July/ August 2007

VOL.80 NO.7 July/August 2007 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

The Healing Power of Love

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CONTENTS The Healing Power of Love July/August 2007 Volume 80, Number 6 FEATURE ARTICLES: EXAMINING LOVE AND MEDICINE

MONTHLY COLUMNS

10 Love: A Chemical Connection—Is there a Pharmacology of Love?

John Mendelson, MD, and Matthew Baggott

4 On Your Behalf

11 An Appropriate Love: Love in the Therapeutic Relationship John Beebe, MD 13 Circles of Support: The Healing Power of Community Nancy Iverson, MD

7 President’s Message Stephen Follansbee, MD 9 Editorial Mike Denney, MD, PhD 18 Classified Ads

16 Intimacy, Wholeness, and HIV: HIV and the Romantic Relationship Frank Sclafani, MFT 17 Love in the Time of Tuberculosis: A Doctor’s Love Makes a World of Difference Sheiva Khayam-Bashi, MD

31 Hospital News

19 The Serpents of Caduceus: A Depth Psychologist’s Reflections on Healing Love Elizabeth James Thompson

OF INTEREST

33 Pedestrian Safety: An Eyewitness Account William Miller, MD

21 The Healing Power of Love: Learning to Heal the Body and the Spirit Karyl Huntley

34 Health Care Reform Proposal Stephen Follansbee, MD

23 Expressions of Love: Art and Medicine Nancy Iverson, MD 24 Rocking the Babies: Loving, Powerful Medicine for Babies at the Crisis Nursery Rosa Estremera

Editorial and Advertising Offices 1003 A O’Reilly

25 Pet Therapy: How Human-Animal Interaction Promotes Healing Jennifer Emmeret, PhD

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

27 A Different Type of Education: Learning About Cancer outside of the Classroom Dani Chammas

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

PATIENT PERSPECTIVES

website, www.sfms.org/advertising, or can

28 Loving Treatment: A Patient Recognizes the Importance of Love in His Treatment Kai Molvig

be sent upon request.

Printing: Sundance Press

29 Love and Lymphoma: A Patient’s Family Gives Gratitude for the Love He Received Linda Jweinat

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

To see San Francisco Medicine Magazine online, please visit our website:

www.sfms.org/magazine

ON YOUR BEHALF

June 2007 Volume 80, Number 6

A sampling of activities and actions of interest to SFMS members Editor Mike Denney Managing Editor Amanda Denz Copy Editor Mary VanClay Cover Artists Amanda Denz and Ashley Skabar Editorial Board Chairman Mike Denney Obituarist Nancy Thomson

Notes from the Membership Department Coming this fall The reprise of the SFMS Night at the San Francisco Symphony and other exciting membership events. Watch upcoming issues of San Francisco Medicine and Action News for dates and further details.

Stephen Askin

Arthur Lyons

Toni Brayer

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Attention Young Physicians

Gretchen Gooding

Stephen Walsh

The San Francisco Medical Society is forming a Young Physicians section to better address the needs and concerns of members age 45 and younger. Social and educational gatherings will be a featured part of this newest component to SFMS membership. If you are interested in participating, contact Tom Lee, MD, at tomxlee@yahoo.com.

Shieva Khayam-Bashi SFMS Officers President Stephen E. Follansbee President-Elect Stephen H. Fugaro Secretary Michael Rokeach Treasurer Charles J. Wibbelsman Editor Mike Denney Immediate Past President Gordon L. Fung

Help Grow the San Francisco Medical Society!

SFMS Executive Staff

Members reaching out to their physician peers remain one of our best ways to gain new members. If your physician peers are not yet members, help them join! Encourage them to attend one of the upcoming social/cultural events and get to know SFMS and its members better.

Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term:

Carolyn D. Mar

You Can Make SFMS Even Better!

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Donald C. Kitt

Term:

Jordan Shlain

Jan 2005-Dec 2007

Lily M. Tan

Gary L. Chan

The San Francisco Medical Society is always looking for feedback on its member services, as well as suggestions for making membership more interesting, valuable, and fun. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 269 or tporter@sfms.org.

Shannon Udovic-

George A. Fouras

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

John W. Pierce

Mei-Ling E. Fong

Daniel M. Raybin

Thomas H. Lee

Michael H. Siu

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

Missing V.A. Hard Drive Holds Sensitive Data on 1.3M Doctors, Including 53K in California The Department of Veterans Affairs (V.A.) recently notified physicians that an external hard drive that went missing in January from the V.A. Medical Center in Birmingham, Alabama, also contained billing and demographic information for more than 1.3 million doctors nationwide.

San Francisco Medicine july/august 2007

Initially, the V.A. indicated that the drive contained personal information on 48,000 veteran patients. Officials later learned that the missing hard drive contained sensitive personal information on nearly 200,000 patients and more than 1.3 million physicians, including 52,733 doctors in California. The V.A. is offering a year of free credit monitoring to those who were affected.

The missing hard drive contained physicians’ Unique Physician Identification Numbers (UPINs), state license numbers, dates of birth, business addresses, and employer identification numbers. While there have been no reported misuses of this information, physicians are urged to take steps to protect themselves from identity theft.

Affected physicians should have recently received a letter with instructions on how to take advantage of the free credit monitoring offer. The V.A. has established a dedicated call center to answer your questions about this issue. Call-center staff can be reached by phone at (888) 368-0312 from 10 a.m. to 7 p.m. (Pacific daylight time) or by e-mail at call.center2@va.gov.

Doctors Experiencing Pediatric Vaccine Delays A number of physicians have reported delays in receiving pediatric vaccines ordered through the CDC’s Vaccines for Children program. Orders that usually take two weeks from order to fulfillment have been taking four to five weeks.

Physicians should be aware that the delays do not signal a vaccine shortage.

According to the California Department of Health Services (DHS), the delays are a temporary result of the recent transition to a new centralized national vaccine inventory and distribution system. Physicians are urged to assess their inventory and adjust their ordering practices to make sure they do not run out of vaccines.

Vaccines for Children provides vaccines at little or no cost to physicians who serve eligible children. For more information on this program, call DHS at (877) www.sfms.org

243-8832 or contact your local VFC representative.

2007 Medicare Quality Reporting Tool Kits Now Available On July 1, the Centers for Medicare and Medicaid Services (CMS) began its Physician Quality Reporting Initiative (PQRI), a voluntary reporting program that encourages quality improvement through the use of clinical performance measures.

To help physicians successfully participate in the program, CMS, in collaboration with the AMA, recently published a PQRI tool kit. The tool kit, available at the PQRI website, contains educational resources and measure-specific worksheets designed to walk the user step by step through reporting for each measure. The tool kit will be expanded as new educational resources become available.

PQRI establishes financial incentives—bonus payments of 1.5 percent of total allowed charges for covered Medicare physician services—for physicians who participate in this voluntary program. The current reporting period is for claims with dates of service from July 1 through December 31. Claims must be received on or before February 29, 2008, to be included in the bonus payment calculation.

For more information, contact Sandra Bressler at (415) 882-5171 or sbressler@ cmanet.org.

honorarium. The ethnic physician award also includes a $1,000 grant for the ethnic physician organization of the honoree’s choice.

Contact Carol Lee, (916) 551-2562 or clee@cmanet.org.

2007 SFMS Seminars!

Please contact Posi Lyon (plyon@sfms. org or (415) 561-0850 extension 260) to register for any of these seminars. Space is limited; advance registration is required.

October 12, 2007 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training in handling phone calls and scheduling professionally and efficiently.

9:00 a.m.–12:30 p.m. (8:40 a.m. registration/ continental breakfast), $99 for SFMS/CMA members/$149 for nonmembers.

November 9, 2007 “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management.

9:00 a.m.–5:00 p.m. (8:40 a.m. registration/ continental breakfast), $250 for SFMS or CMA members/$225 for second attendee from same office/$325 for nonmembers.

July 25–October 12, 2007

Special Exhibit: The Life and Times of Edward Robeson Taylor The San Francisco History Center will host this exhibition exploring the life of Mayor Edward Robeson Taylor, an extraordinary personality and symbol of recovery for the city of San Francisco following the 1906 Earthquake and Fire. Taylor, who was named an honorary member of SFMS in the late 1800s, was also a physician and President of the Cooper Medical School, which became the Stanford Medical School. The exhibition is presented in conjunction with a biography of Taylor in the September issue of the Argonaut, the journal of the San Francisco Museum and Historical Society.

The exhibition is free and open to the public. San Francisco Main Library, Sixth Floor, 100 Larkin Street.

Mayor Newsom Speaks About Health Care at a Local Reception

Mayor Newsom addressing the crowd.

CMA Foundation Seeking Nominations for Annual Leadership Achievement Awards The CMA Foundation is accepting nominations for its annual leadership awards, the Robert D. Sparks, MD, Leadership Award; the Ethnic Physician of the Year Award; and the Adarsh S. Mahal, MD, Access to Health Care and Disparities Award.

The winners will be honored at the CMA Foundation’s Annual Leadership Dinner, held October 28 in Anaheim, during the CMA House of Delegates. Recipients will receive a plaque and a $1,000 www.sfms.org

Hepatitis B Free CME In an effort to increase public awareness of chronic hepatitis B, the “San Francisco Hep B Free” campaign has created a series of educational opportunities for primary care clinicians. Events are available for CME credit. To register for the event listed below, or to find out about other events, visit www.simplyspeakinghbv.com or www. sfhbfree.org.

August 23, 2007 Absinthe—398 Hayes Street 6:30–8:00 p.m.

Guest Speaker: Emmet Keefe, MD, MACP, from Stanford University Medical Center

Mayor Newsom mingling with SFMS leadership.

From left to right: Richard Wolitz, MD; Mayor Newsom; SFMS President Stephen Follansbee, MD; and SFMS Executive Director, Mary Lou Licwinko, JD, MHSA. Photos by Ashley Skabar.

july/august 2007 San Francisco Medicine

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president’s Message Stephen Follansbee, MD

Another Cat Story

M

y mother loved cats. She really loved cats. My father was indifferent to cats—I think he was allergic to them.

However, he really loved her, so I grew up with a cat in the house at all times. My mother didn’t, however, have a cat the last twenty-nine years of her life. She wanted one. We talked a lot about getting one over the years, until about six months before she died. During that time the numerous reasons not to get a cat prevailed, but she continued to love them nonetheless.

My mother moved to an assisted living unit in the last several weeks of her life. In her unit lived a cat. I must have visited her seven or eight times while she lived there and saw the cat only once before my final visit. The last day of her life, that cat appeared at my mother’s door. It stayed on my mother’s bed throughout the last eight hours of her life, until she died. Then the cat left.

The cynic (read “scientist” or “doctor”) in me says that the cat just showed up because the day was warm, my mother was not moving much, her bed was in the sun, and because my sister and I sat with my mother that entire time, so there was a lot of attention for the cat to soak up. There must be a lot of reasons why that cat—whom my mother never fed, touched, or let into her room—showed up on the last day of her life to be with her. I will never know the true reason. All I know is that this cat came out of nowhere and stayed with my mother the last few hours of her life.

I have stopped thinking about why this happened and just let it be one of those mysteries of life.

I had the privilege of hearing Rachel Naomi Remen, MD, speak at the annual staff dinner of the Kaiser Permanente San Francisco medical staff recently. For those of you who are not familiar with her work and writings, she is a clinical professor of family and community medicine at UCSF School of Medicine. Her course, “The Healer’s Art,” is taught at fifty-four medical schools here and abroad. She is also the founder of the Institute for the Study of Health and Illness at Commonweal in Bolinas (www. commonweal.org/ishi). She is the author of two books, Kitchen Table Wisdom and My Grandfather’s Blessings. The title of her talk to our medical staff was “Is There Room for Your Heart in the Practice of Medicine?” It was a very powerful discussion about the will to live and the role and power of physicians in strengthening that will to live in our patients. www.sfms.org

One of her points was that science is “too small” to explain the mystery of life. We, as physicians and as scientists, need to open up our hearts to what we would call the miracles or unanswerable events of life. Her talk was filled with anecdotes, some from her own life dealing with her own illness, and many dealing with examples from her practice, particularly with oncology patients. Her talk included stories about patients with well-documented and usually fatal cancer who survived without treatment. Why? Who knows?

However, we need to be open in our practices to these mysteries and recognize them for something that may, indeed, be outside of the boundaries of science.

This issue of San Francisco Medicine includes articles on the power of love, of pets, of family, and of relationships on health and healing. The danger is that we interpret death as a failure of these things. That is not the case. Yet we all have stories of survival, of health, of the unexplainable will to live in the face of apparently overwhelming odds of dying. Sometimes we are afraid or embarrassed to tell these stories, or share them with our colleagues. We are afraid we will be thought of as soft or inaccurate in our clinical observations and diagnoses.

The practice of medicine is not just about predictable outcomes with standard therapies. That predictability would not give us the joy and vitality we experience as physicians after a hard day at work.

We need to continue to recognize the mystery and magic in what we do, which goes beyond what we prescribe or how we operate as surgeons. This will help us remember the power we play in nurturing the will to live. Continuing to find room for our hearts in the practice of medicine will sustain the profession in times when it seems threatened of being reduced to a guild or just another job.

Dr. Follansbee is the 139th President of the SFMS. An infectious disease specialist, he practices with the Permanente Medical Group. He is Director of Travel Medicine as well as Director of HIV Services at Kaiser San Francisco. He has been Chief of Staff and Director of HIV research and treatment at Davies Medical Center, attending physician at SF General Hospital, Assistant Director of the Bay Area Consortium of AIDS Providers, and has served on the UCSF clinical faculty.

july/august 2007 San Francisco Medicine

They seem happy now.

But can you identify the ones who will file a claim against you for… ...Wrongful termination? ...Sexual harassment by a fellow employee? ...Failure to Promote? ...A violation of the Americans With Disabilities Act? I can’t get up the stairs to see the doctor!

She fired me without cause!

I should have had that job!

If he doesn’t stop telling me those awful jokes...

Neither can we. But let’s look at the facts*: 1. Six out of ten employers have faced employee lawsuits within the last five years.

2. 67% of all employment cases that litigate result in a judgment for the plaintiff.

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

managers is included as well as access to employment attorneys for advice on how to properly handle employment issues to mitigate potential future claims.

Contact Marsh Affinity Group Services at 800-842-3761 for information on the SFMS endorsed special First Time Buyer program.

4. Defense of the average EPLI case, through trial costs over $45,000.

5. The average amount paid for out-of-court settlement is $40,000.

To protect their assets, employers are transferring this risk to an EPLI policy. Now, you can too. Through the San Francisco Medical Society endorsed Employment Practices Liability Program, members may not only receive important coverage for judgments and defense costs up to $1,000,000 but will also have access to risk management tools. Web based training for you and your office

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Administered by:

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Editorial Mike Denney, MD, PhD

C’est l’amour

I

n the early 1960s, there was a prime-time television series called Doctor Kildare. In this weekly drama, the young Doctor Kildare, fresh out of medical school, struggled to become a true healer.

On his first day at Blair General Hospital, he was admonished by his mentor and senior physician, Doctor Gillespie, who stressed the science and technology of medicine, saying, “Our job is to keep people alive, not to tell them how to live.”

Doctor Kildare ignored that advice, and week by week and year by year, under the tutelage of Doctor Gillespie but with the guidance of nurses, patients, and family members, the young resident physician slowly mastered the art of medicine. In this way, through 190 television episodes, Doctor Kildare, in intimate relationship with his patients, learned to tend their souls as he healed their bodies.

On the mornings following the broadcast, many of us who were in residency training during those years would return to our busy university, public, and private hospitals and become aware of the stark contrast between the world of Doctor Kildare and that of our own. And now, upon reflection, we may notice that this stark contrast remains in the current day-to-day practice of medicine.

In our modern, scientific hospitals, offices, and high-tech diagnostic and therapeutic units, only rarely do we find a way to share in-depth understanding about the spiritual and soulful aspects of healing. Instead, we work long and busy hours to learn and apply the science of modern medicine and surgery and to somehow make a living in the morass of third-party entities, malpractice threats, and government disciplinary agencies that admonish us to practice strictly scientifically.

We might legitimately ask, “How did Doctor Kildare find so much time and energy to engage in such intimate conversations and philosophical musings with his patients? Wasn’t he neglecting the urgent needs of other patients, not to mention his professional responsibilities to communicate with his colleagues, to keep accurate records, and to perform administrative tasks?” Indeed, it would not be surprising if we concluded that Doctor Kildare’s medical adventures were nothing but unrealistic fictions, and that our high-tech, frenzied arena of modern medicine is the “real” world.

Still, in a quiet little niche deep in our hearts, some of us might yearn to practice more like Doctor Kildare. In our pensive moments, we may dream that there could be a medical system that offers all the benefits of modern therapy yet integrally tends to an www.sfms.org

emotional, spiritual, and soulful life that is shared by those who are afflicted and the healers themselves. To state it within the theme of this issue of San Francisco Medicine, we may long to share more of the power of healing love.

We don’t often use that word love in medicine. We prefer less intimate terms, such as the patient-doctor relationship, the placebo response, the therapeutic dyad, or transference and counter-transference.

Hippocrates went so far as to say, “Wherever the art of medicine is loved, there also is love of humanity.” Sir William Osler added, “Care more for the individual patient than for the special features of the disease.” This issue of San Francisco Medicine goes further, by bringing love out of the medical closet—that special, natural, compassionate kind of healing love that is ever-present whenever one human being reaches out to another who is ill at ease, frightened, or suffering.

Such loving compassion was gently portrayed in a TV episode in which Doctor Kildare attends a patient, a young woman who suffers from a terminal illness. The story ends with Doctor Kildare, filled with empathy, sitting at the bedside with tears in his eyes as the woman slowly whispers her last words.

To some, a physician crying over death might appear unseemly, but it brings to mind a 1960s song that was contemporary with the Doctor Kildare television program. It’s called “C’est l’amour,” the words of which were written and sung by the famous French chanteuse Edith Piaf. The lyrics, loosely translated, include, “It’s love that makes you dream . . . it’s love that makes you cry . . . and those who cannot shed tears . . . are those who cannot love.”

And so it is that, as we seek to express the meaning of the compassion and caring that must accompany our work, we might learn from Doctor Kildare’s stories and Edith Piaf’s song. In our search for the proper words to describe our special healing relationships, we might clarify the task by simply acknowledging: It’s love—c’est l’amour.

july/august 2007 San Francisco Medicine

The Healing Power of Love

Love: A Chemical Connection Is There a Pharmacology of Love?

John Mendelson, MD, and Matthew Baggott

L

ove, the intense feeling of tender affection and compassion, is the emotional glue of intimate human relationships. All humans need to love and be loved, so it should not be surprising (if unromantic) that there is a biology of love. For a scientist, love can be viewed as a complex neurobiological phenomenon involving trust, belief, and pleasure, which activates specific brain regions and processes.

The anatomic regions essential for perception and activation of love appear to involve the limbic areas, and in many ways love is an unconscious, automatic process. In A General Theory of Love by Lewis, Amini, and Lannon (Random House, 2000), love is portrayed as the coordination of two individual’s limbic systems, an interaction that may stabilize but also disrupt individual physiology. Virtually all of the regulatory systems and pathways necessary for survival and beneficial biological behaviors, such as eating, sex, and reproduction, are implicated in the biology of love.

And where there is biology there is pharmacology. For a pharmacologist, the scientific exploration of love involves understanding the relations between complex behaviors and concentrations of compounds at effect sites. So far, we do not have any exogenous compounds that reliably induce the emotion of love, though many feel chocolate could fill the bill. However, science may find clues to the pharmacology of love by examining two closely-related drugs, MDMA (“ecstasy,” 3,4-Methylenedioxymethamphetamine) and methamphetamine.

The two drugs are kissing cousins in chemical structure and physiological effects, and they seem to influence the same monoamine neurotransmitter systems. But 10

on close inspection, the family resemblance gives way to interesting differences. Users say that MDMA increases feelings of empathy and closeness to others in a way that

“For a scientist, love can be viewed as a complex neurobiological phenomenon involving trust, belief, and pleasure, which activates specific brain regions and processes.” methamphetamine reportedly does not.

In fact, before MDMA was a controlled substance, some psychotherapists used it to facilitate couples therapy. Methamphetamine, in turn, has sometimes been linked to increased sexual desire and risk-taking sexual activity. And, just as love has a dark side when it goes awry, so too do both drugs. They may increase risk-taking and acutely impair judgments requiring assessment of trustworthiness. In addition, a large literature describes their potential for acute toxicity, dependence, and possible chronic neurotoxicity.

Nonetheless, if these anecdotal reports are accurate, we may learn much by comparing similar drugs that enhance tendencies for emotional intimacy in one case and physical intimacy in the other. Helen Fisher and others have argued that sex drive, partner attachment, and romantic longing have partly separable neural substrates and pharmacology. Methamphetamine and MDMA may, respectively, activate these first two systems.

San Francisco Medicine July/august 2007

What is the pharmacology of these effects? Both drugs increase central release of dopamine, norepinephrine, and serotonin, but to different degrees. Animal studies and observations of patients link central dopamine and norepinephrine with sexual motivation and arousal, while central serotonin appears to inhibit sex drive. A straightforward hypothesis, then, is that the drugs’ different social effects are due to the different amounts of neurotransmitter released. A main difference may be that methamphetamine induces more dopamine release, while MDMA induces more serotonin release. The serotonin released by MDMA may inhibit the sexual drive system while enhancing the attachment system.

If MDMA enhances attachment by releasing serotonin, a key player in the mechanism may be oxytocin. Increasing evidence suggests that this endogenous neuropeptide is an important modulator of social affiliation. Because oxytocin is regularly used in obstetric practice, physicians may be surprised to learn just how important the hormone is in human behavior.

Oxytocin is a posterior neurohypophysial nonapeptide hormone best known to physicians for modulating uterine contractions and stimulating the milk-ejection reflex. Its close relative vasopressin regulates water homeostasis and thirst.

Some of the strongest evidence for the role of oxytocin in commitment and love comes from studies in prairie voles. Prairie voles often show pair bonding (commonly referred to as mating for life), whereas montane voles do not. Several elegant studies show that a primary difference between these closely related species is the location of oxytocin receptors in the central nervous

Continued on Page 15... www.sfms.org

The Healing Power of Love

An Appropriate Love Love in the Therapeutic Relationship John Beebe, MD

F

ifty years ago, as a Harvard freshman, I heard the cultural anthropologist Clyde Kluckhohn recall meeting a confident young woman. “My name is Love,” she informed him. Disarmed, the professor found himself thinking, “Eros, Philia, or Agape?”

He told this story to help us appreciate the different meanings Western culture has assigned to love. The Greeks had come up with these distinguishing terms as early as the fifth-century BC. Eros (romantic attraction) and philia (social sympathy or fellow feeling) have lived on in our language as the roots of erotic and of words like philosophy (love of wisdom). Agape—pronounced ah-GAH-pay—which originally meant the satisfaction one brings to loving one’s family or a treasured activity, survives now as a theological term, meaning the love of God for man, or (in the Christian conception) brotherly love in its highest manifestation.

By any of these definitions, however, love is not a word that most doctors would think to use for the attitude they bring to their patients in the course of trying to heal them.

Eros is the part of medical love that worries ethics committees most, though psychiatrists have long recognized that patients need to love their doctors as part of the healing process. Erotic love in the midst of a healing relationship can take the form of a therapeutic “crush,” and, like many crushes, it seems best left undeclared. My last crush, as a patient, was on a new dentist into whose practice I came at midlife. My infatuation saw me through half a dozen root canals and subsequent crowns. Before I found this particular dentist, whose father had been a dentist and who clearly loved dental work, I had had my cavities probed and drilled and filled, but I hadn’t really cared, or felt www.sfms.org

especially cared for. Those earlier dentists worked on my teeth, but the work was, so to speak, all in my head. This new dentist brought a different spirit to the work, and

“By any of these definitions, however, love is not a word that most doctors would think to use for the attitude they bring to their patients in the course of trying to heal them.” so did I. Our exchange, from the beginning, was clearly a form of love, tinged with an eros palpable every time we met.

Let me be clear. I didn’t try to “date” this dentist. Rather, I became passionate about being a good patient. I felt sure that my dentist knew I loved our sessions. Certainly, my teeth became a much happier part of my body than ever before. My mouth, a source of one pain or discomfort after another all through my adult life despite compulsive efforts on my part to “keep up” with my dental care, became a place of durable harmony. After I had gone for more than a year without dental problems, I began to look at my dentist a bit less adoringly. When my mouth was really healed, I could dispense with my attachment to the healer.

By then, I felt I had acquired a friend— and while I would not presume to enact that friendship outside our professional relationship, yet it was one that I honored in a tangible way, by following my dental hygiene routine and by sending some of my own patients as referrals. None, I should

add, formed the same kind of attachment I had, nor had the same level of results from the dental consultation. They all got what seemed to me like the same good advice; they just had more trouble following it.

As a psychiatrist, I have long recognized a similar kind of quietly felt erotic interest in me from my own patients when they are getting deeply into their treatment.

Sometimes, I feel a similar energy toward them. I don’t usually talk about it, and I certainly don’t use it as the springboard for any kind of seduction, but I find it important to recognize that it is there. I was taught, in my training, to call such feelings “transference” and “countertransference,” but after more than forty years of practicing psychotherapy, I prefer to think of them simply as part of a deepening therapeutic relationship.

Some doctors and patients, unfortunately, cannot understand that such erotized caring for the healer belongs to the therapeutic relationship. They need to know that galling disappointment is the near-inevitable result of any attempt to consummate it romantically. The usual result of that is catastrophe, because the love is based on the doctor’s integrity as a doctor and cannot be sustained when the doctor casts that role aside to establish another kind of relationship. The doctor who tries to concretize such a relationship sexually is risking not only the heart of the patient’s morale to take treatment seriously, but also the right to practice medicine. An acted-out medical romance, even if it does not come to the attention of a professional standards committee, is a terrible compromise of the therapeutic relationship. Even if marriage follows, it will likely be shadowed by the mistrust that attends anyone who has cheated on a former deep relationship.

july/august 2007 San Francisco Medicine

11

Philia is easier to contain within a therapeutic frame. It emerges, in the doctor, as a liking for the patient who is capable of sharing a passion for the work of healing.

It is lived through an intense cooperation between patient and doctor in the mutual goals of treatment. Over time, such a love, though shared in the heat of treatment, can be internalized by the patient as a joyous attitude toward supporting and maintaining health after the therapy is over. The doctor is given heart by the memory of this joyful collaboration to carry forward with other patients. We all, of course, learn from our mistakes, but it is the successful collaborations that affirm that we are on the right track, that teach us what a therapeutic relationship can be. In such relationships, based on a comradely participation in the therapeutic process, the patient is both parent and teacher to the developing doctor, teaching him or her in a directly experiential way what it means to a patient to be cared for, and what it means to be able to care for the person delivering the care. This therapeutic engagement has no need to turn into something else to be truly satisfying. The patient who enters this level of attachment to the doctor is not just mirroring the doctor’s own ability to take the medical relationship seriously, but teaching the treating physician to experience love of medical work more authentically; because to be effective, treatment has to be collaborative.

Agape enters the therapeutic relationship as an attitude that accepts the work even when it is not stirred by mutual attraction or by fellow feeling for the details of the work. The Tibetan meditation teacher Chögyam Trungpa, in his chapter on working with others in John Welwood’s Awakening the Heart (Boston: Shambhala, 1983), notes that a therapist sometimes has a certain embarrassment for a client, because the client’s symptoms have made him or her unattractive. To be able to help such a patient, who is not the sort of person one would want to have, even in fantasy, as a lover or a friend, one has first to get over the embarrassment the patient’s symptoms stir up. When one is able to do so with chronic patients with severe and not fully curable conditions who do not always cooperate ideally with their treatment, one can develop an attitude of 12

caring that transcends the eros and philia that come more easily toward patients with better personas and prognoses. It takes time even for a dedicated physician to discover agape, but when it appears, the ability to accept patients just as they are enters the work. Then one loves from another place, which might be called an objective sympathy for the patient’s condition—the same sympathy that enlightened people have always brought to the human condition itself.

Therapeutic work, even when it falls short of its goals, becomes satisfying. For the working doctor, the attitude that appears has nothing to do with pity, which might be termed a compassionate looking down on the other, building up the doctor’s self-esteem (and connection to health) at the expense of the patient’s. Rather, one looks up to the patient with gratitude for the chance to embrace the human condition in all its imperfection. This form of love frequently elicits a similar gratitude from the client, who begins to accept the treatment in a new spirit, not just as a wounded person seeking help from a healer but as someone whose wound has the power to find the wound in the healer that, as the Jungian analyst James Hillman puts it, “becomes a well of cures.” Then both patient and doctor come upon the silver lining of illness: its amazing capacity to nurture acceptance.

When we encounter love in the therapeutic relationship, is it agape, philia, or eros? It can be all three, but love is too good a medicine to be merely deconstructed.

Rather, we must train ourselves to accept it, however it comes, as a gift to the healing enterprise.

Dr. John Beebe, a psychiatrist in practice in San Francisco, is a Past President of the C.G. Jung Institute of San Francisco and a Distinguished Life Fellow of the American Psychiatric Association. An internationally recognized Jungian analyst who lectures throughout the world, he is the author of the book Integrity in Depth, a study of the archetype of moral wholeness.

San Francisco Medicine july/august 2007

Welcome New Members!

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

From the Permanente Medical Group:

Gavin Jacobson, MD Erica M. Metz, MD

interested in sponsoring a new member?

SFMS has embarked on a New-Member Sponsorship program. Upon approval by the Board or Executive Committee, each new member is assigned a sponsor, an established SFMS member whose primary responsibility is to help the new member become better acquainted with the Society and its benefits. Sponsors are expected to connect at least once with the new member socially (over breakfast or coffee, for example) and to invite the member to at least one SFMS event (such as the Annual Dinner, Legislative Day, Candidate’s Night, or a Mixer) during the course of their first year of membership. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@sfms. org for more information or to volunteer. www.sfms.org

The Healing Power of Love

Circles of Support The Healing Power of Community Nancy Iverson, MD

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n a hospital hallway, a four-year-old clung to her father, newly diagnosed with cancer. A facilitator invited her parents into our adult group; another talked with the preschooler and encouraged her to enter our children’s room. Once she was in the circle, a nine-year-old, remembering her first visit to our group as a kindergartener when her mother was starting her battle with cancer, took charge, and with her kindness and wacky, contagious enthusiasm, coaxed a smile from the girl and won over her confidence. During the next two years, both girls remained members of the group. With the others who gathered twice a month, they shared stories, drawings, and songs of fear, anger, sadness, and successes, experienced illness, sometimes cure and sometimes death of a family member, and both offered and received comfort and compassion.

Three years ago, a child with a neurodegenerative disease died in her home in San Francisco. Among the friends and family who gathered with her father, mother, and brother that afternoon were parents her mother knew through a support group she had joined two years before, as her daughter’s disease was progressing. The love and compassion were palpable as the members of this unique community, some who had experienced the death of their own child and some who were caring for children with life-limiting illnesses, offered solace and mourned together.

In 1978, during my pediatric residency, I learned of a children’s support group at the Center for Attitudinal Healing in Tiburon, California. The wisdom of children sharing, teaching, and learning together about their experiences with cancer touched me, and I felt excited and privileged to be a part of the www.sfms.org

One evening in group, working with the theme of “what helps,” Talia Seidman, then nine years old, whose mother had died a few weeks before, drew this picture and explained, “This is the back of the auditorium at the celebration of my mom’s life. Every seat was filled. It helped me feel better to see how many people cared about and loved my mother.”

CAH’s work and development. The work of Drs. David Spiegel and Fawzy Fawzy started to substantiate the benefits experienced by adult cancer patients who participated in support groups in the 1990s. As studies by Dr. Dean Ornish established that coronary artery disease could be reversed with a combination of appropriate diet, an exercise program, and participation in support groups, leading to his book Love and Survival, the context for support groups broadened. Accompanying the expansion of services for patients has been a recognition of the impact of illness on caregivers and family, and groups have developed to help respond to issues relevant for siblings, parents, and children of those living with life-limiting illnesses and for people grieving the loss of a loved one.

Through the Institute for Health and Healing at California Pacific Medical Center, I started the Support for Families Living with Illness program in September

1995. Designed to create a safe, supportive environment for children and adults to explore and develop ease in recognizing and communicating about their feelings and experiences living with illness, the children’s and adults’ groups meet simultaneously but independently. Central to these groups are the tenets of safety, confidentiality, no advice-giving (medical or otherwise), listening, and caring.

Seven years ago, through the invitation from Support for Families of Children with Disabilities, I ran a daylong workshop, “Hope, Despair, and Life Lessons,” intended for parents who had had a child die. As I checked in with the participants, I discovered that no one that day had yet experienced the death of their child but that each was struggling in vast arenas of loss due to their child’s medical conditions.

That workshop grew into an ongoing parent support group, Living with Loss, which is open both to parents caring for medically vulnerable children and parents who have lost a child to death.

Although our original focus in the Living with Illness group was to provide support for families living with illness, our circle has widened to include adults and children from families at all stages of illness, including new diagnosis, recovery, recurrence, and death.

When an established group member died in August 1998, her daughter, who had attended regularly before the death of her mother, asked to continue in the children’s group and invited her father to the adult’s group, and we extended our borders. Since then, as deaths have occurred in families who were longtime group members, the surviving family members have often continued with us, and we have also had families join us after a death has already occurred. In spite of our

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concerns that “mixing” families with illness and bereaved families may be discouraging for the adults and frightening for the children, we have chosen to do so, recognizing the common themes of upheaval and loss that touch any family living with significant illness or bereavement and also because of the extraordinary community that develops for many families within the group.

Being able to participate in and witness the ways in which patients and their families live with illness, death, and grief—and support one another during those times—has taught me much and has emotionally and spiritually sustained me through many challenges as a pediatrician. Not only did I design the program with the intention that the groups would provide service for families but I also hoped to deepen the education and experience of members of the medical community, especially physicians, in the care of patients with life-threatening illnesses. Medical school and residency are years of intense, exhausting exposure to human suffering and death, with little if any attention to effective grieving practices.

Few physicians have developed resources and practices for their own grief process; they also have become so entrenched in the sense that they have “failed” their patients that they may be extremely ill at ease in the presence of patients and/or family members who are experiencing pain, disability, or loss, especially loss of life. With the hope of deepening the education of soon-to-be physicians in the realm of a family’s experience of illness, and of opening and improving the pathways of communication and understanding between members of the medical community and families living with illness, I have maintained my commitment that at least one member of our facilitator staff is a medical student, intern, or resident. In her third year of both medical school at UCSF and as part of our team, Katie Kelly reflects, “This experience in the support group allows a medical student like me to learn things that one cannot teach in the classroom. I look forward to each support group meeting not only for the lessons I learn, but also for the fulfillment I get from witnessing such acts of altruism. Now, as a third-year medical student, I see patients daily. Experiences in the support group and the sensitivity of the 14

children I work with only strengthen my desire to treat my patients with compassion. My memories also remind me to be sensitive to the fact that patients and their families facing a life-threatening illness are

“Being able to participate in and witness the ways in which patients and their families live with illness, death, and grief— and support one another during those times—has taught me much and has emotionally and spiritually sustained me through many challenges as a pediatrician.” dealing with considerably more than simply a physical disease.”

Concerns about children and parenting often claim the most attention in the adult group. Questions that commonly arise are about whether to and how to talk to children about diagnoses and prognoses; how to help children have a “normal” life when the illness of a family member wreaks havoc in the family system; how to deal with school situations, most commonly children acting out in the classroom, fighting on the playground, or dropping off in school performance; and how to “parent quickly” as a parent anticipates a shortened life span and an inability to be present for their son’s or daughter’s whole childhood. After learning of her brain metastases secondary to her breast cancer, one mother articulated a fear common to parents living with life-threatening illnesses: “Is it possible for my son to turn out right if I die while he is young?”

During times of major transitions or imminent death, we adapt the group format to allow most of the focus on the adult from the family in crisis, and very specific concerns may be discussed. Other adults, often anticipating themselves or their spouses in similar circumstances, ask for specifics: “Do you keep the children home from school?”

“When do you call hospice?” “How do you

San Francisco Medicine july/august 2007

start planning a memorial service?” “Do you have your children touch the body?” These sessions, although especially challenging and draining, are often the times in which the group does the “best” work. Members, especially mothers who are quite ill themselves, express appreciation and relief for the opportunity to share stories with someone who is undergoing what they are expecting in their own families. The experiences may trigger reflections and conversations in group and later at home as to individual family values and customs, helping to clarify goals and plans.

Topic-related activities, most often drawing and painting, prevail in the children’s group. Establishing our group as a safe and unique place for sharing feelings and experiences that are otherwise often isolating, we look for opportunities to deepen explorations relevant to feelings about illness, transitions, death, and relationships with family, friends, and medical staff. Common concerns include distress about hair loss, extended hospital stays, and a child’s sense of guilt and causation regarding a parent’s illness. We also draw from school experiences and expand into those of family situations as we encourage children to cultivate resources and develop tools that will help them globally, from school to home to many life situations.

As a regular facilitator in the children’s group, I observe changes in children, especially regular attendees, in their ability to express their feelings and to explore their own personal healing with illness-related experiences. I also get feedback regarding children’s school performance. Children predictably act out or drop off in their school performance when there is illness in the family, and children who have been in the group often improve in school function. In the adult groups, we acknowledge the parents’ ability to extend support to each other and to assist each other in their understanding and “success” in dealing with illness in the family. One father, a reluctant first-time attendee who “only came to the group because of the children,” says he left his first group “feeling like the weight of the world had been lifted from my shoulders.”

He and his children participated regularly in our group during the two years preceding www.sfms.org

his wife’s death; at her memorial service, the priest offered a blessing to our group. The family continued to attend group when the hectic schedules of three children and a single father allowed, and this man calls us “the group that saved my life.”

The continued involvement of families living with loss enriches the group experience by helping to provide some familiarity with the journey ahead for those living with impending bereavement. Families shift from despair as they witness that “life goes on” for family members after a death, with shared experience as to how. Two of our long-term group mothers with cancer became outspoken advocates of including bereaved children in the same group with their children. In response to the question of whether anything good ever happens when someone dies, a third-grader pondered for a moment and responded, “Yes, there is. Once you already had someone die, it would be sad but then you wouldn’t have to be scared about anyone dying anymore because you already know about it.” Bereaved parents speak with eloquence about their experiences, either as a parent of a child who is no longer living or as a single parent following the death of a spouse. Not only are they able to relate their experiences in a way that helps others but they also describe their own sense of unburdening as they share their heartaches, triumphs, and frustrations with the group.

Programs differ as to group members, facilitators, structure, and intention and, like living organisms, transition at certain stages in their growth and development. As we learn and adapt through our experiences with illness, loss, and support services for those encountering these life situations, we can continue to explore ways to cultivate new visions and enhance existing services.

In writing about the Commonweal Cancer Help Program, Michael Lerner says, “Sharing our stories helps us understand each other. Understanding leads to compassion. Compassion flows gently into love. And love heals.” Many families experience the tremendous challenge of living with a life-limiting illness or loss.

We cannot prevent the enormous demands for these children and parents, but we can help guide them through their troubles and www.sfms.org

ease their pain and ours by exploring ways to connect, share our stories, cultivate our resources, build and sustain community, and promote healing.

Dr. Iverson’s experience with support groups began in 1978 at the Center for Attitudinal Healing, where she served as a facilitator in both the parents’ and the children’s groups and has more recently become an educator in program training. In 1993–94 she participated in a series of workshops through the Institute for the Study of Health and Illness conducted by Dr. Rachel Naomi Remen at Commonweal, a cancer retreat center in Bolinas, California.

Since 1994, Dr. Iverson has been part of the faculty for The Healer’s Art, an elective developed by Dr. Remen for students at UCSF. She has also been part of the faculty at Stanford University School of Medicine. She developed and facilitates the groups Support for Families Living with Illness through IHH at CPMC and Living with Loss through Support for Families of Children with Disabilities.

The Pharmacology of Love Continued from Page 10... system (CNS). In the monogamous prairie voles, injections of oxytocin directly into specific CNS loci increase preferences for a single partner over other partners, and injections of specific oxytocin antagonists depress single-partner preference.

In humans, several studies have examined the effects of emotion and intimate contact on circulating oxytocin levels.

Oxytocin levels increase in response to a massage but decrease when recounting the loss of a loved one. While recalling a love event, women in romantic relationships have greater oxytocin increases than women not in relationships. Oxytocin is released during sexual activity and may help mediate postcoital attachments. Thus, although the exact relationships between oxytocin release and emotion are not completely understood, the available data indicate that circulating levels of oxytocin change in response to affiliation and intimacy.

Our research group at California Pacific Medical Center studies the pharmacology of commonly abused drugs, and we have been investigating the effects of MDMA on emotional experience and perception.

Our studies of MDMA effects on oxytocin release are not yet completed. But there are data from animal studies. In male Wistar rats, MDMA stimulates oxytocin release and increases affiliative behavior (assessed by the amount of time animals spent lying next to cage mates). Pretreatment with a 5HT-1A antagonist or a specific oxytocin antagonist abolished this behavior. MDMA probably produces an increase in affiliative behavior through serotonergic mechanisms—the 5HT-1A agonist 8-OH-DPAT also increased affiliation and, like MDMA, either a 5HT-1A or oxytocin antagonist blocked this behavior. These data imply that compounds acting at 5HT-1A and oxytocin receptors may alter sociability and have therapeutic applications in asocial and antisocial conditions. Antisocial personality disorder is common in alcoholism and other addictive disorders—perhaps drugs similar to MDMA will someday be useful in serious medical diseases.

So if methamphetamine facilitates sexual desire and MDMA facilitates affiliation, is that all there is to a pharmacological theory of love? What happened to romance?

No matter how well the biological mechanisms are characterized, the experience of love will always be more than the sum of the parts. We are still a long way from any form of pharmacologic determinism. Indeed, our relatively crude scientific understanding of this most complex and essential emotion suggests that romantic love will continue at the center of the human drama. So, can a pharmacologist make any recommendations to facilitate love? Given the current state of knowledge, we would recommend chocolate and roses. And if that doesn’t work, increase the chocolate dose.

Aristotle stated, “I am,” and Descartes said, “I think, therefore I am.” Based at least in part on emerging neuropsychopharmacologic observations, we may need to modify our definition of humanity to “I love and think, therefore I am.”

John Mendelson, MD, is an Internist and Clinical Pharmacologist. Matthew Baggott is completing his PhD in Neuroscience at U.C. Berkeley. They conduct NIH-funded clinical research on the pharmacology of addictive drugs and consciousness at the California Pacific Medical Center Research Institute.

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The Healing Power of Love

Intimacy, Wholeness, and HIV HIV and the Romantic Relationship Frank Sclafani, MFT The greatest thing you’ll ever learn is just to love and be loved in return.

—Nat King Cole, “Nature Boy”

F

ortunately, after twenty-five years, in the United States HIV disease has evolved into a chronic medical condition. Consequently, a greater number of individuals and couples in relationships are successfully living with and managing HIV. One such couple is Jon and Marc (their names have been changed to maintain confidentiality). They live and work together and describe their current relationship as stronger than ever. HIV is viewed as a small part of the whole of their lives together. “If you have committed to a person, and are in love, you just do what needs to be done,” says one of the partners.

As a relationship counselor, it is encouraging to hear such positive feelings and to observe how this couple has successfully integrated HIV into their relationship. In addition to managing the medical aspects of any chronic illness, it is crucial for health care providers to understand and support the effect of healing on the relationship between partners.

Jon and Marc were introduced by friends at a large annual house party in San Francisco twelve years ago, and they were immediately enamored with one other.

On their third date, Marc disclosed that he was HIV-positive. This was a first-time event for Jon, as he had never knowingly dated anyone with HIV. The encounter triggered a flood of emotions and questions for him: “Would I too get the virus? Can I handle my constant worry? What if he dies?

On the other hand, what if this is the right relationship for me?” Jon concluded that he would take things very slowly, one small 16

step at a time. He reported being very careful initially, always having protected sex and getting tested regularly. After six months of testing negative, his anxiety eased greatly

“ Fortunately, after twenty-five years, in the United States HIV disease has evolved into a chronic medical condition. Consequently, a greater number of individuals and couples in relationships are successfully living with and managing HIV.” and he concluded that his safer sex practices were sufficient precaution.

Shortly thereafter, Marc was diagnosed with a somewhat rare infection, microsporosis, which he contracted while traveling in the Caribbean. After being sick for nearly two years, losing eighty pounds, and being described as “circling the drain” by his doctor, the timely advent of antiretroviral medications completely turned his health around.

Jon was amazed that he stood by Marc throughout the uncertainty of his health.

He had grown to love Marc deeply. He appreciated his courage, the consistency of his optimism, and the spontaneity of his childlike playfulness. From the start, the two had negotiated an open sexual relationship with certain established parameters. They agreed to be discreet, not bring anyone home, and not sleep with friends or with any

San Francisco Medicine July/august 2007

person more than once. Eventually, Marc made a full recovery from his near-death experience. He regularly worked out at the gym and gained back the weight and muscle mass he had lost. Feeling physically and emotionally attractive, Marc soon found himself in the precarious situation of having broken all their rules. This breach of trust almost ended their relationship, and they decided to go into counseling. During the course of therapy, the couple negotiated a new agreement and decided to close their relationship. For the last eight years, they have been content to live happily in a monogamous relationship.

“For me, HIV has been a horse race,” says Marc. “Fortunately, I have been able to stay ahead, though sometimes barely, of the need for new medicines. I have learned to live for today, and I believe I taught this to Jon as well. I feel optimistic these days. Five to ten years ago, I had four to eight T-cells.

Now my CD4 count is above 450 and my viral load is undetectable. I thought I would die at age thirty-nine. This is all borrowed time. Not all days are perfect by any means.

I have learned to communicate to Jon when I am not feeling 100 percent, and I just go lie down. Jon continues to be very supportive, reassuring, and attentive.”

The presence of HIV, or any chronic illness, presents all couples with unique challenges. Given these challenges, healthy communication is of the utmost importance to the growth and survival of the relationship. Partners must actively deal with risk and change as they embark on the healing process.

Initially, they must let the world in and recognize the importance of the ability to ask for help. What often follows is a greater

Continued on Page 18... www.sfms.org

The Healing Power of Love

Love in the Time of Tuberculosis A Doctor’s Love Makes a World of Difference Sheiva Khayam-Bashi, MD The setting: short-term skilled nursing facility, San Francisco General Hospital The year: 2006 The subject: love and tuberculosis

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r. V. was a strikingly thin, frail, and sad sixty-year-old man—he was homeless, with a history of substance use, alcoholism, depression, atrial fibrillation, diabetes, hypertension, chronic kidney disease, osteoporosis, peripheral vascular disease, and now with vertebral osteomyelitis. He had been transferred to the skilled nursing facility at San Francisco General Hospital for IV antibiotics for vertebral osteomyelitis, to complete a six-week course.

When I first met Mr. V. as he arrived on the SNF, I was most astonished by his severely stooped posture, as he walked bent over at the waist. When standing up, his back was fixed in a nearly completely flexed position, such that he could only face the ground when standing or walking. His osteoporosis was severe and he had suffered many vertebral compression fractures, so that his spine was bent chronically at an almost ninety-degree angle. I could not resist the idea that this was not merely a mechanical problem but also a deeply emotional one; his severely stooped posture and fixed, downward gaze were consistent with, and reflective of, his very sad state of mind.

Due to the condition of his back, and possibly due to emotional reasons as well, Mr. V. got around town with his head facing the ground at all times. During his life he had first been abused and then used alcohol and other drugs to cope with severe depression, which led to homelessness and alcoholism by his midtwenties. He had made a life of survival on the streets—a solitary and www.sfms.org

deeply lonely life—and he had always felt unloved and unworthy of love.

When we began to talk, as I admitted him to the ward, I was also struck by Mr. V.’s very sweet and gentle manner. I could see how he could have been abused in his lifetime—he was not a fighter. He wanted to make others happy, and he was sincere and kind in his approach to people. We talked about his life story, as well as his current condition and his level of pain. I examined him and reviewed his care with him, and we came to agreements about his treatment and pain medications.

Over his several weeks with us, my staff and I grew to enjoy Mr. V. very much. Initially he would leave the unit without telling anyone where he was going. Later, after learning that we worried for his safety and needed to know where he went, he agreed to inform us prior to leaving. He would often go out for brief walks on hospital grounds, and he would bring back a few flowers from the garden in a paper cup for us to keep at the front desk. He always smiled sweetly, and we always thanked him. He felt accepted and even appreciated.

We all grew accustomed to his bentover walk, and he was not made to feel unusual or strange at all. He remarked about how grateful he was for the care, as he not only had a roof over his head, a warm place to sleep, food to eat, and a shower, but he also had lovely people surrounding him, people who cared for him. He was an astute man, with little formal education but with much street education—a man who knew a good thing when he experienced it.

One day he began to cough, and this cough progressed slowly each day. He later became short of breath and coughed up a small blood clot. He had denied any cough-

ing at all when I first admitted him, but as I questioned him again, I learned that he had had a cough the year before, which had resolved after several months. It had now returned in a familiar way; he was not concerned. My concern about active tuberculosis versus malignancy suddenly grew. We obtained a chest X-ray, which was equivocal for old TB, and we put him in an isolation room to check his sputum for AFB (acid-fast bacilli). As we explained everything to him at each step, he was always grateful. I am not sure if he always understood fully, but he would smile and say, “Whatever you say, Doc. I trust you completely.”

A few days later, he became even shorter of breath and mildly hypoxic, and his sputum smear returned positive for AFB. I needed to transfer him to the acute medical-surgical unit for closer monitoring and to begin treatment for active TB. I explained the situation to him, and he said that he understood. But, as he stood in his room, bent over and facing the floor, I noticed that there were tears dripping straight down onto the floor, directly under his face.

I said, “Mr. V., are you crying?” He said he was not; but I said that I could see a puddle of tears forming just beneath him.

He laughed. I asked if he was afraid. He said no. I told him more about TB, and about my expectation that he would do well. Still, there were tears silently dripping onto the floor.

I asked him to tell me what he was feeling, so that maybe I could help. He asked if he couldn’t just be treated here, staying on this unit and not having to be moved to another ward. I explained why that was not possible, that he needed a “higher level of care” at this time, but that I expected he would return to us in several days’ time.

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Still, tears dripped quietly onto the floor. I sat with him patiently and held his hand as he cried. Then he finally lifted his head to look at me, and he said, “But you people here love me!”

I nearly cried then myself. Yes, we did love him. And more importantly, he felt loved.

We talked about his feeling better now than he had ever felt in his life, because he felt loved as well as cared for. He feared what would happen when he was transferred upstairs; he feared not being loved.

I assured him that he would be well cared for, and that I would speak to the doctors who would take over his care upstairs.

I called the medicine resident who was admitting new patients that day to come down to meet him. After I explained the case, as well as the emotional situation, to the resident on the phone, she agreed to come downstairs for introductions. I introduced Mr. V., saying, “This is Mr. V. He is very special to all of us here, and I have told you his story.” She kindly shook his hand. He smiled sweetly but looked a little tentative. I asked, “In addition to treating his tuberculosis, will you please love him as much as we do?” She looked a bit surprised but assured him that she and her team would indeed do so.

The resident later told me that she had never been asked to love a patient before,

but she thought it was a wonderful idea. He did enormously well, was well cared for and loved by the medicine team, and he later returned happily to our unit to complete his treatments.

Some six months later, Mr. V. saw me in the clinic where I was attending, and he tapped me on the shoulder and hugged me.

He looked much better, had gained some weight, and did not look as disheveled as before. Most notably, he was actually walking somewhat more upright than I had ever seen him able to do! He had a greater sense of value for himself and he felt less ashamed and unworthy, he said. He said that he wanted to thank me and all our staff for our loving care.

His life changed in some substantial ways after he left the hospital—he found low-income housing, quit drinking, and adopted a cat. He loved the feeling of caring for another living being, and he said that was the greatest sign that he was indeed all better: “Now that I am in a position to give love to something else, I know I must be in good shape.”

Shieva Khayam-Bashi, MD, is Associate Clinical Professor in the Department of Family and Community Medicine at UCSF and at San Francisco General Hospital, and she is Medical Director of the short-term Skilled Nursing Facility at SFGH.

Classified Ad Excellent opportunity for existing internal medicine practice to expand. Central San Francisco. Present physician is part-time with exceptionally pleasant patients.

Inquiries: sfinternalmedicine@gmail.com.

HIV and the Romantic Relationship Continued from Page 16... bandwidth for intimacy, increased receptivity to help from others, and a greater depth of self-compassion. This leads to an even greater willingness to change, the resurgence of hope, and the mastery of current circumstances.

Finally, they often experience renewal and recommitment, an expanded vision of self, increased unity in relationships, and a greater sense of wholeness. The capacity to expand the emotional foundation of support increases as each partner grows in greater acceptance of the other. A stronger circle of friends may develop, which often affects the relationship in a positive way. Open, honest communication continues in outward spirals in all relationships.

Jon and Marc have learned to love and heal on many levels in the shadow of HIV. As helping professionals, we can have a positive effect on couples during the healing process and in the face of chronic conditions. As we recognize their unique challenges, we can teach them to find solutions that will enhance their relationships and promote healing.

Frank Sclafani is manager of Behavioral Medicine at Kaiser Permanente, San Francisco, and practices as a mental health clinician in Primary Care on the HIV Module. He is a licensed Marriage Family Therapist and certified in Pain Management, Addictions and EAP. He serves as board secretary for New Leaf Services for Our Community and is board co-chair for the Kaiser Permanente HIV/AIDS Advisory Board.

Watch Out for the 2007/2008 SFMS Membership Directory!

Directories are on the way and members of the San Francisco Medical Society will receive them shortly. The next issue of San Francisco Medicine will include information about ordering extra copies of this useful desk reference.

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San Francisco Medicine july/august 2007

www.sfms.org

The Healing Power of Love

The Serpents of Caduceus A Depth Psychologist’s Reflections on Healing Love Elizabeth James Thompson

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n his essay “Can a Doctor Be a Humanist?”, the novelist Robertson Davies recounts the legend of the caduceus, wherein the Greek god Hermes “came upon two warring serpents, who writhed and fought upon the ground at his feet. To restore peace, the god thrust his staff between them, and they curled around it, forever in contention but held in a mutuality of power by the reconciling staff. And there they are still, held in check by the power of Hermes from achieving a final victory in their struggle for supremacy.”

To Davies, these serpents—which he sees as the Serpent of Knowledge and the Serpent of Wisdom—are still “vividly alive and relevant” in medicine. The caduceus, therefore, is a perpetual reminder for physicians and psychologists that the god Hermes requires them to hold these two serpents—Knowledge and Wisdom—in balance, for “unless they are reconciled and each made a supporter of the other, they can make the staff of Hermes lopsided, and wanting in its true power.”

As a depth psychologist and daughter of a surgeon, I feel a keen understanding of these warring serpents. I became aware of their presence in my own psyche when I first read the words of Rachel Naomi Remen, MD: “Medicine is as close to love as it is to science.”

Medicine and science, yes—but medicine and love? Of course, the statement appears strange only when read through the eyes of just one serpent. There are two serpents coiled around that healing staff, however, and in my struggle to understand the concept of healing love and its place in medicine and psychology, I had to remember them both. The way I came to understand it, the Serpent of Knowledge has www.sfms.org

a distinct relationship with science, while the Serpent of Wisdom has a relationship with love. Each serpent looks in a different direction, each sees different things—and

“Years ago I said that healing love was “unethical.” Yet there may be a different ethic—a larger ethic that has a natural home in a participatory model of knowing.” each must be “a supporter of the other.”

While not as scientifically minded as my surgeon father, as a psychologist I am nevertheless an offspring of our culture as well, and its main epistemology is one of science—specifically positivist science, which implies that ultimately all healing can be understood through science. As such, it constantly informs my way of thinking.

And so I’ve noticed that when I find myself thinking of “healing love” as something soft, flaky, romantic, or downright “woo-woo,” with no ethical fit in the world of science or medicine, I can be fairly sure that the Serpent of Science has usurped the healing staff in my mind. Not only that, but he also has one eye closed—for science itself is much larger than the positivist model upon which medicine and psychology are based.

Indeed, the lineage of medicine, as Dr. Remen reminds us, extends back much farther than modern science—to a time before the refinements of expertise and the wonders of cure, when healing relied upon the very human, loving qualities of personal related-

ness and connection. Furthermore, each of them—the Serpent of Knowledge/science and the Serpent of Wisdom/love—has its own ethic. My journey into the understanding of this dual ethic began in a therapist’s office, many years ago.

At the time, I was in a session spilling my suffering over the edges of my heart and wondering if it could carry the ache. When I asked my therapist how she could possibly heal me, she quietly said that she knew me, she had faith in me, and she loved me. She loved me? I quickly exclaimed, “You can’t say that. It’s unethical.”

I relate this story because when I think back on that moment I marvel, in a rather disturbed way, at how easily and quickly I was able to separate from my own being and move with detached scientific objectivity to my head—the home of reason, logic, rules, and rationality. In so doing, I disconnected from the soulful experience at hand and put a barrier between myself and her kind offering of healing love. I had no idea that her healing love could be as solid and reliable as anything scientific, or that love had a credible relationship with knowledge—with a way of seeing and knowing that is trustworthy in its own right. And so, in that moment, I went with what I knew to be “real” knowledge—the facts. I “knew” that love did not belong in the professional world—and the code of ethics of any licensing board was all I needed as proof.

Yet her method was founded upon a different epistemology than the culturally dominant one of positivist science. The word “science” comes from the Latin scire, “to know.” And true science—the Serpent of Science that has both eyes open—is much larger than this one form of it. As physicist F. David Peat puts it, “Science is about

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celebrating the universe. It’s about seeing beyond the appearance of things to what lies within. It is understanding the symmetries and patterns of the world. It is the delight in discovering the unexpected, the particular, and the individual.”

Curiously, the root of the word “science” is skei, “to cut,” “to split,” “to separate one thing from another.” How might the healing arts in medicine and psychology be different if science itself had not been split apart, with the positivist approach separated out as the one most reliable and trustworthy? Since a worldview shapes a culture’s approach to healing, and its ethics of healing, the science of medicine can’t help but be influenced by the fact that our worldview is currently in the throes of a major metamorphosis. Positivist science has its roots in the materialist, Newtonian worldview of classical physics. But science in its totality includes the strange and mysterious worldview of quantum physics as well.

Because of this, quantum physicist Niels Bohr called our attention to the necessity of a new attitude, one of complementarity, wherein seemingly opposite ways of knowing live together, just as the Serpents of Knowledge and Wisdom, science and love, share the healing staff.

John Wheeler, the great professor of physics, who worked with Einstein and Bohr at Princeton, brought to our awareness that we live in a participatory universe, far different than the one in which our model of relating is that of the detached, objective observer. This larger scientific worldview is founded on a way of knowing that stresses the web of relationships and interdependencies between the knower and the known.

Such a participatory consciousness—one

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that comes to knowledge through connection rather than detachment—has been slowly moving back into the art and practice of medicine.

And so, while healing love finds no home in a scientific epistemology of detached separation, there is a place for it in the scientific epistemology of participation.

Perhaps our starting point for understanding the power of healing love is to first acknowledge the ubiquity of our culturally preferred way of knowing, and to recognize the ways it shapes our thinking. As author and teacher Parker Palmer puts it, “every way of knowing becomes a way of living … every epistemology becomes an ethic.”

Years ago I said that healing love was “unethical.” Yet there may be a different ethic—a larger ethic that has a natural home in a participatory model of knowing.

A deeper participation may remove a barrier behind which we feel a sense of safety and security and may lead us into the rather messy domain of human emotions. And yet the intellect alone, disconnected from the personal realm, is being revealed as sorely insufficient when it comes to dealing with the complexity of human life. Our emotions, in fact, are critically related to the ways we become ill, and the multitude of ways we heal.

According to biologist Humberto Maturana, coauthor of the book The Tree of Knowledge, love is the only emotion that expands intelligence and broadens the possibilities of what can be known. “When the emotion of love is there, vision expands.”

Thus, through a more participatory approach, we move into a new ethic, a more expansive way of knowing and seeing, and a broader science—one that can include

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mystery, paradox, irrationality, and even love. Maturana says, “Love is the domain of those relational behaviors through which another arises as a legitimate other in coexistence with oneself.” To offer this kind of love to an other “means that you have to let it be, to see it.”

Knowing when to see an other through the eyes of the Serpent of Knowledge/science, and when to see an other through the eyes of the Serpent of Wisdom/love, is part of the art and practice of any medicine or psychology that is founded on participation, which includes healing love. Remembering that each Serpent has its rightful place, its own way of seeing that brings value, keeps them reconciled and returns the power of healing love to the caduceus, the staff of Hermes.

Elizabeth James Thompson is a PhD candidate in depth psychology at Pacifica Graduate Institute, and the daughter and sister of physicians. Her dissertation is entitled “Healing Love.”

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The Healing Power of Love

The Healing Power of Love Learning to Heal the Body and the Spirit Karyl Huntley

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very religion has teaching stories about the healing power of love.

Most families also have told and retold tales about a family member who was an especially loving person and who healed another family member with his or her love.

Sometimes when we are in deep desire to be delivered from a fearful diagnosis, we ask, “Where is that healing love when I need it?” or “How can I become loving enough to fix myself?” or “Where can I learn that powerful way to love so that I may heal my dear friend?”

I would like to examine what we mean by love and healing from a philosophical point of view, and ponder how any of us, no matter what our religious beliefs, can use the power of love to restore well-being.

Love is certainly one of the most overused words in our language. We love our children, our favorite vacation spot, and our favorite food. We use the same word to mean passion, affection, approval, worship, adoration, and preference. For our purposes of healing and restoring well-being, I want us to consider this powerful word in a specific way. I want us to think about love as the most positive state of being that we can imagine for ourselves. When we are in this state, we are peaceful, grateful, expansive, and at ease. We have no room for fear, harsh judgment, anger, shame, or guilt. This feeling is not directed at any one person or situation; rather we simply usher ourselves into a state of joy for no particular reason.

We can actually learn how to create this internal state for ourselves in a number of ways. Most spiritual paths teach methods of prayer and meditation, which encourage internal well-being. However, contemplating a beautiful scene or listening to beautiful music will encourage this state as well. www.sfms.org

Affirmations, such as “I am breathing out tension and breathing in love,” works for some people. Remembering a time and place when you felt absolutely wonderful and

“Curing our physical body can be wonderful, but healing a life can be the biggest miracle we ever experience.” bringing that memory fully back into your heart and mind is another way of creating this peaceful inner state of being. Whether we call this state love or peace or joy, it really doesn’t matter, because the intense well-being we feel when we are in this state encompasses all of these qualities. This is the love that promotes healing.

When we think about healing, most of us mean that we want to return to a state of vibrant health and strength with no symptoms of disease or dis-ease. We want physical and mental comfort instead of pain. We want to return to a level of physical capability that feels appropriate to our desires. We do not want to age or become physically debilitated; we do not want to be sick or uncomfortable. Depending on the severity of our condition, healing can mean anything from feeling more energetic to experiencing a miracle, in the presence of which our doctors shake their heads and say they have never seen anything like this.

At this point we need to differentiate between two connected concepts of wellbeing: curing and healing. Curing is what we mean when we want a cessation of fearful or uncomfortable symptoms. We want our cancer to go into remission; we want our

broken leg bone to knit together. We want our runny nose to stop running and we want our back to stop hurting. These movements toward physical well-being we can call curing. Taking pain relievers or prescribed medicine, doing our exercises and eating well all help with the alleviation of troublesome symptoms and promote curing. Also, love helps with curing.

Many studies show that worry, fear, anxiety, loneliness, depression, and anger fill the body with toxic chemicals that inhibit the natural process of our bodies to restore health and well-being. We can actually worry ourselves sick and depress our immune systems by being chronically unhappy. Conversely, that self-generated state of peace, love, and joy promotes health and well-being by creating a biochemistry that enhances the restoration of right action in all our physical systems.

Curing our physical body can be wonderful, but healing a life can be the biggest miracle we ever experience. To move into a state of forgiveness, nonjudgment, empowerment, trust, truth-telling, acceptance, and connection from an existence that is the opposite of these life-giving qualities can be so monumental as to seem like the reason we took birth in the first place. Healing can happen with or without curing. Love is essential for healing.

When a person with grave symptoms uses the power of love to heal his or her life, it seems as though the disease was the paradoxical gift that began the healing. This is not a rare event at all. Many people who are faced with a life-threatening diagnosis take the opportunity to heal family relationships, tell the long-withheld truth that restores connection, forgive the hurt that is decades old, declare the love that was kept

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silent in the heart for years, and generally exhibit life-enhancing behavior that heals whole families. This is the power of love to heal and restore intense well-being in hearts, minds, and lives. This kind of love not only heals the life of the person who is sick, but heals entire family systems.

When we are sick, do we work toward curing or healing? When love is present, the answer is both. Sometimes we use meditation, visualization, and relaxation techniques to generate the internal state of peace, love, joy, and ease. It is our desire to help with the curing process, because we desperately want to get over being sick and be restored to vibrant health and strength.

In the process of doing the internal work that creates the state of love, we find that there are unhealed places in our lives—perhaps an estranged family member to connect with again, or a lie that is too painful for us to live with any more. With courage and inner strength, we work to heal these rifts in our body/mind system and find that great expansiveness and joy are the result. This is the power of love to heal.

Sometimes we are cured in this process and sometimes we die from our physical disease, but the healing in our lives is so evident and powerful that our hearts are in greater peace than a curing alone would have afforded us. One of the byproducts of this supremely powerful love is trust. When we love, we have the faith that the well-being we feel is the ultimate truth and not linked

to conditions—not even linked to whether we remain alive in our bodies or not. This is the power of love to heal.

We can practice this love whether we are the patient, the caretaker, a family member, a part of the medical community, or a stranger. The results are always healing. It matters not what the symptoms are, what the diagnosis is, how distraught the family is, whether the most challenging aspect of the situation is the disease or the family upset. One of the miraculous aspects of the peace-love-joy state of being is that when that state of well-being permeates a troubled condition, whatever needs to be healed and restored to ease and expansiveness is restored.

You can try this for yourself. First, learn how to generate the state of love within yourself when you are alone. Find a technique that works for you so that you can predictably create a sense of intense well-being that ushers you into your state of happiness and loving-kindness. Practice this skill so that you can give this gift to yourself no matter what conditions are going on around you or what thoughts are going on within you.

This skill, once mastered, puts you into a rare category of peaceful, nonreactive, conscious, openhearted, and safe people who are natural healers. When you have mastered this way of being, you will not need to look for situations or people to heal; they will find you, because you will have transformed

yourself into a powerful healer. Because of the atmosphere around you, people will be eased into a more peaceful state themselves.

They will seek you out because they will feel so much better in your presence. Should you then choose to help a person or family who is suffering from disease or dis-ease, the love that you generate in yourself and around yourself will help them reach the cured state and the healed state.

If many of us sought to create this atmosphere in ourselves and around ourselves, I believe that miracles that have eluded policy makers and governments forever would happen on a worldwide scale. We would have a gentler world, with people who are slow to anger because they are centered in peace and love. We would have a world of diverse cultures that seek to create a tone of mutual acceptance and curiosity. We would have a planet that gratefully accepts the love of the beings who inhabit her and gives back what our bodies need to sustain us in absolute well-being. This is the healing power of love.

Karyl Huntley has had careers in high school teaching, college publishing, and New Thought Ministry. She is currently the senior minister of the Golden Gate Center for Spiritual Living, a Science of Mind Center in Corte Madera, California. She is the author of the book Real Life Rituals, a book of sacred ceremonies for many of life’s experiences and transitions.

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San Francisco Medicine july/august 2007

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The Healing Power of Love

Expressions of Love Art and Medicine Nancy Iverson, MD

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y Dad I love my dad higher than the sky, further than the stars, and deeper than the oceans.

My dad was the kindest person I have ever known. He was also my best friend.…

Thank you, Dad, for giving me life and being the best father you can. You will always be in my heart.

Devastated by his father’s death, as eleven-year-old Sho Kulko shared his poem during his father’s memorial service, he used words to help reconnect to lifelines of love and gratitude and to start his monumental journey of healing from loss.

Seventeen-year-old Caitlin Dolaghan, in the midst of her battle with osteogenic carcinoma, affirmed beauty as she wrote this in her journal: The moon is beautiful tonight. It’s not a full moon and yet it still shines brightly. It shines what it can. I have many things to complain about but I just don’t feel like complaining at the moment. The stars and the moon are out, and they are so enchanting. I do feel like a princess … but I don’t know if this fairy tale will have a happy ending. I love being a princess, one who fears nothing. I am so used to feeling my spirit sink. It’s a nice change to feel happy, and over something so simple as the moon. I love the night sky. I don’t want to close my curtains.

Why do people associate the night with evil?

It’s beautiful. The creatures of the night aren’t evil, they are graceful, they can move silently in the dark.

Fifteen months before her death, her father, John, expressed his anguish, coupled with hope, in his first poem for Caitlin:

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Photos by Moment by Moment, a nonprofit organization of

I walk with my daughprofessional photographers who provide portraits for families of ter in the valley of the shadchildren with life-limiting illnesses, with a goal of creating lasting ow of death.... memories and capturing the role of families, love, and courage I need words of courage in living each day moment by moment. as the shadow of death falls on my daughter’s face.…

We rest by the path, I listen to her hopes I know it can be and dreams, in this shadow that swallows hope, lopsided as a kid’s valentine and makes dreams dark. big as the universe When death’s shadow was distant absent as the tin woodsman’s.

I seldom heard her dreams.

I disagree with anatomy.

She mourns her deep loss, I know for a fact that a heart can I share her tears of pain…. rub We will emerge from this shadowed valley, thrill held firm in our Father’s heart. split We will be together, whether we travel almost give in and quit. on together for a time, or for a time, our paths Yet hearts, great hearts, my friend diverge. can mend!

Way back in medical school, I knew it was essential to conquer all the facts, figures, and skills necessary to cure disease and “save” lives. I also wondered what I would miss if that were my only focus. I reflect back on my meticulous dissections and memorizations in anatomy labs and realize I emerged with only partial insight into the configuration of the human body.

Years later, Kathleen Metcalfe’s poem, from her 2003 collection Signs of Life, deepened my understanding: Lub DUB I disagree with anatomy.

I know for a fact that a heart can be found in a throat at the bottom of the stomach perched on a sleeve.

I know it can freeze in the icy pericardium of winter, thaw in the spring of new beginnings.

With words, music, pictures, and in a myriad of other ways, art accompanies medical experiences and invites us to explore the deep undercurrents of life, illness, death, and healing. We must, of course, bring the best of our knowledge and expertise to our practice of medicine, but we miss so much when we limit ourselves merely to interpreting lab values, reviewing scans, calculating dosages, and writing prescriptions. When we restrict our focus, we may feel only the defeat of disease and overlook the pockets of spirit that inspire courage and resilience—both our own and our patients’. When we compose our poems and hear our patients’ stories, we can listen deeply to the tones of despair and hope, fear and trust, rage and joy. We can enrich our perspective and help navigate not just the terrain of pathology but also the experience of an illness.

We can collectively acknowledge the complexities and wonders we encounter,

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The Healing Power of Love

Rocking the Babies Loving, Powerful Medicine for Babies at the Crisis Nursery Rosa Estremera

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ears ago, while driving, I heard a radio announcement for volunteers to work with children at the Sacramento Crisis Nurseries. “Hmmm,” I thought. I liked the idea of rocking babies that required tender loving care in times of emergency. I tucked away the thought in my mental files. My Puerto Rican father, Enrique Estremera Torres, had instilled in me the concept of returning service and assistance to others in my community, in gratitude for the blessings that one receives in life.

Most of my career, I worked at the University of California, Davis. The majority of my staff experience was as a program manager in the Department of Family and Community Medicine. Four years into it, I began to experience rheumatoid arthritis, eventually joined with fibromyalgia. It was a day-by-day agony that lasted eleven years.

There were days when I felt I wouldn’t make the journey.

With help from loving friends, family members, and physicians, I was convinced to go on disability. At the time, I felt leaving was a surrender to illness. I felt defeated.

Looking back, I know that those who loved and supported me saved my life and put me on the path toward healing.

Two and a half years plus three surgeries later, I felt strong enough to participate as a volunteer at one of the Sacramento Crisis Nurseries for three hours a week. It wasn’t much, but it was a start. Like many volunteer agencies, Sacramento Crisis Nurseries is a financially struggling nonprofit, which valiantly provides sorely needed community service. To participate, volunteers pass through a criminal background check, get fingerprinted, and take a TB test. Children from newborn infants to six years of age are 24

voluntarily brought in by parents for reasons unique to each family. As volunteers, we are not privileged to know the background of each child. That information is held

“As she stared off into space, the girl sadly stated, ‘Estoy sola’ (I am alone). It pained me to hear that a four-yearold child felt alone in this world. I hugged her tighter.” in confidence by the staff members only.

However, over time I learned that children are there for a variety of reasons.

For some, their parents are victims of domestic violence or have financial and/or housing problems. Some of the parents are ill themselves. Children brought in voluntarily can stay for a maximum of thirty days.

Some newborns, who come to the program through Child Protection Services, are there because they were born to mothers who took drugs during pregnancy and delivery. As a group, the children represent all ethnic and cultural backgrounds.

When I first began volunteering, it was physically difficult to adjust. However, eventually my body adapted to the routine, and I now wear supports to protect my wrists and joints. And it was with mutual fascination and wonderment that I came to know the babies and toddlers. I was fascinated by their innocence, incredible beauty, and resilience. They were fascinated by my supports.

There were good days, and there were bad days when they missed their mothers and

San Francisco Medicine July/august 2007

fathers terribly. Sometimes, the whole group would wail despondently. Volunteers and staff alike tried to distract them with hugs and kisses, stories and games. It touched me to see some of the older boys, toddlers themselves, tenderly kissing and comforting the babies, regardless of whether they were siblings or not.

There was an amazing African-American boy whom I nicknamed “Old Soul.”

There was something about him that was worldly and experienced beyond his years.

He played a toy drum like a professional.

He would rub his head up against me like a kitten purring for affection. Then there were days when he was incredibly angry, biting the staff. He was rebelling against too many changes and separations in his young life.

“You are an old soul,” I told him. “I know that,” he answered matter-of-factly. “You are an old soul,” I told him again. “Yup, you already said that,” he answered, annoyed.

The Old Soul was eventually sent to a group home. I could only pray that it was a place of stability and love.

Another child, a Latina, was under considerable emotional stress. One day it was warm in the room, but she was cold.

Her teeth were actually chattering. She wanted to be wrapped in her “pulillo”—a word I didn’t know, though I figured out that she meant her blanket. Although this child resisted any notion of what she perceived as physical restraints, she desperately wanted to be held and wrapped in her “pulillo.” As she stared off into space, the girl sadly stated, “Estoy sola” (I am alone). It pained me to hear that a four-year-old child felt alone in this world. I hugged her tighter.

Sometimes I fancy myself as being able to quiet any crying baby, including those

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The Healing Power of Love

Pet Therapy How Human-Animal Interaction Promotes Healing Jennifer Emmeret, PhD

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o you remember the first time you saw the twitch of a bunny’s nose?

How about the unrestrained excitement of your dog when you got home from school, or the smell of summer in the air when your cat warmed herself? How much would it mean to rekindle those memories if you were detached from your own pets? Therapy animals aim only to share their delight at meeting both the new and the familiar people they encounter. The sheer joy of these special pets has an uplifting and relaxing effect on people, who are able to put their worries aside and achieve a sense of well-being.

Why is Animal-Assisted Therapy such a powerful form of healing? Because companion animals remind us of who we have been, who we are, and who we may yet become—the specifics are individual, but the comfort is universal. Engaging the human-animal bond allows a patient to appreciate the present with a new intensity, while revitalizing the past and suggesting the future. Companion animals’ ability to be so many things to such a variety of people makes Animal-Assisted Therapy a unique aspect of treatment.

Technically speaking, Animal-Assisted Therapy (AAT) and Animal-Assisted Activities (AAA) are distinct enterprises.

AAT requires specific goals and charts progress toward those goals. Consider a person with compromised manual dexterity; AAT visits could be coordinated with a physical therapist to advance the patient from controlling hand and arm movements in order to pet a dog, to holding a brush and grooming the dog, to putting on and removing the dog’s collar. AAA lacks the documented progress toward specific goals.

Instead, the generalized goal of an AAA www.sfms.org

Patients Allura (right) and Richard (above) enjoy the company of Charlie, one of the SFSPCA’s companion animals.

visit is to comfort, engage, and reassure.

Volunteer teams working through the San Francisco SPCA’s Animal-Assisted Therapy Programs conduct both types of visits in approximately seventy-five facilities throughout the city of San Francisco.

It’s been said that the most important thing for a volunteer to keep in mind is to focus on sharing the love of one’s pet with those who cannot have their own companions. More than 100 times a month, our eighty handler-pet teams enter a variety of facilities and share the joy of companion animals with the elderly, ill, and disabled.

Where human interaction fails, the soft brown eyes of a therapy pet succeed.

People become more communicative, less depressed, and more relaxed. Knowing how wonderfully encouraging and supportive your pet is when you’ve had a bad day, imagine how much more comforting that reassurance would be if you were ill or disabled.

The benefits of AAT/AAA are numerous. Physiological benefits to the patient include lowered blood pressure, decreased stress hormones, and decreased heart rate. A recent American Heart Association conference featured a study wherein pet visits were shown to decrease the body’s production of the stress hormone epinephrine, while

improving lung function. The research further demonstrated that within a random sample of acutely ill heart patients, blood pressure in the pulmonary artery dropped by 5 percent in patients receiving a visit with a handler-pet team, but rose in the groups that received a volunteer-only visit or no visit at all (“Study Identifies Heart Patient’s Best Friend,” New York Times, November 16, 2005).

Of course, the psychological benefits are not to be discounted given the enormous impact self-esteem and motivation have on healing. As our facility contacts and handlers attest, companion animals can reach through the illness and disability, inspiring patients to communicate and take more interest in their surroundings and their care.

A number of contacts report that engaging with our “animal therapists” encourages patients to tell stories about animals they’ve had or remember, although those same patients were previously unresponsive to staff. Once the lines of communication are open, staff can more readily develop a rapport with patients.

Our volunteer handlers, or “facilitators,” also report the amazing transformative power their pets have had on people. One handler recently wrote an article for The Bond, the SF-SPCA’s AAT newsletter, in which she described a reticent patient who enthusiastically offered her dog a cup

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Another SFSPCA companion animal makes a visit to an elderly woman.

of water, remarking that the visit was the best thing that had happened to him all week. Another volunteer mentioned that a patient who had self-isolated came out of her room specifically for the pet visits.

These are not uncommon incidents in the world of AAT/AAA, and they don’t occur with canine visits alone. Our program is happy to count three mellow lap cats, three curious guinea pigs, and a very handsome rabbit in our ranks. Historically, we have also sent out a bearded dragon, a turtle, a snake, chinchillas, and rats. Each of these little therapists brings something special to the table. Sandy, our bearded dragon, was a shining example of how an exotic pet can be an impressive therapist. For a considerable amount of time, she exclusively was requested at one of the locked psychiatric facilities, given her ability to captivate and calm even the most anxious patient with her slow, almost preternatural movements.

One of the shared characteristics of our animal therapists is that all species pass behavioral and veterinary testing. Teams wishing to join our AAT/AAA program must prove the pets are nonaggressive, well behaved, and solicitous. Veterinary certification that the pet is current on vaccines and free of zoonotic parasites is also essential to patient safety. Before welcoming pets from any program, facilities should check the program requirements.

Apart from the requisite temperament 26

and veterinary screening, there are a variety of pet personalities that lend themselves to excellent therapeutic work. Of course we have the pets who enjoy sitting on laps or beds for petting. We also have pets who perform tricks—occasionally to commands in a variety of languages—much to the delight of patients. Some are energetic playmates for rehabilitating or depressed patients and their families, while others are soothing by virtue of their gentle comportment. The variety of pet therapists makes assessment of the needs of the patients and the personality of the pets crucial to successful matches.

As we advance toward a more comprehensive approach to health, the assessment of patients themselves may include notes on potential animal therapists and the roles they would play in healing. Even more than they are currently, teams would be assigned to work with specific patients as they move from illness or disability to health and confidence. The value of Animal-Assisted Therapy and Animal-Assisted Activities in healing is becoming more widely understood, and as we move forward, hardworking animal therapists and their facilitators will be there, eager to share the love, comfort, and inspiration forged by the human-animal bond.

For more information on becoming a team or introducing AAA/AAT into your facility, e-mail AAT@sfspca.org or call (415) 554-3060.

Born and raised in Colorado, Jennifer Emmeret grew up in a mountainous region that has a knack for engendering residents with a healthy respect for both domestic and wild animals.

Having been an avid rider and backpacker since she was young, she was always drawn to environmental and animal welfare concerns.

After completing her doctorate in philosophy, she entered the Peace Corps and served two years in Cameroon teaching English, didactics, and HIV/AIDS prevention. Upon her return to the United States, she relocated to San Francisco and began working with the San Francisco SPCA as a Community Programs Specialist in the Animal Hospital, more recently becoming the AAT Program Manager. She currently resides in San Francisco with her husband and

San Francisco Medicine july/august 2007

their enchanting Annie, a Siamese mix adopted from the SF-SPCA.

Rocking the Babies Continued from Page 24... who are nervous and sensitive to sounds and light. I love holding these infants. I love holding them tight and rubbing my cheek against theirs while feeding them. It is hard for me to understand why anyone would want to hurt a child, like one beautiful baby girl who suffered from “shaken baby” syndrome. Another day, I saw a gorgeous toddler bravely crawling around in an arm cast. It was obvious that he had been hurt.

When I don’t go to the nursery, I miss the kids. “I’m going to get my baby-fix today,” I tell my friends. Each child has made a profound impression upon me. My exchange with these children has been healing to my spiritual well-being. I hope that it has been healing for them as well.

To learn more about the Crisis Nursery, visit http://www.crisisnurseryonline.org.

Free CME Course on Domestic Violence www.respondtodv.org Physicians are more likely to recognize, validate, assess, and respond to suspected domestic violence in their patients after participating in an Internet course on the subject, according to new study results reported at the National Conference on Health and Domestic Violence in San Francisco, CA. The “Respond to Domestic Violence” course is a free program provided to physicians and health care providers through support from Blue Shield of California Foundation (www.blueshieldcafoundation.org). California physicians may earn up to 16 CME credits at no charge. 79 percent of physicians who took this course said that they will make practice changes in how they handle suspected IPV, indicating there is an “excellent” or “good” likelihood that they will change practice behavior. For more information and to take the course, visit www.respondtodv.org. www.sfms.org

The Healing Power of Love

A Different Type of Education Medical Students Learn about Cancer outside of the Classroom Dani Chammas

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ideo games, Barbie dolls, and art projects are not formal components of medical school education. For the students participating in the UCSF Pediatric STARS (Sharing Time and Raising Spirits) program, however, these may be some of their most meaningful activities.

The Pediatric STARS program partners medical students with children and adolescents who have been recently diagnosed with cancer. First- and second-year medical students are each matched with a child for at least one year, during which time they have the chance to build a longterm relationship. When the PedSTARS children are inpatients at the hospital, their medical student buddies spend time with them, whether it’s watching SpongeBob, listening to Jimi Hendrix, or playing any game or activity in between. Buddies are in phone contact while the children are at home, receiving outpatient services.

Although PedSTARS is a fairly new program, the idea behind its creation began more than thirteen years ago, with the experience of one pediatric cancer patient. At the age of eleven, Ravi Gogia was diagnosed with Stage IV hepatocellular carcinoma.

This is a very rare illness for a child with no history of hepatitis. The cancer had already metastasized to Ravi’s lungs. Doctors told Ravi and his family that he had an estimated six months to live and encouraged them to begin comfort care. Instead, Ravi’s family pushed for aggressive treatment, embarking upon countless cycles of chemotherapy and a liver resection. He was treated at UCSF and at Kaiser Sacramento, where he grew up. Against all odds and survival statistics, Ravi has been cancer-free for thirteen years.

He is now a third-year medical student at UCSF, the very institution where he first www.sfms.org

got his liver resection.

“I’ve been really interested since then in the welfare of pediatric cancer patients—not so much the medical welfare

“I’ve been really interested since [my experience] in the welfare of pediatric cancer patients—not so much the medical welfare (obviously I care about that), but more so the social and psychological welfare of being a patient at that age.” (obviously I care about that), but more so the social and psychological welfare of being a patient at that age, and what it does to you … and what kinds of things those kids need in terms of making themselves mentally and socially healthier,” Ravi explained. In particular, he realized that “even with the best family support and a lot of friends, which I definitely had at the time, you are socially isolated as a kid who’s in the hospital.” He remembers the time he spent away from his friends and classmates and the social isolation of being taken out of school. He remembers being in the hospital when his blood counts were very low. “There are a lot of times when the only people who can hang out with you are your family, and that’s great, but it gets a little tiring at times,” he acknowledges. “And it’s nice for parents to have a bit of a break. It seemed like a great idea to have another social outlet for these

kids in the hospital.”

Ravi thought about this often during his first year of medical school. And it was from this idea that the Pediatric STARS program grew. Ravi worked with three classmates (Chris Potter, Marisa Gardner, and Teresa Jones), UCSF pediatric oncologist Dr. Mignon Loh, and other members of the UCSF pediatrics team to put together the framework and push the program through.

The program’s primary goal is to help children have a better experience in the hospital—to recreate a semblance of normalcy in their lives. Children in the program gain a friend in the area, which is especially important at a tertiary care center like UCSF, where many of the pediatric cancer patients live in places well outside of the city and have no friends near the hospital. Moreover, their relationships with medical students give the children a distraction from their illnesses and the medical interventions they are experiencing. The goal is fun distraction; students describe stories of video and card games, basketball, dolls, chess, books, music, talking about anything from illness to sports, or whatever the child is in the mood for. If even for just a moment, the children get the chance to remove their illnesses from the forefront of their minds while building a relationship with someone who isn’t part of the medical team.

Over the past few years of the program, pediatric oncologist Loh has noticed that the children greatly look forward to the time they have with their buddies, and the chance it provides to “just be kids.”

“I think it has been a very important part of their rehabilitation in the hospital,” says Dr. Loh. She describes the social and psychological effects of serious illness and

Continued on Page 30...

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The Healing Power of Love

Loving Treatment A Patient Recognizes the Importance of Love in His Treatment Kai Molvig

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he first time I felt truly safe and comforted after having an emergency tracheostomy for a Stage IV throat cancer was when I was lying in the hospital bed, speaking with my doctor.

My doctor is a very loving healer. She sits on my bed, holds my hand. Love and safety flow out of her into everyone around her. What an amazing thing to do with your life.

Love is the undeniably magical thread that is interwoven through every religion and philosophy as part their respective essences, and it is the only supernatural power I have viscerally felt firsthand.

Another extremely significant loving power at work was my incredible family, in particular my brother. Despite our difficul-

ties in the past, almost all of which were the fault of my pigheadedness, he stepped in and orchestrated a flurry of activity, including an outpouring of love from people around the globe. He stopped by regularly with treats and a comforting smile, and he told me the facts of my situation, something medical staffs are not prone to doing.

Even during the physically trying stages, I could only think about getting well enough to demonstrate my love, not only to the doctor and my family, which of course I could never do in full, but in my approach to the world. It was akin to having a healing lozenge in my heart, a reason for attempting to overcome whatever came my way.

True, I’m still in bed, and I still have a trachea tube. But it’s funny—I feel better

Physician Career Fair Sutter Health with facilities in Northern California, from the Oregon Border to the Central Valley, and from the Pacific Coast to the Sierra Foothills, provides boundless practice opportunities, and lifestyles.

Join us to meet Sutter Health physicians and administrators, and to learn about unique practice opportunities Sutter Health has to offer. ●Continental breakfast will be served ●Parking vouchers provided if hotel valet parking is used ●RSVP preferred (docjobs@sutterhealth.org) ●walk-ins welcome ●Free CV critique service available

than I have in a decade.

So please, try it yourself. Share some deeply heartfelt love with others. I promise you’ll immediately sense just how astonishingly therapeutic it is on every level, and for everyone involved.

My mantra, my religion, my philosophy, or however you wish to name it, it is how I fully intend to approach everything... with love.

Kai Molvig is a fifty-year-old, twentyone-year veteran of San Francisco. He does computer consulting for a living but has a wide range of extracurricular interests. The more frequented activities include chess, motorcycling, pool, occasional varied sports, making music, and interacting with the diverse, intriguing minds that flourish in this city.

September 29, 2007 San Francisco, CA 9:30 a.m. - 11:30 a.m.

Grand Hyatt San Francisco 345 Stockton St. San Francisco, CA 94108 For more information 866-448-7070

If unable to attend CVs may be faxed to 916-643-6677 or email to docjobs@sutterhealth.org.

28

San Francisco Medicine July/august 2007

www.sfms.org

The Healing Power of Love

Love and Lymphoma A Patient’s Family Gives Gratitude for the Love He Received Linda Jweinat Note: Mr. Ned Jweinat was a lovely patient, a strong, sweet, and loving man, who gracefully fought advanced lymphoma and who finally passed away in 2004. Linda Jweinat is his loving and devoted widow. Ned and Linda were well known to the hospital staff at San Francisco General Hospital for much of 2003 and 2004, as Ned was hospitalized for long periods. All the while, they both spread a loving and kind energy to the staff, and the staff gave much love to them as well. Linda’s essay represents Ned’s and her experience of the power of love in healing, especially during times of critical and terminal illness. Although Ned finally passed away, his experience of healing near the end of his life was profound, because of his loving nature and his ability to receive and give love during his time of illness.—Shieva Khayam-Bashi, MD

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ove is more powerful than the forces that carve a Grand Canyon, for its work must be done against resistant hearts and wills. Love can enable you to place one foot in front of the other and go on when everything in you aches and screams to be elsewhere. The last two of the twentyeight years Ned and I spent together were governed by lymphoma and love.

In many ways, these were our worst and best years together. To be sure, our relationship had weathered rough times. The kind and gentle man who would emerge during the illness had been glimpsed, but love dug deep to bring that man out fully. So an odd thing happened. The sicker Ned got, the sweeter he became. The doctors and staff assumed I had lived with a saint all those years. I was quick to respond that he’d not always been like this. Though he’d been able to tenderly grow flowers all over the city in any space he could find, he’d not www.sfms.org

always been so nurturing with those loved ones closest to him. This experience was transforming him.

One of my own personal dilemmas was getting up every morning and willing myself to go to SFGH … again. I did not miss one day and often spent nights there. He was “in” for seven months at one stretch, and more in than out during numerous others.

At any given moment, I’m sure many of us would rather be doing something else we assume would bring us more satisfaction, but I don’t think that’s where the richest experiences lie.

What makes willful, self-interested people change this way? I will reference the Bible and say, “in trials, love is perfected.”

And love’s companions—kindness and patience—were very abundant from his medical staff. He treated them respectfully and they reciprocated with gracious care. Amazingly, after some dreadful, awful, almost barbaric procedure, Ned would sincerely thank them. They mentioned they “didn’t always get that kind of response.” He drew much comfort from the medical staff and they seemed to be drawn to him.

I guess what I’m saying is that in the midst of the worst ordeal we would ever face together, a miracle was happening.

Medicine may have been keeping him alive, but love was making it worthwhile. Again, the Bible says to “love each other as if your life depended on it.”

Still, his illness weathered on. Family and friends rallied to our side and brought much comfort, but eventually Ned succumbed. At the end, when a blood clot caused his breathing to become labored, we rushed him to the ER. I’ll never forget it. He and his doctor had a very special relationship. She had been the overshadowing force,

dare I say the love force, that had guided our care since nearly the beginning. In that terrible moment, she and Ned were holding hands and gazing into each other’s eyes. She reminded him that they had spoken of this time, and if this was “it,” was he ready? He gazed tenderly at her and asked, “Are you ready for it?” I cry now as I remember.

Death soon followed, surrounded by siblings, nieces and nephews, friends, a pastor, and loved ones. “Blessed is the man who remains steadfast under trial, for when he has stood the test he will receive the crown of life which God has promised to those who love Him.” There was one more beautiful thing that the hospital staff did for me and in tribute to him. The morning of Ned’s funeral, I awoke to find the path up the hill in front of our home lined with gorgeous potted flowers. This was the very path Ned had forged on his way to tend his garden. His way had been made more beautiful, both physically and spiritually, by this group of caring, loving, and giving people. These people had nurtured his soul.

“Death, where is thy sting?” The sting is in my heart till this day!

Love and prayers didn’t make his sickness go away, but they did make it bearable.

I am eternally grateful to all who were kind and caring to both of us. I realize this could have gone another way were it not for friends. I’ll carry memories of the people we met along the way in my heart forever—and I thank them for all they gave us.

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PedSTARS Continued from Page 27... frequent hospitalization on children as absolutely profound. Socially, children lose routine, face restrictions on their activities, and are isolated from their normal social structures. Other issues are challenges in relationships with siblings due to the unique family dynamic created by illness, and some challenges with normal friendships as well.

During childhood, one’s friendships are heavily centered on the experience of school. “Part of what’s normal and healthy is going to school every day, and these kids often stop going to school for quite a while....

Not seeing their friends on a daily basis isolates them, physically and psychologically,” Dr. Loh says. Children who are sick in the hospital are not doing the same math problems or reading the same books. “That separates them and puts them in their own little universe.” She adds that with all of the challenges foisted upon them, these children are forced to mature very quickly. Illness and hospitalization are, in many ways, challenges to simply being children. By trying to distract them for a few hours a day in the hospital, medical students hope to remind them that they are still youngsters.

PedSTARS also offers parents and families a small window of time for themselves, if even it’s simply enough time to grab a cup of coffee. “You find that these parents give up their lives for their kids during the time that they are sick,” Ravi reflects. “They don’t really take their own welfare into account at all, and so if they just can feel not guilty about going away for even ten or fifteen minutes, it’s good for them.”

At the other end of the relationships created in the PedSTARS program, medical students gain the opportunity to have a unique relationship and learning experience. Most of the students in the program are still in their first and second years of school, learning the ins and outs of medical science. But a medical science background is unnecessary for the lessons learned with their PedSTARS buddies. The program helps students gain a rich appreciation of the ramifications of serious illness on children and on their families—insight that will, they hope, help them become more empathetic 30

doctors. Dr. Tim Kelly, a pediatrician associated with the PedSTARS program, believes the program’s biggest benefit to medical students is altruism—“the reward,” he says, “of making a difference in a kid’s life.”

Dr. Loh expresses the hope that medical students will “incorporate some of the experiences of the patient into their future as practicing physicians.” Medical students express the sentiment of growing both personally and professionally; one student noted that the program “was a significant step in my process of becoming a healer.”

While there is a growing push to recognize the nonmedical aspects of care in medical school curricula, a course on relationships could only provide so much.

There is little substitution for the hands-on experience of a longitudinal relationship of the type PedSTARS offers—one that is beneficial for students and patients alike.

“It’s not rocket science,” Ravi says. “It’s just simple—people being nice and people being normal. We are humans who interact with other people; as soon as you lose sight of that, you run into trouble.”

Dani Chammas will be a second-year medical student at UCSF this fall.

Art and Love Continued from Page 23... from sharing the delight of cherished photographs of loved ones to writing together at a patient’s beside, as in this piece I did with a family in our care and hospice program, Comfort for Kids: I wish This may be The hardest time You ever face.

And that Courage And kindness Compassion And love Warm memories And the making of New ones Will carry you Always.

San Francisco Medicine july/august 2007

As we encourage our patients and ourselves to engage in life artfully, we each rediscover and nurture connections with our own inner resources and may expand our horizons to truly practice the art of healing.

What if We invited Humility and wonder To walk Hand in hand To say “I don’t know” Not with apology But with awe and appreciation Of this great universe Bigger than we are And with anticipation That accompanies “We can explore” What if We listened To “can” and “will” And hope and joy Rather than “Can’t” Or “won’t” Or discouragement Or despair What if We stretched the barriers So thin That we could see through To the other side With fullness Instead of strengthening those barriers Nurturing them with our Limitations Doubts And fears.

What if We just Love A lot —Nancy Iverson, MD Dr. Iverson is a pediatric consultant for Comfort for Kids, a Bay Area in-home pediatric palliative care and hospice organization. www.sfms.org

hospital news Chinese

Joseph Woo, MD

Our thanks to our CEO, Ms. Brenda Yee, and our Hospital Board for another fine rooftop barbeque. This event was held June 1 on our roof’s parking lot, which transforms easily into a warm venue that brings together all of the Chinese Hospital family. Staff from CCHCA, CCHP, CCHRC, and Chinese Hospital joined physicians and board members in enjoying ribs, tri-tip, pasta, salad, and Dove bars in a celebration to kick off the summer. Events such as this one serve to remind us how lucky we are to practice in this unique community.

I was especially pleased to see a couple of our “alumni” from our summer externship program.

Under the guidance of Dr. Seck Chan and Dr. Elena Tinloy, the Hospital and medical staff have been sponsoring several first-year medical students in an externship that takes them to offices throughout Chinatown and also through the various departments of Chinese Hospital. In this way, these young doctors are not only learning about various private practices and specialties but they are also gaining insight into the uniqueness of the Chinatown community. We were proud and happy to see Dr. Alex Ting, who just received his degree from UCSF and has matched in radiology at Massachusetts General; and Dr. Jon Yang, who also received his degree from UCSF and will be at Stanford in ophthalmology.

We hope they will value their time with us and use the friendships they gained here throughout their careers. We are equally excited about our incoming students. This year we have young doctors Tammy Wan from UCD, Vincent Lam from UCSF, James Ho from UCSF, and Jody Chou from U.C. Irvine. All are excellent students who have already demonstrated involvement in community service. Again, thanks to Drs. Seck Chan and Elena Tinloy for developing this curriculum to nurture these young students, and thank you to all the physicians who will be mentoring them. www.sfms.org

Saint Francis

St. Luke’s

Wade Aubry, MD

Jerome Franz, MD

At Saint Francis Memorial Hospital, we believe that the human connection is vital to the patient’s recovery and continued well-being. To that end, we’ve established several programs to ensure that our patients get the interaction they need in order to get well. One of these is our Management Rounding Program. All managers visit a number of inpatients every week. It’s a great way for patients and managers to communicate one on one, reminding managers why we’re here and reminding patients that they’re truly cared for. Patients and managers all report that this program is tremendously helpful and rewarding.

Recently we’ve also partnered with the SPCA to provide pet therapy to our patients.

Once a week, inpatients on units that typically see longer stays, such as Cancer Care and Acute Rehab, are visited by Zola, a golden retrieverpoodle blend specially trained to interact in a therapeutic environment. Affectionate and outgoing, Zola is already a big hit with her clients, and she is especially fond of playing catch.

Because we want our patients to feel connected to friends and family even when they’re far away, we’ve introduced CarePages. CarePages are private, personalized Web pages provided free to our patients and their families. Fully secure, they allow patients and their families to share information and encouragement. Friends and family can post get-well notes and wishes. Patients can update everyone at the same time, without repeated phone calls. CarePages don’t have an expiration date, allowing users to keep in touch before, during, and after hospitalization.

In other news, the medical staff has created a new multidisciplinary Credentials Committee, which is chaired by Guido Gores, MD, immediate past Chief of Staff. We are grateful for his service.

Every day I see the inseparability of love and healing in my practice, whether it’s between parent and child, lifelong partners, or close friends—and I see the lack of healing in people who are lonely, grieving, or depressed. There is also the love of medicine that I bring to the office each day, which allows me to touch others and make a difference in their lives. It is a dedication that we doctors recognize in each other and that bonds us as members of our profession.

This month I want to highlight an example of that quality in a member of our St. Luke’s community. Since 2001, Thomas McCombs, DO, has been training students from Touro University in osteopathic care for the hospitalized patient. These third- and fourth-year students doing clinical rotations at St. Luke’s have been inspired by his enthusiasm for his work; some have remained in the community, setting up private practices. Much of the hospital work has centered around the improvement of respiratory mechanics in pediatric asthma, postabdominal surgery, and pneumonia, while patients also receive standard care. It is hands-on treatment that heals more quickly and with fewer complications, according to studies that Dr. McCombs has shared in Grand Rounds at St. Luke’s.

Dr. McCombs is also board certified in family practice and is a member of our Department of Family Medicine. In June we changed the medical staff bylaws to add Osteopathic Medicine as a division of the department, with Dr. McCombs as the division chief. We hope to continue working with him for many years.

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hospital news St. Mary’s

Richard Podolin, MD

There is extensive literature documenting the health benefits of close personal relationships. Married men are less likely to develop heart disease than single men, and the risk for happily married men is lower than for those unhappily married. Among men and women who have had heart disease, those who were single and lacked close personal friends were three times as likely to die within five years as their more connected counterparts, independent of other risk factors.

In one study, men and women who felt the most loved had significantly less coronary artery disease. In another study of 10,000 men who had coronary artery disease, those who answered positively to the simple question: “Does your wife show her love for you?” reported less angina.

The object of the relationship does not even have to be human. Pet owners tend to have lower blood pressure and lower cholesterol, and are more likely to survive a heart attack than people without pets. Other studies have shown that being involved in community groups, or just performing altruistic service, has salubrious effects. Some of the positive effects of love and affection may be mediated by oxytocin, which lowers catecholamine levels and reduces blood pressure, among other activities.

While this research is illuminating, it can obscure a more essential truth. None of us expect to live, or remain healthy, forever. Illness is to be anticipated; death is certain. We want to live lives that are long and healthy, but also lives that are abundant with joy and rich with meaning. As physicians, we need to be sensitive to our patient’s connections and honor their importance. We also need to consider the physician–patient relationship as a potentially therapeutic relationship. Part of the healing we offer is a human connection based on caring, openness, and honesty.

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UCSF

Ronald Miller, MD

The UCSF pituitary treatment program has been redesigned and is opening as the California Center for Pituitary Disorders. Pituitary tumors are not rare and can cause a wide variety of disorders. Depending on the type, a pituitary tumor can cause loss of libido, depression, fat accretion on some portions of the body and a decrease in fat on others, high blood cortisol levels, hirsutism, cardiac problems, headache, and other afflictions.

The varied nature of these signs and symptoms can make it easy to misdiagnose the true problem.

One of the most common signs of a possible pituitary tumor in men—inability to achieve an erection—is now often ignored because impotence can so easily be treated with sildenafil (Viagra) or other erectile dysfunction drugs.

Because pituitary tumors can interfere with so many body systems, the California Center for Pituitary Disorders hosts numerous specialists: neurological surgeons, head and neck surgeons, otolaryngologists, neuroanatomists, neuro-ophthalmologists, reproductive endocrinologists, pediatric endocrinologists, cardiologists, diabeticians, and others.

One of the challenges that clinicians face is to reeducate the physician population about the prevalence of pituitary tumors and to get patients tested. Those patients on erectile dysfunction drugs should be given blood tests, and if those results suggest anything amiss with the pituitary, they should take the next step and get scans, says UCSF neurosurgeon Sandeep Kunwar.

The potential for treating pituitary tumors has dramatically increased with the use of minimally invasive skull surgery. In these operations, the pituitary is accessed with endoscopic instruments through the nasal cavity. There is no need for extensive cutting of tissue or chiseling of bone, so the operation can be safer and the recovery after surgery quicker.

To get more information or to refer a patient, call (866) 559-5543.

San Francisco Medicine july/august 2007

Veterans

Diana Nicoll, MD, PhD, MPA

The Pets for Vets program at San Francisco V.A. Medical Center links veterans who wish to own a dog or cat with animals who need homes.

The program was started in 2000 by SFVAMC Psychology Director Russell Lemle, PhD, and a group of V.A. employees working through the Medical Center’s Voluntary Services Department. The system is simple. Any veteran who wants to adopt a companion animal receives a voucher for a dog or cat, redeemable at the San Francisco SPCA. Each new pet owner is also given a voucher for a pet starter kit that can be traded at a local pet supply store for food, toys, and, for dog owners, training classes.

Dr. Lemle notes that a number of recent studies indicate the health benefits of pet ownership, including stress reduction and blood pressure control. He says that a pet offers an important emotional connection as well. “Having a companion animal is a way of getting around loneliness,” says Dr. Lemle. “Over the years I’ve had a number of veterans call me to say how much meaning their pets have brought to their lives.”

The program has been funded entirely through private donations. It has placed more than 100 animals.

Visitors to the ground floor of Building Seven at SFVAMC can view “Dog Tags,” a gallery of photographic portraits of veterans with their companion animals by photographer and psychologist Don Crowe. The project began as a series of Pets for Vets portraits, but today it spans a wide range of Northern California veterans and their animals, from horses to birds. “Dog Tags” is updated regularly. “This series speaks about who we treat at the V.A.,” says Dr. Lemle. “These are not simply portraits of veterans, but of whole human beings and their relationships with the beings they value and love.”

Veterans interested in Pets for Vets can call (415) 750-2004, or e-mail gloria.patel@va.gov. www.sfms.org

Public safety update William Miller, MD

Pedestrian Safety: An Eyewitness Account

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s I came to a stop at a red light while driving home along 19th Avenue in San Francisco, I saw an elderly woman on the curb about to cross the street in front of me. She wore a light blue down jacket and a purse over her shoulder. Perhaps it was her hair, which was silver, not grey, or the style of her large glasses, but she immediately reminded me of my own elderly mother. As she began to cross with the green light, I noticed that she carried a handful of letters and I wondered if she was walking home after picking up her mail. I also pondered how long she must have lived here, making San Francisco her home, and if she crossed this street as part of her daily routine. She walked slowly but with purpose as she crossed the three lanes to the center island. As she reached the median, the light turned yellow and she quickened her pace. It then turned red as she started toward the other side. Since in San Francisco there is no safety pause during which all lights are red, the oncoming traffic immediately received a green light to go.

I watched with mounting concern. The old woman was obviously frightened about being stranded on the narrow island in the middle of such a busy street. She began to wave her arms in the air to get the traffic to stop while she tried desperately to make it to the other side. The drivers in the inner two lanes of oncoming traffic waited patiently while she moved halfway across. Just then, there was the roar of an engine and from up the street a vehicle came down the outer lane. From the way the driver accelerated, I can only assume that his mind was besmirched with a sense of rage over the delay. I watched in horror as he sped forward and whipped around in front of the stopped cars, as if in defiance.

The old woman had only an instant to see him coming and made a few faltering steps as she tried to retreat to the center island. The oncoming vehicle struck her with such force that her light blue down jacket literally burst into a cloud of feathers, like one might expect to see at a fraternity pillow fight. Her frail body ricocheted off the windshield and was thrown, spinning head over heels, a good twelve feet into the air and then came to rest in the middle of 19th Avenue in San Francisco.

I rushed to her side and knelt in the rapidly expanding pool of bright red blood on the pavement. She still had a pulse but was unconscious. With each beat of her heart, blood gushed in waves from her body. In moments, the gushing stopped, she became pulseless, and her life ended as she lay crushed and broken on 19th Avenue in San Francisco.

Later, as I stood on the side of the street waiting for the police to take my statement, I noted several things: the impersonal and sterile yellow sheet they placed over her body, which matched the yellow “Police Line Do Not Cross” ribbon they put up around her body; her bare ankles and white shoes www.sfms.org

sticking out from beneath the sheet; the unopened letters scattered about in the street, which made me think that she had friends, family, and loved ones who cared about her; and then I noted that this intersection does not have any “Walk/Don’t Walk” pedestrian signals.

During my interview with the police, one of them commented with a sad shake of his head that this is the seventh recent pedestrian death at that same intersection of 19th Avenue and Noriega. A bystander added that she had just read an article in a local paper that lamented the high rates of pedestrian injuries and fatalities that have been going on in San Francisco for years. After the police spoke with me, I quietly drove home and pondered with increasing consternation the remarkable number of other intersections along 19th Avenue in San Francisco that do not have any crossing signals.

When do we say, “Enough!”? How many more little old ladies have to die, spilling out their blood on the cold pavement of our streets? When are we, as citizens of this proud city, going to start taking responsibility for our actions? What will it take to make our streets safe? How about crosswalk signals with countdowns at all busy street intersections, so that pedestrians can judge their ability to get to the other side safely? How about crosswalk buttons at the same intersections, which when pressed will hold the green light long enough for an older person or one with disabilities to safely cross? How about stricter enforcement of the traffic laws? And if we don’t have enough police to enforce them, then let’s hire more. How about better public transportation to decongest our streets? What about pedestrian crossing bridges over our busier thoroughfares? And why is it that other cities have a two-second safety pause in between lights, when the intersection is red in all directions, but not San Francisco? Are our destinations so important as to justify reckless driving that puts others in harm’s way, just so that we can “get there” a few minutes sooner? It seems that it should be unacceptable to us that San Francisco ranks fourth in the nation of cities its size for pedestrian accidents (“Toward Healthier (Safer) Urban Pedestrianism,” Traffic Safety Center, vol. 3[1], 2006). It seems that if we care about the safety of our fellow San Francisco residents, it’s time to take action.

In response to “Woman Hit and Killed in Crosswalk on 19th Ave.” by Tanya Schevits, San Francisco Chronicle, on Monday, June 4, 2007.

William Miller, MD, serves as the Chief Medical Executive of CPMC’s St. Luke’s Campus in San Francisco. He is also a Director of the SFMS Board of Directors.

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Health Care Reform Stephen Follansbee, MD

Health Care Reform Proposal

O

n May 7, at the regular meeting of the SFMS Board of Directors, Joe Dunn, Executive Vice President of the CMA, challenged us to submit a proposal for California health care reform to the CMA by June 1. The main guideline was that any proposal should be “politically viable.” Joe Dunn and others do not think that a single-payer solution is viable under the current governor, so that option was not included in this proposal.

The CMA staff is to review this and other submissions from county medical societies. This is the result of our efforts.

I think that SFMS members should be proud of the work that went into this document on such short notice. The debate is not over; although I am not convinced that health care reform is the first priority for most of our nation’s voters, it is an important issue. I think we all agree that the status quo is not sufficient. This country cannot continue to spend more per capita for health care than any other country and have such dismal health outcomes. There are a variety of political solutions or “fixes” being proposed. I think the principles outlined in our document are clear. The principles of universal access to health care (Section I) and patient-physician focus (Section VII) should be paramount.

Physicians should not just “be at the table” of health care reform—we should be at the center of the table. I hope you take time to read this short document. I am not sure how the CMA is going to proceed in this discussion. The SFMS, however, is committed to keep all of us up to date on these efforts.

SFMS Health Care Reform Document—Submitted to the CMA May 29, 2007 I. Universal access a. All Californians should have access to health care through insurance. b. Improve enrollment in current public programs: Medicare, MediCal, Healthy Families/SCHIP, S.F. Healthy HAP program. c. Cover current uncompensated care. d. Cover undocumented residents. e. Emphasis on the doctor-physician relationship, not patientinsurance company relationship.

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II.

Coverage a. Affordable and guaranteed preventive and basic care, including mental health, as well as pharmacy and durable medical services. b. State reinsurance for those not covered or ineligible for guaranteed coverage. c. Maximize federal support/subsidies, avoiding components of programs such as the State Child Health Insurance Program (SCHIP), in which vaccine purchasing is not eligible for federal matching grants. d. Guaranteed Major Risk Medical Risk Insurance Program, if otherwise not covered, with graduated or risk-adjusted fees for chronic illness and disability. e. Limited (or no) copayments for preventive services. f. Comprehensive coverage with minimum benefits package. g. Coverage must equal access by including adequate reimbursement. h. Physicians should not be required to work nights and weekends without compensation.

III. Transportable a. Information system to provide up-to-date individual information on all historic care (Personal Health Record or PHR and Electronic Health Record or EHR), which is fully accessible in all systems. b. Coverage not interrupted because of change in health status. c. Supports new and established patient care.

IV. Funding a. Employer: via mandated contribution, with options for employee choice, for all employers with more than a determined minimum number of employees. b. Individual: via incentives (e.g., tax credit vs. penalty), with choices of mode of coverage/access. c. Group coverage, subsidized by public funding, for employees who work for an employer with fewer than the defined number of employees in IV.a. www.sfms.org

V. Additional Financing a. b.

Tax incentives for businesses that provide care.

Maximize matching federal tax sources.

VI. Cost containment a. Transparency of costs in all aspects of health care delivery and services, including health insurance, hospital and other residential health care, professional services, pharmaceuticals, and durable medical goods. i. All insurance contracts should have a comprehensive, detailed list of CPT codes and the associated reimbursements. They should be listed on the website so that physicians and patients can understand the economics. ii. All hospitals and medical clinics should have a comprehensive list of CPT codes and the associated costs. There should also be a clear policy statement regarding those who do not have health insurance and must pay out-of-pocket. b. Medical-loss ratio for health plans: limit administrative costs to 15 percent. c. Utilize the state’s pharmaceutical costs and purchasing power through larger purchaser agreements for pharmaceuticals and vaccines. Statewide vaccine purchasing programs have been running successfully in other states, and in California the Vaccines for Children program has successfully used this approach, incorporating federal matching grants as recommended in II.c. above. d. PHR (see III.a.) to minimize duplication of services with digitalization of imaging and inclusion of laboratory and cardiac lab services, pharmacy records and immunizations, and end-of-life instructions (advanced directives; power of attorney for health care). e. Electronic Health Record (EHR) with uniformity across programs, or ability to translate from one health care system to another if individual or group changes health plan. f. Arbitration for disputes over care. g. Copayments for services that would support costs and balance tendency to over-utilize, as well as possible slidingscale copayments, but with waiver for health services of high value, including preventative care (Ann. Int. Med. 2007;146:603). h. Evidence-based coverage for procedures and medications. i. Access in multiple languages to disease management and preventive medical information, online and through health providers. j. More universal access and recognition of end-of-life care and wishes, with incentives to complete the documentation. www.sfms.org

k. If pay-for-performance to physicians, then documented criteria with physician input and consideration for reduction to waive governor’s Quality Assurance Fee. l. Preserve MICRA, the Medical Injury Compensation Reform Act of 1976, to save health care dollars, preserve patient access to medical care, and provide fair compensation to medically injured.

VII. Patient-physician focus a. b. c. d.

Oversight.

Medical home model of care.

Autonomy.

All decisions regarding scope of coverage for care, procedures, pharmaceuticals, and adjunct services shall be made on an evidence-based, physician-led basis through a cohesive and unified process, without cumbersome preauthorizations or repeated authorizations for routine and covered services. e. Appeals for nonapproved services should be directed to physicians in the same area of expertise, with rationale and explanation for continued denial of alternative and covered treatments. f. Maximize price transparency for patients and among hospitals/clinicians.

VIII. Workforce a. Increased subsidy and availability, including geographic distribution, of adequate training programs for RNs and other health care personnel. b. Incentives for geographic availability of primary care, mental health, and subspecialist providers, as well as for RNs and other health care personnel. c. Physician reimbursement as incentives to complete mandated trainings and cover associated costs.

Would you like to comment on this health care reform proposal?

Please visit our online discussion forum at: www.sfmedicine.blogspot.com Or by clicking on the link on our home page: www.sfms.org.

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