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ON THE COVER: Reed Flute Cave photograph By David D Clarke, MD

The elaborate natural limestone formations in Reed Flute Cave, in Guilin, Guangxi, China, attract many visitors to the area with their diversity and beauty.

The cover of the first issue of The Permanente Journal, Summer 1997, featured Dr Clarke’s photograph of body pigments for sale in a Kathmandu, Nepal market. Twenty years later, we are proud to be publishing high-quality articles graced by high-quality art.

ORIGINAL RESEARCH & CONTRIBUTIONS 4 Body Mass Index and Mortality in a Very

Large Cohort: Is It Really Healthier to Be Overweight? Arthur L Klatsky, MD; Jasmine Zhang; Natalia Udaltsova, PhD; Yan Li, MD, PhD; H Nicole Tran, MD, PhDThis retrospective cohort study in a multi-racial population of 273,843 persons used logistic regression with 7 covariates (sex, age, race-ethnicity, education, marital status, smoking, alcohol intake). With av-erage follow-up exceeding 30 years, there were 103,218 deaths: 41,215 attributed to cardiovascular causes and 62,003 to non-cardiovascular causes. Compared with persons with body mass index defined as normal, persons who were underweight, overweight, and obese were at increased risk of death during a 30-year period.

12 Effect of Age on Outcomes of Shoulder Arthroplasty. Oke A Anakwenze, MD; Tameem Yehyawi, MD; Mark T Dillon, MD; Elizabeth Paxton, MA; Ronald Navarro, MD; Anshuman Singh, MDIn a retrospective cohort study of prospec-tively collected data, using an integrated health care system’s shoulder arthroplasty (SA) registry (1/2007-6/2012), patients were grouped into older (> 75 years) and younger groups (≤ 75 years). The total SA cohort had 2007 patients, 538 (27% > age 75 years), and the reverse total SA cohort had 568 patients, 295 (52%) age > 75 years. In the total SA cohort, older patients had higher risk of readmis-sion and mortality. In the reverse total SA cohort, older patients had lower risk of revision.

17 Nasopharyngeal Carcinoma Diagnostic Challenge in a Nonendemic Setting: Our Experience with 101 Patients. Kevin H Wang, MD; Stephanie A Austin, MD; Sonia H Chen, MD; David C Sonne, MD; Deepak Gurushanthaiah, MDA retrospective chart review (2007-2010) included 101 patients; 70 were of Chinese or Southeast Asian descent. Median time from symptom onset to treatment was 6 months. One-third of cancers were missed with nasal endoscopy and imag-ing. An understanding of the risk factors, presenting symptoms, and limitations associated with these diagnostic tests is necessary to support earlier detection of this insidious cancer.

22 Incidence of Pulmonary Arterial Hypertension in Patients with Psoriasis: A Retrospective Cohort Study. Young M Choi, MD; Shannon Famenini, MD; Jashin J Wu, MDIn a retrospective cohort study (1/2004-11/2012), there were 10,115 patients with mild psoriasis, 3821 with severe psoriasis, and 69,360 matched controls. On multivariable analysis, there was a significantly increased risk of pulmonary

arterial hypertension (PAH) developing in the severe psoriasis cohort vs their con-trols. The systemic inflammatory process underlying psoriasis may be a cause for an increased risk of PAH, but there are numerous secondary causes of PAH.

28 Complementary and Alternative Medicine in an Integrated Health Care Delivery System: Users of Chiropractic, Acupuncture, and Massage Services. Tracy McCubbin, MD; Karin L Kempe, MD, MPH; Arne Beck, PhDFrom 2007-2014, 27,225 patients sought Center for Complementary Medicine (CCM) services (62% female, 73% white). Modalities included chiropractic (67%), acupuncture (18%), and massage (15%). Spine/truncal pain was most commonly reported (71%). Of patients, 59% saw their physician for their condition; 59% had not used CCM services previously; and 60% received medications for their condition. Mean ratings included pain relief with prior treatment (30%), current pain (4.33), and functional impairment ranging from 3.03 for relationships to 5.42 for enjoyment of life.

34 Impact of Longitudinal Electronic Health Record Training for Residents Preparing for Practice in Patient-Centered Medical Homes. Jung G Kim, MPH, CPH; Hector P Rodriguez, PhD, MPH; Katherine AT Estlin, MD; Carl G Morris, MD, MPHThe patient-centered medical home (PCMH) electronic health record (EHR) training consisted of case-based routine clinic visits delivered to 3 resident cohorts (N = 18). Participants (127) completed an EHR competency self-assessment (2011-2016). Comprehensive training de-signed to improve EHR competencies for practicing in a PCMH resulted in improved assessment scores. Findings indicate EHR training as part of resident exposure to the PCMH measurably improves self-assessed competencies, even among residents less engaged in EHR training.

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ISSN 1552-5767

111 BOOK REVIEW

112 CME EVALUATION FORM

Summer 2017/ Volume 21 No. 3

The Permanente Journal/ Summer 2017/ Volume 21 No. 3

SOUL OF THE HEALER 16 Lisbon

Samuel H Glassner, MD 33 The Mercantile Truck

April M Day, MD 45 Sherbrooke Cemetery,

North Dakota Stephen C Henry, MD

69 Plitvice Falls Boardwalk Panorama David D Clarke, MD

77 Bobcat, Los Gatos, California J Richard Gaskill, MD

For information and/or rates for placing an announcement here, please contact amy.r.eakin@kp.org.

BOOKS PUBLISHED BY PERMANENTE AUTHORS:

If you are a Permanente author and would like your book cited here, send an e-mail to max.l.mcmillen@kp.org.

Calamity Jane: How the West Began

Bryan Ney

ISBN-10: 0997747803 ISBN-13: 978-0997747805

Pampano Beach, FL: Dragon Tree Books; 2016

Paperback: 186 pages $10.99

Gestational Diabetes During and After Pregnancy Catherine Kim; Assiamira Ferrara

ISBN-10: 1848821190 ISBN-13: 978-1848821194

New York, NY: Springer; 2011 Hardcover: 394 pages $119.00

IHI AD TO GO HERE

1

40 Mortality After Total Knee and Total Hip Arthroplasty in a Large Integrated Health Care System. Maria C S Inacio, PhD; Mark T Dillon, MD; Alex Miric, MD; Ronald A Navarro, MD; Elizabeth W Paxton, MA In a retrospective analysis of an integrated health care system population in 2010, 10,163 primary total knee arthroplasties (TKAs), 4963 primary total hip arthroplas-ties (THAs), 606 revision TKAs, and 496 revision THAs were evaluated. Patients undergoing primary THA and TKA had lower odds of mortality than expected. Patients with revision TKA had higher-than-expected mortality odds, whereas patients with revi-sion THA did not have higher-than-expected odds of mortality.

Special Report 46 Physician Guide to Appropriate Opioid

Prescribing for Noncancer Pain. Timothy Munzing, MD, FAAFPThe author highlights key topics in the management of patients using opioids (or potentially needing opioids) in outpatient clinical practice; federal and state law enforcement actions regarding physicians’ illegal prescribing of opioids; multimodal approaches to pain control; nonmedication management of pain; response strategies when suspecting a patient of diverting or misusing opioids; and warning signs for abuse or diversion. In addition to individual action, the initiation of systemwide and clinicwide safe prescribing practices sup-ports the physician and patient such that the patient’s well-being is at the heart of all pain management decisions.

Special Report 53 The Kaiser Permanente Northern California

Enhanced Recovery After Surgery Program: Design, Development, and Implementation. Vincent X Liu, MD, MS; Efren Rosas, MD; Judith C Hwang, MD, MBA; Eric Cain, MD, MBA; Anne Foss-Durant, RN, MSN, FNP, MBA; Molly Clopp, RN, MS, MBA; Mengfei Huang, MSc; Alexander Mustille; Vivian M Reyes, MD; Shirley S Paulson DNP(c), MPA, RN, NEA-BC; Michelle Caughey, MD; Stephen Parodi, MDIn this report, the authors describe the design, development, and implementation of an Enhanced Recovery After Surgery program in the Kaiser Permanente Northern California integrated health care delivery system (2014), targeting patients with elective colorectal resection and those with emergent hip fracture repair across 20 Medical Centers. The program lever-aged multidisciplinary and broad-based leadership, high-quality data and analytic infrastructure, patient-centered education, and regional-local mentorship alignment. This program has already had an impact on more than 17,000 patients.

REVIEW ARTICLES 62 Supporting Muslim Patients During Advanced

Illness. Nathan A Boucher, DrPH, PA-C, MS, MPA, CPHQ; Ejaz A Siddiqui, MIS; Harold G Koenig, MD, MHSWorldwide violence perpetrated by people identifying as Muslim has been a grow-ing fear for people living in the US and elsewhere. This article explores conditions needed for prayer, roles of medical treat-ment and religious authority, modesty, and the role of family in making medical deci-sions. Initial recommendations are provided to optimize care for Muslim patients and their families, informed by the described tenets of Muslim faith.

CLINICAL MEDICINE 67 Use of a Technetium99m-Sestamibi Scan

to Detect Ipsilateral Double Adenoma in a Patient with Primary Hyperparathyroidism: A Case Report. Joseph Gabriel Gabriel, MD; Alejandro Contreras, MD; Andrew Rosenthal, MDPatients with primary hyperparathyroid-ism generally have a single parathyroid adenoma that causes excessive excretion of parathyroid hormone. About 2% to 15% of these patients have a double adenoma. Presurgical imaging and nuclear scans can help to localize multiple lesions, and intra-operative parathyroid hormone assays can confirm the diagnosis and cure.

70 A Clinical Approach to Animal Bites with an Avulsion Flap: A Case Report. Andrew Williamson, MD; Cyril Thomas, MS, PA-CA 90-year-old white woman sustained a large dog bite to her hand, over the dorsal aspect of the first metacarpal, which was repaired with the avulsion flap as a bio-logic dressing that employed a perforating technique to successfully treat the wound and allow for optimal wound healing. Photo-graphs at several stages are included.

72 Splenic Abscess in Immunocompetent Patients Managed Primarily without Sple-nectomy: A Series of 7 Cases. S Divyashree, MBBS, MD; Nikhil Gupta, MBBS, MDA microbiological diagnosis of splenic ab-scess is of utmost importance. In this case series, all patients underwent percutane-ous aspiration. This was performed under radiologic guidance (either ultrasonography or computed tomography). Only one patient required diagnostic splenectomy. Appropri-ate antibiotic therapy is the cornerstone of management.

78 Flood Syndrome: Spontaneous Umbilical Hernia Rupture Leaking Ascitic Fluid— A Case Report. Emilie T Nguyen, MD; Leah A Tudtud-Hans, MDThe spontaneous rupture of an umbilical hernia in a 42-year-old man with hepatitis C and alcoholic cirrhosis was complicated by ascites and esophageal varices. This is a

rare complication with high mortality rates and stresses the challenge of treatment that falls in the area between medical and surgi-cal management.

80 Image Diagnosis: Multivessel Percutaneous Coronary Intervention in Dextrocardia: Success with Usual Techniques in a Case of Mirror-Image Heart. Mohamed Morsy, MD; Pranab Das, MD; Inyong Hwang, MD; Rami N Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAIAlthough dextrocardia is very rare, it could be clinically noted in a variety of cardiovas-cular and noncardiovascular conditions. Patients with dextrocardia can have various clinical presentations, including acute coro-nary syndrome and congestive heart failure. Successful diagnostic catheterization and multivessel intervention can be achieved through conventional catheters with appro-priate reversed rotation and without need for right/left reversal of radiologic views.

82 Image Diagnosis: A Gastric Signet-Ring Adenocarcinoma of Type Linitis Plastica Mimicking Splenomegaly in a Patient with Chronic Lymphocytic Leukemia. Leonid L Yavorkovsky, MD, PhD; Shazia Ali, MDTypically, adenocarcinoma of type linitis plastica, known as Brinton disease or leather bottle stomach, is characterized by diffuse infiltration of neoplastic signet-ring cells. This imparts a rigid consistency to the stomach wall, with a thickened, fibrotic appearance. These symptoms in this patient mimicked the appearance of an enlarged spleen.

84 Image Diagnosis: Rapidly Enlarging Scrotal Hematoma: A Complication of Femoral Access? Raza Askari, MD; Rami N Khouzam, MD, FACC, FACP, FASNC, FASE, FSCAI; Dwight A Dishmon, MD, FACCDiagnosis of retroperitoneal bleeding is made with abdominopelvic computed to-mography. Ultrasound or computed tomog-raphy can provide the diagnosis for scrotal hematoma. Treatment of scrotal hematoma has ranged from conservative measures, including scrotal elevation and resuscitation with IV crystalloids or blood products, to open surgical options.

86 Image Diagnosis: Iliopsoas Abscess from Crohn Disease. Ashley S Abraham; Michelle Y Liu; David R Vinson, MDCrohn disease is a common cause of secondary iliopsoas abscesses, occurring in an estimated 0.4% to 4.3% of patients.

Although long-term corticosteroid use with its attendant immunosuppression could increase the risk for abscess formation, a short course is unlikely to have the same effect.

CME credits are available online at www.tpjcme.org. The mail-in CME form can be found on page 112.

Contents continued on next page.

The Permanente Journal/ Summer 2017/ Volume 21 No. 3

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COMMENTARY 88 Considerations in the Neuropsychological

Evaluation and Treatment of Children with Limited English Proficiency. Alonso Cardenas, MD; Laura Villavicencio, MD, MS; Mani Pavuluri, MD, PhDGiven the large number of Spanish speak-ers in the US, the authors illustrate, with a case example, the need to test students in their native language especially when the second language has not yet been mas-tered. Accurate assessment of the brain’s potential may yield enhanced opportunities and optimize expectations, rather than un-dervaluing a developing child’s elastic brain maturation.

90 To Err is Human: Can American Medicine Learn from Past Mistakes? Jeffrey B Ritterman, MDThe history of medicine includes many errors. Some persisted for decades and caused great harm. Several are highlighted in this article, including the mythical thymic diseases: thymic asthma and status thy-micolymphaticus. Some medical mistakes, such as the diet-heart hypothesis of Ancel Keys, continue to cause harm. To avoid future errors and their associated harm, the author suggests a cultural shift encouraging professional humility and greater question-ing of medical dogma. Medical education focused on teaching students this history may help with this cultural shift.

95 The Patient-Centered Medical Home as a Community-based Strategy. Berkeley A Franz, PhD; John W Murphy, PhDAlthough patient perspectives are criti-cal to the patient-centered medical home (PCMH), this article questions whether the PCMH in practice is truly community-based. That is, do physicians, planners, and other

health care professionals take seriously the value of integrating local knowledge into medical care? The argument presented is that community-based philosophy contains a foundational principle that the perspec-tives of health care practitioners and com-munity members must be integrated.

EDITORIAL 100 Philanthropy and Beyond: Creating Shared

Value to Promote Well-Being for Individuals in Their Communities. Thomas E Kottke, MD, MSPH; Nico Pronk, PhD, MA; Andrew R Zinkel, MD, MBA; George J Isham, MD, MSHealth care organizations can magnify the impact of their community service and other philanthropic activities by implementing programs that create shared value. The author uses three initiatives in sectors other than health care to illustrate the concept of shared value, and also presents examples of shared value programs sponsored by health care organizations: telehealth, work-site health promotion, school-based health centers, green and healthy housing, and clean and green health services.

NARRATIVE MEDICINE 105 Lessons Learned in War.

Alberto Hayek, MDIn civilian life one does not encounter these kinds of experiences, but the pain of a family with an ill child confronting a fatal prognosis is akin to a missile sent from an unknown source. As a physician, these painful experiences haunt me when all I can do is to be a silent participant while sharing the pain of unavoidable death.

107 Deer in the Headlights. Tom Paluch, MD“I just don’t know,” I respond flatly. The profundity of those four words is not lost on her. Her eyes widen like those of a deer in the headlights on a lonely country road late at night, frozen by the oncoming, unknown terror, unable to run, waiting to see if this thing, this rushing menace will stop, or sweep it away.

109 Abdominal Distension—An Unexpected Gift. Ching Soong Khoo, MD, MRCP (UK)“That is a baby!” I swiftly showed her the fe-tal heartbeats on the scan. Her eyes imme-diately welled up with tears of joy—relieved that the swelling in her tummy wasn’t some-thing more sinister. Being underprivileged with limited access to health care services, she had felt helpless and frightened by her abdominal distension.

The Permanente Journal/ Summer 2017/ Volume 21 No. 3

More content is available at: www.thepermanentejournal.org.

ONLINE

CLINICAL MEDICINEImage Diagnosis: Bronchial Anthracofibrosis— A Bronchoscopic Diagnosis. Ashok Shah, MD; Shekhar Kunal, MBBSImage Diagnosis: Carcinoid Tumorlets and Pulmonary Sequestration in a Patient With Chronic Cough Without a History of Malignancy. Zhou Zhang, MD; Harleen Hayreh, MDPembrolizumab-Induced Pancytopenia: A Case Report. Dinesh Atwal, MD; Krishna P Joshi, MD; Rahul Ravilla, MD; Fade Mahmoud, MD

Well-Differentiated Neuroendocrine Tumor— A Low b-Grade Tumor’s Aggressive Course and Dismal Outcome: A Case Report. Dinesh Atwal, MD; Krishna Prasad Joshi, MD; Susanne Jeffus, MD; James Ntambi, MD; Fade Mahmoud, MD, FACPSmall-Bowel Intussusception in a Pregnant Woman: A Case Report. Roxana Covali, MD, PhD; Lucian Ambrosie, MD; Micea Onofriescu, MD, PhD; Alexandru Luca, MD, PhD; Gabriela Dumachita-Sargu, MD, PhD; Violeta Aursulesei, MD; Dumitru Gafitanu, MD, PhD

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PermanenteJournalThe

EDITOR-IN-CHIEF: Tom Janisse, MD, MBAASSOCIATE EDITOR-IN-CHIEF: Lee Jacobs, MD

SENIOR EDITORSVincent Felitti, MD Preventive Medicine, Book Reviews

Gus M Garmel, MD, FACEP, FAAEM Clinical MedicineArthur Klatsky, MD Original Articles

Eric Macy, MD ResearchScott Rasgon, MD Corridor Consult

ASSOCIATE EDITORSJames J Annesi, PhD, FAAHB, FTOS, FAPA

Health Behavior ResearchRicky Chen, MD

Medicine in SocietyGary W Chien, MD

SurgeryCarrie Davino-Ramaya, MD

Medical ReviewCharles Elder, MD Integrative Medicine

Philip I Haigh, MD, MSc, FRCSC, FACS Surgery

Lisa Herrinton, PhD Health Systems Research

Robert Hogan, MD Family Medicine, Health Information Technology

Ashok Krishnaswami, MD, MAS Cardiology

David Riley, MD Case Reports

Ruth Shaber, MD Women’s Health

John Stull, MD, MPH Spirit of Medicine Dialogues

Gretchen Summer, PhD, RN Nursing Research and Practice

KM Tan, MD Continuing Medical Education

Calvin Weisberger, MD Cognitive Clinical MedicineWinston F Wong, MD, MS

Community Benefit, Disparities Improvement and Quality Initiatives

Scott S Young, MD Care Management Institute and Quality

EDITORIAL & PUBLISHING OFFICE Merry Parker: Managing Editor & PublisherLynette Leisure: Creative Director Amy Eakin: Business & Publishing Operations ManagerMax McMillen, ELS: Senior Editor & Staff WriterChristopher Dauterman, MBA: Web Developer & AnalystIan Kimmich, ELS: Copy Editor & Publishing Coordinator

EDITORIAL BOARD

Maher A Abbas, MD, FACS, FASCRS Medical Director, Dubai Colorectal Center, UAE; Professor of Surgery, Case Western Reserve University, Cleveland, OhioRichard Abrohams, MD Internal Medicine and Geriatrics, The Southeast Permanente Medical Group, Atlanta, GeorgiaFábio Ferreira Amorim, MD, PhD Professor of Medicine, Escola Superior de Ciências da Saúde in the Department of Postgraduate and Extension Activities, Brasilia, BrazilStanley W Ashley, MD Chief Medical Officer, Brigham and Women’s Hospital; Frank Sawyer Professor of Surgery, Harvard Medical School; Attending Surgeon, Gastrointestinal Cancer Center, Dana Farber Cancer Institute, Boston, MassachusettsThomas Bodenheimer, MD Professor, Dept of Family and Community Medicine, University of California, San FranciscoBrian Budenholzer, MD Associate Clinical Professor in the Department of Family Medicine at the Brody School of Medicine at East Carolina University, Greenville, North CarolinaAlexander M Carson, RN, PhD Associate Dean of Research and Enterprise at the Institute of Health, Medical Sciences and Society at Glyndwr University in Wrexham, Wales, United KingdomIrene Carvalho, PhD Clinical Neurosciences and Mental Health Department, School of Medicine, Oporto University, Porto-Portugal, Oporto, PortugalShamir O Cawich, MBBS, DM Department of Surgery, St Augustine Campus, University of the West Indies, Trinidad and TobagoRita Charon, MD, PhDProfessor of Medicine, Founder and Executive Director of the Program in Narrative Medicine at the College of Physicians and Surgeons of Columbia University Medical Center, New York, New YorkPranab Chatterjee, MBBS, MDScientist, Indian Council of Medical Research, National Institute of Cholera and Enteric Diseases, Infectious Diseases Hospital, Beliaghata, Kolkata, IndiaDan Cherkin, PhDSenior Scientific Investigator, Group Health Cooperative, and Affiliate Professor, Dept of Family Medicine and School of Public Health—Health Services, University of Washington, SeattleMitsuro Chiba, MD, PhD Department of Gastroenterology, Akita City Hospital, Kawamoto, Akita, Japan

Robert R Cima, MD, FACS, FASCRS Professor of Surgery, Division of Colon and Rectal Surgery; Vice Chairman, Department of Surgery, Mayo Clinic, Rochester, MinnesotaEllen Cosgrove, MD Vice Dean, Academic Affairs and Educa-tion, University of Nevada, Las Vegas School of Medicine, Las Vegas, NevadaQuentin Eichbaum, MD, PhD, MPH, MFA, MMCH, FCAP Associate Director of Transfusion Medi-cine; Associate Professor of Pathology; Associate Professor of Medical Education and Administration; Director, Fellowship Program in Transfusion Medicine; Mem-ber, Vanderbilt Institute for Global Health; Vanderbilt University School of Medicine, Nashville, TennesseeRichard Frankel, PhD Professor of Medicine and Geriatrics, Indiana University School of Medicine, IndianapolisCarol Havens, MD Family Practice and Addiction Medicine, Director of Clinical Education, The Permanente Medical Group, Oakland, CaliforniaJames T Hardee, MD Internal Medicine, Colorado Permanente Medical Group; Associate Clinical Professor of Medicine, University of Colorado School of Medicine, DenverArthur Hayward, MD Assistant Clinical Professor, Division of General Medicine, Dept of Internal Medicine, Oregon Health Sciences University, PortlandCatherine Hickie, MBBS Director of Clinical Training, Bloomfield Hospital, Greater Western Area Health Service; Conjoint Senior Lecturer in Psychiatry, University of New South Wales, AustraliaGunver Sophia Kienle, Dr Med Senior Researcher, University of Witten/Herdecke, Institute for Applied Epistemology and Medical Methodology, Freiburg im Breisgau, GermanyAnna Luise Kirkengen, MD, PhD Department of General Practice Research, Institute of Community Medicine, Norwegian University of Science and Technology, Trondheim, NorwayThomas E Kottke, MD Medical Director for Well-Being, HealthPartners; Consulting Cardiologist, HealthPartners Medical Group; Senior Clinical Investigator, HealthPartners Institute for Education and Research; Professor of Medicine, University of Minnesota, MinneapolisTieraona Low Dog, MD Fellowship Director, Academy of Integrative Health and Medicine, LaJolla, California; Director, Integrative Medicine Concepts, Pecos, New Mexico; President, My Own Health; Director, Scientific and Regulatory Affairs, Healthy Lifestyle Brands; Tempe, Arizona

Lewis Mehl-Madrona, MD, PhD, MPhil Director of Geriatric Education, Maine Dartmouth Family Medicine Residency; Director of Education and Training, Coyote Institute, Augusta, MaineColin G Murphy, MCh, FRCSI Department of Trauma and Orthopaedics, Galway University Hospitals, Newcastle, Galway, IrelandMichel M Murr, MD, FACS Director of Bariatric Surgery, Chief of Surgery, Tampa General Hospital, FloridaSylvestre Quevedo, MD Department of Medicine and Global Health Sciences, University of California, San FranciscoIlan Rubinfeld, MD, MBA, FACS, FCCP, FCCSChief Medical Officer-Associate, Henry Ford Hospital; Surgical Lead and Inpatient Co-Lead, Project Helios: The Epic Clinical Integration and Transformation Team, Henry Ford Health System; Faculty Surgeon, Acute Care Surgery, Henry Ford Hospital; Associate Professor of Surgery, Wayne State University School of Medicine, Detroit, MichiganMarilyn Schlitz, PhD Chief Executive Officer of Worldview Enterprises, LLC, and Senior Fellow and President Emeritus at the Institute of Noetic Sciences in Petaluma, CA; Professor in and the Chair of the Doctor of Philosophy in Transpersonal Psychology program at Sofia University in Palo Alto, CATido von Schoen-Angerer, MD, MPH Researcher, ARCIM Institute, Filderstadt, Germany, Attending Physician, Department of Pediatrics, Fribourg Hospital, Switzerland Audrey Shafer, MD Professor of Anesthesia, Perioperative and Pain Medicine, Stanford University School of Medicine/VAPAHCS; Anesthesiologist, Veterans Affairs Palo Alto Health Care System; Director, Medicine and the Muse, Stanford Center for Biomedical Ethics, Palo Alto, CAMark Snyder, MD Specialist Leader, Electronic Medical Record Implementation and Physician Adoption; Deloitte Consulting, LLP, McLean, VirginiaSwee Yaw Tan, MBchB (Edin), MRCP (UK), ACSM, FAMS Senior Consultant Cardiologist, National Heart Centre, Adjunct Assistant Professor Duke National University of Singapore Graduate Medical School, SingaporeWilliam L Toffler, MD Professor Emeritas of Family Medicine, Oregon Health and Sciences University, Portland

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