AN RANCISCO EDICINE S F M VOL.82 NO.10 December 2009 $5.00
JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY
Inspirational Moments in Medicine
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In This Issue
SAN FRANCISCO MEDICINE December 2009 Volume 82, Number 10 Inspirational Moments in Medicine FEATURE ARTICLES
10 Inspiration and the Future of UCSF Mike Denney, MD, PhD 12 Inspiration in Uganda Nancy Griffith, MBA, MS, NP
14 Sharing the Gift of Life Eisha Zaid
16 All This Joy, All This Sorrow Shieva Khayam-Bashi, MD
17 Amazement and Wonder Rachel Orkand, MSW
19 Guiding a Young Physician Ashley Skabar
MONTHLY COLUMNS
4 Membership Matters 7 President’s Message Charles J. Wibbelsman, MD
9 Editorial Mike Denney, MD, PhD 28 Hospital News OF INTEREST
30 Health Policy Perspective: Following the Money Steve Heilig, MPH
20 “Please Don’t Do This to Me” Shieva Khayam-Bashi, MD 21 Learning to be a Physician Ellen Joyce Plumb 22 Breathe In, Breathe Out Lenny Karpman, MD 23 Open Wide Niko Mayer
24 My “Aha” Moment Jordan Shlain, MD
25 Touched by an Angel Toni Brayer, MD, FACP
27 Book Review: The Water Giver Erica Goode, MD
www.sfms.org
Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon request. Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605
december 2009 San Francisco Medicine 3
Membership Matters December 2009 A Sampling of Activities and Actions of Interest to SFMS Members
Volume 82, Number 10 Editor Mike Denney
Managing Editor Amanda Denz Copy Editor Mary VanClay Editorial Board Chairman Mike Denney
Obituarist Nancy Thomson
Stephen Askin
Shieva Khayam-Bashi
Gordon Fung
Ricki Pollycove
Toni Brayer
Linda Hawes-Clever Erica Goode
Gretchen Gooding
Arthur Lyons
Terri Pickering
Stephen Walsh
SFMS Officers
President Charles J. Wibbelsman
President-Elect Michael Rokeach
Secretary George A. Fouras Treasurer Gary L. Chan Editor Mike Denney
Immediate Past President Steven H. Fugaro SFMS Executive Staff
Executive Director Mary Lou Licwinko
Director ofPublicHealth &Education Steve Heilig
Director of Administration Posi Lyon
Director of Membership Therese Porter
Director of Communications Amanda Denz
Board of Directors Term:
Jeffrey Newman
Andrew F. Calman
Michael H. Siu
Jan 2009-Dec 2010 Jeffery Beane
Lawrence Cheung Peter J. Curran
Thomas H. Lee
Richard A. Podolin Rodman S. Rogers Term:
Jan 2008-Dec 2010 Jennifer H. Do
Keith E. Loring
William A. Miller
Thomas J. Peitz
Daniel M. Raybin Term:
Jan 2007-Dec 2009 Brian T. Andrews Lucy S. Crain
Jane M. Hightower Donald C. Kitt Jordan Shlain Lily M. Tan
Shannon UdovicConstant
CMA Trustee Robert J. Margolin AMA Representatives
H. Hugh Vincent, Delegate
Robert J. Margolin, Alternate Delegate
SFMS Members: Save the Date for the Annual Dinner Next year’s annual dinner will take place at the Concordia-Argonaut Club Thursday, January 21, 2010. PresidentElect Michael Rokeach, MD, will be installed as 2010 SFMS President. SFMS members will receive an invitation to the 2010 SFMS Annual Dinner in December. Please return the RSVP card promptly. Contact Posi Lyon, (415) 561-0850 extension 260, with questions.
Important Resources for H1N1
Novel influenza A (H1N1) is a new flu virus of swine origin that was first detected in April 2009. The virus is spreading from person to person and has sparked a growing outbreak of illness in the United States, with an increasing number of cases being reported internationally as well. Clinicians should consider the possibility of H1N1 influenza virus infections in patients presenting with febrile (>100 F or 37.8 C) respiratory illness. If H1N1 is suspected, clinicians should obtain a respiratory swab for swine influenza testing and place it in a refrigerator (not a freezer). Once collected, the clinician should contact the state or local health department to arrange transport and timely diagnosis at a state public health laboratory. Look for suspected cases: Ask all patients with acute respiratory illness if they had close contact with a confirmed human case of swine flu, contact with an animal with confirmed or suspected swine flu, or a history of travel to a swine flu-affected area within the seven days preceding the onset of the illness. In all clinical settings, collect respiratory specimens from patients who meet the definition of a suspected case of swine flu or have an ILI and are hospitalized with an undiagnosed acute respiratory illness or suspected or confirmed seasonal influenza or have an ILI and are presenting to emergency rooms. Report cases to SFDPH Disease
4 San Francisco Medicine December 2009
Control: (415) 554-2830. Suspected cases of swine flu, fatal or severe (requiring ICU) cases of suspected or confirmed seasonal flu in adults and children. Respiratory specimen collection and submission instructions are posted at: www.sfcdcp.org/ swineflu.html. • The case definition of H1N1: www. cdc.gov/swineflu/recommendations.htm • CDC Swine Flu Web page: www.cdc. gov/flu/swine/ • Interim guidance on infection control for care of patients with confirmed or suspected swine flu virus infection in a health care setting is posted at: www.cdc.gov/swineflu/guidelines_infection_control.htm • San Francisco Department of Public Health: www.sfcdcp.org/swineflu.html (swine flu Web page), (415) 554-2830 • Centers for Disease Control and Prevention: www.cdc.gov/flu/swine/ (800) CDC-INFO ([800] 232-4636) and TTY (888) 232-6348, 24 hours every day. The CDC continues to report additional cases and developments via its website.
2010 Annual Participation Enrollment Program Extension
Due to recent revisions that were made to the 2010 Medicare Physician Fee Schedule (MPFS), the Centers for Medicare and Medicaid Services (CMS) has extended the 2010 Annual Participation Enrollment Program end date from December 31, 2009, to January 31, 2010. Therefore, the enrollment period now runs from November 13, 2009, through January 31, 2010. The effective date for any participation status change during the extension, however, remains January 1, 2010, and will be in force for the entire year. Contractors will accept and process any participation elections or withdrawals made during the extended enrollment period that are received or postmarked on or before January 31, 2010. Note: This is an extension of the Annual Participation Enrollment period dates in CR 6637 (Transmittal 1832—Calendar www.sfms.org
Year [CY] 2010 Participation Enrollment and Medicare Participating Physicians and Suppliers Directory [MEDPARD] Procedures), dated October 16, 2009. The Participation Agreement (CMSForm 460) is available on the CD-ROM that is sent out annually by your Medicare contractor during the Annual Participation Enrollment period. Your contractor will also make the Participation Agreement available to you by placing it on the Web site with participation enrollment (and termination) instructions. Questions can be directed to Lydia Cairo at (415) 744-3658 or lydia.cairo@ cms.hhs.gov. She will distribute your questions accordingly.
Help Grow the SFMS AND Get a Break on Your Dues!
Members of the San Francisco Medical Society/California Medical Association know that participation in organized medicine benefits both physicians and their patients. SFMS members have been helping to shape the future of medicine for nearly 150 years. If each member of the San Francisco
Medical Society/California Medical Association encouraged just one new member from among their physician peers to join, SFMS/CMA would become a an even more powerful force on the local level and in the legislature, the courts, and the media. All it takes is one SFMS/CMA member recruiting just one new member to make a significant effect on membership. With the SFMS “Connect the Docs” referral program, you can help grow membership in SFMS and CMA and give yourself a break on your SFMS dues. If you are a full dues-paying member of SFMS/CMA: Recruit four or more new members to the San Francisco Medical Society/California Medical Association and receive free SFMS dues for the 2010 dues year. TPMG members’ dues are paid by Kaiser, but if a TPMG physician refers five or more members (TPMG or not), he or she will receive two free tickets to the SFMS Annual Dinner. Be sure the new member completes the “referred by” information so that you receive appropriate credit. Joining has never been easier, with the
online application system. All a prospective member has to do is visit www.sfms. com and click on the “JOIN SFMS” button in the upper right-hand corner. If the new member has never been a member of CMA before, he or she may be eligible for a 50 percent discount on the first-year dues. You—or the prospective member— can also contact Therese Porter in the Membership Department at (415) 5610850 extension 268 or tporter@sfms.org with questions or to have a membership information packet sent.
The Mixer for Residents and Young Physicians—Another Fun and Successful SFMS Event!
On November 19, residents, fellows, and young physicians gathered at the SFMS offices in the Presidio of San Francisco for an evening of appetizers and wine. Members of the SFMS Board and staff also attended. It was a wonderful opportunity for members and nonmember young physicians and residents to meet and mingle in a relaxed environment. SFMS hopes to make this an annual event.
2009-10 SFMS Directory and Desk Reference Available Now! This important and trusted health care resource contains a comprehensive listing of SFMS members with their specialties and contact information. It is also packed with helpful resources that no medical office should be without! SFMS members receive one copy free as a membership benefit; additional copies are only $45 each. Nonmembers pay $75 per copy. Order your copy today! Contact Carol Nolan at (415) 561-0850 extension 0 or cnolan@sfms.org. Interested in advertising in next year’s Directory? For more information contact Jonathan Kyle at (415) 561-0850 extension 240 or jkyle@sfms.org.
www.sfms.org
december 2009 San Francisco Medicine 5
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President’s Message Charles J. Wibbelsman
Life-Changing Moments
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s I now compose my final message as president of the San Francisco Medical Society for the year 2009, the theme of this month’s magazine gives me the opportunity to reflect back on this year and what inspired me to become involved in organized medicine and to choose medicine as a profession. As you peruse this issue of the magazine, you will read many stories from our colleagues about moments in medicine that were inspirational and perhaps changed their lives in some way. I have my own stories. As a college student attending Xavier University in Cincinnati, I was given the opportunity to work on the weekends as an attendant at a private hospital’s emergency room. Not only did this weekend commitment help defray the costs of college, it also gave me a chance to put my feet in the water and really find out if medicine was the career that I wished to pursue. Although the tasks of an attendant were basic, such as rooming patients in the four treatment rooms and assisting physicians with such procedures as suturing lacerations, I was still very much aware of and enthralled by all the drama and emotions that are so much a component of emergency medicine, then and today. One summer evening, a ten-year-old boy named Donald Z was brought by ambulance after being struck by an automobile while riding his bicycle. In those days, helmets were rarely used nor advocated for children riding bikes. Donald was brought to a treatment room. where he lay for two hours. A few physicians came in to examine him, but there was little intervention. He died in that treatment room. I still remember the faces of his mother and father in the waiting room when they were informed that their son had just died. There were so many tears of anguish, loss, and guilt because their son was gone. But for me, there was anguish that very little had been done in the emergency room to try to save this little boy’s life—or so it appeared to me, as an eighteen-year-old college student. I vowed that someday I would be a doctor and would, I hoped, be able to save such young lives. Another moment that I will also remember was when I was a pediatric intern at Massachusetts General Hospital in the 1970s. One of our block rotations, with every other night on call, was the Newborn Intensive Care Unit and the Pediatric Intensive Care Unit. What a combination of services. A fifteen-year-old youth named Eddie B was flown in by helicopter; he was in a www.sfms.org
coma. I never had the opportunity to speak with Eddie, for he never woke up. As the junior member of the team, I only had seniority above the medical students. I spent many hours with Eddie’s family, especially his mother. The medical history was fairly simple: Eddie had been diagnosed with varicella earlier in the week, and his mom, a good and caring parent, had given him aspirin for the fever. The family was distraught, asking so many questions and looking for answers. We did not have an answer for this family in that year. There was an article a few years previously in Lancet, by a Dr. R. Douglas Reye, noting that liver failure and coma may linked to the administration of aspirin to children with chickenpox. In 1980, the CDC cautioned physicians and parents about the association between Reye’s syndrome and the use of salicylates in children and adolescents with chickenpox. We did not have an answer for Eddie’s family at that time, but research in medicine and giant leaps forward in disease prevention and treatment have given me much inspiration and hope in my career as a medical doctor. How can I ever forget Eddie B? Finally, I truly believe that much of life is about inspiration and motivation. I would not be writing this message if it had not been for the warm camaraderie that the San Francisco Medical Society welcomed me with in 1995, when I began as a delegate with the SFMS delegation to the California Medical Society. It was George Susens, MD, my colleague with the Permanente Medical Group, who asked me in 1994 if I would accept the nomination to be on the ballot. Indeed, many physicians held out their hands to me to join them as advocates for the physicians in San Francisco and as advocates for their patients. Their leadership inspired me over these many years to step forward into this position as president, as did the warmth and collegiality of the San Francisco Medical Society staff, in particular our executive director, Mary Lou Licwinko. Thank you, everyone, for this inspirational year in my life.
december 2009 San Francisco Medicine 7
Strength.
Mark R. Laret, CEO of UCSF Medical Center, Steve McDermott, CEO of Hill Physicians Medical Group, Dr. Sam Hawgood, President of UCSF Medical Group and Interim Dean of UCSF School of Medicine, and Dr. Thomas F. Long, Chief Medical Officer of Hill Physicians Medical Group announce a new affiliation between UCSF and Hill Physicians.
The doctors of UCSF are joining Hill Physicians Medical Group effective January 1, 2010. One of the nation’s best medical centers and one of the nation’s largest physician association are coming together to improve the future of health care in San Francisco. Independence and strength are not mutually exclusive. Hill Physicians’ providers enjoy autonomy and flexibility while receiving exceptional technological, case management, preventive care and claims processing support. That’s why so many of the best join Hill Physicians.
Your health. It’s our mission.
If you’re a physician in San Francisco, South San Francisco or Daly City and want to know more about joining Hill Physicians, contact: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com or visit www.HillPhysicians.com/Providers. Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.
Editorial Mike Denney, MD, PhD
Inspirational Moments
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y most inspirational moment in medicine occurred when I decided to become a doctor. It happened during a desperate teenage period when, having grown up under difficult circumstances during the Great Depression and then World War II, I failed the tenth grade in high school because of truancy and maladjustment. I was being sent to a correctional institution for juvenile delinquents. One late night, I came across the book Magnificent Obsession, by Lloyd C. Douglas. Intrigued, I began to read. I was immediately seized by the story, a tale about a ne’er-do-well young man who had failed in college and was a disgrace to his family. I became fascinated. The pages seemed to speak directly to me in a kind of forgiveness. I read on. In deep sorrow, the young man in the book sought help from an elderly, retired family doctor, who offered understanding and advice. I was enthralled! My heart filled with the wonderful augury that the author of the novel was speaking to me with the same advice the old doctor was giving to the young man in the story. My eyes focused intently upon the pages as I read on through the night. Inspired by the elder physician, the young man in the novel completed college, went on to medical school, then completed his residency in neurosurgery. As the first glimmer of dawn began to filter through the window, the climax of the story seemed to embrace my soul. One night the young neurosurgeon was called to the emergency room to see a woman with a life-threatening head injury. It was the woman with whom he had been infatuated years before while in college. He took her to the operating room, saved her life, and they later became man and wife. Then, it happened. Just as I finished the novel at dawn, a dazzling beam of morning sunlight suddenly streamed through the window and across the room in a shining diagonal shaft. The luminous ray was like the beams of light that might shine across the interior of a church, mosque, or temple. Its brilliance seemed to emanate a divine presence. Gazing at that light, I was awestruck. The golden glow seized me and refused to let go, and I submitted to its grasp. Then a powerful inspiration surged into my heart, and I became imbued with a clarity of spirit I had never before known. In that sacred moment I knew, deep in my heart and without question whatsoever, despite the seemingly insurmountable obstacles before me, that someday I would become www.sfms.org
a doctor. And so it was that my career in medicine and surgery began with spiritual inspiration. But, during my final year of my premedical college education, we students were offered advice on how to handle the interview process for our applications to medical school. When I mentioned my inspirational experience, the instructor said that I should never, never say in the interview that I wanted to become a doctor because of some spiritual vision or a calling from the divine. It would sound self-serving and a little too weird. I should say, the instructor admonished, that I was interested in science and wanted to apply that science to curing disease. I was confused. Why was the most important inspiration of my life unacceptable to a medical school? During the first two years of basic science, studying anatomy, physiology, pharmacology, pathology, and differential diagnosis, I learned why that instructor in premed was so adamant about objective science. Indeed, I realized that the basic ethic in medicine of “do no harm” was construed as practicing strictly within the boundaries of state-of-the-art science. But then the very first patient who was assigned to me as a third-year student on my first day of internal medicine rotation reawakened my teenage inspiration. The patient had experienced a spontaneous remission of an incurable cancer. A miracle. And none of my professors could explain how this could have happened. Over the years, like most physicians, I witnessed other extraordinary medical events—miraculous recovery from seemingly irreversible coma, unexplainable near-death experiences, amazing mind-body cures, heart transplant patients manifesting the traits of their organ donors. Most recently, my own daughter Elizabeth, who has late-stage multiple sclerosis, suffered pemphigus and sepsis, was in an intensive care unit for seven weeks, and survived. She is now at home, stronger than before the acute episode. And now, more than fifty years since graduating from medical school, I wonder about these inspirational stories. I wonder if nowadays my spiritual experience as a teenager would be acceptable as a qualification to enter medical school. I wonder about the union of science and spirituality in the healing arts. Indeed, if in our practices, hospital rounds, research, and committee meetings we opened our hearts to the possibilities, I wonder if each and every moment in medicine could be an inspiration.
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Inspirational Moments in Medicine
Inspiration and the Future of UCSF A Conversation with Susan Desmond-Hellmann, MD, MPH, Chancellor of the University of California, San Francisco
Mike Denney, MD, PhD
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n August 3, 2009, Dr. Susan Desmond-Hellmann assumed her new post as chancellor of University of California, San Francisco, the only campus in the University of California’s ten-university system devoted exclusively to the health sciences. Before being chosen for this position, Dr. Desmond-Hellmann had served for fourteen years as research scientist, then chief medical officer, and, later, president of product development at Genentech. Her career began with her MD degree from the University of Nevada and her MPH degree from U.C. Berkeley. She did her residency training at UCSF, became board-certified in internal medicine and medical oncology, and went on to serve as associate adjunct professor of epidemiology and biostatistics. While teaching and doing research, she devoted two years as visiting faculty at the Uganda Cancer Institute, studying HIV/AIDS and cancer. She also spent two years in private practice as a medical oncologist before returning to clinical research. Dr. Desmond-Hellmann was named to the Biotech Hall of Fame and received the Healthcare Businesswomen’s Association Woman of the Year award for 2006. She was also named by Fortune magazine as one of the “Top 50 Most Powerful Women in Business” and by the Wall Street Journal as a “Woman to Watch.” She was most recently named by Forbes magazine as one of the “Seven Most Powerful Innovators.” Recently we caught up with Dr. Desmond-Hellmann when she served as keynote speaker at the annual awards dinner for the UCSF Association of Clinical Faculty. During her presentation, she
now. Secondly, our teaching and research today, whatever our field of interest, can continue to affect others long after we’ve moved on. I find that very inspirational— that the results of our work will be long lasting.
SFM: In your speech you also emphasized the importance of your clinical work both in the U.S. and abroad, and how it served as the foundation of your work, in research and now in this top UCSF administrative post.
spoke to the gathered practicing physicians of San Francisco about her priorities for the future of UCSF, and she agreed to meet with us to say more about that.
SFM: In your speech at the clinical faculty dinner, you talked about the inspirational aspects of medical education. Can you elaborate on that?
Desmond-Hellmann: When I use the word “inspiration,” it means two things to me—first and foremost, I want the students at UCSF to be inspired by their educational experience. I want them to understand how important their work is, to know what an honor and a privilege it is to be a health professional, and to be inspired by the individuals with whom they interact. During my own nine years as resident, fellow, and faculty at UCSF, my mentors and colleagues were deeply inspiring for me, and I wish the same for the upcoming students and residents
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Desmond-Hellmann: Yes, maybe it’s just me, but when I think of inspiration I tend to think of individual patients. The most inspirational moments I’ve had in medicine, particularly as an oncologist, have been from patients in my care whom I was very worried about. And yet, in their resilience, there shined hope for the individual and the family. I also receive inspiration from seeing students and trainees doing good work with seriously ill patients, and I admire their capacity to learn and to experience the depths of their work.
SFM: You also expressed gratitude for the many volunteer local physicians who teach and provide leadership for the students and trainees.
Desmond-Hellmann: Yes, someone had mentioned that the many, many hours of teaching by clinical faculty that take place at UCSF would amount to millions of dollars every year. Yet the doctors of San Francisco continue to volunteer their time and expertise in the spirit of mentoring the doctors of the future. More important, www.sfms.org www.sfms.org
I think, is that for students and trainees to work with these volunteers is a blessing that is irreplaceable. It provides a window into what it will be really like to care for patients and their families outside the halls of academia.
SFM: One thing that was notable to others as you spoke is that your story, your career in medicine itself, might be inspirational to others.
Desmond-Hellmann: It’s interesting to hear that comment because, frankly, I have never seen myself that way. But it makes me wonder if maybe I could be inspirational to students and trainees, especially women, for obvious reasons. Maybe some of them might think, “Well, maybe I could be a research scientist, or maybe I could be a chancellor someday.” Not having seen many women in leadership roles during my own training, it’s gratifying to think that I might inspire others. SFM: In addition to education, you cited other priorities in your ongoing work as UCSF chancellor: patient health foremost, followed by discovery and research, the business management in these financially changing times, and people and personnel management. This people-priority, you said, includes an emphasis on diversity.
Desmond-Hellmann: Yes, and it comes down to asking, “How will we train our students?” They come from a wide variety of backgrounds, especially here in California, where the population is incredibly diverse. And our patients are also from many different backgrounds. So that only by having diversity among our medical staff, employees, trainees, and students can we effectively serve the medical needs of our communities. Each individual brings her or his own talent and point of view, so what an opportunity it is to learn from people who are different than you.
of them embodies some kind of inspiration in order to be effective.
Thank You!
Desmond-Hellmann: Absolutely. Every one of my five priorities—clinical care, research, education, people management, and fiscal responsibility—can have an impact on outcomes. And, for example, in the current debate about health care reform, we can find ways to use innovation more effectively to improve health and lower costs.
SFM: Certainly, as UCSF chancellor, you will be called upon personally to deal with all of these priorities.
Desmond-Hellmann: Yes, I sometimes remind myself of how fortunate I am and how honored as a health professional I feel to be able to come to work and participate in these priorities. It is an enormous privilege to be a physician. SFM: Dr. Desmond-Hellmann, let me ask: Did you have a particular inspiration that motivated you to become a physician?
Desmond-Hellmann: Yes, it was my father, who was born in San Francisco. He has been a pharmacist all his life, and he ran a family-owned pharmacy in Reno when I was growing up. And I remember very, very distinctly my father worrying about his patients who were very ill, making sure that they got their medications and used them appropriately. I would hear him talking to them on the phone, making sure that they understood. I was totally inspired. Later when I was in college and medical school, my mom would say, “You’re getting to be just like your dad.”
SFM: As one contemplates all of your five priorities, it appears that each
www.sfms.org 11 San Francisco Medicine December 2009
The San Francisco Medical Society, and in particular the editorial staff of San Francisco Medicine, would like to thank outgoing editor Mike Denney, MD, PhD, for his work over the past four years. Dr. Denney’s contributions to San Francisco Medicine have helped take the journal to a new level of quality and depth. It was a pleasure working with him, and he will be missed! Photo by SFMS staff photographer Ashley Skabar, 2008.
december 2009 San Francisco Medicine 11 www.sfms.org
Inspirational Moments in Medicine
Inspiration in Uganda The Resilience of the Patients Leaves a Lasting Impression
Nancy Griffith, MBA, MS, NP
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n 2003, I left a successful career in business to pursue a lifelong dream in global health care. I returned to school and got an MS degree in psychiatric health care and began working with survivors of torture who were seeking asylum in the United States. My dream was not only to work with vulnerable populations in the U.S. but also to work in third world countries on short-term assignments. I was fortunate enough to be contacted by Health Volunteers Overseas (HVO), which asked me to develop a graduate curriculum in psychiatric health care for the department of nursing at Makerere University in Uganda. I left for Uganda on September 2, 2009, looking forward to my first overseas assignment. September 4: As we approached Entebbe airport, I was struck by the beauty of the verdant, hilly landscape, partially shrouded in a low, hanging mist. Once on the ground, I was met by a driver sent by HVO, who drove me to my accommodations at the guesthouse in Kampala, the capital. The guesthouse is very close to Mulago Hospital and Makerere University. September 9: The Mulago Hospital wards are simply large rooms with as many beds crowded in as possible. Patients have no privacy—not even a curtain is pulled when doctors and residents round. Many patients are critically ill and would be in an ICU in the States, but that is not an option here. Patients and their families have to buy any medication the doctor prescribes and pay for any lab tests, X-rays, and scans. Most can’t afford this, so they are sent home to die eventually from whatever brought them to the hospital in the first place. This lack of access to health care, along with malnu-
trition and AIDS, account for an average lifespan of fifty-two years. For the few who can afford to pay, the medications are ones that have been around many years. Lab tests are not very accurate, nor are procedures. Universal precautions such as regular hand washing or use of Purell by the staff are not the standard here. However, they do the best they can with what they’ve got. Anesthesia is often ether or some other medication not commonly used in the United States anymore. There are only eleven anesthesiologists in the entire country of close to thirty-two million people, so this responsibility often falls to RNs. A man whose jaw was crushed, his lower lip severed, and his hard palate split in two as a result of an elephant attack finally had a six-hour surgery yesterday after waiting a week. He had to wait because he could not afford the operation. Someone from another NGO got wind of this and wrote an article in the paper pointing out the government’s neglect in providing coverage for someone in such desperate shape and agonizing pain. Embarrassed by the negative publicity, the hospital finally admitted the man for surgery. Knowing the extent of his injuries, we were all amazed he had survived the prior week. September10: At the invitation of a volunteer MD, I went on rounds this morning in the cardiac pulmonary ward. Patients had uncontrolled hypertension, HIV, chronic heart failure, arrhythmia, pneumonia, diabetes, and strokes. Most have five out of the seven mentioned. Comorbidities are commonplace. I noticed a beautiful young woman a few beds away being cradled in the arms of her husband.
12 San Francisco Medicine December 2009
She had suffered a massive stroke on her left side. She needed heparin to help prevent future strokes but couldn’t afford to pay for it. Knowing she would be discharged without the life-sustaining medication she needed, like the other two women we had just seen, I left before rounds ended. It was truly heartbreaking, knowing the fate of these brave souls. Later in the day, I interviewed a nurse who was from Lira, in the north, where the Lord’s Resistance rebels had been. She did a research project last year, interviewing many young women who were kidnapped and raped in their early teens by the rebels. They were held captive by the soldiers and mutilated if they did not respond to questions posed by their captors. If they were accused of not listening, their ears were cut off. If they gave a wrong answer or no answer at all, their lips were either severed or clamped shut. In spite of reconstructive surgery, they are still very disfigured and have little chance to ever lead normal lives. Yet they have been accepted back into their local villages. September 11: Received an e-mail warning from the American Embassy that riots had broken out and were anticipated to continue through the weekend. We were warned to stay at the guesthouse or in the hospital, as we were in earshot of gunfire. President Museveni did not want the King of the Buganda tribe to travel throughout the capital to visit his people. The Bugandans gathered in protest to support their king. Consequently, the president’s soldiers opened fire with their AK-47s, shooting into the crowd of demonstrators, killing and wounding many. September 12: I went with several www.sfms.org
volunteers, an orthopedic surgeon from Sweden, and a dentist and dental student, to the hospital this morning to see if there was anything I could do to help. The place looks like a war zone. Families are camped on every available bit of floor space, waiting to see their loved ones. The operating theaters were going all night and more wounded continued to flow in. Everywhere one looks, there are acute cases waiting for treatment—many are lying on the floors due to a shortage of gurneys and beds. I went to look in on a thirteen-yearold boy who had climbed a tall tree to escape the rioters yesterday but fell. A neurologist was called because the boy was bleeding from his ears and came in unconscious. However, the neurologist didn’t want to work late, preferring to go home. Thank heaven for the volunteer docs who managed to keep the boy alive through the night! He had a major fracture of his femur, a broken wrist and shoulder, and a fractured jaw. The doctors were only able to temporarily set the leg and try to stabilize him by manually ventilating him all night. Matthew, a local dentist, wired his jaw back together last night, but it didn’t hold. He was on morphine, which was reducing some of the pain, but definitely not all, as he was writhing around in an attempt to release the restraints holding his arms and legs. His condition was too precarious, so surgery would have to wait. The head ER doc told the staff to ignore the rule of not getting X-rays or treating unless the patient could pay. We were glad to hear this, as the doctor sitting in one of the temporary ICUs told us we couldn’t get a brain scan on the young boy unless his family had the money to cover the procedures. September 22: Visited the Acid Survivors Foundation (ASF), which was started in 2003 to help acid survivors cope with their trauma and disfigurement and to raise public awareness to help integrate these people back into their communities, implement what would be equivalent to a “neighborhood watch” program for the purpose of monitoring the sale of black market acid, and to provide legal aid in an attempt to prosecute www.sfms.org
the perpetrators (thirteen have been tried since 2003, receiving anywhere from one month to twenty-five years in prison). Because the survivors are so disfigured, they are often ostracized and are ashamed to be seen even in their own villages. There are several motivations for this sort of crime: A husband or boyfriend suspects his wife/girlfriend of infidelity, a woman is jealous that her boyfriend is dating another woman, or disputes arise related to property and business matters. Acid crimes generally take place when it is dark and a family is gathered around the outdoor dinner table. The perpetrator then sneaks in under cover of darkness and throws the acid in the face of the victim. Even more tragic is the fact that mothers who are targets are often holding their babies, so they are also burned. The ASF is trying to educate victims and their families that dousing the face with cold water immediately can sometimes prevent the acid from eating through to the bone. Those who are able to make the journey to Mulago Hospital are treated over a period of two to three months and then return for plastic surgery, which can help reconstruct destroyed bone and cartilage but little else. Those who have sustained eye injuries receive the surgery they need to save at least partial vision if possible. The cost of medical care is assumed by the government, but that is changing. Only those who can pay will receive treatment, which means most won’t. September 24: I met Jude, the psychosocial counselor, and Samson, the legal counselor, both from ASF, at Mulago Hospital’s burn unit. We were there to see a middle-aged Muslim man who had acid thrown on him a week before. Three of his subordinates at the hospital where he worked were jealous of his position and tried to slander him to his boss. Consequently, all three were fired, as the boss knew he was a good employee. Seeking revenge, one of the three fired men got his brother and another man to throw acid on him on his way to pray at the mosque. Luckily, he had seen a notice in his village (thanks to the ASF) that clean, cold water should be poured on acid burns. He ran to a neighbor who helped him and then
took him to a local hospital. He was then transported to Mulago Hospital to get the treatment he needed. When I met him, he was awake and able to talk. He is a handsome man with a beautiful smile. Only part of the left side of his face was burned, but the worst damage was to his throat and upper chest. Skin had been grafted from his thigh in order to close the gaping wound in his neck and on his chest. Apparently, it will take a week or so to see if the graft is successful. He will remain in the hospital for several weeks and has a caretaker and family who come and attend to him. September 26: As my return flight took off from Entebbe airport, I gazed out the window for a last look at the beautiful night lights dotting the hills of Uganda and reflected on my stay here. In spite of all the hardship and suffering I had seen, I couldn’t help but be inspired by the people and beauty of this country. The Ugandans are friendly and polite people. During my entire stay, I never heard a voice raised in anger among the locals, although so many lived in crowded conditions and abject poverty. I felt no sense of entitlement but a benign acceptance of the way things are and a work ethic that seemed to prevail throughout the country. The tenacity with which the thirteenyear-old boy and the man mauled by the elephant clung to life against all odds, and the acid survivors returned to their villages to lead productive lives, are testimonies to the resilience of the human spirit. Most of all, I will forever relish the images of the local women laughing together and the camaraderie of the men, young and old, as they went about their daily lives—their smiling faces permanently imprinted on my mind. Nancy Griffith is a psychiatric nurse practitioner who works with survivors of torture and trauma in the Bay Area.
december 2009 San Francisco Medicine 13
Inspirational Moments in Medicine
Sharing the Gift of Life A Student Finds Inspiration in the Operating Room
Eisha Zaid
1
0:20 p.m.: I was early. I was told to wait for a nondescript black van. As I stood at the hospital entrance curbside, I anxiously rechecked my pager to make sure I was at the right place, looking up intermittently at any sign of headlights piercing the heavy fog. It was cold; the first rain in many months was starting to fall. 10:30 p.m.: The van finally arrived, on time. I was joined by the other resident surgeon and the transplant fellow. If there is one thing I have learned during my surgery rotation, it is to always be the first one there, which means always being early. ***** Having spent more than a month in surgery, I had learned how different surgery is from the other medical services I had come to know. The hours are longer and more physically demanding; you are on your feet the whole time. As a student in the operating room, you move when told to move, or you stand and watch. It is paralyzing when you are called on to do something. Time stops, as everyone waits for you to complete your task. You pay close attention to detail to make sure you do your task correctly—be it cutting suture, driving the camera during laparoscopic cases, suturing skin, or retracting tissue. Whatever the task may be, you always find yourself fixated on the smallest details. Surgeons, by nature, are perfectionists. And in many ways, surgery is ritualistic, with scrubbing, draping, cutting, dissecting, and suturing. It is perhaps this close attention to detail that makes surgeries successful. The end goal of improving your patient’s health and quality of life represents
a unifying theme throughout all fields of medicine, but the approach is different in surgery. Once surgeons identify a problem, they are motivated to act, one way or another—whether it means operating or electing not to operate. ***** 10:50 p.m.: The ride was bumpy. The rain was starting to fall more heavily as we made our way along the Bay Bridge. The only information I knew was what had been communicated to me through a page I received earlier that evening: “There is an organ procurement tonight. Pickup is at 10:30, Moffitt Hospital.” I would later find out that we were heading to a hospital in the East Bay to harvest organs from a patient who had been proclaimed brain-dead earlier that day. ***** Surgery is a unique practice. By performing surgery, you become acquainted with your patient’s anatomy and you use your hands to fix a problem, whether it is a hernia, enterocutaneous fistula, bowel resection, or organ transplant. Postoperatively, you see how your patient regains bowel function, has improved pain, and starts eating food. The transition can be rewarding when you see your patient discharged in good condition. In the process, you develop special relationships with your patients. It can also be frustrating when your patient does not improve and remains hospitalized, and you are left to wonder what went wrong. ***** 11:24 p.m.: We arrived at the hospital. We quickly unloaded the van and made our way inside, where we were intersected by the surgical nurses, who directed us to the
15 San Francisco Medicine december 2009 14 San Francisco Medicine December
operating room. We traded our blue scrubs for the hospital’s green scrubs and waited for the donor. The donor was wheeled in to the sounds of beeping monitors. On the nurse’s count, we transferred his heavy body to the operating table. As he was positioned on the operating table, he was untangled from the wires and monitors. His dark skin was dry and cold, with areas of scaly skin patches that the nurse flicked off the table. His abdomen was distended and soft. He had a full face with lots of dark freckles; a tube was coming out of his mouth. He had a dejected look on his face. His eyes were closed and framed by wrinkles; dark bags sat under his eyes. I left to scrub for the operation. I had scrubbed many times before, but as I washed my hands, it felt different. Our donor was brain-dead, but his heart continued to beat and his body remained perfused. We were performing an entirely different type of operation. Rather than repairing this patient’s body, we were going to remove his liver and kidneys. ***** The hours on surgery are long. And you work hard. Despite the challenges (namely lack of hours in the day to sleep), there is something special about taking care of patients through the entire surgical process. Patients and families place their trust in you; the patient’s life is in your hands. You are given permission to cut another human being open and manipulate an individual’s organs with your hands and with instruments. In the process, we depersonalize the operation. We drape our patients in blue sheets to create a sterile field, covering the www.sfms.org
face. The anatomy becomes the focus; the body becomes a vessel of parts we navigate through. We cut, tie, and suture. ***** 1:30 a.m.: The patient was exposed on the table. The blue drapes were folded across his body; his face was completely out of our view. His abdomen was left uncovered, stained orange from the prepping solution. After the time-out was called, the fellow proceeded to make the first of a series of cuts, which would provide the best view of the internal anatomy. There is something incredible about a fully perfused body. The thorax was first exposed, revealing a glistening heart rhythmically beating. A thick yellow mesentery covered the abdominal viscera. As the fellow made his way through the abdomen, I retracted and held back the small bowel to improve his view. He meticulously dissected away the fat and tissue to free the liver. I pulled the liver back, holding the dark brown organ in my hands. One by one, the organs were dissected and cut out of his body. I remember holding the heart in my hand, still warm and pink. I ran my fingers through the four chambers, feeling the more muscular left ventricle and the stiffness of the aorta. We had done the same exercise in anatomy lab, but this time, the heart in my hands was fresh and had just been beating. 2:55 a.m.: The liver was removed. 3:10 a.m.: The kidneys were removed right after. The whole experience was surreal. I received my best anatomy lesson that night, as we dissected away organs. At the same time, I felt disconnected, reminded of the questions I had asked as a first-year medical student during anatomy lab. We knew nothing about the donor, except his cause of death. A couple of days prior to operation, he was a member of the same society we live in. He had lived a life and had stories he could tell us. He probably had a family, who would mourn for him. No matter how I justified it, I could not forget the reality of what we were doing. As I wondered about the human underneath the drapes, I remembered we were fulfilling his wishes (or his family’s wishes). He www.sfms.org
would die, but his organs could save lives. ***** Transplant surgeons are some the hardest-working physicians I have known. They work unpredictable hours, perform technically demanding operations, and are at the mercy of phone calls that deliver the news about potential organ procurements. They travel in the middle of the night to harvest organs, which are then transplanted into the recipients. When I spoke with a transplant fellow about how he balances his life, he responded with a simple answer: “There is no balance.” Despite the challenges, transplant surgeons find their careers to be rewarding. They are part of a multidisciplinary team of medical specialists, social workers, pharmacists, nurses, and coordinators who work together to save lives and bring hope to families. The halls of the ninthfloor transplant unit at UCSF are adorned with photographs and thank-you cards addressed to the transplant teams. I have heard from many transplant surgeons about how organs truly represent
“the gift of life.” With more than 100,000 people waiting to receive an organ, many patients will die waiting. I admire the dedication and commitment of transplant surgeons. Any one of us could find ourselves or a family member on that waiting list. It is reassuring to know there are physicians who will work to share the gift of life. ***** 4:40 a.m.: The remaining organs were placed back into his body. The fellow handed me the needle driver loaded with heavy suture and instructed me to close the midline incision we had made. I took the instruments and, stitch by stitch, closed his body. The blue drapes were removed and his body was placed in a white bag. I zipped the bag closed. With the liver and kidneys bagged and placed on ice, our team walked away and set out back to San Francisco in the black van. Eisha Zaid is a third-year medical student at UCSF and is the 2010 recipient of the San Francisco Medical Society’s David Perlman Award for Excellence in Journalism.
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Inspirational Moments in Medicine
All This Joy, All This Sorrow A Doctor is Inspired When Patients Share Their Stories
Shieva Khayam-Bashi, MD
I
t was a moment that changed my perspective and my life. All from a song and a dance. I had just completed my three years of residency and was feeling exhausted, battered, and war-weary from all of the suffering of so many of my dear patients with serious illnesses. Cancers of all kinds and stages, various traumatic amputations, sudden paralysis, disfiguring burns and other serious injuries, debilitating strokes, heart failure, kidney failure, lung failure, brain abscesses, and rare and incurable diseases of all kinds. I had learned so much in these three years, by sharing and bearing witness to the pain and sorrows of so many. I had learned even more from the spirit of joy and love and peace that survived past the pain. Always astonished, I had watched many people as they even seemed to thrive, in spite of (or maybe because of?) the suffering. I knew that surviving and thriving were possible after suffering, but I just could not make sense of the need for suffering to be the catalyst. Of course, with my patients I “dealt with” suffering, but deep inside, I resisted it and I hated it. Why pain? Why suffering? I just could not understand. First, there was silence. Then, a beautiful African-American cancer survivor, dressed in a black dance leotard and beautifully colorful scarves, came out onto the stage. She smiled a warm and loving smile, and she bowed to the silence. Then the clear and crisp sound of John Denver’s pure and resonant voice filled the auditorium, as if he and his piano were right above us. The dancer glided across the stage, smiling widely as her elegant scarves blew behind, in her breathtak-
ing interpretive dance to these achingly simple words: All this joy, all this sorrow All this promise, all this pain Such is life, such is being Such is spirit, such is love City of joy, city of sorrow City of promise, city of pain Such is life, such is being Such is spirit, such is love World of joy, world of sorrow World of promise, world of pain Such is life, such is being Such is spirit, such is love All this joy, all this sorrow All this promise, all this pain Such is life, such is being Such is spirit, such is love Such is spirit, such is love. From the very start of the song, the deepest part of my soul felt electrified. Goosebumps formed on my skin. I was speechless. My heart felt moved in a way that is still beyond full description. It was playing out, right before my eyes and ears, as if the entire production of the song, lyrics, and dance were specially made for my benefit. To tell me, in the most heart-reaching way, that the answer to the question: “All this joy, all this sorrow?” is “Because: Such is life. Don’t resist it, any of it. If you can first accept this for yourself and for others, then you will be free and able to help yourself and others to grow and thrive under all conditions.” Deep inside, I knew that my life had
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been changed, for my heart now understood something that my brain just could not get. In the most soul-reaching way, the song and the dance breathed into my heart the answer that I had been seeking. The only answer that makes any sense rests in the peaceful acceptance that “such is life” and that “such is being.” That, for each and every one of us, life is an artful and colorful mosaic made up of countless joys as well as many sorrows, a blending of the light of promise as well as the shadow of pain. Life is not meant to be all joy—nor is it, thank goodness, meant to be all sorrow. Our challenge is to accept all that comes and to try to thrive, and help others to thrive, in all that happens. How I came to experience this moment of inspiration can be described only as serendipity. In that summer after residency, I was seeking answers to these hard questions of pain and healing, hope, and thriving out of suffering. Needless to say, I was moved deeply when a nurse handed me a brochure that announced an upcoming conference by Healing Journeys (www.healingjourneys.org) called, believe it or not, “Cancer as a Turning Point: From Surviving to Thriving.” As if it came directly out of a genie’s bottle, the brochure spoke precisely to what my heart so ached for. It said, “Healing Journeys is a nonprofit organization whose mission is to support healing, activate hope, and promote thriving. Our vision is that everyone touched by cancer or any life-altering illness be empowered to move from surviving to thriving.” I was flabbergasted that such a thing existed, and that I would learn of it at a time when I so deeply ached for some Continued on page 18 . . . www.sfms.org
Inspirational Moments in Medicine
Amazement and Wonder Stories from an Oncology Social Worker
Rachel Orkand, MSW
I
love dinner parties, and I think I’m a very good dinner party guest. I bring a nice bottle of wine, eat everything, and generally make lively conversation. But inevitably the moment comes when the stranger across the table, the friendof-a-friend, asks me the question, “What do you do?” I gear up for the response as I say, “I’m an oncology social worker,” a response that always goes one of two directions. Response one: “Wow. That sounds like a really hard, depressing job.” Response two: “Wow. You must be a saint to do that kind of work; you are so amazing.” For years I have attempted to craft an adequate response, to explain that I am neither a martyr nor a saint, but in reality a very normal person who is lucky to do what I do. If I were quicker on my feet, what I would say is this: I do this work because I get to be inspired every day. I do this work because at this point it’s hard to imagine what my day would be like if it wasn’t filled with little moments of amazement and wonder. Those moments are equally matched by encounters with frustration and sadness, by a constant recognition that life and death are unfair, that there are never enough resources to help all those in need. But I can’t, at this point, imagine a career that didn’t make me feel this much. A few months ago, my patient Anna lay in bed, awaiting her ambulance to take her home to die with hospice care. She was a beautiful Filipina woman, a former stewardess, who had refused to meet me for the first months of her illness. When she came to clinic, she rebuffed my approaches, stating, “I don’t need a social worker, I’m doing just fine.” Her practical www.sfms.org
needs finally bought me entrée into her world with, first, her mountain of disability paperwork and then her growing need for assistance at home. But it was always on her terms. In that hospital room, a
“I do this work because I get to be inspired every day. I do this work because at this point it’s hard to imagine what my day would be like if it wasn’t filled with little moments of amazement and wonder.”
year later, I got ready to say good-bye and asked her, “Anna, is there anything else you need?” Her massive eyes, so round and gorgeous, seemed to have taken over her face in those last months, as the cancer spread throughout her emaciated body. She had just had a stroke, and her speech was slurred. She stared up at me, and then spread her spindly arms wide, and smiled the sweetest smile imaginable. “A hug?” she asked. And I leaned down, and those skinny arms squeezed me so tight, with a strength that seemed unfathomable from her broken body. And I held her for a long time. Or maybe she held me. It is hard to pin down inspiration. The act of being inspired is, by definition, the “act of moving the intellect or emotions.” It is also defined as “a divine influence or action on a person believed to qualify
him or her to receive and communicate sacred revelation.” Intellectual inspiration is what most people hope for in their professional lives—that deep satisfaction of feeling curiosity and accomplishment, of solving a problem or seeing a problem solved that was thought beyond reach. But I don’t think most people go to work each day expecting their emotional world to be rocked. They don’t wake up and imagine that they will see faith and hope that they only dream of possessing. Carol died a month after Anna. I don’t like to think of dealing with cancer as a war, but for many it is, and Carol fought her cancer for two years as ferociously as the greatest military general. I heard several doctors describe her as “in denial.” A nurse told me, “She just won’t accept that she’s dying.” But Carol was in no denial; she simply acknowledged death by her side, envisioned the heavenly gates she would enter, and then kept on fighting. Carol planned her funeral, appointed her power of attorney, and went to visit her grandchildren. She did all these things with such an extreme positivity, a deep faith in her God and a belief that she would live as long as she was meant to live. And until that point, she would fight and hope and love those around her, and not sit down and wait to die. I asked Carol once if, as she lay in that hospital bed, she was thinking about the past. She was silent for a moment, then replied, “No, I had a hard past, a horrible past. I am thinking about now, and the future.” She had relegated abuse and poverty to the dark corners of her brain and instead lay in that bed, suffering from terminal cancer, but joking with friends and providers.
Continued on the following page . . .
december 2009 San Francisco Medicine 17
Amazement and Wonder Continued from the previous page . . .
She died at home, three days later, just as she planned. She snuggled with her dog, read her Bible, and all day friends and church members sat by her side, until she was gone. Carol lives in my heart, as do Anna and dozens and dozens of other beautiful people. They are people most of my friends and family wouldn’t ever have met. They are poor, or they’ve been in prison; they speak Spanish and Arabic and Tagalog; they live in SROs in the Tenderloin. They deal with more hardship and challenge, in their living and dying, than most people I know will ever encounter. Yet I, like everyone, lose sight of how lucky I am in this world. I get grumpy when sitting in bad traffic, snap at my husband for no reason, and have days when the size of my thighs makes me incredibly unhappy. But in those dark moments, I often hear voices—not ghosts, but little voices deep inside me, a chorus that sings, “You get to live. You have to live.” I remember Anna’s selflessness and the strength and independence that never left her; I remember Carol’s smile and hope, her faith in goodness and friendship. And Ruby’s grace, and Winston’s sense of humor, and Pablo’s anger at the injustices of the world. I hear these voices, and blast beautiful music and sing out loud, and call my best friend on the phone and cry at how lucky we are to be alive and have each other. I’m not sure what more I could ask for. I will try to say all this at the next dinner party I am invited to. But I also might just smile and say, “I am lucky to have my job.” Rachel Orkand, MSW, is an oncology social worker at San Francisco General Hospital.
All This Joy, All This Sorrow Continued from page 16 . . .
help. The entire weekend conference was amazing (and completely free to all)—an auditorium filled with more than a thousand cancer patients and their supporters, and health care professionals as well, all convened to share a weekend full of wisdom and meaning and hope in the form of entertaining “healing stories” by witty and articulate cancer “thrivers” (not just survivors!), and others who shared hope and healing by way of music, art, humor, and educational lectures. The free two-day conferences are still held annually and are full of inspiration, education, celebration, and empowerment to the mind, heart, and spirit of all who attend.
I always recommend them highly to all of my patients and colleagues, as a source for innumerable moments of inspiration. My perspective on life changed in that moment at the conference, when I watched the dancer and heard the song, and as I took it all in with my heart. Truly, I cannot thank them enough for inspiring my life with the deeper wisdom that I so needed. Moments of inspiration come in all forms. For me, it all came from a simple song and a beautiful dance. Shieva Khayam-Bashi, MD, is director of the Short-term skilled nursing facility at San Francisco General Hospital.
SFMS 2009 Election Results 2010 Officers - for one-year term: President-Elect: George A. Fouras, MD Secretary: Peter J. Curran, MD Treasurer: Keith E. Loring, MD
2009 President-Elect, Michael Rokeach, MD, will automatically succeed to the office of President. 2009 President Charles J. Wibbelsman, MD, will automatically succeed to the office of Immediate Past President. Board of Directors (seven elected for threeyear term 2010-2012): Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Shannon Udovic-Constant, MD Joseph Woo, MD
Nominations Committee (four elected for two-year term 2009-2010): Jane Fang, MD Robert G. Gish, MD Kimberly L. Newell, MD Mark J. Savant, MD Young Physicians Section Delegate (twoyear term 2010-2011): Dawn L. Rosenberg, MD
CMA Trustee (three-year term Oct. 2009–Oct. 2012): Robert J. Margolin, MD
18 San Francisco Medicine december 2009
AMA Delegate (two-year term 2010-2011): H. Hugh Vincent, MD AMA Alternate (two-year term 2010-2011): Robert J. Margolin, MD Delegates to the CMA House of Delegates
(First four are delegates; next five are alternates. George A. Fouras, MD, President-Elect, will serve as the fifth Delegate according to the SFMS Bylaws. Two-year term 2010-2011):
Delegates Gary L. Chan, MD Stephen E. Follansbee, MD George P. Susens, MD Charles J. Wibbelsman, MD Alternates Leslie M. Lopato, MD Rodman S. Rogers, MD Judy Lynn Silverman, MD Peter W. Sullivan, MD John I. Umekubo, MD
www.sfms.org
Inspirational Moments in Medicine
Guiding a Young Physician John Callander, MD, Reflects on the Teachers That Inspired Him
Ashley Skabar
W
hen we inspire someone or take the time to listen to them and help them, it may seem like a small gesture, but we can never know how many people that small gesture will eventually affect. This is what I was thinking as I spoke with Dr. John Callander about his life and the people who inspired him to practice medicine and grow into the generous teacher, surgeon, father, and volunteer that he is today. The son and grandson of physicians, John Callander spent the younger years of his life watching the art and practice of medicine; as a teenager he attended surgeries with his father. So it was no surprise when he decided to attend medical school as a young adult and then practice as a general surgeon, as his father did. During medical school, however, Callander met with some resistance. He was born with an incurable hearing disability, and although he had attended lipreading classes throughout his grade school education in San Francisco, he was unable to listen with a stethoscope to make a diagnosis. “I couldn’t operate a stethoscope,” Callander tells me. “I was at Johns Hopkins Medical School, and they told me, ‘You can’t learn physical diagnosis without the ability to use a stethoscope.’ But then I met Helen Taussig, who was at the time the head of cardiology, and she told me she could help me.” Taussig herself had been afflicted with a severe hearing disability and had learned to feel vibrations in place of hearing them through a stethoscope. She took a special interest in Callander and taught him to complete a physical diagnosis with the use of an amplifying stethoscope and www.sfms.org
through feeling instead of hearing. “She really helped me early on,” Callander says. After Callander graduated medical school, the U.S. was at war. Callander
“Beyond the people who have guided his journey, another source of inspiration, according to Callander, has been the simple gratification coming from helping others.”
tried to enlist in the air force, but he was initially rejected because of his hearing disability. “[But] when they found out I was a physician,” he says, “they allowed me to enlist, so I joined the air force before opening my practice.” After he returned from the service, Callander practiced as a general surgeon. Then he transitioned into orthopedic surgery at the insistence of Dr. Bost, who, as Callander put it, was “very persuasive. After meeting him, I didn’t have a choice. It’s what I did.” Since then, Callander has spent a lifetime finding ways to offer himself and his skills in orthopedic surgery to his community, volunteering for organizations such as the San Francisco Free Clinic, the Muscular Dystrophy Association, the Guardsmen, San Francisco Boys and Girls Clubs, the Police Athletic League of San Francisco, and a long list of other chari-
table organizations. Beyond the people who have guided his journey, another source of inspiration, according to Callander, has been the simple gratification coming from helping others. “That’s what really turns me on,” he says, after detailing a trip to Guatemala during which he and his son, Dr. Peter Callander, spent several weeks helping children with severe orthopedic problems. He then went on to describe another project, which began this past October, that teaches low-income children in Hunters Point in San Francisco to grow their own food and cook healthy meals for their families. “It’s inspiring teaching someone to do something and watching them do it,” Callander says. In addition to his part-time practice as a physician, his dozens of volunteer community commitments, his roles as father of six and grandfather of eighteen, he is also a teacher. Many years after learning how to “hear” from Dr. Taussig, Callander now teaches students how to listen. “I tell students to use their eyes and their ears, to depend on looking, listening, and feeling.” At this point in our conversation it becomes clear that Helen Taussig—along with Dr. Bost, Callander’s father and grandfather, and I’m sure many others— are still inspiring and guiding young physicians today through Dr. John Callander, who has his own story of inspiration to share. “It’s a long life,” he laughs. “I started orthopedics in 1949, and here I am, sixty years later, still going and staying busy. Really, my story is that if you have a problem, you can get over it and do a half-decent job.”
december 2009 San Francisco Medicine 19
Inspirational Moments in Medicine
“Please Don’t Do This To Me!” Learning from Unplanned Events
Shieva Khayam-Bashi, MD
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h, no! Please don’t do this to me!” Nadine was rounding on her patients early in the morning, but running late to meet her team for morning report at 7:30 a.m. Ready to see her last patient, she collected Mr. Jones’s vital signs and his lab results, and she was sure that when she peeked in on him, he would say he was fine, as always. But this time, when she said from the doorway, “Good morning Mr. Jones, you’re doing well, right?” he did not say his usual, “Yep, I’m keeping out of trouble, Doc!” Instead, he was sweating profusely as he clutched his chest and said, “Doc, my chest! I can’t breathe!” As the first-year resident recounted the story at rounds, Nadine told us honestly that she was ashamed to realize that her first thought was, “Oh no! Please don’t do this to me! I don’t have time for you to be having chest pain! I am already late as it is, and I have too much to do!” Of course, she did not give voice to these self-centered thoughts. Instead, she quickly did all the right things: getting help, vital signs, nitroglycerin, oxygen, EKG, blood work—and, of course, comforting Mr. Jones with a concerned but calm tone. As she told us the story, we all laughed, because we knew what she felt—his terrible chest pain, his frightful shortness of breath, and, we learned later, his heart attack. It is clear that the one who was having something “done to him,” something very bad, was Mr. Jones. But his problem became his doctor’s problem too. She felt that it was being done “to her” too, at least in the form of this unexpected stress and work, which were not in her plans for the morning. She knew that,
really, she should have felt sorry for him, not for herself. Sadly, we all understood her self-centered perspective, and we had to laugh at ourselves for it. Yesterday, I learned from a colleague that one of our favorite peers had an exceedingly large, malignant tumor removed from his brain two months ago, and that he is now living in an assistedcare facility to recover from surgery, chemotherapy, and radiation. His prognosis is very grim. I felt deeply saddened, for I have always known Gordon as a uniquely energetic, independent, and happy man. I went to see him today, hoping he would be better than I knew he would be. When I saw him, his fifty-year-old face and body looked like a hundred, and he had lost much of his memory, had trouble with speech and finding words, and is now a shell of his usual vibrant self. I felt terribly sad for him. Surprisingly, what I felt inside was, “Oh no! Please don’t do this to me!” This time, the feeling had much less to do with being presented with unexpected work—although, I have to admit, there is much emotional and spiritual work that I know lies ahead for me to do. It is sometimes very hard work to offer reliable, openhearted presence and loving support while helplessly watching the suffering and progressive decline of a friend as he is dying. This time, I felt that the “please don’t do this to me” feeling was not just about the hard “work” that I wish not to have to do, or about the sadness that I now will have to endure again. The feeling of this happening “to me” comes from a much deeper place than the fear of having to do a great deal of hard work. This will sound strange, but, in that deeper place,
20 San Francisco Medicine December 2009
I somehow often feel as though it really is happening to me. At the least, I often see and feel how it could actually be happening to me, or to you, to any one of us. Naomi Shihab Nye wrote in her poignant poem, “Kindness:” Before you learn the tender gravity of kindness, you must travel where the Indian in a white poncho lies dead by the side of the road. You must see how this could be you,how he too was someone who journeyed through the night with plans and the simple breath that kept him alive. The truth is, we all journey through our days and nights with plans. And, one day, our plans for living can be changed by something—something unplanned, like a massive heart attack. Or brain cancer. Something terrible and unplanned could happen to any one of us. And when it does happen to one of us, “You must see how this could be you.” I think this is why I always seem to feel deeply the pain of people whom I see on the news—the black man being brutally beaten with a club, the woman who was assaulted and raped, the shrieking and inconsolable mother holding her dead child in her arms. I think that my instinctive plea, “Please don’t do this to me!” is a plea to God and to the Universe, a plea on behalf of every one of us, one that implores, “Please, don’t let this be happening to you, for the pain that you feel is my pain and our pain, for we are all the same.” I think the plea arises from that place of deep compassion, from that place that knows that you, me, him, her, and us are just different words for the same thing. www.sfms.org
Inspirational Moments in Medicine
Learning to be a Physician A Transitional Moment in the Career of a Medical Student
Ellen Joyce Plumb
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first met Ms. S five days before her death. I was vaguely familiar with her medical story, having heard about her for a week on daily morning rounds, when the intern taking care of her struggled to manage a flowering of medical complications stemming from metastatic uterine cancer. She was the kind of patient that I, as a student, feared—one with a medical chart over a hundred pages long, chronicling every detail of her three-month stay in the hospital. I didn’t even know where to begin. But she did. The first thing she told me was that she was scared to go home—a goal she had been working on for weeks, a goal that screamed out loudly from the multiple inspirational signs and banners placed around her bed by her family. Her family was her life, and she was scared that she was too sick to go home with them. In the morning light, I examined her, carefully and tentatively noting with my hands the grotesquely palpable curves of her cancer. At midnight, I was paged to her room. She was in pain and I heard her the minute I walked onto the ward, her moans loud and animal-like. “I don’t want to go in and I don’t know what I can do,” I thought, ignoring my newly acquired sub-internship responsibility and the authority found in my dirty and wrinkled short white coat. I viscerally experienced the sound of her pain and, once again, I didn’t know where to begin. But she did. Her eyes, pleading for relief from pain, jolted me back into the reality of who I was and what I was supposed to be doing. I was supposed to be taking care of her. I could do that—relieve her pain. It was a simple and temporary answer to her body’s first whisper against death. Both she and I slept through the
rest of the night. Over the next two days, Ms. S became increasingly agitated and uncomfortable as, I believe, a feeling of profound heaviness settled over her chest. As a medical
“I met Ms. S as a nervous sub-intern struggling with how to make sense of her medical problems, never imagining that caring for Ms. S would prove to be the most rewarding experience.”
team, we struggled to communicate her impending death to her family as they pushed back cautiously with cynicism and hope, reading aloud from a book about curing cancer while Ms. S’s breathing became more shallow and then agonal. As we waited with the family, still hopeful, I medically and emotionally understood that Ms. S would die within the hour and I wanted to scream out like a child to them, “This is it! These are the last moments you will have with her. Hold her, talk to her, tell her not to be scared, tell her that you love her.” Encased in my short white coat, I stood very still while inside I crumbled, unable to stand against the waves of evolving emotion around me, inside me—feeling the shattering sense of loss and anger and relief one experiences in the moments of the death of a loved one. In Ms. S’s face,
www.sfms.org 21 San Francisco Medicine December 2009
I saw the faces of the mothers, the friends, the grandmothers in my life who have died and I felt as if I was drowning in my own grief. I did not know what to do. But Ms. S did. I looked at her carefully, blocking out the agonizing sound of her breathing, searching her face for signs of pain, of suffering. I found none. I looked at each member of her family, their faces twisted in confusion and fear and pain. This time, the faces of Ms. S’s family jolted me back into the reality of who I was and what I was supposed to be doing. I was supposed to be taking care of her and, for Ms. S, her life was her family. Immediately, I realized that the only thing I could do to take care of her at this point was to give my entire self to the extraordinary privilege of being part of this moment in the life of a person, a family. Ms. S died in the cradle of her family’s disbelief, holding her son’s hand. I met Ms. S as a nervous sub-intern struggling with how to make sense of her medical problems, never imagining that caring for Ms. S would prove to be the most rewarding experience I have had in medical school and would mark a transition in my education. The experience of taking care of Ms. S during her dying process challenged me to move beyond my limited medical training and begin the long process of learning how to harness my own fear, hope, grief, insecurity, expectations, sadness, anger, energy, and empathy and use those emotions to be fully present for a patient and a family in a way that can comfort and heal. I think that what I am learning is how to be a physician. Ellen Joyce Plumb is a fourth-year medical student at Jefferson Medical College.
december 2009 San Francisco Medicine 21 www.sfms.org
Inspirational Moments in Medicine
Breathe In, Breathe Out A Retired Cardiologist Explores Inspiration
Lenny Karpman, MD “And forget not that the earth delights to feel your bare feet and the winds long to play with your hair.”—Kahlil Gibran
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n the spring of 1996, first, second, and third neurological opinions agreed that I carried a new diagnosis, dementia. Although my cognitive impairment seemed limited mostly to recent memory, all three guessed that it would probably progress and diffuse into all spheres. My father, his brother, and their mother and my mother’s two sisters had had Alzheimer’s. I tried to call off our wedding, to spare Joan the burden of becoming caretaker for a mate who might not even recognize her within a year or two. She insisted that we were already committed “for better or for worse.” We sang a duet of love at our wedding and hoped for the best. Over the subsequent year, fear and depression layered heavily over reality and I saw no improvement. With time, they both abated. My memory seemed no worse, and perhaps a little better. I spent at least a few hours writing every morning to reassure myself that I could, that I had the ability to abstract and reason and find words that dazzled and danced. In time they did. The giant step was begrudgingly coming to terms with my own mortality. Once taken, I felt as if a huge weight had been lifted off my back. I straightened up and saw the horizon instead of the path in front of my dragging feet. Joan resisted the temptation to become overprotective. She gave me the reassurance I needed; the space to bat my wings, to gain confidence that I might once again fly. She didn’t sugarcoat or deny my concerns or usurp my judgment. She didn’t fall into the trap of becoming
parent or nurse. She partnered, listened, and loved. We traveled the world frenetically. I tried to get to the places that topped my must-visit list while I could still enjoy them. In time we traveled more slowly and more gently. We lingered. We absorbed. We basked. We played and laughed and sang. My writing improved. I described exotic cultures, strange foods, and marvelous personal interactions out from under my cloud—in bright sunlight. Writing became a source of pleasure rather than a morning test. It was also mental exercise. Daily activities in strange lands with new languages heightened senses and activated dormant neurons. In 2000, we visited Costa Rica. The warm people, gentle culture, leisurely pace, and perfect climate beckoned. We returned again and again. I started to learn Spanish while Joan polished her fluency. We bought an old farm in a small town and refurbished it. We moved into the house in 2003. Our neighbors became extended family. We became a haven for abandoned critters. Our current census includes a flock of chickens, a pair of guinea fowl, a dozen parrots, a toucan, six Cornish hens, ten parakeets, three finches, six dogs, seven cats, a horse, and a small pond full of large koi. We have fruit trees and flowers galore on our four acres. Iguanas, lizards, possums, rabbits, turtles, and toads wander through. Dozens of different bird species alight and sing. Joan paints glorious pictures, studies and practices yoga, teaches a singing class, rides horses, and assists in surgery with our local vet. I garden, play poker, review restaurants, read good books, and write
22 San Francisco Medicine December 2009
nearly daily. Four books and 160 publications later, I am working on a Costa Rican anthology with our writers’ group, the Bards of Paradise. Joan and I are hosting a group of travel writers from the Bay Area in January, and that combined effort may yield another anthology. We play golf together a few times a week and cook dinners for our friends. We wear sandals or walk barefoot. Our bilingual parrots call her Juanita and me Grandpa. What happened to my dementia? In 2005, a local dementia maven reviewed all the 1996 and 1997 records and concluded that the initiating event had come and gone and that my prognosis is not bad for a man in his seventies, with my family history. My IQ score is no longer Mensa-like, but it is better than age- and education-matched controls. Inspiration became more than taking in oxygen and exhaling carbon dioxide. In came animation, exhilaration, and rejuvenation. Out went trepidation, selfdeprecation, doubt, and fear of dying. The concept of scarcity vanished in the face of abundance. My life would have been more than enough had it ended. Yet every new day became and remains a gift to embrace, an opportunity to discover another gem, to learn more than I forget. Oh, happy day—one day at a time. Costa Ricans call it pura vida. Lenny Karpman writes about food and travel from his nest, a farm in Costa Rica, that he and his wife, Joan Hall, share with their menagerie of rescued critters. For more than thirty years, he practiced medicine as a cardiologist for Kaiser Permanente in San Francisco. To learn more visit, www.lennykarpman.com.
www.sfms.org
Inspirational Moments in Medicine
Open Wide Looking for the Simple Answer
Niko Mayer
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rushing my teeth, I glanced in the mirror to discover that my tongue was black. BLACK! A shade darker than a black rat snake and slimy as a banana rotting in the equatorial sun. Not something you’d want in your mouth— where, I regretted, my tongue was. When Steve and I went to Kenya, my suitcase held, as always, more pharmaceuticals than clothes. I had Bactrim, Capricin, and Amoxicillin full-spectrum antibiotics, plus all the homeopathic equivalents by Boiron. I had Neosporin, Bacitracin, Antimonium Crudum, and a customized formula from the Hsin Kuang Herbal Store and Clinic, as well as the usual Advil, PeptoBismol, and Dr. Scholl’s toe spacers. I had enough drugs to treat a small epidemic: rubber gloves, face masks, and antibacterial gels, pads, and sprays. And two Sawyer snake bite kits—one extractor, one swift. I stopped short of carrying my own blood plasma supply. Fully informed and fully prepared for all hazards, I wore flip-flops in the shower to thwart snails from hitching a ride to my brain, slathered myself in deet against dengue fever (which kills in five days), and gulped antimalaria pills the color of life vests. In spite of all my protective efforts, the morning after we returned from Africa, my tongue was black. I logged onto the computer and Googled black tongue. My God! There were 4,278,236 entries! I chose the first entry from HealthHelp.com. The screen responded immediately: “We could not identify black tongue as a symptom in Symptom Search. Did you mean blackhead?” Well, not yet, but “black head” seemed imminent if my tongue didn’t get fixed soon. In a few days, after Steve noticed my www.sfms.org
absence, what if he found me on the floor in front of the computer—totally paralyzed, breath shallow, faint mustache of sweat on my black upper lip—and thought my black tongue was a result of death, not a cause. I was already feeling buboes swelling in my left armpit. Maybe it was time to go beyond do-it-yourself doctoring. “Stanford has a tropical diseases department,” Steve said, and we headed for Palo Alto. Even though it was early morning, the sun heated up the smell as the ER doors whooshed open. What is that? Disinfectant? Ether? Suppurating wounds? Lunch? Why not franchise with Victoria’s Secret fragrances and douse everybody on the way in? I was relieved when I saw that the doctor assigned to me was older—which I interpreted as experienced and knowledgeable. He had a fuzzy yarmulke of white hair and an unhealthy red flush even under the fluorescent lights, and he needed to lose twenty pounds. Good, I thought, he must spend every weekend in his study smoking cigarettes and reading research journals. Dr. Outtashape asked the usual questions about wounds, fevers, insect bites, and rashes in a slow, methodical way as if he were checking off the boxes on an imaginary medical form. All negative. I was SOOOOO careful while I was in Africa. Finally, he asked, “Did you eat anything unusual while you were on safari?” “No,” I answered. “No?” said Steve, leaning in close to me, bushy eyebrows jetting up to his hairline. “What about the wildebeest?” (Tastes like chicken.) “The hartebeest?” (Tastes like steak.) “Snake?” (Chicken.) “Ostrich?” (Chicken.) “Zebra?” (Both the dark and
white meat tastes like chicken.) I slumped forward and brushed my hair back—a way I have of mentally slapping my forehead. How could I be so stupid as to eat all that weird stuff, I asked myself. But it was thoroughly cooked, I defended myself to myself. It wasn’t as if I had warthog tartare. The doctor was stumped and left the room. My back was to the door, but I could hear it swinging open and closed as the interns peeked inside. August—hundreds of new interns. One came in, pulled open a few cabinet doors, and said, “Sorry. Just looking for a knee immobilizer.” I wasn’t convinced. Wouldn’t that be in some hallway closet with all the other orthopedic supplies? A few residents—some probably not even on duty in the ER—passed through and asked to have a look in my mouth. “Hmmmmm,” they said, practicing the intonation of tentative authority. Of course, that was much better than “Eeeeeeuuuwwwww,” which is what I would have said if our positions had been reversed. An hour went by. Dr. Outtashape returned with a Second Real Doctor. This doctor, very Dr. McDreamy, was maybe more of an expert on recent bacterial mutations. He began the diagnostic queries all over again. Still, I answered everything with “No.” I hadn’t had a scratch, a headache, or even an ingrown hair. In fact, I actually had never been healthier on a trip. Finally, the younger doctor began to smile. Inspired. He looked from me to the first doctor, to Steve, then back to me. He brightened. His eyes widened and then narrowed and then crinkled. He leaned down, opened my mouth, inserted the Continued on page 24 . . .
december 2009 San Francisco Medicine 23
Inspirational Moments in Medicine
My ‘Aha’ Moment Learning to Treat the Patient, Not the Illness
Jordan Shlain, MD
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y “aha” moment came while working like a slave at my resident’s outpatient clinic. The hospital was rife with acute drama and complicated cases, compared to the mundane requests of managing high blood pressure in moderately compliant patients. Colds, sprained wrists, asthma, and a myriad of primary care conditions didn’t get me excited. I was destined for a specialty or a subspeciality or even a sub-subspeciality. Our clinic director approached the residents on that fateful Friday afternoon and described a seventy-eight-year-old lady who was blind, hypertensive, and in atrial fibrillation, with recent bilateral mastectomy and hip replacements. She had a fever and was too weak to come to clinic. She lived near Ocean beach. I thought, “Anything to get out of here, and near the beach. I’m in.” I volunteered to make the house call. I grabbed my stethoscope, a dipstick, and a handful of antibiotic samples, and jumped in my 1983 Alfa Romeo Spider Veloce convertible and drove the home of Ms. J. She was from Australia and had married a U.S. GI in World War II. They’d lived in Open Wide Continued from page 23 . . .
dental speculum again, and beamed his flashlight once more onto my wretched tongue. “Have you taken any Pepto-Bismol?” “Yeth,” I answered with my mouth full of steel. “Lath night on my way to bed. Two chewable tablets.” Dr. McDreamy looked like he had found a cure for Ebola and was heading for a Nobel. “Pepto-Bismol! Bismuth subsalicylate
this flat for forty years until he had died four years ago. She could navigate that flat—blind, mind you—perfectly. She was delicate with a happy and large smile. I noticed long tangles of telephone cord snaking across the floor, clearly a hazard for a blind person. She made chamomile tea, we sat on her couch overlooking the Pacific Ocean, and she told me her life story. It was the most fantastic history of present illness I had ever heard: A love story, a war, dogs, far-away lands, kids, and the flat on Ocean Beach. She eventually got to the part about the fevers. As the medical saw goes, 90 percent of a diagnosis can be found in the history. After a brief exam, I dipped her urine, which was positive for nitrites, blood, and white cells. I had fortunately brought some ciprofloxacin samples and gave her a complete treatment course and asked for her phone number. I called her daily until her fever had subsided. The next week I informed my resident clinic director that I needed to visit Ms. J for follow-up . . . and this time I brought my dog, Java. My visit lasted another hour, and I followed up with a run on the beach with Java. Our is black. The pharmaceutical company tints it pink to make it look palatable, but if your PH is right or you’ve eaten something that’s a sulfide, it will turn black in your mouth or your stool. It’s really common. If you hadn’t just returned from Africa, we would have figured this out in five minutes and sent you on your way.” I left the hospital smiling as broadly as I could without actually opening my mouth. “You look pleased with yourself,” Steve
24 San Francisco Medicine December 2009
visits were timeless, and over the years she became one of my favorite patients. There was no shortage of chronic medical problems to manage. Ms. J transformed my understanding of taking care of a medical problem (or set of problems) into taking care of a patient. I felt like I was transported back fifty years, to when house calls were the norm and Marcus Welby was the model. The relationship that developed reframed my understanding of doctoring—making the “office visit” experience seem sterile, rushed, and problem-focused rather than patient-focused. Her furniture, the smell of her flat, the food in the fridge, the photos around the house gave new meaning to “present history in context”—which is not part of our current clinical experience. I have since made thousands of house calls and much prefer illness visits at home and wellness visits at the office. Context is everything! Jordan Shlain, MD, is a practicing internist in San Francisco. He started the first affordable concierge medical practice in the city, www.currenthealth.com. He is also a longtime member of the SFMS. said as we were leaving the hospital. “I’m not pleased—just amused. I didn’t realize my neurosis about getting sick was contagious, but I just infected the tropical diseases staff and disabled them from diagnosing me. Gotta watch that stuff, huh?” “Open Wide” is an excerpt from Niko Mayer’s book Travelin’ Light Is Not for Me: Worries Weigh a Lot (Palace Press, 2009). www.sfms.org
Inspirational Moments in Medicine
Touched by an Angel A Late Night Plan Turns into a Life Long Road Map
Toni Brayer, MD, FACP
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hile growing up in Arizona, I knew no doctors and no one in my family had gone beyond a high school education. I didn’t really know anyone who had a higher education. I started college late and I had no role models or anyone to give me advice about my education or aspirations. I knew I wanted to be a doctor but had no “inside” information about how to achieve that goal. This was long before the Internet, and just getting information on courses needed for medical school was difficult. I went to my premed office at the University to get information, but I was soundly discouraged because of my age (I was old at 28). It was a cliquey group and the
premed advisors didn’t welcome outsiders. I was told I would not be competitive. I put myself through college by working in the County Emergency Department as a psych tech, screening patients brought in by police and social workers. My shift was overnight and there were often long stretches of drinking coffee and waiting for the events of the night to unfold. I worked one night with a young psychiatric resident and we talked into the wee hours of the night. I shyly told him I wanted to be a doctor and he was the first person who encouraged that dream. He spent the entire night laying out a plan for me . . . what premed courses
to take, how to take the MCATS, how to write an application letter. He gave me the nuts and bolts that I needed, along with tremendous encouragement to go for it. At the end of the long overnight shift, I was ecstatic about the possibilities and going forward. I finally had a plan. I never deviated from that goal and I dug in hard to achieve it. I never saw that young psych resident again. I think he was an angel. Toni Brayer, MD, FACP, has practiced internal medicine in San Francisco for over twenty years. She currently serves on the Editorial Board of San Francisco Medicine. Visit her blog at http://healthwiseeverythinghealth.blogspot.com.
We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company. You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our medical professional liability program, including the Tribute Plan, call The Doctors Insurance Agency at (415) 506-3030 or (800) 553-9293. You can also visit us at www.doctorsagency.com.
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december 2009 San Francisco Medicine 25
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Book Review
The Water Giver The Water Giver The Story of a Mother, a Son, and Their Second Chance Joan Ryan Simon and Schuster, New York, 2009
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n The Water Giver, Joan Ryan has given those of us in the Bay Area in particular a searingly fervent, honest accounting of her own metamorphosis as she moves from the love and frustration of a mom, continually managing, coaching, and prodding her young adopted son, who has ADHD and learning difficulties, hoping to “normalize” him. She is then abruptly jolted into the horrible suspended state known to all helpless parents as they observe a child near death. I know this dark hell, having watched my only sister die of a brain tumor in 1970, at UCSF. It completely undid my mother, whose wounds—as I learned in diary entries found after her death in 1996—broke her spirit and caused the repetitive ruminations about her “caverns of indescribable pain” and her flirtations with the notion of suicide. This she never carried out, but the experience left her a depleted woman. I was furious at what actually caused Shari’s early demise, an overdose of chemotherapy, with complete loss of white count, thrombocytopenia, and intractable gastric hemorrhaging. In fact, this lead me to change careers and enter medicine. But I was not the parent. . . . In this boy’s case, her son had fallen, without a helmet, from a skateboard in midafternoon. The serious blow to his head was observed by neighbors, an ambulance was called, and the initial injury seemed fairly routine, since he had not yet lost consciousness. This quickly changed: He was promptly admitted to Marin General’s ICU, and given his swift deterioration due to traumatic brain injury, he was sedated to avoid intense pain, movement, and further injury. The vigil Joan and her husband Barry kept, during the first weeks at Marin General while sixteen-year-old Ryan was sedated, was like that of the afflicted Job’s three ever-vigilant observers. And like Job, Ryan was severely ill, in what seemed an untenable state of undeserved illness. Luckily for Ryan, who remained completely unconscious, the railings of Job with his God were not part of the process. But Joan and Barry discovered that they had entered the abyss of the unknown. Like the period of birth and death, the days became infused with a seemingly endless lack of control over outcome or timing. Their blessing was the amazingly supportive commitment of dear friends, neighbors, and well-wishers, which allowed them to explore their love for Ryan, and one another, uninterrupted. Joan’s gratitude is palpable as she learns to trust the care given by the hospital neurosurgeons, mainly Mark Eastham (whom she refers to as Dr. Doom) and the RNs, even as Ryan develops www.sfms.org
Erica Goode, MD
blown pupils and nearly suffers herniation due to wildly varying intracerebral pressure changes. Her ability to abide, without self-recrimination, became her most amazing asset. This is the message of Job: that the quiet vigilance, when one can do nothing, provides introspection and intangible, incalculable support for the sufferer and the seemingly helpless, inactive, but loving observer. She notes a miracle: She finally asks her parents to fly out. They are much more religious than she; her father (who is Ryan’s special “Grandpa-buddy”) prays for Ryan, and at that very moment Ryan’s pressures stabilize, which allows for transfer to UCSF. With the UCSF comprehensive ICU team’s ability to provide moment-tomoment care and adjustments, Joan and Barry were able to fully focus on Ryan himself, with the reassurance that ample staffing meant that everything possible was being done. Joan was then able to reflect on all aspects of her life, highlighting the reasons that her and Barry’s approaches to Ryan, during his formative years, included such different agendas and perspectives. Joan, being the mom, had assumed the disciplinarian’s largely practical, scrutinizing role, developing myriad assessment and other programs for Ryan, in an attempt to provide enrichment. Ryan did what he could, with his genuine sweetness, masked often by outbursts and frustration. He clearly loved her, but his “fun” came mostly from his “dad time” with Barry. She came to respect the differences and to focus on just how intensely deep her love for Ryan had become. Ryan gradually recovered, with helpful visits from his lifelong school friend Emma, who had been urged by a perceptive U.C. physician to “be there” for Ryan, as only a peer can be. As Ryan began to recover, very slowly, he was helped by myriad people who shared in the miracle—from physicial therapist to “regular” pediatrician Bill Gonda, from friends’ parents to former teachers, RNs, and many others. The coda to the story is an ongoing one; Ryan is further compromised and has had some big setbacks (like totaling the family car, luckily without harm to self or others). His parents must balance his needs to expand his horizons against the dangers inherent in these excursions into adulthood. But his survival, and their intense passion for one another as a family, is the final miracle. This is an amazing book. And as writer Annie Lamott states in her review, “It is a story about the healing grace of deep friendships and a loving community. I couldn’t put it down” (and neither could I). All names are factual, and the places and settings are known to all of us who live here. Erica T. Goode, MD, MPH, is an internist at CPMC’s Institute for Health and Healing, associate clinical professor for the UCSF Department of Family and Community Medicine, and a longtime member of the SFMS Editorial Board. december 2009 San Francisco Medicine 27
Hospital News Chinese
Joseph Woo, MD
The Chinese Hospital Medical Staff recently hosted its 36th Annual Awards Banquet. This annual event recognizes an individual who has made a significant contribution to the health of the Asian community. Recent past recipients have included Dr. David Ho, Time Magazine Man of the Year, Dr. Lap Chee Tsui, vice chancellor of the University of Hong Kong Medical School, Dr. James Suen, President Clinton’s personal physician and professor of otolaryngology, and last year’s Dr. Sum Lee, dean of the Medical School at the University of Hong Kong and professor of gastroenterology at the University of Washington. This year’s honoree was Shin Lin, PhD. professor of developmental and cell biology, biomedical engineering and physiology and biophysics. Besides being an accomplished researcher at the University of California, Irvine, Dr. Lin is involved in the study of the pathophysiological basis of complimentary medicine and qigong. Our medical staff was treated to a Grand Rounds presentation on this topic at its noon lecture and as a bonus, Dr. Lin presented an additional hour showing qigong techniques, as he is also an established master. An evening dinner was also held in the Peacock Court of the Mark Hopkins Hotel in honor of Dr. Shin, where our board president, Mr. James Ho, Medical Education Chair, Dr. MaiSie Chan, and I presented the Annual Award to him as chief of medical staff. At this time, I was also able to recognize the medical staff leadership and express our appreciation to those physicians who are so dedicated to the Chinese community.
CPMC
Damian Augustyn, MD
The California Pacific Neuroscience Institute’s Neurovascular and Neurointerventional Surgery Suite opened on October 5, 2009. One of only a handful nationwide, this suite is a rare example of a combined neurointerventional and microvascular operating environment, where multiple treatment modalities for cerebrovascular diseases, such as stroke and cerebral aneurysms, can be combined or used sequentially without displacing the patient. This is truly a state-of-the-art healing environment. The NIR opening represents a significant step in the building of the Neuroscience Institute on the Davies campus. While patients who present at the Pacific campus emergency department will continue to receive exceptional stroke care, the main stroke service operations will be relocated to the Davies campus. This unique NIR surgical suite expands our outstanding stroke interventional and neurosurgical service capabilities on the Davies campus and extends them to every patient under our care. The Comprehensive Stroke Care Center Team, led by doctors David Tong, Jeffrey Thomas, Jack Rose, and Nobl Barazangi, along with Ann Bedenk, RN, BSN, program coordinator, have reached out to many Bay Area hospitals, expanding stroke care beyond the walls of our facility. Through their tireless commitment to quality, our stroke program consistently exceeds national standards for stroke care, and we continue to be a Joint Commission Primary Stroke Center and Get with the Guidelines American Stroke Association Gold Performance Achievement Awardwinning facility. Please join me in thanking the dedicated imaging, surgical, physician, construction, and IT teams for sustaining this vision and completing the work that allows CPMC to make this important investment for our community.
28 San Francisco Medicine december 2009 29 San Francisco Medicine december
St. Mary’s
Richard Podolin, MD
Anyone who attended the recent CMA House of Delegates meeting might conclude that joy is a scarce commodity in the house of medicine. Physicians are worried about imminent and sweeping changes to their profession by a political process beyond their control. They are frustrated by bureaucratic obstacles and angered by the intransigence, and at times chicanery, of payers who deny reasonable compensation for services provided. And yet, someone who listened closely would have discerned a deeper but equally pervasive thread. Physicians were sharing stories of commitment: to their patients, their communities, and their profession. They were proud of their work and invigorated by its intellectual, organizational, and emotional challenges. There were few in that room who, given a life to live over, would choose a different path. So is there still joy in medicine? Bringing healing to a suffering patient and relief to a worried family is always a source of joy. But what about the other times—the time spent filling out forms or arguing with insurance companies? What about the times we are powerless to alter the course of a disease, or when our human frailty is exposed and our best efforts fail or go awry? Perhaps we can take inspiration from predecessors who were happy with their profession, despite the knowledge that their armamentarium was meager—a fraction of that we enjoy today. They derived joy from the act of being present in the lives of their patients, from bringing their whole selves to the assistance of another. Whatever extrinsic burdens are laid upon it, the meeting of a patient and a physician remains a sacred space. We are still privileged to inhabit it. The joy of medicine is always available to the physician who walks to the bedside, or enters the exam room, with a grateful spirit and an open heart. www.sfms.org
Veterans
Diana Nicoll, MD, PhD, MPA
In a recent San Francisco V.A. Medical Center (SFVAMC) study of 1,792 male veterans, posttraumatic stress disorder (PTSD) emerged as a significant risk factor for oneyear postoperative mortality for a variety of major surgeries, even after the authors adjusted for age and for preexisting medical conditions. The results of the study were presented by lead author Marek Brzezinski, MD, PhD, a staff anesthesiologist at SFVAMC, at the annual meeting of the American Society of Anesthesiologists. “This is the first time that PTSD has been shown to be a risk factor for surgical mortality,” said Brzezinski. “Important as this finding is for veterans, it is significant for civilians too, since many civilian accident victims have PTSD.” In analyzing the data, which came from the electronic patient database at SFVAMC, the researchers found that a PTSD diagnosis was associated with significantly higher prevalence of risk factors for cardiovascular disease, including high blood pressure, high cholesterol, smoking, and alcohol abuse—all of which are known to increase the risk of surgical mortality. Brzezinski urged anesthesiologists and other physicians to be aware of PTSD as a surgical risk factor. As one follow-up to the study, Brzezinski and his colleagues are beginning another study to determine if the administration of beta-blockers before and after surgery decreases postoperative mortality in patients with PTSD. Beta-blockers are known to significantly improve postoperative mortality in patients with heart disease and are also being investigated by other researchers for their potential in treating PTSD.
www.sfms.org
UCSF
Elena Gates, MD
2009 Milton and Ruth Roemer Prize Awarded to Dr. Mitchell H. Katz of San Francisco!
The UCSF community had the exceptional pleasure this fall of recognizing one of the most inspiring members of our faculty, molecular biologist Elizabeth Blackburn, PhD, as she was awarded this year’s Nobel Prize. As a high school student, Liz first became intrigued by textbooks depicting the molecular basis of life. She devoted the next four decades to understanding basic cellular biology—and in the process transformed the field of biomedical research. She has inspired new generations of young scientists, including Carol Greider, who was drawn to Dr. Blackburn’s laboratory as a graduate student. Blackburn and Greider, PhD, now of Johns Hopkins University School of Medicine, and colleague Jack Szostak, PhD, of Harvard Medical School, won this year’s Nobel Prize in Physiology or Medicine. Their research revolutionized scientists’ understanding of chromosomal function. “As a scientist, a colleague, a mentor, and a woman in science, she is an inspiration to the nation and the world,” said UCSF Chancellor Susan Desmond-Hellmann, MD, MPH. Dr. Blackburn has inspired numerous other scientists, including Elissa S. Epel, PhD, UCSF Associate Professor of Psychiatry, who—in collaboration with Dr. Blackburn— pioneered research on the impact of prolonged stress in their study of women caring for their ill children. Their findings uncovered “a cellular mechanism for how chronic stress may cause premature onset of disease,” said Epel. “Dr. Blackburn was the matriarch of the field of cell aging. Now she is inspiring and supporting researchers in the behavioral and social sciences as well. She is a hard-core renaissance scientist.” One of the strengths of the UCSF community is its enthusiasm about translational research, and the excitement that clinicians experience in partnering with inspiring basic scientists. Liz Blackburn has epitomized this in her collaboration with UCSF clinicians to advance health care for all of us.
The American Public Health Association’s Milton and Ruth Roemer Prize for Creative Local Public Health Work, which recognizes a local health officer for outstanding creativity and innovation, is being award this year to Mitchell H. Katz, MD. Director of health and health officer for the City and County of San Francisco Department of Public Health, Katz has put forth tremendous effort toward improving the health of those living in communities throughout San Francisco. And his visionary work has, in many cases, translated to populations beyond the San Francisco area. “While the challenges of leading a large, urban health department are many, he has consistently shown himself to be thoughtful, persistent, and intelligent even in the face of opposition and controversy,” said Anne Kronenberg, deputy director of health for the San Francisco Department of Public Health, in a letter nominating Katz for the Roemer prize. “This is especially true of his leadership around the uninsured in San Francisco.” Among the programs Katz has initiated or expanded to help the uninsured find coverage are Healthy San Francisco, which provides insurance regardless of income or preexisting medical conditions; Healthy Kids, one of the first California programs to cover children and youth; and the Charity Care Project, which has improved the delivery of free and low-cost health care to the poor and underserved. House Speaker Nancy Pelosi, DCalifornia, said the Healthy San Francisco program “illustrates Dr. Katz’s leadership skills and creativity.” Dr. Katz has been a longtime active member of the San Francisco Medical Society and acts as a consultant to the SFMS Board of Directors.
december 2009 San Francisco Medicine 29
Health Policy Perspective
Following the Money
H
ow much money did you make this past year? Of course, I’m not seriously asking; I know better. That question is one of the last taboos in our culture. People, famous or not, will speak to national media about their intimate personal lives, but questions of one’s income and wealth are, like a national single-payer health system, “off the table.” This is partly because money is so much a factor behind both private and public life, and this can make us uncomfortable. The influence of money in health care debates—and denial of that reality—is no exception. “Money is the mother’s milk of politics,” noted prominent politico Jesse Unruh, who, as California treasurer, knew better than most. Thus, issues of the costs of proposed reforms, whose primary goals are (or were—the outcome is still unknown at press deadline) increasing access to care, were widely seen as getting short shrift in this year’s debate. President Obama held that proposed reforms would not cost more in the long run, but few seemed to have confidence in that reassurance. In any event, what transpired was indeed what New York Times columnist David Brooks predicted would be an “ugly, all-out scramble for dough.” And it worked, mostly— Consumers Union noted that “all industries stand to gain from this legislation” despite specific objections from insurers, drug and device makers, physicians, and hospitals. For patients, as a group, things remained a bit more uncertain. The closer one looks into health care politics, the ever more apparent it is how pervasive money’s influences are in what we otherwise hope and believe to be matters of science, art, and compassion. Here is just one example among many: Earlier in the year, pharmaceutical interests pledged to reduce costs by about $8 million annually for the next decade, in seeming solidarity with Obama’s reform efforts. But now it turns out that the industry has been raising prices faster than at any time in a quarter century—by 9 percent this year, while the Consumer Price Index overall has fallen in the same time. Drug manufacturers stand to gain 30 million new insured customers under the leading “reform” plan—thus, with higher prices, likely more than covering any losses they might endure from the proposed competition from a public plan. That’s “business,” but even some cynics were surprised to learn that one prominent local firm, Genentech, had its lobbyists drafting health reform messages for both Democratic and Republican legislators. Considering that pharmaceutical and health insurance lobbyists were distributing up to $1 million daily to legislators during the reform debates, perhaps it’s not surprising that some elected officials were also
30 San Francisco Medicine december 2009
Steve Heilig, MPH
using their lobbyists as free speechwriters. Earlier this year while the health care reform battle was just heating up, President Obama and his team were quoting from an influential New Yorker article by Atul Gawande, MD, which detailed how certain Texas physicians and hospitals seemed to “game the system” in ways that resulted in very disproportionate, wasteful health spending there—and, not incidentally, very high incomes for them. Leading Dartmouth researcher John Wennberg, MD, recently noted that in order to really address unscientific variations in spending and growth will require “payment models that at least some hospitals and physician groups might not welcome at first.” Dr. Gawande has held out as a partial solution the Mayo Clinic nonprofit model, with salaried physicians who presumably have less incentive for overutilization. Almost everyone agrees that we will need many more primary care physicians, and evening out the pay scales should help that—in fact, it might be the only way to avoid serious primary care shortages. Physician payment is, of course, a sensitive topic. But it seems that views are evolving of themselves, albeit perhaps in a Darwinian manner. A generation or so ago, Kaiser Permanente physicians were not even allowed to join many medical associations. Now Permanente doctors are in leadership positions throughout California “organized medicine”. Older AMA leadership, once so fearful of government involvement of health care, was chastened by the profiteers in “managed care” and other corporate models. Medicare—once labeled “socialized medicine” by the AMA but now supported fiercely there—has taught many Americans, including physicians, to see government as a lesser evil than corporations when health is at stake. Perhaps most important is the evidence that income does not often correlate well with job satisfaction or overall “happiness.” For most physicians, that would only hold true as long as the integrity of medical practice is not compromised, and doctors feel they are truly helping their patients to the best of their training and ability. There’s a heartening lesson in there somewhere.
“Marketing of Medicines”—A Learning Experience The influence of pharmaceutical marketing on medical practice is pervasive and increasingly controversial in recent years. Drug marketing “influences physician prescribing in many ways”, according to faculty of a highly recommended CME course offered by UCSF, worth 2.5 hours of credit: Marketing of Medicines: Course # MED11006 https://www.cme.ucsf.edu/cme/ CourseDetail.aspx?coursenumber=MED11006.
www.sfms.org
Open Wide...
With Confidence!
It’s Open Enrollment time for the San Francisco 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.
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, 2009. Call a Client Service Representative at 800-842-3761 for more information, a brochure and application. Or visit www.MarshAffinity.com/cmadownload.html to download an enrollment kit.
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.
42614 (11/09) © Seabury & Smith Insurance Program Management 2009 • CA Ins. Lic. #0633005
d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, 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).
When was the last time a doctor came to YOU?
At California Pacific Medical Center’s Atrial Fibrillation and Arrhythmia Center we are com-
mitted to a comprehensive team approach in treating your patient. Whether a patient is having debilitating palpitations, recurrent syncope or severe heart failure, sensitive and difficult challenges await – for them and their family. We are Andrea Natale, M.D., Steven Hao, M.D. and Richard Hongo, M.D., electrophysiologists who specialize in complex ablation procedures. In fact, we have the highest atrial fibrillation ablation volume on the West Coast; last year, we performed over 450 procedures. We would
like to make an appointment to see you in your office. Why?
We’d like the opportunity to acquaint you with our facilities, staff and equipment – including California Pacific’s new Stereotaxis lab. We’d also like to help familiarize you with referral indicators for your patients with arrhythmias, particularly atrial fibrillation.
The Atrial Fibrillation and Arrhythmia Center offers: •
Board certified, fellowship trained cardiac electro- physiology specialists
•
State of the art technology and facilities for the treatment of arrhythmias
•
Nationally and internationally recognized expertise in complex ablations, providing care for patients and education for physicians throughout the world
•
In 2008, HealthGrades® ranked California Pacific “Best in the San Francisco Area for Cardiology and Overall Cardiac Services”
•
Dedicated arrhythmia nurse and nurse practitioner to provide continuity from the consultation through the procedure to follow ups
Let’s schedule an appointment for a visit to your office: 415-600-7459
www.cpmc.org/services/heart