Alpha Omega Alpha Honor Medical Society WINTER 2016
THE PHAROS of Alpha Omega Alpha honor medical society Winter 2016
Alpha Omega Alpha Honor Medical Society “Be Worthy to Serve the Suffering” Founded by William W. Root in 1902
Editor Richard L. Byyny, MD Officers and Directors at Large Robert G. Atnip, MD President Managing Editors Debbie Lancaster and Dee Martinez Hershey, Pennsylvania Joseph W. Stubbs, MD Art Director and Illustrator Jim M’Guinness President-Elect Albany, Georgia Designer Erica Aitken Douglas S. Paauw, MD Immediate Past President Seattle, Washington In memoriam Wiley Souba, Jr., MD, DSc, MBA Robert J. Glaser, MD, Editor Emeritus Secretary-Treasurer Helen H. Glaser, MD, Associate and Managing Editor Hanover, New Hampshire Eve J. Higginbotham, SM, MD Philadelphia, Pennsylvania Editorial Board Holly J. Humphrey, MD Chicago, Illinois Jeremiah A. Barondess, MD Daniel Foster, MD Philip A. Mackowiak, MD Richard B. Gunderman, MD, PhD New York, New York Dallas, Texas Baltimore, Maryland Indianapolis, Indiana David A. Bennahum, MD James G. Gamble, MD, PhD J. Joseph Marr, MD Sheryl Pfeil, MD Albuquerque, New Mexico Stanford, California Broomfeld, Colorado Columbus, Ohio John A. Benson, Jr., MD Dean G. Gianakos, MD Aaron McGuffn, MD Alan G. Robinson, MD Portland, Oregon Lynchburg, Virginia Huntington, West Virginia Los Angeles, California Richard Bronson, MD Jean D. Gray, MD Stephen J. McPhee, MD Stony Brook, New York Halifax, Nova Scotia San Francisco, California John Tooker, MD, MBA John C.M. Brust, MD Lara Hazelton, MD Janice Townley Moore Philadelphia, Pennsylvania New York, New York Halifax, Nova Scotia Young Harris, Georgia Steven A. Wartman, MD, PhD Charles S. Bryan, MD David B. Hellmann, MD Francis A. Neelon, MD Washington, DC Columbia, South Carolina Baltimore, Maryland Durham, North Carolina Bonnie Salomon, MD Robert A. Chase, MD Pascal James Imperato, MD Medical Organization Director Peterborough, New Hampshire Brooklyn, New York Deerfeld, Illinois Griffin P. Rodgers, MD, MBA Therese Jones, PhD John S. Sergent, MD Henry N. Claman, MD National Institute of Diabetes and Digestive and Denver, Colorado Aurora, Colorado Nashville, Tennessee Kidney Diseases, National Institutes of Health Lynn M. Cleary, MD John A. Kastor, MD Clement B. Sledge, MD Bethesda, Maryland Syacuse, New York Baltimore, Maryland Marblehead, Massachussetts Jan van Eys, PhD, MD Fredric L. Coe, MD Henry Langhorne, MD Nashville, Tennessee Chicago, Illinois Pensacola, Florida Councilor Directors Abraham Verghese, MD, DSc (Hon.) Jenna Le, MD Regina Gandour-Edwards, MD Jack Coulehan, MD Stanford, California Stony Brook, New York New York, New York University of California, Davis, School of Steven A. Wartman, MD, PhD Medicine Peter E. Dans, MD Michael D. Lockshin, MD Washington, DC Baltimore, Maryland New York, New York David Watts, MD Charles Griffith III, MD, MSPH Lawrence L. Faltz, MD Jerome Lowenstein, MD Mill Valley, California University of Kentucky College of Medicine New York, New York Larchmont, New York Gerald Weissmann, MD Mark J. Mendelsohn, MD Joseph J. Fins, MD Kenneth M. Ludmerer, MD New York, New York University of Virginia School of Medicine New York, New York St. Louis, Missouri Faith T. Fitzgerald, MD C. Ronald Mackenzie, MD Sacramento, California New York, New York Coordinator, Residency Initiatives Suzann Pershing, MD Stanford University
www.alphaomegaalpha.org Student Directors Jeremy T. Bolin Uniformed Services University of the Health Manuscripts being prepared for The Pharos should be typed double-spaced and conform to the format outlined in the manuscript Sciences F. Edward Hébert School of Medicine submission guidelines appearing on our website: www.alphaomegaalpha.org/contributors.html. Editorial material should be sent Richard Latuska, MD to Richard L. Byyny, MD, Editor, The Pharos, 525 Middlefield Road, Suite 130, Menlo Park, California 94025. E-mail: thepharos@ Vanderbilt University School of Medicine alphaomegaalpha.org. Laura Tisch, MD Requests for reprints of individual articles should be forwarded directly to the authors. Medical College of Wisconsin The Pharos of Alpha Omega Alpha Honor Medical Society (ISSN 0031-7179) is published quarterly by Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, Menlo Park, California 94025, and printed by The Ovid Bell Press, Inc., Fulton, Missouri 65251. Periodicals postage paid at the post office at Menlo Park, California, and at additional mailing offices. Copyright Administrative Office © 2016, by Alpha Omega Alpha Honor Medical Society. The contents of The Pharos can only be reproduced with the written Richard L. Byyny, MD permission of the editor or managing editor. (ISSN 0031-7179). Executive Director Circulation information: The Pharos is sent to all dues-paying members of Alpha Omega Alpha at no additional cost. All Menlo Park, California correspondence relating to circulation should be directed to Ms. Debbie Lancaster, 525 Middlefield Road, Suite 130, Menlo Park, California 94025. E-mail: [email protected]. 525 Middlefeld Road, Suite 130 Menlo Park, California 94025 POSTMASTER: Change service requested: Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, Telephone: (650) 329-0291 Menlo Park, CA 94025. Fax: (650) 329-1618 E-mail: [email protected] The Pharos • Volume 79 Number 1 • Winter 2016 In This Issue
News and features ARTICLES
2015 Robert J. Glaser 2 AΩA Fellow in Leadership Award 55 Distinguished Teacher Awards An innovative program for developing physician Reviews and reflections leaders 58 The Worm at the Core: On the Role of Death in Life Joshua Hartzell, MD, Nathan Goldstein, MD, Reviewed by John L. Wright, MD and Monica Vela, MD p53: The Gene That Cracked the Cancer Code 10 Reviewed by Thoru Pederson, PhD A syllabus on healing Doctors of Another Calling: Physicians Francis A. Neelon, MD Who Are Best Known in Fields Other than Medicine Reviewed by Jack Coulehan, MD 14 The physician condolence letter and the role of compassion and healing in National and chapter news modern medicine 62 Minutes of the 2015 Board of Directors Meeting Gregory L. Fricchione, MD, and Marielle J. Fricchione, MD Alpha Omega Alpha elects new officers and directors 24 First principles Robert B. Hinton, MD Poetry To Fall and Rise Again 28 On the significance of the 23 Henry Langhorne, MD Circle of Tugo Luis Nicolas Gonzalez Castro, MD, PhD The Aging Soloist 27 Raymond C. Roy, MD, PhD INSIDE BACK Warfare 36 A recruit enters the COVER64 Danielle Wallace Epidemic Intelligence Service Harry W. Haverkos, MD
Correction 44 Bosch and Bruegel We misspelled an author’s name Disability in sixteenth-century art in the Table of Contents of the Autumn 2015 issue. The author Gregory W. Rutecki, MD of “Sestina for a Father” is Ting Gou, not Tina. We apologize for the error. AΩA Fellow in Leadership Award An innovative program for developing physician leaders
Joshua Hartzell, MD, Nathan Goldstein, MD, and Monica Vela, MD
Introduction • Leading from within—Leading oneself is about creating Richard L. Byyny, MD, Executive Director access to a broader range of ways of being, thinking, and act- Leadership in medicine, medical education, and health care ing to become more effective in dealing with the challenges for is more complex in the twenty-first century than ever before. which the usual solutions are inadequate. Unlike most existing Escalating costs, unequal access, less than ideal outcomes, and programs that teach leadership by imparting someone else’s political challenges facing health care legislation have contrib- knowledge (a third-person approach), this fellowship em- uted to an unprecedented level of uncertainty in the delivery of phasizes creating leaders using a first-person “as-lived/lived- health care and medical education. through” methodology. In working with Fellows to “unpack” The medical profession and the country are in need of their hidden beliefs and frames of reference, new contexts will leadership that is inspiring, insightful, engaging, and humble— emerge that give them more space and more degrees of free- leadership that both understands and represents the needs of dom to lead effectively as their natural self-expression. patients, physicians, medical educators, and trainees. Because • AΩA’s professional values, enumerated in the society’s of their unique knowledge of the practice of medicine and un- motto—“Be Worthy to Serve the Suffering”—and its mission derstanding of medicine’s core professional values, physicians statement: are ideally suited to serve as leaders in this period of change. Alpha Omega Alpha—dedicated to the belief that in the The integral parts of the professional life of a physician are the profession of medicine we will improve care for all by values affirmed in the Medical Professionalism Charter that – recognizing high educational achievement emphasizes the principles of patient welfare, patient autonomy, – honoring gifted teaching and social justice. – encouraging the development of leaders in academia and Encouraging the development of leaders in academia and the community the community has been, and continues to be, one of AΩA’s – supporting the ideals of humanism important missions. In 2013, AΩA developed and implemented – promoting service to others. a Fellow in Leadership Award and selected the first group of • The concepts of servant leadership—Servant leadership Fellows in 2014. is based on specific core values, ideals, and ethics, in much the The AΩA Fellow in Leadership Award recognizes and sup- way that the culture of medicine is shaped. Because medicine is ports the further development of outstanding leaders exempli- at its core a profession that serves others, we believe that effec- fying the qualities of: tive, sustainable, and excellent leadership should be based on
2 The Pharos/Winter 2016 core professional and personal values and the commitment to The three inaugural AΩA Fellows in Leadership—Monica servant leadership, while recognizing the value of other leader- Vela, MD; Nathan Goldstein, MD; and Joshua Hartzell, MD— ship strategies and approaches. were selected for their diverse backgrounds, and employment The five essential components of the AΩA Fellow in and educational experiences. They presented the findings, Leadership Award are: outcomes, and lessons learned from their projects to the AΩA 1. Self-examination, the “inward journey,” leading from Board of Directors during the 2016 meeting of the AΩA Board within. of Directors. The Fellows have now successfully completed 2. A structured curriculum focused on topics related to their year of leadership development and are the first-ever leadership, including an understanding of the relationship be- alumni of the AΩA Fellows in Leadership Award program. tween leadership and management. The Fellows have made major progress in developing as 3. Mentors and mentoring. leaders, including gaining knowledge and understanding 4. Experiential learning to broaden the perspective and of leadership and models of leadership; understanding the understanding of leadership as it relates to medicine and “inward journey” and applying it to leadership; exhibiting health care. knowledge and awareness about the importance of diversity 5. Team-based learning and developing communities of in leadership; developing improved communication skills and practice. writing effectiveness; developing a sense of social and civic re- Fellows are mid-career physicians who provide outstand- sponsibility and understanding of servant leadership; observing ing leadership within organizations in medicine and health the importance of leading based on professional values; suc- care, including schools of medicine, academic health centers, cessfully implementing, pursuing, and completing a leadership community hospitals, clinics, agencies, or organizations, project—all of which will guide them in their careers and lives. with a high promise for future success, leadership, and future For this issue of The Pharos, we invited the Fellows to de- contribution. scribe, reflect, and summarize their AΩA Fellow in Leadership Nominations for the AΩA Fellow in Leadership Award are journeys and experiences, and tell us how they have begun to made by the senior executive of the medical school, hospital, or develop a community of practice and network in leadership. health care organization, who also agrees to serve as a mentor for the Fellow. The nominating organization and Fellow des- The AΩA Fellow in Leadership Award ignate at least one additional mentor who, with the executive Joshua Hartzell, MD, Nathan Goldstein, MD, and Monica leadership mentor, supports the completion of a leadership Vela, MD project, serves as a role model, offers advice as needed, and Medicine is no longer about the lone cowboy riding in and connects the Fellow with key individuals in leadership posi- saving the day, but rather the ability to work within teams to tions. At least one mentor is at the senior leadership level, i.e., provide the best clinical care.1 Despite the ever growing need a Dean, Chief Executive Officer, or the President of an associa- for leadership in medicine, there remains a gap in the training tion or an organization that has a regional or national presence. and development of physicians as leaders. At the undergradu- Fellows may also choose mentors and coaches outside of their ate level, a recent paper illustrated that leadership training is immediate organizations or work groups. uncommon.2 Similarly, a paper related to Graduate Medical These relationships and leadership opportunities and expe- Education shows that the training of leaders is not that much riences, are ongoing through and after the fellowship year. The better at the later stage of physicians’ careers.3 Only forty-five mentors in the Fellow’s organization commit to the mentoring papers relating to leadership development were identified in plan and to allocating time to support the Fellow’s ongoing more than fifty years of publications. It is evident that most leadership opportunities after completion of the fellowship. physicians are not formally trained to be leaders, but rather The Fellows develop and implement an action project for ex- develop through trial and error during leadership roles in what periential leadership development to be completed during the some have called “accidental leadership.” 4 course of the year. Fellows and faculty leaders in AΩA attend a The obvious question is: If leadership is so important, why leadership orientation session that is combined with the course are we as a profession not devoting time and resources to “The Science and Practice of Leading Yourself.” Throughout developing more leaders? If we do not address this issue, we the year, Fellows participate in a defined and structured cur- will find that we are ceding leadership to those who may not riculum with faculty leaders from the AΩA Board of Directors have the same view of medicine or the same relationship with and others with leadership development experiences. The patients that physicians do. We must act now to ensure that Fellows and faculty are expected to develop a network of lead- we are adequately preparing physicians to become the next ers and a Community of Practice. generation of leadership in medicine. The Fellows each received a 25,000 award for further de- As the three physicians who were honored to be the inau- velopment as future leaders, and recognition as an AΩA Fellow gural Fellows for this award, we reflect on our experiences and in Leadership. the ways that the program has enhanced our careers.
The Pharos/Winter 2016 3 AΩA Fellow in Leadership Award: An innovative program for developing physician leaders
The 70-20-10 Model for learning and development.6 The majority of learning is what occurs on the job, while the gaps are filled in with mentoring, coaching, and specific training. Adapted from Tom Aretz, Harvard Macy Program for Educators in Health Professions, 2015.
LTC Joshua D. Hartzell, MD Assistant Chief of Graduate Medical Education Associate Program Director Internal Medicine Residency Challenge, James Kouzes and Barry Posner point out that “The Walter Reed National Military Medical Center best leaders are simply the best learners, and life is their labo- Associate Professor of Medicine ratory.” 5p21 Leadership requires that we continually develop Uniformed Services University, Bethesda, Maryland new skills and learn new things. It requires constant reflection about our leadership experiences so that we can evolve. Leadership and learning are indispensable to each other. During residency and early in our careers we are mainly —John F. Kennedy focused on developing our clinical expertise. The larger question is: How do we learn to meet the changing demands As I reflect back on the past year, I see how the AΩA of leadership? Much like medicine, leadership is a constant Fellowship has helped me to mature as a leader. We began the journey that never ends and requires lifelong learning. The year at the leadership course given by Wiley “Chip” Souba, AΩA Fellowship afforded me the opportunity to explore former Dean of the Geisel School of Medicine at Dartmouth how we grow and learn as professionals and the importance College. During the course, “The Science and Practice of of networking and being part of a community of learners. Leading Yourself,” I quickly developed a better appreciation Throughout the year, I found myself repeatedly wishing I had for reflection as a practice to improve as a leader. We explored previously learned many of the things I was being exposed the importance of context and mental maps, and the bias that to—they would have allowed me to be more successful as an these bring into our decision making and behavior. Being educator and leader much sooner in my career. more aware of these elements allows me to be both more Tom Aretz from Partner’s Healthcare International intro- objective and conscious of what might be driving my actions duced me to a concept that I have found very useful. The fact or the actions of others. I have developed a much greater ap- is that we learn in many different ways, but, in general, we preciation for the study of leadership, and how developing as learn only what we need to accomplish our daily tasks. The 70- a leader directly improves my ability to be a better physician, 20-10 model is a useful framework for physicians as they con- husband, father, and community member. The fellowship has sider how to develop the skills necessary to become leaders.6 given me a deeper confidence in my abilities that allows me to We are often faced with challenging new positions re- better advocate for those I lead. quiring us to identify and learn new skills. These stretch as- During the past year, I have meditated on the importance signments, while initially uncomfortable, become incredibly of learning in leadership. In their book, The Leadership valuable learning experiences. During these assignments,
4 The Pharos/Winter 2016 having a coach or a mentor can be vitally important. The The courses (the 10 percent of the 70-20-10) opened distinction between these two elements of career develop- my eyes to many new possibilities, and have inspired me to ment are important, but they can, and do, overlap at times.7 pursue a Master’s degree in Health Professions Education, A coach is specifically sought out to help develop a particular which I started in September 2015. For anyone who wants to skill. A mentor, however, is someone with more experience in learn more about teaching and leading in academic medicine, the types of challenges you face, and will provide more holistic working towards an advanced degree would be a valuable step. guidance about your career or what to do, or what not to do, in These degrees are designed for working physicians and help certain situations. During the past year, I have been fortunate fill important gaps in our training—educating and leading. to have had multiple mentors both within and outside my Similarly, for those who have an interest in other areas (busi- institution. I would like to thank Colonel Clifton Yu, Colonel ness of medicine, technology in medicine, public policy, etc.) Michael Nelson, Dean Arthur Kellermann, Lieutenant General an advanced degree will likely allow them to be much more (Retired) Eric Schoomaker, and Page Morahan for their time effective in their chosen fields. It is obvious now more than and remarkable counsel and insights. These mentors have ever that being a physician does not fully prepare physicians provided me with advice, and have challenged me to consider for some of these roles. different perspectives or even different career paths. Each The importance of a community of learners or networking provided a different look into my professional development as cannot be over emphasized. We are all connected via e-mail, a leader and educator. Facetime, Twitter, etc., yet we still spend most of our time In addition to the informal learning from mentors, I at- working within our own institutions. Even within our own in- tended two Harvard Macy Programs: Leading Innovations stitutions, we work in silos and not across departments. Many in Health Care and Education, and Program for Educators in of us face the same problems, but we continue to recreate the Health Professions. What I quickly learned in each program wheel on our own. My project for the AΩA Fellowship was was that I had been lacking many important skills that would to develop a leadership curriculum for our graduate medical help me to be much more effective at my job. I have always education trainees. As I began to search for resources, I found considered myself a good teacher, but the educator course many others who were working on the same idea at other challenged many of my assumptions about teaching, and made institutions. We have been able to share background materi- me start to look at teaching in a much more scientific way. It als, lecture outlines, and in some cases, collaborate on giving is always just assumed that physicians should be good teachers the lectures at other institutions. The ability to collaborate or despite the fact that we receive no training. The course inspired have this community of learners has been vital to keeping the and challenged me to be more aware of how I teach and of project moving forward. the teaching of those with whom I work. The course director The challenges we face in medicine and the small amount Elizabeth Armstrong consistently emphasized that we should of time that we have to devise solutions means that, more experiment with our teaching. Since the course, I have become than ever, we need to be working on these issues together. much more driven to experiment and to foster this in others. Large academic organizations need to focus on these joint The second course I took was the Leading Innovations problems and create solutions together. A recent example is Course. It is largely based on Clayton Christensen’s disrup- the cost conscious care curriculum that the American College tive innovation theory, but goes beyond that to examining of Physicians developed. Professional societies have the ability how we approach change in medicine. The course challenges to pull people together to tackle tough problems, alleviating the way we think about doing things. So much of what we do the stress of individuals each trying to independently solve the in medicine is because we have done it that way for decades. same problem at their home institutions. Could each profes- Given the growing use and impact of technology and the many sional society coordinate to develop or tackle one problem changes we face in medicine, we need to examine everything each year or create task forces within their organizations to we do and ask ourselves if it can be done better, more ef- tackle multiple problems? These organizations have thousands ficiently, or more economically. One example would be how of physicians who would love to be part of something mean- we round on patients. Is it necessary to have students present ingful. We need to put this human capital to better use. in a SOAP format now that most attending physicians already The fellowship afforded me many opportunities to grow have all the data and it is readily available? Could we not just through formal classes, mentoring, and self-reflection about go directly to the assessment and plan? It would be obvious if leadership. It has fostered relationships that have been invalu- a student or resident is missing data because their plan would able in my professional development. Thus, it has significantly be off. Breaking the tradition of rounds is not easily done, but enhanced my preparation for future leadership positions in rounds are not likely to be conducted the same way ten years academic medicine, and has reminded me that as I move from now as they are today. It is vital to point out that innova- forward in these positions I must continue to evolve to be an tion in medicine is going to require leaders with the courage effective leader. The fellowship’s impact may be greatest in to risk failure. that I have been able to bring back all that I have learned to
The Pharos/Winter 2016 5 AΩA Fellow in Leadership Award: An innovative program for developing physician leaders
my institution, and have challenged others to think about their was to explore ways to improve the integration of palliative own educational or leadership development. care into the care of patients with advanced heart failure, shortly after being selected I became the Interim Director of Nathan Goldstein, MD the Palliative Care Program at Mount Sinai Beth Israel. Chief of the Division of Palliative Medicine In September 2013, Mount Sinai Medical Center acquired Mount Sinai Beth Israel, New York, New York several new hospitals as part of a merger of health systems I have dedicated my career to providing the highest qual- in the greater New York City area. One of these hospitals, ity of palliative care to patients and their families. Palliative now named Mount Sinai Beth Israel, is an 856-bed teaching care is specialized medical care for people living with serious hospital founded in 1889 on Manhattan’s Lower East Side. illness. It focuses on providing relief from the symptoms and Previously, the palliative care program at Beth Israel was part stress of a serious illness—whatever the diagnosis. The goal is of the Department of Pain and Palliative Medicine; it was an to improve quality of life for both the patient and the family. independent department with a single chairman. As part of Palliative care is appropriate at any age and at any stage in a this transition, the chairman resigned and the department was serious illness and can be provided along with curative treat- split into two sections: Palliative Care, and Pain Medicine. I ments.8 While my original proposal for the AΩA Fellowship took the interim position in June 2014, and was charged with redesigning the organizational structure of this new, stand- alone division; revising the strategic plan and business case for the service; and improving the quality of care delivered by
Nate’s Leadership North Star.
6 The Pharos/Winter 2016 the service to patients and their families. Many faculty and fellowship year. We started with a series of exercises through staff left in the wake of this merger, and as a result there were which I developed my leadership “North Star”—the core significant growing pains associated with the transition. At the values and traits I identified as the principles that I wanted same time there was, and continues to be, considerable and to embody as a leader. My “North Star” is a simple blue note unwavering support from hospital leadership for the Division with my illegible handwriting on it that I keep tacked onto my of Palliative Care at Mount Sinai Beth Israel, especially from bulletin board at my desk and review regularly. It reminds me hospital President Susan Somerville and Chief Medical Officer that I want thoughtful listening, fairness, developing others, Barbara Barnett. and curiosity to be the fundamental elements of my daily work As Josh notes above, 70 percent of learning leadership on as a leader. On calls with Dorothy, I would struggle with both the job involves “stretch assignments,” and this new position the core work of leadership (e.g., how to design my organiza- was most definitely a growth opportunity for my leadership tional chart), as well as my journey to better understand the skills. One of the greatest advantages of my fellowship was the elements of my personality into which I could tap to improve access to the AΩA leadership team, especially to my dedicated the work of our division (e.g., my sense of humor). We also mentor from the program, Dr. John Tooker, the Emeritus Vice created a list of directed readings, which included some of the President and CEO of the American College of Physicians. Dr. classics of leadership publications such as Michael Watkins’ Tooker, along with the entire faculty of the AΩA Fellowship, The First 90 Days,9 Thomas Neff’s and James Citrin’s You’re used their combined experience and knowledge of academic in Charge—Now What? 10 and Patrick Lencioni’s The Five health care systems to help me better understand the organi- Dysfunctions of a Team.11 Dorothy and I then applied these zational culture of my institution, and how to align both my concepts of leadership to my daily work, allowing me to apply position and requests for resources with that of the hospital in real time the new skills and knowledge I was learning. and the health system to better improve care of seriously ill While the last year has been full of challenges and change, patients and their families. The AΩA leadership team, former it was a fortuitous moment in my career to have been thrust deans and CEOs of medical centers and systems themselves, into a leadership role at exactly the same time I received the was able to provide me with valuable insights into the world Fellow in Leadership Award. The award not only provided of academic medicine. They also helped me to better under- support for my leadership training, but also provided me with stand the needs and viewpoints of the senior administrators time to reflect on exactly what kind of leader I wanted to be- of my hospital and showed me how to meet administration come. Indeed, the ability to reflect on my journey to become expectations and frame negotiations in a way that resulted in a leader as I was actually going through the process may have a win-win for seriously ill patients and their families, as well been one of the most valuable aspects of the fellowship itself. as for the hospital. I believe that I have grown both personally and as a leader, As both Josh and Monica note, growing into leadership and my division has expanded and become a highly functional involves personal transformation. One of the most important team. While there is still much work to be done in the coming steps in this process is envisioning oneself as someone quali- months and years as health care changes, I believe that the fied to take over a senior leadership role and avoiding, or at advantages offered to me by this award have truly helped me least minimizing, the imposter syndrome. While there were forge a new career path that will ultimately improve the care many times when I sat in my office thinking, “I can’t do this” of seriously ill patients and their families. In July of 2015, I or “What happens when they find out they put the wrong was officially named Chief of the Division of Palliative Care, a person in this job . . . me?” a quick text with Josh and Monica, testament to my success in my new role and the ways that the or a phone session with Dr. Tooker, or a conference call with AΩA Fellow in Leadership Award has helped me grow. the AΩA leadership team gave me the confidence boost that I needed, as well as the helpful advice to guide me through Monica Vela, MD whatever the current struggle or challenge was. In addition Associate Professor of Medicine, Department of Medicine to this team, I engaged a leadership coach using the funds Associate Dean of Multicultural Affairs that the fellowship provided. I worked with Dorothy Moga, a University of Chicago Pritzker School of Medicine, certified leadership coach with decades of experience in health Chicago, Illinois care. I was particularly lucky in that Dorothy has many years Our journey began with a week-long intensive orientation of direct experience working in both hospice and palliative designed to provide time for reflection, problem-solving, and care. While content knowledge such as this is not required for recognition of our strengths and weaknesses. Imagine being a leadership coach, it did provide additional value to the work placed in a room with some of the top leaders in the medical we did together, since she was familiar with the particular profession and being asked to reflect and share your perspec- challenges associated with running a palliative medicine pro- tives on the following questions: gram in an academic medical center. What did we hope to achieve for the medical profession? Dorothy and I spoke every two weeks throughout the Who was on “our bus” and who was missing?
The Pharos/Winter 2016 7 AΩA Fellow in Leadership Award: An innovative program for developing physician leaders
Over time, and with extended discussions with the AΩA leaders, the answer came in two parts. First, I had failed to claim expertise in the fields I knew well. Despite being listed as an expert in diversity in medicine in a recent U.S. Supreme Court writ, having spent more than a decade as an Associate Vice Chair for Diversity within my department, and Associate Dean for Multicultural Affairs at my institution’s medical school for four years, I had never made the claim to be an expert in diversity. I know the literature regarding women in medicine quite well. Women in medicine are known for their collaborative spirit. They are more likely to devote time and energy to com- mittee work, but less likely to be the committee leaders. They are also less likely to advance to the senior ranks of medical school faculties. While much of this failure to rise in the ranks is due to bias at the workplace, some is due to women’s reluctance to claim expertise in our appointed fields. Failing to recognize our own expertise is unfortunately a common issue for women in medicine. I began to read a great deal about leadership and found great lessons in books like The Leadership Challenge: How to Make Extraordinary Things Happen in Organizations by James M. Kouzes and Barry Z. Posner.5 Sharing expertise is a common practice and commit- What was keeping us from making a difference? ment among most leaders. Where were we in the leadership continuum? The AΩA Fellowship provided me with time and funding In an effort to answer, all three of us quickly reviewed our to attend leadership conferences specific to my areas of inter- applications for the program. We had each included an essay est. Much of my career has been spent building a knowledge on our current projects and had delineated our visions for base in diversity, health disparities, and teaching on health completing those projects. My mentorship team was solid, and disparities. Attending the Society of General Medicine’s I felt proud of the work we were accomplishing at our institu- Associate of Chiefs and Leaders in Medicine conference ex- tion. I have a great working relationship with the dean of our posed me to inspirational leaders in these fields, and provided medical school, the chairman of my department, and the chief me some confidence that I could contribute to the growing of my section. I was already mentoring very successful junior conversations surrounding diversity in medicine. Attending faculty. I already felt valued and supported at my institution. leadership conferences helped me to find my voice and made Each of us outlined our resources and needs, our supports me realize that it was time to start sharing that knowledge and weaknesses, and explored the personal characteristics that base outside of my own institution through collaborations and made us successful—as well as those that kept us from mov- written work. ing forward. We made lists upon lists and drew up elaborate Once I had found my voice and claimed my expertise, I was schema covered in Post-Its on a Grove Gameplan. By the end able to acknowledge that the second thing keeping me from of the second day, we were exhausted; the two-day journey sharing that expertise was my discomfort with writing. I had had taken a great deal out of us. We had expressed apprecia- completed a graduate level writing course years ago, and this tion of our mentors; healthy cynicism over the current system certainly improved my writing skills. Now, books like Bird by of health care and education; had identified obstacles in our Bird by Anne Lamott,12 and On Writing Well: The Classic workdays; and, we had learned that each of us was missing the Guide to Writing Nonfiction by William Zinsser,13 became mark in some way on the opportunities to become true leaders dog-eared through good use in my office. In the words of a fel- in the profession. low faculty member, “good papers are rarely written, they are Specifically, I began to see that I felt most fulfilled spend- re-written.” I scheduled time for writing into my day, just as I ing much of my time “in the trenches”—creating and teaching would schedule time for a meeting. I joined a writing group new curricula, caring for very ill patients, traveling to recruit that meets every two weeks to edit group members’ manu- students, and mentoring students and junior faculty. What I scripts, and I became an avid contributor. These measures was not doing, however, was spending enough time reflecting made a difference. and writing. Why had I not written and published more of my I am particularly proud of a recent publication in the work? I struggled to answer. Journal of General Internal Medicine, titled “National Survey
8 The Pharos/Winter 2016 of Medical Spanish Curriculum in U.S. Medical Schools.” 14 we work within, and our families. As members of AΩA, the This was the result of collaborative work with the national expectation is that you are a leader and we hope that we have Latino Medical Student Association, an organization seeking provided some ideas about how you can sharpen your skills. to improve the health care of Latinos, as well as to improve the representation of Latinos among U.S. medical students. References Advocating for language concordant care of limited English 1. Gawande A. Cowboys and pit crews. New Yorker 2011 May proficient (LEP) patients to promote the quality and equity of 26. their care is a passion of mine. The students and I had begun 2. Webb AM, Tsipis NE, McClellan TR, et al. A first step to- data collection on a national survey of U.S. medical schools ward understanding best practices in leadership training in under- and the curriculum surrounding medical Spanish. As the stu- graduate medical education: a systematic review. Acad Med 2014; dents graduated and began their respective internships, the 89 (11): 1563–70. project lost momentum. Leaving the data unpublished, I now 3. Frich JC, Brewster AL, Cherlin EJ, Bradley EH. Leadership felt, was not an option. The survey revealed that medical edu- development programs for physicians: a systematic review. J Gen cators were making great efforts to teach the curricula but that Intern Med 2015; 30 (5): 656–74. few schools used validated instruments to measure language 4. US Army Medical Corps Leadership Development Program proficiency of the students after completion. This was particu- Working Group. The US Army Medical Corps leadership develop- larly disturbing given that untrained or ad hoc interpreters can ment program. US Army Med Dep J 2013 Jul-Sep: 4–29. http://www. actually worsen the health outcomes of LEP patients. cs.amedd.army.mil/filedownloadpublic.aspx?docid=75540426-8cd5- I reached back and re-charged the group. Despite now 4f93-8a32-c39db3bc228a. being scattered across the country at various institutions, 5. Kouzes J, Rosner B. The Leadership Challenge: How to Make we managed to pull together to complete the manuscript. Extraordinary Things Happen in Organizations. Fifth edition. San We concluded by calling for further research into the best Francisco: A Wiley Imprint; 2012. practices for developing and evaluating the curriculum for 6. Rabin R. Blended Learning for Leadership: The CCL Ap- medical students so that we could work together as a profes- proach. http://insights.ccl.org/wp-content/uploads/2015/04/Blend- sion to improve the care of LEP patients. In the short time edLearningLeadership.pdf. since publication, the manuscript has already been cited twice 7. Travis EL, Doty L, Helitzer DL. Sponsorship: a path to the and is in the top 5 percent of all articles scored by Altmetric, academic medicine C-suite for women faculty? Acad Med 2013; 88 a company that tracks relevant mentions from social media (10): 1414–17. sites, newspapers, and policy documents. 8. Center to Advance Palliative Care. http://www.CAPC.org. One paper is certainly not cause for a wild celebration. 9. Watkins M. The First 90 Days: Critical Success Strategies However, perspective pieces, letters to editors, and other orig- for New Leaders at All Levels. Boston: Harvard Business School inal manuscripts have begun to find their way out of my office Publishing; 2003. and into the review process. The process itself has become 10. Neff T and Citrin J. You’re in Charge—Now What? The 8 fulfilling because I have now used writing as a possible lever Point Plan. New York: Crown Publishing Group; 2005. for change and advocacy. I have begun to teach my mentees 11. Lencioni P. The Five Dysfunctions of a Team. San Francisco: that claiming expertise, sharing expertise through teaching Josey-Bass; 2002. and writing, and collaborating with others outside of our own 12. Lamott A. Bird by Bird: Some Instructions on Writing and institution is a form of advocacy, as well as leadership. I wish Life. New York: Anchor Books; 1995. to thank my mentors, Drs. Marshall Chin, Deborah Burnet, 13. Zinsser W. On Writing Well: 30th Anniversary Edition: The and Holly Humphrey for supporting my application to this Classic Guide to Writing Nonfiction. New York: HarperCollins fellowship and for their continued support in my development Publishers; 2006. as a leader in medicine. 14. Morales R, Rodriguez L, Singh A, et al. National survey of medical Spanish curriculum in U.S. medical schools. J Gen Intern Conclusion Med 2015; 30 (10): 1434–39. Each of our journeys were different, but we recognize the incredible opportunity we had to meet, collaborate, and learn Contact the authors: from each other and our mentors. Each of us grew as leaders Dr. Byyny: [email protected] based on the experiences that we took part in during this past Dr. Hartzell: [email protected] year. As the AΩA Fellowship moves forward, we know that fu- Dr. Goldstein: [email protected] ture recipients will benefit from the program. Ultimately, lead- Dr. Vela: [email protected] ership development starts simply with a motivation to become a better leader. Each of us as physicians has a responsibility to be better leaders for our patients, the health care system
The Pharos/Winter 2016 9 A syllabus on healing
Illustration by Laura Aitken.
10 The Pharos/Winter 2016 Francis A. Neelon, MD The author (AΩA, Duke University, 2002, Faculty) is I felt like I was standing with my finger stuck into an electrical medical director of the Rice House Healthcare Program in outlet, all the time. I couldn’t sleep. I couldn’t read, I couldn’t Durham, North Carolina. He is a member of the editorial eat, I couldn’t remember anything, anything at all. . . . I cried board of The Pharos. all the time. I lost 30 pounds. . . . Weeks passed, then months. I was wearing out my hus- ately I have been thinking about healing; about band and my friends. But I couldn’t calm down. It was almost what doctors do; about treating and (sometimes) as if I had become addicted to these days on fire, to this inten- curing; but mostly about healing. Perhaps that’s sity. I felt that if I lost it, I’d lose him even more. not surprising, since I have just worked my way through Eric Finally I went to a psychiatrist, a kind, rumpled man who LCassell’s illuminating The Nature of Healing, with its empha- formed his hands into a little tent and listened to me scream sis on the etymological sense of “heal” (from the Old English and cry and rave for several weeks. haelan, to make whole).1 But my interest in the topic came Then came the day when he held up his hand and said, before Cassell; it began in earnest when I came across Abraham “Enough.” Verghese’s finely drawn distinction between “curing” and “What?” I stared at him. “healing”: “I am going to give you a new prescription,” my psychia- trist said, taking out his pad and pen. He began to write. we are perhaps in search of something more than a cure—call “Oh good,” I said, wanting more drugs, anything. it healing. If you were robbed one day, and if by the next day He ripped the prescription out and handed it to me. the robber was caught and all your goods returned to you, “Write fiction every day,” it said in his crabbed little hand. you would only feel partly restored; you would be ‘’cured’’ but I just looked at him. not ‘’healed’’; your sense of psychic violation would remain. “I have been listening to you for some time,” he said, “and Similarly with illness, a cure is good, but we want the healing it has occurred to me that you are an extremely lucky person, as well, we want the magic that good physicians provide with since you are a writer, because it is possible for you to enter their personality, their empathy and their reassurance.2 into a narrative not your own, for extended periods of time. To live in someone else’s story, as it were. I want you to do this We can distinguish “curing” (treating, ameliorating, elimi- every day for two hours. I believe that it will be good for you.” nating disease) from “healing” (helping patients visualize and “I can’t,” I said. “I haven’t written a word since Josh died.” regain their sense of purpose and [attainable] goals in life1). “Do it,” he said. But if, as Verghese and Cassell spell out, healing is the essence “I can’t think straight, I can’t concentrate,” I said. of what Carl Binger called the doctor’s job,3 why do we so in- “Then just sit in the chair,” he said. “Show up for work.” 6 frequently hear the word “healing” spoken within the walls of medicine? I go almost every week to two different sets of what, Prescription in hand, Smith sat for three days; on the fourth, in homage to our ancestors, are still called “grand rounds.” I she began to write, and “My novel [On Agate Hill], which I’d hear a lot there about diagnosis and about treatment (especially, planned as the diary of a young girl orphaned by the Civil War, evidence-based treatment), but never, it seems, about healing. It just took off and wrote itself.” 6 makes me wonder whether we doctors really understand what I hope you will agree with me that Lee Smith was healed. we do, at least when it comes to healing. Not that this should be She thinks so (I asked her). So what did the doctor do, and how? so surprising. We really don’t know a lot about the deep work Could the proverbial fly on the wall have known what was oc- of doctoring, about what happens after the door to the exam- curring in the psychiatrist’s head while he “formed his hands ining room or consulting room closes and doctor and patient into a little tent and listened”? Could we, in his place, have are alone. As Mark D. Altschule pointed out,4 this ignorance known when to halt Smith’s rant with an imperious, attention- goes back a long way; we know more, for instance, about what riveting “ENOUGH”? Would we have scratched “Write fiction Copernicus did at night when he gazed at the stars, than what every day” on the prescription pad? When she protested, would he did during the day, when he saw patients.5 we have known to say, “Just sit in the chair. Show up for work,” thereby delivering an effective Ericksonian hypnotic command7 A treasure found to a surely entranced Lee Smith? Would we, by listening to her Here is something rare, an unexpected glimpse into the “scream and cry and rave” have gently primed her to accept hidden world of healing, all the more revealing because it was and respond to that hypnotic command? I am not sure that I recorded unselfconsciously and for a totally different purpose would have known what to do, but the tangible success of the than we will use it for. The novelist Lee Smith poignantly docu- psychiatrist’s efforts makes me want to be able to do it. And mented her prolonged and unremitting grief reaction to the perhaps even more, to be able to answer a young doctor-to-be untimely death of her son, Josh: if she should ask me (as one recently did) how one goes about learning that skill or art or sullen craft.
The Pharos/Winter 2016 11 A syllabus on healing A syllabus for the art of healing Books Balint, Michael. The Doctor, His Patient, and the Illness. Revised edition. New York: International Universities Press; 1964. Esterly, David. The Lost Carving: A Journey to the Heart Nurturing the healer’s art of Making. New York: Viking; 2012. The naïve or uninitiated might think that medical schools Reilly, Brendan. One Doctor: Close Calls, Cold Cases, and residency programs emphasize the teaching of health and and the Mysteries of Medicine. New York: Atria Books; 2013. the healing that helps restore lost capacity. But that does not Lown, Bernard. The Lost Art of Healing: Practicing occur often, if at all, I fear. Is it even reasonable to ask that Compassion in Medicine. Boston and New York: Houghton all doctors be healers? Visualize, if you will, a spectrum of Mifflin; 1996. medical practice that ranges from the extremes of pure healing Sweet, Victoria. God’s Hotel: A Doctor, a Hospital, and a (the province of quackery, perhaps) to one of pure treatment Pilgrimage to the Heart of Medicine. New York: Riverhead of disembodied “disease” (the holy grail of reductionism). Books; 2012. I suspect that most doctors do not dwell at either extreme, Cassell, Eric. The Nature of Healing: The Modern Prac- although many get perilously close to the treatment-only end. tice of Medicine. New York: Oxford University Press; 2013. And one great calamity is that when treatment-only doctors Cassell, Eric. The Nature of Suffering and the Goals of reach the point at which there is nothing more for them to Medicine. New York: Oxford University Press; 1991. do to the patient, they think there is nothing left to do for Osler, William. Aequanimitas and Other Addresses to the patient.8 My hope is that even the most cure-focused of Medical Students, Nurses and Practitioners of Medicine. treating practitioners would want to know something of and Philadelphia: P. Blakiston’s Son & Co.; 1905. Second edi- appreciate Verghese’s distinction between curing and healing, tion available at: https://archive.org/details/aequanimitas- would want to make healing always the partner and ally of wit04oslegoog. treatment, would find healing possible even when treatment Rosen, Sidney. My Voice Will Go with You: The Teaching and cure no longer are, would never let their words or actions Tales of Milton H. Erickson. New York: WW Norton; 1982. un-heal those they treat. Mizrahi, Terry. Getting Rid of Patients: Contradictions Maybe the topic of healing doesn’t come up often in teach- in the Socialization of Physicians. New Brunswick (NJ): ing exercises because it is not easily amenable to teaching Rutgers University Press; 1986. as we have come to know it (or because, to paraphrase Carl Binger, Carl. The Doctor’s Job. New York: WW Norton; Rogers,9 little that is of value can be taught, but much that is of 1945. value can be learned). In any case, if you want to master heal- Davies, Robertson. The Cunning Man. New York: Viking; ing, even dabble in it, you cannot expect to be taught. You will 1995. have to learn it. And how might one learn? In the ideal world, McGilchrist, Iain. The Master and His Emissary: The you might apprentice yourself to doctors recognized to be Divided Brain and the Making of the Western World. New healers, to learn by watching and listening to what the healers Haven (CT): Yale University Press; 2009. themselves may not be able to articulate but know only “in the Bleuler, Eugen. Autistic Undisciplined Thinking in Medi- bone,” know beyond knowledge. And you could read. Because cine and How to Overcome It. Darien (CT): Hafner Publish- a student-correspondent of mine recently asked, I made the ing; 1970. list that I offer here of books and papers that have enlarged my Gawande Atul. Being Mortal: Medicine and What Mat- vision of healing. They do not “teach” how to heal (remember, ters in the End. New York: Metropolitan Books; 2014. little that is of value can be taught), but they do, I think, give Thomas, Lewis; Amini, Fari; Lannon, Richard. A General glimpses into how healing happens (and sometimes into those Theory of Love. New York: Random House; 2000. unfortunate instances when healing is impeded or prevented from happening, and that we want to learn to avoid). Papers I think that I have profited from reading the books and pa- Fitzgerald, Faith T. Curiosity. Ann Intern Med 1999; pers on my list, but the learning is subtle. Reading and reflect- 130: 70–72. ing on what is read changes the unspeaking mind, so healing Ingelfinger, Franz J. Arrogance. N Eng J responses arise automatically and repetitively out of what Sally Med 1980; 303: 1507–11. Fitzgerald, alluding to Flannery O’Connor, called “the habit of Peabody, Francis W. The care of the being.” 10 We should also keep in mind what Milton Erickson patient. JAMA 1927; 88: 877–82. told his amanuensis, Sidney Rosen, “What you don’t realize, Stetten, Dewitt, Jr. Coping with Sid, is that most of your life is unconsciously determined.” 7 blindness. N Eng J Med 1981; 305: Thus we realize that the goal of directed reading is to em- 458–60. bed the constructs of healing so deeply and permanently in the unconscious mind that they come forth from the healer “automatically” because time and place are right. My guess is that Lee Smith’s psychiatrist did not ponder, “Would this be a good time to say ‘Enough’?”; rather, he sensed rightly that
12 The Pharos/Winter 2016 healing required that she be jolted into trance-like attention I have stumbled across, that have spoken to me about healing and moved into action. His was an automatic response, not in- across the divide of time and distance, that resonate still. nate but learned, part of what he had made his habit of being. References You can’t hit the target by aiming at it 1. Cassell E. The Nature of Healing: The Modern Practice of At the end of Being Mortal, Atul Gawande writes, Medicine. New York: Oxford University Press; 2013. 2. Verghese A. The healing paradox. New York Times 2002 Dec We’ve been wrong about what our job is in medicine. We 8. http://www.nytimes.com/2002/12/08/magazine/the-way-we-live- think our job is to ensure health and survival. But really it is now-12-8-02-the-healing-paradox.html. larger than that. It is to enable well-being. And well-being is 3. Binger C. The Doctor’s Job. New York: WW Norton; 1945. about the reasons one wishes to be alive.11p259 4. Altschule MD. Essays on the Rise and Decline of Bedside Medicine. Philadelphia: Totts Gap Medical Research Laboratories; The great paradox of healing (the restoration of well-being) is 1989. that the doctor cannot set out intending to heal. Instead, the 5. Bruce-Chwatt LJ, Bruce-Chwatt JM. Nicolas Copernicus, doctor must be thinking only, “How can I help this person in M.D. Bull NY Acad Med 1973; 49 (10): 895–905. trouble?” Help this patient identify, and if possible, achieve, 6. Smith L. Showing up for work. http://www.leesmith.com/ the attainable goals that will restore a sense of purpose in life?1 works/showingup.php. Uncovering those goals and that purpose is the doctor’s job, 7. Rosen S. My Voice Will Go with You: The Teaching Tales of but how this is done depends uniquely on the dyad of individ- Milton H. Erickson, M.D. New York: WW Norton; 1982. ual doctor with individual patient. The eliciting and support 8. Stetten D Jr. Coping with blindness. N Eng J Med 1981; 305 of a healing response is so variable and so mutable that only (8): 458–60. one common thread runs through all healing interactions: the 9. Rogers CR. Chapter 13. Personal Thoughts on Teaching and devotion of enough time to understand well the patient and Learning. In: Rogers CR. On Becoming a Person: A Therapist’s View his or her predicament, and to sort through the possibilities of Psychotherapy. Boston: Houghton Mifflin; 1961: 272–78. that will help him or her realize and embrace the possibility 10. O’Connor F. The Habit of Being. New York: Farrar, Straus of healing. Like Lee Smith’s psychiatrist, waiting and listening, Giroux; 1979. waiting and listening, then seizing on the right prescription to 11. Gawande A. Being Mortal: Medicine and What Matters in allow her to start healing herself, the doctor has to be willing the End. New York: Metropolitan Books; 2014. not to be or feel rushed. Because healing, when it happens, 12. Paré A. Les Oeuvres d’Ambroise Paré. Lyon: Jean Gregoire; 1664. comes not from the doctor but from within the patient. As Ambroise Paré put it nearly 500 years ago in his description The author’s address is: of the gunshot Capitaine Le Rat, “I bandaged [the wound] and 2216 West Club Boulevard God healed it.” 12 Durham, North Carolina 27705 I make no pretense to have constructed a comprehensive or E-mail: [email protected] even accurate syllabus for a curriculum on healing. Mine is an idiosyncratic and personal list, drawn from books already on my shelf and papers already in my file; the sequence listed is random, and implies no rank-ordered sense of value. I offer it in the hopes that others may find valuable these written works
The Pharos/Winter 2016 13 Illustration by Laura Aitken. Illustration by Erica Aitken 14 The Pharos/Winter 2016 The physician condolence letter and the role of compassion and healing in modern medicine
Gregory L. Fricchione, MD, and Marielle J. Fricchione, MD
Dr. Gregory L. Fricchione is Associate Chief of Psychiatry, ot long ago, Kathryn Fricchione (wife of Gregory Director of the Division of Psychiatry and Medicine, and and mother of Marielle), in the course of transcrib- Director of the Benson-Henry Institute for Mind Body Ning letters from her family’s trove of early American Medicine at Massachusetts General Hospital. He is Professor memorabilia, showed me one dated August 28, 1803, from of Psychiatry at Harvard Medical School. Dr. Marielle J. a physician in Richmond, Massachusetts.1 In it, Dr. John Fricchione is a Pediatric Infectious Disease Fellow at McGaw Merriman addresses my wife’s four-times-great-grandmother, Medical Center of Northwestern University, and the Ann and Clarissa Thomas Metcalf. Clarissa was then living at the family Robert H. Lurie Children’s Hospital of Chicago. Images of the farm in Lebanon, Connecticut, and had last heard from her original letters are courtesy of Kathryn Fricchione. surveyor husband in a letter dated July 9, 1803, from Warren, Massachusetts, about forty-five miles north of Lebanon.2
The Pharos/Winter 2016 15 The physician condolence letter
In the July 9 letter Joseph informs Clarissa that he has attention and respect was paid your dear Husband by Mr and injured his right leg, requiring a recovery of a few days.2 He Mrs Avery that Imagination Could conceive. He was intered uses the word “poisoned,” raising the question of ulceration or in a becoming decent manner by His Fraternal Brothers on cellulitis, but he recovers enough to re-explore the woods on Saturday at half past Eleven A.M. horseback, only to be laid low again by a broken tooth that may have become infected. Perhaps he developed a bacteremia, for Dear Madam he describes a febrile illness that lasted ten days. You have lost an affectionate Husband a Kind pardner the Joseph tells Clarissa that he “Shall probably set out for Choice of your Youth, the pertaker of your pleasure and mis- home in about two weeks,” 2 but he does not return to Lebanon fortunes.— May this Instance of mortality teach us that the by then. Instead, he winds up in the little town of Richmond, Empire of Death is unlimited and universal, and in respect or thereabouts, close to the border of Massachusetts and to this Excellent man He died in the midst of His Extensive New York State, at the home of Mr. Avery, perhaps a friend usefulness. O Ye! lost —consolated Orphans. You have lost or business acquaintance.1 Thus, even after suffering the two your Kind and Indulgent Father. He that was to lead you to illnesses, he apparently spent more than a month working his Felicity and honour. He that was to form your minds for the way through western Massachusetts in what turned out to be world is no more.— In his Death all your matters must be a fateful journey. newly arranged.
The condolence letter At this point in his letter the weary doctor composes a poem Sunday Evening August 28th to Joseph Metcalf’s memory:
Dear Mrs Medcalf, How soon O Metcalf! Should we see thee rise A melancholy scene I am now about to commence. To O banish sorrow from our weeping eyes, write to a disconsolated Widow enforming Her of the death . . . . of a tender husband is a task as painful as disagreeable. Being Of virtue eminent and Sanctity, the attending Physician it would be Ingratitude in me not to Sever one Mortal from the Shaft of Death give a particular History of Mr. Medcalfs sickness and death. And ransom from the Grave his vital breath After a laborious Journey of Several Hundred Miles through the western country in the Sickly Months He ar- I could still write but the cold hand of despair is upon me. rived at Mr Averys. I think on the 13 of the present Month. I shall conclude by wishing you and your Family farewell. He remained their 3 days previous to my being invited to see Him,— Upon much enquiry I discovered Quite a John Merriman Billious Tendency, or habit, together with many Chronic Richmond 18031 Complaints.— He enformed me He had the Dysentary 7 Days whilst on his Journey, that He Restrained the evacu- Recent medical articles recommend a modern template ation with Peruvian Bark and Laudanum.— From so many of the physician letter of condolence based on letters such as complicated complaints I could not accurately determine that written by Dr. Merriman. Physicians are encouraged to His Leading Disorder for 2 Days. Sometimes a Billious acknowledge the death in a personal way, to recall something dysentery with much griping Sometimes much Bloating special about the deceased such as a unique memory, a charac- and Fever— But finally Terminated in a disturbing Billious teristic the doctor admired, or a humorous occurrence shared Fever, Or What is commonly denominated Genasee Fever. with the patient. They are admonished to remind the survivor After Evacuations He appeard to be some better for 3 days. or family of their own strength and tenderness in taking care of Then his disease renewed its attacks with all its violence their loved one, to offer to review the management of the case, and rage [illegible] days previous to his dissolution a Strong to remain supportive during the grieving process, and to con- putrescene Tendency appeared ------Which To our ines- clude with a special mention of how the doctor will maintain pressable grief Terminated Friday Eve, Just 20 minutes past the family of the deceased in his or her thoughts and prayers.3–5 8 o Clock amidst a large concourse of his old former friends Dr. Merriman’s note serves as quite a good forerunner of and others. He resigned his breath without a groan, without this template. After a brief introduction with a gracious paying a Tear and without a murmur.— of respects, Dr. Merriman gives a medical history of the illness He Conducted himself with a great degree of becoming that had befallen Clarissa’s husband. He follows with an ac- firmness through the Several Stages of his Illness.— count of and tribute to Joseph’s conduct as he died, and praises He attracted the attention of all attendance, and in an those who attended him, including Mr. and Mrs. Avery. He especial manner the Family in which He was placed— I then ends by expressing his sympathy to the widow and family mention for the consolation of yourself and Family that every and again gives honor to “this Excellent man.”
16 The Pharos/Winter 2016 The history of the illness to the home on Tuesday August 16. The doctor then spent two According to Dr. Merriman, Joseph’s dysentery began on days trying to figure out the complicated case. Saturday August 6. Joseph tried to “restrain the evacuation with Peruvian Bark and with Laudanum.” 1 As a reflection of its The differential diagnosis importance to travelers of the day, we know that Meriwether In his letter to Clarissa, Dr. Merriman described the patient’s Lewis bought fifteen pounds of “Pulv[erized] Cort. Peru,” condition, telling her that Joseph had a “Billious Tendency” and or Peruvian bark, from Philadelphia druggists Gillaspy and that he had “Dysentary.” Strong for 30—one-third of his total expenditures for medi- The term “dysentery” today refers to frequent stools con- cal supplies—before setting off in May 1804 on the Lewis and taining blood and pus, as well as pain with defecation or te- Clark expedition.6 Jesuit missionaries, told of the healing prop- nesmus.5 However, the differential diagnosis of acute bacterial erties of a certain tree bark by Indians in Peru between 1620 dysentery, or inflammatory enterocolitis, is broad and includes and 1630, advocated the use of this Peruvian bark—or Jesuit’s the species that cause bacillary dysentery (several Shigella spe- bark, as it was also known—for a variety of illnesses. Its value cies and invasive E. coli species), Campylobacter jejuni, amebic was due chiefly to its high content of quinine, although no one dysentery (such as that caused by Giardia lamblia, Entamoeba understood that until the compound was isolated in 1820. In histolytica, or Balantidium coli, specifically termed ciliary June of 1805, William Clark applied it externally to Sacagawea’s dysentery), enteric fever, including typhoid and paratyphoid lower abdomen to treat what some physicians now suspect fever (caused by Salmonella typhi and paratyphi), and Yersinia was pelvic inflammatory disease. Lewis, however, gave the sick enterocolitica, among others.7 woman “two dozes of barks and opium” which “produced an Risk factors for the above syndromes include poor sanitation alteration in her pulse for the better.” 6 with stool contamination; lack of access to filtered or treated Joseph arrived at the Averys’ house seven days later, on water; and, for non-typhoid Salmonella, Campylobacter jejuni, August 13. Three days passed before Dr. Merriman was called and Yersinia enterocolitica, exposure to farm animals. Amebic
The Pharos/Winter 2016 17 The physician condolence letter
Vibrio species (parahaemolyticus) can cause dys- entery, but they are typically transmitted through seafood poisoning and the diarrhea only lasts three to four days.8 Dysentery caused by Shigella can lead to sys- temic illness with fever in one-third of patients, abdominal pain, and copious watery diarrhea that becomes bloody and mucus-containing when it moves to the colon. Symptoms last on average seven days, but can last up to one month and can be more severe in malnourished individuals with weakened immune systems. Febrile seizures, sep- sis, and hemolytic uremic syndrome can result.7 A less likely cause of Joseph’s dysentery might have been leptospirosis caused by the ingestion of the spirochete Leptospira from infected animal urine (such as that of cattle, pigs, and horses). Leptospira infection also causes fever, headache, abdominal pain, jaundice, vomiting, and diarrhea. When fatal, it occurs in two phases, which could explain Joseph’s preceding diarrheal illness and the more severe second phase. The initial phase of leptospirosis lasts five to seven days, followed by improvement in symptoms and disappearance of fever for one to two weeks. The second phase, sometimes called Weil’s disease, has a mortal- ity of 5 to 40 percent and can lead to death by kidney, liver, or cardiac failure, and pulmonary hemorrhage.9 Among the many possibilities, typhoid fever and malaria are most likely to give a patient pro- Cinchona (Jesuit’s or Peruvian Bark), 1795. longed and periodic fevers such as those described From A Physic, by Ebenezer Sibly (London, 1795). Photo credit: HIP/Art Resource, NY. in the letter. Untreated, typhoid fever can lead to febrile illness lasting up to four weeks, with severe complications such as intestinal perforation, hem- orrhage, seizures, and encephalopathy that gener- dysentery is common in those drinking from lakes or rivers. ally occurs after two weeks of fever. Only 20 percent of patients These risk factors would have been nearly universal in America with typhoid fever experience diarrhea, while fever, headache, in the early 1800s and are therefore not helpful in narrowing and anorexia are more frequent in 50 to 90 percent of patients.10 the differential diagnosis. Constipation occurs just as commonly as diarrhea. Untreated One of Joseph Metcalf’s two earlier infection sites could patients have progressively worsening fevers, abdominal pain in have become contaminated or reinfected, leading to bactere- the first one to two weeks of illness, and develop a rash (classi- mia. However it is more likely that his immune system was cal rose spots) during the second week. Without treatment, 10 weakened by these two infections, making him more suscep- to 15 percent of those affected will progress to death over the tible to contracting a gastrointestinal illness. next one to two weeks or recover on their own in three to four Diarrhea from Giardia can last one to two weeks, but weeks. Salmonella typhi can infect the gallbladder and lead to should not cause fever. Yersinia can cause diarrhea for up to cholecystitis, hepatitis, and jaundice.10 one to three weeks, and can be associated with fever, bactere- Malaria would have been common in the eastern United mia, migratory joint pain, and erythema nodosum.7 Cholera States in the summer of 1803, aided by an abundance of is highly unlikely, as it usually is characterized by acute onset swampland and lack of mosquito control. Malaria is spread watery diarrhea that progresses to death quickly without re- by the bite of the female Anopheles mosquito, which injects mitting, usually within one to three days, though sometimes sporozoites in its saliva that travel to the liver and develop into within hours. Patients are typically afebrile.8 Other types of schizonts. The disease is characterized by recurring paroxysms
18 The Pharos/Winter 2016 of fever caused by the rupture of these schizonts, which leads to release of tumor necrosis factor and results in intense fever, chills, rigors, myalgias, and sweating.11,12 Dr. Merriman put great stock in what he saw as a relapsing fever and shakes. Joseph was “some better for 3 days” but then “his disease renewed its attacks with all its violence and rage.” 1 This may have convinced him that Joseph was suffering from the ague (recurring paroxysms of chills and fevers), of something widely known in those days as “Genesee Fever”—now thought to be a mosquito-borne ma- larial illness common in the “sickly months” of sum- mer in the Genesee River Valley region of New York and western Massachusetts. 13 In 1793, this “intermittent and remittent fever,” as malaria was then known, appeared in certain communities in western Massachusetts.11 The town of Sheffield, Massachusetts, only eighteen miles from Richmond, experienced outbreaks of malaria in the early 1800s.14 According to Dr. Merriman, Joseph was beset with “with much griping” during his illness, terminating in a “disturbing Billious Fever.” This likely refers to a sudden onset of fever, muscle aches and pains, severe headache, and chills. Doctors had long recognized that “billious fever” could be associated with a type of malarial fever, known as bilious remittent, due to the presentation of bilious vomiting, gastric distress, and sometimes bilious diarrhea, which accompanied the recurring exacerbations.15 The fact that Merriman specifically mentions three days of relief from symp- toms is particularly intriguing, as malaria caused by Plasmodium falciparum is also known as “Tertian fe- ver” because the fever occurs every forty-eight hours, versus Plasmodium malariae termed “Quarternary fever,” which tends to cause fever every seventy-two hours. Dr. Merriman wrote that Joseph was “some better for 3 days.” Whether symptoms recurred on the third day or after three complete days, the cycli- cal nature of symptoms was clear. Although there is a range of periodicities with each Plasmodium species, they tend to be timed with the particular asexual reproduc- In a 2001 book, Laurence Hauptman describes the Genesee tion cycle of the parasite.12 As the patient defervesces, he be- River and its surrounds and proposes that Genesee Fever comes more somnolent, followed by an asymptomatic period. “despite its singular designation . . . was perhaps a manifesta- Headache, abdominal pain, anemia, and hepatosplenomegaly tion of three separate maladies: malaria, typhus, and typhoid are common in malaria, while more extensive liver involvement fever.” 16p145 Though malaria may not have been the sole cause leads to hyperbilirubinemia and jaundice in severe malaria of Joseph’s death (concurrent bacterial enterocolitis is also pos- patients. Altered consciousness, seizures, respiratory distress, sible), it is still a candidate for a co-morbid diagnosis—perhaps severe anemia, renal insufficiency, hemoglobinuria, and shock even a unifying diagnosis. can occur with life-threatening severe malaria.12 Although diarrhea is not as common as abdominal pain or vomiting, Condolence, compassion, and healing diarrhea is present in many cases of severe malaria and should With great empathy and sympathy, Dr. Merriman provided never rule it out. Clarissa with a glimpse of her husband’s final moments—a
The Pharos/Winter 2016 19 The physician condolence letter
unique memory for her. Joseph died on Friday evening August territories. It is likely that men like Joseph knew the perils 26 at 8:20 PM “amidst a large Concourse of his old former that lay in store for them on the road. Joseph and Clarissa had friends and others. He resigned his breath without a groan, already lost three of their nine children by the time of Joseph’s without a Tear and without a murmur.” He was strong and un- death. Such a litany of losses would not have been rare in 1803. complaining during his ordeal—a characteristic Dr. Merriman These letters are also haunting to me for another reason. Dr. obviously admired. And he reassured Clarissa that the Avery Merriman faced the failure of death after death stinging him family tenderly took care of him. over and over. And still he summoned up the energy and cour- age to write the widow Metcalf a heartfelt letter of condolence. I mention for the consolation of yourself and Family that Gregory Kane recently recounted a personal vignette that every attention and respect was paid your dear Husband emphasizes the stakes when a doctor ignores the need of sur- by Mr and Mrs Avery that Imagination Could conceive. He vivors to maintain their attachment to the physician.4 was intered in a becoming decent manner by His Fraternal Brothers on Saturday at half past Eleven A.M.1 I sat and listened while a tearful patient cried at having received no contact from the physician who treated her hus- The largest section of the letter conveys Dr. Merriman’s band for metastatic lung cancer for a treatment duration of 9 condolences to Clarissa and her children. Here the shared months. As I struggled to comprehend her sense of pain and human reality of mortality and mourning is addressed. The abandonment, I considered offering a possible explanation most important experiences in our lives involve the separation that the physician may not have been “on call” at the time of threats we face and the attachment solutions we seek. The the death and may have mistakenly believed that his partner separation threat of illness creates emotional suffering as well had offered such a gesture verbally. Before I could respond, as physical pain for patients and families; the doctor must do however my patient added that her veterinarian had sent a all that is ethically possible to reduce this pain and suffering. card when the family dog died. I was speechless.4 The vocation of medicine has always demanded commit- ment to healing in its deepest sense. Achieving such healing Kane concluded: requires that doctors help their patients to find ways of main- taining or re-establishing attachments when separated from Years from now, in another age, archaeologists may sur- the things they hold dear and the sources of their resiliency vey the remains of our society and marvel at medical tech- and meaning. This is the essence of compassion and is the only nologies evidenced by the collection of joint replacements, thing powerful enough to heal the deepest human suffering.17 cardiac stents, valvular implants, and titanium plates among It is for this reason that physicians over the centuries have the remains in our places of burial. It would be my hope that felt the obligation to write a letter of condolence to the loved they would also identify in the written archives a condolence ones of their patients who have died. But why have today’s letter to note the personal connections that bound the phy- physicians relinquished this obligation? Maybe today’s doc- sicians of the age to their patients and the surviving loved tors feel too busy, or they think they don’t know the patient ones, providing evidence that we are truly human.4 well enough, or they are just a small part of a treatment team, or they have not seen the patient in the recent past, or their After receiving Merriman’s letter of condolence, Clarissa personal sense of failure or loss is too great, or they just don’t may have extracted a special letter from among her keep- know what to say.3–5 Or maybe it is a fear of litigation. sakes.18 It too has survived. In it, the smitten twenty-year- These reasons do not seem good enough. Dr. Merriman old Joseph writes to his newfound fifteen-year-old love and could certainly have conjured up a few reasons of his own to beautifully expresses, in the language of the day, his desire to avoid one more onerous task late on a Sunday evening at the someday be with Clarissa. And in a poignant foreshadowing, end of his week. Nevertheless, after presenting the medical he decries the “cruel fate” that has “separated true friends from reasons for her husband’s death, he wades in and accompanies each other.” 18 Clarissa and her children into the darkness of the moment. He embraces the moral mission of every physician in the presence ACADEMY of Plainfield Jan. 7th 1783 of separation pain. He tries his best to provide a small attach- Respected Lady, ment solution in the form of a condolence letter. And in re- By way of presumption I importune you with this my counting the dire and sad circumstances he must again expose second inaccurate epistle.—A pleasanter evening was never himself to the “cold hand of despair,” 1 even as he prepares to exhibited to view, than the present: The moon shines in full face another week of doctoring in just a few hours. splendor, displaying her borrowed rays from east-to west; all These letters are haunting. They paint a picture of a nature seems hushed in profound silence, while silent sleep frontier nation at the time of Lewis and Clark, when even sits hovering o’er the brow of each one around me, so that western Massachusetts and upper New York were wilderness I have no one with whom I may be sociable.— Wakeful and
20 The Pharos/Winter 2016 alone I have been meditating on the pleasant hours I have of the attachments that person experienced in life—such as spent in your agreeable company and conversation; and were the attachment Joseph sought in his letter of January 7, 1783. it consistent with reason, could wish to spend them over Also among my wife’s memorabilia is the record of the again. But alas! time once pass’d cannot be recall’d. While marriage of Joseph Metcalf to Clarissa Thomas eleven months I thus indulge my thoughts am ready to cry out; O cruel later on November 25, 1783, in Lebanon, Connecticut. Dr. fate! that separated true friends from each other.— But why Merriman’s letter expresses his reverence for the twenty full do I thus expostulate with the great-ruler of the universe, years of sorrows and joys, strivings and reveries that Clarissa who no doubt— allots to each-one a part— to act on this and Joseph lovingly shared together. And, as Joseph’s “attend- grand theatre; the world. Did I not think it for my Interest ing Physician,” John Merriman himself became attached to the and edification to leave that part of the country, could by no story of their lives. His condolence letter reaches to us from the means endure it.—shall leave you there and rest easy in my past and assures us of his attachment just as it did for Clarissa mind as possible, till I may be so happy as to have a personal on the day she opened it in 1803. interview with you — It is now past 12 O’clock, I will write At times today, circumstances can make the relationship no more at present only assuring you that I am your sincere between the doctor and the patient’s family distant or even friend and well-wisher, adversarial. A condolence letter may then prove difficult to compose, but it is nevertheless a signal way of extending a heal- Joseph Metcalf18 ing hand to grieving families and illuminating the humanity of our profession.
Conclusion These letters are captivating in their ability to il- luminate for us the lives of these early Americans. Perhaps the real reason physician condolence letters are important is that a compassion- ate doctor relieves suffering in the simple act of conveying the dignity of each life he has encountered. By doing so he nurtures the memory
Illlustration by Erica Aitken
The Pharos/Winter 2016 The physician condolence letter
The example of the condolence letter may even inspire us to Mandell, Douglas, and Bennett’s Principles and Practice of Infectious look for other opportunities to connect with patient families. Diseases. Volume 1. 8th edition. Philadelphia (PA): Saunders Elsevier; For example, there may someday be a place for a post-mortem 2014: 1263–69. family meeting, perhaps using technology like Skype to make 8. Waldor MK, Ryan ET. 216 Vibrio cholerae. In: Bennett JE, it possible for family members who live at a distance to attend. Dolin R, Blaser MJ, editors. Mandell, Douglas, and Bennett’s Prin- The condolence letter itself can now be written and received ciples and Practice of Infectious Diseases. Volume 1. 8th edition. in real time using electronic mail. Of course, the caveat with Philadelphia (PA): Saunders Elsevier; 2014: 2471–79. the use of any technology is that it must always reflect the 9. Haake DA, Levett PN. 241 Leptospira Species (Leptospirosis). physician’s appreciation of the unique life of the person who In: Bennett JE, Dolin R, Blaser MJ, editors. Mandell, Douglas, and has died. This is what the patient’s family will remember and Bennett’s Principles and Practice of Infectious Diseases. Volume 1. pass on in a healing way—as Clarissa Metcalf has done with 8th edition. Philadelphia (PA): Saunders Elsevier; 2014: 2714–20. our family. 10. Harris JB, Ryan ET. 102 Enteric Fever and Other Causes of The power of medicine to heal is diminished when we mar- Fever and Abdominal Symptoms. In: Bennett JE, Dolin R, Blaser MJ, ginalize the reverence for life and its attachments. As Arthur editors. Mandell, Douglas, and Bennett’s Principles and Practice of Kleinman recently wrote: Infectious Diseases. Volume 1. 8th edition. Philadelphia (PA): Saun- ders Elsevier; 2014: 1275–82. Modern medical practice’s greatest challenge may be 11. Centers for Disease Control and Prevention. The History of finding a way to keep caregiving central to health care. That Malaria, an Ancient Disease. http://www.cdc.gov/malaria/about/ way will turn on structural and economic developments, history/index.html. technologies, and therapeutic models, but also on the impor- 12. Fairhurst RM, Wellems TE. 276 Malaria (Plasmodium Spe- tance that professionals ascribe to patients’ deep experience cies). In: Bennett JE, Dolin R, Blaser MJ, editors. Mandell, Douglas, and to such enduring moral practices of caring as the laying and Bennett’s Principles and Practice of Infectious Diseases. Volume on of hands, the expression of kindness, the enactment of 1. 8th edition. Philadelphia (PA): Saunders Elsevier; 2014: 3070–90. decency, and the commitment to presence—being there for 13. Martin JH. Chapter 4 Charles Williamson: The Pulteney those who need them. This is the embodied wisdom . . . we Estates in the Genesee Lands. In: Martin JH. Saints, Sinners and all must remember.19 Reformers: The Burned-Over District Revisited. Crooked Lake Rev 2005 Fall. http://crookedlakereview.com/books/saints_sinners/ It is in this context that the doctor’s letter of condolence should martin4.html. be reconsidered as a part of the vocation of modern medicine, 14. Best CR. A History of Mosquitoes in Massachusetts. North- no matter what form twenty-first-century medicine takes. eastern Mosquito Control Association 1993 Nov. http://www.nmca. Can doctors today re-establish the tradition of writing org/Nmca93-4.htm. condolence letters, or find other ways to assure the families of 15. English Glossary of Causes of Death and Other Archaic Medi- patients that we appreciate and embrace the meaning of the cal terms. In: Rudy’s List of Archaic Medical Terms. http://www. lives lost? If we can’t, it is a sad commentary on the state of our archaicmedicalterms.com/English/EnglishB.htm. profession—and on the state of our society. 16. Hauptman LM. Conspiracy of Interests: Iroquois Dispos- session and the Rise of New York State. Edition 1. Syracuse (NY): References Syracuse University Press; 2001. 1. Merriman J. Letter to Clarissa Metcalf, August 28, 1803. Per- 17. Fricchione GL. Compassion and Healing in Medicine and sonal communication from Kathryn Fricchione. 2014 Nov 8. Society: On the Nature and Uses of Attachment Solutions for 2. Metcalf J. Letter to Clarissa Metcalf, July 9, 1803. Personal Separation Challenges. Baltimore (MD): Johns Hopkins University communication from Kathryn Fricchione. 2014 Nov 8. Press; 2011. 3. Bedell SE, Cadenhead K, Graboys TB. The doctor’s letter of 18. Metcalf J. Letter to Clarissa Metcalf, January 7, 1783. Personal condolence. N Engl J Med 2001; 344 (15): 1162–64. communication from Kathryn Fricchione. 2014 Nov 8. 4. Kane GC. A dying art? The doctor’s letter of condolence. 19. Kleinman A. From illness as culture to caregiving as moral Chest 2007; 131 (4): 1245–47. experience. N Engl J Med 2013; 368 (15): 1376–77. 5. Schapira L. Communication at the end of life. J Oncol Pract 2008; 4 (2): 54. Address correspondence to: 6. Discovering Lewis and Clark. The Lewis and Clark Fort Man- Gregory L. Fricchione, MD dan Foundation. http://www.lewis-clark.org/content/article/2431. 25 Glenview Drive 7. Lima AMA, Warren CA, Guerrant RL. 101 Bacterial Inflam- Harvard, Massachusetts 01451 matory Enteritides. In: Bennett JE, Dolin R, Blaser MJ, editors. E-mail: [email protected]
22 The Pharos/Winter 2016 n morning rounds Oa favorite patient collapses before you To Fall and as you struggle to catch him, your knees buckle and you kneel beside him on the floor. You hold him as part of him dies, as others who are dying there but you walk away stronger and Rise for having touched him. Perhaps it is all they need from you: to fall a bit when they begin to fall and to rise again with them. Again Sometimes, it is what you need to rise again from your own despair, to remember who you once were, who you are. Henry Langhorne, MD
Dr. Langhorne (AΩA, Tulane University, 1957) is a retired cardiologist in Pensacola, Florida. His address is: 1910 Seville Drive, Pensacola, Florida 32503. E-mail: [email protected]. Illustration by Erica Aitken.
The Pharos/Winter/Winter 20162016 2323 First principles
Illustration by Laura Aitken.
Robert B. Hinton, MD The author (AΩA, Mercer University, 2002, Resident) going to be close. As a new fellow in pediatric cardiology, is Associate Professor of Pediatrics in the Division of I enjoyed the rhythm of training. After the exhilaration of Cardiology at Cincinnati Children’s Hospital Medical Center. real-time hemodynamics and helping to place a device, I was brought back to earth with the duty of holding pressure in For my grandfather David R. Clare, 1925–2014. the right groin after removing the catheters. As I recited the complications of inadequate hemostasis to myself, I trailed off He was stirred . . . by the ideal of a moral example.1pp52–53 into a counting game that quiets the mind. Starting with the —John Berger thumb, I tapped my fingertips in sequence counting by threes A Fortunate Man: The Story of a Country Doctor (3, 6, 9, …), following my knuckles forward then backward across my hand, the end digits counting once per turn. To 48 ecause I had stopped wearing a watch as an intern, then back to 3, the rhythm somehow comforting. Still bleeding I had to steal a glance at the clock behind me. 16:46. at 16:58. I cursed the last heparin dose, a tradition among car- I was rotating in cardiac catheterization, the third diology fellows, then asked for relief and hurried to the unit. Bcase had run late, and I was expected to round for call in the I was late, but relieved to discover that I was the first to ar- Pediatric Cardiac Intensive Care Unit (CICU) at 17:00. It was rive for rounds. There were more people in the unit than usual
24 The Pharos/Winter 2016 and everyone was in motion, busy and unaware of the time. in Catholicism it is viewed also as a sacrament. I happen to By necessity, ICUs have exquisite temporal resolution, which be Catholic, and I believe in the sacraments. But when the paradoxically obscures perspective: time is measured in min- chaplain on call told me that he was four hours away and utes, not days; medications are titrated to effect through infu- that I should perform the baptism myself, I was alarmed. The sions, not doses; and vital signs are monitored continuously, suggestion was simple. But I was thinking about the post-op not periodically. The charge nurse gave me her unadulterated tetralogy of Fallot patient who was unstable, the hypoplastic assessment. There was much to do. The last room in the sec- left heart syndrome patient who needed a new central line, ond pod was dark and the nurse’s stand was clean, suggesting and the follow-up chest X-ray in the patient with a new chest a vacant room. But after rounding on the second to the last tube, let alone the to-do list I had not yet started to do. bed, the team continued to the last room. The checkout was Straining to remember my catechism teaching, I paused terse: “She was born earlier today, got here a couple hours ago, uncomfortably, then said: “I’m not sure I can do this. I’m not a surgical candidate, the family is coming, care needs to be Catholic and I’m not a priest.” A common misconception, I withdrawn.” The surgeon nodded in agreement. learned. The room was uncluttered and the technology muted. Our “What do you think they are asking you to do, exactly?” the CICU rooms have windows, but little sunlight was left. Aside chaplain asked patiently. from the monitor’s lights, the room was dark, giving me the I remembered a preceptor from medical school telling me sense that I was standing in a shadow. The baby lay motion- that pediatrics is one part medicine and one part advocacy less, sedated and intubated, drips running. The electrocardio- (which is when I realized that those called to pediatrics are gram marched on steadily, elegantly poised despite the sinus first and foremost advocates). I considered the active medical tachycardia. Oxygen saturation blinked 64 percent. She was issues elsewhere in the unit, and tried to convince myself that “dusky,” an unsatisfying but familiar adjective. Her face was performing a baptism might not be the best use of my time. unnaturally drained, not pallid exactly, the color of her orbits Then I remembered something that instantly provided clarity. and mouth an exaggerated almost regal purple, the hypoxemia Act, don’t react. My grandfather’s advice and commitment to akin to drowning. It wasn’t long ago that blue babies were decision making for the long-term has long influenced my compassionately sent home to die. Considering the clinical own thinking and judgment. context of a lethal cardiovascular malformation in an earlier “Tell me how.” The requirements for an official baptism era, I imagine the family’s resignation and the clinician’s frus- are surprisingly straightforward: the word “baptize” must be tration. How was I going to explain our inability to intervene? spoken aloud and water must be applied to the initiate, prefer- Before attending to my first task, placing a chest tube to ably on the head. I wondered if the water had to be sterile, and relieve pleural effusion, I considered the now unusual circum- imagined two priests arguing the merits of using either crys- stance in our specialty of not being able to offer any interven- talloid or colloid. In the end, I found a small bottle of sterile tion, any hope. I pondered what to say while stitching the saline, the size of my thumb, five milliliters maybe, with a stark chest tube in place. white label. I carried it secretly in my pocket while attending The family arrived. Six or seven family members gathered to other patients, turning it over excitedly just as I had my at the foot of the bed, the mother alone at the head, hand on bride’s engagement ring. When the time came, I managed the her daughter’s cool arm. There is a strange perfection to the full formal sentence: “I baptize you in the name of the Father, lower end of pediatric ICU beds: clean military folds and a the Son, and the Holy Spirit.” The mother’s expression was one neatly placed patchwork quilt. The quiet was conspicuous. of profound relief. I marveled at her response and reconsid- I plainly described the anatomy and resulting physiology. I ered the many meanings of healing. explained the lack of treatment options, the reasons surgery The infant died two hours later. After I pronounced the could not be done, and finally the natural history of the death, the mother said “thank you” distantly by rote, and the disease. What does “withdrawal of care” mean to a mother? few of us in the room quickly and quietly departed, leaving her We discussed (I recommended) removing the breathing tube with time alone. She stayed thirty minutes and left without and stopping the medications. She maintained eye contact, saying another word. When things slowed down, I went to and her body language suggested she understood but des- rest, thoughts racing. I watched my fingers tapping, my mind perately sought alternatives. When I asked her if she had any circling the unit bed by bed with a mental check list (3, 6, 9), questions she looked away, away from me and away from her punctuated by images of the mother and child (12, 15, 18), family, then tentatively down at her daughter. We stood in si- some patients tilting in the wrong direction (21, 24, 27), St. lence for ten minutes until my beeper went off, startling all but Peter upside down at the end (30, 33, 36), likely scenarios and the patient. I excused myself, at which time the mother cleared contingency plans (39, 42, 45), St. Peter now at the gate (48 her voice with difficulty, tears finally breaking down her face, and back again). Ultimately the rhythm prevailed and I slept. and asked: “Can she be baptized?” At rounds the next morning, I announced the death and Baptism is generally considered entry into the church, and the baptism. Some were intrigued, others dismissive, most
The Pharos/Winter 2016 25 First principles
were confused by the nonmedical interjection. Medical spe- I find myself considering first principles, conscious of the pros cialization and rapidly advancing technology have resulted and cons that reflective thinking has on decision making in a in increasingly narrow realms of expertise and a convoluted complex medical situation. If thoughtful reflection is a part of parsing of responsibility. Sometimes achieving standards of all momentous personal decisions, considered judgment, the care requires only technical expertise. Interestingly, realizing core of professionalism, should equally be applied to difficult standards of care does not require professionalism. I thought professional decisions. back to the night before, and my grandfather: Act, don’t react. I can imagine Dr. John Sassal, the subject of John Berger’s Be the advocate. A Fortunate Man, taking a practical approach to religion. His ICUs demand timely decisions, and declining to engage identity was formed by both the need to be useful and for his this family might have been justifiable, possibly advisable—but life to have meaning—for his actions to transcend a job and it would not have been professional. The baptism did not ad- become a calling, a profession. His moral example was simple versely affect the care of other patients, and it did not change and disciplined. He was pragmatic, and he attended the dy- the patient’s outcome—but it benefited the family. I needed to ing. He balanced delivering scientific medicine with helping act for the patient and not react to the pressures of expedient patients and families navigate the experience of illness. The decision making. intimacy of the bond between patient and physician reveals the self through illness, as Susan Sontag illuminated in Illness Professionalism in health care delivery is defined as actions as Metaphor.9 Optimal medical care must be based on this that are respectful and collaborative, responsive, ethical, and universal faith in humanism. fair.2–4 Clinical judgment is an essential aspect of medical practice, affecting communication, diagnosis, and decision References making. In addition to the central role of critical thinking in 1. Berger J. A Fortunate Man: The Story of a Country Doctor. clinical judgment, self knowledge and reflective thinking are New York: Vintage Books; 1967. necessary components of effective problem solving and sound 2. Accreditation Council for Graduate Medical Education. decision making, allowing the physician to maintain advocacy Celebrating Teamwork: 2007–2008 Annual Report. https://www. for the patient as the primary goal.5,6 End-of-life situations acgme.org/acgmeweb/Portals/0/PDFs/an_2007-08AnnRep.pdf. contain many complicated issues related to professionalism 3. Greiner AC, Knebel E, editors. Health Professions Education: such as respect for patient autonomy and dignity, as well as A Bridge to Quality (2003). Washington (DC): National Academies the sanctity of human life. Cultural and religious differences Press; 2003. www.nap.edu/catalog/10681. often present challenges to standards of care when a patient 4. Fallat ME, Glover J, American Academy of Pediatrics Com- is dying; professionalism coupled with knowledge is required mittee on Bioethics. Professionalism in pediatrics. Pediatrics 2007; to navigate the complexities.7,8 More broadly, changes to 120 (4): e1123–1133. health care organization may conflict with the basic tenets of 5. Maudsley G, Strivens J. ‘Science’, ‘critical thinking’ and ‘com- professionalism by decreasing access and delivery, as well as petence’ for tomorrow’s doctors. A review of terms and concepts. dramatically changing how medicine is practiced. Med Educ 2000; 34 (1); 53–60. The importance of professionalism cannot be underesti- 6. Kienle GS, Kiene H. Clinical judgment and the medical pro- mated. In the context of health care reform and the increasing fession. J Eval Clin Pract 2011; 17 (4): 621–27. role of various third parties in health care delivery, it is para- 7. Samanta A, Samanta J. Advance directives, best interests and mount that physicians continue to view professionalism as a clinical judgment: shifting sands at the end of life. Clin Med 2006; critical component of medical care. It is encouraging to know 6 (3): 274–78. that professionalism is teachable and that national associa- 8. Edwards SJ, Ashcroft R, Kirchin S. Research ethics com- tions representing medical schools and training programs rec- mittees: differences and moral judgement. Bioethics 2004; 18 (5): ognize its primacy in medicine. But it is discouraging to find 408–27. that professionalism is not practically or rigorously taught, 9. Sontag S. Illness as Metaphor and AIDS and Its Metaphors. and—more importantly, perhaps—not something that we talk New York: Anchor Books, Doubleday; 1988. about openly. While it is critical that both those who lead and those who mentor emphasize the importance of professional- The author’s address is: ism, individual physicians setting an example is the surest way 240 Albert Sabin Way, ML 7020 to show how crucial professionalism is to each of us. Cincinnati, Ohio 45229 E-mail: [email protected] I remember the baptism when difficult situations arise and
26 The Pharos/Winter 2016 THE AGING SOLOiST
There is a joyous song to life I could with passion sing. But now I fear I’m losing voice And melodic rendering. I need a chorus to accompany That knows of staves and clefs. No longer dare I sing alone— No pitch, no range, no breaths. So chorus sing your hymn of joy But let me hum along. Some part of me in harmony Prolongs my life in song. Raymond C. Roy, MD, PhD
Dr. Roy (AΩA, Wake Forest School of Medicine, 2005, Faculty) is Professor Emeritus in the Department of Anesthesiology at Wake Forest School of Medicine. His address is: Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1009. E-mail: [email protected]. On the significance of the Circle of Tugo
28 The Pharos/Winter 2016 On the significance of the Circle of Tugo
Luis Nicolas Gonzalez Castro, MD, PhD The author is a resident in the combined Neurology Residency Program at the Massachusetts General Hospital and Brigham and Women’s Hospital in Boston.
lmost two hours into the neuroanatomy exam, with only a minute to spare, I turned the last page to read the final question: “Describe the location of the Circle of Tugo.” AAlthough I had diligently memorized hundreds of structures, circuits, and pathways, I could not recall anything about this structure. I thought, however, that the fault was with me, since I reasoned that if there was a Circle of Willis, there must also be a Circle of Tugo somewhere in the central nervous system. Time ran out, the question was left unanswered, and I left the classroom with a feeling of disappointment. Later that day, I searched for this structure in several neuroanatomy textbooks, but found nothing. When the exam solutions were posted the following week, I immediately turned to the last page to find the answer to the final question. Imagine my surprise when I saw that the location of the Circle of Tugo was given in the form of a street map. The Circle of Tugo was not an anatomical structure but a traffic circle, or roundabout. And not any random roundabout, but the one at the intersection of Louis Pasteur and Longwood avenues in Boston, directly facing the Harvard Medical School quadrangle. My classmates and I took the answer as a joke by the professor but I remained intrigued. After class I found the Circle of Tugo— the Circle of Oscar C. Tugo, to be more precise. But who was Oscar C. Tugo, and why was he commemorated in the Longwood medical area? Was he a famous physician? A celebrated profes- sor? The discoverer of an important molecule or principle? The answer was unexpected. Searching online and digging into the
Dedication of the Oscar C. Tugo Circle at the intersection of Longwood and Louis Pasteur Avenues in Boston, May 18, 1921. From reference 1.
The Pharos/Winter 2016 29 On the significance of the Circle of Tugo
archives of the Countway Library of Medicine, I learned that Oscar C. Tugo had been a member of the American Expeditionary Force Base Hospital No. 5 during World War I, and the first member of this unit to be killed in action.1–7 The United States had maintained a cautious but observant stance towards the war in Europe since its beginning in 1914. After the sinking of the RMS Lusitania in 1915, in which 128 Americans lost their lives, pressure began to mount for President Woodrow Wilson to declare war against Germany. The president had managed to maintain official neutrality until early 1917 (even while the country was unofficially aiding the Allied effort), when an all-out German submarine offensive against all commercial ships traveling to England resulted in the sinking of several American ships. The dec- laration of war on April 6, 1917, activated official mechanisms to support the preparedness move- ment that had been in place since early 1915. In addition to fighting troops, the French and British commanders were also in urgent need of engineers and doctors.1-2,8–11 In the fall of 1915, U.S. Army Surgeon General Dr. William C. Gorgas had proposed the organization of university-sponsored base hospitals under the auspices of the American Red Cross to Dr. George W. Crile of Western Reserve University and Dr. Harvey Cushing of Peter Bent Brigham Hospital. Both men had led volunteer medical units earlier in the war.3,4 In October 1916, to assess the readiness of the unit and rehearse some of the operations to be conducted, Base Hospital No. 41, under the leader- ship of Dr. Crile, performed mobilization exercises at Philadelphia’s Fairmont Park. (The Base hospi- tals were numbered somewhat arbitrarily—Base Hospital No. 1 of Bellevue Hospital, for example, did not enter service until February of 1918.3,12) Dr. Harvey Cushing, 1917. Reproduced by permission of the Yale University, Harvey Cushing/John Hay Cushing, in charge of Base Hospital No. 5, planned Whitney Medical Library. similar exercises for the following summer on the Boston Common. Dr. Cushing further planned to use his mobiliza- but there were non-medical personnel needs to be met. The tion exercises to deliver actual medical care to the public, with Harvard unit was summoned to action and all activities fo- the goal of generating enthusiasm and recruiting volunteers cused on meeting the remaining personnel needs of the unit.1,3 for the unit. Once war was declared, in a May 1917 edito- The telegram ordering the unit to duty was printed in several rial, “War Obligations,” published in the Boston Medical and Boston papers: Surgical Journal (later the New England Journal of Medicine), the Massachusetts Medical Society exhorted physicians to “en- Orders have been received from the office of the list in the Medical Services of the Army or the Navy” or “help Adjutant-General of the United States Army to have Base organize base hospitals.” The following month, the society, at Hospital No. 5 ready for immediate service abroad. The the annual meeting of its council, voted on several resolutions mobilization on the Common will have to be abandoned. It in support of the war efforts.1,3,11,13,14 is necessary to complete full equipment of enlisted personnel The Boston medical community responded promptly, in the next few days. Wanted cooks, waiters, clerks, orderlies,
30 The Pharos/Winter 2016 Edward Revere Osler at 13 Norham Gardens in 1916. Reproduced by permission of the Osler Library of the History of Medicine, McGill University.
Oscar C. Tugo. From Reference 1.
carpenters, electricians and other artisans for enlistment in to Chicago, where he attended the Nettlehorst Grammar the Medical Corps. Men who have seen service in the Army, School and was described as a “typical high-spirited American Navy or Marine Corps preferred. Age limit 40 years. Apply youth, a leader among his companions, a good student, and at the Harvard Medical School, Tuesday between 4 and 9 in a clean home-loving boy.” He later attended the Chicago the evening.1pp3–4 Business College, and after graduation was employed by vari- ous railroad companies, including the Pullman Company. After Twenty-four-year-old Oscar Tugo from the Forest Hills returning to Boston with his family, he was employed as a clerk neighborhood of Boston promptly signed up. Born in Boston, by the Clyde Steamship Company.1 Oscar was the eldest son of the Tugos, a family of French- On Tuesday, May 1, 1917, he read the notice for enlistment Canadian origin. When he was six years old, his family moved in the morning paper, went directly to the medical school that
The Pharos/Winter 2016 31 On the significance of the Circle of Tugo
Transcript of September 7, 1916, letter from Grace Osler to Harvey Cushing. Courtesy of the National Library of Medicine.
afternoon to sign up, and ten days later was aboard the RMS between Dannes and Camiers.1–3 Saxonia sailing towards Falmouth, England. Unrestricted sub- British Base Hospital No. 11 was an assortment of canvas marine warfare was still in place, with German U-boats actively tents and a few permanent wooden huts located in a low-lying trying to sink any vessels that might be transporting troops and area that was semi-flooded most of the time, especially during supplies to England. Eight days into the crossing, approaching the particularly rainy summer of 1917.1,2 Also dampened was England and the exclusion zone patrolled by the Germans, the spirit of the British doctors, nurses, and other volunteers, everyone aboard was asked to wear life jackets constantly until who had been serving there for much longer and with sig- arrival.1–3 nificantly fewer resources than had initially been anticipated.2 The Saxonia arrived in Falmouth on the morning of May The conditions were best described in verse by one of the men 22, 2017. The men of the unit were sent to Blackpool for train- of Base Hospital No. 5 (M.E.R.C. stands for Medical Reserve ing, while the nurses and officers boarded trains to London. Corps): The unit reunited seven days later in Folkstone on the English Channel in preparation for their crossing to France the follow- In Camiers by the sea, in the 5th M.E.R.C. ing day. On the evening of May 30, under the protection of In mud up to my knee, and it’s mud we get for tea; a dense fog, and with several destroyers flanking the convoy, The stretchers, I found, came hard up from the ground. the unit landed in Boulogne in northern France, and was sent You had to hustle, use all your muscle, to reinforce British Base Hospital No. 11, fifteen miles south And the nurses wore a frown.3p39
32 The Pharos/Winter 2016 Camiers Camp, looking toward “A lines” with the cement works beyond. From reference 3.
The initial focus of members of Base Hospital No. 5 was in Revere had reached the rank of Second Lieutenant with the helping to clean and organize the site. The transition was eased Royal Field Artillery, his third tour of duty during the war, and by the relatively few casualties brought in early in the summer; his second with the British army. He had served his first term the wards were instead full of cases of infection. Base Hospital in 1915 with the McGill Hospital Unit, which had operated at No. 11 had a capacity of 2,000 and was always nearly full. In the site of British Base Hospital No. 11 in Dannes-Camiers. The contrast, the members of Base Hospital No. 5 had prepared to Oslers in Oxford endured each of Revere’s tours of duty with care for 500 patients; the need for reinforcements was obvious. great apprehension, continually fearing the worst and being The Germans conducted frequent air raids in the area, so that comforted only by their son’s frequent letters.15–17 a sense of danger and alarm pervaded the camp.2,3 The Oslers and Harvey Cushing had known each other In late July of 1917, the Allies launched an offensive against since the late 1890s, when Cushing was a surgery resident at the Germans designed to retake the city of Ypres in western Hopkins. Knowing that Cushing was in the area, on August Belgium and interrupt the supply lines of the German Fourth 19 the Oslers informed him of Revere’s presence at Ypres, and Army. Known as the Third Battle of Ypres (or the Battle of asked him to check on their son. Cushing was unable to see Passchendale after the last town taken by Canadian forces Revere until the night of August 29, when he was summoned during the campaign), the action took place only sixty miles by telegram to care for him after he was seriously wounded from Dannes-Camiers. In August alone, more than 5,000 ca- in battle. Cushing traveled sixty miles in the rain to Casualty sualties were evacuated to Base Hospital No. 11. Among those Clearing Station No. 47 in Dozinghem, Belgium, where he fighting in this offensive was Lieutenant Revere Osler, great- found the wounded Revere still conscious but with a very weak great-grandson of American patriot Paul Revere and son of Sir pulse. Dr. George Crile, director of Base Hospital No. 41, and William Osler. 2,8–10,15–17 Drs. George Brewer and William Darrach of Base Hospital No. Revere Osler was born in Baltimore in 1895, during his 2 (New York Presbyterian) were also summoned to care for father’s tenure at Johns Hopkins. He was the Oslers’ only son. Revere. He was operated on and received two blood transfu- When the boy was ten years old, the family moved to England sions, appearing to initially improve, but dying suddenly five after Sir William accepted the Regius Chair of Medicine at hours after the operation, in the early morning of August 30, Oxford University. At the time of the Third Battle of Ypres, 1917.13,15–17
The Pharos/Winter 2016 33 On the significance of the Circle of Tugo
Transcript of August 31, 1917, letter from Grace Osler to Harvey Cushing. Courtesy of the National Library of Medicine.
Revere Osler was buried later that morning in a nearby of the British patients in that tent. The fifth bomb hit the field (currently the Dozinghem Military Cemetery in West- reception tent, usually one of the busiest places in the entire Vlaanderen, Belgium), attended by all who had cared for him complex, killing Private Rudolph Rubino and Private Leslie A. during his last hours. A telegram about Revere’s injury, sent by Woods, and severely wounding Private Aubrey S. McLeod and Cushing the night before, reached the Oslers that afternoon, Sergeant William E. English.1–4 and they immediately began to make arrangements to travel to The bombs dropped by the Germans were of the “daisy- France. But at 9:00 that evening they were notified by phone cutting” variety, sending low-flying projectiles in all directions, that their son had died. Sir William’s grief at the death of his wounding many others besides those affected by the direct only son was unremitting; he died fewer than two years later, impact.2–4 In the chaos that ensued, Dr. Elliot Cutler, later in July 1919.15–18 surgeon-in-chief at the Peter Bent Brigham Hospital, oper- One might imagine that if Revere Osler had continued to ated on many of the wounded. Three days later, the bodies of serve with the Hospital Unit in Dannes-Camiers, away from Lt. Fitzimmons and Privates Tugo, Rubino, and Woods, the the enemy lines, his death could have been avoided. But on first American casualties of the war, were buried at a nearby the evening of September 4, only five days later, tragedy struck cemetery in Étaples. More casualties among the wounded Dannes-Camiers and Base Hospital No. 5. Earlier that evening, followed.2–5 an apparently unsuccessful German air raid had taken place on Base Hospital No. 5 was later transferred to nearby Boulogne the English coast. The all-clear had sounded when at 10:55 PM, and continued to care for the wounded with distinction until without any warning, a German Gotha bomber swept over the early February of 1919, almost seven months longer than ini- area of Base Hospital No. 5 from the direction of the nearby tially intended. Cushing estimated that approximately 46,000 town of Étaples. Five bombs hit the hospital. The first two hit sick and wounded—most of them British—were treated at Base one of the officers’ tents, killing Lt. William T. Fitzimmons and Hospital No. 5 during the unit’s service.2,3 wounding four others, the second two hit one of the patient The remains of Private Oscar C. Tugo were returned to tents, killing Private Oscar C. Tugo and re-wounding many Boston and reinterred with full military honors at the Forest
34 The Pharos/Winter 2016 Hills Cemetery on December 26, 1920. Oscar’s father, Smith C. Barta Press, 1920. Tugo, like Sir William Osler, also could not bear the loss of his 3. Cushing HW. The Story of U.S. Army Base Hospital No. 5: By son and died in February 1921. He was interred next to his son. a Member of the Unit. Cambridge (England): University Press; 1919. On October 19, 1921, the Oscar C. Tugo Circle, at the intersec- 4. American Medical Casualties in France. Boston Med Surg J tion of the Longwood and Louis Pasteur Avenues in front of 1917; 77: 709–12. Harvard Medical School, was dedicated to honor the memory 5. First Bay State soldier slain in war reinterred. Boston Daily of the first enlisted member of the American Expeditionary Globe (1872–1922) 1920 Dec 27: 1. Force to be killed by the enemy.1,5,7 6. Father of first Bay State boy killed with A.E.F. buried in same Besides their legacy of courage and service, the men and lot. Boston Daily Globe (1872–1922) 1921 Feb 14: 1. women of Base Hospital No. 5 also made important contri- 7. Dedicate square to Oscar C. Tugo. First enlisted man of U.S. butions to modern medicine. Cushing pioneered many new forces to be killed. Boston Daily Globe (1872–1922) 1921 Oct 19: 1. methods for the treatment of penetrating head injuries, includ- 8. Gilbert M. The First World War: A Complete History. New ing suction and magnetic extraction of debris, that enabled York: Henry Holt; 1994. significant improvements in mortality.19 Harvard Medical 9. Keegan J. The First World War. New York: Alfred A. Knopf; School’s Walter B. Cannon performed important studies on 1999. hemodynamics and shock, initially at the Casualty Clearing 10. Strachan H. World War I: A History. Oxford: Oxford Univer- Station No. 33 in Bethune, France, and later in England.3,20 sity Press; 1998. Elliot Cutler credited much of his ability to handle a large 11. War Obligations. Boston Med Surg J 1917 May 3; 176: 644. volume of difficult cases to his experience in the war, and 12. Book Notices—Bellevue in France: Anecdotal History of Base went on to pass along this skill to many generations of surgery Hospital No. 1. By Anne Tjomsland, M.D. With eighty-two diagrams residents.21 and illustrations. JAMA 1942; 119 (4): 381. Others in the same circle of Harvard Medical School include 13. Bliss M. Harvey Cushing: A Life in Surgery. New York: Oxford Dr. Paul Dudley White at Base Hospital No. 6 (Massachusetts University Press; 2005. General Hospital) and Dr. Samuel Levine at the British Heart 14. The Annual Meeting of the Council. June 12, 1917. Boston Hospital in Colchester, England, who accurately character- Med Surg J 1917 Jun 28; : 910–19. ized the condition of neurocirculatory asthenia (a condition 15. Keys TE. Edward Revere Osler 1895–1917. Arch Int Med 1964; related to panic disorder) based on their experiences with war 114: 284–93. patients.20–24 16. Bliss M. William Osler: A Life in Medicine. Oxford: Oxford Very much like the Circle of Willis, which provides al- University Press; 1999. ternate blood flow paths at the base of the brain, today the 17. Revere Osler. Can Med Assoc J 1917 Nov; 7 (11); 1011–12. Circle of Tugo provides alternate paths for drivers at a busy 18. In Memory of Second Lieutenant Edward Revere Osler. intersection in the Longwood medical area. However, just as Commonwealth War Graves Commission. http://www.cwgc.org/ the Circle of Willis functionally represents much more than find-war-dead/casualty/153574/OSLER,20EDWARD20REVERE. a simple anastomotic group of arteries, the Circle of Oscar C. 19. Cushing HW. Notes on penetrating wounds of the brain. Br Tugo is also much more than a roundabout at the intersection Med J 1918 Feb 23; 1 (2982): 221–26. of Longwood and Louis Pasteur Avenues—it is a memorial of 20. Benison S, Barger AC, Wolfe El. Walter B. Cannon and the selflessness, valor, and achievement that connects the stories of mystery of shock: A study of Anglo-American co-operation in World some of the greatest names in the history of American medi- War I. Med Hist 1991; 35 (2): 217–49. cine. During this centennial commemoration of World War I, 21. Cutler EC. The education of the surgeon. N Engl J Med 1947; as the country continues its struggles to provide adequate care 237 (13): 466–70. to the wounded men and women of recent wars, it is fitting to 22. White PD. Neurocirculatory asthenia; still a common and remember the story of Private Oscar C. Tugo and of all the men important clinical condition. N Engl J Med 1964; 271: 1362–63. and women who were part of the same cause. 23. Levine SA. The origin of the term neurocirculatory asthenia. N Engl J Med 1965; 273: 604–05. References 24. Paul O. Take Heart: The Life and Prescription for Living of 1. Dedication Exercises of the Oscar C. Tugo Circle, Pasteur & Dr. Paul Dudley White. Boston: Harvard University Press; 1986. Longwood Avenues, Boston, October 18, 1921: In Memory of the First Enlisted Man in the American Expeditionary Force to Be Killed by The author’s address is: the Enemy. Boston: Merrymount Press; 1922. 58 Plympton Street 513 2. Hatch JP. Concerning Base Hospital No. 5: A Book Published Cambridge, Massachusetts 02138 for the Personnel of Base Hospital No. 5, France, 1917–18–19. Boston: E-mail: [email protected]
The Pharos/Winter 2016 35 A recruit enters the Epidemic Intelligence Service
A computer generated image of a cluster of HIV particles. Credit: Science Picture Co / Science Source.
36 The Pharos/Winter 2016 Since its founding in 1951 by Alexander Langmuir as a service/training program, the Epidemic Intelligence Service, “working out of the CDC in Atlanta, Georgia, has sent out more than three thousand officers to combat every imaginable human (and sometimes animal) ailment. These young people—doctors, veterinarians, dentists, statisticians, nurses, microbiologists, academic epidemiologists, sociologists, anthropologists, and now even lawyers—call themselves “shoe leather epidemiologists.” EIS officers have ventured over the globe in search of diseases, sometimes in airplanes or jeeps, on bicycles, aboard fragile boats, on dogsleds, atop elephants and camels.„ —Mark Pendergrast, 20101pxi
Harry W. Haverkos, MD
The author is a retired Captain in the U.S. Public Health eighty people attending the picnic, seventy-five were inter- Service and Associate Professor of Preventive Medicine and viewed, and forty-six had significant diarrheal disease within Biometrics at the Uniformed Services University of Health twenty-four hours. The source of the outbreak was identified Sciences in Bethesda, Maryland. The views expressed in as vanilla ice cream contaminated by one of its preparers. The this paper do not reflect the official policy or position of the exercise introduced us to the steps in the investigation of an Uniformed Services University, the Department of Defense, or outbreak: the U.S. government. 1. Identify potential investigation team and resources and prepare for field work (e.g., administration, clearance, travel, onday, July 6, 1981. Every new Epidemic Intelligence contacts, designation of lead investigator). Service (EIS) officer reports to CDC headquarters in 2. Establish the existence of an epidemic. M Atlanta to attend a mandatory three-week course con- 3. Verify the diagnosis. sisting of a series of lectures, interactive case studies, a primer 4. Construct a working case definition. on biostatistics, and participation in a field study. My EIS class 5. Find cases systematically, develop line listing of cases. consisted of sixty-five new officers: fifty-five physicians, four 6. Perform descriptive epidemiology (i.e., orient the data nurses, three academic epidemiologists, two veterinarians, and an by time, place, and person). anthropologist. Nine of the physicians were international trainees. 7. Develop hypotheses that explain the specific exposures Each year, incoming EIS officers conduct a household that may cause disease. survey on an assigned topic to get “hands-on”—or “shoe- 8. Evaluate these hypotheses by appropriate statistical leather”—experience collecting data on a contemporary public methods using data collected. health topic. Performing the survey introduced us to “field” 9. As necessary, reconsider/refine hypotheses and execute epidemiology and taught us about systematic or probability additional studies. sampling. Our field study on July 15 was a household survey of 10. Implement control and prevention measures as early injuries and violence in Atlanta. Our class designed a question- as possible. naire and assigned groups of two officers to randomly selected 11. Communicate findings. house addresses to conduct the survey. 12. Maintain surveillance to monitor trends and evaluate In the classroom, we studied the well-known 1940 Oswego, control/prevention measures. New York, church supper outbreak of gastroenteritis. Out of Before my first class on Monday, I checked into the
The Pharos/Winter 2016 37 A recruit enters the Epidemic Intelligence Service
Dr. James Curran in 1985. A Seattle man with AIDS has purple marks on his © Steve Ringman/San Francisco Chronicle/San Francisco Chronicle/Corbis. face from Kaposi’s sarcoma, 1987. © Roger Ressmeyer/CORBIS.
Epidemiology component of Parasitology, my assignment as 6. Early in the second week of class, he called again to ask how an EIS officer. My supervisor, Dr. Dennis Juranek, a veterinar- I was coming along with my project; I was unprepared and he ian and staff parasitologist, asked me to meet with Dr. James was unhappy with me. He told me I had to develop and present Curran of the Venereal Diseases division on Tuesday to discuss a case definition and plan to my EIS classmates by the end of a new project. the third week of class, when we would all disperse on our When I met with Dr. Curran, he told me that he and oth- field assignments. Later that day he called yet again, this time ers had been working on a number of new diseases among with welcome news: he had arranged for me to skip classes so gay men in New York and California. CDC’s pathologists had I would have the necessary time to complete the assignment. already confirmed the diagnoses of Kaposi’s sarcoma (KS) and I reported to Curran’s office first thing Monday. He told me Pneumocystis carinii pneumonia (PCP) in several patients from to develop a case definition. He suggested that I review the case biopsy materials. They had confirmed (steps 2 and 3) that those reports collected in the spring, read about the diseases being few cases represented an epidemic. Curran asked me if I had reported, review files on requests for the drug pentamidine, heard anything about it. I told him I knew nothing about KS, and talk with Dr. Kathy Shands, who had developed a surveil- but that I had seen a few patients with PCP (including one gay lance system for toxic shock syndrome (TSS) two years earlier. male) in Pittsburgh during my infectious diseases fellowship. I From my class notes, I knew that surveillance was “informa- told him about my work on open lung biopsies among organ tion for action,” the ongoing systematic collection, analysis, and transplant recipients and cancer patients, and mentioned that interpretation of outcome-specific data essential to the plan- I had read the June 5 Morbidity and Mortality Weekly Report ning, implementation, and evaluation of public health practice. (MMWR) detailing five cases of PCP among gay men in Los I spent Monday and Tuesday in the CDC library reading about Angeles.3 Curran said that he would interview a few of my KS and other opportunistic infections (OIs), including PCP, classmates before making a final decision about staffing a new toxoplasmosis, disseminated herpes virus infections, tubercu- team. If I was selected to join the task force, I had to be willing losis, and cryptococcosis. to work with gay men and make a commitment of at least six By the end of the week I proposed the following three-part months. definition: On Wednesday, Curran called and offered me a position 1. Biopsy-proven Kaposi’s sarcoma and/or culture or with the new investigation team. I accepted. My job was to set biopsy-confirmed life-threatening OIs at least moderately pre- up a surveillance system for those new diseases, steps 4, 5, and dictive of immunosuppression.
38 The Pharos/Winter 2016 2. Persons between the ages of fifteen and sixty years. that TSS had disappeared. Fortunately, active surveillance was 3. No prior evidence of underlying immunosuppression, conducted in Minnesota and Wisconsin, and showed that cases i.e., cancer diagnosis, organ transplant recipients, or use of continued to occur. steroids or other immunosuppressant agents. Passive surveillance refers to data supplied to the health We defined OIs as those in which at least 50 percent of department by the source of the data, often based on a known cases reported in the medical literature had occurred in set of rules or regulations stipulating reportable conditions. A immunocompromised patients. For PCP, essentially every adult review of death certificates, for example, constitutes passive case occurred in an immunosuppressed person. A former EIS surveillance. Shands had conducted passive surveillance: she officer assigned to Parasitology had reviewed all cases of PCP developed a case definition for TSS, published a series of cases reported to CDC between 1967 and 1970, and 191 of the 194 occurring in menstruating women in MMWR, and asked indi- cases he reviewed were clearly linked to immunosuppression. viduals to call her if they knew of any additional cases matching The three outliers were infants.4 her definition. She received calls, as anticipated, from physi- Other OIs were not as clear cut. By my calculations, cians and nurses, but also from patients, their relatives, and cryptococcal meningitis occurred in immunocompromised their neighbors. Given these criteria, undercounting of cases patients in 50 percent of the reports, and in healthy hosts 50 occurs often with passive surveillance systems. percent of the time, so it barely met the criterion for inclusion. Active surveillance, on the other hand, is initiated by the Tuberculosis, on the other hand, occurred predominantly in data collector and involves proactive solicitation of reports, otherwise healthy individuals and less so (about 15 to 20 per- typically from selected health care providers, generally in ad- cent) in immunocompromised patients, so it was excluded. The dition to requests for passive reporting. Active surveillance initial list of OIs included PCP, esophageal candidiasis, crypto- systems are more costly, both economically and in time and coccal meningitis, disseminated infection with Mycobacteria, effort expended. The data generated, however, are usually and extensive mucocutaneous Herpes simplex virus infections. more reliable. During the TSS investigation, epidemiologists I had never heard of KS, much less seen a case during my in the Wisconsin and Minnesota state health departments clinical training, so I had to do more digging. I learned that identified chiefs of medicine at selected large hospitals and dermatologists from New York City and California reported called them regularly to solicit information on potential new twenty-six cases of KS among young gay men between January cases. These chiefs continued to report new TSS cases, even 1979 and June 1981, including five fatalities.5 Prior to 1980, approximately 300 new cases of biopsy-proven KS occurred annually in the United States, predominantly among men aged sixty or older and renal transplant recipients. In elderly pa- tients, KS appeared as persistent skin lesions and rarely proved fatal. Those twenty-six gay men had skin lesions of KS by bi- opsy, but their disease followed a more fulminant course, with spread to the lungs, stomach, and intestines. Seven gay men with KS also had PCP—especially striking since concomitant KS and PCP had never been reported before! In 1872, Moricz Kaposi, a Hungarian-born dermatologist at the University of Vienna, described three fatal cases of hemangiosarcoma in elderly men. Since then the disease has borne his name. In the early 1900s, KS was described in sub- Saharan Africa in adults, mainly young men, and in children— the male to female ratio of cases in Africa was five to one. Italian oncologist Gaetano Giraldo, studying KS in Uganda, linked the sarcoma to cytomegalovirus (CMV) infection, us- ing electron microscopy and blood tests. Another form of KS was reported among organ transplant recipients in the United States in the 1960s.4 Step 5 is to find cases systematically and develop a line list- ing. I discussed the passive surveillance system for TSS with Dr. Shands. In retrospect, she regretted that she had not conducted active surveillance. After TSS was linked to a specific brand of tampons (Rely tampons) and the link was reported widely Dr. Moricz Kaposi. in the press, physicians stopped reporting cases. It appeared National Library of Medicine/Science Photo Library
The Pharos/Winter 2016 39 A recruit enters the Epidemic Intelligence Service
the forms when referring physi- cians reported cases. We avoided collecting information from pa- tients or family members, partly because that approach had cre- ated problems during the TSS investigation and partly because our case definition required a more advanced understanding of pathology and microbiology. I made the report form as easy to complete as possible—mainly a series of check boxes—to keep the phone calls with clinicians as short as possible.4 I continued reviewing the case reports that others at CDC had collected, including the five Physicians meeting with AIDS patient, 1987. © Roger Ressmeyer/CORBIS cases reported by Dr. Michael Gottlieb in the June 5 MMWR. One of Dr. Gottlieb’s patients had had a prior lymphoma and was excluded. The four other men after Rely tampons were taken off the market. Indeed, it was were previously healthy gay men who had PCP, extensive subsequently determined that TSS was caused by an exotoxin F mucosal candidiasis, and multiple viral infections, including subsequent to staphylococcus infection and not specifically by CMV; one had KS. Three of the four patients had prolonged the Rely tampon, although the design of the tampon increased and unexplained febrile episodes. An immunologist at UCLA, the risk of infection. Gottlieb had conducted extensive immunologic studies on My conversation with Dr. Shands convinced me that we his patients. The underlying defect, he suggested, was a low needed an active system to supplement passive reporting. or inverted ratio of T-helper lymphocytes to T-suppressor I proposed that each EIS officer assigned to a field position lymphocytes.6 identify the largest hospitals in their cities and call on chiefs While I was setting up active and passive surveillance, Dr. of infectious diseases, oncology, medicine, and dermatology Curran charged Dr. Harold Jaffe with listing hypotheses of to tell them about our cases of PCP and KS, and find out if causation and designing a study to test them (steps 7 and 8). they had heard of any similar cases at their institutions. They Dr. Jaffe listed his leading hypotheses: would be contacted at regular intervals, and any cases would 1. Cytomegalovirus be reported to me. Curran approved this plan. 2. An environmental toxin, most likely nitrite inhalants We selected six EIS officers from my class and six cities in 3. Immune overload caused by exposure to multiple infec- which to conduct active surveillance: two cities considered by tious agents reputation to have a high percentage of gay men—New York 4. A “new” infection agent, most likely related to herpes or City and Los Angeles; two cities with a moderate percentage hepatitis viruses of gay men—Albany and Rochester, New York; and two cities Cytomegalovirus was on the top of everyone’s list. Gottlieb with a low percentage of gay men—Tallahassee, Florida, and had found evidence of CMV infection in his initial five cases. Oklahoma City. Curran contacted another twelve EIS officers, Giraldo, working with KS patients in Africa, had found evi- assigned them to other cities, and encouraged them to look dence of herpes virus infection in KS tissues, and suggested for new cases. He also sent a letter to all state health depart- CMV as the causative agent. But why would CMV be causing ments asking them to report any potential cases to CDC and an epidemic now? Could it be a new or mutated strain now giving my telephone number as the point of contact (passive circulating among gay men? And what was its relationship to surveillance). immunosuppression: was it causing immunosuppression or I developed a two-page case report form that included the taking advantage of another immunosuppressive cause—was patient’s name, age, self-reported sexual orientation, diagnosis, CMV the chicken or the egg? how the diagnosis was made (biopsy or culture), and contact Inhalants containing alkyl nitrites, commonly known information for the reporting physician. EIS officers completed as “poppers,” were discussed as a possible toxic cause of
40 The Pharos/Winter 2016 immunosuppression. Gottlieb noted that all five of his patients Case-control studies, however, have their own drawbacks. had used them. CDC had conducted a survey of 420 men at- They are often beset by selection, interviewer, and recall bi- tending venereal disease clinics in New York, San Francisco, ases. How does one determine an appropriate control group? and Atlanta, and found that 85 percent of gay men interviewed The investigator must always be concerned about information reported using poppers at least once in the last five years, com- bias and the obscuring effect of confounding variables. Having pared to just 15 percent of heterosexual men. Curran hoped weighed the pros and cons of each study design, Jaffe chose to that poppers or some contaminant of those drugs would be conduct a case-control study.7 implicated as the causative agent because the solution would As a starting point, he defined a case as a gay male with then be straightforward. KS and/or PCP, fifteen to sixty years of age, and with no prior Nitrite inhalants are commonly abused substances in evidence of immune suppression. He decided to recruit all the United States and Europe—used primarily by gay men, patients meeting his case definition in New York City, San adolescents, and young adults to enhance sexual activity by Francisco, Los Angeles, and Atlanta. prolonging penile erection. Alkyl nitrites (e.g., amyl, butyl, Defining the ideal control group presented a greater chal- and isopropyl nitrite) are colorless or yellow liquids at room lenge. The use of controls who were very similar to the cases temperature and highly volatile. They have a fruity odor (often could result in overmatching and could obscure important risk described as unpleasant) and have been nicknamed “poppers” factors. On the other hand, the use of controls very different because of the sound made when the glass capsules contain- from cases could make comparison difficult, so that differ- ing amyl nitrite are crushed. The vasodilatory effect following ences between cases and controls could not be interpreted. inhalation of amyl nitrite vapor was described in 1859 and led Jaffe decided to recruit multiple controls for each case, ranging to the first report of its clinical application to provide relief for from persons relatively similar to the case (friend controls) to angina pectoris in 1867. The substance was initially marketed persons relatively different from the case (heterosexual male by prescription in the United States in 1937 and remained a controls). Since obtaining a true random sample of gay men prescription drug until 1960, when it became available over to serve as controls did not appear feasible, he asked health the counter. Beginning in the 1960s, the nitrates (e.g., nitro- departments, private clinics, private physicians, and individual glycerine, sublingual tablets, dermally applied ointments, and patients, to help recruit controls. Each control was a man of the later, transdermal nitrate patches) replaced amyl nitrite as the same race/ethnicity, age (plus or minus two years), and met- preferred treatment for angina pectoris. In the late 1960s, phar- ropolitan residence as the patient to whom he was matched. macists and drug manufacturers noted widespread purchases Jaffe sought five matched controls per case: one friend control, of amyl nitrite by apparently healthy young men. Those over- a gay male identified by the patient as a friend who had never the-counter purchases became the impetus for the FDA to been a sexual partner; two venereal disease clinic controls, reinstate the prescription requirement in 1968. Soon thereafter, homosexual men who were patients of the venereal disease an underground market for amyl nitrite and other nitrite con- clinic; one private practice gay control, a homosexual patient of geners emerged. Those products were initially sold as “room a local private practice physician seen for an acute illness and odorizers,” and are still being sold, now illegally in the United selected randomly from the referring physician’s rolodex or log States, under that guise. book; and one private practice straight control, an exclusively Finally, a novel infectious agent or some hybrid or muta- heterosexual patient of a local private physician selected ran- tion of a known organism was considered as the possible domly from the physician’s rolodex. immuno-suppressive agent. A new herpes virus, particularly a Jaffe developed a questionnaire and decided who would new CMV, generated much discussion, although other viruses conduct the interviews. One of the greatest strengths of his were also considered. The prevalence of the OI clusters among study was the front-end work he invested in developing the gay men and drug addicts suggested that hepatitis B-like vi- questionnaire, which ensured back-end data that was less likely ruses should be considered and sought. to be contaminated by information bias. Task force members In step 8 the study is finally conducted. For most outbreaks, and other EIS officers—all physicians—conducted the inter- the investigator must decide between a case-control and co- views. The same officer who interviewed a case interviewed all hort study. The former is more efficient when the disease is the controls matched to that case. rare, usually defined as occurring in less than 20 percent of the All of us were trained to conduct the interviews in a population studied. By October 1981, fewer than 100 cases were consistent, non-judgmental fashion. At the training, during recognized in the United States. In addition to the condition’s which Jaffe mock interviewed Curran, I asked if we should rarity, the vast number of exposures requiring investigation fa- be concerned about participants misrepresenting their sexual vored a case-control design. If a cohort study were performed, activity—exaggerating exploits, perhaps, or minimizing certain who would be selected as a participant? How long would they behaviors. Curran acknowledged the difficulty in collecting be followed? How many would be lost to follow-up? And how such private information, but was emphatic about the impor- much would it all cost? tance of the interview data. He pointed out that we were not
The Pharos/Winter 2016 41 A recruit enters the Epidemic Intelligence Service
looking for the truth per se, but for differences between cases up to eight hours each day on the phone talking with physi- and controls. Importantly, we would also collect blood samples cians, the press, anyone who called the number. I filled out the and mouth and anal swabs from all participants for a more surveillance form for each patient while on the phone with the objective investigation of immunologic and infectious markers reporting physician. This was before speaker phones were in- at our Atlanta lab.8 Training now complete, we were prepared vented, and I remember the heat generated by holding a phone to enter the field in October. to my ear for extended periods of time—I would transfer the On Sunday October 4, Curran and I flew to New York phone from ear to ear over and over again. City. On Monday morning we met others at the New York While logging calls about patients with KS and life- City Health Department to get our marching orders. Local threatening OIs, I noticed that clinicians were spontaneously health officers cleared Jaffe’s protocol through the Health reporting a growing number of gay men with unusual clinical Department’s sanctioning process and arranged for us to begin complaints, such as intermittent and prolonged fever, general- our study. We conducted interviews of cases in hospital rooms, ized lymphadenopathy, weight loss, and blood dyscrasias that physician offices, or at patients’ homes. We interviewed con- remained unexplained after extensive workups. I filled out case trols at the venereal disease clinics, physician offices, and even reports for each of those patients and placed them in a separate in our hotel room. After an interview of about forty-five min- file cabinet in my office. utes, we drew blood and collected the swabs. Following stan- In September 1982, CDC coined the term AIDS (acquired dard practice of that era, we did not wear gloves to draw blood. immune deficiency syndrome) to capture this constellation During my month in New York City, I conducted about of OIs and malignancies.9 Our case-control study among ho- sixty interviews. The participants seemed impressed that CDC mosexual men, which identified the two leading risk factors physicians from Atlanta had traveled to New York to engage for infections as the lifetime number of sexual partners and face-to-face with them in any and every setting. By attempting meeting partners in bathhouses, suggested a novel sexually to answer all of their questions, we seemed to gain rapport transmitted agent.7,8 As surveillance continued, however, it with the subjects and the gay community, demonstrating that soon became apparent that AIDS was not confined to homo- CDC was serious about this problem. In turn, I recall being sexual men. Over time, the demographic pattern widened to impressed with how open and apparently honest the partici- include injection drug users, heterosexual women, Haitian- pants were in describing the most intimate details of their lives. Americans, Caribbean islanders, hemophiliacs, When we returned to Atlanta at the end of October, I blood transfusion recipients, heterosexual transitioned from field work to phone work. I spent men, infants and children, health care workers, women who have sex with women, and transgenders. Patients AZT: anti-AIDS drug. were reported from Europe, then Credit: Will & Deni McIntyre / Science Source Africa, South America, Australia, and Asia. In 1983, a French team led by Luc Montagnier isolated a new retrovirus from the lymph nodes of patients in Paris. Called the human im- munodeficiency virus, it is widely known as HIV.10 Two years later, the U.S. Food and Drug Administration (FDA) approved the first diag- nostic test for the virus, an antibody test, designed with the goal of screening donated blood. In 1987, the FDA approved the first medication for the virus, the antiretroviral azidothymidine, or AZT.11 Tremendous progress in the treatment of HIV infection has occurred in the interven- ing years. Twenty-six antiretroviral agents—drugs from multiple classes, such as reverse transcriptase, protease, and integrase inhibitors—have been ap- proved by the FDA. It has been found, moreover, that combination treatments reduce viral loads, enhance CD4 counts, and prolong survival times. Pre- and post-exposure prophylactic regimens have
42 The Pharos/Winter 2016 Acknowledgment Thanks to Drs. Bryant Webber and Lynne Haverkos for their help in editing this manuscript.
References 1. Pendergrast M. Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service. Boston: Houghton Mifflin Harcourt; 2010. 2. Thacker SB, Dannenberg AL, Hamilton DH. Epidemic Intelligence Service of the Centers for Disease Control and Prevention: 50 years of training and service in applied epidemiology. Am J Epidemiol 2001; 154 (11): 985–92. 3. Centers for Disease Control. Pneumocystis pneumonia—Los Angeles. MMWR Morb Mortal Wkly Rep 1981; 30 (21): 250–52. 4. Haverkos HW, Curran JW. The current out- Luc Montagnier in Paris, France on January 23rd, 1987. Credit: Francois LOCHON break of Kaposi’s sarcoma and opportunistic infec- tions. CA Cancer J Clin 1982; 32 (6): 330–39. 5. Centers for Disease Control. Kaposi’s sar- also been tested, demonstrating about 50 percent effectiveness. coma and Pneumocystis pneumonia among homo- Nonetheless, concerns regarding those antiviral medications sexual men—New York City and California. MMWR Morb Mortal abound: they are toxic and expensive; treatment is lifelong; and Wkly Rep 1981; 30 (25): 305–38. improper usage may lead to drug resistance. 6. Gottlieb MS, Schroff R, Schanker HM, et al. Pneumocystis In 2002, President George W. Bush developed the carinii pneumonia and mucosal candidiasis in previously healthy President’s Emergency Plan for AIDS Relief (PEPFAR) and homosexual men: evidence of a new acquired cellular immunodefi- committed 15 billion over five years to provide antiretroviral ciency. N Engl J Med 1981; 305 (24): 1425–31. therapies to two million infected persons in resource-limited 7. Jaffe HW, Choi K, Thomas PA, et al. National case-control settings, with the goal of preventing seven million infections by study of Kaposi’s sarcoma and Pneumocystis carinii pneumonia in 2010. PEPFAR has reportedly prevented more than one million homosexual men: Part 1. Epidemiologic results. Ann Intern Med deaths per year in Africa. 1983; 99 (92): 145–51. Less progress has been realized in changing behaviors to 8. Rogers MF, Morens DM, Stewart JA, et al. National case- prevent new infections. CDC initially encouraged persons to control study of Kaposi’s sarcoma and Pneumocystis carinii pneu- reduce the numbers of sexual partners, and enlisted health monia in homosexual men: Part 2. Laboratory results. Ann Intern departments to close bathhouses. Behavior change strategies Med 1983; 99 (2): 151–58. evolved to recommend use of condoms, and avoid needle 9. Centers for Disease Control. Current trends update on sharing. Newer approaches include male circumcision, pre- Acquired Immune Deficiency Syndrome (AIDS)—United States. exposure prophylaxis, and preventive antiviral therapy.12 A MMWR Morb Mortal Wkly Rep 1982; 31 (37): 507–08, 513–14. vaccine, unfortunately, remains elusive. 10. Barre-Sinoussi F, Chermann JC, Rey F, et al. Isolation of a Despite these advances in addressing HIV/AIDS, more T-lymphotropic retrovirus from a patient at risk for AIDS. Science than 39 million lives have been lost. Furthermore, WHO esti- 1983; 220 (4599): 868–71. mates that 35 million people worldwide are HIV-infected, and 11. Fischl MA, Richman DD, Grieco MH, et al. The efficacy of 2.1 million new infections occurred in 2013. If we are to control azidothymidine (AZT) in the treatment of patients with AIDS and this disease, we must redouble our efforts. We need more stra- AIDS-related complex. A double-blind, placebo-controlled trial. N tegic use of antiretrovirals for HIV treatment and prevention. Engl J Med 1987; 317 (4): 185–91. We must eliminate new HIV infections in children and expand 12. Piot P, Quinn TC. Response to the AIDS pandemic—a global access to pediatric treatments. We must expand and improve health model. N Engl J Med 2013; 368 (23): 2210–18. health care coverage for HIV among key populations world- wide, and develop further innovations in prevention. The author’s address is: Regardless of all the challenges ahead, this fact stands out 4301 Jones Bridge Road in the fight against HIV/AIDS: today, the life expectancy of an Rockville, Maryland 20814 HIV-infected person receiving antiretroviral treatments ap- E-mail: [email protected] proaches that of a person without HIV.12
The Pharos/Winter 2016 43 Portrait of Hieronymus Bosch, 1570s. Cornelis Cort (1533–1578). Found in the collection of The Netherlands Institute for Art History, The Hague. Photo credit: HIP/Art Resource, NY.
Pieter Bruegel the Elder. Painter and Patron (with Bruegel’s self portrait). Drawing. Pieter Bruegel the Elder (c. 1525–1569). Graphische Sammlung Albertina, Vienna, Austria. Photo credit: Erich Lessing/Art 44 Resource, NY. The Pharos/Winter 2016 Bosch and Bruegel Disability in sixteenth-century art
Gregory W. Rutecki, MD
The author (AΩA, University of Illinois, 1973) is a mem- depict ‘many things that cannot be depicted.’ ” 3p6 ber of the Department of General Internal Medicine at the In 1958, French physician Tony-Michel Torrillhon based Cleveland Clinic in Cleveland, Ohio. his doctoral thesis on the assertion that Bruegel’s accuracy in painting eye disease indicated that he was a physician,4 he Italian Renaissance reflected a best of all possible an inference that has never been proven. Torrilhon’s thesis worlds, an Elysian existence peopled by gods, angels, showed extensive examples of Bruegel’s uncanny anatomi- and men and women only a step below the angels.1 cal fidelity. That expertise also appears in both Bruegel’s and TheT Flemish school of art of the same period—ignored for Bosch’s depictions of other physical infirmities, illustrating the centuries—depicted less pleasant realities. Its paintings were artists’ sophisticated knowledge of anatomy.5 Further, their peopled by peasants and beggars. Originating in the Spanish work shows us in their details and settings how their subjects Netherlands, it was a culture soon to be embroiled in a bloody were treated in the sixteenth century. Thus, the subjects of religious war set in motion by the Reformation and Philip II Bosch’s and Bruegel’s paintings—the poor, the infirm, and of Spain. The war would result in the division of the region the sightless—warrant reflection from a medical-humanistic into Catholic and Protestant countries.1 The school of the perspective. Northern Renaissance presented an earthier perspective of the human condition, bereft of angels or gods. Parable of the Blind Leading the Blind (1568) Sadly, the snobbery of the time elevated Italian Renaissance In 1568, Bruegel painted the Parable of the Blind Leading high art while belittling primitive Flemish peasant art, an en- the Blind. It is based on the Biblical narrative in the gospel during bias against the Flemish masters that resulted in the of Matthew (Matthew 15:14): “and if the blind lead the blind, delay of the first international showing of their works until both shall fall in a ditch.” Bosch had previously painted the 1902 in Bruges.1 parable, including only two subjects, but Bruegel chose to de- Pieter Bruegel the Elder (1525–1569) is representative of the pict six blind men, with a sightless leader in the act of falling Flemish genre. Influenced by Hieronymus Bosch (1450–1516), into a brook. In Bruegel’s painting, the eyes of the first blind Bruegel connected himself to Bosch by copying his predeces- man cannot be seen, but those of his followers are visible in sor’s paintings.2 the painting. Some have suggested that the painting shows a The Flemish painters did not go completely unappreciated. verifiable cause for sightlessness for each man whose eye can In 1574, after Bruegel’s death, Abraham Ortelius, cartographer be seen. Writers including Jean Martin Charcot, Paul Richer, and the father of the modern atlas, “wrote that Pieter Bruegel and Torillhon have posited the following potential diagnoses was the most perfect painter of his century” with an “ability to (counting from right to left):5pp58–59
The Pharos/Winter 2016 45 Bosch and Bruegel
Parable of the Blind Leading the Blind. Pieter Bruegel the Elder (c. 1525–1569). Museo Nazionale di Capodimonte, Naples, Italy. Photo credit: Scala/Ministerio per i beni e le Attività culturali/Art Resource, NY.
46 The Pharos/Winter 2016 The Pharos/Winter 2016 47 Bosch and Bruegel
The Adoration of the Kings. 1564. Oil on oak, 111.1 x 83.2 cm. Bought with contributions from The Art Fund and Arthur Serena through The Art Fund, 1920 (NG3556). Pieter Bruegel the Elder (c. 1525–1569). National Gallery, London, Great Britain. © National Gallery, London/Art Resource, NY.
• Blind man 2: Enucleation. It seems that the second man’s eyes have been surgically • Blind man 3: Corneal leukoma. removed, but the cause of the removal is not known. I am • Blind man 4: Atrophy of the globes. not sure if we can say that he had a straightforward enucle- • Blind man 5: Total blindness with the visor misplaced as ation because the eyelids are missing on both sides as well a result of photophobia with the visor askew to protect the as the globes. If the eyelids were removed, it was not really eyes from light. an enucleation but exenteration, which raises the question • Blind man 6: Pemphigus. what could be the cause of bilateral exenteration that left the Ophthalmologist Zeynel Karcioglu, in his survey of the man blind but still alive? 5pp58–59 pathologies illustrated in the painting, asserts:
48 The Pharos/Winter 2016 Man Yawning (The Yawner). Pieter Bruegel the Elder (c. 1525–1569). From the collec- tion of the Musées Royaux des Beauxs-Arts de Belgique, Brussels, Belgium. Photo credit: HIP/Art Resource, NY.
Karcioglu is so confident of Bruegel’s accuracy that he goes on, as in this man, is a large, white, disfiguring scar, it is identified as a leukoma, as opposed to smaller lesions called either nebu- A different possibility is the eyelids that were left behind las (ill-defined) or maculas (localized and smaller). A colleague sealed the anophthalmic sockets. If this were the case, I of mine also felt that they could be cataracts. would have expected to see horizontal scars possibly with The fourth man has a clinical combination of atrophic eyes, embedded eyelashes centrally; Bruegel wouldn’t have over- a large irregular scar on his right upper cheek, and a disfigured looked such detail.5pp58–59 face. The diagnosis proposed is phthisis bulbi. His lower face lesions could be two vertical keloids, and he has lost his eye- Karcioglu also researched the history of enucleation, verifying brows and eyelashes. The combination of injuries may have that the procedure was performed during Bruegel’s lifetime. It been the result of a chemical or thermal burn leading to eye was initially performed in the 1500s by Batisch. He concludes infections that resulted in blindness. that this man lost his vision to cauterization, possibly to re- The next sightless man is thought to have lost his vision to lieve pain or to resolve a persistent infection. pemphigus. Karcioglu writes that he has The third man has large corneal opacities identified as corneal leukomas. Corneal opacities can be a consequence of thickened lower eyelids and conjunctival scarring with many corneal pathologies. If the end stage of corneal disease, obliteration of the palpebral fissure medially and scarring of
The Pharos/Winter 2016 49 Bosch and Bruegel
Head of a Mercenary (Head of a Lansquenet). Wood. Pieter Bruegel the Elder. Musée Fabre, Montpellier, France. Photo credit: Erich Lessing/Art Resource, NY.
corneas. His lips also reveal old mucosal lesions. . . . Most in the the Adoration, as well as in the subject in Head of a likely, the diagnosis for the last blind member of the group Lansquenet.7 This group agrees with the diagnosis of Bruegel’s is bullous pemphigoid.5p59 Syndrome in The Yawner.8
One of my colleagues also plausibly suggested trachoma. Disability in Bosch and Bruegel’s art and times Bruegel’s contributions to ophthalmology through his art Bosch and Bruegel each created works depicting people with were not limited to a single painting. Karcioglu also investigated amputations, in particular Bosch’s drawing, The Procession of other Bruegel works such as Adoration of the Magi.5 The king the Cripples, and Bruegel’s The Beggars. The works are notable in a red cape on the left of the painting has right upper eyelid for their attention to anatomical detail, accurate enough to ptosis, suggesting a seventh nerve palsy. In another painting, allow for a tentative retrospective diagnosis of the infirmities The Yawner, Bruegel’s subject is considered to be the first docu- illustrated. As well, they may also reflect the attitude of the mented example of blepharospasm and lower facial dystonia.5 prevailing culture toward those with such infirmities. The eponymous name for this disorder is Bruegel Syndrome! A joint analysis of The Procession of the Cripples by rheu- Other contemporary ophthalmologists support Dr. matologist Jan Dequeker, orthopedist Guy Fabry, and neu- Torrillhon’s and Dr. Karcioglu’s conclusions. A Spanish group rologist Ludo Vanopdenbosch at the University Hospital in agrees with their diagnoses for The Blind Leading the Blind,6 Leuven, Belgium, offers a reliable methodology for restrospec- and have added a diagnosis of exophthalmos for one subject tive diagnosis.9 First, what are the main changes suggesting a
50 The Pharos/Winter 2016 Beggars (The Procession of the Cripples). Hieronymus Bosch (c. 1450–1516). Pencil on paper. Graphische Sammlung Albertina, Vienna Austria/Bridgeman Images.
The Pharos/Winter 2016 51 Bosch and Bruegel
The Mendicants (The Beggars). Pieter Bruegel the Elder (c. 1525–1569). Louvre (Museum), Paris, France. Photo credit: Erich Lessing/Art Resource, NY.
primary cause for the disability? Second, are there associated femur, loss of left toes. features independent of amputation and prosthetics? The • Associated features—Weakness left limb? Leper’s working diagnosis combines these deductions with historical clothing, mouth-nose mask. information about the pathologies and the prevailing culture. • Working diagnosis—1) Leprosy with post-infectious The cases in the Bosch drawing are numbered starting gangrene; 2) Neural weakness.9 from the top left and proceeding left to right to the bottom. In Case 4, the authors note the following: Cases 8 and 27 are also presumed to be lepers because their associated features—a prominent nose and a facial deformity, • Gender: Male; Age >30. respectively—accompany amputations. Leprosy was endemic • Main changes—Recent high amputation of right distal in Northern Europe during the lives of Bosch and Bruegel,
52 The Pharos/Winter 2016 affecting as many as 25 percent of Northern Europeans of that mark of a hypocrite.9 Why should actual cripples be lumped time.10 in with obvious fakes? Another retrospective diagnosis for cases 2, 14, and 26 is of There were many beggars in Bosch and Bruegel’s society. historical interest. A scourge common in Bosch and Bruegel’s Destitute cripples and fakers alike were treated as petty crimi- time, it is almost unknown today. These men are suspected to nals and were incarcerated in workhouses, of which it has been have experienced ergotism. They show amputations at various said, “the modern sanction of imprisonment for serious crime anatomical sites and wear pilgrim’s capes.9 traces back to the workhouse for the poor more than any other Ergotism results from ingestion of rye or wheat contami- source.” 14 nated with the fungus Claviceps purpurea. The condition The noblemen of the Dutch Revolt, rebelling against the resulted in the deaths and crippling of many thousands of Inquisition, were called beggars as an insult, but turned the people throughout Europe during the Middle Ages.11 The tables and gleefully took the epithet to themselves. fungus produces alkaloids, including ergotamine, that cause vasoconstriction that can lead to dry gangrene and convul- the Leaguers rode into Brussels, and, crowding into the sions, with characteristic burning sensations and central ner- council-chamber, laid their petition for a removal of the vous system effects including mania or psychosis. Ergotism Inquisition before the council. They demanded that a depu- in Europe was primarily caused by rye bread, and a popular tation to press the object of their petition be sent to the king, religious pilgrimage of the time was the Way of St. James to and declared themselves no longer responsible for riots and Santiago de Compostela in northern Spain,12 with rye bread tumults which might arise from neglect of their prayer. a staple food on pilgrimage. The lay fraternity of the Hospital The duchess was very much alarmed at the crowd. Tears Brothers of Saint Anthony was founded in 1095 to care for of distress rolled down her cheeks as their petition was pilgrims and the sick, and particularly for those suffering read. One of the counsellors, Count Berlaymont, to relieve from ergotism; the disease was associated with the order and her fears, uttered the sneer which, like the name “Christian,” commonly called St. Anthony’s fire. It is possible that these lay given by their enemies to the disciples at Antioch, was im- healers had connected rye bread with the incidence of ergot- mediately adopted by the Leaguers, and became the name ism—they grew their own rye for bread in carefully cultivated by which they were known for generations—a name of ter- fields.12 Their therapeutic expertise for easing the symptoms ror to their foes and a rallying-cry to all the friends of liberty of St. Anthony’s fire was legendary. Pilgrims claimed that the in the land. “Beggars” was the contemptuous term used by relics of their order’s patron, St. Anthony, cured ergotism.9 the count: “What, madam!” said the proud lord, “is it pos- Ergot-induced vascular injury was illustrated by other sible your highness can entertain fears of these Beggars?” artists of the period, including Johannes Wechtlin and At once the word was caught up by the party, who had Matthias Grunewald (who painted a triptych for the Isenheim long wanted a distinctive name, and at the banquet held Monastery). In The Temptation of Saint Anthony, Grunewald immediately after the interview in the palace, the hall re- not only depicts dry gangrene of the fingers and feet, but also sounded with cries of “Long live the Beggars!” 15pp215–16 livedo, skin gangrene, and typical ergot-induced vasculitic lesions.9,13 After the Protestant Reformation and its religious wars, Other maladies have been proposed for the remaining the nation of Holland emerged from the former Spanish disabled persons in Bosch’s drawing. Although polio may Netherlands and embraced Reformed Theology. Cripples were also have been endemic then, it probably would not have considered examples of the wages of sin. As Dequeker, Fabry, been distinguished from leprosy.9 The subjects portrayed in and Vanopdenbosch note, “In many sixteenth century paint- Bruegel’s The Beggars are therefore presumed to have had ings of ‘The temptation of St. Anthony,’ the ‘diabolic beggars’ either leprosy or polio. Potts Disease is a possible diagnosis for (le diable boîteux) are often the physically disabled.” 9 cases 2, 12, and 30 in the Bosch drawing. They show marked dorsal hyperkyphosis in older individuals. A post-traumatic Bosch and Bruegel in the medical humanities amputation in an otherwise healthy appearing man in Case 10 is also plausible.9 With so little knowledge of Bruegel at our disposal, we On the other hand, cases 1, 6, 9, and 29 in The Procession may conclude that we are never likely to understand his of the Cripples appear to be fakes. Case 6 is shown kneeling, mind fully or be certain of the meanings of a number of his with a drawing showing an amputated leg before him. He is works. My own view is that he was in large part a moralist potbellied and holds a wine jar, implying alcoholism as his sole and ironist with a deep vein of humanity and humor who impairment. Case 29 has a flexed knee but a healthy surround- perceived the grotesquerie and comedy in the endless spec- ing leg, presumably another fraud. But in Bruegel’s painting tacle of life, a penetrating observer who had a poor opinion The Beggars, most of the men, even though they have what and small expectations of mankind but found a compensa- are clearly real disabilities, have foxtails on their clothing, the tion for this pessimistic vision in his contemplation of the
The Pharos/Winter 2016 53 Bosch and Bruegel
majestic, impersonal order of nature. Art scholars and his- 5. Karcioglu ZA. Ocular pathology in The Parable of the Blind torians of ideas, the northern Renaissance, and related fields Leading the Blind and other paintings by Pieter Bruegel. Surv Oph- will of course continue to study his creations, but it should thalmol 2002; 47 (1): 55–62. be kept in view that what we don’t know of him is perhaps 6. Santos-Bueso E, Sáenz-Francés F, García-Sánchez J. Pa- not very important when we consider the universal appeal of tología ocular en la obra de Pieter Bruegel el Viejo (I). El ciego guía his art and its incomparable inventiveness and transfiguring de ciegos (La parábola de los ciegos). Eye diseases in the paintings by realism, which have provided us with great and unique im- Pieter Bruegel the Elder (I). The blind leading the blind (The parable ages of his world and time. of the blind). Arch Soc Esp Oftalmol 2011; 86 (7): 232–33. —Perez Zagorin, “Looking for Pieter Bruegel” 16 7. Santos-Bueso E, Sáenz-Francés F, García-Sánchez J. Pa- tología ocular en la obra de Pieter Bruegel el Viejo (II). Patología The world of Bruegel and Bosch was cruel. The tragedies orbitaria. Eye pathology in the paintings of Pieter Bruegel the Elder of life were considered to be evidence of sin. But amid the (II). Orbital pathology. Arch Soc Esp Oftalmol 2011; 86 (10): 339–40. tragedy, Bosch and Bruegel steadfastly committed themselves 8. Santos-Bueso E, Sáenz-Francés F, García-Sánchez J. Pato- to artistic realism in chronicling universal suffering. They me- logia ocular en la obra de Pieter Bruegel el Viejo (III). Síndrome de ticulously reproduced the ravages of disease with an accuracy Bruegel. Eye diseases in the works of Pieter Bruegel the Elder (III). that permits plausible diagnoses in the twenty-first century. Bruegel’s Syndrome. Arch Soc Esp Oftalmol 2012; 87 (9): 305–06. Bruegel and Bosch also remind those in the healing profes- 9. Dequeker J, Fabry G, Vanopdenbosch L. Hieronymus Bosch sions that a culture’s response to the most vulnerable speaks (1450–1516): Paleopathology of the medieval disabled and its relation volumes about that society’s values. Are the homeless and dis- to the Bone and Joint Decade 2000–2010. Isr Med Assoc J 2001; 3 abled today still singled out for contempt? Studies remind us (11): 864–71. that contemporary attitudes towards people with physical dis- 10. Hernigou P. Crutch art painting in the middle age as ortho- abilities retain remnants of prejudice.17 The compelling images paedic heritage (Part I: the lepers, the poliomyelitis, the cripples). of Bosch and Bruegel can serve as a powerful introduction to Int Orthop 2014; 38 (6): 1329–35. http://www.ncbi.nlm.nih.gov/pmc/ the vulnerable among us and an invitation to the better angels articles/PMC4037520/. of our natures. In the words of Steven E. Brown, cofounder of 11. Ayarragary JE. Ergotism: A change of persepective. Ann Vasc the Institute on Disability Culture: Surg 2014; 28 (1): 265–68. 12. Nemes CN. The medical and surgical treatment of the pil- People with disabilities have forged a group identity. We grims of the Jacobean Roads in medieval times. Part 1. The caminos share a common history of oppression and a common bond and the role of St. Anthony’s order in curing ergotism. International of resilience. We generate art, music, literature, and other Congress Series 2002; 1242: 31–42. expressions of our lives and our culture, infused from our 13. Nemes CN, Goerig M. The medical and surgical manage- experience of disability. Most importantly, we are proud of ment of the pilgrims of the Jacobean Roads in medieval times. Part ourselves as people with disabilities. We claim our disabili- 2. Traces of ergotism and pictures of human suffering in the me- ties with pride as part of our identity.18 dieval fine arts. International Congress Series 2002; 1242: 487–94. 14. Langbein JH. The historical origins of the sanction of imprison- ment for serious crime. J Legal Stud 1976; 5 (1): 35–60. Acknowledgments 15. Mears JW. The Beggars of Holland and the Grandees of My thanks to Dr. Raphael Arsuaga who translated the ophthalmo- Spain; A History of the Reformation in the Netherlands, from A.D. logical papers published in Spanish, and to Dr. Mac Ronning for his 1200 to 1578. New York: A.D.F. Randolph; ca. 1867. ophthalmological insight. 16. Zagorin P. Looking for Pieter Bruegel. J Hist Ideas 2003; 64 (1): 73–96. References 17. Tervo RC, Azuma S, Palmer G, Redinius P. Medical students’ 1. Foote T, and the editors of Time-Life Books. The World of attitudes toward persons with disability: A comparative study. Arch Bruegel, c. 1525–1569. New York: Time-Life Books; 1968. Phys Med Rehabil 2002; 83: 1537–42. 2. Beyer MS. Bosch and Bruegel: An examination and compari- 18. Eddey GE, Robey KL. Considering the culture of disability son of Tryptich of Temptation of Saint Anthony and The Number- in cultural competence education. Acad Med 2005; 80 (7): 706–12. ing at Bethlehem. http://www.towerofbabel.com/sections/gallery/ boschandbruegel. The author’s address is: 3. Fulton T. Through the artist’s eyes. Ulster Med 1982; 51: 1–22. National Consult Service 4. Torrillhon T-M. La pathologie chez Bruegel. Comm Hist Cleveland Clinic Artis Med 1973; 69–70: 15–55. http://www.orvostortenet.hu/tank- 9500 Euclid Avenue/G10 onyvek/tk-05/pdf/2.11/1973_069_070_torillhon_tony_pathologie_ Cleveland, Ohio 44195 bruegel.pdf. E-mail: [email protected]
54 The Pharos/Winter 2016 2015 Robert J. Glaser Distinguished Teacher Awards
Top, the 2015 Robert J. Glaser Distinguished Teachers. Left to right: 2014–2015 Chair of the AAMC Board of Directors Dr. Peter L. Slavin, AΩA Executive Director Dr. Richard L. Byyny, Distinguished Teachers Dr. Thomas Kwasigroch, Dr. Gurpreet Dhaliwal, and Dr. David Muller, and AAMC President and CEO Darrell G. Kirch. Missing is Distinguished Teacher Dr. Jonathan Kibble.
Left, Dr. Gurpreet Dhaliwal. Photos courtesy of the AAMC.
ach year since , Alpha Omega the award are submitted to the AAMC Emma Meagher, MBBCh, BAO; LuAnn Alpha, in cooperation with the each spring by the deans of medical Wilkerson, EdD. AssociationE of American Medical schools. Winners of the award receive Colleges (AAMC), presents four AΩA This year’s nominations were re- $,, their schools receive $,, Distinguished Teacher Awards to faculty viewed by a committee chosen by AΩA and active AΩA chapters at those members in American medical schools. and the AAMC. This year’s committee schools receive $,. Schools nomi- Two awards are for accomplishments in members were Peter Anderson, DVM, nating candidates for the award receive teaching the basic sciences, and two are PhD; Charles L. Bardes, MD; J. John a plaque with the name of the nominee. for inspired teaching in the clinical sci- Cohen, MD, PhD; James M. Crawford, Richard L. Byyny, MD ences. In , AΩA named the award MD, PhD; Ruth-Marie Fincher, MD; Executive Director to honor its retiring executive secretary Bernard Karnath, MD; Randall King, Robert J. Glaser, MD. Nominations for MD, PhD; Kelley Skeff, MD, PhD;
The Pharos/Winter 2016 55 2015 Robert J. Glaser Distinguished Teacher Awards
Gurpreet Dhaliwal, MD (Clinical) apply. Students report that (AΩA, Northwestern University, 1998) the majority of their clinical Professor of Medicine, University of teachers do clinical reason- California, San Francisco, School of ing as naturally as they ride Medicine a bicycle, yet they often have Dr. Dhaliwal received his MD from difficulty making explicit the Northwestern University in , steps they automatically go completed his residency in Internal through as they solve clini- Medicine at the University of California, cal problems. Dr. Dhaliwal San Francisco (UCSF) in , and is tremendously successful joined UCSF as an Assistant Professor at making explicit the meta- the same year. He was appointed the cognition of clinical prob- Site Director of Internal Medicine lem solving—modeling his Student Clerkships in , a position own clinical reasoning and he continues to hold, and in be- helping students think about came Professor of Clinical Medicine in their thinking processes. the Department of Medicine at UCSF. Learners are riveted as he Dr. Dhaliwal has received more than walks through his stepwise a dozen awards and recognitions dur- approach to even the most ing his tenure at UCSF, including the puzzling cases with clarity, Dr. Thomas Kwasigroch and his wife, Dr. Christine L. Henry J. Kaiser Award for Excellence in organization, and ease.” Kwasigroch. Photos courtesy of the AAMC. Inpatient Teaching in and ; membership in the Haile T. Debas UCSF Jonathan Kibble, PhD (Basic) Academy of Medical Educators in ; Professor and Assistant Dean Student Choice Award in ; awards the USCF Department of Medicine for Medical Education, University of for Excellence in Teaching in and Calvin L. Chou PRIME Teaching Award Central Florida College of Medicine ; and the UCF College of Medicine in ; the UCSF Medical School Dr. Kibble received his PhD in Student Choice Award in . Class of Essential Core Teaching Renal Physiology at the University of Dean Deborah German writes, “Dr. Award for Outstanding Lecture; and Manchester, United Kingdom, in . Kibble is an evidence-based teacher who appointment to the Council of Master He joined the University of Central utilizes what we know about learning Clinicians in the UCSF Department of Florida (UCF) as an Associate Professor to improve the student experience and Medicine in . of Physiology and Medical Education in student learning. His research supports Dean Bruce Wintroub writes of Dr. , was appointed Assistant Dean for his teaching practices and impacts those Dhaliwal, “Dr. Gurpreet Dhaliwal is Undergraduate Medical Education in whom he mentors. While Jonathan may an extraordinary educator and mas- , and Professor of Physiology and not admit to mentoring most of the fac- ter clinician who has made unparalled Medical Education in . ulty, his colleagues will tell you that he contributions to medical student edu- As Chair for the Program Evaluation constantly models and challenges them cation through his direct teaching and Subcommittee of the Curriculum to consider best practices. In this way, by teaching other medical educators— Committee, Dr. Kibble led the devel- Dr. Kibble is a highly influential teacher locally, nationally, and internationally— opment of a program that has been as he plays a role in how other faculty to more effectively teach the difficult recognized with commendation by deliver the curriculum.” skills of clinical problem solving and pa- the Liaison Committee on Medical tient-centered clinical decision making. Education. He was influential in setting Thomas Kwasigroch, PhD (Basic) “What is Dr. Dhaliwal’s secret rec- the direction of the overall curriculum (AΩA, James H. Quillen College of ipe for effectiveness in direct teach- at UCF, as well as establishing policies Medicine of East Tennessee State ing? Those of us who have heard him and processes, while also mentoring University, 1988, Faculty) speak know that he can engage any faculty. He was also instrumental in Professor in Biomedical Sciences/ audience with his erudite style. But, for facilitating the curricular shift from pas- Anatomy, James H. Quillen College medical students, his truest gift lies in sive to active learning strategies. of Medicine at East Tennessee State his ability to deconstruct the complex Recognition for Dr. Kibble’s teaching University process of context-specific clinical rea- skills have resulted in numerous awards Dr. Kwasigroch received his PhD in soning and problem solving into a set of at the University of Central Florida, Anatomy/Embryology at the University tools that early learners can effectively including the Most Effective Teacher of Virginia in . He joined the Quillen
56 The Pharos/Winter 2016 College of Medicine at East Tennessee David Muller, MD (Clinical) and was receiving overwhelmingly posi- State University (Quillen) in as (AΩA, Mount Sinai School of Medicine, tive feedback. Dr. Muller’s early teach- an Assistant Professor of Anatomy, be- 1995, Resident) ing roles for medical students included coming Professor in the Department Professor and Dean for Medical traditional Ward Attending Student of Anatomy and Cell Biology in , Education, the Icahn School of Preceptor for Third Year Internal Assistant Dean for Medical School Medicine at Mount Sinai Medicine Clerks, developing and teach- Curriculum in , and Associate Dr. Muller received his MD at New ing elective courses in Professionalism Dean for Student Affairs in . York University School of Medicine and the Humanities, and delivering a Dr. Kwasigroch introduced the idea of in , and completed his residency curriculum on Reflection and Idealism a flipped classroom to Quillen in , in Internal Medicine at Mount Sinai for trainees rotating through the Mount following his attendance at an AAMC Medical Center in . He held the Sinai Visiting Doctors Program. Dr. conference at which Salman Khan pre- position of Clinical Instructor at Mount Muller also served as a small group sented his ideas for the Khan Academy. Sinai in , and in became the preceptor in a course called Art and In , he obtained iPad technology at Chair of the Department of Medical Science of Medicine (ASM) from its each dissection table, and pushed the Education. He has been Dean for inception in . He was asked to take use of educational apps in gross anatomy Medical Education at Mount Sinai since on the role of interim Course Director lab. Under Dr. Kwasigroch, the anatomy . for one year and continues to teach department has received the most Dr. Muller continues to teach, and in ASM today. These activities earned awards from students in the history of serves each year as a small group pre- him high praise from our students and the school. Dr. Kwasigroch continues ceptor for eight to twelve students who actually led to his being recognized as to teach and provides leadership for the learn physical examination skills and an outstanding candidate for the role Department of Anatomy, and serves on study topics including palliative care, of Dean for Medical Education. In fact, multiple committees and in administra- substance abuse, disparities in health despite the many highly qualified can- tive positions at Quillen, evidence of his care, cultural competency, bioethics, didates who applied for the position focus on improving medical education. and domestic violence. He teaches in the during our national search a decade ago, Dr. Kwasigroch is the most awarded Longitudinal Clinical Experience, a two- the Medical Student Council Executive professor in the history of Quillen. He year immersion that allows incoming Steering Committee advocated strongly received the Dean’s Award for Excellence medical students to join a clinical prac- that Dr. Muller be offered the posi- in Teaching all eight years the award tice and follow patients. Dr. Muller is tion because of his track record as an was offered; received the Lee Brashear’s also a clinical preceptor in Mount Sinai’s outstanding teacher, role model, and Memorial for Excellence in Teaching Inter-Clerkship Ambulatory Care track. advocate for students. and Student Support twice; and was Dr. Muller’s teaching has earned him, “The consistency of [Dr. Muller’s] one of four recipients of the national among many other honors and awards, teaching over so much time, by so Joy McCann Scholar Award in . He the Jacobi Medallion in , the high- many different levels of students, and has been awarded Professor of the Year est honor awarded to alumni of Mount across so many different teaching roles thirteen times, and the Gross Anatomy Sinai; the AMA Foundation Pride in is likely to be unmatched by any of the course has won Course of the Year thir- the Profession Award in ; the teaching faculty at our institution. In teen times. Alexander Richman Commemorative written comments he is cited as an Dean Robert T. Means writes, “Dr. Award for Humanism in Medicine in outstanding educator, role model, ad- Kwasigroch excels in medical education ; the Leonard Tow Humanism in vocate, and mentor. Students remark by not only improving clinical and scien- Medicine Faculty Award in ; the on his unique ability to make learning tific learning experience, but by promot- Housestaff Teaching Award in ; fun, exciting, intellectually stimulating, ing medical student health. Clearly, even and the Mount Sinai School of Medicine and rewarding, while always keeping after thirty-five years of teaching, Dr. Humanism in Medicine Award in . the focus on the needs of patients and Kwasigroch still is improving himself, Dean Dennis Charney says of Dr. their communities.” his classroom and his students. Without Muller, “From his appointment as question Dr. Kwasigroch has diligently Chief Resident until today as Dean for and faithfully served this school, this Medical Education, [Dr. Muller] has community and his country.” been an oustanding teacher. His ini- tial focus in teaching was our Internal Medicine housestaff, but even as junior faculty he was increasingly turning his attention to medical student education
The Pharos/Winter 2016 57 Reviews and reflections David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors
The Worm at the Core: On the Role of Death Happy the hare at morning, for she cannot read in Life The Hunter’s waking thoughts, lucky the leaf Sheldon Solomon, Jeff Greenberg, and Tom Pyszezynski Unable to predict the fall, lucky indeed Random House, New York, 2015, 274 pages The rampant suffering suffocating jelly Burgeoning in pools, lapping the grits of the desert, Reviewed by John L. Wright, MD (AΩA, Drexel University But what shall man do, who can whistle tunes by heart, College of Medicine, 1956) Knows to the bar when death shall cut him short like the cry of the shearwater, Teach me to live, that I may dread What can he do but defend himself from his knowledge? p7 The Grave as little as my Bed; So what’s the big deal? The authors claim it is this fear —Thomas Ken1 that causes man to “so desperately crave self-esteem,” and explains “why we fear, loathe, and sometimes seek to obliter- hese lines are taken from the ate people who are different from ourselves.” pix Further, they seventeenth-century prayer-poem, contend, “Over the course of human history, the terror of T“All Praise to Thee, My God, This death has guided the development of art, religion, language, Night,” by the clergyman Thomas Ken. economics, and science. It raised the pyramids in Egypt and And although the authors of The Worm razed the Twin Towers in Manhattan.” px They also go on to at the Core don’t advocate for prayer as list the many ways this fear contributes to man’s senseless and a solution to man’s dread, they don’t dis- destructive behavior. In fact, given the twenty-first century’s count it either. In fact, the main intent lethal weapons, they write, “And because nation-states will of the book is to teach just that—how use whatever military technology they possess to defend their to live with dread. In the introduction, secular or religious ideologies—whether to ‘keep the world they state, “our overarching goals are safe for democracy’ or ‘to rid the world of evil’—there is a very to reveal the many ways the knowledge real danger that we humans will be the first form of life to be that we are mortal underlies both the responsible for our own extinction.” p149 noblest and most unsavory of human pursuits, and to con- In the early pages, and for me the most satisfying pages of sider how these insights can lead to personal growth and The Worm at the Core, the authors consider human develop- social progress.” pxi ment starting with infancy, emphasizing ingredients crucial Experimental social psychologists Solomon, Greenberg, for growing self-esteem, and the importance of self-esteem and Pyszezynski collaborated for over twenty-five years. In to becoming a convinced and successful participant in one’s the 1970s, as young researchers, they discovered that they inherited culture. “Our beliefs in literal and symbolic im- shared an interest in understanding the fundamental motiva- mortality,” the authors assert, “help us manage the potential tions that direct human behavior. Their studies led them to for terror that comes from knowing that our physical death focus on two basic human drives: “First, . . . to protect our is inevitable.” p9 Much of their understanding falls under what self-esteem. Second, . . . to assert the superiority of our own Becker called the twin ontological motives—human striving group over other groups.” pviii–ix for meaning in life and the escape from loneliness through he- In the early 1980s they discovered the writings of Ernest roic living, or immersing oneself under one banner or another. Becker, who by synthesizing insights from anthropology, soci- Over the past thirty years, the authors of The Worm at the ology, psychology, philosophy, religion, literature, and popular Core and many other social psychologists have conducted a culture, provided a conceptual framework for answering the broad program of research developing a field they call Terror question, “What makes people behave the way they do?” Management Theory. In such investigations, researchers se- Becker’s answer, largely spelled out in his 1974 Pulitzer Prize lect a cohort of persons who have the same roles and typically winning book, The Denial of Death, was the existential fear carry out a specific behavior; for example, a cohort of judges of death—the worm at the core—that every human being car- whose job often entails setting bail for arrested prostitutes. ries within him or her. Furthermore, he and others argue that They then assign participants either to an intervention (a Homo sapiens is the only animal that experiences such fear. brief imaging exercise that requires them to imagine their To illustrate this claim, the authors present the first verse of own deaths) or to a control group without such a reminder. W. H. Auden’s poem, “The Cultural Presupposition.” Then both groups are subjected to situational tests and their responses evaluated—for example, how does intervention
58 The Pharos/Winter 2016 influence a judge’s bail setting behavior? In this particular p53: The Gene That Cracked the Cancer Code case, judges exposed to the intervention tended to set higher Sue Armstrong bail (500 instead of the usual 50, say) than they had set pre- London, Bloomsbury Sigma, 2014, 287 pages viously, while the control judges continue their usual pattern. The authors conclude that, “after being reminded of death, Reviewed by Thoru Pederson, PhD we react generously to anyone or anything that reinforces our cherished beliefs, and reject anyone or anything that calls eaders of The Pharos who were those beliefs into question.” p13 In the case of prostitutes, the in training or embarking on their judges feel more negative and set higher bail. Alternatively, medicalR careers in the 1960s and 1970s reminders of death lead people to hold more firmly to cher- may recall being aware of the on- ished beliefs. The authors hope that such revelations cause us cology community’s passionate belief to, “First, . . . become more aware and accepting of the reality that most human cancer was caused of our mortality. Second, we can strengthen our sense of death by either viruses or chemicals. These transcendence in non-destructive ways.” p218 two ideas about the causation of can- I find the last section of the book the least satisfying. cer were so widely accepted that the Here, the authors discuss how the fear of death is an under- National Cancer Institute launched appreciated contributing factor in psychological disorders. major intramural programs on both That neglect may well be the case, but they tend to portray viral and chemical carcinogenesis, and terror of death as a core feature of almost all significant also began to increase its extramural mental disorders (e.g., schizophrenia, depression, substance funding on projects based on these two ideas. The data at abuse, post-traumatic stress disorder), while ignoring other hand were limited and someday a historian of science will biological and psychological factors. Thus, I do not think this capture this wobble in America’s well-intentioned effort to section contributes significantly to an otherwise authoritative “cure cancer,” a goal that former President Richard Nixon told and comprehensive look at how the knowledge of our demise his interviewer Barbara Walters years later that he regarded as impacts our behavior. his greatest accomplishment (in signing the National Cancer Finally, having begun this review with a quote from Act of 1971). a prayer-poem, I want to end it just so. In his excellent There can be no doubt, from many compelling epidemio- study, Poetry as Survival, Gregory Orr uses, as the epi- logical studies, that some human cancer is initiated by expo- graph to the chapter entitled “Convulsive Transformation of sure to chemicals that mutate DNA (as we now recognize, in the Overculture,” this less than optimistic quote from Sara hindsight, from Percivall Pott’s famously prescient 1775 report Hutchinson, a Cherokee woman: of an increased incidence of scrotal tumors in young men whose profession was evicting the residue of London chim- I pray for many things, things the Overculture neys). And we also know that some human cancer is indeed may never pray for.2 caused by viruses, of which adult T-cell leukemia (HTLV-I) and cervical cancer (human papillomavirus) are the two most notable examples.* References Then the 1980s arrived, and Harold Varmus and Michael 1. Ken T. A Manual of Prayers for the Use of the Scholars of Bishop developed the remarkable insight that most human Winchester College. London: John Martyn; 1675: 139. https://ar- cancer is indeed caused by viruses, but not as an infecting chive.org/details/amanualprayersf02kengoog. agent. Rather, these viruses silently sneak their DNA into 2. Orr G. Poetry of Survival. Atlanta (GA): University of Georgia human chromosomes, where it lies dormant and can incite Press; 2002: 133. The quote is from Crozier-Hogle L, Wilson DB, tumor formation later.1–3 This made scientists realize that editors. Surviving in Two Worlds: Contemporary Native American much human cancer comes from within the genome. The Voices. Austin (TX): University of Texas Press; 1997. gifted writer Sue Armstrong takes up the next phase of cancer research in this engaging book: what keeps these endogenous Dr. Wright is Clinical Professor Emeritus of Medicine at the Uni- cancer-causing genomic invaders in check? versity of Washington. His address is: The author has previously written on broad issues of sci- PO Box 761 ence and health, but in this book dives in deeply, interviewing Edmonds, Washington 98020 all the leading characters in the story and making it come to E-mail: [email protected]
* As a historical point, it is worth noting that Peyton Rous’ discovery of a viral agent causing soft tissue cancer in chickens was not recognized with a Nobel Prize in Physiology and Medicine until .
The Pharos/Winter 2016 59 Reviews and reflections
life. First, a specific protein was identified in a few cell biol- 6. Mukherjee S. The Emperor of All Maladies: A Biography of ogy research laboratories, and because the molecular weight Cancer. New York: Scribner; 2010. of this protein was found to be 53,000, it was dubbed p (for 7. Pederson T. On cancer and people. Science 2011; 332: 423. protein) 53. At first, this protein, which appeared to be in- volved in cell growth, captured little attention. But then the Dr. Pederson is the Vitold Arnett Professor of Cell Biology in the story quickens. Department of Biochemistry and Molecular Pharmacology at the The author then describes the pioneering work demon- University of Massachusetts Medical School. His address is: strating that human cells have genes that can suppress cancer.† Department of Biochemistry and Molecular Pharmacology Nothing about p53 seemed to make sense until scientists be- University of Massachusetts Medical School gan to think that perhaps it functions as a tumor suppression 364 Plantation Street gene. If such a gene mutates and can no longer perform its Worcester, Massachusetts 01605 job, cancer cells can proliferate unchecked. It is now known E-mail: [email protected] that such “loss of function” mutations in the normal gene for p53 are responsible for half of all human cancer. The book closes on how “p53-ology” informs current cancer chemo- Doctors of Another Calling: Physicians Who Are therapy drug design, where I found the author to be very au Best Known in Fields Other than Medicine courant, although there are other equally compelling recent accounts for the general audience.4–7 David K. C. Cooper Having praised the book, I cannot resist conveying one University of Delaware Press, Newark, Delaware, 2014 minor point on which I also torture all my biochemistry stu- Reviewed by Jack Coulehan, MD (AΩA, University of dents. The author states that p53 was named on the basis of Pittsburgh, 1969) its “molecular weight of 53 kilodaltons.” p44 However, molecu- lar weight is a dimensionless parameter, so the correct term is either a molecular mass of 53 kilodaltons, or a molecular n 1795 the Scottish explorer Mungo weight of 53,000 (no units). The fact that Sue Armstrong is Park (1771–1806) set out to dis- not a scientist and this is the only quibble I have demonstrates coverI the source of the Niger River. the fine job she has done. During this first expedition, he en- I recommend this book to all physicians because it is a countered bouts of tropical disease, spellbinding story of biomedical research sleuthing. I suspect hostile natives, and imprisonment for even nononcologists will find it of interest. The author also several months by an Arab chieftain. conveys a back story about the culture of science, viz., how Nevertheless, he managed to reach the tenaciously certain shibboleths can be adopted by a guild, its Niger close to its source and follow its members locked in a mutually agreed upon canon, and how it course several hundred miles down- is usually a few intrepid scientists with open minds that bring stream. The American military officer about a revolution. William Minor (1834–1920) received a medical discharge in 1868 because of References bizarre and violent behavior. He later moved to London, where 1. Varmus H. The Art and Politics of Science. New York: WW he murdered a brewery worker in 1872. Minor was found not Norton; 2009. guilty by reason of insanity and was incarcerated for the next 2. Bishop JM. How to Win the Nobel Prize: An Unexpected Life thirty years in Broadmoor Asylum for the Criminally Insane. in Science. Cambridge: Harvard University Press; 2003. While there, Minor learned about James Murray’s gargantuan 3. Pederson T. Portrait of the Artist. Science 2009; 323: 1292. project of compiling the Oxford English Dictionary, and he 4. Nathan DG. The Cancer Treatment Revolution: How Smart became the dictionary’s most prolific contributor, providing Drugs and Other New Therapies Are Renewing Our Hope and definitions for about 8,000 words. American businessman Changing the Face of Medicine. Hoboken (NJ): John Wiley; 2007. Jules Stein (1896–1981) began his career representing musi- 5. Pederson T. Reviews and reflections: The Cancer Treatment cians, including Guy Lombardo, in the mid-1920s. Starting with Revolution: How Smart Drugs and Other New Therapies Are Re- very little capital, he founded Music Corporation of America newing Our Hope and Changing the Face of Medicine. The Pharos (MCA), which grew into one of the largest and most profitable 2008 Summer; 71: 41–42. entertainment companies in history. What do these three men with such disparate careers have in common? They were all physicians, although only Minor † That work, by Henry Harris, George Klein, and Alfred Knudson, (the insane lexographer) practiced medicine for a substantial has been an annual Nobel Prize candidate for many years, and period of time, first as a field surgeon in the Union Army dur- despite Harris’ death last year this discovery is likely still under ing the Civil War and later at an Army base on Governor’s consideration. Island, New York, where his violent behavior might have been
60 The Pharos/Winter 2016 a symptom of shell shock or PTSD. Mungo Park’s only practice practiced in Bloomsbury, served as president of the Royal experience was a year-long stint as assistant ship’s surgeon on College of Physicians, and eventually became physician to a voyage to Sumatra, while Jules Stein practiced very little after Queen Anne and her Hanoverian successors. Sloane’s passion his chief residency in ophthalmology at Cook County Hospital for natural history, antiquities, books, coins, and manuscripts in Chicago, although he was a lifetime supporter of eye re- led him to amass a great collection of specimens and artifacts search and helped found the National Eye Institute. that he bequeathed to the nation. This became the nucleus The three men also share inclusion in David K. C. Cooper’s of the British Museum, which opened in 1759, six years af- Doctors of Another Calling, an interesting collection of brief ter Sloane’s death. I was aware that in 1954 Roger Bannister biographies of physicians (and medical students) whom the (1929–) became the first runner to break the four-minute mile, editor categorizes as “physicians who are best known in but had not remembered that Dr. Bannister went on to have a fields other than medicine.” This multi-authored collection is distinguished career as a neurologist. Likewise, I had read that unique, I think, for the broad range of non-medical fields it Edward Wilson (1872–1912) was among the men who perished covers and the depth of attention it gives to each of its thirty- with Robert Falcon Scott on his return from the South Pole, but eight physician characters. The biographies themselves range had not realized that he was the expedition’s physician, as well from a few that are merely competent to several engaging and as its naturalist. incisive portraits. The selection of such a small number of winners in a Aside from Park, Minor, and Stein, who are these fa- competition for “best known” is bound to be controversial. I mous doctors of another calling? First, they include many couldn’t help second guessing Dr. Cooper from time to time. of the writers you would expect: John Keats, Oliver Wendell If he reaches back to the Middle Ages (e.g., Dante), then why Holmes, Sir Arthur Conan Doyle, Anton Chekhov, and W. not include the great Jewish physician-philosopher- theologian Somerset Maugham. This list raises an obvious question: what Moses Maimonides? Or what about the French World War I about Rabelais, Oliver Goldsmith, William Carlos Williams, or prime minister George Clemenceau? Among medical students, Walker Percy? As the editor says, his is a personal choice, so we why didn’t the famous (or notorious) twentieth-century poet need not debate his judgment that Abraham Verghese and A. J. Gertrude Stein, who left Johns Hopkins medical school dur- Cronin (both included) are, in fact, better novelists than Walker ing her fourth year, make the cut? Her case raises the more Percy (not included). Other unsurprising entrants are: philoso- interesting question: Why are there no women among the pher John Locke, composer Alexander Borodin, explorer David select thirty-eight? Yes, it’s true, historical circumstances have Livingstone, revolutionaries Sun Yat-sen and Che Guevara, restricted the pool of women, both in medicine itself and in entrepreneur Armand Hammer, and theologian-humanitarian various arts and occupations. But it’s strange that Dr. Cooper, Albert Schweitzer. who has striven to present such a broad range of “best knowns,” What were the biggest surprises? One was the presence of was not able to find a single woman to include in this book. Dante Alighieri, whom I had never associated with medicine. There are, however, two appendices in which he lists numerous James E. Bailey’s chapter on Dante argues that “several lines of writers, entertainers, explorers, political leaders, scholars, and indirect evidence suggest that Dante’s interest in medicine was others who reasonably “might have been chosen,” but didn’t more than passing.” p12 In fact, Dante did at one point join the make the cut. Guild of Physicians and Apothecaries in Florence, and several Doctors of Another Calling is an enjoyable book, full of inter- contemporary images portray him in the typical guise of a esting detail and surprise. It’s neither an authoritative reference physician, i.e., red gown with white fur on the hood. However, work, nor a book that many readers will want to sit down and there is no evidence that the great poet and political theorist read from stem to stern. Rather, its short chapters allow the ever practiced medicine. reader to take small doses of “physicians best known for their Another surprise was T. Jock Murray’s lead-off chapter on contributions to other fields” on a PRN basis. St. Luke. There is an ancient tradition in Christianity that the author of Luke’s gospel was a physician, although an almost Dr. Coulehan is a member of the Editorial Board of The Pharos equally respected tradition holds that the gospel writer was an and one of its book review editors. His address is: artist, to whom several early icons were attributed. In fact, St. Center for Medical Humanities, Luke is now the patron saint of physicians and painters. In any Compassionate Care, and Bioethics case, if Luke was indeed a medical man, he is surely the most Stony Brook University widely read physician writer of all time. Stony Brook, New York 11794 I met several new characters in Doctors of Another Calling E-mail: [email protected] and learned fascinating details about more familiar figures. For example, I became acquainted with Hans Sloane (1660–1753), who studied medicine in London under Thomas Sydenham,
The Pharos/Winter 2016 61 National and chapter news
Attendees of the 2015 Board of Directors meeting. Front row, left to right: Robert Atnip, Joseph Stubbs, Richard Byyny, Douglas Paauw, John Tooker. Middle row: Dee Martinez, Cynthia Arndell, Eve Higginbotham, Laura Tisch, Candice Cutler, Griffin Rodgers, Sheryl Pfeil, Mark Mendelsohn, Debbie Lancaster, Elizabeth Warner, Regina Gandour-Edwards, Holly Humphrey, Monica Vela, Lynn Cleary, and Richard Gunderman. Back row: Richard Latuska, Alan Robinson, Jeremy Bolin, Suzann Pershing, Barbara Prince, Christopher Clark, Joshua Hartzell, Chip Souba, Ronald Robinson, Jane Kimball.
Minutes of the 2015 Board of Directors Meeting Vanderbilt University School of Medicine The annual meeting of the Board of Directors of Alpha • Mark J. Mendelsohn, MD, Councilor Director represent- Omega Alpha was held in Boulder, Colorado, on October 3, ing the University of Virginia School of Medicine 2015. President Douglas Paauw opened the meeting. The fol- • William F. Nichols, CPA, Assistant Treasurer lowing members attended: • Douglas S. Paauw, MD, Member at Large and President • Robert G. Atnip, MD, Member at Large and • Suzann Pershing, MD, Coordinator, Residency President-Elect Initiatives • Second Lieutenant Jeremy Bolin, MSIV, new Student • Sheryl Pfeil, MD, Member at Large Director representing the Uniformed Services University of • Barbara Prince, CPA, Controller the Health Sciences F. Edward Hébert School of Medicine • Alan G. Robinson, MD, Member at Large • Richard L. Byyny, MD, Executive Director • Griffin Rodgers, MD, MBA, Medical Organization • Christopher M. Clark, MD, Student Director represent- Director representing the National Institutes of Health ing the University of Mississippi School of Medicine • Wiley Souba, Jr., MD, DSc, MBA, Member at Large • Lynn M. Cleary, MD, Councilor Director representing • Joseph W. Stubbs, MD, Member at Large and Secretary the State University of New York Upstate Medical University Treasurer • Candice Cutler, Programs Administrator • Laura Tisch, MD, Student Director representing the • Regina Gandour-Edwards, MD, new Councilor Director Medical College of Wisconsin representing the University of California, Davis, School of • John Tooker, MD, MBA, Member at Large and Medicine Immediate Past President • Charles Griffith III, MD, MSPH, Councilor Director representing the University of Kentucky College of Medicine Absent was: • Richard B. Gunderman, MD, PhD, Member at Large • Steven A. Wartman, MD, PhD, Member at Large • Eve J. Higginbotham, SM, MD, Member at Large • Holly J. Humphrey, MD, Member at Large Guests attending were: • Jane Kimball, Membership Administrator and Editorial • Cynthia Arndell, MD, RN, 2015 AΩA Fellow in Assistant Leadership • Debbie Lancaster, Managing Editor, The Pharos, and • Jennifer Ellison, CFA, Bingham, Osborn & Scarborough Chief Technology Officer • Nathan Goldstein, MD, 2014 AΩA Fellow in Leadership • Richard Latuska, MD, Student Director representing (via teleconference)
62 The Pharos/Winter 2016 • Lieutenant Colonel Joshua Hartzell, MD, 2014 AΩA procedures, and schools that lack AΩA chapters. Fellow in Leadership Dr. Stubbs presented the 2015 financial report, 2016 bud- • Diana Lieberman, Financial Consultant get, and the audit of the 2014 financial year. Mr. Nichols ex- • Dee Martinez plained details about the finances and budget. • Ronald Robinson, MD, MPH, 2015 AΩA Fellow in Dr. Byyny presented the report on The Pharos, which in- Leadership cluded an overview of the process of review and publication • Monica Vela, MD, 2014 AΩA Fellow in Leadership of manuscripts. There was discussion about the role of clear • Elizabeth J. Warner, MD, 2015 AΩA Fellow in writing in communication, and the possible use of social me- Leadership dia. It was noted that The Pharos is a peer-reviewed journal and its articles are listed in PubMed. The minutes of the 2014 meeting of the Board of Dr. Pershing presented the report on the residency initia- Directors were approved unanimously. tive and the Postgraduate Award. She noted that a major The investment program report was led by Dr. Stubbs and challenge is the lack of engagement once the member be- Mr. Nichols. Jennifer Ellison from investment firm Bingham comes a resident. This is due to many factors, including a Osborn & Scarborough was present, as was independent fi- lack of time, the difficulty of connecting residents with chap- nancial consultant Diana Lieberman. ters, and the number of residents that can be elected annu- Ms. Ellison introduced Bingham Osborn & Scarborough ally at any given chapter. and its philosophy of investment. Mr. Nichols and Dr. Byyny Dr. Higginbotham and Dr. Byyny presented the report on commented on the investment program. the Fellow in Leadership Award. They were followed by the Dr. Paauw announced the new officers of the Board, effec- reports of the 2014 Fellows on their year’s experiences. The tive the end of the meeting: 2014 Fellows presenting were: • Immediate Past President Douglas Paauw • Monica Vela, MD, Associate Dean of Multicultural • President Robert Atnip Affairs at the Pritzker School of Medicine at the University • President-Elect Joseph Stubbs of Chicago, and Associate Vice Chair for Diversity in the • Secretary-Treasurer Wiley Souba. Department of Medicine at University of Chicago Medicine He welcomed the new directors to the board: • Lieutenant Colonel Joshua D. Hartzell, MD, Associate • Councilor Director Regina Gandour-Edwards Program Director in Internal Medicine, Assistant Chief of • Student Director Jeremy Bolin GME, and Army Intern Director at Walter Reed National He announced the renewal of terms for members at large: Military Medical Center; Associate Professor of Medicine, • Coordinator of Residency Initiatives Suzann Pershing Uniformed Services University of the Health Sciences F. • Member at Large Sheryl Pfeil Edward Hébert School of Medicine • Member at Large Alan Robinson • Nathan Goldstein, MD, Associate Professor, Gerald J. Dr. Paauw presented the President’s report. He pointed and Dorothy R. Friedman Chair in Palliative Care and Chief out that Hofstra North Shore-LIJ School of Medicine, Florida of the Division of Palliative Care at Mount Sinai Beth Israel; Atlantic University Charles E. Schmidt College of Medicine, Director of Research and Quality, Hertzberg Palliative Care and Oakland University William Beaumont School of Institute, Brookdale Department of Geriatrics and Palliative Medicine received full LCME accreditation and were granted Care, Mount Sinai Medical Center charters in 2015. He noted the highlights of the national Dr. Paauw presented the report on the Edward D. Harris programs. Professionalism Award. He summarized the reasons for the Dr. Byyny presented the Executive Director’s Report. He change in focus of the award in 2015, including the results of recognized the outgoing and incoming members, new of- the think tank meetings and the publication of the profes- ficers, and expressed his appreciation for Dr. Paauw’s service sionalism monograph. Dr. Byyny summarized the results of as President. He summarized the national office team and or- this year’s program, mentioning the very positive reception ganization, reviewed communication with members, national for the monograph. programs, and dues solicitations and finances. He discussed The 2016 budget was approved unanimously. plans for the transition to new Managing Editor of The Dr. Paauw and the board thanked and recognized retiring Pharos, Dee Martinez, who will succeed Debbie Lancaster members Dr. Lynn Cleary and Dr. Christopher Clark. after Debbie’s retirement in 2016. The Chapter Handbook The 2016 board meeting will be held in Chicago, will be updated in time for the Councilor Meeting to be September 30-October 1, 2016. held in 2016. He referred to new chapters and potential new Respectfully submitted, chapters, including the plans for a chapter at the University Richard L. Byyny, MD, Executive Director of Connecticut School of Medicine. A discussion followed among the board members regarding election criteria and
The Pharos/Winter 2016 63 Dr. Robert G. Atnip, Dr. Douglas S. Paauw, Dr. Joseph W. Stubbs, Dr. Wiley Souba, Dr. Regina Gandour-Edwards, Second Lieutenant Jeremy Bolin.
Alpha Omega Alpha elects new officers and directors Secretary-Treasurer—Dr. Wiley “Chip” Souba (AΩA, Alpha Omega Alpha Honor Medical Society is pleased to University of Texas Medical School at Houston, 1978) joined announce the election of its new officers and directors for the Board as a Member at Large in 2013. He is taking over the 2015/2016 year. the role of Secretary-Treasurer from Dr. Stubbs. Dr. Souba has most recently served as Vice-President for Health Affairs Officers and Dean of the Geisel School of Medicine at Dartmouth, President—Dr. Robert G. Atnip (AΩA, University of where he maintains a faculty appointment as Professor in the Alabama at Birmingham School of Medicine, 1976) be- Department of Surgery. He is nationally known for his inno- gins his term as President of the Board. He has served on vative approaches to developing leaders and leadership. His the Board since 2006, first as a Councilor Director and specialty is surgical oncology. most recently as a Member at Large. Dr. Atnip has been the Councilor at the Eta Pennsylvania Chapter at the Directors Pennsylvania State University Milton S. Hershey Medical Councilor Director—Dr. Regina Gandour-Edwards Center since 2002 and is Professor of Surgery and Radiology. (AΩA, University of California, Davis, 1984) is joining He is American Board of Surgery certified in surgery, vascu- the Board as a Councilor Director. She has served as the lar surgery, and surgical critical care. He specializes in vascu- Councilor for the Eta California Chapter at University of lar surgery, vascular ultrasound, wound care, and hyperbaric California, Davis since 2011. Dr. Gandour-Edwards be- medicine. gan her career as a public health nurse with a BSN from Georgetown University. She received an MS in Nursing from Immediate Past President—Dr. Douglas S. Paauw the University of California, San Francisco (UCSF), and a (AΩA, University of Michigan, 1983) completed his term MHS from the University of California, Davis (UC Davis), as the President of the Board with this year’s meeting. He and taught community nursing at California State University joined the Board in 2005 as a Councilor Director for the Hayward (now Cal State East Bay). She was a family nurse University of Washington. Dr. Paauw has been Councilor practitioner, which inspired her to become a physician. at the Alpha Washington Chapter at the University of She graduated from UC Davis School of Medicine in 1985, Washington since 1992. He is Director of Medicine Student and continued at UC Davis for her residency training in Programs, Professor of Medicine, and the Rathmann Family Anatomic and Clinical Pathology. She has been a faculty Foundation Endowed Chair in Patient-Centered Clinical member, educator, and active chapter member since 1990. Education. Dr. Paauw has received many teaching awards, She is currently the Vice Chair of Education at the UC Davis including the AΩA Robert J. Glaser Distinguished Teacher Department of Pathology and Laboratory Medicine. She Award in 2001. Dr. Paauw is also co-chair on the AΩA pro- is leader of the Cancer Center Biorepository and Clinical fessionalism committee. His specialty is internal medicine. Laboratory Director for the Jackson Laboratories. Her spe- cialty is surgical pathology. President-Elect—Dr. Joseph W. Stubbs (AΩA, Emory University, 1978) joined the Board in 2008 as a Member Student Director—Second Lieutenant Jeremy Bolin at Large. From 2011 to 2015 he served as AΩA’s Secretar y- (AΩA, Uniformed Services University, 2015) is joining the Treasurer. Dr. Stubbs is in private practice in Albany, Board as a Student Director. Mr. Bolin is beginning his final Georgia. He is past president of the American College of year at the Uniformed Services University and serves as the Physicians (2009–2010), and currently the medical director President of his chapter. He hopes to match into a general of South Georgia Accountable Care Organization. His spe- surgery residency program later this year. He served over cialty is internal medicine/geriatrics. nine years as an active duty Air Force engineering officer with a background in mechanical engineering. He is married and has a son.
64 The Pharos/Winter 2016 We map the enemy’s location with as much foresight and planning as a general going into battle; but this is a civil war against cells that have become too aggressive and are trying to stage a coup. There will be a three-phase attack. First by land, with the scalpel leading the charge and swiftly removing the intruders’ command station in one fell swoop with a border of safety around the target. Next by air, we send invisible radioactive bombs aimed directly at ground zero for a month straight. No reprieve or rest for those combatants who have infiltrated the area. Finally through the sea of veins, receptor-seeking chemicals find the invading cells even if they have scattered and tried to camouflage themselves in distant locations. All this conflict will unfortunately not be without collateral damage; however, the means will be justified when, at the end of this five-year war, there is a survivor standing strong.
Danielle Wallace
Ms. Wallace (AΩA, SUNY Upstate Medical University, 2015) is a member of the Class of 2016 at SUNY Upstate Medical University. Her address is: 241 Lafayette Road, Apartment 342, Syracuse, New York 13205. E-mail: [email protected]. Illustration by Jim M’Guinness. Pharos Art for home or office
A pictorial history of medical care
A pictorial history of medical care By artist Jim M’Guinness
Pharos Art Director Jim M’Guinness created A Pictorial History of Medical Care for The Pharos in 1973, when it was published as a black and white drawing on the Spring 1973 cover. We recently republished the art in color on the Winter 2015 cover of The Pharos, and we are now offering it in three formats for purchase.
The 18 x 24” print is available on our online store as a poster or giclee art print on fine art acid-free paper.
Poster ~ $15 Giclee art print ~ $50 Shipping and handling included Purchase at www.alphaomegaalpha.or/store
A collector’s treasure Hand Colored Limited Edition Lithographic Print Signed and numbered. (11” x 14”) Limited Edition – $400.00 (plus $15 shipping and handling)
Send check directly to Jim M’Guinness 1122 Golden Way, Los Altos, CA 94024. For more information, call (650) 967-3811. Purchase may also be made using Paypal: [email protected]