Officers and Directors at Large Editorial Board Medical Organization Director Councilor Directors Coordinator, Residency Initiatives Student Directors Administrative Office 525 Middle!eld Road, Suite 130 Editorial AΩA and leadership
Richard L. Byyny, MD
illiam Root displayed extraordinary leadership when since I was a history major in college. Since then, I have read he and other similarly minded medical students estab- extensively about leadership, been mentored by excellent lishedW Alpha Omega Alpha Honor Medical Society in . leaders, and identified many leadership opportunities. I have They recognized a lack of appreciation for academic achieve- also engaged in many leadership experiences where I thought ment, leadership, professionalism, teaching, service, and I could make a difference. I have learned much about leader- research in their fellow medical students and medical school ship through this process. Let me share with you some of my faculty. Root decided to do something positive about it. His experiences—maybe you will recognize your own ability to leadership vision for AΩA, to promote and advocate for high become a future or more effective leader. academic achievement, leadership, professionalism, service, In my opinion, the best and most effective sustainable research, and teaching continues today. Now, more than a leadership is grounded in clear professional values, caring, century later, we need highly effective leadership in medicine, and a dedication to serving others. I recommend reading and medical education, and health care. reflecting on the writing of two authors: Jim Collins, who AΩA has done well in selecting leaders in medicine. Fifty- wrote Good to Great and Good to Great in the Social Sector; one Nobel Prize winners in Physiology or Medicine and in and Robert Greenleaf, who wrote Servant Leadership. Great Chemistry are members of AΩA, exemplifying leadership leadership is about doing the right thing in service to others. in science. Nearly seventy-five percent of deans of medical schools in the United States are members of AΩA. Many other Servant leadership members of AΩA are excellent leaders in academic medi- I remember meeting with a hospital director, a Catholic cine, medical societies, hospitals, clinics, and communities. sister, in a hospital located in a neighborhood that was in Unfortunately for medicine, many other AΩA members with transition in a large city. She was the most effective leader leadership potential have not chosen to lead, at least in formal in a hospital I had ever met and observed. Her hospital had leadership roles. the highest census, the most satisfied patients and staff, and I believe this is a lost opportunity for medicine, education, the best outcomes in the region. I asked her where she had and health care, as well as for many of our AΩA members. earned her Hospital Administration degree. She told me she Leadership is about making a positive difference and every didn’t have a degree. She said she had learned to always ask AΩA member has opportunities to make a difference and the question when making decisions, “What is best for the provide leadership. I believe, therefore, that all AΩA members patients?” That was her fundamental value: Doing what she should consciously consider making the commitment to serve knew was right. as leaders and to make important contributions to our profes- Servant leaders live, lead, and act their values based on sion, patients, and society. their inward sense of what is right. Servant leaders also inspire others to care and serve. They develop the best within others. Preparing for a position in leadership They instill a set of values, including fairness (justice), honesty, Leadership for most people is learned through educa- respect, contribution, and trust. These leaders follow truth tion, observation, and experience. Developing into an and principles. They share values and trust among team mem- excellent leader requires more than motivation—it bers. This leads to moral authority in the leader and team. is an ongoing, continuous process. One needs to Servant leaders and their teams dedicate themselves to a recognize the challenges and opportunities and higher purpose, cause, or principle worthy of their commit- then proceed to lead, and in doing so, to make ment instead of focusing on themselves. They find joy, self- a positive difference. respect, and integrity in being used in the service of others I have been a student of leadership and in contributing to an important purpose. Servant leaders
The Pharos/Autumn 2011 1 AΩA and leadership
Characteristics of Servant Leaders Listening One parable states, “Grant that I may not seek so much to be understood as to understand.” Communication is very important, but it starts engage their teams in creating a shared vision—a compelling with listening intently and receptively first. picture of the future—based on values. They inspire others You can better understand the will and point to dig deep within and to use their knowledge, experience, of view of a person or group by listening. Later reflection on what was said can lead and talent both independently and interdependently to serve to enhanced understanding and increased others though this shared vision. Great leaders are passionate respect. about achieving their vision in the context of caring and do- Empathy Servant leaders work to understand and ing good. to empathize with their teams and others. Greenleaf emphasizes a set of characteristics fundamental Empathy is developing the awareness of the to good servant leaders. I have modified the list for this article. thoughts, feelings, and experiences of others Servant leadership involves caring, passion, commitment, without having those experiences yourself. We values, having a positive and realistic attitude, teamwork, and show empathy by respecting other’s views, while not necessarily agreeing with them. service to others both within and outside of the team or orga- nization. Servant leaders lead by expression, humility, authen- Healing Recognize that those who are being served ticity, interpersonal acceptance, stewardship, and providing and those involved in serving share a goal of healing. The collaborative search for wholeness vision and direction. is part of the compact with the servant leader. Great leadership Awareness Be vigilant in observing events and interactions, recognize what is happening, and I assume that those of you who want to lead want to be then draw inferences from what you observe. great leaders rather than just good leaders. Jim Collins argues Be mindful and perceptive in using your that the enemy of “great” is “good.” Many are satisfied with knowledge and experience. being good at what they do, but the leaders who will make the Persuasion Servant leaders rarely use positional authority, most difference are those who want to be great, and want their relying more on value-based authority or teams or organizations to be great. A great leader or organiza- persuasion. They work to persuade others tion delivers superior performance and makes a positive, im- to adopt a point of view through teaching, portant, and distinctive difference over a long period of time. and using knowledge, facts, and opinion to convince others to accept their views. Servant leaders work with their teams to define what it means to be great in what they do and how they serve. Good- Conceptualization This is the ability to conceive and think logically to-great principles apply to the not-for-profit social sector and to evaluate information, issues, events, plans, dreams, visions, and futures beyond day- and to servant leaders as well as they do to the private sector. to-day realities. However, for servant leaders and in the social sector the out- puts are caring, service, and helping others rather than profits. Foresight This is the ability or art of using knowledge of historical and current events and related The measurement of success is how effectively we deliver on situations combined with an understanding our mission and make a distinctive impact relative to our of possible consequences to predict the resources. A consistent and intelligent method of evaluating likely future. Foresight allows you to develop caring and service allows us to assess improvement—or the intuition, the ability to know or understand lack thereof. In the social sector, as in the for-profit sector, it something without proof or evidence. is useful to set audacious goals. Stewardship This involves commitment to the careful and Good-to-great starts with what Collins refers to as “level responsible management of an organization or people entrusted to one’s care. In servant leadership.” Level leaders are passionate about and com- leaders it involves first and foremost a mitted first to the cause, movement, mission, or work—not commitment to serving the needs of others themselves—and have the will and commitment to succeed. and in this context relies mostly on openness, They build enduring greatness through a blend of personal caring, trust, and persuasion. humility and professional will, commitment, and persever- Humility This involves being humble, valuing other ance. The servant leader does not have the executive power people, and treating everyone with respect. Too to make most important decisions alone. In medicine, health many ineffective leaders are noted for hubris care, and education, executive power is usually impractical. In or self-aggrandizement, taking personal credit for what is the work of many. In doing so, they our realm, leadership sets a positive example, taps idealistic demonstrate an unflattering arrogance. passions, and uses persuasion, inclusion, communication,
2 The Pharos/Autumn 2011 language, inspiration, shared values, common interests, a • Working with others who know more about some issues sense of community, teaching, balance, discipline, teamwork, and problems and delegation of responsibility to get things done. • Making decisions Level leaders must be role models and always work as • Evaluating the results hard or harder than everyone else. They are willing to do • Communication and teaching whatever jobs need to be done. They are passionate and car- • Working with teams ing, self-motivated, self-disciplined, and compulsively driven • Continually learning to do the best they can. Servant leaders know their teams • Aspiring to be the best. share their vision, and they develop and support the best teams of people who are motivated by their service and pro- However, many do not recognize their potential for leader- fessional values. ship and how to utilize their knowledge, skills, and experience Great leaders need to ask the question: What is the one as physicians to lead. Each of you needs to make a conscious thing at which our organization can be the best in the world? choice to aspire to lead, and then seek opportunities to serve They focus on that goal and develop a plan to reach it. For as leaders. most of us, that is a social objective to meet human needs. Leadership in medicine, education, and health care is more Once others see tangible results, people will line up to contrib- important now, in the twenty-first century, than ever before. ute and to “push the wheel” that creates momentum. Physicians know best what medicine, medical education, and The servant leader and team must define how to produce health care are about. Physicians know the core values and the best long-term results. This involves first understanding professional values of medicine. Physicians have professional what the organization stands for, why it exists, and what its experiences serving and caring for people, and working with core values are. In other words, what the leader and the team others in the health professions. Physicians know about clini- can do best is determined by understanding how the team cal medicine and clinical insight. Physicians understand edu- can uniquely and effectively contribute to the people it serves. cation of students and residents. Physicians understand the The next greatest need, and a difficult one to achieve, is vital importance of medical and scientific research. Physicians finding the resources—especially the right people—to do great have earned respect for their caring, service, values, commit- work, and saying no to things that may impede achieving the ment, hard work, teaching, and manifold other contributions. vision and service. These are integral parts of the professional life of a physi- Servant leaders celebrate the work and success of those cian. Physicians should be more effective servant leaders in contributing and serving and express appreciation regularly. medicine, medical education, and health care because of their Remember: Everyone matters and everyone can, and does, special professional knowledge, skills, and experiences. To make a difference in serving. best utilize these special professional attributes, qualities, and experiences, physicians should aspire to become leaders. They AΩA and leadership in medicine can then learn to be effective servant leaders who lead based Most medical students, physicians, and AΩA members on caring, service, and professional values. have already learned, developed, and practiced many of the Leadership and management skills can be taught and elements of servant leadership, including: learned by motivated physicians. I urge members of AΩA • Competence and other physicians to ask themselves where and how they • Altruism can provide leadership. Making the conscious decision to be • Caring and act as a leader is of utmost importance to medicine and • Service society. • Knowledge How can Alpha Omega Alpha Honor Medical Society both • Attitude select potential leaders and support those who choose to be- • Skills come leaders in medicine, education and health care? Send me • Professional values your thoughts at [email protected]. • Listening first to understand Richard L. Byyny, MD • Examining and using data Executive Director, Alpha Omega Alpha Honor Medical • Deductive reasoning Society, and Editor of The Pharos • Using probabilities to make decision even with uncertainty
The Pharos/Autumn 2011 3
DEPARTMENTS ARTICLES
Editorial 1 AΩA and leadership Clinical man (Homo clinicus) Richard L. Byyny, MD, editor A satire The physician at the Clifton K. Meador, MD 40 movies Peter E. Dans, MD Midnight in Paris Sarah’s Key Great Expectations (1946) “You’re sick, we’re quick” Retail clinics and their implications for the future Reviews and reflections of the American health care system 47 The Kitchen Shrink: A Psychiatrist’s Reflections on Adam Mikolajczyk, MD Healing in a Changing World Reviewed by Justin Taylor, MD The Language of Pain: Finding Words, Compassion, and Relief Reviewed by George D. Comerci, Jr., MD, FACP Dollars and sense of electronic User-Driven Healthcare and medical records Narrative Medicine: Utilizing Collaborative Networks and The impact of EMR on billing, coding, and Technologies physician reimbursement Reviewed by P. Ravi Shankar, MD Charles Rutter, MD 52 Letters
The list of new members elected in 2011 has been moved to our web site, www.alphaomegaalpha.org, as has the index of The Pharos. On the cover See page 6
AΩA NEWS
Truth, stranger than fiction Program announcements 53 2010/2011 Administrative Silas Weir Mitchell and phantom limbs Recognition Awards 2010/2011 Medical Student Service Eliza C. Miller Project Awards 2010/2011 Volunteer Clinical Faculty Awards 2010/2011 Visiting Professorships 2011 Edward D. Harris Hideyo Noguchi Professionalism Award Controversial microbe hunter POETRY Don K. Nakayama, MD, MBA Ode to a Suppository 19 Myron F. Weiner, MD Sea Foam Ulcers in Papua New Guinea 25 Steven F. Isenberg, MD A contemplation on fairness How’d I like that no-salt 33 diet you put me on? Heather Relyea-Ashley, MD Alan Blum, MD
Spin 39 Daniel J. McCarty, MD Anatomy 46 Emily Silverman Broken 51 Krishna Sury INSIDE First Chair BACK COVER48 Sarah Rapp
We are transitioning to an updated membership database. Thus, all members are receiving The Pharos at their home addresses unless we do not have a home address on !le. If you prefer to receive The Pharos at your business address, please let us know at info@ alphaomegaalpha.org. We apologize for any inconvenience. A satire
Clifton K. Meador, MD
The author (AΩA, Vanderbilt University, 1954) is clinical professor of Medicine at Vanderbilt University School of Medicine, clinical professor of Medicine at Meharry School of Medicine, and execu- tive director of the Meharry-Vanderbilt Alliance.
* The term “Clinical Man” includes both the male and female gender.
6 The Pharos/Autumn 2011 n , I recorded a fictitious interview with the person like that. There is nothing strange about this symbiosis of whom I imagined to be the last well person on earth.1 I medicine and man. Big medicine needs clinical man and mistakenly thought well people were disappearing and I clinical man needs big medicine. That’s just the way it is. wantedI to call attention to their disappearance. I missed the Where would all the endoscopists be without clinical man? big picture and now want to correct my misconceptions. Well And what about all those proceduralists who do interventions people are not disappearing; instead, a new species of man is and biopsies? What would we do with all the CAT scans and emerging: Homo clinicus. MRIs and PET scans without clinical man? How would all the An evolution of the symbiotic relationship between man surgi centers and imaging centers and standalone diagnostic and medicine has been going on for some time. Lewis Thomas centers survive without a long line of clinical men? Don’t deserves the credit for an early spotting of the new species, forget the insatiable needs of big pharma and the relentless first observed in America. He called our attention to this phe- mongering of created, pseudodiseases on television. nomenon in the s. Clinical man goes to the doctor when not sick. That’s part of the definition of the new species. No longer able to decide Nothing has changed so much in the health-care system by themselves, they come in increasing numbers to find out if over the past twenty-five years as the public’s perception of they are sick or well. Some even demand to know what disease its own health. The change amounts to a loss of confidence might loom in the future for them. in the human form. The general belief these days seems to Here are a few of the characteristics of clinical man: be that the body is fundamentally flawed, subject to dis- . Knows his cholesterol level within milligrams percent integration at any moment, always on the verge of mortal . Has been biopsied in at least one nonpalpable organ by disease, always in need of continual monitoring and support age fifty by health-care professionals. This is a new phenomenon in . Has been biopsied in a palpable organ by age forty our society.2p43 . Has had at least one major orifice endoscoped within the past twelve months There has been a progression of terms for this new species. . Is always waiting on a biopsy report or a repeat of a First, there was the “early sick” then “the worried well.” That borderline or false positive lab result was followed by “the worried sick.” We now have arrived at a . Never goes more than twelve months without medical definable new species that differs from pre-clinical man. contact Preclinical man lived largely with medicine out of his con- How did this evolution from an avoidance of medicine sciousness. In fact he lived to avoid medicine. Those of us to medicine becoming a necessity occur? It is actually quite who are still preclinical will recall the earlier saying, “An apple simple: medicine has been assigned successes by television a day keeps the doctor away.” That is almost pure preclinical and the public that are not attributable to medical care. Nearly thinking. Preclinical man only went to the doctor when he was all of the increases in health and life expectancy from birth sick or injured. It was up to preclinical man to decide if he was are traceable to public health measures, clean water and milk, sick or well. It did not take a physician to make that decision. vaccinations, and a myriad of positive effects of the age of If he felt all right he was well; if he felt sick he was sick. Not modernization. so with clinical man. Feelings are no longer a reliable guide to It is a strange irony that at a time of maximum health, more health. Feeling good is not enough. There must be objective people than ever are coming to see doctors. Preclinical man data that nothing is wrong. That’s the problem. Something is will soon be extinct. always wrong if you look long and hard enough at or inside any human. As a medical resident told a colleague, “A well person References is someone who has not been worked up. We can always find . Meador CK. The last well person. N Engl J Med ; : something wrong, if we look hard enough.” 1 –. Clinical man is neither sick nor well. He is simply in clinical . Thomas L. On the Science and Technology of Medicine. In: limbo. As you will see in the definitions of this new species Knowles J, editor. Doing Better and Feeling Worse: Health in the below, he is always under medical surveillance. Clinical man United States. New York: W. W. Norton; : –. requires it. More importantly, medicine requires it. Clinical man either has something that is not quite right or something The author’s address is: that needs to be rechecked. Meharry-Vanderbilt Alliance Medicine and man have evolved in a symbiotic manner— Bio-Medical Building like the whale with those little fish that swim in and out of 1005 D. B. Todd Boulevard the whale’s mouth. The fish need the whale for food particles Nashville, Tennessee 37208 and the whale needs the fish for dental hygiene—something E-mail: [email protected]
The Pharos/Autumn 2011 7 Retail clinics and their implications for the future of the American health care system Adam Mikolajczyk, MD
The author (AΩA, University of Chicago, 2011) is a resident in Internal Medicine at the University of Chicago. This essay won third prize in the 2011 Helen H. Glaser Student Essay Competition.
e live in a world in which innovation is driven by the desire to create products or develop concepts that are more convenient than those that already Wexist. If something does not make life easier, it will not survive in today’s society. This pervasive drive to always improve the ease of using something has extended to the medical field with benefits for the care provider that include automatic blood pressure cuffs, Rapid Strep Tests, and electronic order entry and medical re- cords. Only in the past decade, with the establishment of retail clinics characterized by flat fees, quick and efficient delivery of services, and walk-in visits, have patients begun to benefit from the drive for increasing convenience. The story began in in the Minneapolis-St. Paul met- ropolitan area with a partnership between Cub Foods, a local grocery chain, and QuickMedx (founded by Rich Krieger, who had been recently frustrated by a long wait time at an urgent care clinic to receive care for his son’s sore throat). This joint
Photography by Frank Windgassen
“You’re sick, we’re quick”
Conditions Treated Allergies Athlete’s foot Bladder infections Bronchitis Chlamydia Cholesterol screening Cold sores venture established the first in-store clinics to provide qual- Diabetes screening ity care for relatively simple illnesses in a timely, affordable Diarrhea manner. These pilot clinics charged a cash-only flat fee Ear infections Influenza for rapid testing, diagnosis, and treatment of eleven common Impetigo medical conditions, including pharyngitis, conjunctivitis, oti- 1,2 Insect bites tis media, and seasonal allergies. Laryngitis Following the success of these initial clinics, competitor Lice companies were established and store-based clinics began Minor burns and rashes to rapidly proliferate—from sixty-two in January 3 to Minor skin infections approximately , located in thirty-two states in .4 Minor sunburn QuickMedx changed its name to Minute Clinic and formed Mononucleosis Nausea and vomiting Pinkeye and sties Poison ivy Pregnancy testing Ringworm Sinus infections Strep throat Swimmer’s ear Swimmer’s itch Wart removal
Vaccines Diphtheria, tetanus, and pertussis Influenza Hepatitis A Hepatitis B Measles, mumps, and rubella Meningitis Pneumonia Polio Tetanus
Based on a table in reference !.
10 a partnership with CVS. It has become the largest retail clinic company with about clinics in twenty-six About Adam Mikolajczyk states.5 Minute Clinic’s major competitor, Take Care I graduated from the University of Health Systems LLC, has partnered with Walgreens, Notre Dame in , with a major in sci- the nation’s largest pharmacy chain, to open more than ence pre-professional studies and a minor clinics in thirty cities.6 In , the Convenient in theology. I then attended the Pritzker Care Association was created to establish shared qual- School of Medicine at the University of ity standards of practice for retail clinics and to foster Chicago, where I graduated in . I cur- professional relationships with the medical community.7 rently am a resident in Internal Medicine In-store clinics are typically located in retail stores, phar- at the University of Chicago and plan to pursue a macies, supermarkets, and shopping malls, where they gener- career in academic gastroenterology. I would like to ally occupy to square feet of space, with one to two thank my parents for teaching me to believe in the exam rooms equipped with all the necessities of an outpatient beauty of my dream to become a physician (especially health care office. Most of these clinics are open seven days a my mother, who also instilled in me a passion for writ- week for twelve hours on weekdays and eight hours on week- ing), and my wife, who steadfastly and enthusiastically ends, a schedule that is much more convenient for patients supports me in the pursuit of my many interests within than that of a traditional physician’s office. No appointments the field of medicine. are needed, and a typical visit lasts fifteen to thirty minutes because of the limited number of services rendered and the maximal use of technology to provide efficient care. The table on page shows the typical “menu” at a retail clinic.8 wide range of responses from the American public, employ- These clinics do not treat medical emergencies or chronic ers, insurance companies, and the medical community. In the conditions, and they refuse to refill prescriptions that require Harris Interactive Health Care Poll from , only seven continual use, such as birth control pills or antidepressants. percent of adults reported visiting a store-based clinic, but The prices of the services are clearly posted,1,2 and the aver- ninety-three percent of those said they were satisfied with the age cost of a basic visit is low. Treatment for a sore throat can convenience these clinics provided, and ninety percent said range from to , while a tetanus booster ranges from they were satisfied with the quality of care. Both percentages to .9 Retail clinics initially accepted only cash, but by have remained relatively constant over the , , and approximately eighty-five percent of clinics accepted in- surveys. Seventy-eight percent of the , adults polled surance. Today many major clinics also accept reimbursement agreed that these clinics would provide a quick, convenient from Medicare and Medicaid.10,11 way to receive health care (again unchanged over the three Clinic charges are low because they typically rent small years).13 The Health Tracking Household Survey showed spaces and employ nurse practitioners, or sometimes physi- that seven of eight clinic users cited at least one of three con- cian assistants, who can proficiently diagnose and treat the venience factors (hours, location, and no need for an appoint- most common illnesses found in family practice.1 Although ment) as a major reason for visiting a clinic, while one of three state laws vary regarding the autonomy of nurse practitioners, cited all three as major reasons.11 most companies require that they operate under the oversight Nevertheless, sixty-five percent all respondents expressed of an on-call physician.12 concerns about the qualifications of the staff of the clinic, and Much of the efficiency of care provided by these store- an equal percentage expressed worry about receiving an accu- based clinics is attributable to their use of technology. Most rate diagnosis for a serious medical condition. However, both use touch-screen computer terminals similar to airline self percentages have trended downwards over the three years check-in kiosks for the check-in process1,8 and computer soft- from seventy-one percent and seventy-five percent in . ware programs to guide the caregivers through various medi- This may reflect increasing acceptance. cal protocols that complement the decision-making process; These subjective concerns are not supported by the current software can be overriden by the caregiver. In addition, many data on the quality of care provided by store-based clinics. clinic computer systems track each patient’s total number of In a paper in the Annals of Internal Medicine, Ateev visits for a given complaint. After a predetermined number of Mehrotra and colleagues found no significant differences in visits, the program notifies the provider that the patient needs the quality of care provided by retail clinics, physician of- to seek the care of a physician. Most clinics further use elec- fices, and urgent care clinics across fourteen quality measures tronic medical records and electronically submit prescriptions for treatment of otitis media, pharyngitis, and urinary tract to the adjacent retail pharmacy.1,12 infections (all three were slightly superior in quality to emer- The rapid emergence of store-based clinics has sparked a gency departments).14 A review of the literature reveals many
The Pharos/Autumn 2011 11 “You’re sick, we’re quick”
studies demonstrating that the quality of care provided by but include a call to establish appropriate sanitation/hygienic nurse practitioners for basic medical treatment is equivalent guidelines and to clearly inform patients about the qualifica- to that of physicians. Finally, from the patient point of view, of tions and limitations of the clinic.7,12 A review of the general the respondents who visited a clinic in eighty-eight characteristics of the store-based clinics (as described above) percent agreed with the statement that their providers were demonstrates that they have adhered to the recommendations qualified.13 from the AAFP and the AMA. Some companies have reported savings of , or Many individual physicians report feeling threatened more per year when employees use store-based clinics, lead- by the potential, unwanted effects of retail clinics on their ing several employers—including Target, General Mills, and practices, including a loss in the variety of medical cases en- Bank of America—to encourage their employees to use these countered, fragmentation of relationships with patients, lost clinics for the treatment of minor illnesses.12 Because these opportunities for preventive care, and a drop in revenue. Yet clinics are dramatically cheaper for identical services than there are no data to uphold these fears. Mehrotra and col- traditional clinics for insurance companies, some insurers leagues report that just ten simple clinical issues—including use the incentive of reduced or no copayments for visits to a upper respiratory infections, urinary tract infections, sinus- store-based clinic to encourage patients to use them instead. itis, and immunizations—constitute more than ninety percent Mehrotra and coworkers found that the overall cost of care of all retail clinic visits, whereas these same ten issues only in retail clinics for otitis media, pharyngitis, or urinary tract comprise thirteen percent of adult primary care visits, thirty infection was significantly lower than in physician offices, percent of pediatric primary care visits, and twelve percent urgent care clinics, and emergency departments ( versus of emergency department visits.17 It therefore seems unlikely , , ).14 that these clinics lead to a loss in the variety of cases. Instead, The reactions of physicians and physician organiza- these clinics may alleviate the ever-increasing demands on tions to retail-based clinics have ranged from acceptance to the health care system. intense opposition. The American Academy of Pediatrics The profile of the majority of patients using retail clinics (AAP) recently issued a policy statement declaring its op- is similar to those who visit emergency rooms—young adults position to store-based clinics being used to care for infants, age eighteen to forty-four who pay out of pocket for their care children, and adolescents. It is concerned about the follow- and do not have a primary care physician. Three out of five ing: increased fragmentation of care; the use of episodic care patients visiting store-based clinics did not report having a to treat children with special needs and chronic diseases; primary care doctor so that in most cases no relationship was lack of access to and maintenance of complete health re- disrupted. Preventive care was administered at only eleven cords; potential public health crises as patients with conta- percent of primary care visits for the ten simple clinical issues gious diseases wait in commercial, retail environments; and addressed at ninety percent of retail clinics. Thus, instead of fewer opportunities for pediatricians to treat minor illnesses, thwarting preventive care, these clinics could actually serve to which often affords them the chance to strengthen their re- strengthen it by increasing the convenience of getting immu- lationship with the child and family. Most importantly, the nizations.17 It can also be argued that visits for simple, acute AAP states that these clinics are not committed to the medi- issues lost to retail clinics will be replaced by visits for more cal home model, which is characterized by the provision of complex issues that are reimbursed at a higher rate, resulting accessible, family-centered, comprehensive, continuous, and in no dramatic change in revenue. The financial impact of coordinated care.15 clinics should be studied more thoroughly. Believing that it is more practical to guide the evolution of Many physicians and hospital systems are taking an “if such clinics than to prevent their use, the American Academy you can’t beat them, join them” approach to the upsurge in of Family Physicians (AAFP) released a list of attributes it feels retail clinics.18 Institutions such as the Mayo Clinic and Sutter are essential for patients to receive continuous, coordinated Health have opened “satellite care centers” in retail settings. care. They feel that retail clinics should possess a well-defined As of twenty-six of forty-two (sixty-two percent) clinic and limited scope of medical services; that these services be operators were hospitals or physician groups owning twelve evidence-based; that nurse practitioners work in tandem with percent of total retail clinics in the United States. In that year the patient’s physician to ensure continuity of care; that the Walmart, in partnership with local hospital chains, began to clinic have a referral system for cases that surpass its scope of co-brand retail clinics in its stores, and Cleveland Clinic began services; and that the clinic utilize electronic medical health planning a partnership with Minute Clinic to open nine retail records to both communicate patient information and facili- clinics with integration of their electronic medical records.9 tate continuity of care.16 At the same time, some traditional practices have begun to In a similar vein, the American Medical Association cre- offer extended clinic hours or “open access/advanced access” ated eight principles to guide the operation of store-based scheduling, in which a portion of the physician’s schedule is clinics. These criteria are very similar to those of the AAFP, open for same-day appointments.18
12 The Pharos/Autumn 2011 Retail clinics, in keeping with their complementary busi- . Scott MK. Health Care in the Express Lane: The Emergence ness model, have implemented many systems aimed at of Retail Clinics. Oakland (CA): California HealthCare Foundation; maintaining continuity of care with a patient’s primary care . physician. They provide summaries of each clinic visit that . Scott MK. Health Care in the Express Lane: Retail Clinics include a listing of the laboratory results, services rendered, Go Mainstream. Oakland (CA): California HealthCare Foundation; and prescriptions administered that can then be accessed . through the clinics’ electronic medical records, facsimile, or . Convenient Care Association. About CCA. www.ccaclinics. printed copy. Research exploring the effectiveness of this com- org/index.php?option=com_content&view=article&id=&Itemid munication is still needed. Patients presenting with conditions =. beyond the scope of practice of the clinic are referred to their . Minute Clinic. History. www.minuteclinic.com/about/his- primary care physicians, or to an office or hospital that is part tory.aspx. of the retail clinic’s network of established relationships that . Take Care Health Systems. Our Company. takecarehealth. will treat the patients whether they have insurance or not.1 com/Our_Company.aspx. Take Care Clinic, for example, states that twenty percent of . The Council on Medical Service. Update on Store-Based its Chicago-land patients have been referred to a primary care Health Clinics. CMS Report -A-. Chicago: American Medical physician or specialist for follow-up care.3 Association; . Clinic operators and the media herald the emergence of . Bohmer, R. The rise of in-store clinics—threat or opportu- retail clinics as an effective solution to health care disparities nity? N Engl J Med ; : –. that provide high quality care for the uninsured, underinsured, . Rudavsky R, Pollack CE, and Mehrotra A. The geographic and populations with difficulty accessing health care re- distribution, ownership, prices, and scope of practice at retail clin- sources. This claim is supported by data from the Health ics. Ann Intern Med ; : –. Tracking Household Survey, which revealed that twenty-seven . Laws M, Scott MK. The emergence of retail-based clinics in percent of retail clinic patients were members of uninsured the United States: Early observations. Health Aff ; : –. families and that families with any member uninsured were . Tu HT, Cohen GR. Checking up on retail-based clinics: Is the more likely to use retail clinics than insured families. Hispanic boom ending? Commonwealth Fund Dig ; : –. consumers and families with no usual source of medical care . The Council on Medical Service. Store-Based Health Clinics. were also more likely to use retail clinics than their respective Report (A-). Chicago: American Medical Association; . counterparts. The likelihood of citing cost concern or the lack . Harris Interactive. New WSJ.com/Harris Interactive study of a usual source of care was much higher among uninsured finds satisfaction with retail-based health clinics remains high. and minority clinic users than with their insured and white Press release May . www.harrisinteractive.com/NewsRoom/ counterparts.11 PressReleases/tabid//ctl/ReadCustomDefault/mid// To truly combat disparities clinics must be located in areas ArticleId//Default.aspx. accessible to underserved populations. Unfortunately, a study . Mehrotra A, Liu H, Adams J, et al. The costs and quality by Craig Evan Pollack and Katrina Armstrong found that retail of care for three common illnesses at retail clinics as compared to clinics are more likely to be located in census tracts charac- other medical settings. Ann Intern Med ; : –. terized by higher resident income, lower numbers of black . Retail-Based Clinic Policy Work Group. AAP principles con- residents, and lower rates of poverty, and that they are less cerning retail-based clinics. Pediatr ; : –. likely to be located in medically underserved neighborhoods.19 . Sullivan D. Retail health clinics are rolling your way. Fam Store-based clinics fill a need for change in the American Pract Manag ; : –. health care system and attempt to offer cost-effective, high . Mehrotra A, Wang MC, Lave JR, et al. A comparison of pa- quality, and timely care to patients who are frustrated with tient visits to retail clinics, primary care physicians, and emergency America’s rising health care costs and lack of access to care. departments. Health Aff (Milwood) ; : –. Such clinics are likely to grow to become a more critical ele- . Costello D. Report from the field: A checkup for retail medi- ment of the delivery of medical services in the United States. cine. Health Aff ; : –. Much research is needed to further understand the delivery . Pollack CE, Armstrong K. The geographic accessibility of of care at retail clinics, and the leaders of these clinics should retail clinics for underserved populations. Arch Intern Med ; remain committed to a business model that complements : –. primary care physicians and expands services to underserved areas of the United States. The author’s address is: 924 E. 57th Street References Suite 104 . Hansen-Turton T, Ryan S, Miller K, et al. Convenient care clin- Chicago, Illinois 60637-5414 ics: The future of accessible health care. Dis Manag ; : –. E-mail: [email protected]
The Pharos/Autumn 2011 13
The impact of EMR on billing, coding, and physician reimbursement
Charles Rutter, MD
The author (AΩA, University of Maryland, 2010) is an intern space requirements to skyrocket.7 Furthermore, multiple staff at St. Mary’s Hospital in Waterbury, Connecticut. This es- members frequently need to access a patient’s chart simultane- say won honorable mention in the 2011 Helen H. Glaser ously: nursing staff to chart the chief complaint and vitals, phy- Student Essay Competition. sician staff to document the visit and management plan, and secretarial staff to schedule follow-up tests, consults, and sub- national shortage of primary care physicians is mount- mit the visit for insurance reimbursement. As highlighted in ing, with an estimated need for an additional , the CMAJ articles, effective EMR reduces this astronomically doctors by . Nowhere is this dearth felt more frustrating paper chase, allowing physicians to function more severelyA than in rural areas of the country.1 While senior efficiently and perform the duties they were trained for.5–6 medical students undoubtedly take many factors into account when picking a field for further training, the two disincentives Studies in the literature to a career in primary care most often quoted by the media A four-physician practice in rural upstate New York pub- are lower income relative to more lucrative specialties and a lished a qualitative paper in describing its experience crushing burden of paperwork. These factors have resulted in using EMR. Following the progressive implementation of a a drop in the percentage of graduating senior medical students commercially available EMR system over one year, the practice going into primary care specialties—from fifty percent in saw an upswing in efficiency, evidenced by shorter turnaround to thirty-eight percent in .2 Electronic medical record sys- times for prescription refill orders and school and work let- tems (EMR) may help alleviate these unsatisfactory attributes of ters, improved internal communication, and fewer medication a career in primary care, offering the potential benefits of im- errors and calls from the pharmacy. Physician quality of life proved quality of patient care, more consistent documentation, was improved by the installation of a virtual private network more efficient clinic management, and improved physician (VPN) that allowed physicians to access patient data and field remuneration. However, there are many barriers to the suc- after-hours calls from home, and allowed greater latitude in cessful implementation of EMR, the most important of which is scheduling.3 The observations from this practice were echoed cost. The balance of risk and benefit is most important for small in a publication from the outpatient clinic at Cincinnati private primary care practices, whose financial stability may be Children’s Hospital. Following the installation of EMR, the more uncertain. As of /, only eleven to fifteen percent delay in medication refill turnaround was cut from two days of private primary care practices had implemented EMR.3,4 to just twelve hours, and the time to generate school notes was In a pair of May articles in the Canadian Medical halved. The number of paper chart pulls was reduced, allow- Association Journal (CMAJ), author Paul Christopher Webster ing staff to perform their duties more efficiently. At the same noted that without EMR, as much as thirty percent of patient time, the switch from paper to electronic records freed up care time is spent in a “paper chase.” 5–6 Better known to medi- space for the creation of two additional exam rooms.7 cal students as “scut work,” these tasks include tracking down Several studies have cited an improvement in patient laboratory results, radiology reports, and consultant’s letters, safety and quality of care with EMRs.4,8 In part this is due as well as documenting clinical visits, writing prescriptions, to fewer medication errors from misreading prescriptions.8 making referrals, and ordering labs and imaging. As patients Additionally, a customizable EMR interface makes group- age and comorbidities accumulate, diagnostic and follow-up ing disease-specific signs and symptoms possible, leading to tests clog their medical records, causing chart size and physical more consistent and thorough questioning and examination
14 The Pharos/Autumn 2011 The Pharos/Autumn 2011 15 Dollars and sense of electronic medical records
by physicians,8 which further allows for improved disease sur- and scope of the history and physical determines the rate at veillance and adherence with guidelines and medication regi- which the encounter can be billed. For the sake of this discus- mens.3,4,8 Patients are also spending less of their time in the sion, we will use an established patient visit, where the current doctor’s office, with a drop of . percent seen in one study.4 procedural terminology (CPT) codes vary from to . Finally, another study shows an increase in the percentage of The amount of history taken varies from a problem focused charts containing a problem list from twenty-nine percent to history () to a comprehensive history (). The physi- eighty-four percent over two years.7 cal exam is stratified in a similar fashion. The third component Every benefit, however, has its price, and when it comes to of coding is what is referred to as “medical decision making,” EMR systems, the sticker shock can be staggering. In a study which is classified as straightforward, or low, moderate, or published in , five offices with twenty-eight physicians high complexity. Based on how the history, physical exam, at the University of Rochester Medical Center performed a and medical decision making qualify, a code is assigned, and a staged implementation of an EMR system at a total capital given amount of money is paid. The table following is a highly cost of nearly ,, with an additional , in first- simplified overview of the process of coding. Physicians can year expenses (about , per provider). Annual costs for also bill for ancillary services, which include reviewing labs years two and beyond averaged , (about , per and imaging, discussing a case with a colleague, and so forth. provider).4 The initial costs were recaptured within sixteen The table illustrates that the process of coding is tedious months, with ongoing annual savings of nearly , per and time consuming. Physicians and staff members without provider. However, for many practices, particularly smaller a solid working knowledge might easily undercode a visit groups, implementing EMR may be a serious gamble, as the (i.e., label what should be a as only a ) or neglect large expense is divided among fewer physicians. Moreover, to bill for services for which they do not know the code, with the exception of this study, data on return from this resulting in lower remuneration. A major benefit of EMR investment is largely anecdotal.4 For practices with deep systems is that they store such information and reference it pockets, fully-customized EMR systems can be linked to a automatically. A ten percent drop in undercoding was seen practice’s existing billing and scheduling systems, perform in the study from rural New York , along with an increase in complex tasks, and be custom designed to fit client require- billing for ancillary services, resulting in an eleven percent ments.3,8 But for more cash-strapped groups, off-the-shelf increase in annual revenue in the first year after EMR instal- systems can be significantly cheaper. lation, and twenty percent increase in the second year.3 A To cover this expense, along with the other costs of running significant decrease in and codes was seen in the a practice, a doctor’s office has to get paid. Reimbursement by study from the surgical practice discussed earlier, with a cor- insurance providers is based on a process known as coding. responding increase in and codes. This change For a given situation (i.e., new patient evaluation, established netted the practice nearly more per visit compared to patient visit, hospitalized patient, etc.), the level of complexity their pre-EMR days. An increase in charge per visit of up to
Overview of the Process of Coding CPT Code History Physical Exam Medical Decision Making (MDM) !!"#" Problem focused history Problem focused exam Straightforward MDM • Chief complaint (CC) • Limited to affected area/system • Minimal diagnostic/treatment options • Brief HPI (# to $ descriptors*) • Minimal amount/complexity of data • Minimal risk of complications !!"#$ Expanded problem focused history Expanded problem focused exam Low complexity MDM • CC and HPI as above • Affected area/system • Limited diagnostic/treatment options • Problem-pertinent review of sys- • Related systems (" to %) • Limited amount/complexity of data tems (ROS) • Low risk of complications/mortality !!"#& Detailed history Detailed exam Moderate complexity MDM • CC • Extended exam of affected area/systems • Multiple diagnostic/treatment options • Extended HPI (&+ descriptors) • Exam of other symptomatic or related areas/ • Moderate amount/complexity of data • Extended ROS (" to ! systems) systems (" to %) • Moderate risk of complications/mortality • Pertinent past medical, surgical, family, or social history (PMH, PSH, FH, SH) This table uses an established patient as the example. * Onset, location, quality, radiation, improving factors, exacerbating factors, severity, etc. Note: For each CPT level, two out of three key components (History, Physical, MDM) must be satisfied for that coding level.
16 The Pharos/Autumn 2011 has been reported in other studies.4 The paper from Cincinnati Children’s Hospital above and a study from the Medical University of South About Charles Rutter Carolina (MUSC) both identified an improvement in I grew up in Ellicott City, Maryland, with chart completion rates, allowing for increased billing and my wonderful parents, Eugene and Mary, reimbursement, as many insurance providers require and my siblings, Cailin and Sean. My un- visits to be submitted with completed documentation dergraduate education was at the University within thirty days.7–8 In the MUSC study, completeness of Maryland, Baltimore County, where I at seven days after the visit bumped from . percent to . majored in biology and met my beautiful wife Victoria. percent, and at thirty days from percent to . percent. I then attended the University of Maryland School At thirty days, this . percent increase in completed charts of Medicine, graduating in May . I will spend is equivalent to . percent more billable visits. With approxi- my medicine intern year at St. Mary’s Hospital in mately , patient visits per year, this is roughly , more Waterbury, Connecticut, before heading to Yale-New billable visits. Billable visits at this clinic average , and so Haven Hospital for a residency in Radiation Oncology. this seemingly insignificant . percent increase in complete- I thank Drs. Bui and Saxena of Hagerstown Family ness results in an additional , annually.8 These findings Medicine for their insight into the business of running mirror those seen in the rural New York practice described a small private practice, my inspiration for writing this above, where an increase in revenue was due in part to a drop article. in the number of claims rejected due to incomplete charting or submission beyond insurer deadlines.3 Moreover, one study documents a decrease in the time from the initial visit to reim- the equation, thus eliminating the materials costs associated bursement of five days.4 with assembling new paper charts. In the study from the Clearly, EMRs allow practices to capture revenue that University of Rochester described above, , new charts may otherwise slip through the cracks. But EMRs also allow costing . each were created annually before implementing doctors offices to cut costs by removing paper charts from EMR. The elimination of the charts saved the practice nearly , a year in materials,4 as well as reducing the amount of time staff members spent gathering charts. By six months after EMR implementa- tion, there was a percent decrease in the need to track down paper charts, with a percent decrease at two years. Based on the amount of time to pull one chart, the number of charts pulled annually, and the cumulative pay for the man-hours required, the authors estimated an annual savings of ,. There was also approximately , saved based on reduced filing time for placing documents into charts. In offices previously using tran- scription services, approximately , was saved annually.4 Finally, office workflow was made so ef- ficient by EMRs that two full-time positions were eliminated despite an additional six physicians added to the practice, saving the group approximately , annually.4 The annual savings in this practice (excluding transcription service, which was used sporadically) thus
The Pharos/Autumn 2011 17 Dollars and sense of electronic medical records
total ,. This allowed the practice to break even with of results at patient visits. Doctor’s notes for work and school the initial costs of the EMR in sixteen months, and to save can be created using predesigned templates. Charts are easily approximately , annually thereafter.4 While this expe- accessed both in-office and from home using the office’s VPN, rience will not be representative of all practices, it certainly allowing easy coverage of after-hours calls from home. The demonstrates that the large up-front costs of an EMR can be VPN also allows administrative duties to be performed from recaptured completely and quickly, and implementing it can home. These changes in data access have allowed a significant allow significant savings thereafter. improvement in lifestyle and more time away from the office, while maintaining the quality of patient care. One case study In her article in the New England Journal of Medicine, Hagerstown Family Medicine is a small practice in western Dr. Beverly Woo candidly discusses the good and bad of be- Maryland consisting of three physicians, two nurses, two medi- ing a primary care physician—and the challenges facing the cal assistants, and three administrative assistants. Prior to in- field. The highlights of her career, it seems, are the long-term stalling a commercially available EMR system several years ago, relationships she has with patients and their families, the in- the practice used a combination of paper charts housed in the tellectual challenges posed by having to diagnose any one of a clinic and a warehouse, as well as a DOS-based records system. myriad of diseases and conditions presenting with such pro- During the transition from old to new, forty to sixty hours of tean symptoms as fatigue and abdominal pain, and the oppor- on-site training was supplied by the vendor, and implementa- tunity to improve her patients’ health by understanding and tion was performed all at once. The new system ties together working within the confines of their sometimes- complicated nine computers, a printer, and over one thousand gigabytes of social situations. However, she too is clearly distraught by files via an office intranet. The practice utilizes an off-the-shelf the pressure placed on primary care physicians to see more EMR that includes billing and scheduling applications and fits patients in less time, the insufficient remuneration for her its needs well while still remaining affordable. efforts, and the Everest-sized piles of paperwork that she and Hagerstown Family Medicine invested approximately her colleagues slog through daily.2 While EMR systems may , up front for the EMR system, with annual license not be the panacea for all that ails primary care medicine in and support fees totaling about , (roughly , the United States, their many benefits may be the shot in the and , per provider, respectively). Following installation arm that the field so desperately needs. of the EMR system, the practice discontinued its transcrip- tion services, saving , to , annually (, References to , per provider). The time requirement related to . Herrick DM. Critical condition: Primary care physician short- record keeping and finances decreased markedly, such that ages. Dallas (TX): National Center for Policy Analysis May ; one staff position was no longer necessary, allowing additional Brief Analysis . savings. However, no changes were observed in the percent- . Woo B. Primary care—The best job in medicine? N Engl J age of charges generating revenue, the percentage of claims Med ; : –. rejected due to missing submission deadlines, coding trends, . O’Neill L, Klepack W. Electronic medical records for a rural or time to reimbursement. The absence of these outcomes is family practice: A case study in systems development. J Med Syst explained, at least in part, by the fact that one of the practice ; : –. physicians is a certified professional coder. The patient volume . Grieger DL, Cohen SH, Krusch DA. A pilot study to docu- did not change following EMR installation. Notably, while ment the return on investment for implementing an ambulatory overall revenue did not change with implementation of the electronic health record at an academic medical center. J Am Coll EMR system, annual savings top ,, which allowed the Surg ; : –. practice to break even with its initial investment within two . Webster PC. The pocketbook impact of electronic health and a half years. records: Part . Can Med Assoc J ; : –. The most notable improvements experienced by Hagerstown . Webster PC. The pocketbook impact of electronic health Family Medicine are in the areas of practice efficiency and phy- records: Part . Can Med Assoc J ; : –. sician lifestyle. Adjustment to the new system was fast and very . Samaan ZM, Klein MD, Mansour ME, DeWitt TG. The easy, allowing the providers to see fifteen patients in the first impact of the electronic health record on an academic pediatric day following EMR installation. One of the major gains noted primary care center. J Ambulatory Care Manage ; : –. by the physicians is the ability to complete all documentation . Bennett KJ, Steen C. Electronic medical record customiza- while in the room with the patient, shortening the working tion and the impact upon chart completion rates. Fam Med ; day. Writing prescriptions and refills is fast and easy because : –. the EMR is capable of Internet faxing prescriptions to most local pharmacies. Lab tests are automatically uploaded within The author’s e-mail address is: [email protected] twenty-four hours of their release, allowing efficient review
18 The Pharos/Autumn 2011 Ode to a Suppository You dwell In cool repose Shelved, clad in foil With others of your kind Until You by trembling hands With gentle care Are Uncloaked; your silver Refrigerated wrapper Wantonly cast aside. Now exposed, How to describe you; To capture your essence? No single word does you justice. You are Opaque, Silvery white, Oddly luminous, Sleek, Conical. Less like a Byzantine dome Than a fleetly flying rocket Soft, yet firm to touch Waxy. Slippery. Evasive. Penetrating (after a struggle) Finding your target Exerting your soothing power Aah . . . Myron F. Weiner, MD
The Pharos/Summer 2011 19 Dr. Weiner (AΩA, Tulane University School of Medicine, "#$$) is clinical professor of Psychiatry and Neurology at the University of Texas Southwestern Medical Center in Dallas. His address is: $#%$ Still Forest Drive, Dallas, Texas &$'$'. E-mail: [email protected]. Silas Weir Mitchell and phantom limbs
Eliza C. Miller The author is a member of the Class of 2012 at the fingers are strongly flexed. Columbia University College of Physicians and Surgeons. Another set of cases present a peculiarity which I am at Her essay, “Attuning to Equilibrium: Physician as Artist, a loss to account for. Where the leg, for instance, has been Artist as Physician,” won first prize in the 2010 Helen H. lost, they feel as if the foot was present, but as though the leg Glaser Student Essay Contest. She is a former dancer and were shortened. If the thigh has been taken off, there seems choreographer. to them to be a foot at the knee; if the arm, a hand seems to be at the elbow, or attached to the stump itself.1 n July of , just over a year after the final shots of the American Civil War were fired, an odd account appeared The Atlantic Monthly was one of the most widely read in the pages of the elite New England literary journal the periodicals of the day (at least among the intellectual elite of AtlanticI Monthly. Entitled “The Case of George Dedlow” and the Northeast). George Dedlow’s fascinating and gruesome with no author cited, the article began, “The following notes of account provoked an overwhelming response from the pub- my own case have been declined on various pretexts by every lic, many of whom sent donations in his name to the Stump medical journal to which I have offered them.” 1 A first-person Hospital, a real enough institution.2 But George Dedlow did narrative, the piece told the story of a physician-turned- not, in fact, exist. The anonymous author of the article was soldier who had the misfortune to have all four of his limbs Silas Weir Mitchell, a prominent Philadelphia physician and amputated in the course of his service to the Union army. He physiologist. Mitchell, who had never before tried his hand graphically recounted the horrors of his experiences in battle at fiction, had shown the manuscript to a friend. As Mitchell and in field hospitals, and his recuperation in the famous wrote later, “He, presuming, I fancy, that every one desired to “Stump Hospital” in Philadelphia where hundreds of Civil War appear in the Atlantic, offered it to that journal. To my sur- amputees were cared for. prise, soon afterwards I received a proof and a check.” 3 In addition to his grisly descriptions of the atrocities of war, Silas Weir Mitchell (–) is broadly credited with the author of this account provided a vivid portrayal of his the first clinical description of phantom limb syndromes, unusual sensory experiences after amputation, which were not although they had actually been previously described by a unique to him but shared by many of his comrades: number of authors, most notably sixteenth-century French surgeon Ambroise Paré and seventeenth-century philosopher I found that the great mass of men who had undergone René Descartes.4 It is certainly true that Mitchell coined the amputations, for many months felt the usual consciousness term “phantom limb” in an article in another lay publi- that they still had the lost limb. It itched or pained, or was cation, Lippincott’s Magazine, four years after the Atlantic cramped, but never felt hot or cold. . . . I should also add, piece. In this second article, he described more fully the that nearly every person who has lost an arm above the el- syndrome to which George Dedlow had alluded, but again for bow feels as though the lost member were bent at the elbow, a lay audience; he still did not disclose his authorship of the and at times is vividly impressed with the notion that his Dedlow account. Only with the publication of his classic
20 The Pharos/Autumn 2011 book, Injuries of t h e N e r v o u s System and Their Consequences, did Mitchell thoroughly de- scribe the syndrome to a purely medical audience as part of his chapter “Neural Maladies of Stumps.” In , almost forty years later, Mitchell finally acknowl- edged in print that he was the true author of “The Case of George Dedlow.” 4 Mitchell received his initial training in medicine in his physician father’s office, but showed little prom- ise or enthusiasm for the profession. (Apparently, his father informed him early on, “You are wanting in nearly all the qualities that go to make success in medicine. You have brains enough, but no industry.” 5p183) Nevertheless, he went on to medical school at Jefferson Medical College, graduating in , and subsequently opened a private practice in his native Philadelphia. Mitchell showed a life- long interest in experimental physiology, with particular emphasis on the effects of poisons and toxins. One paper, published in the British Medical Journal in , recounted his personal experiments with mescaline: he took a large dose and then went on with his busy day of general medical practice, all the while recording his own physiological and psychological responses in scrupulous detail.6 With the advent of the American Civil War, Mitchell’s career took the turn that led to his eventual recognition by his contemporaries as “one of the foremost neurolo- gists of his time” (as noted in his obituary in the British Medical Journal).3 In , he was asked to
The Pharos/Autumn 2011 Illustration by Erica Aitken 21 Truth, stranger than fiction
known by the moniker “complex regional pain syndrome” (CRPS). Indeed, his fictional George Dedlow describes this condition in one of his arms prior to amputation, noting that the hand was “red, shining, aching, burning, and, as it seemed to me, perpetually rasped with hot files,” 1 all of which illus- trate cardinal features of CRPS: burning or throbbing pain, allodynia, edema, and sudomotor abnormalities. Mitchell had a flair for words; his obituary in the British Medical Journal noted that “Even the purely medical writings of Weir Mitchell are marked by a charm of style very rare in medical authors.” 3 “The Case of George Dedlow” was his first foray into fiction, but by no means his last, and by the end of his life he had published several novels and “held a leading place among American writers of fiction.” 3 His friend and protégé, the legendary American physician Sir William Osler, wrote in a personal addendum to Mitchell’s obituary that
Versatility was the striking feature of Weir Mitchell’s mind, and it is shown by the remarkable success obtained in other than professional fields. In large part he was able to do this by living a double life and by the development of an extraordinary capacity for continuous work.3
Mitchell’s “charm of style,” “versatility,” and “double life” is nowhere more evident than in “The Case of George Dedlow.” The narrator’s account begins conversationally, and though Dedlow acknowledges his training as a physician, he is careful to distance himself from the medical community (as witnessed by the purported rejection of his case for publication in all medical journals) and align himself more with the common infantry soldiers with whom he served. As the story becomes more gruesome, the narrator assumes a more detached style, in which his considerable powers of observation and inter- pretation come to light, but always tinged with the distinc- tive Mitchell “charm.” In this passage, for example, Dedlow hypothesizes about the cause of his sensations of pain in amputated limbs: Silas Weir Mitchell. Courtesy of the National Library of Medicine. I think we may to some extent explain this. The knowledge we possess of any part is made up of the numberless im- pressions from without which affect its sensitive surfaces, take charge of a Philadelphia hospital dedicated to the care and which are transmitted through its nerves to the spinal of soldiers “suffering from nervous diseases” or “injuries of nerve-cells, and through them, again, to the brain. . . . In the nerves.” 3 During the course of the war, Mitchell cared for other words, the nerve is like a bell-wire. You may pull it hundreds of soldiers who had suffered traumatic nerve inju- at any part of its course, and thus ring the bell as well as if ries, including amputations. His descriptions of these cases you pulled at the end of the wire; but, in any case, the intel- in his monograph, entitled Gunshot Wounds and Other ligent servant will refer the pull to the front door, and obey Injuries of Nerves, rocketed him to the forefront of contempo- it accordingly.1 rary neurology, a field in which he had little prior expertise.7 In addition to his descriptions of phantom limb syndromes, Here we find evidence of Mitchell’s burgeoning interest in he is renowned for his early description of causalgia, a term neurology, as well as a strikingly accurate description of dorsal he coined in . He reported this disorder as a consequence column-medial lemniscus pathways mediating cortical sen- of peripheral nerve injury, with the symptoms that are now sory experiences.
22 The Pharos/Autumn 2011 The end of the story is perhaps the most remarkable. limb syndromes, all well described by Mitchell, may include Dedlow, having lost all of his limbs, begins to question his pain, paresthesias, sensations of cramping or limb flexion, and own existence (“I felt like asking someone constantly if I were the bizarre telescoping phenomenon that Dedlow mentioned really George Dedlow or not” 1) and he becomes “moody and (e.g., a foot at the knee). Current research points to both pe- wretched.” In search of healing, but with great skepticism, ripheral and central mechanisms for these symptoms, with he attends a spiritualist séance. Much to his shock, he has a cortical reorganization and so-called “maladaptive plasticity” transformative encounter in which he briefly experiences the playing a prominent role. For example, the somatosensory illusion that his legs have returned to him, and he is walking; map in the primary sensory cortex may remodel in the ab- this causes him to feel “re-individualized,” but only for a fleet- sence of normal peripheral afferent information, causing the ing moment.1 mouth area to shift into the area formerly occupied by the In considering this extraordinarily strange ending, one now-absent arm. These cortical changes appear to correlate cannot help but bring to bear some current thought on closely with increased phantom limb pain. Of particular note phantom limb syndromes. A review in Nature Reviews is the finding that, while analgesic, antidepressant, and stimu- Neuroscience, published years after “The Case of George lant treatments appear to have little effect on phantom limb Dedlow,” offers some insights. The components of phantom pain, in some cases “mirror treatments” have been employed
Silas Weir Mitchell at his clinic in the Infirmary for Nervous Diseases in Philadelphia. Courtesy of the National Library of Medicine.
The Pharos/Autumn 2011 23 Truth, stranger than fiction
Navy Cmdr. (Dr.) Jack Tsao shows Army Sgt. Nicholas Paupore how to perform mirror therapy to treat phantom pain in his amputated right leg. Courtesy of the US Airforce.
successfully (in which a mirror provides the illusion that the References lost limb is restored).8 . Mitchell SW. The case of George Dedlow. Atlantic Mon ; Mitchell appears to have understood that phantom limb (): –. syndromes were complex phenomena, involving both periph- . Bourke J. Silas Weir Mitchell’s The Case of George Dedlow. eral and central mechanisms. Bearing in mind today’s experi- Lancet ; (): –. mental mirror treatments, Mitchell’s description of Dedlow’s . Obituary: Silas Weir Mitchell, M.D., LL.D.: Ex-president of séance seems less oddball and more prescient. Perhaps, over- the College of Physicians, Philadelphia. BMJ ; (): –. whelmed by the suffering of the many amputees he treated (in . Finger S, Hustwit MP. Five early accounts of phantom limb his book, he noted that eighty-six out of ninety ampu- in context: Paré, Descartes, Lemos, Bell, and Mitchell. Neurosurg tees he cared for suffered from phantom limb syndromes5), ; : –. Mitchell turned to fiction as a way to imagine a possible cure. . Tyler KL. Mitchell, Silas Weir. In: Aminoff MJ, Daroff RB, It would take years for his musings to be translated into editors. Encyclopedia of the Neurological Sciences. Philadelphia: the peer-reviewed literature. Elsevier; : –. A final note on Silas Weir Mitchell, from his Lancet . Mitchell SW. Remarks on the effects of Anhelonium lewinii obituary: (the mescal button). BMJ ; (): –. . Nathanson M. Phantom limbs as reported by S. Weir Mitchell. Perhaps the most striking lessons of his work are the Neurol ; : –. evidence it affords that success in no field need be despaired . Flor H, Nikolajsen L, Jensen TS. Phantom limb pain: a case of because it delays its appearance until well on in middle of maladaptive CNS plasticity? Nature Rev Neuroscience ; : life (for his first really successful novel was published when –. he was ) and the compatibility of a simultaneous devotion . Obituary: Silas Weir Mitchell, M.D. Lancet ; (): . to both literature and the exacting profession of medicine.9 The author’s address is: As an older medical student with a prior career in the arts, 875 West 181 Street #1E coming late to neurology, I find Mitchell’s example both New York , New York 10033 inspirational and encouraging. E-mail [email protected]
24 The Pharos/Autumn 2011 I wish I could carefully Collect sea foam in a plastic S!" Bucket F with# a aplastic$ shovel, Covet it as treasure, and still Not be disappointed as it slowly Disappears. Or spend a day without A purpose—consider it neither Useful nor wasteful—or, Consider not considering It at All. Or how about continuing The walk on the beach As endlessly as the waves, Smiling as strangers pass, Knowing I have succeeded at Last. Steven F. Isenberg, MD
Dr. Isenberg (AΩA, Indiana University, !"#$) is assistant professor of Otolaryngology—Head and Neck Surgery at Indiana University School of Medicine. His address is: !%&& North Ritter Avenue, Suite ''!, Indianapolis, Indiana %('!". E-mail: sisenberg@good%docs.com.
Illustration by Laura Aitken.
The Pharos/Autumn 2011 25 Hideyo Noguchi. Courtesy of the National Library of Medicine.
26 The Pharos/Autumn 2011 Hideyo Noguchi Controversial microbe hunter
Don K. Nakayama, MD, MBA The author (AΩA, University of California, San Francisco, Atsushi Kita presents Noguchi as a lonely scientist in a foreign 1977) is the Milford B. Hatcher Professor and Chair of land who reached success through hard work, deference, and the Department of Surgery at Mercer University School of perseverance, characteristics highly valued in Japan.2 Isabel Medicine in Macon, Georgia. Plesset, in her book, Noguchi and His Patrons, details the debates that surrounded his work and the relentless ero- ideyo Noguchi (–) at the time of his death sion of his assertions as conflicting evidence accumulated.3 was one of the world’s foremost medical researchers Plesset shows Noguchi as a scientist who holds a hypothesis during the heroic “microbe hunter” era of medicine, long after others have demonstrated it to be wrong, a failing knownH for his work with syphilis, yellow fever, and tropical afflicting researchers throughout history. In her mono- diseases in Mexico, South America, and Africa. While his graph on Noguchi, Susan Eyrich Lederer, an authority on the reputation in Japan as one of its greatest scientists continues ethics of human experimentation, recounts the researcher’s today, he is nearly a forgotten figure in his adopted coun- human tests with syphilis and the public controversies that try, the United States, where he did the work that earned surrounded them.4 While his experiments used noninfective him international renown. There are few figures in modern extracts that were first tested on fellow researchers and him- medical history whose reputation is as dichotomous as that self, Noguchi was caught in the rising human antivivisection of Noguchi. movement of the times.* His story is both inspirational and tragic. The son of a Through these three works, we see the character strengths peasant woman, his hand disfigured from burns suffered in that made Noguchi a hero in his native Japan, the human infancy, he immigrated penniless to the United States and rose weaknesses that blinded him to the flaws in his science, and to international fame in one of the West’s most technological the historical happenstance that gave him an early role in a and competitive fields, biomedical research. His staggering major controversy in medical ethics. Plesset’s and Lederer’s capacity for work and drive for recognition, however, led works were published more than twenty-five years ago, but to unethical science: premature publication of findings that they give an added Western perspective to a present-day hero could not be duplicated, clinical application before adequate in Japan and Africa. verification, and questionable human experimentation. His Noguchi’s mother Shiga worked in the rice paddies while untimely death at fifty-one from yellow fever was the result his father did odd jobs and often lost himself in drink. The in part of his unshakable belief—arising from his own faulty infant Hideyo, unattended while Shiga was planting rice, experiments—that the infective agent was a spirochete, not a crawled into the burning coals of the open hearth that warmed virus. Despite being little more than a footnote in U.S. medical the living quarters and cooked the family meals. By the time history, Noguchi’s portrait graces Japan’s basic unit of cur- Shiga heard his screams and rescued him, he had horribly rency, the , yen note, he is honored with a statue in front burned his left hand. With poultices and home remedies the of Tokyo’s National Museum of Nature and Science in Ueno only treatment for the burns, the boy’s hand healed virtually Park, and a major research institute for tropical diseases in 1 Ghana is named after him. The discrepancy in legacies could * Lederer’s paper, “Hideyo Noguchi’s luetin experiment and the not be more different and defies easy explanation. antivivisectionists,” explains the movement against human experi- In a book translated into English in , Dr. mentation that arose from the original opposition to animal vivisec- Noguchi’s Journey: A Life of Medical Search and Discovery, tion.4
The Pharos/Autumn 2011 27 Hideyo Noguchi
fingerless, with its thumb fused to the wrist. It was clear that nearest railway station in Koriyama. he would never become a farmer, one of the few realistic fu- Tokyo was already the world’s largest city when Noguchi tures for a son of peasants. arrived in . It provided a multitude of distractions, par- ticularly in the seedy Yoshiwara entertainment district where But Hideyo was bright and excelled in the village school. impoverished medical students lived. Noguchi likely had his His oral examinations impressed the proctor, Sakae Kobayashi, second encounter there with spirochetes, this time through who was also the schoolmaster at a more advanced private the usual means with local prostitutes. Noguchi discovered school. Touched by the boy’s injury and poverty, Kobayashi that he had syphilis some seventeen years later in the United offered admission to his school tuition-free. It was a difficult States when a physical examination uncovered aortic insuffi- choice for Shiga. Neighbors and friends warned against over- ciency from an inadequately treated infection, a secret he held reaching and predicted disappointment because a peasant had until his own postmortem examination.3 little use for education. It offered the possibility, however, that Noguchi attended a proprietary medical school, Shiga’s one-handed fourteen-year-old son might be able to Saiseigakusha, where students crammed for the national ex- make a living using his sharp mind. aminations. The lectures were given by assistants from the Although Kobayashi’s students were destined for agricul- nearby Tokyo University Medical School in their spare time. ture and small rural business rather than university study, They consisted of recitations from texts from start to finish, they nevertheless learned English. Hideyo’s command of the then rereading them until students felt that they had learned language would later provide the opportunity for emigration enough to take the national exam or their money ran out, of- to America. His schoolmates teased him about his hand, call- ten the cause of discontinuing a medical education. Noguchi’s ing him tembo, an epithet meaning “arm like a stick.” 2p16 A diligent study paid off—within a year he had passed both writing assignment that allowed him to poignantly express his exams, one of only four passing the second clinical test. Still frustration and shame over his deformity moved the school- his future was far from assured. He was awkward and crude master to collect contributions from teachers and students to in society, always without money, and painfully sensitive of his pay for surgery for the boy’s hand. Kanae Watanabe, a physi- dress. He and his instructors worried that patient reactions to cian trained at the University of California who lived in nearby his deformed hand could limit his success as a clinician. Wakamatsu, surgically freed the thumb and what was left of While earning pocket money translating German medical Hideyo’s fingers to allow a rudimentary grasp. texts Noguchi came upon a section on bacteriology that he The experience inspired Hideyo to become a doctor. did not understand. A conversation with one of his instruc- Watanabe took the boy in as an apprentice, a practice more tors for more information kindled an interest in the field. The characteristic of medieval Japan than appropriate to a U.S.- instructor suggested that Noguchi seek a job as a research as- trained physician.3 Hideyo cleaned the rooms and floors of sistant at the Institute for the Study of Infectious Diseases, the the combination clinic-household, helped compound medica- top research facility in the country. An obstacle to obtaining tions, assisted with patients, and when the chores were done a position there was the Institute’s preference for graduates studied long hours into the night. Watanabe’s library had of the University of Tokyo, with which it had an affiliation. texts in English, German, and French, so Hideyo’s facility with Noguchi pestered his instructors into recommending him languages was an advantage. One day Watanabe showed the to Shibasaburo Kitasato, founder of the Institute, who had boy spirochetes with his new German microscope. Fascinated, trained in Berlin under two giants in bacteriology, Robert Hideyo took far longer than his appointed time watching the Koch and Emil Adolph von Behring. In Noguchi joined creatures. The other apprentices in their impatience and jeal- the Institute as a library assistant at the age of twenty-one.3 ousy taunted that he would never be able to use a microscope with his disabled hand, taunts that fed his resolve to become Noguchi in the United States a success. Noguchi dreamed of emigrating to the United States and Watanabe gave his approval for Noguchi to take his medi- Europe for medical training, plans that at the time appeared cal examinations, a demanding two-part examination in hopelessly ambitious. In the means to achieve his aspi- Tokyo. To pay for the necessary months of study in the capital rations arrived when Simon Flexner visited Kitasato and the Noguchi borrowed money, an annoying habit of begging that Institute.3 Flexner, an authority on infectious diseases and would plague his friends and contacts long after his later ar- an assistant to William Welch, dean of the Johns Hopkins rival in the United States. Before departing he carved a vow Medical School, was part of a scientific delegation to the on a wooden pillar in his home: “I will not set foot in this Philippines. Noguchi was chosen to guide the Americans place again until I have achieved all my goals.” The inscription, because of his fluency in English. Noguchi earnestly in- along with Noguchi’s boyhood home, is preserved today as his quired about coming to the United States to study. Flexner memorial.2 Dressed in his provincial peasant garb he walked remembered his response to Noguchi as polite but far from twenty-five miles over footpaths through the mountains to the encouraging. What Noguchi heard, however, was an outright
28 The Pharos/Autumn 2011 English, so it was no use trying to explain anything complex.3 Noguchi was at first uncertain whether he would be retained at Penn for more than an academic year. Over time, however, his work progressed and he became well published, with twenty scientific articles and a chapter on snake venoms for a leading medical text. Flexner and Mitchell brought Noguchi to the meeting of the National Academy of Science in November , introduced him to elite academic society, and successfully sponsored him for a grant from the Smithsonian Institution.3 To his mentors in the United States, Noguchi was a tireless worker and “utterly charming” despite his near- unintelligible English and awkward social manners.3p83 In Flexner was appointed to head the newly an- nounced Rockefeller Institute for Medical Research, the first biomedical research center in the United States, and he planned to take Noguchi with him.3 In prepara- tion he sent Noguchi in to study bacteriology in Copenhagen. One year later Noguchi joined Flexner in New York . In Flexner set Noguchi to work on syphilis, a highly competitive field appropriate to the mission of the new institute and the ambitions of its founder.2 The agent causing syphilis, Treponema pallidum, had just been discovered in by Fritz Schaudinn and Erich Hoffman; one year later the famous complement fixation test was developed by August Paul von Wassermann. Hideyo Noguchi. Noguchi worked long into the nights, chain-smoking ci- Courtesy of the National Library of Medicine. gars, which he considered stimulants. During this period he made the discovery that is now considered his most important contribution to medical science: the discovery invitation to come to Philadelphia, where Flexner was about of T. pallidum in the brain tissue of patients who had suffered to transfer to the University of Pennsylvania. A year and a half paresis from tertiary syphilis, the first demonstration of an later on a cold December day in Flexner was astonished organic cause for psychosis.6,7 to find Noguchi at his office door, nearly penniless, declaring that he was ready to begin work.2 Problems and controversies The child of Jewish immigrants from Germany, Flexner had Noguchi’s work with syphilis led to his first major contro- attended a proprietary medical school in Kentucky, won a re- versy, his claim in of growing T. pallidum in pure culture. search position at Johns Hopkins despite his modest training, While T. pallidum inoculated into a susceptible mammalian and had become a trusted protégé of Welch. Flexner had no host clearly produced the disease, researchers had never been funds for another laboratory assistant, but found a project for able to obtain the organism in pure culture. A pure culture of his unexpected visitor with Silas Weir Mitchell, an authority the organism would allow the development of antisera with on snake venoms, who needed someone to develop antitoxins. potentially important diagnostic and therapeutic uses: specific Noguchi threw himself into the work, reviewing the English, diagnostic serological tests, antiserum-based therapy, and vac- German, and French literature, learning necessary immuno- cine development. logical techniques, and learning to handle venomous snakes.3 We now know that Noguchi could not have done what he Noguchi was lonely, homesick, and isolated. His English claimed. A major barrier to research in the disease is that the was woefully inadequate for daily use. He no doubt felt the organism cannot be cultured in vitro and survives only in live sting of racism and racial discrimination, even though he mammalian hosts.9 Others trying to duplicate Noguchi’s re- settled on the East Coast, away from the hotbed of anti-Asian sults were understandably unsuccessful and became skeptical sentiment on the West Coast.5 At Noguchi’s first seminar, of the claims in his publications. With firsthand knowledge one senior scientist joked that no one could understand his of the chaotic, disorganized, and frenetic manner in which
The Pharos/Autumn 2011 29 Hideyo Noguchi
he worked, his own laboratory technicians questioned his legal complexities of obtaining consent.4 techniques and scientific rigor.3 Test tubes went unlabeled; In using noninfective material that was tested on himself Noguchi insisted that he knew the contents of each one. Based and other coworkers, Noguchi’s use of human subjects are of on this work he was promoted to directorship of his own labo- an entirely different category than later egregious violations ratory and nominated for the Nobel Prize.3 of biomedical ethics such as the Tuskegee syphilis experiment Convinced he had isolated a pure culture of T. pallidum, of through and the Willowbrook hepatitis studies of Noguchi continued his work using false material. In through . Noguchi’s work was an early battle in the Clemens von Pirquet published his work on tuberculin, an developing antivivisection movement that led to modern legal extract of the tubercle bacillus that when injected subdermally restrictions protecting human subjects. detected a patient infected with tuberculosis. Motivated to The luetin affair ended Noguchi’s work with syphilis. find a similar such test for syphilis, Noguchi produced an ex- Noguchi likely was relieved when opportunities came to leave tract from his preparations, which he called “luetin,” after the the country to lecture and receive honors in Europe in the fall common term for the disease, “lues.” 10, 4p35 Noguchi’s prepara- of and Japan in (where he fulfilled the vow carved in tions of luetin included steps that he felt rendered it noninfec- the woodwork of his home). Syphilis was not the only disease tive—in fact, it never had been capable of infecting a recipient to receive his attention. In a single year, , he published with syphilis—and proved its safety in animals. Welch, widely discoveries for the infective agents of rabies (Negri bodies considered the dean of American medicine, encouraged being the infective agent, so Noguchi believed),11 anal condy- Noguchi to proceed with human testing. With the assistance loma (a new species of Treponema spriochete),12 and polio (a of New York area physicians Noguchi tested patients, protozoan forming “globoid bodies” that are visible on light known to have syphilis at various stages, adults and chil- microscopy).13 His conclusions were wrong in all three cases. dren with other nonsyphilitic conditions, and normal chil- Noguchi began work on Weil’s disease, a disease that he could dren. Noguchi reported that luetin detected infected patients, characterize completely using the techniques available at that particularly those with tertiary syphilis, where the reaction time.3 In he nearly died when he acquired typhoid by un- was especially pronounced and where the Wassermann test intentionally aspirating infective organisms through a pipette. was often negative.4 Response in the public health community His convalescence was a hiatus before the turbulent yellow was immediate—requests for luetin flooded the Rockefeller fever research that would kill him. Institute, which considered licensing the compound and con- tracting for its mass production. Yellow fever and the “fatal commitment” The response from antivivisectionists was also prompt. An expedition to Ecuador to study an outbreak of yellow Had human subjects been injected with syphilis? The New fever in held a natural attraction for Noguchi. Yellow York-based Vivisection Investigation League asked, “Are the fever was another “big disease” appropriate to the ambitions helpless people in our hospitals and asylums to be treated as of Noguchi, Flexner, and the Rockefeller Institute.3 Biographer so much material for scientific experimentation, irrespective Plesset terms it a “fatal commitment.” 3p189 Cuban medical sci- of age or consent?” 4p36 In John Lindsay, then president entists, among the leading researchers in the field, had made of the New York Society for the Prevention of Cruelty to several basic and important observations: the organism was Children, instituted a formal complaint against Noguchi on carried by the mosquito Aedes aegypti; it was recoverable from charges of assault. Manhattan’s District Attorney declined the bloodstream from infected individuals only during the first to prosecute the case. The fact that children were subjects three to four days after the onset of the disease; and it passed in the experiments—it later emerged that the children were through all known filters and thus was by definition a “virus.” 3 wards of the New York City Board of Charities—plagued the Flexner and William Gorgas, expedition leader and hero of the Rockefeller Institute.4 yellow fever eradication programs in Havana and the Panama Jerome Greene, business manager for the Rockefeller Canal, disagreed and believed that the infective agent was a Institute, argued that Noguchi observed the standards of the spirochete.3 Noguchi shared their bias, based upon the clinical day regarding human experimentation: the preparation had similarity between yellow fever and Weil’s disease.14 not harmed laboratory animals and the researchers had tested Less than a month after his arrival in Ecuador Noguchi the material on themselves.4 Noguchi had neglected to report announced that he had found the infective agent of yellow that he had tested luetin on himself and his collaborators, pos- fever, a goal that had eluded competent scientists for years. sibly to keep secret his own syphilitic condition. In publica- He claimed that it was a new spirochete, Leptospira icter- tions and testimony Greene, Welch, and Flexner emphasized oides, related to the Leptospira agent of Weil’s disease that the overall benefit to mankind from the advances produced he had characterized the previous year. He claimed that the by the work. The Rockefeller briefly considered legal action Leptospira organisms causing the two diseases could be against the the activists on the basis of libel, but decided distinguished immunologically, but his evidence was scant. against a lawsuit because of the public furor and the emerging Noguchi’s Ecuadorian hosts celebrated him as the conqueror
30 The Pharos/Autumn 2011 of yellow fever, honoring him in celebra- tions throughout the country.3 The Cubans, however, were skeptical.3 Mario Lebredo, a Cuban yellow fever spe- cialist who was also part of the Ecuadorian commission, noted that the peasants the commission studied likely had been ex- posed to a number of tropical diseases, including both yellow fever and Weil’s disease. The diagnosis of yellow fever was questionable because many patients were first seen long after the first days of illness when the organism was recoverable. The descriptions of patients suggested Weil’s disease, not yellow fever. Noguchi’s slip- shod laboratory techniques were nearly impossible to duplicate in remote Latin Hideyo Noguchi. SPL/Photo Researchers, Inc. American backwaters. Noguchi’s use of guinea pigs to make the diagnosis of yellow fever was also an issue, as standard lab ani- mals are not susceptible to the disease. At the time, before the use of rhesus monkeys, human volunteers Coworkers in West Africa in and were unable to were needed.14 Lebredo worried that unproven methods of isolate L. icteroides from yellow fever patients.3 Refusing to immunization based on Noguchi’s claims would compromise believe he was wrong, Noguchi in became convinced that mosquito abatement measures, an intervention known to he should go to West Africa himself to reproduce the work he control the disease.3 had done in Ecuador. After one colleague died of yellow fever Noguchi, undeterred, sent doses of immune serum based without evidence of Leptospira, Noguchi felt that his presence upon the supposed L. icteroides organism to public health of- in West Africa was mandatory.3 ficials in Ecuador and Peru,3 as well as to his field staff when His preparations for the trip had the appearance of an in- they fell ill with symptoms of yellow fever.3 Reports, however, tention to commit suicide. He gave Evelyn Tilden, his longtime began to appear that Noguchi’s immune serum was ineffec- lab assistant and later colleague, specific instructions to send tive against yellow fever, and indeed appeared to have activity money to his sister in Japan should he not return. Leaving against Weil’s disease.3 Noguchi explained that the serum nothing to chance, he gave the same instructions to his wife.3 was developed where Weil’s disease was endemic, so activity At the final staff meeting at the Rockefeller Institute the day against that disease also would be expected. Then, tragically, before his departure Noguchi presented some of his work on in Howard Cross, a young Rockefeller trainee from Johns trachoma. One attendee, Rebecca Lancefield, remembered the Hopkins, died from yellow fever in Mexico despite being im- emotions among those there. Plesset quotes her: munized with Noguchi’s serum.3 By several prominent researchers, particularly the they now recognized the courage with which he was facing Cubans, began to attack Noguchi’s claims for L. icteroides the real danger as well as the humiliation that lay before him. as the causative agent in yellow fever.14 Two years later They all believed that he had been mistaken about yellow fe- Max Theiler and Andrew Sellards at the Harvard School of ver, and that he knew it at the time of his departure. [Philip] Tropical Medicine did basic serological work that proved McMaster [another Rockefeller Institute staff member] said that Noguchi’s organism and the Weil’s disease agent were Noguchi knew he had been wrong before he left and per- identical,15, 14 revealing Noguichi’s work to be “a red herring haps it would have been worse for him if he had lived.3p255 drawn across the whole field of yellow fever research.” 3p188 Theiler later joined the Rockefeller Institute and, long after Noguchi still took the precaution of taking his yellow fever Noguchi’s death, received a Nobel Prize for the development vaccine before his departure.2 “No matter what anyone says of an effective vaccine against yellow fever.16 the icteroides vaccine protects against yellow fever,” he wrote Flexner from Africa.14p139 In October Noguchi left New Noguchi’s death York . His correspondence from Africa revealed his struggle Noguchi, faced with distrust over his techniques and re- to reconcile his biases with facts. In a December letter to his sults, became protective and secretive about his methods.3 wife he wrote that he knew the organism producing yellow
The Pharos/Autumn 2011 31 Hideyo Noguchi
fever . . . was practically valueless and possibly harmful.” 14p144 A contemporary at the Rockefeller Institute, Thomas Rivers, called Noguchi “neither a great nor an honest scientist.” 14p144 In his memoir, Paul de Kruif remembered the opinion of Frederick Novy of Michigan, the most eminent U.S. bacteri- ologist at the turn of the twentieth century:
Noguchi, a gay little Japanese, had earned fame resting partly on his discovery of a spurious spirochete that turned out, alas, to be definitely not the cause of yellow fever. You forgave Noguchi because he was a nice little guy, but Novy, the master of spirochetes, took Noguchi apart without mercy.3p207
In another excerpt de Kruif called Noguchi “a scientific Trilby . . . the slave of his Svengali, Dr. Simon Flexner.” 3p207 In an interview with Plesset before his death Theiler, who ulti- mately attained Noguchi’s dream of a yellow fever vaccine, re- Statue of Hideyo Noguchi in Ueno Park, Tokyo. Photo courtesy of the author. membered with sadness hearing others disparage the Japanese scientist’s work.3p242 In her words, “Theiler recommended that the whole Noguchi matter be allowed to ‘rest in peace’; he said it was surely a psychological problem.” Such withering opin- ions assured the burial of Noguchi’s reputation in the West. In stark contrast is Noguchi’s status as the literal face of Japanese science with his portrait on the , yen note, his statue in front of the country’s major science museum, and his more than one hundred biographies.17 His birthplace in Fukushima Prefecture preserves the thatched-roof wooden house where he was born and features a reconstruction of his laboratory, where a robot in Noguchi’s image greets visitors and narrates events in his life.18 Sapporo Breweries in Japan Hideyo Noguchi’s portrait on a 1,000 yen note. Photo courtesy of the author. released a limited edition of its Black Label beer with a cari- cature of Noguchi on its label in . Noguchi is held as an example of medical professionalism in a lecture, “Learn from Hideyo Noguchi,” given to entering students at the Nippon fever in Africa was not the one he had found in Ecuador.3 In Medical School.19 a letter to Tilden he describes “some funny bug, a filterable His reputation has assumed a global dimension in Africa one,” a reference to a viral pathogen, a clear departure from and Ghana, the country where he died. In the Noguchi his lifelong conviction.14p140 But in a letter to Flexner Noguchi Memorial Institute for Medical Research of the University of announced that he had isolated the bacillary cause of West Ghana was established in Legon. Its nine departments house African yellow fever, his original obsession.14 On May , nearly three hundred persons, including more than one hun- barely six months after his arrival in Accra, Noguchi was dead dred scientists, devoted to the study and control of tropical from yellow fever. William Young, a British pathologist work- disease.1 In the government of Japan established a prize ing with Noguchi, performed the autopsy and confirmed the in his honor, the Hideyo Noguchi Africa Prize, to honor indi- diagnosis of both yellow fever and tertiary syphilis. Befitting viduals for outstanding achievements in medical research and of a microbe hunter of the era, eight days later Young, too, services to combat infectious and other diseases in Africa.20 succumbed to yellow fever.14 Its first awards were made in . It is managed by the Japan International Cooperation Agency, through which the Noguchi’s legacy in the West, Japan, and Africa Japanese government funds . billion yen of economic de- At the end of Noguchi’s career, leading Western bacteri- velopment projects throughout sub-Saharan Africa. Noguchi’s ologists disregarded his work. Aristides Agramonte y Simoni, legacy includes his native country’s support of economic and a member of the original Reed Yellow Fever Board in Cuba, scientific projects in Africa, a continent beset by endemic wrote, “From to the day of his decease, his work in yellow tropical diseases, the field to which he gave his life.
32 The Pharos/Autumn 2011 References . Noguchi Memorial Institute for Medical Research. Univer- sity of Ghana, Legon. http://www.noguchimedres.org. . Kita A. Dr. Noguchi’s Journey: A Life of Medical Search and Discovery. Durfee P, translator. Tokyo: Kodansha International; . . Plesset IR. Noguchi and His Patrons. Cranbury (NJ): Fairleigh Dickinson University Press/Associated University Presses; . . Lederer SE. Hideyo Noguchi’s luetin experiment and the antivivisectionists. Isis ; : –. . Hosokawa B. Nisei: The Quiet Americans. Boulder (CO): University Press of Colorado; . . Whitehorn JC. A Century of Psychiatric Research in Amer- ica. In: Hall JK, editor for the American Psychiatric Association. One Hundred Years of American Psychiatry. New York: Columbia University Press; . . Noguchi H. Moore JW. A demonstration of Treponema palli- dum in the brain in cases of general paralysis. J Exp Med ; : –. . Noguchi H. A method for the pure cultivation of pathogenic Treponema palludum (Spirochaeta pallida). J Exp Med ; : –. . LaFond RE, Lukehart SA. Biological basis for syphilis. Clin Microbiol Rev ; : –. . Noguchi H. A cutaneous reaction in syphilis. J Exp Med ; : –. . Noguchi H. Contribution to the cultivation of the parasite of How’d I like that no-salt diet you put me on? rabies. J Exp Med ; : –. Well, sorta takes the sting outta dyin’. . Noguchi H. Cultivation of Treponema calligyrum (new spe- cies) from condylomata of man. J Exp Med ; : –. Alan Blum, MD . Flexner S, Noguchi H. Experiments on the cultivation of the mi- croorganism causing epidemic poliomyelitis. J Exp Med ; : –. . Dolman CD. Hideyo Noguchi (–): His final effort. Clio Medica ; : –. . Frierson JG. The yellow fever vaccine: A history. Yale J Biol Med ; : –. . The Nobel Prize in Physiology or Medicine : Max Thei- ler. http://nobelprize.org/nobel_prizes/medicine/laureates//. . Ishikawa H. Book reviews: Dr. Noguchi’s Journey: A Life of Medical Search and Discovery. N Engl J Med ; : –. . Hideo Noguchi Memorial Hall Home Page. http://noguchi- hideyo.or.jp/home.htm. . Shimura T, Yoshimura A, Saito T, Aso R. Unique medical education programs at Nippon Medical School. J Nippon Med Sch : –. . Hideyo Noguchi Africa Prize (Fact Sheet)—Hideyo Noguchi Africa Prize–Cabinet Office Home Page. http://www.cao.go.jp/no- guchisho/english/keii/gaiyo.html. From his earliest days as a medical student, Dr. Alan Blum (AΩA, Emory University, "#$%), Gerald Leon Wallace MD Endowed Chair in Family The author’s address is: Medicine at the University of Alabama, has captured thousands of patients’ Medical Education–Department of Surgery stories in notes and drawings. The sketches and jottings bring back the essence of a conversation, a detail of personality, and the fragmentary clues Medical Center of Central Georgia patients give their doctor about the experience of illness. Dr. Blum’s address 777 Hemlock Street, MSC 140 is: &' Pinehurst Drive, Tuscaloosa, Alabama (%)*"-"")$. E-mail: ablum@cchs. ua.edu Macon, Georgia 31201 E-mail: [email protected]
The Pharos/Autumn 2011 33 A contemplation on fairness
Heather Relyea-Ashley, MD
Illustration by Jim M’Guinness
34 The Pharos/Autumn 2011 The author is a resident in Internal which towered on fourteen-foot stilts— Medicine-Pediatrics at the University an attempt at maximizing tropical wind of Cincinnati. This essay won honor- flow into the house and minimizing in- able mention in the 2011 Helen H. vading snakes. I stifled a sigh. Standing Glaser Student Essay Competition. at the sink washing the dishes in rain- All photos are courtesy of the author. water, I was weary. Grief still hung over us, and yet there were needs to be met. e was slightly smelly. Tottering Endlessly. Compassion was hard to res- towards me, his worn stick urrect when pain still ran so deep. brought him to our house. He lived steadied his atrophic spindly Ivau had been in my life as long as down the hill, alone, in a small shack. Hlegs. His toothless beaming mouth was I’d had memory. My parents, American Somehow, he was taken care of, more accentuated by his beard. This beard, a linguists and missionaries, arrived in or less—the Aruamus do not let any- rarity in the village, was a long, scrag- Tiap Village with a very small me in tow one utterly starve, even if rain does not gly brown and gray affair with many in the s. Living in the deep, thick, fall on the gardens and food is scarce kinks. He was most proud of it, and it remote rainforest of Papua New Guinea, at times. Ivau lacked the closeness of was a constant source of entertainment the Aruamu were isolated from the out- a family unit since his wife had died for him and a consistent source of fear side world, but quickly became our fam- and, especially as he continued to age, for the small children he chased with ily. When childless Ivau laid eyes on my his ailments became a way for a lonely it. Screaming with delight and semi- parents, he announced to the village man to milk attention. My mother—as horror, they would dash away, bare feet that my mother would be his daugh- a daughter should be—was dutifully pattering, their dingy, holey clothes flap- ter. This pronouncement automatically compassionate and sympathetic. He was ping behind them as the adults laughed placed my father in the other clan, be- entertaining and we all loved him. merrily. cause the Aruamus avoid consanguinity. A quintessential Ivau incident oc- “Ivau is here,” the seven-year-old Thus, I became the first grandchild. curred one afternoon when a group of messenger had announced a half hour He was the village hypochondriac. In men and women sat in a circle at our earlier. The small boy had stood quietly such a remote rainforest location having house to work on literacy and scripture until we noticed him at the top of the a myriad of terrible illnesses, Ivau’s real checking in Aruamu. Ivau was men- long stairway leading up to our house, and imagined health difficulties often tally sharp and being involved with the
The Pharos/Autumn 2011 35 Ulcers in Papua New Guinea
Literacy Committee was a source of pride for him. This day, however, went down in our family lore. Ivau had man- aged to zip a part of his scrotum in his worn pants. He evidently failed to notice it, but my father found the obvi- ous loop of skin quite distracting as the group delved into the Aruamu Bible. Dad always had a special relationship with Ivau. Both knew how to ham it up and get under each others’ skins. For reasons of propriety and to avoid sexual innuendo, Aruamus never say the name of an in-law. The friendship between my father and Ivau, however, was a joking relationship. Dad often called Ivau by his name, which almost always elicited laughter from everyone. Either that, or he would call him “Tambu”—“In-Law”— and Ivau would actually answer to this, contrary to usual custom. Sometimes throwing cultural boundaries aside is appropriate for forging deep friendships. Since my recent return to the village Ivau had been refusing to bathe. No one was truly responsible for him since he had no family. Despite regularly hob- bling all over the village he refused to go to the river to cleanse himself. The good village women—including my aunt Watarak—did their best to intervene. They offered to carry buckets of water up the mountain for him to use. He refused. Like a stubborn little boy who relished his own sticky dirt, he simply
36 The Pharos/Autumn 2011 blow of reality was crushing. I withdrew from school, put my wed- About Heather M. ding and my hopes for medical school on Relyea Ashley hold, and traveled back to New Guinea The daughter of with my brother, sister, and mother after missionaries, I grew the funeral. There was no way the work up in Papua New among the Aruamu, set to be completed Guinea. After obtain- in six months, could be finished well ing my undergraduate unless my family had assistance. Mom, degree at Harding a highly effective linguist, was under- University, I worked for one standably crushed by the sudden death, year in clinical research at Texas and my younger siblings desperately Scottish Rite Hospital for Children. needed stability. So we did our best to I attended medical school at the band together, despite the overwhelming University of Texas Medical Branch desire to remain in fetal positions. in Galveston, where I was an Osler That was how I found myself not Student Scholar, a Gold Humanism in physics class or studying for the Society member, and a Finalist for MCAT but in Tiap Village that spring the Gold-Headed Cane award. I am was not in the mood to wash. morning, with Ivau waiting. I had nu- thrilled to be starting residency in News of his more pressing problem, merous other things to do that day, but Internal Medicine-Pediatrics at the however, had reached , miles Ivau needed help. His four-month-old University of Cincinnati. I am mar- around the globe several months previ- burn was still very ugly. There was no ried to my high school sweetheart, ously. I read the e-mail from my mother early excision and grafting to be found an orthopedics resident, and we in my college dorm room in Arkansas. in the jungle. My sister Brigette and both share the goal of working long- Ivau had fallen asleep while lying beside I selected the supplies we needed to term in global health. My hobbies the fire in his little shack. What hap- do the best we could. When we met include drinking tea from around pened next is common in the developing Ivau under Watarak’s house next door, the world, playing with my two par- world, but its effects are no less horrific however, we drew the line at his odor. rots, reading, traveling, and spend- even if they are ubiquitous. Ivau woke We refused to dress the wound unless ing time with my family, who are with large burns on his leg from roll- he agreed to wash with a bar of soap often scattered around the globe. ing into the fire. My mother tried to we provided. After much coercion, and help with bandages, pain medication, not a little teasing, he reluctantly took and some doxycycline she had on hand. the soap and washed himself under the cloth. These ulcers were, in fact, how I Antibiotics are over the counter in Papua rainwater tank. Then his dutiful grand- knew vaguely that HIV had invaded our New Guinea, but would have been unaf- daughters dressed his oozing wound island—our parents suddenly made us fordable for Ivau. Sensitivities to bacteria yet again. In his typical joking fashion wear gloves sometime in the early- to were not something one could test in the he asked us where our medical degrees mid-s. I didn’t understand what village, and Mom did her best. were that allowed us to treat him. HIV was at that point, but I remember Just days later, my forty-nine-year- There was something therapeutic feeling frustrated with the barrier I felt old father dropped dead in New Guinea. about caring for wounds in the village. It the gloves put between my friends and I received the wrenching early morning was peaceful and it gave us time with our me. I felt rude putting on gloves to touch phone call from across the ocean. The friends. Brigette and I and our brother them, but I obeyed; my parents seemed horrors of lack of vaccination and eas- Bobby had been doing this for years. very serious about the issue. ily treatable diseases claimed many in Growing up, there were so many needs We spent hours with cotton balls, the village. Death sometimes seemed that our parents harnessed all of us to bleach, vats of hot water, disinfectant, merely a part of life. We’d seen and care for those around us. Many after- antibiotic powder—all low cost ways of experienced hard, difficult things. One noons after school, beginning when we dealing with the wounds. It was some- might’ve said it was a matter of time were in grade school, were spent caring thing tangible we could do to love our until we were touched, too. Death at for tropical ulcers. Some people take friends. With the ever present flies, in- such a personal level still felt so unfair. ballet in elementary school—we fixed fections ran rampant. Some lasted for I’d broken out of the cultural fatalism ulcers. Villagers of all ages would walk years. My friend Gumi had numerous and embraced idealism in my premedi- up with open sores, sometimes ban- ulcers on her legs and feet for most of cal studies in the United States, but this daged with a bit of hibiscus leaf or dirty our childhood. They never healed, no
The Pharos/Autumn 2011 37 Ulcers in Papua New Guinea
carcinoma, as well as topical chemother- apy. We had far more access than our friends did, even at our remote location. We could leave for help if necessary. While my father did die in New Guinea, and lacked the adequate access to care that might have saved him, medical help was also almost never available to our Aruamu friends. Life expectancy for the Aruamus is in the forties; Dad died at a comparable age. In the grand scheme of things life is not fair. It was largely this realization of the horrors of the health disparity between the first and third worlds that compelled me to pursue medicine. In my career goals, I want to fix the world, somehow. The ideas of fairness and sha- lom are quite lofty concepts. How hard it can be to put feet on such dreams. matter what we did. In that jungle, you cut we received must be taken care of And yet, during those long after- sure need your feet. I did not know immediately. Infection was not permis- noons sitting under bamboo and jungle- enough of medicine to consider yaws or sible. I’ll never forget that difference wood houses in the foothills of Papua mycobacteria as etiologies for the cav- between the Aruamus and my family— New Guinea’s northern coast, the wind ernous, hideous openings that exposed scars from large ulcers did not mar our rustling through the palm trees, we my friends’ flesh like hamburger meat. bodies. I remember in college, walking could tangibly make life a little more fair, We did the best with what we had and into my microbiology incubator and even as we laughed and told stories and with what we knew. thinking it felt just like Tiap Village—any cleaned sores. Ulcers aren’t fair. Neither During those years, growing up so wound allowed to go untreated even are burns and not having medicine, vac- closely intertwined with the village as a few hours ended up infected. Tiap cines, food, or education. Neither is a we did, we didn’t see much of a differ- Village was one of the only places on father dying at forty-nine. ence between our Aruamu friends and earth that I think truly warranted show- That day with Ivau, I couldn’t make ourselves. We barely noticed the skin ering with antibacterial soap. But this the world right, bring back my dad, or color difference. Who cared? What was was a place where soap was quite rare; cure the village from all its ailments. a difference in melanin among friends, we used to give bars of soap out for But I could clean Ivau’s sore. And that, I family? As the years progressed though, Christmas presents. think, made the world a little less unfair. differences arose—it became appar- We did get many of the illnesses our All those endless afternoons spent clean- ent that life was not the same for my friends had—all of us had malaria mul- ing ulcers could be viewed as a waste. Aruamu friends as it was for my fam- tiple times. Brigette and Bobby both After all, ulceration would recur after ily. From the start, we had more access survived the cerebral form, somehow. the next cut or bump in the hard life the to medical care. This was when I first Even so, there was still a crucial differ- Aruamus live in the rainforest. To me, deeply grasped the concept of disparity, ence between us and our friends. While however, it wasn’t a waste. I have never if not the word itself. by American standards we were not regretted those hours. It was a way to My father was exceedingly careful in rich, we still had numerous resources connect, to show care. At its deepest his insistence on two things. We must at our disposal. Although my sister and level, cleaning ulcers was, for my brother wear sunscreen, due to our light skin— brother could have died from malaria, and sister and I, a connection between my brother and I were blond, my sister they didn’t. I received major spinal fu- friends who may look different, but are a redhead. His voice would echo across sion surgery for scoliosis in Dallas at age not. And that heals more than just ulcers. the palm trees, “Did you remember sun- fourteen. My mom received her hyper- screen?” as we tried to escape into the tension medications. When she needed The author’s address is: bush with our friends. It was a family it, she had Mohs surgery complete with 231 Albert Sabin Way, ML 0535 joke, with a serious twist. His second a . centimeter exquisitely stitched inci- Cincinnati, Ohio 45267-0535 rule was equally inflexible: any sort of sion on her forehead for squamous cell Email: [email protected]
38 The Pharos/Autumn 2011 Spin One hundred billion spinning galaxies, one hundred billion spinning stars in each, and spinning planets perhaps to Avogadro’s number, began with a BANG from a microscopic font thirteen and a half billion years ago. These luminous fusion factories represent but # percent of universal mass/energy. The rest is mysterious dark matter and the enigmatic energy driving the accelerating expansion of spacetime. In the simplest atom, a spinning electron orbits a spinning proton. —it is a particle of known mass and charge. But, KERPLANCK—it can be at once both here and there! Perhaps it is a wave, or a wave/particle, or neither. On spinning planet GOLDILOCKS, several billion years ago, lightning in an anoxic atmosphere synthesized amino acids. Living cells then developed somehow, somewhere, and, after almost infinite spin cycles of birth, growth, senescence, death, genus Homo and species sapiens evolved. Sapient priests, parsons, rabbis, imams, mullahs, patriarchs, heads of state, and voices on the media, often claim to know the mind of God and invoke his blessing. Daniel J. McCarty, MD
Dr. McCarty (AΩA, University of Pennsylvania, !"#$) is the Ross Professor of Medicine Emeritus at the Medical College of Wisconsin. His address is: W$%" N&'(# Forest Drive, Hartland, Wisconsin #$)%". E-mail: [email protected]. The Pharos/Autumn 2011 39 Illustration by Bruno Vaes. The physician at the movies Peter E. Dans, MD
Owen Wilson in Midnight in Paris. © Sony Pictures Classics.
Midnight in Paris angst-ridden Hannah and Her Sisters; Dianne Weist again, Starring Owen Wilson, Rachel McAdams, Marion Cotillard, this time as a gangster’s talentless moll in the witless Bullets Kathy Bates, and Adrien Brody. over Broadway; Mira Sorvino as that hardy Oscar-winning Written and directed by Woody Allen. Rated PG-13. Running perennial, the heart of gold prostitute in another silly contriv- time 94 minutes. ance, Mighty Aphrodite; and Penelope Cruz as the tempestu- ous ex-wife in Vicky Cristina Barcelona. That helps explain idnight in Paris, which may be characterized as Purple why, despite his sordid personal life, actors are excited to work Rose of Cairo meets Manhattan, represents a return to with him. Starting as a comedy writer (especially for the in- theM form Woody Allen displayed in some of my favorite Allen imitable Sid Caesar), a standup comic, and an essayist for the films: Play it Again Sam, Broadway Danny Rose, Love and New Yorker, much of Allen’s work has been autobiographical Death, Manhattan, and Annie Hall. It’s hard to believe that and psychoanalytic in nature, no doubt drawing heavily on his he has written and directed over forty films since writing the estimated thirty years in analysis. screenplay for What’s New Pussycat? in and then taking Midnight in Paris has a lightness and good humor that over as director as well as screenwriter for What’s Up, Tiger has been missing in many of his later films and, as a result, in Lily? the following year. five weeks, it became the highest grossing of any of his films Despite his shunning of the Oscar ceremonies except in North America. It opens by treating the viewer to an hom- on two occasions, he has received twenty-one nomi- age to Paris to the strains of saxophonist Sidney Behcet’s, “Si nations and three Academy Awards. Fifteen actors tu vois ma mere,” similar to his great cinematographic paean have received Oscar nominations and five actors to New York City in Manhattan. Unlike the latter, it was not have won Oscars for performances in his films: shot on-site but involves what appears to be a series of picture Diane Keaton as the unforgettable Annie Hall; postcard views that show Paris to advantage as the City of Michael Caine and Dianne Weist for the Light both in day and in night, as well as in the rain. I have
40 The Pharos/Autumn 2011 visited Paris three times, and the sequence brought back a ages besides those pictured in the film. For example, he de- flood of happy memories. Ironically, the film’s major theme is votes considerable space to “Paris medicale” with its École de to live in the present and not subsist on nostalgia for a past or Médecine, and numerous hospitals and illustrious physicians golden age that may never have existed. like Guillaume Dupuytren and Philippe Ricord, and especially The Woody-proxy is played very well by a surprising Pierre Louis. He makes a good case for the period from choice, Owen Wilson, better known for more broad comedy to as being Paris’s golden age of medicine that attracted as a slacker or a surfer dude. Here he sensitively carries off the the likes of Bostonians Oliver Wendell Holmes, James Jackson, role of Gil, a screenwriter who, although well paid, aspires to Henry Ingersoll Bowditch, and John Collins Warren, who be a novelist but is suffering from writer’s block. He and his made extended stays there, becoming exposed to a different fiancée Inez (Rachel McAdams) are visiting Paris with her form of medicine, which they then brought back to the United parents John (Kurt Fuller) and Helen (Mimi Kennedy). Inez is States to create our own golden age. McCullough quotes Osler a shallow materialistic princess and her parents are the stereo- as saying in the s that “modern scientific medicine had typic wealthy and obnoxious Americans. They clearly inhabit had its rise in France in the early days of this century. More a different planet than Gil does. They want to go shopping than any others, it was the pupils of Pierre Louis who gave and sightseeing. Gil would rather search for the Paris of the the impetus to the scientific study of medicine in the United s, where he and Inez might reside while he conquers his States.” writer’s block. She wants none of that. This trio represents a Yet, as much as one would be thrilled to study under Louis, movie set-up to get us on Gil’s side and is the weakest part of one would not want to inhabit a golden age of medicine in the film. Fortunately we don’t see them much except as brief Paris before anesthesia and asepsis. In fact, the professional bridges between Gil’s visits to the past. jealousies and political turmoil in France were such that by On a sightseeing expedition to Versailles, their estrange- Osler’s time the place to go was Vienna or Berlin, which were ment surfaces as Inez becomes attracted to her college hero superseded by the United States in the twentiety century. It Paul (Michael Sheen), a pedantic pompous ass. When Paul led me to reflect on how fortunate I was to be trained in the suggests that Gil and Inez join him and Carol (Nina Arlanda) period of the s and s in what might be called the that evening to go dancing, Gil opts to stay in the hotel. Going Golden Age of Internal Medicine (before it splintered into out for walk, he hears midnight strike and all of a sudden F. subspecialties) that included exposure at Columbia to David Scott Fitzgerald (Tom Hiddleston) and wife Zelda (Alison Seegal, Arthur Wertheim, Dana Atchley, and the physicians Pill) pick him up in a s roadster and he time travels to the recruited by Robert Loeb; at Hopkins to Mac Harvey and his world he seeks. There he meets Ernest Hemingway (Corey faculty, including Victor McKusick, Leigh Cluff, Lock Conley, Stoll), who amusingly declaims his work, and Gertrude Stein and Dick Ross; at the Thorndike to Max Finland, Ed Kass, (Kathy Bates), who agrees to read his manuscript. He also and Lou Weinstein; and later to Gordon Meiklejohn and Paul meets Salvador Dali, played wildly over-the-top by Adrien Beeson. I might have hoped that my daughter and other re- Brody, as well as Pablo Picasso (Marcial Di Fonzo Bo) and his cently minted physicians could have been exposed to the likes mistress Adriana (Marion Cotillard). When the latter split, a of them. Yet, like the Paris of Louis, I wouldn’t want them for thoroughly besotted Gil hopes to stay with Adriana in that their patients’ sake to linger long in that era, given how little world, but it turns out that her concept of a golden age is La we could do for patients in too many areas compared with Belle Epoque, to which they then time travel. There she in- today. In short, what Allen may be saying is that we can’t go troduces him to the Paris of Henri de Toulouse-Lautrec, Paul back to that golden age, nor should we want to, but must make Gauguin, and Edgar Degas, a world in which he feels less at of the present our own golden age. home. Mix in Man Ray, T. S. Eliot, Luis Buñuel, Jean Cocteau, Addendum: I can’t resist giving a plug for AΩA’s Leaders Henri Matisse, Cole Porter at the piano, and the dancers at in American Medicine series, endowed by David Seegal.2 It’s a Maxim’s and you have an very appetizing artistic bouillabaisse. set of video interviews with past “giants” of medicine, some of The screenwriting is vintage Woody Allen: clever, literate, and which have been discussed in The Pharos by Oliver Owen,3–8 funny. Watch for Carla Bruni, the wife of French president and which can provide some interesting course material for Nicolas Sarkozy as a sympathetic museum guide. both history of medicine and clinical skills. As to Allen’s thesis about a golden age, by chance, shortly after seeing the film, I listened to the audiotape of David References McCullough’s new book, A Greater Journey,1 about Americans . McCullough D. The Greater Journey. New York: Simon and who went to study and experience Paris from the s to Schuster; . . It too has a heady assortment of famous characters . Leaders in American Medicine. alphaomegaalpha.org/lead- starting with James Fenimore Cooper, Charles Sumner, and ers.html. Samuel F. B. Morse, and ending with Augustus Saint-Gaudens. . Owen OE. Robert H. Williams, M.D. The Pharos Fall : McCullough makes clear that Paris had a series of golden –.
The Pharos/Autumn 2011 41 The physician at the movies
Kristin Scott Thomas in Sarah’s Key. Photofest. © Weinstein Company.
. Owen OE. Russel V. Lee, M.D. The Pharos Summer ; be persistent and believe in one’s work. Having had the same –. number of rejections for two of my books before acceptance, . Owen OE, Avery ME. Gertrude B. Elion, D.Sc. (Hon.), – I can relate, but obviously not to its economic and artistic . The Pharos Summer ; –. success. . Owen OE. David M. Kipnis, M.D. The Pharos Summer ; The movie opens on a happy note in an apartment in the –. Marais, the predominantly Jewish quarter of Paris. Young . Owen OE. David C. Sabiston, Jr., M.D. The Pharos Winter Sarah Starzynski (Mélusine Mayance) and her little brother ; –. Michel are tickling one another and giggling under the covers . Owen OE. Matthew Walker, M.D. The Pharos Spring ; when they are interrupted by the police at the door. Having –. rounded up almost , men on May , , the French have been directed by their German overseers to conduct a Sarah’s Key round-up of women and children. Before leaving the apart- Starring Kristen Scott Thomas, Melusine Mayance, and Aidan ment, Sarah and her mother are allowed to take a blanket, a Quinn. sweater, a pair of shoes, and two shirts. Sarah tells Michel to Directed by Gilles Paquet-Brenner. Rated PG-13. Running wait in the closet until they return. She gives him food and time 111 minutes. water, locks the closet, and holds on to the key. In the street, they are joined by the father who is not very happy with Sarah’s arah’s Key is based on a novel of the same name written by decision but is prevented from re-entering the house. Tatiana de Rosnay.1 It tells the story of a July round- At the Vél d’Hiv, they are all herded together in a facility Sup in which the French police arrested , Jews, including with only ten lavatories (all of which were sealed to prevent , women and , children. They were detained for days escape) and one water tap.2 The sun coming through the glass in the Vélodrome d’Hiver or Vél d’Hiv, an arena built for winter skylight combined with the body heat from so many prison- indoor bicycle racing, before being deported to an internment ers made it so unbearably hot that some committed suicide camp and then on to Auschwitz. De Rosnay’s manuscript was or went mad. Some Quakers, Red Cross workers, and a few rejected by over twenty publishers. Finally, when published doctors were allowed in but they could do little to relieve the years later, it sold over five million copies and has been released suffering.2 in thirty-eight countries.2 It’s a good example of why one must Sarah escapes with a friend from the children’s section of
42 The Pharos/Autumn 2011 about “surprises” that turn out not to be so surprising. The portrayal of Julia’s husband Bertrand Tezac (Michel Duchussevoy) is rather hard to believe. His late hours and lack of attention to his wife while trying to close a deal with the Chinese are totally believable. What is not is his reaction to her happiness about being pregnant. After having gone through fertility treatments to have what they called “a miracle baby” and now hav- ing one naturally, his adamant stance on her having an abortion surprises the viewer as much as it does Julia. Left, Mélusine Mayance in Sarah’s Key. Photofest. © Weinstein Company. Finally, the first scene in which Julia meets Sarah’s son William Rainsferd (Aidan Quinn) in Florence doesn’t ring true, especially in contrast to the internment camp with the help of a guard who had allowed their second meeting at the Tavern on the Green, which con- her to keep an apple and her key during previous encounters. cludes the film. Whatever the case, these are minor flaws in They run for their lives and finally arrive at a small cottage a picture well worth seeing, especially since these tragic and where an elderly couple refuses to take them in. They sleep heinous events are so little-known. with the dog and the next day, the man, seeing that her com- Addendum: The Vél d’Hiv round-up accounted for panion is desperately ill, gives them shelter. At first, he decides more than a quarter of the , Jews sent from France to not to get medical aid because the town doctor is on holiday Auschwitz in , of whom only a little over were said and his substitute is a collaborator. Finally, he does call the to have returned to France at the end of the war. It wasn’t doctor who arrives with a German SS officer. The child dies of until that Jacques Chirac acknowledged the guilt of the diphtheria. The German officer wants to know if there’s anyone French police for collaborating with the Germans and issued else there and the old man asks him if he would have called an apology. them if there were. Sarah then convinces the couple to take her to Paris to References check the apartment and to let her brother out of the closet. . De Rosnay T. Sarah’s Key (Movie Tie-In). New York: St. Mar- The film goes back and forth between the present and past fo- tin’s Griffin; . cusing on journalist Julia Jarmond (Kristin Scott Thomas) who . Dodes R. Film: Sarah’s Key: The Hit No One Wanted. Wall is writing an article about the Vél d’Hiv atrocity. Coincidentally Street J Jul . http://online.wsj.com/article/SB her husband is related to the family that took over the apart- .html. ment shortly after the Starzynskis were forcibly evicted and they are renovating it to live there. As Jarmond tries to learn Great Expectations (1946) what happened to Sarah and what her in-laws knew, the Starring Jean Simmons, John Mills, Francis L. Sullivan, Martita search leads her to Brooklyn, Florence, back to Paris, and then Hunt, Finlay Currie, Alec Guinness, and Valerie Hobson. Manhattan. I’ll leave it there but I will add that a friend who Directed by David Lean. Unrated. B&W. Running time 118 accompanied me to the screening said that the film reminded minutes. him of Sophie’s Choice. He has a good point, especially with regard to the effects on Sarah of her well-meaning spontaneous n June, Turner Classic Movies had a Jean Simmons ret- decision and her survivor guilt. rospective and I taped this classic. Given the dearth of The film is very well done. There is a lot of French dialogue qualityI films in today’s theaters, I decided to review it. Great with excellent subtitles in addition to the English, as well as a Expectations, which was beaten out by Gentleman’s Agreement sprinkling of German and Italian (which are not translated). for the Oscar for Best Picture, is another top drawer J. Scott-Thomas does a great job in tying together the many Arthur Rank production started off by their hardest-working threads in the different storylines, and the girl playing Sarah is employee striking the gong. The director is David Lean, who outstanding. The film could have been shortened, especially to- went on to direct such memorable films as Lawrence of Arabia, wards the end where it starts to drag to heighten the suspense The Bridge on the River Kwai, Summertime, Doctor Zhivago,
The Pharos/Autumn 2011 43 The physician at the movies
and A Passage to India, among others. Lean and his co-screen- irons, as well as “wittles” (victuals), or he will tear out his heart writers did an extraordinary job in distilling Dickens’ sprawling and liver, and roast and eat them. narrative and communicating the essential story without sacri- When Pip returns home, he learns that his sister has been ficing the richness of the characters. It helped that the cast was looking for him. She beats him with a switch, which she also a virtual Who’s Who of British character actors, many of whom administers to her husband (a classic spouse and child abuser). had acted in previous adaptations of the book for the screen The next morning before daybreak, Pip sneaks out with a file, and stage. Though color was available, Lean wisely chose to some brandy, victuals, and a pot pie. He is so fearful that he film in black and white, just as Carol Reed did in filming The thinks he hears the cows and sheep calling out at his perfidy. Third Man in . He manages to see the convict, but not before he sees another The book was the next-to-last of Dickens’ novels. At the escapee, a sworn enemy of Magwitch. After Magwitch is re- time, Dickens was having problems sustaining his literary mag- freshed, the boy asks him if he wants to share the rest with his azine All The Year Round. The author who had supplied him brother escapee. Magwitch flies into a rage and seeks out the with two chapters of a novel each week for serialization had other and, at the risk of being caught, he sets upon him. This done great work, but this time his story was a dud and sales easily allows the soldiers in a search party to apprehend them. were down. So Dickens decided to use a story he had sketched Before Magwitch boards the boat, he makes sure to say that he out to publish elsewhere for bigger payments. Serializing stole the food so as to protect Pip. novels often encouraged authors to pad the writing, especially Shortly thereafter, Pip’s Uncle Pumblechook (Hay Petrie) when getting paid by the word. Yet with a writer of Dickens’ is asked by his landlady, the very eccentric Miss Havisham caliber, much of the filler enriches the characterization while (Martita Hunt), if he knows of a boy who could play with her stringing the reader along so he or she could not wait for ward Estella (Jean Simmons). Miss Havisham has been living in the next installment. Dickens was so popular in the United the same house since she was jilted on her wedding day. All the States that some people waited at the dock to meet the ship clocks have stopped at twenty to nine and all the wedding trap- from England to get the latest installment. This serialization pings have been left as they were. This rejection engendered ran from December , , to August , , allowing him such an antipathy to men that her request that Pip come and to incorporate readers’ comments, including that of Edward play with her ward is part of her training Estella to break men’s Bulwer-Lytton, the author of The Last Days of Pompeii, who suggested that he change the original downbeat ending to a “more acceptable” one.1 Like the book, the film is narrated by the central character Philip Pirrip, Pip (Tony Wager), an orphan boy who is being raised by his sister, Mrs. Joe (Freda Jackson), and her husband, Joe Gargery (Bernard Miles), a blacksmith. The opening is one of the greatest scenes in cinematic history, which the Motion Picture Academy acknowledged by awarding the film Oscars for Best Cinematography and Art Direction. Pip is visiting the graves of his father and mother in the marsh country of England. It’s “a dark and stormy” night, the wind is howling, and a prison ship lies at anchor nearby. Suddenly, Pip is accosted by escaped convict Abel Magwitch, played with gruff menace by Finlay Currie (who would later portray a quite different character, Saint Peter, in Quo Vadis, another classic film). When Magwitch ascertains that the boy lives with a blacksmith nearby, he orders Finlay Currie and Anthony Water in Great Expectations (1946). him to bring him a file to remove his leg © General Film Distributors/Photofest. Photographer: Cyril Sanborough.
44 The Pharos/Autumn 2011 hearts. Simmons is excellent as the beautiful but mali- cious Estella, whom Pip describes as “proud,” “pretty,” and “insulting,” although he is mesmerized by her. When he confesses on the next visit that she is not as insulting, she slaps him and then asks what he thinks now. Later, she allows him to kiss her before turning him out. The visits continue until they reach four- teen, when Ms. Havisham sends Estella off to France for finishing school and Pip starts his apprenticeship with Joe, who, though illiterate and uneducated, is the noblest and most warmhearted character in the story. Six years pass, when Miss Havisham’s lawyer, Mr. Jaggers, played with gusto by Francis L. Sullivan, ar- rives to tell Pip that he has “great expectations” in that an anonymous donor has set up a fund for him to be educated as a gentleman. The post horn sounds and a carriage sets off for London with the twenty-year-old Pip dressed up and wearing an expression of wonder as he embarks on this new adventure. The actor who played Pip as a child is replaced by a young John Mills, who went on to a long career in film and was the father of Hayley and Juliet Mills. He is a more fresh-faced tenderfoot than one would expect from someone who has worked as a blacksmith for six years. Pip is reunited with Herbert Pocket (Alec Guinness), whom he had encountered at Miss Havisham’s. Herbert is now his roommate and unof- ficial mentor on manners and how an affluent dandy Martita Hunt plays Miss Havisham in Great Expectations (1946). should act. As he absorbs those manners and an edu- © General Film Distributors/Photofest. Photographer: Cyril Stanborough. cation, he becomes in his own words “a snob” who is embarrassed when Joe visits him in London. Despite feeling guilty at his shoddy treatment of Joe, Pip decides not to you’re not supposed to really think very much about their ab- stay at his old home at the Forge on a visit, but at the Blue Boar surdity and to just allow yourself to be caught up in the story Inn “where people of quality stay.” and the performances. It’s easy to see how this captivated read- Pip visits Miss Havisham who, he is convinced, is his bene- ers at the time, to be fed only two chapters and then be left like factress. Miss Havisham tells him that “if Estella favors you, the old-time movie serials waiting for the next installment. The love her; if she tears your heart to pieces, love her.” Estella, who film is definitely worth putting on your Netflix list, and if you is back from France, re-enters his life in the person of actress are inclined to read the book, you may wish as I did to locate Valerie Hobson, who is a distinct change from Jean Simmons. a copy of the very beautifully read compact disc version.2 Be Although she’s still disdainful of the lovesick Pip, saying, “You forewarned, though, it consists of sixteen discs. meant nothing to me. You must know, Pip, I have no heart,” somehow she does not have the edge, haughtiness, and, yes, References venom that Simmons conveyed. It’s almost like the game has . Dickens C. Great Expectations. New York: Random House; lost its allure and she wants to protect him from herself. He . still is attracted to her and tries to win her heart but she is . Dickens C. Great Expectations (The Classic Collection). Read betrothed to someone else. The story unfolds in a very interest- by Michael Page. Grand Rapids (MI): Brilliance Audio; . ing manner when the convicts re-enter the picture and provide new links to the principals. Let’s leave it there, except to say Dr. Dans (AΩA, Columbia University College of Physicians and that the ending is even brighter than the book’s revised ending. Surgeons, 1960) is a member of The Pharos’s editorial board and Maybe, like me, you’ll wonder what Miss Havisham’s room has been its film critic since 1990. His address is: must have smelled like with the rats running around a place 11 Hickory Hill Road Finlay Currie and Anthony Water in Great Expectations (1946). that had not seen the sun all those years while Pip and Estella Cockeysville, Maryland 21030 © General Film Distributors/Photofest. Photographer: Cyril Sanborough. were growing up. In a sense, it’s like those Gothic novels where E-mail: [email protected]
The Pharos/Autumn 2011 45
e would see all of him: the wisps of hair around his nipples, the parachute valves inside his heart, his guts, blooming from his abdomen. We would open his kidney like a book and find old pyramids and columns. We would admire the tendons of his palm as they fanned out toward manicured fingernails. We would break into his joints, and bend his knee to find a thick rim of silver, gliding against a translucent root, which was labeled: “ANT.” But on the first day, when we pulled off the cloth (back then, it was still white) and Tommy slid the blade onto the stalk of the scalpel, I looked down and found my gloved hand resting on a pale forearm, my thumb moving back and forth, back and forth. Emily Silverman
Ms. Silverman is a member of the Class of !"#$ at the Johns Hopkins University School of Medicine. This poem won second prize in the !"## Pharos Poetry Competition. Ms. Silverman’s e-mail address is: ems%"!!@ gmail.com.
Illustration by Erica Aitken.
The Pharos/Autumn 2011 25 Reviews and reflections David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors
about psychiatry. They don’t know what schedule her patient for that evaluation. they are missing. This intelligent book by psychiatrist turned first-time author Finally I resort to calling UCLA, Dora Wang is actually less about psy- where I first cared for transplant chiatry than it is about the American patients as a resident. health care system. Psychiatry is simply “I used to evaluate transplant a window for examining the system. Dr. patients at UCLA,” I tell their co- Wang’s vivid memoir shares experiences ordinator. from her medical training, career, and She is sympathetic, kind. “Your personal life as well as insights from the patient was just a child. We make al- lives and stories of her patients to point lowances in cases like this. Our team The Kitchen Shrink: A out the changes that have occurred in would give her a second chance. But Psychiatrist’s Reflections on medicine at the turn of the century. if the insurance company won’t pay, Healing in a Changing World The major theme of the book is there’s nothing we can do.” driven by the story of a young patient “So the insurance company de- Dora Calott Wang, MD that Dr. Wang cares for at the University cides? Not doctors, nurses, or the New York, Penguin Group, 2010, 354 of New Mexico Hospital. After the liver patient?” pages transplant service at the hospital closes “Basically,” she says, “there’s permanently, Dr. Wang continues to nothing we can do.” Reviewed by Justin Taylor, MD ( , AΩA follow transplant recipients as the team Kaliani listens, watching me do University of New Mexico, 2009) psychiatrist. One particular patient, a this strange new work of a doctor. young girl named Selena, struggles with By now it is too late, anyway. hile the catchy title of family issues and grief that impede her Beneath the ICU’s fluorescent this book will entice ability to adhere to her post-transplant lights, I read Selena’s flowsheet. Her Wsome to crack its cover, medication regimen. Selena ends up in creatinine is rising, meaning now some others may over- need of evaluation for another trans- her kidneys are also failing. The soft look it because it plant, this time at a new hospital. Below beeps of the green monitor screen appears to be is an excerpt showing the frustration tell me her heart no longer beats a book solely that Dr. Wang faces when trying to regularly.
The Pharos/Autumn 2011 47 Reviews and reflections
I stand beside Selena’s bed. I hold relationship has eroded. her jaundiced hand.p39 The book is threaded with harrowing stories of some of the consequences for Dr. Wang uses stories like Selena’s to both physicians and patients of changes illustrate physicians’ loss of control over in the practice of medicine. Dr. Wang patient care and their own practice of co-authored a paper demonstrating medicine. She chronicles this change in that one in five physicians working at medicine over the course of her career, medical schools in had significant from medical school at Yale during the symptoms of depression.1 She shares deregulation of the health insurance her personal battle with anxiety and industry and expansion of health main- the story of a colleague whose work tenance organizations to the emergence contributed to her illness. She aptly The Language of Pain: Finding of “prior authorization” requirements explains how patients are also nega- Words, Compassion, and Relief and other hurdles during her first expe- tively affected, relating stories of her David Biro riences in private practice. She grapples father’s poor medical management and W. W. Norton, New York, 2010 with the challenges of a changing sys- the tragic murder of two Albuquerque tem that increase her administrative police officers by a mentally ill man Reviewed by George D. Comerci, burden and detract from the time she whom the health care system had failed Jr., MD, FACP (AΩA, University of has available to spend with patients, to help. And of course, there is the story Arizona, 1982) and explains the unforeseen effects of of Selena. changing reimbursement. The Kitchen Shrink is a compelling ave you ever read The Decline and timely read, published in the midst and Fall of the Roman Empire, Under the old fee-for-service sys- of health care payment reform. Its nar- HDoc?” my patient asked during our first tem, there were abuses, of course, rative format and humor make it easy to encounter in the pain clinic. “Well,” he by physicians who overcharged and read and the author’s positive outlook continued, “there was a story in the overtreated. However, the reason- gives the reader hope. This memoir will book about a woman that was flayed able, ethical physician was in no provoke physicians to remain active alive with sharpened oyster shells. jeopardy. The reasonable physician members of the health policy debate That’s how my pain feels, day and night, was compensated reasonably. and will, above all, remind us to con- like somebody shaving my skin off with Under the for-profit managed- sider the art of healing above the busi- oyster shells.” care system, many reasonable phy- ness of medicine. This patient’s incredibly graphic de- sicians have found it impossible to scription of chronic neuropathic pain, I survive.p180 Reference learned after reading David Biro’s excel- . Schindler BA, Novack DH, Cohen lent book, The Language of Pain, was Rather than continue to see more DG, Yager J, Wang D, Shaheen NJ, Guze P, an example of an agency metaphor. This patients to try to break even, Dr. Wang Wilkerson L, Drossman DA. The impact of occurs when the patient likens his pain decides to work for an institution where the changing health care environment on to some external agent acting against she can serve as an employee and leave the health and well-being of faculty at four the patient’s body. Motivated to write the institution to deal with insurance medical schools. Acad Med ; : –. this book after experiencing his own companies. However, she soon learns very painful illness, Biro, through exam- that insurance companies that also Dr. Taylor is a 2011 graduate of the Uni- ples from literature and art, describes own health care institutions are finding versity of New Mexico School of Medi- the difficulties inherent in expressing cheaper ways to practice medicine to cine, where he was the recipient of Alpha pain and the manner in which metaphor make a profit. Then even the physician- Omega Alpha honors in his junior year and is utilized to achieve this. owned institutions must do the same the Gold-headed Cane award in his senior Pain cannot be measured with a to compete. She relates how she was year. He is beginning Internal Medicine blood test, imaged by an MRI, or ad- asked to see patients in less than fifteen residency training at the Brigham and equately described by the analog pain minutes and how her patients no longer Women’s Hospital in Boston. His address scale which ranks pain on a scale of one received their psychotherapy from her, is: through ten. Biro believes that but from psychologists and therapists. 7 Alveston Street Thus, in order to cut costs, medicine Jamaica Plain, Massachusetts 02130 Expressing pain seems impos- has become more fragmented, less co- E-mail: [email protected] sible, whether the paralyzing pain ordinated, and the patient-physician from ulcers spreading through the
48 The Pharos/Autumn 2011 gastrointestinal tract or the less de- describe pain. The agency metaphor sees her spine depicted as an Ionic col- bilitating kind caused by a blood clot is used when the pain sufferer imag- umn broken in several places. in the eye. Patients, even physicians ines an agent acting upon the body. An As a physician with both a profes- who become patients, find them- example of this would be the descrip- sional interest in pain and a personal selves tongue-tied, unsure how to tion of pain as “like being cut with a interest in literature I found this very begin—how to describe what feels knife” or having one’s skin flayed as thoughtful book to be transformative in so immediate and yet so intangible noted above. Biro further describes a that I have a new appreciation of the im- at the same time.pp12–13 more elaborate version of agency that portance of metaphor in not only com- clinicians use regularly: the military municating pain, but in describing it. Biro devotes the first part of this metaphor, which he attributes to Susan This book is more about literature and book to exploring the difficulties in Sontag in her Illness as Metaphor. He il- language than medicine and, as such, describing pain and the effects that pain lustrates this by quoting a passage from can be bit daunting, especially to those can have on the individual. He notes Solzhenitsyn’s Cancer Ward, in which of us who are more comfortable with that pain is often a very private expe- the main character’s pain is described Harrison’s Textbook of Medicine than rience that isolates the sufferer from as “secondaries tearing his defenses to Hemingway. In rare instances, Biro’s his world; an experience that cannot pieces like tanks.” p87 The agency meta- prose became a bit ponderous and a be known, shared, or understood by phor is perhaps our most effective tool bit repetitive. Nevertheless, I highly the nonsufferer. Of the many examples to describe pain. recommend this excellent book to any from the works of Oliver Sacks, Virginia A second type, the projection meta- clinician who has struggled to under- Wolf, William Styron, and others that phor, is used when the pain sufferer stand the language of suffering and, Biro uses to illustrate pain, his descrip- attempts to transfer his pain and feel- particularly to understand the language tion of Harry, from Ernest Hemingway’s ings onto an object or an animal. As of those who suffer with chronic pain. The Snows of Kilimanjaro, conveys this Harry becomes worse, finding himself concept most effectively. Describing a unable to communicate his pain to his Dr. Comerci is a professor of Internal scene from the story in which Harry is girlfriend, he imagines his pain in the Medicine at the University of New Mexico. contemplating his painful, gangrenous form of one of the hyenas that had been He is the co-director of the UNM Center leg, the author writes stalking their camp. The ability to at- for Pain Assessment and Rehabilitation tribute one’s back pain to a prolapsed and the ECHO Telemedicine Pain Clinic. Harry’s connection to the world disc, whether or not this is the true pain His address is: has been severed. He has retreated generator, can be particularly validating, Department of Internal Medicine into the depths of his body, the only especially for the chronic pain sufferer Project ECHO: Chronic Pain and world that matters now. His girl- who is made to believe that her pain is Headache Clinic friend cannot penetrate that world; not real. In attributing pain to some- University of New Mexico what is so overwhelmingly present thing else, the individual may also be Albuquerque, New Mexico 87106 for him is entirely absent for her. able to infer meaning to the pain. E-mail: [email protected] Nor can he convey what is happen- The third metaphor is the anatomic ing inside him; language has become metaphor, or what Biro describes as p24 useless. Harry is alone. the use of metaphor to “make pictures User-Driven Healthcare and p180 of the body’s interior with words.” Narrative Medicine: Utilizing The second and most prominent part Instead of projecting pain outside the Collaborative Networks and of this book encompasses what Biro body, it is projected inward in a manner Technologies feels is the most effective and important that helps the sufferer better understand means of communicating pain: the use her pain. A common example of this Rakesh Biswas and Carmel Mary Martin of metaphor that is the arthritic who envisions his pain- IGI Global, Hershey, Pennsylvania, fully stiff joints as something mechani- 2010, 610 pages isn’t merely a rhetorical device that cal like rusty hinges or worn bearings. Reviewed by: P. Ravi Shankar, MD dresses up language but a power- Biro’s most effective explanation of the ful and necessary resource of the anatomic metaphor is his description imagination that literally extends the of Frida Kahlo’s famous self portrait, he doctor-patient relationship is a boundaries of our shared world. p16 Broken Columns. In this painting, the mainly unequal one, with the pa- artist—who suffered a disabling spinal tientT in a subordinate role, although Biro notes that three different types fracture as a youth—paints herself bi- changes have been slowly occurring of metaphors are commonly used to sected in such a manner that the viewer around the world. In the case of medi-
The Pharos/Autumn 2011 49 Reviews and reflections
B. M. Hegde, former vice-chancellor education, developing community on- of Manipal University in India, and tologies in user-driven health care, so- Professor Suptendranath, a biomedical cial networking, and the doctor-patient informatics specialist. I also contributed relationship. Patient perspectives in a chapter on MH for the book. diseases ranging from spinal injury to The book combines two related cystic fibrosis are covered. I am not sure fields, narrative medicine and user- about whether some of the topics cov- driven health care, and starts with a ered are strictly useful to understanding description of one patient’s struggle and within the domain of health care. with idiopathic thrombocytopenic pur- While they provide a different perspec- pura and her journey to recover her tive, they also make the book bulky and cine, the two roles are often charac- health. The book uses conversations to constitute more information for the terized as “the one who decides does explore various issues in medicine from reader. The book is hardbound, which not pay and the one who pays does a broader perspective. For too long I presents for me a basic conflict about not decide.” Recently two academicians, believe that we have been concentrating what kind of book it aspires to be. The Dr. Rakesh Biswas from India and Dr. on the technical issues of illness and personal stories are interesting and en- Carmel Martin from Canada have writ- ignoring the personal, family, and social gaging and I feel are best read curled up ten and edited a book on user-driven dimensions. Patient stories, the impact comfortably in bed, while its size and health care and narrative medicine. of their illnesses on self and family, weight makes that difficult! Some of With an international advisory board, and how patients coped or are coping the other chapters are full of theoretical the book has reviewers and contributors is a major theme. I especially liked the constructions and concepts and are a from many countries both developed chapter in which authors, using patient traditional scholarly read. and developing. stories, explore critical illness and the The strength of the book lies in per- In his foreword, Dr. Richard Lehman emergency room. The book introduces sonal stories and stories (conversations) of Oxford University writes, “Medicine the concept of patient journey record about how to interact with other doc- in our time has become alienated from systems (PaJR), which examines illness tors, health professionals, and patients, its users, and even from its practitio- and the struggle to regain health from both face to face and using the Internet. ners. We are all, to a varying extent, the patient perspective. The detailed table of contents at the be- pawns in a global business which is Many chapters also explore the per- ginning will help the reader decide which only incidentally related to helping sick sonal perspectives of doctors, health chapters to read and in which order. The people. . . . We will know when we have professionals, and medical students. Dr. compilation of references at the end, the arrived at a proper model of user-driven A. K. Das writes beautifully about being contributors section, and the index are medicine when there is a free dialogue a medical student and cardiothoracic useful. The book caters to a wide range between each patient’s experience and surgeon in a government institution in of readers, from physicians, other health evidence-based medicine.” Kolkata, India, and how they reused ma- personnel, patients, other academics, I have known Rakesh for a number terials and equipment to reduce costs. and interested lay readers. The editors of years and know his keen interest in The poor socioeconomic condition of are to be congratulated on their work the patient perspective and using sto- the population in eastern India and how and the publishers for their high stan- ries to teach medicine. For the last five they could not afford basic health care dards. The publishers and the editors are years I too have been teaching a module and the implications of the loss/sickness publishing a journal titled International on the Medical Humanities (MH). The of a working family member on fam- Journal of User-Driven Healthcare book brings together many eminent ily finances are powerfully described. (http://www.igi-global.com/bookstore/ personalities, some of whom I know An American physician reflects over titledetails.aspx?titleid=) to con- personally. Among them are Joachim seven decades of medical practice and tinue the debate and discussion on this Sturmberg from Monash University in describes the changes throughout the interesting topic. Australia, a physician and writer; Binod period. Today he abstracts articles from Dhakal, who completed his undergradu- medical journals for the benefit of busy Dr. Shankar is a Professor of Medical Edu- ate medical degree (MBBS) at Pokhara clinicians. cation at KIST Medical College in Lalit- in Nepal; Dr. Huw Morgan, an emi- The book covers issues ranging from pur, Nepal. His address is: nent medical educator who has helped descriptive statistics, medical humani- KIST Medical College with our MH program; Dr. A. K. Das, ties, user-driven learning both in medi- P.O. B ox 14142 a cardiac surgeon now associated with cine and other subjects, on-line learning Kathmandu, Nepal stem cell research in Malaysia; Prof. in discussion groups, on-line health E-mail: [email protected]
50 The Pharos/Autumn 2011 Broken Mom was insistent: Don’t live this way. Just fix it. Deep within me I cried, I am not broken but nobody could hear. Pressing a hand to my ear, I felt the hardness of my hearing aid, nestled snugly in its canal, smugly mocking: fix it, fix it. My ear was fixed quickly by steady hands that brushed swiftly past the curtain of my membrane and entered the domain of ossicles that had turned to stone. The scalpel spoke sharply but scarred ossicles could not vibrate. A titanium incus was set lovingly in its place like the final piece of a puzzle, Or the last block on a precarious tower of Jenga. I woke up to a world where sirens blare and people scream secrets into cell phones. Everyone hears the nasty rumors whispered in lecture halls, But they leave school and suddenly they are deaf to shouted pleas: “Can you spare a little change?” that follow them on the walk to the subway. This !" decibel gift given to my ears has opened my eyes. The world is less kind than I knew. Honking cars and intermittent curses set the beat for the # o’clock symphony of clicking heels, trains that clatter across tracks and into the station. I listen to the sounds of the sad city I love but never really knew, And my gleaming incus pulses in time with my heart: fix it, fix it. Krishna Sury
Ms. Sury is a member of the Class of !"$% at the State University of New York Downstate Medical Center College of Medicine. This poem won hon- orable mention in the !"$$ Pharos Poetry Competition. Ms. Sury’s e-mail address is: [email protected].
46 The Pharos/Autumn 2011 Letters to the editor
Re: “Community-acquired group with the highest mortality was mines the thoughtful investigation pneumonia” the one that received antibiotics within of the individual patient. However, I Kudos to Drs. Lorber and Fekete one hour of arrival. The most likely would be remiss if I did not point out for pointing out the inanity of the explanation is that the sickest people that the authors fall into exactly the term CAP (Spring , pp. –). got treated fastest, and of course were same trap when they observe that the For years I have tried unsuccessfully the most likely to die. Similar con- patient had a “left mid-lung infiltrate.” to teach our residents not to use the founders are almost certainly at work In fact, this patient has a cavitary le- term, but to think in terms of the etiol- for those whose therapy was delayed. sion in the superior segment of the left ogy of the infection. However, given Observational studies such as this one lower lobe with an associated left pleu- the endorsement of the term CAP by can never establish causality, only as- ral effusion. Those observations, had both the IDSA and the ATS we have sociations. This is a very weak reed to they been made, would have strongly little chance of eliminating it from the support a national health care policy suggested the correct diagnosis of lexicon. In most cases they use the with many unintended consequences. Mycobacterium tuberculosis infection term CAP in place of pneumococcal I can only hope that in the future at the time of the initial X-ray examina- pneumonia (the most common cause hospitals will be required to have tion. Failure to correctly characterize of pneumonia in adult civilians), be- microbiology laboratories as part the “infiltrate” allowed the physicians cause they never attempt to isolate of accreditation and that physicians caring for this patient to proceed down a pathogen from the sputum. As the will again learn to turn to the labora- the wrong track. I would strongly sug- authors point out, clinical microbiology tory to them help to diagnose and gest that, had the film been reviewed has been sadly devalued by hospital ad- treat this group of patients rationally. by a trained, experienced physician, ministrators, who outsource the work, Laboratories really can diagnose pneu- the correct diagnosis would have been and most physicians, who don’t order mococcal pneumonia if they get spu- made at the outset and the patient’s the tests. One of the consequences of tum from the patient before antibiotics subsequent complicated course poten- not making an etiologic diagnosis is the are started. That will not always be tially avoided. Failure to appreciate the reliance on broad spectrum antibiotics, possible, but it is a goal. precise location of the abnormality (su- and this is one practice that drives the perior segment of the left lower lobe), current epidemic of antibiotic resis- Reference the fact that it was cavitary with an air tance. It also contributes to the shock- . Meehan TP, Fine MJ, Krumholz HM, fluid level within it, and the presence ingly high incidence of nosocomial et al. Quality of care, process, and outcomes of an associated left pleural effusion Clostridium difficile infections. in elderly patients with pneumonia. JAMA is almost unforgiveable. Reliance on a The authors also point out that ; : –. generic description such as “left mid- there is an overuse of broad spectrum lung infiltrate” is simply too imprecise Joshua Fierer, MD, FIDSA antibiotics for anyone admitted with and leads to the same kinds of errors (AΩA, New York University, ) a respiratory complaint. This is in as lumping all pneumonias into the University of California, San Diego, response to the standard imposed by “community-acquired pneumonia” cat- School of Medicine the Joint Commission, that “initial an- egory creates. As the authors point out, VA Healthcare San Diego tibiotic be received within six hours of “language matters,” as does the need E-mail: [email protected] hospital arrival” (the previous standard to fully appreciate the abnormalities was four hours). However, I disagree so clearly demonstrated on the initial with the authors that there are chest radiograph. studies that provide a rationale I understand and fully support the Carl E. Ravin, MD for this practice. In the article point made by Drs. Lorber and Fekete (AΩA, elected as faculty, Duke they cite,1 the graph relat- in their article on community-aquired University, ) ing time of administra- pneumonia (Spring , pp. –), Duke University Medical Center tion to outcome is which suggests that the term is so Durham, North Carolina very revealing; the broad and nonspecific that it under- E-mail: [email protected]
52 The Pharos/Autumn 2011 2010/2011 Administrative Recognition Awards
MINNESOTA his award recognizes the AΩA chapter administrators Mayo Medical School (Association) who are so important to the functioning of the chapter. Barbara Westmoreland TheT nomination is made by the councilor or other officer of NEW YORK the chapter. A gift check is awarded to the individual, as well University at Buffalo State University of New York School of Medicine & Biomedical Sciences as a framed Certificate of Appreciation. Jacklyn T. Ulinski Good The following awards were made in /: NORTH CAROLINA University of North Carolina at Chapel Hill School of Medicine GEORGIA Sharon Windsor Mercer University School of Medicine OHIO Elaine Pergerson Ohio State University College of Medicine KANSAS Eileen Mehl University of Kansas School of Medicine SOUTH DAKOTA Laura Zeiger Sanford School of Medicine The University of South Dakota MASSACHUSETTS Mary Sutter Tufts University School of Medicine VIRGINIA Mary Broderick Virginia Commonwealth University School of Medicine Sandra Sorrell 2010/2011 Medical Student Service Project awards
NEW YORK egun in as the Chapter of the Year award, this pro- Columbia University College of Physicians and Surgeons gram was intended to recognize outstanding contribu- Columbia University Stay Shady! Program B New York University School of Medicine tions made by an AΩA chapter. In , the program became Improving Attitudes and Behaviors Among Patients of Low Health the AΩA Chapter Development Award, aimed at encouraging Literacy Through a Novel Health Education Literacy Program ongoing original and creative programs being carried out by University of Rochester School of Medicine and Dentistry AΩA chapters. In , the program again changed to the SNACKS (Serving Nutritious and Appetizing Cuisine to the Kin of the Sick) AΩA Medical Student Service Project Award, available to any NORTH CAROLINA student or group or students at a school with an active AΩA University of North Carolina at Chapel Hill School of Medicine UNC chapter. Craniofacial Center—Spanish Resources (second year) Medical Student Service Projects funded by AΩA during OHIO Case Western Reserve University School of Medicine the / school year were: AΩA Research Experience—Connecting Local Cleveland High Schools to Local Researchers ALABAMA Ohio State University College of Medicine University of South Alabama College of Medicine The Buckeye Blanket Bash Health and Screening Fair (Katrina) Wright State University Boonshoft School of Medicine CALIFORNIA Community Collaborative Spring Food Drive (second year) University of California, Davis, School of Medicine PENNSYLVANIA LGBT Psych-Ed Support at Sacramento Mental Health Clinic Jefferson Medical College of Thomas Jefferson University INDIANA Refugee Health Partners (second year) Indiana University School of Medicine Drexel University College of Medicine Taking Root in the Community:Beginning of a Lifelong Journey of Accessibility Adventure Day (second year) Serving Others SOUTH CAROLINA MARYLAND University of South Carolina School of Medicine Johns Hopkins University School of Medicine SNMA—Secondary School Health Science Collaborative Wolfe Street Roots & Shoots (multiple projects) TEXAS MASSACHUSETTS The University of Texas School of Medicine at San Antonio Tufts University School of Medicine BEST (Breastfeeding Education and Support for Teenage mothers) Educating local hair stylists on recognizing suspicious skin lesions as (second year) possibly cancer of the head or neck University of Texas Southwestern Medical Center at Dallas Southwestern MINNESOTA Medical School Mayo Medical School Syringe Disinfection Volunteer Program (second year) Winter Warmth Festival VERMONT NEW JERSEY University of Vermont College of Medicine University of Medicine and Dentistry of New Jersey—New Jersey Medical SAT Preparatory Course for HS Students from Refugee or School Underprivileged Families in Winooski, Vermont Healthy Awareness: Promoting disease prevention in Newark, New WEST VIRGINIA Jersey West Virginia University School of Medicine NEW MEXICO CHASM (Charleston Homeless And Street Medicine) University of New Mexico School of Medicine West Virginia University School of Medicine CHASM (Charleston Spring Giving Tree Homeless And Street Medicine)
The Pharos/Autumn 2011 53 2010/2011 Volunteer Clinical Faculty Awards
NEBRASKA he Alpha Omega Alpha Volunteer Clinical Faculty Award University of Nebraska College of Medicine is presented annually by local chapters to recognize com- Dennis Jones, MD munityT physicians who have contributed with distinction to NEW JERSEY the education and training of medical students. AΩA provides University of Medicine and Dentistry of New Jersey—New Jersey Medical School a permanent plaque for each chapter’s dean’s office; a plate Mario Capio, MD with the name of each year’s honoree may be added each year University of Medicine and Dentistry of New Jersey—Robert Wood that the award is given. Honorees receive framed certificates. Johnson Medical School Larnie Booker, MD The recipients of this award in the / academic year NEW YORK are listed below. Mount Sinai School of Medicine Michael Silverstein, MD ALABAMA New York Medical College University of South Alabama College of Medicine Michaela Mocanu, MD Charles Scott Markle, MD New York University School of Medicine CALIFORNIA Elizabeth K. Hale, MD University of California, San Francisco, School of Medicine State University of New York Downstate Medical Center College of Elizabeth Kantor, MD Medicine DISTRICT OF COLUMBIA Jacob Dimant, MD George Washington University School of Medicine and Health Sciences University of Rochester School of Medicine and Dentistry Peter A. Moskovitz, MD Benson Zoghlin, MD FLORIDA Weill Cornell Medical College University of Miami Leonard M. Miller School of Medicine Jason Kendler, MD Raul de Velasco, MD NORTH DAKOTA GEORGIA University of North Dakota School of Medicine and Health Sciences Morehouse School of Medicine Patrick Welle, MD Jose O. Rodriguez, MD, MBA, FAAP OHIO HAWAII Ohio State University College of Medicine University of Hawaii, John A. Burns School of Medicine Patricia Litts, MD Melvin Palalay, MD University of Cincinnati College of Medicine Barry Brooks, MD ILLINOIS Chicago Medical School at Rosalind Franklin University of Medicine & PENNSYLVANIA Science Drexel University College of Medicine Matthew Nash, MD James Reilly, MD INDIANA Jefferson Medical College of Thomas Jefferson University Indiana University School of Medicine Michael Belden, MD Mark M. Walsh, MD University of Pittsburgh School of Medicine Kenneth Dzialowski, MD IOWA University of Iowa Roy J. and Lucille A. Carver College of Medicine SOUTH CAROLINA Andrea Venteicher, MD Medical University of South Carolina College of Medicine Margarita Murphy, MD KANSAS University of Kansas School of Medicine University of South Carolina School of Medicine Christopher Brunner, MD William M. Moore, Jr., MD KENTUCKY TENNESSEE University of Louisville School of Medicine Meharry Medical College Carlos Ramirez-Icaza, MD Ugo Nwachuku, MD Vanderbilt University School of Medicine LOUISIANA Tony Ross, MD Louisiana State University School of Medicine in New Orleans Edward Lafleur, MD TEXAS Louisiana State University School of Medicine in Shreveport University of Texas Medical School at Houston Sherry L. Ryan, MD Ronald W. Kirkwood, DO University of Texas Southwestern Medical Center at Dallas Southwestern MARYLAND Medical School University of Maryland School of Medicine Rebekah A. Naylor, MD John C. Perkins, MD WASHINGTON MASSACHUSETTS University of Washington School of Medicine University of Massachusetts Medical School Roger Rowles, MD George Abraham, MD, MPS, FACP WEST VIRGINIA MICHIGAN West Virginia University School of Medicine University of Michigan Medical School Brian A. Plants, MD John D. Segall, MD MINNESOTA University of Minnesota Medical School Michael Cady, MD
54 The Pharos/Autumn 2011 2010/2011 Visiting Professorships
University of Missouri—Kansas City School of Medicine eginning in , Alpha Omega Alpha’s board of directors Jonathan Metzl, MD, PhD, Vanderbilt University School of Medicine offered every chapter the opportunity to host a visiting B NEBRASKA professor. Fifty chapters took advantage of the opportunity Creighton University School of Medicine during the / academic year to invite eminent persons Oliver J. Harper, MD in American medicine to share their varied perspectives on University of Nebraska College of Medicine John Frey, MD, University of Wisconsin School of Medicine medicine and its practice. NEW JERSEY Following are the participating chapters and their visitors. University of Medicine and Dentistry of New Jersey—New Jersey Medical School ALABAMA Lawrence C. Parish, MD, MD (Hon), Jefferson Medical College University of Alabama School of Medicine NEW YORK J. Bruce Beckwith, MD, Loma Linda University School of Medicine Albany Medical College ARKANSAS Sue Goldie, MD, MPH, Harvard School of Public Health University of Arkansas for Medical Sciences College of Medicine Columbia University College of Physicians and Surgeons John Holcomb, MD David Valle, MD, Johns Hopkins University School of Medicine CALIFORNIA Mount Sinai School of Medicine University of California, Los Angeles David Geffen School of Medicine Joseph Loscalzo, MD, PhD, Brigham and Women’s Hospital Julie Freischlag, MD, Johns Hopkins Medicine New York Medical College Loma Linda University School of Medicine Molly Cooke, MD, University of California, San Francisco, School of Darrell Kirch, MD, Association of American Medical Colleges Medicine State University of New York Downstate Medical Center College of DISTRICT OF COLUMBIA Medicine George Washington University School of Medicine and Health Sciences Hugh E. Evans, MD, New Jersey Medical School Edward J. O’Neil, Jr., MD, Tufts University School of Medicine State University of New York Upstate Medical University FLORIDA Lewis First, MD, University of Vermont College of Medicine University of Miami Leonard M. Miller School of Medicine The School of Medicine at Stony Brook University Medical Center David T. Stern, MD, Mount Sinai School of Medicine Edward J. Benz Jr., MD, Dana-Farber Cancer Institute, Harvard University of South Florida College of Medicine Medical School Ary L. Goldberger, MD, Harvard Medical School University at Buffalo State University of New York School of Medicine & GEORGIA Biomedical Sciences Morehouse School of Medicine Seymour Schwartz, MD Juanita L. Merchant, MD, PhD, University of Michigan NORTH CAROLINA ILLINOIS Wake Forest University School of Medicine University of Chicago Division of the Biological Sciences The Pritzker James Wilkins, MD School of Medicine OHIO L.D.H. Wood, MD, PhD, University of Chicago (emeritus) Ohio State University College of Medicine Loyola University Chicago Stritch School of Medicine Perri Klass, MD, New York University John Callaghan, MD, University of Iowa PENNSYLVANIA LOUISIANA Jefferson Medical College of Thomas Jefferson University Louisiana State University School of Medicine in New Orleans Richard G. Roberts, MD, JD, FAAFP, FCLM, University of Wisconsin Lewis Goldfrank, MD, New York University School of Medicine and Public Health Louisiana State University School of Medicine in Shreveport Temple University School of Medicine Thomas J. Nasca, MD, MACP, Accreditation Council for Graduate Barbara Bass, MD, FACS, The Methodist Hospital Department of Medical Education Surgery Tulane University School of Medicine Penn State Milton S. Hershey Medical Center College of Medicine Richard Schulick, MD, Johns Hopkins University School of Medicine Daniel Dempsey, MD, FACS, Penn State Milton S. Hershey Medical MARYLAND Center College of Medicine Johns Hopkins University School of Medicine PUERTO RICO Timothy R.B. Johnson, MD, University of Michigan Medical School Ponce School of Medicine and Health Sciences University of Maryland School of Medicine Blanca Durand, MD, Ponce School of Medicine and Health Sciences Arnold Relman, MD, Harvard Medical School Universidad Central del Caribe School of Medicine MASSACHUSETTS Daniel Schidlow, MD, Drexel University College of Medicine Tufts University School of Medicine University of Puerto Rico School of Medicine Joseph E. Scherger, MD, MPH, Eisenhower Medical Center Debbie Salas-Lopez, MD, Chair, Lehigh Valley Health Network MICHIGAN RHODE ISLAND University of Michigan Medical School The Warren Alpert Medical School of Brown University Allan M. Brandt, PhD, Harvard University Ezekiel Emanuel, MD, PhD MINNESOTA SOUTH CAROLINA University of Minnesota Medical School Medical University of South Carolina College of Medicine Timothy Quill, MD, University of Rochester School of Medicine and Nathan Thielman, MD, Duke Global Health Residency Program Dentistry University of South Carolina School of Medicine MISSOURI Darrell Kirch, MD, Association of American Medical Colleges University of Missouri—Columbia School of Medicine SOUTH DAKOTA Douglas Wood, MD, Mayo Clinic Sanford School of Medicine The University of South Dakota David Mutch, MD, Washington University School of Medicine
The Pharos/Autumn 2011 55 TENNESSEE University of Texas Medical School at Houston Vanderbilt University School of Medicine Richard Schulick, MD, Johns Hopkins University School of Medicine Ruth Berggren, MD, The University of Texas Health Science Center at Texas A&M Health Science Center College of Medicine San Antonio Patrick Ober, MD, Wake Forest University School of Medicine University of Tennessee Health Science Center College of Medicine WEST VIRGINIA Kim A. Eagle, MD, MACC, University of Michigan West Virginia University School of Medicine University of Texas Medical Branch School of Medicine Clay B. Marsh, MD, The Ohio State University Medical Center J. James Rohack, MD, Texas A&M Health Science Center College of Medicine University of Texas Southwestern Medical Center at Dallas Southwestern Medical School L. David Hillis, MD, FACP, The University of Texas Health Science Center at San Antonio
2011 Edward D. Harris Professionalism Award
he Board of Directors of Alpha Omega Alpha is pleased to announce the winner of the Edward D. Harris ProfessionalismT Award. The award emphasizes AΩA’s commit- ment to its belief that professionalism is a crucial facet of be- ing a physician, a quality that can be both taught and learned. Originally named the AΩA Professionalism Fellowship, the award has been renamed to honor Edward D. Harris, the long- time executive director of the society, who died in May . Applications were open to medical schools with active AΩA chapters. Faculty who have demonstrated personal dedication to teaching and research in specific aspects of professional- ism that could be transferred directly to medical students or resident physicians were encouraged to apply for these funds. The winner of the Edward D. Harris Professionalism Award is:
Paul Haidet, MD, MPH Director of Medical Education Research, Penn State Milton S. Hershey Medical Center College of Medicine Dr. Haidet received , funding for his project, “Promoting Professionalism Through Reflective Practice and Identity Formation.” A large body of research suggests that medical learners change during their training in response to the organizational culture, or “hidden curriculum,” of medical environments. Documented changes include erosion of altruism, humanism, patient-centeredness, and advocacy. Further, evidence sug- gests that some physicians discard moral values in order to accomplish specific management tasks. and creativity while at the same time making choices within Reflective practice offers a solution to the hidden cur- the constraints of a given clinical environment. While many riculum’s deleterious effects. While trainees may make sound medical schools and residency programs have built structures choices when given time and a safe environment to reflect to foster reflection, these structures are often aimed at reflect- on professional dilemmas, clinical settings, in contrast, are ing after the fact, rather than in real time at the point of care. fast paced, hierarchical, and emotionally charged. In order This program aims to address this gap by implementing a cur- to be reflective practitioners, trainees and physicians need to riculum that will build trainees’ capacity to reflect in action in build capacity to reflect in action, accessing their own values real-world clinical environments.
56 The Pharos/Autumn 2011 FHer!"# white cap$ createdai "my white coat Nursing was her music of healing I marveled at the strains that drifted from her maternal hands Never guessing my future would require similar notes of feeling She was beside me when the letter came Granting the privilege to practice her song Though in a different key with several extra notes I prayed to play it half as strong Unexpectedly, melody gave way to dissonance Cellular rebellion silenced the beat of her heart Though it seemed that science triumphed over spirit The chaos of cancer did not silence her part For we have always known the Composer of life’s symphony Ever trusting His timing and decision For twenty-six years I was her understudy Now I’m the musician Sarah Rapp
Ms. Rapp is a member of the Class of !"#! at the University of Texas Medical School at Houston. This poem won honorable mention in the !"## Pharos Poetry Competition. Ms. Rapp’s e-mail address is: [email protected].
The Pharos/Autumn 2011 1