January 2011 - Greater Louisville Medical Society

Transcription

LOUISVILLE
GREATER LOUISVILLE mEdIcAL SOcIETy
MEDICINE
VOL. 58 nO. 8 jAnUARy 2011
T H E
O R I G I N A L
H O M E
C A R E
P E O P L E
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Attention all Internal
Medicine, Family Practice
and Endocrinology
Physicians who treat
Diabetes patients: The
GLmS Physicians Take
AIm at diabetes Program
invites YOU to participate
in this exciting initiative.
By attaining the NCQA DRP Recognition you:
• Demonstrate to your patients that you are
providing excellence in diabetes care
• Earn increased respect from your peers
The GLMS AIM Program provides at no charge:
• DRP audit support
• DRP practice administrative and
educational support services
• Patient and physician tools
The GLMS AIM Program is excited to
announce:
• PQRI Reporting audit services at no
charge offered when applying for new
DRP services to qualifying physicians.
• Physicians can earn an incentive payment
of up to 2 percent of their total allowed
charges for all Medicare services billed in
2010.
Contact: Dottie Hargett, Director of
Professional Relations and AIM Program
Director at 502-736-6348 or
dottie.hargett@glms.org
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Mutual Interests. Mutually Insured.
Contact Susan Decareaux or Jesse Lawler at mkt@svmic.com or call 1-800-342-2239. svmic.com
GLMS Board of Governors
Lynn T. Simon, MD, board chair
Kimberly A. Alumbaugh, MD, president
David E. Bybee, MD, president-elect
Robert A. Zaring, MD, vice president and
AMA alternate delegate
Heather L. Harmon, MD, treasurer
James Patrick Murphy, MD, secretary
Robert H. Couch, MD, at-large
Elmer Dunbar, MD, at-large
John M. Gormley, MD, at-large
Daniel W. Varga, MD, at-large
Jonathan W. Wilding, MD, at-large
Russell Williams, MD, at-large
Bruce Scott, MD, AMA delegate
Gordon R. Tobin, MD, KMA president
Fred A. Williams, Jr., MD, KMA 5th district trustee
David R. Watkins, MD, KMA 5th district trustee
alternate
K. Thomas Reichard, MD, GLMS Foundation
president
Stephen S. Kirzinger, MD, Medical Society
Professional Services president
Edward C. Halperin, MD, MA, dean,
UofL School of Medicine
Matthew M. Zahn, MD, interim director,
Louisville Metro Dept. of Public
Health & Wellness
Jay P. Davidson, president and CEO,
The Healing Place
Lisa Sosnin, GLMSA president
Louisville Medicine Editorial Board
Editor: Mary G. Barry, MD
Elizabeth A. Amin, MD
Deborah A. Ballard, MD
Arun Gadre, MD
Stanley A. Gall, MD
Larry P. Griffin, MD
Darin Harden, MD
Kenneth C. Henderson, MD
Jonathan E. Hodes, MD
Thomas James III, MD
Michael T. Macfarlane, MD
Joe Maurer, MD
Teresita Bacani-Oropilla, MD
Danielle Pigneri
Tracy Ragland, MD
Charles B. Ross, MD
M. Saleem Seyal, MD
Dave Langdon, Louisville Metro Department
of Public Health & Wellness
Lynn T. Simon, MD, board chair
Kimberly A. Alumbaugh, MD, president
David E. Bybee, MD, president-elect
Lelan K. Woodmansee, CAE, executive director
Bert Guinn, MBA, communications & membership
director
Ellen R. Hale, communications associate
Donna Watts, communications designer
Advertising
Cheri K. McGuire, director of marketing
736.6336, cheri.mcguire@glms.org
LouiSviLLE MEdicinE is published monthly
by the Greater Louisville Medical Society, 101 W.
Chestnut St. Louisville, Ky. 40202 (502) 589-2001,
Fax 581-9022, www.glms.org.
Articles to be submitted for publication in LM
must be received on electronic file on the first day
of the month, two months preceding publication.
Opinions expressed herein are those of individual contributors and do not necessarily reflect the
position of the Greater Louisville Medical Society.
LM reminds readers this is not a peer reviewed
scientific journal.
LM reserves the right to make the final decision
on all content and advertisements.
Circulation: 3,800
LOUISVILLE
MEDICINE
GREATER LOUISVILLE mEdIcAL SOcIETy
VOL. 58 nO. 8 jAnUARy 2011
FEATURE ARTICLES
9
12
18
20
32
39
A Brief Look at the Birth and Growth of neurosurgery
Andy Dzenitis, MD
Behind closed doors
Christi Bradshaw
The Richard Spear, Md, Memorial Essay contest: 2011
Mary G. Barry, MD
issues in Public Health and Preventive care:
Something to Build on
Deborah Ann Ballard, MD
The Gawandes of Athens, ohio
M. Saleem Seyal, MD, FACP, FACC
An unforgettable Patient
Elsa M. Haddad, MD
DEPARTMENTS
5
11
14
From the President
Kimberly A. Alumbaugh, MD
Physicians in Print
Book Review:
Start-up Nation: The Story of Israel’s Economic Miracle
by Dan Senor and Saul Singer
Reviewed by Arun K. Gadre, MD, FACS
22
Book Review:
26
28
30
31
35
Reflections
The Checklist Manifesto - How To Get Things Right
by Atul Gawande
Reviewed by M. Saleem Seyal, MD, FACP, FACC
Say Thank You
Alliance news
Lisa Sosnin, RN
We Welcome You
in Remembrance
Robert Pfeiffer Kraft Jr., Md
Carolyn Kraft
doctors’ Lounge
The Ville Is Not Vegas
Mary G. Barry, MD
Stroke Prevention Breakthrough in Patients with AF
Kerri S. Remmel, MD, PhD
JANUARY 2011
3
FROm THE PRESIdEnT
Kimberly A. Alumbaugh, MD
GLMS President
Meeting with the soon-to-be
most part, all of our practices, hos-
us a reprieve from the bottom of
mayor, Greg Fischer, last month, I
pitals and health systems could be
every good list?
was reminded how similar driven
improved. Couldn’t they? The trick is
individuals are, no matter what their
knowing who your audience is,
vocation. A good mind, a good
knowing what matters
him “close the gap”
heart and a good work ethic are
to them and caring
from where we find
truly the tools of any successful
enough to do something
our city to where
individual, no matter his or her pro-
about it. Intuiting the
our city should be.
fession. The mayor, a businessman,
problems of the system
Our meeting deliv-
has an enthusiasm for his new job
is not difficult, you
ered to him the
that is palpable, and through his
simply need to slow
message that we
connection to medicine, with a wife
down your personal rat
are a physician
who is a pediatric pathologist, he
race long enough to
work force ready to
understands how linked the health
really take a look.
meet any chal-
of our community is to its future.
Mayor Fischer is looking for a
few good men and women to help
As you reassess what
lenge. His message
Folks who hang out with physicians
you did well last year,
in return is that he
often get that perspective a little
what you hope to do
is going to ask us
better than the average business-
better this year and
to help. He is going
man or businesswoman.
where you totally missed
to emphasize what
the mark, try to lend a
is right with our
If you read Mayor Fischer’s bio
online, it is interesting that his
few minutes to the
company, SerVend, was a Baldrige
problems of our city as a
quality award finalist. Hospitals and
health desert. Our medical society is
to move forward together as a com-
progressive companies alike can
loaded with 3,800 physicians who
munity, compassionately. Gosh, it
receive these. The Baldrige awards
are oases of ability and who among
sounds like he has spent some time
are given in multiple fields for
them must have a bazillion neurons
hanging out with a physician ... LM
mayor Greg Fischer
improving competitiveness and per-
that could create a web of thought
formance. What a treat it will be to
so prodigious that we could fix our
watch Mayor Fischer apply best
hometown’s barriers for adequate
practice principles to Metro govern-
health care. We could help find
ment. Not that the local govern-
ways that every child could eat
ment doesn’t run fairly well, it does,
good food and exercise. Couldn’t
but almost every situation can be
we? We could make sure no child
made better with intentional intu-
missed out on health care, couldn’t
ition.
we? If how we treat the least among
Now, sometimes it is true, espe-
city, change what is
wrong and urge us
Note: Dr. Alumbaugh practices Obstetrics and
Gynecology with Total Woman PLLC. E-mail her
at kalumbaugh@totalwomaninky.com.
us is how we ourselves will be
cially in surgery, that great is the
treated, shouldn’t we at least try? I
enemy of good. You know that last
know we all do our small parts every
little snip that leads to 10 extra
day, but isn’t it time for a grand
sutures that you would have liked to
effort to remove Kentucky from the
have done without? But, for the
No. 1 spot on every bad list and give
JANUARY 2011
5
JANUARY 2011
7
A Brief Look at the
Birth and Growth
of neurosurgery
Andy Dzenitis, MD
E
vident from bone
healing in scores of
excavated skulls,
attempts at primitive
brain surgery date back to the
Neolithic period. Though lacking in
therapeutic value, these findings
are more likely a credit to the skill
of the operator and hardiness of
the “patient.”
first pharmacist and operative surgeon, designed
instruments to avoid dural tears during trephination! He also ligated the temporal artery for
headaches and placed opium-laced cloth over the
mouth and nose as intraoperative sedation. He
published Kitab al-Tasrif (a medical encyclopedia),
Continued on page 10
Edwin Smith’s discovery of Egyptian papyri gave
us a record of the cunning and clinical judgment of
Imhotep’s selection of treatable ailments and
wounds (circa 28 to 26 centuries B.C.).
Hippocrates (circa 460 to 377 B.C.) and Galen
(circa A.D. 130 to 210) did appreciate that injuries
to the head led to incapacity or death of the victim.
During the Medieval period, besides the observations of Lefrank (1250-1306) and de Chauliac (13001368), there were no pertinent advances in science
or care of the injured brain.
However, 10th and 11th century Middle Eastern
physicians showed a remarkable understanding of
human anatomy and surgical skills. Two Arabs,
Albucasis and Avicenna, studied writings of
Hippocrates and Galen and corrected and recorded
their misconceptions. Rhazes (A.D. 864) was first to
describe cerebral concussion and showed remarkably accurate understanding of the spine and nerve
roots. Albucasis (A.D. 936-1013), considered the
JANUARY 2011
9
Continued from page 9
writing on spinal anatomy, management of trauma,
cranial fractures, CSF drainage for hydrocephalus,
migraine, back pain and facial palsy. Avicenna (A.D.
980-1037) bridged Eastern and Western cultures
and was decreed the “Prince of Physicians.”
Ambroise Paré (1510-1590), known as the father
of military surgery and skilled in traumatic wound
care treatment (“I dressed him and God healed him”
and “Cure occasionally, relieve often, console
always”), lifted bone fragments and debris from
head wounds. He also reasoned that phantom limb
sense occurred in the brain.
But as late as 1874, London surgeon John
Erichsen wrote: “The abdomen, chest, and brain will
forever be closed to operations by a wise and
humane surgeon.”
Frenchman Jean Louis Petit, inventor of the
tourniquet, and Percival Pott (John Hunter’s
mentor) had some successes treating cranial
trauma and suppuration in the 17th and 18th centuries. However, it was the genius, courage and skill
of the likes of W.W. Keen, Ernst von Bergmann,
William Macewen, Victor Horsley and Harvey
Cushing that initiated neurosurgery as a specialty
of its own.
Philadelphian William Williams Keen (18371932) was the first American brain surgeon who
succeeded in removing a meningioma. During his
long career, he treated Civil War troops, operated
on President Grover Cleveland’s tumor in the neck,
diagnosed polio in President Franklin D. Roosevelt
and later lectured on surgical pathology.
Among the contributions of Russian-born
German von Bergmann (1836-1907) to neurosurgery are aseptic surgical technique, steam sterilization of instruments and follow-up records on
patients.
Glaswegian William Macewen (1848-1924) was
the first to perform a brain operation for tumor
based on clinical findings, thus showing his understanding of cerebral localization (1879). This predated Britain’s Rickham Godley’s extirpation of a
meningioma in 1884.
Sir Victor Horsley (1857-1916) was first to
confine his practice to Neurosurgery and in 1890
published an article on surgical treatment of
hematoma, hydrocephalus, skull fractures and
abscess. He introduced the use of beeswax for
control of bleeding diploic bone.
Trained in Halstedian tradition, Harvey Williams
Cushing (1869-1939) found Horsley’s surgical techniques coarse and mortalities unacceptable. With
10
LOUISVILLE MEDICINE
Cushing’s meticulous surgical skills, operative mortalities dropped from 90 percent to 8, thus setting
new standards in Neurosurgery. He was recognized
worldwide as a teacher, scientist and author.
Cushing was a contributor in endocrinology and
CSF pressure dynamics, utilized Röntgens’ X-rays in
diagnostics and refined Riva-Rocci’s sphygmomanometry in tracking vital signs during surgery.
Additionally, he authored 14 books, 300 articles
and won a Pulitzer Prize for Osler’s biography.
Walter Edward Dandy (1886-1946), a precocious
Missourian, Johns Hopkins-trained, intellectually
gifted and technically skilled, was nominated for a
Nobel Prize owing to his work in neurodiagnostics
(pneumoencephalography, 1919). He established
the principles of CSF circulation and was first to
clip an intracranial aneurysm (PCA), although
Norman Dott had successfully treated an aneurysm
by wrapping it with a muscle pledget. Dandy completed the removal of acoustic neuroma, operated
and described the surgery for ruptured lumbar disc
in 1929 (five years ahead of Mixter and Barr), and is
considered by many as the most gifted American
neurosurgeon of his time.
Prior to the discovery of X-rays, diagnostic judgment in neurology and surgery was largely based
on clinical findings. This often led to missed diagnosis and negative surgical exploration.
In 1895, engineering genius Wilhelm Conrad
Röntgen found that his wife’s hand left different
shadows for bone and flesh when interposed
between cathode rays and a photographic plate.
Roentgenology was born and the Nobel Prize went
to its discoverer in 1901.
The last four decades witnessed development of
radioisotope scanning, computed tomography
(Godfrey Hounsfield, 1967, Nobel Prize in 1979),
magnetic resonance imaging in 1975 and 3-D
image reconstruction. Positron emission tomography scanning was introduced in 1988 by Steven
Petersen and Marcus Raichle and showed brain
function in “real time.”
Today minimally invasive surgery, endoscopic
and intraoperative guided imaging and the
endovascular approach to inaccessible lesions are
commonly employed. Robotics in Neurosurgery
may be “just around the corner.” LM
Note: Dr. Dzenitis is a retired neurological surgeon. He is also clinical professor emeritus in the
University of Louisville School of Medicine’s Department of Neurosurgery.
PHySIcIAnS In PRInT
Arthur JM, Klein jB. Proteomics in CKD. Adv
Chronic Kidney Dis. 2010
Nov;17(6):453-4. PubMed PMID: 21044767.
Bays HE, Maki KC, Schmitz K. Colesevelam HCl
Powder for Oral Suspension versus
Cholestyramine Powder for Oral Suspension:
Comparison of Acceptability and Tolerability.
Endocr Pract. 2010 Nov 1:1-23. PubMed PMID:
21041163.
dimar jR, Carreon LY, Riina J, Schwartz DG, Harris
MB. Early versus late stabilization of the spine in
the polytrauma patient. Spine (Phila Pa 1976).
2010 Oct 1;35(21 Suppl):S187-92. PubMed PMID:
20881461.
Mowlavi A, Pham S, Wilhelmi Bj, Masouem S,
Guyuron B. Anatomical characteristics of the
conchal cartilage with suggested clinical applications in rhinoplasty surgery. Aesthet Surg J. 2010
Jul-Aug; 30(4):522-6.
Funke AA, Kulp-Shorten cL, callen jP. Subacute
cutaneous lupus erythematosus exacerbated or
induced by chemotherapy. Arch Dermatol. 2010
Oct;146(10):1113-6. PubMed PMID: 20956642.
Peitzman AB, Richardson jd. Surgical treatment
of injuries to the solid abdominal organs: a 50year perspective from the journal of trauma. J
Trauma. 2010 Nov;69(5):1011-21. PubMed PMID:
21068605.
Casperson BK, Anaya-Baez V, Kirzinger SS,
Sattenberg R, Heidenreich JO. Coexisting MS and
Lehmitte-Duclos Disease. Radiology Case. 2010
Aug; 4(8):1-6.
Hazani R, Elston, J, Whitney RD, Redstone J,
Chowdhry S, Wilhelmi Bj. Safe treatment of
trigger thumb with longitudinal anatomic landmarks. Eplasty. 2010 Sep 15; 10. pii: e57.
Chinnapongse R, Pappert EJ, Evatt M, Freeman A,
Birmingham W. An open-label, sequential doseescalation, safety, and tolerability study of
rimabotulinumtoxinb in subjects with cervical
dystonia. Int J Neurosci. 2010 Nov;120(11):703-10.
PubMed PMID: 20942584.
Kapoor N, Fahsah I, Karim R, Jevans AJ, Leesar
MA. Physiological assessment of renal artery
stenosis: comparisons of resting with hyperemic
renal pressure measurements. Catheter
Cardiovasc Interv. 2010 Nov 1;76(5):726-32.
PubMed PMID: 20931666.
Chowdhry S, Hazani R, Collis P, Wilhelmi Bj.
Anatomical landmarks for safe elevation of the
deep inferior epigastric perforator flap: a cadaveric study. Eplasty. 2010 May 28;10:e41.
Mays CJ, Steeg KV, Chowdhry S, Seligson d,
Wilhelmi Bj. Wrist joint reconstruction with a vascularized fibula free flap following giant cell
tumor excision in the distal radius. Eplasty. 2010
May 22;10:e38.
Chowdhry S, Yoder EM, Cooperman RD, Yoder VR,
Wilhelmi Bj. Locating the cervical motor branch
of the facial nerve: anatomy and clinical application. Plast Recontr Surg. 2010 Sep; 126(3):875-9.
Merchant ML, Klein jB. Proteomic discovery of
diabetic nephropathy biomarkers. Adv Chronic
Kidney Dis. 2010 Nov;17(6):480-6. PubMed PMID:
21044770.
Pham S, Wilhelmi Bj, Mowlavi A. Eyebrow peak
position redefined. Aesthet Surg J. 2010
May;30(3):297-300.
Van Berkel V, Kuo E, Meyers BF. Pneumothorax,
bullous disease, and emphysema.
Surg Clin North Am. 2010 Oct;90(5):935-53.
Review. PubMed PMID: 20955876.
Banerjee T. A Day in Neurosurgery: Brain + Spine
and a Lot More. PublishAmerica, December 2010.
NOTE: GLMS members’ names appear in boldface
type. Most of the references have been obtained
through the use of a MEDLINE computer search
which is provided by norton Healthcare medical
Library. If you have a recent reference that did
not appear and would like to have it published in
our next issue, please send it to Alecia Miller by
fax (736-6363) or e-mail (alecia.miller@glms.org).
LM
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JANUARY 2011
11
Behind
closed
doors
Christi Bradshaw
It’s 7:30 a.m. on a Monday
morning. My keys rattle as I pull them
out of the debris in the pocket of my white coat
and place them in the lock. I unlock the imposing wooden door and step across the threshold
that separates the outside world of sanity and
propriety, albeit tenuous at times, from the
world where aberration and misfiring neurons reign supreme. In other
words, I step onto the floor of an inpatient psychiatry unit, about to
begin yet another day of my third-year psychiatry clerkship, to be confronted with all the bizarreness that such an experience often entails.
Going into my psychiatry rotation, I expected a number of things
from my time on the inpatient unit, all of which happened: the accumulation of outlandish stories, encounters with eccentric patients, and of
course, medical insight into the subtleties of mental illness. What I didn’t
expect, however, was the degree to which I became attached to some
of the patients, one in particular. In the midst of manic individuals
speaking illogically at high velocities, schizophrenics throwing medication at nurses in order to rebel against “the conspiracy,” and severely
depressed patients who hibernated in bed, there was Mrs. V.
Unbeknownst to her, my interactions with Mrs. V defined the tone of my
psychiatry clerkship and provided me with the most compelling sense of
reward that I had experienced thus far in my clinical rotations.
A middle-aged woman admitted to the unit for profound depression and suicidal thoughts, Mrs. V’s story seemed at first indistinguishable from those of her depressed peers. What began as a nuts-and-bolts
investigation into yet another case of major depressive disorder, though,
quickly morphed into one of emotional investment and reciprocal awe
and respect. The first step in this progression occurred during my first
meeting with Mrs. V in which she shared her story with the physicians
and me. Vulnerable and sincere, Mrs. V tearfully relayed the tale of the
death of her 13-month-old son 17 years ago and the unrelenting guilt
and grief that had plagued her ever since. Her friends’ and family’s incessant and at times callous comments to “take it to the Lord” and “leave it
all up to God” did little to console her, and the pressure of raising seven
other children along with adjusting to her recent diagnosis of myasthenia gravis only hastened her downward spiral. Thoughts of overdose
and an emergency therapy visit later, she sat before me, morose and
fatigued yet eager to embark on the long road to recovery. “I am willing
to do whatever it takes to get better,” she stated with as much fervor as
she could muster, and with that one statement and a look around at the
apathetic group of folks populating the stale beige corridors of the unit,
I knew I had stumbled upon someone special.
12
LOUISVILLE MEDICINE
It didn’t take much time before I found myself looking forward to
my morning dialogues with Mrs. V. Whereas most patients would grunt
responses to my early morning questions, she would willingly expand
upon the topics of inquiry and then end the conversation with “Thank
you so much for your help.” Her compliance was made even more outstanding when juxtaposed with some of the other majorly depressed
patients on the unit, who only emerged from their rooms for meals, if
then. Now, although the politeness and cooperation that characterized
Mrs. V were a rare find during my six weeks on inpatient psychiatry, the
qualities were not unheard of. To be fair, I encountered a handful of
patients who possessed the faculty and insight that allowed them to
recognize the value of the staff’s actions and to subsequently engage
willingly in therapeutic activities. What separated Mrs. V from these similarly afflicted people, however, was how effectively and positively she
was able to deal with her discomfort, whether it was mental, emotional
or physical. During her hospital stay, it was rare to hear her complain
about her struggles with myasthenia gravis. When one day I entered her
room, found her huddled on her bed with her hand over her eye and
asked her what was wrong, it was only then that she revealed that she
had been experiencing double vision, a common finding in myasthenia
gravis sufferers. The dosage of the appropriate medication was quickly
adjusted, an action that would have been missed since she hadn’t let
her debilitating condition prevent her from doing all that was necessary
to achieve recovery from her grief. She’d gotten out of her room to
attend group therapy even with double vision, and also had engaged in
extensive individual psychotherapy with her attending physician. In
short, she hadn’t used her illness as an excuse to wallow in her depression, a convenient behavior that might appeal to most of us human
beings in our times of melancholy.
Aside from her unwavering dedication to improve her mental
health, perhaps the most impressive aspect of Mrs. V’s two weeks on the
unit was how she interacted with her peers on the floor. For anyone
who maintains a relatively accurate grasp on reality and has stepped
onto an inpatient psychiatric floor, it is overwhelming at the best of
times. Witnessing psychosis in action can be assaulting to the senses,
whether it’s one’s first time encountering such a scene or 20th year in
practice. Therefore, it is not surprising that many of the solely depressed
patients on the unit appeared frightened, amused or even repulsed by
their more “unbalanced” roommates or neighbors. Here again, however,
Mrs. V distinguished herself, for she dealt with everyone, from hostile
schizophrenics to irritable bipolar patients to the generally disgruntled
with a kindness and ingenuousness that one seldom sees in daily life
outside the hospital walls. When I inquired as to how she was handling
the color on the floor, she said, “I enjoy talking to everyone here. They’ve
really helped me see that we ALL have problems and that we can use
our different experiences to help one another through hard times.” In
the month after she was discharged, I never heard another patient
capture the value of such encounters more profoundly, and that same
insight is something I certainly hope she will never forget either.
As influential as Mrs. V’s two-week hospitalization was toward her
recovery from grief, so was her impact on my desire to continue pursuing my career in medicine. At one time or another, I’m sure every one of
us who has embarked on the long and arduous road to physician-hood
has questioned whether or not the sacrifice, the commitment and the
64 ounces of caffeine daily are worth it. Even as a mere medical student,
it is all too easy to become jaded and to let doubt creep in. Fortunately,
though, there are moments in medicine that poignantly capture the
true essence of what it means to care for a fellow human being, and as I
walked away from my time in psychiatry, the door to the unit locked
behind me, it is those moments that I most look forward to. LM
Note: Christi Bradshaw is a fourth-year student at the University of Louisville School of
Medicine.
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BOOK REVIEW
Start-up nation:
The Story of
Israel’s Economic
miracle
BY dAn SEnoR
And SAuL SinGER
Twelve, Grand central Publishing, november 2009
Reviewed by
Arun K. Gadre, MD, FACS
Israel appears to be
perpetually in the news
– most of it bad.
On what seems like a daily basis, the
newswires crackle with the actions of human kamikaze
bombers. Newscasts show the saber-rattling of an apparently crazed leader of the once-great Persian nation, with
threatened nuclear annihilation of the Jewish state. These
vie for headlines with news of violence on board a “peace
flotilla” from Turkey headed for Gaza. In the face of the violence and an existential threat, coupled with a nadir in U.S.Israeli relations, this book describes the curiously paradoxical
phenomenon of an ascendancy of the economy of a tiny
sliver of land at the eastern edge of the Mediterranean. As
the authors succinctly put it, “This is a book about innovation and entrepreneurship,” and is undoubtedly one of the
most thought-provoking books I have ever read.
Tuesday evening on March 9, 2010, was yet another gray
winter day in Louisville, and relations between Washington
and Jerusalem were at their soggy best. An expectant crowd
of perhaps 150 people gathered in an off-the-foyer room
within the clubhouse at the Standard Country Club. They
14
LOUISVILLE MEDICINE
came from every walk of life, some
having driven in from as far away as Lexington and
Bowling Green. A few sat stiffly in their chairs, their anticipation palpable, but most made pleasant conversation among
themselves, milling about and nibbling on pastries, and partaking of soft drinks from tables that lined a side of that
large hall. The snacks were a handsome diversion but were
clearly not a huge attraction for those gathered. The 6:30
hour came and passed, and the crowd was restless. Was his
flight delayed as someone had suggested? Soon one of the
organizers took the podium, and the guests began taking
their seats. At the back of the hall, leaning quietly against
the wall, water bottle in hand, stood an unassuming but distinguished gentleman. His was the arrival that was eagerly
anticipated.
He appeared perhaps not quite 40 years old. Boyish features contrasted with a determined square jawline, and
scholarly yet wistful spectacled eyes drew one’s attention
away from a broad forehead and a disarming smile. He wore
well-pressed trousers and a suit jacket over an open-collar
shirt. He sipped from a water bottle that graced his long
fingers. His manner was disarming, and there was nothing
pompous or haughty about one who had, despite his youth,
left an indelible mark on the newly democratic post-Saddam
Iraqi nation. His casual style belied a tremendous depth of
knowledge that became evident as he began to speak. He
paced back and forth while connecting with the audience,
who listened in rapt attention, mesmerized as it were,
hanging on to his every word. The hour passed by too
quickly.
Dan Senor, from appearances on television, had been
the face of the Coalition Provisional Authority in Iraq and
was one of the earliest civilians to follow our military after
the fall of Baghdad in 2003. For a while, he had disappeared
from the glare of the public spotlight but then, quite by accident, I saw him again, on Book TV C-SPAN2, discussing his
first book. It had little if anything to do with Iraq. I was not
about to pass up the opportunity to hear a person with such
distinguished credentials speaking in our fair city.
Start-up Nation is the product of the labor of two
authors, Dan Senor from New York and Saul Singer, who lives
in Jerusalem. The book has 340 pages, 242 of narrative with
the rest including notes, a well-annotated bibliography and
an index. It belongs to the realm of business and economics
rather than history. The project congealed when Mr. Senor,
who is a product of the vaunted Harvard Business School,
took a bunch of students to Israel. These students were not
all Jewish; indeed it was a most international and diverse
group. They were all there to personally witness and study
the great boom in the Israeli economy, despite the backdrop
of violence and war. All determined to answer the same
question … why? Out of their deliberations and interactions
with formidable political and business leaders in the field
was conceived Start-up Nation.
The authors debunk the myth that this success is solely
the result of wealthy Jews of the Diaspora. Indeed, most
multinational companies investing in Israel do so because
they see the value of it, and most are run by non-Jews. They
ascribe the success to a few well-defined attributes. In their
opinion, the military experience of every child after high
school imbues individuals with maturity, so that when they
enter higher education they get more out of that educational experience than their counterparts in other countries.
Military experience also teaches the concept of leadership
and team spirit and the need, indeed the imperative, to
depend on each other, thereby making them resilient and
cooperative. The ability of Israelis to take a critical look at
their mistakes and discuss and argue with each other irrespective of rank or status in society and then come up with a
solution, is refreshing. In the workplace, solutions are ordinarily not ordained from above but come from within the
ranks. In the opinion of the authors this, coupled with favorable government policies toward immigration and business,
is what makes the nation and its economy tick. Each of these
attributes individually may not be unique to the country and
yet the entire package is uniquely Israeli.
Each chapter is laced with true stories that are as inspirational as they are educational. For those who are not fortunate enough (or do not have the time) to read the book,
here are a few snippets. Israel welcomes Jewish immigrants
from very disparate cultures. A Jew from Russia has almost
nothing in common with one from Ethiopia or India (perhaps
16
LOUISVILLE MEDICINE
the belief in one God being the exception) and yet instead of
marginalizing those less privileged, no effort is spared to
uplift and integrate. This provides a source of manpower not
only to defend the country but a motivated work force that
is the lifeblood of its economy.
The book is not a chronological historical document
either, but is a mosaic of stories and examples that in their
totality make the case for Israel’s industrial and technological
ascendancy. Without giving it all away, here are a few things
that I did not know and hope to share. I was surprised to
learn that this small country boasts the highest density of
start-ups and has more companies on NASDAQ than all of
Europe. It is Israeli ingenuity and perseverance, for example,
that took the wind out of the sails of the famous Santa Clara
company’s concept of increasing clock speeds of computer
chips, a process that resulted in increased power consumption and heat. Smarter chip architecture resulted in the production of the Core 2 Duo chips (which are more efficient
and consume less power) for Intel. There is the story of Iscar,
an Israeli company that was bought by the legendary
investor, Mr. Warren Buffet. The factory is located less than
eight miles from the Lebanese border and was the target of
rocket attacks. Eitan Wertheimer, the chairman of Iscar, told
his new boss that that despite the damage, he would make
certain that “all the customers would get their orders on
time or even earlier.” He kept his word.
No country this small has as big a Military-Industrial
Complex. The book theorizes that it was the French betrayal
in 1969 that catalyzed this reality. Georges Pompidou diverted tanks to Libya and Mirage jets to Syria. As an offshoot of
an imperative for independence from other countries, and in
attempting to ensure her own survival through self-reliance,
have come discoveries that have even revolutionized
medical care. Among the several interesting anecdotes in
the book, there were two that captured my imagination. A
gifted rocket scientist modified and miniaturized a light
source with a camera, its power source and transmitter into
a capsule that could be swallowed. It was able to transmit
pictures from inside the gastrointestinal tract. The PillCam
was born. It is astounding that technology housed in the
nose of a lethal missile can also be used to send 18 pictures
per hour for several hours from the gut of a human being.
Moreover these can be accessed and viewed from across the
room or anywhere in the world. Another story speaks about
a subcutaneous implant that combines oxygen-producing
algae from Yellowstone National Park’s famous geysers,
along with fiber optics and beta cells, to be used for the
treatment of diabetes. The authors describe a “mashup” of
multidisciplinary ideas in combination with human experiences both civilian and military, which result in creative solutions that are unique.
The authors then contrast the economic miracle of
Dubai with that of Israel. They also compare and contrast it
with several other smaller countries that may or may not
have threats at their borders such as Singapore, Finland and
South Korea. They underscore the fact that almost all the
large multinational companies have a presence in all of
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these countries; most utilize their presence there for servicing their regional customers. Israel remains one of the few
places where critical research and development is carried
out.
In my opinion a fact that hasn’t, but could have received
more attention, is the presence of superb institutions of
higher learning such as the Weizmann Institute of Science,
the Technion, the Jerusalem Hebrew University and Tel Aviv
University. These among others have created a ferment of
unparalleled intellectual excellence. A critical mass of highly
educated and creative human capital, along with favorable
economic policy, helped rocket creativity. This is nothing
short of enviable. A highly educated and creative work force
is arguably a crucial element that is lacking in surrounding
countries. With investment of petro-dollars it is inevitable
that this gap will close over time, and yet how one is able to
change tradition in hidebound cultures is anyone’s guess.
Another factor that is neglected in the book is that if immigration from the erstwhile Soviet Union was the impetus for
creativity, what happens when this source eventually dries
up?
Israel’s friends and enemies can both learn much from
the book. As our nation prepares for the winding down of
military operations in Iraq and Afghanistan, and as we
welcome our troops home, we need to ponder how this
highly trained and disciplined group can help rebuild our
economy. Progress can be made through discipline, educa-
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tion, innovation and the ability to question authority.
Intellectual cross-fertilization through immigration, an immigration based on national need and individual aptitude,
appears to have helped Israel just as it did the United States
in the ’60s and ’70s. At a time which is economically about
as bad as any in human memory, and when the natural tendency is to turn protectionist, the book may be a source of
inspiration for planners to think outside the box. Cities and
states that have suffered job losses from, say, a problem
within the manufacturing sector could use the principles of
creative destruction to spawn industries as yet unknown.
This is a book I will undoubtedly read again. I have even
made my teenage children read it. It is an uplifting, inspirational and intellectually satisfying book, written in language
that is easy to understand, about a part of the world that is
for the most part portrayed by the media in the bleakest of
terms. I look forward to other books by these authors. I recommend the book most highly to anyone who has had the
fortitude to read this review. LM
Note: Dr. Gadre is the Heuser Hearing Institute Endowed Professor in Otology and
Neurotology in the Department of Surgery and Division of Otolaryngology-Head and Neck
Surgery at the University of Louisville School of Medicine.
JANUARY 2011
17
The Richard Spear, md,
memorial Essay
contest: 2011
W
Mary G. Barry, MD
Louisville Medicine Editor
18
hy did you choose to be a doctor?
Louisville Medicine wants to hear
your story about the people,
places, events and experiences
that led to your career in medicine.
We’re inviting all Greater Louisville
Medical Society physicians and medical students to submit an essay for the fourth
annual Richard Spear, MD, Memorial Essay
Contest. Dr. Spear was a beloved Louisville
surgeon who left GLMS a generous bequest
for an annual essay contest. He wished to
promote good writing among the physicians
in our community.
The first three years of the essay contest
have generated numerous insightful and
well-crafted pieces that have been published
in Louisville Medicine. We look forward to
reading what we’ll receive this year.
The all-volunteer judges will consider
excellence in expression, creativity, readability and clarity. We judge by category and
reward accordingly: $1,500 to the practicing/life physician winner and $500 to the
physician in training/medical student
winner. An honorable mention gift card may
also be awarded.
LOUISVILLE MEDICINE
Please review the guidelines below and
submit your essay by April 1. Good luck!
Guidelines
You must be a GLMS physician or
medical student to participate. All entries
must be original, unpublished writing
intended solely for publication in Louisville
Medicine.
Length: 800 to 2,000 words.
Format: Do NOT put your name on your
manuscript! Our judges are blinded to
authors. Instead, include a separate cover
letter with name, entry category, essay title,
contact information and, if applicable, your
year in medical school.
Deadline: April 1.
Submission: Send via e-mail to Alecia
Miller, at alecia.miller@glms.org. Electronic
versions are preferred, but if not possible,
send essay by mail to 101 W. Chestnut St.,
Louisville, KY 40202. LM
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tenth in a series
Something to Build On
Deborah Ann Ballard, MD
I
In the book, The Blue
Zones: Lessons for Living
Longer From the People
Who’ve Lived the Longest ,
Dan Buettner explores
the characteristics of the
world’s healthiest people. He defines a Blue
Zone as a place where people typically live to
be more than 90 years old, have very low
rates of chronic disease and have almost no
dementia. Blue Zones include places like
Sardinia, Italy, Okinawa, Japan, and Loma
Linda, California (Seventh-day Adventists). It is no surprise that
the healthiest people engage in regular physical activity, eat a
plant-based diet and drink red wine. However, their good
health comes from within as much as from without. Buettner
found that the healthiest people in the world also have:
1.
2.
3.
4.
5.
A purpose in life
Low stress
A healthy social network
A belief system
Strong family lives.
Unfortunately, the American lifestyle is often one of fractured families, social isolation, harried schedules, insatiable consumerism and shallow for-show spirituality. An axiom of public
health practitioners is that knowledge alone is insufficient to
produce behavior change. Indeed, when I ask most patients
why they do not exercise or follow their diet, it not because
they do not believe they should do it or have not been given
There is a growing
consensus among sociologists, political scientists and spiritual
leaders that strengthening our sense of
community is the key
to building a better
world in every way.
Robin Dunbar, a professor of psychology from
the University of
Liverpool, states, “The
lack of social contact,
the lack of sense of
community, may be the
most pressing social
problem of the new
millennium.”
Americans are
losing their sense of
being one community.
We are so divided along
political, ideological,
racial and ethnic lines
that we cannot seem to
work for the common good anymore, with the result that our
communities are hollow and sometimes even hostile places to
live. As the Dalai Lama observed:
“Tibetans are shocked to hear of situations where
the information. Rather they say they are under too much
people are living in close proximity, have neighbors,
stress, have no support system and lack the money (even
and they may have been your neighbors for months
though they can afford cigarettes, cell phones, cable TV and
or even years, but you hardly have any contact with
elaborate manicures). They feel too depressed to make the
them … There is no real connection, no sense of
community … If this sense of community is lacking,
effort.
20
LOUISVILLE MEDICINE
then when you feel lonely, and when you have pain,
Mother Teresa wrote, “For all kinds of diseases there are
there is no one to really share it with. I think this kind
medicines and cures. But for the disease of being unwanted,
of loneliness is probably a major problem in today’s
except where there are willing hands to serve and there is a
world, and can certainly affect an individual’s day-to-
loving heart to love, I don’t think this terrible disease can ever
day happiness.”
be cured.”
It can also have a
profound effect on
health and even survival.
I remember a particularly tragic patient I
cared for as an intern.
She was in her early 60s,
single, disabled and
poor. After having been
“found down” in her
apartment by her landlord, she was brought
into the emergency
room comatose and
hypothermic. An EMS
survey of her medicine
cabinet revealed medicines for all the obesityrelated illnesses – diabetes, hypertension and
hyperlipidemia. She had
decubiti on her back
and buttocks from
being on the floor so
long. No one came to
the hospital to check on
her. She had no family,
no power of attorney, no friends and no community. She never
regained consciousness, but she was kept “alive” for three
weeks in the ICU before she ceased to have measurable vital
signs and we decided she was dead. Her hospitalization probably cost taxpayers more than a million dollars. This tragedy
would never have happened had she lived in a Blue Zone
where at 60, she still would have most likely been vibrant and
healthy, and if she had been ill, her family or community would
have checked on her every day.
Over and over again, I hear patients tell of being alone with
no family or community support. They graze on junk food all
day because there is no one to share a meal with. They can’t
keep appointments for procedures like a colonoscopy because
they have no one to drive them home. They can’t stay out of
the hospital because they have no help at home and fall; can’t
get to doctor or therapy appointments; can’t get their medications.
On a population level, a lack of community support makes
it extremely difficult to deliver effective prevention and wellness programs. It also makes it very difficult to deliver accountable medical care – a new and needed mandate from health
care reform. Sorry, libertarians, but rugged individualism just
does not work in the realm of public health.
John Michael Talbott, author of The Lessons of St. Francis,
writes, “Independence is a pervasive and popular myth. But the
truth is that nothing in our universe is truly independent.
Nature is an interdependent network. The cosmos is communitarian.”
Going forward, Louisville needs to invest in its neighborhoods to build up their capacity to provide effective programs
to prevent disease and to care better for those already ill. Dr.
Adewale Troutman, former director of Louisville Metro Public
Health and Wellness, effectively advocated for many structural
changes toward this end. He will be greatly missed. He started
the process of building a healthier environment, and now we
have to advocate for the process to continue.
Many physicians already volunteer countless hours for
various community and faith-based organizations. As community builders, we can create Blue Zones right here in Louisville.
We can also rally others to join in the effort. Talk to your
patients about community building. Some of them will take up
the cause – and we hope that gradually our neighborhoods will
become happier, healthier places to live, and our jobs as physicians will get a lot easier. LM
Note: Dr. Ballard is the director of community outreach for the Norton Cancer
Institute’s Prevention and Early Detection Program.
JANUARY 2011
21
BOOK REVIEW
The
checklist
manifesto –
How To Get
Things Right
BY ATuL GAWAndE
Metropolitan Books, new York, december 2009
Reviewed by
The fact is that no
one likes checklists,
and most of us actually
abhor checklists irrespective of our vocations. They are
boring, time-consuming and seemingly plain silly. After all,
if you have been practicing medicine, doing procedures and
surgeries for several years and have been working with
experienced nurses and other ancillary personnel in the
hospital, you really have no desire to start your day with
niggling checklists. But that is precisely what Atul Gawande,
MD, tries to convince you to do in his latest book. And, you
must do it daily, on a regular basis, without fail: because
adhering to these ostensibly annoying and bureaucratic
checklists will improve outcomes and save lives. Period!
Dr. Gawande’s article “The Checklist” was published in
the December 10, 2007, issue of The New Yorker, and the
book that
grew out of that article was
published in 2010. The Checklist Manifesto is
the third book by Dr. Gawande, another New York Times
best seller after his blockbuster first two books –
Complications and Better. All his books and articles as a
staff writer in The New Yorker have earned him high accolades and fame. This book starts out with a familiar theme
of patient stories that the author is swapping with a colleague, the first one when a stab victim is brought to the
Emergency Department with an innocuous-looking wound
in the abdomen and overall stable vital signs. The patient
promptly crashes, however, with a precipitous drop in his
blood pressure and cardio-respiratory arrest. Immediate
resuscitative measures are instituted, and the patient is
wheeled emergently to the operating room. There he is
found to have a tear in his aorta due to a bayonet stab
injury, which is repaired, and the patient eventually survives. The second case involves an inadvertent infusion of
an inordinately high dose of potassium during a surgical
procedure, resulting in asystole. But the mistake is quickly
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discovered, resuscitation continues while various means to
reduce the potassium level are carried out pronto, and the
patient recovers. Dr. Gawande stresses the point that,
despite all the technological advances and an unprecedented proliferation of knowledge and science, physicians are
neither omniscient nor all-powerful but, in fact, remain and
will continue to remain constrained by the limitations of
human fallibility. The practice of medicine is never going to
be perfect. Our failures, he points out, are either due to
ignorance (mistakes committed because of poor knowledge) or ineptitude (mistakes made because of our inability
to apply what we do know), and it turns out that the failures
are mostly because of the latter. He describes the everincreasing complexity of our daily lives in the first chapter
of the book, particularly the sheer number of decisions we
as physicians have to make for our patients who present
daily with a myriad of clinical challenges. In critical care
areas of the hospital including surgical suites, procedure
rooms of all types, intensive care units and emergency
departments, where stakes are quite high and the lives and
well-being of patients are on the line, it is incumbent to
have a structured checklist to do things right, and decrease
the oft-quoted errors in medicine that result in close to
100,000 deaths annually in the United States alone.
In the aftermath of the tragic crash of a Boeing 299 in
Dayton, Ohio, during a flight competition for the U.S. Army
in 1935, a pilot checklist was devised for every pilot no
matter how experienced the pilot was, and that revolutionized the way airplanes have been flown. In hospitals, vital
signs that include blood pressure, pulse rate, respiratory
rate and temperature have been the ubiquitous checklist
components for a long time, and nurses have recently
24
LOUISVILLE MEDICINE
added pain rating, medication timing charts and written
care plans. In 2001, Peter Pronovost, MD, PhD, an intensivist
at The Johns Hopkins Hospital, initiated a simple five-point
checklist for preventing central line infections, which when
followed scrupulously produced a remarkable drop in infection rates. Another similar project was initiated on a larger
scale in Michigan’s ICUs, and the study was published in
2006 in The New England Journal of Medicine reporting
savings of $175 million in cost to the hospital and more
than 1,500 lives saved – all because of a simple checklist!
Checklists are everywhere! Dr. Gawande found them in
the building industry, in his favorite Boston restaurant, at
The Boeing Company and in David Lee Roth’s band, to
name a few. He conducted site visits and interviewed key
personnel at various places. He eventually conducted a
worldwide study of preventing surgical errors by implementing a pre-surgery checklist, and the results were uniformly positive in saving money and lives by incorporating
the checklist as a requirement. The “time out” checklist has
become the norm now prior to any invasive procedure
(despite initial resistance by physicians). The patient’s name,
date of birth, the name of the procedure, the preparation
and reaffirmation of the correct site/side, the results of
important and pertinent labs, the availability of blood and
blood components – all are loudly recited by a nurse in a
matter of few minutes. Clinical judgment, of course, plays
an important and sentinel role in taking care of patients.
The checklist is simple and straightforward, easy to implement – despite some physicians’ consternation – and much
more effective in saving lives than taking things for granted.
LM
Note: Dr. Seyal practices Cardiovascular Diseases with River Cities Cardiology MPC.
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REFLEcTIOnS
o
n a Sunday’s
homily, a priest
commented on an
observation, namely, that
to receive is innate in human beings.
A newborn baby does not have to be taught to suckle when put to
the breast. He/she is comfortable being nurtured and cared for without
asking or having to give back. Conversely, giving thanks for services
rendered freely does not come naturally. It has to be taught. “Thank
you” is among the phrases parents teach their children from an early
age.
Presuming the premise is so, do we have proper training in the art
of expressing gratitude? Does saying thanks follow a scale similar to
that of describing pain, i.e. from zero to 10? Are there benefits in giving
thanks? Are there drawbacks? Can it be mistaken for facetiousness or
as a ploy to cull more favors?
Some common occurrences here mentioned touch on the relevance or irrelevance of saying thanks. A godfather spent hours looking
for just the right tennis racquet that his godson needed. It was mailed
with the anticipation that the latter would be delighted with the gift,
but the godfather waited in vain for feedback. Although the racquet
was received, it was never acknowledged. Did the godson just feel
entitled or did he not know any better?
A group of students excitedly giggled while putting up a sign to
greet their teacher, “Happy Birthday.” When the latter went on with
business as usual, the children’s faces fell with disappointment. Did the
teacher think it inappropriate to recognize the honor or had she never
had happy surprises in her life and was clueless on what to say?
A patient being presented during rounds answered questions
repeatedly, was examined in front of all to show his pathology, and discussions were conducted in his presence. Would that these were done
with the utmost delicacy and sincere respect, and would that the
rounding doctors thanked him for his cooperation. Physicians learn
something from every patient they see, and the latter have to have
26
LOUISVILLE MEDICINE
their due, or should patients be beholden to their doctors and give
thanks instead?
When children and grandchildren try to shield their elders from
what they deem might upset them and try their wings at flying solo,
concerned experienced relatives admonish them for their own safety.
But when they make efforts to fulfill expectations, do we encourage
and thank them?
When at a doctors’ gathering the tables are set with flowers, the
snacks or dinners are ready, the programs are present at each place
setting, and the mike is working, had Girl Scouts come and gone incognito? Most likely not. Some ever faithful and thoughtful staff had
planned and executed these to perfection for the comfort of their
honored guests. Are they hovering discreetly around? Do they know
that we know what they did?
When a mother/wife sleepily folds the laundry after a challenging
day at the clinic and puts the clothing in stacks for family members to
take to their rooms, nobody takes notice. Is this just a routine ending of
the daily job she voluntarily chose? And when a dad takes a little extra
time to prepare a special meal and efforts to cook it just so, he takes
pleasure in seeing others gobble down his masterpiece. However, the
likelihood increases that this treat will be repeated if a few verbal compliments or satisfied grunts come from the consumers’ side.
A smile, a small gesture, a passing word of acknowledgement, a
thumbs-up: all work wonders. They banish the monotony and dreariness of everyday work. Sagging shoulders visibly perk up like flowers
after a shower. Words of thanks relieve the stress of not knowing
whether expectations are being met or not. They enhance the joy of
pleasing others and making them happy.
As my observant padre pointed out, saying thank you has to be
taught. Long past the time of parental urging, it can also be selftaught. Then it has to be practiced until it becomes second nature.
At every turn in life, if we look and make ourselves aware, the
opportunities are myriad in finding things to be thankful for. Even the
gifts of life and health cannot be taken for granted. Recognizing and
rediscovering these things, acknowledging them, and giving thanks
make the brand new year before us brighter and something to look
forward to. LM
Note: Dr. Oropilla is a retired psychiatrist.
Medical Society Professional Services
is pleased to announce a new locum tenens program for
GLMS member physicians, offering
Long Term Physician Placements
Short Term Physician Placements
Direct Hire of Physicians
We now are seeking board certified physicians in family
practice and internal medicine for early 2011 placements.
We welcome your listing of physician openings
in your practice
Hourly rates competitive with national placement firms
Professional Liability Insurance Provided
Work with local people you know and trust
For details and a confidential consultation contact
Ludmilla Plenty, Director
Medical Society Employment Services
502.589.2006
ludmilla.plenty@glms.org
ALLIAncE nEWS
Lisa Sosnin, RN
GLMSA President
Happy new year!
We of the Greater Louisville Medical
Society Alliance hope that you and your
family had a wonderful holiday season. What
would the New Year be without making our
list of New Year’s resolutions? Of course, after
gorging ourselves on fine cuisine and spending quite a bit of money on gifts for our
loved ones, some of the traditional resolutions may include eating healthier, losing
weight and spending less money.
My challenge to you is that part of your
New Year’s resolution would be to join the
GLMSA. I can’t promise you that our
members will always eat healthier, lose
weight or manage our money better.
However, I can assure you that we will
provide learning opportunities on how to
have a healthier and less stressful you. Part of
this opportunity would come through the
many friendships that you make being part
of such a wonderfully unique group of individuals who understand what it is to be part
of the family of medicine.
In November, after having a catered
lunch from the Bristol, the GLMSA toured the
Louisville Science Center and watched the
IMAX program, The Light Before Christmas.
Bert Guinn, GLMS communications and
membership director, spoke to our group
about the exciting Pulse of Surgery program
and encouraged all GLMSA members to be
involved. In December, the GLMSA participated in a candlelight tour of Historic Locust
Grove for the holidays. We offered this
evening event so that it would be a family
affair to enjoy the holiday festivities.
A New Year’s resolution for the GLMSA
would be to reach out to as many spouses of
our physicians as possible and offer the gift
of love and friendship. We are resolved in our
belief that we can contribute to our community and schools by serving others. We hope
to offer opportunities to our members to
participate in providing support for our
physicians by learning about legislative
issues and calling our representatives in
Frankfort.
2010 may have come and gone.
However, we can start anew in 2011. Let’s
resolve to not only take better care of ourselves in these stressful times but be proactive and support each other by bringing new
thoughts and ideas to our group. We would
love to hear from you! LM
Note: Lisa Sosnin is a registered nurse and is the
practice manager for her husband’s solo practice,
Bluegrass Community Family Practice, in Bardstown.
E-mail her at lasosnin62@hotmail.com.
GLmS Alliance members
gather outside the exhibit
Sesame Street Presents:
The Body. (clockwise from
top left) Lisa Sosnin,
michelle Feger, Fu mei
Tsai, jeanne Kral, Betty
Allen, millicent Evans and
Barbara cox.
The GLmS Alliance toured the Louisville
Science center in november, including the
BodyWatch exhibit.
Betty Allen (left) and
jeanne Kral check out
the exhibit.
Barbara cox (left) talks with Louisville Science
center tour guide Ally Sauer.
Ilene Booscher (left) and Adele murphy
listen to a presentation on Pulse of
Surgery by Bert Guinn, GLmS communications and membership director.
28
LOUISVILLE MEDICINE
• Full Time IM or FP
Board Eligible or Certified
• Well Established Private Practice
• 5 Days a Week, 1 Call Per Week
Confidential responses to:
Hospital Internal Medicine Associates, PLLC
201 Abraham Flexner Way
Suite 1003
Louisville, KY 40202
Attn: Tina
502.584.4479
tinas@himassociates.com
• Inpatient Care
Salary and Benefits
combined $150K
JANUARY 2011
29
WE WELcOmE yOU
GLMS would like to welcome and congratulate the following physicians who
have been elected by Judicial Council as provisional members. During the next
30 days, GLMS members have the right to submit written comments pertinent
to these new members. All comments received will be forwarded to Judicial
Council for review. Provisional membership shall last for a period of two years
or until the member’s first hospital reappointment. Provisional members shall
become full members upon completion of this time period and favorable review
by Judicial Council.
Candidates Elected to Provisional Active Membership
30
Erickson, Kavita K.
(30297)
Craig K. Erickson, MD
2444 Lakeridge Dr
Newburgh IN 47630
812-618-5221
Radiology/
Neuroradiology
Louisiana State U
Miller, Glenn Alan
(312)
Nita
9342 Cedar Center Way
40291
239-3228
Family Practice 78, 95,
02
U of Louisville 74
Scheker, Luis Roman
(606)
Aurora
225 Abraham Flexner Way
Ste 700 40202
561-4263
Hand Surgery
U de Santo Domingo 76
Ferraz, Francisco
Marconi (30229)
Audrey R. Ferraz
3900 Kresge Way
Ste 41 40207
899-3623
Neurological Surgery
87
Universidade Federal
Pernambuco 75
Nord, Kristi Mahaffey
(30314)
Jonathan Nord
3991 Dutchmans Ln
Ste 200 40207
899-6782
Neurology
The Pennsylvania
State U
Sulkowski, Gregory
Michael (21480)
1169 Eastern Pkwy
Ste 3334 40217
458-9004
Ophthalmology
Harvard Med School 04
Johnson, Michael
William (30163)
Lisa Marie Stoll
810 Barrett Rd Fl 7
40204 852-5587
Anatomic Pathology/
Neuropathology/
Forensic Path
Northwestern U
Ramirez, Allan M
(21401)
Yvette M. Cua
401 E Chestnut St Ste 310
40202
813-6500
Pulmonary Diseases 00
Critical Care Medicine 02
Internal Medicine 98
Northwestern U 95
LOUISVILLE MEDICINE
Candidates Elected to
Provisional Associate
Membership
Conrad, Brandon
Nelson (30293)
Tiffany Sammons
U of Kentucky
Membership
•
Promote your business in a publication
read cover to cover by some of the
more sophisticated, well-educated,
affluent and influential people in the
metropolitan Louisville area.
•
Readership includes 85% of physicians
in Louisville.
•
Mailed to physicians’ homes.
In REmEmBRAncE
RoBERT PFEiFFER
KRAFT JR., Md
(1949-2010)
Robert Pfeiffer Kraft Jr., MD, passed away October 7,
people in ways that helped to reduce anxiety and increase
2010. He was 60 years old and is survived by his wife, Betty
understanding. Among the adjectives most frequently
Price Kraft, two sisters, two stepchildren, a stepgrandson
used to describe him as a professional were “kind,”
and a nephew.
“caring,” “skillful” and “dedicated.” He loved being a physi-
He was graduated in 1971 from Indiana University
with a double major in zoology and chemistry and
received his Doctor of Medicine degree from the
cian, and that showed in his performance, infectious smile
and upbeat manner.
Additional words that describe him in his personal life
University of Louisville in 1975. After completing his resi-
include “fun-loving,” “multifaceted” and “family-oriented.”
dency in Internal Medicine at the U of L-affiliated hospitals
He was a voracious reader and an avid and talented golfer
and serving as the chief resident in Medicine during the
and photographer. He also thoroughly enjoyed music of
final year of that training, he completed his fellowship in
all kinds, movies, socializing with colleagues, theater,
Gastroenterology at the University of Iowa in 1981. He was
cooking, college football and basketball, computers and
board certified in both Internal Medicine and
electronics, landscaping projects and traveling, especially
Gastroenterology. He began a private gastroenterology
to Hawaii. Family, friends and home were infinitely impor-
practice that was later named Gastro East Physicians and
tant to him and were always at the center of his life from
practiced until his retirement in 2004.
childhood until his death.
Bob, as everyone called him, was a native of Louisville
So many more things could be written about Bob, but
and was devoted to his hometown. He always said that
one gentleman who had been his patient for years
Louisville was a wonderful place to pursue a medical
summed it all up eloquently when he attended the funeral
career because of the high caliber of physicians in the
home visitation. He simply said, “Dr. Kraft was the best
community and the strong culture of commitment to
doctor I’ve ever had and the best man I’ve ever known.” LM
learning, research and innovation in so many different
areas of medicine.
The genuine concern that underscored Bob’s desire to
_ Carolyn Kraft, Dr. Kraft’s sister
help individuals to deal with sometimes complex and
frightening information was very much a reflection of his
personality. He was a natural teacher, and patients and
medical personnel alike often commented that he had a
real knack for explaining diagnoses and procedures to
JANUARY 2011
31
The Gawandes
of Athens, Ohio
On a visit to Athens,
Ohio , in 2009 where our
son John was a senior at
the time at Ohio
University, I picked up the phone and
dialed the office number of a local
urologist, Dr. Atmaram Gawande.
Instead of an answering machine or a
secretary, Dr. Gawande himself
answered the phone. After introducing
myself, I pointed out that I was an
admirer of the writings of his son, Atul
Gawande, and have a strong interest in
the history of immigrant physicians in
the United States and their children.
“Ram” immediately invited my wife,
Sally, and I to come over to his home,
which happened to be only a few
blocks from our hotel. We were greeted
warmly at his beautiful yet modest
home and sat down for a chat in their
living room. The following account is a
distillation of my conversation with Dr.
Gawande and his wife.
32
LOUISVILLE MEDICINE
Ram hails from a rural area of Nagpur that lies precisely
in the center of India and is part of Maharashtra, where the
Marathi language is spoken. He earned his medical degree in
1962 and started his Surgery residency there. Like most new
medical graduates in the Indian subcontinent, he wanted to
go to England for postgraduate education, earn the FRCS
(Fellow of the Royal College of Surgeons) designation and
return to India. Coming to America for foreign physicians was
a new phenomenon at that time. After he passed his requisite
ECFMG (Educational Council for Foreign Medical Graduates)
examination, obtained his passport (which took six months)
and secured a visa from the United States Consulate through
the help of the Ventnor Foundation of New Jersey, he landed
in New York with $8 in his pocket. He started his internship at
St. Mary’s Hospital in Brooklyn and came to work with residents from multiple nationalities. His foray into Pathology
residency was boring, and he switched to residency in
Urology at the Martland Medical Center, affiliated with the
New Jersey College of Medicine. During his residency, he met
his wife, Sushila, who came to America from Ahmedabad,
India, and was pursuing a Pediatrics residency. Sushila
Gawande (she likes to be called “Sushi”) followed her physician sister to the United States. Ram was smitten by her and,
after initial resistance (her mother had told her to beware of
Indian men who might be married with a wife back in India),
she relented and started the courtship. They were united in
marriage by an employee from the Indian Embassy who officiated the ceremony, since he knew the marriage rituals.
There were no Hindu temples in New York in the 1960s.
The Gawandes were ready to come back to India in 1970
with their two children, Atul and Sumeeta, when they discovered that Atul was allergic to the smallpox vaccine. The plan
of returning to India was scrapped since they did not want to
take a chance on exposing Atul to smallpox. They moved
from New York to a sleepy little town called Athens in Ohio
(population close to 20,000), located along the Hocking River
in the southeastern portion of the state. Ohio University is
one of the oldest universities in the United States (chartered
in 1804). Ram was the first urologist in town and worked as a
solo practitioner with privileges at the local O’Bleness
Memorial Hospital. Sushila started her pediatrics practice,
which steadily grew, and the couple has been at the same
place for 40 years. Ram informed me that the day I talked to
him was the last day of his private practice at age 73; Sushi
had retired three years earlier.
The Gawandes have given back generously to the community both in Athens and in India. Sushi ensured that she
took care of the poorest children in Athens during her years
in practice, and both Ram and Sushi are involved in numerous charity initiatives. Ram has been a regular member of the
local Rotary Club and currently serves as the district governor.
Twenty-five years ago, the Gawandes gave seed money to
establish a college in Ram’s hometown in Nanded,
Maharashtra, India, named in memory of his mother.
Dr. Atul Gawande was graduated from Stanford
University and obtained his MA in politics, philosophy and
economics from Oxford University, and his MD and MPH from
Harvard. He completed his surgical residency at Brigham and
Women’s Hospital in Boston and joined the faculty as a
general surgeon with special interest in Endocrine surgery.
He was a Rhodes scholar and also won the MacArthur Award
in 2006 for his research and writing. He is an author of three
New York Times best seller books and is a staff writer at The
New Yorker. His sibling, Sumeeta Gawande, is academically
quite accomplished as well. She completed her premedical
studies but switched to women’s studies and obtained her BA
from Cornell and JD from Rutgers School of Law. She practices law in Newark.
It was indeed a delight to spend time with Drs. Ram and
Sushila Gawande in Athens, Ohio. They are an unassuming,
simple, down-to-earth Indian American couple who are
extremely content in achieving their own version of the
American dream. Dedication to work and family, the
Gandhian principle of simple living and help for their fellow
human beings appear to be the components of their guiding
philosophy. LM
Note: Dr. Seyal practices Cardiovascular Diseases with River Cities Cardiology MPC.
dr. Seyal and his wife, Sally, at the home
of drs. Atmaram and Sushila Gawande
drs. Atmaram and Sushila Gawande
JANUARY 2011
33
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LOUISVILLE MEDICINE
SPEAK yOUR mInd
The views expressed in doctors’
Lounge or any other article in this
publication are not those of the
Greater Louisville medical Society or Louisville medicine. If you would like to respond to an
article in this issue, please submit an article or letter to the editor. contributions may be
sent to editor@glms.org or may be submitted online at www.glms.org. The GLmS Editorial
Board reserves the right to choose what will be published.
Mary G. Barry, MD
Louisville Medicine
Editor
editor@glms.org
The ville is
not vegas
The chief executives of Passport
Health Plan have been livin’ Las
Vegas, roaring off in their limos and
leaving the poor and disabled with
facefuls of exhaust and handfuls of
denials: business as usual when you
think of yourself as Mr. Big. Not for
you the stop and wheeze of the
Broadway bus, or the grime and
garbage of the night-cleaning staff,
or the long lines at the food stamp
office; no, you are in the VIP room,
cruising past the velvet rope straight
to the Chateauneuf du Pape. Thanks
to Sen. Tim Shaughnessy, state
Auditor Crit Luallen and veteran
Courier-Journal reporter Tom Loftus,
we have been treated to the true
vision of our community leaders
tasked to serve the poor, and it’s not
one of duty, honor and courage. It’s
“Lodgings were often luxury spas and
resorts,” and “The executives used
limousine services and dined at
expensive restaurants.”
After all, health care is big business, they reason, and aren’t they
just like the owners of Humana and
Anthem and United? Aren’t they entitled to the good life too? They
administer the state’s largest contract of $793 million. They must need
all the help they can get from our
state legislators, for instance, for they
spent a million dollars on lobbying
and public relations, to get language
inserted in a bill to prevent funding
cuts (Gov. Steve Beshear later vetoed
that wording). It sure is hard work to
lobby – all that talk about staying on
message, and who knows whom –
one must surely eat well to survive.
They have face to maintain, too.
They have to throw a bone to the
working class from time to time (why
else would they spend $10,000 to
sponsor a blow-up doll for the
Pegasus Parade) and they have to
sweet-talk the rich, with donations to
the Kentucky Opera, political receptions and campaign contributions.
They showered their own pockets
and those of their friends at
AmeriHealth Mercy with more than
$200,000 in bonuses. All told they
gave away more than $423,000
dollars in gifts and scholarships. To
whom? And why? And where was the
board?
The board was at work, that’s
where, at the helm of every downtown hospital and at U of L. What
they knew about it, and if they knew,
are subjects that The Courier-Journal
has had to go to court to find out. In
keeping with the privileged way they
view themselves, Passport staff
members have maintained that the
exact records of expenditures and
the minutes of board meetings are
private, and not subject to the state
Open Records Act. Ms. Luallen,
backed by Attorney General Jack
Conway, has argued that since
Passport is 100 percent publicly
funded, such meetings must be open
to public inspection.
We therefore have no data on the
board’s proceedings or deliberations.
On the other hand, Passport paid all
of the entities it represents handsome sums – multimillion dollar
transfers – because they were investment partners in the creation of
JANUARY 2011
35
Passport in 1997. Such millions were
not designated solely for indigent
care, however. Such millions (and
from what part of patient care delivery or denial did these funds come?)
went to the general funds of these
institutions, in proportion to their
investments. Was that the intent of
the taxpayers? All of us pay for the
care of those with no means. Did we
intend those monies for the individual needs of Norton or Jewish or
U of L, for example, or did we intend
to pay only for the prevention of
illness and the care of the sick and
disabled, which these institutions do
very well? If well-managed care
results in large savings, should all of
those savings go back into direct
patient services only? Passport
patients help to educate future
doctors and nurses and techs. Should
these monies be directed to pay for
medical education? Should doctors’
and nurse practitioners’ payments be
increased, clinics expanded, and eligibility requirements and formularies
relaxed? Who decides? Secrecy
around the use of public monies
always makes the citizenry uneasy.
As taxpayers and as physicians who
help to deliver this care, we should
Kerri S. Remmel, MD,
PhD
Stroke Prevention Breakthrough
in Patients with AF
As a stroke neurologist, I am not
only interested in the treatment of
stroke but also in the prevention of
stroke. While I treat patients at
36
LOUISVILLE MEDICINE
have free and open access to all of
this financial decision making,
without having to force the issue in
Jefferson Circuit Court.
Passport has maintained that its
managed-care policies save taxpayers money, and that its current
medical cost increase of only 4.5
percent compares very favorably
with the regional increase of 9.3
percent and the national one of 7.1
percent. However, no true cost comparison of Passport with the surrounding 16-county Medicaid region
has been done, and the audit by Ms.
Luallen found that it was impossible
to conclude that overall moneysaving has been accomplished. A
separate study by an outside consultant will be commissioned by the
Cabinet for Health and Family
Services.
Like all doctors of the modern
era, I have written countless letters
to the self-ordained VIPs of this
world begging for better or different
or even barely minimal care for my
patients. I can’t wait to demand that
my patient whose Lyrica has been
twice denied by Passport should
have her coverage restored at least
to the tune of the $3,996 spent on
limos alone. Dr. Walter Badenhausen
University of Louisville Hospital, my
hope is that the number I see
decreases each year.
The problem is that strokes are
difficult to prevent. It’s up to each
individual person to commit to a
lifestyle of healthy behaviors and to
comply with medical treatments to
reduce stroke risk when necessary.
However, with the Food and Drug
Administration’s approval of dabigatran (Pradaxa) for patients with atrial
fibrillation, there is hope that more
strokes will be avoided in the future.
AF patients suffer from cardiac
arrhythmia, which ultimately puts
has spent decades caring for injured
and disabled children and having his
requests for adaptive devices turned
down. Why can’t they now have the
high-tech brace that fits better, or
the lightest wheelchair that rolls
better, in place of the standard-issue
Yugo model, with some of that
$70,000-plus hotel money? The ICUs
of all three downtown hospitals
should get to split the million spent
on lobbying – it won’t cover more
than one indigent patient outlier
with major burns, trauma or sepsis,
but it might buy some really nice respirator tubing.
What these executives have done
is to raid the public trough for
bonuses and parties. They have identified themselves as creatures of the
red carpet instead of guardians of
the public health. The best solution
to this travesty is the establishment
of absolute financial transparency
plus the appointment of a strong
leader who believes in service, not
entitlement. LM
Note: Dr. Barry practices Internal Medicine as an
employed physician with Norton Community
Medical Associates-Barret. She is a clinical associate professor in the Department of Medicine at
the University of Louisville School of Medicine.
them at an increased risk for blood
clots and ischemic stroke. According
to the American Heart Association,
15 percent of strokes occur in people
with AF.
The FDA approved dabigatran as
a result of the Randomized
Evaluation of Long-Term
Anticoagulation Therapy (RE-LY), a
noninferiority, randomized trial that
compared two fixed doses of dabigatran with warfarin (Coumadin) in
more than 18,000 patients with AF.
The primary outcomes were stroke or
systemic embolism.
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Dabigatran 110 mg twice daily
was found to be comparable to warfarin for the primary outcome of
stroke or systemic embolism. This
dose was not FDA-approved.
Dabigatran 150 mg twice daily was
found to be superior to warfarin in
terms of the primary endpoints of
stroke or systemic embolism (1.11
percent per year for dabigatran
versus 1.69 percent per year for warfarin [p<0.001]).
The rate of hemorrhagic stroke
was 0.38 percent in the warfarin
group compared to 0.10 percent in
the dabigatran group at 150 mg
twice daily (p<0.001). All major
bleeding was comparable for the two
groups. Dabigatran 150 mg twice
daily was approved by the FDA for
prevention of stroke and systemic
embolism in patients with AF.
The decreased stroke rates
shown in the RE-LY trial bring good
news for those with AF, because
strokes caused by AF are particularly
devastating. They are large vessel
cardioembolic strokes and can affect
38
LOUISVILLE MEDICINE
the cortex and one’s ability to think
and communicate. The way to
prevent them is through pharmaceutical means. Blood thinners such as
warfarin have been the mainstay to
thin blood and keep clots from
forming in the heart’s chambers,
then traveling to the brain through
blood vessels in the neck. Warfarin
reduces the risk of stroke by 60-70
percent, so it can be an effective
stroke prevention modality for qualified patients with AF, but it is being
underutilized.
Only half of the people with AF
who are appropriate candidates for
warfarin receive the drug. The
problem is that many physicians and
consumers are not comfortable using
it because it can lead to life-threatening bleeding, and there are many
food and drug interactions that
affect the drug levels in the bloodstream.
There have also been concerns
with the appropriate dosing of warfarin. If the level is too high, patients
could experience severe bleeding; if
the level is too low, blood clots could
form.
For those reasons, the FDA’s
approval of dabigatran is a significant breakthrough in the treatment
of patients with AF. There are no
Vitamin K interactions and no need
for blood work to check drug levels.
The primary outcome showed a
lower incidence of both ischemic and
hemorrhagic strokes, which makes
dabigatran an excellent alternative
to warfarin.
A downside to dabigatran is that
people may develop gastrointestinal
bleeding, so individuals with a
history of GI bleeding may not be
appropriate candidates for blood
thinners such as dabigatran.
Dabigatran’s introduction is a big
step toward stroke prevention for
one subset of people. If the risk of
stroke can be reduced for anyone, we
all move closer to establishing an
improved system of stroke care. LM
Note: Dr. Remmel is director of the University of
Louisville Hospital’s Stroke Center.
Disclosure: Dr. Remmel will serve as a member of
a speakers bureau for Boehringer Ingelheim
Pharmaceuticals Inc., the company that manufactures dabigatran.
An Unforgettable
Patient
Elsa M. Haddad, MD
It was about 10 years
ago. My boys were 6 and 7
at the time, and I had a fulltime solo pediatric practice,
which meant my kids did
not always come first.
We had just finished eating dinner when I was paged by one of the
local hospitals to let me know that a child I had sent over earlier for
routine rehydration was taking a turn for the worse. The tone of the
nurse’s voice simultaneously alarmed me and made me skeptical. After
all, what kind of a “turn for the worse” could a kid with mild vomiting
and diarrhea take in such a short time?
I left the house and drove the 10 minutes to the hospital, going
straight to the Pediatric floor. As I walked in the room, I knew it was bad.
They had called the ED physician who was attempting to intubate the
child. We completed the intubation; however, this was not a pediatric
hospital and its crash cart was not equipped to handle the needs of a
10-year-old crashing. The rest of the details are not relevant because the
child did not survive. Looking down at that little boy, so much like my
own, I sat on his bed and could not begin to consider the possibility of
going to tell his father what had happened. I didn’t know what had happened.
It never occurred to me that when I had talked to that dad just a
few hours earlier and reassured him that just as a “precaution” he should
take his son to the hospital to get some IV fluids, I would be telling him
that his child was dead – his only child, whose mom had died two years
earlier.
Why are some people given such horrific challenges in life? Why
did I have to break this man’s heart in such a way that it will never heal?
Why am I the one who gets to keep her two sons while he has lost his
one?
I am not sure how I did it, but my words and tears conveyed a
reality that was beyond my comprehension.
I don’t really remember driving home that night or what time it
was when I finally entered my children’s room. But I do remember
sitting on the bottom bunk bed listening to the steady rhythm of their
breathing, feeling grateful and guilty while making a vow to always
make these two boys my first priority. Then I cried myself to sleep.
The autopsy report showed no relevant findings, and the cause of
death was listed as respiratory failure. For the next two years, I carried
this child’s autopsy report with me and would ask as many pediatricians
who would listen if they had any idea what precipitating events could
have led to this child’s outcome.
I continually replayed the conversation I had had with the dad –
the symptoms he had described, the advice I had given him – and wondered just what I had missed. Because surely kids this healthy with this
mild form of an illness just don’t die, this meant that I must have missed
something. I had always believed that I was really good at the job that I
always referred to as my passion, but after this occurrence, I started to
believe I had just been lucky.
Although I eventually stopped carrying the report, I continued to
carry the memory. It led me to voice my concerns to the hospital administration and work on improving the pediatric facility. Though it was
never explicitly said that even the most well-equipped pediatric trauma
room could have saved that child’s life, the remote possibility was a concrete entity where I could affect change.
However, the greatest change took place inside of me. I began to
realize that the limitations I have as a physician go well beyond limitations in knowledge. They are limitations based solely on my humanity. I
once read a quote by Gandhi that said “It is for us to make the effort, the
result is always in God’s hand.” I am not sure why this concept was so
hard for me to comprehend. Maybe it was arrogance and youth combined with a first-rate medical education and training where the objective was always to save, heal, sew, set, replace – not necessarily to
“allow.”
My practice of medicine changed, subtly at first and then in a more
pronounced way. These were not changes that would be noted by an
outside observer, for it was an internal shift in what I felt to be my
responsibility toward my patients. Realizing that my knowledge was far
from all-encompassing and my ways not the only ways, I became much
more flexible in the doctor-patient relationship. I saw my job as one of
providing the latest and best medical information and giving guidance.
Instead of dictating treatment in non-life-threatening situations, I
allowed parents to be more involved in the decision-making process,
respecting their opinions and concerns. I began to rely on a more holistic approach, and I think I connected on a much deeper level with the
parents and the children. It was a wonderful time, and I once again
began to believe that I was a pretty good pediatrician.
The greatest changes and possibly the most lasting have been in
my own personal life. I committed myself from that night on to be a
better mom and wife, yet I know that those for whom that commitment
was made may not always have seen it that way. But when I look at my
motives and intentions in the naked, raw light of self-inspection, I know
it’s the truth. And that is all I could change. LM
Note: Dr. Haddad works in Pediatrics at Kosair Children’s Hospital and Baptist Hospital East.
JANUARY 2011
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(812) 282-6631 | www
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Jeffersonville,, IN
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