September 2010

AN RANCISCO EDICINE S F M VOL.83 NO.7 September 2010

JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY

Beyond Medical School

Learning to be a Great Physican and Citizen

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In This Issue SAN FRANCISCO MEDICINE September 2010

Volume 83, Number 7 Beyond Medical School FEATURE ARTICLES

10 Medical Education: The Need for Lifelong Learning Molly Cooke, MD, FACP

12 Humanities Are the Hormones of the Mind: “Lubricating” the Minds and Hearts of Those Who Work in Medicine Albert R. Jonsen, PhD 14 Ideas for Practicing Physicians: Balancing the Medical Humanities and the Sciences of Medicine Jock Murray, MD 17 The Physician as Teacher: Perpetuating Core Values Kelley M. Skeff, MD, PhD

MONTHLY COLUMNS

4 Membership Matters 7 President’s Message Michael Rokeach, MD

9 Editorial Linda Hawes Clever, MD 11 SFMS Events Calendar 32 Hospital News 33 Classified Ads

19 It’s Not Too Late: One Dozen Important Topics You Might Not Have Learned Enough about in Medical School Philip R. Lee, MD, and Steve Heilig, MPH

23 After Medical School: Shifting Expectations, Practices, and Influences; Sturdy Values Philip A. Pizzo, MD

25 On the Other Side of the Equation: Five Things I Learned by Being a Patient that I Wish I’d Learned in Medical School Roger J. Bulger, MD, FACP, FRCP

27 One Year out of Training: A Postscript on Clinical Pearls Katie Young, MD

29 Lessons from the Bedside: A Fourth-Year Medical Student Reflects on Important Lessons Learned Eisha Zaid 30 Emergency Segue: An Emergency Physician Makes a Big Shift Scott Schmidt, MD 34 A Fable M. Therese Southgate, MD Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 extension 261 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

www.sfms.org

September 2010 San Francisco Medicine 3

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

Volume 83, Number 7 Guest Editor Linda Hawes Clever Managing Editor Amanda Denz Copy Editor Mary VanClay

Editorial Board Obituarist Nancy Thomson Stephen Askin

Shieva Khayam-Bashi

Toni Brayer

Arthur Lyons

Linda Hawes Clever

Ricki Pollycove

Gordon Fung

Stephen Walsh

Erica Goode SFMS Officers President Michael Rokeach President-Elect George A. Fouras Secretary Peter J. Curran Treasurer Keith E. Loring Immediate Past President Charles J. Wibbelsman SFMS Executive Staff Executive Director Mary Lou Licwinko Director of Public Health & Education Steve Heilig Director of Administration Posi Lyon Director of Communications Amanda Denz Marketing Specialist and Membership Development Associate Jonathan Kyle Board of Directors Term: Jan 2010-Dec 2012

Roger Eng

Gary L. Chan

Thomas H. Lee

Donald C. Kitt

Richard A. Podolin

Cynthia A. Point

Rodman S. Rogers

Adam Rosenblatt Lily M. Tan

Term: Jan 2008-Dec 2010

Shannon Udovic-

Jennifer H. Do

Constant

Shieva Khayam-Bashi

Joseph Woo

William A. Miller Jeffrey Newman

Term: Jan 2009-Dec 2011

Thomas J. Peitz

Jeffrey Beane

Daniel M. Raybin

Andrew F. Calman

Michael H. Siu

Lawrence Cheung CMA Trustee Robert J. Margolin AMA Representatives H. Hugh Vincent, Delegate Robert J. Margolin, Alternate Delegate

SFMS Resident & Fellows Job Fair

2000 by the American Medical Association and other health care provider and patient groups, alleging that United conspired to defraud consumers by manipulating out-of-network reimbursement rates, shortchanging physicians and patients by hundreds of millions of dollars over the past fifteen years.

The deadline to submit claims for payment from the settlement fund is October 5, 2010. Physicians are eligible to file for damages if they provided covered outof-network services or supplies between March 15, 1994, and November 18, 2009, to patients covered by UnitedHealth or its subsidiaries, including PacifiCare. Physicians may recoup underpayments for outof-network services provided to PacifiCare subscribers at any time during the claim period, even before PacifiCare became a subsidiary of United.

Physicians will be paid according to their total “recognized loss” between 1994 and 2009, which is calculated by determining the difference between a physician’s billed amount and the “allowed amount” that United actually paid for covered outof-network services. If the total amount of submitted claims exceeds the settlement Important Changes to the SFMS fund, physicians will receive a pro rata Election Process: Voting Will Be share based on their total recognized loss.

United has submitted data to the Online This Year!

This year the Medical Society is chang- claims administrator showing all the paying how active members cast their votes in ments it made (i.e., the allowed amounts) the SFMS Board election—the process will for covered out-of-network services from be completely paperless! Active members January 1, 2002, to May 28, 2010. Physiwill cast their votes online using a new, cians can request a copy of their own secure online system. No paper ballots claims data from the claims administrator. will be sent out for the 2011 election. The It may take several weeks to receive the slate of candidates and the new procedure report, so the sooner you request your for casting votes will be featured in the copy, the better.

A hearing to determine final apOctober issue. proval of the settlement is scheduled for Claim Your Share of the $350 September 13, 2010, in U.S. District Court in New York.

Million UnitedHealth Settlement For more information about the Don’t miss the chance to claim your settlement and what physicians need to share of the $350 million UnitedHealth Group settlement. The settlement is the re- do to claim their share, visit the California sult of a class action lawsuit, initially filed in Medical Association’s settlement resource Mark your calendars! The San Francisco Medical Society will be holding its first ever resident/fellow career fair at the Millberry Union on the UCSF campus Thursday, November 18th. The event will run from 5:00 p.m. until 7:30 p.m. and is free to any resident or fellow who is a member of SFMS, or who joins at the event. Nonmembers will be charged $5 for admission. The event will be an excellent opportunity for physicians looking to practice in the Bay Area to network with representatives from a variety of local practice types and sizes and enjoy free wine and cheese.

As part of an effort to make participation accessible to all, the pricing structure for hosting a table at the event will be tiered.

Large group practices will pay $250, small/ medium group practices will pay $100, and solo practices will be able to host a table free of charge. If you have any questions about the event, or would like to inquire about reserving a table, please contact the Membership Department at (415) 5610850 extension 240 or e-mail jkyle@sfms. org. We look forward to seeing you there!

4 San Francisco Medicine September 2010

www.sfms.org

section on www.cmanet.org. There physicians can find CMA’s United Healthcare/ Ingenix Settlement Guide, claim forms, and a number of other helpful resources.

Contact Samantha Pellon with questions, (916) 551-2872 or spellon@cmanet. org.

CMA Foundation’s 2010 President’s Reception and Awards Dinner

The CMA Foundation’s fourteenth Annual President’s Reception and Awards Dinner will take place on Sunday, October 3, 2010, at the Hyatt Regency in Sacramento. Proceeds will support the work of the CMA Foundation in linking physicians and their communities to raise awareness about important public health issues. Visit the events section of the CMA Foundation’s website, www.thecmafoundation.org, for more information.

Honored at the dinner will be incoming CMA President James G. Hinsdale, MD, and the recipients of the CMA Foundation Leadership Awards. Included among them are Dr. David Smith, a longtime SFMS member, who will receive the Robert D. Sparks

Leadership Award.

Tickets are now on sale. Contact Maria Moran at (916) 779- 6640 or e-mail mmoran@thecmafoundation.org to make a reservation.

SFMS Events Quick List

Friday, October 29, 2010: This one-day seminar is designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. The seminar teaches the core business elements of managing a practice—this includes critical information that physicians don’t necessarily receive in medical school training.

9:00 a.m. to 5:00 p.m. (8:40 a.m. registration/continental breakfast). $225 for SFMS/CMA members and their staff ($225 each for additional attendees from same office); $325 for nonmembers Contact Posi Lyon at plyon@sfms.org or (415) 561-0850 extension 260 for more information or to register. Advance registration is required.

October 7 Board of Supervisors Candidates’ Interview Night Contact Posi Lyon, (415) 561-0850 extension 260, or e-mail plyon@sfms.org.

SFMS S e m i n a r : “ MBA ” f o r Physicians and Office Managers

See www.sfms.org/events for full event information.

September 23 SFMS-UCSF Student Mixer at UCSF Contact Jonathan Kyle, (415) 561-0850 extension 240, or e-mail jkyle@sfms.org.

October 29 Seminar: “MBA” for Physicians and Office Managers Contact Posi Lyon, (415) 561-0850 extension 260, or e-mail plyon@sfms.org.

November 18 Resident & Fellows Job Fair/Mixer at the Millberry Union, UCSF Campus Contact Jonathan Kyle, (415) 561-0850, extension 240, or e-mail jkyle@sfms.org.

Get Your Copy of the 2010-11 Membership Directory and Desk Reference Today!

This new and improved health care resource contains a comprehensive listing of SFMS members with their specialties and contact information. It is also packed with helpful resources that no medical office should be without!

SFMS members receive one copy free as a membership benefit!

In an effort to make this great resource accessible to everyone, we’ve reduced the price. Members can now purchase additional copies for only $25 each and nonmembers now pay only $50.

To order a copy of this year’s Directory, or to inquire about advertising in next year’s edition, contact Jonathan Kyle at (415) 561-0850 extension 240 or jkyle@sfms.org.

www.sfms.org

September 2010 San Francisco Medicine 5

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President’s Message Michael Rokeach, MD

Continuing Your Education

W

elcome, colleagues, to another stimulating edition of San Francisco Medicine. In this issue we will explore the concept of lifelong learning and how and why physicians continue to expand on their formal medical school and postgraduate training.

From a purely academic standpoint, we can agree that our medical and scientific knowledge peaks somewhere within the first ten years of practice. How then do we continue to enhance our fundamental knowledge and stay abreast of advances in our individual fields? Add to that our need for knowledge, training, and experience in the humanistic side of patient care. In this issue we tap into the minds of some stellar clinicians and great thinkers to point us in the right direction.

In her article on what we don’t learn in medical school, Molly Cooke, MD, a noted educator and clinician, discusses her book on educating physicians and the recommended reforms for our medical education system. She makes the salient, and to some obvious, point that formal medical education should not be limited to the acquisition of specific knowledge or skills. Instead, she writes, the primary goal should be a learning trajectory that will keep physicians focused on patient care characterized by excellence, altruism, humanism, and accountability. Dr. Cooke boldly states that the first goal of medical education is to establish a commitment to learning over one’s professional lifetime, including the skills and practices that support continued learning.

In his hospital news column, Dr. Robert Mithun, MD, of the Kaiser Permanente Medical Group, describes how the electronic health record system in a practice can help physicians continue learning and improve care. He also notes the incredible value that training programs offer to practicing physicians by stimulating learning and promoting the concept of staying on top of our game. Those of us who work in teaching hospitals have been well aware of this for years. We wouldn’t have it any other way.

For many physicians, the history of medicine was an important part of their pathway to becoming a patient advocate and healer. In his enlightening article, Dr. Jock Murray, former dean of medicine and professor of Medical Humanities at Dalhousie University in Halifax, Nova Scotia, recalls the beginning of his academic career after his residency in neurology. Dr. Murray aptly notes that he was well trained but not well educated. He made a resolution to educate himself by reading as many of the www.sfms.org

classics as he could in one summer. He describes how he created a “bucket list to start my education after medical education.” He later notes that it was not difficult to see how these literary endeavors positively influenced how he thought about his patients.

We also learn about the relevance that other humanities have to the practice of medicine. Philosophy, theater, and art can profoundly influence both the provider and the patient. In the future, we can expect to see a more balanced curriculum of medical sciences and the humanities. Above that, true continuing education requires the commitment to incorporate such ongoing learning into our professional lives.

And finally, our guest editor for this issue, Dr. Linda Hawes Clever, simply exudes a passion for learning in her editorial, where she lists a multitude of reasons for perpetuating our education after medical school. She even tips us to the ultimate reason for our efforts to keep learning: We don’t want to be wrong—or, more important, learning brings on the “yes” of accomplishment. Sign me up; I’m ready to learn.

I hope you find this issue of San Francisco Medicine inspiring and thought-provoking, and just the impetus you needed to keep on learning. Cheers.

September 2010 San Francisco Medicine 7

Independent But Not Alone.

James Yoss, M.D. Hill Physicians provider since 1994.

Uses Hill inSite and RelayHealth services for ePrescribing, eReferrals and secure online communications with patients.

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. Hill’s advantages include: • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Deep discounts on EPM and EHR solutions for the federal mandate • Preventive care and disease management reminders for patients • High consumer awareness that attracts patients That’s why 3,500 independent primary care physicians, specialists and healthcare professionals have made Hill Physicians Medical Group one of the country’s leading Independent Physician Associations. Get more for your practice with Hill.

Get more information 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 area: Paula Friend, regional director, (209) 762-5002, Paula.Friend@hpmg.com Hill Physicians’ 3,500 healthcare providers accept commercial HMOs from Aetna, Alliance CompleteCare (Alameda County), Anthem Blue Cross, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage. Medicare Advantage plans in all regions. Medi-Cal in some regions for physicians who opt-in.

Editorial Linda Hawes Clever, MD

Beyond Medical School

M

erlin the magician advised, in T.H. White’s The Once and Future King, “Learning is the thing for you.”

William Osler implied the same: “The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.”

Atul Gawande, surgeon, author, and commentator, told graduates at Stanford Medical School’s 2010 convocation about some of the things he had learned after medical school. He described how his awareness grew—along with his knowledge—when his son was born with an incomplete aorta and when he misdiagnosed his daughter’s fractured wrist.

And you? What have you learned lately, even in the last two weeks? What have you learned about the practice of medicine — not just the business part? What have you learned by practicing— by experience or comparing notes with colleagues and experts, by going online? Have you learned about new medications or interactions? New techniques? Better ways to listen to and talk with your patients? Some facts about community resources your patients can use so they might flourish instead of merely getting by? Have you given up some rules of thumb or some cherished philosophies?

Beyond medical school, what have you learned about yourself, about following your deepest beliefs and aspirations? Therese Southgate, the great cover editor of the Journal of the American Medical Association, who opened hearts and broadened horizons with her incisive and poignant descriptions of masterpieces, said not long ago that she had no idea how her thirty-year career at JAMA happened—but it all developed after medical school, because she followed her passions of journalism and medicine.

Beyond medical school, have you reflected on how you define “success”? Awhile back, I had a conversation with physicians about what they consider success. One said, “Being chief.”

Another said, “Being able to talk with my teenager.” I know that excellence continues to be my own standard, while I have added and shuffled priorities with parenthood (and now grandparenthood!), community service, travel, and the arts. What about you?

This issue of San Francisco Medicine, Beyond Medical School: Learning to be a Great Physician and Citizen, is meant to inspire and provoke. It may send you into deep thought as you read a fable or a poem and as you compare perspectives from a medical student, recent resident, seasoned clinicians, and academics. www.sfms.org

Commentaries about challenges and impermanence in medical education and about conflicts of interest in funding continuing medical education may jolt you into action. You may well want to become a better teacher; this issue will give you some ideas about how to proceed. This issue will also put you in the shoes of a physician who learned the most about medicine when he became a patient. You will walk along with a physician who is making a surprising specialty change. It will make you query some favorite facts and practices. You will probably think more about art and other humanities. You will even get a do-it-yourself guide to great literature and tips on ways to begin humanities and other community-based education programs where you practice, teach, and learn. You will be presented some statistics about medicine and public health that should galvanize you to expand your awareness and enlarge your scope of practice. That is, I hope you will be moved to care for the public as well as for individual patients.

I also hope this issue will change your life—for the better—as a thinking, feeling, active, engaged physician and citizen.

If these aren’t enough reasons to keep on learning, then what are? For one thing, you don’t want to be wrong. You do want to be right and to feel capable. Learning brings on the “yes!” of accomplishment—titrating the insulin just right, seeing the “ah ha” when what you are saying sinks in, knowing you did the ideal procedure, or bending that bonsai or identifying that wine.

Learning is refreshing. It’s handy. It satisfies your curiosity—and sends you further into discovery.

Learning also is a remedy. Before he said, “Learning is the thing for you,” Merlin said, “The best thing for being sad . . . is to learn something. You may grow old and trembling in your anatomies . . . you may miss your only love, you may know your honor trampled in the sewers of baser minds. There’s only one thing for it . . . to learn. That is the only thing which the mind can never exhaust, never fear or distrust and never dream of regretting.”

Linda Hawes Clever, MD, MACP, is president of RENEW, a notfor-profit that helps busy people maintain—or regain—their effectiveness and creativity. She graduated from Stanford and trained there and at UCSF. She is a member of the National Academy of Sciences’ Institute of Medicine, Senior Associate Dean for Alumni Affairs at Stanford, and a clinical professor of medicine at UCSF. Dr. Clever founded the Occupational Health departemt at CPMC, and serves on the editorial board of San Francisco Medicine.

September 2010 San Francisco Medicine 9

Beyond Medical School

Medical Education The Need for Lifelong Learning

Molly Cooke, MD, FACP

M

y UCSF colleagues, David Irby and Bridget O’Brien, and I have just authored Educating Physicians: A Call for Reform of Medical School and Residency (Jossey-Bass/Carnegie Foundation for the Advancement of Teaching, June 1, 2010). In the book, we consider undergraduate medical education and residency, establish some principles for reform, and make a set of recommendations directed both at medical educators and at the leaders of organizations that regulate and accredit medical schools and GME programs and that license physicians. Our focus on the formal phase of medical education should not be interpreted as indicating that we regard the learning that physicians do after completion of their residencies as unimportant. In fact, we assert that the primary goal of medical education is not the acquisition of specific knowledge or skills but the establishment of a learning trajectory that will keep physicians headed toward the goal of patient care characterized by excellence, altruism, humanism, and accountability. In our view, the work of physicians is never, and can never be, good enough. We are always aspiring to better performance. Within this framework, what are the things that we believe that physicians will need to learn after completing their formal training?

Of course, the list of things that doctors learn after residency or fellowship is long and diverse. The typical physician in the United States is between thirty and thirty-five when she begins independent practice or whatever the main activity of her professional life will be. She has had between five and eight years of patient care experience and between three and

six years of concentration on her chosen specialty. She has just completed a phase of education that is highly programmed and that typically affords minimal opportunity for self-determination and expression. It has been argued, in fact, that the single-minded focus of residency and its more or less cloistered lifestyle compromise our ability to attain the usual developmental milestones of early adulthood. Inevitably then, whether despite or because of the twenty-one years of school and three to six years of residency, physicians have much to learn during our years of practice.

Perhaps the most obvious is the necessity to continue learning and relearning medicine. The shelf life of medical knowledge is increasingly short and, as is ubiquitously noted, the rate of medical discoveries that change practice, and the introduction of new drugs and innovative procedures, is constantly accelerating.

Thus no one of us can rely for even five years on what we learned in the course of our formal training. Therefore, the first goal of medical education is to establish a commitment to learning over one’s professional lifetime, and to establish the skills and practices that support that continued learning.

Commitment notwithstanding, there are challenges to maintaining this momentum, even if it is well established in medical school and residency. In fact, discouraging studies suggest that that physician competency begins to fall off after ten years in practice. Given that the average physician will practice for thirty or thirty-five years after residency, this is a serious problem. Why does it happen?

First, there is simply the over-busyness of

11 San Francisco Medicine September 2010 10 San Francisco Medicine September 2010

physicians. Learning in practice requires time to reflect, to study, and to consult.

More important, we have tended to misunderstand how people learn. Nowhere is this misunderstanding more evident than in the design of conventional CME experiences, which have been conclusively demonstrated to be ineffective.

We learn best when we are emotionally engaged and interacting with others. For this reason, residents find morning report and morbidity and mortality conference (at least, good ones) more useful educational venues than noon conference or grand rounds. However, physicians, famously independent by temperament, may underestimate the importance of community in maintaining their skills and advancing their knowledge.

Conventional didactic approaches to teaching, both during medical school and residency and as the mainstay of CME, have reinforced the idea that simple exposure to content results in learning.

Physicians in practice need to learn how to engage together, whether actually or virtually, to support their learning over their professional lifetimes. For strictly practical reasons, this may be especially difficult for doctors in solo or small practices and those in rural settings.

Fortunately, we are beginning to see the development of powerful platforms for continuing medical education. I believe that the various forums in which physicians discuss cases, either clinical challenges provided by website moderators or their own perplexing or fascinating patients, can come to play a role similar to that served by morning report. Sites such as MedScape’s Physician Connect, MDConsult, and some of the sites sponsored www.sfms.org

by specialty organizations and medical journals are beginning to support physicians in just this manner.

Many physicians play a role in their communities beyond that of one-on-one clinician. Developing or blooming this broader physician persona is beginning to be addressed in medical school and residency, but it will always be more prominent in the postresidency learning of physicians. What are we talking about? Doctors provide health education and public health information to schools, camps, congregations, and not-for-profit organizations. Some polish their teaching skills. We volunteer in underserved areas and travel abroad as medical missionaries. Some physicians serve as advocates for patients suffering a specific condition such as diabetes, multiple sclerosis, or HIV/AIDS; engage in the politic process; or even run for office themselves. Still others use creative writing, photography, or painting to respond to their clinical experiences and express the thoughts and feelings that patient care provokes.

While some people come to medical school with a particular interest in one of these domains, many of us do not.

Because the fundamental responsibility of formal medical education is developing the clinical competence required for unsupervised practice and because their clinical activities keep most students and residents busy, most of us wait until after residency to discover how we will take our physician-hood into the larger nonclinical world. In the book we borrow the term “physician-citizen” and stretch it a bit to cover this aspect of professional work.

Finally, to end on a somewhat philosophical note, it seems clear to me that most of us take a long time to absorb truly the reality of our own fallibility. No matter how often we admit our limitations and imperfections, I am not sure that we really believe it at the time we graduate from residency. Like many internal medicine residents, I felt pretty unstoppable by my PG3 year. My knowledge was current, I was adept at the procedures my patients needed, and I was admired by my interns and the students. Even the mistakes that www.sfms.org

I made, and I made some bad ones, didn’t seriously shake the conviction that when I got just a little bit more experience, I would become error-proof.

Coming to terms with the existential impossibility of perfect patient care is difficult. We are trying to achieve an ideal that by its nature is unobtainable, but that doesn’t lessen the imperative that we aspire to it. Sometimes our failings are catastrophic: the missed epiglottitis, the intrathecal injection of a vesicant chemotherapy. But more often they appear as a little selfishness, a moment of irritability, or simple inattention. Charles Bosk called his sociological study of the management of errors in surgery training “Forgive and Remember.” His disciplinary bent inclined him to focus on the organization and its routines and practices. But as individual doctors and as communities of physicians, we also need to learn simultaneously to forgive and remember, never settling for the lapses, always striving to have the execution of our care match our intentions for our patients—even while knowing that they will never be identical. It’s a long lesson, and a difficult one.

Molly Cooke, MD, FACP, professor of medicine, holds the William G. Irwin Endowed Chair as director of the Academy of Medical Educators at the University of California, San Francisco. The Academy of Medical Educators was established to serve as a resource for medical school faculty who demonstrate a significant commitment to medical education. Dr. Cooke has been active in medical education program development throughout her career. She was a founding member of the Division of General Medicine at San Francisco General Hospital (SFGH) and participated in the development of the primary care internal medicine residency at that hospital. Dr. Cooke is also well known in the field of HIV ethics. After her fellowship studies focused on bioethics, she established the first ethics committee at SFGH and served as its chair, becoming experienced with the ethical problems arising in urban public hospitals. A practicing internist, Dr. Cooke has been selected by her peers as one of the Bay Area’s “Best Doctors” repeatedly over the past ten years.

Upcoming SFMS Events September 23, 2010 6:00 p.m. to 7:30p.m.

SFMS-UCSF Student Mixer at the UCSF Campus Bringing the active membership and the future of the profession together for an informal evening of networking and fun. This annual event is one of the most popular SFMS produces.

Contact Jonathan Kyle in the Membership Department for more information or to RSVP, (415) 561-0850 extension 240 or e-mail jkyle@ sfms.org.

October 7, 2010 Board of Supervisors Candidates’ Interview Night Save the Date!

Visit sfms.org/events for the full details, or contact Posi Lyon, (415) 561-0850 extension 260 or e-mail plyon@sfms.org.

November 18, 2010 5:00 p.m. to 7:30 p.m.

Resident & Fellows Job Fair/ Mixer at the Millberry Union, UCSF Campus A way for residents and fellows to meet representatives from hospitals, medical groups, health departments, and other entities to facilitate finding job opportunities, and to become acquainted with the Medical Society.

Contact Jonathan Kyle in the Membership Department for more information or to RSVP, (415) 561-0850 extension 240, or e-mail jkyle@ sfms.org.

See www.sfms.org/events for full event listings.

September 2010 San Francisco Medicine 11

Beyond Medical School

Humanities Are the Hormones of the Mind “Lubricating” the Minds and Hearts of Those Who Work in Medicine

Albert R. Jonsen, PhD

D

r. William Osler (1845–1919) was a key figure in bringing medicine into the twentieth century. He was born on a farm in Ontario, Canada, and trained in medicine at the University of Toronto. He was appointed professor of medicine at the University of Pennsylvania, participated in the founding of the first modern medical school at Johns Hopkins University, and ended his distinguished career as Regius Professor of Medicine at Oxford. This life of assiduous research and clinical activity did not prevent him from being a man of the broadest learning. In 1919, he was elected president of the British Classical Association. He entitled his inaugural lecture “The Old Humanities and the New Science.” In that lecture, he said, “Man’s body is a humming hive of working cells, each with its specific function, all under the control of the brain and heart, and all dependent on materials called hormones, which lubricate the wheels of life. . . . Remove a man’s thyroid gland that secretes thyroxin and you deprive him of the lubricants which enable his thought engines to work. Gradually, the stored acquisitions of his mind cease to be available, and within a year he sinks into dementia. . . . Humanities are the hormones of the mind.”

Humanities are the hormones of the mind! Sir William wrote those words only a few years after the chemical functions called hormones were identified. Ernest Starling, who had isolated secretin, introduced the word hormone in his Croomian Lecture of 1905, at the suggestion of a classicist friend who had pointed out that the Greek hormeo means “stimulate or excite.” Sir William remarks to his audi-

ence of Greek and Latin scholars, “you will recognize from its derivation how appropriate the term is.”

Sir William, physician and classicist, uttered that marvelous metaphor, humanities are the hormones, and illustrated it with one of the clearest and earliest triumphs of nascent endocrinology, the conquest of the devastating disease of myxedema. He marveled that absence of a minute amount of secretion from a gland in the neck would desiccate the body and eventually reach the “thought engines.” He tells his audience that just as the hormones, chemical messengers, target receptors at different and distant sites, so must knowledge of classical literature, with its insights into humanity, history, and nature, reach into and enliven the minds of the young scientists, whose intelligence is being broken into limited, fragmented specialization. He says, “Applying themselves to research, young men get into backwaters far from the main stream. They quickly lose the sense of proportion, become hypercritical; and the smaller the field, the greater the tendency to megalocephaly.”

Unfortunately, Sir William does not take his metaphor much further. Allow me the privilege of pushing it onward. I agree with Sir William that the disappearance of the humanities from medical training and from medical thinking causes a dismaying myxedema of the mind and spirit of medicine, and of many of its practitioners.

I would add, however, that the particular effects of this shrinking of the mind touch two crucial constituents of the work of curing: an appreciation of tragedy and a tolerance for uncertainty.

The humanities range wide, from

12 San Francisco Medicine July/August 2010

music to history, philosophy and painting, but their heart is the great literature of our civilization. And, in my opinion, at the heart of that humanistic literature are the tragedies created by Aeschylus, Sophocles, Euripides, down to Strindberg, Ibsen, Miller, and Beckett, and most vividly embodied in Hamlet, King Lear, and Othello. The essence of tragedy is the illusion of human control over human life. All great tragic drama compels us to believe that it is fate, not human power, that writes the history of each human person, and of human history.

Similarly, woven throughout the humane letters is the theme of uncertainty.

Every rational plan, every clear project, encounters ignorance, error, miscalculation. Who knows at the beginning of a Eugene O’Neill play how the mistaken, misguided characters will end? Both tragic events and uncertain steps mark the plays, epics, and novels that comprise humane letters.

In contrast, modern science, and the medicine that comes out of it, fosters the idea of human control, mastery of the movements of the physical world by systematic investigation, and transfer of knowledge gained into specific maneuvers. Those who learn the science of modern medicine must absorb this sense of control. It seems as if every move of mind and hand must be ruled by premises and axioms and be guided rigorously through the data presented by the body.

Uncertainty, present at every step, must be banished, as far as possible, from this process. Even the most sophisticated theories of clinical judgment, which appreciate the probabilistic waves around each tentative conclusion, are compelled www.sfms.org

to reduce those wave motions as much as possible. The modern physician must be sure of self and of science, and optimistic that the science will conquer disease. It would be foolish to think otherwise.

Yet, around this world of control and certainty, uncertainty lingers and tragedy lurks. In the real world, treatments fail and death prevails. I am not proposing that the physicians become pessimists and doubters. Who, after all, would seek help from a gloomy, indecisive doctor? I only suggest that their scientific and therapeutic optimism can reach the receptors in their patient’s minds and hearts when they, at the same time, deeply appreciate that the therapeutic aim may be beyond their power. Any genuine hope has meaning only against an acknowledgment of tragedy and uncertainty.

Indeed, I believe that only a deep appreciation of this dark side can, to recall Sir William’s primitive endocrinology, “lubricate” the mind and heart of those who engage in the work of medicine, making them move in synchrony with the minds and hearts of those for whom they care. I praise the efforts to introduce medical students to literature, or, as Sir William would have said, humane letters.

Its message will be absorbed by some and subtly change their view of the science and practice. However, that message is constantly threatened and repudiated by the culture in which we live today. We live during a time in which technological and organizational prowess claims to overcome tragedy, although we see tragedy unfold around us every day. Medicine taught in school all too frequently communicates the belief that we can have the power to overcome it, if we only expand our scientific understanding of its causes.

Sir William ended his lecture with reflections on the Great War just ended, in which he had suffered the personal tragedy of losing a beloved son. He concludes, “Let us not be discouraged. The direction of our vision is everything, and after weltering four years in chaos, poor stricken humanity still nurses an unconquerable hope . . . witness of the power of ideals to captivate the mind.” It is the genius of the humanities to link tragedy and hope,

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uncertainty and certainty, and this is the essence of great medicine. In the last lines, he quotes Hippocrates, “where there is love of the art, there is love of humanity.”

Those who love their practice of medicine must love humanity precisely in its tragic fragility and fearful uncertainty.

The humanities consistently reveal to us that love of humanity can prevail amid tragedy, and this is how medicine must be practiced.

Albert Jonsen, PhD, is codirector of the Program in Medicine and Human Values (PMHV) at CPMC, original chief of the division of medical ethics at UCSF, professor emeritus of ethics in medicine at the University of Washington, the only honorary non-MD member of the SFMS, and author of many landmark books and articles.

Note: This essay is a version of a lecture originally delivered at the Humanities in Medicine Joint Conference, New York Academy of Medicine/Royal Society of Medicine, October 7, 2009.

A Poem Osler An eye whose magic wakes the hidden springs Of slumbering fancy in the weary mind.

A tongue that dances with the ready word That like an arrow, seeks its chosen goal, And piercing all the barriers of care, Opens the way to warming rays of hope.

A presence like the freshening breeze that as It passes, sweeps the poisoned cloud aside.

An ear that ’mid the discords of the day, Swings to the basic harmonies of life.

A heart whose alchemy transforms the dross Of dull suspicion to the gold of love.

A spirit like the fragrance of some flower That lingers round the spot that this has graced, To tell us that although the rose be plucked And spread its perfume throughout distant halls, The vestige of its sweetness quickens still The conscience of the precinct where it bloomed.

William Sydney Thayer

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Beyond Medical School

Ideas for Practicing Physicians Balancing the Medical Humanities and the Sciences of Medicine

Jock Murray, MD

W

hen I was a student in the 1950s, sciences were seen as a way into medical school and medical sciences were seen as the key to medical practice. We entered medical school steeped in biology, biochemistry, and physics but with minimal exposure to literature, history, and philosophy unless we were forced by undergraduate and entrance requirements to take these courses. We understood that the sciences were the basis for medicine, so what did the humanities have to do with diagnosing illness and cutting out disease?

This way of thinking about medical education did not recognize that medicine is about people, and that you learn about people and the nature of the human condition through the humanities. Sciences are important, but they teach mainly the understanding of mechanisms and functions and are not well suited to teaching the complexity of individuals and their complex lives and relationships.

When you sit at the bedside of a lonely dying woman; or struggle to get beyond the recalcitrant armor of a fifteen-yearold dragged to our office by frustrated, disappointed parents; or note the quiet, tearing eyes of a struggling single mother, unsure of how she is going to shelter her young brood through the next week, you need to be armed with the wisdom of William Carlos Williams, Robert Coles, Viktor Frankl, and William Osler alongside the newest textbook of medicine and the personal pocket computer on your belt.

My Education after Medical Education

After I had finished my specialty training in neurology and was, with

my wife and four children, comfortably settled in a full-time university position, I realized I was well trained but not well educated. My wife, Janet, who graduated in the arts and majored in philosophy and journalism, was, on the other hand, much better educated.

Although I was brought up as one of the ten children of publisher-columnist parents and in a house filled with books and magazines and newspapers, I spent my early school years disinterested in most of my studies but happy with friends, sports, and hobbies. In university and medical school it seemed enough to read the assigned material. I seldom read books unless they were assigned in my courses.

Three years after my faculty appointment, I made a resolution to read more widely, especially those books it seems everyone knows about. I knew the idea of Moby Dick and Robinson Crusoe—I had read the Classics Illustrated comic book versions—and many other books, but I had never read the originals. So my project that summer was to make a list of the books that I knew about, that seemed part of the culture, were often discussed and quoted, but that I had not read. (See Table 1.)

I read many of them that summer and continued over the next few years, continually adding to the list. It wasn’t difficult for me to see how these readings influenced my thinking about the patients I was seeing and how illness was affecting them and their families, but my growing clinical life was also informing my reading. Some of the books have influenced my career since. For instance, Boswell’s Life of Samuel Johnson started me on

15 San Francisco Medicine September 2010 14 San Francisco Medicine July/August 2010

three decades of research and writing about Johnson and his circle and medicine in the eighteenth century. I read what became my favorite book, Don Quixote.

I have published on Lewis Carroll; Alexandre Dumas, père; and Chaucer. Other works were less influential, as I couldn’t wade through more than a few hundred pages of Gibbon’s Decline and Fall of the Roman Empire before declaring defeat by boredom.

Years later, at the medical school, to create some balance in medical education, we developed a humanities program for undergraduate medical students with activities that we hoped would involve the faculty, staff, and practicing community physicians.

The following is a brief introduction to the activities that particularly involved those in practice.

Literature and Medicine

Since becoming an educator, a historian, and a dean, I have realized the error of not balancing the humanities with the sciences in medical education. I also believe the last century of science emphasis in medical education was a result, but an over-reading, of the American educator Abraham Flexner’s plan for medical education. He emphasized the need for better science and laboratory teaching but he did not want an absence of the humanities. In fact, in the years after his influential 1910 report, he organized a conference of university presidents to discuss his concern about the neglect of the humanities.

The reforms in medical education of the last few decades are aiming for a rebalancing of the humanities and the www.sfms.org www.sfms.org

sciences, so I expect we will see a difference in the attitudes and practice of future physicians. But what of the physician who went through the old system?

Making a list of books to read to become more broadly informed and to enjoy the world of ideas and history and fantasy, and anything else you care about, is a good starting point. Even better is joining a book club, as it gives you structure, broadens your perspective, and demands commitment. It needn’t be a physician group—a mixed or nonphysician group engenders the same discussion and learning. All are effective platforms for discussing books, life, and the human condition.

The book club I belong to, the Circle of Willis, has a monthly meeting, and this year’s reading list is in Table 2.

Another idea we have found exciting is the Annual Autumn Reading Weekend.

Janet and I have arranged one for the last fourteen years. We give prospective attendees (about twenty-two of them) a spring and summer reading list of novels, biographies, essays, short stories, and poems. We meet at in an inn in Nova Scotia in early October, when the autumn colors are spectacular, and we have some good meals, some wine, and a weekend of stimulating discussion. Our reading weekend is informal, with each person briefly introducing a different work, and the discussion begins. Each reading weekend has been magical. There are no wallflowers or domineering voices.

One of our members provides a prize to medical students for creative writing, and the winning student is invited to the weekend and his or her essay is added to our reading list. (See Tables 3 and 4.)

For an excellent resource for literature related to medicine, see the New York University Literature, Arts, and Medicine website at http://litmed.med.nyu.edu/ Main?action=new.

History

There is an increasing interest in history generally, so history channels, videos, and films are readily available on a wide range of interesting subjects. There is also a regular flow of books on medical history. Reading the book reviews in a www.sfms.org

journal such as the Bulletin of the History of Medicine is a good education in aspects of history as well as a window into the latest historical research.

Joining a national society such as the American Association of the History of Medicine or the American Osler Society provides a link into the world of medical history and connection with a community of historians. The annual meetings of the American Osler Society offer three days of papers by clinicians interested in the history of medicine. You don’t need to be a member to attend or to offer an abstract.

In most centers there is a medical history society that offers an introduction to a wide range of subjects, as well as a local group of colleagues interested in history.

Our Dalhousie Society for the History of Medicine has been active for thirty years. The monthly meetings start with a glass of wine and then an informal meal.

This is a nice chance to have interesting discussions with the eclectic membership and the medical students who attend (our Humanities Program pays for the students’ dinner). Following the meal, we have the presentation of two papers. In the beginning years we had three papers each evening, as we developed a large cadre of presenters; but two now allows more discussion. Both university and community physicians and companions attend, and many of the papers come from community physicians. Our students and faculty also present papers at national and international meetings. It is interesting to see that spouses enjoy these papers as much as physicians, and we have had some spouses present papers, and others who continue to attend long after the death of the physician partner.

Your local medical library will have a section on medical history. An enjoyable time, and one that can open many doors, is to spend a series of hours exploring these shelves to see what is available and select a book or two.

A physician interested in being involved with the history of medicine could start with History of Medicine: A Scandalously Short Introduction by Jacalyn Duffin, or The History of Medicine: A Very Short Introduction by William Bynum.

Another introduction is a good history read, such as Michael Bliss’s biography of Sir William Osler, entitled William Osler: A Life in Medicine.

Music Many physicians came into medicine with interesting and impressive backgrounds and interests (that’s why our groups took them!), and it isn’t surprising that many have training and experience in singing and playing musical instruments.

Music is increasingly finding a place in the medical humanities. For example, our medical school has a choir of about 120 singers who meet early each Wednesday evening and enjoy practicing for a series of concerts. It includes medical students, faculty and staff, and community physicians. They perform many concerts in the medical school but also in the community, and as I write this they are touring New Zealand. They have previously given concerts in Pittsburgh and Los Angeles.

Likewise, the concert band is celebrating a thirtieth anniversary. The students flow through during medical school, but some of the community physicians have been there since the beginning.

Within the music program of the Medical Humanities Program there are various singing groups and ensemble players who give many concerts through the year. One group received a grant to spend a summer traveling through the Maritime Provinces, singing at nursing homes and seniors’ residences. This project was spectacularly successful, for both the students and their audiences. The students are busy but say the Wednesday evening singing practice is a highlight in their week. The music program in the Humanities Program has expanded to an extent not predicted at the beginning. It has just celebrated its tenth anniversary and has a musician-in-residence choir conductor.

Philosophy, Theater, and Art

Practicing physicians can take advantage of many of the activities in the Humanities Program, such as arranged gallery and theater evenings and discusContinued on the following page . . .

September 2010 San Francisco Medicine 15

Continued from the previous page . . . sion, visiting speakers, and participation in medical student elective projects in the medical humanities.

We have had several excellent artists, poets, and writers in residence. One of the writers stayed on to give a course in narrative, while one of the poets became an online poet-in-residence for student and faculty poets. Perhaps most exciting of all, our students present an annual art show, which they organize themselves, in which they choose a subject (Alzheimer’s disease, autism, etc.), invite a speaker to discuss the subject with them, and then present a multimedia art exhibit.

Many of our recent graduates who have prized their participation in the medical humanities and are now in practice are asking us for ways to continue their involvement while balancing their professional, family, personal, and community responsibilities. We are working to find innovations and ideas that would help. Any ideas you have would be appreciated (write to jock.murray@dal.ca).

Conclusion

Increasingly, medical schools are developing medical humanities programs and incorporating a more balanced approach to the medical sciences and the humanities in medical education.

In the future, practicing physicians will increasingly wish to incorporate aspects of medical humanities into their lives and practice. The resources and the opportunities are available to most physicians in most communities. To a great extent, it is the commitment to make this part of our professional lives that will make it happen.

Dr. Jock Murray, former dean of Medicine, is professor emeritus and former professor of medical humanities at Dalhousie University in Halifax, Nova Scotia, Canada. His clinical practice and research was with multiple sclerosis patients. He was president of the American Osler Society, chairman of the Board of Regents of the American College of Physicians, and president of the Canadian Society for the History of Medicine.

1. The Reading List to Start My Education after Medical School (1973) Moby Dick Anne of Green Gables On Walden Pond The Great Gatsby Red Badge of Courage The Count of Monte Cristo Boswell’s Life of Johnson Decline and Fall of the Roman Empire Great Expectations 1984

Grapes of Wrath Arrowsmith Will and Ariel Durant’s Lessons of History deTocqueville’s America Something by Ernest Hemingway Something by Agatha Christie Something by Henry James Something by William Faulkner Something by John Steinbeck Something by Winston Churchill

2. Physician Book Club (The Circle of Willis) Reading List 2010–11

3. Reading Weekend 2009

To Kill A Mockingbird by Harper Lee Barney’s Version by Mordecai Richler Madame Bovary by Flaubert Marshall McLuhan by Douglas Coupland The Metamorphosis by Franz Kafka Barrow’s Boys by Fergus Flemming Hamlet by William Shakespeare Candide by Voltaire I Shall Not Hate by Dr. Izzeldin Abuelaish (Final meeting at my cottage at Black Point to select books for the coming year)

Payback by Margaret Atwood “The Running Novelist” by Haruki Murakami “The Loneliness of the Long Distance Runner”

by Allan Sillitoe “What Makes Us Happy” from The Atlantic June edition The Secret Scripture by Sebastian Barry Somewhere Towards the End by Diana Athill Saturday evening discussion by Dr. Michael Cusson on the use of photographs in writing a family memoir Norman Bethune by Adrienne Clarkson Angels and Ages: A Short Book about Darwin, Lincoln, and Modern Life by Adam Gopnik True Patriot Love by Michael Ignatieff Lament for a Nation by George Grant “Living with Depression” by Christine Saveland

4. Autumn Reading Weekend 2010 Friday Evening The Golden Mean by Annabelle Lyon The Penelopiad by Margaret Atwood “The Seirenes State Their Case” (poem) by Brent MacLaine

(Saturday afternoon to explore the area and enjoy the autumn colors. After dinner in the evening there will be a discussion the history and literature of diary writing.)

Saturday after Break (Novel) An Audience of Chairs by Joan Clark

Sunday Morning after Break (Novel) The Bishop’s Man by Linden MacIntyre

Saturday Morning before Break (Short stories) “An Orange from Portugal” by Hugh MacLennan “The Locket” by Ernest Buckler “The Baptism” by Elizabeth Bishop “My Grandfather’s House” by Charles Ritchie “Misery” by Anton Chekhov

16 San Francisco Medicine September 2010

Sunday Morning before Break (Essays) “Skills for Life: Why Cuts in Humanities Teaching Pose a Threat to Democracy Itself” by Martha Nussbaum (from the Times Literary Supplement) “Leech, Leech, et cetera” by Lewis Thomas “Luisa,” award essay by medical student Liz Chapman

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Beyond Medical School

The Physician as Teacher Perpetuating Core Values

Kelley M. Skeff, MD, PhD

I

believe that the role of the physician as teacher is among the most important to each of us. You may have heard the statement that “doctor means teacher.” However, the original term “doctor” that meant teacher was being applied to the greater academic world and not to physicians specifically; thus, this semantic connection of teaching with physicians technically is not correct. Having said that, I personally believe that there is a meaningful synergy that could come from all physicians seeing themselves as members of both the medical and teaching professions. I will attempt to advance this thesis in terms of several examples, including the potential positive impact for patients, trainees of medicine, colleagues, and the profession itself.

The Physician and Patient

Every physician teaches his or her patient. Whether it is in the process of explaining an illness or describing a surgical operation or procedure, part of a physician’s role is helping patients better understand their health status and the decisions to be made to improve their health. That is, each patient is a learner about the content of medicine that affects him or her. The drive of the patient to learn has been made more obvious with the availability of the Internet, enabling patients to be better informed than ever before.

Yet in spite of this major teaching role of physicians, we are not as effective as we could be. Each of us has been asked by friends or relatives to explain a discussion with a fellow physician, whether because of the complexity of the medical terminology, the lack of time for the explanation,

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or the discomfort the patient has in asking questions. The challenges of patient education are even more dramatic given physicians’ increasing requirement for “throughput” in the business of medicine, further constraining time for patient education. Moreover, physicians are often understandably preoccupied with their own learning and may not adequately attend to the learning of their patients.

Although some physicians, clinics, and health care systems are addressing this issue, I have found it uncommon for patients to be consistently given informative handouts or articles to read while they are in the hospital, or information about particular websites for future learning. In the worst circumstance, the learning and learned patient may be perceived as a problem patient, a patient who asks more questions than we have time to answer or who asks questions that we cannot answer. Yet, in reflecting on such situations, we can imagine numerous ways that we could be more effective as facilitators of learning by our patients. We could enhance our roles and effectiveness as physicians by providing resources for learning for all our patients, by having group visits to answer questions, and so forth. Effective approaches will likely depend on more than individual physicians. We can enter into a collaborative learning role, where both patients and physician-teachers learn.

The Physician as Teacher of Trainees and Colleagues

Many physicians inside and outside the formal walls of the academic institution desire opportunities to teach trainees. The role of helping others under-

stand and enjoy the gratification of being a physician is appealing, and, indeed, is part of our professional responsibility. Over the past few decades, there has been an increasing understanding of the importance, complexity, and challenges of the role of the medical teacher. This understanding has led to a recognition that physician-teachers can benefit from training regarding teaching. Skillful teaching is no longer being left to chance.

However, many challenges still occur for physicians to teach trainees. For the purposes of this article, I am going to discuss briefly only one: the negative impact of the town-gown dilemma. Again, like the meaning of the word “doctor,” the towngown terminology did not originally refer to the field of medicine but rather to those within and outside academic institutions.

Physicians can be ensnared in misunderstandings and differing priorities between the two sectors. These differences can undercut physician effectiveness as teachers and learners. First, both within and outside the academic center, the pace of the care of patients has increased. Thus, adequate time for teaching is constrained.

Second, many physicians who would like to teach cannot do so largely because of the logistical challenges of incorporating students and residents into physicians’ practices. Therefore, the resource of the experienced community physician has yet to be adequately used. Third, community physicians may not feel appreciated or respected by the academic center and vice versa, thereby diminishing the desire to collaborate. Derogatory references to the “LMD” and similar references to the “ivory tower” have fueled this attitude.

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Fourth, the business side of medicine can make physicians in different systems literally competitors for the patients. This competition can divert our attention from our common goal of improved physician education and improved patient care in all sites and instead toward business goals of establishing the patient base and enhancing the individualized reputation of “our” practice group to promote the success of “our” individual system.

The town-gown separation has the potential to bring about a negative and adversarial nature of physicians as teachers and learners. All physicians have observed or have even participated in the discussion of a case in which the prior care of a patient or conduct of a physician may not meet the standards or approval of the reviewing physicians.

Although such a discussion may happen more commonly in the academic setting, it can also occur in the community. I have been struck by the comfort, if not pleasure and even pride, that appears to be present in the discussing physicians. Derogatory discussion of the performance of others appears to be acceptable to physicians.

What does this have to do with our roles as teachers? If one were to observe a trainee who is not performing at the acceptable standard, the teacher’s role seems straightforward, although difficult.

Goals must be carefully defined, educational methods must be constructed and implemented, and follow-up evaluation must occur for the benefit of the trainee and patients. Yet, when discussions of colleagues reveal suboptimal performance, our role as physician-teachers for colleagues becomes blurred and challenged.

We are challenged by the relief at not feeling responsible for the care provided by colleagues and by the memories of destructive criticism in prior educational settings, and we are daunted by the discomfort of taking on the role of the teacher to improve the performance of others in our profession. We have not yet developed and consistently incorporated effective communication and teaching skills to assist each other in our common goal of lifelong learning. We need to ac-

quire and practice these teaching skills for others in our profession.

The relevance of these occurrences is poignant. Good teaching of patients, trainees, colleagues, and other members of the health care team is essential in medicine, for patients’ welfare is our common goal.

I have become convinced that physicians not only care deeply about our patients but also care about trainees, colleagues, and the future of our profession. In embodying this caring, many physicians are drawn to the role of being a teacher as they conceive their professional role in medicine.

Fortunately, we are moving from a philosophy of individual excellence to a philosophy of collective excellence. We are moving toward a shared responsibility for ongoing learning shouldered by each of us, and by our profession as a whole. We are moving appropriately toward embracing the role of the physician as teacher.

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Dr. Skeff is currently the vice chair for education in the Department of Internal Medicine at Stanford University, and a co-principal investigator of the Stanford Faculty Development Center (SFDC). The SFDC has trained 325 faculty trainers from 141 institutions in 16 countries to become local, regional, and national resources for the improvement of medical education. These faculty have, in turn, assisted more than 15,000 faculty and residents to improve their teaching effectiveness. Dr. Skeff received his MD from the University of Colorado and his PhD from the Stanford School of Education. He was the residency program director in Internal Medicine at Stanford for twenty years. Dr. Skeff has received several awards from students, faculty, and national organizations for his distinguished leadership, innovations, mentoring, and teaching.

San Francisco Medicine Asks: What Have You Read That Made You a Better Physician and a Better Person?

Perhaps The Story of San Michele sticks in my mind because Swedish physician Axel Munthe sketches the vivid history of poverty, plagues, and professional conflicts in nineteenth-century Europe on a first-person basis. Indelible stories and insights into giants in medical history come alive: Charcot plus a variety of vicomtes and abbès in Paris. More likely, I was transfixed by descriptions of hypnotism, psychosomatic illness, tragic pregnancies, and TB, along with the dismal living conditions of poor people, the lack of real ways to help almost anyone except by “tincture of physician,” and the striking heroism of some physicians. Parts of the book are downright odd, such as the recounting of mystical happenings in Lapland and rural Italy, but then, maybe mystical happenings are commonplace and we simply don’t see them. I have just finished re reading the book for the third time.

Linda Hawes Clever, MD www.renewnow.org; www.thefatigueprescription.com By far the most influential read in my education as a physician was The Adventures of Sherlock Holmes, by Sir Arthur Conan Doyle. The book was among several recommended to medical students at USC for the summer between first and second year. Now, more than thirty years later, I still try to emulate Holmes’s talents of observation as I work in my neurology practice.

Donald C. Kitt, MD CPMC, Vice Chair, Department of Neurosciences, Chief of Neurology

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Beyond Medical School

It’s Not Too Late One Dozen Important Topics You Might Not Have Learned Enough about in Medical School

Philip R. Lee, MD, and Steve Heilig, MPH Note: A previous version of this article appeared in this journal in 2004 (with additional coauthor Pradeep Natarajan, then a UCSF medical student). It stimulated a fair bit of discussion. Some professors have used it as a class handout. Revisiting it now, we note that unfortunately most of the problems discussed are still with us and have even worsened—but with encouraging improvement in some cases. We thus offer this updated version.

M

edical training is intense by design. Starting with medical school, most of the formal curriculum is filled with numerous essential topics, and as scientific and medical knowledge increases, it is further difficult to “triage” what must be learned. Efforts to insert new topics are often fraught with obstacles and resistance. Thus it may seem ridiculous to suggest that even more be taught in those finite years of formal medical education. It is not ridiculous to suggest that practicing physicians put these topics on your to-learn list now.

The following is a somewhat subjective list, but it is based on research, reports, and experience. The discussion of each area is short, with resources listed for those who want to learn more. Again, improvement in these (and other) topics is taking place across the nation. Consider this is an “alert” list conveyed with the hope that future physicians will be aware of these issues on their way to becoming good physicians.

1. Addiction

The American Medical Association has recognized that drug abuse is one of our nation’s prime public health

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problems. It’s a clinical problem too, and the biggest culprits are not stereotypical street junkies; they are often everyday patients using legal drugs. For example, despite much progress in reducing smoking, more than 20 percent of adults still use tobacco. Alcohol overuse is rampant at almost all ages. Abuse of prescription drugs is also rising. As for illegal drugs, the epidemic of methamphetamine addiction has spread everywhere. Yet many MDs are not aware of addiction issues; alcoholism and other problems often go undiagnosed and, even if recognized, untreated. It is known that having MD counsel about smoking, for example, is an important step toward quitting, yet many MDs are uncomfortable even talking about these problems.

More doctors need to know more about and apply addiction medicine principles.

Resources American Society of Addiction Medicine. www.asam-csam.org “Addiction and Recovery: From Neurons to National Policy.” www. sfms.org/source/members/magazine_archive_list.cfm?theme=June%20 2 0 1 0 % 2 0 Ad d i c t i o n % 2 0 a n d % 2 0 Recovery&section=Article_Archives

2. Nutrition and complementary therapies

The dean of the UCLA School of Public Health has stated that, due to obesity, “For the first time in two centuries, the current generation of children in the United States could have shorter life expectancies than their parents.” In a society obsessed with weight but also increasingly obese (or

shockingly bulimic), nutrition becomes a critical matter for patient guidance.

Information about extreme nutritional deficiencies like scurvy or pellagra may be interesting but is usually irrelevant.

More common problems related to physiological development; drug interactions; and use of supplements, herbs, and other “alternative” or “complementary” approaches are far more important.

Unfortunately, patients often do not look for nutritional counseling from their MDs. Physicians should inquire about and become better able to counsel their patients regarding diet and nutrition.

Resources Nutrition in Medicine. CD-ROM series.

Chapel Hill: University of North Carolina. www.med.unc.edu/nutr/nim/

Nutrition Guide for Physicians. Wilson, Bray, Temple, Struble (eds.), www. springer.com/new+%26+forthcoming+ti tles+(default)/book/978-1-60327-430-2

3. Sexuality

Human sexuality has long been taught in a biomedical fashion that often does not reflect real lives. How comfortable is the average MD in talking about sexual practices and health?

Homosexuality? Sexual dysfunction?

Sexually-transmitted infections? Cultural issues? Teen sexuality? With epidemics of sexually related disease a part of modern life, and unwanted pregnancy a perennial problem, education and training to elicit such key aspects of patients’ daily lives are vital. This includes contraception.

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21 San Francisco Medicine September 2010

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Continued from page 19 . . . comfortable” realms of sexuality will not only strengthen rapport but will allow a physician to address specific health needs that tend to go unrecognized.

In Europe, an accepted sexual medicine accreditation and curriculum now exist (see resource below); perhaps the AMA should recognize this subspecialty as well.

Resources Sexual Health in MedlinePlus: www. nlm.nih.gov/medlineplus/sexualhealth. html European Society for Sexual Medicine: www.essm.org/easm/sexual_med_ curriculum.asp

4. Pain

Research shows that pain, particularly chronic pain, is vastly undertreated.

Fortunately, the presence of pain is being considered another vital sign. Concerns about pain at the end of life as well as the overuse of medications are being addressed, and the issue of “assisted dying” at the end of life is not now overshadowing the imperative of pain relief. Medical schools are incorporating pain issues into the curriculum; MDs in California who have been required, often against their will, to complete a CME requirement have often expressed reluctant surprise and gratitude at how much they learned. Progress is being made and needs to continue.

Resources American Academy of Pain Medicine: www.painmed.org American Pain Foundation: www. painfoundation.org

5. End-of-life care

Medicine is not only about cure, but also about caring for patients when cure is no longer an option. Traditionally, however, death scares many physicians as much as anyone else. Now, however, palliative care is a growing discipline with great rewards. Pain, as noted above, is only part of the picture. Physicians need to know how to help ease patients (and their loved ones) into a palliative mode, to

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use therapies and medications in optimal ways as death approaches, and to work with skilled hospice and other similar professionals.

Resources American Academy of Hospice and Palliative Medicine: http://www.aahpm.org/ Education for Physicians on End-ofLife Care: http://www.epec.net

6. Physical fitness

We all know exercise is good, and often the single most important variable in overall good health. Numerous studies have categorized physical exercise as a positive predictor of good health, disease prevention, and longevity. Our bodies are built to be used vigorously. Yet how many MDs effectively address and motivate patients toward sustainable cardiovascular fitness and weight loss?

Although many schools hammer the “stages of change” model into students so they can motivate patients to change their lives, further work needs to be done with practicing physicians to enhance their knowledge of these life-saving techniques.

Resource American Academy of Family Physicians: http://familydoctor.org/059.xml

7. Medical ethics

Ethical questions are common in clinical practice. Medical ethics committees are now required in hospitals. However, formal education of medical ethics varies widely. This variability is evident later in practice, as many physicians see “ethics” as superfluous and may even resist any involvement with an ethics committee.

This is no longer acceptable because ethical standards, processes, and practice are complicated and call for continued reminders and training. The important ethical dilemmas that physicians face remind us of the responsibility of MDs to stay informed and updated on appropriate standards, be they about life-or-death choices, financial conflicts of interest, or other issues.

Resources AMA Council on Ethical and Judicial Affairs: http://www.ama-asn.org/go/ceja “Clinical Bioethics: A Practical Approach to Ethical Decisions in Clinical Medicine,” by Albert Jonsen, Mark Siegler, and William Winslade. www.mhprofessional.com/product. php?search_crawl=true&isbn=0071491538

8. Violence

The media confirm that we live in a violent world. Anyone who has spent time in an emergency department knows that, but much (or arguably most) violence is concealed. “Domestic” (partner, elder, child) violence is endemic. Like addiction, it often goes unrecognized, untreated, and unreported, although it impacts a patient’s health as much or more than any other factor in life. Physicians need to learn methods of identifying and treating or referring issues revolving around domestic abuse, including hospital protocols, patient counseling, and resources available to patients. (Gun control and community violence are unfortunately beyond our scope here.)

Resources “Domestic Violence: A Practical Approach for Clinicians.” San Francisco Medical Society: www.sfms.org/domviol. htm “Simplifying Physicians’ Response to Domestic Violence.” www.ncbi.nlm.nih. gov/pmc/articles/PMC1070885/

9. Environmental health

No man or woman is an island. Our environment affects our health in more ways than we usually imagine. So where and how a patient lives and what they eat, drink, and breathe are all factors physicians need to know something about.

Knowledge is rapidly growing about the impact of chemicals, infectious agents, irradiation, maybe even global warming on our environment, bodies, and health.

An “environmental history” is part of good clinical assessment—particularly for children, who are often most severely affected. Physicians have the unique opContinued on the following page . . .

September 2010 San Francisco Medicine 21

Continued from the previous page . . . portunity to link personal and environmental status, which can be important for prevention and for acute and chronic care.

Resources The Collaborative on Health and the Environment: www.healthandenvironment.org Medicine and the Environment: Practice, Prevention, and Policy: www.sfms. org/AM/Template.cfm?Section=San_ Francisco_Medicine&Template=/CM/ HTMLDisplay.cfm&ContentID=2978

10. Health policy

Many clinicians may believe, or wish, that their practices exist in social vacuums, but that is untrue. Priorities and decisions made—or not made—in legislative arenas affect what kinds of clinical problems come in your door and what you can do about them. Public health—epidemiology, prevention, and so on—have long been neglected factors in medical education and practice. Yet physicians have high credibility among the public and legislators, and that prestige is heightened even more when a respected clinician speaks and acts on behalf of policy issues and public health. This voice becomes ever more important as modern “health reform” evolves.

Resources “Understanding Health Policy: A Clinical Approach,” by Thomas S. Bodenheimer and Kevin Grumbach. http:// www.accessmedicine.com/resourceTOC. aspx?resourceID=56 UCSF Institute of Health Policy Studies: http://www.ihps.medschool.ucsf. edu/

11. The business and organization of medicine

Physicians have rarely been taught much about how to run a medical practice or manage finances. Thus the old stereotype about physicians being brilliant at medicine but ignorant about money is often not too far from the truth. Depending on what type of practice environment a doctor works in, this is more or less

important. But everyone should know, for example, about health insurance, managed care, electronic health records and other information technology, down to negotiating rent and personnel issues.

How to work effectively as a care team is crucial as well. This arena is ever more important with evolving “health reform.”

And knowing about how pharmaceutical industry money has intruded on medical practice (and education) is important, too.

at Stanford University’s program in Human Biology and in the Department of Medicine at UCSF. Steve Heilig is director of public health and education for the San Francisco Medical Society and the Collaborative on Health and the Environment and coeditor of the Cambridge Quarterly of Healthcare Ethics.

Resources Contact your local medical society for educational opportunities on practice management, electronic health records, and so on.

Marketing of Medicines: An online CME course from UCSF: www. cme.ucsf.edu/cme/CourseDetail. aspx?coursenumber=MED11006

12. Your own well-being

Anyone who has read this far might have a sense of being overwhelmed by all there is to know and do. It’s a common feeling among physicians (and medical students); it may be one reason for the tragic fact that that physicians are at elevated risk for depression, substance abuse, and suicide. Frustration in meeting expectations both external and internal, stress from all sources, and the challenge of leading a balanced life are common problems. Many physicians may also struggle with feeling they have an unrewarding life and career. Physicians need to be aware of resources available to address their needs, able to define and maintain priorities, and recognize the numerous daily rewards that are unique to the medical profession. Doing so can help one retain the idealism that so often motivates the career choice of medicine in the first place.

Resources RENEW: www.renewnow.org/ “The Heart of Medicine”: www.theheartofmedicine.org/ Dr. Philip Lee is chancellor emeritus of UCSF, former United States assistant secretary of health, and professor emeritus

22 San Francisco Medicine September 2010

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Beyond Medical School

After Medical School Shifting Expectations, Practices, and Influences; Sturdy Values

Philip A. Pizzo, MD

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n the decades that have passed since I graduated from medical school in 1970, I have on occasion celebrated the thought that I have never have really had a job. Medicine to me has always been a passion, a profession, and, in some ways, a calling. It has presented me with unique opportunities to learn about and impact human life and to influence the world around me. I know many who share this sentiment, as well as others who have become disenchanted and disheartened by life as doctor. To varying degrees this is a function of aspirations, expectations, and the decisions we have made or had imposed on us—as individuals and as a medical community.

I entered medical school with no real understanding or appreciation of what a life in medicine was about. Most of what I knew came from reading books about medical discoverers and scientists, and I had no immediate role models to emulate or even assess. Born into a first-generation immigrant family, I was the first to graduate from high school, and everything that unfolded was new and unexplored. There were no guideposts or ready exemplars.

As a member of the “sixties generation,” I entered medicine with an expectation that knowledge could “change the world” and that medicine was a noble calling. Indeed, a career in medicine was seen as for public good and as a profession that had considerable respect for integrity and compassion. It was a time when doctors were seen as individuals who served their communities—often with personal sacrifice, conviction, and purpose. Many physicians practiced alone or in small groups, and there were more “family doctors” than specialists. While doctors ran their

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clinical practice as small businesses, they were often a family-run enterprises, not infrequently in their homes or neighborhoods. Doctors knew their patients and families over time and stood by them, even when what they had to offer was limited in its real impact on health and disease.

But the personal nature of medicine was often transcendent.

Students entering medical school today still have a desire to act altruistically and a passion for doing good things for the patients they serve and for the world writ large. But much has changed in the profession they enter, and it doesn’t take long for values and aspirations to be influenced by forces that have crept in around the edges and into some of the core values of professionalism. This is related, at least in part, to the market and business forces driving medicine, and by the perverse incentives they instill or that affect the behavior of the broad health enterprise. Some of the changes are related to the use of the technologies that drive modern medicine and that have relocated doctors from a home office to a multispecialty practice or hospital setting. The evolution of doctors from small self-owned private practices to employees of large groups or as corporate partners has had an impact on the personalization of medical practice. This has been accentuated by short visit times and by doctor-patient relationships that are increasingly devoid of personal context. Some of these issues have prompted physicians to enter into “concierge practices” to recapture the “doctor-patient relationship,” but this limits the number of individuals served and fosters a class system of medical care.

At the same time, the positive im-

pact of medicine has also changed enormously—with new drugs, devices, and diagnostics altering the landscape of disease outcomes and expectations. Ironically, the choice and use of many of these new therapies has been influenced by marketing and business tactics—to which physicians have been willing participants and occasional accomplices, with sometimes unintended consequences. I well recall that when I graduated from medical school, I and virtually all of my classmates refused to accept the “doctor’s bag” from industry. There was a strong sentiment that we would not be influenced by the marketing offerings of industry! We felt this way even though, paradoxically, industry had relatively few drugs or devices to offer at that time. But that has changed, as has their marketing impact on the medical profession.

Over the past several decades, the financial connections between doctors and industry have evolved slowly, steadily, and significantly. Studies demonstrate that over 90 percent of physicians receive some form of industry funding, and, even though virtually all claim that it doesn’t influence their decisions or practice, the reality is that industry would not be spending more than $20 billion a year on marketing to doctors if there weren’t a tangible and evident impact on product use. It is not my intent to cast industry as villains. The interactions of marketing departments, sales forces, and doctors— including leading academicians—have been reciprocal and insidious, even if not always fully informed. It’s like the proverbial frog in the pot of water in which the temperature has been steadily Continued on the following page . . .

September2010 San Francisco Medicine 23 2010 San Francisco Medicine 23 September

Continued from the previous page . . . increased rather than brought to a rapid boil. There has been too much shared accommodation and entanglement as the heat has been turned up. The degree of the financial impact of industry on the medical profession is a story that has come to light in the past decade, and while it is the dramatic scandals that have gotten public attention, the reality is that the influence is more widespread than most would care to admit or acknowledge. For both better and worse, my knowledge of the impact of marketing and financial influence has increased greatly since my medical school days.

While many physicians argue that they cannot be influenced by a free lunch or a small gift (although they might acknowledge that colleagues might be influenced by such inducements), the reality is that such inducements have been the vital entrée of the pharmaceutical sales force to the doctor’s office. There is a vast literature that affirms that small gifts influence behavior. Many argue that participating in “speakers’ bureaus” or in industrysponsored continuing medical education programs doesn’t influence their clinical practice or behavior. The evidence, even from industry spokespersons, offers a different conclusion. Indeed, I fully expect that many readers of this commentary may disagree, perhaps even vehemently, with the position I am offering.

I had the honor and privilege of becoming the dean of the Stanford University School of Medicine more than nine years ago. As you might expect, a considerable amount of my energy has been focused on the education of medical and graduate students, along with residents and postdoctoral scholars. And as a leading research-intensive school of medicine, Stanford has sought ways to interact successfully with industry in each of our missions of education, research, and patient care. I would not have envisioned nine years ago that a major component of my time, and that of numerous colleagues and co-workers, would be spent on addressing the financial conflicts of interests that have developed between physicians and industry. And while I do not believe

we can or even should be attempting to “eliminate conflicts” per se, I do very much draw the line when it comes to physicians marketing for industry or being influenced by the marketing tactics of industry. These concerns have led to a series of guidelines called “Policy and Guidelines for Interactions between the Stanford University School of Medicine, the Stanford Hospital and Clinics, and Lucile Packard Children’s Hospital with the Pharmaceutical, Biotech, Medical Device, and Hospital and Research Equipment and Supplies Industries (‘Industry’)” that can be found at http:// med.stanford.edu/coi/siip/policy.html.

I have been reassured by how positively our students and trainees have responded to these policies, and l have also been pleased by the willingness of our faculty to comply with the many changes that have occurred in recent years. I have been surprised by some of the reactions in our community locally and more broadly but fully recognize that change is always difficult, especially for individuals who pride themselves as independent thinkers and practitioners.

In the end, I find that many of the values I have learned since medical school were actually instilled in me when I was a student. They begin with the doctorpatient relationship and put integrity, care, and compassion first and foremost.

They are firmly grounded in the conviction that the role of the physician is to allow knowledge, science, humanism, and professionalism to guide medical practice.

They include the importance of avoiding influences, financial and otherwise, that might distract from doing what is best for the patients. And, finally, they are about preserving the values of altruism, integrity, and professionalism that brought us to medicine—a lesson that we should never forget.

Philip A. Pizzo, MD, became dean of the Stanford School of Medicine in 2001. Before joining Stanford, he was the physician-inchief of Children’s Hospital in Boston and chair of the Department of Pediatrics at Harvard Medical School. Pizzo is recognized for his contributions as a clinical investigator, especially in the treatment of children with cancer and HIV.

24 San Francisco Medicine September 2010

Help Support and Grow the San Francisco Medical Society Membership renewal time is coming in September, and you can get a break on your dues while helping to grow membership. We are proud to announce our revised and improved dues incentive program!

Peer-to-peer communication remains the single most effective recruitment and retention strategy for any organization, but especially those involving physicians; if you ask a fellow member why he or she joined SFMS and CMA, the answer is most likely to be that a colleague suggested it. Increased membership numbers translate to a more diverse and robust membership, greater resources, and a stronger voice of advocacy for the profession and for patients. And now members can reduce their 2011 dues by helping their peers join SFMS and CMA.

SFMS Recruitment Incentive Plan for 2011 Dues • Recruit 1-2 members: Receive $100 off SFMS 2011 dues.

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• Recruit 5 or more members: Receive FREE SFMS dues.

• TPMG physicians: Recruit 4 or more members (non-TPMG) and receive two free tickets to the annual dinner.

Contact Jonathan Kyle in the Membership Department for more information, as well as talking points and other materials. Call (415) 561-0850 extension 240, or e-mail jkyle@sfms.org.

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Beyond Medical School

On the Other Side of the Equation Five Things I Learned by Being a Patient that I Wish I’d Learned in Medical School

Roger J. Bulger, MD, FACP, FRCP What I did learn in medical school

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ver the past two years, as I attempted to write a book about what I learned as a patient, the editor insisted that I search my memory for examples that could bring life to my otherwise academic and arcane manuscript. In doing so, I realized that such stories are useful, subtle tools to use to advise and even educate patients and each other.

After reflecting on my medical education—on what I did and did not learn— and on and on my experiences going through two episodes of widespread, aggressively treated lymphoma, I have boiled my learnings down to five lessons:

Lesson 1: Physicians need to keep learning about the human dimensions of human beings

Life-time continuing education for physicians should include studying human suffering, death and dying; the placebo effect; mechanisms of self-healing; and techniques to improve interpersonal communication. Each of these subjects has a large cadre of experts and a growing relevant bibliography from which to learn, but I think valuable stories are hidden in our own clinicians’ collective experiences, experiences that should be tapped somehow, for all our sakes.

Lesson 2: People need the right kind of help to cope with bad news I remember well an elderly patient who came to my service when I was a medical resident at the University of

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Washington in Seattle in 1965. She had an undiagnosed illness. She was bright and cheerful, although she knew that whatever it was she was suffering from would be biopsied and might well not yield good news. We found a mass and biopsied it, telling her that we would not have definitive results for a few days. However, we had to tell her after three days that the laboratory had to repeat some tests and we had to wait a few more days.

Since she came to us from a great distance, she remained in the hospital. A few days before the results were returned to us, she went mad: incoherent, hallucinating, refusing to eat. We called for the psychiatrist. The results of her biopsy came back and they revealed that there was nothing we could do to treat her. After discussing the likelihood that she could not understand the bad news, we counseled the intern to go in, sit down next to the bed, and tell her as best he could the test results and their implications. He did so.

For the first time in three days, she perked up and thanked him and asked him to get her local relatives together in her room as soon as possible. He did; they came, and we observed the woman we had known when she first came in, taking charge of what remained of her life, setting up all that needed to be done about her passing.

Finally, the psychiatrist came and addressed our perplexity over what had happened. He described the phenomenon of voodoo death, or the bone-pointing syndrome in some primitive cultures, something the great physiologist Walter B. Cannon described in detail concerning his own laboratory technician. The psychiatrist said that when we couldn’t deliver the biopsy news, we were in effect

pointing the bone of death and separation from the community at our patient.

She responded by becoming, in effect, insane. When the intern spoke the truth to her, it set her free from her insanity and allowed her to get back to implementing the plans for her death that she had obviously so carefully prepared. We had inadvertently caused her great though temporary suffering, and later, thanks to her relationship with the intern, she was returned to control of her remaining days.

That woman’s story has been informing me, and I feel certain the others who cared for her, ever since.

Lesson 3: The placebo effect and self-healing play an important role

When I was being trained in internal medicine, I believed that the placebo effect was something to be discounted as a “mental thing” and not the biochemical cure we all sought and valued. If a medicine did no better than a sugar pill or placebo, it was no good. We all knew of the nineteenth-century advice advocated by a French physician “to give all new medicines as often as you can until they are no longer effective.” Also, medical ethicists were declaiming against giving placebos as unethical deceptions of unsuspecting patients. In that context, the placebo was in effect restricted to an inert pill.

Subsequently, the definition of the placebo effect included any unexpected effects that were not related to the known actions of the drug or other therapeutic intervention. The rule of thumb I used was that the placebo effect accounted for positive outcomes in 40 to 45 percent of Continued on the following page . . .

September2010 San Francisco Medicine 25 2010 San Francisco Medicine 25 September

Continued from the previous page . . . patients; the rate of improvement would increase to 60 to 65 percent if the patient believed that the pill or treatment would work and would increase to 80 to 85 percent if the patient and the doctor believed that the treatment would work.

In support of that rule of thumb , fifty years ago, one of America’s leading cardiovascular surgeons achieved an 85 percent improvement rate in severe angina pectoris by doing an internal mammary artery ligation aimed at increasing blood flow through the coronary arteries. Other doctors could only get improvement rates in the 60 percent range, and subsequent randomized controlled studies yielded improvement in the 40 percent range, with no statistical differences between those who had their internal mammary arties tied off and those whose ligature was removed before tying the knot. With those studies, surgeons gave up on the operation and stopped doing it. Those who proved the operation didn’t work were acclaimed appropriately for their work. In a little-noticed follow-up reaction, the patients who benefitted from the operation, some of whom had been able to return to work, said they were still grateful to their surgeon for the operation and the improved health they experienced, even when they knew the randomized trial results.

Lesson 4: Consider the clinician as a human placebo

Nowadays, the placebo effect has a positive connotation and remains the focus of increasing research, but this is probably morphing into studies of the mechanism of self-healing. The placebo is thought of as anything that is provided to the patient. Its effects are usually studied in terms of how the patient responds to the therapeutic environment. But I have always wondered why researchers have left out consideration of the possibility of the clinician as human placebo. By that I mean that there are no studies of the role of the healer in eliciting a positive self-healing response on the part of the patient. We don’t even know if some doctors are more effective in eliciting the

placebo response than are other healers, whether nurses are more effective than doctors, women better at it than men, or what might explain any differences that might be observed.

The trouble with switching totally to thinking of this area in terms of “selfhealing” is simply that it leaves the clinician and the clinical team out. The power of science and expert technology resides largely in the health professions. It seems to me that, in addition to the scientific competencies of physicians and other practicing health professionals, they enter the patient interaction with a special potential influence on whatever the selfhealing capacities of the patients turn out to be. How best to activate that mode in the healing process unfortunately remains largely unexamined. Knowing that trust in the physician goes a long way toward improving the placebo effect of treatments, I have wondered if our own individual effectiveness in developing that trust varies from patient to patient and what are the factors affecting our success or relative failure in building patient trust.

narratives of reasonable brevity that they think might be of interest to others, including patients, health professionals, and administrators. I invite any interested reader with a story to e-mail it to me (roger.bulger@yahoo.com), and maybe we can all learn something positive from our stories!

Roger J. Bulger, MD, FACP, FRCP, is the author of several books. His most recent is Healing America: Hope, Mercy, Justice, and Autonomy in American Healthcare, Prospecta Press, 2010 (available in book stores and at Amazon.com in August, 2010). He has served as president of the Association of Academic Health Centers, president of the University of Texas Health Sciences Center in Houston, chancellor of the University of Massachusetts School of Medicine, and faculty member of the University of Washington and Duke University. He was the first executive officer of the Institute of Medicine of the National Academy of Science.

Lesson 5: Western scientific medicine often gives people back their lives

One day three months after my most recent bout with aggressive chemotherapy, I woke up with a strange euphoria, which seemed to persist. In fact, I figured out that I suddenly felt “normal” for the first time in six months, a state to which I had thought I would never return. I told no one until I read a book that referred to “posttraumatic bliss” in cancer patients who had become convinced that they were likely to die soon, but didn’t. Once provided a name for my “blissful” and persistent state of appreciation for every day of normalcy, I have been able to talk and write with others about this phenomenon. Many physicians and nurses have written me about similar events in their lives as patients. Sharing such things may be helpful for patients to appreciate the difference between fixing the disease and recovering fully from the illness.

I hope to start a blog to which anyone, by name or anonymously, can contribute

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Beyond Medical School

One Year out of Training A Postscript on Clinical Pearls

Katie Young, MD

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ever let the sun set on a bowel obstruction.

Ahh, clinical pearls and rules of thumb.

Those quick tips, guidelines, and pieces of advice for common clinical situations, culled from lifetimes of practice by our most esteemed teachers, eagerly sought by trainees since the beginning of medical education itself.

In a patient subjectively unaware of a fever, think of drug fever.

In the face of an ever-expanding universe of medical knowledge, we’ve all found these bits of freestanding advice and shortcuts to be invaluable. Before smart phones and PDAs, we jotted them down in handmade “peripheral brain” notebooks, or purchased pocket reference guides filled with such rules and pearls for the different clinical rotations in medical school. And even now, with relatively immediate access to online databases of medical information from our phones, students continue eagerly to record these pearls and rules. Indeed, the passage of this kind of experience-based knowledge from attending or resident to medical student remains an integral aspect of medical training, particularly when controlled data are not available.

Clinical pearls abound in every subspecialty field, including my field of psychiatry.

Suspect malingering if a patient alleges auditory hallucinations but claims no attempts or strategies to diminish them.

Direct eye contact is often anxietyprovoking in the psychotic patient; when conversing, position your chairs side by side, instead of face to face.

Such rules provided direction when I

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was at a loss and bolstered my confidence and sense of competence when I first began seeing patients. But grateful as I have been for them, I have also learned, to my chagrin, that such rules are by no means foolproof.

Every month, I meet with a small group of former classmates from residency in a peer supervision group, where we discuss cases for continuing educational purposes. Two cases recently discussed were particularly illustrative of the limitations of these pearls, and they underscore the continual need to proceed thoughtfully when invoking rules of thumb or anything we consider clinical truisms. (Note that personal details have been altered to protect patient confidentiality.)

Case 1: Mr. R is a 37–year-old male who sees a psychiatrist for psychotherapy and medication management for depression and anxiety. He is softspoken and shy and conducts himself with a degree of passivity that has repeatedly caused interpersonal difficulties for him. He works in a busy retail outlet. With recent layoffs, his workload and hours have increased, but he has not been compensated for the extra work. He becomes increasingly frustrated and depressed about this situation.

A truism in mental health readily appreciated by any psychiatrist or primary care physician seems relevant here: A sense of empowerment alleviates depression.

Therefore, if we can assist the patient in asserting himself appropriately, he will feel better. Accordingly, the psychiatrist suggests that he communicate his needs to his employer—higher salary, or fewer work hours. Not unexpectedly, Mr. R is hesitant but does agree it could be helpful.

They role-play a meeting with his employer, and Mr. R then dutifully schedules

a meeting with him. He returns to therapy the following week to report that he met with his supervisor and that the meeting had been . . . a disaster. The supervisor was unsympathetic. He told Mr. R. that he needed to be more of a team player and that he had, in fact, been disappointed with Mr. R’s productivity; he would not be granted an increase in pay but was free to resign if he wished. Mr. R did not advocate for himself further. Then, adding insult to injury, he was subsequently passed over for a much-desired promotion.

This was not the outcome that the psychiatrist hoped for. But why? The concept seems sound.

As it turns out, Mr. R’s habitual passivity cloaks a more problematic issue in Mr. R’s mind—his rage. As the psychiatrist subsequently learns, in Mr. R’s youth he had had significant problems with anger. Ten years prior, he was involved in an incident of road rage in which he had narrowly avoided fatally injuring himself, another motorist, and a child. That incident in particular had frightened Mr. R profoundly; since then, he inflexibly avoided any situation he feared might lead to conflict. In his mind, assertiveness was not empowering, it was dangerous. In failing to appreciate that there might be an occult function for Mr. R’s passivity, the psychiatrist had missed the primary issue. The treatment priority lies with the mediation of Mr. R’s internal conflicts around his aggression, not with assertiveness coaching. Though the correlation between empowerment and mental well-being remains valid, the more appropriate pearl to have been considered in this case was: When a patient clings to an obviously maladaptive behavior, consider Continued on the following page . . .

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Continued from the previous page . . . how that behavior might be serving him unconsciously.

Next, consider the case of Ms. H, a 27-year-old female who seeks treatment after falling victim to an assault the previous year. She presents in a significant depression, punctuated by recurrent panic attacks. She does not offer details of the incident. Initially ambivalent about treatment altogether, she does agree to be seen weekly and starts taking an antidepressant.

After three months, however, her depression and anxiety have not remitted, and she still has not discussed the incident.

Perhaps the most common rule of thumb invoked for the treatment of patients with trauma histories may be: Have the patient talk about the trauma; catharsis is healing. This intervention seemed to be the missing piece of her treatment.

The medication had taken the edge off of her symptoms, but she seemed stuck.

Following this treatment principle, then, the psychiatrist states his sense that she remains symptomatic because she has not yet metabolized her trauma. He gently invites her to speak of it. The patient looks surprised but complies and tells of the incident. As she tells her story, she becomes increasingly distressed, then suddenly slides to the floor and sits mutely, hugging her knees, hunched against her chair. After that session, she does not return to treatment.

Here again, this was not the outcome hoped for. What went wrong? Unfortunately, this particular concept—retelling trauma as therapeutic—is notoriously misinterpreted and misapplied. In fact, the therapeutic management of posttraumatic stress involves far more than recounting the traumatic incident to a sympathetic listener. The patient must first feel safe and in control of the treatment and should not be engaged to recount any incident without his or her explicit permission. To do so without prior consent or sufficient trust can be enormously retraumatizing for patients.

These two psychiatric case examples demonstrate that mishaps can occur using clinical pearls or rules of thumb, particularly by neophytes. Novices in any field are, by definition, prone to misadventures of

this sort, e.g., applying a rule of thumb in the wrong scenario, remembering the rule incorrectly, or using a tip that long ago had been found to be fundamentally flawed.

Medical trainees, I believe, are particularly vulnerable to such pitfalls because the measure of excellence in medicine has always been perceived to be weighted toward the size of one’s fund of knowledge. The statement “I don’t know” may be acceptable and even admirable to hear from a respected attending, but it is rarely an answer a medical student feels comfortable giving. And although seasoned practitioners understand that the quality of one’s fund of knowledge is the more relevant issue, for the third-year medical student who is examined on all major specialities within the course of a single year, size does matter.

Certainly for me as a student, the experience of not knowing felt awful, and so having quick answers that could deflect my feelings of inadequacy were a boon.

But they came at a cost; there were times I acted too hastily, understood things too superficially.

In my practice today, I proceed more thoughtfully. I am more apt to take clinical pearls with a grain of salt, consider alternative courses of action, and seek consultation in times of uncertainty. The central task and ongoing challenge for me has been to cultivate patience, to temper my pernicious reflex to intervene at the first complaint.

As noted psychopharmacologist Steven Stahl advises, the top three tasks when faced with common drug side effects are: Wait, wait, and wait. I think of these words frequently and apply the advice broadly.

I know that only in having the patience and wisdom to wait and watch can any of us make the best choices for our patients from among the vast sea of clinical pearls and tips and rules that we’ve all been so privileged to receive.

Katie Young, MD, attended the UC Berkeley/UCSF Joint Medical Program for medical school and completed her residency in psychiatry at UCSF. She is currently in part-time private practice in San Francisco and also works as a staff psychiatrist for San Francisco’s Community Behavioral Health System.

28 San Francisco Medicine September 2010

Lessons from Residency A Resident Reflects on Unexpected Lessons Beyond Medical Education

A resident friend of mine once said, looking back on her intern year, that she discovered her worst self. I think everyone who has gone through an intern year can empathize. What you don’t realize in medical school is that residency is about edges—the edge of your ability learn, to manage difficult and critical situations, and the edge of your ability of cope.

Every intern comes in with a sense of exuberance and confidence.

After all, by the time someone’s an intern, they’ve survived prerequisites in college, medical school, and two grueling application seasons. Every intern knows that to do this they are at least decently smart, clearly dedicated, and not afraid of putting in long hours. But six months of working at least seventy to eighty hours a week on average, having only four days off in a given month, and constantly trying to negotiate the intricacies of hospital politics—much less dealing with the gravity of caring for another person’s life—you finally meet your worst self. I have seen the most cheerful, delightful, nonconfrontational resident drawn into the most inconsequential argument. I have seen the most stoic resident brought to tears. And as for myself, I watched my easygoing personality fall apart until the most simple of annoyances left me with a sense of rage.

You will meet your worst self.

That’s why I think most residents would agree that forgiveness is the key. You will have to forgive yourself for being imperfect and, in doing so, find a way to live with your worst self. After all, as my friend realized, her worst self wasn’t really that terrible—just human.

Robin Horak UCSF Pediatrics Residency

www.sfms.org

Beyond Medical School

Lessons from the Bedside A Fourth-Year Medical Student Reflects on Important Lessons Learned

Eisha Zaid

W

hen we donned our pristine white coats three years ago, we were told that we were about to embark on an exciting journey of lifelong learning. We have only just begun.

In four years we’re expected to transform from civilians to student doctors charged with taking care of patients. During the process, we become like-minded beings, equipped with the knowledge and skills to think and act in a particular way. We also become problem solvers who are programmed to quickly work through differential diagnoses. Most of this reshaping happens at the bedside, where our patients guide the trajectory of our development into physicians.

In medical education, we are grounded in two years of preclinical education, when the basic sciences marry the clinical medicine. We start with the basics and build a foundation, fact by fact, during a series of structured small groups, labs, and exams. A problem-based approach is applied to simulate what we will experience in the world of patient care. With our glossy syllabi, objectives, and neat clinical cases, we venture forth, mastering the pathophysiology of disease, highlighting every word and digesting the wellpackaged information, fully aware of the expectations while completely sheltered from the reality of patient care.

When we transition to the clinical years, reality hits us hard. We’re indoctrinated into an entirely new culture, where we feel alien in our short white coats and lack of experience. In recognizing our limitations, we also remember that we are bestowed with the responsibility of taking care of human life—a great privilege and challenge. We quickly realize that lessons www.sfms.org

from our early doctoring class have little place in the world of ten- to fifteen-minute clinical encounters and overflowing emergency rooms.

“Human lives are just plain messy,” my medicine attending once told me.

He was right. Although the first two years prepare us with an extensive knowledge base, nothing can truly prepare us for the reality of the clinical years. The complicated pathophysiology of disease pales in comparison to the intricate complexities weaved in the stories of our patients.

As we serve patients during the lowest points in their lives, we become acquainted with the intimate details of their histories. In managing my patients, I have seen a spectrum, everything from the IV-drug user who overdosed to the wife abused by her partner to the patient dying from his metastatic cancer to the homeless patient with HIV to the victim of nonaccidental trauma to the pregnant patient actively using meth. The spectrum of disease pathology is oftentimes grounded in social pathology that exposes us to the dark sides of human nature and the cruelty of society. When we see the intersections, we are reminded of the fragility of life and complexity of managing diseases.

In these encounters, we fumble through our words, break down emotionally, and struggle to understand. With new admissions and high patient turnover, there is no time to process and we are not equipped with the coping skills to comprehend the gravity of what our patients tell us. We initially fall back on the pearls we were taught during our first year of medical school, to express compassion-

ate words that merely fill the silence and void that separates us from our patients.

Slowly, we outgrow our discomfort and we begin to learn, gaining valuable experiences. And despite our inadequacies, we are humbled when our patients turn to us and call us “doctor,” a reminder that we are growing. We may not see the change, but our patients recognize the doctor in us. ***** Although the reality of patient care challenges us, the best lessons in medical education rest in our patient encounters, where disease takes on a human form and becomes cemented in our memories. On the wards, we are often assigned patients based on the learning value of their presentation. The “active patients” represent the gold, sources of intellectual stimulation, full of learning issues and “pimping” topics. Interestingly, when the diagnosis and assessment have been made and the plan is implemented, many physicians feel there is limited learning to be garnered from the “rocks” of the service.

As students, we adopt these patients as our own. Physicians, teams, and nurses switch, but the medical student remains, representing the one constant for these patients. We outlive the transient teams, often relating more to our patients than to the long white coats that surround us.

And each day, like clockwork, we arrive to preround, round, and check in on our patients. In following patients through their hospital course, we learn more than just the details of managing disease—we learn how to become healers through lessons that can only be experienced. ***** Continued on page 31 . . .

September 2010 San Francisco Medicine 29

Beyond Medical School

Emergency Segue An Emergency Physician Makes a Big Shift

Scott Schmidt, MD

I

t all seemed exciting when I was a second-year resident at Harbor-UCLA Medical Center, staring down the gullet of an unfortunate young man with a bullet through his rapidly swelling tongue and a veteran professor leaning over my shoulder, asking if I thought I could get the endotracheal tube where it needed to be. Harbor was, and I imagine still is, a wild place with a certain in-the-trenches camaraderie among the folks working there that made the stress and sheer exhaustion of it all somehow bearable.

I emerged from my training confident and competent, if a little battle-worn, and ready to enter the world of community emergency medicine. Whereas Harbor was ever-bustling with all variety of advanced pathology, the work I’ve done for the last fifteen years has mostly been routine management of common ailments punctuated by the occasional high-acuity situation or the more frequent high drama of the disinhibited drunk, screaming obscenities at the world and at me. It was good for a while, especially as a single man enjoying income I’d never known and plenty of time off.

Soon enough, however, I began to feel a certain weariness creeping into my work life that eventually grabbed my attention. Although there have been and are many moments of timeless and deep connection with patients and families in the ED, they are rare and difficult to really drop into when there’s a constant stream of interruptions and a waiting room full of patients eager to make my acquaintance.

The fast pace and mad multitasking had begun to wear on me. But more than that, it was a yearning for work that more deeply resonated with my soul that finally

led me to consider a change.

I recall as far back as medical school discovering how the world seemed to fall away when it came time to speak of death or grave illness with a patient or family. In those moments of truth-telling, bearing witness, and simply being present, I found a place where I could use all of myself to serve the patients and families I was caring for. Over the years I sought out opportunities to work with people in this way, often in the midst of an ED shift.

My mother’s struggle with ALS, my own brushes with death, and a growing desire to feel more connected in my work led me to turn toward end-of-life work in earnest five years ago. I participated in a wonderful yearlong training in the nonmedical dimensions of caring for the dying at the Metta Institute with Frank Ostaseski and Ange Stephens (www.mettainstitute.org).

Partway through the year I was asked to do some fill-in hospice work for my friend Scott Eberle, with whom I’d done rites of passage work in the desert the year before. What ensued was a lot of personal study and on-the-job training, and, ultimately, a more regular post as associate medical director and hospice physician at Hospice of Petaluma. The people I work with there are an incredibly dedicated, conscious, and loving group, and the time I spend with the patients and families we care for is often very intimate.

Meanwhile a lot else was happening in my life. I moved from San Francisco to West Marin and am now married with a third child on the way. Hospice work comprises about 25 to 30 percent of my work, and although I continue to look for opportunities in the ED that feel good to me, the growing pressure to see people

30 San Francisco Medicine September 2010

faster and faster feels like yet another distraction from the way I want to be doctoring in the world. While I’ve enjoyed some wonderful experiences as the “end-of-life” guy in the ED and in other roles I’ve taken on along the way, I’m again feeling drawn to doing something a little different.

News of my wife Lynn’s current pregnancy came just as I was taking a month off from my emergency medicine work to explore my next move professionally.

During my break from the ED, I allowed whatever arose in my consciousness to just be. I reflected on the great beauty and mystery of death and dying work through a different lens and slowly began to see how the whole big wheel turns.

For years I’ve been interested in legacy, but the questions coming up in my mind were of a slightly different flavor than those I’d entertained before. How does the way my mother lived her life express itself in the way I’m living mine?

How does the way I’m living my life now serve as compost for more life to grow out of? How are we connected to the great mystery of creation? What is my part in it? Where does art come in? Are we fully expressing ourselves in this one precious life? How are we playing the cards we’ve been dealt? Does paying attention to these questions even matter? It does to me. And I realize I’m curious about whether it does for others.

Thus was born the Love Tree Legacy Project, an endeavor still so young you won’t find it anywhere. It will first manifest itself in the world as an event called the Legacy Arts Project, which will likely already have occurred when this article is printed. It will be an evening of art, conversation, and performance that I will faciliwww.sfms.org

tate in an effort to explore these and other questions. Where it leads and what comes next is anybody’s guess. Conversations with funding agencies and nonprofit types mostly concluded with something like, “Well, that’s all very interesting, but don’t expect to make any money doing it.” With a fat mortgage to pay and a third kid on the way, that wasn’t exactly what I wanted to hear. But I’m moving forward anyway and trust that the way will be clear eventually.

In the meantime, I’ll do some community teaching on advance care planning, end-of-life decision making, ethical wills, and more. I’ll continue serving as a hospice doctor and will remain everfaithful to my longtime dojo relationship with Emergency Medicine. While I can imagine a life without it, living in fantasy has never really paid off so far. I’ll keep showing up in the trenches and try to have a good attitude. I keep offering to be the physician wellness champion in the ED, but mostly I just get odd looks or a polite chuckle rather than any genuine interest.

In any case, my creativity feels more alive than ever, and so I’m going to let that rip for a while, too.

Scott Schmidt is an emergency and hospice physician in Sonoma and Marin counties. He lives with his family in West Marin.

www.sfms.org

Lessons from the Bedside Continued from page 29 . . .

As medical students, our learning represent a series of firsts, where our first exposures to disease manifestations and patient encounters shape our subsequent learning, often reinforcing the concepts that were introduced during the preclinical years. Initially, we lack the ability to actively apply our knowledge in the moment, while everyone around us processes and works at a rapid pace.

We lag behind because we are constantly readjusting to new environments while relying on limited experience.

At times, the process can be numbing.

As a student, your role remains somewhat undefined. Your primary job is to take care of patients and learn medicine, in all it shades—the language, the skills, and the details of the culture. Many of us place unreasonable expectations on ourselves.

We always forget that we are nomads, traveling from one rotation to another every couple of weeks, whereas our fellow residents and attending physicians have far more extensive experience.

The uneven learning differential skews the expectations. And we remain uncertain, unprepared, and overwhelmed by the constant pressure of being evaluated. We strive for completeness and efficiency, streamlining our patient’s stories into one-sentence sound bites—the one-liners. Like a shadow, we follow our intern around, unsure where we are supposed to go. We are driven to impress our team by referring to obscure references or citing the evidence-based medicine.

In this process, many of us take on a new identity, while losing a piece of ourselves.

But no one really teaches us how to learn.

In speaking with fellow medical students, we agree that the clinical years require a great deal of relearning; we have to teach ourselves how to be self-directed learners. Aside from the occasional didactic session or presentation from the attending, we are responsible for our learning. We spend our spare moments reading and reviewing the literature. At the end of the day we remember very little, and our patients represent the best teachers. Education comes from manag-

ing our patients, even when we are just beginning to figure out the basics. ***** When we look at ourselves in our soiled and overstuffed white coats three years after beginning this journey, we can acknowledge how far we have come in such a short amount of time. We have become somewhat conversant in the medical language and familiar with the details of the medical culture. More than anything else, we have gained unique experiences that have changed us. The budding physician in us is slowly emerging.

With one year standing between me and residency, I feel frightened and excited. As I move forward, I know I will always feel unprepared. However, I will remember that my patients will continue to be the best teachers.

There are many lessons I have learned. They can be best summed as follows: Be present for your patients.

Listen to your patients.

Do what is right.

Be true to yourself Treat your patients like you would want to be treated.

Although these principles are fundamental, they are sometimes forgotten.

Such lessons have a central role in the education of medical students, but they also represent an integral part of the lifelong learning we will experience in our careers.

Eisha Zaid is a fourth-year medical student at UCSF. Winner of the 2009 David Perlman Award for Excellence in Journalism, she is also author of the blog Eisha’z Inner World at http://eishazinnerworld. blogspot.com.

September 2010 San Francisco Medicine 31

Hospital News Kaiser

Robert Mithun, MD

As medical professionals, we live and practice in a rapidly changing world, where new developments in medicine impact how we continue our education long past school.

Understanding of disease mechanisms and therapies have evolved and changed markedly over the past decade to such an extent that if we don’t actively participate in ongoing education, we run the risk of practicing outmoded care. Adopting new ways of imparting information that efficiently and meaningfully enable physicians to use their time more effectively. In 2002, the Conjoint Committee on Continuing Medical Education adopted a system of competencies (already in use in resident education) emphasizing six focus areas, including patient care, medical knowledge, practice-based learning and improvement, professionalism, and systems-based practice.

Residents and physicians increasingly maintain portfolios, documenting self-assessment and resultant continuing medical education activities to maintain their competencies. The new model of more active participation, as opposed to didactic lectures, has been shown to improve professional practice and affect health care outcomes. Kaiser Permanente’s electronic medical record system is an optimal tool to aide physicians in their continuing efforts to practice medicine at its very best. We have had great success in implementing and using this organization-wide program. In addition to our technological innovations, at Kaiser Permanente San Francisco we have residents and fellows in thirteen accredited programs, with a faculty committed to the development of those embarking on their medical careers.

The presence of these “young learners” is stimulating for the faculty and staff and helps all members of our medical teams stay on top of their game. Using technological innovations such as interactive conferences and simulation models of patient care, we continue to foster the growth and development of our medical staff throughout our careers in health care.

Saint Francis

Patricia Galamba, MD

Following years of study in medical school plus postgraduate training, the reality of survival of the entire health delivery system becomes evident when you actually begin to practice. As physician in practice for more than twenty-five years, I can say how important it was for me to align myself with a hospital that is physician-friendly and continues to provide the best environment to practice within. Saint Francis’ medical staff administration does an exceptional job of coordinating an outstanding program of lectures and workshops that provide me and my colleagues the continuing education to expand our knowledge and stay current in the ever-changing health industry.

Coined “small but mighty” by San Francisco’s EMS Medical Director John Brown, Saint Francis has grown ER capacity to support the densely populated downtown area. After SF General, our emergency room receives the second-largest number of ambulance dropoffs in the City. The hospital is well on its way to being seismically ready for the future. Our Surgical Department is in the fourth and final phase of a total remodel, with nine super-sized ORs equipped with all the state-of-the-art equipment. Next up is a complete remodel and expansion of the Bothin Burn Center beginning in this fiscal year. The Bothin Burn Center was recently chosen by the San Francisco firefighters as the recipient of donations raised at the First Annual Stair Climb held at the Transamerica Building on July 17. The Burn Center has also been chosen as the facility for the Annual Western States Burn Conference occurring in San Francisco this fall.

Saint Francis is pleased to announce our recertification of the Acute Rehabilitation Center by the Commission of Accreditation of Rehabilitation Facilities (CARF). The hospital also received recertification as a Designated Stroke Facility by the Joint Commission. These ongoing efforts, plus the deeply established relationship Saint Francis Memorial Hospital has with the city, make all the effort worth it.

32 San Francisco Medicine September 2010 33 San Francisco Medicine September

UCSF

David Eisele, MD

The practice of medicine is constantly evolving. New treatments and technologies are raising the quality and increasing the safety of care, while the “business” of health care grows in its complexity. Physicians’ education does not—and cannot—stop at the medical school door. In appreciation of this need, UCSF offers a rich Continuing Medical Education Program that provides lifelong learning opportunities for health care professionals in all areas of clinical care and research. The program provides diverse educational activities that aim to increase knowledge, attitude, and skills; enhance practice performance; and improve the health status of patients.

The content of these activities is as diverse as medicine itself. Each UCSF clinical department offers CME activities in its respective field, covering topics in modern medical practice such as public health care, primary care, and the most highly specialized clinical care.

The program also recognizes the interdisciplinary nature of medicine and targets myriad health professionals, including nurses and nurse practitioners, physician assistants, psychologists, social workers, marriage and family therapists, dieticians, and pharmacists.

In addition, UCSF is expanding its activities to address interdisciplinary and other important topics such as health disparities and cultural diversity, evidence-based medicine, physician leadership, and practice management.

UCSF leads a statewide collaborative project of the consortium of the five University of California CME programs. Through a comprehensive catalog presented by the schools in the consortium, the online portal at CMECalifornia.com offers health care professionals a single place to research course offerings and participate in lifelong learning throughout their careers. As part of a nationally recognized medical center and university, UCSF CME courses and materials attract practitioners from around the world. www.sfms.org

Hospital News Veteran’s

C. Diana Nicoll, MD, PhD, MPA

Older veterans with posttraumatic stress disorder (PTSD) appear more likely to develop dementia over a seven-year period than those without PTSD, according to a report in the June issue of Archives of General Psychiatry.

PTSD is a common psychiatric symptom and often occurs in veterans returning from combat. As many as 17 percent of veterans returning from Iraq and Afghanistan are estimated to have PTSD, and 10 to 15 percent of Vietnam veterans had PTSD symptoms fifteen years or longer after their return.

Kristine Yaffe, MD, chief of Geriatric Psychiatry at the San Francisco V.A. Medical Center, and colleagues studied 181,093 veterans aged 55 years and older (average age 68.8, 96.5 percent men) between 1997 and 2000. Of these, 53,155 had PTSD and 127,938 did not.

Over seven years of follow-up, from 2000 to 2007, 31,107 (17.2 percent) of the veterans developed dementia. Veterans with PTSD had a 10.6 percent risk of developing dementia, whereas the risk among those without dementia was 6.6 percent.

According to the authors, PTSD may contribute to the cause of dementia, or chronic stress may link the two conditions. Stress may damage the hippocampus, a brain area critical for memory and learning, or cause alterations in neurotransmitter and hormone levels that could precipitate dementia.

“The finding that PTSD is associated with a near doubling of the risk of dementia has important public health, policy, and biological implications,” the authors conclude. “It is important that those with PTSD are treated, and further investigation is needed to see whether successful treatment of PTSD may reduce the risk of adverse health outcomes, including dementia. In addition, it is critical to follow up on patients with PTSD, especially if they are of an advanced age, to screen for cognitive impairment.” www.sfms.org

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September 2010 San Francisco Medicine 33

Beyond Medical School

A Fable M. Therese Southgate, MD

O

ne day when God was creating the birds, he thought, “All the other creatures walk on the earth. I will give this one wings so that it can fly above the earth.” And so each bird had wings and it flew above the earth. It was the essence of the bird to fly. But then God said, “It is not enough for the bird merely to fly. I wish some also to sing.”

So God gave some of the birds the ability to sing, and every day at dawn and every evening at dusk the birds sang for no other reason than that it was their nature to sing. They gave no more thought to why they sang than they did to why they flew. They were birds and that is what birds did.

Then one day a little bird in the forest became aware of the beauty of his song.

He resolved that he would make his song even more beautiful until it was the most beautiful song in all the forest. And so each day, when the rustle of the leaves announced the approaching dawn, the little bird looked for a song more beautiful than the one he had sung the day before.

But each day after he had sung it he became unhappy because, although it was beautiful, it was not as beautiful as he had intended it to be. So, each day he would look for another song. Over time, he began to stop in the middle of the song he was singing because it was not as beautiful as he wished. He would try another, but after he began it he would be unable to decide if it was more beautiful than the first or not.

This was very tiring. Gradually the little bird ceased singing on those days when he could not find a song that pleased him. The silences grew until finally the little bird was not singing at all. This troubled him. If he was not singing then

that meant he was not a bird, because it was the nature of birds to sing. When the little bird realized that, he gradually began to believe that if he was no longer a bird, then it was futile even to fly. And so he also stopped flying. His wings grew weak and, finally, he was in truth no longer a bird. He had lost his birdhood.

Time passed. The little bird grew older. One day God looked down from his heaven and saw the little bird that could no longer fly nor sing. He was moved with such pity that he created new wings and a new voice for the little bird and sent his angel down to earth to deliver them. Of course, the wings could not take the little bird as high as the old ones did, nor did they allow him to swoop toward earth as swiftly as before, nor could he even soar on an air draft as long as before. But the voice was more beautiful than that of any other creature—the most beautiful sound God had ever created, the other creatures said.

The little bird sings with his new voice every day at dawn and at evening.

But he no longer wonders what song to sing nor whether it will be more beautiful than the one before. He sings the song that is given to him. He sings it because he is a bird and it is the nature of birds to sing.

Moral: Gift with the gift with which you have been gifted. (Cf. Luke 6:38b.)

For almost thirty years as cover editor of the Journal of the American Medical Association, Southgate has been selecting the front covers of JAMA and writing the highly insightful, lyrical essays, that have made her famous among physicians across the U.S. and around the world.

Over the years, she has contributed more than 700 articles, which have been

34 San Francisco Medicine September 2010

collected and appeared in book form, first in 1997 and again in 2001. In the second volume, which explores the connection between the physician and the artist, Southgate reflects, “If art reminds us of our human condition, even more so does the practice of medicine, in which we recognize that all—patient as well as caregiver— are afflicted beings . . . The very act of painting a picture signifies hope, as does the act of treating a patient. That is why patients paint and physicians practice medicine.”

A native of Detroit, Southgate received her undergraduate degree in chemistry from the College of St. Francis in Joliet, earned her MD degree from the Marquette University School of Medicine (now Medical College of Wisconsin) in 1960, and completed a rotating internship at St. Mary’s Hospital in San Francisco before joining the JAMA editorial staff in 1962.

www.sfms.org

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