April 2008

VOL.81 NO.3 April 2008 $5.00

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

Eye to EyePerceiving the World around Us

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www.sfms.org April 2008San FranciSco Medicine�

conTenTS

San FranciSco Medicine april 2008 Volume 81, number � eye to eye: Perceiving the World around Us

FEATURE ARTICLES

10 Seeing with the Heart’s Eye CharlesGarfield,PhD

12 In the Mind’s Eye ShievaKhayam-Bashi,MD

14 The Seeing Tongue PeterWeiss

16 The Feeling of Being Stared At MarilynSchlitz,PhD

18 The Fear of Looking SteveWalsh,MD

20 Saving Sight with a Smile SteveHeilig,MPH

21 Visual Disabilities in the United States SunitaRadhakrishnan,MD

22 Forever Young GaryL.Aguilar,MD

25 The End of Glasses DanielGoodman,MD

27 Through a Glass Darkly SusanKitazawa,RN

29 The Diving Bell and the Butterfly EishaZaid

MONTHLY COLUMNS

4 On Your Behalf

5 Upcoming Events

7 President’s MessageStevenFugaro,MD,andSteveHeilig,MPH

9 Editorial MikeDenney,MD,PhD

�0 Universal Health Care Update MitchellH.Katz,MD

�2 Hospital News

�4 In Memoriam NancyThomson,MD

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4San FranciSco MedicineApril 2008 www.sfms.org4San FranciSco MedicineApril 2008 www.sfms.org

on YoUr BeHaLF

exciting new SFMS event!Don’tmisstheSFMSnightatthede

YoungMuseum!JoinSFMSmembersonFriday,May9forareception—cateredbyBonAppetit—ontheeighthfloorof theobservationtowerfrom5:30to7:30p.m.,withaccesstotheentiretyofthisstunningmuseumuntil it closes at8:30p.m.Thecostforthisexcitingneweventisjust$20(includesmuseumadmission) forSFMSmembersandtheirguests.ContactTheresePorterintheMembershipDepartmentat(415)[email protected](deadlineisMay5).

cMe FormsInstituteforMedicalQualityisanim-

portantphysicianresourceforCME.Youmaycontacttheorganizationorvisititswebsiteforformsandassistanceat:The Institute forMedicalQualityCMECertificationProgram221MainStreet,Suite210SanFrancisco,CA94105www.imq.orgContactPauletteRichardsonat(415)[email protected].

SFMSalsohasCMAformsavailable.

40 Percent of Physicians Have not Yet registered Their nPi with Medi-cal

If youare among the40percentofphysicianswhohavenotyetregisteredtheirNPIswithMedi-Cal,yourclaimswillbedenied.Medi-CalclaimssubmittedwithoutregisteredNPIswillnotbepaid.Toensureuninterruptedclaimspayment,physiciansare encouraged to register theirNPIs assoonaspossible.

PhysicianscanregistertheirNPIwithMedi-Cal using the National ProviderIdentifierCollection(NPIC)toolavailableontheMedi-Calwebsite(www.medi-cal.ca.gov).

A sampling of activities and actions of interest to SFMS members

Contact theMedi-CalNPIHelpdeskat(800)541-5555(selectoption16andthenop-tion18forNPIregistration).

SFMS Seminar ScheduleAdvanceregistrationisrequiredforall

[email protected](415)561-0850exten-sion260formoreinformation.AllseminarstakeplaceattheSFMSoffices,locatedinthePresidioinSanFrancisco.

April18,2008Customer Service/Front Office Telephone Techniques9:00a.m.to12:00p.m.(8:40a.m.registra-tion/continentalbreakfast)Thishalf-daypracticemanagement sem-inar will provide valuable staff train-ing to handle phone calls and sched-uling professionally and efficiently.$99forSFMS/CMAmembersandtheirstaff($89eachforadditionalattendeesfromthesameoffice);$149eachfornonmembers.

May16,2008Managing the Team (for office managers and administrators)9:00a.m.to12:00p.m.(8:40a.m.registra-tionandcontinentalbreakfast)Motivating and Managing Your Office Manager (for physicians)12:15to1:45p.m.(12:00p.m.registrationandlunch)Thesetwoseminarsaredesignedtohelpphy-siciansandtheirofficemanagerssetexpecta-tions,managechange,anddesignapracticeculture that helps the practice thrive.$99 forManaging theTeam forSFMS/CMAmembersandtheir staff ($85eachfor additional attendees from the sameoffice); $149 each for nonmembers.$69 forMotivating andManagingYourOfficeManagerforSFMS/CMAmembers($59each for additional attendees fromthe sameoffice); $109 fornonmembers.

notes from the Membership department

april 2008Volume 81, number �

Editor Mike DenneyManaging Editor Amanda DenzCopy Editor Mary VanClayCover Artist Amanda Denz

Editorial Board

Chairman Mike DenneyObituarist Nancy Thomson

SFMS oFFicErS

President Steven H. FugaroPresident-Elect Charles J. Wibbelsman Secretary Gary L. ChanTreasurer Michael RokeachEditor Mike DenneyImmediate Past President Stephen E. Follansbee

SFMS Executive Staff

Executive Director Mary Lou LicwinkoDirector of Public Health & Education Steve HeiligDirector of Administration Posi LyonDirector of Membership Therese PorterDirector of Communications Amanda Denz

CMA Trustee Robert J. MargolinAMA Representatives

H. Hugh Vincent, DelegateRobert J. Margolin, Alternate Delegate

Stephen Askin Toni Brayer Linda Hawes-CleverGordon Fung Erica Goode Gretchen Gooding

Shieva Khayam-BashiArthur LyonsTerri Pickering Ricki Pollycove Kathleen Unger Stephen Walsh

Board of directors

Term: Jan 2008-Dec 2010George A. FourasKeith LoringWilliam MillerJeffrey NewmanThomas J. PeitzDaniel M. RaybinMichael H. SiuTerm: Jan 2007-Dec 2009Brian T. Andrews Lucy S. CrainJane M. HightowerDonald C. Kitt

Jordan ShlainLily M. TanShannon Udovic-ConstantTerm: Jan 2006-Dec 2008Mei-Ling E. FongThomas H. LeeCarolyn D. MarRodman S. RogersJohn B. SikorskiPeter W. SullivanJohn I. Umekubo

4San FranciSco MedicineApril 2008 www.sfms.org www.sfms.org April 2008San FranciSco Medicine54San FranciSco MedicineApril 2008 www.sfms.org

$150forbothsessionsformembers;$225fornonmembers.October3,2008Customer Service/Front Office Telephone TechniquesThishalf-daypracticemanagement sem-inar will provide valuable staff train-ing to handle phone calls and sched-uling professionally and efficiently.9:00 a.m. to 12:00 p.m. (8:40 a.m.registration/continental breakfast)$99forSFMS/CMAmembersandtheirstaff($89eachforadditionalattendeesfromthesameoffice);$149eachfornonmembers.

November4,2008“MBA” for Physicians and Office Managers 9:00a.m.to5:00p.m.(8:40a.m.registra-tion/continentalbreakfast)Thisone-dayseminarisdesignedtoprovidecriticalbusinessskillsintheareasoffinance,operations, andpersonnelmanagement.$250forSFMS/CMAmembersandtheirstaff ($225each foradditionalattendeesfromthesameoffice);$325fornonmem-bers.

other Upcoming events

May2–4,20082008 CMA Leadership AcademyDisney’sGrandCalifornianHotelinAna-heim,CaliforniaContinuing the Academy’s standard ofprogrammingexcellence,the11thAnnualLeadershipAcademy looks fromthepastto the future toassessbothbroad trendsand specifickeydevelopments affectingthepracticeofmedicineinCaliforniaandbeyond.The realitiesof thepresentwillalsobeaddressedwithaseriesofpracticalandpowerfulworkshopsdesignedtohelpmeet today’smedicalpracticechallenges.Visitwww.cmanet.org/leadershipformoreinformation.

May2–3,2008Monterey Bay Regional Heart SymposiumQuailLodge,CarmelValley,CaliforniaPhysiciansare invitedtoattendthiscon-ference, featuring nationally recognized

primarycareknowledgeandskills.Particularemphasiswillbeplacedonprinciplesofpri-marycare,office-basedpreventivemedicine,practicalmanagementofthemostcommonproblemsseeninprimarycarepractice,andexpanded skills in clinical examinationandcommonofficeprocedures.Emphasiswillalsobeplacedonskillsindermatology,psychiatry,gynecologyandwomen’shealth,andneurology.Formoreinformation,visitwww.cme.ucsf.edu.

cardiologistsandheart researchers, toaidtheirunderstandingandmanagementofcoronary artery disease. Conference feeincludesaneveningbanquetwithhealthy-lifestylecookingdemonstrationsandoliveoil tasting, set in thebeautifulMontereyPeninsula.Formoreinformation,visitwww.montereyheart.org.

June12–15,2008Living on the Fault Line: Advances in Occupational MedicineTheClaremontResortandSpa,41TunnelRd.,Berkeley,California8:00a.m.to6:00p.m.TheCaliforniaSocietyofIndustrialMedi-cineandSurgery (CSIMS), inconjunc-tionwith faculty fromUCSF, isofferingacontinuingeducation seminar thatwilladdress cutting-edge concepts regardingpractice,research,andpolicyinthefieldofoccupationalmedicine.Visitwww.csims.netformoreinformation.

June15–18,2008ENDO 08: The Endocrine Society’s 90th Annual MeetingThe Moscone Center, San FranciscoThismeetingoffersanunprecedentedop-portunitytolearnaboutthelatestadvancesin endocrine research and clinical carewhilenetworkingandcollaboratingwithmore than7,000colleagues fromaroundtheworld.Discoverandevaluatethelatestadvancesinendocrinology.Hearfromlead-ersinthefield.Choosefromamongmorethan200educationalprograms,includingplenary symposia, updates, debates, andmore.Formore information,visitwww.endo-society.org.

August10–15,2008Essentials of Primary Care: A Core Cur-riculum for Ambulatory PracticeResortatSquawCreek,NorthLakeTahoeThiscourseisdesignedtoprovideacompre-hensive“corecurriculum”inadultprimarycare.Itwillserveasanexcellentupdateandreviewforcurrentprimarycarephysiciansandotherprimarycareprofessionals,andasanopportunityforspecialiststoexpandtheir

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Fantastic Member Events Just one of the many benefits

of SFMS membership

SFMS Night at the deYoung Museum

Don’t miss the SFMS night at the de Young Museum! Join SFMS members on Friday, May 9 for a reception—catered by Bon Appetit—on the eighth floor of the observation tower from 5:30 to 7:30 p.m., with access to the entirety of this stunning museum until it closes at 8:30 p.m. The cost for this exciting new event is just $20 (includes museum admission) for SFMS members and their guests. Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or [email protected] for more information or to RSVP (deadline is May 5).

Also in the Works for 2008:

The Togonon Gallery and Jazz Mixer returns this August! Watch for details.

Another SFMS Night at the Symphony is in the works for October or November. More information will be available soon.

In December bring the family to the second annual SFMSNutcracker Night!

Visit our website, www.sfms.org, to see more event listings, including seminars, CMA events, and other local events of interest.

Contact Therese Porter in the Membership Department at (415) 561-0850 extension 268 or [email protected] for more information.

www.sfms.org April 2008 San FranciSco Medicine7

PreSidenT’S MeSSage

“Until we have a nuclear war, the tobacco industry will continue

killing more people than any other man-made cause.”

T hatwasthestartlingbuttruestatementmadebyaresearcheratarecentUCSFconferencetitled“It’saboutaBillionLives.”Andit’ssadlytrue,forallthewell-establishedrea-

sonsabouttobaccobeingbothaddictiveandlethalandbecausethetobaccoindustryhaslongdonewhateveritcantogetmorepeoplesmoking,especiallyyoungones,allovertheworld.

WhichmadeitallthemoredistressingtolearnthattheUni-versityofCalifornia,LosAngeles,accepted$6millionfromtobaccogiantPhilipMorrisfortheotherwiseworthypurposeofstudyingnicotineaddiction.ThiscameaspartofaPhilipMorrisresearchprogramthat,since2000,hassupported470researchproposalsin60Americanmedicalschools.Aspartofthiseffort,in2006–2007,theUniversityofCaliforniareceived23grantsforatotalof$16millioninPhilipMorrisfunding.

UCLAresearchersandofficials,andeventheUCRegents,seemtobeparticipatinginastrongbitofwillfuldenialaboutwhatthisreallymeans.UCLAofficialsdoadmit“theideaforthestudyofteenagersandmonkeysoriginatedwithPhilipMorris.”Butthencomes thisastoundingquote, fromUCLA’svicechancellor forresearch:“IhavenoideawhyPhilipMorrisdecidestofundthisantismokingresearch,buttheydo.Aslongaswedonotfeelthatweareinterferedwithandthattheresearchisdonewiththehighestintentions,what’sinthemindofthefunderisirrelevant.”

Withallduerespect,thatisscientificallyandethicallynaïve.Suchastatementcouldhavebeenmadewithsomevalidity—duetolackofinformation—agenerationorsoago.Nowweknow,fromdecadesofresearchanddisclosureoftobaccoindustrydocuments,and inotherfields suchaspharmaceuticalmarketing, that thesourceoffundingandthemotivesactuallymakeabigdifference.Thedifferencescomeintermsofoutcomeoftheactualresearch,behaviorofcliniciansandotherswhoreadandareinfluencedbyit,marketingactivitiesoftheprofit-motivatedfunders,andmore.Theseinfluencesarefoundevenwhenthereisnooutrightmentionofthefunder’sname—that’soneofthelittlemysteriesofhumanmotivationandthealteringofit,andthetobaccoandotherindus-triesseemtoknowasmuchormoreaboutthatthananyoneelse.

This iswhy,afternumerousembarrassments,most leadingscientificandmedicaljournalshaveadoptedmuchstricter“conflictofinterest”disclosurepolicies,withsourceoffundingforresearchbeingthemainreasonforthat.It’salsowhyarapidlygrowingnum-berofprofessionalschoolsandentireuniversitiesalsohavestricterpolicies,includingmanybanningsuchfundingoutright.

PhilipMorris’sspokesmanaversthecompanyhas“nointen-tionofusingtheresultsorteenagers’brainscanstodevelopmoreaddictivecigarettes.Wewouldneverdothat.”Theproblemisthattheyalreadyhave,asshownbylongandlethalevidenceprovingotherwise.

The tobacco industry’snow-defunctTobacco Institutewasalobbyingarmdisguisedasaresearchcenter,anditfinallyclosedwhenthatbecamecleartoeveryone.NowPhilipMorris,undersimilarpressure,hasjustabandonedtheparticularresearchprogramUCLAparticipatedin,butmoresuchfundingisexpectedfromthemandother“BigTobacco”companies.

UCresearchers andofficials shouldknowall this andactaccordingly.Saying that they“monitor” such fundingcarefully,whilenodoubttrue,isnotenough.TheUCRegentsshouldadoptandadheretoastrictUC-widepolicythatdoesnotallowforanytobaccofundingofresearchatthisgreattax-supporteduniversitysystem.Untilthatoccurs,theevidencewillkeepshowingusthatmoneycanbuyjustaboutanything,includingdenial.

Smoking Out UC

Steven Fugaro, MD, and Steve Heilig, MPH

8San FranciSco MedicineApril 2008 www.sfms.org

eye to eye anatomy:

Ontheleftisa14thcenturydrawingbytheanatomistGuidodaVigevano.Thedissectorlookseyetoeyeatthecorpseinpersonalrelationship,hislefthandembracingthebody,andhisrighthandseemingalmostreluctantlytousetheknife.Ontherightisthefamous15thcenturyillustrationofthefamousanatomistAndreasVesalius.Inthispicture,thehumanbodyismostlyexcludedfromthescene.Theanatomistisnotinrelationshipandlooksawayfromthecorpse,holdingadissectedarmasaspecimentobeviewedwithdetachedobservation.SomehavenotedthistobeanartisticillustrationofthetransitionduringtheRenaissancefromasubjectiveinterrelatedattitudetowardthebodytoamoredetached,objectiveandscientificwayofexperiencingtheartofmedicine.

www.sfms.org April 2008 San FranciSco Medicine9

ediToriaL

A tarecentdinnerparty,ayoungheartsurgeonwasaskedbyawomanfromacrossthetablewhatitfeltlikeactuallytolookatandtouchanotherlivingperson’sheart.Tryingto

sharehissurgicalexperienceobjectively,hereplied,“Well, let’ssee, it looks likepicturesyou’ve seen inanatomybooks,and itfeelssomethinglike,maybe,holdingapieceofsirloinsteakinyourhands.”Astheconversationturnedtoothertopics,mostpartici-pantsseemedunawareofthedisappointedlookonthewoman’sface.Whensheaskedhowit“felt”tolookatanother’sheart,shehadwantedtoknowmoreabouttheyoungsurgeon’ssubjectivefeelings—poetically,howhisheartfeltwhenhewaslookingatandtouchingtheheartofanotherhumanbeing.

InthisissueofSan Francisco Medicine,withitsthemeoftheeyeanditsfunction,wemightnoticethatthescientificobjectivityofthisyoungsurgeon,seeminglysoessentialtomodernphysicians,maybederivedfromtheetymologyofthewordobject.AccordingtotheOxfordEnglishDictionary,thenounobjectmeansthatwhichisthrown,putinthewayof,interposed,exposed,orplacedbeforeone’seyes;thatwhichispresentedtothevieworperception.

Inregardtothisrelationshipoftheeyeandobjectivity,thephi-losopher,poet,andpsychologistRobertRomanyshyn,inhisbookTechnology as Symptom and Dream(Routledge,1989),postulatesthatthefoundationsofmodernscientificthoughtmighthavebegunaroundtheyear1425,whenartistsFilippoBrunelleschiandLeonBattistaAlbertiinventedlinearperspectivevision.Infourteenth-centurypaintings,whichtodaywemightconsidertobedistorted,theviewerseemstobelongwithinthelandscapeorcityscape,withbuildingsorotherobjectssurroundingtheonlooker.However,infifteenth-centurylinearperspectivevision,withitsmore“realistic”distantvanishingpoint,horizon,andever-decreasingproportions,theviewerisadetached,objectiveobserver.

Inthemedicalworld,thisphenomenonoftheeyeasisolatedobserverwasexpressedinthedevelopmentofthestudyofhumananatomy.TheDutchpsychiatristandphilosopherJ.H.vandenBerg,inhisbookMedical Power and Medical Ethics(W.W.Norton,1978),notesthatinthefourteenth-centurydrawingsbytheBolog-neseanatomistVigevano,thedissectorremainsinrelationshiptothecorpse,lookingeyetoeye,whilehislefthandholdsthebodycaringlyandtherighthandperformsthedissection.Bytheyear

1543,thefamouswoodcutofVesaliusdepictsananatomistwholooksnotatthecorpsebutattheviewer,objectivelydisplayingthetendons,nerves,arteries,andveinsofadissectedhumanarm,aspecimentobeviewedwithdetachedlinearperspectivevision.

Bytheyear1628,WilliamHarvey,whostudiedanatomyatPadua,focusedastudiedeyeuponvalves,arteries,andveins,andbymechanically calculatingflowdemonstrated that theheartisapump.BeforeHarvey,theheartwas,inthepoeticwordsofpsychologistJamesHillman,“Mylove,myfeelings,thelocusofsoulandsenseofperson...andtheunfathomabledivine.”Withinthesinglevisionofscience,however,theheartbecomesmerelyamechanizedpump.

Throughout history there were those who protested thetriumphoftheobjectiveeyeoverthefeelingheart.In1602,thephilosopherGiordanoBrunowasburnedatthestakebecauseofhisinsistencethatphilosophyshouldnotbedivorcedfromscience.Intheearlyeighteenthcentury,GiambattistaVicoespousedtheverum factumprinciplethattruthisnotverifiablethroughsciencealone.ThegreatpoetandscientistJohannWolfgangGoethe,inhistreatiseTheory of Colors,challengedNewton’snumericalspectrumofcolorsandincludedthesubjectiveexperience,saying,“Theblueoftheskyrevealstousthebasiclawofcolor.Searchnothingbeyondthephenomena.”

Perhaps themost succinctyetall-pervasivevoiceagainstapurelysecular,mechanistic,andscientificviewoftheuniverseisthepoetWilliamBlake’sprotestagainstthesingle-visionobjectiv-ityoftheorderofthestars,planets,andthewholeuniversesolelyaccordingtothelawofgravity,whenhesaid,“MayGoduskeepfromsinglevisionandNewton’sSleep.”

Andsoitseemsthatwephysicians,practicingobjectivescien-tificmedicineondeeplysubjectivehumanbeings,haveachoice.Wecanobjectifyourworkwithsinglevision,liketheyoungsurgeonatthedinnertable,inwhichcasetheheartlookslikeapictureinabookandfeelslikeasirloinsteak.Orwecanaddtoourscienceourownsubjectivefeelings,andwithaneyeontheheartacknowledgeitasalocusofloveandtheunfathomabledivine.

An Eye on the Heart

Mike Denney, MD, PhD


eYe To eYe

s irArthurConanDoyle,ayoungophthalmologist in1887, foundhimselfboredandaloneinhiscon-

sultingroomat2UpperWimpoleStreet,waiting forpatientswhonevercame. Inaflashof inspirationhecreatedSherlockHolmes, the detective whose powers ofobservationwouldastoundthepeoplewithwhomhecameincontact.

Asweallknow,thefictionalHolmespossessedanuncannyabilitytoobserve,acultivatedcapacitytospotclues.Notreally.What is more important is that ConanDoyle,aneyedoctorwhoseworknaturallyincludedimprovingtheobservationalabili-tiesofhispatients,heededan intuitionalsummons tocorrectcourse, tofill emptyhoursbywritingaboutwhathevaluedmost.Insodoing,hecreatedthequintessentialobserverwhosecapacity tobearwitness,topayattentionwithoutprejudice,knewnoequal.ConanDoyle’scoursecorrectionintheserviceofhiscallingiseverybitasimpressiveasthesleuthingofhiscreation,theamazingSherlockHolmes.

Likemanyhealthprofessionalsinourdaywhohaveawakenedtoawillingnesstoimagine,bearwitness,andrespondcompas-sionatelytothesufferingofotherhumanbeingsandalllife,Holmesknew,asthepio-neeringpsychologistAbrahamMaslowputitinTheFarther Reaches of Human Nature,that“wearenotinapositioninwhichwehavenothingtoworkwith.Wealreadyhaveastart;wealreadyhavecapacities,talents,direction,missions,callings.”

Today,moreandmorehealthprofes-sionalsaremovingbeyondtheperceptuallimitationsofmechanistic technologicalmedicineandmakingthemselvesavailableaswitnessestosocietalsufferingandservantstothegreatergood.Doctors,nurses,mental

healthprofessionals,andclergyhavecometoseenotonlytheirpatientsbutalllivingbeings, in the words of ecophilosopherThomasBerry,as“acommunityofsubjects,notacollectionofobjects.”

Just as Sherlock Holmes was thequintessentialobserverofclues,morethanfifteenthousandShantivolunteersinSanFranciscoalonehavebeenquintessentialwitnesses to suffering.Theyaremenandwomenwhohavechosentomovebeyondbystander statusand to listen, speak,andactfromtheheartaspeoplewithAIDSorcancer shared theirexperiencesand fearsopenly and honestly. These volunteers,whohaveprovidedmorethanthreemil-lionhoursofservicetomorethantwentythousand clients, understand that whattheydoisnotpsychotherapybutpeersup-portbasedoncompassion,honesty, andconsistency—qualitiesmanypeoplepossess.Butusually,thevolunteers’presenceistheirmostvaluableservice.Theyareoftentheonlypeopletowhomclientscantrulyex-pressthechaosoftheirpresent,theiranxietyabout the future.ThisacceptanceallowsShanticlients tofindmomentsofpeace;

forvolunteers,momentsofgrace;often,forboth,momentsofloveandtranscendence.

Likehealthprofessionalswhohavediscoveredthetherapeuticvalueofbearingwitness to the sufferingofothers,Shantivolunteers learn thevalueof cultivatingwhatphilosopherKellyOliverhascalled“thelovingeye,acriticaleye,alwaysonthelookoutfortheblindspotsthatcloseoffthepossibilityofresponse-abilityandopennesstootherness anddifference”—includingallindividualssufferingthepainofsocietalmarginalizationanddiscrimination.Oliverpointsout inherbookWitnessing (Uni-versityofMinnesotaPress,2001)thatthe“lovingeye”sees fartheranddeeperthanmererecognitionofanothernessconferredbyadominantgrouponthosewhosuffer.Itseesintoalovethat“requiresacommitmenttotheadventandnurturingofdifference,”anopenheartedembracingofdifferenceinotherness.

ThelovingeyesofShantivolunteersand all health professionals who havemovedbeyondthestatusofbystanderstodeepsufferingare,inthewordsofMarcelProust, “neweyes” that see“theuniversethroughtheeyesofanother,ahundredoth-ers”andthereby“thehundreduniversesthateachofthemsees.”Theseare“neweyes”thatlookatpatientsnotwithanobjectifyinggazebutwithadeeplyempathiclookofbothaneyewitnessandonewhobearswitnesstotheunseen,ofteninarticulateexperienceswellingupinthebeingofanother.

Oliveralsocontendsthat“subjectivityandhumanityaretheresultofwitnessing,”andforShanticlientsitisthewitnessingoftheirstoriesthatcountsmost.For it isonlywhenonecantellhisorherstorytoacompassionatewitnessthatonecanarticu-lateone’s inner selfand theconsiderable

“Today, more and more health professionals are moving beyond the perceptual limitations of mechanistic technological medicine and making themselves available as witnesses to societal suffering and servants to the greater good.”

Seeing with the Heart’s EyeBearing Witness or Remaining a Bystander

Charles Garfield, PhD


suffering ithasendured. In sharingone’sstorywithsuchawitness,onesimultane-ouslysharesitwithone’sself.

Whetherthestoryistoldbyawealthywomanwith cancer to aphysicianwhorecognizes the life still left in thepatientandhelpsherfindmeaninginherfinaldays,orbyanerrant teenagerwithAIDStoavolunteerwhogentlyhelpshimreconnectwithhisparents, timeandagainwehearfromourpatientshowmuchtheyappreciatethosewhotakethetime,asthepoetJohnMiltonwrote,toserveasthey“onlystandandwait.”

Thewillingnesstomovebeyondthebystander,tolistentothestoriesofthosewe serve,bearwitness to their suffering,andactwithcompassion,isacorecapacityofalmostallofus.Thisisvastlydifferentfromwhatskepticshavebelieved,thatsomanypeoplearehopelessly self-absorbed.Peoplewillchallengetheirpreciouspeaceofmindtoserveothers,notbecausetheyareproddedtodosobutbecausesuchcar-ingenhancestheirownsenseofinnerpeaceandwell-being.

Shantivolunteersneverhavethesat-isfactionofsavingalife,easingbodilypain,orstoppingthespreadofdisease.Dayafterdayandyearafteryear,theyconfrontthesufferingoftheirclients,attimesformingclosebondswithpeopletheyknowwilldie.Giventhatthemajorityofvolunteersareundertheageofforty,theyopenthemselvestotheinnerturmoilandperplexingques-tionsthattypicallyaccompanyahead-oncollisionwithmortality,aself-examinationmostpeopletrytoavoiduntilthelaterstagesoflife,iftheyengageinsuchinquiryatall.

Howmucheasier itwouldbe,or soit may seem, for these twenty-, thirty-,or fortysomethings to remainbystanders.Theycouldbethemenandwomenactuallypresenttothesuffering,neighborsofthoseafflicted,whochoosetoremaindetached,uninvolved. For yearswewatched goodpeople remain silent anddonothing asAIDS ravaged the communities of gaypeopleandpeopleofcolorinepicentercit-iesacrossthenation.Howmuchsufferingistoomuchtowatchandstillremainsilent?Howlongcanwesay,“I’mtoobusy”or“It’snotmyproblem”andretreatquietlytoourjobsandhomes,not-so-distantwitnesses

totragedy?Manyofusrememberhowbravecom-

munityactivistsandcompassionatehealthprofessionalsandvolunteersheldupamirrorforallbystanderswhentheymarchedinthe1980sand1990swithbannersproclaimingthepainful truth, “silenceequalsdeath.”TheirmoralcourageshowedusthewisdomofMartinLutherKing,Jr.’scounselthat“ourlivesbegintoendthedaywebecomesilentaboutthingsthatmatter.”

How do we make sense of the by-stander’spassivity,bothourownandthatofothers?Havewelearnedtoseeourselvesaspowerlessandthereforeinnocenteveninthefaceoftragediesweknowabout?NolessafigurethanAlbertEinsteinremindedus that “thosewhohave theprivilege toknowhavethedutytoact.”

Howwillwechoosetoviewourselvesin these perilous times? As powerlessoutsiders? Innocentbystanders?Respon-siblewitnesses?Involvedcitizens?Hasthebystanderbecomea twenty-first centuryarchetypegrippingus into inactionevenin the faceofglobalclimatechangeandplanetarydevastation?PaulHawkenoffersusanantidote inBlessed Unrest (Viking,2007)whenhewritesaboutthemorethanonemillionenvironmental,socialjustice,andindigenousrightsorganizationsaroundthe world that collectively constitute“humanity’simmuneresponsetotoxinslikepoliticalcorruption,economicdisease,andecologicaldegradation.”

Whathappenstouswhenweobservea steady streamof tragedy and sufferingclosetohomeandthroughouttheworld?Whathappenswhenwefeelanemotionalresponsetosucheventsbutareunableorun-willingtorespond?Whatisthecumulativeimpactofwhatwe’vebecomeaccustomedto?Dr.RichardHazler,AssociateProfessorofCounselorEducationatPennsylvaniaStateUniversity,hasfoundthatadultandchildrenbystanderswhowitness repeatedabuse inflictedonothersmayexperienceboth a psychological and physiologicalstresslevelthat,overtime,canequalthatofthevictim.

InhisbookBowling Alone(Simon&Schuster,2000),sociologistRobertPutnampoignantlydiagnosedthedisintegrationofcommunityinAmerica.Shantiandother

volunteerorganizationsofferaremedyforthisnationaldeterioration,demonstratingthatinconnectingtoanotherhumanbeingthroughacompassionateact,wedeepentheconnectiontoourselves;whenwebondwithotherswhoserve,westrengthenourcommunity.Volunteeringisoneofthebesttherapies inour society.Throughactiveinvolvementinourowncommunitieswebreakthroughthedominantsufferingofourera—thelonelinessandemptinesswefeelinseeingandlivinglifefromaprotectivedistance,blindtotheviewofthelovingeye;thesensemanypeoplehaveoflosingone’slifewhilelivingit.

Charles Garfield, PhD, is an author, lecturer, Clinical Professor of Psychology in the Department of Psychiatry at UCSF Medical School, and founder of Shanti, a widely respected AIDS and cancer service organiza-tion. He is a Visiting Scholar at the Graduate Theological Union in Berkeley and a founding faculty member at the Metta Institute End-of-Life Counseling program.

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eYe To eYe

“The pain of the Mind is worse than the pain of the Body.”—PubliliusSyrus (firstcenturyB.C.)

w henRayCharleswasaroundfiveyearsold,hewatchedhisyounger brother drown in a

washtub.Hegraduallybegantolosehisvi-sion,andoverthefollowingyearortwo,heultimatelybecameblind.Thecauseofhisblindnessisnotcertain;ithasbeensurmisedthathemayhavehadglaucoma.Ithasalsobeen surmised thathisvision lossmighthavebeenacaseof“hystericalblindness.”Heneverrecoveredhisvision.

Ahealthyfifteen-year-oldgirlhadjustlearnedthatherboyfriendwascheatingonher;sheleftschoolearlytogohome,onlytofindhermother inbedwitha strangeman.Whilerunningoutofthehouse,shetrippedandfell.Shedidnothitherheadorloseconsciousness,butwhenshegotup,sherealizedthatshewascompletelyblind.Afternormalexaminationsbyherprimarycaredoctor,ophthalmologists,andneurologists,andafternormalbrainMRIandEEG,thediagnosisofvisualconversionreactionwasmade.Severalmonthslater,sherecoveredfullvision.

Conversionreactionsareanultimateillustrationofthemind-bodyrelationshipatwork. It is adisorderwhosehallmarkis the appearanceof a symptomor loss/alterationofphysicalfunction,suggestiveofaneurologicalorothermedicalillness,butitisactuallyaninvoluntaryphysicalexpressionofapsychologicalconflict.Thesymptomismostcommonlymotor,sensory,orseizure,andthereisnodeducibleorganicpathologyorphysiologicexplanationforthesymptoms.Visualconversionreaction,sometimescalled“ocularhysteria”or“hystericalblindness,”

isonetypeofconversiondisorder,whichisclassifiedintheDiagnostic and Statistical Manual of Mental Disorders IV (DSM IV) underSomatoformDisorders.

Historically, thediagnosisofconver-

siondisorderhasbeencontroversial.Inthenineteenthcentury, conversiondisorderwasrecognizedas“hysteria,”adisorderofthemind,whichwasmainlynotedtobeanafflictionofwomen,sincewomenwerefelttobemoresusceptibletoemotionaleffectsoffear,anger,sexualrepression,andoverallsensitivity.Intheearlytwentiethcentury,itwasstudiedfurtherbyneurologistJean-MartinCharcot andpsychiatristsPierreJanetandSigmundFreud.Theterm“con-version”originatesfromFreud’sexplanationthat psychological/emotional distress isrepressedandisunconsciously“converted”intoaphysicalcondition,therebyrelievingthepatientofthepsychological/emotionaldistress.

ItwasduringWorldWarIthatcon-versiondisorderswere seenmore inmenandwere referred toas “warneurosis”or“traumaticneurosis.” In fact,conversionreactionswereoneof themaincausesofneuropsychiatric collapse inWorldWarI soldiers.Conversionreactionsoftenoc-curredafterwitnessingseverelyviolentin-cidents,oraftertraumaticinjuries,whethermildorsevere.Theyusuallyoccurredafterasoldierreachedaplaceofrelativesafety,

andcouldevenoccurhours,days,weeks,ormonthsaftertheincident.Personswhoexperiencedconversionreactionsveryoftenhadnoprevioushistoryofpersonalitydisor-derorpsychiatricdisturbances.

Ithasbeenestimated that25 to70percentofofficevisitstoprimarycaredoc-torsinvolvepsychologicaldistressthattakesthe formof somatic/physical symptoms.Thisisnotnewstoanyonewhopracticesinprimarycare,asweoftenseethephysi-calmanifestationsof emotional stresses.However,theincidenceofactualconver-siondisorderismuchlesscommon,anditisestimatedthatlifetimeprevalenceinthegeneralpopulationmay rangeanywherefrom10to300casesper100,000people.Estimatesaredifficultandvaryconsiderably,butconversiondisordermayoccurin5to15percentofpsychiatricoutpatientsandmayaccountforabout1percentofdiagnosesinoutpatientneurologicpractices.Conver-siondisordersseemtobemorecommoninwomen,inlesseducatedindividuals,andinlowersocioeconomicclasses.

Conversionreactionsusuallyinvolveneurologicdysfunction,suchasdisordersofspeech,balance, gait, involuntarymove-ments, pseudoseizures, sensation loss inlimbs,paralysis,andvisualandhearingloss-es.Assuch,conversiondisordersareoftenreferredtoas“pseudoneurologicsyndromes”andusuallydonotincludegastrointestinal,genitourinary,cardiac,orpulmonaryprob-lems.Thisdisorder is tobedifferentiatedfrommalingering, somatizationdisorder,hystericalpersonality,hypochondriasis,andpsychogenicpain.

Of conversion disorder symptoms,visual/ocularsymptomsaremuchmorerarebutdooccur.BlindnessisthemostcommonpresentingsymptominVisualConversion

“Conversion reactions are an ultimate illustration of the mind-body relationship at work.”

In the Mind’s Eye

Shieva Khayam-Bashi, MD

“Hysterical Blindness” Examined

12San FranciSco MedicineApril 2008 www.sfms.org www.sfms.org April 2008San FranciSco Medicine1�12San FranciSco MedicineApril 2008 www.sfms.org

Disorder, sometimescalledpseudoneuro-ophthalmologicsyndrome.Intheblindnessofvisualconversiondisorder,patientsoftencomplainof suddenandcomplete lossofvision,but itcanalsobeamoregradualprocess.Othervisualsymptoms,whicharenotexplainedbyorganicpathology, canincludeamblyopia,amaurosis,visualfielddefects,colorblindness,diplopia,ptosis,andunilateralgazeparesis.

Carefulhistoryandphysicalexamsusu-allyhelptoclarifythediagnosis,andorganicpathologymustfirstberuledout.Often,acarefulhistorycanuncoverapsychologicaltrauma thatpreceded thevisual change.Athoroughophthalmologicexamination,includingnormalpupillary reactionsandfunduscopic examaswell as intraocularpressures,shouldexcludeallorganiccauses,exceptcorticalblindness.

Visualconversiondisordersarecom-plexandnotcommonenoughtobewellunderstoodinmedicine.Useofalternativenamesfor“conversion,”suchas“hysterical,”“psychogenic,” “nonorganic,” and “func-tional,” seem topropagate a perceptionofcontroversyanddoubtfulnessofa realcondition.Inthiscondition,thereisa“pri-mary”gaintothepatient, inthathis/herunconscious“conversion”ofaseverepsy-chologicalstressintoaphysicaloneallowsfor relief from thepsychologicaldistress.Buttherecanalsobe“secondary”gainfromthephysicalloss/symptom,suchasfinancialgainsfromdisabilitybenefits,greateratten-tionfromothers,andrelieffromhomeorworkresponsibilities.Asaresult,itisoftenwitha skepticaleye thataphysicianwillapproachapatientwithconversiondisorder,inordertotrytodistinguishitfromfeigningormalingeringforsecondarygains.

Severalyearsago, Ivolunteered inasmallclinicinaveryremotevillagehighinthemountainsofGuatemala.Onenight,aknockattheclinicdoorawokeme,andIfoundmanymembersofafamilyholdingcandlesandaskingmetogotoseetheold-estdaughter,whohadsuddenlygoneblind.Wewalkedonthedirtpathsandthroughthewoodsforalmostanhourtogettotheirsmallfamilyhut,wheretheyoungwomanwas lyingcalmlyonthefloor,and familymemberswereanxiouslytendingtoher.

I learned that shehadhad togo to

thecapitalcitythatday,toagovernmentoffice.Thiswasherfirsttimetoleavehervillage, and shehad to rideonbuses forhourstogettothecity.Uponarrival,shefeltoverwhelmedand“terrified”bythetraffic,clamor,andpandemoniumofthecity.Shefeltoverwhelmingfearforherlife,anditwasawonderthatshefinallyfoundherwaybackhomeafterdark.Onceshearrivedsafelyatherhome,shecollapsedandfellblind.

Tomysurprise,theyoungwomandidnotappeardistressedbyhersuddenbilateralvisionloss,thoughshecouldnotevenseemyfingersinfrontofherface.Herpupil-lary andneurologic examswerenormal.SinceIhadnomydriaticdrops,athoroughfunduscopicexamwaschallenging,but itappearednormalasfarasIcouldtell.Hereyeswereneitherpainfulnorred,cardiacexam revealed no murmur, and carotidexamwasnegativeforbruit.

Her familybelieved thatherblind-nesswaslikelyduetohersevereemotionalresponse to the intense fearof theday’sexperiences.ThoughIreallywishedforanophthalmologist to consult, I concurredwiththefamily’sexplanationsinceherexamwasnormal;Ireassuredherthatshewouldlikely regainhervisionby themorning.Theythankedmeandescortedmebacktotheclinic,whileIprayedendlesslythatshewouldindeedregainhervisionandthatIwasnotmissingsomethingserious,thoughIcouldnotcomeupwithmanyetiologiestoexplainsuddenbilateralvisionlossinahealthyyoungwoman.

Indeed,bymorningsheregainedfullvision;thediagnosiswasvisualconversiondisorder.Herapparentlackofconcernforherloss isreferredtoas“labelleindiffer-ence”andisnotuncommoninconversiondisorders.Afamilyhistoryisalsocommon,andIlaterlearnedthathermotherhadhada similar reactionwhengoingtothecityherselfmanyyearspreviously.Ialsolearnedofapossibleculturalcomponent,inthatitisknowninthissmallvillagethat“goingtothecity”canbeaveryhorrifyingexperience,one thathascaused frightfulmaladies toothervillagersinthepast.

Thisexperienceofvisualconversiondisorderdemonstrates the intimatecom-municationbetweenmindandbody. Inconversiondisorders it couldbe inferred

that, in certain intense situations, it ismoretolerableforthebodytoexperienceaphysicalproblemthan for themind tosufferadeeplypainfulemotionalone, sotheconversionfromemotionaltophysicalseemstheonlyoption.InthefirstcenturyB.C.,PubliliusSyrusencapsulatedtheissuethisway:“ThepainoftheMindisworsethanthepainoftheBody.”

ItwasintheseventeenthcenturythattheFrenchphilosopherandscientistReneDescartessharedhisconclusionthatmindandbodywereseparateentities.Descarteswasnot thefirst toconceptualize suchadistinction,asPlatoalsooutlined thisaswell.Later scientistsandphysicianshaveacceptedthemodelofseparatism/dualism,divisionbetweenmindandbody, in anincreasinglyreductionisticmodelofpractic-ingmedicine.

Inrecentyears,however,thedualismmodelhasbeenchallengedbyareturntotheconceptsofintegrativemedicineandholis-tichealthcare,inwhichmindandbodyareinseparable.Conversiondisordersareoneclearexampleofthisconnection.CountrysingerNaomiJuddoncesaid,“Yourbodyhearseverythingyourmindsays.”Tomanyofuswhoappreciatetherealprinciplesofholismandintegrativemedicine,thisringstrue inallaspectsofmentalandphysicalhealth.Itisvividlyevidentincaseswhenthemind’seyegoesblindasaresultofsevereemotionalstress.

Shieva Khayam-Bashi, MD, is Associate Clinical Professor in the Department of Family and Community Medicine at UCSF and at San Francisco General Hospital, and she is Medi-cal Director of the short-term Skilled Nursing Facility at SFGH.


eYe To eYe

B lindsincebirth,Marie-LaureMar-tinhadalwaysthoughtthatcandleflameswerebigballsoffire.The

39-year-oldwomancouldn’tseetheflamesthemselves,butshecouldsensethecandle’sauraofheat.

InOctoberof2001,shesawacandleflameforthefirsttime.Shewasstunnedbyhowsmallitactuallywasandhowitdanced.There’sasecondmarvelhere:Shesawitallwithhertongue.

The tongue, an organ of taste andtouch,mayseemlikeanunlikelysubstitutefor theeyes.Afterall, it’susuallyhiddeninsidethemouth,insensitivetolight,andnotconnectedtoopticnerves.However,agrowingbodyofresearchindicatesthatthetonguemayinfactbethesecond-bestplaceonthebody for receivingvisual informa-tionfromtheworldandtransmittingittothebrain.

Researchers at the University ofWisconsin,Madison,aredeveloping thistongue-stimulatingsystem,whichtranslatesimagesdetectedbyacameraintoapatternofelectricpulsesthattriggertouchreceptors.Thescientistssaythatvolunteerstestingtheprototype soon loseawarenessofon-the-tonguesensations.Theythenperceivethestimulationasshapesandfeaturesinspace.Theirtonguebecomesasurrogateeye.

Earlierresearchhadusedtheskinasarouteforimagestoreachthenervoussystem.Thatpeople candecodenervepulses asvisual informationwhentheycome fromsources other than the eyes shows howadaptable,orplastic,thebrainis,saysWis-consinneuroscientist andphysicianPaulBach-y-Rita,oneofthedevice’sinventors.

“Youdon’tseewiththeeyes.Youseewith thebrain,”hecontends.An image,once it reachesaneye’s retina, “becomes

nervepulsesnodifferentfromthosefromthebigtoe,”hesays.Tosee,peoplerelyonthebrain’sabilitytointerpretthosesignalscorrectly.

With that inmind,heandhis col-

leagues propose that restoring sight isonlyoneofthemanytrajectoriesfortheirresearch.Restoringstabilitytothosewithbalancedisordersisanother.Soisbestowingpeoplewithbrand-newsenses,suchasthecapabilitytouseheattoseeinthedark.

restoring Lost Vision Firstthingsfirst,however,andforthe

Wisconsinscientists thatmeans restoringlostvision.Swappingthesenseoftouchforsightisnotanewidea.Inthe1960s,Bach-y-Rita,hiscolleagues,andotherscientistsbegandevelopingandtestingdevicesthatenabletheskinofblindpeopletopickupvisualinformation.

ForBach-y-Rita,theexperimentsalsoprovidedinsightintothebrain’splasticity.Hismoregeneralgoalhasbeentofindouthowwellonesensecantaketheplaceofanother.

Untilthe1980s,“oneoftheaxiomsofneurosciencewasthattherewasnoplastic-

ityintheadultcentralnervoussystem,”saysEdwardTauboftheUniversityofAlabamainBirmingham.Today,thefieldhasturnedaroundinresponsetomanystudies,includ-ingBach-y-Rita’s.Now,scientistsviewthebrainasalmostasmalleableinoldageasinyouth,headds.

Theideaoftongueaseyeevolvedfromtheearlierskin-as-eyestudies.Bach-y-Ritaandhiscoworkershadbeenplacingtouch-stimulatingarraysonareasofpeople’sskin,suchas thebackand theabdomen.Thescientists used either electrodesor littlebuzzerstoexcitenerveendingsoftheskinin apattern that corresponded tovisualimages.

Theyfoundthatafterreceivingtrain-ing,blindpeopleusingthesesystemscouldrecognizeshapesandtrackmotion.Somesubjectscouldperceivethemotionofaballrollingdownaninclinedplaneandbatitasitrolledofftheplane’sedge.Otherscouldcarryoutanassembly-linetaskatanelec-tronicsplant.Itrequiredthemtorecognizeglasstubeslackingsolderandthentodepositsomesolderintothosetubes.

These results impressedBach-y-Ritaandhiscolleaguesenoughtobegintryingtoapplytheirbasicresearchtowarddesigningaidsfortheblind,hesays.

Theresearchers’earlysystemshadthelookandfeelofwhattheywere—experi-ments.Thebuzzerswerenoisy,heavy,andpowerhungry.Althoughelectrodescouldstimulatenervesquietlyandefficiently,highvoltagesandcurrentswerenecessarytodrivesignalsthroughtheskin.Thatsometimesledtouncomfortableshocks.

Becauseof thesedrawbacks,Bach-y-Ritabeganthinkingaboutthetongue.“Webrushedhimoff,”recallscoworkerKurtA.Kaczmarek,anelectricalengineerandper-

“A growing body of research indicates that the tongue may in fact be the second-best place on the body for receiving visual information from the world and transmitting it to the brain.”

The Seeing Tongue In-the-Mouth Electrodes Give Blind People a Feel for Vision

Peter Weiss


ceptionresearcher,alsoat theUniversityofWisconsin.“Hetendstobeabitaheadofhisday.”

Intime,however,Kaczmarekwascon-vinced.“Oneday,Isaid,‘Okay,Paul.Let’sgouptothelabandtryit.’Itturnsout,itworkedquitewell,”hesays.

Tongue stimulation, however, isn’tthe only way to circumvent blindness.Onecompetingapproach,forexample,istoimplantmicrochipsintheeyesorbrain.Another scheme, devised by a Dutchscientist,convertsimagestowhathecallssoundscapes,whicharepiped toablindperson’sears.

Tongue Stimulation ToBach-y-Rita,histeam’sswitchfrom

skintotonguestimulationwascrucial.“Wenow,forthefirsttime,havethepossibilityofareallypractical[touch-based]human-machine interface,”hedeclares.HeandhiscoworkersfoundedtheMadison-basedcompanyWicab toexploit thepotential.Kaczmarekpointsoutthefledglingcompanymaybe in for somecompetition, sinceaGermaninventoralreadyhasbeengrantedaU.S.patentforatongue-visionsystem.

“Usingthetongueforseeingisawholenewapproach...Ithinkithasgreatprom-ise,”saysMichaelD.Oberdorfer,programdirectorforvisualneuroscienceattheNa-tionalEyeInstituteinBethesda,Maryland.Hisofficehasbeen funding someof theWisconsingroup’swork.

Thetongueisabettersensorthanskinfor several reasons, saysBach-y-Rita.Forone, it’s coated in saliva—anelectricallyconductivefluid.Sostimulationcanbeap-pliedwithmuchlowervoltageandcurrentthanisrequiredfortheskin.

Also, the tongue is more denselypopulatedwithtouch-sensitivenervesthanmostotherpartsofthebody.Thatopensupthepossibilitythatthetonguecanconveyhigher-resolutiondatathantheskincan.

What’smore, the tongue isordinar-ilyoutofsightandoutoftheway.“Withvisualaidstotheblind,therearecosmeticissues,”saysOberdorfer.“Andyou’dwantsomethingeasytowearthatdoesn’tinterferewitheverydayactivities.”

Currently,theWisconsinresearchers’tongue-displaysystembeginswithacamera

about the sizeof adeckof cards.Cablesconnectitwithatoaster-sizecontrolbox.Extending fromthebox isanothercablemadeofflat,flexibleplasticlacedwithcop-perwires.Itnarrowsattheendtoformtheflat,twelve-by-twelve,gold-platedelectrodearraythesizeofadessertfork.Thepersonlaysitlikealollipoponhisorhertongue.Stimulationfromelectrodesproducessen-sationsthatsubjectsdescribeastinglingorbubbling.

TheWisconsinresearcherssaythatthewholeapparatuscouldshrinkdramatically,becomingbothhiddenandeasilyportable.Thecamerawouldvanishintoaneyeglassframe.Fromthere,itwouldwirelesslytrans-mitvisualdatatoadentalretainerinthemouththatwouldhousethesignal-translat-ingelectronics.Theretainerwouldalsoholdtheelectrodeagainstthetongue.

Thetonguedisplaystillhasalongwaytogointermsofperformance,theresearch-ersadmit. In theBrain Research (July13,2001),Bach-y-RitaandhiscolleaguesEli-anaSampaioandStéphaneMaris,bothoftheUniversitéLouisPasteurinStrasbourg,France,reportresultsfromthefirstclinicalstudyofthetonguedisplay.

Afteraninitial,brieftrainingperiod,12first-timeusers—6sightedbutblindfoldedand6congenitallyblind, includingMa-rie-LaureMartin—tried todetermine theorientationoftheE’sonastandardSnelleneyechart.Onaverage,theyscored20/860invisualacuity.Thecutoffforlegalblindnessis20/200withcorrectedvision.

“It’s not normal sight,” commentsTaub.“It’slikeverydimshadows.Butit’sremarkable.It’sabeginning.”

One obstacle to better vision withthedeviceisthelowresolutionofits144-electrodedisplay.Engineersontheteamsaytheyexpecttoquadruplethearraydensityinthenextfewyears.

Amoreseriousproblemis therangeofcontrast thatcanbe replicatedon thetongue,Kaczmareknotes.Inatypicalim-age,theeyemaysimultaneouslyseelightedregionsthatare1,000timesbrighterthanthedimmestones.Buttheratioofstrongesttoweakesttonguestimulationcanonlybeabout3to1.“That’soneofthethingswe’restrugglingwith,”Kaczmareksays.

Visual Sensations Exactlyhowthe tongue supplies the

brainwith images remainsa focusof theWisconsin team’s research. In his 1993book,The Man Who Tasted Shapes (Put-nam),Washington,D.C.-basedneurologistRichardE.Cytowicmademuchofhowfla-vorsstimulatingthetongueofafriendand,later,anexperimentalsubjectwouldelicitvisual sensations.However, that typeofinvoluntaryandpoorlyunderstoodsensoryblending,which isknownas synesthesia,probably goes beyond what’s needed toexplaintheoperationofthetonguedisplay,Bach-y-Ritasays.

Instead,there’splentyofevidence,hesays,thateventhosebrainregionsdevotedalmostexclusivelytoacertainsenseactu-allyreceiveavarietyofsensorysignals.“Weshowedmanyyearsago thateven in thespecializedeyeregion,auditoryandtactilesignalsalsoarrive,”henotes.

Also,manystudiesoverthepastfortyyearsindicatethatthebrainiscapableofmassively reorganizing itself in responsetolossorinjury.Whenitcomestoseeingviathesenseoftouch,reorganizationmayinvolve switchingportionsof thevisualcortextotheprocessingoftouchsensations,Bach-y-Ritasays.

Inthatvein,thefirstclinicalstudyofthe tonguedevice showed thatusers gotbetterwithpractice.Ofthedozensubjectsin the initialevaluation, twowenton toreceiveanadditionalninehourseachoftraining.Whenretested,theyhaddoubledtheirvisual acuity, scoringanaverageof20/430.

Thebrain’sapparentabilitytoshuntdataforonesensethroughthecustomarypathwaysofanothermayenabletheWis-consin researchers to apply their devicebeyondvision replacement. “It’snot justabout vision,” says Mitchell E. Tyler, abiomedicalengineerwiththegroup.“That’stheobviousone,butit’sbynomeanstheonlygameintown.”

Theteambeganteststhissummerofamodifiedsystemthat’sintendedtoassistpeoplewhohavelosttheirsenseofbalancebecauseof injury,disease,or reactions toantibiotics.Theunitgathers signals fromaccelerometersmountedonapersonthat

Continued on Page 19...


eYe To eYe

H aveyoueverhad the feelingofbeing staredat,only todiscoverthatsomeoneisinfactlookingat

you?Surveyssuggestthatbetweenseventyandninetypercentofthepopulationhasreportedthisexperience.Thequestionis,whatareyouperceivingthatgetsyouratten-tionatjustthatmoment?Isitthatyouarenoticingmovementthroughyourperipheralvision,theconventionalexplanation?Oristhereasubtlefieldofcommunicationthattranscendsknownphysicalmechanisms?Researchintothisphenomenonhasalongandcontroversialhistory.

Initialpapersonthetopicof remotestaring were first published around theturnof thenineteenthcentury.Thefirstexperimental investigation (1913) wasconductedbyaleadingpsychologist,J.E.Coover,atStanfordUniversity.Itinvolvedanexperimentersittingbehindparticipants,eitherstaringdirectlyattheirbacksorlook-ingaway,andthenaskingthemtodecidewhethertheyhadjustbeenstaredat.Inmorerecenttimes,asimilarprocedurehasbeenemployedwithpositiveresults(Sheldrake2005).Other researchershavedevelopedincreasingly sophisticatedmethodologicaland statistical procedures. For example,potentialexperimenter-participantsensorycueshavebeenminimizedbyemployingone-waymirrorsandclosed-circuittelevi-sionsystems(Braud,Shafer,andAndrews1993a,b).Researchershave also createda more sensitive-dependent measure ofparticipant’sarousalbyrecordingtheirelec-trodermalactivity(EDA)ratherthanaskingthemtoreportwhethertheyarebeingstaredat(SchlitzandLaberge1994).

Thebasicexperimentalprocedurethathas evolved includes a “sender” (S)anda “receiver” (R) located in two separate,

sensory-isolated rooms.Aclosed-circuittelevisionsystemfeedsaliveimageoftheRtoamonitorintheS’sroomand,atran-domlydeterminedtimes,theSeitherstaresatthisimagewithintentiontophysiologi-

callyarouseR(“stare”trials)orlooksawayfromthemonitoranddisengageshis/herintention(“no-stare”trials).TheR’selec-trodermalactivity(EDA) iscontinuouslyrecordedduring theexperiment,andanysignificantdifferentialeffectsobserved inEDAbetween“stare”and“no-stare”trialsisinferredtoreflecttheexistenceofanon-physicalconnectionbetweenpeople.

Resultsfromasmallbodyofstudiesaresuggestive,thoughcontroversial.Ameta-analyticreview offifteenexperimentsusingthesetypesofproceduresrevealedasmallbut statistically significantoverall effect(Schmidt,Schneider,Utts, andWalach2004).Whiletheexperimentsdonotalwaysworkandtheresultsappeartovarywithex-perimenters(Schlitz,Wiseman,andRadin2005),themethodologyhasbeenappliedtothefieldofhealthcare.

How do remote Staring and Medicine Meet?

Thescientificobservationsonremotestaringsuggestanexpandedscopeforhu-manperception that isworthyof future

investigation.Theyalsorepresentameth-odologyforexploringthepotentialroleofdistantintentioninhealing.

Intentioncanbedefined in a com-monsenseway as theharnessingofwilltoward someobjectoroutcome (Schlitz1995, 1996). There is a component ofintention inmanyhealing interventions,includingprayer,meditation,andbiofieldhealing.And formany,neitherdistancenorsuggestionmakesadifference.ArecentsurveyofadultAmericans,conductedbytheNationalCenterforHealthStatistics,for example, showed thatof the top tencomplementaryandalternativemedicine(CAM)healingpractices,themostpopularwasprayerforselfandthesecondwasprayerforothers(Barnes,Powell-Griner,McFann,Nahin2004).Whiletheostensibleefficacyofprayerisoftenexplainedthroughrefer-encetopsychoneuroimmunologicalmodelsofself-regulation,therearealsosuggestionsthatdistanthealingintentionsmayplayarole(SchlitzandBraud1997).

DistantHealing Intention (DHI) issometimesusedinthescientificandmedicalliteraturetorefertothisconcept(Schlitz,Radin,Malle,Schmidt,Utts, andYount2003).BecausethemechanismsunderlyingpostulatedDHIeffectsareunknown,mostexperimentshavebeenconcernedwiththestraightforwardempiricalquestion:Doesitwork?Someclinical studies suggest thatDHIismedicallyefficacious(Astin,Hark-ness,andErnst2000),butoveralltheclini-calevidenceremainsuncertain(Bensonetal2006,Krucoffetal2005).

Thelaboratoryevidencemaybeclearerthan theclinical evidencebecause thereareno“competing”intentionstointerferewiththetestresults,suchastheprayersofclinicalpatients’ lovedones,andalsobe-

“The scientific observations on remote staring suggest an expanded scope for human perception that is worthy of future investigation.”

The Feeling of Being Stared AtImplications for an Expanded Model of Medicine

Marilyn Schlitz, PhD


causetinyphysiologicalfluctuationscanbeobjectivelymonitoredinrealtime,whereashealingresponsesmaytakedaysorweeks.Butthecontextoflaboratorystudiesisalsoquitedifferentfromthatofclinicalstudies.In the lab, thepersonassigned to“send”DHI(hereaftercalledthe“sender,”orS)istypicallyavolunteerwhoisnotespeciallymotivatedortrainedtoprovideDHI,andthepersonassigned to receiveDHI(the“receiver,” orR)isoftenjustcurioustoseewhatwillhappen.

a remote Staring Study involving compassionate intention

A recent pilot study illustrates theusefulness of the remote staring testingparadigmforexaminingDHIinthelabora-tory(Radin,Stone,Levine,Eskandarnejad,Schlitz,Kozak,Mandel, andHayssen, inpress).Researchers lookedatwhatwouldhappen when the powerful motivationsassociatedwithclinicaltrialsofDHIwerecombinedwiththecontrolledcontextandobjectivemeasuresofferedby laboratoryprotocols.

This laboratory study recruited long-termcouplesasparticipantsandexploredwhether trainingandpractice in sendingintentionswouldmodulateanymeasurableeffects.Itfocusedonmeasuringshort-termchangesintheR’sphysiologicalstateasitcorrelatedwith theS’s intention. It alsomeasuredthecorrelationbetweenthetwo;ifSwasexcited,forexample,didRshowthesamestate?

Participantswereassigned tooneofthreegroups.Twoofthesegroupsconsistedofadultcouples,oneofwhomwashealthyand theotherofwhomwasundergoingtreatmentforcancer.Thehealthypartnersinoneofthesegroups,calledthe“trainedgroup,”attendedaneducationalprogramonthecultivationofcompassionateinten-tion,definedastheactofdirectingselflessloveandcaretowardanotherperson.Theypracticed this intentionalmeditation forthree months before they came to thelab tobe testedwith theirpartners.Thehealthypartnersinthe“waitgroup”cametothelabwiththeirpartnerbeforetakingthetrainingprogram;andthethirdgroupconsistedofhealthycoupleswithoutspecialtraining,practice,ormotivationotherthan

curiosity.Whenacouplearrivedatthelab,the

experimentersattachedelectrodestoeachperson.TheRwasasked to relax for30minutesinarecliningchairinsideadoublesteel-walled,shieldedchamber.RwastoldthatSwouldbeviewinghisorherlivevideoimagefromadistantlocationforanunspeci-fiedlengthoftime,andatrandomintervals,and thatduring thoseperiods the senderwouldmakeaspecialintentionalefforttomentallyconnect.NeitherSorRknewinadvancethattheintentionalperiodswere10secondsinlength,andnoone,includingtheexperimenters,knewwhentheinten-tionalperiodswouldoccurbecause theywererandomlydeterminedbyacomputer.ThehypothesiswasthatS’sintentionwouldcausethedistantR’ssympatheticnervoussystemtobecomeactivated.

A total of 36 couples participatedin the study:12 in the trainedgroup,10in thewaitgroup,and14 in thecontrolgroup.AnalysisofdatacombinedacrossallcouplesshowedthatR’sskinconductancesubstantially increasedover thecourseoftheaverage10-secondintentionalsendingperiod(p=0.00009).Ahalf-secondafterthe senderbegantodirect intention, thereceiver’saverageskinconductancebegantorise.Itcontinuedtoriseandpeakedattheendof the10-secondperiod, then itbegantodecline.Thiswasmostunexpectedbecausewhenaperson is asked to relaxquietlyinashieldedroomwithnoexternalstimuli, their skinconductancenormallyjustdeclines,indicatingrelaxation.

Comparison of the receivers’ skinconductanceacross groups revealed thatreceivers in all three groups respondedwhen theirpartnerbegan sending inten-tion,but thecontrols’ response subsidedafter4seconds, thewaitgroup’s responsesubsidedafter5 seconds,and the trainedgroup’s response subsidedafter8 seconds.Theseobservations suggest that trainingplusmotivationwasmoreeffectivethanjustmotivation,andmotivationmoreeffectivethanmereinterest.Insum,thisstudy,andmanyotherspreviously reported, suggeststhatDHIhasameasurableeffecton thehumanbody,hopefullyonethatisperceivedasbeneficial.

attempts at MechanismTheeffectsdescribed ina significant

numberofremotestaringstudiesaregen-erally considered scientifically doubtfulbecausethe“distant”inDHImeansshieldedfromallknowncausal interactions.Hav-ingsaidthat, science is slowlycomingtotermswith theconceptofwhatEinsteincalled“spookyactionatadistance”withinfundamentalphysics.Research inquan-tumtheoryhasshownthatundercertainconditions,particles that interact remaininstantaneouslyconnectedaftertheysepa-rate,regardlessoftheirseparationintimeorspace.Ifthispropertyistrulyfundamental,theninprincipleeverythingintheuniversemightbeentangled(Radin2006).Whileeveryday objects and humans have notbeen showntoexhibit suchcorrelations,quantumentanglementbegins tooffer apossiblemechanismforDHI.If thisconceptdoesapplytohumans,itcouldexplainwhyentanglementsbetweenthemindsandbod-iesofan indifferent,unmotivatedcouplemaybedifficulttodetect.Butinahighlymotivated,long-termbondedcoupleaskedtoconnectmentally,andwiththe“sender”trained toprovideDHI, theunderlyingcorrelationmightbecomemoreevident.AsRadinetal (inpress)pointout, sucharelationalmodel isappealingbecauseitdoesnotrequireanything(force,energy,orsignals)topassbetweenSandR.Instead,itpostulatesaphysicalcorrelationvia“nonlo-calthreads”thatmaytrulyweaveustogetherasaseamlesswhole.

For three decades, scientist and anthro-pologist Marilyn Schlitz, PhD, has pioneered clinical and field-based research in the areas of consciousness, healing, and transformation. She is Vice President for Research and Education at the Institute of Noetic Sciences, Senior Scientist at the California Pacific Medical Center, and Chief Learning Officer for Integral Learning Corporation. Schlitz’s books include LivingDeeply:TheArtandScienceofTransfor-mation inEverydayLife(with Vieten and Amorok) and ConsciousnessandHealing:IntegralApproachestoMind-BodyMedi-cine(with Amorok and Micozzi).

For a full list of references, please visit www.sfms.org/archives.


eYe To eYe

“I learnt to restrain speculative tendencies and to follow the unforgotten advice of my master, Char-cot: to look at the same things again and again until they themselves begin to speak.”—Freud

i recentlyrevisitedThe Fear of Looking(UniversityofVirginiaPress,1974)byDavidW.Allen,MD,localpsychiatrist,

psychoanalyst, andpastpresidentof theSFMS.Nowwellintohisninthdecadeoflife,Dr.AllenretiredfrompracticefifteenyearsagoandliveswithhiswifeSallieinSanFrancisco.His123-pagemonographpublished thirty-fiveyears ago stilloffersuseful insights relevant to this month’sSan Francisco Medicinetheme,theeyeandvisual functioning.Dr.Allen focusesonthepsychosocialvicissitudesandconflictsexperiencedwiththepleasurableinstinctualdesirestoseeandtolook(scopophilia)andtoshowandtobelookedat(exhibitionism).Hisbookbrilliantlyillustratesthehistoryandimportanceof scopophilic-exhibitionistic(look-show)factorsinclinicalpsychiatricdisorders, in everyday life, and in thetreatmentsituation.

HereIwanttoconsiderhis“implica-tionsoflook-showfactors”forthecreativeprocess inartand science, the subjectofthebook’sconcludingchapter.Ofrelatedimportance is thecreativeprocess inourmedical clinicalworkwithpatients.Asphysicians,wetryourbesttoseepatientsand theirdisorderedphysicalandmentalphenomenology just as theyare.Robustseeing,looking,listening,andexaminingareusuallyfollowedbyshowinganddisplayofourfindingstoourselves,ourpatients,andourcolleaguesinourbestcreativeclinicalwork.Emotionalconflictsinanyofthosefunctionscanimpairthatcreativity.

Onanother level,ErikEriksononce

remarkedthatoneofthefunctionsofgreatintellectualleadersistomodelpermissiontoexplorenewfields.“Theygivepermissiontolook,tosee,tounderstandthepreviouslyforbiddenorunknown,” statesDr.Allen.“ThisistrueofFreud,asitisofDarwin,Pas-teur,Euclid,andEinstein.AnditisprobablytrueofMoses,Jesus,Gandhi,andMalcolmX”(p.2).Artisticandscientificcreativitydependonlookingandshowingfactorsinthecreators.“Frombirthtodeath inanyculture,bypervasiveattitudes,byrepeatedexamples,bystreamsofsubliminalcues,weall are taught selective inattention,” saysDr.Allen. “Weare taughtwhatwemustknow,whatwemayinvestigate;andwhatwemustnotquestion,say,orshow.Ifitistruethattheartofbeingwiseistheartofknowingwhattooverlook,itisequallytruethatcreativegeniusisthecapacityforseeingrelationshipswhereothersseenone.Anditisofteninobservingthecommonplacethatsuchinsightoccurs”(p.6).

Dr.Allenbelievesthattheindividualbecomescreativeonlyifhepossesses“thatunintimidated,boundingscopophiliathatseesbeyondtheimmediatefocusoflearn-

ing...(andis)balancedwithanassertiveexhibitionism ... challenging us to seethingsastheyare,beyondwhatauthorityhaspreviouslyprescribedorproscribedthatwesee”(p.109).Curiosity(derivativefromscopophilia)isessentialforcreativity.The“aggressivepleasure”ofcreativitydependson “lookingand showingcathexes.”Dr.Allenbelievesthatafundamentalfirststepinthecreativeprocessis“theabilitytobeinwardlycurious, toemploy self-directedscopophiliawithouthampering anxiety”(p.111).Helistsseveral“requirementsofcreative thinking” (p.112)gleaned frompsychoanalyticworkwithcreativepeople.Theseare:

1.) Scopophilia and its derivativecuriositymustbeego-syntonic,playful,andinsatiable.

2.) Exhibitionism (the pleasurableabilitytodisplay)hastobetolerablyego-syntonic.

3.)Rebelliousnessmustbeagreeabletotheego.

4.)Theremustbeatendencytousereversal, to turn things upside down inwholeorinpart.

5.)Sometendencymustexist touseisolationasamentalmechanism“permit-tingabuildupoftensionsthatpotentiatebreakthroughsofobservations,feelings,andthoughtsintonewlyexperiencedcombina-tions.”

6.)Theremustexista loveofplay-ing with one’s thoughts while delayingactions.

7.)Pleasurein“fondling,takingin,andpenetrating”ideasfortheirownsakemustbepresent.

8.)Thereisapleasureinpassiveob-servationoftheselfaswellastheexternalworld,as inShakespeare’s “Whento the

The Fear of Looking Notes on Seeing, Showing, and the Creative Process

Steve Walsh, MD


sessionsofsweetsilentthoughtIsummonupremembranceofthingspast.”

9.)Acapacityforsolitarybrainstorm-ingispresent,withoutprematurecriticismandrejectionbyrationality—asChurchillwrites, “No idea is sooutlandish that itshouldnotbeconsideredwithasearching...steadyeye.”

10.)Theabilitytoenjoytheregressiveelementsofthoughtandtransientregressivestates,“mentalmessinessormuddleheaded-nessthatmaybeprerequisiteforindepen-dentthinking,”isdisplayed.

11.)There is a capacity for realisticrejectionandorderinginfinalreview.

12.)Anabilityexiststoformamulti-tudeof temporary identifications, to shiftpointsofview,anglesofvision,to“produceaclearerperception thanmonoculargaz-ing froma singlepointofobservation....Repeatedshifts...helptosiftoutthereallyrelevantfromthechaff.”

Dr.Allenbelievesthatthecreativityofaculturalgrouporsubgroupdependsontwosources.Oneisthe“culturaloutsiderwhosesetsofselectiveattentionandinat-tentiondiffer fromthegroupnorm,”andtheotheristhe“insiderwhohasbecomepartlyanoutsider,who ...hasescapedorbrokentherigidscopophilic-exhibitionisticinhibitionsofasectorofhisculture...feelinghimselfsetsomewhatapartfromtherigidmajority.”Thepersonwhocan“imaginehimselfinmorethanoneidentityandcanshiftbetweentheidentitiesandfusethembringsustothecreativeadvantageoftheculturalinsider-outsider,thesemi-outsider,thesemi-insider.”

ThereismuchmoreworthyofreviewinDr.Allen’sexcellentmonograph.Hehasdescribedwellapsychoanalyticpsychiatrist’sviewofvisual functioninganditsmentalandemotionalaccompaniments.

Dr. Steve Walsh is a private-practice psychiatrist in San Francisco and Mill Valley. He is past president of the SFMS, the Northern California Psychiatric Society, and of the UCSF Association of the Clinical Faculty. He is a mem-ber of the editorial board and of the psychiatric services committee of the SFMS.

indicatewhenheorsheistilting,andinwhatdirection.Bystimulatingthetonguewithpatternsrepresentingthedegreeanddirectionoftilt,suchadevicemayactasanartificialvestibularsystem.Thenthepersonmightbeabletocorrectbodilypositionandavoidfalling,Tylerexplains.

Although themainemphasisof theWisconsinresearchhasbeenrehabilitation,thegroupalso foreseesusing its technol-ogytoaidpeoplewhodon’thavesensorydeficits.

Interestinenhancementofthesenseshascomeprimarilyfromthemilitary.WhileBach-y-Ritaandhiscolleagueswereusingexternalskinasareceiveroflight-derivedimages, theDefenseAdvancedResearchProjectsAgency inArlington,Virginia,funded them to develop a sonar-basedsystem tohelpNavycommandosorientthemselvesinpitchdarkness.Theprototypeworked,Bach-y-Ritasays.

Tyler proposes that ground soldierscouldalsoreceivedatabymeansofinfrared

camerasorothersensors thatwouldalertthem,throughthetongue,tothepresenceandpositionsof enemy troopsor tanks.Civilianworkers,suchasfirefighters,mightalsobenefitfromsuchinterfaces.

That’s pure speculation right now.Martin’sboutsofvision,however,aremuchmore than that. InanewfilmthatairedonCanadian television in June, a smilespreadsacrossMartin’sfaceasshegetsherfirstglimpseofacandleflame.

Thefilm,Touch: The Forgotten Sense,highlightssomeoftheWisconsinwork.Itsmessageisthis:Touchworksinathousandways,oftenwithoutpeopleevenbeingawareofitsroles.

Bytakingthissenseintonewarenas,suchas the tonguedisplay,Bach-y-Ritaandhiscoworkersintendtoextendtouch’srepertoireevenmore.

For references and further reading please visit our website, www.sfms.org/archives.

Reprinted with permission from ScienceNews, copyright 2001.

The Seeing Tongue Continued from Page 15...


eYe To eYe

w hen I was a kid, my friendsand Iwould sometimesposehypothetical questions such

as,“Ifyoucouldonlykeeponeofyourfivesenses—touch,taste,sight,vision,smell—whichwoulditbe?”AsIrecall,everyone,withoutexception,chosesight.

Muchlater,IwasprivilegedtoassisttheBerkeley-basedSevaFoundationonblind-nessprojects in theHimalayas. Impairedvision in that regionof theworld,wherethereisextremeclimate,muchpoverty,andnoroads—canbeadeathsentence.Blindpeople, includingyoungpatients in theirthirtieswithseverecataract,trachoma,andtrauma—becomewholly relianton theirfamiliesforsurvival.

One suchpatientwasamiddle-agedmanwhohadneverseenhisgrandchildren,havingbecomefunctionallyblindyearsbe-fore.Thevolunteereyesurgeoncompletedthesurgeryandthepatientworebandagesforacoupledays.Whenthebandageswereremoved,hegazeduponhisfamilyatlast.Withinminutes,everyoneintheareawasintears—includingme.ItwasoneofthemostmovingexperiencesI’veeverhad.

ThestoryofSevahasbeenwidelytold:howaseeminglyunlikelybandofintrepidpublichealthexpertsandsixtiescounter-cultureheroes came together inAsia inthe1970stochooseaninterventionwiththebestchanceofhavingrealandlastingimpactinalleviatingsufferingthere.Morethantwomillionsurgerieslater,Seva(thename can be translated from Sanskritroughlyas“servicewithasmile”)hastrainedmultitudesofclinicians,builthospitalsandclinics,andprovidedmuchdirectcareandpublichealthsupport.Patientssometimeswalkforweekstogettoan“eyecamp”orhospitalforservices.

A professed goal ofmuch internationalhealthworkisthatvisitingexpertsandcliniciansshouldtrainlocalstoprovidetheservicesneeded,sothattheworkinthefielddoesnot remaindependentuponvisitorsandthesponsoringorganization.Mostinternationalprogramsdonotattainthis.ButSevadoesso,bothinAsiaandinitsotherprojectsinMexicoandwithNativeAmericans.

EastBayophthalmologistandUCSFassistantclinicalprofessorNaveenChandra,MD,hasvolunteeredhisservicestoSevaatitshospitalinLumbini,inNepal,partlyforthat reason. “Themost impressiveaspectofSeva’swork is that themodelaimsatmakingacharitablemedicalinstitutionself-sufficient,”hesays.“WhenIactuallysawthemagnitudeofwhattheydo,itwasjuststaggering.Theenergyandpassion thesedoctorsandstaffbringtotheirworkissoinspiring.”Asforhisownvisits,heexplains,“AtmylastvisittoLumbini,Iperformedcorneatransplantationsongoodcandidates.Wedidothersophisticatedocularsurfacediseasesurgery:corneallimbalautograft,forexample.Inaddition,andmoreimportantly,Iproctoredtheircorneaspecialist,ManojSharma,oncorneatransplantation.Lastly,Igavelecturestothedoctorsonstaffandintrainingoncorneatopics.”

“IfeellikeIreceivedmorethanIgave,”saysChandra. “This iswhy Iwent intomedicineinthefirstplace:tobeabletohelpatagrassrootslevel,andtocareforpeoplewhoaresoappreciativeofthebenefitsofmywork—itmakesme re-energizedandpassionateaboutbeingaphysician.”

SanFranciscoophthalmologistDavidHeiden,MD,alsoworkswithSevaatitsnewCenterforInnovationinEyeCareinBerke-ley,California. “CMVretinitis iscausingprofoundblindnessinasubstantialgroupofAIDSpatients,”henotes.“We’velaunchedtheAIDSEyeInitiative,andournextstepistofigureouthowandwhattoteachover-workeddoctorsonthefrontlines,learningfromwhatSanFranciscoophthalmologistsdidattheheightofourAIDSnightmare.InsuchplacesastheslumsofRangoonorruralAfrica,howcanwe teachAIDSdoctorswithalmostnoresourcestodothecrucialpartstopreventAIDS-relatedblindness?It’sexactlythesortofproblembestaddressedatacreativeplacelikeSeva.”

The lateDavidSachs,MD,anoph-thalmologistandSFMSpastpresident,firstwenttoNepalwithSevainthelate1980s,afterIreturnedfromatripthereandtoldhimaboutSeva’swork.Whenhereturnedfromthatfirstvisit,hereportedthat“thiswasthebest‘vacation’I’veeverhad,andI’mgoingback.”Hedidso,repeatedly.There’sjust somethingaboutSevathat speaks tothebestinpeople.

For more information on Seva, see www.seva.org or call (877) 764-7382.

The Seva Foundation Sets a Standard for Sustainable “Compassion in Action”

Steve Heilig, MPH

Saving Sight with a Smile

20San FranciSco MedicineApril 2008 www.sfms.org www.sfms.org April 2008 San FranciSco Medicine2120San FranciSco MedicineApril 2008 www.sfms.org

eYe To eYe

V isualdisabilitycanbedefined inseveralways.Formostpatients,thetermblindnessdenotesnotbeing

abletoseelight,butthisformofabsoluteblindnessisinfactsignificantlylesscommonthanpartiallossofvision.Visualdisabilityistypicallydefinedonthebasisofteststhatdonotaccuratelyrepresentactualimpairmentforactivitiesofdaily living.Forexample,patientswithsometypesofmaculardiseasemayhavea“normal”Snellenvisualacuityof20/20butstillexperienceseveredistortionthatprecludesmeaningfuluseofthisvision.However,forlackofbetteralternatives,thedefinitionofvisualdisabilitycontinuestobebasedontwocommontestsofvisualfunc-tion,namelySnellenvisualacuityandvisualfieldmeasurement.Thus,“legalblindness”isdefinedasvisualacuitywithbestcorrec-tioninthebettereyeworsethanorequalto20/200oravisualfieldextentoflessthan20degreesindiameter.“Visualimpairment”isdefinedashavingbestcorrectedvisualacu-ityof20/40orworseinthebettereye.

Visual dysfunction is a significantcauseofdisabilityamongAmericans.Inthe2004studybytheEyeDiseasesPrevalenceResearchGroup reported in theArchives of Ophthalmology, it was estimated that937,000Americansolder than40 (0.78percent)wereblindandafurther2.4mil-lion(1.98percent)hadvisualimpairment.Theleadingcauseofblindnessamongwhitepersons was age-related macular degen-eration(54.4percentofcases).Incontrast,amongblackpersons,cataractandglaucomaaccounted for more than 60 percent ofblindness.Cataractwastheleadingcauseofvisualimpairmentinwhite,black,andHispanicpersons.Thisreportalsoprojecteda70percentincreaseinblindnessandvisualimpairmentbytheyear2020,owinglargely

totheagingoftheAmericanpopulation.Prevalence estimates in this study werebasedonbestcorrectedvisualacuity,thusvisualdisabilityduetouncorrectedrefrac-tiveerrorwasnottakenintoaccount.

Theimpactofvisualdisabilityismul-tifoldandaffectsthepersonalaswellasthepublic domain.At the individual level,visualdisability candrastically alter thephysical,emotional,andeconomicaspectsofaperson’slife.Fromthepublichealthper-spective,itresultsinasignificanteconomicburdenthatcanimpactresourceallocationforotherhealth-relatedinitiatives.

Theeconomicimpactofvisualimpair-mentwas recentlydescribed in the2007reportreleasedbytheorganizationPreventBlindnessAmerica.Thefindingsof thisreportwerebasedontwostudies.ThefirststudybyReinandcolleagueswaspublishedin2006 in theArchives of Ophthalmology.Theauthorsestimated the totalfinancialburdenduetovisualimpairmentat$35.4billion,attributedtodirectmedicalcosts,indirectcosts,andlostproductivity.Out-patientandprescriptioncosts formedthemajorportionofthedirectmedicalcostsin-volvedinthetreatmentofeyedisease,whilenursinghomecareaccountedfornearlyallof the indirectcosts.Whencompared tothegeneralpopulation,thepercentageofvisuallyimpairedorblindpersonsrequiringnursinghomecarewassignificantlyhigher.ThesecondstudybyFrickandcolleaguesre-

portedanannualexcesscostof$5.48billionincurredbyindividualswithvisualimpair-ment,theircaregivers,andhealthcarepay-ers.Mostofthisadditionalexpenditurewasspentonhomehealthcare.Theeconomicburdenofvisualimpairmentisexpectedtoconsiderablyincreaseinthefuture,instepwiththeincreasingageandlifeexpectancyoftheAmericanpopulation.

Given the considerable impact ofvisualdisabilityon the individualaswellas society as awhole, it is important toinitiatemeasures todecrease thisburden.One preventive strategy is to improvescreening forvision-threateningdiseasesbyprograms suchas theEyeSmartpublicawareness campaign, a joint initiativeoftheAmericanAcademyofOphthalmology(AAO)andEyeCareAmerica.Thegoalofthiscampaignis“tolimittheimpactofeyediseasestomorrowbyraisingawarenessofriskfactorstoday,”anditsinitialfocuswillbeonfivemajoreyediseases:age-relatedmaculardegeneration, cataracts,diabeticretinopathy,dryeye,andglaucoma.TheAAOhas also issued aneweye-diseasescreening recommendation,which statesthatadultswithnosignsorriskfactorsforeyediseaseshouldgetabaselinescreeningatage40.Asecondstrategytoreducetheimpactofvision loss is todevelopmoreeffectivetreatmentmodalities.Therecentdevelopmentofantiangiogenesisdrugsforthetreatmentofage-relatedmaculardegen-erationisagoodexample.

Inconclusion,visualimpairmentandblindnessareimportantcausesofdisabilityin theUnitedStates.Theprevalenceofvisualdisabilityand its relatedeconomiccostsareexpectedtodramaticallyincreaseinthenextdecade,andhencepreventivemeasuresmustbeundertakentoday.

Visual Disabilities in the United StatesHow Loss of Vision Impacts Both Patient and Society

Sunita Radhakrishnan, MD

“Given the considerable impact of visual disability ... it is important to initiate measures to decrease this burden.”


eYe To eYe

p ickupalmostanyperiodicalthesedays, from the staid Wall Street JournaltotheNational Enquirer,or

clickthroughtheTVchannelsanytime,andtheoddsaregoodyou’llcomeacrosssomenewdevelopmentorother thatpromisestomakeyoulookmarvelous.Thereisnomysterywhy.Forasratesofsmokingandalcoholusehavedeclined,andasaware-nessofthebenefitsofhealthierdietsandexerciseregimenshaveincreased,notonlyhavelifeexpectanciesshotupbutsoalsohasthedesiretolookasyouthfulaspossibleinallstagesoflife.

To meet that demand, a bewilder-ing arrayofnewgoods and serviceshasexplodedontothescenetomakeuslookandfeelbetter.

Oncevirtually the soleprovinceofbeauticians,hairdressers, andplastic sur-geons, techniques to enhance cosmesisarenowpracticedbyamotleygroupthatincludesspeciallytrainedophthalmologists,dermatologists,otolaryngologists,internists,generalpractitioners,andevendieticiansand other nonmedical personnel, suchas “estheticians,”personal trainers, evenmeditationgurus.

Therehavebeenhugeshiftsinwhatisconventionallyconsideredtobebeautifulovertheyears—fromtherubicundplump-nessfavoredattheturnofthelastcenturytothegauntpallorcelebratedinhighfashionmagazinesduringthelastfiftyyears.Buttheonethingthathasn’tchangedoverallthattimeisthattheeyeshavealottodowithbeauty.Foritistheimpactleftfromfirsteyecontactthatleavesthemostimportantandmemorableimpression.

Butwhat is itabout theeyes that isbeautiful? Is it their color, the distancebetweenthem,thefullnessandangleofthe

lids,thelengthofthelashes?Orisitthecontourofthebrowsandnosethatframetheeyes?Alas,wearehardpressedtonameafeature,whetherofeye,brow,ornose,thatdeterminesbeauty.Butweinstantlyknow

beautifuleyeswhenweseethem.Andyetnotallbeholdersagree.

ApriorgenerationswoonedatMarleneDietrich’shigh,archingeyebrows.Today,many consider that somewhat freakish,preferringthelow,flateyebrowsofaBrookeShieldsora JenniferConnelly.Then,ofcourse,ethnicandracialdifferencesoftenexplain why some fancy uncreased, flatAsian eyelids and others the rounded,creased “Western” lids.Among the spe-cialistswhohavebeenmost affectedbythevagariesofeyebeautyarearelativelynewgroupofspecialists,ophthalmicplasticsurgeons.

Agroupofophthalmologists servingduringWorldWarIIdedicatedthemselvestothegrim,delicatetaskofreconstructingthe shatteredeyelids andorbitsof those

wounded inwar,gainingvastexperiencegiven theabundanceofmaterial toworkwith.Afterthewarthelessonslearnedwereputtogooduseforbothfunctionalaswellascosmeticpurposes.Themostinfluentialpapers and textbooks on anatomy andphysiologyoftheeyelidsandorbit,aswellasfunctionalandcosmeticeyelidsurgery,werewrittenby thosebattle-trainedophthal-mologists. In1969, thegroupestablishedaneworganization,theAmericanSocietyofOphthalmicPlasticandReconstructiveSurgery.

Throughitsmembersanditsjournal,Ophthalmic Plastic and Reconstructive Surgery,remarkableadvances inboth the scienceandartofophthalmicplasticand recon-structivesurgeryhavebeencommunicatedtobothmembersandrelatedmedicalspe-cialistsalike.

Asanindicationofhowrapidlythingshavechanged,amongtheinnovationsthatdrawthemostpublicandprofessionalatten-tiontodaytoeliminateage-relatedwrinklesandhollowsfromtheeyelidsaretreatmentsthatwere scarcely imaginedagenerationago.PerhapsthemostwellknownoftheseisamusclepoisonthatwasfirstisolatedanddevelopedbyaSanFranciscoophthalmolo-gist,AlanB.Scott—botulinumtoxintypeA,knownpopularlyas“Botox.”

Witharemarkablesafetyrecord,botu-linumtoxinprovidesanonsurgicalwaytovirtuallyeliminatecrow’sfeet,intra-eyebrowfrownandworrylines,andeventheperioralwrinkles(rhytids)attheedgesofthelips.Unfortunately,thetreatmentsaretempo-raryandonemustberetreatedabouteverythreemonthstostaywrinkle-free.Recentreports concerning life-threatening risks,whileworthnoting,shouldbeoflittlecon-

“As rates of smoking and alcohol use have declined, and as awareness of the benefits of healthier diets and exercise regimens have increased, not only have life expectancies shot up but so also has the desire to look as youthful as possible in all stages of life.”

Forever YoungIn the Quest for a Youthful Appearance, the Eyes Remain a Focus

Gary L. Aguilar, MD

Continued on the Following Page...

22San FranciSco MedicineApril 2008 www.sfms.org www.sfms.org April 2008San FranciSco Medicine2�22San FranciSco MedicineApril 2008 www.sfms.org

cerntocosmeticpatientssincethemortalcomplicationsprincipallyaffectedchildrenwhowerebeinginjectedwithvastlyhigherdosesofBotoxfornoncosmetic,musculardisorders.Cosmeticpatients,however,arenot immune topotentialproblems.ThemostcommoncomplicationofcosmeticBo-toxoccurswhenthematerialmigratesawayfromtheinjectionsite,causingatemporarydroopyuppereyelidordoublevision.

Anotherincreasinglypopularapproachtotheproblemofwrinklesandhollowsistofill them.Thevalueandpopularityofsuchtechniqueshasfollowedaseachangeinhowweperceivethe idealoutcomeofcosmetic surgery. Whereas it was oncebelievedthesurgeon’sgoalwastoremoveasmuch fat as possibleduring aestheticsurgery,leavingthehollow-eyedlookofanunderfedsupermodel,itisnowrecognizedthat“skeletonizing”theeyelidsisnowaytorestoreyouth.Thepresenceofsomefatisacharacteristicofyouth.Leavingabitofitinjusttherightplacesaccentuatesyouthfulbeauty.Toachievethedesiredeffect,ithasbecomecommonduringsurgerytotransferthepatient’sownfatfromaplacewhereitistooabundant—in,say,anupperorlowereyelidorthebelly—toaplacewherethereisoftenanunsightlyhollow—intheinferiormedialeyelids,justbelowthebonyorbitalrim,forexample.

Butsometimestherejustisn’tenoughfat to goaround, and so a substitute forvolumeenhancementiscalledfor.Inject-able collagen, both human-derived and

bovine-derived, is approved for injectionbytheFDA,andbothhavebeenpopularchoicesforaugmentation.Buttheirwidestusehasbeeninfillingsmalldefects,fromthedepressionsassociatedwithscarstocrow’sfeet,frownlines,andthefinerhytidsatthelipmargins.Bothtendtolastnolongerthansixmonths,andthelessexpensive,bovine-extractedproductrequiresskintestingforallergyprior touse.During thepastfiveyears,abevyofnewproductshasbeenaddedtothefillerarmamentarium,productsthatcarrynoneofthefewrisksthatareposedbycollagenandproductsthatarecapableofdoingmuchmorethanjustfillingthesmallfurrowsaroundthelipsandlids.

While an exhaustive discussion ofalltheproductsthatarenowavailableonthemarketiswellbeyondanyreasonablespace constraints, a brief overview is inorder to prepare members for questionspatientsmighthave.TheproductsknownasRestylane,Hylaform,andJuvédermareFDA-approvedandareformulatedusingaproductofnature,hyaluronicacid.Theycannotonlyfillthesmallfurrowsbutalsomuchlargerdepressions,includingdepressedscars,thehollowdepressionsunderneaththeeyes,theso-callednasolabialfold,thecreasesthatruninferiolaterallyfromthesidesofthenos-trilstowardthebottomofthecheeks,andsoon.Noskintestsarerequiredtousetheseproductsand,except forusuallyminimal,temporarybruising,thereisnodowntimeas-sociatedwiththesetreatments.Dependingontheformula,theeffectcanlastfromfourmonthstooneyear,anditisnotuncommon

forpatientstohavelargedepressionsfilledwhilesimultaneouslyreceivingBotoxtreat-mentstoeliminatefinewrinkles.

Forpatientswantinga longer-lastingeffect,Radiesse, a compoundmade fromcalciumhydroxylapatite,asyntheticformofmaterial foundinboneandteeth,andSculptra,asyntheticpoly-L-lacticacid,areavailable.Aswiththeothernewgenerationoffillers,noskintestingisusedandpatientsexperience little ornodowntime.Boththeseproductslastupwardsofoneyear,andthereinliesthemost importantfactor forbothpatientandphysicianinconsideringtheseproducts.Forwhethertheeffectlastsfourmonthsoroneyear,theeffectlastsfourmonthsoroneyear.Itisincumbentuponboththepatientandphysiciantoknowthattheyarecommittingtoa“certainlook”foralongtime.Inmostcases,it’swisetostartoffslowly,withshorter-actingproducts,andthenmove to longer-duration injectionswhenthereisamorecompleteunderstand-ingoftheultimateoutcome.

Theopportunitiestomaintainayouth-fulappearancehaveneverbeenbetter.Butaswithallpromisinginnovations,perhapsthemostimportantthingforus,asphysi-cians,tokeepinmindistheoldsaw“donoharm.”Theability toalter someone’sappearanceshouldnotbetheonlyreasonfordoingso.Andjustbecauseapatientwantsaheraldednewtreatment,thatshouldnotbethesolereasonweprovideit.

Gary L. Aguilar, MD, is a Clinical Pro-fessor of Ophthalmology at UCSF.

Continued from the Previous Page...

2008-2009 SFMS Member Directory Coming Soon!

Directories will be out in June! All SFMS members receive one copy of this valuable resource as part of their memberships. Please watch for your copy in the mail. If you are interested in ordering additional copies please contact Carol Nolan at (415) 561-0850 extension 0 or [email protected] for information.


commitment

whatdrivesyou?A commitment to excellence.

A passion for the art of medicine.A basic desire to heal.

Whatever it is that sustains you through the daily challengesof your profession, know that you have an ally in NORCAL.

(800) 652-1051 l www.norcalmutual.com

Providing San Francisco physicians and surgeons with superior professional liability protection.

www.sfms.org April 2008 San FranciSco Medicine2524San FranciSco MedicineApril 2008 www.sfms.org

eYe To eYe

H aveyoueverwonderedhowaseverelynearsight-ed caveman survived?

Howdidmyopicprehistoricmanandwomanhunt,scanthehori-zonduring theirwanderings,orstudy the starsatnight?Orwasit the nearsighted individualswhostayedathomeinthecave,mindedthefire,preparedmeals,andtendedtotheyoung?

AlthoughthefirstevidenceoftheuseofacorrectivelensdatesbacktotheemperorNero—whowassaidtowatchgladiatorgamesthrough an emerald—SalvinoD’Armateiscreditedwithinvent-ingthewearablespectaclelensinItaly,during the late thirteenthcentury.

Benjamin Franklin is wellknownas the inventorofbifo-cal spectacles (1784),whichhedevelopedtocurehisowncombi-nationofmyopiaandpresbyopia.Contactlenseswereactuallycon-ceivedandsketchedbyLeonardodaVinci,butthefirstglass-blowncontact lensesweredesignedbythe German glassblower F.A.Muller (1887),andplasticcon-tactswerefirstintroducedbytheCaliforniaopticianKevinTuohy(1948).

Theeraoflaservisioncorrectionbeganinthelate1980s,withthedevelopmentoftheexcimer laser to reshape thecornealsurface,andsubsequentlytheflap-makingtechnologytoallowLASIK(LaserAssistedIn-situKeratomilieusis).Theexcimerlaseris a193nm“cold”ultraviolet laser that,duetoitsspecificabsorptioncharacteristicsin thecornea,candisrupt intramolecular

carbon-carbonbondsandthusverypreciselyreshapethecornealsurface,therebyreduc-ingoreliminatingrefractivedisordersoftheeye—includingnearsightedness,farsighted-ness,andastigmatism.TheexcimerlaserwasapprovedbytheFDAin1995,andoverthepastdecadeithasproventobeaverysafeandeffectivemeansofcorrectingrefractiveerrors.Anearsighted(myopic)eyehasanelongatedaxial length,but the refractiveerrorcanbeneutralizedbyflattening the

corneawitha central ablation.Afarsighted(hyperopic)eyecanbesimilarlycorrectedwithamid-peripheral “doughnut-shaped”ablationthateffectivelysteepensthecentralcornea.Astigmatismis essentially an ovality of thecorneal surface, and it can beeliminated by a correspondingelliptical laser ablationpatternthat establishes amorenormalcornealsphericity.

Inrealestate,it’s“location,location, location,”and in laservision correction—as in anysurgicalprocedure—it’s “patientselection,patient selection,pa-tient selection” that isofpara-mountimportance.Sophisticatedscreeningtools,includingcornealtopographers (which measurecornealshapeandcurvature)andultrasonicpachymeters (whichmeasurecornealthickness)allowforoptimalpatientselection.

Recentadvancesinexcimerlaser ablation include the ad-ventof“wave-fronttechnology,”which allows for more precisemeasurementofrefractiveerrorsandgreaterprecisioninthedis-tributionofthelaserablationpat-

tern.Asinmanymedicalindustries,thereis a greatdealofmarketinghype—bothfromsomemanufacturersandsomephysi-cians.Whenthewave-fronttechnologywasinitially released, the lasermanufacturerspromoteditascapableofproducing“supervision,”allowingpatientstoroutinelyseebetterthan20/20.Butintruth,laservisioncorrectioncanonlyallowaneyetoseeas

The End of GlassesThe Future of Laser Vision Correction

Daniel Goodman, MD



wellastheconcentrationofanindividual’sretinalphotoreceptorrodsandconesper-mits,whichisgenerallytheirbestcorrectedvisionwithglassesorcontactlenses.Somepatientshavea “normal”visionof20/25(whichmeanstheycanseeat20feetwhatthe “normal”personwill seeat25 feet),whileothershavethecapacitytosee20/15or better. (Over the past ten years, forexample, Ihaveexaminedallof theSanFranciscoGiantsbaseballplayerseachyearinspringtraining,andthe“normal”profes-sionalbaseballplayer routinelyhasvisualacuityof20/10orbetter—whichmeanstheycanseeat20feetwhatthe“normal”personwillseeat10feet.)Somephysiciansalsopromote theirdiagnosticequipmentorlasertechnologyas“better”thanothers(“mylaserisbetterthanyourlaser”or“mycorneal scanner is better thanyour cor-nealscanner”),but,intruth,therearenosignificantdifferencesbetweentheseveralexcimerlasersavailable;eachproducesuni-formlyexcellentresultsinthehandsofthethoughtfulandcarefulophthalmicsurgeon.

Dependingonthedegreeofrefractiveer-ror,between90and98percentofpatientswillsee20/20withoutspectacleorcontactlenscorrection,followinglaservisioncor-rection,andmorethan99percentwillsee20/40(thelevelrequiredbytheDMVforadriver’slicense).

Therearepotentialsideeffectsoflaservisioncorrection.Less than1percentofpatientsstill requirespectaclesorcontactlensesforfull-timevisioncorrection.Whentheexcimerlaserwasfirstdeveloped,nearly5percentofpatientsexperiencedglareorhaloes atnight.Thechief advantageofwave-fronttechnology,itturnsout,isthatithasdramaticallydecreasedtheincidenceofpost-opnighttimedifficulties, in thosepatientsatahigherrisk for thesesideef-fects,tolessthan1percent.Somepatientsexperienceaperiodofdryness followinglaservisioncorrection,but,inmyexperi-ence, this isnotapermanentcondition.Not infrequently,patientshaveadegreeofadryeyeconditionpriortoLASIK,andafterwardtheyreturntotheirownlevelofocularsurface“dryness”orhealthatvary-

ingrates.Thoughlaservisioncorrectionisboth

safe and effective, it’snot for everyone.Patientswithabnormalexams, includingabnormallythinorirregularcorneasorthosepatientswithanabnormalocularsurface,maynotbecandidatesforLASIK—thoughtheymaybecandidates for lens implantsorotheremergingtechnologies.Certainlyournearsightedprehistoricancestorswouldhavebeenthrilledtohavehadspectacles,andeven today, somepatientsarebetterservedwithglassesorcontactlenses.

Daniel Goodman, MD, is the Medical Director of the Goodman Eye Center and the Eye Surgery Center of San Francisco. He is a Clinical Associate Professor of Ophthalmology at UCSF Medical Center and one of the team doctors for the San Francisco Giants baseball team.


The Best Care -The Best CareerVeterans A�airs Medical Center San Francisco

PRIMARY CARE PHYSICIAN/BOARD CERTIFIED INTERNISTThe Department of Veterans Affairs is searching for a Primary Care Physician/Board Certified Internist for the Ukiah VA Outpatient Clinic located 100 miles north of SF on Hwy 101. The clinic serves Mendocino and Lake Counties where affordable living meets outstanding recreation with easy access to the spectacular coastline. Responsibilities include: building a manageable panel size across the adult age continuum; some administrative duties, and no call. Great supportive staff and potential for growth await the enthusiastic, self starter who values team spirit and cooperation. Full time position available.

Interested candidates please contact Linda Mulligan, MD at (707) 468-7704 and send a CV c/o Ken Browne, Ukiah Outpatient Clinic,

630 Kings Court, Ukiah, CA 95482. Fax (707) 468-7733.

US Citizenship required. Selected applicant is subject to random drug testing. Equal Opportunity Employer.

26San FranciSco MedicineApril 2008 www.sfms.org www.sfms.org April 2008 San FranciSco Medicine27

eYe To eYe

s tunnedby freshbadnews, some-times we can manage to utteronly an anguished “Oh, no….”

Perhapsmyoptometristmighthavefoundamoremeasuredwaytoinformmethathewasseeingsignificantcuppingofmyopticnerveduringaroutineexam.But,instead,this goodmanwhohadbeenour familyoptometristforalmosttwentyyearssaidatfirst, fromhisheart, simply, “Oh,no….”Withthat,Iwaswelcomedtotheworldofgraduallyworseningvisionloss.

Eightyearsago,Ihadnoticedblurringofmydistancevision.Iwashavingtroublereadingabovethe20/80 lineas I ranmypediatricpatientsthroughtheSnellenchart.Imyselfhadworncorrectivelensessincefirstgrade,whenIhadprovedunabletoseethebigEatthetopofthechart.Withmyopiaasmylongtimecompanion,IthoughtthenthatmyrecentdecreasedacuitywouldbecorrectedassoonasIfoundtimetogoinfor a routine refraction andnew lenses.Besides,weallknowthatregisterednurses,likedoctors,takecareofthoseotherpeoplewhohavehealthproblems.Wouldthatthismagicalthinkingactuallyprotectedusfrombecomingoneofthose other people!

Last week I bought my first whitecane,theshorter,lighter“identity”versiondesignedtoalertthegeneralpublicthatthebearerhasgoodreasontomovesocautiouslydownthestairstoBARTorthatherrequestsforassistancearemore than just learnedhelplessness.Visionrehabilitationstafftellmethat,later,Imaygraduatetoalonger“mobility”cane,madeofmaterial strongenoughtowithstandimpactwithconcretecurbsandmetalmailboxes.

Bitbybit, I’vehad to take leaveofthings.Mydriver’slicenseisgonenow(butnotthoselovely,vividdreamsofdriving,

stickshift).Mypriorlife’sworkasaregis-terednursehascometoanend.Theslight-estshadowsnowdisguisetheonce-familiarfacesoffriendsandfamily.Idomanythings

differentlynow,ofnecessity,eventhoughI’mstillonlypartwaydownthepathtowardlegalblindness.

Whenaskedtowriteaboutvisionlossfromapatient’spointofview, Iquicklyagreed to do this—and then wonderedwhat I could say thatmightmakeadif-ference. Iknowonlymyownexperienceofthisgrowingdarkness,eventhoughmyvision-impairedpeersandIoftenlaugh,andsometimescry,indiscoveringhowmuchweshareeven thoughwe liveverydifferentlivesfromoneanother.

I’mhumbledbytherealization,despitemyownpatients’pastpraiseformyempa-thyforthem,thatIhadso littlesenseofthedepthandcomplexityofwhatitistolivewithachronicandworseningmedicalcondition.Wefullyunderstandsomethingsonlyinlivingthemourselves.Notknowingwhatitistobecompletelyblind,norhav-

ingtheexperienceofalifelongdisability,Ireporthereonthatgrayzoneofvisionlossinhabitedbythosewhooncecouldseequitewellandwhonowarelostsometimeseveninfamiliarsurroundings.

In his honest and insightful bookTouching the Rock: An Experience of Blind-ness (1990),universityprofessor JohnM.Hullwrote,“Itissohardtobeanormalpersonwhenoneisnotanormalperson.”Withvision loss,manyof themundanetasksoflifebecomearduousandfrustrating.Ordinaryroutinecancallforextraordinaryandexhaustingeffort andaneed for anunfamiliarpatience.

Day-to-daysocialrealitychangeswithsignificantvision loss.We introduceour-selvestoourclosefriendsbecausewedon’trecognizethem,orwewalkbythem,appear-ing to ignore them,becausewedon’t seethatthey’rethere.Wepourourselvesaglassof7-Upatapartyandcompletelymisstheglass.Requestinghelpreadingthepriceonanitem,wemayfindthestoreclerkreplyingvery slowly and loudly,sometimespattingusonthearminagestureofcomfort.Visiondisabled,wefindthat someothersappar-entlyviewusascognitivelyimpairedoraslessabletomakeourowndecisions.

Geographicboundariescanshrinkintowardus.ASundaydriveuptoPetalumaoratriptopickupafewboxesofcatlitternowrequire sometimescomplexadvanceplanning,asistrueforallwithouttheveryAmericanluxuryofhavingbothadriver’slicenseandacar.Asvisionfades,therangeofwhatweseearoundusclosesinsothat,at theendpoint, theworldwill seem,attimes,tobejustourownbodyandtheairaroundus.

Visionlosscanchallengeone’ssense

“Last week I bought my first white cane, the shorter, lighter ‘identity’ version designed to alert the general public that the bearer has good reason to move so cautiously down the stairs to BART or that her requests for assistance are more than just learned helplessness.”

Through a Glass DarklyLiving with Vision Loss

Susan Kitazawa, RN



of personhood. When we look in themirrorandnoonelooksback,orperhapsweseeonlyapartial face,missinganoseandhalf amouth,we can experience adisconcerting senseofno longerexistingasthesamesolidbeingthatweoncewere.JohnHullwritesofthelossofbeingabletosee the friendly smilesorfleetingglancesofrecognitionfromothersaroundus,thesocialacknowledgementsthatconfirmourexistence. Sometimes forced to give upformerliferoles,weseeknewwaystobefullyengagedmembersof thecommunity;wemaysensetherestoftheworldrushingpastus,possessedwithaspeedandanefficiencythatseembeyondourgrasp.

Forthoseofuswithsignificantvisionloss,where is thegoodnews?Whatcanhelp?

Engagingpatients inagive-and-takeexchangeregardingthemanylessobviousconsequencesofvisionlosswouldbeofgreathelptous.Onlyafterayearofexperienc-ingthedisconcertinghallucinatoryimagesofwhat InowknowasCharlesBonnetsyndromedidIlearnthatthisisafairlycom-monexperienceamongthosewithpartialvisionloss.Ifirstlearnedaboutthisfrommy

partiallysightedpeers.Almostallofushadchosennottomentionthissymptomtoourdoctors,fearingtheywouldthinkusmad.(TheRoyalNationalInstitutefortheBlindprovidesanoverviewofBonnet’satwww.rnib.org.uk, aswellasprovidingmuchusefulinformationforthosewithvisionloss.)

Providersshouldoffertogivepatientsspecificreferralinformationtolocalagenciessuchas theLighthouse for theBlindandVisuallyImpaired(www.lighthouse-sf.org).Again, itwasavision-impairedpeerwhofirst referredme to thishelpfulnonprofitagency.TheLighthouseoffersa rangeofclassesandactivitiesaswellasastoresellingadaptiveaids.Apeer-ledvisionlossdiscus-siongroupmeetsattheLighthousetwiceamonth.TheLighthousealsosupportspeopleinaccessingmanyotherlocalorganizationsproviding services andadvocacy for theblindandvision-impaired.

Encouragingandsupportingpatientsinlinkingwithotherslivingsuccessfullywithvision lossmaybe themostworthwhilestrategy. Iammostgrateful forblindandvision-impaired peers who have sharedwisdom,humor,andpracticalresourcesthathelpusalongthisstillpoorlymarkedtrail.Iamgratefulfortheencouraginginsightof

authorJohnM.Hull,who,aftermusingonthepossibilityofblindnessbeinga“dark,paradoxical gift,” concluded instead thatblindness ismore “thewrapping”aroundagiftthanthegiftitself,thatlosingone’seyesightcanbeapassagewayintoadeeper,“moreconcentratedphaseoflife.”

Withthesupportofothers,especiallytheongoing supportofpeers, thoseofusexperiencingvisionlossmaycometofindadeeperunderstandinganda richer ap-preciation of life that can balance thedifficultiesinherentinourseeingthroughaglassdarkly.

Susan Kitazawa, RN, enjoys writing, other creative arts, and dancing (mostly Argen-tine tango). In the past, she worked as a nurse at the University of California, San Francisco, in the San Francisco Department of Public Health, and for the San Francisco public schools. She holds degrees in cultural anthropology, nursing, and education.

Reference:Hull,JohnM.Touching the Rock: An

Experience of Blindness.NewYork:VintageBooks,adivisionofRandomHouse,1990.


Continuing mediCal eduCationThe California Medical Association is accredited by the Accredita-tion Council for Continuing Medical Education to provide continuing medical education for physicians. The California Medical As-

sociation designates this educational activity for a maximum of 19 AMA PRA Category 1 Credits ™. Physicians should only claim credit

commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education.

28San FranciSco MedicineApril 2008 www.sfms.org www.sfms.org April 2008 San FranciSco Medicine29

eYe To eYe

w hen Jean-Dominique BaubywroteTheDiving Bell and the Butterfly, he couldnot speak

ormove;hecouldonlyblinkhislefteye.Intellinghisstory,imaginationcombineswithrealityanddreamstocreateanewformofconsciousnessforJean-Do,theformerFrencheditorofElle,whobecomes imprisonedinhisownbodyafterdeveloping“locked-insyndrome”fromacerebrovascularaccidentattheageof43.Althoughphysicallyparalyzed,hisbrain function,cognition,and sensesremainintact.

Jean-Do’smemoirwasmasterfullycap-tured inacriticallyacclaimedFrenchfilmthatwasawardedGoldenGlobeAwardsforbestforeignfilmandbestdirector.ThefilmthreadsthestoryofJean-Doamidtheback-dropofhisnewlifeinhospitalroom119intheNavalHospitalatBerck-sur-MerontheFrenchchannelcoast.Thislife,characterizedbytherapists,medicalroutines,feedingandbronchialtubes,baths,nurses,andrelivingmemories,isanexistencefarremovedfrombeingafather,son,lover,writer,andmemberofFrenchsociety.

ThecreativeimageryinthefilmreflectsJean-Do’sfeelingsashebecomesphysicallyencasedintheheavyshellofhisbody.Hebecomesdependentonthenurses,whowashhim,changehisclothes,movehislimbs,cleanhisfeedingandbronchialtubes,andattendtohismostbasicneeds,asifhehadregressedtoastateofinfancy.TheresonatingimageofadiverinadivingbellmirrorsJean-Do’shelp-lessnessashedelvesdeeper intounknowndepthsofhisownsoultoconfronthishelpless-ness,fear,confinement,andshame.

WeseehowJean-Docontinuestoper-ceivetheentireworldthroughhislefteye,whilestrugglingtocommunicatewiththosearoundhimandconnectwiththenewreality

ofhislife.Asheopenshiseyefromastateofcoma,theworldslowlycomesintofocus—asterilehospitalroomwithwhitecoatsbustlingaroundhim,withspecialattentiongiventotheneurologistwhodelivers thediagnosis

toamuteandlistlessJean-Do.WeheartheinternaldialogueandfrustrationthatJean-Doexpressesashecoherentlyprocessestheinformationbeingdeliveredtohimbytheneurologists,whilefailingtorespondbacktothegrimnewsthathehasbecomereducedtoavegetativestate.

ThesightofJean-Dosittinginhiswheelchairwithbronchialtubesprotrudingoutofhisneckandsalivatricklingdownhischinashestaresblanklywithhislefteyeevokesfeelingsofpityandsadness.Buthisabilitytoeloquentlyandpowerfullyexpresshisvoicere-mindsyouthatappearancescanbedeceiving.WehearJean-Donarratingthefilmthroughhisordeal,speakingforhimselfandechoinghisthoughtsaswefollowhimthroughhispreaccidentmemories,currentexperiencesasapatient, imaginativeadventures,andmomentsofself-reflection.Wenotonlyseehislifeflashonthescreen,wegainadeeperunderstandingofJean-Do’scharacterashe

comestogripswithhisdiagnosis.Hisvisionisnotlimitedtoseeingthe

world;herelivespastmoments inhis life,dreamsabouthiscondition,holdssteadfastlytoimagininglifeashewouldliketoliveit,andexperiencestheworldthroughsmells,sights,andsounds.WewatchhowJean-Docomestotermswithhiscondition,atransformationthatstartswithdepressionandanxietyandthoughtsofdeath,laterdevelopingintoac-ceptanceofanewlifeasheregainshisabilitytocommunicateusingtheblinkreflexwiththeassistanceofhisspeechtherapist.

ThroughprojectingtheworldthroughJean-Do’seyes,wedevelopprofoundempathyforJean-Doasheworksthroughtheadversityinhislife.Inlearningtocommunicate,Jean-Doputswordstogether,letterbyletter,inaprocessthatrequirespatience,concentration,andpractice.Despitethechallenges,regain-inghiscommunicationskillsallowsJean-Dotorecollectthepiecesofhislifeanddiscoverawaytoescapetheshacklesofthedivingbellthathadbeenplunginghisspiritdeepintoanabyssofdreadandself-pity.Likethebutterflythatreappearsthroughoutthefilm,herisesabovehisphysical impairment,aclassicaldemonstrationofmindovermatter.

ThefilmskillfullydeliversapoignantmessagethroughoverlayingpowerfulvisualimagerywithJeanDo’sdominatingvoiceashedirectlyconfrontshisbiggestfear,thatofbeingdisconnectedfromhisworld.Despitetheinsurmountablechallengesheconfronts,hisphysicaldeteriorationdoesnotextinguishhisinsatiablehungerforlife,andhisinnervoicecannotbesilenced.JeanDoservesasanexemplarytestamenttothehumanspirit’sabilitytoovercomethemostunimaginablecatastrophes.

Eisha Zaid is a first-year medical student at UCSF.

The Diving Bell and the ButterflyA Movie Review

Eisha Zaid

“The film skillfully delivers a poignant message through overlaying powerful visual imagery with Jean Do’s dominating voice as he directly confronts his biggest fear, that of being disconnected from his world.”

�0San FranciSco MedicineApril 2008 www.sfms.org�0San FranciSco MedicineApril 2008 www.sfms.org

i mpatientwiththelackofprogressatfederalandstatelevelsinreducingthenumberofuninsuredAmericans,manycountiesacrosstheUnitedStatesareseekingtheirownsolutionstothe

healthcarecrisis.Unfortunately,localeffortstoachieveuniversalcoverageoftenencountersubstantialobstacles,includingthehighcostofinsuranceplans,thelossoffederalandstaterevenuesthatbenefittheuninsured,andlimitedauthoritytomandateinsurancecoverage.

Tobroadenaccesswhileavoidingtheseproblems,thegovern-mentoftheCityandCountyofSanFranciscolaunchedHealthySanFrancisco(HSF)inApril2007.Buildingonthesuccessofanearlierefforttoprovidehealthinsurancefornearlyallthecity’schildren,HSFisanovelinitiativedesignedtomakecomprehensivehealthcareavailabletoSanFrancisco’s73,000uninsuredresidents(13percentofadultsundertheageofsixty-five).

Currentlyintheformofaphasedstart-up,HSFisnotaninsur-anceprogrambutratherarestructuringofthecounty’shealthcaresafetynet.AdministeredbytheSanFranciscoDepartmentofHealth,whereIamDirectorofHealth,HSF’suniversal-accessmodelfeatureskeyelementsofmanagedcare,suchas“medicalhomes,”definedpar-ticipationandpoint-of-servicefees,andcustomerservice.Itprovidesinpatientandoutpatientcare,tertiarysubspecialtycare,prescriptioncoverage,laboratoryservices,durablemedicalequipmentcoverage,andtreatmentformentalillnessesandsubstanceabuse.(Cosmeticprocedures,dentalservices,fertilitytreatments,organtransplantation,visioncare,andlong-termcareareexcluded.)

Alluninsuredresidentsbetweeneighteenandsixty-fiveyearsofageareeligibletoenrollinHSFregardlessofincome,employmentstatus,immigrationstatus,orpreexistingconditions.Duringanonlineapplicationprocess,clients’eligibilityforfederalandstateprogramssuchasMedicaid isfirstdetermined.Thosewhoareeligiblecanenrollintheappropriateprogram;thosewhoarenotareenrolledinHSFandchooseaprimarycarehomefromamongfourteencountyandeightprivate,nonprofitclinics.(Asenrollmentgrows,wehopetobroadenthenetworkofproviders.)Participantsaregivenanidentificationcard,ahandbookexplaininghowtoobtainservices,alistofstandardpoint-of-servicecharges,andaccesstomultilingualcustomerassistance.Participationisfreeforresidentswhoseincomesfallbelowthefederalpovertylevel.Otherspayquarterlyparticipationandpoint-of-servicefees,withtotalfeesforthoseatorbelow500percentofthefederalpovertylevelamountingtolessthan5percent

offamilyincometoensureaffordability.HSFprovidesenrolleeswithmanyofthebenefitsofmanaged

care.Assigningpatientstoamedicalhomeandprimarycareproviderimprovestreatmentoutcomesandreducesthelikelihoodofcostlyemergencyroomvisitsandduplicationofcare.Thesmall-feechargeisexpectedtoattractsomepeoplewhohaverefrainedfromseekingcarebecausetheyconsidereditunaffordableandrefusedtoaccept“charitycare.”AndtheprovisionofcontinuouscoveragethatisnottiedtoemploymentgivesSanFranciscanssecurityeveniftheychangejobsorbecomeunemployed.

Therearesomedisadvantagesofanon–insurance-basedsystem.Onlyservicesprovidedataparticipant’sprimarycarehomeandas-sociatedhospitalarecovered(rightnow,onlythecountyhospitalisparticipating).Emergencycareobtainedatnoncontractedhospitalsisnotcovered.AlthoughemergencycareisguaranteedbythefederalEmergencyMedicalTreatmentandActiveLaborAct,thecostisbillabletothepatientandcanresultinaseriousfinancialburden.Inaddition,unlikeinsurance,HSFwillnotpayforcarereceivedoutsideofSanFrancisco,andenrolleeswillloseallbenefitsiftheymovetoanothercity.

Despitethesedrawbacks,HSF’suniversal-accessmodelisalogi-caloptionforSanFranciscofromacostandfinancingstandpoint.Thedirectcostsoftheprogramareestimatedat$198perpersonpermonth—substantiallylessthanthecostofcommercialhealthinsurance(thoughthisestimateisadmittedlybasedonthesomewhatunfairassumptionthattherewillbenoadverseselection—thatpeoplewithgreaterhealthcareneedswillnotbemoremotivatedtojointhanthosewithfewerneeds).Administrativeexpensesareexpectedtobelowerthanisusualforahealthplan—5percentversus9to14percent—sinceHSFdoesnotprovidecertainservicesthatinsurersdo(forinstance,theprogramwillnotbeadjudicatingout-of-networkclaims).Assuminga7percentinflationrateforthefirsttwoyearsofgradualenrollment,theoverallcostofHSFinitsthirdyear,whenenrollmentisexpectedtobeat60,000(82percentoftheuninsured),willbeapproximately$171million.

Thereareothercostadvantagestoauniversal-accessmodel,includingadecreasedriskof“crowd-out,”whichoccurswheninsuredindividualsorbusinessesdroptheircoveragetotakeadvantageofasubsidizedplan,apracticethatcandrainsubsidydollarsandleadto insufficientprogramfunding.ThefactthatHSFdoesnotpayclaimsoriginatingoutsidethemedicalhomereducesthelikelihood

Mitchell H. Katz, MD

UniVerSaL HeaLTH care UPdaTe

Golden Gate to Health Care for All?

�0San FranciSco MedicineApril 2008 www.sfms.org www.sfms.org April 2008 San FranciSco Medicine�1�0San FranciSco MedicineApril 2008 www.sfms.org

ofcrowd-out.Unlikeinsurance,auniversal-accessmodelallowsthecountytocontinuereceivingcertainfederalandstaterevenues,whicharecriticalformaintainingHSF’sfiscalviability.Inaddition,HSFenrolleeswillremainqualifiedforcertainfederalandstatebenefits(e.g.,theAIDSDrugAssistanceProgram)thatareunavailabletoinsuredpatients.

Financing forHSFis slatedtocomeprimarily fromexistingcountyfundsforthecareoftheuninsured,whichin2007totaledapproximately$123million.Anannual$20million isexpectedfromexisting federalandstatehealthprograms,andathree-yearhealthcareexpansionawardfromthestatewilladd$24millionperyeartothebudget.ItishopedthatsincethesourceofthesefundsisCalifornia’songoinghospitalwaiver,fundedthroughtheCentersforMedicareandMedicaidServices,therevenuewillbemaintainedyearafteryear.

Inaddition,ahealthcarespendingrequirementforemployerswasenactedunderthesameordinanceasHSF.Employerswith100ormoreemployeeswouldberequiredtospend$1.76perworkhourperemployeeonhealthbenefits;thosewithtwentytoninety-nineemployeeswouldhavetospend$1.17perhour.Employerscouldusethismoneytoprovidehealthinsurance,createhealthsavingsaccounts,payhealthcareclaims,orcontributetowardemployees’participationinHSF,therebyqualifyingemployeesforfreeordis-countedcoverage.

Theemployerspendingrequirementwaslegallychallengedbyalocalrestaurantassociation.AU.S.districtcourtruledinfavoroftheassociation,statingthatthegoalsoftheprogramwere“laudable”butthatthespendingmandatewaspreemptedbytheEmployeeRetire-mentIncomeSecurityAct(ERISA)enactedbyCongressin1974.Thatactwasdesignedtoprotectemployersfromhavingtotailortheirbenefitplanstoavarietyoflocalregulations.However,thecityappealedthecasetotheU.S.CourtofAppealsfortheNinthCircuitandaskedthecourttograntastayofthedistrictcourtdecision.TheCourtofAppealsgrantedthestay,notingthatthecityhasa“stronglikelihood”ofsuccessinarguingthattheemployerspendingmandateisnotpreemptedbyERISA.Therefore,thespendingmandateisineffectpendingtheappealofthecase.

TheHSFmodelismostapplicabletocountieswithmultiplesafety-netproviders.Systematizing the services thatcountyandcommunityclinics,privatedoctors,andhospitalsprovidetotheuninsuredwill result in improvedcareandbetterdata forhealthcareplanning.Ourexperiencesuggeststhat,evenincountieswithasolecharitycareprovider,offeringenrollmentidentificationcardsandclear,up-frontcostinformationmaycomfortpeoplewhowouldotherwiseworryaboutpayingforcare.Inaddition,havingparticipantspayprospectivelyencouragesthemtoseekpreventivecare.

Withabout7,400peopleenrolledinHSFasofDecember2007,itisstilltooearlytotellhowsuccessfultheprogramwillbe;never-theless,wehopeitwillinspiremoreenergeticeffortsatthestateandfederallevels.Withanestimated47millionuninsuredpeopleinthe

UnitedStates,andoverwhelmingevidencethattheuninsuredhavelessaccesstocareandpoorerhealthoutcomesthantheinsured,itiscriticalthatwetakeactionnow.

This article is a slightly edited version of that which appeared, with references, in the NewEnglandJournalofMedicine on January 24, 2008 (NEJM 358:4:327-9).

COMMENTARY FROM SFMS REPRESENTATIVES:AsrepresentativesoftheSFMSwhoservedontheinitialMayor’s

panelthatdraftedplansfortheHealthySanFranciscoprogram(withGordonFungcontinuingontheOversightAdvisoryCommitteefortheprogram’simplementation),wearegratifiedtoseebothhowwelltheimplementationisproceedingtodateandthatthelegalchallengehasbeensuccessfullyansweredsofar.Giventhatfederalandstatehealthaccessplansdonotseemtobependinganytimesoon,despitemuchdebate,SanFranciscoisprovidingauniquelaboratoryforonemeansofaddressingthisissue.Whilenosuchprogramwillbeperfect,weagreewithDr.Katzthatthisisaworthyeffort.Andweareawarethatpeoplearoundthenationarewatchingitwithinterest.

—Gordon Fung, MD, and Steve Heilig, MPH(Note:TheSFMShasnottakenaformalpositiontodateon

theHSFprogram.)

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�2San FranciSco MedicineApril 2008 www.sfms.org�2San FranciSco MedicineApril 2008 www.sfms.org

CPMCDamian Augustyn, MD

KPSFRobert Mithun, MD

Dr. Martin Brotman, CPMC PresidentandCEO,hasbeenchosentoreceivethehigh-est award inAmericangastroenterology, theJuliusM.FriedenwaldMedaloftheAmericanGastroenterologicalAssociation,whichisgiventotheindividualwhohasdonethemostoveralifetimeandacareertoinfluencethefieldofgastroenterologyintheUnitedStates.TheawardwillbepresentedataspecialceremonyinSanDiegoinMay2008.

Dr.BrianAndrewswasrecentlyappointedChair of the Department of Neurosciences.Dr.AndrewsisagraduateofUCSFSchoolofMedicineandhasbeenamemberoftheCPMCmedicalstaffsince1988.HehaspreviouslyservedasChief ofNeurosurgery andViceChair ofNeurosciencesatCPMC.

CPMC has become the first medicalresearchinstitutionintheworldtouseagenesilencingtherapyto treatHepatitisB.CPMCteamedupwithPennsylvania-basedNucleonics,Inc.,andotherinvestigatorsworldwidetotestaninnovativemethodofhelpingpeoplesufferingfromtheHepatitisBvirus(HBV).HBVcreatesstrandsofgeneticmaterialcalledRNA,whichturnthecellintoaminiHBVfactory,effectivelychurningoutnewcopiesofthevirusthatspreadthroughout the liver. In thenewRNAi ap-proach,thepatientgetsaninfusionofplasmids,orcircularsegmentsofDNA.Onceintheliver,thesesegmentsproducesomethingcalled“shortinterferingRNA”(siRNA),whichbindtotheHBVRNA.ThesiRNAthenusesamolecularscissoreffecttodestroytheviralRNA,essentiallyblockingthevirus’sabilitytoreplicateitselfinthelivercell.BypreventingHBVfrommultiply-ing,thismethodeffectivelyparalyzesthevirusandmakes itunable tocreate infectiousvirusparticles.It ishopedthatbyimmobilizingthevirus,thepatient’sbodywillbegivenachancetofightagainstitandperhapsevenclearHBVfromthebodycompletely.

SaintFrancisWade Aubry, MD

Ourongoingefforttoimproveocularser-vicestopatientstakesmanyforms.Forseveraldecades,wehavebeeninvolvedwithCPMCinanophthalmologyresidencytrainingprogram,inwhichaseniorresidentspendsfourmonthsatKPSFworkingcloselywithoursurgeons.AlltheresidentsintheCPMCprogrameventuallyrotatethroughourprogram,andsomeevenchoosetobegintheirmedicalcareersatKPasaresultoftheexperience.Havingjustoneresidentatatimeenablesacloseandhighlyefficientrelationshiptoformbetweentrainersandtrainee.

Inaddition,weareareferralcenterforoursisterKaiserPermanentefacilitiesinanumberofophthalmicsubspecialties.Ourexpertisehasgrowntoincludeglaucoma,cornea,vitreoretinal,andrefractivesurgery.Oursurgeonsarebackedbyadedicatedteamofoptometristsandtechnicalstaff.Bybeingareferralcenter,weareabletoin-corporatenewsurgicaltechniquesandstayatthecuttingedgeofophthalmicsurgerypractice.

Finally,ourophthalmologicserviceshaveembracedtechnologyinalmostallaspectsofthepractice,fromtheexaminationroomtotheoper-atingroomandbeyond.Becauseophthalmologyisoneofthemosttechnologically-basedspecial-tiesinmedicine,weaggressivelyfocusresourcesandtrainingonthelatesttechnologiesastheybecomeavailable.Frommicroscopestodigitalphotographytolaserscanners,wehaveincorpo-ratedthelatesttoolsavailabletobetterserveourpatients.Atthispointtheophthalmologicprac-ticeatthemedicalcenterisessentiallypaperless,andourpatientsareevenabletocommunicatewithuselectronicallyfromhome.

Withafocusontraining,anexcellentrefer-ralservice,andacommitmenttousingthelatesttechnologicaltoolsavailable,wehopetofurtherimproveandstreamlineouralreadyprogressiveophthalmologicpractice.

AtSaintFrancisMemorialHospital,we’vebeen focusingoureffortsoncombatingsepsis.Severe sepsis is the leadingcauseofdeath inthenoncoronaryICU.Aboutone-thirdofthe750,000newcases thatoccur in theUnitedStateseachyearare fatal.Themortality ratesassociatedwithsepsisareextremelyhigh:30to50percentforseveresepsisand50to60percentforsepticshock.Sepsisplacesasignificantburdenonhealthcareresources,accountingfor40per-centoftotalICUexpenditure.Averagecostperindividualcaseisapproximately$22,000.

Basedonthesefacts,SFMH’sgoalforthenextthreeyearsistominimizethevariationinthecareofsepsispatients,followingguidelinesfromtheSurvivingSepsisCampaign.Measur-ablegoalsincludedecreasingourcurrentsepsismortalityrateby20percentandreducingthecostofcare.PulmonologistFredHom,MD,hasassumedthe roleofPhysicianChampionandwillbeaidedbySFMH’snewInfectionControlManager,WendyKaler.Ilookforwardtowork-ingwithDr.Hom,WendyKaler,ourphysicians,andthemedicalcommunityinreducingsepsismortalities.

Inothernews,we’repleasedtosharethatSFMH’sSoniaMelara,ExecutiveDirectorofRallyFamilyVisitationServices,was recentlyappointed to theSanFranciscoHealthCom-mission,thegoverningandpolicy-makingbodyoftheDepartmentofHealth.SoniawillserveasCommissionVicePresident.TheCommis-sionaims toprotect andpromote thehealthof allSanFranciscansbymanagingCityandCountyhospitals, regulating andmonitoringemergency medical services, and overseeingmattersrelatedtothephysicalandmentalhealthoflocalresidents.

HoSPiTaL neWS

�2San FranciSco MedicineApril 2008 www.sfms.org www.sfms.org April 2008 San FranciSco Medicine��2San FranciSco MedicineApril 2008 www.sfms.org

St.Mary’sGuest Columnist: Steve Chang, MD

St.Luke’sJerome Franz, MD

UCSFRonald Miller, MD

TheFebruary23 issueof theSan Fran-cisco Chroniclehadafront-pagestoryaboutourhospitalandtheongoingstruggleforitsfuture.CPMChastakenastepbackfromitsinitialplantocloseacutecareby2010andhasrespondedtocommunityvoicesexpressingtheneedfortheseservicesSouthofMarket.Itisparticipatingina public-private planning process developedunder the guidance of Supervisor MichelaAlioto-PierandDr.MitchellKatz,DirectorofPublicHealth.

Bythetimethisarticlegoestopress,ablueribboncommitteewillhavemetseveraltimestodevelopaplanforbothacutecareandoutpatientservicesatSt.Luke’s.Thecommitteeconsistsofleadersinhealth,business,community,andlaborandwillbechairedbyDr.WilliamShortell,Deanof theSchoolofPublicHealthatU.C.Berkeley.ThevicechairistheRt.Rev.MarcAndrus,EpiscopalBishopofCalifornia.Dr.EdKershwillrepresenttheSt.Luke’smedicalstaff,andDr.KenBarneswill represent theSaveSt.Luke’sorganizationofdoctorsandhospitalemployees.Dr.DamianAugustynwillbeonthepanel,andDr.SteveLockhartwillactasacommunityliaisontobringtheinputofotherindividualsandgroupstothecommittee.

The questions are many. How does atax-exemptcorporation respond to theneedsof its communityand stillmaintainfinancialviability?Howdoesacash-strappedgovernmentcontinue toprovidehealthcare to itspoorestcitizens?WhatdotheneighborhoodsSouthofMarketreallyneed?AreportisexpectedbytheendofJune.

Inthelastfewyears,extraordinarydevelop-mentshaveoccurred intheworldofophthal-mology.Newtechniquesinthefieldofcataractandrefractivesurgeryareexciting forboththemedicalprofessionalandthepatient.Withrecenttechnologicaladvancements,thereareahostofinnovationsandnewlyapprovedprocedures.

More thanelevenmillionpeoplehaveundergone LASIK, which has become evensaferandmoreprecisewiththeadventof thefemtosecondlaser(usedtocreatethecornealflap)inanall-laser“bladeless”experience.However,laservision-correctionisnot“onesizefitsall”anymore.

The much-anticipated FDA-approvedalternativetolaserrefractivesurgeryisnowavail-ableintheformoftheimplantablecontactlens(ICL).Similartoastandardcontactlens,theICLcancorrectmoderatetohighlevelsofmyopiaornearsightedness.Insteadofsittingonthesurfaceoftheeyeasdoesatypicalcontactlens,theICLisdelicatelyplacedinsidetheeye.Itprovidesexcep-tionalvisualclarityandismaintenance-free.

Significantimprovementshavebeenmadeinthefieldofintraocularlenses(IOLs)usedincataractandrefractive lensexchangesurgeries.Aside from the standard single-focus lenses,wavefrontoptimizedversionsandastigmatismcorrectingIOLsnowprovidethehighestpossiblequalityofvisionaftersurgery.

PerhapsthemostexcitingadvancementintheIOLfieldhasbeenthepresbyopia-correctinglens.Forthefirsttime,lensesareavailablethathavebuilt-in“zoom”—providingsimultaneousdistance,intermediateand,mostofthetime,near-visioncorrectionwithouttheneedforglasses.

Three FDA-approved lenses, ReZoom(AMO), ReSTOR (Alcon), and Crystalens(Eyeonics),nowprovidearemarkablesolutiontothepresbyopiariddleandanopportunityformillionsofbabyboomerstogetridoftheirbifocalsandreadingglassesforever.Formoreinformation,call(415)668-1000.

One-yearsurvivalratesforpatientsreceiv-ingheart, liver,and lungtransplantsatUCSFMedicalCenterarehigherthannationalaver-agesatstatisticallysignificantlevels,accordingtorecentdatacompiledbytheScientificRegistryofTransplantRecipients.Recognized for tacklingthemostdifficulttransplantsurgeries,UCSFistheonlyhospitalintheU.S. News & World Report 2007honorrollofthenation’stop18hospitalstoexceednationalaveragesorexpectedsurvivalratesatsignificantlevelsinallthreeprograms.Theone-yeartransplantsurvivalrateatUCSFforheartis100percent,comparedwiththeexpectedrateof87percent;forliver,92percentcomparedwith88percent;andforlung,90percentcomparedto80percent.DataarecollectedbythenationalOrganProcurementandTransplantationNetwork.

Ateamofvolunteersfromorthopaedicsur-geryandsportsmedicineatUCSF—spearheadedbyKevinBozic,MD—joinedwiththeAmericanAcademyofOrthopaedicSurgeonsinMarchtobuilda safeandaccessibleSanFranciscoplay-groundinoneday.AAOScoordinatedwithlocalcommunitygroupsontheproject,whichtookplacethedaybeforethebeginningoftheAAOSannualmeeting indowntownSanFrancisco.Theprojectwaspartofanongoingcampaignbytheacademytobuildplaygrounds throughoutthecountry.

TheFDAapprovalprocessformedicalde-vicesneedstochangeinordertoimprovehealthoutcomes,accordingtoarecentanalysisbyUCSFresearchers ledbyMitchellFeldman,MD,andJeffreyTice,MD.Ina“Perspectives”pieceintheJanuary2008issueoftheJournal of General Internal Medicine,theteamevaluatedthefederalreviewprocess(themethodbywhichdevicescometomarket),howthescientificliteraturereportsonclinical trials involvingmedicaldevices, andtheeffectivenessof independentreviewboardsin improvingatechnology’smedicalbenefittopatients.

�4San FranciSco MedicineApril 2008 www.sfms.org

John J. niebauer, MdDr.JohnJ.Niebauer,anotedhandsurgeonwhodevelopedoneofthefirstprostheticjoints

forthehand,passedawayinhisMarinCountyhomeonDecember14,2007,age93,afteralongillnesswithParkinson’sdisease.

HewasborninSanFranciscoonJuly1,1914.HeattendedLickWilmerdingHighSchool,transferringtoTamalpaisHighSchoolwhenhisfamilymovedtoMarinCounty.HegraduatedfromCollegeofMarin,wherehischemistryprofessorencouragedhimtoattendStanfordUniversity.HegraduatedfromStanfordSchoolofMedicinein1942.Afterhisinternshipandresidencyinorthopedics,hepracticedatStanfordLaneHospital(whichhassincebecomeCaliforniaPacificMedicalCenter).HewasChiefofHandSurgeryandlaterChiefofStaff.HetaughtatUCSFandStanfordandwasaconsultantinhandsurgerytoboththeU.S.ArmyandtheU.S.Navy.Hewasinstrumentalindevelopingandorganizingaprogram,aboutwhichhefeltstrongly,forthetrainingoforthopedicassistants.

HejoinedtheSanFranciscoMedicalSocietyin1947andwasaffiliatedwithmanyotherorga-nizations,aswellasbeingapopularlecturerandauthorofjournalarticles.Althoughaninnovativeleaderinhandsurgery,hewasanold-fashionedphysicianatheart.Hetookalovinginterestineachofhispatientsandhadabedsidemannerthatevokedtrustandcomfort.

Afterretiring,Dr.Niebauerpursuedhisinterestinstudyinganthropologyandmanyothersub-jectsatCollegeofMarin,includingthePaleo-IndiancampsiteslocatednearhisPlumasCountycabin.Hewasanavidoutdoorsman,lovingwalkswithhisfamily,friends,andhisbelovedEnglishSetters.Healsoenjoyedflyfishing,gardening,painting,reading,andornithology.Hewasanenthusiasticsportsfan,rootingforthe’49ers,theSanFranciscoGiants,andtheStanfordCardinal.

HeissurvivedbyJean,hiswifeofsixty-fiveyears;hissonsDoug,Pete,andSkipandhiswifeJanelleandtheirtwosons;andhisdaughterPatHendricksonandherhusbandStanandtheirthreechildren.Theywillrememberhimforhisjoyofstorytellingaroundthecampfireandtheloveandlaughterheprovidedforbothhisfriendsandfamily.

William e. Winn, Jr., MdDr.WilliamE.Winn,Jr.,knownas“Ted,”passedawaypeacefullyathishomeinSanFrancisco

onDecember26,2007,aged82.HewasbornonNovember25,1925,inBeaumont,Texas.HegrewupinDallas,attendingHighlandParkHighSchool,SMU,andHarvardMedicalSchoolwitharesidencyattheMayoClinic.

TedpracticedophthalmologyinMarin,whereheprescribedtheonlymonocleinthecounty,thenatKaiserSanFrancisco,formanyyears.HejoinedtheSanFranciscoMedicalSocietyin1972.Hewasincrediblyhappytobeaphysicianandwasastrongsupporterofuniversalhealthcare.

ANavyveteranofWorldWarIIandtheKoreanWar,hewasamemberoftheAlexanderHamiltonAmericanLegionPost448formanyyears.HewasinterviewedforSteveEstes’sbookAsk and Tell(UniversityofNorthCarolinaPress,2007).

Tedwasverygregarious,enjoyingmembershipinmanygroups,especiallythoseconcernedwithfoodandwine,music,andlanguages.Helovedtosingandbelongedtoseveralchoralgroups,andheplayedthepianowell.Hewasanenthusiasticattendeeandsupporterofmanymusicalorganizations.HetraveledtheworldfromSouthAfricatoRussia,hismanytripsinvolvinghikingornaturetoursaswellasseeingchurchesandpipeorgans.Hetooklotsofphotographs.Helovedlanguages,especiallyFrenchandGerman,andhostedconversationgroups.Hewasinvitedtomanyconsulareventsandwasneverwithoutaforeigndictionaryinhispocketincaseofmeetingaforeigntourist.

Hewasprecededindeathbyhisparents,WilliamEdwardandMarjorieDanielWinn,andbyhisbrother,RobertDanielWinn.Heissurvivedbyhispartneroftwenty-threeyears,AlanNicholson,hissisterMarjorieWinnFordofDallas,andmanyniecesandnephews.

TheSanFranciscoV.A.MedicalCenterre-centlyopenedanewhigh-techSimulationCenterthatcreatesrealisticmedicalscenariostoallowclinicianstoimproveandrefinetheirmedicalskillsandtechniques.Themomentumforthisprogramcamefromtheinstitution’sstrongcommitmenttoqualityofcareandpatientsafety,withtheprimaryfocusbeingimprovingtheefficiencyandeffective-nessoftheentirehealthcareteam.TheSimulationCenterincludesasimulationlabthatcanbeconfig-uredasapatientroom,anintensivecareunitroom,oranoperatingroom,aswellasaclassroomandcommunicationroom.Staffparticipateinhands-oneducationalprogramsspecificallydesignedforphysicians,nurses,andotherhealthprofessionalswithafocusonhealthcareteamtraining.

Thesimulatorhasafull-sizeSimMan,whichisacomputer-controlledmannequinwhosemajorbodysystemshavebeenprogrammedtorespondrealisticallytotheenvironment,medicines,andotherinterventions.Themannequin’sresponsesaremanipulatedfromthecontrolroom,andSimMancanbechangedtoappeartohaveincisions,brokenbones,injuries,orcertaindiseases.Themannequinmaybeusedtopracticeanumberofphysicalex-aminationtechniquesormedicalprocedures,suchastrachealintubation,cardiopulmonaryresuscita-tion,chesttubeinsertion,andIVinsertion.Othersimulatordevicestrainstaffinairwaymanagement,chesttubeplacement,andcentrallineplacement.Thereisalsoanexpandingprogrambothtotrainyoungsurgeonsinlaparoscopicor“bellybuttonsurgery”techniquesandtoprovideadvancedsurgi-caltrainingforexperiencedsurgeonstohelpthemenhancetheirskills.

“We’reveryexcitedabouttheopeningofthenewSimulationCenter,”saysCenterDirectorRichardFidler.“Wehavecreatedaconfidential,nonjudgmentalenvironmentwhereourclinicianscanlearnbetterclinicalmanagementskillsandimprovethewayweall functionasmembersofateam.”

VeteransDiana Nicoll, MD,

PhD, MPA

Nancy Thomson, MD

in MeMoriaMHoSPiTaL neWS

�4San FranciSco MedicineApril 2008 www.sfms.org

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April 2008

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