Alpha Omega Alpha Honor Medical Society Winter 2015 Alpha Omega Alpha Honor Medical Society Spring 2015

Claude1813 Bernard, - 1878 THE PHAROS of Alpha Omega Alpha honor medical society Spring 2015

“Be Worthy to Serve the Suffering” Alpha Omega Alpha Honor Medical Society Founded by William W. Root in 1902 Officers and Directors at Large Editor Richard L. Byyny, MD Douglas S. Paauw, MD President Seattle, Washington Editor Emeritus (in memoriam) Robert J. Glaser, MD Robert G. Atnip, MD President-Elect Associate Editor and Helen H. Glaser, MD Hershey, Pennsylvania Managing Editor John Tooker, MD, MBA (in memoriam) Immediate Past President Philadelphia, Pennsylvania Managing Editor Debbie Lancaster Joseph W. Stubbs, MD Secretary-Treasurer Art Director and Illustrator Jim M’Guinness Albany, Georgia Eve J. Higginbotham, SM, MD Designer Erica Aitken Philadelphia, Pennsylvania Holly J. Humphrey, MD Chicago, Illinois Editorial Board Richard B. Gunderman, MD, PhD Indianapolis, Indiana Sheryl Pfeil, MD Jeremiah A. Barondess, MD Faith T. Fitzgerald, MD Stephen J. McPhee, MD Columbus, Ohio New York, New York Sacramento, California San Francisco, California Alan G. Robinson, MD David A. Bennahum, MD Daniel Foster, MD Janice Townley Moore Albuquerque, New Mexico Dallas, Texas Young Harris, Georgia Los Angeles, California John A. Benson, Jr., MD James G. Gamble, MD, PhD Francis A. Neelon, MD Wiley Souba, MD, DSc, MBA Portland, Oregon Stanford, California Durham, North Carolina Hanover, New Hampshire Richard Bronson, MD Dean G. Gianakos, MD William M. Rogoway, MD Steven A. Wartman, MD, PhD Stony Brook, New York Lynchburg, Virginia Stanford, California Washington, DC John C.M. Brust, MD Jean D. Gray, MD Shaun V. Ruddy, MD New York, New York Halifax, Nova Scotia Richmond, Virginia Medical Organization Director Charles S. Bryan, MD David B. Hellmann, MD Bonnie Salomon, MD Griffin P. Rodgers, MD, MBA Columbia, South Carolina Baltimore, Maryland Deerfeld, Illinois National Institute of Diabetes and Digestive and Robert A. Chase, MD Pascal James Imperato, MD John S. Sergent, MD Peterborough, New Hampshire Brooklyn, New York Nashville, Tennessee Kidney Diseases, National Institutes of Health Bethesda, Maryland Henry N. Claman, MD John A. Kastor, MD Clement B. Sledge, MD Denver, Colorado Baltimore, Maryland Marblehead, Massachussetts Fredric L. Coe, MD Henry Langhorne, MD Jan van Eys, PhD, MD Councilor Directors Chicago, Illinois Pensacola, Florida Nashville, Tennessee Lynn M. Cleary, MD Jack Coulehan, MD Jenna Le, MD Abraham Verghese, MD, DSc State University of New York Upstate Medical Stony Brook, New York New York, New York (Hon.) University Stanford, California Ralph Crawshaw, MD Michael D. Lockshin, MD Charles Griffith III, MD, MSPH Portland, Oregon New York, New York Steven A. Wartman, MD, PhD Washington, DC University of Kentucky College of Medicine Peter E. Dans, MD Kenneth M. Ludmerer, MD Gerald Weissmann, MD Mark J. Mendelsohn, MD Baltimore, Maryland St. Louis, Missouri New York, New York University of Virginia School of Medicine Lawrence L. Faltz, MD J. Joseph Marr, MD David Watts, MD Larchmont, New York Broomfeld, Colorado Mill Valley, California Coordinator, Residency Initiatives Suzann Pershing, MD Stanford University

Student Directors www.alphaomegaalpha.org Christopher Clark, MD University of Mississippi Medical School Richard Latuska Manuscripts being prepared for The Pharos should be typed double-spaced, submitted in triplicate, and conform to the format Vanderbilt University School of Medicine outlined in the manuscript submission guidelines appearing on our website: www.alphaomegaalpha.org. They are also available Laura Tisch from The Pharos office. Editorial material should be sent to Richard L. Byyny, MD, Editor, The Pharos, 525 Middlefield Road, Suite Medical College of Wisconsin 130, Menlo Park, California 94025. Requests for reprints of individual articles should be forwarded directly to the authors. The Pharos of Alpha Omega Alpha Honor Medical Society (ISSN 0031-7179) is published quarterly by Alpha Omega Alpha Honor Administrative Office Medical Society, 525 Middlefield Road, Suite 130, Menlo Park, California 94025, and printed by The Ovid Bell Press, Inc., Fulton, Richard L. Byyny, MD Missouri 65251. Periodicals postage paid at the post office at Menlo Park, California, and at additional mailing offices. Copyright Executive Director © 2015, by Alpha Omega Alpha Honor Medical Society. The contents of The Pharos can only be reproduced with the written Menlo Park, California permission of the editor. (ISSN 0031-7179) Circulation information: The Pharos is sent to all dues-paying members of Alpha Omega Alpha at no additional cost. All correspondence 525 Middlefeld Road, Suite 130 relating to circulation should be directed to Ms. Debbie Lancaster, 525 Middlefield Road, Suite 130, Menlo Park, California 94025. E-mail: Menlo Park, California 94025 [email protected] Telephone: (650) 329-0291 Fax: (650) 329-1618 POSTMASTER: Change service requested: Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, E-mail: [email protected] Menlo Park, CA 94025. The Pharos • Volume 78 Number 2 • Spring 2015 In This Issue

DEPARTMENTS On the cover

Alpha Omega Alpha Honor Medical Society Winter 2015 See page 23 Editorial 2 The academic health center in a disrupted world Steven A. Wartman, MD, PhD, MACP

New members of the Pharos 37 editorial board

The physician at the movies 39 Peter E. Dans, MD Unbroken American Sniper ARTICLES Reviews and reflections 43 Being Mortal: Medicine and What Matters in The $6 million physician the End 10 A history of robotics making surgeons better, Reviewed by Dean Gianakos, MD The Health Humanities Reader stronger, faster Reviewed by David A. Behhanum, MD Marc A. Polacco, MD The Birth of the Pill: How Four Crusaders Reinvented Sex and Launched a Revolution Reviewed by William P. Reed, MD 23andWe 46 Letter to the editor 16 How can doctors decode direct-to-consumer genetic testing? 2014 donations to Alpha Omega Melissa Pritchard 48 Alpha Claude Bernard

POETRY 23 A failed playwright Med Students Irving Kushner, MD 29 Richard F. Gillum, MD Stroke Breaking the silence 36 Henry N. Claman, MD 30 N. Karp, MD Hope Springs Eternal 47 Albert I. Kaufman, PhD Inside Back Emesis Cowboy 60Cover Aaron McGuffin, MD 32 Thomas T. McGranahan, Sr., MD

The Doctor Jim Health Plan 34 Joel L. Chinitz, MD

The academic health center in a disrupted world Steven A. Wartman, MD, PhD, MACP

Introduction of providing synergies that are vastly larger than the sum of Richard L. Byyny, MD its individual parts. Academic health centers (AHCs) are, in a Executive Director, Alpha Omega Alpha sense, evolving works-in-progress that innovate continuously At the time of the founding of Alpha Omega Alpha in to meet the challenges and opportunities of twenty-first- 1902, the Flexner Report was still eight years in the future century trends in patient care, education, and research. and the academic health center as we know it today did not Over the past decade, the world of AHCs has begun an exist. These institutions developed as a mid to late twentieth- especially interesting and important transition, sparked by century approach to aligning education and research with the emergence of both unprecedented—often daunting— patient care, and have become critically important to the challenges and exhilarating new opportunities. I believe a medical profession and health care worldwide. Academic new model of the AHC is evolving. AHCs are currently in a health centers have evolved to represent the best in medical prolonged period of “mission disruption”—preserving some care, research, and medical education in the United States. But traditions and jettisoning or transmogrifying others, while what has become the traditional structure of academic health simultaneously forging ahead in wholly new directions. Each centers faces significant challenges in an increasingly hostile AHC’s unique priorities and issues mean that many new budgetary and globalized environment, requiring these insti- models are emerging. Here, however, I will focus on general tutions to find the leadership they need to guide them through and overarching trends that apply broadly to the universe of this period of economic, social, and technological disruption. AHCs. Dr. Steven Wartman, President and CEO of the Association An AHC is an accredited, degree-granting institution of Academic Health Centers, wrote this editorial at my invita- of higher education consisting of a medical school (either tion to explain to members the structure and function of aca- allopathic or osteopathic), one or more other health profes- demic health centers, and to tell us about the challenges they sions schools or programs (e.g., allied health sciences, den- face in the twenty-first century, and the kinds of leadership tistry, graduate studies, nursing, pharmacy, public health, they will need to master these challenges. veterinary medicine), and an owned or affiliated relationship with a teaching hospital or health system.1 AHCs are thus The author (AΩA, Johns Hopkins University School of unique hybrids of business and academics, pursuing simulta- Medicine, 1970) is President/CEO of the Association of neously the business of patient care and the missions of edu- Academic Health Centers, a member of the Board of cation and research. The use of the term “center” to describe Directors of Alpha Omega Alpha, and a member of the what these institutions do is more historical than contempo- editorial board of The Pharos. rary—in reality, AHCs might be better described as “systems” or “networks,” in that they include an expanding geographic n my role since 2005 as president of the Association of range of institutions and facilities that offer many different Academic Health Centers (AAHC)—and building on my kinds of services. prior experience in academic leadership—I have gained There are two prototypical models of the organizational Ia unique perspective about the institutions comprising the structure of AHCs: health-related components of universities. The mission of 1. The fully integrated model, in which academic, clinical, these institutions is to educate the next generation of health and research functions report to one person and one board professionals, conduct cutting-edge basic and clinical re- of directors. search, and provide comprehensive and advanced patient care. 2. The split/splintered model, in which the academic and Their central defining feature is the ability to align education clinical/health system operations are managed by two or more and research with patient care. As such, they are horizontally individuals reporting to different governing boards.2 This focused organizations that aspire to remove the traditional model typically includes a defined contractual relationship boundaries between health professions, schools, specialties, between a medical school and a teaching hospital. departments, and other divisions to create a whole capable Obviously, there are a number of nuances of the two types,

2 The Pharos/Spring 2015 including variations in locating the responsibility for faculty national or international health systems. practice plans and other health system components. At the same time, of course, AHCs are also being buffeted AHCs are vital to their communities, whether they be by broader trends—to cite just a few, these include changes regional, national, or international, fulfilling a broad social in societal needs and values, disease patterns, economic mission. Their three central activities of education, research, trends, globalization, politics, population demographics, and patient care improve health and well-being and expand policy changes, and advancing science and technology. the boundaries of knowledge.3 AHCs train future generations Meanwhile, the day-to-day operations of AHCs are pre- of health professionals in medicine, nursing, public health, and dominantly affected by market consolidation, changes in clini- related disciplines. They develop transformative knowledge cal funds flows, and downward pressures on research funding. through biomedical research that often leads to innovative A recent survey of AAHC members found clear markers of therapies. They deliver a comprehensive range of medical disruption and change: services informed by continuous improvement. In addition, • Forty-one percent are undergoing major expansions of AHCs address the intractable challenges such as rare diseases their hospital or physical network. and threats to public health—including Ebola and HIV—that • Thirty-seven percent are embarking on large-scale cost- otherwise would not receive focused attention.4 Many AHCs reduction measures. serve as safety net institutions, caring for a significant propor- • Thirty-six percent are opening a new health professions tion of the uninsured.5,6 They provide what is often the only school or new branch campus. local source of specialized services, such as burn units and • Thirty-one percent are changing their governance struc- transplant centers, and stand at the forefront of the country’s tures or significant reporting relationships. defense in response to public health outbreaks, natural disas- These dynamic realities challenge or perhaps even upend ters, local crises, and potential terrorist attacks.7 the grand tradition of the “virtuous cycle,” in which the busi- AHCs also serve as powerful economic engines. They em- ness side of academic medicine subsidizes the research and ploy thousands of people, with billions of dollars paid for sala- education functions, while the academic side enhances the ries, research funding, and direct spending.8 The research they margins and reputation of the clinical programs.12 In the face support generates original products and technologies driving of the forces of disruption, however, new realities about health economic growth and benefiting the health and well-being of care must be acknowledged and appropriate new business millions of people worldwide. AHCs are economic anchors of models evolved. their communities and often serve as the nucleus for groups Three trends, among others, are particularly noteworthy as of biomedical industries that grow around them. harbingers of disruption and transformation for AHCs: Clearly, a strong future for AHCs must be secured and sus- 1. New economic realities tained. But to continue to flourish in increasingly competitive 2. The trend towards interprofessional (team) education national and global economies, AHCs must achieve unprec- and practice edented scales of efficiency and agility in their mission areas 3. The evolving relationship of medicine and machine. of education, patient care, and research. The challenges they face have never been more acute. Economic realities Patient care Disruption and transformation* Since the advent of Medicare and Medicaid, AHCs have in- The forces of disruption in medicine today are many. The creasingly relied on clinical revenues to support research and explosion of consumer empowerment created by the internet teaching. This model is unique to the United States. Today, and related technologies challenges the knowledge hegemony this long-standing arrangement is being challenged by changes of caregivers. The “omics” revolution and entrepreneurial ad- in health care delivery and economics. These changes are so vances in health and internet-related technologies is creating disruptive that I euphemistically describe them as creating a a new scale of “personalized medicine.” The long-standing and “new physics” of patient care. With apologies to Dr. Einstein, highly successful U.S. model of biomedical research in AHCs, the following frames my argument for rethinking the way in which clinical revenues subsidize research and teaching, AHCs deliver health care.13 is increasingly fragile given the downward pressures on re- imbursement and lack of real growth in many funding agen- cies, including the U.S. National Institutes of Health (NIH).9 Further, ongoing consolidation within the health marketplace, * Portions of these observations are adapted from my chapter, especially in the United States,10 raises serious concerns about “Academic Health Centers: Future Shock or Future Success?” in reference . the ability of individual AHCs to compete with far larger

The Pharos/Spring 2015 3 The academic health center in a disrupted world

E=mc3 community health care safety nets. To flourish, such AHCs E = emerging model of health care where will need to form new alliances and strategic partnerships, m = population, individually and collectively while still meeting the challenges of preserving and maintain- c3 = c1 = care anywhere ing their fundamental missions. c2 = care in teams Against this complex backdrop, there is no perfect payment c3 = care by large data sets model. As a 2001 paper put it: “There are many mechanisms for paying physicians; some are good and some are bad. The three worst are fee-for-service, capitation, and salary.” 14 The sad truth is that each payment methodology has its flaws: fee- for-service can lead to overuse of health services; capitation can lead to underuse; and salaries can lead physicians to do less work less efficiently. As health systems adapt to new market realities, a hybrid of payment methodologies reflecting health system priorities and political contingencies will evolve. These methodologies will be calibrated according to the degree of risk for popula- tion health that is assumed by the care provider. Being willing to take risks in the first place, and being able to manage risk well, will eventually be defining characteristics of the “new In this tongue-in-cheek model, care anywhere (c1) reflects physics” of patient care. two key trends. First, technological advances allow care to be delivered wherever the patient happens to be, rather than The changing dynamics of research and the future of the keeping it tethered to a hospital or clinic. Second, increas- single-lab funded investigator ingly knowledgeable and informed consumers are seeking Research is rarely a profit center for institutions, either more convenient options for receiving health care. Among academic or commercial. Data collected by AAHC’s Research other implications this means that large infrastructures, such & Analytics program indicate that, on average, external grants as hospitals, while continuing to be necessary, will need to and contracts are the largest funding source for U.S. medical be configured differently as part of systems or networks that schools, and that thirty-five percent of total research expenses expand far beyond their fixed boundaries. are funded using internal funds. Thus, for every one dollar Care in teams (c2) refers to the reality that the once sacro- increase in research expenses funded by external grants and sanct one-to-one doctor/patient relationship is giving way to contracts, U.S. medical schools pay an additional fifty-two patient relationships with multiple kinds of health profession- cents.15 als. In this context, determining how to gain the most value Much of that fifty-two cents has traditionally come from from team care will be crucial. Reimbursement practices will patient care revenues. It is no coincidence that the rise in NIH need to be realigned to support this new model, and the scope funding has been largely paralleled by the rise of non- tenure of practice will likely need careful redesign as interprofes- track clinical faculty. However, as clinical margins shrink and sional health care teams play a much larger role in health care traditionally available resources either lose purchasing power delivery. or become more competitive, institutions in both the public Care by large data sets (c3) suggests that with the rise of and private sectors—as well as international institutions—will Big Data, enormous volumes of information can and will be need to compete aggressively for new sources of research sup- collected for each individual patient, often continuously, re- port. More attention is also being paid to research efficiency quiring fundamental shifts in practices for analysis. Big clini- and research emphases: institutions are increasingly moving cal data sets may yield insights that will transform individual to shared resource models that offer the promise of lower patient care, but will also create challenges in developing best overhead and increased economies of scale. One result is that, practices to manage and operationalize them. A new interpre- for many institutions, it is no longer economically practical to tive and functional infrastructure will be required to manage consider every grant a “good” grant. Rather, institutions are in this remarkable flow of data. This trend is likely to lead to a the early stages of adopting a more business-like approach to new confluence of medicine and machines. R&D, with careful budgeting that focuses on areas of priority. Grants falling outside these focal areas will be scrutinized— Evolving payment models and possibly even declined. Moreover, it is likely that these The market forces driving institutional consolidation and economic forces will drive further differentiation among consolidated provider power particularly threaten AHCs AHCs in the extent and reach of their research portfolios. that serve as comprehensive care providers and often as The image of the brilliant, single-minded scientific

4 The Pharos/Spring 2015 researcher producing astounding insights is indelible. From health care in general, and our growing understanding of the Archimedes to Galileo to Newton to Einstein, the dazzling social determinants of health21 all argue for integrated health accomplishments of lone scientists reinforce society’s precon- care across the full diversity of health care professionals. In ceptions of how science is done. Indeed, the classic model of the United States, the increase in demand for health services the single-lab funded principal investigator has historically by baby boomers over the next several decades suggests that been the backbone of much biomedical research at AHCs. In effective interprofessional care will lead to decreased demand contrast, today’s breakthroughs increasingly derive not from for acute care services. The reality is more likely to be a shift in lone researchers but from teams of scientists collaborating needs for acute care. For example, while the demand for acute across disciplines. That trend, now also seemingly indelible, care of diabetes and hypertension may diminish, the need for has significant implications for AHCs, including for budgeting. care in other critical areas, such as cancer and Alzheimer’s At the same time, other fundamental building blocks in disease, will increase as people live longer. Robust and well- the economics of laboratory research are crumbling. The integrated collaboration among diverse health professionals R01 model is significantly challenged, of course, by erosion will be crucial to meet these health care needs. in NIH funding, both in terms of the decrease in the number And fundamentally, interprofessional health care provides of successful R01 applications—now at record low levels— patients with better access to core provider competencies. and the reality that funding for the NIH overall has not kept Consumers will increasingly demand that such care be acces- pace with inflation and has thus been eroded in general.16 sible as readily as any other service. The ability of the health As if changes in the economics of lab research did not pose care system to provide easy access will require more wide- a significant enough threat to current budgeting practices in spread use and acceptance of interprofessional health care, AHCs, broader factors also apply. The rise of mega data sets, which will lead to increased effectiveness of care, improving combined with the possibilities of cloud- and crowd-sourcing, health care outcomes and quality, while lowering costs. point to control of research beginning to shift from tightly contained, peer-reviewed mechanisms to a more open frame- Barriers to interprofessional health professions education: work. With the possibility of data aggregation open to individ- A baseball metaphor uals through new medical apps and body sensors, for example, As they develop and enhance their interprofessional educa- patients may choose to consult millions of their peers rather tion programs, AHCs will need to master new electronic and than participate in clinical trials. Finally, the public in general, digital education platforms to help develop interprofessional and legislators in particular, are increasingly impatient for teams. New teaching modalities such as the “flipped class- research results—factors that affect not just funding but also room” add important alternatives to problem-based learning public opinion about research. Each of these trends creates its and other standard methodologies.22 While information over- own innate and potentially truly significant impact on AHCs. load in curricula is not a new problem, what and how to teach Budgeting for research in AHCs has not yet definitively have become increasingly difficult and important questions, shifted to a model based on team science. AHCs still mostly especially since today’s students will probably still be practic- design budgets and allocate space based on the increasingly ing medicine in 2050. inefficient construct of a lone R01-funded investigator heading In participating in discussions on interprofessional educa- up his or her single-PI lab. Can such research effectively meet tion, I have often reflected on the barriers to practicing it. the evolving economic, socio-political, and big science im- One conversation on the topic occurred during the World peratives? In short, the rise of team science coupled with the Series, and started me thinking about these impediments in economic realities of supporting research is a game-changer terms of baseball. Too often, those of us seeking better ways for the traditional science paradigm of AHCs. This challenging to integrate interprofessional education and practice spend issue demands profound thinking and hard decisions, includ- inordinate energy pursuing home runs: trying to develop ing deep scrutiny of long-held assumptions. the large-scale fixes that will solve many things all at once. Maybe our attention would be more productively focused on Health care teams: The need for interprofessional incremental fixes: to round the bases one by one, addressing education and practice17, 18, 19 challenges incrementally in ways that might eventually result The new physics of patient care points to care increasingly in more wholesale reform. delivered by interdisciplinary teams. AHCs need to organize Let’s call first base the “guild mentality” of the health and manage their health centers to maximize the value of professions. We silo health care disciplines, which not only input and collaboration across the full diversity of health care divides health practitioners and knowledge, but creates com- professionals. Indeed, across medicine writ large, a strong petition and duplication where today we urgently need col- business case can be made for interprofessional health care.20 laboration and efficiency. The guild mentality inhibits an Worldwide, the increasing predominance of non- integrated, interdisciplinary approach to a full spectrum of communicable diseases, the pressing need for better access to health care and population health. To get beyond first base, we

The Pharos/Spring 2015 5 The academic health center in a disrupted world

need to develop strategies that overcome the attitudes and be- integration of interprofessional education and practice. liefs that get in the way of true interprofessional learning and Scoring is the ultimate goal. In the area of interprofes- practice and that arbitrarily divide health care professionals. sional education and practice, however, reaching home plate On second base, we need to carefully review current uni- is perhaps the most formidable task. This involves aligning versity and hospital structures and procedures. Traditionally, the incentives of the health care delivery system to support professions, disciplines, hospitals, and health systems are and promote the kind of system we would like to envision. It separated administratively into departments and other units, is becoming readily apparent that interprofessional education each with its own schedules, operating principles, and poli- and practice will serve an increasingly important role in health cies—such as those for promotion and tenure—that deeply im- care in the years ahead. It is therefore incumbent upon AHCs pact behavior. As well, they often compete with each other for and health systems to begin an organized process of aligning limited resources. The lack of alignment between management curricula and policies to support and nurture true collabora- and infrastructure thus drives a wedge between types of pro- tion among health practitioners at all levels. The “four bases” fessionals. How can we restructure institutions to ensure better scenario described above, which considers the guild mentality integration and alignment? Addressing that challenge would of the health professions, university policies and procedures, move us that much farther along a path to broader reform. accreditation and regulatory bodies, and the incentives of the health care system, offers an approach to this important and challenging issue.

Medicine and machines: Toward a new paradigm of University professional intelligence Structure The practice of medicine is increasingly taking place at the nexus of patients and machines. From diagnosis to rapid data analysis and robotic surgery, computer-assisted advances are transforming the delivery of health care. Couple that with patients’ expanding access to medical information on the internet, and the traditional role of health providers is challenged. The doctor may no longer be the principal Regulation/ Guild Accreditation Mentality expert and possessor of unique skills. Machines are fun- damentally changing the nature of the provider-patient connection—and, ultimately, what it means to deliver health care. The profession needs to refine its thinking about the intensifying marriage of medicine and machine. Foremost is the issue of how the physicians being trained today will develop the expertise needed for the future. Health Currently we educate and train health professionals quite well System for practice as it was, and less well for how it is and will be. The curriculum now needs to focus on the development of a new kind of proficiency that I call professional intelligence, defined as the confluence of professional values and expertise. The curriculum for professional intelligence has yet to be written, but we need to get started. It needs to acknowledge that no human can effectively process the exploding volume Third base addresses the dizzying variety of regulation and of medical knowledge and data, as well as the implication that accreditation requirements for various health professions. machines will know more and be able to perform more tasks Licensure requirements, scope of practice laws, accreditation than physicians. Scientific and technological advances are al- requirements, and other regulations complicate coordination ready creating devices that out-perform human capacity both and collaboration across professions. Such strictures limit, cognitively and physically. Computer algorithms, for example, for example, who is qualified to serve as an educator. They offering rapid analyses and suggesting both diagnostic and overburden some clinicians and undervalue others. Generally, therapeutic possibilities, far out-perform what a human expert the lack of coordination and consistency among regulators can review to reach a reasonable decision.23 and accreditors impedes the efficient delivery of health care. The pressing need to instill a new form of professional in- A deep look at this body of regulations with reform in mind telligence in our students and trainees demands that we accel- would greatly facilitate the process of moving us closer to true erate the preparation of students in the health professions for

6 The Pharos/Spring 2015 practice as it will be. It is not surprising that health professions Similarly, candidates with a high level of narcissism and/or schools concentrate more on training for the development of arrogance may be perceived—incorrectly—as well suited for skills and competence than expertise. Skill is the ability to per- the job. A charismatic personality may obfuscate a candidate’s form a concrete act, and competence is the level at which you actual managerial and administrative capabilities. In the quest are able to perform that skill. Expertise, however, refers to the for top-level talent, therefore, those participating in the search ability to see the big picture, to understand all the unique ele- process should be advised about the importance of distinguish- ments involved, and to draw appropriate conclusions. While ing confidence from competence. many skills and competencies will eventually be largely taken over by machines, expertise is uniquely human. Changing the dim view of leadership Faculty often have the vague impression that the administra- The leadership imperative tion (the “suits”) is adversarial to the academic ethos. Part of Clearly, the challenges and emerging opportunities that the problem is that there is insufficient understanding of what AHCs face—and will face—underscore the importance of hir- leadership actually entails. Faculty may believe that the leader is ing, nurturing, and supporting exceptionally capable leaders. “sitting on a pile of money and not giving me any of it.” Because Making high-level appointments at academic institutions is of the lack of deep comprehension of and appreciation for the arguably one of the most important actions to be undertaken. leadership role, faculty members do not often seek leadership In working with and visiting more than 100 AHCs, however, positions, but may find themselves becoming “accidental lead- I have found that identifying and keeping high quality leaders ers” when they happen to be appointed. As a result, there is not is extraordinarily challenging. Too often, and too regularly, a clear preparatory pathway to obtaining leadership positions. AHCs find themselves wondering how to reach the next level, Academic administration needs to be “demystified” through and searching, yet again, for new talent to fill key leadership open and transparent leadership styles that clearly demonstrate positions. the realities and challenges of leadership, along with the devel- In part, the problem is often attributable to two types of opment of programs (e.g., leadership academies) to promote the lapses: lack of understanding of the characteristics of success- development of effective leaders. ful leaders for these complex institutions, and breakdowns in the recruitment process itself. Through a collaborative Finding successful leaders effort with academic health center leaders and leading search Broadly speaking, search processes for institutional leaders firm executives, the AAHC has analyzed the search process have been only intermittently successful. In part, this is due to in depth and made a series of recommendations to improve a lack of detailed organization for the search itself and the lack the likelihood of a successful outcome. These suggestions of a “pathway” to becoming an AHC leader. apply broadly for searches, not just in AHCs but throughout Ideally, a search process consists of three distinct phases and academe.24 proceeds in an orderly and efficient manner. • Phase I, the pre-search phase, establishes the principles Defining successful leaders and foundation for a successful search. Being a successful academic does not mean someone can • Phase II, the active search phase, involves screening, inter- be a successful leader. While a strong academic track record viewing, and ultimately selecting the final candidate. is often an important prerequisite for top leadership posts in • Phase III, the transition/on-boarding period, introduces AHCs, other factors—such as humility and emotional intel- the successful candidate to the institution and is designed to ligence—may be as important, or even more important, to help the new hire adapt successfully to his or her new role. successful leadership in these institutions. The path forward The landscape of disruption and change has many ramifi- Academic Skills Leadership Skills cations for AHCs. Clearly, these challenges call for a strong, Intellectual capacity Emotional intelligence definitive course of action. That mandate will be no less de- manding over the next decade. In this regard, I believe AHCs Narrow knowledge base Broad range of topics must get back to fundamentals, using as a guide the answers to Strong work ethic Strong work ethic two essential questions: Self-motivated Institution-motivated • How best can we apply knowledge to improve health and well-being? Gets individual results Gets institutional results • How best can we build the knowledge economy and apply Rises up the academic Manages 360° it in patient care? ladder The answers will both serve as a general approach as the institution moves forward in a disrupted landscape and provide

The Pharos/Spring 2015 7 The academic health center in a disrupted world

the backdrop for the specific actions that need to be taken. Six 5. Be willing to change steps seem particularly warranted: A disruptive environment poses something of an existential 1. Find the best mission balance. problem for AHCs. Writer Clay Shirky addressed the heart 2. Adjust to changing funding streams. of this dilemma when he noted “Institutions seek to preserve 3. Develop an integrated interprofessional vision. the problem to which they are the solution.” 26 To meet the 4. Broaden the understanding of what AHCs encompass. challenges of constrained resources, for example, AHCs must 5. Be willing to change. transform the way they teach, conduct research, and deliver 6. Find visionary leaders skilled in the art of change patient care. But how do they shake loose their insular, siloed management. traditions to change their culture and behavior? A large part of the answer is to have visionary leaders who are skilled in the art 1. Find the best mission balance of change management. I believe each AHC must decide its own best mission bal- ance, emphasizing areas in which it can make the most differ- 6. Find visionary leaders ence and greatest contributions. Once it makes a decision, it AHCs need to find the kind of leadership that can guide must budget accordingly, preparing for the end of open-ended them through disruption. These leaders need to be highly funding and developing methodologies and tools to assess and skilled in transactional operations, but they also need to be able improve efficiency, especially in the area(s) on which it chooses to envision how to help transform their institutions and reposi- to focus. tion them. Bold new thinking is necessary not only to foresee what new kinds of leadership are needed, but to rethink the 2. Adjust to changing funding streams processes AHCs are using to recruit tomorrow’s leaders. As dis- AHCs must find new ways to optimize efficiency, includ- cussed earlier, the specific identification of leadership abilities is ing clear and delimited resourcing of research and teaching. essential, along with a search process designed to optimize the New methodologies to assess efficiency in all mission areas chances of a successful outcome. are needed. Difficult questions need answers, such as what is meant by research and education full-time equivalents (FTEs). Concluding remarks Institutions will also need to establish how much they are will- AHCs will be well-positioned for success if they can success- ing to invest for optimization in both current and new areas. fully achieve three overarching strategic goals: Business models need to be adapted to the operational im- 1. Function as organizations that align academics (teaching plications of the changing clinical care delivery and payment and research) with the care of patients. systems. 2. Focus on the next generation of education, research, and patient care. 3. Develop an integrated interprofessional vision 3. Have the transformational leaders necessary to change To thrive in an era of disruption and change, an AHC needs culture and behavior. to pursue strategies that capture the combined power of its AHCs are in the process of transforming themselves to meet component parts, largely through bringing disciplines together ever-changing societal needs and priorities, while dealing with in purposeful alignment. evolving health care delivery and economic conditions in the midst of rapid scientific, technologic, and pedagogic advances. 4. Broaden the understanding of what AHCs encompass As they do so, I am confident that they will ultimately be suc- Fundamentally, AHCs need to expand the scope of their cessful and lead the way in educating a new generation of health mission, shifting from a focus on management of individual professionals, making scientific breakthroughs that offer new patients to management of community and population health— diagnostic and therapeutic modalities, and providing cutting- locally, regionally, nationally, and globally. This includes the edge patient care—all with the goal of improving health and need for AHCs to address the social determinants of health as well-being. a critical part of improving health and well-being.25 Including expertise from disciplines previously thought of as external, Acknowledgments such as engineering, business management, and the social sci- I would like to acknowledge the editorial assistance of Stephen Pelletier ences, would provide both immediately applicable benefits and and the proofreading of Lynn Bentley. tools that can catalyze system change. Broadening the scope of interdisciplinary thinking in this way could lead to potential References advances in effective system redesign, medical device develop- 1. Association of Academic Health Centers. Academic Health ment, and advancing population health. Centers: Defined. http://www.aahcdc.org/About.aspx. 2. Wartman SA. The Academic Health Center: Evolving Or- ganizational Models. Washington (DC): Association of Academic

8 The Pharos/Spring 2015 Health Centers; 2007. Available at: http://aahci.org/policy/reddot/ aspx. AAHC_Evolving_Organizational_Models.pdf. 16. Boadi K. Erosion of funding for the national institutes of 3. Wartman SA. Academic health centers: The compelling need health threatens U.S. leadership in biomedical research. Center for recalibration. Acad Med 2010; 85: 1821–22. for American Progress; 2014 Mar 25. Available at: https://www. 4. Task Force on Academic Health Centers. Envisioning the americanprogress.org/issues/economy/report/2014/03/25/86369/ Future of Academic Health Centers. New York: The Commonwealth erosion-of-funding-for-the-national-institutes-of-health-threatens- Fund; 2004. Available at: http://www.commonwealthfund.org/~/me- u-s-leadership-in-biomedical-research/. dia/files/publications/fund-report/2003/feb/envisioning-the-future- 17. Mitchell P, Wynia M, Golden R. et al. Core Principles & Val- of-academic-health-centers/ahc_envisioningfuture_600-pdf.pdf. ues of Effective Team-Based Health Care. Discussion paper, Institute 5. Cunningham P, Felland L. Environmental Scan to Identify the of Medicine. Washington (DC): National Academy of Sciences; Major Research Questions for Monitoring the Effects of the Afford- 2012. Available at: http://www.iom.edu/~/media/Files/Perspectives- able Care Act on Safety Net Hospitals. Washington (DC): Center for Files/2012/Discussion-Papers/VSRT-Team-Based-Care-Principles- Studying Health System Change; 2013. Available at: http://aspe.hhs. Values.pdf. gov/health/reports/2013/SafetyNetEnvScan/rpt_ACA_and_Safety_ 18. Josiah Macy Jr. Foundation. Transforming Patient Care: Align- Net_20EnvScan.pdf. ing Interprofessional Education with Clinical Practice Redesign. New 6. Task Force on Academic Health Centers. A Shared Responsi- York: Josiah Macy Jr. Foundation; 2013. Available at: http://macy- bility: Academic Health Centers and the Provision of Care to the Poor foundation.org/docs/macy_pubs/TransformingPatientCare_Confer- and Uninsured. New York: The Commonwealth Fund; 2001. Available enceRec.pdf. at: http://www.commonwealthfund.org/~/media/files/publications/ 19. Patient-Centered Primary Care Collaborative. Progress and fund-report/2001/apr/a-shared-responsibility--academic-health- Promise: Profiles in Interprofessional Health Training to Deliver centers-and-the-provision-of-care-to-the-poor-and-uninsured/ahc_ Patient-Centered Primary Care. Washington (DC): Patient-Cen- indigentcare_443-pdf.pdf. tered Primary Care Collaborative; 2014. Available at: https://www. 7. Institute of Medicine Committee on the Roles of Academic pcpcc.org/resource/progress-and-promise-profiles-interprofessional- Health Centers in the 21st Century. Academic Health Centers: health-training-deliver-patient-centered. Leading Change in the 21st Century. Washington (DC): National 20. Knettel A. Making the business case for interprofessional Academic Press; 2004. Available at: http://www.nap.edu/openbook. education and training. Washington (DC): Association of Academic php?record_id=10734. Health Centers; 2011. Available at: http://www.aahcdc.org/Policy/ 8. Association of American Medical Colleges. The Economic PressReleases/PRView/tabid/85/ArticleId/99/Making-the-Business- Impact of AAMC-Member Medical Schools and Teaching Hospitals. Case-for-Interprofessional-Education-and-Training.aspx. Washington (DC): Association of American Medical Colleges; 2012. 21. Marmot M, Wilkinson R, editors. Social Determinants of Available at: http://www.aamc.org/download/326478/data/trippum- Health: The Solid Facts. Second edition. Geneva (Switzerland): bachcorrected.pdf. World Health Organization; 2003. Available at: http://www.euro.who. 9. Howard DJ, Laird FN. The new normal in funding univer- int/__data/assets/pdf_file/0005/98438/e81384.pdf. sity science. Issues Sci Technol Fall 2013. Available at: http://issues. 22. EDUCAUSE. 7 things you should know about flipped class- org/30-1/the-new-normal-in-funding-university-science/. rooms. EDUCAUSE; 2012. Available at: https://net.educause.edu/ir/ 10. Tsai TC, Jha AK. Hospital consolidation, competition, and library/pdf/ELI7081.pdf quality: Is bigger necessarily better? JAMA 2014; 312: 29–30. 23. Cummings ML. Disruptive innovation, technology, and the 11. Wartman SA. Academic Health Centers: Future Shock or future of healthcare. Presented at the Association of Academic Health Future Success? In: Wartman SA, editor. The Transformation of Centers 2013 Annual Meeting: Technology and the Transformation of Academic Health Centers: Meeting the Challenges of Healthcare’s the Academic Health Center. September 25–27, 2013. Changing Landscape. Waltham (MA): Elsevier; 2015. 24. Wartman SA. Searching for Leadership: Best practices for 12. Wartman SA. Toward a virtuous cycle: The changing face of academic institutions. Washington (DC): Association of Academic academic health centers. Acad Med 2008; 83: 797–99. Health Centers; 2014. 13. Inspired by this TED talk: Dishman E. Health care should be a 25. Marmot M. Social determinants of health inequalities. Lan- team sport. TED.com; 2013. Available at: https://www.ted.com/talks/ cet 2005; 365: 1099–1104. eric_dishman_health_care_should_be_a_team_sport?language=en. 26. Kelly K. The Shirky Principle. The Technium; 2010. http:// 14. Robinson JC. Theory and practice in the design of physician kk.org/thetechnium/2010/04/the-shirky-prin/. payment incentives. Milbank Q 2001; 79: 149–77. Available at: http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2751195/pdf/milq_202.pdf. Dr. Wartman’s address is: 15. Association of Academic Health Centers. How Much Does Association of Academic Health Centers Research Cost? Three Key Findings for U.S. Medical Schools. Asso- 1400 Sixteenth Street, NW, Suite 720 ciation of Academic Health Centers; 2014. Available at: http://www. Washington, DC 20036 aahcdc.org/Resources/BenchmarksandMetrics/TheCostofResearch. E-mail: [email protected]

The Pharos/Spring 2015 9 Illustrations by Anne and Bruno Vaes. Da Vinci Robot courtesy of Bayshore Womens Healthcare.

10 The Pharos/Spring 2015 The $6 million physician A history of robotics making surgeons better, stronger, faster

Marc A. Polacco, MD The author is an intern in Otolaryngology at Dartmouth- hospital for recovery—his group recognized the potential for Hitchcock Medical Center in Lebanon, New Hampshire. This robotics to improve the procedure and patient care.6 paper won an honorable mention in the 2014 Helen H. Glaser They started with a system commercially available at Student Essay Competition. the time, the Unimation Programmable Universal Machine for Assembly (PUMA) 200, a descendant of Devol’s and he idea of an inorganic creation Engleberger’s original Unimation robot. The procedure in- capable of performing actions au- volved attaching a stereotactic frame to the patient’s head and tomatically for a master can be obtaining CT images, followed by attachment of the robot to Ttraced back at least as far as ancient Greek the frame, which could then be calibrated using the CT images mythology. It was said that Hephaestus, to orient the probe toward the target lesion. The device kept the god of fire, forged two gold handmaid- the probe aligned with the target lesion as the surgeon changed ens that could speak.1 The term “robot” did the position of the apparatus to avoid hitting blood vessels and not appear until 1921, when it was coined by Karel critical anatomical structures. By maintaining alignment with Capek for his play, Rossum’s Universal Robots.2 the lesion at all times, the system ensured an improvement in Derived from robota, a Czechoslovakian word mean- accuracy of the biopsy site. ing “work,” the word was used to describe machines cre- Like any new technology, the system had to be tested before ated to replace repetitious and mundane human tasks. The play being used on human subjects. In a research study that would veered in a sinister direction when, similar to Mary Shelley’s surely have captured the attention of youngsters, Kwoh and his Frankenstein, the creations gradually became more powerful team used the robot to locate copper-coated BBs placed inside and independent, eventually turning on the humans who made watermelons, performing the task with a one millimeter error them. Although centuries old in concept, robots are still a for each spherical pellet retrieved. The target practice paid off popular subject that captures the imaginations of people today, though, as the first attempt at using the system to assist in a from the cute, environmentally friendly protagonist of WALL-E, brain biopsy was successful, using only local anesthesia. Dr. to the nefarious Decepticons depicted in Transformers. Ceverha, the neurosurgeon who performed the procedure, later It was not too long after Capek’s play that the concept of said in an interview that robot-assisted surgery was “another robots—albeit lacking the humanoid appearance of those in adjunct to the vast number of techniques we have for treating the play—began to move beyond science fiction and imagina- people. I don’t think it will revolutionize neurosurgery, but its tion to that of feasibility and practical application. In 1954, applications are probably limited by human imagination.” 5 George Devol and Joe Engleberger designed the first program- mable hydraulically driven robotic arm. Seeing a commercial Prostates and potatoes potential for their invention, in 1961 they founded Unimation John Wickham, MD, a prominent figure in the field of and began producing robots for industrial use, the automo- urology, was one of the pioneers in developing endoscopic tive industry being among their first clients.3 It was not until techniques for treating kidney stones. He is often credited with the 1980s, however, that surgery began to make use of robotic coining the ubiquitous term “minimally invasive surgery.” In technology. Despite a relatively short life in medicine thus far, 1988 at the Imperial College of London, he collaborated with surgical robots have become a billion-dollar industry in a range Brian Davies, PhD, to develop a robot to assist in a transurethral of specialties from gynecology to otolaryngology.4 resection of the prostate (TURP), a procedure commonly used to alleviate urinary difficulty in patients with benign prostatic Target practice hyperplasia.7 The year was 1985. While technology was invading house- There were several reasons why the group felt that a ro- holds all across America via the Nintendo Entertainment bot would be ideal for performing a TURP.8 The procedure System, Dr. Yik San Kwoh, the director of research in the radiol- required passing a resectoscope through the urethra to reach ogy department at Long Beach Memorial Medical Center, had the prostate, followed by repeated conical resections of tis- a problem that he thought robotics could solve.5,6 Performing sue, a maneuver a robot could potentially perform reliably stereotactic brain biopsies was time-consuming, at times in- with accuracy. The procedure at the time took approximately accurate, and required the patient to stay several days in the an hour to complete, with the surgeon in an uncomfortable,

The Pharos/Spring 2015 11 decade. There were three key players in the beginning: the Stanford Research Institute (SRI), the National Aeronautics and Space Administration (NASA), and the Defense Advanced Research Projects Agency (DARPA).11 Joseph Rosen had not always been interested in medicine.12 In fact, as a child he wanted to be an artist and was particu- larly fond of Picasso. But as a freshman at Cornell, he built a robotic hand programmed to crack lobster shells, and from there he delved further into robotics and continued to be fascinated with joints. Building on his interests in human anatomy and art, Rosen eventually decided to attend medical school, and completed residency training in plastic surgery at Stanford in the early 1980s. During his plastic surgery training, he developed a particular interest in hand microsurgery, and he saw the potential for robotics to aid in a field involving the tiniest manipulations of nerves and blood vessels. With this goal in mind, he collaborated with Philip Green, restricted position for the duration of that hour, multiplied by an engineer at SRI, to develop a robot that would produce the however many TURP procedures were scheduled for the day. minute manipulations required for microsurgery as the surgeon Wickham and Davies also used the PUMA system and simi- controlled it remotely from an operating console, a concept larly used food as a test subject, practicing many initial resec- known as telesurgery. tions on potatoes. Once the troubleshooting and programming While working on their system, the team at SRI met Scott had been largely completed, the robot was able to make conical Fisher, PhD, who was working with a team at the NASA Ames resections with radii within 1.5 mm of the specifications, an ac- Research Center in the development of virtual reality, interac- curacy comparable to that of a human surgeon. Furthermore, tive three-dimensional environments. The two teams decided the robot was able to carve out the pieces in a staggering five that they would work together to create a two-part system. The minutes, turning an hour-long endeavor into the duration of a team at Stanford would design a pair of gloves that would re- coffee break.9 cord the surgeon’s hand movements and control the robot arms, They named their creation the Probot. However, despite the while the team at NASA would create a head-mounted virtual speed and accuracy the Probot provided, the device required reality display to provide a three-dimensional rendering based eight degrees of freedom to complete the resection, raising on cameras located on the robot. Technological limitations concerns about the potential to cut structures other than required the teams to scale back the complexity of the system, the prostate. A misstep could lead to excessive blood loss or, opting for a controller instead of gloves, and a standard monitor worse yet, nerve damage, resulting in irreversible complica- instead of a head-mounted device. The final result was similar tions such as loss of bladder control or impotence. To address in concept to a video game console, with a controller used to this safety concern, the team developed a ring placed around manipulate the events on a screen. the Probot arm, limiting the movements of the cutting tool. It The third member of the development team, Richard Satava, took three years of hard work and numerous visits to the local MD, was a general surgeon in the Army. He had just re- grocery store, but in 1991 the Probot was used in the very first turned from the 1989 Society of American Gastrointestinal robotically assisted TURP. This achievement paved the way for Endoscopic Surgeons conference, at which he had watched a robotics in urology, which has expanded to include a variety of video of Jacques Perrisat performing the very first laparoscopic complex procedures, from cystectomies (removal of the blad- cholecystectomy, a common procedure today.14 Dr. Satava im- der) to pyeloplasties (reconstruction of a kidney component mediately imagined the potential for robotics to extend the that helps the organ drain).10 possibilities of minimally invasive surgery. Although the team continued to develop the robotic system with the intention of Big ideas, small beginnings addressing hand microsurgery and other open techniques, the Perhaps the most well-known robotic surgery system in possibility of using the device to perform laparoscopic surgery use today, the development of the da Vinci robot (Intuitive was yet another avenue to explore. Surgical, Inc., Sunnyvale, California) is a tale of multi- By the early 1990s, the team had performed a demonstration institutional collaboration and innovation spanning over a for a bowel anastomosis using their system, which catapulted

12 The Pharos/Spring 2015 Dr. Satava to the position of program manager for Advanced About Marc Polacco Biomedical Technologies at DARPA. He was now in charge Hailing from Minnesota, I gradu- of a project to develop a robotic system for performing open ated from Gustavus Adolphus College in surgery on wounded soldiers during transport to a Mobile 2010 where I studied biology, chemistry, Advanced Surgical Hospital. As many as ninety percent of and music. I am grateful to have had the deaths on the battlefield occurred before transport, often due opportunity to devote four years at the to hemorrhage.13 It was hoped that a robot controlled by a sur- University of Iowa to medical school and geon miles away from a combat zone could be used to perform am currently an otolaryngology resident at Dartmouth- initial wound treatments and slow or stop blood loss, signifi- Hitchcock Medical Center. Interestingly, I have since cantly decreasing casualties. Development on the project was operated with Dr. Rosen, whose knack for teaching is halted because the close-quarters combat in urban war zones just one among his many talents. Although residency is limited the utility of a mobile surgical robot. Dr. Satava’s work time-consuming, I make an active effort to stay balanced was not without benefit, however, as the telesurgery system through pursuits in music, writing, and art. caught the eye of Dr. Frederick Moll. The year was 1994.

It’s just business Dr. Moll was a surgical resident at the Virginia Mason applied to his goals of enhancing minimally invasive surgical Medical Center in Seattle in the early 1980s when he became technology. interested in the inadequacies of surgical tools.15 He had al- In 1995 Dr. Moll founded Intuitive Surgical and the company ways thought incisions were unnecessarily large and invasive, began to rework the telesurgery concept, developing prototypes but after observing gynecologists using laparoscopic tools for for what would eventually become the da Vinci. Each prototype sterilization procedures, he found the courage to leave his was named in honor of the famous Italian polymath, begin- residency program to find a way to bring minimally invasive ning with the Lenny, moving on to the Leonardo, and then the technology to general surgery. Leaving Washington and the Mona. The Mona boasted seven degrees of freedom deriving rain behind him, Dr. Moll headed for Silicon Valley, where he from wrist-like mechanics at the end of each robotic arm, al- earned a graduate degree in management at Stanford and be- lowing the surgeon to make a variety of maneuvers with relative gan delving into the medical equipment business. It was at this ease. Furthermore, the system used haptic technology (tactile time that Dr. Moll met Dr. Satava and learned of his telesurgery feedback) to give the surgeon a more realistic representation of program. Although Moll saw little future commercial potential the forces being applied and tension on the tissues. And unlike for long-distance surgery, he thought that the concept could be the two-dimensional visuals provided by the camera in manual laparoscopic surgery, the combination of the surgeon console and robotic camera used with the Mona allowed for three- dimensional visualization of the surgical field. On March 3, 1997, Mona was used to perform the very first cholecystectomy using a robotic system, sending a wave of excitement through both the medical and robotics fields.13 Then in 1999, when much of the technology world was bracing for the problems that the Y2K bug was expected to bring, the Mona was used to complete a 200-patient clinical trial to demonstrate safety for a cholecystectomy and a Nissen fundoplication, a procedure in which the upper part of the stomach is wrapped around the lower end of the esophagus and su- tured in place, helping the lower esophageal sphincter to close and reducing acid reflux for the patient. In 2000, the next generation model, da Vinci, was approved by the Food and Drug Administration.13 This version of the robot consisted of three parts: the sur- geon console, the patient trolley, and the imaging system. The surgeon console was somewhat reminiscent of an arcade cabinet both in relative size and by the familiar combination of a screen, joysticks, and foot pedals. The patient trolley (the robot unit) consisted of three arms, one for the camera and the other two for using

The Pharos/Spring 2015 13 The $6 million physician

a variety of interchangeable surgical instruments such as scal- Technological upgrades have certainly improved the capa- pels, scissors, and electrocautery. The final piece, the imaging bilities of the da Vinci, but its wide use across medical special- system, was a tower comprised of a light source, an insufflator, ties has had a much more significant impact on expanding the a dual camera, and a monitor sitting at the top that displayed scope of what the machine can do. Although the initial tasks the surgical image for other operating room personnel and of the da Vinci were to assist with laparoscopic procedures of observers. the abdomen and coronary artery bypass grafts, physicians in surgical specialties as diverse as urology, gynecologic oncology, Da Vinci today and otolaryngology have developed ways of using the da Vinci Since 2000, there have been multiple updates to the da Vinci to enhance procedures. system. In 2003, models with a fourth arm were introduced, About ten years ago in the field of urology, an explosion of allowing the surgeon to hold an extra instrument, thus saving studies showed how the da Vinci could be applied to procedures time by having to switch instruments less often. Soon after, two including removal of the prostate, kidney, or bladder.16 The more models were developed, the da Vinci S in 2006 and the da versatility displayed by the da Vinci has inspired urologists to Vinci Si in 2009. The da Vinci S was marketed based on having continue to push the envelope and strive to expand the system’s a high definition display, enabling the surgeon to have clearer repertoire. visualization of the operating field. The da Vinci Si brought In gynecologic oncology, laparoscopic tools were first used the advantage of two surgeon consoles. Not only did this allow to visualize pelvic anatomy as a diagnostic procedure in the the surgeon to have an assistant, but it also facilitated teaching 1960s, and this progressed to using the technology for pelvic resident physicians how to use the system. Finally, this year the surgeries such as hysterectomies. With minimally invasive FDA approved the da Vinci Xi model, which was designed to surgery already well established in their field, gyncologic on- increase operative flexibility with its thinner arms now situated cologists thus took to using the da Vinci fairly quickly, and overhead. the FDA approved the system for certain pelvic procedures in 2005. Today gynecologic oncologists are among the da Vinci’s most frequent users, and in 2010 alone more than 1200 of these specialists were trained to use the robot platform for pelvic surgery.17 Head and neck surgeons, too, have developed ways of uti- lizing robot surgery. A testament to the versatility of the da Vinci, in 2006 clinical studies completed at the University of Pennsylvania showed that it was safe and effective to use the robot to perform transoral resections of certain tumors of the head and neck region. Otolaryngologists have found that the da Vinci allows for better visualization and an enhanced range of motion for tumor resections in the small operating field around the mouth. The FDA approved transoral robotic surgery (TORS) in 2009.4

Costs versus benefits Despite the widespread use of robot-assisted surgery, some physicians are concerned about whether the medical community has adopted the new technology too quickly. The benefits of robotic surgery most commonly cited in- clude smaller incisions, less pain, shorter hospital stay, faster return to performing daily activities, less blood loss, and an improved cosmetic outcomes. But the da Vinci costs about 1.4 to 2.2 million, plus 100,000 to 200,000 for annual maintenance contracts, and 1,000 to 2,000 for disposable robotic instru- ments that must be replaced after each case.16 In addition, most robotic procedures take longer than their laparoscopic counterparts because of set- up time, driving costs up even further. Determining whether the benefits from robotic surgery are

14 The Pharos/Spring 2015 worth these costs has been a challenge. Assuming the cost to lization. New York: Oxford University Press; 2003. the patient remains reasonable, from the patient perspective 2. Capek K. Rossum’s Universal Robots. New York: Doubleday; robotic surgery is a positive. However, there are many more 1923. factors at play. Insurance companies and health care providers 3. Camarillo DB, Krummel TM, Salisbury JK. Robotic technol- want evidence that the patient benefits are real and come at a ogy in surgery: Past, present, and future. Am J Surg 2004; 188 (Suppl feasible cost to the hospital instead of being clever marketing. Oct 2004): 2S–15S. Most early studies reported ambiguous results; many hospitals 4. Rinaldi V, Davide P, Torretta S, Pignataro L. Transoral robotic that had nevertheless hastily adopted the new technology made surgery in the management of head and neck tumors. ecancer 2013; meager profits or even lost money. 7: 359. Now that more physicians are trained on and experienced 5. Blakeslee S. A robot arm assists in 3 brain operations. New with the technology and patient volumes are higher, many York Times 1985 Jun 24. http://www.nytimes.com/1985/06/25/ hospitals are reporting results comparable to or improved from science/a-robot-arm-assists-in-3-brain-operations.html. traditional approaches, with the caveat that the benefits of using 6. Kwoh YS, Hou J, Jonckheere EA, Hayati S. A robot with im- the robot are dependent on the procedure being performed and proved absolute positioning accuracy for CT guided stereotactic brain the operating experience of the surgeon.18 surgery. IEEE Trans Biomed Eng 1988; 35: 153–60. 7. Hodgson D. Standing on the shoulders of giants: 3. John Limited by human imagination Wickham based on an interview 7/11/2009. Br J Med Surg Urol 2012; Regardless of debates about the benefits versus shortcom- 5: 111–14. ings of robotic surgery, history indicates that there will be 8. Harris SJ, Arambula-Cosio F, Mei Q, et al. The Probot—an no slowing in adopting new technologies to improve surgical active robot for prostate resection. Proc Inst Mech Eng H 1997; 211: procedures and patient outcomes. The da Vinci is already over 317–25. a decade old, practically ancient in the tech world. Newer ad- 9. Gomes P. Surgical robotics: Reviewing the past, analysing the ditions include the Sensei (Hansen Medical, Mountain View, present, imagining the future. Robot Comput Integr Manuf 2011; 27: California) and the Niobe (Stereotaxis, St. Louis, Missouri) 261–66. for catheter guidance in cardiac electrophysiology procedures 10. Murphy D, Challacombe B, Khan MS, Dasgupta P. Robotic such as ablation,19 and Titan Medical Inc.’s Single Port Orifice technology in urology. Postgrad Med J 2006; 82: 743–47. Robotic Technology is expected to be commercially available by 11. Satava RM. Robotic surgery: From past to future—a personal 2017. The future of robotic surgery is uncertain, which is pre- journey. Surg Clin North Am 2003; 83: 1491–500, xii. cisely why it is so exciting. We may see an eventual switch to us- 12. Slater L. Dr. Daedalus (eccentric plastic surgeon Joe ing small, low-cost—perhaps even disposable—special-purpose Rosen). Harper’s Mag 2001 Jul 1. http://www.highbeam.com/ robots instead of large multi-purpose ones.10 Nanotechnology doc/1G1-76134278.html. is a rapidly expanding field and it is not hard to imagine a day 13. Ballantyne GH, Moll F. The da Vinci telerobotic surgical sys- when surgeons will perform procedures with nanobots capable tem: The virtual operative field and telepresence surgery. Surg Clin of performing the smallest of incisions, making today’s concept North Am 2003; 83: 1293–1304. of minimally invasive surgery appear absolutely barbaric. 14. Perissat J, Collet DR, Belliard R. Gallstones: Laparoscopic The explosion of technology over the past decade alone treatment, intracorporeal lithotripsy followed by cholecystostomy or has been astounding. We live in an era in which robots may cholecystectomy—a personal technique. Endoscopy 1989; 21 (Suppl be found performing tasks just about everywhere, from work- 1): 373–74. ing in assembly lines at factories to vacuuming living rooms in 15. Feder BJ. Prepping robots to perform surgery. New York Times homes. And this is just the beginning, with drones and driver- 2008 May 4. http://www.nytimes.com/2008/05/04/business/04moll. less cars consistently making headlines. But even though we html?pagewanted=all&_r=0. are surrounded by rapidly advancing technologies, medicine at 16. Yates DR, Vaessen C, Roupret M. From Leonardo to da Vinci: its core remains, and always will remain, a humanistic profes- The history of robot-assisted surgery in urology. BJU Int 2011; 108: sion. Robots may aid in removing a tumor from a patient, and 1708–13. perhaps one day they may be able to do so without human 17. Krill LS, Bristow RE. Robotic surgery: Gynecologic oncology. assistance, but it is unlikely that patients will ever appreciate Cancer J 2013; 19: 167–76. learning of their prognoses from a machine or find comfort in 18. Lendvay TS, Hannaford B, Satava RM. Future of robotic sur- a metal arm placed gently on the shoulder. Healing, whether gery. Cancer J 2013; 19: 109–19. physical or emotional, is an experience of life, one that technol- 19. Ernst S. Robotic approach to catheter ablation. Curr Opin ogy can never replace. Cardiol 2008; 23: 28–31.

References The author’s e-mail address is: [email protected] 1. Gera DL. Ancient Greek Ideas on Speech, Language, and Civi-

The Pharos/Spring 2015 15 23and

How can doctors decode direct-to-consumer genetic testing?

J a n e D o e 456 Main Avenue City, State, 08435

Illustrations by Felicia Gilman and Erica Aitken.

16 The Pharos/Spring 2015 implies that someone or something is and breast cancer, biotech company standing so obstructively between pa- Myriad Genetics sequenced the BRCA1 tients and their genetic information and BRCA2 genes, enabling them to test that the entire premise of the product for these genes for clinical purposes. is to bypass this unnamed roadblock. It then patented the locations and se- Of course, the roadblock is the same quences of these genes, and by virtue as that standing between a patient and of that information, the ability to test any medical test—the patient’s doctor. for mutations. One patent in particular, These implied issues of accessibility 17Q-linked breast and ovarian cancer spurred the evolution of genetic testing. susceptibility gene (U.S. 5747282 A), Genetic testing for years has been a filed in 1995, enumerates an (unsurpris- rare but valuable tool for those at risk for ingly) extensive list of the scientific and specific conditions, or a novelty for the therapeutic items that the invention curious few willing to spend a significant relates to, most relevant here being “the amount of money for a look at their ge- screening of the BRCA1 gene for muta- netic code. But in recent months, rapidly tions, which are useful for diagnosing changing policies, increased commercial the predisposition to breast and ovarian availability, and evolving public opinion cancer.” 2 This broad patent prevented have made DTC genetic testing much others from conducting testing and re- more accessible, and much more popu- search surrounding the BRCA genetic lar. Now patients can—and will—order sequences, prompting the Association personalized genetic testing without any of Molecular Pathology to contest its involvement from their physicians. This validity. has its downsides: physicians cannot The patent asserts that the regula- ensure that the information will be reli- tory sequences, promoter regions, cod- able, or that the provider will ensure that ing regions, and specific mutations of the results are fully understood. They chromosome 17 are Myriad’s scientific also have no control over whether the creation. That position was negated in consumer/patient’s privacy will be pro- Justice Thomas’s unanimous majority tected. But these advances also provide opinion, which elaborated on the state- physicians with a unique opportunity ment that, “A naturally occurring DNA Melissa Pritchard to help patients understand the genetic segment is a product of nature and not The author is a member of the Class information given to them and—even patent eligible merely because it has of 2017 at Boston University School of more importantly—to further engage been isolated,” 1 and noted that Myriad Medicine. This essay won third prize patients in their own health and health did not seek to patent any sequencing in the 2014 Helen H. Glaser Student care. method or machine to which a patent Essay Competition. could have actually been applied. Justice A free-for-all of genetic testing Thomas made the point that the BRCA hen I first heard the term The technology to conduct genetic gene sequences have been isolated as a “direct-to-consumer (DTC) tests has been available for years, but naturally occurring DNA sequence un- genetic testing,” I had two in many ways the race toward widely like, say, cDNA, which is created as a Wautomatic responses. First, I immedi- available DTC genetic testing began on complementary sequence to the edited ately began to re-label the “consumers” June 13, 2013, when the Supreme Court downstream messenger RNA sequence, as patients—after all, if someone is get- handed down a decision in Association and is patent eligible because it is an ting medical tests, it seems fair to con- of Molecular Pathology et al. v. Myriad inherently man-made entity. The oral sider him a patient. People seek genetic Genetics, Inc., et al.1 This case not arguments of the case ranged far and testing because they want information only brought up many of the most di- wide, ultimately comparing the differ- about their health—no one gets genetic visive issues surrounding genetic test- ence between patenting naturally oc- testing instead of going to a concert or ing, the decision enabled companies to curring genes and modified, lab-created buying a television—and in my mind move forward with offering more tests. cDNA to the difference between patent- that makes them patients. My second Following studies at the University of ing a tree and a wooden baseball bat. reaction was to ask why the product is California, Berkeley, that demonstrated The Supreme Court’s invalidation touted as direct-to-consumer. The term the association between BRCA genes of Myriad’s patents eliminated the

The Pharos/Spring 2015 17 23andWe

company’s monopoly on the genetic the FDA demanded that the test for BRCA, which, given the preva- company immediately stop lence of breast cancer in America, is a marketing its Personal widely sought after metric. The service Genomic Services (PGS). that Myriad had charged approximately In a scathing warning 4,000 to provide was suddenly suscep- letter, the FDA argued tible to competitive market rates, and that 23andMe had mar- was incorporated into existing DTC keted the PGS as a genetic testing kits. As the breadth of medical device, information available in these kits grew, “intended for the companies providing them found use in the di- ways to make them more widely afford- agnosis of dis- able as well. ease or other No company achieved rapid name conditions or in recognition, popularity, and affordabil- the cure, mitiga- ity quite the way that 23andMe did. tion, treatment, 23andMe was founded in 2006, and by or prevention of 2008 its personalized genetic testing kit disease . . . or in- was Time Magazine’s “Invention of the tended to affect the Year.” 3 At that time, 23andMe sold what structure or func- Time dubbed the “Retail DNA Test” for tion of the body” and 399—not prohibitive, but not quite an that as a result, it was impulsive Christmas gift for the curious. subject to the regula- In the five years following that ar- tions of section 201(h) ticle, 23andMe incorporated a number of the Food Drug of new tests—notably the BRCA tests, & Cosmetics Act, 21 which were added in 2013. Even more U.S.C. 321(h).6 By order- importantly, the company received ing 23andMe to comply with these regu- should be the medical profession’s an influx of cash from venture capital lations, the FDA essentially required greatest concerns surrounding DTC (much came from Google,* an obvious that the company demonstrate that its genetic testing—how reliable is it? And choice when you consider that the com- tests actually detect what they claim to can we make clinical decisions based on pany plans much of its further expan- detect. The warning letter cited as an such tests? Of course, a demonstration sion through gathering and monetizing example the potential consequences of of just how reliable 23andMe’s services “personal information” 4). This increase false test results for the BRCA genes— are is exactly what the company has in funding allowed 23andMe to offer either an unnecessary prophylactic pro- been cited for not providing, so the jury its kit at the ultimate bargain-basement cedure in the event of a false positive, is still out. In a public statement in reply price: 99. At that price, it’s no surprise or a lack of preventive screening or to the FDA’s warning, co-founder Anne that as of November 2013, 23andMe had prophylaxis in the event of a false nega- Wojcicki insisted that, “We have worked sequenced the genotypes of approxi- tive. The alternative response, which extensively with our lab partner to make mately 500,000 individuals, making it 23andMe has employed in the mean- sure that the results we return are accu- the most popular and visible provider of time, is to offer genomic sequencing rate. We stand behind the data that we DTC genetic testing.5 for consumers with absolutely no in- return to customers—but we recognize But popularity doesn’t mean invin- terpretation of what the information that the FDA needs to be convinced of cibility, and by rising to the top of the might mean—in essence, eliminating the quality of our data as well.” 7 food chain, 23andMe acquired a target the troubling marketing element and While providers clash with the on its back. The largest controversy so making it no longer a “medical device.” FDA, the public discussion of the po- far erupted in November 2013, when Yet once 23andMe has provided the data tential inaccuracy of these tests is get- and modifications required by the FDA, ting louder. On December 30, 2013, it is likely that they will be able to return the New York Times featured an article to their original model of operation. by Kira Peikoff, a bioethics student * It is worth noting that andMe co- at Columbia, in which she underwent founder Anne Wojcicki and Google co- Concerns from all sides genetic testing provided by three dif- founder Sergey Brin are married, although now separated. The FDA’s warning outlines what ferent companies—23andMe, Genetic

18 The Pharos/Spring 2015 Testing Laboratories (GTL), interpreting results for patients, so that why the others did not look at them. But and Pathways Genetics— even if numerical accuracy is assured, of the BRCA carriers who did view their and compared the results. consumers may not really understand results, only 41 of them knew that the The discrepancies were what their results mean. test was included when they purchased alarming. The results This issue of interpretation is more it. This begs the question—why did diverged on Peikoff’s ge- contentious—it is easy to agree that so many not know the full nature of netic risk for a number of the results should be accurate, but it the product they were ordering? Did conditions: for example, is unclear what the obligation a com- 23andMe obtain the informed consent 23andMe’s test estimated pany has to explain results to a patient. of these customers before viewing their her lifetime risk of psoria- Companies are eager to refute accusa- test results? 23andMe does try to keep sis as 20.2, while GTL’s test tions that their consumers do not fully its customers from being unwittingly placed her risk at 2. Even in understand the results they are given, surprised by the result by adding the cases in which they did agree on yet criticism persists that, as a result of extra step of “unlocking” the result. the numbers, the companies offered poorly explained testing, patients are Yet electing to undergo the testing and different interpretations of those num- not making fully informed decisions, choosing to view the results are two bers, categorizing identical results as and that incomplete understanding of separate steps, and the patient should “reduced risk” versus “medium risk,” results leads to poorly informed health be able to give informed consent at both and giving significantly different im- care decisions and significant anxiety. stages.9 pressions about what concurring results 23andMe’s research division con- One study by Kaufman et al. exam- meant.8 Both of these types of discrep- ducted its own evaluation of custom- ined the ability of a group of consumers ancies are alarming—it is clear that at ers who were BRCA-positive and had to interpret the results least one of these companies provided agreed to participate in research. of some basic sample Peikoff with results that were just plain test results. For the wrong, while it is also clear the these study, participants companies have no standardized way of were given an ex- ample lifetime risk of a certain disease, in addition to the gen- eral population’s risk of that disease, and were asked to interpret whether the example had an increased or reduced risk of the disease. Ninety percent of the subjects correctly interpreted the first example, and 94 correctly interpreted the second example. Yet those who an- swered incorrectly were likely in the 12 of participants who described their own results as difficult to understand, leading to the conclusion that those who are confused about the results are profoundly confused. Furthermore, the Their first notable finding single best predictor of confusion in was that of this group, only 67 interpreting DTC genetic test results had elected to view their results for the was advanced age, a population for BRCA mutations. Had the other 33 whom screening and preventive health decided that, having sent in their test care is extremely important. The study kit, they did not actually want that piece also went on to ask the participants of information? Were they unaware to make a subjective judgment about that the test was included? Were they, the examples given—classifying them like me, lost in the infinite labyrinth of as high, moderate, or low risk—with 23andMe’s website? The research team widely varying results. The only con- only contacted individuals who viewed sistency revealed by this analysis was their results, so there is no way to know that individuals without postgraduate

19 research on an unprecedented scale, the New England Journal of Medicine, About Melissa many distrust the extent of the com- Bloss and colleagues found only 26.5 Pritchard pany’s privacy protections. The possi- of consumers shared their results with Originally from bility for misuse of data that combines their physicians.12 A follow-up study in Washington, DC, I genetic and personal information ap- 2013 by the same group found that 39.5 am now a second- palls conspiracy theorists wary of the of their respondents had discussed their year medical partnership of 23andMe and Google. results with a physician.13 These results student at Boston University Yet these suspicions have little firm suggest that although some 39.5 of School of Medicine. I gradu- basis in fact, and the question of genetic DTC genetic testing patients may be ated from Amherst College in privacy in DTC genetic testing is a bet- receiving valuable information about 2011 as a neuroscience major. ter question for lawyers than for physi- their genetics from their doctors, 60 I then spent two years as a re- cians. Regulations such as the Genetic or more of patients are left to interpret search assistant in the Geriatric Information Non-Discrimination Act of their results on their own, meaning an Psychiatry department at 2008 prevent health insurance providers increased potential for a consumer to McLean Hospital in Belmont, and employers from discriminating on forgo important screenings, to place less Massachusetts. the basis of genetic information.11 But importance on certain lifestyle choices, as genetic testing continues to evolve, or to simply feel anxious about elements physicians can expect to be called upon of their results. All of these potential to advise lawmakers about the best ways problems will decrease if more physi- to protect patients in the fact of advanc- cians ask their patients whether they education were more likely to minimize ing technology. have joined the growing ranks of the the risk of an example with elevated risk DTC-tested. of disease.10 These results show that The role of physicians in DTC The 2011 Bloss study also presented a even in a clear-cut example of increased genetic testing more heartening finding—those patients risk, understanding of the results was As 23andMe and its competitors take not perfect, and interpretation of the off, today’s medical students can rea- results varied considerably. This find- sonably assume that by the time we ing reinforces concerns that patients are practicing medicine, it will be who have DTC genetic testing do not our responsibility to integrate fully understand their test results and DTC genetic testing into the therefore are not benefiting from the doctor-patient relationship. information they are given. They may In the not-too-distant fu- even be harmed by misunderstandings ture, just asking a patient of their results. whether he has undergone Medical professionals and the public genetic testing may prove alike have also raised concerns regard- important. In a 2011 study in ing the privacy of patients’ genetic in- formation in the hands of DTC genetic testing providers. It is possible that in- dividual genetic information could be abused, leaked, or stolen, and when the information is in the hands of a for-profit company—as opposed to a hospital dedicated to provid- ing care—the possibility for misuse seems greater. 23andMe acknowledges that it is retaining its customers’ de- identified information for the pur- poses of creating a dataset that will be marketed to industries like the pharmaceutical industry. While this has the potential to generate useful

20 The Pharos/Spring 2015 who underwent genetic testing and did procedures than those who did not dis- 3. Hamilton A. 1. The retail DNA choose to discuss the results with their cuss their results with their physician. In test. Time 2008 Oct 29. http://content. physician were significantly more likely the event that a significant risk of a ge- time.com/time/specials/packages/print- to make lifestyle changes than those who netic condition is identified, this should out/0,29239,1852747_1854493_1854113,00. did not. These patients both increased be viewed as reason to investigate fur- html. their physical activity and decreased ther. In light of the current doubts about 4. Google invests in genetics firm. their fat intake. Similarly, the Kaufman the validity of DTC genetic testing, re- BBC News 2007 May 22. http://news.bbc. study observed that patients who dis- sults that are strongly associated with co.uk/2/hi/business/6682451.stm. cussed their results with a physician serious conditions should be replicated 5. Fact Sheet —The 23andMe Media were significantly more likely to reduce before proceeding. Yet regardless of Center. http://mediacenter.23andme.com/ their fat intake and undergo preventive whether an individual result proves to fact-sheet/. screening tests. While the relationship be a true-positive or a false-positive, it 6. Inspections, Compliance, Enforce- might not be causal, and it seems likely remains likely that many patients will ment, and Criminal Investigation: 23andMe, that a self-selecting demographic elects eventually learn of significant genetic Inc. 11/22/13. Warning Letter. Document to undergo genetic testing, the result risk for a serious illness that would oth- Number: GEN1300666. http://www.fda. is still encouraging. If a 99 test can erwise have gone undetected. Therefore gov/ICECI/EnforcementActions/Warnin- help patients feel more engaged in their it makes sense that DTC genetic testing gLetters/2013/ucm376296.htm. health care, and can create a personally could serve as a first-line screening tool, 7. Wojcicki A. An update regard- applicable impetus for them to make despite its many shortcomings. ing the FDA’s letter to 23andMe. http:// healthier choices, physicians should con- Physicians must navigate the com- blog.23andme.com/news/an-update-re- sider this an opportunity. Patients are plex arrival of genetic consumerism in garding-the-fdas-letter-to-23andme/. aware of the impact of lifestyle choices the clinic both because of, and in spite 8. Peikoff K. I had my DNA picture on health, but because these seem broad of, the potential pitfalls. Physicians must taken, with varying results. New York and unspecific, patients often struggle be involved because the consumers of Times 2013 Dec 30. http://www.nytimes. to apply this knowledge directly to their DTC genetic testing are patients—and com/2013/12/31/science/i-had-my-dna-pic- own lives. Using genetic testing to re- the potential consequences of DTC ge- ture-taken-with-varying-results.html. late to patients their personal risk of netic testing’s problems are medical. 9. Francke U, Dijamco C, Kiefer AK, et diseases that are affected by how they Physicians are thus those who are best al. Dealing with the unexpected: Consumer behave could be the direct link between situated to ensure that patients are edu- responses to direct-access BRCA mutation an individual’s health and lifestyle that cated and protected when they use DTC testing. PeerJ 2013; 1: e8. motivates him to make better choices. genetic testing. Furthermore, physicians 10. Kaufman DJ, Bollinger JM, Dvoskin Physicians can also view a patient’s are those who can bring this method of RL, Scott JA. Risky business: Risk percep- decision to undergo genetic testing as testing to its full potential. The infor- tion and the use of medical services among indicative that the patient is particularly mation gained is intended to inform a customers of DTC personal genetic testing. receptive to discussing preventive health patient’s medical decisions and lifestyle J Genet Counsel 2012; 21: 413–22. care. The physician should seize the choices, and physicians are the most 11. Public Law 110-233. Genetic Infor- opportunity to acknowledge suited to help patients use this informa- mation Nondiscrimination Act of 2008. 122 that the patient has taken tion in the best way possible. DTC ge- Stat. 881; May 21, 2008. this step towards assess- netic testing continues to advance, and 12. Bloss CS, Schork NJ, Topol EJ. Effect ing his own health status as its reliability becomes established, so of direct-to-consumer genomewide profil- and capitalize on the fact will its popularity. Therefore physicians ing to assess disease risk. N Engl J Med 364; that he might want to do must prepare to meet this new player in 6: 524–34. more. Even if an increased health care, and seize the opportunity to 13. Bloss CS, Wineinger NE, Darst BF, et risk of a particular condi- use it to its full potential. al. Impact of direct-to-consumer genomic tion is not identified, the physi- testing at long term follow-up. J Med Genet cian can still use this opportunity References 2013; 50: 393–400. to engage the patient in discussing 1. Association for Molecular Pathol- what preventive screenings or lifestyle ogy et al. v. Myriad Genetics, Inc., et al. U.S. The author’s e-mail address is: choices are most important to him. The 12-398 (2013). [email protected]. 2013 Bloss follow-up study found that 2. Skolnick et al. 1998. 17Q-linked patients who discussed their results breast and ovarian cancer susceptibility were more engaged in their health care, gene. US Patent 5,747,282, filed Jun. 7, 1995, undergoing significantly more screening and issued May 5, 1998.

The Pharos/Spring 2015 21 Claude Bernard

The Lesson of Claude Bernard (1813-78) or, Session at the Vivisection Laboratory, 1889 (oil on canvas), painted by Leon Augustin Lhermitte, (1844-1925).

22 The Pharos/Spring 2015 A failed playwright

Irving Kushner, MD The author (AΩA, Washington University in St. Louis, 1954) is Professor Emeritus of Medicine at Case Western Reserve University School of Medicine.

n the rue des Écoles in Paris, adjacent to the Sorbonne but entirely independent of it, sits the nearly 500-year- Oold Collège de France, an institution historically com- mitted to fundamental research.1 In front of the entrance stands a statue of Claude Bernard. Most American tourists ask, “Who was he?” In contrast to Louis Pasteur, Bernard’s student, colleague, and admirer, few Americans have heard of him. In fact, Claude Bernard taught us how to investigate biology, laid the foundation for scientific medicine, and created an intellec- tual revolution in philosophy in his own lifetime. The story of his life is fascinating and full of human interest.2–5 In 1813, as Napoleon’s reign was drawing to a close, Claude Bernard was born in the tiny village of St. Julien in France’s Beaujolais region. His father scratched out a living from his small vineyards, supplemented by tutoring a few local children. Claude’s parish priest, engaged to teach him Latin, saw some promise in the boy and arranged for him to receive secondary education at the Jesuit collège (secondary school) in the big regional town, Villefranche. Claude didn’t do well academically, so he spent another year at a more distant school in Thoissey. At these schools he was influenced both by Romanticism and by the writings of René Descartes, with their emphasis on the search for truth and the importance of doubt. While this combination of interests seems odd today, in fact the romantic imagination was inspired by the sense of wonder that emerged from scientific advances in the late eighteenth and early nine- teenth centuries.6 At the age of eighteen Claude became a pharmacy appren- tice in a suburb of Lyon, serving largely as a handyman, deliv- ery boy, and floor sweeper. He helped to prepare Thériaque, a mixture of some sixty-odd drugs, plants, and other ingredients

The Pharos/Spring 2015 23 Claude Bernard

Claude Bernard, 1813–1878. LaFosse, 1866. Courtesy of the National Library of Medicine.

that had been prescribed for 2,000 years for a variety of Arthur de Bretagne. Shortly afterwards he made a foolish mis- symptoms. He was disconcerted by the fact that there was no take in the pharmacy, and by mutual consent his apprentice- evidence for its efficacy and that his employer threw leftovers ship was terminated. from other prescriptions into the mixture. Back on the farm he polished his play. His mother had Claude used his one night off a month to attend the theater a friend whose illegitimate son (by the king’s father, thus in Lyon, which inspired him to write a successful light comedy he was the king’s half brother) was Minister of Public and that earned him 100 francs. Encouraged by this success, he Historic Buildings in Paris. Mme. Bernard obtained a letter started work on an ambitious five-act historical drama entitled of introduction for Claude. Armed with this letter, Claude, a

24 The Pharos/Spring 2015 twenty-one-year-old provincial, set off for Paris after the grape nearly a century later by Carl and Gerty Cori of Washington harvest, manuscript in hand, hoping to become an acclaimed University in St. Louis, for which they received the Nobel Prize playwright. The minister referred him to France’s leading in 1947.) In addition, he described the role of the pancreas in literary critic, Saint-Marc Girardin. Girardin evaluated the digestion, the central role of the nervous system in regulation play, found it mediocre, and told Claude: “You have not the of body temperature, and the control of heart function by the temperament of a dramatist, you have done some pharmacy, vagus nerve. At the age of thirty-six, he was awarded a prize study medicine.” 4 in experimental physiology from the Académie des Sciences. After some hesitation, Claude followed this suggestion. Bernard was asked to fill in for Magendie’s lectures at the To enter medical school, he first had to pass the baccalaureat Collège during the summer of 1847. He famously began his exam, which he barely did on his second try. Although some of first lecture: the traditional approaches to medicine were beginning to be questioned at the time,7,8 the profession was largely empiric, The scientific medicine which it is my duty to teach you does bound by tradition, and still in thrall to the humoral theory not exist. The only thing to do is to lay the foundation upon of disease.9 Oliver Wendell Holmes was correct a few decades which future generations may build, to create the physiology later when he stated that “if the whole materia medica, as now upon which this science may later be established.13 used, could be sunk to the bottom of the sea, it would be all the better for mankind,—and all the worse for the fishes.” 10p39 In the end, he accomplished just that. Bernard began his clinical studies at the age of twenty- In 1854 a chair in General Physiology was created for three, but found the lectures at the medical school boring and Bernard at the Sorbonne. An awkward lecturer, he did not enjoy didactic. He pestered his teachers about the treatments they es- the job, which consisted of lecturing to undergraduate students poused, demanding proof of efficacy. In contrast, he found the from a fixed prescribed curriculum. In contrast, when he lec- research-based lectures at the Collège de France exciting, par- tured at the Collège de France, he enthusiastically presented ticularly those of François Magendie, professor of Experimental his findings and their significance. The next year Magendie Medicine and a pioneer in experimental physiology.8 Bernard died, and Bernard was appointed to his chair. His lectures there lent a hand in preparing anatomic specimens for these lectures. captivated the members of his audience who, increasingly, came He had superb dissecting skills and was hired as Magendie’s from every walk of life and from every corner of the earth. research assistant in 1841. He pursued a few of his own research Not surprisingly, his was not a happy marriage. “In order ideas in the lab, but since Magendie was not entirely happy with to become a physiologist” he wrote, “one must live in the this, Bernard found a cellar in which to do his experiments— laboratory.” 3 His wife Fanny did not understand him; she coincidently across the courtyard from the site where Dr. wanted him to follow in her father’s footsteps and become a Guillotine had tested his new decapitating machine on sheep a prosperous physician. Bernard’s experiments largely involved half century earlier. Bernard was imaginative and intuitive and vivisection, still a new and unpopular idea. Fanny became an made some interesting findings related to glucose absorption ardent anti-vivisectionist—she denounced him to the police, from the gut that became the basis for his MD thesis. threatened to commit suicide unless he stopped, and turned In the end, Bernard didn’t think much of what he had been his daughters against him, enlisting them in anti-vivisection taught in medical school. He concluded that medical practice demonstrations. Every fall Bernard returned to St. Julien to see was not for him, and decided to commit his life to research. his mother and help with the grape harvest, but Fanny rarely Easier said than done—at the time, there was no such thing went with him. Bernard’s family moved to a larger apartment as a full-time career in experimental medicine. To pursue any in 1863, but he went home only to eat and sleep. In 1869 he and research at all Bernard needed an academic post, but he failed Fanny legally separated. the relevant competition and faced the prospect of life as a vil- In 1864, with Louis Pasteur, Bernard was invited for a lage doctor. At this point, two friends intervened. They knew a weekend to the Imperial Château at Compiègne. There, over successful society physician, Henri Martin, with an unmarried the course of two hours, he explained his work to Emperor daughter who would come with a nice dowry. An arranged Louis Napoleon, who was impressed: “You are a great man marriage would allow their friend to pursue his research. of science.” 2p127 He developed a lasting friendship with the Bernard was surprised by the suggestion, but agreed—it was Emperor’s cousin, Princess Mathilde, and his visits to her salon the only way he could pursue a research career. He was thirty- enabled him to meet many prominent people, including archi- two years old when he married Fanny Martin. tects, engineers, artists, and philosophers. He became a close Bernard achieved meteoric early success in the laboratory. friend of the philosopher Ernest Renan. At the age of fifty-nine, Among his major discoveries was the finding in 1848 that Bernard was chosen to be the first president of the French there was something in the liver from which glucose could be Association for the Advancement of Science, an acknowledg- formed, a substance he named glycogen (sugar-forming).11,12 ment, said the press, of his status as the foremost scientist of (The critical molecular steps in this process were defined France. He was apparently a gentle, kind person. His greatest

The Pharos/Spring 2015 25 Claude Bernard

student, Paul Bert, commented on his kindness, simplicity of considered a tribute to his memory.17 soul, and naïve generosity. Louis Pasteur said of him: “a great gentleness, and amiable kindness.” 2p153 Finally, as Bernard grew older his attention increasingly So in what did his greatness lie? In addition to the many turned to broad biological issues and to the philosophical specific facts he uncovered, he made three broad major contri- implications of his approach to research, culminating in his butions. The first dealt with the doctrine called vitalism. Before masterwork, An Introduction to the Study of Experimental Bernard’s work, it was widely held that living things were not Medicine, published in 1865. This book consists of essays on governed by the same principles that governed chemistry and his philosophy of the experimental method and discussions physics. It was felt that a mysterious supernatural influence, of how to carry out biological experimentation. He illustrated a “vital spark” distinct from physicochemical forces, played a his general principles with experiments from his own labora- central role. If true, this would have rendered scientific inves- tory. Metaphysical or teleological questions of why something tigation extremely difficult, at best. The cumulative effect of happened were disdained—not why, but how. In this volume Bernard’s work was to demolish vitalism.14 He showed that the he stated, phenomena of life were as determinable and definable as those of the other sciences. The experimental method is the scientific method which Undoubtedly his most important scientific contribution was proclaims the freedom of the mind and of thought. It not his recognition that our cells live in a fairly constant internal only shakes off the philosophical and theological yoke; it environment—the milieu intérieur.5 Regardless of environmen- does not even accept any personal scientific authority. This tal fluctuations or challenges, the fluid that bathes our cells— is by no means pride and boastfulness; experimenters, on the interstitial fluid—changes very little. Bernard’s initial insight contrary, show their humility in rejecting personal authority, into this topic was published in 1857 and subsequently evolved: for they doubt their own knowledge also and submit the authority of man to the authority of experience and of the The blood constitutes an actual organic environment laws of nature.18 intermediary between the external environment in which the complete individual lives and the living molecules which can- Today we take this approach for granted. At the time, it was a not safely be brought into direct contact with this external game changer. environment.2p107 Bernard insisted on experimentation as the criterion for va- lidity. Thus, one of his students, Silas Weir Mitchell, who went And in a compilation of lectures published soon after his on to found the study of neurology in America, remembered death in 1878, Lectures on the Phenomena of Life Common to a conversation: Animals and Plants, he arrived at this sweeping, but accurate, generalization: I recall one remark of Bernard’s. I said, “I think so and so must be the case.” “Why think?” he replied, “when you can all of the vital mechanisms, however varied they may be, experiment. Exhaust experiment and then think.” 2p69 have always but one goal, to maintain the uniformity of life in the internal environment.15p168 What was Bernard’s approach to truth? In An Introduction to the Study of Experimental Medicine he states: The great British biologist J. B. S. Haldane reflected: “No more pregnant sentence was ever framed by a physiologist.” 15p168 When we meet a fact which contradicts a prevailing theory, This concept was, however, way ahead of its time and not we must accept the fact and abandon the theory, even when seriously pursued until the early part of the twentieth century, the theory is supported by great names and generally ac- when Joseph Barcroft in England and Lawrence J. Henderson cepted. 18 and Walter B. Cannon at Harvard expanded on it and began to define the mechanisms by which the constancy of the milieu So how should one proceed? First, a hypothesis is suggested intérieur was maintained. Under the term homeostasis, coined by an observation, or alternatively, by intuition or imagination, by Cannon in 1926, this subject established the agenda for both of which Bernard valued. An experiment to test that hy- physiologists for the ensuing two generations.16 The preface to pothesis is then performed. If the findings support the hypoth- the French edition of Cannon’s great book on the subject, The esis, they must then be found to be reproducible. If they are, Wisdom of the Body (1932) states: the hypothesis was promoted to a theory. And what is a theory?

The central idea of this book . . . is directly inspired by theories are only hypotheses, verified by more or less numerous the precise views and deep understanding of the eminent facts. Those verified by the most facts are the best; but even French physiologist Claude Bernard. This book can even be then they are never final, never to be absolutely believed. 18

26 The Pharos/Spring 2015 We sometimes forget that Bernard warned us against drawing absolute conclusions. He elaborated on this point:

When we propound a general theory in our sciences, we are sure only that, literally speaking, all such theories are false. They are only partial and provisional truths which are nec- essary to us, as steps on which we rest, so as to go on with investigation.18

Science owes its authority to the fact that it is self-correcting, always a work in progress. An Introduction to the Study of Experimental Medicine had an impact not only on science, but on philosophy and the his- tory of ideas as well.14,19,20 In that volume Bernard confronted the philosophic issues that arose from his approach to truth. Philosophy—the love of wisdom—had embraced the whole field of knowledge for centuries. Science began as a branch of philosophy—natural philosophy. The early fathers of the modern scientific method such as René Descartes and Francis Bacon were regarded as, and saw themselves as, philosophers. But by the mid-nineteenth century science was distancing itself from the traditional rational approach of philosophy—critically Apparatus for the study of the effects of heat on animal death. thinking things through—by adding a requirement for data for Claude Bernard, Paris, 1876. empirical verification. Bernard put it well: Courtesy of the National Library of Medicine.

the experimental method is nothing but reasoning by whose help we methodically submit our ideas to experience,—the experience of facts.18 latter goal are currently under way.22,23 Louis Pasteur (1822–1895), nine years younger than Bernard, Writings about the methods of science were regarded as audited Bernard’s lectures in the early 1860s. They became highly relevant to philosophy. In 1913, on the centenary of friends and colleagues; Bernard helped Pasteur in his studies Bernard’s birth, the philosopher Henri Bergson stated that the to debunk the idea of spontaneous generation and they worked impact of An Introduction on his era was somewhat compa- together in a futile attempt to investigate the cause of a cholera rable to that of Descarte’s great work, Discours de la Méthode, outbreak in 1865.24 Speaking of Bernard, Pasteur quoted the on the seventeenth and eighteenth centuries.20 Bernard’s work chemist Jean-Baptiste Dumas: “Bernard is not a great physiolo- was translated into a dozen languages and used in courses on gist. He is physiology itself.” 2p153 An appreciation of Bernard’s physiology and philosophy for another century14—and still contributions, entitled, “Claude Bernard, the importance of warrants reading today. In the introduction to the 1957 edi- his writings, teaching and method,” was published by Pasteur tion, ninety-two years after its original publication, I. Bernard in 1866, in which he praised An Introduction to the Study of Cohen, Professor of the History of Science at Harvard, stated Experimental Medicine as a masterpiece.25 that it was “as splendid a statement of the basic features of But why do we know Pasteur and not Bernard? Pasteur, scientific research as has ever been written.” 15p111 At the age domineering, inflexible, dogmatic, was an aggressive self- of fifty-five Bernard was elected to a seat in the prestigious promoter, obsessed with how posterity would regard him.24 He Académie Française on the basis, not of his scientific contribu- focused on practical issues that would soon pay off with useful tions, but of his literary and philosophical work. or profitable applications. Bernard, in contrast, was taciturn, And the application of Bernard’s approach ultimately had modest, retiring, and constantly beset by doubts. He was inter- greater practical results than even he could guess. The literary ested in neither utility nor profitability. His goal was to make figures Edmond and Jules de Goncourt mockingly satirized medicine rational and scientific. All he wanted to do was to the long-term consequences of the use of his method with understand how the normal body functions, without which, he bizarre possibilities deemed inconceivable: after one hundred felt, one could not understand the diseased body. The research years one would be able to make laws for organisms and carry methods that he established, rather than benefiting the public out creation in competition with the creator himself.21 In fact, directly, would benefit subsequent investigators. laws for organisms have been defined and efforts to achieve the When Bernard died in 1878, France gave him a state funeral,

The Pharos/Spring 2015 27 the first scientist to be so honored. A cortège of over 4,000 fol- tion Discovered the Beauty and Terror of Science. New York: Pan- lowed the hearse from the church of St. Sulpice to the historic theon Books; 2008. Père Lachaise cemetery. His friend Ernest Renan was elected 7. Ackerknecht EH. Medicine at the Paris Hospital, 1794–1848. to Bernard’s seat at the Académie Française and, on taking his Baltimore (MD): Johns Hopkins Press; 1967. seat, delivered the traditional eulogy of his predecessor. He 8. Lesch JE. Science and Medicine in France: The Emergence described Bernard as having had a life wholly devoted to the of Experimental Physiology, 1790–1855. Cambridge (MA): Harvard truth and indicated that Bernard was aware that his work bore University Press; 1984. on fundamental philosophic issues.21 9. Kushner I. The 4 humors and erythrocyte sedimentation: Bernard had never abandoned his hope of being recog- The most influential observation in medical history. Am J Med Sci nized as a dramatist. About a year before he died he entrusted 2013; 346: 154–57. a young friend, George Barral, with his forty-three-year-old 10. Holmes OW. Current and Counter-Current in Medical Science: manuscript Arthur de Bretagne. He gave permission to have With Other Addresses and Essays. Boston: Ticknor and Fields; 1861. it published, but not until at least five years after his death; it 11. Olmsted JM. Claude Bernard and glycogenesis. J Am Diet was ultimately published in 1887. Bernard had stipulated that Assoc 1954; 30: 545–49. this note appear in the publication: “Read and refused, with 12. Young FG. Claude Bernard and the discovery of glycogen: A many corrections, by Saint-Marc Girardin in November 1831.” century of retrospect. BMJ 1957; 1: 1431–37. Two years after it was published, however, Bernard’s wife and 13. Lefèbvre P. Claude Bernard (1813–1878). Diabetologica daughters brought suit. They felt that George Barral’s introduc- 2005 June; 48. http://www.diabetologia-journal.org/webpages/cov- tion was defamatory when it stated that they had left him “in a ers/2005/june.html. cruel state of abandonment” in 1869. The suit was successful; a 14. Normandin S. Claude Bernard and an introduction to the court ordered that all copies of the book be destroyed. study of experimental medicine: “physical vitalism,” dialectic, and So, in addition to the statue mentioned at the beginning, epistemology. J Hist Med Allied Sci 2007; 62: 495–528. how is Claude Bernard memorialized? A plaque identifies the 15. Tarshis J. Claude Bernard: Father of Experimental Medicine. site of his laboratory at the Collège de France. One of the major New York: Dial Press; 1968. universities in Lyon is named after him, and his statue stands 16. Cooper SJ. From Claude Bernard to Walter Cannon. Emer- there as well. But what is his true monument? Let me draw a gence of the concept of homeostasis. Appetite 2008; 51: 419–27. parallel with Sir Christopher Wren, who designed St. Paul’s 17. Cannon WB. The Wisdom of the Body. New York: WW Cathedral in London. Under its dome sits a commemorative Norton; 1932. plaque marking his burial site. On it is written: Lector, si monu- 18. Bernard C. An Introduction to the Study of Experimental mentum requiris, circumspice—Reader, if you seek his monu- Medicine. Greene HC, translator. New York: Dover Publications; ment, look around you. Of Claude Bernard, one might similarly 1957. say: If you seek his real monument, look around you—at the 19. Conti F. Claude Bernard: Primer of the second biomedical state of knowledge of the biomedical sciences and the capabili- revolution. Nat Rev Mol Cell Biol 2001; 2: 703–8. ties of medicine today. 20. Virtanen R. Claude Bernard and His Place in the History of It’s really not such a tragedy that he wasn’t a very good Ideas. Lincoln (NE): University of Nebraska Press; 1960. playwright. 22. Gibson DG, Glass JI, Lartigue C, et al. Creation of a bacterial cell controlled by a chemically synthesized genome. Science 2010; Acknowledgment 329: 52–6. I am grateful to Dr. David Samols and Professor P. K. Saha for helpful 23. Gibson DG, Venter JC. Synthetic biology: Construction of a suggestions. yeast chromosome. Nature 2014; 409: 168–69. 24. Debré P. Louis Pasteur. Forster E, translator. Baltimore (MD): References Johns Hopkins University Press; 1998. 1. The Collège de France, a unique institution. http://www.college- 25. Sinding C. Claude Bernard and Louis Pasteur: Contrasting de-france.fr/media/en-about-college/UPL5529630110265851492_ images through public commemorations. Osiris 1999; 14: 61–85. NOTE_DE_PRESSE_2012___ENGLISH_VERSION.pdf. 2. Olmsted JMD. Claude Bernard and the Experimental Method The author’s address is: in Medicine. New York: Henry Schuman; 1952. Division of Rheumatology 3. Wise P. Claude Bernard—1844-48: First Projects. http://www. MetroHealth Medical Center claude-bernard.co.uk. 2500 MetroHealth Drive 4. Silverman BD. Claude Bernard. Clin Cardiol 1996; 19: 916–18. Cleveland, Ohio 44109 5. Gross CG. Claude Bernard and the constancy of the internal E-mail: [email protected] environment. Neuroscientist 1998; 4: 380–85. 6. Holmes R. The Age of Wonder: How the Romantic Genera-

28 The Pharos/Spring 2015 Med Students

Sorted into groups of ten The novices come hungry To the table, eager to Taste slices of mystery Hypnosis, prayer Near-death experiences Spontaneous remissions And chew them into True-false facts Before the next exam. As priests of science They will handle fiber-optic Serpents, cast out cancers, And speak in tongues of jargon. But who among the multitude Will be wholly healed? Richard F. Gillum, MD

Dr. Gillum (AΩA, Northwestern University, 1969) retired after a career in epidemiology research at the Centers for Disease Control and Prevention. As an adjunct faculty member, he is the Campus Advisor for the Christian Medical and Dental Association chapter at Howard University College of Medicine. E-mail: [email protected]. Illustration by Jim M’Guinness. 29 Breaking the silence

N. Karp, MD uring the last eight years of said I was beautiful and smart, and he He was quick to get angry when my medical education, I was admired my passion for my work. As we argued. It was confusing, at first— taught over and over again to a fellow physician, he understood my why was this person, who supposedly lookD for and recognize signs of inti- daily triumphs and challenges, and pro- adored me, so furious with me? Over mate partner violence. As a resident vided comfort after stressful days. He something so small? My inevitable physician in obstetrics and gynecology, planned out the life we would have to- tears enraged him even further. He I screened and counseled countless gether, complete with the house, three would shout and threaten to leave. I women affected by domestic abuse. I children, and two dogs. As the child would cry harder, ask for forgiveness, have a dedicated medical education, of divorced parents, he offered me the and beg him to stay. I became depen- an undergraduate psychology degree, nuclear family I had craved for years, dent on him for my happiness and and a generally independent and self- wrapped in a comforting blanket of self-worth. I needed him. Perhaps it reliant personality. Despite all of that, adoration. In hindsight, it was infatua- surprised even him to watch the inde- in the middle of my residency training tion, but at the time it felt like love, and pendent woman he fell in love with col- I became ensnared in an abusive rela- I thought I was lucky to have found it. I lapse into an apologetic heap, weak and tionship, and it took me almost a year relaxed into the fold of the relationship, insecure. I just wanted so desperately to leave. never doubting the love from this man for him to be happy, for us to be happy. It was slow and almost calculated who would seemingly do anything for He always followed the outbursts with work, that began with his complete me. This, of course, was the first step remorse. He just had a quick temper, devotion to me. He gave me a speed- of the process: gaining my trust. he said. If I learned to stop reacting like ball dose of attention that I never even I do not know exactly how or that, he would say, everything would realized I wanted, but to which I was when the dynamic began to change. change. If I could just be better, I easily attracted. He was intelligent, Seemingly benign arguments escalated thought, everything would be perfect. hardworking, and gregarious. He in- quickly, and developed a common Initially I was honest with close cluded—or, in retrospect, ingrained— theme: it was always my fault. I was friends about our trials as a couple. It me in every aspect of his life. He inconsiderate. I hurt his feelings. I con- was toxic, they said. Not normal. Not showed up at the hospital with coffee fided in my friends more than in him, healthy. They saw a gradual disman- when I was on call. He made a point and didn’t make him feel important in tling of my confidence and happiness, to introduce me to his friends, and my life. The guilt had a paradoxical ef- until I was only a shell of the friend bring me to work functions. He told fect, pulling me closer to him, and fur- they had known. But I was invested, me he loved me early and often. He ther from my support network. and I loved him. So I did the easiest

30 The Pharos/Spring 2015 thing. I stopped telling them. Step two with staying was one of the final steps around my neck. He smashed my cell of the process: isolation. of my isolation. phone, and stormed out of my apart- We functioned beautifully as a dys- There were always just enough posi- ment, leaving me with no way to call functional couple, and we excelled at tive interactions to convince me to stay. for help. maintaining appearances. I continued I deluded myself into thinking we were How had I gotten to this place, hud- to be responsible for all of our difficul- a couple that was working through dled on my floor in the middle of the ties. If he was unhappy, I accepted the our “issues.” My tactics of strategically night, scared, bruised, and alone? How blame. He became more controlling, hiding information from most of my was I going to take care of patients, dictating when we would go out, and friends and family had worked, and having gotten so deep into a situation with whom. He had opinions on every I had avoided intervention. I could in which I had lost myself? My life was aspect of my life: I should exercise dismiss my own doubts with various wrapped so intricately around him, more. I should do fellowship at this excuses. I love him. He loves me. He that despite those events, initially I program, not that one. Not even little apologized. The first time it occurred still ached to have him back in my life. things, such as my habit of listening to to me I was in an abusive situation, I I knew that what had happened was white noise to fall asleep, escaped his was in our gynecologic oncology clinic. wrong, but I still mostly blamed myself. criticism. My patient had just quit smoking, and I was still weak enough to potentially The constant struggle for his ap- I congratulated her and asked her how let him back in my life. To prevent that, proval chipped away at my sense of self, she had done it. She said, “I just real- I finally broke my silence. I told my leaving me with a heart-crushing sense ized it was like an abusive relationship. closest friends. I told my family. I even of loneliness. I could not bring myself It wasn’t doing anything but hurting told my residency program director to reach out to anyone, and became me. And I had to leave.” I felt her words and another trusted faculty mentor. even more desperately attached to him. wash over me, and then they struck me And I was fortunate to be showered When he yelled at me, I cried so hard as if I had been punched. She was tell- with the support and resources I it caused petechiae around my eyes. I ing my story. And yet, I stayed. needed to close that door forever. would curl up in a ball, and he would Why? I still torture myself with this It is difficult to understand how I glare down at me with harsh, cold eyes. question. Part of it was a sense of de- opened myself up to such a toxic situ- It was a frightening look that seemed termination, of trying to hold on and ation. We collided in a way that clearly filled with hate. He told me I was crazy. make things work. It was as though brought out the worst in both of us, That no one would ever love me. And the tenacity that had been a positive once the initial infatuation had faded, then, he would film me, sobbing on the attribute in other facets of my life be- but I was blind to it then. The self- floor. He recorded me crying, begging came displaced and destructive. I can- blame has subsided, but the question him to stay, and said, over and over not deny that I wanted that fairytale still lingers: How did I miss my own again: “See how crazy you are? You picture he had initially painted. As a diagnosis? Unfortunately, this pattern think your friends don’t know you’re resident, with work being the over- is not as uncommon as we would like crazy? You think anyone could ever love whelming portion of my life, I craved to believe. It was a tremendously dif- this? Look at what you’ve become.” balance. I thought that in order to be ficult and painful experience that I en- I should have seen it coming, should settled I would have to settle. And dured, but because of it I am stronger have known that physical abuse would though I feared him, I also loved him. today than I have ever been. Reaching follow the emotional abuse. At that The fights escalated, and became out to those around me and allowing point my blinders were fixed, and so more physical. I went to our chief resi- them to help was the key to my recov- instead it came as a shock. The first dents’ graduation with a baseball-sized ery. By breaking my silence, I want to time, I was pointing at him while we bruise on my knee that I carefully cov- empower others to recognize what I argued. He reached out, grabbed my ered after being thrown to the ground. could not see in myself. I hope to help index finger, and bent it backwards. He It was my fault, of course. We were patients, friends or colleagues who may held it there as I cried out in pain, and arguing, and as I begged him not to find themselves in a similar cycle break then slowly released his grip, that same leave, he picked me up and threw me free, seek help, and find their own cold look in his eyes. I pulled away, and onto the bed. He had purposely thrown strength and independence. stared at my hand. Would I be per- me there because he did not want to manently injured? Would my surgical hurt me, he said. It was my fault I fell Please address correspondence about this career be over? He showed up the next off onto the hardwood floor. Only a article to Managing Editor Debbie morning with ice and apologies. He week later, it escalated even further. Lancaster at [email protected] promised it would never happen again, Again we argued, and in a blur, I found or 525 Middlefield Road, Suite 130, Menlo and I stayed. The shame that came myself pinned on my couch, his hands Park, California 94025.

The Pharos/Spring 2015 31 Cowboy Thomas T. McGranahan, Sr., MD The author (AΩA, University of Cincinnati, 1957) supports and Maybe if I can remember what happened I can figure it out. teaches EMR for Volunteers in Medicine in Bend, Oregon. Mama had been called to an emergency board meeting at the university, and I had a little cold so she had kept me home. wish I knew where I was. I know I must be some- Lizzy, Mama’s good friend who usually stays with me, was where, and I guess I’m not dead or I wouldn’t be teaching at her school, and since it was daytime, all the neigh- thinking and wondering where I am, but I can’t seem bors were at work. Mama didn’t want to leave me alone and Ito move anything, or see anything. I feel like I am tied down she had never done that before, but she said this was an emer- like Gulliver, but I’m blind too. I can hear a little if noise is gency and wouldn’t take long. We had had family fire drills, so loud or someone talks into my ear. My father seems to get I knew what to do in a fire, and she had taught me how to dial real close and talk to me sometimes. He says everything is the new emergency number, 911. And I was NOT to answer the OK and I will be fine, but where am I, and what has hap- door if anyone knocked or rang the bell. pened to me? There is some kind of whooshing sound right I was reading Gulliver’s Travels and blowing my runny nose near my right ear. I seem to make the sound when I breathe. when the doorbell rang. I didn’t open the door, but went to Oh God, I’m scared. Sorry, Mama, I know I shouldn’t say the bay window where I could see who was there. I had seen God like that, but I am really scared. Maybe if I can go to a picture in a book in Mama’s office and when I pulled it out sleep I will feel better when I wake up. and asked her who it was, she said it was my father, who had Well, I am awake now, and I am still here, wherever this is. gone away before I was born. The person at the door looked

Illustration by Erica Aitken 32 The Pharos/Spring 2015 just like the picture, but older. never stopped for more books. I didn’t know what to do. I wasn’t supposed to open the As we got further west we started seeing signs for a big door, but surely that didn’t apply to my father. After he rang drugstore in Wall. There were signs for miles and miles, and three times I opened the door. we finally got there. The drugstore was more like a carnival, “Jimmie,” he shouted, and grabbed me and kissed my and they sold everything. Father bought me a cowboy hat, cheeks and neck and held me tight and I think I saw tears in boots, a pair of jeans, and a shirt with shiny buttons that he his eyes. He held me for the longest time, but finally he put me said were mother of pearl, and after that I wore my cowboy down. clothes every day. We didn’t even wash them. “How would you like to take a trip with your father?” was Father was funny about time. When I would ask him what the first thing he said after he put me down. Wow, I had never time it was, he would say Grennich mean time is whatever even seen him and he wanted to take me on a trip, an “ad- and it never seemed like that time of day to me, but he said venture” he said. I explained that Mama would be home in a Grennich mean time was the only true time. little while and we could plan it with her. His face got a mad The last thing I can remember is that we were in Wyoming, look and he said, no, if we were going we had to leave now. camping on a hillside way out nowhere. I saw a few antelope We went up to my room and he put some of my clothes in a on a hill in the distance. I had never seen antelope before or backpack. I didn’t know what to do. I knew we should wait for any animals in the wild. It was a beautiful, clear morning with Mama, but he was almost dragging me around by my arm. a warm breeze and I wanted to ride my bicycle. Father said not “Is there anything special you want to take with you?” he to go downhill because I might go too fast and fall, but ride asked. I said I wanted to take Gulliver’s Travels and Swiss back and forth on the road on the hillside. Family Robinson, I could get those into the backpack. Now I am here, wherever this is. At first I had to pee really “Can we take my bicycle?” I asked. bad, but they stuck something up my johnny and now that is “We can get it in the truck,” he said, and that really made better. Mama said to call it my penis, but I still like johnny. me happy. I left a note for Mama saying that I was going on an That’s funny, I can’t really feel most things, but I can feel my adventure with my father, so she wouldn’t worry. Then we put johnny and my throat. There is something stuck in there, too. my bicycle into his old red Ford pickup, put the backpack be- And I have a headache. If I could do anything, I would ask for hind the passenger seat with some other stuff, and we were off. an aspirin. Every so often something clicks on and off right Father said we were going west, and I could be a cowboy. over my face, or at least somewhere between my ears We only got about 200 miles the first day and found a place I don’t know how long I have been like this. I can’t tell time, to camp. Father had a little tent and a tiny stove that burned not even Grennich mean time. I just figure it is day when I am little white things. Then we would build a real campfire with awake, and night if I am asleep. Father talks to me every day any wood we could find around. Each day we had donuts for and once I thought I heard Mama talking very loud and angry. breakfast, would stop at a McDonalds for lunch, and at night We probably shouldn’t have left without telling her. father would heat up some beans on the stove and make hot Well, I am awake again, and I heard someone say some- chocolate if we had gotten some milk, but sometimes we had thing about a plug. I hope they are talking about the thing in to just use water. my johnny. I sure could do without that, though I don’t know After about three days father began to smell bad and I how I could pee. didn’t smell too good either, really smoky, and I was pretty Father just told me that it is almost over and that we would dirty. Mama would have thrown me into the bathtub. So we be going back out to where I rode my bicycle, and I could stay stopped at a real motel. Father said he was looking for one on there. He was going to use his art training to design a place for the old highway with a garage. He thought it would be safer if me. That seems like a lonely place to stay. He said my cowboy the truck and the bicycle were under cover. He finally found outfit had been washed and that I could wear that, but we what he was looking for, and stayed for the night. It wasn’t too weren’t going to go until it was midnight Grennich mean time. modern. Some of the wallpaper was peeling off and there was I am awake again. It must be midnight by father’s time. an old ring in the tub, but we got a bath and it felt really good. They are taking that thing out of my johnny and, wow, they Father washed out some our clothes and hung them on a rope are taking the thing out of my throat too. Oh, it is a little hard to dry. We tucked them in the back of the truck the next day to breathe, and God I am scared again. Sorry, Mama. I need to so they wouldn’t blow out and let the sun finish drying them. go to sleep and when I wake up it should all be over. That’s it. I At night I would read my books by the campfire, or some- need to go to sleep. times in the motel, until I fell asleep. I was sure I would finish them before we got to wherever we were going. I asked Father The author’s address is: if he knew where there was a library. He said that the only li- 18160 Cottonwood Road #793 brary he knew was at a famous state institution where he had Sunriver, Oregon 97707 lived. He said he had worked there and studied art. But we E-mail: [email protected]

The Pharos/Spring 2015 33 The Doctor Jim Health P lan

Joel L. Chinitz, MD The author (AΩA, SUNY Downstate of herself on the street. “I’m supposed to understandable sentence. Was this really Medical Center, 1961) is retired from use warm compresses and dry dressings. Orlando the wheezer? Dr. Jim wondered. practice in nephrology. Ha, that’s a joke,” she added. Yes, it was. “And where have you That was how the morning had been?” ennifer Gribben. . . . Jennifer.” started. Then there was Bill. It was not “I’ve been away.” There was no response. The wait- easy, Bill and Dr. Jim agreed. Not easy “Away?” ing room, as always, was crowded to take care of yourself when you have Away, Orlando explained, meant Jand loud. He would have to be louder. diabetes and live in a cardboard box. that he had been picked up on a parole “Jennifer Gribben.” “I keep the box dry,” Bill reassured violation and away was the Burlingame “She’s here somewhere,” MaryAnn the doctor, whose head was shaking. “I Prison Facility upstate. reported and then pointed to a woman, just can’t see that well in there to get the Suddenly Jim realized where he slumped over, eyes closed in one of right amount of insulin. And someone had gone wrong this Tuesday and ev- the phony leather chairs with cracked stole my glucose tester.” ery Tuesday since 1994. There was, he cushions. MaryAnn shook the woman’s At least Arnold Benedict did have a thought, hope for Orlando and for every shoulder, and with the next “Jennifer place to live. It was in the basement of other homeless drug dependent schizo- Gribben” she stood, rubbed her eyes, his daughter’s house. “But they is always phrenic with no health insurance. Hope and followed Dr. Jim up the stairs and drinkin’ and fightin’, ” he told the doctor, for every skin-popping heroin addict into the first room on the left. who wanted to know why Arnold hadn’t on Keeley Street. But the hope was not He was Dr. Jim because no one in the been back to get his blood pressure pills. here on Brewster Street. The hope was clinic could pronounce his last name. And look at how much weight he had two hundred miles north in Burlingame He was also Dr. Jim because this was lost. With his collar fully buttoned it Prison. How could he have missed that not one of the fancy offices on Highland would be possible to fit another neck in fact? “Things will never be the same,” Jim Avenue or Dilworth Street. This was his shirt. whispered to himself. the free clinic on North Brewster where This went on and on that Tuesday “Didn’t catch what you said, Doc.” you could get a shower, new socks, and morning. The schizophrenic who would Orlando, leaning forward on the exam- a chance to use the phone, if you were not take her pills. The crack addict who ining table, responded. But Jim shrugged lucky. had crushing chest pain when smoking his shoulders and smiled. He would not Dr. Jim opened the chart as Jennifer but couldn’t stop. repeat the words or reveal the plan they inched up onto the examining table. It was only Orlando, the last patient had triggered. “How are things going?” he asked as he called into the room, who seemed fit. Dr. The plan, set into action that day, was put the chart down and moved toward Jim had known Orlando since the day he obvious only two years later. Obvious her. Having seen her just two weeks ago, started coming to the clinic nine years only after the local police had the ben- it didn’t take long for him to receive the ago. He had watched him grow weaker efit of the new Crimestat Computer and answer. The cavity on her right forearm with dry cracking skin and bloodshot Jennifer Gribben’s confession. was full of creamy debris and had raised eyes. He had seemed to age as rapidly as Her confession brought the police red edges. this old row house they called a clinic. to the twisted peeling green door of the “You’ve got to stop skin popping and But now on this rainy morning, af- Brewster Street clinic and up the stairs start taking care of yourself. Things are ter not having seen Orlando for more to the examining room. getting worse, and you have more ulcers than a year, Dr. Jim was shocked. The “Doc,” Officer Trevail asked Dr. Jim, on your arms than last time.” guy looked great with full cheeks, no who turned from the chart he was writ- “Well, but, eh, this one is getting bet- pimples, and without that twitch in his ing on. “Do you know a woman named ter, see,” she protested, pointing. It was right shoulder. And he spoke using full Jennifer Gribben?” hard to stop using and hard to take care words, one following the next into an “Well, I know her skin.”

34 The Pharos/Spring 2015 “She told me that you gave her the Dr. Jim shrugged his shoulders. Dr. Jim smiled. “Thank you. Yes, offi- floor plan of Beck’s TV Land so that she “. . . and that seventeen of your pa- cer, a crime has been committed. Isn’t it could burgle the place.” tients are now doing time.” a crime that so many people need to go Silence. Beads of sweat collected on Jim’s to jail to get the basic services and health “Is that true, Doc?” neck. care that they need?” More silence. “Do you have anything to say about “We would have ignored, skipped that?” The author’s address is: over, that little fact until we came to “Yes, officer,” Jim smiled as he spoke. 265 Wenner Way notice that the area crime rate, high as “I have a question. How are they doing?” Fort Washington, Pennsylvania 19034 it was, has increased 472.6 in the last “Far as we know, they are all doing E-mail: [email protected] eighteen months . . .” quite well.”

The Pharos/Spring 2015 35 Stroke You sit quietly, now and then silently waving your left hand. You volunteer nothing, yet struggle to retrieve the right answer from the thicket. She proclaims your marvelous progress— a cheerleader without a team. Henry N. Claman, MD

Dr. Claman (AΩA, University of Colorado, 1979 Faculty) is Distinguished Professor of Medicine (retired) at the University of Colorado School of Medicine. His address is 596 South Olive Way, Denver, Colorado 80224. E-mail: [email protected].

36 The Pharos/Spring 2015 New members of the Pharos editorial board

e are pleased to announce the and Professor in Halifax, Nova addition of six new members to of Medicine Scotia, Canada. Wthe Pharos editorial board. in Psychiatry. She completed He the found- residency training at Lynn Cleary, MD ing Chair of the Dalhousie in 1999, Dr. Cleary Ethics Committee followed by a fellow- (AΩA, Ohio State of New York- ship in psychother- University, 1978) Presbyterian Weill apy at the University is Professor of Cornell Medical of Toronto. She Medicine at Upstate Center where he obtained a Masters Medical University, is an Attending of Education de- Distinguished Physician and gree from Acadia Teaching Professor Director of Medical Ethics. A member University in 2013, her thesis research at the State of the Adjunct Faculty of Rockefeller focusing on the teaching and assessment University of New University and Senior Attending of professionalism. York (SUNY), and Physician at The Rockefeller University Dr. Hazelton has published in the currently serves as Vice President Hospital, he co-directs the Consortium areas of medical education, humani- for Academic Affairs at Upstate. She for the Advanced Study of Brain ties, and ethics. She has been awarded previously served as Senior Associate Injury (CASBI) at Weill Cornell and the 2012 Royal College Fellowship for Dean for Education in the College of Rockefeller. He is a Senior Research Studies in Medical Education, and the Medicine. Dr. Cleary is an active clini- Scholar in Law at the Yale Law School. 2011 Gerald and Gale Archibald Gold- cian in both inpatient and outpatient Dr. Fins is a member of the Institute Headed Cane Award for excellence in general internal medicine and a clini- of Medicine of the National Academy the field of medical humanities. Her cian educator. Her scholarship is in of Sciences, a Fellow of the American current areas of research and scholarly the area of medical education and she Academy of Arts and Sciences and activity include narrative, remediation has served as an ad hoc reviewer for an Academico de Honor of the Real in medical education, and the peda- Academic Medicine and the Annals Academia Nacional de Medicina de gogy of critical thinking. Since 2012, of Internal Medicine. Dr. Cleary is España. she has worked as a general adult out- currently Vice-Chair of the Board of Dr. Fins is the author of over 300 patient psychiatrist at the Cobequid Directors of the National Board of publications. His most recent book Community Health Centre near Halifax, Medical Examiners and Governor of is A Palliative Ethic of Care: Clinical Nova Scotia. the Western region of the New York Wisdom at Life’s End (Jones and State chapter of the American College Bartlett, 2006). His current scholarly Jerome of Physicians where she received a interests include ethical and policy is- Lowenstein, MD Laureate Award for service. She has sues in brain injury and disorders of Dr. Lowenstein served as councilor for the New York consciousness, palliative care, research (AΩA, New York Gamma Chapter of AΩA at Upstate ethics in neurology and psychiatry, University, 1957) since 2003, and is a councilor direc- medical education, methods of eth- is Professor of tor on the board of directors of Alpha ics case consultation, the history of Medicine and Firm Omega Alpha. She serves on the medicine and bioethics in the Spanish- Chief at New York Advisory Board of The Healing Muse, speaking world. He is a co-author of the University School a journal of literary and visual arts 2007 Nature paper describing the first of Medicine. His published annually by the Center of use of deep brain stimulation in the full time activities Bioethics and Humanities at Upstate minimally conscious state. His forth- include teaching, Medical University. coming book, Rights Come to Mind: patient care, and translational research. Brain Injury, Ethics & The Struggle for In 1979, Dr. Lowenstein founded and Joseph J. Fins, MD, MACP Consciousness will be published in 2015 still directs the Humanistic Aspects of Dr. Fins (AΩA, Weill Cornell by the Cambridge University Press. Medical Education program at NYU. Medical College, 2011, Faculty) is the He is the Founding Publisher of the E. William Davis, Jr. MD Professor Lara Hazelton, MD Bellevue Literary Press and the Senior of Medical Ethics and Chief of the Dr. Hazelton is an Associate Editor for Non-fiction of the Bellevue Division of Medical Ethics at Weill Professor with the Department of Literary Review. Cornell Medical College where he Psychiatry and Director of Academic Dr. Lowenstein is the author of is Professor of Medicine, Professor Faculty Development for the Faculty four books: Acid and Basics (Oxford of Health Care Policy and Research, of Medicine at Dalhousie University University Press, 1992); The Midnight

The Pharos/Spring 2015 37 New members of the Pharos editorial board

Meal and other Essays about Doctors, Special Surgery, University of Patients, and Medicine (Yale University he has pursued an Maryland School Press, 1997; University of Michigan interest in medical of Medicine. He Press, 2005); Henderson’s Equation ethics both at the is a Master of the (Gadd Books, 2008); and Zichronot/ medical institu- American College Memories: A Journal (Mulberry Tree tions with which he of Physicians Press 2012). is affiliated as well (ACP) and a for- as with his major mer governor of Therese Jones, professional soci- the Maryland chap- PhD ety, the American ter of the ACP. He Dr. Jones is College of began his career in Associate Director Rheumatology. In academic medicine of the Center for this capacity he was formerly Chair of as an Epidemic Intelligence Officer with Bioethics and this national organization’s Ethics and the Centers for Disease Control in the Humanities and Conflict of Interest Committee. He is a early 1970s. In 1975, he joined the faculty Director of the Arts consulting physician in Rheumatology of the University of Texas Southwestern and Humanities in at Memorial Sloan Kettering Hospital. Medical School in Dallas, where he rose Healthcare Program Selected as a faculty scholar in to the rank of Professor of Medicine be- at the University of the Ethics Division at the New York fore joining the faculty of the University Colorado Anschutz Presbyterian Hospital (2002–2004), of Maryland School of Medicine in 1988. Medical Campus (www.coloradobioeth- Dr. MacKenzie was recently named a Dr. Mackowiak has published over ics.org) and an Associate Professor in member of the American Osler Society. 150 peer-reviewed articles, editorials the Department of Medicine. She has Dr. MacKenzie has published numerous and book chapters on a variety of medi- published and presented extensively peer reviewed articles, book chapters, cal topics and is perhaps best known on HIV/AIDS and the arts; literature, and abstracts and regularly lectures on in the medical community for his work film, and medicine; and medical educa- matters pertaining to the rheumatic on the diagnosis, prognosis and treat- tion; and is the editor of the Journal diseases, medical ethics, and medicine ment of fever. His book, Fever: Basic of Medical Humanities (Springer) and in general. His book, The Perioperative Mechanisms and Management, now in lead editor for the Health Humanities Care of the Orthopedic Patient, was its second edition, is the first compre- Reader published by Rutgers University published in 2014. hensive monograph on the subject since Press in October 2014 (see our re- Apart from his professional respon- one published by Wunderlich in 1868. view on page 44). Her classes include sibilities Dr. MacKenzie previously For almost two decades, Film and Healthcare at the School served on the Board of the Health Care Dr. Mackowiak has hosted an of Pharmacy; and at the School of Chaplaincy of New York, an organiza- internationally-acclaimed series Medicine, Reel Psychiatry: Film and tion devoted to the training of health of Historical Clinicopathological Mental Illness, The Doctor-Patient care chaplains and to the spiritual Conferences in Baltimore. These have Relationship in Literature and the care of hospitalized patients. This year given rise to over a score of peer- Arts, and AIDS and American Culture. he joined the Board of the Newport reviewed articles, as well as a book Recent projects include developing the Festival Foundation. In his spare time entitled Post Mortem: Solving History’s first health and humanities undergradu- Dr. MacKenzie is a musician (clari- Great Medical Mysteries. These works ate minor for University of Colorado netist), a member of the Westchester earned Dr. Mackowiak the American Denver. Her areas of interest include Symphonic Winds. In his nearly College of Physicians’ 2010 Nicholas humanities and arts in medical educa- twenty-five year association with this E. Davies Memorial Scholar Award for tion, cultural studies of medicine, and organization he has performed at Avery Scholarly Activities in the Humanities disability studies. Fisher Hall and the Caramoor Music and History of Medicine, and have Festival. He holds dual citizenship in established him as one of today’s most C. Ronald MacKenzie, MD the United States and Canada. accomplished medical historians. In Dr. MacKenzie is an Attending 2013, Oxford University Press pub- Physician at the Hospital for Special Philip A. Mackowiak, MD, MBA, lished a sequel to Post Mortem, en- Surgery and Professor of Clinical MACP titled Diagnosing Giants: Solving the Medicine and Public Health (Medical Dr. Mackowiak (AΩA, University Medical Mysteries of Thirteen Patients Ethics) at Weill Medical College of of Maryland, 1992, Faculty) is Emeritus Who Changed the World. Cornell University. Recently awarded Professor of Medicine and the Carolyn The C. Ronald MacKenzie Chair in Frenkil and Selvin Passen History of Ethics and Medicine at the Hospital for Medicine Scholar-in-Residence at the

38 The Pharos/Spring 2015 The physician at the movies

Jack O’Connell is Louis Zamperini in Unbroken, directed by Angelina Jolie. © Universal Pictures

Peter E. Dans, MD

Unbroken of war. With its many scenes of brutality, the movie certainly Starring Jack O’Donnell, Takamasa Ishihara (Miyavi), does not qualify as entertainment, but it does tell an important Domhnall Gleeson, Finn Whitrock. true story. Actually, as the book’s subtitle implies, there are Directed by Angelina Jolie. Rating PG-13. many layers to the story. Some are done well. Others, especially Running time 137 minutes. the last part, would have benefited from more fleshing out. The film begins with a harrowing crash landing of a B-24 ntense” best describes this film based on Laura Hillenbrand’s catching flak just after Zamperini releases its bombs. Viewers outstanding book Unbroken: A World War II Story of are effectively brought into the plane as it starts to lose altitude. Survival,I Resilience, and Redemption,1 which chronicles the ex- The crew manages to get back to the base; remarkably, all sur- traordinary life of Olympian Louis Zamperini (Jack O’Donnell). vive. They are not as lucky on their next mission. A clueless He survived two crash landings, the last one followed by forty- administrative desk jockey assigns them a plane that they know seven days on a raft at sea and two years as a Japanese prisoner has been cannibalized to provide parts for other planes and,

The Pharos/Spring 2015 39 The physician at the movies

sure enough, the engines go out and they crash into the sea. complied were treated to good food and hotel accommoda- Swallowing blood and oil, Zamperini surfaces, and he and the tions. Zamperini does one broadcast in which he just says he is two other survivors, pilot Phil Phillips (Domhnall Gleeson) and alive but refuses to read the script. He is sent back for twenty- gunner Mac McNamara (Finn Whitrock), are left clinging to a five more months of torture at the infamous Japanese POW raft in a limitless part of the Pacific Ocean with no landmarks. camps Ofuna, Omoki, and Naoetsu. Director Jolie then takes a step back to introduce us to Louie He is eventually freed at war’s end. The film ends when he Zamperini, a juvenile delinquent in a loving and respected gets back to the United States and is welcomed by his family. Italian-American family. His brother Pete sees the good in He had lost nearly 100 pounds, and weighed 65 pounds when him—and his ability to run fast. Track gives Louie an identity, he returned home. His conditioning probably helped him sur- and Pete acts as his brother’s timekeeper. When Louie is dis- vive. Amazingly, despite all the trauma, he lived to 97. couraged, Pete tells him, “If you can take it, you can make it,” an The “redemption” in the subtitle is covered in a few scroll- admonition that will serve him well later on. Louie ultimately ing paragraphs as part of the final credits. On Greta Van sets the state high school record for the mile, earning him the Susteren’s show in December 2014, Franklin Graham, son nickname “The Torrance Tornado.” of the Reverend Billy Graham, discussed his new film Louis Zamperini qualifies for the U.S. Olympic Team to compete Zamperini: Captured by Grace, which focuses on what Paul in the 1936 Summer Games held in Berlin. Despite coming in Harvey used to call ”the rest of the story.” Although careful eighth in the 5000 meters, he runs the last lap in a phenomenal to commend Jolie for doing a good job, he noted that the film 56 seconds, shattering the record of 69.2 seconds. Hitler seeks makers chose to end the movie at the book’s chapter 33, leaving him out to shake his hand, calling him “the boy with the fast out five chapters and an epilogue in which Billy Graham played finish.” Everything looks rosy for his chances in the upcoming a prominent role. In doing so, she missed the opportunity to Olympics to be held in Tokyo in 1940. The games are called off create a real-life story of post-traumatic stress disorder (PTSD) because of the war and Zamperini joins the Army Air Corps. and the difficulty veterans have re-entering civilian life, as well The film returns to the Pacific, where Zamperini tries to as the role of faith in combating it. If she had, a good film could ration the precious fresh water and chocolate, which are de- have been a great film, ranking with the 1946 Academy Award- pleted when a frightened Mac wolfs down a week’s worth of winning Best Picture The Best Years of Our Lives. provisions. The men are beset by sharks, and on the twenty- In Graham’s film, Zamperini recounts the perils of being seventh day they are finally spotted by planes that turn out to a “hero.” Everybody wanted to buy him a drink or to invest in be Japanese. They are strafed for thirty minutes as they try to some deal. He descended into alcoholism; drinking to oblivion escape the bullets and the sharks. The rafts are left with forty was the only way to blot out the nightmares of torture at the bullet holes, but the men manage to craft an intact one from hands of Bird, whom he vowed to kill. In May 1946, he married the remnants. On the thirty-third day, McNamara dies. During Florida debutante Cynthia Applewhite, with whom he had a a particularly bad storm, Zamperini prays, promising that if he child. The nightmares did not abate, and psychiatric treatment survives he will give his life to God. didn’t help. One night, he woke up with his hands around his Finally, after drifting 2000 miles, Zamperini and Phillips pregnant wife’s throat. Afraid and fed up with his benders, make land in the Marshall Islands. They are captured by the Cynthia filed for divorce. Attending a tent meeting during the Japanese and sent for interrogation to Kwajalein, which was Reverend Billy Graham’s first national tour, Cynthia accepted known as “Execution Island” because as soon as the prison- Graham’s invitation to welcome Christ into her heart and ers gave whatever information they seemed to have, they urged Louie to go hear him. He told her that he didn’t need were executed by beheading. Zamperini’s life is spared in anybody to tell him that he was a sinner. She responded that if recognition for his track prowess. He is sent on a “hell ship” he attended she would not divorce him. to another POW camp; on the way, eighty prisoners die. The first night, he stormed out of the meeting. The next There he is tortured mercilessly by the sadistic camp direc- day, he was about to walk out again—then he remembered his tor Corporal Mutsuhiro Watanabe, played convincingly by promise to serve God. He stayed and heeded Graham’s call to Takamasa Ishihara, a Japanese rock star whose stage name is conversion. He went home and “got rid of his liquor, cigarettes Miyavi. Called “The Bird,” Watanabe was the scion of wealthy and girlie magazines” and retrieved the New Testament that family. Washing out of officers school left him insecure and servicemen were given but which he had never consulted. As bitter about being unappreciated, which he proceeds to take he contemplated his life, he realized that he had survived; God out on his captives. He holds a special animus for the famous had kept his promise but he hadn’t. The rage, fear, and humili- Zamperini. Their interaction is covered almost to excess: ation seeped out of him to be replaced by peace, and the Bird when the Bird tells all the prisoners to slug Louie in the jaw, a left his dreams. He dedicated his life to helping wayward boys couple of times would have sufficed—we didn’t need to see a as the director of the “Victory Boys Camp.” squad of men do it. The Japanese had POWs do propaganda He decided to return to Japan to preach forgiveness. His broadcasts about how well they were being treated. Those who message to 850 war criminals at Sugamo Prison touched a

40 The Pharos/Spring 2015 number of guards, many of them his former captors. Before his Marines and American and Iraqi soldiers as they fought and conversion Louie had wanted to kill the Japanese; now he was captured such hostile towns as Fallujah and Ramadi. The film able to go back and forgive them. opens with his father teaching him how to hunt and conveying Addendum: It is estimated that twenty-seven percent of a philosophy of life. He divides people into sheep, wolves, and western POWs died in Japanese captivity, seven times that of sheep dogs. The sheep are like innocent Americans, the wolves British and American POWs held by the Germans.2 Watanabe are those who want to hurt them, and the sheep dogs are those was in the Top 40 list of war criminals. Unrepentant, he was who protect the sheep. They are the ones who care for others. aghast at being ranked with Tojo and went into hiding. He Kyle is a Texan who aspires to be a cowboy, spending his came out only when, for political reasons (the Korean War had time on the rodeo circuit busting broncos and carousing until broken out and a rehabilitated Japan was essential for stabil- he sees news footage of the 1998 U.S. embassy bombings and ity in the region), General Douglas MacArthur, pardoned all finds his calling. A self-professed sheep dog, he commits his criminals not in custody. The remaining captives who had not life to getting the bad guys and protecting the sheep from the been tried were freed when the American occupation ended in wolves. He trains as a Navy SEAL, training so rigorous as to 1952. The Bird never agreed to meet Louie. He died in 2003 at border on what some might consider torture, conducted by eighty-five, a wealthy man. hard-nosed drill sergeants spouting profanity and insults to toughen up the recruits. He meets his future wife Taya (Sienna References Miller) in a bar. Their romance and marriage are well-handled 1. Hillenbrand L. Unbroken: A World War II Story of Survival, ,and the light-heartedness is a nice counterbalance to the SEAL Resilience, and Redemption. New York: Random House; 2010. training and what is to come later. 2. McClarey DR. The Pacific War Online Encyclopedia: http:// Following the September 11 attacks, he begins the first of www.pwencycl.kgbudge.com/P/r/Prisoners_Of_War.htm. four tours in Iraq that will ultimately total 1000 days. In be- tween the tours, he is zombie-like, often sitting on a chair in American Sniper the house. Meanwhile he and his wife have two children. His Starring Bradley Cooper, Sienna Miller, and Kyle Gallner. wife says she needs him to be human, but he finds it difficult Directed by Clint Eastwood. Rated R. be a father or to connect with his wife and others on the home Running time 132 minutes. front. He wants to go back to protect his men, Life in Iraq is primitive, but they do have cell phone access. f Unbroken is a 10 on the intensity scale of 1 to 10, this film I was surprised to see him talking to his wife while stalking a rates a This Is Spinal Tap 11. It tells the story of Chris Kyle target. He must stay alert for hours as he covers the Marines (BradleyI Cooper), a Navy SEAL whose job was to protect going door-to-door, never knowing what’s behind one. When

American Sniper, directed by Clint Eastwood. From left, Kyle Gallner and Bradley Cooper. © Warner Bros.

The Pharos/Spring 2015 41 he has to relieve himself, he does so in a special bag. As the his position. He is wounded and during a sandstorm he barely number of his kills rises to 255 (160 officially confirmed), mak- makes it to a rescue helicopter. ing him “the most lethal sniper in U.S. history,” the terrorists Again, he finds it difficult to adjust to life back home. There put a bounty on his head. He wants to get Anwar al-Awlaki, the is an excellent scene portraying a Navy psychiatrist to whom American recruiter for al-Qaeda who was placed by President he admits that he is haunted by the guys he couldn’t save. The Obama on an authorized to kill list in 2010. During Kyle’s tours, doctor takes him back to a ward filled with seriously injured al-Awlaki is protected by the Butcher, who kills and beheads survivors. The sheepdog again finds a mission and as he helps any Iraqi collaborator who reveals their whereabouts. On Kyle’s them, he overcomes his PTSD. Bradley Cooper bulked up forty pounds by eating 8000 cal- ories a day to play Kyle, whom he resembles. He carries ninety percent of the film. Cooper de- served the Oscar nomination for Best Actor and should have been a front runner for captur- ing the award, as should the film have been for Best Picture. This is considered by many to be the first film to realistically portray the Iraq war and to show that the men who volunteer to pro- tect us do it for love of coun- try. I was swept into the movie and experienced a frisson of fear as the Marines went house to house, only to do it again the next day if they survived. If I were one of those men who sur- vived or a relative of one who From left, Bradley Cooper and Jake McDorman in American Sniper. © Warner Bros. died, I would be heartbroken to see those towns being re- captured by ISIS once America withdrew from Iraq. The film first tour, the Butcher does just that to a father and son while broke the box office record for a drama or an R-rated film, Kyle is pinned down by an Al Qaeda sniper. During his second garnering 105.2 million, well over its budget of 58.8 mil- tour he just misses taking down the Butcher. lion, in the first weekend it opened.1 People who had given up Kyle is not interested in the number of kills or in his being on Hollywood’s ability to get it right are going to theaters in considered a “legend” by those he protects. He prefers to focus droves. It is not an easy film to watch but it is worth seeing, on how many Americans and Iraqi soldiers he has saved from no matter your political persuasion or attitude about the war. I bombs, grenades, and IEDs, a figure essentially unknowable didn’t know the ending and was glad I didn’t. but estimated to be in the thousands. His work is carefully regulated and monitored. He must see the weapon to assure References that the target is armed; otherwise he can be brought up on 1. Fritz B and Molinski D. American Sniper gets a hero’s wel- charges. This is especially difficult because weapons can be come: Resonating with people in smaller cities, military film has carried undetected by women and children. Hampered by huge 105.3 million debut weekend. Wall Street J 2015 Jan 20: B1–2. sudden sandstorms and often up to a mile from the target, his job is extraordinarily difficult. During his third tour, the sniper Dr. Dans (AΩA, Columbia University College of Physicians and named Mustafa kills one of his buddies. Kyle feels guilty and Surgeons, 1960) is a member of The Pharos’s editorial board and agrees to an unprecedented fourth tour. During a particularly has been its film critic since 1990. His address is: dangerous attempt to get the Butcher, Kyle calls his wife and 11 Hickory Hill Road tells her he has had enough. Meanwhile Mustafa is spotted over Cockeysville, Maryland 21030 a mile away and Kyle tries a shot that alerts the terrorists to E-mail: [email protected]

42 The Pharos/Spring 2015 Reviews and reflections

David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors

have focused on the wrong things? it almost impossible to be sure who In Being Mortal, Gawande asks simi- the dying even are? Is someone with lar questions of doctors: Is it possible we terminal cancer, dementia, or incur- are focused on the wrong things, espe- able heart failure dying, exactly?p157 cially when it comes to delivering care at the end of life? Is it possible for older Gawande tells moving stories about adults to find meaning in their lives as older adults coping with illness and de- they suffer loss after loss? How can doc- cline. The best one is about his father— tors help them to do that? an energetic surgeon like his son—who Not long ago, I admitted a stoic, develops a life threatening spinal tumor. eighty-year-old man to the hospital. His Gawande shares the difficulties of mak- family said he had been vomiting for ing decisions in the face of contrary several days. The patient did not com- medical opinions, his father’s conflicted plain about it. He looked ill and wasted. values, and his own feelings about what There were dark, bilious stains on his should be done. Between the stories, hospital gown. His breaths were shallow; he offers insightful commentaries on Being Mortal: Medicine and his pulse weak and rapid. One week ear- modern medicine’s inadequate attempts What Matters in the End lier, he had been diagnosed with rectal to help ageing and ill patients like his fa- Atul Gawande cancer, and had extensive metastases to ther find meaning in their lives. He also New York, Metropolitan Books, Henry his liver, peritoneum, and lungs. He did provides interesting histories of pauper Holt, 2014, 282 pages not argue with the oncologist when she houses, nursing homes, hospice, and suggested a trial of chemotherapy. His the assisted living movement. He offers Reviewed by Dean Gianakos, MD children were all for it—“There’s always advice from palliative care experts and a chance, dad, right?” Not wanting to geriatricians. As an internist who sees hen Atul Gawande was recently disappoint the doctor or his family, he primarily older adults, I learned another asked what book he would most consented. During this admission, the good question to ask patients: “If time Wrecommend to aspiring doctors today, palliative care specialist declined to see becomes short, what is most important he answered, Leo Tolstoy’s The Death the patient until the oncologist deter- to you?” p182 of Ivan Ilych.1 The story and its themes mined there was “nothing more to do.” If there is one shortcoming to this figure prominently in Gawande’s new Here’s the dilemma, perfectly de- excellent book, it is this: Gawande of- book, Being Mortal: Medicine and What scribed by Gawande: fers few suggestions on how to slow the Matters in the End. In the opening pages, medical imperative. He acknowledges he Dr. Gawande recounts how Ivan Ilych, a In all such cases, death is certain, but is short on answers. His hope is the book Petersburg magistrate, strives to live a the timing isn’t. So everyone strug- will raise awareness of the problem, in socially proper, pleasant, and comfort- gles with this uncertainty—with how, the same way illness roused Ivan Ilych to able life. He gets promotions at work. He and when, to accept that the battle is question the meaning of his life: lives in the right neighborhoods, and be- lost. As for last words, they hardly longs to the right clubs. Everything goes seem to exist anymore. Technology This is a book about the modern pleasantly well for him until he develops can sustain our organs until we are experience of mortality—about what a mysterious, deadly disease that con- well past the point of awareness and it’s like to be creatures who age and founds his doctors. During his illness, coherence. Besides, how do you at- die, how medicine has changed the he asks himself serious questions: What tend to the thoughts and concerns of experience and how it hasn’t, where is the meaning of my life? Is it possible I the dying when medicine has made our ideas about how to deal with our

The Pharos/Spring 2015 43 Reviews and reflections

finitude have got the reality wrong. chapters. The editors and authors rep- As I pass a decade in surgical prac- resent some of the most distinguished tice and become middle-aged my- scholars of the medical humanities. The self, I find neither I nor my patients parts are: Disease and Illness, Disability, find our current state tolerable. But I Death and Dying, Patient-Professional have also found it unclear what the Relationships, the Body, Gender and answers should be, or even whether Sexuality, Race and Class, Aging, Mental any adequate ones are possible. I Illness, Spirituality and Religion, Science have the writer’s and scientist’s faith, and Technology, and Health Professions however, that by pulling back the veil Education. and peering in close, a person can In contrast to the analytical writ- make sense of what is most confus- ing of a number of the authors, there ing or strange or disturbing.p9 are several graphic stories illustrat- ing the value of images to narrative. Gawande successfully pulls back the In fact the importance of narrative is veil, and leaves physicians with a vital stressed throughout the volume, espe- question: if time becomes short, what cially the insights of Arthur Kleinman is most important to your patient? It’s a and commentary that will be of most and Howard Brody that have influenced question we hope our own doctors will value to teachers of the social sciences many of the scholars and writers repre- ask us when our time comes. and literature to students of the health sented. Digging through the demanding sciences, rather than to the students analysis of the essays in this book, the Reference themselves. While I found a number reader can find much wisdom in the ed- Atul Gawande. New York Times 2014 of interesting essays and stories, I par- itors’ understanding of the importance Oct 26: BR8. Available at: http://www.ny- ticularly appreciated “What Is Sex For? of narrative to the encouragement of times.com/2014/10/26/books/review/atul- Or, the Many Uses of the Vagina,” by empathy and to the practice of listening gawande-by-the-book.html. Alice Dreger, which was simply hilari- to patients. In reality, if there is a fun- ous, as well as sad and often scary. On damental problem in modern scientific Dr. Gianakos is associate director of the first reading I found much of the vol- medicine, it may be the too common Lynchburg Family Medicine Residency in ume heavy on the analysis. But I must failure of so many physicians—often Lynchburg, Virginia, and a member of the admit that my bias is for the story, the pleading their lack of time—to listen for editorial board of The Pharos. His address poem, or the case rather than the the- and elicit the patient’s story, the history. is: ory. However, as I delved deeper into As the grandfather of a young boy Lynchburg Family Medicine Residency the collected essays I did find the theory who is on the autistic spectrum, I was 2323 Memorial Avenue intriguing and quite instructive. very interested in the essay “Teaching Lynchburg, Virginia 24501 Another exception to the rule Autism Through Naturalized Narrative E-mail: [email protected] that this is serious stuff was my col- Ethics: Closing the Divide between league Jack Coulehan’s “Occupational Bioethics and Medical Humanities,” by Medicine,” a charming reminiscence of Julie M. Aultman. She comments on the The Health Humanities Reader his time as a college student working in difference between medical ethicists the Wheeling Steel plant in Steubenville, and humanities scholars. Therese Jones, Delese Wear, and Lester Ohio. Discovering that their greenhorn Friedman, editors apprentice was premed instantly el- The often unspoken, but ever- Rutgers University Press, 2014, 603 evated him to the rank of physician present social divide between medi- pages in the estimation of his co-workers: cal ethicists and medical/health Reviewed by David A. Bennahum, “I turned into ‘Doc’ . . . ‘Hey, Doc, my humanities scholars is created in MD (AΩA, University of New Mexico, wife’s gall bladder is acting up.’ ‘Hey, part from the ways illness, disability, 1984) Doc, my youngest boy, he’s been cough- and death are conceptually, descrip- ing all night.’ ‘Listen, Doc, Brick’s got tively, and normatively examined. the clap again. He says penicillin doesn’t Medical ethicists use theories, prin- he Health Humanities Reader, work. What do you think he should ciples, and approaches to ethical de- edited by Therese Jones, Delese do?’ ” pp149–50 cision making to recognize, resolve, TWear, and Lester D. Friedman is a 600- The text is divided into twelve parts, and reflect on ethical problems. The page compendium of stories, poetry, each part composed of three or four humanities scholar, in contrast, is

44 The Pharos/Spring 2015 not solely concerned with problem Harvard scientist Gregory Goodwin solving, per se, but seeks to under- Pincus, an expert in the hormonal as- stand the human condition—those pects of pregnancy. Considered to be a who suffer, those who are disem- brilliant scientist, his work on in vitro powered by disease, those who want fertilization in animals was widely re- their children to be “normal.” They ported by the press, although misrep- also seek to understand the webs of resented as an attempt to produce test relationships in which individuals tube or bottle babies. (He was in fact are embedded, along with the mean- re-implanting fertilized eggs in experi- ings of those relationships.p479 mental animals.) The notoriety led to Harvard’s refusal to renew his contract. Edmund Pellegrino wrote that the After unsuccessfully applying for jobs good physician was both competent and at many universities, Pincus eventually compassionate. But that same physician gained a minor appointment at Clark and nurse are often wounded warriors. University in Worcester, Massachusetts, Long hours, the suffering and death of where he established his laboratory in a patients, work that separates the health dirty basement. Unlike other scientists care professional—especially young Sanger had contacted, Pincus believed house officers—from family and friends, that it was possible to create a birth The Birth of the Pill: How Four all exact their toll. A defense and a control pill. He immediately focused Crusaders Reinvented Sex and strategy for healing from the unavoid- on progesterone and manmade proges- Launched a Revolution able deformation that is a consequence tins. Progesterone concentrations were of caring for the sick is the search for Johnathon Eig known to be elevated during pregnancy meaning through images and literature, New York, WW Norton, 2014 and were presumed to be the reason music and dance, and the other arts and that pregnant women did not ovulate. Reviewed by William P. Reed, MD humanities. Medicine is indeed an art, Some progestins were known to block what the Greeks called techne, or the ovulation at much lower concentrations craft of medicine. And it is often indeed he history of the development of than were required for progesterone in the humanities where those of us who the birth control pill is remarkable itself. Over the next decade Pincus con- care for the sick can find meaning and forT the low cost of the process and the centrated his experiments on the birth healing. simplicity of testing and marketing it, control problem and became the scien- This book will be very helpful to as told by Johnathon Eig in this detailed tific brains behind the idea. teachers of the humanities to medical and readable book. The idea began with To pay for the experiments, Sanger students, physicians, nurses, and all Margaret Sanger, the fiery and well relied on her friendship with Katherine other health professionals who wish known proponent of woman’s rights. Dexter McCormick, the daughter-in- to prepare themselves to use a variety Mr. Eig summarizes her role in the first law of the founder of International of materials such as short stories, im- sentence of the book: “She was an old Harvester. Dexter had earned a BSc in ages, music, and the social sciences to woman who loved sex and she had spent biology at the Massachusetts Institute of encourage the natural empathic skills of forty years seeking a way to make it bet- Technology in 1904, and later that year their students, and to offer meaning and ter.” Sanger fervently believed that there married Stanley McCormick. In 1906, healing to those engaged in the privilege should be a way for a woman to take a Stanley McCormick was diagnosed with of caring for the sick. It belongs in every scientifically designed pill in the morn- schizophrenia, and he was declared le- health sciences library and on the desk ing and have sexual intercourse later in gally incompetent some years later. After of many humanities and social science the day with no fear of pregnancy, while meeting Pincus, McCormick became teachers. knowing that she could stop taking the interested in his experiments, and sup- pill and return to normal fertility. She ported them until they were complete. Dr. Bennahum is a book review editor for had asked many medical scientists if For the first part of his animal studies The Pharos and a member of its editorial such was possible, and had always re- Pincus had worked on using progester- board. His address is: ceived the answer that no, there was no one or a progestin as an agent to prevent 1707 Notre Dame NE way that such a pill could be developed. ovulation. Because he had no idea what Albuquerque, New Mexico 87106 At age seventy-one, still looking for dose to use in humans and what the E-mail: [email protected] a scientific way to fulfill her dream, toxicity of the drug would be, he needed Sanger visited forty-three-year-old a medical doctor to oversee that part

The Pharos/Spring 2015 45 Reviews and reflections Letter to the editor

of the study and to run the subsequent addition of estrogen had reduced the Re “How postoperative respiratory clinical trials. That was John Rock, MD, side effects, leading him to incorporate distress conspired with friendly the last major person to become involved low-dose estrogen in the pill. fire to kill ‘Stonewall’ Jackson” in the development of the birth control Application to the Federal Drug Kudos to DuBose et al. for their pill. Rock was a Harvard professor of Administration (FDA) faced the prob- paper in the Autumn 2014 edition of obstetrics and gynecology, one of the lem that no criteria existed for approv- The Pharos (pp. 18–24). I was raised world’s leading experts in the treatment ing a drug to be taken by healthy women in a house devoid of racism but built of infertility, and intensely interested in for contraception, given the existence of on a confederate fort (Fort Pemberton) women being able to control their own non-drug options, as well as opposition in Charleston, South Carolina. You reproduction. Rock had a sterling repu- by the Catholic Church. It was decided could say that disparity is an adequate tation and became the ethical standard to apply for permission to market the description of my take on general bearer for the study. Before his participa- drug for menstrual disorders (too much Thomas Jonathan Jackson and the War tion, and even after he became involved, bleeding or painful periods), for which between the States. parts of the trial had ethical lapses that there was adequate experimental evi- Having studied the Civil War, I must would be unlikely to be tolerated today. dence that the pill had value when taken admit that Jackson was the most amaz- In one case, female Puerto Rican medi- for several cycles. The FDA at the time ing commander of our “civil” tragedy. cal students were told in one class that was seriously understaffed and over- He was a leader of men, a genius in they had to be subjects in an early study worked, and sought outside advice. The both strategy and tactics. In war time evaluating the safety of the drug, and drug was finally approved in 1957; there this defines a general who will conquer that their grades would partly depend on is no evidence that it could have been and, by design, kill. His fanatical sense their participation. While Pincus knew approved as a contraceptive. Pincus of duty was praised and envied by both and approved of this attempt to force touted Enovid’s use as a contraceptive sides and highlighted by commanding participation, Rock did not. at conferences, noting that physicians general Robert E. Lee’s dependence Even as the date approached on could prescribe it off-label for that pur- upon this rebel general. After hearing which the group had hoped to have pose. This was reported widely in the the news of the incident and amputa- the pill on the market, Pincus had not news media, leading to the drug being tion, Lee commented, “He has lost his decided which progestin he would use. regularly prescribed for contraception. left arm, but I my right.” 1 He finally settled on a 10 mg dose of Enovid was approved for contraception The only part lacking from the norethylnodrel, a G.D. Searle patented in 1960 as an amendment to the original above paper was one quote, a few progestin. The drug choice may have approval. simple words whispered from the frail been influenced by Searle’s willingness It would be difficult to think of an- lips of a dying man who had found his to provide the progestin and manufac- other drug that has had a greater ef- purpose. After all of the generalship, ture and market the drug, although the fect on human behavior than Enovid, after all of the killing, Jackson left to cost to the company was very low. The initially marketed at about fifty cents a history these last words, “Let us cross dose was chosen since Pincus knew pill. And it is remarkable that only four over the river and rest under the shade that it would provide near 100 percent people were primarily responsible for of the trees.” 2 efficacy in preventing pregnancy; the its development: Sanger with her dream Can one’s last words make a warrior side effects could be reduced later if and drive to make it happen, Pincus poet? necessary by reducing the dose.* One with his scientific knowledge and skill batch of the drug provided to Pincus to develop the drug, McCormick with References was inadvertently contaminated by es- the funds and commitment to pay the 1. Robertson JI Jr. Stonewall Jackson: trogen—when Pincus learned of this, majority of the costs, and Rock with his The Man, the Soldier, the Legend. New he realized from the test data that the clinical skills and reputation that made York: MacMillan Publishing; 1997: 746. the drug successful. 2. McGuire H. Death of Stonewall Jack- son. Southern Historical Soc Papers 1886; *In a study of eighty patients, only five Dr. Reed is retired from a professorship in 14: 162–63. had no side effects. Common side effects Internal Medicine and Infectious Diseases were nipple swelling or discoloration, sore- William B. Crymes, Jr., MD at the University of New Mexico School of ness of the breast, nausea or vomiting, vag- (AΩA, Medical University of South Medicine. His address is: inal discharge, changes in libido (usually an Carolina, 2003) increase), and occasional subjects experi- 317 Hermosa SE Charleston, South Carolina enced lactation. In other studies there was Albuquerque, New Mexico 87108 breakthrough bleeding. Thrombophlebitis E-mail: [email protected] was later noted as a side effect.

46 The Pharos/Spring 2015 When I was thirteen My father died in his sleep; I heard his death rattle, I watched my mother’s efforts to revive him, And I listened, without hearing, As the doctor tried to comfort me. Hope Springs I saw my father in his coffin, And saw that coffin lowered into the ground; Eternal Yet, weeks later, When, from a distance, I saw a man that looked like him, Walked like him and dressed like him, I ran to get a closer look, Hoping I’d been cruelly tricked— Realizing I had not. Now in my seventy-seventh year, Beloved friends and relatives have died; I saw them in their coffins, I saw their coffins lowered into the ground, And still I run after their look-alikes, Only slower. Albert I. Kaufman, PhD

Dr. Kaufman (AΩA, State University of New York, Downstate Medical Center, 1991) is Associate Professor of Physiology Emeritus at the State University of New York Health Science Center at Brooklyn. His address is: State University of New York Downstate Medical Center, 2609 Avenue S, Brooklyn, New York 11229. E-mail: [email protected]. Illustration by Jim M’Guinness. 2014 donations to Alpha Omega Alpha

Thank you to our members who donate to the society. Your contributions, in addition to dues, help us to both support and expand our national programs for medical students, faculty, and residents. Members are listed in alphabetical order. The member’s induction year and the school at which he or she was inducted are noted in parentheses.

A Robert F Ashman (1966 Columbia University) Gary N Abberbock (1982 State University of New York, Downstate Carl I Austin (1946 SUNY Upstate Medical University College of Medical Center) Medicine) Elliot E Abbey (1974 New York University) Francisco Aviles-Roig (1967 University of Puerto Rico) Warren R Abel (1987 Medical College of Georgia at Georgia Regents Karen Laice Axelsson (1988 University of California, San Francisco) University) Irving Paul Ackerman (1949 Columbia University) B Stephen D Adler (1968 Stanford University School of Medicine) Janiine Babcock (1984 Baylor College of Medicine) Vincent Robert Adolph (1988 Louisiana State University School of Robert W Backus (1976 University of Vermont) Medicine in New Orleans) David Brian Badesch (1982 University of Virginia) Ali Al Shanqeeti (1998 Michigan State University College of Human Byron J Bailey (1994 University of Texas Medical Branch) Medicine) John H Bair (1983 Northeast Ohio Medical University) Frank Philip Aloi (1995 MCP Hahnemann [Allegheny University]) Bruce E Baker (1965 SUNY Upstate Medical University College of Mara J Aloi (1995 MCP Hahnemann [Allegheny University]) Medicine) Jorge E Alonso (2013 University of South Alabama College of Medicine) Ronald F Baldwin (1994 Indiana University) Kenneth S Alpern (1988 University of Texas Medical Branch) David C Ballard III (1974 Medical College of Georgia at Georgia Regents David F Alstott (1963 Indiana University) University) Richard Daniel Amelar (1991 New York University) James O Ballard III (1968 University of Maryland) Akshay N Amin (1990 University of Maryland) Wiley P Ballard III (1978 Emory University) Louis F Amorosa (1979 Rutgers Robert Wood Johnson Medical School) Samir K Ballas (1967 American University of Beirut) Clay M Anderson (2006 University of Missouri) Leonard C Bandala (1984 University of Illinois) Joseph Thomas Anderson (1989 University of South Carolina) Francis E Banich (1957 Loyola University, Stritch School of Medicine) Richard M Anderson (1958 Emory University) Jeremy Baran (2010 Uniformed Services University) Shirley C Anderson (1983 University of Washington) Thomas J Barloon (1975 Medical College of Wisconsin) Tom Anderson (1982 Medical College of Wisconsin) John F Barlow (1979 University of South Dakota) Sonia Andonian (1949 Wayne State University) Margaret M Barnes (1981 Temple University) Kenneth W Andre (1972 University of Chicago) Florence C Barnett (1992 Medical College of Georgia at Georgia Ellen Andrews (1984 Meharry Medical College) Regents University) Linda B Andrews (1988 University of Oklahoma College of Medicine) Linda Marie Barney (1985 Wright State University Boonshoft School of M Dewayne Andrews (1970 University of Oklahoma College of Medicine) Medicine) Andrea Lynn Baron (1987 Emory University) Robert John Andruss (1989 University of Minnesota) Charles P Barsano (1997 Rosalind Franklin University of Medicine & Jared L Antevil (1998 University of Virginia) Science) Ronald I Apfelbaum (1965 MCP Hahnemann [Allegheny University]) Jared B Barton (2002 University of Washington) Mary Saxe Aplin (1984 University of Miami) Khurram Bashir (1997 Southern Illinois University) Herbert H Applebaum (1963 University of Miami) Jerome V Basinski (1962 Saint Louis University) Gary Wilson Archer (1978 University of Kentucky) James G Bassett (1976 Drexel University College of Medicine (merged Bernadette Arnecke (1984 University of Texas Medical Branch) with Hahnemann in 1998)) Dominic D Aro (1993 New York Medical College) Barry C Bauer (2001 University of South Dakota) Dion J Arthur (1991 New York Medical College) David M Bear (1971 Harvard Medical School) Arthur K Asbury (1958 University of Cincinnati) Jimmie L Beasley (1973 University of Tennessee Health Science Center) Paul Levon Asdourian (1981 SUNY Upstate Medical University College Joshua A Becker (1957 Temple University) of Medicine) Richard A Beison (1958 Indiana University) Howard R Belkin (1997 Wayne State University)

48 The Pharos/Spring 2015 Laurel L Bell (1999 University of Maryland) Donald D Brown (1965 University of Iowa) Alan H Bennett (1963 Albany Medical College) James T Brown (1994 University of Illinois) J Claude Bennett (1990 University of Alabama at Birmingham School of Karen T Brown (1979 Boston University School of Medicine) Medicine) Thomas Edwin Brown (1990 Medical University of South Carolina) Warren Lee Berggren (2010 University of Nebraska) Thomas A Bruce (1955 University of Arkansas) Steven C Bergin (1974 Medical College of Wisconsin) William B Bruce (1976 University of Miami) Jacqueline M Bernard (1999 Uniformed Services University) Richard D Buchanan Dr (1961 Vanderbilt University) Stephen A Bernard (1972 University of North Carolina) Tracy L Buckingham (1989 SUNY Upstate Medical University College Sol Bernstein (1956 University of Southern California) of Medicine) Frank W Berry Jr (1962 Meharry Medical College) Louis E Buettner (1964 University of Alabama at Birmingham School of Howard Bessen (1978 David Geffen School of Medicine at University of Medicine) California, Los Angeles) Terrence J Bugno (1982 Northwestern University) Robert F Betts (1964 University of Rochester School of Medicine and Louis Maximilian Buja (1967 Tulane University) Dentistry) Jeffrey M Bumpous (1988 University of Louisville) Joseph N Biase (1989 Rutgers Robert Wood Johnson Medical School) Susan C Bunch (1983 University of Louisville) Michael C Bidgood (1971 University of Washington) Petra Burke Ramirez (2001 University of Puerto Rico) Brian Bigelow (2001 Indiana University) John K Burkus (1979 Yale University School of Medicine) Charles Billington (1978 University of Kansas) Charles G Burton (2005 Mercer University School of Medicine) Linton H Bishop Jr (1980 Emory University) Dale Robin Burwen (1988 Tufts University School of Medicine) Robert P Bishop (1956 Howard University) Joseph K Bush (1961 University of Tennessee Health Science Center) Nancy E Bizzell (1980 Emory University) Suzanne Yancey Bush (2011 Florida State University) Cary M Bjork (1972 University of Colorado) John T Bushore (1970 University of Tennessee Health Science Center) Dennis D Black (1978 University of Tennessee Health Science Center) Neil A Busis (1977 Raymond and Ruth Perelman School of Medicine at Edgar R Black (1976 Raymond and Ruth Perelman School of Medicine the University of Pennsylvania) at the University of Pennsylvania) Sidney N Busis (1945 University of Pittsburgh) Robert Leo Black (1988 University of Illinois) John E Buster (1982 David Geffen School of Medicine at University of R Don Blim (1979 University of Kansas) California, Los Angeles) Gary F Bloemer (1982 University of Louisville) Louis A Buzzeo (1972 Tufts University School of Medicine) Eugene C Bloom (1960 University of Miami) Edwin D Blumberg (1967 Columbia University) C Oheneba Boachie-Adjei (2008 Weill Cornell Medical College) Enrico Caiola (1994 University at Buffalo, School of Medicine & Bradford D Bobrin (1995 MCP Hahnemann [Allegheny University]) Biomedical Sciences) Ernie Bodai (1988 University of California, Davis) Rafael A Calabria (1964 University of Puerto Rico) William M Boehme (1969 Albany Medical College) Mark A Caldemeyer (1987 Indiana University) Eugene V Boisaubin (1970 University of Missouri) Maria Capparelli (2013 New York Medical College) Richard J Bonforte (1964 Georgetown University) Bradley D Card (1980 University of Western Ontario Faculty of Christopher A Bonnet (1982 University of Pittsburgh) Medicine and Dentistry) Donald L Boos Jr (1984 University of Toledo College of Medicine) Dennis J Card (1966 Georgetown University) L Bradford Boothby (2007 Boston University School of Medicine) Marcia B Cardelli (1985 Wayne State University) Charles W Bouch (1996 Tulane University) Michael A Carducci (1987 Wayne State University) Carl W Bourne (1974 Howard University) Donald J Carek (1956 Medical College of Wisconsin) Susan B Boutilier (1992 University of California, Davis) Mark M Carpenter (1975 University of Wisconsin School of Medicine James K Bouzoukis (1956 University of Maryland) and Public Health) Victor D Bowers (1984 University of South Florida) Martha A Carpenter (1958 University of Virginia) Mark S Box (1986 University of Missouri) Francisco Carpio (1992 Universidad Central del Caribe) Melville D Bradley (1995 Universidad Central del Caribe) Laura R Carucci (1995 SUNY Upstate Medical University College of Steven P Braff (1975 Wayne State University) Medicine) Jennifer Brainard (1994 Ohio State University) James Louis Caruso (1988 University of Illinois) Karen Jean Brasel (1990 University of Iowa) Margaret S Casey (1993 Dalhousie University Faculty of Medicine) Randall P Brewer (1992 Louisiana State University Health Sciences Nelson D Castellano (1970 University of Miami) Center in Shreveport) Deena M Castellion (1993 Wake Forest School of Medicine) Mellena D Bridges (1990 Medical College of Georgia at Georgia Regents John C Cate IV (1967 University of Tennessee Health Science Center) University) Benedict S Caterinicchio (1957 New York Medical College) Gary Brigham (1990 University of Illinois) Robert P Cavallino (1959 Tufts University School of Medicine) Gilbert D Brinckerhoff (1966 George Washington University) John A Cece (1980 Rutgers Robert Wood Johnson Medical School) Richard R Brock (1957 Sidney Kimmel Medical College, Thomas Assaad Alfred Chahine (1989 Saint Louis University) Jefferson University) Naga P Chalasani (1993 Emory University) Roy D Brod (1983 Temple University) George P Chambers Jr (2000 SUNY Upstate Medical University College Albert Compton Broders III (1972 Duke University School of Medicine) of Medicine) James E Brodhacker (1964 Saint Louis University) Lawrence S Chan (1995 Northwestern University) Christine Z Brody (1991 David Geffen School of Medicine at University Robert Gregory Chandler (1988 University of Tennessee Health Science of California, Los Angeles) Center) David A Browdie (1963 Case Western Reserve University) Richard N Channick (1984 Temple University)

The Pharos/Spring 2015 49 2014 Donations

Nancy L Chapin (1983 Boston University School of Medicine) Thomas Joseph Curran Jr (1987 University of Southern California) James D Charasika (1976 Meharry Medical College) Mary F Curtis (1983 Oregon Health & Science University School of Francis T Chardo (1969 Medical University of South Carolina) Medicine) Marvin H Chasen (1973 Ohio State University) Louis B Chaykin (1960 Temple University) D Allan J Chernov (1963 University of British Columbia Faculty of Samuel Dagogo-Jack (2006 University of Tennessee Health Science Medicine) Center) Raja Cheruvu (1994 Boston University School of Medicine) David C Dale (1966 Harvard Medical School) Francis A Chervenak (1976 Sidney Kimmel Medical College, Thomas Douglas D Dalke (1982 University of Nebraska) Jefferson University) Peter E Dans (1960 Columbia University) Ann Marie Chiasson (1996 Dalhousie University Faculty of Medicine) Robert B Daroff (1983 Case Western Reserve University) Richard C Childs (1980 University of South Alabama College of Phyllis Anast Darrow (1984 University of Colorado) Medicine) Edward A Dauer (2011 University of Kansas) Arva Yahua Chiu (1990 Wake Forest School of Medicine) Ezra C Davidson Jr (1957 Meharry Medical College) Mahmoud Choucair (2010 American University of Beirut) Stuart Davidson (1965 University of California, San Francisco) Jim C Chow (2007 University of South Carolina) Alonzo J Davis IV (1992 East Carolina University Brody School of Raymond C Christensen (1951 University of Iowa) Medicine) Robert J Christie (1990 Virginia Commonwealth University) Courtland H Davis Jr (1967 Wake Forest School of Medicine) James H Christy (1970 Emory University) John C Davis (1998 University of Alabama at Birmingham School of Lindy Lee Cibischino (1990 Rutgers New Jersey Medical School) Medicine) Lucy Civitello (1979 New York Medical College) Paul J Davis (1994 Albany Medical College) Mark F Clapper (1984 Uniformed Services University) Lloyd A Dayes (1959 Loma Linda University) Bernard J Clark (1954 Georgetown University) Patricia Monique de Groot (2003 University of Texas Medical Branch) Terence M Clark (1971 University at Buffalo, School of Medicine & Caridad M De La Uz (2005 Georgetown University) Biomedical Sciences) Darryl C De Vivo (1963 University of Virginia) Gregory D Clarke (1988 West Virginia University) Thomas M Dean (1972 University of Rochester School of Medicine and Lynn M Cleary (1978 Ohio State University) Dentistry) Dennis Clements (2005 Duke University School of Medicine) George W Dec (1978 Johns Hopkins University) James A Clifton (1973 University of Iowa) Lawrence DeGan (1982 Indiana University) Brian T Clista (1992 University of Pittsburgh) Peter J Dehnel (1981 University of Minnesota) Jay M Coblentz (1968 Raymond and Ruth Perelman School of Medicine Joseph B Delcarpio (2005 Louisiana State University School of Medicine at the University of Pennsylvania) in New Orleans) Douglas A Coe (2007 University of Missouri-Kansas City) Mahlon R Delong (2001 Emory University) Stephanie M Cohen (1991 Georgetown University) Marlene DeMaio (1985 MCP Hahnemann [Allegheny University]) Francis R Colangelo (1984 Sidney Kimmel Medical College, Thomas Mark Emil DeMichiei (1984 Ohio State University) Jefferson University) Jaime Rice Denning (2005 Case Western Reserve University) Elliott H Coleman (1963 Temple University) Mariellen Dentino (1973 Indiana University) James U Collins (1965 Wayne State University) Scott Denton (1995 University of Arizona) Melba Colon (2012 Universidad Central del Caribe) Ellen S Deparedes (2004 Virginia Commonwealth University) Michael J Connor Jr (2007 Warren Alpert Medical School of Brown George Dermksian (1954 Weill Cornell Medical College) University) Joseph P Derrick (1953 Northwestern University) J Lyle Conrad (1974 George Washington University) Sabrina Fraser Derrington (2004 University of California, Davis) William F Conway (1981 University of Chicago) Marvin A Dewar (1980 University of South Florida) Thomas G Cooney (1991 Oregon Health & Science University School of Nancy W Dickey (1976 University of Texas Medical School at Houston) Medicine) Richard L Dillard (1959 University of Tennessee Health Science Center) Dennis W Cope (1970 University of Kansas) Susanne Ruth Dillon (1987 Oregon Health & Science University School Eugene C Corbett Jr (2001 University of Virginia) of Medicine) Mark Oliver Cosentino (1986 Rutgers New Jersey Medical School) Carol R DiRaimondo (1980 Vanderbilt University) Robert B Couch (1956 Vanderbilt University) Dale Distant (1992 State University of New York, Downstate Medical Steven L Coulter (1976 University of Oklahoma College of Medicine) Center) Marilyn L Cowger (1956 University of Nebraska) Sarina Joanne Distefano (1980 New York Medical College) Cris G Cowley (1976 University of Utah) Corinne R Dix (1981 University of Colorado) Sylvia S Crago (1992 University of New Mexico) Cathleen Doane-Wilson (1980 University of Vermont) James L Craig (1956 University of Tennessee Health Science Center) Maryanne L Dokler (1978 Creighton University) Walter P Craig Jr (1969 Tulane University) Bruce R Dolitsky (1981 University of Illinois) Barbara J Crain (1975 Duke University School of Medicine) Karen B Domino (1978 University of Michigan) Lucy S Crain (1991 University of Kentucky) Vincent Donnabella (1987 Rutgers New Jersey Medical School) Richard L Cronemeyer (1976 University of Kansas) John M Dorsey Jr (2002 Wayne State University) Lee R Crowe (1971 University of Tennessee Health Science Center) Bonnie B Dorwart (1966 Temple University) Donna Kathryn Culhane (1990 University of Nebraska) Donald J Doughman (1961 University of Iowa) Carolyn A Cunningham (1966 Indiana University) Stephen P Dretler (1962 Tufts University School of Medicine) James Anthony Cunningham (1980 New York Medical College) Thomas W Dugdale III (1980 MCP Hahnemann [Allegheny University]) Charles B Cuono (1970 West Virginia University) Igor Dumbadze (1973 University of Cincinnati)

50 The Pharos/Spring 2015 W Christopher Duncan (1959 Baylor College of Medicine) Kevin F Forsthoefel (1986 University of Cincinnati) Ramon S Dunkin (1956 Indiana University) Mario D Forte (1986 University of Washington) Lawrence A Dunmore Jr (1955 Howard University) James M Foss (1975 University of Washington) Robert F Dunton (1979 Albany Medical College) Burt Fowler (1975 University of Oklahoma College of Medicine) Barbara J Fox (1979 University of Cincinnati) E Brendan M Fox (1954 Tufts University School of Medicine) James Eastman III (1972 University of Cincinnati) Joan M K Fox (1985 University of Minnesota) Timothy J Eberlein (1976 University of Pittsburgh) Alvin L Francik (1963 University of Illinois) Samuel R Eby (1981 University of Colorado) Paul B Francis Jr (1966 University of Tennessee Health Science Center) Florence F Eddins-Folensbee (2007 Baylor College of Medicine) Marvin G Frank (1964 Virginia Commonwealth University) Arnold H Einhorn (1975 Albert Einstein College of Medicine of Yeshiva Harold D Frankl (1955 University of Southern California) University) Robert W Frater (1971 Albert Einstein College of Medicine of Yeshiva Howard J Eisen (1980 Raymond and Ruth Perelman School of Medicine University) at the University of Pennsylvania) Erling W Fredell (1954 Stanford University School of Medicine) Richard R Ellis (1971 University of Illinois) Craig A Fredericks (1981 George Washington University) F E Ellison Jr (1963 Medical University of South Carolina) Lawrence E Freedberg (1968 New York University) Stephanie H Elmore (1994 University of Texas Medical School at Barbara K Freeman (2004 Case Western Reserve University) Houston) Eliot Freeman (1973 Temple University) Iheanacho Emeruwa (1980 Howard University) Susan L Freeman (2012 Temple University) Benjamin P Eng (2001 Eastern Virginia Medical School) Nicole Frei (1994 University of Cincinnati) Calvin T Eng (1984 University of California, San Francisco) Cesar Freytes (1979 University of Puerto Rico) Timothy R Enright (2005 University of Wisconsin School of Medicine Arno H Fried (1980 Meharry Medical College) and Public Health) William H Frishman (1978 Albert Einstein College of Medicine of Christopher Thomas Erb (2008 University of Illinois) Yeshiva University) Richard W Erbe (1962 University of Michigan) Arthur H L From (1962 Indiana University) Frederick J Ergen (1979 University of Tennessee Health Science Center) Robert A Fuhrman (1966 Rosalind Franklin University of Medicine & Corinne S Ertel (1979 University of Michigan) Science) Harry C Eschenroeder Jr (1981 University of Missouri) Conrad Fulkerson (1968 University of Missouri) Angel F Espinosa-Lopez (1997 University of Puerto Rico) Scott A Fulton (1989 Wayne State University) John D Everett (1980 Wayne State University) Frank E Fumich (1999 Marshall University School of Medicine) F William B Furgerson Jr (1955 University of Louisville) Phillip F Fuselier (1963 University of Texas Medical Branch) Melanie A Farrell (1986 Sidney Kimmel Medical College, Thomas Jefferson University) G Kimberly N Feigin (1997 University of Rochester School of Medicine Gayle A Galan (1978 Case Western Reserve University) and Dentistry) Anthony N Galanos (2007 University of South Alabama College of J R Feild (1957 University of Tennessee Health Science Center) Medicine) Seymour H Fein (1974 New York Medical College) Wm Ted Galey (1996 Oregon Health & Science University School of Donald I Feinstein (1972 University of Southern California) Medicine) James P Felberg (1996 University of New Mexico) S Raymond Gambino (1952 University of Rochester School of Medicine Bruce A Feldman (1965 Harvard Medical School) and Dentistry) Charles R Felton (1977 University of Texas Health Science Center at San Robert P Gannon (1959 Medical College of Wisconsin) Antonio) James C Garbutt (1973 University of Illinois) Melissa C Fenner (1986 University of Texas Southwestern Medical William Gardner (2013 Northeast Ohio Medical University) Center at Dallas) W Timothy Garvey (1977 Saint Louis University) John J Fennessy (1974 University of Chicago) Walter J Gaska (1964 SUNY Upstate Medical University College of Kenneth R Ferguson (1951 University of Western Ontario Faculty of Medicine) Medicine and Dentistry) James C Gay (1978 Emory University) Eduardo E Fernandez (1993 Rutgers Robert Wood Johnson Medical Thomas A Gennarelli (1968 Loyola University, Stritch School of School) Medicine) Ruth-Marie E Fincher (1976 Medical College of Georgia at Georgia Craig John Gerard (1985 Wake Forest School of Medicine) Regents University) Dale N Gerding (1967 University of Minnesota) Nancy Fishback (2004 Eastern Virginia Medical School) Richard L Gerety (1976 University of New Mexico) T Lawrence Fleisher (1956 University of Puerto Rico) Michael H Gewitz (1988 MCP Hahnemann [Allegheny University]) Lewis Flint Jr (1981 University of Louisville) Charles Eugene Giangarra (2010 Marshall University School of David N Flitter (1975 State University of New York, Downstate Medical Medicine) Center) Eric Paul Gierke (1990 University of Washington) Alan M Fogelman (1965 David Geffen School of Medicine at University William Donal Gieseke (1968 Indiana University) of California, Los Angeles) Edward B Gilmore (1965 Harvard Medical School) Alexander Alb Fondak (1972 Georgetown University) Robert A Gisness (1979 University of South Dakota) Eric W Fonkalsrud (1957 David Geffen School of Medicine at University Wolfram Glaser (1969 University of Alabama at Birmingham School of of California, Los Angeles) Medicine) Edward H Forgotson (1956 Washington University in St Louis School of Paul R Glowienka (1982 Uniformed Services University) Medicine)

The Pharos/Spring 2015 51 2014 Donations

Richard J Gnaedinger (1993 University of Illinois) Michael S Harris (1966 University of Texas Southwestern Medical James E Goddard Jr (1957 University of Pittsburgh) Center at Dallas) Edward L Goldblatt (1966 University of Alabama at Birmingham School Frank N Harrison Jr (1973 Medical College of Georgia at Georgia of Medicine) Regents University) Francisco Gonzalez-Scarano (1975 Northwestern University) Gregory T Harshbarger (1974 Creighton University) Erica T Goode (1994 University of California, San Francisco) John A Haugen (1975 University of Minnesota) Samuel Goodloe Jr (1968 Howard University) Arthur Haut (1949 Columbia University) Gary G Gordon (1958 State University of New York, Downstate Medical Donald R Hawes (2005 Indiana University) Center) Jackie Hayes (1987 University of Mississippi) Ronald A Gosnell (2000 University of Minnesota) Helen Hays (1987 University of Alberta Faculty of Medicine and Bobby L Graham Jr (1982 University of Mississippi) Dentistry) Caleb Michael Graham (2013 University of Mississippi) L Julian Haywood (1981 Howard University) Carla C Graham (1990 East Carolina University Brody School of Jerris R Hedges (1994 Oregon Health & Science University School of Medicine) Medicine) Avrum Vremmie Gratch (1959 University of Chicago) R David Heekin (1997 Uniformed Services University) Mark T Grattan (1978 University of California, San Francisco) Alexandra S Heerdt (1986 Sidney Kimmel Medical College, Thomas Gilman D Grave (1966 Harvard Medical School) Jefferson University) David Wayne Gray (1987 University of Illinois) James J Heffernan (1976 Boston University School of Medicine) Leonard Joseph Graziani (1975 Sidney Kimmel Medical College, Anthony Hein (1994 David Geffen School of Medicine at University of Thomas Jefferson University) California, Los Angeles) Alan R Green (1969 New York Medical College) David Joseph Heinsch (2010 Medical College of Georgia at Georgia Jacob B Green III (1964 University of Texas Medical Branch) Regents University) Burton H Greenberg (1960 University of Illinois) Richard Hellman (2005 Rosalind Franklin University of Medicine & Harold L Greenberg (1965 University of Miami) Science) Mary A Greene-McIntyre (1983 Meharry Medical College) John H Helzberg (1980 University of Rochester School of Medicine and William B Greenough III (1957 Harvard Medical School) Dentistry) Dorothy R Gregory (1958 University at Buffalo, School of Medicine & Dennis L Hemingway (1960 University of Wisconsin School of Biomedical Sciences) Medicine and Public Health) Christopher P Grenier (1986 Louisiana State University School of John W Henderson (1940 Northwestern University) Medicine in New Orleans) Marlene A Henning Sachs (1997 Geisel School of Medicine at Jamie B Grimes (1990 Uniformed Services University) Dartmouth) Thomas J Grogan (1979 University of Cincinnati) Charles Michael Herndon (1977 University of New Mexico) J D Guillory Jr (1958 Louisiana State University School of Medicine in Michelle Montoney Herron (1996 University of Rochester School of New Orleans) Medicine and Dentistry) Thomas F Gumprecht (1975 University of Washington) Guy M Hicks Jr (1949 Tulane University) Robert Allen Gustafson (1986 West Virginia University) Eve J Higginbotham (2008 Morehouse School of Medicine) Brett B Gutsche (1984 Raymond and Ruth Perelman School of Medicine John V Hill (1964 University of Iowa) at the University of Pennsylvania) William A Hill (1968 University of Alabama at Birmingham School of Medicine) H Mark W Hinshaw (1965 University of Missouri) Edward D Haak Jr (1967 University of Virginia) Frederick P Hobin (1962 University of Vermont) Clayton R Haberman (1949 University of Wisconsin School of Medicine Scott C Hobler (1992 University of Toledo College of Medicine) and Public Health) Larry Hobson (1994 Meharry Medical College) Michael D Hagen (1975 University of Missouri) Melanie Catherine Hodge (2013 Pennsylvania State University College David R Hall (1990 Medical College of Georgia at Georgia Regents of Medicine) University) Irwin Hoffman (1993 University of New Mexico) Geoffrey G Hallock (1974 Sidney Kimmel Medical College, Thomas Robert Cary Holladay (1987 Louisiana State University Health Sciences Jefferson University) Center in Shreveport) Steven K Hamar (1974 Baylor College of Medicine) Gary N Holland (1979 David Geffen School of Medicine at University of Christopher D Hamilton (1988 David Geffen School of Medicine at California, Los Angeles) University of California, Los Angeles) Anne M Hollister (1982 University of California, Davis) Edwin H Hamilton (1999 Meharry Medical College) Silas Wendell Holmes Jr (1990 University of South Carolina) Elizabeth L Hamilton-Byrd (1987 University of Southern California) Elmer J Holzinger (1996 University of Pittsburgh) Stanley F Handel (1964 University of Texas Medical Branch) Daniel L Hood (1984 Wright State University Boonshoft School of Peter R Handley (1993 Wayne State University) Medicine) Lara C Hanlon (2001 Geisel School of Medicine at Dartmouth) Beulette Yvonne Hooks (2013 Mercer University School of Medicine) Nancy B Hansen (1978 University of Tennessee Health Science Center) Alan R Hopeman (1950 University of Minnesota) Sami J Harawi (1973 American University of Beirut) Melvin Horwith (1950 Albany Medical College) Joseph E Harlan Jr (1976 Wake Forest School of Medicine) Sharon L Hostler (1985 University of Vermont) Lawrence L Harms (1982 University of Nebraska) Mary F Hotchkiss (1988 Ohio State University) Gregory R Harper (1975 Albany Medical College) Robert Smith Howard II (1987 University of Kentucky) Ian J Harrington (1964 University of Western Ontario Faculty of Teresa Ann Howard (1990 University of Kentucky) Medicine and Dentistry)

52 The Pharos/Spring 2015 Wm James Howard (1963 Raymond and Ruth Perelman School of Harold Lawrence Karasic (1998 MCP Hahnemann [Allegheny Medicine at the University of Pennsylvania) University]) Harold R Howe Jr (1980 Wake Forest School of Medicine) Riyad C Karmy-Jones (1989 George Washington University) Harry E Howe (1952 University of Vermont) Barry H Kart (1968 Temple University) Jimmy F Howell (1973 Baylor College of Medicine) Donald J Kastens (1981 University of Oklahoma College of Medicine) William F Hoyt (1970 University of California, San Francisco) Leonid Katz (1999 University of California, Davis) Judith A Hsia (1978 University of Illinois) James P Kauth (1961 Medical College of Wisconsin) Daphne T Hsu (1982 Yale University School of Medicine) Rae-Ellen W Kavey (1972 State University of New York, Downstate Ana G Huaman (1990 University of New Mexico) Medical Center) Philip J Huber Jr (1993 University of Texas Southwestern Medical John A Kazmierowski (1970 University of Illinois) Center at Dallas) Michael J Kearns (1980 University of California, Irvine) Hubert Carl Huebl (2004 Wayne State University) Richard P Keeling (1972 Tufts University School of Medicine) William E Hughes (1984 University of South Alabama College of Edward J Keenan (2003 Oregon Health & Science University School of Medicine) Medicine) Edgar W Hull (1964 Yale University School of Medicine) Virginia T Keeney (2001 University of Louisville) Tracy Lynn Hull (1986 Ohio State University) Elisabeth A Kelley (1989 Georgetown University) Vernon B Hunt (1971 University of Pittsburgh) Debra Jean Kelsh (1991 University of Kansas) Nadene D Hunter (1944 Tulane University) H Ronald Kennedy (1979 University of South Florida) David D Hurd (1972 University of Illinois) James A Kenning (1973 Sidney Kimmel Medical College, Thomas Thomas P Hutchens (1979 Emory University) Jefferson University) Maj Gen Edward J Huycke (1953 University of Kansas) Rose M Kenny (1969 Sidney Kimmel Medical College, Thomas Jefferson Vera C Hyman (1968 Medical University of South Carolina) University) William F Kern (1979 State University of New York, Downstate Medical I Center) Omer Aslam Ilahi (1989 Baylor College of Medicine) Jack D Kerns (1974 University of Iowa) Ricky L Irons (1980 University of Alabama at Birmingham School of Douglas S Kerr (1965 Case Western Reserve University) Medicine) Lawrence J Kerzner (1974 Georgetown University) John A Irvine (1992 University of Southern California) Martin E Kessler (1979 Weill Cornell Medical College) Luis A Izquierdo (1994 Universidad Central del Caribe) Hooman Khorasani (2004 University of Southern California) J Ernest A Kiel (2005 Louisiana State University Health Sciences Center in Shreveport) Edward Cornelious Jacobs (1968 Loma Linda University) Thomas W Kiernan (1988 Rutgers New Jersey Medical School) Christopher F James (1977 University of Maryland) Patti A Kile (1979 University of Minnesota) David W Jaskar (1971 Medical College of Wisconsin) Nancy Kim (2002 Rutgers New Jersey Medical School) William R Jewell (1960 University of Illinois) John C Kincaid (1975 Indiana University) Tamison Jewett (2010 Wake Forest School of Medicine) Thomas M King (1981 University of Minnesota) Abiodun O Johnson (1996 Meharry Medical College) Adam P Klausner (1995 SUNY Upstate Medical University College of Brent Edward Johnson (1987 University of Arizona) Medicine) Cheryl A Johnson (1993 Pennsylvania State University College of Caroline M Klein (1993 University of Texas Medical Branch) Medicine) Kenneth M Klein (2004 Rutgers New Jersey Medical School) Daniel J Johnson (1979 Ohio State University) Barbara Jane Klencke (1989 University of California, Davis) David H Johnson (1975 Medical College of Georgia at Georgia Regents John A Kline (1969 Sidney Kimmel Medical College, Thomas Jefferson University) University) Gary K Johnson (1969 University of Washington) Quentin F Knauer (1957 Case Western Reserve University) Mark Leo Johnson (1991 University of Minnesota) Norman Miles Kneteman (1990 University of Alberta Faculty of Richard T Johnson (1955 University of Colorado) Medicine and Dentistry) Tom M Johnson (1984 University of North Dakota School of Medicine Steven Knezevich (1984 Rush Medical College) and Health Sciences) Kermit Knudsen (1955 University of Illinois) Robert E Jones (1975 University of Utah) Alfred J Kobak Jr (1958 University of Illinois) Kirk G Jordan (1990 University of Texas Medical Branch) Mordecai Koenigsberg (1962 Albert Einstein College of Medicine of Patricia K Joseph (1979 University of Florida) Yeshiva University) Martin F Joyce-Brady (1979 University of Maryland) William M Kohen (1974 Wayne State University) K Colette M Kohler (1955 University of Texas Medical Branch) Evan R Kokoska (1994 Washington University in St Louis School of Andreas Kaden (2008 University of Texas Medical School at Houston) Medicine) Donald L Kahn (1967 MCP Hahnemann [Allegheny University]) Jeffrey I Komins (1970 MCP Hahnemann [Allegheny University]) Frederick A Kam Jr (1992 University of Miami) James Duval Koonce (2006 University of Tennessee Health Science Elaine S Kamil (1973 University of Pittsburgh) Center) Nathan H Kander (1983 Wayne State University) Stephen S Kornbluth (1979 Albany Medical College) Charles F Kane (1945 Raymond and Ruth Perelman School of Medicine James S Kort (1977 Johns Hopkins University) at the University of Pennsylvania) Martin A Koschnitzke (1986 University of Texas Medical Branch) Gary J Kanter (1993 Rutgers Robert Wood Johnson Medical School) Richard J Kossmann (1959 Weill Cornell Medical College) Louie Kantzavelos (2002 University of Illinois)

The Pharos/Spring 2015 53 2014 Donations

Nicholas T Kouchoukos (1961 Washington University in St Louis School Samuel M Lesko (1976 Sidney Kimmel Medical College, Thomas of Medicine) Jefferson University) Mark Kozak (1984 Johns Hopkins University) Raymond L Lesonsky (1960 University of Southern California) Nicholas A Kozlov (1975 University of Illinois) Robert W Letton Jr (1990 University of Kentucky) Robert A Krall (1976 Sidney Kimmel Medical College, Thomas Jefferson Jennifer A Levin Popovsky (1995 Temple University) University) Jerome M Levine (1950 Raymond and Ruth Perelman School of Janet P Kramer (1997 Drexel University College of Medicine (merged Medicine at the University of Pennsylvania) with Hahnemann in 1998)) Stephanie M Levine (1988 George Washington University) John R Krause (1965 University of Pittsburgh) Richard A Levinson (1957 University of Illinois) Michael J Kraut (1977 Wayne State University) Seymour H Levitt (1953 University of Colorado) Robert A Kreisberg (1957 Northwestern University) Philip A Lewalski (1988 Wayne State University) Lawrence A Kriegshauser (1977 University of Missouri) Richard S Lewis (1997 East Carolina University Brody School of Joan Margaret Krikava (1986 University of Minnesota) Medicine) Paul A Krogstad (2010 Tulane University) Theophilus Lewis (2001 State University of New York, Downstate Kyle Gregory Krohn (1989 University of Texas Southwestern Medical Medical Center) Center at Dallas) Thomas P Lewis (1977 New York University) James C Kudrna (1976 Northwestern University) Robert A Liebelt (1957 Baylor College of Medicine) Kenneth M Kurokawa (1962 University of California, San Francisco) Richard S Liebowitz (2000 University of Arizona) William J Kurtz (2003 University of North Dakota School of Medicine Alton L Lightsey Jr (1970 University of Mississippi) and Health Sciences) Vivian Lim (1985 University of Texas Health Science Center at San James P Kushner (1961 University of Pittsburgh) Antonio) Walter E Limehouse Jr (1973 Medical University of South Carolina) L Alexander L Lin (1994 Northwestern University) Anthony Labruna (2003 Weill Cornell Medical College) Daniel V Lindenstruth (1964 University of Maryland) Carolyn Lacey (2003 Drexel University College of Medicine (merged Shari Ling (1989 Georgetown University) with Hahnemann in 1998)) Rebecca M Lipscomb (2001 Eastern Virginia Medical School) F Marc LaForce (1981 Rutgers New Jersey Medical School) Kenneth A Litwin (1995 MCP Hahnemann [Allegheny University]) Luis E Laguna (2000 Ponce School of Medicine) Rolf Charles Loescher (1985 Indiana University) Kimberly F Lairet (2003 University of Nebraska) Randall Loftus (1992 University at Buffalo, School of Medicine & Randy J Lamartiniere (1987 Louisiana State University Health Sciences Biomedical Sciences) Center in Shreveport) James P Logerfo (1968 University of Rochester School of Medicine and Donald H Lambert (1977 University of Vermont) Dentistry) Y Alan Lambert (1951 Baylor College of Medicine) Thomas A Lohstreter (1979 University of Minnesota) Ronald W Lamont-havers (1945 University of Toronto Faculty of William E Lombard (1973 Temple University) Medicine) David C Long (1976 Oregon Health & Science University School of Harry William Lampiris (2013 University of California, San Francisco) Medicine) Gary L Lamson (1979 University of Minnesota) Jose Eugenio Lopez (1969 University of Puerto Rico) Karen W Landau (1975 Boston University School of Medicine) Alfred E Lounsbury (1979 University of Minnesota) Christopher A Lang (1978 University of Cincinnati) Donald Bruce Louria (1987 Rutgers New Jersey Medical School) Glenn A Langer (1953 Columbia University) Maureen Helen Lowery (2009 University of Miami) Christopher E Larson (1986 University of Pittsburgh) John F Lucas III (1981 Duke University School of Medicine) Michael N Laslie (1965 Medical College of Georgia at Georgia Regents Amanda Luchsinger (1993 Medical College of Wisconsin) University) Carlos Luciano (2012 University of Puerto Rico) Francis Y Lau (1964 Loma Linda University) Kenneth Marc Ludmerer (1986 Washington University in St Louis Hillard M Lazarus (1974 University of Rochester School of Medicine School of Medicine) and Dentistry) Dennis J Lutz (2007 University of North Dakota School of Medicine George F Leatherman (1979 University of Texas Southwestern Medical and Health Sciences) Center at Dallas) Dennis J Lynch (1965 Georgetown University) George F Lee (1967 Albany Medical College) Hyung M Lee (1978 Virginia Commonwealth University) M J Fletcher Lee (1960 Duke University School of Medicine) Giles F MacDonald Dr (2000 University of Alberta Faculty of Medicine R H Lee (1948 Stanford University School of Medicine) and Dentistry) Shuk Yi Lee (1991 State University of New York, Downstate Medical Rob Roy MacGregor (1964 Harvard Medical School) Center) Sidney D Machefsky (1977 Vanderbilt University) Edward J Lefeber Jr (1966 University of Texas Medical Branch) George E Maha (1953 Saint Louis University) Bob L Leibowitz (1970 University of Illinois) Richard J Mahler (1973 New York Medical College) Leonard Leight (1967 University of Louisville) Adel A F Mahmoud (1982 Case Western Reserve University) James C Leisen (1975 Wayne State University) Gerald A Maida (1972 Loyola University, Stritch School of Medicine) Nancy Ann Leitch (1990 University of Minnesota) Eyal Maidan (2011 University of Kansas) Mark Steven Lemel (1986 Case Western Reserve University) Frank A Maldonado (2012 Rosalind Franklin University of Medicine & George A Lentz Jr (1956 University of Maryland) Science) Jack L Lesher Jr (1980 Medical College of Georgia at Georgia Regents Wilford E Maldonado (1958 University of Oklahoma College of University) Medicine)

54 The Pharos/Spring 2015 Peter C Mancusi-Ungaro (1967 University of Miami) Norman Bret Medow (2003 State University of New York, Downstate Dean S Mann (1992 University of Miami) Medical Center) Karen Virginia Mann (2007 Dalhousie University Faculty of Medicine) Joan Younger Meek (1986 University of Kentucky) Beth Ann Marcinkoski (1986 Northeast Ohio Medical University) Anthony S Melillo (1986 Medical College of Wisconsin) Stuart L Marcus (1983 Albert Einstein College of Medicine of Yeshiva Victor N Meltzer (1975 Northwestern University) University) Victor D Menashe (1967 Oregon Health & Science University School of Walter E Margie Jr (1950 Temple University) Medicine) David A Margileth (1971 Baylor College of Medicine) David I Mendelson (1963 University of Pittsburgh) Charles H Marino (1953 University at Buffalo, School of Medicine & Richard A Menin (1970 Temple University) Biomedical Sciences) Kofi Agyare Mensah (2011 University of Rochester School of Medicine Anthony Markarian (1956 MCP Hahnemann [Allegheny University]) and Dentistry) Charles Markle (1964 SUNY Upstate Medical University College of Michael E Merhige (1979 University of Kentucky) Medicine) John F Mermel (1980 George Washington University) Eric S Marks (1973 Wake Forest School of Medicine) Boyd E Metzger (1958 University of Iowa) Richard E Marsan (1966 University of Nebraska) Michael H Metzler (1971 Albany Medical College) Suzanne Martens (1995 Medical College of Wisconsin) Joseph P Meurer Dr (1974 Oregon Health & Science University School Charmaine Martin (2011 Texas Tech University) of Medicine) George L Martin (1975 Rosalind Franklin University of Medicine & Carol F Meyer (1966 Medical College of Georgia at Georgia Regents Science) University) Nancy Sharon Martin (1982 University of Mississippi) Morgan Paul Meyer (1978 University of Illinois) Robert G Martin (1967 University of Louisville) Ronald C Meyer (1965 Albany Medical College) Gabriel A Martinez (1990 Ponce School of Medicine) Frank L Meyskens Jr (2001 University of California, Irvine) Benjamin M Maser (1990 Sidney Kimmel Medical College, Thomas Alan Micco (2012 Northwestern University) Jefferson University) John D Middleton (1978 University of Texas Medical Branch) M Richard Maser (1957 Raymond and Ruth Perelman School of Kristi J Midgarden (1997 University of North Dakota School of Medicine at the University of Pennsylvania) Medicine and Health Sciences) Alfonse T Masi (1954 Columbia University) Donald J Mielcarek (1968 Saint Louis University) Ravi B Masih (1998 Creighton University) Philip J Migliore (1955 University of Pittsburgh) Clinton E Massey (1979 Medical College of Georgia at Georgia Regents Frederick Miller (1961 Stony Brook University School of Medicine) University) Henry S Miller (2000 Wake Forest School of Medicine) Guy G Massry (1990 University of Southern California) Virginia I Miller (1966 University of Puerto Rico) Allan W Mathies Jr (1960 University of Vermont) York E Miller (1974 Duke University School of Medicine) Anne Schlafke May (1987 James H Quillen College of Medicine of East Robert E Mines Jr (1959 Meharry Medical College) Tennessee State University) Paul R Minton (1956 Boston University School of Medicine) K Jane Mayberry-Carson (1995 James H Quillen College of Medicine of Jose Maria Miramontes (1989 University of California, San Francisco) East Tennessee State University) Dace B Mitchell (1975 University of California, San Francisco) Bette G Maybury (1983 Indiana University) Mark R Mitchell (1981 Meharry Medical College) Eugene H Maynard Jr (1992 University of North Carolina) Mark R Mitchell (1981 Meharry Medical College) John E Mazuski (1981 David Geffen School of Medicine at University of Ilan Mizrahi (2012 Boston University School of Medicine) California, Los Angeles) Alan R Mizutani (1950 University of Vermont) C Kenneth McAllister (1970 Emory University) Jeanette Mladenovic (1974 University of Washington) Lori A McBride (1992 Louisiana State University School of Medicine in David J Moeller (1981 University of Texas Medical Branch) New Orleans) David Mohr (1975 Baylor College of Medicine) Charles A McCallum (1986 University of Alabama at Birmingham George Carl Mohr (1957 Harvard Medical School) School of Medicine) Barry L Molk (1971 University of Colorado) James P McCarron Jr (1968 University of Virginia) Kathryn Leah Molt (2013 Albany Medical College) Paul L McCarthy (1969 Georgetown University) Juan Montes (2012 Universidad Central del Caribe) Robert N McClelland (1953 University of Texas Medical Branch) Walter Joseph Moore (2005 Medical College of Georgia at Georgia George R McCollum (1956 University of Pittsburgh) Regents University) Franklin Dennis McCool (1976 Saint Louis University) Richard A Morin (1983 University of Nebraska) Amy A McDonald (1996 Indiana University) Kenneth C Morley Jr (1959 Boston University School of Medicine) Timothy J McDonald (1993 Emory University) Deborah L Morris (1992 University of North Carolina) Timothy G McGarry (1987 University of Virginia) Linda S Moser in the name of Robert H Moser (1969 Georgetown Robert K McKechnie (1960 University of Louisville) University) Edward M McMahon Jr (1970 Duke University School of Medicine) Harold Moskowitz (1959 State University of New York, Downstate John T McManus (1983 Medical College of Wisconsin) Medical Center) W Kendall McNabney (1987 University of Missouri-Kansas City) Judd W Moul (1982 Sidney Kimmel Medical College, Thomas Jefferson George N McNeil Jr (1970 Columbia University) University) John P McNulty (1950 Tulane University) Samdeep Konda Mouli (2006 Northwestern University) David R McNutt (1965 Ohio State University) Andrew M Muckle (1990 David Geffen School of Medicine at John A McPherson (1993 David Geffen School of Medicine at University University of California, Los Angeles) of California, Los Angeles) Joseph C Muhler II (1974 Loyola University, Stritch School of Medicine) Jason L Meadors (1947 Emory University) Jeannie Muir (1997 Rosalind Franklin University of Medicine & Science)

The Pharos/Spring 2015 55 2014 Donations

Raghu Mukkamala (1996 James H Quillen College of Medicine of East Mildred MG Olivier (2010 Rosalind Franklin University of Medicine & Tennessee State University) Science) John B Muldowney (1975 Northwestern University) John Olson (1995 University of Iowa) Francisco J Muniz MD, FACP (2012 University of Puerto Rico) Alice Amy Onady (1987 Wright State University Boonshoft School of Joseph N Muok (1987 Meharry Medical College) Medicine) Daniel T Murai (1998 University of Hawaii) Beale H Ong (1959 George Washington University) Dale P Murphy (1971 Ohio State University) Cindy A Opolka (1991 Wayne State University) David R Murray (1985 University of Illinois) E Mitchel Opremcak (1981 Ohio State University) John F Murray (2000 University of Southern California) Walter A Orenstein (1972 Albert Einstein College of Medicine of Marc J Myer (2000 University of Wisconsin School of Medicine and Yeshiva University) Public Health) Ralph M Orland (1984 University of Illinois) Evan R Myers (1992 Duke University School of Medicine) Jose A Ortiz Rosado (2000 Ponce School of Medicine) Mark C Myron (1972 University of Missouri) Kwame Osei (1988 Ohio State University) Mark L Ostlund (1981 University of Minnesota) N David Joseph Overley (2002 University of Louisville) Nagendra Nadaraja (1963 University of Rochester School of Medicine William O Owen (1955 Northwestern University) and Dentistry) James W M Owens (1997 University of Washington) Andrew M Namen (2000 Wake Forest School of Medicine) Calvin E Oyer (1952 Indiana University) Virginia B Neaville (1985 University of Arkansas) Francis A Neelon (2002 Duke University School of Medicine) P Samuel E Neff (1949 University of Colorado) Douglas L Packer (1979 University of Utah) David Nelson (1993 University of California, Davis) Heriberto Pagan-saez (1987 University of Puerto Rico) David L Nelson (1962 Washington University in St Louis School of Nancy Laraine Palmer (1986 Rutgers New Jersey Medical School) Medicine) Diamondis John Papadopoulos (1987 Emory University) Don G Nelson (1964 University of Illinois) Leslie J Parent (1986 Duke University School of Medicine) John D Nelson (1976 University of Minnesota) Jerry M Parker (1960 George Washington University) Mario R Nevarez Alonso (2003 University of Puerto Rico) Joseph C Parker Jr (1961 Virginia Commonwealth University) David N Nevin (1981 University of Wisconsin School of Medicine and Robert W Parkey (1983 University of Texas Southwestern Medical Public Health) Center at Dallas) J Paul Newell (1965 University of Western Ontario Faculty of Medicine Cynthia J Parlato (1980 University at Buffalo, School of Medicine & and Dentistry) Biomedical Sciences) Jeffrey B Newton (1969 Albert Einstein College of Medicine of Yeshiva Donald E Parlee (1958 Temple University) University) Earl Parson (1985 Meharry Medical College) Anh Van Nguyen (1988 University of Texas Medical Branch) Eugene H Paschold (1977 Wake Forest School of Medicine) Alfred L Nicely (1961 Ohio State University) Hiren P Patel (1997 University of Minnesota) Stephen W Nicholas (1981 University of Colorado) Manish Surendra Patel (2006 Eastern Virginia Medical School) John E Niederhuber (2009 Ohio State University) Celeste H Patrick (1982 Medical University of South Carolina) Wilberto Nieves-Neira (1990 University of Puerto Rico) Michael K Patrick (1996 Medical College of Wisconsin) Michael J Nissenblatt (1972 Columbia University) Roman L Patrick (1957 Duke University School of Medicine) Bruce C Nisula (1969 Harvard Medical School) Richard D Patten (1991 University of Maryland) Howard John Noack (1992 Pennsylvania State University College of Jean Marie Payer (1985 Rutgers New Jersey Medical School) Medicine) George J Pazin (1963 University of Pittsburgh) Thomas M Nolen (1973 University of Tennessee Health Science Center) Dallas Earl Peak (1990 Indiana University) Phillip T North (1976 University of Chicago) Alan Pechacek (1967 University of Iowa) Howard B Norton (1953 Medical University of South Carolina) Elizabeth K Peck (2001 Texas Tech University) Patricia Norwood (1983 Louisiana State University Health Sciences Marc R Peck (1962 Raymond and Ruth Perelman School of Medicine at Center in Shreveport) the University of Pennsylvania) Jose O Novoa (1992 Howard University) William A Peck (1960 University of Rochester School of Medicine and Edward R Nowicki (1965 Sidney Kimmel Medical College, Thomas Dentistry) Jefferson University) Timothy A Pedley (1968 Yale University School of Medicine) Michael S Nussbaum (2006 University of Cincinnati) Vincent D Pellegrini Jr (1979 Geisel School of Medicine at Dartmouth) Robert A Nussbaum (1986 Icahn School of Medicine at Mount Sinai) William T Pennington (1994 Medical College of Wisconsin) Gerald J Pepe (2005 Eastern Virginia Medical School) O Paul E Pepe (1975 University of California, San Francisco) Robert S O’Connell (1975 Weill Cornell Medical College) Judith S Perdue (1981 Virginia Commonwealth University) William N O’Conner (1994 University of Kentucky) F Xavier Perez (2000 Meharry Medical College) Robert F Oakley Jr (1975 University of Texas Medical Branch) Miguel Perez-Arzola (1993 Ponce School of Medicine) S Scott Obenshain (1992 University of New Mexico) Gordon W Perkin (1958 University of Toronto Faculty of Medicine) Samuel A Ockner (1984 University of Cincinnati) Marc B Perlman (1978 Albany Medical College) Dennis M OConnor (1971 Creighton University) John R Perry (1989 Washington University in St Louis School of Milford S Ofstun (1955 University of Wisconsin School of Medicine and Medicine) Public Health) Sophia Brothers Peterman (1980 University of Michigan) Adedamola A Ogunniyi (2008 Columbia University) Brian L Pettiford (2001 University of Pittsburgh)

56 The Pharos/Spring 2015 Samuel R Pettis Jr (1978 Howard University) Peter J Reiter (1973 University of Iowa) Garth D Phibbs (1972 University of Western Ontario Faculty of Elizabeth Rhea (1957 University of Tennessee Health Science Center) Medicine and Dentistry) Larry Rhodes (2011 West Virginia University) Carol A Phillips (1974 University of Vermont) Virginia A Rhodes (1988 Ohio State University) Stuart I Phillips (1959 Louisiana State University School of Medicine in Gioia Jo Riccio (1993 Ponce School of Medicine) New Orleans) Eve Hart Rice (1988 Icahn School of Medicine at Mount Sinai) Theodore J Phillips (1980 University of Washington) Harold G Richman (1953 University of Minnesota) Chester M Pierce (1967 University of Oklahoma College of Medicine) Ren L Ridolfi (1972 University of Michigan) Elizabeth Pierce (1978 Virginia Commonwealth University) Ronald N Riner (1974 Weill Cornell Medical College) William C Pierce (1987 David Geffen School of Medicine at University Terry N Rivers (1982 University of South Alabama College of Medicine) of California, Los Angeles) John W Roark Jr (1977 David Geffen School of Medicine at University of Donald J Pinals (1958 State University of New York, Downstate Medical California, Los Angeles) Center) Paul G Robertie (1984 Medical College of Georgia at Georgia Regents Jeffrey M Pines (1973 Columbia University) University) Anthony Pirrello Jr (1961 Temple University) John F Roberts (1964 University of Colorado) Marshall Plaut (1967 Johns Hopkins University) Christopher Robinson (2004 Medical University of South Carolina) Richard A Plessala (1960 Saint Louis University) David P Robinson (2005 University of Missouri) Donald A Pocock (1972 Case Western Reserve University) Edward N Robinson Jr (1979 Wake Forest School of Medicine) Tod R Podl (1996 Case Western Reserve University) Luther D Robinson (1995 Howard University) Joseph W Poe (1995 Marshall University School of Medicine) William K Robinson (1975 Louisiana State University School of Ross B Pollack (1977 Georgetown University) Medicine in New Orleans) Daniel J Pollman (1990 University of South Alabama College of David M Robirds (1977 Saint Louis University) Medicine) Leeann M Rock (1985 University of Minnesota) Donald D Pollock (1962 Albany Medical College) Robert L Roe (1966 University of California, San Francisco) Maria Carol Poor (1985 Indiana University) Alan K Rogers (1980 Baylor College of Medicine) Jerome B Posner (1978 Weill Cornell Medical College) Arvey I Rogers (1973 University of Miami) Bradley K Post (1994 University of Texas Medical School at Houston) Lee F Rogers (1958 Northwestern University) Robert H Posteraro (1973 Texas Tech University) Milton W Roggenkamp (1952 Indiana University) Josephine Pressacco (1999 University of Toronto Faculty of Medicine) Michael J Rokoff (1965 University of Maryland) William J Preston (1962 University of Oklahoma College of Medicine) Luis Roman (1958 University of Puerto Rico) Donald L Price (1959 Albany Medical College) John Peter Rosculet (1987 University of Michigan) Sandy James Pritchard (1976 University of Western Ontario Faculty of David Mayer Roseman (1951 Johns Hopkins University) Medicine and Dentistry) David I Rosen (1963 SUNY Upstate Medical University College of Ronald J Pritza (1999 Creighton University) Medicine) Warren R Procci (1971 University of Wisconsin School of Medicine and Anne L Rosenberg (1981 Sidney Kimmel Medical College, Thomas Public Health) Jefferson University) Lawrence J Prograis Jr (1975 Meharry Medical College) David Evan Rosenberg (1987 George Washington University) W Pulliam (1966 Washington University in St Louis School of Robert D Rosenbloom (1973 Loyola University, Stritch School of Medicine) Medicine) Ivor N Purchas (1976 Howard University) Robert C Rosenquist (1977 Loma Linda University) Claire A Putnam (1999 University of California, Irvine) Anne E Rosin (1994 University of Wisconsin School of Medicine and Robert W Putsch III (1964 University of Colorado) Public Health) Albert H Roth (1961 University of Minnesota) Q Andrew J Roth (1992 Icahn School of Medicine at Mount Sinai) Eugene A Quindlen (1969 University of Virginia) Walton T Roth (1964 New York University) R David R Rovner (1954 Temple University) Patricia Rowe (1983 David Geffen School of Medicine at University of Eric Charles Rackow (1971 Rosalind Franklin University of Medicine & California, Los Angeles) Science) Henry D Royal (1974 Saint Louis University) Jerome Radding (1944 Oregon Health & Science University School of Deborah C Rubin (1981 Albert Einstein College of Medicine of Yeshiva Medicine) University) Eric L Raefsky (1979 Temple University) Robert T Rubin MD, (1961 University of California, San Francisco) John Edward Ratmeyer (1988 State University of New York, Downstate Arthur L Ruckman (1978 Louisiana State University Health Sciences Medical Center) Center in Shreveport) James M Raveret (1971 Medical College of Wisconsin) Ross Rudolph (1965 Columbia University) Sekou Robertson Rawlins (2010 SUNY Upstate Medical University Matthew Rudorfer (1977 State University of New York, Downstate College of Medicine) Medical Center) Terry William Raymer (1985 University of California, Davis) Andrea J Ruff (1980 University of California, San Francisco) James I Raymond (1973 University of Pittsburgh) Gregory Duncan Rushing (2008 Eastern Virginia Medical School) John Richard Raymond (1987 Duke University School of Medicine) Edward D Ruszkiewicz (1971 Saint Louis University) Glenn A Rediger (1980 Indiana University) William H Ryan III (1977 University of North Carolina) Robert A Reed (1962 Emory University) Stots B Reele (1971 Baylor College of Medicine) Donald T Reilly (1974 Case Western Reserve University)

The Pharos/Spring 2015 57 2014 Donations

S David E Seals (1996 Albany Medical College) Richard Joseph Saab (1965 University at Buffalo, School of Medicine & James Leo Sebastian (1992 Medical College of Wisconsin) Biomedical Sciences) Jackie R See (1983 University of California, Irvine) John H Sadler (1986 University of Maryland) Jerry G Seidel (1954 University of Chicago) William P Sadler (1956 Johns Hopkins University) Michael J J Seider (1983 University of Texas Medical School at Houston) John Saiki (1977 University of New Mexico) Elyse L Seidner-joseph (1986 Columbia University) Sandra Z Salan (1964 University of Maryland) Charles J Seigel (1966 University of Pittsburgh) Robert A Salata (1978 Case Western Reserve University) Kristen M Seitz (1998 Oregon Health & Science University School of Anthony Salem (1987 University of South Dakota) Medicine) Michael J Samson (1984 George Washington University) Reed W Seligman (1992 Medical College of Georgia at Georgia Regents Philip Samuels (1982 Texas Tech University) University) Chander N Samy (1990 Yale University School of Medicine) Sudha Seshadri (2004 Boston University School of Medicine) John R Sanborn (1974 University of Michigan) Daniel J Shapiro (1949 Albany Medical College) Jorge L Sanchez (1965 University of Puerto Rico) Jason F Shiffermiller (1998 University of Nebraska) Albert E Sanders (1958 University of Texas Medical Branch) Peter M Shimkin (1965 Raymond and Ruth Perelman School of Harvey J Sanders Jr (1974 Medical College of Georgia at Georgia Medicine at the University of Pennsylvania) Regents University) Harry L Shufflebarger Jr (1966 Emory University) Karl Alan Sanders (1989 University of Kansas) Claire N Shumway (1947 University at Buffalo, School of Medicine & Thomas J Sanders (1981 Louisiana State University Health Sciences Biomedical Sciences) Center in Shreveport) Neil H Shusterman (1977 Sidney Kimmel Medical College, Thomas Paul E Sangster (1973 University of Arizona) Jefferson University) Nicholas Spartan Santavicca (2010 State University of New York, William W Simmons (1986 University of Toronto Faculty of Medicine) Downstate Medical Center) Laura J Simon (1970 University of Illinois) Patricia C Santiago (1999 University of Puerto Rico) James S Simpson III (1974 Medical College of Georgia at Georgia Eduardo A Santiago-Delpin (1964 University of Puerto Rico) Regents University) Carlos R Santos (1993 University of Puerto Rico) Andrew P Siskind (1984 University of California, Irvine) John F Sarwark (2000 Northwestern University) David L Slater (1982 University of Minnesota) Ashley Saucier (2012 University of Tennessee Health Science Center) Matthew Sloan (1966 Saint Louis University) Michele Smallwood Saysana (2010 Indiana University) Gerald J Smallberg (1968 Yale University School of Medicine) Laura E Schaefer (1975 MCP Hahnemann [Allegheny University]) Barry Smith (2011 Geisel School of Medicine at Dartmouth) Allen H Schaeffer (1973 Johns Hopkins University) Eileen P Smith (1981 University of Southern California) James F Schauble (1954 Johns Hopkins University) Larry E Smith (1991 Howard University) Roger W Schauer (1996 University of North Dakota School of Medicine Michael Scott Smith (1991 Wake Forest School of Medicine) and Health Sciences) Morton E Smith (1959 University of Maryland) Heinrich G Schettler (1975 Baylor College of Medicine) Randolph R Smith (2001 Medical College of Georgia at Georgia Regents John E Scheub (1972 University of Cincinnati) University) Gerold L Schiebler (1963 University of Florida) Thomas J Smith (2002 Virginia Commonwealth University) Mary E Schlegel (1991 Icahn School of Medicine at Mount Sinai) Tina Louise Smusz (1985 Southern Illinois University) Stephen L Schlesinger (1970 Virginia Commonwealth University) Peggy A Smythe (1956 Raymond and Ruth Perelman School of Medicine Paul G Schmitz (1982 Creighton University) at the University of Pennsylvania) Charles L Schnee (1990 Tufts University School of Medicine) Mark H Snyder (1978 Sidney Kimmel Medical College, Thomas Aaron P Scholnik (1968 Rosalind Franklin University of Medicine & Jefferson University) Science) James V Soldin II (1978 University of Minnesota) Larry W Schorn (1973 University of Texas Southwestern Medical Center David B Soll (1955 Rosalind Franklin University of Medicine & Science) at Dallas) Irwin Solomon (1947 University at Buffalo, School of Medicine & Kathleen S Schrank (1979 University of Miami) Biomedical Sciences) Dan Schuller (1991 Washington University in St Louis School of Joel B Solomon (1962 State University of New York, Downstate Medical Medicine) Center) Elizabeth Marlow Schulwolf (2002 University of Tennessee Health Charurut Somboonwit (2009 University of South Florida) Science Center) Christopher J Sonnenday (1997 Vanderbilt University) David R Schwartz (1991 State University of New York, Downstate Mary Ann South (1969 Baylor College of Medicine) Medical Center) David I Soybel (1990 Washington University in St Louis School of Lawrence Roger Schwartz (2003 Wayne State University) Medicine) M Roy Schwarz (1962 University of Washington) James C Spann (1990 University of Arkansas) Mark William Scioli (1982 Texas Tech University) Helena N Spartz (2006 Indiana University) Michael Scoppetuolo (1979 Rosalind Franklin University of Medicine & Wayne C Spiggle (1993 University of Maryland) Science) Jerome Spivack (1960 Sidney Kimmel Medical College, Thomas Earl D Scott (1962 University of Missouri) Jefferson University) Michael Craig Scott (1987 Medical College of Georgia at Georgia MaryJane Stackowski (1961 Temple University) Regents University) Sarah Jane Stair (1987 University of Iowa) Ajovi Scott-Emuakpor (1991 Michigan State University College of Bonita F Stanton (1976 Yale University School of Medicine) Human Medicine) John F Stapleton (1976 Georgetown University) Alan L Scriggins (1965 McGill University Faculty of Medicine) Michelle P Stas (1993 University of Virginia)

58 The Pharos/Spring 2015 Susan B Stearns (2006 SUNY Upstate Medical University College of John V Temte (1969 University of Wisconsin School of Medicine and Medicine) Public Health) Ralph E Steele (1975 University of Chicago) Patrick O Tennican (1978 University of Arizona) Lawrence Emil Steinbach (1990 Sidney Kimmel Medical College, Amadea R Tette (1983 Howard University) Thomas Jefferson University) Heidi S Thomas (1980 Oregon Health & Science University School of Marc Peter Steinberg (1977 University of South Florida) Medicine) Michael P Steinberg (1989 Washington University in St Louis School of Deborah M Thompson (1982 Howard University) Medicine) Linda Ruth Thompson (1966 University of Virginia) Mark J Stephan (1971 University of Colorado) Mark E Thompson (1981 Wright State University Boonshoft School of Evan L Stepp (1999 University of Texas Medical Branch) Medicine) Judith K Stern (1983 University of Nebraska) Paul A Thompson (1975 Creighton University) Penny Maureen Stern (1989 Albert Einstein College of Medicine of Robert S Thornton (1968 Medical College of Georgia at Georgia Yeshiva University) Regents University) Janet M Stewart (1960 Temple University) Edwin M Thorpe Jr (1981 Meharry Medical College) Mervin S Stewart (1952 University of Pittsburgh) Joseph R Thurn (1983 University of Minnesota) Susan K Stewart (1973 University of California, San Francisco) A Judson Tillinghast (1971 Louisiana State University School of Richard H Stienmier (1961 University of Colorado) Medicine in New Orleans) Byron Stinson (1980 Ohio State University) Melissa Times (2013 Wayne State University) Kathleen S Stokes (1987 Medical College of Wisconsin) Russell B Tippins (1993 Medical College of Georgia at Georgia Regents Alan W Stone (1964 Yale University School of Medicine) University) Richard K Stone (1966 New York Medical College) Peter V Tishler (1962 Yale University School of Medicine) Robert C Stough (1979 Raymond and Ruth Perelman School of Sigrid L Tishler (1963 Yale University School of Medicine) Medicine at the University of Pennsylvania) Clifton P Titcomb Jr (1978 Georgetown University) Clifford J Straehley (1946 Harvard Medical School) Christine C Toevs (1992 East Carolina University Brody School of Susan M Strahosky (1980 Boston University School of Medicine) Medicine) K Michelle Strasen-harden (1986 University of Southern California) Bruno P Tolge (1960 Albany Medical College) Dwight G Straub (1962 University of Utah) Tracy Ann Tomac (1990 Texas A&M University) Arthur J L Strauss (1957 Columbia University) John P Tooker (1970 University of Colorado) Tracy Elmer Strevey Jr (1958 University of Southern California) Mikhail T Torosoff (2013 Albany Medical College) Thomas Joseph Strick (1985 Medical College of Wisconsin) Ascension M Torres (1981 University of Cincinnati) Geoffrey R Stroh (1993 University of Miami) Esther A Torres (1996 University of Puerto Rico) Jack Strom (1955 Ohio State University) Robert D Toto (1976 University of Illinois) Richard Scott Stuart (1986 Johns Hopkins University) Robert C Trautwein (1980 Tufts University School of Medicine) Dorothy E Stubbe (1984 University of Arizona) Justin James Trevino (1987 Wright State University Boonshoft School of Ronald Lee Stuk (1959 Wayne State University) Medicine) Albert Suarez-Dominguez (2013 University of Puerto Rico) Philip C Trotta (1968 Saint Louis University) Michelle L Surbrook (1995 University of Tennessee Health Science Annapurni J Trouth (2002 Howard University) Center) Miles K Tsuji (1986 University of California, San Francisco) Armando Susmano (1975 Rush Medical College) David J Tulipan (1983 Albert Einstein College of Medicine of Yeshiva Elliot J Sussman (1977 Harvard Medical School) University) Cindy Sutton Barrett (2003 University of Vermont) Jan K Turcotte (1974 Medical College of Wisconsin) David S Swan (1962 Wayne State University) Dennis A Turner (1975 Indiana University) Mark A Swancutt (1991 University of Texas Southwestern Medical Patricia T Turner (1975 Louisiana State University School of Medicine Center at Dallas) in New Orleans) Bernard T Swaykus (1962 Saint Louis University) Claude R Swayze (1960 University of Toronto Faculty of Medicine) U M Monica Sweeney (2013 State University of New York, Downstate Eberhard H Uhlenhuth (1951 Johns Hopkins University) Medical Center) Donald A Underwood (1975 Case Western Reserve University) Edward Rowe Sweetser (1970 Georgetown University) Charles B Upshaw Jr (1954 Emory University) James G Urban (1960 University of Wisconsin School of Medicine and T Public Health) Mark D Taber (1978 Northwestern University) John I Takayama (1985 New York University) V Elizabeth K Tam (1978 University of California, San Francisco) Charles A Vacanti (2003 University of Nebraska) Filemon K Tan (2006 University of Texas Medical School at Houston) James L Vacek (1976 Creighton University) Troy M Tanji (1990 University of Hawaii) Vainutis K Vaitkevicius (1969 Wayne State University) Ernest M Tassoni (1954 Temple University) Stephen A Valenti (1978 University of Maryland) Larry D Taylor (1978 University of Arkansas) Phyllis A Vallee (1984 Albert Einstein College of Medicine of Yeshiva Lara J Teal Clement (1997 Wake Forest School of Medicine) University) John F Teichgraeber (2010 University of Texas Medical School at Nancy Van Vessem (1982 Saint Louis University) Houston) William A Vandecker (1983 Georgetown University) Margaret C Telfer (1992 University of Illinois) Steven J Vandoornik (1979 Wayne State University) Sonia R Teller (1997 University of Louisville) Charles James Vanhook (1985 University of Wisconsin School of Medicine and Public Health)

The Pharos/Spring 2015 59 2014 Donations

Jerry B Vannatta (1988 University of Oklahoma College of Medicine) Stephen B Wilson (1984 Medical College of Wisconsin) Elizabeth Vazquez (1982 University of California, San Francisco) Roland H Winter (1983 Medical College of Wisconsin) Cathleen M Veach (1995 Oregon Health & Science University School of Curtis B Winters (1983 University of Southern California) Medicine) Samuel K Wirtschafter (1957 University of Southern California) Otto F Veidlinger (1959 University of Toronto Faculty of Medicine) Roy Witherington (1952 Medical College of Georgia at Georgia Regents Vladimir I Vekshtein (1984 New York University) University) James V Vest (1975 University of Missouri) Philip Witorsch (1961 New York University) Christopher J Vesy (1993 Ohio State University) David J Wlody (2013 State University of New York, Downstate Medical Ivana M Vettraino (1992 Washington University in St Louis School of Center) Medicine) Judith E Wolf (1980 Weill Cornell Medical College) John M Vierling (1972 Stanford University School of Medicine) Claire V Wolfe (1996 Ohio State University) Nicholas A Volpicelli (1988 Temple University) John R Wolfe (1967 Virginia Commonwealth University) Stanley E Von Hofe (1970 Vanderbilt University) Eugene E Wolfel (1976 Sidney Kimmel Medical College, Thomas Jefferson University) W Gerald A Wolff (1960 Washington University in St Louis School of Grant H Wagner (1964 University of Kansas) Medicine) Milton L Wagner (1955 University of Texas Medical Branch) Gerald S Wong (1961 University of Toronto Faculty of Medicine) Howard Dennis Waite (1966 Ohio State University) Earle G Woodman (1957 Boston University School of Medicine) May M Wakamatsu (1983 Case Western Reserve University) Donna Ailport Woodson (2010 University of Toledo College of David L Wallace (1968 University of Minnesota) Medicine) Elizabeth L Walters (1994 Loma Linda University) Daniel Scott Woolley (1997 Rutgers Robert Wood Johnson Medical William T Walton (1985 Tulane University) School) Robert C Wang (1978 State University of New York, Downstate Medical Joseph H L Worischeck (1987 Saint Louis University) Center) Richard S Woronoff (1966 State University of New York, Downstate Frank T Ward (1994 Uniformed Services University) Medical Center) Howard F Warner (1951 Temple University) Brandon Wesley Wright (2010 Texas Tech University) Alan A Wartenberg (1972 Medical College of Wisconsin) Donald F Wuori (1968 State University of New York, Downstate Steven G Wassilak (1977 Saint Louis University) Medical Center) Ray L Watts (1980 Washington University in St Louis School of Medicine) Y George H Weaver (1954 University of Alabama at Birmingham School Jack E Yakish (1981 MCP Hahnemann [Allegheny University]) of Medicine) Dean T Yamaguchi (1976 Tulane University) Mark E Weaver (1980 University of Arkansas) Mary C Yankaskas (1986 Rutgers Robert Wood Johnson Medical Thomas R Weber (1971 Ohio State University) School) Mary Ellen Wechter (2003 University of Michigan) Jame S T Yao (1989 Northwestern University) Rudolph F Weichert (1960 Tulane University) David L Yarian (1974 Washington University in St Louis School of Leslie P Weiner (1961 University of Southern California) Medicine) Alan M Weintraub (1956 University of Chicago) Francis E Yates Dr (1954 Stanford University School of Medicine) Stephen A Weirich (2007 Case Western Reserve University) Philip A Yazbak (1994 Geisel School of Medicine at Dartmouth) Ilene C Weitz (1976 Drexel University College of Medicine (merged Abideen O Yekinni (1991 Indiana University) with Hahnemann in 1998)) Gordon G Yenokida (1975 University of California, Davis) Mell B Welborn Jr (1962 Emory University) John F Yerger Jr (1960 Temple University) William R Welborn Jr (1967 Vanderbilt University) Ernest L Yoder (1992 Wayne State University) Steven Judson Westgate (1980 University of Florida) Mark Yoffe (1976 University of Florida) Lennox S Westney (1996 Howard University) Paul C Young (1966 Northwestern University) Robert A Whisnant Jr (1961 Virginia Commonwealth University) Mihae Yu (1979 University of Hawaii) Eric B Whitacre (1983 Weill Cornell Medical College) Christopher White (2003 Southern Illinois University) Z Lynne Meador Whyte (1987 Duke University School of Medicine) Patrick F Zazzaro (1975 Rutgers Robert Wood Johnson Medical School) Rosemary A Wiegand (1993 Pennsylvania State University College of Charles J Zelnick (1979 University of Cincinnati) Medicine) Norman P Zemel (1964 Sidney Kimmel Medical College, Thomas William E Wilcox (1977 University of South Alabama College of Jefferson University) Medicine) Anthony P Ziebert (1960 Medical College of Wisconsin) B Robinson Williams III (2008 Emory University) Timothy John Ziemlewicz (2004 Wayne State University) Dan Williams (2007 James H Quillen College of Medicine of East Gretchen M Zimmerman (1980 MCP Hahnemann [Allegheny Tennessee State University) University]) John F Williams Jr (1993 George Washington University) Michele M Zormeier (1993 Wayne State University) Kay Williams-kirchler (1980 University of Alabama at Birmingham Craig W Zuppan (1979 Loma Linda University) School of Medicine) Michael P Zygmunt (1972 Loyola University, Stritch School of Mary Alissa Willis (2006 University of Mississippi) Medicine) Ellen E Wilson (1988 George Washington University) Robert K Wilson Jr, (1961 University of Alabama at Birmingham School of Medicine)

60 The Pharos/Spring 2015 Emesis

There is, perhaps, grace in the way my toes elevate with each guttural heave; predictable and precise, like the slosh pound of saltwater onto pilings of a weakened pier. The commotion of swirl, scent, and sound, circulate around my hunched shoulders; a drown of gasps among successive retch. Feeble hands landlock on wobbled knees. The grotesque drip of acidic scraps, their frothy repel thick from the lips. A therapeutic cleanse, repulsive. A rugated stomach now hollow from a purge and scourge. The body, cleaning house the way it knows how. Aaron McGuffin, MD

Dr. McGuffin (AΩA, Marshall University, 2002) is Associate Professor of Pediatrics at the Marshall University Joan C. Edwards School of Medicine. His address is: 1600 Medical Center Drive, Suite 3413, Huntington, West Virginia 25701. E-mail: [email protected]. Illustration by Jim M’Guinness. A pictorial history of medical care By artist Jim M’Guinness

Limited Edition – $415 (including shipping and handling) Signed and numbered, hand-colored lithographic prints

Paypal : [email protected] Or send check to Jim M’Guinness 1122 Golden Way, Los Altos, CA 94024 For more information, call (650) 967-3811

Mr. M’Guinness is shipping the artwork directly from his studio, so this item is not being sold on our web site.