March 2010

AN RANCISCO EDICINE S F M VOL.83 NO.2 March 2010

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Advice to My Patients

Unparalleled Service and •

Another large dividend - $20 million back to MIEC policyholders For 35 years, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services, we’ve partnered with our policyholders to keep premiums low.

Added value: At MIEC we have a long history of big dividend distributions. Because of excellent financial results and low overhead, MIEC has been able to return dividends to our California policyholders 17 of the last 20 years with an average savings on premiums of 25.5%.

For more information or to apply contact: n www.miec.com or call 800.227.4527 * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

MIEC 6250 Claremont Avenue, Oakland, California 94618 800-227-4527 • www.miec.com

SFmedSoc_ad_02.11.10

MIEC Owned by the policyholders we protect.

In This Issue

SAN FRANCISCO MEDICINE March 2010

Volume 83, Number 2 Advice to My Patients FEATURE ARTICLES

10 Advising Patients about Mammograms William H. Goodson III, MD 11 Advising Parents about Vaccines Shannon Udovic-Constant, MD 13 Advice to My Patients Online Toni Brayer, MD

15 Tricks of the Trade Collected Submissions from Linda Hawes Clever, MD, MACP; Nora V. Hirschler, MD; Christopher Cox, MD; Gordon Fung, MD, PhD; Amelia Kaymen, MD; Karen Oxford, MD; and Clete A. Kushida, MD, PhD 17 Advice to My Doctor Your Patients

18 Understanding Patients Amanda Denz

19 Philosophy, Wisdom, and Advice Stephen J. Walsh, MD

21 Gasping for Air Eisha Zaid OF INTEREST

23 SFMS 2010 Annual Dinner Photos 28 Book Review: Too Much Information?

Steve Heilig, MPH

29 Public Health Report: Ambiguity and Intolerance William S. Andereck, MD

www.sfms.org

MONTHLY COLUMNS

4 Membership Matters 5 Classified Ad 7 President’s Message Michael Rokeach, MD 9 Editorial Toni Brayer, MD 26 Hospital News

30 In Memoriam Nancy Thomson, MD

Editorial and Advertising Offices

1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833 Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon request.

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

March 2010 San Francisco Medicine 3

Membership Matters March 2010 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 83, Number 2 Guest Editor Toni Brayer, MD Managing Editor Amanda Denz

Upcoming EHR Seminar

Copy Editor Mary VanClay

What to Think about Before You Think about an EHR Implementation: A Workshop for Physicians and Practice Managers If you’re a physician or practice manager who is thinking about (or thinking about thinking about) EHRs, this one-day, hands-on workshop is for you.

Practices that take the time to plan before implementation have the highest chance for success and a return on investment.

Join Amy Berlin, MD, as she leads this lively, hands-on workshop for physicians and practice managers who are thinking about an EHR implementation.

March 31, 2010, 9:00 a.m.–4:00 p.m.

UCSF Mission Bay Conference Center, 165 Owens Street, Conference Room 1, San Francisco, CA Bring your laptops. This will be a hands-on workshop that guides you through several key resources. You’ll come away with a strong framework in place to continue planning a successful EHR implementation.

Cost is $25 for SFMS members; $100 for nonmembers. Space is limited; registration deadline is Wednesday, March 17. Contact the SFMS Membership Department to register: (415) 561-0850 extension 268.

Editorial Board Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes Clever

Ricki Pollycove

Gordon Fung

Stephen Walsh

Erica Goode SFMS Officers President Michael Rokeach President-Elect George A. Fouras Secretary Peter J. Curran Treasurer Keith E. Loring Immediate Past President Charles J. Wibbelsman 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 2010-Dec 2012

Roger Eng

Gary L. Chan

Thomas H. Lee

Donald C. Kitt

Richard A. Podolin

Cynthia A. Point

Rodman S. Rogers

Adam Rosenblatt Lily M. Tan

Term: Jan 2008-Dec 2010

Shannon Udovic-

Jennifer H. Do

Constant

Shieva C. Khayam-Bashi

Joseph Woo

William A. Miller Jeffrey Newman

Term: Jan 2009-Dec 2011

Thomas J. Peitz

Jeffrey Beane

Daniel M. Raybin

Andrew F. Calman

Michael H. Siu

Lawrence Cheung CMA Trustee Robert J. Margolin

Save the Date! CMA Legislative Leadership Day

CMA Legislative Day 2010 is scheduled for Tuesday, April 27, 2010, at the Sheraton Grand Hotel in Sacramento.

Please note the new date. More details and registration information will be coming before the event.

2010 SFMS Seminar Schedule

AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate

4 San Francisco Medicine March 2010

Friday, April 16, 2010 Benchmarking: How Does Your Practice Compare?

This hands-on workshop provides specialty-specific data to compare with your

own practice data on practice expenses, A/R, staffing FTEs, and wage costs to improve your bottom line net income. 9:00 a.m.–12:00 p.m. (8:40 a.m. registration/ continental breakfast) $149 for SFMS/ CMA members and their staff ($99 each for additional attendees from the same office); $199 each for nonmembers.

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

Medicare Posts List of PECOSEnrolled Physicians Online

Medicare physicians who have not updated their enrollment information in the past five years may need to fill out another application or face payment problems for ordered or referred services.

The new rules, which take effect April 5, authorize Medicare to reject claims if an ordering physician is not identified in Medicare’s PECOS enrollment system.

If you are not sure if you are already in the PECOS system, the Centers for Medicare and Medicaid Services has posted a list on its website of all physicians enrolled in PECOS. See www.cms.hhs. gov/MedicareProviderSupEnroll/06_ MedicareOrderingandReferring. asp#TopOfPage.

Be aware that this is an enormous document, containing more than 13,000 pages, and so it will take time to download. To see if you are on the list, go to the search tool and enter your type 1 (individual) NPI number, or last name, and hit “Enter.” If you do not appear on this list, you will need to revalidate your enrollment with Medicare. This list will be updated periodically so that applications currently being processed can be added to the list.

If you determine that you do need to submit a new enrollment form, you can do so online using the Web-based PECOS system at https://pecos.cms.hhs.gov/pecos/ login.do or by filling out the appropriate paper enrollment form(s) (CMS-855I www.sfms.org

and CMS-855R, if appropriate). Mail the forms, along with any required additional supplemental documentation, to Palmetto, which will enter your information into PECOS and process your enrollment application. If you enroll online, be sure to also mail to Palmetto the signed and dated Certification Statement within seven days.

With questions, contact Michele Kelly at (213) 226-0338 or mkelly@cmanet. org. The toll-free hotline for CMA help is (800) 786-4262.

Helpful Webinars

SFMS will be offering increasing opportunities to participate in webinars to help you address significant issues in your practice, including EHR implementation, Medicare reimbursement, and other topics. These will be announced in Action News and the Membership Blast.

Additionally, CMA offers a wide variety of webinars, both live and recorded, to help you address crucial health care issues and manage your practice. Registration is free for members and their staff. Space is limited, so register soon.

Visit the CMA Calendar online for more information. Most webinars are available for on-demand playback shortly following the live presentations; see the webinar archives at CMA’s members-only website.

For more information, contact Shannon Navarra-Lujan at (800) 786-4CMA or slujan@cmanet.org.

The Frontline Fight for Health Reform

CMA physician leaders have been making regular visits to Washington to meet face to face with congressional leaders and advocate for California doctors and patients. Regardless of the direction reform efforts may take, CMA remains committed to: repealing the Medicare payment formula (SGR),which is scheduled to cut physician payments by 40 percent in the next four years; eliminating or modifying a proposed advisory board mandated to cut Medicare spending if it exceeds its targets; updating the Medicare www.sfms.org

locality system (GPCI) to reflect changes in practice costs; increasing Medi-Cal reimbursement rates to Medicare rates to ensure the 2 million additional Medi-Cal enrollees can see a doctor; ensuring patients have the right to privately contract with Medicare physicians.

The Trial Lawyers Won’t Give Up, and Neither Will CMA

Last year the trial lawyers made two failed attempts to overturn the noneconomic damages cap in the Medical Injury Compensation Reform Act (MICRA). This 1975 law keeps California’s professional liability rates affordable. Once again, MICRA is under attack! And again, it’s a challenge to the constitutionality of its cap on noneconomic damages. The trail lawyers won’t give up, and neither will CMA.

Everybody Wants to Be a Doctor The California Department of Public Health (CDPH) is continuing efforts to enact regulations that would expand the scope of practice of psychologists and potentially all other health care practitioners working in licensed health care facilities. Thanks to CMA opposition, the California Office of Administrative Law (OAL) rejected these proposed regulations in October 2009.

But CDPH is trying again to pass regulations that could, among other things, allow nonphysician practitioners to admit patients, perform medical examinations, place patients in restraints, complete medical records, coordinate care, and order transfers. CMA has, again, voiced its strong opposition to the OAL and is fighting to keep patient care where it belongs—in the hands of those whose name ends with MD. A final decision from the OAL is expected on March 15, 2010.

Become a fan of the SFMS on Facebook!

(Once logged in, search for San Francisco Medical Society.)

Cancer survivors sought for Stanford study of online workshop Researchers at the Stanford University School of Medicine and The Cancer Research Center of Hawaii are recruiting participants for a study of an online, highly interactive workshop aimed at improving the lives of cancer survivors.

“Cancer: Thriving and Surviving” is a six-week, Internet-based workshop intended to help cancer survivors deal with their unique problems and concerns.

Each workshop will bring together about twenty-five people and will be facilitated by two trained moderators—at least one of whom is a cancer survivor. The study will assess the workshop’s effectiveness.

While there is no set meeting time, participants will be asked to log on at their convenience two or three times for a total of about two hours each week over the six-week period. Participants’ privacy will be strictly protected.

Stanford is recruiting adults who have been diagnosed with cancer during the past five years and who have completed cancer treatment (with the exception of hormonal treatments). Potential participants must live in the United States and have access to a computer with an Internet connection and an e-mail account.

Kate Lorig, PhD, is the principal investigator for the Stanford arm of the study, and Erin Bantum, PhD, is the principal investigator for the University of Hawaii arm.

To register for the study, visit http:// cancersurvivors.stanford.edu, or e-mail cancersurvivors@stanford.edu.

Visit Us Online!

Classified Ad

Read the SFMS blog http://sfmedicalsociety.wordpress.com/

ON-CAMPUS medical space at St. Mary’s (650) 282-4620 or tleonard@baysiderp.com.

Follow the SFMS on Twitter http://twitter.com/SFMedSociety

March 2010 San Francisco Medicine 5

Dr. Charles Lee, MD reconstructive plastic surgeon

The san Fr ancisco Wound care and reconsTrucTive surgery cenTer aT s T. M a r y ’ s More than 152 years ago, eight Sisters of Mercy sailed to San Francisco with a few medical supplies and a plan: To cure suffering.

Today, our plastic and reconstructive surgeons still use the same tools our founders used: The most advanced tools available in modern medicine. Their hands.

pressure ulcers • venous stasis & diabetic ulcers • radiation wounds • abdominal hernia & ostomy wounds • varicose veins • lymphedema • osteomyelitis • neuropathic pain and ulcers • post surgical wounds •

The MosT sophisTicaTed surgery.

For more inFormaTion or To schedule an appoinTmenT, call 415-750-5535.

President’s Message Michael Rokeach, MD

Giving Advice “Doctor, what do you think I should do?”

T

he physician-patient relationship and the communication between patient and doctor can have profound effects on a person’s life. One of the more satisfying aspects of practicing medicine has been learning how to better communicate with my patients, and even with other physicians.

In this issue of San Francisco Medicine, we have contributions from wonderfully talented communicators who have honed their skills on advising patients. We also learn what certain specialists want other physicians to know and understand so they will be more effective in treating their own patients.

I was particularly fascinated by the “Advice to My Doctor” column. It is highly important for medical professionals (all types, not just doctors) to know what our patients want from us. One recurring theme was that patients want their doctors to have adequate time to spend with them. In the emergency department, where I work, we make every effort to sit down in the patient’s room while taking their history. Studies have shown that when the ER doctor does that, not only do patients like it but their perception of time spent with the doctor increases.

The use of the Internet and electronic health records is rapidly changing the way we interact with patients. Dr. Toni Brayer, a former SFMS president, writes a fascinating column on how to help patients get the most out of electronically available public information. She notes that some physicians are slow to come around to the fact that a huge percentage of patients go to the Web for information and advice. Not only do patients seek medical advice on line, they also research their hospitals and physicians.

How to advise patients in the face of medical controversy is one of the themes of this edition. Dr. Shannon Udovic-Constant, a pediatrician and mother, describes efforts to educate parents about the importance of childhood immunizations. We are now seeing cases of measles in our community due to a decline in immunization rates. Dr. Bill Goodson, a breast surgeon and another SFMS past-president, tackles the mammogram controversy. He concludes his discussion by describing the physician’s role in helping patients come to a reasonable decision based www.sfms.org

on objective information and on the patient’s own values.

Steve Heilig talks about the concept of participatory research, in which scientists use their own bodies for their research. That reminded me of one of my medical school professors, who tested his theory on mechanism of idiopathic thrombocytopenia by injecting himself with the serum of one of his patients. Lo and behold, his platelet count dropped and he even suffered a neurologic injury. I wonder what kind of advice he gave his patients!

My favorite section of this issue is what we refer to as tricks of the trade. This is a compilation of advice from noted specialists in various fields to their non specialty colleagues, such as primary care and emergency physicians. We include the Cliff’s Notes version of what other physicians should know about ophthalmology, dermatology, joint replacement surgery, occupational medicine, and sleep medicine. You see, doctors don’t only advise patients; they also advise other doctors. That is one of the more enjoyable aspects of this profession. Many difficult cases have been solved in the doctors’ lunchroom.

And finally, Dr. Stephen Walsh, yet another former SFMS president, harvested an abundance of ideas from his years of practicing clinical psychiatry. He points out that philosophy and wisdom are closely aligned to the art and science of medicine and how we advise patients. Knowing the patient is key to individualizing the medical advice we give. My favorite quote in the article really pulled the concept together: Dr. William Osler once said, “It is less important what disease the patient has than what patient has the disease.” Now I understand the key concept he is teaching—the right advice for the right patient.

My advice to you is to read and enjoy this terrific issue of San Francisco Medicine. You won’t be disappointed, I promise.

March 2010 San Francisco Medicine 7

Strength.

Mark R. Laret, CEO of UCSF Medical Center, Steve McDermott, CEO of Hill Physicians Medical Group, Dr. Sam Hawgood, President of UCSF Medical Group and Interim Dean of UCSF School of Medicine, and Dr. Thomas F. Long, Chief Medical Officer of Hill Physicians Medical Group announce a new affiliation between UCSF and Hill Physicians.

The doctors of UCSF are joining Hill Physicians Medical Group effective January 1, 2010. One of the nation’s best medical centers and one of the nation’s largest physician association are coming together to improve the future of health care in San Francisco.

Independence and strength are not mutually exclusive. Hill Physicians’ providers enjoy autonomy and flexibility while receiving exceptional technological, case management, preventive care and claims processing support. That’s why so many of the best join Hill Physicians.

Your health. It’s our mission.

If you’re a physician in San Francisco, South San Francisco or Daly City and want to know more about joining Hill Physicians, contact: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com or visit www.HillPhysicians.com/Providers.

Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.

Editorial Toni Brayer, MD

Words Make a Difference

T

his issue of San Francisco Medicine focuses on how doctors communicate with patients and how we give medical advice that will help them heal. The advice may be different depending upon the doctor, the patient, and the medical condition, but the connection between a physician and her patient is most sacred. Advice can come in a number of forms. A doctor can counsel a patient about a course of action. Advice can be a warning, such as, “If you don’t stop eating ice cream every night, your diabetes will end up killing you.” Or advice can give information.

When we teach patients about a condition or give information about the effects of a treatment, our advice can change their lives.

I have been amazed to learn that what I say to patients, even in an off-hand manner when I don’t think of it as “medical advice,” makes an impact that is lasting. After twenty-four years of internal medicine practice, I am still learning that my words make a difference.

I recently saw a patient that I had not seen in a few years. One of the joys of comprehensive internal medicine (aka primary care) is the chance to follow patients throughout changes in their lives.

This thirty-year-old patient opened the conversation by saying, “Oh, what you told me the last time I saw you made all the difference, and I am so glad I listened to you.” I had no idea what she was referring to and I had to ask, “What did I say?”

“Don’t you remember when I was so down and you said, ‘Look, Heather, you are too young to be in a job you hate.’ That really hit me, and I made the change and I appreciate that advice so much. It really made a difference,” she replied.

Wow, a snippet of an off-the-cuff conversation from years earlier made a difference in a person’s life. I certainly didn’t think of it as significant medical advice, but the effect was as powerful as anything I would plan as a treatment.

Another patient credited me with her recovery from alcoholism. I have no recollection of making any profound recommendations or treatments. We all know that any recovery from an addiction is up to the patient, and the physician can only advise, encourage, and facilitate. Something I do not remember and probably could not duplicate again seemed to have worked.

I wish I knew what it was.

Most of what we do in medicine is mundane. Patients might www.sfms.org

see the glamor and think that our lives are like what they see on the TV shows House or Scrubs. In real life, Dr. House would be sanctioned by the medical staff as a disruptive physician and never be allowed to play Sherlock Holmes in the hospital halls. But what is mundane and ordinary to us may actually be life-changing to a patient. A doctor’s words of advice can certainly have the “butterfly effect.” This is a metaphor for the concept that there is a sensitive dependence where a small difference can create a large variation in the long term. A butterfly’s wings might create a tiny change in the atmosphere that may ultimately change the path of a tornado or create an atmospheric change that would alter events completely. That tiny difference has ramifications that lead to large-scale events. When we successfully convince a patient to give up smoking, we may be adding years to that person’s life. The effect ripples through the entire family and even the community.

That patient may avoid a sudden heart attack. He may walk his daughter down the aisle and coach his grandchild’s soccer team.

One child on the soccer team may be inspired to stay in school and even go to college. And on and on.

I know from personal experience that how a physician speaks and the words that are chosen can make a profound difference in medical decisions and outcomes. I recently underwent a total knee replacement that I knew I needed but was afraid to undergo. The out-of-work time would be significant and I wanted to make sure the risk was worth the benefit. I obsessed about the decision for months. I watched the procedure online (a mistake) and I read about all the complications and newest techniques. I was armed with information but still could not commit until I finally knew what I needed to hear from the orthopedic surgeon. One day I grabbed him by the shoulders, looked him straight in the eye, and said, “Tell me that this will be a life-altering decision.”

“This will be a life-altering decision,” he replied.

That was all I needed to hear. Decision made, confidence restored, mental attitude ready. He won’t remember that day, but I will.

Toni Brayer, MD, has practiced internal medicine in San Francisco for over 20 years. A past-president of the SFMS, she currently serves on the editorial board for San Francisco Medicine. She is also an avid blogger. Visit her blog at www.EverythingHealth.net.

March 2010 San Francisco Medicine 9

Advice to My Patients

Advising Patients about Mammograms How to Advise When There is Conflicting Information

William H. Goodson III, MD

E

very patient has an inalienable right to choose her treatment.

What a woman should do is not my decision, even if I wish it were—even if she tells me to decide. I always need to understand the wishes of the patient and respect her goals and how she wants to feel about her choices after the treatment has been completed.

It is the question of how the patient will feel about her decision when all is said and done that requires the most effort and usually receives the least attention.

Before I meet any patient, she has already made many life decisions. She has decided whether to wear a seat belt, whether to smoke, whether to drink alcohol and if so in what amount, whether to exercise regularly, whether to eat organic food, how much candy to eat, what style of clothes to wear, how much to study in school—and the list goes on. These decisions are unavoidable as we mature and become independent adults who are responsible for our own lives. We make each decision one way or another, and even pretending that we are not going to decide is, in effect, a decision. In the process of deciding these issues, a woman defines how risk-averse she will be in her life, how much effort she is willing to put into her health, and how she balances present convenience with future gains—or losses.

My role as a physician is to help a woman understand how the different options available to her might fit with her previous personal choices concerning risk, money, her health, and more. In this role I eventually become a counselor, but first I am a listener. I need to listen to what a woman tells me and try to understand

her perspective on what is happening.

Every patient has two stories. First, there is the story of her disease. This may be a long story if she has had previous surgery or complications. Or it might be a very short story if she is a previously healthy woman coming in to decide whether to have a screening mammogram.

The second story is the history of her medical life. This begins with previous illnesses or surgery, but it is much more important for what it tells us about her way of making decisions about her own health. Does she smoke? Does she drink more than three or four glasses of alcohol a week? Does she exercise? Is she overweight?

People are confronted with a wide variety of information sources, some reliable and others not, and the constant message is that they should be informed and make informed decisions. However, it takes years of study and clinical experience to understand the nuances of disease and the subtleties of treatment, and it is difficult to make life-and-death decisions without some experience. Consider that a physician has spent years studying the basic anatomy of diseases, the biochemistry and physiology, the clinical story and typical laboratory tests, and the various ways to treat or screen patients—those used in the past, those used now, and those in the pipeline of the future.

So, objectively, it is difficult to believe that a patient can make a truly informed decision—although it is not impossible.

I have considered how I would make personal decisions about certain aspects of therapy and know that for myself, even with years of experience, there are choic-

10 San Francisco Medicine March 2010

es that would present no clearly superior option and decisions that would still be uncertain. Yes, there are relatively obvious decisions: Get childhood immunizations.

Remove an inflamed appendix. Get a flu shot. Remove a cancer. I know that if I had node-positive breast cancer, I would take chemotherapy. But there are decisions that are less clear.

The role of physician as guide is to help patients think about how they want to feel about their decision in a few months. What is the way they want to look back on it? Do they want to be extremely careful? Do they want to meet what seems to be the basic need, but not do more than they really need to? Do they want to feel that they have done everything that they can do? The latter, of course, is a slippery slope, since taken to the extreme it can lead to excessive testing or treatment.

A recent example of how to advise patients comes from the many women who have asked whether they should continue to have routine screening mammograms.

My answer is always a question: “How much are you worth?” After all, cost is a central issue—if not the central issue—in the debate.

The controversy about mammograms began in November 2009 when authors of an article in Journal of the American Medical Association opined, though somewhat indirectly, that doctors order too many mammograms. This opinion was based not on new research but on reinterpretation of data that had been around for years. The authors cited the higher cost of saving a life with mammography for a woman between ages forty and fifty, and that women who Continued on page 12 . . . www.sfms.org

Advice to My Patients

Advising Parents about Vaccines Providing Information and Letting Them Decide

Shannon Udovic-Constant, MD

I

am examining a two-month-old baby and the parent says, “So I’ve been reading this book about vaccines by Jenny McCarthy, and I am not sure I want to give all the vaccines.” I would like to say, “Do you think it is a good idea to get medical advice from an actress?” Instead I take a deep breath and jump into a difficult conversation about vaccines.

Vaccines. In this area, medicine is a victim of our own success. Just a few generations ago, everyone knew someone who had developed polio or was affected by a pool closure because of a polio exposure.

Now very few patients read about or are touched by the illnesses vaccines prevent.

Unfortunately, physicians are still aware of people who needlessly suffer from a vaccine-preventable illness. Just last year, a baby died of Hib meningitis because the family didn’t vaccinate their baby. Every year in the Bay Area, a baby gets pertussis and spends weeks in an ICU fighting to breathe. We cannot become complacent about vaccines.

Despite the fact that scientific data solidly supports vaccines as safe and effective, concern over harmful side effects, often taken out of context in the media and on unmonitored and biased websites, cause substantial and often unrealistic fears.

Families used to come in asking about mercury (thimersol) in the vaccines. Now that the mercury has been removed from routine vaccines, families have turned to asking about aluminum, an adjuvant in the vaccines. Daily I am asked about autism in relation to vaccines, despite multiple Institute of Medicine reviews that show that vaccines are not causing autism.

I believe strongly in vaccines. Immunizations are one of the most important www.sfms.org

public health tools, along with safe water, to keep individuals healthy. Despite how I feel about vaccines, however, a growing number of parents are choosing to delay or decline needed vaccinations.

Back in the exam room, after taking my deep breath, I approach the family who is debating giving their child vaccines by providing education in an open and compassionate way: Ask what the parents’ concern is. I used to have a vaccine monologue that I would launch into, but, realizing I was spending unnecessary time on topics that the family wasn’t concerned about, I now first attempt to understand the parent’s reason for refusing one or more vaccines.

By taking these few minutes, I can tailor the conversation to what the family is concerned about. The conversation will be different with the family whose nephew has autism versus a different family’s concern about the number of vaccines given on the day of shots.

Educate. I make sure the family understands what illnesses the vaccines are to prevent. I explain what meningitis and whooping cough are. We discuss how ill a child with measles is. Then I explain that measles can cause death and that Hib meningitis can cause death or permanent hearing loss. We discuss the morbidity that whooping cough causes in an infant.

The benefits of vaccines must be clearly outlined.

Be honest about the potential risk of giving vaccines. Describe the common side effects and mention the possibility of a serious adverse event.

Answer questions. I then pause and ask if there are any specific questions about the information that has been provided.

Maintain a supportive relationship. I work to be nonjudgmental and also not condescending, otherwise I will alienate the family.

Tell them my personal experience as a pediatrician and the mom of two young kids. I tell all of my families that all the pediatricians that I know, myself included, vaccinate our own children and do it according to the recommended schedule. I want families to hear that I, having access to all of the science that is available, see the value and benefit of choosing to vaccinate my children.

Accept compromise. It is better to have a family accept some vaccines than no vaccines at all. If , after my discussion with them, a family still has concerns about the number of vaccines given at one time then I help them prioritize which vaccines should be given first.

Know when to stop trying to convince.

I used to keep at it, thinking that if only I said it in the right way, I could convince a family to see it my way. I now stop when the information has been provided, and I let the family decide. Ultimately, it is their decision.

Have the parent sign a refusal-to-vaccinate form. If a family has decided to not vaccinate or to only partially vaccinate, I then have them sign a refusal-to-vaccinate form (www.cispimmunize.org/pro/pdf/ RefusaltoVaccinate.pdf). I feel that it is important for the family to understand the seriousness of this decision and clearly see in writing the potential risk that is being taken by not receiving all vaccines.

Revisit the discussion at all subsequent visits. At all visits, I discuss the vaccinations that are due or that the child is behind on Continued on the following page . . .

March 2010 San Francisco Medicine 11

Advising Parents about Vaccines Continued from the previous page . . . and ask if the family would like to receive any vaccines at this time.

So often in medicine, we work with our patients and their families to help them to achieve maximal health and wellness. The issue of access to medical information on the Internet has been beneficial for improving health in many ways. Unfortunately, when it comes to vaccinations I think the issue of too much information has made it challenging for families. It feels as though families have a decision to make regarding vaccinations.

Should they give them? If they do, should they give them all at once? I hope that we get back to trusting in the safety and necessity of vaccines.

In the meantime, I will keep having these discussions and hope that I will be viewed as a more reliable and trusted source than an actress.

Shannon Udovic-Constant, MD, is a pediatrician in San Francisco. She is also a member of the SFMS Board of Directors and the SFMS Political Action Committee.

Advising Patients about Mammograms Continued from page 10 . . . have abnormal mammograms—that are found on review or after biopsy to be benign—experience a lot of avoidable stress.

They suggested this is a reason not to do mammograms. But, interestingly, they overlooked the complete lack of comparative data on the stress experienced by women who have skipped mammograms for several years and then have found that they have an advanced cancer.

They also observed that cancers recognized in the interval between screening mammograms are—on average—more dangerous than the cancers found by mammograms. This is true, but they left the impression that since the cancers found by mammograms are—on average—less dangerous, they are less important. A more careful statement would have been that mammograms find a mixture of more and less aggressive cancers. Some of the cancers identified by mammography may well be ones that could be left alone and not treated, but in 2010 we do not have the ability to discern

Peter J. Panagotacos, MD Board Certified Dermatologist Specializing in

Hair Restoration

for men and women for over 35 years at

2001 Union Street San Francisco, CA 94123 (415) 922-3344 Award-winning educational website

www.HairDoc.com Author of the guide to hair loss causes and medical and surgical treatment options.

Hair Loss Answers 2nd edition

• • • • •

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

12 San Francisco Medicine March 2010

which cancers are not dangerous before biopsy and, in most cases, removal.

They conclude, “Screening for breast and prostate cancer has increased the number of cancers detected, generating expense and morbidity from detection and treatment of cancers that pose minimal risk.” The casual reader—and certainly many reporters who covered this for the press—took this to mean that most cancers found by mammograms were clinically irrelevant. Making this statement, without a closely connected acknowledgment that the majority of cancers found by mammography are relevant to a woman’s future health, left many women in a state of unnecessary and avoidable anxiety, the very state the authors claimed they were trying to avoid.

Yelling, “Fire!” in a theater comes to mind.

In contrast, a month later Partridge and Winer in the New England Journal of Medicine reviewed the same old data but encouraged consideration without unnecessary anxiety. “But despite overdetection [of cancers that ‘might never have caused any difficulty’] and underdetection, mammography remains our best breast-cancer screening tool for the general population.”

When discussing mammography, or any controversy, with a woman, the best choice seems to be to acknowledge that she has heard or read some of the coverage in the media and then to help her understand the biases, prejudices, and selective presentation of information that might lie behind these sensational opinions. Some women will decide to have mammograms, and some will not.

Thus, our role as physicians is twofold: to provide information in an objective and unsensationalized form, and to discern the patient’s preferences and help her see how she can make decisions that are consistent with her own values.

William H. Goodson III, MD, is a Senior Clinical Research Scientist at the California Pacific Medical Center Research Institute.

He is also in active practice as a breast surgeon at CPMC, and is a Past-President of the SFMS. www.sfms.org

Advice to My Patients

Advice to My Patients Online How to Advise Patients on Using the Internet for Medical Research

Toni Brayer, MD

I

f you don’t think your patients are using the Internet to research health issues—and even to research you— you are probably mistaken and maybe a little behind the times.

The number of patients who use the Internet to research health issues has increased from 90 million in 2004 to 190 million today (according to Manhattan Research). Seventy-nine percent of adults have access to the Internet and, according to the Pew Research Center and the California HealthCare Foundation, 61 percent of adults look online for health information.

What were the most common reasons those patients went to the Internet?

Sixty-six percent looked for information on a specific disease or medical problem and 55 percent looked up a medical treatment. Fifty-two percent researched exercise or fitness, with 47 percent researching doctors and 38 percent researching hospitals. Searches for prescription drugs, alternative treatments, and mental health issues have also been growing each year.

Most patients start their search with Google. No one is in charge of the Internet, so Google searches can go anywhere and everywhere. When I googled “hot flashes,” the page came up with eleven sponsored links to commercial supplement sites posing as medical authorities. Advancing the search produced more ads. Mixed in the search results were reputable sites such as mayoclinic.org, but the user had to sift through hundreds of sites that were selling something or just offering unqualified opinions.

The beauty of the Internet is that people can access information for free, with a click of the mouse. This has made www.sfms.org

the Encyclopedia Britannica seem as oldfashioned as the Model T. Libraries, with their stacks of reference books, look like they should be museums. But the fact that patients can have access to scientific articles as well as forums where they discuss their problems with strangers who suffer from the same disease is both a blessing and a curse.

Just as we educate patients about health risks and medications, we also need to guide our “e-patients” so they can get the most out of Internet searches.

I advise my patients how to be savvy users of the Internet. For each site, I tell them to ask this question: What is the purpose of the site?

That is, is it to inform? Sell a product?

Raise money? Will this site protect your privacy?

The otherwise reputable cardiothoracic-surgeon-turned-media-doc Dr. Mehmet Oz was busted for his “RealAge” website, which sold millions of users’ personal information to pharmaceutical companies for targeted advertising. Dr. Oz’s continued promotion of this service has exposed tens of millions of health consumers to this deceptive marketing front for Big Pharma.

Online patient communities and patient forums can be found all across the Web, and they focus on a number of diseases and treatments. This collective knowledge and the act of patients helping patients can serve a great benefit. People support each other by talking about their shared experiences and lending emotional support for both chronic conditions and surgical recovery. A patient can find forums for insomnia, cancer, epilepsy, total joint replacement, arthritis, autism,

and just about any condition. But some of the disease forums can lead to anxiety and confusion. The information passed around can be incorrect and filled with self-diagnosis and conflicting information. Encouraging patients to bring questions to the physician can help them sort through the facts versus the opinions that they find online.

Some patients can go overboard with their health concerns and spend so much time researching that they develop “cyberchrondria.” When I see this happening, I tell patients they have enough information and searching for more will be counterproductive. “Stop researching on the Internet; you have enough information” can be valued advice for the anxious patient who continues to search for more and more answers.

One study showed that 31 percent of physicians believe that the Internet complicates their relationship with patients and undermines their credibility.

One prestigious doctor in a professional presentation on polyarthritis (found online at CRM Healthcare) actually said, “Keeping [patients] off the Internet is an important thing to do.” This shows a profound lack of understanding of the new informed patient and implies that patients are incapable of reading and processing information.

There is no doubt that health information on the Internet is changing the relationship between doctors and patients. I love to treat informed patients, and it does not increase my workload, but it does take new communication skills to manage the time. If they bring in an article they found online, I will accept it Continued on the following page . . .

March 2010 San Francisco Medicine 13

Continued from the previous page . . . and read it and discuss it. If I disagree or if it is without substantiation, we talk about it. Sometimes I learn something new, but usually it is just a starting point for education and understanding what the patient already knows about the problem.

When I don’t have time to educate a patient, I often refer them to a website to get information. Their ability to read about a condition and learn self-help tricks or diet or exercises for musculoskeletal problems saves me time. Guiding patients to reputable, credible websites can save time in the long run and help patients manage their own conditions.

The e-patient is here to stay. Helping him or her use the Internet wisely for health conditions is the responsibility of health professionals.

Top websites I recommend for patients • www.mayoclinic.org • www.healthfinder.gov • www.nih.gov • www.mdanderson.org • www.familydoctor.org • www.high-bloodpressure.com (but warn patients to avoid the ads) • www.medlineplus.gov • www.kidshealth.org • www.mylifestages.org (for women) • www.merckhomeedition.com

My favorite health blogs

• www.EverythingHealth.net (my own passion) • www.healthnewsreview.org/blog (calls it like it is) • www.Runningahospital.blogspot.com (a transparent CEO) • www.55wordsfromanmd.blogspot.com (a new and fascinating site) • www.kevinmd.com/blog (the master of aggregating blogs) • www.wachtersworld.com (local patient safety and quality maven) • www.getbetterhealth.com (blog aggregator and interesting reading) • www.other-things-amanzi.blogspot.com (writings from a South African surgeon)

14 San Francisco Medicine March 2010

San Francisco Heart Health An innovative cardiovascular practice providing the means to achieve and maintain optimal heart health with less dependence on drugs or invasive surgery.

Peter Curran, MD Director

Benefits: • • • • •

Direct access to your cardiologist Unhurried appointments Individual electronic health profile House calls Validated parking

909 Hyde Street, Suite 317 San Francisco, CA 94109 (415) 885-4971 nobhillheart@att.net sanfranciscohearthealth.com

Helping in Haiti One Good Option Haiti is often referred to as the poorest nation in the Western Hemisphere, so the earthquake there has been doubly devastating. For those wishing to help with a contribution of any size, one great option in the health arena is Partners in Health, founded by Paul Farmer, MD, a leading figure in international health work. PIH has been active in Haiti for many ears and is an efficient, respected group. They have made it easy to donate at http://www.pih.org/home.html.

Visit Our Blog! http://sfmedicalsociety.wordpress.com/

www.sfms.org

Advice to My Patients

Tricks of the Trade Advice Points from Various Specialists

Collected Submissions

T

his month the editors of San Francisco Medicine asked physicians of various specialists the following question: What top points from your specialty would you like all physicians to know to improve the quality of patient care? Below are the collected answers.

Occupational Health

Linda Hawes Clever, MD, MACP Everyone works, whether or not they get paid. This makes occupational health an important part of a physician’s armamentarium. My favorite tips include the following: A person’s history may be a distant root of their problems. Learn about exposures during military service, previous jobs, and at home (including pesticides and computers).

All businesses are required to have Material Safety Data Sheets for every chemical. To investigate a potentially troublesome workplace substance, ask your patient to obtain appropriate MSDSs. Call the emergency phone number at the top of the first page to get immediate answers.

Office setups (including your office) can turn workers into pretzels. Headaches, neckaches, and repetitive strain injuries from shoulder to fingertips all can be ameliorated by getting an occupational therapy analysis of a workplace so that computers, chairs, and desks can be rearranged.

Don’t assume that musculoskeletal complaints all stem from work. Check out a patient’s hobbies, too. Sculptors, furniture refinishers, social networkers, and computer game-players can all have musculoskeletal damage. Hobbies can also cause respiratory problems (wood dust from carving), neuropathies (solvents from painting), and www.sfms.org

lead poisoning (stained glass).

Lives, work, and health interact. Great physicians know their patients’ workrelated pressures—and even pleasures.

Linda Hawes Clever, MD, MACP, is a clinical professor at UCSF, a senior physician in occupational health at CPMC, and Associate Dean of Alumni Affairs for Stanford University Medical School. She is also founder of RENEW a not-for-profit aimed at helping dedicated people maintain and regain enthusiasm and resolve the dueling demands of work and life.

Blood Banking Nora V. Hirschler, MD I wish every other doctor knew that even with the best treatments and all of the advances in medicine, lifesaving blood transfusions still come from volunteers who give selflessly and anonymously so that others may live. And there is no substitute for it.

Unfortunately, only a very small population donates blood (less than 4 percent in the Bay Area) and, as a result, our region faces frequent and severe blood shortages.

Every day, our blood center must import blood from outside our region simply to meet the needs of the forty hospitals we serve. If I walk downstairs right now to our shipping and receiving department, I’ll see boxes of blood coming in from North Dakota, Texas, and New Mexico, to name a few of the states that send us blood. But we cannot always rely on those imports—it is imperative that more people right here in our community donate blood.

I also hope that every doctor knows that our blood supply is extremely safe.

In fact, with the advent of nucleic acid amplification (NAT) testing, the rate of HIV infection via blood transfusion and of

hepatitis C is currently one in two million.

The rate of hepatitis B infection is one in two hundred thousand, although since hepatitis B vaccination is universally used, the actual number of cases seen is insignificant. Patients should feel confident that receiving blood is safe and doctors should encourage patients’ friends and family members to donate blood and platelets frequently.

Nora V. Hirschler, MD, is the president and CEO of Blood Centers of the Pacific (formerly Irwin Memorial Blood Bank), a nonprofit organization that provides blood to forty hospitals throughout Northern California. She is also a clinical professor of laboratory medicine at UCSF.

Orthopedics Christopher Cox, MD There is no such thing as “minimally invasive joint replacement surgery.” Incisions have been made smaller and pain management improved, but in the end, I am cutting your bone. That is about as “invasive” as you can get. Ultimately, the long-term results depend on putting the implants in correctly regardless of the incision or approach. Short-term results are much more dependent on the age, comorbidities, and home situation. Anything else is just marketing.

Hip pain classically is groin or thigh pain. Pain in the buttock is usually referred from the back.

Just because your knee hurts doesn’t mean you need an MRI. Patients read the paper and the Web and often feel that unless they have an MRI, they just have not been evaluated. A history and physical still go a long way. Obvious acute severe injuries may necessitate an immediate MRI. More Continued on the following page . . .

March 2010 San Francisco Medicine 15

Continued from the previous page . . . modest pain that exceeds two weeks’ duration and cannot be explained by exam may as well. Most minor pains go away with symptomatic treatment in two to six weeks.

Christopher Cox, MD, attended medical school and residency at UCSF. He completed his fellowship training in joint replacement surgery in 1992. He has been in practice at CPMC for seventeen years and is the current medical director of the Joint Replacement Center at CPMC.

Cardiology Gordon Fung, MD, PhD The most important things that physicians and patients should know about cardiology to improve their health are: Fruits/vegetables and forty minutes of walking per day will definitely help keep your cardiologists away! Not entirely, but remember that coronary heart disease is considered a preventable disease. Adopting the heart-healthy lifestyle does more than benefit your general health—it prevents heart disease and strokes.

The earliest complaint of heart failure is fatigue or shortness of breath on exertion or walking. Sure, age and overweight and deconditioning can do that too, but they should be considered diagnoses of exclusion. If you have adopted a daily exercise program and find it becoming more difficult, don’t blame your age or your weight before you get it checked out.

High blood pressure has not gone away—it remains a silent killer in all populations. The vast majority of hypertensive patients require more than one drug to control the disease and bring their blood pressure to target. If your patient is not on goal with one medication and lifestyle changes, keep trying—don’t give up.

Exercise activities can be fun and invigorating. Try dancing, yoga, tai chi, bike riding, or swimming. Just forty minutes a day can keep the doctor away.

Gordon L. Fung, MD, PhD, is Director of Cardiac Services At UCSF Mount Zion and of the Asian Heart & Vascular Center. Fung also holds a Doctorate of Philosophy in Chinese Philosophy from CIIS. He is also a clinical professor of medicine and cardiology at UCSF and past-president of the SFMS.

Dermatology Amelia Kaymen, MD To start with, it would great if every doctor had a good understanding of skin cancer risk profiles. Skin type and eye color, previous sun exposure, and family history are extremely important in determining the probability that the patient’s changing lesion is serious.

Exams are critical. Please get the patient undressed! Look for the ugly-duckling spot, the one that sticks out from the background as being distinctly different.

Next, it takes comfort with three classes of topical steroids to practice dermatology. Become familiar with a mild potency one for the face and the genitalia, a middlelevel potency one to use if you need to treat a wide area, and a super-potent one for two weeks at a time in small areas. Make sure they are available generically, too—that makes things much easier.

Lastly, dry skin is the single biggest cause of itch. Have patients use less soap, avoid fragrance, take short showers, and lubricate. Recommend that they use lotion every morning and lotion or ointment at night.

Amelia Kaymen, MD, is a dermatologist at CPMC and UCSF who sees complex medical dermatology cases in children and adults and does some basic cosmetic work as well.

Ophthalmology Karen Oxford, MD Although most of us had limited exposure to ophthalmology in medical school, we often encounter patients with ocular complaints in our practices. For my nonophthalmic colleagues, here are some tips for staying out of trouble when it comes to seeing patients with eye problems: LASIK patients with subsequent ocular trauma, however mild, need to be referred.

LASIK flaps become loose, torn off, or easily infiltrated after injury.

Never prescribe steroid eye medication. Even in an eye that appears to be normal, herpes simplex can be reactivated with steroid drops. If there’s a fungus among us, steroids will only potentiate the infection. Steroids can also cause glaucoma and cataracts.

Polycarbonate protective eyewear is a

16 San Francisco Medicine March 2010

wonderful thing.

Anesthetic eyedrops can cause the cornea to melt. Don’t prescribe them for yourself or your patients. Most patients with topical anesthetic abuse are health professionals.

Not all red eyes are infectious. Iritis and a host of culprits could be at work. Worsening vision or pain should prompt a referral.

A burst of floaters, flashing lights, or a veil in the vision should trigger thoughts of retinal detachment. A zigzag light pattern in both eyes that resolves in about twenty minutes usually means ophthalmic migraine.

Karen Oxford, MD, is director of the Cornea and External Disease division of Pacific Eye Associates in San Francisco.

Sleep Medicine Clete A. Kushida, MD, PhD There are close to 90 different sleep disorders, and the majority are easily diagnosed and treated by a sleep specialist.

Patients should be referred to a sleep specialist if they have chronic difficulty falling or staying asleep; are unrefreshed in the morning or unable to remain alert throughout the day; have heavy snoring, breathing pauses, restlessness, or unusual behaviors during sleep; and/or have problems with attention, memory, or mood that appear to be related to daytime fatigue or sleepiness.

Effective sleep tips for patients who are unable to sleep when they wish to include: Stay as consistent as possible to a set awakening time and bedtime; expose yourself to about thirty minutes of bright light (either by going outside or staying in an area that receives a lot of sunlight) within five minutes of morning awakening; establish a pattern of relaxing behaviors before bedtime (such as meditation, yoga, a warm bath); avoid alcohol, caffeine, nicotine, exercise, heavy meals, and heavy fluid intake before bedtime; avoid watching television or reading in bed, unless they make your drowsy; avoid staying in bed longer than twenty minutes if you can’t sleep or can’t fall back asleep after waking in the middle of the night.

Clete A. Kushida, MD, PhD, is director of the Stanford Sleep Medicine Center and president of the American Academy of Sleep Medicine. www.sfms.org

Advice to My Patients

Advice to My Doctor What You Could Do to Improve Care

Your Patients

I

n this month’s issue on advice, the editors of San Francisco Medicine wanted to turn the tables and find out what main points of advice patients had for doctors. Below are the responses that came in. Although the points of advice varied, the recurring themes centered on improved communication. Read on to hear exactly what these patients want.

“I am a person, not an organ or a body part. I live with me every day. You get to see me for fifteen to twenty minutes once or twice a year. Listen to me, let me finish before you make a decision or ask the next question. Look at me when you speak to me, and give me the advice or information in context and in language I can understand.”—Raquel, 64, emergency management specialist

“Use e-mail. I’m not timid or afraid of asking my doc questions, but being busy and preoccupied, I don’t want to have to make an appointment or sit on the phone to get what I believe are a few easy questions answered. If my doc had e-mail, things would be more efficient for both of us.”—Mikhael, 29, editor “Don’t just treat the symptoms. Give me more information on prevention. And don’t make me feel that I’m being rushed through my appointment when I’ve waited an hour to see you.”—Dawn, 51, marketing executive “I am a patient with a chronic condition, so I’d like to see more communication between my internist, my neurologist, and, in a perfect world, my naturopath. I also like electronic medical www.sfms.org

records and getting the results of tests by e-mail.”—Betsy, 60, consultant “Give me more information, especially about the drugs you are prescribing.”—Dorothy, 78, retired

“Wash your hands and use antibacterial hand lotion in front of me. I don’t know where your hands have been.”

—Ron, 81, retired “Take the time to explain to patients and family the plan of care. Patients need to be educated about their options so they feel that they have control of their plan.”—Alexandria, 52, human resources professional “Apply a sense of cultural sensitivity to your patient’s health practices and beliefs. Please don’t discount my knowledge and experience of my own health and of my condition. And please don’t treat my herbal therapies, which are essential to my healthy function, as silly, unreal, or replaceable with pharmaceuticals.”

—Hattie, 30, food server and student.

“Educate patients on how to pay attention to their minds, bodies, diets, and lifestyles in order to identify the details that lead to a more holistic approach to health care. Approach illnesses and symptoms with a more holistic mindset; take the time to get to know your patients in order to provide the best care.”—Michele, 41, teacher “I would like to feel like my doctors have all the time in the world to see me and listen to my concerns. Although I

know I am getting great care, I often have the sense that they need to go, even as we are wrapping up our conversation. We all know time is limited, but if they can just pretend to not be in a hurry, it would really be great.”—Nicole, 42, teacher

“I want my doctor to respect that I have the most understanding and knowledge of my health and my body.

Mutual respect is key. Good listening and not being in a hurry are also respectful and important.”—Erin, 61, retired “I wish my doctor would listen and be open to the whole holistic presentation of symptoms before I get quickly boxed into a routine diagnosis.”—Olga, 56, psychologist

“Kindly strike the phrase ‘standard protocol’ from your vocabulary when speaking to me. When you use such a phrase in our conversations, I have to understand you are not looking at the particulars of my case, and that I am being lumped with everyone else who shares my diagnosis, mostly for the convenience of the insurance company. I need you to convey to me that you understand that I am an individual, not a statistic, and that my optimal health is more important to you than not upsetting the insurers. If you will not fight for my care against the insurance companies, who will? I need to trust this to you in order for our work together to be effective.”—Anna, 53, unemployed

March 2010 San Francisco Medicine 17

Advice to My Patients

Understanding Patients An Interview with Kate Lorig, RN, DrPH, of the Stanford Patient Education Research Center

Amanda Denz

T

his month San Francisco Medicine reached out to Kate Lorig, RN, DrPH, a professor at the Stanford Patient Education Research Center, to find out about the average patient’s understanding of medicine and how to better communicate information.

San Francisco Medicine: What level of understanding does the average patient have about the inner workings of his or her body?

Kate Lorig: I think that’s irrelevant, because I can floss and brush my teeth every day without having any idea how many teeth I have or about the anatomy and physiology of my teeth. What is relevant is for the individual to know what they can do to remain healthy or to have as healthy a life as possible in the face of illness—you don’t have to have a great deal of scientific knowledge to know that.

Doctors feel much more comfortable explaining the anatomy and physiology, but that isn’t usually what a patient needs to know. What a patient wants to know is: What does this mean for my life and how much is it going to hurt?

So how should physicians apply that idea to their interactions with their patients?

Giving information about health or about a diagnosis should be done as a slow process. Whenever a diagnosis is given, the doc needs to understand that even if it’s a fairly benign diagnosis, it can be devastating in a patient’s eyes. I’ve seen people who’ve been given a diagnosis of osteoarthritis who absolutely panic. So the important thing to do is to give a diagnosis and then say, “ . . . and there are lots

of things we can do about this.” This offers assurance. Then the physician should be ready with resources so that the person can read or research on the Web about what’s going on.

All doctors should have a list of websites, books, and printouts that they approve of. What specific resources they use depends on the doc and on the disease, so physicians should search around online a bit and find out what they like. About 80 percent of patients with a new diagnosis will be on the Web within two to three days, and there’s good stuff on the Web and there’s bad stuff. The docs should spend some time on the Web finding out what they like and approve of. And this doesn’t just mean picking a name of an organization and providing that to the patients—it means finding specific sites and articles for specific diagnoses.

Given two hours on a rainy Sunday afternoon, someone can compile a reference list of books and websites so that when someone gets newly diagnosed, that doc can say, “Here are some websites, here are some books, and what I’d like to do is see you again in a week or two and we’ll discuss in more detail what you found out and what the options are.” And ask them to write down any questions that come up and bring them in.

Physicians might also want to suggest that for the follow-up appointment, the patient bring somebody with them. For a patient, being in a physician’s office is always a stressful situation, and therefore information can be missed. I didn’t personally understand how important that was until I myself had cancer. I had a friend who wanted to go to all my appointments with me, and she took notes and would e-mail

18 San Francisco Medicine March 2010

them to me the next day. I was missing about 20 to 25 percent of what was being said—and I am very good at listening. If you had asked me, I would have told you that I had not missed a thing.

Do you have any other tips for physicians to improve patient communication?

Base one-to-one teaching on the patient’s main concerns. These can be determined by asking, “When you think of arthritis, what do you think of?” or, “What are you afraid might happen?” Use the answers to tailor your education.

Know about community resources such as exercise classes, patient education classes, meditation classes, support groups, and so on. If at all possible, visit some of these so you really know about them. Then refer with a specific name and telephone number.

Keep a small patient education library in your waiting room.

Make yourself available to your patients by phone or e-mail. This is difficult given a busy schedule, legal considerations, and the present lack of reimbursement for these services. Nevertheless, most patients do not abuse this privilege, and it’s an excellent way to catch problems before they grow, to encourage patients, or to relieve them of needless worry.

When a patient presents with symptoms, even if they aren’t medically significant, be sure to address the symptoms when giving reassurance.

Close the loop. At the end of the visit you want to say, “What I understand that we’ve decided upon is A, B, and C; is that your understanding?” Because very often we forget to close the conversation. www.sfms.org

Advice to My Patients

Philosophy, Wisdom, and Advice Understanding the Patient to Give the Best Advice

Stephen J. Walsh, MD

W

hen I interviewed for medical school at age nineteen at the University of Iowa, I told the interviewer-psychologist, Dr. Woodrow, that I wanted to become the kind of person the physicians were in my Iowa hometown of Ames. He looked at me with amusement and skepticism, then moved on to further questions about my motives and qualifications, apparently hearing enough to support my admission to medical school.

In fact, my hometown doctors were our local heroes in the 1950s. They tended to be wise, kind, practical, realistic, and generous with good advice. Of course, at times some could be irritable and hurried, but I always admired what they were able to do—practice a highly useful art based on a formidable science.

Patients forgive much when the doctor’s heart is in the right place.

Much of the joy I have experienced in general medical practice, and later in general psychiatry, has been in knowing hundreds of fellow physicians with those same qualities I admired in the doctors in my home town. These included my late beloved father, Dr. Eugene Walsh. Most excellent physicians I have known have had coherent philosophies guiding their lives and practices. The experiences of medical practice inform and catalyze the development of those philosophies. Seeing patients day after day is an incredible laboratory for observing human nature and learning how particular values, beliefs, and philosophies play out in peoples’ lives. We see the consequences of these beliefs and behaviors up close and personal. Through our patients, we have windows on many universes of www.sfms.org

human experience. Medical and psychiatric practice is a grand opportunity to grow whatever practical wisdom (and other adaptive strengths or “virtues”) we have started with. That’s obviously helpful to patients in evaluating, treating, and advising them, and it’s a form of compensation for the doctor as we age.

Psychoanalyst Dr. Erik Erikson believed that an “adaptive virtue or strength” develops along with each of the eight stages, or “crises,” of human development from birth to old age.

For example, the first stage (infancy) involves developing a sense of trust (versus mistrust), with the adaptive strength being an ability to hope. The second stage (toddler) of a sense of autonomy (versus shame and doubt) develops an ability to use one’s strength of will sensibly. Several stages later, the issue is a sense of integrity (versus despair), with the adaptive strength or virtue being the development of wisdom. The developmental stages build on one another, but even this later stage is developing long before old age, during the working years. Physicians with good and growing clinical wisdom, combining knowledge and practical judgment, are widespread among our younger colleagues.

Philosophy, from the Greek words philos (loving) and sophos (wise), is the love of wisdom and the search for it. It can inform our work with patients in useful ways. Medicine grew partly from philosophy in early Greece. Hippocrates was a contemporary of Socrates, among other philosophers. Philosophers then and through the ages have contributed much that is still helpful in our relations with patients, the advice we give them,

and how we assess their complaints and symptoms. The Roman Stoic Epictetus advises, “We are distressed not so much by what happens to us as by our thoughts about what happens to us.” The philosopher-psychiatrist Freud similarly said, “We are made more ill by our fantasies about reality than by reality itself.” A recent bumper sticker in San Francisco stated, “Don’t believe everything you think.” How important it is to explore with patients their thoughts, beliefs, assumptions, and what they are telling themselves about their symptoms, life events, and illnesses. Holding this all up to the light of reason and objectivity often helps patients see the negative consequences of what they are thinking that isn’t really true, or for which there is little evidence.

The philosopher Edmund Husserl contributed in his philosophy of phenomenology the useful notion of “bracketing out” our preconceptions and beliefs about what we are observing, and striving to see with fresh eyes (a kind of cultivated naïveté) so that we can apprehend reality as it is more clearly— useful advice for the physician trying to study patients accurately. Freud said, “I learned from my master Charcot to look, and to look, and to look again until the things themselves begin to speak.” Heidegger and the existential philosophers Kierkegaard and Sartre, and the psychiatrist-philosophers Jaspers, Binswanger, and others all emphasized the crucial importance of focusing on patients’ inner subjective experience/awareness for accurate empathic helpfulness—a kind of “living in” to the patient’s self/ Continued on the following page . . .

March 2010 San Francisco Medicine 19

world constructs. For medical advice giving, this can take the form of “checking in” with patients about what they are hearing you say, what meanings they are attributing to your advice, and how they are experiencing their encounter with you. For example, one can ask, “How’s this going so far?” “How is what I’m saying sitting with you?” “Are we leaving out anything that might also be important to you?” “Could you say back to me what you hear me saying to you today?”

The existential writers Rollo May and James Bugental emphasize the importance of the doctor’s “presence.”

Presence includes the qualities of being accessible, receptive, expressive, and responsive to the immediate situation, with a more or less here-and-now focus when that is useful. Carl Rogers has emphasized the importance of accurate empathy, genuineness, and nonpossessive warmth as crucial healing ingredients in the doctor’s way of being present with patients. Existential psychiatrist Irvin Yalom has emphasized attending to the ways patients are responding to and experiencing the “existential givens” in their lives. These include the givens of inevitable mortality (“death whirs continually beneath the membrane of existence”), freedom/choice and one’s attendant responsibility for self, the separateness of each of us from others, and the issue of finding or creating meaning in life (for example, is the patient engaging with people and projects meaningful to them?). Dr. Viktor Frankl wrote eloquently (Man’s Search for Meaning) of the drive for meaning and the survival value of discovering meaning in whatever circumstances we find ourselves in.

We must know the patient as much as possible from the inside out to give individualized medical advice. Novelist Franz Kafka said, “To give a medicine is easy. To come to an understanding of people is hard.” Dr. William Osler said, “It is less important what disease the patient has than what patient has the disease.” The hard-won wisdom about people that we manage to acquire in this most interesting and difficult profession of medicine can serve us and our patients

well. Philosophy and our own thoughtful experience have much to contribute to our skills and to how we understand and advise our patients.

Stephen J. Walsh, MD, is in the private practice of psychiatry in San Francisco

20 San Francisco Medicine March 2010

and Mill Valley. He is a Clinical Professor of Psychiatry at UCSF. He is a past-president of the SFMS and former editor for San Francisco Medicine. He is currently on the editorial board of San Francisco Medicine.

Welcome New Members!

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

Melinda Aquino, MD, Solo/Small Practice Referred by Susan Bailey, MD

Jacqueline Dolev, MD, Solo/ Group Practice Michael Drennan, MD, Solo/Small Practice & SF General Hospital Referred by Mitch Katz, MD Milton Louie, MD, St Mary’s Hospital Referred by John Umekubo, MD

Michael Treece, MD, St Luke’s Hospital Referred by Andrew Calman, MD Venktesh Ramnath, MD

Tracy Zweig Associates INC.

A

REGISTRY

&

PLACEMENT

FIRM

Physicians

Nurse Practitioners ~ Physician Assistants

Locum Tenens ~ Permanent Placement V oi c e : 8 0 0 - 9 1 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FA X : 8 0 5 - 6 4 1 - 9 1 4 3

tzweig@tracyzweig.com w w w. t r a c y z w e i g . c o m www.sfms.org

Advice to My Patients

Gasping for Air A Medical Student Learns about Making Decisions at the End of Life

Eisha Zaid

I

t had been raining all week. The soggy gray weather had shrouded the city in a wet blanket of haze. Today, the sun was actually shining. I got a glimpse of a crisp San Francisco morning through the window of Mr. W’s new room.

Earlier that morning, I had walked into his old room. As I made my way to this room, half-stumbling through early morning sleepiness, I looked in the corner, where he usually lay. I was surprised to find an empty bed covered in freshly laundered white sheets. I searched the room, identifying the three other patients, only to realize Mr. W was not there.

I turned my attention to the sitter, who was staring at me from behind a computer in the middle of the room.

“They moved Mr. W’s body to Room 10,” she said. ***** Mr. W had died earlier that morning.

I heard the words echoing in my head as I sat and listened to our resident dictate the discharge/death note, “He expired at 5:50 a.m.”

I had been following Mr. W through the later course of his illness during the previous week. I never directly spoke to him; I made use of translator phone, which connected me remotely to an interpreter, who echoed my questions in Cantonese.

This eighty-four-year-old man had been admitted to our neurology service two weeks earlier after he had been found unresponsive in his bathroom. The CT would later show that he had suffered a right-sided stroke after a major artery (middle cerebral artery) had been acutely occluded. As a result of the ischemia and subsequent brain damage, he was left www.sfms.org

with a left-sided paralysis.

Even before his stroke, his days had been numbered. He had advanced lung cancer with metastasis to his liver and bones.

He was initially observed in the ICU and later transferred to our ward team.

When he first came out of the ICU, he was coherent, answering our questions, verbalizing his complaints, and actively trying to move his flaccid left arm with his good arm.

Initially, he was set on participating in acute rehab, despite the intensity. His family remained committed to recovery and was even interested in continuing chemotherapy for his lung cancer. But within a couple of days, his health started to decline, and he expressed a desire to die. ***** Mr. W finally got his own room with a window that overlooked a busy San Francisco highway. As the cars buzzed by, the stillness in Mr. W’s room could be palpated. A big red sign that said, “Caution, Fall Risk” hung over his bed. I could not help but note the irony in the message that hung over the body of a dead man.

His gray hair was disheveled. His mouth was still open, as though he were gasping for air. His two large brown front teeth and a row of overcrowded bottom teeth were visible. His face had a yellow hue and his eyes were closed. His frail body looked stiff. A name tag was tied around his right big toe and a large white bag was folded below his feet.

I walked up to his body. I lay my hand on his right side; his skin was still moist and slightly warm. I stood there alone, lamenting his death and wondering how

much he suffered while he gasped for his last breaths. I closed my eyes and prayed he would find the peace he had been denied during the last days of his life. And I said good-bye. ***** When making medical decisions, physicians must ask if the patient has the capacity to make decisions, or if he has impaired decision making. A patient is presumed competent until proven otherwise. The same reasoning must be applied during end-of-life care discussions.

To determine decision-making capacity, a patient must have the following abilities: communicate a choice, understand the relevant information, appreciate the situation and its consequences, reason about treatment options (Appelbaum 2007).

A fine balancing act must be achieved, whereby physicians respect patient autonomy but prevent patients from making Continued on the following page . . .

March 2010 San Francisco Medicine 21

Continued from the previous page . . . decisions that lead to undue harm. During the end of life, the question is mainly about when to withdraw life-sustaining measures and transition to comfort care with a focus on symptom management.

If it is deemed that a patient has impaired judgment and lacks capacity, we rely on a substitute decision maker.

A conflict emerges when a patient lacks capacity, did not draft an advanced directive, and a surrogate decision maker acts against the patient’s wishes or the medical team’s advice, which, during the end of life, often results in an escalation of care when little improvement can be expected. At this point, we must ask if we are actually doing harm and making our patients suffer. ***** In the week that I took care of Mr. W, I had become familiar with his neurologic exam. He could not move the left side of his body and did not even withdraw from painful stimuli. He had a left facial droop and looked to the right. Sadly, during the last week of his life, I watched him decline, becoming more delirious and agitated.

Initially, he was alert and oriented and would follow commands. But he became hypoxic and required more oxygen to be comfortable. Because he was at risk for aspirating the food he ingested, he required a feeding tube, which was placed in his nose. He had to be restrained because he tried to pull out the plastic tube. And he was flailing his right leg and tugging at his restraints to be freed. A shrill moan was audible from the hallway any time you passed by his room.

He was miserable.

Each morning, I could hear him groaning. And each day his mental status declined. He went from verbalizing his complaints to responding to yes/no questions to becoming completely unresponsive and only communicating with mumbling. The translator could not make out his responses. He needed a diaper because of his incontinence and would swat me when I examined him.

He lay in a room surrounded by three other patients; a sitter was in the middle of the room. When I watched him flailing

his leg and his restrained arm, which was contained in a large white mitten tied to the bed, I felt pity for this man. It was undignified to keep him tied down during the last days of life. He was suffering, and a part of me wanted to tell his family that he would be better off at home surrounded by his loved ones than surrounded by strangers and tied down in an impersonal hospital room.

But his family could not make the decision that we, the neurologists, felt was in the best interests of the patient. ***** Doctors are not very good at prognosticating, especially when it comes to predicting someone’s life expectancy.

Thus, lifespan is presented in ranges— days to weeks, weeks to months, and months to years.

We gave Mr. W weeks to live. His death did not come as a total surprise.

The writing was on the wall from the day he came out of the ICU. We, the neurologists, could all could see it, but the family did not. He was not a good candidate for acute rehab due to his weakness. And when his health started to decline, we all knew he would be better served by comfort measures.

Despite the inevitable, we were not able to communicate our expectations to his daughter early in the course of his hospitalization, nor to conduct a candid discussion about his prognosis. The daughter, who was charged with making medical decisions, initially insisted on acute rehab and chemotherapy because she did not realize his days were numbered.

We did not discuss goals of care until after Mr. W had become restrained and started to decompensate. It was only after he had repeatedly expressed, “Please let me die. Please let me die,” that we consulted the palliative care service.

Even when we presented the options relating to removing life-sustaining measures to the daughter, she could not make the decision we all wanted her to make—she could not withdraw care. And she wanted to suspend making a decision. ***** At the end of life, we place a large

23 San Francisco Medicine March 2010 2010 22 San Francisco Medicine March

burden on the families of our patients. We look to them to make decisions based on limited information, because we expect them to know what the patient would want. As easy as it is for us to make our recommendations, we do not have to live with the consequences of such decisions.

I can only imagine the anxiety Mr. W’s daughter faced when she had to make the final decision about Mr. W’s end-oflife care.

We ended up agreeing on comfort measures, such as Haldol to help the agitation and morphine for pain. But his feeding tube remained in place and he still had to be restrained. He continued to groan. In the end, Mr. W died of respiratory compromise, gasping for air. ***** When I left the hospital, I felt a heaviness inside me, along with feelings of guilt and sadness. I wondered what I could have done differently to help Mr. W in the last days of life. Mr. W lacked the capacity to make medical decisions, and I respected the family’s wishes. I only wish we could have included Mr. W in the discussion earlier to better understand what his wishes were. I kept replaying the conversations we should have had with the patient and family. But in the end, I realized that we sometimes just need to accept death as it comes, even if it does not meet our criteria for a dignified or comfortable death. It is a sad truth.

As I drove away, the rain started again.

Eisha Zaid is a third-year medical student at UCSF. She is the winner of the 2009 David Perlman Award for Excellence in Journalism and she is the author of Eisha’z Inner World, a blog about her journey through medical school: http:// eishazinnerworld.blogspot.com.

Reference: Appelbaum P. Assessment of patients’ competence to consent to treatment. N Engl J Med 2007; 357:183440.

www.sfms.org www.sfms.org

SFMS 2010 Annual Dinner Photos The 2010 San Francisco Medical Society annual dinner was held on January 21, 2010, at the Concordia-Aurgonaut Club in San Francisco. Michael Rokeach, MD, was installed as the 2010 president of the SFMS. After a lovely dinner, Elizabeth McNeil, Vice President of Federal Government Relations at the California Medical Association, delivered the keynote speech on health care reform.

SFMS Executive Director and 2010 Officers: (from left to right) Mary Lou Licwinko, JD, MHSA, Executive Director; Keith Loring, MD, Treasurer; Peter Curran, MD, Secretary; Michael Rokeach, MD, President; George Fouras, MD, President-Elect; Charles Wibbelsman, MD, Immediate-Past President

Roy Lyons, MD, Mary Lou Licwinko, JD, MHSA, Katherine Margolin, MD, and Robert Margolin, MD

www.sfms.org

Roland Barakett, MD, Jaqueline Barakett, Hugh Vincent, MD and Joan Watson, RN

March 2010 San Francisco Medicine 23

Left: A Group of Medical Students with George Fouras, MD, SFMS President-Elect Below: Ashley Stiles Turek and Paul Turek, MD

Shannon Udovic-Constant, MD, Mary Lou Licwinko, JD, MHSA, Robert Mithun, MD, and Charles Wibbelsman, MD

Steve Walsh, MD, playing the piano and Kristen Razecca, MD

24 San Francisco Medicine March 2010

Mark Kono and Bill Kapla, MD

Loretta and Ed Chow, MD, Shoko and John Umekubo, MD

www.sfms.org

Charles Wibbelsman, MD, 2009 President, passing the gavel to Michael Rokeach, MD, 2010 President Above: 2010 SFMS President Michael Rokeach, MD, and his wife, Shiela Right: Fifty Year Members Art Lyons, MD (left), and Xaviar Barrios, MD (right), with Michael Rokeach, MD Below: Keynote Speaker Elizabeth McNeil

Congratulations to UCSF medical student Eisha Zaid (below) for winning the Perlman Award for Excellence in Journalism for her outstanding contributions to San Francisco Medicine!

Our thanks to the following corporate sponsors who helped make the January 21 SFMS Annual Dinner possible: Brown and Toland Medical Group, California Pacific Medical Center, Chinese Hospital and Chinese Hospital Medical Staff, Hill Physicians Medical Group, IMAGE Financial & Insurance Services of N. CA, Kaiser Permanente San Francisco Marsh, Medical Insurance Exchange of California, St. Francis Memorial Hospital, St. Mary’s Medical Center, UCSF Medical Center

Special thanks to Duramed Pharmaceuticals, Inc, a subsidiary of Barr Pharmaceuticals, Inc. for sponsoring both the Perlman Award and the dinner.

And special thanks to Saint Francis Memorial Hospital for providing meeting space and parking for the 2010 SFMS board meetings. www.sfms.org

March 2010 San Francisco Medicine 25

Hospital News Chinese

Joseph Woo, MD

I had the pleasure of attending the Chinese Hospital Board Installation ceremony on January 25. Mr. James Ho continues as our board president, along with Mr. Joe Chan as his vice president. In attendance, as usual, was the parade of City officials. Most notable were former Mayor Willie Brown, who has been an ardent supporter of the hospital and community. President of the Board of Supervisors David Chiu performed the swearing-in ceremony. Also in attendance were Supervisors Carmen Chiu, Sean Elsbernd, Eric Mar, and Aaron Peskin; City Attorney Dennis Herrera; City Administrator Ed Lee; City Assessor Phil Ting; the Consul General from China; and many leaders from the San Francisco Chinese Community.

I must also welcome back our own Dr. Randall Low, who recently recovered from illness to return to his position as the medical staff board representative. As you may know, the modern Chinese Hospital was built with the support of the twelve founding members of the Chinese Association, along with the medical staff who currently each send a representative to make up our Board.

On our IPA side, our president, Dr. Eric Leung, returns for another term. Clearly our leadership remains strong with Dr. Shu-Wing Chan serving as vice president, Dr. Gustin Ho as our treasurer, and Dr. William Chung as our secretary. Other board members include Drs. Seck Chan, Lawrence Chao, Hans Yu, Raymond Li, Ho Tan, Rachel Shu, and me.

Our Medical Executive Committee welcomes its newest member, Dr. Nicholas Jew, who assumes the reigns of chief of medicine.

My thanks to his predecessor, Dr. Gustin Ho, who was a terrific chief these past several years.

CPMC

Damian Augustyn, MD

Fifteen CPMC physicians and nurses have made their way to Haiti as part of a Sutter Health surgical team that is providing critical medical care to earthquake victims. This is part of Sutter Health’s $1.25 million commitment to relief efforts. The group not only took its skills and expertise but also much-needed medical supplies, surgical equipment, and anesthesia. A heartfelt thanks to the dedicated members of the team.

On January 1, 2010, with the approval of the Secretary of the State, California Pacific Medical Center, Novato Community Hospital, St. Luke’s Health Care Center, Sutter Lakeside Hospital, and Sutter Medical Center of Santa Rosa officially became part of the Sutter West Bay Hospitals. The Physicians Foundation at CPMC and Sutter Medical Foundation North Bay united as Sutter West Bay Medical Foundation (doing business as Sutter Pacific Medical Foundation).

Dr. Warren Browner, president and CEO at CPMC, has been named one of the Thirty Best Physician Leaders of Hospitals and Health Systems in the U.S. by Becker’s Hospital Review. The Review is distributed to more than 15,000 hospital leaders across the country.

Other physicians on the list include the CEO of Johns Hopkins, the president of Brigham and Women’s Hospital, and Nobel Prize winner Dr. Harold Varmus of Memorial-Sloan Kettering Cancer Center.

CPMC welcomes Delvecchio Finley, FACHE, our new vice president of Operations, Support, and Professional Services. He comes to us from San Francisco General. Prior to that, he served as the acting chief operating officer for Laguna Honda and also led a variety of physician/ambulatory care services for UCSF. He is a current regent of the American College of Healthcare Executives for Northern and Central California and a past president of the California Association of Healthcare Leaders.

26 San Francisco Medicine March 2010 27 San Francisco Medicine March

Kaiser

Robert Mithun, MD

The twenty-first century has arrived at Kaiser Permanente in the form of an electronic medical record (EMR). EMR is revolutionary in aiding communication between providers and patients. At the San Francisco Medical Center, one of the most useful tools our providers are using is the After Visit Summary (AVS), given to each patient after an appointment. During the scheduled visit, the provider reviews with the patient his or her medical record through the EMR, noting changes in everything from blood pressure to cholesterol levels. With each visit, a comparison can be made with results of tests from the past couple of years, and the provider is able to advise the patient on how to modify and take charge of his or her own health. This may include lifestyle changes, diet, and regular exercise.

Kaiser Permanente’s focus on prevention, the extensive capabilities of the EMR, and an integrated model of health care delivery afford providers the ability to draw from a vast array of resources, including vaccination and preventive health screening updates, when advising patients. One physician in our Bilingual Chinese Primary Care Module remarks that with both an electronic and printed AVS, she has the opportunity to remind her patients what they need to do to stay healthy and recover from illness or injury.

The AVS includes tests and medication orders for the visit, specific instructions (such as changes in medication dosage), a list of current medications and dosages, medication allergies, relevant patient education information, and future appointments with the primary care provider or a specialist. This information is given to patients during their visits and patients can access this information when they securely sign on to their health record on kp.org. For patients who are traveling, significant health information is available on a password-protected portable flash drive for convenience and safety. www.sfms.org

Hospital News Saint Francis

Patricia Galamba, MD

With more than twenty-five years in private practice, I must admit that the three words I use most in advising my patients are live, laugh, and love. I recommend finding enjoyment in the things that you do and have purpose in your life. Find humor in things that surround you; laughter is some of the best medicine. Care about your family and friends.

This is like putting money in the bank; you are sure to get a great return.

On a closer look at what’s happening here at Saint Francis, we are pleased to announce that Phase II of our complete surgical remodel is complete. In early February, the hospital opened up three additional OR suites. Each suite averages around 500 square feet and is fully integrated with state-of-the-art anesthesia, surgical equipment, computerized imaging, and light booms. Phase III is underway, and we hope for completion by this summer.

Saint Francis is also pleased to announce the appointment of new Chief Medical Officer Andrew Smith, MD. Dr. Smith begins his new position in mid March. He comes to Saint Francis from Northern Michigan Regional Health System, where he served as vice president and CMO for seven years. He brings a strong background in quality/utilization management, information technology, and medical staff development. We look forward to his arrival and his involvement with the San Francisco Medical Society.

On a fun note, Saint Francis hosted Leung’s White Crane Dragon and Lion Dance troupe during the Chinese New Year Celebration. The lions and drummers started from the sidewalk, performing through the hospital lobby and into the cafeteria, where they entertained patients, visitors, and staff with their ritual dance and drumming to “ward off evil spirits,” bringing in the Year of the Tiger. www.sfms.org

Veterans

St. Mary’s

Diana Nicoll, MD, PhD, MPA

Michael Rokeach, MD

St. Mary’s Medical Center is a community hospital, the first in San Francisco, and we have remained true to our mission: We continue to provide high-quality, affordable health care to the communities we serve, including the poor and disenfranchised. But St. Mary’s has also has a tradition of innovation that remains vital today. Our spine surgeons continue to pioneer new techniques. Most recently they invented the X-stop, a device now used around the world to treat spinal stenosis with a minimal incision, saving many patients from the risks and discomfort of traditional spine surgery.

Our Northern California Melanoma Center, a collaboration of physicians and surgeons from various specialties, researchers, and nurses who work together to treat melanoma patients from around the globe, has more than fifteen investigational treatments under study. The surgeons in our PROS and Wound Care Center have developed innovative techniques to save limbs and restore function.

The spirit of exploration and innovation at St. Mary’s extends beyond the development of new treatments. Despite the advances of medical science, the actual delivery of medical services nationwide is too often marred by error, inefficiency, and even injury. Under the leadership of our new hospital president, Anna Chung, members of the medical staff, administration, and nursing staff are meeting and collaborating on an almost daily basis, exploring creative solutions to enhance the safety, comfort, and quality of the care our patients receive.

At St. Mary’s, we know that as valuable as new drugs and devices are, they do not diminish the benefit patients receive from having compassionate, thoughtful, and dedicated primary care physicians coordinating their care.

For this reason, we have established a unique Primary Care Counsel that is working to assure that our hospital is responsive to the needs of our primary care physicians and their patients.

A recent study, “Mental Health Diagnoses and Utilization of VA Non-Mental Health Medical Services Among Returning Iraq and Afghanistan Veterans,” conducted by researchers at the San Francisco V.A. Medical Center (SFVAMC) and published in the Journal of General Internal Medicine, analyzed medical records of first-time users of V.A. medical services. In the study of nearly 250,000 veterans of the wars in Iraq and Afghanistan, authors found that those with PTSD used nonmental health medical services provided by the Department of Veterans Affairs, including primary care, emergency care, and visits to other specialists, at a 91 percent higher rate overall than those without mental health diagnoses.

Veterans with a mental health diagnosis other than PTSD had a 55 percent higher use rate than those without mental health diagnoses.

“The results are consistent with studies of veterans from earlier wars,” says author Beth E. Cohen, MD, MAS, a staff physician at SFVAMC. “What we don’t know from this data is whether these veterans are using medical care more often because they have more medical diseases, or because they need help with mental health concerns but seek care in other medical settings because of the stigma associated with mental health treatment.”

To explore the factors driving use of nonmental health care, Cohen plans to evaluate the effects of different models of care delivery on use. One such model, says Cohen, is the OEF/ OIF Integrated Care Clinic at the SFVAMC. At this clinic, all patients are seen by primary care, mental health, and social work providers, potentially reducing the stigma of seeking mental health care.

“Integrated care is a priority for V.A. nationally,” notes Cohen. “It may be that when a veteran sees both a primary care and mental health care provider who work together as a team, we can deliver care more efficiently.”

March 2010 San Francisco Medicine 27

Book Review Steve Heilig, MPH

Too Much Information?

Experimental Man What One Man’s Body Reveals About His Future, Your Health, and Our Toxic World

By David Ewing Duncan (Wiley; 370 pages)

I

n medical science there is a long, if somewhat fringe, tradition of “participatory research,” wherein scientists use their own bodies to test whatever substance or theory they are looking into. Some have even put themselves at great risk by exposing themselves to infectious diseases or other hazards. San Francisco writer David Ewing Duncan does not go to that extreme, but he does explore deep within his tissues, genes, and health to give a startling and sometimes disturbing look at how our bodies are, and might be, affected by life in the modern industrial era.

Duncan begins with a simple experiment: joining a fishing trip out of Bolinas Lagoon, catching a halibut, eating from it, and in so doing driving his body’s mercury load to over double the recommended safety level. He donates numerous vials of his blood for testing by a wide array of scientists, both academic and commercially inclined, and he spends considerable time in MRI machines having his brain scanned and the results interpreted.

His intent is to examine his genetic makeup, brain, and body in an attempt to “humanize science by having a real person with a family and children intimately participate in leading-edge technologies.” By so doing, he hopes to provide some insight into a coming “new era of medicine” wherein we will be able to “acquire profound new powers of knowledge about ourselves, possibly more than we want to know.”

Duncan purposefully loses his “genetic virginity,” mostly so that scientists might tell him of his probability of developing various diseases. His brother has a disabling condition traced to his genes.

Duncan does not, but is told that he is at increased risk for heart disease, among other potential hazards.

He undergoes biomonitoring, having his body checked for industrial chemicals, including those he may have only been exposed to as a child. Of the 80,000-odd chemicals used in modern life, some are known to be hazardous to humans and many more are suspected to be. Duncan’s tests find 185 of them. “It was my own secret stash of compounds, acquired by merely living,” he writes.

Moving to his neurological insides, Duncan goes to UCSF, where he undergoes various cognitive testing for memory, reaction time, and so forth. Finally, he has some more common tests, including a

28 San Francisco Medicine March 2010 29 San Francisco Medicine March

check of his cholesterol levels, to factor in with everything that has been learned about his body and brain to date.

So, what might readers most want to learn from Duncan’s travails—how such testing might benefit them, when it will be usefully available, and what it might cost?

The answers are, for the most part, not encouraging. As Duncan concedes, most of the diagnostic and predictive powers in such tests are nascent, and if they do become truly useful, that time is still far off. Many of the researchers Duncan consults—including his own girlfriend, he wisely discloses—have financial interests in bringing such tests to market. But he receives often-conflicting interpretations of his test results from various providers. And almost without exception, the independent scientists and physicians he consults about these new tests use terms such as “tentative” or even “irrelevant.” Further, the recommendations offered by the true believers tend to be already well-established advice we should already know—exercise more, don’t be overweight, don’t smoke, drink alcohol moderately, beware of high blood pressure, and so on.

Duncan was offered most of the testing free or at great discount, but the prices quoted range from a few hundred dollars to as much as $40,000. These fees are rarely, if ever, covered by health insurance, so far with good reason. His own personal physician seems wisely skeptical, and a Harvard geneticist labels some of the new genetic testing “technology hucksterism.”

Thus, some bright minds are betting big money on a high-tech version of “personalized medicine” where “diagnoses and treatments—everything from pills to surgery—will be customized to individuals based on their own genes, environmental input, and other factors specific to them.”

But as Duncan astutely asks, “Who will have the time to analyze the data and to indulge the healthy in possible scenarios of future illness?”

It’s a good question, even if at this point the answer is likely something like “mostly affluent hypochondriacs, and health insurers looking for new ways to exclude ‘risky’ patients.” Many physicians are already immersed in the “new era of medicine,” wherein patients bring in all manner of “data” from various sources, for better or worse. Duncan explores many possibilities in his fascinating book, but for the foreseeable future the wisest approach to these experimental tests is likely that of an entirely non-technological type: Let the buyer beware.

An earlier version of this review appeared in the San Francisco Chronicle. www.sfms.org

Public Health Report William S. Andereck, MD

Ambiguity and Intolerance

T

he phone rang at 3:00 in the morning. It was the emergency room. A fellow physician was calling.

“I want to tell you that we have found out what is wrong with your patient,” Dr. Jones proudly proclaimed. He said she had arrived by ambulance at 10:00 the previous night after complaints of dizziness at a cocktail party. After determining that her blood alcohol level was low, the emergency room team considered the possibility of a heart attack and ordered a series of electrocardiograms and blood tests that ruled out that diagnosis.

There was no answer to what had caused her dizziness, which had subsided by then. The patient also reported that in the past week she had experienced discomfort in her face, just below the left eye. Additionally, she had had a skin cancer removed from her nose five years earlier. Faced with the possibility that she could be suffering from an extensive tumor, Dr. Jones ordered a CT scan of the head and sinuses. He had found the answer, and now he was calling me to see how I wished to proceed.

The patient was suffering from a sinus infection.

I listened patiently, clearing my head from sleep as Dr. Jones recounted his case. When he finished, I thought to myself that he should apologize to the patient for spending $10,000 to make a diagnosis that could have been made in a doctor’s office in ten minutes.

As I wrestled myself back to sleep, my thoughts drifted to the high cost of health care and the major decisions facing Congress as it struggles to deal with them. The House has spoken, and now we turn to 100 senators with varied levels of understanding of the issues. My patient’s medical encounter brought me to the realization that our decision makers could be making a misdiagnosis about what motivates physicians.

I reject the belief that physicians act like Dr. Jones because of a financial incentive. In most cases, doctors receive no direct financial compensation from the tests or procedures they order that are performed by others. Such was the case for Dr. Jones.

He would be paid for his own efforts, but he would receive no personal compensation for the much more expensive X-rays and lab tests he ordered. Likewise, I reject the assumption that the fear of malpractice litigation motivates physicians to order more and more tests. In reality, most physicians never have been successfully sued for malpractice.

Dr. Jones’s behavior is better explained by a personality or character trait common to physicians. www.sfms.org

Doctors as a group test quite well in most types of IQ tests.

There is one significant exception, however. Physicians, unlike CEOs of major corporations, score poorly on a test evaluating “tolerance for ambiguity,” which demonstrates that physicians are uncomfortable when presented with ambiguous information. Their natural instinct is to seek additional information to clarify and support any decision. Intolerance for ambiguity suggests a psychological tendency to avoid uncertainty. In fact, the more intolerant of ambiguity a doctor is, the greater the tendency to enter a specialized field, ever seeking a smaller body of knowledge and a greater chance of mastery.

We doctors are psychologically programmed such that if we can be 90 percent sure of a diagnosis with our own clinical skills, but there is a $10,000 test that can make us 95 percent certain, we will order the test. Our expressed reason is that the patient deserves the best care we can provide.

Our underlying psychological motivation is that we want to know.

Tolerance for ambiguity is a character trait that is found commonly in risk takers. But attention to detail and a tendency for perfectionism is a different trait that might be more prevalent in those pursuing a medical field. The rational pursuit of knowledge by the empirical method of observation and demonstration, known as the scientific method, has served medicine and society well. Advances in technology and training have been achieved by physicians who demand scientific accuracy and precision. These are individuals who are selected into their profession because of their rigorous attention to certainty. Perhaps it comes down to the question, “Who do you want rummaging around in your medulla oblongata, a scientifically minded neurosurgeon or Donald Trump?”

However, if scientifically trained doctors are psychologically predisposed to order expensive tests to quiet their own inner turmoil over uncertainty, paying for the costs of health care reform will be a lot more difficult than anyone has imagined.

Dr. William S. Andereck, a former editor of San Francisco Medicine, has practiced internal medicine in San Francisco since 1979. He is a director of the Program in Medicine and Human Values at California Pacific Medical Center and a former trustee of the California Medical Association. A version of this essay appeared in the San Francisco Chronicle.

March 2010 San Francisco Medicine 29

In Memoriam Nancy Thomson, MD

Ralph O. Wallerstein, MD Dr. Ralph O. Wallerstein was born in Dusseldorf, Germany, on March 7, 1922, and died June 1, 2009, at his vacation home in Glen Ellen after a long illness. He was 87. He had a long and interesting medical career and was a researcher, teacher, healer, and an important figure in local and national medicine.

Dr. Wallerstein’s father, also a physician, brought his family to San Francisco from Aachen, Germany, in 1938. Young Ralph graduated from Lowell High School in 1939, from U.C. Berkeley in 1943, and from UCSF Medical School in 1945, an unusually swift pace because of the World War II need for physicians. After interning at S.F. General Hospital, he served as a captain in the U.S. Army Medical Corps in Japan from 1946 to 1948. Upon return he had postdoctoral training as a research and teaching fellow in hematology at the Thorndike Memorial Laboratory, Harvard Medical Service, under Dr. William Castle at Boston City Hospital.

Dr. Wallerstein joined the San Francisco Medical Society in 1949 and held increasingly responsible positions at UCSF and Children’s Hospital (later the California campus of CPMC), where he served as chief of staff from 1968 to 1972 and was chosen Physician of the Year at Children’s in 1989. He was a hematology consultant to Letterman Army Hospital and the V.A. hospitals, receiving the Outstanding Civilian Service medal from the Army in 1981.

For nearly thirty years, from 1952 to 1981, Dr. Wallerstein was chief of clinical hematology at San Francisco General Hospital. He received the Charlotte Baer Award for outstanding teaching at UCSF in 1996. He was appointed clinical professor of medicine and laboratory medicine at UCSF in 1969 and, on retirement, named Emeritus Professor. He also maintained a busy private practice both as a hematologist and an internist. In 1964 he diagnosed the importance of the Rh protein in pregnancy and helped pioneer the treatments that produce a healthy baby.

Dr. Lloyd H. Smith, associate dean emeritus of UCSF medical school, called Dr. Wallerstein a “superb generalist at a time when narrow specialization has become the mode.” Smith also called him “a delightful humanist and scholar and a natural leader.” Former U.C. Chancellor Dr. Julius Krevans remembered Dr.Wallerstein as a leader in medicine who was “absolutely devoted both to his patients and to the extremely important organizations on which he served.” According to Krevans, it was highly unusual for a physician in private practice to be asked to serve on the American Board of Internal Medicine, which is largely dominated by academic physicians. However, Dr. Wallerstein, who had joined in 1971, served as chairman of the organization’s Board of Governors in 1982 and 1983. He was also a member of the American Society of Hematology since 1960 and was its president in 1978. Ten years later he was elected President of the American College of Physicians, where he had been a member since 1953. He was elected to membership in the Institute of Medicine, an arm of the National

30 San Francisco Medicine March 2010

Academy of Sciences, in 1982.

After retiring, Dr. Wallerstein enjoyed travel and photography. He had several shows of his photographs and was published in several medical magazines. He was on the board of directors of the Fromm Institute of Lifelong Learning and enjoyed both the opera and the symphony.

He was married for fifty-six years to Betty Christensen Wallerstein, whom he met while training in Boston. Their son, Dr. Ralph O. Wallerstein, Jr., predeceased him in 1996. He is survived by his wife, Betty, his son Richard and wife Lisa of Berkeley Heights, New Jersey; his daughter Ann Story and husband Ray of Fairfield, California; and seven grandchildren and one great-grandson.

This obituary was adapted from a longer piece that originally appeared in the San Francisco Chronicle.

Thomas R. Vaughan, MD

Dr. Thomas R. Vaughan, age 72, died November 30, 2009, at his home in Novato, after living with pancreatic cancer for more than a year. He was born June 18, 1937, in Colorado Springs, Colorado, and grew up in Bronxville, New York. He graduated from Phillips Exeter Academy and went on to Yale, where he decided to make medicine his career. He graduated from Cornell Medical School in 1964. Following his internship and his residency in internal medicine, he joined the staff of St. Francis Memorial Hospital.

Dr. Vaughan served as chief of staff and on the hospital’s board. In addition, he was a fellow at UCSF’s Cardiovascular Research Institute and later a clinical professor and a staff physician at San Francisco Veterans Hospital. He joined the San Francisco Medical society in 1974 and was a member of the American Thoracic Society and the American College of Chest Physicians. In recent years, he practiced at Kaiser in San Rafael as a pulmonologist and critical care specialist retiring in 2009.

Dr. Vaughan enjoyed teaching, and his ongoing intellectual curiosity kept him engaged in life, sharing his professional knowledge with his colleagues. However, he had many other passions in addition. He had a great love of the outdoors and appreciated the natural beauty of places near and far. At Yale he had gone out for crew, developing a lifelong love of rowing. He spent many mornings training in his singleshell kayak. He ran countless miles on the trails of Mt. Tamalpais and in the Tiburon hills, often accompanied by one of his beloved, naughty dogs. He traveled extensively, usually centering his trips on an athletic endeavor: mountain climbing, bicycling country roads, or kayaking beautiful waters. Ten years ago, he put his love of music into practice and began playing the flute, which brought him immeasurable joy. He was appreciated for his quiet wisdom, dry wit, unassuming kindness, and his overall humility.

He is survived by his wife, Anne Sasaki; his sister, Cynthia Urfer; his three children, Geoffrey, Elizabeth, and Peter Vaughan; his former wife and mother of his children, Judy Vaughan; and six grandsons. www.sfms.org

Protect Your Assets and Your Future With the recent downturn in the economy and the impact on personal assets, many members are reassessing their need for Long Term Care insurance.

With so many options to choose from, where do you turn for assistance?

A

s a member of the San Francisco Medical Society, you don’t have to worry. That’s because you have access to Long Term Care Insurance specialists from Marsh, the Society’s sponsored insurance program broker and administrator.

You’ll get first-rate service you deserve from licensed consultants who will: • Tell you about the 5% member discount offered by two insurance carriers • Offer needs-based analysis customized for your personal situation and budget • Help guide you through the Long Term Care insurance buying process • Custom-tailor a plan for you What’s more, you’ll never be pressured to buy and you’re never under any obligation.

Discuss this important decision with a source you can trust.

Call toll-free 1-800-747-5123 ext. 7147 today.

SPONSORED BY:

ADMINISTERED BY:

46644 (3/10) ©Seabury & Smith Insurance Program Management 2010 d/b/a in CA Seabury & Smith Insurance Program Management 777 South Figueroa Street, Los Angeles, CA 90017, 800-842-3761 CMACounty.Insurance@marsh.com • www.MarshAffinity.com

CA Ins. Lic. #0633005, AR Ins. Lic. #245544

Now is the Time Heart Failure and Transplantation Program 24/7 DIRECT PHYSICIAN ACCESS: 866-207-4417 cpmc.org/services/heart

If your patient has progressed from stable heart failure to advanced heart failure – medical management has failed and the patient is not a transplant candidate – now is the time to consider Destination Therapy for left ventricular assist device (LVAD) implantation.

California Pacific Medical Center’s Heart Failure and Transplantation Program is the only CMS-approved Northern California hospital using the HeartMate II for Destination Therapy (DT) since 2006.

To help your patient, timing is critical. According to the national database for mechanical circulatory support, survival rates increase nearly 20% when a patient receives an LVAD implant when they are not in critical condition.

DT therapy significantly improves your patient’s quality of life, as evidenced during several standard tests administered at two years. Findings confirm a 51% improvement during a six-minute walk test. The Minnesota Living With Heart Failure Questionnaire shows a 154% improvement in a patient’s physical, emotional, mental and social quality of life. The similar Kansas City Cardiomyopathy Questionnaire shows an improvement of 159%.

In a recent article published in the New England Journal of Medicine, the survival rate for Class-IV CHF patients with Optimal Medical Management is 25% after one year and 8% after two years. However, for similar patients implanted with a HeartMate II LVAD, the survival rate is 68% after one year and 59% at two years.

CPMC has also successfully used the HeartMate II LVAD for Bridge-to-Transplant patients since 2006 and performed over 390 heart transplants since the inception of the program.