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VOL.81 NO.5 June 2008 $5.00


Felt your hands and it was like magic, a memory in my skin somewhere deep, a dance a rhythm a heartbeat the way two cells meet and know each other, like seeing something you’ve always seen and getting close. like breathing in and out to make something new, shedding something used to be reborn. it is a touch of magic, this feeling, this organic exchange of memory and moment like a foam crested wave, freed slave of the sea, like writing over yourself again and again with scars and wounds, healing yourself in this patchwork life. We could have met somewhere else, but we wouldn’t really be the same; this body, these scars, this memory it is what makes us, what makes this touch magical. Like the way we see colors, hear sounds; it’s like coming home, back to that first breath, that first heartbeat. I am here now; I am the work of years of growth, a product of bruises and aches and fevers. I am a piece of artwork, I am all that I have touched eaten seen loved. I am made of memories and moments. What we feel we feel now because of all we’ve felt before.

the wisdom of the body

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CONTENTS SAN FRANCISCO MEDICINE June 2008 Volume 81, Number 5 The Wisdom of the Body



10 A Blind Man Cannot Be a Voyeur—Robert Romanyshyn, PhD

4 On Your Behalf

12 Authentic Movement—Tina Stromsted, PhD, MFT, ADTR

6 Executive Memo Mary Lou Licwinko, JD, MHSA

14 An Interview with Yoga Journal’s Medical Editor Timothy McCall, MD 16 The Mechanical and the Poetic Body—Dennis Slattery, PhD 18 Women’s Breasts—Marilyn Yalom

7 President’s Message Steven Fugaro, MD 9 Editorial Mike Denney, MD, PhD

20 Healing the Body, Healing the Self—Leslie Davenport, MS, MFT 41 Hospital News 22 Anemia as Metaphor—Robin Barre, MA 23 Exposed—Eisha Zaid 25 Journey into the Body—Helen Ye, MS, LAc Editorial and Advertising Offices

26 Compassion Fatigue—Susanne Babbel, MFT, PhD 29 Examining Unexplained Symptoms—J. Jewel Shim, MD

1003 A O’Reilly

San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833

31 An Interview with Irvin Yalom, MD—Steve Heilig, MPH

Email: Web:

33 Hearts and Minds Revisited—Brent Cox, MD, and Steve Walsh, MD 34 A Good Night’s Rest Does the Body Best—Shannon S. Sullivan, MD, and Clete A. Kushida, MD, PhD

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

35 The Dancing Saints—Megory Anderson 38 Book Review: Yoga as Medicine—Toni Brayer, MD

Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605

39 NIA in a Nutshell—Megan Finkeldey, LCSW

June 2008 San Francisco Medicine 


June 2008 Volume 81, Number 5

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

Notes from the Membership Department

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

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes-Clever

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

SFMS Officers President Steven H. Fugaro President-Elect Charles J. Wibbelsman Secretary Gary L. Chan Treasurer Michael Rokeach Editor Mike Denney Immediate Past President Stephen E. Follansbee SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Membership Therese Porter Director of Communications Amanda Denz Board of Directors Term: Jan 2008-Dec 2010

Jordan Shlain

George A. Fouras

Lily M. Tan

Keith Loring

Shannon Udovic-

William Miller


Jeffrey Newman


Thomas J. Peitz

Jan 2006-Dec 2008

Daniel M. Raybin

Mei-Ling E. Fong

Michael H. Siu

Thomas H. Lee


Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

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

The SFMS Night at the deYoung was one of our most exciting events yet! More than eighty SFMS members, staff, and guests mingled and enjoyed appetizers, beverages, and lively conversation before exploring the wonders and delights of this spectacular new museum. Watch for pictures of this terrific time!

This popular event is always a great time for members and their guests, and it also provides a terrific way to introduce nonmembers to the San Francisco Medical Society. The cost is just $20 for members, $25 for nonmembers and guests. New members who join at this event will have their event cost deducted from their already discounted first year’s dues! Contact Therese Porter in the Membership Department at (415) 5610850 extension 268 or for more information or to RSVP.

Upcoming SFMS Events Buying a Home in San Francisco: Realizing the Dream A seminar by Donald M. Schmidt, Licensed Real Estate Broker and CPA. Thursday, June 26, from 6:30 to 8:30 p.m. at the San Francisco Medical Society offices (1003A O’Reilly Avenue in the Presidio) Don Schmidt will discuss the intricacies of buying a home in San Francisco. He is committed to providing real estate services with honesty and integrity and provides innovative real estate and financial consulting. He works closely with clients and their advisors to maximize their real estate and financial goals. Don will also be joined by a representative of the Wells Fargo Real Services section, who will discuss what Wells Fargo’s partnership with SFMS can do to assist with the financial aspects of purchasing a home. The cost is $15. Space is limited, so RSVP by Wednesday, June 23, to Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@

Back and Better than Ever: The Jazz Mixer at the Togonon Gallery! Mark your calendars! Thursday, August 28, from 6:00 to 8:00 p.m., enjoy beverages, hors d’oeuvres, great jazz, and exciting art while mingling with your fellow physicians. The Togonon Gallery is located at 77 Geary Street, just blocks from Union Square in San Francisco (

New! A Family-Friendly Matinee at the San Francisco Lyric Opera! Sunday, September 21: Performance of Aïda at 2:00 p.m. at the Cowell Auditorium at Fort Mason, with a postperformance reception and opportunity to meet some of the singers. The Lyric Opera offers a fun and accessible way to enjoy opera for all ages. More information to follow, and be sure to visit the group’s website at www.

In the Works Coming in late fall, the Medical Society will once again enjoy a Night at the Symphony, and in December SFMS will return to the Opera House for its popular Night at the Nutcracker. More details to follow in this magazine and on the website. Visit for the latest on SFMS events, seminars, and much more. The San Francisco Medical Society is committed to making membership as useful and fun for its members as possible. If you have ideas or suggestions, please contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or

SFMS Seminar Schedule Advance registration is required for all SFMS seminars. Please contact Posi Lyon at or (415) 561-0850 extension 260 for more information. All seminars take place at the SFMS offices, located in the Presidio in San Francisco.

October 3, 2008 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training to handle phone calls and scheduling professionally and efficiently. 9:00 a.m. to 12:00 p.m. (8:40 a.m. registration/continental breakfast) $99 for SFMS/CMA members and their staff ($89 each for additional attendees from the same office); $149 each for nonmembers. November 4, 2008 “MBA” for Physicians and Office Managers 9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast) This one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management. $250 for SFMS/CMA members and their staff ($225 each for additional attendees from same office); $325 for nonmembers.

Congratulations Hugh Vincent, MD, on Your AMA Appointment! Hugh Vincent, MD, a member of the SFMS Board of Directors, was recently appointed to AMA’s Council on Long term Planning and Development. It’s a four-year term with a second four-year term possible. The Council plays a key role in identifying and studying important strategic issues in the ever changing environment in which medicine and the AMA must function. It collects, studies, and interprets the data and makes recommendations to the Board regarding direction and means to fulfill the AMA’s vision, goals, and priorities. It also identifies and evaluates ways to enhance the AMA’s policy development processes, including methods to make the AMA’s policies more readily accessible. “I think it is a place where I can give something back to the organization that might have a long term effect,” says Vincent, “I feel very privileged to have been given the opportunity to serve in this way.”

Blue Shield Fee Schedule Changes Take Effect July 1 Blue Shield of California recently notified physicians of changes to its standard physician fee schedule that will take effect July 1. In a letter to physicians on May 1, Blue Shield notified physicians that it would be making changes to the fee schedule, but failed to provide details about the changes. The letter says only that Blue Shield plans to modify payment levels for many CPT codes, some being increased and others decreased. CMA believes that this type of “notification” is not only unfair and burdensome, but also illegal. State law requires health insurers to provide physicians with at least 45 days advance notice of any material change to their contracts, and the opportunity to terminate the contract before the change takes effect. “First, there is no notice of the change,” wrote CMA legal counsel Astrid Meghrigian in a letter to Blue Shield last. “The letter does not provide underlying information concerning the change itself; rather, it merely notifies providers that there will be changes and sets forth a complicated process for providers to follow in the event they wish to know what these changes are.” CMA also believes that Blue Shield is required by law to provide fee schedule information electronically. Currently, physicians must either call or fax a request to the insurer and wait 10 days for a response. Although CMA has asked Blue Shield to postpone implementation of these fee schedule changes and provide physicians with electronic access to the new rates, you should not wait to begin assessing the impact the changes will have on your practice. To help you, CMA has published a toolkit available free to members at CMA’s members-only website, http://www.cmanet. org/member. Included in the toolkit is CMA’s financial impact worksheet, which will help you calculate the impact of the fee schedule changes based on your most commonly billed CPT codes. Physicians are also urged to read CMA’s contracting toolkit, “Taking Charge: Steps to Evaluating Relationships and Preparing

for Negotiations—A Focus on Payor Contracting.” This toolkit was designed to help physicians analyze proposed fee schedules and negotiate and manage complex thirdparty payor agreements. It is available free to members at the members-only website. Nonmembers can purchase the toolkit for $100 in the CMA bookstore, http://www. For more information, contact Jodi Black (916) 551-2863 or jblack@cmanet. org.

Other Events August 10-15, 2008 Essentials of Primary Care: A Core Curriculum for Ambulatory Practice Resort at Squaw Creek, North Lake Tahoe, California This course is designed to provide a comprehensive “core curriculum” in adult primary care. It will serve as an excellent update and review for current primary care physicians and other primary care professionals, and as an opportunity for specialists to expand their primary care knowledge and skills. Particular emphasis will be placed on principles of primary care, office-based preventive medicine, practical management of the most common problems seen in primary care practice, and expanded skills in clinical examination and common office procedures. Emphasis will also be placed on skills in dermatology, psychiatry, gynecology and women’s health, and neurology. For more information, visit October 2-3, 2008 California Primary Care Association Annual Conference Double Tree Hotel, Ontario Airport, Ontario Contact Carole Loeb at (916) 440-8170 extension 206 or or visit for more information.

June 2008 San Francisco Medicine 

Executive Memo Mary Lou Licwinko, JD, MHSA

CMA Legislative Leadership Conference


n April 15, 2008, members of the San Francisco Medical Society (SFMS) participated in the 34th Annual California Medical Association (CMA) Legislative Leadership Conference in Sacramento. The morning began with a panel of political pundits that included Richie Ross, Democratic strategist, Dan Schnur, Republican strategist, and Greg Lucas, political writer and analyst, who served as moderator. Ross reminded us that one year ago when Senator Clinton had a big lead in the polls, he predicted that Senator Obama would be the Democratic candidate for President. Schnur countered that Senator Clinton was to him like the New York Giants football team, while he did not like either one of them, he never counted them out. The luncheon and keynote speaker was businessman, entrepreneur and Insurance Commissioner Steve Poizner. Poizner, who oversees the Department of Insurance, reviewed his successes, including bringing lawsuits against some of the largest health care insurance companies in

 San Francisco Medicine June 2008

the State, and sounded very much like a man running for Governor. In white coats, physicians proceeded to march silently to the Capitol carrying signs protesting the 10 percent cuts in MediCal and indicating the amount of money MediCal cuts would cost different jurisdiction throughout the State. Once inside the Capitol, SFMS members met with Assembly member Mark Leno, Assembly member Fiona Ma, and Senator Carol Migden as well as staff of Senator Leland Yee. The main topics of discussion were the budget deficit and the devastating cuts proposed to MediCal but also included scope of practice issues, funding for new physicians practicing in underserved areas and child health issues. Physicians who attended from SFMS were: Drs. Andrew Calman, Richard Caplin, Gary Chan, George Fouras, William Goodson, III, Michael Siu, Shannon Udovic-Constant, and Chuck Wibbelsman. My thanks to all who attended and to Therese Porter, SFMS Membership Director, for making the day so successful.

president’s Message Steven Fugaro, MD

Mind-Body Interaction


became aware of the true complexity and depth of the mindbody interaction in disease as a young resident in internal medicine, when I was confronted by two different patients in my outpatient clinic. Neither patient seemed to fit the “usual” paradigm of physical illness, as had been drilled into me by my professors in medical school and by my mentors in the residency program. Both patients confounded my ability to frame “illness” as a purely physical and biologic phenomenon. The first patient was a high-powered, extremely intense executive who was the CEO of a small and very successful technology business. She presented with multiple episodes of spontaneous falls, each with transient hemiplegia. Despite the appearance of a stroke syndrome, there were no other neurologic sequelae, and an extended, multiyear workup revealed no discernible illness. Needless to say, these symptoms were quite disconcerting to the patient and she was resistant to the idea of a somatoform disorder. The patient transferred care to another provider and continued what ultimately proved to be a fruitless search for an “organic” disorder. The second patient was a successful researcher with a happy marriage and several children. Quite suddenly he became withdrawn, morose, dysphoric, and profoundly fatigued. He withdrew emotionally from both his professional career and his marital relationship. An evaluation for a variety of “physical” illnesses was unremarkable and a psychiatrist diagnosed severe unipolar depression. Fortunately, antidepressant medication combined with psychotherapy rapidly reversed his decline and he returned to his previous state of superb health. These patients began to deepen my understanding of the extraordinary manner in which our mind and body interface in ways that defy conventional medical constructs. The mind-body interaction is so basic to human existence that it normally goes unnoticed. For example, I might feel hungry, and then the thought occurs to me, “I’ll go to the refrigerator for some food.” Amazingly, in the next moment my legs are moving to the kitchen. Philosophers as far back as Plato and Aristotle have attempted to give an accurate description of the mind-body interaction and to explain the apparent dualism of mind and matter. A well-known version of dualism is attributed to René Descartes, who in the 1600s was the first to clearly identify the mind with consciousness and to

distinguish this from the brain—the seat of intelligence. He further claimed that these two entities causally interact, in that mental events cause physical phenomena and vice versa. This is an idea that continues to be featured prominently in many non-European philosophies and underpins much of what we now recognize as integrative or alternative medicine. Yet how can the immaterial mind produce a physical response in a material body, and vice versa? Until recently, there was little biologic evidence of how this remarkable interaction might actually occur. Over the past thirty years, however, neurobiological evidence has come to light about how the central nervous system and the immune/inflammatory system cross-communicate in myriad ways. Studies of the hypothalamic corticotropin-releasing hormone, the locus coeruleus, cytokines, and the sympathetic nervous system reveal a fascinating interplay between our nervous and immune systems. Any disruption of communication between the brain and immune system may lead to greater susceptibility to inflammatory disease and infectious complications. Animal studies demonstrate that impairment of the brain’s stress response often enhances the body’s response to inflammation. This recent discovery of the common underpinning of the immune and stress responses may provide an explanation for why a patient can be susceptible to both inflammatory/infectious disease and depression. Indeed, such a relationship may help clarify the popular belief that stress exacerbates illness and that removal of stress ameliorates it. In this issue of San Francisco Medicine, a number of authors explore the many facets of mind/body dualism. There are discussions about movement and dance, somatic psychology, and the concept of one’s body during an illness or stress. Further study of the fascinating and cryptic concept of the mind/body interaction may yet yield explanations of why we become depressed, how the mind creates symptoms in times of stress, the mechanisms of how physical illness impacts psychological well-being, and why extreme grief can induce death or serious disease. We may even be able to finally explain why my patient years ago, an otherwise healthy woman, could repeatedly fall to the ground—paralyzed, frightened, and yet with no definable physical “illness.” A profound example of the mystery inherent in our very souls, hearts, and minds.

June 2008 San Francisco Medicine 

Cochlea: Inner Ear Hearing Mechanism

Snail Shell

Ciliary Body of Eye

Mushroom Gills

Tongue Surface

Caterpillar Spines

These images originally appeared in The Architecture and Design of Man and Woman by Alexander Tsiaras (Doubleday, 2004)  San Francisco Medicine June 2008

Editorial Mike Denney, MD, PhD

The Wisdom of the Universe


ver the centuries, a consensus among scientists, scholars, philosophers, and healers seems to be that the human body contains an inherent wisdom. In the Old Testament, the suffering Job cries out, “Who hath put wisdom in the inward parts?” Hippocrates claimed that when taken as a whole rather than its parts, the human body has within the wisdom and ability to cure itself. The bombastic fifteenth-century physician Paracelsus responded to a more scientific colleague by saying, “Every hair on my neck knows more than you and all your scribes.” And Doctor Albert Schweitzer said, “Every patient carries her or his own doctor inside.” In 1923, the physician and physiologist Ernest Starling, of Starling’s Law of the Heart, delivered an oration before the Royal College of Surgeons called “The Wisdom of the Body,” in which he stressed the intricate regulation of bodily processes by hormones. In 1932, Harvard physiologist Walter B. Cannon developed the concept of homeostasis in a popular book called The Wisdom of the Body, and that title was also used by scientist Charles Sherrington in his Gifford Lectures at the University of Edinburgh in 1937. In 1997, the famous surgeon-author Sherwin Nuland published his book The Wisdom of the Body (Knopf), and in it he acknowledges those who had previously used that title. Nowadays, the idea of the wisdom of the body is so ubiquitous that it has become almost a cliché. The Body Wisdom Massage Therapy School offers the wholeness of the inner healer; an Osher Lifelong Learning Institute conducts a four-week seminar called The Wisdom of the Body; and John Kabat-Zinn’s book Full Catastrophe Living tells how to use “the wisdom of your body and mind to relieve stress, pain, and illness.” The Journal of Humanistic Psychology tells us what the wisdom of the body has to offer psychotherapy, and Berkeley psychologist Peter A. Levine promotes his six-audio CD set on restoring wisdom to your body. A website called Abortion Clinic Days tells us that the wisdom of the body helps with decisions about unwanted pregnancy; Evelyn and James Whitehead publish a book called The Wisdom of the Body: Making Sense of Our Sexuality; and a Jungian psychotherapist in San Francisco shows us how yoga can make the ordinary body become the Wisdombody. On a blog called The Oik, a proponent explains the wisdom of the body through Aikido, and a somatic psychotherapist in San Francisco translates the wisdom of the body through a practice called the Hakomi Method. Oprah

endorses a book called The Wisdom of Menopause; Judith Roche views the wisdom of the body in her poetry on sex, death, and the experience of living; and the Whole Earth Review offers “The Wisdom of the Body” as the title of a sexually explicit short story. In this issue of San Francisco Medicine, we adopt this theme of The Wisdom of the Body and acknowledge the concepts of homeostasis, hormone balance, and the immune response as essential factors that verify an inherent bodily self-awareness and self-regulation in the human organism. We go a step farther, however, noticing the wisdom that can be conveyed poetically by bodily posture, gesture, and kinetics and that manifests in such disparate ways as authentic movement, hip replacement surgery, and dancing. Perhaps the body contains even more wisdom. In his book Your Inner Fish (Random House, 2008), Neil Shubin, professor of anatomy at the University of Chicago, offers an eloquent review of the 3.5billion-year history of the human body, which verifies that the body contains a wisdom that extends throughout the animal kingdom. And in what is perhaps the most wondrous book on anatomy ever published, The Architecture and Design of Man and Woman (Doubleday, 2004) artist-photographer Alexander Tsiaras, with text written by Barry Werth, shows the human body not as cadaver dissections, but in exciting full-life form, movement, and relationship. The book also contains hundreds of photographs of plant tissue and human tissue, revealing the amazing similarities in the microanatomy of, for example, the inner ear hearing mechanism with a snail shell, the ciliary body of an eye with mushroom gills, and the surface of the tongue with caterpillar spines (see images on opposite page). As we contemplate these delicate enfoldments of the human body, we cannot help but reflect upon our relationship to that moment billions of years ago when, out of the big-bang creation, stardust emerged and then formed atoms that formed chemical elements that formed molecules that formed carbon compounds that by yet another emergent quirk learned to reproduce themselves, thereby transcending into this magnificent order called life. And so it is that as we contemplate the miracle of being human, we begin to notice that the wisdom of our bodies is, indeed, the wisdom of the universe.

June 2008 San Francisco Medicine 

The Wisdom of the Body

A Blind Man Cannot Be a Voyeur A Brief Reflection on the Known and the Knowing Body Robert Romanyshyn, PhD


bout thirty years ago, I had an occasion to visit an art museum with one of my sons, who at that time was seven years old. He had wandered away and when I found him he was standing, as though transfixed, in front of the painting Lamentation, by Giotto, (pictured right). When I asked him what attracted him to this painting, he said in a loud voice, and with that kind of insouciance born of innocence, “That guy doesn’t know how to paint.” Inquiring further into his judgment, he explained that the people in the painting looked like cartoon figures. He walked away and I walked into a puzzle that took some years to understand. Giotto’s painting dates from approximately 1305, and the bodies that he depicts are not yet the anatomically correct bodies that will appear in Western art after the invention of linear perspective drawing in the fifteenth century. With our vision shaped by the anatomical body as we have come to know it, the figures in Giotto’s painting do look incorrect, and while “cartoonish” might be somewhat harsh, it is not so completely off the mark. Watch a cartoon and you do see a key difference between the body as we know it and the “cartoon body.” The anatomical body is in space, while the “cartoon body” generates space from its actions. Over the years I have come to describe this body that generates space as the gestural body, and I have come to appreciate the difference between the gestural body and the anatomical one. To get a sense of this difference, look at the figure in Giotto’s painting whose arms are swept back in a mood of deep grief. Placed in the center of the painting, those arms radiate a field and define an emotional space. The posture of the figure is somewhat awkward 10 San Francisco Medicine June 2008

and we can feel its tension within our own flesh. It would be very uncomfortable to be in that position for any length of time. In addition, the arms seem to be rather long, even exaggerated. Did Giotto not know how to paint? That is hardly an option. Something else is at work here, something that tugs at the ragged edges of our collective memories. Giotto’s figures of lamentation remind us of the body that we live in in everyday life, the knowing body as a power to transform mechanism into meaning, the gestural body that through its actions generates and, indeed, is its situation. But this body is too often forgotten under the sway of identifying the body as we have come to know it with the real and true body. The anatomical body trumps

the gestural body even though the former is a special case of the latter. Let’s take as an example the question of the muscles in one’s arms. Where are these muscles? In one of the first textbooks of modern anatomy, De Humani corporis fabrica libri septem, published in 1543, Andreas Vesalius is depicted holding a dissected arm (see illustration on opposite page). The dissected arm clearly replies to our question. The muscles are inside the arm. But look again and notice that Vesalius is holding an arm that belongs to no body. These muscles and this arm belong to no one—or to everyone. They are anonymous muscles. In addition, they are muscles that are unrelated to any particular situation.

But who can doubt the truth of those dissected muscles? Only a fool, or a poet perhaps, might object. And yet, when do we know that reality of the muscles inside the arm? That reality becomes true only on the condition that one’s living, embodied relation to the world has been disrupted. When I lift that last shovel full of dirt to seed my garden and I strain my right arm, then in that broken connection with the world the muscles in my arm “move” inside. Before that, they are “in” my work; they are muscles that efface themselves for the sake of the gestures that generate the multiple daily situations that define my living engagement with the world. They are here in the typing of these remarks as much as they will be in the gestures of greeting when later in the evening I meet some old friends for dinner and clasp them in a hug. They are here in this moment and activity as much as the muscles in the arms of Giotto’s figure of lamentation were extended in their gestures of grief. This is the body that Giotto painted. Those arms express the wrenching despair of grief. They depict the agony of loss, and while no camera would ever show those arms, they are as real and true as the dissected arm shown by Vesalius. We need, however, different eyes to perceive those gestural arms, eyes that are not reduced to anatomical orbs. The eye that blinks is not the same as the eye that winks, and between the blink and the wink we live in a space of difference between the known and the knowing body, within a difference that makes a difference. While it is certainly the case that the body we know, the body as anatomical object, is a special case of the body we live, the gestural body, it is also certainly the case that the anatomical body is the foundation for the gestural body. A blind man cannot be a voyeur. The anatomical body is a limit, and yet as foundation and as a limit case that body exists in a tangled hierarchy in which the gestural body is the capacity to take up its foundation for the sake of transforming it. The wonder of being an embodied human being lies in this power. It lies in the difference between the anatomical body and the gestural body, and to forget this difference is to forget an important aspect of our humanity. Illness is a disruption of our engagement in the world, and anyone who has suffered

from even a mild case of the flu knows how one’s world shrinks to the size of one’s bed. If we define illness solely in terms of the anatomical body, we lose this lived sense of illness as a disturbance in the patient’s existence. The explanation of illness is one thing, its meaning is another. No one will ever find the latter under a microscope or in a blood sample. What one will find there are the causes. The curious and wondrous thing about the body is this intersection of mechanism and meaning, this chiasm of the knownknowing body, where the body that is known is known by a knowing body that can know itself as a body that is known. To say this in another way, the brain observed is not the observing brain. Our humanity is nestled within this paradox. Our humanity is nourished within this difference that makes a difference. To close my essay, I offer a story to illustrate my last remark. When one of my other sons was in the first grade, his teacher, who was introducing the students to some basic ideas of science, asked parents to visit and speak about a topic of their choosing. I chose to do a demonstration about microscopes. My intention was to show these first graders both the power of this way of seeing and the conditions that make it possible. Having prepared in advance slides of various items, like a fly’s wing and a grain of pepper, I asked in class for a volunteer who would allow me to cut a piece of hair from his or her head to place upon a slide. Then with great fanfare I proceeded to enact how one had to take the lock of hair from its living context and look at it through a microscope by turning away from the situation, bending down and closing one eye. All of these actions were, of course, deliberately exaggerated in order to impress upon these young people the simple point that what we see under a microscope requires a different attitude or disposition toward the world. I could not simply tell them that the scientific attitude was a different and particular way of being in the world. I had to show it. Continuing in this vein, I marveled at what I saw and, of course, every student wanted his or her turn. Captured by the marvels revealed under the microscope, their imaginations soared as they told stories about

their visions and expressed their belief that anything could be cut away from its context and seen in this fashion. Though these demonstrations taught them that science is and can be a creative endeavor, I also had another intention in mind, which I framed with a question. Is there anything, I asked, that could not be seen under a microscope? No, they said, anything could be cut away from its context, like that lock of hair, and put on a slide. But I asked again and waited, and the second time they seemed less sure. Finally a girl sitting in the back of the room raised her hand and said with a slight lisp that she did know something that could not be seen in this way. Hesitating for a moment, she then said what it was. A smile! My son who was present on that occasion suffers from Parkinson’s disease, and he has of late that facial mask that allows no smile. While I understand the anatomical and physiological explanations for his condition, I miss his smile and the beauty of the world that it once opened. Robert D. Romanyshyn, PhD, is a teacher, writer, and psychotherapist trained in phenomenology and depth psychology. In his many books, he applies his knowledge to an analysis of contemporary cultural and historical issues. He is a core faculty member at Pacifica Graduate Institute, Carpinteria, California. June 2008 San Francisco Medicine 11

The Wisdom of the Body

Authentic Movement The Dancing Body in Psychotherapy Tina Stromsted, PhD, MFT, ADTR “The symbols of the self arise in the depths of the body.”—C. G. Jung


here are many approaches to dance/ movement and somatic psychotherapy. One of them, an unstructured therapy called Authentic Movement, was originally developed by Mary Starks Whitehouse and described in her 1996 article The Tao of the Body. With roots in dance and in C. G. Jung’s active-imagination approach, the practice of Authentic Movement allows individuals to attend more fully to feelings, body sensations, movement impulses, and images that may be present, as well as to tend to associated thoughts, memories, feelings, and fantasies that may arise. In this process, the client is invited to find a place in the room, listen inwardly, and slowly allow her body to be moved without performance or plan, allowing herself to be aware of her bodily experience. Eyes closed, in order to reduce outer distractions, the client increases her movements into a spontaneous dance. There is no music, no choreography, no agenda to follow, and no “right” or “wrong” way to move. Instead, there is an attending to and surrendering to one’s feelings, rhythms, and authentic response. In this way, one brings awareness to, and more fully “inhabits,” what is already going on in the body, rather than trying to control the process with an outcome based on old patterns or notions about how one “should” be. During this process, the therapist/witness sits to the side of the space. Though the therapist/witness’s eyes are open, according to Janet Adler in her essay in Authentic Movement (Pallaro 1999), “she is not ‘looking at’ the person moving, she is witnessing, listening, bringing a specific 12 San Francisco Medicine June 2008

quality of attention or presence to ... the experiences of the mover.” In the safety that is created, the mover can listen deeply and follow her own imagination and movement

“Authentic Movement is powerful and affirming work, and it can restore the person’s sense of inner authority and the voice with which to articulate it. Blocks to creativity may be liberated, reestablishing a sense of hope and direction in life that springs from a deep inner source.” impulses, engaging with unconscious material directly, through embodied expression. Thoughts, ideas, and images that arise are further integrated by speaking about the experience with the therapist. Authentic Movement is powerful and affirming work, and it can restore the person’s sense of inner authority and the voice with which to articulate it. Blocks to creativity may be liberated, reestablishing a sense of hope and direction in life that springs from a deep inner source. The process also develops the capacity to be present, both with oneself and with another, in a more vital, embodied, and increasingly conscious relationship.

Working with Dance/Movement Therapy As I meet with my client, I am assessing her access to spontaneity, range of movement and feeling, and the degree of relatedness between parts of her body. I note areas that seem isolated or cut off from her overall expression. I note how she holds herself, knowing that this reflects how she has been held—how supported she has felt—and how she continues to carry her experience. I also ask her about any medical problems, physical symptoms, bodily injuries, or traumas she may have had, as well as any pleasurable physical memories. One woman might talk with cold scientific exactness, as if putting her body under a microscope. Another will speak with a sense of vagueness, inaccuracy, disgust, or disdain. Sometimes a client becomes annoyed with my request, impatient with my attention or interest in her bodily experience. Others may present their information with compulsive attention to somatic detail, almost hypochondriacally, and with inappropriate affect. I often begin by engaging my client in becoming more aware of her own physical responses, inviting her, with her eyes open or closed, to notice what sensations she is aware of in her body, encouraging her to “tune in” or “listen to” what she’s experiencing internally at that moment. In an effort to lay the foundation for her to pay attention to and reinhabit herself, I may ask, “If this image, incident, dream, or story were ‘living’ or residing anywhere in your body, where would it be?” Authentic Movement also may be employed within the context of group psychotherapy. Before assembling an Authentic Movement group, I screen group members to ensure that each has sufficient

ego strength to engage in this unstructured approach; that is, to discern reality from fantasy and to manage anxiety-provoking material. Screening includes asking applicants about their history in therapy, including whether they are taking any medications or have ever been hospitalized in a psychiatric setting, and about their experience with other forms of bodywork or movement and what has been helpful for them. As an Authentic Movement group facilitator, I assume the simultaneous roles of witness and therapist. I am functioning as a group therapist when I offer participants the basic elements and safety guidelines of the practice of moving and witnessing. These guidelines include encouraging group members to engage in a practice of deep inner listening with an attitude of curiosity and respect for one’s own embodied experience, reminding them that there is no “right” or “wrong” way to move. Physical contact sometimes occurs naturally between group members in the practice of Authentic Movement. When this occurs, I function as a therapist, encouraging each mover to move away from any unwanted contact or to take the risk to engage in contact that feels genuine and consistent with his or her own process and development. Such experiences, when brought to consciousness, can be reparative, providing a sense of safety in one’s own skin while relating to another. As the work unfolds, through my example as a witness, I demonstrate a containing sense of presence. The focus and concentration I bring, together with the group’s quiet attention, contributes to creating a safe and protected space for the movers. When I provide verbal responses at the end of a movement session, I am again a witness but also a therapist as I look to guide the witnesses in giving responses that are as nonprojective, noninterpretative, and nonjudgmental as possible. How can we, as psychotherapists and physicians, increase our awareness of the role of the body in illness, both physical and psychological, so that we can model this with our clients and not unconsciously impose limitations on the direction of the work? As we engage in healing work, it is essential to remember that in individual

therapy there are not only two psyches in the room but two bodies, two souls seeking incarnation—a critical element that may often be overlooked in verbally-oriented psychotherapy. In working with a client, we might become more attuned to the music of the work as it plays through the bodies and imaginations of both people, deepening our ability to listen for the many voices. In Authentic Movement, many other important elements and areas of application, such as age, gender, race, culture, and specific areas of physical or psychological limitation, emerge that are beyond the scope of this paper. Advances in the fields of trauma work, neuroscience, pre- and perinatal psychology, and attachment theory are deepening our understanding of the relationship between body, psyche, and spirit within the intricate dance of self and other. This, in turn, offers new hope for the prevention and treatment of developmental impasses, including traumas that occurred before the acquisition of language. In the medical arena, Authentic Movement can offer a great deal to people struggling with a range of illnesses. For example, experience in working with postmastectomy women has engendered a great respect for the power of Authentic Movement in assisting women in reinhabiting the body, which they often feel has betrayed them. Adding a somatic component to primarily verbal psychotherapy can facilitate a deeper understanding and more direct access to deep traumas, neuroses, and psychoses. Somatic practitioners, dance therapists, analysts, and medical professionals could learn a great deal from one another and work more effectively by communicating along these deep interfaces. Authentic Movement psychotherapy, whether structured or inner-directed, is a process of soul-making and body-making. Together, body and psyche, matter and spirit, find union and generate new form. This unfolding, creative process yields enriched access to the self, enhances relationships, and assists in building community. What moves me most has to do with embodied presence, and how it awakens and grows. I find wonder in the richness of life as we experience it through our senses. And I trust the power of this wisdom to inform

our spirited participation with one another in the natural world. Shall we dance? Tina Stromsted, PhD, MFT, ADTR (Registered Dance Therapist), is past cofounder and faculty member at the Authentic Movement Institute in Berkeley. Currently she serves on the faculty and board of directors of the Marion Woodman Foundation and teaches in the doctoral program at Santa Barbara Graduate Institute, the California Institute for Integral Studies, public programs at the San Francisco Jung Institute, Esalen, and other universities and healing centers internationally. She is the author of numerous book chapters and articles in professional journals and a candidate at the C. G. Jung Institute of San Francisco. Her private practice is in San Francisco. This article was excerpted from an essay by Tina Stromsted’s in Patrizia Pallaro’s book Authentic Movement: Moving the Body, Moving the Self, Being Moved. London: Jessica Kingsley Publishers, pp. 202–220.

2008-2009 SFMS Member Directory Coming Soon! Directories will be out in late June! All SFMS members receive one copy of this valuable resource as part of their memberships. Please watch for your copy in the mail. If you are interested in ordering additional copies please contact Carol Nolan at (415) 561-0850 extension 0 or for information. June 2008 San Francisco Medicine 13

The Wisdom of the Body

Learning about Yoga An Interview with Yoga Journal’s Medical Editor Timothy McCall, MD


rained in primary care internal medicine, Yoga Journal’s medical editor, Oakland resident Dr. Timothy McCall, gave up his medical practice ten years ago and began a full-time investigation of the health benefits and therapeutic potential of yoga. This culminated last year with the publication of the critically acclaimed best seller Yoga as Medicine: The Yogic Prescription for Health and Healing (see book review on page 38). When San Francisco Medicine spoke with Dr. McCall, he had recently returned from two months in India, his fourth visit to that country in the last six years.

where I was living in Cambridge, Massachusetts. Although I had no idea of who she was at the time, my teacher, Patricia Walden, turned out to be one of the most highly regarded in the U.S. She does Iyengar Yoga, a style that aims for precise anatomical alignment in the poses. Because it’s more conceptual and less New Age than other styles, it was a good place for a skeptical scientist like me to start. I took to it early on, even though I’m about as far from a natural at it as can be.

San Francisco Medicine: When you talk about yoga, you don’t just mean the stretching poses, do you?

From the beginning, I was hearing all kinds of stories about yoga’s health benefits. One student told me she’d had terrible back pain for years and now it was gone; or I’d hear things like, “This is a good pose for sinus problems.” And then there was my own experience. Before yoga, I had frequent insomnia, lousy posture, chronic upper back tension, intermittent migraines, all of which improved greatly once I started yoga. Psychologically, I became more resilient; little stuff wasn’t getting to me the way it once had. So I got curious, started tracking down all the research I could find, and eventually traveled to India to visit research institutions and major yoga therapy centers. Meanwhile, the changes in medicine, particularly getting so much less time with each patient, were making practicing more stressful and less rewarding for me. My first book had been successful, I was getting lots of writing work for magazines, I had a gig on public radio, and in 1997, I had a thought: What if I stopped practicing and pursued this stuff full-time? In ten minutes I knew it was right, and I’ve never looked back. The

Dr. Timothy McCall: The physical poses are really only part of a much more comprehensive system that includes breathing techniques, meditation, philosophical ideas, and even community service. But in the U.S., most people start with the poses and may or may not add other yogic tools later. One thing that’s nice about yoga is that you can take the parts that serve you and discard the rest. You don’t want to chant Om? Don’t chant it. There are so many styles of yoga, and so many ways the practices can be modified, that almost anyone’s needs can be met. I’ve seen yoga adapted for people in wheelchairs or those who are bedridden. All that’s required is consciousness. How did you get into yoga? Yoga is just one of those things I’d heard about and decided to try. In 1995, a friend recommended a particular yoga center near 14 San Francisco Medicine June 2008

How did you go from taking classes to making yoga the focus of your work?

funny thing is my interest in yoga therapy has brought me back to something that feels a lot like patient care. And I like that. Why did you write Yoga as Medicine? No one had written a comprehensive book on the health aspects of yoga. My research and direct experience has convinced me that yoga is more than just an interesting form of exercise or great stress reduction technique, and certainly more than just a benign way to elicit the placebo response. By poking around for several years, I found a surprising amount of clinical research on yoga that I thought people would be interested in. I also figured that the perspective of a physician who is also a dedicated yoga practitioner would be useful. And even though the book is aimed at the general public, in the back of my mind I was also addressing physicians. Why are you so interested in reaching doctors? The primary reason is that I think yoga is something that could help the majority of patients. While I don’t think yoga by itself is a cure for much, there’s almost nothing it can’t help. Studies suggest, for example, that women who practice gentle yoga as they go through conventional breast cancer treatments have less nausea, fatigue, and other side effects. Yoga appears to benefit people with heart disease, type 2 diabetes, asthma, and hypertension, and it’s particularly useful for a variety of “lifestyle diseases” and psychosomatic illnesses that don’t necessarily respond that well to medicine’s usual ministrations. Finally, as someone who understands science and patient care, I’m hoping to be able to reach physicians by talking

about yoga in a language they understand and can relate to. I talk much more about the autonomic nervous system and cortisol levels than about prana and chakras.

The group yoga class is actually an invention of the last fifty years or so. In the old days, the guru always designed a specific practice for each student and then modified it as the student’s abilities and needs changed. And this is precisely what a good yoga therapist does. For those with less serious conditions or those looking for a little exercise or stress reduction, group classes can be great, but they aren’t right for everyone.

How does yoga work from a medical standpoint? Yoga has been shown in hundreds of studies to have numerous salutary effects. Research suggests it improves strength, flexibility, balance, and even coordination and reaction time. It lowers cortisol levels, reduces both systolic and diastolic blood pressure, lowers total and LDL cholesterol levels, and improves immune function (such as heightening antibody response to the influenza vaccination). It improves the functioning of the autonomic nervous system as indicated by better heart-rate variability and baroreceptor sensitivity. It helps patients drop weight, probably more by increasing awareness, improving habits, and lowering cortisol than by burning calories per se. It has been shown to improve mood and other measures of psychological health. My guess is that yoga works by invoking dozens of these mechanisms simultaneously, likely with additive benefits. Some gurus claim that yoga can cure any disease. Those claims should be taken with a big grain of salt. In my role as the medical editor of Yoga Journal, I’m constantly riding teachers about how they talk about yoga. In an effort to make yoga sound more legitimate, they use scientific language, but often in an imprecise or incorrect way, or they make unsubstantiated assertions. I try to get teachers to stop claiming that yoga “removes toxins” or “balances the endocrine system,” since I don’t even know what those terms mean, and to stick to what we actually know. That said, if you let the pronouncements of yoga’s most extreme proponents, or the hyperbolic claims of some of the ancient texts, scare you off, you’ll miss the chance to learn about something that’s a surprisingly effective adjunct to medical care. How safe is yoga? Some physicians are seeing quite a few injuries.

How can physicians help protect their patients?

Photos of Dr. McCall courtesy of Michal Venera

Yes, that’s unfortunately true. I think the majority of yoga injuries could be prevented if people didn’t do practices and classes that are too advanced for them; if they learned to not push themselves so hard; and if teachers, students, and their doctors were more aware of contraindications. People with serious illnesses should not be doing most of the classes that are offered in gyms. They are too strenuous, and most teachers in gyms aren’t trained to deal with students with serious conditions, and many aren’t sufficiently aware of contraindications. To cite just one example, students with retinal disease or poorly controlled hypertension shouldn’t be going upside down into headstands and shoulderstands. That’s part of why I put so much focus on yoga safety and contraindications in Yoga as Medicine. Rather than attending a random class, I recommend that those with a serious illness try to consult an experienced yoga therapist who can tailor a program to their specific needs. So there’s a difference between yoga therapy and taking a yoga class? Yes. Group classes tend to be a one-size-fitsall proposition, but those who are ill need to have some practices modified, or skip them entirely, and this isn’t possible in most group classes. As I’ve traveled through the U.S. and India, observing the work of many of the world’s top yoga therapists, I’ve noticed that they all personalize their prescriptions.

Having some idea of the different styles of yoga would be a start. Bikram and hot yoga are vigorous styles done in a room heated to more than 100 degrees Farenheit. Ashtanga, vinyasa flow, and power yoga are similarly challenging practices that require a fair amount of fitness and flexibility. These stronger styles attract a lot of weekend warriors, though, and that’s where a lot of the injuries are coming from. On the other hand, styles such as Integral, Viniyoga, Kripalu, and “gentle” hatha yoga are much milder and less likely to cause injuries. Iyengar and Anusara are two styles that are intermediate in intensity, and both pay a lot of attention to aligning muscles and bones well, which may keep the injury rates down. The key to safe yoga is good instruction, and the very best teachers are themselves longtime practitioners. What should a physician do when patients indicate that they would like to try yoga? Try to get some idea of the practice they hope to pursue. You might suggest that patients bring in a book illustrating the kind of yoga they’re contemplating, to help gauge its appropriateness. A lot of avoiding contraindications is just applying common sense. As a doctor, I always try to assess the risk-benefit equation. If a particular pose or breathing practice is questionable, there’s always something else in yoga that can be substituted, so I try to err on the side of safety. If the patient is interested in yoga therapy and can afford it, often a private or smallgroup consultation with an experienced teacher [see the International Association

Continued on Page 17... June 2008 San Francisco Medicine 15

The Wisdom of the Body

The Mechanical and the Poetic Body A Poet Receives a Titanium Hip Dennis Slattery, PhD


t is early morning in the hospital. At 5 a.m. all lights are on in the halls, as they have been all night. The corridors are full of talk and activity, and the energy level is high as the night crew is replaced by the day orderlies, nurses, interns, residents, and surgeons. Beds are rolling past my door like the cars beginning their buildup on the freeway just down the street from the hospital. Some of the gurneys have already found their passengers; others are roaming the halls looking for particular rooms to gather their charges and take them to early surgery. My anxiety increases as I hurriedly get up and brush my teeth and wash up at the sink before I am beckoned. I am alone at this hour and feel the growing anxiety associated with falling into a medical sinkhole. An empty gurney slows outside my door, stops, and the orderly checks his slip with the name and number posted on the door and enters, clanging his stretcher against the walls and the bed across from mine (which has blessedly remained empty all night). Cheerful and terrifying at the same time, this young man, a corridor warrior, dressed in his light green uniform, has come for me. As a runner, I was used to the aches in the joints that often followed a jog along a path or on a track. But as a persistent and increasingly angry left hip called for more sustained attention, I visited a sports medicine doctor and was told my problem was tendonitis. Nothing serious and easily corrected, I was assured. Fitted with an expensive pair of orthotics, I continued my runs four times a week, until the pain grew unbearable. After X-rays and a CAT scan, what had been diagnosed as tendonitis became in an instant osteoarthritis. The cartilage was almost completely 16 San Francisco Medicine June 2008

gone and bone was grinding on bone. I could feel the crunch when I walked, and to alleviate it I began to limp excessively. My disease was given back to me through a growing number of voices at work,

“During this entire experience, I felt myself moving away from my body, thinking of it as something like my automobile, whose front end had gone out of alignment and now needed its castors and cambers realigned or replaced.” which began to ask with more frequency if I had hurt myself. Soon, everyone was asking what was wrong, as my limp, my own body’s way of conveying my malady through an unambiguous gesture, a gesture of favoritism, grew steadily worse until only a complete hip replacement would ease the pain and stop the damage to my spinal column that was the consequence of such a weathered gait. And so the orderly came for me, the next installment to alleviating disease through a procedure that had become commonplace in the medical lexicon. My two bodies became very apparent to me during this time, for the night before, a close friend came to see me and to pray with me for a successful surgery. When we had finished, Sister Martha Ann turned to me and asked me the question that brought to the fore the body as lived experience. She asked if I

wanted to say anything to the bones in my hip that were to be removed, bones that had served for five decades but now, worn out, must be removed and consigned to the oblivion of the furnace in the basement of the hospital where certain body parts are disposed of; they were to be replace by prosthetic devices made of stainless steel, titanium, and cupped with a polyurethane container. With some coaxing from her, I began to speak to my hip, to thank it for the years of faithful service and to tell it that I would miss our intimate association. And then something happened that is rare for me. I began to weep over the loss of the hip, this part of me that had suffered the arthritis in so much silence but that now wanted to speak. It was a moment in which I am not sure if I have ever been closer to the sense of my own enfleshed being in the world (unless it was being present and assisting at the birth of my second son). And to pray over bones, I was to learn, was a custom in earlier people’s religions, as well as in the Catholic Church through the relic embedded in altars, which brings the body into a living emotional presence. Perhaps something of our own souls is permanently in our body, each of its parts. To lose something of ourselves is to lose something of psyche, even of a memory that is embedded deep in every organ. I felt that the body had taken on a poetic and sacred sense that is usually hidden from us in our everyday lives. That was the body that I felt deeply was my identity. Thanking the old bones and the crushed joint, raspy and irritable though they had been of late, seemed to calm the hip down, and I was able to sleep well the night before surgery. But this morning, as I climbed onto the gurney and began the trip down the brightly

lit linoleum hall, shiny with wax and full of others gurneys heading in generally the same direction as morning traffic began to snarl, I felt a growing alienation from myself, and specifically from my own flesh. Lying on my back, I watched the ceiling full of small holes in the soft tile and began to count the bright lights that passed in pairs above my head. They looked brightly down on me, efficient and indifferent, just doing their job. As I entered the prepping room, I could see on the large board with the schedules of surgery for that day some two dozen or more names, each one to have a major procedure before 4 p.m. It was a traffic jam of gurneys, orderlies, surgeons, and anesthesiologists, all jockeying for their respective patients and all very careful to ask each one being prepped for repair to state the nature of their procedure. One orderly took a black magic marker and gingerly drew a black “L” on my left leg so there would be no confusion once I was transported into another galaxy via the anesthetic. During this entire experience, I felt myself moving away from my body, thinking of it as something like my automobile, whose front end had gone out of alignment and now needed its castors and cambers realigned or replaced. This body was a mechanical apparatus, its hips mere struts. Toe in, toe out. The operating theater became a very clean and cool body shop to which, like a car dealership’s morning traffic of vehicles being dropped off in various stages of infirmity or woundedness, bodies were brought for professional readjustments. “Do it now, while the warranty is still valid,” I kept repeating to myself. This is the body of medicine, I reflected later. Here I am a commodity, one that needs to be made unconscious so the work can take place without my presence. Consciousness needed to be severed from the body, to turn it into a corpse for a short time—the psychic trade-off for replacing the parts. I thought as well of how place defines not only how we are but who we are. In this context, my body was something separate from me. Joking, the anesthesiologist remarked that I would now get my morning Margarita mix (so called because of its lime green color and its cool feeling as

it enters the circulatory system), and that I would begin to feel pretty good. Talking to myself loudly about nothing in particular, I saw a nurse at the end of my bed and told her I was freezing; could she give me more blankets. She came to me and I asked her when I would have surgery so that the ache in my left side would stop. She responded with a smile that I had just come out of a surgery that had lasted three hours. So, I had a new prosthetic hip, made of titanium and polyurethane. Part of my body was now artificial, technological, and better than what had been removed. But part of me was also gone forever, a hip that I had been born with and that had been a lifelong companion. As the days of healing began in the hospital, and then at home, I could not bear to look at the twelve-inch scar on the outside of my left thigh. But the wound, now only a thin red line down the side of my leg, still contains the tale, as the lines of a pen on paper mark out the line of words that come together to form a narrative, or like the black letter marks on the white background of a computer screen that scratch out the narrative. How powerful it is in that way that this slice of red line contains or carries such indelible memories. The wound is the trace of that memory, what I have left of the experience; it also marks the place of deep memory, an indelible recollection. Then there is the absence of pain, which is the memory of the worn-out bone. And so the body wounded is a very mortal flesh remembered in a particularly unique way. What is this poetic body? What is the wound in its relation to identity and to being named? Does being wounded, marked, scarred change our relation to the way we express ourselves through body gesture or in language? Does it change the way we are placed, or in place in the world? To the poetic sense of the body we must yield in order to find in the interstices of the flesh the more profound mysteries of our incarnation. Thus the wounded body is sacred in some deep level of its existence; it is a body specialized and formed by experience; in its new way of being present to the world, the wounded body gains something not possessed before. The wound is a gift. And it is the poet who dreams the body back

to its deepest layers of meaning most forcefully and convincingly, in order to show us the finitude of being enfleshed. Dennis Slattery, PhD, is a poet and a professor of psychology and mythology at Pacifica Graduate Institute. His published books of poetry include Just Below the Water Line and Casting the Shadows.

Learning About Yoga Continued from Page 15... of Yoga Therapists at is the best and safest way to go. Ideally, the patient leaves the yoga therapist with a prescription for which poses and other practices to do on their own. Even though most people equate yoga with taking a class, in terms of effectiveness and therapeutic utility, a steady home practice appears ideal. My teacher Patricia always used to say 15 minutes a day beats a longer session once a week. I suggest people try to fit a few poses or breathing practices into the cracks of their day. With so much on their plates, why should physicians pay attention to yoga? Yoga done well is healing, but done improperly it can cause harm. Millions of patients are already practicing yoga, whether they are discussing it with their docs or not. And although physicians may not be sensing it yet, yoga therapy is growing more rapidly than yoga itself. According to the 2008 Yoga Journal survey, the percentage of people coming to yoga for health reasons has increased almost tenfold in the last four years, up from about 5 to 50 percent. In the same survey, 45 percent of adults agreed that yoga would be beneficial if they were undergoing treatment for a medical condition. Baby boomers in particular are now developing various chronic diseases and are looking for alternatives that are safe, cheap, natural, selfdirected, and effective, and yoga fits that bill perhaps better than anything else out there. With a little good direction from physicians, patients can do it more safely. Yoga is also something a lot of stressedout docs would enjoy and benefit from. I certainly have. Timothy McCall, MD, can be found on the Web at June 2008 San Francisco Medicine 17

The Wisdom of the Body

Women’s Breasts A Historical Overview Marilyn Yalom


he assumptions we Westerners take for granted about the breast prove especially arbitrary when we adopt a historical perspective. During twenty-five thousand years, certain moments occurred when a specific conception of the breast took hold in the imagination and changed the way it was seen and represented. Underlying this progression is a basic question: Who owns the breast? Does it belong to the suckling child, whose life is dependent upon a mother’s milk or an effective substitute? Does it belong to the man or woman who fondles it? Does it belong to the artist who represents the female form, or the fashion arbiter who chooses small or large breasts according to the market’s continual demand for a new style? Does it belong to the clothing industry, which promotes the “training bra” for pubescent girls, the “support bra” for older women, and the Wonderbra for women wanting more noticeable cleavage? Does it belong to religious and moral judges who insist that breasts be chastely covered? Does it belong to the law, which can order the arrest of “topless” women? Does it belong to the doctor who decides how often breasts should be mammogrammed and when they should be biopsied? Does it belong to the plastic surgeon who restructures it for purely cosmetic reasons? Does it belong to the pornographer who buys the rights to expose some women’s breasts? Or does it belong to the woman for whom breasts are parts of her own body? These questions suggest some of the various efforts men and institutions have made throughout history to appropriate women’s breasts. As a defining part of the female body, the breast has been coded with both “good” and “bad” connotations since the beginning 18 San Francisco Medicine June 2008

of recorded time. Eve, we remember from Genesis, was both the honored mother of the human race and the archetypal female temptress. Jews and Christians may proudly claim that she gave suck to their ancestors,

“During twenty-five thousand years, certain moments occurred when a specific conception of the breast took hold in the imagination and changed the way it was seen and represented.” but they also associate the apple of the Fall with Eve’s applelike breasts—a connection made visible by innumerable works of art. When the “good” breast model is in the ascendance, the accent falls on its power to nourish infants, or, allegorically, an entire religious or political community. This was the case five thousand years ago, when female idols were worshipped in many Western and Near Eastern civilizations. It was the case five hundred years ago in Italian paintings of the nursing Madonna, and two hundred years ago in bare-breasted images of Liberty, Equality, and the new French Republic. When the “bad” vision dominates, the breast is an agent of enticement and even aggression. This was the position taken not only by the author of Genesis, but also by the Hebrew prophet Ezekiel, who represented the biblical cities of Jerusalem and Samaria as wanton harlots with sinful breasts. And it was true for Shakespeare when he created the monstrous figure of Lady Macbeth, to

mention only the most memorable of his “bad-breasted” women. The vision of the “bad” breast often issues from a combination of sex and violence, as found in much contemporary cinema, TV, advertising, and pornography. It goes without saying that most representations of the breast—or any other subject, for that matter—have traditionally expressed a male point of view. To discover what women in the past felt about their breasts has been an ongoing challenge. In what instances do women decide how their breasts should be clothed or used? To what extent could they choose whether or not to breast-feed their children? When have they had some say about the medical treatment of their breasts? How have they used their breasts as commercial and political vehicles? Have their literary and artistic representations of the breast differed from men’s? Certainly women have made efforts to reclaim the ownership of their breasts—most notably in the late twentieth century. The journey from Paleolithic goddesses to the women’s liberation movement has been long and full of surprises. Along the way, we encounter prehistoric statues whose breasts were invested with magical powers. We also meet the bare-breasted snake priestesses of Minoan Crete and the multibreasted cult statues of Artemis, marking the last wave of pre-Christian worship inspired by women’s mysteries. In the world of the Hebrew Bible, we find women validated primarily as mothers, and in the world of the New Testament, the Virgin Mary celebrated as the miraculous mother of the Christian God. In both Jewish and Christian traditions, breasts were honored as milk-producing vessels necessary for the survival of the Hebrew people and, later, the

followers of Jesus. The example of the baby Jesus suckling at his mother’s breast became a metaphor for the spiritual nurturance of all Christian souls. The nursing Madonna, invented in fourteenth-century Italy, soon had to do battle with a new, predominantly sexual, image of the breast. In countless paintings and poems of that proliferated in Italy, France, England, and Northern Europe during the fifteenth, sixteenth, and seventeenth centuries, the breast’s erotic potential came to overshadow its maternal and sacred meanings. These sacred and sexual objects represent two different tugs at the breast. The mandate to nurse and the mandate to titillate are competing claims that continue to shape women’s fate. Since the beginning of the Judeo-Christian era, churchmen and secular males, not to mention babies, have considered the breast their property, to be disposed of with or without women’s consent. In the seventeenth-century Dutch Republic, a new force entered the contest—that of civic responsibility. The lactating mother who provided for her child was seen as making a major contribution to the overall well-being of her household and community. A century later, maternal breast-feeding became part and parcel of the French Revolution. Following Rousseau, many French subjects were led to believe that a general social reform would result if mothers nursed their own babies, as opposed to the common practice of sending them out to wet nurses. Individually, a woman’s obligation to breast-feed merged with the collective responsibility of the Nation to “nurse” its citizens—an idea translated into numerous pictures of the Republic as a woman with uncovered breasts. Thus breasts became “democratized” in the passage from absolute rule to representative government. No study of the breast can be complete without attention to its medical history. Although twentieth-century medicine has increasingly focused on breast cancer, early medical literature, as far back as the Greeks and Romans, was equally concerned with the nursing mother. Detailed advice on changes in the breasts during pregnancy,

diet and exercise, proper modes of suckling, the care of abscesses, and the process of weaning can be found in numerous medical treatises in many languages, especially since the eighteenth century. Such works tell us much about the ways in which the medical profession not only advanced the healthy care of their patients but valorized women primarily as breeders and feeders. While nineteenth-century physicians placed moral connotations on breast-feeding, the new disciplines of psychology and psychoanalysis highlighted the breast’s crucial place in the child’s emotional life. By the turn of the century, Sigmund Freud was mounting psychoanalytical evidence to prove that sucking at the breast was not only the child’s first activity but also the starting point of one’s entire sexual life. On a popular level, the breast according to Freud found its way into movies and fiction, cartoons, jokes, T-shirts, and countless magazines. All these representations loudly confirm the irrepressible attraction of the breast for the adult male. Since the nineteenth century, the demands on the breast have multiplied with the speed of everything else in an industrial and postindustrial age. Commercial interests have barraged women with advertisements for breast supporters, shapers, and enhancers of all kinds: corsets, bras, creams, lotions, silicone implants, weight-loss programs, and body-building machines. Although breasts have always been commercialized in some way, it has only been in the past hundred years that the full force of capitalism has seized upon the breast as a profit-related object. Breast undergarments have been used as far back as the Greeks and Romans, and corsets were indeed common from the late Middle Ages, at least for the wealthy; but factory-made corsets, introduced in the mid-nineteenth century, and bras, invented at the beginning of the twentieth century, made specialized underwear available to women of all classes. With mass production, “breast control” became mandatory for everyone. Since undergarments are always fashioned to fit the prevailing body ideal, the history of breasts can be charted according to the times when they been downplayed or emphasized. For example, compare the

flattened, “boyish” look of the 1920s with the sexy projectiles of the 1950s. Corsets and bras have alternately been designed to constrict and conceal the breasts or prop them up like apples or torpedoes. It is significant that the women’s liberation movement of the later 1960s began with the much-publicized act of bra-burning. However maligned outside feminist circles, “bra-burners” established a paradigm of resistance to external strictures. By burning bras, more figuratively than literally, women undermined the basic idea of control coming from outside oneself. Henceforth women could question the authority of such previously sacrosanct agencies as medicine and fashions. Women started to decide for themselves whether to wear bras, whether to go topless, whether to breast-feed, and even whether to have a mastectomy. Women have been obliged to confront the powerful meanings breasts convey as lifegivers and life-destroyers. On the one hand, breasts are associated with the transformation from girlhood to womanhood, sexual pleasure, and nursing. On the other, they are increasingly associated with cancer and death. For women, the opposition between the “good” breast and the “bad” breast does not pit the mother or saint against the tramp and the whore, as in many male-authored texts. Nor does it evoke the opposition between the child’s perceptions of the “good” nurturing breast and the “bad” withholding breast that underlies certain psychoanalytic theories. For women, their breasts literally incarnate the existential tension between Eros and Thanatos—life and death—in a visible and palpable form. Marilyn Yalom is senior scholar at the Institute for Women and Gender at Stanford University. She is the author of many books about women and, most recently, of The American Resting Place: 400 Years of History Through Our Cemeteries and Burial Grounds. This article was excerpted, in part, from Marilyn Yalom’s book, A History of the Breast (1997 Random House).

June 2008 San Francisco Medicine 19

The Wisdom of the Body

Healing the Body, Healing the Self Guided Imagery and Psychotherapy in Medicine Leslie Davenport, MS, MFT “I don’t recognize myself: My body doesn’t feel the same at all. And suddenly there is a division between myself and the people I love. I’m in the ‘heart attack’ club now, and my family has no idea what this is like. Friends are becoming strangers, and strangers in cardiac rehab are becoming friends. Everything has been hijacked: my vitality, my spiritual beliefs (this doesn’t happen to someone like me!), my financial security, my future. I have no idea who I am anymore. And I’m terrified.”—Daniel


aniel’s story is familiar to me. Having offered psychotherapy with guided imagery to hundreds of patients with severe illness and injury, I have seen how multiple losses—physical, spiritual, and psychological—stemming from a health crisis deconstruct a core sense of self, leaving them feeling like a stranger in a strange land. Guided imagery has proven to be a valuable tool for helping patients find a safe harbor within themselves during these extremely stormy times. Guided imagery, which incorporates relaxation training, is a natural, meditative process that reliably offers direct access to inner strengths and clarity of mind. But more than simply providing respite during distress, imagery can help patients reconstruct their sense of self with an even greater depth and meaning than before their health crisis. Let’s follow Daniel’s recovery to get a glimpse into the role imagery can play in healing the body and healing the self. Daniel was not familiar with guided imagery, but he came to my office on the recommendation of his cardiac rehabilitation team, who prescribed imagery as a useful stress management technique. His physician had related to me the level of ter20 San Francisco Medicine June 2008

ror that accompanied the days immediately following Daniel’s heart attack. In addition to addressing his known fears and concerns, imagery guided Daniel into areas of surprising levels of healing.

“More than simply providing respite during distress, imagery can help patients reconstruct their sense of self with an even greater depth and meaning than before their health crisis.” By the time Daniel contacted me, he had tucked away his early terror. If he brought an expectation of healing to our initial appointment, it was from the hurryup-and-get-on-with-it school of life—a stoic and earnest desire for a quick solution to the recent medical distractions that had gotten in the way of significant momentum in his career in finance. Daniel had suffered a heart attack at the age of fifty-one. When he first arrives in my office, ten minutes early, he takes advantage of that extra time in the waiting room to work on his laptop. His crisp, tailored appearance expresses his success and professionalism. Although he seems friendly and upbeat, I think it is mostly the subtle slump in his upper back, a fatigue around his eyes, and a weight that rests in his voice that points to sadness not far below the surface. In the first few sessions, we focus on some practical tools around his goals, such as reducing muscular tension by learning progressive relaxation and breath work. We also brainstorm tips for ending his work fo-

cus at the end of the day in a more complete way. He is eager to do the homework from our sessions in order to meet his goals, and he does report sleeping better in the first couple of weeks. Daniel now asks if there is a way we could address the pain in his chest. Although the surgical procedure, which had implanted a stent in an artery to increase the blood flow to his heart, had healed well, there is still lingering pain. Trusting the success of our work together so far, he agrees to try guided imagery to visit his heart as a way to discover more about the pain. “Close your eyes,” I begin, “and take those long, full breaths you’ve been practicing.” I watch Daniel fill his abdomen with breath, then expand the breath through his rib cage, continuing until the breath rises up under his collarbones. The out-breath is just as complete, and his body softens a little more fully with each exhalation. We take time for several breath cycles to deepen his relaxation. “Now that you are fully relaxed, bring your attention inside your chest and sense your heart. Invite an image, which may be literal or symbolic, to arise for your heart. Whatever appears, describe aloud what you become aware of.” An image forms easily, and Daniel describes his heart as “tender and bruised with blue, purple, and pink patches.” He says this heart feels battered. This makes sense to him as he considers his recent surgery and heart attack. He also describes his heart as having weight to it, as if there is something heavy caught at the bottom. I suspect this is related to the heaviness I have heard in his voice.

I encourage him to continue exploring and ask, “If your heart had a voice, or some way of expressing itself, what would it want you to know right now?” There is a pause, and then emotions flash across his face—eyebrows rising in surprise and then downturned lips. He speaks with the gentle voice of his heart: “I’ve been waiting a long time for you to come back.” Although he can’t say why he feels tearful or even know quite what the message means, he is deeply moved and curious. Over the next few weeks, he tells me the story of how his family had moved to this country from Eastern Europe when he was three years old. His father, who had died four years earlier, was very committed to the family and had been a hardworking man, a shopkeeper by trade. Making ends meet had not come easily in those days. When his father finally found the means to move his family to America, fueled by the strong purpose of fulfilling the dream of a better life, it was a momentous event. With some gentle sorting out over the next several sessions, it becomes clear to Daniel that he is living his father’s dream, his father’s heart’s desire, and not his own. He had learned early that it broke a strong family rule to voice his own view if it deviated from the family values. Although Daniel has proven to be quite capable in the business world, he had silenced his own call to landscape gardening as a young man because it did not fit the family legacy’s picture of success. “How would you like to respond to your heart’s message?” I ask him during another imagery session a few weeks later. His response arises immediately in a clear and strong voice: “I want to give my father’s dream back to him so that there is more room for my own.” It’s not uncommon for such a bold declaration of change to summon other “selves,” other internal beliefs poised nearby. So we take time exploring his inner voices of ambivalence, guilt, and fear. He learns how to follow the banner of each of these feelings rather than ignoring them, which he had routinely done. Over time, it becomes clear to Daniel that he wants to anchor his life in the strong, clear voice of his heart, which

had championed his own dreams. The intention for such deep change can be accelerated when it is made visible. This is evident in the rituals and ceremonies that arise within all cultures. They mark transitions. For example, a wedding ceremony makes visible the intention and reality of a relationship that has evolved into a life partnership. The ritual of clapping at the end of a musical performance marks the transition out of the theatrical experience. I encourage Daniel to consider whether there is a way to honor his significant transition to reclaim his heart’s desire through a symbol or ritual. Not long after, Daniel arrives at our appointment and has barely taken his seat when he fishes a small round stone out of his pocket. He had found it on one of his walks at the botanical gardens in his neighborhood. He rests it in the upturned palm of his left hand. “I’m not really a religious man,” he says as he curls his fingers over the stone, “but I feel like I’ve been praying all week, sending thanks to my father for what he’s given me. I’ve been imagining that the parts of my father’s life I’ve been carrying have seeped into this stone in my pocket.” He opens his hand, showing me the stone, now infused with his father’s dreams. He announces his plans to visit his father’s grave next month and respectfully place the stone there. When we conclude our work together, Daniel is feeling much clearer and stronger in his body and in his life. It is not clear whether Daniel is going to remain in the finance business or make a significant career shift. It is clear, however, that he is now making choices, on a daily basis, more responsive to his own heart. The last time I see him, I can recognize it in the ease of his walk and hear it through the new clarity in his voice. He has placed his fingers on the pulse of his own life and discovered the life rhythms that have heart and meaning for him. Daniel’s story is only one among hundreds that illustrate how imagery evokes a healing response that travels along the interconnected web of body, mind, emotions, and spirit. Whether dealing with cancer, chronic pain, or any other medical

crisis that shakes the very foundations of a patient’s sense of self, imagery offers a path into the person’s own wisdom and strength, and a path out of crisis.

Leslie Davenport, MS, MFT, is a psychotherapist in private practice in Kentfield, California, and also in the Health and Healing Clinic at California Pacific Medical Center in San Francisco. She was the founding director of the Humanities Program at Marin General Hospital in 1989 and has more than twelve years of teaching experience at universities including Cal State University, Hayward; Mills College; Holy Names College; the University of San Francisco; and JFK University. She has established imagery programs in five Bay Area hospitals and consults internationally. Daniel’s story is an excerpt reprinted from her upcoming book, Healing and Transformation Through Self-Guided Imagery, published by Celestial Arts, an imprint of Ten Speed Press, Berkeley, California. It is currently available for presale on Amazon. Leslie Davenport can be reached at (415) 459-4235, or by e-mail at Alchemy.

For Magazine Archives, Health Care News, and Local Events of Interest Please Visit Our Website, June 2008 San Francisco Medicine 21

The Wisdom of the Body

Anemia as a Metaphor A Mythological Experience of Illness Robin Barre, MA “i like my body when it is with your body. It is so quite a new thing. Muscles better and nerves more. i like your body. i like what it does, i like its hows”—e. e. cummings


begin this essay with cummings’s poetry in an attempt to revivify my own body, to peer into the dark crevices of illness, to lend depth and richness to the arid condition of anemia. Poetry, metaphor, mythology, and the gods are my tools to reanimate an illness that fell victim to a world where soul could not be found. Through my twoyear bout with this condition, before I was diagnosed, my constant refrain was, “I feel so dry, so wrung out.” By the time of my diagnosis, I was so sick there was brief talk of a blood transfusion, and I was at risk for a heart attack. What causes me such wonder is that, as sick as I was, I was not aware of it. How is it possible to be so disconnected from one’s body? How is it possible to walk around in this container, this vessel, and not know that something vital is missing? There was an awareness on the periphery, but during the experience, I was not in my body. So I begin with a poem that honors bodies, “muscles better and nerves more,” and the body’s “hows.” To enter into the medical world of our Western culture is to enter into a world that struggles with imagination. Modern biomedical science tends to desoul the human body by viewing it as a series of disconnected parts, one having nothing to do with the other. My anemia was a result of a labyrinthine integration of conditions between my digestive system, my structural anatomy, my reproductive system, my respiratory system, and how I was living my life—my psychology, if you 22 San Francisco Medicine June 2008

will. It was not, per se, a circulatory system issue. Yet, despite multiple examinations and scientific tests, the medical professionals with whom I worked were not hearing me, not talking to one another, nor were they hearing my body. But I was not listening to my body either. This deafness, I believe, came from a lack of imagination regarding how the soul speaks through the body. In Re-Visioning Psychology, the depth psychologist James Hillman calls this act of imagining “personifying,” an act of animating or ensouling a thing. Science long ago emptied words of their power when the nominalists took away the upper-case lettering of essential concepts. For example, a collective cosmic event such as “Beauty” became the simplistic subjective experience of “beauty.” Hillman writes of the inherent divinity in words, their “angelology,” implying that inherent in the layered history of words lay messages and powerful significances. To personify would have allowed me, perhaps, to enter into the medical fray differently. Perhaps I might have entered into my body with imagination. Perhaps I could have then had ears with which to hear my body speaking. After my first attempts to give voice to what my body was saying and feeling, I and my doctors seemed to have lost the confidence of my own bodily experience and the power of imagination. Personifying and capitalizing words gives them back their weight, their legitimacy and power. To personify the experience of the Body, rather than just the body, is a powerful thing, though it is sadly and profoundly lacking in our culture and thus in the medical world. To sit in the doctor’s office and say, “My Body is Arid and full of Dust. My Breath is weak and lacks Spirit. My Body is tired and wants Rest” would

convey the imaginings of the Body and its lack of life-giving Blood. These words, having been personified with the poetic divinities and the long stories they tell, would carry the voice of an ensouled body’s experiences and would articulate the language of the soul which is image. What does it mean to simply speak of the soul’s images? Is it possible to do this in a medical system and still address the physical medical issue? This is not an argument to throw out the miracles of modern medicine for the sake of living a soulful life. Exact diagnostic speech has a place and purpose. There is an imbalance, however, that can be addressed. To engage in a dialectic between the fantasy of anemia and my soul would be one way to correct the imbalance and give the soul voice. Pathology and illness are often the voices of the unconscious, where powers that speak poetically reside. We are commanded to pay attention when these powers speak thus. My anemia was caused by a long, slow leak, the result of a lesion on the wall of my stomach, which in turn was caused by an esophageal hiatal hernia. The hernia was diagnosed early, but the lesion remained undetected. Over a period of several years, the lesion slowly eked out my life’s blood, drop by drop, until finally there was little enough to spare and it could no longer be ignored. A pathology, one could say. Yet we could argue that just about any physical condition is also a psychic one. Anemia is a pathological metaphor for the lack of something vital. This lack may in fact reside in the idea of wholeness itself. Wholeness, our experience argues, is illusory, and the attempt to achieve it, paradoxically, is what causes us to fall apart. There is falling

Continued on Page 24...

The Wisdom of the Body

Exposed A Lesson in Anatomy Eisha Zaid


sing a scalpel, we made an incision along the midline of the face. We then peeled the flaps of skin from each side. With the skin pulled back, we began the process of removing the soft yellow fat to identify the muscles, nerves, vessels, and glands on the face of our cadaver. *** Our anatomy lab is located on the thirteenth floor of the UCSF Health Sciences building. Our lab overlooks the City of San Francisco and the Pacific Ocean, providing a breathtaking panoramic view. When I first walked into the anatomy lab in September, the view did not catch my attention; the rows of white body bags propped on metal gurneys did. As I nervously made my way to my table on the first day of anatomy, I did not really know what to expect for the year. I have always been fascinated with the human body in all its strength, grace, diversity, and mystery. As I started anatomy, I wondered how my perception of the body would change as I started seeing the body from within, and how I would react when we unzipped the white bag lying in front of me. The experience of anatomy is one of transformation. Within the first week of starting medical school, we are given our short white coats and recite an oath to promise to do no harm to our patients. We are indoctrinated into a new culture that begins with learning the complex language of anatomy. There was the initial trepidation involved with actually cutting another human body, the inevitable smell (a mix of formaldehyde and rotting tissue that can be unbearable), the crowded table of inquisitive first-year medical students asking questions, negotiating scalpel time, and spending

countless hours navigating the body looking for structures (some very obvious and some not so obvious). And there were all the moments of realization that we were becoming doctors. *** I never knew I would one day be cutting someone’s face. Before we began the face dissection, we removed the gauze, strip by strip, to reveal the face of our cadaver, the same face that has remained hidden from our view and from our thoughts through the entire year of anatomy. It was so odd looking down at her swollen face; she was frowning. As I made the incision on her pasty white skin, I did not even flinch. This is not normal, I thought. Just a year ago, I would not have been able to look at our cadaver’s face. And now I was actually dissecting a part of the body that is so personal and unique. Seeing her face reminded me that we were working on individuals, who each had very different lives. *** We all start anatomy with our fresh blue scrubs and wide eyes ready to visualize the human body from the outside to the inside. Some of us are more ready than others, committing the anatomical terms to memory before lab and returning after hours to gain a better view. We learn quickly to detach the human identity from the body that looks up at us from the metal table. We quickly dissect and cut away, looking to uncover the particular artery or nerve or muscle, dirtying our scrubs and getting our gloved hands covered in body juices during the process. We initially struggle to make sense of the complex language of anatomy, with all its long, Latin-derived names, and we concoct mnemonics to remember the order of nerves and specific structures of the human body.

And with time, continued exposure to “our” bodies, and repetition, we become masters of anatomy, memorizing terms and locations of key structures, sometimes at the cost of looking at our cadaver as a vessel of parts. *** When I looked down at the opened face, I began to wonder about her life. Seeing her face evoked some deep questions. What was her name? Did she have a family? Where was she from? What did she do for a living? What made her smile? And then I thought about myself and how far I had come from the first-year medical student who grimaced every time we opened our body bag earlier in the year to the one holding the scalpel. Up to that point, we had been dissecting without seeing her face, which certainly makes it less difficult, akin to working on a faceless body. We could easily forget the human story of the individual when we faced three hours for each lab and needed to plow through a lab section, a list of objectives, and terms to learn. And yet in the back of my mind, I could not help but feel guilty. I still wonder about her story and her life. I know all about the intricate structures of her anatomy; I have cut her face, touched her heart, removed her lungs, felt her uterus, traced the blood supply though her arteries and veins, observed her muscles move when we tugged on the tendons, seen her abdominal viscera, removed her skull cap, and cut thin slices of her brain. It is remarkable what she has taught us, and yet it is sad to have done so much damage to her body. I know nothing about her as an individual, aside from the cause of death (renal failure) and gender (female). And perhaps it is better that I do not know anything.

Continued the Following Page... June 2008 San Francisco Medicine 23

Exposed Continued from Previous Page... We all have those moments of human realization, when we are startled by what is in front of us. Seeing the hands, face, and toes reminds us about the truth that we sometimes suppress. We realize that we are opening up the bodies of other human beings, individuals who were once mothers, fathers, sisters, brothers, sons, daughters, friends, and members of the same society we currently live in. But we learn to not be bothered, and we continue to expose the body. *** I will never forget our cadaver’s face; she has watched over us all these months and has seen how we have changed, and now we have seen her. I still wonder about how I could so easily take a scalpel and destroy her face. Have I become desensitized? Or have I matured and overcome the initial trepidation I had associated with confronting issues of death and dying? *** At times anatomy is like navigating the unknown, looking to understand the anatomical landmarks and intricacies and all those details, while you learn about yourself and your limits. I bid farewell to the hours in lab spent standing around “our” body, navigating the complex geography of the human body. Anatomy has given me more than just a knowledge of the structures of the body; I walk away with a deeper appreciation for the human body and fragility of life. I move forward with a new fascination for the body and a better understanding of myself and how far I have come. I am deeply indebted to the family that donated the ultimate gift for the sake of our learning; I cannot even begin to express my gratitude for what I have been bestowed from complete strangers. In the end, anatomy has taught me to always remember the human within ourselves, especially when it stares right back at us from the dissecting table. As we move forward in our medical education, we must remain empathetic and compassionate toward our patients, asking ourselves how we would want our bodies treated when we are exposed. Even as students, dissecting a body, we cannot completely detach the 24 San Francisco Medicine June 2008

human spirit from the bodies that have taught us so much. And we cannot disconnect ourselves completely from the human within ourselves. Eisha Zaid is a first-year medical student at the University of California, San Francisco and acts as a student representative to the San Francisco Medicine editorial board.

Anemia as a Metaphor Continued from Page 24... apart, and then there is falling apart. Falling apart because one is trying to hold oneself together is like coming to pieces without a container, like breaking into a million fragments in an isolated hinterland, like disintegrating in the world’s oceans. This is one kind of falling apart. This is the activity in which we are currently engaged in our culture: a soulless, unreflective hurrying about to fix this, cure that, put a Band-Aid on this wound, ingest this psychotropic for that dis-ease. What we sometimes forget is that the poetic is present in pathology. An alternate poetic and mythological experience of falling apart is when one sits at the altar of Dionysus, the Greek god who was dismembered by the Titans, the god of chaos and falling apart, and the god the Greeks often associated with the elemental body. While we normally think of Dionysus as the carefree god of wine and dance, he also holds the energies of madness and falling to pieces. When we fall apart as if we were in the presence of this god, honoring these energies of madness and chaos, then the event becomes one of intentionality and consciousness. This falling apart happens within a container and allows one to honor the parts of the self that have remained silent, unheard, or unseen. More importantly, an experience of Dionysus is one that happens within the body. Honoring the god within the illness honors the verbs of the body, its actions, its speaking, its “hows.” These were lessons I had yet to learn. Dionysus demands homage; we either fall apart with his blessing and guidance, or we are made to fall apart until we fall at his altar. While I was busily going from doctor to doctor to fix my stomach problems, the energies of Dionysus were neglected, shunned, and repressed. Busyness effectively silenced

his voice and the voice of my body. So the god spoke more loudly, and I continued to fall apart until I could only descend down into the arid land of the Underworld. If one does not listen to the upper-world gods, then one often must make the descent to Hades’s throne, the place where soul feels most at home. It is soul’s and life’s ultimate paradox that if we want to live, then we must heed the presence of Death. Death is the final voice and the voice of finality. For us to heed Death’s voice, we must listen to the body. While Death is not welcome, it is in this presence that we find life’s weightiness and meaning. Meaning is found in the cosmic particularities of the lived experience and in the acknowledgement of the presence of Death. Any experience can be one in which meaning and the poetics of metaphor are present, the experiences from which we can no longer turn away, explain away, or deny that something “other than” is present. My anemia was such an experience because of a negation, the absence of something. The absence was itself a presence. I continue to reflect on this absence. It is the voice of Dionysus who has called to me since the physical ailments have been resolved. It is his crudeness and his madness that interest me. Anemia was a doorway through which I could step to discern what gods were missing from my life. Falling apart through physical illness has been the first step on the long road back to the temples of the soul and body that have been long neglected and have stood empty. In a session with a therapist who uses movement and engages the body, I lie on my stomach on her floor. In this position, I can feel my breath, my chest rising and falling, pushing against the fact of the floor, my Breath, my Spirit. I realize that I can feel my body most strongly when it is in relationship with something, whether it is the floor, another body, or the earth. cummings’ poem resonates: “i like my body when it is with your/body. It is so quite a new thing.” Robin Barre holds a master’s degree in Counseling Psychology. Currently she is a second-year student at Pacifica Graduate Institute, working toward a PhD in Depth Psychology. She is also the director of a small alternative high school in Seattle.

The Wisdom of the Body

Journey into the Body Healing through Chinese Medicine Helen Yee, MS, LAc “At first I started feeling a little tired, then I started to develop pain in my joints—I thought this was because I hadn’t been going to the gym as regularly, because of my travel schedule and work. Then everything got so bad I could barely walk, and I couldn’t sleep because the sensation of the sheet created so much pain.”—Maria


his is the beginning of Maria’s story. At age twenty-nine, she had a successful career as a management consultant and enjoyed a loving relationship with her husband. Her life seemed perfect. By age thirty, her body was showing increasing signs of fatigue and pain; as time progressed, she experienced more symptoms and was spending more time in doctors’ offices than she had in her entire life. When I met Maria, she was thirty-two years old. She had spent the last two years working intensively with numerous doctors and specialty centers all over the country to seek out a clear cause for her symptoms and ways to alleviate them. Maria could no longer work, and depression began to sink more deeply. Her daily pill intake was well over twenty, between medications and supplements. She had worked hard to get into the best schools and the best jobs, and she continued to work hard as a patient wanting help and answers. Still, there was no definitive cause for her multiple symptoms. Maria’s health care team included a neurologist, integrative medical physician, naturopath, chiropractor, psychologist, and Chinese medicine practitioner. Of this team, Maria worked most closely with her naturopath to oversee her medications and supplements, and with me, her Chinese medicine practitioner. When she came to me, Maria wanted to improve her energy and mood, decrease

pain, and improve the function of her body. She was hesitant to reveal her additional list of wishes, but they unfolded over time. Maria lamented her inability to do some of the simplest things she once took for granted, such as filling out forms, keeping track of time, being social, and being physically strong. “I used to be a dancer, lean and strong. I could do a hundred crunches and not feel anything.” I saw Maria weekly over six months. To assess Maria’s body diagnostically, I felt for nine pulses on each wrist, observed her tongue and face, and palpated various acupuncture points and pathways. When I first assessed Maria, I knew her digestive and hepatic systems were significantly out of balance and her Chinese kidney system was weak. Initially, I used acupuncture to rebalance her organ systems and to improve her mood and calm her spirit. As her energy and digestion improved, so did her mood and pain. I also recommended changes to her diet and sleep patterns, and I taught her self-acupressure and massage techniques, Qigong exercises, and exercises to improve her breathing. Through our work together, Maria learned to track her symptoms and become more aware of her body and its positive or negative responses to various foods, stress, and the environment. Maria now not only accepts her body but is enjoying small but meaningful accomplishments. She is receiving training in a new profession using the many difficult lessons she has learned on her path to better health. She no longer complains about her body but views flare-ups as reminders that she has pushed her body more than it can handle. In Maria’s case, I used a great deal of what Chinese medicine has to of-

fer—acupuncture, massage, dietary and lifestyle changes, Qigong and breath work exercises. Maria didn’t want to use Chinese herbs, another key component of Chinese medicine, because she was taking so many medications already. Chinese medicine is inherently a holistic system that accepts a strong mind-body connection: the etiology of a physical condition may be due to an emotional cause or vice versa. Likewise, treatment modalities are inherently holistic; multiple recommendations within the realm of Chinese medicine are used. Even the use of a single modality, such as acupuncture, has positive physical and emotional effects. (The National Institutes of Health and the World Health Organization have developed separate lists of conditions improved by acupuncture.) Chinese medicine has been extremely helpful in Maria’s case and is very helpful for many other conditions, both acute and chronic. Sprained ankles, recurrent colds, insomnia, low back pain, depression, cancer, and stress-related disorders are some of the conditions helped by Chinese medicine. Other conditions include difficult situations for physicians who are too busy to manage the breadth and depth of a patient’s care or are having difficulty treating patients who do not respond well to Western medicine, or who have limited options. This is true for some of my patients. Angela, an eighty-two-year-old woman accompanied by her daughter, was diagnosed with end-stage pancreatic cancer and given one to two months to live after our first meeting. Concurrent with some chemotherapy treatments and a referral to a Chinese energy healer, I used acupuncture and herbs to improve her immune system, strengthen her digestive function, relieve negative effects of

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The Wisdom of the Body

Compassion Fatigue The Bodily Symptoms of Empathy Susanne Babbel, MFT, PhD


edical professionals such as physicians, nurses, psychotherapists, and emergency workers who help traumatized patients may develop their own Posttraumatic Stress Disorder (PTSD) symptoms as an indirect response to their patients’ suffering. This phenomenon has been referred to as compassion fatigue, vicarious traumatization, or secondary traumatic stress. A survey showed that “86.9 percent of emergency response personnel reported symptoms after exposure to highly distressing events with traumatized people . . . 90 percent of new physicians, between 30 and 39 years old, say that their family life has suffered as a result of their work.” When health care professionals struggle with their responses to the trauma suffered by their patients, their mental health, relationships, effectiveness at work, and physical health can suffer. Caregivers who reported experiencing compassion fatigue expressed such feelings as, “I frequently dissociated and felt that I walked around in an altered state. I didn’t realize that I had been in a gray space all year. That had sort of creeped in,” and “It got to the point where I would feel physically sick before the appointment, feeling nauseous.” Others described taking on their client’s symptoms, explaining that they had “tightness in the exact same spot” as their clients and that they continued to carry the sensation, sometimes for days. One psychotherapist explained, “I am the ‘empathy lady’ from the old Star Trek episode—I may get a 45 percent hit of what my patients are feeling 100 percent of.” The helpers’ symptoms, frequently unnoticed, can cover a range of psychological issues, such as dissociation, anger, anxiety, sleep disturbances, nightmares, or feeling 26 San Francisco Medicine June 2008

powerless. However, professionals may also experience physical symptoms, including nausea, headaches, general constriction, changes in body temperature, dizziness, fainting spells, and impaired hearing. All are important warning signals for the caregiver that need to be addressed, or they can lead to ongoing health problems or burnout. Researchers and authors such as Babette Rothschild, Charles Figley, Laurie Anne Pearlman and Karen Saakvitne, and B. Hudnall Stamm have recognized that medical personnel and psychologists may experience trauma symptoms similar to those of their clients. They speculate that the emotional impact of hearing traumatic stories could be transmitted through deep psychological processes within empathy. Rothschild further hypothesizes that it is the unconscious empathy, the empathy outside awareness and control, that might interfere with the well-being of the caregiver. Hearing and witnessing horrific stories of abuse and other traumas can be highly stressful, and trauma experts have found that self-care techniques, both psychological and somatic, can reduce susceptibility to the internalization of traumatic stress and compassion fatigue. Bernstein indicates that paying attention to and being aware of physiological signals and somatic countertransference, such as “dizziness, emptiness, hunger, fullness, claustrophobia, sleepiness, pain, restlessness, sexual arousal, and so forth,” can be an important method of preventing and managing compassion fatigue. Somatic countertransference entails the psychotherapist’s reaction to a client with bodily responses such as sensations, emotions, and images that can only be noticed through body awareness. Since somatic countertransference is often neglected in

both the literature and in the caregiver’s training, many are not aware of the somatic countertransference elicited in the helperpatient relationship. Reducing compassion fatigue means not fighting the symptoms but working with feelings that occur during and after the interactions with the traumatized patient. One psychotherapist said, “If I start to not feel my body, I pause and just take a moment.” There is a lot to take in. Giving oneself permission to take a break for a short time and taking care of oneself may not only help the caregiver but may also provide a role model of self-care for the patient. Taking a break might be just to stop and feel one’s body, asking the patient to slow down, taking a deep breath, or making a small movement, which are forms of regulating the nervous system and decreasing the stress of working with traumatized patients. Since caregivers commonly dissociate, staying connected or reconnecting to one’s identity and physical presence has been rated as highly important as well. Some professional helpers use visual or kinesthetic reminders of their lives outside of their work. Visual reminders might be placing pictures of family, certificates, and favorite artwork in the office. Whereas kinesthetic reminders bring awareness back to the body and might be accomplished by feeling one’s feet on the floor, intentionally fiddling with a wedding ring, or holding the office chair. One caregiver said that every time she opens the office door, she uses the door as a kinesthetic reminder and says, “That is my life outside, and that’s where I’m entering.” Studies have also shown that attitudes toward life, such a sense of humor, self-confidence, curiosity, focusing on the positive, and feeling gratitude ranked high in being

helpful in treating traumatized people. Additionally, support, supervision, balancing work and private life, relaxation techniques, and vacation time have been proven useful in treating caregivers. Research indicates that caregivers are not immune to trauma and might experience compassion fatigue. Better understanding and knowledge about this phenomenon, as well as self-care techniques that include both psychological and somatic tools, can help caregivers deal more effectively with patients’ sufferings. Susanne Babbel, MFT, PhD, is a licensed marriage and family therapist, somatic psychotherapist, and workshop leader in San Francisco. If you would like further information on this topic, please visit her website at www.

Journey into the Body Continued from Page 25... chemotherapy, and ease back pain. Tracking Angela’s health through tongue and pulse diagnosis, her symptoms decreased, and she was diagnosed cancer-free after a number of months. Unfortunately, her energy also started to decrease. Angela was used to daily outdoor walks and after a while could not walk very far or for very long. Then her memory started to fade more quickly. With increasing physical symptoms, she initially fought the idea of slowing down. With acupuncture and herbal treatments, she eased more gracefully into her slowing process—she walked in the hallways of her nursing home and asked to listen to her favorite music when she couldn’t walk. For the times she was anxious with certain medical procedures or visits, I used acupuncture to calm her anxiety; and for the times she was tearful and depressed after a visit to her husband or old home, or frightened by the prospect of death, I used acupuncture to lift her spirit and help her find some emotional peace. These modalities helped her ease more gently into death. Angela outlived her doctor’s prognosis and enjoyed life for a full year. In the end, it wasn’t the cancer that took her but the fact that her body no longer had the energy it

needed to function. During the last year of Angela’s life, I also treated her sixty-year-old daughter, Patricia. She was the primary caregiver, taking Angela to all her appointments and attending to her daily needs until she was forced to find a nursing home for her. Providing care for her mother took a significant emotional and physical toll on Patricia. She was tired and stressed; her sugar cravings worsened and her moods were all over the map. Through the use of acupuncture and herbs, Patricia was better able to manage all aspects of her mother’s care while she was alive, and better able to cope with her death. During the periods when she wasn’t able to receive acupuncture treatments or forgot to take her herbs, she noticed herself feeling more scattered and emotional, less able to focus, and more likely to indulge in sweets. Patricia still mourns the death of her mother, but she finds that her treatments help her stay more emotionally and physically “grounded in her body” and able to “stay in the present.” During the time she was caring for her mother and then after her mother’s passing, Patricia did not catch any colds like many in her situation, and the treatments helped her avoid sugar binges and added weight gain. The stories of Maria, Angela, and Patricia show how Chinese medicine can be used to help people change their perception of their health condition and allow the body to heal and flourish in ways we may not expect. Chinese medicine, with its multiple approaches from acupuncture to diet and lifestyle recommendations, can allow a patient’s care to be completely customized even in conjunction with Western medicine. The more people are able to incorporate Chinese medicine into their treatment plan, the better outcomes they can achieve not only physically but emotionally as well. Helen Ye, MS, LAc, is a Licensed Acupuncturist and Chinese medicine practitioner in San Francisco. She sees patients in her private practice and at California Pacific Medical Center’s Health & Healing Clinic. To learn more about Chinese medicine, visit or read The Web That Has No Weaver: Understanding Chinese Medicine, by Ted J. Kaptchuk, or Between Heaven and Earth: A Guide to Chinese Medicine, by Harriet Beinfield and Efrem Korngold.

Welcome New Members! The San Francisco Medical Society would like to welcome the following new members: Jennifer Baron, MD

Referred by David Berman, MD

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Ofelia Maristela, MD Online Application

Mark J. Savant, MD

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Judith Friedman, MD Janice S. Lee, MD

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Constance Wong, MD Sue Yom, MD Referred by AMA

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Steven P. Chan, MD

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June 2008 San Francisco Medicine 27

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The Wisdom of the Body

Examining Unexplained Symptoms Somatization and the Somataform Disorders J. Jewel Shim, MD


omatization, or the presence of medically unexplained symptoms, is common in all areas of medicine. This phenomenon, in its various forms, has long been recognized, dating back to the ancient Greeks and the term hysteria. More recently, in the nineteenth and twentieth centuries, physicians such as Briquet, Charcot, and Freud added their theories about the connection between the psychological and the physical. Somatization is considered a physical manifestation of underlying psychological problems. Diagnostic workups are often unrevealing of a medical diagnosis or cannot fully explain the extent of the patient’s symptoms. As the diagnosis remains elusive and treatment is ineffective, patients and physicians can become more frustrated. Patients may escalate their need for medical intervention and become functionally more impaired. The personal impact of somatization on patients is also profound, affecting individuals in all spheres of social, personal, and occupational functioning. This disability is increased if psychiatric illness is also present (Barsky et al 2006). For the provider, treating patients who somatize can be unrewarding and even burdensome. It is estimated that about half of all primary care visits are for somatic symptoms, and up to a third of these are medically unexplained (Dickinson et al 2003). Moreover, treating patients with somatization is costly for the health care system. At a national level, total health care costs are estimated to be more than $250 billion dollars a year, even after adjusting for comorbid psychiatric disorder (Barsky et al 2005). Somatization should be differentiated from the somatoform disorders, which are

a group of disorders defined by psychiatrists with strict criteria for diagnosis. Frequently, patients who somatize do not meet criteria for one of the somatoform disorders. However, the impact of somatization is no less significant. In the case of the somatoform disorders, the Diagnostic and Statistical Manual of Mental Disorders IV, text revision (DSMIV-TR), lists seven distinct disorders. These are somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder not otherwise specified. In general, in all of these disorders the patient has a physical complaint or complaints that are medically unexplained, or whose symptoms and disability are not fully explained by existing physiological abnormalities. The symptoms are not intentionally produced or feigned, such as in fictitious disorder and malingering. In somatization disorder, patients must meet extensive criteria for diagnosis, which include multiple kinds of symptoms in different areas (pain, gastrointestinal, sexual, and pseudoneurological), as well as have onset before age thirty. Such patients may seek extensive medical workup and undergo many different procedures and treatments, which may result in significant disability. Undifferentiated somatoform disorder has less stringent criteria, requiring only one physical complaint for a duration of at least six months with associated significant distress or impairment in functioning. When patients present with symptoms affecting voluntary motor or sensory function and there is a suggestion of contemporaneous psychosocial stressors, a diagnosis of conversion disorder may be considered. Patients often have la belle indifference or

even neglect of the affected part of the body or sensory function. Typically, the pattern of the neurological deficits does not suggest any known neurological illness. Similarly, in pain disorder, psychological factors appear to be associated with the onset or change in symptoms. Patients who meet criteria for this disorder have pain in one or more sites and have significant distress or impairment as a result. For a diagnosis of hypochondriasis, patients must be intensely preoccupied with having a serious disease. These patients may have symptoms which they attribute to having this condition. These fears persist even in the face of negative workup and physician reassurance, and patients must have these symptoms for at least six months. In body dysmorphic disorder, patients are focused on some perceived defect in their appearance, or their concern about an existing defect is excessive and leads to significant distress or functional impairment. Finally, somatoform disorder not otherwise specified captures those patients who have significant symptoms of somatization or suggesting a somatoform disorder but do not meet full critieria for any one disorder. Specific conditions such as pseudocyesis, the false belief that one is pregnant, may be included in this category.

Evaluation and Diagnosis Somatization can have a wide range of expression, from a transient, stress-related exaggeration of symptoms to a chronic, severe, and disabling condition when patients meet criteria for a specific somatoform disorder. Regardless of the terminology and whether patients meet criteria for a specific disorder, it may be more helpful for clinicians to consider somatization in cases

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Continued from Previous Page... where patients have physical symptoms that are multiple and vague, have no clear pathophysiological explanation, are not responding to standard treatments, and there is evidence of psychiatric disorder. There appears to be a significant relationship between psychological distress, particularly depressive and anxiety disorders, and somatization. More than two-thirds of primary care patients with depression present with somatic complaints (Greco et al 2004). It has also been found that the incidence of psychiatric disorder seems to increase with the number of physical symptoms (ServanSchreiber et al 2000). The challenge to diagnosis occurs when patients concurrently have real medical illnesses. Therefore, the first step in evaluation should be to rule out medical illness with a careful history and physical exam with select diagnostic workup, when appropriate. However, the presence of a medical illness does not necessarily rule out the existence of a psychiatric disorder. Therefore, the second step is to screen for psychiatric illness. A number of scales that assess for psychiatric illness are available, including the PRIME-MD (Spitzer et al 1994) and the Patient Health Questionnaire (PHQ) (Spitzer et al 1999). In addition, the clinician should inquire about current psychosocial stressors. For a more formal assessment for somatoform disorder, the physician may consider referring the patient for psychiatric evaluation.

any workup or treatment. Emphasizing that while a complete “cure” might not be possible, maximizing functioning should be the primary goal. Reassuring the patient that, regardless of outcome, the physician will continue to treat the patient is also helpful. If there is evidence of psychological distress, the physician should address this directly with the patient, taking care not to suggest that the psychological issues are the source of the physical problems. Instead, acknowledging that the physical problems have taken a toll on the patient emotionally can be a good starting point.

Medications There are no FDA-approved medications for somatization or somatoform disorders, though there have been some studies examining the effect of SSRIs with certain somatoform disorders, with some positive results (Fallon 2004). A recent study found that antidepressants are most effective when there is a diagnosed comorbid depressive or anxiety disorder, and there is some evidence that treating the psychiatric disorder can improve somatic symptoms (Greco et al 2004). The combined serotonin-norepineprine reuptake inhibitors (SNRIs), venlafaxine and duloxetine, have demonstrated efficacy in treating pain syndromes, with duloxetine having FDA approval for the treatment of diabetic neuropathic pain. Their mechanism of action is thought to be mediated through inhibitory descending pathways at the level of the spinal cord (Jackson et al 2006).



The management of somatizing patients should incorporate several general guiding principles. It is essential that there is clear communication between the patient and the physician. The clinician should also validate the patient’s concerns by acknowledging his or her distress. Understanding how the patient has conceptualized the problem is also important and may guide the physician in elucidating additional information about concurrent psychosocial stressors as well as reassuring the patient and planning next steps. The physician is additionally advised to clarify expectations and perceived realistic outcome of

Cognitive behavioral therapy has been the most extensively studied of all therapies. It has been used in the treatment of some somatoform disorders and functional somatic syndromes and has demonstrated effectiveness in reducing levels of pain and somatic symptoms and improving function (Jackson et al 2006, Allen et al 2006). However, in most cases this would require a referral to a specialist.

30 San Francisco Medicine June 2008

managing psychosocial issues in their patients, while for others their comfort level is not as high. When the provider feels truly out of his or her area of expertise, as in cases where patients’ depressive or anxiety symptoms are not responding to standard pharmacotherapy, referral is advised. The clinician should discuss with the patient his or her limits in clinical expertise and explain that the need to refer is based on concern that the patient is not getting adequate care in this area. If patients can be engaged in the treatment plan and understand that referral does not equate abandonment by their provider, they may be more likely to agree to see a mental health clinician. Somatization is ubiquitous in the medical setting and poses challenges in recognition, evaluation and diagnosis, and management. It highlights the impracticality of a demarcation between what is categorized as physical and what is described as psychological. It is more useful to understand that each patient’s individual experience of illness is unique. Past experiences, coping styles, expectations, current psychological illness, and psychosocial stressors all affect how patients understand their symptoms and how they interface with the medical system. It is imperative that the physician appreciate the complexity of the interaction of these factors and the key role he or she can play in helping patients achieve their goals for alleviating illness. J. Jewel Shim, MD, is an Assistant Clinical Professor in the Department of Psychiatry at UCSF. Portions of this article originally appeared in Behavioral Medicine in Primary Care, published by McGraw-Hill, and The Journal of Patient Care. For a full list of references, please visit

When to Refer The decision to refer patients to a mental health provider is clinician-specific. Some practitioners feel very comfortable

The Wisdom of the Body

Confronting Mortality A Talk with Irvin Yalom, MD, on the Fear of Dying, Grief, and “the Wild Dogs in Our Cellar” Steve Heilig, MPH “Sorrow enters my heart. I am afraid of death.”—Gilgamesh, c. 2600 BC


tanford psychiatrist Irvin Yalom is a widely renowned author of best-selling books such as Love’s Executioner and the novel When Nietzsche Wept, and the landmark textbook Existential Psychotherapy. His new book is Staring at the Sun: Overcoming the Terror of Death. San Francisco Medicine: What prompted you to write about death and the fear of it? Irvin Yalom, MD: A lot of people suggested that perhaps I was writing this book to deal with my own personal concerns about death, as I am now seventy-six years old. There’s some truth to that. But actually I’ve been dealing with mortality for a very long time. Early in my training, I became interested in an existential approach to psychiatry in addition to the more formal analytic approach I was trained in. I was interested in philosophy and how the problems of existence and the anxieties of nonbeing played a role in the psyche. Later I spent years writing a book called Existential Psychotherapy, and part of that book dealt with how we know death is inevitable and how we deal with that. This fear is somewhere inside us and is usually hushed up, but many people cannot do that and have much anxiety about it. So experiences with such patients over the years led to my writing on this topic as well. You write that the fear or even terror of death actually can be manifested in other ways, and that physicians should be aware of that. Right, and this is hardly a new idea. Epicurus wrote about this 2,400 years ago when he

talked about how much of human misery emanates from fear of dying. He said that the job of philosophy is partly to help people overcome that fear. He also said that fear of death manifests in attempts to achieve some sort of immortality, through seeking fame, having buildings named after us, getting political power, and so forth. I agree with those who hold that the fear of death is the “mother” of all religions. Do you think that many physicians, who logically might have more exposure to mortality, tend to be more comfortable or otherwise sophisticated about mortality? Not necessarily, even though physicians have to confront death quite nakedly in their first year of medical school when they dissect a cadaver, which can be a shocking experience. But we tend to use a lot of diversion and humor to avoid dealing with what that really means—that it will happen to us, too. And in psychotherapy, my specialty, one can have long years of psychoanalysis and discussion and the topic of mortality never comes up, even though it is one of the fundamental facts our minds have to deal with. Nobody escapes this fate. On that note, you wrote that the response to this book among friends and colleagues was quite different than that of your previous books. Oh, absolutely. When my wife and I would go to dinner parties and people would ask what I was working on and I’d tell them I was writing about death, they would quickly turn to my wife and ask her what she was working on. Now, she has just finished writing a book of her own titled The American

Resting Place, about graveyards and gravestones, and by the time she had answered their question a general pall had come over the whole dinner conversation. We might not get invited back to those homes. Do you think that our approaches to dealing with death and dying have improved in the past decade or so, with increased public and professional attention being paid to the issues? I think so. About thirty years ago I started working with patients with untreatable conditions, particularly cancer patients. We started some of the first support groups for such patients, which are very common now. And one does hear more talk about mortality, at least in some circles and circumstances. Your Stanford colleague David Spiegel, MD, published landmark work in that arena, possibly demonstrating increased survival linked to such groups. That is controversial, but to me the arguing missed the point, which was not about extended life but improving whatever time patients had left. That’s right. And it’s very clear that these groups, which do involve talking about death, improve quality of life. The fact of death can be a very isolating experience and can lead to despair, and being with other people facing the same situation can be a tremendous relief. Do you have an opinion on the right-todie controversy, particularly physician involvement in hastening a patient’s death?

Continued on the Following Page... June 2008 San Francisco Medicine 31

Continued from Previous Page... My perspective leans towards sympathy for this option, with the proviso that you must have sensitive, intelligent clinicians who can really help patients air it out, and who can make differential diagnoses as to whether this is a depression that can be treated. We have to avoid decisions people might have cause to regret. But if all else is gone and patients are nearing death in great discomfort and wish to take their lives, I do have some sympathy for that approach.

That is probably true, I’m afraid. I led a study of groups of parents who had lost children, and those groups just never really got going. The parents were too often just too grieved and could not talk about it. And the breakup of marriages among those who have lost a child is amazingly high, perhaps because they just can’t talk about it, and because males and females often grieve in different ways. Males often seek to distract themselves with work and other busy activities while women try to talk and deal directly with the feelings, so each interferes with the other’s grieving.

Beyond sympathy, though, do you think a permissive policy can be managed, as has been done in Oregon or the Netherlands, for example?

In your book you quote Nietzsche: “To become wise, you must listen to the wild dogs barking in your cellar.” What are those “dogs”?

Well, if the strictures are there and we can be as certain as possible that treatable conditions are not present and the decisions are being made with a lucid and clear mind, with family members in agreement, yes, I agree with such policies.

First, I should say that the quote is problematic, as I am now not sure it was Nietzsche who said that. But in any event, the point is that we all have lots of unwieldy, dark feelings and fears inside, and we have to incorporate all of these into our lives before we become truly wise. That’s why many of the cancer patients I worked with reported a basic change, that the confrontation with death led them to lead and see their lives very differently. So facing death acts as a kind of awakening.

Beyond fear of our own demise, it seems to me that much of the fear related to death is more about grief over the death of others. True. I do work a lot with people in grief. One counterintuitive aspect is that when we lose somebody with whom we have had a long, close, positive relationship, we tend to recover better than when that person is someone with whom we had a relationship fraught with conflict. That’s because in the latter case, there is so much guilt, and much that is unfinished and unsettled. The other thing is that grief is often not only about the other, deceased person, but a confrontation with our own mortality. It brings the fact of mortality into focus. A wonderful 20-year-old person who was like a daughter to me in many ways died tragically just last week, and frankly I don’t believe it yet. I’m afraid of what I’ll feel when the denial fades. In “rankings” of traumatic experiences, I have seen the loss of a child noted as the worst such experience. Any thoughts on that?

32 San Francisco Medicine June 2008

It seems to me that’s a common message in some religions, such as Buddhism, and in literature.

Again, Epicurus counseled that we are mortal and have nothing to fear from the afterlife, as when the brain dies, the mind dies as well, and that’s all. This is frightening to some people, but others find it comforting, especially if they are fearful about punishment after life, as many religions have emphasized through the ages. Another of his arguments has been called the “symmetry” argument: that we will be in the same state after life that we were in before, which may in fact be something other than nothing at all but is still where we were before, and so not to be feared.

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Right. Death is a part of life. Socrates said that to learn how to live is to learn how to die, and vice versa. The idea that life is transitive means that we should view and imbue each moment with poignancy, and as something to be treasured. Rather than worrying that we are wasting time, or marking time, or waiting for something to happen, we should realize this is the only life we have and that we should be living as usefully as possible. People who, as they grow older, feel they have had an unlived life and a lot of potential they have never capitalized upon often have a lot more pain and fear of death. And what of fears or concerns about what might come after this life?

The Wisdom of the Body

Hearts and Minds Revisited Coronary Artery Disease, Depression, and Anxiety Brent Cox, MD, and Steve Walsh, MD


our years ago in San Francisco Medicine (February 2004), we reviewed the evidence for the muchincreased cardiac mortality rates in patients with post-myocardial infarction (MI) with major depressive disorder (MDD) compared to post-MI patients without depression. We also described the much-increased mortality risk in depressed patients with congestive heart failure, depressed patients with unstable angina, and depressed patients with systolic hypertension over that of nondepressed patients with those diagnoses. In patients with MI, depression is a risk factor equivalent to left ventricular dysfunction and prior MI. Additionally, recent studies show that successfully cardioverted atrial fibrillation patients experience a twofold increase in early recurrence of their atrial fibrillation if they are depressed. In this article we update our review of the shared pathophysiologic mechanisms existing in MDD and in coronary artery disease (CAD), and we include information about anxiety states as an additional risk factor in patients with CAD. Several altered physiological mechanisms appear to be shared in MDD and CAD: (1) Hyperactivity of the hypothalamicpituitary-adrenal (HPA) axis is a common thread linking CAD and MDD. Sustained hypercortisolemia results in diminished nucleus accumbens dopamine release, hippocampal toxicity, activation of amygdalamediated conditioned fear responses, and mobilization of free fatty acids that trigger endothelial inflammation, excessive clotting, hyperlipidemia, and insulin resistance. (2) Sympathoadrenal hyperactivity with increased circulating catecholamine levels represents a critical link between MDD and CAD. Hypersecretion of

epinephrine exists in unipolar depression. It contributes to progression of CAD by stimulating platelet aggregation, elevating serum lipids, and increasing endothelial shearing forces. It also may trigger vasospasm or malignant cardiac arrhythmias. Successful depression treatment with SSRIs normalizes catecholamines. (3) Lipid abnormalities are common in both MDD and CAD. A higher incidence of “Syndrome X,� with lowered HDLs, decreased omega-3 fatty acid levels, and increased levels of saturated and monounsaturated fatty acids, exist in both conditions. This is presumably caused by HPA hyperactivity. The dyslipidemias increase insulin levels and ultimately increase C-reactive protein, inflammation, and vascular barrier dysfunction. (4) Omega-3 fatty acids deficiency in red blood cells is associated with both increased risk of sudden cardiac death and with MDD. Over the past century, patterns of increasing MDD and CAD correlate with decreased intake of omega-3 relative to omega-6 fatty acids. Adding omega-3 fatty acids to conventional medication treatments after MI consistently reduces cardiac mortality, perhaps because this diminishes release of inflammatory cytokines and reduces triglycerides. Omega-3 deficiency may play an etiologic role in both unipolar and bipolar depression. Recent studies of patients with both patterns of depression show significantly lowered recurrence rates and much-reduced scores on depression ratings for patients given omega-3 fatty acids compared to patients in the placebo group. Antidepressant and mood-stabilizing effects may be due to suppression of inflammatory cytokine release from WBCs and membrane stabilizing effects in neurons.

(5) Elevated plasma homocysteine levels are also associated with both MDD and CAD. In several studies of both disorders, supplementation with folic acid was useful, leading to decreased carotid plaque formation, decreased cardiovascular risk in patients with hyperhomocysteinemia, and robust antidepressant effects in elderly patients with MDD. Several recent studies of high-dose folic acid treatment failed to demonstrate statistically significant reductions in cardiovascular events. However, on more careful analysis it is clear that the studies were not adequately powered and used an excessively brief assessment interval of one to two years. Even with the limitations of the current studies, it is now clear that folic acid supplementation produces at least a 12 percent reduction in events related to ischemic heart disease and a 22 percent reduction in risk of stroke. A very new study published in JAMA in early May of this year was sufficiently powered and of long enough duration to suggest that folate supplementation’s cardiovascular benefits may be most prominent as primary prevention for patients who have not yet developed significant heart disease, or for treatment of patients with existing cardiovascular disease who have markedly elevated homocysteine levels at baseline. There have also been studies showing more depression symptoms in patients with high homocysteine levels. The antidepressant effects of folate are accentuated by concurrent use of pyridoxine and vitamin B12 and are thought to be mediated through increased levels of endogenous SAMe as well as increased omega-3 fatty acid levels. (6) Altered inflammatory response mechanisms are common to both MDD

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The Wisdom of the Body

A Good Night’s Rest Does the Body Best The Importance of Breathing Well during Sleep Shannon S. Sullivan, MD, and Clete A. Kushida, MD, PhD


bstructive sleep apnea (OSA) is a sleep-related breathing disorder characterized by repetitive episodes of complete cessation of airflow (apnea) or decreases in airflow (hypopnea) due to upper airway obstruction. Approximately a quarter of the men and a tenth of the women in the U.S. show evidence of this disorder in polysomnography (“sleep study”). In addition, 1 to 3 percent of children are estimated to have OSA. Identification and treatment is imperative, given that untreated OSA is associated with an increased risk of cardiovascular comorbidities such as heart attack, systemic and/or pulmonary hypertension, stroke, daytime sleepiness and risk for automobile accidents, mood disorders, and cognitive dysfunction. Cognitive impairment in executive function and attention, memory, learning ability, and psychomotor performance has been reported in multiple studies. In children, the condition may result in school or learning difficulties, inattention, and hyperactivity. In both children and adults, OSA may be associated with parasomnias (unusual behaviors during sleep) such as sleep walking (somnambulism) or night terrors. Risk factors for OSA include being overweight or obese, male sex, certain facial skeletal structural features, or conditions of the upper airway such as chronic nasal allergies. In children, the disorder is often associated with sizeable tonsils and adenoids. While history and physical examination are critical to suggest the diagnosis of OSA, the gold standard for diagnosis is overnight polysomnography, during which brain activity (electroencephalogram, or EEG), eye movement, snoring, respiratory flow and effort, muscle movement, oxygen saturation, and cardiac (EKG) data are monitored. 34 San Francisco Medicine June 2008

The mechanisms leading to impairments associated with OSA are complex, but they are generally believed to occur because of sleep fragmentation, autonomic dysfunction, and intermittent, recurrent hypoventilation and hypoxemia. Deficits are partially or fully reversible after treatment of airway obstruction. For adults, CPAP (continuous positive airway pressure) constitutes the current first-line treatment for OSA; upper airway surgery and dental appliances are also therapeutic options. Conversely, in children tonsillectomy and adenoidectomy is a successful treatment modality the majority of the time. Orthodontic expansion in children also has begun to show significant promise in the treatment of childhood OSA. But the field of sleep medicine extends far beyond OSA, to the diagnosis and treatment of common conditions such as insomnia, circadian rhythm abnormalities, and restless legs syndrome to somewhat rarer conditions such as narcolepsy and REM sleep behavior disorder. Insomnia, for example, has a prevalence of approximately 11 percent in the general population. Although pharmacologic agents are often used to treat chronic insomnia, evidence indicates that cognitive behavioral therapy, performed by board-certified therapists found at certain specialized sleep centers such as the Stanford Sleep Disorders Clinic, improves long-term outcomes in insomnia. Insomnia specialists at Stanford run both small-group workshops and individual sessions for those suffering from insomnia. Circadian rhythm disorders such as sleep phase delay are also commonly diagnosed and effectively treated with proven nonpharmacologic techniques. While overnight polysomnography is most commonly performed to evaluate

for OSA, other sleep disorders may also be evaluated using this test. For example, nocturnal seizure activity can be detected, and additional EEG leads are often used if this diagnosis is suspected. Movement disorders such as periodic limb movement disorder can also be identified. Certain daytime studies, such as the multiple sleep latency test (MSLT), may be indicated when excessive daytime sleepiness is present; other times, the maintenance of wakefulness test (MWT) may be invoked to evaluate risk of sleepiness in certain jobs, or to assess improvement after treatment of underlying sleep disorders. The Stanford Sleep Disorders Clinic is an internationally renowned center for sleep medicine research and outstanding patient care. In addition, it houses one of the largest ACGME-accredited fellowship programs in the country. The clinic finds its home in the Stanford Department of Psychiatry but is multidisciplinary in nature, staffed by sleep medicine specialists who are also board-certified in psychiatry, neurology, pulmonology, and pediatrics. Founded by internationally known experts in the field, including William Dement and Christian Guilleminault, the clinic has a long history of important contributions to this relatively new frontier in medicine. In addition to excellence in patient care, researchers and physicians are leading the field in recent and current research studies, including the Apnea Positive Pressure Long-term Efficacy Study (APPLES), which is the largest clinical trial ever funded by NIH in the field of sleep and which is focused on the effects of CPAP on neurocognitive function, mood, sleepiness, and quality of life in patients with OSA. There are also groundbreaking

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The Wisdom of the Body

The Dancing Saints Connecting with the Divine through the Body Megory Anderson


here is a church on Potrero Hill called Saint Gregory Nyssa Episcopal Church, and it is filled with dancing: Saints dance on the walls, and people join them below. Dance as part of the liturgical rite dates back to ancient Christian practices. (“Once there was a time when the whole rational creation formed a single dancing chorus looking upward to the one leader of this dance. And the harmony of motion that they learned from his law found its way into their dancing.”—Gregory of Nyssa, fourth-century Cappadocian bishop and theologian, in his commentary on Psalm 50.) Inside this San Francisco church, you look up and see men and women, children, and elders; Muslim, Jewish, Christian; some dead four hundred years, some only a decade or two. The figures are in bright blues and reds and whites, with golden orbs around their heads. All are connected in a spiral dance, arm in arm, circling the walls of Saint Gregory’s, inviting the community of here and now to join them. What is it about that invitation to the dance? And how does it work to enhance a community’s spiritual life?

Many religious traditions use the body and motion in prayer. Watch an Orthodox Jew, wrapped in prayer shawl, as his body sways back and forth in prayer. See a room full of Muslims as they prostrate themselves on the floor, heads touching the ground, facing Mecca, in submission to the Divine. There is something amazingly beautiful as a whirling dervish twirls around and around as music and prayer intensify. Our bodies help us both draw inward toward the inner presence of the Divine and reach out to the transcendent creator of the universe. At Saint Gregory’s, however, movement and dance go beyond traditional use of the body in prayer. If you walk into the church on a Sunday morning, there are some things you notice right away. One is that there is both stillness and movement. You sit and listen to words and to silence. And then you move. You move from one space to another, from the quiet, still space to the wide and open rotunda where the altar sits, and you dance, around and around the table. Just like the shared silence, movement is a community action. Another thing you notice is that you are not alone at Saint Gregory’s. The spiritual experience is a shared one; it is intertwined. There is something profound about being invited to place your hand on the shoulder of the person in front

of you and move into a circle of prayer and communion. You go together, holding on to someone who is holding on to you. You become an integral part of the movement, a link. And the icon saints who dance in a circle above your head are not there for ornamentation; they are truly part of that community. They raise you both figuratively and literally into the dance. But does spiritual practice have to contain movement? Not always. As in the discipline of tai chi, there is significant value to balance. Stillness is good. Movement is good. Together, they can create wholeness. So what does it mean to go from an observer’s experience of spiritual connection to one of bodily connection, where you are not only moving your own body but you are moving in rhythm with so many others? One member of the congregation said, “When I need solitary prayer, I can find it in the quiet moments. But on Sunday mornings, I am pulled into the dance. I have to recognize that God wants all of me, body and soul, and we are in this together. I look up at those saints—and I do have my favorites—and realize that I have to keep moving too. One foot in front of the other. There are times when I can barely recognize the melody, much less do the dance, but most often, those dancing saints keep me focused and inspired. I dance because they dance. I am here because they are here.” Saint Gregory Nyssa Episcopal Church ( is located at the corner of Mariposa and DeHaro Streets on Potrero Hill. Megory Anderson, a longtime member of the congregation, is the founder and director of the Sacred Dying Foundation (www. in San Francisco. Photos Courtesy of David Sanger.

June 2008 San Francisco Medicine 35

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Hearts and Minds Revisited Continued from Page 33... and CAD. C-reactive protein (CRP) elevations, inflammatory cytokine production increases, and several other altered immune system mechanisms appear in both disorders. Specific antidepressant treatment appears to modulate the inflammatory response cascade at multiple levels based on recent studies, with potential implications for our understanding of depression and the treatment of heart disease. (7) Altered platelet reactivity occurs in both atherosclerotic heart disease and major depressive disorder. Platelet reactivity is influenced by increased catecholamines, elevated free fatty acids, and endothelial injury. A series of steps leads to platelet aggregation, thrombosis, vasoconstriction, and vessel occlusion. This may be the single most important mechanism for increased risk and poor prognosis of coronary vessel disease in patients with major depression. Acute and chronic mental stresses increase platelet activation and aggregation, increase fibrinogen levels, and thus can lead to thrombus formation and ischemic cardiac events. Major depression is associated with accelerated platelet aggregation and increased risk of thrombus formation. Several mechanisms may mediate this. Serotonergic agents (SSRIs especially) appear to inhibit platelet aggregation and modulate platelet reactivity. This suggests potential therapeutic synergisms in patients with comorbid depression and CAD. Differential effects on platelet reactivity exist among the antidepressants with the strongest “antiplatelet” effect from clomipramine, fluoxetine, paroxetine, and sertraline. SSRIs modulate platelet reactivity through mechanisms independent of those used by conventional antiplatelet agents, suggesting potential therapeutic synergisms for patients with comorbid depression and heart disease. These pathophysiologic processes common to both MDD and CAD suggest synergistic interplay between the two disorders resulting in worse CAD outcomes in patients with MDD. Theoretically, since depression worsens CAD outcomes, treatment of the depression should reduce cardiac morbidity and mortality as well as

improve quality of life. Treating depression One exception is a recent study showing may also delay development of CAD and that panic attacks in postmenopausal women improve adherence to treatment and life- appear to be an independent risk factor for style changes such as dietary improvement, cardiovascular morbidity and mortality in weight loss, increased exercise, and stress these older women, although the design of reduction. We believe every patient with this study may have overlapped women exCAD should be screened for depression periencing early undiagnosed dysrhythmias and vice versa, with follow-up care provided with those experiencing classic panic disoras needed. Some treatments address both der. Clearly, more study is needed to establish disorders at the same time, as we have seen. the relationship of specific anxiety disorders Anxiety disorders comorbid with CAD may to CAD events and development. also result in worse outcomes, but this has This article has described some of not been studied as well as the MDD/CAD the complex and interesting body-mind relationship. Acute anxiety can increase interfaces common in psychiatry and mediarrhythmias in CAD patients, but chronic cine. They are among the reasons many anxiety has not been proven to do this. of us still love and enjoy this remarkable Several recent studies purporting to show profession. a relationship between anxiety and worse Dr. Brent Cox is a psychiatrist in private CAD outcomes failed to control for the pres- practice in Petaluma, with a specialty in psyence of depression, which clearly is associ- chopharmacology. He was formerly director of ated with worse CAD outcomes. Depression Psychiatric Liaison Services for St. Mary’s Hosis comorbid at very high levels (up to 70 to pital in San Francisco and a faculty instructor in 90 percent) with panic, generalized anxiety, psychosomatic medicine at McAuley Institute. and other anxiety disorders. Therefore, studDr. Steve Walsh is a psychiatrist in private ies not controlling for depression will not practice in San Francisco and Mill Valley. He is be helpful in demonstrating anxiety effects past president of the SFMS, the Northern Calion CAD. fornia Psychiatric Society, and the Association Anxiety does seem to reduce heart rate of the Clinical Faculty, University of California, variability, which can predispose to arrhyth- San Francisco. He serves on the Editorial Board mias and sudden cardiac death. The recent of San Francisco Medicine. discovery of peripheraltype benzodiazapine receptors abundantly distributed through vascular endothelium, striated cardiac muscle, vascular smooth muscle, and platelets may High Resolution PET/CT scans represent a previously Fusion Diagnostic Group’s advanced technology unknown pathway for and software bring evaluation and measurement anxiety states to imtools to the Physician to use in the clinical setting. pact on cardiovascular we also have a full time physician on staff. function. Many studies of anxiety states in Mon - Saturday 8-5 + (flexible hours with advance request) patients with CAD fail to differentiate in Positron Emission Tomography (PET) their subjects among Computed Tomography (CT) the several nonuniform Molecular / Functional Imaging anxiety disorders such Accurate & Precise Imaging as panic, generalized 1700 California St. #260 anxiety, agoraphobia, California at Van Ness in San Francisco, CA OCD, simple phobias, (415) 921-7226 • 1 (800) 334-0336 • (415) 921-7225 FAX posttraumatic stress order, and the like. June 2008 San Francisco Medicine 37 The width is 3.5 by 4” high CALL Kae with any questions or concerns 415-567-5888

The Wisdom of the Body

Yoga As Medicine A Book Review Toni Brayer, MD Yoga as Medicine The Yogic Prescription for Health and Healing By Timothy McCall, MD Bantam Books, 568 pages; August 2007


good physician continues learning new ways to help patients. Trained to use differential-diagnosis thinking and to tailor treatment for the individual patient, we believe we can prescribe the best that modern science has to offer. Yoga as Medicine, by Timothy McCall, MD, asks us to open our minds to the real possibility that our healing and treatment toolbox is incomplete. Yoga is a powerful tool that increases efficacy over time, complements all other prescriptions, and has no adverse affects. And McCall goes further, believing that prescribing yoga as a medicine for patients should start with the physician taking up yoga him- or herself. McCall, a board-certified internist with more than twenty years of practice experience, started yoga in midlife, and he extols the reader to “suspend judgment and disbelief” just long enough to try a few sessions. “Take a step; no matter how small,” even if that means just doing one pose today. He asks us to commit to practice every day for one week and see what happens. No review of research or reading about yoga is sufficient to understand its healing ability, says McCall. It is a treatment that must be experienced, and this ancient practice is complementary and additive to the science of medicine. Unlike a pill or a surgical procedure, yoga’s healing benefits increase with experience and will transform the doctor as well as the patient. According to McCall, “Yoga is quite simply the most powerful system of overall 38 San Francisco Medicine June 2008

health and well-being I have ever seen.” This is a profound statement, and it’s the basis of Yoga as Medicine. The book uses language that resonates with scientifically trained doctors, and it delineates health conditions, citing research that shows benefits from the practice of yoga. Included is the usual list of difficult-to-treat chronic conditions such as fatigue, irritable bowel syndrome, insomnia, and fibromyalgia. But he also addresses such diseases as cancer, asthma, infertility, pancreatitis, and tuberculosis, among many others. He wisely avoids off-putting explanations of chakras, pranas, and “cures” in an attempt to engage the skeptical Western reader. After his overview of yoga and a stepby-step explanation of different types of yoga and how to get started, McCall uses each chapter to highlight a specific condition and a recognized yoga practitioner with expertise in treating it. He cites basic physiology, the known scientific evidence, and the approach with a patient. Using clear photos, the reader can see the postures that are recommended. Contraindications and special considerations are mentioned for each disease. The book points out that yoga, like all medical therapies, should be individually tailored to obtain the specific results desired for each patient. The true yoga master, he explains, evaluates each person individually and designs the yoga practice specifically. Even so, the photos and steps outlined in each disease chapter can be followed straight from the book.

When a patient asks, “What else can I do for high blood pressure?” it’s nice to know there is data to show that yoga is an effective treatment. The chapter on hypertension shows the recommended yoga exercises along with other suggestions about diet and exercise. The chapter on back pain points out that a one-size-fits-all approach is flawed. Recommending abdominal strengthening to all back pain patients is simplistic; the yoga expert believes back pain can be helped with a complex combination of posture, yoga exercises, and body awareness. Awareness and the focus on breathing differentiate some yoga stretches from similar-looking exercises you get in conventional physical therapy. Yoga as Medicine is an inspiring and thought-provoking book. The reader comes away with an appreciation of the complexity of the yoga toolbox and the number of ways it can combine with Western medicine to help patients. One of the most profound aspects of the book, which McCall handles exceedingly well, is to inspire the reader to start his own yoga practice. He says, “If science is the modern world’s greatest contribution to knowledge, then yoga is the gem of the ancient world. It is my belief that these two ways of knowing—which seem so different—can be reconciled, advancing our understanding more than either discipline alone.” He shows us that yoga is a powerful medicine indeed, for body, mind, and spirit.

The Wisdom of the Body

Nia In a Nutshell Experiencing the Joy of Movement Megan Finkeldey, LCSW


he Nia Technique is a unique synthesis of three sets of arts: the healing arts, such as yoga, the Feldenkrais Method, and the Alexander Technique; various elements of the martial arts, including aikido, tae kwon do, and tai chi; and dance arts. And the goal of a Nia class is to experience the “joy of movement,” regardless of your background or level. Nia is practiced in a group—usually in a setting similar to a dance class. Classes are loosely choreographed and involve a great deal of improvisational movement. At its core, Nia is an invitation for every part of a person—body, mind, emotions, and spirit—to venture into a world, and whirl, of kinesis. Add to that some mindfulness and a willingness to pay attention and listen to your sensations, and you’re onto something physically delicious and, in the end, potentially integrating for the mind, body, and spirit. A typical class consists of an hour of movement. The teacher begins by setting a focus for the class and perhaps touching on some of the specific moves, and the class ends with a cool-down, which is affectionately known as floor-play. Classes are generally held in dance or yoga studios as well as some fitness clubs, and they feature a wide array of music, such as world beat, New Age, Eastern, or popular ballads and instrumentals. The variety is tremendous, as is the choreography, which is carefully chosen so as to lead us toward bodily sensations that are in line with the focus of the class, such as systemic movement, the extremities, the core, or the “joy of movement.” Loose-fitting dance or exercise clothing is worn but shoes and socks are not—though people with tender or ailing feet may wear flexible shoes if they feel more comfortable

that way. The idea, however, is to feel the whole foot on the floor and to better develop a sense of a “base.” Movements start slowly, allowing for increased depth and breadth as the class progresses. Over time, the student develops greater familiarity with the repertoire of choreography and more self-awareness and strength. It is always fine to take things at an easier level rather than pushing beyond one’s ability; as a matter of fact, this approach is strongly encouraged. While some classes might be slower and deeper overall, there is always a period when the movement is potentially highly aerobic—although without an undue amount of impact, one of the original reasons for Nia’s existence. The teacher demonstrates and leads the way, not only in terms of the choreography but in terms of possible ways of viewing the movements themselves, and in practicing the sounding and audible breathing that helps students get in better touch with themselves. It was twenty-five years ago that Debbie and Carlos Rosas got together and the practice of Nia was born. She had been trained as a medical illustrator and was an aerobics teacher. He was a professional tennis player who was injured and started taking her class. The rest, as they say, is history: They were a highly dynamic and innovative duo and Nia, their innovative approach to dance and movement, began to grow in popularity. During the last quarter century, the practice has deepened in its ability to help the body with alignment, gaining strength, losing weight, and adding muscle and definition. Practitioners report that they feel better in any number of ways. Here is a glimpse into what it looks like today, in its many parts and its gestalt.

Nia’s Three Art Forms DANCE The first art form is dance, in all of its various modes. These include but are by no means limited to forms such as Isadora Duncan-style dance, Limone Technique, and the stylized feel of jazz. Improvisation is frequently part of the picture, adding a whole new level of self-expression and calling upon one’s authentic sense of self. Dance allows for self-expression, the playfulness and gross-motor physicality that can come with strong rhythm and lyrical motives, and the more delicate, ornamental movements that are produced by what we call intrinsic movement. It provides multiple opportunities to express one’s feelings through associations with the music—its rhythms, melodies, harmonies, lyrics, and emotions. Of course, our bodies respond naturally to music, and its various forms incite a variety of feelings. Physical sensations are a consistent focus during the course of Nia movement, and they encourage emotions to emerge. Once we are in motion, the physical voyage becomes inextricably bound with the emotional. The spirit realm is just as affected by music and movement, harkening back to a much earlier time when music and the sacred were first paired with one another. Visualization can become part of the movement; hands, arms, and legs can extend to “heaven, earth, and community.” Over time, as practitioners focus on their sensations, they can feel the personal and collective energy that is conjured up by the class. It is an electromagnetic force that conscious focus on the sensations can reveal. And from there the integration of body, mind,

Continued on the Following Page... June 2008 San Francisco Medicine 39

Continued from the Previous Page... and spirit develops all the more. MARTIAL ARTS The element of chi and its related movement form, the martial arts, are a second component of Nia. The notion of chi focuses on the energy force in and about us. Practitioners call it a “sea of chi” as they quickly and slowly, boldly and delicately “carve” the space with themselves, using both body and mind. The blocks, punches, and “tai chi arms” require constant attention to the core, specifically the lower abdomen. This area is referred to as the hara. The full strength of a martial artist requires the simultaneous development of mind, body, and spirit, and so it is with Nia. Mindfulness, preparation, and lots and lots of breath, or prana, all contribute to the power of the move. These disciplines and notions are often used in a strengthening, uplifting, and highly empowering way. Simply vocalizing, making a deep “huh” sound, connects us directly to our abdominal muscles. Putting the chin to the chest as you bend over and exhale audibly will also tug at your abdominal muscles and strengthen them. All audible sounding connects us to our core and, from there, to interwoven emotions. Developing stronger abdominal muscles can build and exercise the “guts”—both in body and attitude. Practicing mindfulness allows us not only to sense the tightening and activation of muscles more deeply but also permits us to feel an increasing sense of control and mastery over them, and an encompassing, self-empowering process taking place. HEALING ARTS Last but not least, the body integration therapies, or healing arts, are an essential component of Nia. These therapies often help people decrease overcompensation of one body part for another, and they aid in correcting poor posture and alignment. These arts also regularly use breathing as a mechanism for healing through the various movements or poses. Practitioners incorporate ideas from Feldenkrais or the Alexander Technique during any type of movement, and yoga and pilates are marvelous for 40 San Francisco Medicine June 2008

cooling down the body and calming the nervous system. Speaking as a practitioner, I can say that so much of what we do in Nia is unbelievably fun, stimulating, freeing, and cathartic. As a licensed clinical social worker and psychotherapist (as well as a performing artist and, now, a Nia teacher), I have been able to recognize some of the changes that I have undergone. Greetings from classmates beckon me to feel more energized and positive. A sense of belonging emerged that has never departed. I started toying with visualization techniques during certain movements, which permitted me to envision getting rid of figurative globs of emotional phlegm that had lingered despite years of more traditional therapy. Martial arts blocks and punches carried with them emotions and often the desire to set a limit or knock the life out of an issue of which I had not yet been able to rid myself. And yes, there is a place for sadness and psychic pain, too. When felt in conjunction with movement I understood, and “knew” it all better. The best thing to do in Nia (and, I would venture to say, in life in general) is to stop thinking so much, and to let your sensations set the pace. The opportunities are there for the taking—opportunities for blending and integration through listening to our bodies and sensations. The possibilities are limitless; it is up to us, as individuals, to drop our guard and open to our own potential. The unique blend that is Nia is not merely a synthesis of movements and concepts. It becomes a synergistically bound thread that weaves together our physical being with our emotions, with our spirit. It is, truly, something that must be experienced. Once you start to actively pursue it and feel its effects, you will know you are where you need and want to be. For me personally, I have learned to perceive more, understand myself better, and gain a greater sense of physical and mental well-being. I am at home with the movement and with the people I have exposed my very heart and soul to, and there is nothing else like it. Megan Finkeldey is a licensed clinical social worker, a psychotherapist, and Nia Blue Belt instructor.

A Good Night’s Rest Continued from Page 40... studies on narcolepsy, functional magnetic resonance imaging (fMRI) studies in OSA patients, and new medications for the treatment of insomnia and restless legs syndrome. Anyone with the cardinal signs of OSA, such as loud and disruptive snoring, witnessed breathing pauses, and/or daytime fatigue or sleepiness, as well as those with cardiovascular disease and risk factors for OSA, should be evaluated by a sleep specialist. Those suspected to have one or more of the other sleep disorders described above may also benefit from an evaluation by a sleep specialist. The main number for the Stanford Sleep Disorders Clinic is (650) 723-6601. Shannon S. Sullivan, MD, is a Clinical Fellow at the Stanford Sleep Disorders Clinic. Clete A. Kushida, MD, PhD, is the Acting Medical Director of the Stanford Sleep Disorders Clinic, Director of the Stanford Center of Human Sleep Research, and an Associate Professor in the Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center.

hospital news CPMC

Damian Augustyn, MD

The Fourth Annual CPMC Orthopaedic Education Conference will take place on Friday, September 5, 2008, at the Miyako Hotel in San Francisco. This year’s conference will focus on the treatment and diagnosis of musculoskeletal diseases. For more information, please contact Beverly Hoover at (415) 600-6484. Please save the date for the Third Annual CPMC Pediatric Hospital Medicine Conference. This two-day conference will take place September 11–12, 2008, at the Grand Hyatt Hotel in San Francisco. The conference, designed for pediatric and neonatal hospitalists, pediatricians, family practice physicians, and emergency medicine physicians, will cover topics involving the care and management of sick children and neonates. For more information, please contact Beverly Hoover at (415) 600-6484. California Pacific Medical Center is pleased to offer the 2008 Community Health Grants Program. The Medical Center works to improve community health in a number of ways, and the grants program is one means by which we invest in the community and fulfill our not-for-profit mission. The four funding priority areas this year are access to health services, chronic diseases prevention and management, communicable diseases prevention, and violence and injury prevention. If you know of community-based organizations in San Francisco that are working in these areas, please feel free to share this resource with them. Visit http://www.cpmc. org/about/community/ or contact Shirley Manly Lampkin, RN, PhD, at (415) 600-2817 ext. 62976 or


Robert Mithun, MD

One of the greatest advances in psychiatry over the last decade has been an increased appreciation of how psychological process affects physical and somatic wellness. While the mechanisms that underlie these connections are complex and not fully understood, we know they exist. Since the days of Freud, who posited a connection between psychological trauma and specific somatic complaints, (e.g., an unexplained paralysis in the arm that was forcibly grabbed by an attacker), psychiatry has been on a quest to understand how mind and body connect. In our daily lives, these connections are hard to miss. One might think of the muscle stress and strain one feels after a particularly difficult day. Or the negative effects that uncontrolled stress and depression have on our immune systems. Consider how chronic anxiety negatively impacts weight management and hypertension control. It seems that every few months, a new correlate is discovered. The good news is that treatment of the psychological condition often leads to improvement of the physical symptoms. At Kaiser Permanente, our focus has long been on prevention of illness. Through a variety of health education programs that range from learning about nonmedical approaches to infertility to healthy lifestyles management to online resources dedicated to weight management and smoking cessation, our programs try to keep our members healthy, whether they suffer from chronic illness or just everyday health concerns. Mental health is no different. We offer programs that concentrate on mindfulness-based approaches to stress and anxiety management. Using the techniques pioneered by John Kabat Zinn, mindfulness practice focuses on the here and now, teaching participants how to use their breathing, as well as all their senses, to experience the moment as a way of reducing stress. At the heart of these programs lies the knowledge that mind and body cannot be separated.

Saint Francis

Wade Aubry, MD

Saint Francis Memorial Hospital recognizes the importance of both the mind and the body in the healing process. To that end, we are very grateful to our Spiritual Services Department. Headed by Rev. Doug Lubbers, the department supports patients and their families by offering spiritual counseling and emotional support with sensitivity to cultural needs. Rev. Lubbers is assisted by the department’s diverse staff. Four chaplain residents minister to patients of all different faiths and backgrounds. They also work to buoy staff morale, visiting departments to offer tea and blessings on our caregivers’ hands. We are thankful for all their efforts. I would also like to acknowledge a few individuals who have accepted new roles within the hospital. We welcome Dr. John Rampulla, Medical Director of the ED, who brings us nearly thirty years of emergency medicine experience. Our thanks and good wishes go to departing ED Medical Director Dr. Philip Piccinini. We also welcome Dr. Fernando Miranda, Medical Director of the Stroke Center. Dr. Miranda is a Certified Member of the American Society of Neurorehabilitation and is a Qualified Medical Examiner for the State of California. He takes over from Carlos Quintana, MD, who saw the hospital through its recent successful JCAHO accreditation as a Primary Stroke Center. Thanks to Dr. Quintana for his excellent work.

June 2008 San Francisco Medicine 41

hospital news St. Luke’s

Jerome Franz, MD

For many years St. Luke’s ran a Neighborhood Clinic under a state charter to provide free or reduced-fee care to uninsured residents of our community. Our primary care physicians worked for a few hours each on regular schedules, and specialists consulted pro bono. In the 1990s the clinic became a vehicle to start new practices in adult medicine, OB/GYN, pediatrics, and orthopedics. It was renamed the St. Luke’s Health Care Center and had its own board and management team that reported to the hospital board. In subsequent years a number of doctors were hired and left, and a few remained loyal to the mission, notably St. Luke’s Pediatrics, St. Luke’s Women’s Center, and the orthopedic group started by David Atkin fifteen years ago, and which he expanded to include another orthopedist, a back surgeon, and two physiatrists. Within the last seven years the center also hired an infectious disease consultant, Daniel Goodman, an endocrinologist, Christian Tuan, and a breast surgeon, Lora Burke. They have all turned out to be outstanding additions to our medical staff. However, because it is outside of the charter to have a specialty clinic, efforts have been under way for a while to transition the specialists into private practice. The change was completed at the beginning of this year, and initially it has been successful, although two orthopedists left and two OBs went elsewhere due to the restructuring of the Health Care Center. The center now consists of the pediatric and ob/gyn practices and the Health First comprehensive adult medicine clinic described in previous columns. We expect this to be the core of the new St. Luke’s as we await the recommendations of the Blue Ribbon Committee.

42 San Francisco Medicine June 2008


Ronald Miller, MD

UCSF Children’s Hospital has become the first medical center in California to hire a staff musician, in an effort to help ease young patients’ anxiety, depression, and discomfort. Percussionist Gabe Turow has studied the effects of rhythm on the brain and edited an anthology on the topic. He is a talented musician who has taught music to children and plays in a local rhythm band. Now a staff member in the Children’s Hospital, Turow performs for patients and teaches children to play, write, and record music in an on-site UCSF studio. He hopes to expand the program to allow children to leave the hospital with their own instruments. The UCSF Child Life Department also employs a full-time drama therapist who leads art and drama therapy programs with pediatric patients. UCSF researcher Lawrence Fong, MD, has found that enhancing immune responses in prostate cancer patients can lead to clinical responses and shrinking of tumor metastasis. In a phase I prostate cancer clinical trial, Fong and his colleagues found that blocking CTLA-4, a cellular molecule on lymphocytes that inhibits immune response, produced meaningful clinical benefits in patients with prostate cancer who no longer responded to hormone therapy. Blocking CTLA-4 effectively works by removing the brakes on the immune system. UCSF marked a milestone in April with the 500th procedure in its Thoracic Transplant Program, which specializes in heart and lung transplants. UCSF’s transplant population includes patients with unique rheumatologic disorders and those with end-stage lung disease secondary to congenital heart disease, diseases that are just now being considered viable for transplantation. UCSF researchers are presently investigating a blood test instead of a biopsy to identify patients who might reject their donor organ. They are also studying the possibility of using inhaled immunosuppressants to stop transplant rejection.


Diana Nicoll, MD, PhD, MPA

The San Francisco V.A. Medical Center (SFVAMC) has rapidly expanded the clinical and research programs in the area of Posttraumatic Stress Disorder (PTSD). The PTSD Program has been designated as one of two PTSD Clinical Programs of Excellence in the national V.A. health care system. Over the past several years, it has emphasized providing rapid response to veterans suffering from psychological problems. The clinical program provides well-established treatments such as individual cognitive behavior therapy, couples and family therapy, psychopharmacology, and group psychotherapy. In response to the needs of recently returning combat veterans, the program has greatly expanded the provision of new treatment modules, including education and group classes for spouses and family members, health and wellness groups, stress management groups, anger management groups, dual diagnosis substance abuse groups, and drop-in education classes. The program has also created a new women’s trauma program in collaboration with the Women’s Clinic. The SFVAMC PTSD clinical program is a core training site for UCSF School of Medicine medical students, as well as residents in psychiatry and neurology. The research program in PTSD has expanded in the past three years. The creation of the Neuroscience Center of Excellence by the Department of Defense, in collaboration with the SFVAMC and the Northern California Institute for Research and Education (NCIRE), has greatly expanded the breadth of research in PTSD. The focus of research involves a broad portfolio of studies, epidemiology, health service utilization, basic neuroscience, brain imaging, and sleep disorders. Treatment research remains the dominant focus of research. The program is developing novel drug and behavioral treatments aimed at improving care with the overall goal of achieving full clinical remission of PTSD.

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

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

Following are some highlights of the Employers program:

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

• Employers will provide a member credit on new and renewal policies of SFMS members. • Employers will provide members insured with Blue Cross on a group (2 – 250 employees) basis an additional discount on their workers’ compensation premium. • This program is available to members only through Seabury & Smith Insurance Program Management (Marsh).

Sponsored by:

Underwritten by:

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

Administered by:

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

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

Our Excellent Electrophysiology Service Just Got Better!

The Heart and Vascular Center at California Pacific Medical Center is proud to be one of only three West Coast hospitals to have a remote magnetic navigation system (also known as a Stereotaxis Lab), used during complex electrophysiology and coronary intervention procedures. This advanced system allows our physicians to remotely control precise computerized interventional procedures with greater efficacy than conventional mapping techniques. The procedures performed could vary from implanting a cardiac resynchronization device for the management of heart failure to performing a complex ablation for the treatment of various heart rhythm problems.

The Stereotaxis Lab has numerous advantages over the traditional conventional equipment n Reduced exposure to x-ray n More precise and accurate digital reconstruction (mapping) of the cardiac anatomy n Less likely to cause serious complications, such as heart perforation, due to the soft catheter tip used with the system

For more information or to refer your patient, please call: 888-637-2762

California Pacific’s Heart and Vascular Center offers quality, comprehensive, patient-centered cardiovascular care by a team of pioneering physicians integrating leading-edge technology.

Profile for San Francisco Marin Medical Society

June 2008  

San Francisco Medicine, June 2008. The Wisdom of the Body.

June 2008  

San Francisco Medicine, June 2008. The Wisdom of the Body.