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VOL.80 NO.4 May 2007 $5.00

SAN FRANCISCO MEDICINE JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Medicine and Religion


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CONTENTS SAN FRANCISCO MEDICINE May 2007 Volume 80, Number 4 Medicine and Religion Religious Roots Monthly Columns 10 A Christian Perspective on the Relationship between Medicine and Religion Lizette-Larson-Miller 12 The Notion of Healing in the Jewish Tradition Rabbi Eric Weiss 13 Relieving Suffering through Buddhism Gordon Fung, MD, MPH, and Gregory Fung, MD, MS, PhD 14 An Islamic View of Healing Naghmeh Rabii 15 Well-Being through Buddhist Meditation and Kundalini Yoga Stuart Sovatsky, PhD 17 Catholic Tradition and End-of-Life Care Carol Bayley, PhD

4 On Your Behalf 7 President’s Message Stephen Follansbee, MD 9 Editorial Mike Denney, MD, PhD 37 HPV Vaccine Update Charles Wibbelsman, MD 35 Hospital News 38 In Memoriam Nancy Thomson, MD 39 Classified Ads 39 Upcoming Events

In the Hospital Editorial and Advertising Offices

18 Spiritual Healing at CPMC Sat Kartar Khalsa-Ramey and Landon Bogan 19 Through the Lens: Sacred Spaces in San Francisco Hospitals Amanda Denz and Ashley Skabar 21 Religious Diversity at San Francisco General Hospital Elizabeth J. Welch, MDiv 23 Dealing with a “Difficult” Family Evelyn Hadadd, MD

A Closer Look 24 Sacred Dying Becomes Us Megory Anderson 25 Pastoral Care at St. Gregory’s Lynn Baird, Cheryl Hendrickson, and Sara Miles 28 Science and Prayer Mike Denney, MD, PhD

A Personal Experience 30 Learning to Heal the Spirit Towie Fong, MD

Bridging the Gap 32 United Religions Initiative Peggy Olsen 33 Restoring Health, Hope, and Dignity at St. Anthony’s Clinic Francis Aviani

www.sfms.org

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/magazine Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org/advertising, or can be sent upon request. Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605

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www.sfms.org/magazine Visit today to find the current issue, archives, information about upcoming themes, and subscription forms. may 2007 San Francisco Medicine 


ON YOUR BEHALF

May 2007 Volume 80, Number 4

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

Notes from the Membership Department

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

Arthur Lyons

Toni Brayer

Terri Pickering

Gordon Fung

Ricki Pollycove

Erica Goode

Kathleen Unger

Gretchen Gooding

Stephen Walsh

Shieva Khayam-Bashi SFMS Officers President Stephen E. Follansbee President-Elect Stephen H. Fugaro

Golf Events Were a Success The two SFMS Golf Events at the Presidio Golf Club—the April 5 reception and the May 3 short-game clinic and Mixer—were well-attended and much enjoyed. Attendees were able to experience the beauties and amenities of this terrific course while enjoying opportunities for socializing with their peers in a relaxed setting. Over the next several months, SFMS will be offering more social events, including the Summer Gallery Event in late June or early July.

Secretary Michael Rokeach Treasurer Charles J. Wibbelsman Editor Mike Denney Immediate Past President Gordon L. Fung 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:

Carolyn D. Mar

Jan 2007-Dec 2009

Rodman S. Rogers

Brian T. Andrews

John B. Sikorski

Lucy S. Crain

Peter W. Sullivan

Jane M. Hightower

John I. Umekubo

Donald C. Kitt

Term:

Jordan Shlain

Jan 2005-Dec 2007

Lily M. Tan

Gary L. Chan

Shannon Udovic-

George A. Fouras

Constant

Jeffrey Newman

Term:

Thomas J. Peitz

Jan 2006-Dec 2008

John W. Pierce

Mei-Ling E. Fong

Daniel M. Raybin

Thomas H. Lee

Michael H. Siu

CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Judith L. Mates, Alternate Delegate  San Francisco Medicine may 2007

An Opportunity to Reach Out to Fellow Members! SFMS has embarked on a program to mentor new members. Upon approval by the Board or Executive Committee, each new member is assigned an established SFMS member as a sponsor, whose primary responsibility is to help the new member become better acquainted with the Society and its benefits. Sponsors are expected to connect with the new member socially (over breakfast, coffee, etc.) at least once and to invite the member to at least one SFMS event (Annual Dinner, Legislative Day, Candidate’s Night, Mixer, etc.) during their first year of membership. Sponsors will also be asked to report to the Board on the results of their interactions with the new member. All members are encouraged to participate in this program. Contact Therese Porter in the Membership Department at (415) 5610850, extension 269 or tporter@sfms.org for more information or to volunteer. Help Grow the San Francisco Medical Society! Members reaching out to their physician peers create a tremendously effective way to gain new members. If your physician peers are not yet members, encourage them to join! 

You Can Make SFMS Even Better! The SFMS is always looking for feedback from its members, as well as suggestions as to how to make membership more interesting, valuable, and fun. Contact Therese Porter in the Membership Department at (415) 561-0850, extension 269 or tporter@ sfms.org.

2007 SFMS Seminars! Please contact Posi Lyon (plyon@sfms. org or (415) 561-0850, extension 260) to register for any of these seminars. Space is limited; advance registration is required. June 18, 2007 Transitioning Your Practice: Retiring, Selling, or Buying a Practice This is a not-to-be-missed seminar designed for all physicians who are contemplating retirement, bringing in an associate, joining a practice as an associate, relocating, buying or selling a practice, or changing careers. 6:00– 9:00 p.m.(5:45 p.m. dinner/registration), $149 for SFMS/CMA members/$199 for nonmembers. October 12, 2007 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training in handling phone calls and scheduling professionally and efficiently. 9:00 a.m.–12:30 p.m. (8:40 a.m. regi s t r a t i o n / c o n t i n e n t a l b r e a k f a s t ) , $99 for SFMS/CMA members/$149 for nonmembers. November 9, 2007 “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of finance, operations, and personnel management. 9:00 a.m.–5:00 p.m. (8:40 a.m. regist r a t i o n / c o n t i n e n t a l b r e a k f a s t ) , $250 for SFMS or CMA members/$225 for second attendee from same office/$325 for nonmembers. www.sfms.org


FDA Approves First Bird Flu Vaccine The U.S. Food and Drug Administration approved the first-ever bird flu vaccine. The vaccine will not be available commercially but will be stockpiled by the government for use in the event of a bird flu pandemic. The two-shot vaccine appears to provide protection to 45 percent of adults at the highest dose. By comparison, seasonal flu shots typically protect more than 90 percent of healthy adults. Should an influenza pandemic emerge, the vaccine may provide early limited protection in the months before a vaccine tailored to the pandemic strain of the virus could be developed and produced. The government plans to buy and stockpile enough vaccine for 20 million people, including emergency and health care workers. For more information, contact Sandra Bressler, (415) 882-5171 or sbressler@cmanet.org.

Physicians Beware of Deceptive PPO Solicitations CMA has learned of a possible scam targeting physicians. Physicians report receiving a request via fax to confirm their participation in Three Rivers Provider Network (TRPN). The deceptive and misleading notice, formatted to mimic an HIPAA compliance document, implies that the physician has treated one or more TRPN patients and that, in order to authorize the patients’ eligibility, the physician must agree to the terms described in the document. This is merely an underhanded attempt to get providers to join the TRPN network and agree to accept its discounted rates as payment in full. CMA urges physicians to alert their office staff about this solicitation and to be wary of requests for physician information from unknown payors.

Don’t Be Caught Off-Guard by Health Plan Contract Changes Physicians are urged to carefully review all notices from their contracting health plans, as these may include material modifications to contract terms that could significantly impact their practices. www.sfms.org

You should also be aware that you have the right to terminate an agreement if any such material change is not beneficial to your practice. There have been a number of recent developments that demonstrate the importance of such vigilance by physicians and their staff. 1. MultiPlan/Private Health Care Systems (PHCS) Merger Although MultiPlan and PHCS will continue to market their products under different names, physicians were recently notified that, effective May 1, the PHCS agreement will supersede any other agreement in place. In other words, physicians’ relationships with MultiPlan will be governed by the PHCS agreement. Physicians were also notified that, effective May 1, the newly merged entity will adopt MultiPlan’s practice of tying fee schedules to the current year’s RBRVS. This new policy will significantly decrease the current PHCS fee schedule. 2. First Health Acquisition of Community Care Network Physicians were recently notified that Community Care Network (CCN) would be absorbed into the First Health network. Physicians should be aware that the First Health physician contract supersedes the CCN contract, and physicians treating CCN patients will be paid according to the First Health fee schedule for dates of service on or after January 1, 2007. (CCN patients will eventually be issued new First Health cards.) Because there was no change to the First Health fee schedule, the plan was not required to give physicians advance notice or the option to terminate. Physicians should be aware that they do have the right to terminate any health plan contract “without cause,” with advance written notice. (The amount of advance notice will depend on the terms of the contract.) 3. Blue Cross Prudent Buyer Plan Fee Schedule Changes CMA has learned that Blue Cross recently updated its Prudent Buyer Plan physician contract, and the new contract

becomes effective June 1. According to a notice recently mailed to physicians, payment levels for many codes have been modified (some increased and some decreased). Physicians are urged to assess the impact these changes will have on their practices. The new fee schedule will be available on the Blue Cross provider website as of April 15. In the meantime, fee schedule questions should be directed to Blue Cross at (800) 933-6633 (select option 3). To help physicians negotiate and manage complex third-party payor agreements, CMA has published a contracting toolkit called Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations—A Focus on Payor Contracting. The toolkit is available free to members at the members-only website. Nonmembers can purchase the toolkit for $100 in the CMA bookstore. CMA has also created a financial impact worksheet to help physicians assess the impact that fee schedule changes will have on their practices, based on their most commonly billed CPT codes. For more information, including a copy of the solicitation in question, see www.cmanet.org or contact CMA’s reimbursement help line, (888) 401-5911 or gfonseca@cmanet.org. Visit www.calphys.org for more information on these and other practice management resources from CMA, or contact the Reimbursement Help Line at (888) 401-5911.

Gov. Schwarzenegger Keynote Speaker at Annual CMA Legislative Leadership Conference This year’s event was a well attendedsuccess! To view the full text of Governor Schwarzenegger’s address, visit www.gov. ca.gov.

Photo courtesy of the Governor’s Office

may 2007 San Francisco Medicine 


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president’s Message Stephen Follansbee, MD

A Prescription for Prayer?

A

s the son of a Presbyterian minister, I am aware of how much I am my late father’s son, despite my different career path. My voice sounds like his. My hand gestures and mannerisms are like his. I think that at times, when talking with patients about life-threatening illness, death, and dying, or advising them about how to talk with their families and friends, I must naturally rely on some of my father’s innate counseling skills. Is the practice of medicine that far from religion? As physicians, are we that different from clergy? The answer is a resounding “yes,” even though a majority of hospitalized patients would like us to consider their spiritual needs. I think this issue of San Francisco Medicine will help us understand how these two separate aspects of the human experience interact. As physicians, we are certainly aware of the conflict that can arise between religion and medicine. A 2005 study entitled “When Patients Choose Faith over Medicine: Physician Perspectives on Religiously Related Conflict in the Medical Encounter,” by Curlin, Roach, Gorawara-Bhat, Lantos, and Chin, looked at this issue. The authors conducted one-to-one, in-depth, semistructured interviews with twenty-one physicians from a broad range of religious affiliations, specialties, and practice settings. Although admittedly based on a small study sample, their conclusions are interesting. The authors categorize the conflicts between medicine and religion into three overlapping domains: religious doctrine versus medicine, ethical controversy, and faith versus medicine. The refusal of Jehovah’s Witnesses to accept blood products is an example of religious doctrine. Lawsuits have been won by patients who have sued their physicians for battery after saving their lives with transfusions of red blood cells, against their expressed wishes. The courts are clear: A patient’s religious convictions must be respected, even if doing so conflicts with the doctor’s own judgment about appropriate medical care. Ethical controversies arise in such areas as prenatal and endof-life care. Many religious persons feel that life under any circumstances, even if in a vegetative state, is “God’s will” and therefore must be honored. This belief mandates that these individuals and their families reject attempts by physicians to convince them of the “futility” of medical care in extreme situations. Faith in God can also lead individuals to feel that healing is in www.sfms.org

God’s “hands” and therefore reject recommendations for important diagnostic tests or for standard treatments, such as chemotherapy. They wish to turn to prayer or meditation or other “interventions” that they believe will provide the desired outcome. All these situations place medical practitioners in a difficult position. I believe that, as physicians, we are ill-trained to deal with spirituality, both in terms of understanding various religious backgrounds and in terms of dealing with conflict. A recent study by Marr, Billings, and Weissman (2007) entitled “Spirituality Training for Palliative-Care Fellows” confirmed that even in palliative-care fellow training programs, spirituality training was not robust, nor were there standards to determine that fellows had obtained the desired attitudes, knowledge, and skills in this area. I refer readers to an interesting perspective that argues that physicians should not be linking religion to health. A 2000 New England Journal of Medicine article by Sloan et al. entitled “Sounding Board: Should Physicians Prescribe Religious Activities?” argues that the physician’s role is to provide evidence-based advice. Religion and faith are private matters. In the absence of adequate physician training, and in the absence of solid and generalizable evidence linking religious activity and health, the authors argue that linking them not only trivializes religion but is inappropriate in the context of medical practice. I hope you find this issue of San Francisco Medicine interesting. It is important that, as physicians, we understand the basic tenets and foundations of faith and religions. It is important that we strive to understand the issues of religious doctrine, faith, and ethics in the context of our duty as physicians to heal and do no harm. It is also important that we seek expert opinion when we feel that we are encountering such conflict in our own practices, even if it means arranging care for one of our patients by another physician. Yet it is equally important to remember that, difficult as these issues may be, we are enriched by them and their interplay with our profession. Dr. Follansbee is the 139th President of the SFMS. An infectious disease specialist, he practices with the Permanente Medical Group. He is Director of Travel Medicine as well as Director of HIV Services at Kaiser San Francisco.

may 2007 San Francisco Medicine 


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Editorial Mike Denney, MD, PhD

Religion and Healing

A

ccording to Harold G. Koenig, MD, director of the Center for the Study of Religion, Spirituality, and Health at Duke University Medical Center and author of many books, including Spirituality in Patient Care: Why, How, When, and What, “There have been more than 1,200 studies on religion and healing. Two-thirds to three-fourths of them find a link between religious practices and physical and emotional well-being. For example, religious patients are less likely to be depressed or anxious than others, and they’re more likely to be in better physical health, with better-functioning immune systems and lower blood pressure.” On the other hand, scrutiny of scientific studies of religious effects upon healing has exposed serious flaws. Lynda Powell, PhD, epidemiologist at Rush University Medical Center, reviewed nearly 150 studies on religion and healing and, noting scientific weaknesses, concluded that although subjective faith has its place in relieving suffering, it cannot be said to influence objective physical outcomes of disease. Reporting in The Lancet, Richard Sloan, MD, Professor of Medicine at Columbia University, cites weak data and erroneous logic. After evaluating the literature, Sloan says, “Doctors should feel free to refer patients to hospital chaplains, but that’s as far as the religious conversation should go.” Religious leaders have also criticized scientific study of spiritual beliefs, noting that to reduce God to biomedical statistics may be an arrogant affront to the divine. Raymond J. Lawrence, an Episcopal priest and director of pastoral care at New York-Presbyterian Hospital of Columbia University, states flatly, “Scientists who undertake the work of theologians are as reckless as theologians who pretend to be scientists.” Viewed from a mythological and historical perspective, these opposing arguments may seem superfluous. Religion has always been closely associated with sickness, health, and healing. The Encyclopedia of Religion (Macmillan) notes, “Healing occupies a singular and prominent place in religious experience throughout the world. Often the most important figure or symbol in any given religious tradition is the source of healing.” In their book Future Science, John White and Stanley Krippner offer names for spiritual healing energy from ninety-seven different cultures, including qi in China, prana in India, and num among the !Kung of the Kalahari. From the indigenous ancient shamans through the cultures of www.sfms.org

Egypt, Mesopotamia, and Greece, the priest-physicians emphasized religion in their healing methods. Then one day in the Asclepeion at Cos, Hippocrates turned away from the sacrificial altar, went to the patient’s bedside, and began to write down his empirical observations. Later, during the Renaissance and the subsequent Enlightenment, the practice of medicine became separated from religion as science established itself as the primary source of knowledge in Western culture. Today, our performances as physicians are evaluated and regulated by our ability and willingness to practice scientifically. Yet our objective science seems inadequate when it comes to measuring those religious aspects of healing that seem to be inborn. Many psychologists and philosophers, including Freud, Jung, Hume, and Kant, have described an innate natural propensity in humans to seek the divine. William James, the father of American pragmatic psychology, speaking of religious experiences, put it this way, “Treating these as purely subjective phenomena, without regard to the question of their ‘truth,’ we are obliged, on account of their extraordinary influence upon action and endurance, to class them amongst the most important biological functions of mankind.” At the very least, we accept the fundamental subjective reality that there seems to be something rather than nothing—and we can become awestruck when contemplating whence that “something” came. And when we become sick, our awe may turn to deep concern about our own place in the cosmos. And so it is that as in this issue of San Francisco Medicine we contemplate the place of religion in medicine, we quite naturally accept the reality that sick patients experience a relationship with the mystery of life and death. With articles on the many facets of the relationship of medicine and religion, we find a salutary union of objective science and subjective faith working together to heal both body and soul. In the words of the great theologian Paul Tillich in the book The Meaning of Health, “Only a medicine which denies the nonbiological dimensions of life in their significance for the biological dimension can come into conflict with theology. An understanding of the differences as well as the mutual within-each-otherness of the dimensions can remove the conflict and create an intensive collaboration of helpers in all dimensions of health and healing.” may 2007 San Francisco Medicine 


Religious Roots: Christianity and Medicine

A Partnership in Healing A Christian Perspective on the Relationship between Medicine and Religion Lizette Larson-Miller

T

he plethora of healing practices and claims made by various religious and spirituality groups must seem like a landslide of competing ideologies from the perspective of the health care profession. Even if individual health professionals believe in one or multiple versions of the practices, the sheer variety and number must give pause to those who strive for the best, from all sources, for their patients. Assuming the best of intentions from religious groups associated with healing, what is it that they hope to add to the well-being of the patient that cannot be addressed by medical attention alone? Almost inevitably, they try to address the entirety of the socio-psychosomatic person, by focusing healing rituals on those parts of the human being they perceive medicine might be overlooking; and/or they try to address a divine entity, whose perceived power goes beyond what scientific knowledge can produce, with intercessions for healing. But similarities of intent might not go much further than that, because the bases of belief and practice vary so widely among religious and spirituality systems. Even within Christianity there is variety in understanding of and approach to participation in healing, from prayer for acceptance of what God sends, to active prayers for healing, to a number of ritual actions performed for the sick individual. Knowing the difficulty of generalizing Christian understandings of what health, sickness, cooperation with the world of modern medicine, and effective healing rituals mean and can accomplish, and knowing that other specific approaches and practices will be addressed elsewhere in this journal, this essay hopes to contribute to the dialogue between religion and medicine by looking at two aspects of the relationship 10 San Francisco Medicine may 2007

from a Christian perspective: 1. The expectations and assumptions that may exist among individual Christian practitioners of healing and medical professionals; and

“Even within Christianity there is variety in understanding of and approach to participation in healing, from prayer for acceptance of what God sends, to active prayers for healing, to a number of ritual actions performed for the sick individual.” 2. Parallel developments in medicine and Christian healing that grow and benefit from engagement in the common mission of healing the sick.

Christian Healers and Medical Experts Not many Christians would object to identifying Christianity as a religious system vitally concerned with healing. While other religions could make the same claim, for Christianity the identification is rooted in Jesus the Christ and the record of his healing acts in the New Testament. While the majority of those accounts are based in compassion, the action of healing is generally presented as pointing beyond itself to a greater truth. The act of healing reveals the presence of the reign of God,

or the overcoming of eternal mortality; or it functions as a sign of the power and authority of God, or as a counter to human law and limited understanding. The ongoing story of Christian healing, then, is a story of continuing that witness and ministry. Only when Christianity is engaged in healing ministry is it fundamentally faithful to both its scriptural foundation and its tradition of practice and reason. The roots in the person of Jesus reflect for Christians the interest and belief in the possibility of physical healing, based on the goodness of creation and the incarnation of God. These roots also reflect a belief in a healing—a wholeness—that puts a person back together, giving peace, strength, and courage to deal with suffering, pain, and, perhaps, imminent death. The result may not be a physical cure but a healing to wholeness of life. Much of this rhetoric of healing and wholeness is not foreign to medical schools or hospital-based continuing education. The move toward treating the whole person, attending to emotional fears and mental health in addition to isolating and treating the physical ailments, has been increasingly a part of medical education for the past twenty years. In light of this common ground, why are there continuing tensions between health professionals and clergy, chaplains, or others concerned with prayer and healing? The reasons may be as varied as the individuals involved: discomfort on the part of health experts with the particular faith or approach of the clergy; a lack of expertise of many kinds on the part of the chaplain, clergy, or other person; a lack of time on the part of either or both to talk about how to work together; the perception that prayer and healing rituals get in the www.sfms.org


way of necessary medical procedures; or the perception that either party is not respectful or appreciative of the other. And often, if the illness is terminal, the overriding medical impulse to heal and sustain life may find itself at odds with an acceptance of death as neither defeat nor the end. There is also the potential that the same words may presume different meanings, as in the case of the concept of suffering. There is a misconception that Christianity is ambivalent toward or, worse, encourages suffering. To desire suffering is antithetical to Christianity and a misuse of the tradition. What Christianity does offer is that when suffering comes and is unavoidable, it has meaning (“pain demands a response, while suffering demands an interpretation”). Suffering as meaning, aside from the medical necessity of pain as an indicator of larger problems, is generally not a medical assumption, which may result in two different understandings of the reality of suffering. Perhaps a more articulate expression of terminology and beliefs from Christian chaplains, clergy, and others as well as a self-examined understanding of reactions and impatience from medical experts might result in more fruitful exchanges. In the end, the science of medicine deals with what can be discerned through concrete methods, human senses, or quantifiable results. Christian healing generally addresses what cannot be discerned in concrete ways, through human senses, or with quantifiable results. Christian engagement in the art of healing (as with most other religions) calls for seeing more than meets the eye, for remaining open to imagination and mystery even as practical and informed medical decisions physically sustain the patient.

Parallel Developments in Medicine and Christian Healing Of the many possible topics that could be used as examples of points of convergence between Christian practices and medicine, the parallelism between palliative care and palliative spirituality seems particularly notable these days. The rise of palliative care in medicine has grown from the English restoration of hospice care in the early twentieth century, www.sfms.org

then an exception and now a widespread and common practice, either within certain sections of hospitals, in residential hospice programs, or in dedicated hospice centers. The accompanying educational component in medical school curricula has meant increasing numbers of health professionals are familiar with the philosophy and the ethos of palliative care, regardless of their professional specialty. The situation in Christian healing practices is both similar and dissimilar, institutionally and individually. As long as Christianity has existed, there have been Christian rites for the dying that are distinct from the rites for the sick, but the categories spent a number of centuries being intertwined and confused, at least institutionally. The rediscovery of the distinctiveness in some denominations, along with the recovery of any of the practices in some churches of the Reformation in the past fifty years, has given rise to questions perhaps similar to those in the medical profession. When does one move from praying for recovery—for physical healing—to praying for reconciliation, for peace and acceptance, and for dying well? When does one move from aggressive medical intervention to assuring the patient of comfort, or at least a minimum of pain in dying? How does one engage the patient, the family, and other loved ones in the shift regarding treatment and prayer, while sustaining care and presence? How do doctors, nurses, and other health professionals on the one hand, and clergy, parishioners, and pastoral visitors on the other hand, better communicate with each other that medical and religious changes have been enacted? The reality is that many places have developed ways of sharing knowledge, especially in meetings with all concerned parties. Another reality is that, in some cases, neither medical advances nor changes in prayer and ritual can predict that a recovering person will not die or a dying person will not live. There is still the unknown, the surprise, or the miracle that gives caution to all concerned. Whether in increasing communication and cooperation between individual practitioners, or in recognizing parallel developments that can inform each other, it

seems apparent that here and in many other realities, religion and medicine can and are partners in healing and care of patients. Specifically Christian pastoral care of the sick tries not to duplicate what medical skills do better, but asks different questions and prays for the healing of the whole person in their relationship with God, with themselves, and with their communities. Most Christians include prayers for this cooperation, and for the individuals whose skills save lives through knowledge and care, as in this text from The Book of Common Prayer: “Sanctify, O Lord, those whom you have called to the study and practice of the arts of healing, and to the prevention of disease and pain. Strengthen them by your life-giving Spirit, that by their ministries the health of the community may be promoted and your creation glorified; through Jesus Christ our Lord. Amen.” Lizette Larson-Miller is a core doctoral faculty member at the Graduate Theological Union (GTU) and the Nancy and Michael Kaehr Professor of Liturgical Leadership at the Church Divinity School of the Pacific, a GTU member school. References DuBois, Paul M., The Hospice Way of Death (New York: Human Sciences Press, 1980) King, Dana E., Faith, Spirituality and Medicine: Toward the Making of the Healing Practitioner (New York: The Haworth Press, Inc., 2000. Selling, Joseph A., “Moral Questioning and Human Suffering,” in God and Human Suffering (Louvain: Peeters Press, 1990), p. 164. Stanworth, Rachel, Recognizing Spiritual Needs in People Who Are Dying (Oxford: Oxford University Press, 2004).

may 2007 San Francisco Medicine 11


Religious Roots: Judaism and Medicine

Moving toward Wholeness The Notion of Healing in the Jewish Tradition Rabbi Eric Weiss

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he notion of healing in Jewish tradition is multivalent. There are biblical, theological, and cultural roots to its development. At the core of this development is the notion in Jewish life that every person is created b’tzelem elohim, in the unique image of God. Part of our life’s task is to grow more fully into our God-created selves. Because each person, uniquely created in God’s image, represents something of the Divine, our diversity is a testament to God’s unfathomable creativity. As we live more fully in our God-created selves, both individually and communally, we become whole. Any act of healing brings greater wholeness. Fundamentally, healing is a journey toward wholeness. Hebrew is the core language of Jewish life. The word in Hebrew for healing is refuah. Among its many Biblical references is one in Numbers 12:13, in which Moses cries out to God that Miriam be healed: “Oh, God, pray heal her!” It shares, in modern Hebrew, the same root as the word for physician: rofeh. When someone is ill, we wish them a refuah shleimah, a full and complete healing. The Biblical vision of healing is essentially the notion that God heals a person who has a physical ailment. Modern theological reflections have expanded the Biblical perspective to include the idea that we need other kinds of healing. If we are created in God’s image, then our bodies are not the only part of our selves that is Divine. If we are to live fully in our God-created selves, then our emotional and spiritual lives contribute to a greater, deeper understanding of what it means to be fully human. We therefore become aware of the different ways in which we may need healing. A core Jewish value is God as Re12 San Francisco Medicine may 2007

deemer. It is encapsulated in the story of the Exodus and the experience of entering into a sacred relationship with God at Mount

“As we live more fully in our God-created selves, both individually and communally, we become whole. Any act of healing brings greater wholeness. Fundamentally, healing is a journey toward wholeness.” Sinai. Modern theological perspective has built onto this core relationship the understanding that we are healed by others, we can heal ourselves, and that we ourselves are capable of healing others. A simple example, though a controversial one, is the power of forgiveness. When we are forgiven, we return to a greater sense of wholeness. If we can forgive, we offer the possibility of deeper wholeness to someone else. The range of healing from the Biblical to the modern tells us that healing is not necessarily cure. We all know that no one gets through life unscathed. We all know that medicine may or may not cure. But we all know that nothing can ever replace the possibilities of human connection in the power of the human spirit. Somewhere, today, in a hospital nursery, there is a father who is holding his newborn daughter. Cooing in awe at her ten tiny perfect fingers, ten tiny perfect toes, somewhere in the depths of his spirit

he is saying something like, “My God, thank you.” Whether he can articulate it or not, part of his work as a father will be to support his daughter to grow into her full self. And somewhere, today, in an end-of-life care setting, there is a wife holding the hand of her dying husband. She is reflecting on their lives together. Remembering how they met, their wedding, their honeymoon, their years of raising children, somewhere in the depths of her spirit she is saying something like, “Oh, God, please.” Whether she can articulate it or not, she is reflecting on ways in which she and her husband led their lives as fully as they possibly could. In our city, today, this spectrum of life’s journey toward wholeness holds the hope for healing from the first breath to the last. Created in God’s image, we are born with a natural spiritual hunger. It is a hunger as natural as the need for food, shelter, and intimacy. We spend our lives trying to understand our spiritual hunger, seeking ways to satisfy it and become more fully ourselves. From a Jewish perspective, the healing journey is the lifelong hope to move to broader and deeper levels of wholeness. Rabbi Weiss is the Executive Director of the Bay Area Jewish Healing Center. To learn more about the center, see its website, www. jewishhealingcenter.org.

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Religious Roots: buddhism and Medicine

Healing Insight Relieving Suffering through Buddhism Gordon Fung, MD, and Gregory Fung, MD, MS, PhD

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uddhism’s relationship to healing as the practice of relieving suffering goes back to the first sermon by Sakyamuni Buddha. In this sermon, the Four Noble Truths were expounded in a format recognizable to any physician today, beginning with a diagnosis of the human condition (suffering), inclusive of an etiological explanation for that condition (desire), followed by the recognition that the condition was curable (cessation of suffering) by way of a treatment plan requiring individual commitment to lifestyle changes (the Eightfold Path). Since those words were spoken 2,500 years ago, Buddhism has spread from its origins in India throughout Asia and to the West. It is the primary religion for approximately 500 million individuals worldwide, including approximately two to four million persons within the United States. Since Buddhism’s founding, its teachings have been adapted, extended, and refashioned into numerous schools, sects, and divisions—each with its own traditions. Despite those modifications, there remains emphasis on the practice of knowing one’s motives, thoughts, and actions so that one might put effort into increasing wholesomeness (kusala), diminish unwholesomeness (akusala), and deepen wisdom (prajna). This insight provides the physician who is a practicing Buddhist with the understanding that each patient’s condition is more than simply the sum of his or her physiologic processes—that it is also significantly shaped by immediate anxieties, worries, and fears against the background of a lifetime of attitudes, perceptions, and habituations. These nonphysiologic concerns are as important as, if not more important than, the physiologic ones to be dealt with www.sfms.org

by the physician. By understanding these, the patient may come to understand symptoms, listen carefully to recommendations,

“Buddhism is a teaching that was formulated entirely with the goal of relieving suffering. As such, it offers a healing approach to everyday living, as well as a healing approach to curing diseases.” and manifest both the determination and the flexibility that are so important to any patient’s ability to adapt to and manage a condition—whether what are needed are short-term changes necessary to overcome an acute illness, or a lifetime of change designed to prevent or adapt to a chronic illness. The patient’s insights help guide the healer to address those fears, worries, and blind spots, which influence how the patient thinks about his condition and what he will do to help care for himself. These insights are informed and guided by the Buddhist teaching of compassion (karuna), which recognizes the complexities of each individual. For each person, help is defined as not only assistance in feeling better physically, but also as assistance in adjusting to recommendations and therapies that may cause risk or discomfort in their own right. Such compassion is manifested in many ways, including explaining a medical condition in a manner that is understandable to the patient, providing the reassurance that

helps a patient handle uncertainty and accept not only the risk but the discomfort of diagnostic and therapeutic regimens, and offering the comfort so often necessary not only to patients but also to those who care for them. Other complexities include the relationships that a patient has with family, friends, and coworkers. A patient’s condition and the management of that condition might influence and be influenced by those relationships. Other complexities, such as a fear of needles, enclosed spaces, medications, or surgery might prevent a patient from getting needed testing or might prevent him from accepting, or even consenting to, the required treatment. Buddhist compassion recognizes that these barriers arise from thoughts that have been colored and tainted by previous thoughts. These thoughts can influence present decisions and stop a patient from taking necessary actions. Buddhism asks us to be aware of these barriers, and to help patients recognize and overcome them. Buddhism is a teaching that was formulated entirely with the goal of relieving suffering. As such, it offers a healing approach to everyday living, as well as a healing approach to curing diseases. In the practice of medicine—which can be focused on small parts rather than on the whole—Buddhism reminds us that it is a whole person who is suffering from a disease, and that whole person is connected to other people. What each patient thinks can, and does, seriously impact the course of that suffering as well as the ability of both patient and physician to treat and manage that disease. Buddhism has been called a path of practice leading to insight into the true nature of life. For the

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Religious Roots: Islam and Medicine

Going beneath the Surface An Islamic View of Healing Naghmeh Rabii

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n an Islamic story, a particular neighbor of Muhammad often dumped refuse on the Prophet’s porch or on nearby paths. On one occasion, Muhammad noticed an absence of litter, so he went to the neighbor’s house to see if the man was sick and offered to bring him relief. In classical Islamic tradition, efforts on the part of physicians and others to heal the sick are regarded as sacred acts—as in Christianity, Judaism, Hinduism, and Buddhism. In Islam, there is a profound emphasis and pronounced directive to alleviate suffering and save lives; and there is a broader, transcendent meaning to the concept of healing. Speaking about hakims (sages, wise men, and doctors), Shaykh Fadhlalla Haeri, a master scholar whose ancestors were among the greatest teachers of the Islamic tradition, says, “The great hakims would often find medicine close to where the illness lay. The seeker of Reality views this world as a hospital in which he is a patient. Whether we like it or not, we are here to achieve ultimate well-being, which is to drown in the well of Oneness.” The use of the word reality in that statement points out that language plays a key role in Arabic, because inherent in the meaning of the word is an Islamic worldview. The word reality has an essentially different meaning in Arabic-speaking countries than in the West. In English the term reality is related to the Latin word res, which means “thing.” Embedded in this definition is an inherent materialism. In Arabic, the word for reality is haquiqa, the root word being Haq, which is a name of God. Al haquiqa means “The Real” and is something beyond this world. Similarly, the term iman in Arabic is related to an individual’s connection 14 San Francisco Medicine may 2007

to his Creator, or God Consciousness; translated broadly, it means “faith.” Iman literally means “to make oneself safe and secure.” According to the Islamic scholar and founder of the Zaytuna Institute in Hayward, California, Shaykh Hamza Yusuf Hanson, “The idea here is that faith is an anchoring element in the human experience, and a lack of faith creates a type of trouble or turbulence within the psyche itself.” This idea is especially relevant to individuals who are in the midst of a crisis—when they are ill, for example, or anticipating treatment such as surgery. Those are the moments when faith enters one’s consciousness. When such faith-based concepts and practices find themselves embedded in the more secular, scientific, and objective approaches of Western medicine, conflict may arise, and some amalgamation of science and spirituality becomes necessary. Faiz Khan, MD, internist, emergency physician, and Assistant Imam/Khateeb at the Islamic Center of Mid-Manhattan and the Islamic Center of Long Island, says, “Many patients hesitate to discuss religion and spirituality with their doctors precisely because they see the doctor as an ally of science, and science as antagonistic to or dismissive of religion and spirituality. The need to address certain concerns of the patients—which from the traditional religious perspective belongs not to the realm of mind as machine, but psyche as soul—has been well known by any experienced physician.” Dr. Khan recalls treating a hospitalized elderly Baptist woman who refused treatment to improve her lung disease. She said that she would rather not take the medicine but to rely on God to fix her. The woman’s sweetness, resolve, piety, and sincerity were readily apparent. Khan, a practicing Muslim

who was familiar with the place of religion in medicine, smiled and struck up a discussion about divine will with the patient as his hospital team fretted impatiently. Soon the woman chuckled and agreed to comply with the treatment—perhaps, according to Dr. Khan, because she felt more comfortable and less alienated from the hospital experience. Susan Stangl, MD, a family physician at the UCLA Medical Center, describes a reverse situation: a Western physician treating a Muslim patient. The incident occurred while she was discharging a Muslim patient during the holy fasting month of Ramadan. Perusing his chart for a spiritual history—routine for all hospitalized patients at UCLA—she chose a once-a-day medication that could be taken after sundown. Stangl reflects, “If we hadn’t talked about it, I would have written him a prescription for four times a day, and he would not have taken it.” Islam actually does allow dispensation for those who must take medications during Ramadan, but some people—doctors and patients—are unaware of this. From an Islamic perspective, including a religious component in purely scientific clinical medicine takes healing far beyond the goal of achieving a physical cure. It is a sacred practice. Pertinent to those whose knowledge of healing is purely physical, scientific, and objective, the Qur’an says of those who eschew the spiritual, “They know a bit about the outer surface part of this world’s life, whereas of the ultimate things they are utterly unaware.” Naghmeh Rabii is a research analyst specializing in health care for a hedge fund. She practices and studies within the Shiite Islamic tradition and is an avid reader of the poet Mowlana Jalaluddin Rumi. www.sfms.org


Religious Roots: Buddhism, yoga, and Medicine

The Future of Healing Well-Being through Buddhist Meditation and Kundalini Yoga Stuart Sovatsky, PhD

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wenty-five hundred years ago, an inquisitive Indian boy named Siddhartha was born into a royal family and given the following astrological reading: “The boy will become either a great saint, or a great king.” To deter him from the first unwieldy possibility, he was discretely sequestered from all visible suffering and surrounded only by pleasures and beauty. To see suffering at an early age might have awakened his compassion for others and distracted him from the luxuries of a courtly life. In such a mood, he might have veered toward sainthood. Despite all protections, however, Siddhartha one day glimpsed an old man laboring his way down a cobblestone street and was stunned by the sight. Minutes later, he saw a diseased person lying in great duress and was shocked. Then, happening upon a funeral procession, his heart plummeted as he fathomed the significance of the lifeless corpse. “There must be a way out of this!” he pondered in naïve disbelief. Within the next years, he did find the way out, just as Christ and many others have: Through an unswerving and compassionate regard for all who suffer (and after intensive meditations), he attained an extraordinary awakening and was known forever after as Buddha, “one who is awake.” He saw a glowing light that dwells in all beings and his own mortal fears subsided within an overwhelming love and maturity of spirit. His mere look or touch quelled fears in the despondent. His words repeated the ancient Truth: Know the selfless Self and love one another, and you will conquer death. Buddhist healing is believed to radiate from the person who has meditated perhaps tens of thousands of hours on metta, the www.sfms.org

mood of loving-kindness. We might say she has become the vibration of compassion, and her mere proximity conveys well-being. Will double-blind studies bear out this claim? If so, perhaps the most prestigious medical schools will one day include meditation retreats in their curricula. Indeed, last year Kaiser Diablo Valley Care chaplain Jurgen Schwing organized a “hand-blessing” meditation for the few dozen medical staff he expected, but more than a hundred showed up. In the further elaborations of Buddha’s primordial awakening, numerous other yogis (Thirumular, Abhinavagupta, Jnaneshvar Atmarama, and others) mapped out the more detailed warp and woof of this radiance—the soul’s anatomy, as it were—in scriptures known as tantras, the “expanding weavedness.” The “weaving” referred to the ways in which ever subtler dimensions of human subjectivity, the so-called “mentalemotional bodies,” penetrate into the ever more dense or objective dimensions of the fleshly body, known as anna-maya kosha, or “food-eating body.” Thus, in the fleshly body one feels the physicality of the throbbing heartbeat, while in the “subtle heart” one feels the subjectivity of love or concern. More subtle yet is another heart wherein the profoundly subjective awe of Being can be known, the pulse of Blake’s “fearful symmetry.” The tantric name for this body? Ananda-maya-kosha, the eternally blissful causal body. It is the basis of all spiritual experiences, including those that seem to transcend death. When Buddhist monks self-immolated while sitting in motionless meditation to protest the Vietnam war, the world got to see people deeply grounded in ananda-maya-kosha—and the world was

stunned. Some have said their unflinching martyrdom (in contrast to suicide bombing) crumbled the war effort. Such is the power of the awakened causal body. Gandhi called this inner power satya-graha, the power of embodied Truth. In the gestating fetus and in newborns, the inner radiance was named kundalini, “ultimate mothering energy,” due to its heightened developmental powers. Kundalini (and its precursor, pranotthana) wove the subtlest and most profound of human potentials into the densest dimension of bodily manifestation. Its activity is visible in the vibrations of chromosomes during meiosis, in the uncanny migration of cells from zygote into blastula, gastrula, embryo, and the budding forth of limbs, fingers, and facial features. As fetal development becomes complete, pranotthana provokes maternal birth contractions, as well as the later spontaneous stretching and jolting developmental movements of newborns. After the first couple years, things quiet down and we, for the most part, learn to conform our bodies to function in the society in which we live. Yet spontaneous or “inspired movements”—particularly those originating from the spine—in adults are described in numerous spiritual traditions worldwide. Indeed, their emergence often gels those affected into religious sects or cults to support their manifestation. From the perspective of kundalini, these inspired or ecstatic movements are continuous with gestation and neonatal development. In the Darwinian light of homo erectus and homo sapiens, their spinal origination stirs thought of an evolutionary significance. Cross-culturally, this would include the autonomic spinal-rocking

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Continued from Page 15... prayers of Judaic davvening and the Sufi zikr as well as the inspired axial whirling of the transported dervish. Other “manifestations” (as they are known among Pentecostals) can be seen in shamanic trance or “possession” dancing, the uncontrolled “quaking” and “shaking” of early Quakers and Shakers, in Eastern Orthodox hesychastic quivering, the “Holy Ghost” movements of Charismatic Christians, and in the more esoteric Middle Eastern schools of inspired belly dancing. This physical-spiritual energy can also be seen in Tibetan tumo heat, whereby barefoot Himalayan monks can endure subfreezing temperatures, in the spontaneous tai chi that underlies the formal practice, in Kaligari thxiasi num, as well as in the spinal tumescence known as uju kaya in Buddhism and seen in numerous other “upright” meditation traditions. In hatha yoga, the inspired movements are the kriyas (purifying maturational movements) of sahaja (naturally arising) yoga postures that occur during highly energized meditation. As Jnaneshvar (1275–1296), one of the most matured of kundalini yogis in the past thousand years, noted, “That is called [yogic] action of the body in which reason takes no part and which does not originate as an idea springing up in the mind. To speak simply, yogis perform actions [asanas, ‘postures’] with their bodies [spontaneously], like the movements of [babies].” (Jnaneshvar, 1987, p. 102) Thus, hidden within the many styles of yoga that some twenty million Americans now practice is another far more mysterious yoga, as innate to us as gestational movements. Yet it remains dormant unless the appropriate developmental conditions obtain. But, with so many people “doing” yoga, why don’t we see sahaja asanas? First, its recent Indian exporters intentionally shaped yoga to function more as fitness and stretching exercise than as an ecstatic spiritual practice, as Sjoman clearly showed; so the emergent shaking and quivering of devotional moods is largely excluded. Second is the dearth of matured kundalini-awakened gurus (such as Swamis Muktananda and Kripalvanand), whose mere presence would 16 San Francisco Medicine may 2007

evoke sahaja—akin to the way Elvis Presley could evoke screams and shudders in his teenaged audiences, but at a level far beyond adolescent puberty. Indeed, one of the oldest names for yoga is shamanica medhra, “maturing beyond genital puberty.” For, as my previous descriptions imply, this yoga is emergent from human passions that are forever breaking through one stage of maturation into the next, from wriggling newborns to gyrating teenagers, from davvening Jews, shamanic trance dancers, and holy rollers to deathdefying saints and charismatic healers. The summit of shamanica medhra was the complete awakening of the pineal gland, where bliss-inducing endorphins, neuropolypeptides, and photovoltaic melatonin cognates known as soma would secrete the most sought-after substance in the oldest of spiritual texts, the Rig Veda: the fabled elixir of immortality. Thus also the stunning sworn affidavit of Los Angeles mortician H.T. Rowe, who stated that, regarding the corpse of Autobiography of a Yogi author Paramahansa Yogananda, “No physical disintegration was visible in his body even twenty days after death…. No mold … desiccation … [or] odor of decay” (Yogananda, 1977, p. 575). Whether it is the simplicity of love uplifted to a profound and irreversible embrace of everyone and everything, or the mind-boggling complexity of bodily potentials so rare we have no English words to name them, one thing is for sure: Having read this far, you might begin to wonder if the intersection of Buddhism and yoga with modern medical science has only just begun. Indeed, we have translated barely ten percent of the Indo-Tibetan archive. With a few laboratory studies of little-known advanced yogis, our current holistic mind-body medicine might appear as a mere precursor to what comes next. Perhaps the next study will be of the wizened yogi who appeared at a recent Kumbha Mela “Great Gathering of Yogis” in India, who claimed he was more than 250 years old (Hebner and Osborn, Kumbha Mela, 1990, p. 59). Or perhaps we will become interested in the Indian sound healer, Shruti, who uses Sanskrit mantras to treat epilepsy. Or maybe Dr. R. Ganesh, who meditatively awakened

intellectual powers enabling him to learn seventeen languages; write twenty-four books; become expert in physics, biology, literature, and computer technology; and be able to engage in conversations with one hundred people simultaneously without losing his place with anyone. Should you want to meet either of these, they will be presenting (along with hundreds of other advanced meditators, shamans, and yogis worldwide) at the event I am coconvening in India in 2008, www.WorldCongressPS2008.org, to help what is next emerge a little sooner. If you want to know more, please contact Dr. Ricki Pollycove, who is convening a panel on Spirituality and Medicine, or me (at stuartcs@jps.net). Stuart Sovatsky, PhD, a Bay Area psychotherapist, studied religion at Princeton and psychology at the California Institute of Integral Studies, where he is a trustee. He is the author of Words from the Soul and Your Perfect Lips. References: Hebner, J., and D. Osborn, Kumbha Mela. La Jolla, CA: Entourage Publishing, 1990. Jnaneshvar, S. Jnaneshvari. Translated by V. Pradhan. Albany: SUNY Press, 1987. Sjoman, N. The Yoga Tradition of the Mysore Palace. Delhi: Abhiva Publications, 1996. Yogananda, P. Autobiography of a Yogi. Los Angeles, CA: Self-Realization Fellowship, 1977.

Buddhism Continued from Page 13... healer, this is a mandate to explain, comfort, and persuade at each step along the way, using the truth about what is really going on both inside and outside the patient. And for patients, this is a mandate to become cognizant of and commit to the changes they need to make to heal themselves. Gordon Fung is the Immediate Past-President of the San Francisco Medical Society. He specializes in cardiovascular disease and internal medicine at UCSF. His brother and coauthor, Gregory Fung, MD, MS, PhD, received his PhD in Asian and Comparative Studies from the California Institute of Integral Studies in 2003.   www.sfms.org


Religious Roots: Catholocism and Medicine

Patient-Centered Care Catholic Tradition and End-of-Life Care Carol Bayley, PhD

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y taking particular stands on the issues, the Catholic Church has contributed to the greater social understanding of medical ethics—particularly in end-of-life care. You may recall the first American “death with dignity” case, that of Karen Ann Quinlan. In the mid1970s, there was no established legal right to refuse treatment, no right to create an advance directive, no right to have one’s medical decisions made by a surrogate. In the absence of legal precedent, the Court looked to Catholic teaching for a coherent set of principles on which to base its decision regarding removal of mechanical ventilation from Karen Quinlan. For somewhere close to 500 years, the Catholic Church has taught that some medical treatment could be burdensome to a patient, and if it was too burdensome, the patient was not obligated to undergo it. This has always been a patient-centered evaluation, not a treatment-centered one. One traditional example regarded the moral obligation to undergo amputation. The Church fathers taught that because an amputation to a farmer would constitute a grave burden, interfering with his whole livelihood of taking care of his farm and his animals, the farmer was not obligated to undergo it. On the other hand, if the patient were instead a scholar, whose daily activities were not dependent on his ability to walk around, an amputation might not be seen as gravely burdensome; and if not, the scholar would be morally obligated to undergo it. Another example showed that burdens and benefits might include those of the financial variety. The thinking went that if a person could only sustain his life by eating partridge eggs (apparently partridge eggs were expensive at the time) and would www.sfms.org

bankrupt his family by doing so, he was not obligated to take the partridge-egg cure. Both stories from the tradition illustrate important points in the understanding of current Catholic moral thinking: First, moral obligation is a result of the calculation of burdens and benefits to the patient (which could therefore differ from one patient to another); second, any burden that is considered a burden to the patient, whether financial or psychological or familial, counts as a burden. In this, the Church anticipated what we would call a holistic view of the patient as someone with physical, spiritual, and emotional aspects, at least partly constituted by his relationships to family, society, and God. To be ethical, medicine must respect all these and not elevate any one—for example, the physical—above the others. Another important aspect of the traditional Catholic moral teaching on care at the end of life regards the management of pain. Contrary to the “drugs are bad” or “just say no” mentality physicians sometimes face when trying to aggressively and appropriately treat a patient’s pain, the Church has for many years taught that the appropriate management of pain, even with strong narcotics, was a morally laudable goal of medicine, even if pain control came at the expense of hastening the moment of death. As long as the intention of giving the drug was not to cause death but to minimize pain, Catholic tradition supported it. (Nowadays, we have many reasons for exactly the same trade-off: We know that a person whose pain is controlled breathes more deeply, rests better, and has emotional energy to complete important psychological tasks at the end of life. The Catholic Church taught it for a very religious reason: A person in

terrible pain was in danger of forsaking God at the moment of death.) Finally, as with many of the great religious traditions, Catholic teaching understands that death is not always the enemy, that all flesh is mortal, and that patients should be helped to prepare for death. Physicians can contribute to the ability of a patient to prepare for death by cleaving to their own Hippocratic tradition and not continuing to treat a patient whose “disease has overmastered him.” They can remove burdensome treatments while managing symptoms. They can also call in the reinforcements—the chaplains or priests who can minister to the dying person and his or her loved ones. Physicians may or may not know the religious belief system a patient holds. But even if the physician knows a patient is Catholic (or Jewish or Confucian), by that alone the physician does not know much. The Catholic tradition, like many, is a capacious tent. Patients who consider themselves Catholic may or may not subscribe personally to each and every teaching of the Church (think of the number of Catholics you know who believe birth control is morally acceptable). In some cases, they may not even be familiar with the tradition. As good physicians know, in every interaction with a patient—about lifestyle, compliance, or religion—it’s always best to ask. Carol Bayley, PhD, is the Vice President of Ethics and Justice Education at Catholic Healthcare West, San Francisco.

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medicine and religion: in the hospital

Spiritual Healing in the Hospital An Opportunity to Learn at CPMC Sat Kartar Khalsa-Ramey and Landon Bogan

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very day in the hospital, there is someone crying out to God—a new birth is taking place, a person is being moved off life support, or a family needs comfort in their loss. Every one of these situations is an invitation for spiritual healing to take place and the sacred to be honored. At these significant moments in life, we continue to rely on and need this kind of ministry. For more than forty years, the Spiritual Care Department at California Pacific Medical Center has trained chaplain residents from around the world in the art of spiritual care. The hospital offers a unique setting for learning, and there are many opportunities for the chaplain residents to attend to the spiritual and emotional needs of patients, family, and hospital staff. The aim of our Clinical Pastoral Education (CPE) program is to help chaplain residents take their faith tradition (often learned in seminary or formalized educational programs) and integrate an embodied spirituality into the way they meet and minister to others. Our program is a multicultural, interfaith professional training program for people headed into careers in hospital chaplaincy or for those seeking to deepen their skills in the parish or other ministries. It is also an integral part of the Institute for Health & Healing, the integrative medicine program at the California Pacific Medical Center. As spiritual care providers, we may enter at any point in a person’s journey in the hospital. Sometimes it is a life-defining moment. On one occasion, a chaplain was 18 San Francisco Medicine may 2007

called to the bedside of a fifty-five-year-old man. Shortly after being admitted to the hospital, the patient received a diagnosis of stage IV cancer, and he died within a month. During his hospitalization, the multidisciplinary team, which included the

The meditation room at CPMC.

chaplain, played a significant part in the care and healing of the patient and his family. In the case above, it may be difficult to imagine what could be called “healing,” given circumstances that are irreversible. Webster’s Dictionary defines healing thus: (a) to make or sound whole; (b) to restore to health; (c) to cause an undesirable con-

dition to be overcome. When cancer or another life-threatening illness takes its hold on life, and impending loss is looming, these notions of healing are often forgotten. Still, healing is needed all the same. One age-old practice of making whole is to include the sacramental, or to make sacred. For example, when the chaplain entered the room shortly after the patient died, the family was standing around the bed sharing memories of their beloved father and husband. Space was held for them to speak about the meaning and purpose of his life—to restore him in their memory. By sharing their stories and memories, they were asserting his life’s value in the face of death. Just as the patient’s family was impacted by the news of his medical condition, so too was the multidisciplinary team of practitioners who participated in his care. They also needed to share their feelings about his death. In CPMC’s Schwartz Rounds, a forum where caregivers can discuss emotional and social issues that arise in caring for seriously ill patients, the care team talked about the impact of the patient’s life and dying process, and their part in it. There was discussion about how patients impact staff in very personal ways. One social worker remembered the death of her father and described it as a defining moment in her life. Sometimes it is healing to remember people for their very best qualities and attributes, thereby restoring them to health in our remembrance. But another definition

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Sacred Spaces in San Francisco Hospitals In keeping with this month’s theme, Medicine and Religion, we traveled around San Francisco to find the sacred space in each of the city’s hospitals. The spaces varied from religious to secular, spacious to intimate, modern to traditional. Some were filled with people—either praying or awaiting a service. Some had only remnants of those who visited—a piece of paper in the prayer box, or a melted candle. One common thread through each sacred space was the calm, peaceful environment it provided in the middle of a bustling, busy hospital. Photos by Ashley Skabar.

Father Rory Murphy of Seton Medical Center smiles at those who await his noon sermon.

Seton Medical Center Chapel has a noon mass daily.

Saint Mary’s Medical Center broadcasts its services to televisions in each patient room

The meditation room at St. Francis is a quiet place to pray.


Sacred Spaces in San Francisco Hospitals Continued...Photos by Ashley Skabar

The staff chaplains of Saint Mary’s Medical Center, from left to right: Timothy Yip, Chaplain Resident; Jane Hetherington, Chaplain Resident; Amy Upchurch, Chaplain Resident; Blake Arnall, Staff Chaplain.

The meditation room at UCSF Mount Zion echoes of waterfalls.

St. Luke’s Chapel is complete with a stunning stained glass window.

The meditation room at Kaiser Permanente provides a peaceful escape.

The American flag stands tall in the VA Medical Center Chapel.


medicine and religion: in the hospital

Religious Diversity Volunteer Chaplains Serve a Wide Range of People at SFGH Elizabeth J. Welch, MDiv

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hen I entered the room, more than fifteen family members were crowded around the patient. A few wept openly; one lovingly stroked the patient’s hair; one chanted a prayer in a slow, steady voice; others stood with heads bowed and eyes closed, their lips silently mouthing the familiar prayer. A nurse quietly circled in and out of the room, weaving agilely through the crowd to give the patient medications and monitor the machines keeping her alive. In a family conference with physicians, nurses, social workers, and chaplains, the family began to discuss whether or not they should withdraw artificial life supports and allow the patient to die. They asked many questions about her medical prognosis, but they primarily focused on two questions: “What does God want?” and “Could there be a miracle?” On my way to lunch, a patient stopped me in the hallway and pleaded, “Please pray for me to be healed.” Later in the afternoon, I visited the spouse of a patient who was concerned that the hospital food lacked the qi, or vital energy, needed to restore the patient to health. These are typical situations that chaplains face every day at San Francisco General Hospital. Our volunteer chaplains support the faith, beliefs, and values of patients, their loved ones, and staff. Sojourn Chaplaincy at SFGH is a multifaith chaplaincy. One moment a chaplain may be supporting a declared atheist who is struggling to make meaning of his diagnosis, and the next she may be praying to Jesus with a dying Christian patient. How do we train chaplains to work in the wildly diverse environment that is SFGH? Often people assume that we teach about various religious traditions and belief systems. But the reality is that www.sfms.org

Welch pictured above in the non-denominational chapel at SFGH

understanding the tenets and rituals of a particular faith tradition tells me very little about the spiritual needs of an individual. Instead, we help our trainees deepen their self-awareness and develop active listening skills. Self-awareness is essential because a chaplain must understand her own beliefs, values, and biases before she can honestly affirm an individual with conflicting beliefs or dissimilar life situations. And one of my first lessons in training as a chaplain was to realize how rarely we really listen to one another. How often do we find ourselves listening with one ear while mentally going over grocery list, or smiling pleasantly while asking ourselves, “How can she think that!” I am reminded daily that the spiritual lives of human beings, like our physical lives, are complex. A patient who was raised as a Roman Catholic but now identifies as a Buddhist may find herself saying the Hail Mary she remembers from childhood as she lays dying in a hospital bed. A physician who identifies as a humanist may feel bewildered and frustrated when a patient suddenly refuses to take pain medication because he needs to “be alert to repent and pray to God.” I used to think of medicine and religion as sometimes in conflict and sometimes in synch. Now I see simply that both are pieces of the complex reality of being human in the world. One cannot be separated from the other, because both religion and medicine are tied to the deepest realities of being human: our ability to inflict hurt and our ability to extend healing, our desire for happiness, the inevitability of suffering, the certainty of mortality, and, perhaps above all, our search to make meaning of our lives. One of my mentors once told me that every

patient has two questions: “Am I alone?” and “Am I loved?” In my experience, every human being asks these questions, and—if asked honestly—these questions place us in a space of vulnerability, a space of needing one another. And perhaps this space of vulnerability is where both religion and medicine need to return more often. Both religion and medicine have proved they have the power to bring healing and the power to cause suffering, both have the power to bring dignity and the power to dehumanize. In my experience, physicians are required to see too many patients, they have too little time to spend with each individual, they are progressively paid less and less, and they must live in fear of malpractice lawsuits. At the same time, chaplains and spiritual care are cut from financially struggling facilities. Meanwhile, patients state that they want physicians who listen and they need spiritual and emotional support. I have come to believe that justice in our health care system, a justice that respects the dignity of all human beings—patients and medical personnel alike—will be achieved only when medical and religious leaders can lobby together for reform. Elizabeth Welch, MDiv,is the Coordinator of Programs for Sojourn Chaplaincy at San Francisco General Hospital and is in the process of being ordained as an Episcopal priest. Sojourn has a twofold mission: to train clergy and lay persons to offer compassionate spiritual support to diverse populations; and to offer emotional and spiritual support to the patients, their loved ones, and the staff of SFGH. Sojourn is a multifaith, nonprofit organization and operates primarily through the assistance of private donations.

may 2007 San Francisco Medicine 21


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medicine and religion: in the hospital

Dealing with a “Difficult” Family A Tale about the Importance of Understanding a Patient’s Religious Beliefs Evelyn Hadadd, MD

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very night, I saw them gathering in the hall. Being the CCU resident, I didn’t think about what family member was lying in the intensive care unit. I didn’t know if the patient was getting better or worse. The only contact I had with this family was a glance as I walked by them in the hall on my way to catch a few hours of sleep before the next admission. Two weeks passed, and I continued to walk by and simply smile. I smiled because as I passed them they would continue to speak to each other loudly, and what most people perceived as unintelligible noises were, to me, familiar words. One night, as the next rotation started, I looked at my list of my patients and realized that this family’s patient was now mine. I had switched rotations and was now the ICU resident. The sign-out told me about the patient’s chief complaint, which read, “Difficult family situation.” As I walked into the “difficult family situation,” I wondered how everyone involved had negotiated their way into it. The family was able to stay in the patient’s room twenty-four hours a day—despite many signs that posted the limited visiting hours and the clear policy stating that family members were not allowed to be in the room during rounds. But relatives were sitting in the patient’s room watching and criticizing every move that the medical staff made. I had heard stories of how they made a respiratory therapist cry, made Attendings wait half an hour for a family meeting, and how they almost broke into a fistfight with a nurse. The case was difficult on many levels, including the diagnosis, the lack of treatment options, and the family dynamics. But how could this have escalated to such a level? Instead of feeling anger or hesitancy, I www.sfms.org

was excited to meet them and use my Arabic. Most people don’t realize that I am half Middle Eastern, and neither did this family.

“Living in San Francisco, we are constantly presented with cultures that may not be familiar. How do we, as physicians, deal with that challenge?” When I met them, instead of saying “Hi,” I said, “Marhaba,” and of course they looked surprised. I went on to introduce myself in Arabic, and I stated that I would be the resident who would now help take care of the patient. With that, the family conveyed a flood of information to me. Their anger and distrust of the hospital seemed to ring out loud. I wondered how this could be, since the message I had received from my previous colleague was that the family was causing anger among the staff, and the staff did not feel the family had its sick relative’s best interests at heart. How could the same situation be perceived so differently by each group? As I look back, I realize that the root of the conflict was poor communication, communication that seemed to have failed at every level. The family made it hard to communicate by not coming to scheduled family meetings and instead visiting the patient at late hours. The hospital made it difficult by failing to communicate and enforce the guidelines regarding visiting hours. The staff did not realize the importance of labeling the patient’s disease as a “neuromuscular disease” instead of ALS—a significant

distinction to the family. Communication was lacking not only in the words each party chose, but also in the body language and actions each party used. Living in San Francisco, one of the melting pots of society, we are constantly presented with cultures that may not be familiar. How do we, as physicians and caregivers, deal with that challenge? As I grow as a physician, I have realized the importance of good communication. When a difficult family situation is brewing, the importance of open communication becomes even more evident. Our customs and traditions influence our reactions, and despite the same inner feelings we all possess, the ways an individual or family reacts to and deals with any event can vary a great deal, depending on the norm of their culture. As I watched this family, it was difficult not to compare their reactions to what mine might have been. I find myself doing this with all my cases, and if a patient’s or family’s reaction is similar to mine, the situation usually passes without a scene. If their reaction causes a great emotional effect in me, I try to stop and figure out why. As I viewed this family, sitting by the relative’s bedside twenty-four hours a day, watching every move the medical staff made, it was easy to know why their actions bothered my colleagues. They seemed to be attacking and criticizing everything everyone did. But for my part, I could easily imagine my own family refusing to leave my bedside, feeling no one could take care of me as well as they could. Taking this into consideration while watching the family yelling and demanding certain privileges caused fewer harsh feelings to arise in me than in my colleagues. My ability to empathize with the family played a larger part in my reaction. may 2007 San Francisco Medicine 23


medicine and religion: a closer look

Sacred Dying Becomes Us Religion and Medicine for End-of-Life Care Megory Anderson

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nd of life, it seems, is beginning to come out of the closet. A number of new books about end-of-life issues and the medical community have recently made headlines. Last Rights: Rescuing the End of Life from the Medical System (Stephen P. Kiernan, St. Martin’s Press) and Pauline Chen’s Final Exam (Knopf) are two that have appeared in the last few months. In these writings, authors consistently stress that the spiritual needs of the dying are basic, yet underserved, needs. Traditionally, Western culture held that religious rites and practices took precedent; dying was a spiritual act. However, as our society became medicalized in the late nineteenth and the twentieth centuries, religion’s role and traditions dwindled away. Death is now marginalized—it is the enemy—and for clinicians, the ultimate failure. As medicine took over in the care, treatment, and standards of end of life, religious communities grew more uncomfortable, knowing less and less how to interact, not only with the dying but with medicine in general. The historical dance between medicine and religion has always been an uneasy one. Who leads? Who follows? Who even gets to choose the music? Today, medicine is still very much the “decider.” The hospice model of an integrated team approach is a good one, and palliative care is gratefully modeling that; but for the most part, religious communities have given up their role in orchestrating the deathbed. Even funerals are less and less in religion’s domain, as memorial “celebrations” tend toward secularization. A majority of the surveys we use today to understand the psychosocial needs of the dying tell us that spiritual/religious needs are 24 San Francisco Medicine may 2007

listed at the top, along with pain control and not dying alone. And yet those needs are not being met. In the Journal of Clinical

“Traditionally, Western culture held that religious rites and practices took precedent; dying was a spiritual act. However, as our society became medicalized in the late nineteenth and the twentieth centuries, religion’s role and traditions dwindled away.” Oncology (February 2007), a study headed by Tracy A. Balboni assessed end-stage cancer patients. Eighty-eight percent of the population reported that religious/spiritual concerns were important for coming to terms with their illness and pending death, adding significantly to their quality of life (QOL). However, 72 percent said that they were supported “minimally or not at all” by their medical team, and virtually half (47 percent) said that their spiritual needs were not met by representatives of religion. So what are we to do? Send in a chaplain to say more brief prayers? Not good enough, the dying say. Craft ethical answers to tricky situations? Helpful to some, but generally not immediately applicable to the person dying of cancer in Bed 25A. What do dying people want? In the work that the Sacred Dying Foundation has been doing over the past ten years, I have

found that they want to be cared for physically and palliatively; they want to have dignity and respect for this very important experience they are going through; they want a community of people to love them and be present with them; and they want time and opportunity to make peace with life, their death, and with the Divine.

Community. Presence. Prayer. Acceptance. What does that look like for practitioners in our medical and our religious institutions? I am not suggesting that clergy start practicing medicine, and that physicians begin having spontaneous healing services. However, the lines between body and spirit come together most significantly when a person is preparing to die. Yet, ironically, physicians and clergy are often extremely uncomfortable with death. And that means they don’t know how to be with those who are going through it. One of the things I hear from dying people quite often is, “My doctor has been taking care of me all through this ordeal, and now when I need him the most, he disappears. Couldn’t he just stay here with me a little bit? Tell me it is going to be all right? Just sit with me a few moments? I’m scared.” But many doctors think that is the job for clergy. And many clergy think the dying person is being cared for by the medical persons. We leave our dying in the netherworld, with no one really taking care. Sometimes, though, it is different; vigiling can serve as a bridge from this netherworld to the next world. I sat vigil with an elderly woman who seemed to take

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medicine and religion: a closer look

Pastoral Care at St.Gregory’s Healing in a Religious Community Lynn Baird, Cheryl Hendrickson, and Sara Miles

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raying and caring for one another, and for strangers, is at the heart of our spiritual life as a community. At St. Gregory’s Episcopal Church, we don’t provide pastoral care with the expectation that we can fix all problems or cure all illnesses and sorrows. Although we understand that there are clinical, medical, and psychological dimensions to pastoral care and to healing, we don’t pretend to be doctors or psychologists. Our focus is on spiritual support: We believe that by opening ourselves to others and accompanying one another through ordinary human joys and suffering, we will find more of God. Praying with others, sharing their grief and delight, and offering or asking for practical help opens us to receive what Jesus calls “life, abundant.” Cheryl Hendrickson, a member of St. Gregory’s, volunteers as a chaplain at San Francisco General. “When I randomly entered an ICU,” she writes, “I met Leon’s mother. I learned that Leon had been shot in the back of his head, execution-style, leaving him unconscious. Leon’s mother tried to reveal a bit about her only son, and then she told me, ‘I went home and cleaned his boxers. I did it out of habit, but he might not need them again.’” “Then the mother asked, ‘Honey, do you have kids?’ “‘No,’ I replied. “I started to wonder what I could do for the mother. I could have stayed and ‘fixed’ the problem, telling her that things would be fine and that God was working a purpose out, or something cheesy like, ‘God needs Leon up there.’ I did not know Leon. I could have left the room, giving the mother time to be alone with her son. That would have been easy. I could have left the www.sfms.org

image of tubes, breathing machines, and loss behind. “There was a third option, staying and

“Our focus is on spiritual support: We believe that by opening ourselves to others and accompanying one another through ordinary human joys and suffering, we will find more of God.” being. This meant that I needed to sit with my own fears of losing a family member and to sit with the fear that, as a childless chaplain, I was inadequate. “I stayed with the mother and I just said, ‘This has to be so hard.’ She looked to her son and she cried and I did not leave. I did not leave and I was uncomfortable. There was nothing I could ‘do’ but be comfortable with the uncomfortable feelings and believe that God was present in that space. In a space that was very close to the ground, very unadorned.” At St. Gregory’s, pastoral care is not the property of one pastor—the traditional overworked parish priest who hears all confessions, visits all the sick, counsels all troubled souls, and manages the health of an entire dependent congregation. Instead, we see pastoral care as the responsibility of a healthy and mutually pastoring congregation. The work is peer- and communitybased, serving church members, visitors, and the broader community. It relies on a network of trained volunteers work-

ing—usually in teams—under the direction of a pastor. We offer practical, logistical support for patients and families during emergencies and illness; prayer, calls, and pastoral support during illnesses and deaths; and spiritual and emotional support through individual and group meetings. We maintain contact with homebound members and reach out to those in trouble. We offer healing prayer after church services and coordinate ongoing support groups (for example, for those dealing with aging parents or chronic illness) and special trainings (for example, on end-of-life issues). We work with St. Gregory’s Food Pantry to serve the more than 400 low-income families who come to the church every week for groceries. Our pastoral care e-mail list, with more than a hundred subscribers, circulates requests for prayer and serves as a forum for staying abreast of pastoral care issues in the community. Because we’re Christians—a religion of incarnation––a lot of our pastoral care is intimately about bodies. We touch one another liturgically and in healing prayer; we share bread and wine together; we carry the sick, hold the injured, and rub the feet of the dying. St. Gregory’s—a church known for its liturgical dancing, its integration of children and adults in services, its fullthroated a cappella singing, and its feeding of the hungry––doesn’t separate the “spiritual” from the “physical.” Our baptismal font, an outdoor rock fountain, is just a few feet away from the columbarium that holds the ashes of our members. Our spiritual life is grounded in physicality: touch, bread, wine, oil. Lynn Baird, the priest who developed the pastoral care program at St. Gregory’s,

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CPMC Continued from Page 26... of healing includes “causing an undesirable condition to be overcome.” For example, some of the care team involved in this case entered at a very different point in the patient’s care. They encountered a family

Chaplains Pray with a hospital visitor in need.

restore their hope in life again. This case illustrates the ways in which spiritual care may attend to the healing that is needed with patients, family, and staff. The chaplain stepped into the cycle of the patient’s life at a critical moment. The patient’s experience had an impact on his family, and there was a ripple effect as it impacted all those who surrounded him. Reflection on this experience happened at many levels: in the chaplain’s training with peers and supervisor, in the room with the patients, and in the context of Schwartz Rounds with the hospital staff. The reflection broadened the chaplain’s pastoral identity and offered hope to the family, just as it broadened and brought hope to all those who shared in the patient’s care. While the patient was not restored to physical health, the spirit of his life did live on through the sharing of his memory. One participant quoted Dylan Thomas’s poem “Do Not Go Gentle into That Good Night,” reminding us to “rage, rage, against the dying of the light.” The chaplain came

who needed to express anger and pronounce death’s injustice. The lamentations of the Hebrew Scriptures illustrate this universal human need quite well, saying, “I am the one who has seen affliction.… [God] has made me sit in darkness like the dead of long ago” (Lamentations 3:1,6). Such expressions of one’s affliction are often needed to overcome the painful circumstances of death and loss. A healing act can be to simply hold space for this emotional expression to be heard. For this family, loss was additionally significant because meaning and hope for the future were tied to the person who had just died. His death represented the loss of hope and future for the family. After sharing their stories, their anger, and their views about death with the chaplain and multidisciplinary care team, the family members were eventually able to Everyone joins hands as a sign of support. 26 San Francisco Medicine may 2007

to see healing in the hope that was restored for the family as they honored their loved one, wrestled with the significance of his death, and created for themselves a new vision for the future. Sat Kartar KhalsaRamey, MA, is the Director of Hospital Chaplaincy and Clinical Pastoral Education at California Pacific Medical Center. She was ordained by Sikh Dharma of the Western Hemisphere and is responsible for creating a healing ritual called “Blessing of the Hands,” which is now offered at hospitals throughout the country and which honors the healing work of nurses and other hospital staff. Landon Bogan, MDiv, is a chaplain supervisor at California Pacific Medical Center and a candidate for certification in the Association for Clinical Pastoral Education (ACPE). He is an ordained minister in the Presbyterian Church, USA, and a graduate of Princeton Theological Seminary. For more information about Hospital Chaplaincy, Clinical Pastoral Education, or the Institute for Health & Healing at California Pacific Medical Center, please visit www.myhealthandhealing.org. Photos courtesy of CPMC.

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Sacred Dying Continued from Page 24...

St. Gregory’s Continued on Page 25...

her dying very slowly. It was evening, and her family had decided to wait until after she died to travel across country. (“There’s really nothing we can do.…”) So I was alone with her in the hospital room. We had some soft music on, a candle glowed quietly, and I had prayed familiar prayers. The book at her bedside had been open, and I was reading to her when a doctor in scrubs walked in. “Are you family?” she asked me. “No,” I replied. “I’m just here so Martha won’t be alone. We’ve done a few rituals, and I think she is ready to go soon.” The doctor nodded, and then looked at the book. “What are you reading? The Bible?” I smiled. “No, it’s actually Jane Austin. I saw she was a fan. Maybe thoughts of Mr. Darcy will help Martha happily home.” The doctor smiled at that and then asked if she could take a turn at reading. I handed over the book and as we heard about Elizabeth Bennett and her struggles with the ever-prideful Mr. Darcy, I took out some oil and began to rub Martha’s feet. I felt her shudder a bit and then her body relaxed into the rhythm of the words and the warmth of my hands. As the doctor and I stayed together in the room, listening to the quiet of the night, watching for signs of changing breaths, I saw the reality of medicine and religion in that meeting place. We created a quiet and sacred space for Martha, and then we sat with her so she wouldn’t be alone. We couldn’t “fix” or “heal” her; we couldn’t even guarantee her entrance into heaven. Her dying was totally her own. Our job was to hold the space and be present with her. And we did that together.

writes, “What is pastoral care? The best im- Knowing that you are not alone makes all age I have was given to me by a parishioner. the difference in the world. She came to me and said, ‘I think I know “We also pray for those around the sick: what pastoral care is. When my mother was the doctors, nurses, and other care facilitadying, L. would sit next to me at church and tors, that they will be blessed with wisdom hold my hand while I cried, and she would and compassion as they perform their minischeck in with me regularly. It was like walk- tries of care and healing. We pray for family ing through a swamp with my head tilted members that they will have patience and back and my nose just clearing the muck. strength for the journey. But she was willing to not have any answers “The relationship between religion and and hold my hand and walk by my side.’ healing means walking through the swamp “As hard as we try to stay healthy, together, holding hands, supporting those sooner or later we will get sick. The bottom who are weak, allowing ourselves to be line is that we all die; we don’t like to think supported when we are weak, knowing that about that fact. Acute illnesses can be cured, together we will get to the other side.” but some of us live with chronic illnesses. I As our caregivers know, there are all am one of those: My own relapsing-remit- kinds of healing, and very few of them look ting multiple sclerosis, after almost twenty miraculous. Prayer does not cure mental years, is becoming more progressive. The illness; prayer does not cure tuberculosis or congregation has always known about my Down’s syndrome or even a cold. illness and I often preach about it and the At St. Gregory’s, we believe that impact it has on my life. I also preach about people find healing through experiencing the gifts it has brought me. That is not to be themselves as connected to other human Pollyannaish about suffering. To be blunt, beings, and to God. Pastoral care supports suffering sucks. that healing and offers a space for individu“Being in the presence of someone’s als to both receive and give help. suffering for which you can do nothing provokes an almost universal reaction: the desire to run away as quickly as possible. It is frightening to Valley Medical Billing Services be with someone who is suffering and to feel Accurate & Complete helpless in the face of anguish and uncertainty. It brings us up close We are a full service billing company currently to our own vulnerability accepting new clients. Our dedicated staff and the uncertainty of brings over 30 years of experience to each life. account. We are a proud member of the “Being part of a pasAmerican Billing Association, Better Business toral care community means learning to be Bureau and the Chamber of Commerce. with those who are suffering even when you 2155 W. March Ln. Ste. 3D feel helpless. I believe Stockton, CA 95207 we are not helpless. We can be beacons of hope (209) 475-0309 Phone ~ (209) 475-0387 Fax and light for one another, holding the faith valleymedicalbillingservices@yahoo.com that God is at work even www.valleymedicalbillingservices.com when we can’t see how.

Megory Anderson is Founder and Executive Director of the San Francisco-based Sacred Dying Foundation. She is a member of Saint Gregory Nyssa Episcopal Church, where she has been a part of a community that takes care of its dying.

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may 2007 San Francisco Medicine 27


medicine and religion: a closer look

Science and Prayer An Update on the Status of Clinical Research Mike Denney, MD, PhD

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erhaps the most assertive and certainly the most celebrated advocate for prayer in healing has been Larry Dossey, MD, who has written extensively and lectured widely to present the scientific evidence. In his 1993 book, Healing Words (HarperCollins), Dossey states emphatically, “The most important reason to examine prayer in healing is simply that, at least some of the time, it works. The evidence is simply overwhelming that prayer functions at a distance to change physical processes.” In a later article, republished in 2004 in the anthology Consciousness & Healing (Churchill Livingstone, 2004), Dossey’s apparent enthusiasm remains unabated, but his language shows a subtle maturation. This time, he says about prayer for healing, “It apparently works. An impressive body of evidence suggests that prayer and religious devotion are associated with positive health outcomes.” Thus, Dossey changes his previous unequivocal semantics, now using instead phrases such as “apparently works” and the “evidence suggests.” He no longer implies a direct causal relationship of prayer to “physical processes,” and he removes the phrase “at a distance,” weakening his previous use of “nonlocality” in quantum physics as a theoretical basis. Dr. Dossey’s change in rhetoric seems parallel to developments in the overall results in research on prayer and healing. In the fourteen years since his original statement, many scientific studies have been done on the use of intercessory prayer for a variety of maladies, including rheumatoid arthritis, kidney failure, wound healing, anxiety and depression, alcoholism, drug addiction, infertility, and heart disease as treated in coronary care units, cardiac catheterization, and coronary artery bypass 28 San Francisco Medicine may 2007

surgery. Most of the early research was done without adequate controls and with too few case samples for statistical significance. In 1988, a controlled study of 393 patients in the coronary care unit of San Francisco

General Hospital, conducted by Randolph Byrd, MD, cardiologist at University of California School of Medicine, showed some statistical positive results. Conclusion: The control patients required ventilatory assistance, antibiotics, and diuretics more frequently than patients in the prayer group. In 1999, Harris et al. at Saint Luke’s Hospital in Kansas City reported on patients in coronary care. Conclusion: Prayer may be an effective adjunct to standard medical care. In 2000, Matthews et al. at the Arthritis/Pain Treatment Center in Clearwater, Florida, studied forty patients in a private rheumatology service. Conclusion: In-person intercessory prayer may be a useful adjunct to standard medical care for certain patients with arthritis, but supplemental distant intercessory prayer offers no additional benefits. In 200l, Leonard Leibovici of the Department of

Medicine, Rabin Medical Center in Israel, studied 3,393 patients who were hospitalized with bloodstream infections. Conclusion: Remote intercessory prayer said for a group is associated with a shorter hospital stay and shorter duration of fever. Recent studies have been more carefully designed and controlled. In 2001, Aviles et al. at the Mayo Clinic studied 799 coronary care unit patients. Conclusion: As delivered in this study, intercessory prayer had no significant effect on medical outcomes. In 2005, Krucoff et al. at Duke Clinical Research Institute studied 748 patients who were undergoing percutaneous coronary intervention. Conclusion: Neither masked prayer nor music, imagery, or touch therapy significantly improved clinical outcomes. The most recent, significant, and scientifically rigorous study was overseen by the longtime proponent of spirituality in healing Herbert Benson, MD, Director of the Mind/Body Medical Institute, Beth Israel Deaconess Medical Center of Harvard Medical School, together with researchers at five other medical centers. In 2006, the long-awaited results of the study were published in the American Heart Journal [151(4): 934–942]. The patients, all of whom underwent coronary artery bypass surgery, were divided into three groups: 604 received prayer after being informed that they may or may not receive prayer; 597 did not receive prayer after being informed that they may or may not receive prayer; 601 received prayer after being informed that they would for certain receive prayer. Conclusion: Intercessory prayer itself had no effect on complication-free recovery from CABG, but certainty of receiving intercessory prayer was associated with a higher www.sfms.org


incidence of complications. In what may be an up-to-date trend in prayer research, one careful and expert evaluation is offered by the Department of Psychology at the University of Syracuse, in the August 2006 issue of Annals of Behavioral Medicine. In a statistical meta-analysis of fourteen major controlled studies, the researchers Masters, Spielmans, and Goodson conclude, “There is no scientifically discernable effect for intercessory prayer as assessed in controlled studies. Given that intercessory prayer literature lacks a theoretical or theological base and has failed to produce significant findings in controlled trials, we recommend that further resources not be allocated to this line of research.” This reference to a lack of a theoretical basis for the research of potential effects of prayer on healing may offer a clue as to why studies have been equivocal. The original proposals for prayer studies were based upon basic plant, animal, and human studies in animal magnetism and so-called extrasensory relationships. The theory proposed was quantum physics, which affirms that in deep reality, subatomic particles can exist in two places at once, can move from one place to another without traversing the intervening space, can act upon one another at a distance instantaneously, and do not exist in space/time reality until they are observed. Although these phenomena occur reliably in linear accelerators and are clearly the nature of reality, they simply do not have objective, logical, cause-and-effect application in such phenomena as human intention or prayer in healing. As the famous quantum physicist Neils Bohr said, “If you think you understand quantum, then you just don’t understand.” Aside from the lack of a theoretical basis, current studies on prayer and healing contain deep flaws. In addition to the ordinary criteria for statistically significant and controlled studies, a more pertinent and as yet unacknowledged weakness is the impossibility of ordinary science to objectively standardize the subjective ex-

perience of prayer. For example, researchers cannot control the “dose” and the nature of prayer in healing, which might vary from one participant to another—some praying participants will inevitably pray longer, more earnestly, more skillfully, or more convincingly than others. Some might even have a privileged line of communication with the divine. Furthermore, researchers cannot control the effects of “extraneous” prayers that might be offered by individuals outside of the study and that would vary from patient to patient. The irony inherent in trying to objectively study the subjective function of prayer is even more profound. Standardization of the content of the prayers would impact specifically upon the statistical outcome of studies. Researchers could devise a study, for example, in which the praying participants would all recite a standardized prayer that asked that God’s will be done and that the ailing individual would someday, somehow be relieved of suffering. Thus, the researchers could reach the erroneous conclusion that prayer in healing was 100 percent effective. On the other hand, one could devise a study in which the participants would pray that the ailing individual would be cured immediately, or very quickly, and be free of the offending disease. The results of this study would indicate falsely that the effectiveness of prayer in healing is zero. Or, to compound the paradox, if one patient in the study underwent a spontaneous remission that had nothing to do with the prayer, the researchers could conclude erroneously that prayer was effective. The current status is that there is no valid scientific evidence for the effectiveness of prayer in healing. In view of this, some advocates call for more research to follow up on “promising” results. Others, both scientists and theologians, state that we should no longer devote precious resources to a project without merit. However, there is another path. Rather than conclude that prayer in healing is ineffective—a conclusion that goes against

“The irony inherent in trying to objectively study the subjective function of prayer is even more profound.”

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the accumulated wisdom of human beings over the ages—we might instead admit the possibility that our objective biomedical science is inadequate to measure the subjective experience of prayer, and that if we are ever to understand more about the place of spirituality in healing, we will need a new methodology that transcends our current state of knowledge. We may also notice that the question of whether science is capable of measuring the effects of prayer is not purely a scientific question—it is also a spiritual question. So, rather than subordinating or reducing prayer to ordinary empirical science, we could focus financial and human resources on the task of finding new methods of research that include a union of science and spirituality in the healing arts. This path of research could, indeed, have a theoretical basis in such new sciences as quantum physics and spontaneous emergence out of complexity. Where are the funds and where are the researchers who might divert their attention from scientism and be willing to engage in transcendent methodologies that include both science and spirit, and that might offer hope in understanding the relationship of matter and spirit, body and soul, healing and prayer? Perhaps it is here, in this union of opposites, that we will discover the healing power of prayer. Meanwhile, we might contemplate the words of the most famous scientist of the twentieth century, Albert Einstein, who said, “Not everything that can be counted counts, and not everything that counts can be counted.”

may 2007 San Francisco Medicine 29


medicine and religion: a personal experience

Learning to Heal the Spirit One Physician’s Story of Opening a Solo Missionary Practice at Age Sixty Towie Fong, MD

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am a Christian physician, a Baptist. For as far back as I can remember, I’ve always desired to stay close to the Creator. Unlike my siblings, by age ten I was already attending daily mass at a Catholic grade school in Hong Kong. Now, after thirtythree years of professional life—thirty-one of which were spent as an internist and geriatrician at Kaiser Permanente, San Francisco—I have a missionary practice in San Francisco’s Chinatown. When I got out of my medical residency I was, like most people of that age, an idealistic young doctor. Naturally I wanted to be the best clinician there was and to deliver great care. I soon found out that in a medical center where more than twenty languages were spoken daily, you could not begin to talk about delivering good medicine without taking into account each patient’s cultural values and health practices. This idea inspired a new passion that led me, along with many other committed professionals, to devote time and energy in establishing an infrastructure for culturally competent patient care at Kaiser. For twenty-five years, my mission was to teach this topic to Kaiser physicians nationally—and this was years before culturally competent patient care became a federal mandate. Then, at age sixty, I decided it was time to sit back and reminisce about my accomplishments at Kaiser. Little did I know that my God had other plans for me. About two years ago, I noticed an unusual phenomenon in my practice. I realized that I could no longer draw a clear boundary between the various roles I played in my practice—those of physician, counselor, social worker, clergyman, and friend. It seemed that God was revealing a new calling to me. The task I decided to take on was one 30 San Francisco Medicine may 2007

of becoming a missionary doctor in the heart of Chinatown here in San Francisco. Unlike my last undertaking at Kai-

“One of my beloved former residents put it best when he said, ‘Teacher, are you losing your mind?’ But upon hearing that question, I experienced a pivotal moment of clarification.” ser, this was a mission I was reluctant to embrace. To be honest, I was terrified. In response, my wife and I did what we always do whenever things in life seemed hard to handle: We sought out guidance through prayer. We prayed about this daily for two months. My practical side kept reminding me that nobody starts a solo practice at age sixty. One of my beloved former residents put it best when he said, “Teacher, are you losing your mind?” But upon hearing that question, I experienced a pivotal moment of clarification. It seemed as if his words transformed into a lightening rod. It struck, and suddenly I could see everything clearly. When it comes to God and religion, you have got to “lose your mind” in order to partner with God. You must give up control and allow yourself to be led. The blessings of joy, peace, faith, love, and hope will surely follow. Being a doctor, a professional who is used to being in control at all times, letting go was difficult. Should I willingly give up my intellect and my analytical acuity for religion’s sake?

My first impulse was to say, “No way!” Yet, after much consideration, my wife and I concluded that we would have to take a leap of faith. It was the only way to pursue this journey. Deep in our hearts, we both knew that there would be nothing more honorable than to work for God. Finally, we submitted ourselves with a prayer: “Here we are, Lord. Send us” (Isaiah 68, NIV). Today, my clinic in Chinatown is up and running. It is frequented by elderly patients, mostly widows who are lonely and depressed. It is a little-known fact that, among all ethnic groups, the highest suicide rate in the USA among women between ages sixty and seventy-five belongs to the Chinese. Most of my geriatric patients come to my clinic for companionship—someone to talk to and to confide in. When I first opened my doors, I sometimes sensed emptiness and a void in their hearts. I would feel sad sending them away at the end of their visits. I could tell they were sad too, so I came up with a solution. I now tell all patients that they are welcome to return to the clinic after clinic hours. Between 6:30 p.m. and 8:00 p.m., three evenings a week, I host what I call “Chat Time,” which is free of charge. Chat Time gives me a great opportunity to learn more about my patients and, if they are interested, to introduce them to an important aspect of my life: a loving God, a God who cares, who understands, and who forgives and saves. I often ask if they will allow me to pray for them and, if they wish, with them. So far, no one has turned me down. I know, and of course respect, that they often have other religions, the majority being Buddhists. I offer Chat Time as a way to fill the void and ease the loneliness they often experience. Through my new work, I’ve begun to www.sfms.org


understand God’s latest plan for me. I’ve learned that you do not have to go abroad to a remote area to do missionary work. There is plenty to do right here in our city. “Open your eyes and look at the fields. They are ripe for harvest” ( John 4: 35, NIV). God is patiently waiting for his willing and faithful servants to report to work. The Bible teaches that we are made up of three parts: the physical body, the soul, and the spirit. Nowadays, when I see a patient sitting in front of me in my office, I see all three parts. We physicians have generally done very well with the ailments of the body. As for the soul, which represents emotions, mental health, and creativity, we are getting much better. But my observation has been that very few physicians are willing to tackle the spirit part of our being. Yet I believe that our spirit is the most precious part of the three. The spirit is the part of us that we use to communicate with our Gods or other spirits. As a Christian doctor, I am convinced that our body can never be truly healthy and our soul cannot feel completely at ease unless our spirit is at peace with our Creator. I also believe that all healings come from God, and we are His instruments only. In my clinic, I am ready to meet my patients’ needs on any of these three levels. I have learned to find out with sensitivity and respect where people are in their own faith journey, and to meet them there. Sometimes a religiously competent physician can make a major difference in the diagnosis and the treatment of a patient. The following is a vivid illustration, one that I have permission from the patient to pass on. A few days after New Year’s Day this year, I received a frantic call from the pastor of a Christian church in town, telling me that one of his church members had jumped out of her open window on the second floor. The member was a woman in her mid-forties. Miraculously, she sustained only three fractured ribs and a minor compression fracture of her lumbar spine. She was rushed to the psychiatric crisis ward, and the pastor asked if I could meet him there. When I arrived at the hospital, the patient had already received a moderate dose of sedatives and antidepressants. Her diagnoses were suicide attempt and severe depression. Her nurse told me she had been www.sfms.org

talking “nonsense” all day. After I spoke with the patient, it was obvious to me that she had had very strong, delusional religious thoughts during her daily devotion and Bible study earlier that morning. She had been reading the Book of Revelation and became totally convinced that Jesus was returning that day; all believers would be taken up to heaven, and she was certainly not going to miss out on meeting her Creator. She was also convinced that she would be able to fly once she jumped out of that window. I conveyed the religious meaning of her “nonsense” to her attending psychiatrist, who prescribed an antipsychotic medication. Her diagnosis was changed from depression to schizophrenia, and she has since done well on medication. I remember that back in medical school at USC thirty-eight years ago, I was taught that you do not mix religion and the practice of medicine. I now strongly question that teaching. I am thankful for my long quest to incorporate the two in my career. At this juncture of my professional life, I could not be any happier or more satisfied with what I am doing. Sometimes I wish I had answered this calling earlier. As I get older, the purpose in my life seems much simpler and clearer. It has been reduced to four Chinese words, my clinic motto, now hanging conspicuously in my waiting room:

In Cantonese, these characters are pronounced wing sun yig yun, meaning, “To glorify God and to benefit fellow men.” For this doctor, the relationship between religion and medicine does matter.

Agency in Washington, D.C., on culturally competent care issues. He also hosts a live radio show, Ask the Doctor: Blessings, Longevity, Health, and Peace, syndicated by a local Christian evangelical organization.

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

Towie Fong, MD, practiced with the Permanente Medical Group as an internist and geriatrician for thirty-one years before starting a solo practice in San Francisco’s Chinatown in May 2005. He is now affiliated with the Chinese Community Health Care Association. He was on the clinical faculty of UCSF and Stanford University and now serves as a consultant to the Health Resources and Services may 2007 San Francisco Medicine 31


medicine and religion: bridging the gap

United Religions Initiative Healing Violence and Terrorism through Religious Dialogue Peggy Olsen

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n 1993 the United Nations contacted William Swing, Episcopal Bishop of California, to ask for his help with the plans for the fiftieth anniversary of the signing of the U.N. charter. In response, Bishop Swing organized an international youth conference in 1995 at Grace Cathedral to coincide with the more formal fiftieth anniversary celebrations at the San Francisco Opera House. Following the ceremonies, he began to think about the places in the world that U.N. had and had not been successful in conflict resolution. He remembered the words of theologian Dr. Hans Kung: “There will be no peace among nations if there is no peace among religions. There will be no peace among religions if there is no dialogue among religions.” There, at the steps of Grace Cathedral, the idea of the United Religions Initiative was born. Bishop Swing and his wife set off for a trip around the world to meet with leaders of different faith traditions and soon found that the majority of the leaders were not interested in interfaith dialogue. Swing decided that this would need to be a grassroots, global organization enabling people of different faiths to cooperate in ending religious conflict. The concept of Cooperation Circles is the URI’s basic unit of organization. It is a nonhierarchical, self-governing group of seven or more volunteers from three or more faith traditions. They agree to put aside

animosities and work together, promoting peace, justice, and healing through dialogue and service. Today there are more than 340

“There will be no peace among nations if there is no peace among religions. There will be no peace among religions if there is no dialogue among religions.” Cooperation Circles in sixty countries, involving more than one million people from 120 faith traditions. The following are a few examples of the things Cooperation Circles have accomplished: •In Nigeria, where thousands die every year in violence between Christians and Muslims, members of both religions formed a CC to build houses for the poor of all faiths. •After a deadly uprising in Gujarat, India, a local CC established a community peace committee and is now working with the office of the Prime Minister. •In Uganda, Muslims and Christians free child soldiers. •In Israel, mothers of innocent victims

on all sides work together for peace. •In the Philippines, Christians, Muslims, and Hindus have helped negotiate peace between warring gangs. URI is more than a group of top religious leaders getting together occasionally. It is the hard work of daily cooperation among people who have historically been enemies. It is a million people in villages, towns, and cities all over the world challenging their prejudices and stepping out of their comfort zones every day. The CCs do the practical, hands-on projects that improve people's lives now. Preventing the spread of AIDS, providing the basics for survival, and teaching job skills are but a few of the activities of local CCs. They also work with existing organizations such as international relief agencies, UNESCO, the Heifer Project, and Habitat for Humanity. Throughout the world, religion has been central to most acts of terrorism and war. That has been true throughout recorded human history. By addressing the ancient prejudices between faith traditions and opening meaningful dialogue between them, URI hopes to make significant inroads in the eradication of violence. Peggy Olsen is United Religions Initiative’s Trustee Emeritus.

Send Your Message to 2,500 Health Care Professionals The San Francisco Medical Society offers multiple advertising opportunities ranging from full-page, 4-color display ads to classified ads with discounted rates for members. Please contact Ashley Skabar for more information, (415) 561-0850 extension 240 or askabar@sfms.org.

32 San Francisco Medicine may 2007

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medicine and religion: bridging the gap

Restoring Health, Hope, and Dignity St. Anthony’s Free Clinic Aims to Heal San Franciscans in Need Francis Aviani

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ne of the first free clinics in the Currently, St. Anthony Clinic staff is trol what her son eats at school and is often United States, St. Anthony’s Free seeing an increase in two populations: the too tired to cook when she comes home Medical Clinic (SAFMC) was working poor and the pediatric obese. The from work, so she prepares prepackaged originally established in the back of the working poor served by SAFMC cannot meals laden with fat and starch. At school, St. Anthony Dining Room, so that guests afford health insurance, do not qualify for Jose eats pizza, hot dogs, and french fries as coming in for meals could also be screened sliding scale fees at Department of Pub- part of the school lunch program. Although for tuberculosis. That lic Health clinics, there are fruits and vegetables available, he was in 1956. Since and cannot afford rarely eats them. Clinic Medical Director Dr. Ana Valthen, SAFMC has the medical bills at continued to respond other health care fa- dés and Guadalupe discussed the dangers of to the changing cilities. As they must Jose’s obesity, and together they discovered health care needs of oftentimes choose some strategies to start making lifetime San Francisco’s most between working to changes for both Guadalupe and her son. To needy populations. feed their families ensure that her son has healthy snacks and Over the years, or taking time off for foods after school, Guadalupe can purchase SAFMC services their own health, by fruits and vegetables instead of potato chips the time they arrive and soda. And by going to the farmer’s marhave expanded to Dr. Ana Valdez (right) with a patient in the clinic their ket at closing time, she may get a better price include primary care, urgent care, pediatrics, podiatry, immuniza- illness is often advanced and requires a high on fresh produce. Both Guadalupe and Jose tions, HIV testing and medical care, smok- level of care. can share a healthy lifestyle change by making cessation, acupuncture, health educaA second trend is the increasing num- ing a habit of walking together every day. tion, and mental health services. With a ber of pediatric patients suffering from child“We have served so many segments guiding mission to “restore health, hope, and hood obesity. Fresh produce is rare in the of the population, from the homeless and human dignity” to those in need, SAFMC Tenderloin markets, and it costs more than substance abusers to newly immigrated cares for those whose life circumstances the starch-heavy, monolingual populahave brought them to the doorstep of one fast-food meals that tions to the working of San Francisco’s poorest and most diverse are as prevalent as poor. What doesn’t neighborhoods. safe exercise and change is the imporFrom Southeast Asian refugees in the play areas are scarce. tance of recognizing late 1970s to early AIDS diagnoses in the Childhood obesity trends in health care 1980s to the swell of dual- and triple-diag- and its correlative needs so we can best nosed homeless people in this decade, St. illnesses of high chomeet the population Anthony has been on the forefront of pro- lesterol, diabetes, and where they are, and viding needed free medical services. Today poor dental health as early in the trend the clinic serves more than 3,500 people, are becoming more as possible,” notes Dr. St. Anthony’s Clinic Pharmacy in more than 12,000 visits, every year. It is and more common Valdés. To address known for providing accessible care with in children under the age of ten. the large numbers of patients suffering from dignity and respect, as well as for its culturAn example of this trend can be seen diabetes, SAFMC has changed the way it ally competent and multilingual staff. The in the case of Guadalupe and her son, Jose. provides chronic care. It has taken the focus staff speaks eleven languages combined, Guadalupe is in her late thirties and works away from physician mandates to empowerwith more than half of those languages two jobs. Her nine-year-old son, Jose, weighs ing patients to understand their illness and represented by native speakers. nearly 200 pounds. Guadalupe cannot conContinued on Page 39... www.sfms.org

may 2007 San Francisco Medicine 33


hospital news Chinese

Joseph Woo, MD

I recently had the pleasure of attending our Board of Trustees Installation Ceremony at the Four Seas Restaurant in Chinatown. I was happy to see the support that the Chinese Hospital maintains in the City. In attendance were former Mayor Willie Brown, current Chief of Staff Phil Ginsberg, City Administrator Ed Lee, City Attorney Dennis Herrerra, Consul General for the People’s Republic of China Peng Keyu, Supervisors Aaron Peskin and Ed Jew, Chief of Police Heather Fong, Fire Chief Joanne HayesWhite, District Attorney Kamala Harris, and City Assessor Phil Ting. (Who was left running City Hall?) Former Deputy Mayor James Ho handed the Board President’s reigns to Attorney Joe Chan, and Supervisor Peskin performed the formal swearing-in ceremony. The composition of our hospital board dates back to the roots of our hospital itself. As many of you know, San Francisco’s Chinese, isolated by the policies of the time, were unable to access health care at the turn of the century. In response, the community founded the Tung Wah Dispensary to provide care to those who had no other access. In 1925, as this small facility had become inadequate, fifteen community organizations took the lead to raise money and build the first and only Chinese hospital in the country. These founding organizations continue to send one representative each, which makes up our all-volunteer hospital board. While the demographics of San Francisco and Chinatown have changed, it is clear from both our patients and our community support that the Chinese Hospital’s importance and relevance in San Francisco health care delivery remain as strong as ever.

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Kaiser

Robert Mithun, MD

Our organization and medical center are secular institutions that allow members of all faiths to experience care in a nonjudgmental and open environment. This is not to say that we ignore the specific and particular beliefs and customs that our diverse San Francisco population presents in both our doctors’ offices and the hospital. Our goal is to heal the body, mind, and spirit with all the resources available to us as health care providers. In 1995, Deborah Chiarucci, MD, a hospital-based specialist, established multiple mindfulness programs at several Northern California Kaiser Permanente facilities. Dr. Chiarucci found there was a need in her own practice for ways to reduce stress and cope with the many pressures that health care creates for providers. In Dr. Chiarucci’s own words, “As health care providers, we’re often in the midst of chaos at a time when patients most need our support and stability. By the end of the day, we’re often drained and in need of a way to renew our energy and cope with the stress. The discipline of meditation practice, even for a few minutes, can help us refocus on what is important.” Our medical center also employs Father Pablo Iwaszewicz, an Orthodox priest with an impressive ability to communicate in several languages. Father Pablo has completed his Clinical Pastoral Education, which is a year-long, specialized postgraduate course that prepares clergy for work in health care facilities. Providing members in the hospital with spiritual guidance, religious rites, and good conversation are part of Father Iwaszewicz’s role as chaplain at KP San Francisco. He is a resource that enables both members and their families to find comfort during what can be very challenging and trying times. We will continue to explore ways to minimize the stress of our providers and tend to the health and well-being of our members, both in body and in mind.

Saint Francis

Wade Aubry, MD

I’d like to begin my first column as Saint Francis Memorial Hospital’s new Chief of Staff by thanking my predecessor, Guido Gores, MD, for a job well done. Dr. Gores, who served two terms as Chief of Staff, was recently honored with the Saint Francis Physician Value in Action Award for Stewardship. Dr. Gores leaves a legacy of achieving outstanding success in hospital quality core measure compliance. Under his leadership, Saint Francis has consistently been ranked in the top third for quality among the forty-two CHW facilities. We’re extremely grateful to Dr. Gores for all he’s done for our hospital and our community. In keeping with this issue’s theme, medicine and religion, Saint Francis Hospital, as part of Catholic Healthcare West, is committed to treating the whole person—body, mind, and spirit—and to meeting the particular needs of each patient. Located between Chinatown and Russian Hill, Nob Hill and the Tenderloin, the hospital serves a spiritually diverse population. Every day, our staff sees visitors from all over the globe, as well as patients who reside only blocks away but worlds apart. For Rev. Doug Lubbers, Director of Spiritual Care Services, this means being prepared for anything. On a typical day, Rev. Lubbers might be asked to provide prayer mats for a Muslim family, call the medical examiner on behalf of a Jewish family concerned that an autopsy will violate Jewish burial guidelines, or help clinicians understand the traditional Southeast Asian practice of coining. Rev. Lubbers is assisted by the department’s diverse staff. Five chaplain residents minister to patients of all different faiths and backgrounds. It’s been my pleasure to be a part of the tradition of quality care here at Saint Francis for the past twenty-five years, and I look forward to enhancing this tradition and improving the environment for both patients and physicians during my tenure. may 2007 San Francisco Medicine 35


hospital news St. Mary’s

Kenneth Mills, MD

St. Mary’s Medical Center recognizes the importance of taking care of a person’s spiritual health as well as his or her physical ailment. Spiritual Care Services at St. Mary’s is committed to providing care to patients, families, and caregivers. Chaplains are available to St. Mary’s patients and their families twenty-four hours a day, seven days a week. The chaplains of Spiritual Care Services are multifaith and multiethnic. St. Mary’s has an interfaith chaplaincy staff comprised of Catholics, Protestants, Quakers, and a Buddhist. Chaplains support people of every faith or no faith. They are spiritual caregivers, specially trained to assist people who are dealing with issues such as fear, loneliness, hopelessness, and questions of meaning. As part of Spiritual Care Services, a professional chaplain helps individuals and families draw upon their religious traditions, faith, or sense of life-purpose to face their crises. Chaplains seek to promote healing and help individuals and families through the course of illness and recovery, as well as through the many challenges that accompany the end of life. St. Mary’s and the staff of Spiritual Care Services believe that spirituality helps people maintain health; cope with illness, trauma, and loss; and adjust to life transitions by integrating body, mind, and spirit. Programs such as Spiritual Care Services at St. Mary’s promote well-being and longevity by nourishing people’s personal sense of meaning and faith. St. Mary’s believes in a holistic approach to treatment and care.

36 San Francisco Medicine may 2007

UCSF

Ronald Miller, MD

John K. Chan, MD, has been named the new chief of the Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences at the UCSF School of Medicine. As chief of gynecologic oncology, Chan will oversee all of the division’s clinical, research, and educational activities. Chan was most recently on faculty at Stanford University. Also a clinical and translational scientist, Chan recently has focused his research on ovarian cancer. Chan’s research focuses on novel therapeutics in the treatment of ovarian cancer and, in particular, on immunotherapy for ovarian cancer. He is also interested in outcomes-based research in gynecologic malignancies. In addition to his academic accomplishments, Chan has served on professional committees and has received numerous honors and awards. In the community, Chan is currently on the board of directors of the American Cancer Society Northern California Chinese Unit. He is fluent in Chinese (Mandarin and Cantonese) and medical Spanish. “It is wonderful to be joining a division and department that are so strong, and to have the opportunity to expand research and focus on care delivery and on achieving the next level of excellence. It’s exciting,” said Chan. “I am pleased and honored to be joining the faculty at UCSF.” Among Chan’s many accomplishments are his numerous awards, including a New Investigator Award from the Gynecologic Oncology Group/Ovarian Cancer Research Fund and an Outstanding Faculty Award from the Department of Obstetrics and Gynecology at Stanford University School of Medicine. He joins UCSF as a recipient of the National Institutes of Health Reproductive Scientist Development Award.

Veterans

Diana Nicoll, MD, PhD, MPA

At the San Francisco VA Medical Center, as at all VA health care facilities, chaplains are allies and advocates for veterans and their families, according to SFVAMC Chief Chaplain Joseph R. McAfee. Under VA regulations, he says, chaplains are the guardians of veterans’ right to worship, believe, and engage in spirituality in whatever manner they choose. The Chaplain Service of the Department of Veterans Affairs dates back to 1865, when President Abraham Lincoln signed legislation establishing the first National Homes for disabled volunteer soldiers. Chaplains were paid $1,500 and “forage for one horse” per year.Today, VA chaplains are boardcertified through the National Association of VA Chaplains (NAVAC). A VA chaplain must have at least a Master of Divinity degree and 800 hours of Clinical Pastoral Education (CPE) in hospital settings. Board-certified chaplains may have training in palliative care, hospice care, and disaster response. At the San Francisco VA, there are three staff chaplains, three consulting chaplains, and four chaplain interns who are completing their CPE unit credits. This allows for even more personal contact with veterans, says Chaplain McAfee. Representatives of almost fifty faith groups are available in the community at all times to assist the needs of veterans. The San Francisco VA satellite clinics in Ukiah, Eureka, San Bruno, and downtown San Francisco offer chaplain services as well as group interaction. The San Francisco VA also offers a Spiritual Care Volunteer program, which operates under the supervision of the Chaplain Service. Medical center staff members volunteer to visit regularly with a particular veteran one-on-one, on their own time. In addition to providing companionship to veterans, the program allows staff members who do not have direct patient contact to “remember why they’re doing their job,” says Chaplain McAfee. www.sfms.org


hpv vaccine update Charles Wibbelsman, MD

The HPV Vaccine Explored

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n June 30, 2006, the Advisory Committee on Immunization Practices (ACIP) met in Atlanta and approved a new vaccine to protect against types 6, 11, 16, and 18 of the human papilloma virus. This quadrivalent vaccine, approved by the FDA, is a product, Gardasil, of and marketed by Merck & Company. It is a series of three injections given over a six-month period. Genital human papillomavirus (HPV) is passed from person to person during sexual contact. This includes intimate sexual contact, but not necessarily only vaginal or anal intercourse. It is the most common sexually transmitted infection in the United States. Approximately twenty million people in the U.S. are infected, with 6.2 million new reported infections each year. The HPV vaccine may be effective in preventing genital warts associated with HPV types 6 and 11 and may prevent as many the 70 percent of cases of cervical cancer that are associated with HPV types 16 and 18. This vaccine is not meant to replace the pap smear for cervical cancer screening; and the recommendations of the National Cancer Institute and ACOG for screening women within three years of sexual activity or beginning at age twenty-one years are still in place. The population group for which this vaccine has been approved are females nine through twenty-six years of age. Clinical trials of this vaccine are now being conducted among males. However, licensure and approval is not expected for a few years. The target age group is composed of young adolescent females ages eleven and twelve years of age. The rationale is that the maximum effectiveness of this vaccine is achieved if given before the onset of sexual activity. Data from the CDC’s Youth Risk Behavior Survey (2006) show that more than 50 percent of high school students aged sixteen years self-report sexual activity, and as many as 10 percent admit to sexual activity (vaginal intercourse) prior to the age of twelve years. Effectiveness of this new HPV vaccine is contingent upon completion of the vaccine series prior to sexual activity. Thus, as health care providers of children and adolescents, it is our mantra to advise, advocate for, and counsel our patients about this new vaccine. It is hoped that the availability and administration of this vaccine will open the door of preventive health for adolescents. Bringing young teens into the office for initiation of the vaccine series offers providers the opportunity to perform a risk assessment www.sfms.org

of these patients, offer anticipatory guidance, and also update this age group with other vaccines that offer protection against pertussis, meningitis, and hepatitis A. In California, the health and safety code for confidential care of adolescents states that anyone twelve years of age or older can consent for themselves for the diagnosis and treatment of a sexually transmitted infection (STI). However, this does not include the prevention of an STI; therefore, parental consent is required for both the HPV vaccine and the hepatitis B vaccine. Since the ACIP has recommended this vaccine for females as young as nine years of age and up to twenty-six years of age, clinicians will need to assess who will benefit most from the vaccine series. In many scopes of practice, adolescent females ages eighteen and younger are routinely offered the vaccine series, even if they are already sexually active (and providers need to ask them this question). Women nineteen to twenty-six years of age who have not begun sexual activity clearly will benefit. However, women who are sexually active at any age and have had multiple partners, or their partners have had multiple partners, should be cautioned that they may benefit less from receiving the vaccine. The five most frequently reported symptoms after vaccination, among 542 reports, include injection site pain (18 percent), dizziness (11 percent), syncope (11 percent), fever (9 percent), and nausea (9 percent). This vaccine is preventive against sexually transmitted infections and preventive against cervical cancer. It is anticipated that this vaccine will indeed have a significant, positive impact on our clinical practice in the years ahead. Charles Wibbelsman, MD, is a member of the San Francisco Medical Society Board of Directors as well as the Executive Committee. He specializes in Pediatrics and Adolescent Medicine.

may 2007 San Francisco Medicine 37


In Memoriam Nancy Thomson, MD Rolf Eissler, MD Rolf Eisler, MD, passed away at his San Francisco home on March 3, aged 94. He was born in Vienna, Austria, on November 19, 1912, the youngest of four sons. At age 18, he left Vienna to work in Paris for four years, returning to his native city to study law and medicine. In 1938 he traveled through Italy and France, then sailed to New York City with his brother Karl and his sister-in-law. He earned his medical degree at Rush Medical College and took a residency in ophthalmology at Michael Reese Hospital, both in Chicago. Having become a U.S. citizen, he served as a physician in the U.S. Army during and after WWII. In 1946, he moved to San Francisco and started his ophthalmology practice, which he continued for forty years. He was on the staff of Mt. Zion Hospital and was a member of the clinical faculty at UCSF, where he taught residents and attended clinical Grand Rounds even after he retired. He conscientiously served patients of all social and economic backgrounds. Dr. Eissler was a staunch individual who never hesitated to raise a question, and he accepted information only on his own rigorous scrutiny. He had an active and vigorous mind and was readily fascinated by a wide range of topics, especially medical and scientific advances. His actions were always guided by his integrity and deep concern for others. He was active well into his nineties, enjoying playing with his two grandchildren. He married Dr. Margaret Ems, an obstetrician and gynecologist, in 1956. She predeceased him in 1991. He is survived by his daughter, Ellen Eissler, son-in-law Jonathan Pritikin, and grandchildren Ethan and Anne Pritikin.

Fred G. Hudson, MD Fred G. Hudson, MD, passed away March 1, 2007, at the age of 76. He was born in Enid, Oklahoma, to Dr. Frederick Auld Hudson and Grace Elizabeth Goltry Hudson. He attended Kemper Military School, Carleton College, and the University of Oklahoma Medical School. He came to San Francisco for an internship at St. Luke’s in 1950 and retired in 1992. Fred was a man of impeccable taste and reveled in the rich cultural life of San Francisco. He enjoyed music, antiquing, and travel, especially to London, where he attended the races at Ascot several times. He was also a philanthropist, active on the boards of the San Francisco Opera, the Salvation Army’s Harbor Lights Program, and the board of trustees of Grace Cathedral. He was a

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member of the Society of California Pioneers, the Fang and Claw Club, and the Sovereign Military Hospitaller Order of St. John of Jerusalem of Rhodes and of Malta. He was founder and director of STOP NOW, Inc., a critical care alcoholism treatment program at the former Presbyterian Hospital in San Francisco, which assisted many alcoholics into recovery. He was also on the board of directors of Harbor Lights. He had many friends and could often be seen dining at the restaurants near his home on Nob Hill. His parents and sister, Virginia Hudson Chambers, preceded him in death. He is survived by his adopted son, C.L. “Jack” Bell of San Francisco.

Benjamin H. Maeck, Jr., MD Benjamin H. Maeck, Jr., MD, aged 80, died peacefully in January in his San Francisco home with his family present. He was born in Shelburne, Vermont, on January 6, 1927, the son of Benjamin Harris and Hannah Hegerton Tracy Maeck. He was a graduate of Northwood School in Lake Placid, New York, and went on to Dartmouth College and the University of Vermont College of Medicine. He interned in surgery at St. Luke’s Hospital in New York and completed an orthopedic surgery residency at New York Orthopedic Hospital, Columbia Presbyterian Medical Center, New York. He followed this with a fellowship at the Royal National Orthopedic Hospital in London. He served as a medical corpsman in the U.S. Navy during World War II. In 1960, he began his orthopedic practice at Franklin Hospital (now Davies Medical Center). He is remembered as a caring and dedicated physician with a warm, ready smile and a quick Vermont wit. Dr. Maeck was a happy dry-fly fisherman, whether at the headwater of the Fall River or in the chalk streams of England. He was a lifetime member of the Flyfishers’ Club, London. His family will long remember their annual August hikes in the Sierra and their time together at the Vogelsang High Camp—time for fishing, philosophy, literature, and poetry. He was also a Son of the American Revolution. Dr. Maeck is survived by his wife of forty-five years, Charlotte; his children, John Van Sicken II, Elizabeth Hylton (husband Greg), Benjamin Harris III, MD, and William Durkee; and his three grandchildren. His brother John, also a physician, predeceased him.

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

St. Anthony’s Continued from Page 33... actively participate in their care through patient education and outreach. Patients are encouraged to set attainable goals toward healthier living and can take advantage of group education sessions, yoga and relaxation classes, and mental health services. St. Anthony Free Medical Clinic is expanding its services to meet the needs of today. As part of the more comprehensive clinic currently being built, one which will have more examination rooms for more patients to be seen by physicians, SAFMC is also developing a free dental clinic. “It is exciting that lawmakers are starting to understand the need to insure California citizens to promote the overall health of the state,” says Dr. Valdés. “With 6.6 million uninsured in California, this process will take time. Meanwhile, we remain aware of the ever-changing needs of our unique patient population. One of the greatest ways you can invest in a community is to attend to its health care needs.” To learn more about St. Anthony’s, please visit them online at www.stanthonysf.org. www.sfms.org

Events SFMS Seminars Please contact Posi Lyon to register. plyon@sfms.org, (415) 561-0850 extension 260. Advance Registration is required. June 18, 2007 Transitioning Your Practice—Retiring, Selling or Buying a Practice This is a not-to-be-missed seminar designed for all physicians who are contemplating retirement, bringing in an associate, joining a practice as an associate, relocating, buying or selling a practice, or changing careers. 6:00–9:00 PM (5:45 PM dinner/registration) $149 for SFMS/ CMA members / $199 for non members October 12, 2007 Customer Service/Front Office Telephone Techniques This half-day practice management seminar will provide valuable staff training to handle phone calls and scheduling professionally and efficiently. 9:00 AM - 12:30 PM (8:40 AM registration/continental breakfast) $99 for SFMS/CMA members / $149 for non members November 9, 2007 “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of finance, operations and personnel management. 9:00 AM – 5:00 PM (8:40 AM registration/continental breakfast) $250 for SFMS/CMA members / $225 for second attendee from same office, $325 for non-members

Other Area Events June 8-9, 2007 Best Practices in Primary Care South San Francisco Conference Center Primary Care Network offers 16 hrs of CME in this 2-day, multi-topic educational program. Topics include osteoporosis, rheumatoid arthritis, menstrual migraine, insomnia, hypertension, dyslipidemia, COPD, sexuality, PAD, cardiometabolic risk, type 2 diabetes, and sleep-wake disturbances. To register, or receive more information, visit the website at www.primarycarenet.org/bp_primarycare.html, or call 1-877-594-1770. June 27, 2007 New Orleans Common Ground Clinic and Road Recovery Benefit Concert The Great American Music Hall Sponsored by David Smith and the Smith Family Foundation. For more information please see www.FreeCC.org. may 2007 San Francisco Medicine 39


Northern California Physician Opportunities Sutter Health offers a wide variety of practice styles, geographies, and life styles. With facilities in Northern California from the Oregon Border to the Central Valley, and from the Pacific Coast to the Sierra Foothills, you have boundless career opportunities to fit your goals. We have open opportunities in a variety of specialties. Contact us for more information.

Sutter Health Physician Recruitment 866-448-7070 916-454-6645 fax docjobs@sutterhealth.org www.sutterhealth.org

Hot Jobs Cardiology Dermatology Family Practice Gastroenterology General Surgery Hospitalist Internal Medicine OB-GYN Orthopedic Surgery Otolaryngology Psychiatry Radiology Surgical Oncology Breast Urgent Care Urology Other opportunities available


May 2007