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DEPARTMENTS On the cover
See page 6 Editorial 2 The data deluge: The information explosion in medicine and science Richard L. Byyny, MD, editor
Alpha Omega Alpha elects 35 honorary members
The physician at the movies 36 Peter E. Dans, MD Tinker Tailor Soldier Spy Moneyball
Reviews and reflections 44 Open Heart: The Radical Surgeons ARTICLES Who Revolutionized Medicine Reviewed by Taylor Prewitt, MD DNR: Do Not Resuscitate–Real Success, professionalism, and the medical Stories of Life, Death and student Somewhere in Between Reviewed by Walter Forman, MD, Richard B. Gundrman, MD, PhD FACP, FAAHPM Anatomy of a Kidnapping: A Doctor’s Story Through a glass darkly Reviewed by Charles S. Bryan, MD After We Die: The Life and Times of J. Joseph Marr, MD the Human Cadaver Reviewed by Jack Coulehan, MD A History of Immunology, Second Paulinia Edition Reviewed by Carla C. Keirns, MD, Clifford Straehley, MD PhD, MSc
N a t i o n a l and chapter news Allvar Gullstrand, Albert Einstein, and a 47 2011 AΩA councilors meeting Nobel dilemma revisited Curtis E. Margo, MD, MPH, and Lynn E. Harman, MD POETRY The Anatomy of Melancholy Catching Leaves 9 Steven F. Isenberg, MD Burton and Osler A Vision in the Infusion Henry N. Claman, MD 34 Suite Adam Possner, MD The case for integrating public health and My Pacemaker medical education and how to do it 40 Herbert S. Harned, Jr., MD Jonathan Ryan Barry, MSPH INSIDE BACK In Honour to a Mentor 39COVER Carl Rothschild, MD, FRCP(C)
Editorial The data deluge: The information explosion in medicine and science
Richard L. Byyny, MD, FACP
he explosive increase in the amount and flow of informa- discovered the efficacy of cowpox vaccination to prevent tion and data represents an important professional chal- smallpox. The discovery that quinine was a specific treatment lengeT for those of us in medicine and science. for malaria occurred during the same period. Today, data sets are measured in petabytes ( bytes), The concepts of cell theory, cellular pathology, physiology, and data is so efficiently gathered and stored that it presents and pathophysiology were established. Anesthesia and anti- a major challenge when evaluating its reliability, extracting sepsis dramatically improved surgery and its outcomes. The its useful information, and using it effectively to improve our germ theory of disease was put forth and microbial agents understanding of science and medicine. causing disease were isolated, identified, and characterized. Five years ago there was already billion gigabytes (Gb) This was followed by the development of antimicrobial drugs, of digital information, and about billion Gb of analog in- the use of antitoxins, and the development of more vaccines formation. The data continues to accumulate and physicians to prevent disease. continue to struggle with how to organize it and use it to The twentieth century brought a dramatic rise in the pub- understand science, to prevent disease, and to better serve lication of scientific journals and monographs, most of which the suffering. As Nobel Prize winner Tom Cech notes, we are were not critically reviewed. However, most physicians had no still in the contemporary Dark Ages when trying to access access to the available medical literature. and utilize the available data and information being produced Sir William Osler, the author of The Principles and Practice and stored. of Medicine, the leading textbook of the early twentieth cen- Physicians and other scientists are good and getting better tury, was very concerned about the increase in the medical at producing data. But we must become proficient—with or literature. He worried about the lack of quality, limited ac- without the help of technology—at mining and managing the cess, and how it would be used. Osler and his colleague, John data in ways that will allow us to use it to maximum effect. Shaw Billings, one of the innovators and leaders in medical Throughout history, changes in technology have often in- librarianship,* worked together to further the development of creased the production of information and its dissemination. medical libraries. When we advanced from verbal communication to written For most of the last fifty years, physicians and scientists records we could slowly produce manuscripts and books that have retrieved needed information on paper: they subscribed some could read and learn from. In concert with the devel- to journals, filled filing cabinets or their office floors with opment of writing were archives, repositories of tablets and commonly referenced papers, or visited libraries. Biomedical other permanent records, which evolved to become libraries. scientists developed hypotheses about a gene, RNA, protein, But the ability to easily disseminate collected information had receptor, or pathway, and performed experiments that resulted to await the fifteenth century. in huge advances in our understanding of health and disease, Around , Johannes Gutenberg invented the printing along with ever increasing data. press, resulting in a dramatic increase in the spread of infor- Throughout the twentieth and now twenty-first centu- mation at a more reasonable cost. Even then, many lamented ries, the flow of information has been increasing at nearly the problem of too much information. exponential rates, until it now threatens to drown us in data. The integration of the rational sciences with medicine By , more than biology, chemistry, and medical in the s and s built the foundation for scientific journals were being published. PubMed listed one million medicine. During this period the pursuit of observational articles. Publication of randomized controlled trials, the gold science evolved and the study and understanding of anatomy progressed to pathologic anatomy and the identification of the relationship between clinical symptoms and signs to post- * Billings was the creator of the Index Medicus, modernized the mortem findings and disease. Physicians developed new in- library of the Surgeon General’s Office of the Army, and was the first director of the New York Public Library. struments and methods to study diseases and patients. Jenner
2 The Pharos/Spring 2012
standard of clinical research, has increased rapidly since the first study was published in the s, such that it is estimated that just to keep up on reading RCTs for the ten most common di- agnoses in a field would mean reading twelve pub- lications per week. The development of computers and the Internet—instant access to virtually any and all information—has fun- damentally changed the way knowledge is gathered, stored, and disseminated. With more than a billion peo- ple online and ten billion pages of information available on the Internet, we have evolved through Web . and . and are heading into the “semantic web,” Web ., in which human- computer interaction is projected to provide access to usable “metadata”—data that is aggregated, organized, and ready for analysis. In the past, a scientist’s first goal was to develop a hypoth- esis. That hypothesis was then proved or disproved through simple experiments. Proven hypotheses became working theories, providing valid answers to experimental questions. Today, the science of living organisms has become so complex that any investigation requires looking at many interactive processes, such that, more than ever, an interdisciplinary systems approach is needed to understand biology and the sci- ence of medicine. Data from multiple sources is coming at us petabytes are not unheard of. in bigger pieces, faster, and cheaper. In genomics, for example, As noted above, traditional science is based on developing the amount of data has increased from about Gb per year hypotheses and then designing experiments to confirm or in at a cost of , per megabyte (Mb), to about disprove them, a process in many ways the antithesis of data , Gb in the year , at a cost of per Mb. Other mining. Data mining more resembles longitudinal population- areas of medicine show similar explosions in data, including based studies in which cohorts of people are followed over that of diagnostic imaging, in which data sets of up to a period of time to identify associated predictors of disease.
The Pharos/Spring 2012 3
The data deluge: The information explosion in medicine and science
Asking the appropriate question and assessing the appropriate Today, just-in-time learning plays an increasingly impor- databases is critical in designing longitudinal studies, as it is tant role. Information is most useful applied at the right time. in data mining. Dr. Reynolds knew that learning is more likely to be useful, So how will we deal with the data deluge? As in Osler’s era, remembered, and teachable if it is tied to a problem or event. medical scientists partner with librarians—which these days As a clinical scientist, practitioner, educator, and learner I, too, include computational scientists and technology experts—to have long believed in just-in-time learning. Fortunately, the develop new ways to store and retrieve information in forms development of the internet and World Wide Web has greatly that are useful. How do we present data in ways that allow us facilitated just-in-time access to information and data. to grasp the essential and useful information and ignore the Although I have many issues with the use and utility of rest? proprietary electronic health records and systems, it does Key to the challenge of being able to use the flood of provide one major advantage for just-in-time learning. While information that is threatening to overwhelm us will be the sitting with a patient and wondering about a diagnosis, test, development and use of “intelligent agent software,” programs or treatment I can immediately go to the online library and that can automate commonly performed tasks and learn from find the answer. their interactions with people. Such software could conceiv- Before overloading your brain, recognize that not every- ably identify unrecognized opportunities to analyze data, solve thing in medicine changes rapidly, if at all. New diseases problems, bring in interdisciplinary expertise, and integrate appear infrequently. The clinical manifestations of most dis- and prioritize diverse data sources in large, complex, and eases change slowly, if at all. The symptoms in the history and distributed information systems. To be truly useful, we would physical findings, although varying from patient to patient, need the agents to know: are usually consistent over time. And the physician’s use of • What parts of particular sets of information are relevant deductive reasoning to reach a conclusion from the clini- to a specific individual and the current situation cal information doesn’t change. If I work hard to learn what • Which medical references pertain to a specific patient’s doesn’t change rapidly in medicine and continue to practice condition the skills and use that knowledge, I will have a good, reliable, • To which web sites a physician should refer a patient for and persistent foundation of knowledge to draw from in caring relevant information for patients. I can then look up information “just-in-time” to • How to recognize potential unexpected relationships answer questions that arise that I don’t know or that may have between the diverse information sources. changed recently. But it doesn’t stop there. We would also need new tools and What does change rapidly in medicine includes diagnostic biomedical curators to categorize the data with common and strategies, technologies, and therapies. These areas require integrated languages. Data collected should be curated and constant attention and continuous learning. Make it a habit organized in a commonly agreed-upon format, then submit- to stay current in advances within these areas. Although not ted to repositories that will allow interconnections among data everything changes all the time, many things are changing. For sets. Data needs to become knowledge. issues too complex for this strategy, you can and should rely Until that happens, we need an effective way to take things on subspecialty consultants—those whose depth and breadth in. I believe just-in-time learning is currently the most effec- of knowledge are more profound. It is also important to recog- tive approach. Almost fifty years ago, one of my teachers and nize that patients now have access to much of the same infor- mentors, Dr. Telfer Reynolds, explained to me his strategy mation as their physicians, and can bring useful or confusing for continuous learning in medicine. He kept a black book in information to bear on their ailments. his lab coat pocket. When he discovered something he didn’t It is estimated that , new articles and randomized know about medicine or a patient—which seemed rare—he controlled trials are added to Medline each week, and that would write it down in his book. Once a week, he would go to new medical articles appear at a rate of one every twenty-six the Los Angeles Medical Society Library. He would start at the seconds. We clearly need a plan to keep up as well as we can. top of his list of questions and look up the information needed Here is my proposed strategy: to answer his question, as well as other pertinent literature. At . Read the literature to attain, maintain, or improve closing time, he would tear out his list, crumple it, and throw knowledge and/or medical competence. it in the trash so he could start a new list for the next week. Dr. . Maintain your curiosity and inquisitiveness—with an Reynolds’ use of just-in-time learning for specific reasons—to appropriate degree of skepticism. diagnose a problem or to teach students—meant that he was . Information is most helpful when used to answer ques- that much more likely to remember what he had just learned. tions about a patient’s condition, pathobiology, diagnosis,
4 The Pharos/Spring 2012
therapy, or prognosis. to assess the usefulness and validity of the reported findings. . Pick a place to start. This will depend on your own It is the “basic science” of evidence-based medicine. When knowledge of a topic. If your knowledge is limited, start with critically reviewing the medical literature it is also helpful to general textbooks written by experts and then move to more begin with a list of questions, as in the table.
Critical Appraisal of the Medical Literature: List of Useful Questions Is the study’s research question relevant? Was the study design appropriate for the research question? Is the topic relevant to a question or to one’s own field of work? Did the study design and methods address the question? Does the study, if valid, add anything new? Are there important sources of bias or interpretation in the study? Are there stated incremental advances of value? How were participants selected and allocated? What type of research question does the study pose? How was data collected? What is the stated hypothesis? Did the study follow the protocol? Who is the population of patients or subjects studied? Was the analysis and assessment rational, appropriate and valid? What are the measurable parameters or outcomes of interest? Is the sample size sufficient for validation? Is it a study related to diagnosis, therapy, frequency of events, prognosis, Does the data justify the conclusions? or something else? What is the study design? Are there sources of potential conflicts of interest? – Meta-analysis of randomized controlled trials Are the findings clinically or scientifically relevant? – A randomized controlled trial – A cohort study, prospective or retrospective – A case-control study – An observational study – A descriptive study – A systematic or historical review
specialized textbooks, including online textbooks. Once you A key part of our professional responsibility is continuous have satisfactorily increased your understanding of the prob- learning to improve our knowledge, skills, and our practice of lem or issue, move on to critical reviews and original studies the art of medicine. Information overload makes this much and research articles for more in-depth knowledge or to an- more difficult. It is ironic that we have exchanged what was swer specific questions. a lack of access to medical information in Osler’s time for the . Develop a strategy for evaluating research articles and contemporary problem of drowning in data. studies to determine if the article is of high quality and if the I don’t doubt that Osler would have embraced the abun- information will be useful. It is often useful to quickly scan or dance of information and the new technologies for finding read the title, abstract, introduction, and conclusion to deter- and spreading it. But he, like many of us today, would have mine if the information is relevant to your practice, patients, recognized and worried about the dilemma we face in distin- knowledge, or teaching. If the scan of the article is positive guishing the useless from the useful, and in deciding how to then spend more time on the stated hypothesis, study design, put the useful to best use. So even though challenging, it’s up results, analysis, assessment, and discussion. to us to make sense of and organize the vast knowledge avail- . Critically appraise the research and article content. able to become more worthy to serve the suffering. I recommend the JAMA series on “Step-by-Step Critical Appraisal” that describes how to critically appraise medical Dr. Byyny (AΩA, University of Southern California, 1964) is the literature. These have been published in JAMA for many years, Executive Director of Alpha Omega Alpha and editor of The with emphasis in each article about different types of research Pharos. His address is: and how the articles should be critically reviewed. 525 Middlefield Road, Suite 130 Critical appraisal is a proven systematic process used to Menlo Park, California 94025 identify the strengths and weaknesses of a research article and E-mail: [email protected]
The Pharos/Spring 2012 5
Richard B. Gunderman, MD, PhD
The author (AΩA, University of decade. The family had contributed far he choked with emotion. The students Chicago, 1992) is Professor of more than their share to the education seated in the front rows could see tears Radiology, Pediatrics, Medical of future physicians, and it was time to welling up in his eyes. Education, Philosophy, Liberal Arts, give their son a rest. He had been used Throughout the father’s story, one Philanthropy and In the Honors as a pincushion long enough, she said, student in the second row sat rapt in at- College at Indiana University. He is and it was time to let some other family tention, never averting his eyes. When a councilor director on the Board of shoulder the load. the father winced, a hint of a grimace Directors of Alpha Omega Alpha and The father disagreed. He argued that swept across his face. When the father councilor of the chapter at Indiana it was important for each year’s group sighed, you could see the student’s shoul- University School of Medicine. of young doctors to meet their son for ders fall ever so slightly. And when the themselves. The encounter would help father’s voice faltered, the student’s eyes he second-year students were them learn the signs of his disease. More welled up with tears. He was deeply im- gathering in one of the medi- importantly, they would hear firsthand mersed in the story, as though he were cal school’s amphitheater-style what it had been like for his parents to reliving their decade-long struggle right classrooms.T Soon after the hour turned know that something was wrong with along with them. and the final student had taken a seat, him, yet to be told by the doctors that In the first row sat another student. a middle-aged father and his adolescent they could not make a specific diagnosis. No more than five minutes into the class son entered through the front door. The These future physicians needed to hear session, he opened up his lecture notes, boy sat in a wheelchair, and it was im- what it is like to learn that your son has a pulled out his audio device, and donned mediately apparent to everyone present relentlessly progressive, irreversible, and his ear phones. Throughout the follow- that he was neurologically devastated. lethal neurologic disorder. ing minutes, he never once looked up at His posture was contorted, his head was As the father related this story, it was the father or paid any attention to what tilted back and to one side, and his eyes clear that the conversation had proved a was being said. stared blankly up toward the heavens, very emotional one. From time to time, What are we to make of the conduct evidently registering nothing. he looked out at the students, hands out- of these two students? Which one will The father began to tell of a conversa- stretched, as though pleading with them be a better physician? Which of the two tion with his wife the evening before. The to understand how trying it had been. He would their fellow students regard with boy’s mother argued that they should added more than once that he wanted a greater admiration? And perhaps most not bring their son to the medical school the students to understand how seriously importantly of all, which of these two again. He had been poked and prodded he and his wife took their education. future physicians would we most likely by each new crop of residents, interns, As he spoke, particularly about their turn to if our own parent, spouse, or and medical students for more than a son’s deterioration over recent years, child needed medical care?
6 The Pharos/Spring 2012 Excellence in medicine is not strictly a of life. But the end is always the same, more than diagnose and treat our pa- matter of what we know. You can be the and every human being, even a doctor, tients. We must also care about our pa- most knowledgeable, technically skilled, needs someone with whom to share it. tients. They need us to bring the best widely published, extensively funded, and There are times when our patients need of our compassion, courage, and hope. most successful physician in the room, us to be human beings first and experts Above all, they need us to be worthy but still leave a great deal to be desired as second. of their trust. Trust is about more than a doctor. Medicine is not simply a matter They need someone who sees them avoiding breaches in confidentiality. It of what we know and what we can do. as more than a malfunctioning machine means carrying gently, like a newborn Medicine is also a matter of who we are. that needs repair. Sickness manifests it- baby, the lives and the life stories en- And who we are shines forth through self in many ways, from pain to nausea trusted to us. Patients and families share every interaction with a patient. Patients to vertigo to loss of function. But this is with us something fragile and deeply need more from us than mere expertise. no less true of our household pets than precious. Are we fit to receive it? Are we What else do patients need? They of human beings. What distinguishes faithful stewards? need us to be genuinely curious about human beings is the fact that suffering Of equal importance is how effec- them and to take a sincere interest in is a problem for us. We not only feel tively we cultivate this sense of mission in their lives, not just with a view to ar- it, we also try to make sense of it, to the minds and hearts of our successors. riving at a diagnosis or prescribing a understand it in the larger context of Will future physicians set their hearts therapy, but simply to share their experi- our lives, to find in it some meaning on conventional signs of success, such ence. Everyone will get sick. Everyone and purpose, insights into where we as prestige, authority, and income? Or will die, even the doctor. Medicine may have been, where we are, and where we will they think first of their patients, the turn the tide for a time, offering a re- have yet to go. human beings they have cared for, and prieve of months, years, or even decades To excel as physicians, we must do the lives they have been privileged to
The Pharos/Spring 2012 7 Success, professionalism, and the medical student
touch and become part of? What do we tell medical students about what matters most to us, and what do we show them Dr. Gunderman related this through each patient encounter? anecdote at the September The student in the second row who AΩA Councilor Meeting never took his eyes off the father and in Chicago following my son did well in school and garnered a presentation on “AΩA and fine position in a good primary care res- Professionalism.” A rather idency program. When I think about the shocked silence was followed by kind of physician I would want to care vigorous discussion about schol- for my parents, my wife, our children, arship, professionalism, and the or me, his is one of the faces that come values AΩA should look for, and to mind. He is not only a fine doctor but exams, and graduated at the top of his hopefully instill, in its members. a real human being, someone who truly class. A year and a half before graduation Looking back at the two stu- cares for his patients. day, while still a junior, he was elected dents, I only hope that the sec- And the student in the front row? to membership in Alpha Omega Alpha ond one, who became an AΩA He is now completing his postgraduate Honor Medical Society. member in his junior year, will training in one of the country’s most read this and learn to care about competitive fields at one of the most The author’s address is: his patients. prestigious programs. He earned the Indiana University Richard L. Byyny, MD highest score on the exam, and then the 702 North Barnhill Drive, Room 1053 Executive Director and Editor highest grade in the course. In fact, he Indianapolis, Indiana 46202 earned the highest grade on many of his E-mail: [email protected]
8 The Pharos/Spring 2012 Ca Leaves tch ng inIn autumn, through forested paths Showered by falling leaves, Each is a life fallen before mine. I catch some at full stride— And release to the ground The lives of those I loved. Someday I will bud Atop a magnificent tree, Enduring spring’s winds, Basking in summer’s warmth, To a grand exit In yellow, red or brown, Gracefully drifting into the hand Of someone who loves me. Steven F. Isenberg, MD
Dr. Isenberg (AΩA, Indiana University, !"#$) is assistant professor of Otolaryngology—Head and Neck Surgery at Indiana University School of Medicine. His address is: !%&& North Ritter Avenue, Suite ''!, Indianapolis, Indiana %('!". E-mail: sisenberg@good%docs.com. The Pharos/Date 9 Illustration by Laura Aitken
J. Joseph Marr, MD The author (AΩA, Johns Hopkins myth of philosophy upon which so much pneumonectomy for cancer several years University, 1964) is a retired academic argumentation is based—the rational before. His chart, when it came from the physician and business executive and man—or, far more likely, the mecha- record room, was replete with sporadic a member of the editorial board of The nized cog of society portrayed by Charlie infections and evidence of chronic bron- Pharos. Chaplin. Interactive, meaningful, human chitis. He was garrulous, in complete de- contact with life requires emotions that nial of the situation, febrile, and short of For now we see through a glass, link us to others and without which even breath. The x-ray confirmed the physical darkly; memories are simply a slide show. We examination: all segments of the left — Corinthians : are not speaking here of the emotional lung were involved with pneumonia. At displays devoid of reason, perspective, that time, we did our own Gram stains e live in four dimensions. or knowledge that are so in evidence and laboratory work. The sputum was In the moment, we live among us today, but the interpersonal laden with leucocytes and Gram-positive in three. Could we live in bonds that come with the understanding diplococci; the white count was elevated. Wfewer? Suppose we had only length and of another and the circumstances of that He was placed on oxygen, antibiotics, width but no depth, where the depth is other. Are we living without these in our and intravenous fluids, given as much perspective based upon empathy for our society? Are we doing it in medicine? intensive care as we could and left to the fellow creatures? Could we live without mercies of Atropos. that? Knowledge and reason give us a Case history After the examination and the orders position, but the emotional connection That evening I admitted a man of for treatment, I sat with his wife. She with others and with the past give us a about fifty years in serious condition. He was a quiet, fragile woman in late middle life. Without this, we risk becoming that had a long history of smoking and a right age who looked at me expectantly yet
10 The Pharos/Spring 2012 without anticipation. We spoke of his up and left the room. I sat and thought and without emotional connection to her situation, its causes, and the intensity about this for some time. world. Did she enjoy seeing the sunrise; of the treatment he was receiving. Her did she have children and love them; reply indicated that she was aware of all Primum non nocere could she relate to a symphony; did she of this and it was why she had brought The answer is “Yes!” we can live with- go out to see the leaves in the fall? She him to the hospital. She had asked him out human emotional relationships. She was a frighteningly and completely ratio- to stop smoking but could do no more. did and others have, but at what price? nal person. I cannot imagine how much He did not listen. She looked at me as I What did medicine do to her those many of the flavor of life was taken from her explained the severity of his disease and years ago when the leucotome went in by that procedure but I do know that the efforts we would make to reverse above the eyes and cut those connec- she missed the essence of living. Her life it. I implied that we might fail and she tions that made her human? Presumably must have been as grey as the clothing nodded and then picked up her purse she was difficult to manage in one way or she wore the various times I saw her. to leave. I halted her with a word or another, so a terrible procedure, which I did not think of her for many years two and rephrased my message since I enjoyed a vogue among some physi- but during the past few years our en- thought she had not understood. She cians for some decades and was vigor- counter and my reaction to it have come nodded again, thanked me, and left. ously fought by others, was employed to back with increasing frequency. Her During the next two days I spent change her life and make the lives of her husband and his laughing denial of his much time with him. He remained talk- caretakers simpler. (See the excellent his- terrible situation have recurred as well. ative, insofar as he could be, given his tory of lobotomies and their influence in They were a team then and they remain respiratory situation, and apparently medicine by Mary Ellen Ford, MD,1 and so—Janus, caught in a situation. cheerful about his outcome. His role Laurence M. Weinberger, MD.2) The situation that caused me to think in the tableau, as he appeared to un- This woman, when I met her, was well about her again, and later him, crystal- derstand it, was as the entertainment: dressed, well spoken, apparently intel- lized at a “Town Meeting” some time serious disease for the physicians and a ligent, devoid of real facial expression, ago that our congressional representative raconteur for everyone else. had arranged. I admired him because he His fever did not break and his blood spoke directly and seemingly honestly pressure was kept up with fluids. As while many representatives were unwill- anticipated, his clinical course went ing to visit their constituents between slowly downhill and on the third day he elections due to their understandable became increasingly confused and died fears of a verbal pummeling. In response that evening. to my question regarding Medicare ad- I called his wife and she came in to ministration and funding and what ap- the hospital. I told her again of his death petite Congress might have to reconsider and spoke with her regarding his clini- the fundamentals of the program, he cal course and the mechanics of therapy paused and then responded that there as she sat quietly. There was increasing was no appetite and the issue probably confusion on my part and some frus- would not be addressed until the tration as she failed to react either crisis was even more acute. My re- to my explanation or the fact of her action—and that of the audience— husband’s death. After some time, she was, in essence, a silent shrug of the interrupted me quietly, probably to shoulders and the thoughts: “prob- stop my iterations, and said that she ably an honest answer” and “suspi- understood completely and thanked cions confirmed.” Why did I and why me for the explanation and the work did we acquiesce like that? No one to try and save her husband’s life. said a word. Why were we and why “But you see, I had a lobotomy and was I not upset or concerned or I cannot react to what you are telling incensed by the flagrant lack of fiscal me. I understand the situation, and I and social responsibility by a legisla- expected it, but I feel nothing. I have tive body elected to take responsibil- felt nothing now for many years, so ity for exactly those things? Shortly you should not be concerned. Thank thereafter, the woman and her hus- you very much for your work and your band came back into my mind. explanation. Now I should go and When I think about medicine make arrangements.” Then she stood and where we seem to be now, one
The Pharos/Spring 2012 11 Through a glass darkly
or the other and sometimes both of them Physicians as a group are pragmatic or contained. It does not matter whether look at me. Are we as physicians, in and some who understood where medi- these providers are private or govern- fact, living in a way that both that pa- cal practice was going joined the ranks mental as far as the business model is tient and his silent partner would un- of business in order to help manage concerned. derstand? Some of us work within a the process—myself included. However, We seem now to be a part of and sus- greatly changed system to deliver good once involved, we were co-opted into the taining members of a greatly distorted medical care as best we can and to game system and, of necessity, became part system that only Torquemada could have the system as best we can—turn it into of it. All discussions have become fiscal designed. Our excuse is that we came a job and manage the economics—in and patient benefit and the historic and into it by a long series of compromises. denial of what has occurred. Others con- altruistic goals of medical practice have But where is our outrage at the result tinue to give good medical care but have been eroded rapidly. Many of us try to and at what is taking place in patient disconnected emotionally in order to help patients whenever and however care? Why are we as silent and rational preserve their own mental balances. Do we can—but when have we made a con- in our acceptance as that woman? Have both groups, each in its own way, avoid certed, visible, and united effort to de- we, through a long process of acquies- thinking about a noble profession that mand that patient care be given priority cence, subconsciously applied the leuco- has been subverted and, perhaps, per- and that profits take a second place? It tome to ourselves? verted by fiscal considerations? is not necessary to make fortunes in the We can look back through the locked Most of us probably act as the “ser- delivery of medical care; but it is neces- glass door that allows us to see the vari- vant leaders” described by Dr. Byyny in sary to deliver that care. ous stages of our pasts but will not per- his recent editorial.3 These are people The entry of big business in the mit us to re-enter. As time and change who, by example and teaching, try to s, under the guise of employing occur, I believe we see the humanism make better their immediate surround- good business practices to improve ef- and idealism of that era less clearly. The ings. All physicians, particularly mem- ficiency and cut costs was, in my view, events of those times may be somewhat bers of AΩA, in my opinion, should the death of patient-centered medical clear, but the sense and ethics of those be servant leaders at the very least but care. It is one thing to change a cottage times are dim. Is this dark glass a defense also should try to be more than that. industry model into a more modern or a survival mechanism? Have we given There are many leaders in medicine, and efficient delivery system but quite up or do we truly not care anymore? I working quite hard to, if not change the another to forget, damage, and alienate cannot bring myself to believe it is either system, at least slow its headlong plunge the consumers in the process. Why did of the latter. We simply need more hope into simply a business. I am referring to medicine not protest loudly on behalf and may have to supply that for our- something else here. of the patient? We certainly spoke about selves by taking some action. Quarterly earnings and market share it amongst ourselves. Perhaps we were The editorial “AΩA and Leadership” have become important topics not only too busy trying to understand what was raised questions about leadership among in the administration boardrooms but transpiring and to survive it. But we are the AΩA membership and what the also at medical staff meetings. People in it now, and this wreckage of a delivery organization might do to assert a leader- are not being seen because of fiscal system will not change until the profit ship role in medicine. Perhaps declining considerations and the country’s mor- motive is removed. patient care and the subjugation of the bidity and mortality statistics place us Why not consider the delivery of human to the fiscal are issues on which lower among nations of the world than medical care a fundamental social re- AΩA could take a position and articu- one would expect the wealthiest coun- sponsibility, fund it as necessary but late it strongly. That is, if we truly wish try in the world to be. We continue to change the business model? As one ex- to “Be Worthy to Serve the Suffering.” maintain an enviable place in research. ample: remove the quarterly earnings Younger physician-scientists are every focus from large provider systems and References bit as bright and dedicated as those of insurers. Investors in these organiza- . Ford ME. A history of lobotomy in us who went before and the knowledge tions could expect a reasonable return the United States. The Pharos Summer base from which they draw is far more on investment, but as a healthy dividend ; : –. advanced. That is not the issue. The –similar to a bond or utility company . Weinberger, Laurence M. Lobotomy: issue is that patient care and access to –rather than an incremental share price. A personal memoir. The Pharos Spring that care have declined. With respect The funds that would be otherwise paid ; : –. to planning for and delivery of medical out as earnings and administrative sala- . Byyny, R L. AΩA and leadership. The care, the adage primum non nocere no ries and bonuses for fiscal performance Pharos Autumn ; : –. longer applies. would be returned to the system to maintain it—as is the case now—and to The author’s address is: A minuet of accountants fund indigent care. This is but one ex- 14885 Irving Street None of this is new, of course; ample and there are others, but none will Broomfield, Colorado 80023 we have known about it for years. work until the profit motive is removed E-mail: [email protected]
12 The Pharos/Spring 2012 Paulinia
Clifford Straehley, MD The author (AΩA, Harvard Medical School, 1946) is Then she made an interesting request. “Dr. Straehley, please Professor Emeritus at the University of Hawaii John A. take me to the Waikiki Pancake House one more time.” Burns School of Medicine and retired Clinical Associate On the following Sunday, the chief nurse and I took Professor of Surgery at Stanford medical School. Paulinia on a gurney in an ambulance to the Waikiki Pancake House. We had called the manager beforehand, and he had set aulinia was a beautiful and intelligent child. She was up a table and alerted all of his employees. They came out to seven years old and very ill with a massive abdominal greet her as she was wheeled in. Paulinia smiled and laughed tumor. I had performed a laparotomy in the hope that as several of the employees kissed her and wished her aloha. theP tumor would prove to be resectable, but it surrounded One of them brought her a lei. the aorta, all of its visceral branches, and the vena cava. All After we returned to the hospital, Paulinia asked me, “Dr. I had been able to do was biopsy the tumor, which proved to Straehley, will you sit beside me and hold my hand when I die?” be a liposarcoma. Paulinia was unable to eat, although she I left orders that when her vital signs began to fail, I should could retain oral fluids. be called regardless of the time of day. Several nights later I A few days after the biopsy, Paulinia asked me, “Dr. received the expected call. As I sat at her bedside and held her Straehley, am I dying?” hand, Paulinia said, “You came.” Many years ago, during medical school and my surgi- Shortly thereafter she died. On her face there rested a beau- cal residency, I was told that one informs the family, but tiful smile. Paulinia had died in peace. protects the child from the knowledge of impending death. But I knew that if I lied to her she would lose faith in me. The author’s address is: I answered, “Yes, Paulinia, God has decided to take you to 2416 Ptarmigan Drive #2 heaven with him.” Walnut Creek, California 94595
The Pharos/Spring 2012 13 Burton and Osler
Henry N. Claman, MD The author (AΩA, University of Colorado, 1979) is And even so, no matter how charming Robert Burton’s Distinguished Professor of Medicine and Associate Director company may be—perhaps he is another Montaigne—why of the Medical Humanities Program at the University of spend pages on the subject of depression (a word he didn’t Colorado, Denver. He is a member of the editorial board of use), even if the book did turn out to be an instant bestseller? The Pharos. Let us step back a little and look at Burton and his fam- ily. He was born in to Dorothy and Ralph Burton, the squire of Lindley, a small landholding about fifty miles north of Oxford. Robert was the fourth of eleven children and the he Anatomy of Melancholy, written by Robert Burton second son. He later calculated the exact moment of his con- in , is probably the most fantastical book that you ception, and learned the minute of his birth (: ). Thus haven’t read. It’s right up there with Finnegan’s Wake, he could determine that he was born under the sign of Saturn perhaps also with The Life and Opinions of Tristram Shandy, (the “star” of melancholy) and we can get a hint of his interest Gentleman. The very size of the book is itself somewhat of an in astrology, and his analysis of his own character. obstacle; it weighs in at almost ¾ pounds, and stretches on In , he entered Brasenose College, Oxford, and then for , pages of text followed by more pages of notes— in he became a Student (like a Fellow) of Christ Church, most of which are in Latin.1 Furthermore, because of its unusually dense style, one Right, Frontispiece from the 1632 edition of The Anatomy of cannot really read this book as you would read other books. Melancholy. From top left, Zelotypia (jealousy?), Democritus Instead, you are more likely to dip into the text, to stroll by of Abdera in his garden, Solitude, the Lover, title material, the Hypochondriac, the Superstitious (with a rosary and crosses), the introductory poems, to peruse the complex outlines of portrait of the author, named Democritus Junior, the Maniac, the book’s structure, or to mine the almost endless quotations Borage, publisher’s identification, Hellebore. Note the numerous from the Greek and Roman classics, the Bible, the Church signs of the zodiac and other astrological symbols in the clouds. Fathers, and so on. Courtesy of the National Library of Medicine.
20 The Pharos/Spring 2012
The Anatomy of Melancholy
Robert Burton (after the portrait at Brasenose College, Oxford). Courtesy of the New York Public Library.
Oxford, where he lived for the rest of his life. He earned the There were, in Greek antiquity, two philosophers, Democritus degrees of Bachelor and then Master of Arts, and then in and Heraclitus. Democritus was “the Laughing Philosopher” became a Bachelor of Divinity (as befitted a second son). He (although Burton calls him melancholic, like himself). held several church offices and referred to himself as “a divine,” Heraclitus was “the Weeping Philosopher.” Democritus but he always lived in Christ Church College. He never mar- laughed at the activities and condition of humankind while ried and did little traveling, preferring to live among books, Heraclitus cried over them. Burton calls himself Democritus which were indeed his life. As he put it, he did his traveling “by Junior to indicate his own tendency to ridicule his fellows and card and map.” And of books he had plenty—his own collec- also to connect himself with the classical tradition. This device tion, then those volumes and manuscripts belonging to Christ is also a signal to the reader that The Anatomy is not in its es- Church (where he himself became Librarian in ) and most sence a medical book but a philosophical treatise. notably the Bodleian Library, which had opened in . The preface, on one hand, does ramble somewhat, but on Indeed he was “a man of the books.” the other, it drops information about what is to come in the The organization of The Anatomy is crucial to its objective, Partitions. Indeed, on page , Burton already tips his hand by the study of melancholy. It is in four parts; a long preface and declaring (with the poet, Horace,) that all mankind is “mad” three “partitions.” “For indeed who is not a fool, melancholy, mad? . . . who is not The -page preface is titled “Democritus Junior to the brain-sick? Folly, melancholy, madness, are but one disease, Reader.” (The author is supposed to be Democritus Junior.) delirium is a common name to all.” 1Preface, p39 Later (page
22 The Pharos/Spring 2012 and on), he indulges his passion for enumeration by mention- • Melancholy—cold and dry, thick, black, sour (bile) ing that the following (and others) are all mad: great men, Illness is made manifest by imbalances between the hu- philosophers, scholars, teachers, poets, lovers, most women, mors, and it is the physician’s task to rebalance them correctly; youths, the aged, the rich, the covetous, as well as the prodigal, this will then lead back to health. These four humors have indeed, the lot. By now it has become clear that Burton has some analogy with the four elements and also the four ages chosen for the subjects of his analysis not only the sad and of man. fearful but, indeed, all of humanity. Of course, as an academic, Burton is concerned to define After the preface, Burton gets right to work, but he pro- his subject. What, indeed, is melancholy? Here he is: ceeds slowly, starting Partition I with the causes of melancholy. It would be hard to improve Of the matter of melan- upon the characterization of choly, there is much ques- Burton’s modus operandi made tion betwixt Avicenna and by another very noted biblio- —hot, dry, bitter (gall) Galen, as you may read in phile, Holbrook Jackson: Cardan’s Contradictions, —cold and moist (liver) Valesius’ Controversies, Like most interesting men, M o n t a n u s , P r o s p e r he is not quite consistent. He —hot and moist (blood) Calenus, Capivaccius, preaches the happy mean and Bright, Ficinus, that have does not practise it. His book —cold and dry, thick, black, sour (bile) written either whole tracts, is always excessive. He over- or copiously of it in their loads every statement. It is the several treatises of this sub- most sententious book ever ject. “What this humour is, written, yet it reads trippingly as a novel. It is packed with or whence it proceeds, how it is engendered in the body, common sense and uncommon nonsense. He is never tired neither Galen nor any old writer hath sufficiently discussed,” of apologizing for his long-windedness, and immediately as Jacchinus thinks.1PtI, p173 starts expatiating again. He fears that he will go too far in his exposition of love-melancholy, and does. He was never Now this is classical Burton; author after author is men- married, but marriage has no mysteries for him.2pxxi tioned, and quoted, every cause is enumerated, every possi- bility is aired—yet nothing is concluded, nothing is definitive. First, he lauds man’s excellence and nobility above all But the ride gallops on. creatures of the world. Immediately, however, he bewails the We see Burton’s dilemma. Intellectually, he stands “on the miserable state this magnificent creature finds himself in. cusp” (as they say) of the Age of Reason. His book was pub- lished just after The Advancement of Learning (–) The impulsive cause of these miseries in man, the priva- and The Novum Organon () of Francis Bacon and just tion or destruction of God’s image, the cause of death and before A Discourse on Method () of Descartes. Bacon diseases, of all temporal and eternal punishments, was the and Descartes urged observation, experience, experiment, sin of our first parent Adam, in eating of the forbidden fruit, and doubt—the essentials of the rational method. In their by the devil’s instigation and allurement.1PtI, p131 scientific approach, however, while there is much discussion of newer methods, not enough time had elapsed for extensive Shades of St. Augustine (called St. Austin in our version)—we fact-finding and experiment. That is yet to come. But, as an have not arrived at the Age of Reason quite yet!) The instru- English man of the cloth, Burton is also firmly committed to mental causes (by means of which God’s purposes are carried the Christian beliefs in revealed truth. He juggles these two out) include the stars, heavens, elements, often with diabolical positions—the scientific and the religious—through his far- help from magicians, witches, poisons, etc. rago of quotations, and in general, medicine and physic are Then, having digressed into anatomy (both of body and seen as the servants of divinity. But here, too, the causes of soul) Burton gives us a neat and precise summary of the bases melancholy are complex—they include not only divinity but of health and disease, i.e., the concept of the Four Humors, its opposite, malignity (in the form of witches and magicians) that theory of Hippocrates, Galen, Celsus, and Avicenna that and of course the stars and planets —and old age. predominated right through the Middle Ages and Renaissance. Burton, perhaps surprisingly, even tackles genetics, saying We note: that there is no doubt “but that it [melancholy] is an inherited • Choler—hot, dry, bitter (gall) disease,” 1PtI, p212 promoted by consanguinity; thus “the Church • Phlegm—cold and moist (liver) and commonwealth, human and divine laws, have conspired • Sanguineous—hot and moist (blood) to avoid hereditary diseases, forbidding such marriages as are
The Pharos/Spring 2012 23 The Anatomy of Melancholy
any whit allied.” 1PtI, p212 Partition III is entitled “Love-Melancholy.” It is almost as Having mentioned the above “natural” causes of melan- long as the first section. As it is written by a single (and pre- cholia (i.e., those “according to nature”) that are hard to avoid, sumably celibate) curate, (yet one who advocates marriage), Burton then turns to causes and influences he calls “non- one starts reading it and wonders what he will say about love. natural” (i.e., not ordained nor innate), which today we might Most readers will be disappointed, as his earlier instructive describe as those of “lifestyle.” He mentions six: diet, retention and entertaining style becomes more labored and, if possible, and evacuation, air (climate), exercise, sleeping and waking, more rambling. His analyses deal with desire, seen as a form and perturbations of the mind (including habits). As lack of of melancholy-equals-madness, amorous love (in the most proper balance in these areas may lead to or exacerbate melan- general terms), and jealousy (love turned awry). choly, so diligent attention to their rectification later becomes The final section is on “Religious Melancholy,” and deals an integral part of melancholy’s cure. in terms of love of God himself. Such love, practiced in the Burton loves bimodal distinctions, and while he emphasizes “right” (i.e., Burton’s) way, is the love of God’s beauty and all the mind/body (or soul/body) dichotomies, he is convinced his excellences and mercies. This is natural. But there are also of their interdependence. He is certain that disturbances of devil-inspired beliefs and practices appearing as religion. He the mind can perturb the body and cause disease, and that calls these superstitions and idolatry. Finally, there is religion disorders of the body can in turn derange the mind. (Do we “in defect” (i.e., too little religion of any kind)—atheism. He have here an early recognition of “psychosomatic medicine”?) is sorry that only one-sixth of mankind is Christian, and Quoting his authorities on this matter, however, he cannot even that fraction includes those of the “wrong” Christianity, come to any conclusion as to which—soul or body—has the mostly Catholics. As to the superstitions, he is harsh in his dominant influence over the other. condemnations, particularly of the Jews, whose beliefs he Partition II concerns the means of curing melancholy. calls “mad, . . . absurd, . . . ridiculous, impossible, incred- Again, both religion and science are called upon, and they in- ible,” 1PtIII, p351 without any arguments to the contrary. As to the teract with each other. Right off, Burton insists that “unlawful Jews themselves, he presumes that “no nation under heaven cures” (those not divinely sanctioned), are forbidden. Thus, (sic) can be more sottish, ignorant, blind, superstitious, wilful, “diabolical” means may not be used to cure diseases—even obstinate, and peevish.” 1PtIII, p361 One is led to wonder about those diseases produced by diabolical causes (about which Burton’s acquaintance with Jews and Judaism. After all, they Burton had no doubt). He deplores the “common practice of had been expelled from England in and had not yet been some men to go first to a witch, and then to a physician, if allowed to return in any numbers. Those who were in England one cannot [help] the other shall.” 1PtII, p7 “Lawful cures” come may well have hidden their religious identification and prac- primarily from God, without (or most often with) the help of tices. Burton treats the Muslim faith and Asian religions in the physician—“God’s intermediate ministers . . . We must use the same way. our prayer and physic both together.” 1PtII, p9 At the very end, Burton gives what he thinks is the essence Immediately there arises the question of whether lawful aid of the “cure” for melancholy. After all the myriad pages and may come via saints and relics—a tricky issue in a Protestant quotations, it is indeed brief: England still hostile to and suspicious of “papists.” Here, our English clergyman is firm and decisive—the answer is Be not solitary, be not idle.1PtIII, p432 “no.” 1PtII, pp11–14 As to the physician’s armamentarium for curing melan- Perhaps he was tired. Perhaps he is also being subtle, and choly, Burton is also quite clear. He also can sound rather there is more than just a kernel of truth here. Maybe he means modern. For him, physic (i.e., medicinals and blood-letting) that the “cure” is in the search, which, like the book itself, does not come first. Instead, he recommends detailed attention never seems to end. So . . . keep on . . . reading! to those “non-natural” activities previously mentioned, par- What, then was the fate of this quixotic magnum opus? ticularly diet, “air,” (he has a long digression on the importance Was the public interested? Indeed it was; it sold quickly in of climate), exercise (thirty pages), and proper sleep. He wants the quarto format. In fact, it sold so well that a second edition to moderate the passions and discontents of the mind, to curb was printed in , this time in the larger folio format. There “immoderate Venus,” and to use the healing powers of music were first a total of five editions, each larger than the one be- as well as of mirth and merry company. fore it. He had even revised it for a sixth edition, but this was After all these measures, then comes physic. But Burton is not printed until after he died. Thus, the book seemed never wary of and indeed is ambivalent about pharmaceuticals. In to be finished. one place he says they come from God, in another, from the What kind of a book (or books) was this best-seller? In devil. In either case he believes that most physicians “prescribe spite of claims to the contrary (see later), it was not a textbook too much physic, and tire out their [patients’] bodies with of medicine. It was written by an English layman (who was continual potions, to no purpose.” 1PtII, p17 not a physician, in spite of his “inclination”), and for English
24 The Pharos/Spring 2012 lay readers. It put forth opinions, but did not choose among them. Indeed, it was more of an encyclopedia of theories and practices. For whom was it written (and pre- sumably, by whom was it bought)? We must of course recognize that Burton was himself a melancholic. For instance, early on he says “I write of melancholy by being busy to avoid melancholy.” 1Pref, p20 Thus, he is writ- ing for himself! Furthermore, in writ- ing of melancholy, he was writing about himself. But, in spite of the size of this book about him, we never feel that we know him as well as we come to know Montaigne from his Essays. Burton is reserved, at times almost hidden behind his enormous erudi- tion. We know that he was unhappy with the university system where he lived and worked, unhappy with the lot of scholars and dissatisfied by the unrealized promises of patrons. He was eccentric in his melancholy, William Osler holding Vesalius’ Tabulae Anatomicae Sex at the Bodleian Library, Oxford, but could be rescued to merriment 1912. Courtesy of the Osler Library of the History of Medicine, McGill University. by companions and by his books and quotations (he must have had a pro- digious memory, especially in Latin.) And, as he considers that everyone is melancholic, he is thus William Osler and Robert Burton writing for everyone. So he hopes that his book, although not Osler, (–), was even more of a Burton devotee a textbook of medicine nor a book of sermons, will help the than Johnson. He was an avid, almost fanatical, collector whole world. He states at the beginning, “I doubt not but that of books and letters on the history of medicine and of sci- these following lines [over a thousand pages of them], when ence. He pursued this avocation wherever he was—at McGill they shall be recited, or hereafter read, will drive away melan- University (his alma mater), the University of Pennsylvania, choly . . .” 1Pref, p38 Johns Hopkins, and finally at Oxford. Rare inscribed copies Reader, heal thyself. and first editions were always on his mind (and on his wallet Burton died in . He is buried in a chapel in Christ as well). He patronized used bookstores and auction rooms. Church, under a bust effigy, and with an epitaph that he wrote He was so keen on this subject that he amassed what may have in Latin. It does not include his own name but harks back to been the largest and greatest private collection of its time, now the frontispiece of The Anatomy, reading (in translation) the centerpiece of the Osler Library at McGill. The catalogue of this library, called Bibliotheca Osleriana, is a massive vol- Here lies DEMOCRITUS junior ume first published in , ten years after Osler’s death. It To whom Melancholy gave life and death is annotated in detail and lists items, including books (many of them multivolumed), papers, letters, manuscripts, Burton was indeed an original. As a master of books, he incunabula and so forth.4 endeared himself to two other unique bookmen—Samuel Osler’s connections to Burton and The Anatomy were Johnson and William Osler. Johnson himself was prone to many, and these can be seen best in the landscape of books, melancholy, sometimes rather profoundly so, so his interest in libraries, and the Bibliotheca. When Osler arrived at Oxford Burton is understandable.. He told Boswell that The Anatomy in as the newly elected Regius Professor of Medicine, he of Melancholy was the only book that ever took him out of bed found that he automatically became a curator of the Bodleian two hours sooner than he wished to rise.3p323 Library, where he knew that Burton had spent many hours of his life. The Bodleian also housed the large collection of
The Pharos/Spring 2012 25 The Anatomy of Melancholy
Christ Church College, Oxford. Courtesy of the Osler Library of the History of Medicine, McGill University.
Burton’s personal library. The tie to Burton was even closer. described as “the literary works written by medical men, and Although the Oslers lived “in town” in Oxford, Osler himself books dealing in a general way with doctors and the profes- also had study rooms in Christ Church—Burton’s own lodg- sion.” 4pxxv And so it is. ing for forty years. Although nobody knew for certain exactly Outside of the Bibliotheca, Osler’s formal tribute to Burton which rooms Burton had lived in, Osler mentioned several was a set of three essays, written and read in various venues, times the delightful possibility that he was occupying real between and , and printed together and called Robert estate that had been inhabited by Burton himself. Burton, the Man, His Book and His Library.5 In it, Osler We are not surprised that the Bibliotheca tells us that Osler writes glowingly of a man and a work he greatly admired, and had a copy of all the editions of The Anatomy published in he did so with his usual mix of enthusiasm, skill in writing, Burton’s lifetime, and the posthumous sixth edition as well. and scholarship. We would expect nothing less. But one can easily imagine what Osler must have felt when he got his copy of the first No book of any language presents such a stage of moving edition. In that edition, Burton’s name indeed appears, al- pictures—kings and queens in their greatness and in their though only at the end. There it is printed: “Robert Burton. glory, in their madness and in their despair; generals and From my Studio in Christ-Church, Oxon. Decemb. , .” conquerors with their ambitions and their activities; the (Burton appears on the frontispiece as the real author only in princes of the Church in their pride and in their shame; phi- later editions.) Osler must have been thrilled to know that The losophers of all ages, now rejoicing in the power of intellect, Anatomy may have been ended (if not completed) perhaps in and again groveling before the idols of the tribe, the heroes the very room that Osler himself was working and writing in of the race who have fought the battle of the oppressed in all almost years later. lands . . . all are there.5 The Bibliotheca is organized in sections, the first two pre- senting original scientific works—Galileo, Harvey, Galen, etc. (Do we detect some infection in Osler caused by the literary Now Osler, in a famous passage, had called Burton’s Anatomy virus of Burton himself?) a medical treatise, the greatest indeed written by a layman. As one would expect when one bibliophile is considering He may have had misgivings about this statement because another, Osler delves into curiosities such as marginal annota- The Anatomy does not appear with the other medical texts tions and details of the various editions of The Anatomy. in these sections but in the third section, “Litteraria,” which is Osler died in Oxford on December , , age . On
26 The Pharos/Spring 2012 New Year’s Day, a service was held for him in Christ Church. Let me close with the end- ing words by Harvey Cushing in his Life of Sir William Osler. (Cushing was not only Osler’s principal biographer but his disciple and friend.) The service was over.
So they—the living—left him overnight; alone in the Lady Chapel . . . with the quaint effigy of his beloved Robert Burton near by— lying in the scarlet gown of Oxford, his bier covered with a plain velvet pall on which lay a single sheaf of lilies.9p686
References . Burton R. The Anatomy of Melancholy. Jack- son H, editor. New York: New York Review Books; . . Jackson H. Introduction to the Edition. In: Burton R. The Anatomy of Melancholy. Jackson H, editor. New York: New York Review Books; . . Boswell J. The Life of Samuel Johnson, Wom- ersley D, editor. London: Penguin Classics; . . Osler W. Bibliotheca Osleriana: A Catalogue of Books Illustrating the History of Medicine and Science. Collected, Arranged and annotated by Sir William Osler and bequeathed to McGill Univer- sity. Oxford: Clarendon Press; . . Osler W. Robert Burton, The Man, His Book, His Library. In: McGovern JP, Roland CG, editors. The Collected Essays of Sir William Osler. Volume III. The Historical and Biographical Essays. Bir- mingham (AL): The Classics of Medicine Library; : –. . Cushing H. The Life of Sir William Osler. Volume II. Oxford: Clarendon Press; . Osler’s rooms at Christ Church College, Oxford. Courtesy of the Osler Library of the History of Medicine, McGill University. Additional readings Babb L. Sanity in Bedlam: A Study of Robert Burton’s Anatomy of Melancholy. East Lansing (MI): Michigan State University Press; . Cambridge University Press; . Cox-Maksimov DCT. Burton’s Anatomy of Melancholy: Philo- O’Connell M. Robert Burton. Boston: Twayne Publishers; . sophically, medically and historically: Part I. Hist Psychiatry ; Radden J, editor. The Nature of Melancholy: From Aristotle to : –. Kristeva. Oxford: Oxford University Press; . Cox-Maksimov DCT. Burton’s Anatomy of Melancholy: Philo- sophically, medically and historically: Part . Hist Psychiatry ; The author’s address is: : –. Mail Stop B164 Dewey N. Sir William Osler and Robert Burton’s Anatomy of Research 2 Melancholy. JAMA ; : –. 12700 E. 19th Avenue, Room 10100 Lund MA. Melancholy, Medicine and Religion in Early Mod- Aurora, Colorado 80045 ern England: Reading The Anatomy of Melancholy. Cambridge: E-mail: [email protected]
The Pharos/Spring 2012 27 28 The Pharos/Spring 2012
Jonathan Ryan Barry, MSPH
The Pharos/Spring 2012 29 The case for integrating public health and medical education and how to do it
The author is a member of the Class of 2013 at the The American public health workforce is aging. In , University of Tennessee College of Medicine. This essay the Association of State and Territorial Health Officials won honorable mention in the 2011 AΩA Helen H. Glaser (ASTHO) conducted the State Public Health Workforce Student Essay Competition. Survey and concluded that twenty-four percent of public health workers were then eligible for retirement. A follow-up ere’s a typical question among medical students: survey, completed in , reported that the percentage of “What specialty are you interested in?” The most the public health workforce eligible to retire by had in- common replies—internal medicine, emergency creased to twenty-nine percent.10 In addition, a similar survey Hmedicine, or pediatrics1—may draw nods of approval, but my conducted by the National Association of County and City response, preventive medicine, many times provokes a ques- Health Officials reported that vulnerable health departments tioning look from my peers. (i.e., those serving populations fewer than ,) reported To be honest I, too, would probably know little about the largest percentages of retirement-eligible staff.11 Moreover, preventive medicine—and would most likely not be pursuing ASTHO notes that by over fifty percent of some state it as my career—had I not first deferred admission to medi- health agency workforces will be eligible to retire.10 cal school and earned a Master of Science in Public Health Concurrently, the total number of public health physicians (MSPH). Years ago, an eighth-grade hospital tour unexpect- and preventive medicine residency positions is decreasing. edly piqued my interest in public health. At the end of the tour, From to the early s, the number of public health our guide, a public relations employee, anxiously took ques- physicians has dropped from . to . percent.9 In addition, tions and I asked why the hospital’s new cardiac care center the number of preventive medicine residency programs has was needed. Slightly perplexed, he responded that the growing decreased from ninety in to seventy-five in , and rate of cardiovascular disease in the area created the need. I the total preventive medicine residency positions declined by nodded and he smiled back, presumably confident that he had twenty percent ( versus ) between and .9,12 satisfied my curiosity. The truth is, however, he only fueled it As veteran public health workers exit and fewer new further. Sure, perhaps the current clinical demand justified the graduates enter our nation’s public health system, leadership new cardiac center, but what underlying factors caused this deteriorates. Eleven states have no appointed physician lead- need? Asking why has ultimately helped me to shape my fu- ers in their entire local public health systems, and twenty-nine ture and prompted me to lobby for a new, more public health- states lack physician state health directors or commissioners.13 centric direction in American medical education. Not only is physician leadership in public health departments Let’s step back for a moment from the modern dogma that declining, but this decline also correlates with less effective medical advances will always lead us forward. It’s true that public health responses. In , twenty-three percent of local today we live longer than ever before thanks to technological, health agencies were directed by physicians, with only eight surgical, and pharmacological advances.2 I fear, though, that percent led by physicians who held MPH degrees or were we are reaching a point of diminishing returns.3 Even with American College of Preventive Medicine fellows.13 A our many advances, we still face many ubiquitous threats: study by Dr. Laura Kahn, research scholar with the Program on rising levels of obesity, adolescent type II diabetes, and bacte- Science and Global Security at the Woodrow Wilson School rial drug resistance, among others.4–6 These threats are best of Public and International Affairs of Princeton University, managed by effective public health surveillance methods and on the leadership practices in American public health depart- treatment approaches.7,8 Prevention would be better! ments concluded that departments lacking physician leaders Modern medical education deemphasizes the traditional handled public health outbreaks and other medical emergen- public health and preventive medicine curriculum, downplay- cies less well than those directed by physicians.13 ing the role of public health and its ability to improve health care. More than ninety-five percent of current medical edu- Public health medical education deficiencies cation curriculum is devoted to diagnosis and treatment of I analyzed forty areas of medical education instruction diseases in individual patients (versus populations), and less from thirteen of the latest Association of American Medical than half a percent of faculty are trained in public health or Colleges (AAMC) Graduation Questionnaires ( through preventive medicine.9 Perhaps because of this, data show that ). In these annual questionnaires, students rated their our public health infrastructure is growing weaker. I argue medical education in specific areas as inadequate, appropriate, that to strengthen this weakening infrastructure we must or excessive. Using the interquartile range to develop a four- fully integrate these separate educational disciplines into joint letter grading scale, I then compared these educational areas medicine-public health programs for all medical students. and found several deficiencies. Graduating medical students rated instruction in many Previous page, Public health in 1854 London: The Broad Street areas vital to improving the nation’s public health infrastruc- pump. Illustration by Jim M’Guinness ture as inadequate. Of twenty-one educational areas related to
30 The Pharos/Spring 2012 Type Mean Type Mean Area of Instruction of Skill Percent Grade Area of Instruction of Skill Percent Grade Patient interviewing skills M !."! A Epidemiology P !!.!# C Care of hospitalized patients M !.$% A Culturally appropriate care for diverse P !!.!# C populations Physician-patient relationships/ M &.$% A Health determinants P !!.$$ C communication skills Professionalism M &.'$ A Community medicine P !"."( C Diagnosis of disease M $.!! A Health issues for underserved populations/ P !&.(" C health care disparities Problem solving M '.'# A Biostatistics P !).$( C Patient confidentiality and privacy/HIPAA M ).&" A Public health P !*.)" C Clinical reasoning M ).*# A Health surveillance strategies P "&.#! C Management of disease M *.&' A Role of community health and social P "$.!! C service agencies Drug and alcohol abuse M %.$$ A Environmental health P &#.** C Ethical decision making M %.%' B Health care quality improvement/ P &(.(* F assurance Health maintenance M (#.#* B Health care systems P &!.(# F Physical examination skills M ((.&$ B Global health issues P &!.%# F Care of ambulatory patients M ((.&* B Complementary and alternative medicine P &&.'' F Interpretation of laboratory results M (!.&* B Health policy P &$.!! F Biomedical ethics M (!.%' B Biological, chemical, and natural disaster P &'.%' F management Evidence-based medicine in general M (".#% B Occupational medicine P &).") F Disease prevention P ($.$* B Health services financing P $!.%" F Physician-physician communication skills M ('.)% B Managed care P $$.%) F Continuity of care M (%.*$ B Medical economics P '&.!" F The forty areas of instruction are taken from the practice of medicine areas in the AAMC Graduation Questionnare for years (%%* through !#(#. The mean percentage is the average percentage of medical students reporting that instruction in a particular area is “inadequate.” The grade is based on a four-letter grading scale as follows: between # and %.)' = A; between %.)' and !(.#" = B; between !(.#" and &(.#" = C; greater than &(.#" = F. M = Medical practice skill, P = public health practice skill. public health, ten achieved a grade of C (“satisfactory instruc- for Public Health Careers recently estimated that the United tion”) and ten earned a grade of F (“incompetent instruction”). States faces a ,-person shortage in the number of public Only one public health practice area earned a B (“good instruc- health physicians.15 tion”) and none merited an A. Conversely, of nineteen medical practice skills analyzed, none earned a grade lower than B, and What to do? there is an almost equal number of A’s () and B’s (). Dr. Laura Kahn wrote in a o paper in Health Affairs The average mean percentage of students who rated medi- that “The nation’s schools of medicine should collaborate cal core practice instruction as inadequate was . percent with schools of public health to provide high-quality courses versus . percent who rated public health core pratice area relevant to macro medicine practice, so that all medical instruction as inadequate. school graduates can be effective members of public-private Data from both the Council on Graduate Medical efforts.” 13 I suggest taking Dr. Kahn’s recommendation even Education (COGME) and the Institute of Medicine (IOM) farther: we must fully integrate public health education with further highlight this lack of instruction. In its “Physician medical school curriculum for all graduating medical stu- Education for a Changing Health Care Environment,” COGME dents. Today, only . percent of all medical schools offer details a need to review curriculum content and learning joint MD/MPH or DO/MPH degrees. A national public health processes in modern medical schools, and recommends that curriculum would give all medical students a solid education medical schools emphasize public health-related disciplines, in public health.16,17 including epidemiology and population-based approaches, Key stakeholders, including the AAMC, Association of health care policy and systems, and disease prevention and Schools of Public Health, and American Association of wellness.14 The IOM’s Committee on Training Physicians Colleges of Osteopathic Medicine, could develop and mount
The Pharos/Spring 2012 31 The case for integrating public health and medical education and how to do it
governance, environmental health, health services manage- About Jonathan Ryan Barry ment, health services research, health promotion, and general I graduated from Wake Forest public health. Each area will consist of modular coursework; University in , where I studied biol- several courses can be used to fulfill requirements for differ- ogy and health policy and administration. ent focus areas. The modular design would not only accelerate Deferring medical school, I then matricu- the curriculum’s development but would also decrease overall lated at the London School of Hygiene operating costs and curriculum administration. & Tropical Medicine where I earned my First-semester modules would serve as essential (or core) MSPH, specializing in health promotion courses for the MPH while term two and three modules would and management. While in London, I was financially be elective courses chosen by medical students depending on supported by a Rotary International Ambassadorial which focus area they choose to pursue. These online courses Scholarship, and it was my pleasure to speak at eighty would integrate videos, computer presentations, and interest- Rotary Clubs in the United States and England. In ing case studies. Review quizzes would be available for students July , I was commissioned an ensign in the U.S. to test their knowledge, and formal assessments for each course Navy Reserve and accepted into the Health Professions would be completed via secure, online portals. Coincidentally, Scholarship Program. I am a third-year medical student at this online teaching strategy will not only serve as an economi- the University of Tennessee College of Medicine. I would cal approach in which to develop and administer the MPH cur- like to serve as a Navy preventive medicine physician. I riculum, but it will also support a COGME recommendation in strongly believe that preventive medicine is awaiting a which medical schools should utilize the internet and distance fresh renaissance, and I want to contribute my talents to learning technology in the educational process.14 increasing our collective health through innovation and An overall curriculum change integrating public health and personal responsibility. medical education will reinforce the American public health infrastructure and provide trained physicians for public health leadership positions. It may also increase the number of medi- cal students who choose to enter primary care, which may an educational innovation competition to create an online also improve access to primary care. This will not only reduce national MPH curriculum for all American medical students. reliance on specialty care but may also improve the efficiency Schools would compete in submitting their own existing in- and quality of health care delivery.21 house MPH-related coursework, which could serve as the Regardless of specialty, medicine-public health students basis for a national MPH curriculum for all medical students. should be able to select a concentration from one of the focus The educational innovation competition would be used to areas to complement their personal interests and career objec- design and implement the proposed national MPH curriculum: tives. New focus areas could be added to keep up with national . Stakeholders/organizers would be identified and brought health trends and medical student interests. Using existing on board, and a steering committee will delineate the focus ar- schools of medicine and public health to jointly develop the eas for the curriculum. MPH curriculum should result in high-quality courses and . The committee would announce the list of public health class materials at low costs and administrative overhead. focus areas and recruit schools of public health and schools The Committee on Educating Public Health Professionals of medicine to submit lesson plans, course blueprints, and for the st Century (CEPHP) recommends that “serious examination questions for specific courses within a particular efforts be undertaken by academic health centers to pro- focus area. vide joint classes and clinical training in public health and . The committee would evaluate the submitted lesson medicine” and that “a significant proportion of medical school plans and other documents, and select the ones that will com- graduates should be fully trained in the ecological approach pose the topical courses within each public health focus area. to public health at the MPH level.” 22 The CEPHP further . The steering committee would work with a panel of notes that “medical schools should partner with accredited educators and a technology partner to develop and implement programs in public health to provide for public health educa- secure, online portals to provide access to course materials. tion.” 22 An educational innovation competition to assemble . Medical students pilot the courses. medicine-public health curriculum would uniquely accom- . All medical students begin taking classes. plish that task. The recent passage of the Patient Protection and Affordable The MPH academic year Care Act will likely advance substantial changes to the Medical students would begin their MPH year as the first American medical care landscape. One of the most significant year of a new nationwide five-year joint medicine-public health yet under-emphasized aspects of the Act is the creation of the program. I propose six academic focus areas: public policy and National Prevention, Health Promotion and Public Health
32 The Pharos/Spring 2012 Council.23 President Obama has charged the Council, chaired . National Association of County & City Health Officials. by the U.S. Surgeon General, to develop a National Prevention National Profile of Local Health Departments. Washington (DC): and Health Promotion Strategy.23 This presents a tremendous National Association of County & City Health Officials; : . opportunity to highlight prevention and wellness, and perhaps . Brenner S, Siu K. Preventive medicine and public health resi- this renewed focus on preventive services will help to begin a dency training: Federal policy and advocacy opportunities. J Public national dialogue on public health education. Health Management Practice ; S–S. When I think about my eighth-grade hospital tour, I feel . Kahn LH. A prescription for change: The need for qualified that my asking “Why?” has not only shaped me into the physician leadership in public health. Health Aff ; : –. medical-public health student that I am today but also into . Council on Graduate Medical Education. Physician Educa- the medical-public health physician that I will be tomorrow. tion for a Changing Health Care Environment. Thirteen Report. Asking “Why?” has broadened my scope of thinking about Washington (DC): U.S. Department of Health and Human Services, health, and I look forward to the patients and populations that Health Resources and Services Administration; : –. Avail- I will serve in the future. I hope my argument has piqued your able at: http://www.cogme.gov/.pdf. interest and that now you’ll find yourself asking “Why not?” . Hernandez LM, Munthali AW, editors. Committee on Train- Why not integrate public health and medical education? The ing Physicians for Public Health Careers, Board on Population need is clear, the consensus is there, and the national focus on Health and Public Health Practice, Institute of Medicine. Training prevention is growing. Together let’s ponder “Why not?” and Physicians for Public Health Careers. Washington (DC): The Na- make it happen. tional Academies Press; : –. Available at: http://www.nap. edu/openbook.php?record_id=&page=R. References . Association of American Medical Colleges. Directory of . National Resident Matching Program. Results and Data: MD/MPH Educational Opportunities. https:/www.aamc.org/stu- Main Residency Match. Washington (DC): National Resident dents//mdmph. Matching Program; : . Available at: http://wwwnrmp.org/data/ . American Association of Colleges of Osteopathic Medicine. resultsanddata.pdf. Dual Degree Programs. In: Osteopathic Medical College Infor- . Miniño AM, Xu J, Kochanek KD. Deaths: Preliminary data mation Book. Chevy Chase (MD): American Association of Colleges for . National Vital Statistics Reports ; . Available at: of Osteopathic Medicine; . Available at: http://www.aacom.org/ http://www.cdc.gov/nchs/data/nvsr/nvsr/nvsr_.pdf. resources/bookstore/cib/Documents/cib/cib-whole.pdf. . Charlton BG, Andras P. Medical research funding may have . Member Medical Schools. Association of American Medi- over-expanded and be due for collapse. Q J Med ; : –. cal Colleges. http://services.aamc.org/memberlistings/index. . Centers for Disease Control and Prevention. Overweight and cfm?fuseaction=home.search&search_type=ms. Obesity. http://www.cdc.gov/obesity/data/trends.htmlState. . American Association of Colleges of Osteopathic Medicine. . Centers for Disease Control and Prevention. Diabetes Public U.S. Colleges of Osteopathic Medicine. http://www.aacom.org/ Health Resource. http://www.cdc.gov/diabetes/projects/diab_chil- about/colleges/Pages/default.aspx. dren.htm. . Association of Schools of Public Health. Member Schools. . World Health Organization. New survey finds highest rates http://www.asph.org/document.cfm?page=. of drug-resistant TB to date. http://www.who.int.mediacentre/news/ . Medicare Payment Advisory Commission. Report to Con- releases//pr/en/index.html. gress: Reforming the Delivery System. Washington (DC): Medicare . Kumanyika SK, Obarzanek E, Stettler N, et al. Population- Payment Advisory Commission; : –. Available at: http:// based prevention of obesity: The need for comprehensive promo- www.medpac.gov/documents/Jun_EntireReport.pdf. tion of healthful eating, physical activity, and energy balance—A . Gebbie K, Rosenstock L, Hernandez LM, editors. Commit- scientific statement from American Heart Association Committee tee on Educating Public Health Professionals for the st Century, for Prevention (Formerly the Expert Panel on Population and Pre- Board on Health Promotion and Disease Prevention, Institute of vention Science). Circulation ; : –. Medicine. Who Will Keep the Public Healthy? Educating Public . Gushulak BD, MacPherson DW. Population mobility and Health Professionals for the st Century. Washington (DC): The infectious diseases: The diminishing impact of classical infectious National Academies Press; : . Available at: http://www.nap. diseases and new approaches for the st century. Clin Infect Dis edu/openbookphp?record_id=&page=. : : –. . The Patient Protection and Affordable Care Act. Public Law . Hull SK. A larger role for preventive medicine. Virtual Men- -; : –. Available at: http://origin.www.gpo.gov/fdsys/ tor ; : –. pkg/PLAW-publ/pdf/PLAW-publ.pdf. . Association of State and Territorial Health Care Workers. State Public Health: Workforce Survey Results. Arlington The author’s address is: (VA): Association of State and Territorial Health Care Workers; 1186 Natchez Point, Apartment 35 : . Available at: http://www.astho.org/Display/AssetDisplay. Memphis, Tennessee 38103 aspx?id=. [email protected]
The Pharos/Spring 2012 33 From the Book of Treatment And the Chemotherapy came to him and said, Give Me your fields, your flowing fields of hair, from atop your head to your toes every single follicle—all of them give them to Me, your Chemotherapy so that you will feel naked although clothed. And give Me your flock, your bountiful flock of mucosal epithelial cells the cells by which you consume and digest give them to Me, your Chemotherapy so that you will be a leper to food. And give Me your soldiers, your brave soldiers of your immune system, your white blood cells from the tribe Neutrophil and Lymphocyte give them to Me, your Chemotherapy so that you will know how fragile you are. Give these, your most prized possessions, to Me amid incense of rubbing alcohol upon an altar of reclining chair. In return, I shall smite your enemy the cancer, cause of suffering and death. I, and no scalpel; I, and no x-ray. I will poison the primary tumor and his children and his children’s children throughout your flesh, in every hiding place. Their cytoplasm will run in your veins! I will destroy them all, without mercy so that you will know bad happens to good in order for worse to happen to bad. So did the Chemotherapy declare. And the follow-up CT scan was good. Adam Possner, MD
Dr. Possner (AΩA, University of Michigan, !""#) is assistant profes- sor in General Internal Medicine at Medical Faculty Associates, George Washington University. His address is: Medical Faculty Associates, George Washington University, !$%" Pennsylvania Avenue, NW, Suite !-$"% South, Washington, DC !""&'. E-mail: [email protected]. Illustration by Jim M’Guinness.
34 The Pharos/Spring 2012 Alpha Omega Alpha elects honorary members
ndividuals who have contributed Thomas Cech, PhD Martin George Tauber, MD substantially to medicine and fields Dr. Cech received a BA in Dr. Tauber is a Professor of related to medicine, but who are Chemistry from Grinnell College and a Medicine at the University of Bern. He Inot eligible for membership in AΩA as PhD in Chemistry from the University received his MD from the University graduates of a medical school with an of California, Berkeley in . He is of Zurich, Switzerland, and specialized AΩA chapter or as a faculty member currently the Director of the Colorado in Internal Medicine and Infectious of a medical school maintaining an ac- Initiative in Molecular Biotechnology Diseases. He has served as the co- tive AΩA chapter, may be nominated and Distinguished Professor at the director of the Institute for Infectious for honorary membership by any active University of Colorado Boulder. He Diseases, University of Bern, as Dean member of the society. In Alpha won the Nobel Prize in Chemistry in of the Medical Faculty, University of Omega Alpha’s board of directors ex- for discovering that ribonucleic Bern, and as Vice-Rector for Research tended invitations to the following dis- acid molecules serve as enzymes or and Rector-elect of the University of tinguished physicians and scientists. ribozymes in addition to their role in Bern. He has published extensively producing proteins. He has published regarding infections of the meninges extensively in chemistry and biol- and brain and treatment of CNS in- ogy. He is a member of the American fections. He is on the editorial board Academy of Arts and Sciences, the for the European Journal of Clinical Institute of Medicine, and the National Microbiology and Infectious Diseases. Academy of Sciences. He was awarded He has also published regarding medi- the National Medal of Science in , cal education. He has an international the Lasker Basic Medical Research reputation as an investigator in infec- Award in , and many other honors tious diseases and as a distinguished and awards. He has been a Howard educator. Hughes Medical Institute investigator since and served with distinction as the HHMI President from to . He is on the Board of Trustees for Grinnell College. He has excelled as a scientist and his discoveries and work have had a major impact on medicine and science. He has been an academic and scientific leader throughout his distinguished career.
The Pharos/Spring 2012 35 The physician at the movies
Peter E. Dans, MD
Tinker Tailor Soldier Spy Starring Gary Oldman, Mark Strong, Colin Firth, and Tom Hardy. Directed by Tomas Alfredson. Rated R. Running time 130 minutes.
ost readers are probably familiar with John Le Carre who wrote the book on which this movie Mis based.1 Le Carre (aka David Cornwell) was a mem- ber of the British foreign service from to . He has written twenty-one novels, the best-known of which is The Spy Who Came in from the Cold. The latter was made into a movie, as were seven others including The Constant Gardener, The Russia House, and The Little Drummer Girl. His best books concern the intrigues inside the British intelligence service MI- during the Cold War, when MI- was sparring with the intelligence services of the Soviet Union, East Germany, and even the United States. The movie principally deals with the existence within MI- of a highly placed mole or double agent turned by the Russian spymaster Karla, and the at- tempt to discover his identity. Not having read the book nor watched the acclaimed BBC miniseries, I had some difficulty getting into the movie. There are many threads to the story, which the director introduces in From left, Gary Oldman and John Hurt in Tinker Tailor Soldier Spy (2011). fragments before hopping to another one in flashbacks. Focus Features/Photofest. In addition, the central character, George Smiley (Gary Oldman), says very little for the first twenty minutes of the film, and, when he does, he is very laconic. I finally did figure out what was going on and came away accepting that counting cherry stones, waistcoat buttons, daisy petals or the it was a thinking person’s movie and worth seeing, especially seeds of timothy grass:1 Tinker, Percy Alleline (Toby Jones); given the dearth of films that tell stories and engage the viewer. Tailor, Bill Haydon (Colin Firth); Soldier, Roy Bland (Ciaran In addition, it led me, as I will note later, to sample the various Hinds); Sailor; Rich Man; Poor Man, Toby Esterhase (David other forms in which the story has been told. Denesic); Beggarman, George Smiley; Thief. He skips Sailor The film opens in with the Cold War in full force. because it is too close to Tailor and Rich Man because agent Britain’s Secret Service MI-, codenamed “The Circus” for Esterhase is always complaining of being underappreciated, its fictional location in a nondescript building on Cambridge thus Poor Man. Circus, has been suffering reverses, with agents in foreign The mission goes badly and Prideaux is shot twice in the countries being exposed, and secrets being leaked to Moscow back. Although originally thought to be dead, he is later and other enemies. The spymaster nicknamed Control (John tortured by Russian superspy Karla in an attempt to reveal Hurt) suspects a mole at MI-’s highest level, in the person of the Hungarian spy network and to determine who else in one of his top five underlings. Told that there is a Hungarian the Circus knows of his operation. Prideaux will reappear general who wishes to defect and who knows the identity of in England teaching in a Boy’s Prep School (one of the many the mole, he sends for agent Jim Prideaux (Mark Strong), who enigmas in the story). London is notified about the capture is familiar with Hungary and who has been away from the of a British spy and the mission is hastily covered up. Control Circus during the period when the mole is suspected is replaced as being over the hill and because his suspicions of having operated. Prideaux is instructed to send are considered outlandish, and his trusted lieutenant George back a cable after meeting with the general, iden- Smiley is sacked. The rest of the film deals with Smiley being tifying the mole using one of five code names rehired by the undersecretary who supervises MI- when it assigned to them. The assignment is drawn becomes clear through rogue agent Ricki Tarr (Tom Hardy) from a popular English children’s fortune- that the mole does exist. Smiley is assigned the job of ferret- telling rhyme used when presumably ing out the mole with the help of Peter Guillam (Benedict
36 The Pharos/Spring 2012 Mark Strong in Tinker Tailor Soldier Spy (2011). Focus Features/Photofest.
Cumberbatch), a loyal lieutenant whom Smiley had recruited Smiley had been assigned to turn early in his career, is allowed into the service. to keep it before returning to Moscow. The most incongruous Mix in another thread with the Istanbul-based Tarr falling scene involved a drunken Christmas party that the director in love with a Russian spy who knows the mole’s name but will inserted using as background music “La Mer,” sung by Julio only reveal it to Percy Alleline, the new head of the Circus. Tarr Iglesias. A particular favorite of mine written during World cables the information to London, setting into motion another War II by Charles Trenet, his classic version of the song was betrayal (the real theme of the film). Smiley methodically and used to great effect and much more appropriately in the film surreptitiously works to discover the traitor. Another thread Mr. Bean’s Holiday. The director liked it too, and decided that involves the existence of an operation kept secret outside the the party conveyed all that MI- was not, fun and camaraderie. Circus called “Witchcraft” and controlled by the mole who Since I am addicted these days to audiobooks, I decided passes on to England a mixture of low level accurate infor- to learn more about the story by trying to find one, but could mation and bogus disinformation while funneling secrets to only locate a BBC radio adaptation that ran about three hours Merlin, the code name of a Russian Embassy operative who with repetitive credits, somewhat longer than the movie but all but the mole consider to have been turned, but is loyal to actually quite similar to it in presentation.2 Then I watched the Moscow. miniseries that ran on three discs of minutes each.3 The film is full of lots of walking to and fro, which I would This much more robust presentation of the story is the most have preferred to have been replaced by making the story more satisfying audiovisual rendition of the book, not just because transparent. There is one scene with a plane in the background it stars Alec Guinness as George Smiley, but because the extra that I found difficult to understand, as Smiley and Guillam grill time allows the story to be better-paced and more comprehen- Esterhase who is not believed to be the mole. The miniseries sible. If you have the time, I recommend watching it. Still, Gary handled that scene much better. Oldman, who has been nominated for an Academy Award for In all the presentations of the story, a mostly unseen charac- Best Actor, does a great job of channeling Alec Guinness and ter is often mentioned, namely George Smiley’s estranged wife, the film is certainly worth a rental. If you want to view a more with whom he is still in love despite the fact that she notori- lighthearted and entertaining movie about spies, I strongly ously sleeps around. It apparently fuels feelings of inadequacy recommend Hopscotch, starring Walter Matthau and Glenda as a husband in Smiley and explains his withdrawn nature. A Jackson. It’s a hoot. lighter she gave him also figures in the story when Karla, whom Addendum: In an excellent twenty-eight-minute
The Pharos/Spring 2012 37 The physician at the movies
interview that is part of the miniseries on DVD, Le Carre has real assistant whose ideas Beane took a chance on implement- some fascinating insights into Alec Guinness’s approach to act- ing was Paul De Podesta, actually a Harvard graduate whose ing (look for him doing the simple action of putting on a glove persona was wonderfully fictionalized. Thinking he was being or walking in a meadow). He also discusses how his personal portrayed too much as a nerd, he asked that his name not be life led to a career both in intelligence work and writing, as used, but he helped with the film.3 Hill, who also received an well as how the story has historic resonance. The existence of Academy Award nomination, plays him with great timing, fa- highly placed double agents was known even before the Soviet cial expressions, and comebacks that make the scenes with him Union imploded and KGB files were made public. Agents didn’t and Pitt a joy to watch. Their remarkably collaborative interac- always report that they suspected that someone was a mole tion generates humor while moving the story along. because they could monitor them and for fear that the press The story is set in , a time when baseball fans and would get wind of it; they were less worried of it being discov- sports media, especially ESPN, were obsessed with home runs ered by Moscow than by the press.4 and the distance they traveled, as well as the signing of free- Le Carre also comments on the changing nature of the class agent players with big salaries. In charge of a small-market structure in England that had contributed to a greater loyalty team, Beane began applying what has came to be called sa- to one’s class. The intelligence service was mostly comprised of bermetrics, developed by William James, a more mundane people who had studied at Eton, Oxford, and Cambridge and statistical analysis of players’ contributions to winning baseball. were in the upper tier of society. They started out very idealis- It put a lot of emphasis on on-base percentage, assuming that tic but often became cynical, especially as the British Empire the more you got on base the more likely you were to be batted disintegrated after World War II, taking with it the whole idea in. It also encouraged players to take more pitches, not only to of Britannia ruling the waves, the sun never setting on the see the starters’ entire repertoire and possibly get a better pitch British Empire, and doing things for King and Country. Indeed, to hit, but also to increase the pitch count and thus get into in the film, the mole mentions this disillusionment after his the bullpen sooner. Beane made enemies of veteran scouts and discovery as being a factor in why he turned traitor. executives by downgrading the role in player evaluation of a scout’s intuition and a player’s physique. As he said, “We’re not References selling jeans.” In addition to relying on objective criteria, not . Le Carre J. Tinker, Tailor, Soldier, Spy. New York: Penguin just eyeballs, he emphasized dedication to the team concept Books: . rather than on individual prima donna attitudes. . Le Carre J. Tinker, Tailor, Soldier, Spy. BBC Audiobooks One might think that a film lauding an efficiency expert and America. statistics would be boring, but this one isn’t. Like the original . Le Carre J. Tinker, Tailor, Soldier, Spy. Acorn Media; . version of Cheaper by the Dozen with Clifton Webb, also . Epstein EJ. The lesson of “Tinker, Tailor, Soldier, Spy.” Wall about an efficiency expert, humor and humanity are woven Street J Jan : A. into the film. This is seen not just in the interactions with the manager Art Howe (Philip Seymour Hoffman), players, scouts, Moneyball and Brand, but also in the interweaving of Beane’s personal Starring Brad Pitt, Jonah Hill, Philip Seymour Hoffman, Kerris story. Growing up in a middle-class suburban San Diego neigh- Dorsey and Robin Wright. borhood, he was a heavily recruited high school football and Directed by Bennett Miller. Rated PG-13. Running time 133 baseball player and was offered a scholarship at Stanford and minutes. a tryout with the New York Mets. Deciding to join the Mets in and to forgo college, his dreams of stardom were never oneyball is the most entertaining film I’ve seen in a fulfilled, as is shown in flashbacks. Thus, this job offered him long time. Based on the book by Michael Lewis.1 the an opportunity for redemption and recognition in the baseball Mstory centers on the innovations introduced by Oakland A’s world. The most touching parts of the film are those scenes general manager Billy Beane in constructing his baseball team. that focus on the relationship between the divorced Beane He took a team that had the second lowest payroll and whose and his daughter Casey (Kerris Dorsey), and in part with his clubhouse Lewis described as “the cheapest and least charm- ex-wife Sharon (Robin Wright). The film ends somewhat on a ing real estate in professional baseball,” 2 and melded it into high note with the A’s coming back to win a playoff game, while one that won twenty consecutive games on its way to wins. he connects in a very poignant way with his daughter. Still, the You don’t have to be a sports fan to enjoy the film, largely due director makes it clear that his was not a storybook ending. to the crackling dialogue and the Academy Award nominated Like many Hollywood biopics, which are primarily enter- performance of Brad Pitt. He is in almost every scene and his tainment and not documentaries meant to convey historic interactions with the players, scouts, executives, manager, truths, this one has had its detractors. First of all, they point and, most especially, Paul Brand (Jonah Hill), the Yale-trained out that it doesn’t give credit to the pitching, which in the economist he hires as a special assistant, are pitch-perfect. The end really wins world championships.4 Having three bona
38 The Pharos/Spring 2012 Brad Pitt in Moneyball (2011). © Columbia Pictures.
fide number one pitchers on the staff played as large a role made statistical analysis commonplace to the point where it’s or maybe more than the statistical methods in reversing the gotten ridiculous, as one can see in the Wall Street Journal’s fortunes of the team. Second, Art Howe, who is thin and laid- section on sports.5 back as opposed to the paunchy Hoffman who plays him as uniformly stubborn and negative, is livid about his portrayal. References Howe is widely recognized as a brilliant manager and the A’s . Lewis M. Moneyball. New York: W. W. Norton; . wouldn’t have won games had he not been creative. . Phillips M. The un-”Natural” triumphs. Baltimore Sun Third, though his methods were innovative, Beane was not Sep : . the first to use the new statistics and he has never won a world . IMDb.com. Moneyball. http://www.imdb.com/title/ championship. Indeed he did have an opportunity to move to tt/. the Red Sox to use his sabermetrics but refused the offer; the . Barra A. The “Moneyball” Myth. Wall Street J Sep : D. Red Sox made Theo Epstein the general manager. Epstein hired . Futterman M. Baseball after Moneyball. Wall Street J William James, and using the same methods with more money Sep : D. at his disposal, he was able to win a World Series in for the first time since , ending the curse of the Bambino. The Dr. Dans (AΩA, Columbia University College of Physicians and Red Sox had never won a World Series since trading Babe Ruth Surgeons, 1960) is a member of The Pharos’s editorial board and to the Yankees for , at the end of the season, a has been its film critic since 1990. His address is: move that has gone down as the worst trade in baseball his- 11 Hickory Hill Road tory. Finally, it’s worth noting that a large part of the success Cockeysville, Maryland 21030 of sabermetrics was due to the revolution in computers that E-mail: [email protected]
The Pharos/Spring 2012 39 Hail to thee, my gizmo smart That sends live current through myMy heart. Pacemaker My sinus node has lost its vigor And needs adjustment of its trigger. Your electric mind has figured out Proper rhythms to give the clout For contracting pumps both left and right Rushing blood to proper sites. Needed oxygen to the brain For thoughts and conscience to maintain. Pacer, you mean all to me— Whether to be or not to be. Herbert S. Harned, Jr., MD
Dr. Harned (AΩA, Yale University, "#$%) is a retired pedi- atric cardiologist and professor at the University of North Carolina School of Medicine. His address is: &%' Carolina Meados Villa, Chapel Hill, North Carolina &(%"(. E-mail: [email protected].
Illustration by Jim M’Guinness
40 Reviews and reflections
David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors
be heart disease. Charles Bailey of the the first clinical trial on the artificial Hahnemann Hospital in Philadelphia heart. The chapters are organized ac- was the surgeon, and this particu- cording to surgical milestones, such as lar cover is reproduced in David K. the concept of the heart-lung machine C. Cooper’s Open Heart: The Radical and heart transplantation. This format Surgeons Who Revolutionized Medicine. created the problem of where to place Dr. Cooper, a cardiac surgeon him- surgeons who figured in several chap- self, bases his account on personal ters of the story. The author includes interviews with many of the pioneer Michael DeBakey and Denton Cooley in surgeons still living when he began writ- the chapter on mechanical hearts, even ing the book in . Otherwise he in- though DeBakey was also known for Open Heart: The Radical terviewed associates, coming away with aortic aneurysm surgery, and they were Surgeons Who Revolutionized a history that is strongly personal—a both known for innovations in coronary Medicine significant advantage in that medicine bypass surgery. David K. C. Cooper, MD in general, and surgery in particular, Some of the stories go beyond leg- New York, Kaplan Publishing, 2010 remains a personal endeavor despite ends I had previously heard. One of current trends that tend to emphasize the trainees under DeBakey told of Reviewed by Taylor Prewitt, MD the team, the group, and the institution. being in the ICU for ninety days at a Large portions of the story are told stretch—you slept in the ICU, meals he intense, focused eyes of a sur- by the participants themselves; the au- were brought in. A former resident of geon, in a scrub cap with mask thor refers to it as an oral history. This John Kirklin in Birmingham reports danglingT from his neck, stared straight is the stuff of legend, passed on in remi- that routine morning rounds began at through me as I saw the cover of the niscences at meetings and courses and : a.m., and a call had to be made current issue of Time Magazine in kept alive by those who trained under to Dr. Kirklin to report on his patients the spring of —“Inside the Heart: these innovators who had the “right at exactly : . Call a few minutes Newest Advances in Surgery.” Having stuff.” early, and he would hang up. Call a few just started a premedical curricu- Some thirty cardiac surgeons are minutes late, and you were in trouble. lum, this image and its accom- featured, from Robert Gross, who per- Their methods were sometimes ex- panying article convinced formed the first closure of a patent treme, but the stakes were high. Patients me that my primary ductus arteriosus in , to William often died. These were brilliant and dar- interest in medi- DeVries, who was featured on the ing young men, many of whom had fin- cal school would cover of Time in for carrying out ished at or near the top of their medical
The Pharos/Spring 2012 41 Reviews and reflections
school classes, but with steep learning so much time in the operating room curves for performing new operations. that postoperative care was often left to How did they get away with it? The others. Another hero, Dr. Brian Barratt- more lenient medico-legal climate of Boyes of New Zealand, was critical of the time permitted Dr. James Hardy of Cooley’s early work: “His results were Mississippi to perform the first heart not good, and never comparable to transplant with only a one-paragraph those of the Mayo Clinic.” p375 consent form, signed by the patient’s Cooley enjoyed operating, made it next of kin and not mentioning that the look easy, and did so calmly and with- heart donor would be a chimpanzee. out intemperate language. Some other The relatively small threat of being sued surgeons were notorious for cursing for malpractice also helped fuel their and throwing instruments. Not all were determination to persist with a new blessed with great manual dexterity. procedure in the face of a “bad run” Alfred Blalock and Russell Brock, two DNR: Do Not Resuscitate— of operative or postoperative deaths. of the early innovators, are said to have Real Stories of Life, Death and But persistence came with a price. Dr. had “technical limitations in the op- Somewhere in Between p52 Lillehei admitted that sometimes he erating room” that accounted for Lauren Jodi Van Scoy, MD (AΩA, Drexel was “almost ready to quit.” His remedy their “difficult behavior,” p52 but did not University, 2010) was “a good night’s sleep, and maybe a prevent them from making significant Van Scoy Consulting and Publishing, few belts at the local bar.” p200 Dr. Kirklin contributions. 2011 said that often he went home and cried. Perhaps, as Lewis Thomas wrote “Surgeons are people who cry in mov- some forty years ago, coronary artery Reviewed by Walter Forman, MD, ies,” p230 he once said. bypass surgery is a “halfway technol- FACP, FAAHPM As a cardiac surgeon himself, Cooper ogy,” the best we can do until we learn addresses the issue of the importance to prevent or reverse coronary disease s I finished reading DNR by Lauren of manual dexterity to a surgeon. Atul by nonsurgical means. But the develop- Jodi Van Scoy, MD, I felt so very Gawande, a surgeon and well-known ment of the heart-lung machine, which Asad for those people for whom this book writer on current medical issues, has allowed open heart surgery to become was written, “as a glowing inspiration emphasized that rigorous training and almost commonplace, must stand as for patients and their families as they sound habits are more important than one of medicine’s great advances, surely struggle with approaching mortality.” technical prowess in achieving surgi- worthy of the Nobel Prize that never The writer herself struggles with the dif- cal success. Those who spend a lot of came. ficult question that patients and families time in the operating room know who Charlie Bailey and William DeVries so often ask: “What should I do?” The the technically good surgeons are. (As were not the only ones to arrive on the author answered: “It is up to you.” I sug- a cardiologist, I knew the best surgeons cover of Time. As illustrated in Open gest that while it is rarely the physician’s by results and reputation, though I was Heart, Michael DeBakey did so in role to directly answer this question, unable to fully appreciate their elegant for his work “toward an artificial heart,” she can assist the patient and families work on my rare visits to the O. R.) and Christian Barnard was featured in their moment of crisis by having a Cooper, however, quotes a description in after he performed the first thoughtful discussion that starts by ask- by Dwight Harken, a legendary pioneer human-to-human cardiac transplant. In ing, “What do you understand about in his own right, of the virtuosity of this enjoyable book, David Cooper has your loved one’s situation?” To do this Denton Cooley, a surgeon who “operates given us their stories, along with those well, the physician must be aware of the with Woolworth volume and Tiffany of their colleagues who dominated a cultural background of the families and quality.” p374 And when DeBakey and surgical era that captured the imagina- any internal conflicts. She must always Cooley were operating together, their tion of the world—not just that of a ask if there are documents indicating synchronicity was “wonderful to see,” young premedical student in Arkansas what the patient would have wanted. according to Viking Bjork, another of in . The physician should refrain from of- the greats. Observing DeBakey and fering an opinion unless the patient or Cooley was described by another as Dr. Prewitt is a retired cardiologist in Fort surrogate decision makers insist or it “like watching an octopus operate. Smith, Arkansas. His address is: is in the patient’s best interest. The art There were hands everywhere.” p377 8311 Mile Tree Drive of medicine truly lies in how well the And yet, some of the most skillful Fort Smith, Arkansas 72903 physician communicates with patients surgeons, such as Denton Cooley, spent E-mail: [email protected] and families, but the acquisition of this
42 The Pharos/Spring 2012 skill depends on thoughtful mentoring that up with the procedure in her insti- and repeated practice. tution for making that determination, DNR contains five stories, each about valuable information for any physician. a person with an illness that in the usual The final case presentation is course of events ends in death. Victoria’s story. Here we find an elderly Bruce’s story concerns a man in his woman taken to the hospital with what early fifties with severe progressive car- she thinks is an allergy attack. A chest diac failure. Details about his clinical roentgenogram makes it clear that she course are elucidated, but Dr. Van Scoy has a malignancy with metastasis to both questions the continued treatment of lungs. Van Scoy then describes a won- this “terminally ill” person. Yet the story derful presentation to the family, some ends happily after Van Scoy meets the forty members of whom are gathered in a patient after he has received a cardiac small conference room, about the options transplant and is about to ride off on for whether or not to begin resuscitation Anatomy of a Kidnapping: A his motorcycle. The reader is left to efforts if the patient’s status worsens, or Doctor’s Story “think about” the difficulty of accurate whether to keep her pain free and allow prognosis. the disease to progress along its expected Steven L. Berk (AΩA, Tennessee State Mrs. Chandler is an elderly woman clinical course to death. The family de- University, 1986) with a strong family, whose members cides not to request resuscitative efforts. Lubbock, Texas, Texas Tech University insist that everything that is medically Victoria is intubated, administered intra- Press, 2011, 248 pages possible be done for her. The author venous morphine, which allowed her to Reviewed by Charles S. Bryan, MD quotes one relative: “It’s the need to help. expire quietly. Here the question might (AΩA, University of South Carolina, It’s the need to be there for your family be raised as to why the intubation, when 1992) member. Maybe it’s guilt. But it is almost intravenous morphine alone would have certainly love.” Mrs. Chandler dies after resulted in the same end with far less intensive intervention and with multiple discomfort. South Carolina clergyman was dic- medical devices in place. While love The last sentence summarizes the tating his next sermon into a tape certainly played a very prominent part entire book: “I backed out the door, re- recorderA when a robber burst into his in her care, Van Scoy regrets that her treating into the unit and back into the study, put a gun to his head, and said, suffering was prolonged at the end of her world of science and medicine.” among other things, “Give me three life. Could this have been avoided with DNR serves the purpose of allow- reasons I shouldn’t kill you.” The clergy- more explicit discussions about exactly ing a physician to express her thoughts man’s third reason: “Because you’ll have what interventions would entail? and feelings about critically ill people to answer to the Lord.” He survived and Patrick is a young man of nineteen for whom she had cared. In my view it later described a surrealistic calm that with cystic fibrosis, entering hospice would have been helpful if an interdis- embraced him during his moment of care. Oddly, Van Scoy recounts that ciplinary team had been brought in to peril. caring for him “was a nice change of consult on each case. Thankfully, cur- Steven L. Berk found a similar calm pace from the chest pain patients and rently over fifty percent of medical in- in William Osler’s motto, aequanimi- the confused elderly patients with pneu- stitutions in the United States now have tas. About : on the morning monia.” This is the story of a mother an interdisciplinary palliative care team of Sunday, March , , Berk, then who gave birth to a child with a fatal that is available to consult on these most regional dean of a campus of the Texas congenital illness. Her story is told to difficult situations. I recommend that Tech University Health Science Center the author some two years after Patrick’s every physician and health care worker School of Medicine, made himself a cup death. One feels that Van Scoy missed learn how to establish contact with his of coffee and went upstairs to his study. the opportunity to tell the important or her team. At about the same time, a fugitive crimi- story about the bereavement period and nal entered the residential subdivision how it affected the family. Dr. Forman (AΩA, Wayne State University, of Amarillo, Texas, turned into a back Walter is a twenty-nine-year-old man 1963) is Professor of Medicine Emeritus alley, found an open garage door, and who sustained a major intracranial bleed at the University of New Mexico School of entered Berk’s home. He found Berk in and is “brain dead,” although his heart Medicine. His address is: his study, pointed a shotgun at his head, and lungs function “normally.” Here Van 652 Cougar Lane NE and said, “I will kill you if you don’t do Scoy renders a fine description of how Albuquerque, New Mexico 87122 what I say.” Berk spent the next four brain death is determined. She follows E-mail: [email protected] hours riding around Amarillo and the
The Pharos/Spring 2012 43 Reviews and reflections
surrounding countryside at the mercy violence, and crime. Such empathy no of a desperate, emotionally unstable doubt resulted in his roadside release armed robber. somewhere in the Texas prairie, minus Berk was unarmed—indeed, he could his billfold but unharmed. not distinguish between a shotgun and Berk artfully weaves into this a rifle—but proved a poor choice of vic- wrenching story the tapestry of his au- tim. He had little cash in his possession. tobiography, the making of a doctor, He did not know how to use an ATM a teacher, a husband, and a father. He machine. He did not know his PIN. He avoids the major pitfall of autobiogra- was, however, quite capable of memo- phy—narcissistic self-justification—in rizing the ten numbers and four letters part by relating how he, too, has made of the vehicle identification number on mistakes, including a warfarin interac- the left lower windshield. This infor- tion that cost a man his life. He reminds mation led to arrest, conviction, and us that we are all of the same clay. As sentencing. one of my teachers used to say after In this can’t-put-it-down memoir, each encounter with a down-and-outer, Berk elaborates on aequanimitas, de- “There but by the grace of God go I.” fined by Osler as the mental counterpart subject to. A distinguished law profes- to the physical attribute of imperturb- Dr. Bryan is a the Heyward Gibbes Dis- sor and author of such books as Legal ability. “Being calm is what we do,” Berk tinguished Professor of Internal Medicine Frontiers of Death and Dying and later told a newspaper reporter.p204 He Emeritus at the University of South Caro- Advance Directives and the Pursuit quotes from Osler’s address to lina School of Medicine, and a member of Death With Dignity, Cantor tackles graduating medical students: of the editorial board of The Pharos. His this vast array of material with insight, address is: elegance, and wit. For those of us not Imperturbability means coolness 6222 Westshore Road turned-off by the topic, this is an engag- and presence of mind under all cir- Columbia, South Carolina 29206-2121 ing book to read. cumstances, calmness amid storm, E-mail: [email protected] The author begins at the begin- and clearness of judgment in mo- ning, the diagnosis of death and physi- ments of great peril, immobility, and cal characteristics of the corpse. He impassiveness. then investigates the legal status of the “postliving.” The common assumption Berk also reminds us that, prop- After We Die: The Life and that cadavers are, at least in some sense, erly understood, aequanimitas implies Times of the Human Cadaver property that can be disposed of ac- emotional response appropriate to the Norman L. Cantor cording to the preferences of relatives circumstances. We must seek balance Washington, DC, Georgetown University has little basis in American law. To the between detached objectivity with hu- Press, 2011 contrary, cadavers have legal rights, manistic empathy. Osler exhorted stu- justified under a concept Cantor calls dents to cultivate Reviewed by Jack Coulehan, MD “prospective autonomy,” which allows (AΩA, University of Pittsburgh, 1969) decisions made by the person when such a judicious measure of obtuse- alive to be enforced after death. The ness as will enable you to meet the he title of Norman Cantor’s new author also reviews the right to a decent exigencies of practice with firmness book is intriguing. Most books that burial, to “quiet repose,” and to privacy and courage, without, at the same tackleT “after we die” topics deal with of personal information, although clear time, hardening “the human heart theology, spirituality, or the world of legal exceptions exist to each of these. by which we live.” the paranormal. Cantor, however, ap- The chapter on decomposition is proaches “after we die” from a more very graphic. I was surprised to learn Chasing such balance is a lifelong en- (literally) down-to-earth perspective. that the practice of embalming cov- deavor, never complete. He surveys what he terms “the life and ers a wide range of methodology and In the end, such balance probably times” of human corpses, including potential results. One early example saved Berk’s life. He was able to estab- their legal status and rights, methods of of high-grade embalming was that of lish rapport with his kidnapper, to ex- disposal, natural history of decomposi- Mrs. Van Butchell, who died in . plore his feelings, to empathize with his tion, social roles, and the various types She and her husband had a prenuptial descent into alcohol, drugs, domestic of desecration and abuse cadavers are agreement that said he could control
44 The Pharos/Spring 2012 her estate “as long as she remained the chronically insufficient pool of should be of interest to a broad range above ground.” Thus, after she was em- cadaveric organs is particularly inter- of practicing physicians, as well as to balmed, he kept her above ground in a esting. He argues that permitting a mar- specialists in medical ethics, health law, glass case in his drawing room. I learned ket in organs—allowing dying patients and organ transplantation. that extreme chemical embalming can or their families to sell them—would prevent decomposition almost indefi- be unlikely to substantially enlarge the Dr. Coulehan is a book review editor for nitely, but the trade-off is a much less pool. His favored approach, based on a The Pharos, and a member of its editorial lifelike appearance of the corpse, gener- communitarian rationale, is to presume review board. His address is: ally unacceptable and unnecessary given consent and routinely remove usable Center for Medical Humanities, Com- the usual goal of a prompt burial after organs, giving individuals the option passionate Care, and Bioethics viewing. Other methods of preventing (obviously prior to death) of informed Stony Brook University decomposition include cryopreserva- refusal. Several countries in Western Stony Brook, New York 11794 tion, mummification, and plastination, Europe have successfully adopted this E-mail: [email protected] a very expensive new process made system. Cantor reviews several possible notorious by traveling commercial exhi- constitutional arguments against the bitions like Body Worlds. Perhaps with enactment of laws allowing routine use tongue-in-cheek, Cantor also mentions of cadaver organs for transplantation, sainthood as a “possible antidote to but (surprisingly, in my opinion) he dis- bodily decomposition,” citing numerous counts them all, while at the same time stories of saints miraculously preserved admitting that “donation” in the face for hundreds of years. of family objection would probably be Cryopreservation, or cryonics, based unacceptable in practice. on the idea that freezing the corpse Two of the other roles that cadavers could preserve it sufficiently that future might perform are those of teacher and scientific advances might someday allow parent. Cantor considers the common its resurrection, made a big splash when use of recently dead persons by stu- introduced in the early s. Although dents to practice intubation and other the process has increased in chemi- medical procedures. He supports these cal sophistication over the years, there practices, but only with explicit premor- is widespread skepticism that “cryo- tem consent, or postmortem consent nauts” could ever be resuscitated, due to by family members, since such proce- widespread cellular damage during the dures violate the right to “quiet repose.” freezing process. At present there are He suggests that premortem consent fewer than two thousand cryopreserved might be included in routine hospital bodies in the United States. The other admission forms, which to me is ethi- end of the spectrum, in terms of bodily cally questionable, since the pro forma preservation, is cremation, a process admissions process would necessarily A History of Immunology, that has rapidly increased in popularity include insufficient information disclo- Second Edition in recent decades. In only four per- sure to allow any such consent to qualify Arthur Silverstein cent of dead bodies were cremated, but as “informed.” Cadavers might serve as London and New York, Academic by the year , twenty-eight percent parents in a variety of ways, ranging Press, 2009, 530 pages were disposed of in this way, and a from extraction of sperm, to be frozen survey indicated that forty-six percent and used later, from a recently dead man Reviewed by Carla C. Keirns, MD, of Americans would elect to have their to gestating a live fetus in a brain-dead PhD, MSc bodies cremated. woman being maintained on a ventila- Perhaps organ donation is the most tor. According to Cantor, the key issue desirable social role for today’s cadavers. in each case is the likelihood that pro- hen Arthur Silverstein, a special- Cantor traces the development of laws ducing a postmortem child reflects the ist in immunological diseases of and practices governing organ donation, actual wishes of the deceased person. Wthe eye, published the first edition of his including the relatively recent practice In summary, the author covers al- impressive intellectual history, A History of organ removal after pronouncement most every conceivable aspect of “the of Immunology in , he explained of death by cardiac criteria. His discus- life and times of the human cadaver.” that he had become concerned that too sion of proposed methods for increasing After We Die is a masterful work that many of his colleagues think “the entire
The Pharos/Spring 2012 45 Reviews and reflections
history of immunology could be found of vaccines in many countries across in which penetrating injury to one eye within the last five years’ issues of the more than two centuries, not to men- can later cause blinding inflammation most widely read journals.” He recounts tion a steady stream of books on AIDS. in both eyes, illustrating the importance that his historical interests became se- Given all of that activity, revising A of antigenic sequestration—the immune rious when he was asked to review a History of Immunology promised to be a system had never “seen” proteins from paper that essentially replicated a study massive undertaking. Some would have the lens of the eye and therefore didn’t published by Paul Ehrlich some eighty given up. Instead, Silverstein has taken recognize it as “self.” This disease nicely years before, using modern techniques on the project of including much of this illustrates the importance of clinical but giving the same results. Silverstein substantial new work, adding two chap- examples to the development of ideas wrote that he hoped to provide mod- ters to the intellectual history section in immunology. However, Silverstein ern practitioners of immunology with and eight chapters on developments in spends relatively less time exploring some perspective on the development the realms of public response (notably the immunologic basis of lupus and of their field. In the original edition he vaccination and anti-vaccination move- other traditional autoimmune diseases, predominantly explored acquired im- ments), research funding and funders’ leaving the complexity of clinical obser- munity to infectious diseases, though priorities, scientific societies, and tech- vations, pathological findings, labora- he also included chapters on allergy, nological change. tory testing, and therapeutic options in autoimmunity, and transplantation Two of these new chapters deal the individual autoimmune diseases to with references almost exclusively to with the generation of antibody diver- other historians. He has set circa original scientific literature in English, sity and the clonal selection theory, as the end of his narrative and, as the French, and German, and some archi- drawing on the work of Alfred Tauber, mechanisms of diseases like lupus, mul- val sources. His introduction, entitled Scott Podolsky, and Pauline Mazumdar, tiple sclerosis, and inflammatory bowel “History and Historians,” is perhaps the among others. The social history sec- disease are still being worked out, this best short introduction to historical tion starts with a revised chapter on is a sensible historical choice. A number method I’ve ever seen, as he cautions vaccination, the “Royal Experiment” of scholars are actively working in this contemporary scientists that the past is to test smallpox inoculation, and the area, and much like Silverstein’s first just as full of wrong turns, wasted effort, promise and problems with “magic bul- edition, the second can expect to inspire and blinkered funders as is the present, lets.” Other social history chapters are and guide a new generation of scholar- and therefore historical progression is new to this edition, including one on ship in the history of immunology. hardly as neat and orderly as it appears the impact of scientific meetings and Given Silverstein’s focus on the his- in later textbooks. societies, drawing on insights about the tory of scientific ideas in immunology, When Silverstein published the first importance of networks for innovation the text will be of greatest interest to substantive monograph on the history and dissemination of ideas and prac- readers with scientific or medical train- of immunology in , he was at the tices. A chapter on Metchnikoff, Burnet, ing in immunology, as well as medi- lead of a now wide-ranging historical and Darwin explores the resurgence of cal historians, but physicians with a literature. In just the first decade after evolutionary thinking in this most mo- strong personal interest in immunology his book appeared, the field grew dra- lecular of sciences, a field where stud- or medical history should also find this matically, with the publication of books ies of mechanism once largely eclipsed an engaging and intellectually satisfying on the work of Élie (Ilya) Metchnikoff, broader thinking about biological sys- book. father of cellular immunity; Macfarlane tems. Burnet’s clonal theory; the develop- Silverstein’s sections on autoim- Dr. Keirns is Assistant Professor of Preven- ment of bacteriology; antibodies; rec- munity highlight the contrast between tive Medicine, Assistant Professor of Medi- ognition of self and non-self; humoral basic immunologic theory and the his- cine, and Clinical Ethicist at Stony Brook and cellular immunity; monoclonal an- tory of clinical immunology. Silverstein University. She is Director of the Program tibodies; transplantation; and serum meticulously traces Ehrlich’s idea of on the History of Medicine there. Her ad- therapy for diphtheria. The next decade horror autotoxicus, and the difficulties dress is: saw Silverstein’s own new book on Paul that many immunologists had in ac- Center for Medical Humanities, Com- Ehrlich’s receptor theory, biographies of cepting that the immune system could passionate Care & Bioethics Emil von Behring and Niels Jerne, and cause, as well as protect from, disease. Stony Brook University books on the history of allergy, multiple He illustrates the value of consider- HSC Level 3, Room 80 sclerosis, interleukin- treatment, and ing autoimmunity to explain the curi- Stony Brook, New York 11794-8335 stories about the development and use ous case of sympathetic ophthalmia, E-mail: [email protected]
46 The Pharos/Spring 2012 2011 AΩA councilors meeting staff, alumni, and faculty that can be nominated by each The September AΩA Councilors meeting took chapter. The number of eligible students is proportional place in Chicago on September and , and was at- to the size of the student body, but chapters are limited to tended by a record number of forty-two councilors. The two faculty members, two alumni, and three house staff, meeting identified and discussed a number of issues of regardless of the size of the school. In effect, this makes importance to chapter councilors. An electronic survey AΩA membership much more difficult to achieve for can- was distributed to all councilors before the meeting, and didates at larger institutions. This is an important issue, the results were used to set the meeting program. It was in part because faculty and alumni members often prove co-chaired by Richard Gunderman, representing Alpha to be among the most engaged and supportive. There was Chapter of Indiana, and Gabe Virella, representing Alpha broad support among attendees for making these numbers Chapter of South Carolina. proportionate to the number of students. A motion con- All AΩA chapters have a chapter councilor appointed cerning proportionate representation will be prepared by by the dean of the school of medicine. Chapter council- the co-chairs of the councilors meeting and submitted to ors serve as important role models and provide valuable the AΩA board. leadership for their chapters, schools, and members. They While a few chapters receive funding from their dean’s work in partnership with the AΩA executive director and office, more chapters assess chapter membership dues, national office staff. Councilors supervise the election of which generally provide a stable base of funding. However, chapter officers and organize and manage the nomination some attendees commented that the distinction between of new members each year according to the criteria set local and national dues can be confusing to members. forth in the AΩA Constitution. They also coordinate and Other chapters also generate revenue from the member- select proposals from medical students and faculty apply- ship induction banquet, at which members are invited ing for national programs and awards. Most enjoy some to contribute to the organization. When chapters solicit administrative support from their school. Many chapters members for chapter dues, it is important to clarify that assess dues to support chapter activities and functions. In these are for chapter support and that members should sum, AΩA chapter councilors are critical to the ongoing also pay their annual or lifetime AΩA national dues. success of the society. Chapter activities include educational programs, The most intensely discussed issue at the meeting mentoring, student health clinics, and fundraising. Some concerned the criteria and procedures for selection of councilors, particularly those at schools where students new members. All chapters must follow the membership are elected only in their fourth year, noted that it can be guidelines presented in the AΩA constitution, Article IV. difficult to generate sustained student involvement. The Scholastic achievement should be the primary, but not fourth-year students tend to be busy with residency ap- the sole basis for nomination of a student. “Leadership plications and interviewing in the fall and winter, and by capabilities, ethical standards, fairness in dealing with spring many students are not so focused on school activi- colleagues, demonstrated professionalism, potential for ties. The challenges in generating involvement among resi- achievement in medicine, and a record of service to the dents and fellows can be even greater. school and community at large shall be criteria in addition When asked to name the AΩA national office program to the academic record.” of most benefit to the chapters, members overwhelmingly However, chapters use different processes for nomi- endorsed the visiting professor and lecturer program. nating students. Some of the challenges in selecting Many chapters solicit suggestions for speakers from stu- candidates for membership include identifying the top dents, faculty, and department chairs. In an effort to en- twenty-five of the class; criteria for recognizing leadership, hance two-way communication between chapters and the service, and professionalism; and identifying candidates for national office, councilors were urged to invite AΩA board membership as house staff, alumni, and faculty. members to serve as visiting professors and lecturers. This Concerns were also raised about the numbers of house would enable the board to learn more about local chapter
The Pharos/Spring 2012 47 National and chapter news
life, while also enabling board members to share informa- tion about national activities, such as new initiatives in the areas of leadership and professionalism. It is impor- tant to clearly identify AΩA supported lecturers as AΩA Visiting Professors and to publicize their activities within the institution and community. It was recommended that everyone attending a celebratory banquet or AΩA func- Left to right: Dr. Gunderman, Dr. Virella, and Dr. Byyny. tion receive an AΩA brochure, which summarizes the national programs and awards. The councilors emphasized the importance of a cel- ebratory banquet to honor the student AΩA nominees Fellowship was approved at the board meeting that fol- and their families and friends. By inviting AΩA members lowed the councilor meeting. from the faculty and community, some get more than A final topic of discussion was communication within attendees. The dean should be invited and have this on AΩA. Improving the quality of communication would his or her annual calendar. Many invite their AΩA visit- benefit the entire organization. For the time being, the ing professors, who also speak at the award dinner. Some Pharos and dues notices are mailed to members, al- charge to attend the banquet and the fee can include though these could begin to move toward an electronic payment for student attendees. The invitation letter of- delivery model. One possibility to improve communi- ten includes a request to support someone else from the cation among chapters and between chapters and the chapter. Some recommended informing student members’ national office would be to utilize an outside vendor to parents that a gift of AΩA lifetime dues could be a part create an electronic communication network. Various of their graduation present. Some partner with the local opinions were expressed on this point, and the decision academy of medicine and or local or regional societies for was made to investigate options in more depth before invitations and financial support. It is appropriate to re- reaching a decision. The AΩA national office has since quest financial support from the dean or dean of students. implemented a member and councilor e-mail distribution Brief remarks on the importance of nomination to AΩA system to facilitate communication with AΩA members for students are well received and inspirational. and chapters. Chapters are strongly encouraged to include profes- The meeting generated considerable enthusiasm sionalism in member selection criteria. Some attendees among attendees. The discussions were lively and spirits noted that professionalism can be difficult to evaluate, were generally high, as participants got to know one an- though all agreed that it is vital. Moreover, chapters can other and shared insights and experiences. Those present help to promote a culture of professionalism in their agreed that such meetings play a vital role in the health schools, for example by sponsoring lectures and discus- and vitality of the organization, by helping councilors to sions on the topic and highlighting the fact that profes- realize that the challenges they face are not unique and sionalism is an important criterion for selection to AΩA. creating relationships for sharing ideas. There was broad The curricula of many medical schools are so focused agreement that such meetings should be available to new on scientific, technological, and clinical material that councilors on an annual basis, so that they can “learn topics such as leadership tend to be overlooked. Yet the the ropes” quickly and become part of this invigorating future of individual institutions and the profession of camaraderie. New councilors should invite experienced medicine as a whole hinges to a substantial degree on the chapter councilors as visiting professors who can fulfill quality of leadership they enjoy. AΩA can play an impor- the responsibilities of the visiting professor and can work tant role in helping to promote the development of medi- to educate and support the new chapter councilor. cal students, residents, and faculty members as leaders. Councilors should work to network with each other Again, AΩA chapters can sponsor lectures and discus- or with regional cohorts to learn from and support each sions on the topic, and also ensure that chapter activities other. are carried out in a way that optimizes their leadership development potential. Richard B. Gunderman, MD, PhD The role of residents and fellows in AΩA chapters Gabriel Virella, MD, PhD was discussed. A new program, the AΩA Postgraduate Richard L. Byyny, MD, FACP
48 The Pharos/Spring 2012
Years of plodding strife have taught me our heroes, our mentors, are not always known nor are their caring laps and filtered voices soon recalled, though from some burning core, they carry on. My mentor’s genius lay in finding meaning in a child’s play amazed by all the dramas that unfold, admitting to the undeceiving face of pain, and meeting it with kindness, his special way of helping others to heal their many “raveled sleaves of care.” When we have learned the art of “being there,” “open-to” and “holding,” while another dares to come alive, we learn to feel respect, aware our mentors live in us. As well, we must allow each the grace to age retaining their essential glistening eye, allowing them the many stations of our lives and honour them, by learning how to tread the self same stony way, knowing that our touching hands and minds spread over time will make one unbroken soul, one unending day.
Carl Rothschild, MD, FRCP(C)
Dr. Rothschild (AΩA, George Washington University, !"#$) is a Child and Family Psychiatrist at the Alan Cashmore Centre of Vancouver Coastal Health in Vancouver, British Columbia. His address is: %&'( W. ))rd Avenue, Vancouver, British Columbia, Canada V#M !C&. E-mail: carl"&*"@telus.net.
The Pharos/Spring 2012 1 Presenting the AΩA scarf
AΩA's new scarf highlights the society's insignia, based on the shape of the manubrium sterni. The center medallion features the Pharos lighthouse of Alexandria, one of the seven wonders of the ancient world, for which AΩA's journal is named. The borders are stylized DNA strands.
Scarves are x inches, of m/m silk twill with handrolled hems. Four colorways are available as shown: red/black, turquoise/purple, peach/mint, and navy/lavender. Scarf design by J&J Designs of San Francisco.
To order, send a check for to: Alpha Omega Alpha, Middlefield Road, Suite , Menlo Park, CA Or order online at www.alphaomegaalpha.org/store.html (Price includes shipping and handling)