critical mass of physicians of Chinese descent to make our voice heard, our interest count, and to build a foundation for our posterity in the field of medicine in this great continent of North America.” Our own Doctors Collin Quock, Harry Lee, Dexter Louie, and most recently Randall Low have played major leadership roles.

FCMS remains primarily an organization that represents organizations. Lately, however, many of my colleagues have been asking, “What has FCMS done for me?” In my opinion, if its only accomplishment were education, the organization should be considered a success; but FCMS also has roles in advocacy and supporting research.

Moreover, I was reminded at this last conference of the importance of collegiality and friendships.

Dr. John Chu, historian and Toronto Conference organizer, collapsed in front of the hotel as the nighttime gala was beginning. San Francisco members helped his wife get to the hospital, followed by supportive visits from colleagues from New York, Los Angeles, and Canada. For my part, I am thankful that FCMS has allowed me the privilege of knowing such fine, caring people from across North America.

CPMC

Damian Augustyn, MD

For children’s emergencies, California Pacific Medical Center’s new Pediatric Emergency Department (ED) is the first in San Francisco to offer care tailored to children ages birth to 18. Focused entirely on treating infants and children in a childfriendly environment, the Pediatric ED provides private rooms and child-sized equipment, as well as doctors trained in pediatrics and emergency medicine. Child Life staff is also an integral part of the team, helping children cope with medical emergencies and the hospital environment.

This facility is located at the California Campus, 3700 California Street. Doctors treat both life-threatening illnesses and other less serious conditions, including: abdominal pain, dehydration, fever, croup, severe vomiting or diarrhea, asthma or seizures, broken bones, fractures, athletic or head injuries, or lacerations The Pediatric ED is recognized as a critical care receiving facility by Emergency Medical Services.

Researchers at the CPMC Research Institute have discovered that a protein found in the common human virus cytomegalovirus (CMV) appears to be a key factor in making brain tumors spread more quickly and aggressively. The protein known as IE1 plays a number of roles, modifying brain cancer cells in a way that makes them grow more rapidly and confirming a potential role for CMV in the malignant process of this cancer.

CPMC neurosurgeon Dr. Charles Cobbs first made the discovery that CMV was associated with malignant brain tumors in 2002. Now, by identifying the mechanism that helps CMV fuel tumors, it is believed that it could speed up the search for new treatments. CMV is a common virus, causing a persistent infection in 50 to 80 percent of all Americans. Because it often produces few symptoms, most people are unaware they are infected. In normal, healthy individuals CMV poses few risks, but it can pose serious health problems for people with compromised immune systems such as people with HIV/AIDS, organ transplant recipients, and pregnant women and their fetuses.

28 San Francisco Medicine december 2008

Kaiser

Robert Mithun, MD

The choice that caregivers of children currently face when confronted with the vast popular and technical literature on vaccines is daunting. Many pediatricians at Kaiser Permanente, and in other medical practices, are fielding an increasing number of vaccine-related questions from their patients’ caregivers, thanks to the media, confusion over the efficacy and safety of vaccines, and word-of-mouth concerns voiced by other parents.

Pediatricians at Kaiser Permanente are encouraged to remain abreast of the most current information regarding vaccines and advise caregivers accordingly. Obviously there is a breadth of experience that each physician brings to a discussion of vaccination, and recognizing each person’s opinion is part of the process.

Some of the most important aspects to keep in mind when advising caregivers are the sources of their information, their understanding of the risks and benefits of vaccines, and what potential health issues may arise by not administering vaccines.

To maintain a united front on a course of action can be a formidable task for any medical group made up of so many diverse physicians.

By keeping channels of communication open among all concerned parties, from researchers to administrators, physicians to caregivers, we are most likely to find a comfort zone that keeps everyone well informed and to make the choices that are best not only for individuals but also for the greater population.

www.sfms.org

Hospital News Saint Francis Wade Aubry, MD

In keeping with the theme, Children and Medicine, I would like to acknowledge the Bothin Burn Center team, as this is the only pediatric service at Saint Francis Memorial Hospital. In a recent column for the Medical Society, I announced the news that our Burn Center was reverified by the American Burn Association and the American College of Surgeons, Trauma Division.

Quality burn care goes beyond simple wound care. A major burn causes stress to the entire body, affecting every organ as well as the patient’s ability to function physically and socially. The burn team in the Bothin Burn Center is highly trained to meet the complex needs of burn patients from critical care through rehabilitation. Pediatric patients in a hospital setting require age-specific care. This involves assessing each child’s developmental level and tailoring care accordingly.

Comprehensive care includes close attention to developmental milestones, immunization status, family background and situation, and nutritional history. The burn unit closely monitors the above as well as examining the family situation to ensure that no abuse or neglect caused the burn injury.

Up until the early eighties, parents were not allowed to stay at the Center with their child, and visits were restricted. However, current practice is family-centered. The parents are allowed to stay in the room with the child and, when appropriate, they participate in treatments and offer continual support to their child. This approach greatly reduces anxiety for both the parents and the child.

The multidisciplinary team also is enhanced by a recreation therapist, who works with each child daily to assure that developmental needs are being met and to allow the child to participate in therapeutic play. Lastly, nurses in the Bothin Burn Center are required to have specialized pediatric training and certifications that are renewed every two years. Medication administration is closely monitored, and all pediatric medications at Saint Francis are double-checked by two RN’s prior to administration. www.sfms.org

St. Mary’s

St. Luke’s

Richard Podolin, MD

Jerome Franz, MD

We of the St. Luke’s campus of CPMC were taken aback by the precipitous announcement on October 17 that eliminated the office of Chief Medical Executive, occupied by William Miller since its inception four years ago as a means to involve the medical staff more fully in day-today administration. Out the door at the same time was our Chief Administrative Officer of two years, Judy Li, who has moved to a position of health planning for CPMC. Although the only constant, change is hard to accept when it comes so quickly.

Our shock was mitigated by the installation of Steve Lockhart as the first Vice President of Medical Affairs; he has earned great respect in the community for his leadership in the Blue Ribbon Panel process that culminated in the decision to rebuild St. Luke’s. His immediate task is to oversee the architectural planning that must be completed by the end of the year. We look forward to working with him.

Meanwhile, the holiday events that crowd our calendars keep coming. The St. Luke’s Auxiliary hosted its Musée and silent and live auctions on November 19 at a performance of Beach Blanket Babylon. On November 20, Ed Kersh hosted the opening of a new exhibit by the Asian American Women Artists Association at his office suite in the Monteagle Building, benefiting the CPMC Foundation for specific St. Luke’s projects. The opening was preceded by a lecture, “How to Survive a Heart Attack,” for a general audience.

Nearly a century ago, Abraham Flexner released a report for the Carnegie Foundation emphasizing the social role of the physician and arguing that the public good would be served by tying all medical education to scientific discipline. The consequences of this association have been so profound, and the benefits so great, that it is hard to imagine that it was once otherwise.

No group has reaped more from this alliance than children, countless of whom have been saved by antibiotics, vaccines, surgical correction of congenital heart disease, and effective treatment of childhood malignancies —all products of scientific progress. Even decidedly low-tech advances, such as oral rehydration solutions for diarrheal illness, or mosquito nets that prevent the spread of malaria, owe their acceptance to the rigor of the scientific method.

But now we face epidemics impervious to our beloved science. To tackle childhood obesity, with its attendant diabetic complications, we need to address the subsidization of high-fructose corn syrup, the proliferation of fast food, and the choices made by harried parents and sedentary children. What pride should our profession take in the science of oral rehydration solutions and mosquito nets if thousands of children die each day because we lack the political will to make needed interventions available? Perhaps it is time for a new report on medical education. If physicians are to remain the stewards of health in our society, we will have to train our young colleagues to enter not just the laboratory but also the public square.

december 2008 San Francisco Medicine 29

Hospital News Veterans

UCSF

Diana Nicoll, MD, PhD, MPA

Elena Gates, MD

UCSF Children’s Hospital has opened an innovative new clinical unit focusing on the infant brain—the first facility of its kind in the U.S. The unit features clinical research and specialized treatment for infants who show signs of brain damage at birth and who may be at risk of developing cerebral palsy, mental retardation, and other cognitive disorders. “My hope is that by bringing scientists and clinicians together in the Neuro-Intensive Care Nursery, we will be able to establish the root causes of brain damage in infants so that we can offer patients and their families real therapeutic options,” said David Rowitch, MD, PhD, chief of Neonatology at UCSF. UCSF’s Pediatric Environmental Health Specialty Unit (PEHSU) provides expert clinical and public health evaluations of children and communities with suspected environmental health problems. The U.S. Environmental Protection Agency awarded UCSF one of twelve Children’s Environmental Health Champion Awards for outstanding commitment to protecting children from environmental health risks for its accomplishments in educating the public about how forest fires affect children’s health.

The PEHSU created fact sheets that the state and federal governments used in response to recent California wildfires.

The Child Life Department at UCSF Children’s Hospital runs an actual classroom, a kind of one-room schoolhouse, so that patients’ academic work can continue during a hospital stay. The on-site school is actually part of the San Francisco Unified School District, and two of the six teachers are SFUSD employees. “Kids need to go to school—that’s their job,” said Michael Towne, Coordinator of the Child Life program.

“Keeping them in school here lends some normalcy to their lives.” Child Life teachers work with the children’s classroom teachers on curriculum and homework and help reintegrate patients back into their home classrooms after their release from the hospital.

A research group headed by Michael Weiner, MD, Director of the Center for the Imaging of Neurodegenerative Diseases (CIND) at the San Francisco V.A. Medical Center, has been granted a $6.04 million Biomedical Technology Research Resource (BTRR) Award from the National Institutes of Health.

The award will be used to support development of new techniques to improve the sensitivity and resolution of magnetic resonance imaging (MRI) in order to better diagnose and track neurodegenerative diseases, such as Alzheimer’s disease.

“In the face of the coming Alzheimer’s epidemic, many potential treatments for Alzheimer’s are now in development,” said Weiner, who is a Professor of Radiology, Medicine, Psychiatry, and Neurology at the University of California, San Francisco. “It’s essential that we have the most sensitive possible imaging technologies at our disposal so that we can identify the most likely candidates for treatment, as well as monitor and assess the effects of these treatments in the brain.”

Weiner is principal investigator of the Alzheimer’s Disease Neuroimaging Initiative, a nationwide, longitudinal $64 million study of Alzheimer’s disease progression.

He says the improved techniques will also be applied to the diagnosis, monitoring, and treatment of many other neurological diseases and conditions, including posttraumatic stress disorder, traumatic brain injury, Gulf War illness, Parkinson’s disease, epilepsy, HIV dementia, and other dementias.

BTRR awards are given to support researchers in the development of technologies that have application to a broad range of basic, translational, and clinical research.

SFVAMC has the largest medical research program in the national V.A. system, with more than 200 research scientists, all of whom are faculty members at UCSF.

30 San Francisco Medicine december 2008

Children and Justice Continued from Page 22...

The Youth Treatment and Education Center (YTEC) pursues its mission “to break the cycle of juvenile alcohol and other drug abuse and to reduce high rates of delinquency, recidivism, and school dropout among juvenile offenders.”

This unique effort started by the San Francisco Superior Court, San Francisco Juvenile Probation Department, San Francisco Unified School District (SFUSD), San Francisco Department of Public Health, and Youth Treatment and Education Center, collectively known as the Principals’ Center Collaborative (PCC), works out of the PCC High School to provide educational and behavioral health services to San Francisco youth who are on probation. Walden House and Catholic Social Services are part of this effort and provide staff as well.

The unique curriculum of the PCC enhances YTEC’s program, which integrates social skills, school readiness, academic performance, positive self-control, moral reasoning, and family stability. The two long-term goals are drug-free and crime-free lifestyles. When their PCC school requirement is completed, youth can choose to join the Leadership Fellows Program, which is an “aftercare” leadership and peer mentoring program. YTEC also provides a Diversion Program that consists of a seven-week substance abuse education and prevention course that targets youth in the early stages of their use. The goal is to prevent any escalation in substance abuse and the high-risk behaviors that often accompany it.

If you would like to support youth served by the Youth Treatment and Education Center and PCC, please call (415) 242-1647. Each of these programs was founded by Judge Ina Levin Gyemant during the twenty years she served as a Superior Court Judge. For her work on the YTEC program, she recently received the Jefferson Award for Community Service. She was elected to the Municipal Court in 1981, elevated to the Superior Court in 1986, and retired from the bench in 2001. Now retired, she currently provides mediation and arbitration services in San Francisco. Judge Gyemant is married to SFMS member Dr. Leonard Shlain. www.sfms.org

Dental Open Enrollment Effective Date: January 1, 2009!

It’s Open Enrollment time for the San Francico Medical Society sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expense of regular dental care.

This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits that can save you money: • Annual Benefits of $2,000 per person for dental care, using network providers ($1,500 if you use non-network providers).

• During Open Enrollment only, members may join as an individual or as a group with your employees.

• Low calendar year deductible of $50 per person, ($100 per calendar year maximum for families).

• Pay no deductible on oral exams, x-rays and routine cleanings.

• Rollover Benefit – This feature allows for the unused portion of the maximum benefit amount from one year to roll over and be used in the following calendar year.

Remember, the open enrollment period is available once per year. To be eligible for coverage applications must be received during the special open enrollment period that ends on December 31, 2008.

Call a Client Service Representative at (800) 842-3761 for more information, a brochure and an application. Or e-mail CMACounty.Insurance@marsh.com.

Sponsored by:

Underwritten by:

Administered by:

Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states.

Limitations and exclusions apply. Plan documents are the final arbiter of coverage.

DBA in CA Seabury & Smith Insurance Program Management • CA Insurance License #0633005 • 10/08 © 2008 Seabury & Smith Insurance Program Management • 777 S Figueroa St., Los Angeles, CA 90017 • (800) 842-3761 • CMACounty.Insurance@marsh.com www.MarshAffinity.com

Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer, and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

Outreach Clinics n Stockton n Crescent City n Chico n Santa Rosa

We’ve come a long way.

There are now a growing number of adult survivors of congenital heart disease (ACHD).

In fact, these adult survivors are the fastest growing population in medical cardiology.

California Pacific’s Adult Congenital Heart Disease Program provides your patient with a multidisciplinary team of physicians with ACHD expertise within obstetrics, pulmonary, congenital heart surgery, hepatology, renal and electrophysiology. All diagnostic, interventional and surgical modalities are available, including non-invasive imaging. This team provides: n Management planning for long-term follow-up n Patient counseling n Comprehensive diagnosis at initial evaluation

n Transition of from pediatric to adult care n Patient support groups facilitated by a social worker n Encouragement of patients to maintain close relationships with PCPs

For more information, a referral or to schedule a transfer, please call

888-637-2762.

California Pacific’s Heart and Vascular Center offers quality, comprehensive, patient-centered cardiovascular care by a team of pioneering physicians integrating leading-edge technology.

Beyond Medicine.