september 2006

VOL.79 NO.6 SEPTEMBER 2006 $5.00

psychiatryat the

edges of life

SAN FRANCISCO MEDICINEJ O U R N A L O F T H E S A N F R A N C I S C O M E D I C A L S O C I E T Y

www.sfms.org september 2006San FranciSco Medicine�

conTenTS

San FranciSco Medicine September 2006 Volume 79, number 6Psychiatry at the edges of Life

FEATURE ARTICLES

10 Developmental Care: A Hands-on Experience in a High-Tech NICU ChrisRetajczyk,MD

12 Trauma and the Inner Life of Babies AliciaF.Lieberman,MD

14 Speaking to Children in the Language of Play PatriciaSpeier,MD

17 Double Snapshot: A Single Trauma Captured Twice in Life LenoreTerr,MD

18 Narrative Medicine DavidElkin,MD,andKhenuSingh,MD

20 Psychological Development in Late Life AllanB.Chinen,MD

22 Dying in California: The Principles and Practices of End-of-Life Care MichaelRabow,MD

24 Dealing with Death: Medical Students Reveal Their First Impressions ManishaBahl

25 Dealing with Death: Physicians Share Their Experiences KatieKelly

OF INTEREST

2� Some Thoughts about My Death DickYork

26 In My Opinion: To Be or Not To Be—Is That the Right Question? HarveyMaxChochinov,MD,PhD

27 In My Opinion: Physician Assistance-in-Dying RobertLiner,MD

�0 Film Review: The Bridge EricaGoode,MD

2� Book Review: The Girls Who Went Away NancyThomson,MD

MONTHLY COLUMNS

4 On Your Behalf

5 Upcoming SFMS Events

7 President’s Message GordonFung,MD,MPH

9 Editorial MikeDenney,MD,PhD

�2 Hospital News

�4 Classified Ads

�5 In Memoriam NancyThomson,MD

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4San FranciSco Medicineseptember 2006 www.sfms.org4San FranciSco Medicineseptember 2006 www.sfms.org

on YoUr BeHaLF

Member EventsTheMembershipMixeronAugust

24was a funandwell attended success!Newandestablishedmembersenjoyedachancetomeetandmingleinacongenialenvironmentwithlotsofgreatfood,wine,andmusic.

Thenextmembershipeventon thehorizonistheSFMSNightattheSanFran-ciscoSymphony.MarkyourcalendarsforThursday,November30.Enjoyapreconcertreceptionwithhorsd’ouevresandbeveragesandavibrantprogramofRachmaninoffandTchaikovskyconductedbyVladimirAshkenazy.Orchestraseatsare$77.00,1sttierare$67.00.Formore information,ortoordertickets,contactTheresePorterintheMembershipDepartmentat(415)561-0850,[email protected].

The Membership Department, andthephysicianmembersoftheMembershipCommittee,areactivelyexploring futureeventsandservicestobenefitSFMSmem-bers.Thenextseveralmonthsaresuretobeexciting!Asalways,memberinputandsuggestionsareappreciated.

It’s YOUR Society!TheSanFranciscoMedicalSociety

is continually looking forways tomakemembershipmoremeaningfulandvaluable.Yourfeedbackandparticipationareappreci-ated.FeelfreetocontactTheresePorter,DirectorofMembership,at(415)561-0850extension 268 or [email protected] withquestions,comments,andsuggestions.

Are You Receiving Action News? If you do not receive Action News,

ourmonthly fax/e-mailnewsletter,pleasecontacttheMedicalSocietyat(415)561-0850tobesureyourcontactinformationisup-to-date.Governor issues executive order

A sampling of activities and actions of interest to SFMS members

Banning er BillingGovernorArnoldSchwarzeneggeris-

suedanexecutiveorderinAugustdirectingtheDepartmentofManagedHealthCare(DMHC)tolimittherightofaphysiciantobillthepatientfortheremainderofthebillwhenahealthplandoesnotpaytheircharges.Thisdiscussionfocusesspecificallyonbillingbynoncontractedphysiciansinemergency roomsettings—whereneitherthe patient nor the physician has anychoice.

Whilethegovernor’sorderdidnottellthedepartmenthow toaccomplish this,theorderattacked the futureviabilityofphysicianpractices,whiledoingnothingtosolvetherealunderlyingissueoffor-profitHMOsrefusingtopayfairlyforemergencycareprovided to theirenrollees.Patientsdonotwantorexpecttobebilledbecausetheirinsurancecompaniesdon’tpayreason-ablechargesforcoveredservices.However,limitingERbillingwithoutalsoaddressingtheunderlyingissueswouldrewardfor-profitHMOsforrefusingtopayfortheirinsureds’emergencyhealthcare,givingthemafreehand topaynoncontractedphysiciansaslittleaspossibleandeliminatinganyincen-tivefortheplanstocontractwithphysiciansandcapitatedmedicalgroupsatfairrates.

TheDMHChasnowrespondedbyfil-ingproposedregulationsthatwouldpreventphysiciansfrombillingforservicesrendered,modifytheGouldcriteria,andsetupadis-puteresolutionprogram.TheregulationsarepostedontheDMHCwebsiteforreview:http://wpso.dmhc.ca.gov/regulations/#1.TheperiodforpubliccommentaryontheproposedregulationsisopenuntilOctober2,2006.Please see theabovementionedwebsitefordetails.

TheCMAisopposedtotheproposedregulationsandtheCMAlegalcounselispreparedtofighttheproposedregulationsthroughtheregulatoryprocessandsueiftheregulationsareadoptedasproposed.

CMAisalsodevelopingagrassrootscampaignandwillbeworkingwithcounty

September 2006Volume 79, number 6

Editor Mike Denney, MD, PhD

Managing Editor Amanda Denz

Copy Editor Mary VanClay

Cover Artists Ian Thomas, Cliff Sullivan, Raul Vargas

Editorial Board

Chairman Mike Denney

Obituarist Nancy Thomson

SFMS oFFicErS

President Gordon L. Fung

President-Elect Stephen E. Follansbee

Secretary Charles J. Wibbelsman

Treasurer Stephen H. Fugaro

Editor Mike Denney

Immediate Past President Alan Greenwald

SFMS Executive Staff

Executive Director Mary Lou Licwinko, JD, MHSA

Director of Public Health & Education

Steve L. Heilig, MPH

Director of Administration Posi Lyon

Director of Membership Therese Porter

CMA Trustee Robert J. Margolin

AMA Representatives

H. Hugh Vincent, Delegate

Judith L. Mates, Alternate Delegate

Judith L. Mates, AMA’s Women

Physicians Congress Governing Committee

Stephen Askin

Wade Aubry

Toni Brayer

Corey Maas

Jerome Fishgold

Alan Greenwald

Erica Goode

Board of directors

Mei-Ling E. Fong, MD

Thomas H. Lee, MD

Carolyn D. Mar, MD

Rodman S. Rogers, MD

John B. Sikorski, MD

Peter W. Sullivan, MD

John I. Umekubo, MD

Gary L. Chan, MD

George A. Fouras, MD

Jeffrey Newman, MD

Thomas J. Peitz, MD

Gretchen Gooding

Samuel Kao

Thomas Lee

Arthur Lyons

Rita Melkonian

Kathleen Unger

Kenneth Maybury

John W. Pierce, MD

Daniel M. Raybin, MD

Michael H. Siu, MD

Richard L. Caplin, MD

Lucy S. Crain, MD

Jane M. Hightower, MD

Brian J. Lewis, MD

Michael Rokeach, MD

Jordan Shlain, MD

Alan M. Teitelbaum, MD

Judith Mates

Ricki Pollycove

Jordan Shlain

Leonard Shlain

David Smith

Leo van der Reis

Stephen Walsh

notes from the Membership department

4San FranciSco Medicineseptember 2006 www.sfms.org www.sfms.org september 2006San FranciSco Medicine54San FranciSco Medicineseptember 2006 www.sfms.org

medical societies tofindphysicians foraspeakers’ bureau (which could involvemediainterviews,speakingtocommunitygroupsorwritingletterstotheeditor).Con-tactSusanBassett at (916)[email protected].

TheCMAwouldliketofindasolutionthatwilltakethepatientoutofthemiddleand requirehealthplans topay fully forERcare.Formoreinformation,seewww.calphys.org.

Blue cross continues to Spend Less than 80% of Premi-ums on Patient care

CMAreleased its thirteenthannualKnox-KeeneHealthPlanExpendituresRe-port thismonth, detailing thefinancialstatusofCalifornia’sHMOs.This year’sreportshowsthatforthefifthyearrunning,BlueCrossofCaliforniahasspentlessthan80%ofpremiumdollarsonpatientcare.Just78.9%ofitsrevenuewenttopatientcareinfiscalyear2004-2005,with21%goingtoprofitsandadministration.

“Vital patient care is being short-changedbyfor-profitHMOsthatsendever-increasingportionsofpremiums toWallStreetinsteadofspendingitonpatients,”saysCMAPresidentMichaelSexton,MD“Ifa substantialpartof theseprofitswerekept in thehealthcare system, itwouldhelpmakeCalifornianshealthier,stabilizetheendangeredemergencycaresystem,andensurethatallpatientsgetaccesstothecaretheyexpectanddeserve.”

State law requires,under theKnox-Keene Act, that no more than 15% ofinsurancecompanyrevenuesgotoadmin-istrativecosts,includingmarketing.Whentheactbecamelawin1975,theintentwastorequireinsurerstospend85%ofpremiumdirectlyonmedicalcare.Becausethevastmajorityofhealthplansatthetimewerenonprofitanditwasexpectedthatthenon-profitmodelwouldprevail,thelawdidnotincludelanguageregardingprofits.For-profithealthplanshavesinceinterpretedthistomeanthatprofitsareanexpensethatcancome fromthe85%intended forpatientcare.Inanironythatreflectstheindustryviewofhealthcare, insurancecompaniesuniversally refer towhat they spendonpatientcareas“medicalloss”andtheycallthepercentage“themedicallossratio.”

CMAthisyear sponsoredabill thatwouldhavebarredhealthplansfromspend-ing more than 15% of premium dollarscombined for profit and administration.Althoughthebill(SB1591)died,theissuehasconsiderablesupportintheLegislatureandCMAwill continue topursue suchlegislation.

Achangeinthelawwouldprovideanenormousbenefittopatientsandthehealthcare system.BlueCrossandAetnaalonecollected$12billioninpremiumsfrompa-tients.Ifjustthesetwoimmenselyprofitableinsurancecompanieswererequiredtospendanother6%onhealthcare,anadditional$720millionwouldbeavailableforpatientcareinCalifornia.

InadditiontoBlueCross,severalotherplansdonotmeetthe85%threshold.AetnaHealthCare,forinstance,spentonly78.7%ofitspremiumdollarsonpatientcare.BlueCrossinsuresmorethan4.5millionCali-fornians;Aetnafewerthan300,000.Manyhealthplansdospendatleast85percentofpremiumonpatientcare.KaiserFoundationHealthPlanscoredthehighestofthemajorplans,spending93%ofitsfundsonpatients.MolinaMedicalCenter/AmericanFamilyCare,alsonoteworthy,spent88.4%ofitsfundsonpatientcare,a5%increasefromthepreviousyear.

contract Problems with Pacifi-care and United Healthcare

Therehavebeenanumberofcallsfromphysicianmembers regardingPacifiCare/UnitedHealthcarecontracts. Theareasof concern range fromcontractnegotia-tionsandfeeschedulestoconcernsaboutcontract terminations and inappropriatenotifications topatients informing themthattheirphysicianhasnotsignedacon-tract.GiventhemagnitudeofissuesraisedbyPacifiCare/UnitedHealthcare’saggres-sivepractices,CMAhaspulled togethera“PacifiCare/UnitedHealthcareSurvivalKit.”Itcanbefoundonthegroup’swebsite,www.cmanet.org.

IfanySFMSmembersareexperiencingissueswithPacifiCare/UnitedHealthcare,they should contact CMA’s Center forEconomicServicesat(916)551-2037.

Upcoming eventsOctober13,2006CME Program: Environmental Medicine and Health UCSFLaurelHeightsAuditorium,9am-5pmFormoreinformationcontactSteveHeilig,[email protected](415)561-0850extension270.

October25,2006Beyond Zero Tolerance: New Directions in Drug Education and School DisciplineFortMasonConferenceCenterinSanFrancisco,CA8AM-4PMLandmarkBuildingACo-sponsoredbytheDrugPolicyAlliance,SanFranciscoMedicalSociety,OfficeoftheMayor,CityandCountyofSanFranciscowithMayorGavinNewsomprovidingopening remarks,SanFranciscoDepartmentofPublicHealth.Formoreinformationcall(916)608-8686.

January28-30,2007UCSF-CHE Summit on Environmental Challenges to Reproductive Health and FertilityMissionBayConferenceCenter,UCSF,SanFrancsicoThissummitwillprovideoverviewsbyleadingresearchersofscienceandenvi-ronmentalcontaminantimpactsonreproductivehealthandfertility,andwillalsoexplore:translationofthisresearchtoclinicalcareandmedicaltraining,aswellaspolicy;federalregulatoryagency/researchinstituteenvironmentalreproductivehealthpriorities;reproductivehealthpatientadvocateandcom-munityhealthconcerns,includingtheneedsofunderservedcommunities;andtheformationofpartnershipsforeffectivecollaborativeagendasandaction.ContactMaryWade formore information, (415)[email protected].

Share your voice.

When we speak as one, patients win.Doctors from all specialties need to unite more than ever before. Why? Because when we do, America’s patients benefit. Our role is to give you and those you treat a voice that will not be ignored. From stopping Medicare physician payment cuts to increasing access to care, we work together on behalf of patients. To renew or join the AMA, call the San Francisco Medical Society at (415) 561-0850.

Helping doctors help patients.

www.sfms.org september 2006San FranciSco Medicine7

Learning Something New

Gordon Fung, MD, MPH

PreSidenT’S MeSSaGe

t hethemeforthismonth’sSan Francisco Medicineis“Psy-chiatryattheEdgesofLife.”SinceIknowlittleaboutthissubject,thisisatremendousopportunityformetolearn

somethingnew.AsIsatintheeditorialboardmeetingtodevelopthisedition,Iwasstruckathowfaciletheboardmemberswerewiththistopic,andIreflecteduponmyownclinicalpracticethatmainlyaddressedpatientswithintheextremesoflife—andoccasionallyapproachingtheextremesoflife.AsIleftthemeetingIfeltveryfortunatetobeapracticingphysician,becauseI’velongfeltthatamongthegreatestjoysinthepracticeofmedicinearethelearningopportunitiesthatarestimulatingand,attimes,challenging.Whenanewdevelopmentoccursoutsideourownspecialty,wehavetheopportunitytoexpandourmindsabouttheever-growingfieldofmedicine.Nomatterwhatthetopic,learningandapplicationarekeystoasuccessful,satisfyingpracticeinmedicine.

Whileinthefirstyearofmedicalschool,wespentalotoftimememorizingnormalmetabolicpathways,anatomy,physiology,andclinicalskillssuchastalkingtoandexaminingpatients.Thiswasfollowedbyayearofdelvingintotheorganblockstolearnthepathologicalprocesses,andnextcametworigorousyearsofclinical

clerkshipsandelectivework.Thepurposeofmedicalschoolwasnottoprovideuswithalltheinformationthatwewouldneedfortherestofourmedicalcareersbuttoprovideuswithafoundationofknowledgefromwhichtobuildand,mostimportantly,instillinusasenseofinquiryandexcitementaboutconstantlearning,discovery,andinnovation.ThislaststatementisthecurrentfocusofUCSFSchoolofMedicine—tocreateacultureofinquiry,discovery,andinnovationateverylevelofmedicaleducation,fromthestudenttotheadvancedclinicalandresearchfellow.IbelievethatthiswasthegoalofthefacultywaybackwhenIwenttomedicalschool,butitwasn’taswellarticulated,andeveryfacultymemberapproachedthegoaldifferently.

Asapracticingphysician,Iameagertolearnaboutthisissue’stopic,sincemanyofmypatientsaremovingtowardtheedgesoflife.AsIlearnmoreaboutthepsychologyinvolved,IbelievethatIcanbemorehelpfultomypatientsasareferralsource.AsaclinicalfacultymemberatUCSF,I’mequallyeagertolearnmoresothatIcansharenewknowledgewiththemedicalstudents,residents,andfellowsintraining,sothatwecanallbeofgreaterassistancetoourpatients.Enjoylearning.

Why is Employment Practices Liability Insurance needed?* • Statistics show an employer is more likely to have an employment claim

than a property or general liability claim.• The average amount paid for out-of-court settlement is $40,000.• Defense of the average EPLI case, through trial, costs over $45,000.• The median compensatory award in EPLI cases is $218,000.• 67% of all employment cases that litigate result in a judgment for the plaintiff.• 10% of awards in cases involving discrimination and wrongful termination

are in excess of $1,000,000.• Six out of ten employers have faced employee lawsuits within the last five years.

Employment related suits usually involve one or more of the following: discrimination, sexualharassment, wrongful termination or workplace torts. The purpose of the SFMS program is to providemembers with the needed tools and protection generally missing from other insurance policies.

SFMS’s claims made program provides members with significant benefits: • Web based training for members, office managers and employees to help minimize exposure

to employment practices lawsuits.• Access to a legal information hotline staffed by employment practices attorneys.• Review of employee handbooks and employment applications.• Economically priced Employment Practices Liability Insurance** that provides for defense costs

and losses an insured becomes legally obligated to pay as a result of a covered claim.• Choice of policy limits of $250,000, $500,000 or $1,000,000.• Low minimum premiums.• Low per claim deductibles.• 60 day extended reporting endorsement included.

For more information on the Special First Time Buyers Program or to receive a brochure andapplication, call a Marsh Client Service Representative at 800-842-3761 or [email protected].

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* Society for Human Resource Management – 2002 ** Coverage provided by a carrier rated A by AM Best

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deParTMenT TiTLe HereMike Denney, MD, PhD

Golden Apples and Golden Halls

ediToriaL

I nNorsemythology,Idunnisthedivinegoddessofspringtimeand rebirth,andguardianofmagicgoldenapples thatcanpreventagingandguaranteeperpetualyouth.Ironically,Idunn

ismarriedtoBragi,anoldmanwithalongwhitebeard,whoisgodofpoetryandwelcomesdeceasedheroestoanafterlifeinthegoldenhallsofValhalla.ItseemsnighimpossibletoresistimaginingthatIdunnandBragi,withtheirmarriageoftheoppositesofyouthandoldage,mightsomehowfindaplaceinthisissueofSan Francisco Medicine,withitstheme“PsychiatryattheEdgesofLife.”

Psychiatrywasderivednotfromtheedgesoflifebutfromthemiddleof life—actually, frommostlymiddle-agedwomenwhowerethoughttobesufferingfromanailmentcalledhysteria. In1842,morethanfiftyyearsaftertheanimalmagnetismofMesmerhadbeendiscreditedbyacommissionoftheFrenchAcademyofSciences,theScottishphysicianJamesBraid,impressedwiththehealingqualitiesofthisphenomenon,renamedithypnotism.Thismysteriousmind-bodydynamicgainedrespectabilitywhenitwasstudiedandappliedbythefamousneurologistCharcotatSalpêtrièreHospitalinParis,where,inthelatenineteenthcentury,thousandsofwomenwerehospitalizedwithsymptomsofhypnotic poseur andadiagnosisofhysteria.

In1885,ayoungVienneseneurologistnamedSigmundFreudarrivedinParis,studiedforayearunderCharcot,systematizedthepsychosomaticaspectsofhysteria,therebyderivedthetheoryoftheunconscious,andwentontopublish Interpretation of Dreamsin1900,thusbeginningtheageofdynamicpsychiatry.

PerhapsbecauseofFreud’semphasisuponearlydevelopment,thespecialfieldofchildpsychiatrysoonemergedwiththeworkofhisdaughterAnnaFreud.ItwasrefinedbyMelanieKlein,whoelucidatedtheimportanceofthemother-childdyadinearlyin-fancyinwhatshecalled object relations.Theinterestinthespecialemotionalneedsofchildrencontinuedtogrow,andby1953theAmericanAcademyofChildandAdolescentPsychiatrywasformedtopromotediagnosis,research,andtreatment.

Psychiatryoftheelderlywaslesspromptinitsdevelopment.LydiaSicher,astudentofFreud’scontemporaryAlfredAdler,spokemorbidlyoftheindividual’srevoltagainstgrowingold,describingitasthe“panicoftheclosingdoor,”andshelikenedpsychological

agingtotheshellshockandbattlefatigueofsoldiers.CarlJungwasthefirsttoincludetheelderlypositively,withtheconceptoflifetimematurationor“individuation,”thelasttaskofwhichwastospirituallyreconcileoneselfwithaginganddeath.Thefieldofgeriatricpsychiatrygained impetus in1950,whenErikEriksondescribedeightstagesoflife,thelastofwhichwascharacterizedbyastruggleinoldagebetweenintegrityanddespair,whichcouldberesolvedbywisdomandstrengthofcharacter.TheAmericanAssociationofGeriatricPsychiatrywasfoundedin1978.

WonderingwhereourNorsedivinitiesIdunnandBragimightfindtheirplaceinthispsychiatryattheedgesoflife,wemightrecallthattheseventeenth-centuryempiricistphilosopherJohnLockepostulatedthatatbirthourmindsarea tabula rasa,anemptyslate,andthentheydevelopwithexperience.Asmodernempiricists,wemightscientificallyparaphraseLockebysayingthatwearebornwithaneocortexcontainingroughlytwentybillionneurons,andthateachoftheseneuronscanmakeasmanyasathousandcon-nections,therebyformingtwentytrillioncombinations;andthatsomeoftheselinksareinrecurrentloops,sothataninestimablezillionsofcognitivepatternsmaydevelop.Forthemindsofadults,wemightinventatermsuchastabula plena,orfullslate,andthenrecognizethatinoldagemanyoftheneuronalconnectionsmadeduringa lifetimeare, in fact,deteriorating—andwilldisappearupondeath.

ButIdunnandBragiofferusmuchmorethancognitivelinksofneurons.Thoughtheyrepresentopposites,theyare,afterall,divinelymarriedandtherebyformaunionofSpringandAutumn,youthandoldage,birthanddeath.Andfromsomewherewithinthismysteriousunionofopposites,transcendingthelinearscienceofcomplexneuronalnetworks,therespontaneouslyemergestheinexplicableexperienceofconsciousnessandthecapacitytoimag-ine.Yes,IdunnandBragioffertoourthemeofpsychiatryattheedgesoflifemuchmorethancognitivescience.Theyofferpoetry,metaphor,andasenseofsoul—fromthegoldenapplesofyouthtothegoldenhallsofValhalla.


PSYcHiaTrY aT THe edGeS oF LiFe

Developmental Care

Chris Retajczyk, MD

I n the last decade, improvements incaring forbabiesbornweeksorevenmonthsbeforetheduedatehaveled

preterm infantmortality rates to fall sig-nificantly.WhileVeryLowBirthWeight(VLBW) infants’mortality rates throughrespiratoryfailurehavebeenreduced,theincidenceofbraindamagesustainedduringthevitalearlyweeksof these infantshasremainedaboutthesame.

Ifababyweighinglessthan3.3pounds(1,500grams)atbirthsurviveshisfirstyear,hestillhasa5to10%chanceofcontractingcerebralpalsy,anda10to25%riskofsuf-feringsignificantcognitivedeficits.

ThemajorityofVLBWchildrenarenotseverelyhandicapped,butmanyhavesignificantdevelopmental or behavioralproblemsthatpreventthemfromachiev-ingaswellastheirpeers.Fewerthanhalfof VLBW children perform within theexpected range in school, andall are atriskoflaggingbehindtheirfellowstudentsin every domain of learning, includingworddecoding, reading, comprehension,arithmetic, andwrittenwork.Moreover,there is growingevidenceof impairmentamongVLBWchildreninotherdomainsofpsychologicalorneurologicaldevelopment,includingtheabilitytointeractsociallyandtoformfriendships,andtherearealsoindi-cationsthatthesechildrenaremorepronetoattentiondeficithyperactivitydisorder,orADHD.ThecumulativeeffectofalltheseproblemsisthatVLBWchildrenare3to10timesmorelikelythantheaveragenon-VLBWchildtorequirespecialhelpduringtheirprimaryeducation.

Inorder forVLBWchildren tonotjust survivebut succeed in life,wemustpaycloserattentiontotherolethatearlyenvironmentplays,especiallytheenviron-

mentoftheNICU(neonatalintensivecareunit).Severalphysicalfactorsconsistentlycorrelatetomortality:gestationalage,birthweight,gender,prematureruptureofmem-branes,maternalsepsis,andwhitematter(brain)injury.

Environmentalfactors impact neuro-developmental out-come as well. Otherstudies have focusedon family educationaland economic condi-tions.However,theroleof the early practicesandenvironmentintheNICUdeservesgreaterattention.

Putting the Family at the CenterDevelopmentalCare, alsoknownas

Family-CenteredCare, isused inNICUsacrossthecountrytoreducethestressoftheNICUexperienceonpremature,orVLBW,babies.Developmentalcare isoneof themostimportanttoolsintheNICUtomakethebaby’sstaythebestitcanbe.Hospitalsthatpracticedevelopmentalcarehaveseentheirbabiesbottle-feedsooner,gainweightmorequickly,andbedischargedsooner.

Developmentalcareseekstodecreaseenvironmentalstressorsandsupportparents’understandingoftheirinfants’behavior,inorder to facilitate theparents-infant rela-tionshipduringthehospitaladmissionandafterdischarge.

Thebrainsofbabiesbornearlyareveryimmatureandunderdevelopedwhencom-paredtobabiesbornatterm,whichisaftermorethanthirty-sevenweeks’gestation.Be-causeofthis,VLBWinfantsareill-equippedtohandlethebatteryofexternalstimulation

theyaresubjectedtoafterbirth.Althoughsomeofthisstimulationisnecessarytothebaby’ssurvival—needles,tubes,lights,andsoundsareanormalpartoflifeinahospi-tal—muchcanbedone to support these

babies and help themtobettercopewiththeirenvironment.

Thenurses in theNICU are speciallytrained in reading thebehavioral cues ofVLBWinfantsandarethereforeadeptatcus-tomizingaplanofcarefor each baby. Eachindividualizedplan isdesignedtoprovideanenvironmentthatsup-

portsthebabywhilehisorherbrainisstilldeveloping,encouragesactiveinvolvementoftheparentsinthebaby’scare,promotesthe comfort of the infant, andprovidesstrategiesfortheinfanttosuccessfullyinte-gratehisorherresponsestoenvironmentalstimuli.

Developmental Care in the NICUincludesawidevarietyofpracticesdesignedtodecreasethestressonprematurebabies,includingthefollowing:

Kangaroo Care,thepracticeofplacingthebabyonaparent’sbarechestwiththebaby’shead turned tohear theparent’sheartbeat, has been proven to reduceinfantmortality.ProvidingthespaceandquietforKangarooCarepromotesparentalbondingandcanmakeabigdifferenceinthelivesofthebabiesaswellasthelivesoftheparents.

Swaddling isanancientpractice thathasarespectedplaceinthemodernNICU.Caregiversusespecialbedding(orrolled-up

“Very Low Birth Weight (VLBW) children are 3 to 10 times more likely than the average non-VLBW child to require special help during their primary education.”

A Hands-on Experience in a High-Technology NICU


receivingblankets)topositionthebabyashewouldhavebeen in thewomb:kneescurleduptothechest,feetconfined,andarmswrappedclosetotheface.Themorecontainedthebabyis,thelowerhisstresslevelbecomes.NICUstaffcanbedirectedtowrapthebabysnuglywhendoingweightchecksormovingthebabyacrossthenurs-ery.Thiskeeps thebaby feeling safeandsecure,evenoutsidehiscrib.

Lighting and Noise Levels should bekeptlow.UnnecessarilybrightlightsintheNICUareimplicatedasacauseofRetinopa-thyofPrematurity,orROP.Ifbrightlightsarenecessaryforthestaff,adarkpieceofclothcanbeplacedoverthebaby’seyestopreventROPdamage.

Parental Involvement inall aspectsoftheirchild’sNICUstay is extremely im-portant.ThemoretheparentisabletodoforthechildintheNICU,themoretheywillfeelcomfortabledoingwhenthechildgoeshomewiththem.NICUstaffshouldbeencouraged to involve theparents indevelopinganindividualcareplanandinholding,diapering,andfeedingtheirbaby.

BecauseVLBWinfantsdiffergreatlyfrom term infants in their responses tostimuli, the educational needs of theirparents arealsounique.Parentsneed tobetaughthowtohandletheirbabiesinamanner that is comforting to the infant.Interpretingababy’sresponsestohandlingand/orstimulationcanbetrickyforeventhemostexperiencedparents.NICUparents,withthehelpoftheirbaby’snurses,tendtolearnveryquicklythelikesanddislikesoftheirparticularbaby.Parentsshouldbeencouragedtocontributetoandparticipateintheirbaby’scarewheneverpossible.

Touch—anexpandingbodyofresearchhasdocumentedtheshort-termadvantagesofgentletouchandmassageforhealthyterminfants and somegrowingandmedicallystableVLBWinfants.Thepracticeofmas-sage techniqueshasnowbeenextendedto very small, fragile newborns and haspromptedtheutilizationofnewpersonnelinNICUswhosejobitistoprovidemassagetherapyfornewborns.

Massage can elicit a wide range ofsensoryperceptionsintherecipient.Thesesensationsareamongtheearliesttodevelop

duringthebaby’stimeinthewombandul-timatelyprovidestimulation,organization,communication,andemotionalexchange.Touchprovidesthefoundationforcomplexandintimatebondingbetweentheinfantandcaregiver,providingtheinfantwithabeginninginterpretationoftheworldandtherelationshipsonwhichheorshewillcometorelyforsurvival.Eventofull-terminfants,touchisessentialinestablishinganurturing,protectiveattachmentrelation-shipbetweentheprimarycaregiverandtheinfant,whichinturnestablishesthefounda-tionforlearning,emotionregulation,andsocialinteractions.ThebenefitstoVLBWbabiescouldbeequallyprofound.

This does not mean that massageshouldbeperformedoneverybaby.Notwo babies are exactly the same. Somelovetobeheld,othersbecomeagitatedatatouch.SomearestressedoutbythenoiseintheNICU,othersrelishit.ThatiswhyanIndividualCarePlanshouldbecreatedforeachbabyandplacedateachbedsidetowarnvisitors,familymembers,andmedicalstaffofababy’sparticularstressors.

But Does It Really Work?A number of recommendations for

changes in theNICUenvironmenthavealreadybeenmadeatseveralhospitals.Themostcommonandeasiesttoachievearetoreducenoise levelsand limitexposure tobright light.Suchrecommendations,plusadditional guidelines for care inposture,physicalhandlingoftheinfant,andinter-actionwiththeparentwhileintheNICU,havebeenincorporatedinprogramssuchas theNeonatal IndividualizedDevelop-mental Care and Assessment Program(NIDCAP).

Thelong-termpositiveimpactofde-velopmentalcareonaVLBWchildisnotyetwelldocumented.ArecentsystematicreviewfromtheCochraneReviewGroupconcluded that Developmental Caredemonstratessomebenefitwithrespecttogrowthandbehavioraloutcome,decreasedrespiratory support, and lengthandcostof hospitalization. Another study, fromtheDepartmentofPediatricsatStanfordUniversitySchoolofMedicine,foundthatVLBWinfantswhoreceivedindividualizedtreatmentplansincorporatingthetenetsof

developmentalcarelaidoutaboverequiredless timeonaventilatorandstayed forashortertimeinthehospital.Moreover,thebabiesreceivingdevelopmentalcareshowedfavorableeffectsweeksafter their returnhome.Moretrialsthatincorporateshort-andlong-termevaluationareneededbeforeacause-and-effectrelationshipcanbefirmlyestablishedbetweendevelopmental careandimprovedlong-termdevelopment.

The Future of Developmental CareNeonatalhealthcareprofessionalsand

neurobehavioral specialists in theUnitedStatesandEuropehavepublishedarangeofstudiesaboutdevelopmentalcare.Un-fortunately,thereisnosystematicreviewinNICUsaboutpracticesandpoliciesregard-ingdevelopmentalcarepractices.Tofurthercomplicatethings,therearepoorscientificlinksbetween researchers fromdifferentdisciplines—neonatologists,psychologists,neurodevelopmentalspecialists,nurses,andotheralliedprofessionals—studyingearlydevelopmentalcare.

Itisclearthatdevelopmentalcarehasthepotential todramaticallychange thelives ofVLBW babies everywhere.Thechallengewillbe successfully implement-ing these techniques inanarenaofhightechnologymedicine.

Dr. Chris Retajczyk is a neonatologist with the San Francisco Neonatology Medical Group at California Pacific Medical Center. He is also the Founder and Medical Director of Pediatric Independent Contractors (www.pedicontractors.com), a hospitalist consulting group based in Northern California.



Trauma and the Inner Life of Babies

Alicia F. Lieberman, PhD

s tarting at birth, babies seekouthuman connections. From thefirsthoursaftertheyareborn,they

discriminateandresponddifferentiallytoavarietyofstimuli,preferringhumansignalsandfamiliarsights,smells,andsounds.New-bornsturntheirheadspreferentiallytowardtheirmother’ssmell,respondtovoices,andgazelongerathumanfacesthanatabstractobjects.Thesecognitiveabilitiesaresoonimbuedwithfeeling.Beforetheyarereadytocrawl,infantsarecapableofdifferentiatingamongdifferentemotions, including sad-ness,happiness,andanger,andcanmatchtoneofvoicewith theappropriate facialexpression.Inthecourseofdevelopment,babiesandyoungchildrenusetheir inte-gratedcognitiveandemotionalperceptionstodevelophypothesesabouthowtheworldworksandhowitwill treatthem,andtoguidetheirresponsesinordertomaximizeasenseofsafetyandwell-being.

Just as there are basic motivationsto loveand learnthatoperate fromearlyinfancy,therearealsotypicalanxietiesthatallchildrenmanifestfromthefirstyearoflife.Theseearlyanxietiesemergewithinapredictabletimetable.Fearofloss,expressedinseparationanxiety,beginstobeincreas-inglynoticeableatabouteightmonthsofage, gains intensitybetween twelve andeighteenmonths,andstarts todeclineasthetoddlerlearnsthatpeopleandobjectscontinue toexistwhenoutof sight andthatthebelovedparentwillreturnafteranabsence.Theprevailingquestionsorganiz-ingthechild’sinnerworldatthistimeare:“WillImeasureuptotheexpectationsofthoseI love?Doesmymomstill lovemewhenshepunishesme?Willmydadeverplaywithmeagain?”

Another normative developmental

anxiety, fearofbodydamage,overlaps intimewith the fear of losing love and ismanifested.Finally,anxietiesaboutone’sinherent goodness and the fearofbeing“bad,”whichstarttakinganexistentialim-mediacywhenthechildisaboutfouryearsold,indicatethatthechildisinternalizingasocialconscienceandbegin-ningtounderstandtherudimentsofmorality,as shown in shame,guilt, and self-blameaboutrealorperceivedinfractions.Thesefearsbecome exacerbatedwhenthechildexperi-encesstressortrauma,compoundingtheemotionalimpactoftheexternalevent.

Traumatizedyoungchildren suffer ashatteringof theirdevelopmentallybasedexpectationthattheirattachmentfigurewillprotectthemfrompainanddamage.Suchashatteringoccursregardlessofthenatureofthetrauma—whetheritconsistsofviolenceperpetratedbytheparentsthemselves(asinthecasesofphysicalabuse,sexualabuse,anddomesticviolence)orwhetheritistheproductof impersonal forces suchas caraccidents,neardrowning,intrusivemedi-calprocedures,naturaldisasters,orothersourcesofoverwhelmingfearandpainthatexacerbatetheprimordialanxietiesofinnercollapse,abandonment,lossoflove,fearofbodydamage,andmoralanxiety. In thissense, the experienceof trauma is para-digmaticofpsychopathologicalprocessesthatare triggeredby theconvergenceofemotionally taxingexternal eventswithinternalpreoccupations.

Akey factor inpredicting the long-term impactof traumaticeventsand thechild’sprognosisforrecoveryisthenatureof the child’s attachments. Children’sperceptionoftheirparents’effortstopro-

tect them—thebuildingblockofahealthy,secureattachment—is pivotalin countering the trau-matizedchild’sself-blameand loss of trust and inrestoringdevelopmentalprogress. When a childfeelsalonewiththeterrorgenerated by traumaticevents,heorsheismuchmorelikelytosufferfromlong-termmentalhealthrepercussions. Primary

carephysicians,pediatricians, andotherhealthcareproviderscanprovideimmea-surablehelptotheiryoungpatientsiftheyareawareoftheemotionalcostoftraumaticevents,whichmaylastlongafterthechildhashealedphysically,andiftheyhelptheparents understand the child’s need fortheirempathyandsupportasessentialaidsinrecovery.

Themanifestationsoftraumaticstressinyoungchildrencanbeorganizedinthreemajor symptom clusters: reexperiencingthetrauma,avoidanceofremindersofthetrauma,andhyperarousal.Thesesymptomclusters resemble theDSM-IVdiagnosisofPosttraumaticStressDisorder inolderchildrenandadults,buttheyareexpressedin age-specific behaviors. Reexperienc-ing trauma in thefirstfiveyearsof life ismanifested inposttraumaticplay, recur-rent recollectionsof theeventoutsideofplay,nightmares, distress in response toremindersofthetrauma,andepisodeswith

A Prelude to Adult Mental Health Disorders

“Just as there are basic motivations to love and learn that operate from early infancy, there are also typical anxieties that all children manifest from the first year of life.”

12San FranciSco Medicineseptember 2006 www.sfms.org www.sfms.org september 2006San FranciSco Medicine1�12San FranciSco Medicineseptember 2006 www.sfms.org

situationsthatinvolvethechild’sparentsastheperpetrators,suchasdomesticviolenceandchildabuse.Themore repeatedandpervasivethetraumaexposure,particularlywhensuchexperiencesbeginearlyinlife,themorelikelyitisthatthechildwillshowgeneralized and chronicdisturbances incognitive,social,andemotionalfunction-ingandthatthesedisturbanceswillbecomeentrenched, eventually taking the formof severe adultpsychopathology.This isparticularlythecasewhen,inadditiontothespecificimpactofthetraumaticevent,the child is negatively affected by thecompoundedimpactofadditionalriskfac-tors,suchaspoverty,communityviolence,andlackofaccesstoresourcessuchassafeneighborhoods, adequate housing, andeducationalopportunities.Children fromethnicandracialminoritybackgroundsareparticularlyaffectedduetotheconvergenceandcumulativeeffectsof thesemultiplesourcesofhardship.

TheUCSFChildTraumaResearchProjectatSanFranciscoGeneralHospitalisaprogramdedicatedtodeveloping,testing,anddisseminatingapproachestothetreat-mentofchildrenexposedtoviolenceandotherstressors.TheprogramhasdevelopedandestablishedtheefficacyofChild-ParentPsychotherapy,arelationship-basedtreat-ment inwhich thechildand theparentaretreatedtogetherinordertoimprovethequalityoftheirrelationshipfollowingatrau-maticexperience.Thetreatmentfocusesonhelpingthechildarticulatehisexperienceofthetraumaticeventandinenablingtheparenttounderstandandrespondsupport-ivelytothechild’sexperience.Thechildandparentareencouragedtoplay,draw,tellstories,readbooks,andtalkaboutfeelingswiththegoalofmakingsenseofthetrauma.Randomizedcontrolledstudieshaveshownthat this relationship-based treatment ismore effective than standard individualtreatmentinreducingsymptomsofposttrau-maticstressdisorderandothersymptomsinboththechildandthemother,andthattheimprovementpersistssixmonthsaftertheterminationoftreatment.

“Makingsenseofthetrauma”involvesseverallayersofmeaning.Firstandforemost,suchaprocessmustresultinrestoringthechild’s developmental momentum and

repairing thechild’s trust in theparent’scapacitytoprovideprotection.Inthecaseofasingletraumaticeventthatoccursinthecontextof awell-functioning familylifeandlovingandsupportiveparent-childrelationships, treatment is gearedat cor-rectingthechild’smisperceptions,enablingthe parent to understand the meaningof thechild’s symptomsasexpressionsofanxietyandfear,andfosteringparent-childactivitiesandinteractionsthatassuagethechild’sfearsandencourageareturntoage-appropriatepursuits.Inmoreseverecases,where themother and/or fathermaybeagentsofthetraumathroughinvolvementindomesticviolenceorchildmaltreatment,thetreatmentaimsatcreatingasafefamilyframework by transforming the parent’sviolent lifestyleandunpredictable,harsh,andpunitivecaregivingpractices.

Physiciansandmentalhealthproviderscanplayapivotalroleinhelpingtoprotectchildren from thedestructive impactoftrauma.Thefirst step is to recognize thepossible traumatic origins of children’sbehavioralproblemsandtoasktheparentsaboutthepossibleoccurrenceofviolenceorothertraumainthechild’slife.Thesecondstepistoadoptanattitudeofsupportandhopetowardparentswhodiscloseviolenceandtrauma.Thethirdstepistoprovideap-propriatereferralstomentalhealthprovid-ersandothersourcesofsupport.Therewardforsuchactionsistheknowledgethatonemayhavepreventedlife-longsufferingandofferedhopeforabetterfutureforthechildandthefamily.

Alicia F. Lieberman, PhD, is Professor of Medical Psychology and Vice Chair for Aca-demic Affairs in the Department of Psychiatry, UCSF. She is Director of Child Trauma Re-search Project at SFGH; Director of the Early Trauma Treatment Network; President Elect of Zero to Three: National Center for Infants, Toddlers, and Families; and author and coau-thor of several books, including TheEmotionalLifeoftheToddler (The Free Press, 1993). A trilingual, tricultural Jewish Latina, she is particularly interested in culturally competent early mental health treatment and training.

objectivefeaturesofaflashbackordissocia-tion,suchasunintentionalreenactmentsoftheevent.

Avoidance ismanifested throughaf-fectivenumbing, socialwithdrawal, andconstriction of affect, loss of previouslyacquiredskills,anddecreaseandconstric-tionofplay.Increasedarousalismanifestedinnight terrors, difficulty falling asleep,repeatednightwaking,attentiondifficultiesanddecreased concentration,hypervigi-lancetotheenvironment,andexaggeratedstartleresponse.Inaddition,youngchildrenfrequently shownewsymptoms followingexposure toa traumaticevent, includingaggression,separationanxiety,self-defeatingorprovocativebehavior,somaticproblems,andnewfears.

Tosomecaregiversandparents,chil-drenwhoengage in thesebehaviors arefrequently perceived asmanipulativeorspoiled,or ashavingbehaviorproblems.Adultstendtobelievethatyoungchildrenaretooimmaturetorememberatraumaticeventor tounderstand itsmeaning.Thismisperception, which originates in thewishtothinkof infancyasatimethatisfree fromconflict andpain, is bolsteredbytheundevelopedlinguisticskillsofthisdevelopmentalstage.Preverbalchildrenareunabletoarticulatewhattheysaw,heard,orfelt;verbaltoddlersandpreschoolersmayhave the rudimentary language to speakaboutthetraumabutmaybereluctanttodo sounless explicitly asked, for fear ofreexperiencing the terrorof theeventorupsettingtheparents,orbecausetheyblamethemselvesforwhathappened.Theinnerlifeofthechildmaybecomebifurcatedbytheknowledgethatsomethingunspeakablehappenedandthatshecannotturntotheparents forunderstandingandhelp.Thechild’ssymptomsbecomeasecretlanguagebywhichthechildexpresseswhatcannotbespokenabout,butthesymptomsoftenhave theparadoxical resultof alienatingtheparent,whomisconstrues thechild’sbehaviorassignsofwillfulness,disaffection,orworse.

Although a single traumatic event,suchasacaraccident,adogbite,oraneardrowning can have serious effects on achild’swell-being,themostdevastatingef-fectsoftraumastemfromrepeated,chronic



“From a Jungian viewpoint, children’s play stems from the natural tendency of the Self to learn, grow, and heal. Play can lose its capacity to heal, however, if it becomes restricted or blocked.”

understandbetterwhatishappening.Later,elementsoftheplaycanbeinterpretedinthemetaphoroftheplay.

Kidswilloftentrytogetme,astheirtherapist, to revealmy judgmentsbyde-mandingthatImakeuppartoftheplay.They may also try to make the play sounbearablethatmostadultswouldhaveanurge tomake the storymorepalatableormoralisticthanthestorythechildfearsto

fullytell.Byresist-ing that impulse, Ican help childrendealwiththeirfearofrevealingthedarksideoftheconflictstheyareexperienc-ing—theirhurt,an-geratthemselvesorothers,envy,hope-lessness—whateverpainfulfeelingsaretroublingormoti-vatingthem.Chil-

drenusuallyplayoutvariationsofastoryoverandover.Astheydothis,myinterestin the story,occasionalcommentsabouttheirplay, andcarefulparticipationhelpthemtodeveloptheplayfurther.Theycandeepenthepersonalitiesofthevariouschar-actersweplay,tryoutdifferentviewpointsor possibilities, and slowly resolve theirconflictsinamorereflective,constructiveway.When theydevelop the charactersintheirstory,theyaredevelopingaspectsof their own personalities. When theyresolveaconflictintheplay,theycanuseanincreasedunderstandingofthedisplacedissuetohelpresolveissuestheyfaceintheirexternalworld.

OnepatientIworkedwith,Alice,wassixyearsoldwhenshefirstpresentedtome

Speaking to Children in the Language of Play

I oftenwonderwhatcomestomindwhenparentsthinkaboutchildtherapy.MostparentsIdealwithgenerallyask,“How

areyougoingtohelpmychild?”Afterhear-ingmyresponse,theyoftenhavedifficultyunderstandingmymethods.Iusuallydon’ttalkmuch tochildrenduring therapy,oractlikeasuper-parentwhoisgoingtoin-structthem.Iusuallydon’tmedicatethemeither, thoughthereare timeswhenthatwillbeapartof theirtreatment.What Idowithchildren is play.Thereisnobetterway,Ibelieve,toreallyun-derstandtheirdynam-ics andbehavior. If Icandeeplyunderstandachild’sconflictsfromhisorherpointofview,both conscious andunconscious, then Icanhelpthatchildfeelunderstood andworkthroughhisorherdilemmas.

FromaJungianviewpoint,children’splaystemsfromthenaturaltendencyoftheSelftolearn,grow,andheal.Playcanloseitscapacitytoheal,however,ifitbecomesrestrictedorblocked.ThefirstgoalofJung-ian-orientedchildtherapyistoseewhereachild’splaymaybeblockedandtohelpreopenthechanneltotheSelfthatallowsforfullerexpression.Todothis,thetherapistbecomesapartoftheplaybuttriesnottointrudeonthedevelopingstory.Judgmentsanddirectionsaresuspended.Charactersinthestorycanbekilled,childrenareallowedtocheatatgamesorcreategameswithmon-strouslyunfairrules.Thetherapistinitiallytalksabout theplayonly to reflecton itorclarifyit,sobothpatientandtherapist

becauseshefrequentlycomplainedtohermother,overasix-monthperiod,thatshewantedtodie.Finally,shewrote,“IloveyoubutIwanttokillmyself”onabirthdaycardshegavetohermother.Thatgotherpar-ents’attention.Iadmiredtheintelligenceandintensityshehaddemonstratedindoingthis,andIwasveryconcernedabouthowdesperate she revealedherself tobewiththatcard.Itookwhatshewassayingveryseriously,but Ialso felt shehadqualitiesthatwouldhelpherfunctionverywellintherapy,whichcouldhelpherworkthroughsomeofthepainshewasexperiencing.

Whenshefirstsawme,Alicelookedatmewithdisdainandtoldme,“Idon’twanttotalktoyouandIwon’tsaywhyI’mhere.”Iagreedthatshedidn’thavetobuttoldherthatthereweresometoysinmyofficewithwhichshecouldplay.Shetoldmethatmyofficewas “boring,”butafterawhile shefoundaballandstarteddribblingit,point-edly turningaway fromme. I likedhowdeterminedshewas,andIwasimpressedbyhowwellshecoulddribbleaball—especiallyforherage.Itoldherso.Shecontinuedtopretendtoignoreme,butshedribbledwithmore focusand trieda few tricks.WhenshetriedtoturnaroundandthenreturntodribblingItoldherthatIthoughtitwasahardtricktodo.Thecommentsincreasedherpersistence.

“Icandoitmorethanonce,”shetoldme,anddiditthreetimesinarowbeforemissing. I countedeach time,which sheclearlyappreciated,althoughshedidn’tsayso.Itwasclearshewasn’tusedtothiskindofadultattention.“NowI’mgoingtodotwentyinarow,”sheturnedandtoldmeexcitedly.

“Ibetyoucan,butitwon’tbeeasy,”Itoldher.

Patricia L. Speier, MD


“Youcountforme,”shedirectedme.Ittookmanytrials.Sheinchedclosertohergoalneartheendofoursession,andwhenshefinallymadehertwentyturns,webothexultedinheraccomplishment.

Thensheturnedtomeandsaid,“Canwedothisagainnexttime?”Itoldherwecould.“Bytheway,”shesaid,“youknowI’mherebecauseIwanttokillmyself,don’tyou?”Itoldherthatherparentshadtoldmethat,but Iwanted toknowwhat shethought. “It’s true,” she said. “Ihatemy-self.”Itoldherthatfeelingthatwaymustbehard. “It is,” she toldmeasweendedoursession.

Nextsessionwereplicatedthe“dribblegame,”andthenshedecidedtoreexploremytoys.Shefoundapairofswordsandweplayedatfightingforawhile.Iwatchedherfiddlingatplayuntilshedecidedwhatshereallywantedtodo.“CanIkillyou?”sheaskedwhen Iparriedanawkward thrustshemadeatme.

“Sure,”Isaid.Immediately,sheaimedher sword at my heart and I pretendedI couldn’t stop her. She pushed at mychestwiththesword,carefullysothatshewouldn’thurtme,and I fellback, slowlygaspingwith the appropriate amountofpainandsurpriseforsomeoneabouttodie.I groanedandpretended, as realisticallyaspossible,todie.ThenIlaythereonmycouch,asstillasIcould.Mostchildrenareveryuncomfortablewith lettingme staydeadforlong;itcreatestoomuchguiltandanxiety.ButAlicewaselectrifiedbyitandstoodtherestaringatme.Afterafewveryslowminutes Iwhispered softly,withoutmoving,“Whathappensnext?”

“You can’t talk, you’re dead,” shesaid.

“Yes,I’mdead,”Iwhispered,“sowhathappensnext?”Ididn’tmakeeyecontactormovemyhead,tohelpherunderstandthat althoughmycharacterwasdead, I,her therapist,wasobserving the situationwithher.Ididn’tunderestimateherintel-ligence—sheunderstood.

“CanIchopyouup?”sheaskedexcit-edly.Herpent-upragewasrevealingitselfinthispowerfuldisplacement.

“Yes.”Myreplywasbarelyaudible.“ThenI’mgoingtocutoffyourearsand

yournoseandgougeoutyoureyes,”shesaid,

proceedingtoplaythisout.Theintensityofthemomentmadethehairsstanduponthebackofmyneck.“AndthenI’mgoingtocutoffyourhandsandputthem in yourmouthandcutoff your feetandputtheminyourears.”Theviolenceoftheseactswas fright-ening,andIfeltawaveoffear,revulsion,andsadnessatherneedtoutterlydestroyandde-grademeintheplay.Shewhisperedtome,“Can Ipullout yourteeth,too?”

“Yes,” I replied,andshepretendedtoyankthemout,oneata time, stringing themonan invisiblestrand.

“I’m making a magic necklace toprotectme,”shesaid,puttingtheinvisibletalismanaroundherneck.“NowI’llcutoutyourguts.”

“Whatwillyoudowiththem?”“I’llgivethemtothebearstoeat.”“Arethebearsmaleorfemale?”“Female.They really likeeatingyou

up.”Shepaused, then said, “Okay,we’refinishedplaying thatnow.Canwedo itagainnexttime?”Iassuredherwecould.Shethenproceededtoconfideinmehowmuchshehatedschoolandwhy,andherfeelingsoflonelinessathome.IaskedherifIcouldtalktoherparentsabouthowtohelpwiththat,andsheagreedthatIcould.

When we met the following week,sheplayedthesamestory,andforthetwoweeksthatfollowedsheplayedashortenedversionofit.Herparentstoldmeinasessionwiththemthatsheseemedmuchhappierathomeandwasdoingmuchbetteratschool.Isuggestedsomewaystheycouldspendtimeindividuallywithher.Shehadtoldmehowlittleattentionshefeltshewasgettingfromeitherofthem.

Afterthesixthtimeweplayed“beargirl,” as we named the play, Alice an-nouncedthatshewasfinishedwithit.Wehaddevelopedotherplayscenariosandcon-tinuedthese,butAlicehadfeltunderstood,andherdeepestissueshadbeenmetabolizedinthe“beargirl”storyshecreated.Shetold

me,afterwewereengaged inotherplayscenarios,thatshelikedherselfnowandnolongerwantedtokillherself.

I n J u n g i a nterms, I would saythat Alice had todealwithhernega-tive mother com-plex. Ina complextherearealwaystwofigures,andthesplitbetweenthepositiveandnegativepolesofthesefiguresneedstoberesolvedinor-der for the personto feelwhole.Themother complex

containsbothamotherandachild,andeithercanbeidealizedordevalued.Alicewas struggling toholdon to thegoodofhermotherbywishingtodestroythebadchildinherself.Thiswascreatingherself-hatred.Intheplay,sheneededtoacceptthedestructive childwithinherself anduseherragetodestroythenegativemotherinthestory.Byfeedingthatenergytothefemalebears,alsoprimalmotherfigures,shewasrecreatingamoreintegratedandtoler-able“greatmother.”Myabilitytoreceiveheraggressionand thepowerofher ragehelpedhertobearitwithinherselfandwasthefirststepinherbeingabletotransformthisenergyintosomethingshecouldutilizemorepositively.Shebeganplayingsoccer,asporthermotherloved,andthetwobondedaroundthis.Shealsobegansinging;shehadabeautifulvoiceandtookgreatjoyinshar-ingherfavoritesongswithme.Inthisway,wealsoembodiedthepositivepoleofthemothercomplex.Shecouldbelikeagoodmother,feedingmewiththenourishmentofmusic,andcouldatthesametimebethegoodandspecialdivinechild,sharingthespiritofsong.

Patricia L. Speier, MD is a Child, Ado-lescent and Adult Psychiatrist with practices in San Francisco and Berkeley. She is an Associate chinical Professor at UCSF and an Advanced Candidate at the C. G. Jung Institute, San Francisco. Dr. Speier specializes in play therapy for children and depth work with adolescents and adults.

“My ability to receive her aggression and the power of her rage helped her to bear it within herself and was the first step in her being able to transform this energy into something she could utilize more positively.”

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“As individuals reach new developmental milestones, they may find new significances in long-past events. Sometimes people can deal with these new meanings all by themselves, but sometimes they go to their physicians.”

Double Snapshot

t raumatizedchildren, ifuntreated,carry the scars of their psychictraumas into thenextphases of

childhood.A studyof twenty-sixChow-chilla,California,schoolchildrenwhowerekidnappedfromtheirbusandburiedalivein1976revealedthat,fiveyearslater,theywereeachstilltraumatized,thoughaspectsoftheirprocessingoftheeventhadchanged.The traumawas the samebut, incertaincases,themeaninghadshiftedsomewhat(Terr,1990).

Adifferentstudy,also from NorthernCalifornia,foundthataWorldWar II vet-eranat theSanFran-cisco V.A. Hospitalhad developed fearsandbehaviors relatedtothewar,somethirtyyears later. He hadnotbeendiagnosedastraumatizedduringthewaritself,butonceheenteredthelaterstagesof life, his own newphysical illnessandthe lossof significantothersprecipitated stresses related to thewar (VanDyke,Zilberg, andMcKinnon,1985).

As individuals reach new develop-mental milestones, they may find newsignificancesinlong-pastevents.Sometimespeoplecandealwiththesenewmeaningsallbythemselves.Butsometimestheygototheirphysicians,whohavetheopportunitytotakea“doublesnapshot”ofthemandoftheirinternallyrevisedmeanings.SuchisastoryfrommypracticethatoccurredinMay,1984,andMay,2006.The“picture”isfirstofatoddlerandthenofamotheroftwo.

hadfailedtoheedherpredictions;beingonfreewaysisadangerousthing;firesoccurinOklahomabecausebadOklahomans setthem;whenparentsgotojail,childrenareleftallalone.

HowdidIlearnaboutthesemeanings?In sixpsychiatric sessions,Kathleen toldthem tome.Shealsodemonstratedherideasinherplay.Forinstance,Ikeepaboxofcarsandtrucksinmyoffice.Thetoddlerpulledoutthepolicecarsandemergencyvehicles,whichthenchaseddownallthegood, “working guys” in vans and littletrucks.Thepolice, in fact,“kicked”goodguys“inthe face.”Theywerealsopoisedtothrowmudatinnocentpeople.Alittlegirldoll—Kathleen—was“supposedtotellherDaddyifthepolicecome.”Shedrewapictureofa“freeway”andtalkedaboutherfatherbeing “lonely” and in “handcups”now.

IdiscussedalltheseissueswithKath-leen.Whenwesaweachother,shevigor-ouslyplayedoutherintensefearandanger.Ialsoattemptedtogivehernewcontextswithwhichtounderstandherdisappearancefromhermom’spointofview,andfromherownaswell(inparticular,herunderstand-ingofthelossofhermother).Sherepeatedlycheckedmywaitingroomtomakesurehermotherwas still there.We talkedaboutthat,too—andaboutthecourtsandjudgeswhotrytoinsurechildren’ssafety.Then,tocorrectforthetrauma,ItaughtKathleentomakephonecallstoMomorto911fromwherevershewas.Ishowedhermotherhowtotapephonemoneyintothearchesofherchild’sshoes.AndItestifiedforKathleenincourt.HerfatherpermanentlylostcustodyofKathleen.Themotherandchildnolon-gerneededmyhelp.Ireceivedaniceletter

Kathleen,theredheadedchildofun-marriedparents,wasbroughttomeattheageofthreebyhermother,whohadrecentlytraveledtoOklahomatobringherdaugh-terbacktoCalifornia.Kathleenhadbeenstolenandhiddenfor100daysbyherdad.Abirthday,celebratingherpassage fromagetwotothree,hadcomeandgone.Ma-ternalpleastopaternalgrandparents,whohadknownexactlywhereKathleenwas,hadfallenondeafears.TheOklahomapo-

liceeventually foundyoungKathleenand,in the process, theyarrestedherfatherandthrewhiminjailwhilearrangingforthetod-dlertostayinafosterhomeuntilhermoth-ercouldcomeandgether.Foratoddlerwhohad initially lovedand depended uponhermother,theentireprocesswasanight-mare.Foramother,the change in her

ownchild—completelybeyondhercon-trol—wasanightmaretoo.NolongercouldKathleenmakegoodeyecontactwithoth-ers.Nolongercouldshecomfortablysnuggleortreathermomwithtrust.Shefearedmilk,saying itwasfilledwith “ghostess.”Shefearedfreeways,policecars,andfires.

The toddler understood her child-snatching tomean that shehadmovedwithDadtoOklahoma;Momdidn’tcareorwantheranymore;thepolicewerebad,scarypeoplewhohad tobewatchedonhighwaysandwhowouldeventuallyputgoodpeopleintojail;shehadwarnedherfatherthatthepolicewerecoming,andhe

Lenore Terr, MD

A Single Trauma Captured Twice in Life

Continued on page 21...



Narrative Medicine

t hepremiseofanarrativeapproachtomedicalcareisdeceptivelysim-ple.Allpeopleconstructacoherent

story,ornarrative,abouttheir lives.Thisnarrativeisdynamicbutself-organizing,anditchangeswithstressorsinaperson’slife.

What follows isahistoricalexampleofnarrativemedicine.AlbertEinsteinwashospitalizedwithaleakingaorticaneurysm.Surgeonsproposedtorepairtheleak,butEinstein wanted to know what possiblecomplicationsmightresult.Afterhearingaboutthepossibilityofstrokeoramputation,Einsteinrejectedhissurgeons’advice,stat-ingthathehadliveda“simplelife”andthatthepossibleadverseconsequencesofsurgerywouldnotbeinkeepingwithhissubjectivesenseofhislife—hisnarrative.Interestingly,whatwenowknowfromhisbiographersisthatEinstein’slifewasanythingbutsimple.Butthisisexactlythepoint—thatwhatisimportantisthatEinsteinviewedhislifeasuncomplicated.Hechoseanendingto itthatreflectedhisvalues.

RitaCharon,MD,PhD,haswrittenextensivelyabout thenarrativeapproachtomedicalcareandwhatsheterms“narra-tivecompetence.”AprofessorofmedicineandliteratureanddirectorofthePrograminNarrativeMedicineatColumbiaUni-versity,Charonseesparallels innarrativeapproachestobothmedicineandtolitera-ture.Specifically,hercritiqueofmedicineliesinthechangesinthefieldthathaveledclinicianstolosethetimeandskilltotrulyheartheirpatients’stories.Thusphysiciansfocusonthebiologicalprocessesaffectingtheirpatients to theexclusionofhearingtheir patients’ narratives, of suspendingtheiragendasandallowingthemselves tobedrawnintopatients’“stories”oftheirill-nesses,andhowthoseillnessesarecoherent

evenmoreadamantthatshewouldnotbe“bulliedinto”theprocedure.

Catherinedid accept a referral to apsychiatrist—me,andIquicklyscheduledanappointmentat the surgeon’sbehest.Catherinedeniedanypreviouscontactwithmentalhealthservices.Shecameacrossasabright,thoughtfulindividualwithconsider-able strengthofcharacter.Sheexplainedthatshesimplydidnotwanttobe“rushedintoanything.”

At thispoint Icouldhavechosenanumberof strategies. Icouldhave joinedwiththechorusofherphysician’svoicesinurginghertoquicklydealwithherbreastmass. I couldhaveaskedaboutpreviousunpleasantexperienceswithillnessorpriorphysicians.Instead,Ireaffirmedmyinterestinhelpingherbeempoweredtoselectthecareshefeltwasappropriate.IdecidedtoaskwhetherCatherinecouldtellmeaboutherlife.Withconsiderableenergy,shedescribedherchildhoodinanidyllicsmalltown,withmanybrothersandsistersandaclose-knitfamily.Butshebecamedowncastandangryasshedescribedheradolescence.

“Iwasbusytakingcareofmymother,”shesaid,hervoicecrackingwithemotion.She described her mother’s devastatingexperiencewithbreastcancer,andherownrole reversal as shecared forhermotherduringchemotherapy treatments.Severalyears later,whenCatherinewas sixteen,hermother’s cancer recurredandprovedunresponsivetotreatment.“Itookcareofherwhileshedied,”Catherineexplained.Shewentontodescribethemosttraumaticaspectofhermother’seventualdeath:“Twoweeks after the funeral, my father an-nouncedthathewasmarryingourneighbor.Mymother’spictureswereallputawayandnoonewouldtalkaboutheranymore.Itwas

withinthenarrativesthatformtheirlives.Values,Charonposits,areacorepart

ofthenarrativethateachpersonlivesby.Thusthenarrativeapproachisparticularlyhelpfulinhelpingpatientsmakedecisionsintimesofcrisisandshouldbeacorecom-ponentofeachphysician’sunderstandingofethicalanalysis(inadditiontothebetter-

known“mantra”ofautonomy,beneficence,nonmalificence,andjustice).Thenarrativeapproach ispatient-centeredand focuseduponthepatients’understandingof theirlives.Patientscopewithdiseaseinpartbyincorporatingtheirunderstandingoftheirillnesswithintheirownnarratives.

Hereisamorecontemporaryexample.Catherine,athirty-year-oldwoman,sched-uledanappointmentwithherprimarycarephysicianafternoticingasmallbreastlumponself-exam.Herphysicianconfirmedthemassandarrangedforasmall-needlebiopsy.However,afterthesurgeonexplainedtheprocedure toher,Catherine stated thatshewould“have to thinkaboutwhetherthiswastherighttime.”Hersurgeontriedtopush the issue, insisting thatanymasscouldprovetobebreastcancerandshouldbeevaluatedpromptly.Catherinebecame

“All people construct a coherent story, or narrative, about their lives. This narrative is dynamic but self-organizing, and it changes with stressors in a person’s life.”

David Elkin, MD, and Khenu Singh, MD


Ofcourse,narrativeapproachesshouldtriggerasimultaneousexplorationofthesto-riesofourownlivesasphysiciansandhealthcareprofessionals.Eachofuscanconsidertherootsofourinterestinmedicine.Whatdreweachofustothefield?Howdidwesurviveandbecometransformed throughourtraining,aswefoundthattheknowl-edgewewere striving toaccumulatewastransmutingintowisdomasfactscollidedwiththerealityofourclinicalexperiences?Howhavewebalancedourprofessionalidentitieswithourpersonallives?Whatareourcontinuedhopesandfearsaswestrivetopracticeourart?Surelytheunhappinessthatsomephysiciansexperiencepainfullyreflects the failure tofind theseanswers,oreventoactivelyposethequestionsthatmightallowthemtounderstandtheirdis-satisfactions.Thusnarrativeapproachestomedicalcareencourageus tohealothersevenaswebearwitnesstoourownstories,andstrivetohealourselves.

asifshehadneverexisted.”I pointed out—perhaps somewhat

obviously—thatCatherine’sownpossiblebreast cancermustbeclosely remindingherofhermother’sexperience.Moreover,her physicians’ concern andpressure toperform a biopsy and other therapeuticinterventions,ratherthanfeelinghelpfultoher,remindedhertoomuchofherfamily’spressure tomakehermother “disappear”fromthefamilynarrative.Catherineread-ilyagreed.

Interestingly,shescheduledsubsequentappointmentswithmebuthadthebiopsyperformedbythetimeshesawmeasecondtime. Fortunately, thebiopsywasnega-tive—indicatingabenignmass—but shewaseager to talkaboutheradolescence,herflightfromherfamilyinphysicaltermsbutthecontinuedstrandsofhurtandan-gerthatanchoredhertothem.Itemergedthathermother’sdeathhadleftherfeelingparalyzed,astraumaoftencan;herlifefeltasthoughshehad“becomestuck.”Shehadabandonedherplanstogotocollegeandfelt“trapped”inarelationshipthatlackedpassionandengagement,butshewasquietlyterrifiedof“beingalone.”Despiteherobvi-ousintelligenceanddesiretoconnect,shefoundherself isolatedandquitedesperatetobehealed—tohave someone to“bearwitness”toherstoryandhelpherconstructanew,viableongoingnarrative, so thatherlifecouldcontinueinawaythatgaveherthesenseofmeaningandengagementthathadbeensolackingformorethanadecade.

Iraisethesedetailstogiveasenseofthedepth that is often lurkingbeneatheachmedical encounter, a domain thatourpatientsareofteneagertoshare.Thephysician’s role is tohelppatientsbetterunderstandtheirlivesthroughanarrativesense—theidentificationofmajorthemesinourpatients’livesandourassistanceinhelping themexplorehowtheir illnessesimpact theirunderstandingof their lives,andprovidethechancetochangetheirun-derstanding.InCatherine’scase,herbreastcancer scare representednot justdanger,butthepossibilityforgrowthandchangeinherlife.Apurelybiomedicalapproachthatfailedtoacknowledgethispossibilitywasunlikelytomeetwithsuccess.

Further Reading

•Charon,Rita. “NarrativeMedicine:A Model for Empathy, Reflection,Profession,andTrust.” JAMA286(5):1897–1902.October17,2001.

• Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science. Picador:2003.

•Groopman, Jerome.The Measure of Our Days. Penguin:1998.

•Huyler,Frank.The Blood of Strangers: Stories from Emergency Medicine.Picador:2004.

•Reynolds,Richardand JohnStone.On Doctoring(thirdedition).FreePress:2001.

SethD.Ammerman,MDPediatricsCarlaAngulo-Callao,MDThePermanenteGroupInternal MedicineRosamaniD’Souza,MDThePermanenteGroupInternal MedicineRogerE.Flanigan,MDThePermanenteGroupPsychiatryKennethA.Fox,MDThePermanenteGroupNeurologyMarthaCeciliaGonzalez,MDThePermanenteGroupPediatricsJustinV.Graham,MDLumetraInfectious DiseasesMatthewHannibal,MDOrthopedic SurgeryCraigE.Hou,MDNeurologyHongT.Hua,MDThePermanenteGroupVascular SurgeryMichaelKotton,MDThePermanenteGroupRadiologyJenniferY.Lee,MDThePermanenteGroupDiagnostic Radiology

GrantStuartLipman,MDCaliforniaEmergencyPhysiciansJosephLeung,MDThePermanenteGroupInternal MedicineSreelataMaddipati,MDThePermanenteGroupAnesthesiologyCarolynE.Million,MDGeneral SurgeryTheresaM.Moore,MDThePermanenteGroupInternal MedicineEun-HaPark,MDThePermanenteGroupOphthalomology

VivianM.Reyes.MDThePermanenteGroupEmergency MedicineHootanC.Roozrokh.MDThePermanenteGroupTransplantation SurgeryBellaSeerke,MDThePermanenteGroupInternal MedicineCalvinS.So,MDThePermanenteGroupAllergy & ImmunologyJeffreyE.Thomas,MDNeurological SurgeryCheng-YangC.Tuan,MDEndocrinologyChristinaWang,MDThePermanenteGroupOccupational MedicineWeiWang,MDMedical OncologyCorinneR.Widico,MDThePermanenteGroupEmergency MedicineAngelaLiyarWong,MDThePermanenteGroupPediatricsJosephWoo,MDChineseHospitalEmergency MedicineRichardL.Xu,MDThePermanenteGroupHematologyYuwenXu,MDThePermanenteGroupFamily PracticeResidentsMatthewJ.Callaghan,MDDereckRichardJohnson,MDLuigiMaccotta,MDMedical StudentsJenniferAustinManishaBahlAnhBuiLisaChuBillyCordonGenevaBrookeDavisViamDinhSandeepKulkarniDavidStahlChristopherStoehrJoyceAnnViloriaDerekWard

TheSanFranciscoMedicalSocietywould liketowelcomethefollowingmemberswhojoinedbetweenSeptember2005andAugust2006

Welcome new Members!



any fishermen who might be caught out in the storm, as their sons had been years before. In the middle of the night, someone pounded on their door. A group of young fishermen danced and sang outside. “Thank you for saving our lives!” they exclaimed.

“What do you mean?” the old man asked. The fishermen explained that when the storm hit, they could not see where land was until the old man set out the light for them. “A light?” he asked. So they pointed. And the old man saw his fish hanging from the eaves, shining with such a great light it could be seen for miles around.

From that day on, the old man hung out the fish each evening to guide the young fisher-men home, and they shared their catch with him. And so he and his wife lived in comfort and honor the rest of their days.

Thisheartwarming storyprovides acharming metaphor about late-life psy-chologicaldevelopment.Thestorythemesarerepeatedineldertalesfromaroundtheworldandare thusanalogous toadreamthatrecursoverseveralnightstounderscoreits importance.The storyopenswithanoldmanandhiswifelivinginpovertyanddesolation,and their situationdramatizesthemultiplelosseswefearinlaterlife—ofhealth,wealth,friends,and,ultimately,life.Theoldman thenmeetsa strangerwhogiveshimabagofgold—magicreturnsun-expectedlyinthecourseofordinaryevents.Wecaninterpretthestranger’sgiftsasthereal-lifeboonsofoldage,whichweoftenoverlook.Thesegiftscanbequitepracticalorordinary,suchaswealthfromalifetimeofwork,thejoyofgrandchildren,ormoreleisureandfewerday-to-dayresponsibilities.Thegiftsmightalsobeunexpected, suchastheemergenceoflong-dormantcreativetalents,asdramatizedbyGrandmaMoses;

in the yard.The next day, the old man awoke to find

that his wife had cooked a wonderful breakfast. “Where did you find the money for all this food?” he asked her.

“You did not bring home any wood to sell, so to buy food, I sold the manure to the farmer down the road.” The old man ran out and found the gold gone. He had to work and so dragged himself back to the forest.

There he met the stranger again, who said, “I know what you did with the money, but I still want to help.” He gave the old man another purse filled with gold, and the old man ran home. Along the way he started thinking, “If I tell my wife, she will squander this fortune . . .” And so he hid the gold under the ashes in the fireplace. The next day he awoke to find his wife had cooked another hearty breakfast.

“You did not bring back any wood to sell,” she explained, “so I sold the ashes to the farmer down the road.”

The old man glumly returned to work in the forest and met the stranger a third time, who said sadly, “You are not destined to be rich, but I still want to help.” He offered the old man a large bag. “Take these frogs, and sell them in the village. Then use the money to buy the largest, freshest fish you can find!” Then the stranger vanished.

The old man sold the frogs, but once he had the money, he was tempted to buy wine, cheese, and sausage. But he finally decided to follow the stranger’s instructions, and he bought the largest, freshest fish he could find. He returned home too late in the evening to clean the fish, but since it had started to rain, he hung the fish outside from the eaves. Then he and his wife went to bed.

That night it stormed, and the old man and woman could hear the waves pounding on the shore below their home. They prayed for

Grow old along with me! The best is yet to be, the last of life, for which the first was made.

—RobertBrowning

w hile medicine traditionallyfocusesonthedeclinesofoldage,new researchhighlights

thepotential inhealthy individuals foralate-life psychological renaissance. Oneaccountof thisphenomenoncomes froma surprising source—a folktale. Handeddown over centuries, in a process likenatural selection, the stories that surviveare those that“ringtrue”overmanyerasandcontaintime-testedinsightsabouthu-mandevelopment.Mostfamiliarfolktalesareaboutchildren,like“Cinderella,”andreflect the psychology of youth. Storiesspecificallyaboutoldpeoplehavelongbeenoverlooked,buttheyareespeciallyinsightfulaboutthedevelopmentaltasksofoldage.Such“eldertales”areastonishinglysimilaracrosscultures;astoryfromItaly,“ShiningFish,”isprototypical.

Once upon a time, an old fisherman and his wife lived alone in a house on a cliff overlook-ing the sea. Years before, their three fishermen sons had drowned, leaving the couple desolate in old age. Physically unable to sail, the old man gathered fallen wood in the forest and sold it for kindling.

One day in the wilderness, he met a man with a long white beard. “I know all about your troubles,” the stranger said, “and I want to help.” He gave the old man a small bag filled with gold, and then he vanished. The old man rushed homeward, but along the way he thought, “If I tell my wife about the gold, she will waste it.” And so when he arrived at home, he hid the money under a pile of manure

Psychological Development in Late LifeAllan B. Chinen, MD


ora late-life transformation fromruthlessambition tophilanthropic inspiration,ashappenedtoJohnRockefeller.

However, the story emphasizes notwhat thegiftsmightbe,buthow tousethem. Afterreceivingthegold,theoldmanhidesthe treasurewithout tellinghiswife.Hewantstokeephisgiftsforhimself.Heactsoutof suspicionandgreedand loses thegold—twice,sowegetthemessage.Thisisacommonfairytaletheme,inwhichgreedyorbadpeoplearepunished.Whathappensnextisthussurprising.Withthethirdgift,theoldmanovercomeshisgreedandfol-lows the stranger’sadvice.Suchpersonaltransformationistheruleineldertalesbutextremelyrareinstoriesaboutyoungpeople.Here elder taleshighlight an importantmarkofmaturity—reflectingononeselfandchanging,ratherthanblamingothers.Whatcontemporaryresearchadds is thatindividualswhodoaccepttheir“shadowy”sidedowellastheyage,comparedtothosewhodonot.

Thestranger’sadvice—tobuythelarg-estfreshfishatthemarket—seemsoddandimpractical.Suchafishwouldspoilbeforetheoldcouplecouldeatitall.Infollowing

thestranger’sadvice,theoldmanillustratesanotherthemeineldertales—“crazywis-dom.”Thisisdoingsomethingthatseemsirrationalbut turnsout tobeprofoundlywise.Real-life examples range from theprosaictothesublime.Crazywisdomcanbeas simple asbecomingchildlikewithone’sgrandchildrenorasboldastakinguppoliticalprotestandcivildisobedienceforthefirsttime,thewayBenjaminSpockandVoltairedid.Manytraditionalculturesex-plicitlyencouragespiritualpursuits,butthiscanbedifficultinmodern,secularsociety.Successfulexamplesarethusdramatic:Al-fredNorthWhitehead,themathematician,turnedtotheologyinlatelife.

Theultimate endof a late-life gift,however, isnotpersonal illumination,asthe storyquicklygoeson to show.Afterbuyingthelargestfishhecanfind,theoldman returnshomeandhangs it outsidefromtheeaves.Doingsoiscrazywisdom,becausethefishmightbestolenoreatenbyanimals.Theact,however,underscoresthefactthattheoldmanhastranscendedhisgreed,suspiciousness,andegocentricity.Henolongertriestohoardthestranger’sgiftsforhimself; insteadhe symbolicallyoffers

thefishtotheworld.Thefish-beaconsavesthelivesofsev-

eralyoungfishermen,introducingthefinalthemeineldertales:Theoldmanbringsmagicintotheworldforthebenefitofthenextgeneration.ThisiswhatErikEriksoncalledgenerativity,thelasttaskinthelifecycle.Whateldertalesunderscoreisthatgenerativityisultimatelyaspiritualtask.Itisnotamatterofgivingadvice,butbeinganexample,abeacon.

Besidesshowingwhatlate-lifedevelop-ment involves, stories like “TheShiningFish”helpusgetthere—ifweputourselvesinthestory.Forexample,wecanaskour-selvesquestions:Whenhave Ihiddenapreciousgiftunderapileofmanure?WhatgiftofgoldhaveIsquanderedinmylife?Whatistheshiningfishinmylife?HaveIofferedittotheworldyet?

In youth tales, a magical, wise oldmanorwomantypicallyrescuestheyoungprotagonist.“TheShiningFish”showshowtheelder gains the “magic” andwisdomthrough thedevelopmental tasksof laterlifeinajourneybeyondtheselfandtowardtheilluminationofsociety.

happilywithacomputerengineer.TheysharedahousewithKathleen’smother,whowouldsoonberetiringfromacareerasaparalegalinalargelawoffice.Oncesheretired,“Mom”wouldmovetoanocean-sidetown,adreamshehadcherishedallofherlife.

SoIaskedKathleenaboutherchild-snatch-ing,nowthatshewasanadult.Allofherfearsofpolice,offreeways,ofghosts,offireshadresolved,shesaid.Butonceinawhile,sheconfessed,shefeltasenseofgeneralizedpanic.Andshedidn’tlike the feeling engenderedby “cars passingme.”Sherealizedthattheoriginalsourceofherproblemshadbeenher father’s insistenceoncontrol,nothermother’scoldheartedabandon-ment.Asamatteroffact,Kathleen’sfatherhadcontactedherwhensheturnedtwenty-oneandhadattempted to speakwithher, apparentlyanglingtowardgettingbackintoKathleen’slife.Sheabsolutelyrefused.Infact,shewentsofarastotakeoutarestrainingorderonhim,andtolearnwherehelivedsoshecouldstayoutofhisway.Otherthanherpanicandfather-avoidance,didKathleenhavefurthersignsoftheeffectof

describingKathleen’sprogress,butbeyondthatIheardnothing.

InMay,2006,amotherandchildcametomyoffice for treatmentof the seven-year-old girl’s obsessive-compulsivedisorder.Theproblemwasprobablyageneticone, comingdownthrough the father’s family.RedheadedLaurawasafraidofschoolbathroomsbecauseofsmellsanddirt.Stayingoutofthebathroomswasleadingtourinarytractinfectionsandintenseurethralirritation.Apsychiatristlistedonthefamily’sinsuranceplanhadofferedsixmonthsoftreatmentwithaselectiveserotoninreuptakeinhibitor,anacceptableenoughthoughmini-malistplan.ButLaura’smominsistedinsteadonbringinghertome.“Can’tyoutalkandplayitout—thewayyoudidwhenmydadkidnappedmetoOklahoma?”

Here, I realized,wasKathleen—nowthetwenty-five-year-oldmotherofaseven-year-oldgirlandathree-year-oldboy!Shewasabouttograduatecollegewithabachelor’sdegreeinearlychilddevelopment.Shehadmarriedyoungbut

her100-day, toddler-ageordeal?Well, ratherthandrawingcompleteconclusions, I’llnotethat“livingwithMom”attwenty-fivemaynotnecessarilybeanentirelyeconomicdecision,andacollegedegreein“earlychildhoodstudies”isnotentirelycoincidentalforanearly-childhoodtraumavictim.

Do treated children carry scars too?Ofcoursetheydo.Thejobofthoseworkinginchild/adolescentpsychiatryistominimizethescars,toplanethemdownsothattheydonotdisfigureorinterferewithfunction.That’sall.

I was pleased with the adult I viewedthroughmypsychiatriclens.Herlookandherfunctionwerejustfine.AsforlittleLaura,shehashad four sessions so far—nomedicationsafterall—andshe’susingtheschoolbathroomsnowandquicklylearningthatbeing“interesting”is farpreferable tobeing “perfect.”Laurawasfascinatedwithhermom’sstory,andshethinksthattheideaoftapingphonemoneyintoshoesmightbegoodforhertoo.

Double Snapshot: Continued from page 17...



Dying in California

Michael Rabow, MD

BoardofHospiceandPalliativeMedicine.Notably,palliativecarewillsoonbeformallyrecognizedas amedical specialtyby theAmericanBoardofMedicalSpecialties.

Hope for the Best, Prepare for the Worst

Whiletheconceptofa“gooddeath”hadsomepopularityintherecentpast,mostpeoplewhohavelostalovedonerecognizethatdeathisrarely,ifever,“good.”Instead,expertend-of-lifecareworkstomaximizethequalityof life forpatients and theirfamiliesduringatragicperiodoflife.End-of-lifecareusesa“bio-psycho-socio-spiritual”approach,attendingtoalldomainsofper-sonhood,includingthephysical,emotional,interpersonal,andspiritual.End-of-lifecareismeanttobecomprehensiveandseekstoaddresstheconcernsofpatientsandtheirlovedones.Althoughpainmanagementisoftenafocusinend-of-lifecare,dyingisnotexclusivelyorevenprimarilyabiomedicalevent.Itisanintimatepersonalexperiencewithprofoundpsychological,interpersonal,andexistentialmeanings.Formanypeopleattheendoflife,theprospectofimpendingdeath stimulatesadeepandurgentassess-mentof their identity, thequalityof theirrelationships,andthemeaningandpurposeoftheirexistence.

End-of-lifecare is typicallyprovidedbyaninterdisciplinaryteamofclinicians,including a physician,nurse, and socialworker.Pharmacists and chaplains lendparticularexpertise thatmayaddress theprimary need of a particular patient orfamily.Otherdisciplinesthatmaybepartof the team includepsychologists;musicthanatologists; art therapists; physical,occupational,or rehabilitation therapists;nursingassistants;andlayvolunteers.

carephysicianconsultation.In2004,23%ofCaliforniahospitalsofferedpalliativecare,althoughthenationalaveragewas25%.ArecentreportstatedthatCaliforniahospitalswerelesslikelythanthoseinNewEnglandtohavepalliativecareprograms.

Basedondata fromtheU.S.CensusBureauandtheCaliforniaDepartmentof

HealthServices,Californiaphysicianscareforapproximately10%ofthe2.4millionpeoplewhodieintheUnitedStatesannu-ally.However,mostCaliforniaphysiciansdidnothaveend-of-life care training inmedical schoolor residency. It isnowarequirementformedicalschoolsnationallyandforanincreasingnumberofresidencyprograms. Importantly,California isoneofaboutahalfdozenstatesnationallythatrequirephysicians tohave some traininginpainmanagementandend-of-lifecare(CaliforniaAB487legislation).Therearenearly200CaliforniaphysicianscertifiedaspalliativecareexpertsbytheAmerican

e nd-of-lifecare isprovided topa-tientsinthelastdays,weeks,andmonths of life. End-of-life care

generallyfocusesentirelyonsymptomreliefandqualityoflife,ratherthanattemptingtocurediseaseorforestalldeath.Hospiceisoneexampleofend-of-lifecare,providingcom-prehensivecareinhomesorinstitutionstopatientsexpectedtodiewithinsixmonths.Butonlyaboutone-quarterofdyingpatientsenrollinhospiceattheendoflife.Palliative careisamoregeneraltermforcarefocusedonsymptommanagementandqualityoflife,anditmayoccurconcurrentlywithcurativecareormaybethesolefocusofcare,asinend-of-lifecare.

Althoughmanypatientsandcliniciansassociateend-of-lifecarewithcancer,theprognosis from severeheartdisease (thenumber-onecauseofdeathinCalifornia)maybeaspoorasorworsethantheprogno-sisassociatedwithacancer(thenumber-twocauseofdeathinCalifornia).Californiansdiefrombothterminalandseriouschronicillness, suggesting that the distinctionbetweenthesetwotermsmaybeartificial.Thechallengeisthatseriouschronicillnessusuallyfollowsamuchmorevariablepathtodeath,and itsprognosis ismuchmoredifficulttopredictthanthatofmetastaticcancer.Forexample,inalargeclinicaltrialofpatientsinthelastmonthsoflife,patientswithadvancedcongestiveheartfailurehadthesamestatisticalchanceofdyingthenextdayastheydidofdyinginsixmonths.

The Demographics of End-of-Life Care in California

MostCaliforniansdieinhospitalsandlong-termcarefacilities.However,onlyaminorityofCaliforniahospitals providepalliativecare services, suchaspalliative

“While the concept of a ‘good death’ had some popularity in the recent past, most people who have lost a loved one recognize that death is rarely, if ever, ‘good.’ Instead, expert end-of-life care works to maximize the quality of life for patients and their families during a tragic period of life.”

The Principles and Practice of End-of-Life Care

22San FranciSco Medicineseptember 2006 www.sfms.org www.sfms.org september 2006San FranciSco Medicine2�22San FranciSco Medicineseptember 2006 www.sfms.org

Integraltoend-of-lifecareisafocusonpatient-centeredcommunication.Excel-lentend-of-lifecareempowerspatientstoparticipateindecisionmakingandtoplanproactivelyforcontingenciesasillnesspro-gresses,inawaythatisconsistentwiththeirvalues.Thisprocess iscalledadvance care planningandincludes,butisnotlimitedto,appointingasurrogatedecisionmakerandcompletinganadvancedirectivedocument.End-of-lifecareworkstoidentifyandhonorpatients’owngoalsforcare.

End-of-life care continues throughthedeathofthepatient,includingsupporttothefamilyduringbereavement.Qualityend-of-lifecareisintegratedacrossallcaresettings,includinghome,hospital,nursinghomes,andhospices.

Forphysicians,end-of-lifecarepresentsbothchallengesandopportunities.Workingwithdyingpatients requires theability totolerateuncertainty, ambiguity, andexis-tentialconcern.Cliniciansmust recognizeandrespecttheirownlimitationsandattendtotheirownneedsinordertoavoidbeingoverburdenedoroverlydistressed.On theotherhand,manycliniciansfindcaringforpatientsattheendoflifetobeoneofthemostrewardingaspectsofpractice.Engagedinsuchcare,manyphysiciansfindadepthofmeaning,thepotentialforintimateinterper-sonalconnection,andalastingsatisfactionthat is sometimesmissingfromotherareasoftheirwork.

Dr. Michael Rabow is an Associate Pro-fessor of Clinical Medicine, Division of General Internal Medicine, UCSF. Board-certified in Internal Medicine and Hospice and Palliative Care, Dr. Rabow is an attending physician on the medical wards at Moffitt-Long Hospital. He directs the Symptom Management Service at the UCSF Comprehensive Cancer Center. Dr. Rabow has an active outpatient primary-care medicine practice at UCSF/Mount Zion. He is also an assistant editor for a bimonthly section in JAMA entitled “Perspectives on Care at the Close of Life” and is a Faculty Scholar in the Soros Foundation Project on Death in America. He serves as the Director of the Center for the Study of the Healer’s Art at the Institute for the Study of Health and Illness.

By Dick York, patientAs a successful real estate developer, it’s a normal day. Lots of calls, decisions,

plans—plans for the future. Then the phone rings. Doctor tells me that my biopsy is posi-tive for melanoma. More tests, surgery, more tests. Answers that no one wants to hear. But guess who just won the SuperLotto for dying?

Initial reaction: fear, anxiety. Like the usual reaction to a new real estate development project—profits, losses, possible bankruptcy. Walk the tightrope long enough and you come to relish the adrenalin rush. Otherwise you would have become realistic years ago and gotten a real job. I never became realistic. I just continued to “walk away from another successful project.” Got to admit, I have been an adrenaline junkie for most of my 72 years.

After the fateful phone call, I realize that I’m getting a fantastic new opportunity. Wow, I get to do what no one still alive has done. I certainly never died before. Is there an instruction book? A Dying for Dummies” book? Can a novice do it without being awkward? Do you need a lubricant? Do you need to organize it? To organize, you need lists: advantages, disadvantages, knowns, unknowns.

Advantages: You do not need a permit. You do not have to go through a review process, attend endless meetings, or obtain an Environmental Impact Report. You do not have to stand in line.

Disadvantage: You are no longer allowed to participate in life, love, friends, or relationships, at least as we know them.

Knowns: It’s a new adventure, another project. I am allowed to do this thing that no one living has yet done. (Of course, it’s equal opportunity employment—we all get our turn.)

Unknowns: What happens after you die? Who knows for sure? Maybe you just walk away from another successful project. Just hope I don’t get stuck with seventy-two virgins.

Some Thoughts about My Death



o neofNeilSachs’first andmostpoignantexperienceswithdeathoccurred during his third-year

internal medicine clerkship. Sachs wasinvolved in the care of an elderlyChi-nese-speakingwomanwhohadcontractedtuberculosisthat, forreasonsunknowntothemedicalteam,hadn’tresolveddespiteaggressive treatment.Sachscared for thepatientformorethanonemonth,growingincreasinglyfrustratedaboutherconditionandthecommunicationbarriersthatweak-enedtheirrelationship.Herdeathdeeplysaddenedhim,especiallybecause“shehadenduredsomuchsufferingandhadbeensoisolatedforthelastfewweeksofherlife.”Sachsneededmorethan justhismedicalteam’sbriefacknowledgmentofherdeathtocometotermswithwhathadhappened,soheturnedtofriendstohelpprocesshisthoughtsandemotions.

Medicalstudentsbegintheirclerkshipsfullyequippedtodiagnoseandtreatdiseasebut often feel inadequately prepared tofacedeathandtocommunicatewithdyingpatientsandtheirfamilies.Infact,thelit-eratureonmedicaleducationsuggeststhatmedicalschoolcurriculatendtofocusex-clusivelyondiseasediagnosisandtreatment,whilepayinglittleattentiontoeducationaboutend-of-lifeissuesandpalliativecare.Giventhelackofstudenttraininginthisarea,howdomedicalstudentsenvisionthedyingprocess,relatetopatientsandtheirfamilies,andconfront theirowngrievingprocesswhenpatientsdie?

Whilemoststudentsbegintheirthird-yearclerkshipswiththebeliefthatdeathisalwaysanegativeoutcome,somelearntoviewcertaindeathsas“gooddeaths”whentheyareconductedinthemannerdesiredbypatientsandtheirfamilies.ForAlexKeedy,

Dealing with Death

Manisha Bahl UCSF Second-Year Medical Student

therealizationthatsomepeopleaccepttheirdyingwithgraceandpeacefulnessoccurredattheendofhisthird-yearclerkship.Keedywasinvolvedinthecareofanelderlymanwhohadcometothehospitalwithjaun-dice.AfterundergoingadiagnosticERCP,whichrevealedanaggressivemalignancy,thepatientrefusedany furtherdiagnosticortherapeuticprocedures.Hepassedawayshortlythereafter.Intalkingwiththepa-tientshortlybeforehisdeath,Keedyfoundhim tobe surprisingly contentwith thelonglifehehadlivedandfullypreparedtoembracedeath.

“Hewascomfortableandwasn’tscaredofdeath,”saysKeedy.“Ifhewasn’tscared,Ithought,whyshouldIbe?”

Studentsmayalsobemorepsycho-logicallyandemotionallyaffectedbydeathsamongpatientsintheiragegroup,oramongpatients who remind them of personalexperienceswithloss.Keedy,forexample,foundhisexperiencewithayoungmanwhocommitted suicideparticularlydifficult tohandlebecauseof their similarity inage.ForKelliBarbour,interactingwithayoungwomanwhohadmiscarriedwasparticularlydifficultbecauseofhermother’sexperienceswithmiscarriage.

“Iknewthat Ihad tomake senseofthisformyself,andsoItooktimetothinkthroughit,”saysBarbour.“Icouldn’tsolvetheproblem,butIcouldhelp,andIhelpedinthewaythatIwantedmymothertohavebeenhelped.”

Studentsuseseveralcopingstrategieswheninteractingwithdyingpatientsandtheirfamiliesorwhenfacedwithapatient’sdeath.Whilesomeusewritingandprayer,mostcopebydiscussingexperienceswithfriends,allowingthemtoprocessthoughtsand emotions without worrying about

academicevaluation.For some students,sittingwithpatientsand their families isitself therapeutic.Often, additional sup-portisavailablethroughacademicadvisors,facultymentors,andschool-widecounselingservices.

Althoughsomemedicalstudentslearnaboutend-of-lifeissuesandpalliativecarethroughdidactic lectures,particularly inelectivepalliative care clerkships,manyrelyonrole-modelingbyattendingphysi-ciansandresidentsastheprimarymethodofteaching.Duringhisfourth-yearelectiveclerkshiponpalliativecare,ByronTaylorobservedanattendingphysiciancommu-nicatewithaterminallyillelderlypatientandhisfamily,allofwhomwerestrugglingtoacceptthepossibilityofdeath.“Thephy-sician’scommunicationskills,hisopennesstohearingbothsidesfully,andhisabilitytolistentoandunderstandthegapsintheirunderstandingallowedthepatientandhisfamilytocometotermswithdeath,”Taylornoted.Throughthephysician’sattitudeandbehavior,Taylorbelieveshelearnedhowtofocusontheimportanceofcareratherthancureandtoredefinesuccessfulinterventioninthecontextofdying.

Withlimitedtrainingandexperience,it is understandable that students oftenfeel fearful, anxious,andhesitant to facedeathandtointeractwithdyingpatientsandtheirfamilies,butthisdiscomfortandanxietywilllikelylessenwithexperience.Dealingwithdeathduringmedicaltrainingcanteachstudentstobecompassionate,toconsiderqualityinsteadofquantityoflife,and,ultimately,togrowasindividualsandphysicians.

Medical Students Reveal Their First Impressions



p icture the following scene: Afifty-year-oldmandyingfromcoloncancerscreamsoutinpainregularly

atthehospitalinwhichyouwork.Asyoupasshisroom,thesmellofnecrotictissueemanatingfromhisroomisoverpowering.Heseesnovisitors.Youwonderwhetherhehasanyfamilyorfriendsleft,orifthefamilyhedoeshaveisavoidinghim.Youthink,“Nooneshoulddielikethis….”

ThatiswhatwentthroughDr.Dan-ielThwaites’mindashe recounted thismemoryfromhisfirstyearinresidencyatSFGH.“DeepdownIvowedthatIwoulddoeverythinginmypowertorelievethiskind of suffering,” says Thwaites. “Suf-fering fromphysicalpain, suffering fromemotionalpain—asnoonecouldgetnearthisman—andthespiritual sufferingoneexperienceswhenfacingdeath.”

NowtheAssociateMedicalDirectorattheModestoCommunityHospice,Inc.,Thwaiteshastheopportunitytoaddresstheaboveetiologiesofsufferingonadailybasis.However,hereflectsthatmakinglife-and-deathdecisionsforotherscanleadto“anger,fatigue,and,attimes,greatanguish.”

How do medical professionals pro-tectthemselvesfromsuchfeelings?Manyphysicians feel thatacknowledgmentandthenacceptanceofanyfeelingsthatarisefromdealingwithdeath isof theutmostimportance.And,whileitisimportanttodoeverythingpossible forapatient, it isimportant to realizeandacceptpersonallimitations—bothasadoctorandasahu-manbeing.

Whenaskedaboutwhathelpsmostincopingwiththedeathofhispatients,Dr.DanielPound,MedicalDirectorofUCSFLakesideSeniorMedicalCenter,advises,“Acknowledgewhat you feel.Talkwith

Dealing with Death

Katie Kelly UCSF Second-Year Medical Student

otherpeopleabouttheemotionsyoufeel,especiallywhenadeathhasaffectedyouinanunusualway.”

Dr. Thwaites comments similarly,“Beingadoctordoesnotprotectmefrombeingsadorangry.Irealizethatthisispartoftheprocess,andwhathelpsmeistofirstacknowledge the feelingand then,moreimportantly,tonotdiscountorignoreit.”

Certain challenges, such as lack oftime, training,and resources,often resultinaskingaphysician,anordinaryhumanbeing,totranscendsuchfeelings.Further-more,manystudentsentermedicalschoolunderstanding that they will gain theresourcesnecessary tomakeadifferencewhereotherscannot.Uponrealizingthatthis“difference”canbelimited,especiallywhendealingwithaterminalillness,manyphysiciansfindthemselvesinanunfamiliaranduncomfortablesituation.

“ThissenseofburdenseemedgreatestwhenIwasaresidentorhadjustfinishedresidency,sinceIfeltinexperiencedorun-certain,”saidPound.“Ihavesimilarfeelingslessoftennow,becauseIrealizethatasingledecisionbyasingledoctorisnottheonlyfactorthataffectssomeone’slifeordeath.”

Yetatsomepoint,allphysiciansrealizethatcurrentknowledge isnotenough tosaveallpatients.Althoughthisinadequacycanproducefeelingsofhelplessnessinpeo-ple,somefindstrengthandconfidenceinunderstandingthatcuringsomeone’sdiseaseisnottheonlywaytotreatapatient.

Dr.MichaelRabow,DirectorofSymp-tomManagementService,UCSFCompre-hensiveCancerCenter,saidthathelearnedavaluablelessonduringhisresidencyintheCCUontheimportanceofbeingpresentwithpatientsduringtheirlastmoments.

“Iwastooscaredofhisdyingtomove

totheheadofhisbedtofacehimdirectly,tosaygood-bye,”saysRabowofonepatient.“Theexperienceleftmefeelinglikeafailure,notatmedicinebutatbeinghuman.Sincethen,I’verememberedhimwheneverthereisanopportunitytosaygood-byetoapa-tientwhoisdying.Italwaysfeelslikeabitofcourageisnecessarytostanduponbehalfofthelivingandbearwitnesstosomeonedy-ing.Sincethen,I’veneveragaindealtwithmyfearofafarewellbystayingaway.”

Experienceswithdeath can inspirepeopletotakeactionaswellasevokeanddeveloppersonalqualities thatmanyareproudof.Rabow’smemoryprovidednotonlyinspirationonhowhewantedtotreatfuturepatients,but also toarticulatehisexperiencesinpoetry:

Physicians Share Their Experiences

Grace UndoneThere is always a first dying patient that means the

world to a young doctor. Mine was named Grace.

Yesterday, June became the most recent one. But in my heart, they are all named Grace.

Syringomyelia?Years ago I excused myself in the middle to look it up

the first time I met her.Yesterday I had to press right up to her lips to hear her failing voice as she asked when she could no longer

wipe herself would I help her end her life?And although I had taught about this very topic in class the week before, I did not know what to say.

At the end of our visit, I leaned forward even further and hugged her.

I felt the bones in her back and her left arm hanging limp at her side, and her right arm spastic and strug-

gling to reach around to hug me back. And hugging, I did not want to let her go.

—M. Rabow



theimportanceofexistentialconsiderations,suchaslossofdignity,lackofcontrol,lossofsenseofmeaningorpurpose,andasensethatonehasbecomeaburdentoothers.

Intheseparticularwaysthen,thedyingandthelivingmaynotbesodissimilar.Withoutasenseofpurpose,meaningorbeingvalued—allsubsumedwithinwhatwehavecoineda“dignity-con-servingmodelofcare”—whosewilltolivemightnotbeinjeopardy?EventheHemlockSocietyhasconceded,“Ifmostindividualswithaterminalillnessweretreatedthisway[accordingtothedignity-conservingmodelofcare],theincentivetoendtheirliveswouldbegreatlyreduced.”

Fornow,palliativecareprofessionalswillcontinuetobecoaxedintoweighinginontheissueofphysician-assistedsuicide—tobeornottobe.Thereasonfortheirhesitation,however,shouldnowbetransparent.

They are tactfully trying to shift thequestion tohow tohelppeoplelivethebestandfullestqualityoflifepossible.Inalllikelihood,inspiteoftheverybestthatpalliativecarecanoffer,therewillalwaysbeatinyminorityofpatientswhowillpushfordeath-hasteningoptions.Findingcompassionateandmoralwaystoaddresstheirneedswillremainachallengeforpolicy-makersandcaregiversalike.

Harvey Max Chochinov, MD, PhD, is the Canada Research Chair in Palliative Care, Director of the Manitoba Palliative Care Research Unit at CancerCare Manitoba, and Professor of Psychiatry at the University of Manitoba.

Reprintedwithpermission fromCURE: Cancer Updates, Research, & Education. CURE providesthelatestincancerinfor-mationforpatientsandtheircaregivers,freeofcharge.TosignupforCURE,gotowww.curetoday.com.

November4-5,2006,SanDiego,CACURE Patient & Survivor forum Joincancerpatients,survivors,andcaregiversfromaroundthecountry.PresentedbyCURE:CancerUpdates,Research&Education,theforumisdesignencouragesattendeestointeractwithnationallyrecognizedcancerexpertsinsmallgroupsettingsaswellasthoseinthecancercommunitywhoseexpertiseiscomplementarytotherapiesandpsychosocialissues.Formoreinformationgotowww.curetoday.comorcall(888)949-0045.

To Be or Not To Be: Is That the Right Question? Harvey Max Chochinov, MD, PhD

L ikesomanypeoplewhoworkinpalliativecare,Iamfre-quently,thoughreluctantly,drawnintoconversationsabouteuthanasia andassisted suicide.There is anassumption

somehowthatknowinghowtocareforpeopleneartheendoflifeconfersexpertiseontherightsofpatientstoseekoutahasteneddeath.BecauseIdoresearchandpublishstudiesthattrytounder-standthepsychologicallandscapeofpeoplewithlife-threateningillnesses,myphoneringswheneverthemediafeaturessomeonerequestingphysician-hasteneddeath,orwhentherearerumblingsaboutachallengeinthelegislativestatusquo.

Foryearsnow,ourresearchgrouphasbeenstudyingthewholenotionofwhatitmeanstomaintaindignityinthefaceofalife-threateningorlife-limitingillness.Andnosurprise,myphoneringsmorethanever.Theterm dignity,afterall,hasbecomesynonymouswiththeright-to-diemovement,thekeyplatformofwhichisthattheabilitytoendone’slifeatachosentimeaffordstheultimatedignity.Intheircontinuedefforttopromotesocialpoliciesthatincludeeuthanasiaandphysician-assistedsuicide,itisworthaskingifproponentsofthismovementarepushingustowardorawayfromthemostpressingquestionsfacingpalliativecaretoday.

Take foramomentthe issueofhungerand imaginebeingaskedtofocusyourattentiononhowtosuppressappetiteinpeoplewhoarestarving,ratherthanengagingthequestionofhowtofeedthem.Inviewoftheproblem,thesolutionwouldseem,puttingitdiplomatically,offthemark.Asfortherighttodie(notsomucharight,butratheraphysiologicalobligation),Ithinkthemostin-triguingquestionsrelatetothemyriadfactorsthatinfluenceasickperson’sdesiretogoonliving.Nodoubt,athoroughandhonestexaminationofthesequestionsinformshowtoprovidebettercareforthedying,whileofferingimportantlessonsfortheliving.

Studyafterstudyhasshownanassociationbetweenalossofwilltoliveanduncontrolledpain,inadequatesocialsupport,andpsychologicaldistress.Ourmorerecentstudieshavealsopointedto

in MY oPinion

reminder: Physicians Must complete Pain cMe by end of Year

California lawrequiresphysicians tocomplete twelvehoursofcontinuingmedicaleducation(CME)inpainmanagementandthecareofterminallyillanddyingpatients.PhysicianshaveuntilDecem-ber31tosatisfythisrequirement.DoctorslicensedinCaliforniaafter2002havefouryearsfromthedateoflicensuretocompletetheCMErequirement.


awomanwhoisdyingfromovariancancer.Supposeallattemptsatcurehavebeenexhausted.Yourpatienthashospicecare.Shehasbenefitedfromthebestpossiblepalliationofsymptomsrelatedtotheprogressionofherdisease.Supposethosesymptomsarenowdefeatingeveryremedysaveone:Youcanincreasethedosageofhernarcoticandantianxietymedicationtothepointof“terminalsedation.”Butsupposethatweeksago,whilestillfullycompetent,shetoldyoushewouldconsideritanathematolinger,technicallyalivebutobtundedtothepointthatshewasdispossessedofcon-sciousnessandtheabilitytocommunicatewiththosesheloves.Whatcanyoudoforher?

Medicalopinionandthecourtshaverecognizedtheso-called“doubleeffect” in terminal sedation.When sedation results inthepatient’sdeath,potentialprosecutorsaregenerally inclinedtogivedoctorsthebenefitofthedoubtthattheirintentwastorelievesuffering.Nevertheless,yourpatienthaspresentedyouwithadilemma:Youneedtorelieveheragony,butintheprocessyoumayviolateherwishtoavoidtheunconsciouslingeringthatshehastoldyoushewouldconsiderafateworsethandeath.Thisbillwouldhaveallowedyouandyourpatienttoavoidarrivingatthisimpasse—buthavingarrivedthereandonceplacedinthisdilemma,youmayfinditdifficulttobeclearaboutyourownintent.Asyouincreasethepatient’ssedation,youmayunderstandablyfeelthatyouareventuringontothinice.Whenoneisatriskofcommittinganarguablycriminalact,favorableoddsonbeinggiventhebenefitofthedoubtarenosubstitutefortheprotectionthatwouldcomefromimprovedclarityandbetteroptionsinthelaw.Atpresent,sadly,optionsandclarityarebothlacking.

Oregon’sDeathwithDignityActwentintoeffectinNovem-berof1997.Between1998and2005,atotalof240,000Oregoniansdied.Amongtheirnumberwere246patientswhohastenedtheirdeathswiththeassistanceofphysicianswholegallyprescribedforthem.Anothergroupofpatients—themajorityofthosewhore-questedaprescription—chosenottotaketheprescribedmedicationbutreportedthattheyweregreatlycomfortedbyknowingthatadecisiontodosowaswithintheirpower.OpponentsofOregon’slegislationunderstandablyworriedabouta“slipperyslope.”Groundsforthatconcernhavenotmaterialized.Aftermorethaneightyears,scrutinyoftheOregonexperiencerevealsnoabuseofanykind.NearlyallofthepatientswhohaveavailedthemselvesofOregon’slawdiedwhilereceivinghospicecare.Dueinnosmallparttothe

Physician Assistance-in-Dying

in MY oPinion

Robert Liner, MD

t hispast June,AB651, theCaliforniaCompassionateChoicesAct,suffereddefeatinathree-to-twovotebytheSenateJudiciaryCommittee.Speakingasadoctorwhohas

practicedinthisstateforthirty-sixyears,Ithinkthat’sashame.Reasonablemindsandequallywell-intendedpeopledisagreeaboutphysicianassistance-in-dying.TheAmericanpublicfavorsthecon-ceptbyamarginof70%,andaMarch2005HCDResearchsurveyofU.S.physiciansatlargeindicatedthat62%ofourcountry’sdoctorsbelievethat,withpropersafeguards,physiciansshouldbepermittedtodispenselife-endingprescriptions.Formanyyearsnow,theSFMShasmaintainedapositionofneutralityinthisdebate—apositionthatfoundcogentsupportina2003paperbyDrs.QuillandCassel:“ProfessionalOrganizations’PositionStatementsonPhysician-As-sistedSuicide:ACaseforStudiedNeutrality”(NEJM,183:3).

California’sthwartedlegislationwascarefullymodeledafterOregon’sDeathwithDignityActand incorporatedevenmoresafeguards.Oregon’slawhasservedthepeopleofthatstatewellfornearlyadecade.AsinOregon’slaw,theprovisionsofCalifornia’sbillwouldhavebeenlimitedtoterminallyill,competentadults.Twophysicianswouldhavetoagreeonthediagnosisandprognosis,andinCalifornia’sstatuteamentalhealthevaluationwouldbemandatory.Twooral requests,awritten request,and twowait-ingperiodswouldbe required,and,onceprescribed, the lethalmedicationwouldhavetobeself-administered.Thebillspecificallyprohibitseuthanasia.Italsoprohibitssurrogatedecisionmaking;thepatientwouldhaveexclusivepowertoinitiatetherequestforadeath-hasteningdrugandwouldpossess soleauthority for itsadministration.Finally,nodoctorwouldberequiredtoparticipate;coercionofanykindwouldbeantitheticaltothelanguageandintentofthebill,whichwasaboutgrantingpeopleautonomyandchoiceintheirmedicaldecisions.Weallknowthat,inpractice,physiciansdo sometimeshastendeathswhencompassionandgoodjudgmentcall forsuchintervention.Buttheseactionsareclandestine,unregulated,andsometimesinsufficientlyinformed,andpatientcaresuffersaccordingly.

Improvementinthequalityandavailabilityofpalliativecareissometimesofferedasanalternativetophysicianassistance-in-dying,asiftheseinterventionsweremutuallyexclusive.Allcaringphysi-ciansfavoreffortstoimprovepainmanagementandotheraspectsofpalliativecare.Theseeffortsarenecessaryanddesirable,butthemostenlightenedandcreativepalliationissometimesinsufficienttomeettheneedsofdyingpatients.Take,forexample,thecaseof

Postmortem Reflections on the California Compassionate Choices Act


28San FranciSco Medicineseptember 2006 www.sfms.org

www.sfms.org september 2006San FranciSco Medicine2928San FranciSco Medicineseptember 2006 www.sfms.org

socialinnovationofthatlaw—twiceapprovedbyOregon’s voters—and to thedebate thatsurrounded that referendum, end-of-life careisbetterinOregonthananywhereelseinthenation.

Someof thosewho took issuewithAB651 have voiced a concern that economicforcesmightresultinthebestofpalliativecarefor privilegedmembers of society,while theeconomicallydisadvantagedwouldbehastenedoffwith“ahandfulofpills.”Oregon’sexperiencearguesagainstthatconcern.ThoseOregonianswhohastened theirdeaths tended tobewell-educatedandinsured.Aproponentandanop-ponentofthisformoflegislationaddressedthefactsinajointlypublishedarticle:“WhatArethePotentialCostSavingsfromLegalizingPhysi-cian-AssistedSuicide?”(Battin,M.andEmanuel,E.J.,NEJM,July,1998).Theirstudiesconcludedthatanypossiblesavingswouldbetoosmalltoconstituteaneconomicincentivetoabuse.

IfourhypotheticalpatientlivedinOregon,shecouldhavebeen legallyprovidedwithaprescriptionforSeconalinaquantitysufficienttogiveher theoptionofbringingaboutherowndeath,surroundedbyherlovedones,ata

Physician Assistance-in-Dying: Continued from page 27...

pointconsistentwithherownvaluesandfinalconsiderations.CounselfortheCMA,opposingthebill,suggestedthatlegalizingphysicianassis-tance-in-dyingwoulddistortandinjectmistrustinto thedoctor-patient relationship.Bedsideexperiencewithdyingpatientsbelies thatas-sertion, recognizing its inherentpaternalism.Patientswillnotbeconfusedaboutthemotivesofdoctorswhorespecttheirautonomyandtheirexpressedwishes.Norshouldwephysiciansbeconfusedaboutourcallingandourlimitations.Detractorssometimesproclaimthat“aphysicianshouldcure,notkill,”atruismthatisvacuousin this context.Neither curingnorkilling isrelevanttothisdiscussion.Wearecalledupontocure—yes,whenevercureispossible.Butwearetalkingaboutpatientswhoareintheprocessofdying.Theonlyquestionishowtheywilldie,andonwhoseterms.Andif,asinthisexample,thepatientdiesaweekor twobeforeher lifefunctionsmightotherwiseceasebutdies inamannerandamomentshehaschosen,stillabletosay“good-bye,”whereistheharm?

Whydoesthenotionofschedulingone’sownimminentdeathcauseconsternation?Wescheduleothermomentousoccasions inour

lives.We frequently schedulebirth,knowingthatwhileprematurity isarisk, therearealsocomplicationswhenbirthistoolongdelayed.Aspatientstellus,weshouldhavethesameregardfortheconsequencesofunnecessarilydrawingouttheprocessofdeath.PhysicianswhowouldrendercompassionateassistancetotheirpatientsinaccordwithalawliketheoneembodiedinAB651wouldbeactinginamannerconsistentwiththebestethicalstandardsofourprofession.

IftheprotectionoflegislationsimilartoAB651becomesavailabletousinCalifornia,willIeverbelikelytoavailmyselfofitsoffering?Idon’tknowabetterwaytoanswerthatquestionthaninthewordsofGarretKeizer,aministerwhoseessay“LifeEverlasting”waspublishedinHarper’s Magazine(February2005):“IdonotknowifIwouldeveruseitmyself.Iremainseatedthroughthecreditsofmovies,eventhoseIdidn’tmuchlike,andafterI’vefinishedmydrink,Ichewthepulpfromthelime.IsuspectI’llwanttostayfortheduration…butthepertinentquestionhereisnotwhatIwilldoonmydeathbedbutwhatIampreparedtopermitotherstodoontheirdeathbeds…andonthatquestionIamclear.”

Grand Hyatt, San Francisco345 Stockton St.

San Francisco, CA 94108

For more information866-448-7070

9:30 a.m. - 11:30 a.m.Sutter Health with facilities in Northern California, from the Oregon Border to the Central Valley, and from the Pacific Coast to the Sierra Foothills, provides boundless practice opportunities, and lifestyles.

Join us to meet Sutter Health physicians and adminis-trators, and to learn about unique practice opportunities Sutter Health has to offer.

•Continental breakfast will be served•Parking vouchers provided if hotel valet parking is used•RSVP preferred, walk-ins welcome

If unable to attend CVs may be faxed to 916-454-6645 or email to [email protected].

San Francisco, CASeptember 23, 2006Physician Career Fair

�0San FranciSco Medicineseptember 2006 www.sfms.org�0San FranciSco Medicineseptember 2006 www.sfms.org

The Bridge

Erica Goode, MD

FiLM reVieW

t heninety-minutefilmThe Bridge is amust-see foranyphysician,medicalstudent,parent,oryoungsterovertheageofl5.Itis,infact,animportantfilmforanyoneliving

intheBayArea.Likemanythingsinlife,itimmediatelybringsupquestionsofpriorities,money,andpoliticalintrigue.

Itshowstheviewertheterribletruthofthisalluringlybeautifulicon,theGoldenGateBridge—thetruthbeingthatwelosean-othersuicidalpersoneveryl5days,yearinandyearout,duetothelow,temptinglysurmountablerailing.CamerasontheBridgeitselfmonitorthesejumps.Thereisaresponseeffortwhenpassersbyseeajump:Theycall9llandtheCoastGuardappears,usuallyrecoveringanothercrumpled,drownedperson—unlessthebodyhasbeensweptouttosea.Duetothisfactor,theconfirmednumberofjumpersisinvariablylowerthanthenumberofactualdeaths.

Thefilmisbeautiful,usinglong-rangelensestocapturethehauntinglylovelyfog.Themessageisstrengthenedbythefactthatasimplerailingcouldpossiblymakeadifference.Onegirl,capturedonfilm,waspulledtosafetybyapasserby;onefellowspentninetyminuteswanderingtoand fro,hairandblackclothingbuffetedbythewind,beforehurlinghimselfover.Itisalmostimpossibletomonitor thevariablebehaviorof the jumpers—onecrossedhimselfbeforehand,calmlyclamberedover,andwasgone.Thefilmedinterviewwithasurvivingjumper,KevinHines,whowasnineteenatthetimeofhisattempt,summarizedthepositionof

manysurvivingjumpers.Hinesisgladtobealiveandnowspendstimeandeffortspeakingwithyoungpeople,urgingthemtoseekhelpfordepressionandothermentalhealthissues.

Inl976DavidRosen,MD,thenaprofessorofpsychiatryatUCSF,interviewednineBridgejumpsurvivorsandpublishedhisreportintheWestern Journal of Medicine.Allsurvivorsfeltthiswasalife-alteringevent,andallconsequentlydevotedtheirenergiestowardpreventingdepressionandsuicideamongthemselvesandothers.

EricSteel,whodirectedandfilmed The Bridge,isgivingprof-itstothebarrier-buildingeffort.ActivistsaretryingtoconvincetheSanFranciscoBridgeDistrictthatitisnecessarytomakethischange.Thereislittleinthenewsaboutthesetwenty-fiveormoreannualdeaths,incontrasttotheoneortwohead-oncrashesperdecadeonthespan.Thisfilmfinallybringstheissuetotheforefront.However, there is resistance;oneSanFranciscoSupervisorhasexcoriatedthefilmanditsmotiveswithouthavingseenit,despitethereviewsandpraiseitreceivedattheNewYorkFilmFestivalthispastyear.

Ifyouwishtohelpthebarrier-buildingeffort,please urgeyourlocaltheater,theCastro,Kabuki,andothers,toshowthefilm,andcontact thedirectorof thePsychiatricFoundationofNorthernCalifornia,JaniceTagart,at(4l5)[email protected].

�0San FranciSco Medicineseptember 2006 www.sfms.org www.sfms.org september 2006San FranciSco Medicine�1�0San FranciSco Medicineseptember 2006 www.sfms.org

websitewithafulllistofstatedisclosurelawsandprovidesupdatesonpendinglegislation;andtheNationalAdoptionInformationClearinghouseprovidesanonlinestate-by-statelistingwithdetailsaboutwhomayaccessinformation,whatisavailable,andwhichagencyordepartmenttocontact.

Probably the best-known and most successful mutualconsentregistrieshavebeenstartedbythosewhohaveavestedinterest.JeanPaton,anadopteeandasocialworker,iscreditedwithorganizingthefirstregistryandbeginningtheadoptees’rightsmovementin1949.Hersearchorganization,OrphanVoyage,andher1954book,The Adopted Break Silence, werefirstsoftheirkind.Butitwasnotuntiltheearly1970sthattheregistriestookholdwithFlorenceFisher’sALMASociety.ALMAhasanationwidenetworkof supportgroupsandcontinues to facilitate reunionsthroughitsregistrydatabase.TheotherwidelyusedregistryistheInternationalSoundexReunionsRegistry.CommonlycalledSoun-dex,itwasfoundedin1975byEmmaMayVillard,thedaughterofanadoptee.Althoughregistriesarean importantpartof thesearchprocess,mutualconsentregistriesdependonbothpartiesknowingtheregistryexists,takingthesteptoregister,andupdatingcontactinformation.Ingeneral,motherswhohavefiledaletterwiththeadoptionagencyinthehopethattheiradultchildrenwillcontacttheagencyhavehadbettersuccess.However,theyhavetopreparefortheemotionalintensityofareunion,whichcanbearoller-coasterride.

FesslerisprofessorofphotographyatRhodeIslandSchoolofDesign,andshebeganherinterviewsforanaudiovisualinstallationproject.ShewaseventuallyawardedtheprestigiousRadcliffeFel-lowshipfor2003–04attheRadcliffeInstituteforAdvancedStudy,HarvardUniversity,wheresheconductedextensiveresearchforherbook—whichbeginsandendswiththestoryofherownsuccessful,andtime-consuming,questtofindherownbirthmother.

Fessler,Ann. The Girls Who Went Away: ThePenguinPress,2006.

The Girls Who Went Away

Book reVieW

Nancy Thomson, MD

A nnFessler’sbook The Girls Who Went Away isadeeplymovingandmyth-shatteringwork.Quotationsfrommoth-ersforcedtosurrendertheirbabies,suchastheoneabove,

aresprinkledthroughoutthetextasFesslerrevealstheastonishinguntold storyof themillionandahalfwomenwhosurrenderedchildrenforadoptionduetoenormousfamilyandsocialpressureinthedecadesprecedingRoevs.Wadein1973.

Althoughthesexualrevolutionwasheatingupinthepost-WorldWar IIyears, sexual informationwasnotavailable fromfamilyorschool,birthcontrolwastightlyrestricted,andabortionwasstillillegalinmoststates,aswellasbeingprohibitivelyexpen-siveor life-endangering.Whileyoungmenwhoengaged in sexoftensawtheirreputationsenhanced,singlewomenwhobecamepregnantwereshunnedbytheirfamiliesandfriends,evictedfromschool(until1972’sTitleIX),andsentawaytomaternityhomestohavetheirchildrenalone.Theyweretoldthatsurrenderingtheirchildrenwasthebestsolutionandthatdoingsowouldallowthemtosimplymoveonandforget.

But theyneverdid forget.Fessler,herself anadopteewhorecentlymadecontactwithherbirthmother,traveledthecountryinterviewingmorethan100womenwhowerewillingtotalkabouttheirexperiences.Manyofthesewomenhadneverdiscussedtheirexperienceswithanyone—noteventheirmothers,sisters,friends,orspouses—duetoshameandguilt.

However,fortheadoptees,therewasaneedtoknowtheirhis-tories.Andforthemothers,itwasthehealingofanoldwound.NotallmothersFesslerinterviewedhavehadcontactwiththeirchil-dren.Itwasofteneasierforthechildrentofindthemothers,iftheycouldfindacopyoftheiroriginalbirthcertificate.However,inthepost-WorldWarIIadoptionboom,moststatessealedtheserecords,andthedebateaboutopeningthemisongoing.TheAmericanAdoptionCongresswasfoundedin1978tobringaboutchanges,andaGooglesearchof“adoptionreunionregistry”willyieldabout150hits.BastardNation,anadoptees’rightsorganization,hasa

The Bridge

“This was in that period of time when there wasn’t much worse that a girl could do. They almost treated you like you had committed a murder or something.”—ToniinThe Girls Who Went Away


IfChineseHospitalhadaHallofFame,thenDr.RollandC.Lowewouldcertainlybeaunanimousfirstballotselection.After forty-threeyears,Dr.LowerecentlyretiredfromhissurgicalandgeneralmedicalpracticelocatedinChinatownandChineseHospital.Hedidnotreceivejustoneretirementparty,butthree:onegivenbyhundreds fromthecommunity,onebycolleagues,andonebythehospital.Amonghismanyaccomplishmentsarebeing thefirstAsianPresidentoftheSanFranciscoMedicalSocietyand, later, thefirstAsianPresidentoftheCaliforniaMedicalAssociation.Justlastyear,hewastherecipientoftheCMAFoundation’sfirstEthnicPhysicianLeadershipAward.Hewashonoredforservingasateacher,rolemodel,andtrailblazerforethnicphysiciansandforhelpingtocreateCMA’sEthnicMedicalOrganizationSectionandthefoundation’sNetworkofEthnicPhysicianOrganizations.

ServingthecommunityhasalwaysbeenanimportantpartofDr.Lowe’scareer,andthiswillnowbehisfocusashestepsdownfrommedicine.HewasafounderoftheChinatownYouthCen-terandhasservedonnumerousboards,includingthoseoftheSanFranciscoFoundation,theSanFranciscoPlanningandUrbanResearchAsso-ciation,Self-HelpfortheElderly,andthecity’sCivilServiceCommission.Thankyouforyourserviceandcongratulationsonyourallofyouraccomplishments,Dr.RollandLowe!

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TheSocietyofChestPainCenters(SCPC)hasawardedCaliforniaPacificMedicalCenteritsChestPainCenteraccreditation.CPMCisnowoneoffiveaccreditedChestPainCentersinCalifornia.Thisaccreditationisgivenonlytofacilitiesthathavedemonstratedtheircommit-mentandexpertiseinprovidingpatientswithconsistentqualityinthedeliveryofemergencycardiaccare,basedonnationalguidelinesestab-lishedbyleadersincardiovascularandemergencymedicine.

“This accreditation denotes heart careexcellencetoourpatientsandourcommunity.Wewanted todemonstrateourdedication toprovidingqualitycardiaccarebybecomingaChestPainCenter,”statesRichardGray,MD,MedicalDirectorof theSutterPacificHeartCentersandCPMCcardiologist.

TheInstituteforHealthcareImprovement(IHI)isshowcasingCPMC’sHealthandSafetyPassportonitswebsite,asaresourceforotherorganizations:www.ihi.org/IHI/Topics/Patient-Safety/MedicationSystems/Tools/Healthand-SafetyPassport.htm.

CongratulationstotheCenterforPatientandCommunityEducationandtheCommuni-cationsandMarketingDepartmentonthisveryvisibleacknowledgmentoftheirwork.

Dr.LawrenceWerboffwasrecentlyreap-pointedforasecondtermasChairoftheDepart-mentofUrology.Dr.WerboffisagraduateoftheUniversityofPittsburghSchoolofMedicineandhasbeenamemberoftheCPMCmedicalstaffsince1980.

Dr.MichaelVerhillewasrecentlyappoint-edChiefoftheDivisionofGastroenterologyatCPMC.Dr.VerhilleisagraduateofUniversityofIllinoisatChicagoandhasbeenamemberoftheCPMCmedicalstaffsince1990.

ChineseFred Hom, MD

CPMCDamian Augustyn, MD

Life’sharshestandmostdifficultmomentsoftenpresentthemselvesattheleastopportunetimes:tenminutesbeforelunchoronaFridayafternoon;atthebeginningofastringoftwentymessagesthatneedtobeansweredinfartoolittletime;orwhenachildisdemandingmoreenergythanonehastogive.

Toourpatients,theyarelife-definingmo-ments.Tous,wehope,theyareopportunitiestoperformthebestcareweknowhowtogive,whenourcompassionandempathyshouldbeattheirstrongest.

Thesemomentsgoundermanydifferentguises:the13-year-oldwhoreceivesapositivepregnancytest; the30-year-oldwholearnsheisHIV-positive;themiddle-agedwomancling-ingtolife,evenascancerravagesherbody;thefatherwhosesonhasjustbeenfoundwashedupon the shore,after jumping fromtheGoldenGateBridge.Howdowe,asphysicians,balanceourownreactionstotheseeventswithourneedtocommunicateconcisely,dispassionately,andimpartiallywithourpatients?

Sometimes,theanswerissimple.Allowthepatienttocry.Allowyourselftocry.Expressyoursorrowatthedifficultyofthemomentthatyouareprivilegedtoshare.Onlythenshouldyouandthepatientconstructaplan,discusstreatment,ordeterminewhatwillcomenext.Thepatientwillnotrememberyouractionsbutwillhavesensedyourempathy.Reflectonthelasttimeyouheardtrulybadnews.Yourememberthekindtouch,thesoftwords,andthesincerecompassion,notthenextappointmentdate.

Finally, seeksolace fromyourcolleagues.Wehaveallbeenthere,andwillbeagain.Rec-ognizethatnoneofuscanpracticemedicineinavacuum.Existingattheedgesoflifewithourpatients requiresour technical expertise,butaboveallitrequiresourhumanity.

KaiserRobert Mithun, MD

�2San FranciSco Medicineseptember 2006 www.sfms.org www.sfms.org september 2006San FranciSco Medicine��2San FranciSco Medicineseptember 2006 www.sfms.org

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St.Mary’sKenneth Mills, MD

St.Mary’sistheonlyCatholicHospitalinSanFrancisco,aswellastheoldesthospitalinthecity.Thusweareveryawareofourrootsandespeciallyour faith-based foundation. In1854theSistersofMercyarrivedfromIrelandandin1857foundedSt.Mary’sHospitalonRinconHillbythewaterfront.WearenowpartofCatholicHealthcareWest,whichissponsoredbyseveralreligiousordersofSistersandoperatesmorethanfortyhospitalsinCalifornia,Arizona,andNe-vada.Withthisbackgroundinmind,IambothsadandproudtoreflectontheuntimelypassingofanextraordinarypersonintimatelyconnectedwiththeSistersofMercy,CatholicHealthcareWest,andSt.Mary’sMedicalCenter.

St.Mary’shadnobetterfriendthanSisterDianeGrassilli.Thisremarkable,youthful,fifty-six-year-oldwomanwas recently taken fromusafterabriefillness.Creative,energetic,andresourcefulareonlyafewwaystodescribehertalents.BorninSanFrancisco,raisedinBurl-ingame,agraduateofMercyHighSchoolandRussellCollege,shebecameaSisterofMercyandbeganherprofessionasaneducator,teachingatMercyHighSchoolsinSanFranciscoandBurl-ingameandeventuallypresidingasDean.

1986wastheyearofformationofCatholicHealthcareWest,andSisterDianewasinvolvedfrom the start. She was the assistant to thePresident,andstrategicplanningwasherforte.SheservedontheBoardofDirectorsandwasPresidentoftheCHWBoardfrom2002to2005.ShewasalsoPresidentoftheSistersofMercy,Burlingamecommunity.

SisterDianewasatirelessadvocateforSt.Mary’sHospitalandservedonourFoundationBoard.Whetherpresidingover theBoardofCHWorthrowingtheopeningpitchforaGiantsgame,herwinningsmileandengagingpersonal-itywerehercallingcards.St.Mary’sjoinsinthemourningofthisremarkablehealthcarestrategistandbestfriend.

ThePancreasandPancreaticIsletTrans-plantProgramatUCSFMedicalCenter,thefirstandlargestinCalifornia,isakeycomponentofaconcertedefforttofindadvancedtreatmentsfor insulin-dependent (Type I)diabetes.Yetmanydiabetics—andevensomephysicians—donotrealizethatasuccessfulpancreastransplantisacure fordiabetes.Ahealthypancreascaneliminatetheneedforinsulininjections,reduceor eliminatedietary andactivity restrictions,anddecreaseoreliminatetheriskofseverelowblood-sugarreactions.

“Pancreastransplantsprovidetheopportu-nityformanyTypeIdiabeticstoenjoyinsulinindependenceforthefirsttimeintheirlives,”saidPeterStock,MD,directoroftheUCSFpancreastransplantprogram.

“Unfortunately,thisprocedurecanbenefitonlyasmallnumberofTypeIdiabeticpatientswithlife-threateningdiabetes,”Stocksaid.“Thisis the reason thatUCSF is activelyenrollingpatients for the less invasiveislet transplantprocedure.Currentclinicaltrialsarestudyingtheefficacyand longevityofthe insulin indepen-denceproducedbyislettransplantation.”Sofar,UCSFoffersislettransplantsandpancreas-onlytransplantsprimarilytoTypeIdiabeticswhosebloodsugarisparticularlydifficulttocontrol.

Mostpeoplewithdiabetesreceiveapan-creas transplant simultaneouslywithakidneytransplant.Toshortenthewaitingtime,UCSFpatientswithqualifieddonorsnowmayreceivea living-donor kidney transplant, followed(aftersixmonths’recoverytime)byapancreastransplant.More than80%ofUCSFpatientsremain insulin-independent three years aftertransplant.

Formoreinformation,seewww.ucsfhealth.org/organ_transplant.PhysiciansmaycontactUCSF’spancreasandkidney/pancreastransplantnurse-coordinator,SandydelGrosso,RN,at(415)353-1371.

UCSFRonald Miller, MD

SaintFrancisGuido Gores, MD

Withthismonth’s theme,“PsychiatryattheEdgesofLife,”mycolleaguesandIwouldberemissifwedidn’tacknowledgetheprofessionalcommitmentofpsychiatristMelBlaustein,MD.Dr.BlausteinisViceChairoftheDepartmentofPsychiatryatSaintFrancis,PresidentofthePsychiatricFoundationofNorthernCalifornia,andChairoftheFoundation’sTaskForceonaGoldenGateBridge suicidebarrier.Throughtheirtirelesswork,Dr.BlausteinandtheFounda-tionhavehelpedcreatetremendoussupportforabarriertopreventmoretragediesontheBridge,themostcommonsuicidesiteintheworld.

HereatSaintFrancis,weareverysaddenedbythenewsthatourPresidentandCEOCherylFamahasannouncedherplanstoleaveSaintFrancisforpersonalandfamilyhealthreasons.Cheryl beganher twenty-twoyears atSaintFrancis in1984asVicePresidentofPatientCareServices. In1989sheassumedtheCEOposition.In1995shebecamePresident,andthenPresidentandCEOin2001.Shehas fosteredgrowthandvisibilityof existingprogramsaswellasdevelopmentofnewprograms,suchastheSpineCenter,TotalJointCenter,WoundHealingCenter,andBehavioralHealthDayPro-gram.ShehasbeeninstrumentalinestablishingcommunitypartnershipswithorganizationssuchasGlideMemorialFoundation,theMacMillanStabilization Center, and the HomecomingServicesProgram.Throughherleadership,theSanFranciscoBoardofSupervisors recentlyrecognizedSaintFranciswithaproclamationfor“outstandingcommunityservices.”Forfouryearsrunning,CherylhasbeenhonoredasoneoftheBayArea’sTop100WomeninBusiness.

OnbehalfoftheentireSaintFrancismedi-calstaff,wethankherforherdedicatedserviceandcommitment.During the transitionandsearchforanewhospitalpresident,TomHen-nessy,whohasbeenVicePresidentofOperationsatCHWforsevenyears,willbeourPresident.


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A study led by researchers at the SanFranciscoV.A.MedicalCenter (SFVAMC)hasshownthatextremelylowdosesofestrogenoverthecourseoftwoyearshadnoilleffectson thecognitiveabilitiesorgeneralhealthofolderwomen.

“Thisshowsthatwomencantakeestrogensafely,”observesauthorKristineYaffe,MD,ChiefofGeriatricPsychiatryatSFVAMC.

Thestudy,publishedintheJuly2006issueofArchives of Neurology, lookedspecificallyatthepotentialeffectsofestrogenoncognitiveabilitiesandqualityof life.Agroupof417postmeno-pausalwomenagedsixtytoeightywererandomlyassignedtoreceiveadaily.014milligramdoseofeitherestradiol,aformofestrogen,oraplacebothroughaskinpatchfortwoyears.Thewomenweregivenabatteryofstandardizedcognitivetestsandatestofhealth-relatedqualityoflifeatthebeginningofthestudy,afteroneyear,andaftertwoyears.

Attheendofthestudytherewasnodiffer-encebetweenthetwogroupsineithercognitiveabilitiesorhealth-relatedqualityoflife.

“Theresultsareveryreassuring,becauseitsuggeststhatwomencanusethispatchwithoutharmfortwoyears,”saysYaffe.

SenatorBarbaraBoxertouredSFVAMC’sNationalCenterfortheImagingofNeurodegen-erativeDiseasesonJuly7,2006.Shespoketoanaudienceofresearchersandothermedicalcenterstaffemphasizingheractive supportofV.A.’sresearchandhealthcareprograms.ThesenatorhassponsoredlegislationthatwouldfundV.A.andtheDepartmentofDefensetoprovidead-ditionalmentalhealthandrehabilitativeservicesfor returningOperations IraqiFreedom(OIF)andEnduringFreedom(OEF)veterans.

VeteransDiana Nicoll, MD,

PhD, MPA

St.Luke’sJerome Franz, MD

ThepositivestoryatSt.Luke’sinthefieldofmentalhealthisseveralyearsold.TheCenteringPregnancyProgramoffersgroupsupportforpre-natalcareaspartoftheobstetricalservicesoftheWomen’sCenter.ItwasorganizedandcontinuestoberunbyLizSteinfeld,CNM.Manywomencontinuetomeetafterchildbirthtosupporteachotherduringthedifficultpostpartumperiod.

LastyeartheinpatientpsychiatricfloorwasclosedatSt.Luke’sduetolowvolume.OuronlyinpatientpsychiatricconsultantwasMarkPerluntilMayofthisyear.Markwasverybusyandanxioustosharetheduties.WenowhaveLauraDavies,whoalsotreatschildren,andIanWeb-ber,whoprovidesareferralserviceformanagedcarepatients.

Bythetimethiscolumnisprinted,wehopethatthemergerbetweenCPMCandSt.Luke’shasbeenfinalized.BecausetherehasbeennoresponsefromtheAttorneyGeneral,thelawyershavesentatwenty-daynotice,whichwillallowthemergertotakeplaceunlessanobjectionisissuedbyhisoffice.Thecompletionwillhelpthementalhealthofouradministrations,whohavebeenactingasifthemergerwasfaitaccompli.

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Thwaitesexpressesgratefulnessashecommentsonthewayshiscareerinpallia-tivecarehaveaffectedhim.“Onaregularbasis,itmakesmequestionmydogmasandstrengthensmy faith.Thus Icontinue togrowasaperson.Iseeamazingthings.ThereisastrongspiritualparttowhatIdothatIdidnotfindinotherspecialties.AndIgainhumility.Ultimately,Idon’thavecontrol.Instead,Ihaveapeacefulacceptancethatfatewilltakeitscoursesometimes.AndIfindstrengthinknowingthatwhenyoutryyourbest,sometimesitisreallyoutofyourhands—eventhoughthismeansthatIamnotassignificantasmytitleimplies.”

Dealing with Death: Continued from page 27...

Congratulations Dr. Sikorski

SFMSwouldliketocongratulateDr.Sikorskionwinning the2005Dr. J.ElliottRoyerAward.Theaward,givenbytheUCSFSchoolofMedicine,goestoaPhysicianinSanFranciscowhohasmadeasignificantcontributiontotheadvancementofpsychiatry.

�4San FranciSco Medicineseptember 2006 www.sfms.org www.sfms.org september 2006San FranciSco Medicine�5�4San FranciSco Medicineseptember 2006 www.sfms.org

in MeMoriaM

Herbert S. kaufman, Md HerbertS.Kaufman,MD,passedawayatage71inhisMillValley

homeonJuly6,2006,afteracourageousbattlewithprogressivesupra-nuclearpalsy.HewasborntoGeorgeandElizabethKaufmaninSalina,Kansas,onApril30,1935.HegraduatedfromtheUniversityofKansasin1957andearnedhismedicaldegreefromBaylorUniversityCollegeofMedicinein1961.HereceivedhistraininginallergyandimmunologyatUCSFinSanFranciscoandatOxfordUniversity.AlthoughheneverlosthisloveforhisKansasroots,hemadeSanFranciscohishomein1964.

Dr.Kaufman,knowntofriendsandfamilyasHerb,establishedhisfirstmedicalofficeinSanFranciscoandthenopenedasecondofficeinKentfield,whereheworkedformorethanthirty-fiveyearsuntilhewasdiagnosedwithPSPthreeyearsago.Hiscontributionsanddiscoveriesinthefieldofimmunologyandallergieshavehelpedpeopleworldwide.Manyyearsago,whilevisitingfellowallergistDr.JohnnyFeminiofFlorence,Italy,Herbwasshownaplantthatwasnativetothatareaandknowntocausesevereallergies.Yearslater,afterbeingunabletotreatapatientsuc-cessfully,hefoundthatsameplant,unknowntothisarea,growingatthepatient’shome.HeworkedtodevelopatestingandtreatingantigenthatisusedtothisdaytotreatPanteteriaallergies.

HerbwasaDiplomatoftheAmericanBoardofAllergyandImmunol-ogyandaFellowoftheRoyalSocietyofMedicine.HewasalsoamemberofseveralBritishandAmericanallergysocietiesandofTechnion,theIsraelInstituteofTechnology,wherehedidallergyresearchfortreatingchildrenwithasthmaatthehospitalinArad,Israel.Formanyyears,HerbdeliveredtheBayAreapollencountduringallergyseasononKGOradio,wherehewasknownasthe“CoughMan.”

Herbwasapassionateandcommittedphotographerwhotraveledtoexoticandremotepartsoftheworldwithcamerainhand.Heenteredhisphotographsinlocalandnationalcompetitionsandrecentlywon“BestofShow”attheMarinCountyFair.Healsohadaloveofclassiccars—heevenonceheldabirthdaypartyforoneofthecarsinhiscollection.Hisloveoftheland,whichbeganinhischildhoodinKansas,stayedwithhim,andhetreasuredthetimeworkingthesoilathisvineyardinNapa.HewasamemberoftheMarinchapteroftheFoodandWineSocietyofAmerica(HaskelNormanchapter).HealsoservedforseveralyearsontheboardofGuideDogsfortheBlind.

Heissurvivedbyhiswife,VivianJohnsKaufman;childrenAlisaRu-bel(Zigmund),JeanetteKaufman,andRichardKaufman;stepsonCharlesGedeon;sisterJeanneAnshel(Arthur);andtwosisters-in-lawandthreebrothers-in-law,aswellasmanyniecesandnephews.HealsoleftbehindhisdogDan,abelovedandlovingcompanion.

alfred Wheeler childs, Md AlfredWheelerChilds,MD,passedawayJuly5,2006,attheageof

83,afterafour-monthillness.HewasborninSanFranciscoonOctober11,1922, theoldest childofAlfredWheelerChilds andGenevieveMeloche.

HegraduatedfromSequoiaHighSchoolinRedwoodCityin1940.HegraduatedfromU.C.Berkeleyin1943andearnedhisMDatUCSFin1946.HewasaninternatPermanenteHospital,Oakland,from1946to1947.HewasenlistedintheArmyReservefrom1943to1946,intheAirForceasMedicalOfficerfrom1947to1949,andintheAirForceReservefrom1949to1964.Hewasavisiting fellow inMedicineatColumbiaUniversityinNewYorkfrom1954to1956andearnedamaster’sdegreeinPublicHealthfromU.C.Berkeleyin1964.

Dr.ChildspracticedinternalmedicineinSanFranciscofrom1956to1962andinBerkeleyfrom1975untilhisfinalillness.HetaughtmedicalcareadministrationonthefacultyoftheU.C.BerkeleySchoolofPublicHealthfrom1964to1975andservedontheclinicalfacultiesofStanfordMedicalSchoolandUCSF.HewasalsoonthemedicalstaffofPresbyterianHospital,SanFrancisco(nowCPMC);AltaBatesHospitalinBerkeley;andPeninsulaHospitalinBurlingame.AtPresbyterianHospital,hewasdirectoroftheArtificialKidneyUnit,andinthiscapacityheappearedonScience in ActiononKRONandDoctor’s News ConferenceonKTVU.

In1991,hereceivedanAlumniCitationfromU.C.Berkeley,andin1993,hereceivedtheAlumnioftheYearAwardfromBerkeley’sSchoolofPublicHealth.In1994and2001,hereceivedtheTrustee’sCitationfromtheU.C.BerkeleyFoundation.

HewasamemberoftheSanFranciscoMedicalSociety,theAlameda-ContraCostaMedicalAssociation,theCMAandtheAMA,theCaliforniaand theAmericanPublicHealthAssociations, theAmericanSocietyof InternalMedicine, theWesternSociety forClinicalResearch, theAmericanAssociationforHealthServicesResearch,andtheCaliforniaAcademyofMedicine.HewasalsoadirectoroftheProjectHopeAlumniBoard,forwhichhevolunteeredinPeruin1962.HewasalsoamemberoftheLambdaChiAlphaFraternity.

Heenjoyedhiking,contemporaryart,andmusic.Hewasamemberofmanyartsocieties,servedontheBoardoftheSanFranciscoContem-poraryMusicPlayers,andwasoneof thefirstmembersofSECAandSFMOMA.

He is survived by his wife, Eunice Mahler Childs, his sisters,brother-in-law,goddaughter,andnumerousnieces,nephews,andcousins.

Nancy Thomson, SFM Obituarist Dealing with Death: Continued from page 27...

For Local Events of Interest Visit the SFMS WebsiteOur events page is now updated on a regular basis to include SFMS events and other local events of interest. Just go to our home

page and click on “Calendar of Events” on the left-hand side. Visit us at: www.sfms.org

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