September 2011

VOL. 84 NO. 7 September 2011

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

Medicine for the Stages of Life

Pediatric and Adolescent Medicine Erikson Revisited Pediatric Cancer: No Longer a Death Sentence

Psychotropic Medicine for Youth Healthy Media Use for Teens

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

September 2011 · Volume 84, Number 7

Pediatric and Adolescent Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 Erikson Revisited: Eight Life Stages and Their Adaptive Strengths Steve Walsh, MD

4 Membership Matters

12 One More Cheerio: Confessions of a Pediatrician, Working Mom, and Nutrition Junkie Kimberly Newell, MD 14 Childhood Cancer: No Longer a Death Sentence Elizabeth Robbins, MD

16 A Parent’s Role: Guiding Young People on Healthy Media Use Shannon Udovic-Constant, MD 18 Struggling with Drug Use: Unique Challenges of Substance Use in Adolescents David Pating, MD 19 Working Partnerships: Pediatric Consultation Liaison Psychiatry Lynn Ponton, MD 21 Teen Pregnancy: Prevention Is the Key Kristina Roloff, MD 23 Psychotropic Medication for Youth: The Discussion Continues George Fouras, MD 25 The Development of Fetal Surgery: The Role of San Francisco Physicians Priyanka Ghosh 27 Health Policy Perspective: Rehab?

Steve Heilig, MPH 30 SFMS Hosts the Hiroshima 18th Medical Team

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

7 President’s Message George Fouras, MD 9 Editorial Gordon Fung, MD, PhD 28 Hospital News

MEMBERSHIP MATTERS A Sampling of Activities and Actions of Interest to SFMS Members

SFMS Takes on Local Community Issues

SFMS Art & Wine Member Mixer

In the last few months, SFMS has been actively involved in and has taken positions on a number of issues that could affect the practice of medicine in our community. On two of these issues, SFMS aligned itself with other community groups, and our combined efforts have resulted in successful outcomes.

Here are some recent SFMS activities:

Networking is ranked as one of the most valuable services provided by SFMS. To realize the full power of networking, SFMS will host a series of events that will help members connect in a relaxed, no-agenda format aimed only at networking. They’ll provide a great way to meet fellow SFMS members from the local community and share your experiences. Please check the SFMS blog at http://sfmedicalsociety.wordpress. com/ for details about upcoming mixers.

SFMS submitted an amicus curiae (friend of the court) brief supporting the lawsuit to remove the circumcision criminalization initiative from the San Francisco ballot. The SFMS brief argued that the

initiative violated state law that forbids municipalities from regulating the performance of medical practices for which physicians are licensed to perform, as well as interfering with the physician-patient relationship. The brief was prepared pro bono by the law firm of Wilson Sonsini Goodrich & Rosati and was widely quoted in the judge’s final decision.

SFMS joined the local coalition to defeat the ballot initiative designed to repeal the City’s “Care Not Cash” program. The public outcry against this initia-

tive has resulted in two of the five supervisors who had previously supported the initiative withdrawing their support. The initiative has been pulled from the November ballot.

SFMS participated in the July 27 launch meeting of the Health Care Services Master Plan Task Force. The Task Force was formed as a result of the San Fran-

cisco ordinance sponsored by Supervisor David Campos that became effective January 2011. The ordinance requires the creation of a Health Care Services Master Plan to identify the current and projected needs for health care services within San Francisco and to guide land-use decisions for health carerelated projects. SFMS Executive Director and CEO Mary Lou Licwinko, JD, MHSA, serves on the Task Force as the SFMS representative.

SFMS Night at the Symphony—October 28, 2011

Join SFMS on Friday, October 28, for an evening at the SF Symphony! Reserve your seat to see Alan Gilbert of the New York Philharmonic conduct Beethoven and Hayden. The $75 per person package includes access to the Green Room with complimentary drinks and hors d’oeuvres and one ticket to the orchestra section. For more details or to RSVP, contact SFMS at (415) 561-0850 or membership@sfms.org.

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San Francisco Medicine September 2011

SFMS Career Fair

Calling all residents, fellows, and employers! SFMS will be hosting our second annual Career Fair on Tuesday, September 27 in the Enright Room at CMPC, Pacific Campus . The event runs from 5:00 p.m. until 8:00 p.m. and is complimentary to residents and fellows. This is an excellent opportunity for physicians looking to practice in the Bay Area to network with representatives from a variety of practice types and settings, and for employers to connect with physician job seekers.

As part of an effort to make participation accessible to all, we are offering a tiered pricing structure for employers, ranging from $100 to $250; solo practices can exhibit free of charge. Exhibitor set up will be from 4:30 p.m. to 5:00 p.m.

For event details or to inquire about exhibiting, contact the Membership Department at (415) 561-0850 or e-mail membership@sfms.org.

Members Honored as Health Care Heroes

SFMS members Mason Turner, MD, and Shirley Tamoria, MD, were recognized at the Business Times Health Care Heroes Award Breakfast in late July, for their dedication to improve health care and the lives of their patients. Please join the SFMS in celebrating Drs. Turner and Tamoria for their accomplishments and service to our community.

Photo by the SF Business Times. www.sfms.org

September 2011 Volume 84, Number 7

New Assessment Tool for Tackling Health Disparities Communication can go a long way toward reducing health disparities and improving care for all patients. The Communication Climate Assessment Toolkit (C-CAT), a new set of assessments developed by the AMA, can help physician practices measure how well they communicate with patients. The free C-CAT contains surveys that can help you or the organization you work in gauge whether effective communication is taking place. Questions focus on common communication problems facing diverse patient populations, such as culture, language, and health-literacy gaps. The C-CAT also features various data tools to demonstrate whether a practice’s policies, practices, and culture promote effective, patient-centered communication.

C-CAT surveys are open to the public and available for download at http://www.ethicalforce.org.

Plan Now for ICD-10

ICD-10 is shaping up to be the largest health care compliance-driven convergence and coordination of people, information, technology, and education in more than twenty years. SFMS has partnered with ACCMA to offer a webinar on October 5, 12:30 to 1:45 p.m., to help members prepare their practices for compliance. Register today by contacting Dennis Scott at dscott@accma.org or call (510) 654-5383.

SFMS On-Site Seminars

October 14: Creating a “Director of First Impressions”—Customer Service, Patient Relations, and Telephone Techniques This half-day practice management seminar provides valuable training for both front- and back-office staff to handle patients and tasks efficiently and professionally, using superlative customer service skills. This seminar will provide your staff with the tools necessary for positive patient relations. 9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast). $95 for SFMS/CMA members and their staff ($85 each for additional attendees from the same office); $150 each for nonmembers.

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

October 28: “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. This seminar teaches the core business elements of managing a practice that physicians don’t receive in medical school training. 9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast). $225 for SFMS/CMA members and their staff ($200 each for additional attendees from same office); $325 for nonmembers. Contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260, for more information.

CMA Webinars

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events.

• October 5: Providing Extraordinary Customer Service • 12:15 p.m. to 1:15 p.m.

• October 19: EOB Analysis—Successful Claims Appeal • 12:15 p.m. to 1:15 p.m.

• October 26: Key Financial Ratios to Increase Profitability • 12:15 p.m. to 1:15 p.m. and 6:15 p.m. to 7:15 p.m.

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Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD

SFMS OFFICERS President George A. Fouras, MD President-Elect Peter J. Curran, MD Secretary Lawrence Cheung, MD Treasurer Shannon Udovic-Constant, MD Immediate Past President Michael Rokeach, MD SFMS EXECUTIVE STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon

BOARD OF DIRECTORS Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD

Term: Jan 2009-Dec 2011 Jeffrey Beane, MD Andrew F. Calman, MD Lawrence Cheung, MD Roger Eng, MD Thomas H. Lee, MD Richard A. Podolin, MD Rodman S. Rogers, MD

Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Shannon UdovicConstant, MD Joseph Woo, MD CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

September 2011 San Francisco Medicine

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San Francisco Medicine September 2011

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PRESIDENT’S MESSAGE George Fouras, MD

Protecting Children: How Far Do We Go? Over the years, we as a society have felt that the protection of children from specific items or events is in the best interest of the child. For example, we have legislation that prohibits youth under the age of eighteen from smoking and for youth under the age of twenty-one from drinking alcohol, and minors from having sexual intercourse. In addition, we have, as a society, prohibited advertisements for tobacco products and alcohol over network television.

We have done this because we recognized that children are not developmentally ready to deal with such concepts, and to empower parents and caretakers of children to make the decisions they feel are appropriate in the raising of their children.

Oddly enough, the depiction of extreme and gratuitous violence, on television and in movies targeted toward the teenage audience, is permitted. Recently, Senator Leland Yee authored legislation designed to protect children from violent video games and to empower families in controlling what media their children are exposed to. As expected, this issue finally reached the U.S. Supreme Court, which, in a seven-to-two decision, struck down this law on free-speech grounds, stating that children have a right to view such media. In a recently published op-ed piece, the gaming industry took this “win” as an affirmation of its position. The piece that was missing is that the basis of the argument was, in my opinion, flawed.

These games were compared to Saturday morning cartoons.

But the fallacy is that kids do have a capacity to tell fantasy from reality. They know that rabbits cannot speak. But shooting a “hooker” for points is a reflection of life.

In another example of irony, the film industry may be compelled to give an R rating to a film that portrays normal, healthy, romantic, and sexual relationships among human beings or portrays violence in a historically accurate manner, yet may give a PG-13 rating to a movie that contains gratuitous violence.

Much attention has been raised recently over the nutritional value of foods that are targeted toward children. This has most recently been brought into focus by the First Lady’s campaign to raise awareness regarding childhood obesity and the increased incidence of diabetes among children. The medical community has long known of the poor nutritional value of foods targeted toward children, often in the form of highcalorie and high-fat meals with little nutritional value. We have had some wins over the years but are still challenged in trying to change societal norms versus overwhelming corporate influence to maintain the status quo. In the July 25, 2011, issue of American Medical News, the Opinion column noted

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that the June report of the Institute of Medicine that stated that approximately 10 percent of children from infancy to age two are obese, a figure that rises to 20 percent by age five. Excess weight gained early in life may affect metabolic systems, which may then raise the risk of chronic disease later in life.

For another example of corporate influence, we have to look no further than the tobacco industry. After decades of trying to make a difference in how cigarettes and other tobacco products are marketed, and finally winning legislation that can control the tobacco industry, a new development has occurred. The introduction of E-cigarettes, a tobacco-less, smokeless form of nicotine delivery, is being strongly marketed, especially to children and teenagers, using fruity flavors and smells that are appealing to younger people and adults alike.

E-cigarettes have the potential of addicting thousands and millions of people to nicotine. They completely circumvent all tobacco legislation and present new challenges to efforts to control nicotine addiction. Working with our health department, which recently adopted new policy to bring ecigs under tobacco regulations, the SFMS will be asking the CMA to look at this on a statewide basis as well.

The common thread in all of these examples is that children and teenagers are still growing and developing both mentally and physically. Family members should be the primary people to set rules and boundaries and raise youth to be able to handle more adult choices and situations. Our role as a society is to empower families and to shield them from overwhelming influences that subvert their abilities to raise their children. This is why we must continue to pursue these goals and educate the people who have the political power to help.

September 2011 San Francisco Medicine

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Come see it for yourself. Because when it comes to surgery, Saint Francis gives you plenty of room to operate.

THURSDAY, SEPTEMBER 22, 5:00 - 7:00 PM Saint Francis Memorial Hospital 900 Hyde Street (at Pine) RSVP: 415.353.6547 or linda.gillespie@chw.edu

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San Francisco Medicine September 2011 saintfrancismemorial.org

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EDITORIAL Gordon Fung, MD, PhD

Medicine for the Phases of Life In contrast to the way we learned medicine initially, as specific courses in anatomy, physiology, biochemistry, and microbiology, beginning with the normal and progressing to the abnormal and then moving through our clerkships in the different specialties of medicine, surgery, ob/gyn, pediatrics, neurology, psychiatry, family medicine, and anesthesia, most physicians approach the practice of medicine as problem-based issues.

We see and listen to each patient and then try to come up with a diagnosis and a treatment plan. For the more difficult patient, we will pursue a diagnostic workup that can be quite involved before we actually come up with a diagnosis, and sometimes we are forced to begin treatment for the most pressing issue while the diagnostic workup continues. Ultimately, we can make a diagnosis and develop a treatment plan that will be specific for every patient, which must include the patient as a partner in his/her own management, the support system, and medical care team. With whatever field of medicine we choose to specialize in, there is more to study in terms of the origin of disease, the mechanism of the disease process, and how it may be transmitted or spontaneously occur. There is ongoing research to determine the genetic mutations that cause disease or allow certain individuals to be more susceptible to diseases.

Currently, most medical schools are actively engaged in curriculum redesign, moving away from large classroom lectures to more problem-based learning in smaller groups.

Instead of trying to offer the student a comprehensive background and foundation of medicine (which is constantly growing and expanding), the focus is to work with the students to provide each one with the tools and resources to learn on their own. One such approach is the basis of the current series in San Francisco Medicine.

Over the next four months, we will attempt to look at medicine through the phases of life—young, middle-aged, and elderly—and then the phases of a medical life or the life of a physician. Some of the thought behind this series will become more clear as each edition unfolds, but we recognize that most physicians who take care of patients appreciate that people are constantly moving through different phases of life, and that illnesses can occur at any one of those phases. There is a growing amount of literature and research into how people of different ages, ethnic backgrounds, and genders not only acquire diseases but also respond to different diseases. There is also an increasing awareness that certain diseases will affect the different age groups with different incidences. A prime example is cardiac disease: Young people would tend to be more affected by congenital heart disease, while the middle-aged and elderly would be more affected by the acquired diseases of coronary heart disease and valvular disease that progress www.sfms.org

with complications.

Another major focus of medical care now is prevention.

There is a widely accepted premise that the best way to decrease health care costs and improve the health of the population is to prevent disease. The vast majority of medical care costs come from treating patients at the end of life, or treating diseases—atherosclerotic diseases, diabetes, hypertension, obesity—that are largely preventable. Physicians and other clinicians who care for patients mostly in the middle and later phases of life should still be emphasizing prevention, if the diseases that are common to that group have not yet struck, but it is more important to begin prevention among the family members of the adults and elderly. We also need to look at all the different phases of life to see when and how prevention strategies can be most effectively and efficiently applied.

There is every hope that if we can apply the right strategies and education, supported with peer pressure, we can make an impact on cigarette smoking and especially the obesity epidemic and its usual cohorts of diabetes and hypertension.

So we start this month with Part I: Pediatrics and Adolescence. Dr. George Fouras, our current SFMS president, will present some of the latest discussions and controversies on ADD and ADHD. Dr. David Pating, from Northern California Kaiser and past president of the Society of Addiction Medicine, provides an article on the problems of addiction in youth. Dr. Elizabeth Robbins, professor of pediatrics and a specialist in oncology, discusses the development and some of the milestones in pediatric oncology. There is also a discussion on the latest developments in fetal surgery. Shannon Udovic-Constant, a current SFMS board member and pediatrician, discusses the issue of teens and the media. Nancy Iverson will explore the issue of terminal illness in this phase of life. Also, we will have a discussion on proper nutrition for this group. We hope you enjoy reading the next several issues as we explore medicine for the stages of life.

September 2011 San Francisco Medicine

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Pediatric and Adolescent Medicine

Erikson Revisited Eight Life Stages and Their Adaptive Strengths Steve Walsh, MD

This and the two following issues of San Francisco Medicine explore life-stage-related medical and psychiatric concerns among our patients and, perhaps, among ourselves. This article revisits Erik

Erikson’s now-classic perspective on the human life cycle and its eight stage-related developmental tasks, conflicts, and “crises.” Most physicians, during their premedical and medical school education, have some exposure to the Eriksonian developmental model. Review of this may be useful for framing this month’s theme of childhood and adolescence, next month’s adulthood and midlife theme, and the following month’s theme of maturity and old age.

Perhaps less familiar to physicians is Erikson’s description of what he calls the development of “adaptive human strengths” and “a schedule of virtues” associated with the eight stages of the life cycle. Here he speaks of the development of the “inherent strengths” and capacities for hope, will, purpose, competence, fidelity, love, caring, and wisdom in individuals as they proceed from infancy to old age. Erikson regards these “ego strengths” as related to the survival of human individuals and groups, and therefore selected for in the course of evolution. He says, “For man’s psychosocial survival is safeguarded only by vital virtues which develop in the interplay of successive and overlapping generations living together in organized settings.” This added conceptual frame rests on his earlier eight-stage model of individual development published in 1950 in Childhood and Society. The eight “inherent human strengths and adaptive virtues” work was published later as “Human Strength and the Cycle of Generations” in 1964 in Insight and Responsibility, a collection of essays. It was an expansion of his address, in memory of Sophie Mirviss, MD, given here in San Francisco for the Psychoanalytic In10 San 11 SanFrancisco FranciscoMedicine Medicine September September2011 2011

stitute and Mt. Zion Medical Center in 1960.

To review Erikson’s eight “crises”/developmental tasks/conflicts in human development, I list them here as follows, along with the respective “human strength” associated with each of the eight stages: 1.) A development of trust versus mistrust (birth to eighteen months; capacity for hope) 2.) A development of autonomy versus shame and doubt (eighteen months to three years; capacity for will) 3.) A development of initiative versus guilt (three years to five years; capacity for purpose) 4.) A development of industry versus inferiority (five years to thirteen years; capacity for competence) 5.) A development of identity versus role confusion (thirteen years to twenty-one years; capacity for fidelity) 6.) A development of intimacy versus isolation (age twenty-one to forty years; capacity for love) 7.) A development of generativity versus stagnation (age forty to sixty years; capacity for caring) 8.) A development of ego integrity versus despair (age sixty until death; capacity for wisdom)

Erikson’s work was a product of early psychoanalytic research, based on individual cases in which individual psychodynamics, family and social environments, societal forces, and history are interwoven with great skill.

Cross-cultural and biographical research also underlay his views of these universal major stage-related conflicts and issues. As in Freud’s psychosexual stages, most www.sfms.org

of Erikson’s stages in ego development occur in childhood and adolescence. Unlike the Freudian conception, Erikson’s stages are predominately psychosocial, more about the developing ego’s relations to the social world, to culture and traditions. They relate to the “cogwheeling” interactions with older “others” working through their own individual developmental stages and “inherent strength” development in complementary ways. Erikson, more than Freud, also described the developmental tasks of youth, middle age, and old age. We focus on these in the following two issues of San Francisco Medicine. The first five stages, of childhood and adolescence, are of most concern this month.

Erikson’s model of psychosocial development across the life cycle is itself modeled on the epigenetic principle of organismic growth in utero. Here development proceeds along largely predetermined lines, with elements of each phase present from birth and differentiating over time. Each stage has its time of “crisis,” a turning point of “opportunity and heightened potential.” Each is a period of increased vulnerability and “therefore, the ontogenetic source of generational strength and maladjustment.” Work on any stage is never complete, and old developmental conflicts can be reactivated by current stressful life events.

There is a potential to rework the old issues in a better way. Good psychotherapy is important at these times. Recently a patient of mine affirmed this, saying, “Doc, I don’t want to just feel better. I want to be better!”

Each development stage is dependent on how earlier phases have gone. Erikson has said that “psychosocial development proceeds by critical steps—’critical’ being a characteristic of turning points, of moments of decision between progress and regression, integration and retardation.” Parental attitudes and the values and customs of the child’s culture obviously strongly affect their experience of these turning points.

From birth to approximately eighteen months, the infant is ideally interacting with trustworthy others in a reciprocally active and satisfying way, developing a sense of trust over distrust. The infant’s capacity for hope as a basic quality of experience develops in this stage. Erikson describes hope as an “adaptive virtue,” as “the enduring belief in the attainability of fervent wishes, in spite of the dark urges and rages which mark the beginning of existence.” The development of the capacity to will flows from the emergence of the child’s growing sense of autonomy between eighteen months and three years of age. The emerging conflict is with a sense of shame and self-doubt at this stage of early speech and sphincter and muscle control. A favorable ratio of these feelings leads to the capacity to will as “the unbroken dewww.sfms.org

termination to exercise free choice as well as self-restraint, in spite of the unavoidable experience of shame and doubt in infancy.” From age three to five the third vital “adaptive virtue” of purpose, based on the preceding development of hope and will, can emerge from the third “crisis” of the developing sense of initiative versus feelings of guilt. Erikson defines purpose as “the courage to envisage and pursue valued goals uninhibited by the defeat of infantile fantasies, by guilt and by the foiling fear of punishment.” From age five to thirteen, the child discovers the pleasures of being productive, of learning new skills and taking pride in things made.

The growing sense of industry may be experienced along with a vulnerability to feelings of inferiority. Teachers and other role models are crucially important in the child’s ability to overcome a sense of inferiority. This develops the virtue/adaptive strength of competence. Erikson defines this human strength as “the free exercise of dexterity and intelligence in the completion of tasks, unimpaired by infantile inferiority.”

Erikson’s fifth stage, of adolescence into early adulthood, age thirteen to twenty-one years, includes puberty onset with its social and physiological changes. Here arises the question of identity formation versus role confusion.

He states that “youth are primarily concerned with what they appear to be in the eyes of others as compared to what they feel they are, and with the question of how to connect the roles and skills cultivated earlier with the occupational prototypes of the day.” The integration occurring in the formation of ego identity includes childhood identifications with important others, and “the accrued experience of the ego’s ability to integrate these identifications with the vicissitudes of the libido, with the aptitudes developed out of endowment, and with the opportunities offered in social roles.” Identity is an “accrued confidence,” an “inner sameness and continuity that . . . can be taken for granted.” There is an “ideological” seeking after inner coherence and a durable set of values. A successful outcome here leads to the ego quality or capacity for fidelity. Erikson describes fidelity as “the ability to sustain loyalties freely pledged in spite of the inevitable contradictions of value systems.” A good sense of identity and a capacity for fidelity (to values, work, others) depend on how well the previous life stages and their “crises” have been positively resolved. In turn, future development of adult “virtues” of love, caring, and wisdom depend on the formation of a positive identity and the developed capacity for fidelity.

In these first five stages of child and adolescent development, Erikson, like Freud, includes consideration of stage-related biological changes in his extensive research and writing. His unique contributions have been to “ego psychology” and to understanding the “cogwheeling” mutuality between the generations, each contributing to the others’ development throughout the life cycle. His insights and frameworks for understanding these complexities remain highly useful in our time.

Steve Walsh, MD, is a psychiatrist, former SFMS president, and member of the SFMS Editorial Board.

September 2011 San Francisco Medicine

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Pediatric and Adolescent Medicine

One More Cheerio Confessions of a Pediatrician, Working Mom, and Nutrition Junkie Kimberly Newell, MD

I love food. Real food. Food that looks like something that you could grow in your own backyard.

We grew lots of vegetables in my backyard in the mountains of North Carolina, and I can still taste the sweet summerness of peas stolen from the plant and popped into my mouth during a game of hide-and-seek. And so the bounty of California produce, available year round in variety I could never have imagined growing up, is one of the biggest benefits of life in San Francisco for me.

As a pediatrician, counseling patients on nutrition is at the core of my practice, not least because so many of my patients are over- or undernourished. By that I mean that one-third of the patients in our practice are overweight or at risk of being overweight (overnourished), and yet many of those patients are not well nourished: They get plenty of calories, but they don’t get enough healthy ones. And many of the foods they get are full of pesticide residues and arrive in 12 13

San Francisco Medicine September 2011

plastic bottles or cans made with chemicals such as bisphenol-A that may be damaging to their neuroendocrine systems.

In my practice, I struggle to find the right ways to motivate families to change eating habits that are entrenched in their households and that are exacerbated by the influences of media, marketing, and the frustratingly easy availability of inexpensive, unhealthy processed foods compared to the poor availability and the expense of real food.

So imagine my excitement when I became a mother and could be completely in control of the intake of my little one: Suddenly I had a clean plate/palate/ palette, a completely dependent child whom I could keep free from pesticides, preservatives, and BPA plastic residues. I was elated when my (now eight-month-old) daughter was old enough to start eating something other than breast milk. Processed rice cereal? No way. I diligently woke from the sleep-deprived slumber of a new mother to steam and puree brown rice, pears, sweet potatoes, and bananas in anticipation of the big day.

Much like me, my daughter had been an eater: She doesn’t sip her milk; there’s nothing ladylike at all in her manner as she slurps and smacks and chugs. She is also incredibly orally interested: All objects in the world seem to exist only insofar as they can be put in her mouth. And so I assumed that she’d be just as eager and efficient when I introduced pureed foods to her.

No dice. My independent young lady grabs the spoon, flips it around, and shoves the non-food-bearing end deep into her throat, gurgling in pleasure. But if I try to get food into her mouth, she clasps it shut and makes a face as if she’s being tortured; if some food gets into her mouth by some miracle, she responds with an enormous (drama queen!) gag.

What to do? I’ve tried everything: patience (surely she’ll grow to like food!), variety (if not the yellow cling peaches, perhaps she’ll favor the white nectarines), and equipment (she takes the little mesh bag full of apples or pears that she is supposed to gnaw on and turns it around and merrily chomps on the plastic handle). The only thing she consistently gets excited about is . . . processed food. Those tempting little Oshaped cereal bits that she can put into her mouth and that easily dissolve on the tongue as she grins cheekily at her whole-food mother. www.sfms.org

And now comes the difficulty of being a working mom: My breast-milk production during a busy day at work is not up to snuff. My goal had been to never give her any factoryderived “milk” product (i.e., formula), but I’m coming up against a wall: My baby needs calories and I can’t provide them (or she refuses them).

Back in my practice, I spend my day between my breast pump and my patients, still honing my conversation about nutrition. Luckily, this year, the USDA has come to help with a completely new vision of how we should discuss eating with our patients: the plate method (http://www.choosemyplate. gov/). The food pyramid never worked for me; it’s complicated and doesn’t help distinguish between members of food groups (for example, whole grains = healthy; pasta and breads made from simple carbohydrates = less healthy). The plate method is better—it’s simple and easily understandable.

I also turn to a Bay Area food celeb, Michael Pollan, who has summed up my nutrition recommendations so beautifully that I quote him constantly when discussing nutrition with my patients’ families: “Eat food. Not too much. Mostly plants.”

Pollan’s mantra is like the best haiku, the best Zen koan: simple, brief, and yet complex and universal.

Another Bay Area writer and physician, Daphne Miller, gave me inspiration for my counseling in her book The Jungle Effect.

After reading Dr Miller’s book, I started telling my patients, “Try to only eat food that your grandmother would recognize.” “My grandmother’s favorite food is hot chips!” retorted one young patient of mine. Then I realized that I have several patients whose great-grandmother is alive and well, and in some cases is the primary caretaker and provider of junk food to the family. So now I resort to this advice: Try to mostly eat food that an ancestor of yours who lived 100 years ago would recognize.

I also like to warn my patients of some of the more egregious ways that processed food companies try to hide the unhealthy contents in ingredient lists. For example, the many names of “sugar” ingredients are split in the ingredient list to disguise the overall sugar content. A “healthy” snack may contain sucrose, honey, lactose, maltodextrin, xylose, and corn syrup: That’s five different types of “sugar.” And then there’s the bad boy on the street: high-fructose corn syrup. Some research suggests that high-fructose corn syrup (HFCS) is metabolized in a way that is different than sugars such as sucrose and may lead to more obesity, kidney disease, and diabetes.

Others argue that it’s just the same as other forms of sugar.

But regardless of the truth, it has gotten a bad name. What do you do when you have a bad name? Change it. The makers of HFCS are petitioning the USDA to change the name to “corn sugar.”

Sneaky. www.sfms.org

As I finish up my day counseling patients and head home from work worrying about making enough milk to feed my daughter, I contemplate her lot: What is the first ingredient in the formula that I will probably soon have to give my daughter? You guessed it: corn-syrup solids.

Let me pause to say that I know many healthy people who were raised entirely on formula. And I’ve counseled many parents of infants that giving them formula will not harm them in any way. But am I good at taking my own advice? Of course not.

Why do I worry? I’m raising my daughter in a world where sugar calories account for 15 percent of our diet. That’s 50 percent higher than when I was raised in the 1970s. She’s growing up in a world where our air, water, and soil contain unprecedented quantities and types of chemicals that have not been adequately researched. She’s growing up in a world where food companies have honed their products to make them more and more attractive (or may I say addictive) and in the process less and less healthy.

In these short eight months, I have realized that I cannot control my daughter’s diet. Our world is too complicated. My biology is not cooperating. I am a working mother and that brings its own challenges, along with the rewards.

And so though I know what I should give you, what I wish you would accept, here’s one more Cheerio, my love. . . .

Kimberly Newell, MD, is a pediatrician with Kaiser Permanente San Francisco.

References http://well.blogs.nytimes.com/2010/09/14/a-new-name-forhigh-fructose-corn-syrup/ http://well.blogs.nytimes.com/2008/10/30/still-spooked-byhigh-fructose-corn-syrup/ http://www.choosemyplate.gov/

Calling All Residents, Fellows, and Employers!

SFMS Annual Career Fair Tuesday, September 27, 2011 5:00 p.m. to 8:00 p.m. (exhibitor set up 4:30 p.m.)

Enright Room at CPMC, Pacific Campus This is an excellent opportunity for physicians looking to practice in the Bay Area to network with representatives from a variety of practice types and settings, and for employers to connect with physician job seekers.

Employers: As part of an effort to make participation accessible to all, we are offering a tiered pricing structure for employers ranging from $100 to $250; solo practices can exhibit free of charge. For event details or to inquire about exhibiting, contact the Membership Department at (415) 561-0850 or email membership@sfms.org.

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Pediatric and Adolescent Medicine

Childhood Cancer No Longer a Death Sentence Elizabeth Robbins, MD

Cancer survivor, now four years old and cancer free (pictured here during treatment).

Just fifty years ago, a child diagnosed with cancer had only about a 10 percent chance of survival.

Today nearly 70 percent of children with cancer survive, and young children diagnosed with pre-B acute lymphoblastic leukemia (ALL) have close to a 90 percent survival rate.

Early progress in childhood cancer began in the 1960s with Sidney Farber’s work at Children’s Hospital, Boston.

At the time, children with ALL survived an average of three months. Farber administered aminopterin, a folic acid antagonist, to sixteen children; a temporary remission was achieved in ten. Additional drugs were tested, and by 1962 vincristine, l-asparaginase, and 6-mercaptopurine were also available.

Combinations of these and other drugs, including corticosteroids, produced lasting remissions in children with leukemia.

Unfortunately, however, the disease usually recurred, often in the central nervous system and meninges. “Total therapy” to address these sites included cranial spinal irradiation; this was eventually replaced, in most cases, with intrathecal chemotherapy, which does not cause the significant cognitive and 14 15

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behavioral complications associated with cranial radiation.

Progress in other childhood cancers has also been dramatic. Wilms’ tumor, a cancer of the kidney curable in only 30 percent of children in the 1960s, is now curable in 90 percent of patients. In 1969, a consortium of pediatric hospitals founded the National Wilms’ Tumor Study Group (NWTSG). A series of treatment protocols over the next decade succeeded in defining curative treatment for Wilms’ tumor; subsequent protocols focused on decreasing the duration of chemotherapy required. Current treatment for resectable Wilms’ tumor involves just twenty-four weeks of chemotherapy with actinomycin D and vincristine. Late effects from this regimen are minimal. Radiation therapy is only required in a minority of patients who have nonresectable disease.

Further advances in pediatric oncology occurred coincident with the formation of national, multi-institutional cooperative treatment groups. Four groups combined to form the Children’s Oncology Group (COG) in 1999. Nearly all hospitals that treat children with cancer are members of COG. COG fowww.sfms.org

cuses on treatment protocols and research; study committees for each disease direct the group’s efforts. In addition to firstline treatment protocols, COG also develops Phase I treatment protocols with investigational drugs and numerous tumor biology and epidemiology studies. Because of the relatively large number of children enrolled in cooperative studies, treatment efficacy and toxicities are quickly identified. Open treatment protocols, with clinical research components, are available for most childhood cancers.

Although cancer is the leading cause of disease-related death for children under age fourteen, childhood cancer is uncommon. Approximately 12,400 children under age twenty are diagnosed with cancer each year in the United States.

A new baby faces approximately a one in 300 chance of being diagnosed with cancer prior to reaching adulthood.

Acute leukemia and tumors of the central nervous system account for more than half of all cases.

Symptoms of cancer in children can be subtle, often mimicking those of an insignificant viral illness. Early symptoms of leukemia can include fatigue, fever, and pallor. Often it is only when the illness persists or when the symptoms worsen to include bruising or bone pain that parents and physicians begin to suspect a serious underlying disease. Headache, a fairly common symptom in children, is sometimes the first sign of a brain tumor; cervical lymphadenopathy, also common in children, can be the first manifestation of lymphoma.

Approaches to the treatment of pediatric cancer continue to evolve. Early drugs such as methotrexate targeted cellular metabolic pathways; while effective against malignant cells, these drugs also caused significant injury to normal cells, resulting in well-known side effects such as cytopenias, mucositis, and organ damage. Recently developed drugs are more specific: Mechanisms of action include targeting an abnormal gene or pathway within a malignant cell. The tyrosine kinase inhibitor imatinib (GleevecÂŽ) is an example of this type of drug. In addition to targeted therapy, a recent focus has been the study of biologic markers at diagnosis that can stratify patients into good and poor risk groups prior to initiating therapy. For patients with neuroblastoma, analysis of the oncogene MYCN, DNA ploidy, and cytogenetics, coupled with stratification based on patient age and staging, can identify a group of patients expected to have a favorable outcome with only minimal therapy. For patients with ALL, favorable cytogenetics (e.g., the ETV6-RUNX1 translocation; trisomies of 4, 10, and 17) coupled with stratification based on age, WBC count, and phenotype, can identify a group of patients whose survival is expected to be 90 percent or greater; therapy in this group of patients is less intensive than in high-risk groups.

Supportive care for children with cancer has been one of the great success stories of the past twenty-five years. Pain, often present in children with cancer, can now be nearly completely avoided. Central venous catheters provide acwww.sfms.org

cess for blood draws and chemotherapy infusions, avoiding the need for repeated pokes for IV access. Topical lidocaine/ prilocaine cream effectively numbs the skin prior to access of a subcutaneous port. Painful procedures such as bone marrow aspirates and lumbar punctures are often performed under general anesthesia. Finally, the development of serotonin receptor antagonists such as ondansetron have dramatically reduced and in many cases eliminated nausea and vomiting caused by chemotherapy.

Numerous organizations provide emotional and practical support to families and patients. The Leukemia & Lymphoma Society, in addition to providing funds for basic research, also provides funds for basic family needs, including travel expenses. The Make-a-Wish Foundation provides a wish for every eligible child with a life-threatening illness. Popular wishes include a trip to Disneyland, a vacation in Hawaii, or a meeting with a professional athlete or movie star. Finally, a child’s educational needs are continuously addressed during chemotherapy treatment: Many hospitals have schoolrooms staffed with certificated teachers. Local school districts can often provide patients with home teachers and tutors. With this support, children with cancer can almost always remain at grade level despite intensive chemotherapy regimens.

Challenges for the future abound: Ongoing efforts are focused on tailoring treatment to each child in order to provide more intense and effective treatment to those with high-risk disease, and to reduce treatment and resulting side effects for those children expected to have a high cure rate. Microarraybased gene expression profiling may be a helpful tool in this effort. The ultimate challenge is to elucidate specific causes of malignant transformation, thereby opening the door to cancer prevention.

Elizabeth Robbins, MD, is a clinical professor of pediatrics at the University of California, San Francisco.

References Pearson HA. History of pediatric hematology oncology.

Pediatr Res. 2002; 52:979-992.

Gurney JG, Bondy ML. Epidemiology of Childhood Cancer, in Principles and Practice of Pediatric Oncology, fifth edition; Pizzo PA, Poplack DG. 2006; Lippincott, Williams, and Wilkins.

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Pediatric and Adolescent Medicine

A Parent’s Role Guiding Young People on Healthy Media Use Shannon Udovic-Constant, MD A parent’s role in young people’s media use in the past was to ask that the television get turned off or to tell them to get off the phone to get their homework done. Now young people use their computer to do their homework and are attached to phones with texting ability, so we can’t get them away from the distractions and the potentially harmful effects of social media use.

There are also major issues affecting a young person’s well-being that may arise from social media use. We are seeing an increase in the harmful effects of social media.

In the news lately are stories such as a teen girl sending her boyfriend a “sext”—a sexual text—that then got forwarded broadly. The young person who forwarded it was charged with felony child pornography. Another story in the news is that of a young college student in Southern California who posted on her Facebook page an inappropriate comment about a certain ethnic group and is now transferring to another college due to the social isolation she received.

With all of this, a parent’s first reaction might be to try to ban his or her child from social media. But there are also social benefits for young people, including enhancing communication, social connection, and even technical skills. Also, the most dangerous concept regarding an adolescent’s digital media use is to deny them access without guidance. Young people will try to use such media behind their parents’ backs by using a friend’s computer or a computer at school—and then the parent will not have any idea what the teen is involved in.

Instead, we want to create “digital citizens”—young people who are skilled in the healthy and responsible use of social media.

Here are some questions and answers designed to help you and your child/teenager use social media in a healthy, safe, and fun way.

1. At what age should I allow my child to sign up for a social networking site such as Facebook or MySpace?

The youngest age should be thirteen. Congress set the age of thirteen years in the Children’s Online Privacy Protection Act (COPPA), which prohibits websites from collecting information about children younger than thirteen years without parental permission. Also, falsifying the child’s age sends a mixed message about lying and online safety.

2. How do I keep them from releasing information that is unsafe?

Review online safety with your child. Use the appropri16 17

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ate privacy settings. Remind them not to post their location online, not to chat with a stranger or to “friend” a stranger. A good site to review with your child on online safety is http:// www.thesafeside.com/documents/The_Safe_Side_Internet_ Safety_Family_Guide.pdf.

3. Should I monitor their site?

For most young people the answer is yes. You should be honest with them about this when it is getting set up. Arrange regular family meetings to review the site together. Advise your child that continually reviewing privacy settings helps keep them and their site safe. Also, you can take things down that are not appropriate and help navigate online citizenship and healthy behavior.

4. What is cyberbullying?

Cyberbullying is bullying, intended to be hurtful to another person, by using any form of technology. Cyberbullying occurs among 75 percent of teens, based on a study at UCLA. Only one in ten reported the problem to a parent or adult.

Signs to identify that your child is being bullied online:

• Subtle changes in behavior • Not wanting to go to school or doing poorly in school • Being upset after use of cell phone or computer • Switching screens when an adult enters a room • Sleep disturbance—especially staying up late to text or use the computer • Withdrawal, anxiety • Being overly vigilant with technology

6. What should I do if my child is being threatened or harassed online?

Tell your children always to alert you to things that are said that hurt their feelings. Also remind them not to respond to such messages. Generally, the best thing to do is to alert someone at school. Schools now have set up guidelines for this. The reason to involve the school is that if you approach the parent of the bullier, there are two usual outcomes that are not ideal: One, the parent ignores it, which lets the bully think it is all right. Two, the child engaging in the inappropriate behavior gets in trouble and blames your child. Involving the school will make sure that the behavior stops. School administrators can do this confidentially, without naming your child as the one who brought it to their attention. www.sfms.org

Resources • Kidsareworthit.com • Stopthebullying.org

6. What is sexting?

Sexting is sending a text message with pictures of naked body parts and/or sex acts. This can start as young as in the fifth grade. Sexting is dangerous and has serious legal implications. The young person can be listed as a sexual offender, because sexting is considered child pornography. If this occurs, then Child Protective Services usually gets involved.

7. How do I help my child understand the right things to post online?

This needs to be learned, which is why monitoring a child’s site and having conversations about online activity is important. At issue is that once something is sent, you can’t get it back. It is permanent and can be sent to others.

Before sending anything digitally, ask: Is the digital message RITE?

• Reread your message to be sure it sounds OK. • Imagine if you were receiving the message—would you be upset or hurt?

•Think about whether it needs to be sent now or can wait a bit.

• Enter—send the message. (from Cybersafe, by Gwenn Schurgin O’Keefe)

Skills that all of us need to be successful media users include: • Learning how to manage online identity • Learning to behave ethically online • Being able to assess the credibility of information • Learning how to multitask well

Finally, parents should be encouraged to be active in their child’s media life. Some examples of strategies to achieve this include: • Ban the TV from the kids’ bedrooms.

• Turn the TV off at dinner. Family dinner is protective against a variety of negative issues.

• Place the computer in a central location at the home.

• Ask kids about their media day.

• As parents, work on your own “participation gap” at home by becoming better educated about the many technologies your children are using.

• Set limits on the amount of time allowed www.sfms.org

online per day for kids.

• Review the sites children may visit and those that are prohibited.

• Develop a family online-use plan that involves regular meetings to discuss online topics, checks of privacy settings, and reviewing online profiles for inappropriate posts.

• Review Internet safety guidelines with your children.

• Turn off your phone—be a role model.

• Discuss with your children what to do if they are ever harassed or threatened online.

• Help your children learn to be the drivers of (and not be driven by) technology.

Shannon Udovic-Constant is a pediatrician who works in the outpatient clinic at Kaiser San Francisco. In addition, she serves as the San Francisco Medical Society treasurer and is the cochair for the American Academy of Pediatrics-California State Government Affairs Committee. In her free time she enjoys spending time with her husband and two young children.

References O'Keeffe GS, Clarke-Pearson K, Council on Communications and Media. The impact of social media on children, adolescents, and families. Pediatrics. 2011; 127(4):800-4.

American Academy of Pediatrics. Talking to kids and teens about social media and sexting. Available at www.aap. org/advocacy/releases/june09socialmedia.htm.

Accessed September 7, 2010.

American Academy of Pediatrics. Safety net. Available at http://safetynet.aap.org. Accessed September 7, 2010.

American Academy of Pediatrics. Internet safety. Available at www.healthychildren.org/english/search/pages/ results.aspx?Type=Keyword&Keyword=internet+safety. Accessed September 7, 2010.

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Pediatric and Adolescent Medicine

Struggling with Drug Use Unique Challenges of Substance Use in Adolescents David Pating, MD Jessica, a sixteen-year-old high school sophomore, is escorted by her mother to the teen clinic after she was caught using marijuana after school.

Jessica’s older boyfriend was recently expelled from school for selling drugs (OxyContin). Her grades had been falling and her mother was told Jessica could also be expelled if she was caught using marijuana on campus again. Jessica’s mother asks you for help. What do you do? ***** Nationwide trends in adolescent alcohol and drug use are complex. Parallel to trends in alcohol use among twelfthgrade teens, which has fallen steadily for more than a decade, general drug use (e.g., cocaine) has declined. Still, 23 percent of twelfth graders report having had five or more drinks on a single occasion within the last two weeks (down from 40 percent in the 1980s). Marijuana use is rising, with 6.1 percent of twelfth graders reporting daily marijuana use; many more have sampled. And we are witnessing a significant increase in illicit prescription drugs (15 percent use in the past year) and opiates, including Vicodin (8 percent annual prevalence) and heroin (0.7 percent prevalence) (MTF, 2010). As one Bay Area epidemiologist noted, “Kids may now be using less, but they use more dangerous drugs earlier.”

Drug use among teens exceeds our surveillance capacity.

New drugs of abuse arrive daily, including dextromethorphan, pseudoephedrine, smokable bath salts (stimulants), and air fresheners. These are micro-epidemics floating beneath the prevailing adult epidemics in methamphetamine, ketamine, and OxyContin. Direct marketing to children of sweetened Kool-Aid-like alcoholic beverages, known as alcopops, has posed a particularly insidious risk that is, fortunately, rousing the ire of the FDA and local California politicians.

Before I wander too far, let me emphatically state: Early adolescent drug use is not good! Due to their developing brains and personalities, adolescents are uniquely vulnerable to the disruptive effects of alcohol and drug use, including disruptions in parental attachment, peer bonding, academic achievement, and self-esteem. The earlier children use drugs, the greater the likelihood of early-adult onset of dependence, and the greater the consequences. Even marijuana, which nursed a generation of young adults through the antiwar movement in the 1960s, carries additional risk for youth, which is more apparent in teens than in adults. Due to the cognitive effects of marijuana, adolescents who have smoked more than 100 times leave school 5.8 times more often, enter college 3.3 times less often, and earn a college degree 4.5 times less often; and children who are predisposed have higher rates of anxiety and psychotic disorders when exposed to marijuana.

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Due to these same developmental risks, screening for adolescent alcohol and drug use must be multimodal. The risks for substance-use disorders co-occur with school truancy, early sexual promiscuity, criminal activity, and comorbid mental health conditions. The U.S. Department of Health and Human Services (SAMHSA) recommends focusing on the big “red flags” as the indicators of serious substance abuse (see sidebar, page 22) and incorporating these into the medical interview. This is harder than it sounds. Researchers in Kaiser Permanente’s Northern California Region are studying improved methods for brief screening for substance abuse in adolescents. I hope they find the Holy Grail. Until then, I recommend starting with, “How are you doing? Are you having any problems lately?” Teens are open to inquiries from genuinely caring adults who respect their budding autonomy and take the time to follow their bread crumbs leading to diagnosis.

Sometimes the harder conversation is not with the adolescent but with the adult parent. For at-risk adolescents, family involvement is essential. Family support is the most critical protective risk factor of the prevention quartet, which includes intrinsic resiliency, caring parents, school achievement, and positive peer norms.

For the teen, everything begins and ends with the family—both as a source of risk (family histories of alcoholism) and as a solution. While a discussion of systemic family therapy as a means to assist families is beyond this review, bringing in counselors and psychologists skilled in strengthening the family response to behavioral red flags is an excellent primary care prescription when faced with an adolescent exhibiting at-risk alcohol or drug use.

Beyond this, I recommend the following evidence-based advice to all parents (and their physicians): deny/delay, deter, and detect. Deny and delay the use of alcohol and drugs by adolescents as long as possible. The earlier they use, the earlier the problems. Even casual “experimental” drinking or marijuana use, when supervised by parents in the home over dinner, will increase risk. If your teen does use alcohol or drugs, then deter the consequences (drunk driving, date rape). Don’t let experimental use become abuse. Educate, edu-

Continued on page 22 . . . www.sfms.org

Pediatric and Adolescent Medicine

Working Partnerships Pediatric Consultation Liaison Psychiatry Lynn Ponton, MD mentally exhausting. There are new consults almost every day, and the questions posed by the pediatricians and the pediatric residents are varied and thought provoking. Questions in the last two years have included, among others, “How can we help a fifteen-year-old boy who is dying of cancer, a boy whose family does not visit often? He spends a lot of time staring out his window, not saying much.” Or “Can you give us direction about working with a paranoid psychotic mother who has just given birth to a new baby, who is very sick and may die. Her current paranoid ideas are focused on the hospital trying to kill her baby.” Or “Can you evaluate a seventeen-year-old who tried to kill herself last week by jumping out a window? She did not succeed, but she may never be able to walk again.” Lastly, “Can you find an antidepressant medicine that will not interact with the twenty medicines that a twelve-year-old child is already taking for his autoimmune condition? He has already experienced significant side effects with most of his medications and is refusing to add another one.”

Each of these questions highlights the diverse related issues that develop on a busy pediatric service. My years of experience have taught me that there are no easy answers to most, if not all, of these questions.

When the fifteen-year-old who is dying of cancer wonders why he, and not other children, was chosen to die from cancer, there is no easy answer. Yes, suffering comes to everyone, but why him, now?

Pediatric consultation liaison psychiatry, also referred to as pediatric psychosomatic medicine, is the subspecialty of child and adolescent psychiatry that provides mental health services to physically ill pediatric patients. Child and adolescent psychiatry consultants complete psychiatric evaluations, advocate for mental health services for their young patients, support pediatric practitioners, and provide education about physical and psychological conditions and other related issues, of which there are many (Shaw and DeMass, 2006). I am fortunate because I have had a unique opportunity to work in this challenging field for seventeen years. I work in a hospitalbased practice at the University of California, San Francisco, where I consult to the inpatient pediatric services with the aid of two residents in their final year of training.

It is a challenging job, one that is often physically and www.sfms.org

The staff that works with the paranoid mother discover that she will respond well to guidance and comfort from staff that she has a relationship with, so they work hard to build this, but then the mother seems to forget them, and they have to start all over. The experience of working with her is frightening—will she hurt herself, her baby, or them?

The seventeen-year-old who recently tried to kill herself and now can’t walk blames herself. All wonder if she’s safe even in the hospital. We wonder how we can keep her safe here and find the ongoing psychiatric treatment that she will need once she leaves. The twelve-year-old boy, grappling with a greater number of medicines than any adult should have to take, let alone a boy of his age, needs to be helped to understand and comply with this part of his treatment before an antidepressant can be added. The pediatric staff and the child’s parents work hard to make this happen, but the boy’s autoimmune ill-

Continued on the following page . . .

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Working Partnerships Continued from previous page . . . ness is not well understood and the plan needs to keep changing. There are no easy answers to the questions that are asked of the child and adolescent psychiatry consultant on a busy pediatric service. But then, neither diseases nor the medical aspect of their care are easy.

Some of the cases that we are consulted about concern children with emotional disorders that develop before or after a physical illness and are only coincidentally related to it. For example, the mother’s psychiatric illness coincides with her newborn’s illness but is not causally related. Other cases reveal situations where psychiatric symptoms actively contribute to a physical illness. On a pediatric service, these psychosomatic cases pose some of the most challenging questions for pediatric and psychiatric staff alike. To illustrate this type of challenge, I have chosen a case reminiscent of one of Sigmund Freud’s adolescents, a fourteen-year-old girl suffering from a conversion disorder, a case that is almost always more difficult than it first appears.

Conversion disorder is from a category of psychiatric illnesses called somatoform disorders, where the presence of physical symptoms in a child or adolescent suggests a general medical condition but is not fully explained by it. In contrast to malingering and factitious disorder, the symptoms are not intentional (under voluntary control). A conversion disorder involves unexplained symptoms affecting voluntary motor or sensory functions and suggests either neurological or other general medical conditions. (DSM IV) The term conversion, a holdover from the nineteenth century, is derived from the hypothesis that a child’s somatic symptoms represent a symbolic resolution of an unconscious psychological conflict and serve to reduce the child’s anxiety, keeping the conflict out of his or her awareness. The current DSM IV criteria set does not imply that the symptoms of the child or adolescent are focused around such a construct, but it does require that psychological factors be related to the onset and or exacerbation of symptoms. These illnesses often occur in children whose families do not have a frame that takes emotions and psychological events into account. The following case will illustrate some of these points.

Case Study

Mary is a fourteen-year-old girl admitted to the pediatric inpatient service, who had a history of documented seizure activity for which she had taken medications when she was eight years old. Several weeks prior to admission, Mary was being taken to an amusement park by her mother for her fourteenth birthday, along with several of her girlfriends, when she experienced her first “episode” of limbs shaking, eyes rolling, and perceived loss of consciousness.

The mother witnessed Mary having this seizure, which resembled those she had seen when Mary was younger. Mary herself appeared dazed and unsure regarding what happened. The birthday celebration ended but these “seizures” continued, becoming even more frequent over several weeks and greatly impairing her functioning. After Mary was admitted to the hospital for evaluation, a neurologic consult and sequenced panel of EE6’s 20 San 21 SanFrancisco FranciscoMedicine Medicine September September2011 2011

showed no seizure activity. A psychiatric interview revealed an adolescent girl with neither observable nor reported psychiatric problems. Mary’s parents were interviewed, with and without Mary, and again no easily discernable problems were uncovered.

Mary did meet the criteria for conversion disorder—a deficit affecting motor function that suggested a neurologic condition. Her problem did not appear to be intentionally produced and was not explained as medical after a full evaluation, and it had already caused Mary and her family significant difficulty.

Neither Mary nor her parents were particularly receptive to psychological formulations. They had agreed to a psychiatric consult because it had been skillfully portrayed by the pediatric resident as a necessary part of a complete medical evaluation. Now that the more medical aspects were receiving less discussion and the psychological more, they doubted them and frankly resisted.

Maybe they would search for a hospital where the true cause of Mary’s problem would be found. Gradually and subtly, over the course of approximately three days, things changed, and the parents and then even Mary came to accept that psychological factors played a part, maybe even the largest part, in her illness.

What made the difference? First, both the pediatric and the psychiatric staff visited regularly and emphasized the connections between the mind. Second, open confrontation and conflict with Mary and the parents about her diagnosis were purposefully avoided on the part of the staff. Gradually, staff noticed slight conflicts between Mary and her mother about what teenagers should be able to do. Both were encouraged to talk about this between themselves and among others. Lastly, the importance of ongoing aftercare, both psychological and pediatric, was explained and such care was encouraged and arranged. Recently, I spoke with Mary and her mother. Things are not perfect, but there have been no more seizures.

Mary’s story, and in my experience the cases of adolescents with conversion disorder, is greatly aided by a strong cooperative effort between psychiatry and pediatrics. In working with families, the bonds between these two disciplines are underscored both clinically and theoretically. Languages and vocabulary are also shared. The pediatric treaters speak and understand some of the psychiatric lingo, helping to demystify it. The psychiatric treaters also try to be practical and work to understand the needs of the team as a whole. Mutual sharing of ideas, diagnoses, and treating strategies is key in this ongoing working partnership.

Lynn Ponton, MD, is a professor of psychiatry at UCSF, a practicing psychiatrist and psychoanalyst, as well as the author of The Romance of Risk: Why Teenagers Do the Things They Do and The Sex Lives of Teenagers: Revealing the Secret World of Adolescent Boys and Girls. She works primarily with adolescents, focusing on risk behaviors such as sexual experimentation and eating disorders.

Reference Shaw RJ and DeMaso DR. Clinical Manual of Pediatric Psychosomatic Medicine: Mental Health Consultation with Physically Ill Children and Adolescents. 2008: Washington, D.C. American Psychiatric Publishing, Inc. www.sfms.org

Pediatric and Adolescent Medicine

Teen Pregnancy Prevention Is Key Kristina Roloff, MD The year 2009 saw a 37 percent decrease in live births to teenage mothers, according to the CDC. This is largely attributed to an increase in the use of contraception and a larger number of teens choosing to wait to have sex.

Still, 2009 saw 410,000 infants born to teenagers (ages fifteen through nineteen) in the U.S., a rate that is one of the highest in the developed world. The majority of teen pregnancies are unintended.

A teenager’s developmental immaturity and predisposition to live in the present with little regard for the future contribute to the high rates of unintended pregnancy. Many teens engaging in unprotected sex are looking for love, and they think sex is the path to social acceptance. Teenage pregnancy carries a large financial and social cost. An estimated $3 billion is spent on these teens and their infants per year. Children born to adolescent parents have more learning disabilities and academic difficulty; higher rates of drug abuse, mental illness, early sexual activity; and they are more likely to be adolescent parents themselves, creating a dysfunctional pattern difficult to break.

What Are the Maternal Health Consequences of Teenage Pregnancy?

Teen pregnancies have worse obstetric outcomes, including preterm birth, low-birth-weight infants, and neonatal mortality. Neonatal death is nearly double that of infants born to adult mothers. In addition, teenagers are exposed to more sexually transmitted infections, are less likely to access prenatal care, have a higher incidence of anemia and poor nutrition, are more likely to be underweight at conception, and suffer more depression. One quarter of teenage mothers have an additional pregnancy within two years, with an even higher preterm delivery rate. This further exacerbates the teen mom’s risk for poor medical, economic, and educational outcomes.

Is the social status of a teenager enough to explain her worse obstetric outcomes, or is there a biologic difference between the adult and the teen? It is well established that lower socioeconomic status is associated with poor reproductive outcomes, such as preterm birth and low-birth-weight infants. Pregnant teens are more often of the lower socioeconomic demographic, have poor access to health care, and are more likely to be unemployed. However, in a cohort study, Fraser et al (1995) showed an intrinsic difference in pregnancy outcomes in the adolescent mother. In developing countries where teen pregnancy is encouraged, there are still similar consequences noted in the very young mother (<14). Thus, poor reproductive outcomes in the teen are likely a combination of sociodemographic factors and biology and are confounded by the developmental immaturity of the mother, which in turn leads to poor judgment. www.sfms.org

The consequence of a teenage pregnancy does not resolve with delivery for the mother. Teen mothers have poorer physical and mental health outcomes later in life (although mental disease may be related to other factors than the pregnancy itself). Social programs, many of which focus on reducing repetitive and subsequent adolescent pregnancy, may help mitigate the impact of a teenage pregnancy. Strategies to reduce subsequent teen pregnancies that use new technology, i.e., cell phones, have been successful among teens under age seventeen, but not so among the eighteen-to-nineteen-year-olds. This highlights the need for multiple and different ways of targeting this population.

What about the Infant Born to Adolescent Parents?

Infants of teen mothers experience the sequelae of their obstetric experience. Preterm birth and small-for-gestationalage neonates may suffer from a myriad of health problems including acute respiratory, gastrointestinal, and/or immunologic problems, and they may experience long-term motor, hearing, or visual deficits, or growth delays.

Children of adolescent parents also suffer from cognitive and behavioral problems; up to 10 percent of these children are diagnosed with mental retardation. Disruptive behaviors are common in children of teen parents, and they often manifest in preschool-aged children.16 Maternal depression, poor child-rearing skills, and economic disadvantage have all been implicated in the root cause of these problems. Perhaps these early problems contribute to the high rates of drug abuse, early sexual activity, and adolescent pregnancies seen in adolescence among these offspring.

Children born to teen mothers show lower educational achievements, lower salaries, and less life satisfaction than their siblings born when that mother was an adult. Thus, the optimal time for pregnancy is sometime after the teenage years.

How Can Health Care Providers Help Improve the Lives of Adolescents?

Continued on the following page . . .

September 2011 San Francisco Medicine

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Teen Pregnancy Continued from previous page . . .

Struggling with Drug Use Continued from page 18 . . .

The number of teen births correlates with behavioral practices of teens. That is, the more teens who access contraceptive options or delay sexual intercourse, the lower the teen pregnancy rate. In certain groups, there is a cultural barrier to the use of contraception, as well as an acceptance of poor reproductive practices and unintended pregnancies.

The average age of sexual debut in the U.S. is seventeen years old. Fortunately, almost 80 percent of teens who are sexually active use some kind of contraception. The remaining 20 percent of sexually active teens have a 90 percent chance of becoming pregnant within a year. These are the patients whom health care providers need to target; education of the teen is crucial to impacting their health. Emergency contraception (EC) has been on the market in France since 1970 and available without a prescription since 1999. In turn, France has seen an increase in all contraceptive use and has one of the lowest abortion rates in the world. In the U.S., we know that only half of sexually active females use contraception prescribed by a health care provider. Up to one-hlf of unintended pregnancies can be prevented by emergency contraception. Thus, it seems imperative that we improve knowledge of, access to, and coverage for EC. EC is easy to write for. Plan B One Step and Next Choice are available to men and women over seventeen years of age without a prescription, but costs vary. Plan B and Next Choice contain levonorgestrel (a progestin) that is preferably taken within seventy-two hours, or up to five days after unprotected sex. Ulipristal (Ella) is a prescription-only progesterone agonist/antagonist approved for use as EC. If you do have pregnant teen, counsel her regarding her pregnancy options, including abortion, continuing the pregnancy, and adoption. Most important, refer her for early and comprehensive prenatal care.

cate. Remember, 23 percent percent of teens and 50 percent of college students binge drink, and each one is a potential car wreck. Lastly, for those in harm’s way, detect problems as soon as possible and seek help. Treatment works. ***** Following a brief psychosocial history and physical, Jessica’s physician excused her mother from the room to proceed with a frank talk. Jessica reported unprotected sex with her boyfriend, as well as pressure to get high with him. She expressed difficulty sorting through mixed feelings, because her mother kept blaming her. At times, Jessica cried. Realizing there was more to this story, her physician offered this brief advice: “Jessica, you are a maturing young woman with the capacity to make good choices for yourself, your body, and your health. Please use protection when having sex and avoid using drugs. If you are willing, I want to refer you to someone with whom you can talk and get help.”

There are so many Jessicas in our daily practice. Good luck!

• Talk openly and privately with your adolescent patients about their thoughts, attitudes, and experiences with sex.

• Recommend folic acid supplementation, adequate nutritional intake, and address weight issues (both under- and overweight).

• Discuss options for contraception with your teenage patients, regardless of your specialty.

• Use motivation and not deprecation to encourage waiting for motherhood.

• Give your adolescent patients a prescription for emergency contraception.

• Plan B One Step (1.5 mg levonorgesterol)#1. Sig: Take one pill as soon as possible following unplanned intercourse.

• Next Choice (.75mg levonorgesterol) #2. Sig: Take one pill within 72 hours of unprotected sex, and the second 12 hours later.

• Ella (ulepristal acetate 30mg) #1. Sig: Take one tablet within 120 hours (5 days).

Substance Use Disorder-Related • Use of substances during childhood or early teenage years • Substance use before or during school • Peer involvement in substance use • Daily use of one or more substances

What Can You Do?

Kristina Roloff, MD, is an obstetrician/gynecologist in practice as an attending physician at the busy county resident training facility Arrowhead Regional Medical Center in Colton, CA. Her other full-time position is to care for her three children.

A full list of references is available online at www.sfms.org.

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San Francisco Medicine September 2011

David Pating, MD, is chief of addiction medicine at Kaiser Permanente San Francisco Medical Center Chemical Dependency Recovery Program.

References Johnston LD et al. Monitoring the future—National results on adolescent drug use: Overview of key findings, 2010.

2011: University of Michigan, Ann Arbor.

Indicators for Assessment for Substance Abuse

Psychosocial • Physical or sexual abuse • Parental substance abuse (including driving under the influence/driving while intoxicated) • Sudden downturns in school performance or attendance • Peer involvement in serious crime • Marked change in physical health • Involvement in serious delinquency or crimes • HIV high-risk activities (e.g., intravenous drug use, sex with intravenous drug user) • Indicators of serious psychological problems (e.g., suicidal ideation, severe depression) (Source: CSAT TIP 31, 1999, http://www.ncbi.nlm.nih.gov/ books/NBK14906/) www.sfms.org

Pediatric and Adolescent Medicine

Psychotropic Medication for Youth The Discussion Continues George Fouras, MD Since I last covered the topic of prescribing of psychotropic medication to youth in April 2001, our awareness and understanding of the issue has increased. Over the last decade, a considerable amount of

awareness has been raised about the “overprescribing” of psychotropic medications to children and adolescents. The problem with the use of this term is its subjective nature. In the past, the issue was largely raised by the lay public, which—for good reason—was reacting to media evidence that the number of prescriptions being written for children was increasing dramatically. While at face value the problem appears to be real, the subject of psychotropic medications also carries a large emotional weight that has the potential to harm those who genuinely benefit from such medications, or who would benefit but are receiving inadequate or no mental health services. For these children, the term “underprescribing” would be just as applicable, but not many people in the public or in medicine are discussing this.

So what evidence does exist that would support the hypothesis that psychotropic medications are being overprescribed for youth? An article published in Pediatrics in 2008

by Zito et al looked at psychotropic medication patterns among foster care youth in Texas, based on Medicaid data from July of 2004. In that study, youth in foster care were prescribed psychotropic medications at a rate greater than three times that of other youths who were Medicaid beneficiaries.

Of these foster children, 41.3 percent received three or more different classes of psychotropic medications, while 15.9 percent received four or more classes of medication. The use of two or more medications within the same psychotropic medication class occurred in 22 percent of cases.

Christopher Bellonci, MD, in his testimony before a U.S. House subcommittee, noted that a possible explanation for the apparent overuse of psychiatric medications was related to the documented higher rate of mental illness found among foster youth.

Specifically, a high number of these children meet DSM-IV criteria based on the trauma they experienced that resulted in their removal from their families, in addition to a higher number of cases of mental illness occurring in this population that predate the initial detention and removal from their families.

A report published by the Rutgers Center for Education and Research on Mental Health Therapeutics in June 2010 www.sfms.org

provided startling data on antipsychotic medication usage in children and adolescents who were insured by Medicaid/ Medi-Cal. A consortium of sixteen states collaborated on the project, which began in June of 2007, analyzing antipsychotic usage rates and trends in the Medicaid population. The subsequent report presented data from a combined 16-state enrollment of 12 million children and adolescents in the Medicaid system. Two key findings from this project were as follows: In 2007, a total of 193,178 youth received an antipsychotic prescription, which was 1.6 percent of the total fee-for-service population under age nineteen. This was a 10 percent increase over data from 2004, which indicated a rate of 1.45 percent. Of the children in foster care, 12.9 percent were prescribed antipsychotic medications, compared to a rate of 1.4 percent for those children who were not in foster care. This represents a prescription rate roughly nine times higher than

Continued on the following page . . .

September 2011 San Francisco Medicine

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Psychotropic Medication for Youth Continued from previous page . . . for non-foster-care youth. A disturbing statistic indeed.

Several factors exist that may account for this data. For example, several years ago the state of California introduced a program entitled Structured Decision Making, which uses objective tools to help Child Protective Services make decisions as to whether to “screen in” a case, whether to detain a youth, or what level of services may be required. The preference is to maintain children within the family if possible, and to refer to community-based organizations rather than making the child or adolescent a court dependent. The significant result of this paradigm is that the number of youth in foster care has decreased over time; however, the proportion of youth with physical and mental health issues who are in foster care has increased.

Furthermore, children who remain in the foster care system will likely suffer further sequelae based on disrupted attachments to their biological families and from multiple foster family and school placements.

What is less well known, and requires more study, are the areas of concern, or circumstances, that may have the effect of stimulating medication use. For example, a youth in foster care is more likely to be referred for a psychiatric evaluation for medications in order to stabilize a placement or school setting. This situation becomes more prevalent as a result of a lack of other resources being available, such as individual or family therapy or group therapy, secondary to budgetary cutbacks or a lack of providers in the public or private sectors.

Direct marketing from pharmaceutical companies, both in print and on television, may drive biological or foster families to pursue medication as a “quick fix” for the behavioral problems that their children are experiencing. The recent addition of the black box warnings attached to SSRI medications has had the effect of a precipitous decline in prescription rates for this class of medication, especially among primary care providers. This has been suggested as a contributing factor to the increase in the rate of atypical antipsychotic medications as a treatment choice, since they do not bear the increased risk associated with a black box warning. For those youth who become psychiatrically hospitalized, secondary to danger to others or self, the hospitals must “do something” in order to avoid having a denial of days (payment) occur. This “something” has become the prescribing of medications, since other interventions, such as family or group therapy, may question the “medical necessity” of the admission and will lead to a denial of days or the entire hospitalization. A newer, more insidious, factor is the increasing pressure from the effects of social media. For example, if an MD does not do what a patient wants or expects, a negative review on social media sites could be detrimental to that physician’s practice or career, thus motivating that physician, subconsciously, to prescribe medication in order to placate the patient, even if the medication is not clinically warranted.

So where do we go from here? In order to use the term “overprescribing,” and as a corollary “underprescribed,” one would need to know with 100 percent certainty the correct 24 25

San Francisco Medicine September 2011

diagnosis for each youth in question. Clearly, this information is not readily available. What we are really talking about is not overprescribing or underprescribing but rather the inappropriate prescribing of medication to youth. When looked at from this point of view, concrete recommendations become more apparent, but an exhaustive list is beyond the scope of this article.

A few of the more significant ones, in my opinion, are as follows: (1) Efforts must be made to raise awareness among psychiatric providers and pediatricians regarding this issue.

Continuing education that helps providers review current evidence and practice should be routine offerings in the community as well as part of the training curricula. This also includes support from and education of the community at large in order to help physicians resist influences from social media sites, pharmaceutical companies, and other stakeholders to prescribe medication over other treatment modalities. (2) The use of a comprehensive psychiatric evaluation becomes even more crucial in this population, which may have a higher acuity of problems when compared to the general population.

This also includes a greater effort to coordinate the care of physical and mental health between providers. The implementation of the “medical home” could meet this criteria. (3) Efforts must be made to avoid poly-pharmacy or the use of unconventional treatments. For example, a review by a consultant could be initiated when a youth is prescribed three or more medications, or two within the same class. In addition, treatments that have more evidence to support their use are preferred over novel treatments.

One final caveat: We should, as a society, resist the urge to enact knee-jerk policy decisions that, while well meaning, have the potential side effect of setting onerous requirements for physicians to meet. This would most likely have the undesirable effect of diminishing access to care for our youth, not enhancing it.

George Fouras, MD, is an adolescent psychiatrist focusing on kids in the foster care and juvenile justice systems. He is also a long time member and the current president of the SFMS.

References Medicaid Medical Directors Learning Network and Rutgers Center for Education and Reasearch on Mental Health Therapeutics. Antipsychotic medication use in Medicaid children and adolescents: Report and Resource Guide from a 16-state study. July 2010. http://rci.rutgers.edu/~cseap/ MMDLNAPKIDS.html.

Statement of Christopher Bellonci, MD, before the House Subcommittee on Income Security and Family Support. Prescription psychotropic drug use among children in foster care.

Rep. Jim McDermott, MD, Chair. May 8, 2008.

Zito J et al. Psychotropic medication patterns among youth in foster care. Pediatrics. 2008; 121(1):157-163.

www.sfms.org

Pediatric and Adolescent Medicine

The Development of Fetal Surgery The Role of San Francisco Physicians Priyanka Ghosh The Fetal Treatment Center at UCSF, the birthplace of fetal surgery, is a world-renowned leader in treating complex and fatal congenital defects in utero. In January 1978, Dr. Michael Harrison accepted a fac-

ulty position at University of California, San Francisco (UCSF) with one incredibly ambitious and revolutionary idea: to use surgery to fix fetal anatomical defects before birth, saving the lives of babies who were unable to sustain life on their own after birth. With this vision, Dr. Harrison developed techniques for open fetal surgery in animal models. Merely a year later, in 1981, Dr. Harrison performed the landmark first open fetal surgery at UCSF. With the successful completion of this operation, Dr. Harrison marked the beginning of a new era in surgical intervention, garnering him the title “Father of Fetal Surgery.”

This new era of fetal surgery grew exponentially in the 1980s.

The decade saw many landmark surgeries, ranging from a sonographically placed fetal urinary catheter to the first fetal lung surgery to the first open fetal surgery for a congenital diaphragmatic hernia. The 1980s were also rife with novel techniques and research, including the first uterine stapling device for fetal surgery and the first transplantation of fetal hematopoietic stem cells in utero in animal models.

The 1990s saw further growth in advances in fetal surgery, including the development of radiotelemitters to monitor fetus’ condition during and after surgery, the invention of the ex utero intrapartum treatment (EXIT) procedure for fetal airway obstruction, and the design of the first fetoscopic temporary tracheal occlusing for CDH (named the “Fedeto Clip procedure”). The surgical realm was also filled with a number of novel and successful high-risk surgeries, such as first resection of a fetal sacrococcygeal teratoma and fetoscopic laser treatment of a single A-V communication in twin-twin transfusion syndrome. The NIH sponsored the first randomized controlled trial for fetal surgery, done at UCSF. Perhaps the most exciting evolution in fetal surgery in the 1990s was the repair of fetal myelomeningocele (spina bifida) first demonstrated in animal models in 1994, and the revolutionary in utero technique of fetoscopic repair of fetal spina bifida in 1999. The new millennium continued the tradition of cutting-edge research, development of innovative techniques, and landmark lifesaving surgeries.

From Dr. Harrison’s simple vision, the UCSF Fetal Treatment Center has now grown into a multidisciplinary center that is entering its third decade. At the center, now under the direction of Dr. Hanmin Lee, obstetricians, anesthesiologists, geneticists, sonographers, surgical subspecialists, neonatologists, nurses, and ethicists collaborate daily to build and strengthen the first fetal treatment center in the United States. The center continues its tradition of groundbreaking innovation and medicine with its current team www.sfms.org

of surgeons, including Diana Farmer, Hanmin Lee, Doug Miniati, Tippi Mackenzie, and Shinjiro Hirose. These world-renowned specialists confine their surgical practices exclusively to fetal surgery, focusing on repair of complex birth defects involving the chest, lung, abdomen, bowel, and bladder. Currently, UCSF fetal surgery is continuing its tradition of cutting-edge research and surgical innovation. Most recently, the university published the results of its groundbreaking MOMS (Management of Myelomeningocele Study) Trial. The MOMS Trial was run under principal investigator Dr. Diana Farmer, the first female fetal surgeon. The MOMS Trial is an NIH-sponsored multicenter clinical trial that evaluated the best treatment for myelomeningocele: fetal surgery or surgical repair after birth. The results of this novel study showed prenatal surgery significantly reduced the need to shunt fluid away from the brain, improved mental development and motor function, and increased the likelihood that the child will walk unassisted in the future.

The future of fetal surgery at UCSF looks just as bright as its innovative past. In 2014, UCSF will open its new children’s hospital in Mission Bay. This will be another victory for the advancement of fetal surgery, allowing it to grow and continue its tradition of helping mothers and children everywhere.

Priyanka Ghosh is a second-year medical student at UCSF.

Peter J. Panagotacos, MD Board Certified Dermatologist Specializing in

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Member of SFMS and CMA for over 30 years AMA Lifetime Member • Fellow of the American Academy of Dermatology Member of Advisory Council of American Society of Hair Restoration Member of International Society of Hair Restoration Surgery Member of International Society of Dermatologic Surgery

September 2011 San Francisco Medicine

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San Francisco Medicine September 2011

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HEALTH POLICY PERSPECTIVE Steve Heilig, MPH

Rehab?

“I want people to hear my voice and just forget their troubles for five minutes.” – Amy Winehouse, age 12 Is addiction a disease? For many of us, it seems a late

date to be debating that, but the answer still seems to depend on whom you ask. If you ask those with the most experience and training—including doctors and scientists in the field— the answer is yes. With the recent, tragic death of singer Amy Winehouse, though, the commentary came fast and furious about how much she and others were responsible for her struggles and demise. The best popular piece I’ve seen came from also-young actor Russell Brand, who is himself a recovering addict and wrote that he lived in fear and anticipation of “a phone call in the night” from his friend Winehouse, calling about her struggle—or from somebody else, about her demise. As is too often the case, his expertise comes from similar experience, and it clearly has given him insight and compassion. But he was too late.

Listening to Winehouse now, it seems amazing that a then-twenty-two-year-old woman could write and sing with such pathos and force. Her words and voice were of a woman who had already lived much longer. When she was still around, her biggest hit, “Rehab”—“I said no, no, no”—seemed funny and ironic. But she’s now joined the much-remarked “27 Club,” those many musicians who died at that age, or close to it, including Hendrix, Joplin, Morrison, Cobain, Parsons, Buckley, and too many others. Many have speculated about the dangers of that age, but I’d wager that the clustering of overdoses and deaths in that late-twenties zone has more to do with what has been called the natural history of addiction. Many, if not most, addicts start using in their teens, and it commonly takes years for addiction to truly take hold and take over. And musicians, especially if they’re successful, lead lives without the more conventional constraints of obligations that give incentives for moderate use. Couple that with longstanding media imagery that it is cool to be high, and the risks can be too daunting to overcome. And thus, struggle and tragedy, often romanticized unto death.

As for the “responsibility” issue, it’s of course not all or nothing; anybody who’s struggled with the problem, especially if that person has encountered twelve-step programs, knows that willpower and commitment are essential, and tested, if one tries to overcome addiction. Still, stigma and judgment are strong in our culture, and over and again I have seen that most people do not really understand addiction until they see it firsthand in somebody they love—or in themselves.

We tend not to guilt-trip people with other chronic, progressive, relapsing conditions, such as diabetes, when they fail to www.sfms.org

perfectly adhere to ideal treatment guidelines. But addiction comes with stigmas, and it often negatively impacts others more than most diseases.

Much of the “professionalization” of modern, medicalized treatment of addiction can be traced here, to the Bay Area.

The Haight-Ashbury Free Medical Clinics were founded partly as a reaction to the stigmatization of addicts by mainstream medicine. Doctors there, besides treating the addicted, realized they had to advocate for better standards and research in this field, and eventually professional medical associations focused on addiction were formed. The Haight Clinic even formed a Rock Medicine program to staff major concerts, and it pioneered new approaches. The California Society of Addiction Medicine also has its roots here and is the locus of much groundbreaking science, training, and policy.

All that said, our national drug policy is still in dire need of improvement—rehab, one might say. There have been many authoritative calls for reform and improvement of our approaches to addiction, but thus far progress has too often been stymied. The American Medical Association has identified addiction as our biggest public health problem, when all the morbidity, mortality, and costs are factored in (although obesity may be in the number-one slot by now). The “tobacco wars” continue, and alcohol abuse remains rampant. Abuse of prescription medications is still increasing. Illegal drugs are often a scourge, and our long-standing “drug war” has not helped much, objectively viewed. There are still huge unmet needs for treatment, more science-based policies, better drug education, health insurance coverage, and more.

If there’s a take-home message in Winehouse’s struggle and death, it may be that we sometimes have to risk resistance and even ridicule by being assertive with those we care about when they have a drug-related problem. It’s not easy. Even the late, sweet former First Lady Betty Ford, a pioneer in this arena, recalled that she called her family “monsters” when they tried to intervene in her addictions. But she later realized that their concern set her on a path that saved her life. If only everybody, famous or not, were so fortunate.

Steve Heilig, MPH, is associate executive director of the SFMS; a previous version of this piece appeared on his Huffington Post blog. For more on addiction medicine, see http://www. csam-asam.org/.

September 2011 San Francisco Medicine

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HOSPITAL NEWS KAISER

St. Mary’s

CPMC

Robert Mithun, MD

Francis Charlton, MD

Michael Rokeach, MD

At Kaiser Permanente San Francisco, preventive care for children and adolescents has always been a high priority. Annual well visits with a pediatrician are recommended to keep children and teens current on immunizations, and they emphasize our commitment to preventive care. At present, Kaiser Permanente is very close to meeting the recommended HEDIS measure of having all of our patients fully immunized by the age of two years. Our current rate reveals that nearly 86 percent of our patients are fully immunized by their second birthday.

The strength of this preventive care is based on our implementation of an electronic medical record five years ago. All children and adolescents who register for a clinical visit have a Preventive Health Prompt printed out for them, which details when well visits and immunizations are due. Patients now have access to their medical records via our website, kp.org, and they can have conversations with their physicians using “My Doctor Online,” which enables parents and teens to view immunization records, send messages to physicians, and access patient education links.

Continuity of care during the often challenging transitions of an individual’s first twenty-five years, preserving the medical home, and acknowledging the increasing independence with progression of age are all pressing issues we address with our young patients. At Kaiser Permanente, we are able to meet the needs of our “aging” pediatric population with a multidisciplinary Adolescent Clinic that serves our patients from ages eleven through eighteen, as well as an innovative Young Adult Clinic for our teen graduates, ages nineteen through twenty-six years. We also provide multiple communication options for our young patients, from text messaging for appointments to refilling prescriptions online.

Pediatrics, adolescent medicine, and young adult medicine offer patients the bestquality medicine with preventive care, and easy access to care with same-day appointments.

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Japan has been center stage in the news this year. Most recently, the world exulted in the astonishing resilience demonstrated by its Women’s World Cup soccer team in its lastminute come-from-behind victory over the favored USA team. In addition to being huge underdogs, worldwide support was on their sideline due to the enormous and catastrophic devastation and loss of life in the wake of the earthquake and tsunami that hit Japan earlier this year. The Japanese people have a long and well-deserved history of overcoming tragic mass destruction, whether it be in the form of acts of nature or manmade.

In 1945, the U.S. dropped atomic bombs on the cities of Hiroshima and Nagasaki. The devastation was immediate, but the fallout is still being felt in the lives of the survivors and their children. Since 1981, the San Francisco Medical Society has partnered with the Hiroshima Prefectural Medical Association to enable A-bomb survivors living in Northern California to undergo detailed and extensive medical examinations to assess the long-term effects of their wartime radiation exposure.

St. Mary’s Medical Center has freely donated the use of the Sister Mary Philippa Health Clinic as the site for these examinations since 1995. Every two years, a multispecialty delegation of physicians comes from Japan to evaluate and reevaluate the health of these survivors, and even that of their children. Most recently, on July 16 and 17, more than 100 of these examinations took place in our clinic. This represents approximately 10 percent of North American A-bomb survivors.

The spirit of cooperation and the humanitarian effort demonstrated by the San Francisco Medical Society, St. Mary’s Medical Center, and the Japanese delegation and their sponsors is beyond heartwarming. It is exactly what the world needs now, more than ever before.

San Francisco Medicine September 2011

The 2011–2012 U.S. News & World Report Best Hospital rankings name CPMC as one of the best hospitals in the Bay Area, ranking us nationally in five adult specialties: cancer, gastroenterology, nephrology, neurology and neurosurgery, and orthopedics. U.S. News and World Report created its Best Hospitals list more than twenty years ago. This year, the national publication released its first-ever Metro Area Rankings of Best Hospitals. According to this publication, hospitals ranked in their metro area scored in the top 25 percent among peers in at least one of sixteen medical specialties. More information is available at U.S. News and World Report.

CPMC achieved a perfect score for its nondiscrimination policies in creating a welcoming environment for lesbian, gay, bisexual, and transgender patients. The results are announced in the 2011 Healthcare Equality Index, an annual survey by the Human Rights Campaign Foundation. Participating hospitals are judged on four criteria: patient nondiscrimination, visitation, cultural competency training, and employment nondiscrimination. The goal is to identify hospitals or medical centers that have adopted policies to protect their patients and employees from discrimination based on sexual orientation and/or gender identity.

CPMC liver disease specialist Dr. Natalie Bzowej and a team of researchers have found that the drug Incivek, when given in combination with two other medications, can dramatically increase the chances of people chronically infected with untreated genotype 1 hepatitis C virus achieving a cure. The findings were published in the June 23 issue of the New England Journal of Medicine. The results stem from a Phase 3 randomized, double-blind, placebo-controlled study, considered the gold standard for clinical research.

The team followed 1,095 people infected with genotype 1 chronic hepatitis C virus (HCV) who had not previously been treated for the disease. www.sfms.org

UCSF

Veteran’s

Saint Francis

David Eisele, MD

C. Diana Nicoll, MD, PhD, MPA

Patricia Galamba, MD

We all know sleep is important, especially for active, growing children. Poor sleep quality has been linked to a variety of problems including chronic enuresis, poor growth, and attention and learning problems. More recent data suggests that even mild snoring and disrupted sleep can cause permanent neurocognitive changes. Traditionally, otolaryngologist/headand-neck surgeons felt they had a “cure” to offer most families of children with snoring and poor sleep, by removal of the tonsils and adenoids.

Historically, cure rates with this procedure were reported to be as high as 90 percent. More recent data suggests, however, that cure rates are not nearly this high and that in certain populations of patients, such as those with Down syndrome, adenotonsillectomy provides relief only 50 percent of the time. Generally, adenotonsillectomy is still recommended as first-line surgical treatment for children with sleep-disordered breathing (SDB), but if children remain symptomatic postoperatively after an adequate amount of time for recovery, and then a repeat sleep study is recommended. If these results are abnormal, the challenge that remains is what to do next. Most children do not tolerate wearing continuous positive airway pressure (CPAP) masks at night, a nonsurgical treatment that is commonly used for adult patients with SDB. For mild SDB, nasal steroids can sometimes used as a temporary measure until further facial growth occurs. Newer diagnostic testing is now available in the UCSF Division of Pediatric Otolaryngology for children with persistent SDB: druginduced sleep endoscopy, or DISE. This is done in the operating room in coordination with pediatric anesthesiologists. By trying to simulate the airway dynamics of a sleeping child, the goal is then to precisely identify the locations of persistent upper airway obstruction by direct visualization with a flexible endoscope to be able to recommend targeted surgical intervention. One of the most commonly identified sites of persistent obstruction has been the base of tongue.

Outcomes studies are currently being conducted at UCSF to try to determine what procedures at the level of the tongue base are most effective, with the least morbidity. www.sfms.org

Patients diagnosed with traumatic brain injury (TBI) had over twice the risk of developing dementia within seven years after diagnosis compared to those without TBI, according to a study by researchers at the San Francisco VA Medical Center (SFVAMC).

About 1.7 million Americans are diagnosed with TBI each year, and it is often referred to as the signature wound of the wars in Iraq and Afghanistan. It accounts for 22 percent of casualties and affects up to 59 percent of troops exposed to blasts.

Lead author Deborah Barnes, PhD, said that the study is one of the first to examine the association between dementia and different types of TBI diagnosis, including intracranial injuries, concussion, post-concussion syndrome, and skull fracture.

The study analyzed the medical records of more than 280,000 veterans age 55 or older who received care through the VA from 1997 to 2000 and did not have a history of dementia. Fifteen percent of veterans diagnosed with TBI developed dementia by 2007, compared with seven percent of those not diagnosed with TBI. Even after controlling for factors such as age, medical history, and cardiovascular health, TBI diagnosis still doubled the risk of dementia.

The findings were presented at the 2011 Alzheimer’s Association International Conference on Alzheimer’s Disease in Paris.

Among potential causes for the increased risk is the association between TBI and swelling of the axons that form connections between neurons in the brain. This swelling is accompanied by the accumulation of proteins, including beta-amyloid, which is a hallmark of Alzheimer’s disease.

“Older veterans who have had some kind of head injury should be monitored over time so that if signs of dementia develop, treatment can begin as soon as possible,” Barnes said. “Early treatment and rehabilitation following TBI may help prevent the development of dementia over the long term for younger veterans.”

Well, it’s good news all around here at Saint Francis. Just last week we received a letter from Blue Shield of California and the Blue Cross and Blue Shield Association stating that our Total Joint Center and our Spine Care Institute have met the selection criteria necessary to be designated as Blue Distinction Centers. This designation means that our centers of excellence in spine and joint surgery have met objective, evidence-based selection criteria that demonstrate reliability in delivering spine surgery and knee and hip replacements with better overall outcomes for patients. We are honored to be among the best centers nationally.

On a separate note, last week Saint Francis attended the San Francisco Business Times Health Care Heroes Awards breakfast at the Palace Hotel. Nearly all the Bay Area’s hospitals were represented. Our Bothin Burn Center Nursing Team was the recipient of the award in the category of nursing. Members of the team were on hand to accept the award.

“The Business Times created the Health Care Hero Awards to give credit where credit is due,” says Mary Huss, publisher of the Business Times. “The goal in creating the awards was to recognize exceptional professionals who go above and beyond their job descriptions, to discover inspiring individuals working to improve the health care system and the lives of patients in the Bay Area.” If you ever want to see a hardworking, well-oiled machine in process, come visit the Bothin Burn Center. They do impressive work giving patients their lives back.

And finally, as summertime nears an end, Saint Francis continues to meet deadlines and enhance our delivery of surgical services. The construction on our new Surgical Department will be complete by September 1. Watch for an invitation to our open house. Until then, gone fishin’!

September 2011 San Francisco Medicine

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SFMS NEWS SFMS Hosts the Hiroshima 18th Medical Team A team of physicians from Hiroshima visits San Francisco every other year to examine local Hibakushaâ&#x20AC;&#x201D;survivors of Hiroshima and Nagasaki. The 18th Medical Team, consisting of physicians specializing in ra-

diation effects from Hiroshima, Japan was in San Francisco in August to conduct the 18th biennial medical examinations of Americans of Japanese and Korean ancestry who survived the atomic bombings during World War II. This year marked the 34th anniversary since the Hiroshima Medical Prefectural Association has participated in these missions. Since 1977, the Hiroshima Prefectural Medical Association has sponsored official biennial medical missions for the benefit of American survivors living in the United States.

The SFMS has had a sister relationship with the Hiroshima Prefectural Medical Association since 1981 and provides the local affiliation necessary to conduct the medical examinations in San Francisco.

The group, along with SFMS leadership, is pictured left.

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San Francisco Medicine September 2011

www.sfms.org

The San Francisco Medical Society and CMA are pleased to announce a new 10-year and 20-year Term Life program for members. You now have a choice of locking in your premium rate for the first 10 or 20 years of your policy,* enabling you to achieve dramatic premium savings. And you can apply for limits of up to $1,000,000!

Now is the time to take a good look at the SFMS/CMA plan if: • It has been more than one year since you last reviewed your life insurance protection • You had a change in lifestyle (e.g., married, had a child, adopted a child, taken out a mortgage or business loan or invested in a new practice) • The long-term assets that you once counted on for your financial planning no longer seem as secure as they once did Endorsed by:

• You think you may be paying too much • The amount of coverage provided by your medical group isn’t enough and you can’t take it with you if you leave

Call Marsh today at 800-842-3761 for information on this new program and to determine how you can save on your life insurance!

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Insurance is provided by ReliaStar Life Insurance Company, a member of the ING family of companies.

*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days advance written notice.

51423 (6/11) ©Seabury & Smith Insurance Program Management 2011 • d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com

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We Celebrate Excellence – Corey S. Maas, MD, FACS CAP Member, San Francisco plastic surgeon, and founder of “Books for Botox®” community outreach program, benefitting the libraries of local underfunded public schools

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For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like general surgeon Calvin Lee, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

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CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

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