May 2008

VOL.81 NO.4 May 2008 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Back to the Future of Medicine Medicine as Told from the Year 2050

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CONTENTS SAN FRANCISCO MEDICINE May 2008 Volume 81, Number 4 Back to the Future of Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 A Look Back from the Future: Twenty-first Century Biomedical Practice and Research 4 On Your Behalf Mike Denney, MD, PhD 6 Executive Memo 12 Missing the Mumps: A Medical Anthropologist Reports from the Year 2050 Mary Lou Licwinko, JD, MHSA Meg Jordan, PhD, RN 7 President’s Message 14 Learning from Our Past: Lessons for Our Financial Future Steven Fugaro, MD Thomas H. Lee, MD 9 Editorial 16 Sounds Simple, Wasn’t Easy: Finding Good Health for Physicians Mike Denney, MD, PhD Linda Hawes Clever, MD, MACP 35 Hospital News 18 Looking Back and Beyond: Holistic Health in the Year 2050 William B. Stewart, MD 38 In Memoriam Nancy Thomson, MD 20 A Fragile Balance: Humans and Microbes in the Year 2050 Kristen J. Razzeca, MD Editorial and Advertising Offices 1003 A O’Reilly

22 Darwin Revised! Reflecting on Darwin’s Theories in the Year 2050 Leonard Shlain, MD 24 Psychiatric Moments: Experiences from the Years 2008 and 2050 Lynn Ponton, MD

San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions:

26 Biomedical Imaging: Computerized Radiology in the Year 2050 Gretchen A. W. Gooding, MD 27 Bad Bugs Bite Back: A Cautionary Tale Steve Heilig, MPH

$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

28 The Future of AI: A Look at Stanford’s Artificial Intelligence Program Ashley Skabar and Amanda Denz

www.sfms.org

P.O. Box 26605 Tuscon, AZ 85726-6605

May 2008 San Francisco Medicine

ON YOUR BEHALF

May 2008 Volume 81, Number 4

A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay

Notes from the Membership Department

Cover Artist Ashley Skabar and Amanda Denz Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes-Clever

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

There are many exciting SFMS social events in the works for the rest of the year.

Watch upcoming issues of San Francisco Medicine, SFMS Action News, and fax/e-mail Membership Updates for more information about these events. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org with your questions and comments.

Member Benefit Update SFMS Officers President Steven H. Fugaro President-Elect Charles J. Wibbelsman Secretary Gary L. Chan Treasurer Michael Rokeach Editor Mike Denney

The contact person for SFMS members at Wells Fargo has changed. If you are interested in exploring the financial services available to members, please contact Jon Polaha at (650) 855-7769 or Polaha.jon@ wellsfargo.com.

Immediate Past President Stephen E. Follansbee

Marsh Affinity Update: Workers’ Compensation

SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term: Jan 2008-Dec 2010

Jordan Shlain

George A. Fouras

Lily M. Tan

Keith Loring

Shannon Udovic-

William Miller

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

Daniel M. Raybin

Mei-Ling E. Fong

Michael H. Siu

Thomas H. Lee

Term:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Donald C. Kitt CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate San Francisco Medicine May 2008

San Francisco Medical Society members renewing their workers’ compensation insurance this year don’t have very far to go to see how their membership can help save them money. Not only are rates going down again this year, SFMS members will enjoy a special member discount not previously available.

The special member discount is only available through Marsh, SFMS’s sponsored insurance program administrator. The program is underwritten by Employers Compensation Insurance Company (ECIC), rated “A-” by the A.M. Best Company.

SFMS members insured through Marsh will receive the new discount on renewal.

If you are not insured through the SFMS-sponsored workers’ compensation program, call Marsh for information on how you can access your discount. And depending upon where you have your group health insurance, you may be entitled to even larger discounts. Find out today by calling Marsh at (800) 842-3761.

CMA Requests Physician Participation in a Study The California Medical Association (CMA) needs your assistance for a study in which it is currently engaged. At its last House of Delegates, CMA was mandated to develop a report on current peer review in California. The study will cover: (1) adequacy of fair hearing rights under the law; (2) sham peer review in all its manifestations; (3) whether and to what degree a peer review hearing panel member’s financial relationship with the hospital has an effect on the ability of that member to render an impartial decision in the matter; (4) the physician’s right (or lack thereof) to choose arbitration in lieu of peer review; (5) the benefits and possible structure of an external peer review program; and (6) any other mechanisms available to improve peer review in these and any other relevant peer review issues, which would include, but not be limited to, legislative and legal advocacy.

CMA staff is currently in the process of preparing this study and requests that if you, or anyone you know, would like to provide input or know of individuals who have been contacted by Lumetra—the entity that contracted with the Medical Board to review peer review—that you do so in writing and submit comments to Astrid Meghrigian at ameghrigian@cmanet.org.

Medical Board Changing CME Requirements The Medical Board of California is changing its continuing medical education (CME) requirements for physicians.

Though it is unclear exactly when the new requirements will take effect, the medical board has announced that physicians will be required to complete 50 CME hours during every two-year licensure period. Currently, physicians are required to complete 100 every four years.

The medical board has also clarified that CME hours are to be calculated based on the physician’s personal license-renewal www.sfms.org

date (the last day of the month of your birthday), not the calendar year.

Physicians are reminded that CMA’s Institute for Medical Quality (IMQ) certifies physicians’ CME activity for credentialing purposes to the Medical Board of California, as well as to hospitals, health plans, specialty societies, and others. CME certification is $29 a year for members, $49 for nonmembers.

For more information, contact Paulette Richardson at (415) 882-3387 or prichardson@imq.org.

The Claremont Resort and Spa, 41 Tunnel Rd., Berkeley, California 8:00 a.m. to 6:00 p.m.

The California Society of Industrial Medicine and Surgery (CSIMS), in conjunction with faculty from UCSF, is offering a continuing education seminar that will address cutting-edge concepts regarding practice, research, and policy in the field of occupational medicine. Visit www.csims. net for more information.

What Have We Done for YOU Lately?

The San Francisco Medical Society/California Medical Association form a valuable resource for members. What follows is a sample of the benefits of membership: • The SFMS Physician Referral Service, which helps you expand your practice by enabling potential patients to find you.

This service is available to patients both on the SFMS website and by calling the SFMS offices. All members are eligible to June 15–18, 2008 participate.

ENDO 08: The Endocrine Society’s 90th • Listing in the SFMS Membership SFMS Seminar Schedule Annual Meeting Directory, a trusted health resource that Advance registration is required for all The Moscone Center, San Francisco enables easy access to member information SFMS seminars. Please contact Posi Lyon at This meeting offers an unprecedented op- for members, patients, and other health care plyon@sfms.org or (415) 561-0850 exten- portunity to learn about the latest advances professionals. sion 260 for more information. All seminars in endocrine research and clinical care • Access to medical-legal resources take place at the SFMS offices, located in while networking and collaborating with through CMA and help from CMA’s nathe Presidio in San Francisco. more than 7,000 colleagues from around tionally-recognized reimbursement advothe world. Discover and evaluate the latest cates to help you get paid what is rightfully October 3, 2008 advances in endocrinology. Hear from lead- yours.

Customer Service/Front Office Telephone ers in the field. Choose from among more • Access to a comprehensive array of Techniques than 200 educational programs, including insurance services (personal and profesThis half-day practice management seminar plenary symposia, updates, debates, and sional) at competitive rates. will provide valuable staff training to handle more. For more information, visit www. phone calls and scheduling professionally endo-society.org.

With CMA, the San Francisco Medical and efficiently.

Society has fought for issues crucial to the 9:00 a.m. to 12:00 p.m. (8:40 a.m. registra- August 10–15, 2008 practice of medicine, including: tion/continental breakfast) Essentials of Primary Care: A Core Cur• Stopping the governor’s two-percent $99 for SFMS/CMA members and their staff riculum for Ambulatory Practice tax on physicians. ($89 each for additional attendees from the Resort at Squaw Creek, North Lake Tahoe • Fighting insurance company abuses same office); $149 each for nonmembers.

This course is designed to provide a compre- against doctors and patients. hensive “core curriculum” in adult primary • Stopping nonphysicians from pracNovember 4, 2008 care. It will serve as an excellent update and ticing medicine.

“MBA” for Physicians and Office review for current primary care physicians • Opposing Medi-Cal cuts.

Managers and other primary care professionals, and as 9:00 a.m. to 5:00 p.m. (8:40 a.m. registra- an opportunity for specialists to expand their SFMS is constantly advocating on behalf tion/continental breakfast) primary care knowledge and skills. Particular of San Francisco physicians and their paThis one-day seminar is designed to provide emphasis will be placed on principles of pri- tients. Recent examples include: critical business skills in the areas of finance, mary care, office-based preventive medicine, • Cosponsoring, with the Sutter operations, and personnel management. practical management of the most common Health Institute, a palliative care workshop $250 for SFMS/CMA members and their problems seen in primary care practice, and on state-of-the-art end-of-life care. staff ($225 each for additional attendees expanded skills in clinical examination • Cosponsoring an international confrom same office); $325 for nonmembers. and common office procedures. Emphasis ference, attended by practitioners from all will also be placed on skills in dermatology, over the world, examining the effects of the Other Events psychiatry, gynecology and women’s health, environment on fertility.

June 12–15, 2008 and neurology. For more information, visit • Working with the City and County Living on the Fault Line: Advances in www.cme.ucsf.edu. of San Francisco to advocate improved Occupational Medicine health care access for the City’s uninsured. www.sfms.org

May 2008 San Francisco Medicine

Executive Memo Mary Lou Licwinko, JD, MHSA

Travels in India

E

arlier this year I participated in a study mission to India with the American Society of Association Executives. The purpose of the trip was to educate ourselves about India as an emerging world market and to learn how associations might play a part in the future of India. Our travels took us to Mumbai, Delhi, Jaipur, and Agra, where we met with corporate executives, government leaders, diplomats, health workers, newspaper editors, university professors, and even a producer from Bollywood.

The sheer volume of people living in India has a tremendous effect on everything that goes on, from traffic to business to health care delivery. India is currently home to 1.1 billion people, making it second only to China in population, but geographically it is about a third the size of China. There are 29 states and 6 union territories in India, 22 languages with 122 dialects, and 9 different religions. The Indians we spoke with often referred to the “two” Indias: one is comprised of a burgeoning middle and upper class, and the other lives in poverty in the slums of the cities and in the shantytowns of the countryside. Only about 10 percent of the population lives in cities. There is great awareness that poverty needs to be dealt with in India. There was never an attempt to hide or ignore the poverty, and the sentiment we often heard was that it was better to see it than to pretend it does not exist.

The Indian health care sector is valued at $34 billion and is one of the fasting-growing segments of the Indian economy. In 2004, national health care spending was about 5.2 percent of the GDP, or about $34.9 billion; by 2009 it is expected to total 5.5 percent of the GDP, or about $60.9 billion. Other estimates indicate that by 2012, health care spending could comprise 8 percent of the GDP and employ 9 million people. These figures are based on the expectation that demand for health care will outstrip supply over the next decade; it is estimated that about 80,000 new hospital beds will be needed every year for the next three to four years in order to meet this demand.

There are more than 5 million physicians in India, and 162 highly competitive medical schools. The medical delivery system is split between the public and private sectors. There is no universal health care coverage in the country, and less than 10 percent of the population has health insurance, so health care is delivered San Francisco Medicine May 2008

through a patchwork of public and private hospitals, community health centers, primary health centers, primary health posts, urban health posts, and nursing homes. It is believed that the private sector provides 60 percent of the all the outpatient care in India and as much as 40 percent of all inpatient care. It is estimated that 70 percent of all hospitals and 40 percent of all hospital beds in the country are in the private sector. A number of the hospitals are accredited by international agencies and provide health care that is of as good a quality as anywhere in the world. Because of its high-quality health care facilities, which are cheaper than those in many other countries, India has begun to capitalize on “medical tourism” by trying to attract foreigners to receive health care services there.

India has been able to deal somewhat successfully with infectious diseases and there has been a shift in the health care system from emphasis on diseases such as typhoid and cholera to heart disease, arthritis, and diabetes. As in other developing and developed countries, chronic diseases and obesity are on the rise and are becoming the dominant health care concerns for the Indian population.

We were impressed by the optimism of the people we met about the future of India. The glass always seemed to be half full instead of half empty, despite poverty and infrastructure problems.

We also learned that there is an “Indian context” that needs to be understood. One of the speakers who discussed opportunities in India left us with a list of “realities” about doing business in that country. The final reality was that “[f]or every question, there are at least three right answers.” www.sfms.org

president’s Message Steven Fugaro, MD

The Medical Future ...

As Seen from Our Past

O

rgan transplants, MRI scans, kidney hemodialysis, defibrillators, HIV—these are but a few of the tremendous medical advances, inventions, and challenges that have transformed the field of medicine in the last forty years. In fact, the only absolute and immutable aspect of medicine is that change will always prevail. As we begin the twenty-first century, the rate of change continues to accelerate, and we are left to wonder where medicine will be in the coming years.

In this issue of San Francisco Medicine, various authors explore a truly fascinating premise: Where will medicine be in 2050? In the next forty years, what will have happened in medical economics, psychiatry, imaging, HIV, etc., and how will physicians themselves change? Will there be new illnesses to challenge us? Will our battle with resistant bacteria ultimately overwhelm us? The answers to all of these questions are, of course, extremely speculative. Yet pondering where we as physicians may end up in 2050 is a compelling and ultimately useful exercise if we have any hope of shaping our future.

How then to approach the unknowable, the uncharted territory of our future, the hidden face of medicine in 2050? One way of at least appreciating the enormity of this task is to reflect back on what has transpired in medical science in the past forty years, a period that encompasses much of our lifetimes.

Since 1968, infectious diseases and advances in antimicrobial therapy have impacted almost everyone on the planet. Vaccines were developed against mumps, rubella, hepatitis A, hepatitis B, and meningococcus. Multiple new antibiotics and antiviral medications have been developed. It is now thought that viruses cause 15 percent of all cancers. Yet the biggest change in this area by far is our discovery of “new” diseases—HIV being clearly the most prominent, but also including such infections as hepatitis C, SARS, Ebola virus, and H5N1 avian influenza, all affecting populations around the globe.

Medical technology has engineered some of the greatest transformations of the last forty years. Only a few active physicians remember trying to make diagnoses before CAT scans, MRI machines, ultrasound, and echocardiography made the interior of the human body infinitely more accessible. Endoscopy and laparoscopy have utterly changed our ability to enter the human body less invasively and more successfully. Cardiac pacemakers and defibrillators are now routinely implanted to prevent sudden death. www.sfms.org

Some of the most important and transformative changes have occurred as the results of advances in biotechnology. The molecular revolution has finally borne fruit—the discovery of the secrets of DNA by Watson, Crick, and Franklin in the 1950s directly resulted in the miracles of recombinant DNA research from the 1970s onward. Pioneering biochemists at both Stanford and UCSF did much of the original work in this field. The consequences of this research are the plethora of biologic agents available to us now, particularly drugs that are employed in hematology, oncology, and rheumatology.

An even more profound ramification of this work has been our ability to identify defective genes in multiple illnesses and to become aware of the prominent role of oncogenes in the development of cancer in our patients. Recently the Human Genome Project has made us aware of the sequences of every human chromosome, raising the real possibility of being able to understand all pathologic processes at the genetic and molecular levels.

Cardiac transplantation is also new in the last forty years, and other organ transplantation (liver, kidney, etc.) has become commonplace. The success of these remarkable procedures is also a testament to the discoveries in the field of immunology and the ability to safely prevent organ rejection with drugs targeted at specific components of the immune system.

Finally, as we have become ever more proficient in advancing the science and technology of medicine, there has been an increasing awareness of the need to focus on the well-being of our patients. Physicians and patients have thus begun embracing the various aspects of integrative medicine—meditation, acupuncture, therapeutic massage, and mindfulness. These techniques all share the goal of enhancing our ability to heal our patients from both within and without.

When one reflects on what the past forty years have wrought in our field, it is both exciting and intimidating to contemplate what the next four decades may bring. The varied articles in this issue attempt to give us some hint at this extraordinary future. All that we know for sure is that physicians in 2050 reflecting back on us will most likely find that what we now think of as sophisticated and cutting-edge is hopelessly primitive by the standards of the mid-twenty-first century!

May 2008 San Francisco Medicine

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Editorial Mike Denney, MD, PhD

Prognosis and Prophecy

C

assandra could predict the future. In the ancient tale, the Iliad by Homer, Cassandra prophesied the death of her brother Hector, the dire consequences of allowing the Trojan horse to enter the walls of the city, and the ultimate destruction of Troy. She even foretold the devastation of the Greek army as it returned home from the battle. However, Cassandra also was cursed.

Despite her power to foresee events, no one would ever believe her until it was too late to stop the disaster from occurring.

Contemplating this issue of San Francisco Medicine with its theme of predicting the future of medicine, we might pause to reflect upon the gift and the curse of Cassandra. In the nineteenth century, without solid scientific evidence, doctors like Ignaz Semmelweis, Joseph Lister, Marion Sims, and William Halsted predicted that cleanliness on the part of caregivers would result in prevention of infection. Like Cassandra, they were ridiculed by those who did not believe them, yet their predictions came true. Conversely, other doctors, who apparently had neither the gift nor the curse of Cassandra, made predictions of cure by other techniques, like internal mammary artery ligation for heart disease, the routine use of milk and baking soda to treat peptic ulcers, and hypophysectomy for breast cancer, to name a few. These doctors were believed by many established physicians, but their predictions for future success did not come true.

In everyday medical practice this uneasy art of prophecy is called prognosis: from the Greek pro, before, plus gnosis, to know—to know beforehand, or the knowledge to predict the future. In the Hippocratic Corpus, the treatise on Prognosis states: “Anyone who is to make a correct forecast of a patient’s recovery or death, or of the length of his illness, must be thoroughly acquainted with the signs and form his judgment by estimating their influence on one another, as has been described in speaking of urine, sputa and other subjects . . . the bad being always bad and the good, good.” In modern terms, we might say that when predicting the future of sick patients physicians must weigh all the scientific evidence.

In his book Death Foretold (1999), Nicholas A. Christakis, professor of sociology and medicine at the University of Chicago, notes that prognosis may involve merely the biological and technical parts of medical care, but that adding the more spiritual element of prophecy brings transcendent creativity, meaning, and purpose www.sfms.org

to the task. He admonishes doctors, saying, “The avoidance of prognosis represents the shirking not only of a clinical but also of a moral responsibility, a responsibility that pertains both to individual physicians and to the profession as a whole.” Although Christakis admits that “The true prognosis can never be known definitely in a specific patient,” he deems a “deliberate assessment of prognosis as absolutely necessary.”

Thus, practicing physicians are caught in a dilemma. They are called upon to engage in prognosis, yet they do not have Cassandra’s gift of prophecy—they cannot predict the future. Medical experience is replete with people who died unexpectedly while undergoing treatment and others who far outlived the prognosis for their demise, some who even experienced a spontaneous remission of incurable disease. Indeed, from a scientific point of view it is clear that all the clinical statistics in the world cannot foretell what will happen to any individual patient. In fact, the scientific approach to medical prognosis might be aptly characterized as carefully predicting the future of patients after thoroughly evaluating insufficient data.

As we face this dilemma in medical practice, we might notice that Cassandra was wont to predict only tragedy, failure, and bad outcomes. In Troilus and Cressida, Shakespeare’s play about the fall of Troy, Cassandra shrieks, “Cry, Trojans, cry! Lend me a thousand eyes/And I will fill them with prophetic tears.” She even predicted her own death. We might also observe that the name of Christakis’ book is not “life foretold”—it is “death foretold.” Clearly, it seems far easier to predict destruction than cure.

And so it is that recognizing that the true prognosis can never be known definitely in a specific patient and that sometimes prognosis is necessary, we can do our best to offer thoughtful, empathetic, and helpful assessments. Moreover, perhaps we can add to prognosis the more spiritual element of prophecy, remembering that the famous ancient Greek prophet, the Oracle at Delphi, always gave predictions that could be interpreted in more than one way. We might transcend the perspective of Hippocrates of “the bad being always bad, and the good, good,” so as to include in our work the inherent mystery of the future. Thus, prognosis can bring meaning and purpose to both life and death.

May 2008 San Francisco Medicine

Back to the Future Of Medicine

A Look Back from the Future Twenty-first Century Biomedical Research and Practice Mike Denney, MD, PhD

F

orty-two years ago, back in the year 2008, in the May issue of San Francisco Medicine, a revolutionary new biomedical research and clinical methodology was proposed by Dr. Mike Denney.

The proposal called for an advanced methodology that surpassed and transcended ordinary empirical science in its efficacy for the medical treatment of human beings, and that included in its research not only the objective but also the subjective, not only quantities but also qualities, not only fragmentation but also wholeness, and not only matter but also spirit.

The presentation of this new science was somewhat obtuse because it made, curiously, a proposal for the future that was written in the past tense. This had resulted from the fact that for that May 2008 issue of San Francisco Medicine, the Editorial Board had decided to offer articles about “Back to the Future of Medicine,” with the unique slant of having the authors write as though they were living in the year 2050, thus recording in the past tense their predictions for the future of medicine. It was a subtle, mind-bending literary exercise that gave an entertaining feel but that, understandably, might have led some readers to think that Denney’s proposal was just frivolous speculation, a time-warp play on words, or an idle fantasy. But today, now that it is the year 2050, we know, of course, that the proposal for a new kind of science was profoundly serious, and that its publication eventually resulted in changes in the way medical care in this mid-twenty-first century is researched and practiced.

There were others back in 2008 who purported to include a new science and spirituality in healing. Research of “alternative” healing practices such as acupuncture, 10 San Francisco Medicine May 2008

energy healing, biofeedback, meditation, tai chi, yoga, and prayer, among others, was financed by grants from the National Institutes of Health and private foundations. In healing institutions across the country, this research claimed to bring about an integration of alternative, “evidence-based” healing with conventional, scientifically proven medical practice. Organizations in the San Francisco Bay Area, such as the Institute of Noetic Sciences, the Osher Center at the University of California at San Francisco, and the Institute for Health and Healing at California Pacific Medical Center, engaged in research that purported to foster a union of science and spirituality in healing.

As laudable as these efforts were, however, it is now clearly evident that this research did not engage in true integration. The studies offered neither a union of the objective and subjective aspects of healing nor a marriage of quantitative science with qualitative and poetic ways of knowing. Instead, the researchers simply tried to subject and subordinate intuitive,

transpersonal, and mind-body healing to empirical statistical data, seemingly unaware that their methodology, ordinary empirical science, was inadequate to measure the metaphoric, poetic, and spiritual qualities of the phenomena they chose to study.

The theoretical foundation for a new methodology actually originated during the transition from late nineteenth-century Positivism to early twentieth-century discontinuity and paradox in the arts and sciences. To start with, in the year 1900, Bertrand Russell, who had completed his Principia Mathematica, realized that the entire work—intended to be the final word on the perfection of mathematics—contained a basic error, a recursive paradox that had been pondered by philosophers throughout history. After explaining the paradox with complicated mathematics, he expressed it in the vernacular: What man shaves the barber in a town in which the barber shaves the men who do not shave themselves?

Russell’s realization of a fundamental paradox in mathematics was probably a result of ideas expressed during the Paris World’s Fair of 1900 at the Second International Congress of Mathematics and the International Congress of Philosophy.

Famous mathematicians of the old Positivist school, such as David Hilbert, proposed that there were no problems in mathematics that could not be readily solved, and that mathematics would soon attain absolute rigor and formality with nothing left undefinable. However, other mathematicians and philosophers argued that it was impossible to define what is mathematically definable, citing such paradoxical concepts as the nature of numbers and the mathematical nature of infinity.

By 1931, Kurt Gödel, a twenty-fivewww.sfms.org

year-old doctoral graduate in logical mathematics at the University of Vienna, set out to explain away the illogical recursive paradox, but to his surprise he proved instead that the recursive paradox would never go away. In his Incompleteness Theorem, mathematics proved that mathematics would forever be incomplete, locked in the recursive paradox.

Earlier, the mathematician, physicist, and philosopher of science Henri Poincaré, who had attended the meetings in Paris in 1900, had calculated the recursive paradox into his own theory of chaotic deterministic systems, which proposed that highly complex systems do not follow the logic of mathematics. After Gödel’s Incompleteness Theorem, Poincaré’s ideas concerning chaos gained credence. Alan Turing investigated the recursive paradox and discovered that not only were there mathematical problems that could not be solved, there were an infinite number of such problems. Turing was the father of the modern computer, and it was with a computer that the idea of chaos and complexity theory was finally realized.

In 1961 at the Massuchusetts Institute of Technology, the meteorologist Edward Lorenz programmed a computer to predict the weather. He entered some numbers that were slightly less accurate than the computer was capable of, and when he returned a few hours later, the whirring computer had invented an entirely new organization of mathematics. Thus the idea of complexity and chaos theory became reality. Small changes in the wholeness of complex systems can result in transcendent phenomena that spontaneously emerge and that therefore cannot be measured or predicted by ordinary science. The theoretical incompleteness in mathematics had become manifest in the real world, and the new, enchanted quality of emergence transcended linear logic.

In the year 1900, physicist Max Planck wrote a formula that explained why black metal glows red when heated. In doing so, he used for the first time the concept of the quantum, the smallest unit of matter or energy possible. Thousands of experiments done in linear accelerators now confirm what is accepted to be the most accurate description of reality ever known. As explained by physicist Amit Goswami: quantum particles www.sfms.org

can be in two places at the same time, can be here and then appear over there without traversing the intervening space, cannot be said to exist in space/time reality until they are observed, and can affect one another at a distance and faster than the speed of light. The very nature of matter and energy was thereafter understood to go far beyond that which can be explained by ordinary science.

Summarizing all of this incompleteness of mathematics and discontinuity of quantum physics, the astrophysicist John D. Barrow, in his book Impossibility: The Limits of Science and the Science of Limits (Oxford University Press, 1998), concluded that, paradoxically, science proves that science cannot prove everything, and thus, “No nonpoetic description of reality can be complete.”

In his 2008 proposal for a new poetic methodology in biomedical research and practice, Denney observed that such biological events as the beginning of life from inorganic carbon molecules, the evolution and mutations of DNA, and the birth of mind and consciousness from the matter of the brain are examples of spontaneous emergence out of complex systems. Moreover, he noticed that human beings are the most complex entities in the known universe and that they exhibit quantum particle exchanges at the tens of billions of neuron synapses in the brain and within the zillions of cells of the body—affecting neurology, physiology, psychology, and bodily-felt qualities of imagination, intuition, and metaphor. Thus, all healing of the human body, taken in its wholeness instead of fragmented parts, must include aspects of spontaneous emergence of events in complex systems and the discontinuity and paradox of quantum physics.

That’s why he proposed a new biomedical research methodology that would include not only the objective but also the subjective, not only quantities but also qualities, not only fragmentation but also wholeness, and not only matter but also spirit. He pleaded for researchers to begin exploring pathways to new transcendent and poetic methodologies.

For many years, Denney’s ideas were rejected or unnoticed except by a few enlightened individuals who discussed them

in esoteric metaphysical meetings; in think tanks; and in the courses in Spirituality and Science, Integral Healing, and Frontiers of Depth Psychology that Denney taught at advanced graduate schools such as the California Institute of Integral Studies and Pacifica Graduate Institute.

Finally, in the year 2045, his work was brought forward, not by scientists but by philanthropists contributing money for biomedical research, some of whom insisted that their dollars go to inquiry into the new methodology that Denney had proposed back in 2008. Now, in the year 2050, there are at least three research projects investigating his ideas: 1) an open-ended study in which scientists and poets engage in dialogue so as to fuse logic with metaphor, seeking pathways toward specific, new integrated methodologies; 2) a study in which radiologists interpret biomedical imaging studies objectively as usual, then describe their own deep subjective and metaphorical experiences as they imaginatively and artistically engage the images on the X-rays and scans; 3) a cardiac surgery experiment in which outcomes are not only measured quantitatively but also take into account the deeply qualitative poetic, subjective, and spiritual experiences of both the patients and the caregivers.

Unfortunately, this new research did not occur during Denney’s lifetime. He died prematurely at the age of 110, on his birthday in the year 2040, and thus never learned of the fruition of his work. Still, during his twilight years he often spoke of a deep gratification that his proposal for a new biomedical science was published in that May 2008 “Back to the Future” issue of San Francisco Medicine.

Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from full-page, 4-color display ads to classified ads with discounted rates for members. Please contact Galen Foster for more information, (415) 5610850 extension 240 or foster@sfms.org.

May 2008 San Francisco Medicine 11

Back to the Future Of Medicine

Missing the Mumps A Medical Anthropologist Reports from the Year 2050 Meg Jordan, PhD, RN

W

hen the last vestiges of chronic disease were wiped out through biogenetic engineering four years ago, in the year 2046, celebrations occurred around the galaxy. We had no idea then how illness would be missed, how its soul-shaping ministrations would leave the human race grimly well. Looking back fifty years to the year 2000, it is hard for most people to believe that there was a time when we could not heal broken nerves or reprogram epigenetic matrices.

At one time medical anthropologists theorized that the onward march of obesity and diabetes witnessed in the early twentyfirst century was a sociopolitical disorder, but once the Sino-Indian Stem Cell Dispensary Units were securely in place in the designated High Disease Burden areas, the warnings from international teams of social scientists were considered archaic and roundly dismissed.

Still, the eradication of inherited disorders and so-called “diseases of lifestyle”—along with every known infection, contagion, and pandemic that plagued humanity from 1400 to 2046—has created a discomfiting well-being at best. It seems that illness itself provided biological scaffolding that allowed the human spirit and determination to flourish. This is not a philosophical view, but rather a significant finding from qualitative interviews and ethnographic inquiry with more than 100,000 human informants from every sociopolitical quadrant.

EERIE Research From 2046 to 2050, thirty-eight medical anthropologists participated in the four-year EERIE Research (Encounters with Eradication of Illness Ethnographic 12 San Francisco Medicine May 2008

Research) study. The group then disseminated those findings to the First Intergalactic Consortium of Health and Longevity in January. Reporting this first hologramcast event, the medical anthropologists were

“Looking back fifty years to the year 2000, it is hard for most people to believe that there was a time when we could not heal broken nerves or reprogram epigenetic matrices.” prepared for some resistance to the findings among the professional heterodox medical establishment, but there was little if any.

Most of the rebuttal came from the transnational corporate sponsors of the consortium and philanthropic special-interest groups, as well as health policy decision makers and governing elite actors.

Our attempts to organize the findings according to traditional categories (social origins of disease, biosocial attributes, class, race, ethnicity, gender) broke down. The term class was refuted by the Economic Equity Council, which argued that significant clusters of financial and social inequity were no longer identifiable and could certainly have no impact on medical disparity. This argument, of course, held no merit for those remaining outpost scientists who track water privatization consequences in the Restricted Zones, where squalid, inhumane conditions, sporadic power sources, poor treatment of women and children, and deplorable living conditions still abound.

Race was declared an outmoded con-

cept, since the fourth symposium on Rethinking Race in the Americas in 2014 merged the critical dialogue in genealogical identity with developments in biological anthropology.

As for gender, any attempts to understand gender’s implication in medical diagnosis and treatment were drowned out in a heated discourse in which twenty-two distinct genders were identified, threefourths of which were dependent on elective transgenic-meiosis fabrication.

What follows is a summary of the findings presented to the Consortium.

Study Parameters Sample: More than 140,000 people were enrolled in the study, while 100,000 (approximately 52,000 women and 48,000 men) completed the four-year protocol. Indepth qualitative interviews were conducted through use of teletransfer technology at the beginning, two midpoints, and at the end of forty-eight months. Data from observation and interviews were organized into specific categories by Illiac72 software with analysis under the guidance of the Institute of Holistic Health Studies.

Questions determined a stratum of trustworthy representation. More than 90 percent of informants had successfully been declared disease-free through scientific measurements. More than 88 percent had received stem cell replacement, while the remaining 12 percent had surgical procedures to exert control over disease formation processes. Only 2 percent had functional transplants.

Findings The Gift of Stigma The stigma of coping with a chronic www.sfms.org

illness created lifelong adaptations that had unexpected advantages. Informants who were once deaf (prior to transplant surgery) did not deny that their former conditions were often painful or difficult; however, the identities also created dilemmas that were resolved through new social interactions that normalized the harsh realities and brought forth an insider’s language, camaraderie of lived experiences, and compassionate interaction with those sharing identity and understanding. With the transplant success, they were suddenly new actors in a hearing world, stripped of their social networks.

A former deaf man said, “I don’t know how to communicate anymore. I don’t have my humor, irony, sarcasm, jokes, sign language—there’s no reason to convey what I’m up against.” The functions of self-help groups and nonprofit disease advocacy groups were left without a raison d’être, dismantling extensive social networks that provided a sense of belonging and community.

The Eclipsing of Difference Since genetic expression signatures were routinely annotated for hopeful parents applying for childbirth licenses, state-sponsored doctors have been able to integrate genomic information with clinical and pathological risk factor assessment, thereby refining prognosis and therapeutic options.

The end result of this early intervention removed the stratum of “identified otherness” within society: no more birth defects, deformities, autism, impaired cognitive abilities, or developmental disabilities were evident in social circles or on the streets of developed societies. However, key informants related a backlash to this whitewashing of the gene pool. Some illegal parents anonymously reported clandestine birthing operations in rural areas, where “children of a lesser god” were safeguarded and eventually revered, some even idolized, as having the ability to listen inwardly and therefore have access to specialized knowledge.

Welcoming of Penultimate Health The evolution of early attempts at integrative medicine (conventional biomedicine with a menu of options from alternative www.sfms.org

or complementary health modalities) in the 1990s into the new Penultimate Health Care model was viewed as a positive change by informants. In short, the vast network of medical and allied health professionals, pharmaceutical firms, hospitals, clinics, university health systems, and related industries had little to do after the eradication of illness. Billions of people required work, purpose, and occupation.

Prominent health researchers and medical personnel from the San Francisco Bay Area contributed to the new social indicators for health, namely, California Institute of Integral Studies’ Integrative Health (IHL) program, the Institute of Holistic Health Studies (IHHS) from San Francisco State University, and the Health Medicine Institute and Forum. IHL devised the widely accepted salutary measurement scale of integrative well-being, while IHHS outlined how the evolution of consciousness, the adaptation of biomimicry principles from nature, and the deep integration of creative lessons on sustainability were chief characteristics for developing and sustaining health and longevity. Progressing people along this Salutary Scale has become the major activity of the health care system today.

Social Intelligence When major medical research and funding organizations elevated social isolation as a leading risk factor for heart disease and certain cancers in 2010, neurobiologists tracked the seat of belonging within the human psyche, genome, biochemistry, and neural network. The challenge was immediately posed: If society was indeed now “bowling alone,” what could be done to redirect human behavior to healthy bonding? Genetic transplants from Bonobo apes into human adolescents were among the first experimental procedures performed to instill more social intelligence and reverse isolation trends. The results reproduced the earlier ancestral traits of nesting, grooming, and easy intimacy among the human subjects.

One informant in the EERIE Research study who was a recipient of the Bonobo Gene fragments reported, “I shriek when I’m alone now and can only be comforted by instant copulation.” Again, the unin-

tended consequences of this intervention are unthinkable to our group of medical anthropologists. As one Irish dramatist told the researchers, “This spells doom for self-reflection. Dark nights of the soul are relegated to history’s waste heap. Where do you think creative thinking comes from if not the transformed fires of loneliness?”

The Revival of Religious Healing A significant number of informants (23 percent) believed the eradication of illness was the direct result of divine intercession, and not the concerted efforts of millions of international scientists and medical researchers. These informants identified themselves as neoconservative members of religious healing sects. Religious healing methods (a more dogmatic version of traditional faith healing) were driven by the two dominant theocracies (Christian and Islamic) that flourished in the early twenty-first century. These religious-cultural social forces actively resisted intervention from medically pluralistic (biomedical and naturalistic) systems and practitioners.

EERIE Research ethnographers concluded that disaster-related trauma and certaintyoriented belief systems were foreground issues that spawned this archaic revival of religious healing fervor. These informants did receive their stem cells, transplants, and inoculations, however. They simply attributed their good health to divine causes.

Frozen Embryo Generation Informants who were part of the frozen embryo generations continue to provide the greatest challenge to medical ethicists. They have reframed the debates on identity, kinship, lineage, and origins of life. Informants asked, “Who do I belong to?” “When was I alive?” “Where was I when I was frozen?”

Finally, the greatest point of contention from the Consortium was over the issue of Mandatory Health outlined in the international treaties. Any employer, whether public, private, or government, when faced with recalcitrant, uncooperative, or openly defiant resisters to the Mandatory Health program, are fined, imprisoned, or penally rehabilitated. Lawsuits brought to employers by overweight people, smokers,

Continued on Page 17...

May 2008 San Francisco Medicine 13

Back to the Future Of Medicine

Learning from Our Past Lessons for Our Financial Future Thomas H. Lee, MD May 18, 2050 To the Editors:

I

n this year 2050, health care is in crisis. Costs are rising faster than ever, explosions in biogenetic and microtherapeutic technology are overwhelming today’s providers, and workdays are only getting longer. Meanwhile, the obliteration of food supplies and the global spread of prion diseases pose real threats to the human race. It occurs to this humble reader that we should halt all debate on the proposed increase in membership dues and begin to consider the real problems that face our noble profession.

Though a distant memory already, it was only near the turn of the century when we faced challenges that seemed equally insurmountable. As recently as 2012, health care costs totaled a whopping 23 percent of GDP and notable businesses such as Ford and GM nearly went bankrupt before the federal government intervened. It may be hard to believe, but back then more than 80 percent of physicians used paper for record keeping, 50 million patients remained uninsured, HIV was considered a terminal illness, and nearly all vaccines were still delivered by injection.

Yes, we’ve made dramatic progress since then and we can do the same going forward, but we must remember that these changes didn’t happen without hard work, tough changes in policy, and a firm desire to do what’s right for the patient. Lest we forget, our last fifty years of accomplishments have been driven by key moments, movements, and milestones that should serve as inspiration for our next fifty years. Given today’s environment of political divide and turmoil, it’s important to remember some of 14 San Francisco Medicine May 2008

the more pivotal events in recent memory and put our current challenges in proper perspective.

motion.

Financial Crisis of 2010

To the surprise of most experts, however, the health care system did not collapse. Mortality rates remained unchanged while health care expenditures leveled off.

Patients started making financially-minded health care decisions and commercial health plans seized the opportunity to create even more consumer-directed programs.

Physician dissatisfaction, however, peaked during this period. Real incomes continued to fall while cost-conscious patients increasingly turned to their physicians for financial advice. Frustrated, a growing number of primary care physicians and specialists stopped accepting insurance altogether. Over the next several years, the exodus from insurance-based reimbursement continued despite calls for legislation, and by 2015, almost 25 percent of physicians did not accept any form of health insurance, and almost 30 percent of consumers belonged to a high-deductible health plan.

Boutique and concierge practices thrived in this new environment, while radical new forms of delivery models began to appear. Web-based microconsultation, packaged lifestyle services, a la carte health plans, and ultra-boutique models all came into existence during this time. Internetenabled services and what were then called “electronic health records” became standard among physicians, mostly fueled by the need to innovate and differentiate in an increasingly digital world. Though there was some concern that these radical new delivery models selectively targeted the more affluent, it also appeared that some of these models demonstrated quality

Perhaps the most important event in the history of U.S. medicine was a financial one. The recession and near collapse of the federal banking system, beginning in 2008 with the mortgage meltdown and further exacerbated by the near bankruptcy of several financial institutions and blue-chip companies, resulted in a radical wake-up call for policy makers in Washington.

Despite the nation’s withdrawal from the Middle East, military conflicts worldwide and a growing number of domestic terrorist threats necessitated the expansion of a military budget that was rivaled only by that of Medicare.

Facing the possible threat of federal collapse, the President and lawmakers passed the Emergency Medicare Reform Bill, despite fierce and universal opposition. Though the bill was positioned as a temporary five-year cap on total Medicare expenditures, it was renewed for another five years until it was ultimately replaced by the landmark Health Care Reform bill of 2020.

Suddenly, the lifeline of the health care economy had been cut. And the cuts went deep. Terminal illness: nonreimbursable after six months. Experimental procedures: uncovered. Lifestyle-related procedures and hospitalizations: 20 percent coinsurance or mandated gap insurance. Doomsday projections of plague and personal bankruptcy abounded. Health care stocks plummeted while emigration to Canada skyrocketed.

The monumental shift to consumer-based financing of health care had been put into

Rise of Innovative Delivery Models (2010–2015)

www.sfms.org

and cost outcomes superior to traditional insurance-based delivery systems. With the economy just coming out of a prolonged recession, lawmakers were reluctant to make any new moves and consumers by then had grown used to a two-tier system. Congress decided to focus on other priorities and, as a consequence, almost one third of all next-generation delivery models (many of which we still see today) were born during this pivotal period.

Microtechnology for the Masses (2015–2030) As next-generation practices were just becoming mainstream, new environmental threats began to pose large-scale public health threats, the likes of which had not been seen since the rise of MDR-TB and HIV. Global climate shift, microclimate variation, population growth, and the emergence of Asia all contributed to horrific scenes of drought, famine, and a new strain of radically toxic retroviruses (later named RTRs). Within two years, millions were dying worldwide.

The RTRs first hit the U.S. in 2017 and, by 2020, death tolls were estimated in the hundreds of thousands. Despite wellestablished protocols, rapid immunization programs failed to effectively contain the virus, which mutated at alarmingly fast rates.

First-line responders and primary care teams were overwhelmed as the next-generation delivery models showed their first signs of weakness. Well designed to manage the care of individual patients, the patchwork of practices failed to respond as a cohesive public health system.

Although bio- and microtechnology funding had fallen during the prior decades, it was nonetheless two breakthroughs from the private and public biotech sectors that ultimately stemmed the tide against RTRs. The first was the ability for microfilament sensors to detect the first signs of RTR infection in the bloodstream. And the second was microadaptive denaturization delivered via long-acting inhaled therapeutic vehicles. By being able to instantaneously detect the first signs of infection and then overwhelm the virus with high-exposure inhaled therapeutics, the concept of needle-based injections and immunizations became instantaneously www.sfms.org

obsolete. IRMT (or Instant Response Modulated Therapy) was later adapted to treat a broad range of virus families and ultimately led to the near eradication of HIV just ten years later.

In the wake of RTRs and to better address the lingering concerns about the responsiveness of the public health system, Congress passed the landmark Health Care Reform bill of 2020. To this date, most of the health care system as we know it today traces its origins back to this important overhaul of our finance and delivery mechanisms.

The legislation not only restructured our public health system with federally covered preventive and disaster-response programs supported by a rich network of public health data centers and practice co-ops, it also effectively dismantled the remaining elements of Medicare and Medicaid.

The success of IRMT also resulted in a huge influx of capital supporting bio- and microtechnology innovation. Over the next ten years, we saw the commercialization of several blockbuster products, including firstgeneration ID sensors, immune modulators, and gene repair kits. And it was during this period that completely new industries, such as transplant genomics and genotherapeutics, came into existence.

Renaissance Period (2030– 2040) In the face of our current challenges, it’s easy to take for granted what we have today: the lowest health care costs per capita anywhere; the near eradication of infectious disease as we know it; and a dynamic, flexible delivery system able to quickly adapt to changes in the environment.

But it was just twenty-five years ago that worldwide famine and global extinction were realistic probabilities. And our public health and delivery systems were pushed to the financial and operational brink. How did we arrive here—from there?

I’m sure most of us remember the thirties as an idyllic time in health care. And it was. Economic growth fueled by falling health care costs resulted in economic resurgence in the U.S. and a greater willingness by consumers to spend money on novel health care concepts. Home-based care, telemedicine, portable sensors, and multi-

specialty consultation essentially replaced the need for office visits altogether. Alternative and integrative practices thrived.

Mortality rates fell for a broad range of illnesses. And obesity and diabetes finally trended downward, given the unique fusion of social networking and home monitoring technologies. Overall, consumers in 2035 spent 30 percent less in real terms than their counterparts in 2010, yet still received dramatically higher levels of personalized and accessible care.

But the prosperity of the thirties and forties was ultimately created from the challenges of the previous two decades. Had we not faced financial crises or environmental threats, we might still be using paper charts and needles today. Out of hardship arose novel and revolutionary solutions that brought about change and improvements in our health care system. And it is those sorts of challenges that we face again today.

New Threats (2040–present) The health and environmental challenges we face as a society today are obvious.

The stories permeate our newsfeeds and monitor-scopes almost hourly. Over the last decade, we have become complacent and overconfident in our ability to fight illness, climate change, and bioterrorism. We have allowed pockets of discontent to proliferate, and they now employ the same innovative technologies, in a weaponized form, against us. Fraud, faulty products, and indifference have eroded the good names of physicians and researchers. And the threat of dispersive prions looms in the not-so-distant future.

Over the last fifty years, critical moments and crises have pushed our society to improve for the better. As policy makers, entrepreneurs, and caregivers, we have all been involved in making that change happen. How we rise to meet the challenges of our day will determine what our world becomes. Let us not forget that it is ultimately our responsibility to take ownership of these problems today—to help shape a better future.

Respectfully, Thomas H. Lee, MD

May 2008 San Francisco Medicine 15

Back to the Future Of Medicine

Sounds Simple, Wasn’t Easy Finding Good Health for Physicians Linda Hawes Clever, MD, MACP

H

ere is the good news in this year 2050—and there is no bad news.

During the last fifty years, physicians have learned one concept and two strategies that, along with other approaches, have saved lives, saved health, and saved relationships. These have saved physicians’ lives, health, and relationships, not only patients’.

Now, at this mid-twenty-first century mark, let’s recollect some history to put this amazing progress into perspective. Back in the year 2000, when PalmPilots were new and confusing because they had nothing to do with coconuts or aircraft, a fair number of physicians were in sorry shape. Some, especially in primary care, were tense and bitter, scrabbling to pay expenses, never mind funding the children’s tuition and personal retirement plans. Proceduralists seemed to be sitting pretty, but they had to agitate for equipment, space, and staff. Researchers felt as if they were caught between Edgar Allen Poe’s pit and pendulum with increased competition for decreased support from NIH and elsewhere. Faculty had to snatch moments from patients, students, and their own families to do the research that was required for tenure—if achieving tenure were desirable anymore. All physicians were pressed for time and felt under the gun even as they tried very hard to be competent and responsive. They wanted to do more than scrape through the day. They searched for excellence and meaning—and they wanted some joy in their lives, too.

It is no wonder that feelings leaked into behavior. According to data published in the year 2000, physicians’ rates of divorce were about 10 to 20 percent higher than that of the general population, perhaps because they worked more at medicine 16 San Francisco Medicine May 2008

than at marriage. Somewhere between 3 to 5 percent of physicians were disruptive each year, back then when there were scalpels to throw across an operating room and charts to slam on the desk at nursing stations (some readers may recall scalpels and nursing stations). It is hard to imagine, but physicians committed suicide quite often, 1.4 times more often than the general population for men and more than 2.3 times more often than the general population for women.

Those premature deaths stole 258 to 369 colleagues from us each year—well over two medical school classes’ worth of talent and hard work.

What happened to change that sad picture to the good news of 2050? One concept and two strategies appeared on the scene and took hold.

The Concept The revolutionary concept started to float around in San Francisco in the late 1900s: It isn’t selfish to take care of ourselves.

It’s self-preservation—so we can do what we want to do. This concept was difficult to accept, because physicians were trained to work until they dropped. They were supposed to meet every relentless demand. But there was never enough time. To be sure, their efforts were often rewarded with a grin or a thank-you or their own sense of accomplishment, but the heat was on, always on.

The misery titer was high enough that more than a few wanted relief and wondered, “OK, so how do I take care of myself?”

In a real breakthrough, for example, some physicians were moved to find their own physician, although about one third still had no “physician-in-chief” for themselves. These latter physicians were more likely than physicians-with-a-physician to

miss mammograms, colonoscopies, and vaccinations, thus putting themselves in harm’s way. A doctor acquiring a doctor may be an acknowledgment that physicians—just like patients—are human, not superhuman.

Our DNA spirals just like everyone else’s.

Having someone help take care of us is part of taking care of ourselves.

The two strategies that grew from the “Not Selfish but Self-Preservation” concept—hence the now-familiar “NSBSP” acronym—were learning more about how physicians’ personalities are wired, and learning how to say “no”—and “yes”—at the right time.

The First Strategy Of the many charms and challenges of physicians’ personalities, we and our patients appropriately treasure our thoroughness and contentiousness. We simply must think and rethink, check and recheck, in order to do our work well. (Raise your hand if you make lists. Raise your hand again if you add an item to the list so you can check it off if you do it after the list was made. Ahhh, the satisfaction!)

Perpetually seeking perfection has disadvantages, however. We may have trouble with close relationships because we want everyone else to be perfect as well, and we imply, “My way or the highway.” This message often transmits to colleagues, kids, and spouses or partners, not all of whom welcome having our directives thrust upon them. Also, because we want to control and fix everything in order to meet our own high standards, loss of control is almost intolerable to us. Therefore, having a perfectly reasonable request senselessly turned down by an insurance company (this was before universal coverage was enacted) was like www.sfms.org

someone rubbing sand on a second-degree sunburn.

Going for perfection and having obsessive-compulsive traits are more than double trouble. They lead to exceptional vulnerability to criticism. We may flare if a shadow of doubt is cast over one of our diagnoses or decisions. Furthermore, our own intuition suggests that perfection is not possible and that we are trying to live a lie, leading to chronic discomfort. All of these elements can result in high self-doubt and even low self-esteem.

Once physicians learned this, they could, as a mentor once advised me, temper the wind to the shorn lamb. They began treating each other with more empathy because they saw that physicians themselves were sometimes the shorn lambs, underslept, overwhelmed, and insecure. They saw others’ mistakes as potentially their own and sought to use them as opportunities for learning and compassion, rather than viewing them with disgust or antipathy.

As physicians learned why they were so defensive, they were able to stop rearing up and striking out. They were able to listen and learn from researchers, other colleagues, nurses, and patients, and they found cures for those long-gone maladies, irritable bowel syndrome and the common (now uncommon) cold. They listened to and learned from their spouses, children, and friends and found new sources of meaning and joy.

They cut themselves some slack and began to enjoy their whole, healthy lives.

The Second Strategy Discovering the second of the two strategies put the doctors over the top and into robust health and fulfillment. They recognized that, along with their other admirable yet sometimes sabotaging attributes, they liked to please others. Most of us still do, and that is good. The problem is that wanting to please may lead us to say “yes” far too much and “no” not nearly enough.

Even now, in 2050, it can be hard to say “no” when we are asked to be on a committee, take more holidays on call, chair the fund drive, serve on a board, clear our desk or garage, do double shifts, volunteer again and again. Sometimes physicians were, and are, afraid—afraid of being perceived as www.sfms.org

weak, lagging, incapable, or, to use a sports term, not a “team player.” Besides, physicians liked to think of themselves as limitless and always having the only/best ideas. Quite quickly, as the NSBSP—some called it “renewing”—movement took hold, physicians saw that saying “no” gave them strength, energy, time to learn new medical skills, time to flourish with family and friends, time to take care of themselves, exercise, and vote! When exhausted incumbents said “no” more often, new blood, vigor, and ideas could be infused into the jobs they had vacated, allowing worthy projects to reach new heights.

Saying “no” took a script and some practice, as you can imagine. If you find yourself attracted to the siren call of inappropriate “yes” answers, choose one or two favorite “no” responses from the following list and tattoo them into your frontoparietal lobe. You could give yourself a refresher in front of a mirror. Some people have to use their fingers and actually move their lips into the shape of the words: •“No” or “No, thank you.”

•“I’ll have to take something else off my plate.”

•“Not now but maybe later.”

•“Who else can pitch in?”

•“I’d love to do it, but you deserve and need a better job than I can do right now.”

•“This is my year for saying ‘no.’”

•“You want me to do what?”

Or try the anatomical approach: Bite your tongue and sit on your hands.

Overall, this is an important story of concepts, strategies, learning, and perseverance, all en route to assuring greater health for physicians who, after all, need and deserve it. The story has no end, actually.

What will happen in the second half of the twenty-first century? It is easy to slip back into brain-deadening schedules, soul-searing misunderstandings, desperation, or torpor.

The ringing cheer that has resounded for the first half of the twenty-first century needs refreshing: Taking care of yourself is not selfish. It is self-preservation—so you can do what you want to do.

Linda Hawes Clever, MD MACP, is the founder of RENEW, a program that helps busy health care professionals regain and maintain

their vitality in the face of competing professional and personal demands. She also serves as Chief of Occupational Health at CPMC. References Miller NM, McGowan RK. The painful truth: Physicians are not invincible.

South Med J. 2000; 93:966-973.

Leape LL, Fromson JA. Problem doctors: Is there a system-level solution? Ann Intern Med. 2006; 144:107-115.

Schernhammer ES, Colditz GA. Suicide rates among physicians: A quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004; 161:2295-2302.

American Medical Association: Women Physicians’ Conference Table 1. Accessed at http://mw.ama-assn.org/ama/pub/ category/12912.html on 23 March 2008.

Gross CP, Mead LA, Ford DE. Arch Intern Med. 2000; 160:3209-3214.

Missing the Mumps Continued from Page 12... and those with eradicable illness who have not received Mandatory Health benefits are fast-tracked in the courts.

Questions of self-responsible behavior versus legal-cultural impositions are discussed in the complete list of findings from the EERIE Research Study, available at WIFI/hhh dialin: Telestar 200042. The researchers welcome your comments and have established a forum, in the hope that the EERIE Research dimensions will be debated for years to come.

Meg Jordan, PhD, RN, is a medical anthropologist, health journalist, president of Global Health Media, and author and presenter on faculty at San Francisco State University and California Institute of Integral Studies.

References Becker C. Coping with stigma: Lifelong adaptation of deaf people. In Understanding and Applying Medical Anthropology (P. Brown, ed.), 1998, London: Mayfield; 311-315.

Inhorn M. Coping with stigma: Lifelong adaptation of deaf people. In Understanding and Applying Medical Anthropology (P. Brown, ed.), 1998, London: Mayfield; 315-321.

May 2008 San Francisco Medicine 17

Back to the Future Of Medicine

Looking Back and Beyond Holistic Health in the Year 2050 William B. Stewart, MD

W

hat a compelling invitation, to write from the year 2050! Yes, in my reverie I contemplate the hospital in which I work—the sunlight, streaming into the entry atrium of the medical center, warms the decorative stone floor and the spacious, plant-filled space. The sound of the bubbling fountain is complemented by the music of a harp. As I inhale the soothing fragrance of lavender . . . suddenly my reverie is interrupted, and I am struck with the realization that I am 107 years old! Was my genetic and geographic luck, and the effectiveness of my medical assistance and self-care, such that I can now conceive of such longevity?

To envision what is now called integrative medicine and holistic health is a fresh reminder that we live lives of possibility and probability. No matter how well we research, plan, and prepare, the elements of unpredictability, uncertainty, and impermanence, in the final analysis, prevail.

Looking back from the year 2050 reminds me of the reality that it has been forty years since my graduation from medical school. In the 1960s, heart surgeons were reconfiguring the cardiac anatomy. Organ transplantation was an emerging frontier for pioneers and visionaries. Imaging equipment was on the drawing boards that would revolutionize diagnostic capabilities.

Information on new drugs was fattening the print edition of the annual Physicians’ Desk Reference, and government-sponsored health insurance for the elderly, Medicare, was voted into law.

In the 1990s, the boundaries of the practice of medicine continued to evolve and expand. The human genome was mapped and the elucidation of complex cellular and subcellular physiologic pro18 San Francisco Medicine May 2008

cesses were occurring at the same time that practices such as traditional Chinese medicine, Ayurveda (indigenous medicine of India), homeopathy, naturopathy, yoga, and meditation were becoming better known,

“To envision what is now called integrative medicine and holistic health is a fresh reminder that we live lives of possibility and probability.” understood, and more widely applied. There was an individual and collective movement toward relationship, collaboration, integration, wholeness, and prevention in the practice of medicine.

This was all happening even as biotechnical, pharmacologic, and genetic breakthroughs were reported almost daily.

Back in 2008, Cohen et al (NEJM 2008) noted that “preventable causes of death, such as tobacco smoking, poor diet, physical inactivity, and misuse of alcohol, have been estimated to be responsible for 900,000 deaths annually—nearly 40 percent of total yearly mortality in the United States.” In large part, these “preventable” causes of death were treatable with therapeutic lifestyle changes. Furthermore, the estimates of the number of people whose symptoms and signs represented “psychosomatic,” “functional,” or “stress-mediated” illness continued to be significant. With chronic illness in all age groups on the increase and an aging population, the challenges to health care providers were clear and

growing. It was understandable that people were seeking guidance and solutions from sources related to the practice of integrative medicine, and it seemed likely they would continue to do so in the future.

Eisenberg (JAMA 1998) had documented the large number of people drawn to complementary and alternative medical practices (CAM). According to John Astin, PhD, of the CPMC Research Institute, an important reason that people sought alternative therapies was because there patients found “ … an acknowledgment of the importance of treating illness within a larger context of spirituality and life meaning. The use of alternative care gradually became a part of a broader value orientation and set of cultural beliefs, one that embraced a holistic, spiritual orientation to life” (JAMA 1998). By definition, medicine slowly came to mean the art and science of healing rather than just a scientific methodology for cure.

Medicine specialties ranged from aviation medicine to environmental medicine; from forensic and geriatric to internal and physical; from socialized to tropical and veterinary; and from alternative, indigenous, unorthodox, traditional, and nontraditional to complementary, comprehensive, mind-body, multidimensional, preventive, integrative, and simply “good” medicine.

The profession had many nuances, nooks, and crannies, as it sought to reduce and relieve pain and suffering, cure disease, and heal illness.

Prior to this first half of the twenty-first century, we lived with many metaphors to help define and characterize our mission.

One of these was the “battlefield” metaphor.

Here disease was the enemy; doctors, nurses, and healthcare professionals were soldiers; and our minds and bodies were the battlewww.sfms.org

grounds. The therapeutic armamentarium included the medications and technologies employed as we waged war against cancer, fought heart disease, wiped out resistant infections, and advanced battle lines and frontiers. In another metaphor, the “marketplace,” health was a commodity, something of trade and commerce. Patients became consumers, clients, and “managed lives.”

Hospitals and clinics became providers, while insurance companies and HMOs were payers. In this view, lines of revenue, cost centers, books of business, and bottom lines came to dominate.

Looking ahead to today’s medicine in the year 2050, we can enjoy an “ecologic” metaphor. In this metaphor for medicine, disease is an imbalance, the work of the physician and nurse is stewardship, healing becomes part of the process of change, and the hospital part of the ecosystem. With the wisdom of nature as a guide, the ecologic metaphor offers a workable and sustainable approach to health that acknowledges key principles such as evolution (i.e., we are in a continuous, dynamic state of change), interdependence (our existence is part of a larger web of life), limits (we have limited resources and defined boundaries), diversity (every part of the whole is a unique and essential contribution), and cycles (we are a part of nature’s cyclical patterns and rhythms).

Now, in the year 2050, there are several new features in the design of medicine.

These include technological currency that can monitor “best practices” in clinical medicine and quality and safety. These features are partnered with efforts to humanize the technological medical experience. This has brought about a greater emphasis on the importance of “therapeutic presence” and the value and impact of relationship for health care professionals. The appreciation of the power of light, color, and beauty has transformed the design of our places of healing, making them more welcoming, calming, and tranquil. The meaningful and vital practices that occur in these spaces, from midwifery to birth and death to ministering to all forms of disease and illness, make the experience between healer and patient more sacred. This has transformed the hospital setting into a templelike environment, www.sfms.org

rather than one that tends toward being antiseptically sterile and mechanistically procedural. Compassion, hope, presence, and love are seen as healing energies as powerful as any. These and other “feminine” aspects of health care, such as listening, service, and attending skills, have changed the face of medicine. Further, as it has done with politics, economics, and issues of the environment, the global, multicultural view has come to dominate medicine and health care. Awareness of systems of healing has spread across international borders via the Worldwide Web and the collaboration and cooperation of practitioners. The public has come to favor, whenever possible, holistic, nontoxic, minimally invasive, “natural” care. Consequently, care that is preventive and occurs earlier in the presence or progression of a disease state has now become more commonplace, and the care of end-stage disease is less consuming of resources.

Patients in 2050 continue to demonstrate a desire for empowerment. They take more personal responsibility for their self-care and lifestyle choices, even as they continue to seek the very best in expert advice and care. Understanding of the term “health plan” has taken on a new meaning and significance beyond the narrow implications of insurance for disease care. More costeffective solutions help balance the high costs of technologically based care. Health care emphasizes programs for well-being, disease prevention and early detection, optimal aging, recovery from interventions, and the replacement of bad habits with good ones. Integrative medicine is now a well-recognized, comprehensive approach in the practice of contemporary medicine, an approach that is relationship-centered.

It educates and empowers individuals to be active participants in their own care, while complementing biotechnical medicine with a broad understanding of the nature of health, illness, and healing. Integrative medicine acknowledges a holistic approach to the health and healing of mind, body, and spirit in the context of the collective and the community. It makes use of a broad spectrum of evidenced-based therapies from multiple cultures to create personal wellbeing, the public health, and global healing.

Integrative medicine has a strong link to

ancient and timeless medical knowledge and practices. The “remembering” of this heritage has the potential to strengthen the practice of contemporary medicine as new knowledge and practices are discovered over the coming decades.

In the second half of the twenty-first century, people will have a greater awareness and appreciation for the health impact of thoughts, emotions, attitude, intention, optimism, gratitude, happiness, spiritual practices, social networks, and altruism.

Evidence will continue to grow supporting the beneficial effects of a healthy lifestyle on morbidity and mortality.

Dr. Stewart is cofounder and Medical Director of the Institute for Health & Healing at California Pacific Medical Center, San Francisco. He is a well-known ophthalmic plastic surgeon; editor of the three-volume classic text Surgery of the Eyelid, Orbit, and Lacrimal System, published by the American Academy of Ophthalmology; and past Chair of the Department of Ophthalmology at CPMC. He is presently a member of CPMC’s Senior Management Team and is the author of Deep Medicine, a book about unlocking the healing power of your inner wisdom.

References Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money?

Health economics and the presidential candidates. New England Journal of Medicine.

2008; 358,7:661- 663.

Eisenberg DM et al. Trends in alternative medicine use in the United States, 1990–1997, Journal of the American Medical Association. 1998; 280,18:1569-75.

Astin JA. Why patients use alternative medicine. Journal of the American Medical Association. 1998; 279,19:1548-53.

The Institute for Health & Healing began in 1990 at CPMC. Today it is a wellestablished hospital-based integrative medicine program. The Institute provides a wide range of inpatient and outpatient services across the spectrum of care and the life span. The Institute is located at CPMC, Marin General Hospital, and Mills-Peninsula Health Services. Learn more at www.myhealthandhealing.org or call (415) 600-HEAL (4325).

May 2008 San Francisco Medicine 19

Back to the Future Of Medicine

A Fragile Balance Humans and Microbes in the Year 2050 Kristin J. Razzeca, MD This article is not based on facts or even on predictions of inevitable future events. It is a projection of possible infectious disease evolution and of the ramifications of some of our current treatments.

It is a brief look into what we may be focusing on in the year 2050 in the world of microbes and their effects on humans.

I

n this year of 2050, we continue to face public health challenges created by emerging or reemerging infections. Zoonoses have been the major newly identified infections. Contributing factors underlying the emergence of infectious diseases include microbial adaptation and mutation, changes in human demographics and behavior, increased flow of international commerce and travel, and failure of public health measures. Rapid recognition and response on a global level are necessary to control infectious diseases.

In the late twentieth and early twentyfirst centuries, we were immersed in several viral epidemics—human immunodeficiency virus (HIV), hepatitis B (HBV), hepatitis C (HCV), and human papillomavirus (HPV).

Antiviral therapy was developed and refined, providing effective control, if not eradication, of some of these viral infections.

By 2008, HIV was considered a controllable but not curable illness. Projected average life expectancy of newly infected HIV patients was thirty years, with appropriate antiviral treatment. Preventive and therapeutic vaccines against HIV were aggressively pursued but remained elusive. The retrovirus’s ability to mutate rapidly resulted in many diverse clades of HIV, precluding a vaccine engineered to recognize all these subtypes.

The futile attempt at vaccine development was a difficult and expensive lesson we were forced to learn.

20 San Francisco Medicine May 2008

As of 2050, an effective vaccine for HIV has not been developed. In 2008, funds were reallocated for aggressive prevention programs and research shifted to manipulations of the immune effector cells.

These manipulations involved the receptors (CCR5 and CXCR4) on the surface of the CD4 T cells which were targeted by HIV to allow entry of the viral RNA into the cytoplasm of the T cell. Later, in 2022, a new chemokine, Interleukin 18 (Il-18), produced by the CD8 T cells that had been activated against a similar retrovirus, was identified. This chemokine could completely block expression of the receptors (CCR5 and CXCR4) on the CD4 cells. A synthetic version was formulated in pill form. People can now take this pill once each month for six months, and the receptors on their CD4 T cells become permanently obsolete. HIV is now a preventable infection. In patients already infected with HIV, Il-18 has been used as a therapeutic tool in conjunction with antivirals. Because the coreceptors’ expression is blocked, HIV is not able to commandeer the CD4 T cell to use in its replication, and so it eventually dies out.

The most devastating epidemic in recent history has finally come to an end.

Information learned from the HIV epidemic was invaluable in treating the hepatitis epidemics. The recombinant HBV vaccine has remained an effective and inexpensive preventive therapy. A vaccine directed against HCV, although initially difficult to refine, was finally developed in 2040 and has proved to be efficacious. Adequate treatment of those already infected

by HBV and/or HCV followed the path outlined for HIV. High-potency drugs used in combination to set a high genetic barrier were required to reduce the development of

resistance by the viruses.

The development of an HPV vaccine has proved to be an example of ignoring or at least not fully understanding the information we had learned working with HIV. Human papillomavirus was also a virus capable of rapid mutations, resulting in numerous strains. As with HIV vaccine attempts, it was impossible to produce a vaccine able to identify all the various strains. However, given that the majority of diseases (anal and genital warts, anal and cervical dysplasia, and cancers) were caused by four of the strains, a vaccine was developed against only those four strains. The second major mistake was the recommendation that only a portion of the population at risk (girls and young women ages thirteen to twenty-five) should receive the vaccine, leaving a large group at risk for infection. This produced a selective pressure on the virus, allowing mutations to arise. Now in 2050, forty-five years after introduction of the HPV vaccine, we are again immersed in an epidemic. Several of the previously “benign” strains have transformed into pathogenic and/or oncogenic strains causing significant morbidity. We are witnessing more recalcitrant anal and genital warts and more aggressive cervical and anal cancers.

The influenza A pandemic of 2046 was an example of rapid recognition, international collaboration, and effective control measures. The pandemic was predicted and anticipated by analyzing the antigenic shifts of the virus and identifying two highly pathogenic strains found in avian populations cocirculating with human influenza viruses. Rapid response teams were quickly deployed to control the infection in the avian populations, implementing a quarantine and isolation policy in affected www.sfms.org

communities and enforcing the closing of schools, churches, shopping malls, and gyms. The travel industry, including airports and bus and train terminals, was quickly closed down. Stockpiling of the antiviral supratamivir (a fourth-generation oseltamivir) and the use of protocols that allowed rapid dissemination of the medication to “hot spots” proved to be efficacious and prevented significant morbidity and mortality. Despite these efforts, the influenza pandemic of 2046 still claimed the lives of six million people, mostly the elderly and the very young.

Many of the zoonoses, transmitted through vectors, that had appeared in the first half of the twenty-first century were particularly challenging. Climate variability had fostered increases in the mosquito population, resulting in several outbreaks of zoonoses such as dengue, West Nile virus, malaria, and others. Aggressive mosquito control programs were undertaken, incorporating aerial spraying of infested areas and reduction of larval breeding sources.

Dengue and West Nile virus outbreaks were last identified in 2030. Cases of malaria have declined significantly.

Poor and underdeveloped countries give rise to many of the zoonoses capable of causing life-threatening disease. Emerging infectious diseases require that proactive rather than reactive action be taken. The bushmeat trade and wildlife encroachment have been stopped. Conservation and disease surveillance programs have been implemented and have played integral roles in curtailing outbreaks.

Developed countries have also experienced challenging problems. Thousands of people worldwide have been infected with a variant of Creutzfeldt-Jakob virus, causing early dementia. It was not until 2045 that many governments instituted stricter inspection and control measures in the beef industry, sharply reducing the number of new cases.

Vaccinations remain a cornerstone of infectious disease prevention. Understanding transmission pathways and identifying natural, definitive reservoirs for the viruses help determine candidates for vaccination.

Bats were identified as definitive hosts for a number of lethal infections including www.sfms.org

Marburg/Ebola, SARS coronavirus, and Nipah/Hendra viruses. Humans were accidental targets. A vaccine was developed against the lethal Marburg/Ebola virus and was given to the African miners whose work brought them into close contact with bats.

An outbreak of Marburg/Ebola has not been documented since 2025. Attempts at vaccine development against these and other deadly pathogens continue.

Mutating bacteria developing resistance to antibiotics have continued to be problematic. Highly resistant strains of tuberculosis continue to evolve. New medications have kept this reasonably controlled, but it became apparent that additional measures were needed. At the United Nations Millenium Summit in 2000, representatives from several nations authored the Millennium Development Goals to help poorer countries. Proposals addressing several issues such as poor nutrition, availability of clean water and health care, educational opportunities, gender inequality, and preservation of the environment were funded. Significant improvements were made and the goals have been reviewed and reestablished, or additional ones formulated and funded, every fifteen years. The achievements resulting from this collaborative endeavor have been extensive and are expressed in a major decline in TB cases.

Another rapidly mutating bacterium, Staphylococcus aureus (MRSA), is still making headlines in the year 2050.

Methicillin-resistant Staph aureus became a major problem in hospitals where antibiotics use was prevalent. Communityacquired MRSA (CA-MRSA) appeared as a daunting problem in the first decade of the twenty-first century. Outbreaks in gyms, prisons, schools, and in the gay community posed difficult challenges as the bacteria developed resistance to previously effective antibiotics such as vancomycin, linezolid, and tigecycline. Third-, fourth-, and fifth-generation antibiotics are now used in combination to control this infection. Medical students are instructed carefully on judicious use of antibiotics, and routine use of antibiotics is prohibited in the livestock industry. Basic personal hygiene, with frequent hand-washing, cleaning of group equipment, and wearing of masks and

respirators in high-risk encounters, has been shown to decrease transmission of several infectious diseases.

The mapping of the human genome, one of the most innovative and collaborative enterprises in the history of science, provided us a unique means of intervening in human disease states. Coupled with the ability to harvest stem cells from the skin, gene therapy is now widely used in the prevention and treatment of several common diseases—cystic fibrosis, diabetes, schizophrenia, major depression, and multiple sclerosis—as well as less common illnesses such as Huntington’s, Wilson’s, and Marfan’s. We now order a genogram for the individual patient to identify abnormalities detected in their DNA, to predict the possibility of disease occurring, and to decide whether intervention is warranted.

Oncology and immunology have been the most rapidly developing fields using these methods. Today treatment of a malignancy is tailored to specific receptors expressed on the tumor. The appropriate immunomodulators to suppress these receptors, allowing less toxic chemotherapy to be more effective, are used. Computerized analysis of submitted biopsy specimens generates a histologic diagnosis, identifies chromosomal translocations and gene rearrangements, and describes receptor expression. The specific immunomodulators and chemotherapy required for destruction of the neoplasm can then be selected. Finally, in 2050, we can say we are winning the war on cancer.

This retrospective look at the first fifty years of the twenty-first century has focused on the accomplishments as well as the mistakes made in infectious disease control. New and old infectious diseases continue to emerge and reemerge. Even now, as in the history of the last 200 years, it remains obvious that old-fashioned personal hygiene is an essential component in limiting disease transmission.

So please remember to wash your hands and continue to use condoms.

Kristin J. Razzeca is an immunologist and HIV specialist at Stanford University School of Medicine, with a clinical practice at Camino Medical Group.

May 2008 San Francisco Medicine 21

Back to the Future Of Medicine

Darwin Revised!

Reflecting on Darwin’s Theories from the Year 2050 Leonard Shlain, MD

H

ere we are in the year 2050, already making preparations to celebrate the bicentennial of Charles Darwin’s culture-transforming opus On the Origin of Species (1859). As I reflect on this momentous upcoming occasion, I am amazed at how Darwin’s original theory has had to be revised. The ramifications of these major changes have had their greatest impact on medicine and continue to reverberate with each new stunning innovation.

Darwin’s book did for biology what Newton’s 1687 Principia did for the field of physics: It presented an entirely new paradigm. During the 200 years after Newton’s publication, physicists became increasingly convinced that his theories were the final word. What a shock, then, when Einstein’s relativity theory and Bohr’s refinement of the quantum forced physicists to abrogate Newton’s seemingly immutable laws for the world of the very fast and the very small. So, too, has the same turn of events come to pass for Darwin, whose explanation concerning life was also thought by biologists to be definitive.

Let us briefly review Darwin’s central idea. Evidence exists that life appeared on this planet approximately 200,000 years after the planet coalesced four billion years ago. From the beginning, the carbon benzene ring has formed the basic building block of every life form. The improbability that heavy atoms forged in distant superheated supernova managed to combine with carbon, nitrogen, and oxygen to form amino acids in the vast wasteland of frigid intergalactic dust clouds staggers the imagination. That here on Earth these amino acids would arrange themselves into the self-replicating molecule DNA is another cause for sheer wonder.

22 San Francisco Medicine May 2008

According to Darwin, life bots progressed in fits and starts, seeking environmental niches in which they could survive.

Adaptations to change came about through beneficial mutations of individual genes

“The ramifications of these major changes have had their greatest impact on medicine and continue to reverberate with each new stunning innovation.” (an earlier Mendelian discovery of which Darwin was unaware). Initially, cloning was the preferred form of reproduction, but it suffered one major drawback: Clones are immortal. It was slow going until an entirely unexpected event turned the whole show into a riotous profusion of life forms. Out of nowhere, natural selection served up two startling innovations—sex and death.

Sex shuffled and reshuffled the genes of organisms that were constantly faced with environmental challenges. Resembling a planetary vaudeville act, an ongoing conga line of possibilities snaked across the stage under the limelight, auditioning for a part in the play called life. Death sat in the darkened second row, deciding which acts would be in the next season’s production and whose careers would be extinguished.

Sex combined with death proved to be an exceedingly successful program. Natural selection populated the entire planet with a bewildering variety of living creatures that swam, flew, crawled, plodded, leapt, and stalked—and all of whom eventually died. Despite their profusion, every species’

chassis had as its basis the ubiquitous carbon molecule. And an absolutely essential requirement of all living forms was that they needed a physical body in order to exist.

After more than four billion years, one species emerged that broke the mold. Homo sapiens developed a complex form of communication that went beyond anything that had preceded it. No scientist has a credible explanation for how or why human language emerged in all its rococo complexity, but for the first time in the history of earthbased life, something emerged that defied the general scheme of Darwin’s grand thesis.

Human language was the first living entity that did not possess a physical body.

Language is a symbiotic organism that needs the corporeal bodies of a critical mass of humans in order to exist. And humans as a species would never have attained their exalted position without their incessant ability to yakitty-yak. Languages possess all the characteristics of a living form: They are born, they mature, they compete with one another, they adapt, they splinter into new species, and they die.

Human language short-circuited natural selection. For a child to learn to look both ways before crossing the street under the old (speechless) method would have required that many generations of children died before a beneficial mutation appeared in the genome that forced the child to look both ways. With the advent of speech, parents could teach their children the lesson in a few hours instead of the eons it would have taken to wait for a mutation.

Knowledge accumulated in the vast web of culture. Language midwifed into existence an ancillary improvement in survival for humans called medicine. There is nothing in the observable behavior of www.sfms.org

other animals that suggests that they have mastered the art of interfering with natural selection by inventing medicines and procedures that can cure, palliate, and prolong the life span of their species by tampering with the natural order. Some evidence exists that chimpanzees, our closest cousins, plus baboons and a few other species, intuitively know to choose certain medicinal plants to alleviate that which ails them. But without language there could be no science and obviously no New England Journal of Medicine, nor all the other advances that have accrued to the species due to humans’ constant, invisible doppelgänger—language.

Medicine did not really begin to alter our species until the refinement of the scientific method, which began in the Renaissance and flowered in the Enlightenment. In the nineteenth century it gained speed and momentum, and in the twentieth century an astonishing array of medical advances aided and prolonged life spans.

Thus humans, in league with their symbiotic ectoplasmic partner, mushroomed into the most populous large mammal on the planet and in the process gained dominion over all the beasts and fowl. And the cross talk that language engendered led to a series of modern medical advances that finally gave humans dominion over bacteria, parasites, and most viruses.

But it was the first half of the twentyfirst century that witnessed another sharp rift with the law of natural selection. The emergence of an insubstantial symbiotic life form allowed this one species to build a new hybrid that began to break life’s utter dependence on the carbon ring.

Carbon is one of the most common elements on the planet. Another, found

in abundance, is silicon. When combined with oxygen in the form of silicon dioxide, it forms sand and dirt. The silicon atom, one of the trace elements necessary to maintain homeostasis, played a minor role in keeping living things healthy. And then, in the latter half of the twentieth century, clever humans discovered that silicon dioxide possessed a property that would allow it to conduct a low-resistance electric current. From that discovery, combined with a new branch of physics known as quantum mechanics, the modern transistor was born. Replacing bulky vacuum tubes, transistors began to appear in increasing numbers in all electrical appliances. Every device—radios, TVs, cell phones—shrank. But silicon compounds possessed another property that made some of them especially felicitous for medicine: They failed to arouse the ever-vigilant immune system. Encasing silicon dioxide transistors in a silicone sleeve allowed physicians to implant sophisticated minimachines into the human body.

Soon surgeons were implanting all sorts of silicon-based devices that increased life spans, alleviated disease, and even increased sexual allure. Cardiac pacemakers, insulin and morphine pumps, transistor-based arrays to let the blind see and the deaf hear all became increasingly routine. Monitors to check for arrhythmias and oncoming epileptic fits competed for space in the physical body alongside older carbon conglomerations.

As the twenty-first century progressed, the speed with which new medical advances arose, especially those that relied upon silicon dioxide transistors, took one’s breath away. More and more humans were living healthier, longer lives because of these

implants.

As the amount of silicon increased in relation to the amount of carbon in a person’s body, it became increasingly clear that Darwin’s theory of natural selection would have to be revised once again as humans morphed into cyborgs (cybernetics + organic). Partially inorganic and partially organic, we constituted an entirely new life form. Further, the massive computers that allowed medical researchers to manipulate the genome depended on the interaction of silicon and carbon to unexpectedly revise Darwin’s theory in another species-changing manner. Who could have imagined that such a stunning series of events could happen to evolutionary processes when On the Origin of Species appeared in 1859!

Complexity theory, formerly known as chaos theory, proposes that as systems become more complex, the possibility increases that an emergent property will suddenly appear that no one examining the system could have ever predicted. (Hydrogen, a flammable gas, combined with oxygen, a combustible gas, can yield a liquid that extinguishes fire! Who woulda thunk!)

As we enter the last half of the twenty-first century, deeply immersed in the annealing of technology and life forms, who can possibly anticipate what might come next?

We humans are undergoing a profound metamorphosis as we transition into an entirely novel species. For those who doubt it is happening, remember: When you are buffeted in the center of a spinning washing machine, it is nearly impossible to notice that the clothes are becoming cleaner.

Leonard Shlain can be reached at lshlain@ aol.com.

Welcome New Members!

The San Francisco Medical Society would like to welcome the following new members:

ACTIVE REGULAR MEMBERS Cary Canoun, MD—Referred by Gregory Buncke, MD Ping Chow, MD—Referred by CMA Ofelia Maristela, MD—Online Application Amir Ali Rafii, MD—The Permanente Group Mark J. Savant, MD—Referred by Robert Murray, MD

www.sfms.org

May 2008 San Francisco Medicine 23

Back to the Future Of Medicine

Psychiatric Moments Experiences from the Years 2008 and 2050 Lynn Ponton, MD

I

n the following two snapshots, two cases will be presented—one from the year 2008, the other from 2050. The first underscores missing aspects of treatment in 2008, and the second covers hoped-for treatment in 2050.

Psychiatric Moment 2008 Two months ago, a mother and father called my office asking for my advice about the psychiatric care of their eighteen-year-old daughter, Eva, who has anorexia nervosa.

They told me that Eva began dieting twoand-a-half years ago when she was fifteen years old, but they mention, sadly, that they didn’t notice the seriousness of her behavior until almost a year later. “She looked so much better, thinner, that we didn’t recognize her dieting could be such a problem.”

One year later, at the recommendation of Eva’s pediatrician, who was concerned about her weight drop at her yearly physical, they sought psychiatric treatment even though they discovered that their daughter’s condition—and, in fact, most mental health problems—was not covered by their health care insurance. Their first treatment experience was with a family therapist who treated anorexia nervosa solely from this perspective.

After six months, they understood their family better, but their daughter had continued to lose weight. Frustrated and worried, they changed treatment and this time worked with a psychopharmacologist who diagnosed Eva with depression in addition to anorexia and began a selective serotonin reuptake inhibitor, but no other therapy. Their daughter’s weight continued to fall and she complained that she had no one to talk with. Her parents switched treatment again, this time to a therapist who worked individually with patients with anorexia nervosa. During this 24 San Francisco Medicine May 2008

treatment, the girl stopped her medication abruptly and her new therapist refused to talk with Eva’s parents, because of confidentiality. Their daughter said she was happier, but her weight continued to drop and her now very worried pediatrician insisted that the parents call me.

They do call and, not surprisingly, they are angry. In our first session together we explore several reasons why they are angry.

First, they are angry with themselves because they missed the early symptoms of anorexia nervosa; in addition, they are angry with a culture that overvalues thinness in adolescent girls. They are also angry with the three treaters who adhered exclusively to their own perspectives on health care while their daughter’s health declined. And lastly, they are angry with their insurance company, which does not cover most mental health illness. Although they cannot say it, they are also angry with their daughter for having this illness and not getting better.

They are frustrated when I describe they type of care that I believe is needed to help their daughter—regular vital-sign and weight checks with their pediatrician and, if necessary, a specialist in adolescent medicine; and a combination of individual, family, and psychopharmacologic therapies with someone who works with eating disorders. I add that group and inpatient treatment might also be necessary, depending upon the severity and chronicity of Eva’s illness. I explain that anorexia nervosa is often a tough illness that requires the combined energy and care of several treaters and perspectives to fight, and that I am sorry that the treatment that their daughter has received so far has not helped her more and that their insurance plan does not cover most mental illness.

To best help, I tell them that I will meet

with them and their daughter and consult with all of their daughter’s treaters, her school, and their insurance company. Then, with their daughter present, we will strategize together, looking at what will work best to help her and them, and also examining what treatment is absolutely necessary. What can they afford? What treatments can they find at no or low cost?

When I meet with Eva I discover that she, like her parents, is disheartened by the treatment experiences of the last year and a half. She regrets the tremendous expense that she has caused her family and is struggling to change both her thoughts and her behaviors, but she admits to me reluctantly that the negative patterns have become stronger over the past two-and-a-half years, and that she now spends much of her free time on Internet anorexia sites that support her illness.

When I speak with her three treaters— each recognized experts in their respective specialties of family therapy, psychopharmacology, and individual therapy with adolescents—I am impressed with their knowledge and concern for their young patient, but I am also struck by their inability to think outside their own box and creatively strategize about Eva’s treatment.

Next I speak with the health insurance company, which tells me that it will pay for care—that is, if Eva is hospitalized for malnutrition they will cover her costs because they view that as a medical illness, but they will not cover any outpatient psychiatric treatment. Scouting for low-cost or free services, I discover that there are several programs available. A research study will provide free short-term care—four months for Eva while she is in their program—but follow-up is not available. I consult with Beyond Hunger, a grassroots anorexia organization, which offers www.sfms.org

a positive experience for many girls, schools, and families.

Although I have worked with adolescent girls with eating disorders for more than thirty years, I also consult the recent literature, looking, in this case, for treatment advances that are applicable to Eva and her family. While online, I visit the growing number of anorexia sites that Eva spends so much time on and note their increasingly seductive outreach. The sites offer an identity with other girls who have anorexia, providing exchange of information, connection, and a certain power to the girls who frequent the sites.

When I meet with Eva and her parents to discuss my ideas, I outline several serious problems along with possible strategies. I recommend and offer to help them find a single treater, experienced in work with eating disorders, who can prescribe medications, conduct both individual and family therapy, and work closely with their pediatrician. A second choice would be a therapist who can conduct both individual and family therapy and collaborate closely with the psychiatrist who will evaluate Eva for medications.

I also recommend that Eva and her school counselor (who has been helpful, letting me know that Eva and several of her friends are part of a mini-epidemic of girls struggling with eating disorders) attend Beyond Hunger, the grassroots educational group—and that the counselor develop the stress-reduction meditation group she has been planning to start at Eva’s school. I help Eva’s pediatrician, who has been valiantly struggling with her care, connect with an adolescent medicine physician who specializes in this area. I help the parents limit computer access to the anorexia sites.

At the end of this evaluation, Eva’s parents are less angry and Eva is more willing to cooperate with her treatment. But her treatment is still expensive—prohibitively so for many families—and her case highlights major problems associated with mental health care in 2008.

Challenges in 2008 Failure to Recognize Mental Health Illness as Disease The treatment of mental illness has suffered seriously during the past twenty-five www.sfms.org

years, victim to a failure to acknowledge the problem. There are many reasons for this.

Public stigma against mental illness, present for centuries, continues despite valiant efforts from individual and national organizations.

In addition, Eva’s illness, anorexia nervosa, is often seen as a positive trait by a public seduced by unhealthy, air-brushed images of adolescent girls whose collective bodies are used to sell consumer goods to a female population whose dissatisfaction with their bodies is incited by the media. Lastly, mental illness is frequently not acknowledged by insurance companies, for financial reasons.

Failure to Pay for Mental Health Care Private insurance and federal payers alike refuse to cover even a portion of the costs of mental health care. Chronic mental health care is financially debilitating for patients and their families. Eva’s anorexia falls into this category. Recent laws have made an impact, requiring health care companies to provide parity for some mental diseases; but often necessary health services are so “carved out” that payment for them leaves more than anorectics starving.

Adherence to One Theory or One Treatment Approach Psychiatric and psychological treaters often limit themselves by learning and using one treatment perspective on care. Eva’s case illustrates this problem. Anorexia nervosa in girls under eighteen is best treated with an integrative approach that combines family work with individual therapy, which uses cognitive behavior aspects at the beginning of treatment when a girl’s weight is dangerously low, paired with dynamic relational elements as her weight increases and she further engages. Medications are used as needed. Most important is the recognition of the integration of mind and body in practical and effective treatment approaches.

Dogmatic adherence to a single theory or treatment approach is limiting to patient and clinician alike. In summary, delivering psychiatric treatment in 2008 leaves much to work on and to hope for.

Clinical Moment 2050 In 2050, Eva’s daughter and her husband receive a call about Eva’s granddaughter, Eri-

ca, from the high school clinic. The counselor there has noticed Erica’s weight is dropping and that she is no longer eating her lunch.

Erica is then invited to join a “healthy lunch” group with several of her friends who are also dieting. Her mother and her father are asked to participate in a four-part prevention program for families, which educates them about unhealthy dieting, negative media influences, adolescent development, and risk-taking and disease. One month later, when the school’s nurse practitioner notices Erica’s weight has continued to drop, her pediatrician initiates regular visits, coming to the school clinic one afternoon a week. In addition, a psychiatrist specializing in adolescent eating disorders begins treatment using an integrative approach, meeting with Erica one hour per week. The costs are paid for by a basic health care package that covers all health concerns—for both mind and body. These two aspects of each person are no longer treated separately but are seen as parts of an integrated whole. As part of this treatment package, family therapy and dietary counseling are designed for Erica and her parents. Individual therapy is available for Erica’s mother and father for an additional fee. Supported by the family therapy, Erica’s mother elects to participate in it.

At the time of Erica’s treatment in 2050, anorexia nervosa, an illness that has varied epidemiologically over the past 2,000 years and is affected by cultural components, still exists. There are, however, several important changes in its treatment: • Prevention efforts targeting adolescent girls are ongoing, and earlier detection leads to earlier treatments.

• Research is built into both the treatment and prevention efforts, which begin at Erica’s high school and its associated health clinic. Further research studies have demonstrated and reinforced the importance of early detection of anorexia nervosa, diagnosis and treatment of comorbid disorders, and family participation and treatment in addition to individual and psychopharmacologic treatment.

• New and more effective medications address anxiety and abdominal discomfort associated with refeeding.

• Most important, anorexia nervosa is now widely understood as an illness involv-

Continued on Page 31...

May 2008 San Francisco Medicine 25

Back to the Future Of Medicine

Biomedical Imaging Computerized Radiology in the Year 2050 Gretchen A. W. Gooding, MD

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ubject: Annual Back-to-the-Future Report on the status of Departments of Radiology and Biomedical Imaging, 2050

Patient Procedures Advances in systems and procedures for biomedical imaging have progressed in the past fifty years so that now, in the year 2050, patients who need diagnostic or therapeutic imaging make their appointment by computer, register into the department via a retinal scan, and have their prescribed studies (X-ray, whole-body CT or MR, US, nuclear medicine). When the procedure is complete, the patients leave with the dictated report in their hands, the referring physician having been automatically sent the report simultaneously with the study. If a visually guided biopsy was needed, the procedure was done during this initial visit.

As an example of the increased efficiency of biomedical imaging, a diagnostic workup for jaundice in the 1960s might have taken many weeks. In the 1990s, with the advent of CT, the diagnosis of obstructed bile ducts could be made at the time of the CT examination, then an ERCP and biopsy would ensue over the next few days, after which a treatment regimen could be instituted. Nowadays, in the year 2050, the diagnosis of the malignancy can be identified in one visit and treatment instituted immediately.

Professional Staffing Departments are largely devoid of people who once were the backbone of radiology.

There is no need for receptionists, clerical persons, or transcriptionists. It is all done by computer. The only personnel on site are the radiological interventionalists, their 26 San Francisco Medicine May 2008

technicians, and their nurses. Radiologic ultrasound technicians and IT (information technology) workers are on hand and are held in high regard for their unique skills, the latter maintaining the picture archiving communication systems (PACS).

In teaching institutions, a core of centralized academicians supervise residents and fellows who may be working in different institutions—videoconferencing allows face-to-face contact to discuss procedures or particular teaching points.

Radiologists Radiologists can practice in real time anywhere in the world for patients and referring physicians anywhere else in the world.

The radiologists review the cases sent by computer, using advanced electronic enhancing techniques for details. Most of the studies are initially read by robotic neural networks and then sent for confirmation to the radiologists.

For the reports, the radiologists simply speak to the computer, which recognizes each individual voice, prints out the reports, and speeds them off almost instantaneously to the referring facilities.

If radiologists need to review cases that had previous biomedical imaging at another hospital in another state or country, the radiologists, using an access code, can get ready access to these images and the dictated reports.

Recognizing the global impact of imaging, radiologists are now credentialed under one process in all of the United States and some foreign countries, rather than by antiquated state licensing boards.

Ultrasound Standard ultrasound is now a tool that most clinicians carry in their pockets: a small

imaging computer for quick assessment of free fluid in the chest, abdomen, or soft tissues; for foreign body detection; for calculi in the kidney; for gallstones; for early pregnancy detection; and for masses, superficial or deep. In some cases, families are provided with these compact computers and taught how to use them at home to screen family members at home for gross abnormalities or to monitor their follow-up care. These home units can send the images instantly to the attending physicians for further evaluation. Additionally, most medical schools have an ultrasound unit in their science sections so that students can learn anatomy and some physiology in real time with ultrasound.

Ultrasound in departments of biomedical imaging and radiology is now mechanized, similar to CT, to scan large areas of the body in record time with no radiation dose. Transducers have been developed to penetrate the skull and are used to localize lesions quickly in 3-D, and then focused ultrasound energy can be directed to a specific location for lesion ablation. Nanotechnology targets tumors producing antigens with antibodies that light up in the organ to be treated with focused ultrasound.

Ultrasound within biomedical imaging departments also is now “volume� oriented for the capability of ablation procedures of tumors such as hepatoma, uterine fibroids, and thyroid lesions. It is combined with elastography to detect firmness of lesions, an indicator of malignancy. Color flow has developed to show microcirculations in masses and has largely replaced angiography in the assessment of vascular disease. Images are generated in a matter of seconds and signal to noise is greatly enhanced for images of incredible fidelity.

Continued on Page 31... www.sfms.org

Back to the Future Of Medicine

Bad Bugs Bite Back: A Cautionary Tale A Bacteria Looks Back at the Medical “Age of Miracles” As told to Steve Heilig, MPH

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irst, I should say, it was never personal. But we’re the invisible bugs, and we won.

We were here first, you know, before any other living thing and for two billion years before you started to show up. But it was nice having you humans around for a relatively short while, even though for a time there you seemed deluded enough to think you could get rid of us. Your skin and internal bodies were such good hosts—in fact, we sometimes colonized up to 90 percent of the cells in your bodies, with maybe one hundred trillion of us microbes thriving in and on you, from tooth to toe. While we tried to reach a nice balance—what you fancily called a “homeostatic host/parasite relationship”—whenever possible, we’re sorry so many of you had to die when we reproduced a bit too exuberantly. We tended to be the leading cause of human death worldwide, in fact. But then, your species also seemed to reproduce too much and there were always enough of you to reinfect. Well, up until the end, anyway.

You did spook us with that “magic bullet” thing, at least for a couple decades.

Those antibiotics you discovered worked very well when they were new, didn’t they? One of your famous doctors, soon after you discovered those drugs, opined that “the age of infectious diseases is over.”

But thanks to biological diversity and that Darwin guy’s dynamics, a few of us tended to survive whatever you threw at us. Those lucky few got to reproduce like, well, rabbits (although we infected those other mammals too, which helped us get around). And as you soon learned, we found ways to pass the antibiotic resistance around like a basketball, even when your drugs weren’t directly www.sfms.org

involved. In 2008 you even caught us eating those very antibiotics for food. Pretty tricky, no? But thanks for lunch.

You helped us in some other ways too.

We liked the way some of you handed out the antibiotics even when they weren’t really needed. I imagine it could be tough to resist the pressure from drug companies and patients, and some of you did and some of you didn’t. Those countries where the drugs were just sold directly to anyone with a sniffle or an itch, well, that was convenient (for us too). It was especially helpful when you used, oh, about 70 percent of all the antibiotics you had on those farms and feedlots. Using just enough to allow our very fittest brethren to thrive was kind of you.

When some of you stopped vaccinating your kids, we had a big celebration. And when it became tougher and tougher for you to find new antibiotics to toss at us, well, the gig was up, sorry.

Our tricky little cousins, the viruses, have had a quite a good time with you as well. I know that HIV bug really caused havoc and misery and spooked you. Sorry.

But of course that was just the beginning; there was soon MRSA, need I remind you, and meanwhile, some of our old benchwarmers like tuberculosis and others were

gearing up again, now multiply-resistant, waiting for the right conditions, which they did eventually find. As more people and communities and entire nations slipped further into poverty, with dirty water, tainted food, bad air, cramped and crowded conditions, all manner of insects and other mobile parasites breeding away, well, for us it was party time.

Especially with your richer people flying around everywhere on the globe, sharing the air and so forth.

For those who could afford it, you certainly did come up with some very impressive treatments and technologies.

We enjoyed all the predictions about how other, more chronic problems were all going to be taken care of eventually, when many warnings pointed the other way. But that kind of optimism in your kind was always sort of endearing.

Some of you used to speculate that only cockroaches and microbes would survive your possible self-inflicted nuclear holocaust. And as many of you believed in spaceships as did in evolution. But your extinction came more with a whimper than a bang. We’ll figure out how to best deal with the roaches later. As for a postmortem diagnosis, well, in hindsight we’d have to call your condition Human Hubris. What’s “hubris”? Oh, c’mon; you saddled so many of us with old Latin names, you should be able to figure this Greek one out on your own. I mean, if you had survived it.

For related information, see w w w . keepantibioticsworking.com and www.aware.md.

Reference Dantas et al. Bacteria Survive on Antibiotics. Science. 2008; 320:100-103 May 2008 San Francisco Medicine 27

Back to the Future Of Medicine Photos by Ashley Skabar Text by Amanda Denz

The Future of AI A Look at The Stanford Artificial Intelligence Program

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hen one imagines what life in the year 2050 will really be like, the idea that that we might each have a home robot similar to “Rosie” on The Jetsons is not that far-fetched. As Morgan Quigley, a PhD candidate at the Stanford Artificial Intelligence Laboratory, says, “we already have robots in our homes—our dishwashers, our washers and dryers, our answering machines. Once a robot comes out that can combine multiple home functions, that’s when we’ll see consumers buying them and having robots as personal home assistants.”

At Stanford, Quigley is working as part of a team to develop the type of robot that will someday function as a home assistant.

Currently, the team has STAIR (Stanford Artificial Intelligence Robot) I and II, two robots that appear to be nothing more than robotic arms on a cart with cameras mounted to the top.

While STAIR I and II may not appear as one would think a robot should in a leading academic institution, “the ability to make

28 San Francisco Medicine May 2008

a physical casing for the robot that is more appealing already exists,” says Quigley. “Here we’re focusing on developing the software.”

These aesthetically simple one- and two-arm robots provide the team with everything it needs to the conduct experiments that lead to improved programming. Instead of aesthetics, the focus is on teaching these robots to learn and think independently.

In order to train STAIR I and II to recognize items, the team shows each robot more than 200 images of the same object, rather than programming in the specifications of, say, one apple. The hope in doing so is that the robots will be able to decide on their own what makes an apple an apple and a pear a pear. In real-life situations, where things are not necessarily of perfect dimensions or arranged in a specific order, having a broader idea of what constitutes an apple, gained from hundreds of examples, will make the robots more likely to successfully identify the apple.

“Right now there are robots working in factories,” says Quigley,

www.sfms.org

“but the factories are closed environments and only people who have been trained can enter them. The real challenge is getting a robot to function in the unpredictable environment that is the real world—to take in new information and evaluate it the way a person would.”

Robots that can function in unstructured environments, such as the home, would be ideal assistants to the elderly and disabled.

“Would you want a robot changing your bandage? Maybe not,” says Quigley, “but would it be helpful if a robot did the laundry, cooked a meal, and fetched things for you if you were bedridden? Probably.”

As of right now, STAIR I and II have a culinary repertoire that is limited to microwavable burritos, but the team at Stanford hopes to change that. What will these robots be up to in the year 2050? “Well, they’ll certainly look better,” says Quigley, “and a lot of progress is currently being made on how their vision works in unstructured environments, on new modalities of sensing, and, in general, on how robots are programmed and trained.”

To lean more about the Stanford AI Robots, and to watch a short video of STAIR II retrieving items from around the lab, please visit http://stair.stanford.edu.

These robots perceive their surroundings in two ways: They have cameras perched on top (pictured left) to take in two-dimensional information. They are also equipped with laser range finders, which help the robots perceive the depth and placement of objects by measuring the time of flight of low-power laser pulses. “When searching for an apple, the laser range finder is what helps STAIR make the distinction between the apple on the table and the poster of an apple behind it on the wall,” says Quigley.

Quigley demonstrates a device (pictured right) that allows humans to control a robot’s function. His team is currently working to teach the robot to control itself independently at the same level of precision that humans can attain.

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Psychiatric Moments Continued from Page 25... ing the mind-body entity. Treatment of mental illness is considered part of standard health care, which is understood as a priority for all.

Erica’s treatment, aided by technologic devices that allow her team to be in close connection, is reviewed monthly by the entire treatment team, including Erica and her parents. Although there are many differences in 2050, the core of psychotherapeutic treatment remains the same: the development of a strong therapeutic alliance and a relationship that supports change for the patient and her family.

Lynn Ponton, MD, grew up in Wisconsin and received her BA from the University of Wisconsin, Madison. After graduating, she worked at the Pasteur Institute in Paris before returning to the University of Wisconsin, Madison, to obtain her MD. She worked as an intern in pediatrics and completed two residencies in adult psychiatry. After finishing her work as a fellow in child and adolescent psychiatry in 1983, she began her training at the San Francisco Psychoanalytic Institute and joined the faculty at UCSF. Besides working as a professor of psychiatry, Dr. Ponton is also a practicing psychiatrist and psychoanalyst, as well as the author of The Romance of Risk: Why Teenagers Do the Things They Do and The Sex Lives of Teenagers: Revealing the Secret World of Adolescent Boys and Girls. In her practice she works primarily with adolescents.The mother of two young-adult daughters, Dr. Ponton lives in San Francisco.

Biomedical Imaging Continued from Page 23...

Computer-Assisted and Positron Emission Tomography PET/CT, in combination with molecular imaging, provides a method by which abnormalities light up in different colors to indicate various kinds of pathology— lymphomatous nodes are designated in purple, neuroendocrine tumors in orange, metastatic disease in red, and inflammation in green. Degenerative brain disease is readily differentiated by this type of imaging, and response to therapy is indicated by changes www.sfms.org

in the molecular makeup readily seen in the imagery.

For CT and MRI, sequences have been refined so that contrast agents are not required to get superb images, resulting in remarkably reduced radiation for whole-body scanning.

Oncologic radiologic referrals are now more focused, since genetic profiles and molecular markers make initial workup more specific as to the imaging needed. With a diagnosis, targeted drugs can then be directed to treatment.

Current Status of Biomedical Imaging Diagnostic and Therapeutic Procedures

at room temperature that are excited by an electrical field, which can produce images from various angles and perspectives without rotating the imaging device.

Service for malfunctions is done on-site by off-site computers that make the diagnosis and provide the solution.

In past decades, radiologists would see huge tumors, pseudocysts, and masses that were exceedingly difficult and timeconsuming to diagnose and treat. As imaging became more prevalent, efficient, and precise, we discovered these space-occupying lesions earlier and when they were much smaller, potentially more amenable to treatment.

With molecular imaging becoming much more sophisticated, we are more likely to deal with microscopic rather than macroscopic disease. Thus we can treat disease much sooner and with greater success, and we can provide a much wider range of minimally invasive procedures. Who knows what the future may bring?

Gretchen A. W. Gooding, MD, is Professor in Residence, Department of Radiology and Biomedical Imaging, University of California, San Francisco, and she serves on the Editorial Board of San Francisco Medicine.

Currently, radiation therapy is delivered with robotics combined with CT scans to pinpoint the radiation field precisely, differentiating the tissue to be treated from the normal tissue to be spared.

Cardiac MRI and CTA have replaced cardiac catheterizations for imaging the heart.

Routine gastrointestinal studies of upper GI and barium enemas have been completely supplanted by cross-sectional imaging.

Virtual colonoscopy has replaced endoscopy for the diagnosis of colon cancer, and interventional radiology is used to treat the polypoid colon masses by embolization.

Vascular surgery has been largely supplanted by interventional radiologic techHigh Resolution PET/CT scans niques of stenting, laserFusion Diagnostic Group’s advanced technology directed and radio-freand software bring evaluation and measurement quency (RF) ablations tools to the Physician to use in the clinical setting. of tumors and veins, we also have a full time physician on staff. embolizations, and atherectomies. Other Mon - Saturday 8-5 + (flexible hours with advance request) interventional techniques such as vertePositron Emission Tomography (PET) broplasties have largely Computed Tomography (CT) replaced many surgical Molecular / Functional Imaging procedures of yore.

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May 2008 San Francisco Medicine 31 The width is 3.5 by 4” high CALL Kae with any questions or concerns 415-567-5888

hospital news KPSF

Robert Mithun, MD

Fast-forwarding forty-two years, the field of medicine will see revolutionary genetic, biomedical, and technological advances.

Newborns will have genetic profiles enabling us to anticipate any necessary medical interventions. In light of this information, we will create individualized health-maintenance road maps; any subsequent health concerns requiring pharmaceuticals or treatments will be tailored to an individual’s genetic blueprint implications.

The medical system will support life’s stages of birth, growing, aging, and death as natural events, not billable codes or diagnoses. Individuals will be members of their own health care teams, which will provide dignity, compassion, and empowerment throughout life’s journey.

Maintaining health will be a part of daily life as health care will partner with schools, communities, and employers. Virtual access to a fully integrated interdisciplinary health care team will be the norm for every member of society.

As needed, patients will access local telemedicine diagnostic suites, which use minimally intrusive testing methods, and the data will be transmitted to health care teams to review. Once diagnosed, patients will go to specialized care centers, such as cardiovascular or sports medicine centers, with radically less invasive medical interventions. They will receive follow-up care throughout their rehabilitation processes.

Mammoth leaps in technology, with requisite privacy and security, will allow people to keep their relationships with health teams over time and location. With advanced communication systems and instant access to people’s full medical stories, health care teams will focus on healing and compassionate treatment.

Kaiser Permanente’s current commitment to the future vision of universal preventive health, virtual access, integration, and technology is guiding us back to our core mission: helping people thrive.

32 San Francisco Medicine May 2008

Saint Francis

Wade Aubry, MD

At Saint Francis Memorial Hospital, we recently had the chance to experience the future of rehabilitation in our Sports Medicine Center, which conducted a monthlong trial of the G-Trainer Anti-Gravity Treadmill. The machine allows patients to exercise at a fraction of their body weight and was recently cleared by the FDA for use in medical applications. The treadmill may be a useful tool for patients rehabilitating after injury or surgery, allowing them to build strength and range of motion at a very low impact to the body. The machine’s gravity differential technology was originally developed at NASA. It uses an advanced air-pressure system that creates a lifting force with an “unweighting” effect. The result is similar to the weightlessness achieved in a pool, but without the limited range of motion. Hospitals that have used the machine report faster recovery times and lower treatment costs.

We’re also proud to announce that Saint Francis recently earned the Gold Seal of Approval from the Joint Commission for Primary Stroke after an extensive on-site JCAHO review.

The seal recognizes centers that can quickly diagnose strokes, tailor treatment plans, and analyze data to improve care for future cases. I’m thankful to everyone who worked so hard to make this happen, including physician leaders Carlos Quintana, MD; Marcus Zachary, MD; Keith Loring, MD; and Fernando Miranda, MD; as well as staff members Aly Hemphill, Celia Ryan, Gloria Lau, Cherie Volk, Laura Gutierrez, Theresa Edison, Tom Panaccione, and Judith Bolker.

Kudos to orthopaedic surgeons Thomas Sampson, MD, and Elly LaRoque, MD, for their participation as presenters at the recent American Academy of Orthopaedic Surgeons in March.

St. Luke’s

Jerome Franz, MD

2050 is beyond any expectations I have for myself, but I have experienced the changes in the delivery of medical are over just such a scope of years.

Whether there will be a St. Luke’s Hospital in 2050 has been in doubt for years, starting with the increasing deficits of the 1990s. The affiliation with Sutter in 2001 brought new hope that the institution would become more financially sound through better management. However, the losses only increased over the next five years, and Sutter, despairing, turned the reins over to CPMC. CPMC was in the middle of planning how to meet a 2013 deadline for the seismic retrofitting of its three campuses. From their side, it seemed reasonable to move acute care at St. Luke’s to the planned new medical center at Cathedral Hill. They did not expect the outcry this proposal brought from the South of Market communities that depended on St. Luke’s as the only private hospital in the area. Nor did CPMC anticipate that the Department of Public Health would oppose the effective closing of St. Luke’s emergency room, which has been important as a relief valve for San Francisco General Hospital.

Enter Supervisor Alioto-Pier, who listened to our supporters. Along with Mitch Katz, and with the wholehearted cooperation of CPMC, she established a Blue Ribbon Panel to evaluate the role CPMC is to play in the citywide delivery of health care services—what is needed and where.

The group is composed of distinguished leaders from community organizations, the health care field, and the unions. Their charter is to determine the form of acute care services at St. Luke’s beyond 2013, not whether such services will exist.

By the time this column is printed, the panel will have met three times. Its report to the CPMC Board is due June 30. I will save my speculations about 2050 until then. www.sfms.org

hospital news St. Mary’s

Richard Podolin, MD

Patients at St. Mary’s Medical Center (SMMC) Acute Rehabilitation Unit are building endurance, strength, and coordination by using the popular video game system Nintendo Wii. Known as Wii-habilitation, this new form of physical therapy is helping inpatients meet rehabilitation goals using a fun, interactive technique.

“Wii-habilitation is a fresh approach to physical and cognitive rehab therapy,” says Dr. Marc Wakasa, medical director of the Acute Rehabilitation Unit at SMMC. Wii-habilitation is used to move the body in ways similar to traditional therapy exercises.

The Nintendo Wii uses a wireless controller to direct the actions of animated athletes on screen.

The Wii’s interactive format helps inpatients recovering from strokes, spinal injuries, broken bones, and surgery. Patients use the skill sets associated with sports to rebuild lost skills and improve concentration and physical functions.

Currently, SMMC offers Wii-habilitation video games for tennis, ping-pong, and bowling.

The program was pioneered and developed

by Dr. Justin Liu, chair of back and trauma rehabilitation at SMMC. According to Dr. Liu, “In today’s world of constant innovation, it is only natural that we use cutting-edge technology to push the envelope of physical rehabilitation while making the overall process more exciting and fun.”

Wii-habilitation is a cost-effective program, totaling $1,300 for equipment and setup.

Compared to traditional hospital gym equipment, this is significantly more economical and space-efficient. This innovation continues the hospital’s tradition of advanced medical care.

The Acute Rehabilitation Unit specializes in stroke rehabilitation, spinal cord injury, head injury, and general rehabilitation. For more information on Wii-habilitation at SMMC, call (415) 750-5933.

www.sfms.org

UCSF

Ronald Miller, MD

UCSF Medical Center has dramatic plans for the future of medicine and health care in the Bay Area. A campaign is already underway to build a new complex of specialty hospitals for children, women, and cancer patients on a 14.5-acre parcel of land at the UCSF Mission Bay Campus.

The complex will nearly double the Medical Center’s current capacity, while creating a world-class and family-centered healing environment. Its location at Mission Bay will foster “translational research,” using knowledge gained in the laboratory to directly benefit patients. It also offers an opportunity to expand the clinical programs that will be based in the current Medical Center at Parnassus Heights, by freeing up and revitalizing much-needed space for expansion of world-class programs such as neurosurgery, cardiology, and transplant surgery.

The planned complex is critical to UCSF’s ability to provide the quaternary and tertiary care on which its patients depend. UCSF Medical Center is the smallest of the nation’s top ten medical centers, and it has been operating at full capacity for years. In the past six years alone, the average daily hospital census has risen 25 percent to more than 500 patients per day, without space to expand.

On completion of the first phase in 2014, the new complex will include a 183-bed children’s hospital with urgent/emergency care and pediatric primary and specialty facilities; a 36-bed women’s hospital with a birth center, cancer care, specialty surgery, and select women’s services; and a 70-bed adult cancer hospital.

Plans call for the facility to meet LEED environmental standards, including a reduced energy footprint, natural light throughout, and rooftop gardens for patients and their families.

It also will use evidence-based design to support a built environment that can positively affect healing, health, safety, and well-being.

Veterans

Diana Nicoll, MD, PhD, MPA

V.A. health care of the future will be more innovative, designed to meet the needs and expectations of a new generation of veterans, while also focusing on prevention, treatment, and management of diseases suffered by older veterans.

To meet these challenges, the San Francisco V.A. Medical Center has plans to expand its community-based outpatient clinics located in Santa Rosa and Ukiah, as well as to develop a new clinic in Lake County.

We have had great success with our OEF/ OIF Integrated Care Clinic, which exemplifies a new model of health care for returning combat veterans that integrates primary care, mental health care, and social work within one clinical setting. We are now expanding this innovative concept and integrating primary and mental health care throughout all of our primary care clinics.

We are well into the project to expand our Emergency Department. Once completed, this new state-of-the-art department will have twelve acute-care beds as well as improved patient privacy, nursing work and waiting areas, and built-in outdoor decontamination showers.

Our telehealth program continues to grow, particularly in our community-based outpatient clinics. Telehealth involves the use of video, digital pictures, and messaging devices to treat patients who may be hundreds of miles from the medical center. We have also expanded into the area of telemental health, which allows us to increase access in geographically remote areas where no mental health services currently exist.

The Home-Based Primary Care program will play a significant role in the future. This offers primary health care in the home, with the goal of helping veterans avoid hospitalizations and assisting them and their caregivers in preventing premature nursing-home placement.

May 2008 San Francisco Medicine 33

In Memoriam Nancy Thomson, MD Aubrey W. Metcalf, MD Aubrey W. Metcalf, MD, died of cancer, December 7, 2007, age 76. He was born in Los Angeles on September 3, 1931. He attended UCLA and then began medical school in Austria, though is time there was interrupted while he served in the Korean War. He graduated from U.C. Berkeley and finished medical school at UCSF in 1958. He and his bride, Beverly, lived in France and Austria, where they had their first child, Franz, before returning to UCSF for his residency in psychiatry.

Dr. Metcalf used to say he used his private office in West Portal to finance his “teaching habit.” As a professor of psychiatry at UCSF, his vision expanded as those he supervised and mentored carried it forward. One of the first psychiatrists to embrace attachment theory, he encouraged its new thinkers. He sincerely cared for his patients and his colleagues. He ever championed the psychotherapeutic relationship, despite the field’s increasing reliance on drugs. He was awarded a lifetime achievement award from the Regional Organization of Child and Adolescent Psychiatry (ROCAP), citing his “outstanding service to his profession, students, and patients.” ROCAP is now creating an annual award in his name to be given to deserving medical students. His crossdisciplinary work also enriched his and Beverly’s support of the Multidisciplinary Association of Clinical Educators (MACE) and the Association of Educational Therapists (AET). He became a member of the San Francisco Medical Society and the AMA in 1965.

He enjoyed life as do few others, and he shared his passion for fishing, camping, poetry writing, and book annotating with friends and family. He is survived by his wife, Beverly; his son, Franz (Nina Ruscio); daughter, Heidi (Michael Cooperman); and granddaughter, Pearl Metcalf.

review. He was founder and first director of the San Francisco Peer Review Organization and became director of the California Peer Review Organization. After retirement from surgery, Dr. Feldman continued to work for the improvement of patient care. He was an expert in quality care at hospitals and wrote about physician and hospital error for various medical journals.

He is survived by his wife, Dr. Louise Taichert, a child/family psychiatrist; two sons, David (Linda) of Coronado, California, and John (Carol) of Albuquerque; two daughters, Wendy Feldman of Albuquerque and Laurie Feldman (Saverio Santoliquido) of Torino, Italy; and two granddaughters.

On April 1, 2008, Blue Cross of California became Anthem Blue Cross.

Sanford E. Feldman, MD Dr. Sanford E. Feldman, a past president of the San Francisco Medical Society (1969), died at his home in Santa Fe, New Mexico, February 4, 2008, from a melanoma originating on his scalp. He was 93. He was born April 20, 1914, and was a longtime resident of San Francisco and Mill Valley before moving to Santa Fe. He went to Stanford University as an undergraduate and received his MD from Stanford in 1938. Although he was in private practice as a surgeon, he had a lifelong interest in science and for years did basic research on food and water intake with Dr. Samuel Lepkovsky at the University of California at Berkeley. After serving in the military during World War II, he joined the San Francisco Medical Society in 1948. He was also active in the California Medical Association and a pioneer in the area of peer

And the state’s first health benefits company suddenly became its youngest one with a fresh attitude and renewed commitment. A renewed commitment to improving the health of all Californians.

This is a formative time in American health care. Expect Anthem Blue Cross, an old friend with a new name, to lead the way.

Welcome to Anthem Blue Cross, California’s oldest and newest health benefits company.

Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.

EXTRA! New Discount Announced for Workers’ Compensation Insurance! For SFMS Members!

We are pleased to announce a new enhancement to the sponsored San Francisco Medical Society / CMA Workers’ Compensation program, underwritten by Employers Compensation Insurance Company (rated “A -” by A.M. Best Company). Members are now eligible to receive a rate of $1.13 per $100 of annual payroll.

Workers’ Compensation insurance is required by law and covers your employees in the event of a job-related injury. Coverage is standardized by state law and includes hospital and medical expenses, work-related disability income and a death benefit.

Following are some highlights of the Employers program:

For more information and a premium indication, please call a Marsh Client Service Representative at 800-842-3761, or go to www.MarshAffinity.com/ pages/cmadownload.html to download a premium indication request form.

• Employers will provide a member credit on new and renewal policies of SFMS members.

• Employers will provide members insured with Blue Cross on a group (2 – 250 employees) basis an additional discount on their workers’ compensation premium.

• This program is available to members only through Seabury & Smith Insurance Program Management (Marsh).

Sponsored by:

Underwritten by:

See how much you could be saving on Workers’ Compensation Insurance!

Administered by:

© 2008 Seabury & Smith Insurance Program Management • CA License #0633005 • 4/08

777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer, and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting).

California pacific Medical Center’s vascular institute

Most physicians treat patients with everyday vascular issues. But more intricate vascular problems may be harder to handle.

Do you have patients: N

With debilitating short distance claudication or other sequelae of lower extremity arterial insufficiency?

N

With thoracic aortic pathologies (aneurysm, dissection, penetrating ulcers)?

N With a DVT who you feel may benefit from vascular consultation for thrombolysis?

N

Who are female and complain of pelvic pain, urinary frequency or heavy bleeding with periods?

N

In liver failure and awaiting a transplant?

N

With renovascular hypertension or mesenteric ischemia?

N

With swelling of an extremity or signs of arterial emboli?

California Pacific Medical Center’s Vascular Institute offers a wide variety of leading-edge services provided by a unique, multi-disciplinary team of Vascular Surgeons, Radiologists and Cardiologists treating the complex biology of vascular pathologies. Physicians merge and improve skill sets while patients and families benefit from the efficient evaluation and completeness of our integrated approach. From risk factor modification to the latest in minimally invasive procedures, patients greatly benefit from the collegial relationships of the specialists in the Vascular Institute. Our experienced team currently performs over 5500 various procedures per year. And our team’s experience includes performing over 350 AAA repairs.

For more information, find a specialist or schedule a patient transfer, please call 888-637-2762.

Pictured, members of the Vascular Institute Team (from left to right): Anna Michael, R.N., Nurse Coordinator; Myron Marx, M.D., Interventional Radiologist; Jon P. Wack, M.D., Interventional Radiologist; Daniel Nathanson, M.D., Vascular Surgeon/Interventional Radiologist; Edward L. Baker, M.D., Interventional Radiologist; Bruce N. Brent, M.D., Interventional Cardiologist; John Rhee, M.D., Interventional Radiologist; John B. Long, M.D., Vascular Surgeon

www.cpmc.org