September 2006

VOL.79 NO.6 SEPTEMBER 2006 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

psychiatry at the edges of life

CONTENTS SAN FRANCISCO MEDICINE September 2006 Volume 79, Number 6 Psychiatry at the Edges of Life FEATURE ARTICLES

MONTHLY COLUMNS

10 Developmental Care: A Hands-on Experience in a High-Tech NICU Chris Retajczyk, MD

4 On Your Behalf 5 Upcoming SFMS Events

12 Trauma and the Inner Life of Babies Alicia F. Lieberman, MD

7 President’s Message Gordon Fung, MD, MPH

14 Speaking to Children in the Language of Play Patricia Speier, MD

9 Editorial Mike Denney, MD, PhD

17 Double Snapshot: A Single Trauma Captured Twice in Life Lenore Terr, MD 18 Narrative Medicine David Elkin, MD, and Khenu Singh, MD

32 Hospital News 34 Classified Ads 35 In Memoriam Nancy Thomson, MD

20 Psychological Development in Late Life Allan B. Chinen, MD 22 Dying in California: The Principles and Practices of End-of-Life Care Michael Rabow, MD

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24 Dealing with Death: Medical Students Reveal Their First Impressions Manisha Bahl

Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org

25 Dealing with Death: Physicians Share Their Experiences Katie Kelly

Subscriptions: $45 per year; $5 per issue Advertising information is available on our

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website, www.sfms.org, or can be sent upon request.

23 Some Thoughts about My Death Dick York

Printing: Sundance Press

26 In My Opinion: To Be or Not To Be—Is That the Right Question?

Harvey Max Chochinov, MD, PhD 27 In My Opinion: Physician Assistance-in-Dying Robert Liner, MD 30 Film Review: The Bridge Erica Goode, MD 23 Book Review: The Girls Who Went Away Nancy Thomson, MD www.sfms.org

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How Does This Issue of SFM Look?

We are trying a few new things at San Francisco Medicine Magazine and would appreciate your feedback. If you have any comments on the look, style, or printing quality of this issue, please let us know! All comments should be directed to Amanda Denz, our managing editor, by calling (415) 561-0850 extension 261 or sending an e-mail to adenz@sfms.org. september 2006 San Francisco Medicine

ON YOUR BEHALF

September 2006 Volume 79, Number 6

A sampling of activities and actions of interest to SFMS members Editor Mike Denney, MD, PhD Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artists Ian Thomas, Cliff Sullivan, Raul Vargas Editorial Board Chairman Mike Denney Obituarist Nancy Thomson Stephen Askin

Gretchen Gooding Judith Mates

Wade Aubry

Samuel Kao

Toni Brayer

Thomas Lee

Corey Maas

Arthur Lyons

Ricki Pollycove

Jordan Shlain Leonard Shlain

Jerome Fishgold Rita Melkonian

David Smith

Alan Greenwald Kathleen Unger

Leo van der Reis

Erica Goode

Kenneth Maybury Stephen Walsh

SFMS Officers President Gordon L. Fung President-Elect Stephen E. Follansbee Secretary Charles J. Wibbelsman Treasurer Stephen H. Fugaro Editor Mike Denney Immediate Past President Alan Greenwald SFMS Executive Staff Executive Director Mary Lou Licwinko, JD, MHSA Director of Public Health & Education Steve L. Heilig, MPH Director of Administration Posi Lyon Director of Membership Therese Porter Board of Directors Mei-Ling E. Fong, MD

John W. Pierce, MD

Thomas H. Lee, MD

Daniel M. Raybin, MD

Carolyn D. Mar, MD

Michael H. Siu, MD

Rodman S. Rogers, MD

Richard L. Caplin, MD

John B. Sikorski, MD

Lucy S. Crain, MD

Peter W. Sullivan, MD

Jane M. Hightower, MD

John I. Umekubo, MD

Brian J. Lewis, MD

Gary L. Chan, MD

Michael Rokeach, MD

George A. Fouras, MD

Jordan Shlain, MD

Jeffrey Newman, MD

Alan M. Teitelbaum, MD

Thomas J. Peitz, MD CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate Judith L. Mates, AMA’s Women Physicians Congress Governing Committee

Notes from the Membership Department

Banning ER Billing

Governor Arnold Schwarzenegger issued an executive order in August directing the Department of Managed Health Care Member Events (DMHC) to limit the right of a physician The Membership Mixer on August to bill the patient for the remainder of the 24 was a fun and well attended success! bill when a health plan does not pay their New and established members enjoyed a charges. This discussion focuses specifically chance to meet and mingle in a congenial on billing by noncontracted physicians in environment with lots of great food, wine, emergency room settings—where neither and music. the patient nor the physician has any The next membership event on the choice. horizon is the SFMS Night at the San FranWhile the governor’s order did not tell cisco Symphony. Mark your calendars for the department how to accomplish this, Thursday, November 30. Enjoy a preconcert the order attacked the future viability of reception with hors d’ouevres and beverages physician practices, while doing nothing to and a vibrant program of Rachmaninoff solve the real underlying issue of for-profit and Tchaikovsky conducted by Vladimir HMOs refusing to pay fairly for emergency Ashkenazy. Orchestra seats are $77.00, 1st care provided to their enrollees. Patients tier are $67.00. For more information, or do not want or expect to be billed because to order tickets, contact Therese Porter in their insurance companies don’t pay reasonthe Membership Department at (415) 561- able charges for covered services. However, 0850, extension 268 or tporter@sfms.org. limiting ER billing without also addressing The Membership Department, and the underlying issues would reward for-profit the physician members of the Membership HMOs for refusing to pay for their insureds’ Committee, are actively exploring future emergency health care, giving them a free events and services to benefit SFMS mem- hand to pay noncontracted physicians as bers. The next several months are sure to little as possible and eliminating any incenbe exciting! As always, member input and tive for the plans to contract with physicians suggestions are appreciated. and capitated medical groups at fair rates.

The DMHC has now responded by filIt’s YOUR Society! ing proposed regulations that would prevent The San Francisco Medical Society physicians from billing for services rendered, is continually looking for ways to make modify the Gould criteria, and set up a dismembership more meaningful and valuable. pute resolution program. The regulations are Your feedback and participation are appreci- posted on the DMHC website for review: ated. Feel free to contact Therese Porter, http://wpso.dmhc.ca.gov/regulations/#1.

Director of Membership, at (415) 561-0850 The period for public commentary on the extension 268 or tporter@sfms.org with proposed regulations is open until October questions, comments, and suggestions.

2, 2006. Please see the above mentioned website for details.

Are You Receiving Action News?

The CMA is opposed to the proposed If you do not receive Action News, regulations and the CMA legal counsel is our monthly fax/e-mail newsletter, please prepared to fight the proposed regulations contact the Medical Society at (415) 561- through the regulatory process and sue if the 0850 to be sure your contact information regulations are adopted as proposed. is up-to-date.

CMA is also developing a grassroots Governor Issues Executive Order campaign and will be working with county

San Francisco Medicine september 2006

www.sfms.org

medical societies to find physicians for a speakers’ bureau (which could involve media interviews, speaking to community groups or writing letters to the editor). Contact Susan Bassett at (916) 444-5532 or sbassett@cmanet.org to volunteer.

The CMA would like to find a solution that will take the patient out of the middle and require health plans to pay fully for ER care. For more information, see www. calphys.org.

Blue Cross Continues to Spend Less than 80% of Premiums on Patient Care CMA released its thirteenth annual Knox-Keene Health Plan Expenditures Report this month, detailing the financial status of California’s HMOs. This year’s report shows that for the fifth year running, Blue Cross of California has spent less than 80% of premium dollars on patient care. Just 78.9% of its revenue went to patient care in fiscal year 2004-2005, with 21% going to profits and administration.

“Vital patient care is being shortchanged by for-profit HMOs that send everincreasing portions of premiums to Wall Street instead of spending it on patients,” says CMA President Michael Sexton, MD “If a substantial part of these profits were kept in the health care system, it would help make Californians healthier, stabilize the endangered emergency care system, and ensure that all patients get access to the care they expect and deserve.”

State law requires, under the KnoxKeene Act, that no more than 15% of insurance company revenues go to administrative costs, including marketing. When the act became law in 1975, the intent was to require insurers to spend 85% of premium directly on medical care. Because the vast majority of health plans at the time were nonprofit and it was expected that the nonprofit model would prevail, the law did not include language regarding profits. For-profit health plans have since interpreted this to mean that profits are an expense that can come from the 85% intended for patient care. In an irony that reflects the industry view of health care, insurance companies universally refer to what they spend on patient care as “medical loss” and they call the percentage “the medical loss ratio.”

CMA this year sponsored a bill that would have barred health plans from spending more than 15% of premium dollars combined for profit and administration.

Although the bill (SB 1591) died, the issue has considerable support in the Legislature and CMA will continue to pursue such legislation.

A change in the law would provide an enormous benefit to patients and the health care system. Blue Cross and Aetna alone collected $12 billion in premiums from patients. If just these two immensely profitable insurance companies were required to spend another 6% on health care, an additional $720 million would be available for patient care in California.

In addition to Blue Cross, several other plans do not meet the 85% threshold. Aetna Health Care, for instance, spent only 78.7% of its premium dollars on patient care. Blue Cross insures more than 4.5 million Californians; Aetna fewer than 300,000. Many health plans do spend at least 85 percent of premium on patient care. Kaiser Foundation Health Plan scored the highest of the major plans, spending 93% of its funds on patients.

Molina Medical Center/American Family Care, also noteworthy, spent 88.4% of its funds on patient care, a 5% increase from the previous year.

Contract Problems with PacifiCare and United Healthcare There have been a number of calls from physician members regarding PacifiCare/ United Healthcare contracts. The areas of concern range from contract negotiations and fee schedules to concerns about contract terminations and inappropriate notifications to patients informing them that their physician has not signed a contract. Given the magnitude of issues raised

by PacifiCare/United Healthcare’s aggressive practices, CMA has pulled together a “PacifiCare/United Healthcare Survival Kit.” It can be found on the group’s website, www.cmanet.org.

If any SFMS members are experiencing issues with PacifiCare/United Healthcare, they should contact CMA’s Center for Economic Services at (916) 551-2037.

Upcoming Events October 13, 2006 CME Program: Environmental Medicine and Health UCSF Laurel Heights Auditorium, 9am-5pm For more information contact Steve Heilig, heilig@sfms.org or (415) 561-0850 extension 270.

October 25, 2006 Beyond Zero Tolerance: New Directions in Drug Education and School Discipline Fort Mason Conference Center in San Francisco, CA 8AM - 4PM Landmark Building A Co-sponsored by the Drug Policy Alliance, San Francisco Medical Society, Office of the Mayor, City and County of San Francisco with Mayor Gavin Newsom providing opening remarks, San Francisco Department of Public Health. For more information call (916) 608-8686. www.sfms.org

January 28-30, 2007 UCSF-CHE Summit on Environmental Challenges to Reproductive Health and Fertility Mission Bay Conference Center, UCSF, San Francsico This summit will provide overviews by leading researchers of science and environmental contaminant impacts on reproductive health and fertility, and will also explore: translation of this research to clinical care and medical training, as well as policy; federal regulatory agency/research institute environmental reproductive health priorities; reproductive health patient advocate and community health concerns, including the needs of underserved communities; and the formation of partnerships for effective collaborative agendas and action.

Contact Mary Wade for more information, (415) 476-2563 or wadem@ obgyn.ucsf.edu.

september 2006 San Francisco Medicine

Share your voice.

When we speak as one, patients win.

Doctors from all specialties need to unite more than ever before. Why? Because when we do, America’s patients benefit. Our role is to give you and those you treat a voice that will not be ignored. From stopping Medicare physician payment cuts to increasing access to care, we work together on behalf of patients. To renew or join the AMA, call the San Francisco Medical Society at (415) 561-0850.

Helping doctors help patients.

president’s Message Gordon Fung, MD, MPH

Learning Something New

T

he theme for this month’s San Francisco Medicine is “Psychiatry at the Edges of Life.” Since I know little about this subject, this is a tremendous opportunity for me to learn something new. As I sat in the editorial board meeting to develop this edition, I was struck at how facile the board members were with this topic, and I reflected upon my own clinical practice that mainly addressed patients within the extremes of life—and occasionally approaching the extremes of life. As I left the meeting I felt very fortunate to be a practicing physician, because I’ve long felt that among the greatest joys in the practice of medicine are the learning opportunities that are stimulating and, at times, challenging. When a new development occurs outside our own specialty, we have the opportunity to expand our minds about the ever-growing field of medicine. No matter what the topic, learning and application are keys to a successful, satisfying practice in medicine.

While in the first year of medical school, we spent a lot of time memorizing normal metabolic pathways, anatomy, physiology, and clinical skills such as talking to and examining patients. This was followed by a year of delving into the organ blocks to learn the pathological processes, and next came two rigorous years of clinical

www.sfms.org

clerkships and elective work. The purpose of medical school was not to provide us with all the information that we would need for the rest of our medical careers but to provide us with a foundation of knowledge from which to build and, most importantly, instill in us a sense of inquiry and excitement about constant learning, discovery, and innovation. This last statement is the current focus of UCSF School of Medicine—to create a culture of inquiry, discovery, and innovation at every level of medical education, from the student to the advanced clinical and research fellow. I believe that this was the goal of the faculty way back when I went to medical school, but it wasn’t as well articulated, and every faculty member approached the goal differently.

As a practicing physician, I am eager to learn about this issue’s topic, since many of my patients are moving toward the edges of life. As I learn more about the psychology involved, I believe that I can be more helpful to my patients as a referral source. As a clinical faculty member at UCSF, I’m equally eager to learn more so that I can share new knowledge with the medical students, residents, and fellows in training, so that we can all be of greater assistance to our patients. Enjoy learning.

september 2006 San Francisco Medicine

‘‘A former employee is suing me for wrongful termination. Does my insurance cover that?”

It does if you have

Employment Practices Liability Insurance.

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• The median compensatory award in EPLI cases is $218,000.

• 67% of all employment cases that litigate result in a judgment for the plaintiff.

• 10% of awards in cases involving discrimination and wrongful termination are in excess of $1,000,000.

• Six out of ten employers have faced employee lawsuits within the last five years.

Employment related suits usually involve one or more of the following: discrimination, sexual harassment, wrongful termination or workplace torts. The purpose of the SFMS program is to provide members with the needed tools and protection generally missing from other insurance policies.

SFMS’s claims made program provides members with significant benefits: • Web based training for members, office managers and employees to help minimize exposure to employment practices lawsuits.

• Access to a legal information hotline staffed by employment practices attorneys.

• Review of employee handbooks and employment applications.

• Economically priced Employment Practices Liability Insurance** that provides for defense costs and losses an insured becomes legally obligated to pay as a result of a covered claim.

• Choice of policy limits of $250,000, $500,000 or $1,000,000.

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DEPARTMENT TITLE HERE Editorial Mike Denney, MD, PhD

Golden Apples and Golden Halls

I

n Norse mythology, Idunn is the divine goddess of springtime and rebirth, and guardian of magic golden apples that can prevent aging and guarantee perpetual youth. Ironically, Idunn is married to Bragi, an old man with a long white beard, who is god of poetry and welcomes deceased heroes to an afterlife in the golden halls of Valhalla. It seems nigh impossible to resist imagining that Idunn and Bragi, with their marriage of the opposites of youth and old age, might somehow find a place in this issue of San Francisco Medicine, with its theme “Psychiatry at the Edges of Life.”

Psychiatry was derived not from the edges of life but from the middle of life—actually, from mostly middle-aged women who were thought to be suffering from an ailment called hysteria. In 1842, more than fifty years after the animal magnetism of Mesmer had been discredited by a commission of the French Academy of Sciences, the Scottish physician James Braid, impressed with the healing qualities of this phenomenon, renamed it hypnotism. This mysterious mind-body dynamic gained respectability when it was studied and applied by the famous neurologist Charcot at Salpêtrière Hospital in Paris, where, in the late nineteenth century, thousands of women were hospitalized with symptoms of hypnotic poseur and a diagnosis of hysteria.

In 1885, a young Viennese neurologist named Sigmund Freud arrived in Paris, studied for a year under Charcot, systematized the psychosomatic aspects of hysteria, thereby derived the theory of the unconscious, and went on to publish Interpretation of Dreams in 1900, thus beginning the age of dynamic psychiatry.

Perhaps because of Freud’s emphasis upon early development, the special field of child psychiatry soon emerged with the work of his daughter Anna Freud. It was refined by Melanie Klein, who elucidated the importance of the mother-child dyad in early infancy in what she called object relations. The interest in the special emotional needs of children continued to grow, and by 1953 the American Academy of Child and Adolescent Psychiatry was formed to promote diagnosis, research, and treatment.

Psychiatry of the elderly was less prompt in its development.

Lydia Sicher, a student of Freud’s contemporary Alfred Adler, spoke morbidly of the individual’s revolt against growing old, describing it as the “panic of the closing door,” and she likened psychological www.sfms.org

aging to the shell shock and battle fatigue of soldiers. Carl Jung was the first to include the elderly positively, with the concept of lifetime maturation or “individuation,” the last task of which was to spiritually reconcile oneself with aging and death. The field of geriatric psychiatry gained impetus in 1950, when Erik Erikson described eight stages of life, the last of which was characterized by a struggle in old age between integrity and despair, which could be resolved by wisdom and strength of character. The American Association of Geriatric Psychiatry was founded in 1978.

Wondering where our Norse divinities Idunn and Bragi might find their place in this psychiatry at the edges of life, we might recall that the seventeenth-century empiricist philosopher John Locke postulated that at birth our minds are a tabula rasa, an empty slate, and then they develop with experience. As modern empiricists, we might scientifically paraphrase Locke by saying that we are born with a neocortex containing roughly twenty billion neurons, and that each of these neurons can make as many as a thousand connections, thereby forming twenty trillion combinations; and that some of these links are in recurrent loops, so that an inestimable zillions of cognitive patterns may develop. For the minds of adults, we might invent a term such as tabula plena, or full slate, and then recognize that in old age many of the neuronal connections made during a lifetime are, in fact, deteriorating—and will disappear upon death.

But Idunn and Bragi offer us much more than cognitive links of neurons. Though they represent opposites, they are, after all, divinely married and thereby form a union of Spring and Autumn, youth and old age, birth and death. And from somewhere within this mysterious union of opposites, transcending the linear science of complex neuronal networks, there spontaneously emerges the inexplicable experience of consciousness and the capacity to imagine. Yes, Idunn and Bragi offer to our theme of psychiatry at the edges of life much more than cognitive science. They offer poetry, metaphor, and a sense of soul—from the golden apples of youth to the golden halls of Valhalla.

september 2006 San Francisco Medicine

Psychiatry at the Edges of life

Developmental Care A Hands-on Experience in a High-Technology NICU Chris Retajczyk, MD

I

n the last decade, improvements in caring for babies born weeks or even months before the due date have led preterm infant mortality rates to fall significantly. While Very Low Birth Weight (VLBW) infants’ mortality rates through respiratory failure have been reduced, the incidence of brain damage sustained during the vital early weeks of these infants has remained about the same.

If a baby weighing less than 3.3 pounds (1,500 grams) at birth survives his first year, he still has a 5 to 10% chance of contracting cerebral palsy, and a 10 to 25% risk of suffering significant cognitive deficits.

The majority of VLBW children are not severely handicapped, but many have significant developmental or behavioral problems that prevent them from achieving as well as their peers. Fewer than half of VLBW children perform within the expected range in school, and all are at risk of lagging behind their fellow students in every domain of learning, including word decoding, reading, comprehension, arithmetic, and written work. Moreover, there is growing evidence of impairment among VLBW children in other domains of psychological or neurological development, including the ability to interact socially and to form friendships, and there are also indications that these children are more prone to attention deficit hyperactivity disorder, or ADHD. The cumulative effect of all these problems is that VLBW children are 3 to 10 times more likely than the average nonVLBW child to require special help during their primary education.

In order for VLBW children to not just survive but succeed in life, we must pay closer attention to the role that early environment plays, especially the environ-

ment of the NICU (neonatal intensive care unit). Several physical factors consistently correlate to mortality: gestational age, birth weight, gender, premature rupture of membranes, maternal sepsis, and white matter (brain) injury.

Environmental factors impact neurodevelopmental outcome as well. Other studies have focused on family educational and economic conditions. However, the role of the early practices and environment in the NICU deserves greater attention.

they are subjected to after birth. Although some of this stimulation is necessary to the baby’s survival—needles, tubes, lights, and sounds are a normal part of life in a hospital—much can be done to support these babies and help them to better cope with their environment.

The nurses in the NICU are specially trained in reading the behavioral cues of VLBW infants and are therefore adept at customizing a plan of care for each baby. Each individualized plan is designed to provide an environment that supports the baby while his or her brain is still developing, encourages active involvement of the parents in the baby’s care, promotes the comfort of the infant, and provides strategies for the infant to successfully integrate his or her responses to environmental stimuli.

Developmental Care in the NICU includes a wide variety of practices designed to decrease the stress on premature babies, including the following: Kangaroo Care, the practice of placing the baby on a parent’s bare chest with the baby’s head turned to hear the parent’s heartbeat, has been proven to reduce infant mortality. Providing the space and quiet for Kangaroo Care promotes parental bonding and can make a big difference in the lives of the babies as well as the lives of the parents.

Swaddling is an ancient practice that has a respected place in the modern NICU. Caregivers use special bedding (or rolled-up

“Very Low Birth Weight (VLBW) children are 3 to 10 times more likely than the average non-VLBW child to require special help during their primary education.”

Putting the Family at the Center Developmental Care, also known as Family-Centered Care, is used in NICUs across the country to reduce the stress of the NICU experience on premature, or VLBW, babies. Developmental care is one of the most important tools in the NICU to make the baby’s stay the best it can be. Hospitals that practice developmental care have seen their babies bottle-feed sooner, gain weight more quickly, and be discharged sooner.

Developmental care seeks to decrease environmental stressors and support parents’ understanding of their infants’ behavior, in order to facilitate the parents-infant relationship during the hospital admission and after discharge.

The brains of babies born early are very immature and underdeveloped when compared to babies born at term, which is after more than thirty-seven weeks’ gestation. Because of this, VLBW infants are ill-equipped to handle the battery of external stimulation

10 San Francisco Medicine september 2006

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receiving blankets) to position the baby as he would have been in the womb: knees curled up to the chest, feet confined, and arms wrapped close to the face. The more contained the baby is, the lower his stress level becomes. NICU staff can be directed to wrap the baby snugly when doing weight checks or moving the baby across the nursery. This keeps the baby feeling safe and secure, even outside his crib.

Lighting and Noise Levels should be kept low. Unnecessarily bright lights in the NICU are implicated as a cause of Retinopathy of Prematurity, or ROP. If bright lights are necessary for the staff, a dark piece of cloth can be placed over the baby’s eyes to prevent ROP damage.

Parental Involvement in all aspects of their child’s NICU stay is extremely important. The more the parent is able to do for the child in the NICU, the more they will feel comfortable doing when the child goes home with them. NICU staff should be encouraged to involve the parents in developing an individual care plan and in holding, diapering, and feeding their baby.

Because VLBW infants differ greatly from term infants in their responses to stimuli, the educational needs of their parents are also unique. Parents need to be taught how to handle their babies in a manner that is comforting to the infant.

Interpreting a baby’s responses to handling and/or stimulation can be tricky for even the most experienced parents. NICU parents, with the help of their baby’s nurses, tend to learn very quickly the likes and dislikes of their particular baby. Parents should be encouraged to contribute to and participate in their baby’s care whenever possible.

Touch­—an expanding body of research has documented the short-term advantages of gentle touch and massage for healthy term infants and some growing and medically stable VLBW infants. The practice of massage techniques has now been extended to very small, fragile newborns and has prompted the utilization of new personnel in NICUs whose job it is to provide massage therapy for newborns.

Massage can elicit a wide range of sensory perceptions in the recipient. These sensations are among the earliest to develop www.sfms.org

during the baby’s time in the womb and ultimately provide stimulation, organization, communication, and emotional exchange.

Touch provides the foundation for complex and intimate bonding between the infant and caregiver, providing the infant with a beginning interpretation of the world and the relationships on which he or she will come to rely for survival. Even to full-term infants, touch is essential in establishing a nurturing, protective attachment relationship between the primary caregiver and the infant, which in turn establishes the foundation for learning, emotion regulation, and social interactions. The benefits to VLBW babies could be equally profound.

This does not mean that massage should be performed on every baby. No two babies are exactly the same. Some love to be held, others become agitated at a touch. Some are stressed out by the noise in the NICU, others relish it. That is why an Individual Care Plan should be created for each baby and placed at each bedside to warn visitors, family members, and medical staff of a baby’s particular stressors.

But Does It Really Work?

A number of recommendations for changes in the NICU environment have already been made at several hospitals. The most common and easiest to achieve are to reduce noise levels and limit exposure to bright light. Such recommendations, plus additional guidelines for care in posture, physical handling of the infant, and interaction with the parent while in the NICU, have been incorporated in programs such as the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP).

The long-term positive impact of developmental care on a VLBW child is not yet well documented. A recent systematic review from the Cochrane Review Group concluded that Developmental Care demonstrates some benefit with respect to growth and behavioral outcome, decreased respiratory support, and length and cost of hospitalization. Another study, from the Department of Pediatrics at Stanford University School of Medicine, found that VLBW infants who received individualized treatment plans incorporating the tenets of

developmental care laid out above required less time on a ventilator and stayed for a shorter time in the hospital. Moreover, the babies receiving developmental care showed favorable effects weeks after their return home. More trials that incorporate shortand long-term evaluation are needed before a cause-and-effect relationship can be firmly established between developmental care and improved long-term development.

The Future of Developmental Care Neonatal healthcare professionals and neurobehavioral specialists in the United States and Europe have published a range of studies about developmental care. Unfortunately, there is no systematic review in NICUs about practices and policies regarding developmental care practices. To further complicate things, there are poor scientific links between researchers from different disciplines—neonatologists, psychologists, neurodevelopmental specialists, nurses, and other allied professionals—studying early developmental care.

It is clear that developmental care has the potential to dramatically change the lives of VLBW babies everywhere. The challenge will be successfully implementing these techniques in an arena of high technology medicine.

Dr. Chris Retajczyk is a neonatologist with the San Francisco Neonatology Medical Group at California Pacific Medical Center.

He is also the Founder and Medical Director of Pediatric Independent Contractors (www. pedicontractors.com), a hospitalist consulting group based in Northern California.

september 2006 San Francisco Medicine 11

Psychiatry at the Edges of life

Trauma and the Inner Life of Babies A Prelude to Adult Mental Health Disorders Alicia F. Lieberman, PhD

tarting at birth, babies seek out human connections. From the first hours after they are born, they discriminate and respond differentially to a variety of stimuli, preferring human signals and familiar sights, smells, and sounds. Newborns turn their heads preferentially toward their mother’s smell, respond to voices, and gaze longer at human faces than at abstract objects. These cognitive abilities are soon imbued with feeling. Before they are ready to crawl, infants are capable of differentiating among different emotions, including sadness, happiness, and anger, and can match tone of voice with the appropriate facial expression. In the course of development, babies and young children use their integrated cognitive and emotional perceptions to develop hypotheses about how the world works and how it will treat them, and to guide their responses in order to maximize a sense of safety and well-being.

Just as there are basic motivations to love and learn that operate from early infancy, there are also typical anxieties that all children manifest from the first year of life. These early anxieties emerge within a predictable timetable. Fear of loss, expressed in separation anxiety, begins to be increasingly noticeable at about eight months of age, gains intensity between twelve and eighteen months, and starts to decline as the toddler learns that people and objects continue to exist when out of sight and that the beloved parent will return after an absence. The prevailing questions organizing the child’s inner world at this time are: “Will I measure up to the expectations of those I love? Does my mom still love me when she punishes me? Will my dad ever play with me again?”

Another normative developmental

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anxiety, fear of body damage, overlaps in time with the fear of losing love and is manifested. Finally, anxieties about one’s inherent goodness and the fear of being “bad,” which start taking an existential immediacy when the child is about four years old, indicate that the child is internalizing a social conscience and beginning to understand the rudiments of morality, as shown in shame, guilt, and self-blame about real or perceived infractions. These fears become exacerbated when the child experiences stress or trauma, compounding the emotional impact of the external event.

Traumatized young children suffer a shattering of their developmentally based expectation that their attachment figure will protect them from pain and damage. Such a shattering occurs regardless of the nature of the trauma—whether it consists of violence perpetrated by the parents themselves (as in the cases of physical abuse, sexual abuse, and domestic violence) or whether it is the product of impersonal forces such as car accidents, near drowning, intrusive medical procedures, natural disasters, or other sources of overwhelming fear and pain that exacerbate the primordial anxieties of inner collapse, abandonment, loss of love, fear of body damage, and moral anxiety. In this sense, the experience of trauma is paradigmatic of psychopathological processes that are triggered by the convergence of emotionally taxing external events with internal preoccupations.

12 San Francisco Medicine september 2006

A key factor in predicting the longterm impact of traumatic events and the child’s prognosis for recovery is the nature of the child’s attachments. Children’s perception of their parents’ efforts to protect them—the building block of a healthy, secure attachment—is pivotal in countering the traumatized child’s self-blame and loss of trust and in restoring developmental progress. When a child feels alone with the terror generated by traumatic events, he or she is much more likely to suffer from long-term mental health repercussions. Primary care physicians, pediatricians, and other health care providers can provide immeasurable help to their young patients if they are aware of the emotional cost of traumatic events, which may last long after the child has healed physically, and if they help the parents understand the child’s need for their empathy and support as essential aids in recovery.

The manifestations of traumatic stress in young children can be organized in three major symptom clusters: reexperiencing the trauma, avoidance of reminders of the trauma, and hyperarousal. These symptom clusters resemble the DSM-IV diagnosis of Posttraumatic Stress Disorder in older children and adults, but they are expressed in age-specific behaviors. Reexperiencing trauma in the first five years of life is manifested in posttraumatic play, recurrent recollections of the event outside of play, nightmares, distress in response to reminders of the trauma, and episodes with

“Just as there are basic motivations to love and learn that operate from early infancy, there are also typical anxieties that all children manifest from the first year of life.”

www.sfms.org

objective features of a flashback or dissociation, such as unintentional reenactments of the event.

Avoidance is manifested through affective numbing, social withdrawal, and constriction of affect, loss of previously acquired skills, and decrease and constriction of play. Increased arousal is manifested in night terrors, difficulty falling asleep, repeated night waking, attention difficulties and decreased concentration, hypervigilance to the environment, and exaggerated startle response. In addition, young children frequently show new symptoms following exposure to a traumatic event, including aggression, separation anxiety, self-defeating or provocative behavior, somatic problems, and new fears.

To some caregivers and parents, children who engage in these behaviors are frequently perceived as manipulative or spoiled, or as having behavior problems.

Adults tend to believe that young children are too immature to remember a traumatic event or to understand its meaning. This misperception, which originates in the wish to think of infancy as a time that is free from conflict and pain, is bolstered by the undeveloped linguistic skills of this developmental stage. Preverbal children are unable to articulate what they saw, heard, or felt; verbal toddlers and preschoolers may have the rudimentary language to speak about the trauma but may be reluctant to do so unless explicitly asked, for fear of reexperiencing the terror of the event or upsetting the parents, or because they blame themselves for what happened. The inner life of the child may become bifurcated by the knowledge that something unspeakable happened and that she cannot turn to the parents for understanding and help. The child’s symptoms become a secret language by which the child expresses what cannot be spoken about, but the symptoms often have the paradoxical result of alienating the parent, who misconstrues the child’s behavior as signs of willfulness, disaffection, or worse.

Although a single traumatic event, such as a car accident, a dog bite, or a near drowning can have serious effects on a child’s well-being, the most devastating effects of trauma stem from repeated, chronic www.sfms.org

situations that involve the child’s parents as the perpetrators, such as domestic violence and child abuse. The more repeated and pervasive the trauma exposure, particularly when such experiences begin early in life, the more likely it is that the child will show generalized and chronic disturbances in cognitive, social, and emotional functioning and that these disturbances will become entrenched, eventually taking the form of severe adult psychopathology. This is particularly the case when, in addition to the specific impact of the traumatic event, the child is negatively affected by the compounded impact of additional risk factors, such as poverty, community violence, and lack of access to resources such as safe neighborhoods, adequate housing, and educational opportunities. Children from ethnic and racial minority backgrounds are particularly affected due to the convergence and cumulative effects of these multiple sources of hardship.

The UCSF Child Trauma Research Project at San Francisco General Hospital is a program dedicated to developing, testing, and disseminating approaches to the treatment of children exposed to violence and other stressors. The program has developed and established the efficacy of Child-Parent Psychotherapy, a relationship-based treatment in which the child and the parent are treated together in order to improve the quality of their relationship following a traumatic experience. The treatment focuses on helping the child articulate his experience of the traumatic event and in enabling the parent to understand and respond supportively to the child’s experience. The child and parent are encouraged to play, draw, tell stories, read books, and talk about feelings with the goal of making sense of the trauma.

Randomized controlled studies have shown that this relationship-based treatment is more effective than standard individual treatment in reducing symptoms of posttraumatic stress disorder and other symptoms in both the child and the mother, and that the improvement persists six months after the termination of treatment.

“Making sense of the trauma” involves several layers of meaning. First and foremost, such a process must result in restoring the child’s developmental momentum and

repairing the child’s trust in the parent’s capacity to provide protection. In the case of a single traumatic event that occurs in the context of a well-functioning family life and loving and supportive parent-child relationships, treatment is geared at correcting the child’s misperceptions, enabling the parent to understand the meaning of the child’s symptoms as expressions of anxiety and fear, and fostering parent-child activities and interactions that assuage the child’s fears and encourage a return to ageappropriate pursuits. In more severe cases, where the mother and/or father may be agents of the trauma through involvement in domestic violence or child maltreatment, the treatment aims at creating a safe family framework by transforming the parent’s violent lifestyle and unpredictable, harsh, and punitive caregiving practices.

Physicians and mental health providers can play a pivotal role in helping to protect children from the destructive impact of trauma. The first step is to recognize the possible traumatic origins of children’s behavioral problems and to ask the parents about the possible occurrence of violence or other trauma in the child’s life. The second step is to adopt an attitude of support and hope toward parents who disclose violence and trauma. The third step is to provide appropriate referrals to mental health providers and other sources of support. The reward for such actions is the knowledge that one may have prevented life-long suffering and offered hope for a better future for the child and the family.

Alicia F. Lieberman, PhD, is Professor of Medical Psychology and Vice Chair for Academic Affairs in the Department of Psychiatry, UCSF. She is Director of Child Trauma Research Project at SFGH; Director of the Early Trauma Treatment Network; President Elect of Zero to Three: National Center for Infants, Toddlers, and Families; and author and coauthor of several books, including The Emotional Life of the Toddler (The Free Press, 1993).

A trilingual, tricultural Jewish Latina, she is particularly interested in culturally competent early mental health treatment and training.

september 2006 San Francisco Medicine 13

Psychiatry at the Edges of life

Speaking to Children in the Language of Play Patricia L. Speier, MD

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often wonder what comes to mind when parents think about child therapy. Most parents I deal with generally ask, “How are you going to help my child?” After hearing my response, they often have difficulty understanding my methods. I usually don’t talk much to children during therapy, or act like a super-parent who is going to instruct them. I usually don’t medicate them either, though there are times when that will be a part of their treatment. What I do with children is play.

There is no better way, I believe, to really understand their dynamics and behavior. If I can deeply understand a child’s conflicts from his or her point of view, both conscious and unconscious, then I can help that child feel understood and work through his or her dilemmas.

From a Jungian viewpoint, children’s play stems from the natural tendency of the Self to learn, grow, and heal. Play can lose its capacity to heal, however, if it becomes restricted or blocked. The first goal of Jungian-oriented child therapy is to see where a child’s play may be blocked and to help reopen the channel to the Self that allows for fuller expression. To do this, the therapist becomes a part of the play but tries not to intrude on the developing story. Judgments and directions are suspended. Characters in the story can be killed, children are allowed to cheat at games or create games with monstrously unfair rules. The therapist initially talks about the play only to reflect on it or clarify it, so both patient and therapist

understand better what is happening. Later, elements of the play can be interpreted in the metaphor of the play.

Kids will often try to get me, as their therapist, to reveal my judgments by demanding that I make up part of the play.

They may also try to make the play so unbearable that most adults would have an urge to make the story more palatable or moralistic than the story the child fears to fully tell. By resisting that impulse, I can help children deal with their fear of revealing the dark side of the conflicts they are experiencing—their hurt, anger at themselves or others, envy, hopelessness—whatever painful feelings are troubling or motivating them. Children usually play out variations of a story over and over. As they do this, my interest in the story, occasional comments about their play, and careful participation help them to develop the play further. They can deepen the personalities of the various characters we play, try out different viewpoints or possibilities, and slowly resolve their conflicts in a more reflective, constructive way. When they develop the characters in their story, they are developing aspects of their own personalities. When they resolve a conflict in the play, they can use an increased understanding of the displaced issue to help resolve issues they face in their external world.

One patient I worked with, Alice, was six years old when she first presented to me

“From a Jungian viewpoint, children’s play stems from the natural tendency of the Self to learn, grow, and heal. Play can lose its capacity to heal, however, if it becomes restricted or blocked.”

14 San Francisco Medicine september 2006

because she frequently complained to her mother, over a six-month period, that she wanted to die. Finally, she wrote, “I love you but I want to kill myself” on a birthday card she gave to her mother. That got her parents’ attention. I admired the intelligence and intensity she had demonstrated in doing this, and I was very concerned about how desperate she revealed herself to be with that card. I took what she was saying very seriously, but I also felt she had qualities that would help her function very well in therapy, which could help her work through some of the pain she was experiencing.

When she first saw me, Alice looked at me with disdain and told me, “I don’t want to talk to you and I won’t say why I’m here.”

I agreed that she didn’t have to but told her that there were some toys in my office with which she could play. She told me that my office was “boring,” but after a while she found a ball and started dribbling it, pointedly turning away from me. I liked how determined she was, and I was impressed by how well she could dribble a ball—especially for her age. I told her so. She continued to pretend to ignore me, but she dribbled with more focus and tried a few tricks. When she tried to turn around and then return to dribbling I told her that I thought it was a hard trick to do. The comments increased her persistence.

“I can do it more than once,” she told me, and did it three times in a row before missing. I counted each time, which she clearly appreciated, although she didn’t say so. It was clear she wasn’t used to this kind of adult attention. “Now I’m going to do twenty in a row,” she turned and told me excitedly.

“I bet you can, but it won’t be easy,” I told her. www.sfms.org

“You count for me,” she directed me. It took many trials. She inched closer to her goal near the end of our session, and when she finally made her twenty turns, we both exulted in her accomplishment.

Then she turned to me and said, “Can we do this again next time?” I told her we could. “By the way,” she said, “you know I’m here because I want to kill myself, don’t you?” I told her that her parents had told me that, but I wanted to know what she thought. “It’s true,” she said. “I hate myself.” I told her that feeling that way must be hard. “It is,” she told me as we ended our session.

Next session we replicated the “dribble game,” and then she decided to reexplore my toys. She found a pair of swords and we played at fighting for a while. I watched her fiddling at play until she decided what she really wanted to do. “Can I kill you?” she asked when I parried an awkward thrust she made at me.

“Sure,” I said. Immediately, she aimed her sword at my heart and I pretended I couldn’t stop her. She pushed at my chest with the sword, carefully so that she wouldn’t hurt me, and I fell back, slowly gasping with the appropriate amount of pain and surprise for someone about to die.

I groaned and pretended, as realistically as possible, to die. Then I lay there on my couch, as still as I could. Most children are very uncomfortable with letting me stay dead for long; it creates too much guilt and anxiety. But Alice was electrified by it and stood there staring at me. After a few very slow minutes I whispered softly, without moving, “What happens next?”

“You can’t talk, you’re dead,” she said.

“Yes, I’m dead,” I whispered, “so what happens next?” I didn’t make eye contact or move my head, to help her understand that although my character was dead, I, her therapist, was observing the situation with her. I didn’t underestimate her intelligence—she understood.

“Can I chop you up?” she asked excitedly. Her pent-up rage was revealing itself in this powerful displacement.

“Yes.” My reply was barely audible.

“Then I’m going to cut off your ears and your nose and gouge out your eyes,” she said, www.sfms.org

proceeding to play this out. The intensity of the moment made the hairs stand up on the back of my neck. “And then I’m going to cut off your hands and put them in your mouth and cut off your feet and put them in your ears.” The violence of these acts was frightening, and I felt a wave of fear, revulsion, and sadness at her need to utterly destroy and degrade me in the play.

She whispered to me, “Can I pull out your teeth, too?”

“Yes,” I replied, and she pretended to yank them out, one at a time, stringing them on an invisible strand.

“I’m making a magic necklace to protect me,” she said, putting the invisible talisman around her neck. “Now I’ll cut out your guts.”

“What will you do with them?”

“I’ll give them to the bears to eat.”

“Are the bears male or female?”

“Female. They really like eating you up.” She paused, then said, “Okay, we’re finished playing that now. Can we do it again next time?” I assured her we could. She then proceeded to confide in me how much she hated school and why, and her feelings of loneliness at home. I asked her if I could talk to her parents about how to help with that, and she agreed that I could.

When we met the following week, she played the same story, and for the two weeks that followed she played a shortened version of it. Her parents told me in a session with them that she seemed much happier at home and was doing much better at school.

I suggested some ways they could spend time individually with her. She had told me how little attention she felt she was getting from either of them.

After the sixth time we played “bear girl,” as we named the play, Alice announced that she was finished with it. We had developed other play scenarios and continued these, but Alice had felt understood, and her deepest issues had been metabolized in the “bear girl” story she created. She told

me, after we were engaged in other play scenarios, that she liked herself now and no longer wanted to kill herself.

In Jungian terms, I would say that Alice had to deal with her negative mother complex. In a complex there are always two figures, and the split between the positive and negative poles of these figures needs to be resolved in order for the person to feel whole. The mother complex contains both a mother and a child, and either can be idealized or devalued. Alice was struggling to hold on to the good of her mother by wishing to destroy the bad child in herself. This was creating her selfhatred. In the play, she needed to accept the destructive child within herself and use her rage to destroy the negative mother in the story. By feeding that energy to the female bears, also primal mother figures, she was recreating a more integrated and tolerable “great mother.” My ability to receive her aggression and the power of her rage helped her to bear it within herself and was the first step in her being able to transform this energy into something she could utilize more positively. She began playing soccer, a sport her mother loved, and the two bonded around this. She also began singing; she had a beautiful voice and took great joy in sharing her favorite songs with me. In this way, we also embodied the positive pole of the mother complex. She could be like a good mother, feeding me with the nourishment of music, and could at the same time be the good and special divine child, sharing the spirit of song.

“My ability to receive her aggression and the power of her rage helped her to bear it within herself and was the first step in her being able to transform this energy into something she could utilize more positively.”

Patricia L. Speier, MD is a Child, Adolescent and Adult Psychiatrist with practices in San Francisco and Berkeley. She is an Associate chinical Professor at UCSF and an Advanced Candidate at the C. G. Jung Institute, San Francisco. Dr. Speier specializes in play therapy for children and depth work with adolescents and adults.

september 2006 San Francisco Medicine 15

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psychiatry at the edges of life

Double Snapshot A Single Trauma Captured Twice in Life Lenore Terr, MD

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raumatized children, if untreated, carry the scars of their psychic traumas into the next phases of childhood. A study of twenty-six Chowchilla, California, schoolchildren who were kidnapped from their bus and buried alive in 1976 revealed that, five years later, they were each still traumatized, though aspects of their processing of the event had changed.

The trauma was the same but, in certain cases, the meaning had shifted somewhat (Terr, 1990).

A different study, also from Northern California, found that a World War II veteran at the San Francisco V.A. Hospital had developed fears and behaviors related to the war, some thirty years later. He had not been diagnosed as traumatized during the war itself, but once he entered the later stages of life, his own new physical illness and the loss of significant others precipitated stresses related to the war (VanDyke, Zilberg, and McKinnon, 1985).

As individuals reach new developmental milestones, they may find new significances in long-past events. Sometimes people can deal with these new meanings all by themselves. But sometimes they go to their physicians, who have the opportunity to take a “double snapshot” of them and of their internally revised meanings. Such is a story from my practice that occurred in May, 1984, and May, 2006. The “picture” is first of a toddler and then of a mother of two.

Kathleen, the redheaded child of unmarried parents, was brought to me at the age of three by her mother, who had recently traveled to Oklahoma to bring her daughter back to California. Kathleen had been stolen and hidden for 100 days by her dad.

A birthday, celebrating her passage from age two to three, had come and gone. Maternal pleas to paternal grandparents, who had known exactly where Kathleen was, had fallen on deaf ears. The Oklahoma police eventually found young Kathleen and, in the process, they arrested her father and threw him in jail while arranging for the toddler to stay in a foster home until her mother could come and get her. For a toddler who had initially loved and depended upon her mother, the entire process was a nightmare. For a mother, the change in her own child—completely beyond her control—was a nightmare too. No longer could Kathleen make good eye contact with others. No longer could she comfortably snuggle or treat her mom with trust. She feared milk, saying it was filled with “ghostess.” She feared freeways, police cars, and fires.

The toddler understood her childsnatching to mean that she had moved with Dad to Oklahoma; Mom didn’t care or want her anymore; the police were bad, scary people who had to be watched on highways and who would eventually put good people into jail; she had warned her father that the police were coming, and he

“As individuals reach new developmental milestones, they may find new significances in long-past events.

Sometimes people can deal with these new meanings all by themselves, but sometimes they go to their physicians.”

www.sfms.org

had failed to heed her predictions; being on freeways is a dangerous thing; fires occur in Oklahoma because bad Oklahomans set them; when parents go to jail, children are left all alone.

How did I learn about these meanings?

In six psychiatric sessions, Kathleen told them to me. She also demonstrated her ideas in her play. For instance, I keep a box of cars and trucks in my office. The toddler pulled out the police cars and emergency vehicles, which then chased down all the good, “working guys” in vans and little trucks. The police, in fact, “kicked” good guys “in the face.” They were also poised to throw mud at innocent people. A little girl doll—Kathleen—was “supposed to tell her Daddy if the police come.” She drew a picture of a “freeway” and talked about her father being “lonely” and in “handcups” now.

I discussed all these issues with Kathleen. When we saw each other, she vigorously played out her intense fear and anger.

I also attempted to give her new contexts with which to understand her disappearance from her mom’s point of view, and from her own as well (in particular, her understanding of the loss of her mother). She repeatedly checked my waiting room to make sure her mother was still there. We talked about that, too—and about the courts and judges who try to insure children’s safety. Then, to correct for the trauma, I taught Kathleen to make phone calls to Mom or to 911 from wherever she was. I showed her mother how to tape phone money into the arches of her child’s shoes. And I testified for Kathleen in court. Her father permanently lost custody of Kathleen. The mother and child no longer needed my help. I received a nice letter Continued on page 21...

september 2006 San Francisco Medicine 17

Psychiatry at the Edges of life

Narrative Medicine David Elkin, MD, and Khenu Singh, MD

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he premise of a narrative approach to medical care is deceptively simple. All people construct a coherent story, or narrative, about their lives. This narrative is dynamic but self-organizing, and it changes with stressors in a person’s life.

What follows is a historical example of narrative medicine. Albert Einstein was hospitalized with a leaking aortic aneurysm.

Surgeons proposed to repair the leak, but Einstein wanted to know what possible complications might result. After hearing about the possibility of stroke or amputation, Einstein rejected his surgeons’ advice, stating that he had lived a “simple life” and that the possible adverse consequences of surgery would not be in keeping with his subjective sense of his life—his narrative. Interestingly, what we now know from his biographers is that Einstein’s life was anything but simple.

But this is exactly the point—that what is important is that Einstein viewed his life as uncomplicated. He chose an ending to it that reflected his values.

Rita Charon, MD, PhD, has written extensively about the narrative approach to medical care and what she terms “narrative competence.” A professor of medicine and literature and director of the Program in Narrative Medicine at Columbia University, Charon sees parallels in narrative approaches to both medicine and to literature. Specifically, her critique of medicine lies in the changes in the field that have led clinicians to lose the time and skill to truly hear their patients’ stories. Thus physicians focus on the biological processes affecting their patients to the exclusion of hearing their patients’ narratives, of suspending their agendas and allowing themselves to be drawn into patients’ “stories” of their illnesses, and how those illnesses are coherent

within the narratives that form their lives.

Values, Charon posits, are a core part of the narrative that each person lives by.

Thus the narrative approach is particularly helpful in helping patients make decisions in times of crisis and should be a core component of each physician’s understanding of ethical analysis (in addition to the better-

“All people construct a coherent story, or narrative, about their lives. This narrative is dynamic but self-organizing, and it changes with stressors in a person’s life.” known “mantra” of autonomy, beneficence, nonmalificence, and justice). The narrative approach is patient-centered and focused upon the patients’ understanding of their lives. Patients cope with disease in part by incorporating their understanding of their illness within their own narratives.

Here is a more contemporary example.

Catherine, a thirty-year-old woman, scheduled an appointment with her primary care physician after noticing a small breast lump on self-exam. Her physician confirmed the mass and arranged for a small-needle biopsy.

However, after the surgeon explained the procedure to her, Catherine stated that she would “have to think about whether this was the right time.” Her surgeon tried to push the issue, insisting that any mass could prove to be breast cancer and should be evaluated promptly. Catherine became

18 San Francisco Medicine september 2006

even more adamant that she would not be “bullied into” the procedure.

Catherine did accept a referral to a psychiatrist—me, and I quickly scheduled an appointment at the surgeon’s behest.

Catherine denied any previous contact with mental health services. She came across as a bright, thoughtful individual with considerable strength of character. She explained that she simply did not want to be “rushed into anything.”

At this point I could have chosen a number of strategies. I could have joined with the chorus of her physician’s voices in urging her to quickly deal with her breast mass. I could have asked about previous unpleasant experiences with illness or prior physicians. Instead, I reaffirmed my interest in helping her be empowered to select the care she felt was appropriate. I decided to ask whether Catherine could tell me about her life. With considerable energy, she described her childhood in an idyllic small town, with many brothers and sisters and a close-knit family. But she became downcast and angry as she described her adolescence.

“I was busy taking care of my mother,” she said, her voice cracking with emotion.

She described her mother’s devastating experience with breast cancer, and her own role reversal as she cared for her mother during chemotherapy treatments. Several years later, when Catherine was sixteen, her mother’s cancer recurred and proved unresponsive to treatment. “I took care of her while she died,” Catherine explained.

She went on to describe the most traumatic aspect of her mother’s eventual death: “Two weeks after the funeral, my father announced that he was marrying our neighbor.

My mother’s pictures were all put away and no one would talk about her anymore. It was www.sfms.org

as if she had never existed.”

I pointed out—perhaps somewhat obviously—that Catherine’s own possible breast cancer must be closely reminding her of her mother’s experience. Moreover, her physicians’ concern and pressure to perform a biopsy and other therapeutic interventions, rather than feeling helpful to her, reminded her too much of her family’s pressure to make her mother “disappear” from the family narrative. Catherine readily agreed.

Interestingly, she scheduled subsequent appointments with me but had the biopsy performed by the time she saw me a second time. Fortunately, the biopsy was negative—indicating a benign mass—but she was eager to talk about her adolescence, her flight from her family in physical terms but the continued strands of hurt and anger that anchored her to them. It emerged that her mother’s death had left her feeling paralyzed, as trauma often can; her life felt as though she had “become stuck.” She had abandoned her plans to go to college and felt “trapped” in a relationship that lacked passion and engagement, but she was quietly terrified of “being alone.” Despite her obvious intelligence and desire to connect, she found herself isolated and quite desperate to be healed—to have someone to “bear witness” to her story and help her construct a new, viable ongoing narrative, so that her life could continue in a way that gave her the sense of meaning and engagement that had been so lacking for more than a decade.

I raise these details to give a sense of the depth that is often lurking beneath each medical encounter, a domain that our patients are often eager to share. The physician’s role is to help patients better understand their lives through a narrative sense—the identification of major themes in our patients’ lives and our assistance in helping them explore how their illnesses impact their understanding of their lives, and provide the chance to change their understanding. In Catherine’s case, her breast cancer scare represented not just danger, but the possibility for growth and change in her life. A purely biomedical approach that failed to acknowledge this possibility was unlikely to meet with success. www.sfms.org

Of course, narrative approaches should trigger a simultaneous exploration of the stories of our own lives as physicians and health care professionals. Each of us can consider the roots of our interest in medicine. What drew each of us to the field? How did we survive and become transformed through our training, as we found that the knowledge we were striving to accumulate was transmuting into wisdom as facts collided with the reality of our clinical experiences?

How have we balanced our professional identities with our personal lives? What are our continued hopes and fears as we strive to practice our art? Surely the unhappiness that some physicians experience painfully reflects the failure to find these answers, or even to actively pose the questions that might allow them to understand their dissatisfactions. Thus narrative approaches to medical care encourage us to heal others even as we bear witness to our own stories, and strive to heal ourselves.

Further Reading • Charon, Rita. “Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust.” JAMA 286(5): 1897–1902. October 17, 2001.

• Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science.

Picador: 2003.

• Groopman, Jerome. The Measure of Our Days. Penguin: 1998.

Welcome New Members!

The San Francisco Medical Society would like to welcome the following members who joined between September 2005 and August 2006

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Grant Stuart Lipman, MD California Emergency • Huyler, Frank. The Blood of Strangers: Physicians

Stories from Emergency Medicine. Picador: Joseph Leung, MD Residents 2004.

The Permanente Group Matthew J. Callaghan, MD Internal Medicine Dereck Richard Johnson, MD

Luigi Maccotta, MD • Reynolds, Richard and John Stone.

Sreelata Maddipati, MD

On Doctoring (third edition). Free Press: The Permanente Group Medical Students Anesthesiology Jennifer Austin 2001.

Manisha Bahl Carolyn E. Million, MD Anh Bui General Surgery Lisa Chu

Billy Cordon Theresa M. Moore, MD Geneva Brooke Davis The Permanente Group Viam Dinh Internal Medicine Sandeep Kulkarni

David Stahl Eun-Ha Park, MD Christopher Stoehr The Permanente Group Joyce Ann Viloria Ophthalomology Derek Ward

september 2006 San Francisco Medicine 19

Psychiatry at the Edges of life

Psychological Development in Late Life Allan B. Chinen, MD Grow old along with me! The best is yet to be, the last of life, for which the first was made.

—Robert Browning

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hile medicine traditionally focuses on the declines of old age, new research highlights the potential in healthy individuals for a late-life psychological renaissance. One account of this phenomenon comes from a surprising source—a folktale. Handed down over centuries, in a process like natural selection, the stories that survive are those that “ring true” over many eras and contain time-tested insights about human development. Most familiar folktales are about children, like “Cinderella,” and reflect the psychology of youth. Stories specifically about old people have long been overlooked, but they are especially insightful about the developmental tasks of old age.

Such “elder tales” are astonishingly similar across cultures; a story from Italy, “Shining Fish,” is prototypical.

Once upon a time, an old fisherman and his wife lived alone in a house on a cliff overlooking the sea. Years before, their three fishermen sons had drowned, leaving the couple desolate in old age. Physically unable to sail, the old man gathered fallen wood in the forest and sold it for kindling.

One day in the wilderness, he met a man with a long white beard. “I know all about your troubles,” the stranger said, “and I want to help.” He gave the old man a small bag filled with gold, and then he vanished. The old man rushed homeward, but along the way he thought, “If I tell my wife about the gold, she will waste it.” And so when he arrived at home, he hid the money under a pile of manure

in the yard.

The next day, the old man awoke to find that his wife had cooked a wonderful breakfast.

“Where did you find the money for all this food?” he asked her.

“You did not bring home any wood to sell, so to buy food, I sold the manure to the farmer down the road.” The old man ran out and found the gold gone. He had to work and so dragged himself back to the forest.

There he met the stranger again, who said, “I know what you did with the money, but I still want to help.” He gave the old man another purse filled with gold, and the old man ran home. Along the way he started thinking, “If I tell my wife, she will squander this fortune . . .” And so he hid the gold under the ashes in the fireplace. The next day he awoke to find his wife had cooked another hearty breakfast.

“You did not bring back any wood to sell,” she explained, “so I sold the ashes to the farmer down the road.”

The old man glumly returned to work in the forest and met the stranger a third time, who said sadly, “You are not destined to be rich, but I still want to help.” He offered the old man a large bag. “Take these frogs, and sell them in the village. Then use the money to buy the largest, freshest fish you can find!” Then the stranger vanished.

The old man sold the frogs, but once he had the money, he was tempted to buy wine, cheese, and sausage. But he finally decided to follow the stranger’s instructions, and he bought the largest, freshest fish he could find.

He returned home too late in the evening to clean the fish, but since it had started to rain, he hung the fish outside from the eaves. Then he and his wife went to bed.

That night it stormed, and the old man and woman could hear the waves pounding on the shore below their home. They prayed for

20 San Francisco Medicine september 2006

any fishermen who might be caught out in the storm, as their sons had been years before. In the middle of the night, someone pounded on their door. A group of young fishermen danced and sang outside. “Thank you for saving our lives!” they exclaimed.

“What do you mean?” the old man asked.

The fishermen explained that when the storm hit, they could not see where land was until the old man set out the light for them. “A light?” he asked. So they pointed. And the old man saw his fish hanging from the eaves, shining with such a great light it could be seen for miles around.

From that day on, the old man hung out the fish each evening to guide the young fishermen home, and they shared their catch with him. And so he and his wife lived in comfort and honor the rest of their days.

This heartwarming story provides a charming metaphor about late-life psychological development. The story themes are repeated in elder tales from around the world and are thus analogous to a dream that recurs over several nights to underscore its importance. The story opens with an old man and his wife living in poverty and desolation, and their situation dramatizes the multiple losses we fear in later life—of health, wealth, friends, and, ultimately, life.

The old man then meets a stranger who gives him a bag of gold—magic returns unexpectedly in the course of ordinary events.

We can interpret the stranger’s gifts as the real-life boons of old age, which we often overlook. These gifts can be quite practical or ordinary, such as wealth from a lifetime of work, the joy of grandchildren, or more leisure and fewer day-to-day responsibilities.

The gifts might also be unexpected, such as the emergence of long-dormant creative talents, as dramatized by Grandma Moses; www.sfms.org

or a late-life transformation from ruthless ambition to philanthropic inspiration, as happened to John Rockefeller.

However, the story emphasizes not what the gifts might be, but how to use them.

After receiving the gold, the old man hides the treasure without telling his wife. He wants to keep his gifts for himself. He acts out of suspicion and greed and loses the gold—twice, so we get the message. This is a common fairytale theme, in which greedy or bad people are punished. What happens next is thus surprising. With the third gift, the old man overcomes his greed and follows the stranger’s advice. Such personal transformation is the rule in elder tales but extremely rare in stories about young people.

Here elder tales highlight an important mark of maturity—reflecting on oneself and changing, rather than blaming others.

What contemporary research adds is that individuals who do accept their “shadowy” side do well as they age, compared to those who do not.

The stranger’s advice—to buy the largest fresh fish at the market—seems odd and impractical. Such a fish would spoil before the old couple could eat it all. In following

the stranger’s advice, the old man illustrates another theme in elder tales—“crazy wisdom.” This is doing something that seems irrational but turns out to be profoundly wise. Real-life examples range from the prosaic to the sublime. Crazy wisdom can be as simple as becoming childlike with one’s grandchildren or as bold as taking up political protest and civil disobedience for the first time, the way Benjamin Spock and Voltaire did. Many traditional cultures explicitly encourage spiritual pursuits, but this can be difficult in modern, secular society.

Successful examples are thus dramatic: Alfred North Whitehead, the mathematician, turned to theology in late life.

The ultimate end of a late-life gift, however, is not personal illumination, as the story quickly goes on to show. After buying the largest fish he can find, the old man returns home and hangs it outside from the eaves. Doing so is crazy wisdom, because the fish might be stolen or eaten by animals. The act, however, underscores the fact that the old man has transcended his greed, suspiciousness, and egocentricity. He no longer tries to hoard the stranger’s gifts for himself; instead he symbolically offers

the fish to the world.

The fish-beacon saves the lives of several young fishermen, introducing the final theme in elder tales: The old man brings magic into the world for the benefit of the next generation. This is what Erik Erikson called generativity, the last task in the life cycle. What elder tales underscore is that generativity is ultimately a spiritual task. It is not a matter of giving advice, but being an example, a beacon.

Besides showing what late-life development involves, stories like “The Shining Fish” help us get there—if we put ourselves in the story. For example, we can ask ourselves questions: When have I hidden a precious gift under a pile of manure? What gift of gold have I squandered in my life?

What is the shining fish in my life? Have I offered it to the world yet?

In youth tales, a magical, wise old man or woman typically rescues the young protagonist. “The Shining Fish” shows how the elder gains the “magic” and wisdom through the developmental tasks of later life in a journey beyond the self and toward the illumination of society.

Double Snapshot: Continued from page 17...

happily with a computer engineer. They shared a house with Kathleen’s mother, who would soon be retiring from a career as a paralegal in a large law office. Once she retired, “Mom” would move to an ocean-side town, a dream she had cherished all of her life.

So I asked Kathleen about her child-snatching, now that she was an adult. All of her fears of police, of freeways, of ghosts, of fires had resolved, she said. But once in a while, she confessed, she felt a sense of generalized panic. And she didn’t like the feeling engendered by “cars passing me.” She realized that the original source of her problems had been her father’s insistence on control, not her mother’s coldhearted abandonment. As a matter of fact, Kathleen’s father had contacted her when she turned twenty-one and had attempted to speak with her, apparently angling toward getting back into Kathleen’s life.

She absolutely refused. In fact, she went so far as to take out a restraining order on him, and to learn where he lived so she could stay out of his way. Other than her panic and father-avoidance, did Kathleen have further signs of the effect of

her 100-day, toddler-age ordeal? Well, rather than drawing complete conclusions, I’ll note that “living with Mom” at twenty-five may not necessarily be an entirely economic decision, and a college degree in “early childhood studies” is not entirely coincidental for an early-childhood trauma victim.

Do treated children carry scars too? Of course they do. The job of those working in child/ adolescent psychiatry is to minimize the scars, to plane them down so that they do not disfigure or interfere with function. That’s all.

I was pleased with the adult I viewed through my psychiatric lens. Her look and her function were just fine. As for little Laura, she has had four sessions so far—no medications after all—and she’s using the school bathrooms now and quickly learning that being “interesting” is far preferable to being “perfect.” Laura was fascinated with her mom’s story, and she thinks that the idea of taping phone money into shoes might be good for her too.

describing Kathleen’s progress, but beyond that I heard nothing.

In May, 2006, a mother and child came to my office for treatment of the seven-yearold girl’s obsessive-compulsive disorder. The problem was probably a genetic one, coming down through the father’s family. Redheaded Laura was afraid of school bathrooms because of smells and dirt. Staying out of the bathrooms was leading to urinary tract infections and intense urethral irritation. A psychiatrist listed on the family’s insurance plan had offered six months of treatment with a selective serotonin reuptake inhibitor, an acceptable enough though minimalist plan. But Laura’s mom insisted instead on bringing her to me. “Can’t you talk and play it out—the way you did when my dad kidnapped me to Oklahoma?”

Here, I realized, was Kathleen—now the twenty-five-year-old mother of a seven-year-old girl and a three-year-old boy! She was about to graduate college with a bachelor’s degree in early child development. She had married young but www.sfms.org

september 2006 San Francisco Medicine 21

Psychiatry at the Edges of life

Dying in California The Principles and Practice of End-of-Life Care Michael Rabow, MD

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nd-of-life care is provided to patients in the last days, weeks, and months of life. End-of-life care generally focuses entirely on symptom relief and quality of life, rather than attempting to cure disease or forestall death. Hospice is one example of end-of-life care, providing comprehensive care in homes or institutions to patients expected to die within six months.

But only about one-quarter of dying patients enroll in hospice at the end of life. Palliative care is a more general term for care focused on symptom management and quality of life, and it may occur concurrently with curative care or may be the sole focus of care, as in end-of-life care.

Although many patients and clinicians associate end-of-life care with cancer, the prognosis from severe heart disease (the number-one cause of death in California) may be as poor as or worse than the prognosis associated with a cancer (the number-two cause of death in California). Californians die from both terminal and serious chronic illness, suggesting that the distinction between these two terms may be artificial.

The challenge is that serious chronic illness usually follows a much more variable path to death, and its prognosis is much more difficult to predict than that of metastatic cancer. For example, in a large clinical trial of patients in the last months of life, patients with advanced congestive heart failure had the same statistical chance of dying the next day as they did of dying in six months.

The Demographics of End-of-Life Care in California Most Californians die in hospitals and long-term care facilities. However, only a minority of California hospitals provide palliative care services, such as palliative

care physician consultation. In 2004, 23% of California hospitals offered palliative care, although the national average was 25%. A recent report stated that California hospitals were less likely than those in New England to have palliative care programs.

Based on data from the U.S. Census Bureau and the California Department of

“While the concept of a ‘good death’ had some popularity in the recent past, most people who have lost a loved one recognize that death is rarely, if ever, ‘good.’

Instead, expert end-of-life care works to maximize the quality of life for patients and their families during a tragic period of life.”

Health Services, California physicians care for approximately 10% of the 2.4 million people who die in the United States annually. However, most California physicians did not have end-of-life care training in medical school or residency. It is now a requirement for medical schools nationally and for an increasing number of residency programs. Importantly, California is one of about a half dozen states nationally that require physicians to have some training in pain management and end-of-life care (California AB 487 legislation). There are nearly 200 California physicians certified as palliative care experts by the American

22 San Francisco Medicine september 2006

Board of Hospice and Palliative Medicine.

Notably, palliative care will soon be formally recognized as a medical specialty by the American Board of Medical Specialties.

Hope for the Best, Prepare for the Worst While the concept of a “good death” had some popularity in the recent past, most people who have lost a loved one recognize that death is rarely, if ever, “good.” Instead, expert end-of-life care works to maximize the quality of life for patients and their families during a tragic period of life. End-oflife care uses a “bio-psycho-socio-spiritual” approach, attending to all domains of personhood, including the physical, emotional, interpersonal, and spiritual. End-of-life care is meant to be comprehensive and seeks to address the concerns of patients and their loved ones. Although pain management is often a focus in end-of-life care, dying is not exclusively or even primarily a biomedical event. It is an intimate personal experience with profound psychological, interpersonal, and existential meanings. For many people at the end of life, the prospect of impending death stimulates a deep and urgent assessment of their identity, the quality of their relationships, and the meaning and purpose of their existence.

End-of-life care is typically provided by an interdisciplinary team of clinicians, including a physician, nurse, and social worker. Pharmacists and chaplains lend particular expertise that may address the primary need of a particular patient or family. Other disciplines that may be part of the team include psychologists; music thanatologists; art therapists; physical, occupational, or rehabilitation therapists; nursing assistants; and lay volunteers. www.sfms.org

Integral to end-of-life care is a focus on patient-centered communication. Excellent end-of-life care empowers patients to participate in decision making and to plan proactively for contingencies as illness progresses, in a way that is consistent with their values. This process is called advance care planning and includes, but is not limited to, appointing a surrogate decision maker and completing an advance directive document.

End-of-life care works to identify and honor patients’ own goals for care.

End-of-life care continues through the death of the patient, including support to the family during bereavement. Quality end-of-life care is integrated across all care settings, including home, hospital, nursing homes, and hospices.

For physicians, end-of-life care presents both challenges and opportunities. Working with dying patients requires the ability to tolerate uncertainty, ambiguity, and existential concern. Clinicians must recognize and respect their own limitations and attend to their own needs in order to avoid being overburdened or overly distressed. On the other hand, many clinicians find caring for patients at the end of life to be one of the most rewarding aspects of practice. Engaged in such care, many physicians find a depth of meaning, the potential for intimate interpersonal connection, and a lasting satisfaction that is sometimes missing from other areas of their work.

Some Thoughts about My Death

By Dick York, patient As a successful real estate developer, it’s a normal day. Lots of calls, decisions, plans—plans for the future. Then the phone rings. Doctor tells me that my biopsy is positive for melanoma. More tests, surgery, more tests. Answers that no one wants to hear.

But guess who just won the SuperLotto for dying?

Initial reaction: fear, anxiety. Like the usual reaction to a new real estate development project—profits, losses, possible bankruptcy. Walk the tightrope long enough and you come to relish the adrenalin rush. Otherwise you would have become realistic years ago and gotten a real job. I never became realistic. I just continued to “walk away from another successful project.” Got to admit, I have been an adrenaline junkie for most of my 72 years.

After the fateful phone call, I realize that I’m getting a fantastic new opportunity.

Wow, I get to do what no one still alive has done. I certainly never died before. Is there an instruction book? A Dying for Dummies” book? Can a novice do it without being awkward? Do you need a lubricant? Do you need to organize it? To organize, you need lists: advantages, disadvantages, knowns, unknowns.

Advantages: You do not need a permit. You do not have to go through a review process, attend endless meetings, or obtain an Environmental Impact Report. You do not have to stand in line.

Disadvantage: You are no longer allowed to participate in life, love, friends, or relationships, at least as we know them.

Knowns: It’s a new adventure, another project. I am allowed to do this thing that no one living has yet done. (Of course, it’s equal opportunity employment—we all get our turn.)

Unknowns: What happens after you die? Who knows for sure? Maybe you just walk away from another successful project. Just hope I don’t get stuck with seventy-two virgins.

Dr. Michael Rabow is an Associate Professor of Clinical Medicine, Division of General Internal Medicine, UCSF. Board-certified in Internal Medicine and Hospice and Palliative Care, Dr. Rabow is an attending physician on the medical wards at Moffitt-Long Hospital. He directs the Symptom Management Service at the UCSF Comprehensive Cancer Center. Dr. Rabow has an active outpatient primary-care medicine practice at UCSF/Mount Zion. He is also an assistant editor for a bimonthly section in JAMA entitled “Perspectives on Care at the Close of Life” and is a Faculty Scholar in the Soros Foundation Project on Death in America.

He serves as the Director of the Center for the Study of the Healer’s Art at the Institute for the Study of Health and Illness.

www.sfms.org

september 2006 San Francisco Medicine 23

Psychiatry at the Edges of life

Dealing with Death Medical Students Reveal Their First Impressions Manisha Bahl UCSF Second-Year Medical Student

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ne of Neil Sachs’ first and most poignant experiences with death occurred during his third-year internal medicine clerkship. Sachs was involved in the care of an elderly Chinese-speaking woman who had contracted tuberculosis that, for reasons unknown to the medical team, hadn’t resolved despite aggressive treatment. Sachs cared for the patient for more than one month, growing increasingly frustrated about her condition and the communication barriers that weakened their relationship. Her death deeply saddened him, especially because “she had endured so much suffering and had been so isolated for the last few weeks of her life.”

Sachs needed more than just his medical team’s brief acknowledgment of her death to come to terms with what had happened, so he turned to friends to help process his thoughts and emotions.

Medical students begin their clerkships fully equipped to diagnose and treat disease but often feel inadequately prepared to face death and to communicate with dying patients and their families. In fact, the literature on medical education suggests that medical school curricula tend to focus exclusively on disease diagnosis and treatment, while paying little attention to education about end-of-life issues and palliative care.

Given the lack of student training in this area, how do medical students envision the dying process, relate to patients and their families, and confront their own grieving process when patients die?

While most students begin their thirdyear clerkships with the belief that death is always a negative outcome, some learn to view certain deaths as “good deaths” when they are conducted in the manner desired by patients and their families. For Alex Keedy,

the realization that some people accept their dying with grace and peacefulness occurred at the end of his third-year clerkship. Keedy was involved in the care of an elderly man who had come to the hospital with jaundice. After undergoing a diagnostic ERCP, which revealed an aggressive malignancy, the patient refused any further diagnostic or therapeutic procedures. He passed away shortly thereafter. In talking with the patient shortly before his death, Keedy found him to be surprisingly content with the long life he had lived and fully prepared to embrace death.

“He was comfortable and wasn’t scared of death,” says Keedy. “If he wasn’t scared, I thought, why should I be?”

Students may also be more psychologically and emotionally affected by deaths among patients in their age group, or among patients who remind them of personal experiences with loss. Keedy, for example, found his experience with a young man who committed suicide particularly difficult to handle because of their similarity in age.

For Kelli Barbour, interacting with a young woman who had miscarried was particularly difficult because of her mother’s experiences with miscarriage.

“I knew that I had to make sense of this for myself, and so I took time to think through it,” says Barbour. “I couldn’t solve the problem, but I could help, and I helped in the way that I wanted my mother to have been helped.”

Students use several coping strategies when interacting with dying patients and their families or when faced with a patient’s death. While some use writing and prayer, most cope by discussing experiences with friends, allowing them to process thoughts and emotions without worrying about

24 San Francisco Medicine september 2006

academic evaluation. For some students, sitting with patients and their families is itself therapeutic. Often, additional support is available through academic advisors, faculty mentors, and school-wide counseling services.

Although some medical students learn about end-of-life issues and palliative care through didactic lectures, particularly in elective palliative care clerkships, many rely on role-modeling by attending physicians and residents as the primary method of teaching. During his fourth-year elective clerkship on palliative care, Byron Taylor observed an attending physician communicate with a terminally ill elderly patient and his family, all of whom were struggling to accept the possibility of death. “The physician’s communication skills, his openness to hearing both sides fully, and his ability to listen to and understand the gaps in their understanding allowed the patient and his family to come to terms with death,” Taylor noted. Through the physician’s attitude and behavior, Taylor believes he learned how to focus on the importance of care rather than cure and to redefine successful intervention in the context of dying.

With limited training and experience, it is understandable that students often feel fearful, anxious, and hesitant to face death and to interact with dying patients and their families, but this discomfort and anxiety will likely lessen with experience.

Dealing with death during medical training can teach students to be compassionate, to consider quality instead of quantity of life, and, ultimately, to grow as individuals and physicians.

www.sfms.org

psychiatry at the edges of life

Dealing with Death Physicians Share Their Experiences Katie Kelly UCSF Second-Year Medical Student

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icture the following scene: A fifty-year-old man dying from colon cancer screams out in pain regularly at the hospital in which you work. As you pass his room, the smell of necrotic tissue emanating from his room is overpowering.

He sees no visitors. You wonder whether he has any family or friends left, or if the family he does have is avoiding him. You think, “No one should die like this….”

That is what went through Dr. Daniel Thwaites’ mind as he recounted this memory from his first year in residency at SFGH. “Deep down I vowed that I would do everything in my power to relieve this kind of suffering,” says Thwaites. “Suffering from physical pain, suffering from emotional pain—as no one could get near this man—and the spiritual suffering one experiences when facing death.”

Now the Associate Medical Director at the Modesto Community Hospice, Inc., Thwaites has the opportunity to address the above etiologies of suffering on a daily basis.

However, he reflects that making life-anddeath decisions for others can lead to “anger, fatigue, and, at times, great anguish.”

How do medical professionals protect themselves from such feelings? Many physicians feel that acknowledgment and then acceptance of any feelings that arise from dealing with death is of the utmost importance. And, while it is important to do everything possible for a patient, it is important to realize and accept personal limitations—both as a doctor and as a human being.

When asked about what helps most in coping with the death of his patients, Dr. Daniel Pound, Medical Director of UCSF Lakeside Senior Medical Center, advises, “Acknowledge what you feel. Talk with www.sfms.org

other people about the emotions you feel, especially when a death has affected you in an unusual way.”

Dr. Thwaites comments similarly, “Being a doctor does not protect me from being sad or angry. I realize that this is part of the process, and what helps me is to first acknowledge the feeling and then, more importantly, to not discount or ignore it.”

Certain challenges, such as lack of time, training, and resources, often result in asking a physician, an ordinary human being, to transcend such feelings. Furthermore, many students enter medical school understanding that they will gain the resources necessary to make a difference where others cannot. Upon realizing that this “difference” can be limited, especially when dealing with a terminal illness, many physicians find themselves in an unfamiliar and uncomfortable situation.

“This sense of burden seemed greatest when I was a resident or had just finished residency, since I felt inexperienced or uncertain,” said Pound. “I have similar feelings less often now, because I realize that a single decision by a single doctor is not the only factor that affects someone’s life or death.”

Yet at some point, all physicians realize that current knowledge is not enough to save all patients. Although this inadequacy can produce feelings of helplessness in people, some find strength and confidence in understanding that curing someone’s disease is not the only way to treat a patient.

Dr. Michael Rabow, Director of Symptom Management Service, UCSF Comprehensive Cancer Center, said that he learned a valuable lesson during his residency in the CCU on the importance of being present with patients during their last moments.

“I was too scared of his dying to move

to the head of his bed to face him directly, to say good-bye,” says Rabow of one patient.

“The experience left me feeling like a failure, not at medicine but at being human. Since then, I’ve remembered him whenever there is an opportunity to say good-bye to a patient who is dying. It always feels like a bit of courage is necessary to stand up on behalf of the living and bear witness to someone dying. Since then, I’ve never again dealt with my fear of a farewell by staying away.”

Experiences with death can inspire people to take action as well as evoke and develop personal qualities that many are proud of. Rabow’s memory provided not only inspiration on how he wanted to treat future patients, but also to articulate his experiences in poetry: Grace Undone There is always a first dying patient that means the world to a young doctor.

Mine was named Grace.

Yesterday, June became the most recent one. But in my heart, they are all named Grace.

Syringomyelia?

Years ago I excused myself in the middle to look it up the first time I met her.

Yesterday I had to press right up to her lips to hear her failing voice as she asked when she could no longer wipe herself would I help her end her life?

And although I had taught about this very topic in class the week before, I did not know what to say.

At the end of our visit, I leaned forward even further and hugged her.

I felt the bones in her back and her left arm hanging limp at her side, and her right arm spastic and struggling to reach around to hug me back.

And hugging, I did not want to let her go.

—M. Rabow

Continued on page 34...

september 2006 San Francisco Medicine 25

in my opinion

To Be or Not To Be: Is That the Right Question?

Harvey Max Chochinov, MD, PhD

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ike so many people who work in palliative care, I am frequently, though reluctantly, drawn into conversations about euthanasia and assisted suicide. There is an assumption somehow that knowing how to care for people near the end of life confers expertise on the rights of patients to seek out a hastened death. Because I do research and publish studies that try to understand the psychological landscape of people with life-threatening illnesses, my phone rings whenever the media features someone requesting physician-hastened death, or when there are rumblings about a challenge in the legislative status quo.

For years now, our research group has been studying the whole notion of what it means to maintain dignity in the face of a lifethreatening or life-limiting illness. And no surprise, my phone rings more than ever. The term dignity, after all, has become synonymous with the right-to-die movement, the key platform of which is that the ability to end one’s life at a chosen time affords the ultimate dignity. In their continued effort to promote social policies that include euthanasia and physician-assisted suicide, it is worth asking if proponents of this movement are pushing us toward or away from the most pressing questions facing palliative care today.

Take for a moment the issue of hunger and imagine being asked to focus your attention on how to suppress appetite in people who are starving, rather than engaging the question of how to feed them. In view of the problem, the solution would seem, putting it diplomati­cally, off the mark. As for the right to die (not so much a right, but rather a physiological obligation), I think the most intriguing questions relate to the myriad factors that influence a sick person’s desire to go on living. No doubt, a thorough and honest examination of these questions informs how to provide better care for the dying, while offering important lessons for the living.

Study after study has shown an association between a loss of will to live and uncontrolled pain, inadequate social support, and psychological distress. Our more recent studies have also pointed to

the importance of existential considerations, such as loss of dignity, lack of control, loss of sense of meaning or purpose, and a sense that one has become a burden to others.

In these particular ways then, the dying and the living may not be so dissimilar. Without a sense of pur­pose, meaning or being valued—all subsumed within what we have coined a “dignity-conserving model of care”—whose will to live might not be in jeopardy?

Even the Hemlock Society has conceded, “If most individuals with a terminal illness were treated this way [according to the dignityconserving model of care], the incentive to end their lives would be greatly reduced.”

For now, palliative care professionals will continue to be coaxed into weighing in on the issue of physician­-assisted suicide—to be or not to be. The reason for their hesitation, however, should now be transparent.

They are tactfully trying to shift the question to how to help people live the best and fullest quality of life pos­sible. In all likelihood, in spite of the very best that pal­liative care can offer, there will always be a tiny minority of patients who will push for death-hastening options. Finding compassionate and moral ways to address their needs will remain a challenge for policy-makers and caregivers alike.

Harvey Max Chochinov, MD, PhD, is the Canada Research Chair in Palliative Care, Director of the Manitoba Palliative Care Research Unit at CancerCare Manitoba, and Professor of Psychia­try at the University of Manitoba.

Reprinted with permission from CURE: Cancer Updates, Research, & Education. CURE provides the latest in cancer information for patients and their caregivers, free of charge. To sign up for CURE, go to www.curetoday.com.

Reminder: Physicians Must Complete Pain CME by End of Year

November 4-5, 2006, San Diego, CA CURE Patient & Survivor forum

California law requires physicians to complete twelve hours of continuing medical education (CME) in pain management and the care of terminally ill and dying patients. Physicians have until December 31 to satisfy this requirement. Doctors licensed in California after 2002 have four years from the date of licensure to complete the CME requirement.

Join cancer patients, survivors, and caregivers from around the country.

Presented by CURE: Cancer Updates, Research & Education, the forum is design encourages attendees to interact with nationally recognized cancer experts in small group settings as well as those in the cancer community whose expertise is complementary to therapies and psychosocial issues. For more information go to www.curetoday.com or call (888) 949-0045.

26 San Francisco Medicine september 2006

www.sfms.org

in my opinion

Physician Assistance-in-Dying Postmortem Reflections on the California Compassionate Choices Act Robert Liner, MD

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his past June, AB 651, the California Compassionate Choices Act, suffered defeat in a three-to-two vote by the Senate Judiciary Committee. Speaking as a doctor who has practiced in this state for thirty-six years, I think that’s a shame.

Reasonable minds and equally well-intended people disagree about physician assistance-in-dying. The American public favors the concept by a margin of 70%, and a March 2005 HCD Research survey of U.S. physicians at large indicated that 62% of our country’s doctors believe that, with proper safeguards, physicians should be permitted to dispense life-ending prescriptions. For many years now, the SFMS has maintained a position of neutrality in this debate—a position that found cogent support in a 2003 paper by Drs. Quill and Cassel: “Professional Organizations’ Position Statements on Physician-Assisted Suicide: A Case for Studied Neutrality” (NEJM, 183:3).

California’s thwarted legislation was carefully modeled after Oregon’s Death with Dignity Act and incorporated even more safeguards. Oregon’s law has served the people of that state well for nearly a decade. As in Oregon’s law, the provisions of California’s bill would have been limited to terminally ill, competent adults.

Two physicians would have to agree on the diagnosis and prognosis, and in California’s statute a mental health evaluation would be mandatory. Two oral requests, a written request, and two waiting periods would be required, and, once prescribed, the lethal medication would have to be self-administered. The bill specifically prohibits euthanasia. It also prohibits surrogate decision making; the patient would have exclusive power to initiate the request for a death-hastening drug and would possess sole authority for its administration. Finally, no doctor would be required to participate; coercion of any kind would be antithetical to the language and intent of the bill, which was about granting people autonomy and choice in their medical decisions. We all know that, in practice, physicians do sometimes hasten deaths when compassion and good judgment call for such intervention. But these actions are clandestine, unregulated, and sometimes insufficiently informed, and patient care suffers accordingly.

Improvement in the quality and availability of palliative care is sometimes offered as an alternative to physician assistance-in-dying, as if these interventions were mutually exclusive. All caring physicians favor efforts to improve pain management and other aspects of palliative care. These efforts are necessary and desirable, but the most enlightened and creative palliation is sometimes insufficient to meet the needs of dying patients. Take, for example, the case of www.sfms.org

a woman who is dying from ovarian cancer. Suppose all attempts at cure have been exhausted. Your patient has hospice care. She has benefited from the best possible palliation of symptoms related to the progression of her disease. Suppose those symptoms are now defeating every remedy save one: You can increase the dosage of her narcotic and antianxiety medication to the point of “terminal sedation.” But suppose that weeks ago, while still fully competent, she told you she would consider it anathema to linger, technically alive but obtunded to the point that she was dispossessed of consciousness and the ability to communicate with those she loves.

What can you do for her?

Medical opinion and the courts have recognized the so-called “double effect” in terminal sedation. When sedation results in the patient’s death, potential prosecutors are generally inclined to give doctors the benefit of the doubt that their intent was to relieve suffering. Nevertheless, your patient has presented you with a dilemma: You need to relieve her agony, but in the process you may violate her wish to avoid the unconscious lingering that she has told you she would consider a fate worse than death. This bill would have allowed you and your patient to avoid arriving at this impasse—but having arrived there and once placed in this dilemma, you may find it difficult to be clear about your own intent. As you increase the patient’s sedation, you may understandably feel that you are venturing onto thin ice. When one is at risk of committing an arguably criminal act, favorable odds on being given the benefit of the doubt are no substitute for the protection that would come from improved clarity and better options in the law. At present, sadly, options and clarity are both lacking.

Oregon’s Death with Dignity Act went into effect in November of 1997. Between 1998 and 2005, a total of 240,000 Oregonians died. Among their number were 246 patients who hastened their deaths with the assistance of physicians who legally prescribed for them. Another group of patients—the majority of those who requested a prescription—chose not to take the prescribed medication but reported that they were greatly comforted by knowing that a decision to do so was within their power. Opponents of Oregon’s legislation understandably worried about a “slippery slope.” Grounds for that concern have not materialized. After more than eight years, scrutiny of the Oregon experience reveals no abuse of any kind.

Nearly all of the patients who have availed themselves of Oregon’s law died while receiving hospice care. Due in no small part to the Continued on page 29... september 2006 San Francisco Medicine 27

28 San Francisco Medicine september 2006

www.sfms.org

Physician Assistance-in-Dying: Continued from page 27... social innovation of that law—twice approved

by Oregon’s voters—and to the debate that surrounded that referendum, end-of-life care is better in Oregon than anywhere else in the nation.

Some of those who took issue with AB 651 have voiced a concern that economic forces might result in the best of palliative care for privileged members of society, while the economically disadvantaged would be hastened off with “a handful of pills.” Oregon’s experience argues against that concern. Those Oregonians who hastened their deaths tended to be welleducated and insured. A proponent and an opponent of this form of legislation addressed the facts in a jointly published article: “What Are the Potential Cost Savings from Legalizing Physician-Assisted Suicide?” (Battin, M. and Emanuel, E. J., NEJM, July, 1998). Their studies concluded that any possible savings would be too small to constitute an economic incentive to abuse.

If our hypothetical patient lived in Oregon, she could have been legally provided with a prescription for Seconal in a quantity sufficient to give her the option of bringing about her own death, surrounded by her loved ones, at a

point consistent with her own values and final considerations. Counsel for the CMA, opposing the bill, suggested that legalizing physician assistance-in-dying would distort and inject mistrust into the doctor-patient relationship. Bedside experience with dying patients belies that assertion, recognizing its inherent paternalism.

Patients will not be confused about the motives of doctors who respect their autonomy and their expressed wishes. Nor should we physicians be confused about our calling and our limitations.

Detractors sometimes proclaim that “a physician should cure, not kill,” a truism that is vacuous in this context. Neither curing nor killing is relevant to this discussion. We are called upon to cure—yes, whenever cure is possible. But we are talking about patients who are in the process of dying. The only question is how they will die, and on whose terms. And if, as in this example, the patient dies a week or two before her life functions might otherwise cease but dies in a manner and a moment she has chosen, still able to say “good-bye,” where is the harm?

Why does the notion of scheduling one’s own imminent death cause consternation? We schedule other momentous occasions in our

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lives. We frequently schedule birth, knowing that while prematurity is a risk, there are also complications when birth is too long delayed. As patients tell us, we should have the same regard for the consequences of unnecessarily drawing out the process of death. Physicians who would render compassionate assistance to their patients in accord with a law like the one embodied in AB 651 would be acting in a manner consistent with the best ethical standards of our profession.

If the protection of legislation similar to AB 651 becomes available to us in California, will I ever be likely to avail myself of its offering? I don’t know a better way to answer that question than in the words of Garret Keizer, a minister whose essay “Life Everlasting” was published in Harper’s Magazine (February 2005): “I do not know if I would ever use it myself. I remain seated through the credits of movies, even those I didn’t much like, and after I’ve finished my drink, I chew the pulp from the lime. I suspect I’ll want to stay for the duration … but the pertinent question here is not what I will do on my deathbed but what I am prepared to permit others to do on their deathbeds … and on that question I am clear.”

September 23, 2006 San Francisco, CA 9:30 a.m. - 11:30 a.m.

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september 2006 San Francisco Medicine 29

Film review

The Bridge Erica Goode, MD

T

he ninety-minute film The Bridge is a must-see for any physician, medical student, parent, or youngster over the age of l5. It is, in fact, an important film for anyone living in the Bay Area. Like many things in life, it immediately brings up questions of priorities, money, and political intrigue.

It shows the viewer the terrible truth of this alluringly beautiful icon, the Golden Gate Bridge—the truth being that we lose another suicidal person every l5 days, year in and year out, due to the low, temptingly surmountable railing. Cameras on the Bridge itself monitor these jumps. There is a response effort when passersby see a jump: They call 9ll and the Coast Guard appears, usually recovering another crumpled, drowned person—unless the body has been swept out to sea. Due to this factor, the confirmed number of jumpers is invariably lower than the number of actual deaths.

The film is beautiful, using long-range lenses to capture the hauntingly lovely fog. The message is strengthened by the fact that a simple railing could possibly make a difference. One girl, captured on film, was pulled to safety by a passerby; one fellow spent ninety minutes wandering to and fro, hair and black clothing buffeted by the wind, before hurling himself over. It is almost impossible to monitor the variable behavior of the jumpers—one crossed himself beforehand, calmly clambered over, and was gone. The filmed interview with a surviving jumper, Kevin Hines, who was nineteen at the time of his attempt, summarized the position of

30 San Francisco Medicine september 2006

many surviving jumpers. Hines is glad to be alive and now spends time and effort speaking with young people, urging them to seek help for depression and other mental health issues.

In l976 David Rosen, MD, then a professor of psychiatry at UCSF, interviewed nine Bridge jump survivors and published his report in the Western Journal of Medicine. All survivors felt this was a life-altering event, and all consequently devoted their energies toward preventing depression and suicide among themselves and others.

Eric Steel, who directed and filmed The Bridge, is giving profits to the barrier-building effort. Activists are trying to convince the San Francisco Bridge District that it is necessary to make this change. There is little in the news about these twenty-five or more annual deaths, in contrast to the one or two head-on crashes per decade on the span. This film finally brings the issue to the forefront.

However, there is resistance; one San Francisco Supervisor has excoriated the film and its motives without having seen it, despite the reviews and praise it received at the New York Film Festival this past year.

If you wish to help the barrier-building effort, please urge your local theater, the Castro, Kabuki, and others, to show the film, and contact the director of the Psychiatric Foundation of Northern California, Janice Tagart, at (4l5) 391-7774 or by e-mail at jtagart@pfnc.org.

www.sfms.org

Book Review

The Girls Who Went Away Nancy Thomson, MD

“This was in that period of time when there wasn’t much worse that a girl could do. They almost treated you like you had committed a murder or something.”—Toni in The Girls Who Went Away

A

nn Fessler’s book The Girls Who Went Away is a deeply moving and myth-shattering work. Quotations from mothers forced to surrender their babies, such as the one above, are sprinkled throughout the text as Fessler reveals the astonishing untold story of the million and a half women who surrendered children for adoption due to enormous family and social pressure in the decades preceding Roe vs. Wade in 1973.

Although the sexual revolution was heating up in the postWorld War II years, sexual information was not available from family or school, birth control was tightly restricted, and abortion was still illegal in most states, as well as being prohibitively expensive or life-endangering. While young men who engaged in sex often saw their reputations enhanced, single women who became pregnant were shunned by their families and friends, evicted from school (until 1972’s Title IX), and sent away to maternity homes to have their children alone. They were told that surrendering their children was the best solution and that doing so would allow them to simply move on and forget.

But they never did forget. Fessler, herself an adoptee who recently made contact with her birth mother, traveled the country interviewing more than 100 women who were willing to talk about their experiences. Many of these women had never discussed their experiences with anyone—not even their mothers, sisters, friends, or spouses—due to shame and guilt.

However, for the adoptees, there was a need to know their histories. And for the mothers, it was the healing of an old wound. Not all mothers Fessler interviewed have had contact with their children. It was often easier for the children to find the mothers, if they could find a copy of their original birth certificate. However, in the post-World War II adoption boom, most states sealed these records, and the debate about opening them is ongoing. The American Adoption Congress was founded in 1978 to bring about changes, and a Google search of “adoption reunion registry” will yield about 150 hits. Bastard Nation, an adoptees’ rights organization, has a

www.sfms.org

website with a full list of state disclosure laws and provides updates on pending legislation; and the National Adoption Information Clearinghouse provides an online state-by-state listing with details about who may access information, what is available, and which agency or department to contact.

Probably the best-known and most successful mutual consent registries have been started by those who have a vested interest. Jean Paton, an adoptee and a social worker, is credited with organizing the first registry and beginning the adoptees’ rights movement in 1949. Her search organization, Orphan Voyage, and her 1954 book, The Adopted Break Silence, were firsts of their kind.

But it was not until the early 1970s that the registries took hold with Florence Fisher’s ALMA Society. ALMA has a nationwide network of support groups and continues to facilitate reunions through its registry database. The other widely used registry is the International Soundex Reunions Registry. Commonly called Soundex, it was founded in 1975 by Emma May Villard, the daughter of an adoptee. Although registries are an important part of the search process, mutual consent registries depend on both parties knowing the registry exists, taking the step to register, and updating contact information. In general, mothers who have filed a letter with the adoption agency in the hope that their adult children will contact the agency have had better success. However, they have to prepare for the emotional intensity of a reunion, which can be a roller-coaster ride.

Fessler is professor of photography at Rhode Island School of Design, and she began her interviews for an audiovisual installation project. She was eventually awarded the prestigious Radcliffe Fellowship for 2003–04 at the Radcliffe Institute for Advanced Study, Harvard University, where she conducted extensive research for her book—which begins and ends with the story of her own successful, and time-consuming, quest to find her own birth mother.

Fessler, Ann. The Girls Who Went Away: The Penguin Press, 2006.

september 2006 San Francisco Medicine 31

hospital News Chinese

Fred Hom, MD

If Chinese Hospital had a Hall of Fame, then Dr. Rolland C. Lowe would certainly be a unanimous first ballot selection. After fortythree years, Dr. Lowe recently retired from his surgical and general medical practice located in Chinatown and Chinese Hospital. He did not receive just one retirement party, but three: one given by hundreds from the community, one by colleagues, and one by the hospital. Among his many accomplishments are being the first Asian President of the San Francisco Medical Society and, later, the first Asian President of the California Medical Association. Just last year, he was the recipient of the CMA Foundation’s first Ethnic Physician Leadership Award. He was honored for serving as a teacher, role model, and trailblazer for ethnic physicians and for helping to create CMA’s Ethnic Medical Organization Section and the foundation’s Network of Ethnic Physician Organizations.

Serving the community has always been an important part of Dr. Lowe’s career, and this will now be his focus as he steps down from medicine.

He was a founder of the Chinatown Youth Center and has served on numerous boards, including those of the San Francisco Foundation, the San Francisco Planning and Urban Research Association, Self-Help for the Elderly, and the city’s Civil Service Commission. Thank you for your service and congratulations on your all of your accomplishments, Dr. Rolland Lowe!

CPMC

Damian Augustyn, MD

The Society of Chest Pain Centers (SCPC) has awarded California Pacific Medical Center its Chest Pain Center accreditation. CPMC is now one of five accredited Chest Pain Centers in California. This accreditation is given only to facilities that have demonstrated their commitment and expertise in providing patients with consistent quality in the delivery of emergency cardiac care, based on national guidelines established by leaders in cardiovascular and emergency medicine.

“This accreditation denotes heart care excellence to our patients and our community.

We wanted to demonstrate our dedication to providing quality cardiac care by becoming a Chest Pain Center,” states Richard Gray, MD, Medical Director of the Sutter Pacific Heart Centers and CPMC cardiologist.

The Institute for Healthcare Improvement (IHI) is showcasing CPMC’s Health and Safety Passport on its website, as a resource for other organizations: www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Tools/HealthandSafetyPassport.htm.

Congratulations to the Center for Patient and Community Education and the Communications and Marketing Department on this very visible acknowledgment of their work.

Dr. Lawrence Werboff was recently reappointed for a second term as Chair of the Department of Urology. Dr. Werboff is a graduate of the University of Pittsburgh School of Medicine and has been a member of the CPMC medical staff since 1980.

Dr. Michael Verhille was recently appointed Chief of the Division of Gastroenterology at CPMC. Dr. Verhille is a graduate of University of Illinois at Chicago and has been a member of the CPMC medical staff since 1990.

32 San Francisco Medicine september 2006

Kaiser

Robert Mithun, MD

Life’s harshest and most difficult moments often present themselves at the least opportune times: ten minutes before lunch or on a Friday afternoon; at the beginning of a string of twenty messages that need to be answered in far too little time; or when a child is demanding more energy than one has to give.

To our patients, they are life-defining moments. To us, we hope, they are opportunities to perform the best care we know how to give, when our compassion and empathy should be at their strongest.

These moments go under many different guises: the 13-year-old who receives a positive pregnancy test; the 30-year-old who learns he is HIV-positive; the middle-aged woman clinging to life, even as cancer ravages her body; the father whose son has just been found washed up on the shore, after jumping from the Golden Gate Bridge. How do we, as physicians, balance our own reactions to these events with our need to communicate concisely, dispassionately, and impartially with our patients?

Sometimes, the answer is simple. Allow the patient to cry. Allow yourself to cry. Express your sorrow at the difficulty of the moment that you are privileged to share. Only then should you and the patient construct a plan, discuss treatment, or determine what will come next. The patient will not remember your actions but will have sensed your empathy. Reflect on the last time you heard truly bad news. You remember the kind touch, the soft words, and the sincere compassion, not the next appointment date.

Finally, seek solace from your colleagues.

We have all been there, and will be again. Recognize that none of us can practice medicine in a vacuum. Existing at the edges of life with our patients requires our technical expertise, but above all it requires our humanity.

www.sfms.org

hospital News Saint Francis

Guido Gores, MD

With this month’s theme, “Psychiatry at the Edges of Life,” my colleagues and I would be remiss if we didn’t acknowledge the professional commitment of psychiatrist Mel Blaustein, MD. Dr. Blaustein is Vice Chair of the Department of Psychiatry at Saint Francis, President of the Psychiatric Foundation of Northern California, and Chair of the Foundation’s Task Force on a Golden Gate Bridge suicide barrier. Through their tireless work, Dr. Blaustein and the Foundation have helped create tremendous support for a barrier to prevent more tragedies on the Bridge, the most common suicide site in the world.

Here at Saint Francis, we are very saddened by the news that our President and CEO Cheryl Fama has announced her plans to leave Saint Francis for personal and family health reasons.

Cheryl began her twenty-two years at Saint Francis in 1984 as Vice President of Patient Care Services. In 1989 she assumed the CEO position. In 1995 she became President, and then President and CEO in 2001. She has fostered growth and visibility of existing programs as well as development of new programs, such as the Spine Center, Total Joint Center, Wound Healing Center, and Behavioral Health Day Program. She has been instrumental in establishing community partnerships with organizations such as Glide Memorial Foundation, the MacMillan Stabilization Center, and the Homecoming Services Program. Through her leadership, the San Francisco Board of Supervisors recently recognized Saint Francis with a proclamation for “outstanding community services.” For four years running, Cheryl has been honored as one of the Bay Area’s Top 100 Women in Business.

On behalf of the entire Saint Francis medical staff, we thank her for her dedicated service and commitment. During the transition and search for a new hospital president, Tom Hennessy, who has been Vice President of Operations at CHW for seven years, will be our President. www.sfms.org

UCSF

St. Mary’s

Ronald Miller, MD

Kenneth Mills, MD

St. Mary’s is the only Catholic Hospital in San Francisco, as well as the oldest hospital in the city. Thus we are very aware of our roots and especially our faith-based foundation. In 1854 the Sisters of Mercy arrived from Ireland and in 1857 founded St. Mary’s Hospital on Rincon Hill by the waterfront. We are now part of Catholic Healthcare West, which is sponsored by several religious orders of Sisters and operates more than forty hospitals in California, Arizona, and Nevada. With this background in mind, I am both sad and proud to reflect on the untimely passing of an extraordinary person intimately connected with the Sisters of Mercy, Catholic Healthcare West, and St. Mary’s Medical Center.

St. Mary’s had no better friend than Sister Diane Grassilli. This remarkable, youthful, fiftysix-year-old woman was recently taken from us after a brief illness. Creative, energetic, and resourceful are only a few ways to describe her talents. Born in San Francisco, raised in Burlingame, a graduate of Mercy High School and Russell College, she became a Sister of Mercy and began her profession as an educator, teaching at Mercy High Schools in San Francisco and Burlingame and eventually presiding as Dean.

1986 was the year of formation of Catholic Healthcare West, and Sister Diane was involved from the start. She was the assistant to the President, and strategic planning was her forte.

She served on the Board of Directors and was President of the CHW Board from 2002 to 2005.

She was also President of the Sisters of Mercy, Burlingame community.

Sister Diane was a tireless advocate for St. Mary’s Hospital and served on our Foundation Board. Whether presiding over the Board of CHW or throwing the opening pitch for a Giants game, her winning smile and engaging personality were her calling cards. St. Mary’s joins in the mourning of this remarkable health care strategist and best friend.

The Pancreas and Pancreatic Islet Transplant Program at UCSF Medical Center, the first and largest in California, is a key component of a concerted effort to find advanced treatments for insulin-dependent (Type I) diabetes. Yet many diabetics—and even some physicians—do not realize that a successful pancreas transplant is a cure for diabetes. A healthy pancreas can eliminate the need for insulin injections, reduce or eliminate dietary and activity restrictions, and decrease or eliminate the risk of severe low blood-sugar reactions.

“Pancreas transplants provide the opportunity for many Type I diabetics to enjoy insulin independence for the first time in their lives,” said Peter Stock, MD, director of the UCSF pancreas transplant program.

“Unfortunately, this procedure can benefit only a small number of Type I diabetic patients with life-threatening diabetes,” Stock said. “This is the reason that UCSF is actively enrolling patients for the less invasive islet transplant procedure. Current clinical trials are studying the efficacy and longevity of the insulin independence produced by islet transplantation.” So far, UCSF offers islet transplants and pancreas-only transplants primarily to Type I diabetics whose blood sugar is particularly difficult to control.

Most people with diabetes receive a pancreas transplant simultaneously with a kidney transplant. To shorten the waiting time, UCSF patients with qualified donors now may receive a living-donor kidney transplant, followed (after six months’ recovery time) by a pancreas transplant. More than 80% of UCSF patients remain insulin-independent three years after transplant.

For more information, see www.ucsfhealth. org/organ_transplant. Physicians may contact UCSF’s pancreas and kidney/pancreas transplant nurse-coordinator, Sandy del Grosso, RN, at (415) 353-1371.

september 2006 San Francisco Medicine 33

hospital News Veterans

Diana Nicoll, MD, PhD, MPA

A study led by researchers at the San Francisco V.A. Medical Center (SFVAMC) has shown that extremely low doses of estrogen over the course of two years had no ill effects on the cognitive abilities or general health of older women.

“This shows that women can take estrogen safely,” observes author Kristine Yaffe, MD, Chief of Geriatric Psychiatry at SFVAMC. The study, published in the July 2006 issue of Archives of Neurology, looked specifically at the potential effects of estrogen on cognitive abilities and quality of life. A group of 417 postmenopausal women aged sixty to eighty were randomly assigned to receive a daily .014 milligram dose of either estradiol, a form of estrogen, or a placebo through a skin patch for two years. The women were given a battery of standardized cognitive tests and a test of health-related quality of life at the beginning of the study, after one year, and after two years.

At the end of the study there was no difference between the two groups in either cognitive abilities or health-related quality of life.

“The results are very reassuring, because it suggests that women can use this patch without harm for two years,” says Yaffe.

Senator Barbara Boxer toured SFVAMC’s National Center for the Imaging of Neurodegenerative Diseases on July 7, 2006. She spoke to an audience of researchers and other medical center staff emphasizing her active support of V.A.’s research and health care programs. The senator has sponsored legislation that would fund V.A. and the Department of Defense to provide additional mental health and rehabilitative services for returning Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) veterans.

St. Luke’s

Jerome Franz, MD

The positive story at St. Luke’s in the field of mental health is several years old. The Centering Pregnancy Program offers group support for prenatal care as part of the obstetrical services of the Women’s Center. It was organized and continues to be run by Liz Steinfeld, CNM. Many women continue to meet after childbirth to support each other during the difficult postpartum period.

Last year the inpatient psychiatric floor was closed at St. Luke’s due to low volume. Our only inpatient psychiatric consultant was Mark Perl until May of this year. Mark was very busy and anxious to share the duties. We now have Laura Davies, who also treats children, and Ian Webber, who provides a referral service for managed care patients.

By the time this column is printed, we hope that the merger between CPMC and St. Luke’s has been finalized. Because there has been no response from the Attorney General, the lawyers have sent a twenty-day notice, which will allow the merger to take place unless an objection is issued by his office. The completion will help the mental health of our administrations, who have been acting as if the merger was fait accompli.

Dealing with Death: Continued from page 27...

Thwaites expresses gratefulness as he comments on the ways his career in palliative care have affected him. “On a regular basis, it makes me question my dogmas and strengthens my faith. Thus I continue to grow as a person. I see amazing things. There is a strong spiritual part to what I do that I did not find in other specialties. And I gain humility. Ultimately, I don’t have control.

Instead, I have a peaceful acceptance that fate will take its course sometimes. And I find strength in knowing that when you try your best, sometimes it is really out of your hands—even though this means that I am not as significant as my title implies.”

Congratulations Dr. Sikorski SFMS would like to congratulate Dr. Sikorski on winning the 2005 Dr. J. Elliott Royer Award. The award, given by the UCSF School of Medicine, goes to a Physician in San Francisco who has made a significant contribution to the advancement of psychiatry.

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in memoriam Nancy Thomson, SFM Obituarist

Herbert S. Kaufman, MD

Alfred Wheeler Childs, MD

Herbert S. Kaufman, MD, passed away at age 71 in his Mill Valley home on July 6, 2006, after a courageous battle with progressive supranuclear palsy. He was born to George and Elizabeth Kaufman in Salina, Kansas, on April 30, 1935. He graduated from the University of Kansas in 1957 and earned his medical degree from Baylor University College of Medicine in 1961. He received his training in allergy and immunology at UCSF in San Francisco and at Oxford University. Although he never lost his love for his Kansas roots, he made San Francisco his home in 1964.

Dr. Kaufman, known to friends and family as Herb, established his first medical office in San Francisco and then opened a second office in Kentfield, where he worked for more than thirty-five years until he was diagnosed with PSP three years ago. His contributions and discoveries in the field of immunology and allergies have helped people worldwide. Many years ago, while visiting fellow allergist Dr. Johnny Femini of Florence, Italy, Herb was shown a plant that was native to that area and known to cause severe allergies. Years later, after being unable to treat a patient successfully, he found that same plant, unknown to this area, growing at the patient’s home. He worked to develop a testing and treating antigen that is used to this day to treat Panteteria allergies.

Herb was a Diplomat of the American Board of Allergy and Immunology and a Fellow of the Royal Society of Medicine. He was also a member of several British and American allergy societies and of Technion, the Israel Institute of Technology, where he did allergy research for treating children with asthma at the hospital in Arad, Israel. For many years, Herb delivered the Bay Area pollen count during allergy season on KGO radio, where he was known as the “Cough Man.” Herb was a passionate and committed photographer who traveled to exotic and remote parts of the world with camera in hand. He entered his photographs in local and national competitions and recently won “Best of Show” at the Marin County Fair. He also had a love of classic cars—he even once held a birthday party for one of the cars in his collection. His love of the land, which began in his childhood in Kansas, stayed with him, and he treasured the time working the soil at his vineyard in Napa. He was a member of the Marin chapter of the Food and Wine Society of America (Haskel Norman chapter). He also served for several years on the board of Guide Dogs for the Blind.

He is survived by his wife, Vivian Johns Kaufman; children Alisa Rubel (Zigmund), Jeanette Kaufman, and Richard Kaufman; stepson Charles Gedeon; sister Jeanne Anshel (Arthur); and two sisters-in-law and three brothers-in-law, as well as many nieces and nephews. He also left behind his dog Dan, a beloved and loving companion.

Alfred Wheeler Childs, MD, passed away July 5, 2006, at the age of 83, after a four-month illness. He was born in San Francisco on October 11, 1922, the oldest child of Alfred Wheeler Childs and Genevieve Meloche.

He graduated from Sequoia High School in Redwood City in 1940.

He graduated from U.C. Berkeley in 1943 and earned his MD at UCSF in 1946. He was an intern at Permanente Hospital, Oakland, from 1946 to 1947. He was enlisted in the Army Reserve from 1943 to 1946, in the Air Force as Medical Officer from 1947 to 1949, and in the Air Force Reserve from 1949 to 1964. He was a visiting fellow in Medicine at Columbia University in New York from 1954 to 1956 and earned a master’s degree in Public Health from U.C. Berkeley in 1964.

Dr. Childs practiced internal medicine in San Francisco from 1956 to 1962 and in Berkeley from 1975 until his final illness. He taught medical care administration on the faculty of the U.C. Berkeley School of Public Health from 1964 to 1975 and served on the clinical faculties of Stanford Medical School and UCSF. He was also on the medical staff of Presbyterian Hospital, San Francisco (now CPMC); Alta Bates Hospital in Berkeley; and Peninsula Hospital in Burlingame. At Presbyterian Hospital, he was director of the Artificial Kidney Unit, and in this capacity he appeared on Science in Action on KRON and Doctor’s News Conference on KTVU. In 1991, he received an Alumni Citation from U.C. Berkeley, and in 1993, he received the Alumni of the Year Award from Berkeley’s School of Public Health. In 1994 and 2001, he received the Trustee’s Citation from the U.C. Berkeley Foundation.

He was a member of the San Francisco Medical Society, the AlamedaContra Costa Medical Association, the CMA and the AMA, the California and the American Public Health Associations, the American Society of Internal Medicine, the Western Society for Clinical Research, the American Association for Health Services Research, and the California Academy of Medicine. He was also a director of the Project Hope Alumni Board, for which he volunteered in Peru in 1962. He was also a member of the Lambda Chi Alpha Fraternity.

He enjoyed hiking, contemporary art, and music. He was a member of many art societies, served on the Board of the San Francisco Contemporary Music Players, and was one of the first members of SECA and SFMOMA. He is survived by his wife, Eunice Mahler Childs, his sisters, brother-in-law, goddaughter, and numerous nieces, nephews, and cousins.

For Local Events of Interest Visit the SFMS Website Our events page is now updated on a regular basis to include SFMS events and other local events of interest. Just go to our home page and click on “Calendar of Events” on the left-hand side. Visit us at: www.sfms.org

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september 2006 San Francisco Medicine 35

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