Alpha Omega Alpha Honor Medical Society Summer 2014

THE PHAROS of Alpha Omega Alpha honor medical society Summer 2014

“Be Worthy to Serve the Suffering” Alpha Omega Alpha Honor Medical Society Founded by William W. Root in 1902 Ofﬁcers and Directors at Large Editor Richard L. Byyny, MD John Tooker, MD, MBA President Philadelphia, Pennsylvania Editor Emeritus (in memoriam) Robert J. Glaser, MD C. Bruce Alexander, MD Immediate Past President Associate Editor and Helen H. Glaser, MD Birmingham, Alabama Managing Editor Douglas S. Paauw, MD (in memoriam) President-Elect Seattle, Washington Managing Editor Debbie Lancaster Joseph W. Stubbs, MD Secretary-Treasurer Art Director and Illustrator Albany, Georgia Robert G. Atnip, MD Designer Erica Aitken Hershey, Pennsylvania Eve J. Higginbotham, SM, MD Editorial Board Philadelphia, Pennsylvania Richard B. Gunderman, MD, PhD Indianapolis, Indiana Jeremiah A. Barondess, MD Faith T. Fitzgerald, MD Janice Townley Moore Sheryl Pfeil, MD New York, New York Sacramento, California Young Harris, Georgia Columbus, Ohio David A. Bennahum, MD Daniel Foster, MD Francis A. Neelon, MD Albuquerque, New Mexico Dallas, Texas Durham, North Carolina Alan G. Robinson, MD John A. Benson, Jr., MD James G. Gamble, MD, PhD William M. Rogoway, MD Los Angeles, California Portland, Oregon Stanford, California Stanford, California Wiley Souba, MD, DSc, MBA Richard Bronson, MD Dean G. Gianakos, MD Shaun V. Ruddy, MD Hanover, New Hampshire Stony Brook, New York Lynchburg, Virginia Richmond, Virginia Steven A. Wartman, MD, PhD John C.M. Brust, MD Jean D. Gray, MD Bonnie Salomon, MD Washington, DC New York, New York Halifax, Nova Scotia Charles S. Bryan, MD David B. Hellmann, MD John S. Sergent, MD Columbia, South Carolina Baltimore, Maryland Nashville, Tennessee Medical Organization Director Robert A. Chase, MD Pascal James Imperato, MD Marjorie S. Sirridge, MD Carol A. Aschenbrener, MD Stanford, California, and Brooklyn, New York Kansas City, Missouri Association of American Medical Colleges Jaffrey, New Hampshire John A. Kastor, MD Clement B. Sledge, MD Washington, DC Henry N. Claman, MD Baltimore, Maryland Marblehead, Massachussetts Denver, Colorado Henry Langhorne, MD Jan van Eys, Ph.D., MD Councilor Directors Fredric L. Coe, MD Pensacola, Florida Nashville, Tennessee Lynn M. Cleary, MD Chicago, Illinois Jenna Le, MD Abraham Verghese, MD, DSc State University of New York Upstate Medical (Hon.) Jack Coulehan, MD New York, New York University Stony Brook, New York Stanford, California Michael D. Lockshin, MD Mark J. Mendelsohn, MD Ralph Crawshaw, MD New York, New York Steven A. Wartman, MD, PhD Washington, DC University of Virginia School of Medicine Portland, Oregon Kenneth M. Ludmerer, MD Gerald Weissmann, MD Peter E. Dans, MD St. Louis, Missouri Alan G. Wasserman, MD New York, New York Baltimore, Maryland J.Joseph Marr, MD George Washington University School of David Watts, MD Lawrence L. Faltz, MD Medicine and Health Sciences Mill Valley, California Larchmont, New York Stephen J. McPhee, MD San Francisco, California Coordinator, Residency Initiatives Suzann Pershing, MD Stanford University

Student Directors www.alphaomegaalpha.org Christopher Clark, MD University of Mississippi Medical School Tonya Cramer, MD Manuscripts being prepared for The Pharos should be typed double-spaced, submitted in triplicate, and conform to the format Chicago Medical School at Rosalind Franklin outlined in the manuscript submission guidelines appearing on our website: www.alphaomegaalpha.org. They are also available University of Medicine & Science from The Pharos office. Editorial material should be sent to Richard L. Byyny, MD, Editor, The Pharos, 525 Middlefield Road, Suite Laura Tisch 130, Menlo Park, California 94025. Medical College of Wisconsin Requests for reprints of individual articles should be forwarded directly to the authors. The Pharos of Alpha Omega Alpha Honor Medical Society (ISSN 0031-7179) is published quarterly by Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, Menlo Park, California 94025, and printed by The Ovid Bell Press, Inc., Fulton, Administrative Ofﬁce Missouri 65251. Periodicals postage paid at the post office at Menlo Park, California, and at additional mailing offices. Copyright Richard L. Byyny, MD © 2014, by Alpha Omega Alpha Honor Medical Society. The contents of The Pharos can only be reproduced with the written Executive Director permission of the editor. (ISSN 0031-7179) Menlo Park, California Circulation information: The Pharos is sent to all dues-paying members of Alpha Omega Alpha at no additional cost. All correspondence relating to circulation should be directed to Ms. Debbie Lancaster, 525 Middlefield Road, Suite 130, Menlo Park, California 94025. E-mail: [email protected] Menlo Park, California 94025 Telephone: (650) 329-0291 POSTMASTER: Change service requested: Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, Fax: (650) 329-1618 Menlo Park, CA 94025. E-mail: [email protected] The Pharos • Volume 77 Number 3 • Summer 2014 In This Issue

DEPARTMENTS On the cover Editorial See page 8 2 Rethinking leadership development Wiley W. Souba, Jr., MD, ScD, MBA The physician at the movies 38 Peter E. Dans, MD Jack Ryan: Shadow Recruit The Grand Budapest Hotel Grand Hotel

Reviews and reflections Detroit Institute of Arts. Bridgeman Images 42 A Condition of Doubt: The Meaning of Hypocondria Far from the Tree: Parents, ARTICLES Children, and the Search for Identity What Matters in Medicine: Lessons The surgery panel in Diego Rivera’s from a Life in Primary Care 8 Detroit Industry Murals Eugene Braunwald and the Rise of Don K. Nakayama, MD, MBA Modern Medicine Minimally Invasive: peoms on a life in surgery Vital amines, purple smoke Scissored Moon 18 Was a Doctor A select history of vitamins and minerals Common Illness Stanley Gutiontov

2014 Helen H. Glaser Student 49 Essay Awards An obstetric story 2014 Pharos Poetry 25 J. Allan Wolf, MD, FACOG 49 Competition winners 2014 Medical Student The mysterious illness of Emma Lazarus, 50 Service Leadership Project Lady Liberty’s poet Awards 28 Robert S. Pinals, MD 56 Letters to the editor 2014 Carolyn L. Kuckein The most memorable patient I never saw 58 Student Research Fellowships 34 Arthur Lazarus, MD, MBA Changes to the Pharos 61 editorial board INSIDE BACK The Robert H. Moser Pharos Editor’s Prize COVER

POETRY Sonnet for a Last Dance 07 George Young, MD Corrections Spring 2014 issue We misspelled Dr. Owsei Temkin’s name in the article “Healing, Harming, and Hippocrates” A Guest at Communion 33 Richard Bronson, MD (pp. 20-25) on page 24. We apologize for the poor proofreading. In the introductory material to “Dennett’s Echo” (pp. 5-13) we erroneously indicated that Sharon Spaulding is the great- On the Trail granddaughter of Mary Ware Dennett. She married into the family and is working to archive the 64 Myron F. Weiner, MD materials about Dennett.

Illustration by Laura Aitken

2 The Pharos/Summer 2014 Editorial Rethinking leadership development

Wiley W. Souba, Jr., MD, ScD, MBA

Dr. Souba is Vice-President for Health values provide us with a solid founda- health care challenges is not an option. Affairs, Dean of the Geisel School of tion for leadership. The result is im- We need more effective ways of being, Medicine at Dartmouth, Professor of plementation of our new AΩA Fellow thinking, and collaborating in order to Surgery at Dartmouth, and a member in Leadership award and program that deal successfully with those challenges of the Board of Directors of Alpha provides an important opportunity for for which traditional strategies are not Omega Alpha. rethinking leadership development and enough. But exactly how we broaden our what it means to be a leader. AΩA’s leadership bandwidth is often unclear. Fellow in Leadership Award is based We’ve all experienced how difficult it Introduction on the premise that the principles of is to let go of and transcend our deep- Richard L. Byyny, MD leadership from within can be taught, rooted, familiar ways of leading. Executive Director, Alpha Omega experienced, and learned by those who Recently, the AΩA Board of Alpha aspire to become great leaders. Directors introduced the AΩA Fellow in eadership has long been a core I asked Dr. Wiley Souba, an experi- Leadership Award as a testament to their value of Alpha Omega Alpha Honor enced leader and teacher in medicine, continued commitment to developing MedicalL Society (AΩA). New and ef- medical education, and health care—and leaders in medicine. Because health care fective leaders in medicine, health care, a member of the AΩA board of direc- transformation efforts are often unsuc- and medical education are vital to our tors—to write the editorial for this issue cessful because they overlook the im- profession to serve patients and society. of The Pharos. His editorial, “Rethinking portance of personal transformation, the We asked the question: How can AΩA leadership development” is informative fellowship emphasizes the inner work as an interdisciplinary honor medical and provocative. of leading oneself. Fellows learn what society best support and contribute to it is to be a leader and what it means to leadership promotion and development exercise leadership effectively by making as part of our mission and as one of our Rethinking Leadership use of a model that distinguishes being a core values—to improve care for all by Development leader as the foundation for the leader’s encouraging the development of leaders Wiley W. Souba, MD, DSc, MBA actions. Why is the being of leadership in medicine, academia, community, and anagement consultant and author foundationally primary? An illustration society? Peter Drucker once said that “the is helpful. We recognize that leadership in med- greatestM danger in times of turbulence Suppose I were to ask you, “What icine, medical education, and health care is not the turbulence; it is to act with is an Accountable Care Organization is more complex in the twenty-first cen- yesterday’s logic.” 1 Yet, the past is what (ACO)?” You answer, “An ACO is a tury than ever before. We also believe we know and it is what we draw on health care organization with a pay- that physicians’ unique knowledge and when making judgments and choices. ment and care delivery model that aligns expertise in medicine and our under- Most people, however, would argue that provider reimbursements with quality standing of medicine’s core professional using yesterday’s logic to solve todays’ metrics and cost savings for a given

The Pharos/Summer 2014 3 Rethinking leadership development

population of patients.” Your answer in reference to what it means to exist in you could handle them effectively? In provides me with characteristics that various ways as a leader, such as being other words, the “you” that showed up describe and identify the entity. Suppose dedicated or focused. Again, meaning was you in your “A” game. Suppose you I then ask, “What does it mean to be a always precedes entity. weren’t limited to those automatic, inef- patient in a (high-performing) ACO?” Much as understanding what it fective ways of being that tend to hijack In response, you say, “To be a patient in means to be a patient will tell us what your amygdala? What would it be like to an ACO means to be provided with reli- is essential in building a health care be at the top of your game, leading from able access to care, support for activities system, what it means to be a leader your natural self-expression rather than and behavior changes to improve health, should be the basis for the way in which from some anthology of theories in the trustworthy information to help make we educate and train leaders. If I under- latest bestseller on leadership? What if treatment decisions, and better health stand what it means to be a leader, I will that “inner critic” that was always there outcomes.” The first question, “What know what is required to develop lead- judging you wasn’t there? What if you is an ACO?” is answered with refer- ers. In other words, what it means to be had access to a much wider range of ence to other entities such as providers, a leader is prior to what kind of entity a possible ways of being rather than being payment models, quality metrics, cost leader is. confined to those default ways of being reductions, and populations. The second What we discover with a bit more that have become so entrenched yet are question is answered with regards to scrutiny is that we are not preparing so unproductive? what it means to “be” (exist) in an ACO leaders in keeping with what it is to be Our effectiveness as leaders is first in various ways, such as being engaged, a leader. Most leadership development and foremost a product of our way of secure, informed, and healthier. In con- programs focus on knowing (expertise), being, which is a function of the way in trast to the first question, the question having (power, resources), and doing which the circumstances we are dealing of the meaning of anything is always an- (competing), not “being” a leader. Yet, if with occur for us.3,5 From a neuroscience swered in reference to other meanings. you’re not being a leader, it is impossible perspective, what we mean by occur cor- If we now ask which question comes to act like a leader.3 An emerging ap- responds to that which is generated by first, it should be clear that what it means proach to leadership development starts the particular activated neural networks to be a patient in an ACO is the basis for with four pillars of being a leader— in the brain that produce the experien- the ACO being designed the way it is awareness, commitment, integrity, and tial perceptions—via our senses—that (or at least it should be). In other words, authenticity—as the ontological founda- are projected into the external world. what it means to be a patient in an ACO tion for what leaders know and do.4 This Unless and until we shift the way in is prior to what kind of “thing” an ACO way of understanding leadership is core which our leadership challenges occur is. If I understand what it means to be a to the basic tenets of professionalism.4,5 (“show up”) for us—from a problem that patient in an ACO, I will know what is Our understanding of what it means is someone else’s to one that we’re all required to make an ACO. The inquiry to be—a physician, a medical student, responsible for—our predictable ways of into what it means to be a patient in a researcher, a leader—is changing. being and acting will prevail and the fu- an ACO is not only different from the Accordingly, the institutions that are re- ture will largely be a continuation of the question about what kind of thing is an sponsible for preparing these individuals past. Health care costs will continue to ACO, it is also prior to it, for the mean- to be effective in an everchanging health escalate, unwarranted variations in care ing ultimately explains the entity.2 care environment must change. Medical will persist, and tens of millions of our Suppose I now ask, “What is a schools are revising their curricula to fellow human beings will have little re- leader?” You answer, “A leader is a per- include population health, new payment course. The response, “If the uninsured son who has a title and authority, knows models, and value-based care in order would just pull themselves up by their strategy, allocates resources, and gets re- to prepare physicians to practice in the bootstraps like I did,” is both ignorant sults.” Your answer to my question pro- twenty-first century. And they are start- and arrogant. Yet, this perspective con- vides me with attributes and roles that ing to take a stronger stand on develop- tinues to be pervasive. Oddly, the pano- describe or identify a leader. Suppose ing leaders. ply of pompous solutions to our health I then ask, “What does it mean to be a care predicament—change this, change leader?” In response, you say, “To be a Imagine that, get rid of this, get rid of that—tend leader is to be self-aware, honest, au- Each of us has had the unnerving to exclude a fundamental imperative: “I thentic, fair, and committed.” The first experience of being confronted with a need to change too.” question, “What is a leader?” is answered leadership challenge and not knowing in reference to other entities such as how to deal with it. Imagine for a mo- Accessing leadership followers, a strategic plan, and a posi- ment what it would be like if, regardless The word “access” refers to making tion. The second question is answered of the problems you were faced with, something available so as to use it, apply

4 The Pharos/Summer 2014 it, or take advantage of it (e.g., a data- third-person observations about leader- game of leadership is played. base, the internet, the medical record). ship behaviors and their neural pro- I have been belaboring the point The idea that leadership is something cesses, second-person experiences and about accessing being a leader and lead- we access may seem counterintuitive their social correlates, and first-person ership for three reasons. First, direct as we generally think of leadership as subjective conscious experiences. In the access is not as simple as it might seem. something that people just have (or don’t meantime the only direct access we have A rigorous examination of the structure have). However, when we recognize that to what it is to be a leader is by way of of our conscious leadership experiences leadership is about expanding our range the first person “as lived” experience. entails a careful phenomenological ob- of ways of being, thinking and behaving Consider this somewhat ludicrous servation. This takes practice because so we can be more effective in dealing example. You and I have no direct access our taken-for-granted beliefs and as- with those challenges for which con- to what it means to be a gallbladder. We sumptions invariably get in the way. In ventional strategies are inadequate, the can only measure (third-person) what order to gain access to more effective notion of access makes more sense.3 a gallbladder does and then describe ways of leading, we must first expose Without the ability to access new ways of its properties and functions (stores, our engrained beliefs and worldviews being, reasoning, and working together, concentrates, and secretes bile). But about leadership (e.g., I have to have the we will default to what is comfortable these properties give us no direct (first- answers) that are holding us back. This when we are called to take on a major person) access to what it means to be a will allow us to relax those limiting (and leadership challenge and our results will gallbladder. Moreover, when someone often hidden) ways of being and acting be mediocre at best. explains to you how to remove a gall- that have become our automatic go-to Access to leadership can occur bladder, their third-person account gives winning formulas (e.g., avoiding tough through first-person, second-person, you no direct access to performing the conversations, blaming others) that ac- and third-person inquiries, each of surgical procedure. You may memorize tually constrain our freedom to lead.3 which provides a different, but comple- the atlas on gallbladder surgery and even Second, in accessing leadership it is mentary perspective. Observing leaders watch a video on cholecystectomy, but important to recognize that you and I do and describing their behaviors and attri- until you experience for yourself what it not lead from a theoretical standpoint; butes is about objectivity (third-person is to be in the operating room with a lap- we live moment-to-moment, situation- data). This third-person approach to aroscope in your hands, what it’s like to to-situation in the way we experience studying leadership, which focuses on dissect the gallbladder off the liver, and leadership “as lived,” that is, from a first- what leaders know, have, and do is, by what it is to perform an intraoperative person point of view. Third, the primary far and away, the most common leader- cholangiogram, you will never master tool we use to gain access to leadership ship pedagogy. Leadership education laparoscopic cholecystectomy. is language. In other words, language that is based largely on concepts and Similarly, you may keep a list of the (discourse) is the vehicle in and through explanations—where the subject has characteristics and attributes of leaders which we access the world. It functions indirect, inferential access—provides in your pocket, but this gives you no as a kind of lens that brings our leader- limited access to the being and actions direct access to what it means to be a ship challenges into sharper focus, al- of an effective leadership.4 Theories and leader. You do, however, have direct ac- lowing us to see details and “make sense” textbooks provide us with third-person cess to what it is to be human. It’s the more perceptively. Language does not access to leadership, but they alone do only entity to which you have direct ac- merely reflect reality; as a constitutive not impart what is required to be a cess. And through accessing what it is to element it has the power to shape, even leader, much as textbooks do not teach be human—who you really are—you can create, how we represent reality. Thus, what it is to be a physician. access what it is to be a leader. Likewise, the transformative power of language re- Rather than teaching leadership when someone describes leadership to sides in its ability to create new futures. from a theoretical (third-person) van- you, their explanation gives you no di- tage point, the ontological (first-person) rect access to leadership. You may be A new language of leadership perspective teaches leadership as it is able to recite all the leadership books, We all know people who excel, almost lived and experienced. Such subjective but until you experience for yourself without effort, in their particular disci- experiences (first-person data) cannot firsthand what it is to deal with a com- plines. They take on difficult problems be described entirely by objective reality. plex leadership challenge and what it is with grace and ease. We often believe When one exercises leadership “as lived,” to confront your fears and inadequacies that these individuals are born with a concurrently informed by theories, one in dealing with it, you will never be a special gift or a distinctive temperament performs at one’s best. A science of master leader. You can’t lead effectively that allows them to deal with complex leadership will eventually generate a from the stands as a third-person spec- issues more effectively than the rest of framework that systematically integrates tator. You must be on the ice where the us. Actually, what allows such people to

The Pharos/Summer 2014 5 Rethinking leadership development

be so effective is that they have mastered extraordinary in any domain is mastery day, to become the wiser, more effective the conversational domain necessary to of the unique conversational domain leaders that we must become.5 perform exceptionally in their particular that gives one access to that domain.5 Curiously, our enhanced leadership field of interest.3 This mastery allows Conversational domains, once mas- effectiveness won’t be, first and fore- them to interpret and tackle problems in tered, grant considerable power. Experts most, because we acquired another tech- a unique manner. could not create new knowledge without nical skill—rather, it will be because the By conversational domain, we having mastered their domains’ language perspective from which we operate has mean—for example, in the case of medi- because the specialized language is what changed.6 A different “you” will show up. cine—the network of discipline-related gives them actionable access. Medical What is transformed is not us per se but terms that form the special linguistic school and residency are “first-person the way in which we interact with what- domain through which a physician per- as-lived” experiences that are intended ever we are dealing with. Said somewhat ceives, comprehends, and interacts with to teach physicians to become masters of differently, the ensuing improvement in her patient’s body, history, illness, and the conversational domain of medicine. effectiveness is less the result of having suffering.5 This specific conversational Conversational domains can overlap grasped some new theory and more a domain is required to be a master physi- and frequently do. The field of bioinfor- function of having altered the context cian and to practice medicine expertly. matics was born when the intersection through which we “see” our leadership Mastery of the conversational domain between computer science and biol- challenges. This incredible capacity—to particular to any discipline—biomedical ogy was harnessed. Over the past few go beyond our ordinary selves to unleash informatics, astrophysics, population decades, the conversational domain of our best selves—is unique to human health, etc.—is essential if one is to ef- bioinformatics has become more sophis- beings and is only possible because we fectively perform, communicate, and ticated as researchers have developed are not determinable by a what, like an innovate in that domain. To participate a shared language that functions as a entity, but by a who that is shaped by our successfully in a conversational domain kind of lens that grants better actionable choices over time. (discourse community), the interlocu- access to the world of bioinformatics. tors must be familiar with both the im- This improved access, which enables References plicit and explicit “rules” about how its new linguistic distinctions that further 1. Palus C, Horth D. The Leader’s terms are communicated. A key goal advance the field, is the result of a more Edge: Six Creative Competencies for Navi- of higher education should be to help refined set of specialized terms that are gating Complex Challenges. New York: John students master the spoken and written linked together to create the discourse Wiley and Sons; 2002. language of their disciplines. community. This process of mastering 2. Gelven M. A Commentary on Hei- A bioinformaticist, for example, be- a conversational domain such that it degger’s Being and Time. Dekalb (IL): comes a master by mastering the con- “uses” the master by providing a context Northern Illinois University Press; 1989. versational domain of bioinformatics. (a way of perceiving, interpreting, and 3. Souba W. The science of leading Mastery allows her to observe, inter- relating to the corresponding knowledge yourself: A missing piece in the healthcare pret, understand, and interact with the domain) is key to performance and in- reform puzzle. Open J Leadership 2013; 2 world of bioinformatics through a set of novation whether one is a geneticist, a (3): 45–55. Available at https://geiselmed. specialized terms (for example, compu- plumber, or a physician. dartmouth.edu/who_we_are/creating_lead- tational biology, genomics, proteomics, Because many of the changes that ers/science_of_leading_yourself.pdf. deconvolution, relational database) that are taking place in health care are in- 4. Souba W. The being of leadership. are networked together in a specific evitable, mastering context as a leader Philos Ethics Humanit Med 2011; 6 (5). way to form the linguistic domain of is critical. Content (the particular situa- Available at http://www.ncbi.nlm.nih.gov/ the world of bioinformatics. Similarly, tion at hand) is always observed within a pmc/articles/PMC3050817/. a population health scientist becomes a linguistic context and, as human beings, 5. Souba W. A new model of leadership master by observing, interpreting, and we have the freedom to recontextualize performance in health care. Acad Med 2011; interacting with the world of population our leadership challenges by shifting the 86: 1241–52. health by means of a set of specialized context. In so doing, we can be a differ- 6. Souba W. Health care transformation terms (for instance, outcomes, dispari- ent kind of leader. When we change our begins with you. Acad Med (in press). ties, determinants, risk factors, health thinking and speaking, a different reality production function) that are networked becomes available to us. Shifts in our The author’s address is: together in a certain way to form the dis- mental maps generate new possibilities Geisel School of Medicine course community of population health for actions and outcomes not previously 1 Rope Ferry for a master population health scien- accessible. Only by means of language Hanover, New Hampshire 03755 tist. In other words, the source of being can we lead ourselves, each and every E-mail: [email protected]

6 The Pharos/Summer 2014 Sonnet for a Last Dance

T he retired judge, a widower and avid barbershop tenor, dutifully came once a month to sing with the twenty-odd ladies of the Alzheimer’s ward. But only a few ever joined in. The rest just sat, chin on chest, slumped in their wheelchairs. Until one day he said: Let’s all sing the Anniversary Waltz. Then one head did look up. One who had not moved before, stood and slowly walked towards him, arms outstretched. He grasped the cold bony fingers in his hands and began to waltz around and around; and, although this never happened again, when they were done, the mouthed words came: I love you. George Young, MD

Dr. Young (AΩA, University of Southern California, 1963) is retired from the Boulder Medical Center. His address is: 2315 Hawthorn Avenue, Boulder, Colorado 80304. E-mail: [email protected]. Illustration by Jim M’Guinness.

The Pharos/Summer 2014 7 >

The surgery panel in Diego Rivera’s Detroit Industry Murals The surgery panel in Diego Rivera’s Detroit Industry Murals The surgery panel in Diego Rivera’s Detroit Industry Murals

The Surgery Panel. The surgeon performs an orchiectomy at center. The blood-stained drapes form a mound that is both a volcano and a pyramid, images seen at the top registers of the south and north walls of the courtyard. Arrays of organs surround the surgeon’s hands: base of brain with pituitary in center; digestive organs and endocrine glands to the left; male and female reproductive structures and breast to the right. Note the duodenum to the left; a pipe in the assembly line has the same configuration. Juxtaposition of female and male reproductive organs reflects the androgyny of the titans on the top registers of both walls. The wave motif signifies energy and is the dominating pattern in the middle register of both walls. Grey ropy material resembling semen flows from the left to form crystals on the right. Detroit Institute of Arts. Gift of Edsel B. Ford. Bridgeman Images.

Don K. Nakayama, MD, MBA The author (AΩA, University of California, San Francisco, operation, because to his or her eye, it is an orchiectomy. Not 1978) is professor and chair of the Department of Surgery at the usual images in public art. West Virginia University School of Medicine. Why did Rivera include them in his work, the one that he considered his greatest effort?1 There are no direct quotes from asily overlooked, high in the upper left corner of the Rivera on the reasons for his choice of organs and operation. south wall of Diego Rivera’s (1886–1957) monumen- Some suggest that because the overall composition celebrates tal Detroit Industry Murals (1932–1933) at the Detroit all Detroit industries and not just automobile production, the EInstitute of Art, is a pair of bloodied surgeon’s hands at op- panel represents medicine as one of the modern activities for eration, one of the smallest panels of the twenty-seven in the which the region was noted.2 Misidentification of the operation composition. To each side are human organs, some whole as and some of the organs by Rivera scholars makes answering the animal organs are displayed and sold at a Mexican mercado, question more difficult. Understanding Rivera the artist and others in cross section as they appear in anatomy texts. They his overall vision for the work reveals the surgery panel as the are small, soft, and delicate amid the industrial machinery, allegorical assembly of a human worker, both male and female, gigantic symbolic figures, and the subterranean hive of human from human parts, the central orchiectomy being the life-giving labor that surround a visitor to the museum’s central court. and death-demanding Aztec act of human sacrifice. Close observation is necessary to discern the identity of each Four books are the basis for most of the discussion that organ and surgical details because of the height of the painting follows. Linda Bank Downs’s study, Diego Rivera: The Detroit above the courtyard. Most are glands; also present are a histo- Industry Murals,1 is the definitive review of the murals, their logical section of the small intestine; the posterior anatomy of execution, the industrial machinery and persons featured, the lower male urinary tract with prostate, seminal vesicles, and and the iconography represented. She uses Rivera’s notes, bladder; a fallopian tube and ovary; and a female breast partially correspondence, and interviews related to the work, much of cut away to reveal the lactiferous ducts. A surgeon, particularly which are available for review in the museum library. Dorothy a urologist, may be among a small handful of museum visitors McMeekin’s monograph, Diego Rivera, Science and Creativity to look beyond the graphic bloody sponges and drapes of the in the Detroit Murals,3 focuses on the scientific images in the

10 The Pharos/Summer 2014 work. She gives a detailed discussion of the surgery panel, but Valentiner, museum director, awarded forty-six-year-old Rivera misidentifies some of the organs and states that the operation a commission to decorate the large areas of the north and south is a craniotomy for a brain tumor. Patrick Marnham’s biogra- walls of the inner garden court of the museum with mural art, a phy of Rivera, Dreaming with His Eyes Open, traces his artistic medium for which the artist had become world famous. Despite development as master muralist.4 The author links important his Communist political beliefs Rivera became fascinated by the personal events that occurred during Rivera’s stay in Detroit, power of American industry and the factories and skyscrapers specifically the miscarriage of Frida Kahlo, his wife. Diego that were its monuments. He later wrote, “In all the construc- Rivera, the Complete Murals, edited by Luis-Martin Lozano and tions of man’s past—pyramids, Roman roads and aqueducts, Juan Rafael Coronel Rivera, is a chronological compendium of cathedrals, and palaces—there is nothing to equal these.” 1p27 He all of Rivera’s murals with history and commentary.5 Weighing was so inspired by the Detroit offer that he proposed a compo- nearly twenty pounds it probably is best viewed in a library. sition to include nearly all the paintable surface in the museum The Detroit Institute of Arts website displays the murals of the courtyard. In response Ford convinced museum philanthropists Diego Court, including the surgery panel and other detailed to raise the grant from the initial figure of 10,000 to 20,889, a close-ups.6 princely sum at the height of the Depression.1 The subject would be Detroit industry, the major theme the Background manufacture of automobiles. The Ford Motor Company Rouge In 1932 Edsel Ford, scion of the Henry Ford family and prin- Plant on the banks of the Rouge River was the largest industrial cipal benefactor of the Detroit Institute of Arts, and William complex in the world at the time, an immense operation that

Diego Rivera painting the East Wall of Detroit Industry. Detroit Institute of Arts, USA. Bridgeman Images

The Pharos/Summer 2014 11 The surgery panel in Diego Rivera’s Detroit Industry Murals

North wall of a mural depicting Detroit Industry, 1932-33 (fresco). Diego Rivera (1886-1957) Detroit Institute of Arts. Gift of Edsel B. Ford. Bridgeman Images.

he top register of the North wall of Rivera Court machines. Vaccination is in the small panel at top Thas a volcano at center, hands thrusting from right, controversial because of its secular depiction the earth holding raw ore. The Native American titan of the holy family, the kidnapped Lindbergh baby as to the left holds red iron ore; the African American, Jesus, Jean Harlow as Mary, the physician as Joseph, coal. Crystals of red hematite form in the midst of and scientists as the three wise men. Healthy Human red waves of the mineral, while coal, containing fossil Embryo is the small middle panel to the right, Cells animals, becomes diamonds. Beneath the volcano Suffocated by Poisonous Gas is beneath the poison is the blast furnace, energy flowing first rightward, gas workers in the small middle panel to the left. The then to human figures going clockwise. Human faces predella shows workers in line to clock in for their turn cadaveric green in the segment at middle left. shifts at left, then show a number of factory activities Assembly line is between the two rows of white as images progress to the right, ending in a lunch break at far right.

12 The Pharos/Summer 2014 included producing steel from blast furnaces, claimed that he had eaten the flesh of cadavers in the com- smelting iron ore and coke, manufacturing pany of friends who were medical students with access to the tires from raw rubber, and generating its own morgue.4 power. Rivera and his assistants travelled the Early in his career, while perfecting his artistry in Europe, Detroit area widely and were given full access Rivera visited the operating theatre of Jean-Luis Faure, a sur- to the vast plant and other industries in the geon and brother of Rivera’s mentor, art historian, art dealer, area.1 Downs notes that the artist was deeply and physician Élie Faure. Jean-Luis Faure had a powerful influ- impressed: ence on the artist, inspiring his politics and convincing him to study fresco painting in Italy, which would become his most [The Ford Rouge Plant’s] sheer energy, famous medium. Faure held that surgery was important in power, and magnitude made him associate it understanding art: with the vast archeological sites in Mexico, and the individual industrial processes be- It was while I was watching a surgical operation that I uncov- came analogous to religious rituals.1p165 ered the secret of “composition” which confers nobility on any group where it is present. . . . The group formed by the Ford the industrialist and Rivera the un- surgeon, the patient, his assistants and the onlookers seemed apologetic Marxist shared a deep appreciation to me to form a single organism in action. . . . It was the event of the spectacle of industrial power: itself which governed every dimension and every aspect of the group, the position of arms, hands, shoulders, heads, none Henry Ford conceived of his automobile in- of which could be [altered] without breaking the harmony dustry as having power, breadth, and scope and rhythm of the group immediately. Even the direction of that went beyond the human scale of man- the light was arranged so that each of the actors could see agement, labor, and machines to take on a what he had to do.4p145 universal life of its own. Rivera instinctively understood this and compared it to Aztec There is no doubt that Rivera absorbed Faure’s message. He cosmological beliefs.1p67 included a scene of Jean-Luis Faure operating in his 1925 mural in the Mexican Ministry of Public Education.8 In the Detroit The entire work, twenty-seven panels and murals he began to populate his work with realistic medical im- some 434 square meters of surface, took more ages. Later he would compose entire works devoted to medical than seven months to complete, with Rivera science (Water the Source of Life, 1942–1957), physicians (The sometimes working twenty-hour days. Its im- History of Cardiology, 1943–1954), and clinical practice (The agery attests to the mysticism behind his hom- History of Medicine in Mexico: The People’s Demand for Better age to the power of American industry to work Health, 1953–1954). raw materials from the earth to mass-produce autos, airplanes, and weapons.1 Labor as human sacrifice But in the midst of blast furnaces, convey- Rivera identified closely with labor and industrial workers. ors, steel presses, and turbine generators how Four human figures—Rivera called them titans—dominate the did a surgical operation come to be included in the bravura top panels of the main south and north walls. They embody composition? human labor as a primary source of industrial power. Each represents a human race: Caucasian and Asian atop the south Medical imagery wall; Native American and Black on the north. Both Downs and The human body fascinated Rivera. He and his wife Frida McMeekins note the androgyny of the figures,1,3 Rivera’s per- Kahlo kept their Detroit apartment amply supplied with medi- sonification of male and female workers. Massive human hands cal texts and illustrated books that provided illustrative material thrust from the earth, minerals in each clenched fist, the human for both.1 Kahlo had both studied and personally experienced energy required to mine raw ore from the earth.1 medicine. She had completed premedical studies before a Real human figures in the hive of industrial activity below horrific streetcar accident at age eighteen caused injuries that the idealized figures, however, show industry’s destructive side. would blight the rest of her life, require more than thirty opera- In contrast to the bright yellow-white heat of the furnace, the tions, and lead to her early death.7 She took up painting during human faces are pale and wan and fade in a grotesque transition the enforced months-long bed rest after the initial reparative to a cadaveric green, their life energy drained. While they have operations following the accident, famously self-portraits, many recognizable racial and ethnic features, all share a grim visage alluding to her painful surgical treatments. Rivera’s experience reflecting the physical exertion and monotony of assembly line was more indirect, typically flamboyant, and apocryphal. He work. The predella beneath the main panels on the north and

The Pharos/Summer 2014 13 The surgery panel in Diego Rivera’s Detroit Industry Murals

south walls depicts a day in the life of a worker. In shades of field. The mound of bloody surgical sponges and drapes be- grey to mimic bas-relief, the workers remain featureless from comes an Aztec pyramid, the scene of human sacrifice. The the point at which they arrive to work bundled in hats and coats panel occupies the same wall as the dark, brooding pyramid and on the far left of the north wall to where they return to cars at the industrialized image of the bloodthirsty goddess Coatlicue, day’s end, bent from fatigue, at the far right of the south wall. the creator and destroyer. Thus modern industry drains human energy, a contempo- The surgeon becomes a modern-day Aztec priest remov- rary form of human sacrifice. The dominant image of the au- ing a testis, the gland that in Rivera’s male eyes at least, is both tomotive panel of the south wall is a giant industrial press that life-giving and the seat of masculine energy, the sacrifice made stamps three-dimensional auto bodies from sheets of steel in in the name of industrialism. The surgeon’s right hand holds the form of the terrible Aztec goddess Coatlicue, both life-giv- an ovoid organ, the opposite hand providing counter-traction. ing and life-destroying, who demanded human sacrifice. It has McMeekin, in her monograph addressing the science depicted an appropriate position beneath in the murals, mistakes the operation as an Aztec pyramid, dark and in sil- brain surgery (the right hand holding a houette, at the center of the top brain tumor), and the figure at top center register of the wall.1 Downs notes: an open skull showing the tumor.3 A photo of Rivera at work on the surgery panel Rivera’s understanding of ancient from a line drawing clearly shows the ovoid religious concepts included the testicular shape in the surgeon’s hand, the idea of a compact between Aztec opposite hand providing counter-traction Indians and their gods. Humans to stretch the spermatic cord.2 were created by the sacrifice of the Misidentification thus misses the sig- gods and therefore humanity must nificance of the organ: the seat of masculine reciprocate by sacrificing lives in energy, the human raw material of industry. order to nourish the gods with hu- When painting the Detroit murals, Rivera man hearts and blood. Just as the Aztecs were human fodder for the sun, Rivera drew the analogy to the factory workers who sacrifice their energy for the technological universe.1p166

Rivera embraced human sacrifice as his Aztec heritage. His epic Visions of the History of Mexico (1929–1935) on the walls of central staircase of the Palacio Nacional has at its exact center an Aztec priest holding a human heart aloft, the victim in a bloody white shroud, a brutal image of the country’s Aztec heritage and the blood sacrifice Mexicans paid throughout its history.9 Each of the pyramids in his later mural The Great City of Tenochtitlan (1942–1953), also at the Palacio Nacional, has bloodstained steps from the temple at its apex.5p445–48 So where is human sacrifice in the Detroit murals?

Pyramid and volcano The central image in the Surgery Panel is the operative

Above, detail from the South wall. The giant machine is a steel press used to make three-dimensional panels from steel plates. It is the industrial representation of Coatlicue, Aztec goddess of life, death, and rebirth (left). Rivera used an older version of the press that had not been in use because it more closely resembled the carved image. Right, Coatlicue, the Earth Mother, creator of man and goddess of life and death. Werner Forman Archive. Bridgeman Images was at the height of his artistic powers and had left dozens of sexual exploits (a nude Helen Wills Moody, a Rivera inamo- lovers in his wake. He likely viewed castration viscerally as an rata, stretches across the ceiling in his San Francisco mural at unthinkable act, a sacrifice of a part of himself that energized the Pacific Stock Exchange),10 Rivera might be showing more both his personal and artistic life. Removal of a testis would be restraint and less explicit imagery for his Detroit benefactors. the modern equivalent to the Aztec ritual removal of the heart. The mound of white sponges with its bloody crater-like cen- An assembly line—for a worker ter also becomes a white-sloped volcano with red lava flowing To the left of the surgeon are the digestive organs and from its summit. It thus recalls the volcano atop the furnace endocrine glands that provide human energy. McMeekin of the opposite north wall, and the iconic geologic landmarks misidentifies several organs, missing altogether the pituitary, of the Aztec capital, the snow-capped volcanoes Popocatépetl thyroid, adrenal, and thymus. No doubt dependent on her and Iztaccíhuatl. It is an image Rivera used before in the human medical sources she sees a gall bladder where there isn’t one, sacrifice scene in his mural at the Palacio National. The white says that the segment of duodenum attached to the pancreas shroud covering the victim and the bloody rent in its side is to be partially obstructed small bowel (it isn’t), and identifies peaked, taking the form of a snow-covered Popocatépetl with one of the organs as “an intussusception” (not so).3 By wrongly lava flowing from its summit.8 including pathological conditions she misses one interpretation of the array of organs to each side of the surgeon; it is an as- Energy sembly line for the formation of a human worker. Beneath the Flowing toward and away from the operative field in a broad furnace on the north wall is an assembly line of parts hanging “V” are broad waves in light grey, viscous and amorphous on the from a conveyor in the same broad “V” as the organs on each left, then coalescing into crystals toward the right. It recapitu- side of the surgeon. Some parts on the conveyor to the left are lates the strata motif in the middle registers of the main north bent pipes with open mouths on each side, one in a “C” shape and south walls. The waves signify the energy locked within in the same orientation as the duodenum, pancreatic head inanimate raw materials. Downs suggests that Rivera would seated in place, both ends open. The surgeon, then, might well have known the early twentieth-century writings and beliefs be placing organs into a living being rather than removing one, of theosophists Annie Besant and Walter Russell, who became becoming the life-giving embodiment of Coatlicue. president of the Artists’ League of New York in the early 1930s. They proposed that the recent discovery of the wave properties of light explained the movement of energy on earth in the form of waves.1 Downs quotes Rivera biographer Bertram Wolfe:

Rivera had always been intrigued by the image of the wave. Increasingly it had been implicit in his painting. . . . Now he set out to paint the wave explicitly, the wave that runs through electrons, mountains, water, wind, life, death, the seasons, sound, light, that does not cease to undulate in the dead, nor in things that never lived.1p107

Understanding the image to signify human energy and recalling Rivera’s appetite for sex, the ropy material on the left resembles semen, which one could imagine Rivera’s personal image of germinal energy. Never before shy in his personal

Detail from the north wall. Workers in assembly line work. Each has distinct facial features and identifiable racial and ethnic features, the human counterparts to giant figures above. The con- veyors form a “V,” the wave motif in the left conveyor, assembly parts displayed to each side. Pipes fashioned in a “C” resemble the duodenum in the surgical panel. Both occupy the same position on the left arm of the “V.” Detroit Institute of Arts. Gift of Edsel B. Ford. Bridgeman Images.

The Pharos/Summer 2014 15 The surgery panel in Diego Rivera’s Detroit Industry Murals

Henry Ford Hospital, 1932. Frida Kahlo (1907-1954). Fundación Dolores Olmedo, Mexico DF, Mexico. © Gianni Dagli Orti/The Art Archive at Art Resource, NY.

To the right of the operation are male and female sexual Frida Kahlo’s medical art in Detroit glands and female breast that are the basis of reproduction and Rivera was not the only artist producing memorable medi- infant nurturing (each of which McMeekin correctly names). cal artwork in Detroit. Frida Kahlo painted some of her most This begins several scenes in the composition that shows the famous masterpieces during their stay in Detroit. In 1932 while genesis, nurturing, and destruction of humans: a human em- he was painting what he considered his finest work, his wife bryo (Healthy Human Embryo panel, upper right corner of the was enduring a miscarriage and the news of her mother’s death north wall), a fetus gestating in the embrace of the roots of a more than 2,000 miles away in Mexico City. Three of her works plant (Infant in the Bulb of a Plant, center of the east wall), two that year, the lithograph Frida and the Abortion (1932) and two women (in Downs’s words, “exuding fecundity” 1p74) holding paintings on metal, Henry Ford Hospital (1932) and My Birth fruit and grain (both east wall), vaccination (above the Embryo (1932), portray brutally explicit medical images that have be- panel), and death (Cells Suffocated by Poisonous Gas, upper come landmarks of Surrealism.7 left corner of north wall). The juxtaposition of male and female In Downs’s words, Kahlo’s stay in the United States “was structures also reveals the hermaphroditic identity of the an- wretched.” 1p58 She had just suffered a miscarriage. She was drogynous titans atop the composition. not fluent in English and felt isolated among the glitterati that surrounded them. While her husband embraced the accoutre- ments of wealth, she disapproved of American capitalism. The

16 The Pharos/Summer 2014 obese sybaritic extrovert could be seen in San Francisco stuffed that included Frida and the Abortion and Henry Ford Hospital beside blond haired Moody in her convertible. Kahlo handled attracted thousands and generated blockbuster revenues for her own affairs with both men and women during her stay with the High Museum of Art in Atlanta.13 Downs notes the irony: more discretion.4 “Kahlo’s tiny paintings done in this difficult time in Detroit Kahlo became pregnant again in Detroit. She and a trusted have now become well known and a significant part of world friend, Leo Eloesser, a San Francisco surgeon, debated whether popular culture, and Rivera’s gigantic murals . . . which were she should have an abortion or try to carry the child. Rivera intended to reach the masses, are little known outside of that was not interested in a child, anticipating that one would be city.” 1p60 a nuisance to his work and travels. A child would keep Kahlo from accompanying him, something she wanted to do. Eloesser References and Rivera were also concerned about the effects either an 1. Downs LB. Diego Rivera: The Detroit Industry Murals. New abortion or childbirth would have on her health. Kahlo wanted York: W.W. Norton; 1999. a child but was convinced that childbirth would kill her. She 2. Perriot GR, Richardson EP. Diego Rivera and his Frescoes of requested an abortion and received quinine and castor oil as Detroit. Detroit: The Detroit Institute of Arts; 1934. an abortifacient that produced only a light hemorrhage. She 3. McMeekin D. Diego Rivera: Science and Creativity in the then decided to continue the pregnancy, but miscarried in July Detroit Murals. East Lansing (MI): Michigan State University Press; 1932. Rushed to Henry Ford Hospital, she recuperated as an 1985. inpatient for a week.4 4. Marnham P. Dreaming with His Eyes Open: A Life of Diego Kahlo grieved her loss despite her ambivalence about the Rivera. Berkeley (CA): University of California Press; 2000. pregnancy. In both Frida and the Abortion and Henry Ford 5. Lozano L-M, Rivera JRC. Diego Rivera: The Complete Mu- Hospital Kahlo cries large oversized tears. While Rivera may rals. Hong Kong: Taschen; 2008. not have wanted a child, the connection she feels for him is 6. Detroit Institute of Art. Rivera Court: Diego Rivera’s Detroit unmistakable. Marnham notes a resemblance between Rivera Industry Fresco Paintings. Art at the DIA: Visit Diego Court. http:// and the fetus in Frida and the Abortion (1932).4 She had previ- www.dia.org/art/rivera-court.aspx. ously depicted Rivera as her unborn child in a earlier drawing 7. Bernstein HB, Black CV. Frida Kahlo: Realistic reproductive after her 1930 abortion; she later erased the image.7 images in the early twentieth century. Am J Med 2008; 121: 1114–16. Against the advice of her doctors Rivera brought medical 8. Mello RG. Chapter II. Political vision. In L-M Lozano and texts and references to Kahlo’s bedside and encouraged her JRC Rivera, editors. Diego Rivera: The complete murals. Hong Kong: to paint. Obstetrician Helene Bernstein notes that the medi- Taschen; 2008: 26–133. cal images in the works that resulted are the most strikingly 9. Gomez NU. Chapter XI. Metaphorical readings on history. accurate portrayal of reproductive anatomy and childbirth in In L-M Lozano and JRC Rivera, editors. Diego Rivera: The complete art history to that date.6 Rivera understood that behind the murals. Hong Kong: Taschen; 2008: 434–501. anatomic accuracy there was profound agony: 10. Lozano L-M. Chapter V. Revolutions and allegories. Mexico and San Francisco. In L-M Lozano and JRC Rivera, eds. Diego Rivera. [Frida] began work on a series of masterpieces which had The complete murals. Hong Kong: Taschen; 2008: 264–299. no precedent in the history of art—paintings which exalted 11. Rivera D with March G. My Art, My Life: An Autobiography. the feminine qualities of endurance to truth, reality, cruelty, New York: Dover Publications; 1991. and suffering. Never before had a woman put such agonized 12. Gallagher J, Stryker M. DIA art takes center stage in high- poetry on canvas as Frida did at this time in Detroit.11pp123–4 stakes drama to decide Detroit’s future. Detroit Free Press 2013 May 26. http://www.freep.com/article/20130526/ENT05/305260073/ Both artists used medical images, startling in their realism, Detroit-Institute-of-Arts-and-bankruptcy. to produce artistic masterpieces. Rivera’s work covered hun- 13. Bentley R. Kahlo and Rivera: The intersection between art, dreds of square yards in the center of one of America’s great pain and politics. Atlanta Journal-Constitution 2013 Feb 5 2013. museums; Kahlo’s were on two small sheets of metal barely a http://www.ajc.com/news/entertainment/calendar/kahlo-and-rivera- foot square, easily small enough to be packed away and sent the-intersection-of-art-pain-and-/nWGPH/. back to Mexico City, out of view in private collections. (Today Henry Ford Hospital is in the Dolores Olmedo Museum; pop The author’s address is: star Madonna owns My Birth.) Department of Surgery Today popular acclaim has taken a turn. Thousands poured 1 Medical Center Drive, P.O. Box 9238 into the museum courtyard after it reopened to the public Health Sciences South, Suite 7700 March 21 1933, 10,000 on Sunday March 26 alone.1 Now the Morgantown, West Virginia 26506 museum is at risk of having its collection sold off to pay mu- E-mail: [email protected] nicipal debt.12 A recent exhibit of Rivera and Kahlo’s work

The Pharos/Summer 2014 17 Vital amines, purple smoke A select history of vitamins and minerals

Stanley Gutiontov The author is a member of the Class of 2015 at the Feinberg School of Medicine at Northwestern University. This essay won third prize in the 2013 Helen H. Glaser Student Essay Competition.

ntil 1907, scurvy was thought to be a strictly human disease. In that year, Theodore Frølich and Axel Holst, two Norwegian physicians studying beriberi, a similar appearingU but fundamentally unrelated disease, decided for no very compelling reason to use guinea pigs instead of pi- geons as their research animals. To their surprise, the guinea pigs on the experimental diet did not develop beriberi, but

18 The Pharos/Summer 2014 scurvy instead.1 Serendipity often graces science: guinea pigs not himself believe that citrus fruit alone was a cure for scurvy. accidentally made toothless due to weakened connective tissue This illustrates an important aspect of scientific progress: if a led to the discovery of vitamin C and, along the way, helped stir scientist cannot conceive of a reason for a given result, he is far up public support for the initiative to iodize salt in the United more likely to attribute the result to chance. The term “vitamin” States. would not be coined for another one hundred and fifty years Much of the developed world has in recent years become and hundreds of thousands of sailors would die from scurvy over -inundated with news about vitamins, minerals, anti- after 1753. oxidants, flavonoids, and the like. Today it is hard to imagine a Finally, in 1794, lemon juice was issued on board the HMS time when people did not know about the relationship between Suffolk on a twenty-three week nonstop voyage to India. There vitamin C and citrus fruit, or when iodine was just an unnamed was no major outbreak of scurvy on the voyage. This stunning element dissolved in the sea. The thoughtlessness with which result, coupled with the work of Gilbert Blane, chairman of we can pop a pill filled with thirteen vitamins, thirteen miner- the British Navy’s Sick and Hurt Board, who knew of Lind’s als, and six trace elements belies the tortuous path knowledge experiment, resulted in the provision of fresh lemons to the can take. While we are a far cry from Anaxagoras’ 475 BC Royal Navy during the Napoleonic Wars. The improved health proclamation of the existence of “homeomerics” (generative of British sailors played a critical role in naval battles, including components) in food, it is also true that the primary cause of the Battle of Trafalgar. There is nothing like defeat in war to mental retardation in 2013 is lack of iodine, an easily curable make a country take notice; the French and the Spanish adopted mineral deficiency.2 The history of vitamins and minerals is a fascinating look—uplifting and discouraging in turn—into how we interact with scientific truth and with each other.

The Limeys, scorbutus, and vitamin C Hippocrates wrote one of the earliest known descriptions of scurvy. As quoted in A Treatise on the Scurvy, he wrote that patients “had ulcers on the tibia, and black cicatrices.” 3p290 It is from these cicatrices—which form because of aborted collagen synthesis resulting in impaired tissue repair—that the disease got its Latin name, scorbutus, which then became, via a short detour through Scandinavia, the English scurvy. In 1747, Scottish naval physician James Lind undertook what was the first almost clinical trial in history.3 Twelve sailors with scurvy were divided into six groups of two, each of which got the same diet but with one different ingredient. One group got cider, one vitriol, another vinegar, the fourth seawater, the fifth oranges and lemons, and the sixth a spicy paste plus barley water. The results of the trial—one cure and one nearly complete recovery after six days in the oranges and lemons group, as well as partial recovery in the cider group—were published in Lind’s 1753 work, A Treatise on the Scurvy.3 Lind was by no means the first to suggest a cure. John Woodall in the early 1600s persuaded the Dutch East India Company to provide lemon juice along with “Limes, Tamarinds, Oranges, and other choice of good helps” for its sailors.4p164 And in 1536, the crew of Jacques Cartier, the explorer who claimed Canada for the French, was saved from scurvy by the suggestion of Iroquois prince Domagaya to drink a tea brewed from the annedda (arbor vitae) tree.5 These discoveries notwithstanding, scurvy caused the deaths of two million sailors, including the majority of the crews of both Vasco da Gama and Magellan, between 1500 and 1800. Why did it take centuries to institute something as simple as Back view of a male scurvy victim, showing characteristic hem- citrus fruit in the diets of navies worldwide? 6 orrhages under the skin. Illustration from Skorbut in veroeffentli- Part of the answer lies in an astonishing fact: James Lind did chungen (1920). Courtesy of the National Library of Medicine.

The Pharos/Summer 2014 19 Vital amines, purple smoke

the British solution in their navies soon after.7 structure was deduced by British chemist Walter Haworth a And yet this is only half the story. Three factors combined to year later, and it was named ascorbic acid in honor of its anti- deeply confuse matters in the nineteenth century. First, lemons scurvy properties. Szent-Györgi was awarded the 1937 Nobel were replaced by West Indian limes—thus the term Limeys for Prize in Medicine and Haworth shared the 1937 Nobel Prize in British sailors—because they were more easily obtained from Chemistry, marking the culmination of the search for the cure Britain’s Caribbean colonies. But limes intrinsically have one- for scurvy. quarter the vitamin C content of lemons, and they were served as juice that had been exposed to light and pumped through Polished rice copper tubing, further decreasing their vitamin C content. This was another reason for Lind’s skepticism: after his experiment At first there is paralysis of the extensors of the legs; the bird he had switched from fresh citrus to lime juice, which was not sits on a flexed tarso metatarsal joint. Paralysis soon extends nearly as effective. Second, fresh meat also cured scurvy, and to the wings, nape of the neck and the entire musculature. there was no obvious connection between the two foods. Third, The animal then lies motionless on its side; a deep prostration the infectious theory of disease was coming into vogue. Under appears frequently on the second or third day after the onset this theory, scurvy was attributed to “ptomaines”—alkaloids—in of paralysis—at the latest, in one week—and is followed by tainted meat. As late as the early twentieth century, voyagers to death in all cases; the whole course of the disease is run in a Antarctica developed scurvy.8 very short time.10p93 It was at this crucial time—in 1907—that Frølich and Holst’s guinea pigs came into the picture. The two scientists found So reads Casimir Funk’s chilling description of chicken beriberi. they could cure the animals using a variety of fresh food and The disease has existed for millennia. The terms for it extracts. Unable to make sense of their results, the scientific community ignored their contribution for decades. By 1928, the anti-scurvy agent, whose structure was still unknown, was referred to as “water-soluble C.” That year, two separate teams,

Albert Szent-Györgi. From the cover of Modern Medicine, August 30, 1965. Courtesy of the National Library of Medicine.

one in Hungary led by Albert Szent-Györgi, the discoverer of the citric acid cycle, and one in the United States led by Charles Glen King, began work to isolate the compound. Szent-Györgi isolated hexuronic acid as a candidate for vitamin C but could not prove it without a biological assay. In 1931, he sent the last of his hexuronic acid to King’s lab, which proved that it was indeed Beriberi victim. Illustration from Die Vitamine (1914), Casimir the long-sought vitamin C in 1932.9 The compound’s chemical Funk. Courtesy of the National Library of Medicine.

20 The Pharos/Summer 2014 vary widely: Arabic buhr, asthma, and bahr mean “a sailor”; an infectious cause, and Singhalese Bharyee means “weak movement”; Sudanese beri- although none was im- beri, beribit, berebet refer to “pottering walk”; Hindustan mediately discerned, an Bharbari is swelling, edema, while beri refers to “a sheep, in al- undeterred Eijkman, lusion to the peculiar gait in some instances of the disease.” 11p445 by now the Director All describe the generalized weakness, the bizarre gait, and the of the Geneeskundig paresthesias that were outlined by Jacobus Brontius, the physi- L a b o r a t o r i u m i n cian for the 1627 Dutch East India Company in Java—whose Indonesia, continued his ship, incidentally, was likely amply stocked with lemon juice.11 work injecting chickens How did a disease in the exotic East influence the direc- with isolates from people tion of Western vitamin research when Europeans weren’t the who had died of beriberi. ones getting sick? In the latter half of the nineteenth century, In 1889 he got lucky. A European imperialism had made forays deep into Asia; many disease eerily similar to Asian countries assimilated European technology. Steam-driven beriberi broke out among Christiaan Eijkman. Courtesy of the mills sprang up all over the continent, efficiently stripping the the chickens. Eijkman National Library of Medicine. hulls (“polishings”) off of rice. White rice quickly replaced was nothing if not thor- brown rice as a staple food, and in the wake of this so-called ough—when he learned superior product, the incidence of beriberi skyrocketed. that the chicken feed had recently been switched to white rice, From 1878 to 1882, one-third of Japanese Navy sailors de- he began feeding experiments and found that both unpolished veloped the disease and many died. Kanehiro Takaki, later to rice and the discarded rice polishings cured the disease. be affectionately dubbed the “barley baron” for his work, was Old habits die hard. Influenced by the ubiquitous “ptomaine” a Japanese naval physician who had trained both in traditional theory, Eijkman clung to his infectious framework for years, Chinese medicine and in London. In 1883 on a training mis- writing that “cooked rice favored conditions for the develop- sion from Japan to Hawaii, he noticed two things: the high ment of micro-organisms . . . and hence for the formation of a incidence of beriberi among enlisted men, whose diet was poison causing nerve degeneration.” 11p447 He thought his results mainly composed of white rice, and the absence of the disease important enough to share, however, and in 1895, before leaving among officers, whose diet consisted of vegetables and meat. for Europe due to ill health, he told Adolphe Vorderman of his Takaki petitioned the emperor to fund an experiment with an feeding studies. improved diet on the same mission the next year. It was a great As the physician responsible for medical inspection of the success—the incidence of beriberi dropped an order of mag- prisons across the East Indies, Vorderman was intrigued: he nitude. The diet, which included meat, barley, and fruit, was remembered having noticed in passing that prisons with dif- implemented throughout the Japanese Navy, virtually eliminat- ferent rice had different beriberi incidence. Vorderman was ing the disease from the fleet. unique in his efforts to avoid scientific bias, both in himself Takaki attributed the incidence of beriberi to protein defi- and in others, and the study he designed and implemented, ciency; thus, he was wrong in the particulars. But the disease though imperfect, was a tour de force of epidemiology.14 His is indeed caused by dietary deficiency, and in that sense Takaki first step was to write each prison governor with regards to was years ahead of the prevailing infectious view held both by beriberi incidence and the type of rice used, without suggest- his fellow Japanese and by Europeans. As late as the Russo- ing a possible connection. When the correlation seemed nearly Japanese War of 1904–1905, tens of thousands of deaths from perfect, Vorderman visited all 101 prisons he had written to, beriberi occurred among soldiers in the Imperial Japanese Army with the purposely vague official mission of “looking in to the because the doctors in this branch of the armed forces had been health status of prison inmates.” He sampled the rice from each trained at Tokyo Imperial University, which subscribed to the prison, placed it in containers marked only with de-identifying theory of an infectious cause of beriberi.12 letters, and sent them for analysis. The results were staggering: A Dutch physician, F. S. van Leent, had in 1879 proposed that in prisons with white rice, the proportion of beriberi cases to a one-sided rice diet was the cause of beriberi.13 But Europeans number of prisoners was 1:39; in prisons with fully unpolished ignored both his results and those of Takaki. In 1886, two years rice, this fell to 1:10,725. after beriberi rates had begun plummeting in the Japanese Dutch physician Gerrit Grijns continued Eijkman’s work navy, the disease was endemic in the Dutch East Indies and the with Vorderman’s results in the back of his mind. He excluded Dutch government sent a commission to discover the cause. as a cause every one of the dietary components of a “complete” One of the investigators was Christiaan Eijkman, whose thesis nineteenth century diet. The nutrient beriberi patients lacked had been On Polarization of the Nerves, making him an ideal was neither a protein, a carbohydrate, a fat, nor an inorganic candidate to investigate the peripheral neuropathy of beriberi. salt. Grijns took particular note of the fact that had bedeviled Eijkman’s studies with Robert Koch predisposed him to assume scurvy researchers for years: scurvy could be cured by fresh

The Pharos/Summer 2014 21 Vital amines, purple smoke

About Stanley Gutiontov I am a third-year medical student at meat or by citrus fruits. In 1901, putting two and two to- Northwestern University Feinberg School gether, he postulated that there was some hitherto unknown of Medicine. I majored in biomedical class of nutrient and that the missing substance in beriberi physics and took many writing classes at was either necessary for maintaining metabolic functions Northwestern University, I love perform- in the peripheral nervous system or protecting the nervous ing slam poetry, having long discussions system from some other environmental agent. about cosmology and other things that are way above In 1912, Polish chemist Casimir Funk isolated an amine that my head (both literally and figuratively), and reading he thought was the anti-beriberi compound (in fact it was ac- voraciously. tually nicotinic acid, vitamin B3, contaminated with thiamine, vitamin B1) and coined the term “vital amines,” shortened to “vitamines.” That same year, Frederick Hopkins published his of reasons, Chatin’s idea work demonstrating that “complete” nineteenth century diets was stifled by the French fail to support animal growth. History is not always just; Grijns, Academy of Science; io- whose work corrected Eijkman’s hypothesis and preceded that dine would not be widely of Hopkins, was barely mentioned in either of their Nobel lec- reevaluated as a treatment tures in 1929.13,15 for goiter for another fifty One final peculiar turn of fate: chickens take a long time to years, despite the fact that develop beriberi and are therefore not ideal research animals for it was actually used suc- the disease. The isolation of the anti-beriberi factor was there- cessfully in France around fore tremendously accelerated by the accidental observation that very time to improve that the bonbol, a small tropical bird, develops beriberi with goiter in 4000 of 5000 alarming alacrity. In 1926, aneurin (for anti-neuritic vitamin)— children.17 subsequently renamed thiamine for a previously overlooked People were once sulfur atom in the chemical structure—was discovered by B. C. again rediscovering—and P. Jansen and W. F. Donath. And so we come full circle: today promptly forgetting— we eat white rice without fear of beriberi because it has been something known for fortified since the 1950s with synthetic thiamine, the vital amine ages. It was fitting that stripped off in Asia more than a century ago. Courtois named the sea- Jean Baptiste J. D. Boussingault. weed-borne mineral af- Courtesy of the National Library of Medicine. The goiter belt and the globe ter a Greek color, for the Between 1804 and 1814, with the Napoleonic wars rag- ancient Greeks had been ing across Europe, France was in dire need of gunpowder. using seaweed to treat goiter thousands of years earlier. In the Gunpowder was manufactured from saltpeter, a collection of first century AD, the Roman poet Juvenal wrote, “who wonders nitrogen-containing compounds, made then by mixing manure at a swollen throat in the Alps?” 19 In 1215 an illustration from with wood ash and composting the two with straw. Parisian the book Reuner Musterbuch depicted an imbecile with an im- Bernard Courtois was at that time running his family’s saltpeter mense goiter, perhaps the first recorded association between business, and in 1811 the wood ash began running low. He began goiter and cretinism.20 Swiss physician Felix Platter gave a de- to experiment with seaweed ash. One day, after adding sulfuric tailed description in 1602: acid to the ash, he was startled to find a purple vapor coming out of the glassware. The newly discovered element was later Besides, the head is sometimes misshapen: the tongue is huge named iodine, after iodes, the Greek word for “violet.” 16 and swollen; they are dumb; the throat is often goitrous. Thus Soon after Courtois’ discovery, Swiss physician Jean-Francois they present an ugly sight; and sitting in the streets and look- Coindet speculated that the mineral might be the ingredient in ing into the sun, and putting little sticks in between their fin- seaweed that was effective against goiter.17 He began dispens- gers, twisting their bodies in various ways, with their mouths ing an iodine tincture to patients with goiter as early as 1820. agape they provoke passersby to laughter and astonishment.21 Jean-Baptiste Boussingault, a French engineer, chemist, and agricultural scientist, in his travels throughout South America, The link between the thyroid gland, goiter, and cretinism noticed that the prevalence of goiter varied with geography was not firmly established until 1885, when neurosurgeon Sir and was highest in areas that did not have access to sea salt. William Horsley, known primarily as the first to perform pitu- Boussingault advocated the use of iodinated salt—in 1833! In itary surgery, pieced together his own patients’ thyroidectomy the 1850s, French chemist Adolphe Chatin wrote as explicitly as outcomes and wrote in the British Medical Journal: “I am pre- could be: “the main cause of goiter seems to be a low concentra- pared, in my first two lectures, to support the dictum . . . that tion of iodine in drinking water in certain areas.” 18 For a variety cretinism . . . [is] due to . . . arrest of the function of the thyroid

22 The Pharos/Summer 2014 Sporadic cretinism. Illustration from Atlas of Clinical Medicine, Volume I (1892), Byrom Bramwell. Courtesy of the National Library of Medicine.

Today, it costs five cents per person per year to iodize salt. Yet, according to conservative estimates, twenty million people worldwide are mentally handicapped because of lack of iodine, with nearly two billion having insufficient iodine intake.24 Even these statistics are a striking improvement from pre-1993 data, the year—almost two centuries after Boussingault’s suggestion—that the World Health Organization (WHO) adopted universal salt iodization. The WHO, along with organizations such as the Head and neck views of abnormal thyroid growth by Herbert International Council for the Control of Iodine Deficiency Louis Treusch. Courtesy of the National Library of Medicine. Disorders (IDDICC), has made major strides in recent years. Ten percent of households consumed iodized salt in the 1990s. In 2003, this number has risen to sixty-six percent. Though gland.” 22 Ten years later, German chemist Eugen Baumann dis- much work remains to be done, it is not unreasonable to look covered thyroiodine in thyroid tissue, making it easy to under- forward to a time when an accidental byproduct of French gun- stand how iodine deficiency might lead to cretinism. powder manufacturing reborn from ash brings forth the true Only in 1907 did American physician David Marine be- potential of millions of children the world over. gin work using iodized salt to prevent goiter; it took almost a decade to get an eventually successful large-scale trial of Reflections on a saga iodized salt in Cleveland public schools underway. Even this A few interesting observations on medical progress can be success, however, was not enough to get iodization of salt onto gleaned from the history of medical advances: the list of national priorities. It was only during World War 1. Science moves forward by the hard work of brilliant and I, when the United States military noticed that the draft had lucky people—Adolphe Vorderman’s trek to 101 prisons in the disqualified many men with goiter in the Pacific Northwest, Dutch East Indies was hard work, Kanehiro Takaki’s insight into Northern Michigan, and Wisconsin—the latter two being part the true nature of beriberi was brilliant, and Axel Holst’s and of the so-called “goiter belt”—that the necessary impetus finally Theodore Frølich’s switch to guinea pigs was lucky. materialized. David Murray Cowie, professor of pediatrics at 2. Discovery is rarely the product of one person—while the University of Michigan, began a push for salt iodization, Albert Szent-Györgi received the 1937 Nobel prize in Medicine citing the results of Marine’s trial as well as the Swiss practice for his discovery of vitamin C, the prize could well have been of iodizing salt. The timing was perfect: it was the 1920s, and divided infinitely among the Iroquois people, James Lind, James “important discoveries of vitamins and their roles in food nutri- Woodall, Frolich and Hølst, Charles King, and on and on. True, tion” 23p222 were occurring. Public opinion was behind him, and Szent-Györgi put it all together, but he built on a multitude of on May 1, 1924, iodized salt appeared; later that year the Morton contributions. Salt Company began national distribution. Goiter incidence in 3. Truth is not enough—Domagaya’s annedda tea, Kanehiro the United States plummeted, in Detroit from 9.7 percent to 1.4 Takaki’s improved diet, Adolphe Chatin’s calls for iodized drink- percent within six years. ing water—none of them had a permanent effect on pushing

The Pharos/Summer 2014 23 Vital amines, purple smoke

science forward. Sometimes, 9. National Library of Medicine. Profiles in Science: The Albert timing is everything. Szent-Györgyi Papers. Szeged, 1931-1947: Vitamin C, Muscles, and 4. Disease does not respect WWII. http://profiles.nlm.nih.gov/ps/retrieve/Narrative/WG/p- international boundaries, and nid/149. neither does scientific prog- 10. Funk C. The Vitamines. Dubin HE, translator. Baltimore: Wil- ress. When we ignore this liams & Wilkins; 1922. simple fact, people the world 11. Lanska DJ. Chapter 30: Historical aspects of the major neu- over suffer. On the other hand, rological vitamin deficiency disorders: the water-soluble B vitamins. when we remember this fun- In: Aminoff MJ, Boller F, Swaab DF, editors. Handbook of Clinical damental interconnectedness, Neurology. Volume 95. Amsterdam: Elsevier; 2010: 445–76. medicine serves its true pur- 12. Carpenter KJ. Beriberi, White Rice, and Vitamin B: A Disease, David Marine (ca. 1953). pose: the prevention and cure a Cause, and a Cure. Berkeley (CA): University of California Press; Courtesy of the National Library of of disease, wherever it might 2000. Medicine. be found. A final episode from 13. Eijkman C. Nobel Lecture: Antineuritic Vitamin and Beriberi. vitamin history illustrates the http://www.nobelprize.org/nobel_prizes/medicine/laureates/1929/ point: Wernicke-Korsakoff eijkman-lecture.html. syndrome, mainly observed in Europe and the United States 14. Vandenbroucke JP. Adolphe Vorderman’s 1897 study of beri- and long thought to be a result of alcohol toxicity, was hypoth- beri: an example of scrupulous efforts to avoid bias. James Lind esized in the 1930s to be caused by thiamine deficiency. This Library: Documenting the evolution of fair tests. http://www.james- was conclusively demonstrated in the 1950s. Thus a treatment lindlibrary.org/illustrating/articles/adolphe-vordermans-1897-study- first discovered to prevent beriberi in Japanese naval soldiers in on-beriberi-an-example-of-scrupu.pdf. the late nineteenth century was shown to heal Western alcohol- 15. Hopkins F. Nobel Lecture: The Earlier History of Vitamin ics in the mid-twentieth. Research. http://www.nobelprize.org/nobel_prizes/medicine/laure- History is laced with serendipitous beauty. There is perhaps ates/1929/hopkins-lecture.html. no better reminder of this truth than the vital chemicals hiding 16. Cranefield PF. The discovery of cretinism. Bull Hist Med 1962; in our food and the stories of the people who discovered them. 36: 489–511. Indeed, as the vitamin pill begins to dissolve in our stomachs, 17. Swain PA. Bernard Courtois (1777–1838), famed for discover- spilling its molecular intricacies, a saga bought with the toil and ing iodine (1811), and his life in Paris from 1798. Bull Hist Chem 2005; insight of millennia begins to unfold. 30: 103–11. 18. Lindholm J, Laurberg P. Hypothyroidism and thyroid substitu- References tion: Historical aspects. J Thyroid Res 2011; 809341. http://www.ncbi. 1. Norum KR, Grav HJ. Axel Holst and Theodor Frølich— nlm.nih.gov/pmc/articles/PMC3134382/. pioneers in the combat of scurvy. Tidsskr Nor Lægeforen 2002; 122: 19. Chatin A. Recherches sur l’iode des eaux douces; de la 1686–87. présence de ce corps dan les plantes et les animaux terrestes. Comptes 2. de Benoist B, Andersson M, Egli I, et al, editors. Iodine Status Rendus Hebdomadaires des Séances de l’Academie des Sciences 1851; Worldwide. Geneva: Department of Nutrition for Health and Devel- 31: 280–83. opment, World Health Organization; 2004. http://www.who.int/nu- 20. Horsley V. The Brown Lectures on Pathology. The thyroid trition/publications/micronutrients/iodine_deficiency/9241592001/ gland: its relation to the pathology of myxoedema and cretinism, to en/. the question of the surgical treatment of goitre, and to the general 3. Lind J. A Treatise on the Scurvy. London: A. Millar in the nutrition of the body. BMJ 1885; 1: 111–15. Strand; 1757. 21. Markel H. “When it Rains it Pours”: Endemic goiter, iodized 4. Woodall J. The Surgeons Mate. London: Rob. Young, for salt, and David Murray Cowie, MD. Am J Public Health 1987; 77: Nicholas Bourne; 1639. 219–29. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1646845/pdf/ 5. Martini E. Jacques Cartier witnesses a treatment for scurvy. amjph00253-0087.pdf. Vesalius 2002; 8: 2–6. 22. Hetzel B. Towards the Global Elimination of Brain Damage 6. Drymon MM. Disguised as the Devil: How Lyme Disease Due to Iodine Deficiency. Ottawa (ON): International Council for Created Witches and Changed History. South Portland (ME): Wythe the Control of Iodine Deficiency Disorders. http://www.iccidd.org/ Avenue; 2008. f142000224.html. 7. Bown SR. Scurvy: How a Surgeon, a Mariner, and a Gentle- man Solved the Greatest Medical Mystery of the Age of Sail. New The author’s address is: York: Thomas Dunne Books; 2004. 10 E. Ontario Street, Apartment 3308 8. Cegłowski M. Scott and Scurvy. 2010 Mar 7. http://idlewords. Chicago, Illinois 60611 com/2010/03/scott_and_scurvy.htm. [email protected].

24 The Pharos/Summer 2014 An obstetric story

J. Allan Wolf, MD, FACOG

The author (AΩA, New York while in residency, and both mother crashed her, and I got the baby deliv- University, 1972) was a medical direc- and baby had died. None of the six ered in under two minutes from skin to tor for UnitedHealthcare until his retire- other OB/GYNs in the practice I had placenta. It was of no avail. The baby, ment in April 2014. joined had ever seen a case with he- deep in shock, could not be resusci- patic rupture; nor had any of the other tated and was pronounced dead almost n July 1977, having finished medi- OB/GYNs in my community. immediately. cal school, internship, a residency The definitive cure for severe pre- Mom did better. With the surgeon in obstetrics and gynecology, and eclampsia with HELLP syndrome be- working on her exploded liver, the an- Ia one-year fellowship in family plan- gins with ending the pregnancy, but I esthesiologist pouring unit after unit ning with training in the treatment of feared that my patient would not with- of blood, platelets, and cryoprecipitate sexual dysfunction, I went to work as stand induction of labor. I also knew into her, and me working on her mas- the junior associate in a well-respected that to proceed with a Caesarean sec- sively hemorrhaging uterus, we man- local OB/GYN practice in southern tion at that moment might well prove aged to get her under good enough California. One night six weeks into fatal for her, so I opted for an initial control to make it to the ICU. my new role as private practitioner, I effort at stabilization with standard I had now been up for around thirty was on call for the group when one of measures for treating preeclampsia: hours. One of my associates sent me our pregnant patients near term was dark room, bed rest, antihypertensive home to get some sleep and took over brought to the hospital by her husband. medication, anticonvulsant therapy to her care. Shortly after I left, however, I was there to meet her when she try and prevent eclamptic seizures, and he had to take her back to the operat- arrived. A young primigravida near something for pain. My plan was to ing room for a hysterectomy because term, she appeared acutely ill with give her six hours to settle down and of uncontrolled bleeding secondary markedly elevated blood pressure and then do the Caesarean section. I was to a consumptive coagulopathy, a well abdominal pain that I quickly realized frightened, but I also knew that panic known complication of HELLP syn- wasn’t labor. Physical examination and wasn’t going to help. drome. Postpartum, she developed lab work confirmed that she had severe The night passed with agonizing Sheehan’s pituitary necrosis requiring preeclampsia with HELLP (hemolysis, slowness and was complicated by the comprehensive hormone replacement elevated liver enzymes, low platelets) need to manage another labor and de- but, at least, I took some consolation syndrome, a potentially fatal complica- livery that, fortunately, went well. knowing that she had survived. tion of pregnancy in which red blood Finally, at 7 AM, I decided that it She continued to see me for care cells break down, the liver and other was time to deliver the baby. While for nearly nine months. Then, her organs swell, liver function is altered, transferring her to the operating table, husband’s business failed and, in fi- and the number of platelets falls, in- she suddenly went into shock and, nancial straits, the couple filed a law- creasing the risk of hemorrhage. A from my reading about the few cases suit against me for wrongful death of major risk associated with HELLP syn- that had been reported, I was certain the infant, the allegation being that I drome is hepatic rupture with massive that she had ruptured her liver and was should have intervened several hours intraperitoneal bleeding. I had seen bleeding internally. I put out a call for earlier to deliver the baby. The expert one case of such catastrophic rupture a general surgeon, the anesthesiologist brought in by my malpractice attorneys

The Pharos/Summer 2014 25 26 The PharosIllustration/Summer by Laura 2014 Aitken predictably disagreed, noting that re- been dragging her down with me in defend providers wrongly or unfairly gardless of the timing of delivery, both ways I would never have wished. Over accused of substandard practice or perinatal and maternal mortality rates the next year and a half and despite unethical conduct has enabled me to were high in pregnancies complicated many tense days, she stood by me as redirect what was disappointment and by HELLP syndrome with hepatic I worked to move my career in some disillusionment with the reality of my rupture. The case dragged on for three meaningful direction without throwing personal experience in medical practice years until, a couple of days before the away my years of training. into the meaningful pursuit of fairness trial was to begin, I received a call from I will not detail all of the intervening for both patients and providers caught my malpractice attorneys to tell me steps that led, progressively, to the role up in situations that can often spiral that a former professor and mentor had I have played for the last nine years wildly out of control. agreed to testify in court that my care that culminated in my recent retire- In so doing, I have come to accept had been below acceptable standards. I ment, but this final professional role that the vast majority of patients are was devastated and yielded to pressure has been, in many ways, my salvation well intentioned even when wrong in from the attorneys to settle the case. Of and the way I finally have been able their allegations, and that physicians the six figure settlement, the woman’s to put away the experience that has and other medical personnel over- attorneys got forty percent. haunted me so terribly for so long. whelmingly strive daily (and nightly!) to Shortly after the settlement was In 1999 I went to work for a large perform their duties at the very high- inked, it came out that the plaintiff’s health care insurance company and, est levels of both ethics and clinical attorneys had lied, and my profes- although it wasn’t the role I had been competency. But it is a fact that there sor had not agreed to testify but had, hired into at the outset, after several are outliers: sometimes patients, who in fact, told them that my care was years I segued into a full time posi- can often be angry, depressed, unrea- entirely appropriate. Despite my insis- tion doing quality management and, sonable and vindictive, and sometimes tence that the case be reopened, my at- specifically, addressing grievances filed providers, who may be insensitive, torneys refused, saying they didn’t want by insured health plan members, prob- aloof, and unfortunately lacking in skill to risk putting the woman on the stand lems with impaired or incompetent or deficient in their personal conduct and getting enough jury sympathy to physicians, and defending physicians or communication skills. It has become swing the verdict against me. and medical facility staffs wrongly ac- my good fortune, in the end, to be Shattered emotionally, I spent the cused by patients and their supporters someone privileged to seek a reason- next five years in deepening depression of incompetence, ethical breaches, or able path through the maze of human and self-doubt, unable to find the joy other clinical or administrative inad- behavior complicating the doctor- I’d hoped for in my chosen specialty, equacy. My role has led me to interact patient relationship. I now view human paranoid in my interactions with pa- with medical experts in a variety of nature in a way I formerly did not, and tients, and ultimately seriously enough fields, with (and against) attorneys because of this I have overcome the impaired to consider suicide. My 2 AM both admirable and despicable, with bitterness, hurt, and depression that drives down a twisting mountain road hospital, outpatient urgent care, and destroyed my early career. from home to the hospital for laboring surgery facilities, and with pharmacies, Finally, I’ve evolved enough to feel patients were filled with thoughts of all with the goal of finding truth while compassion without anger for the simply driving over the edge to escape being fair to all, and trying to develop young couple whose baby was lost the suffering I thought I could no lon- and implement appropriate corrective over the course of that horrific night ger bear. Finally, though, frightened actions when necessary. and morning nearly forty years ago, and realizing that while suicide might While it is certainly true that people whose ability to have a mutually be an answer for me, it would be no many grievances filed against doctors, conceived baby was lost forever, whose answer for my wife and young daugh- nurses, and other medical profession- source of income was suddenly cut off, ters, I erupted into the open and told als have merit and require intervention and who lashed out at me in grief and my wife I couldn’t go on and would to prevent ongoing and future harm, all-too-human anger and frustration have to leave practice, even though I it is equally true that many accusa- as their world collapsed around them. had no well-thought-through idea of tions made by patients are ground- I do not know whether they have ever what I would do next. less, born of anger over imagined or found sufficient peace or understand- As we talked, I realized that I had trivial slights, disappointment over ing to forgive me, but I have forgiven had no real understanding of how my unpreventable adverse outcomes and, them, and I am happy. depression had been affecting her—but not least, billing disputes. Being in a her immediate willingness to support position both to advocate for patients The author’s e-mail address is: k6jw@arrl. my decision made it clear that I had with legitimate grievances and to net.

The Pharos/Summer 2014 27 The mysterious illness of Emma Lazarus, Lady Liberty’s poet

28 The Pharos/Summer 2014 The mysterious illness of Emma Lazarus, Lady Liberty’s poet

Robert S. Pinals, MD The author (AΩA, University of Rochester, 1955) is Clinical Professor of Medicine in the Department of Medicine at the Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey.

The New Colossus Not like the brazen giant of Greek fame, With conquering limbs astride from land to land; Here at our sea-washed, sunset gates shall stand A mighty woman with a torch, whose flame Is the imprisoned lightning, and her name Mother of Exiles. From her beacon-hand Glows world-wide welcome; her mild eyes command The air-bridged harbor that twin cities frame. “Keep, ancient lands, your storied pomp!” cries she With silent lips. “Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!”

mma Lazarus is remembered today mainly for her iconic sonnet, written hastily to include in a booklet used in fundraising for the pedestal of the Statue of Liberty.1–3 The statue was a gift from the French to the American people to celebrate liberty and other values shared by the two nations.1–3 The poem attracted little attention in 1883 and, in

Left,E Illustration of a group of immigrants on the steerage deck of a steamship viewing the Statue of Liberty as they arrive in New York Harbor, circa 1887 (© FPG/Getty Images) Above, Emma Lazarus. Engraving by T. Johnson (© Bettman/CORBIS)

The Pharos/Summer 2014 29 The mysterious illness of Emma Lazarus, Lady Liberty’s poet

Manuscript of The New Colossus by Emma Lazarus. © Bettmann/CORBIS

fact, seemed to have little connection with the intent of the Life and career gift. When Lazarus died four years later, at age thirty-eight, Emma Lazarus was born in New York City in 1849, the her obituary did not mention Lady Liberty’s sonnet, but re- second of five children of a wealthy sugar refiner. She was edu- viewed her poetry and other published works in complimen- cated at home by tutors, who emphasized cultural and literary tary terms.4 Lazarus never saw the statue after it was erected interests and fluency in languages. Summers were spent at the on its pedestal in 1886; she was travelling in Europe at the seashore in Newport. At age eleven she began writing poetry time and already ill. At the ceremonial unveiling of the Statue and her first collection was published privately when she was there were speeches by many dignitaries, but no mention of seventeen. Her poems also appeared in periodicals and she de- the poem or of immigrants. Not until several years later, when veloped many connections within the New York literary com- great hordes of destitute refugees arrived in New York Harbor munity. Her Sephardic Jewish family was fully assimilated and from Eastern and Southern Europe, was it recognized that did not practice their religion; virtually all of her friends were with her prescient words Lazarus had envisioned the essence Christian. She never married and was never known to have had of America’s future. a romantic relationship with a man. Lazarus’s life was transformed by violent anti-Semitic outbreaks in Russia in the early 1880s. She took part in relief

30 The Pharos/Summer 2014 efforts for immigrants and incorporated their distress into her November 19, 1887. The death certificate was signed by E. L. poetry and essays. Lazarus was the first American to propose Partridge, MD, a prominent New York physician whose special a Jewish state in Palestine, more than a decade before the first interest was in obstetrics. The names of other attending phy- Zionist Congress in Europe. Her passionate identification with sicians are unknown. The diagnosis, one rarely made at that the newly arriving Russian Jewish refugees emerged when she time, was Hodgkin’s disease. was invited to submit a poem for the Statue of Liberty pedestal fundraising campaign in 1883. Later, Lazarus realized that Discussion immigrants with other religious and national backgrounds Our limited knowledge of the clinical details of the illness had similar problems. Lazarus had returned from her first that led to Emma Lazarus’s death at age thirty-eight is derived European trip three months earlier; she was thrilled to have almost entirely from her letters. It is difficult to reconcile the met many famous writers and artists and looked forward to group of symptoms described with the diagnosis of Hodgkin’s another visit. Unfortunately, however, this was delayed by what disease on her death certificate. The observations of the team may have been the first symptoms of her illness in 1884 and by of attending physicians in New York City are unavailable and her father’s death the following year. In April 1885 she felt well it is highly unlikely that an autopsy was performed, given her enough to sail. high social class, her death and funeral service at home, and her burial, which followed directly. Illness and death What was known about Hodgkin’s disease in 1887 and how Almost all of the information about Lazarus’s illness is was that diagnosis made? In 1832, Thomas Hodgkin, a London derived from her letters, particularly those to a close friend, physician, described the clinical and gross pathologic findings Helena DeKay Gilder.1,2 The illness may have presented as early that included lymph node and spleen enlargement.5,6 By 1887 as September 1884 when she developed a “severe and danger- Pieter Klaases Pel and Wilhelm Ebstein had described the in- ous malady from which she slowly recovered.” 1p209 After arriv- termittent fever associated with Hodgkin’s disease in a minority ing in England she complained of severe fatigue and “mental of cases.6 Late nineteenth-century reports of the histopathol- incapacity,” 1pp217–18 but did not allow this to interfere with her ogy featured a distinctive association of mononuclear cells and ambitious tour, which also included France, Holland, and Italy. giant cells, which would eventually replace the gross pathology At some point, probably in December 1885, she developed as the basis for diagnosis. Hodgkin’s disease was considered a fever that reappeared intermittently during the remainder to be a variant form of tuberculosis by W. S. Greenfield (1878) of her life. She found it necessary to spend more days in bed, and Carl Sternberg (1898) although the characteristic giant but refused to abandon sightseeing and meetings with inter- cells were atypical.6 In 1902, after Robert Koch’s discovery of esting people. During the summer of 1886 she was staying in the tubercle bacillus, Dorothy Reed, then a recent graduate and Herefordshire, near the home of Elizabeth Barrett Browning’s research fellow in Pathology at Johns Hopkins Medical School, father, when a “mysterious disease” struck suddenly.3 She pointed out the organism’s absence in Hodgkin’s disease.7 She had severe pain. Swallowing was difficult and digestion was concluded that it was “a histopathological disease entity.” 6 Not impaired.3 These symptoms were accompanied by extreme until the mid-twentieth century would it be recognized with fatigue and cognitive dysfunction. certainty as a neoplastic condition.6 By January, 1887 she was too weak to write and dictated a At the time of Lazarus’s death in 1887 surgical pathology, letter transcribed by her sister Annie.2 She was bedridden and which had started in Germany, was in an embryonic stage in very discouraged. Annie wrote the next letter three weeks later, America.8 Contemporary case reports included some with describing night sweats and fever, and also noting that Emma confirmation by autopsy,9 but diagnosis by biopsy lay several was groaning with pain. In April Annie wrote: “Her face is very years in the future. We must presume that the physicians car- much paralyzed now—one ear is quite deaf & her eyes are both ing for Lazarus made a bedside diagnosis of Hodgkin’s disease going very fast. . . . she can’t bear a ray of light.” 2p165 Somehow based her lymphadenopathy, splenomegaly, and history of in- Emma was able to rally and dictate a letter in July, saying that termittent fever. Various neurologic signs and symptoms had she had regained enough strength to undertake the voyage been reported previously10 and would not have been surprising home but “I have no use of my eyes . . . and fear I shall be crip- in an advanced case with obvious cachexia. Hodgkin’s disease pled for many months to come.” 2pp166–67 Although we presume was considered to be an atypical form of tuberculosis; central she sought medical care in Europe, we have no information on nervous system (CNS) involvement by tuberculosis was well that subject, nor about any treatment she may have received. recognized. She returned to New York on July 31 and was put to bed Lazarus’s neurologic deficits included motor loss, facial in the family home, closely attended by doctors and nurses. weakness, loss of vision and hearing, dysphagia, photophobia, Her pain required opiates and her downhill course continued. and cognitive dysfunction. Several paraneoplastic syndromes On August 6, her sister Josephine wrote that “Emma is decid- associated with Hodgkin’s disease and other lymphomas have edly worse and the doctors say she is failing.” 2p169 She died on some of these manifestations, including motor neuron disease,

The Pharos/Summer 2014 31 The mysterious illness of Emma Lazarus, Lady Liberty’s poet

Guillain-Barré syndrome, inclusion body myositis, Sweet syn- celebrated Lazarus’s role in transforming the statue into the drome, and primary CNS vasculitis.11 In addition, the immu- Mother of Exiles. During World War II Hollywood’s patriotic nodeficiency associated with Hodgkin’s disease may increase fervor gave rise to recitations of the sonnet’s last few lines in susceptibility to rare viral infections, particularly JC virus, several movies. In Saboteur, a 1942 film directed by Alfred which causes progressive multifocal leukoencephalopathy Hitchcock, the dramatic climax takes place on the Statue of (PML). The cardinal clinical features of PML are visual deficits, Liberty’s torch hand, from which a Nazi saboteur falls to his motor weakness, and cognitive impairment.12 With the very death. After the war, lines from the sonnet were included in the limited information available on Lazarus’s illness we can only Broadway musical Miss Liberty by Irving Berlin, an immigrant speculate about the nature of her neurologic condition; PML from Russia. Today, Emma Lazarus is acclaimed as a champion may be the best guess. of immigrants, a warrior against anti-Semitism and a proto- The cause of Lazarus’s severe intermittent pain is also Zionist visionary.1 Almost single-handedly she reinvented the mysterious, as we have no knowledge of its location, duration, message of the colossal woman occupying New York harbor’s or character. Bone or visceral involvement or inflammatory entrance, a statue which she had only imagined but never arthritis are possible and, especially in relationship to its epi- seen. Lady Liberty, in Lazarus’s own words, would become the sodic nature, one might mention the pain induced by alcohol Mother of Exiles, lifting her lamp beside the golden door. ingestion in some patients with Hodgkin’s disease.13 Lazarus drank wine but probably not regularly. However, many popular References liquid medications of that era contained alcohol. In one series, 1. Schor E. Emma Lazarus. New York: Schocken; 2006. seven percent of Hodgkin’s disease patients had this pain and 2. Young BR. Emma Lazarus in Her World: Life and Letters. its frequency was disproportionately higher in women. The Philadelphia: The Jewish Publication Society; 1995. pain appears very soon after alcohol is ingested, even in small 3. Jacob HE. The World of Emma Lazarus. New York: Schocken; amounts and subsides within thirty minutes to several hours. 1949. Almost all patients have objective evidence of disease near 4. Emma Lazarus. Death of an American poet of uncommon the site of the pain. Painful lymph nodes become swollen and talent. New York Times 1887 Nov 20: 16. warm, suggesting that vasodilatation may be the mechanism, 5. Hodgkin T. On some morbid appearances of the absorbent but other vasodilators fail to reproduce the pain. glands and spleen. Med Chir Trans 1832; 17: 69–97. During her short life Lazarus’s main goal was to have her 6. Bonadonna G. Historical review of Hodgkin’s disease. Br J work recognized and approved by the literary establishment.1,2 Haematol 2000; 110: 504–11. Unfortunately, during her lifetime the barriers to the accep- 7. Reed DM. On the pathological changes in Hodgkin’s disease, tance of creative work by women were enormous. Even Emily with especial reference to its relation to tuberculosis. John Hopkins Dickinson, now one of America’s most revered poets, died in Hosp Rep 1901–2; 10: 133–96. 1886 virtually unrecognized and unpublished. Lazarus had cor- 8. Hazard JB. An introduction to the history of surgical pathol- responded with Ralph Waldo Emerson, the leading American ogy. Am J Clin Pathol 1981; 75 (3 Suppl): 444–46. poet, and even travelled to Massachusetts to spend some 9. Satterthwaite TE. Hodgkin’s disease: five cases with two post- time with him. He was very encouraging and supportive, but mortem examinations. Post-Graduate MY 1887–8; 3: 85–91. when Parnassus, an anthology of special poems he selected, 10. Hutchinson JH. Case of adenoid (Hodgkin’s); enlargement of was published none of Lazarus’s work was included. She was the cervical glands with multiple lymph-adenomatous tumors of the heartbroken and protested vigorously in a letter to him, but he brain, spinal column, lungs, sternum, subcutaneous tissue, etc.; with did not respond. remarks, an analysis of fifty-eight recorded cases, and a bibliography. At the time of her death there was little public awareness of Trans Coll Phys Phila 1874–5; 3: 47–67. Emma Lazarus and her work outside of the New York literary 11. Briani C, Vitaliani R, Grisold W, et al. Spectrum of para- community and those who had shared in her immigrant relief neoplastic disease associated with lymphoma. Neurology 2011; 76: efforts. Her sonnet had not been mentioned during the cer- 705–10. emonies at the Statue of Liberty’s public opening in 1886. Her 12. Berger JR. The clinical features of PML. Cleveland Clin J Med sisters destroyed her papers and diaries, and in 1889 published 2011; 78 Suppl 2: 8–12. some of her poems, but not “The New Colossus.” 13. Atkinson K, Austin DE, McElwain TJ, et al. Alcohol pain in However Lazarus had influential friends who had not for- Hodgkin’s disease. Cancer 1976; 37: 895–99. gotten her; one of them, Georgina Schuyler, successfully promoted the mounting of a memorial plaque upon which “The The author’s address is: New Colossus” was engraved on the pedestal of the Statue of 18 Pickman Drive Liberty in 1903. Bedford, Massachusetts 01730 On the fiftieth anniversary of the statue’s dedication a Email: [email protected] Slovenian immigrant writer, Louis Adamic, and many others

32 The Pharos/Summer 2014 A Guest at Communion

The Pastor wipes the chalice clean, as one by one they come to drink. Some place the Host within their mouth then sip. Others dip into the wine, partake as one the body & the blood. Between hymns and homily, from under his robes the Pastor takes a handkerchief, blows his nose. With an eye for illness, I wonder what might pass from one to another. This congregation shares their faith and more. Perhaps the blood of Christ destroys all germs. But to be safe, I’d rather be a wafer dipper than a goblet sipper. Richard Bronson, MD

Dr. Bronson (AΩA, New York University, 1965) is Professor of Obstetrics & Gynecology and Pathology, Vice Chairman for Education, and Director of Reproductive Endocrinology at Stony Brook University Medical Center. He is a member of the editorial board of The Pharos. His address is Stony Brook University Medical Center, T9-080, Stony Brook, New York 11794-8091. E-mail: richard. [email protected]. Illustration by Jim M’Guinness.

The Pharos/Summer 2014 33 The most memorable patient I never saw

Illlustrations by Jim M’Guinness

Arthur Lazarus, MD, MBA

The author (AΩA, Temple University School of Medicine, “This is Dr. Hendricks (not her real name) in the ER. Are 1980) is adjunct professor of Psychiatry at his alma mater. you the on-call psych resident tonight?” “I am,” I answered drowsily. oon after midnight, after a busy day on the inpatient Every physician knows that nightly awakenings are part psych unit, I slipped into a deep sleep. Then the phone and parcel of being on-call. And like most residents, I had rang in the residents’ on-call room. learned how to short-circuit several stages of sleep to quickly S“Dr. Lazarus?” the voice on the other end inquired. attain alertness when paged. But tonight it was really difficult “Yes,” I replied, half asleep. to wake up.

34 The Pharos/Summer 2014 “We have a patient down here. I don’t think you need to see This time, I couldn’t get back him, but I’d like to run the history by you and see if you agree to sleep. I asked myself how this with the treatment plan before we send him on his way.” could have happened. The patient I sat up in bed and said, “Sure. Go ahead.” was stable, according to the medical “The patient is in his twenties. He has a diagnosis of resident. He did not have command schizophrenia, and he lives in a local boarding home. One of hallucinations. He was not suicidal the staffers escorted him to the ER. The patient tells me he is or self-injurious. I lay awake second- hearing voices, but the voices are not telling him to do any- guessing myself—and the resident— thing bad or hurt himself. Do you think it’s okay to increase until daybreak. I should have seen the dose of his Haldol from 15 to 20 mg a day and set him up the patient, I bemoaned, rather than with an outpatient appointment in the psych clinic?” take the word of a physician with “Yeah, that sounds fine to me,” I replied, still groggy. There less experience in my specialty. were other aspects of the history that should have been ex- To make matters worse, in the plored, so I added, “Do you want me to come down and see morning, the ER staff notified the him?” consultation-liaison (C-L) team “Oh, no. That won’t be necessary,” remarked the medical about the incident before I did, and resident. “He looks pretty good. I’m just not too familiar with a rumor had spread that I had Haldol, and I want to know if bumping up his dose by 5 mg is refused to see the patient in appropriate.” the emergency room. Shame “It could go higher,” I explained, “but that can be evaluated and guilt set in immedi- further when he is seen in clinic.” ately, like an IV infusion. “Okay, then, Dr. Lazarus. Thanks for your help.” I was interrogated by the “Is it quiet tonight?” I asked before hanging up. That was upper-year resident on code for asking whether any other psych cases were pending the C-L service. I as- and whether I could count on a good night’s sleep. sured the senior resi- “Not much happening,” the resident replied. “Thanks dent and the attending again.” physician of the C-L It took me less than ten minutes to reverse the sleep cycle. service that I had of- I nodded off with a good feeling, comfortable that I was able fered to go to the ER at to provide consultation without having to see the patient. It’s midnight, but I was told it about time I caught a break, I thought, considering that it was was unnecessary. The C-L team ap- spring and I was two-thirds of the way through my first year peared to be satisfied with my ac- of residency. count but not with my judgment to The emergency department was run by the medical house do a telephone consultation rather staff, who liberally called upon psych residents to see de- than evaluate the patient in person. pressed, addicted, and psychotic patients, even though these Clearly, the damage was done. patients were supposed to be transported and seen at the com- The patient had sustained serious munity “crisis center” located at another hospital. I felt I was injuries. The house staff dubbed fortunate to be spared a midnight consultation. I also thought him the “jumper,” and I had be- it was admirable that my counterpart in internal medicine at- come infamously associated tempted to handle the case herself. with him. No matter Suddenly, the phone rang at 3 AM. I woke faster than be- how many times I fore. “Dr. Lazarus, this is Dr. Hendricks again from the ER. replayed the inci- You’re never going to guess what happened!” dent, I could not Before I could utter a word, the resident continued in forgive myself for distress, “Remember the patient from the boarding home? not seeing the pa- Well, the paramedics just brought him back. He jumped out tient, even though a the third-story window and it looks like he broke both legs. face-to-face consul- We’re going to take him to X ray now, and he’ll probably need tation had not been surgery. I just wanted to let you know.” requested. I berated All I could say was, “Okay, thanks for letting me know. myself, thinking I should I’ll make sure the psych consultation team sees him in the have known better, that a morning.” bad outcome would ensue.

The Pharos/Summer 2014 35 The most memorable patient I never saw

I became overwhelmed with anxiety. I began to dread being the patient had put a plastic bag over his head to suffocate on-call. I tried to avoid difficult cases. I became depressed. My himself. Alarmed by the incident, his wife took him to the hos- performance suffered, and it was noted by many of the faculty. pital, and he was admitted to the surgical floor. I found him to I was placed on probation midway through the second year of be despondent and hopeless. I thought he would benefit from my residency. inpatient psychiatric hospitalization, and I recommended I sought the help of a senior psychiatrist, who became my transfer to the psych unit. therapist. He was a kind and compassionate man who un- However, the patient’s doctor, a powerful head and neck derstood what I was going through. He assured me that even surgeon and the father of one of my medical school class- a modest improvement in my defenses—unconscious ways mates, resisted my recommendation. I stood toe-to-toe with of managing conflict and strong emotion—could result in a him and strongly argued for psych admission even though I sizable improvement in my life. But he warned me, “Art, un- had not yet had a chance to discuss my plan with the C-L at- less you can acknowledge that a patient’s fate is beyond your tending physician. The surgeon capitulated, and the patient control, you will not survive in practice.” was transferred for treatment. He was discharged a week later My residency director opened my eyes to the fact that in much better spirits. psychiatry, like other specialties, has a mortality rate—from Over the course of my residency, I went from turmoil to suicide and homicide. He said I could not predict the behavior triumph. I was asked by the chairman of the psychiatry de- of my patients with any more accuracy than could a lay person, partment to stay on-board and join the faculty. I spent the much less that of a patient I had never seen. In fact, research next four years in the department, initially as an instructor, has shown that psychiatric residents are not able to predict and I was promoted to assistant professor. I was becoming violent behavior in patients any better than chance.1 quite the academic, and residents began to call me “Article” Another psychiatrist pointed out that practice norms Lazarus, because I was either handing out articles on rounds vary widely across the United States. Neither evidence from or publishing my own. clinical trials nor clinical observation can dictate action—nor Unfortunately, I never could come to terms with the inaction—in particular circumstances. The management “jumper.” I suffered from post-traumatic stress disorder decision for a single patient is complex, requiring a synthesis (PTSD), and I experienced “anniversary reactions” every of incomplete and imperfect information and medical knowl- spring in the form of distressing memories of the event. I had edge. “What makes you think,” the psychiatrist probed, “this difficulty delegating responsibility to medical students and decision is made with any precision in the head of a sleep residents, and I worried excessively about my patients, even deprived resident?” about writing their prescriptions. On a few occasions I called Intellectually, I agreed with all three psychiatrists, but my patients to “check” that I had written for the correct dosage. emotionally, I was a wreck. I continued to blame myself for As time passed, I learned to hide my fears, but the “jumper” the incident, and I feared my reputation had been tarnished. clearly haunted me and left an indelible mark on my psyche. I thought about leaving residency for a position in industry. I I left academia for a career in industry after all. Although actually interviewed for a job and was offered the position— the burden of caring for patients was removed, my PTSD ironically, working for the makers of Haldol! I decided instead morphed into a generalized anxiety disorder (GAD) that has to stay and complete my residency, if possible. persisted throughout my nonclinical career. Given that PTSD I slowly regained my confidence, and my probation was and GAD commonly co-occur,2 perhaps it was only a matter lifted after six months. My performance evaluation contained of time until a different patient or traumatic event would have a note from the chairman of the department: “There was some triggered such intense anxiety. In fact, prior to the publication comment on your earlier fear of the psychotherapeutic role, of the fifth edition of the Diagnostic and Statistical Manual but the consensus was that this has improved markedly.” of Mental Disorders3 in 2013, PTSD was considered an anxiety The director of residency training added, “The faculty felt disorder. It is now classified as a trauma- and stressor-related you should be less concerned about making mistakes, that disorder. we all learn from making mistakes, and that nobody here is The popular notion of PTSD is that symptoms of the expecting you to know the answer every time.” disorder, such as flashbacks, intrusive thoughts, and feeling I knew I had “arrived” when, in my final year of residency, on-guard, coincide with highly stressful and specific traumatic I was elected chief resident. I was now the senior resident on events, for example, wartime combat, physical violence, and the C-L service. And what was about to transpire would have natural disasters. In truth, affected individuals may be exposed shaken me to the very core had I not had the benefit of therapy directly or indirectly to the stressful event. Exposure to the and additional clinical experience since my encounter with the stressor may involve actual or threatened death, serious injury, “jumper.” or sexual violence. And although symptoms of PTSD usually I was consulted to evaluate a man who had recently under- occur within the first three months after the trauma, their gone extensive surgery for laryngeal cancer. While at home, onset may be delayed by six months or longer.

36 The Pharos/Summer 2014 PTSD is usually not considered a result of medical train- embarrassment of making a mistake? And how do we over- ing. But in reality, both residents and physicians suffer a high come our fear of making mistakes? rate of PTSD due to medical practice, whether or not they Despite psychotherapy and support from my colleagues, I treat trauma patients or patients with life-threatening condi- was unable to resolve these issues. Assurance that I was a good tions.4 Apparently, the stress of practice alone is sufficient to doctor was insufficient. Guidance from my mentors didn’t sink cause symptoms characteristic of PTSD. PTSD has also been in. Textbooks and self-help books seemed inadequate. Advice diagnosed in professionals exposed to repeated or extreme to “get tough” with patients—and, alternatively, to distance aversive details of traumatic events in the course of health- myself from them—was rejected. related work. Examples include first responders collecting hu- I did learn, however, that caring for seriously ill patients, man remains and police officers repeatedly exposed to details and those who have the potential to become seriously ill, of child abuse. can significantly impact our inner lives. “The inner life of Dr. James S. Kennedy, formerly at Vanderbilt University individual physicians should, to some extent, be brought into Medical Center, stated, “The resulting feeling that physicians the outer life of physicians as a collective,” remarked Dena [with PTSD] ignore most is toxic shame . . . the belief that Schulman-Green of the Yale Center for Excellence in Chronic one is defective. . . . Once in practice, patient care ‘retriggers’ Illness Care.8 In that case, writing this article has been long the toxic fear, loneliness, pain, anger, and shame physicians overdue. experienced in training.”5 I thought I was reading about myself Anaïs Nin said, “We don’t see things as they are, we see when I read that passage. things as we are.” Practice protocols may guide treatment, PTSD is discussed in Dr. Danielle Ofri’s book What Doctors but our emotions, prejudice, tolerance for risk, and personal Feel: How Emotions Affect the Practice of Medicine.6 Dr. Ofri, knowledge of the patient guide our clinical judgment. We an associate professor of Medicine at New York University learn how to obtain good outcomes even when care decisions School of Medicine, describes the riveting story of Eva, a are made with incomplete or flawed data—the so-called art first-year pediatric resident who was traumatized when a se- of medicine. Along the way, we learn from our mistakes, and nior resident instructed her to let a newborn infant die in her hopefully we learn how to forgive ourselves and seek forgive- arms—in a supply closet of the hospital no less—because the ness from those we have harmed. infant was doomed to a quick death due to Potter syndrome. Dr. Ofri commented, “Eva’s residency was truly a traumatic References experience in which survival was the mode of operation. 1. Teo AR, Holley SR, Leary M, McNiel DE. The relationship And the PTSD that resulted was real. . . . Certainly, in the between level of training and accuracy of violence risk assessment. breakneck pace of Eva’s residency, there was barely a blip of Psychiatr Serv 2012; 63: 1089–94. acknowledgment for the wells of sadness that bloomed, day 2. Brown TA, Campbell LA, Lehman CL, et al. Current and after day.” 6pp106–7 lifetime comorbidity of the DSM-IV anxiety and mood disorders in Dr. Ofri, herself, experienced long-lasting shame and hu- a large clinical sample. J Abnorm Psychol 2001; 110: 585–99. miliation after committing an error that nearly killed a patient. 3. American Psychiatric Association. Diagnostic and Statistical Exactly two weeks into the second year of her residency, Dr. Manual of Mental Disorders, Fifth Edition. Arlington (VA): Ameri- Ofri mismanaged the insulin therapy of a patient in diabetic can Psychiatric Association; 2013. ketoacidosis. She was severely reprimanded by a senior resi- 4. Wilberforce N, Wilberforce K, Aubrey-Bassler FK. Post- dent in the presence of her intern. “I could almost feel myself traumatic stress disorder in physicians from an underserviced area. dying away on the spot,” Dr. Ofri remarks. “The details of my Fam Pract 2010; 27: 339–43. insulin error in the dingy Bellevue ER are crisply stored in the 5. Kennedy JS. Physicians’ feelings about themselves and their linings of my heart.” 6p130 patients. JAMA 2002; 287: 1113. In medical school, many of us are told to “get over” our 6. Ofri D. What Doctors Feel: How Emotions Affect the Practice insecurities. It is only through a “hidden curriculum” 7 that we of Medicine. Boston: Beacon Press; 2013. learn that not all patients can be saved or rescued. Over time, 7. Hafferty FW, Franks R. The hidden curriculum, ethics teach- we realize the limits of our abilities. Recognition of what it ing, and the structure of medical education. Acad Med 1994; 69: really means to be a physician—the sense of power and pow- 861–71. erlessness, of hope and helplessness—is both an attitude and 8. Schulman-Green D. Physicians’ feelings about themselves and a skill that must be acquired during training. their patients. JAMA 2002; 287: 1114. Still, it is legitimate to ask: Who provides physicians the necessary skills to cope with loss and despair? Who con- The author’s address is: soles us when our best turns out to be not good enough? 29 Shinnecock Drive Who teaches us how to deal with uncertainty inherent in Palm Coast, Florida 32137 medical practice? How do we rise above the scandal and E-mail: [email protected]

The Pharos/Summer 2014 37 The physician at the movies Peter E. Dans, MD

Jack Ryan: Shadow Recruit therapy. She can’t date patients but when she is no longer his Starring Chris Pine, Keira Knightley, Kevin Costner, and caregiver and has embarked on her ophthalmology residency, Kenneth Branagh. they begin a relationship. After he leaves the hospital, Ryan is Directed by Kenneth Branagh. Rated PG-13. Running time recruited by CIA operative Thomas Harper (Kevin Costner) as 105 minutes. an analyst to monitor the Russians who are plotting to destroy the dollar. We are treated to screensful of computer-generated he film opens in London on September 11, 2001, where figures and assorted mumbo-jumbo that essentially show that John Patrick Ryan (Chris Pine) is pursuing an economics the Russians are hiding numerous accounts and could dump Tdegree. The 9/11 attack leads him to join the Marines. Cut next billions in treasury bonds on the market at a critical time, to to Afghanistan where he and other Marines are being trans- devastating effect. Ryan is sent to Moscow, where he escapes ported in a helicopter while discussing the relative merits of killers, helps advise the tracking down of terrorists, all the the Baltimore Ravens and Cincinnati Bengals. (This dialogue while racing against the clock to prevent a stock market col- was probably an homage to Tom Clancy, a Baltimorean and lapse. He is almost killed by the person who is sent to meet the author of the Jack Ryan novels.) This is the only Ryan story him at the airport to “protect” him. This is the first of three that was not based on a novel; it is a prequel to the series cre- all-out battles to save his life. ated by Adam Cozad and David Koepp with the blessing of The movie becomes more interesting when he meets Clancy, who died on October 2, 2013, after production Russian oligarch Victor Cherevin (Kenneth Branagh), the was completed. Soviet mastermind of the two-pronged attack on the United The helicopter is shot down and Ryan sus- States that is code-named “Lamentations.” This is an allusion tains serious injuries. He is sent to Walter Reed to the Russian Orthodox religion that was suppressed by the Hospital where he meets and falls in love with Communists but is now flourishing. Cherevin’s plan is aimed Cathy Muller (Keira Knightley), a medi- at extracting revenge as a retribution for the loss of his son cal student rotating through physical when the United States backed the mujahedin against Russia

38 The Pharos/Summer 2014 in Afghanistan. His first prong involves the activation of his There is also an excellent dinner scene where the wine is other son Constantin (Lenn Kudrjawiski)—who has lived in an Haut Brion, reminding me of having visited that vineyard Dearborn, Michigan as a mole for years—to carry out a terror- with my wife Colette on our honeymoon in 1966. The owner ist attack on Wall Street. The location made me wonder if this offered to sell us a case of what he said was an excellent vin- was originally scripted to involve Muslims and, sure enough, tage but I demurred. Being unschooled in wine (a deficit that it was set originally in Dubai. One wonders what pressure was persists), we probably would have never held on to it. exerted to get this changed. The second prong is the cashing Finally, as if to confirm that this is a Geezer movie, the in of the billions of bonds timed to coincide with blowing up film received the inaugural AARP Movies for Grownups seal Wall Street. All this is accomplished by Ryan in what has to be intended to recognize films that have a special appeal to age an exhausting forty-eight hours with his bad back and gimpy 50+ audience members.1 What more can I say! legs. There are the requisite and hair-raising lunatic car chases in Moscow and Lower Manhattan. Totally far-fetched. Reference Add the cheesy low-budget sets—for example, shots of 1. AARP Debuts “Movies for Grownups” Seal. http://www.aarp. Saint Basil’s having been filmed in England (I assume the org/about-aarp/press-center/info-01-2014/aarpdebuts-movies-for- Russians nixed location shots)—and you get a not-very-good grownups-seal.html. picture and one that I would usually tell people to avoid. Yet it’s strangely entertaining. It fits the category of pictures that The Grand Budapest Hotel are so exquisitely bad that they are good. What makes it so Starring Ralph Fiennes, Tom Wilkinson, F. Murray Abraham, is the likeability of the cast, especially Branagh whom Muller and Tony Revolori. diagnoses with jaundice and who has only a few months to live, Directed by Wes Anderson. Rated R. Running time 100 minutes. a life expectancy that is likely to be shortened by his colossal bungling. Kevin Costner is excellent as Ryan’s CIA handler, f I can convince even one reader to skip this movie and who acts as a calming influence as Ryan races around Moscow to put the time to better use, I will have accomplished my and the United States. Knightley is perfect as Ryan’s fiancée objective.I If I hadn’t gone to the screening with two guests I who, because they are not married, cannot be told that he is would’ve walked out. I haven’t sat through so terrible a film as working for the CIA. When she learns that he is she says, “Thank God.” She thought all his absences were because he was cheating on her. She is invited by Cherevin, who has a soft spot for women, alcohol, and heroin, to come to Moscow and she plays a major role in identifying and tracking the terrorists. The best line is at the end when Ryan and Harper are to meet the president and Harper tells Ryan to “Wipe that Boy Scout on a field trip look off your face.” It’s exactly the persona that’s made Pine unpopular with Ryan aficionados. I kind of liked it. There were some interesting touches, such as the Snellen chart throw pillow on Muller’s sofa. I also resonated with Ryan meeting his handler at the Film Forum near Lincoln Center during the playing of Sorry Wrong Number, starring the much underrated Barbara Stanwyck, who never won an Academy Award despite numerous outstanding performances. She plays a bedridden hypochondriac who overhears a telephone conversation involving a murder plan and gradually realizes she is the intended victim. This scared the life out of me when I was eleven and swore me off me Paul Schlase, Tony Revolori, Tilda Swinton, and Ralph Fienes in The Grand scary movies. Budapest Hotel. ©Fox Searchlight Pictures

The Pharos/Summer 2014 39 The physician at the movies

this since Last Year at Marienbad with its long, long couloirs known as humanity.’ ” 3 All I can say about that is “Wow!” (corridors). Like Marienbad, this film will appeal to intel- Let’s give John Podhoretz, the Weekly Standard’s movie lectual cinephiles, not middlebrows like me. It is a succession critic the last word: Comparing Anderson to Bertolt Brecht, of visuals with a weird story line, if it can be called that. It he said, “I loathe Brecht, but at least he was up to something. also has the added attribute of appealing to those who like to What the hell is The Grand Budapest Hotel about? Beats me.” 4 spot the stars playing mostly cameo roles: see Bill Murray, see Edward Norton, see Adrien Brody, see F. Murray Abraham, References see Jude Law, see Owen Wilson, see Tom Wilkinson, see Ralph 1. Denby D. Lost time. New Yorker 2014 Mar 10: 78-79. Fiennes. That doesn’t include two of my least favorite actors 2. Phillips M. Precisely Wes Anderson. Baltimore Sun 2014 Mar who play menacing roles: Harvey Keitel (with a New York 21: 16. accent), and Willem Dafoe (although, I did like Dafoe in Mr. 3. Morgenstern J. Multistoried “Hotel”: Wicked, wild Wes. Wall Bean‘s Holiday where he plays a caricature of himself). Street J 2014 Mar 7: D3. Its other appeal involves what I call “doing the Tarantino” 4. Podhoretz J. Just checking in. Weekly Standard 2014 Mar 31/ (the ex-video store clerk turned director). The game involves Apr 7: 47. recognizing visuals that pay tribute to other films like The Seventh Seal, Night Train to Munich, The Lady Vanishes, Grand Hotel etc. Some people in the audience of the pre-release screening Starring Greta Garbo, John Barrymore, Joan Crawford, laughed at the inside jokes before the punch line. Wallace Beery, and Lionel Barrymore. To call the film “quirky” understates the grotesqueries with Directed by Edmund Goulding. Not rated. B&W. Running time the lopped-off heads in a basket and fingers broken off by 115 minutes. the closing of an elevator. A better description is pretentious and confusing, as the director skips around from one place to eeing The Grand Budapest Hotel made me want to check another. Give Ralph Fiennes credit for trying to connect the out the 1932 classic, Grand Hotel, a showcase of the lumi- dots and hold the film together as the central character M. nariesS in the Metro-Goldwyn-Mayer studio, which trumpeted Gustave, “the finest hotel concierge known to humankind,” that it had “more stars than there are in the heavens.” The film presiding over a Middle European hotel between the wars. is based on Vicki Baum’s novel of the same name, drawn from Wes Anderson is considered an auteur director, which allows her work as a chambermaid at two hotels in Berlin between him to film his personal hallucinations whether the audience the wars. The film’s premise is that “nothing ever happens at understands them or not. David Denby, critic for the New the Grand Hotel. People come and people go but nothing ever Yorker, characterized the movie thus: “the past becomes vis- happens.” Actually, many things happen behind the scenes at ible in stages, as if seen through the wrong end of a telescope the sprawling hotel—including murder. that gets repeatedly extended.” He concluded his review by It opens with the old-fashioned switchboard operators saying that the film is ”no more than mildly funny,” producing expertly handling calls coming in and going out of the most “murmuring titters rather than laughter—the sound of viewers expensive hotel in Berlin. Would-be guests congregate at the affirming their own acumen in so reliably getting the joke.” 1 front desk vying for a room; this includes Lionel Barrymore To be fair I should note that some people liked this film. as a worker in the factory of another hotel guest, a brutish Michael Phillips, critic for the Chicago Tribune called it “one industrial magnate played by Wallace Beery. Barrymore* has of Anderson’s cleverest and most gorgeous movies, dipping only a few months to live and decides to use his savings on a just enough of a toe in the real world—and in the melancholy fling. Beery is a loudmouth Prussian who is trying to engineer works of its acknowledged inspiration, the late Austrian writer a deal under false pretenses to avoid financial ruin. Greta Stefan Zweig—to prevent the whole thing from floating off Garbo plays an aging Russian ballerina who no longer draws into the ether of minor whimsy. It’s a confection with bite. . . . an adoring crowd. The twenty-seven-year-old Garbo signals Even when the dialogue slips into jokey anachronisms or less her despair both in the film and probably in her personal life than sparkling repartee.” 2 Talk about pretentiousness! in her opening line: “I’ve never been so tired in my life.” She Joe Morgenstern of the Wall Street Journal said, “Hardly shoos away her hangers-on uttering her signature line that will a moment goes by in Wes Anderson’s ‘The Grand Budapest later become a favorite of mimics, “I want to be alone.” Hotel’ when there isn’t something to make us smile—a pretty image, a funny line, a droll sight gag, a charming set, a striking juxtaposition of color or tone. . . . Cosmopolitan, self- ironic and sexually ambiguous, just as Zweig was, Gustave is * For all except John Barrymore who plays the Duke I will use the a picaresque hero, but he is also a fierce survivor who speaks name of the star since the film is really about them and not the characters they play. Indeed the tales of their interactions during the more than once of ‘this barbaric slaughterhouse that was once making of the film are legendary.

40 The Pharos/Summer 2014 have his head examined. Most of the players give impossibly bad performances. They chew up the camera. But if you want to see what screen glamour used to be and what, originally, ‘stars’ were, this is perhaps the best example of all time.” 1 If you want to see an entertaining film about hotels, I recommend Weekend at the Waldorf a 1945 remake of Grand Hotel. It stars Ginger Rogers, Walter Pidgeon, Lana Turner, Van Johnson, Edward Arnold, and humorist Robert Benchley, who opens the movie as a concierge walking a dog and inviting us into the hotel. I have a fondness for the picture, which also features Xavier Cugat, who with his pre-Charo singer Lina Romay and his orchestra, was regularly in residence at the hotel. The hotel retains most of the elegance it had when our high school senior prom was held in its Starlight Roof in 1953. There’s a wonderful clock in the middle of the foyer and the piano that Cole Porter played when he lived there. New York Greta Garbo in Grand Hotel. ©MGM in 1945 is best captured in the excellent book Manhattan ’45.2

Reference A world-weary fifty-year-old John Barrymore plays a Duke 1. Kael P. 5001 Nights at the Movies. New York: Picador; 1991: who has turned jewel thief to pay off his gambling debts. He 299. intends to steal the ballerina’s pearls, which ironically mean 2. Morris J. Manhattan ’45. Baltimore (MD): Johns Hopkins nothing to her anymore because her career seems to be over. University Press; 1998. Joan Crawford plays a stenographer hired by Beery in one of the sexiest roles she ever played. There’s a great scene with her Dr. Dans (AΩA, Columbia University College of Physicians and and the Duke, who when he learns she’s a stenographer asks Surgeons, 1960) is a member of The Pharos’s editorial board and her if she wouldn’t mind taking dictation from him. The scene has been its film critic since 1990. His address is: would have been cut a few years later, but the film was made 11 Hickory Hill Road in what is called the pre-code era between the time when the Cockeysville, Maryland 21030 Motion Picture Production Code was enacted and its strict E-mail: [email protected] enforcement in 1933. Crawford was clearly trying to upstage Garbo and did so to such effect that Garbo complained to Irving Thalberg, MGM’s so-called boy genius who was responsible for the film being made. Thalberg arranged to shoot some extra scenes of Garbo to give her more screen time, including a love scene with the Duke who gains entry to her apartment but changes his mind about wanting to steal her pearls when he sees the vulnerability of the despairing ballerina on the verge of suicide. He makes love to her, speaking such deathless lines as, “I want to be with you; I want to breathe the air that you breathe.” His love energizes Garbo as he tells her, “You must believe that I love you. I’ve never loved anyone like you.” The film, which cost eighty million in today’s dollars, made substantially more than that. It won the Academy Award as the Best Picture of 1932, but is the only Best Picture that had no other awards. How could it have, being replete with a bevy of actors with large egos jockey- ing for supremacy and who made their mark emoting in silent movies. The worst is Wallace Beery. Pauline Kael said it best: “Anyone who goes to see this movie expect- John Barrymore and Joan Crawford in Grand Hotel. ©MGM ing an intelligent script or even ‘good acting,’ should

The Pharos/Summer 2014 41 Reviews and reflections

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

hypochondria are: the patient’s fear that position is of one who fears and doubts disease is present, embodied resistance that disease lurks hidden in the body, to surveillance (that is, doctors can find (3) The position is of one who expects no evidence of disease), doubt about that there must be a doctor somewhere reassurance, informed responsibility on with technology to expose all the body’s the part of both patient and doctor, and inner threats, and (4) The position is a narrative-based cultural context. of one who tries to discern the body’s Having defined hypochondria, Dr. future by listening to its symptoms and Belling approaches her question, “How examining the body. can you tell?” by dividing her book into In “Part Two: A Medical Condition,” four sections: Dr. Belling traces the history of hy- A Condition of Doubt: The • “Part One: A Biological Condition” pochondria and exposes the difficulty Meanings of Hypochondria focuses on hypochondria as a function that medicine faces when it attempts Catherine Belling of our human experience as embodied to include the word or condition in its New York, Oxford University Press, beings who understand our bodies in diagnostic classification. She focuses 2012 ways that biological science understands in some detail on psychiatry’s efforts at them. classification. In psychiatry’s Diagnostic Reviewed by Sally K. Severino, MD • “Part Two: A Medical Condition” and Statistical Manual (DSM)-4, hypo- ( , University of New Mexico, AΩA highlights hypochondria’s challenge to chondriasis appeared as a somatoform 1997) the validity of medical knowledge and disorder. In the new DSM-5, published doctor’s practices. in 2013, hypochondriasis and somato- Condition of Doubt: The • “Part Three: A Cultural Condition” form disorder are reconceptualized as Meanings of Hypochondria portrays the cultural context that frames a new category called somatic symp- isA written by Catherine F. Belling, medical information and gives rise to tom and related disorder. This recon- PhD, who is Associate Professor in modern hypochondria. ceptualization addresses two concerns Medical Humanities and Bioethics • “Part Four: A Narrative Condition” of Dr. Belling: (1) that hypochondria at Northwestern University Feinberg describes the challenge that hypochon- is a condition of primary care medi- School of Medicine. As such, she is in dria poses to medical narrative. cine because the patient’s symptoms are medicine but is not a medical doctor. In each section, Dr. Belling views real, and (2) that a diagnosis be based She views medicine and asks the impor- hypochondria not with a physician’s on positive signs and symptoms rather tant question, “How can you tell what is eyes that objectively evaluate a patient’s than an absence of medical explana- health and what is illness?” body, but with the eyes of someone tion for somatic symptoms. It does not, She approaches this question by who understands the hypochondriac’s however answer another issue: the way focusing on the medical condition of subjective experience of body as repre- medical students are formed into phy- hypochondria, which she defines as sented in literature, drama, and other sicians. Here Dr. Belling emphasizes “mental distress caused by uncertainty cultural expressions. This lends itself the cultural change that occurred in about the meaning of actual somatic to a rich experience for the reader as medicine during the eighteenth cen- experience.” p16 Hypochondria is not Dr. Belling introduces us to a wealth of tury. Before Enlightenment science, the malingering (pretending to be sick), serious humanities scholarship that has patient’s experience and the doctor’s in- not a delusion, and not a medi- informed her view of medicine. terpretation co-constructed a diagnosis. cal syndrome of unexplained In “Part One: A Biological Condition,” After Enlightenment science, the doc- symptoms such as chronic Dr. Belling arrives at her view of hypo- tor’s search for pathological anatomy pain syndrome. Rather, chondria, which I summarize as follows: of a material lesion became more real the five necessary (1) Hypochondria is not a mental or than what the patient felt. The ramifica- conditions for physical illness but a position, (2) The tions of this change have been further

42 The Pharos/Summer 2014 complicated by the social context of In the end, Dr. Belling concludes health care since the 1970s, in which that the answer to the question, “How patients have learned to challenge the can you tell?” is: “Sometimes you evidence or lack of evidence of disease can’t.” Hypochondria challenges medi- and doctors have been trained to be not cine to admit that sometimes there is entirely sure about whether a hidden no objective understanding of reality. biological reason might exist for the pa- Hypochondria cannot be reduced to a tient’s symptoms. Hypochondria, thus, pathology or a diagnosis. is a medical condition at the center of Hypochondria suspects a diseased a modern contest between patient and body. Medicine, finding no lesion, can doctor. best acknowledge that there may be illness In “Part Three: A Cultural within, but since it can’t be confirmed, it is Condition,” Dr. Belling focuses on three best to live as if it did not matter. cultural contexts that frame medical Whether you agree with Dr. Belling’s or weeks, but a work to be consulted information and give rise to modern portrayal of hypochondria or not, her over time. For those of us whose un- hypochondria. The first context is the perspective is erudite and interesting. derstanding of illness is rooted in medi- availability of medical information on As an insider—though not for the di- cal science, Solomon presents not just the Internet that blurs the boundaries agnosis of hypochondriasis—for the fact and supposition but the narrative between doctors’ and patients’ use of revisions of DSM-III-R, DSM-IV, and detail of what it is like to care for and this information and generates what DSM-IV-R, I welcome Dr. Belling’s per- to live with those whose many human she calls “cyberchondria.” The second spective on hypochondria, on medicine, experiences differ from the norm or the context is public health communication, and on the human condition. As an ideal. The author has copious research which moves masses emotionally to be- undergraduate major in the humanities, to buttress his stories, yet this is the least have in certain ways to prevent disease I commend Dr. Belling for her valuable opinionated of works. Rather it is rich rather than providing medical infor- collection of hypochondria narratives. with narrative that carries the reader as mation about disease. The cautionary As a bridge-builder for cross-disciplin- close as possible to the actual experience tales of public health communication ary dialogue, I recommend this book to of living with and coping with difference. contribute to hypochondriacal anxiety readers who search for much food for The book is divided into twelve chap- about risk of disease. Early detection of thought. ters that include “Son,” “Deaf,” “Dwarfs,” disease has created the term “previvor,” “Down Syndrome,” “Schizophrenia,” someone who has survived a disease be- Dr. Severino is Professor Emeritus of Psychi- “Disability,” “Prodigies,” “Rape,” “Crime,” fore it has begun. Such is the example of atry at the University of New Mexico Health “Transgender,” and “Father.” Deborah Linder who, when she learned Sciences Center School of Medicine in Al- As I watch my son and his wife love that she carried the gene that predis- buquerque, New Mexico. Her address is: and care for their seven-year-old son poses some women to cancer, had both 1050 Joshua Drive SE diagnosed as on the autistic spectrum I breasts removed. The third context is Rio Rancho, New Mexico 87124-1258 was particularly interested in Solomon’s reading or seeing horror stories. Horror E-mail: [email protected] chapter on autism. Let me quote from stories offer an infectious anxiety. Both that chapter. hypochondria and horror prevent clo- Far from the Tree: Parents, sure that would render events meaning- Children, and the Search for Some experts argue that we ful and prevent catharsis that would Identity are simply diagnosing it more fre- maintain reassuring order. Andrew Solomon quently, but improved diagnosis can In “Part Four: A Narrative Condition,” New York, Scribner, 2012 hardly be the full explanation for the Dr. Belling illustrates how the structure escalation from a rate of 1 in 2,500 of stories that tell of hypochondria denies Reviewed by David A. Bennahum, births in 1960 to 1 in 88 today. We closure and how the discourse in which MD (AΩA, University of New Mexico, don’t know why autism is on the the stories are told denies credibility. 1984) rise; indeed we don’t know what au- Hypochondria is the story that won’t be- tism is. It is a syndrome rather than gin and won’t end. It is like a time bomb. ndrew Solomon has written a sensi- an illness because it is a collection No one knows when it will explode. And, tive, informed, and quite extraordi- of behaviors rather than a known when organic disease is not found, “the naryA book that deserves a place in every biological entity. The syndrome en- patient is trapped in a story that is end- physician’s library. At 960 pages this is compasses a highly variable group lessly just about to begin.” p222 not a book to be absorbed in a few days of symptoms and behaviors, and we

The Pharos/Summer 2014 43 Reviews and reflections

have little understanding of where He writes that parents spend inordinate it is located in the brain, why it oc- energy and time trying to help their chil- curs, or what triggers it. We have no dren communicate, and in the process way to measure it but by its external often neglect other aspects of education manifestations. The Nobel Laureate such as mathematics, history, and phi- Eric Kandel said, “If we can under- losophy. He writes that the experience stand autism, we can understand of these children and their parents “felt the brain.” That is a generous way arrestingly familiar to me because I am of saying that we will understand gay. Gay people usually grow up under autism only when we understand the purview of straight parents who feel the brain.p221 that their children would be better off straight and sometimes torment them A wonderful quality of Solomon’s by pressing them to conform. Those writing is his ability to switch from the gay people often discover gay identity in of memoir, meditation, and health care science to the stories. For example in adolescence or afterward, finding great policy. He weaves these elements to- discussing their child Cece, her par- relief there.” p3 gether into a design that, for me at least, ents Betsy and Jeff described visiting a The measure of this book is the cour- was not immediately clear, but which, neurologist when Cece was four. After age of the author, whether in writing of upon further reflection, I found deeply examining the child he said, “If she’s not his own struggles in coming to terms meaningful. talking at all after this high-quality early with his natural identity or with his own At its most general level, What intervention [the child had had inten- depression, which he chronicled in a Matters in Medicine asks the question: sive preschool experience], she’ll never previous book, The Noonday Demon: “What would the practice of medicine talk, and you should get used to that. An Atlas of Depression. The intelli- look like if it were ruled by common She has serious autism.” p225 gence, honesty, and compassion found sense, if we set out to do only the right in reading Far from the Tree leaves one thing?” p168 In answering, the author Cece has actually spoken four with a sense of hope and optimism that sketches a picture that most of us would times in her life, and every time perhaps we can really take the world find appealing—more time spent with the words were appropriate to the in for repairs, as Richard Selzer once patients, meaningful personal relation- situation. When Cece was three, wrote, if only we listen to our patient’s ships, shared decision making, com- Betsy gave her a cookie; she pushed stories as well as studying and learning munity support. Will today’s rapidly it back at her saying, “You eat it, the science. changing medical scene, he then asks, Mommy.” Jeff and Betsy exchanged end in the final demise of primary care? glances and waited for their world to Dr. Bennahum is a book review editor for In other words, are “common sense” change. Cece said nothing more for The Pharos and a member of its editorial and “only the right thing” dying out, or a year. Then one day Betsy stood up board. His address is: is there hope for them in tomorrow’s to turn off the TV, and Cece said, “I 1707 Notre Dame NE medicine? want my TV.” At school, three years Albuquerque, New Mexico 87106 Drawing from the literature, as well later, she turned on the lights and E-mail: [email protected] as from his own broad experience, the said, “Who left the lights on?” Then author discusses the central features of one day a puppeteer visited the relationship-centered medical practice Cece’s class; when he asked, “Hey, and the limits placed upon them in con- kids! What color is the curtain?” What Matters in Medicine: temporary medicine. He is cautiously Cece responded, “It’s purple.” The Lessons from a Life in Primary optimistic about the Patient-Centered capacity to formulate and deliver Care Medical Home (PCMH) movement as a these sentences suggests a tantaliz- David Loxterkamp, MD possible future. In fact, his own Seaport ing lucidity below the silence. . . . Ann Arbor, University of Michigan Press, Family Practice in Belfast, Maine, was “I think that she might be prelit- 2013, 184 pages part of a national demonstration proj- erate,” Betsy said. “I believe that she ect that “sought to determine what was has a wild intelligence somewhere. I Reviewed by Jack Coulehan, MD, needed to transform existing practices worry that her soul is trapped.” p225 MPH (AΩA, University of Pittsburgh, into the PCMH model” p163 and is cur- 1969) rently engaged in a five-year effec- In chapter one, “Son,” Solomon tiveness study of twenty-five PCMHs writes that in 1993 the New York Times avid Loxterkamp’s What Matters in serving 170,000 patients throughout assigned him to investigate deaf culture. DMedicine is a fascinating mixture Maine. Among the salient features 44 The Pharos/Summer 2014 the author describes are same-day ap- happiness in marriage than they found to embracing expensive new drugs or pointments, utilization of information in the discharge of their duties.” p41 These procedures for their own sake. Perhaps technology, employment of midlevel were men whose lives were defined by I am reading too much into the stories practitioners, emphasis on teamwork, their work, which eventually diminished of those mid-twentieth century general measurement of outcomes, and involve- or destroyed them. They had certainly practitioners, but I can’t help but believe ment in the community. However, Dr. set out “to do the right thing,” but theirs that better care for generalist doctors is Loxterkamp also adds a cautionary note, were not the rosy-colored lives that our a necessary component in providing a “What is clear . . . is that the medi- nostalgia for the general practitioner viable future for primary care. cal home will need more than time to imagines. Something was missing. succeed.” p162 The author then turns to his personal Dr. Coulehan is a book review editor for With this statement in mind, let me memoir in “Departure,” the book’s sec- The Pharos and a member of its editorial return to “Staging: A Moral Capital,” the ond major section: his training in family board. His address is: first third of What Matters in Medicine. medicine; his decision to settle in Belfast, Center for Medical Humanities, Com- In this section Dr. Loxterkamp intro- Maine; the growth and development of passionate Care, and Bioethics duces the reader to the lives of three his professional practice; his later aspira- Stony Brook University mid-twentiethth century general prac- tion to become a writer; and ultimately Stony Brook, New York 11794 titioners. The first is Ernest Ceriani of his national recognition as a model fam- E-mail: John.Coulehan Kremmling, Colorado, who was the sub- ily doctor (à la Dr. Ceriani) in a 1998 Life @stonybrookmedicine.edu ject of “Country Doctor,” a 1948 photoes- cover story and an ABC television docu- say by W. Eugene Smith published in Life mentary in 2000. He accompanies this magazine. The young Dr. Ceriani served narrative with a series of engaging stories as the centerpiece of an article glorifying about his relationships with patients. traditional medical practice and oppos- At this point the reader is left with ing President Truman’s drive to establish the contemporary example of the suc- a national health insurance plan. The cessful—indeed the “model”—Dr. second physician he discusses is John Loxterkamp occupying the foreground, Eskell, a British general practitioner who, but in the background there remain under the pseudonym “John Sassal,” be- the three similarly dedicated physicians came the subject of John Berger and Jean of the past who sacrificed their health Mohr’s A Fortunate Man, a book-length and happiness to the overwhelming de- photoessay in which Dr. Sassal appears as mands of primary care. It seems evident a consummate country doctor, dedicated that the author views these predeces- to his community and immersed in the sors as professional role models, but at lives of his patients. The third general the same time he has sought to under- practitioner introduced is the author’s stand and avoid the pitfalls to which they own father, Dr. E. O. Loxterkamp, who succumbed. Eugene Braunwald and the lived and practiced in Rolfe, Iowa. While Dr. Loxterkamp succinctly Rise of Modern Medicine In the stories of these men, summarizes his “wish list” for improve- Thomas H. Lee ( , Cornell University, Loxterkamp discovers dedication, altru- ments in primary care, he is less direct in AΩA 1978) ism, and compassion, but he also finds a explaining how the primary care doctor Cambridge, Harvard University Press, darker side—alienation and depression. can maintain his or her own mental and 2013 As he grew older, Dr. Ceriani experienced spiritual balance. I think the answers lie conflicts with colleagues and bitter sepa- in the story of the author’s professional Reviewed by Daniel Friedman, MD ration from his wife. Dr. Eskell became development, along with his brief discus- severely depressed and eventually com- sion of Balint groups and reflective prac- mitted suicide. The elder Loxterkamp tice.pp164–67 Though not explicitly stated s a young cardiologist I had the good died of a heart attack when David was as such, these insights include creation fortune to hear Eugene Braunwald only in seventh grade. The author writes, and nourishment of supportive peer re- speakA on a number of occasions. I first “It is tempting to say they died with lationships, development of personally- met him when he gave the keynote ad- less than they deserved. They deserved fulfilling interests outside of medicine, a dress at an annual meeting of the Stanley longer and less harried lives, more colle- team-approach to practice, and creative Sarnoff Endowment for Cardiovascular gial respect, the understanding and sup- engagement with new ideas that actually Research. He spoke to a room filled with port of their communities, and no less enhance patient care, i.e., as opposed current and future investigators and

The Pharos/Summer 2014 45 Reviews and reflections

leaders in academic cardiology. Much After the NIH, Braunwald made a cru- not ignored. Despite his prominence, impressed by his brilliant reputation I cial and very brave decision to go to the he was unable to convince Bristol Myers had purchased every edition of his fa- University of California at San Diego, a Briggs to fund several large clinical trials mous textbook since entering the field new medical school, as its first Chairman of their products. Far more importantly, and seen his name on countless papers. of Medicine. It was there that he learned virtually every medical professional has Still it was on that day in Washington, to build a great department on the model heard of the John Darsee affair. This bril- DC that I began to recognize the true of Donald Seldin at the University of liant young investigator working under magnitude of his contribution to modern Texas Southwestern. It was also at the the supervision of Braunwald commit- cardiology. University of California that he learned ted profound levels of fraud. Lee write, Dr. Lee gives us an even deeper appre- to lead a research effort beyond his own “The revelation that John Darsee had ciation of a man who might be crowned work and to guide junior colleagues. committed research fraud not just once, the cardiology king of the last half of the In 1972, he and his family headed east but repeatedly over the years at Notre twentieth century. Many physicians are once more to New England. The last Dame, Emory, and then Harvard came familiar with his scientific contributions forty years in Boston has resulted for him as a shock to the many faculty members in ischemic heart disease, textbooks, and in an unrivaled place in this century’s who had been so impressed with him at teaching. The biography before us tells so history in cardiology. He was the Chair those institutions.” Countless papers had much more as Lee gives us insight into of Medicine at the Brigham Hospital and to be withdrawn. “Suddenly Braunwald’s his deep involvement in unraveling the later also at Beth Israel Hospital, a com- own prodigious rate of research publica- consequences of hypertrophic cardio- bination of jobs that he held with some tions became a focus of criticism instead myopathy and valvular and congenital regret, finding it to be highly draining. of respect.” The question of whether heart disease. Still, he helped raise academic cardiol- he had demanded too much of his ju- Although the book is well referenced ogy in Boston to the pinnacle of the nior colleagues had to be considered and and largely based on scientific facts, the field. Even before his arrival in Boston, great lessons were learned. Braunwald early portions tell the dramatic and tragic he had become instrumental in the de- himself came to realize that an outside story of his early life in the cauldron velopment of the Harvard Community team must pursue the investigation when of Hitler’s Europe. It gives the reader a Health Plan, a model for the nation. His a team member’s research honesty is glimpse of the challenges faced by the support of this early Health Maintenance called into question. He further realized young Braunwald when he and his fam- Organization not only provided good that once fraud is uncovered the “burden ily were forced to flee from Vienna and patient care, but also became an impor- must shift from finding other evidence with great luck landed in New York City tant instrument for departmental fund- of misconduct to proving the scientists’ in 1939. As a Jew in Austria, “his op- ing. Several times Dr. Lee mentions Dr. other data were produced honestly.” The tions had been limited at each stage of Braunwald’s great regard for physician book does not play down this momen- his life; but perhaps because of those “triple threats,” those excelling in clini- tous event, but it is placed in the context restriction he wanted to do all he could cal, research, and teaching endeavors. of all of Braunwald’s other phenomenal to keep his future wide open.” His deci- Whether we should consider that the accomplishments. sions along the way are profoundly edu- best use of creative people today is an- Braunwald told this story the day I cational to any young person mapping other question. met him at the Sarnoff meeting. He was out an important career. Much of Lee’s The biography also concentrates on telling young investigators how a remark- writing deals with the deliberate manner the great doctor’s personal life. On grad- able career develops. He told the story in in which Dr. Braunwald made choices uating from medical school, Braunwald a simple matter of fact way. He was not at each respective stage of his life, both married classmate Nina Starr, who be- boasting, but rather putting together a personal and professional. came a prominent heart surgeon in her brief road map of an almost unbelievable He was careful during aspects of his own right. Working alongside Dr. Glenn path. Dr. Lee takes us further down that training in New York to keep his options Morrow, she performed the first mi- road. open. In addition to clinical experiences, tral valve replacement. The Braunwalds he began to learn the art of being an worked together to balance their impor- Dr. Friedman is Director of the Presbyterian investigator. He then spent a “magical tant careers while raising two daughters. Heart Group in Albuquerque, New Mexico. decade” at the NIH as chief of cardiol- The author pays close attention to this His address is: ogy. During that time he came in contact challenge, which can help many young Presbyterian Heart Group with many of the great basic and clinical professionals recognize that one part- 201 Cedar SE, Suite 7600 science minds of our time. The list of ner’s success does not have to be at the Albuquerque, New Mexico 87107 his colleagues there reads like an atlas expense of the other. E-mail: [email protected] of Who’s Who in American cardiology. The difficulties Braunwald faced are

46 The Pharos/Summer 2014 Poetic encounters: A review of metaphorical truth beyond doubt. poetry by four clinicians Minimally Invasive offers us an amaz- ingly tender look at a life in surgery. Reviewed by Jack Coulehan, MD (AΩA, University of Pittsburgh, 1969) Reference 1. Williams WC. The Autobiography of ometimes I fantasize that poetry is a William Carlos Williams. New York: New healing wave sweeping over the face Directions; 1951: 357. Sof contemporary medicine. When I was young, doctor poets were rare. Perhaps a few existed, but they didn’t publish. Who could have imagined that one day poetry would appear as a regular fea- drawn from professional practice: the ture in medical journals like JAMA, The panoply of surgical clamps, “the rabbit Lancet, and Annals of Internal Medicine? hole” a surgeon plunges into, the “fatty While an average literary journal might curtain,” “the clap of steel on rubber reach one or two thousand readers, a glove,” and “good guts” sliding “to quiet poem published in JAMA might be read corners” of the abdomen. Consider also by 360,000. Nowadays dozens of poetry the extraordinary lyricism of poems like collections by physicians appear each “So Good,” “Euterpe,” and “Goodnight year. Poetry conferences and workshops Womb,” with its evocation of a well-loved have invaded many medical schools. children’s bedtime story. And some clinician-poets, like Rafael The transparent honesty of Maria Campo, Roy Jacobstein, Richard Berlin, Basile’s work is perhaps its most striking and David Moolten have “broken out” of characteristic. In this era of glib emotion, the strictly medical realm to win major her integrity shines through in every line. Scissored Moon national poetry competitions. It’s a dif- In the final stanzas of “To Sylvia,” ad- ferent world out there. dressed to the unstable Ms. Plath, Basile Stacy R. Nigliazzo In this review I want to consider reflects on her own work: Winston-Salem, North Carolina, Press several recent collections by new or 53, 2013 lesser known clinician poets. The first The surgeon at 2 a.m. is is Minimally Invasive, a remarkable stroking sunset blood on college-ruled yricism is also prominent in chapbook by Maria Basile, a practicing canvas, breathing blue Scissored Moon, a first book by colorectal surgeon. abandonment between lines, Lemergency room nurse Stacy Nigliazzo. drenching gauze decay in bleach In “Confidant” p10 she begins Minimally Invasive: poems on a and lye. life in surgery I am your nurse. She is writing Maria Basile for her life.p16 No one knows Gynedd Valley, Pennsylvania, The Lives the things You Touch Publications, 2011 Here the sentiment, the scene, the I know. meaning are utterly convincing. In his inimally Invasive breaks com- Autobiography, William Carlos Williams pletely with surgery’s macho wrote that medicine “was my very food And later affirms, “Face to face—/I will image—IM should say macha image, I sup- and drink” as a writer, “the very thing listen.” Indeed, Nigliazzo’s poems reflect pose, for a feminine surgeon. Some char- which made it possible for me to write.” 1 active listening, as well as compassion- acteristics remain. Surgeons cut to the Likewise, in “Truant” Dr. Basile writes: ate seeing and sensitive touch. Scissored heart of the problem and fix it, if they Moon embraces all the senses in exqui- can. They don’t take detours, or beat I have found poetry in the hands of site detail. Her book depicts a nurse’s around the bush. Likewise, Dr. Basile’s a patient, read history by the lines world fraught with illness, trauma, loss, poems on a life in surgery demonstrate on his face, heard symphonies in the endurance, hope, and sometimes heal- a unique combination of precision, lyri- rumbles of his gut. ing. This is a world of vibrant images, cism, and honesty that cuts to the core of like “his pupils quivering . . . slowly spill- experience. Consider her precise images These lines strike the reader as a ing over like bursting inkwells,” “Her

The Pharos/Summer 2014 47 Reviews and reflections

voice, a razored sliver . . . ,” “clover in the Disconnection. I miss green fleck of my eye,” and “a baby bird the relationships where I was collected from the sidewalk—/a freshly important to someone and incised gallbladder.” could pretend to be in charge. Yet, the true genius of these poems lies in their empathy, in the poet’s abil- Why did he close his practice? As he ity to express deep connections with says in “Nobody Dies on My Shift,” for her patients, “I see myself always . . . re- many reasons, flected in the eyes of my patients.” In the Catholic Church the word “viaticum” but most of all I was getting tired of refers to the holy oil used to bless a dy- interviewing and the clinical encounter. patients dying, especially ing person. In the poem of that name, It’s not surprising, then, that most of people I had known so long Nigliazzo delivers her own very physical his poems reveal little “sparks” of in- and loved so much blessing, sight that arise from interactions with and never wanted to bid goodbye.p65 patients. These insights are engaging, The retired physician—but very active I tied her wrists to the bed sometimes humorous, and always hu- poet—acknowledges these feelings, when she started to hit herself. Gave mane. They reveal Platt’s underlying while also experiencing a sense of unex- more humility in the face of life’s slings and pected joy and freedom. As he tells us arrows. For example, in “Fired” p10 a sedatives to keep her in “Some Days,” there are times he can patient’s wife dismisses him as her hus- comfortable.p34 wake up and band’s doctor, a tactic she has employed Many of her poems touch on the with many other doctors. Even so, hum a little tune . . . themes of end-of-life care and saying “when I’m told I need to study bedside and the world is fine, so fine goodbye. For example, in “Valediction” manner/it pains.” The poem concludes, you might imagine no one anywhere she visualizes assisting her patient as “There’s no pleasing everyone,/from has it in for his neighbor or for us she embarks on her last journey, which I take/no solace.” and those days I know I’m going The first half of Was a Doctor consists to do all right.p74 I am the needle— of practice-poems, collectively called the weeping blood on bone— “The Stories.” In “L-thyroxin” there is Common Illness the ripple of pulse and breath the 102-year-old woman who “drags a bit.” She is hypothyroid, “so I fixed her,/ Aaron McGuffin ( , Marshall on spiraling wax paper. AΩA spruced her up with/L-thyroxin,/livened University, 2002) I carry you her up to eighty or so.” But she doesn’t Wentworth & Collins, Publishers, 2013 like butterfly wings . . . p68 take the medicine. What happens? Now she is 104 and “still she drags.” p33 And urning now to a younger genera- With Scissored Moon Stacy Nigliazzo what about the man, “enormously fat, tion, Aaron McGuffin is a pediatri- joins a select group of nurse-poets, like with a huge head”? He talks funny and cianT and medical educator at Marshall Cortney Davis and Judy Schaefer, whose “I’m convinced he’s crazy/until I look University in West Virginia. Common work demonstrates the highest stan- in his throat . . .” and see the pus “boil- Illness, his first collection, is structured dards of craft, as well as the deep insight ing” behind his tonsils. Platt reflects, “I around the human life cycle, with six of compassion. feel a lot of remorse/that I had so little sections ranging from infancy to old compassion,” yet he is thankful he can age. He begins with a certain clinical Was a Doctor prescribe penicillin: “At least there I can detachment, as evidenced in the first Frederic W. Platt help.” (“Streptococcus,” p. 30) poem, “Common Illness,” which con- Denver, Colorado, Big Owl Press, 2014 The past tense of Was a Doctor cludes, “Death is a common illness,/ jumps to the fore in the book’s second diagnosed at birth.” p8 Detachment he title of Frederic Platt’s Was a half, after retirement, when “All that is is transformed into gentle humor in Doctor highlights the identity cri- left are/the memories and the stories/ “Press Conference,” p19 which describes sisT many physicians experience when and the fading ring upon the water.” an imaginary encounter with reporters they retire from medical practice. (“Was a Doctor,” p. 59) These poems are over a breast milk stain on the front Dr. Platt was a pioneer in the field of full of thoughtful nostalgia, as in “Lost of this pediatrician’s shirt. They ask physician-patient communication and or Misplaced,” p61 which ends, him about his “lactation sources” and has published several books on medical “pump” for more information. Finally,

48 The Pharos/Summer 2014 of purpose and tenderness of action. other side/when I must be the patient.” He mourns a young boy run over by As he reflects on his own sometimes a truck. At a clinic in Honduras, in a cavalier or trivializing reassurance to room is packed with suffering patients, patients, he awaits the dentist’s version McGuffin reflects, “There is everything of the same, in their nothingness.” The oldest in a family of six children runs over to him, This won’t take long, you shouldn’t feel a thing, we’re almost done.p79 I touch and we talk in a universal tongue, Common Illness betrays its title. It is, in fact, an uncommonly fine collection the weary poet confesses: the smile of my eyes staring back at our normalcy.p87 of poems. I can tell they see holes in my story, that my heralded claims The empathic connection is universal Dr. Coulehan is a book review editor for of being the world’s first male wet nurse and normal. Or at least it should be. The Pharos and a member of its editorial are all titular. These poems are remarkable for board. His address is: I’m about to be all dried up. their clarity, intelligence, and engaging Center for Medical Humanities, images. And, again, McGuffin has the Compassionate Care, and Bioethics However, beneath McGuffin’s cool- uncommon ability to convey the medi- Stony Brook University ness under pressure lies a vein of deep cal experience with self-deprecating Stony Brook, New York 11794-8335 feeling. Many of his poems evoke the humor, as in “A Doctor in a Dentist’s E-mail: john.coulehan@ tension in medicine between steadiness Chair,” which begins, “I hate it/on the stonybrookmedicine.edu

2014 Helen H. Glaser Student 2014 Pharos Poetry Essay Awards Competition winners

he thirty-second annual Alpha Omega Alpha Helen H. he Pharos Poetry Competition awards were made in Glaser Student Essay Awards were made in May. This April. This year’s winners are: year’sT winners are: TFirst prize: Bryan Cheyne of the Class of 2014 at the First prize: Amy Huang of the Class of 2017 at the State University of Utah School of Medicine for his poem, University of New York Downstate Medical Center College “Wounded.” of Medicine for her essay, “In the Hollow of Her World: Second prize: Alyse Marie Carlson of the Class of 2016 at Healing and the Defiance of Illness in Christina’s World.” the University of Iowa Roy J. and Lucille A. Carver College Second prize: Steven Krager, Class of 2014 at Creighton of Medicine for her poem, “The Weight of Marbles.” University School of Medicine for his essay, “The Lullaby.” Third prize: Aisha Harris of the Class of 2017 at Third prize: Melissa Pritchard of the Class of 2017 Georgetown University of Medicine for her poem, at Boston University School of Medicine for her essay, “Sandglass.” “ 23andWe: How Can Doctors Decode Direct-to-Consumer Honorable mention: Trang Diem Vu of the Class of 2016 Genetic Testing?” at Mayo Medical School for her poem, “Breast Exam.” Honorable mention: Marc Polacco of the Class of 2014 at Honorable mention: Glenna Martin of the Class of 2014 the University of Iowa Roy J. and Lucille A. Carver College at the University of Washington School of Medicine for her of Medicine for his essay, “The Six-Million-Dollar Physician: poem, “Third Year Medical School Encounter.” A History of Robotics Making Surgeons Better, Stronger, Winning poems will be published in future issues of The Faster.” Pharos. Winning essays will be published in future issues of The Pharos.

The Pharos/Summer 2014 49 2014 Medical Student Service Leadership Project Awards

lpha Omega Alpha is committed to preparing future leaders in medicine and health care. Leadership is about makingA a positive difference, and is learned through education, observation, and experience, and working with leader mentors. Service leadership may develop an excellent opportunity for students to develop as servant leaders. The most effective leaders are well grounded in and committed to positive professional values. AΩA developed this award to support leadership development for medical students through mentoring, observation, and service learning. The award provides 5000 for the first year, 3000 for the second year, 1000 for the third year. Second and third year funding are contingent on acceptable interim reports. The winners of this year’s award are:

University of North Carolina at Chapel Hill School of Medicine—Medical Students at UNC Leading, Teaching and Interacting with the Community (MULTI) From left to right, Amelia F Drake, councilor, with student leaders Emily C. Ambrose, Justin Morse, Stephanie Kiser, and Jacob N. Stein. Student team leader Stephanie Kiser (AΩA, University of North Carolina, 2013) and student team members, Jacob Stein, Justin Morse (AΩA, University of North Carolina, disease processes in which more than one medical discipline 2013), and Emily Cohn. Mentor leader Amelia Drake, MD has expertise. Multidisciplinary team care offers unique (AΩA, University of North Carolina, 1996, Alumnus), and advantages to patients, health care providers, and medical mentor team members Jeyhan Wood, MD (AΩA, University students. At UNC, the Head and Neck Tumor Board, North of Texas Medical Branch, 2007), Brent Golden, MD, DDS, Carolina Children’s Airway Center, and Craniofacial Team are Carlton Zdanski, MD (AΩA, University of Texas Medical some examples of this concept at work. In addition to provid- Branch, 2013, Alumnus), and Mark Weissler, MD (AΩA, ing benefit to patients, these teams of specialists offer a dis- Boston University, 1979). tinct opportunity for medical student leadership development. Currently, no course at UNC School of Medicine is offered in ver the past fifty years, the concept of multi-disciplinary leadership or multidisciplinary care. Therefore, a unique occa- Ocare has become standard for patients with certain sion exists to pilot a medical student course that would allow

50 The Pharos/Summer 2014 students to gain valuable experience in managing complex Leadership Academy in Medicine). This recently added lead- medical and psychosocial issues while also developing es- ership course is entering its third year at UNC. The goals of sential leadership skills as a part of one of these sophisticated the program include promoting leadership and management health care teams. Our service leadership proposal involves development training, enhancing strategic thinking, problem- three parts: solving and negotiation skills, and providing mentoring and 1. Developing a curriculum for a new elective in multidis- academic counseling. The program also includes a retreat ciplinary care where participants study the latest models and frameworks for 2. Starting and leading an interest group in leadership in leadership, participate in exercises that demonstrate leader- multi-disciplinary care for medical students ship styles, learn from the leadership skills and approaches of 3. Establishing medical student participation in a formal their peers, and develop their own actionable individual lead- leadership course. ership development plan. This grant provides the opportunity for extension to medical students and simultaneously opens Multidisciplinary Care Elective the doors to allow further participation by medical students The elective will serve as the first component of our pro- in the coming years. gram and will be designed to expose students to the intricacies of multidisciplinary care through active involvement in all as- Indiana University School of Medicine—Boys and pects of one of the multidisciplinary teams already established Girls Club-Indiana University School of Medicine at UNC. Students rotating on the elective will be able to choose Partnership Program a specific track (i.e., Head and Neck Tumor Board, Pediatric Airway Center, or Craniofacial Center) or a combination of Student team leader Andrew Krack (AΩA, Indiana University, these. They will develop a formal educational curriculum with 2014) and student team members Lori Myers, Josh Lukas, selected readings on different aspects of care management and Taylor Coleman, Meagan King, Ryan Freedle, Courtney leadership. Student team members will pilot this elective as the Myers, Mimi Huang, Mike Kalina, Kaleigh Fetcko, Colin Ray, first participants this upcoming academic year. Samer Kawak, Kayla Swick, Aurora Shands, Leah Oswalt, Korbin Davis, Mary Mattern, Milan Patel, Lindsey Junk, Interest Group in Leadership Jeremy Sherer, Hari Vasu (AΩA, Indiana University, 2013), The interest group, entitled “Leadership in Multidisciplinary Jonathan Parish, Kenny Moore, David Yang (AΩA, Indiana Care,” will be a foundation point for organization of commu- University, 2014), Katie Byrd, Kasiemobi Onyejekwe, Peter nity outreach efforts and speakers on leadership. The AΩA Haigh. Mentor leader Mitchell Harris, MD (AΩA, Indiana UNC Gamma Chapter will take a leadership role in the organi- University, 1990), and fellow mentor Kathleen Boyd, MD. zation and maintenance of this interest group, inviting speakers for conversations about leadership and multidisciplinary lpha Omega Alpha Alpha of Indiana and the Indiana care, with an expected four speakers recruited annually. In University School of Medicine (IUSM) Medical Student addition, it is through this interest A group that community outreach efforts will be organized. In keeping with the focus of the interest group, community outreach events will be centered on multidisciplinary care. The interest group serves as an avenue to which the entire medical student body can effectively be involved with leadership development and service events; we anticipate large participation from first and second year medical students.

ACCLAIM Leadership Course The final part of the proposal involves having the student team members of this proposal participate in an ongoing formal leadership course in the School of Medicine, entitled ACCLAIM (Academic Career

The Pharos/Summer 2014 51 2014 Medical Student Service Leadership Project Awards

Council (MSC) are partnering with the Boys and Girls medical leadership at large. During months opposite the journal Club (BGC) of America in nine cities around the state club, guests from the IUSM and Indianapolis community will of Indiana—Indianapolis, Gary, South Bend, Muncie, Fort speak on their personal experiences with service-learning and Wayne, Lafayette, Bloomington, Terre Haute, and Evansville. leadership. The newly-established Boys and Girls Club/IUSM Partnership In February 2014, AΩA Alpha of Indiana member Lori Program (BIPP) exposes IUSM students throughout the state Myers and IUSM MSIII Samer Kawak travelled to Miami to of Indiana to underserved youth and engages students at all present the BIPP concept at the Annual University of Miami nine IUSM campuses in civic leadership through the organiza- Department of Community Services Conference. In March, tion of events in collaboration with each respective Boys and American Medical Association students from around the Girls Club. Midwest collaborated with the Indianapolis BIPP chapter for The initial idea for their project budded from the action of a morning of health education at a local Boys and Girls Club. a second-year medical student, Samer Kawak, at the IUSM- Other IUSM student interests groups are also taking notice and Northwest campus. His idea was warmly received by AΩA planning joint projects with BIPP. Alpha of Indiana members and the IUSM MSC following the success of a year-long pilot partnership of event-based men- University of Miami Miller School of Medicine— toring between students at IUSM-Northwest and mentees at Medical Students without Borders (MSB) Leadership the BGC of Gary/Merrillville, Indiana. Project AΩA Alpha of Indiana, the IUSM MSC, and IUSM student body will use funding from the AΩA MSSLP Award to pro- Student team Leader Christine Bokman and student team mote improvements in BCG children’s knowledge and health members Arash Sayari, Yuliya Tipograf (AΩA, University of literacy in areas including, but not limited to, physical activity, Miami, 2014), Julia Amundson, and Amir Sharim. Mentor injury prevention, diet, social relationships, positive behavioral Leaders Julie Kornfeld, PhD, MPH and Alex Mechaber, MD choices, bullying, mental and sexual health, and prescription/ (AΩA, George Washington University, 1998 ) and mentor illicit drug use. Their initial educational project will focus on team members Michael Kolber, MD, PhD (AΩA, University bicycle safety and traumatic brain injury in sports along with of Miami, 2013, Alumnus), Stephen Symes, MD (AΩA, the distribution of approximately 300 free bicycle helmets. Howard University, 1988), and David Birnbach, MD, MPH In order to accommodate the variable needs of nine dif- (AΩA, University of Miami, 2013, Faculty). ferent Indiana BGC Chapters, there is and will continue to be a significant opportunity for character and leadership development at the IUSM campuses. Programming novel activities for the BCG mentees will require the active use of executive functioning skills including decision-making, social interac- tion, planning, troubleshooting, and compassionate leadership that will allow the students to development robust, practical leadership intelligence. IUSM faculty Drs. Mitchell Harris and Kathleen Boyd are serving as advisors for the project and overseeing a leadership development and service-learning curriculum. A journal club will meet every other month at which BIPP student leaders will discuss articles pertain- From left to right: Arash Sayari (MS4), Christine Bokman (MS4), Dr. Julie Kornfeld, Assistant ing to leadership and service- Dean for Public Health, and Dr. Alex J. Mechaber, Senior Associate Dean for Undergraduate learning and reflect on BIPP and Medical Education.

52 The Pharos/Summer 2014 ith the advent of telemedicine, electronic health re- nducting its first class of twenty-three mentors and thirty cords, and a rapid increase in international travel, mentees in October 2013 the University of South Florida Wmedical professionals are extending treatment beyond borders (USF)I Health Plexus mentoring initiative at the USF Morsani to reach patients throughout the world. The Miami Students College of Medicine (MCOM) connects health professional without Borders (MSB) Leadership Program, a four-year students (medicine, pharmacy, and physical therapy) with global health leadership program for UM medical students, pre-health undergraduate students to facilitate the develop- will create physicians who are able to act as leaders not just ment of professional behaviors and characteristics. A semi- within their local communities, but also within the global formal program, Plexus includes eight monthly modules that community that the evolution of medicine demands. The span the academic year and cover a variety of topics ranging University of Miami Miller School of Medicine is particularly from professionalism to resource awareness. Mentors receive tailored for this type of leadership program because of its di- training for each module and then deliver this information to verse indigent patient population and unique location relative their mentees on an individualized basis. In conjunction with to countries outside the United States. the USF Office for Student Diversity and Enrichment, Plexus The MSB Leadership Program will complement the four- also hosts mentee group sessions that aim to reinforce recent year medical curriculum and focus on experiential learning, modules, provide an administrative perspective, and address including interactive discussions, presentations, fieldwork, questions or concerns from participants. and a service project. Progress will be evaluated by upperclass- Wishing to expand its efforts, Plexus has partnered with men mentors with the oversight of faculty members. USF faculty in the development of a leadership curriculum • Years one and two focus on the interactive seminars, for mentors. Furthering these leadership development efforts, which include the Foundations of Global Health Leadership I Plexus has also collaborated with Tampa Bay Street Medicine & II, a Global Health Seminar, and the Cultural Awareness and (TBSM) to provide a service learning opportunity for par- Global Health Disparities Case-Based Learning. Students will ticipants. TBSM is a new USF MCOM organization that will also participate in global health fieldwork to integrate leader- provide care to the homeless community in the Tampa Bay ship skills from the classroom and to lay the groundwork for a area. The overarching theme of the Plexus/TBSM coalition global health leadership service project. will be, “Learning leadership through teaching leadership and • Years three and four require students to assume an active partnering in service.” leadership role by mentoring first and second year students, The current model is set to become the new first year assisting faculty in leading seminars, and carrying out a ser- curriculum for incoming mentors and mentees, with the vice project. Projects will focus on global health leadership new leadership curriculum offered to continuing second year such as designing a public health program in a developing professional student mentors. The leadership curriculum will country or in an underserved population in the United States. also be required for all student leaders of Plexus and TBSM, By the end of the four years, students will be able to dem- in an effort to maximize its utility and unity. The curriculum onstrate the five proficiencies in global health leadership: 1) will consist of the following eight workshops: global health and social justice leadership; 2) professional 1. Myers-Briggs—Understanding your personality and the responsibility; 3) socio-cultural awareness; 4) communication personalities of others and teamwork management; and 5) knowledge of global health. 2. Negotiation Skills—Learning to compromise Ultimately, the program will prepare future physicians to en- 3. Financing Your Initiatives—How to create an effective gage in collaborative capacity-building activities, understand budget and manage funds the importance of evidence-based strategies to implement ef- 4. Health Policy—Keeping pace with changes and how fective global health programs, work effectively within varied they affect your organization cultural settings, and apply leadership skills to advance health 5. Politics—Understanding the motives of others equity and social justice on a global scale. 6. Time Management—How to effectively manage your commitments USF Health Morsani College of Medicine— 7. Public Speaking—How to deliver an effective USF Plexus/TBSM Leadership through Service presentation Cooperative 8. Dean for a Day—Possibly becoming a one-month elective for fourth year students Student team leader S. Nick Kovacs and student members In addition to gaining valuable skills at these sessions, men- Jason Riccuiti and Bailee Olliff. Faculty leader Shirley Smith, tors will have the opportunity to forge new relationships with MD, and mentor team members Catherine Lynch (AΩA, faculty who may serve as role models in the art and practice University of South Florida, 1990), Dr. Steven Specter, MD of leadership. (AΩA, University of South Florida, 2012, Faculty), and After receiving the above leadership education Plexus Elizabeth Warner, MD. mentors will relay these principles to their mentee(s). Then

The Pharos/Summer 2014 53 2014 Medical Student Service Leadership Project Awards

Weil Cornell Medical College— Weill Cornell Center for Human Rights (WCCHR) Leaders in Health and Human Rights Initiative

Student team leader Eleanor Emery (AΩA, Weill Cornell Medical College, 2014), Alexandra Tatum (AΩA, Weill Cornell Medical College, 2014), Alejandro Lopez, Krista Dubin, and Carmen Stellar. Mentor leader Joanne Ahola, MD, and mentor team members Terri Edersheim, MD (AΩA, Albert Einstein College of Medicine of Yeshiva University, 1980), and Yoon Kang, MD (AΩA, Washington University, 2000).

CCHR is a medical student-run human rights clinic dedicated Wto providing forensic medical evaluations to survivors of persecution seeking From left to right: Third-year medical students Bailee Olliff, Kathleen Pombier, Kathryn asylum in the United States. Founded Dean, Cindy Shavor. Photo credit by Anabel Anon (MS3). in 2010 through a partnership with Physicians for Human Rights, WCCHR is the first student-run asylum clinic at a U.S. medical school and has been her- together, Plexus mentors and mentees will apply their new alded as a model for future asylum evaluation programs. The skills to serving the community through participation in organization is comprised of a diverse and growing team of TBSM. It is a future goal of this coalition for senior graduate volunteer clinicians and medical students committed to serv- student mentors to eventually teach the leadership curriculum ing asylum seekers and educating health professionals and the to second year mentors. This will then create a cycle of health general public about the asylum process. care professionals working together to learn from and teach WCCHR was founded on the twin pillars of service and each other, reinforcing interdisciplinary teamwork, leadership, education. Service is provided to victims of torture from coun- and service. tries across the globe seeking asylum on multiple grounds, Students committed to the Plexus/TBSM combined pro- including persecution due to race, gender, religion, sexual ori- gram will be required to volunteer for “street runs” at least entation, and political affiliation. Asylum seekers with medical twice per semester. During these “street runs” teams com- affidavits that have been prepared by trained physicians are prised of upper and lower-level professional students, under- three times more likely to be granted asylum than those with- graduate students, and volunteer physicians will be equipped out medical documentation. It has been estimated that there with clinical supplies, common over-the-counter medica- are over 500,000 foreign-born torture survivors in the United tions, and wound care supplies to provide basic primary care. States and approximately twenty percent of them reside in By providing direct care, medical education, and access to the New York metropolitan area. Thus, WCCHR is uniquely resources, students will gain valuable insight into the issues situated to assist this population in the daunting process of faced by this medically underserved population. Students will attaining asylum in the United States. also gain a better appreciation for barriers to care in medicine WCCHR is also committed to educating medical students, while humanizing and breaking down common stereotypes as- residents and practicing physicians about human rights viola- sociated with this vulnerable population. By working together tions and ways in which they can utilize the unique skills of to apply the newly acquired leadership skills and attributes, their profession to defend victims of torture. The Center participants in the Plexus/TBSM Leadership through Service provides training sessions and educational seminars to teach program will complete the cycle of “Learning leadership physicians and students how to evaluate torture survivors, through teaching leadership and partnering in service.” identify the physical and psychological sequelae of torture and abuse, and write medical affidavits documenting their findings.

54 The Pharos/Summer 2014 Trained medical students observe every evaluation conducted Brown, UMichigan, UMDNJ, Yeshiva, and UC Davis and by WCCHR’s physician volunteers and assist the overseeing is currently advising teams of students from many of these physician or psychologist in writing the medical affidavit. institutions. As of December 2013 WCCHR has conducted 130 forensic The goal of the Weill Cornell Center for Human Rights’ evaluations for 113 clients from thirty-nine countries. To date, proposal to AΩA’s Medical Student Service Leadership Project one hundred percent of WCCHR’s clients who have been to entitled the “Leaders in Health and Human Rights Initiative” court have been granted asylum or another form of legal pro- is to formally acknowledge and cultivate the leadership skills tection in the United States. WCCHR has also trained a total that medical students already develop as members of the Weill of 262 medical students, 139 from WCMC and 123 from insti- Cornell Center for Human Rights Student Board. This project tutions across the country. In addition, to date WCCHR has will include the development of a number of new service, edu- trained a total of forty-three health professionals to conduct cation, and research projects, each with structured mentorship forensic evaluations and currently has sixteen active evaluators: and feedback components to promote the development of twelve for psychiatric evaluations, three for medical evalua- leadership skills and facilitate the creation of areas of expertise tions and one for gynecological evaluations. for medical students within the fields of human rights and asy- WCCHR is governed by a twenty-member Student Board lum law. The new subcommittees that will supplement the cur- composed of MD and MD/PhD students with oversight from rent experience of WCCHR student leaders include Education, three Medical Directors and a Faculty Advisory Board. As Self-Care, Advocacy, Continuing Care, and Research. These the first student-run asylum evaluation clinic in the country, subcommittees each emphasize core skills with relevance that WCCHR has served as a national role model. WCCHR is extends beyond the mission of WCCHR: students will develop playing a lead role in training students and health profession- expertise applicable to their future careers as physician leaders als across the country as they develop human rights centers. dedicated to service. WCCHR has trained students from UPenn, Columbia, NYU,

The Pharos/Summer 2014 55 Letters to the editor

“Fall from grace” Dr. Marr responds to Dr. Volpintesta next few years. In his interesting essay, “Fall from I am in complete agreement with 2. The subject matter brings to grace” in the Winter 2014 issue (pp. Dr. Volpintesta’s comments regarding mind the title of three songs: “9 to 5,” 8–13), J. Joseph Marr, MD, mentioned the overuse of technology as a defense “I Surrender, Dear,” and “[I Did It] My how modern technology defined the against frivolous malpractice suits. Way.” standard of medical care and how be- The malpractice industry, as with so 3. “From shaman to skilled labor.” cause of its accuracy and effectiveness many things, began as a legitimate at- Wrong. physicians were beguiled into favoring tempt to help patients who had been 4. Dr. Marr rightly indicates that the technological shortcut it gave them wronged as a result of negligence; yet, many physicians have been “complicit” over their clinical judgment and skills. it has become a terrible scourge in the in the changes that now challenge But I was surprised that he didn’t practice of medicine due to its lucra- physicians. But he wrongly attributes emphasize the role that defensive tive returns to attorneys, whether a suit this to “hubris.” The real error in medicine played in driving doctors to be legitimate or frivolous. I considered physicians’ approach has been their use or overuse technology. In fact, de- putting something about this in the understandable desire to protect their fensive medicine is so ingrained in our article. However, I did not because this patients from the adverse effects of professional minds that to not practice defensive use of technology actually is those changes, rather than allowing defensive medicine is considered fool- tangential to the thesis—the inevitable them to feel their own pain—and to ish. dilution of the clinician’s role in diag- thus be motivated and politicized to Physicians are obliged to use almost nosis due to increasingly precise diag- resist. every new diagnostic or therapeutic nostic technology. That is a different, 5. The nexus of physician/nurse/ advance because if they don’t and a and larger, issue. Although defensive patient, with the legitimate addition bad outcome occurs, there is a chance medicine is a significant contributor to of physician extenders, survives as the that they could be sued for not using it. health care costs, due to the total costs indispensable core of medical care, This Catch-22 is the great dilemma of of the tests and the loss of time that with the physician as the diagnostician modern medicine. could be used elsewhere, and is worth and coordinator of that care. That the My point is that most physicians an article of its own, I do not believe it physician can now supervise and guide shudder at the thought of being sued is relevant here. the work of several nonphysicians en- for malpractice. And for those that hances rather than diminishes the phy- J. Joseph Marr, MD have been sued their inclination to sician’s central role in the process. (AΩA, John Hopkins University, 1964) practice defensive medicine is very 6. “Patient visits per unit time”: a Broomfield, Colorado great. corrosive idea. We learned in medical It is important when discussing the Although offered by “a retired school that, of the three attributes that overuse and overdependence on tech- academic physican and business ex- a physician can offer his patient—abil- nology to emphasize the role of defen- ecutive,” Dr. Marr offers an excellent ity, affability, and availability—the most sive medicine. review of the progress of Medicine and important is availability. Clearly, it is imperative that better particularly of the voyage of physicians 7. Yes, younger physicians are dif- ways of dealing with malpractice be during the last sixty years. I can also ferent, as are their entire generations. found. Specifically, the adversarial at- address this course, as a privately prac- It remains to be seen whether these titude that dominates the malpractice ticing clinician for the last fifty-seven younger MDs, the 9-to-5ers, will have system and which often prolongs the years . . . and counting. the foundation, the grit, and the joy tensions and hinders the resolution of My comments will be of little value of practicing medicine for the many conflict between defendant and plain- unless the reader has studied Dr. Marr’s decades that their older colleagues tiff must be eliminated. article, which I recommend particularly embrace—despite the recent “troubles.” Special health courts presided over for younger physicians—since older Or will they succumb, not as much to by judges with special training in doctors have lived it and are continuing burnout, as to ennui. medical malpractice have been to live it. I disagree with the author’s 8. And that brings up the future. suggested as an alternative. conclusion, beginning with the title of Demography is destiny. Patients will the article. increase in number, age, and debility. Edward Volpintesta, MD 1. We have not fallen from grace: Physicians will decrease in number and Bethel, Connecticut we are being pushed. But we will have commitment. But those who remain a soft landing if only we can survive the will be highly valued and appreciated

56 The Pharos/Summer 2014 for their knowledge and for their de- health. One need not look further Dr. Marr responds to Dr. Sprecace votion to their patients. They will be than the Hippocratic Oath, which and Dr. Spaeth sought out. enjoins physicians to be sure they do The reader response to “Fall from 9. And so I end with a quote from not share their knowledge “with other Grace” has been gratifying. I have re- Dr. Marr’s fine review, and with my than their brethren.” Teaching patients ceived more than fifty letters directly— reaction: “The physician will become— to take care of themselves is actually not for publication—and essentially has become—decreasingly the guide contrary to the first paragraph of the all have been very empathetic. The and guardian of the system and more Hippocratic Oath. observations and conclusions seem to and more of a supervisor in the mosaic Medicine has always been a busi- be shared widely by physicians—or the of provision of care.” Wrong. ness. Doctors sell services. They are older ones at least. really no different from street vendors Several asked about some specific George A. Sprecace, MD, JD selling bananas or bracelets. Physicians issues and whether they should have (AΩA, State University of New York, have all been reimbursed in various been included—defensive medicine Downstate, 1957) ways. They are all involved in a busi- was mentioned more than once—but New London, Connecticut ness. the intent of the piece was to paint the I read with great interest the very There have, of course, been models mural rather than focus too sharply. fine article, “Fall from grace.” of self-sacrificial physicians, such as With respect to Dr. Sprecace’s letter, it Dr. Marr’s analysis of what has hap- Arrowsmith, the protagonist in the appears that we are seeing and living the pened during the past 100 years or so novel of the same name by Sinclair same events but are reaching sometimes is penetrating. He may have omitted Lewis. Indeed, the idealized physician similar and sometimes different conclu- something of importance, however. He has often been put forward as a person sions. I cannot comment further on that, and most physicians appear to assume whose life is dedicated to the well being but do agree with what I understand as that the basic purpose for being a phy- of others. It is not surprising, though, his underlying theme: that quality and sician is to help other people, and that that such self-sacrificial physicians dedication are important and may cor- the medical profession considers that often die young, and so cease being rect some of the abuses over time. The a physician’s purpose is to “help the able to help people, as they could have letter from Dr. Spaeth raises interesting sick.” It is worth considering whether continued to do had they not been so questions. Physicians enter into medicine this is, in fact, correct. Is not the basic, self-sacrificial. for the best of reasons (Arrowsmith was primary purpose for most physicians Being a physician, in truth, is a won- one of my formative books many years usually the same as the basic, primary derful way to earn an income. Perhaps ago) and over time succumb to varying purpose for almost everybody else? it is a noble way, perhaps nobler than degrees to the vagaries of life. Physicians Specifically, is not the major, primary, some other ways. But still, at its base, should be paid appropriately, without and basic purpose for any man or is the idea that being a physician will question, and the survival instinct cer- woman to support himself or herself allow one to make a living while at the tainly is there. I believe we are seeing that and his or her family? Is not that the same time being of use to society. in motion now, as physicians do what primary reason why the overwhelming I love being a physician. I get paid economics requires and, as a result, are majority of physicians practice, teach, for what I love to do. But I get paid. As increasingly driven by business practices or perform the other roles that physi- much as I love being a physician, it is rather than medical practices. That was cians play? Of course, physicians act on not likely that I would continue to work one of my points. However, in saving the basis of motivations for which they as one if all I had was overhead and ourselves we have been forced to sacrifice receive no reimbursement, such as the no income (though, actually, I’ve had many of the original reasons we entered desire to help, the passion for teaching, months like that). It is hard to believe into this so many years ago. Stated an- or hope of leaving a legacy about which that the primal instinct to survive is other way, we are now too busy keeping they can be proud. But where physi- not just as strong in physicians as it is the machine running to remember why cians act that way they usually rely on in beggars or kings. we turned it on in the first place. Time, their paying jobs in the clinic, the labo- changes in our technology and society, George L. Spaeth, MD ratory, the academic office, or other and consequent economic mandates have (AΩA, Harvard Medical School, 1959) source of income to pay their bills. undone us, as they have in so many oth- Wills Eye Hopsital/Jefferson Medical It seems unlikely that physicians ers in other walks of life. College have had as their primary purpose Philadelphia, Pennsylvania J. Joseph Marr, MD helping patients learn how to take (AΩA, John Hopkins University, 1964) care of themselves in order to keep Broomfield, Colorado themselves healthy or to improve their

The Pharos/Summer 2014 57 2014 Carolyn L. Kuckein Student Research Fellowships

n 1982, the board of directors of Alpha Omega Alpha Eric Anderson Class of 2016, Stanford University School of Medicine Iestablished five student research fellowship awards to en- Pilot trial to evaluate the effect of vitamin D on melanocyte courage and support student research. Since then, the awards biomarkers have grown in number to more than fifty each year. Mentor Jean Tang, MD, PhD The fellowship emphasizes a student-designed and -intiated Association Chair Charles G. Prober, MD project with an academic mentor. Recipients of the fellowship Joshua Bakhsheshian tell us that the awards have helped them to learn about the Class of 2015, Chicago Medical School at Rosalind Franklin University of Medicine & Science joys of scientific and scholarly discovery, and increase their Using wireless technology to assess objective measures of functional critical understanding of scholarship and research in health recovery in patients undergoing major elective spine surgery care and science. Many recipients of the fellowship have Mentor Zachary A. Smith, MD followed up their work as student-researchers to become Councilor Michael J. Zdon, MD physician-scientists. Devang Bhoiwala The student receives a 5000 award, with 1000 available Class of 2016, Albany Medical College for travel to a national meeting to present the research results. The influence of systemic iron overload on retinal iron overload and retinal degeneration In 2004, the name of the fellowship program was changed to Mentor Joshua Dunaief, MD, PhD the Alpha Omega Alpha Carolyn L. Kuckein Student Research Councilor Neil Lempert, MD Fellowship awards in honor of Carolyn L. Kuckein, AΩA’s Phillip Bonney longtime administrator, who died in January 2004. Class of 2016, University of Oklahoma College of Medicine Evaluations of the fellowship proposals were made The roles of EMR2 and EMR3 in invasiveness in glioblastoma: by the following reviewers: C. Bruce Alexander, MD; evaluation of cellular migration and investigation of downstream pathways Thomas T. Andersen, PhD; Carol A. Aschenbrener, MD; Mentor Michael Sughrue, MD Robert G. Atnip, MD; Jeremiah Barondess, MD; Syamal K. Councilor William F. Kern, MD Bhattacharya, PhD, CLD; Paul A. Bunn, MD; Tim Byers, MD, Trent Bowen MPH; Ken Byrd, MD; Julio A. Chalela, MD; Stephen Y. Chan, Class of 2016, University of Arizona College of Medicine MD; Lynn M. Cleary, MD; Benjamin Clyburn, MD; Graciela The Role of Myocilin in Receptor Endocytosis and Pathogenesis of De Jesus, MD; Daniel Foster, MD; Bruce M. Frankel, MD; Glaucoma Doug Fredrick, MD; Gillian Galbraith, MD; Boyd Gillespie, Mentor Brian McKay, PhD Councilor Joseph S. Alpert, MD MD; Richard F. Gillum, MD, MS; Richard B. Gunderman, Karen Bowers MD, PhD; Diane Harper, MD, MPH, MS; Joseph A. Hill, MD, Class of 2015, Virginia Tech Carilion School of Medicine PhD; Pascal Imperato, MD, MPH&TM; Marc G. Jeschke, Ketamine as an adjunct to opiates for acute pain in the emergency MD, PhD, FACS; J. Michael Kilby, MD; Paul R. Lambert, MD; department Patricia G. McBurney, MD, MSCR; Mark J. Mendelsohn, Mentor Corey Heitz, MD MD; Lesley Motheral, MD; Gokhan M. Mutlu, MD; Douglas Association Chair Apostolos P. Dallas, MD, FACP S. Paauw, MD; Ronald G. Pearl, MD, PhD; Thoru Pederson, Bristol Brandt PhD; Suzann Pershing, MD; Sheryl Pfeil, MD; Noah S. Philip, Class of 2017, University of Kansas School of Medicine Antibiotic Administration and Progression of Sepsis MD; Paul B. Pritchard, MD; Steven P. Ringel, MD; Alan G. Mentors Guoqing Chen, MD, PhD, MPH; Steven Q. Simpson, MD; Robinson, MD; William M. Rogoway, MD; Shashikumar Russ Waitman, PhD Salgar, PhD; Wiley Souba, MD, ScD, MBA; Joseph W. Stubbs, Councilor Steven Simpson, MD MD, MACP; Bruce H. Thiers, MD; John Tooker, MD, MBA, Bianca Bromberger MACP; Kenneth L. Tyler, MD; Gabriel T. Virella, MD, PhD; Class of 2015, Raymond and Ruth Perelman School of Medicine at the Alan G. Wasserman, MD; Gerald Weissmann, MD; John A. University of Pennsylvania Living Donor Utilization Among Kidney Transplant Recipients Zic, MD. Sensitized by Pregnancy The recipients of the 2014 fellowships are: Mentor Paige M. Porrett, MD, PhD Councilor Jon B. Morris, MD Mizanur Ahmed Patricia Carr Reese Class of 2017, State University of New York Downstate Medical Class of 2017, George Washington University School of Medicine and Center College of Medicine Health Sciences VpreB Expression in Mature B Cells Alters B Cell Development Schistosoma haematobium and urinary tract infections among Leading to Autoantibody Production women in rural Malawi Mentor Christopher Roman, PhD Mentor Abigail Norris Turner, PhD Councilor Douglas R. Lazzaro, MD Councilor Alan G. Wasserman, MD

58 The Pharos/Summer 2014 Gaurav Chattree Surbhi Gupta Class of 2017, University of Texas Southwestern Medical Center at Class of 2017 Michigan State University College of Human Medicine Dallas Southwestern Medical School Hemocompatibility comparison of medical grade polymers incorpo- Dissecting synaptic changes that underlie the temporal control of vo- rated with nitric oxide donors cal behavior Mentor Hitesh Handa, PhD Mentor Todd Roberts, PhD Councilor Gary Ferenchick, MD, MS Councilor Kevin Klein, MD Austin Ha Megan Chock Class of 2016, The Warren Alpert Medical School of Brown Class of 2015, Mayo Medical School University Health care use by suicide decedents compared with members of the Nrf2 and Other Gene Expression Profiles of Responders vs. Non- general population responders to Hyperbaric Oxygen Therapy Mentor J. Michael Bostwick, MD Mentor Paul Y. Liu, MD Association Chair Carola Arndt, MD Councilor Charlotte M. Boney, MD Abigail Cline ByoungJun Han Class of 2017, Medical College of Georgia at Georgia Regents Class of 2017, New York University School of Medicine University Use of an automated eye tracking system for early detection of DNA Damage and Apoptosis in Epidermal-Specific Protein Kinase D1 hydrocephalus Knockout Mouse Skin upon Ultraviolet B Irradiation Mentor Uzma Samadani, MD, PhD Mentor Wendy Bollag, PhD Councilor Linda Tewksbury, MD Councilor Clarence Joe, DMD, MD, FACR Kristen Hart Sahitya Denduluri Class of 2015, Boston University School of Medicine Class of 2016, University of Chicago Division of the Biological Defining the Role of Gut Hormones in Feeding Intolerance in Sciences The Pritzker School of Medicine Premature Neonates Modulating insulin-like growth factor 1 receptor (IGF-1R) signaling Mentor Camilia Martin, MD, MS as a potential treatment for osteosarcoma Councilor David McAneny, MD Mentor Hue Luu, MD Lydia Hartsell Councilor Adam Cifu, MD Class of 2015, University of Minnesota Medical School Rami Diab Pilot study assessing the prevalence of Schistosomiasis haematobium Class of 2015, American University of Beirut School of Medicine among Tanzanian obstetric fistula patients and potential impact of Role of hsa-miR-4747-5p and hsa-miR-4313 in the regulation of infection on fistula characteristics and surgical outcome CYP2B1 and CYP4F4 activity in diabetic nephropathy-induced kid- Mentor Kristin Chrouser, MD, MPH ney injury: An in-vivo and in-vitro model of Type I Diabetes Councilor Charles Billington, MD Mentors Assad E. Eid, PhD, and Hanna Abboud, MD Jason Huang Councilor Ibrahim S. Salti, MD Class of 2017, University of Illinois College of Medicine Peter Dorschner Regulation of PAI-1 by miRNA-17~92 and Its Role in Pulmonary Class of 2016, Northwestern University The Feinberg School of Arterial Hypertension Medicine Mentors J. Usha Raj, MD, and Guofei Zhou, PhD A Retrospective Study of Early Post-Transplant Nosocomial Councilors Melvin Lopata, MD, and Jessica Ryan Hanks, MD Infections Anna Huguenard Mentor Michael J. Ison, MD Class of 2016, Emory University School of Medicine Councilor John P. Flaherty, MD Deep brain stimulation as a novel treatment following traumatic Benjamin Farnia brain injury: An immunohistochemical analysis for promotion of Class of 2015, Baylor College of Medicine neurogenesis and neuroplasticity Assessing predictive factors of intratumoral hemorrhage following Mentor Emad Eskandar, MD stereotactic radiosurgery for metastatic intracerebral tumors Councilor Thomas C. Pearson, MD, DPhil Mentor Paul Brown, MD Peter Ireland Councilor Kristin Angelie Kassaw, MD Class of 2017, Saint Louis University School of Medicine Jesse Fitzpatrick Cell-based Screening of Beta-Thujaplicinol Derivatives as Potential Class of 2015, Duke University School of Medicine Therapies for Herpes simplex Viruses Can MRI inform return-to-play-guidelines in brain injury: An em- Mentor Lynda Morrison, PhD piric study to identify predictive MRI markers in a mouse model of Councilor Dennis O’Connor, MD repeated traumatic brain injury Kathleen Jee Mentor Christopher Lascola, MD Class of 2015, Johns Hopkins University School of Medicine Councilor Edward Buckley, MD Examination of Angiopoietin-like 4 in Patients with Diabetic Eye Justin Gibson Disease Class of 2017, University of Cincinnati College of Medicine Mentor Akrit Sodhi, MD, PhD Role of adenosine signaling in protection against secondary brain Councilor Charles W. Flexner, MD injury Andrew Kadlec Mentor Jed Hartings, PhD Class of 2017, Medical College of Wisconsin Councilor Robert W. Neel, MD Effect of Novel Otoferlin Mutations on Temperature-Sensitive Auditory Neuropathy Spectrum Disorder Mentor Christina L. Runge, PhD Councilor James L. Sebastian, MD The Pharos/Summer 2014 59 2014 Carolyn L. Kuckein Student Research Fellowships

Roger Khouri Jessica Regan Class of 2017, University of Michigan Medical School Class of 2017, Virginia Commonwealth University School of Medicine Growth Hormone Therapy to Improve Recovery from Chronic The impact of Interleukin-18 (IL-18) blockade on inflammation in a Muscle Tears model of heart failure with preserved ejection fraction (HFpEF) Mentors Christopher Mendias, PhD, ATC, and Asheesh Bedi, MD Mentor Antonio Abbate, MD, PhD Councilor Cyril M. Grum, MD Councilor Susan DiGiovanni, MD Khameer Kidia Timothy Richmond Class of 2017, Icahn School of Medicine at Mount Sinai Class of 2015, Ohio State University College of Medicine System-Level Analysis of Mental Health Services in Zimbabwe Role of nucleolin in the development of chemo- and radio-resistance Mentor Craig Katz, MD in cancer cells Councilor Carrie Ernst, MD Mentor Carlo Croce, MD Sushma Kola Councilor Sheryl Pfeil, MD Class of 2017, University of Pittsburgh School of Medicine Sharmistha Rudra Regenerating Trabecular Meshwork by Mobilizing Adjacent Stem Class of 2015, The University of Texas School of Medicine at San Cells in ex-vivo Human Eyes Antonio Mentor Nils Loewen, MD, PhD Role for the Alternatively Spliced BAFF Isoform in Patients Without Councilor Carl R. Fuhrman, MD Chronic Graft Versus Host Disease (cGVHD) Arooshi Kumar Mentor Stefanie Sarantopoulos, MD, PhD Class of 2017, University of Louisville School of Medicine Councilor Erin Nelson, MD Genetic Heritability Estimates of Ischemic Stroke Severity and Post- Cristian Serna-Tamayo stroke Outcome Class of 2015, Rutgers New Jersey Medical School Mentor Natalia Rost, MD, MPH Poxviruses as Oncolytic and Immunotherapy for Melanoma Councilor Daniel Danzl, MD Mentor Liang Deng, MD, PhD Daniel Mascarenhas Councilors Clark Lambert MD, FAAP, and Robert A. Schwartz MD, Class of 2017, University of Maryland School of Medicine MPH “Is CT enough?” The Subaxial Cervical Spine Injury Classification Sasha Targ (SLIC) System: Can CT alone predict the need for surgical Class of 2017, University of California, San Francisco, School of intervention Medicine Mentor David Dreizin, MD Molecular Mechanism of IL-21 Mediated Regulation of IgE Antibody Councilors Donna Parker, MD, and Yvette Rooks, MD Responses Ari Morgenthau Mentor Christopher Allen, PhD Class of 2017, New York Medical College Councilor Lee Atkinson-McEvoy, MD The role of lactoferrin binding protein B during infections with Siobhan Thomas-Smith pathogenic Neisseriaceae Class of 2015, University of Washington School of Medicine Mentors Anthony B. Schryvers, PhD, MD, and Scott Gray-Owen, Electronic Health Assessment for Adolescents Study PhD Mentor Laura Richardson, MD, MPH Councilor William H. Frishman, MD Councilor Douglas S. Paauw, MD Justin Morse Anthony Trenga Class of 2015, University of North Carolina at Chapel Hill School of Class of 2017, University of Virginia School of Medicine Medicine Radiographic patterns of congenital bony spinal deformities and their Optimizing Decellularized Bone as a Scaffold for Novel Stem Cell association with neural axis abnormalities on MRI Therapies Mentor Mark Abel, MD Mentor John A. van Aalst, MD, MA Councilor Mark J. Mendelsohn, MD Councilor Amelia Drake, MD Justin Tse Sahar Naseer Class of 2015, University of California, Los Angeles David Geffen Class of 2015, University at Buffalo State University of New York School of Medicine School of Medicine & Biomedical Sciences Tissue Engineering the Vocal Fold: A Multidisciplinary Approach Next-Generational Sequencing in Pemphigus Vulgaris Mentor Jennifer Long, MD, PhD Mentor Animesh A. Sinha, PhD Councilor Neil H. Parker, MD Councilor Frank Schimpfhauser, PhD Grant Turner Matthew Recker Class of 2015, University of Nebraska College of Medicine Class of 2017, Drexel University College of Medicine The role of IFT88 on ciliogenesis of motile respiratory epithelium The role of mTOR in exercise dependent axon regeneration through and the regulation of ciliary motility a peripheral nerve graft following spinal cord injury Mentor Joseph Sisson, MD Mentor John D. Houle, PhD Councilor Jason Shiffermiller, MD Councilor Kathleen Ryan, MD Michal Ursiny Russell Reeves Class of 2015, University of Vermont College of Medicine Class of 2017, Geisel School of Medicine at Dartmouth Minimizing Cost and Antibiotic Resistance When Treating Determining Nanoparticle Distribution for Treatment Planning Using Uncomplicated E. coli Cystitis SWIFT Mentors Turner Ostler, MD, and Brian Eisner, MD Mentor P. Jack Hoopes, DVM, PhD Councilor Gilman Allen, MD Councilor Susan Harper, MD

60 The Pharos/Summer 2014 Nikki Vyas Caroline West Class of 2015, USF Health Morsani College of Medicine Class of 2016, Medical University of South Carolina College of Comparing Whole Slide Digital Images versus Traditional Glass Medicine Slides in the Detection of Common Microscopic Features Seen in Developing a model of screening for diabetes in the resource poor Dermatitis setting of rural Tanzania Mentor Drazen M. Jukic, MD, PhD Mentor Michael Sweat, PhD Councilor Patricia J. Emmanuel, MD Councilor Christopher G. Pelic, MD Andrew Walls Sherry Yan Class of 2016, Georgetown University School of Medicine Class of 2015, Columbia University College of Physicians and Metabolic Pathway Analysis in Pediatric Patients Diagnosed with Surgeons PANDAS Changes in EGFR genomic mutational profile in response to concur- Mentor Earl Harley, MD rent chemoradiation for treatment of locally advanced NSCLC Councilor Michael Adams, MD Mentor Simon Cheng, MD, PhD Timothy Wen Councilor John C.M. Brust, MD Class of 2016, Keck School of Medicine of the University of Southern Yang Yu California Class of 2015, University of California, Irvine, School of Medicine “Never Events”: Evaluating the quality and safety of pediatric hydro- Variable Pathogenicity of Different Propionibacterium acnes Strains cephalus shunt procedures on a national level Mentor Jenny Kim, MD, PhD Mentors William Mack, MD, and Steven Y. Cen, MD Councilors Michael L. Berman, MD, and Ranjan Gupta, MD Councilors Paul Holtom, MD

Changes to the Pharos editorial board

and industry to work to im- non-profits. To address the lack of prove access to health care of mental health services for children, Oregonians as well as those in 1961 he and an engineer-magnate globally, to protect the for- established what became Lifeworks ested watershed of Portland’s Northwest. Today this agency annually water supply from environ- serves over 17,000 children, adolescents, mental degradation, and to and adults with abuse prevention, men- educate physicians about tal health, and addiction recovery ser- managing pain. vices. Decades ago he foresaw mental Born in Brooklyn, he health as part of community health. found at age eleven his call- In 1982 he formed Oregon Health ing in medicine in the movie Decisions and moderated scores of its Arrowsmith. Crawshaw’s town halls statewide to engage public career highlights his broad dialogue in shaping health policy. Their interests and recognition. medical priorities undergirded State Ralph Crawshaw, MD, 1921–2014 Service as a volunteer ski Senator John Kitzhaber’s 1993 legis- On May 24, 2014, Ralph Crawshaw trooper and later as a Navy physician lation that provided medical services of Portland, Oregon died of natural to marines in World War II bracketed to 300,000 working poor through the causes. Medical pioneer and tireless so- graduation from NYU and a Menninger seminal Oregon Health Plan, a kinder, cial activist, author, and passionate ide- residency. Scholarly pieces on evolving community-shared form of rationing alist driven to solve problems through medical oaths, election to the Institute limited resources. Following a rash practical innovation, Ralph left a legacy of Medicine in 1978, presidency of his of suicides of physicians challenged of achievements and organizations. His county medical society, and Senior for their drug prescribing, Crawshaw focus was the health of the commu- Scholar at OHSU’s Ethics Center iden- pushed the 1984 creation of The nity. In a few of many examples, he tify a renaissance character. Foundation for Medical Excellence, an gathered leaders from many professions Crawshaw conceived several educational approach parallel to the

The Pharos/Summer 2014 61 Changes to the Pharos editorial board

concerns of the supportive state licens- film series tracing the trajectory of good was accomplished. One of the ing board. TFME would more generally Hollywood’s portrayal of physicians. last things that we kicked around was address the doctor-patient relation- We started with the 1946 film Miss starting a society named after Antoine ship and physician professionalism and Susie Slagle’s about the early days of the Lavoisier. A tax collector, lawyer, and well-being. The Foundation continues twentieth century when Johns Hopkins banker, Lavoisier’s main claim to fame to sponsor regional courses on pain medical school acted in loco parentis, was his revolutionizing the science of management, several annual lectures through Hospital, which showed the chemistry and proving that it was oxy- by national authorities on health policy dark side of medicine and patient care gen and not phlogiston that was re- and education, monthly colloquia on in an inner city New York hospital, and sponsible for combustion. The society’s social and historical topics, and publica- finally to The House of God, a cult book motto was to be: “No good deed goes tions on health care reform. In 1986 in about hardened and profane residents at unpunished.” No one illustrated that JAMA Ralph urged fellow practitioners a Boston hospital that was turned into a motto better than Lavoisier whose tax to aid colleagues in developing coun- movie but never distributed. collecting gig caught up with him—he tries. Healthcare Volunteers Overseas In 1990 Ralph decided to give up finally rode the tumbrel to a rendezvous resulted, as of today having sent over writing the column, and he recom- with Dr. Guilliton’s so-called “humane” 4500 volunteers on over 8000 missions mended me to Editor Robert Glaser. dispatcher to the next world, an event worldwide. That led to at least quarterly phone calls that led the eighteenth-century French Ralph was a cheerful, generous, and or letters of support for my efforts. In mathematician Joseph Louis Lagrange compassionate—while relentless—per- his review of my book about doctors in to say, “Only a moment to cut off that suader, who stimulated the intellect and the movies, in his typical enthusiastic head and a hundred years may not give effectiveness of colleagues, community way, he suggested to Steve Schroeder, us another like it.” The same might be leaders, and newspaper editors alike. then the president of the Robert Wood said about Ralph. Medicine has lost a He deplored inaction when logic de- Johnson Foundation, that a copy be sent great advocate for professionalism and manded action. Friendly debates, never to every medical student. Steve, being compassion and many of us have lost a arguments, over such topics as the more prudent, graciously agreed to send dear friend. soul versus the spirit of medicine were a copy to every medical school library. Peter E. Dans, MD lively, but seldom resolved. Eclectic, Our conversations, which lasted (AΩA, Columbia University, 1960) energetic, apolitical in the party sense, right up to last year, would end up with Cockeysville, Maryland naturally perceptive about human be- his soliciting my thoughts about, and havior, he persuaded others by “invit- involvement in, his latest efforts to im- ing their higher angels.” In every way prove the profession and assure compas- Retirement Ralph Crawshaw epitomized the worthy sionate patient care. Like Don Quixote, Editorial board member Eric Pfeiffer, physician-citizen. he was always tilting at windmills, try- MD, published poet, founding director ing to make the seemingly impossible of the Eric Pfeiffer Suncoast Alzheimer’s John A. Benson, Jr., MD possible—and he often succeeded. He Center, and emeritus professor of (AΩA, Oregon Health & Science compiled many of his ideas and efforts Psychiatry at the University of South University, 1968) in his 2002 book Compassion’s Way: A Florida College of Medicine, is retiring Portland, Oregon Doctor’s Quest into the Soul of Medicine from the Pharos Editorial Board. Ralph Crawshaw launched “The (Medi-Ed Press, 2002). He didn’t look Dr. Pfeiffer served as Interim Editor “Physician at the Movies” column in like a revolutionary. He wasn’t starry- of The Pharos in 2011 after the death of 1971. A psychiatrist, he probed the psy- eyed or wild-eyed, but being Brooklyn- Executive Director Edward D. Harris, chological aspects of films in his reborn, he was realistic. He knew that Jr., and before the appointment of Dr. views, many of which remain classics. I revolutionaries often die on the bar- Richard L. Byyny. We thank him for the got to know him when I invited him to ricades and to the extent that they suc- inestimable help and support he gave us be an AΩA visiting professor at Johns ceed it is others who often get the credit. during that difficult time. Hopkins in the early 1980s for a two-day This didn’t bother him as long as some

62 The Pharos/Summer 2014 Henry Langhorne, MD Jenna Le, MD Janice Townley Moore

New editorial board members Capability, Hurricane Review, The Competition, a William Carlos Williams We are pleased to announce the addi- Panhandler, JAMA, and The Pharos. Poetry Competition finalist, a Michael E. tion of three new members to the Pharos Jenna Le received a BA in DeBakey Medical Student Poetry Award editorial board: Henry Langhorne, MD; Mathematics from Harvard University finalist, a Pushcart Prize nominee, and a Jenna Le, MD; and Janice Townley and an MD from Columbia University. PEN Emerging Writers Award nominee. Moore. She is a radiology resident at Montefiore Janice Townley Moore, a native of Henry Langhorne graduated from Medical Center/The Albert Einstein Atlanta, is Professor Emeritus at Young Tulane Medical School 1957 and trained College of Medicine of Yeshiva University Harris College in the mountains of north in cardiology at Tulane and Charity in Bronx, New York. In 2015/16, she will Georgia, where she has had a long career Hospital New Orleans. He has practiced be a Musculoskeletal Radiology fellow of teaching English and creative writing. cardiology in Pensacola, Florida since at Montefiore Medical Center. Dr. Le For a dozen years she served as poetry 1963 as a senior member of Cardiology is the author of Six Rivers, a book of editor of Georgia Journal. Her poems Consultants. Dr. Langhorne has eight poetry that was published by New York have been published in such journals collections of poetry published by the Quarterly Books in 2011 and was a Small as Prairie Schooner, Georgia Review, West Florida Literary Federation and Press Poetry Bestseller. Her poetry, fic- JAMA, Connecticut Review, The Pharos, Pelican Press. He is the former Poet tion, essays, book criticism, and transla- and in many anthologies including The Laureate of Northwest Florida (1999– tions of French poetry have appeared Bedford Introduction to Literature and 2009), selected by the West Florida or are forthcoming in many respected The Southern Poetry Anthology (Texas Literary Federation. Over the past literary journals including AGNI Online, Review Press). twenty years, he has published poetry Barrow Street, Bellevue Literary Review, in a number of periodicals includ- The Southampton Review, and 32 Poems. ing Plainsongs, The Cape Rock, Poem, Her past national honors include being The Chattahoochee Review, Negative a two-time winner of the Pharos Poetry

The Pharos/Summer 2014 63 n the Trail I learned from a CD jacket George Gershwin died At thirty-eight, in ‘37 From a symptomatic glio; suspected but undetected. Gave a concert before noon. O Was decerebrate by night, He departed at full gallop. I learned from the Times this year That Oliver Sacks, nearly 80, Wants death in the saddle too; But in old age, after A time of leisure and freedom To wrap it up. How death has changed, From random, rapid, unexpected, To predictable, slow, anticipated Withering, weakening Autoconsumption. There is time for contemplation, but Survival is the preoccupation. Death has been displaced By erosion of self, And wishing for day’s end to be trail’s end. Myron F. Weiner, MD

Dr. Weiner (AΩA, Tulane University, 1955) is Emeritus Professor of Psychiatry at the University of Texas Southwestern Medical Center in Dallas. His address is: 5945 Still Forest Drive, Dallas, Texas, 75252. E-mail: [email protected]. 64 Illustration by Erica Aitken The Pharos/Summer 2014 The Robert H. Moser Pharos Editor’s Prize

obert H. Moser, MD, MACP, served for many years as an we have set a fundraising goal of 100,000 to fund the award enthusiastic and skilled member of the editorial board of annually. Dr. Moser’s wife Linda has pledged 10,000 toward TheR Pharos. He was the book review editor of the journal from this amount. If you would like to contribute to funding this 2001 to 2004, and continued to contribute to The Pharos until award to honor one of the giants of American medicine of the his death last August. last century, please send your contribution, noting that it is for Alpha Omega Alpha wishes to honor Dr. Moser by estab- the Moser Award to: lishing an annual award in his name to recognize excellence Debbie Lancaster in writing in The Pharos. We invite your help. We propose an Managing Editor annual award of up to 6000, to which Alpha Omega Alpha Alpha Omega Alpha would contribute 2500 annually. To reach our goal of a presti- 525 Middlefield Road, Suite 130 gious and significant award, worthy to bear Dr. Moser’s name, Menlo Park, CA 94025

Medical Center in Honolulu. During this period, he was instrumental in setting up programs that guided the education of generations of internal medicine house officers by integrating university-level training standards in Army teaching hospitals. He remained passionate about medical education throughout his life. • During his years of private practice in internal medicine in Maui, he served as one of the doctors treating patients at the Kalaupapa leper colony on Molokai. • Dr. Moser was the author of several medical reference books, some still in use today, and was one of the first physician/writers to deal with the problem of drug- induced disease. • As editor-in-chief of the Journal of the American Medical Association from 1973 to 1975, Dr. Moser in- stituted sweeping changes in the journal that are still evident today. • Dr. Moser served as Executive Vice President of the American College of Physicians in Philadelphia from 1977 to 1986. While there, he was invited to the People’s Republic of China to observe medical practice there in one of the earliest signs of detente. More importantly, he met his wife Linda while working at the ACP. • In the 1980s, he served as Director of Medical Affairs for Monsanto’s NutraSweet division. Dr. Moser’s illustrious career included an enormous • After so-called retirement, he and his wife formed variety of fascinating endeavors: a medical consulting company to establish networks • He organized and serving as a surgeon in one of the of medical experts in various specialties for large first MASH units during the Korean War. corporations. • He was a pioneering flight controller who monitored • Not least, Dr. Moser was a frequent contributor to the physiological and psychological performance of as- The Pharos and a member of its editorial board, on which tronauts for the Project Mercury through Project Apollo he served until his death. space programs. Dr. Moser published his autobiography, Past Imperfect: • He served as Chief of Medicine at Walter Reed Army A Personal History of an Adventuresome Lifetime In and Medical Center in Washington, DC; William Beaumont Around Medicine, in 2002. A video of reminiscences by Army Medical Center in El Paso; and Tripler Army Dr. Moser is available here: https://vimeo.com/22113933.