January/ February 2010

AN RANCISCO EDICINE S F M VOL.83 NO.1 January/February 2010

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Animals and Medicine

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In This Issue

SAN FRANCISCO MEDICINE January/February 2010

Volume 83, Number 1 Animals in Medicine FEATURE ARTICLES

11 The Healing Power of Animals John Lipp 14 Animal-Assisted Therapy Jennifer Emmert, PhD 16 Hippotherapy Jonathan Kyle

18 Helping Hands Amanda Denz

20 Dogs Sniff out Cancer Amanda Denz 22 The Dog and I Mike Denney, MD, PhD 23 A Dog in the Office Uma Lerner, MD

24 Confessions of a Medical Canine Buddy Wood (as interpreted by Steve Heilig, MPH) 26 Inside the Animal Mind Amanda Denz 28 A Horse’s Prayer Author Unkown OF INTEREST

32 SF Hep B Free Clinician Honor Roll Angela Pang

MONTHLY COLUMNS

4 Membership Matters 7 President’s Message Michael Rokeach, MD

9 Editorial Shieva Khayam-Bashi, MD 30 Hospital News

34 In Memoriam Nancy Thomson, MD

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

33 Healthy San Francisco Update: Our Local Public Option Steve Heilig, MPH

www.sfms.org

January/February 2010 San Francisco Medicine 3

Membership Matters January/February 2010 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 83, Number 1 Guest Editor Shieva Khayam-Bashi Managing Editor Amanda Denz

Visit Us Online!

Copy Editor Mary VanClay

The San Francisco Medical Society is pleased to announce our new online presence. We are now blogging, tweeting, and becoming active on many popular social networking sites, such as Facebook, LinkedIn, and Flickr. We’ve also updated the look of our website. 2010 will be an exciting year for the SFMS, when we attempt to engage both members and the community through our online presence.

Please join us on the following sites:

Editorial Board Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes-Clever

Ricki Pollycove

Gordon Fung

Stephen Walsh

Erica Goode SFMS Officers President Michael Rokeach President-Elect George A. Fouras Secretary Peter J. Curran Treasurer Keith E. Loring Immediate Past President Charles J. Wibbelsman SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors

Read the SFMS blog: http://sfmedicalsociety.wordpress.com/

Follow the SFMS on Twitter: http:// twitter.com/SFMedSociety Become a fan of the SFMS on Facebook!

(Once logged in, search for San Francisco Medical Society.)

Check out event photos on Flickr: www.flickr.com/photos/sfmedicalsociety And visit our website, www.sfms.org, to see the new look!

Term: Jan 2010-Dec 2012

Roger Eng

Gary L. Chan

Thomas H. Lee

Donald C. Kitt

Richard A. Podolin

Upcoming Seminar

Cynthia A. Point

Rodman S. Rogers

What to Think About Before You Think About an EHR Implementation: A Workshop for Physicians and Practice Managers If you’re a physician or practice manager who is thinking about (or thinking about thinking about) EHRs, this one-day, hands-on workshop is for you.

Practices that take the time to plan before implementation have the highest chance for success and a return on investment.

Join Amy Berlin, MD, as she leads this lively, hands-on workshop for physicians and practice managers who are thinking about an EHR implementation.

March 31, 2010, 9:00 a.m.–4:00 p.m.

UCSF Mission Bay Conference Center, 165 Owens Street, Conference Room 1, San Francisco, CA.

Adam Rosenblatt Lily M. Tan

Term: Jan 2008-Dec 2010

Shannon Udovic-

Jennifer H. Do

Constant

Shieva C. Khayam-Bashi

Joseph Woo

William A. Miller Jeffrey Newman

Term: Jan 2009-Dec 2011

Thomas J. Peitz

Jeffrey Beane

Daniel M. Raybin

Andrew F. Calman

Michael H. Siu

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

4 San Francisco Medicine January/February 2010

Bring your laptops. This will be a hands-on workshop that guides you through several key resources. You’ll come away with a strong framework in place to continue planning a successful EHR implementation.

Cost is $25 for SFMS members; $100 for nonmembers. Space is limited; registration deadline is Wednesday, March 17. Contact the SFMS Membership Department to register: (415) 561-0850 extension 268.

CMA Legislative Leadership Day

Save the date! CMA Legislative Day 2010 is scheduled for Tuesday, April 27, 2010, at the Sheraton Grand Hotel in Sacramento (please note the new date). More details and registration information will be coming closer to the date.

Attention, Young Physicians!

SFMS is developing a Young Physicians Group. Medicine is changing rapidly in SF, and young physicians are most likely to feel the impact. The group is comprised of young, academically trained physicians who practice in San Francisco and are interested in creating a social/educational forum for young MDs in the City. The purpose is to socialize with other young physicians, learn from each other, and periodically discuss and debate important public health/policy issues relevant to physicians in practice.

If you are interested in participating, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

Updated Resources for H1N1

Almost all confirmed influenza infections in northern California continue to be due to H1N1 (“swine”) influenza A virus, and the severity of H1N1 infections continues to be similar to seasonal flu, with most cases being mild. Although flu activity has declined slightly from its peak, clinicians should continue to expect visits www.sfms.org

for influenza-like illness. A “third wave” of disease could manifest as an increase in flu activity this spring.

SFDPH publishes H1N1 guidelines specifically for San Francisco clinicians, covering topics such as specimen submission, reporting, vaccination, treatment, and infection control. These are updated as needed and can be found at www. sfcdcp.org/swinefluforproviders.html.

They include the following: Most patients with influenza-like illness do not need diagnostic testing. The Public Health Laboratory system accepts specimens only from patients who have died, are hospitalized, or are among the first cases at a long-term care facility. The new specimen submission form can be found at the above Web address.

Report cases to SFDPH disease control (at [415] 554-2830) for patients who have died, are hospitalized and requiring ICU care, are residents of a long-term care facility, or are part of an outbreak of illness in an institutional setting with high-risk residents.

For infection control in health care settings, use standard and droplet precautions when dealing with patients with influenza-like illness or suspected or confirmed H1N1 influenza. Clinicians can wear a surgical mask in most situations; N-95 respirators are recommended for aerosol-generating procedures.

For the latest vaccine information from the San Francisco Department of Public Health, please visit http://www. sfcdcp.com/fluvaccine.html.

Guidance for long-term care facilities can be found at http://www.sfcdcp.com/ h1n1facilities.html.

Lesbian Health Fund Call for Submissions

The Lesbian Health Fund (LHF), a program of the Gay and Lesbian Medical Association (GLMA), is accepting proposals for research on lesbian health. LHF is especially interested in applications that address the diversity of sexual minority women’s communities and studies of www.sfms.org

health promotion and health improvement in lesbian and bisexual women, as well as studies that are potentially publishable and that are conducted as first steps toward larger grant applications.

Proposals for the spring grant cycle are due on May 15. LHF is the only U.S. fund dedicated solely to the unique health needs of lesbians. Grants range from $500 to $10,000.

Founded in 1992, LHF has given more than $600,000 to fund lesbian health research. LHF’s mission is to improve the health of lesbians and their families through investigation and research.

Research goals include: determination of rates and risk factors for cancers and other diseases among lesbians; issues of access to medical care for lesbians; studies of mental health concerns for lesbians and their families; definition and investigation of lesbian family issues; methodologic exploration of diversity in the lesbian population; interventions to reduce risk among sexual minority women.

Please share this announcement with anyone who might be interested. GLMA and LHF board members or paid consultants are ineligible to submit grants. If you will be sending this to any listservs, please let us know! Contact LHF at (415) 2554547 or lhf@glma.org with any questions.

2010 SFMS Seminar Schedule

(in conjunction with Practice & Liability Consultants)

Tuesday, February 16, 2010 Repairing Leaks in Billing to Boost Profits in 2010: Billing, Coding, and Collection Strategies Devise strategies for repairing operational leaks that cause profit losses in your practice. A full day packed with the latest updates on new diagnosis and CPT codes; new Medicare requirements, the Office Inspector General (OIG) work plan for 2010, and successful denial and appeal management strategies.

9:00 a.m.–4:00 p.m. (8:40 a.m. breakfast/ registration) $210 for SFMS/CMA mem-

bers and their staff ($195 each for additional attendees from the same office); $270 each for nonmembers.

Contact Posi Lyon at plyon@sfms.org or (415) 561-0850 extension 260 for more information.

Tuesday, March 23, 2010 Transitioning Your Practice: Retiring, Selling, or Buying a Practice This is a not-to-be-missed seminar designed for all physicians who are contemplating retirement, bringing in an associate, joining a practice as an associate, or buying or selling a practice. Physicians (spouses welcome at a nominal fee, if space permits) will learn legal obligations when leaving their practices, valuation methodologies for buying and/or selling, incentives for bringing in an associate, and road-to-partnership essentials.

6:00–9:00 p.m. (5:45 p.m. dinner/registration); $149 for SFMS/CMA members and their staff; $199 for nonmembers.

Contact Posi Lyon at plyon@sfms.org or (415) 561-0850 extension 260 for more information.

Friday, April 16, 2010 Benchmarking: How Does Your Practice Compare?

This hands-on workshop provides specialty-specific data to compare with your own practice data on practice expenses, A/R, staffing FTEs, and wage costs to improve your bottom line net income.

9:00 a.m.–12:00 p.m. (8:40 a.m. registration/continental breakfast) $149 for SFMS/CMA members and their staff ($99 each for additional attendees from the same office); $199 each for nonmembers.

Contact Posi Lyon at plyon@sfms.org or (415) 561-0850 extension 260 for more information.

January/February 2010 San Francisco Medicine 5

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President’s Message Michael Rokeach, MD

A New Year Begins

A

s I begin my tenure as San Francisco Medical Society President, I feel especially privileged to hold this position during what likely will be a year of dramatic change, both locally and nationally. Health care reform and the job of providing access to care for millions of Americans who remain outside the insurance umbrella is the number-one issue on every physician’s mind. Whether or not meaningful change is voted in by Congress remains to be seen. Democratic rule of law can be a slow, arduous, and mostly unpredictable process.

History tells us that health care reform is the so-called greased pig of American politics. Many in the past have tried, but few have succeeded in bringing about meaningful change. I remain optimistic, however, that the current administration in Washington will be successful in crafting a plan that will move us in the right direction.

Locally we have seen one of the first successful programs that brings access to thousands of uninsured San Francisco residents. Healthy San Francisco has enrolled nearly 50,000 patients and uses preventive care and a “medical home” as its signature features. Our own Steve Heilig, who was a member of the appointed group that helped design the program, writes an excellent summary in this issue of the structure and status of HSF. In the article, Steve describes a friend whose life was markedly improved as a result of treatment he received through HSF. But the theme of this issue, Animals in Medicine, is especially near and dear to my own heart. I have always felt the personal comfort that being around animals has brought to my own family. After a traumatic episode when our house was burglarized more than fifteen years ago, we sought relief with a pet dog. For a year my young son would not sleep alone in his room. But once we found our new dog, after researching various breeds and breeders at the annual dog show in San Francisco, everything changed for the better. I currently have three dogs, and we just finished breeding our first litter of puppies. Organizing the process of mating, pregnancy, and whelping the puppies was extraordinary. I couldn’t have chosen a more personally relevant topic for the first issue of my presidency.

Our guest editor, Shieva Khayam-Bashi, MD, writes about a patient of hers who nearly died and spent months in the hospital www.sfms.org

convalescing from tuberculosis, and she credits his ultimate recovery to acquiring a pet cat. She cites scientific evidence showing that animals can lower heart rate and blood pressure and cholesterol, reduce stress, and combat depression. I can’t think of any drug that has so few side effects, either!

Other articles describe a dog with psychotherapeutic skills that assists his psychiatrist owner in treating patients. We learn about an incredible program called Helping Hands: Monkey Helpers, in which monkeys are trained and then matched with disabled patients. The monkeys become family members and help the patients with simple chores they couldn’t otherwise manage. It started as a scientific experiment at Tufts University, and the author cites examples of current patients in California whose lives are vastly improved after they bond with a nonhuman primate.

And then there is a terrific story written by Steve Heilig, as told by his friend. The story is told in first-person by a dog who claims to have practiced medicine—or healing—without a license. The dog visits patients, often ones with terminal illnesses, in hospitals and hospices. He is able to elicit smiles and laughs from people who haven’t experienced such emotions in weeks or months. How can we place a value on that skill, I ask you?

And last we learn about the healing power of the humananimal bond that is the vision of PAWS, or Pets Are Wonderful Support. This amazing organization began nearly twenty-five years ago, providing support services to help people with HIV/ AIDS live independently with their pets. The group researched the healing power of the human-animal bond and published a book called The Health Benefits of Companion Animals. Many of the findings are listed in the article, and after reading them you will probably want to visit the next dog show in your area.

I wish to close my first president’s message by thanking the physician colleagues and the staff of SFMS for making me want to be a part of this wonderful and productive organization over the past twenty years. The privilege I feel in leading it is exceeded only by the joy of membership. Let the games begin.

Michael Rokeach, MD, is 2010 President of the San Francisco Medical Society. He is an emergency medicine physician and is Chief of Staff at CPMC. January/February 2010 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 Shieva Khayam-Bashi, MD

Animals as Soul-Awakeners “Until one loves an animal, a part of one’s soul remains unawakened.”—Anatole France (1844–1924)

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n a busy clinic setting one afternoon, a man in his fifties tapped me on my shoulder. When I turned around, he beamed and said, “Hi, Doc! Remember me? It’s Joseph! I am a thousand percent better now!” Joseph was indeed a new man, whose transformation was more of the heart than of the body.

Joseph had been in hospital for four months with active pulmonary tuberculosis. When I first met him, he was mostly bones covered by a bit of skin, his dull eyes reflecting the emptiness of his soul. Living on the street, he was lonely, hungry, and hopeless. It mattered to no one, including Joseph, whether he lived or died.

For Joseph, the diagnosis of tuberculosis came as a blessing; it was his ticket for staying in the hospital, where he received food, shelter, medication, and kindness from our staff. His hospital course involved many complications, and it was a wonder that he recovered as well as he did. His ailing body received medical care, while his despairing heart found compassion, respect, and love.

Week by week, we noted his improvements. When it was time to discharge him from the hospital, I felt apprehensive, knowing that much of his recovery stemmed from being in an environment where he was cared for. What would happen when he left us to live alone in a single-room-occupancy hotel in the Tenderloin?

Despite my worries, it was a much healthier man who tapped me on the shoulder three months later. He was remarkably healed and awakened. Delighted, I asked him the cause of his newfound well-being. Smiling widely, he showed me the white furry head that was nestled under his jacket: “See? I got a cat!” he exclaimed. “Or really, she got me!”

I thought Joseph’s healing must have been complete; not only was he able to care for himself but he was now able to take care of another living being. Or perhaps it was the other way around, and he healed more completely because he adopted and took responsibility for another living being. I asked Joseph, “Which came first—your healing or the cat?” www.sfms.org

A patient of Dr. Khayam-Bashi’s visits with her chihuahua “The cat!” he cried.

Joseph’s story is not unusual. We are learning more about the many ways that animals help us heal. In The Healing Power of Pets, Dr. Marty Becker describes how animals help lower heart rate, blood pressure, and cholesterol; reduce stress; combat depression; and stimulate exercise. And never underestimate the importance of nurturing another creature. “At a time when the ill person is feeling disconnected from the world, incapable of his or her normal responsibilities, the pet demonstrates that they are still needed by another and that their presence would be terribly missed.”

Last week I met a man on the streets, pushing a shopping cart with his little dog inside—he collected scrap metal under the energetic supervision of his canine companion (see photo on the following page) He shared with me the story of his difficult life and recent homelessness. But each morning his dog wakes him by licking his face, motivating him to get on his feet and scrape together a living for the two of them. Petting his dog lovingly, he said, “This little guy is my reason for living a clean, sober, and honest life.”

Having an animal is a blessing for anyone who is open to the gifts that an animal can bring: friendship, loyalty, comfort, and Continued on the following page . . .

January/February 2010 San Francisco Medicine 9

A homeless man and his dog in San Francisco Editorial Continued from the previous page . . . the opportunity to give and receive love unconditionally. Caring for an animal enables us to see beyond our own self-centered worries and focus on giving to another being. In doing so, we serve the animal and serve ourselves as well. After his stroke, one of my patients slipped into a deep depression over his condition. He finally became motivated to walk again—not by his physical therapist, psychologist, chaplain, or me—but by his dog’s wagging tail and excited whimpering pleas to be walked.

Mary Oliver’s poem about her dog Percy personifies the comfort and simple healing powers of animals: Little Dog’s Rhapsody in the Night (Percy Three) He puts his cheek against mine and makes small, expressive sounds.

And when I’m awake, or awake enough he turns upside down, his four paws in the air and his eyes dark and fervent.

Tell me you love me, he says.

10 San Francisco Medicine January/February 2010

Top: “Super Dog” in a Halloween pet parade in San Francisco Bottom: Dr. Khayam-Bashi’s beloved cat, Sofi

Tell me again.

Could there be a sweeter arrangement?

Over and over he gets to ask it.

I get to tell.

In loving and being loved by animals, a part of our soul is awakened. It is this awakening that may be the fundamental basis of the healing power of animals.

As I write this, my cat has been curled up and sleeping on my lap, making me feel loved and valued. Could there be a sweeter arrangement?

Shieva Khayam-Bashi, MD, is the guest editor for this issue of San Francisco Medicine. She is director of the short-term skilled nursing facility at San Francisco General Hospital. She is also a member of the editorial board for San Francisco Medicine. Photos

by Shieva Khayam-Bashi, MD

www.sfms.org

Animals in Medicine

The Healing Power of Animals The Human-Animal Bond Comes Alive at PAWS San Francisco

John Lipp

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any people intuitively believe that they and others derive health benefits from relationships with their animal companions, and numerous scientific studies performed over the past twenty-five years support this belief. Among other benefits, animals have been demonstrated to improve human cardiovascular health, reduce stress, decrease loneliness and depression, and facilitate social interactions among people who choose to have pets. The twelve full-time staff members and nearly 500 volunteers of Pets Are Wonderful Support (PAWS) in San Francisco see the healing power of the human-animal bond in action every day.

PAWS began in 1986 by providing support services so people living with HIV/AIDS could continue living independently with their own pets. Over time, PAWS expanded its mission to include low-income people living with all disabling illnesses as well as seniors over the age of sixty. PAWS estimates that over the past twenty-three years, it has helped thousands of people maintain the love and companionship of their furry miracle workers.

Today, PAWS serves more than 800 San Franciscans (and their 1,000-plus companion animals) with a variety of support services, including free annual vaccinations and wellness exams, subsidized vet care, free pet food and supplies, and volunteer support that includes in-home cat care, dog walking, delivery of pet food, transportation to pet-related appointments, plus foster care so people who are hospitalized can focus on their own healing without worrying about who is taking care of their pets. The organization www.sfms.org

also has an advocacy program for people who are facing eviction because of their service animals and a community education program that, among many things, publishes “safe pet� guidelines to help minimize the risk of disease transmission between animals and people with compromised immune systems.

To help human health professionals and their patients decide when and in what ways a companion animal may provide assistance, the PAWS education department surveyed the latest research on the healing power of the humananimal bond and recently published The Health Benefits of Companion Animals.

The findings below are excerpted from this publication. The entire publication, including a list of all works cited, is available online at www.pawssf.org.

Physiological Benefits Identified

by Researchers

Dog owners experienced increased survival time after myocardial infarction.

Study subjects experienced decreased risk factors for cardiovascular disease, particularly lower systolic blood pressure, plasma cholesterol, and plasma triglycerides.

Subjects showed decreased heart rate from petting a dog or watching fish in an aquarium.

Subjects displayed greater reduction of cardiovascular stress response in the presence of a dog in comparison to friends or spouses.

Elderly people watching an aquarium displayed decreased pulse rate, increased skin temperature, and decreased muscle tension.

Following a quiet thirty-minute ses-

sion of interacting with a dog, subjects showed enhanced hormone levels of dopamine and endorphins associated with happiness and well-being, as well as decreased levels of cortisol, a stress hormone.

After as little as five minutes of interaction with a therapy dog, health care professionals showed reduced levels of the stress hormone cortisol.

Children exposed to pets during infancy showed fewer allergies and less wheezing and asthma.

Adults at age twenty-eight showed increased protection against adult asthma and allergies if they had been exposed to pets before age eighteen.

Subjects showed less frequent illnesses and less susceptibility to upper respiratory infection related to a significant increase in IgA levels that occurred after petting a dog.

Lung transplant patients allowed to have a pet showed increased lung function and overall quality of life.

Children undergoing major operations showed significantly reduced perceived pain after participation in pet therapy programs.

Subjects showed a significant reduction in minor health problems for at least ten months after acquiring a dog.

Elderly pet owners averaged fewer doctor visits per year than did nonowners.

Psychological benefits identified by researchers include: Recently widowed women who owned pets experienced significantly fewer symptoms of physical and psychological disease and reported lower medication use than Continued on the following page . . .

January/February 2010 San Francisco Medicine 11

The Healing Power of Animals Continued from the previous page . . . widows who did not own pets.

In bereaved elderly subjects with few social confidants, pet ownership and strong attachment were associated with less depression.

Patients with AIDS reported that their pets provided companionship and support, reduced stress, and a sense of purpose.

Patients with AIDS reported that cats were an important part of a support system to prevent loneliness.

Patients with AIDS who owned pets, especially those with few confidants, reported less depression and other benefits compared to those who did not have pets.

Homeless pet owners that were attached to their pets often reported that their relationships with their pets were their only relationships, and most would not live in housing that would not allow pets.

More than 40 percent of homeless adolescents reported that their dogs were a main means of coping with loneliness.

Mobility-impaired individuals indicated increased “freedom to be capable” since receiving an assistance dog. Participants additionally reported increased independence and self-esteem and decreased loneliness, and they experienced frequent friendliness from strangers.

Quality of life improved in families of epileptic children when a dog that responds to seizures is present in the home.

The mere presence of animals positively alters children’s attitudes about themselves and increases their ability to

relate to others.

Pets help children develop in various areas, including love, attachment, and comfort; sensorimotor and nonverbal learning; responsibility, nurturance, and competence; learning about the life cycle; therapeutic benefits; and nurturing humanness, ecological awareness, and ethical responsibility.

Alzheimer’s patients still living at home with pets had fewer mood disorders and fewer episodes of aggression and anxiety than did non-pet owners.

Female pet owners that have suffered physical abuse report their pets are an important source of emotional support.

Dog owners were found to be as emotionally close to their dogs as they were their closest family members.

Psychiatric disability patients who participated in a ten-week horseback riding program had increased self-esteem and augmented sense of self-efficacy.

Social Benefits Identified by Researchers

One study found that elderly people who live in mobile homes and walk their dogs in the area had more conversations focused in the present rather than in the past than those people who walked without their dogs.

Disabled individuals in wheelchairs accompanied by service dogs during shopping trips received a median of eight friendly approaches from strangers, versus only one approach on trips without a dog.

Observations of passersby encoun-

tering persons in wheelchairs revealed that passersby smiled and conversed more when a service dog was present.

When a resident dog was introduced into a ward housing persons with Alzheimer’s disease, fewer problem behaviors were noted during the four weeks of the study.

Patients with Alzheimer’s disease showed increased calmness and improved social interactions when they received visits from golden retrievers.

Nutritional intake and weight of Alzheimer’s disease patients increased significantly when fish aquariums were introduced into their dining areas.

Elderly schizophrenic patients who participated in animal-assisted therapy had increased independent self-care, mobility, and interpersonal contact.

Companion animals have been shown to provide valuable physiological, psychological, and social benefits. These benefits are often especially significant in vulnerable individuals. Because many individuals who visit health care professionals are especially sensitive due to illness and the effects illness can have on one’s quality of life, it is important for health care professionals to support the vital role of animal companionship in their patients’ lives.

For more information about PAWS, contact Andrea Brooks, director of Education and Client Advocacy, at (415) 9799550 extension 304 or abrooks@ pawssf. org. Check out PAWS online at www. pawssf.org.

Helping in Haiti One Good Option

Haiti is often referred to as the poorest nation in the Western Hemisphere, so the earthquake there has been doubly devastating. For those wishing to help with a contribution of any size, one great option in the health arena is Partners In Health, founded by Paul Farmer MD, a leading figure in international health work. PIH has been active in Haiti for many years and is an efficient, respected group. They have made it easy to donate at: http://www.pih.org/home.html

12 San Francisco Medicine January/February 2010 13 San Francisco Medicine January/February

www.sfms.org

A Family of Animals Brings Love into One Man’s Life Jane Irene Kelly Through a new partnership with Meals on Wheels San Francisco (MOWSF), PAWS is now providing support to Dick, a man who has been struggling with addiction and other serious health issues during the past several years. In 2008, Dick became gravely ill, slipped into a coma, and nearly died. He credits his family of seven—canaries, finches, and a double yellow-headed Amazon parrot named John—with giving him the will to live. “I’ve had John for about five years and he is the meanest bird on two wings,” laughs Dick.

Dick has raised birds for fifteen years. He says, “Birds are more demonstrative than people think. They really show affection. With my alcoholism and growing older, being ‘alone in my head’ is not the best place in the world for me sometimes.

I can tell you that during some really dark times when I have been in pain, the only reason I got out of bed was to take care of my birds. Feeding them is something I have to do. Even if it took me a few attempts to get up and do it, I would do it.”

In August 2008, Dick expanded his family by adopting three-year-old Sadie (pictured on left), a tawny brown terrier mix, from the San Francisco SPCA. (During a hospital stay in 2008, Dick says he made a decision to adopt a dog after “falling in love” with a shih tzu who was brought into cheer and comfort patients.) “Sadie came from a shelter in Fresno,” says Dick. “I believe she was a ‘bait dog’—you know, a dog that cannot defend itself, which is released into the pit to get other dogs frothing for a fight. She has some scarring on her chin, so they clearly got to her a little bit. The timing must have been extraordinary with her rescue. She doesn’t bark often and is afraid of some people, but she is such a sweetie.”

Dick—who was once a professional puppeteer—has been a MOWSF client for five years. Of becoming a PAWS client he says, “This is a terrific program—a very positive experience.”

PAWS volunteers deliver dog and bird food every month and send flea medication for Sadie by mail. Dick says he has also been taking advantage of PAWS’s free dog washing services, which are offered at a location near his home. He walks Sadie himself, even at times when he has been on crutches.

“I can’t get over how much Sadie has changed my life,” says Dick. “I think a lot of people get old earlier than they have to because they don’t take care of anyone else. They don’t occupy themselves with anything positive. Caring for another living creature is just so rewarding. I don’t know what I’d do without my birds or Sadie. And with organizations like PAWS and MOWSF around, there is so much support. I am grateful for their services.”

Photos by Michael Tedesco Photography

www.sfms.org

January/February 2010 San Francisco Medicine 13

Animals in Medicine

Animal-Assisted Therapy The San Francisco SPCA Brings the Role of Animals One Step Further

Jennifer Emmert, PhD

T

he mention of Animal-Assisted Therapy (AAT) often calls to mind a friendly dog visiting a senior center or hospital ward, traveling from person to person, bed to bed, offering kisses. Less familiar is the idea of a cat, rabbit, or other small animal working in AAT, a therapy pet helping children learn to read or giving children and adults working through posttraumatic stress disorder the chance to master a skill set and reenter their welcoming community.

All of these opportunities take shape and affect the lives of tens of thousands in our city through the AAT programs at the San Francisco SPCA. Psychological and physiological advantages of engaging with pets range from reduced anxiety and depression to increased immunity and reduced blood pressure. While these benefits are the most widely documented, many of the encounters reported by volunteers and facility contacts highlight the ease of communication when pets are present.

The community members we serve have a variety of reasons for being withdrawn, but often even the most reticent open up to embrace and engage therapy pets and their volunteer guardians.

Pet owners readily see how gaps in communication are bridged when a companion animal enters the scene. How often have you walked down the street with your pet and been asked your pet’s age, whether it can be petted, and any number of other questions? Even those pet lovers without their own companion animal can relate. Just consider the likelihood of stopping someone on the sidewalk and engaging the person in conversation.

The confidence to approach a stranger

can increase dramatically when a pet is present; many people would readily stop a passerby and ask to meet a friendly dog.

This phenomenon is not limited to sidewalks and dog-friendly cafes. When our volunteers enter a facility with their trained companion animals, everyone knows that something fun is about to happen: a welcome respite from trauma, boredom, or stress. For those we serve, there is an element of safety in knowing that this pet will not reject them, will not administer treatments, and will lovingly come back for affection again and again.

When Sandra Gordon and her boxer, Mason, arrive for a visit, they never know how many patients they will see. Sometimes they visit in a larger activity area, but frequently they work in hospitals and see patients in individual rooms. Mason’s enthusiasm for meeting new people and his easygoing demeanor make him a natural. Of course, many orthopedic patients especially connect with him.

Seeing a large three-legged dog joyfully working and being heartily welcomed offers a stunning example of strength and acceptance.

Sandra has seen her loving pet engage a variety of patients. On a recent visit they met a young man who was just coming out of a coma. The patient was largely unresponsive until she sat down. “Mason sat on my lap next to his bed (all seventy pounds of him) and put his head forward to the patient’s hand. His eyes tracked to Mason and his hand came up to pet him. The nurse and I cried—it was such an amazing moment!” Then, when they returned the following week, the patient and Mason “reconnected like old friends.”

Working in nursing homes, physical

15 San Francisco Medicine January/February 2010 14 San Francisco Medicine January/February

rehabilitation centers, and other hospital settings has been the bedrock of AAT programs across the country. For those facing an uncertain diagnosis, a future within unfamiliar walls, or an invasive procedure, connecting with a pet offers both a rekindling of personal identity and relief from stress. The healing offered by pet therapy is equally applicable in mental and behavioral health settings.

One of our strongest partnerships has been with Langley Porter Psychiatric Hospital, where volunteers take their pets on semiweekly visits. Tom Benson, MT-BC, has been our contact there for several years. Through hosting AAT visits, he has seen that “for patients too isolative, distressed, or impaired to engage in the therapeutic program, the SF/SPCA AAT visit is often the first successful and positive interactive experience that they feel safe and trusting enough to participate in.” This observation speaks to the heart of how therapy pets can enable staff to better treat patients by giving them a safe activity as a starting point and paving the way for success.

By easing communication, pet therapy can be part of a comprehensive plan to assist those struggling to amass skills needed for full community participation.

Providing a safe, supportive, and friendly experience can help children overcome learning differences and reading anxiety.

We find that children working with a dog through the Puppy Dog Tales Reading Program (PDT) not only learn to read more fluently but also begin to enjoy reading. Attaining basic literacy provides significant opportunities and is just one of many competencies strengthened, and even discovered, by working with www.sfms.org

therapy pets.

Some of our most striking examples of skill development through animal intervention come from a new program designed for children, adolescents, and adults who have either not developed or need to rediscover social connectedness.

Most have endured significant trauma, and many have coexisting conditions that present further obstacles.

Our first series of Mastery, Empathy, and Social Conscience through AAT (MESCAAT) was an eye-opening experience for everyone involved. Teens in a local residential program learned to clicker-train dogs for AAT visitation and then went out on visits in senior centers. Among the most striking effects was the sense of confidence and hope reported by one participant and his father. It was incredibly powerful to hear this young man talk about feeling a sense of accomplishment and looking forward to learning more.

The simple fact that he sat onstage at a lecture series and spoke about his participation demonstrated the significant results of working with a therapy pet.

These stories are not isolated incidents. AAT pet-guardian teams go on visits nearly every day of the year. With more than 250 visits scheduled per month, there are too many experiences to condense into the snapshot we can give here.

Every volunteer has changed someone’s life by sharing the love of their dog, cat, bird, or small animal; every contact has stood amazed at the therapeutic benefits of the human-companion animal bond.

It is an honor to provide comfort in a time of anxiety and fear, to offer solace before departure, and to witness the acquisition of new (or newfound) skills enabling someone to realize untapped potential. If you have patients who would benefit from engaging with a friendly, loving pet, please contact us so that we may assist in your therapeutic efforts and promote a sense of well-being, motivation, empathy, and relief by sending our fantastic teams your way.

Collaborating to help others surmount obstacles and celebrate successes is incalculably rewarding. If you have a friendly, healthy companion animal and www.sfms.org

Gordon’s Boxer, Mason, poses for the camera. Photo provided by Sandra Gordon.

Charlie the dog visits a boy named Jesse at Kaiser Permanente in San Francisco. Photo provided by the SFSPCA. would like to share him or her with those facing personal challenges or medical crises, please contact the San Francisco SPCA AAT programs at AAT@sfspca.org or (415) 554-3060.

With a background largely in academic philosophy and community development, Jennifer Emmert, PhD, completed her doctorate and then joined the Peace Corps to work in HIV/AIDS Education in Cameroon. Upon return to the United States, she was able to realize a childhood dream

of working to advocate for companion animals and guardians. For the past three years, Emmert has had the opportunity to manage the AAT Programs at the San Francisco SPCA. she currently resides in San Francisco with her partner, Michael, and their two “personal” therapy pets, Annie and Newton.

January/February 2010 San Francisco Medicine 15

Animals in Medicine

Hippotherapy Equine Involvement in Therapy Proves Effective for Many Children

Jonathan Kyle

I

f four-year-old Chase Roza and his family had resigned themselves to doctors’ predictions, he might not be walking today.

Chase was diagnosed with cerebral palsy when he was six months old—after insistence by his family that something was wrong, according to his mother, Tish Roza. “He was my fourth [child] and I knew there was something different and something definitely wrong.” Early MRI scans conducted on Chase revealed significant brain damage, and Chase’s mother says doctors expressed doubt as to whether the boy would ever be able to walk, talk, or use the bathroom on his own.

Since the time of his bleak prognosis, however, Chase has continually exceeded doctors’ expectations, and his family attributes a great deal of his progress to hippotherapy.

The American Hippotherapy Association’s website defines hippotherapy as “a physical, occupational, and speechlanguage therapy treatment strategy that utilizes equine movement as part of an integrated intervention program to achieve functional outcomes.” Tish first learned about hippotherapy through her sister-in-law, who had seen a television program highlighting how people with disabilities such as Chase’s had benefitted from it.

Chase has been doing hippotherapy sessions at the National Center for Equine Facilitated Therapy in northern Californias since he was eighteen months old. And during that two-and-a-half-year period, he has developed far beyond what many thought was his ceiling.

“When he first got here he couldn’t

even sit up,” says NCEFT executive director Gari Merendino. “He couldn’t make eye contact with you.”

Merendino has a corporate background, having worked for such companies as Levi Strauss, but he wound up at NCEFT as a volunteer in 2004 after he was laid off from his job. His enthusiasm for horses and dedicated vol- Chase looks happy after his hippotherapy session. unteering efforts earned him a chance to become the barn manager ing the property. “This has got to be better than being in a little sterile clinic.” and eventually the executive director.

Chase and his family could not agree “I really enjoyed it,” Merendino says.

“I thought it was the horses, but it turns more. Though Chase supplements his out it wasn’t the horses. It was the kids, hippotherapy sessions at NCEFT with and helping other people, and being able more traditional forms of physical, occuto make a difference that was really draw- pational, and speech therapy, the general consensus among his family is that, for ing me here.”

Situated on twelve acres of farmland Chase, hippotherapy has worked the best.

“It’s not just a typical pony ride,” in Woodside, California, NCEFT has been providing patients like Chase with a Tish explains. “They work him so hard. In nontraditional therapeutic arena since traditional therapy he cries. But being on its inception nearly thirty-eight years a horse, he’s so distracted that he doesn’t ago. Though a strong majority of the realize all the work he’s putting in. “[At first] he had no trunk control nearly 100 patients who come to NCEFT for hippotherapy or therapeutic riding whatsoever,” Tish adds. “He was very are children, the organization also offers soft and pliable. Now he’s walking. He’s specialized programs aimed at treat- talking. He’s ripped.”

From looking at the enthusiastic ing veterans, which are free thanks to a special veterans’ fund NCEFT developed. blond-haired boy, who has aspirations of Additionally, NCEFT has collaborated being a cowboy, one probably would not with various treatment facilities, such as believe how far Chase has come. When the the Laguna Honda Hospital and Reha- Rozas first started bringing Chase to hipbilitation Center, to provide patients with potherapy, in addition to his limited motor skills, he was unable to form words or positive work opportunities.

“Part of the reason this is so effective even make the babbling sounds that are is that it’s here,” says Merendino, indicat- expected out of infants, says his mother.

17 San Francisco Medicine January/February 2010 16 San Francisco Medicine January/February

www.sfms.org

After two months of hippotherapy, Chase finally began making noises. His improved posture eased the flow of oxygen in his lungs and provided Chase with a new capacity to project his voice.

Chris Swan, the program director and one of the therapists at NCEFT, has worked at the organization for the past two-and-a-half years and seen Chase’s development firsthand. Swan first got involved with hippotherapy through an internship she did while getting her degree in physical therapy. In order to become certified to practice hippotherapy, one must first be a licensed physical, occupational, or speech therapist, Swan says.

Next comes completion of a combination of onsite training and classes through the American Hippotherapy Association.

“We’re still applying physical therapy principles,” Swan says. “It’s just that I’m using the horse to get a lot more done than I could in a clinic.”

Swan and other staff members at NCEFT have worked on behalf of patients to help get hippotherapy covered by insurance providers whenever possible.

“We use the same billing codes as regular physical therapy,” she explains.

Though many providers are beginning to at least partially cover hippotherapy, according to Merendino, getting approval can be an arduous process and often requires persistence on the family’s behalf. And some families, such as the Rozas, have been unsuccessful in their efforts to get hippotherapy covered by their insurance. The Rozas are insured through Kaiser, which considers hippotherapy a “Cadillac service.” Though NCEFT does provide financial assistance to some patients, the Rozas did not qualify. As a result, all of Chase’s hippotherapy has been privately funded.

Chase’s aunt started a fund-raiser for his hippotherapy, which has helped allow the Rozas to continue bringing Chase to NCEFT. Funds are beginning to dry up, however, and the family is uncertain as to how much longer Chase will be able to continue with hippotherapy. When he started at NCEFT, he was attending four thirty-minute sessions per week, at $118 per session. But prices have risen www.sfms.org

Five-year-old Aidan participates in a session with his therapist and a volunteer. and funds have dwindled. Given these costs and Chase’s other educational and therapeutic obligations, the family has had to scale back to two weekly sessions, according to his mother.

Under his current regimen, Chase usually alternates between two different horses: Cowboy and Odie. Which horse he rides is determined largely by what the therapist wants to work on that particular day. With Cowboy, Chase rides on a saddle to help extend his legs and apply added weight to his right leg, which he tends to favor. This helps ensure that both of Chase’s legs are equally fatigued by the end of his session. Chase rides Odie when his therapist wants to focus on his core strength and balance.

Therapeutic riding is another part of Chase’s overall therapy. NCEFT has thirteen horses that are used for both hippotherapy and therapeutic riding. The horses never exceed four thirty-minute sessions per day and receive weeklong breaks every ten weeks. “They get better benefits that we do,” Merendino says.

Unlike hippotherapy, therapeutic riding is not considered a medically-based treatment, as it focuses more on patients’ social development. As such, therapeutic riding is not covered by insurance companies, even though it has brought about some remarkable changes in patients.

Many of the horses at NCEFT have been donated, according to Swan. Assuming they meet the standards for temperament and size, the NCEFT staff conducts tests to ensure that each horse is physically sound and stable enough to

facilitate the desired motions in patients.

If all criteria are met, the horse is trained onsite.

“Part of my job as a therapist is to assess the kid and the horse and how to match them the best,” Swan says. “The neatest thing is when I see a kid and I get him or her on the right horse. They may start out looking like this little bump on a log, but as they get used to that rhythmic input, they start to adapt to it and their muscles start to fire properly and hold them upright.”

A crucial component of the pairing process is finding a horse that will force the patient’s body to repeatedly move in the way that it needs to in order to perform a certain motor function, such as walking. The repetition is necessary for developing both the patient’s strength and muscle memory.

In addition to working with the horse and the therapist, patients like Chase are further assisted by a horse handler and, usually, two volunteers during hippotherapy sessions, says Merendino. This intensive supervision helps ensure that both patient and horse remain calm and comfortable throughout the session.

“He’s just taken to this like second nature,” Tish says of Chase, immense pride resonating in her voice. “If you ask him, he’s a cowboy. We’re from an athletic background. Baseball, football, basketball, and now we’re horse people.”

For more information about programs offered by NCEFT, or to donate, please visit the organization on the Web at www.nceft.org.

January/February 2010 San Francisco Medicine 17

Animals in Medicine

Helping Hands Monkeys Provide Great Assistance and Companionship to People with Disabilities

Amanda Denz

F

ounded in Boston in 1979, Helping Hands: Monkey Helpers began as an experimental project at Tufts University, blending rehabilitation medicine, occupational therapy, rehabilitation engineering, and behavioral psychology. Since the beginning, Helping Hands’ primary mission has been to provide assistance to individuals with mobility impairments as a result of injury or illness. The first monkey-helper partnership was created in 1979. Thirty years later they have placed 144 monkeys in 33 states across the U.S., with the majority of those placements taking place from 2002 to 2009. San Francisco Medicine spoke with Jill Siebeking, OTR/L OTD, who is a placement specialist for Helping Hands.

San Francisco Medicine: How do you select and train your monkeys?

Siebeking: The monkeys in our program have all been bred in a closed colony within the U.S. After several years in foster care, where the monkeys are given time to mature before training, they enter formal training in Boston at the Monkey College.

All training is done through positive reinforcement and imitation (“monkey see, monkey do”).

How do you select your recipients?

What type of situation makes a person a good fit for a monkey helper?

To apply for a monkey helper, a recipient must fit the following criteria: They must be at least one year postinjury; they must have a reliable attendant situation; the majority of their time is spent at home; they have sufficient motor ability to control an electric wheelchair; they have unimpaired cognitive function,

adequate verbal communication, and demonstrated responsibility and maturity; all children in the household must be over the age of twelve; and they must have a desire for companionship as well as enthusiasm and a sense of humor.

Monkeys, like humans, have varied personalities and different levels of intelligence. We match our monkeys based on level of training of the monkey and recipient needs as well as personality traits of both the monkey and recipient.

For example, a monkey that is at the “top of the class” and is fully trained may go to an individual with a higher-level spinal cord injury who needs more assistance, while a monkey that may learn some tasks but will not make it through all of training may go to an individual with a lower-level injury who needs less complex monkey tasks.

What are some tasks the monkeys usually help with?

Tasks monkeys may assist with are retrieving dropped objects from the floor, scratching an itch, turning a light or computer on and off, repositioning a limb on a wheelchair, pushing a recipient’s eyeglasses up if they are sliding down.

Monkeys that are fully trained can load and unload a DVD and retrieve and open water bottles from a small refrigerator.

Monkeys do not help with personal care tasks or medication.

What results have you seen—how have monkey helpers impacted the lives of recipients?

There are magical moments that happen on each monkey placement, from the first day a recipient gets a glimpse of his or

19 San Francisco Medicine January/February 18 San Francisco Medicine January/February 2010

her monkey to the first time the monkey cuddles in a recipient’s lap making happy, grunting noises. These are the small moments that have the greatest impact on our recipients’ lives. Although the tasks our monkeys provide are an important part of the monkey-helper relationship, it is the companionship and empowerment a recipient receives from his or her monkey that is immeasurable.

Where can physicians learn more about monkeys as helpers?

To learn more about our program, please visit our website at www. monkeyhelpers.org. You can also contact Jill Siebeking, occupational therapist and placement specialist, with any questions or for more information.

Where can physicians refer their patients who might be a good match?

If you have a client that you think may be a good candidate or is interested in our program, please refer them to our website. Here they can click on the “Apply for a monkey” link. They can also contact me (Jill Siebeking) directly at JillS@ monkeyhelpers.org or at (617) 787-4419 extension 109.

www.sfms.org

The People and Monkeys of Helping Hands Megan Talbert, COO of Helping Hands

Carol and Sadie, Wisconsin (pictured left): Carol was diagnosed with limb girdle muscular dystrophy at age nine.

Throughout her life, Carol has lived with the progression of her disease, and a few years ago she came to Helping Hands in search of the assistance of a service monkey. In May 2007, Carol was matched with her new monkey, Sadie, and the placement has been a great success. Carol and her husband Tim run their own business, and the dexterous hands of a service monkey help her with office tasks throughout the day when she is alone. In their free time, Carol and Tim enjoy camping—and they love to bring their little “Sadie girl” along for the adventure.

“It is truly amazing how a little six-pound monkey can enhance our lives and be such a wonderful companion. Both my husband and I are grateful for the hard work and dedication that the staff of Helping Hands has provided to make this monkey placement a success.”

Craig and Minnie, California (pictured right): Craig was Helping Hands’ first monkey-helper recipient in California. (Today, we have four active placements in the state.) Craig sustained a C-5 spinal cord injury as a result of an auto accident just weeks before his thirtieth birthday. Now a member of the Helping Hands Board of Directors, Craig received Minnie in 2004 and the pair have been inseparable ever since. A lifelong Anaheim Angels fan, Craig also loves to watch the games at home with his own personal rally monkey!

“Minnie has made my life so much richer and fuller. My independence has been increased and I have the security of knowing that Minnie can assist me with tasks that would be impossible for me without her. She really alleviates the pain of being in a wheelchair.”

Tim and Webster, California (pictured left): Twentyfive-year-old Tim Jeffers was injured from an IED explosion on May 18, 2006, while serving our country in Iraq. After recovery and rehab abroad and back in the States, Tim learned about our program through Helping Hands’ collaboration with the Injured Marine Semper Fi Fund. He received his Helping Hands service monkey, named Webster, in May 2008.

“Webster is my best friend. I’ve had him now for fifteen months, and we have grown to understand each other more and more. He’s a major part of my life now. I think it has given me an understanding of what it is like to be a father.”

www.sfms.org

January/February 2010 San Francisco Medicine 19

Animals in Medicine

Dogs Sniff out Cancer An Interviews with the Pine Street Foundation on Its Cancer Detection Research

Amanda Denz

I

n 2006, the Pine Street Foundation in San Anselmo received national attention when it released a study describing the training of five dogs to detect cancer from breath samples of patients. The dogs, three Labradors and two Portuguese water dogs, had a 99 percent accuracy rate in detecting lung cancer in patients. The researches embarked on the study after successfully training a standard poodle named Shin-Ling to detect cancer in 2003. Shing-Ling was a therapy dog at the Pine Street Chinese Benevolent Association who was trained to sniff out cancer using the same methods used to train dogs to sniff out explosives. After realizing Shing-Ling was quite accurate, the Pine Street Foundation decided to organize a formal study of the phenomenon. San Francisco Medicine spoke with Michael McCulloch, LAc, MPH, PhD, and head researcher on this project, about man’s best friend and cancer detection.

San Francisco Medicine: Could you tell us about where this idea originated?

McCulloch: We were inspired to begin this work by two ideas: First, we saw an article published in the medical journal Lancet describing a case report of a seventeen-year-old woman whose dog was licking, pawing at, and barking at a mole on her calf. After this persisted for some weeks, she’d gone to her doctor, who referred her to a dermatologist who performed a biopsy and found melanoma.

We reasoned that if a dog could spontaneously display this behavior on her own, then she could be trained to do it. And . . . we wanted to have dogs with us at work!

Freeman, a Black Lab. You got a lot of publicity in 2006 when your first study came out. What’s new since then?

We’ve been working on a study to detect ovarian cancer, again using exhaled breath samples. In this study, we’re comparing them to both healthy controls and controls with endometriosis or polycystic ovarian syndrome. That way we can be sure we’re detecting cancer itself, not some other abnormality. This study is still open for enrollment, and we can accept women with primary or recurrent ovarian cancer, fallopian tube cancer, or primary peritoneal cancer. We can also accept women with endometriosis or polycystic ovarian syndrome. Women interested may phone (415) 407-1357 (they must be either newly diagnosed or recurrent, and prior to beginning treatment). This study is also listed at www. clinicaltrials.gov and at www.pinestreetfoundation.org.

This study is different from prior studies of dogs detecting cancer in that it’s

21 San Francisco Medicine January/February 2010 20 San Francisco Medicine January/February

a nose-to-nose competition, held between our trained dogs and the laboratory of a scientist who has the world record for being able to detect compounds in gas mixtures at low concentrations. This is our collaborator and good friend Touradj Solouki, PhD, at the University of Maine.

Where do the dogs come from and who trains them?

Several of our dogs have come to us from Guide Dogs for the Blind in San Rafael, and the rest are the pets of people who live near our training facility.

What do the dogs sniff and what exactly are they sniffing for?

We’re using exhaled breath samples.

The theory is that women with ovarian cancer cells give off metabolic waste products that are different from ordinary healthy cells, and that those compounds give a unique odor that can be detected in exhaled breath. www.sfms.org

What is the current accuracy rate?

We’ve just begun to analyze the data for publication, and we’ll know soon.

We’ve submitted an abstract for presentation at this year’s annual meeting of ASCO (the American Society of Clinical Oncology).

What do you plan to do with this information? What implication does this have for detecting cancer?

We plan to go to work on developing a “breathalyzer” for cancer, which we hope will help make existing tests for ovarian cancer more accurate by reducing false positives and false negatives, and helping clarify those cases where a test gives an ambiguous result.

Where can physicians go to learn more about this?

We’re listed on the National Cancer Institute’s trial registry: http:// clinicaltrials.gov. Search for the trial ID number NCT00757952. We have descriptive materials about the study at

Captain Jennings, a Black Miniature Poodle. www.pinestreetfoundation.org.

We’re working on the design of future studies, and we welcome physician participation or collaboration. Visit www.

pinestreetfoundation.org for our contact information.

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www.sfms.org

January/February 2010 San Francisco Medicine 21

Animals in Medicine

The Dog and I An Unexpected Research Result

Mike Denney, MD, PhD

I

t happened many years ago in a research laboratory at Wayne State University in Detroit. I met a dog I would never forget.

In 1963, after the second year of my surgical residency, I elected to do an extra year of research in preparation for the possibility that my career path might be in academic medicine. My project centered on a report a year earlier that the thoracic duct chyle in patients with Laennec’s cirrhosis contained gross blood. At the same time, while doing research for unrelated purposes, my friend and colleague Charles Lucas, MD (currently professor of surgery in charge of trauma at Wayne State University, Detroit Receiving Hospital), serendipitously discovered that the thoracic duct chyle in dogs with surgically created abdominal arteriovenous fistulae also contained gross blood. Was there a connection between these two findings?

My task was to operate on many dogs that year to create variously located arteriovenous fistulae so as to more accurately explicate this phenomenon.

On a routine morning, David, my lab technician, would bring in dogs from the animal quarters. These dogs were from the municipal stray animal pound where they would have been put to death had they not been selected for medical research. One morning, David brought in three dogs. Two of them he attached with their leashes to metal fixtures on the wall.

The other one I anesthetized, intubated, and put on a respirator. I deftly made an abdominal incision and proceeded with the operation.

But something on this particular day was different. As I performed the surgery, I felt a strange uneasiness, a hesitancy

not considered good form for a surgeon.

What was it that seemed to impose upon me this unwelcome discontent?

I glanced up from the exposed dog viscera on the operating table and looked toward the two waiting dogs. The small shaggy one had curled up and was asleep.

The larger, short-haired tan one sat back on his haunches, his front legs extended, not unlike the posture of the great Egyptian Sphinx. I was strangely transfixed.

The dog and I seemed to be seeking a mutual understanding. He looked at me with soulful eyes, seeming almost to know what I was doing. It was as though he was admonishing me gently, but more as though he wanted to speak to me. What did he want to say? Was he seeking comfort from another of God’s creatures? Was he yearning to be set free? Indeed, was he asking me to spare his life?

I turned my attention back to my work, gently placing vessel clamps on the aorta and inferior vena cava, making longitudinal incisions on the inner wall of both, then delicately sewing them together with 6-0 nylon vascular suture so as to create a fistula between the arterial and venous circulations. But all the while I was distracted. Those soulful eyes seemed to plead with me, repeatedly demanding my attention. Something welled up inside of me, a sense of wonder and awe. What was going on? This was just a routine research procedure. Yet I felt a strange connection to that dog, and I soon experienced a kind of transformation that touched my deepest awareness. I somehow knew that I could never again treat an animal dispassionately. I knew that I could no longer view my research dogs as objects to be manipulated. I would strive, instead, to

22 San Francisco Medicine January/February 2010 23 San Francisco Medicine January/February

honor those animals for the great sacrifice they were called upon to make, for their extraordinary contribution to the healing of human beings. Above all, I knew that I could not operate on the dog who had taught me this great lesson.

I told my lab technician that we would need another dog, and that we should give some food to the one with the soulful eyes. But what to do with this newfound canine friend?

I proceeded to operate on two more animals, all the while glancing at my new soul mate. We seemed now to have an understanding, and I could return his soulful gaze. Then the opportunity came. In the mid-afternoon, a man walked through the laboratory. He was a plumber who had been summoned to fix some pipes in the building. He stopped and said, “What a beautiful animal.” I said, “You can have him if you want.” He said, “Oh, that’s great.

We have one dog, and we both work. We were thinking of getting another one to keep ours company during the day.” He took the dog by the leash and happily went out the door. But not before the dog and I shared one good-bye gaze—a pat on the head—a friendly lick of his tongue.

The results of my research that year were later published in Physiologist, the Journal of the American Medical Association, and Archives of Surgery. What’s more important to me now, though, is the dog with the soulful eyes whom I will never forget.

Mike Denney, MD, PhD, is a former editor of San Francisco Medicine.

www.sfms.org

Animals in Medicine

A Dog in the Office A Pug Goes beyond Greeting Patients in One Psychotherapy Office

Uma Lerner, MD

P

acino Lerner is a four-year-old fawn pug dog. He was adopted by his parents, George and Uma Lerner, at the tender age of eight weeks.

Pacino was able to participate in much of his parents’ psychiatric residency training and managed to learn a fair amount about diagnosis, case formulation, interpretation, and treatment. He has been assisting in his mother’s private psychiatry office for the past year, and it seems he has quite a knack for therapy.

Pacino greets the patients in the waiting room and walks them back to the office. Like a seasoned psychotherapist, he can, within the first five minutes, identify the patients struggling with depression.

He offers the supportive psychotherapy technique of flopping down right beside the person on the couch, offering his belly to be rubbed, and falling asleep. After weeks of this empathic gesture, a strong therapeutic alliance is built and Pacino moves on to his next intervention—acceptance and nurturance. This is carried out by Pacino standing on the person’s lap, licking his or her face, and then flopping over on the couch to fall asleep.

But he doesn’t only do supportive psychotherapy. He also does powerful work in transference and dream interpretation. Therapists have long known that patients can project information and feelings onto the treater, feelings that actually originate from another relationship or somewhere in the patient’s psyche.

Pacino has experienced his fair share of patient projections. Patient A began the session by talking about a stressor he experienced the past week. Pacino employed his falling-asleep technique. Mr. A was offended and hurt. He turned to the www.sfms.org

human therapist and said angrily, “I guess I’m too boring for Pacino.” This created an opportunity for the patient to talk about his feelings of insecurity and ideas about other people’s perceptions of him.

Patient B brought a dream to session.

The dream was marked by significant anxiety and featured her son, with whom she had been in conflict. The human therapist asked Ms. B what she thought the dream was about. She said she didn’t know and began recounting the dream again. Pacino had been asleep next to her, and at one point in the retelling, he got up and moved to the other side of the couch. “I afraid that my son will leave me, and that I will lose him!” Ms. B exclaimed.

Pacino is experienced in couples therapy as well. Patient C, who usually sits in the chair away from Pacino, brought his girlfriend into session one week. This time Mr. C sat on the couch. When his girlfriend attempted to sit next to him, he said, “No, that’s where Pacino sits,” thus forcing her to sit alone on the chair. After some discussion, the girlfriend asked Mr. C if she could move to the couch, and he agreed.

She sat on the opposite end of the couch far away from Mr. C. Pacino then moved from lying next to Mr. C to having his paws touching both Mr. C and his girlfriend. The two people began petting Pacino, and their hands met in the middle.

Now, Pacino does not only work with the “worried well.” He also has a few patients with schizophrenia, and with these patients reality testing is an important technique. Patient D has significant paranoia about being spied on. She believes that her apartment, her parents’ home, and the therapist’s office are all bugged.

The first day Ms. D met Pacino, he kept

an appropriate distance by sitting on the chair away from her. This is important with paranoid patients, as they can easily feel intruded upon. After about half the session had passed, Pacino jumped off the chair to join Ms. D. They eyed each other carefully from opposite sides of the couch.

Finally, the patient asked, “Is this a dog?”

The human therapist responded in the affirmative, and the patient asked, “How can you be sure?” The human therapist gave all the reasons she had for knowing.

For the first time in therapy, Ms. D relaxed.

Pacino moved closer and offered Ms. D his belly for petting.

As you can see, Pacino, the canine therapist, is very well versed in the art of psychotherapeutics. Of course, we have to give credit to his parents, George and Uma Lerner, and the family’s psychiatry residency program at UCSF. While Pacino offers a variety of techniques in working with the diverse group of patients whom he has in his practice, his most important skill is that he offers a safe and respectful environment and an empathic relationship.

Patients’ names and other details have been changed to protect confidentiality.

Uma Lerner, MD, is a psychiatrist in private practice in southern Marin. She is currently on the clinical faculty at UCSF and on staff at Marin General Hospital. Dr. Lerner completed medical school at Baylor College of Medicine and residency at UCSF. She sees both adults and teens in therapy and medication management.

January/February 2010 San Francisco Medicine 23

Animals in Medicine

Confessions of a Medical Canine Lessons from Uncredentialed Interspecies Practice

Buddy Wood (as interpreted by Steve Heilig)

Y

es, I am a dog—a purebred one, if you must know. I am here to confess that for a time I “practiced medicine”—or healing, at least—without a license. I do have a dog license, of course, but my training for clinical work is . . . well, nonexistent, really. I’m just a dog, but that seemed to be enough for many ailing people.

One of my human family members had seen other dogs in action in health care settings and seemed to think I’d be good at it too. There is training, or at least screening, for this sort of work, but we figured I could fake it well enough. I’m cleaner than some of the humans in those places, in any event. So, knowing that if you fake it well enough you are halfway in the door (even at the White House, it seems!), he took me to work at a local hospital—never mind which one, as we skipped the credentialing process—and I got to visit sick kids.

There’s a reason one of the first words many little humans utter is “doggy!” I would trot into a ward or room where the ailing kids were and relative pandemonium—the joyful kind—would ensue. Kids who had not smiled or spoken in some time would light up like bulbs. My tongue and tail might make more contact with them than their parents or some staff might prefer, but that couldn’t really be helped, and besides, I’m “cleaner” than many humans. I’m not bragging when I say that most kids loved it and could not wait for me—or one of my colleagues—to get back there. Most of the nurses and other staff seemed to concur.

I also went to a couple of hospices.

This was a tough crowd, but I used the same approach. Some of the patients,

usually older folks, were on heavy medication and had not responded to much stimulus lately. I had to use my expert nose/ tongue/tail technique on them too, and more than a few times, they would open their eyes and we’d see Buddy relaxing on the beach in Bolinas, CA. a flash of a smile— maybe the first in some time. I’ve been human might opine. Of course many of called “permanent puppy,” but when it us help blind or deaf people, and others comes to a good goofy dog of any age, who have trouble with mobility. Some of us might be able to sniff out cancer! many humans are always kids.

A true story: A renowned UCSF We rescue people in emergencies and surgeon once recalled that when he was on battlefields, find lost folks, try to help in medical school many decades ago, his keep airliners safe, and so forth. We might parents called to tell him that their be- even be the best presence there is for kids loved family dog was dying and that “his with conditions like autism, and some of time had come.” The student demurred, us help out in classrooms and prisons. So asking them to wait a couple weeks until you never know what we might show you. his exams were done and he could say As America’s greatest poet, Walt Whitgood-bye. They did so, but when he got man—who was even shaggier than me, home and saw the suffering of his pup, he by the way—noted, “I contain multitudes.” realized he had been selfish and vowed He must have known a good dog or three.

I’m eleven years old and retired from to never again make man or beast “wait” for his own purposes. The now-senior formal practice now, but I try to help surgeon had tears in his eyes when he where I might. It was nice to be able to recalled that long-ago lesson. So I suspect use my popularity for a good cause. As a that dog’s painful wait was not wholly in new book has it, “Every dog is a therapy vain, and that surgeon’s lesson resulted dog.” Now, even I admit that’s pushing in much less human suffering than might things, but I do try to set a good example, keeping in mind the wise human adage, have been the case otherwise.

Thus, we teach in many ways. Re- “Lord, help me to be the person my dog ports have shown that we dogs can believes me to be.” Or, as one of my pals improve productivity and morale in says, just spell “dog” backwards.

One last thing—are you planning to workplaces, courthouses, schools, and senior homes. Well, “duh,” as a teenaged eat the rest of that sandwich?

25 San Francisco Medicine January/February 2010 24 San Francisco Medicine January/February

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January/February 2010 San Francisco Medicine 25

Animals in Medicine

Inside the Animal Mind A PBS Series Explores the Nature of Animal Intelligence

Amanda Denz

A

re animals smart? Do they feel what we feel? Are they conscious of their lives and of the world around them?” asks George Page, narrator of a three-part PBS series entitled Inside the Animal Mind. Through a series of interviews with animal trainers, pet owners, and top researchers in the field of animal intelligence, Inside the Animal Mind explores these questions and attempts to provide answers, given the current impossibility of knowing the absolute truth.

Are Animals Intelligent?

One way animal researchers evaluate intelligence is based on the ability of an animal to create a “mental map.” Using a mental map shows that there is a thought process beyond behaviors learned by trial and error. Through several studies, researchers have proven the existence of mental maps in birds, bees, mice, and elephants.

Insight, or the ability to solve novel problems in one’s head, is another measure of intelligence. As a result of our insight as human beings, we often create tools to help us solve problems or achieve desired results. Jane Goodall, the wellknown primatologist, was one of the first humans to observe tool use in animals.

“When I first observed a chimpanzee at Gombee using an object as a tool, there was a sense of disbelief among many scientists, because at that time we were supposed to be the only tool-using and tool-making animal. The chimpanzee not only used little pieces of grass to fish for termites but they would sometimes pick leafy twigs and strip the leaves off of them, which is the beginning of tool making.

That single observation was a very excit-

ing one. Since then we’ve realized that the chimpanzees use many objects in many different ways and they modify them very, very frequently,” says Goodall.

The ability to recognize patterns and concepts is yet another mark of intelligence. In one study, researchers demonstrated a pigeon’s ability to differentiate between works painted by Picasso and works painted by Monet.

But one of the ultimate marks of intelligence is the ability to engage in abstract thought—the apex of which is the understanding and use of language.

Many animals, from meerkats to ducks, use specific calls to each other that mean specific things. And dolphins take that understanding one step further: A dolphin understands that word order affects meaning—an ability not found in many other animals.

“The evidence from experiments on mental maps, problem solving, abstract thought, and language suggest that animals do vary in their mental abilities and that some minds may be similar to ours.

But why are animals like dolphins and chimpanzees so smart?” asks Page.

“To large-brained animals that live in social groups, intelligence is extremely important, because each of these other animals in a group has a personality and an individuality and you need to know exactly who is who in order to behave in an appropriate way,” explains Goodall. “Not only must you know your own relationship to each of these other individuals, but you also need to know their relationships with each other.”

In short, the complexities of social life demand a higher complexity of intelligence.

27 San Francisco Medicine January/February 2010 26 San Francisco Medicine January/February

Do Animals Have Emotions?

Every animal has a built-in response to danger, but do animals experience the emotion of fear? And what about happiness and love?

“I don’t think that anybody who has a knowledge of human children and who then is shown for the very first time a group of young chimpanzees playing could fail to believe that chimpanzee infants and human infants have the same kind of emotional needs and emotional expressions,” says Goodall. “It’s very easy to tell from the chimp’s facial expression the kind of emotion that he or she is feeling.”

Chimpanzees have faces that express emotions in the same way that we do, but not all animals have faces that we can read as easily. Does that mean their emotions are beyond our grasp?

“We’re such social beings and are so used to expressing the emotions we’re feeling that we are kind of taken aback by animals who do not visually express emotions,” explains Page. “In order to understand the nature of animal emotions, we must put the expression part aside and learn to understand the actual emotions.”

Animals regularly engage in behaviors that stimulate the pleasure center of the brain, and this can be a useful tool for survival—pleasure can make animals engage in behaviors necessary for survival in the same way that fear can help them avoid danger.

The behavior of chimpanzees in play has been shown to release dopamine, and play is a way to help chimps improve motor coordination and learn social skills that will help them survive in their society.

A study of baboons in the plains of Africa reveals that they can be sad and feel www.sfms.org

stress in a manner similar to ours. These baboons have enough food to eat and, as a result, not all of their day is taken up by eating and survival. In baboon society, the dominant males do a number of things to the lower-ranking males that place stress on them—they harass them psychologically—and these stressed baboons suffer from many of the same physical disorders as stressed humans, including ulcers, hardened arteries, and heart disease.

In animals exhibiting stress and anxiety, drugs such as Prozac remedy the situation in a similar manner as in humans.

It’s hard to draw the line between which animals have emotions and which do not. On the one hand you have animals that make decisions based on survival, and on the other you have animals that are capable of complex learning and make decisions that are not always cut and dry—decisions that might be based on emotions.

“Our inability to know what another creature feels is not evidence that it has no feelings,” says Page. “When we discover that not only the behavior but also the structure and chemistry of the brain is similar in humans and animals, then we have to assume that they feel as we do.

And treating animals as humans may not be such a big mistake.”

Are Animals Conscious?

“Human beings are aware of themselves in the world. Do other animals share this consciousness? Do they have thoughts, dreams, fears?” asks Page.

“Humans have come to accept that some animals have consciousness, such as dogs and monkeys, but what about jellyfish? Where do we draw the line?” he continues.

The first step to answering this question is to define what exactly consciousness is. This alone is a huge topic with more questions than answers, but scientists are currently finding ways to investigate.

Some defining factors include the ability to have abstract thought, selfawareness, and awareness of mortality.

The neocortex—part of brain used for abstract thought—is not something www.sfms.org

all animals have.

And self-awareness can mean different things, just as consciousness can mean different things. “At the most basic level, there is bodily selfawareness,” says journalist Stephen Budiansky. “Certainly my horse, when he walks through the woods, doesn’t bump into trees, so he is aware of the physical dimensions of his own body.

But there is another sort of self-awareness—and I think this is really the essence of the matter— which is the ability to be aware of one’s own existence as a being, to be able to imagine how others view us, to be aware of the consequences of Donkeys in a field. Photo by Shieva Khayam-Bashi, MD. one’s own actions, to be able to imagine the future for ourselves, animals. In a moment caught on camera, a and to contemplate our own mortality. group of deer are grazing when a member That is a very different thing.” of the group is shot. Once the deer recover One way that researchers test self- from the shock of the loud noise, they awareness is to evaluate an animal’s continue grazing—some of them mere response to his or her image in the mir- feet away from their fallen cohort—exhibror. Baboons act as if they are looking iting no change whatsoever in behavior. at another being in the mirror. Dolphins Elephants, on the other hand, regularly who see a mirror, on the other hand, do make visits to areas where the bones of not exhibit behaviors that they engage in deceased members of their group are toward other dolphins; they start making strewn. They spend hours caressing the poses and engaging in an entirely different bones and pacing around the site. They set of behaviors that are similar to how don’t do this with the bones of any other humans act when they see themselves. In animal they encounter. one test the researcher shows a chimpan“Throughout history, people have zee a mirror and then covers the mirror believed that the inner identity of a perand puts a sticker on the chimp’s forehead son survives death, that it lives on as the while patting her. The chimp goes about immortal soul,” says Page. “Could animals her regular behavior and a few minutes comprehend immortality? Could they later the researcher shows her the mir- share with us a wonder and a spiritual ror again. As soon as the chimp sees her awareness of the world?” reflection, she notices the red sticker. She In summary, Budiansky offers the immediately grasps her own forehead— following thought: Animals may experinot the image in the mirror—and removes ence the world in very different ways the sticker, showing that she understands than humans, and understanding that— that the sticker is on her head and that the rather than thinking of them as subpar mirror is simply a representation of reality. humans—is a truer way to appreciate Response to death also varies among their perspective of the world.

January/February 2010 San Francisco Medicine 27

Animals in Medicine

A Horse’s Prayer How do Animals View Humans?

Author Unknown

D

ear Lord, Please watch over our humans; they are so weak. They have no claws or teeth, they can’t run fast or fly away, neither can they burrow or build a nest in which to be safe.

They smell bad, do strange things that aren’t altogether intelligent, and have no real ability to communicate with us, although we are able to figure out what they want.

Lord, grant us the ability to watch over our humans; care for them; cheer them when they are down; make them A horse stands in a field at sunset. Photo by Shieva Khayam-Bashi, MD. laugh, smile; and shower them with our love. We pray that They expect us to know what they want the effort. You placed these humans in dowe can bring a little joy into their other- even though sometimes they don’t know minion over us, but you charged us with wise mundane existence and preserve the what we want. Some of them really try the task of caring for them and showing emotional and perhaps even psychic link and we know they love us, but some of them your love every day, through us.

God bless these mere mortal huthat we used to all share millions of years them are so dumb—yet our love for them mans; they know not that we are their remains intensely unfaltering. ago, but that they have, sadly, forgotten.

Lord, when we die, please make sure guardian angels sent in love to task them Lord . . . please let them know that when we insist on getting attention, it’s so to send us ahead to wherever our humans so that they may grow to be part of your we can check their emotional well-being are going to be, so we can pave the way plan.

Author unknown, reprinted from and boost their morale. When we pester for them, vouch for them, and be there for them for different foods, toys, etc., it’s them when they too die. Their souls are www.findingbeau.com/poems.htm. so they will learn to see us in ways they weighed by the good they’ve done in life, hadn’t considered, bringing them closer our souls are weighed by the good we’ve and back into the fold of Nature, which caused them to do. . . . Please allow us to they are part of but keep forgetting about. continue proving that humans are worth

29 San Francisco Medicine January/February 28 San Francisco Medicine January/February 2010

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January/February 2010 San Francisco Medicine 29

Hospital News CPMC

Damian Augustyn, MD

Congratulations to Dr. Robert I. Kahn, who was recently appointed chair of the Department of Urology for a five-year term. Dr. Kahn has been a member of the CPMC medical staff since 1985.

California Pacific Medical Center is now able to care for melanoma patients from head to toe. The Melanoma Program, one of our newest Physician Foundation programs, is pleased to announce the addition of three renowned physician specialists to the excellent melanoma services we already provide.

Joining Drs. Mark Singer, medical director of the Head and Neck Cancer Program, and David Minor, oncologist and melanoma research specialist, are Mohammed Kashani-Sabet, MD, director, Melanoma Program; Richard W. Sagebiel, MD, Melanoma Pathology; and Stanley P.L. Leong, MD, MS, FACS, Cutaneous Oncology.

The Melanoma Program offices are located at 2340 Clay St., second floor, on the Pacific campus. Drs. Kashani-Sabet, Sagebiel, and Leong bring years of experience in treating melanoma and cutaneous lymphoma, as well as diagnostic and pathology expertise in helping identify skin cancers earlier for better patient outcomes. Contact the Melanoma Program at (415) 600-3800 for more information or to refer a patient.

Kaiser

Robert Mithun, MD

Medical research supports the health benefits of owning a pet. While initially met with skepticism in scientific circles, grants from the National Institutes of Health (NIH) have given new weight to what pet owners have known for years—having a pet is good for your health.

In fact, in 2009 the NIH formed a partnership with Mars, the world’s largest maker of pet food, to fund and encourage research in this area of health promotion. This research found that people living in the San Francisco area who reported owning a pet had a 30 percent lower risk of developing non-Hodgkin’s lymphoma compared with non-pet owners.

The longer people owned a pet, the more protection from this illness they appeared to have.

At the Kaiser Permanente San Francisco Medical Center, our long-standing pet therapy program has enhanced the therapeutic process for many of our inpatient members, including many pediatric patients who are receiving care for a variety of conditions. Our pet therapy team includes not only dogs but also cats and rabbits.

Several geriatric nurses have reported that their dementia patients appear more alert when pets are brought to their bedside, and many adult patients feel a greater sense of ease when petting one of the animals rounding on the hospital units. Patients who spend extended periods of time in the hospital report that a pet visit helps minimize their stress.

Additionally, animals often have a calming effect on combative patients, while they enliven those who are more withdrawn.

We are pleased to include therapeutic animal visits for many of our hospital members and look forward to further research supporting our efforts.

30 San Francisco Medicine January/February 2010 31 San Francisco Medicine January/February

Saint Francis

Patricia Galamba, MD

Assistance animals not only guide the visually and hearing impaired; they also can help persons with physical and mental disabilities.

Saint Francis Memorial Hospital has actively supported a pet therapy program at our hospital for a number of years. With the help of our friends at the San Francisco SPCA, we have been able to provide certified pet visits to our inpatients, two to three times a week. Two of our regular visitors include a charming West Highland terrier named Angus and a lovable goldendoodle by the name of Zola.

The American Heart Association has shown scientifically that pet therapy can alleviate anxiety and ease the fears of hospitalized patients. We know that a pet therapy visit can decrease stress hormones and improve blood pressure as well as provide a distraction from the pain patients feel. Our visiting pet therapists (mostly certified dogs) often visit patients in our Stroke Program and Acute Rehabilitation Center, helping patients improve movement, speech, and cognitive functioning.

Pet visits to our Oncology and Infusion Centers provide therapeutic support and bring a smile to our patients’ faces.

Pet therapy visits not only help our patients; they also lift the spirits of our staff, visitors, and volunteers. You can hardly resist an amiable four-legged friend in a hospital setting. They provide unconditional love and bring joy to the day. We often hear patients say that these visits were the highlights of their days. In addition to the active program with the SPCA, our patients are also allowed to have their own pets visit them during hospitalization.

With 2010 upon us, let me wish the members of the San Francisco Medical Society and medical community a happy, healthy, and prosperous New Year. www.sfms.org

Hospital News UCSF

Elena Gates, MD

Dogs and humans share more than companionship. “Our long relationship with dogs provides knowledge about canine medical issues, including anxiety disorders that are very similar to those seen in humans,” says UCSF geneticist Steven Hamilton, MD, PhD. Hamilton’s lab, partly funded by the NIH, is looking for genes associated with anxiety conditions in more than 1,000 dog saliva and blood samples provided by owners and veterinarians. Finding genetic variants should increase understanding of the biochemistry triggering human anxiety disorders and, Hamilton hopes, improve treatments. Hamilton is using similar approaches to explore genetic commonalities in age-related hearing loss between humans and dogs. For two decades, dogs have been comforting children at the UCSF Children’s Hospital. Studies show the benefits of animal-assisted therapy, including stress reduction and lower blood pressure.

Each week, specially trained canines and their handlers visit sick children; parents often comment it’s the first time their child has smiled in weeks. “The unconditional love of a dog offers a sense of connection and happiness, especially for those children in neutropenic isolation. It’s a simple act with huge benefits,” says Michael Towne, manager of UCSF Child Life Services. The hospital plans to bring a permanent canine companion to its playroom soon. Kyvan Nguyen, PharmD, completed the Clinical Veterinary Pharmacy residency at U.C. Davis School of Veterinary Medicine, the only training of its kind in the nation. Nguyen combines his knowledge of human medicine with an understanding of veterinary medicine by directing a new UCSF veterinary drug compounding service. The program will cover the needs of numerous veterinary institutions, such as zoos and private practices. Nguyen also coordinates the veterinary elective course for UCSF pharmacy students. www.sfms.org

Veterans

Diana Nicoll, MD, PhD, MPA

Paul Volberding, MD, chief of Medicine at the San Francisco V.A. Medical Center and a widely recognized pioneer in HIV/AIDS care and treatment, has created a video documentary on the first years of the AIDS epidemic in San Francisco.

Life Before the Lifeboat: San Francisco’s Courageous Response to the AIDS Outbreak was created by Dr. Volberding in collaboration with director, writer, and producer Shipra Shukla.

The thirty-minute video features interviews with many of the people who helped shape San Francisco’s initial response to the unprecedented epidemic. “I was invited to give a lecture on the early HIV epidemic here in San Francisco, but I was concerned that my viewpoint would

be biased compared to the experience of many others,” says Volberding. “So I had the idea of interviewing others involved during the early days of the epidemic and was fortunate to find a video producer who could help me realize this vision.”

As chief oncologist at San Francisco General Hospital in June 1981, Dr. Volberding treated some of the very first documented cases of AIDS in the U.S. He went on to cofound one of the first AIDS clinics and played a key role in developing HIV/AIDS treatment practices and protocols that are still the standard of care today.

“I firmly believe there are important lessons to be learned from such a traumatic experience and hope that this film conveys that,” he says. In connection with World AIDS Day, the film was premiered at SFGH and other locations in San Francisco. It is currently being shown across the country. Dr. Volberding is principal investigator and codirector of the UCSF Center for AIDS Research. Over the course of the AIDS epidemic, he has served in a variety of policymaking and advisory capacities nationally and internationally.

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Public Health Update Angela Pang

SF Hep B Free Clinician Honor Roll

T

his winter, the San Francisco Hep B Free campaign will begin publication of the San Francisco Hep B Free Clinician Honor Roll to promote the growing number of doctor’s offices that are testing patients for hepatitis B and working to prevent liver cancer.

“It should be standard of care for all primary care physicians to screen and test Asian and Pacific Islanders for hepatitis B,” said Mitch Katz, MD, director of the San Francisco Department of Public Health. “We want to highlight those who are already actively working to prevent hepatitis B in San Francisco and to inspire other physicians to do the same.”

The list will be widely publicized among peers, patients, and the public at large. It will run in publications including this one, mainstream news outlets, digital media, and ethnic media such as Sing Tao Daily, Philippine News, Korea Times, and AsianWeek.com.

The Honor Roll features more than 700 clinicians and debuted on Oct. 15 at the “B a Hero” Gala, an annual fund-raiser for SF Hep B Free. The list is now available on sfhepbfree.org.

Establishing the Clinician Honor Roll follows the release last year of new national screening guidelines for hepatitis B, established by the Centers for Disease Control. SF Hep B Free’s goal is to have every primary care provider routinely screen patients for hepatitis B. The San Francisco Hep B Free Clinician Honor Roll includes any clinician who has completed a patient follow-up form for the San Francisco Department of Public Health Chronic Viral Hepatitis Registry before August 2009. Other clinicians can join the Honor Roll by signing a pledge to screen patients at risk

for HBV infections in accordance with CDC guidelines, or by responding to information requests from the SFDPH regarding patients with chronic hepatitis B. “As a doctor in a city where more than one third of residents are Asian, I always make it a priority to screen my Asian and Pacific Islander patients for hepatitis B, which gravely affects 1 in 10 and can lead to liver cancer and death,” said Dr. Lisa WingYee Tang, who works at Kaiser Permanente in San Francisco and chairs the SF Hep B Free Clinician Outreach Committee.

“I encourage my colleagues to screen as well. Liver cancer is a disease that can be prevented.”

Susan Fernyak, MD, director of Communicable Disease Control and Prevention at the SF Department of Public Health, hopes the Honor Roll will include every eligible physician in San Francisco. “We encourage all clinicians serving adults—including obstetricians, gynecologists, and family practitioners—to sign the new pledge form as a commitment to collaborate with the San Francisco Department of Public Health in its efforts to prevent the transmission of hepatitis B in San Francisco,” said Fernyak.

“San Francisco has the highest liver cancer rate in the nation, and if doctors make a conscious effort to screen for this disease, we can one day eradicate hepatitis B,” added Tang.

The SF Hep B Free Honor Roll project is being coordinated through the AsianWeek Foundation, in partnership with the San Francisco Department of Public Health.

To become included on the San Francisco Hep B Free Clinician Honor Roll, pledge online today at http://sfhepbfree.org/ clinicians/ or call (415) 321-5894.

Clinician Pledge I, _______________________________, pledge to be a Hepatitis B Clinician Hero by: Screening patients at risk for chronic viral hepatitis B infection in accordance with the national guidelines published by the Centers for Disease Control and Prevention, including all patients from areas of the globe with intermediate to high prevalence rates, especially Asia and the Pacific Islands. www. cdc. gov/MMWR MMWR 2008; 57 (RR-8) – OR – Returning a completed chronic hepatitis B patient follow up form for patients with positive HBV lab results to the SFDPH Chronic Viral Hepatitis Registry as requested. Signature: ___________________________________________Today’s Date: ________________________________ Clinician Name (please print clearly):_____________________________________________________________________ Title (MD, NP, etc.): ______________ Name of Practice (if different from above):___________________________________________________________________________________________________ Mailing Address:________________________________________________________________________________________________________________________________ Phone: _______________________________________Fax:_________________________________ Email: ______________________________________________________ To be included on the SF Hep B Free Honor Roll, please FAX this form to (415) 397-3080.

32 San Francisco Medicine January/February 2010 33 San Francisco Medicine January/February

www.sfms.org

Healthy San Francisco Update Steve Heilig, MPH

Our Local Public Option

O

n my walk to work one morning, I heard my name being called, and there was Morris, a pal of many years whom I had not seen in a long time. We stopped to chat and I noted his very obvious limp—in fact, his severely bent knee was visible even through his pant leg. “It was an old football injury that never got fixed, and then the arthritis turned it really bad,” he explained.

“It’s been miserable, man,” he went on. “But I am getting it fixed just next week—and it will cost me only a couple hundred bucks because of a new program called Healthy San Francisco— have you heard of it?”

I nodded and mentioned that in fact I had served on the group appointed by the mayor to help design the program. And then something memorable happened. Morris—a street-tough African-American who has long been self-employed, with no health insurance—looked me in the eye, grabbed me by the shoulders, and hugged me, saying, “Thank you, thank you,” adding, “It hurt so bad for so long, I didn’t know if I was gonna make it.” I have to admit I got a bit choked up.

Implementation of Healthy San Francisco (HSF) began in 2007, after completion of initial guidelines by Mayor Newsom’s Universal Health Council. The goal was to provide access to the up to 80,000 San Francisco residents without any health insurance. As of the end of 2009, approximately 50,000 patients have enrolled.

As described on the HSF website, “Healthy San Francisco is not insurance but provides a ‘medical home’ and primary physician to each program participant, allowing a greater focus on preventive care, as well as specialty care, urgent and emergency care, laboratory, inpatient hospitalization, radiology, and pharmaceuticals.” HSF is administered by the SF Department of Public Health.

San Francisco Director of Health Mitch Katz, MD, feels that “it is very rewarding that while the country continues to debate about whom to include in health care coverage, and who should provide the coverage (public or private), San Francisco has already enrolled over 49,000 uninsured persons to a program that provides comprehensive coverage. Unlike the divisiveness that characterizes the federal debate, San Francisco succeeds because of the willingness and desire of the providers (public and private) to work together to solve the problem.”

The “medical homes” are 50 percent in SFDPH clinics, including that at SF General Hospital; 43 percent in other community clinics; and 7 percent other, including private medical offices and Kaiser Permanente. The Chinese Community Health Care www.sfms.org

Association has been an early participant in terms of providing private physician sites. Patients are from all neighborhoods in the city and must have income below 500 percent of the federal poverty level (about $50,000 per year).

Depending on income, patients pay a quarterly fee and point-of-service fees. Employers of more than twenty people are required to provide some kind of health access. The mandated employer contribution has been controversial and a local restaurant association has sued to stop it, but to date, HSF has prevailed in court (and the SFMS has supported the health department in those cases). Independent evaluations of the program have shown that it has not had an adverse impact on employment, and that patients rate it very highly.

As for local restaurants, the San Francisco Chronicle noted that “most owners pass along the costs of city-mandated health care coverage to their customers—and say they’re delighted to finally be able to afford it. Most customers say they’re OK with paying extra.” As for the 1 percent of customers who have complained about it, noted one eatery owner in the same story, “They were the 1 percent we didn’t want to come back anyway.”

UCSF cardiologist and SFMS past-President Gordon Fung, MD, also served on the committees designing and implementing HSF. He now notes, “What started out as a bold experiment in a conference room full of stakeholders is morphing into a health care delivery mechanism that is providing chronic disease management and prevention, supporting innovation in increasing efficiency in the system of delivery, and decreasing expensive emergency room usage. The health care community continues to increase its support of the program through cooperative projects to improve access.”

Despite numerous kinks still be worked out and much patient and public education still to be done, HSF has drawn positive attention nationwide, even garnering comments from President Obama. Although the initial plans to have such a “public option” in national health reform have not panned out, it is perhaps ironic—although also characteristic—that San Francisco has implemented such a program. And on a personal note, the little part that I and the SFMS have contributed to this program makes me proud.

As for my old friend Morris, the next time I saw him, he was walking just fine. He smiled and said, “My leg is 100 percent better—pretty soon, I’ll be dancing again, too!”

Healthy San Francisco information and patient enrollment: www.healthysanfrancisco.org.

January/February 2010 San Francisco Medicine 33

In Memoriam Nancy Thomson, MD

Edwin M. Jacobs, MD

Bernard M. Kramer, MD

Edwin M. Jacobs, MD, age 84, died peacefully at home on Saturday, October 17, 2009. Born in San Francisco on September 8, 1925, he was a fourth-generation Californian. He attended Presidio Open Air Grammar School and Montezuma High School, after which, at age 18, he enlisted in the U.S. Army 86th Division Blackhawks. He saw combat duty first in Europe and then in the Philippines.

Upon return, he received a bachelor’s degree from Portland’s Reed College and his medical degree from New York’s Cornell Medical School, with training in the developing fields of oncology and chemotherapy. After ten years’ training, he returned to San Francisco, joining the San Francisco Medical Society in 1963. He was appointed head of Clinical Research at UCSF’s Cancer Institute, where he was a pioneering oncologist in northern California in the use of chemotherapies. For fifteen years, he devoted his considerable expertise and compassion to his patients, who adored and respected him. One of his very first patients, riddled with cancer, is still alive at age 70, thanks to Dr. Jacobs’s innovative treatments.

Dr. Jacobs then went on to the National Institutes of Health in Washington, D.C., for a decade, allocating grant money for the country’s regional cancer centers. Returning home in 1985, he continued donating his time and skills to professional groups such as UCSF’s Protocol Review Committee. He received many honors for his service and dedication.

In addition to his love for medicine, a passion for music dominated his life ever since he first attended concerts as a young boy. Beautiful performances never ceased to enthrall him, and his knowledge of the repertoire was vast. With his friend Dick Wahlberg, he spent many afternoons listening to and discussing music. A patron of the performing arts, he was a member of the Pierre Monteux Society.

Dr. Jacobs is survived by his beloved wife, Shari; stepsons David, Walter, and Robert; his brother Bob (Nina) Jacobs; adored grandchildren Loren and Aaron; and many cousins and devoted friends.

Dr. Bernard M. Kramer, MD, died September 23, 2009, in Napa, California, at the age of 80. He was born April 20, 1929, to Dora and Samuel Kramer in Fond du Lac, Wisconsin, and raised in Milwaukee.

He received his medical degree in 1952 from the University of Wisconsin in Madison and moved to San Francisco in 1953 to intern at Mount Zion Hospital. From 1953 to 1955 he was a first lieutenant in the U.S. Army and was decorated with the Army Occupation Medal and the National Defense Service Medal.

Dr. Kramer completed his residency in otorhinolaryngology at UCSF in 1958. He was a fellow of the American College of Surgeons and a member of the American Academy of Otolaryngology, the American Board of Otolaryngology, and the San Francisco Medical Society. He was a clinical professor at UCSF, where he taught surgery for thirty-five years.

He became interested in nonsurgical consultative practice for general otolaryngology with special emphasis on snoring, sleep apnea, and hearing loss. He was founder and president of Sleep Labs, Inc., and coinventor of Snoremaster (PureSleep).

Dr. Kramer was committed to community service and served on the board of directors of the SF SPCA for more than twenty-five years. He was on the advisory board of San Francisco School Volunteers and was a founder of the Institute for Myeloma and Bone Cancer Research (IMBCR) in Los Angeles.

He served on the hospital ship HOPE (Health Opportunities for People Everywhere) in Jakarta, Saigon, and Nigeria and as deputy director of Project Hope in Eastern Europe.

Dr. Kramer is survived by his wife, Elizabeth Jill; his daughters, Elizabeth Wrege (Kevin) and Margot Boehle (Kyle); and three grandchildren.

Visit Our Blog!

http://sfmedicalsociety.wordpress.com/ 34 San Francisco Medicine January/February 2010

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