November 2007

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CONTENTS SAN FRANCISCO MEDICINE November 2007 Volume 80, Number 9 The Compleat Physician

FEATURE ARTICLES

MONTHLY COLUMNS

11 A Compleat Physician Is ...

4 On Your Behalf

12 Following in Complete Footsteps John Callander, MD, and Peter Callander, MD

7 President’s Message Stephen Follansbee, MD

14 What We Weren’t Taught in School Charles Garfield, PhD

9 Editorial Mike Denney, MD, PhD

16 “...One Is Silver and the Other, Gold” Linda Hawes Clever, MD, MACP

32 In Memoriam Nancy Thomson, MD, and Steve Heilig, MPH

36 Hospital News

18 Holding On to Your Inner Healer Shieva Khayam-Bashi, MD 20 Reaching Out to the Person Within Priscilla Park, NP 21 Balanced Life Lessons Elizabeth Adams

38 Classified Ads 39 SFMS Night at the Symphony

22 Learning to Heal by Being Healed DJ Lucena, RN, ADN 23 Radiology Upside Down Britta Gooding, MD

Editorial and Advertising Offices

25 Serving the Community as Physicians: A Photo Essay Beth Skabar

Phone: 415.561.0850 ext.261

1003 A O’Reilly San Francisco, CA 94129 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org

28 What Is Left Unsaid Kristen Day, MD 30 Creative Expressions: Physician Artwork Mardi Horowitz, MD, and Michael W. Rabow, MD

Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon request.

OF INTEREST

Printing:

35 The Annual CMA House of Delegates Brian Lewis, MD, and Steve Heilig, MPH

P.O. Box 26605

www.sfms.org

Sundance Press Tuscon, AZ 85726-6605

November 2007 San Francisco Medicine

ON YOUR BEHALF

November 2007 Volume 80, Number 9

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

Staff Photographer Ashley Skabar Cover Artists Ashley Skabar and Amanda Denz

SFMS Nutcracker Night!

Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Arthur Lyons

Toni Brayer

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

Shieva Khayam-Bashi SFMS Officers President Stephen E. Follansbee President-Elect Stephen H. Fugaro Secretary Michael Rokeach Treasurer Charles J. Wibbelsman

An exciting new member event is in the works: San Francisco Medical Society’s Nutcracker Night will take place on Saturday, December 29, 2007. This fun, family-friendly event will also feature a festive reception. For more details, contact Therese Porter at (415) 561-0850 extension 260 or tporter@sfms.org.

Also on the horizon is the return of the popular SFMS Tennis Mixer at the San Francisco Tennis Club in January.

Remember—nonmembers are welcome at SFMS membership social/cultural events, which is a great way for them to get to know SFMS and its membership better.

Editor Mike Denney Immediate Past President Gordon L. Fung SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig

Save The Date!

The SFMS Annual Dinner will be held on January 24, 2008. Details will be printed in next month’s issue of San Francisco Medicine.

Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors 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

Term:

Jordan Shlain

Jan 2005-Dec 2007

Lily M. Tan

Gary L. Chan

Shannon Udovic-

George A. Fouras

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

John W. Pierce

Mei-Ling E. Fong

Daniel M. Raybin

Thomas H. Lee

Michael H. Siu

CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate, and Judith L. Mates, Alternate Delegate

Promoting Membership Just Got Easier!

Did you know that your physician peers can now join the San Francisco Medical Society online? Prospective members can go to www.sfms.org and click “Join SFMS” on the top of the home page. It’s quick and easy, and new members get a 50 percent discount on their first year’s dues!

Thank you to our members who have already referred their fellow physicians— physicians talking to physicians remains the strongest and best way for the Medical Society to grow its ranks and help shape the future of medicine.

Have You Returned Your Records Update Form Yet? We recently sent out letters to our membership requesting updates on phone number, e-mail address, and NPI number.

Each year we update our records so that our

San Francisco Medicine November 2007

members are kept up to date. We are especially focusing on adding our members’ NPI numbers to their membership files, and in 2008 members will have the option of having their NPI included in their Membership Directory listing. You can respond by fax, e-mail, or the postage-paid return envelope included in the mailing. If you haven’t received your update packet, or you have any changes in your contact information, please contact Therese Porter, Director of Membership, at (415) 561-0850 extension 268 or tporter@sfms.org.

Congress Delays Medicaid Security Prescription Law; New Implementation Date Is April 1 President Bush signed a bill delaying implementation of the law requiring physicians to use tamper-resistant prescription pads for Medicaid patients. The new implementation date is April 1, 2008. This sixmonth extension will allow physicians and pharmacists time to make sense of the new and somewhat confusing rules and ensure that patient care and access to prescription drugs is not negatively impacted.

President Vetoes Health Insurance for Children of Working Poor Despite bipartisan support in both houses of Congress, President Bush vetoed a bill that would have expanded the State Children’s Health Insurance Program (SCHIP) to cover ten million poor children.

The expansion would cost an additional $35 billion over five years (for a total of $60 billion), which would have been financed by a 61-cent increase in the federal tobacco tax.

The program, which currently provides insurance for 1.1 million children in California and 6.6 million nationwide, expired in September. If the program isn’t extended, millions of children could at least temporarily lose their health insurance as early as November. www.sfms.org

The bill passed 67 to 29 in the Senate, with enough support to override a veto. But the 265-to-159 House vote fell short of the two-thirds margin needed.

“Failure to fund SCHIP is a slap in the face to America’s children, whom we need to make a health care funding priority,” says CMA President Anmol S. Mahal, MD.

Gay and Lesbian Medical Association to Survey Physicians on Health Care Needs of LGBT Patients The Gay and Lesbian Medical Association (GLMA) announced that it will conduct a national survey to study physicians’ attitudes, knowledge, and beliefs about lesbian, gay, bisexual, and transgender (LGBT) patients’ unique health care needs.

The AMA is supporting this effort with a $100,000 grant to GLMA. The survey of a random sample of U.S. physicians, along with a survey of LGBT-identified physicians, will be fielded in early 2008.

“Many physicians do not have all the tools and knowledge they need to address the health needs of their LGBT patients,” said GLMA Executive Director Joel Ginsberg. “This survey will give us the best information available to date about physician attitudes and knowledge with respect to LGBT patients.”

For more information, visit www. glma.org.

November Is National Hospice and Palliative Care Month

October 22–24 Obstetrics and Gynecology Update: What Does the Evidence Tell Us? Sir Francis Drake Hotel

Save the Date January 24, 2008 Anxiety Disorders in Primary Care Mission Bay Conference Center at UCSF 8:00 a.m.–5:00 p.m.

Preregistration required. CME available. For more information, or to register, contact Sharon Palmer, (916) 606-5360, or visit www.sfdph.org.

SFMS Member Honored for Ethnic Health Achievements More than 100 physicians attend the Network of Ethnic Physician Organization’s Leadership Summit that took place on September 15–16 at the Radisson Hotel in Sacramento.

Edward Chow, MD, was presented with the 2007 Ethnic Physician Leadership Award in recognition of the hard work he has dedicated to meeting the linguistic and cultural needs of the Chinese community in San Francisco and advocating for Asian health issues and access and quality of care for underserved ethnic communities, coupled with a remarkable resume of professional accomplishments.

2008 UCSF Obstetrics and Gynecology CME Courses Register today for any of the following CME courses by visiting www.cme.ucsf.edu, calling (415) 476-4251, or e-mailing info@ ocme.ucsf.edu.

April 3–4, 2008 Reproductive Endocrinology and Infertility Hilton Financial District June 5–7 Antepartum and Intrapartum Management The Grand Hyatt Hotel

www.sfms.org

(Left to Right): Dexter Louie, MD, JD; Steve Fugaro, MD; Mary Lou Licwinko, JD, MHSA; Edward Chow, MD; Harry Lee, MD; Rolland Lowe, MD; and Roger Eng, MD

November is National Hospice and Palliative Care Month—a good time to reflect on the increased options hospice allows you to offer your patients and their families.

Hospice has developed from a little-known volunteer effort to a specialized medical practice providing pain management, symptom control, emotional support, and spiritual care for patients and their families as they come to grips with life-limiting illnesses.

2007 also marks the twenty-fifth anniversary of the Medicare Hospice Benefit.

Originally serving primarily cancer patients, hospice began progressively serving more noncancer patients; now cancer represents about 46 percent of hospice admissions. The most common noncancer diagnoses are neurodegenerative conditions such as dementia, end-stage Alzheimer’s and Parkinson’s diseases, and cardiovascular disease.

This change in the clinical landscape has created challenges for physicians: difficulty in prognostication, discussions about hospice, and long-term care concerns. New research may allow health care providers to shine a more positive light on hospice.

A study of 4,493 patients published in the March 2007 issue of the Journal of Pain and Symptom Management found that those admitted to hospice lived an average of twenty-nine days longer than those who did not elect hospice. Knowing this, some patients may better recognize that you are offering the optimum in care when you suggest hospice.

If you would like more information about hospice benefits, contact the National Hospice and Palliative Care Organization at www.nhpco. org; or, for local resources, contact Pathways Home Health, Hospice and Private Duty at (888) 755-7855, e-mail info@pathwayshealth.org, or visit the pathways website at pathwayshealth.org.

November 2007 San Francisco Medicine

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© 2007. The Doctors Company. All rights reserved.

president’s Message Stephen Follansbee, MD

The Compleat Physician “Being a physician is not a profession, it is a diagnosis.”

I

’ve taken liberties with a well-known quote, but this version is apt. While I’m sure that medicine is not the only profession whose responsibilities can seem overwhelming, it certainly ranks high. But we physicians know we are good at what we do. We’re used to being in charge and in control.

This feeling may not be as easily achieved in other areas of our lives, however. Our relationships may be difficult and require compromise. Our children may not always hold us in the highest esteem. We may not feel totally respected as we drive home from work and encounter aggressive and hostile motorists. There are innumerable opportunities for us to feel less valued than we feel when we’re actually practicing medicine. It is well established that in the U.S., the suicide rate among male doctors is 40 percent higher than among men in general, and the rate among female doctors is 130 percent higher than among women in general.

This issue of San Francisco Medicine addresses the reality of being a physician. You, the members of the San Francisco Medical Society, have an incredible range of interests, talents, and strengths outside of medicine. I know that among our ranks are athletes, musicians, writers, painters, carpenters, vintners, and chefs—and there are many others, more than I can name. I am sure that these interests, whether we are very skilled or not so accomplished, help balance our lives. But they do more than that: I think they make us better physicians. They allow our minds, bodies, and spirits to focus on other issues, and then we return to medicine refreshed. We are reenergized for our professional activities as doctors.

However, I do not think that it is always necessary to look outside of medicine to achieve some of these benefits. I strongly believe that as physicians, we can round out our professional lives, providing more than direct patient care. Some of us who take care of patients also teach. Some of us are involved in clinical research.

Some write within the profession, be it textbooks, articles, or review articles for publication. Some of us take on administrative responsibilities that allow us to contribute to the practice and sustainability of medicine.

I would not be the president of our society if I did not feel that membership and involvement in the San Francisco Medical Society can help round out the “compleat physician.” This sounds like a shameless plug for membership, but it is not. I think that, as www.sfms.org

physicians, we have a responsibility to each other to see that our voices are heard locally, regionally, and nationally. We owe it to ourselves, to our patients, and to those individuals who will follow in our footsteps to help ensure that our expertise and opinions are heard, appreciated, and acted upon to improve the health of our profession, our patients, and our communities. I do not think it is enough to do this within our specialty societies, as important as they are. We need to speak as a united group of physicians, and we need to be heard as a single, loud, and articulate voice.

I maintain, then, that the compleat physician cannot afford to ignore organized medicine. We must guarantee that our perspective is carried forth. The additional benefit is that as individuals, we get some satisfaction, some additional pride, and some sense of accomplishment for the achievements that result.

I dedicate this article to Neal Cornell, PhD, who was my mentor and advisor in biochemistry while I was in college. Neal and his wife Molly took an extraordinary interest in me and several fellow students as we navigated the science curriculum, the tumultuous college years of 1966 to 1970, and the prospects for our future. Neal was the reason that I set out for a PhD program in biochemistry and molecular biology. At the end of the first year of graduate school, when I realized that this course was not the right one for me, it was to Neal and Molly that I turned. They were living in Woods Hole, Massachusetts. I stayed with them over one weekend as I explored what my future might hold. It was Neal who advised me to “find an interest, an activity, something that you do only for yourself and no one else.” It was incredibly important advice. It is advice that continues to make me a better physician.

I do not think that the high suicide rate of physicians is necessarily related directly to the stresses and hours of our profession.

There are undoubtedly other issues at play. However, I do think that the lesson provided to me by Neal Cornell, and the lessons outlined in the articles in this issue, serve me well. I suspect they will serve you well also.

For a list of references, please see www.sfms.org.

November 2007 San Francisco Medicine

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Editorial Mike Denney, MD, PhD

The Doctor and the Poet

I

n the year 1902, at a military academy in Germany, a nineteenyear-old student who aspired to be a poet became entranced by a little book of poetry written by the famous Rainer Maria Rilke. The young man was so moved he audaciously sent samples of his writing to Rilke, asking for help. Perhaps because he had also attended a military academy—a period he described as “one long terrifying damnation”—Rilke began a correspondence with the young man. Rilke’s letters were later compiled into a book, Letters to a Young Poet, which offered deep insights into what it was like to be a poet. He wrote, “Describe your sorrow and desires, the thoughts that pass through your mind, and your belief in some kind of beauty—describe these with heartfelt, silent, humble sincerity.”

In the year 1982, in New Haven, Connecticut, Yale surgeon and author Richard Selzer, MD, entranced by Rilke’s Letters to a Young Poet, published his own book, Letters to a Young Surgeon (Harcourt Brace, 1982). Selzer offered deep insights into what it was like to be a doctor, to tend the sick. He wrote, “The surgeon, armed to the teeth, seeks to overwhelm and control the body; the medical man strives with pills and potions to cooperate with that body.”

Despite these contrasts, Rilke and Selzer, poet and doctor, each go beyond differences to explore the mysterious realm between science and metaphor, medicine and poetry. Rilke says to the young poet, “You are also the doctor who has to watch over himself. But in every sickness there are many days when the doctor can do nothing but wait.” And Selzer says to the young doctor, “Surgery is, in one sense, a judicious contrivance, like poetry . . . here among the ranting machinery and brazen lamps of the operating room.”

In the language of Rilke and Selzer, the kinship of poetry and healing the sick becomes increasingly apparent. Rilke admonishes the young poet, “Keep growing, silently and earnestly, through your whole development; you couldn’t disturb it more violently than by looking outside and waiting for outside answers to questions that only your innermost feelings in your quietest hours, can perhaps answer.” As if in response, Selzer says to the young doctor, “You will work both night and day. You will be tired, I know, and I don’t want any more of that kind of tired. An intern, like a poet, is at the disposal of the night. The more one drinks of the night the more one thirsts for the light of day.”

In the words of these two writers, the likenesses and differwww.sfms.org

ences of medicine and poetry become more subtly intriguing. For example, Rilke says, “Love your solitude and try to sing out with the pain it causes you,” whereas Selzer says, “To be spattered with the phlegm, vomitus, and blood of suffering is to be badged with the highest office.” Rilke laments, “If only human beings could receive mystery—which the world is filled with, even in its smallest things,” while Selzer confidently asserts, “Listen, I will tell you what you already know: There is nothing like an honest piece of surgery. Say what you will, there is nothing more satisfying to the spirit than the lancing of a boil!”

In this issue of San Francisco Medicine, with its theme of The Compleat Physician, is it possible that a union of Selzer and Rilke, of doctor and poet, can bring new understanding? Is there inspiration for one to become a complete physician within the mysterious realm between science and spirit, medicine and poetry?

We might recall that in Greek mythology, Apollo was the god of science and medicine, and he had two sons, Asclepius the doctor and Orpheus the greatest of all poets. Angered after Apollo punished his wife Coronis for her infidelity and performed a C-section to deliver Asclepius, Zeus commanded that thereafter Apollo would divide his time between these two sons, spending at least three months of each year away from Asclepian science and instead living in the hyperborean realm to the north, the mysterious land of Orpheus the poet.

Recently, at a large medical meeting, the moderator spoke of a dedication to studying mysterious phenomena with the scientific method. As only a pure scientist might, the moderator misquoted Rilke as saying, “Love the questions. Live the answers.”

But both a doctor like Richard Selzer and a poet like Rainer Maria Rilke would disagree with the reduction of mystery implied in that erroneous quote. Selzer said, “The light in the operating room is no less important than the light in the artist’s studio.” And Rilke did not say, “Love the questions. Live the answers.” He said, “Love the questions. Live the questions.”

November 2007 San Francisco Medicine

Get Paid What You’re Worth

All around California, physicians are being pressured by giant PPOs to accept lower reimbursement rates in exchange for patient volume. It’s a tough choice, but one fact stands clear: Every time you lower your rates, you have to work longer hours for less pay.

The Pacific Foundation for Medical Care offers you a better choice.

Since 1957, we have reimbursed physicians at generous rates that maximize your income—not ours. We’re nonprofit, and we’re governed by physicians. Our Mission is simple: To pay you what you’re worth.

Pacific Foundation for Medical Care To learn more about PFMC, or for a membership application, visit www.pfmc.org or call Kathy Pass at 800-548-7677, Ext. 115

A Compleat Physician Is ...

SFMS Honorary and Retired Members Share Their Views “ ... a professional who is gentle, compassionate, takes his time to listen and examine his patients, and treats them not as a disease but as a person with a disease.”—Rolland Barakett, MD

“ ... one who sees patients in relationship to the totality of their life experience: home, family, community, and spirit.”

—Rolland Lowe, MD (above)

“ ... perpetually dedicated to the proposition that the first priorities in medical practice are those elements that are in the best interest of his patients’ comfort, happiness, and well-being.”—Brad Cohn, MD

“ ... an Oslerian concept of extraordinary achievement in teaching, research, and the ethical, humane, compassionate practice of medicine.”

—Byron Pevehouse, MD

“ ... one whose love for his/her profession is balanced by love for family and community.”

—Bruce Sams, MD

“ ... one who takes care of other human beings with compassion.”—Edgar Wayburn, MD

“ ... one who treats each patient as a unique individual, not just a collection of signs and symptoms.”—Nancy Thomson, MD

The Compleat Physician

Following in Complete Footsteps Father and Son Physicians Discuss Attaining a Complete Body, Mind, and Spirit Peter Callander, MD, and John Callander, MD Peter: OK, Dad, we’ve been asked to participate in an article for San Francisco Medicine. And the theme is “The Compleat Physician.” As your son who followed in your footsteps to become an orthopedic surgeon, I think of you as a complete physician. I’ve modeled my own practices after you. Even as a child I participated in hospital rounds with you, and at the age of twelve I had my first surgical experience, being there in the OR and watching you work your magic.

So I’d like to ask you some questions now about your many years of practice.

I guess my first question goes directly to the theme: What do you think it takes to be a complete physician?

John: A complete physician is one who addresses the whole patient, one who knows something about the person and the family so that he can approach the illness with an awareness of any problems that might affect the treatment.

Peter: Have the many changes in the delivery of health care affected these ideals?

John: Yes. For example, in past years we made house calls, and you learned a lot about a person and the home environment.

Now, the practice is focused upon the office, and you don’t get the whole picture.

Peter: What might you advise us to do now?

John: I would advise doctors to spend time listening to their patients. I think that doctors today don’t have the time, and they must jump to conclusions, and they do tests

that sometimes aren’t necessary to try to fill the void. But with a little more time, you can sometimes make the diagnosis more accurately than the tests can.

Peter: I know that over the years in San Francisco you have been known as “Doctor Bedside.”

John: We used to make hospital rounds on patients instead of the current system of turning over the care to a hospitalist.

Nowadays, you don’t get a chance to sit down on the edge of the bed, talk to patients, give them confidence, and learn what is going on. That time we used to spend with patients paid dividends in terms of the ultimate outcomes.

Peter: And I guess that also goes for office visits.

John: Yes, and the pressure is on there, too.

Doctors have a few minutes to look at the patients, checking their casts or alignment or circulation, and then they’re out the door, and they don’t learn anything about the patient. I think that’s just really bad.

Peter: How long have you been practicing orthopedics?

John: Since 1954, when I finished my training at Shriners Hospital for crippled children, and I joined Dr. Abbott and Dr. Bost. I learned a lot from them. Now, they were old-school doctors who listened and took time with their patients—and they made house calls.

Peter: In regard to the complete physician, I’m aware that for you it’s been

12 San Francisco Medicine November 2007

about practicing medicine, but it’s also been about family life. You’ve been married now for fifty-seven years, and you have six children. How have you been able to make this personal part of your life successful also?

John: Of course, my wife Barbara was always the strong fiber that held the family together. Spending time with the family was the secret. Barbara and I didn’t take vacations unless we took the children with us. And the family dinner at least three times a week was considered crucial. I would sometimes schedule surgery at night so that I could be at home with family, and then operate on three hip fractures afterward.

Peter: Yes, I remember that well. We all had to be there at the dinner table, and sometimes we had to eat quickly because Dad had to go back to work.

John: I remember an older doctor once telling me that his daughter’s wedding was coming up and that he had been so busy in his practice that he didn’t really know the young woman that he was giving away. I did not want that to happen to me, so we always considered the family dinner as that place that we could all come together and talk about things and be close.

Peter: And, Dad, I know that you have also given to the community. You have five sons and we all became Eagle Scouts with your leadership. But you also helped out in many other community organizations.

John: You know, Peter, when I was a boy I became deaf. We didn’t have hi-tech www.sfms.org

hearing aids then, but someone took the time to teach me to read lips. And I got really good at it. So later, when I wanted to go into the military and I couldn’t pass the hearing test, a high-ranking officer noticed how proficient I was at understanding the spoken word, and he waived the requirement and let me in. Later, it was a consideration of whether I could go to medical school, and at Johns Hopkins the famous cardiologist, Helen Taussig, who herself was deaf, took me under her wing and helped me get started. So I am thankful for those gifts of kindness, and I want to offer them to others.

Peter: You’ve been very active in the Boys and Girls Club of San Francisco.

John: Yes, I’ve been with them for fortyfive years. We have eight clubhouses in San Francisco and we’ve served over 17,000 underprivileged youngsters. We have a camp up in Mendocino that accepts about 1,500 kids every summer. We teach them how to ride horseback and other sports, but mainly we teach them how to be integrated into community, by stressing deportment and such practical things as how to fill out applications for schools or jobs.

Peter: Why do you do this, why do you feel it’s important?

John: When I was young, my dad used to take me to the hospital—he was the head of surgical anatomy at the University of California Medical School—and we would bring presents to the children there, and that got me started. It’s kind of in the family. Both Barbara and I have been active in benevolent organizations over the years.

trips was when you were a first-year medical student and came with me to Guatemala.

advice would you give young doctors today?

Peter: Oh, and we might also mention your work with the Guardsmen, another San Francisco organization that helps underprivileged children get into summer camps and into good schools. Not to mention that you’re now vice-chair of the California Pacific Medical Center Foundation.

John: I would advise them to not rely too much on technology, but to use their eyes, their ears, their hands, and their brains.

And to take the time that is necessary.

John: Yes, we’re trying to raise money to build a new hospital.

Peter: So we talk here of your mind and spirit, and I also know that as a complete physician you’ve taken care of your body.

John: Yes, I’ve played squash since I was a teenager.

Peter: And we might just mention Operation Rainbow, the organization in our office here, started and managed by Dr. Taylor Smith, through which we do volunteer orthopedic work in Central or South America, China, and the Philippines. We teach the local doctors and the nursing and technical people and also do complex surgery.

John: The best part is when I get to play squash with my sons.

John: Yes, and one of my most enjoyable

Peter: Returning to medicine, what

www.sfms.org

Peter: Four years ago, you underwent a five-vessel coronary bypass operation, and four months after the surgery you won the championship for your age group in squash—number one in the United States!

Peter: You’ve mentioned time repeatedly.

What do you mean by time?

John: Well, I’m eighty-four years old now.

And I’d say that if you can help somebody, then take the time to do it. If you can do something to improve someone’s mental and physical state, that’s what I think time should be used for. For me, that’s what time is.

Peter: So, Dad, to wind this up, let me ask: What was the most important moment in your career?

John: Well, Peter, as you know, my great-grandfather was a veterinarian. My grandfather was a surgeon who did a lot of orthopedics. My father was the head of surgical anatomy at the University of California Medical School. I’ve had a most rewarding career. So the most important moment for me was when you, my son, graduated from medical school.

November 2007 San Francisco Medicine 13

The Compleat Physician

What We Weren’t Taught in School Reflections of a Health Professional Charles Garfield, PhD

W

hen my nephew Teddy was nine years old, he asked me one day, “What kind of work do you do?”

I told him I work at a medical school and my job was to teach doctors and nurses how to care.

Teddy stared at me, incredulous, and said, “You mean they forgot?”

Thirty-five years ago, a generation of young adults, perplexed by the fog of the Vietnam war, tried not to forget how to care.

Today, the best minds and hearts of a new generation face a similar challenge. Some of these men and women, health professionals committed deeply to protecting life, asked me recently, “What can we learn from war and its deadly consequences?”

I began my answer with a question: “Can physicians and all health professionals learn to view our caring work, in the words of William James—arguably America’s greatest psychologist—as a moral equivalent of war?” That is, as something heroic that “will be as compatible with our spiritual selves as war has proved itself to be incompatible”?

What follows is the rest of my response: As a young man, I got up every day with a message: “The world can be a tough place, and winners are better off than losers. So work hard, do everything you can to excel, to stand out, and good things will come your way.” I certainly didn’t understand the relentless drives that spurred me to excel, or whether they served a purpose higher than personal advancement. I did feel pressured to excel because I was convinced that bad things happen to those who failed to do so.

Excelling constantly only got harder as time went on. In graduate school, one of

my mathematics professors told me that all the great discoveries in the field were made by a half-dozen geniuses. I wondered how in the world I could ever rise to such a level.

Years later, I heard my medical students and colleagues voice similar worries about where they ranked in their own pantheon of health care high achievers, as if they were competing in a battle zone with fellow students or coworkers.

If these reflections resonate with your experience, if you’re laboring under an intense pressure to succeed in the eyes of the world—and in your own eyes—then I invite you to slow down, consult your heart, and consider the following reflections.

Five Lessons for Health Professionals

1. Nothing meaningful, important, or deeply satisfying ever came from composing a life by the numbers.

Trying to succeed by sticking to a

14 San Francisco Medicine November 2007

straight and narrow career path may be predictable for some ambitious people who seek stature and reward. But the well-paved road is always someone else’s road leading to someone else’s life. Avoid walking in lockstep mimicry of anyone else’s version of what your career is supposed to be.

Don’t let anyone else, no matter how well intentioned, sell you a version of the good life or the good career that isn’t your own.

Someone else’s good life or career will not be as good for you as advertised.

What can be difficult but soulsatisfying is to let go of the blind desire to excel and instead embrace the lifelong work of knowing yourself. What values most move you? What offers you enduring happiness in your work? What does the world most need from you? Who is your heart calling you to be?

2. Life’s two most important questions are: What is the good person? What is the good society?

Humanity is facing unbearable pressure—war, terrorism, environmental degradation. At this crucial time, we must choose either to continue warring with “enemies” at home and around the world or to learn to cooperate and live justly. No man or woman is an island, on the job or elsewhere. We’re all in this life together. If my end of the boat sinks, so does yours. Don’t let anyone convince you that “looking out only for number one” is a way to live. We are all cocreating our shared world, and each of us is responsible for doing our best to serve both ourselves and others.

I care more about your values than your diplomas or your investment portfolio.

I care about your willingness to be tough on problems yet tender on people more than www.sfms.org

your success in the rat race. As Lily Tomlin said, “The problem with the rat race is that even if you win, you’re still a rat.”

3. Pay close attention to the choices you make every day.

Don’t just drift through life or leap impulsively at each hot new advancement opportunity. When I left a promising career in space science, after the Apollo Eleven moon landing, to study psychology at U.C. Berkeley, colleagues and friends told me I was making a serious mistake. It didn’t matter to them that I had discovered my life’s calling and that it focused on helping people rather than solving equations. My experience on the first lunar landing team taught me that Sir George Pickering, the renowned clinical researcher and Professor of Medicine at Oxford University, was correct when he said, “Not everything that counts can be counted, and not everything that can be counted counts.”

Later, when I turned down tempting academic appointments in psychology to found a volunteer organization named Shanti, which cared for seriously ill people and their loved ones, a new set of authorities told me I was crazy. Somehow I trusted my inner sense that I was making the growth choice, not the fear choice, and that this caring work was constitutionally right for me. I had learned from my patients that the need to care for others is as deep as the need to care for ourselves. Founding and leading Shanti, which became the first community-based AIDS service organization in the U.S., taught me that my career choices might matter profoundly to both myself and others.

I began to understand the forces that induce so many of us to remain bystanders in our time of promise and peril. What will it take, I wondered, to awaken the conscience of bystanders in the face of the environmental, political, and social dilemmas that confront us? What are the psychological and physiological effects on the bystander of witnessing but failing to respond to the suffering that surrounds us?

4. If you want to be happy on the job, in school, and in your personal life, remember that “people don’t care how much www.sfms.org

you know until they know how much you care.”

Thinking well is necessary, but insufficient, for a life well lived. Our capacities for empathy and compassion for those in need

“If you’re laboring under an intense pressure to succeed in the eyes of the world—and in your own eyes—then I invite you to slow down, consult your heart, and consider the following reflections.” are every bit as vital as critical thinking.

Kindness is never optional, or somehow less important than the so-called “hard realities” measured in scientific calculations and presented in evidence-based research reports.

The need to care is as basic as the need for care. Compassion means “to suffer with.” It’s an imaginative entrance into the world of another person’s pain. Through compassion, we close the distance between one person’s experience and another’s, and we start to bridge the divisions between us.

Our society needs caring communities of compassionate and skilled souls far more than it needs a slew of striving, upwardly mobile high achievers whose focus is on themselves and their own desires.

After nearly thirty-five years of serving men and women who have been left out of our nation’s safety net—the poor, hungry, homeless, and infirm; the social casualties whose presence we’ve convinced ourselves is normal since “they’ve always been with us”—I’ve learned that these neighbors of ours are far more like us than they are different.

Today, stress overload, harmful budget cuts, staff shortages, and increasingly bureaucratic models of organization have, sadly, become the norm in health care.

Organizations suffering from chronic stress disorder, operating with a siege mentality, create the conditions for burnout and compassion fatigue that will erode your spirit and exhaust your soul. All too often, our orga-

nizations lose track of their caregiving missions and focus their time and energies not on superior service delivery but on money and staying alive—as organizations—while slipping more and more into hierarchical rigidity and poorly executed downsizings that end up crushing the survivors. The problem, of course, is that we then have to serve our patients with overburdened, crushed people whose energies are focused on surviving the day.

Such empathy-eroding circumstances will eventually find many of us far from our original calling of giving care. Eventually we may discover, in the words of Hermann Hesse, that “we kill at every step, not only in wars.…We kill when we close our eyes to poverty and suffering.… All hardheartedness, all indifference … is nothing else than killing.”

The quality of service we offer our patients will be no better than the quality of service we offer one another. Our organizations would work far better if they were structured as chains of service rather than chains of command. We need to get our houses in order internally, to create caring organizations in which to do our caring work. Simply put, the old command-andcontrol, boss-subordinate paradigm is dead.

It’s an old story that we need to replace with a team-based partnership story in which a chain of service exists from the boardroom to the patient; a story of compassionate service delivery that will gratify us far more than chasing the phantoms of power and prestige.

5. Never forget that you are a miracle, an expression of the miraculous never before seen on Earth.

Now there’s something to put on your resume! I remember an old poster from the 1970s. At the top was a photo of babies in a maternity ward—beautiful, wide-eyed miracles, overflowing with life and fidgeting with promise and potential. Directly underneath was a second photo of passengers on a New York subway staring morosely in a hypnotic trance, waiting for their ride, their day, and—unconsciously—their lives to be over.

At the bottom of the poster were the words, “What happened?” Each of us was once a Continued on Page 17...

November 2007 San Francisco Medicine 15

The Compleat Physician

“ ... One Is Silver and the Other, Gold” A Good Friend Can Go a Long Way Linda Hawes Clever, MD, MACP

S

everal years ago, my mother died in one month and our home was burglarized the next. Because of cutbacks, I lost two jobs that I loved. Then my father died, and my husband, Jamie, was diagnosed with cancer and survived major surgery. This all happened in eighteen months. I was flattened. My lifelong trajectory had shifted from up to down.

After a while, I noticed that some people stayed in particularly close touch. I said to one, after her repeated phone calls, “Why do you keep calling me? I have nothing to offer. I’m not Sparkle Plenty.” She said, “I am your friend.” I said, “Oh.” Until my hard times, I had considered friends as boon companions to share the good times. I hadn’t realized that friends could help me bounce back and move forward. I hadn’t really realized the staunchness, the tenacity of friends. That’s when I devised the two-casserole test. Like many tests, it starts with a question, “How many people in your life will bring you more than one casserole when you need it, when troubles roll on and on and even multiply?”

Neighbors, church, the office will send one casserole (or card or bouquet). Friends know you so well that they will hang in there with you and send two or five or seven casseroles.

The rest of the question, of course is, “How many people in your life will you take two casseroles to when they need it?” There are no correct answers to the test, and most highly educated people have rather few close friends—maybe two to four, maybe six or so.

The test is meant to get us thinking about one of the most important relationships we can have, as well as one of the most important words in our language: friends.

It seemed a lifetime later, but the other day I was talking about medicine and life

with a colleague who said, “I love my patients and my practice. I have a great staff and a great home life. I have enough time for my hobbies, too, and that’s relaxing. Life is good … except that I have no friends.

That is sad.”

It is sad.

Why? Some of us, perhaps many of us, especially older physicians, may never have learned about friends. Medical school, internship, and residency may have sorted through the gene pool and selected individuals who are long on endurance but short on social skills—or even short on social awareness and acknowledgment that friends can be a help. One physician-friend said not long ago about his experiences in training, “We went in people and came out friendless.”

Times change. This generation’s medical students and interns report on day one of their training that “losing and making relationships” are two of their biggest wor-

16 San Francisco Medicine November 2007

ries, along with “screwing up.”

Even in our hectic and somewhat isolated lives, most of us know deep down that friends are important, somehow. The word itself is powerful. It comes from Old English, as do many of our most meaningful words. Its root means “love.” Girls Scouts sing praise to friends in a melodious campfire round: “Make new friends but keep the old. One is silver and the other, gold.”

Friends are a source of care, comfort, and ideas. The relationship is reciprocal, so we are resources to them, too. We give each other backing and feedback. Sometimes help flows mainly in one direction, as circumstances require, but over time the relationship equals out.

Friends are far more than colleagues.

Although colleagues surely help and buoy us, we may become competitive or develop dividing differences. Let’s face it, as close to us as they are, our colleagues will not change our diapers. Friends—and family—will likely be there when we need them. Friends respond, time and again. They coach, cheerlead, and share. We are safe with them. We walk with each other so we do not have to walk our own roads alone.

Friends may be coconspirators. We may get into fun—or into trouble—with them.

(Think loud parties.) It is a privilege to help a friend. Neither feels annoyed nor imposed upon—nor belittled—by helping or being helped because we are so comfortable with and so committed to each other. A Holocaust survivor once told me, “A friend is someone who will take you in, in the middle of the night, when you are running away.”

Or, as comic book writer Len Wein said, “A friend is someone who is there for you when he’d rather be anywhere else.”

It’s true that friends may grow apart as www.sfms.org

interests change, geography or jobs separate, or we lose touch with each other. We once lost track of a dear couple who, we learned when we reconnected, had lost three babies in three years and simply could not bear any contact at all.

It is said that it takes three years to develop a firm friendship. Like gardens, friendships need attention and time to mature. But if we are so busy and friendships take so long, how can we find and keep them?

Our daughter, Sarah, organized special interest groups as she moved back and forth across the country for her medical training.

At each university, she started a book club and a poker club. The get-togethers were refreshing diversions that brought pleasure and friendships. Sarah sent a posse from her poker club to scout out safe neighborhoods when she was buying her house in Baltimore.

Jamie and I have worked out some ways, with friends, to keep friendships robust. We and four other couples have met about once a month for twenty years to talk about weighty and nonweighty matters: contending with change, politics, discrimination, going green, caring for parents, dealing with our own health and hopes. Sometimes we play Cranium or go to the flicks. Thinking and laughing together help build our sense of belonging and community. We become more resilient, too.

With other friends, we have season tickets to the symphony or theater. We join with another couple to try to win Il Fornaio’s trip to Italy for two (all four of us will go and split the prize). We have done this once a month for four years and haven’t won anything except forty-eight delightful evenings—with ever-better friends. Some people meet likeminded volunteers who become friends in more formal groups—Sierra Club, Scrabble contests, Red Cross units, museum docent training programs, the 49ers Boosters.

Although time constraints or distance can corrode a friendship, there are ways to reach toward each other. A tickle file of birthdays and anniversaries along with a stash of postcards or greeting cards, an e-mail group to bounce around news and jokes, a party to celebrate a solstice or a theater opening, a potluck Thanksgiving dinner, a picnic, a hike, a hobby all can relink and www.sfms.org

reaffirm our bonds.

Can we have a meaningful life without friends? Possibly.

Some of us may prefer to go it alone. If that preference sneaks up on us, however, it may be a sign of medical or emotional

“Friends respond, time and again. They coach, cheerlead, and share. We are safe with them. We walk with each other so we do not have to walk our own roads alone.” trouble. If we have no energy or blow up easily or are overtaken by gloom, friendships may suffer. This is a danger signal that requires attention from our own physician or counselor.

The writer C.S. Lewis said, “Friendship is unnecessary, like philosophy, like art … it has no survival value; rather it is one of those things that give value to survival.” Friends can work with us on the very meaning of our lives as we wonder, “Am I climbing the right mountain?” Friends reflect with us and tell the truth when we ponder, “Can I or can’t I…?”; “Should I or shouldn’t I…?”

I believe that there are many elements of a “compleat” physician. Some elements have to do with knowledge, wisdom, and skills; others have to do with attitudes; others with personalities. We need to have an uncommon amount of energy. We need to be kind; we need to be able to tolerate frustration and disappointment. Above all, perhaps surprisingly, we need to take good care of ourselves—body, mind, and spirit. I believe that to be a complete physician, we therefore need to pursue, find, and sustain the rich, sustaining relationships that yield the assurance, “I am your friend.”

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 California Pacific.

To learn more, visit www.renewnow.org.

What We Weren’t Taught in School Continued from Page 15... maternity-ward miracle, and each of us can avoid the fate of those who go through life hypnotized by someone else’s dream.

I can assure you that one day when your heart is broken or when you’re grieving the loss of a loved one or when you want to succeed badly at something but fail instead, it’ll be a boost beyond measure to remember how much of a miracle you are.

And, as you attend to your patients each day, remember that they, too, are expressions of the miraculous—and they need and deserve the wisest and most caring guidance you can offer them.

One day you may find yourself speaking to a young man or woman wrestling with a tension of opposites that lives within each of us; someone struggling to reconcile the hostility of aggression and the kindness of compassionate care. Look him, or her, in the eye, smile, and tell that young person you have the utmost faith in his capacity to further health care’s sacred mission, our moral equivalent of war. And how fulfilling his life will be when he aligns his own dream with that caring mission and makes his unique contribution to the greater good that sustains us all.

Charles Garfield, PhD, is an author, lecturer, Clinical Professor of Psychology in the Department of Psychiatry at UCSF Medical School, and founder of Shanti, a widely respected AIDS service organization. He is a Visiting Scholar at the Graduate Theological Union, Berkeley; a founding faculty member at the Metta Institute End-of-Life Counseling program; and, until recently, a board member of the C.G. Jung Institute of San Francisco.

Earlier, Dr. Garfield was a mathematician working on the Apollo Eleven’s first lunar landing. His ten books include Sometimes My Heart Goes Numb: Love and Caregiving in a Time of AIDS; Training Volunteers for Community Service; Wisdom Circles: A Guide to Self-Discovery and Community Building in Small Groups; and the Peak Performance trilogy.

November 2007 San Francisco Medicine 17

The Compleat Physician

Holding On to Your Inner Healer Young Medical Students See People as People, Rather Than Symptoms—How Can They Hold On to That?

Shieva Khayam-Bashi, MD

H

e is surprisingly calm and pleasant, considering that he has recently been told that he has a terminal disease and little time to live. He is only fifty-five years old and has always been a very healthy and active man; after a minor motorcycle accident a few weeks ago, he went in to see why he still had persistent back pain. It was then, just last week, that he was given the unexpected news that he has Stage IV lung cancer, widely metastatic to his spine and brain. He is now in the hospital, recovering from surgery to stabilize the collapsed portions of his spine, and he will soon have radiation to his brain.

She takes a deep breath before she tentatively enters the hospital room to interview this gentleman and his wife. He is her first patient, ever. She is a first-year medical student, only in her second week of medical school; she sits very attentively in the chair beside his bed and listens to her patient and his story. She expresses her sadness at the shocking news of his illness, and she asks how he feels and how he and his wife are coping. She hears his generally positive attitude and his gratitude about the care he is receiving from the medical and nursing teams. He only alludes briefly to his sadness about the prospect of not completing his life as he had hoped. She wonders if she should pursue this further, but she does not know how.

As her faculty facilitator, I observe the conversation between the student and the gentleman and his wife. I observe how gentle and unrushed she is, and how interested she is in their story. She is kind, asks thoughtful questions, and listens carefully to both of the people in the room, understanding that they are both deeply affected by the terrible illness. She hears their comments about

how good the nurses are, and how good the doctors are, too, since they all seem to care and they explain everything carefully. Both the patient and his wife tell her that they know how seriously ill he is, but that they appreciate being treated “like people.”

It was a beautiful thing to observe, a young first-year medical student interviewing her first patient. In actuality, it was not so much an interview as it was a conversation: a man and his wife who had been given terrible news about a serious illness, talking with a young woman who was starting on her journey of learning how to care for people like them. The student did not know much “medicine,” and the conversation was simply a heartfelt communication between human beings; it was not an information-gathering or an information-giving exchange. It was an exchange of humanity.

After the interview, I went with the student, a group of five of her classmates, and my faculty colleague to the courtyard, where

18 San Francisco Medicine November 2007

we sat outside to reflect on the experience.

We gave the student thoughtful feedback on how her conversation seemed to flow well, how her body language and tone of voice and mannerisms demonstrated that she really cared, how her questions were careful and gentle, how she honored their story and listened with attention. We also reflected on how sad the story made everyone feel, and how they would have liked to know more about them as people: Are they afraid? If so, how will they deal with the fear? Do they have other sources of emotional and spiritual support? Do they have children?

Will he go back to work again? They also wondered what his prognosis would be, what kind of treatments would be best, what radiation would involve, whether he would need some kind of chemotherapy. They revealed that they felt very inadequate as “physicians,” since they know almost nothing “medical” yet. When would they learn “real medicine”?

At this early stage in medical education, the student experienced and understood the person whom she met as a person, not yet as a patient. At this point, she was frustrated by the fact that she has very little medical knowledge; her only real experience is based in knowing how to be human, and therefore the interaction between her and the patient is one based on humanity alone.

This seems to the student to be pleasant but inadequate. She is not yet trained in gathering medical information, nor is she trained in giving medical information—she is simply establishing rapport and relationship, honoring the humanity that lives in and between herself and the patient.

What medical students look forward to is learning progressively more medical knowledge. They look forward to becomwww.sfms.org

ing medically focused: they will learn how to gather information (through structured history and physical exams as well as lab/ radiology tests and procedures), and how to give information (e.g., diagnoses, treatments, prognoses). They are eager to gain this knowledge and these skills; indeed, they will learn all of this and more.

This is the beginning of a subtle transition in the minds of students, and in the training they receive. This is when people are no longer referred to as “people”—they become “patients.” This is when the fiftyfive-year-old motorcycle-riding CEO of a company becomes the “55 yo man with Stage IV lung cancer, status post fixation of the T-spine.” This is when the seventy-twoyear-old widow and grandmother of twelve, who now has a problem with her heart and is scared of dying, becomes the “72 yo woman with Afib and CHF.” Regrettably, this is when the importance of a person’s humanity ranks second to the importance of his or her diagnosis.

At this early point in medical school, the transition going on in students’ minds is disturbingly insidious; no one realizes what has happened until years later. The students eagerly take on the “medical” manners of speaking and thinking, because they think that’s the way to become physicians—and that, after all, is why they came to medical school. They are somehow honored to acquire this new skill, to learn to communicate about patients as diagnoses, abbreviations, and acronyms; and they are eager to be able someday to offer proper diagnostic and therapeutic plans. What they do not realize is that, while gaining new clinical knowledge, they may unknowingly lose their natural and innate knowledge as healers—as those who see the person as a whole; those who can link the mind, heart, body, and spirit of a patient in order to ease suffering and restore wholeness; those who understand the healing value of interpersonal relationships.

By their third year, students are rather suddenly thrown into the realities of clinical medicine in the most intense of settings.

They are now among very ill patients who are often refererred to as “admissions,” not “people.” They are taught and judged by residents and attending physicians who are often overworked physically, overstressed www.sfms.org

emotionally, and sometimes depleted spiritually. They are taught many bad habits, such as getting the H&P done quickly and efficiently, leaving little time to get to

“While gaining new clinical knowledge, [students] may unknowingly lose their natural and innate knowledge as healers—as those who see the person as a whole.” know the person with the illness. They may learn to reduce “social history” to whether the patient is housed, and whether s/he uses drugs/alcohol/cigarettes, rather than asking, “Who is this person, really?”

During this process of third-year training in medical school, there is a rapid replacement of one goal set for another. The preclinical goals of humanism, compassion, understanding, wholeness, and healing have given way to the goals of detachment, efficiency, diagnosing, pathology, and curing. For many students, there does come a distress signal. Many students have said that by the middle or end of their third year, they feel depleted, drained, exhausted, broken, indifferent, jaded, and even devoid of compassion. How does this happen? How does the vibrant, exuberant, eager, promising student, who began medical school with her

Dr. Osmena (650) 873 3338

humanity intact, develop to the point that her inner healer withers, recedes, and fades out during the course of medical training?

Most medical schools do an excellent job of teaching the ideals of healing and becoming healers during the preclinical years; it is clearly evident that what is sorely needed is a way to extend the teaching of the healer to incorporate the clinical years as well. This should be the real task of medical school: to train intellectually capable and knowledgeable clinicians who can understand, diagnose, and treat illness, while concurrently cultivating proficient and skillful healers who understand the wholeness of the person who suffers from the illness, and who can promote healing and wellness by relating to that wholeness.

When the first-year medical student and I closed our interview that day, I asked our fifty-five-year-old gentleman with newly diagnosed metastatic lung cancer if he or his wife had any advice for our students as they begin their medical journey. His wife said, “Don’t forget that your patients are people, just like you and your own family.

You will need to know a lot of medicine, but don’t forget to know your patients as people, too. You could actually heal each other that way. ” Shieva Khayam-Bashi, MD, is Associate Clinical Professor in the Department of Family and Community Medicine at UCSF and at San Francisco General Hospital, and she is Medical Director of the short-term Skilled Nursing Facility at SFGH.

Dear Colleagues: I am Maria Osmena, a pediatrician practicing at my medical clinic in San Bruno, only 20 minutes from San Francisco.

I have an exceptional office sharing opportunity available for an internal medicine physician or any health-care related professional that may be compatible with my office setting. This opportunity is ideal for a physician desiring to go solo or a physician interested in expanding his/her practice to San Mateo County.

In appreciation of your time and effort, I will reward a referral leading to a signed contract with a $500 gift certificate. www.livewellmedicalclinic.com November 2007 San Francisco Medicine 19

The Compleat Physician

Reaching Out to the Person Within A Medical Student Hopes to Heal Patients Rather Than Treat Them Priscilla Park, NP

A

s a new, first-year medical student, most days I feel like a complete novice. Many of my classmates have just finished college and, because they majored in subjects like neurobiology, the introduction to the basic sciences is review for them as opposed to the challenge it is for me. One area, however, where I have the experience that many of my classmates do not is in working with patients. I was a nurse for eight years before going to medical school, and for two of those I worked as a nurse practitioner. Many of those years were spent at San Francisco General Hospital, where I learned a great deal about the realities of life from the patients I worked with. I also saw many doctors and nurses who made incredible differences in their patients’ lives, to the point of having healed them.

One patient I worked with this summer was a woman who had been healed.

Ms. B was a chronically ill woman in her fifties with disabling lung disease. The first day I met her, she practically threw me out of her room because she was so furious with the system in general, and specifically with being transferred to the skilled nursing ward without any advance warning. She felt dehumanized by the public hospital and its ongoing resource-limitation problems.

Over the two weeks she stayed with us, I learned that Ms. B had a primary doctor, Dr. E, who had become her ally and who had healed her. Unfortunately, Dr. E was on a research sabbatical and the patient acutely felt the absence of her doctor in her life.

She carried a picture in her wallet of Dr. E that she had cut out of a newsletter five or ten years before. I asked her to tell me more about what worked in their doctorpatient relationship, and it was clear that her doctor’s patience and kindness to her

had made the difference. Other doctors had prescribed antibiotics or had admitted her to the hospital while Dr. E was away; but Ms. B wasn’t being healed by the antibiotics, she was being healed by the relationship. Ms. B

“Now that I am in medical school, starting off on day one with a class of 147 people who are training to be doctors, I can see that, despite the best efforts of the medical school curriculum to humanize doctors and patients, there are competing messages.” also understood boundaries and remarked that she would never intrude on her doctor’s life outside the doctor-patient relationship.

Nonetheless, she communicated that she really loved her doctor. In the end, Ms. B felt that Dr. E really listened to her and cared about her, an intervention that went miles beyond the inhalers or antibiotics, in Ms. B’s mind and heart.

I’ve worked with many chronically ill patients like Ms. B and often, between their painful symptoms and frustration at dealing with the health care system, they lose hope.

But some of them can also point to someone who made a difference, a healer.

Now that I am in medical school, starting off on day one with a class of 147 people who are training to be doctors, I can see that, despite the best efforts of the medical

20 San Francisco Medicine November 2007

school curriculum to humanize doctors and patients, there are competing messages. We have anatomy lab and cut into cadavers, quickly becoming accustomed to the body as distinct from the person.

Sitting in the classroom learning about blood cells, the lecturer says that sickle cell disease is a substitution in a single amino acid in hemoglobin, and then shows a slide of sickled red blood cells. One amino acid—how can that description communicate the suffering of the young woman with sickle cell disease who came to my skilled nursing unit this summer for rehabilitation after she fell out of her wheelchair and broke her hip? One amino acid, and yet she is disabled and tired and in pain. She will need smart doctors and nurses to care for her, who understand what sickle cell disease is and how to meet her medical needs. But if one of those people also takes the time to look into her eyes and reach out to the living person inside the broken body, her healing will be that much more complete.

What makes a healer? The term healer conjures up historical roles that seem disconnected from modern American life.

Religious healers and shamans who harness divine spiritual powers to cure physical and emotional illnesses by negotiating directly with God on their patient’s behalf come to mind when this term is uttered. How, then, does a modern doctor take on the role of healer? Just as we say in medical school, “Pain is what the patient says it is,” we could probably say, “Healing is what the patient says it is.” We can fill this role as healer by listening to patients, since they know healing when they see it and feel it.

www.sfms.org

The Compleat Physician

Balanced Life Lessons A Student Learns about Balance by Observing the Choices of Her Physician Parents Elizabeth Adams

A

s I face new demands on my time, I increasingly value and respect the concept of balancing, and I appreciate the guidance that my parents have given me in this area. Being the oldest of three daughters to two physician parents, I have learned firsthand that attentive, conscious, and meticulous decision-making is crucial to the art of balancing one’s life. From the beginning of my education, my parents emphasized the importance of developing the “whole person.” My kindergarten teachers advocated to my parents the importance of balancing a child’s intellectual, physical, emotional, and spiritual development.

To this firm foundation, adolescent years added greater demands for socializing and academics. My early twenties now bring considerations of graduate work, medical school, and the eventual prospects of marriage and family life. Add future responsibilities including mortgages, bills, careers, and parenting, and life is not looking as simple as it did in kindergarten. Fortunately, my parents have supported me; and I have grown up surrounded by women who are adept at sculpting their lives to fulfill their multiple responsibilities and find love, compassion, and intellectual stimulation.

My mother is the epitome of such a female role model. A psychiatrist, she has always been busy balancing her personal and career goals, while creating a supportive home environment that fosters ambition.

When I was growing up, my mother made a conscious effort to expose me to the professional possibilities open for women in the twentieth century. By the age of three, I was so accustomed to the presence of talented female doctors in my life that, upon meeting one of my mom’s male colleagues, I expressed my surprise and satisfaction that www.sfms.org

“they are finally letting boys be doctors, too!” My mother encouraged my interest in science and took me to events such as Take Your Daughter to Work Day at the university hospital, both to expose me to career possibilities and to further teach me about her professional life. I now appreciate the substantial impact she had in establishing the foundation for my own professional aspirations.

As I am interested in pursuing a career in medicine, I realize that I must also consider how to balance this desire with my other personal goals, such as wanting to have a family of my own. In this regard, I Elizabeth Adams pictured with her parents, Dr. Carolyn Graice look to my mom and the ex- and Dr. James Adams ample that she has set in leading a balanced because our household has two incomes. life. Through choosing to run her private My father is a cardiologist who works in a psychiatric practice, she has allowed herself group of other cardiologists and surgeons, to be at home after school, take vacation and thus he has had to allocate his time time with her family, and always be there differently than my mother does. He has a for my sisters and me. When selecting her demanding, time-intensive work schedule. specialty, she considered lifestyle factors and My mom recalls my voice from the car seat put limits on her practice, such as not having questioning, as we drove by the hospital, “Is a hospital practice or hospital on-call sched- that where daddy lives?” His different comule. Mastering multitasking tricks, such as mitments and responsibilities inherently listening to CME recordings on her iPod generate a different equation for him to and answering patients’ pressing questions balance. Within their marriage, my parents via cell phone, has allowed her to excel in mutually agree upon and respect their choher many roles. At home she also helped sen division of the responsibilities necessary maintain her life’s balance by employing the to keep a household afloat. necessary help with household chores.

The most difficult life component for My mother reminds me that she is busy physicians to preserve, I have observed, able to structure her practice in such a way Continued on Page 24... november 2007 San Francisco Medicine 21

The Compleat Physician

Learning to Heal by Being Healed A Nurse Receives a Lesson in Patient Care by Becoming a Patient DJ Lucena, RN, ADN

“H

ello, my name is DJ, and I will be your nurse today in the ER/ CCU.” In the sixteen years that I’ve been a nurse, I have said this phrase or something similar at least 10,000 times as I leaned over the rails of beds and gurneys at the beginning of my shift or just after getting a report. In other words, I have always been on the sending end of this message, letting the patient know through the confidence and compassion of my voice and personality that I was going to be the best caregiver that I could be. I never expected to be on the receiving end of such a message, and definitely not during a life-threatening situation.

On April 23, 2007, I presented to my own emergency room with the worst headache I had ever had. It had not gone away in three days of home treatments, and my family had noticed that my speech and balance seemed off. My daughter drove me to the ER and physically dragged me across the waiting room, yelling, “This is DJ and she needs help right now!”

Within twenty-five minutes, the cause of my headache was known to all my caregivers: an aggressive tumor in my right temporal lobe had a ruptured blood vessel, which was causing a midline shift.

In less time than it takes to drink a chai tea, I went from being a provider to being a patient.

Doctor Goradia, neurosurgeon, came to ER to meet me. I can just imagine his first impression because, although he practiced in my hospital, we had not yet met. “Are you a Bollywood doctor?” I asked, as he came into the room dressed nattily in a dark suit with a striped tie.

“How do you know Bollywood?” he asked, probably thinking that my tumor

was invading more than just my optic and olfactory nerves, and that perhaps it was into my frontal lobe personality, too.

“Well, when I am not an ER nurse, I am a professional belly dancer.”

It was during this first examination that my husband and mother really began to grasp how much the tumor had already changed me. As Doctor Goradia conducted a visual exam, it became rapidly apparent to my family that I could not see anything peripherally in my left visual fields. Doctor Goradia now began the informed-consent procedure for the brain surgery, which he scheduled for April 25, in two days, assuming that my bleeding remained stable.

I didn’t hear a lot of what was said, mostly because I was tuning out the information that I didn’t want to hear: based on its position, size, and the fact that it was bleeding, the tumor was most likely a glioblastoma multiforme.

As Dr. Goradia made sure that my husband, parents, children, and friends understood the seriousness of my situation, I began to develop a respect and love for him as a complete healer. He didn’t act at all like I had expected a neurosurgeon to act.

You know the joke: What is the difference between God and a neurosurgeon? God doesn’t think he’s a neurosurgeon!

Dr. Goradia answered our questions with patience and compassion. He explained the use of steroids to decrease the brain swelling and alleviate some of my headache. He carefully instructed the nurses, “We must treat DJ like we would any other patient. Just because she is one of ours, we might miss something if we are not careful.”

Each day when he came to visit with me, he always asked if my husband or other

22 San Francisco Medicine November 2007

family members had any questions, and he was always dressed in a suit. This last fact became the topic of conversation with my husband after each visit. “I wonder why he wears a suit? None of the other doctors do.”

Most of the other surgeons we observed while we were in the ICU wore scrubs.

On Wednesday, April 25, Dr. G did the craniotomy and biopsy that confirmed that the tumor was a GBM. The bleeding was controlled and, if all went well, I could go home on Saturday. “But all the nurses say you don’t discharge on Saturday, because that’s the day that your suit is at the cleaners!” I exclaimed.

But, true to his word, after I spent three more uneventful days in ICU and Oncology, Dr. G came to my room one last time and discharged me himself. My husband asked, “Doc, what is this with you and the suits?”

Dr. G’s answer solidified for us that he was really a complete healer. In a quiet yet strong voice, he said, “I wear a suit because I respect the part of the human body that I work on.”

Then he handed me a copy of the book The Power of Now, my first inspiration on the road to recovery.

The next time I saw him, to get my staples out for radiation therapy, he asked, “Are you up to a hug?” A hug from a neurosurgeon….

My journey toward becoming a complete healer started many years ago, but now as I recuperate and plan my return to the world of medicine that I love, I know that I have changed. Being a patient has been a revelation in communication, compassion, and touch.

For the last nine years, DJ Lucena, RN, ADN, has been a lead nurse in the busy trauma ER at Mercy San Juan Medical Center in Sacramento. www.sfms.org

The Compleat Physician

Radiology Upside Down A New Model of Practice Helps Balance the Life of One Physician Britta Gooding, MD

W

hen I was in training, it seemed there was a stigma associated with teleradiology. “Real” radiologists practiced in academics or traditional private practice groups. My first private practice job out of fellowship, however, had me driving from location to location reading MRIs. I seemed to spend more time driving than reading cases. It was frustrating and inefficient. There was talk of consolidating our centers and performing internal teleradiology, but it never happened. As teleradiology became more mainstream, it seemed common sense to be able to read these cases from anywhere in the world—but how?

Between residency and fellowship, I spent a year in academics, working at a massive public hospital in Auckland, New Zealand. It was an incredible experience. In addition to working really hard and meeting talented Kiwi radiologists, I had the opportunity to travel all over the Southern Hemisphere. I went to Sydney for the Olympics and fell in love with the city. I remember thinking I would jump on the opportunity to work there someday. Australian radiology board certification requires intensive examination in pathology as well as radiology, and I was not up to the task of tackling the Robbins’ tome of pathology again. I had heard of an American group that had just started reading U.S. cases from Sydney and was intrigued, but it seemed risky and premature to join such a fledgling company.

Fast-forward four years, when the allure of a traditional private practice group had waned, and my wanderlust had grown.

I signed on with NightHawk Radiology Services (NRS) and relocated to Sydney.

The business model we use takes advantage of the time difference between the U.S. and Australia. U.S. board-certified radiologists www.sfms.org

are stationed here, reading after-hours cases from across the U.S., because of course when it’s nighttime in the U.S., it’s daytime Down Under. We are alert and wide-awake reading cases while our clients are asleep. Our

“I love being a global citizen and participating in a group that is changing the way medicine is practiced.” team of assistants allocates the cases based on our expertise, and we fax our reports back immediately. This makes for an extremely efficient turn-around of cases.

All of our radiologists are credentialed in multiple states and at each hospital they cover. Overall, NightHawk radiologists read cases for about 24 percent of U.S. hospitals.

Yet despite the scale, I have a rapport with those ER physicians with whom I speak frequently. Our conversations are usually held over the phone, although a number of physicians have visited our Sydney reading center in person.

It’s exciting to be a part of this new technology. The rapid growth in NightHawk technology and the services we provide—not to mention the stellar group of radiologists and radiology assistants that make the wheels turn—make it a dynamic working environment. On any given day, I read cases from Maine to California, from simple renal colic to complex multitrauma.

Most of the cases are emergent, and it feels good to have real-time impact on patients’ lives. I speak to the referring ER physicians or surgeons whenever necessary, and I truly believe we are providing a great service not

only to the patients we diagnose, but also to our referring physicians and the radiology groups that hire us.

Since I joined NightHawk Radiology Services, we have opened reading centers in Zurich, Switzerland; San Francisco, California; and Austin, Texas, where our newest cardiac and 3-D lab is located. The corporate headquarters of the company is in Coeur d’Alene, Idaho. NRS radiologists are able to read from any of these centers.

Some are stationed full-time in Australia or Switzerland, while others wander the globe at their will. Since the opening of the San Francisco office this summer, my plan is to split my time between S.F. and Sydney. The flexibility in lifestyle and the opportunity to live abroad and enjoy foreign culture are the highlights for me.

Having worked with the company for three years now, I have witnessed the integrity of radiology practiced, and I realize that quality medicine can be achieved via telemedicine. I still have access to referring physicians, and I can discuss difficult cases or get additional history or clinical context.

I am able to follow up on interesting cases and access surgical, pathologic, or lab results.

Emergency Radiology fellows from the Brigham and Women’s Hospital in Boston rotate through Sydney, and they help put together our teaching files. We also have an extensive quality-assurance program that ensures radiologist accountability.

Our practice continues to evolve. We have morphed from a handful of radiologists in Australia to more than a hundred scattered across the globe. We now cover not only after-hours emergency preliminary work but also final reads, daytime coverage, cardiac CT angiography (CCTA), and Continued on Page 24...

november 2007 San Francisco Medicine 23

Radiology Upside Down Continued from Page 23... other subspecialty reads. The company offers technological and business solutions to our radiology clients as well. The emphasis has always been to partner with our fellow radiologists rather than compete, with the goal being for us to offer a solution to any radiologic need.

I love being a global citizen and participating in a group that is changing the way medicine is practiced. It is a pleasure working with my radiology colleagues, IT specialists, and QC and QA assistants—all of whom are committed to professional quality and integrity within a nontraditional work environment. It is a challenging and ever-changing practice, and I wouldn’t have it any other way.

Britta Gooding, MD, is the Medical Director for NightHawk Radiology Services.

Balanced Life Lessons Continued from Page 21... is caring for one’s self and incorporating rest into one’s daily life. Perhaps this is due in part to the fact that those who choose to participate in the medical profession are generally driven, compassionate individuals with high self-expectations, who are also very devoted to others. My father is so passionate and dedicated to his family and his patients, and so excited by medical advances, that he exerts himself beyond the scope of what is humanly possible, often at the expense of concern for his own health (he sleeps less than I, a college student, do!). My mother is more conscious of her responsibility to herself, as she deliberately incorporates exercise into her daily routine, chooses to eat healthy foods, and recognizes the importance of down-time. However, she too has an incurring sleep debt, and she regrets that she does not have enough time to socialize and relax with friends. She recognizes that she can’t do everything and has lowered her expectations in some arenas. For example, she has resigned herself to the fact that she will never have the “Pottery Barn” house, and that hiding the miscellaneous clutter in the master bedroom before guests arrive will have to suffice!

Being a successful physician, mother, and clinical professor at the university, my mother inevitably hits points of exhaustion.

She sometimes fantasizes about what life would be like if she were a stay-at-home mom, which she knows is a full-time job.

When she vocalizes this thought, however, I remind her that she would miss the intellectual stimulation and satisfaction that her profession affords her. She helps her patients and loves her career, and I now know that this aspect of her life helps keep the other aspects in balance, too. The satisfaction from intellectual stimulation is a crucial part of her self-care.

I further learned about balancing medical practice with family life in a course called “Becoming a Doctor: Readings from Medical School, Medical Training, Medical Practice,” taught by Dr. Larry Zaroff at Stanford University. Dr. Zaroff taught us about the reality of pursuing a career in medicine. We read literature that opened up a forum for class discussion and examination of medical topics, such as responsibility to a patient, coping with a patient’s death, public perception of doctors, and insight into the various specialties. One of the topics that Dr. Zaroff emphasized most was the difficulty and importance of finding the balance between one’s personal life and a medical practice.

This class corroborated and articulated the principles for successfully pursuing a career in medicine and having a family that I have observed in my parents’ decisions. Dr. Zaroff invited a panel of three physicians to the class to discuss how they each found a balance in their lives. Though they differed in specific decisions and in family situations, they all concurred that a doctor must make sacrifices and must consciously decide how to allocate her time. Ultimately, it is the doctor’s passion for her family, medicine, and other personally important areas that propel her in this challenge. Learning to accept one’s human limitations is one of the more difficult conquests.

My parents have helped me and my sisters practice this skill throughout our educations. Although my parents expect us to work hard in school, they recognize and reinforce the importance of personal development and growth. For example, the night before an organic chemistry exam, I’ll call

24 San Francisco Medicine November 2007

my dad just to hear him tell me that it is OK to get some questions wrong, and that he’ll give me “a nickel for every wrong answer!”

When my peers are studying on Saturday night, I call my mother to hear her encourage me to relax and spend time with friends: “You can’t study all the time! The rest of the world doesn’t study on Saturday night!” Such reminders and support continue to teach me how to balance my life.

I must consciously remind myself that no one is perfect; thus it follows that no one can achieve the “perfect balance.” Yet, as my mom has taught me through example, with forethought and care, coupled with passion and compassion, I can create my own personally acceptable and fulfilling life balance. And my dad reminds me that I will make mistakes but that, in the end, a collection of nickels really pays off!

Elizabeth Adams is a junior at Stanford University, majoring in human biology, with an area of concentration in Neurobehavioral Biology and Its Ethical Applications. She is the daughter of Dr. Carolyn Gracie, Clinical Professor of Psychiatry at UCSF, and Dr. James Adams, Clinical Faculty Member at UCSF. She is premed and is currently recovering from a summer of organic chemistry by spending her fall quarter studying abroad in Australia.

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 Ashley Skabar for more information, (415) 561-0850 extension 240 or askabar@sfms.org. www.sfms.org

Doctors Yadaorao and Vimal Raut

Serving the Community as Physicians

By Beth Skabar

D

r. Yadaorao Raut and his wife, Vimal, both physicians in Umarkhed, India, never stop serving their community. Although they have clinics of their own, they often see patients outside their home, sometimes long after the workday has ended.

“Our specialty is that we do everything,” says Yadaorao.

Umarkhed is a dusty farmer’s town in Maharashtra, India. Most of the townspeople travel by bicycles, motorcycles, and scooters down dirt roads replete with herds of buffalo, goats, and cows. People live very close together, so viruses sweep through Umarkhed much as they do in a kindergarten class. In late September of this year, more than half of the town had conjunctivitis.

During the festival of Ganpathi, when drumbeats echoed through streets filled with song and dance, the Rauts were entertaining guests at their home when the doorbell rang. Yadaorao descended the stairs to find a mother holding her one-year-old son, who had a foreign body lodged in his ear. She had tried to go to another doctor’s practice, but he was not available because of the festival. His assistant gave her an ear probe and told her to seek out Dr. Raut, who never turns a patient away.

Because of the low income of the surrounding villages, there are very limited medical facilities in Umarkhed; there is no emergency ward and the nearest ICU is forty kilometers away on slow-going roads. The government-operated hospital has one wheelchair and no specialists.

There is no anesthesiologist in town, so the only surgeries that are performed regularly are vasectomies and hysterectomies, done with a local www.sfms.org

anesthetic. While the hospital is nearly free (5 rupees for a week’s stay) and the services are affordable for the patients, the facilities and services provided are largely inadequate. So there is a demand for private practices, despite their higher costs.

Yadaorao began his practice in 1974, after borrowing 15,000 rupees ($375) from his father. “Back then, I was charging 3 rupees per patient. I made 9 rupees my first day of work.” Currently, he charges 30 rupees per consultation (.75 USD), which is immediately paid in cash. He provides pro bono services for the 10 percent of his clients who are too impoverished to afford his services.

“I live for the patients,” says Yadaorao. “I don’t want to extract excessive amounts of money from them. I want them to have the minimum debt possible.”

The Rauts’ clinic is modest but effective. After walking through a thin sheet that serves as a door between the waiting room and the examination room, a patient notices a bed and a small table of medical supplies and tools. Of these, the most-used are a flashlight and an otoscope that Yadaorao received fifteen years ago from his uncle, Ram Gawande, a physician in Athens, Ohio. This tool, while common in the U.S., is something special here in rural India. It is his trademark.

“We do the most we can with the least available,” says Yadaorao.

Yadaorao sees a hundred patients a day, on average. He quickly but thoroughly examines each patient, speeding through the long line of clients in the waiting room. There is no paperwork, no files to fill out. He November 2007 San Francisco Medicine 25

Dr. Yadaorao Raut, 65, has been practicing medicine in Umarkhed, India, for thirty-three years. He went to Sholapur Medical College of Sholapur in Maharashtra, India, with an ENT specialization. In 1974, he started his practice after taking a loan from his father for 15,000 rupees ($375). His first day of work, he earned 9 rupees, charging 3 rupees per patient for three patients. Now he charges 30 rupees per patient. He provides pro bono services for 10 percent of his clients.

“I earn lakhs and lakhs of rupees with this tool,” Raut says, regarding his ENT speculum (pictured below). “Nobody else in town has this.” He received his otoscope and auriscope from his uncle, who practices medicine in Ohio.

(Left) Dr. Vimal Raut inspects a patient for glossitis.

(Below) Dr. Vimal Raut, OB-GYN, right, has just informed Joti Kale, center, that she is pregnant. Kale has been married for two months.

(Bottom right) Raut asks that all of his patients return to the clinic after receiving their medications from the nearby pharmacy, so that he can check that the pharmacy gave them the correct medicine and to explain to them how to take it. Raut is afraid that the chemist will either give them the wrong medicine or will overcharge unknowing patients.

gives each patient a few quick minutes to diagnose their problem, writes a prescription, and sends them to the nearby pharmacy. A few minutes later, the patient returns with a bag of medicine, which Yadaorao goes through in detail, to be sure the patient understands how to take the medicine as well as to make sure the pharmacy did not overcharge them or give them counterfeit medicine.

Yadaorao and Vimal have been married since 1973, shortly after completing their educations. While the couple has no biological children of their own, the Rauts adopted their niece and nephew after their parents, Vimal’s brother and his wife, died in a car accident. Their now-grown nephew, Ashish, has two children of his own; along with the daughter of their now-deceased niece, there are three grandchildren living in the Rauts’ household, all dependent on them for love, time, and support.

In addition to the title of physician, Yadaorao also voluntarily holds the titles of Secretary of the Gawande Sitram College, Charter President of the Rotary Club of Umarkhed, and Assistant Governor of Rotary International, District 3030.

“It is my pleasure to serve people,” says Yadaorao. “I work hard for my earnings, and in my leisure time, I work for the community by engaging in social work. I have to do something for society, because society has given me many things. Society gave me this position.”

Beth Skabar, a graduate from the Viscomm School of Design, is a photojournalist currently pursuing documentary work in India.

The Compleat Physician

What Is Left Unsaid A Physician’s Journey to Understanding Kristen Day, MD

W

hen I was first asked to write about the “compleat physician,” I expected to write about how I strive to maintain humanity for both my patient and myself in our work together. Or about how expressing one’s inner artist is integral to maintaining one’s humanity. A few weeks later while on vacation, looking out the window at the beauty of the Tuscan landscape, I knew this essay would become something altogether different. I was in a community hospital in Pescia, Italy, with my severely sprained left ankle in a cast and my right leg in traction for a tibial pilon fracture, comminuted fibular fracture, and complete disruption of my tibiotalar joint. Due to an unfortunate misstep and apparently exceptional gravitational pull, I’d found my way here.

was much clearer and the calls were few and far between. Only once, in significant pain, did I entreat, “Signora, per favore … ”

“Capisco Poco”

“Lina!”

I was in a miniward with three other patients, settling into my bed on the floor. To my right was a woman who’d had a knee arthroplasty, diagonal a Scandinavian tourist who’d fallen and broken an arm. I couldn’t see the woman across from me due to the height of my traction device, but the next morning on rounds I would see her C-spine film as the attending held it up to the light of the window. It was amazing she wasn’t a high quadriplegic. “Lina ... LINA ... LINAAA!!” she called out, increasing in volume and intensity when her calls went unanswered. I would learn later that she was calling for her daughter. For the next two days she would call out for her, despite being visited two to

three times daily. Sometimes the nursing staff would answer, “She’s coming later,” but nonetheless her unanswered calls would get louder and louder.

As I gazed out the window, I was surprised that her calls didn’t seem overly disturbing to me. I realized that I saw it as “normal”—this happens all the time in the hospital. I know this because my patients tell me so. Over the next two days, I would hear calls for Lina, and when those calls went unanswered new calls came for Eduardo, Paolo, Roberta. Ultimately I would hear six different names, presumably all her children.

The calls came any time she was awake and Lina was not present. By the third day, she

28 San Francisco Medicine November 2007

I’d prepared for the trip with some beginner’s Italian language lessons. Of course my hospital circumstances exceeded my expressive ability immensely. Once on the ward I tried using English and Spanish words to get across the message that I had to urinate, to no avail. Finally, I put together what I thought was a pretty good sentence: “Vorrei un toilette.” After a few seconds my nurse asked, “Pee pee?” I nodded, “Si,” and she returned with the bedpan. When I asked her in Italian, “How do you say that?” she told me, “padella,” and helped me with my pronunciation.

But then she told me that I could just say “pee-pee” because it would be easier for me.

I understood that her intention was to make things as easy and understandable as possible for me. Many of the nurses and physicians used the same phrase for non-English speaking patients in the hospital. There was no way for her to know that language and words are very special to me, or that I see the use of specific words in a context as not only clarifying meaning, but also expressing values about the speaker and respect toward her listener.

I understand that for some, the patient’s comfort is primary and using such phrases can attain this. I believe that was what she intended. But because we didn’t have shared words to communicate, she would never see this essential part of me. www.sfms.org

In the next day or two I would mangle the word, often adding extra syllables (padenella, panadella, panella). Halfway through my stay, however, “Vorrei la padella, per piacere” would roll off my tongue.

Understanding Not Understanding I awoke bolt upright and screaming late one night. The initial pain due to the instability of my leg and ankle had returned despite traction. In the midst of my pain and screams, I became intensely aware of the actual vocalizations. There are very distinct sounds that patients make that reflect their region of origin. I’ve witnessed sounds from such places as Central America, Mexico, the Pacific Islands, the Ukraine, Laos, China, Yemen, and Eritrea. From my body came the sounds of these patients, sounds that are not of my culture. The “Aiii” sound, hisses, and tongue clicks were the language I’d learned over the past twenty years as student, resident, and attending. These were the sounds that I meant, and as I made them, I recognized their innate truth. Holding my leg, I used one hand to wave over it as I clicked my tongue and my nurse examined the traction device. In my wave I was telling her, “It hurts so bad, please don’t touch it and make it worse. But please help me all the same.”

My nurse recognized the traction failure and uttered words that I did not comprehend but understood to be, “I know it hurts.

You’ll be OK, but I have to do this. It’ll be OK.” I understood and felt her concern for my pain, but also that she was firm and clear about what had to be done. When she had finished and the pain was calming down, I used the only words I had to communicate what I understood about what had happened: “Grazie signora, grazie.”

I’ve learned over the years from my patients that it can take some time before your call button is answered. I’ve learned from nurses that they’re very busy and can’t drop everything unless it’s urgent. Therefore I thought of using the call button as pulling a number for my place in line. I tried to use it as needs were arising, as opposed to when I was desperate. My pain management was quite decent until the night after my ORIF (open reduction internal fixation). The IV Lixidol (ketorolac), which had worked so www.sfms.org

well when I was in traction, was no longer working. I tried to wait for at least an hour after my dose before calling again. Then it was the ContraMal (tramadol) that was not working. I text-messaged a friend that I might be becoming a “problem patient.”

Later that night, my nurse returned to see how I was doing. She was Eastern European, speaking Italian and I believe Romanian, with very few words in English.

I had English and Spanish, and limited Italian. Then we discovered that we also both spoke limited French. Over the next few minutes I drew her a time curve of my pain levels from 9/10 with the fracture, and 0/10 with the epidural during surgery, showing that I was now wavering between 6/10 and 7/10, and indicating the timing of my latest medications. She listened, asked questions, and watched me draw. Using sentences composed of three to four languages each, we talked. I was worried that the pain would continue to increase; she was worried that she would overdose me. We moved from medicine and pain to home and family, also in multilingual sentences. We stumbled and fumbled, but we both understood that we wanted to understand each other, and that we were trying to connect. Given our limitations, that would have to be enough.

On my last day, she and I would wave and say, “Ciao-ciao,” both of us wanting to be able to say more.

Proclamation “Discharge!”

I had been told to expect discharge on day seven of my stay. Over the weekend, my surgeon was off-duty, but others in his group rounded on me. After chatting about my neighbor and her TKA(Total Knee Arthroplasty), the nurse would give the attending a rundown of my last twenty-four hours.

Two days prior to my expected discharge, the nurse told the attending that I was doing well, using very little pain medication, had been up to the wheelchair, and had had no fevers.

“Do you want to go home?” asks a man I’d never met before, and whose name I don’t know. “Uh, yeah,” I answer, and he proclaims I’m to be discharged today. So I attempt to tell him what I need: PT to teach me to properly transfer to and from a wheelchair, transport to my hotel, copies

of my X-rays, and a brace for my sprained left ankle. He assures me my left ankle is not broken and the pain will subside over the next month. How do I say, “But I have a grade III anterior talofibular sprain and need an ankle air-cast for two to four weeks” in Italian? As he moves on, I decide to trust that these things will happen.

I know this situation and tell my mother, who is there with me, that it happens all the time. How many times have I been the attending on the inpatient team who asks, “Why can’t she go home? Let’s send her home.” When I’ve made the proclamation, I understand that there may be little details to be worked out, but there are “people” who take care of those. I’m not the one to call PT, order copies of the X-rays, arrange transport, and order durable medical equipment. I just sign things, and all this other stuff happens.

So after PT came, and I took a wheelchair stroll down the hall, I was not that surprised to see that my ambulance transport team was there. I was still in my gown, had my IV in place, no X-rays, no ankle brace, and the transport team was telling me, “Andiamo!” I think, “You’ve got to be kidding” and, simultaneously, “This happens, it’s normal.” I’ve seen patients respond in one of two ways over the years. One is indignation and fear, while the other is composed and calculating. The latter tends to get more cooperation and patience from the team, so I made a list of the vital things that needed to happen and told my nurse. I reverted to the former response when she told me that I couldn’t get my X-rays because the Radiology Department was closed for the day. I insisted on seeing my doctor, and my nurse became upset and left the room muttering in frustration. While we ultimately worked out a solution, I tried to communicate to her that it was not personal, that I knew she was doing all she could for me. I knew she was working hard and had a lot of other things to attend to. I don’t think I was able to communicate these things to her, and more was left unsaid.

A special thanks to Dr. Bruno De Paola, the physicians, and especially the nurses and staff of the Orthopedics and Traumatology Ward of the Regional Hospital in Pescia, Italy.

November 2007 San Francisco Medicine 29

The Compleat Physician

Creative Expressions Physician Artwork Mardi Horowitz, MD, and Michael Rabow, MD

Painting

By Mardi Horowitz, MD Mardi Horowitz, MD, is a Psychiatrist and a Professor of Psychiatry at the University of California, San Francisco, where he has initiated and directed clinical research programs, including the Psychotherapy Evaluation and Study Center, Center for the Study of Neuroses, and the Program on Conscious and Unconscious Mental Processes. Dr. Horowitz is also a prominent artist, painting in oil, water colors, and pastels. Before going to medical 30 San Francisco Medicine November 2007

school, he studied at the San Francisco School of Fine Arts, now the San Francisco Art Institute, where he later taught. During his residency, Dr. Horowitz helped his finances by selling paintings. He says, “My art is integrated into my psychiatric practice in that, by having drawn and painted people, I am more deeply observant and can see the ‘music’ in the person.” www.sfms.org

His eyes were those of a dead person, fixed and dilated.

There was no life in his lungs.

His blood was dark and cold.

He was so wasted and thin it seemed hard to imagine he ever looked alive.

I felt obligated to explain.

I tried to be reassuring.

“Your roommate just passed away.

He was very sick.”

“I know.

I heard,” he said with more strength And understanding than I expected.

“I didn’t think he was going to make it through the night.

He was having a real hard time breathing.”

By eight AM he had gotten more drugs and electrical shocks, more bagged breaths than a dead person needs.

This man seemed strangely at peace, Ready to fight again today And try to leave this hospital.

Death was in the room.

We called off our code.

He was pronounced.

Behind the Curtain

By Michael W. Rabow, MD At seven forty-five the morning after my last night of call (my last night of residency!) a code was called.

A code was called during the last fifteen minutes I was ever to be responsible for running to a code.

In a small, dark hospital room, a youngish man lay motionless.

Large, dark purple Kaposi’s blotches Spread across the frail, wasted chest I was crushing with CPR. He lay motionless except for the rhythmic bouncing I created as I weighed down on him with the heels of my hands.

As twenty people, there for the futile excitement, filed out, I realized we had been crammed into just half of a room.

A faded yellow curtain spread across the middle of his semiprivate room.

I stepped carefully by the discarded drugs and gloves, the code cart, the end of the deathbed, and slowly approached the curtain.

Peering around, I found another youngish man, motionless in bed, sheets held tightly under his chin, eyes wide open, not blinking and staring right at me.

I wanted to say, “Everything is going to be alright” but it was not bound to be.

Instead I offered, “Take care” and held his eyes in mine for an extra moment to make sure he knew all I meant to say.

He nodded and slowly closed his eyes for the first time.

“Take care,” I repeated gently and pulled the curtain closed behind me.

Dr. Rabow is an Associate Professor of Clinical Medicine at UCSF. He directs symptom management services at the UCSF Comprehensive Cancer Center and also has an active primary care practice at UCSF Mount Zion.

San Francisco Medicine Seeks Your Creativity!

If you would like to submit your artwork for inclusion in our “Physician Artwork” section, please contact Amanda Denz, the managing editor, for more information. She can be reached at (415) 561-0850 extension 261, or adenz@sfms.org. We welcome drawings, paintings, photographs, sculptures, poems, short stories, or any other medium we can either print or include an image of.

www.sfms.org

November 2007 San Francisco Medicine 31

In Memoriam Nancy Thomson, MD, and Steve Heilig, MPH

William A. Atchley, MD

W

illiam A. Atchley, MD, a promiHe was an honorary fellow of the Amerinent physician, medical ethicist, can Association for the Advancement of Sciand environmentalist, died of ence and a fellow of the American College of prostate cancer at his home in Tiburon on Physicians and the Royal Society of Medicine, August 9, 2007. He was 85. and a member of the Gold-Headed Cane He was born on May 17, 1922, in New Society at UCSF, among many other honors.

York City, and spent most of his childhood In his clinical work and teaching, he early in Englewood, New Jersey. He attended recognized the value of good palliative care Harvard and Harvard Medical School and and was a pioneering champion of hospice completed an internship at Columbia Presprograms, helping establish some of the first byterian Medical School, where his father, programs in Marin and beyond. Long after Dana Atchley, MD, was a prominent medical his retirement from clinical practice, he was professor. While still in school, he was “the still serving on the ethics committee at Marin first human to be treated for staphylococcus General Hospital, and still visiting the bedwith penicillin and survive”—an experience sides of friends and, when asked, others who that confirmed his commitment to medical Dr. Atchley’s original SFMS application, 1955 were dealing with serious illness. All found his science. presence and expertise a blessing.

Moving to Marin in 1952, he was told by a senior UCSF phyUpon his retirement in 1991, he turned his focus to the envisician that “‘anywhere is good except for Sausalito—that’s where ronment, saying (according to his wife Annelies) that “the world those bohemians live.’ So of course I went straight there, and found is now my patient.” He served as Chairman of the Environmental out to my delight that it was true.” Atchley later moved to a small Forum of Marin (EFM) and of the Romberg Tiburon Center for house in Tiburon, where he lived the rest of his life.

Environmental Studies, which gives an annual award in his name.

Having a longtime love of basic science—he once shared a “He informed a lot of people on global warming,” says Dr. L. Martin laboratory with DNA-discoverer Dr. James Watson—Atchley Griffin, cofounder of the EFM. “He took it on as a cause and gave began work at UCSF as one of the first physician researchers at wonderful talks for different groups.” the Cancer Research Institute and soon became the head of the As one of San Francisco’s most beloved and respected physiunit. But before long, he decided that “I liked people too much to cians, he was a valued mentor to many. Despite his background and just do research,” and he turned to teaching and clinical practice. education and all his lofty positions, he was entirely unpretentious.

Although he deemed himself “rusty” in some areas, he was the first “Dr. Bill” was widely known to people of all walks of life in San resident at the then-new Moffitt Hospital and the Chief Resident Francisco, Marin, and beyond. He was also a longtime sailor who in 1954–55. His internal medicine practice at 350 Parnassus soon once sailed a small craft across the Atlantic. became a highly desired one, with some of San Francisco’s most “Medicine is not, or should not be, looked at in a vacuum,” he prominent citizens vying for patient slots. He was chief of the UCSF once warned. “Economics is a big part of it, like it or not, and we medical staff and chair of the ethics committee at both UCSF are in a new era where we have to be very careful how we deal with and the San Francisco Medical Society, where he was elected an financial issues and incentives in medicine. Likewise, the world of honorary member in recognition of his devoted and distinguished ecology impacts our health, and if we don’t consider the broader clinical teaching and advocacy contributions. In 1988 he founded natural world, and the future, we will find that much of our amazing the International Bioethics Institute, which sponsored international science and medicine will be for naught.” conferences on the role of bioethics committees in hospitals and He is survived by his wife of twenty-seven years, Annelies; his health care settings. He also established a leading professional sons Mark Atchley of Mill Valley and Bill Atchley, Jr., of Tahoe City; journal, the Cambridge Quarterly of Healthcare Ethics, and consulted stepson Karl Vischer of San Rafael; and two grandchildren. with hospitals and other institutions around the world.

32 San Francisco Medicine November 2007

www.sfms.org

In Memoriam Nancy Thomson, MD

Sidney Edward Foster, MD

S

idney Edward Foster, MD, passed away on August 17, 2007, in Greenbrae, California, after a long and distinguished career in medicine. He was 86 years old. He was born in Manitoba, Canada, on May 27, 1921, one of three bright children, to Ben and Clara Foster. His father was an attorney who was very politically involved at one time, managing the campaign of Canadian prime minister MacKenzie King.

Dr. Foster came to California Dr. Foster, circa 2000 and attended Stanford University, graduating in 1944, and then graduated from Stanford Medical School in 1945. He was a war-time intern at Mt. Zion Hospital in San Francisco and practiced radiology at 490 Post Street with his partners, Ray Cummins, MD, and Paul Gutman, MD, for more than forty years before retiring in 1995. He was also on the staff of Marshal Hale Memorial Hospital.

Sid was truly a Renaissance man. He loved his patients, taking histories and examining each patient referred to him, charging less than many doctors but doing more for the money. He did, however, invest the money he made wisely and was therefore highly respected in business circles.

Sid has his own thoughts on what makes a “compleat physician.” In an article commemorating the 130th anniversary of the San Francisco Medical Society, he wrote, “… the joy that the practice of medicine brings; the fulfillment achieved by being a physician, and the satisfaction of achieving one’s objective in the betterment of the public’s health, are the true reasons one becomes a physician.… In this age of emphasis on the economics of medicine, we tend to lose sight of why we became physicians. It is up to all of us to bring the focus back to what sets the practice of medicine apart from other trades. Because of your status as a physician, it is essential that you become a role model for the community, for your patients, and for the general public.”

Sid believed that working in organized medicine was critical for maintaining the integrity of the profession. Like his father before him, politics became his passion. He held multiple posts in organized medicine and had a role in many of the medical reforms we www.sfms.org

appreciate today through CALPAC (California Political Action Committee), where he served for many years on various committees and where he was Director and Chairman from 1987 to 1989. He was honored by the CMA as a recipient of the James C. MacLaggan political action award.

He became a member of the San Francisco Medical Society, the CMA, and the AMA in 1949.

Among many other committee appointments, he served as a director of the San Francisco Medical Society from 1972 to 1977. He was a delegate to the CMA from 1976 to 1983, an alternate delegate from 1960 to 1964 and again from 1974 to 1975, and an AMA alternate delegate and delegate from 1978 to 1983. He received the Speaker’s Recognition Award from the CMA House of Delegates in 1995, and he was awarded the CMA’s Young Physicians Award as leader and mentor to young doctors.

He was a member of the National Democratic Finance Counsel, a State Insurance Commissioner for the State of California, and a Health Insurance Commissioner for San Francisco.

In 2000, the San Francisco Medical Society named Sid Foster an honorary member, an accolade given only to a handful of truly accomplished physicians.

Among Sid’s many personal interests were his family, traveling, fishing, snowmobiling, boating, and horticulture. He lost the sight of one eye in a golfing accident, challenging his stereo-optic abilities, but with his intelligence he learned to compensate.

His wife of fifty-four years, Sandra Lee Foster, predeceased him. He leaves two sons, Brian and Craig, one a dental technician and former acrobat, the other a salesman; and three grandchildren, Amanda, Robin, and Kevin. Sid truly enjoyed filling the role of “Poppy,” as his grandchildren called him.

He had a sunny personality, and it was hard to imagine him being depressed. He was passionate about medicine, and he was one of those people who was unable to think an unkind thought about anyone. He was passionate about life and at one time had a bleeding ulcer to prove it.

As they say in show business, his will be a hard act to follow.

November 2007 San Francisco Medicine 33

34 San Francisco Medicine November 2007

www.sfms.org

Brian Lewis, MD, and Steve Heilig, MPH

Setting Policy Amid the Smoke CMA’s Annual House of Delegates Meeting

S

outhern California was still covered in soot and smoke from October’s disastrous fires when the California Medical Association’s House of Delegates gathered for its annual meeting in Anaheim.

The HOD is the CMA’s policy-making body, composed of elected physician delegates from each county and many specialty and other groups. With almost 500 participants, it seems an unwieldy group, but the process is reasonably democratic and efficient, given the broad array of issues addressed.

Your SFMS delegation of eighteen is relatively small, but San Francisco has historically had a disproportionate impact in terms of leadership and adopted policies. This year was no exception. We submitted eleven resolutions, most of which were adopted as CMA policy and moved on to the AMA for consideration as national policy. This is no academic or symbolic exercise. CMA policy, as set by the HOD, guides the group’s legislative, educational, and advocacy activities—and this year the CMA had a 100 percent advocacy-success rate in Sacramento, despite leadership changes and financial challenges.

Some of our successful policy resolutions (listing original authors) include: • Parental consent for STI vaccines: CMA will seek legal changes so that parental consent is not required for twelve- to seventeen-year-olds who request vaccination for sexually transmitted diseases (Charles Wibbelsman, MD, adolescent medicine; and Shannon Udovic-Constant, pediatrics).

• FDA drug safety: CMA endorsed new provisions for better review of medications both new and already approved and will ask the AMA to advocate these changes (Gordon Fung, MD, cardiology; and George Susens, MD, internist).

• Conflict of interest on FDA panels: CMA and the AMA will urge adoption of policy excluding FDA consultants with any conflict of interest from voting on any relevant matter (George Susens, MD, internist).

• Blood products liability: CMA will ask AMA to help make blood centers recognized as health care providers, giving blood products the same liability protection that hospitals and physicians have (Nora Hirschler, MD, president of the Blood Centers of the Pacific).

• Opposing “abstinence-only” sex education: CMA opposes all federal, state, and international mandates for abstinence-only sexual education, in line with conclusive evidence that these approaches are ineffective (E. Ann Myers, MD, internist).

• Modern chemicals: CMA will support scientifically based approaches to approval and marketing of chemicals with known or suspected impacts on human health (Lucy Crain, MD, pediatrician; and Robert Gould, MD, from Santa Clara).

• Cancer and environmental chemicals: CMA recognizes growing www.sfms.org

scientific evidence linking industrial chemi2007 SFMS DELEGATES cals and cancer and will advocate for better TO THE CMA relevant education and policy (Brian Lewis, MD, oncologist).

Lucy Crain • Resuscitation of marginally-viable Stephen Follansbee newborns: CMA will advocate for broader George Fouras education and adherence to established Steve Fugaro guidelines for treatment decisions for seGordon Fung verely compromised newborns (Lucy Crain, Thomas Lee MD, and Shannon Udovic-Constant, MD, Brian Lewis (Chair) pediatricians).

Dexter Louie • Pharmaceutical grants and gifts: CMA Judith Mates supports disclosure and public reporting of Rita Melkonian all gifts, honoraria, travel, etc., provided to Ann Myers physicians, other than samples for patients Rachel Shu and meals provided as part of CME programs Peter Sullivan (George Susens).

George Susens Some of the debate was civil but heated John Umekubo on these and other proposals. An SFMS-supShannon Udovic-Constant ported resolution by member Robert Liner, H. Hugh Vincent MD, urging neutrality on the contentious issue of physician-assisted dying received support but did not succeed. Our proposal to OTHER SAN FRANCISCO stop the AMA from selling MD prescribing REPRESENTATIVES: data to pharmaceutical companies generated controversy and did not pass as written, but Robert Margolin should improve the AMA’s approach. CMA William Andereck will advocate for a new “physician diversion” Eric Tabas program to replace the recently defunded Gary Chan one. A more fair reimbursement increase for Charles Wibbelsman vaccines will be pursued. All this and much Suketu Sangvhi more was discussed.

Thomas Addison The meeting is demanding, and we Brad Cohn are always impressed with the collegiality of Andrew Calman our group. Like any new delegate, this year’s Roger Eng rookie Shannon Udovic-Constant, MD, was immersed in a whirlwind of data, proposals, politics, and new faces (she did wonderful work in addressing difficult issues, mentored by veterans such as former delegation chair Hugh Vincent, MD). This is one time of the year that physicians of all specialties, ages, and types of practice meet and are reminded, and remind one another by example, of much of what is best about medicine as a career and calling.

November 2007 San Francisco Medicine 35

hospital news Chinese

Joseph Woo, MD

Chinese Hospital is proud to be the first city hospital to be fully on board with the San Francisco Hep B Free initiative. This campaign has the ambitious goal of turning San Francisco into the first city in the nation to be free of hepatitis B cases. One in ten Asian/Pacific Islanders has chronic hepatitis B contracted at birth or early in childhood. The disease is responsible for 80 percent of all liver cancers, and without proper care, one in four people with chronic hep B will die from liver cancer or liver failure.

The goals of this program are to create provider and public awareness about the importance of this issue, and to make routine the testing and vaccinating of Asians. This unprecedented two-year-long campaign will screen, vaccinate, and treat all San Francisco Asian and Pacific Islander (API) residents for hepatitis B (HBV) by providing convenient testing opportunities that are free or low-cost at partnering health facilities and events.

The S.F. Hep B Free campaign puts San Francisco at the forefront of America in fighting chronic hepatitis. It will be the largest, most intensive health care campaign for Asian and Pacific Islanders in the U.S. This initiative has received national attention and is being looked to as a model by the California legislature. The city’s Board of Supervisors and Health Commission have passed unanimous resolutions supporting S.F. Hep B Free, and Chinese Hospital is excited to be a part of this ambitious and worthwhile project.

Kaiser

Robert Mithun, MD

The Permanente Medical Group recognizes that demands on physicians are complex and unrelenting. In response to these pressures, we developed a new physician orientation program that addresses many of the concerns and benefits of working in a large and varied group practice. During a two-day orientation, we focus on many aspects of our culture, including safety and emergency preparedness, human resources issues, and wellness/well-being, where we encourage physicians to take part in activities and programs that enhance their experience. In addition, we offer an ongoing series to our physicians called the SFO Permanente Practice.

These workshops include such topics as patient safety, volunteerism/caring for our community, and physician wellness. The workshops are an opportunity for all the medical staff to extend the scope of their work and become a part of an active and thriving culture. We believe that by being a part of the larger whole within the group practice, our physicians will have a more gratifying and stimulating professional experience. In order to help new physicians navigate, we instituted a mentoring program in which a more seasoned provider helps acculturate a new physician by meeting with him or her individually on a regular basis. We feel that a balanced practice includes, for many physicians, involvement in the larger workings of the group, beyond taking care of their patients full-time.

The diversity of work encourages longevity in the group and enables physicians to broaden the scope of their formal training and career goals. The new electronic medical records system, known as KP HealthConnect, allows physicians to complete their documentation of clinic visits remotely, after getting home in time for an evening with family or friends. We feel that for our physicians to truly achieve the highest level of professional satisfaction, their needs as both practitioners and individuals outside of work must be addressed. By offering them opportunities to take part in programs and activities that help them achieve this balance, we are creating a new environment for physicians.

36 San Francisco Medicine November 2007

Saint Francis

Wade Aubrey, MD

Over the years, many members of the medical staff at Saint Francis have used their medical skills to volunteer in various ways, such as serving on the voluntary clinical faculty at UCSF, traveling to Central America and elsewhere to repair cleft palates and remove cataracts, and working in free clinics in San Francisco to treat homeless patients in need. For the last several years, Saint Francis physicians have also provided medical care at sporting events, including USGA and PGA Tour golf tournaments at the Olympic Club and Harding Park, as well as staffing the medical clinic at AT&T Park for the San Francisco Giants. At this year’s U.S. Amateur Championship in August, the Center for Sports Medicine at Saint Francis provided personnel and supplies to staff first aid and emergency medical operations, in conjunction with the S.F. Fire Department. Volunteer Saint Francis physicians at the event included Victor Prieto, Richard Naidus, Phil Piccinini, Ron Valmassy, Richard Blake, Thomas Leach, and Wade Aubry.

Saint Francis has a longstanding tradition of promoting camaraderie among its medical staff. To this end, we recently revived a popular medical staff event known as Saint Francis Day, held this year on October 10 at the Olympic Club. The daylong event encouraged medical staff to unwind with sports events including golf, tennis, bicycling, and walking, followed by a reception and sports award ceremony. Medical staff members and their spouses got a chance to relax and interact outside the hospital setting, and a good time was had by all.

The day concluded with a dinner dance honoring medical staff members for their years of service. Medallions, plus a photo montage of our physicians through the years, were presented to honor those with twenty-five to fifty-five years with Saint Francis.

www.sfms.org

hospital news St. Luke’s

Jerome Franz, MD

The Compleat Physician theme prompts me to write about some of the people I admire.

The closest to Izaak Walton is Ed Kersh, once and always my teacher, who loves the mountain streams and lakes, where he practices catch and release of beautiful trout and renews the energy that helped him establish our outstanding cardiovascular service at St. Luke’s.

The rest are not fishermen, but physicians one can emulate. Marc Snyder, at St. Luke’s for twenty-five years and head of the emergency department for most of that time, plays saxophone in his own quartet, Dr. Jazz, which provides music for the annual Auxiliary holiday benefit. He has been a leader in the medical executive committee and was on the hospital board for nine years.

Kenneth Barnes, cofounder of BayWest Medical Group and on staff for twenty-nine years, has always been active in community affairs. He chairs the African-American Health Disparities Committee and the Ethics Committee. He trained in acupuncture and has promoted other modes of complementary medicine at St. Luke’s. David Atkin, avid surfer, came from the beaches to the Mission to serve the orthopedic needs of our disadvantaged population. Twice a year he takes a team to a third-world country to help people with even fewer resources under Operation Rainbow. Bonita Palmer, sister of the Order of St. Francis, which mandates service to the poor, is a leader in the Episcopal community in San Francisco, active with the Bay Area Organizing Committee, and has practiced Reiki and other healing arts at St. Luke’s since 1993.

There are more, but I will finish with Tony Franzi, former Chief of Staff at St. Luke’s, who passed away August 10 at age 92. He founded the group I practice with. He took care of everything for his patients, many of whom were Italian immigrants. He delivered babies, took out gallbladders and appendices, and knew everyone in the families he served. He was a duck hunter and a fisherman. www.sfms.org

St. Mary’s

UCSF

Richard Podolin, MD

Ronald Miller, MD

Since the earliest days of medicine, physicians have been asked to assume multiple roles: practitioner, scholar, and investigator. In recent years, our hats have multiplied explosively.

Depending on the setting of our practices, we may also need to be patient advocates, insurance specialists, negotiators, computer gurus, teachers, community activists, organizational leaders, small-business owners, entrepreneurs … and the list goes on. The roles of a physician have become so myriad that it no longer makes sense to ask if one is a “complete physician”—always an elusive goal. Instead, as physicians, we should ask ourselves two questions: Are we dedicated, and are we fulfilled?

Dedication implies service to a higher goal, and it is different from hardworking. In medicine, dedication implies investing one’s self in the alleviation of another’s suffering, and that investment need not be measured in hours spent at work. Dedication is manifested in our struggle to advance or keep abreast of medical knowledge, in the empathy and compassion with which we greet our patients, in the intellectual rigor we bring to their evaluation and treatment, and in the consciousness and humility with which we accept our own fallibility.

Fulfillment is more personal and more idiosyncratic. Many physicians of my generation were taught that fulfillment would follow from dedication alone. The truth was always more complicated, but the fundamental principle was in fact correct. Fulfillment does not come from attempting to fill our own lives but from reaching outward, to our patients, our families, and our communities. I believe that the best we can do for the young physicians who come to train with us is to share our commitment, our engagement, and our belief in our mission. Then we must trust them to integrate these experiences into careers and lives that are both personally satisfying and rich with meaning.

The UCSF Pain Management Center and UCSF Pain Center for Advanced Research and Education have been honored jointly by the American Pain Society among just six centers of excellence nationwide—the only designation made west of the Mississippi. The honor recognizes UCSF for outstanding clinical pain care offered to patients and efforts in creating pain management education programs for busy practitioners. More than ninety health care organizations competed for the honor. Pamela Pierce Palmer, MD, PhD, is director of the two UCSF centers. UCSF pain management practitioners treat more than 10,000 patients annually.

New hospital rankings by U.S. News &World Report list UCSF Children’s Hospital as one of the top twenty pediatric facilities in the country. Ranked at number sixteen, the hospital is home to a team of medical specialists who currently are leading more than ninety studies aimed at improving childhood health, according to Sam Hawgood, MD, Chair of the Department of Pediatrics. UCSF is currently planning a new children’s hospital that will be part of an integrated complex—also dedicated to women and cancer patients—to be constructed within the next decade at the UCSF Mission Bay campus.

Talmadge E. King, Jr., MD, an internationally respected expert in lung disorders, is the Constance B. Wofsy Distinguished Professor at UCSF, and is the new Chair of the Department of Medicine at the UCSF School of Medicine.

Since joining UCSF in 1996, he has served as Vice Chair of the department and Chief of Medical Services at the UCSF-affiliated SFGH. He is recognized for improving the quality of clinical care and research at SFGH and for strongly advocating for the public hospital. As Chair, he will guide the research, education, and patient care activities of more than 500 full-time faculty, along with volunteer clinical faculty, residents, and fellows.

November 2007 San Francisco Medicine 37

hospital news Veterans

Diana Nicoll, MD, PhD, MPA

Classified Ads Medical Consultants

One of San Francisco V.A. Medical Center’s “compleat physicians” is Bree Johnston, MD, MPH, who effectively balances career, family, professional commitments, and extracurricular activities.

Dr. Johnston is a staff physician at the V.A. and Associate Professor of Clinical Medicine/ Program Director of the UCSF Geriatric Fellowship. She is Chair of the Society of General Internal Medicine’s Geriatrics Interest Group and the principal investigator for a study focusing on integrating geriatric content into all levels of medical education. She is also active with the Physicians for a National Health Program, an organization advocating for a universal, comprehensive single-payer, national health program.

On the personal front, she is mother to a nine-year-old son, owner of two dogs, and an avid hiker, bird watcher, bike rider, and gardener. Her husband is a writer who works from home. “My husband shares so much of our home and family work that it gives me a lot of opportunity to have balance in my life,” she explains. “I can only hope that he feels his life is balanced, too.”

Dr. Johnston enjoys her career at the V.A. because of the team-oriented environment and the importance V.A. places on the care of the elderly. “V.A. recognizes the importance of the care of older people, so it’s a very attractive place to work. I also believe that because we are a system of care, we’re a lot more nimble in being able to respond to the changing needs of patients.”

Being involved in many different activities just comes naturally to Dr. Johnston. “I’m passionate about all of these things, and it’s really hard to give any one of them up,” she says.

“When I think about them individually, I think that’s what I want to focus my energies on—but I really love them all.”

Physicians needed to review musculoskeletal specialties and internal medicine cases as Medical Consultant Contractors for the Social Security Administration.

Requirements: Valid doctorate license in medicine anywhere in U.S>; board certified or eligible in relevant specialty. Current/Recent clinical experience and/or disability case review.

Contract Info: Part time. Electronic review and decision making of disability cases.

No claimant contact. Work performed in Richmond, California. Rate cap of $77.20 per hour. Minimum 12 and Maximum 38 hours per week. Work begins January 2008.

To review a synopsis of the requirement from the Federal Procurement Website, go to www.fedbizopps.gov . Click on “FedBizOpps Vendors,” then “Find Business Opportunities,” Under “Full Text Search” enter solicitation number SSA-RFQ-09-08-0001 (without the dashes). Click on “Start Search,” After solicitation and download 3 documents: cover letter, SF1449 and solicitation. Carefully read all instructions regarding requirements to be submitted with your proposal no later than 11/16/07.

For further information contact Phyllis Scaduto at 510-970-8310.

Office Space

38 San Francisco Medicine November 2007

Space to rent part-time downtown San Francisco. (415)706-1920.

Welcome New Members!

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

Caroline Capitano, DO Peter Curran, MD John Horning, MD David Hwang, MD Sirish Maddali, MD Susan Philip, MD Referred by Jeff Klausner, MD James Reid, MD Felicia Saltzberg Hall, MD Referred by Vail Reese, MD David Warren, MD Referred by Stephen Follansbee, MD HOUSE OFFICER/RESIDENT David M. Carlson, MD

STUDENTS—UCSF Stephanie Garcia Alexis Jannicelli David Kaufman Fortune Meriwether

Kyle Paredes Karla Solheim Mark Sorenson

www.sfms.org

SFMS Night at the Symphony

SFMS Member Stephen Walsh, MD, plays the piano while other members mingle at the pre-concert reception

T

he San Francisco Medical Society Night at the Symphony was a tremendous success. This popular annual event affords members an opportunity for relaxation, cultural stimulation, and fellowship.

This year’s event took place on Thursday, October 18, and was well attended, including new members Dr. David Warren and Dr. Peter Curran, as well as several SFMS Directors and officers. At the preconcert reception, while enjoying wine and hors d’oeuvres from La Mediterranee, members were treated to an impromptu “tickling of the ivories” by Steve Walsh, MD. The exciting programme featured music by Beethoven, Liszt, and Prokofiev.

The next SFMS social outing will be something new and different: a Night at the Nutcracker on Saturday, December 29, which will feature a lively reception with sweet treats and a performance of the San Francisco Ballet’s ravishing new production of the beloved holiday ballet.

For more information about social and professional events for members, visit the website at www. sfms.org or contact Therese Porter in the Membership Department at (415) 561-0850, at extension 268, or at tporter@sfms.org.

For Upcoming Events Check Our Website

www.SFMS.org/events www.sfms.org

November 2007 San Francisco Medicine 39

Dental Open Enrollment Effective Date: January 1, 2008!

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

New for 2008! Rollover Benefit: This new feature allows for the unused portion of the maximum benefit amount from one year to roll over and be used in the following calendar year.

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

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

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

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

Remember, the open enrollment period is available once per year. To be eligible for coverage applications must be received during the special open enrollment period that ends on December 31, 2007.

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

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