September 2009

AN RANCISCO EDICINE S F M VOL.82 NO.7 September 2009 $5.00

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Local Heroes in Medicine

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In This Issue

SAN FRANCISCO MEDICINE September 2009 Volume 82, Number 7 Local Heroes in Medicine

FEATURE ARTICLES

10 A Heroic Profession: Redefining the Modern Physician Allan B. Chinen, MD 11 The Heroine’s Journey: Finding a Place of Balance Maureen Murdock, MA, MFT

12 Arthur H. Coleman: A Life of Service to an Underserved Community Erica Goode, MD 15 David Smith: Pioneering Community-Based Health Care Steve Heilig, MPH

16 Paul Volberding and Molly Cooke: Caring for AIDS Patients from the Start Kelly Terr 18 Rachel Naomi Remen: A Pioneer in Holistic and Humanistic Medicine Dawn Yun

19 Acts of Daily Giving: San Francisco General Employees Go Above and Beyond Beni Seballos, MD 21 Denise and Elliott Main: Heroes Among Us Toni Brayer, MD

22 Women in History: Pioneers that Shaped Medicine in San Francisco Nancy Thomson, MD 24 Leonard Shlain: Left Brain, Right Brain, and Ironies of the Heart Jordan Shlain, MD

MONTHLY COLUMNS

4 Membership Matters 7 President’s Message Charles J. Wibbelsman, MD

9 Editorial Mike Denney, MD, PhD 32 Hospital News

OF INTEREST

14 San Francisco Medical Society: Advocating for Physicians and Patients 34 Health Policy Perspective: Covering the Cost of Alcohol Abuse Steve Heilig, MPH Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Web: www.sfms.org

Advertising information is available on our website, www.sfms.org, or can be sent upon request.

26 Rolland Lowe: Caring for the Chinese Community of San Francisco Emerald Yeh

29 Edgar Wayburn: Physician and Conservationist who Preserved Over 100 Acres of Open Space Harold Gilliam 31 Victor Richards: A World-Class Surgeon Steven J. Askin, MD

www.sfms.org September 2009 San Francisco Medicine

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Membership Matters September 2009 A Sampling of Activities and Actions of Interest to SFMS Members

Volume 82, Number 7 Editor Mike Denney

Managing Editor Amanda Denz Copy Editor Mary VanClay Editorial Board Chairman Mike Denney

Obituarist Nancy Thomson

Stephen Askin

Shieva Khayam-Bashi

Gordon Fung

Ricki Pollycove

Toni Brayer

Linda Hawes-Clever Erica Goode

Gretchen Gooding

Arthur Lyons

Terri Pickering

Stephen Walsh

SFMS Officers

President Charles J. Wibbelsman

President-Elect Michael Rokeach

Secretary George A. Fouras Treasurer Gary L. Chan Editor Mike Denney

Immediate Past President Steven H. Fugaro SFMS Executive Staff

Executive Director Mary Lou Licwinko

Director ofPublicHealth &Education Steve Heilig

Director of Administration Posi Lyon

Director of Membership Therese Porter

Director of Communications Amanda Denz

Board of Directors Term:

Jeffrey Newman

Andrew F. Calman

Michael H. Siu

Jan 2009-Dec 2010 Jeffery Beane

Lawrence Cheung Peter J. Curran

Thomas H. Lee

Richard A. Podolin Rodman S. Rogers Term:

Jan 2008-Dec 2010 Jennifer H. Do

Keith E. Loring

William A. Miller

Thomas J. Peitz

Daniel M. Raybin Term:

Jan 2007-Dec 2009 Brian T. Andrews Lucy S. Crain

Jane M. Hightower Donald C. Kitt Jordan Shlain Lily M. Tan

Shannon UdovicConstant

CMA Trustee Robert J. Margolin AMA Representatives

H. Hugh Vincent, Delegate

Robert J. Margolin, Alternate Delegate 4

Don’t Miss the Educational Session on HIT Mark your calendars and spread the word: The new date for the SFMS educational session on health care IT for all members will be October 6, 6:00 to 7:30 p.m.

The meeting will be held in the Enright Room on the first floor of the California Pacific Medical Center (2333 Buchanan). We are very excited that Dr. Paul Tang, chief medical information officer for Palo Alto Medical Foundation, will be the featured speaker. Dr. Tang is also vice chair of the Federal HIT Policy Committee and cochair of the California HIE Advisory Board. The educational session will also provide a good opportunity to discuss SFMS’s role in the development of a San Francisco Health Information Exchange (SFHEX), a means of securely exchanging health care data across disparate entities and technology platforms.

Please RSVP to Posi Lyon at (415) 561-0850 extension 260 or plyon@sfms. org.

Do We Have Your Correct Contact Information?

Don’t run the risk of missing out on important information from SFMS and CMA because your contact information is not correct! You should have received a database-update mailing in August, which gives you an opportunity to update your information. There is also a card in the most recent edition of the SFMS Membership Directory that you can use any time during the year. Additionally, you can update your records online or by contacting the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.

There has never been a more critical time for health care, and the San Francisco Medical Society wants to ensure that you have the information you need. If we don’t have your e-mail address, please let us know (SFMS does not share its members’

San Francisco Medicine september 2009

e-mail addresses).

New Ways to Pay Your Dues!

The 2010 dues statements go out in mid-September. This year SFMS is adding a new option for paying dues: paying your dues via credit card installments. You may also use the online dues payment system on our website, or pay by check or credit card via fax or U.S. mail. Details and an authorization form will be on the dues statements.

Mark Your Calendars for the UCSF Student-SFMS Mixer

Thursday, September 24, 6:00–7:30 p.m., UCSF campus (exact location TBA).

An opportunity for the students of UCSF and the physician members of the San Francisco Medical Society to meet in a fun and informal setting. It will be a wonderful chance for our physician members to meet and talk with the next generation of doctors, who are equally eager to meet those already established in the profession. This event was one of our most successful events last year, and we hope for an even bigger turnout this time. Watch for more details.

The 2009-2010 SFMS Membership Directory and Desk Reference

All active members receive one free copy the SFMS Membership Directory and Desk Reference as a member benefit.

This trusted health care resource is also available for sale. Members—including retired members—can order extra copies for $45 each (a significant discount from the nonmember cost of $75). To purchase more directories, contact Carol Nolan at (415) 561-0850 extension 0 or cnolan@ sfms.org.

If you are an active member and have not received your directory, or if you have any questions, contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or tporter@ sfms.org. www.sfms.org

Retired Physician Luncheon Presented by Clinic by the Bay

Blue Shield Fee Schedule Changes Take Effect October 1

Date change: Thursday, October 1, 2009, 12:00–2:00 p.m. The Julia Morgan Ballroom at the Merchants Exchange Building, 465 California Street, 15th Floor, San Francisco.

SFMS is partnering with Clinic by the Bay, a new community nonprofit organization that is establishing a Volunteers in Medicine (VIM) clinic in San Francisco. VIM is a model of health care that engages retired physicians, nurses, and others to provide compassionate care, free of charge, to the working uninsured. Founded in 1992 by Dr. Jack McConnell, VIM now has seventy-three clinics throughout the country. Join us for a hosted lunch to learn more about VIM and how you can get involved in Clinic by the Bay. Your professional colleagues are also welcome to attend.

RSVP to (415) 956-8300 by Thursday, September 25, 2009.

Blue Shield of California recently notified physicians of changes to its standard physician fee schedule that will take effect October 1. In a letter to physicians on August 1, Blue Shield notified physicians that it would be modifying payment levels for many CPT codes, some being increased and others decreased. Physicians are urged to calculate the financial impact the fee schedule changes will have on their practices. (Use CMA’s financial impact worksheet, available at the CMA members-only website.) The new rates are available at the Blue Shield website.

CMA reminds physicians that they do not have to accept bad contacts or contracts that are not mutually beneficial.

You should also be aware that you have the right to terminate an agreement if any “material change” to the contract terms is not acceptable to your practice.

If you do not agree with proposed changes, you can terminate the contract before the October 1 effective date. Letters of termination can be mailed to Blue Shield of California, Attn: Senior VP Network Management, 6300 Canoga Ave., 12th Floor, Woodland Hills, CA 91367.

If you have questions about the new fee schedule, call Blue Shield Provider Services Department at (800) 258-3091. You may also contact CMA’s reimbursement help line at (888) 401-5911 or awetzel@ cmanet.org.

FTC Delays Enforcement of Red Flag Rules for Another Three Months

The Federal Trade Commission (FTC) recently announced it would again delay enforcement of its new Red Flag Rule, which requires “creditors”—including many physicians—to develop and implement identity-theft detection and prevention programs. The new regulations are now scheduled to take effect on November 1, 2009.

According to the FTC, it will also release additional guidance to help “creditors”—particularly small businesses and those with a low risk of identity theft—to understand their obligations under these regulations.

For more information on the Red Flag rule, see CMA’s Red Flag Rule toolkit and webinar, available free to members at the CMA members-only website. Contact Samantha Pellon at (916) 551-2872 or spellon@cmanet.org.

www.sfms.org

Mind-Body Awareness Project

Based on cutting-edge research in neuroscience, the Mind Body Awareness Project developed an evidence-based mindfulness and emotional intelligence intervention to rehabilitate incarcerated youth. Its program is now being scaled into a new national model and is concurrently being brought into medical contexts to treat adolescents who have been exposed to repeated trauma. An effective, low-cost, experiential intervention, it pays for itself many times over in later health costs avoided. Mind Body Awareness also conducts trainings in self-care,

mindfulness, and emotional intelligence for caregivers and health care providers seeking practical tools for self-care, stress reduction, and cultivating emotional intelligence in their lives and in relationship to their patients.

You can learn more about Mind Body Awareness Project’s work at www. mbaproject.org or by contacting Gabriel Kram, director of Consulting Services, at (415) 827-7084.

2009 SFMS Seminar Schedule

All SFMS Seminars require preregistration. Please contact Posi Lyon for more information, plyon@sfms.org or (415) 561-0850, extension 260.

October 16, 2009: Customer Service/ Front Office Telephone Techniques/ Difficult Patients Skills This half-day practice management seminar provides valuable training to enable your staff to handle front desk tasks and patients both efficiently and professionally. Physicians and Managers should not assume staff inherently have customer service/patient relations skills.

This seminar will give them the tools for positive patient relations for the practice.

9:00 AM – 12:00 PM (8:40 AM registration/continental breakfast); $105 for SFMS/CMA members and their staff ($85 each for additional attendees from the same office); $150 each for non members.

November 17, 2009: “MBA” for Physicians and Office Managers This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing and personnel management.

This seminar teaches the core business elements of managing a practice that physicians don’t receive in medical school training.

9:00 AM – 5:00 PM (8:40 AM registration/continental breakfast); $250 for SFMS/CMA members and their staff ($225 each for additional attendees from same office); $325 for non-members.

september 2009 San Francisco Medicine

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President’s Message Charles J. Wibbelsman, MD

Heroes in Medicine

O

ur issue this month, Heroes in Medicine, pays tribute to some of our finest physicians in San Francisco. As physicians, we have all taken the Hippocratic Oath, devoted many years of our lives to attending undergraduate college as well as a college of medicine, followed by a residency and years of practice, often punctuated by long hours each day and many commitments and responsibilities that are involved in caring for patients. Yet, beyond this long-term commitment, we have colleagues with whom we practice in the medical community of San Francisco who have gone beyond this measure—physicians who have literally placed their lives on the line to save patients’ lives. These are our everyday heroes that we salute today.

I especially would like to recognize in this column those other physicians and health care workers who joined Drs. Paul Volberding and Molly Cooke in the courageous efforts to care for those patients who, in the 1980s, presented in the initial phase of the HIV epidemic. Dr. Volberding had trained as an oncologist/ hematologist before the words human immunodeficiency virus were even written. For him and others caring for these patients who presented with dark purple rashes, weight loss, and unexplained infections, this was truly a dedication to the care and well-being of these patients. Examining them, drawing blood on them, taking the chance of a needle stick they placed their own lives on the line without their knowing what the consequences to their own health would be. These were the Father Damiens of the 1980s, and San Francisco was the Molokai, an island of patients with a disease that many physicians in most areas of the country had not even seen nor diagnosed. (Father Damien died at the age of forty-nine of Hansen’s disease in Molokai in 1889.)

In the middle to late 1980s, those physicians and health care workers who were caring for patients with the “Gay Plague” not only crossed the barriers of placing themselves at risk for an infectious disease but also had the courage, personal self-confidence, and wherewithal to care for these gay male patients whom no one else would care for. I can recall, most unfortunately, hearing of a practicing pathologist who would not perform an autopsy on patients who had died of this new disease. Sadly, in the early years of this epidemic, there were

some of our colleagues in medicine who were uncomfortable caring for these patients or who refused to accept them into their practice. But many of us can remember the early days of Ward 86 at San Francisco General and the brave staff who cared for the patients on that unit. In addition, there were committed and courageous medical staff and health care workers within all the medical centers of this city.

I would like to take this opportunity to salute all of the heroes of medicine who are acknowledged in this issue of our magazine for their courage as physicians in leading the way to improve the health of patients when many others did not join them. I would also like to point out, in this message, that Dr. David Smith’s Haight Ashbury Free Medical Clinic was the spark of the entire free clinic movement in the nation, and it is a clinic that continues to this day. Also, we should all acknowledge the many unsung heroes who were the physicians and other health care workers, as well as those in training, who cared for these patients. Many are still in out midst, but a few acquired HIV through needle sticks or “sharp” exposures and are no longer with us.

We should additionally recognize the family and friends, including some with HIV themselves, who tirelessly cared for their friends and family members before there was a lot of information on how to do so safely. Lastly, we should acknowledge the role the San Francisco Medical Society played at the level of organized medicine, advocating both locally and with the California Medical Association for fair, humane, and evidence-based treatment of people with HIV, opposing the voices of hysteria and unreason at all professional levels. We are truly fortunate to have so many heroes in San Francisco.

www.sfms.org September 2009 San Francisco Medicine

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Independent But Not Alone.

Richard Ward, M.D. Hill Physicians provider since 1994.

Uses Ascender preventive health reminders and RelayHealth online communications for patient care and ePrescribing solutions.

Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians.

• Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Preventive care and disease management reminders for patients • Deep discounts on EMR and EPM solutions That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.

Your health. It’s our mission.

Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin: Paula Schmit, regional director, (209) 762-5002, Paula.Schmit@hpmg.com Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.

Editorial Mike Denney, MD, PhD

Heroes and Health Care Reform

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n Daniel Quinn’s award-winning fantasy novel Ishmael: An Adventure of the Mind and Spirit, the story begins when the protagonist reads an ad in a newspaper: Teacher Seeks Pupil. Must have an earnest desire to save the world. Apply in person.

In this novel, upon reading this advertisement in the personals section, Quinn as narrator angrily throws the newspaper into the trash, muttering about the arrogance of the “teacher” to think that he or she knows how to save the world, and grumbling about the kooks, creeps, and crazies who might answer such a stupid ad.

Soon, however, Quinn is called again, his curiosity having been aroused. He wants to confront this so-called teacher face to face, so he retrieves the newspaper from the trash and goes to the address given. Then, something supernatural happens.

The individual who put the ad in the newspaper turns out to be a gorilla named Ishmael. This gorilla knows better than anyone else about the fragile balance in the ecology of the planet, and he is worried that the human propensity to want more and more and more will result in the destruction of the world.

Quinn is intrigued, having himself harbored fears about the ecological crisis, and he listens intently. He has been fortified by the magical nature of the teacher, and he thus has been initiated into a new way of perceiving the world. The rest of the novel is about Quinn’s enlightenment as he departs from the ordinary, there to be initiated into new possibilities, and hopefully to return with a boon to the world community.

This intriguing novel carries the reader through the phases of the typical story of the hero’s journey. In his book The Hero with a Thousand Faces, the great mythologist, Joseph Campbell, teaches us about the phases of the typical hero’s journey story, the “departure,” the “initiation,” and the “return.” In the novel Ishmael, after Quinn’s departure from the usual and initiation into a new way of thinking, he and the gorilla plan the later phase of their earnest desire to save the world—the return with a boon to the community.

In this issue of San Francisco Medicine, we offer a few of the many journeys of local heroes who have lived through the three phases of the departure, the initiation, and the return so as to achieve major boons in the advancement of medicine through

innovative science, community action, and teaching. As we read these stories, we may remember that the hero has a thousand faces and thus reflect upon the thousands of local unsung heroes, doctors who attend to their patients and their profession every day. In doing so, we each may also ponder our own place as a hero within our profession.

As we do so, we may notice that currently the most urgent calling we face is health care reform in this United States of America. It seems as though this calling permeates our entire culture. Yet, instead of seeking transformative ways to improve health care, our political leaders seem to be embroiled in the usual politics of self-interest and ideological controversy.

Lately, our leading newspapers elucidate these partisan, ideological, and monetary self-interests with such headlines as “Health Care Hullabaloo,” “A Bombast Escalates,” “An Incoherent Truth,” “Growing Unease on Health Plan,” and “The Town Hall Mob.” Many columnists are beginning to predict failure. Charles M. Blow, columnist for the New York Times, speaking about those who seek change, says, “They’re losing control of it. That’s unfortunate because the debate is too important to be hijacked by hooligans.”

Economist and journalist Paul Krugman describes the four pillars of health care reform—regulation, mandates, subsidies, and competition—and observes, “knock away any one of the four pillars of reform, and the whole thing will collapse.” Judith Warner says it matter of factly: “Just a few months ago, health reform felt inevitable—just like it did in 1993. Now, just like in ’94, that sense of inevitability is fading.”

Perhaps this circumspect point of view was stated most succinctly by SFMS’s own Steve Heilig in his column in the June issue of this journal when, analyzing the odds of success of current efforts toward health care reform, he recalled an old adage: “Don’t hold your breath.”

If failure of politicians to effect health care reform is to be avoided, we may need some heroes to depart from the usual, to become initiated into a new way of thinking, and to return with a boon to all. Where will these heroes come from? Perhaps we should put an ad in the newspaper: Patients seek heroes. Must have an earnest desire to save health care reform. Apply in person.

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Local Heroes in Medicine

A Heroic Profession Redefining the Modern Physician

Allan B. Chinen, MD

P

hysicians were heroes for most of the twentieth century. We fought in—and won—the war on polio and smallpox. We steadily win ground against cancer, AIDS, cerebrovascular diseases, and the terrible traumas of war and urban violence. The physician was the archetypal hero-warrior, the brave man or woman who takes up arms against a terrible enemy, defeating it in a great battle and rescuing its victims.

The heroic physician is actually a recent development: a product of the twentieth-century union of science and medicine. Previously, doctors could mainly provide comfort—if they did not actually harm the patient with leeches and toxic potions.

Today the status of doctors changes again. There is no better indicator of this than military medicine in Iraq and Afghanistan: Doctors can now save soldiers who, just ten years ago, would have died from their injuries. The problem is the aftermath—the long rehabilitation required, for example, for traumatic brain injuries. This is now true of medicine in general, as we struggle with chronic ailments that no single, heroic intervention will solve. Instead of an evil but magnificent dragon, we face a host of scorpions, lurking in dark, low places.

Epidemics are no longer just biological but psychosocial—drug abuse, murder, suicide, and suicide bombers are all infectious conditions. Poverty breeds resistant tuberculosis and deadly new flu strains, so conquering them involves long-term economic and political efforts.

Perhaps worse of all, the physician has been demoted from hero-warrior to hired gun, a mercenary employed by insurance

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companies.

Older physicians mourn the loss of the hero-warrior, and many now retire early. In this changed world, we need a new ideal of healing, something beyond the hero. We find this, I suggest, in the original paradigm of healing, the shaman-trickster. Far older than the hero, the shaman and trickster appear in cave paintings from twenty to thirty thousand years ago, whereas warriors do not emerge until five to ten thousand years later. While the shaman may be familiar to most readers, the trickster usually is not, because he has been associated in Western culture with the Devil, the father of trickery and lies. Tribal cultures, particularly hunter-gatherers, present a different picture of the trickster, such as Coyote for Native American tradition, or Eshu and Legba from Africa. The trickster is essentially the divine version of the shaman; both carry out similar functions, and what they do provides a model for today’s physicians.

Shaman and trickster are principally healers. They do not work, however, by attacking the causes of diseases, as the hero does. Instead, shamans and tricksters negotiate with those causes, personified by demons and other underworld figures.

The ultimate nemesis of any healer, after all, is one nobody can defeat—death.

Knowing when to fight and when not to is critical for today’s health care system.

It’s the difference between heroic ICU care and hospice, length of life versus quality.

Coming to terms with limitations requires the shaman-trickster’s second basic function: He is a storyteller and, perhaps more important, a listener of stories. Both skills are crucial. Hearing a patient’s story and

San Francisco Medicine september 2009

translating medical jargon into an understandable narrative are essential for healing. (Both also prevent malpractice suits.)

Besides healing, shaman-tricksters are musicians, as many physicians are.

Music, however, is not a hobby for the shaman-trickster. In some of the most ancient known art, such as the Trois Frères cave in France, the shaman-trickster is portrayed playing a flute. Music reminds us of the many alternatives to science and technology in healing. Healing touch, prayer, meditation, and therapeutic music are, after all, older than randomized clinical trials. “Whatever works” is the trickster’s motto, rather than rule-following. Indeed, tricksters routinely lie, steal, and cheat, which is one reason they have gained a bad name, particularly in Western culture.

However, the trickery is always in the service of generativity, to benefit other people and life itself. For all the trickster’s foibles, he has a distinctive characteristic in mythologies around the world: The Creator specifically gives him a mission to make the way safe for humanity. That divine calling is what prevents the trickster from simply becoming a criminal. It is a calling that most physicians, on some level, have felt, but which we often forget (particularly with paperwork).

While doctors usually focus on individual patients, the shaman also tends to the collective, tribal welfare. When there is some kind of conflict within the group, the shaman’s task is to ferret out the root of that disorder. In the process, shamans and tricksters often must force people to change their customary way of doing things. Indeed, the trickster typically brings revolutionary innovations to Continued on page 14 . . . www.sfms.org

Local Heroes in Medicine

The Heroine’s Journey Finding a Place of Balance

Maureen Murdock, MA, MFT

M

edical schools are now made up of more than 50 percent women who, during their education and training, are required to be linear, scientific, and some would say masculine in their thinking. The path they follow is very much that of the “Hero’s Journey,” delineated by Joseph Campbell in his book The Hero with a Thousand Faces, which includes thresholds to cross, dragons to slay, and finding the magic elixir to heal the patient. But what happens to some women in and out of medicine who follow the heroic path is that, at some point, there is a feeling that something is missing.

In 1983, I had the opportunity to discuss with Joseph Campbell my model of the “Heroine’s Journey.” I knew that the heroine’s journey incorporated aspects of the journey of the hero, but I wondered if the focus of a woman’s psychospiritual development was to heal what might be a split between herself and her feminine nature. I also intuited that the movement through the model was cyclic and could be entered at any stage of the journey. After Campbell looked at my model, he said, “Women don’t need to make the journey.

In the whole mythological tradition, the woman is there. All she has to do is to realize that she’s the place that people are trying to get to. When a woman realizes what her wonderful character is, she’s not going to get messed up with the notion of being pseudo-male.”

His answer stunned me. I found it deeply unsatisfying, because the women I knew and worked with in my psychotherapy practice did not want to be there, the place that everyone was trying to get to, like Penelope weaving and unweaving her

father-in-law’s shroud while waiting for Odysseus to find his way home. Perhaps Campbell meant that, mythologically, the feminine was there if he was equating the term feminine with the spiritual nature.

If the feminine is seen as negative, passive, or manipulative, as some mothers of previous generations were who had no choices about career or childbearing, the child rejects those qualities she associates with the feminine, even rejecting such positive qualities as the ability to nurture, intuition, emotional expressiveness, and creativity, to “get ahead.” On a cultural level, the separation from the feminine often comes from the images of the feminine that are presented by the media.

The second stage of the Heroine’s Journey is an identification with the masculine, the patriarchal masculine, whose driving force is power. An individual in a patriarchal society may seem to be driven to seek control over herself and others in a desire for perfection. Some women seek power and authority either by becoming like men or by becoming liked by them.

The young girl sees men and the male world as adult; she becomes identified with the inner masculine voice, whether that is the voice of her father, the medical establishment, or the church.

The next stage, like the hero’s journey, is the road of trials, where the focus is on the tasks necessary for ego development.

Everything is geared toward climbing the academic ladder; achieving prestige, position, and financial equity; and feeling powerful in the world. In the outer world, the heroine goes through the same hoops as the hero to achieve success.

The first part of the heroine’s journey is propelled by the mind, but the later part

is in response to the heart. The heroine has been working on the developmental tasks necessary to be an adult, to get ahead in the outer world. Even though she may have achieved her hard-earned goals doing everything she was supposed to do, she may not feel complete.

At this point, the heroine is faced with a mythological descent or dark night of the soul, a time of major destructuring.

We all know what this feels like: A descent brings sadness, grief, a feeling of being unfocused and undirected. What usually throws a person into a descent is leaving home; separating from one’s parents; the death of a parent, child, lover, or spouse; the loss of identity with a particular role; a major disappointment; a serious physical or mental illness; an addiction; the midlife transition; divorce; aging; and loss of community. The descent may take weeks, month, years, and cannot be rushed, because the heroine is reclaiming not only parts of herself but the lost soul of the culture. The task for some women is to reclaim the discarded parts of the self that were split off in the original separation from the feminine.

A client of mine, a dentist in her late thirties who lost one breast to cancer, decided to take time off from her practice to write, garden, and to mother. “It’s a difficult decision,” she said. “The steady paycheck makes me feel secure and useful, and I expect it will be close to impossible to get health insurance because of my preexisting condition, but I’m impatient to do those things that were important to me before dentistry pushed everything aside.”

The heroine must become a spiritual warrior. This demands that she learn Continued on page 14 . . .

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Local Heroes in Medicine

Arthur H. Coleman A Life of Service to an Underserved Community

Erica Goode, MD

D

r. Arthur H. Coleman, who was born and raised in Philadelphia, came to San Francisco in 1948 and was one of the first African American physicians to open a medical practice in the city. Honorably discharged from the Air Force, the young twenty-eight-yearold had originally planned to practice in Georgia, where he had heard of a primarily African American community that needed a physician. But as he drove through the South an unpleasant incident abruptly changed his mind. He had simply stopped for gas and didn’t realize in that era that he must say, “Yes sir, no sir” to the station manager—an omission for which he received a punch in the face.

He continued on to California and rented a small office in the Bayview Hunters Point neighborhood of San Francisco, where many African Americans had migrated to work in the naval shipyards.

Almost two weeks passed before his first patient came. It was a slow start to what turned out to be a popular and busy practice spanning more than fifty-four years, with more than 25,000 patients in a community that later honored him with a parade down Third Street to celebrate his fiftieth year of practice.

Dr. Coleman was the first in his family to pursue a medical career. His parents, particularly his mother, emphasized academics, and she was quick to call him in to study while other children in the neighborhood continued to play. He graduated from high school with honors and entered Penn State as one of thirteen black students in a student body of 7,000, where he made the Dean’s List. Later, in his third year at Howard University Medical School, his high academic achievement

earned him admission into the Alpha Omega Alpha honor society. Later in life, his leadership qualities led him to serve as president of many national and local organizations, b o a rd s , a n d commissions, including the National Medical Association; the American College of Legal Medicine; the Black Congress on Health, Law, and Economics; National Medical Fellowships, Inc.; St. Luke’s Board; and the San Francisco Port Commission, to name a few.

In 1956, while practicing full-time by day and attending Golden Gate University at night, Dr. Coleman earned a J.D. degree and passed the California State Bar on his first attempt, becoming one of only twelve individuals in the United States at that time to possess dual degrees in medicine and law. He was spurred on to this by his many patients, who viewed him as an educated man and came to him seeking legal advice as well as medical care.

12 13 San SanFrancisco FranciscoMedicine Medicine september September 2009

Arthur Coleman, 1954

Dr. Coleman obtained funding, designed, and oversaw the building of a twostory multispecialty clinic at 6301 Third Street in San Francisco, which housed eleven African American doctors under one roof. The grand opening, which took place on February 28, 1960, was attended

by San Francisco supervisors, other political leaders, citizens, and physicians. It was a celebratory moment for the Bayview Hunters Point community, and pictures www.sfms.org www.sfms.org

on display at the clinic show folks dressed in their Sunday best, touring the newly built facility that would end the need to travel across town for comprehensive medical care and ancillary services, such as lab work and X-rays.

Dr. Coleman’s vision of the benefit of providing accessible medical care within an underserved community proved to be auspicious. Decades later, many of his original patients are still alive and in their eighties and nineties. His daughter, Patricia Coleman, who stepped in as the executive director of the clinic in 1980 and provided much of the narrative for this story, feels that the remarkably low number of hospitalizations and emergency room visits among his patients is directly related to the medical home concept that he instilled in multigenerational families.

When Dr. Coleman passed away from cancer in December 2002, the patients literally begged his daughter to keep the doors of the clinic open. She was particularly touched by one patient who came to her and said, “I don’t have the schooling to help you with paperwork, but I’m willing to clean toilets if it will help you keep the clinic open.”

It was the love that his patients expressed by stopping by the office or calling on a daily basis after he passed away that motivated her to recruit physicians to continue her father’s commitment to providing quality medical care to the underserved.

Operating the clinic has been a daunting task, with poor reimbursement for primary care providers in private practice, and, adding to the challenge, difficulty in attracting specialists willing to come to the neighborhood and provide medical services. Sometimes it has felt like one step forward and two steps back. Patricia Coleman cites CPMC pulling the lab and X-ray department that St. Luke’s Hospital had run for the past twenty-six years as one example. Having to travel to St. Luke’s for those services was a blow to the patients who were accustomed to having the services conveniently located a hallway down from where they saw the doctor.

She knew patient compliance would suffer as a result of the hardship that travel

outside the community poses for many.

When the OB/GYN and midwifery practice closed because they were unable to afford their malpractice premium, Pat rallied, calling around the city to try to find funding to prevent the community from loosing the two dedicated providers who were willing to work deep in the trenches of the housing projects to educate women about the importance of prenatal care and the rising rate of HIV among African American women. It is still hard for her to reconcile that the inability to raise a mere $19,000 meant another devastating loss to a community that already has fewer health providers than any other neighborhood in the city except the Tenderloin.

The need for competent and caring medicine rendered mainly by African American physicians and staff remains strong. Some of their patients, even today, have tested the waters in other physician’s offices in San Francisco, only to be blatantly discouraged from returning. Pat expressed dismay that in this day and age she would repeatedly hear stories from patients about doctors not wanting to touch them or seeming afraid of them.

The most egregious insult came from a physician who walked in, saw an African American woman on his exam table, and simply stood in the door, arms crossed, saying, “What are you here for, drugs?”

However, Dr. Coleman’s daughter is not one to be easily discouraged. She continues to soldier on and preserve the legacy of patient advocacy that her father began. In 2006, along with Dr. Marilyn Metz, she founded the Arthur H. Coleman Community Health Foundation (AHCCHF) as a nonprofit arm of the clinic. Through grants from the likes of the San Francisco Foundation, the California Wellness Foundation, and Kaiser Permanente, the AHCCHF has been able to supplement patient care with free health education programs, such as diabetes education taught by a certified diabetes educator; weight management taught by a registered dietitian and professionally trained chef; fitness classes led by certified personal trainers; and workshops conducted by psychologists to help residents of the neighborhood cope with issues in the community

such as violence, stress, depression, and chronic pain. She is hopeful that eventually funding will be found to cover physician salaries and other expenses that will assure sustainability of the clinic.

It is no wonder that Pat Coleman’s perception of the need to refurbish, fund, and keep the clinic alive in its original, lovely state is so intensely fervent. The need that her father so clearly saw more than half a century ago continues to this day. His words, when asked what motivated him to so unselfishly dedicate his life to the underserved, resonate within her: “I truly believe the Good Lord placed me on this earth to serve, and that is what I have done.”

Another guardian angel needs to arrive, now that Dr. Coleman and a more benevolent economic climate seem so ephemeral.

Erica Goode, MD, MPH, is an internist at the Institute for Health and Healing, CPMC, and an associate clinical professor at UCSF. She is also on the Editorial Board for San Francisco Medicine.

Welcome New Members!

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

Melinda Scully, MD, CPMC From The Permanente Medical Group

John Hall, MD Referred by Chuck Wibblesman, MD

Terry Jue, MD

Referred by Chuck Wibblesman, MD

Mark Thoma, MD Mark Chen, MD

Referred by Chuck Wibblesman, MD

Susan Tran, MD

Referred by Chuck Wibblesman, MD

Veronica Velasco, MD

www.sfms.org September 2009 San Francisco Medicine

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The San Francisco Medical Society Advocating for Physicians and Patients As San Francisco Medical Society members know, since its inception in 1868 SFMS has been an activist organization when it comes to the health of our community. Many projects and activities that have begun in San Francisco have gone on to have implications for the state and the nation. Here are some highlights from the current SFMS community health agenda.

Agenda for 2009 • Preserving the safety net and public health programs in times of severe budget cuts.

Opposing Proposition 1D and 1E in special election.

• Testifying in support of antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies. With the California Medical Association, submitting amicus brief opposing lawsuit to overturn the ban.

• Working with Mayoral Task Force to develop and support the Healthy San Francisco program and participating in the lawsuit to preserve the program.

• Providing physicians for medical consultation for the San Francisco Unified School District.

• Working on legislation to allow minors to receive vaccines to prevent STIs without parental consent.

• Participating in the Hep B Free program in San Francisco and educating physicians and patients on prevention and treatment of hepatitis B.

A Heroic Profession Continued from page 10. . .

humans, such as fire. Medicine plays a similar role today, as with stem-cell technology, genetic mapping, and humanhybrid clones, all of which raise disturbing ethical questions but open the possibility of dramatic new methods of healing.

Ironically, as we grapple with the future of medicine, we find inspiration and guidance by reaching back to the past, to the roots of healing in the shamantrickster, from long before the hero.

Allan B. Chinen, MD, is a clinical professor of psychiatry at the UCSF, and in private practice in San Francisco. He has lectured extensively and presented numerous workshops on the role of myths, fairy tales and legends on our life stories—the scripts we live out. He is the author of Once upon a Midlife, Beyond the Hero, Waking the World, and In the Ever After. To learn more visit his website, www.storydoctor.net.

SFMS Community Health Activities

REBUILDING AND PRESERVING SAN FRANCISCO GENERAL HOSPITAL: SFMS spokespersons have taken a lead in advocacy for full funding of the necessary seismically sound rebuild and in acting on the Mayoral committee to advise where and how that would occur. Many of our members and leaders trained and have practiced at SFGH. UNIVERSAL ACCESS TO CARE: SFMS leaders have long advocated that every San Franciscan should have access to quality medical care, and most recently our representatives served on the Mayoral Task Force that designed the Healthy San Francisco program. SFMS joined in the lawsuits to preserve that program as well. SFMS members advocated for, and even created, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s.

ANTI-TOBACCO ADVOCACY: SFMS advocates were in leadership roles in the banning of tobacco smoking in San Francisco restaurants, ahead of the rest of the state and nation; we advocate for ever-stronger protections from secondhand smoke, for removal of tobacco products from pharmacy settings, for higher taxes on tobacco products, and more. SFMS recently signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies.

HIV PREVENTION AND TREATMENT: The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, appropriate tracking and reporting, optimal funding, and more.

SCHOOLS AND TEEN HEALTH: SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and worked on improving school nutritional standards; it provides ongoing medical consultation to the SFUSD school health service. In addition, SFMS has authored a resolution allowing minors to receive vaccines to prevent STIs without parental consent.

ENVIRONMENTAL HEALTH: SFMS’s many environmental health efforts include establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for the reduction of mercury, lead, and air pollution exposures.

REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a state and national leader in advocating for women’s reproductive health and choice, including access to all medicalindicated services.

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San Francisco Medicine September 2009

The Heroine’s Journey Continued from page 11. . .

the delicate art of balance and have the patience for the subtle integration of the feminine and masculine aspects of her nature. She first may hunger to lose her feminine self and merge with the masculine, and once she has done this, she begins to realize this is neither the answer nor the end. She must not discard nor give up what she has learned throughout her heroic quest, but view her hard-earned skills and successes as one part of the entire journey. This focus on integration and the resulting awareness of interdependence is necessary for many women, and may be especially pertinent to women physicians as they work not only to cure the body but also to heal the person, and to preserve and promote the health and balance of life on earth.

Maureen Murdock is a Jungian-oriented psychotherapist in private practice in Santa Barbara, California. She is the author of The Heroine’s Journey. She edited an anthology of memoir writing entitled Monday Morning Memoirs: Women in the Second Half of Life. Her website is www. maureenmurdock.com. www.sfms.org

Local Heroes in Medicine

David Smith Pioneering Community-Based Health Care

Steve Heilig, MPH

R

ecently, as the national debate over health care reform heated up, Speaker Nancy Pelosi referred to health care as “a right, not a privilege.” How many who heard or read those remarks knew that those words originated at a landmark San Francisco clinic opened by a newly minted graduate of UCSF’s medical school? David Smith started medical school in 1960, after attending U.C. Berkeley. He figured on a career in research and teaching, but history tells us otherwise.

“I was born and raised in Bakersfield and my mother was a nurse, which was why I went into medicine. I had no ‘political’ interests at that time,” he recalls.

“UCSF had an outstanding pharmacology program and I was most interested in that field. When I graduated in 1964 with an MD and MS, my goal was academic medicine. My parents had died and I inherited a little bit of money and had no home to go back to, so I bought an apartment in the Haight—simply since it was close to UCSF. I was doing a fellowship in clinical pharmacology and was director of the drug and alcohol screening unit at SFGH.” Then there was a cultural explosion in the Haight-Ashbury, starting in 1965, with thousands of ‘hippies’ starting to arrive. They brought along their medical needs, including drug problems. “If they needed care, they would be sent to SFGH, as nobody else wanted to see them,” Smith recalls.

“But there were all sort of political meetings and movements going on, about civil rights and so on, and attending a few of those exposed me to a broader world, and my values started to shift. My education was coming from the street as I found that suddenly I was learning as much from

my walks home among the hippies as I was at UCSF. And there were a lot of sick people out there—the segregated care I heard about in the American David Smith (left) and George Harrison (right), 1974 South was present here, too.

“I learned that you could open a private doctor’s office and call it alone. But out of that start came a movewhatever you wanted. We found an old ment to mainstream addiction treatment dental office at 558 Clayton at Haight, and medicine, via advocacy by the SFMS which we leased and called ‘David Smith, and establishment of specialty societies MD, d/b/a the Haight-Ashbury Free Medi- that led to the American Board of Addiccal Clinic.’ And one of the slogans that came tion Medicine.”

Smith feels that the only real resisout of the creative explosion at that time was, ‘Health care is a right, not a privilege.’ tance from within medicine was skeptiThat became our founding motto. We had cism. “One of my medical professors asked a $500 donation from a church and $100 me, ‘David, where did you go wrong?’

I had from giving a lecture, so that was our There were others who called us ‘socialists’ first month’s budget. But we had hundreds and so forth, just like is happening now of volunteers, including physicians, and with respect to health care reform.

“I felt that in a certain sense we were were open twenty-four hours a day for a time, with no vision beyond the impend- going back to old-time, community-based ing 1967 ‘Summer of Love,’ as it came to medicine, consistent with our medical oath and ethics. Others agreed, with musicians be called.”

For the next four decades, the Haight- such as George Harrison, Janis Joplin, and Ashbury clinic saw millions of patient visits others doing benefits for us; music proand grew into a multiunit organization that moter Bill Graham helped us and we then served not only as an integral part of the started ‘Rock Medicine,’ developing models local health care system but as a model for of care there, too.

“John Luce, a journalist before he other such clinics around the nation. The hippies mostly moved on, the neighbor- became an esteemed physician at SFGH, hood evolved for worse and better, but the wrote about us for a national magazine, clinics kept providing care and innovations and my medical liability carrier canceled our coverage. I went to the SFMS and they in addiction treatment.

“Back then you could get arrested for got us new insurance, so I’ve been a loyal using a scheduled drug in detoxing an ad- member ever since. So much of national dict,” Smith recalls. “Don Wesson, MD, and impact has come from here; the free clinic I developed a program where we figured movement is just one such idea, and I’m we were committing hundreds of felonies proud to have been part of it.”

Steve Heilig, MPH, is the Director of a day in that regard. Undercover police kept coming in and taking pictures of our Public Health and Education for the San sign that said, “No Dealing,” and they left us Francisco Medical Society.

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Local Heroes in Medicine

Paul Volberding and Molly Cooke Caring for AIDS Patients from the Start

Kelly Terr

P

aul Volberding, MD, says it seemed like fate that brought him and Molly Cooke, MD, together thirty years ago on the cancer ward at UCSF, where they were both in training.

They didn’t know their lives would become inextricably linked with HIV and the AIDS epidemic, an area in which they have both become experts, leaders, and pioneers. These two remarkable individuals have balanced a marriage spanning more than three decades, raised a family, served patients and the medical community, and helped chart the course of the AIDS epidemic away from disaster and toward a more hope-filled future.

In 1977, Dr. Cooke was a secondyear resident at UCSF and Dr. Volberding was a young oncologist who had just completed medical school at the University of Minnesota. They began dating, and within a few years they were married. “It’s been thirty years of continuous happiness, and a good collaboration,” says Volberding.

While completing her residence at UCSF, Cooke trained in ethics and stayed on at San Francisco General Hospital as chief resident. Volberding joined the UCSF staff after doing clinical research as a fellow in the virology lab of Dr. Jay Levy, who was later a codiscoverer of HIV. Around this time, they each witnessed the first cases of young, previously healthy gay men coming into SFGH with rare and deadly illnesses, their health deteriorating rapidly due to compromised immune systems.

Meanwhile, in 1981, Cooke and Volberding had their first child. By the time Cooke returned from maternity leave, the hospital was full of patients with this

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Paul Volberding

new disease. The AIDS epidemic had arrived in San Francisco.

Ready When the Need Arose

While Volberding worked on clinical science and health care delivery system design, Cooke focused on ethical issues in the health care environment, going on to become the founding chair of the Ethics Committee at San Francisco General Hospital Medical Center.

“It was an interesting accident that we got caught up in working with AIDS. We each had different lenses through which we viewed the epidemic,” says Cooke. Her background in ethics and education was immediately put to use by the diverse range of issues that the epidemic brought up. One of the challenges was renegotiating traditional ideas of proxy decision makers.

“There I was, with a hospital full of

San Francisco Medicine September 2009

patients who were socially stigmatized, many of whom had had complicated relationships with their families or hadn’t spoken with them in ten years, and these questions came up—who do you turn to when you have to turn to someone to make these decisions on behalf of somebody else?”

Other ethical issues she worked on included how to optimize care for HIV and AIDS patients and provide training to students and staff, while minimizing occupational risk, as well as taking into account the professional responsibility of the training program if any residents became infected with HIV. “There were things that came up in my work that were different, yet complementary to the other work going on.”

Volberding also reflects on the impact he was able to make as a result of chance.

“In retrospect, it just happened that I www.sfms.org

was completely, ideally prepared for the epidemic when it hit. I had trained in oncology and I was also trained in retrovirus labs, in just the type of virology that HIV turned out to be,” he says.

In 1983, Volberding cofounded the AIDS clinic in San Francisco, along with the late Constance Wofsy, MD, an infectious disease specialist, and Donald Abrams, MD. The AIDS Clinic at SFGH was the first multidisciplinary AIDS clinic and the first inpatient AIDS clinic in the world. Volberding served as director of the AIDS clinic at SFGH from its inception until 2001, and under his leadership, the clinic’s doctors pioneered in drug studies, such as AZT on symptom-free HIV patients, while nurses and physicians created a model of care on the AIDS ward that would be influential in creating a blueprint for compassionate care across the country.

Dealing with the Stress

Both Cooke and Volberding do recall that early on there were stressful times, as they were both fully immersed in the work, with young children at home, and still many unknowns about the disease.

“Yet the fact that we both felt compelled to help made it easier on us, compared to what we saw with some other couples,” said Cooke. Some residents would go home to their nonphysician partners and be met with questions and fear about the safety of what they were doing. “We never second-guessed one another,” said Cooke.

“Even though we had private moments of fear, we kept it under control and pretty hidden,” Volberding says. He remains convinced the reaction of the medical community helped shape the public reaction away from the negative hype and toward a more positive community reaction.

Ongoing Involvement

As practitioners, teachers, advocates, and leaders in AIDS education, research, and treatment, they have each remained completely involved in HIV and AIDS through their various leadership roles and ever-increasing list of professional

and academic achievements.

In 2001, after heading the San Francisco AIDS clinic for twenty years, Volberding took on his current position as chief of medical services at San Francisco Veteran Administration Medical Center, where he is highly involved in teaching also treats HIV patients at the SFVAMC. He is also the vice chairman of the Department of Medicine at UCSF, and he is the codirector of the Gladstone Institute of Virology and Immunology (GIVI) Center for AIDS Research, which strives to coordinate all the research for HIV in San Francisco and create a community of HIV investigators in San Francisco.

“HIV, to me, is an amazing story of medicine,” he says. “It’s been just an amazing experience to see the worst epidemic ever to happen in front of our eyes, to be a part of that, to see the incredible devastation of what it can do, and to see treatments develop that are so powerful that almost overnight it became a chronic disease.”

Across town at UCSF, Dr. Molly Cooke has been a professor of medicine since 1992. She is also the director of the Academy of Medical Educators and a Senior Scholar at the Carnegie Foundation for the School of Teaching, as well as a William G. Downing Endowed Chair. As an internist, she sees patients, fifty percent of whom have HIV, and she is also highly involved in supporting teachers and residents in the School of Medicine.

“One of the things that’s fascinating about HIV,” she says, “is its different dimensions—the scientific dimension, the medicine and what we’ve learned about the immune system and viruses, that they are treatable; the policy dimensions, of which there are always interesting

Molly Cooke

debates; and then the poignant, sad, and sometimes triumphant personal stories of patients.”

Both Dr. Volberding and Dr. Cooke are increasingly interested in and energized by the debate going on about health care reform. As president of the American College of Physicians, an organization that is highly involved in the health care debate, Cooke has been lobbying and speaking about health care reform. “We can’t go on running our health care system the way we do,” she says.

In addition to their practices, their teaching, and their involvement with the current debate surrounding health care, Cooke is also working on a book, and Volberding has plans to make a documentary about the early days of the AIDS epidemic.

Yet even with all that they have going on, expect these two local heroes to make a large impact on the current issue of the moment: If history is any indicator, when the cards fall in such a way that they must rise to meet a challenge, they are unstoppable forces.

Kelly Terr is a freelance writer that lives and works in San Francisco.

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Local Heroes in Medicine

Rachel Naomi Remen A Pioneer in Holistic and Humanistic Medicine

Dawn Yun

W

hen Rachel Naomi Remen’s grandmother opened her refrigerator too quickly, causing an egg to break, she would say, “Today we make sponge cake.”

At fifteen, Remen was diagnosed with Crohn’s disease and told she wouldn’t live past forty. Her mother held her hands, reminded her of her grandmother, and said, “Rachel, we’re going to make sponge cake of this.”

In the fifty years since receiving that diagnosis, Remen has done far more than simply survive Crohn’s, a chronic disease that affects the digestive system, the joints, and many other systems of the body. She has become a doctor, a bestselling author, and a pioneer in holistic and humanistic medicine.

“My mother pointed out that it was possible to grow even with this terrible thing,” said Remen, now sixty-five. “None of my doctors pointed out the possibility that one could live a good life even though it wasn’t an easy life. My mother pointed to a dream. It’s very important to have a dream when you get a diagnosis. “(Otherwise), you can hold yourself too small and live too far in your limitations. You may not push to the edge of things, and life is where the edges are.

It’s where life is all the time, where the wisdom is and where you can discover who you are and what’s important.”

Remen’s dream since age five was to be a doctor. She was fourteen when she entered Cornell University and twentythree when she graduated from its medical school. She did her internships and residency there, then went to Stanford for a medical fellowship from 1965 to 1967. From 1967 through 1974, she was

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Rachel Naomi Remen

an associate professor of pediatrics at Stanford and was the associate director of its Pediatric Clinic.

In those days, there weren’t many female doctors and even fewer ill ones.

“John Wayne was the father of medicine then,” she said.

Rather than talk about her medical condition with fellow doctors whom she knew didn’t want to hear about it, she did

San Francisco Medicine September 2009

something unique: She told her patients.

And they did want to hear about it.

“We supported each other,” said the Mill Valley resident. “I got to really understand courage from them and I saw the greatness of the spirit. And in the process of being ill, something was growing inside me. I found myself deepened as a human being.”

Continued on page 20 . . . www.sfms.org

Local Heroes in Medicine

Acts of Daily Giving San Francisco General Employees Go Above and Beyond

Beni Seballos, MD

“J

ohn, this must have taken you hours!” I exclaimed to my coworker, my amazement growing with every page of a patient service application that he was asking me to sign. John is one of the medical assistants at the Family Health Center, a primary care clinic at San Francisco General Hospital. The role apparently includes filling out ten-page patient service applications on behalf of a monolingual Chinese-speaking patient for a provider who is on vacation and then finding another physician to sign it. In response to my outburst, John just looked at me quizzically. Because I continued to gape at the rows of meticulously-listed medical data, he replied simply, “Yes.” Still incredulous, I finished reviewing the document and eventually handed it back to him with a heartfelt but feeble “Thanks, John. Nicely done.”

John’s efforts are evidence of a special alchemy that takes place at the county— one that transforms the most mundane tasks into heroic feats. Perhaps a stronger case for heroism can be made for the dramatic interventions that piece back together the bodies and lives of gunshot victims. I, however, have been sustained more by the understated advocacy, like John’s, that happens all around me every day.

The System

urgent care clinic, “is the ability to adapt to increasing levels of dysfunction.” We were discussing the impact of another round of budget cuts, the simultaneous expansion of the county’s health access program and the growing numbers of unemployed—and therefore uninsured.

Rich has the unenviable task of finding primary care homes for patients with chronic disease who present to urgent care. His tenacity never ceases to amaze me. A few months ago, he greeted me on my cell phone with an excited “I got one!” He had secured an appointment for a patient with recurrent oral cancer and uncontrolled hypertension who was sent to the urgent care for preoperative clearance. “How?!” I marveled. I myself had spent long moments on the phone a few days prior, talking to well-meaning staff on clinic back lines, only to be rerouted from one dead end to another. No room at the inn. “Well, I called all the usual places and no one had anything,” he explained.

“So I walked over to one of the clinics and found a triage nurse who could give me one.” One part of me was outraged that it took that much work to get such a basic task done. A larger part of me shared Rich’s triumph at securing a precious resource for someone who clearly needed it. “Thanks, Rich!” I gushed. “Nicely done!”

John’s willingness to color outside the lines of an already-expansive job description is exceptional but not unique.

In an overburdened system such as the county health department, it is also indispensable. “The defining characteristic of a county employee,” I once remarked to Rich, a medical social worker in the

Without belittling Rich’s efforts, I should add that this particular appointment was a pleasure to earn. The gentleman with cancer truly was a gentleman.

He had waited in urgent care for the usual several hours, only to be told that we could not complete the forms he needed and that he would need a primary care

The Patients

provider to monitor his hypertension and coordinate his surgical and oncological services. Through all that, and my initial failed attempts to get him an appointment with a primary care provider, he remained pleasant and appreciative.

Many patients in the county system battle mental illness and poverty, and these struggles become even more challenging when they are acutely sick. I recently helped take care of a man who is addicted to heroin, homeless, and who came in with pain and swelling at one of his injection sites. His medical history includes years of recurrent hospital visits for some combination of these three problems. While labs were being drawn for his evaluation, he became enraged, pulled out his IV, overturned the phlebotomy tray, and stormed out of the clinic, swearing at the top of his lungs. Alice, one of the nurses, came to tell me what had happened. I went to re-evaluate the patient who, in an oddly endearing way, earnestly asked me, “Isn’t it good that I didn’t lose my temper?” After he and I negotiated a treatment plan, I passed the room he had occupied. Supplies were scattered all over the blood-spattered floor. In sharp contrast to her chaotic surroundings, Alice was calmly putting things back in place. Her measured movements deepened my appreciation for my colleagues who take care of all our patients—even those who do not take care of themselves or others. “Thanks, Alice.” I murmured.

“Nicely done.”

The Reason

I tell applicants to the Family Medicine program that I knew residency would

Continued on the following page . . .

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Acts of Daily Giving Continued from page 19 . . .

make me smarter. True enough; the clinical skills I gained serve me well in my daily practice. “What I didn’t expect,” I add, “is that it would make me nicer, too.” Like all the interns in my entering class, I came to residency with a demonstrated commitment to working with the underserved. I did not think there was much I could be taught about passion, compassion, and optimism.

Looking back, I am grateful to remember how wrong I was. In addition to the many people like the understated John, tenacious Rich, and kind Alice, there were coresidents and attendings whose activities of daily giving were antidotes to exhaustion and burnout. I caught one playing a post-call game of chess with a hospitalized patient; overheard another painstakingly explaining to an alcoholic why it’s not productive to pick fights with the security officer; picked up printouts from the computer for many others tirelessly lobbying at individual, local, and national levels for the well-being of our patients and our health care system. I don’t know for certain why each one of them does what they do. When I ask, they tell me it’s because the work is important or rewarding or right.

For all that my many heroes do and have taught me: “Thanks, folks. Nicely done.”

Beni Seballos graduated from the Family and Community Medicine residency program at San Francisco General Hospital in June 2008. She stayed on as an associate physician and clinical instructor at the Family Health Center. She will soon leave the nest to work as a staff physician at Thundermist Health Center in Woonsocket, Rhode Island.

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Rachel Naomi Remen Continued from page 18 . . .

Her unique role as patient and physician gave her an unusual perspective on medicine. By her own account, it also made her a better doctor. While the scientific part of medicine appealed to her, Remen found herself increasingly drawn to its emotional and spiritual side, something not taught in medical schools at the time.

“As doctors, we’re trained to a certain professionalism, which makes us vulnerable to burnout, cynicism, and depression. The task of the physician is not just fixing the body. It goes far beyond that.’’

Remen was determined to pursue a new kind of medicine, one that also involved the heart, soul, and spirit. Her catalyst came in 1972, when she and eleven other doctors were invited to meet once a month for two years at the Esalen Institute with Joseph Campbell, George Leonard and other seminal thinkers of the then-emerging human potential movement. Esalen is an alternative educational center in Big Sur. Remen realized that her true calling in life was to be of service to others. She decided to devote herself to practicing and teaching mind/body holistic health medicine and became one of its earliest pioneers.

To share with the public what she’s learned about herself, her patients, her family and the human spirit, she has written two best-selling books, Kitchen Table Wisdom: Stories that Heal and My Grandfather’s Blessings: Stories of Strength, Refuge and Belonging.

To teach doctors, medical students and medical educators about humanistic medicine, and to “help them overcome their training,” she founded the Institute for the Study of Health and Illness at Commonweal in 1991. Commonweal is a health and environmental research institute in Bolinas.

Dr. Roland Minami, a plastic and reconstructive surgeon in Greenbrae, has taken one of Remen’s courses and said it changed the way he practices medicine.

“It has helped me not to be afraid and to be more engaged with patients,”

San Francisco Medicine September 2009

he said. “You can cry with them. You can pray with them. When some patients are given a terrible diagnosis, sometimes I give them an origami crane as a guardian angel. One of Dr. Remen’s sayings is to be a good physician you have to be in recovery from being a doctor. Her idea is that unlike what we’re taught in school, we should stress humanity.”

Remen has worked with cancer patients for more than twenty years. She is cofounder and medical director of the Commonweal Cancer Help Retreat. Since 1985 it has held more than 100 weeklong retreats for cancer patients, families and friends. A clinical professor of family and community medicine at UCSF, as well as a noted national public speaker, Remen has refused to allow her disease to get in the way of her mission.

“Illness is a wake-up call,” she said.

“We need to receive that call. It’s an opportunity to learn what is really important, what is most honest and genuine in life.

Am I spending time on the things that are most important, and if not, why not? Don’t allow yourself to be limited by certain ideas about your disease. People can be more limited by their beliefs about their disease than by the actual disease itself.”

Remen, who has had eight major abdominal surgeries, knows firsthand what it is like to be a patient who is told that she will die. She is troubled by doctors who tell patients how long they have to live because there is always hope, she said.

“I’ve not been dead these past twenty-five years. I feel the real thing to say to people is that you have a significant illness here. I will do everything possible. You’re going to do everything possible. We’ll do it together. I have no idea how this will end up, but count me in.”

This article originally appeared in the San Francisco Chronicle.

www.sfms.org

Local Heroes in Medicine

Denise and Elliott Main Heroes Among Us

Toni Brayer, MD

D

octors Denise and Elliott Main are an exceptional couple. They are a shining example of how to blend professional success and personal happiness with a life of giving. Like many modern-day heroes, they are humble, and I knew them for years before I was aware of their mission helping persons afflicted with HIV in Honduras. I am honored to tell their story.

While in college, they met and fell in love. They attended medical school together and have remained married for thirty-seven years. Both are specialists in perinatology with medical practices at CPMC, and they have established outreach clinics throughout Northern California, caring for women with high-risk pregnancies.

In San Francisco, we are blessed with many outstanding and accomplished leaders in medicine. So what makes Denise and Elliott so different? Their story is a good one….

With their love of Latin America (Denise grew up in Venezuela and speaks fluent Spanish) and with two kids in tow, they vacationed in Honduras after Hurricane Mitch devastated that country in 1999. Seeing a need, they got involved in reconstruction of houses and providing OB supplies to two large public hospitals.

While there, the doctors also became aware of many Hondurans dying of AIDS. The disease was ignored, the infected were stigmatized. And, despite Honduras having the highest rate of HIV of any Spanishspeaking country (almost 2 percent in the early 2000s), there was no education or treatment available.

Denise and Elliott jumped in and supported the first local HIV self-help group.

By 2002, triple antiretrovirals (ARVs) had

come on the scene and treatment was possible. But at a cost of $14,000 per patient per year, there would be no possibility for such treatment for Hondurans, among the poorest in the world outside of subSaharan Africa.

With creative thinking and persistence, the Mains worked out a deal for generic ARV medications from India that could be purchased for $450 per patient per year. Time was Denise and Elliott Main ticking away. Within one week in February 2003, they turned around a grant proposal and partnered logoed bags, hospital gowns, gift bags, and with the AIDS Healthcare Foundation and baby clothes.

Denise says, “From the beginning, we the Episcopal Church of Honduras, convinced the Honduran Ministry of Health to worked with dedicated Hondurans to make approve their clinic, found a lab that could sure the program addressed the needs of perform CD4 counts, got permission to those infected while we provided medical import the medication, and hired a local expertise and financial support. It took doctor. The first Siempre Unidos clinic time to develop their trust that we would respect local opinion and not try to do our was born.

With treatment available for the first own thing. One of our most significant time, they saw emaciated, sick patients accomplishments is that we have helped who would have died become healthy and empower Hondurans to address the AIDS resume normal family life within three epidemic.”

Fast-forward to 2009: Siempre Unidos, months of treatment initiation. But because of employment discrimination, these pa- still under the leadership of Drs. Denise tients still could not find work, so Denise and Elliott Main, now has three Honduran established two fair-trade workshops locations in Roaton, San Pedro Sula, and where HIV-positive clients make jewelry Siguatepeque. They treat more than 500 inspired by indigenous designs and sew Continued on page 27 . . .

www.sfms.org September 2009 San Francisco Medicine

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Local Heroes in Medicine

Women in History Pioneers that Shaped Medicine in San Francisco

Nancy Thomson, MD “Women should not be expected to write or fight or build or compose scores.

She does all by inspiring men to do all.”

—Ralph Waldo Emerson (1802–1882)

I

n 1948, when I started college at Stanford University, my physicianfather discouraged me from preparing for medical school, saying that I would take a man’s place, then marry and never practice. Lois Scully, MD, a San Francisco internist, Stanford graduate, and 1979 president of the American Women’s Medical Association, ran into the same bias at about the same time when the Stanford physician who interviewed her told her to go home, marry, and have five children.

In the early 19th century, Lucy Stone (1818–1893) wanted a good education, but the only college in the world that accepted women at that time was in Brazil.

Luckily, Oberlin University was founded in 1835 in Ohio, the first U.S. college to accept both women and African-American students. Stone enrolled and graduated in 1847. However, when it came time to seek a profession, the only field open to women was teaching. In 1849 (the year Elizabeth Blackwell graduated from Geneva Medical College in New York), Lucy Stone wrote, “We believe that if the system of educating females for physicians be generally adopted, a great amount of suffering and death will be saved.”

In fact, the number of female medical school graduates rose steadily from 1849 to 1900. By 1900 in Boston, women represented 18 percent of practicing physicians. However, by 1903 women’s participation in medicine began to decline, as most of the women’s medical

22

schools established in the previous 50 years were closed or merged with maledominated schools, which continued to reject women applicants. This situation generally prevailed until the 1970s, when the feminist movement and antibias legislation brought about an increase in women attending medical schools.

In 1970, female admissions to medical schools were at 9.2 percent; in 1980 they had risen to 27.9 percent, and they are at almost 50 percent today. The decline in economic potential for physicians (which was historically one of the foremost motivations for male medical students) is given comparatively little importance by female students, who cite longtime interest in medicine and science, the desire to help others, and dissatisfaction with other types of work among their reasons for choosing medicine.

The following time line highlights women’s place in the medical history of San Francisco.

Historical Time Line

From the time of landing at Plymouth Rock, women as well as men practice medicine in New England, often after an apprenticeship with a practicing physician. However, when American medical schools are established, they follow the European pattern of barring women from seeking medical degrees.

1863

Elizabeth Pfeifer Stone, the first woman to practice medicine in California, settles in San Francisco. Probably German-born and -trained, she previously practiced in New York.

San Francisco Medicine September 2009

1873 University of California acquires Toland Medical School in San Francisco, and since U.C. is already coeducational, Lucy Maria Field Wanzer, a thirty-threeyear-old teacher, is accepted as its first female medical student. However, the dean suggests to her fellow students that they “make it so uncomfortable for her that she cannot stay.”

1874

Charlotte Blake Brown applies to the San Francisco Medical Society for admission. Some members of the membership committee feel strongly that females are mentally, physically, and morally unfit to study medicine, let alone practice the profession. On advice of mentors, Brown withdraws her application.

1875

Following the model of Elizabeth Blackwell’s New York Infirmary for Indigent Women, Pacific Dispensary for Women and Children is founded by three women[ARE THEY ALSO PHYSICIANS?], all educated on the East Coast: Charlotte Blake Brown, Martha Bucknall, and Sarah E. Browne. This outpatient clinic, initially located at 510 Taylor Street, is intended to provide opportunities for women physicians to obtain internship experience.

1876

San Francisco Medical College of the Pacific accepts its first female student, Alice Boyle Higgins, who graduates in 1877.

1877

Having been admitted to the Califor-

Continued on the following page . . . www.sfms.org

nia Medical Society along with four other women in 1876, Lucy Wanzer becomes the first female member of the San Francisco Medical Society.

1880

Founders of Pacific Dispensary create the first nursing school west of the Rockies. Its one-year course becomes a two-year curriculum in 1882.

1887

The Pacific Dispensary moves to a new two-story building at California and Maple Streets and becomes Children’s Hospital. Interns and residents can be either male or female, but there are no men allowed on the medical staff.

1895

Citizens of San Francisco raise money to build the Little Jim Building for pediatrics at Children’s Hospital.

1896

One year after X-rays are discovered, Elizabeth Fleischman-Aschheim, an engineer, opens the first X-ray laboratory in California, at 611 Sutter Street.

1896

William Randolph Hearst leads the campaign for the Eye and Ear Pavilion at Children’s Hospital.

1904

Dr. Charlotte Blake Brown dies at age fifty-eight. Her daughter, Adelaide Brown, MD (1868–1933), carries on her mother’s work at Children’s Hospital but also serves on the Stanford faculty at Lane Hospital. She fights locally and nationally for clean milk, sanitary garbage disposal, maternal and child welfare, visiting nurse services, and clinics offering cardiac care and birth control.

1906

The San Francisco earthquake forces the demolition of the 1887 Children’s Hospital building.

1911

A new, four-story brick Children’s

Hospital building opens at California and Cherry Streets.

1912

The Contagious Disease Pavilion opens at Children’s Hospital, with money donated by William Randolph Hearst, to care for diphtheria, scarlet fever, measles, TB, and, later, polio.

1915

Children’s Hospital affiliates with the University of California for the teaching of medical students.

1915

The American Medical Association admits its first female member.

1916

Henries Hagar Duggan, MD, becomes a pioneering medical anesthesiologist.

She works at various hospitals but settles at Children’s for twenty-five years, retiring after the end of World War II.

1938

UCSF pediatricians Mary Olney and Ellen Simpson found summer camps for children with diabetes.

1946

Marian Yueh Mei Li arrives in San Francisco, having completed medical school in Shanghai. She eventually opens a private practice and becomes the first Chinese female ophthalmologist to practice in Chinatown.

1952

Pediatrician Hulda Thelander establishes the Child Development Center at Children’s Hospital for children with cerebral palsy, developmental delays, and congenital defects.

1960

Internist Roberta Fenlon, MD, becomes the first female president of the San Francisco Medical Society.

1971

Dr. Roberta Fenlon becomes the first female president of the California Medical

Association.

1977

Linda Hawes Clever, MD, MPH, founds (and chairs) the Department of Occupational Health at California Pacific Medical Center. She is also the first female editor of the Western Journal of Medicine and is the founder of RENEW, an organization to help fight professional exhaustion and dissatisfaction.

1980

Children’s Hospital acquires St. Joseph’s Hospital.

1988

Marshall Hale Hospital, formerly Hahnemann Homeopathic Hospital, merges with Children’s Hospital.

1991

Children’s Hospital and Pacific-Presbyterian Medical Center merge to create California Pacific Medical Center (CPMC).

CPMC joins the Sutter Health chain.

1995

Judith M. Mates, MD (ob-gyn), becomes the second female president of the San Francisco Medical Society.

1996

Toni J. Brayer, MD (internist), becomes third female president of SFMS and, in 1990, the first female chief of staff at California Pacific Medical Center.

2003

Rita Melkonian, MD, FACOG (obgyn), becomes the fourth female president of the San Francisco Medical Society, with E. Ann Myers, MD (endocrinology), as the president-elect.

In closing, it’s interesting to note that in 1868, while debating the admission of women, the American Medical Association recorded this statement by Dr. Alfred Stille, prominent teacher of pathology: “Another disease has become epidemic. The woman question in relation to medicine is only one of the forms in Continued on page 33 . . .

www.sfms.org September 2009 San Francisco Medicine

23

Local Heroes in Medicine

Leonard Shlain Left Brain, Right Brain, and Ironies of the Heart

Jordan Shlain, MD

I

was rummaging through some old college files last month and stumbled across a paper I wrote for my Physiology 101 class on May 8, 1989, at U.C. Berkeley, titled “Learning and neural adaptation: Postsynaptic potentiation.”

It was an analysis of neuronal plasticity.

After reading it, I was reminded that the map that charts the path of understanding neuroscience is byzantine, sophisticated, and very exciting.

Neuroscience is one of the last great medical frontiers. Encompassing biochemical neurotransmitters, high-definition imaging, computer-aided modeling technology, and much more, this field assists us in deciphering the staggering complexity of the human mind. And there is the irony about the cognitive and intellectual horsepower of the mind invested in the study of itself.

I am acutely aware of one individual, my late father, who devoted the last twenty-five years of his life to demystifying the nuance of the parallel and distinct universes that are the right and left brain. His interest and scope transcend the focused study areas in neuroscience; he bridged the nano and macro and wove a tapestry as elegant in its simplicity as the human brain itself. He focused on the ultimate byproduct of neuroscience—behavior. As a genetic pupil, I will do my best here to illuminate some of the works of my father, including the as-yet-unpublished one he finished just before he died in May. Leonard Shlain asked many questions in his life. The one that started him on his journey for understanding the right brain/left brain dichotomy took place at the Museum of Modern Art in New York.

My sister, who was and still is a talented

25 24

artist, asked him, “Dad, could you please describe that to me? I don’t understand it,” as she pointed to a piece of abstract modern art. He paused and realized that the zeitgeist of modern art was as inexplicable and inscrutable as was the world of quantum physics.

In his first book, Art and Physics: Parallel Visions in Space, Time and Light, he posited that the right brain describes the world through the medium of art while the left brain describes the same world using science as its medium. Furthermore, the right brain is evolving slightly ahead of the left brain, such that major shifts in artistic movements precede corresponding discoveries in physics. My father’s example of this was Picasso’s Cubism and Einstein’s subsequent Theory of Relativity. Cubism was an artistic movement that described on canvas the idea that you could look at one image from multiple perspectives from one vantage point. The theory of relativity says that space and time are one and the same, and what you see depends on where you are in space-time. Historically, artists and physicists have paid scant attention to one another’s work, but he develops the idea that the most innovative artists nonetheless prepare the public’s mind for expanded conceptions of reality.

Dad’s next exploration into the mystery of hemispheric lateralization began with the question: What happened five thousand years ago that changed the sex of god of Western religion? Why did Western civilization transform from an abundance of goddess-centric, matrilineal, and matriarchal societies into a singular, strict patriarchal one? The answer, upon close inspection, is the left brain: The “male” brain wrested control of the vox

San Francisco Medicine September June 2009 2009

Leonard Shlain, 1969

populi. The male brain was the hunter brain, the dispassionate and linear brain.

The sequential property of the written word made acquisition and adoption by the left brain easy. The right brain, or “feminine” brain, was holistic, abstract, image based, and nurturing. The complete control of the written word did not allow the right brain to have a seat at the table of organized religion, especially given that the first known written words are the Ten Commandments—and that the third commandment says there shall be no art (idols). The Alphabet Versus the Goddess: The Conflict Between Word and Image has the audacity to question myths, legends, history, and science, all through the lens of neuroscience.

The third work, Sex, Time and Power: How Women’s Sexuality Shaped Human Evolution asked another question: Why did big-brained Homo sapiens suddenly emerge some 150,000 years ago? He argues that profound alterations in female sexuality hold the key to this mystery.

Long ago, due to the narrowness of her bipedal pelvis and the increasing size of her infants’ heads, the human female began to experience high childbirth death rates, precipitating a crisis for the species. Natural selection adapted her to this unique environmental stress by drastically reconfiguring her hormonal reproductive cycle. Her estrus disappeared and menses mysteriously entrained with the periodicity of the moon. Women formulated the concept of a month, which in turn allowed www.sfms.org

them to make the connection between sex and pregnancy. Upon learning the majestic secret of time, these ancestral females then gained the power to refuse sex when they were ovulating. Men were forced to confront women who possessed minds of their own.

Women taught men about time and the men used this knowledge to become the planet’s most fearsome predators.

Unfortunately, they also discovered that they were mortal. Men then invented religions to soften the certainty of death.

Subsequently, they belatedly grasped the function of sex. The possibility of achieving a kind of immortality through heirs drove men to construct patriarchal cultures whose purpose was to control women’s reproductive choices.

As you may sense by this point, the good Dr. Leonard Shlain was not afraid to ask tough questions, research voraciously, and beautifully synthesize disparate themes. His final question, which is the topic of his latest and still-unpublished book, does not ask a question—it makes a statement. Leonardo da Vinci is likely the only human being in recorded history who could have won a Nobel Prize in both art (right-brain dominant) and in science (left-brain dominant). This final masterpiece is the study and exploration of Leonardo da Vinci’s brain. Rather than paraphrase, I will allow you to peruse some of the book’s nuggets: ” . . . How, then, are we to explain the fact that in all of history there has been only one person who combined a genius so spectacular that he incandescently illuminated both the fields of art and science?

Why does Leonardo occupy his solitary niche in the history of humankind across thousands of cultures and generations?

His uniqueness has continued to enthrall commentators throughout the nearly five centuries that have followed his death in 1519.” ”He gives precise instructions to painters how they should depict the penumbra of shadows and how to position objects relative to each other in a composition so that the laws of perspective are rigorously followed. The only contemporary artist he mentions by name, Sandro

Botticelli, is taken to task for his lack of interest in faithfully adhering to the axioms of perspective. How then to explain the unsettling discovery, when carefully examining Leonardo’s paintings, that he cleverly violates the laws of perspective in all of them? These anomalies will be detailed in a later chapter. Leonardo is both an extraordinary left-brained academician obsessed with portraying perspective correctly, and a right-brained impish trickster who takes delight in fooling the viewer with perspectivist sleights of hand.” ”If creativity begins in the right brain, it must at some point make the journey across the great divide between the hemispheres. To translate an insight into words or action, the left hemisphere must be involved—but not always. In the kinesthetic arts, such as dance or basketball, the right brain may invent a creative maneuver never used by anyone before.

In some cases there is no conscious input and the right hemisphere will simply put the innovation in place in the middle of a routine or game. In general, however, the left lobe must translate the insight into words, or verify the insight using paint or equations. This step requires that the insight be formally introduced to the left lobe.” ”After arising in isolation in the right hemisphere, the creative insight must climb aboard the corpus callosum express to be ferried across to the left side of the brain. This raises the question: Is the corpus callosum merely a conduit or does it serve a higher, more integrative function? The corpus callosum is the most poorly understood structure in the human brain, and it also happens to be the largest. Arching over the midline, the corpus callosum is an enormous band of neurons numbering well over 200 billion.

Neuroscientists are of two minds as to what this broad band of connecting fibers function is. The first is a down-to-earth, no-nonsense approach that posits that the corpus callosum serves only as a conduit that allows the right hand to know what the left hand is doing and vice versa. The opposing theory proposes that the corpus callosum integrates information from each side and represents an über hemisphere

2009

in that it functions as a third brain producing something qualitatively different from what the right and left brain generate individually.”

I will leave you, teary eyed, with the last paragraph of the epilogue, written May 8, 2009—twenty years to the day after I finished my undergraduate paper. ”As I write this, I am grateful for the extended time. My MRI, which had revealed the doubling of the size of the tumor the last time, showed that with the treatment of Avastin, my determination to live, and the phenomenal outpourings of prayers and good wishes from people, some of whom I know and many others who have only read my books, the tumor has shrunk to over two-thirds the size. I am walkin’ and talkin’, two things that are the left brain’s province, an indication of the left’s control of body movements and speech which are currently not showing any disability. I hope to see you in the spring of 2010, when the book will be published.”

On May 11, four days after completing his book Leonardo’s Brain, my father, himself a modern-day Leonardo, succumbed to a brain tumor. Irony squared.

Jordan Shlain, MD, is the only son of Leonard Shlain and a practicing internist in San Francisco. He started the first affordable concierge medical practice in San Francisco, www.CurrentHealth.com, and lectures at UC Berkeley and around the country. He was recently named one of the top 100 innovators by HealthSpottr.com and is building an online, physician/patient follow up tool which facilitates better outcomes and enables twitter sized messaging between patient and office—decreasing the number of phone calls. He can be reached at DrShlain@CurrentHealth.com.

www.sfms.org September 2009 San Francisco Medicine

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Local Heroes in Medicine

Rolland Lowe Caring for the Chinese Community of San Francisco

Emerald Yeh

D

r. Rolland Lowe is a community doctor in the truest sense. He has cared for some 20,000 patients in more than four decades of practicing medicine in San Francisco’s Chinatown.

At the same time, he has tended to a much larger community, not only redefining and improving health care for low-income patients in Chinatown but serving as a role model for minority doctors statewide and nationwide as an advocate for their patients’ needs. Dr. Lowe recently retired from medical practice after forty-three years of service.

Rolland Lowe came into this world with activism in his blood, born as the only child of parents who were willing to take risks to speak out against the suffering of others. His father, Lawrence, was born in China and joined the Communist Party in the 1920s at the age of twenty-two.

“He was idealistic and concerned about the plight of the Chinese people and thought that the Communist Party offered the best answer,” Dr. Lowe says. “In those days, if you were arrested for being a Communist, there was no trial. They just killed you. So you could call my dad a radical, but he was willing to pay the price of his own life for others. It is an example that inspires me to this day, in which you sacrifice the ‘me’ for the greater ‘we.’”

Dr. Lowe’s mother, Eva, was born in California and used to stand on a soapbox in Chinatown to decry the imperialists, referring to the Japanese who had invaded China. Even recently, at the age of ninety-four, Eva Lowe was raising money for the elementary school in the family village in China.

Rolland Lowe was born in San Fran-

26 27

Rolland Lowe

cisco’s Chinatown in 1932. His first exposure to the cruelties of history and circumstances came at an early age, when his family moved to Hong Kong.

His father was teaching Chinese and his mother taught English. But World War II broke out, and Rolland recalls watching from their second-floor balcony as dump trucks came down the street every morning to pick up the bodies of the many villagers who had fled to Hong Kong during the war, only to perish in the streets.

The family made it out of Hong Kong in 1941 on the last U.S.-bound ship. Arriving back in San Francisco, his father took a job at the Mark Hopkins Hotel, working nights until he could save and borrow enough money to buy a grocery store in West Oakland.

During high school, Lowe joined a progressive youth organization, the Chinese-American Democratic League,

San Francisco Medicine September September 2009 June 2009 2009

that met in a basement on Stockton Street in San Francisco’s Chinatown. They organized picnics and singing groups, published a newsletter, and studied the teachings of Mao. “We never advocated the overthrow of the U.S. government or renounced our allegiance to America,” Dr. Lowe says. But it was the 1950s, and he was eventually investigated by the U.S. government for his association with progressive activities.

Nonetheless, the experience was to form the bedrock for his later years of involvement and dedication to the organization Chinese for Affirmative Action.

Dr. Lowe’s experience with the organization also shaped him in another way.

“I learned to see major contradictions in situations and to analyze the main forces pushing one way or another, as well as how opposing forces can be balanced and how to work as a group and come to www.sfms.org

a consensus.”

Meanwhile Dr. Lower finished high school at the age of fifteen, college at U.C. Berkeley at eighteen, and medical school at UCSF at the age of twenty-two.

He confesses, however, that learning by rote memory was not his strength, so the first two years of medical school were especially difficult for him. It was during the clinical years of medical school, which involved actual practice of medicine, that Dr. Lowe excelled. That was when he decided to specialize in general surgery.

Right after medical school and before shipping out to Korea as an army captain, Dr. Lowe married his wife, Kathy, with whom he recently celebrated his fiftieth anniversary. After completing his military service, he came back to San Francisco to do his surgical residency at UCSF. Then he opened his practice in Chinatown, just half a block from where he had gone to nursery school.

In doing so, Dr. Lowe turned down lucrative offers from prestigious clinics around the Bay Area. Not only was he getting paid less than he could have been had he worked elsewhere but as a vascular surgeon, he was also overqualified to take care of the kinds of patients he saw routinely, patients with problems such as high blood pressure and diabetes. “But that didn’t bother me,” he said. “I got to practice where I wanted to. Chinatown was my home and is my passion.”

Dr. Lowe was not only taking care of patients but also taking the pulse of the community, assessing things in a way that was to become the hallmark of his leadership style—looking at the big picture and figuring out how to move things to the next level. As a doctor, Rolland Lowe wanted to do more than heal. “Healing is a restoration to where you were before,” he said. “But I like to move things forward.”

So not only did Dr. Lowe serve as the chief of surgery, chief of staff, and chair of the board of trustees at Chinese Hospital, where he helped ensure access to highquality care for low-income immigrants.

He took things a step further, getting Chinese Hospital rebuilt and pushing for a health plan for his community. He helped form the Chinese Community Health

Care Association in order to provide comprehensive, culturally sensitive and affordable care for the Chinese. Today, 172 private-practice physicians provide this care to 25,000 people through various health plans and at hospitals including CPMC, UCSF, and St. Francis as well as Chinese Hospital.

In 1982, the year that the Chinese Community Health Care Association was founded, Dr. Lowe became the first Asian American to be elected as president of the San Francisco Medical Society. In 1997, he became the first Asian American president of the California Medical Association and later helped start the Network of Ethnic Physician Organizations to address disparities in health care.

On the national level, Dr. Lowe helped form the Asian Pacific Islander American Health Forum, a recognized national voice of the Asian Pacific Islander community.

The fact that Dr. Lowe’s influence and impact is known far and wide is evidenced by the recognition as a philanthropic hero he received in 1999 from President and Mrs. Clinton.

There is a Chinese saying: “When drinking water, remember the source.”

Dr. Lowe, whose Chinese name means “to move the wheel of history,” always remembers the source of his guiding philosophy in life. He says, “We all need a moral compass. I was blessed by parents who gave me moral values. The greatest joy is passing on a moral compass, not the profession and not the assets.”

An observer noted that Dr. Lowe could have been ten times richer had he not given away so much of his medical services and so much of his time for nonprofit causes. But Dr. Lowe responds by saying, “Wealth is the satisfaction of being able to help your community be a better place. That is priceless.”

This biography, written by local health journalist Emerald Yeh, was presented at the gala of the Annual Asian Pacific Fund, a Bay Area Community Foundation. Visit the organization online at www.asianpacificfund.org.

Denise and Elliott Main Continued from page 21 . . .

patients with ARVs, as well as many family members—since AIDS affects the entire family. The clinics are staffed with local doctors and nurses who are assisted by home visitors and outreach educators. Under Honduran inspiration and initiative, Siempre Unidos now focuses even more on HIV prevention, working closely with high-risk groups such as street kids, commercial sex workers, and prisoners. They have delivered thousands of condoms and offer truly confidential counseling and HIV screening.

Not neglecting the lower-risk population, Siempre Unidos provides education at churches, schools, and universities as well as running a weekly radio show turning the community’s fatalistic view of AIDS on its head with the message that “SIDA = VIDA” (AIDS = LIFE.). Siempre Unidos employs sixty-eight Hondurans, many of whom are HIV positive.

Denise visits five to six times a year and has frequent contact via Skype. She and Elliott coordinate groups of volunteers that take supplies, build additions on the clinics, and do medical treatment. It costs about $500,000 annually to run the clinics, outreach, and workshops, so there is no relief from fund-raising. “My nights, weekends, and vacation time are all spent on Siempre Unidos,” Denise says without complaint.

Abbott and Gilead have been major donors, and the Episcopal Relief Development Fund is a partner. They also have support from UNAIDS and the Global Fund for basic ARVs. But it takes constant attention from both Denise and Elliot to make sure Siempre Unidos fulfills its ambitious mission. In addition to financial contributions, they seek unexpired ARVs to treat patients with resistant HIV and always need orders for logoed bags, gowns, and baby clothes.

Hats off to Drs. Denise and Elliot Main for showing how to live a life of professional, personal, and spiritual success. They have made a difference.

Toni Brayer, MD, has practiced internal medicine in San Francisco for over 20 years.

A past-president of the SFMS, she currently serves on the editorial board for San Francisco Medicine. Visit her blog, http:// healthwise-everythinghealth.blogspot.com/.

www.sfms.org September 2009 San Francisco Medicine

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29 San Francisco Medicine September 2009

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Local Heroes in Medicine

Edgar Wayburn Physician and Conservationist who Preserved Over 100 Acres of Open Space

Harold Gilliam

O

n most Bay Area weekends, thousands of hikers and picnickers fan out through the region’s coastal parklands, from Tomales Bay and Olema Valley near Point Reyes to Mount Tamalpais, the Marin Headlands, the Presidio in San Francisco, and Crystal Springs Lakes on the Peninsula—all within the boundaries of the sprawling Golden Gate National Recreation Area.

Probably most of those hikers— meandering along woodland trails through groves of redwoods and Douglas fir, admiring panoramas of the Bay Area from open hills, watching the surf explode on wave-carved cliffs—take these privileges for granted and are totally unaware of the decades of toil, sweat, political battles and unflagging leadership that preserved those natural treasures from the bulldozers.

Chief among the unsung heroes of this immense Bay Area playground is the man who first envisioned it in the 1940s and worked for thirty years to bring it about: Dr. Edgar Wayburn. Dr. Wayburn, an honorary member of the SFMS, worked many years as a respected physician and dedicated conservationist.

As a former five-term president of the Sierra Club—now, aged 104, the club’s honorary president—Wayburn has led decadeslong campaigns to save not only Bay Area open space but more than 100 million acres of American wilderness and parklands elsewhere on the continent: redwoods, boreal forests, wild rivers, glacial valleys, coastlines and invaluable enclaves of nature in metropolitan regions.

His relative obscurity has been his choice. He has always been the quiet conservationist, avoiding publicity, practicing

his profession as a physician until recently and doing most of his volunteer conservation work nights and weekends.

Whether he’s talking to a patient or a politician, he speaks calmly and sympathetically, with a voice of authority, a command of the facts and an ability to listen— precisely the qualities that have made him both a revered physician and a respected advocate for nature in the corridors of power from Sacramento to Capitol Hill.

Friends say the only time he has ever raised his voice was during an encounter with a roaring grizzly on an Alaska wilderness trail, where his yells and arm-wavings persuaded the giant mammal to retreat.

His hope for a major park at the Golden Gate was born one day in the 1940s when he looked across the strait from San Francisco to the Marin Headlands and Mount Tamalpais, where he often hiked.

“It seemed incredible to me,” he recalls, “that there were no cities or suburbs built on those Marin hills, so close to

Edgar Wayburn, 2007

San Francisco. I wondered how long that miracle would last.”

In that era, the notion of a national park to preserve open land in a burgeoning metropolitan era would have been laughed off as fantasy. National parks existed to protect mountain wilderness areas, not cities.

It’s almost impossible in 2004 to grasp the mind-set of that period in U. S. Continued on the following page . . .

www.sfms.org September 2009 San Francisco Medicine

29

Edgar Wayburn Continued from previous page . . .

history. The post-war building boom was under way; the developers and freeway builders were unchallenged; waves of urbanization were rolling in an apparently irresistible tide into the countryside from every city in California.

“Growth” was the magic mantra.

The word “environmentalism” had not yet been coined, and the idea was still decades in the future.

Wayburn was well aware of the odds against keeping those hills open, but he knew he would have to try. He wisely decided to start on a small scale. Working with the Sierra Club and local conservationists, he took time from his medical duties to go to Sacramento and lobby for the expansion of the small Mount Tamalpais State Park—at first unsuccessfully.

But he kept returning to Sacramento, occasionally to the chagrin of bureaucrats and legislators who sometimes headed for the back door when they saw him coming. Eventually, his persistence paid off. At intervals over a period of decades, despite frequent rebuffs, he and his fellow volunteers persuaded state officials to pick up large pieces of land.

As a result, the park was expanded from 870 acres in 1948 to 6,300 acres by 1972. Areas added included such popular places as Steep Ravine and much of the Dipsea Trail, site of the annual run from Mill Valley to Stinson Beach.

As Sierra Club president, beginning in 1961, Wayburn became a prime mover in a score of hard-fought national causes, working with other conservation groups, including an eight-year struggle for the national Wilderness Act of 1964, which set aside millions of acres of federal land where roads and other developments are off limits.

He was also involved in the 1962 creation of Point Reyes National Seashore, the first major national park unit in a metropolitan region.

But his ultimate goal for the Bay Area was a much larger national park, both north and south of the Golden Gate.

In 1964, he had a chance encounter that proved portentous. On one of his regular

30

visits to Washington, he ran into San Francisco’s newly elected congressman, Phillip Burton, in a hotel dining room. A long dinner conversation turned out to be the beginning of a partnership that ultimately resulted in the creation of the Golden Gate National Recreation Area.

Wayburn worked alongside Amy Meyer, a San Francisco art teacher and neighborhood activist, through the numerous ups and downs that eventually resulted in a bill where for the first time in history a national park unit was to take over the property of a major city (other than small historic sites). It included most of San Francisco’s lands along the Golden Gate and all of Ocean Beach from the Cliff House to the San Mateo County line, plus a large chunk of southern Marin, and Alcatraz and Angel islands.

An added bonus, thanks to Burton’s foresight, was the Presidio, all spectacular 1,480 acres of it overlooking the Golden Gate, to be added to GGNRA if and when the Army should decide to pull out—a retreat that occurred in 1994.

But Wayburn was still not satisfied.

He wanted GGNRA enlarged to extend from Point Reyes National Seashore to the Peninsula, creating combined parklands along 70 miles of coastline. Over the course of the next six years Wayburn, Burton, and Meyer worked to pass a series of bills that doubled the size of GGNRA. Altogether Bay Area coastal parks, including GGNRA, Point Reyes National Seashore, Tamalpais, other state parks, watershed lands and Peninsula regional parks now embrace some 200,000 acres, an area about seven times the size of San Francisco, probably a world’s record for parklands in a populous metropolitan region.

Ed Wayburn has continued to work into his later years. He was saddened and out of action for a time in 2002 after the death of his wife and collaborator, Peggy Elliott Wayburn. But he went on to finish his memoir, “Your Land And Mine: Evolution of a Conservationist,” published

by Sierra Club Books and University of California Press in 2004.

He no longer backpacks into the wilderness or rides on whitewater rivers, but

San Francisco Medicine september 2009

continued to head the Sierra Club’s Alaska Task Force for years, which is resisted the Bush administration plans to open more Alaska wildlands to logging and oil drilling. In 2002 he made his 35th trip to the biggest state, where he was honored by the Alaska Conservation Foundation and the Alaska chapter of the Sierra Club.

In the Bay Area, has continued to push for the expansion of the GGNRA. He wants the park extended farther southward to include San Mateo County’s entire Coastside from the mountains to the sea, except for the towns, in a pattern similar to West Marin’s.

He refuses to rest on his conservation laurels, which include 21 local, national and international honors, such as the Albert Schweitzer Award for Humanitarianism and the Presidential Medal of Freedom, presented by President Clinton.

His most substantial laurels are in the millions of acres of American earth he has been instrumental in preserving, from the Golden Gate to the redwoods to Alaska and nature enclaves throughout the country—his gift to future generations. By any measure he belongs high among the pantheon of environmental superheroes and activists beginning with John Muir.

This article was excerpted from a full-length account of Wayburn’s environmental activism that originally appeared in the San Francisco Chronicle. The author, former Chronicle environmental writer, Harold Gilliam is the author of Weather of the San Francisco Bay Area. To read the article in full visit www.sfgate.com/ cgi-bin/article.cgi?f=/c/a/2004/04/25/ CMG2C5T4GU1.DTL#ixzz0QYD21pUc.

www.sfms.org

Local Heroes in Medicine

Victor Richards A World-Class Surgeon

Steven J. Askin, MD

F

rom 1964 to 1968, I was fortunate enough to be accepted in the surgical residency run by Victor Richards, MD. Dr. Richards was one of the outstanding people, physicians, and surgeons I have known, and he should be considered a medical hero.

The first thing that comes to mind is Dr. Richards’ superior intellect. He just seemed smarter than everyone else. He graduated from Stanford Medical School when he was too young to apply for a medical license and therefore couldn’t perform certain procedures during his training. Finally he began his practice and soon established a reputation as a brilliant surgeon. He was appointed the chief of surgery at Stanford at the age of thirty, becoming the youngest to ever bear that title. Many of his patients were physicians or family members of physicians. Because he never charged other physicians, his income was lower than a busy surgeon deserved in those days.

In the late fifties, Stanford Medical School moved to Palo Alto. Dr. Richards, along with others, chose to remain in San Francisco. Stanford Lane Hospital was renamed Presbyterian Medical Center, and Victor Richards became the Chief of Surgery there as well as at Children’s Hospital. He established a residency in surgery at Presbyterian Medical Center.

When I arrived there to intern, I served on the surgical service and got to know Dr. Richards. He made the specialty of surgery so interesting that I returned in 1964 for a surgical residency.

An outstanding quality of Dr. Richards was his ability to communicate with and relate to people. He seemed to befriend to everyone, from the most impor-

tant professor or politician to the most humble patient. His sense of humor was legendary.

He had a patient with polyps of the colon, which he removed on two occasions. The patient was also his barber. Vic told me, “I take out his polyps and he cuts my hair.” These communication skills served him well in his teaching of residents and interns. He was always able to cut through details and impress on us important principles one could always rely on.

Victor Richards was a high-energy person. A typical day illustrates this: He would make early-morning patient rounds alone. At 7:30 a.m., the house staff would meet him in the OR and surgery would begin—the highlight of the day.

Many cases were unusual or interesting, as he got more referrals than other surgeons. In addition, the spectrum of procedures he could perform was large. He was known to do some neurosurgery and back surgery as well as all thoracic and abdominal surgery, in addition to traditional general surgery. At one point he organized an open-heart surgery team at Children’s Hospital; he was one of the surgeons. The operations were instructive and colorful.

His surgical technique was impeccable.

He provided humorous banter, sprinkled with quotes from famous individuals in Latin or other languages. He often said, “It took me twenty years to learn this operation, and I’m going to teach it to you in five minutes.”

After several operations, he would make teaching rounds on patients with house staff, which no one wanted to miss; they were too much fun. Then he would

Victor Richards, circa 1950s

attend a teaching conference at one of the private or military hospitals in the area.

This would involve patient presentation, making important clinical points, and often-humorous interchange between Dr. Richards and other professors. Other activities included speaking at surgical meetings around the country, supervising in the research laboratory, and writing books on a variety of surgical topics.

Last but not least, I never heard him say a mean word to anyone. Dr. Richards, now deceased, was a world-class surgeon, thought to be the best in the Bay Area in his day. He was also a world-class person.

I would like to recount one other episode. In his hurried driving around the city, Vic was once hit by a Muni bus while in his car. He palpated his own abdomen to rule out a ruptured spleen but was found to have fractured ribs and a thirtyplus pneumothorax. His surgeon friends recommended a chest tube be inserted, but the famous surgeon refused, insisting the pneumothorax would resolve. It did.

I present Dr. Victor Richards as a medical hero.

Steve Askin, MD, is a retired surgeon and member of the editorial board for San Francisco Medicine.

www.sfms.org September 2009 San Francisco Medicine

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Hospital News CPMC

Damian Augustyn, MD

Congratulations to Dr. David Goldberg, who was appointed chair of the department of psychiatry for a full five-year term. Dr. Goldberg has been a member of the CPMC medical staff since 2001.

Sutter West Bay Region President Martin Brotman, MD, recently received an honorary doctor of science degree from his alma mater, the University of Manitoba. The university honored Dr. Brotman at its 125th convocation for a lifetime of contributions to clinical care, education, research, and health care leadership locally, nationally, and internationally.

He went on to give the convocational keynote address on “the science and art of professionalism” and gave a presentation on “changing organizational culture.”

“Current Topics in Cardiovascular Medicine: The Interface Between Primary and Specialty Care” will be held October 3–4, 2009, at the Ritz-Carlton Half Moon Bay. This program has been designed for primary care, family practice, and internal medicine physicians and cardiologists. Our educational objective is to provide current information that can be used to improve decision-making practices in the early identification, management, and referral of patients with cardiovascular and peripheral vascular disorders. Program topics include: Cardiovascular Risk Assessment and Screening: Is there anything new and worthwhile? Cardiovascular Pharmacology: What to prescribe, how drugs interact, and the effect of over-the-counter agents Electrophysiology: How to address common rhythm problems based on new developments Cardiac and Peripheral Interventions: Is earlier referral justified by the latest results?

For more information about this program, please contact Paula Rowbury via phone at (415) 600-5896 or via e-mail at rowburp@ sutterhealth.org.

32

St. Mary’s

Richard Podolin, MD

Baseball great Casey Stengel said, “Never make predictions, especially about the future.”

But we can make some predictions about medicine. Doctors will have less autonomy, will be subject to greater public scrutiny, and will have to adapt to new modes of practice and new incentives. And for these reasons, I believe new physicians are entering medicine at the best time in the history of our profession.

Let me defend this position.

Protocols and core measures limit autonomy but address the indefensible variation in the practice of medicine. The best treatment is not always known, or appropriate, for an individual patient, but more often it is inconsistently applied. Those who fear “cookbook medicine” should not worry. Like us, new physicians will spend their careers struggling to make critical clinical decisions with too little empiric guidance. No one practicing medicine suffers from an excess of certainty in their professional life.

Those of us who practice in teaching hospitals know that it is precisely public scrutiny, embodied in our bright and inquisitive house staff, that motivates us to be more scholarly and informed than we might otherwise be.

We need to be vigilant that reporting does not overburden physicians or become a disincentive to provide care to the sickest or neediest patients. But increased transparency will force us all to improve. Health care reform presents the risk of failure, with dispirited physicians or declining quality of care. But we can’t let fear dissuade us from tackling the disparities before our eyes. If we show our determination to assure that all Americans have access to health care, we will enhance our stature as stewards of the nation’s health.

St. Mary’s has been training new physicians for more than 100 years. Our goal is to prepare our young doctors for meaningful lives in medicine in which they can serve their communities with knowledge, wisdom, and compassion, sharing our pride in our profession.

San Francisco Medicine September 2009

UCSF

Elena Gates, MD

Heroic efforts aren’t always dramatic gestures. Every day, locally and globally, clinicians extend themselves to make long-lasting improvements in the health of vulnerable populations. Through the Housecalls program, UCSF faculty make 1,100 yearly home visits to San Francisco housebound elders. “The program brings preventive and acute primary care into the home for frail elders who can’t get to the office,” said Rebecca Conant, MD, program director and associate clinical professor. “We also provide palliative and end-of-life care in the home.” In addition to caring for patients, Housecalls provides a valuable educational experience for dentistry, nursing, pharmacy, and medical students. Housecalls is celebrating its tenth year and relies on philanthropy for half its budget.

Glide Health Services, a nurse-managed health center, is a ten-year partnership among Glide Memorial United Methodist Church, Saint Francis Memorial Hospital, and the UCSF School of Nursing. Its integrated model includes primary care, disease management, mental health treatment, HIV testing, and outpatient substance abuse treatment. A Federally Qualified Health Center, the center’s innovative approach provides health care access to approximately 3,000 uninsured clients in San Francisco for 13,000 visits annually. “Our practice incorporates a nursing model with successful partnerships locally and nationally, while teaching new health professionals,” said Clinic Director Pat Dennehy, RN, MS, FNP, DNPc. Suellen Miller, CNM, PhD, is challenging global maternal mortality. Miller directs UCSF’s Safe Motherhood Program, which conducts studies on Lifewraps—neoprene garments that resuscitate women in shock from obstetric bleeding.

There has been a greater than 50 percent decrease in maternal mortality where the device was used. The first studies were in Egypt and Nigeria; Miller and her team are conducting further studies in Zambia and Zimbabwe. www.sfms.org

Hospital News Veterans

Diana Nicoll, MD, PhD, MPA

The second annual gathering of the “Brain at War” conference was held recently at the San Francisco V.A. Medical Center (SFVAMC).

The event, sponsored by NCIRE—The Veterans Health Research Institute, brought together some of the world’s leading experts on posttraumatic stress disorder, traumatic brain injury, and related neurological and psychological conditions. One of the distinguished presenters included Brigadier General Loree K. Sutton, MD, director of the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury. Brig. Gen. Sutton spoke about the “Real Warriors” campaign, an initiative launched by the Defense Center of Excellence to build resilience, facilitate recovery, and support reintegration of returning service members, veterans, and their families. DCoE is focused on ensuring that the Department of Defense meets the needs of the nation’s military warriors and families through a partnership with the Department of Veterans Affairs and a national network of military and civilian agencies, community leaders, advocacy groups, clinical experts, and academic institutions. These groups will work to establish best practices and quality standards for the treatment of psychological health and traumatic brain injury. The highlight of the day was a research presentation on “Advances in Telesurgery and Telementoring” by U.S. Army surgeon Lieutenant Colonel T. Sloane Guy, MD, who spoke via video teleconference from the 47th Combat Support Hospital in Iraq, where he is serving as chief of surgery. Dr. Guy conducted the initial research on his project while serving in his previous posting as a cardiothoracic surgeon at the SFVAMC. “Dr. Guy’s story exemplifies the kind of multi-institutional scientific initiative that NCIRE works to foster,” said NCIRE Executive Director Robert E. Obana. “Dr. Guy demonstrated his results direct from the war zone using the very sort of technology that is at the heart of his research project.”

Women in History Continued from page 23 . . .

2009-2010 SFMS Membership Directory Available Now!

which the pestis mulieribus vexes the world. In other shapes it attacks the bar, wriggles in the jury box, and clearly means to mount upon the bench; it strives thus far in vain to serve at the altar and thunder from the pulpit; it raves at political meetings, harangues in the lecture room, infects the masses with its poison, and even pierces the triple brass that surrounds the politician.”

If only Dr. Stille could see us today.

We’ve sure come a long way.

Nancy Thomson, MD, was a practicing anesthesiologist at Children’s Hospital from 1963 to 1985. In 1988 she received her master’s in public health from the University of California at Berkeley. From 1991 to 2000 she worked as the infectious disease officer and staff physician at San Quentin State Prison. Dr. Thomson currently serves on the editorial board for San Francisco Medicine and is the magazine’s obituarist.

The 2009–2010 SFMS Membership Directory and Desk Reference is now available. Members should have already received their copy. Extra copies are now also available for sale. Members can order copies for $45, nonmembers can order them for $75, s/h included.

To order additional Directories, contact Carol Nolan at (415) 561-0850 extension 0 or cnolan@ sfms.org.

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www.sfms.org September 2009 San Francisco Medicine 33 33 San Francisco Medicine september 2009 www.sfms.org

Health Policy Perspective Steve Heilig, MPH

Covering the Cost of Alcohol Abuse

A

s our state and local financial crunch continues, we seem to be in denial about at least one logical source of healthy revenue: a rational tax on alcoholic drinks.

It is past time we confront the issue, and this is one reason why the SFMS Board of Directors has endorsed action to increase taxes on alcoholic beverages, and why San Francisco Supervisor John Avalos has proposed a local alcohol mitigation fee to offset some of what alcohol abuse costs us.

And alcohol abuse costs us a lot. Just how much is unlikely to ever be determined fully, but a local organization has recently made a valiant attempt. Looking at my home state, California, the Marin Institute, a private, nonprofit organization devoted to improving alcohol-related policy and reducing harms from drinking, released a 2008 report titled “The Annual Catastrophe of Alcohol in California.”

The report makes for sobering reading. We don’t yet know what the costs are for San Francisco, but for the state, the study found that the total economic cost to California from alcoholrelated causes is $38 billion per year—$18 billion for illness, $8 billion in traffic/DUI costs, $8 billion for crime, and $4 billion for injuries. This is about twice the costs attributed to tobacco use.

One can quibble with the numbers, but there is no denying that the societal burden imposed by alcohol use is substantial. For the nation as a whole, the costs are astronomical.

Addressing California’s huge budgetary shortfall, earlier this year Governor Schwarzenegger proposed a five-cents-per-drink tax increase on beer, wine, and distilled spirits. This would raise about $750 million per year, hopefully targeted at funding some crucial and underfunded services, including but not limited to addiction treatment. But that proposal quietly vanished in subsequent versions of the proposed budget.

California alcohol taxes have not increased since 1992, and then by only a penny. Opponents argue such taxes are onerous, or even akin to Prohibition. But taxing tobacco to pay for health costs is now widely accepted, and in fact President Obama has just expanded children’s health coverage with a substantial increase in such taxes.

We should also acknowledge the uncomfortable fact that “Big Alcohol”—the collective term for the largest alcoholic beverage companies—is no friend to our population’s health, having long used tobacco-type tactics to market alcohol to young people (most recently in the form of “alcopops,” sweet alcoholic drinks

34

San Francisco Medicine September 2009

with an obvious appeal to young drinkers).

A group of state attorney generals, including California’s, has sued to stop such practices. One of the big alcohol companies, MillerCoors, recently settled with a similar group of state authorities and will stop marking alcohol-fueled “energy drinks,” another category of alcoholic beverages favored by teen drinkers. Again, as with tobacco, there is long and well-documented history of alcohol marketing to teens in deceptive guises, including via sporting events and youth-targeted media. We all pay for that in some way.

Call it a tax or a fee, a nickel a drink isn’t much—the Marin Institute actually feels 25 cents per drink is a more fair and supportable tax, one that could raise more than $3.4 billion per year for our state. It doesn’t qualify as a “sin tax,” as most drinkers are responsible and not all drinking is harmful. It would not significantly impact any consumer who does not have a serious drinking problem—which is another issue. But it would raise real money to offset what alcohol costs us all.

In 2008, the CMA House of Delegates called for a “voluntary” fund established by the alcohol industry to address harms and costs related to their products—but nobody should be holding their breath for that to transpire. The AMA already endorses increased federal taxes on alcoholic beverages and encourages states to advocate for higher taxes with revenues targeted at prevention and treatment of alcohol-related harms, stating that “when state legislative efforts to increase alcohol taxes are stymied, encourage state medical societies to give consideration to the use of ballot initiatives in the twenty-four states that allow such initiatives.” So the SFMS will be urging the CMA to push for a state tax, while working on a local one as well.

A recent review in the American Journal of Public Health concluded, “Increasing alcohol taxes saves lives; that’s the bottom line.” And while such an increased tax would not solve California’s financial problems, it would help. Given the medical, public health, and economic facts, a fair increase in alcohol taxes is long overdue. We should take a similar approach to that we have taken with tobacco, using the funds to prevent alcohol abuse and pay for its related harms.

Steve Heilig, MPH, is the Director of Public Health and Education for the San Francisco Medical Society.

www.sfms.org

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most complex cardiac patients, including those with severe coronary artery disease and depressed left ventricular function who are deemed to be too high risk to undergo coronary revascularization by most surgeons and interventional cardiologist. As one of only a handful of U.S. medical centers using the Impella, a percutaneous left ventricular assist device, we have the capability and expertise to treat these patients by using temporary hemodynamic support.

I am interventional cardiologist Peter Hui, M.D. and I would like to make an appointment to see you in your office. Why? I would like the oppor-

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