The Wake County Physician Is a Publi- 2010 Cation for and by the Members of the Michael Thomas, MD, Phd, FACE Wake County Medical Society

July 2010 Volume 15 No. 3 TTHEHE WWAKEAKE CCOUNTYOUNTY PPHYSICIANHYSICIAN Magazine

Celebrating medicine, the arts, intellect, ideas and curiosity.

North Carolina Museum of Art Rodin Court at night. (Photograph by Jesse Turner) THE WAKE COUNTY Wake County Medical Society TABLE OF CONTENTS PHYSICIAN Officers and Executive Council Page 1 President’s Message The Wake County Physician is a publi- 2010 cation for and by the members of the Michael Thomas, MD, PhD, FACE Wake County Medical Society. The Wake President Page 1 Time to Apply Cutting Edge County Physician is published in April, Micheal Thomas, MD, PhD, FACE To the Brain, Nobelists Says April, July and October. We will consider Treasurer James Watson, PhD for publication articles relating to medi- cal science, editorials, opinion pieces, David Cook III, MD Page 2 Editorial letters, personal accounts, photographs Assad Meymandi, MD, PhD, DLFAPA Past President and drawings. Prospective authors Page 3 The Role of Social Sciences & Humanities should feel free to discuss potential Raynor Casey, MD Jeffrey P. Braden, PhD articles with the editorial board. Assad Meymandi, Page 4 Letters to the Editor Manuscript Preparation Submissions MD, PhD, DLFAPA Page 8 Physician Profile: Dr. Edward B. Yellig should be sent electronically to Founding Editor and Editor-in-Chief [email protected] Fiona Morgan Page 10 The Evolution of a Children’s Hospital Submit photographs or illustrations as Editorial Board Mark Piehl, MD high quality 5 x 7 or 8 x 10 glossy L. Jarrett Barnhill, MD prints or a digital JPEG or TIF file at 300 Jeffrey Engel, MD Page 14 WCMS Update DPI no larger than 2” x 3” unless the Brian Go, MD Paul Harrison artwork is for the cover. Please include Douglas I. Hammer, MD, DrPH Page 15 WCMS Society News names of individuals or subject matter Ken Holt, MD Page 16 WCMS New Members for each image submitted. Photos may Nell D. Joslin Page 18 Mental Health Corner: Celebrating be sent directly to: Fiona Morgan Nicholas Emanuel Stratas, MD, DLFAPA Tina Frost Nicholas Stratas, MD 708 Merrion Park Lane Phillip Timmons, MD Page 22 North Carolina Treasures Morrisville, NC 27560 Susan T. Weaver, MD Peter White, PhD [email protected] - 919.671.3963 Randall W. Williams, MD Page 23 At Placebos, Magic & Faith Healing Authors Bio and Photos L. Jarrett Barnhill, MD, DFAPA, AACAP Council Members Submit a recent 3x5 or 5x7 black and Page 24 Issues on End of Life Care white or color photo (snapshots are Susheel Atree, MD Gary S. Winzelberg, MD suitable) along with your submission for Jeffrey Engel, MD publication or a digital JPEG or TIF file Manish Fozdar, MD Page 26 POINT: Health Care Reform at 300 DPI no larger than 2” x 3” (Send Brian Go, MD J. Bradley Wilson, JD to Tina Frost at the above address.) All Warner L. Hall, MD Page 27 COUNTER POINT: Health Care Reform photos will be returned to the author. Doug Holmes, MD James S. Fulghum, III, MD Include a brief bio along with your prac- Ken Holt, MD tice name, specialty, special honors and Page 28 Project Access positions on boards, etc. Please limit M. Dixon McKay, MD Pamela Carpenter Assad Meymandi, MD, PhD, DLFAPA the length of your bio to 3 or 4 lines. Page 30 Public Health Issues David Miller, MD Submissions may be mailed to: Dale Oller, MD Jeffrey Engel, MD, MPH Editor, The Wake County Physician Page 32 Poetry Corner 2500 Blue Ridge Rd, Ste 330 Patricia Pearce, MD Raleigh, NC 27607 Susan T. Weaver, MD John Balaban Phone: 919.782.3859 Fax: 919.510.9162 Page 34 Thinking Things Through WCMS Alliance Co-Presidents E-mail: [email protected] Assad Meymandi, MD, PhD, DLFAPA LaRinda Kaplan Page 36 Quarterly Morbidity Report Ad Rates and Specifications: Maya Zumwalt Full Page $300 Jeffrey Engel, MD, MPH 1/2 Page $150 VISION FOR WCP Page 37 True Health Reform A MAGAZINE 1/4 Page $75 - with appeal to the family of medicine in Wake Tor Dahl Trim Size: 8 1/2” x 11” County and to the larger world beyond bound Page 38 Editor’s Notebook Binding: Saddlestitch together by scientific, intellectual and artistic Assad Meymandi, MD, PhD, DLFAPA glue. (Urbi) For ad placement information contact Page 40 Consultant’s Corner - with the collaboration of the Alliance, bringing Paul Harrison. together Wake County medical families through Lloyd A. Hey, MD, MS Phone: 919.792.3620 Fax: 919.510.9162 words and pictures. To know who dies, who Page 42 The Humanities Corner marries, who gets promoted, and those who go Camera ready artwork for advertise- Gary Comstock, PhD to which medical school. ments should be sent via email to: Page 43 Clinical Corner - a powerful instrument to attract and induct Tina Frost at [email protected] members to organized medicine, particularly Alan Rosen, MD, FACR the WCMS, NCMS and AMA (orbi) Page 44 Galen’s All-Purpose Antidote - read globally in intellectual, spiritual, academ- “The Wake County Physician George W. Houston, PhD ic and business centers beyond Wake County Page 48 Book Reviews Magazine is an instrument of the and North Carolina through online circulation. Assad Meymandi, MD, PhD, DLFAPA Wake County Medical Society; - a globally recognized and credible instrument however, the views expressed are to bridge the gap between medicine, basic Page 52 In Memory not necessarily the opinion of the sciences, ethics and bioethics; the arts, such Back Role Model Worth Emulating as music, opera, dance, poetry; and all of the Cover Melba Watson Woodruff, MD Editorial Board or the Society.” humanities such as philosophy, history, patrio- tism, epistemology, theology and rhetoric. Leon F. Woodruff, Jr., MD

President’s Message By Michael Thomas, MD, PhD, FACE

aleigh Winston-Salem as Bowman Gray School has had of Medicine. Rthree Although it has been ninety-two years medical since the Leonard Medical School at Shaw schools in University closed and seventy years since its past. The Wake College School of Medicine moved. Leonard Medi- Wake County continues to enjoy a rich cal School at academic medical tradition. Medical resi- and Grand Rounds beyond Wake County Shaw Univer- dents perform their postgraduate training borders. Thus, academic medicine contin- sity was one at WakeMed, and medical students rotate ues to pervade Wake County at multiple of the first black through various medical practices. Many levels. medical schools in the nation, opening Wake County physicians are employed With this in mind, I am pleased to an- its doors to students in 1882. However, by Duke University Medical Center or nounce that the Wake County Medical they eventually closed in 1918. In 1901, University of North Carolina Hospitals, Society will be hosting an evening event the University of North Carolina ap- and some private Wake County physi- on the role of academic medicine in Wake pointed Dr. Hubert Ashley Royster Dean cians have joint academic appointments at County on November 18, 2010, at the of the Raleigh Department of Medicine, University of North Carolina, Duke, and North Raleigh Hilton Hotel, at 6:30 PM. which lasted until closure in 1909, in other institutions. A large proportion of This venue will feature speakers from our order to consolidate the two-year medical Wake County physicians are graduates of two nearby medical schools, Dr. Victor program at Chapel Hill. Nevertheless, local medical training programs. Some Dzau and Dr. William Roper. We will prior to closure of Raleigh Department of individuals, including myself, have had explore what the academic missions of Medicine, eighty-seven students matricu- careers in academic medicine before mov- these institutions are in Wake County, and lated and seventh-six students graduated ing on to private practice in Wake County. the impact they will have in the forthcom- from the capital campus. In 1902, Wake Several of our practitioners are experts ing years. We invite physicians to attend Forest College of Medicine opened and with national and international reputations, and carry on our academic tradition into stayed until 1940 when it relocated to presenting at professional conferences the twenty-first century. § Time to Apply Cutting Edge To the Brain, Nobelists Say James Watson helped figure out the structure of DNA, and now he wants a crash multibillion-dollar research program to figure out the brain.

From Wire Services structure of DNA 60 years ago. Writing in the March 26 Science, A research agenda that leads to Watson and colleagues (including he time has arrived for a intensified study of neural circuitry fellow Nobel Prize winners Syd- massive push to explore and sequencing the genomes of ney Brenner, M.B., B.Ch., and Eric Tthe roots of psychiatric 100,000 individuals would push Kandel, M.D.) called for spending illnesses with the latest scientific neuropsychiatric understanding $2 billion over the next decade to tools, according to the scientist who ahead substantially, said James use “a new perspective and a combi- helped define the double-helical Watson, PhD, in an interview. nation of novel tools and analytical [Continued on page 3] WAKE COUNTY PHYSICIAN • JULY 2010 | 1 Editorial Assad Meymandi, MD, PhD, DLFAPA Founding Editor

of North Carolina and Research Triangle portunity to develop further understanding Park, in 2003, the fiftieth anniversary of of ourselves, the new science, the science the discovery by having Dr. James Watson of mind, provides us with a powerful amongst us. The understanding of DNA, instrument for further development of the and subsequent expansion of the knowl- field. If the twentieth century was known THINKING ABOUT THINKING, EPISTEME, CHRESTOMATHY TWENTY-FIRST CENTURY THE AGE OF MIND

[Excerpts from the lecture to the North Carolina Psychoanalytic Institute, Committee on Research, given on March 20, 2010, at the Lucy Daniels Foundation, Cary, North Carolina—Ed.]

n preparing for this essay, obviously I edge and advancement of human genome for the discovery of DNA, genomics and was drawn to psychoanalytic litera- project which was completed in 2003 by epigenetics, the twenty-first century will Iture of the late nineteenth and early Dr. Craig be known twentieth century. But the further I dug, Venter, for the dis- the more it became obvious that psycho- Director, covery and analysis did NOT start with Freud. Many The Institute understand- of Freud’s teachers and predecessors had for Genomic ing of the expounded on the theory of unconscious. Research, in science of Plato, Shakespeare, Kant, Schopenhauer my opin- mind. And and Nietzsche have all dealt with, and ion, was the promise expounded on the possibility of the uncon- the greatest of establish- scious, the soul and metaphysics. Yes, I achieve- ing such a was taken all the way back to Aristotle, a ment of the discipline student and rival of Plato, whose writ- twentieth rests with ings are so very organized and detailed, century. espousing making the reader feel like they are biting Now, psychoanal- into stone. Aristotle had a lot to say about facing the ysis with psyche (soul), God, ether and metaphysi- twenty-first biological cal phenomena. Psychoanalysis thrived in century, sciences, the first 60-70 years of the 20th century, with wars neurosci- but experts fear the threatened demise of going on ence and the field. What is the answer? The an- every corner neurobiol- swer lies with uniting psychoanalysis with of the globe, ogy. biological sciences. Let me elaborate: humans kill- Of course, In a recent discussion with an academic ing humans the concept colleague who was identifying the twenti- for a few of scientific eth century’s greatest achievement as the pieces of understand- discovery of the atomic bomb, I suggested mud prized ing of mind rather forcefully that the contribution of as land, the is not new. the twentieth century was advancement of need for Sigmund Father Gregor Mendel’s genetics through understand- Freud in the discovery and understanding of RNA ing human Beyond the and DNA by James Watson and Fran- behavior Pleasure cis Crick in 1953. They were awarded makes psychoanalytic research more Principle wrote an increase in plasma Nobel Prize for Medicine or Physiology urgent. And I believe we have the op- ACTH and glucocorticoid responses in 1962. We celebrated at the University [Continued on page 46] 2 | JULY 2010 • WAKE COUNTY PHYSICIAN TIME TO APPLY continued from page 1 Still, research efforts to date problems. have not failed, said lead author Some of these illnesses are heri- methods” to understand the origins Huda Akil, Ph.D., the Gardner table, as twin studies have shown, of psychiatric disorders. The article Quarton Distinguished University but many possible most—mutations grew out of a conference in Decem- Professor of Neuroscience and occur de novo in the developing ber 2009 at the Cold Spring Harbor Psychiatry and codirector and senior organism, and hundreds of gens Laboratory on Long Island, where research professor at the University may be involved in one psychiatric Watson is chancellor emeritus of of Michigan’s Molecular and Be- illness, said Watson. the Watson School of Biological havioral Neuroscience Institute. Thus, many individual genomes Sciences. “It’s not that people haven’t must be analyzed to detect the pat- Two factors besides the prestige contributed real understanding or terns that characterize a disorder. of the Nobelists add weight to their that different perspectives are not “Given the complexity of schizo- conclusions, said Thomas Insel, valid, but the techniques in genetics phrenia and most other mental M.D., director of the National Insti- and neuroscience are just catching illnesses, we’re going to have to tute of Mental Health (NIMH), who up to the challenge that psychiatric sequence a large number of people,” attended the December meeting. disorders demand of use,” said Akil said Watson. “As long as there’s “People outside the usual realm in an interview. this sense of urgency, and it won’t of psychiatric research, from oncol- The complexity of the human bankrupt anyone, why not get it ogy to immunology, now think that brain lies at the core of the chal- done fast?” really exciting breakthroughs will lenge, said the authors. The cost of sequencing the ge- come from research into mental illness.” Insel told Psychiatric News. “In addition, the scientific tools for studying genetics and neural circuitry have progressed dramatically in the last two years so that the field is ready for increased investment.” These tools include high-throughput gene sequencing, quantifi- able studies of brain circuitry, and the use of optogenetics to manipu- late circuitry in rodent models. The last tech- nique has transformed the study of circuits and behavior, the said. James Watson, Ph.D., of the Cold Spring Harbor Laboratory, leads a The problem is one that is familiar to psy- group of scientists urging a $2 billion “Manhattan Project” to define chiatrists: few break- the genetics and neurocircuitry underlying psychiatric illness and throughs in treatment achieve needed breathroughs in diagnosis and trreatment. have occurred in the last decade, and treatment effects If any of the thousands of genes nome of one individual is expected vary so widely among patients that that regulate neural development to eventually fall below $10,000. At a “sizable proportion are resistant to or function go awry, the result can that prices, sequencing the genomes all currently available treatments.” lead to a variety of neuropsychiatric of 100,000 [Continued on page 6]

WAKE COUNTY PHYSICIAN • JULY 2010 | 3 LettersExcerpts from letters to the Editor What do you think? Share your could not get his revenues to the point are downright smug and arrogant about thoughts in WCP Forum. We are where he could cover his share of the it. It’s as though no other perspectives reaching a multitude of readers in overhead, again due to Medicare bun- are deemed worthy of consideration since medicine, business, universities, dling and cuts. This when the Triangle’s they alone have superior information, public libraries, and hospitals. unemployment rate is over 11% and the importance, judgment and wisdom and Letters to the Editor and contri- nation’s near 10%. they alone are able to decide what’s best butions are welcome and will be Unlike many primary care doctors who for everyone. I’m convinced that they considered for publication. ration Medicare appointments, our patient have no real awareness of the depth and population is about 65% Medicare as you breadth of the outrage, frustration, dis- would expect in a cardiology practice. If gust, distrust and sense of betrayal that the Health Care Reform Medicare continues to abruptly fail to pay American people feel toward them. reimbursements, community cardiologists Not only were there no physicians in- In spite of the Health Care Reform bill will be ‘snuffed out,’ as the Wall Street cluded in this Summit meeting, apparently passage the debate continues (see pages Journal termed the war on specialists. As there was no one with expertise in human 26-27) Congress dithers and threatens to pass behavior, group dynamics, conflict resolu- through reconciliation a bill opposed by tion or process management involved The Editor: 75% of the population, according to a in the planning and preparations for this I am astonished that no one has writ- CNN poll, unelected bureaucrats threaten meeting. As a trained team facilitator, a ten a letter revealing that the Medicare both access and quality medical care. certified NCDRC mediator, a commis- Administration did not pay the doctors Our practice has communicated this sioned Stephen Minister and a lifelong during the first two weeks of January information to all the Medicare patients student of human beings, I was appalled because they were revising reimburse- he has seen during the last five years. to see that, based on the set up and pro- Many have written or seen their legisla- cess factors alone, this meeting was, quite tors. Etheridge brushed off one man predictably, doomed to fail right from the that has known him for years. Hagan’s start. It’s no surprise to me that it was office did not know what health care a total waste of time and resources with legislation the patient referred to, and no productive outcomes, much less any when two Raleigh cardiologists traveled significant breakthroughs. to Washington to see her, she only had Surely, President Obama and/or at time for a 15 second photo with them. least some of his advisors must have No discussion. In a private meeting with known that the set up and process were Burr, he told Jim that Medicare costs not conducive to fostering true bipartisan had to be brought down regardless of cooperation. It was classic insular Wash- the consequences to patients. Jim’s pa- ington, DC, arrogance in action - seat- tients, many Blue Dogs, are infuriated. ing everyone elbow to elbow around the Obama is done. perimeter of a big square made of tables But more to the point, the danger to nearly touching the walls and crowded by medicine at this moment is the irre- the press, with the President strategically sponsible and arrogant behavior of the placed right in the center seat, completely bureaucrats who threaten to destroy in charge, running a tightly controlled medicine. No doctors, no medicine. meeting, deciding who would be allowed Employees expect to be paid. to speak, responding in judgment to ment codes, and will not pay them again every bit of input with words of praise or for work done during the last two weeks Virginia Scanlan for Cardiologist James rebuttal and sometimes even interrupting of March while they await Congress’ Scanlon, MD’s Practice the person speaking to interject offhand decision on the proposed 20% reduction Raleigh, NC remarks. One has to question whether the in reimbursements. In a separate action, agenda was truly to exchange ideas and Jim’s reimbursements already have been The Editor: find some common ground or just to host cut from 5 to 40% depending on the code. I agree with your comments about the a charade of bipartisanship, complete with As a result of this action, he has fired five Obama Health Care Summit. Our leaders photo ops, in an effort to appear inclusive long-time, highly-trained employees and seem to be completely caught up in that and proactive. Is that the best we can do let a young doctor leave the practice who insular Washington, DC, culture, and they in this great country?

4 | JULY 2010 • WAKE COUNTY PHYSICIAN Just think how much more productive ening to the healing power of hope, tilling the Feds will be increasing our taxes and the day would have been if the partici- new soil in which good will can begin to I fully expect the State to do likewise as pants had started out by asking for divine grow again, and opening our spirits to new both have grossly overspent. wisdom and guidance, pledging to listen songs that bring peace to our sense of mor- Even if the building might be over- with open minds and hearts, seeking tality and love for the gift of the moment. built and it may cost more down the road, more to understand than to be understood Redeeming rhetoric has been wrested with an improved economy citizens will and being ever mindful that the highest from the pens of poets and music is the be better able to financially support it. I form of leadership is servant leadership. exclusive business of markets. Ideology think you may be forgetting the depth and Instead of the typical Washington, DC, and idolatry have been folded into a dull length of this recession and he impact it high profile formal meeting, it would have relativism that sanctions indifference to is having. It is easy for those of us who been much more productive to work in ideas. might can afford to do it now to forget small teams of four to six with a mix of A blessing offered in the name of any many of our citizens cannot afford it. political parties, viewpoints, regions, etc., deity enrages some while lifting the spirits Aside from the cost issue, I am unsure represented in each group. Then, each of others. that it makes sense to have all the police/ group could have included certain key If we can’t truly wish one another well emergency functions in a single location constituent representatives/experts (includ- and, in so doing, acknowledge our humble as I would think they should be dispersed ing physicians, hospital administrators, place in the vast reaches of life, how, then, in the event there should be some disaster state governors, health insurers, judicial do we even think about “healing” the at the central location...a form of backup if system/litigation experts, corporate CEOs, system for medical care? you will. small business owners, etc.) to The teams I have read your comments for over could focus on specific issues or questions 40 years and they continue to be very Jack Alphin in manageable pieces. A skilled facilita- thoughtful and evocative. Thank you. I Raleigh, NC tor assigned to each team would keep the wish you and WCP magazine the best. discussion constructive and on point, and Alzheimer’s Disease the press would not be invited into the Jim Paul, Ed D team meetings. Now, that’s a set up and Tampa, FL The Editor: process with some potential! Your discussion of Alzheimer Disease The Lightener Law in the Quindecennial issue of WCP and on Margaret S. Glass, JD, MBA,CFP Enforcement Center Dr. William Friday’s interview ”NC Peo- Raleigh, NC ple” were most instructive. In addition, The Editor: mitochondrial dysfunction may suggest The Editor: With all due respect, there are a lot of a new therapeutic target in the treatment I agree with your political and psychiat- our citizens suffering financially in our of Alzheimer’s disease (AD). Learn more ric assessment of the Healthcare summit. city who cannot bear additional taxes that about the multifactorial pathophysiology Here’s an idea. I would like to suggest this facility will place on our citizens... of AD. We include the link. that you team up with a few physicians just remember the unemployment and and have a real health summit. A people’s underemployment numbers. To compound Jeffrey Cummings, MD, Neurologist summit, a gathering of medically informed the tax burdens of our citizens, you know UCLA outsiders. A political diagnosis has a low Los Angeles, CA likelihood of leading to responsible and effective medical treatment. (metaphor intended) I wish such an idea could work but, unfortunately, the complexity of the problems coupled with the unconscionable insurance, pharmaceutical, and medical equipment lobbies and self-interested legislators appear to be positioned to defeat any rational solution. It is ironic that a healthy (competent, caring, effi- cient) system for delivering health care is not in the vocabularies of even the most cynical political pundits. Imagination has been blunted by cynicism that has grown through the long and deep experience well-fought battles lost to greed. Shame- fully, a very weak heart now beats for a fair and just society. We are who we are and a transplant is not possible. Stints might help. We need a rebirth of commit- ment to the common good, a deep awak-

WAKE COUNTY PHYSICIAN • JULY 2010 | 5 TIME TO APPLY continued from page 3 perspectives, too.” Lieberman More planning will be needed told Psychiatric News. if the equivalent of a Manhattan people would cost $1 billion. If a “For example, we might de- Project for neuropsychiatry is to similar sum were allotted for imag- fine phenotypes better and look at become reality. ing neural circuitry, the project social and environmental factors, “We welcome a statement call- Watson envisions would cost $200 from urbanism to cannabis, which ing for increased emphasis and million a year over a decade. can increase susceptibility and pre- resources for research on the The payoff would presumably cipitate mental illness,” he said. causes of mental illness from such be a more precise understanding Breakthroughs in understanding an eminent group of scientists,” of the origins and development of the origins of psychiatric illness said Lieberman. “We would hope mental disorders and new avenues must also be translated into thera- that the response to their call also of treatment. peutics, he said. “Research has considers the importance of im- Insel agreed with the added em- yielded genes for cystic fibrosis, mediate clinical needs of patients phasis on genetics and circuitry but Huntington’s disease, and Al- in terms of development of more also noted that NIMH “needs to zheimer’s disease, but not effective effective therapeutic agents and have a very diverse research port- treatments.” interventional strategies. folio,” a view with support from Realizing Watson’s proposal “We should ot forget the patients within organized psychiatry. agenda would demand some com- who are currently affected by The focus on the basic research bination of federal, private, and mental illness and need treatment and translational research for ge- foundation money. and care.” § netics and neurocircuitry has to be “We want to get the White supplemented by work on clinical House and Congress interested,” An abstract of “The Future of trials, services research, epidemi- Watson said. Psychiatric Research: Genomes ology, and health policy research, One model for coordinating the and Neural Circuits” is posted at said Jeffrey Lieberman, M.D. chair enterprise might be the federal at the College of Physicians and Committee, set up by Congress Surgeons at Columbia University, in 2008, said Insel. The commit- director of the New York State tee pulled together all parties Psychiatric Institute, and director interested in autism, planned of the Lieber Center for Schizo- research directions, and phrenia Research. identified gaps in funding. Lieberman is chair of APA’s Council on Research and Quality Care. He was invited to the Cold Spring Harbor meeting but was unable to at- tend because of prior commitments. “Genetics are a high prior- ity because genes identify pathogenic factors that influence brain development and pathology, but there are other

6 | JULY 2010 • WAKE COUNTY PHYSICIAN approaches to un- between derstanding health, mind and THE ROLE OF SOCIAL and virtually none body that of that is targeted to are reified SCIENCES AND HUMANITIES the humanities; the in religious rest is committed to doctrines, IN HEALTH AND WELL-BEING supporting inquiry suggesting paradigms driven the mind is RESEARCH by life sciences. spiritual and Although I marvel sacred, and by Jeffery P. Braden, PhD* at the many impres- the body sive achievements material and If the only tool you have is a hammer, of biomedical profane. you tend to see every problem as a nail. research, such as Such think- A. Maslow vaccines, medi- ing may cines, and surgi- have sub- cal procedures, I stantial influences on health and disease. wonder whether For example, sexual behaviors are far investment in the more politically and socially controversial humanities and so- when sexuality is viewed as profane; such cial sciences might views complicate candid study, discus- produce similar sion, and resolution of sexual health breakthroughs in issues. Likewise, narratives emphasizing preventing and the importance and eternity of the after- treating illness— life may undermine the value placed on not to mention en- health in the here-and-now. And the entire hancing well-being domain of what it means to live well, what and quality of life. defines and contributes to people’s sense Let me start of well-being, is largely the province of by speculating the humanities—yet those attributes have about the ways profound effects on our health. Humanities ealth research funding is over- in which social scholars might shed light on how cultures whelmingly targeted to the life and behavioral sciences might enhance and people frame and understand health- Hsciences. Research intended to re- primary medical care. Currently, my related issues, and the implications of duce or cure cancer, obesity, heart disease, physician (and nearly every physician I those understandings for improving health or other problems typically frames the know) presumes what might be called the and well-being today. problem in terms of insufficient knowl- “rational actor” model of behavior. That Of course, one reason why there has edge of the basic life sciences that could is, she identifies a condition that could been little inclusion of the humanities and shed light on the problem and its ultimate be improved by changing my behavior social/behavioral sciences in health and resolution. Consistently, health researchers (e.g., reducing obesity or hypertension well-being research is that those fields adopt a basic paradigm in which they seek through diet and exercise), she shares that are far less developed than biomedical to understand the differences in biological information with me, and she expects me research technologies and paradigms. processes between those who have health to understand it is in my best interest to What deeply concerns me is that the gap problems and those who do not, whether follow her advice. Of course, we don’t between biomedical research and social/ those processes are focused on genes, need behavioral scientists to tell us that behavioral and humanities research will environmental exposure, or other variables the “rational actor” model of behavior is almost certainly increase. According to the best understood and explored through a rarely accurate; we need only look back at National Humanities Indicators Prototype biomedical paradigm. the leading causes of disease and death to released in 2009, United States universi- A predominate emphasis on biomedi- realize that rational processes do not con- ties devote less than 0.5% of their annual cal research strikes me as unfortunate. sistently control eating, exercise, alcohol research expenditures to the humanities, Nine of the ten leading causes of death in consumption, smoking, sexual activity, or and the social sciences are well below 15-44 year olds are behavioral in nature, other risk-related behaviors. The mecha- 20%. The trend toward emphasizing “big whether directly— by suicide or automo- nisms that control those behaviors are not science” (e.g., biomedical technologies, bile accidents, for example—or indirectly, well understood—and are likely to remain pharmaceuticals, patentable procedures such as from complications associated obscure, given the relative absence of the and products) will become greater as with smoking or obesity. In other words, social sciences in health research. public research dollars become fewer and many deaths could be averted by changing Likewise, the humanities may have a more difficult to obtain. And private sector people’s thoughts and actions. significant role to play in disease pre- funding is unlikely to replace or augment Yet, less than 10% of federal health vention and health promotion. Western public funding in the humanities and funding is targeted to behavioral or social cultures tend to draw sharp distinctions social sciences [Continued on page 45]

WAKE COUNTY PHYSICIAN • JULY 2010 | 7 PHYSICIAN Dr. Edward B. Yellig PROFILE: By Fiona Morgan and when it went well for everybody, it was a joy.” Listening He describes the process to the patient, as “respecting the mystery listening to of life and death without having to control it or own it the practice of or manage it. A lot of times, medicine. the family tried to manage it right down to the last second. The more they tried to hang on, the more suffering they created. On the other hand, when people acknowledge that death was coming and they respected it and understood it, and looked forward to it because it meant their lives of suffering and dependency would be coming to an end, they started to rejoice in the lives they had had, in the family and relationships they had, and they looked back on their lives with pride in their accomplishments.” In the early years of his career, Ned moved back and forth between the East and West coasts. He received his M.D. from the Jefferson Medical College at Thomas Jef- ferson University, and then completed an internship at Santa Clara Valley Medical Center in San Jose, California and a first-year residency in internal medicine at Mon- tefiore Hospital in Pittsburgh. In the early 1970s, he served as a medical officer at the U.S. Naval Dispensary at Trea- sure Island in San Francisco and completed a residency in ambulatory and community medicine at UCSF, meanwhile volunteering his time as a physician at the Haight-Asbury Free Clinic. By 1975, he was Chief Medical Resident at hat is for many doctors the darkest aspect of Highland Hospital in Rochester, New York. their work became for Ned Yellig the most He has always been attracted to the psychosocial ap- Waffirming. Many physicians in Wake County proach, addressing the messy and complex life circum- know Ned as medical director of Hospice of Wake County stances that play into the symptoms, causes and cures of from 2001 through 2008. He founded the Horizons Pal- illness. While in San Francisco, he trained at the Family liative Care, a division of Hospice of Wake, which he ran Therapy Center, and he later completed a fellowship in until he retired in late 2009. For six years, he has written a the Medical-Psychiatric Liaison Unit at the University of column for this magazine called “Issues on Care at the End Rochester’s Strong Memorial Hospital. of Life.” When he moved to Raleigh in 1977, Ned became medical But Ned’s hospice work did not begin until he had trav- director of Wake Health Services, a nonprofit primary care eled a long and winding path. After a two-decade career community health center. In 1982, he brought the psycho- practicing internal medicine, he found that helping patients social approach into private practice, focusing on health manage chronic pain, and helping manage the expectations promotion, wellness, and preventive medicine. of family members in their loved one’s final days, was “Anytime somebody came down with an acute illness, some of the most meaningful and personally fulfilling work I looked for the psychosocial setting in which the onset of of his medical career. the illness began, and almost all the time, it began in a situ- “There are a lot of ways to die, with either suffering or ation of stress for that person, either family or job stress,” satisfaction,” he said. “I was the facilitator in that process, he said. “We had an opportunity to [Continued on page 20

8 | JULY 2010 • WAKE COUNTY PHYSICIAN BORN: 1943, Pittsburgh, Pennsylvania Wake County, Inc., 2005-2009. derful that I started picking up the book he was writing about and read it, too. It EDUCATION: 1961-1965, University COMMUNITY: took me two years to read the whole bi- of Pennsylvania, B.A. Chemistry Volunteer Physician, Haight-Asbury ography and I read six or seven Dickens 1965-1969, Jefferson Medical College, Thomas Jefferson University, M.D. Edward B. Yellig, M.D., F.A.C.P. (Ned) CAREER HISTORY: Rotating internship, Santa Clara Valley Medical Center, San Jose, California, Free Clinic, San Francisco, California. books in the process. 1969-1970. 1971-1974. First-year resident in Internal Medicine, Founding Member, Board of Directors, LAST BOOK READ: I read an interest- Health Center Hospitals of University of Hospice of Wake County, 1977-1980. ing book recently called Descent into Pittsburgh: Montefiore Hospital, Pitts- Health Promotion Task Force, Wake Chaos: The U.S. and the Disaster in burgh, Pennsylvania, 1970-1971. County Hospital System, Inc. (Devel- Pakistan, Afghanistan, and Central Asia General Medical Officer, United States oped North Carolina Health Promotion by Ahmed Rashid, a prominent Pakistani Naval Dispensary, Treasure Island, San and Wellness Institute). 1981-1983. journalist who is an expert on the region. Francisco, California, 1971-1973. Board of Directors, The Wellness Cen- It’s about Afghanistan, our role in it, and Second-year resident in Ambulatory ter, Inc. 1982-1986. how horrible the whole situation became. and Community Medicine, University Volunteer Physician, Open Door Clinic, The book I’m reading now The Heart of California, San Francisco, California, a free clinic for homeless and indigent of Christianity: Rediscovering a Life 1973-1974. patients, Raleigh, North Carolina. 1985- of Faith by Marcus Borg, a wonderful Trainee, beginning and advanced 2001. Christian progressive author. courses, Family Therapy Center of San Community Services Committee, Holly Francisco, San Francisco, California, Hill Hospital. 1988-1989. LAST FILM SEEN: Sherlock Holmes 1973-1974. Lifetime Investment – Fitness Education; and Avatar. Assistant and Associate Resident in Founder, Chairman. 1988-1992. Internal Medicine, University of Roch- Youth Fitness Committee, Governor’s LIKES ABOUT THE TRIANGLE: ester Associated Hospitals Program in Council on Physical Fitness and Health. The diversity and entertainment, all Internal Medicine, Rochester, New York, 1989-1993. levels of entertainment – restaurants, 1974-1976. North Carolina Youth Fitness Task theaters, live productions, athletics – it’s Chief Medical Resident, Highland Hos- Force. 1991-1993. just wonderful. We’ve got fabulous insti- pital, Rochester, New York, 1974. Wake County Council on Physical Fit- tutions and fabulous city life in Raleigh Fellowship, Medical-Psychiatric Liaison ness and Health. 1991-1999. now. Unit, Strong Memorial Hospital, Univer- Health Education Advisory Council, sity of Rochester, Rochester, New York, Wake County Public School System, DISLIKES ABOUT THE TRI- 1976-1977. North Carolina. 1992-2001. ANGLE: I would improve alternative Medical Director, Wake Health Services, Chairman, Health Education Advisory means of transportation, including rail Inc. a federally subsidized nonprofit Council, Wake County Public School and bicycle. I think if we became a primary care community health center, System, North Carolina. 1995-1999. bicycle-safe city, a lot of people would 1977-1982. University of North Carolina School of ride. Primary care internist in private, single- Medicine: Eugene S. Mayer Honor Soci- and multi-specialty internal medicine ety for Community Service, 2001. ADVICE TO YOUNG PHYISICANS group groups, 1982-2001. STARTING PRACTICE: Pay attention Clinical Professor of Medicine, Universi- PROFESSIONAL SOCIETIES: Wake to the patient and develop a relationship ty of North Carolina School of Medicine, County Medical Society, North Carolina to the patient. Make their concerns your for on-site Community Medical Educa- Medical Society, American Medical concerns. tion programs in ambulatory primary Association, American Academy of care, 1994-2001. Hospice and Palliative Medicine WHAT HE WISHES THE PUBLIC Fellow, American College of Physicians BETTER UNDERSTOOD ABOUT (FACP), 1996. FAMILY: Wife, Sylvia White. Sons, MEDICINE: Medicine is a relation- Retired from internal medicine practice, John and Christopher. ship between two people in which one is 2001. helping the other become healthier. It’s a Adjunct Clinical Professor of Medicine, FAVORITE LEISURE ACTIVITY: collaboration between two humans, one University of North Carolina, 2001- Reading, music, gardening, sailing. of whom is knowledgeable about the sci- 2009. ence and the other who is knowledgeable Medical Director, Hospice of Wake FAVORITE AUTHORS: Charles about their personhood. I think there’s County, Inc., 2001-2008. Dickens. I read a wonderful biography of as much responsibility on the part of the Founding Medical Director, Horizons him by Peter Ackroyd (Dickens: Public patient as on the part of the doctor to Palliative Care, a division of Hospice of Life and Private Passion). It was so won- participate in that collaboration.

WAKE COUNTY PHYSICIAN • JULY 2010 | 9 This issue of the WCP Magazine is made possible by financial support of WakeMed.

THE EVOLUTION OF A CHILDREN’S HOSPITAL By Mark Piehl, MD* • Cardiology What the • Infectious Disease • Rehabilitation New • Psychiatry WakeMed • Psychology • Prevention and education programs aimed at control- Children’s ling childhood obesity, type 2 diabetes and asthma Hospital Means to A Region of Growth and Change Physicians Clearly, great health care for children is available in the and Patients Triangle. But as Wake County continues to grow, access to certain specialists and services close to home has become increasingly limited. As recently reported in the News & igh quality care for children of all ages has been a Observer, by 2012 Wake County will eclipse Mecklenburg priority for WakeMed Health & Hospitals since the County as the state’s largest metropolitan area. Hhealth system’s founding in 1961. During these Evidence of the region’s rapid growth can also be found years, my pediatric colleagues have helped WakeMed build in WakeMed on most days, where children often wait hours a program that is responsive to the needs of area children or even days for a bed in one of WakeMed’s pediatric units. and fills the gaps where community resources are limited. Similarly, patients must often wait months for appoint- WakeMed developed unique pediatric services including: ments and then travel out of county to receive care from a variety of pediatric specialists. It has become clear to pro- • The first Children’s Emergency Department in the viders, parents and patients that Wake County, the Triangle state and the surrounding region need access to more pediatric • One of only six Level I Trauma Centers in North services to keep pace with area growth. Carolina In the midst of rapid population growth and demand for • The only Pediatric In-patient and Intensive Care Unit pediatric services, community physicians increasingly look in Wake County • The only Level IV Neonatal Intensive Care Unit (NICU) staffed with the most experienced neonatal providers in Wake County • A list of pediatric specialties that continues to grow: • Pediatric Surgery • Emergency Medicine • Endocrinology • Radiology • Pediatric and Neonatal Intensive Care • Urology • ENT • Orthopaedics • Neurology • Anesthesia • Gastroenterology Nurses Station

10 | JULY 2010 • WAKE COUNTY PHYSICIAN Bernstein, MD, whose work has been instru- mental in the creation of WakeMed Children’s.

• Treat- ment Rooms: For children who need minor pro- cedures with sedation located within the Children’s Hospital. Waiting Room • Play- to WakeMed to meet the needs of area children. Our room, Teen Room and Family Respite Areas: These rooms offer beautiful new inpatient facility is evidence of WakeMed’s comfort and distractions (games, videos, etc.) to family commitment to children in Wake County and the region, members and patients of all ages, as well as opportunities and is the first phase of a larger plan to address these needs to keep up with school work during longer admissions. comprehensively. This will include increased neonatal intensive care capacity and the addition of pediatric special- The addition of pediatric specialists and subspecialists is ists and specialty services. a crucial aspect of our growth. An exciting development is the recent appointment of pediatric surgeon J. Duncan Phillips, MD, as Surgeon-in-Chief of the new children’s Adding Specialties and Services hospital. Dr. Phillips will lead our pediatric surgery group and the growth of our surgical subspecialties. We are extremely excited about the upcoming opening Another recent development has been the growth of our of the first phase of the Children’s Hospital, our inpatient Children’s Diabetes and Endocrinology Center under the and pediatric critical care units. Occupying the 4th floor leadership of Bill Lagarde, MD. Diabetes is the second of WakeMed’s new Patient Tower, specific features of the most common chronic illness in children, and the incidence Children’s Hospital include: is growing. We have an active and experienced team of diabetes educators caring for a large population of children • New Patient Rooms: A 30 percent increase in pa- with diabetes, as well as an innovative type 2 diabetes tient beds, including 12 observation beds. All rooms are prevention program, which is now in place throughout the designed to be patient- and family-friendly, with sleeping state. Dr. Lagarde also cares for children with a wide vari- areas, bathrooms and facilities for parents. We also have ety of endocrine disorders. He has recently added a nurse two, two-bed suites where hospitalized siblings can room practitioner and, because of increasing demand, soon will together. add a second endocrinologist. Provider-to-provider communication is a key priority for • Pediatric Intensive Care: The most seriously ill us as increasingly inpatient and outpatient care are provided children will be treated in a state-of-the-art new Pediatric by separate physician groups. An exciting development on Intensive Care Unit (PICU), in an environment conducive the near horizon is the ability to immediately provide elec- to healing, family involvement and privacy. Parents will be tronic communication to primary care providers any time a invited and encouraged to remain in the room throughout patient enters the WakeMed system, has a significant event their child’s stay, and full sleeping and bathroom facili- like surgery, or is discharged. Electronic communication ties are available in each room here as well. The PICU is can never replace personal conversations between provid- funded through a generous donation given in honor of Jerry ers, but will greatly enhance [Continued on page 12]

WAKE COUNTY PHYSICIAN • JULY 2010 | 11 Patient Room

CHILDREN’S HOSPITAL Southeast. With a dedicated staff and together all of the many children’s continued from page 11 high-fidelity mannequins representing specialty resources that we currently our ability to inform area physicians a variety of patient ages and sizes, the offer and will add in coming years. about the care of their patients at Center provides us a unique opportu- We are excited about the many ways WakeMed. nity to educate our own staff, trainees, WakeMed Children’s will continue and other providers from around the to evolve and grow along with Wake Growing Above and Beyond (With region in children’s emergency care. County and the region. We are Your Continued Support) We recently held the first ever Pediat- thankful for the generous support of ric Emergency Resuscitation course at individuals and businesses – including We look forward to phase 2 of our the Center, where emergency medi- area physicians who have contributed development as fundraising for the cine fellows from across the country more than $700,000 – who will make expansion of the WakeMed Neonatal participated in intensive simulation our continued growth possible. Intensive Care Unit (NICU) begins training. Our growing Children’s I would love to speak with you at soon. Each year, 7,000 deliveries oc- Transport Team uses the Center to any time about the services WakeMed cur in the WakeMed system, and more prepare for the wide variety of situa- Children’s provides to your practice than 700 premature infants receive tions they may encounter when caring and your patients, and welcome any care in our Level IV NICU. As with for children in outlying hospitals and comments or suggestions you may our ED and inpatient units, the NICU emergency departments. have. Please always feel free to of- We continue to prioritize prevention frequently operates beyond capac- fer feedback on what we do well or efforts in the community, particularly ity. NICU expansion will allow more what we need to improve, and new regarding the childhood obesity epi- mothers and babies of the region to ideas you may have on the growth demic. Our Energize! type 2 diabetes receive care close to home. In particu- of children’s health care services in lar, this will provide more high-risk prevention program has been a suc- cessful component of this effort, and our community. We are proud of our mothers access to the specialized care new Children’s Hospital and hope you they need to potentially avoid pre-term we continue to seek creative ways share our excitement in Wake Coun- delivery. to grow the program and serve more ty’s newest community asset. § Other exciting areas of growth at-risk children. Early outcomes are include our Center for Innovative encouraging and should be published Learning (CIL) and Children’s Critical in the near future. *The writer is the Medical Director Care Transport Team. The CIL Future plans will include the de- of WakeMed Children’s Hospital and is a state-of-the-art medical simula- velopment of a dedicated outpatient Pediatric Intensivist. tion center unlike any other in the specialty center where we can bring

12 | JULY 2010 • WAKE COUNTY PHYSICIAN WAKE COUNTY PHYSICIAN • JULY 2010 | 13 WCMS Update By Paul Harrison, Executive Director WCMS

third party payors are actually inclined to as an uncharged service, please email this “do the right thing” when it comes to appro- information to Paul Harrison, Executive priate allowed amounts for vaccines. How- Director, Wake County Medical Society at ever, the burden is on the physicians and [email protected]. practice administrators to closely monitor vaccine cost and reim- **Note: This article was drafted for state- bursement transactions wide distribution to physician’s practices, NC PHYSICIANS PAID LESS and contact insurance chiefly primary care, who administer vac- THAN THE COST OF VACCINES** companies with factual cines to patients of all ages. I am includ- evidence when such ing it here thinking that local physicians, underpayments occur. including many specialists, would benefit The Problem Statement In general, and from initial limited experi- from this information. Please be sure to The Wake County Medical Society has ence, it appears that insurance companies share this with your practice managers for released the results of a 2009 North Caro- and third party payors will respond favor- due diligence follow up as appropriate. lina study that focused on a comparison of ably by establishing a reasonable allowed acquisition cost vs. reimbursement of four amount for each vaccine. The practice may commonly prescribed vaccines- Gardacil, need to submit the invoice/ acquisition cost The Second Annual Health Fair, Prevnar, Rotateg and Menactra- by physi- statement from the wholesaler or manufac- jointly organized by Triangle Area Hindu cians practicing in pediatrics and family turer; alternatively it is quite possible the Temples(TAHT) and Triangle Indian- medicine. The vaccines included in the information will be accepted by phone. American Physicians Society (TIPS), was study were purchased by the participating held June 12, 2010. The community and the private practices and are not included in the Additional Support for Your organizing committee was very apprecia- list of vaccines provided free of charge by Practice tive of the enthusiastic participation by the the State of North Carolina. physicians which ensured the success of the In the event that you are unsuccessful The study demonstrated that physicians Health Fair. The health fair was hosted at resolving a vaccine below cost pricing prob- were underpaid 15% of the time. Hindu Society of NC’s Main Hall. Physi- lem, as described above, the Wake County In other words, practices received reim- cians from primary care, as well as vari- Medical Society stands ready to support and bursement that was less than net acquisition ous specialties were requested to serve the represent you. Should efforts to resolve a cost in fifteen percent of the cases studied. community and discuss lab work and consult vaccine pricing below cost problem arise, The study examined the experiences of a with patients about their medical problems. statistically valid number of third-party the Wake County Medical Society will payors and primary care practices located serve as your across North Carolina (and not limited to WCMS Wake County), for the four vaccines listed advocate member, above. The cost factor in the study included with the Dr. Assad only the net acquisition cost of the drug Office of Meymandi, (after any applicable discounts) and did the NC has endowed not include the associated cost of refrigera- Insur- tion, compliance requirements, equipment, ance the Touring inventory, etc. The reimbursement amount Commis- Exhibit Hall was established by the allowed amount as sioner of the new determined by insurance companies or third and the NC Mu- party administrators. insurance seum of Art company for his late How Best to Resolve a or third father. The party Problem Meymandi payor. Concert Hall The problem statement is the bad news; For is named however, there is good news for discerning prompt physicians and practice administrators. The for his late assis- mother. good news is that insurance companies and tance,

14 | JULY 2010 • WAKE COUNTY PHYSICIAN Society News

Congratulations Lisa Tolnitch, MD to Dr. Prashant a Raleigh breast Patel for being cancer surgeon and appointed by the founder of Pretty Governor Bev- In Pink Foundation, erly Perdue to the was recognized with North Carolina a 2010 Soroptimist State Health Coordinating Council (SHCC) that over- Ruby Award: For sees, among other things, Certificate of Need. Women Helping This is a significant accomplishment which came about Women. Soroptimist not only due to his exposure through TIPS (Triangle is an international Indian-American Physicians Society) and the North volunteer organization of business and profes- Carolina Indian-American Political Action Committee sional women. (NCINPAC) but is recognition of his work with the North Carolina Medical Society (as a member of the Charlotte Hesterburg, RN was rec- Legislative Cabinet). SHCC is charged with providing high level health care access ognized by The News & Observer as an to its citizens. Congratulations Prashant and thank you for your service to the Indian- outstanding nurse during National Nurses American community and the State of North Carolina. Week. Hesterburg, who joined Hospice DANA COPELAND, MD of Wake County in 2008, serves as an 2009 RECIPIENT RN case manager and J. MICHAEL WEEKS AWARD also volunteers to help with on-call responsi- he J. Michael Weeks Award for humanitarian- bilities. As noted by ism was established in 1989 by the WakeMed clinical social worker TMedical Executive Committee to honor one who Jacque Grady, “Char- has devoted extraordinary time to teaching or to the care lotte has a knack for… of those less fortunate; one who has participated signifi- instilling confidence cantly in an event which visibly demonstrates a commit- in [patients and families] that she will be a ment to those less fortunate; or, one who has demonstrat- reliable source of care and support. Her goal ed leadership and participation in a significant project which directly contributes to is always her patients’ care and comfort and the welfare of the citizenry. support for their families.” All members of the Medical Staff are eligible to submit nominations for this an- nual award. Recipients can be any member of the WakeMed hospital family who has distinguished himself or herself for service to humanity. The inaugural award went to Mr. Michael Weeks in 1989 and subsequently to the following: 1990 William G. Sullivan, MD 2001 Stephen C. Boone, MD 1991 Donald T. Lucey, MD 2002 Raymond L. Champ 1992 John A. Paar, MD 2003 Dale W. Oller, MD 1993 Mr. William Andrews 2004 David L. Ingram, MD 1994 W. Charles Helton, MD 2005 James K. Hartye, MD 1995 Mr. Earl Bardin 2006 Peter Morris, MD 1996 William H. Sprunt III, MD 2007 Robert J. Caudle, MD 1997 James R. Moseley, MD 2008 Stephen P. Montgomery, MD 1998 Linda Alexander, RN Juan L. Granados, MD 1999 George C. Debnam, MD 2000 James D. Thullen, DO

WAKE COUNTY PHYSICIAN • JULY 2010 | 15 WCMS New Members

Practice: WakeMed Health & Hospitals Surgeon Practice: Taylor Vitreoretinal Center Lee Edmundson, MD P. J. Hamilton-Gaertner Medical School: Medical School: Duke University School Daniel Amitie, MD UNC – Chapel of Medicine Medical School: Indiana University Hill Year Graduated: 1996 School of Medicine Year Graduated: Specialty: Emergency Medicine Year Graduated: 2001 1995 Practice: WakeMed Health & Hospitals Specialty: Anesthesiology Specialty: Internal Practice: American Anesthesiology of NC Medicine Tina Harris, MD Practice: Raleigh Medical School: UNC – Benjamin Antonio, MD Medical Group Chapel Hill Medical School: Kirksville College of Year Graduated: 1999 Osteo Matthew Specialty: Internal Year Graduated: 1999 Ellison, MD Medicine Specialty: Anesthesiology Spouse: Anne Practice: Raleigh Practice: American Anesthesiology of NC Ellison Medical Group Medical School: Erhan Atasoy, MD Medical College Medical School: University of Louisville of Wisconsin Brendan L. Howes, MD Year Graduated: 1995 Year Graduated: Medical School: UNC – Chapel Hill Specialty: Anesthesiology 1994 Year Graduated: 2004 Practice: American Anesthesiology of NC Specialty: Otolar- Specialty: Anesthesiology yngology – Head Practice: American Anesthesiology of NC Brad Everett Butler, MD & Neck Surgery Medical School: East Carolina University Practice: Duke Otolaryngology of Raleigh Michael School of Medicine Huening, MD, Year Graduated: 2003 Phelicia PhD Specialty: Family Medicine Flanagan, MD Spouse: Tracy T. Practice: Harnett Health Angier Medical Medical School: Huening Services Medical College Medical School: of Virginia University of Dan Chaksupa, MD Year Graduated: Medicine of Medical School: 2005 New Jersey and West Virginia Specialty: Ob- Dentistry of New School of Medicine Gyn Jersey Year Graduated: Practice: Wilker- Year Graduated: 2003 2002 son Ob-Gyn Specialty Board certified in Anatomic Specialty: Internal and Clinical Pathology, with subspecialty Medicine Nitin Gupta, MD board certification in Cytopathology Practice: Raleigh Spouse: Mousami Practice: Raleigh Pathology Lab Associ- Medical Group Gupta ates (WakeMed Health & Hospitals) Medical School: Olly Duckett, MD Brody School of Steven Medical School: Medical College of Vir- Medicine at ECU Kubicki, MD ginia Year Graduated: Medical Year Graduated: 1995 2002 School: George Specialty: Emergency Medicine Specialty: Retinal Washington

16 | JULY 2010 • WAKE COUNTY PHYSIͳ WELCOME!

Washington University Neeraj Sachdeva, Colleen Year Graduated: 1984 MD Sullivan, PA Specialty: Pediatrics Medical School: Medical Practice: Capitol Pediatrics & Adolescent New York Medi- School: Duke Center cal College University Year Graduated: Medical Center 1995 Physician As- Sarah Specialty: Gastro- sistant Program Maddison, enterology Year Gradu- MD Practice: Raleigh ated: 2004 Medical Medical Group - Specialty: School: East Gastroenterology Orthopaedic Carolina Uni- Surgery versity Derek Quentin Practice: Raleigh Orthopaedic Surgery Year Gradu- Schroder, MD, ated: 1998 FACP Sherri’ James- Specialty: Ob- Spouse: Alka Surgers, MD Gyn Mehta Medical School: Practice: Mid Medical School: University of Carolina Ob-Gyn University of Miami School of Arizona College Medicine Naveen V. of Medicine Year Narahari, MD Year Graduated: Graduated: 1992 Specialty: Gastro- 1991 Specialty: Ad- enterology Specialty: Internal Medicine ministrative & Practice: Digestive Practice: Cary Medical Group Family Medicine Healthcare Practice: Wake Sylvia P. Health Services, Inc. Shoffner, MD Medical School: Richard Tim, UNC MD Year Graduated: Medical School: 1995 University of James F. Palombaro, MD Specialty: Inter- California – San Medical School: SUNY/Syracuse nal Medicine Diego Year Graduated: 1989 Practice: Cary Year Graduated: Specialty: Emergency Medicine Medical Group 1986 Practice: Wake Emergency Physicians, PA Specialty: Neu- rology M. Lisa Roy, PA Elee Stewart, MD Practice: Raleigh Medical School: Medical School: UNC Chapel Hill Neurology Associates University of Year Graduated: 2005 Kentucky Specialty: Anesthesiology Interested in becoming a Year Graduated: Practice: American Anesthesiology of NC 1991 WCMS member? To register Specialty: Inter- WCMS online simply go to nal Medicine Practice: Raleigh Your Advocate for www.wakedocs.org Medical Group HEALTH or call 919.792.3623

WAKE COUNTY PHYSICIAN • JULY 2010 | 17 Mental Health Corner ing his opinions and advice to consumers and family members. He was appointed to the advisory board for the only psychiat- ric hospital in Wake County, Holly Hill Hospital by the Wake Dr. Nicholas Emanuel Stratas County Human Services Board. This is a hospital he helped to establish many years ago. He is very open and approachable and NAMI’s 2010 Annual is often quoted in news articles related to the public mental health system where he is quick to share his perspectives about issues Exemplary Psychiatrist such as system organization, consumer inclusion and funding for services. Dr. Stratas has been an active spokesperson and Award Winner participant in NAMI Wake County efforts to positively impact the transformation of North Carolina’s mental health system he annual “Exemplary Psychiatry Awards” honor psychia- including picketing in front of the Governor’s mansion and rally- trists who have “gone the extra mile” in their commitment ing at the Legislature. Dr. Stratas serves as an active member of Tto excellent care, reducing the stigma surrounding mental an advocacy group organized by NAMI Wake County which is illness and working closely with National Alliance on Mental trying to convince local general hospitals to establish psychiatric Illness (NAMI) members in their communities. NAMI Wake units. Dr. Stratas has impacted the whole state in so many ways County and by his training of residents at so many of the teaching hospitals NAMI North Carolina joined to nominate Dr. Nicholas Stratas (including UNC Chapel Hill) and it is always done in a way for this very prestigious award presented during the 2010 Ameri- that values and respects the consumer and the family, rather than can Psychiatric Association’s Annual Meeting on May 24, 2010 what we see so often with the “expert” model of service delivery. in New Orleans, Louisiana. When people say Dr. Stratas’ name they truly become uplifted, Dr. Stratas is a tireless contributor in many ways. He was and in awe of his amazing support of consumers in a truly person honorary Chair for the NAMI North Carolina NAMIWalks in centered manner that is often talked about, but rarely lived. Raleigh last year. Although his title was “honorary,” Dr. Stratas Dr. Stratas was one of the cofounders of a free psychiatric eagerly engaged in personal appeals to friends and associ- clinic in downtown Raleigh providing treatment to people with ates to support the Walk. A distinguished psychiatrist, no resources. He has a long-time association with Ra- he is trained in a variety of psychiatric specialties, leigh Psychiatric Associates where he maintains an and has worked in both the public and private active psychiatric practice helping many patients. sector, including appointments from Duke and The practice’s mission “To assist individuals, the University of North Carolina. He is the couples, families, and groups to acquire and use founder, co-founder, developer of adaptive, coping, and self-fulfillment public, private and free community skills to maximize human compe- programs and state programs in tence” speaks to the comprehensive mental health, developmental nature of the treatment he provides. disabilities, and substance abuse, He has a very active engagement including serving as the former with many mental health providers state deputy commissioner of and attorneys, keeping them men- mental health. A past president of tally fit which is no easy task. Dr. the North Carolina Medical Board and North Carolina Stratas served as medical director of an Open Door Com- Psychiatric Association, he is the author of over 100 professional munity Mental Health Clinic which ran for 10 years with appoint- publications. ments given to over 500 people, all without any fees. Dr. Stratas As a distinguished psychiatrist, Dr. Stratas’ advice is sought by believes and speaks often about his view that everyone is at a local county and state governmental officials as well as elected point in their life where they are trying to attain the next level, i.e. officials. He is an active user of electronic media and internet working on themselves in some way. He doesn’t like distinguish- groups advocating for better mental health services and consumer ing between consumers and others. At the NAMI North Carolina inclusion in the decision-making process. For example, he is on Conference, Dr. Stratas gave a presentation on recovery. This is the Board of North Carolina Mental Hope, an organization with one quote from his presentation which summarizes his philoso- an active online mental health advocacy group which often ben- phy: “Recovery is a personal and unique process so everyone efits from Dr. Stratas’ input. Dr. Stratas is just as comfortable with a psychiatric illness develops his or her own definition of presenting his advice and ideas to the Governor as he is offer- recovery. In addition ‘normal’ is a [Continued on page 47]

18 | JULY 2010 • WAKE COUNTY PHYSICIAN WAKE COUNTY PHYSICIAN • JULY 2010 | 19 EDWARD B. YELLIG continued from page 8 formation. medicine and new techniques and tools In fall of 1999, he said, “I and information that I had to learn—and help them with the issue of stress and realized that my career in internal also intense physician-patient relation- took care of their ailment at the same medicine was over. I was working for a ships based on life and death issues,” he time, whether it was a back strain, ulcer, large multi-specialty medical group that said. “I had never taken care of people headaches, anxiety or depression.” was focused more on money and not who were so sick, facing death, so it This “broad-spectrum” approach not relationships with partners, patients, or was a physical, psychological, and spiri- only brings about better outcomes, it staff.” He set a goal to retire by 2001. tual crisis for them.” gets at the heart of Ned’s philosophy When the group dissolved in 2000, he He believes he could not have been as as a physician. “You’re taking care of worked for a smaller group and secured successful in hospice had it not been for the whole person, not just the blood his replacement before leaving the his time off and his spiritual awakening. pressure or the diabetes. If you don’t practice. “When you’re talking to people about include the person, then a lot of times The next year and a half, Ned calls his the most intimate spiritual process of the illness won’t be managed as well or “period of discernment.” Raised Pres- life, which is uncontrolled illness, un- as quickly.” byterian, Ned had not been particularly controlled pain and suffering leading to Public service and teaching have also religious for most of his life. “I wasn’t death, you’re talking about the very core been significant aspects of Ned’s career. a big churchgoer,” he said. As many of a person, their very heart and soul. He has served on numerous boards and people do, he began to attend more To relate to someone at that level was volunteered for the Open Door Clinic in regularly after his children were born. so satisfying and so rewarding. I had to Raleigh for more than 15 years. And be- As they grew into adulthood and his let go of my own boundaries so I could ginning in the late 1980s, he undertook professional life began to take detours talk to them at the very deepest levels of projects in physical fitness and wellness into new territory, spirituality began to human communication. And it was this education for children. He founded Life- play a larger role in his life. He is an ac- integration and conversation at this level time Investment-Fitness Education, or tive member of Pullen Memorial Baptist that proved to me to be the right thing LIFE, a group of concerned physicians, Church, a culturally progressive congre- for me to do.” parents and educators who lobbied for gation focused on social justice issues. While at Hospice of Wake, Ned childhood fitness education. The effort He contemplated going to divinity launched its program in palliative care, helped secure a seed grant for a pilot school. A friend, Nancy Osborne, was an approach to dealing with the needs of project to develop state-recognized a fellow Pullenite and also a chaplain at patients suffering prolonged pain and/ physical education and nutrition cur- Rex Hospital. She suggested he spend or terminal illness. He earned a certifi- riculum at Combs Elementary in Wake a school year doing clinical pastoral cation in hospice and palliative care in County, a state demonstration school education, a requirement for a Master of 2004. for P.E. Ned served on the Governor’s Divinity degree. So at the age of 58, he A few months ago, Ned retired -- for Council on Physical Fitness and Health, retired from more than two decades of the second time. Yet he’s unlikely to sit the North Carolina Youth Fitness Task medical practice and began an intern- still. So far, he’s settled into a routing Force, and the Wake County Public ship at Rex. of riding his bike to Pullen for Bible School System’s Health Advisory Meanwhile, Bill Dunlap, founder of study and tending to “messes around Council, which he chaired from 1995 Hospice of Wake County, tapped Ned my life, like files, finances, yard, house -1999. to become the organization’s medical and things that have gone undone for 25 Education and public speaking have director. “He said, ‘This won’t take years. It’s going to probably take me a also an ongoing part of his career. He much time. You work 10 to 15 hours year to get that stuff done.” taught medical students from UNC for per week.’ It sounded simple.” What Ned will do next is unknown, more than 25 years. He was a reviewer But he had also committed to teach- including to him. “In the past I’ve been for the North Carolina Medical Journal ing a seminar at UNC School of Medi- guided by listening for spiritual direc- for eight years. At conferences, debates cine. Well into his retirement, he found tion from God or a higher being or intu- and organizations across the Triangle, himself committed to three different ition or however humans get that kind he has spoken about disease prevention, “part-time” jobs, each with it’s own of communication, which is a marvelous psychosomatic medicine, stress manage- steep learning curve. mystery. That led me to hospice care. ment, childhood fitness and the bioeth- “By October, I thought I had commit- I’m going to trust that the process will ics of dying. ted professional suicide,” Ned recalled. take place again over the next year or The year Ned moved to Raleigh, he But the experience gave him the oppor- two, and I’m not going to be impatient.” became a founding member of board of tunity to discover his true passion. “Some sense of direction will unfold. directors of Hospice of Wake County. “I found that the hospice medical I don’t know what it will be, but I’m But hospice did not become central to director job was the perfect blend of open to whatever it will be. It’s very his work until he went through a pro- what I felt like doing, a combination exciting.” § found personal and professional trans- of clinical medicine—the science of

20 | JULY 2010 • WAKE COUNTY PHYSICIAN You can now find the Wake County Physician Magazine displayed in the Wake County Library, Cameron Village Raleigh, North Carolina

Go check it out!

WAKE COUNTY PHYSICIAN • JULY 2010 | 21 NORTH CAROLINA BOTANICAL GARDEN THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

By Peter White, PhD* Director of North Carolina Botanical Garden

outdoor flowering and educational exhibits, Plants are gifts in the sense that they like those of the 40 year old Display Garden originate in wild nature--the plant kingdom nearby. is one of the earth’s great treasurers. And Gardens and gardeners like to think of North Carolina has very high plant diversity themselves as green in outlook. We liter- with some 4,000 species. The state ranges reen Garden, Green Gift: the North ally make the world green and colorful. But from the coastal plain with the most north- Carolina Botanical Garden’s new his building is green in a second sense--it erly palms and epiphytic orchids (subtropi- GEducation Center has been designed at the Platinum, or high- cal life forms) to the highest mountains east Charles Darwin once observed: “A trav- est, level of the American Green Building of the Black Hills of South Dakota, with eler should be a botanist, for in all views, Council’s LEED (LEED stands for Leader- plants like the Greenland Sandwort that plants form the chief embellishment.” ship in Energy and Environmental Design) flourishes around Hudson’s Bay. In addi- Plants are the foundation of ecosystems and certification program for environmental tion to the habitat diversity, North Carolina their photosynthesis takes carbon out of the performance. We have three other Plati- was never covered by continental glaciers atmosphere, a benefit during these times of and evolution is old accumulating carbon dioxide, along with here. Venus Fly- the threat of global warming. But even for trap, a unique insect those who don’t travel, plants are funda- eating plant known mental--they give us shade, color, beauty, all over the world is the singing of birds, and the dizzy flight of native to only North butterflies, whether in nature, parks, or the and South Carolina. gardens around our homes, schools, and The Venus Flytrap work places. is an example of The North Carolina Botanical Garden is one of our botanical about both the planted garden and nature’s treasures and occurs own gardens. It is from the earth’s rich only here because of array of plant diver- the great age of the sity that we take our land. garden plants and the Plants are also health of the garden gifts in the sense world and the natural that they yield world are connected. seeds that help allow us to grow plants This year, we, at without destroying the source. At the North the North Carolina Carolina Botanical Garden we display many Botanical Garden in species of North Carolina plants propagated Chapel Hill, opened a by seed (and we can teach you how to do new facility, the Edu- this, too). Great wildflowers, shrubs, and cation Center. The trees share the state with us. 29,000 square foot The new Education Center is also a gift to building designed the community, state, and beyond because it by Raleigh’s Frank was accomplished, not with tax dollars, but Harmon Architects, through the generosity of over 500 dona- includes three struc- tions. tures joined by porches and breezeways: num Buildings in North Carolina but this Among the green features are photovol- an auditorium building (with seminar and would be the first in the University of North taic panels, a geothermal heat exchange conference rooms), an exhibits and informa- Carolina system and the first that is a public system, porous pavement for storm water tion building (with reference library and space for the demonstration of state-of- management, a rain water harvest system gift shop), and a classroom building. Soon the-art technology and the interpretation of for irrigation, high recycled content of ma- the Education Center will be surrounded by how people can live more sustainably in a terials, high percentage of regional materials healthy environment. (which supports [Continued on page 41]

22 | JULY 2010 • WAKE COUNTY PHYSICIAN At Placebos, Magic and Faith Healing– Our Dilemma By L. Jarrett Barnhill, MD, DFAPA, AACAP*

e consider modern medicine as calls our attention to another foundational far removed from the healing concept: in spite of the power of scientific Wtrances and rituals of shamans medicine, our yearning for miracles reveals and healer-priests. These healers rely on a deep-seated need for different experi- special gifts of divination and ritual to ences and methods of understanding. These address the underlying causes of disease. psychosocial expectations segue into our In such cultures within the community, dis- discussion of the role of ritual in placebo eases are linked to emotional dissonances. response. The task for practitioners is to resolve this Prior to e scripting, the ritual of writing psychosocial disequilibrium while matching a prescription provided the patient with a beliefs about of causality (what is wrong), tangible symbol of our healing prowess. what to do about it, and how do we go about There is a sense of mystery tied to this ac- getting it (which ritual path). This approach tion even though noncompliance after a few than any detailed narrative. seems primitive by our standards of indi- doses is common (perhaps another variation In addition, most of us compete with the vidualism in which diagnosis and treatment of placebo response). For prescribers, this persuasive power of TV physicians. These are private matters. We also tend to mini- ritual represents an unconscious step to- medical rock stars distribute their message mize the power of such rituals. We gener- wards activating the patient’s faith in us as with great skill. I recently caught the very ally begin with the patient’s recognition that healers and the efficacy of our actions (the end of Dr. Oz receiving a standing ova- something is amiss, scheduling an appoint- drug). We tend to add another cultural di- tion for his performance -- anyone had that ment with a physician. The physician’s job mension to this process. In contrast to many response lately? For us not-so-charismatic is to properly diagnose and treat a specific traditions where old treatments are best, we physicians, it is a struggle to temper expec- illness. We expect lab tests, MRIs, EKG or believe that new drugs are superior to older tations with dull facts and evidenced-based EEGs and look askance at practitioners who ones -- especially if ads are effective. By logic. Our reliance of scientific medicine deviate too far from these expectations. Yet joining the patient in this dance of frequently results in valuable time spent many patients still expect some acknowl- beliefs, we are relying upon dissuading patients from dropping effective edgment of social and psychological their anticipation of a treatments for the latest advertised marvel. distress focused on seeking restoration positive outcome; call- However, in medical lore, showmanship has of a sense of individual well-being. ing upon the power of always been effective, especially the capac- This expectation is tempered by the placebo responsiveness ity to use the symbols and rituals associated relationship between expectations while placing this ritual with healing. Nowadays physicians want to for improvement and the nature into a larger psychologi- be dispassionate dispensers of evidenced- and severity of the condition “and cal and cultural context. base science, not snake-oil salespeople. what it takes to get better to pain or Cynics among us may We lack the media savvy to create a star suffering (palliative) or if reason- downplay these nonsci- persona even though our hard science is far able get better.” entific aspects of western less seductive and entertaining. Obviously severe medicine. However, take How did we get into this position? In brain trauma lies a careful look at another retrospect, the 1960 Kennedy-Nixon televi- along a different piece of evidence -- the sion debates provided a glimpse of this continuum of sever- power of media physi- emerging clash of cultures- the changing of ity and potential cians and medication ads. the guard from old style dark suit-type to lethality than fibro- There is far more power in the young media savvy politician. Likewise, myalgia or irritable the image of caring faces we have witnessed the rapid emergence of bowel syndrome. or voices than in scientific artistry over substance in news casting -- For many chronic illnesses, arguments or evidence imagine Walter Cronkite stacked up against getting better still requires some based journal articles. The the today’s news anchors, or John Stewart understanding of the indi- crafted images are burned all or Steven Colbert mixing satire with news vidual’s place in their psycho- too frequently into our emotional stories. As physicians, we face this chal- social community. To reach this memories as we are unconsciously lenge at a time when we are taught to abide goal, physicians must constantly conditioned to link character portrayals with by facts. This contrasts with the expecta- struggle to find a balance between anticipated positive outcomes -- provided tions of many patients who crave the image, science and technological wizardry, hope you use their product. In short, we continu- impressionism and in some settings scripted and faith. This is the realm of placebo re- ally experience Marshall McLuhan’s thesis empathy. sponse and a constant reminder of the heal- that the “medium is the message” and that Ponder these questions for a moment. Is ing power of psychological forces. It also a TV image is emotionally more powerful there an inverse [Continued on page 25]

WAKE COUNTY PHYSICIAN • JULY 2010 | 23 Issue on Care At The End of Life

By Gary S. Winzelberg, MD*

PROMOTING COMFORT FOR COMFORT MEASURERS ONLY PATIENTS: PALLIATIVE CARE’S ROLE IN CARING FOR HOSPITALIZED PATIENTS

Having a comfort measures only chart if offered by the physician. designation was associated with fewer This chart review served as my intro- s a first year medical student, in disease-oriented treatments without neces- duction as a medical student to end-of- 1993, my summer research project sarily providing symptom relief. life care. I recognized that seriously ill Awas a retrospective chart review Perhaps using comfort measures only hospitalized patients had unmet needs of 72 consecutive deaths among adult was intended to note that the patient was for symptom relief and communication. patients treated at my school’s teaching dying, and the physicians did what they A few years later, I learned that patients hospital. Most patients died of chronic could to minimize discomfort by with- throughout the country had these needs as illnesses such as cancer, heart and lung drawing treatments but was less able to one of the seminal studies on end-of-life diseases. My goal was to examine these decrease existing symptom burden. While care was published in JAMA. The SUP- dying patients’ symptoms and treatments reading these charts, I felt concerned that PORT study prospectively observed the during their last days of life. In this patients and families were being informed care of more than 9,000 patients with one small sample almost half of the patients that comfort measures only would be pro- or more life-threatening conditions at five experienced, pain, shortness of breath vided but continued to experience discom- geographically diverse teaching hospitals and agitation within a few days of their fort. I also tried reading between the lines (including Duke). deaths. In addition, one in three patients of patients with prolonged hospitalizations Among patients who died in this study, died in the intensive care unit, and in their to understand whether they were choosing one-third spent at least ten days in an last two days of life one in ten received a to receive intensive care unit treatments intensive care unit, one-half had moderate resuscitation attempt and one in four were at the end of life, or whether they would to severe pain according to their families, mechanically ventilated. have decided on a different care approach and one-half had physicians who didn’t I knew little about the pa- tients’ disease processes, and reading their charts provided relatively few details about the decision-making process informing their treatment deci- sions. Yet I was intrigued to discover that almost half of the patients had a physician order or progress note specifying comfort measures only. What were comfort mea- sures only? This designation brought a distinction with minimal difference. Compared with other dying patients, individuals receiving “com- fort measures only” were less likely to receive care in an intensive care unit or other interventions such as antibiot- ics or being weighed. How- ever, levels of pain, shortness of breath and agitation were similar among the two groups.

24 | JULY 2010 • WAKE COUNTY PHYSICIAN know their preference to not receive a the vast majority of palliative care is palliative care consultation. Providing cardiopulmonary resuscitation attempt. A provided in the hospital setting although palliative care services helps hospitals nurse-led intervention to provide physi- services are beginning to be offered in the meet various JCAHO standards although cians with patients’ prognostic estimates clinic and nursing homes. having a program is not presently required facilitate physician-patient communication The number of hospital-based palliative for accreditation. about treatment preferences and encourage care programs doubled between 2000 and Once fellowship training becomes a attention to pain control did not result in 2008 with one-third of hospitals having requirement for board certification there improved patient outcomes. The inves- a registered program as of two years ago. may neither be enough programs to tigators proposed several theories for the Seventy-seven percent of large hospitals provide training nor enough interested intervention’s ineffectiveness, including (> 250 beds) have a palliative care pro- physicians. There is currently only one that physicians may have been less willing gram. Seventy hospitals in North Carolina accredited Palliative Medicine fellowship to change practices based on nursing input report providing palliative care services, in North Carolina that trains one physician as compared with recommendations made including three hospitals in Wake County. each year. by other physicians. Hospice and Palliative Medicine became Additional programs will need to be SUPPORT was at the forefront of defin- a medical subspecialty certified by the created although the potential demand for ing the extent of seriously ill hospitalized American Board of Medical Specialties in fellowship training is likely unknown. patients’ needs for improved symptom 2006. In an unprecedented collaboration Sixteen years ago patients receiving management and physician communi- ten member boards requested that their comfort measurers only were not neces- cation. Over the past 15 years, I have physicians be able to seek subspecialty sarily any more comfortable than patients witnessed the creation and evolution of certification in Hospice and Palliative without this designation. Palliative Care as an interdisciplinary field Medicine: Providing palliative care to not only dy- to address these patients’ and families’ Anesthesiology, Emergency Medicine, ing patients but also to individuals at ear- needs during hospitalizations. From my Family Medicine, Internal Medicine, lier stages of serious illness helps ensure perspective the growth of Palliative Care Obstetrics and Gynecology, Pediatrics, that in 2010 comfort care is both ordered represents one of most important develop- Physical Medicine and Rehabilitation, in the chart and provided at the bedside. § ments in health care since I entered medi- Psychiatry and Neurology, Radiology cal school. and Surgery. More than 1,200 physicians *Gary Winzelberg, M.D. MPH is a Clini- Palliative Care may be defined both by from one of the ten cosponsoring boards cal Associate Professor in the Division of what it is and what it is not. A patient- passed the initial Hospice and Palliative Geriatric Medicine and Palliative Care oriented definition (from www.getpallia- Medicine certifying examination in 2008. Program, University of North Carolina tivecare.org) describes palliative care as, An examination will be offered this year School of Medicine. “medical specialty focused on the relief and in 2012 as part of the grandfathering of the pain, stress and other debilitating period in which physicians may qualify to symptoms of serious illness. Palliative take the examination based on experience PLACEBOS, MAGIC AND FAITH Care is not dependent on prognosis and rather than after completing a Palliative continued from page 23 can be delivered at the same time as treat- Medicine fellowship which will become ment that is meant to cure you. The goal the requirement as of the 2014 examina- relationship between the time we are al- is to relieve suffering and provide the best tion. Additional details about the certi- lowed with patients and the growth of the possible quality of life for patients and fication process can be located at http:// caring and empathetic media physicians? their families.” www.aahpm.org/certification. With the rise of technician-dominated The primary components of palliative Despite its rapid growth in recent years, medical practitioners, is there a similar care are symptom management, commu- the future of palliative care is by no means trend emerging in which people trust the nication and support for both patients and certain. Palliative care consultations internet more than their primary care phy- families. While communication between are often time-intensive and insurance sician or specialist. Looking retrospective- patients, families and palliative care teams reimbursement alone provides inadequate ly, we may be in the midst of a scientific- may result in a recommendation for a compensation to physicians and other medical Reformation. During the first treatment approach focusing exclusively interdisciplinary team members. Many reformation, there was a movement to on comfort (and potentially including a palliative care programs therefore depend replace the interpretive authority of priest hospice referral), this recommendation is on hospital and philanthropic support to and popes with an individual interpreta- not based on the team’s agenda but rather maintain and expand services. Hospitals tion of the scriptures. Our reformation is an understanding of the patient’s goals may value palliative care in terms of im- one that challenges our status as heal- in the context of prognosis and expected proved patient satisfaction and care quality ers. Our role is slowly eroding under the treatment benefits and burdens. as well as reducing costs. pressure from information technology and Palliative Care is not hospice, which Recent studies using administrative data media-savvy practitioners who dispense can be difficult for patients and physicians (Morrison RS. Arch Intern Med 2008; hope and a strange form of participating in alike to recognize. Patients may continue Hanson LC. J Pain Symptom Manage medical care. to receive disease-based treatments with 2008) suggest cost savings associated with These questions provide the starting curative or life-prolonging intent while inpatient palliative care consultations. At point for our exploration of placebo re- also receiving palliative care services. least one randomized trial is currently sponse and placebo responders. Next, we Involving palliative care does not require enrolling patients to assess the clinical will look the role of placebo in research patients to have a limited prognosis, and and economic effects of hospital-based design. §

WAKE COUNTY PHYSICIAN • JULY 2010 | 25 Much work remains before us, how- tal effect on how health insurance rates ever, because most of the factors that are set. Before reform, premiums in the have led to escalating costs are still in ef- individual market were based primarily fect. Also, while reform will create more on health status. Post-reform, premiums affordable options for many Americans, for individuals and small groups will some of the new requirements will have be calculated primarily for three group- the unfortunate effect of raising premi- ings based on age (rates can also reflect ums for others. family composition, geographic region Health reform does not address several and tobacco use). That’s great news for factors that drive health care costs. The some, but healthy people will pay more first is general inflation that adds a few than they would have under the previous percentage points each year. system. POINT New technology that makes care better And because the mandate to purchase and more sophisticated also contributes a health insurance lacks a strong penalty, there is a risk that healthy people will opt to pay a modest penalty rather than pay- THE HEALTH REFORM FIGHT IS OVER ing for coverage. Without a large enough By J. Bradley Wilson pool of healthy individuals to balance the risk of the sick (who will now be guaran- President and CEO teed coverage), there would be nowhere Blue Cross and Blue Shield of North Carolina for costs to go but up. To make reform work, we have to move beyond simply reapportioning who pays and begin to slow the growth of et the work begin. few percentage points to the increase. total spending. This calls for bold and Since becoming CEO of Blue Add a few more percentage points for creative thinking. Cross and Blue Shield of North L the aging of our population, which inevi- BCBSNC will work as partners with Carolina (BCBSNC) in February, I have tably leads to a greater need for care. doctors, hospitals and employers to pilot traveled the state listening to customers, For years, health care economics have payment methods that reward the swiftest employers and community leaders. In encouraged doctors and hospitals to pro- and most reliable paths to good health these discussions, I am frequently asked vide additional services of limited value. outcomes, not the number of medical two questions: “What is your take on Doctors who find the quickest path to a procedures performed. We must leverage health care reform legislation?” And good health outcome are not rewarded. technology that cuts administrative costs “What do we need to do to get health care This inefficiency contributes a few more and improves quality. And we will look costs under control?” percentage points. inside our own house to cut administra- People are surprised to hear that – And there is the effect of medical mal- tive costs wherever possible. contrary to how Blue Cross has been practice, which includes both the direct Let us get beyond reform’s portrayed – we have always favored cost of lawsuits and difficult-to-measure partisan battles and get to work. At health care reform. This includes nearly impact of defensive medicine. Blue Cross and Blue Shield of North all the key components of President All of these cost drivers were in ef- Carolina, we are committed to that ef- Obama’s reform initiative, particularly fect before health care reform – and are fort and we invite everyone interested the central goal of getting coverage for largely unaffected by health care reform. in improving quality and reducing costs as many Americans as possible. Insurers Health care reform will have a fundamen- to join us. § know that the best way to spread costs is by expanding the risk pool to include both young and old and both sick and healthy. We have also been strong ad- vocates of ending pre-existing condition exclusions and medi- cal underwriting, and allowing family policies to cover de- pendent children until they are 26. We are already doing that. We are glad that Congress has passed reform legislation. And we are ready to do our part in helping to build a more rational, sustainable health care system.

26 | JULY 2010 • WAKE COUNTY PHYSICIAN hen the Federalist BCBS 15 years ago, became the COO, COUNTERPOINT essays were being published and, in early 2010, the CEO. He has Win 1787-88 in New York noted, “The only thing scarier than a Newspapers advocating approval of flawed (Health care reform) bill is no the national constitution, an intellectual bill at all.” argument was made for a good and Is this the best we can do? A straight coherent Government. down-the line partisan vote employing In Paper no. 62, Publius (in this case, all the furies of class warfare, half- James Madison) argues for Senators of truths, funding distortions, and even wisdom and maturity, and offers some claims of racism? Shame on both par- methods of selection and management ties, Democrats and Republicans, for for the operation of the Senate. General sliming the citizens who entrusted their Washington describing the ideal func- country to them. tion of the smaller, slower Senate com- It is important to listen to the CEO of pared the body to the saucer cooling the the health in- hot tea. A caution from Madison notes surance com- the danger of the laws...so voluminous pany with REDUCTIO AD ABSURDUM that they cannot be read, or so incoher- 97% of the By James S. Fulghum, III, MD* ent that they cannot be understood. business in Blue Cross CEO, Brad Wilson, was North Caro- quoted in an interview in the Herald lina when he Sun in February describing the Senate tells us that, health care reform bill which has now as a result become law as too long, too politicized care system is tar- and incomprehensible. geted in negative No doubt many are as ecstatic as Dr. ways by the new David Tayloe Jr. who declares upon law. The promised passage of the legislation a new day in Medicare doctor fix did not happen and a 21.9% fee cut went into effect April 1, with im- mediate effects on patient access. The next wave of primary care Docs will be PAs. In Massachusetts, where the national single payer template is modeled, pend- ing legislation will make participation of passage of the Senate in the state and federal Medicare/Med- bill, individual premiums in icaid programs a condition of medical North Carolina would increase licensure, effectively making physicians by 50% and small business employees of the state. premiums by 30%. As this administration takes us north It is also important to under- of $ 670 billion in new taxes and insists stand the elevated perspective on becoming a business partner in areas of Blue Cross and Blue Shield where it has little competence one would with five billion dollars in hope that those Americans with law revenue for 2009 and a CEO degrees and health care administration America and honors “Presi- salary of four million dollars. backgrounds would not cop out by say- dent Obama. Sen. Harry The reductio ad absurdum nature of ing, “Better a flawed bill than none at Reid, Rep. Nancy Pelosi and this latest example of legislative mal- all.” § countless other courageous mem- practice is that the alleged goal, health bers of Congress.” care for all, was not really the point at *The writer is a Raleigh neurosurgeon. Brad Wilson, after serving as Gov- all. The current infrastructure in terms He is married to Dr. Mary Susan ernor Jim Hunt’s legal counsel, joined of manpower and facilities of the health Fulghum.

WAKE COUNTY PHYSICIAN • JULY 2010 | 27 Project Access By Pamela Carpenter

Project Access received participant in the world and to utilize my abilities to the fullest. a generous donation To that end, I have taken care to maintain a sense of direction, from a remarkable young man, Christopher-Marcus Gibson. synthesizing my experiences and gleaning insight into the person He was the recipient of a $10,000 award for the Aldus Books whom I wish to be; but to sight one’s goal is not enough. It must national essay contest. He donated $5,000 of that award to The be achieved, and to inform one’s life requires achievement more Wake County Medical Society’s programs, Su Hogar Médico and than perhaps any other goal. Already I have experienced many Project Access. I asked Marcus to submit a short bio for this is- ways in which that process can take place, through the circum- sue of The Wake County Physician. stances by which my own lifestyle was shaped. Accordingly, among those circumstances, what I am now I Christopher-Marcus Gibson owe to my mother above any other influence. As the only child n January 2009, I donated the $5,000 grant I received from of a single parent, I have witnessed firsthand the extent to which the Aldus Books national essay contest to Wake County one can make a gift of oneself, to which resolve can overcome IMedical Society, a nonprofit whose mission is to provide obstacles beyond the scope that reason would judge feasible. medical care for the under-insured and uninsured. Since that Surpassing my mother’s efforts to expand my horizons, the very time I have had a pivotal role in the allocation of fact that she provided so much in the most those funds. I have participated in a number of difficult times has been the greatest example initiatives, including management board meet- to me of the potential in people to shape the ings with the executive and medical directors world around them and the others that inhabit of the organization and its case managers. As it. Over the years, I have been exposed to a result, I have directed the donation to finance works of art, literature, and film; under their an uninsured patient’s surgery, as well as to influence, I began to write developing what negotiate the breaking of a lease on an apart- I consider one of my greatest passions. The ment whose conditions were so deplorable as novels of Dostoevsky, García Márquez, and to be deemed potentially lethal by the engineer Chesterton quickly gained their place among from the Environmental Protection Agency with my favorites; my taste in music expanded whom I inspected it. I then arranged for a new from the concertos of Rachmaninoff and the apartment and the moving of the impoverished contemporary compositions of Yuki Kajiura to family in question, whose members include a the songs of artists such as Queen and Michael number of children suffering from asthma. I Jackson; and my appreciation for achievements allocated the grant to Wake County Medical in cinema by directors such as Akira Kurosawa Society because I wanted the funds to make a and actors such as Peter O’Toole grew with difference in the lives of individuals in need each film I watched. Witnessing such vari- of medical treatment who do not have the means to obtain it. ous methods of examining the world, I discov- Accordingly, I also spent the summer working at an internship ered my fascination with philosophy: I delved into the works of for Project Access and Su Hogar Médico, two medical initia- Aristotle and Aquinas, of Kierkegaard and Nietzsche, and thus tives within Wake County Medical Society whose missions are enriched my appreciation for my own tradition as a practicing to provide specialized care for uninsured chronic patients and to Roman Catholic. Uniting this newfound passion to my first, I provide translation and medical education services for Hispan- wrote all the more strongly on topics of literature, philosophy, ics respectively. Over the course of those months, I worked with and theology -- at the age of fifteen I completed an essay on case managers in conducting scholarship interviews of students at religious fundamentalism that would later be awarded a national Wake Tech Community College and assisted nurse case manag- prize for $10,000, what I hope to be merely a small success in my ers and environmental engineers from the Environmental Protec- writing career. tion Agency in home-visit inspections. I chose to work at Wake Continuing to pursue my studies in this fashion, I began to County Medical Society because I wanted my contribution to go anticipate the prospect of discovering my vocation. Whether it beyond a mere donation and oversee the funds’ distribution at the is a career in economics, academia, or authorship, my profession most fundamental level. is sure to utilize my enthusiasm for writing and philosophy, and To speak of oneself and do the topic justice I believe requires thus I continue to cultivate that avidity. Now, as I continue to the benefit of habitual self-scrutiny. Over recent years I have work towards that profession, the examples and influences that I taken care to cultivate such a habit, a predisposition for careful encountered through my formative years continue to propel me examination, though perhaps for more directly personal reasons: forward; and with every effort I hope that by my actions today I consider myself a seeker in pursuit of the best possible way for and in the years to come, I will do honor to the lives that helped me to view the world, not to remain a spectator, but to become a shape my own. §

28 | JULY 2010 • WAKE COUNTY PHYSICIAN WAKE COUNTY PHYSICIAN • JULY 2010 | 29 Public Health Issues By Jeffrey Engel, MD, MPH North Carolina State Health Director

PREVENTION IN HEALTH CARE REFORM: THE TIME HAS COME

he Patient Protection and Affordable Care Act (PPACA) months after passage of the PPACA) for new plans. Any existing passed by Congress and signed into law by the President health plan coverage at the time PPACA was signed into law on Thas in it provisions that says, “Ensure that all Americans March 23, 2010, is considered a grandfathered plan. New cover- have access to free preventive services under their health insur- age plans issued after the enactment date would have to provide ance plans and invests in prevention and public health to encour- such benefits by the September date. age innovations in health care that prevent illness and disease before they require more costly treatment.”1 What I intend to Prevention Services in Government Health Insurance Plans: discuss are the specifics of prevention and the investments in the Medicaid and Medicare public health infrastructure in the PPACA. The PPACA expands preventive health service coverage in the Prevention Services in Private Health Insurance Plans government-entitled health insurance plans in Medicaid (mainly The majority of the PPACA concerns the health insurance for poor women and children) and Medicare (for the elderly and industry and mandates on the coverage of preventive health ser- disabled). Because these are federal programs run by the United vices. These mandates intend to promote preventive health care States Department of Health and Human Services Center for and improve the public health by helping people live healthier Medicaid and Medicare Services, the expansions will not occur lives, which will restrain the growth of health care costs over through mandates as in the private sector, but rather through time. In the private sector, the law provides so-called first dollar policy and rule changes in CMS. Thus they can be implemented (meaning only premium costs) coverage by eliminating cost more rapidly. The preventive health services added to the CMS sharing requirements (co-pays or deductibles) for recommended programs by the PPACA include: preventive care and screenings including: • Under Medicare, the Act provides seniors with free annual • Current recommendations with a rating of A or B of the wellness visits and personalized prevention plan services. United States Preventive Services Task Force (USPSTF).2 • Under Medicaid, the Act: • Immunizations recommended by the Advisory Committee o Provides coverage for comprehensive tobacco cessation on Immunization Practices (ACIP) to the federal Centers for services for pregnant women, and Disease Control and Prevention (CDC).3 o Offers incentives to beneficiaries who successfully com- • Preventive care and screenings, including oral and vision care, plete certain healthy lifestyle programs targeting chronic dis- for children and adolescents, supported by the Health Resources ease risk factors such as high blood pressure, high cholesterol and Services Administration (HRSA).4 and diabetes. • Additional preventive care and screenings recommended for Since Medicaid programs require implementation at the state women and supported by HRSA.4 level (through the Division of Medical Assistance in the North For the patient and the family, first dollar coverage removes Carolina Department of Health and Human Services) with state the financial barrier of having to pay upfront in order to receive matching dollars, the PPACA also provides incentives to states to evidence-based preventive services and screenings (e.g., vaccines implement the Medicaid expansions of preventive health services or mammography). The PPACA allows employers to offer pre- coverage. These incentives include: mium discounts and other awards for up to thirty percent of the • The provision of a one percentage point increase in the total premium to individuals who satisfy a health standard (such federal medical assistance percentage (FMAP, or the federal as quitting smoking, maintaining a body mass index below the portion of the match) to states that offer Medicaid coverage for level of obesity, and having a regular medical home where blood all USPSTF recommended services and immunizations recom- pressure, cholesterol, and diabetes can be managed) and includes mended by the ACIP. provisions to ensure that discriminatory practices do not occur. • Requires the Secretary of the United States Department of There is also a requirement for the CDC to study, evaluate, and Health and Human Services to issue guidance to states and educate employers on the benefits of worksite health promotion. health care providers about Medicaid’s coverage of obesity- The timeline for implementation of these changes will be Janu- related services and preventive services and requires each state ary 1, 2014, for grandfathered plans and September 23, 2010, (six to design a public awareness campaign on such services.

30 | JULY 2010 • WAKE COUNTY PHYSICIAN Population Health and Public Health Infrastructure Im- clinical treatment. provements • Funding for a pilot program to test the impact of providing individualized wellness plans for at-risk populations who use Independent of reforms centered on prevention in health insur- community health centers. ance plans, the PPACA devotes several sections to health promo- • Competitive grants to the state and local level for programs tion with the goal of improving the factors that contribute the that promote individual and community health by reducing most to death and disability (e.g., tobacco use and obesity) in the chronic disease rates, addressing health disparities, and devel- United States. In the legislation, population health improvement oping a strong evidence-base of effective prevention program- will be facilitated by new federal authorities to reduce tobacco ming. use and promote weight loss. • Creation of a national public-private partnership that address- First, to organize and allocate new resources, the PPACA es prevention and health promotion outreach including: establishes the National Prevention, Health Promotion, and o An education campaign that raises public awareness on Public Health Council. The Council will provide leadership on health improvement across all ages. an expanded and sustained national investment in prevention and o Outreach that addresses proper nutrition, regular exercise, public health programs, direct the creation of a national preven- smoking cessation, and the five leading causes of death in the tion and health promotion strategy, and expand the independent United States. Community Preventive Services Task Force to review scientific • Creation of a national science-based media campaign to evidence on the effectiveness and appropriateness of community advance health promotion and disease prevention. preventive interventions.1 • Creation of a web-based prevention tool to help individu- Second, PPACA elevates the National Center on Minority als make informed health decisions and create a personalized Health and Health Disparities at the National Institutes of Health prevention plan. from a center to a full institute, reflecting an enhanced focus • Award community transformation grants that focus on on minority health.1 It codifies into law the Office of Minority healthier school environments, active living communities, and Health within the United States Department of Health and Hu- access to nutritious foods. man Services and establishes a network of minority health offices • Requirements for certain chain restaurants to display calorie within the Department to monitor health, health care trends, and counts of their meals on menus and menu boards and to pro- quality of care among minority patients and evaluate the success vide specified nutritional information upon request. of minority health programs and initiatives.1 The public health infrastructure will be advanced by workforce Implementation at the state level will focus on grants that development provisions in PPACA. These include loan repay- promote individual and community health through prevention ef- ment programs to public health students who agree to work three forts. Many of these provisions in PPACA authorize Congress to years in a public health agency or who serve in underserved fund these initiatives but do not appropriate funds, thus timelines areas. Authorization for funding of training for mid-career public are not yet defined. Nevertheless, the following list of individual health professionals, preventive residency programs, and public and community health promotion initiatives in PPACA has the health fellowships is also included. potential to greatly benefit the health of North Carolinians. • Authorization of states to purchase adult vaccines under Opportunities and Challenges CDC contracts (thirty percent less than the private market) and as well as a state demonstration program to improve adult im- The PPACA is in many ways an embodiment of the public munization coverage. health agenda through changes in health insurance plans or direct • Expansion of the CDC Epidemiology and Laboratory Capac- funding to prevention and public health infrastructure. The chal- ity grant to state health departments to support communicable lenge will be to smoothly implement programs across federal, disease control. state, and local jurisdictions without creating duplication and • Appropriation of twenty-five million dollars in funding for redundant bureaucracy. § the Childhood Obesity Demonstration Project, which was established through the Children’s Health Insurance Program References (CHIP) legislation. Grants will be awarded to develop commu- 1. The Patient Protection and Affordable Care Act and the nity models for reducing childhood obesity. Health Care and Education Reconciliation Act. Democratic • Appropriations for maternal, infant, and early childhood Policy Committee website. http://dpc.senate.gov/dpcdoc-sen_ home visiting programs using evidence-based strategies that health_care_bill.cfm. Accessed April 27, 2010. lower infant mortality and improve school readiness. 2. Preventive services recommended by the United States Pre- • Authorization of a grant program for the operation and de- ventive Services Task Force. Agency for Healthcare Research velopment of School-Based Health Clinics, which will provide and Quality website. http://www.ahrq.gov/clinic/pocketgd09/ comprehensive and accessible preventive and primary health gcp09s1.htm. Accessed April 27, 2010. care services to medically underserved children and families. 3. Advisory Committee for Immunization Practice Recom- • Creation of an oral health care prevention education cam- mendations. Centers for Disease Control and Prevention web- paign at CDC to target key populations, including children and site. http://www.cdc.gov/vaccines/pubs/ACIP-list.htm#comp. pregnant women. Accessed April 27, 2010. • Grants for programs for people ages fifty-five to sixty-four to 4. Maternal and Child Health Bureau. Health Resources and evaluate chronic disease risk factors, conduct evidence-based Service Administrations website. http://mchb.hrsa.gov. Ac- public health interventions, and help at-risk individuals receive cessed April 28, 2010.

WAKE COUNTY PHYSICIAN • JULY 2010 | 31 Poetry Corner John Balaban, Professor of English NC State University Poetry Section Editor

Another Spring By Judith Behar

The Quatrains of Baba Taher Oryan of Hamadan Across the lake, two dogwoods, (11th CenturyPersian Mystic) one pink, one white, cast their reflections into the water, I am that ocean now in foam and tide; I am that sun, but now in rays abide. doubling the day’s I move and burn, and then reverse my course; perfection. Indoors, I shine and glow and then grow low and hide. silence: she lies in bed

I am that sea now gathered in a tear. figuring her odds I am that universe now centered here. of getting to June, figuring I am that book of destiny which seems how to sit up, walk To form a lonely dot of hope and fear. twelve steps to the bathroom, I am a rose that grows on hills of love holding the doorway, the wall, I am a soul that learns the drills of love. prove she can do it, I am a heart in agony and joy. care for herself, live. From fire and chills and woes and thrills of love.

What if a sword should rob me of my sight, Geese call What if a wind? Should send my soul to flight, as evening settles What if a nail were driven through my hands, I still would feel thy presence and thy light. over the grass, the lake, If I am trapped in flesh and lust - I’m thine the houses. Reflections And though I doubt your ways, or trust - I’m thine. Whether to Christ I cling or Mazda’s Wing* disappear Behind these veils of dreams and dust - I’m thine. in darkness, her light Whether I cling, whether I part- you know. Whether I break or keep my heart - you know. visible Whether I crown my head or drown my eyes, on the shore. You know my goal from end to start - you know. * Judith Behar is an attorney in I find my ill in you, my cure in you. Greensboro, North Carolina I part from you and then endure in you. If knives would cut my tissues each from each, My naked soul is e’er secure in you. Baba Taher Oryan 32 | JULY 2010 • WAKE COUNTY PHYSICIAN Long Lens By Peter Makuck An art book I bought in Paris I tells how poor painters like Van Gogh

After she gave me her camera and Gauguin bought the cheapest pigments— for my weekly trek through three counties colors that destabilized faster than they knew. and asked for photos of anything she might improve into a painting, Folding and sorting, I look out a window that frames whitecaps chalking the chill-blue bay. those flatlands rose to attention again— tobacco barns, most of them tumbled Hell, all colors fade—anyone does laundry or slumped, some smothered with kudzu, knows this, Dad and I joking, then talking or those three men with shotguns, about a cheapskate judge we worked for once, orange vests drifting through corn stubble but his money helped to pack my suitcase behind tracking golden retrievers, with new clothes and put me on a train or that barrel of flames by a shack that took me to a college four states away. where two black boys warmed their hands, then dribbled, shot for a rim nailed to a tree. III

But poverty is an easy score For a week of blowtorch days in July, and not what had me parking we had graded and paved a winding driveway next to a barbed wire fence by a field for this Quaker Hill judge. He watched us drifted along its furrows with a snow from his high study window of cotton the harvesters had left. and from the cool hum of his gabled house On the field’s far side, a house emerged only once—to underpay us at the end of white clapboard with a tin roof. In the yard, on blocks, a black Chevy, because the job took three hours less than our guesstimate. I had shoveled and raked, (like the one I had as a teen), but what pounded stakes for the 1” x 6” wooden borders, held me wasn’t some proud idea of prevailing— it was a roofed-over well with a bucket, wheel-barrowed load after spilling load and between two pines a wash line from the cement truck chute. Then together we sawed the screed, long and heavy, back waving its dazzling sheets, blue jeans dancing, red and yellow shirts bloated with wind. and forth in a thirsty slanting light. Fenced out by sharp wire, but focusing That red evening, hotter and later than usual, a long lens over the distance of a winter field, sweaty, our clothes full of dust, my father

I saw my mother, a tan wicker basket and I bounced down our lane in his truck. at her feet, reaching down clothes. At the last rise our house lurched into view and he stopped. What was he looking at? II Wash was waving in the back yard, just behind Folding laundry, I can see our clothesline our well with its pulley and bucket. His face waving its patches of color like the flag seemed painted by something lost, of a foreign country where I had happily lived then he smiled, and we jounced ahead in a small clapboard house surrounded by pines. toward my mother, lamb chops, roasted potatoes and the good cool water from our well. I can hear my mother in her strong accent saying she didn’t want a dryer From Peter Makuck, Long Lens: New & Selected Poems (BOA Editions, 2010). Peter Makuck, author of books of prose and even when we could finally afford one— poetry, is Distinguished Professor Emeritus at East Carolina Our sheets won’t smell of trees and sunlight anymore. University where he founded and edited Tar River Poetry for many years.

WAKE COUNTY PHYSICIAN • JULY 2010 | 33 hinking Things Through T By Assad Meymandi, MD, PhD, DLFAPA

BARUCH SPINOZA: THE PHILOSOPHER’S PHILOSOPHER

Opera-logue lecture given on April 17, 2010, Around 1663, Spinoza was an adamant pantheism is sown deep in every form of before the musical performance “Spinoza” anti-Maimonedian. Late in his life, he immanentism (religious theories postulat- at Mandela Auditorium, Global Education changed his mind and gave Maimonides ing that a deity, mind, or spirit is imma- Center, UNC, Chapel Hill; produced and his due respect. Also, he used well the nent in the world and in the individual). directed by Broadway producer, Suzanne rich resources he extracted from the The rationalism of Descartes was to be Ishee, a native of Fayetteville, NC, and Terry Rhodes, Chair, Department of Music, UNC, Eastern philosophers to the point that quickly and logically bent in this direc- Chapel Hill. his behavior (i.e., his lack of regard for tion by Spinoza, while other Cartesians, money and material things, his giving up such as Malebranche and Leibniz, tried— pinoza had a vast mind the size of all his inheritance to his stepsister) dem- with less logic—more middle-of-the-road Central Park and Hyde Park put onstrated his Sufi lifestyle and mentality, solutions between pantheism and the Stogether. I have always thought even though he was not a Muslim. transcendence of God. Descartes was a in my imagination how nice it would be The philosophy of Spinoza is sys- major figure in 17th-century continental to have permission to just amble around tematic, logical, and rational and was rationalism, later advocated by Spinoza Spinoza’s vast mental space. developed by him in the 17th century in and Gottfried Leibniz and opposed by the Baruch Spinoza was born on Novem- Europe. It is a system of ideas built from empiricist school of thought consisting of ber 24, 1632, in Amsterdam. His parents basic building blocks with an internal Hobbes, Locke, Berkeley, Jean-Jacques and grandparents were Portuguese Jews consistency with which Spinoza tried Rousseau, and Hume. who, because of intolerance and anti- to answer life’s major questions and in Leibniz, Spinoza, and Descartes were semitism, emigrated to Amsterdam and which he proposed that “God exists only all well versed in mathematics as well as converted to Christianity. He learned philosophically.” He was heavily influ- philosophy, and Descartes and Leibniz Hebrew, paleo-Hebrew, Aramaic, Greek, enced by well-known thinkers, such as contributed greatly to science as well. Latin, and to some degree Arabic. He was Descartes, Euclid, and Thomas Hob- As the inventor of the Cartesian coordi- a polyglot and a polymath. bes, as well as theologians in the Jewish nate system, Descartes founded analytic Spinoza became known in the Jew- philosophical tradition, such as Maimo- geometry, the bridge between algebra ish community for positions contrary to nides, all of which I will review in this and geometry, crucial to the discovery of prevailing Jewish belief of the period, article, but his work was in many respects infinitesimal calculus and analysis. He is wherein he harbored critical positions, a departure from the Judeo-Christian best known for the philosophical state- and thus the seed of his Cherem (excom- tradition. He promoted pantheism and ment cogito ergo sum” (French: Je pense, munication; etymology: Arabic/Aramaic panentheism, which is a belief system that donc je suis; English: I think, therefore I Haram, forbidden as opposed to Halal, posits that God exists and interpenetrates am; or I am thinking, therefore I exist), permitted) were sewn. He was not a every part of nature and timelessly ex- found in Part IV of Discourse on the Muslim, but behaved like a Sufi in that tends beyond as well. Method (1637, written in French but with he gave away all his possessions to his René Descartes is considered the father inclusion of cogito ergo sum) and Part I step sister. He was heavily influenced by of modern philosophy and the founder of of Principles of Philosophy (1644, written Al Ghazali, Ba Ba Taher Oryan, and Al the rational method as applied to philo- in Latin). Descartes has been described as Farabi. For example Al Ghazali, who was sophical research. In fact, he is the first “Spinoza’s starting point.” Spinoza’s first a promoter of the philosophy of skepti- philosopher to begin with the impressions publication was his geometric exposi- cism, which was the position that nothing that are in our intellect (intellectual phe- tion (formal math proofs) of Descartes, can be known, was Spinoza’s favorite nomenalism) and lay down the laws that Parts I and II of Descartes’ Principles of hero. Al Ghazali said, “Doubt is a musi- reason must follow in order to arrive at Philosophy (1663). cal note that embellishes the intellectual reasonably certain philosophical data. Spinoza has been associated with symphony of a man’s life.” This phenomenalism did not find its Leibniz and Descartes as a “rationalist” in Spinoza was not a theologian; however, full development in Descartes. Indeed, contrast to “empiricist.” From December his treatises make one aware of a rich Descartes reaches metaphysical conclu- 1664 to June 1665, Spinoza engaged in repository of spirituality, transcendence, sions that are no different from those of correspondence with Blyenbergh, an ama- and “Godliness.” His short life shows that scholastic philosophy. He maintains the teur Calvinist theologian, who questioned he was an advocate of the theology of transcendency of God and upholds hu- Spinoza on the definition of evil. Later hope, possibility, and redemption. man liberty and Christian morality. But in 1665, Spinoza notified Oldenburg that 34 | JULY 2010 • WAKE COUNTY PHYSICIAN he had started to work on a new book, the pronouncement preceding the ban reads: had many friends but kept his needs to a Theologico-Political Treatise, published “The chiefs of the council make known minimum. One reviewer noted, “No one in 1670. Leibniz disagreed harshly with to you that having long known of evil has ever come nearer to the ideal life of Spinoza in Leibniz’s own published Refu- opinions and acts of Baruch de Spinoza, the philosopher than tation of Spinoza, but he is also known they have endeavored by various means Spinoza.” Another wrote, “As a teacher to have met with Spinoza on at least one and promises to turn him from evil ways. of reality, he practiced his own wisdom occasion, and his own work bears some Not being able to find any remedy, but and was surely one of the most exemplary striking resemblances to specific impor- on the contrary receiving every day more human beings ever to have lived.” And yet tant parts of Spinoza’s philosophy, known information about the abominable heresies another wrote, “In outward appearance he as Monadology. practiced and taught by him, and about the was unpretending, but not careless. His Because of his rant against Jews and monstrous acts committed by him, having way of living was exceedingly modest and Jewish theology, the Jewish community is- this from many trustworthy witnesses who retired; often he did not leave his room sued to Spinoza the writ of cherem, a kind have deposed and borne witness on all for many days together. He was likewise of excommunication. Righteous indigna- this in the presence of said Spinoza, who almost incredibly frugal; his expenses tion on the part of the synagogue elders at has been convicted; all this having been sometimes amounted only to a few pence Spinoza’s heresies was not the sole cause examined in the presence of the Rabbis, a day.” Spinoza appears to have had no for his excommunication; there was also the council decided, with the advice of sexual life. the practical concern that his ideas, which the Rabbi, that the said Spinoza should By the beginning of the 1660s, Spi- disagreed equally well with the orthodox- be excommunicated and cut off from the noza’s name became more widely known, ies of other religions as with Judaism, nation of Israel.” There is a tremendous and eventually Gottfried Leibniz and would not sit well with the Christian lead- historical parallel between Spinoza and Henry Oldenburg paid him visits, as stated ers of Amsterdam and would reflect badly Martin Luther. They both started to study in Matthew Stewart’s, The Courtier and on the whole Jewish community, endan- the law, Baruch in Amsterdam, Luther in the Heretic. gering the limited freedoms that the Jews Wittenberg, they were both rebellious and Later in life, Spinoza made a uturn and had achieved in that city. contemptuous of orthodoxy, and they were eventually reconciled with the teachings of The terms of his cherem were severe. both excommunicated from the mainstay Moses Maimonedes and even wrote pieces He was, in Bertrand Russell’s words, religious institutions (Spinoza from the in which he agreed with Maimonedes and “cursed with all the curses in Deuter- synagogue and Luther from the catholic his assertions about “self-discovery.” Mai- onomy and with the curse that Elisha church). monedes was a doctor, a Rabbi, a philoso- pronounced on the children who, in After his Cherem, Spinoza became pher, a writer, a clinician, and a counselor consequence, were torn to pieces by the acquainted with several collegiants, to the Caliphs. Spinoza was inspired to read the Torah, which was written in Judeo-Arabic, although he had read them all as a child. As the result of this re-read, Spinoza’s three famous and essential trea- tises were born: On the Improvement of the Understanding,Principles of Cartesian Philosophy, and A Theologico-Political Treatise. These works demonstrated the signature of Moses Maimonides. When the public reactions to the anony- mously published Theologico-Political Treatise were extremely unfavourable to his brand of Cartesianism, Spinoza was compelled to abstain from publishing more of his works. Wary and independent, he wore a signet ring engraved with his initials, a rose, and the word caute (Latin for “cautiously”). The Ethics and all other she-bears.” The cherem was, atypically, members of an eclectic sect with tenden- works, apart from the Descartes’ Prin- never revoked. Following his excommuni- cies towards rationalism. This is when he ciples of Philosophy and the Theologico- cation, he adopted the first name Bene- began reading and studying Descartes. Political Treatise, were published after dictus, the Latin equivalent of his given Many of his friends belonged to dissident Spinoza’s death, in the Opera Posthuma name, Baruch; they both mean “blessed.” Christian groups, which met regularly as edited by his friends in secrecy to avoid In his native Amsterdam, he was also discussion groups and typically rejected confiscation and destruction of manu- known as Bento (Portuguese for Benedict the authority of established churches as scripts. The Ethics contains many still- or blessed) de Spinoza, which was the in- well as traditional dogmas. unresolved obscurities and is written with formal form of his name. The ban, written Textbooks and encyclopedias often a forbidding mathematical structure mod- in Portuguese, is still preserved in the ar- depict Spinoza as a solitary soul who eked eled on Euclid’s geometry and has been chives of the Amsterdam community. The out a living as a lens grinder; in reality, he described as a [Continued on page 45]

WAKE COUNTY PHYSICIAN • JULY 2010 | 35 Quarterly Morbidity Report By Jeffrey Engel, MD North Carolina State Health Director WCP Magazine Public Health Editor

Wake County Morbidity Table (Preliminary data, as of 5/25/2010)

The Morbidity Table includes the num- Condition 1stQtr 2010 YTD 2010 (Q1) YTD 2009 (Q1) ber of reportable diseases and condi- Campylobacter 14 14 10 tions reported to the Chlamydia 1129 1129 966 Wake County De- Cryptosporidiosis 1 1 3 partment of Health Cyclosporiasis 1 1 - and Human Services E. coli, Shiga toxin 1 1 4 by Physicians and Ehrlichiosis, Granulocytic - - 1 laboratory directors Ehrlichiosis, Monocytic - - 1 as mandated by NC Gonorrhea 321 321 290 Law. The list of re- Haemophilus influenzae, invasive 4 4 2 portable diseases is Hepatitis A 1 1 1 not comprehensive Hepatitis B, acute 0 0 3 as rare diseases with Hepatitis B, carrier 16 16 34 zero case reports Hepatitis C, acute 1 1 - (e.g. CJD, Leprosy) HIV/AIDS 34 34 46 are not shown. Legionellosis 1 1 - For a complete list of Lyme disease 1 1 4 reportable conditions Malaria 2 2 - see: (http://www. Meningitis, pneumococcal 1 1 - epi.state.nc.us/epi/ Meningococcal Disease 1 1 - gcdc/manual/report- Mumps - 1 1 able_diseases.html) Pertussis 3 3 8 RMSF 4 4 15 The Morbidity Table Salmonellosis 10 10 28 is offered by the Shigellosis 1 1 10 Public Health Com- Strep, Group A invasive 3 3 2 mittee of the Wake Syphilis, Early 26 26 20 County Medical Tuberculosis 2 2 3 Society.

Notes: cases reported in that year.) diagnosed/reported in prisons No value in a cell means 0 cases (state, federal) are excluded reported. The data presented *Novel influenza virus infection: from this report so that the totals are based on cases reported in Case-based reporting was discon- (for Wake County) match those tinued in NC in the third week of the most current year. (i.e., September, 2009. published in our quarterly surveil- comparative of previous year lance report. Incomplete reports may not be comprehensive for HIV and AIDS cases that are are not included.

36 | JULY 2010 • WAKE COUNTY PHYSICIAN THE HEALTH CARE DEBATE CONTINUES By Tor Dahl*

he United States has just passed legis- Even health insurance reform is a work Tlation on health insurance reform. in progress. Soon we may see queues, like It is not a bill on health reform, nor is it those in Canada and Europe, resulting from focused on health sector reform. increasing demand for care not matched It does open up the door for insurance by increasing supply. That affects avail- companies to take positive and effective ability. steps to bend the cost curve in many ways. Then there will be tension between those Early in the twentieth century, New who believe in evidence-based medicine as York Life did exactly that. It hired reg- a condition of insurance coverage in con- istered nurses to visit their policy holders trast with what might be called the art of and talk about hygiene, nutrition, smoking medicine. I am reminded of the inscription and habits known to shorten life. Since over the entrance of the Sorbonne Medical New York Life was an insurance company School in Paris: “To cure, rarely; to help, significant. that benefitted financially from having sometimes; to comfort, always.” Should Seventy-five percent of health care costs long-lived customers, the visiting nurses insurance cover “comfort?” If so, what if in the United States derive from chronic put New York Life’s competitors behind comfort is given by other than health care disease, and half of these diseases can be the curve, and its clients in an enviable professionals? What appropriate care prevented. position. truly is may never be finally settled. The health sector can prevent about ten Insurance compa- Then there is the acceptability of percent of premature deaths. (The mortal- nies will now care. The ity rate is still 100%, but we can postpone deaths, within certain limits.) About 50% of premature deaths (deaths before age 65), we cause ourselves. The personal choices we make about smoking, drinking, driving, eating, exercise and the way we live our lives can postpone Death’s arrival. Now let me address the affordability of care. The root cause of this problem is the negative productivity of the health sector. If the health sector were to show the same annual improvement in productivity as the average American worker, this is what compete for some 49 million uninsured kind of care that produces would happen: Americans. Approximately 32 million of enough mistakes to cause at least 1. We would need to hire no additional these will be required to take out insurance. 98,000 Americans to die each year in this people to deliver care. The rest are estimated to be undocumented nation’s hospitals is not acceptable. 2. We would be able to treat ALL aliens or people choosing to pay a fine Consider the accountability of care. Ac- Americans with no increase in personnel. rather than to be insured. countability is not about tort reform. It is 3. Health care workers would continue The insurance industry now is offered about the positive philosophy of accepting to receive the same high increases every the opportunity of a lifetime to negotiate responsibility for the care that is delivered, year in fees, wages and salaries they have plans that reward healthy behaviors, incen- conscientious follow-up with patients, every year for the ten last years. tivize efficient and effective health care learning from mistakes, reporting mistakes, 4. Health care costs would decrease ev- delivery, cover preventive medicine, and reporting all outcomes, and making health ery year; after ten years the United States allow for integrative medicine. This is the care transparent. would, as a nation, pay ten percent less (in potential of health insurance reform. True health reform must focus on two real dollars) than what it does today. By itself, insurance only improves ac- key areas: 5. If we truly address that which we cess to care. It does not necessarily ensure 1. What makes people healthy, and know will make us healthy, Americans will the availability of care, the appropriate- 2. Acting on that knowledge. be the healthiest nation on Earth. ness of care, the acceptability of care, the About 20% of all causes of prevent- And that, my friends, will be true and accountability of care or, above all, the able deaths are genetic and another 20% comprehensive health reform. affordability of care. are environmental — people still die from But insurance could reward steps that breathing polluted air, living in hazard- * The writer is an economist consultant would positively affect all of these desired ous neighborhoods and living in coun- and Associate Professor in Public Health, objectives. tries where human life is considered less University of Minnesota.

WAKE COUNTY PHYSICIAN • JULY 2010 | 37 ditor’s Notebook E By Assad Meymandi, MD, PhD, DLFAPA Happy Birthday to care of 150 orphans and is always full. Kobra, who was always called All Mothers Janbibi—means BiBi or Lady and Jan is short for Jahan which means the n May 11, 1893, close to mid- world—never ever did anyone call night, a girl was born to the Han- her by her given name, Kobra, which with intoxication and spiritual élan, I cel- Ojari household of Kerman Iran. would have been blasphemous -- loved ebrate that lady’s birthday. I wish all to They named her Kobra which means The life. She lived triumphantly until 1994, be infused with love of knowledge, love Greatest. Kobra is the feminine form of well past 101 years of age. She loved mu- of wisdom, love of sensitivity to the needs masculine “Akbar” that we hear Islamists sic, dance, poetry, singing, chansons, and of others with beneficence and altruism. shout “Allah Akbar, means God is the parties. And yes, she loved to travel. She, That would satisfy Kobra Meymandi, our Greatest. ...” A bit of Arabic language like her parents, fed the poor and there Janbibi, and our Lady of The World. and etymology always helps! were regular intervals that they made rice Happy Birthday, dear Mom. We love That baby grew up, became superbly and lamb and served them in huge copper you and celebrate your memory. Your educated and turned into a beautiful fair trays to the masses that would come to youngest. skinned, red hair, young lady with angelic court yard. Our mother was equally seri- countenance and a heart full of love and ous about knowledge, learning, education AM compassion. There are many recorded and studying. She had us all memorize tales of her childhood how her family fed Hafez, Saadi, Rumi and of course, the NC Symphony the poor and gave to the Mosque. She Holy Quoran. Right up to the last days met her future husband, Farajollah Mey- of her life when I would talk to her on the s a heavy consumer of classi- mandi, a wise teacher who was a much phone, after the preliminary exchange of cal music and a NC Symphony older gentleman (he was born March 2, greetings she asked, “What did you learn Asupporter, I am writing to thank 1872). They married. Farajollah’s father, today?” or “What are you reading today? N&O for the coverage Rob Christensen Haj Hossein Meymandi, built a huge …” She loved to travel. When she and I has been given to our financially chal- house with stone columns, spacious halls climbed the Washington Monument in the lenged symphony. The NC Symphony with 40 feet ceilings, industrial size kitch- fifties, at the top she would say, “Can you has survived past crises and I am confi- en, vast rooms, and corridors with grape tell me how steps?” Likewise, she had the dent that it will survive the current one. vines in the middle of the court yard. This same question while climbing the Eifel Music is a necessity. It is a life giving is where all nine of Meymandi’s children Tower, the crown of the Liberty Statue, commodity, just like food, air and water. grew up. Brother Mohammad Hossein steps that connect Buda and Pest (Bu- NC will not allow its beloved symphony was the oldest dapest), the to perish. and I, Assad, Cathedrals the young- of Rome, AM est, with seven Toulouse, sandwiched in Florence and between. Three Notre Dame. Novel Cancer Treatment of the children, The reser- Cleared a set of twins, voir of her Dendreon’s ‘Therapeutic Vaccine’ and a little boy, knowledge Prompts Body to Attack Prostate Javad, died of was incred- Tumors; High Cost Is a Hurdle complications of ibly vast, and various infectious her hunger endreon Corporation’s novel way diseases such as to learn more to attack prostate cancer won measles; six sur- and enjoy Dgovernment approval Thursday, vived. The house life more was offering men with advanced forms of along with an unparalleled. the disease a fresh option and potentially endowment was … ushering in a new approach for treating all given to the City Today, as sorts of cancers. of Kerman. It is I recall my The highly anticipated decision by the equipped to take Whistler’s Mother mother, and Food and Drug Administration (FDA)

38 | JULY 2010 • WAKE COUNTY PHYSICIAN clears the way for the first “therapeutic son to adopt Carolina vaccine” for cancer to reach the market, an a healthier public health accomplishment that has eluded research- lifestyle. researcher, ers and drug companies for decades. Overall, said the Rather than target cancer like a drug, 314 people results are in the treatment, called Provenge, stimulates studied had line with pre- a patient’s own immune system to attack all four vious studies the tumor, much like a preventive vaccine unhealthy that examined prompts the immune system to attack an behaviors. the combined outside agent such as small pox. Among them, effects of “This is the first proof of principle that 91 died dur- health-related immunotherapy works in cancer,” said ing the study, or 29 percent. Among the habits on longevity. Philip Kantoff, chief of solid tumor oncol- 387 healthiest people with none of the four The findings don’t mean that everyone ogy at Harvard-affiliated Dana Farber habits, only 32 died, or about 8 percent. who maintains a healthy lifestyle will live Cancer Institute in Boston. “This opens The risky behaviors were: smoking to- longer than those who don’t, but it will the door to a whole world of new therapies bacco; downing more than three alcoholic increase the odds, Stevens said. based on that concept across all cancers.” drinks per day for men and more than two The FDA’s action is a watershed event daily for women; getting less than two Dear Dr. Insel, for Dendreon, a Seattle-based biotechnol- hours of physical activity per week; and Director, National Institute ogy company that had to overcome the eating fruits and vegetables fewer than agency’s controversial rejection of its three times daily. of Mental Health: application three years ago. When combined, these habits sub- The treatment faces several challenges. stantially increased the risk of death and was pleased to see your commentary First, it is expensive, and some insurers made people who engaged in them seem in JAMA, March 24, 2010. Although may balk at paying for it. Dendreon said 12 years older than people in the healthi- I you discussed in a gentle and tangen- it will charge $31,000 for each of three est group, said lead researcher Elisabeth tial manner that psychiatrists ought NOT required courses of treatment administered Kvaavik of the University of Oslo. to participate in money making ventures over one month, for a total of $93,000 per “You don’t need to be extreme” to be involving pharmaceuticals, you spent most patient. in the healthy category, Kvaavik said. of the essay on comparing psychiatry with Second, it extends life by only a few “These behaviors add up, so together it’s other specialties. Doing wrong is absolute months on average, though that is typical quite good. It should be possible for most and should not excuse the guilty because for treatments targeting late-stage cancers. people to manage to do it.” others are doing the same things. I hope In the clinical trial that led to approval, For example, one carrot, one apple and in your subsequent writings you would use the median survival on Provenge was a glass of orange juice would suffice for stronger language to behoove our col- 25.8 months, or 4.1 months longer than the fruit and vegetable cutoffs in the study, leagues to avoid engaging in these shady prostate-cancer patients in a control group. Kvaavik said, noting that the amounts are practices. Meantime, for your reading In addition, 32% of those on Provenge in pretty modest and less strict than many enjoyment, we are attaching the online the 512-patient test were alive three years guidelines. edition of the April issue of WCP maga- after treatment compared to 23% of those The United States government generally zine. Thank you not getting the therapy. recommends at least 4 cups of fruits or Because of limited manufacturing vegetables daily for adults, depending on AM capacity, the company expects to be able age and activity level; and about 2½ hours to treat just 2,000 patients during the next of exercise weekly. Catholic Church 12 months. Making the treatment is a Study participants were 4,886 British complex process requiring a patient’s own adults aged 18 and older, or 44 years old t is regrettable to see the Catholic live cells as a critical ingredient. on average. They were randomly selected Church appealing to public rela- from participants in a separate nationwide Itions gimmicks, using victimization British health survey. Study subjects were tactics, simulating the besieged Catholics Bad Habits asked about various lifestyle habits only to the victims of Auschwitz, to deny and Really Will Kill You once, a potential limitation, but Kvaavik soft-peddle the crimes of pedophilia al- Put together, they age you 12 years said those habits tend to be fairly stable in legedly committed by the priests. The adulthood. Catholic Church must take action, defrock our common bad habits combined Death certificates were checked for the all the current and past abusers and refer — smoking, drinking too much, next 20 years. The most common causes them to civil authorities for prosecution. Finactivity and poor diet — can age of death included heart disease and cancer, With nearly 50 years of teaching and clini- you by 12 years, sobering new research both related to unhealthy lifestyles. cal practice, I am not at all sure that any suggests. Kvaavik said her results are applicable type of “treatment” is helpful in dealing The findings are from a study that to other westernized nations including the with pedophilia. tracked nearly 5,000 British adults for 20 United States. years, and they highlight yet another rea- June Stevens, a University of North AM [Continued on page 41]

WAKE COUNTY PHYSICIAN • JULY 2010 | 39 Consultant’s Corner By Lloyd A. Hey, MD, MS*

WHATEVER HAPPENED TO SCOLIOSIS SCREENING?

While scoliosis screening was done t is late on a Friday afternoon, and an consistently during the 1970s and anxious call comes into Hey Clinic 1980s, many school districts moved Ifrom a pediatrician that she had an away from scoliosis screening during urgent spine consult for a young man with the 1990s in part because of the United an apparent rapidly growing spinal tumor States Preventive Services Task Force growing out of his lower back. My staff (USPSTF) began to raise questions made arrangements to get this young man regarding the effectiveness of such and his mom into see me right away. The screening. In their 1996 report, it was adolescent indeed had a fairly large hump their belief that there was insufficient on his left lower back. X-Ray revealed a evidence to warrant the costs associated very large thoracolumbar scoliosis as the with widespread scoliosis screening in Using Scoliometer for Scoliosis Screening cause of the hump. The mom was actu- schools. ally quite upset to the point of tears: “Why As a result, many school districts many Wake County pediatricians, they have wasn’t this picked up earlier? Don’t they began to discontinue their scoliosis screen- found that the Scoliometer has been very screen for this?” ing programs during the 1990’s, including helpful to help add an objective high tech Many of us adults remember being most school districts in North Carolina. By measure to their documentation to show that screened as a middle schooler in gym class 2004, this same organization updated its they checked for scoliosis. It also gives our or by our school nurse. Gym teachers opinion to state that scoliosis screening was well-educated Wake County population, or school nurses often would have large considered “Grade D: Not recommended, (who also like objective measures) some vi- groups of children bend forward, examin- with fair evidence that the screening was sual proof that we checked their child/teen- ing the upper and lower back for asym- ineffective or harms outweigh benefits.” ager thoroughly and that nothing is being metries (humps) that would then result (http://www.ahrq.gov/clinic/3rduspstf/sco- overlooked or missed: they will remember in a letter going home with the child to liosis/scoliors.htm.) that you put a device on their child’s back, have them seek further evaluation and an Many States used this document to elimi- whereas they may not remember that you X-Ray. It seemed like a good idea from a nate the requirement for scoliosis screen- eye-balled them for potential rib hump. public health standpoint: early diagnosis ings in their schools, and as a result, school Screening for scoliosis is becoming even could lead to earlier treatment with molded scoliosis screenings have become quite more difficult as obesity becomes more scoliosis braces, and the possible avoidance variable nationwide. As a result of this prevalent in the adolescent and adult popu- of surgery. dramatic drop in school screenings, overall lation. Very large, well-balanced curves Dr. Ralph Coonrad, cared for thousands awareness of scoliosis among families and can be nearly completely invisible. As of children and adolescents with scoliosis even some physicians has dropped. shown below, two young ladies have simi- from all over Durham, Orange and Wake Now that school scoliosis screenings have larly appearing backs on clinical exam, with Counties for over thirty years. Back in the been largely eliminated, what role, if any, possible slight curve. The one on the left 1970s, Dr. Coonrad along with other physi- does the pediatrician, family physician, OB/ actually has an 80 degree scoliosis, twice cians, nurses and school administrators who GYN and orthopaedic surgeon play in the as large as the young lady on the right who helped develop and implement the scoliosis detection of scoliosis? Many are choosing has a single 40 degree curve. The scoliom- screening programs in the Triangle area and to include scoliosis screening as a part of eter has proven to be helpful in this obese even around other areas of North Carolina. their usual physical examination for chil- population as well. Most, if not all of the local school districts dren, adolescents and adults. Many are also had some form of screening program in using the Scoliometer, which is a tilt gauge *Hey Clinic for Scoliosis and Spine place by the end of the 1970s. Similar tool that helps define paraspinal asym- Surgery screening programs were implemented metries that are large enough to warrant an Raleigh, North Carolina across the United States. X-Ray evaluation. In my discussions with http://www.heyclinic.com 40 | JULY 2010 • WAKE COUNTY PHYSICIAN EDITOR’S NOTEBOOK continued from page 39 tional scientist hastily assembled in Munich, Valley and Boston area several years ago in Germany; researcher Uri A. Girly, PhD this category. Hooray for Raleigh! From the Wire Services: presented the paper; Phytoestrogens in Hops Beer. In summary Dr. Girly found that with Litigation Center of AMA Sydney, Australia the consumption of large amounts of beer and the State Medical all study subjects were observed to: Societies Win Settlements esearchers at Sydney University Against UnitedHealth Group report find- 1. Argued over nothing ing female R 2. Refused to apologize when orth Carolina Medial Society hormones in beer. obviously (NCMS) was a leader in generat- While studying wrong ing settlements with UnitedHealth hops as a natural N Group the exceed $350 million. During the 3. Gained weight source for estrogen 2007-2010 much ink was spilled on the to treat meno- 4. Talked excessively without pages of WCP documenting the malignity pausal women; sci- making sense of UnitedHealth Group, the malfeasance of entist discovered its CEO, and the poor treatment of MDs by elevated levels of 5. Became overly emotional the company. We are happy to report that phytoestrogen a the collective efforts of organized medicine, female hormone. 6. Couldn’t drive intense coverage of the media and atten- Director Dr. Hardy 7. Failed to think tion of the NY Attorney General, Andrew Iman warns that rationally Cuomo, lawsuits against the company consumption of brought settlements of $350 million. In 8. Had to sit down while large quantities addition Mr. Cuomo’s settled with the com- urinating of phytoestrogens pany for another $50 million which calls for found in hops beer the creation of a new UCR database for out Raleigh’s Ranking could potentially turn men into women. of network reimbursement. Scientists conclude that men should take a our article about Raleigh’s ranking AMA reports that the patients and physi- considered look at their beer consumption. in the world of culture and educa- cians are now beginning to reap the rewards Further concerns about the safety of beer Ytion, N&O, December 29, needs of more than ten years of efforts by the were raised by the June 2009 Journal of to be complemented with another bragging litigation Center of AMA and the State Science report by investigators at the Uni- right that Research Triangle Park embracing Medical Societies. We know that NCMS versity of Toronto. Acting on the Sydney the three universities, UNC, NCSU, Duke, and our own Robert Seligson were heavily discovery Canadian researchers studied 100 and now the fourth, the evolving NCCU involved in these activities. The company male volunteers following consumption of into a research campus, has more MDs and over the span of 10 years under reimbursed 8 schooners of beer within a one (1) hour PhDs per capita than anywhere in the world patients and their physicians for out of period. Standing before a throng of interna- except for Israel. RTP surpassed Silicon network care. §

NC BOTANICAL GARDEN continued from page 22 relationship of gardens and na- Center and to enjoy and learn at the North ture, biodiversity conservation, Carolina Botanical Garden. Visit our web- the local economy while reducing carbon and people and their environ- site, www.ncbg.unc.edu for more informa- dioxide emissions from long-distance ment. We offer a rich array of educational tion--and join the Garden so that you can transport), and high diversion of construc- programs to all ages, provide beautiful receive our Newsletter, full of information tion waste form the landfill (an amazingly gardens (including the Coker Arboretum on on plants, horticulture, and the classes, field ambitious goals was reached, only 4% of the University of North Carolina campus), trips, and lectures we have available. the construction waste by weight went to and carry out active conservation pro- the landfill, and 96% was recycled). grams. We protect and restore natural areas *Peter White has been Director of the North The building was designed to be a (including Battle Park and Mason Farm Carolina Botanical Garden and a Profes- gateway to gardens and to 1000 acres of Biological Reserve), hold a “Noah’s Ark” sor of Biology at the University of North natural lands. Abundant day lighting makes like collection of endangered species as a Carolina at Chapel Hill since 1986. After a the building a joy to work and learn in and last resort against extinction in the wild, and B.A. from Bennington College, he received provides wonderful views of the outdoors, reintroduce plants to natural habitats. We a Ph.D from Dartmouth College and was while also reducing the need for electric also curate the University of North Caro- a postdoctoral fellow at the Missouri lights. lina Herbarium, with 700,000 pressed and Botanical Garden in St. Louis. He served The North Carolina Botanical Garden’s dried plant specimens, the largest museum as a research biologist with Great Smoky mission is to inspire understanding, ap- of plant collections in the Southeast and a Mountains National Park (where he and his preciation, and conservation of plants in great archive of information that is critical students still do research, including projects gardens and natural areas and to advance to understanding the identity and distribu- associated with the Park’s big biological a sustainable relationship between people tion (historical and present) of North Caro- inventory, the All Taxa Biodiversity Inven- and nature. As this mission suggests, we lina and Southeastern plant species. tory) and the University of Tennessee before have always been a garden that stresses the We welcome you to the new Education moving to Chapel Hill.

WAKE COUNTY PHYSICIAN • JULY 2010 | 41 The Humanities Corner

By Gary Comstock, PhD, Professor of Philosophy, NCSU

INTRODUCING ON THE HUMAN

r. Meymandi which it is being put by the media. We include two links, one to a invited me to research publication and another to the media’s representation of Dprovide a descrip- the research. tion of On the Human (OTH)—an online project on which he and 4. Teaching Resources gathers pedagogical strategies, links, and I collaborate—and I am happy to oblige. suggestions for success in the classroom. How-to papers reflect On the Human is a virtual community (onthehuman.org) on the experiences of instructors who are alums of the National consisting of junior and senior students and scholars in the sci- Humanities Center’s Human Nature seminars. ences, humanities, engineering, and technology. We take on 5. Guiding Papers provides introductory, orienting essays. big questions. What are humans? How do we differ, if at all, Written by members of the OTH community, articles describe from nonhuman animals and advanced artificial intelligences? authors’ research interests and the way each one construes our In recent years, several scientific disciplines have converged in subjects. studying the most traditional subject of the humanities: the hu- 6. Archives is a library of papers, videos, pictures, and other man. From evolutionary biology to cognitive science to primatol- materials from our site and its ASC predecessor. ogy, disciplines outside the humanities are providing powerful new descriptions and analyses of fundamental human attributes The Wake County area has been well represented in the Forum such as language, emotions, social behavior, creativity, and moral during our first year. Contributors included four from Duke feelings. How, if at all, will these empirical findings pressure University traditional understandings of our nature, if we have one? How, • Professor Michael Allen Gillespie on “Science and the Hu- if at all, are advances in science changing the limits of human manities” life or disturbing the idea that we are singular creatures of self- • Professor Katherine N. Hayles on “Distributing/Disturbing the understanding? Chinese Room” On the Human brings scientists together with humanists to • Professor Tim Lenoir on “Contemplating Singularity” investigate such questions. Carrying on the excellent work begun • Professor Alex Rosenberg on “The Disenchanted Naturalist’s in the National Humanities Center’s three-year initiative on Guide to Reality” Autonomy, Singularity, Creativity (2006-09), the online initiative And one from University of North Carolina, Chapel Hill, Profes- employs new media strategies to pursue two objectives: sor Bill Lycan on “Qualitative Experience in Machines.” • To stimulate humanities research on the philosophical and ethical implications of recent advances in bio- and information- The OTH Editorial Board is technologies, especially as new scientific discoveries help to • Gary Comstock, Editor-in-chief advance understanding of our evolutionary past and aid ethical Philosophy, NC State University evaluation of proposals to enhance future cognitive capacities • Phillip Barron, Managing Editor • To engage the public in this scholarship using Web2.0 tools National Humanities Center such as structured e-conversations and open courseware • Parker Shipton, Editor, Animals Anthropology, Boston University OTH consists of six resources: • Sally Haslanger, Editor, Humans Philosophy 1. The Forum is an online conversation providing open access MIT to experts on persons and the animals and machines that surround • Bill Lycan, Editor us. Every two weeks an invited Contributor posts a brief essay Machines Philosophy, UNC, Chapel Hill and the public is invited to respond. 2. Open Seminar On the Human (OSOTH) is a repository of Stephen Zachary compiles In the News. Joining Dr. Meymandi free, expert-maintained undergraduate-level courses designed to on the Advisory Board is Robert Pippin (Philosophy) of the Uni- deepen our understanding of the human. Collaborative and inter- versity of Chicago, and Robert Strassler (independent scholar) of Great Barrington, MA. We receive critical support from the institutional, OSOTH offers a suite of model syllabi, structured National Humanities Center’s Geoffrey Harpham (Director), Don readings, interactive exercises, a calendar, videos, discussion Solomon (Director of Communications), Richard Schramm (VP questions, podcasts, and a social network group on Facebook. for Education Programs), and Stephanie Tucker (Chief Financial 3. In the News is a monthly round-up of research and the use to Officer). Please join us!

42 | JULY 2010 • WAKE COUNTY PHYSICIAN Clinical Corner By Alan Rosen, MD, FACR, Medical Director Duke Radiology of Raleigh Duke Raleigh Hospital

TIPS FOR IMAGING IN 2010

erhaps more than in any other subspecialty of medicine, It is also important to shop carefully Pthere has been an overwhelm- for the radiology group that you will ing advance of technology within the send your patients to for imaging work imaging field. Constantly improv- ups. Not all MR and CT scanners are the ing computer-based technology has same and there is a huge range of quality given us improved MR imaging, especially in outpatient offices. Newer faster and more flexible CT scan- and more expensive scanners produce ning, a fairly new modality with sharper and more diagnostic images PET/CT and an overall bewildering and provide computer manipulations of amount of information for the refer- the images making the interpretations ring physician to absorb. more accurate and helpful. Patients are Short of taking a review course charged the same amounts for state of the in imaging and directly becoming art scans and embarrassingly poor exams familiar with all the new modalities, – buyers beware! I recommend using your radiolo- As we have become more knowl- gist as a guide and teacher through edgeable about contrast agents and the increasingly complex maze of their effects on the kidneys and as we diagnostic work ups. The radiologist have learned about the rare but serious should not be viewed simply as an complication of nephrogenic systemic interpreter of images but rather as a fibrosis with MR contrast agents we consultant to the referring physician. realize that patients must be carefully You should feel free to consult us in screened for evidence of kidney disease. person and on the telephone. Giving contrast agents to patients with We are all becoming more and even mild renal failure can have drastic more cost conscious and the best consequences. You will notice your ra- way to save money on diagnostic diologists commonly assessing BUN and work ups is to order the correct creatinine levels and determining GFR’s test. For example, MR is the best in order to determine if contrast can be modality for viewing changes given safely. Currently, we are using a related to multiple sclerosis and CT GFR of over 40 as a safe zone, 30-40 as is fairly worthless in that setting. So a cautionary zone (administer contrast it makes no sense to start with a CT only if clearly clinically indicated), and scan and then work up to an MR if we tend not to give contrast to patients the CT is negative – MR should be with GFR’s under 30. the first and only imaging modality As computers become more and more for MS. CT has become the stan- prevalent in medical practice, it is worth dard exam for working up the uri- paying some attention to the electronic nary tracts and IVP’s have become storage facilities that are appropriate for outmoded. By ordering the right test your practice and which ease follow up initially, we will save money for our of your patients. Clearly, having all your patients and the system and arrive at patient data and imaging exams in one accurate diagnoses earlier and more system simplifies the practice of medi- easily. cine. §

WAKE COUNTY PHYSICIAN • JULY 2010 | 43 Galen’s All-Purpose Antidote By George W. Houston, PhD*

poisonous bites”) or Mithridatium, by Galen, comments on in his text. You should catch had a long history. the snakes in the spring, cut off their heads Mithridates VI (120 – 64 BC), the King and tails (which have little meat on them), of Pontus (a region corresponding roughly skin and gut them, then boil what remains to north central Turkey), either invented or and separate the flesh from the bones. The elaborated upon an all-purpose antidote that flesh, when dried, is to be powdered and consisted of dozens of herbs. Some of the mixed with a small amount of bread, so that ingredients were believed to be beneficial it can then be added to all the other ingredi- but many were themselves poisons, the the- ents and the whole fashioned into capsules ory being that you could fortify your body for consumption. against a poison by taking a It’s Rough Work, But small amount of that poison Someone’s Gotta Do It oison, for the ancient Romans, was a on a regular basis. After his Galen himself went problem. There were clearly venom- death, Mithridates’ recipe to considerable effort Pous creatures—spiders, scorpions, became known to Greek to obtain the necessary and serpents—and there were plants such and Roman physicians, and ingredients, which had to as mushrooms, henbane, and aconite, that from then on we hear of be brought to Rome from could make you ill, drive you insane, or various treatises on venom- many different parts of even kill you. So much was obvious. Also, ous animals or poisons and the Empire. He haunted there were many ailments that came upon how to guard against them. the you suddenly and mysteriously. How could Most, if not all, of these spice markets in order to you be sure it was simply a disease if the recipes clearly derived from compare, for example, physicians could not explain the cause of an Mithridates’ original work. the hulwort and germander that was import- affliction? There was always the possibility The Great Contribution of Andromachus ed from the eastern Adriatic coast with what that some personal enemy or rival had poi- Of all of the post-Mithridates recipes, was grown in Italy itself, and Italian iris to soned you, and, as everyone knew or at least Galen’s favorite was one that had been the iris imported from Africa. He squirreled believed, there were professional poisoners, developed by a certain Andromachus the away as much cinnamon as he could, storing people adept in the black arts and skilled in Elder, one of the physicians of the emperor it, along with many other spices and drugs, the use of poisons. Under the circumstances, Nero. Andromachus, Galen tells us, had in a rental unit in one of the great imperial you could not be too careful. perfected the theriaka by moving beyond warehouses. In short, preparing the theriaka Wealthy and powerful people were, it was mere herbs: he included the boiled and was a labor-intensive business that involved reckoned, especially likely to be poisoned, flaked flesh of poisonous snakes. Not only various skills, from snake-catching to com- for their wealth and power were envied and that: Andromachus had gone to the trouble parison shopping to fashioning little capsules coveted, and the very wealthiest and most of composing a poem that described the New of medication. Was it worth it? Galen cer- powerful, the Roman emperors, had to be Improved Theriaka and told all about it in tainly thought so. Like Andromachus before particularly careful. The rich did have ways 87 elegiac couplets. Galen quoted this poem him, he recommended that his patients take of protecting themselves. In some house- and commented on it at length. In the poem, a pill every day to protect themselves and, holds (including the emperor’s), slaves Andromachus began with a short dedication incidentally, as a pick-me-up, so they would tasted food and drink before it was served to to Nero, and then listed the poisons, venom- generally feel better. And maybe it did help. their master. In addition, a few wealthy men ous bites, and diseases against which the Antoninus died at age 75 of natural causes. ate very simple diets so that the presence theriaka is effective. These include hem- Marcus Aurelius passed away in AD 180 of poison might more readily be detected. lock, poppies, and other plants; snakes and at the relatively early age of 59, but he had Most interesting, though, were the prophy- scorpions; rabies; and, among other diseases, survived and remained healthy through the lactic antidotes, elaborate confections of epilepsy, consumption, and urinary tract and whole period of the Great Plague that first many ingredients that physicians prepared kidney problems. struck Rome in 166. Neither of these men, and emperors consumed. To provide protection against these many be it noted, died of poison or snake-bite. The Origins of the Theriaka afflictions, Andromachus prescribed a pill And Mithridates? Legend had it that he was We know about such antidotes from that included some sixty ingredients. Small defeated in battle, and he intended to commit numerous ancient sources, but the single amounts of hemlock and other poisonous suicide by taking poison, only to find he most informative source is the physician plants are included, as well as many more was immune. Consequently, he had to kill Galen (ca. A.D. 129 – ca. 200), who in two benign items: rose leaves, iris, cinnamon, himself by falling on his sword. § different treatises tells us in detail about an cassia, spikenard from India, honey, wine, antidote that he prepared for Antoninus Pius and dozens more. Special attention must be *The writer is Professor of Classics (reigned 138-61), Marcus Aurelius (161-80), paid to the preparation of the viper’s flesh, Emeritus at the University of North Carolina and members of their families. This anti- and to this topic Andromachus devotes a at Chapel Hill. dote, called “theriaka” (= “the antidote for full 44 lines, which Galen then explains and Email:

44 | JULY 2010 • WAKE COUNTY PHYSICIAN BARUCH SPINOZA continued from page 35 his analysis of monetary and fiscal knowledgeable metaphysics. Francis Pas- policy under different xchange rate che (1981) discusses the idea of “practical “superbly cryptic masterwork.” regimes. He created the Euro, the psychoanalysis.” Gilles Deleuze’s work on Spinoza was also impressed by Aqui- monetary unit that binds the economy of Spinoza, Expression in Philosophy (1992), nas because he translated all of Aristotle the European continent. He is now busy has opened the way toward a confrontation from Greek to Latin. It is believed that the creating a similar economic unit of cur- between Spinozistic and psychoanalytic beginning or anlagen of Spinoza’s work rency for Asia. ethics. Finally, several psychoanalytic in Ethics and dualism and his intellectual We know as a child, Spinoza gained authors (Bertrand, 1984; Ogilvie, 1993; love affair with Euclid and Descartes starts a reputation of constantly and sometime Burbage and Chouchan, 1993) have with his reading Aquinas’s work, from irritantly asking “why.” He had a reputa- discovered unconscious implications in which he learned how to think and argue. tion of being “that little WHY boy.” His Spinoza’s philosophy. One last thing that The only book that bears Spinoza’s name mother was loving and helped him to find impresses me personally is that Spinoza on the spine is the fruit of that love affair: answers to his questions by buying him shares the concept of grace and salvation Ethica Ordine Geometrico Demonstrata books and reading him bedtime stories. with Saint Augustine of Hippo, Moses (The Ethics) (1677), translated by Jona- She even bought him a telescope to see Maimonides of Cordoba, Ibn Khaldoun, than Bennett. The first translation of this and study the stars. He was very close to and Saint Thomas of Aquinas: The road work into Hebrew was done by Samuel his mother, whom he lost at age 7. map to salvation and grace is to know Ibn Tibbon Teshuvot, who collected cor- Authors who have tried what is good inside of you, such as love, respondence and response, including a to speculate on Spinoza compassion, empathy, and selflessness number of public letters (on resurrection vis-à-vis psychoanalysis and what is good outside of you, such and the after life, on conversion to other have pondered several as music, flowers, dance, faiths, and Iggereth Teiman - addressed to different kinds of ques- poetry, connectedness the oppressed Jewry of Yemen). Trea- tions. with family and tiseon Logic (Arabic: Maqala Fi-Sinat W. Aron (1977) friends, and to Al-Mantiq) has been printed 17 times, asked about the over- be thankful by including editions in Latin (1527), German all influence of Spinoza giving some- (1805, 1822, 1833, 1828), French (1935), on Freud’s thought. C. thing back. and English (1938), and in an abridged Rathbun (1934) noted that Spinoza Hebrew form. the libido, a fundamental indeed Spinoza was interested in another Arab concept of psychoanalysis, gave polymath, philosopher, economist, and is adumbrated in Spinoza’s much. music advocate—Ibn Khaldoun (Abu concept of conatus, an inborn Zayd Abdu-Rahman Bin Mohammad Ibn drive that leads to striving Khaldoun Al- Hamadi, 1332–1406). Ibn and persisting. On Walter Khaldoun, the father of trickledown eco- Bernard’s reading (1946), nomics (Reaganomics), influenced many it is perhaps closer to European economists, especially Austrian eros or desire. But what, economists, including Ludwig Von Mises according to these authors, (1881–1973). In 1993, while studying were Spinoza’s therapeutic Palladian Villas on an architectural tour principles? These works today appear of Italy, we were privileged to have lunch dated, indicative as much of the intel- with Robert Mundell, former Chairman lectual state of psychoanalysis, particu- of Economic Advisors for the late Presi- larly in Anglo- Saxon countries, as of a dent Reagan. Much of our enthusiastic poorly informed reading of Spinoza. Some discussion at the table centered around Ibn authors, such as Abraham Kaplan (1977), Khaldoun and Von Mises. Mundell won recall that Spinoza’s philosophy was not the Nobel Prize in Economics in 1999 for a protopsychoanalytic science, but a very

THE ROLE OF SOCIAL SCIENCES continued from page 7 be enhanced by bringing together para- because there is far less opportunity to it promotes the disciplines within my digms from the life sciences, the social reap financial profit from those enterprises college. I concede the point, but not the and behavioral sciences, and the humani- than investment in products and patents. argument. Indeed, as the Maslow quote ties. Or, to put it in terms first promulgated In the interests of full disclosure, I must above suggests, it may be that only those by the Jewish sage Hillel: “If I am not for confess I have a significant stake in mak- who are immersed in the humanities and myself, than who will be for me? But if I ing this case. First, I am a social scientist social sciences can make this case to those am only for myself, then what am I for?” § (a psychologist, to be exact); second, I who view the world (and especially health am dean of the College of Humanities and well-being) through the lens of the *The writer is Dean, College of Humani- and Social Sciences at North Carolina life sciences paradigm. I firmly believe ties and Social Sciences and Professor of State University. Therefore, some might that health research—and ultimately, the Psychology North Carolina State Univer- view my argument as self-serving, as health and well-being of all people—will sity, Raleigh, North Carolina WAKE COUNTY PHYSICIAN • JULY 2010 | 45 There is no doubt that psychoanalysts Jonathan Lear and others have argued, a THINKING ABOUT THINKING could and did make many useful and philosophy of mind, and the psychoana- continued from page 2 original contributions to our understanding lytic literature — from Freud to Hartmann of the mind simply by listening to patients. to Erickson to Winnicott — must be read to stress as adults. Thus, differences in We must, at last, acknowledge that at this as a modern philosophical or poetic text an infant’s interactions with its mother point in the modern study of mind, clinical alongside Plato, Shake¬speare, Kant, — differences that fall in the range of observation of individual patients, in a Schopenhauer, Nietzsche, and Proust. naturally occurring individual differences context like “the psychoanalytic situation On the other hand, if the field aspires, as in maternal care — are crucial risk fac- that is so susceptible to observer bias, is I believe most psychoanalysts do aspire, tors for an individual’s future response to not a sufficient basis for a science of mind. to be an evolving, active contributor to stress. In the same book, he further elabo- Psychoanalysis research is depleted from an emerging science of the mind, then rated, “The deficiencies in our description opportunities to add more knowledge” so psychoanalysis is falling behind. would probably vanish if we were already say the late Kurt Robert Eissler (1908- Biology might reinvigorate the psycho- in a position to replace the psychologi- 1999) and Hartvig Dahl (1924-2007). analytic exploration of mind. I should say cal terms with physiological or chemical Marshall Edelson in his book, Hypothesis at the outset that although we have the ones. ... We may expect [physiology and and Evidence, offer persuasive argument outlines of what could evolve into a mean- chemistry] to give the most surprising for the holy marriage between psycho- ingful biological foundation for psycho- information and we cannot guess what analysis and biology must take place: “We analysis, we are very much at the begin- answers it will return in a few dozen years must bring psychoanalysis and biology ning. We do not yet have an intellectually of questions we have put to it. They may together.” satisfactory biological understanding of be of a kind that will blow away the whole Psychoanalysis is based on the con- any complex mental processes. of our artificial structure of hypothesis. cept that individuals are unaware of the In the next century, biology is likely …” Further reference: In his classic paper, many factors that cause their behavior to make deep contributions to the under- “On narcissism” he wrote, “We must and emotions. These unconscious factors standing of mental processes by delineat- recollect that all of our provisional ideas have the potential to produce unhappiness, ing the biological basis for the various in psychology will presumably one day which in turn is expressed through a score unconscious mental processes, for psychic be based on an organic substructure.” On of distinguishable symptoms, including determinism, for the role of unconscious the cusp of twenty-first century, we really disturbing personality traits, difficulty in mental processes in psychopathology, and need a contemporary Freud to orchestrate relating to others, or disturbances in self- for the therapeutic effect of psychoanaly- the disparate parts of the symphony of esteem or general disposition As I have sis. Now, biology will not immediately en- life, psychoanalysis, biological sciences, suggested earlier, most biologists believe lighten these deep mysteries at their core genomics, neurosciences and neurobiol- that the mind will be to the twenty-first We have seen that one point of conver- ogy to produce the rich symphony of century what the gene was to the twentieth gence between biology and psychoanalysis better understanding mind and ultimately century. I have briefly discussed how the is the relevance of procedural memory for life. Well, we do have a few contemporary biological sciences in general and cogni- early moral development, for aspects of Freud; one is Eric Kendal whose most tive neuroscience in particular are likely transference, and for moments of mean- recent book, The Science of the Mind, we to contribute to a deeper understanding of ing in psychoanalytic therapy. We have reviewed two years ago in these pages. a number of key issues in psychoanaly- considered a second point of convergence Dr. Kendal who is a Nobel Laureate psy- sis. An issue that is often raised is that a in examining the relationship between chiatrist and professor at Columbia Uni- neurobiological approach to psychoana- the associative characteristic of classical versity insists that to save psychoanalysis lytic issues would reduce psychoanalytic conditioning and psychological determina- and pump vigorous life into this elegant concepts to neurobiological ones congru- cy. Here, I want to illustrate a third point field, we need to bring about fusion of ence between psychoanalysis and biology. of convergence: that between Pavlovian the two disciplines of psychoanalysis and Psychoanalysts could and did make many fear conditioning, a form of procedural biology. Otherwise, there is a wide spread useful and original contributions to our un- memory mediated by the amygdala, signal concern about viability of psychoanalysis derstanding of the mind simply by listen- anxiety, and posttraumatic stress syn- as a scientific discipline. For example, ing to patients. We must, at last, acknowl- dromes in humans. Psychoanalysis and Jonathan Lear and others have argued edge that at this point in the modern study cognitive neuroscience would accomplish that psychoanalysis and psychoanalytic of mind, clinical observation of individual two goals for psychoanalysis, one concep- literature from Freud to Hartmann to patients, in a context like the psycho- tual and the other experimental. We must Erickson to Winnicott, will be read as a analytic situation that is so susceptible to recollect that all of our provisional ideas modern philosophical or poetic text along- observer bias, is not a sufficient basis for a in psychology will presumably one day be side Plato, Aristotle, Shake¬speare, Kant, science of mind. Psychoanalysis research based on an organic substructure. Schopenhauer, Nietzsche, and Proust (the is depleted from opportunities to add more American psychologist best known literature I went through for preparation knowledge: Kurt Eissler and Hartvig Dahl. for his maternal-separation and social of this essay). On the other hand, if the Marshall Edelson in his book Hypothesis isolation experiments on rhesus monkeys, field aspires, as I believe most psychoana- and Evidence says we must bring psycho- which demonstrated the importance of lysts do aspire, to be an evolving, active analysis and biology together. care-giving and companionship in social contributor to an emerging science of the If psychoanalysis is to rest on its past and cognitive development. He conducted mind, then psychoanalysis will survive. accomplishments, it must remain, as most of his [Continued on page 47]

46 | JULY 2010 • WAKE COUNTY PHYSICIAN THINKING ABOUT THINKING disciplines involved who could produce return to its former vigor and contribute continued from page 46 great symphonic music out of the compo- importantly to our future understanding nent parts. of mind, psychoanalysis needs to examine And to accredit the what appears to be and restructure the intellectual context in research at the University of Wisconsin– a disparate and ill defined effort under which its scholarly work is done and to Madison, where humanistic psychologist the name of “Psychoanalytic Institutes.” develop a more critical way of training the Abraham Maslow worked for a time with For many years both the Association for psychoanalysts of the future. Thus, what him. — Sigmund Freud, “On Narcissism.” Psychoanalytic Medicine at Columbia and psychoanalysis may need, if it is to survive Hans Selye had pointed out as early the New York Psychoanalytic Institute, as an intellectual force into the twenty-first as 1936 that humans and experimental to use but two examples, have instituted century, is something akin to a Flexner animals respond to stressful experiences neuropsychoanalytic centers that address Report for the psychoanalytic institutes. § by activating their hypothalamic-pituitary- interests common to psychoanalysis and adrenal (HPA) axis. The end product of neuroscience, including consciousness, the HPA system is the release of gluco- MENTAL HEALTH CORNER unconscious processing, autobiographical continued from page 18 corticoid hormones by the adrenal gland. memory, dreaming, affect, motivation, The deficiencies in our description would infantile mental development, psychophar- probably vanish if we were already in a condition to be defined by each person for macology, and the etiology and treatment her or himself.” § position to replace the psychological terms of mental illness. The prospectus of the with physiological or chemical ones. ...We New York Psychoanalytic Institute now Reprinted with permission IRIS NAMI may expect [physiology and chemistry] to reads as follows: give the most surprising information and Publication, April 2010. Dr. Stratas’ col- “The explosion of new insights into umn will return in the next issue. we cannot guess what answers it will re- numerous problems of vital interest to turn in a few dozen years of questions we psychoanalysis needs to be integrated in have put to it. They may be of a kind that meaningful ways with the older con- will blow away the whole of our artificial cepts and methods as do the burgeoning structure of hypothesis. research technologies and pharmacologi- An increase in plasma ACTH and glu- cal treatments. Similarly neuroscientists cocorticoid responses to stress as adults. exploring the complex problems of human Thus, differences in an infant’s interac- subjectivity for the first time have much to tions with its mother — differences that learn from a century of analytic inquiry. fall in the range of naturally occurring Make a significant fraction of psychoan- individual differences in maternal care — alysts technically competent in cognitive are crucial risk factors for an individual’s neuroscience and eager to test their own future response to stress. — Sigmund ideas with new methods. The challenge Freud, Beyond the Pleasure Principle. for psychoanalysts is to become active The prefrontal association cortex has participants in the difficult joint attempt two major functions: it integrates sensory of biology and psychology, including psy- information, and it links it to planned choanalysis, to understand the mind. If this movement. Because the prefrontal cortex transformation in the intellectual climate Your Advocate for HEALTH mediates these two functions, it is thought of psychoanalysis is to occur, as I believe to be one of the anatomical substrates of it must, the psychoanalytic institutes them- The Mission of the Wake goal-directed action in long-term planning selves must change from being vocational County Medical Society is to and judgment. Patients with damaged pre- schools — guilds, as it were — to being serve and represent the interests frontal association areas have difficulty in centers of research and scholarship.” of our physicians; to promote achieving realistic goals. As a result, they To examine this problem, the Carn- the health of all people in Wake often achieve little in life, and their behav- egie Foundation commissioned Abraham County; and to uphold the high- ior suggests that their ability to plan and Flexner to study medical education in the est ethical practice in medicine. organize everyday activities is diminished United States. The Flexner Report, which Conscious procedural or episodic memory was completed in 1910, emphasized that Other aspects of WCMS include to unconscious declarative memory (clas- medicine is a science-based profession providing physicians with leader- sic conditioning). and requires a structured education in both ship opportunities, fostering What to Do? What is Next? basic science and its application to clinical volunteerism, promoting health For one thing, we must transcend ter- medicine. To promote a quality education, studies and educating the public. ritorial imperative, and learn to speak each the Flexner Report recommended limit- other’s language, neuroscientists the lan- ing the medical schools in this country to Interested in becoming a Wake guage of psychoanalysts, and psychoana- those that were integral to a university. County Medical Society member? lysts the language of neuroscience. So that As a consequence of this report, many To register online simply go to we can read and understand one another. inadequate schools were closed, and www.wakedocs.org or call We need to identify a charismatic mae- credentialed standards for the training and 919.792.3623. stro, with all inclusive knowledge of the practice of medicine were established. To

WAKE COUNTY PHYSICIAN • JULY 2010 | 47 BookBy Assad ReviewsMeymandi, MD, PhD, DLFAPA Christianity, The First 3000 years part the history of Greek beginnings, Rome and the com- By Diarmaid MacCoullouch ing of the Roman Empire are discussed. 1184 pages In the second part Israel (1000-100 CE is examined. Viking Second Part, “One Church, One Faith, One Lord?”, Je- sus, Paul, Gospel of John, the Book of Revelation, and the Introduction Jewish Revolt and the End of Jerusalem, and finally the Imperial Church, Constantine and Papacy are discussed. aithful readers of the In part three, “Vanishing Futures: East and South (451- book review section of 1500)”, a close examination of Asia and Africa, church Fthis magazine recall the fathers such as Saint Augustine of Hippo, Emergence of review of Paul Johnson’s Book Islam in 620 CE, the Church of China, Mongols and Islam History of Christianity, 600 in Africa are scrutinized. pages long, which we present- Part four, “The unpredictable Rise of Rome” (300- ed previously. In that book, 1300), the making of Latin Christianity, Latin Christen- the author has favored Ref- dom and “The church of All People” are painstakingly ormation, Martin Luther, and dissected. Protestantism. We now have another colossal work, Di- Part five, “The Imperial Faith” (451-1800), the emer- armaid MacCulloch’s 1184 pages, Christianity, The First gence of the new Rome, Orthodoxy and the Russian 3,000 years, in which one detects strong anti-catholic bias. Church are examined. However, undeniably, the book is a landmark in its field, Part six “Western Christianity dismembered” (1300- astonishing in its range, compulsively 1800), Martin Luther, Reformation, readable, full of insight and points of Papal monarchy, Wittenberg and Lu- interest for the general reader. It is ther’s 95 questions/theses, and other not the over-illustrated coffee-table reformers are discussed. type book you might expect. The Part seven, “God in the Dock”, book is scholarly, dense, yet, written (1492-present), the author examines in a readable and engaging style, but the age of enlightenment, Judaism, not as well written as Plato’s Republic skepticism, and Deism, crowning the or Edward Gibbon’s Rise and Fall of section with a more precise dissection the Roman Empire. The impressive and deeper understanding of the roots volume provides an excellent over- of religion in America’s deep south. view of Christianity. It also gives the reader an understand- The book begins with Judaism ing of evangelical fervor and culture and Greek philosophy, giving the wars. background to the remarkable his- The book has 67 illustrations, maps torical phenomenology of Christendom. It is prodigious, and paintings. The text is 1014 pages; the alphabetically thrilling, and gives the reader a master class of a history arranged notes are 89 pages, and 49 pages of index, plus without leaving one’s chair. MacCulloch is to be congrat- introduction, totaling 1185 pages ulated for his accessible handling of so much complex and The title of the book, Christianity, The First Three difficult material. This is a book generous in detail and Thousand Years, is fascinating if not intellectually chal- sound in judgment. It fills the gaps that heretofore existed lenging. We know that Christianity is only 2000 years. in history of religion. Where does the author get 3000 years of Christianity? At the first glance, the reader knows not whether the author is The Content going to address 1000 BC to today or from the beginning of Christianity until one thousand years from now. Well, The book consists of seven parts. The first part is about in this review I will attempt to answer that very ques- “A Millennium of Beginnings (1000 BCE-100CE). In this tion. The title refers to the former, one thousand years

48| JULY 2010 • WAKE COUNTY PHYSICIAN before Christ until today. The author skillfully documents It is comforting to have MacCulloch’s complementary that there was Christianity before Christ. There was a history of the Christian Church. MacDiarmid MacCullouch Socrates whom many historians and theologians including is a better writer than Paul Johnson, and his book is a lively Soren Kierkegaard call Saint Socrates. As a matter of fact and entertaining effort. On the downside, unfortunately, Soren wrote his PhD thesis “On the Concept of Irony with there is a strong anti-Catholic bias throughout his work Continual Reference to Socrates”. Soren was a Socrates which is even more disturbing than Johnson’s pro-Catholic “groupie!” We know that Socrates is exalted because of his stance. In fact, there are several passages in the book that reverential devotion to teaching enlightenment to his young almost give you the impression that MacCulloch must students for which he was accused, tried and executed. have been writing them with a permanent sneer on his MacCullouch’s “alternative” religious history, favoring the face. In summary, if you are English and Protestant and Catholic Church, holds that Christianity really began 4000 believe that the best thing that happened to England was the years ago. He asserts that before Christ there was a Jew- Reformation, then you will probably love this book. If not, ish God, Yahweh, and a Greek God. There were prophets the author’s multiple biases and prejudices will probably such as the Persian prophet Zarathustra and there were grate on you. I consider the book a triumphantly executed other prophets of the Old Testament Bible such as Isaiah, achievement. Ezekiel, Jeremiah, etc., all of whom he calls precursors to Strengths and weaknesses of this very impressive and Christianity which came on the scene 2000 years ago. comprehensive text are many. I have read Edward Gib- MacCulouch devotes considerable space to examine how bon’s “The rise and fall of the Roman Empire” starting Christianity has spread throughout the globe. He follows in my native tongue of Farsi then in French and finally in this spread, starting with the origins of the Hebrew Bible, English, many times. Gibbon’s English syntax is delicious tracing the three main religions of Judaism, Christianity reminding the reader of lyrical poetic writings of Plato in and Islam, filling in often neglected accounts, including Republic. Well, I found the use of language in this book to conversions and confrontations in Africa and Asia. He also be dry and matter of fact. The syntactic enjoyment is lack- explains the crusades. Further, Mr. MacCullouch looks at ing! On the other hand I learned more about the rise and the roots of the faith that galvanized America, charting the fall of the Roman Empire by reading this book, than read- rise of the evangelical movement from its origins in Ger- ing Gibbon’s work. Another weak or prejudicial point is many and England to the southern Plains of America. In that I found references are lacking or outright non-existant. his book, MacCullouch explains that Christianity, one of The Scholarly world knows that the father of skepticism is the world’s great religions, has had an incalculable impact Al Ghazali, (1058-1111), the Persian poet, theologian and on human history. In a systematic manner, the author de- philosopher. Yet, in Part seven of the book, discussion of votes several chapters to the main ideas and personalities of skepticism, there is no mention of either Al Ghazali or Al Christian history. As cited above, other chapters are given Farabi (870-950). to the organization and spirituality of the church; and how Finally, to the members of my family and close friends Christianity has changed politics, sex, and human society. who received this review in advance, I wrote “If you want a The author’s range of discussion spans from Palestine in delicious book, a feast of a book, a sumptuous and excit- the first century to India in the third; from Damascus to ing intellectual and spiritual banquet for you and for your China in the seventh century; and from San Francisco to family, this book is it!—especially if you read it along with Korea in the twentieth. Paul Johnson’s book either back to back or simultane- ously—“ Global History of Christianity Another attraction the book has for me is that it is about the Bible, a book which I truly enjoy and admire. In a In my view this huge volume is the first truly global his- recent interview for a national magazine, the interviewer’s tory of Christianity. This formidable compendium is the last question was: most comprehensive and up to date single volume work in English that presents the development of Christian his- If you were forced to live on a deserted island and were tory differently from any of its predecessors. The author allowed to bring one book, one selection of music, and shows how, after a semblance of unity in its earliest cen- one piece of artwork, what would they be? turies, the Christian church divided during the next 1400 years into three increasingly distanced parts, of which the Book western Church was by no means always the most impor- That book has not been written. It would be a book tant. He observes that at the end of the first eight centuries containing the genomic display of all the biblical charac- of Christian history, Baghdad might have seemed a more ters including Christ. If it is not written by the time I am likely capital for worldwide Christianity than Rome. He assigned to a deserted island, I will take pen and paper to concludes that all in all, Christianity is a landmark in the write it myself. Nobel Laureate, Craig Venter, whose book history of the faith that continues to shape the world [Continued on page 50] WAKE COUNTY PHYSICIAN • JULY 2010 | 49 BOOK REVIEWS continued from page 49 de Vere and Christopher Marlowe, book concentrate on the 19th and early among others, are on the rise. An 20th centuries, when the search for I have reviewed in this space, has given appetite for conspiracy theories, alternative claimants took off. The us a taste of that venture. Since I have combined with a call for “balance” two main characters in his story are not written that book and it is not yet from some sectors of academe and the Delia Bacon, who in 1857 put forward available, I guess I will settle for the rise of the internet have given the thing a Renaissance philosopher Francis Bible, an amazingly comprehensive new life. Respectable Bacon (no relation); and complex book. For example, there audiences turn up to and J.T. Looney, who are 114 references to King Cyrus of listen to lectures on it. in 1920 proposed an Persia alone in the Bible (see Isaiah 45 The controversy is even Elizabethan courtier, where Cyrus the Great is called Mes- taught at university Edward de Vere, 17th siah) level. “What difference Earl of Oxford. Mr. does it make who wrote Shapiro takes them both Music: the plays?” some- seriously, patiently fol- Beethoven’s Ninth Symphony, a one asked the author lowing their lives and piece of transcendent theology, musical wearily. Mr. Shapiro contextualizing their genius, bringing the message of hope, (for whom Shakespeare ideas. It is no accident promise, possibility and redemption was definitely the man) that by the time De- to all humans. I have already devoted thinks it matters a lot, lia Bacon entered the space to dissecting this truly miracu- and by the end of this field, Shakespeare had lous opus magnum book, his readers will become almost a god in Art: think so too. the public imagination. Pieta The authorship con- Both she and Looney troversy turns on two things: snobbery developed their theories in a spirit of Contested Will: Who and the assumption that, in a literal religious doubt, and in the throes of way, you are what you write. How their own personal crises. wrote Shakespeare? could an untutored, untraveled glover’s “Contested Will” is dense with lives son from hickville, the argument goes, and stories and argument. It is also By James Shapiro understand kings and courtiers, affairs entertaining. The quest for the true Simon & Schuster 367 pages of state, philosophy, law, music—let claimant drove people mad. Here are alone the noble art of falconry? Worse secrets and codes, an elaborate cipher- aithful readers of this space recall still, how could the business-minded, breaking machine, an obsession with that we have had several serious property-owning, moneylending ma- graves and crazy adventures to find lost Fdiscourses and discussions about terialist that emerges from the docu- manuscripts. One man spent months anti-Stradordian who from 1630 on mentary scraps, be the same man as the dredging the River Severn. Mr. Sha- have doubted William Shakespeare’s poet of the plays? Many have shaken piro himself turns sleuth, exposing as authenticity. We have defended the their heads at the sheer vulgarity of it fraudulent a piece of evidence long position that there was a man by the all, among them Mark Twain, Helen thought to be genuine—one more hoax name of William Shakespeare who Keller, Henry James, his brother Wil- in the long history of Shakespearean wrote all those poems, plays, tragedies, liam, and Sigmund Freud. wild goose chases. comedies, etc; just as there was a man Mr. Shapiro teases out the cultural The last chapter is a return to san- by the name of Mozart who wrote close prejudices, the historical blind spots, ity: a brilliant defense of the man from to 650 pieces of music and operas. and above all the anachronism inherent Stratford. Piece by piece, Mr. Shapiro Now comes a formidable book written in these questions. No one before the builds the case— the contemporary by James Shapiro. late 18th century had ever asked them, witnesses, the tracks left by printing He follows his award-winning book or thought to read the plays or sonnets houses and theatrical practice, the thou- on William Shakespeare, “1599”, for biographical insights. No one had sand details that show, apart from any- which came out in 2005, with an un- even bothered to work out a chronol- thing else, how unnecessary the whole likely subject: an investigation into the ogy for them. The idea that works of farrago has been. The Shakespeare that old chestnut that Shakespeare wasn’t literature hold personal clues, or that— emerges is both simple and mysteri- the man who wrote the works. more grandly—writing is an expression ous: a man of the theatre, who read, Most mainstream Shakespeareans and exploration of the self, is a rela- observed, listened and remembered. stand aloof from it. But apparently tively recent phenomenon. Beyond that is imagination. In essence, the claims of Francis Bacon, Edward The central chapters of Mr. Shapiro’s that’s what the book is about.

50 | JULY 2010 • WAKE COUNTY PHYSICIAN BOOK REVIEWS continued from page 50 are more likely to be spanked.” ROLE MODEL WORTH Among mothers surveyed in 20 EMULATING continued from back cover Seminal Literature cities when their children were both 3 and 5 years old, nearly half (45.6%) she presented the original manuscript The Long-Term Effects of reported not spanking their 3-year- of “Hail to Teachers’ College” to the Spanking olds in the previous month, 27.9% School of Music. A multiyear study shows spanking reported spanking once or twice that Melba won numerous community kids makes them more aggressive month, and 26.5% reported spanking awards including Johnston County later on. more than twice. As 5-year-olds, the Citizen of the Year and was named a children who had been spanked were “Living Legend” by Johnston County From Wire Services more likely than the non-spanked to Community College. She was a mem- be defiant, demand immediate sat- ber of numerous education and music isfaction of their wants and needs, professional societies, performed pub- isciplining young children is become frustrated easily, have temper lically as a soloist. And often accompa- what parents are supposed to tantrums and lash out physically nying musical groups, choirs, and other Ddo — most moms and dads against other people or animals. performers. have no trouble agreeing with that. The reason for this may be that Notwithstanding her numerous But should the punishment include spanking sets up a loop of bad behav- awards and achievements, Melba is spanking? ior. Corporal punishment instills fear most remembered for her caring spirit As many parents can attest, few dis- rather than understanding. Even if and generous, supportive nature. She ciplinary measures stop a child from children stop tantrums when spanked, recognized the best in others and was misbehaving as quickly as a swift that doesn’t mean they get why they an attentive friend to everyone. She smack or two on the bottom. shouldn’t have been acting up in the was most proud of her two sons, both But in a new study published in first place. What’s more, spanking who were awarded the Morehead Pediatrics, researchers at Tulane Uni- sets a bad example, teaching children Scholarship at the University of North versity provide the strongest evidence that aggressive behavior is a solution Carolina in Chapel Hill. She liked to yet that children’s short-term response to their parents’ problems. tell people, “I have two sons, one a to spanking may make them act out “There is now some nice hard data doctor and one a lawyer.” more in the long run. Of the nearly that can back up clinicians when “The importance of education was 2,500 youngsters in the study, those they share their caution with parents taught me by my mother at an early who were spanked more frequently against using corporal punishment,” age,” says Leon. “She would often get at age 3 were much more likely to be says Dr. Jayne Singer, clinical direc- up with me before school to review my aggressive by age 5. tor of the child and parent program at work or give me an oral exam before The study, led by community- Children’s Hospital Boston, who was my tests.” Gordon relates “mother health-sciences professor Catherine not involved with the Tulane study. taught us organization skills. With Taylor, was the first to control for a The American Academy of Pediat- all she had to do as a single parent, host of issues affecting the mother, rics (AAP) does not endorse spanking schoolteacher, and organist she never such as depression, alcohol and drug under any circumstance. It’s a form missed one of my athletic contests or use, spousal abuse and even whether of punishment that becomes less ef- musical performances.” she considered abortion while preg- fective with repeated use, according Melba Woodruff lived a long, full nant with the child. After controlling to the AAP; it also makes discipline life, residing independently at home for all these factors — each of which more difficult as the child outgrows it. until her last year when she moved can contribute to a child’s aggression Instead of spanking, the AAP into an assisted living facility after a — spanking remained a strong predic- recommends time-outs, which typi- hip fracture. While there, even up to tor of violent behavior. “The odds of cally involve denying the child any her final months, she frequently played a child being more aggressive at age interaction, positive or negative, for a the piano for the other residents. She 5 increased by 50% if he had been specified period of time. These quiet died on March 27, 2008, at age 94. A spanked more than twice in the month moments force children to calm down scholarship has been established in her before the study began,” says Taylor. and think about their emotions rather honor at Johnston Community College. The association remained even after than acting on them reflexively. After her team accounted for varying levels all, the goal of punishment is to get Sons: Leon F. Woodruff, Jr., M.D., of natural aggression in children, children to understand not just that Obstetrican/Gynecologist Raleigh, suggesting, she says, that “it’s not just they did something wrong but also 1976-present and Gordon C. Woodruff, that children who are more aggressive what motivated them to do it. § Lawyer, Smithfield, 1976-present.

WAKE COUNTY PHYSICIAN • JULY 2010 | 51 n MemoryBy Assad Meymandi, MD, PhD, DLFAPA I Solidas et amice, ave atque vale her husband and surviving son, attorney, been translated into numerous languages, Nicholas Stratas. including Japanese and Chinese. Major Byron A. Stratas, MD innovations that transpired under his Age 52 Benson Reid Wilcox, MD leadership as division chief include the Age 77 initiation of heart, lung, and heart-lung transplantation programs, the facilitation Dr. Benson Reid Wilcox, Professor of of the treatment of neonatal congenital Surgery at the University of North Caro- heart diseases, and the establishment of lina at Chapel Hill and Emeritus Chief the Carolina Parent Network. of the UNC Division of Cardiothoracic He was a kind and generous gentleman Surgery, died at his home. who touched and enhanced the lives of Dr. Wilcox, an expert in congenital many. We are grateful for his time with us. heart disease, pediatric cardiac morphol- His former students, patients and friends ogy and pediatric chest disease, has will miss him. worked at the UNC School of Medicine since 1963. Linda Brown Cartner Miller, He is survived by his wife, Patsy Davis, MD and by his four children and their spouses. Ben Wilcox was born May 26, 1932 in Age 54 Charlotte, North Carolina. He graduated from Darlington School in Rome, Georgia Dr. Miller was born Jan. 11, 1956, in Loving father, husband, cherished in 1949, and entered the University of Lenoir, North Carolina, daughter and friend, and son who loved the Lord North Carolina where he received his B.A. second child of John Alexander Cartner deeply, passed away February 8, 2010 in 1953 and M.D. in 1957. Following a Jr. of Lenoir and Anna Gertrude Hardison in Tampa, Florida. He is survived by his surgical residency at Barnes Hospital in Cartner of Pitt County. She was educated wife Caroline Barden Stratas, daughters St. Louis, Missouri, he served as Surgical in the public schools of Greenville, North Ashleyanne Rene and Grace Frances Clinical Associate at the National Heart Carolina, and graduated from Stuart Hall Stratas and son Hughes Byron Stratas. Institute School, Staunton, Virginia, in 1974. Also surviving are his father Dr. Nicholas at the She attended and graduated from North E. Stratas and mother Rene Stratas and Na- Carolina State University in textile engi- his brother Nicholas A. Stratas Byron tional neering in 1978 and was awarded the M.S. was a graduate of the University of North Insti- degree in the same field in 1980 where her Carolina undergraduate school and East tutes thesis was on the knot strengths of sutures. Carolina Medical School. He did his for She was employed in the textile in- ophthalmology training at the Medical Health dustry in Tennessee and North Carolina University of South Carolina. He used his in where she developed a further interest training to help others see clearly, spiritu- Bethes- in medicine from her volunteer efforts ally and physically, in Africa, South and da, as an emergency medical and paramedi- Central America, and the United States. Mary- cal technician. Dr. Miller graduated from Our condolences to his father, our honor- land. In the Brody School of Medicine of East able and honored colleague, Dr, Nicholas 1962 Carolina University in 1999 and where Emanuel Stratas. he re- she performed her resident training in turned to the UNC Department of Surgery psychiatry. She subsequently practiced in Rene Stratas in Chapel Hill as a faculty member of the Beaufort, Martin and Pamlico Counties as Age 80 medical school. In 2008 Dr. Wilcox’s a child psychiatrist. great friend, R. B. Fitch endowed the Lady Rene Stratas, author, playwright, Benson R. Wilcox Distinguished Profes- Charles L. Wells, MD critique, polyglot, intellectual, journal- sorship in Cardiothoracic Surgery. Age 76 ist, mother of the late Dr. Byron Stratas, He co-authored scores of articles and and wife of Nicholas E. Stratas died in co-edited several books, including Surgi- Dr. Charles Lewis Wells of Fayetteville, Raleigh. Our deepest condolences to cal Anatomy of the Heart, which has died peacefully on April 15, 2010.

52 | JULY 2010 • WAKE COUNTY PHYSICIAN He was the son of the late Dr. and Mrs. from the University of California, Berkley While practicing, she belonged to the Lewis E. Wells of Farmville, Virginia. and earned his M.D. from the University of Durham-Orange Medical Society, the Born on August 30, 1933 he was a graduate California, San Francisco. After an intern- North Carolina Medical Society, the of Allegheny College in Pennsylvania and ship at Georgetown University Hospital American Medical Association, and was University of Pittsburgh Medical School. he served two years as a medical officer in a life member of North Carolina Medical He completed his residency in Danville, the United States Army, stationed at Pratt Association. Virginia and then moved to Fayetteville General Hospital, Coral Gables, Florida where he served as pathologist at Cape and at Ft. Myers, Virginia. He completed William Dumas McLester, Fear Valley Medical Center from 1969- a residency and fellowship in orthopedic 1992. He will be missed by his family and surgery at the University of Pennsylvania MD friends. Charles was a patron of the arts before moving in 1953 to Chapel Hill to Age 73 and endowed a violin chair in memory of join the medical faculty at the University of his late wife, Phyllis “Pat” Wells. North Carolina, advancing to Professor of William Dumas McLester died Saturday, Surgery (Orthopedics). May 15, 2010 at his home. Thad H. Pope, MD His long and outstanding career at UNC Dr. McLester was born in Lumberton, Age 78 was recognized by numerous teaching and North Carolina. He was a graduate of the distinguished service awards and election UNC School of Medicine, Class of l1965, received his Doctorate of Philosophy in Thad H. Pope, M.D. of Indianapolis, to the national Medical Honor Society and experimental pathology from UNC in Indiana, formerly of Dunn, North Carolina, to many medical association leadership 1967, and served his country in the US died November 6, 2009. positions. He made numerous contributions Army in Korea. He devoted several years Survivors to the orthopedic literature. to research at UNC, practiced Pathology include his in Fayetteville, then attended the Medi- wife, Anne Elizabeth Marie Roberts, MD cal College of Virginia with a Residency Jacobs Age 93 in Ophthalmology and returned to Fay- Pope of etteville to practice until his retirement in the home; Dr. Elizabeth Marie Roberts, a resident 1999. daughters, of Bahama, died at her home at the age of Dr. McLester had served a President of Marion 93. She was born near Bahama on Novem- the Cumberland County Medical Society Pope ber 21, 1916. and as Chief of Ophthalmology at Cape Gibson and She graduated from WP Mangum High Fear Valley Hospital. husband, of School and Women’s College (now Uni- Indianapo- versity of North Carolina at Greensboro) A personal note: We used to call Bill a lis, Indiana, where she “Paradox,” “Pair of Docs” for his MD Rasalind recently at- and PhD. He loved that title. Bill was one Pope of tended her of the most learned and educated physi- Indianapolis, Indiana, Susan Pope of 70th class cians. He continued his special interest Durham, North Carolina; and a sister, Polly reunion. in the Department of Religion Studies at Pope Clapp and Gordon Clapp of Dunn, She at- UNC until the end. We will miss you Dear North Carolina. tended the Friend. Medical Harry Robert Brashear, Jr., University MD of South Age 89 Carolina and gradu- ated in Harry Robert Brashear Jr., M.D., died 1949 with peace- honorable fully on mention. March She then served as an intern and assistant 28, 2010. resident at Watts Hospital, in the interven- Bob ing years, she worked in hospitals as a was born Medical Technologist, received a Masters in St. degree from the University of Minnesota Louis, and was an instructor one year at Women’s moved College. with his She did the general practice of medicine parents for fifteen years in and around Bahama to Los then worked as a clinic physician at the Angeles, Durham County Health Department until graduated retirement.

WAKE COUNTY PHYSICIAN • JULY 2010 | 53 THE WAKE COUNTY MEDICAL SOCIETY NON-PROFIT 2500 BLUE RIDGE ROAD, SUITE 330 ORG RALEIGH, NC 27607 US POSTAGE PAID Raleigh, NC Permit #2152

Music is a sacred art which brings all men together, like cherubim around a shining throne. It is the most holy of the arts! Holy Music! Richard Strauss (1864-1949) The profession of Medicine is holy. Medi- cine is a calling and a priesthood. It should not be desecrated by business concerns. Assad Meymandi, MD. PhD, DLFAPA (From Dr. William Friday’s television program NC People)

Melba Watson Woodruff, MD: A Role Model Worth Emulating Life-long musician, educator, and friend By Leon F. Woodruff, Jr., MD

elba Watson was born on February 14, 1914, in piano for her church by the time she was a teenager. Kenly, North Carolina. Her parents had cho- While attending East Carolina Teacher’s College (now Msen a name for her, but the doctor attending her East Carolina University) she composed “Hail to Teach- home birth persuaded the family to name her “Melba” ers’ College,” which was the school’s alma mater for in honor of the many years. She also received several graduate degrees famous Austra- from Atlantic Christian College (now Barton College). lian opera diva She served as organist at Selma Baptist Church from Dame Nellie 1938-1987, during which time she wrote and published Melba, who was several compositions for choir. The church honored her performing in with “Melba Woodruff Day” in 1984 and later named its Raleigh that eve- choir and music room for her. ning. This por- As an educator, first in a private kindergarten in her tended Melba’s home and then in the Johnston County public schools, interest and long Melba used her musical talents greatly throughout her career in music. teaching career. She had several songs published in The By age five, she Grade Teacher Magazine, and she compiled a book, Sing was able to play the Basics, which was used in the Follow Through Program the piano and in Johnston County and the state. In 1979, she was award- accompany her ed the Johnston County N.C.A.E. Terry Sanford Award for father’s fiddle outstanding contributions to education in Johnston County. playing. She In 2004, she was honored by East Carolina University for was playing her contributions to the school and her profession where [Continued on page 51]