AN RANCISCO EDICINE S F M VOL.82 NO.5 June 2009 $5.00
JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY
Ritual in Medicine
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In This Issue
SAN FRANCISCO MEDICINE June 2009 Volume 82, Number 5
Ritual in Medicine FEATURE ARTICLES
12 Symbols of Healing Jeanne Achterberg, PhD
13 Procedure, Ritual, and Medicine Ashley Skabar
15 Surgery as Ritual Tonya Clayton
17 Outgrowing the Short White Coat Eisha B. Zaid
19 Cultural Rituals Surrounding Healing Amber Elizabeth Lynn Gray
21 Learning Human Anatomy Neal H. Cohen, MD, MPH, MS, and Andrew Corson 22 Rituals in Spiritual Care Rev. Michele Shields, D.Min
23 Ritual in Family Medicine Ann Marie Chiasson, MD, MPH, CCFP 26 A Ritual to Say Goodbye Steve Heilig, MPH
27 An Ancient Ritual for Healing Chanda Williams, MA
MONTHLY COLUMNS 4 On Your Behalf
5 Health Care Reform Steve Heilig, MPH
7 Executive Memo Mary Lou Licwinko, JD, MHSA
9 President’s Message Charles Wibbelsman, MD
10 Editorial Mike Denney, MD, PhD 28 Hospital News
30 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
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June 2009 San Francisco Medicine
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On Your Behalf June 2009 A Sampling of Activities and Actions of Interest to SFMS Members
Volume 82, Number 5 Editor Mike Denney
Managing Editor Amanda Denz Copy Editor Mary VanClay Editorial Board Chairman Mike Denney
Obituarist Nancy Thomson
Stephen Askin
Shieva Khayam-Bashi
Gordon Fung
Ricki Pollycove
Toni Brayer
Linda Hawes-Clever Erica Goode
Gretchen Gooding
Arthur Lyons
Terri Pickering
Stephen Walsh
SFMS Officers
President Charles J. Wibbelsman
President-Elect Michael Rokeach
Secretary George A. Fouras Treasurer Gary L. Chan Editor Mike Denney
Immediate Past President Steven H. Fugaro SFMS Executive Staff
Executive Director Mary Lou Licwinko
Director ofPublicHealth &Education Steve Heilig
Director of Administration Posi Lyon
Director of Membership Therese Porter
Director of Communications Amanda Denz
Board of Directors Term:
Jeffrey Newman
Andrew F. Calman
Michael H. Siu
Jan 2009-Dec 2010 Jeffery Beane
Lawrence Cheung Peter J. Curran
Thomas H. Lee
Richard A. Podolin Rodman S. Rogers Term:
Jan 2008-Dec 2010 Jennifer H. Do
Keith E. Loring
William A. Miller
Thomas J. Peitz
Daniel M. Raybin Term:
Jan 2007-Dec 2009 Brian T. Andrews Lucy S. Crain
Jane M. Hightower Donald C. Kitt Jordan Shlain Lily M. Tan
Shannon UdovicConstant
CMA Trustee Robert J. Margolin AMA Representatives
H. Hugh Vincent, Delegate
Robert J. Margolin, Alternate Delegate 4
San Francisco Medicine June 2009
Making Membership Matter As a member, you can make a meaningful contribution to the health of San Francisco. Over the next several months, Membership Update bulletins will be featuring opportunities for members to get involved in community outreach projects, public health, and other volunteer projects. If you do not yet receive the Membership Update by e-mail or fax, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.
Shaping the Future of the Medical Profession
Are you an active member who works with residents? SFMS is making an especial effort to reach out to San Francisco-based residents. Because of an arrangement between the California Medical Association and the San Francisco Medical Society, dues are complimentary for the duration of the physician’s residency. The Membership Department will be visiting medical staff offices at the City’s hospitals throughout the summer. If you have a graduate medical office, contact, or suggestion for outreach opportunities, please contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@ sfms.org.
Help Grow the San Francisco Medical Society/California Medical Association and Get a Break on Your Dues Members of the San Francisco Medical Society/California Medical Association know that participation in organized medicine benefits both physicians and their patients. SFMS members have been helping to shape the future of medicine for nearly 150 years. If each member of the San Francisco Medical Society/California Medical Association encouraged just one new member from among their physician peers to join, SFMS/ CMA would become an even more powerful force in the legislature, the courts, and the media, and on the local level. Through the
“Connect the Docs” program, CMA and SFMS reward peer-to-peer recruitment. If you are a full-dues paying member of SFMS/CMA: Recruit three new full-dues paying members and get a 50% discount on your 2010 CMA dues (SFMS dues remain due and payable). Recruit five or more new full-dues paying members and get a 100% discount on your 2010 CMA dues (SFMS dues remain due and payable). In addition, any SFMS member who refers four or more new members also gets free SFMS dues for the upcoming dues year, in addition to the CMA discount TPMG members’ dues are paid by Kaiser, but if a TPMG physician refers five or more members, he or she will receive two free tickets to the SFMS Annual Dinner. To receive dues rewards, you need to bring in three or more new members by the end of September 2009. Be sure that your referred peer completes the “referred by” information so that you receive appropriate credit. You could be paying reduced, or even no, CMA/SFMS dues for 2010! Joining has never been easier with the online application system. All a prospective member has to do is visit www.sfms.com and click on the “JOIN SFMS” button in the upper right-hand corner. If the new member has never been a member of CMA before, they may be eligible for a 50% discount on their first year of dues. You—or the prospective member—can also contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org with questions or to have a membership information packet sent.
An Exciting Update about Dues
Starting with the 2010 dues period, members will be able to pay their dues in either monthly or quarterly installments using their credit card. Watch for further details about this new and convenient way to manage your membership.
www.sfms.org
Advocacy Report
Health Care Reform The Year of Predicting Dangerously Steve Heilig, MPH Is 2009 the year of major reform of the American health care system? That seems to be a near-consensus among some very smart people. Others, veterans who have heard variations on this theme before, are not placing any bets yet. At this year’s sold-out CMA Health Care Leadership Academy, what should and/or might happen depended on who was speaking. The faculty was a stellar group overall. Diagnosis, prognosis, and optimal therapy were laid out by generalists and specialists, but there was so much conflict on all three counts that some sort of “ethics consult” was indicated. “It’s misleading to say we even have a health care system,” quipped John Noseworthy, MD, of the Mayo Clinic. “We get exactly what we pay for now—a dysfunctional bureaucracy that delivers very mixed quality.” His point was probably best illustrated by Anthony Iton, MD, JD, MPH, director of public health for Alameda County. Iton’s exploration of what he called “health apartheid”—albeit in an evidence-based, noninflammatory manner—was a highlight, despite making some feel we needed antidepressants right then. “I spent my clinical time trying to change poor behaviors and found that very frustrating,” Iton recalled. “I was trying to cure social ills with pills.” His skilled mapping of health and socioeconomic factors left little doubt that factors such as education, housing, nutrition— what he called “the life-sustaining resources of my patient, the community”—influence health more than medicine alone. “The medical model is important,” he averred, “but if you walk into a community on fire, you do put out the fires first. “But you have to look upstream at what’s causing the fires,” he added. Still, noted Francis Crosson, MD, of Kaiser Permanente’s Health Policy group, “this is the year of health system reform, and the only thing worse than no www.sfms.org
reform is bad reform—we should take a sort of Hippocratic approach to health policy.” He described the increasingly popular “medical home” model—one that relies upon primary care physicians. He and others made it clear that there will not be enough of those in the not-too-distant future, given current trends, and that “if physicians don’t address those shortages, some other group will take up the slack.” The biggest “system,” of course, is Medicare. Michael Cannon of the libertarian Cato Institute (funded by “big tobacco” and “big pharma”) opined that “Medicare is the single biggest reason for the decline in quality in health care.” He offered no solutions. A more real-world perspective was provided by Howard Dean, MD, who noted, “What’s happened in the last ten years is that Medicare has not gotten any better, but private insurance has gotten much worse.” Dean pinpointed this as a major reason for the surge in support for some sort of single-payer system, even among physicians. But as Noseworthy had already predicted, “The only way we’d get a single-payer system would be if there was a total collapse of what we have now.” Dr. Dean—who had even the Orange County audience mostly eating up his lunchtime remarks—unsurprisingly made a pitch for the sort of “public option” system the Obama administration is working toward. “I do think that for the first time we will have reform that will mean something,” he said. But he too focused on prevention and behavior: “The biggest problem in American health is that we think we can eat at McDonald’s for forty years and then in the last year somebody will stick something in us to fix everything” (many uneaten desserts were then left on the lunch tables). Dean shared the conviction that stronger incentives for primary care will be crucial.
Another absorbing lunchtime speaker, former senior Google “recovering geek” Adam Bosworth, felt that health care needed to catch up with banking and other industries that let customers do almost everything online on their own time, and that information technology would “democratize health care knowledge” so that we would all be “better educated patients who are much more compliant.” Thus saving money while improving quality—for those who have access, presumably. This is just a small sample of the conference’s many offerings—there were plenty of practical, practice-management-type sessions too. “Reform” is indeed hot in the halls of politics, and the sabers are rattling. Within two weeks of the meeting, the same folks who torpedoed Clinton-era reform were rolling out TV spots featuring horror stories about “socialized medicine” in Canada and Europe. Seeing scary graffiti on the wall, major players got together with Obama and pledged to cut $2 trillion in costs in the coming decade. The powerful interests with the most funding and lobbyists are at work again, and they usually—well, thus far, always—get their way and preserve the status quo. “Only fools predict the future,” somebody once said, and I would logically thus join in, but space prohibits that. So here is the best quasi-medical advice regarding reform I’ve heard yet: Don’t hold your breath. Details about the highly recommended meeting are here: www.cmanet.org/leadership/index.asp
June 2009 San Francisco Medicine
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The New Membership Directory Available Soon!!
The 2009–2010 SFMS Membership Directory and Desk Reference went out in June. This year’s Directory features a beautifully redesigned look and revamped content, with an expanded and updated Health Organization and Services section as well as a tear-out card you can use to make updates to your contact information. This trusted health care resource will also be available for sale. Members can order extra copies for $45, a significant discount from the nonmember cost. If you know of nonmembers who wish to purchase the Directory, they are available for $75, s/h included. To order additional Directories, contact Carol Nolan at (415) 561-0850 extension 0 or cnolan@ sfms.org.
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www.sfms.org www.sfms.org
Executive Memo Mary Lou Licwinko, JD, MHSA, and Steve Heilig, MPH
SFMS 2009 Community Health Agenda
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s San Francisco Medical Society members know, since its inception in 1868 SFMS has been an activist organization when it comes to the health of our community. Many projects and activities that have begun in San Francisco have gone on to have implications for the state and the nation. My column this month highlights the current SFMS community health agenda as well continuing activities that promote the health of San Francisco citizens.
Agenda for 2009
• Preserving the safety net and public health programs in times of severe budget cuts. Opposing Proposition 1D and 1E in special election. • Testifying in support of antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies. With the California Medical Association, submitting amicus brief opposing lawsuit to overturn the ban. • Working with Mayoral Task Force to develop and support the Healthy San Francisco program and participating in the lawsuit to preserve the program. • Providing physicians for medical consultation for the San Francisco Unified School District. • Working on legislation to allow minors to receive vaccines to prevent STIs without parental consent. • Participating in the Hep B Free program in San Francisco and educating physicians and patients on prevention and treatment of Hepatitis B.
SFMS Community Health Activities
REBUILDING AND PRESERVING SAN FRANCISCO GENERAL HOSPITAL: SFMS spokespersons have taken a lead in advocacy for full funding of the necessary seismically sound rebuild and in acting on the Mayoral committee to advise where and how that would occur. Many of our members and leaders trained and have practiced at SFGH. UNIVERSAL ACCESS TO CARE: SFMS leaders have long advocated that every San Franciscan should have access to quality medical care, and most recently our representatives served on www.sfms.org
the Mayoral Task Force that designed the Healthy San Francisco program. SFMS joined in the lawsuits to preserve that program as well. SFMS members advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s. ANTI-TOBACCO ADVOCACY: SFMS advocates were in leadership roles in the banning of tobacco smoking in San Francisco restaurants, ahead of the rest of the state and nation; we advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and more. SFMS recently signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies. HIV PREVENTION AND TREATMENT: The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more. SCHOOLS AND TEEN HEALTH: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and worked on improving school nutritional standards; it provides ongoing medical consultation to the SFUSD school health service. In addition, SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent. ENVIRONMENTAL HEALTH: SFMS’s many environmental health efforts include establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures. REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and national leader in advocating for women’s reproductive health and choice, including access to all medical-indicated services. This is just a sampling of SFMS advocacy on behalf of physicians, patients, and public. There has been, and will be, more such work, and members, both current and potential, are welcome to join in as we work for a healthier future. June 2009 San Francisco Medicine
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President’s Message Charles J. Wibbelsman
Physician “Rites”
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his month’s magazine brings us the unique topic of Rituals in Medicine. Beginning with our days in medical school, then residency, and eventually practice, we have all encountered some unique traditions and rituals in our profession. One of my first memories of such a “rite” was when I was a medical student working as an attendant in the emergency room of Good Samaritan Hospital in Cincinnati. Every evening at 9:00 p.m., the hospital chaplain would come to the hospital telephone operator’s room and turn on the overhead page. He would begin his sermon, “Now I lay me down to sleep, I pray the Lord my soul to keep” as the evening prayer. This overhead homily was heard by everyone in the hospital every single night. In the very busy emergency room, Father’s message was heard amid multiple conversations and cries of help. One evening a patient, who had just been a victim of an auto accident, was placed in an examination roomand fell asleep, as the wait for a physician was long. The patient was awakened by our traditional evening prayer and thought he had gone to heaven! The prayers continued. In addition to traditions and rituals of hospitals organizations, many subspecialties of medicine also have their own unique rituals. In pediatrics, whether one is practicing on the East Coast or West Coast, there is a well-understood and well-
respected “rite” between the pediatric attending physician and the pediatric resident or medical student currently on a pediatric rotation whenever a lumbar puncture (spinal tap) is performed on an infant or child. When the lumbar puncture is performed by a medical student or resident, and the results of the tap reveal a clear tap (no cells in the fluid), the student or resident lumbar puncturist receives a bottle of wine purchased by the attending pediatrician. This is a long-honored tradition among pediatricians. In the days before we had the haemophilus B vaccine and the meningococcal vaccines for infants and children, there were many children admitted to the hospital with meningitis or suspected meningitis. Lumbar punctures were a daily part of every pediatrician’s life. Today, many fewer spinal taps are performed compared with twenty years ago; however, the bottle of wine is still awaiting the medical student or resident. Traditions such as this one often originate in response to a common occurrence in medicine. However, after the need for that response passes—for example, in the story above after the vaccine was developed—the physicians who have long followed the tradition keep it alive, connecting us that practice now to the past. A ritual such as this then takes on a new meaning as it lives on, passed from physician to physician.
UCSF Welcomes New Chancellor Susan Desmond-Hellmann, MD, MPH, physician, pioneering cancer researcher, and biotechnology industry executive who most recently served as president of product development for the biotechnology company, Genentech, Inc., was named chancellor of UCSF on May 7, 2009, by the University of California Board of Regents and on the recommendation of UC President Mark G. Yudof, LLB. The appointment takes effect August 3, 2009. “Dr. Desmond-Hellmann brings exceptional science and health care expertise to the post, as well as the business savvy we need now to take advantage of the sea changes around us,” comments UCSF School of Pharmacy Dean Mary Anne Koda-Kimble, PharmD. “She is a new kind of chancellor for a new time—for a changing university.”
www.sfms.org
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Editorial Mike Denney, MD, PhD
Everyday Healing Rituals
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any years ago, a young surgeon started doing a little healing ritual in his practice. After years of the academic demands of medical school and the disciplined, exhausting, sometimes punitive training of residency, he had begun to feel that somewhere within the rigorous objectivity of science and the hectic rush of practice he had lost touch with the youthful ideals that had originally motivated him to become a doctor—a desire to help others, a heartfelt connection to community, a meaningful life of healing, a relationship with the mystery of life and death, and perhaps even a yearning for a sense of the divine in his work. That’s when the young surgeon began to perform his ritual. In the operating room, when a delicate procedure was essentially completed and it was time to close the thoracic or abdominal surgical wound, he would pause for a minute or two to look up from the exposed viscera to tell everyone in the room something about the anesthetized human being who lay there, hidden beneath the surgical drapery. He would tell something about the patient’s family or work or creativity, and perhaps add a phrase or two about the person’s hopes and dreams. Although this little ritual was highly meaningful to the young surgeon, the acknowledgment of information that was extraneous to the operative procedure expressed on a deeply personal, feeling, and soulful level proved to be very uncomfortable for some of the anesthesiologists, assistant surgeons, operating room nurses, and other personnel. It wasn’t long before he received a letter from the chief of the department of surgery. After the matter had been discussed by the Executive Committee, it had been decided that the young surgeon should desist from this ritualistic behavior because it disrupted the normal operating room routine and potentially could be detrimental to treatment outcomes. Some of the members of the committee suggested that his ritual would be better conducted in the hospital chapel. Of course, millennia before there was any such thing as “normal operating room routine,” it was normal for healing to be done by ritual. In his classic work Shamanism: Archaic Techniques of Ecstasy, Mircea Eliade, the twentieth-century historian and philosopher of religion at the University of Chicago, elucidated the roots of sacred healing by studying the medicine men of Siberia and Central Asia. Eliade noted that the shaman
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was believed to have died and been reborn, and thus could rise above human nature to reach a state of ecstasy in which he was in communication with the divine and not bound by the laws of life and death. Using a healing ritual of dance and drumming, the shaman entered a spiritual state of consciousness, traveling to the underworld to retrieve the lost souls of his patients. The shaman was “believed to cure, like all doctors, and to perform miracles.” Modern medicine would conclude that the “cures” were the result of a placebo response or mind-body phenomenon. There has been a long, tedious historical path from the rituals of shamanism through the development of such secular healing techniques as treating fever, tending to wounds, setting fractures, administering herbs, and soothing the emotionally disturbed, and then on to the advanced high-tech and scientific medicine of the twenty-first century. Still, even while recognizing the great advances in medical science, some healers wonder whether something has been lost in this exclusion of ritual from science. After Eliade’s groundbreaking work, there have been numerous books about the place of the essence of shamanism in modern healing. Such titles as The Soul of Shamanism, The Sacred Heritage, The Way of the Shaman, The Flowers of Wircuta, and The Shaman and the Medicine Wheel all attest to a growing sense that the spirit of soul in shamanism through healing ritual may have a place within modern medical practices. In her book The Scalpel and the Silver Bear, Lori Arviso Alvord, MD, the first Navajo board-certified surgeon, describes how she combines the traditions and rituals of indigenous American healing within her surgical practice. Alvord says, “In my culture—the Navajo culture—medicine is performed by a hataatii, someone who sees a person not simply as a body, but as a whole being. Body, mind, and spirit are seen as connected to other people, to families, to communities, and even to the planet and universe.” Inspired by his Cherokee and Lakota heritages, Lewis Mehl-Madrona, MD, PhD, a graduate of Stanford Medical School with residency training in family practice and psychiatry and a doctorate in clinical psychology, has published a trilogy of books that integrate indigenous American healing with conventional www.sfms.org
Western medicine—Coyote Medicine, Coyote Healing, and Coyote Wisdom. Convinced that ancient rituals and modern scientific medicine should be integrated in a way that offers patients the benefits of both, Mehl-Madrona asks, “Should conventional doctors be more like shamans? Should they care for the souls of their patients?” Without arguing the relative values of the disparate healing modalities of shamanism and modern medicine or doing statistical analyses of their respective treatment outcomes, we might find some integration by returning to the young surgeon who wanted to have a little ritual within his operative procedures. Is it only in the chapel that healing ritual is acceptable, or can it also find an appropriate place within normal hospital routines? After all, the young doctor was trying to rejuvenate his soul-felt desires and find meaning in his work. His ritual was one that meant a deeper relationship with the desires, hopes, and dreams of his patients. Is it reasonable to assume that his ritual might have inspired him to provide better preoperative, intraoperative, and postoperative care and that his more personal relationships might have offered patients great comfort, emotional well-being, and even improved physical healing? Was Hippocrates insightful when he said, “It is more important to know the person who has the disease than to know the disease the person has”? Was Sir William Osler wise when he said, “The secret to the care of the patient is caring for the patient”? Recently, like the young surgeon of many years ago whose operating room ritual was rejected by the medical staff, Dr. Yehonatan Turner, a young radiologist at Shaare Zedek Medical Center in Jerusalem, began a healing ritual. Turner felt too separated from the human beings whose CT scans and X-rays he routinely interpreted, so he began to attach to each file a photograph of the patient. He felt that seeing a photo of the patient’s face helped him relate more personally, which might then result in better radiographic reports, thus improving medical care. Instead of rejecting his ritual, the radiologists at Shaare Zedek agreed to participate in a controlled clinical study. The results were remarkable. When a photograph was attached to the patient’s file, the radiologists’ reports were more thorough, more recommendations were made, and more incidental findings were recorded. The radiologists also reported that the photographs of patients made them feel more like authentic physicians. The young surgeon who yearned for ritual in his operating room routine is now an elder who is delighted with the radiological study at Shaare Zadek Medical Center. He knows that scientific minds might judge him to be misguided. Nevertheless, he wonders what other routine medical procedures might be improved by integrating within them a ritual. He is curious as to whether it is possible that the hand washing doctors perform as they move from room to room could include a ritualistic component, offering an opportunity for meditation upon the patient’s wellbeing. Somewhere in his right-brain neocortex there dwells the www.sfms.org
fantasy that the simple act of placing patients into the mysterious temples of CAT and MRI scanning machines might be viewed as a sacred ritual related to the patient’s soul. Sometimes he wonders whether the spoken word, touch, and movements of all invasive and noninvasive medical procedures could more explicitly inspire an awareness of the patient’s hopes and desires for health and happiness. Indeed, he has the temerity to imagine that all acts of healing—looking into the eyes, palpating the body, auscultating the lungs, talking about illness and its treatment, listening to the heart—all of the aspects of the normal daily routine of medical care might tend the soul as well as the body if they were administered as everyday healing rituals.
Welcome New Members!
The San Francisco Medical Society would like to welcome the following new members: Ivan Cheng, MD—The Permanente Medical Group Lynn Flint, MD—Referred by MIEC Rochelle Gordon, MD—Referred by Sally Kaufmann, MD Lynne McInnes, MD—The Permanente Medical Group Loan P. Ngo, DO—The Permanente Medical Group— Referred by Chuck Wibbelsman, MD Kelly Pfeifer, MD—Administration/DPH John Touhy, DO—The Permanente Medical Group— Referred by Chuck Wibbelsman, MD Stewart Wong, MD—The Permanente Medical Group— Referred by Chuck Wibbelsman, MD
House Officers David Bowden—CPMC, Completion 2011 Mar Pravdin, MD—TPMG, Completion 2009 Afshin Zadfar, MD—TPMG, Completion 2009
UCSF Students Chelsea Bowman Eli Carrillo Christopher Cox Vanessa Diaz Edwin Dietrich Nicholas Gastelum Kate-Hirschmann-Levy Patricia Hom Tanzib Hossain Cali Johnson
Tom A. Joseph Kenneth Kay Anna Loeb Samali Lubega Chemtai Mungo Daniel Perez Nathan Singh Michael Torken Jacqueline Weiss
June 2009 San Francisco Medicine
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Ritual in Medicine
Symbols of Healing Ritual as the Foundation for Transpersonal Medicine
Jeanne Achterberg, PhD
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serious study of how humans help themselves and each other in times of illness is sobering, humbling, and shreds any mantle of arrogance that holds effective treatment to be a modern invention. From the beginning of recorded history, however, the search for the truth of what will cure or relieve suffering has proved to follow a convoluted and ever-mutating path. Potent psychotherapies come and go. Drugs listed in the Physicians’ Desk Reference (PDR) are said to lose their effectiveness quickly and must be replaced by new compounds with different names and shapes. Treatments and diagnoses also differ from tribe to tribe, even among the “tribes” of the Western world—Great Britain, Germany, the United States, and France—where outcomes are, nevertheless, essentially similar. If there is a thread of common experience running through the past and present of medicine, it is the ritual accompanying the medicaments, ministrations, and various gadgets that humans have used to treat each other for millennia. Indeed, these things and practices may well be regarded as symbols of healing only, and not the part of the process of healing itself. A wide range of cultural and temporal diversity in symbols is therefore to be expected, because all symbols must address the current metaphor or myth if they are to have any power to communicate or represent the unseen worlds. Therefore, let us put aside for a time any imputed psychologically or biologically active properties of the symbols of healing and look instead to any inherent healing potential of the ritual itself. 12
San Francisco Medicine June 2009
Ritual and Medicine Ritual is the medicine of the transpersonal—it reenacts in the outer world what is experienced in the invisible
“If there is a thread of common experience running through the past and present of medicine, it is the ritual accompanying the medicaments, ministrations, and various gadgets that humans have used to treat each other for millennia.”
world of dreams, death, vision, and feeling. Through ritual, people traverse their inner worlds of self and one another, connecting with thought, prayer, and the sustenance of their presence. Ritual, when performed in the truest sense, is done in space that is called sacred. Rituals for healing have the purpose of giving credence and significance to life’s transitions; they provide maps of form and guidance for behavior during perilous times when bodies, minds, and spirits are broken. The acts of ritual allow people to share their common experiences and to give visible support to one another. The symbols and events of healing ritual cement the healer/healed bonds and engender faith and hope that the passage into the place of wholeness, harmony, or
relief of suffering will be achieved. The dual face of healing ritual is that all members of the participating community benefit by receiving and by giving, by caring for others and surrendering to receive care. The other duality of healing ritual is that in transcendent moments, one is reminded both of the grounded, uniting connection in the flow of all life and, at the same time, one can perceive revelatory visions that are far beyond the life experience itself. Modern health care is by no means devoid of ritual. Physicians, badly miscast in the shaman’s role, are the ritual makers for most of life’s major passages—birth, death, pregnancy, menopause, puberty, and old age. A stay in the hospital or a visit to a clinic is heavily steeped in ritual, with prescribed behaviors, dress, and demeanor, and with prominently displayed symbols of healing (diplomas, the caduceus). These rites and symbols have great power—a nod of the head or a word can be either life-giving or the kiss of death. The missing element, therefore, is not ritual per se but rather an awareness of participation in its transpersonal functions. Healing rituals both reflect and create the values of a culture. Therefore, in our discussion, it is important to keep in mind that for many people (though not all), effective modern healing rituals must affirm the knowledge and wisdom of this time, including advanced technology and the marriage of health care to the scientific metaphor. Jeanne Achterberg, PhD, is Professor of Psychology and past president of the Association of Transpersonal Psychology. Visit www.jeanneachterberg.com for more. www.sfms.org
Ritual in Medicine
Procedure, Ritual, and Medicine A Discussion of Ritual in Medicine
Ashley Skabar “You must understand that in life we face two kinds of problems. One kind demands [the] question, ‘What are we going to do about it?’ The other calls for a different question: ‘How does one behave toward it?’” –Edward Golub quoting T.S. Eliot, from The Limits of Medicine: How Science Shapes Our Hopes for the Cure
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n contemplating this issue’s theme, Ritual and Medicine, several rituals that clearly function within medical practice immediately came to mind— namely, the structured procedures of medical practice itself, the personalized rituals created by individual physicians and surgeons within their practices, the ritualistic behaviors associated with psychological and behavioral disorders, and the various rituals patients create as coping methods while in treatment. However, interestingly, when presenting this notion of medical practices as ritual to several doctors, most claimed that they could think of none. In this article, I’d like to address this aversion to ritualistic association outside of the parameters of psychological diagnosis within the medical field, the difference between what is considered a procedure versus a ritual, and explore the possibility that perhaps this aversion is related to medicine’s modern representation as a science, or a “system of knowledge covering general truths or the operation of general laws especially as obtained and tested through scientific method.” In science, as in a puzzle, we are convinced that there is always an answer somewhere, or at the very least a tangible explanation. Science is an exploration of rules that moves through steps of study. www.sfms.org
While the study of the function of religious rituals and ceremonies within society has long been explored from sociological and anthropological vantages,
“While the study of the function of religious rituals and ceremonies within society has long been explored . . . much less has been focused on rituals inherent within the medical field . . .”
and cultural rituals have been studied and revered for their antiquity, much less has been focused on rituals inherent within the medical field, with the exceptions of classifying ritualistic behaviors in patients of psychological or behavioral disorders, or discussing what is most commonly referred to as “alternative” medicine. Within philosophical, cultural, or religious discussions, we are open to sociological analyses of the values of ritual and compulsion, especially those pertaining to death ceremonies and grieving; we accept and recognize the functionality of what André Droogers refers to as the “internal” and “external” dimensions of religious ritual, and we accept that meanings behind rituals are relative and not absolute. In his article “What Health Care Professionals Need to Know about Ritual: A First Lesson,” Tom F. Driver discusses the problematic title of patient and the impor-
tance of rituals in healing: The problem of healing begins (and ends) with the patient. We might even say that the problem begins with the naming of the patient as patient. For patient comes from the same root as pathos and passion, which means “to suffer” or “to undergo.” From the same root also comes passive. The problem of healing begins with the regard of the patient as the passive one, the one upon whom the affliction has come. The victim. . . . This way of thinking is changed, but also magnified, by medical science: Pain has an origin in some malfunction of the body, called a disease and given a specific name if possible. The aim of medicine is to find the offending disease, analyze its cause, eradicate that cause, and thus bring an end to the pain. (Driver, 3) Driver goes on to state that the “impulse to make ritual is the impulse to become actively involved,” spiritually and emotionally, in a process that is otherwise rational. To empower the patient, the medical professional, according to Driver, “has an important role to play. . . . It is the work of showing the patient, who is really a learner, what she is able to do for herself. . . . The first thing to know about ritual is that it is a way of calling ourselves to a radical affirmation of the here and now. The business of ritual is to unify.” (Driver, 17) In this argument, patients need rituals to connect with their recovery, and health care professionals will be more effective if they choose to “behave toward” a patient rather than “do about” a patient’s ailments. Continued on the following page . . .
June 2009 San Francisco Medicine
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Procedure, Ritual, and Medicine . . .
While Driver believes that more rituals are needed in the medical practice in conjunction with healing, some believe ritual to already have a distinct presence in the medical process. Tonya Clayton, in her article “Surgery as Ritual,” explores the similarities between tribal rituals with the modern process of surgery. The medical rituals of a patient are similar to the social rituals and rites of passage within tribes, according to Clayton. In her article, she highlights the preoperative fasting (as prescribed by the doctor’s “NPO” order), changing of clothes, cleansing, retreat from family, and reemergence into society as healed, and she likens these to traditional tribal rites of passage. Speaking specifically of plastic surgery, she quotes Dr. Loren Eskenazi, who boldly states that “plastic surgery is more about what’s going on in patients’ lives and less about their body parts than most people are willing to admit . . . if we had more ritual, there would be less plastic surgery in our society.” (Clayton, 1) In her article “The Key Role of Ritual in Modern Medicine,” M. L. Elks, a physician on the faculty of the Morehouse School of Medicine, likewise describes the process of modern diagnosis as “similar to primitive healing rituals” in that the patient is required to “confess misdeeds, wear special garments, and perform certain tasks,” after which a diagnosis is made. (Elks, 5) As could be argued by any physician, however, these procedures function as precautionary measures, providing safety for surgeon and patient, and are procedures, not rituals. Does it matter if we view these actions as procedures or rituals? In fact, by definition, procedure and ritual are not that different. A procedure, according to the Merriam-Webster Dictionary, is “a series of steps followed in a regular definite order” or “a traditional or established way of doing things,” while a ritual is defined as “an act or series of acts regularly repeated in a set precise manner.” The distinct difference that seems to exist between what we, in Western society, perceive as ritual and what we refer to as procedure could be surmised in Jan Platvoet’s definition in Pluralism and 14
San Francisco Medicine June 2009
Identity, which states that “Ritual may cause [persons] to experience a satisfactory social condition which can objectively be shown to be exploitive.” (Platvoet and van der Toorn, 35) In a procedure, there are concrete steps to some end. A ritual, however, is multilayered, saturated with meanings that can only be speculated upon by the observer, and is often discomfiting from an objective standpoint. While a sense of comfort and order is brought to the person enacting the ritual by virtue of this “satisfactory condition,” to the observer there can be only questions. With this in mind, Elks cautions fellow physicians regarding the rituals of interaction performed within medical practice: Often unconsciously, we doctors use these ritual aspects of medical practice to distance ourselves from the emotions of our patients, to keep ourselves from being overwhelmed by their traumas. We wear “power clothes” while the patient is nearly naked, covered only by the drape. When we keep patients waiting, we send the message that we are more important than they are. We often use technical language that patients cannot understand, in an attempt to deflect their likely emotional reactions to diagnoses of serious illness. (Elks, 5) While the learned procedures and rituals of modern medicine are in place perhaps in order to instill a sense of confidence by limiting the emotional connections between physicians and patients, these rituals, when viewed by the outsider—the patient—may instead be disconcerting. Perhaps the counterargument to Elks’ assertions is that that these rituals do, in fact comfort; the crisp difference between doctor and patient can provide guidelines and stability during the overwhelming distress of patienthood. This, again, brings us back to the nature of ritual, which is not based on absolute truths, as is the objectivity in science. For example, in reading Mike Denney’s editorial for this issue, I was intrigued by his story of the young surgeon, in which the physician creates a personalized ritual to give meaning and a “deeply personal,
feeling, and soulful” expression to his practice in the midst of “the rigorous objectivity of science.” For this young surgeon, his was a ritual created to humanize and personalize the patient in an effort to quell his own intense feelings during the procedure—a ritual that, as might be expected, was not accepted among his peers. As a patient who underwent an intensive hospital stay of several months, I developed what at first will seem less of a ritual and more of a hobby—the daily completion of The New York Times crossword puzzle. This is of interest to me now as many rituals are, in fact, similar to crossword puzzles in their function, seeking to add definition to abstract concepts and feelings in the way that a crossword puzzle defines stark, uncontrollable space, assuring the puzzled that there is a concrete answer to every question. Almost every patient with whom I was hospitalized also created her own ritualistic behaviors surrounding these puzzles, all founded upon arbitrary rules and time schedules; some needed to get the paper immediately after our morning vitals were taken, some needed to finish the puzzle from start to finish or from top to bottom, and so on. Of course, most persons could place their own meanings to these rituals. For me, it seemed simple: The hospital was a scary place, and, as some of us faced death and some of us recovery, in the face of grand uncertainty this simple ritual, this bit of controlled and instantly gratifying question-and-answer, was a calming structure in the midst of chaos. So, again: does it matter if we consider the medical practice one that is founded on procedures or one that is founded on rituals? Is there a compromise between the two? In his book The Limits of Medicine: How Science Shapes Our Hopes for the Cure, Edward Golub explores the history of medicine and medical science, as well as his model for a future medical profession that focuses on prolonging wellness rather than diagnosing disease. He begins his book with a quote by T.S. Eliot, made after a philosophical lecture at which the poet was asked, Continued on page 18 . . . www.sfms.org
Ritual in Medicine
Surgery as Ritual Elective Surgery as a Rite of Passage
Tonya Clayton
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t’s a day almost like any other in the operating room. A nurse sets up an IV, a technician lays out shiny instruments, and an anesthesiologist makes last-minute checks. But patient and surgeon are occupied with less conventional preparations. The patient, who has come for a new breast, walks in and positions two small rocks and two photographs on a rolling surgical tray. She then sits on the operating table, knee-to-knee and hand-in-hand with her doctor. The two talk softly, glancing now and then at the altar on the tray. The physician asks her patient what today’s surgery means to her, beyond the addition of a body part. They talk about femininity and energy and healing. After about ten minutes, the patient lies back and calmly spreads her arms. The medical team moves in, and the reconstructive surgery begins. The surgeon is Loren Eskenazi, MD, class of ’90, and that moment of pre-op connection is one way she honors the age-old urge to engage in ritual. Noting parallels between elective plastic surgery and ancient rites of passage, she says many Americans are using plastic surgery, consciously or unconsciously, as an initiation rite to mark significant transitions in their lives. Approaching surgery as ritual—what she calls “transformational surgery”—can benefit patient and physician, she says. “Plastic surgery is more about what’s going on in patients’ lives and less about their body parts than most people are willing to admit,” says Eskenazi, a boardcertified plastic surgeon in San Francisco and a fellow of the American College of Surgeons. She specializes in cosmetic and breast surgery for women and is a contributing author to Consciousness and Healing, a 2005 collection of essays on health, healing, www.sfms.org
and mind-body medicine.
Transformational in More Ways Than One Lydia Barrett, a 42-year-old software executive from Pleasanton, California, says she knew in March, after her fourteenth unsuccessful infertility treatment: “It’s time.” Within months she was in the OR with her two small rocks and the photos. “I had been living for four years with one breast, and I could have continued to do that,” says Barrett, who had a mastectomy in 2001. “But the reconstruction is, for me, really more than just surgery. It’s almost a gaining back of something around my femininity.” Having taught about cross-cultural practices of body modification when she was a Stanford resident, Eskenazi says that the timing of these elective surgeries is an initiatory process. “The whole surgical sequence is the exact same as any ritual sequence in any culture at any time throughout history.” She notes the basic similiarities: The occasion of a rite of passage is often some social or personal crisis. Similarly, patients are brought to surgeons’ offices by illness, accident, or another potentially life-changing event. Formal rites of passage often begin with fasting and contemplation. In the surgical sequence, the patient follows the doctor’s “NPO” order—nothing by mouth for hours before the operation. Ritual initiates are ceremonially cleansed with smoke or water. Surgery patients wash with antibacterial soap. Initiates are stripped of outer garments and redressed in ceremonial garb. Patients relinquish street clothes and don
standard-issue hospital gowns. Initiates ceremonially proceed to a temple or other sacred ground and lie down on an altar. Patients bid family a temporary good-bye, proceed to the “otherworldly” space of the OR, and lie on the operating table. Initiates undergo the transformational ceremony—often a blood ritual—in an altered state, induced perhaps by dancing, drumming, or hallucinogens. Patients yield consciousness to sodium thiopental and undergo surgery, which Eskenazi characterizes as “a modern blood ritual enacted for the purpose of healing.” Initiates rejoin their community as newly reborn into a different role: Perhaps a boy has become a man or a widow is available for remarriage. Patients emerge from the recovery room forever visibly changed, to undertake healing and rejuvenation. Eskenazi emphasizes she does not recommend using surgery as an initiation rite. Rather, she believes that while other societies engage in ceremonial ear piercing or tattooing to mark life transitions, plastic surgery has become something of a substitute ritual for Americans. “We don’t have the communal witnessing of a person stepping from one position in their life to another,” she says.
The Role of Ritual
“If we had more ritual, there would be less plastic surgery in our society,” says Eskenazi, who is writing a book about cosmetic surgery and ritual to be published by HarperCollins. The breast specialist says the surgeryas-ritual notion doesn’t fit every patient, but it resonates for some. So once a month
Continued on page 18 . . .
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Ritual in Medicine
Outgrowing the Short White Coat Ritual in Medical Education
Eisha B. Zaid
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ometimes I get the feeling that the pockets of my short white coat are about to rip. As a third-year medical student, I have made use of nearly every crevice of my coat, recently discovering the inner pockets. It is amazing how much one can fit in the pockets—everything from thick handbooks to a stethoscope to an iPhone to keys to pens to endless stacks of notes. My pockets are bulging, making sitting in a chair a bit challenging. I was given my white coat during our school’s White Coat Ceremony about two years ago. When I think back to the ceremony, I remember the excitement of being cloaked in a pristine white coat. In my three-inch black stilettos, I nervously hobbled on the stage, reminding myself not to trip and to breathe. My mind was racing, but when my name was called, I made my way to get my coat from my mentor, in what seemed like a blink of an eye and a white flash. One by one, we each received our coats. After all my classmates had been through the ritual, we stood up in our freshly ironed white coats and recited the Oath of Louis Lasagna, a modern version of the Hippocratic Oath. We stood unified, assuming a new identity and committing ourselves to the care of our future patients. ***** In September, I had the privilege of photographing the White Coat Ceremony and listening to the new first-year medical students recite the same oath. I saw the ceremony through my lens and vicariously relived the experience in my mind, some parts as clear as day, others hazy, and others completely forgotten. The sea of white coats spoke in unison. As they recited, I looked through www.sfms.org
my lens, snapping photographs. Frame by frame, I was reminded of a time not so long ago when I had just arrived on the UCSF campus, brighteyed and blissfully unaware. The dean welcomed the class of 2012 in the presence of the faculty members, whose names and faces I have come to know. Addressing the new students and their families, he reminded students that when you put the white coat on, you are “accepting a sacred responsibility to your patients.” According to one of the ceremony speakers, the first white coat was worn in medical settings 150 years ago. Surgeons were the first to wear the white coat, a symbol of cleanliness and sterility. Community doctors soon followed, picking up the coat and taking up the aseptic look in an initial attempt to differentiate the physicians from the quacks, in what the speaker described as a “massive publicity stunt.” As I watched the new medical students receive their coats, I could see the happiness and pride in their faces, along with a mix of disbelief, relief, and something to the effect of “I have no idea about what I’m getting myself into.” It was a pleasure to watch families congratulate their medical students and pose in the post-ceremony photographs. It was not so long ago when I was standing in those photographs smiling widely, unsure about what would happen next.
***** You start out as an actor in a white coat. One of the biggest challenges of the first year is differentiating yourself from the modern-day equivalent of a quack. In many ways, when you start out, the only thing that sets a medical student apart from most any person off the street is that white coat. We put it on and take on the role of the student doctor even though we have very limited knowledge of medicine, let alone skills in conducting a patient interview and physical exam. We fumble with our words and stethoscopes, hoping our patients take us seriously. You put on your white coat and start by interviewing standardized patients, actors who memorize a script and usually have normal physical exam findings. In your coat, you provide empathetic statements (on cue) to certain trigger words during the course of your conversation. You know this is all an act akin to a dress rehearsal for the real patient encounters that await you in third year and beyond. With time and practice, you expand
Continued on the following page . . .
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Outgrowing the Short White Coat Continued from previous page . . .
your repertoire as you meet real patients in the community and the hospital. Your white coat becomes wrinkled with increased use, as you become more comfortable interviewing patients and performing the physical exam. You start to piece the history and physical exam with a differential diagnosis that is limited to the few items you remember from lecture. You build confidence, and your white coat feels less impersonal. As we descend into the wards, we enter an entirely new culture and learn a new language that changes every six to eight weeks. We are like nomads, traveling into strange lands. Our white coat allows access into these new worlds. We will fixate on what to wear, what to carry in our pockets, and how to deliver the perfect presentation and write a note. We are undergoing a transformation from a lay person with two years of formal medical education to a physician. During the process, we struggle to become fully indoctrinated into this mysterious medical culture. We often feel outside our team of long white coats, standing on the periphery, watching and not really understanding, especially when we begin to navigate the complexities of the wards and the details of our patient’s lives and diseases. We start by relating more to our patients than to the physicians we are about to become. The third year has been compared to a socialization process during which we develop our identities as physicians. As part of process, we learn to function as part of a medical team. In the wards, we join other students, all immediately identifiable in our short white coats. As teams, we march through the wards, a white blur to any spectator. As we learn how to become healers, our white coats become soiled, wrinkled, and dirtied; our pockets bulge. And with time, we begin to closely identify with the doctor inside of us, and we outgrow the short white coat. Eisha Zaid is a second-year medical student at USCF. 18
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Surgery as Ritual Continued from page 15 . . .
Eskenazi performs “transformational surgery.” A good candidate is someone receptive to the idea that a hankering for a perkier nose or smoother brow might have some deeper meaning. The patient spends several hours with a collaborating counselor, exploring the emotions behind the desire for surgery and designing a modest ritual to accompany the procedure. “We encourage the mind to be in line with what the body is about to go through,” Eskenazi says. After surgery, patients meet again with the counselor. Barrett had not heard of transformational surgery before, but she leapt at the opportunity. “It let me manage what the surgery meant in my life,” she says, “as opposed to feeling like a victim of the circumstance. Here I was just two weeks before a major surgery, and I felt almost excited about it.” Another cancer survivor symbolically chucked her “patient identity” by locking old medical records in a suitcase that Eskenazi tossed into a hospital trash bin. Patients often conduct a brief ritual right in the OR. “It’s very moving to have an entire operating room stop and be quiet and listen to someone saying something very intimate before they have surgery,” Eskenazi says. “It completely changes the tenor of what goes on during the surgery.” The patients’ pre-op exercises have post-op effects, Eskenazi says, based on her clinical observations and patients’ follow-up interviews. “The people who do that work beforehand have less nausea, less pain, less bleeding, and less need for repeat surgery.” The surgeon has plans for a formal, quantitative study. Inspired by the power of ritual to touch lives and affect healing, Eskenazi recently founded the nonprofit Institute for Transformational Surgery. She intends to expand her practice of surgery as ritual. “It’s made me feel like much more of the healer that I was trying to be when I went to medical school.” This article was originally in Stanford Medicine, Fall 2005. It was reprinted with permission.
Procedure, Ritual, and Medicine Continued from page 14 . . .
“Mr. Eliot, what are we going to do about this problem?” “My dear sir,” Eliot responded, “you have asked the wrong kind of question. You must understand that in life we face two kinds of problems. One kind demands your question: ‘What are we going to do about it?’ The other calls for a different question: ‘How does one behave toward it?’” (Golub, xi) A procedure is something that we do to some end; it is linear, one-dimensional and objective; it is an answer to the question asked of T.S. Eliot, “What are we going to do about it?” As humans treating humans, is it possible to be procedural? Are we not always behaving toward our obstacles, whatever they may be, creating rituals that function in our lives in a variety of meaningful ways? In a science, we move through steps, procedures that are objective movements in and of themselves, with a goal in mind. If we were to remember that, as humans, even our procedures are rituals, might we not actually be more objective in our movements, taking into consideration the many possible meanings that are not only communicated to patients but also to physicians?
References
Clayton, Tonya. “Surgery as Ritual.” Stanford
Medical Magazine. Fall 2005.
Drier, Tom F. “What Health Care Professionals
Need to Know about Ritual: A First Lesson.” Bulletin. Issue 5, August 1998.
Elks, M. L. “The Key Role of Ritual in Modern
Medicine,” Bulletin. Issue 5, August 1998.
Golub, Edward S. The Limits of Medicine: How
Science Shapes Our Hope for the Cure. Chicago: University of Chicago Press, 1997.
Platvoet, J. G. and K. van der Toom. Pluralism and
Identity: Studies in Ritual Behavior. Boston: Brill, 1995.
Procedure. (2009) In Merriam-Webster Online
Dictionary. Retrieved May 29, 2009, from http://
www.merriam-webster.com/dictionary/procedure.
Ritual. (2009). In Merriam-Webster Online Dic-
tionary. Retrieved May 29, 2009, from http://www. merriam-webster.com/dictionary/ritual.
www.sfms.org
Ritual in Medicine
Cultural Rituals Surrounding Healing Lessons from the Street Children of Haiti
Amber Elizabeth Lynn Gray
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en years ago, when I worked as a psychologist and dance/movement therapist in Haiti, I became curious about how the dance and rhythm-based rituals and traditions of Haiti and the practice of vodou might fit into the concept of therapy. Initially I imagined that dance/movement therapy, a somatic and creative arts psychotherapy with roots in ancient healing traditions from around the world, would be a perfect and well-suited healing modality for working with the children who suffered from the multiple forms of ongoing violence and abuse that are remnants of the slaveryrelated oppression, disease, and violence that have been an integral part of Haiti’s history. As it turned out, however, it was the children who taught me. They showed me ancient rituals to begin and end each session as a way to integrate the meaning of our work together into daily life. They used a simple cleansing ritual, using water to retain the coolness of the dance after clearing the soul of excess energy and burden. At all times, the children stressed the importance of communal action in making connection with ancestors, asking for assistance and support, and discovering what must be done to take the right action. These children carried on the amalgam of spiritual beliefs and practices of Haiti that had evolved from the forced fusion of many tribes and thus gave rise to the tradition of communal rituals, rhythms, dance, and healing rites now known as vodou. Years of civil unrest and conflict, political instability, extreme poverty, and violence in the streets have contributed to ongoing trauma and sufwww.sfms.org
fering. Yet Haiti’s extreme conditions have given rise to a spiritual force that fosters resiliency and the ability to endure. When I began my work in Haiti, I was not prepared to encounter a culture with such a strong spiritual basis, its rituals infused with healing, faith, and a strong sense of family, community, and social responsibility. As a white American dance movement therapist, I learned from these children that Western psychotherapeutic perspective must undergo a transmutation into communal, ritual, and spiritual forms consistent with Haiti’s traditions. Both Haitian ritual and dance movement therapy often are performed in a circle, and the dance therapist facilitates a rhythmic, kinesthetic, and empathic participation. But the complexity and nuances integral to Haitian dance go beyond the physical. In vodou, for example, the ceremonial dances have a clearly delineated center, called the poteau mitan, which represents the intersection of the vertical and horizontal dimensions, the point where the physical world and the spiritual world meet. Within this spiritual context, each human life has a ti bon ange (little good angel), the part of the soul directly associated with the individual, and a gros bon ange (big good angel), the life force that all sentient beings share. At a person’s birth, these spirits enter the individual; when death occurs, the spirits return to the universal source of life force. This principle of collective experience informs a strong sense of responsibility to both the ancestors and to all those with whom life is shared. Vodou has allowed a traumatized culture to maintain an ongoing relationship with the natural, ancestral,
and spiritual worlds. In one group session, the children quickly abandoned my recorded music, and several of them began to drum. Others began to move in and out of the center of the circle, one at a time, taking turns leading, being followed and following. As each child created a movement phrase in the center, he or she turned toward each child in the outer or witness circle, and they mirrored movements to one another. No child missed being witnessed by each member of the group. Each person had to spend time in the center to lead or initiate movement, to be seen, and then to offer back to each mover in the center the mirroring of his or her movement. This practice is similar to the tradition of the solo circle that exists in African dance and rituals (and in other cultures), though here the process of being seen and witnessed as an individual seemed more consciously enacted. In this sea of abandoned street children, the ritual ensured that each one was individually acknowledged. Amber Elizabeth Lynn Gray is the director of Restorative Resources Training and Consulting and is also the refugee mental health coordinator for New Mexico’s Department of Health. Contact her at restorativeresources@gmail.com or visit www.restorativeresources.net.
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Ritual in Medicine
Learning Human Anatomy Ritual in the Anatomy Lab
Neal H. Cohen, MD, MPH, MS, and Andrew Corson
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ith advances in the science of medicine and our understanding of human disease, medical student training has undergone dramatic changes. No longer are didactic lectures the primary form of education; integration of basic and clinical science has become an essential aspect of medical training. In addition, new models, including simulation, have become routine methods to teach many of the skills necessary to become a physician. Despite the introduction of new approaches to medical education, however, one tradition remains: Each September, a new group of students beginning careers in medicine at UCSF is introduced to one of the most unique learning tools in medicine, the human cadaver. No technology or scientific advance has been able to replace the human body and the important role it plays in defining the physician. The first year of gross anatomy has long been considered a rite of passage, and students approach it with a mixture of anticipation and apprehension. They emerge from the lab understanding the systems of the body, knowing every vessel, nerve, muscle, and bone, how they work together and how to apply this information to clinical situations. What makes the experience unique is that working with a cadaver is the first encounter with death for many students, and a sobering reminder of our own mortality for others. Students learn early on that the experience of studying anatomy with the aid of a cadaver is a privilege not to be taken for granted. While computer programs, image projections, high-tech cameras, and other modern developments certainly aid in the learning experience, nothing can replace www.sfms.org
knowledge gained from hands-on experience: the sight, feel, and yes, even the smell of working with real cadavers. At UCSF, students are introduced to their cadavers slowly. Faculty show pho-
“The first year of gross anatomy has long been considered a rite of passage, and students approach it with a mixture of anticipation and apprehension.”
tos of the outside of the medical school and then move into the lab and finally to a covered cadaver. Faculty and students from earlier classes discuss the range of reactions the new students might feel when they walk into the lab, explaining that mixed responses to a strange situation are normal. Faculty encourage a relaxed approach when working in the lab, rather than a somber one. They also remind students that we each may use different methods to cope with our anxieties, excitement, and the uniqueness of this experience, we but must always maintain the highest level of respect for the cadavers. When students arrive in the anatomy lab, the cadavers are shrouded. They are uncovered slowly as the course progresses. Study begins first on the thorax and abdomen, as students examine skin and surface anatomy with the help of a dermatologist. They look for external clues revealing conditions that affected the donor during
life and ponder the clinical implications of each discovery. Eventually the cadaver is fully uncovered, laying bare the humanity behind the donor’s choice to play an invaluable role in training the next generation of physicians. As months pass and dissections progress, students are reminded that the cadavers were once living, vibrant beings not unlike the students themselves. Each student has a unique response to the experience of interacting with the cadaver and the anatomy lab. While dealing with all of the challenges associated with being a student, the relationship with the cadaver raises many issues that most students have not previously encountered. Usual life events, everyday joys and stresses, often take on new meaning as students are reminded of life’s impermanence each time they walk into the lab. This awareness can be heavy at times, and faculty keep an eye on those who struggle under its weight. The cadavers used as part of the UCSF anatomy course are available because of the selflessness of the 300 or so people a year who donate their bodies to medical education and research. People donate their bodies for a variety of personal reasons. Some suffer from chronic illnesses and recognize donation as an opportunity to advance the study of related conditions or medical science in general. Others believe that donation makes more sense than burial, occasionally joking that it’s the ultimate form of recycling. Some are health care professionals who remember and value their own experiences in the anatomy lab. Whatever the reason, the gift donors make has an immeasurable impact on both an understanding of the human body in all its complexity and the importance of the
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Ritual in Medicine
Rituals in Spiritual Care Bringing Meaning to Illness
Rev. Michele Shields, D.Min
A
support group of breast cancer patients gathers weekly to discuss their spirituality in relation to their health crises. At the close of their meeting, the facilitator rings a bell and names one of the group members, and all silently send their well wishes, loving-kindness, and healing thoughts and prayers to that person. They do this for each member of the group, as a closing ritual. A Roman Catholic priest anoints the ICU patient with oil on her forehead and prays for her healing, as the family is gathered around the bedside. A hospital chaplain with a guitar sings a familiar hymn and all join in. This ritual has been repeated for two thousand years in the Christian tradition. A hospital chaplain delivers “Passover in a Box,” a kit with the elements of the Passover ritual, to a Jewish patient so that he may celebrate the holiday in his hospital room. This act connects him to his faith community and rich tradition. A Christian mother of a critically ill newborn requests that the hospital chaplain baptize her baby, believing that God specially pours out His grace on this child when the ritual is performed. Religious and nonreligious rituals invite people in health crises to enter into a sacred space of mind and find meaning, structure, and connection to community in all of these passages of life. Rituals are visible expressions of the community bonding with and showing support for people when they need this most. Many of these rituals have persisted for centuries because they address the core spiritual needs of people for meaning and direction, loving relationships and reconciliation, and 22
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self-worth and belonging in community. These are core spiritual needs shared by all people, regardless of whether or not they are religious. For example, a young man with an incurable brain tumor requested that a chaplain marry him to his fiancé in the ICU. He knew that he did not have long to live and that this would mean so much to him, his fiancé, his family, and his friends. The chaplain and the patient’s fiancé went to City Hall to get the marriage certificate. Shortly before the patient died, the chaplain performed the marriage ceremony, a ritual of meaning and direction in life, as family, friends, and nurses gathered at the bedside. The words of the marriage vows, “in sickness and in health, to love and to cherish, till death do us part,” never meant more than they did in this setting. The core spiritual need for loving relationships and reconciliation is addressed in the Roman Catholic sacrament of confession and reconciliation. The experience of illness frequently raises the issue of broken relationships. Upon whom can the sick person depend for love and support as he faces a health crisis? Many people want to resolve resentments and mend relationships. For example, when a patient was facing a life-threatening heart condition, he decided that he wanted to mend his broken relationship with his parents. He regretted how he behaved in the past toward them and wanted to ask for their forgiveness. The priest heard his confession and offered behavioral guidance about mending his relationship with his parents. The ritual began the process of reconciliation. The experience of illness may also raise the person’s core spiritual need for
self-worth and belonging in community. For example, a victim of domestic violence blamed herself for her partner’s abuse. She had been isolated from family and friends as part of the pattern of abuse, as her partner discouraged and opposed her connection to others. In the emergency department, she met with a social worker who valued and supported her by listening carefully to her story and providing her with resources for victims of domestic violence. When she met with a chaplain during her hospitalization, she expressed the desire to connect with her childhood faith community, which was Buddhist. The chaplain referred her to a Buddhist priest, who visited her as well. Eventually she joined this faith community in the ritual of taking refuge in the Buddha, the dharma (teachings), and the sangha (community). This community became a means of support for her. Not all patients find religious rituals to meet their core spiritual needs. For example, nonreligious communities and interest groups can easily meet a person’s need for community. These communities often have their own rituals of joining and celebration. Yet rituals persist in society because they do meet people’s spiritual needs and are often very important to patients in the experience of illness. The Rev. Michele Shields is the director of Spiritual Care at UCSF Medical Center and Children’s Hospital. She is also on the faculty of the UCSF School of Medicine and the UCSF School of Nursing, teaching spirituality, ethics, cultural humility, and end of life.
www.sfms.org
Ritual in Medicine
Ritual in Family Medicine Ritual, Ceremony, and Meaning
Ann Marie Chiasson, MD, MPH, CCFP
Y
ears ago I asked myself, “How can I help facilitate healing without involving the mind?” This question came after watching patients use the mind to continue patterns and thoughts that did not promote healing. It is the “Yes, but I can’t because . . . ” that tripped up so many of my patients when wanting to bring about a change. The question is not forbidden but may be lost or forgotten in these times of psychiatry and mind-body medicine, in these times of “getting conscious” or “getting insight” into the underlying dynamic of illness. What if we just healed without “getting it”—since healing is the outcome most of my patients are seeking, not insight. Broken bones heal without insight. Most of the bodily functions do. Is there anything we can do to get out of the way to further facilitate or augment this healing response? A patient burst into my office once and said, “I had forgotten! We can change, but we must ask for help with the change!” Ask who, ask what, and how do we ask? We ask and speak to this Other, Source, Great Mystery, or the Unconscious, through ceremony. In ceremony, we present to the edge of the unknown. Every culture and tradition in the world has this wisdom and is compelled to use ceremony, albeit with different methods and different words. In psychoanalytic work, one would attempt to contact the unconscious, while in indigenous traditions one implores the ancestors and spirits for help; in the shamanic tradition one asks the other worlds or realities to step in and assist. I ponder how the rest of nature is involved in this as I watch ant hills or listen to the coyotes yipping during a kill. Ceremony is our innate way of connecting to something www.sfms.org
greater or deeper so we may let go, jump in, and live a transition. One transition we experience is called healing. We use ceremony for births, deaths,
“We use ceremony for births, deaths, life-stage changes, initiations, unions, dissolutions, and healings. Each ceremony has common components; these components look different according to the culture.”
life-stage changes, initiations, unions, dissolutions, and healings. Each ceremony has common components; these components look different according to the culture, yet all are steps to “thin the veils” and gain access to deeper aspects of ourselves and this mystery we are living. These components are easily seen in a wedding ceremony. The first step is planning the shift, which occurs during the proposal. Here is the acceptance and desire to ask for a deep union to occur. The next stage is preparation. The dates are picked and the wedding planned, with all of the components the couple feels are meaningful to them and their tradition. Next, one enters into the ceremony. This is done through gates; gates are thresholds upon entering into ceremony that an-
nounce and symbolize that one is no longer in ordinary awareness but in a deeper or more connected state. This would be the front door of the church, walking down the aisle, getting to the altar. One feels the ceremony when the bride walks down the aisle and the ritual is started. Here the leader of the ceremony steps in. The role of the leader is to induct a state of consciousness so the participants can receive the ceremony. The more this person can hold a sacred state and connect to and induct the Other, or mystery, the more access this allows everyone involved to connect to the deeper process. Next, the “doing” of the wedding occurs: Vows are made and the union is set and witnessed. Finally, the ceremony ends. The couple and wedding guests leave, again through the gates, and it is over. Everyone returns to daily ordinary awareness, the shift having occurred. Black Elk, a leader in the Sioux tribe and an extraordinary ceremonial leader, once wrote, “Of course it was not I who cured. It was the power from the outer world, and the visions and ceremonies had only made me like a hole through which the power would come to the two-leggeds. If I thought that I was doing it myself, the hole would close up and no power would come through it“ (Neihardt, J. Black Elk Speaks: Being the Life Story of a Holy Man of the Oglala Sioux. 1932, State University of New York Press.) I began to connect to the ceremony of the practice of medicine and the simple ceremony of coming to a family practice office. Even if our patients are not aware of it, the office visit is certainly a ceremony for healing. First patients decide to come, and they call the office; planning and
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Ritual in Family Medicine . . .
preparation are under way. Some make a list of concerns and health matters for discussion and healing, and some worry prior to the visit. Next, they come in to the office. Entering the front door, passing by the front office staff, and entering the patient room are all forms of passing through gates, as is the wait before we see them. Patients often enter a nonordinary awareness at this point, even if it is subtle. We know that some patients do not remember what was said during the visit, especially with difficult diagnoses—a prime example of being in a nonordinary state of consciousness. I wonder if white coat hypertension is another indicator of our patients entering into a heightened or nonordinary state. Then the physician enters the exam room. We do our healing work with the patient, and, finally, we all leave. The patient does not reenter normal awareness of daily life until they actually leave the office. A wise malpractice lawyer taught that the most important aspects, for a patient, to ensure a meaningful visit and avoid malpractice were two things: First, the front office staff must be courteous; and second, the MD must touch the patient in a meaningful way on the shoulder or arm during the visit. In the ceremony view, this makes perfect sense. The staff is the first gate, and it must be welcoming. The healing and feeling of being cared for are the reasons for the visit, and the touch addresses this at a deep level. Are physicians good ceremonial leaders? Knowing that my patients may be placing so much value and meaning on the visit, at a deep or unconscious level, I began to change my approach in the office. I began to plan and approach my office as sacred, as a place of the healing ceremony. I became aware of myself as involved in deeper mystery with my patients, like a ceremonial leader. They have come in for a healing, and the interaction between us in this modern medical office ceremony would provide it. My office times did not increase. Nothing changed, except the approach I had toward the visit. I did change the way I dressed. I dressed up a bit more, as many of my patients dressed up when they came in. I started to pipe in music in 24
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the office that I associated with ceremony to remind me we were in sacred space. I began to enjoy my job more, and I found it more energizing. I touched my patients or hugged them at the end of each visit, and I knew I was connecting to them with this touch. I realized the interaction with the patient was not over until they left the office. I stayed with them while they were with my staff to get lab requisitions if I had time. I began to chart in the room, only so I could enjoy the sacred space with the patient a bit longer. Finally I had connected into the meaning my patients held in coming to see me, and through that, I had reconnected into my own meaning for my job. I never spoke of this to my staff or patients. It was not necessary; yet there was a palpable shift. To this day, I approach all office visits this way. In the psychiatric literature, there are reports questioning the effectiveness of ceremony because it is healing “without insight.” There is, however, some consensus that ceremony may work at the level of behavioral therapy, or from an ability to express emotions not often expressed. In the anthropological literature, there are many case reports of spontaneous and lasting healing of depression and other psychiatric problems—healings associated with one ceremony. There can be complete and spontaneous healing without insight. Some cultures, such as Native American and Hawaiian, often use ceremony for healing as the first healing modality. I think many of our patients see alternative medicine practitioners for just this; they need the ceremony of the healing these practitioners provide. I have seen both simple progress and extraordinary healings through ceremony. I have seen a Native American prayer lodge heal a chronic case of fibromyalgia. I have seen tumors shrink and even disappear, dramatic healing of visual difficulties, and attitudes toward illness undergo seismic shifts. While these are wonderful and dramatic, I am just as amazed by the simple daily office ceremony. I also work in a hospice now, and home visits provide ample opportunity for me to practice this ceremony of medicine with patients and families.
I prepare some of my patients for surgery with this perspective now. I discuss with them that they are going into the unknown, and we explore the gates they will pass through. I help them see it as a deep process in the psyche and the unknown, and to understand that a general anesthesia is profound and similar to death to a deep part of them. They do not need the surgeon to be aware of this appreciation they are holding; they can be the ceremonial leader for themselves. If the surgeon or anesthesiologist approaches it in a similar vein (and many do), then the ceremony may be felt even more deeply. Carl Jung once said that he did not know if this type of a perspective actually made things go more easily, but things certainly appeared to go more easily. I will offer to help plan or perform a ceremony with my patients from time to time. Large transitions, leaving behind old habits, serious illness, particularly painful processes, or a patient requesting help will often stimulate this offering. While I can facilitate the planning and preparation, they often do the ceremony at home with their families. I make very few suggestions, since it is crucial that they use symbols that have meaning for them. I do ask them a few questions prior to our planning session to help them prepare. The questions are directed at the meaning of the illness. “If this illness is not a mistake, what is its meaning to you? What has this illness taught, how has it served?” I suggest they honor the illness and the wisdom of their bodies before asking for a shift. My patients report back that they find these ceremonies helpful and meaningful. I find the process helpful and meaningful as well. Some physicians pray with their patients; perhaps ceremony is my form of prayer. Ann Marie Chiasson, MD, MPH, CCFP, is assistant clinical professor of medicine at the Arizona Center for Integrative Medicine, University of Arizona, and she is also Medical Director for Valor Hospice and Palliative Care as well as the Haven Rehabilitation Center for Women in Tucson, Arizona.
www.sfms.org
Ritual in Medicine
A Ritual to Say Goodbye Reflections on a Hospice Memorial Service
Steve Heilig, MPH
I
t’s a chilly winter night outside, but it’s very warm inside the Zen Hospice guesthouse. The people gathered here have wished one another a happy New Year and have settled on cushions in the meeting hall. Both fireplaces are lit, and the many little white cards with the names of each person who died here last year are arranged over the fireplaces and on a table in the center of the room. Paul, our teacher for the evening, says a few simple and wise words about impermanence and about being “of service,” then explains tonight’s ritual: We, the volunteers in attendance, will pick up the cards (choosing a specific patient’s name or taking one at random) and take them one by one to the fires, dropping them in and saying something about each deceased person. The idea is to hear a litany of names being remembered and honored and sent onward—to wherever—as volunteers flow steadily to and from the fireplaces. It begins; someone rises from her cushion, walks to the front of the room, picks a card, reads a name, and softly says, “May you be at peace.” The fire crackles as the paper is consumed. Others follow. I sit in the corner, listen, and watch. Last year at this service I had only been a volunteer for a short time and hadn’t yet really known anyone who had died. This time it is different: I hear names I know, some quite well: Donald, Greg, Jackie, Loy, Jim, Elsie, Victor, Philip. . . . My throat begins to constrict a little— I’m getting choked up. I swallow, get up, go looking for a card, and find it: Cheri. Not his real name, but one he chose. I carry his card to the fire, remembering
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his last words to me, maybe his last to anyone: “Thanks for the respect.” Saying something a little silly about this poor soul who tested some of us so consistently, I drop Cheri’s card into the flames and sit back down, thinking: That’s enough for me, let the others do the rest. But looking around, I notice no one else is getting up; the flow has stopped and it’s still and quiet. This makes me anxious—I want the ceremony to go smoothly. As I am about to get up one more time, someone else beats me to it and reads off a name with a gently humorous comment that triggers a hearty outburst of laughter. Others rise and the flow recommences. When this thoughtfully planned process works, it’s all as beautiful as could be hoped for. For years, I’ve been immersed in the evolving field of health care ethics, full of terms and concepts like “double effect,” “slippery slope,” “palliative care,” and so on. However, at the bedside, faced with patients or loved ones dying, the abstractions don’t mean much. In fact, they can get in the way of doing what’s best for the person we are trying to help make a graceful, dignified exit from life. Sitting with a dying person, it’s surely best to try to clear one’s head of all those complexities and really be present, listening. But sometimes that can be difficult. Looking up from my musings, I see the name cards are almost gone. But I have not heard the name of a patient I particularly liked. I lean over to my neighbor and ask if Louis’s name was read. Yes it was, she replies. Damn—it must have been while I was worrying about the ritual. Or maybe while I imagined my own name being read and
dropped into the fire, 10 or 50 years from now—a possibility that seems just fine, as we all should be so fortunate as to be released from this life in such a warm, ritualistic setting. I’ve already learned a lot here, from the people who have spent some part of their final days here. They’ve taught me, intentionally or not, a little bit about what is most important, about not wasting my life on trivialities, about how short our time here really is. But above all, my experiences have shown me how much more I have to learn. About paying attention, for example—for one thing, I missed Louis’s farewell tonight. I remember the last words I heard him say, when I asked how he was doing during his final hours here: “Fine . . . just breathing in, and breathing out.” And then he smiled. And now, so do I.
SFMS Member Edward Chow Honored with Award!
The Northern California Chapter of the American College of Physicians honored Dr. Edward Chow with its Laureate Award. The award honors College Fellows and Masters who have demonstrated a commitment to excellence in medical care, education and research, and who have provided service to their communities and to the College. Dr. Chow is currently Medical Director of the Chinese Community Health Plan and he also serves as Executive Director of the Chinese Community Health Care Association. Dr. Chow is a long time member and past-president of the SFMS. The SFMS extends its congratulations to Dr. Chow for this award honoring his work. www.sfms.org
Ritual in Medicine
An Ancient Ritual for Healing Yoga as Ritual
Chanda Williams, MA
S
itting peacefully in a cross-legged posture, I join my hands together at the center of my chest. Time slows down, and I set an intention to move mindfully, to breathe consciously, and to open my heart. This simple daily practice has been duplicated for thousands of years throughout the world and across all social strata. Yoga invites participants to embrace the opportunity to slow down, observe, and connect to our bodies in a deep and meaningful way. Yogic understanding is based on the insight that while we are individual beings, our essence is not individual or separate. At our core, we are interconnected in both our bodies and our spirits. A ritual’s primary function is to make that connection conscious and present in our lives. Any given ritual may be an expression unique to a particular culture or society. Rituals dissolve boundaries and allow the participants to engage in a shared bond. Since the beginning of civilization, cultures throughout the world have conducted ceremonies to unite their communities, express a collective belief, and reawaken their union with the divine. Yoga is a transcultural and transtemporal ritual precisely in that sense: It not only allows us to make the connection between our bodies and minds palpable, it makes transparent and develops the understanding of the connection between all living beings. Our Western mindset, premised upon achievement, competitiveness, and the material, is often challenged by yoga’s emphasis on spiritual development. In the West, we have the propensity to move throughout the day at a speed that lends little time for reflection, conwww.sfms.org
nection, or ritual. African spiritual teacher Malidoma Patrice Somé, author of Ritual: Power, Healing, and Community, challenges Westerners to see the speed of modern life as a form of spiritual abandonment, and she blames the pace at which we live for the loss of the sacred. “When you slow down,’ Somé writes, “you begin to discover . . . a silent awareness of what it is you do not want to look at: the anger of nature within us, the anger of the gods, the anger of the ancestors or the spirit world. . . . Thus speed is a way to prevent ourselves from having to deal with something we do not want to face. . . . To be able to face our fears we must remember how to perform ritual. To remember how to perform ritual we must slow down.” Yoga practice slows us down, focuses us, and allows us to feel a range of emotions otherwise unconscious. In doing so, it provides us with a daily ritual that attunes the body and mind to our inherent divinity in preparation to meet the day’s challenges. The sadhana (Sanskrit for “practice”) provides us with the opportunity to cultivate greater compassion, patience, balance, and clarity of mind on the mat so that as we move out into the world, we are more aware of our interactions with others as well as how we relate to ourselves. In the asanas, or yoga poses, one can experience a full range of feelings, from frustration to elation to fear; but what is most important is the practitioner’s ability to devote attention to this maelstrom of emotions as a silent witness, without judgment or criticism. This practice is refined and cultivated over time, reflecting our commitment and devotion to our spiritual growth and development.
I have implemented a ritual at the end of the yoga classes that I teach. I invite the participants to allow the body to remain undisturbed to allow the peace and wisdom to arise from within. As I speak, I continue to observe the bodies as they lay peacefully on their mats. I can see the softening of muscles as tension is released, and I can sometimes hear the sweet slumber that at times signifies the entry into theta-wave brain activity—the stage of quiet focus, self-healing, and deep sleep. Upon inviting the participants to return to a more “wakeful” state, I encourage them to offer the merit of their yoga practice to someone. This offering symbolizes our gratitude for health and well-being, as well as our support of others in need of assistance. We can begin to create rituals within our lives by acknowledging the sacred in the ordinary. When washing our hands, we can recognize the precious resource flowing between our fingers. In transit, on the way to work or school, we can witness the movement of the body and celebrate the fluidity of this dance we call life. Look at the tremendous quantity of leaves on a tree and realize the utter abundance that lies within the body and out in the world. Even as necessity calls for us to complete our daily tasks, we can begin to fulfill our life’s purpose by slowing down, honoring the sacred, and turning within. Chanda Williams has just completed her master’s degree in integral health and healing in the Consciousness Studies Department at the California Institute of Integral Studies in San Francisco.
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Hospital News Chinese
Joseph Woo, MD
We had the pleasure of hosting our SFMS President, Dr. Charles Wibbelsman, at our semiannual medical staff meeting in April. Dr. Wibbelsman was both enthusiastic and forceful in his pleas for nonmembers to join the medical society. I was pleased that Chuck was able to hear the concerns of our “rank and file” medical staff, and also that he was able to meet Dr. Ken Tai, medical director of Northeast Medical Services. Hopefully, our colleagues at NEMS will find a way to join and participate in SFMS. Of course, the Chinese Hospital medical staff has a long history of providing leadership and support, with such members as Drs. Rolland Lowe, Ed Chow, Dexter Louie, and Gordon Fung, to name just a few. More accolades to our staff: Dr. Collin Quock was made Emeritus Clinical Professor of Medicine at UCSF, and Dr. Edward Chow was honored by the Northern California Chapter of the American College of Physicians with its Laureate award. Dr. Seck Chan continues to do an outstanding job with the student summer preceptorship program. We currently sponsor four medical students between their first and second years, providing them with exposure to clinical office and hospital practice in the Chinese community. Our “alumni” have commented on the great experience they had and how helpful it has been in their education and career decision making. This year we have students from around the country who will rotate with our volunteer medical staff. Please mark your calendars for the 15th Conference on Health Care of the Chinese in North America, sponsored by the Federation of Chinese American and Chinese Canadian Medical Societies (FCMS), which will be held October 8–10 in Los Angeles, California.
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CPMC
Damian Augustyn, MD
Dr. Warren Browner was appointed to succeed Dr. Martin Brotman as the CEO of CPMC effective May 4, 2009. Dr. Browner served with great distinction as CPMC’s vice president of Academic Affairs and scientific director of the Research Institute; he has also been a member of the Executive Management Team since he came to CPMC in 2000. He has had a successful career in clinical care, administration, education, and research and is uniquely prepared for his new role. Before joining CPMC, Dr. Browner was a practicing general internist, the chief of General Internal Medicine, and the acting chief of the Medical Service at the San Francisco V.A. Medical Center. He was also professor of medicine and of epidemiology and biostatistics at the University of California, San Francisco, and executive editor of the American Journal of Medicine. He received his medical degree from UCSF and his master’s degree in public health from the University of California, Berkeley. Dr. Browner’s research focuses on the genetics of human longevity. He is the author of several books and numerous articles in scholarly journals. He recently initiated a collaborative effort between CPMC and Dartmouth Medical School, giving third-year students at the Hanover, New Hampshire school an opportunity to do their clerkships at CPMC, enhancing CPMC’s reputation as a leading teaching hospital. Also, I was selected by the American Gastroenterological Association (AGA) Governing Board as a recipient of the 2009 AGA Distinguished Clinician Award. I am being honored for my contributions and abilities to combine the art of medicine with the skills demanded by the scientific body of knowledge in service to patients.
Kaiser
Robert Mithun, MD
As students and practitioners of medicine, we are taught a series of rules and regulations to mediate suffering. Temperature is high; consider infection. Cholesterol above target means a prescription for statins or dietary restrictions. Blood pressure greater than we would like? Better think of increasing the ACE inhibitor. But medicine is more than the rote memorization and application of an algorithm. Every day, as physicians, we are granted a unique opportunity: to see the lives of our patients through their eyes and not our own. To understand the import of the patient’s viewpoint, we must exercise the time-honored attributes of the astute clinician: imagination and creativity. For our patients are not a singular entity; they represent the lifestyles, choices, and maddening vagaries of those whom we serve. A prescription for a medication is nothing if we don’t understand what the daily act of taking a pill means to the patient. And a recommendation that one exercise will fall on deaf ears if we don’t understand how this directive will affect the daily life of the patient for whom this is suggested. What are creativity and imagination in the practice of medicine? The understanding of the individual needs of a patient and the recognition that what works for one does not work for the many. And the final acceptance that our erudite proclamations mean nothing if we understand little about what those instructions mean for those we serve. In your daily practice of medicine, remember that our work is not that of an algorithm or a textbook approach but is the application of our own imagination and creativity in achieving an end: the health and wellness of those who choose to call upon us. Never forget that the practice of medicine is a privilege and an honor that we must cherish. www.sfms.org
Hospital News St. Mary’s
Richard Podolin, MD
Medicine is, intrinsically, an imaginative profession. We sometimes work magic in the eyes of our patients, but for every physician, each medical encounter starts with a reflexive act of imagination: We imagine our patient restored to health, or relieved of pain, or comforted in the face of inevitable mortality, and then we strive to make that vision real. Here at St. Mary’s Medical Center, we have had a history of innovative physicians who thought “outside of the box” and used their creativity to advance the health care of their patients and of our community. Our Northern California Melanoma Center (NCMC) is made up of physicians, surgeons, researchers, and nurses from various specialties working together to treat melanoma patients from around the globe. Working as a team, with each member contributing the unique perspective of his or her discipline, the NCMC strives to construct a comprehensive understanding of each patient. The NCMC Panel includes an immunologist, an oncologist, a surgical oncologist, dermatologists, and a research team. The Panel collaborates every week to review each new patient’s medical history, physical examination, diagnosis, and health records, and as a team they recommend a treatment plan specific to each patient. The NCMC has many clinical trials in progress, and sometimes these offer the best or only option for melanoma patients. Currently there are only three FDA-approved drugs to treat melanoma, so the NCMC strives to find more effective treatments. Dr. Lynn Spitler, the director, has been leading the NCMC for more than thirty years, and her model is imaginative and unique. All physicians are grounded in reality, cognizant of limitations, and yet optimistic. In the office, operating room, and community clinic, as at the research bench, we are motivated by our visions of something better. www.sfms.org
UCSF
Elena Gates, MD
Turning patient-safety practices into actual rituals greatly decreases risk of harm to patients, according to Robert Wachter, MD, chief of UCSF’s division of hospital medicine and a nationally known patient-safety expert. “The simple ritualization of a five-item checklist to ‘hardwire’ a set of safe practices every single time a patient has a central line inserted has led to a staggering decrease in infections and mortality,” says Wachter. “Other industries have traditionally embraced these kinds of strategies. For example, it is inconceivable that a plane would take off without the pilot performing the ritual of the preflight checklist.” UCSF midwives practice ritual listening. The theme of the American College of Midwives is “Listen to Women,” and UCSF’s midwifery program focuses on listening: to moms, to fetal heartbeats, to laboring women’s body language when words are inadequate. “What adds to this ritual of listening is the recognition of birth as a spiritual experience,” says Amy Levi, CNM, PhD, FACNM, and director of the Interdepartmental Nurse-Midwifery Education Program. “Midwives honor the woman’s beliefs around giving birth and being part of what she is going through. It can be as simple as making eye contact and using body language to let the woman know that we are listening.” Patients often request rituals around spiritual issues of birth, illness, and death. UCSF’s Spiritual Care Department employs Jewish, Buddhist, Protestant, and Catholic clergy and can refer to other clergy to bring rituals to patients’ bedsides. “Our affiliated clergy run the spectrum of faith traditions,” says Reverend Michele Shields, D.Min., director of UCSF’s Spiritual Care Services. Chaplains can provide a patient with a Native American prayer to the four directions, for example, or a Christian clergyperson for ritual anointing with oil. “When people ask for a ‘prayer for healing,’ they may be thinking of physical or spiritual healing,” Shields says.
Veterans
Diana Nicoll, MD, PhD, MPA
Researchers with the Alzheimer’s Disease Neuroimaging Initiative (ADNI), a five-year, nationwide, longitudinal study of possible markers of Alzheimer’s disease, announced that a genomic analysis of the 800 participants in the study is more than 95 percent complete, and that the data will be shared with scientists around the world for further analysis. The genomic data will be used by researchers to search for genes that contribute to the development of Alzheimer’s disease, according to ADNI Principal Investigator Michael Weiner, MD, director of the Center for the Imaging of Neurodegenerative Diseases at the SFVAMAC and professor of radiology, medicine, psychiatry, and neurology at UCSF. Alzheimer’s disease currently affects up to five million people in the United States alone, observes Weiner. The primary goal of ADNI is to use data from magnetic resonance imaging; positron emission tomography; and blood, urine, and spinal fluid samples to determine whether brain imaging, other biological markers, and clinical and neuropsychological assessment can accurately measure the progression of mild cognitive impairment and early Alzheimer’s disease. The identification of specific biomarkers will provide a useful tool for researchers and clinicians in both the diagnosis of early Alzheimer’s disease and in the development, assessment, and monitoring of new treatments, Weiner notes. “The release of this genetics data, in combination with the clinical, cognitive, MRI, PET, and blood/cerebrospinal fluid data already in the ADNI database, will now allow investigators to explore genetic factors related to the rate of progression of Alzheimer’s disease,” he says. “Access to this huge amount of data on a public website, from an ongoing clinical study, is unprecedented,” says Weiner. All data from the ADNI consortium are available to qualified investigators through a Web-based database (www.loni.ucla.edu/ADNI).
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In Memoriam Nancy Thomson, MD
Leonard Shlain, MD Leonard Shlain, best-selling author and San Francisco surgeon, died Monday, May 11, 2009, at his home in Mill Valley after a battle with brain cancer. He was 71 years old. Admired among artists, scientists, philosophers, anthropologists, and educators, Dr. Shlain authored three best-selling books: Art and Physics, The Alphabet Versus the Goddess, and Sex, Time, and Power. He delivered multimedia presentations based on his books in venues around the world, including Harvard, the New York Museum of Modern Art, CERN (European Organization for Nuclear Research), Los Alamos, the Florence Academy of Art, and the European Council of Ministers. His fourth book, Leonardo’s Brain, about Leonardo da Vinci, will be published next spring by Viking. Dr. Shlain was a surgeon for thirty-eight years at California Pacific Medical Center, where he headed the Laparascopic Surgery Department; and he was an associate clinical professor of medicine at UCSF. Leonard Shlain was a loving and generous man with a larger-thanlife intellect and a prodigious curiosity. He was a widely respected surgeon and attentive father and husband. He had an encyclopedic knowledge that he interwove with highly creative insights in his books and presentations. A voracious reader, he took pride in finding the perfect metaphor and delighted in making connections between everything from art and physics to human evolution and sexuality. Dinner conversations ranged from the Heisenberg uncertainty principle to politics, literature, and hilarious jokes. When his children were young, he brought a human brain in a bucket of formaldehyde to school for show and tell. When he came home after a hard day’s work as a young surgeon, he would excitedly diagram his operation of the day on a napkin. Later, his diagrams became more adventuresome and expanded to thought experiments that included what it would be like to sit astride a beam of light and how that corresponded with Picasso’s Rose Period or Blue Period. This eventually led him to write his first book, Art and Physics. He was born on August 28, 1937, in Detroit, Michigan. He graduated Central High School at the age of fifteen, attended University of Michigan and then graduated Wayne State University Medical School at twenty three (AOA), where he was recently honored as the alumnus of the year. After serving as a captain in the U.S. Army stationed in France, he interned at Mt. Zion in San Francisco, began his surgical residency at Bellevue Hospital in New York, and then completed it at California Pacific Medical Center in San Francisco, where he set up his general surgical practice in 1969. An early pioneer of gall bladder and hernia laparascopic surgery, in 1990 he was one of the first California surgeons to use this technique. He was flown around the world to train doctors in the new techniques, patented several surgical instruments, and pioneered new techniques for gall bladder and hernia operations. Leonard is survived by his wife, retired judge Ina Gyemant, and his children, artist Kimberly Brooks, filmmaker and Webby Awards founder Tiffany Shlain, and doctor/entrepeneur Jordan Shlain. He was also father in-law to filmmaker Albert Brooks and scientists/artists Ken Goldberg, PhD, and Caroline Eggli, PhD. He had two stepchildren, attorney Anne Gyemant Paris and writer Roberto Gyemant, Jr. His son-in-law Michael Paris is a medical engineer. He is predeceased by his sister Shirley Wollock and survived by siblings Marvin Shlain and Sylvia Goldstick, as well as grandchildren
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San Francisco Medicine June 2009
Shawn, Jacob, Claire, Odessa, Amber, Sophia, Elena, Daphne, Arthur, and a new grandchild due May 28. Editor’s Note: This obituary was provided by the family of Dr. Shlain.
William H. Thomas, MD William H. Thomas, MD, passed away on September 21, 2008, aged 90, ten days after experiencing a stroke. He was born on February 25, 1919, and grew up in Logan, Utah. He attended Utah State University, where he met his future wife, Farrell Ensign, and from 1941 to 1944 he attended medical school at Columbia University in New York. He completed residency training in internal medicine at UCSF in 1946. After serving as a medical officer in the U.S. Army, he completed cardiology residency training with Paul Dudley White, one of the founders of modern cardiology, in 1951. He joined the San Francisco Medical Society in 1949, and in 1951 he was the third boardcertified cardiologist to set up practice in San Francisco. He practiced the art and science of cardiology and internal medicine at his office and many of San Francisco’s hospitals for forty-seven years, until 1998. Dr. Thomas was a loving husband and father who cared deeply for the health and welfare of his patients. He and his wife moved from their San Francisco home to the San Francisco Towers Retirement Center in 1999, where they joined a supportive community and staff. His wife of sixtyone years preceded him in death, as did his daughter, Farrell Ann; but he is survived by his brother, Paul Thomas, MD, of Sacramento; his son, Gregory Thomas, MD (wife Bonita), and two grandchildren. Learning Human Anatomy Continued from page 21 . . .
physician-patient relationship. Donations are made through the UCSF Willed Body Program, which facilitates donations and ultimately becomes the steward for the majority of the donated bodies in Northern California. In addition to guiding donors and their families through the donation process, the program works with approximately fifty other state, community, and private universities that rely on the program and its donors for their anatomy and physiology courses. All donors are cremated and scattered at sea once studies are complete. At the conclusion of the course, the students organize a private memorial service to honor their cadavers. The service is entirely student-run and provides an opportunity, through music, poetry, and reflection, for students to process and share what they experienced. For the students, the service is an important part of their experience, a way to thank those who donated their bodies and thus provided one of the most essential and memorable experiences in medical education. Neal H. Cohen, MD, MPH, MS, is professor of Anesthesia and Perioperative Care and Medicine at UCSF and vice dean of the UCSF School of Medicine. Andrew Corson is coordinator of UCSF’s Willed Body Program. For more information about UCSF’s Willed Body Program, please visit http://anatomy.ucsf.edu/WBP/index.html. www.sfms.org