MOMENTS in MEDICINE at MICHIGAN Nicholas, 6, and Justin, 2

Fourth-year U-M Medical School students Edmond Baker, David Corteville, Karen Fauman, Njeri Thande and Photovoice James Yu were the first to participate in a new and unique elective course offered by the school in 2003. The course, “Using Photovoice to Explore Professional Values, Social Responsibility, and Health Policy Issues,”challenged students to use photography to communicate the significance of issues they felt needed attention. Provided with digital cameras, the students documented subjects related to their chosen topics, which ranged from nursing shortages to the struggles of the uninsured, and presented the images and accompanying information to policy makers — and to faculty and members of the media on January 28 of this year. Fauman’s presentation, “Hospitals and Nutrition: The Mixed Messages We Send,” included images of vending machines which blanket the U-M Hospital and some less-than-healthy options offered in the hospital cafeteria. Most striking of all, Fauman presented juxtaposed images of the sign for Wendy’s (located in the hospital) and the construction site for the new U-M Cardiovascular Center (visible from a window just down the hall from the fast food counter). She used this example of “the cloggers and the un-cloggers” to illustrate the conflicting nutritional messages she believes are experienced by patients and staff. Healthy alternatives were represented by fresh vegetable displays from a local market. —MF Find out more about the Photovoice concept and other Photovoice projects at www.photovoice.com. Visit www.medicineatmichigan.org/magazine to see the students’ complete presentations. Dear Alumni and Friends:

Proven disparities in access to American report requested by Congress, identified disparities in health health care, as well as in health care care as one of the most serious health care problems our coun- outcomes, comprise an important topic try faces today. of discovery and discussion for leading It is also imperative that we prepare today’s students to deliver academic research institutions, and at patient-based health care that takes into account the whole Michigan, researchers are pursuing person, including multicultural factors that can affect patients’ these issues with a sense of urgency. receptiveness and responsiveness to health care. This is one The leadership of the U-M Medical goal of curriculum revisions we implemented this past year. School feels a strong responsibility for This charge means not only training all students to understand improving the health care of the citi- multicultural issues and how they affect health and health care zens of Michigan and the nation. In the delivery; it also means training students from a broad spectrum cover story of this issue of Medicine at of diverse groups. A fundamental fact of medical care is that Michigan, we explore some of the important research U-M many patients are most comfortable receiving care from physi- faculty and staff members are conducting in this complex area cians who share elements of their own background. — research that seeks to reveal and better understand the reasons disparities exist and, ultimately, bring them to an end. As medical training grows costlier each year, all of our students are affected, but especially students without the family Our nation has always been enriched by the differences among resources necessary to support years of medical school and res- us — differences of ethnicity, race, lifestyle and a host of other idency training. Another of this issue’s feature articles, begin- factors. But the components of our multicultural society are ning on page 26, explores the complicated factors and forces not static entities. They are always in flux as immigration, pop- that have come to bear on medical ulation shifts, and the increasingly education costs over recent decades, global nature of society in general outpacing inflation and other eco- bring fluid and constant change to As a welcoming nation that prides nomic indicators. The issues of edu- the face of America. itself on the democratic fundamentals cational costs and student indebt- For example, the U.S. Census of freedom, liberty and justice for all, edness present us with a profound Bureau projects that our Hispanic our system of health care delivery challenge to do all we can to pre- and Asian populations will triple serve access to the study of medicine over the next 50 years; non- falls far short of meeting the needs for all the bright and talented indi- Hispanic whites may drop to half of all its citizens. viduals who wish to pursue it. of the total U.S. population. The This challenge is why scholarship nation’s total population is pro- support represents a top priority for the U-M Medical School jected to increase by 49 percent by 2050, in contrast to most within the University’s new fund-raising campaign, The European countries whose populations are expected to decline. Michigan Difference. The largest campaign ever undertaken by The social and cultural ramifications of these and other demo- a public university in America, The Michigan Difference will graphic shifts will, in turn, dramatically affect the delivery of help provide the means for ensuring the enduring quality and health care to many. accessibility of a Michigan education, as well as the margin of As a welcoming nation that prides itself on the democratic fun- excellence that distinguishes a good university from a truly damentals of freedom, liberty and justice for all, our system of great one. As stewards of this remarkable school and its future, health care delivery falls far short of meeting the needs of all we can strive for nothing less. its citizens. All groups do not receive the same care, nor do Sincerely, they experience the same treatment outcomes. All groups do not enjoy the same access to care. The disparities are biological as well as social in origin: genetic predisposition toward certain diseases and conditions places various groups at higher risk, and that higher risk often occurs within groups that are Allen S. Lichter (M.D. 1972) underserved or uninsured. The Institute of Medicine, in a 2002 Dean Letters

center has recently opened, and fetal in the card room of the old Nu Sigma Nu interventions are on the horizon. The fel- fraternity house at 1015 East Huron lowship training program, which cur- prominently shows the back of my head. rently has 13 fellows (soon to be 15), is This will give you an idea of what I look one of the largest in the country. like. Gil Ross, also of the Class of 1954, is on the left, so ours was the youngest The MCHC is proud to be a part of the class appearing in the picture. Michigan Cardiovascular Center and feels that its presence makes the center a Barry and accompanying characters more formidable force in the battle made the Nu Sig house a special place, against heart disease. laugh after laugh. To give you an idea … three of them went to undergraduate Peter Fischbach, M.D. (Residency 1999) rushing and introduced themselves as Assistant Professor Frank Breech, Austin Flint, and a third Director, Electrophysiology Laboratory medical term now lost to my memory. Division of Pediatric Cardiology They wore gravy-stained coats and ties and complimented the fraternity brothers on the beautiful drapes. Carl Rauch, also Given the sheer volume of outstanding in the picture, was an older, married initiatives in research, education and WW II veteran who looked like a stu- clinical care in the great institution that dent’s father more than a student. I smile is the U-M Health System, we often must whenever I look at that LIFE photo. Caring for the Hearts make hard choices about of Children what we can feature at any given time. Readers I applaud Sally Pobojewski’s story on the interested in the open- new cardiovascular center (fall 2003). heart surgery that takes This clinical and research enterprise is place within the Mich- something we can, as a university, be very igan Congenital Heart proud of. Clearly a single article cannot Center may enjoy read- touch on all of the accomplishments of ing about Edward Bove, the cardiovascular program. One area M.D. (Residencies 1977, that is frequently overlooked is the Michi- 1979), one of the cen- gan Congenital Heart Center (MCHC) at ter’s three cardiac sur- C.S. Mott Children’s Hospital. geons, whose work was The MCHC has established an interna- featured in the summer tional reputation for excellence in the care of infants and children with heart disease, as well as young adults who have survived with congenital heart disease. Congenital heart disease is the most com- The MCHC is proud to be a part of the Michigan mon form of birth defect, occurring in Cardiovascular Center and feels that its presence eight out of every 1,000 live births. The makes the center a more formidable force in the MCHC is currently the largest congenital battle against heart disease. heart center in the Midwest and performs the second most open-heart surgeries for congenital heart disease in the country. Innovations from MCHC physician- 2000 issue of Medicine at Michigan, The articles about Ralph Straffon (such a researchers in the fields of interventional available on the Web at timely piece, given his passing soon after) catheterization, echocardiography, elec- www.medicineatmichigan.org/magazine. and Tom Peterson (pages 50 and 49, trophysiology, post-operative patient respectively) caused me to remember a management and heart transplantation third member of the distinguished Class have helped drive the field forward. Memories of Life at Michigan of 1953 who played football while a Additionally, basic science investigations freshman in medical school: Bill Bartlett. The fall 2003 issue of Medicine at Mich- He was second-string quarterback. Bill is focused on vascular biology and cardiac igan sure brought back some memories. development are helping to uncover the now a retired pediatrician in Madison, mysteries of the development of congeni- The LIFE magazine photo (page 48) of Wisconsin. Like Tom, Bill has played an tal heart disease. A new fetal diagnostic Barry Breakey, Tom Peterson and friends important role in sports medicine, in

4 Spring/Summer 2004 magazine © Time Inc. © magazine In the next ISSUE of Medicine at Michigan: The Medical Genetics Division: where the genetics revolution meets the patient … Taubman Photo: Alfred Eisenstaedt/ LIFE Medical Library in the 21st century … clinical trials at Michigan seek new and better paths to treatment of disease. Also: The annual White Coat Ceremony welcomes the Class of 2008.

Medical students play cards at the Nu Sigma Nu fraternity house in 1950.

Madison and throughout Wisconsin. He Morley’s mentor, Norman Miller, deliv- was probably too deeply anesthetized and organized high school sports medical ered my twin sister and me on June 9, a few minutes later I couldn’t get a pulse programs in Madison and worked hard 1935. George Morley delivered my son or a blood pressure. I wasn’t sure what to to get the legislature to pass a law that Douglas on April 7, 1958, and Douglas do (or worse, what I had done to the allows M.D.s to serve at high school eventually trained under him in ob/gyn. patient). I announced the problem to Dr. games without fear of lawsuits. Like Now Douglas has a gynecology practice Morley and asked for the circulator to Ralph and Tom, he is a wonderful guy — in Chelsea, Michigan. Michigan, Miller send for my attending, stat. Dr. Morley as well as my sons’ pediatrician. Also and Morley hold an important place in immediately stopped, put his hand into from the Class of 1954, Ozzie Clark our family’s history. the cavity, then calmly said, “Relax, Peggy, I feel an aortic pulse.” (Residency 1960) played with Ralph on Charlotte H. Portz the 1950 team as starting end. So, back Horton, Michigan After the attending came in, turned then, Nu Sigma Nu included four mem- down the halothane and disappeared bers of the U-M football team studying again (with me internally vowing I at the medical school. would never ever consider being an anes- William L. Kopp Thank you for the profile of George thesiologist), dear Dr. Morley, sensing (M.D. 1954, Residency 1962) Morley and his career. I truly love the my angst, kindly said, “Sit down and rest Jackson, Mississippi man even though I haven’t seen him in a minute and then we’ll proceed,” and over 30 years. It is nice to see that he is stopped his operation briefly and chatted well and getting the adulation he deserves. with the resident while I regained my bearings. Needless to say Dr. Morley has Nu Sigma Nu, founded in 1881, is the always occupied a very warm, fuzzy nation’s oldest medical fraternity. Cur- Dr. Morley has always place in my heart. rently located on Geddes Avenue across And, oh, yes: I somehow ended up an from Nichols Arboretum, the fraternity’s occupied a very warm, anesthesiologist. house accommodates 32 graduate stu- fuzzy place in my heart. dents who today also include students Margaret (Peggy) Zanotti Harrington from the schools of pharmacy, law, busi- (M.D. 1971, Residency 1972) ness, engineering and social work. When I was an upper-class medical student rotating through anesthesia I was Medicine at Michigan Mailings Medicine at Michigan given an “easy” case — a healthy young A few of our readers have been receiving multiple with Morley woman having a laparotomy, for which copies of Medicine at Michigan. Our apologies. Our Dr. Morley was the surgeon. In those mailing list is pulled from a variety of sources, and I always enjoy reading your excellent days we monitored only with temporal while we try to eliminate duplications, we ask that you publication and particularly enjoyed the pulses and blood pressure, and used offer any extra copies to those who may share your interest in medical research, education and patient fall 2003 edition and the excellent article halothane. After the induction the attend- care at the University of Michigan Health System. on George Morley, to which I can add ing dialed in a percentage of halothane the following personal notes. and left to cover other rooms. The patient

Medicine at Michigan 5 Above the Huron

Mapping the Human Proteome MICHIGAN PIONEERS GIL OMENN, PHIL ANDREWS AND SAM HANASH EXPLORE THE CHALLENGING WORLD OF HUMAN PROTEINS

une 26, 2000, was a big day for DNA. At a press conference in Washington, D.C., sci- Jentists announced the long-awaited first draft of the genetic code for all 30,000-plus genes in the human body. As reporters strug- Vloet Photo: Martin gled to explain the inner workings of DNA to the general public, champagne corks started popping in genetics laboratories around the world. But even as geneticists celebrated the culmination of years of hard work, three scientists in the U-M Medical School were already thinking ahead to the next step: how to map the human proteome. They knew one thing for sure: it wouldn’t be easy. U-M scientists Gil Omenn, M.D., Ph.D., Phil Andrews, Ph.D., and Sam Hanash, M.D. (Ph.D. 1976), are pioneers in proteomics — an important emerging field in the life sciences. While geneticists study the genes in a cell or organ- ism, proteomics researchers concentrate on proteins — complex molecules that do the work of living cells. To understand the function of a gene, scientists must identify the proteins pro- duced when that gene is active and figure out Gil Omenn and Sam Hanash what those proteins do in the cell. When scientists say a gene is active, they mean that a copy of its DNA is being transferred from the cell’s nucleus to the ribosome, the cell’s pro- “The proteome’s complexity goes to the heart tein production plant. of why proteins are so important, because But the path from gene to protein is seldom direct. Unlike genes, which are stored perma- they are responsive to and mediate changes nently on DNA in the cell’s nucleus, proteins are ephemeral. They come and they go, associated with health and disease.” responding to genetic instructions or biochem- —Gil Omenn ical signals from other cells or proteins. To make it even more complicated, most genes can produce several variants of the same pro- (HUPO). “The human proteome contains hun- and, shortly afterward, a group decision to tein. And interactions with other proteins and dreds of thousands of constantly changing pro- focus on proteins in three types of human tis- signaling molecules can radically change a teins. The proteome’s complexity goes to the sue — blood plasma, liver and the brain. protein’s structure and function. heart of why proteins are so important, because they are responsive to and mediate changes The Plasma Proteome Project was chosen as “We’re tracking a moving target,”says Omenn, a associated with health and disease.” the first HUPO initiative, because blood is the professor of internal medicine and human most accessible human tissue. It’s easy to genetics in the U-M Medical School and of pub- HUPO began in April 2001, when Omenn and obtain blood samples with informed consent lic health in the U-M School of Public Health. Hanash, a U-M professor of pediatrics, met from volunteers or use stored samples from Omenn directs the Human Plasma Proteome with 30 scientists and policy-makers from sev- blood banks. “Since blood bathes all cells and Project — one of several initiatives organized by eral countries to work out a strategy for tackling organs in the body, it contains proteins which an international collaboration of scientists that the challenge of the human proteome. That could be biomarkers of changes associated make up the Human Proteome Organization meeting led to the formation of HUPO, with with specific diseases,” Omenn says. Hanash agreeing to serve as its first president,

6 Spring/Summer 2004 The second major initiative focuses on pro- Detecting trace amounts of a protein — which While researchers in the U-M Proteomics teins in the human liver. “The liver plays a role may exist in cells only for fractions of a second Consortium focus on new technologies, in many different diseases,” Hanash says. — requires extremely sensitive and expensive HUPO’s scientists are concentrating on their “There are major public health problems equipment to rapidly separate, analyze and immediate goal — developing scientifically related to liver disease, especially in China identify all protein components in a cell sam- valid methods for the preparation and analysis where hepatitis is widespread and primary ple, according to Andrews.This generates mas- of proteins in tissue specimens. Currently, sci- cancers of the liver are a leading cause of sive amounts of data, which must be entists have many different ways to separate death. Chinese scientists are taking the lead processed and stored in powerful, high-speed and identify individual proteins in a mixed on this initiative with funding from the Chinese computers.And, just to keep things interesting, sample, but no one knows which way is most government.”Scientists in Germany are leading the technology is moving so fast, it is usually accurate, reliable and cost-effective. outdated within two to three years. U-M scientists emphasize that much basic research remains to be done before proteomics can live up to its potential in medicine. But that potential could make all the hard work worthwhile. Photo: Martin Vloet Photo: Martin “Right now, if you want to diagnose breast cancer, you use mammography,” Hanash says. “If your doctor suspects lung cancer, you get a CT scan. For colon cancer, you need a colonoscopy. We’re talking about a blood test with screening panels for all the common types of cancer.” “When I was in medical school 40 years ago, only 15 percent of lung cancer patients were still alive five years after they were diagnosed,” Omenn says. “Here we are in 2004 and the survival rate is exactly the same. It’s even worse for patients with pancreatic cancer. If we had biomarkers for these cancers, we would have a chance to diagnose them at a stage where a surgeon could remove them or they could be targeted with new drugs. That would be a wonderful legacy.” —SFP

Phil Andrews

the third HUPO initiative, which concentrates In 2003, Andrews received an $11.9-million on proteins in the human brain. grant from the National Center for Research Resources, a branch of Back in 1998, when the field of proteomics Medical School the National Institutes of Health, was in its infancy,Andrews, a U-M professor of making U-M a national leader Advances to 7th in Nation biological chemistry, received a $750,000 for research and develop- pilot grant from the medical school to create ment on advanced pro- The University of Michigan Medical School now ranks No. 7 the first U-M proteomics center. Andrews used teomics technologies. among the nation’s 125 accredited medical schools, according this initial investment to build the basic infra- to the annual “Best Graduate Schools” rankings released structure required to receive a $13.7-million “This additional funding in April 2004 by U.S. News & World Report. grant in 2001 from the Michigan Life Sciences made it possible to Corridor to provide proteomics technology and expand our program in The school’s seventh-place finish continues a steady advance expertise to industry and academic investiga- emerging proteomics in rankings from 12th in 2000, to 10th in 2001 and 8th the tors throughout the state. technologies,” Andrews last two years. Only one other medical school affiliated with says. “For proteomics a public university placed higher than U-M. “Proteomics is important to researchers in to reach its full poten- many specialties, but especially in biomedical U.S. News & World Report also placed the medical school tial, we need to develop research,” Andrews says. “Genetic differences in the Top 10 for four medical specialties: more sensitive techniques between people are reflected in the different family medicine (5), geriatrics (5), internal for use with smaller tissue mix of proteins in their cells. Proteins show how medicine (8) and women’s health (5). specimens, new mapping cells respond to pathogens or chemicals, and technologies, and improved See complete medical school rankings how cells change as they age. Proteins also software and computational information at: www.usnews.com serve as traffic cops directing complex bio- tools.” chemical signaling pathways in the body.” —SFP

Medicine at Michigan 7 Scans Find Urological Problems Other Tests Often Miss

new procedure requiring one 15-minute Ascan with a modern computed tomography (CT) machine may be all it takes to find tiny can-

cers, stones and other problems in the kidneys, Vloet Photo: Martin bladders and urinary tracts of high-risk patients — saving them from additional tests and the risks of delayed detection and treatment. Called multi-detector CT urography, or MDCTU, the procedure uses modern CT machines found in many large hospitals. MDCTU can spot problems in the tiny vessels of the body’s urine collection system, as well as detect bladder cancer, kidney and bladder stones, and kidney cysts and cancers. Radiologists in the U-M Health System say that MDCTU is a better option for high-risk patients than the traditional intravenous pyelogram (IVP) or urography (IVU). Often performed on patients with symptoms such as blood in their urine or problems with urination, X-ray exams using IVP or IVU are far less accurate and have high rates of false-positive or false-negative results. “Our experiences with MDCTU in patients with prior bladder and urinary tract cancers have Richard Cohan and Elaine Caoili convinced us that it is as good as IVP — and probably far better — for detecting all abnor- kidneys and urinary tract, allowing the CT scan- malities of the urinary system,”says Richard H. “We’re able to see ner to make detailed images of the patient’s Cohan, M.D., a professor of radiology in the entire urinary system in “slices” less than one U-M Medical School. tumors as small as millimeter thick. Computers combine them to “We’re able to see tumors as small as two- to make cross sections and three-dimensional three-millimeters, in areas where other exams two- to three- images, which can be viewed in different ways can’t go, and we’ve been able to save patients millimeters, in areas to spot problems. the delay and aggravation of coming back for Says Caoili,“We hope that MDCTU will become repeated diagnostic scans and procedures,” where other exams the first and only imaging test used for evalu- adds Elaine Caoili (M.D. 1993), a clinical ating high-risk patients with urinary system assistant professor of radiology. can’t go … ” symptoms, and that it will soon allow patients everywhere to get accurate early diagnoses Working closely with physicians in the —Elaine Caoili Michigan Urology Center, U-M radiologists that might improve their clinical outcomes.” have spent four years perfecting MDCTU tech- —KG nology. With more than 1,000 patients MDCTU scans use super-fast helical CT scan- scanned, they are one of the most experienced ners, which pass X-rays through the patient’s Read an expanded version of the story: MDCTU teams in the nation. Through presenta- body from many angles and collect them on www.med.umich.edu/opm/newspage/ tions at medical meetings, U-M radiologists the other side using multiple detectors sur- 2003/ctscans.htm are sharing their methods and encouraging rounding the patient. During the scan, the path colleagues to adopt the new technique, which of the X-rays is slightly altered by a contrast More information on cancers of the kidney, they say is extremely sensitive, very accurate dye given intravenously to the patient. The dye bladder and urinary tract: and relatively easy to learn. works its way through the bloodstream into the www.cancer.med.umich.edu/learn/leadis.htm

8 Spring/Summer 2004 Physicians Report More Parents Questioning Vaccines Causes of Yeast Infection

Challenged by Study Photo: Marcia Ledford

omen may be able to blame their husbands or boyfriends for Wheadaches, tears and stress, but contrary to popular belief, they can’t blame them for common, recurrent yeast infections. According to a new U-M study, certain sexual activities are the real culprits. “Many physicians, and many women, believe that women get recurrent yeast infections because their partner passes the yeast back to them during intercourse,”says Barbara Reed, M.D., a professor of family medicine in the U-M Medical School. “Our study refutes that belief.” The study, which was published in the December 2003 issue of Journal of Women’s Health, involved 148 women with confirmed Candida vulvo- vaginitis and 78 of their male sexual partners. U-M researchers found many factors were unrelated to recurrent infection. These included the presence of Candida bacteria in either the man or woman, number of sexual partners, frequency of inter- Photo: Gregory Fox Photo: Gregory course and the woman’s age at first Gary Freed intercourse. Receiving oral sex was the most common factor associated with recurrent infection. ediatricians and family physicians on the “front lines” of the Research suggests that Candida Pnation’s childhood vaccine delivery system are being asked more exists in some women in balance questions by parents about the safety and effectiveness of routine with other organisms and immune childhood vaccinations. components in the vaginal area, According to a recent national survey, 69 percent of 743 physicians and that saliva may disrupt the bal- reported a substantial increase in the number of parents’ questions ance, leading to symptoms of yeast or concerns about childhood vaccines. Ninety-three percent of infection. pediatricians and 60 percent of family physicians responding to The study was funded by the the survey reported that a parent had refused a vaccination for his National Institute of Allergy and or her child. Infectious Diseases. Other U-M Many of the concerns reported in the survey involved known short- researchers included Philip Zazove, Barbara Reed term effects from vaccines, such as pain and fever. But other con- M.D., clinical professor of family medicine; Daniel W. Gorenflo, Ph.D., cerns were about unproven, or disproved, allegations that research investigator in family medicine; and Carl L. Pierson (Ph.D. childhood vaccines can cause everything from autism to diabetes. 1972), assistant professor of microbiology in pathology. The study was directed by Gary Freed, M.D., M.P.H.,the Percy and —NF Mary Murphy Professor of Pediatrics and Child Health Delivery in the U-M Medical School, and his colleagues in the U-M Health System’s Child Health Evaluation and Research Unit. Read the expanded version of the story: www.med.umich.edu/opm/newspage/2003/yeastinfections.htm “It’s important for physicians to respond with sensitivity to parents’ concerns about vaccine safety and be prepared to provide up-to- For patient information on yeast infections: date, accurate information about side effects and complications, www.med.umich.edu/1libr/aha/aha_candidia_crs.htm as well as the benefits of vaccination,” says Freed. —KG For an expanded version of this story: www.med.umich.edu/opm/newspage/2003/vaccineconcerns.htm U-M Health System’s vaccine safety resource page for parents: www.med.umich.edu/opm/newspage/2003/vaccinefacts.htm

Medicine at Michigan 9 The Force Surely U-M Medical School Miller, Photo: Richard A. Was with Him oda, the world’s oldest mouse, celebrated his fourth birthday Yon April 10 in a quiet, pathogen-free rest home for geriatric mice belonging to Richard A. Miller, M.D., Ph.D., a professor of pathology in the Geriatrics Center of the University of Michigan Medical School. At 1,460 days old, Yoda’s longevity equates to about 136 human years. The lifespan of the average laboratory mouse is slightly over two years. Sadly, 12 days beyond his remarkable milestone, Yoda, a dwarf mouse, died peacefully with his cage mate, Princess Leia, at his side. Miller is an expert on the genetics and cell biology of aging. His geriatric mice are providing important clues about how genes and hormones affect the rate of human aging and risks of disease late in life. His current work focuses on identifying defects Yoda contemplates a model of a fruit fly, the other major genetic model used in research in T cells from aged mice that interfere with a normal immune on aging. response, and finding ways to reverse those defects. —SFP

Mott Family Network: C.S. Mott Children’s Hospital is the first chil- Computer connections for every child dren’s hospital in the Midwest to provide a computer network connection and computers at every bedside. Patients and their families can access the Mott Family Network at no charge using either a donated Mott computer or the patient’s

Photo: Martin Vloet Photo: Martin personal computer. Patients can use the network to access the Internet, e-mail, DVD movies and games. Online educational programs and software are available to help patients keep up with their schoolwork. The network is user-name and password protected to ensure secure and controlled access to online materials. The project was made possible with funding from the annual C.S. Mott Golf Classic. In addition, several computer corporations donated maintenance support, software and hardware. Nearly 70 U-M employees volun- teered hundreds of off-shift hours to design, wire, build and install the computers. —KH Read an expanded version of this story: Patient Adrian Leach plays a flight simulation game on a Mott Family Network computer while recovering from a recent procedure just days before his 17th birthday. Adrian, who lives in Maine, has been a Mott patient most of www.med.umich.edu/mott/ his life, flying in for care when necessary, and uses the bedside computers to keep up with his homework as well newsletter/spring04/p14.html as keep in touch with friends and family back home.

10 Spring/Summer 2004 Inflammation Linked to Deep Vein Thromboses

Thomas Wakefield is

Photo: Martin Vloet Photo: Martin trying to figure out exactly what happens inside veins when a blood clot develops. In a recent research study with genetically engineered mice, he and colleague Daniel Myers discovered that inflammatory molecules and immune system cells play a major role in the process.

Daniel Myers and Thomas Wakefield

eep vein thromboses, or DVTs, are a serious health problem, espe- of mice lacked the gene required to produce P-selectin. The mice were Dcially in the elderly. When blood clots form in deep leg veins, they surgically treated to induce thrombosis in the major vein carrying blood can permanently damage the venous system or even be fatal, if a clot from the lower body back to the heart. travels to the lungs. Myers and Wakefield found that mice with the highest levels of P-selectin Until recently, deep vein thromboses were thought to be solely a blood in their blood developed the largest venous blood clots and had more or vascular disorder. Now, U-M Medical School scientists have discov- inflammatory cells in their vein walls. Blood from mice with high levels of ered intriguing new evidence to support the idea that the development P-selectin also contained microparticles — small fragments of cell mem- of blood clots in veins — just like blocked arteries in atherosclerosis — is brane from degraded cells, which accelerate the clot-forming process. an inflammatory process. Wakefield says the ultimate goal of his research is finding new ways to “When a blood clot develops in superficial veins of the leg — a condition inhibit clot formation in his patients by using an anti-inflammatory called phlebitis — the redness and swelling associated with inflammation approach, instead of relying on anticoagulants to treat DVT after it devel- are visible,”says Thomas W. Wakefield, M.D., a professor of surgery in the ops. “All current blood-thinning medications can cause serious bleeding medical school and a vascular surgeon in the U-M Cardiovascular Center. problems in patients, so there’s a need for new treatment options,” he “When a clot forms deep inside the leg, these signs are hidden, so physi- says. “The more we understand about the mechanism of DVT formation, cians have rarely associated DVTs with inflammation.” the better our chances of finding safer ways to treat it.” Working with Daniel D. Myers, D.V.M., an assistant professor of vascular The study was funded by the National Institutes of Health and Wyeth surgery and animal medicine in the medical school, Wakefield is trying Research of Cambridge, Massachusetts. to figure out exactly what happens inside veins when a blood clot devel- —SFP ops. In a recent research study with genetically engineered mice, he and Myers discovered that inflammatory molecules and immune system cells play a major role in the process. Read an expanded version of this story: www.med.umich.edu/opm/newspage/2003/venous.htm One strain of mice used in the study had a genetic mutation, which caused them to have abnormally high levels of a pro-inflammatory mol- For more information on deep vein thromboses: ecule called P-selectin circulating in their blood plasma. A second group www.med.umich.edu/1libr/aha/aha_dvthromb_sha.htm

Medicine at Michigan 11 Zapping Faulty Heartbeats TECHNIQUE BRINGS HOPE – AND DRAMATIC RESULTS – TO PATIENTS WITH ATRIAL FIBRILLATION

n innovative procedure, tested and per- Photo: Martin Vloet Afected at the U-M Cardiovascular Center, completely cures the overwhelming majority of patients with atrial fibrillation — the most common form of irregular heartbeat. Called radiofrequency catheter ablation, it delivers tiny bursts of intense energy that destroy areas of disorganized electrical activity in heart muscle and connecting veins, while sparing nearby tissue. In recent presentations at the American Heart Association’s Scientific Sessions 2003 meeting and an article published in Circulation, U-M cardiologists reported that more than 85 percent of U-M Health System patients with intermittent atrial fibrillation were cured after a single session of catheter ablation. After the procedure, these patients no longer needed medications to stabilize their heartbeat and cut their risk of clotting and strokes. Compli- cation rates were extremely low. “We have treated more than 500 patients in the last three years and have achieved very Fred Morady and Hakan Oral favorable results,”says cardiologist Hakan Oral, M.D., an assistant professor of internal medicine in the U-M Medical School. “It’s still a technically challenging procedure, but we hope to continue to simplify and improve it, and train The U-M Health System is one of only a handful in others to perform it.” the world where catheter ablation is performed. More than 2.2 million Americans have atrial fibrillation. In addition to causing heart palpi- tations, fatigue and pain that can be debilitating, the condition greatly increases the risk of importance in the treatment of atrial fibrilla- research team include Christoph Scharf, M.D., stroke and can cause heart enlargement. tion. Recent developments, including new Aman Chugh, M.D., Burr Hall, M.D., Peter ablation strategies and the ability to make Cheung, M.D., Eric Good, D.O., Mehmet Ozaydin, The U-M Health System is one of only a hand- three-dimensional digital maps of the heart M.D., Srikar Veerareddy, M.D., and Frank Pelosi ful in the world where catheter ablation is per- and its electrical signals, have enhanced the Jr., M.D. (Residency 1999). formed. In addition to treating patients with procedure, according to Oral. Morady points to paroxysmal atrial fibrillation, U-M cardiologists increased success at ablating areas in the left —KG treat patients with a much more debilitating atrium wall, rather than just the juncture Read an expanded version: and harder-to-treat form of the disorder called between the pulmonary veins and the left www.med.umich.edu/opm/newspage/2003/ persistent AF. atrium. atrialfibrillation.htm Oral and Fred Morady, M.D., a professor of The U-M team’s research is funded by the Ellen For patient information on atrial fibrillation: internal medicine in the U-M Medical School, and Robert Thompson Atrial Fibrillation www.med.umich.edu/1libr/aha/ hope to make more cardiologists and patients Research Fund. Other members of the U-M aha_atfibril_car.htm aware of radiofrequency catheter ablation’s Cardiovascular Center’s atrial fibrillation

12 Spring/Summer 2004 Photo: J. Adrian Wylie

Chris Hall, from Wellington, Ohio, who received his Ph.D. from the University of Texas– M.D. Anderson Cancer Center, is a postdoctoral fellow at the U-M Comprehensive Cancer Center, where he researches prostate cancer metastasis. In addition to his postdoctoral work, he is a husband and father of two.

Chris Hall with wife, Catherine, and sons MOMENTS IN MEDICINE AT MICHIGAN Nicholas, 6, and Justin, 2

“Postdocs are sort of the driving force of the lab. We have the research experience to take a novel idea, one of our own or one based on the focus of the laboratory, all the way from inception to publication. At the same time, we’re developing our careers — learning from the principal investigator how to be independent researchers ourselves. “The postdoctoral fellowship is considered the best time of your life, because you’re not in school and you’re not yet a principal investigator. It’s protected time. You need to be really excited about what you’re doing so you can come in every day and drive the research. But there is also a general angst among postdoc fellows. “We’re spending longer periods of our careers as postdocs because it’s become difficult to transition into faculty positions — the positions that were predicted just 10 years ago aren’t there. This is creating a bottleneck at the postdoctoral training level. “There can also be a sense of isolation as a fellow. It’s possible to work 24 hours a day, seven days a week, and never see another person. An individual needs social as well as academic roundedness to succeed. Networking is very important for maintaining that balance. This is why I helped found the University of Michigan Postdoctoral Association, whose mission is to foster scientific collaboration. “Family is a big issue for most postdocs. I’ve decided to be equal part dad and researcher. I’m here nine hours a day, and I’m as productive as I can be during that time … because in the evening I pick up my children from daycare and give my full attention to being a dad.” Interview by Ryan Sherriff

Those interested in learning more about the U-M Postdoctoral Association are invited to visit the association’s Web site at www.med.umich.edu/pibs/postdoc.

Medicine at Michigan 13 HEALTH CARE IN AMERICA IS NOT THE SAME FOR EVERYONE, Unequal

TREATMENTby David Wilkins

As U.S. medicine becomes patient-based and patient populations grow more diverse – culturally, ethnically, racially, and in terms of faith, lifestyle and demographics – the national institution that is medicine in America must unravel and address serious disparities in health care treatment and delivery that the Institute of Medicine has decried as one of the nation’s “most serious health care problems.”

14 Spring/Summer 2004 Illustration: Shayne Davidson

AND U-M RESEARCHERS ARE ASKING WHY

hile diabetes is virtually Why? The question is compelling, the ably as long as statistics have been gath- non-existent among Arab answers complex and often unclear. ered on these issues,” says David Gordon, nomads in the Egyptian M.D., professor of pathology and associ- The tangled web of contributing forces to desert, 40 percent of Arab ate dean for diversity and career develop- disparities in disease prevalence, health Wimmigrants in southeast Michigan are ment. “Some gaps have lessened over the care and medical outcomes includes dis- diabetic or glucose intolerant. African- crimination, acculturation, lifestyle and years with improvements in health care, Americans seeking medical help for behavior, as well as limited access to and but most remain and some may even be chronic pain report more severe symp- utilization of health care, variations in widening with time. toms — greater pain intensity and sever- diagnosis and treatment, exposure to ity, depression, disability and post- “Interestingly, medical conditions with environmental health risks, genetic pre- traumatic stress disorder — than white the greatest disparities — including car- disposition and socio-economic factors. patients do. Native American women are diovascular disease, obesity and related less likely than women from other racial “Disparities in the health of — and in diseases, and prostate and breast cancer and ethnic minority groups to contract health care delivery to — different racial, — are the major causes of death for the breast cancer, but more likely to die ethnic, and socio-economic populations entire U.S. population,” he says. “So the within five years when it is detected. have existed for at least decades and prob- opportunity is clear. Any insights on

Medicine at Michigan 15 how to improve health status and health • Minorities receive lower quality and them, U-M researchers say — by top- care delivery in these areas should lead less intensive health care and diagnos- pling barriers to care, rooting out bias, directly to improvements in the overall tic services than whites across a wide correcting communication lapses between health of our country.” range of medical conditions and treat- doctors and patients, identifying varia- ment regimens. tions in treatment, understanding biolog- The Institute of Medicine’s groundbreak- ical differences, and targeting unhealthy ing 2002 report, Unequal Treatment: While the important work of document- patient behavior with carefully calibrated Confronting Racial and Ethnic Dis- ing disparities continues, medical education. parities in Healthcare, concluded that: researchers, including dozens at U-M, “We need to understand the underlying are digging deeper. Their goal is to • The most significant barriers to equi- reasons for these disparities in order to understand why disparities occur. Why, table care are factors which affect design interventions that are person- after suffering a stroke, are Mexican- access to treatment — differences in specific or group-specific,” says Carmen Americans less likely than non-Hispanic income, lack of health insurance or R. Green, M.D. (Residency 1992), a U-M whites to take blood-thinning drugs that reliance on publicly funded insurance, anesthesiology professor who studies can reduce the risk of another stroke? high co-payments, inadequate trans- physician decision-making and disparities Why are African-Americans four to five portation, and a scarcity of nearby in pain management. “In doing so, we can times more likely than other groups to health care services. improve the quality of life for all people.” develop kidney disease? Why are there • When limited access to care is often treatment delays when a woman Treating patients equitably, then, does removed from the equation, however, suffers a stroke? not mean treating them identically. It significant disparities in morbidity and means, in fact, accounting for and Understanding why these differences mortality persist — suggesting bias addressing the differences that create exist is the first step toward eliminating and stereotyping play a large role. disparities — the tendency to under-prescribe pain medication for minorities, women and the elderly, for example, or the way Westernized lifestyles and genetic predisposition combine to make

Photo: Martin Vloet Photo: Martin Arab immigrants susceptible to diabetes.

s a fellow in the U-M Multi- disciplinary Pain Center in the early 1990s, Green wondered why some patients coped bet- Ater than others with unrelenting pain. She also noted variations in the care they received. “I saw differences in treatments “Disparities have existed probably as long as statistics have been gathered on these issues.” —David Gordon, associate dean for diversity and career development

that had previously been provided or were currently being provided. I started asking why.” A decade later, Green is a national leader in the study of disparities in the way people perceive, assess, seek help for, and are treated for pain. In a series of studies published in Pain Medicine (2001-03) DAVID GORDON and the Journal of Pain (2003), for

16 Spring/Summer 2004 FROM CAUSE TO INTERVENTION U-M RESEARCHER LEADS INVESTIGATION OF BREAST CANCER DISPARITIES AMONG NATIVE AMERICAN WOMEN

hile developing a presentation on breast cancer several years ago, Marilyn Roubidoux, M.D., an asso- Wciate professor of radiology in the U-M Medical School, found a vast amount of research exploring factors Vloet Photo: Martin which influence a woman’s propensity for the disease — and little on how these underlying factors affect racial and ethnic minorities. “There were few articles about breast cancer risk factors in minority women and nothing at all on Native American women,” says Roubidoux. “I thought we ought to study this in minority populations as well as Caucasians.” Roubidoux subsequently became the first investigator to review and report on Native American women’s mammogram results. She has researched family history for breast cancer, breast tissue density and other risk factors among Aleut and Eskimo women in Alaska, native tribes in the southwest, and Sioux tribes in South Dakota. From these data, Roubidoux has attempted to evaluate whether the Gail Model — a widely used screening tool for assessing breast cancer risk — is appropriate and effective for Native American women. “We don’t know whether the Gail Model really fits in a native population, because it is based on research which studied white women,” she says. “The same question has been raised regarding African-American women.” Her research also delves into differences within the native population. Breast cancer incidence and mortality rates are six times higher among Native American women in Alaska and the northern plains states, for example, than they are in the Southwest. Understanding the reasons for these variations — which could involve diet, smoking, lifestyle, genetics, breastfeeding and child- birth practices, and the ages at which menstruation begins and menopause occurs — could have benefits far beyond the Native American population, Roubidoux says. “The disparities between native groups might give us a clue about the factors MARILYN ROUBIDOUX contributing to breast cancer,” she says. “Once you understand the causes you can create interventions.” Native American women are less likely than women from other racial groups to contract breast cancer, but more likely to die within five years when it is detected — which may suggest that limited access to screening is delaying diagnosis and treatment. “Findings among the native population can potentially benefit all rural or underserved women,” Roubidoux says.

Medicine at Michigan 17 Photo: Martin Vloet Photo: Martin

JOSEPHINE KASA-VUBU ADOLESCENT GIRLS AND LIFESTYLE: WHY SOME ARE MORE VULNERABLE THAN OTHERS TO CERTAIN DISEASES

osephine Kasa-Vubu, M.D. (Residency 1988), a Who tolerates and benefits from intense exercise and pediatric endocrinologist at Michigan, views who suffers from it? Why do some obese, inactive ado- Jhealth disparities through the lenses of age, gender lescents get diabetes while others do not? “I’m inter- and lifestyle. She studies the ways in which exer- ested in the adolescent girl across the weight spectrum, cise or obesity can affect adolescent girls’ reproductive from lean to overweight,” she says. “What is the impact function, bone density and other health outcomes. of energy balance on her menstrual cycle and her bone health, on one hand, or her risk for type 2 diabetes on “Excessive exercise, on one end of the spectrum, and the other? How does that happen? This information is inactivity and obesity on the other, can cause menstrual particularly important at a time when more girls will irregularities,” she says. “There is no question that need to be counseled in weight control strategies to curb exercise is beneficial to all; however, adolescent girls the growing obesity epidemic in youth. are unique as they may be more vulnerable to the consequences of exercise even if they are a normal weight.” “Girls who over-train typically don’t realize they have crossed a line to a place where exercise can be detri- Kasa-Vubu is interested in the point at which over- mental,” she says. But at the other end of the spectrum, training causes amenorrhea and an increased long-term the perception of physical activity can also be a prob- risk of osteoporosis. She studies endocrine changes lem, and parents of Kasa-Vubu’s obese adolescent associated with exercise that may have an impact on patients often don’t view their daughters as sedentary bone health. But weight and exercise (or their lack) are and overweight. “As I started recruiting for my study, I linked, and she also studies the point where obesity noted that adolescent girls, in general, are very inter- triggers type 2 diabetes, impaired fertility and a long- ested in their health, nutrition and exercise. I had term risk of heart disease. Her research explores why mothers inquire about the study and wonder how and these points vary among young women and seeks to why their daughter’s menstrual cycle was affected by identify factors — such as body composition or pitu- training,” she says. “But we need a better way to guide itary hormones — which indicate whether a girl’s them through this process. There’s not a one-size-fits- lifestyle places her at risk of an ‘energy imbalance.’ all solution.”

18 Spring/Summer 2004 example, she and colleagues found that affects the level of care delivered. This dominantly minority communities in physicians are more likely to prescribe tendency may be more pronounced New York City were less likely than optimal pain treatment for men who among minorities for several reasons. pharmacies in white neighborhoods to have metastatic prostate cancer or post- Many Hispanic and African-American maintain an adequate stock of opioid operative pain after a prostatectomy than patients adopt a stoic outlook, research analgesics for the treatment of severe they are for women who have metastatic suggests, and subscribe to the belief that pain. In a study presented at a meeting of breast cancer or postoperative pain after pain is an inevitable part of a serious dis- the American Pain Society in May 2004, a myomectomy. ease and must be accepted. Minorities Green and her colleagues replicated and also may tend to rely on alternative and extended this study across the state of In other recent studies, Green concluded complementary treatments, prefer to Michigan and found that pharmacies in that African-Americans across the age take analgesics only when pain is severe, minority neighborhoods were less likely continuum are in significantly greater to stock opioid analgesics as well. These distress than white Americans when they studies provide examples of the ways in initially seek medical help for pain. which certain areas are under-served. Further research is needed, she says, to Treating patients understand the reasons behind this dis- Green and her colleagues recommend parity. Possible causes include ineffective equitably does not improved training for health care doctor-patient communications, differ- providers and education for patients. ences in pain tolerance, variable health mean treating them Patients can benefit, they say, by seeking insurance and financial status, and treatment, from information on how to physicians being less aggressive in pro- identically. It means discuss their pain with their doctor, and viding minorities with pain medications also from realistic expectations of treat- and referrals for specialized pain care. accounting for and ment. Patients who expect pain relief and African-Americans in Green’s studies are willing to take appropriate analgesics generally were covered by health insur- addressing the may elicit more responsive pain manage- ance — but they were more likely than differences that ment from their health care providers whites to be covered by Medicaid or who, in turn, need to educate themselves Medicare and also were more likely to create disparities. regarding pain assessment and treatment say medical care for chronic pain was a and to be willing to listen to as well as significant financial burden. elicit patients’ pain complaints. The team of researchers also called for increased Green recently led a multidisciplinary and have a heightened fear of potential participation of minority subjects in bio- team of researchers from around the adverse effects of opioid drugs, including medical research, increased federal fund- country, including the U-M School of addiction, developing tolerance and ing for the study of health care disparities Public Health, which conducted an intolerable side effects. in vulnerable populations, and increased unprecedented review of research on fac- Studies also have found that minority funding for minority researchers. tors contributing to racial and ethnic dis- patients may be less involved than non- parities in pain treatment. In a paper Pain, Green says, has an enormous minorities in decision-making about published in the September 2003 edition impact on sufferers’ productivity, per- their treatment — although they partici- of Pain Medicine, they concluded that sonal relationships and enjoyment of life pate more actively when their doctor racial and ethnic disparities exist in pain — and these burdens now fall dispropor- shares their ethnic background — and perception, assessment and treatment in tionately upon minorities. “Pain is one of that minorities are referred less fre- all medical settings and for all types of the top reasons patients visit their physi- quently for specialized care. pain. They cited one study, for example, cians and it’s the No. 1 reason for dis- which found that white patients arriving Caregiver decision-making can be another ability,” she says. “The suffering, the in the emergency room with a broken leg factor. Health care providers have not impact on quality of life — it’s huge, and were twice as likely as Hispanics to widely employed consistent protocols and we are a better country than this.” receive pain medication — and the dis- guidelines for treating many painful con- parity was not explained by the severity ditions, including back pain, cancer pain, of the injury or the patients’ gender, pri- and sickle cell anemia. As a result, clinical he issues raised in Green’s mary language, insurance status, or sus- decisions are idiosyncratic and widely research mirror, to a large pected intoxication. Little is known also variable, which may contribute to less degree, the agenda of the U-M about the pain experiences of other than optimal pain care in general, and dis- Medical School’s Office of indigenous people. parities in care for racial and ethnic TDiversity and Career Development, minorities in particular. established in 2002 to create a “work- Green and her co-authors explored the force and new methodology that will interwoven collection of causes that may Access to health services also plays a sig- improve the health of minority and dis- contribute to these types of disparities, nificant role in pain treatment. It has advantaged populations.” some of which involve patient attitudes been shown — notably in a study con- and doctor-patient communication. ducted by researchers from the Mount The breadth of the office’s focus is Patients with serious medical conditions Sinai School of Medicine and published unusual among academic medical centers. often under-report the severity of their in the New England Journal of Medicine Pipeline programs encourage talented pain, a phenomenon which directly in April 2000 — that pharmacies in pre- grade school, high school and college

Medicine at Michigan 19 students from historically dis- ecruiting minorities advantaged and under-repre- for clinical trials, sented populations to pursue Gordon explains, careers in the sciences, health Vloet Photo: Martin often requires inves- services and biomedical pro- Rtigators to overcome not only fessions. “Our overarching cultural barriers but also mission is to coordinate med- patients’ suspicion that they ical school efforts to identify are being exploited by a health and nurture those individuals care system which is other- from groups which are ‘under- wise unconcerned with their represented in medicine’ as day-to-day medical needs. well as individuals from the majority population who will “Our investigators need help work to eliminate these health with explaining how their disparities,” Gordon says. research is addressing the unmet health needs these Recruiting, retaining, and communities face,” Gordon supporting career develop- says. “Many of our investiga- ment for outstanding faculty, tors don’t even know how to staff and students from under- begin such dialogues. So represented groups and diverse we’ve established a commu- backgrounds is critical to that nity advisory board composed mission. According to Gordon, of individuals interested in the “Professionals who are under- health needs of our local represented in medicine are minority communities. This more likely to serve disadvan- provides investigators with a taged populations.” ready audience who will hon- Gordon’s team also coordi- estly critique their research nates staffing to programs plans, ask representative that support health care dis- questions, and provide them parities research. “We have with advice on who to con- programs to promote increased tact and what to emphasize networking among those or change to better appeal to investigators doing health dis- potential trial subjects.” parities work and to promote Researchers from U-M and increased interactions with Wayne State traversed this our local communities con- CARMEN R. GREEN challenging terrain expertly cerning these unmet medical for a study of diabetes preva- needs,” he says. lence among Arab-American These responsibilities com- U-M’s concerted, integrated immigrants in southeast monly are spread among sev- Michigan. eral departments within a approach is intended to promote William Herman, M.D. (Resi- medical school, but U-M’s dency 1982), a professor of concerted, integrated approach knowledge-sharing, synergy and internal medicine in the U-M is intended to promote knowl- Medical School as well as a edge sharing, synergy and diversity, and to generate U-M School of Public Health diversity, and to generate professor of epidemiology, momentum for initiatives that momentum for initiatives that investigated diabetes rates target disparities in health care. target disparities in health care. among Arabs residing in The Minority Health Research Egypt in the early 1990s. He Program, a key collaboration between tional contacts between our clinical found diabetes was virtually non-exis- the General Clinical Research Center research investigators and surrounding tent among Bedouin tribes dwelling in and the Program for Multicultural minority communities, and to promote the desert, while prevalence climbed to 5 Health, fosters disparities research increased inclusion of minorities in our percent in rural villages, 10 percent within the U-M Health System and clinical research studies. This makes our among low-income people living in works to increase the participation of investigators better able to include such cities, and 20 percent among urban- minority and historically underserved research participants, while at the same dwellers with higher incomes. The varia- populations in U-M clinical research time addressing some of the health tions, Herman says, appeared to result studies. “This program,” Gordon says, information and care needs of our local from lifestyle factors influenced by chang- “has two main goals: to provide educa- communities.” ing socio-economic status — increased

20 Spring/Summer 2004 TRUST AND UNDERSTANDING IN NUECES COUNTY ACCULTURATION’S TOLL ON THE MEXICAN-AMERICAN POPULATION

ueces County in southern Texas is geographically iso- The ramifications of Morgenstern’s work are enormous: lated and its population is evenly split between Hispanics are the largest minority population in the United NMexican-Americans and non-Hispanic whites, making States and Mexican-Americans are the largest sub-group within it an ideal laboratory for the research of Lewis Morgenstern this growing population. “For the country as a whole, stroke in (M.D. 1990), associate professor of neurology, emergency Hispanics is a huge economic and social burden,” he says. “I medicine and neurosurgery, and director of the U-M Stroke don’t think we recognize the impact this is going to have. By the Program. Morgenstern is the principal investigator of BASIC, middle of this century, it’s going to be astronomical.” or Brain Attack Surveillance in Corpus Christi, a 10-year study, now half completed, exploring disparities in stroke treatment, prevention and medical outcomes. BASIC strives to ascertain the incidence of stroke among Mexican-Americans and the risk factors contributing to it. The Vloet Photo: Martin goal is to gain insights that will lead to more effective stroke- prevention initiatives. “The effort to reduce stroke’s impact on the Hispanic population must mean more than simply trans- lating brochures into Spanish,” Morgenstern says. “We must look at the role that acculturation plays, especially issues of understanding and trust of the health care system.” In Nueces County, BASIC has found that Mexican-Americans who suffered strokes were younger, less educated, and had lower income than white stroke victims. They also were more likely to have diabetes and less likely to have atrial fibrillation, conditions which increase risk of stroke. The two populations had similar rates of alcohol use and smoking and were equally likely to have visited a doctor in the previous year. Mexican-Americans were less likely than whites to be taking blood-thinning medication that can reduce the risk of a second stroke. They also expressed less confidence in their ability to prevent stroke, more distrust of the health care system, and more concern that money impedes their access to care. These findings, Morgenstern says, suggest stroke prevention efforts targeting Mexican-Americans should emphasize the importance of reducing risk factors and address socio-economic issues. They also must overcome mistrust of the medical establishment and possible fatalistic beliefs held by some Hispanic populations — potentially by engaging the trusted LEWIS MORGENSTERN family physician and churches in educational efforts.

Medicine at Michigan 21 CHRONIC RENAL DISEASE AND AFRICAN-AMERICANS U-M PARTICIPATES IN NATIONWIDE STUDY OF ALL ASPECTS OF DISEASE, INCLUDING DISPARITIES

kinlolu Ojo, M.D., Ph.D., an associate professor of internal medicine at Michigan, will spend five years Amonitoring 500 Detroit-area patients as part of a multi- Photo: Martin Vloet Photo: Martin center clinical trial documenting all aspects of chronic renal disease — including racial disparities. The Chronic Renal Insufficiency Cohort Study will examine genetic, demographic, environmental, behavioral, nutritional and quality-of-life factors affecting patients with kidney disease. It also will explore their access to and utilization of health resources. The study, which will follow 3,000 patients nationwide, is funded by the National Institutes of Health and involves researchers at Case Western Reserve University, Johns Hopkins, Tulane, the University of Illinois, the University of Pennsylvania and Kaiser Permanente, in addition to the U-M. More than 10 million Americans have chronic renal disease — and it is four to five times more likely to afflict African- Americans than other groups. Ojo and his colleagues at U-M have formed a unique alliance with investigators in the Detroit area to ensure that 150-250 African-Americans are recruited for the project, which began in September 2001 and is scheduled for completion in 2008. Researchers will monitor patients’ renal function and cardiovascular health, and patients whose condition progresses to end-stage renal disease will be tracked as they undergo dialysis and kidney transplants. “One of the most difficult and unfortunate things about loss of kidney function is that patients don’t notice anything until the kidney function gets quite low, almost to the point of no return,” Ojo says. Disparities in healthcare have long been of interest to Ojo. Early in his career, he and colleagues at Texas A&M University conducted a study that found socio-economic factors — income, education, employment, and insurance status — created barriers to kidney transplantation. In another project, he inves- AKINLOLU OJO tigated why African-American men have lower survival rates following kidney transplants than non-Hispanic whites — and found evidence that large out-of-pocket costs made it difficult for some patients to maintain a steady supply of crucial transplant medications. “This was an attempt to determine whether non-compliant behavior was a function of financial hardship,” Ojo says. “Patients who are left with a substantial amount of out-of-pocket payments for transplant medications are more likely to lose their transplants prematurely.” Today, in collaboration with the Gift of Life Foundation of Michigan and the NIH, Ojo is evaluating means for increasing organ donation among racial minorities. He also is a co-principal investigator for the African-American Study of Kidney and Hypertension, the first major study of kidney disease among blacks. 22 Spring/Summer 2004 caloric intake, decreased physical activ- pate and be assured the visiting health fit to the participants or the community. ity, and increased obesity, for example. care providers were not competitors. Fear of uncovering a medical problem, culture that did not emphasize preven- The study questionnaire and consent A decade later and thousands of miles tive care, and misconceptions about the form were translated into Arabic, away, Herman and colleagues are study- seriousness of diabetes and the risks of reviewed for linguistic and cultural accu- ing diabetes among Arab immigrants in treatment also generated reluctance to racy, and field-tested. Questions about Dearborn, home to the world’s largest participate. Arabic population outside the Middle religious beliefs and income, and a stan- East. The team recently unearthed dard disclaimer describing plans to share Investigators countered with an startling and troubling findings: 41 extensive media campaign that relied percent of the study subjects suffered on the local Arabic newspaper and from diabetes or other types of glu- television and radio stations. They cose intolerance and half the cases explained the scientific relevance of were previously undiagnosed. the study, discussed its methods and procedures, and shared information In a paper in Diabetes Care in 2003, about the risks of diabetes and the the investigators characterized their benefits of early diagnosis and proper findings as a major clinical and pub- treatment. lic health problem. They surmised that contributing factors may include Study participants who viewed the lack of access to and use of health project favorably were asked to help care, and culturally related attitudes recruit additional subjects, while peo- and beliefs including fear of uncover- ple who expressed reluctance were ing medical problems. “Community- immediately contacted by the princi- based intervention programs to pal investigator so questions could be prevent and treat diabetes are answered and concerns alleviated. urgently needed,” they wrote. The study required subjects to Subsequent research explored the undergo medical testing, creating impact of acculturation on Arab- inconvenience and requiring a signif- Americans’ propensity for diabetes. icant time commitment. To minimize Genetic predisposition also may play the burden, researchers accom- a role, Herman says, a supposition modated flexible scheduling for clinic supported by the fact that other eth- visits, including weekend appoint- nic groups typically do not experi- WILLIAM HERMAN ments. They also provided trans- ence such a pronounced spike in portation and coordinated appoint- diabetes following emigration to ments for relatives, friends and America. “The goal is to make a neighbors. The clinic was equipped with a room supplied with maga- These important findings came to difference — to recognize zines, children’s books, toys, a televi- light largely because the researchers sion and a VCR. exercised great care and sensitivity this problem, understand in working with the community. In the end, the project’s participation “We spent a great deal of time why it’s occurring … and rate was an astonishing 87 percent. preparing the community for the The research team had prepared the project,” says Herman, who credits do something about it.” ground so well, in fact, that the study Wayne State University pharmacy endured the tensions and suspicions professor and co-investigator Linda —William Herman, professor of internal spawned by the September 11 Jaber with leading this outreach medicine and health care attacks, which occurred while the effort. The team collaborated on the disparities researcher research was underway. Work was study with Dearborn’s Arab Com- halted for two weeks, then resumed. munity Center for Economic and study data with government agencies, The current task, Herman says, is to bet- Social Services, formed a 16-member raised concerns about confidentiality, ter understand the causes of the commu- advisory board of local leaders, and racial profiling and investigators’ motives. nity’s elevated diabetes propensity and established a committee of local physi- Immigrants recruited for the study design effective interventions. “We don’t cians to ensure that participants with “often were from a place where that have a clue whether people will want to medical problems uncovered by the study kind of information could be used pursue lifestyle interventions or medical received appropriate referrals and fol- against a person,” Herman points out. interventions or both or neither,” he low-up care. The questionnaire and consent form says. “The goal is to make a difference Primary care physicians in the community were revised. — to recognize this problem, understand were contacted and provided information Another obstacle was a perception in the why it’s occurring ... and do something about the project so they could reassure community that research amounted to about it.” their patients who were asked to partici- experimentation and had no direct bene-

Medicine at Michigan 23 INSTITUTE OF MEDICINE COMMITTEE CALLS FOR UNIVERSAL HEALTH INSURANCE Photo: Martin Photo: Martin Vloet Co-chair Mary Sue Coleman: ‘No excuse for delay’

laiming “there is no justifiable excuse for Cdelay,” University of Michigan President Mary Sue Coleman, Ph.D., speaking on behalf of the 16- member Institute of Medicine Committee on the Consequences of Uninsurance, urged that work begin immediately on a plan for providing universal health coverage to everyone in the U.S. by 2010. On January 14 at a press briefing in Washington, D.C., Coleman presented results from the Institute of Medicine’s final report documenting the economic, social and personal consequences of not providing health insurance to 43 million uninsured Americans. The report is the culmination of three years of work by the IOM committee, which was co- chaired by President Coleman and Arthur Kellerman, M.D., M.P.H., professor and chair of the Department of Emergency Medicine at Emory University’s School of Medicine. The committee’s report emphasizes that the consequences of uninsurance, in economic as well as health care delivery terms, affect everyone in America, not just those without health coverage. “Lack of health insurance in the United States is a critical problem that can and should be eliminated,” says Coleman. “Achieving universal coverage will require federal leadership and support.” The committee advanced what it called five guiding principles for any proposed solutions to insuring all Americans: • health care coverage should be universal; • it should be continuous; • it should be affordable to individuals and families; • the strategy for health insurance should be affordable and sustainable for society; • health insurance should promote access to high-quality care that is effective, efficient, safe, timely, patient-centered and equitable. “Lack of health insurance in the United The Institute of Medicine is one of the National Academies created by the U.S. Congress to serve as States is a critical problem that can and an independent scientific adviser to the nation, striv- should be eliminated,” says Coleman. ing to provide advice that is unbiased, based on evidence and grounded in science. The Office of “Achieving universal coverage will require Congressional and Government Affairs is the principal liaison office between the National Academies federal leadership and support.” and Capitol Hill. The committee’s full report is available online at www.iom.edu/report.asp?id=17632. —SFP

24 Spring/Summer 2004 How do the problems of the unin- What is the impact of uninsured ‘A Shared sured affect all Americans? populations on the U.S. health An important aspect of the IOM care system? committee work was to document Our committee concluded that the Destiny for how individuals and health care impact of uninsured populations is institutions are affected by the large straining the very fabric of health All Americans’ and growing uninsured population care in this country, and that a plan in this country. Clinics and hospitals for universal coverage is urgently located in communities where unin- needed. Nearly two years into her tenure as surance is prevalent confront finan- the University of Michigan’s 13th cial risk that places even those with What about the enormous cost of president, Mary Sue Coleman, insurance at jeopardy for loss of crit- providing care to the uninsured? Ph.D., has long been involved in ical services. And the burden of pay- We estimated that the cost to the issues relating to health care and ing the approximately $35-billion nation of not providing universal health care delivery, and the policies annual bill for unreimbursed med- coverage is between $60 billion and and issues that affect them. As the ical care falls on taxpayers and the $130 billion annually. So, there is leader of a dynamic research univer- nation’s healthcare delivery system. great cost to doing nothing. It is dif- sity with an academic health system Insurance coverage, or its lack, is a ficult to estimate the precise cost of ranked among the very best in the shared destiny for all Americans. extending universal coverage because nation, Coleman, who is also a pro- that will be dependent on the design fessor of biological chemistry in the What role does American culture of a basic benefit package. However, U-M Medical School, a member of play in the personal and national our committee strongly believes that the Institute of Medicine, and a fel- policy choices that have been trepidation about cost issues should low of the American Association for made regarding health care over not prevent the public policy debate the Advancement of Science and of the past 25 to 50 years? about how this nation will cope with the American Academy of Arts and Health insurance in this country has a growing crisis in health care, espe- Sciences, understands the intricate historically been tied to employment cially given the significant cost asso- complexities of health care — and and to “safety net” public programs ciated with not providing universal health insurance. for the very poor. The only compre- coverage. Upon concluding three years of hensive program that provides coverage regardless of employment status What role can U-M play in solv- work with the Institute of Medicine ing this critical national problem, Committee on the Consequences of or income is the Medicare program, a public policy decision made nearly or, more broadly, what role can Uninsurance, which she co-chaired, academic medicine in America and release of the committee’s sixth 40 years ago that revolutionized care for those 65 and older. play? and final report, President Coleman We are fortunate to have on our fac- reflected with Medicine at Michigan As medical treatments and interven- ulty here at U-M many leading on some of those consequences, and tions for chronic diseases have experts in health policy. Those indi- on the urgent need for universal become more effective, the gap in viduals are already engaged in setting health care coverage in America. morbidity and mortality related to important research agendas about insurance coverage is becoming uninsurance, conducting scholarly more pronounced, making health work on this issue, and advocating insurance a more critical necessity for a renewed public debate. All of now than it was a few decades ago. these activities will be crucial to the Employers are backing away from goal of extending coverage to all. In offering insurance coverage as costs addition, I believe that U-M has the rise, and our public programs are capability to test model programs overwhelmed with those needing and thus take a leadership role in this assistance. The IOM Committee area, making major contributions to found little evidence that people who solving one of the most serious prob- do not have health insurance choose lems facing our society today. to forego insurance because they do not believe they need it. Rather, they are most often working where no insurance is offered, or is offered at prices they cannot possibly afford.

Medicine at Michigan 25 26 Spring/Summer 2004 THE

‘PERFECTby Jeff Mortimer STORM’? As complex, turbulent forces — economic, social and technological — con- verge upon the costs of medical education, the academic system struggles to keep medical training within reach for students and to sustain a robust pool of American-trained physicians for tomorrow’s health care needs.

he vast majority of our medical students are burdened with more debt at graduation than many Americans amass in a lifetime,” wrote Jordan J. “ Cohen, M.D., president of the Association of American Medical Colleges, Tin the July 2002 issue of the AAMC Reporter. According to data from the association’s annual survey of medical school graduates for 2003, 82 percent had borrowed to finance their education — direct costs, such as tuition and fees, as well as indirect subsistence costs — and their median indebtedness was $105,500. Public school students’ median debt was lower than that of their peers at private institutions — $100,000 compared to $135,000 — but the gap was narrow-

Illustration: Shayne Davidson ing: The median debt for public school graduates jumped 8.7 percent from the year before, compared to a 6.3 percent increase for private school students, as state-supported schools scrambled to offset shrinking revenues from government, clinical practice and endowments with tuition increases.

Medicine at Michigan 27 he picture is slightly less bleak “If you’re a student without means and you know at the University of Michigan, where tuition increases for the you’re going to have to borrow $150,000 or last five years have averaged Tabout 3 percent a year, more or less $175,000, you begin to question whether you matching the rate of inflation. “When we took a cut in state appropriations last year should go to medical school at all,” says Dean and this year, we did not pass that on to Allen S. Lichter. “The hill becomes so steep that our students,” says Dean Allen S. Lichter (M.D. 1972). “We simply absorbed it. We many people we would love to see enter the field of are trying our best to be good stewards of this medical school and recognize that we medicine go into other fields.” cannot pass all the costs onto the backs of our medical students.” Despite historically low interest rates, a the last 20 years and, potentially, a who may not have the resources that medical school graduate pursuing a four- determinant of who gets that care, and some of their prior colleagues or some of year residency with $100,000 in federal from whom. my colleagues 50 years ago had,” says Stafford loans, the most common vari- Giles Bole (M.D. 1953, Residency “You cannot make this question simple,” ety, can expect to pay more than 1956), dean of the U-M Medical School says Roland G. “Red” Hiss (M.D. 1957, $50,000 in interest over a 10-year repay- from 1990 to 1996. “If you look at the Residency 1964, Fellowship 1966), long- ment plan. If he or she has chosen a 25- picture of the class of 1953, it was heav- time chair of the Medical School’s year extended repayment plan, the ily dominated by white males, probably Department of Medical Education. “It’s interest could surpass $200,000, more middle to upper middle class. The not simple. It’s a very complex issue with than double the amount originally bor- resources to go to school as well as to multiple driving forces.” rowed. And due to changes in federal pay the tuition were not as dependent on student loan regulations, students have the individual student’s efforts.” to start repaying their loans during their But now the prospect of such a debt load residency years. A typical monthly loan may intimidate potential students who payment can easily consume more than come from less affluent backgrounds or 40 percent of a resident’s net income. Photo: Martin Vloet Photo: Martin groups that have been historically under- U-M Medical School endowment funds represented in medicine, thus damaging earmarked for scholarships have more the effort to more closely align the demo- than tripled in the last five years, from graphics of the profession with the popu- $7 million to $22 million, and so has lations it serves, which was one of the scholarship support, from $1 million goals of expanding the pool in the first distributed to 91 students in 1997-98 to place. $3.2 million awarded to 247 students in “Many members of those groups can’t 2002-03. About a million of those dollars imagine borrowing $100,000 for any- came from the dean’s discretionary fund, thing, much less something intangible paying for 40 full-tuition scholarships, 10 like education,” says Robert Sabalis, the per class. AAMC’s associate vice president for stu- “That money could have been used for dent affairs and programs. “If you’re liv- faculty recruitment, research support, all ing in a $500-a-month apartment, who the things a medical school is involved can think about borrowing $100,000? in,” says Lichter, “but we felt that our We don’t want to scare off people in this best use of some of these discretionary Allen S. Lichter country who we need in the medical pro- dollars was to help reduce this debt bur- fession in the future with the prospect of den. I felt we couldn’t begin to ask our these huge debt amounts.” alumni and our benefactors for scholar- It also has a multitude of possible conse- “If you’re a student without means and ship support if we ourselves inside the quences and solutions. Chief among the you know you’re going to have to bor- medical school were unwilling to do it.” former, in the view of many authorities, is its effect not only on who goes to med- row $150,000 or $175,000, you begin In addition to the dean’s office, he says, ical school but also what they choose to to question whether you should go to “Just about every clinical department in do with that education once they’ve medical school at all,” says Lichter. “The the medical school has agreed to support received it. hill becomes so steep that many people a full-tuition scholarship.” we would love to see enter the field of “The more diversified student body that medicine go into other fields.” It’s a good beginning, but only that. The this medical school and many others student debt issue is long-term, systemic have achieved during the last 15 or so The evidence for this is still largely anec- and structural, both a symptom of the years, and appropriately so, has obvi- dotal, although there are apparently radical changes in health care finance of ously brought to the school students enough such tales that the AAMC is cur-

28 Spring/Summer 2004 Bole found plenty to concern him during practice rather than research. I think that his service in the mid-1990s on a com- there is a major domino effect of debt mission advising Congress on physician which not only keeps people out of med- specialty choice. “Our staff of 15 civil icine but also keeps them out of parts of servants did a lot of spadework to look medicine that are most critical for its at these accusations [that financial con- self-renewal.” siderations were in the driver’s seat], and Hiss is adamant that one critical part of many times they were just that,” he says. “But there was good evidence, as you medicine that’s seriously endangered by looked at the percentages of students students’ deepening financial hole is pri- who were going into the surgical special- mary care practice. “The student debt ties and some of the high-income med- issue is having a major impact on the ical specialties, that to be able to recover health care delivery system of this coun- that student debt load was at least there try,” he says, “because the students who as something they would admit to if you are burdened with that debt know it will quizzed hard.” be forever before they pay it off if they go into family practice or general inter- “I am certain that it discourages some nal medicine or pediatrics. The number people from pursuing certain aspects of of senior medical students who are elect- medicine that don’t pay as well,” says ing family practice or general internal Red Hiss Marc Lippman, M.D., chair of the U-M medicine for post-graduate or residency Medical School’s Department of Internal has been going down for the last three Medicine. “People will now not be as or four years. We are drying up our likely go into internal medicine to begin American-trained primary care physician rently conducting a study of students who with, and even within internal medicine, supply. Student debt isn’t the only rea- have been accepted into medical school as they will avoid certain important sub- son, but it’s a significant one.” well as students who considered it but specialties like infectious disease, rheuma- Like Lippman, many observers believe changed their minds, in order to “try to tology and endocrinology because they don’t pay very well. Even if they choose it’s also a growing factor in drying up the determine what factors lead people to not a subspecialty like cardiology or gas- supply of researchers, as well as physi- apply and what factors lead people to troenterology, they will pursue clinical cians in public service and doctors apply,” says Sabalis. The report is scheduled for publication in 2004.

oes students’ debt influence their core decisions at the Debt has grown faster than tuition and fees. other end of medical school? Tuition and fees have grown faster than CPI. What little data there is on the 55 Dsubject is dated, and opinions range $$ $$ from “it’s not much of a problem” to $$ $$ $$ Special Mean Ed Debt $$ “the future of medicine is at stake.” 44 $$ Private Schools $$ $$ $$ $$ $$ Special Mean Ed Debt “I don’t think anybody knows what the $$ $$ $$ $$ Public Schools $$ $$ effect of indebtedness is on decisions by $$ $$ $$ Median tuition and fees $$ 33 $$ medical students,” says Peter Ward $$ $$ non-resident private $$ $$ $$ $$ $$ schools $$ $$ $$ (M.D. 1960, Residency 1963), chair of $$ $$ $$ $$ $$ $$ $$ Median tuition and fees $$ $$ $$ $$ the Department of Pathology and interim $$ resident public schools 22 $$ $$ $$ $$ $$ dean from 1983-85. “One would think $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ Consumer Price Index $$ $$ $$ $$ $$ $$ that if a student has $100,000-$150,000 $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ $$ debt that he or she would want the high- 11 $$ $$ $$ est income in order to pay off the debt as 1984198419891989199419941999199920042004 quickly as possible. Whether or not that’s true, I think is unclear.” Special Mean = Product of the median for indebted students and the fraction of students who have debt. “If it is true, it’s relatively true at the margin, but it does need to be studied again,” says Michael Whitcomb, the AAMC’s vice president, division of medical educa- This chart displays the national growth of tuition, indebtedness and consumer prices, reduced to a common tion. “The last study looking at whether scale. Medical education debt is 4.5 times as high in 2003 as it was in 1984, while tuition in private medical schools is 2.7 times as high, and in public medical schools it is 3.8 times as high. The consumer price index is indebtedness had an impact on students’ less than twice as high as it was 20 years ago. That indebtedness has increased more rapidly than tuition specialty choice was done about five years implies that other components of the cost of attending medical school have risen faster than tuition. Tuition ago. The data at that time, and all previ- made up less than half of the total cost of attendance in 2002 at public medical schools. ous data, was of such a nature that it was Source: Medical School Tuition and Young Physician Indebtedness © AAMC 2004. Reprinted with permission of the Association not possible to make a relationship.” of American Medical Colleges.

Medicine at Michigan 29 who choose to practice in rural areas or medical school. They have different inner cities. It would be naïve to suggest relationships with their sponsoring that financial considerations have never institutions, different levels of state and played a role in such decisions, but that private funding, they pay for things in role seems to grow in tandem with stu- different ways, they have different levels dent debt. of endowment. Trying to get a national handle on 126 institutions who deal “The Michigan State Medical Society with their finances in many different does regular surveys of physicians, ways can be a daunting job.” including their salaries,” says Bole, “and there’s no question that the same special- But this is not to deny that the economic ist who practices in the Upper Peninsula driving forces of increased student debt has a net salary that is probably two- are pervasive and abundant, regardless thirds of what he or she would get in of their proportions at any particular Ann Arbor or the northern suburbs of site. Virtually every significant income Detroit. And that’s hard data; it isn’t category has taken major lumps. somebody’s opinion.” Managed care shrank the clinical revenues that helped subsidize research and “It’s hard to say about career choice because we don’t necessarily follow people education. Cash-strapped governments that long,” says Sabalis, “but people inter- at all levels reduced their support. Robert Sabalis ested in public service won’t be able to pay At the same time, the cost of providing back these loans because they’re making medical education continued to grow. salaries that are half the market rate.” Expensive technology became common- rounds in the hospital and the attending place in both practice and pedagogy. t’s always been very difficult to physician interviewing a patient in the More and more training took place in ascertain precisely what it costs presence of medical students and resi- ambulatory rather than hospital settings. “ to educate a medical student,” dents. You’ve got graduate medical edu- Regulatory expenses rose. So did faculty says Bob Jones, AAMC vice cation going on, patient care going on, salaries, as schools competed with the presidentI for medical school services and and medical student education going on. private sector for talented clinicians. studies. “I think many schools really And not all schools pay all those costs in With caveats duly stipulated, Jones cites don’t know.” real dollars. Schools are very different in recent research that puts the average the ways they’re arranged organization- This is not necessarily a failing on their medical school’s annual educational cost ally and financially.” part. “It’s not like manufacturing, where at $55,000-$60,000 per student. “One you can give precise costs for things,” he Or, as Sabalis puts it, “If you’ve seen could argue with certain assumptions says. “Think about somebody doing one medical school, you’ve seen one and say it’s more than that,” he says,

Fraction of Graduates Median Educational Debt Who Are in Debt of Indebted Graduates 100%100% $$ $$ $$ $$ 140,000140,000 $$ $$ $$ $$$$ $$$$ $$ $$ $$ $$ $$ $$ $$ 80%80% $$$$ $$$$ $$ $$ $$ $$ $$ $$ $$ $$ $$ 120,000120,000 $$ $$ $$ Public 60%60% $$ 100,000100,000 $$ $$ Schools $$ $$ $$ 40%40% $$ Private 80,00080,000 $$ $$ $$ $$ $$ Public $$ $$ $$ Schools $$ 60,00060,000 $$ Schools $$ $$ 20%20% $$ $$ $$ $$ $$ $$ $$ Private 40,00040,000 $$ $$ $$ $$ $$ Schools 0%0% $$ $$ 20,00020,000 $$ $$ $$ $$ 1984198419891989 199419941999199920042004 Includes graduates with undergraduate debt, 00 medical education debt, or both 1984198419891989199419941999199920002000

Source: AAMC Graduation Questionnaire Source: AAMC Graduation Questionnaire

In 1984, 87% of public medical school students graduated with medical school debt, and the median amount for those who had debt was $22,000. For private medical schools, 90% had debt, and the median amount was $27,000. While the fraction of 2003 graduates who have medical school debt has declined to 85% for public school medical students and 81% for private school medical students, the median amounts for those who have debt have enormously increased, to $100,000 and $135,000, respectively. At Michigan’s medical school, approximately 85 percent of students graduate with debt, and the average indebtedness has risen from $84,000 in 1999 to an estimated $109,000 in 2004.

Sources: Medical School Tuition and Young Physician Indebtedness © AAMC 2004, reprinted with permission of the Association of American Medical Colleges; U-M Medical School Office of Financial Aid.

30 Spring/Summer 2004 “but I’m not sure that it’s really less. It’s “There’s been a huge increase in costs certainly much greater than anyone’s related to regulatory requirements with tuition bill.” no offsetting access to federal revenue,” says Ward. “At Michigan right now, The atmosphere is markedly different we’re budgeting close to two million dol- than it was 20 years ago. “It used to be lars a year for the institutional review understood that the medical profession boards required for biomedical research. did good things for the populace and we Five years ago, it was about $250,000. cut it some slack,” says Joel Howell, The Americans with Disabilities act is a M.D., Ph.D., a professor of internal med- mandate that has no offsetting revenues icine and the Victor Vaughan Collegiate from the federal government but repre- Professor of the History of Medicine. sents a series of regulations that are quite “Now we have people coming from the costly to implement. And increasing fed- auto industry and saying, ‘We buy steel, eral regulations for animal care have lead, glass, and we want to buy health caused the per diem rates for animals to probably triple over about a two- or three-year period. All of these costs have had to be absorbed by the institutions, so it’s not surprising that the costs of operating a medical school have risen sub- Michael Whitcomb stantially over the past five to 10 years.” “In the 1960s and into the early 1970s, professors in the medical school made you need a faculty member in front of salaries that were not too different from each group, so it takes eight or 10 faculty professors in the English department,” members to deliver educational content says Dean Lichter. “That means there vs. one faculty member standing in front wasn’t nearly as much strain on tuition. of a class.” But as physicians’ salaries began to rise oes looking only at averages in the private sector, we had to keep and means and totals mask cir- some pace in order not to lose the entire cumstances that would miti- faculty. That’s true of every medical gate the scope of the problem? school in the country.” D “I think, in part, the increase in student Not only that, but teaching itself is more debt is a function of the fact that the avail- labor-intensive, for both practical and ability of student loans has risen quite sig- philosophical reasons. Bob Jones nificantly over the years,” says Ward. “Medicine has changed so much that if In Whitcomb’s view, that availability you spend most of your time in the hos- could have the same effect as those daily pital, you’ll miss a huge amount of edu- credit card solicitations in the mail, which care.’ In the good-bad old days, you cation,” says Lichter. “Today, we charged everybody a little more and the induce students to incur debt when they manage people entirely as outpatients otherwise might not have done so or people who couldn’t pay would be subsi- who, when I went to medical school, we dized. Now the people who are paying needed to. “By declaring themselves as managed as inpatients. We used to have independent, with no resources from fam- for health care are working very hard to ward service with an attending physician see that doesn’t happen.” ily funds, they can borrow all the money and four or five medical students and even if they come from families that could “Hospitals used to think having medical lots of house staff doing a lot of teach- have paid their entire way,” he says. students and residents was a good ing. Now, more and more, a tremendous “Where does the responsibility lie within thing,” says Sabalis, “but when you start amount of learning about medicine families who have the means, but find it doing cost accounting, you find that it occurs in the outpatient clinic, where a easier to have their son or daughter bor- makes the physician less efficient in his student is one-on-one with a faculty row the money?” or her clinical activity. It’s like any other member. It’s a much more costly venue to product line, which is how things have teach in but it’s absolutely critical that Moreover, he adds, “Students — and I changed over the last couple of decades. we do it, and we do. We are on track to can say this about my own kids who are in professional school — tend to borrow People in medicine who never thought deliver close to half our clinical educa- to the limits, believing that they’ll be able they’d be hearing language about prod- tion in ambulatory clinics. to retire that debt in a reasonable way uct lines are now talking that language “We are also now beginning to divide up once they complete all their training. every day in an effort to keep their heads classes into small groups of 10 or 15 They aren’t limited by other activities in above water.” with a faculty member in front of each terms of the amount they’re willing to And the waves keep rising, on all sides. group, so there’s much more interaction borrow in order to go to school. I don’t The phrase “perfect storm” comes to mind. and self-directed interactive learning. But think they concern themselves very much with the amount that they borrow.”

Medicine at Michigan 31 That includes consumer debt. While expenses unrelated to education aren’t “I think it’s an achievable goal for us over time to included in any of the student indebted- retire the debt of many, if not all, of the students ness figures that have been cited, those costs have also grown, causing some to who want to get a medical education here, and at wonder if medical students aren’t, well, getting soft. the same time improve the quality of the students.” “The idea that you were going to live the —Marc Lippman, chair, U-M Department of Internal Medicine Spartan life through those medical school and residency years has faded,” says Bole. “It’s still tough sledding, but I “$150,000 is a lot of debt,” says Howell, years. There eventually comes a breaking think students have expected to live at “but if you’re going to walk into a job point. I don’t think we’re there yet, but …” least a decent life.” with a starting salary from $100,000 to But why wait until there’s a front-page $250,000 a year, you can pay it off. Can “There are people who are questioning crisis before attempting to reduce stu- you pay it off and buy a vacation house whether this generation of students is will- dent debt and level the playing field? and a new car and send your children to ing to sacrifice as much as prior genera- private school? Probably not. I know I’m Those who spoke with Medicine at tions,” says Sabalis. “There is some dis- going against the party line, but physi- Michigan offered myriad suggestions, cussion that they don’t want to sacrifice cians get so much privilege in society that some radical, some more ordinary. sometimes I wonder if this whole issue “I think medical education should be isn’t a little bit overdrawn.” subsidized by the government — federal “The reverse side of the debt picture is or state,” says Howell. “After one com- something that I’ve been trying to figure pletes one’s medical education, one ought

Photo: Martin Vloet Photo: Martin out now for a couple of years,” says to owe some period of service to the state Sabalis. “This is not debt like buying a — we can debate how long that ought to car that loses 20 percent of its value the be — and I would not let people buy minute you drive it off the showroom their way out of it. I think we would floor. This is an educational investment wind up with just as good, if not better, that is pretty much guaranteed to ‘pay physicians, who would be just as focused off,’ in that if the average bachelor’s on healing. I don’t make policy or sit in degree holder in this country makes per- policy-making bodies, but I think offer- haps $40,000 a year and the average physician makes $160,000 a year, this $100,000 or $110,000 is a sound investment financially for the future of his or

her family. We have to look at both sides Vloet Photo: Martin of the coin.” Such a view doesn’t alter Bole’s concerns. “Not everybody nets $150,000 the day Giles Bole they walk out of their residency,” he says, “and the bills are coming due both from this debt load and from the other things the family side of their lives for the pro- you have to do if you’re raising a family or fessional side. It’s a controversial issue, trying to live a reasonably secure profes- and I don’t want to be misperceived. I sional life. If you look at some of the pri- don’t think everyone thinks it’s a nega- mary care disciplines that have taken a dip tive thing to balance your private life in the last five to seven years in terms of and your professional life.” the number of individuals entering them compared to the number that the man- But trying to do that can raise those loan aged care folks want us to believe we have balances, too. to have, those folks take a long time While not dismissive of the potential before they mature to a net of $150,000, Joel Howell effects of student debt, some in the pro- so the primary care disciplines will be all fession question the consistency of the more difficult to fill with American- attempting to convince prospective stu- trained medical students.” ing enough financial aid so that anybody who is smart enough and dedicated dents who are financially challenged that And Sabalis qualifies his comments with enough to go to medical school can do so it’s a good investment on the one hand, an emphatic “for now.” “If you look at is a wonderful place to start.” while asserting that its enormousness five more years of reduced support for will adversely affect the course of medi- higher education, students are going to be There are templates for such a plan. As cine on the other. another $30,000-$40,000 in debt in five Whitcomb says, “Students do have other

32 Spring/Summer 2004 choices to make about how to finance AAMC has two debt management pro- $2.6 million has been raised for it, and their education. There are state programs grams — (MD)2, or Monetary Decisions four scholarships are awarded annually. in which students can go into under- for Medical Doctors, for premedical and Internal Medicine gives a free ride for the served areas and have their debt retired.” medical students, and DEBTHELP for fourth year to outstanding students in The National Health Service Corps is a residents — but the dean emeritus thinks the department who are interested in similar federal program, and some med- intervention should start sooner. academic careers. ical schools, as well as the National “The issue of better counseling is some- Institutes of Health, will forgive the edu- The first year that the dean funded 12 thing that really needs to be addressed,” scholarships from his office’s discre- he says. “I did a very detailed study of tionary funds, the results were dramatic. pre-med counseling the year after I left “Instead of getting 5 or 10 percent of the the dean’s office and was amazed. The top students he went after, he got 80 per- Michigan undergraduate school always cent,” says Lippman. “He wound up ranks in the top three or four schools Photo: Martin Vloet Photo: Martin going only to about number 15 on the that place students in medical schools. list to get those 12. Money talks.” Berkeley is another school of that cut. And yet if you look at how students are And it’s music to Lippman’s ears. “It’s a advised in the pre-medical setting, it’s a business, or at least in my view it is,” he pretty ragged affair, and I don’t think it’s says. “If you thought that Michigan was changed, here or anywhere else, since I as good as some peer institution, or rendered my report.” maybe 1 percent less desirable because it’s not near salt water, and Michigan If some of these ideas sound like patches, offered a free ride, what would you do? they are. The system, such as it is, is a I think it’s an achievable goal for us over patchwork. To change that, “We’re time to retire the debt of many, if not all, going to have to turn around a couple of of the students who want to get a med- decades of thinking about how medicine ical education here, and at the same time should be approached and develop a improve the quality of the students.” new solution,” says Sabalis. “We’re talking about a whole system, from the way Lippman was on the faculty at Marc Lippman physicians are educated to the way Georgetown University for 13 years patients are treated, that’s broken and before coming to Michigan in 2001. probably needs to be rethought. That’s “There was much more of a tradition of cational debt of graduates who join uni- going to take a systemic approach.” philanthropy and much more of a tradi- versity faculties and engage in research. tion of fundraising there,” he says. “It was done with a great deal more intensity But, says Ward, “The number of gradu- ntil that happy day, school- and a great deal more conviction and a ating medical students who take up such based scholarships, funded by great deal more investment than is cur- offers is pretty small, and I believe the endowments, would take the rently made here. It’s just an area that we attitude of the public is ‘They’re well biggest bite of all out of stu- don’t do well. There are a million expla- paid anyway, so why should public Udent debt. “Career selection is a national funds go to offset the indebtedness nations given, none of which is cogent to problem,” says Hiss, “and a significant they’ve incurred?’ I don’t get the impres- me. The fact is we have a tremendous cause for that problem is student debt. sion that the public is strongly support- case statement. We are among the best Therefore, the most likely principal ive of a program of debt forgiveness to medical schools and potentially the best means for solving it is scholarships.” entice M.D.s to locate in certain areas or hospital in America, but we haven’t practice under certain conditions.” “Can the scholarship funds that Dean approached succeeding at philanthropy Lichter has pushed very hard as a prior- the way we’ve approached succeeding at Such practical considerations are why ity for the school help with this?” asks other aspects of our mission. And it’s not Bole sees any proposal for government- Bole. “I think the answer is yes. It only a central part of our mission, but subsidized medical school as a non- depends on whether previous genera- one of the most effective ways to achieve starter. “Can you convince the state or tions of physicians and other people greatness as a medical school.” the feds to put more money into medical interested in medicine make it a higher education?” he asks. “I doubt it. I put in That’s reason enough to keep it on the a lot of time on a couple of commissions priority, and it’s going to have to be sold radar. “We’ve already begun to make a and I never heard anybody in the U.S. very hard as a legitimate societal goal. difference with gift support,” says Congress express much sympathy for It’s certainly more promising than trying Lichter, “but I’m not unrealistic enough medical students, for many of the rea- to convince the state legislature to give to think we’re going to solve this prob- sons we’ve talked about. The perception us more money.” lem in a couple of years. We’re in this for is ‘They’re a high-income cohort, so let Michigan’s heightened efforts are already the long haul.” them pay for it.’” bearing fruit. In Pathology, for example, Bole believes better counseling could be the first department to establish an both economical and effective. The endowed scholarship fund, more than

Medicine at Michigan 33 MAKING A DIFFERENCE Phil Jenkins’ ‘sweeping’ philanthropy focuses on results

ll I am is a sweeper manufac- turer from Dexter, Michigan,” “ says Phil Jenkins.

Photo: Gregory Fox A Well, not quite. Jenkins was a young engineer working for Caterpillar Tractor in 1949 when he got a call summoning him home to Dexter to take over the family farm equipment business. Once back in Michigan, a call from an old classmate — an automobile dealer — changed everything. Jenkins recalls, “He mentioned that if he just had a sweeper on the front of his Jeep, he could sell a hun- dred of them.” Jenkins and his shop manager, Jim Klaperich, spent a weekend fashioning such a vehicle, and Sweepster was born. A half-century later, Sweepster, Inc., manufactures attachment, walk-behind, self-propelled and airport runway sweepers for all types of equipment used in airports, municipalities, agriculture and construction around the globe. Annual sales total about $50 million, with aviation products generating about 25 percent of the gross revenue. And if that’s not enough, Jenkins has channeled his success into a selfless and inspiring philanthropy. He funded the creation of the Genera- Phil Jenkins tions Together center in Dexter where preschool children and senior citizens enrich each other’s lives. He supported the expansion of the Ann Arbor Hands- On Museum to encourage more children

34 Spring/Summer 2004 to go into engineering-related fields consultation, and I can take the time that the tide has turned, and that depres- instead of overcrowded fields like law. with them they need. I can go to a sion is now being addressed as a chronic But it’s his commitment to health care patient’s house, or talk on the phone disease like diabetes. This extraordinary that has proven truly extraordinary. with them. People are now using this as support brings us closer to effective a model of what can be accomplished treatments for this devastating disease.” In 1999, Jenkins learned of the work of when a patient and a health professional Mark Moyad, a young Michigan Jenkins, whose wife, Lyn, lived with get together and share a vision of making researcher, and his holistic approach to depression before her death in 1999, is all health care better. Phil is a person who prostate cancer research and treatment. too familiar with the toll the disease takes invests in people, not in concepts or Impressed and eager to help, he gave on people. “I see depression everywhere,” things that, maybe 100 years from now, $1.5 million to establish the Phil F. he says. “It’s an insidious thing we really might do something.” Jenkins Complementary and Alternative don’t recognize. One problem is that we Medicine Endowment Fund at the Jenkins didn’t stop there. Last year, he don’t admit that we have it — it carries a University of Michigan. “I did it for gave $2 million to the U-M Medical stigma, and we have to get over that. “I believe in John Greden. He’s an honest and straightforward guy, probably “I can’t think of one person who has had more of the most common-sense psychiatrist I’ve an impact on my medical career and the lives of my ever met.” Jenkins’ gift will be used to help build patients,” says Mark Moyad. the U-M Depression Center facility — a place where research, clinical care and Mark Moyad,” says Jenkins. “He’s a School to help build the new U-M education will intersect in an environ- brilliant guy doing a great job for breast Depression Center. ment of hope. and prostate cancer around the country “This is a thrilling and gratifying devel- Once constructed, the University of and around the world. I’m just amazed opment,” says John Greden, M.D., the Michigan Depression Center will be the at the guy. What I want is results. I want Rachel Upjohn Professor of Psychiatry first comprehensive research and treat- to see the U-M get more researchers like and Clinical Neuroscience in the medical ment facility in the United States devoted Mark Moyad and keep them here.” school, chair of the Department of to depressive illnesses. Says Greden, “I can’t think of one person who has had Psychiatry and senior research scientist “One of our goals for the center is to more of an impact on my medical career at the U-M Mental Health Research diminish the stigma of depression. Other and the lives of my patients,” says Institute. “The Depression Center at disorders, like cancer, were stigmatized Moyad. “Phil Jenkins has set up a situa- Michigan is dedicated to being a leader in the past. Now we have a national net- tion I call ‘old fashioned medicine in a in the study and treatment of depressive work of 21 cancer centers. Ten years modern time.’ Because of his support of illnesses and to forging a new public pol- from now, I hope we will have a national my time, I can spend as much time with icy toward this disorder. That people like network of depression centers; it is our a patient as necessary. I can see a retired Phil Jenkins are coming on board in sup- goal to catalyze this trend with our ini- couple who aren’t wealthy but need a port of this endeavor truly demonstrates tiative at Michigan.” —WH

Medicine at Michigan 35 Photo: Paul Thacker

by Whitley Hill

36 Spring/Summer 2004 Photo: Paul Thacker

he invisible epidemic: that’s “I was 29, working Jackson was admitted to what the American Diabetes at the U-M Office Michigan’s comprehen- T Association calls the disease of Administrative sive, six-day inpatient that last year took the lives of 170,000 Systems as a techni- program where her blood Americans, a number that continues to cal writer. I was liv- glucose levels were stabi- rise. Each year, 25,000 new cases of ing alone and had a lized. She consulted with blindness are caused by diabetes. It is the boyfriend; I was dietitians, attended group most common cause of renal failure in playing a lot of fid- sessions with other newly the country. Today, diabetes is the fourth dle music. I can say diagnosed people, and leading cause of death by disease in the that I never even began to learn to accept U.S. Nearly 20 million Americans have mentioned the word the reality of life with a this disease. A third of them don’t even ‘diabetes’ in my life. Martha Funnell chronic, potentially seri- know. Then suddenly I ous disease. started to lose weight and was walking But it doesn’t have to be this way. Every “I felt overwhelmed,” she recalls. “I around with a water bottle, chips, candy day at the University of Michigan, some took every instruction very seriously. bars. I was always hungry but I kept los- of the world’s best and brightest scien- Eat at the same time every day. Follow ing weight, which I thought was great at tists work at the frontline of the fight the diet plan exactly, eating the pre- the time. I even began lifting weights at against diabetes and its devastating scribed amount of carbohydrates. Give the Y! complications. That battle is the work of two distinct centers at Michigan: the Michigan Diabetes Research and Train- ing Center, which supports research, U-M scientists are beginning to test a triple antioxidant training, education and community outreach, and its sister center, the Juvenile therapy that could prevent diabetic neuropathy. They are Diabetes Research Foundation Center exploring how cells react to oxidative stress, how growth for the Study of Complications in Diabetes, which brings together basic hormones contribute to complications, and how surrogate and clinical scientists to understand and islet cells could be implanted into people with diabetes. treat the complications of the disease. The Diabetes Informatics Core is taking the sharing of Together, the two centers fuel a powerful environment that nurtures research, research findings to a new level. Michigan researchers are education and patient care, and targets asking tough questions about health care delivery and one of mankind’s most frustratingly pervasive and deadly diseases. At the making changes that save lives. core of it all are the patients treated here, people like Anne Jackson. Diagnosed with type 1 diabetes in 1986, “Soon I was feeling horrible — ‘spaced- your shot 20 minutes before eating. Jackson has received all her treatment at out’ and tired all the time. My vision Keep a detailed log — write down every Michigan, given birth to two beautiful, was getting blurry. I’d been seeing a psy- meal, every dose of insulin, your activ- healthy children, participated in clinical chiatrist and told him about it, and he ity level. It was painstaking. After all trials, and kept her doctors on their toes ordered a blood test. That night, he these years, I still get overwhelmed by with an insistent curiosity about new called me at home and said, ‘You’re all the monitoring I have to do to stay developments in research. But at the going to the emergency room. Pack healthy, but my ability to handle it is beginning, she was an exhausted, fright- your overnight bag, you’ll be there for a much better.” ened face in an ER waiting room, living while.’ My blood sugar was 890. proof of John Lennon’s adage, “Life is Normal is 80-120. In the ER, they told Helping people “handle” their diabetes what happens when you’re making other me, ‘Ms. Jackson, you’re going to be is the work of Martha Funnell. A clini- plans...” taking insulin for the rest of your life.’” cal nurse specialist for more than 30

Left: U-M Nurse practitioner Nugget Burkhart with diabetes patient Lydia. “When I first went on the pump, I was scared, but I learned that it isn’t as scary as I thought,” Lydia says of the insulin pump that regulates her diabetes. “Nurse Nugget helped me not to be scared.” Medicine at Michigan 37 years, she also is the admin- “We’ve come to realize that knowing what’s care. The sad part is that istrator for both of Mich- best for diabetes is not the same as knowing we’re often people’s last igan’s diabetes centers, a hope. They’ve been told diabetes educator, and a what’s best for someone with diabetes.” there’s not much that can be past president of Health —Martha Funnell, administrator for done to help them in terms Care and Education for the U-M’s diabetes centers of complications and other American Diabetes Associa- issues. They come here tion. Her work with patients because we treat patients and health professionals with respect; we recognize reflects a sea change in the clinical care knowing what’s best for diabetes is not their right to be involved in the decision- of people with diabetes. Gone are the the same as knowing what’s best for making process, and they respond posi- days of a didactic, one-size-fits-all someone with diabetes.” tively to that.” approach that obliged patients to “obey” ur work has been largely ometimes, it seems, research a rigid set of rules. Today, the patient is focused on helping health moves at a glacial pace. Basic recognized as the key to his or her own professionals let go of the old science must yield a molecular health. “O S idea of ‘getting people to change.’ It isn’t foundation for success. Then follow ani- “The concept of patient empowerment possible and it’s not our job or responsi- mal trials, then clinical trials that can last grew out of our work with patients here bility. Instead, our job is to help people for many years. Eva Feldman (M.D. at the center and with others around by creating a partnership — ‘you tell me 1983, Ph.D. 1979) is thrilled to make note the country,” says Funnell. “Empower- what you want, how hard you want to of a center study that is today making the ment is the recognition that people with work, and I’ll help you to reach those jump from basic science to clinical trials. diabetes give 99 percent of their own goals.’ This is a huge paradigm shift!” The center’s goal: understanding what causes the devastating complications that care and that each is the most important Funnell says that word of the care develop when blood glucose soars too person in determining their outcomes. patients receive at Michigan has high. What complex chain of chemical spread far and wide. “People “Professionals used to try to get events causes nerve damage, heart disease, come here because they people to care for themselves in the kidney failure and a host of other prob- know they’re going way health professionals thought lems? Five years ago, the center received was best. We’ve come to realize that to get excellent

Anne Jackson with son, Charlie Held, daughter, Alice Held, and husband, Peter Held Photo: D.C. Goings

38 Spring/Summer 2004 DIABETES 101 Time-dependent changes in PET images of the left ventricle of the heart from a 26-year-old “Diabetes” is an umbrella term for two female with type 1 diabetes. Blood flow to the heart, shown in the top four panels by blood distinct diseases that yield similar out- vessels’ ability to take up N13-ammonia, is normal. Sympathetic innervation, shown in the bottom four panels, indicates extensive lack of neurotransmitter tracer uptake and loss of comes. Type 1 diabetes, or “juvenile dia- nerve endings in the heart, a characteristic of cardiac autonomic neuropathy. betes” strikes most often in childhood, though more and more adults are developing it, for reasons doctors have been a landmark $6.6-million grant from the placebo. Each candidate undergoes a unable to explain. Type 1 is considered Juvenile Diabetes Research Foundation to PET scan at the beginning of the trial to an autoimmune disease, in which the work on answering these questions. It’s assess the innervation of the heart. We’ll body’s own T cells attack and destroy been money well spent. learn how well each subject’s heart is the insulin-producing islet cells in the innervated, then two years later, repeat pancreas. Without insulin in the blood- Says Feldman, a professor of neurology the PET scan and look for damage. stream, the body cannot properly and director of the center, “We have a metabolize glucose; nerve-damaging unifying underlying hypothesis: that “Nearly all of us at the center are physi- toxins accumulate in the blood. People diabetes complications are caused by cians who see patients and are doing with type 1 diabetes are dependent on glucose-mediated oxidative stress. What basic science. Our goal is to take what insulin injections, often several times a we have shown is that high blood glu- we learn in the lab and apply it to our day. Approximately 2 million Americans cose levels damage the mitochondria — patient population, and now that’s have type 1 diabetes. the powerhouse in human cells that pro- starting to happen.” duces the energy required by cells to Type 2 diabetes usually develops in But this is just one of several intriguing function. High glucose causes the mito- adulthood. The body continues to pro- avenues of research at the center. Says chondria to become dysfunctional and duce insulin, but is unable to respond to Feldman, “We are looking at the antioxi- to produce toxic metabolic byproducts it. Often, it can be controlled with diet dant response element, a little piece in a called superoxides. These superoxides and/or oral medications. Approximately gene that, when triggered, allows the cell (also called “reactive oxygen species”) 18 million Americans have type 2 diabetes. to get stronger, to fight oxidative stress cause oxidative stress in cells that are more vigorously. Many natural com- Both types can cause diabetic neuropa- prone to diabetic injury: kidney, nerve pounds appear to increase the cell’s ability thy — the degeneration of nerves — and retina.” to fight oxidative injury. Botanicals — the which can be manifested in many ways: Preliminary studies in tissue culture and active ingredients in broccoli and other urinary, digestive and heart problems, or mouse models of diabetes have paved plants and vegetables — appear to be very simply pain in the feet and legs. the way for a human clinical trial to test potent inducers of this antioxidant —WH a potential preventive treatment for dia- response element which then causes the betic neuropathy. “The idea is to use transcription of genes and the translation therapies that target multiple points of proteins used by the cells to fight off along the pathway that leads to oxida- oxidative injury. Theoretically, you could tive stress,” says Feldman. “We’re in the couple one of these potent botanical midst of a double-blind, placebo-con- agents with the amino acid taurine — trolled trial with three drugs. Partic- also a very potent antioxidant — and a ipants will receive alpha lipoic acid, more standard antioxidant, as a new nicotinamide, and allopurinol — each of triple therapy. Each component would which affects a different segment of the work on a different part of the pathway. oxidative stress pathway — or a Together, they’d be synergistic.”

Medicine at Michigan 39 In February of 2003, The New Yorker Arvan was recruited to U-M in 2003 The second area Arvan’s team is study- magazine published an article by from Albert Einstein College of Medicine ing involves potential gene therapies for Jerome Groopman, M.D., entitled in New York City. He brought with him type 1 diabetes. “Specifically, we’re “The Edmonton Protocol,” about seven coworkers without whom, he says, interested in trying to generate what’s advances in pancreatic islet cell trans- he never would have moved. known as a single-chain insulin analog plants. Subjects received donor islet — an artificial replacement gene. I see a “My lab is working on two main areas: cells via a tantalizingly simple proce- day when stem cells could be used that insulin secretion from cultured beta cell dure and were immediately freed from could differentiate into beta cells. lines,” says Arvan, “and from authentic insulin dependency. If it seemed too Surrogate cells, genetically engineered islets, from animal models — rats and good to be true, it was — for now at to generate insulin, could do the job and mice. We’re trying to understand how least. Michigan researchers are as anx- be implanted into an individual.” insulin gets packaged in an intracellular ious as anyone to find a cure for this compartment known as the secretory Ultimately, adds Arvan, the problem of disease, but transplant is not yet the granule. Ninety-nine percent of all insulin diabetes has to be attacked on multiple solution. For one thing, two or more is stored in this compartment. The for- levels. And at Michigan, that’s happening. pancreases are needed to harvest enough mation of this compartment in beta cells cells for a transplant. With a million Feldman concurs that although finding and the relationship of this insulin are Americans living with type 1 diabetes a lasting cure for diabetes is an ongoing crucial to glucose-regulated secretion of and only a few thousand acceptable goal, learning to prevent or control its insulin into the bloodstream.” donors per year, the barriers to equitable distribution are daunting. Photo: Juliana Thomas – Reproduced by permission of the Juvenile Diabetes Research Foundation “There is an incipient program for islet International transplantation at U-M, but so far none have taken place here,” says Peter Arvan, M.D., chief of endocrinology at the U-M Medical School. “The mainstay of diabetes treatment is still insulin, insulin, insulin. The single biggest advances in diabetes management are still advances in insulin.”

Eva Feldman and her team front: Tracy Schwab, Ph.D., research investigator; Arno Kumagai, M.D., clinical assistant professor of internal medicine; Frank C. Brosius, M.D. (Residency 1983), professor of internal medicine and of physiology back: Andrea Vincent, Ph.D., research investigator; Eva Feldman; Martin Stevens, M.D., associate professor of internal medicine; James Russell, M.D., associate professor of neurology; Christin Carter-Su, Ph.D., professor of molecular and integrative physiology; Kelli A. Sullivan, assistant research scientist

40 Spring/Summer 2004 Photo: Paul Jaronski Photo: Paul Peter Arvan and his team front: Young-nam Park, Ph.D., research associate; Peter Arvan; Xiang Zhao, graduate student back: Jaemin Lee, graduate student; Yukihiro Yamaguchi, Ph.D., postdoctoral fellow; Jose Ramos-Castaneda, Ph.D., postdoctoral fellow; Ming Liu, M.D., Ph.D., research associate; Roberto Lara-Lemus, M.D., Ph.D., postdoctoral fellow complications will have the most imme- molecular and integrative physiology in sue is much more complex, and that it diate impact. And, she says, the discov- the U-M Medical School. acts as an endocrine organ that releases eries made here may be easily applied to hormones. The hormones regulate the Curious and intrepid, Saltiel is deter- a host of other neurological diseases. body’s response to insulin.” Further mined to understand how cells respond research into this area by Saltiel and oth- “There’s an underlying common thread to insulin’s signals. His team is looking ers may lead to a new generation of in nerve damage,” she says, “whether at what happens inside the cell’s intri- drugs to fight diabetes or burn fat. it’s in the brain — such as in Alzheimer’s, cate machinery to determine how so “Understanding problems with how we Parkinson’s and Huntington’s diseases — many signals can spring from one hor- handle fat might provide a valuable clue or in the peripheral nerves. In all these mone-receptor interaction. They’ve to developing new therapies for dia- disorders, it appears that cells undergo a found that each signal appears to travel betes,” he says, “but we first need a bet- similar process of programmed death. a different path through a cell, depend- ter understanding of how insulin works So if we understand and clearly treat ing on what it’s saying. Says Saltiel, on healthy people. one neurological disorder, such as dia- “The inside of the cell isn’t just a bag of betic neuropathy, there should be appli- gunk; it’s very well organized.” “Diabetes is a worldwide epidemic — cability to other neurological diseases as and a terrible epidemic in our state. Here Though no one knows what triggers it, well.” at the Life Sciences Institute, we’re build- the first stage of developing diabetes is a ing a matrix organization to focus on hat role does insulin play in cel- reduced sensitivity to insulin’s signaling, important problems like this. It’s a hub lular signaling? How is insulin he explains. The clues may lie in the for scientists working in different areas, able to “tell” a cell to open its physiology of obesity, which is a hall- W but focused on common problems. That’s membrane to accept sugar, to burn up mark of type 2 diabetes. But why does the exciting part for me. The NIH sup- sugar, or to store it as glycogen or fat? an abundance of nutrition interfere port is great, but still inadequate. We’re with this system? Alan Saltiel, Ph.D., is trying to find out. looking to the Life Sciences Corridor, pri- “Fat cells were once thought of as merely vate industry, foundations and other You can’t talk about diabetes research a cargo space for energy storage,” says types of philanthropy, and hope to mount at the University of Michigan without Saltiel. “Now we know that adipose tis- a big effort in this area.” mentioning this affable scientist. With an international reputation as an expert on insulin, and well over 200 papers and 12 patents in his wake, Saltiel, the “Diabetes at Michigan has a remarkable history. It truly John Jacob Abel Collegiate Professor of the Life Sciences, was the first principal makes you feel part of a scientific family. I’m very proud investigator to join the U-M Life to be part of this long tradition of diabetes research and Sciences Institute in 2001 — the latest chapter in the University of Michigan’s treatment at Michigan.” tradition of world-class biomedical — Eva Feldman, professor of neurology and director, research. He became the institute’s U-M Juvenile Diabetes Research Foundation Center director in 2002, and also serves as a professor of internal medicine and of

Medicine at Michigan 41 Photo: Paul Thacker Photo: Paul Thacker

he leading diabetes research taking place at Michigan every T day owes a profound debt to every dedicated investigator who has come before. Stefan Fajans (pronounced “fi-yuns”) (M.D. 1942, Residency 1949) has researched and treated diabetes at the University of Michigan since 1946. Now retired, he still comes to his office every day to continue deciphering the fascinating puzzles of this disease. Fajans points to the top shelf of his bookcase, Alan Saltiel Stefan Fajans to a long line of battered, beige note- books dating back to 1950 and chroni- room learning from each other. Jason cling diabetes in one Michigan family there yet. The prevention and cure of asks Anne about her initial diagnosis, since 1958. Fajans’ careful observation diabetes isn’t going to happen overnight, how the news of her diabetes was broken of that and other families led to a star- but progress is being made at an to her, and how that felt. Suhani asks her tling discovery that has significantly astounding rate. I’m hoping that with about the different doctors she’s seen, affected medicine’s understanding of time, we’ll reach the stage where dia- how their styles of communication dif- type 2 diabetes by introducing the con- betes mellitus is no longer a worldwide fered. Then, the group completes an cept of MODY (mature-onset diabetes affliction.” exercise. All of them, including the stu- of the young). new program at U-M is dents, share a story of a personal loss, “See all those books up there?” he asks. designed to give medical stu- and how someone helped them cope “These are all records of individuals — A dents direct experience with with that loss. people who were completely asympto- people who are living with chronic dis- The students gain valuable interviewing matic and healthy. Most weren’t dia- eases. Says Arno Kumagai, M.D., who and listening skills, but beyond these betic at the time of their first conceived of and initiated the program, obvious things, they encounter patients examination. But they had a first-degree “The Family Centered Experience is a on their home turf, seeing them as much family history of diabetes: a parent, a required course for first- and second-year medical students. The purpose is to give sibling, a child. The conventional wis- more than just a collection of symptoms. them the opportunity to learn medicine dom in those days was that type 2 diabetes occurred only in middle age, but by doing these family studies, and by testing not only adults but also kids, I found that type 2 diabetes developed “The prevention and cure of diabetes isn’t going to and could be diagnosed in children as happen overnight, but progress is being made at an well. This familial predisposition was actually inherited in an autosomal dom- astounding rate.” inant fashion in some families to form a subtype of type 2 diabetes (MODY). By — Stefan Fajans, professor emeritus of internal medicine making the diagnosis early and treating young patients, we have avoided complications.” In 1991, he co-published the ‘from the other side of the stethoscope’ Says Bacha, “The program helps us first paper to describe a genetic marker by listening to the stories of individuals understand how the patient experiences for MODY; from this discovery, the gene with chronic or serious illnesses.” their illness outside of the doctor’s office, itself was found in 1996. In addition to and the profound effects that an illness Anne Jackson and her family are partici- that pioneering research into MODY, can have not only on a patient’s body, Fajans led the team in the 1960s that pating in the program. On an icy evening in January, medical students Jason Bacha but also on their sense of self, their emo- showed the involvement of amino acids in tions, their family, their beliefs, their insulin release. and Suhani Bora stand in the Jackson/ Held family’s front hall, stomping the relationships, their work ... in other “I love the discovery of new knowl- snow from their boots. Within a few words, their entire life. It’s one thing to edge,” he says, “and being able to help minutes the students and the entire fam- read about an illness in a textbook, but families with diabetes. But we’re not ily are sitting downstairs in the family it has been an entirely different experi-

42 Spring/Summer 2004 ence meeting, talking with and learning endocrinologist, Dr. Robert Lash. I’m with her colleague Bob Anderson helped from an individual who actually has the living proof of someone who has bene- coin the term “patient empowerment,” illness. fited from medical research and the new is that while her involvement with her technologies and treatments for type 1 patients’ health yields immediate satis- “Getting to know Anne and her family diabetes. When I was diagnosed, I was faction, communicating the wide spec- has been an extraordinary experience told I’d be on insulin for the rest of my trum of diabetes research at Michigan for me. Not only has she taught me life. It’s been 18 years and, yes, I’m still stirs ongoing excitement. “It’s a thrill to more about diabetes than I’ve learned on insulin, but instead of four shots per be able to tell people about all the from lectures, but the entire family has day, my insulin is now delivered by an research that’s going on here. That’s also taught me, through their own per- insulin pump the size of a beeper. I’m where the hope comes from — it’s sonal experiences and stories, how to be a looking forward to the day the insulin important for anyone with an illness.” more caring and compassionate doctor.” pump will be so small that it can And Funnell confides she has a hope of It’s this balance between hard-line basic be implanted and deliver insulin auto- her own. “My fervent wish,” she says science and the immeasurable value of matically, acting much like a ‘normal’ with a smile, “is that one day I’ll be out personal interaction between patient pancreas.” and health professional that makes of a job .... ” Michigan’s approach to diabetes singu- sk anyone with diabetes about larly effective. Jackson concurs. hope and the answer will come A swiftly: a transplant. A cure. “I have the best of both worlds in my Or an end to diabetic complications. medical care — the latest knowledge and technology at my disposal, and car- Part of the joy of her job, says Funnell, ing, patient-focused clinicians, like my the nurse and diabetes educator who

Suhani Bora, Jason Bacha and Anne Jackson ht:DC Goings Photo: D.C.

Medicine at Michigan 43 Looking Back

Paul de Kruif PAUL DE KRUIF: A MAN OF SCIENCE ... A MAN OF LETTERS

t was, arguably, one of those great, The unemployed bacteriologist was De Kruif went on in 1926 to write one of bristling, energizing, explosive times introduced to Sinclair Lewis, and de the best-selling and most widely read sci- Ito be alive: When Paul de Kruif Kruif, Markel writes, “was officially at ence books of all time. Microbe Hunters (Ph.D. 1916) arrived at Michigan in liberty to give up the dull drudgery of late has been translated into 18 languages 1912, bacteriology — the field he stud- nights in the laboratory for what he per- and was the first book with a totally sci- ied — and the germ theory of disease ceived to be the exciting life of a medical entific theme to sell over a million were revolutionizing medical science and journalist.” Lewis and de Kruif agreed to copies. At least two Hollywood movies practice, much the way the fields of collaborate on a medical novel. and a Broadway play were based on genetics and proteomics are today. Microbe Hunters, which is credited with Globally, the winds of war would gather “Within weeks,” according to Markel, inspiring an entire generation of biologi- over the decade, taking de Kruif himself “the two sold the book to Lewis’s pub- cal scientists to take up careers in to Army service in France where he rose lishers Harcourt and Brace and booked research. The book, which describes the in rank from first lieutenant to captain. passage on a steamship to the West Indies work of Leeuwenhoek, Spallanzani, And freedom flourished in literature and where they could work without distrac- Pasteur, Koch and others, is still in print journalism that dared confront the real- tions.” Arrowsmith was published in 1925 and available from Amazon.com, where ity behind the American façade, as with Sinclair Lewis listed as sole author, it continues to attract rave reviews for a works like Sinclair Lewis’ Main Street though Lewis had told Harcourt and timeless relevance that prompted one broke new literary ground. Brace before finishing the novel, “There’s reviewer to enthuse: a question as to whether [de Kruif] won’t De Kruif (rhymes with “life”) returned have contributed more than I shall have.” “From the top of today’s news, where to Ann Arbor after World War I to work reports of Ebola and HIV loom large, with bacteriologist Frederick Novy, but Indeed Markel writes, “De Kruif was comes the story of microbes, bacteria, in 1920 joined the Rockefeller Institute essential to the novel. Nearly all the sci- and how disease shapes our everyday for Medical Research (now Rockefeller entists, physicians, and medical institu- lives. The superheroes in this scheme are University) in New York City where he tions portrayed in Arrowsmith were the scientists, bacteriologists, doctors was assigned to a study of pathogenic drawn from his experience as a graduate and medical technicians who wage bacteria and the causes of respiratory student at the University of Michigan active war against bacteria. The new infection. As Howard Markel (M.D. and, later, as a research investigator at introduction to this book places this his- 1986), Ph.D., George E. Wantz Professor the Rockefeller Institute ... Martin tory in a thoroughly modern context.” and director of the U-M Center for the [Arrowsmith] comes under the spell of an History of Medicine, writes in his article immunology professor named Max Microbe Hunters was de Kruif’s most “Prescribing Arrowsmith,” de Kruif, in Gottleib, who is an amalgam of de Kruif’s successful and enduring work, and it just two years, “was fired by the mentor at Michigan, the professor of bac- earned him recognition as “America’s Rockefeller’s director, Simon Flexner, for teriology Frederick Novy, and his idol at first great science writer.” He continued writing a four-part series of articles on the Rockefeller, biologist Jacques Loeb.” writing books and magazine articles and, the medical profession entitled ‘Our late in life, moved to Holland, Michigan, Medicine Men,’ published in The Arrowsmith won the Pulitzer Prize in where he died in 1971, leaving behind an Century magazine.” Though de Kruif’s 1925, but Lewis turned it down saying he impressive body of work and what is contribution was anonymous, his didn’t believe in such awards. Though de undoubtedly one of the U-M Medical authorship of the scathing assessment of Kruif was complicit in not being listed as School’s most colorful stories. medicine in 1920s America as a co-author in order to preserve the book’s —RK “mélange of religious ritual, more or less sales (in which he held a 25 percent accurate folklore, and commercial cun- stake), he nonetheless decried in his ning” devoid of “a scientific approach to memoirs, The Sweeping Wind, the “brief Howard Markel’s “Prescribing Arrowsmith” appeared word of thanks in the acknowledgements in The New York Times Book Review on September disease prevention and treatment” was 28, 2000. found out. for ‘technical assistance.’” John Barton contributed to this article.

44 Spring/Summer 2004 The annual ritual of residency matching landed the U-M Medical School’s Class of 2004 at the following locations for the next stage of their training. This year’s Match Day IT’S A MATCH! event was held March 18 at Ann Arbor’s Sheraton Inn. MATCH DAY 2004

ANESTHESIOLOGY Scott Kelley Jaclyn Liston Susana Gonzalez Robert Christensen University of Michigan Hospitals Oregon Health & Science University New York-Presbyterian University Hospital, University of Michigan Hospitals Billy Liang Julie Phillips Columbia University Christian Consilvio University of Michigan Hospitals University of Michigan Hospitals Alice Gray Brigham and Women’s Hospital, Boston Elana Metlitzky Mark Shaver Duke University Medical Center, Durham Anna Dubovoy Maricopa Medical Center, Phoenix Oregon Health & Science University Amanda Hough University of Michigan Hospitals Michael Nauss Jean Wong University of Michigan Hospitals Nicholas Russo University of Cincinnati Hospital University of Michigan Hospitals Eric Humke Cleveland Clinic Uzoma Nriagu Barnes-Jewish Hospital, Saint Louis GENERAL SURGERY Vijay Saluja University of Rochester/Strong Memorial Denis Kapkov Beth Israel Deaconess Medical Center, Hospital Emily Bugeuad Ahmed Mount Sinai School of Medicine-Cabrini Boston Brian Rice University of Chicago Hospital Medical Center, New York City Valeri Walker University of Michigan Hospitals Alexander Ayzengart John Leung UCLA Medical Center Daniel Wachter University of California – San Francisco University of Iowa Hospitals and Clinics, University of Michigan Hospitals Medical Center Iowa City DERMATOLOGY Sumit De Gallia Levy Susan Tosh Butler EMERGENCY/INTERNAL MEDICINE Drexel University College of Medicine, Stanford Hospital and Clinics, California Saint Louis University School of Medicine Sergio Morales Philadelphia Ali Mahajerin Aaron Cetner East Carolina University School of Jennifer Ellis University of Michigan Hospitals University of Illinois College of Medicine, Medicine, Greenville Henry Ford Health Sciences Center, Renee Micielli Chicago Detroit University of Michigan Hospitals FAMILY PRACTICE Naomi Simon Alero Fregene John Miller University of Michigan Hospitals Tracy Bozung Henry Ford Health Sciences Center, Lenox Hill Hospital, Manhattan National Capital Consortium, Malcolm Detroit Dara Spearman Vaishalee Padgaonkar Grow U.S. Air Force Medical Center, University of Michigan Hospitals Mark Hausman New England Medical Center, Boston Bethesda University of Michigan Hospitals Jennifer Vis Chithra Perumalswami Maribel Flores University of Michigan Hospitals Natalie Hubbard University of Michigan Hospitals Scripps Memorial Hospital, La Jolla Henry Ford Health Sciences Center, Amir Rabbani Debra Graetz Detroit EMERGENCY MEDICINE University of Michigan Hospitals Munson Medical Center, Traverse City Brian Knipp Gretchen Carter Lorin Sanchez Andrew Heyman University of Michigan Hospitals Carolinas Medical Center, Charlotte Emory University School of Medicine, University of Michigan Hospitals Richard Carter Ruchi Mishra Atlanta Brehan King University of California Davis Medical Cook County-Stroger Hospital, Chicago Sean Sanchez University of California – San Francisco Center, Sacramento Christopher Hashikawa Emory University School of Medicine, Medical Center Brigham and Women’s Hospital, Boston Zarry Tavakkol Atlanta University of Washington Affiliated Manish Sharma Hospitals University of California – San Francisco Jason Toranto Medical Center University of Alabama Hospital, Virginia Skiba Birmingham National Naval Medical Center Chandu Vemuri Photo: Gregory Fox Njeri Thande University of Michigan Hospitals New York-Presbyterian University Hospital, Candace Williams Columbia University Baylor College of Medicine, Houston Susannah Watson University of Michigan Hospitals INTERNAL MEDICINE Justin Weiner Rene Aguirre University of Chicago Hospital Vanderbilt University Medical Center, Nashville MEDICINE – PEDIATRICS Amer Ardati Kristen Coulter Duke University Medical Center, Durham University of Minnesota Medical School, Daniel Becker Minneapolis Brigham and Women’s Hospital, Boston Aaron Daniel David Corteville University of Rochester/Strong Memorial University of California – San Francisco Hospital Medical Center Susan Hunt Daniel Dorgan Duke University Medical Center, Durham New York-Presbyterian University Hospital, Kari Mazur Columbia University Michigan State University, Kalamazoo Hien Duong Valerie Press Grand Rapids Medical Education and University of Chicago Hospital Research Center Carra Kettler and Aaron Daniel match with Strong Memorial Hospital at the University of Rochester.

Medicine at Michigan 45 Bretton Schloesser OTOLARYNGOLOGY Ohio State University Medical Center, Sara Cheng Columbus University of Colorado School of Medicine, Denver MEDICINE – PRELIMINARY Vasu Divi Photo: Gregory Fox Ojas Patel University of Michigan Hospitals Henry Ford Health Sciences Center, Detroit Vanessa Erickson Stanford Hospital and Clinics, California MEDICINE – PRIMARY Theresa Kim Erin Fouch University of California – San Francisco University of Washington Affiliated Medical Center Hospitals Ian Smith Johns Hopkins Hospital, Baltimore NEUROLOGICAL SURGERY Emun Abdu PATHOLOGY Oregon Health & Science University, Michael Bachman Portland Hospital of the University of David Bauer Pennsylvania, Philadelphia University of Alabama at Birmingham Christopher Hysell Allison Schnaar Rodgers shares the news of her match. Health System Massachusetts General Hospital, Boston Sachin Patel Martin Powers University of Michigan Hospitals New York-Presbyterian Hospital, Cornell PEDIATRICS/PSYCHIATRY/CHILD RADIOLOGY – DIAGNOSTIC AND ADOLESCENT PSYCHIATRY Chandan Reddy University, New York City Alicia Arnold University of Iowa Hospitals and Clinics, Andrea Ribier Brigham and Women’s Hospital, Boston Kajal Sitwala Cincinnati Children’s Hospital Medical Iowa City University of Michigan Hospitals Corey Bregman Center Rush University Medical Center, Chicago Allecia Wilson NEUROLOGY Jason Dykstra University of Michigan Hospitals PHYSICAL MEDICINE & Matt Bianchi Oakwood Hospital, Dearborn REHABILITATION Harvard Massachusetts General Hospital Jeffrey Hamlin PEDIATRICS Joline Skinner and Brigham and Women’s Hospital, Henry Ford Health Sciences Center, Shannon Carey Mayo Graduate School of Medicine, Boston Detroit Michigan State University, Kalamazoo Rochester OBSTETRICS – GYNECOLOGY Kristen Coulter Jamal Ksar Henry Ford Health Sciences Center, University of Minnesota Medical School, PLASTIC SURGERY Suzanne Bukrey Detroit University of North Carolina Hospital, Minneapolis Christian Kauffman Andrew Lipnik Chapel Hill Aaron Daniel University of Nevada School of Medicine, Reno McGaw Medical Center, Northwestern Aarti Dharmani University of Rochester/Strong Memorial University, Chicago Metrohealth Medical Center, Cleveland Hospital Karen Powers Sachit Malde Karen Hajra Marcos De La Cruz Virginia Commonwealth University Health Systems Henry Ford Health Sciences Center, University of Michigan Hospitals Medical College of Wisconsin Affiliated Detroit Hospitals, Milwaukee Jenifer McCarthy PSYCHIATRY Deepa Pai University of Michigan Hospitals Sarah DeHaan University of Michigan Hospitals University of Michigan Hospitals Smitha Anilesh Allison (Schnaar) Rodgers Emory University School of Medicine, Nita Parekh Metrohealth Medical Center, Cleveland Karen Fauman Atlanta University of Iowa Hospitals and Clinics, University of Michigan Hospitals Casey Tinianow Joshua Bess Iowa City San Antonio Uniformed Services Health Judy Galvez University of Michigan Hospitals Ario Rezaei Education Consortium Children’s Memorial Hospital, Chicago Ushimbra Buford The University Hospital, Cincinnati Alison Gehle OPHTHALMOLOGY Jackson Memorial Hospital, Florida Christopher Roth University of California – San Francisco Duke University Medical Center, Durham Eiyass Albeiruti Marie DeWitt Medical Center Rush University Medical Center, Chicago Jason Smythe Henry Ford Health Sciences Center, Susan Hunt Detroit Howard Liu UPMC Medical Education Program, Duke University Medical Center, Durham University of Michigan Hospitals Pittsburgh Gregory Fenton Cara Kettler Wills Eye Hospital, Philadelphia Ante Luburic Jason Swenson University of Rochester/Strong Memorial McGaw Medical Center, Northwestern University of Michigan Hospitals Jorge Fortun Hospital Baylor College of Medicine, Houston University, Chicago Alice Wang Amber (Kyle) Burnette Brian Mickey Ohio State University Medical Center, Craig Lewis Children’s National Medical Center Columbus Cleveland Clinic University of Michigan Hospitals Washington, DC Diana Mirzoyan Pauline Lim SURGERY – PRELIMINARY Jason Mailloux Harbor-UCLA Medical Center University of California Davis Health Edmond Baker Ohio State University Children’s Hospital, Sarah Mohiuddin System University of Michigan Hospitals Columbus University of Michigan Hospitals Vanetta Levesque ORTHOPAEDIC SURGERY Kari Mazur Paul Pfeiffer Michigan State University, Kalamazoo University of Michigan Hospitals Jaret Butler University of Michigan Hospitals Saint Louis University School of Medicine Melissa Pike Gabriel Valencia University of Southern Alabama, Mobile Daniel Chan University of Michigan Hospitals RADIATION ONCOLOGY Brian Alexander Jackson Memorial Hospital, Florida Valerie Press TRANSITIONAL University of Chicago Hospital Brigham and Women’s Hospital, Boston Michael Paczas Joel Slade Kiran Devisetty University Hospitals Cleveland Bretton Schloesser Naval Medical Center, San Diego Lawson Smart Ohio State University Medical Center, University of Chicago Hospital Yale-New Haven Hospital Columbus Kevin Oh UROLOGY University of Michigan Hospitals Vijay Thangamani Lauren Selph Hector Pimentel McGaw Medical Center, Northwestern University of Alabama Hospital, James Yu University of Illinois College of Medicine, University, Chicago Birmingham Yale-New Haven Hospital Chicago

46 Spring/Summer 2004 Incoming Residents, 2004 We welcome the following residents from other medical schools who begin their training at the University of Michigan Hospitals this year.

EMERGENCY MEDICINE Zachary Hector-Word Cynthia Brincat Laura Walls Christina Bruns Tulane University School of Medicine Loyola University Chicago Stritch School Saint Louis University Health Sciences University of Cincinnati College of Medicine Michele Hirsch of Medicine Center Temple University School of Medicine Camaryn Chrisman William Cardon PSYCHIATRY University of Chicago Pritzker School of Ted Huang Wake Forest University School of Medicine Medicine Southern Illinois University School of Praveen Kambam Medicine ORAL AND MAXILLOFACIAL University of Tennessee Health Science Eric Goldlust Center College of Medicine University of California – San Diego Gopa Iyer SURGERY/ HOSPITAL DENTISTRY School of Medicine Vanderbilt University School of Medicine Swapna Karkarla Belinda Koo University of Cincinnati College of Medicine Megan Laniewicz Nirmal Kaur Boston University School of Medicine Vanderbilt University School of Medicine State University of New York at Buffalo Irene Renieris Jennifer Kreisher School of Medicine Indiana University School of Medicine University of Chicago Pritzker School of LeVon O’ Haodha Medicine University of Minnesota – Minneapolis Robert Kennedy Zarar Tariq School of Medicine Jefferson Medical College of Thomas University of Maryland Cecile Lee University of Medicine and Dentistry of Paul Pazdalski Jefferson University Sarah Kohnstamm PATHOLOGY New Jersey – Robert Wood Johnson Georgetown University School of Medical School Medicine Yale University School of Medicine Jason Carvalho Reena Nandihalli Timothy Peterson Daniel Leventhal University of Wisconsin Medical School Case Western Reserve University School Malti Kshirsagar Michigan State University College of University of Cincinnati College of Osteopathic Medicine Medicine of Medicine Ohio State University College of Medicine Benjamin Sigal Meenakshi Mehrotra Amir Lagstein SURGERY Brown Medical School Vanderbilt University School of Medicine Tufts University School of Medicine Brett Almond Holly Weymouth Tyler Murphy Matthew Wasco University of Florida University of Vermont College of Medicine Medical College of Ohio University of Massachusetts Medical School Bradford Bader Douglas Nam University of Texas FAMILY MEDICINE University of Chicago Pritzker School of Medicine PEDIATRICS Dawn Barnes Christine Kistler University of Cincinnati College of Medicine University of North Carolina Shyamala Navada Peter Aziz Amy Chin Michael McCartney University of Illinois College of Medicine Ohio State University College of Medicine, Columbus University of Detroit Mercy Medical College of Ohio Sheri Nemeth Indiana University School of Medicine Sara Boblick John Erickson Cheryl Strzoda University of Texas Southwestern Medical University of Illinois College of Medicine Northwestern University – The Feinberg Sachin Parikh School of Medicine Center at Dallas University of Medicine and Dentistry of Ismael Yanga Timothy Frankel Wayne State University School of Medicine New Jersey – Robert Wood Johnson Jin Chang Medical School Boston University School of Medicine George Washington University INTERNAL MEDICINE Brian Parkin Cecile Danao Christopher Hempel University of Missouri Brian Bauman Medical College of Ohio Medical College of Ohio Case Western Reserve University School Shalini Paruthi Joyeeta Dastidar Simon Kim of Medicine University of Missouri Kansas City School Vanderbilt University School of Medicine Finch University of Health Sciences – Chicago Medical School Caroline Baumann of Medicine Aditi Dave University of Rochester School of Sharon Poisson University of South Florida College of Jeffrey Kozlow Medicine and Dentistry Indiana University School of Medicine Medicine Johns Hopkins Hospital Melike Bayram Deepika Polineni Amanda Flint Laura Monson Northwestern University – Feinberg University of Missouri Kansas City School Albany Medical College Wayne State University School of Medicine School of Medicine of Medicine Patrick Gordon Andrew Moore Jignesh Bhavsar Antwon Robinson Medical College of Georgia, Augusta University of North Carolina University of Medicine and Dentistry of University of Tennessee Health Science Marc Knepp Daniel Orringer New Jersey Center College of Medicine University of Illinois College of Medicine Ohio State University College of Medicine Allen Bruce Sima Saberi Jeffrey Knipstein Farhang Raaii Washington University School of Medicine Wayne State University School of Medicine Washington University School of Medicine Washington University School of Medicine Eric Cober Shannan Sams Kristin McAdams Matthew Rand Pennsylvania State University Milton S. University of Louisville School of Medicine Finch University of Health Sciences – Tufts University School of Medicine Hershey Medical Center George Skandamis Chicago Medical School Michael Salata Joseph Contessa Medical College of Ohio, Toledo Elizabeth Oh Case Western Reserve University School Medical College of Virginia Jessica Slocum Wayne State University School of Medicine of Medicine Commonwealth University Wayne State University School of Medicine Yaa Ohene-Fianko Bedabrata Sarkar Rowena Delos Santos Nicklaus Slocum Meharry Medical College School of New York University Creighton University School of Medicine Wayne State University School of Medicine Medicine Nicholas Seibert Najwa Elnachef Ashish Thekdi Gabe Owens University of Chicago Pritzker School of Wayne State University School of Medicine Case Western Reserve University School Case Western Reserve University School Medicine James Farry of Medicine of Medicine Miller Smith State University of New York at Syracuse Michael Walls Michelle (Ellington) Robida University of Alberta College of Medicine Saint Louis University Health Sciences Medical College of Georgia Lisa Tibor Brian Garvin Center Robert Rock University of California – San Francisco Boston University School of Medicine Mark Zaros Finch University of Health Sciences – Medical Center Robert Grande University of Miami School of Medicine Chicago Medical School Rou Wang Medical College of Ohio Bryan Zweig Ami Shah Northwestern University – Feinberg John Gribar Indiana University School of Medicine Wayne State University School of Medicine School of Medicine Jefferson Medical College of Thomas Sushant Srinivasan P.Daniel Ward Jefferson University OBSTETRICS/GYNECOLOGY University of Massachusetts Medical University of Utah Pavan Gupta Katherine Ballenger School Andrew Zwyghuizen University of Pittsburgh School of University of Louisville School of Rebecca Vartanian Vanderbilt University School of Medicine Medicine Wayne State University School of Medicine Medicine

Medicine at Michigan 47 Class Notes

1940s Margaret E. Grigsby (M.D. 1948), of Washington, MEDICINE AT MICHIGAN D.C., recently was elected by the American College of Physicians Board of Regents as the 2004 recipient GOES TO FLORIDA of the James D. Bruce Memorial Award for Dis- On February 2nd and 3rd, the Medical Center Alumni Society tinguished Contributions in Preventive Medicine. She and members of the U-M Health System visited Palm Beach

was also elected to mastership in the college by the McCarthy Photos: Megan and Naples, Florida, to update alumni and friends there on board in recognition of her career achievements. At the latest in research, Medical School education and clinical age 81, Grigsby reports that she is “still overwhelmed care at Michigan. A total of 357 people attended the semi- by the honors I am to receive from the ACP.” nars, which featured U-M Medical School Dean Allen Lichter, U-M Executive Vice President for Medical Affairs and Health System Chief Executive Officer Robert Kelch, Comprehensive 1960s Cancer Center Director Max Wicha, Ophthalmology Chair Floyd F. Miller, M.D. (Residency 1961), lives in Paul Lichter, and two of the U-M Cardiovascular Center’s Tulsa, Oklahoma, where he has spent decades directors, Richard Prager and James Stanley.The group spoke treating patients with pulmonary problems such as about exciting new initiatives in visual sciences, cardiovascu- asthma. He has served as president of both the lar health and cancer research and treatment. Oklahoma State Medical Association and of the Oklahoma University College of Medicine Alumni Association, and is founder, chairman and president of the state medical association’s self-insurance fund, PLICO. E.H. Newel Smith, M.D. (Residency 1961), of Windsor, Ontario, Canada, was recognized in February as one of four physicians who best served Grace Hospital during the past 40-50 years at a dinner recognizing the hospital’s closing. During his career at Grace Hospital, Smith encouraged many to donate their eyes to the eye bank and was an early supporter of corneal transplants in Ontario. James Ravin (M.D. 1968, Residency 1974) was recently voted president-elect of the Academy of Medicine of Toledo and Lucas County, and is president-elect of the Toledo Surgical Society. His article “Sir Frederick Treves and Sympathetic Ophthalmia” has authored. To was published in the January 2004 issue of the learn more about Archives of Ophthalmology. Haas and his practice, or to order his 1970s books, visit www.elsonhaas.com. Richard T. Miyamoto (M.D. 1970) has been elected a member of the Ralph M. Stanifer Institute of Medicine of the (M.D. 1973, Resi- National Academies. He is dency 1977) was appointed vice the Arilla Spence DeVault president and chief medical officer Professor and chairman of at Saint Luke’s Regional the Department of Oto- Medical Center in Sioux City, Frank Miller (M.D. 1974) was awarded distin- laryngology-Head and Neck Iowa on October 1, 2003. guished fellowship status in the American Psychi- Surgery at the Indiana Uni- Stanifer, a board-certified atric Association in 2003. He served as president of versity School of Medicine. ophthalmologist, will con- the North Carolina Council of Child and Adolescent He resides in Indianapolis. tinue to practice medical Psychiatry from 1985-89, was first chairperson of and surgical ophthalmology. the American Academy of Child and Adolescent Elson M. Haas (M.D. 1972), founder and director He was previously in private Psychiatry’s committee on HIV from 1988-90, and of the Preventive Medical Center of Marin in San practice in Sioux City since was Faculty of the Year at the University of South Rafael, California, has published several books 1990. In addition to his U-M Carolina at Columbia School of Medicine in 1996. dealing with preventive medicine, nutrition, and training, Stanifer served an internship at St. Joseph He also serves as child psychiatrist consultant to detoxification. Staying Healthy with Nutrition, The Mercy Hospital in Ann Arbor, and completed a fel- North Child Advocacy Institute. He and his wife have Staying Healthy Shopper’s Guide, Staying Healthy lowship in corneal surgery and external disease at one biological and one adopted daughter, and are With the Seasons, The Detox Diet, and The False the Cullen Eye Institute at the Baylor College of currently caring for their eighth foster child. Miller Fat Diet are some of the publications Haas Medicine in Houston, Texas. can be reached at [email protected].

48 Spring/Summer 2004 going on to medical school and residency training at the Max Karl Newman, Pioneer of Physical Medicine, U-M. He was a member of Dies at 94 the U.S. Air Force and Max Karl Newman (M.D. 1934), 94, died of a stroke on October reached the rank of captain before being honorably dis- 22, 2003, at his home in Bloomfield Hills, Michigan. He was a charged in 1962. Messer pioneer in physical medicine and rehabilitation, as well as an dedicated much of his pro- educator and philanthropist. Newman, who suffered from polio fessional life to the educa- as a child, helped form the specialty of physical medicine and tion of medical students rehabilitation and in 1953 founded the Detroit Institute of and ob/gyn residents. He spoke frequently across Physical Medicine and Rehabilitation, where he served as direc- the nation for many of the professional organiza- tor until his death. He was a consultant at the Jewish Home for tions he belonged to. Messer was an examiner for the Aged, the Catholic Home for the Aged, the Detroit House of the American College of Obstetricians/Gyne- Correction, three veteran’s health administration hospitals and cologists and served as chairman of the ob/gyn the Rehabilitation Institute of Detroit. He taught and/or held pro- departments at the University of Nebraska, fessorships at the University of Michigan, Michigan State University of New Mexico, and Texas Tech University. University and Wayne State University, where he served his In 1997 Texas Tech awarded him their Health internship after medical school. Newman also lived in Sciences Center Distinguished Faculty Service Award Scottsdale,Arizona, for 10 years with his wife, Sophia, where he developed a program for hand- and appointed him professor emeritus in the icapped children at the Samuel Gompers Clinic. He was widely published and a member of Department of Obstetrics and Gynecology, where he several medical and legal organizations related to his field. Throughout his career, his practice had served for 10 years. and interests focused on patients with neuromuscular abnormalities, such as cerebral palsy, residual effects of polio and muscular dystrophy, and, in more recent years, on aging patients David M. Mumford, M.D. (Residencies 1955, with stroke-related problems and degenerative orthopedic and neurological diseases. 1957, 1958), of Houston, Texas, died at age 76 on November 24, 2003, after suffering a stroke. Calvin Williams (M.D. 1955) died on January 2, Ralph Straffon’s Achievements Took Him from the Rose 2004, at his home in Encino, California. He was 86. Bowl to President of the ACS Williams was chief of the radiology department at Vanowen Radiology Medical Group and Valley Ralph A. Straffon (M.D. 1953, Residency 1956) died on Presbyterian Hospital for 35 years. Memorial contri- January 22, 2004, in Bonita Springs, Florida, at the age of 76. butions may be made to the Calvin and Annette In addition to receiving his medical training at the U-M, Straffon Williams Scholarship Fund, U-M Office of Medical was also a fullback on the football team and played in the 1951 Development, 301 E. Liberty St., Ste. 300, Ann Rose Bowl, helping the Wolverines beat University of California- Arbor, MI, 48104. Berkley, 14-6. Specializing in urology, Straffon helped pioneer dialysis and kidney transplantation programs at Michigan before leaving for the Cleveland Clinic in 1959. In Cleveland, Straffon held the positions of chair of urology, chief of surgery and chief of staff. The high point of his career, according to Straffon, was his election to the American College of Surgeons as a regent from 1980-89, and as president from 1991-92. WHAT’S “IN STORE” FOR YOU? MedGear — the Health System’s Lives Lived was named professor emeritus of pathology and of dentistry. Contributions may be made to the Ken new online store — is now open for Kenneth McClatchey (M.D. 1975, Residency business at 1978), a professor of pathology at the U-M Medical McClatchey Memorial Scholarship Fund, U-M Office School and professor of dentistry at the U-M School of Medical Development, 301 E. Liberty St., Ste. www.med.umich.edu/medgear of Dentistry, died December 21, 2003, at the age of 300, Ann Arbor, MI, 48104. MedGear is a secure online shop- 61. In addition to his medical degree and residency, James McKay McCord (M.D. 1942) died peace- ping service offering a wide variety McClatchey also received a bachelor’s of science fully at home on December 18, 2003 at the age of of quality merchandise at compet- (1964), a doctorate of dental science (1968) and 86. He served as a captain in the Army Air Corps a master’s of science (1971) from the U-M. During itive prices. All items are printed or and, following his education at U-M, he entered into embroidered with the official logo his U-M career, he was associate chair of the private practice in obstetrics and gynecology in Department of Pathology, and specialist in oral and Cincinnati, Ohio. of the U-M Health System, the forensic pathology and in clinical microbiology/ U-M Medical School or U-M virology. He received numerous awards from the Robert H. Messer (M.D. 1956, Residency 1961) Hospitals and Health Centers. Pro- medical and dental schools, as well as from died on August 13, 2003, in Sanford, Florida, at age ceeds support FRIENDS of the national organizations. He was active in the College 71 after battling a brain tumor. Born in Ludington, University of Michigan Hospitals. of American Pathologists, serving on its board of Michigan, Messer received his bachelor’s degree in governors from 1993-96. Upon his retirement, he chemistry from the University of Wisconsin before

Medicine at Michigan 49 A MICHIGAN MIRACLE IN CHICAGO by Peter J. Littrup (M.D. 1985)

erhaps to the dismay of legions of devoted alumni, I actually got P“Go-Blue’d out” after a short stint in the Michigan Marching Band (1978- 79). But fear not, this is a story of friends, medicine, miracles and how we all come home to roost, and root. My undergraduate days at U-M were a joy (B.S. ’80), but I came home from the 1978 Rose Bowl a beaten band-jock. It wasn’t just the defeat by USC and Charles White’s “invisible” touchdown, but also watching the band director cuff a kid for yawning at morning practice. After our Rose Bowl loss, we then watched Woody Hayes belt a Clemson player on national TV for having the audacity to intercept a pass in front of the Ohio State bench in another bowl game. Too much “rah-rah” gone awry for me. However, a saving grace in my freshman year was meeting Seth Kaplan. Five weeks after surgery, Peter Littrup (left) visits Seth Kaplan in front of Kaplan’s home in Chicago. He was also pre-med, but more gifted in knowing how to “score the grades.” While I suffered through honors chem- tion. The Chicago Tribune emphasized forced me to the floor. I could barely istry for a “B,” he coasted for the easy the shocking effect his sudden death had move. I put my head between my knees “A” in regular freshman chemistry. upon all who knew him. Other articles and called for help. Seth’s son Justin was described the rare, sometimes confusing already awake, watching TV on the next I’ve always been pretty much a loner. symptoms of aortic dissection. Many level of their brownstone. Marching to the beat of a different patients didn’t make it to the hospital. The next thing I knew, Seth was there. I drummer seemed to me more interest- Others, like Ritter, died on the operating asked him how long it might take for an ing. It also made me content to live table from complications of the massive, ambulance to arrive. He said, “It might alone in a large upper flat on Catherine yet delicate surgery. Of those who sur- Street the first year of med school. Seth vived, many experienced some form of take up to 45 minutes.” “I don’t think I thought it was strange to be living alone brain and heart damage. Being a radiolo- have 45 minutes,” I told him. Seth and like that, and he needed a roommate in gist, I hadn’t thought much about this his wife whisked me into their car a house he was managing. The low rent deadly condition, but I was struck by the despite me being just shy of dead weight. was quite appealing. Those last three humanity of the article and never know- The original plan was to go to years solidified a friendship that truly ing when “your time may be up.” These Northwestern Hospital, but when Seth turned out to be for life. thoughts were soon to become the basis saw my gray color in daylight he decided of some crucial decisions. on the closest level 1 trauma center, Last September I gave a couple talks in Illinois Masonic. Seth is a practicing Chicago and was staying at a resort that The next morning when I awoke and sat ophthalmologist, but I trusted his deci- had a lap pool. Swimming had resurfaced up, I was hit by a searing pain in my sion. He first had been board certified as in my life as a great stress reducer, and I chest that ripped upward toward my an emergency room physician and had had put in a mile that Thursday and throat from deep inside. I tried to shake trained in Chicago. I didn’t recognize the again on Friday. But Seth encouraged me it off by taking a shower. The pain less- hospital, so I just asked Seth to try to get to stay the remainder of the weekend at ened somewhat and I thought I should the best surgeons to come in on that his home near Lincoln Park until I had to be a good jock and “walk it off.” After Sunday morning. I already had a premo- return home on Sunday. Before giving all, morning pains get more common nition of aortic dissection. another talk on Saturday afternoon, I after 40! But I became dizzier in the enjoyed a leisurely morning of reading in shower; I had to sit down. Something When we arrived, Seth transformed into Seth’s kitchen. An article about the was really wrong. Somehow I got Super Doc. He doesn’t want to hear it, tragedy of John Ritter grabbed my atten- dressed, but an overwhelming weakness but he certainly seemed like my “hero”

50 Spring/Summer 2004 at the time. He parked right at the chaplain to say a prayer before they the aortic arch, limiting the extent of the entrance, grabbed a wheelchair and got wheeled me off to the operating room. repair needed. Better yet, the blood and me into it. He blew through security and clot they found in and around the head Only an hour-and-a-half had passed triage saying, “I’m an ER doc and my vessels of the aortic arch were removed since the first ripping pain. I continued friend is having a massive MI. I’m taking without causing stroke or significant holding Seth’s hand down the hallway to him right to a cardiology bay!” I wanted side effects. Seth knew I was going to be surgery, quietly praying. I promised to tell him it felt more like a dissection, all right when I focused my combative- but hey, he was the guy who knew how ness after surgery on wanting an alpha- to score the grades. He certainly got bet board hanging on the wall in the everyone primed and moving! My blood intensive care unit. Despite being intu- pressure hovered in the 70s and they Seth knew I was going bated and groggy, I wanted to tap out couldn’t get an initial temperature. The the message, “I M-A-D-E I-T!” Maybe I cardiac surgeons appeared after an to be all right when I believed my wife and sons could hear it, echocardiogram showed an aortic dis- focused my combative- too. But the best thing I ever heard a sur- section, complete aortic insufficiency geon say came from Dr. Montoya the and pericardial fluid. Things had pro- ness after surgery on next morning. He told me that the repair gressed into partial rupture, and my wanting an alphabet that he and Thomas had done looked blood pressure was becoming unstable. “gorrrrgeous!” I was going to be fine. Seth told me not to worry since the lead board hanging on the The rest of the story has yet to be told. surgeon, Donald Thomas (M.D. 1986), wall in the intensive I’m not sure why my life was saved that was also a Michigan-man just a year day. Time can only be my friend in solv- behind us. I didn’t know it at the time, care unit. Despite being ing that mystery; every day is now a pre- but his partner, Alvaro Montoya, had 30 intubated and groggy, cious reminder of my second chance. All years experience and had led the cardiac I know is that it took a miracle to avert a transplant service at Loyola. These guys I wanted to tap out catastrophe. When I analyze it, a catas- turned out to be my Dream Team. trophe and a miracle seem to be diamet- Somehow I remained conscious through the message, ric opposites on a probability scale. Both the pre-op frenzy and even selected a “I M-A-D-E I-T!” are rare, unforeseen events. The odds for biological over a mechanical aortic valve everything going right that day seem in a power-chat with Dr. Thomas. From incalculable, inexplicable and divine. I’m having seen complications on CT, I grateful that I can write these words of knew I wanted to avoid the powerful myself that it was not going to be the last thanks to all the wonderful people anticoagulant Coumadin if possible. But conversation I would have with my son! involved every step of the way. I am par- time was running out. My skin color had faded to a mottled ticularly grateful for long-time friends, as blue-gray and my pressure was dropping. well as new ones that I have yet to make. Seth displayed character traits that I will My neck veins bulged in an ominous sign I treasure the power of a parent’s love, be eternally grateful for in a physician of impending death from tamponade, allowing us to fight against all odds just and a friend — love and compassion. He whereby the blood could no longer enter to “be there.” What seems certain is a held my hand so often during this entire a heart that was being squeezed like a new calling to watch over my sons, like ordeal that my sheer terror was kept at boa constrictor by the surrounding blood someone did for me. In the follow-up bay long enough to talk to my son. At in the pericardium. I told those around aftermath, Gerrit was diagnosed with first, Seth couldn’t reach my wife, me that I was getting even dizzier. The mild hypertension and a dilated aortic Martha, but he asked if I wanted to last thing I heard was, “Pressure 60 and root. My Michigan cardiologist, Kim speak with my oldest son, Gerrit, 15. dropping. We gotta go now!” Eagle, perhaps gave me the most pro- When I heard Gerrit’s voice, the ugly found insight: “If you’re wondering why facts of operative mortality and morbid- After getting me on bypass, my chest you made it through this incredible ity choked me up. I could tell him only was opened. A large amount of bluish event, perhaps it’s so you have the chance that I was truly scared because I was blood was found around my heart, pre- to be your son’s guardian angel…” going into a big operation. I regretted venting it from beating effectively. Dr. telling him even that, but I wanted to be Thomas later told me I didn’t have min- Finally, I can’t escape the fact that I now honest. My thoughts were getting fog- utes left, only moments. My aorta was have renewed pride in being “a gier as the sustained hypotension took torn and dilated up to six centimeters Michigan man,” even though I never its toll. I was finally able to talk to while my otherwise clean coronary want any more blue blood squeezing my Martha but the fog was getting thicker, arteries were just hanging off this blown heart. So, hail to the victors … hail to and all I could manage was, “I love segment. Had it not been for the swim- my conquering heroes! Go Blue! you.” I felt like I was literally clinging to ming, and perhaps also my more anaer- life and I focused on holding the hands obic interval training, I might not have of Seth and a wonderful nurse, come out of the ordeal without obvious Peter Littrup, of Bloomfield Hills, is a professor of Meredith. I even asked the surgeons to heart damage. Curiously, the dissection radiology, urology and radiation oncology at Wayne pray for me. Meredith got a hospital stopped there and didn’t wrap around State University School of Medicine.

Medicine at Michigan 51 In the Limelight

Thomas Carli (M.D. 1972, ment of cardiovascular science.” Ginsburg, who is Development, has been Residency 1973), clinical also a research professor in the U-M Life Sciences appointed to the National associate professor of psy- Institute, a Howard Hughes Medical Institute Institutes of Health’s Advisory chiatry, has been named investigator, and co-author of one of the leading Committee on Research on assistant dean for clinical textbooks for medical students, was one of two Women’s Health. His mem- affairs. In his new role, he will prize winners this year. He was cited for “pivotal bership on the committee will focus on medical and dis- discoveries ... that open the way to more effective be effective through January ease management programs, strategies for prevention and treatment of numer- 31, 2007. The committee is the development of inte- ous major inherited bleeding and clotting disor- responsible for advising the grated services, and new ders, including von Willebrand disease.” director of the NIH Office of models of care for chronically ill populations. Carli Research on Women’s Health on appropriate also directs the U-M Depression Center’s commu- Carmen R. Green, M.D. research activities to be undertaken by the nity and network programs. He is the former direc- (Residency 1992), associate national research institutes with respect to tor of the managed behavioral health division and professor of anesthesiology, women’s health and related issues. Johnson initi- current M-CARE medical director for behavioral participated in a first-of-its- ated the Women’s Health Program at U-M, which health. For the past four years, he has also been kind symposium entitled has received designation and funding by the U.S. medical director of the U-M Health System’s “Narrative, Pain and Suf- Department of Health and Human Services as a Medical Management Center and Disease fering,” held at the Bellagio National Center of Excellence in Women’s Health. Management Programs. In this capacity, he serves Study and Conference Center as medical director of health plans with Ford Motor located on Lake Como in Ovide F. Pomerleau, Ph.D., professor of psychol- (Partnership Health), General Motors (Activecare), Bellagio, Italy, in October, ogy in the Department of Psychiatry and director and county Medicaid (Washtenaw Community 2003. The center is owned by the Rockefeller of the Behavioral Medicine Program, was Health Organization). His research interests include Foundation and is renowned as a retreat where awarded the 2004 Ove Ferno Award for Clinical the development of new care management models the likes of Verdi and John F.Kennedy Jr. wrote sig- Research for innovative research on nicotine and for people with chronic illnesses. nificant works. Green’s presentation focused on tobacco. Given once every three years by the the role of disparities in pain as they relate to age, Society for Research on Nicotine and Tobacco, the Valerie Castle, M.D. (Resi- race, gender and social stratification, as well as award acknowledges groundbreaking conceptual dency 1990), the Ravitz the role narrative medicine might play in helping and scientific contributions to the field of tobacco Foundation Professor of Ped- the physician. and nicotine research, and outstanding leader- iatrics, chair of Pediatrics and ship in nicotine and tobacco research dissemina- Communicable Diseases, Genevieve Kruger, M.D./ tion activities. Pomerleau received the award at and pediatric oncologist, Ph.D. candidate in the the society’s annual conference in Scottsdale, received the 2003 RARE Medical Scientist Training Arizona, where he presented a plenary lecture on Foundation award for Health- Program and the Program in his research. care Excellence. The RARE Cellular and Molecular Bio- Foundation’s mission is to logy, is one of 17 graduate Howard Shevrin, Ph.D., a recognize achievement and reward excellence by students from the U.S. and professor of psychology in identifying people in the local working community Canada chosen to receive the Department of Psychiatry who set exceptional examples for today’s youth. the 2004 Harold M.Weintraub and in the U-M College of Rather than celebrating the famous, the Michigan- Graduate Student Award Literature, Science, and the based foundation acknowledges the accomplish- sponsored by the Basic Sciences Division of Fred Arts, was named one of four ments of those who serve as local role models Hutchinson Cancer Research Center. Nominations winners of the Mary S. and heroes in everyday life. Castle received the were solicited internationally; the winners were Sigourney Award for 2003. award in a ceremony on October 27, 2003, held selected on the basis of the quality, originality and He received the award on in Detroit. significance of their work. The award, established January 23 in New York. The in 2000, honors the late Harold M. Weintraub, award recognizes outstanding achievements in David Ginsburg, M.D., the Ph.D., a founding member of Fred Hutchinson’s applied psychoanalysis and research. Given by the James V. Neel Distinguished Basic Sciences Division, who died in 1995 from Mary S. Sigourney Award Trust, an independent Professor in the departments brain cancer at the age of 49. Weintraub was an foundation named for a California publisher who of Internal Medicine and international leader in the field of molecular biol- sought to reward new activity in psychoanalysis, Human Genetics, has been ogy. Kruger studies neural crest stem cells, primi- the award is given to U.S. recipients only once awarded the American Heart tive cells that generate the peripheral nervous every three years. For more than 40 years, Shevrin Association’s Basic Research system during early fetal development. has worked at the boundaries between the disci- Prize, one of the associa- plines of neuroscience and psychoanalysis, look- tion’s highest accolades, for Timothy R.B. Johnson, M.D. (Residency 1979), ing for evidence that Freudian concepts such as his discovery of molecular the Bates Professor of the Diseases of Women the unconscious and repression could be docu- genetic defects causing major bleeding disorders. and Children, chair of obstetrics and gynecology, mented through physical measures of brain The association awards the prize annually to rec- professor of women’s studies, and research scien- activity. ognize “outstanding contributions to the advance- tist in the Center for Human Growth and

52 Spring/Summer 2004 Gil Omenn to Serve as President of the American Association for the Advancement of Science

Gilbert S. Omenn, M.D., Ph.D. — professor of internal medicine and of human genetics in the U-M Medical School and a professor in the U-M School of Public Health — is the president-elect of the American Association for the Advancement of Science (AAAS). With nearly 10 million mem-

Photo: Martin Vloet Photo: Martin bers,AAAS is the world’s largest general scientific society and the publisher of the prestigious journal Science.

Omenn’s three-year term of office on the AAAS Board of Directors began at the association’s annual meeting in February. He will serve as the association’s president for one year, beginning in February 2005. In addition to leadership responsibilities for the organization, the president serves as an international spokesperson for issues related to scientific research and policy.

Omenn, who came to Michigan in 1997 when former U-M President Lee Bollinger appointed him the university’s executive vice president for medical affairs and CEO of the U-M Health System, was formerly dean of the School of Public Health and professor of medicine and environmental health at the University of Washington in Seattle.

New Department Chair for Neurology

he U-M Medical School has chosen David Fink, M.D., a clinical neurologist and gene Photo: Marcia Ledford Ttherapy expert, to be the new chair of its Department of Neurology and the first Robert Brear Professor of Neurology. Fink is a clinical neurologist whose research focuses on developing gene therapies for diseases of the nervous system. He comes to U-M from the University of Pittsburgh where he was a professor of neurology, vice chair for VA affairs in the Department of Neurology, chief of the neurology service at the VA Pittsburgh Healthcare System, and director of the system’s Geriatric Research Education and Clinical Center. “Gene therapy is one of medicine’s most exciting new frontiers. David Fink’s expertise in this area will help strengthen U-M’s reputation as a leader in the development of thera- peutic technologies in this promising field,”says Allen S. Lichter (M.D. 1972), dean of the U-M Medical School. “David’s rare combination of research excellence, clinical skill and leadership ability will be invaluable to the U-M Medical School and its neurology department as we continue to expand programs in research and patient care.” Fink received his M.D. from Harvard Medical School. He completed his residency in internal medicine at the Massachusetts General Hospital in Boston, was a postdoctoral research fellow in neurochemistry at the National Institutes of Health, and served as resident and chief resident in neurology at the University of California, San Francisco. He is board certified in internal medicine and neurology. —SFP David Fink

Medicine at Michigan 53 William L. Smith (Ph.D. 1971), the Minor J. Coon Professor of Biological Chem- istry and chair of the Depart- Walter Block, Professor Emeritus of ment of Biological Chemistry, Biochemistry, Dies at 92 has received the 2004 Avanti Award in Lipids, sponsored Walter D. Block (Ph.D. 1938), associate professor emeritus of biochemistry in the U-M by the American Society for Medical School’s Department of Dermatology and professor emeritus of human nutrition Biochemistry and Molecular in the U-M School of Public Health, died January 5 in Ann Arbor. He was 92. Biology, in recognition of his outstanding research contributions. Smith pre- Born in Dayton, Ohio, Block received his bachelor’s degree in chemical engineering from sented a lecture, entitled “Structure, Function and the University of Dayton and his master’s and doctoral degrees from U-M. From 1939 to Regulation of Cyclooxygenases,” at the society’s 1944, he served as an instructor in the Department of Biological Chemistry and as a annual meeting in Boston in June. research associate in the Rackham Arthritis Research Unit. He went on to become an assistant professor of biological chemistry in the Department of Dermatology, and in Rajiv Tandon, M.D., professor 1967 joined the faculty of the U-M School of Public Health, where he taught until his of psychiatry and director, retirement in 1982. From 1970 to 1976, Block was chair of the Nutritional Science Schizophrenia Division, and Program in Rackham Graduate School. Tom Carli (M.D. 1972, Residency 1973), clinical Throughout his career, he served as a consultant and advisor to clinical and research lab- associate professor of psy- oratories in Michigan and Indiana. During the late 1940s, he was a biochemical consult- chiatry and assistant dean ant for the Viobin Corporation in Springfield, Ohio. His many research interests included for clinical affairs, have been protein-calorie malnutrition, the role of standardized exercise on tissue-lipid distribution, appointed by Michigan triglyceride and carbohydrate metabolism in normal adults and in patients with coronary Tandon Governor Jennifer Granholm heart disease, and biochemical studies related to the renowned Tecumseh Community to the Michigan Mental Health Survey. He was the author or co-author of more than 250 scientific publications Health Commission. Established as a temporary and several books, including the first textbook on the treatment of arthritis with gold salts body appointed by executive order, it is the state’s and a genetic study on amyloidosis in the Amish population of Bluffton, Indiana. first commission designed to recommend sweeping changes in both the delivery of service and effectiveness of Michigan’s mental health network. Members will meet in 2004 to re-evaluate the state’s publicly funded mental health system with cytokines, complement and protease inhibitors. Warren also was elected by the Michigan Health the ultimate goal of using its recommendations to More than 400 of Ward’s papers have appeared in and Hospital Association as treasurer of its cor- transform Michigan’s mental health system into a peer-reviewed journals. porate board through July 2004. Corporate board national model. The commission is comprised of officers direct the Lansing-based association’s mental health consumers, advocates, care Larry Warren, associate vice statewide representation of Michigan hospitals, providers, and representatives from law enforce- president of the U-M Health health systems and health care providers through ment, the courts, policymakers and the public. System, has been reap- education, advocacy and communication. pointed for a second term Peter A. Ward (M.D. 1960, through early 2008. Warren Gregory T. Wolf (M.D. 1973), Residency 1963), the Godfrey first served as interim direc- chair and professor of oto- D. Stobbe Professor of Path- tor of the U-M Hospitals and laryngology — head and neck ology and chair and profes- Health Centers for nearly two surgery, received a Presi- sor of pathology, was elected years before being named dential Citation from the as an inaugural fellow of the executive director in 1998. American Academy of Oto- Council on Cardiopulmonary, Along with his reappointment for a second five- laryngology — Head and Perioperative and Critical year term,Warren received a new title, director and Neck Surgery in September Care, which carries the desig- chief executive officer of the U-M Hospitals and 2003 at its annual meeting nation of Fellow of the Ameri- Health Centers. The reappointment also continues in Orlando, Florida. The cita- can Heart Association. Ward has served on his current title within the health system leader- tion was awarded to Wolf for his leadership in numerous national review boards, has been pres- ship and his adjunct professorship in the U-M establishing multi-institutional trials in head and ident of the U.S. and Canadian Academy of School of Public Health. Warren is credited with neck oncology that helped redefine organ preser- Pathology, the American Board of Pathology, the leading the hospitals and health centers to excel- vation. Wolf began his service at U-M in 1980, American Society for Experimental Pathology, and lent financial health, increased clinical activity and when he was recruited from the National Cancer Universities Associated for Education and Research high quality of care during a time when many hos- Institute. He became chair of the Department of in Pathology.He also served as interim dean of the pitals have struggled due to declines in reim- Otolaryngology — Head and Neck Surgery in U-M Medical School from 1982-85. His research bursement and major increases in costs for 1993. relates to mediators and regulators of the inflam- technology, pharmaceuticals, regulatory compli- matory response, with particular emphasis on ance and staff compensation.

54 Spring/Summer 2004 Michigan’s Continuing Medical Education Program IN PRINT Caring for children with chronic illnesses … addressing geriatric problems in primary care … Parkinson’s disease … practical By Ragavendra R. Baliga, M.D., clinical assistant professor of internal training in vascular interventions … just a medicine: Self-Assessment in Clinical Medicine. W.B. Saunders, 2003. sampling of the upcoming topics in U-M’s Continuing Medical Education program. By Bruce M. Carlson, M.D., Ph.D., professor of anatomy and cell and For information on course content, dates developmental biology: Human Embryology and Developmental Biology, and locations, visit Medical Education’s Web third edition. Elsevier Inc., 2004. site at www.med.umich.edu/meded, call Edited by Kim A. Eagle, M.D., chief of clinical cardiology and the (734) 763-1400 or (800) 800-0666, or Albion Walter Hewlett Professor of Internal Medicine: Current Journal e-mail [email protected]. Review. American College of Cardiology and Elsevier Inc., 2004. Edited by Evan T. Keller, D.V.M., Ph.D., associate professor of com- Upcoming Events in the U-M parative medicine and of pathology, and Leland W.K. Chu, Ph.D.: The Biology of Skeletal Metastases, volume 118 of Cancer Treatment and Medical School Research. Kluwer Academic Publishers, 2004. Edited by Israel Liberzon, M.D. (Residency 1992), associate professor of AUGUST psychiatry: Neuroimaging of Emotion. CNS Spectrums, April 2004. 2 M-1 Orientation Week begins By Howard Markel (M.D. 1986), Ph.D., director of the Center for the 8 Class of 2008 Family Day History of Medicine and the George E. Wantz Professor of the and White Coat Ceremony History of Medicine: When Germs Travel: Six Major Epidemics That Invaded America Since 1900 and the Fears They Have OCTOBER Unleashed. Pantheon/Random House, 2004. 8-9 Reunion Weekend Edited by Mark Pearlman, M.D., S. Jan Behrman Collegiate Football Game: U-M vs. Professor of Reproductive Medicine, professor of obstetrics and Minnesota gynecology and of surgery; Judith E. Tintinalli, M.D. (Residency 12 Institute of Medicine 2003 1974); Pamela L. Dyne, M.D.: Obstetric and Gynecological Inductees Reception Emergencies: Diagnosis and Management. McGraw-Hill, 2004. 21 Inauguration of the William K. and Delores S. Brehm Professor- By Kenneth Pienta, M.D., professor of internal medicine and of urology ship in Type 1 Diabetes Research and director, urologic oncology, and Mark A. Moyad, Phil F. Jenkins 28 Inauguration of the Frederick Director of Complementary Medicine, Department of G.L. Huetwell and William D. Urology: Prostate Cancer from A to Z. J.W. Edwards, Robinson Professorship in Inc., by special arrangement with the Ann Arbor Media Rheumatology Group, 2004. Edited by Kenneth Pienta: The Conundrum of Rising Prostate-Specific Antigen: Prevention and Treatment, volume 62, NOVEMBER number 6B of Urology. Elsevier Inc., December 2003. 15 4th annual Faculty Awards Dinner Edited by Scott Ransom, D.O., associate professor of obstetrics and gynecology: The Wisdom of Top Health Care CEOs. American College of Physicians Press, 2003. Edited by Bruce Richardson, M.D., Ph.D. (Residency 1979), pro- Corrections fessor of internal medicine: DNA Methylation in the Immune The fall 2003 issue of Medicine at Michigan mis- System, volume 109, issue 1 of Clinical Immunology. Elsevier, Inc., takenly cited new Department of Pediatrics and October 2003. Communicable Diseases Chair Valerie Castle, By Sanjay Saint, M.D., associate professor of internal medicine, M.D., as the David Murray Cowie Professor of and Craig D. Frances, M.D.: Saint-Frances Guide to Inpatient Pediatrics. In actuality, Castle has been named to the Ravitz Foundation Professorship in Pediatrics Medicine, second edition. Lippincott Williams & Wilkins, 2004. and Communicable Diseases. Edited by Susan E. Shore, Ph.D., research associate professor, In “Class Notes,” we reported that Joel Zrull (M.D. Kresge Research Hearing Institute; Stephanie Clarke; and Eric M. 1957, Residency 1961) received the Agnes Rouiller: Central Auditory Processing: Integration with Other Purcell McGavin Award for Distinguished Career Systems, volume 153, number 4 of Experimental Brain Research. Achievement in Child and Adolescent Psychology Springer-Verlag, December 2003. from the American Psychiatric Association. The award was, of course, in psychiatry, not psychology.

Medicine at Michigan 55 Message from the Executive Vice President for Medical Affairs

The University of Michigan can take great pride in with other county agencies, and many of the its ongoing contributions to solving the critical Washtenaw Health Plan enrollees also receive pre- national problem of disparities in health care, scription drug coverage through innovative county including the plight of the uninsured. U-M President programs. Nearly 37,000 people in the county — Mary Sue Coleman has taken a national leadership including 6,500 children — are among the unin- role by chairing the Institute of Medicine’s sured, a critical community concern. Committee on the Consequences of Uninsurance; In Washtenaw County, more than 2,000 individuals the final report of that committee’s three years of access the Homeless Shelter each year, where volun- work is described on pages 24 and 25 of this issue. teer U-M physicians provide physical health care. In Our attention, however, is not exclusively focused on the coming year, internal medicine residents will the national arena. One of the strategic principles begin rotating through the shelter, increasing the that guides the work of the U-M Health System is amount of care provided. that of “taking care of our own.” We have an obli- We are far from solving the social problem of the gation to our community and remain committed to uninsured and underserved, but we have the com- improving the health of the population in our pri- mitment we need from health care leaders, mary service area. Academic health centers charac- providers and the community to teristically have a significant social work together in tackling this mission, which includes providing tough problem. care to the most needy in their area, We have an and we at Michigan embrace that obligation to our “Taking care of our own” also mission. includes those at the heart of the community and U-M Health System itself — the The Washtenaw Community Health employees who, on a daily basis, Organization is a prime example of remain committed often in unheralded but heroic U-M’s service to the local commu- to improving fashion, go about the quiet work nity. A public entity formed by the of sustaining the intricate func- U-M regents and the Washtenaw the health of the tions and systems that result in top County commissioners, the WCHO population in quality health care for all of our brings together mental health, sub- patients. One of my greatest con- stance abuse and physical health our primary cerns for the future is the mainte- services for the Medicaid and unin- service area. nance of a highly effective, satisfied sured populations in the county. By and productive workforce, espe- merging resources and care, we are cially in view of current and pend- integrating services for vulnerable populations across ing workforce shortage projections. We will do different treatment settings and improving care for everything we can to retain great employees, many previously underserved members of the com- retraining them as new knowledge creates new tech- munity. The WCHO serves some 15,000 M-CARE nology and treatments, in order to continue provid- Medicaid members, including more than 3,000 indi- ing expert care with ever-increasing efficiency and viduals with serious mental illness, and provides cost effectiveness. additional services to the remaining Medicaid and uninsured in the county. In its local efforts, the The challenges, nationally as well as locally, are pro- WCHO administers over $20 million per year in found, but so are our collective resources. I am physical health care services and nearly $50 million pleased to live and work in an area where so many per year in community mental health services. In its people are working together to improve care for regional affiliation with Lenawee, Monroe and everyone who needs it. Livingston counties, the WCHO administers an additional $50 million annually in mental health and sub- stance abuse services. The U-M Health System also is a founding partner in a program that provides health care to the uninsured in Washtenaw County. The Washtenaw Health Plan enrolls 4,000 residents; half are Robert P. Kelch (M.D. 1967, Residency 1970) assigned to the U-M where they receive all outpa- U-M Executive Vice President for Medical Affairs tient and inpatient care. Close coordination occurs and CEO, U-M Health System

56 Spring/Summer 2004 Photo: Gregory Fox

“With a scholarship gift, you get to see results right away.”away.”

Ophthalmologist and Michigan medical alumnus Tom Varbedian (Class of 1956), whose scholarship gift this year is assisting second-year student Stephen Warnick, who comes from the city of Eastpointe north of Detroit.

Annual named scholarships, which may be established with gifts of $5,000 or more, provide financial support to a medical student in need and create an opportunity to be involved in the life of the University of Michigan Medical School and the future of medicine in an immediate and meaningful way. To learn more about how to establish your own named annual scholarship in the U-M Medical School, or to provide help to a resident in a particular department, please contact Sandi Campione at (734) 998-0358 or [email protected]. You may also request a copy of “Lifting the Burden…Realizing the Dream,” a 12-minute video on the need for scholarship support, in VHS or DVD format, by contacting Ms. Campione.