August 2010 - NEW - Greater Louisville Medical … Public Health & Wellness Lynn T. Simon, MD, board...

MEDICINELOUISVILLEGREATER LOUISVILLE mEdIcAL SOcIETy VOL. 58 nO. 3 AUGUST 2010

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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Katrina Hood, M.D., F.A.A.P.

AUGUST 2010 3

LOUISVILLEGREATER LOUISVILLE mEdIcAL SOcIETy

6

MEDICINEVOL. 58 nO. 3 AUGUST 2010

10catching a MemoryDanielle Pigneri

Greater Louisville Medical Society committees 2010-2011What Should We Make of the debate about WhetherAntidepressants Work?Jesse H. Wright, MD, PhD

A Reflection on Minimally invasive SurgeryKelly McMasters, MD, PhD

Healthy Hoops Kentucky Program Educates children with AsthmaRonald Morton, MD, Tammy Pasko, RN, CPNP, Marcelline Coots, Nemr Eid, MD

F E A T U R E A R T I C L E S

D E P A R T M E N T SFrom the PresidentKimberly A. Alumbaugh, MD

Book ReviewAutism’s False Prophets by Paul A. Offit, MD Reviewed by Stanley A. Gall, MD

ReflectionsChoosing a Doctor Teresita Bacani-Oropilla, MD

Book ReviewWaking Up Blind: Lawsuits Over Eye Surgery by Tom Harbin, MD Reviewed by Larry D. Florman, MD

in RemembranceJoseph M. dew, MdKevin Dew, MD

Physicians in Print

We Welcome You

Alliance newsLisa Sosnin, RN

doctors’ LoungeSee-Thru Is Not Always ObsceneMary G. Barry, MDHealth Reform and IndependenceLarry P. Griffin, MDMoving from the Curative and the Palliative Model of MedicalCare to a New Universal Health Care ModelKenneth C. Henderson, MD, FACPEDerby PartyDavid Seligson, MD

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LouiSviLLE MEdicinE is published monthlyby 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 LMmust be received on electronic file on the first dayof the month, two months preceding publication.

Opinions expressed herein are those of individ-ual contributors and do not necessarily reflect theposition 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 decisionon all content and advertisements.

Circulation: 3,800

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GLMS Board of GovernorsLynn T. Simon, MD, board chairKimberly A. Alumbaugh, MD, presidentDavid E. Bybee, MD, president-electRobert A. Zaring, MD, vice president and

AMA alternate delegateHeather L. Harmon, MD, treasurerJames Patrick Murphy, MD, secretaryRobert H. Couch, MD, at-large Elmer Dunbar, MD, at-largeJohn M. Gormley, MD, at-large Jonathan W. Wilding, MD, at-large Russell Williams, MD, at-large Bruce Scott, MD, AMA delegateGordon R. Tobin, MD, KMA president-electFred A. Williams, Jr., MD, KMA 5th district trusteeDavid R. Watkins, MD, KMA 5th district trustee

alternateK. Thomas Reichard, MD, GLMS Foundation

president Stephen S. Kirzinger, MD, Medical Society

Professional Services presidentEdward C. Halperin, MD, MA, dean,

UofL School of MedicineAdewale Troutman, MD, MPH, director,

Louisville Metro Dept. of Public Health & Wellness

Jay P. Davidson, president and CEO, The Healing Place

Lisa Sosnin, GLMSA presidentLouisville Medicine Editorial BoardEditor: Mary G. Barry, MDDeborah A. Ballard, MDEugene H. Conner, MDArun Gadre, MDStanley A. Gall, MDJeremy Gerwe, MDLarry P. Griffin, MDDarin Harden, MDKenneth C. Henderson, MDJonathan E. Hodes, MDThomas James III, MDMichael T. Macfarlane, MDJoe Maurer, MDTeresita Bacani-Oropilla, MDDanielle PigneriTracy Ragland, MDM. Saleem Seyal, MDDave Langdon, Louisville Metro Department

of Public Health & WellnessLynn T. Simon, MD, board chairKimberly A. Alumbaugh, MD, presidentDavid E. Bybee, MD, president-electLelan K. Woodmansee, CAE, executive directorBert Guinn, MBA, communications & membership

directorEllen R. Hale, communications associateDonna Watts, communications designer Advertising Cheri K. McGuire, director of marketing736.6336, [email protected]

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LOUISVILLE MEDICINE4

Our oldest daughter gotmarried this weekend, and I am stillrecovering from organizationaloverload. In the end, she was happyand as she flew off to Arizona wefelt we had done our job as parents.Of course, our role as parents is notover, it probably is now moreexample-driven than ever. Truly atthe do as I do stage, not the do as Isay stage, our grown children cansimply decide to thank us for ouradvice and move along on theirown paths. They have watched howwe have done “it” and decided thatthey know they can do it better andthey are raring to try. About 20years from now they will hopefullylook at us and say, you guys havehad such a great life, and thank youfor being such a good example ofwhat to do. Now, they could alsosay, “For 20 years I have watchedyou struggle to figure this out. Youcan’t heal the world, so could youjust heal yourselves and decide tobe a little more light-hearted?”

By light of heart I would guessthey would mean to be withoutworries, and, as much as I wouldlike to be there, I know few physi-cians who are without worry thesedays. Health care’s next iteration isupon us like a final without a noteset. There is a syllabus, of sorts, butno real guidance on what toprepare for, no inside scoop of whatwill definitely be on the test –leaving many physicians wondering,now what do we do?

First, it is imperative that webecome electronic. It is costly, youmay not like it, and the records,although they reflect and trap morepersonal data, may end up with apaucity of truly useful information.

You know, those notes in themargin that remind you that Mrs.Jones’ mother is in the nursinghome and she is not getting muchhelp from her family? Or thatSherri’s been really working on herweight so don’t forget to build herup a little. It also doesn’t allow youto circle and draw the arrow to thepicture of exactly what this thinglooks like so the next partnerreading the chart will know. Ofcourse, you could use words, butsometimes a picture is worth athousand.

Nonetheless, the electronicform of our records will be the cur-rency by which we are judged, paidand progress. If you haven’t gotteninformation about the wealth ofoptions that exist, and what specificelements you should ensure theycontain, you need to speak with ourGLMS experts on this topic. Over thelast three years they have amassedan amazing amount of data aboutthese systems and how they willinterface with payers. They are agreat resource for all our membersto prevent us all from making thesame mistakes. Remember all of thebenefits you reaped from learningwhat not to put in a contract? GLMSis working to make the forthcomingchanges the health care act bringseasier for you and your office staff.

Second, we need to revisit ourunderstanding of the relationshipsbetween hospitals, insurers andphysicians. No longer can we workin an adversarial fashion. We haveto find ways to interact that aremutually beneficial for all and maxi-mally beneficial for our patients.Bundled payments and medicalhome places may be out there

sooner than we think, and strategicalignments for physicians will becritical.

Third, but of course not finally,because we are just scratching thesurface here, we are going to haveto look at ways to emphasize qualitymetrics. We are going to have toprove that we are the good physi-cians we say we are. Data-drivendecisions that make sense mustguide us, not costly unnecessaryoveruse of services. Having seensome of the nonsensical metricsthat the insurers send our way,physicians need to be involved inthe development of new metricsthat truly elucidate quality of care.Specialty organizations have beenworking on these quality indicatorsfor years, and there are abundantresources for physicians to tap into.But, tap into it we must before weare thumped over the head by it inthis new health care paradigm.

So, let me end this month’spage by saying that the passage oftime has brought me to a new placein my life with a grown marriedchild, and what I do next with thatrelationship is uncharted territory.The passage of the health care actplaces physicians similarly inuncharted territory. For me, thetrick with both will be assimilatingwhat I know into figuring out whatthey need and learning how to com-municate it and use it in ways thatare mutually beneficial. I wish us allgood luck.

Note: Dr. Alumbaugh practices Obstetrics andGynecology with Total Woman PLLC. E-mail herat [email protected].

FROm THE PRESIdEnTKimberly A. Alumbaugh, MDGLMS President

AUGUST 2010 5

LM

s a third-year medical student on myOB/GYN clerkship, I was simultaneouslyexhilarated and terrified by the idea of

“catching,” or delivering, a baby. It was my fifthor sixth day on the Labor and Delivery service(L&D), and I had yet to deliver one of my own.Sure, I had delivered plenty of placentas, assist-ed in C-sections, taken cord blood samples and

even performed a circumcision under the close supervision of residentsand an attending, but actually delivering a baby – that was the stuff ofdreams.

Invariably it always happened the same way. My team of studentswould arrive at 5 a.m., still shaking off the sleep from the night before,and eagerly check The Board. The Board was a list of L&D room numbersand the corresponding soon-to-be-mothers’ information. Based on age,previous number of deliveries, orientation of the fetus within the mom,and cervical effacement and dilation, we would hedge our bets. Wewanted moms who were likely to deliver within our 12-hour shift butwho weren’t likely to need a C-section. Since this was our third clinicalassignment within our OB/GYN clerkship, we all had already seen ourshare of C-sections. You also didn’t want a mom who was going todeliver right away. The night team of residents and students didn’t offi-cially check out to us until 7:30 a.m., making any baby born before thattime theirs to guide into this world.

As it turned out, I was very, very bad at this game. Every mother Ipicked would either deliver before 7:30 a.m., end up needing a C-sectionor tease me all day, slowly progressing but ultimately saving her deliveryfor the night team.

And so it was very different on that morning of my fifth or sixth daywhen I walked in and one of the night students said, “Danielle, youshould take the girl in Room 5.”

“Really? Why?”“She specifically requested no males. It’s a religious thing. She’s

really nice. So is her mother-in-law. You’ll like them.” I looked at The Board. She was 19. This was her first pregnancy, but

it was progressing well. The baby was head down and the mother’scervix was dilated 9 cm. Perfect. With a prickly tingle of excitement risingup my spine, I entered Room 5 to introduce myself before things got toochaotic.

As I pushed open the wooden door and stepped into this wonder-ful place where I was to deliver my first baby, it became immediatelyclear that this was not what I had expected. There she was, sittingupright on the corner of her bed … crying … loudly. Unfortunately, wehad not covered this yet in medical school.

“Hi. I’m Danielle, the medical student who’ll be with you for yourdelivery. What’s wrong?”

“Pain,” she said in a thick accent I could not identify. “So muchpain.”

It turned out that she had previously refused an epidural, havingdecided it would be best to go the most natural route. But now, sittingin the actual L&D room, feeling the force of her contractions as they

revved up for childbirth, this was something different than what she hadimagined when she decided on going without.

I tore out of the room, determined to get this woman some painrelief fast. We called Anesthesia, and I went back to Room 5 to let themknow the call had been placed. Help was on the way. Both my patientand her mother-in-law were relieved, and they thanked me for lettingthem know. But my patient continued to hold her belly and cry.

What was I to do? I felt compelled to stay in the room. It didn’t feelright to leave a patient in so much obvious pain, but I was also helplessto do anything to alleviate this pain. Did she find my presence comfort-ing despite my medical impotence in this matter, or would she preferprivacy during this difficult time? Fearing the latter, I left and postedmyself at the nursing station right outside her room. I wasn’t there long.

Her nurse went in to see her, and I tagged along. As soon as shehad examined my patient, this nurse set in motion a cascade of events. Iwould later discover these to be strategically planned and carefully exe-cuted motions, but at the time they seemed like a whirlwind of franticactivity.

First was the intern. “I’m OK with letting you get this one if you’reOK. What size gloves do you need? I’ll be right behind you.”

When we realized the Anesthesia team wasn’t going to have timeto get an epidural placed before the baby came, I was at a loss for words.How do you tell someone that they can’t have pain medication through-out one of life’s most painful experiences?

“I’m very sorry to tell you this, but the baby is coming now,” theintern explained. “This means there won’t be time to give you an epidur-al now. I’ll be right here with you the whole time. It’s going to be OK.”

In flew more residents and the attending. The nurse who had ledme into the room had already set up a table of sterile instruments andhad scrubbed in. She helped me into my gown and gloves, and Istepped into place. The intern was on one side of me and the attendingon the other, each of them providing me with clear instructions in asoothing tone.

I touched the baby’s hair as it peeked through the birth canal andtold my patient that we could see her baby’s head. There, for just aninstant, my patient stopped crying. I don’t know if I could really call it afull smile, but her expression changed to one markedly happier than Ihad seen this whole time. I massaged and stretched the perineum. Iinstructed and encouraged my patient on when and how to push. Whenthe moment finally came, I guided the baby’s head out. I rotated thehead to the left, applied downward pressure until the anterior shoulderappeared, and then upward pressure until the posterior shoulderarrived. From there, the rest of the baby came shooting out, and I sud-denly understood why delivering is also referred to as “catching.”

I wrapped my hands firmly around this beautiful, slippery little bluecreature and held it up to show the mother. “It’s a girl!” I said with somuch excitement that I surprised myself. “A beautiful little girl.”

Despite my firm grip and calculated hand placement, this slipperylittle girl was finding a way to slide further and further from my grasp. Tokeep from letting her slip any more, I placed her on her mother’s belly,on the blanket that had been placed there for that purpose. As I laid herdown, she started to cry. It was that beautiful, new-baby cry. It felt so dif-ferent from all the C-section and observed delivery new-baby cries I hadheard in the past. Something about this one was perfect.

I looked up and saw that the mother was crying, too. But this wasdifferent. This was a soft, happy, wonderful cry. I felt my own eyes watera bit as I took in this sight. Even without an epidural, through all themother’s pain and all my personal uncertainty, this baby had safelymade her way into the world. And for that mother, that beautiful 19-year-old wife and mother, everything had changed.

Note: Danielle Pigneri is a student at the University of Louisville School of Medicine.

catching amemory

Danielle Pigneri

A


LM

AUGUST 2010 7

Linda Shelburn, RNDiabetes Disease Care Manager

“I am here to help our Passport Advantage members

along the way.”

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Care Manager“One of the things

I enjoy most is helping our Passport Advantage

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Margot French, RRTCOPD Disease Care Manager

“It’s so rewarding to work one-on-one with our Passport Advantage

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e make a great team.As Care Managers, we support members in helpful and respectful ways. We are trained healthcare professionals who are knowledgeable and experienced. We eliminate the stress and worry members and their families may experience. Our programs include: Behavioral Health Management Case Management Chronic Obstructive Pulmonary

Disease (COPD) Management Coronary Artery Disease Management Diabetes Management

We appreciate your participation as a Passport Advantage provider. With your support, Passport Advantage HMO continues to be an excellent Medicare choice for Passport Health Plan members with Medicare Parts A and B.

To learn more about how our care coordination services may benefit both providers and members, visit us online at www.passportadvantage.org or call Provider Relations at 502.585.7943.

Passport Advantage is a Health plan with a Medicare contract. This Plan is available to all Passport Health Plan members with Medicare Parts A and B. Premiums, co-pays, coinsurance, and deductibles may vary based on the level of help you receive. Please contact Passport Advantage for further details. H1807-001 PA-10145 6/10

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AUGUST 2010 9

BOOk REVIEw

LM

Paul Offit, MD, is the Maurice R. HillemanProfessor of Vaccinology and Professor ofPediatrics at the University of PennsylvaniaSchool of Medicine, and Chief of InfectiousDiseases and the director of the VaccineEducation Center at The Children’s Hospital ofPhiladelphia. He is a national expert on vaccinesand challenges the modern day false prophets

who have misled the public in their zeal to attribute the cause of autismto vaccines. Children with autism have been subject to numerous thera-pies that have injured or killed these children with the false promise offinding a cure for autism. Dr. Offit begins his book with the descriptionof an autistic child. In 1938, Leo Kanner published a paper titled “AutisticDisturbances of Affective Contact.” Kanner used the word autisticbecause he had been impressed with the children’s self-absorption.Kanner guessed that autistic children had an innate inability to formaffective contact with people and held onto little hope for a cure.

Dr. Offit indicated that since the mid-1990s, the number of childrenwith autism has increased dramatically to as many as one in every 150children. This is the result of a broadened definition of autism to includemilder forms (Asperger’s syndrome). Additionally, in the past childrenwith severe symptoms of autism were thought to be mentally retarded.Today as the diagnosis of autism increases, the diagnosis of severemental retardation has decreased.

Parents of severely affected autistic children often face unimagin-able emotional and financial stress. This has led parents to seek outextreme therapies and even the killing of the child. This has also led to avariety of therapy approaches that Dr. Offit describes in great detail inthis book.

An early technique that became popular in the early 1990s was“facilitated communication.” The facilitator who held the child’s handswhile guiding their fingers to letters on a keyboard was believed toenable the autistic child to communicate. The technique gained nationalattention and parents thought there was hope for their children.However, more than 180 trials were done where valid communicationcould have been demonstrated and none did, thereby revealing thistherapy as a hoax.

The next lifeline to parents of autistic children was secretin therapy.Children were injected intravenously with the hormone secretin, derivedfrom pigs. Parents reported remarkable improvement in sympathologyand affect. Word of the secretin miracle spread and on October 7, 1998,Jane Pauley on Dateline NBC told the story of secretin therapy causing

the demand forsecretin to soar. Adouble blind randomized studyusing a single injected dose of human secretin or normalsaline was done. The results published in The New England Journal ofMedicine, December 9, 1999, showed that secretin was no better thannormal saline. More than 15 studies of secretin were performed, and notone showed secretin was effective in treating autism.

The most impressive figure in the autism story is a British physician,Andrew Wakefield. He held a news conference in February 1998 andannounced he had found the cause of autism. He announced thatmeasles vaccine caused autism. Researchers from around the worldattempted to duplicate the results that Wakefield had published in TheLancet (February 28, 1998). Wakefield recommended that children notbe vaccinated with the MMR vaccine. During the next few years, journal-ists wrote more than 1,500 articles about Wakefield, the MMR vaccineand autism. The impact was that many parents stopped vaccinatingtheir children. The results were devastating, with immunization ratesfalling to 50 percent and outbreaks of measles occurring with deathsdue to measles. On March 6, 2004, 10 of the 13 co-authors of The Lancetpaper issued a retraction that appeared in that day’s Lancet stating, “Thecaused link between MMR vaccine and autism was not proven and thedata was insufficient.” In May 2010, the United Kingdom medical regula-tor revoked Wakefield’s medical license because of “serious professionalmisconduct,” saying his work had been presented in an “irresponsibleand dishonest” way and had shown “callous disregard” for the childrenin his study.

Dr. Offit described the thimerosal scare that caused autism.Thimerosal was a bacteriostatic agent containing ethyl mercury that wasused in all multidose vials of vaccines. It has been disproved to be acause of autism, and since 2000 almost all vaccines are thimerosal-free.The incidence of autism has continued to rise despite the removal ofthimerosal from vaccines. Dr. Offit describes the effects of chelationtherapy and the intersection of politics and trial lawyers. He discussesthe problems of our current culture that make it difficult to communi-cate science because of the prevalence of ancient beliefs. Anotheraspect of our culture is that it is easy to scare people and that we live ina sea of poisonous metals, toxic chemicals and environmental pollu-tants.

Dr. Offit attempts to describe the efforts to find the cause of autismin genetic research. He describes the research that takes the cause backto the developing fetus.

This book is informative, provocative, entertaining and well-written.You will not want to put it down.

Note: Dr. Gall is a professor in the University of Louisville School of Medicine’sDepartment of Obstetrics, Gynecology and Women’s Health. He practices Obstetricsand Gynecology with University OB/GYN Associates.

Reviewed by Stanley A. Gall, MD

BY PAuL A. oFFit, MdPublisher: columbia university Press, September 2008

Autism’s FalseProphets


Membership in appointed committees remainsopen throughout the year. If you are interested inserving, e-mail [email protected]. Unless otherwisenoted, meetings are held at GLMS.

Bioethics committeeAddresses ethical issues with multidisciplinaryapproach. Meets monthly – first Wednesday, 5:30p.m.

centralized Application ProcessingService (cAPS) committeeOversees centralized staff application processingservice for hospitals and providers. Meets asneeded.

community connections committeeServes as a bridge builder and connector to otherlocal organizations interested in helping thesociety advocate for the health and well-being ofthe community. Meets monthly – first Thursday, 7a.m.

Editorial BoardReviews and approves content of monthly journal,Louisville Medicine. Members are encouraged toalso write articles and opinion pieces. Meetsmonthly – fourth Wednesday, 7 a.m.

Emerging medical concepts committeeExamines the nature of change in physician prac-tices and proposes action plans for GLMS. Meetsbi-monthly (even-numbered months) – thirdTuesday, 7 a.m.

Golf Tournament SubcommitteePromotes the GLMS Foundation scholarships ini-tiative to raise funds for medical school scholar-

ships. This committee’s function includes theorganization of the golf outing, enlisting partici-pation of local business leaders for team sponsor-ships as well as enlisting participation of physi-cians, both practicing and in-training (residentsand medical students). Meeting times vary.

Grievance committeeInvestigates and seeks to resolve grievancesbetween members and patients. Meets monthly –first Tuesday, 5:30 p.m.

Health care careers andScholarships committeePromotes the pursuit of health care careers anddevelops vehicles through which scholarships canassist in this endeavor. This is accomplished byeducating/mentoring middle school and highschool students as well as hospital co-ops/intern-ships and the creation of a GLMS ScholarshipFund for Medical School Students. Meets bi-monthly (odd-numbered months) – secondWednesday, 8 a.m.

Indigent care committeeDevelops and implements strategies to amelioratethe challenges faced in indigent health care bysurveying the needs of Louisville Metro indigent,understanding existing medical resources andexisting models and partnering with and/or sup-porting activities undertaken by other organiza-tions to meet the needs of indigent citizens.Meeting times vary.

Judicial councilActs on applications for membership referred by theMembership Committee. Also, acts on cases involvingmembers or related peer review cases for final disposi-tion. Meets monthly – third Friday, 7 a.m.

Greater Louisvillemedical Society

committees 2010-2011

11AUGUST 2010

kmA delegationDevelops GLMS resolutions for submission to theKMA. Resolutions approved at the KMA AnnualMeeting become part of KMA policy and its lob-bying efforts at the state and federal level.Meeting times vary.

Legislative committeePromotes effective communication betweenGLMS physicians and their respective state legis-lators. Coordinates local activities to lobby theKMA/GLMS legislative policy. Evening meetings,dates vary based on Kentucky legislative session.

Leadership and Programdevelopment committeeDevelops future physician leaders by implement-ing programs, events and mentoring for medicalstudents, residents and newly practicing physi-cians. Meets bi-monthly (even-numbered months)– second Tuesday, 5:30 p.m.

medical missions committeeServes to improve health care in needy or disad-vantaged areas (local, state, national, internation-al) through medical missions. This is accom-plished by proactively seeking mission needs,assessing our capacity to meet the needs, thenselecting and implementing medical mission proj-ects. Meeting times vary.

nominating/Tellers committeeRecruits and recommends candidates for leader-ship; validates election results. Meets twice annu-ally.

Old medical School Preservation committee Cultivates and solicits continued support to pre-serve and maintain The Old Medical SchoolBuilding as the vital piece of medical history thatit is, as well as fulfill its role as the home for theGreater Louisville Medical Society. Meeting timesvary.

Physician Practice AdvocacycommitteeRepresents the GLMS membership on third-partypayer issues while seeking to hold insurance car-riers accountable. Provides practice management

programs and services to members. Meetsmonthly – second Thursday, 7 a.m., at GLMS orBaptist Hospital East.

PPAc Insurance Issues ResolutioncommitteesFive separate committees meet quarterly with themajor carriers in Kentucky (Anthem, Humana,National Government Services, Passport,UnitedHealthcare) to facilitate hassle factorreports, communicate trends identified by GLMSmembers and push for resolutions. Meet quarterly– times vary.

Public Safety committeeProvides a forum to address concerns and seekresolution on police, fire, hazmat, disaster plan-ning, EMS and diversion issues. Members includeemergency room doctors and managers, hospitalrepresentatives, EMS, FBI, U.S. Marshals Service,community physicians, Kentucky HospitalAssociation and Kentucky Army National Guard41st Civil Support Unit. Meets monthly – fourthFriday, 7 a.m.

Pulse of Surgery Task ForceNew program launching in the winter of 2010 willallow middle and high school students visitingthe Louisville Science Center to view live heartsurgeries and interact with surgical teams as partof a project that seeks to boost interest inmedical careers and promote healthy lifestylesamong young people. Members of this committeewill develop content for this exciting newprogram. Meetings TBD.

Quality Improvement andPatient Safety committeeIdentifies nationally recognized peer-developed per-formance measures appropriate for patient care andencourages GLMS members to apply them. Also,demands the application of these measures by payersinstituting performance-based reimbursement modelsand seeks to inform the public about the importance of“true” quality measurements. Meets monthly – fourthThursday, 7 a.m. LM


he publication ofa meta-analysisearlier this yearon the efficacyof antidepres-sants in thetreatment ofdepression setoff a firestorm of

debate in the medical communi-ty as well as the lay public aboutthe possibility that these drugsmight be considerably less effec-tive than had been concludedpreviously. The meta-analysis,published in The Journal of theAmerican Medical Association inJanuary, and led by Jay C.

Fournier of the University ofPennsylvania, looked at six majorstudies of antidepressant drugsin which the active medicationwas compared with placebo andtreatment lasted at least sixweeks. The investigators con-cluded that the extent of effec-tiveness of antidepressant med-ication compared with placeboincreased with the severity ofdepression symptoms and couldeven be minimal or nonexistentin patients with mild or moder-ate symptoms. For patients withsevere depression, the medica-tions did prove decidedly benefi-cial, the study authors said. 1

Jesse H. Wright, MD, PhD

T

what Should we makeof the debate about whetherAntidepressants work?

AUGUST 2010 13

The findings of this study spilled outside the context ofprofessional conversation and into the lay media with promi-nent articles published in outlets including The New York Timesand Newsweek magazine. The cover of Newsweek pictured acrying pill with the caption, “Antidepressants Don’t Work: TheDebate over the Nation’s Most Popular Pills.” The commentaryin these articles suggested that physicians were prescribingthese drugs for patients who might not need them or benefitfrom them. Particular criticism was focused on using antide-pressant drugs in primary care settings in which the practition-er might not perform a full diagnostic assessment and mightprescribe antidepressants for mild symptoms.

So where does the truth lie? Should these findings changethe face of depression treatment or are the results beingoverblown in the lay media? I believe these findings have somevalidity, but I also believe that antidepressants should continueto play a fundamental role in the treatment of depression andanxiety disorders.

The JAMA study has prompted questions that could behelpful to us in determining not only how to treat our patientsbut how to better treat our patients. For example, is evidence-based psychotherapy underutilized? A large survey of primarycare patients found that people with depression preferred to bereferred for psychotherapy as compared to pharmacotherapy.2

Also, there is strong evidence that certain forms of psychother-apy for depression, especially cognitive-behavior therapy, areeffective and have robust relapse prevention effects. Yet,doctors may reach first for their prescription pad or check thesamples cabinet before recommending counseling.

Another option that might be considered is the use ofalternative therapies that could be useful either alone or incombination with medication or psychotherapy, particularly inthose patients with mild to moderate depression. A review ofalternative therapies in Current Psychiatry found good supportfor exercise as a treatment for depression with a more positiveeffect for high-energy aerobic activity or resistance trainingthan walking. 3 This review also concluded that yoga may havebenefits in reducing depressive symptoms. Although results ofstudies on Omega-3 and Omega-6 fatty acids have been mixed,a recent study found that consuming a Mediterranean dietreduced the risk for depression. 4

The JAMA article has been criticized on many fronts: forone thing, the investigators limited their analysis to only sixstudies and 718 patients. Also, in controlled trials patientsassigned to placebos typically are seen by a psychiatrist for 20to 30 minutes about every two weeks. The impact of these clini-cian visits, in which at least some psychotherapy is presumablyconducted, is unknown. An earlier meta-analysis looked at abroader range of medications than were covered in the JAMAstudy and a much larger number of subjects – more than25,000 in 117 randomized, controlled trials. Although the largermeta-analysis was not restricted to placebo-controlled trials, itprovided very useful clinical information. Four drugs – sertraline(Zoloft), mirtazapine (Remeron), escitalopram (Lexapro) andvenlafaxine (Effexor) – were found to be more effective thansome of their counterparts. The authors recommended that ser-traline might be the best drug to start with in treating moder-

ate to severe depression in adults because of its tolerability andgeneric status. Escitalopram and sertraline had fewer sideeffects than venlafaxine and mirtazepine. 5

One concern with all of the attention the JAMA studyreceived is that patients who may benefit greatly from antide-pressant medication or patients who could relapse if taken offtheir medications could be adversely affected by these findingsand the discussion that followed.

Patients with recurrent depression have high rates ofrelapse if they stop antidepressants, so we need to be cog-nizant about this risk when interpreting these findings. Patientswho have had relapses in the past when taken off their medica-tions are probably best kept on them. Likewise, if the depres-sion has lasted a long time and has impacted a person’s abilityto function sometime in the past, antidepressants clearly have aplace in the overall treatment plan.

The bottom line is, we have to be careful. For depressionwith a low or moderate level of severity, it would be reasonableto think of taking a watchful approach, possibly referring apatient for psychotherapy or prescribing useful lifestylechanges. But for patients with more severe depression, medica-tion may be a needed component of effective treatment. Whendepression is causing major problems in a person’s life, theweight of research evidence favors a combined approach ofantidepressants and psychotherapy.6 We must remember, evenwith the media hoopla, that the validity of treating thesepatients with antidepressants is not in question.

References

1. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, AmsterdamJD, Shelton RC, Fawcett J. Antidepressant Drug Effects andDepression Severity. JAMA. 2010 Jan 6; 303(1):47-53.

2. Dwight-Johnson M, Sherbourne CD, Liao D, Wells KB.Treatment preferences among depressed primary care patients.J Gen Intern Med. 2000 Aug; 15(8): 527-34.

3. Saaed S, Bloch RM, Antonacci DJ, Davis CE, Manuel C. CAM foryour depressed patient: six recommended options. CurrentPsychiatry. 2009; 8(10): 39-47.

4. Sánchez-Villegas A, Delgado-Rodríguez M, Alonso A,Schlatter J, Lahortiga F, Serra Majem L, Martínez-González MA.Association of the Mediterranean Dietary Pattern with theIncidence of Depression. Arch Gen Psychiatry. 2009 Oct; 66 (10):1090-8.

5. Cipriani A, Furukawa TA, Salanti G, Geddes JR, Higgins JP,Churchill R, Watanabe N, Nakagawa A, Omori IM, McGuire H,Tansella M, Barbui C. Comparative efficacy and acceptability of12 new-generation antidepressants: a multiple-treatmentsmeta-analysis. Lancet. 2009 Feb 28; 373(9665):746-58.

6. Friedman ES, Wright JH, Jarrett RB, Thase ME. Combiningcognitive therapy and medication for mood disorders.Psychiatric Annals. 2006; 36(5): 320-328.

Note: Dr. Wright, a psychiatrist, is the director of the Depression Center at the University ofLouisville.

LM

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inimally invasivesurgery becamepopular in the 1990s,with its application

expanded from mainly gynecol-ogical procedures to general surgery settingsincluding the laparoscopic cholecystectomy. Theadvent of the da Vinci robot and its use in prostatesurgery and for other indications made “minimallyinvasive” a buzz term in the late ’90s and early2000s. Nowadays, the attention of the mainstreammedia and lay public has turned away from mini-mally invasive surgery; these procedures areaccepted and expected for the surgical treatmentof many types of diseases and conditions. So, herewe are in 2010. Are there any circumstances underwhich an open surgery is preferable to a minimallyinvasive one? Certainly. Are we called upon, as sur-geons, to explain to patients why a minimally inva-sive technique may be best for them, or, converse-ly, to explain how a minimally invasive approachmight not be preferable? Yes, and yes. I thought itwas a good time to reflect on where we’ve comewith minimally invasive techniques, and where wehave yet to go.

The revolution in minimally invasive surgery has made it possibleto do many operations with a laparoscope or the robot, resulting insmaller incisions (Band-Aid-sized, in many cases), decreased pain andquicker recovery time that lead to a faster return to work and shortertime in the hospital. These procedures have turned inpatient operationsinto outpatient ones in some cases. It has even become possible to dosingle incision laparoscopic operations, through the belly button, forinstance, and in those cases there is no scar when we are finished. Thiscan be used for procedures to remove the gallbladder, spleen andappendix as well as for many other indications.

Looking at the body, from head to toe, there are minimally inva-sive options for almost all areas. For head and neck cancers, we canapproach the tumor through the oral cavity, with no external incision atall. Or, some procedures can be performed without a skin incisionthrough scopes inserted in the stomach, rectum or vagina. Proceduresof this type are known as NOTES (natural orifice transluminal endoscop-ic surgery) or TORS (TransOral Robotic Surgery).

A recent small pilot study looking at TORS showed that use of therobot can provide a magnified three-dimensional view allowing thesurgeon to see more than he or she could with previous trans-oral tech-niques. The patients in the study had clean surgical resection margins,no perioperative complications and no mortality due to the surgicalprocedure.1

In the chest, thoracoscopic surgery allows for the removal of partof the lung for the treatment of cancer, through three small incisionsand the use of a camera to guide the surgeon’s hands. Studies haveshown that this procedure can allow patients to heal faster and there-fore receive chemotherapy more quickly, which may improve their out-comes.2 Studies in this area have also shown that thoracoscopic lobec-tomy is associated with lower morbidity than its open counterpart. 3

In the heart, we are able to do minimally invasive valve surgery torepair or replace diseased heart valves.

In the abdomen, of course, we can treat common conditions likegastro-esophageal reflux with similarly favorable outcomes and shorterhospital stays than open approaches. Removal of tumors of thestomach is often done with a laparoscope, and we can laparoscopicallyresect the distal pancreas and spleen as well, which results in quickerrecovery time and less morbidity for many patients.

A recent study showed that liver resection can be done laparo-scopically with excellent results. Laparoscopic hepatic lobectomy wasshown to be associated with significant improvements in operativetime, blood loss, transfusion requirements, length of hospital stay andmorbidity, without compromising resection margins.4 And adrenalecto-my, which once was seen as a fairly extensive open operation, can nowbe done most of the time laparoscopically with an overnight stay in thehospital.

In the field of colorectal cancer, many questioned whether the out-comes in patients who were treated minimally invasively were as goodas those treated with an open surgical approach. The results of the 872-patient COST study (Clinical Outcomes in Surgical Therapy) showed thatrates of recurrent cancer were similar after laparoscopically assistedcolectomy versus open colectomy, although morbidity was less for thelaparoscopic group. This suggests that minimally invasive surgery is areasonable alternative to an open approach.5 In rectal cancer, studieshave shown that while minimally invasive techniques are promising,laparoscopic resection for mid to low rectal cancer is still investigationaland may not be as safe or effective as open surgical resection. 6

Robotic procedures, in which the surgeon sits at a control stationand controls robot arms that perform the operation, can be used inconfined places such as the pelvis, for hysterectomy, prostatectomy andrectal cancer operations, and this is being done routinely. Indeed, the

A Reflectionon minimallyInvasiveSurgery

Kelly McMasters, MD, PhD

m

Continued on page 16


overwhelming preponderance of evidence suggests that minimallyinvasive approaches in experienced hands can result in excellent out-comes for patients with less morbidity and shorter recovery time.

Of course, as with any relatively new technique, there is a learningcurve, and it is important that things progress slowly with a lot of train-ing and time spent in residency and fellowship programs educatingtrainees on the use of these techniques. With robotic surgery there aremany guidelines as to the credentialing a surgeon must receive inorder to use the robot on patients, and increasingly there will likely bemore stringent credentialing guidelines for the conduct of these typesof procedures.

In some patients, an open operation remains the gold standardand likely will for some time. For some operations, the size of the inci-sion is not what causes the risk of morbidity. While minimally invasivepancreaticoduodenectomy (Whipple operation) and esophagectomyhave been reported, these types of operations likely will be the last togain widespread acceptance with a minimally invasive approach. Inpatients with challenging surgical problems – retroperitoneal tumors,bile duct tumors, extensive adhesions from prior open operations andmany other situations – an open approach will still be preferable. Wemust be cognizant of the fact that though minimally invasive surgicaltechniques have exploded in the past nearly 20 years, they are notalways the answer, and each individual case must be discussedbetween patient and doctor.

There are minimally invasive surgical techniques in practice foralmost all areas of the body, and I have no doubt the list will increase astime goes on; as a surgical community, we need to keep studying out-comes and paying close attention to the training of surgeons in thesetechniques to ensure the safety and best possible outcomes for ourpatients.

References1. Park YM, Lee WJ, Lee JG, Lee WS, Choi EC, Chung SM, Kim SH.Transoral robotic surgery (TORS) in laryngeal and hypopharyngealcancer. J Laparoendosc Adv Surg Tech A. 2009 Jun;19 (3):361-8.

2. Petersen R, Pham D, Burfeind W, Hanish S, Toloza E, Harpole D,D’Amico, T. Thoracoscopic Lobectomy Facilitates the Delivery ofChemotherapy after Resection for Lung Cancer. Ann Thorac Surg 2007;83:1245-50.

3. Villamizar N, Darrabie M, Burfeind W, Petersen R, Onaitis M, Toloza E,Harpole D, D’Amico T. Thoracoscopic lobectomy is associated withlower morbidity compared with thoracotomy. J Thorac CardiovascSurg. 2009 Aug;138(2):419-25.

4. Martin R, Scoggins C, McMasters K. Laparoscopic Hepatic Lobectomy:Advantages of a Minimally Invasive Approach. J Am Coll Surg2010;210:627–636.

5. Nelson H et al. A comparison of laparoscopically assisted and opencolectomy for colon cancer. N Engl J Med. 2004 May 13;350(20):2050-9.

6. Row D, Weiser MR. An update on laparoscopic resection for rectalcancer. Cancer Control. 2010 Jan; 17(1): 16-24.

Note: Dr. McMasters is the Sam and Lolita Weakley Endowed Professor of Surgical Oncologyand chair of the Department of Surgery at the University of Louisville School of Medicine.

LM

Continued from page 15

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choosinga doctor

decorated andmuch awardedophthalmologistwas attending

the 55th year or emeraldjubilee of his graduation

from medical school. As a reserve officerin the Army, he had operated on friend andfoe alike in Iraq. From his successful practicein Michigan, he has headed county hospitalboards and presided over medical societies.He, aided by his wife, had organized andserved in almost yearly medical missions inAsia, South America and the Caribbean forthe past 40 years, giving the gift of sight topeople blinded by cataracts. For the reunion,he composed the class song and accompa-nied it with his violin. Life for him is anoyster that continues to yield pearls for hisand the enjoyment of others. He remembersthat in high school, he was challenged whenhe was told that he would never be as suc-cessful as others in his class. It seems theyhad underestimated his capabilities then.

On the last day of the reunion, he received an ominous callfrom his son. “Mom is in a coma in the hospital.” His wife hadjust been diagnosed with aneurysm of the posterior communi-cating artery of her brain. With the availability of modern tech-nology at his wife’s service, he hurried home, faced with thedilemma of who, among many doctors, he would trust toattend to his wife. This process, gone through by all patientsand their families, is always a critical issue. On his choice maydepend the eventual survival and quality of life of his lovedone.

He had to ponder,“Does the doctor have theproper expertise? Is hestrategically placed? Doeshe/she have the courage andfortitude to carry out thetreatment plans? Will he bewise and utilize resourcesadequately? Will he be reli-able and humble enough to

seek help when and if needed? Can he be counted on to be apillar of strength and adhere to the moral values of the family?”Although these seem to be too many expectations from aphysician, isn’t that what we look for in a doctor and isn’t thatwhat doctors strive for?

As a pebble dropped on a placid lake makes concentricripples that affect the whole surface, so does every decisionthat physicians make. On the wisdom of those decisions, theadvice they give, the skill of their hands, will depend theoutcome of a patient’s illness and in turn affect those who carefor that patient. There is very little room for error each andevery time. What an awesome responsibility and an honor to betrusted with such!

The doctor finally made his choice, his wife was beingtreated, some complications arose, but the die was cast. Thewaiting period is always long and excruciating. Every sign ofimprovement gives momentary hope. The family talks of thegood times, the happy times and the future. In the meantime,they wait.

For us, his friends and colleagues, as we witnessed newlyminted high school graduates (some our own kin), proudlymarch to receive their diplomas during the graduation monthof June, we have to trust that among these, some will take upthe challenge to be the physicians of the future. They havebeen molded in character and knowledge by their families,their teachers and the world around them. Although they havea long way to go, we hope that the seeds have been sowed toraise a new crop of dedicated humanitarians who will take careof the ills of tomorrow. They too will be selected and trustedwith the life of others someday, which is a good thing. We mustnot underestimate their potential.

Note: Dr. Oropilla is a retired psychiatrist.

REFLEcTIOnS

Teresita Bacani-Oropilla, MD

A

LM

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sthma remains the most

common chronic disease of child-

hood.1 In the U.S., asthma

accounts for more than 14 million school

days lost per year and is the third-

leading cause of hospitalization for chil-

dren less than 15 years old.2 In Kentucky,

the prevalence of asthma among middle

school and high school students is esti-

mated at 10 to 14 percent.3 At Kosair

Children’s Hospital, asthma is the leading

cause for emergency visits and hospital-

izations. Because of this significant mor-

bidity associated with childhood asthma,

Passport Health Plan in conjunction with

the University of Louisville established

the Healthy Hoops Kentucky Coalition in

2007-08.4

Ronald Morton,MD (pictured atleft), TammyPasko, RN, CPNP,Marcelline Coots,Nemr Eid, MD(pictured at left)

HealthyHoopskentuckyProgramEducateschildrenwithAsthma

A

Photos courtesy of Healthy Hoops kentucky

Screening room peak flow test.

AUGUST 2010 21

Many children and coaches do not know the relationship betweenasthma and exercise. Exercise can act as a trigger (something thatworsens symptoms) for the child with asthma, a condition known asexercise-induced asthma (EIA). The child may complain of chest tight-ness, dyspnea (shortness of breath) or wheezing associated with exer-cise. Typically the classic symptoms begin at the end or within five to 10minutes after stopping exercise (the refractory period).6 EIA can be diag-nosed through an exercise challenge test (a simple treadmill exercisechallenge). The diagnostic criteria for EIA on the exercise challenge testis at least a 15 percent drop in FEV1 (forced expiratory volume in onesecond) with exercise.7 Treatment for EIA involves a warm-up andcooldown period with exercise, pretreatment with a short-acting beta-agonist (i.e. albuterol) 15-20 minutes prior to exercise and possibly ananti-inflammatory medication.8 For individuals not improving with con-ventional treatment, referral to an asthma specialist may be appropriateto exclude an alternative diagnosis (such as vocal cord dysfunction) orhelp with management. The Healthy Hoops Kentucky programattempts to impart the basic knowledge about EIA to the participantsso they can participate in normal physical activities (physical education,sports or play) without fear of an “asthma attack.”

Healthy Hoops Kentucky is an innovative program developed togive children and their families the tools they need to take control oftheir asthma.5 These tools include the following:

1. Monitoring asthma, including asthma action plans 2. Proper use of lung function testing (spirometry or peak

flow monitors)3. Proper use of asthma medications4. The role of different asthma triggers5. Environmental tobacco smoke prevention6. Nutrition counseling 7. Maintaining a physically active lifestyle

Armed with this toolbox of knowledge and skills, the family and childwith asthma can feel confident to take control of their asthma.

Families attending the Healthy Hoops Kentucky Tip-Off Eventbegin the day with registration and completion of the health assess-

ment form. Once the form is completed, the family proceeds to thehealth screening area. The child and parent rotate through eight differ-ent skill stations with trained asthma educators and volunteers. First, abasic health screening is performed for each child including: height,weight, body mass index (BMI) and blood pressure reading. The rela-tionship between worsening asthma and obesity is well-known.9 Bymaintaining a normal BMI through proper diet and exercise, the childmaintains better control of symptoms and lung functions. The nutritionstation instructs the family on healthy food choices and the five basicfood groups. Nutrition information given to the family also emphasizesthe importance of healthy snacks and the avoidance of foods high infats and sugars. Second, the degree of asthma control is assessedthrough both lung function testing and the ACT (asthma control test).We also administer a standard asthma quality of life questionnaire.10

Participants meet with health care professionals who review theircurrent medications and develop a personalized written asthma careplan. They are provided a spacer and peak flow meter to take homeand instructed in the proper technique for both. At the final station, theasthmatic child and the parent or guardian sit down with a physicianspecializing in asthma management for one-on-one consultationreviewing their current plan of care and spirometry. The family is pro-vided copies of the child’s asthma action plan, spirometry and recom-mendations by the specialist to facilitate communication and follow-upwith their primary care provider. Any child with diminished lung func-tion is given a short-acting beta-agonist and spirometry is repeated toensure he or she is able to participate in the basketball clinic withcelebrity coaches. A free lunch is then provided to participants andtheir families.

One of the goals of the national asthma guidelines is that the childwith asthma maintains normal physical activity, whether through par-ticipation in P.E. in the schools, sports programs or regularexercise.1 The Healthy Hoops Kentucky programpromotes an active lifestyle through an

LM


The second annual Healthy Hoops kentucky Tip-Off Event last Septemberdrew more than 200 attendees to Louisville male High School.

Former University of Louisville basketball playercandyce Bingham and Healthy Hoops kentuckyHonorary chair darrell Griffith.


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afternoon basketball clinic conducted by local basketball coaches.Darrell Griffith, University of Louisville and Utah Jazz basketball star, hasacted as honorary chair of Healthy Hoops Kentucky. Darrell is a graduateof Louisville Male High School and led the University of Louisville to itsfirst NCAA basketball championship in 1980. He was drafted by theUtah Jazz in 1981 and played 11 years in the NBA. The basketball clinicteaches the participants basic drills for improved performance and self-confidence. One child commented, “I never knew I could participate insports with my asthma.” While participants interact with celebritycoaches, parents may attend a group meeting to discuss issues theydeal with in raising a child with asthma. The support group meeting ismoderated by a physician specializing in asthma management.

Healthy Hoops Kentucky begins its third year of fun and learning in2010. Children between the ages of 7 and 13 years are eligible to partic-ipate. This free event will be held at Louisville Male High School onSeptember 25 from 11:30 a.m. to 4:30 p.m. To register, volunteer or formore information, please call (800) 578-0603 ext. 78429 or visit theHealthy Hoops Kentucky website at www.healthyhoopsky.com.

References1. National Asthma Education Program (NAEP) 2007 Guidelines,National Heart Lung and Blood Institute.http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.

2. American Lung Association, Epidemiology and Statistics Unit,Research and Program Services. Trends in Asthma Morbidity andMortality. May 2005.

3. 2009 Kentucky State Plan for Addressing Asthma.http://chfs.ky.gov/nr/rdonlyres/23a767bb-66d2-4f3d-a060-c81f8f5a36c3/0/2009stateplanforaddressingasthmainkentucky.pdf.

4. Healthy Hoops Kentucky website http://www.healthyhoopsky.com.

5. Morton R, Coots M, Vance K, Legleiter J, Eid NS. Basketball ClinicEducates Asthmatic Children. The Physician and Sports Medicine June2009. 37 (2): 112-119.

6. Kaelin M, Morton R, Eid N. Coaching the Asthmatic Athlete. Strengthand Conditioning Journal August 2002. 24 (4):57-60.

7. Guidelines for Methacholine and Exercise Challenge Testing—1999Am J Respir Crit Care Med 2000. Vol 161. pp 309–329, Internet address:www.atsjournals.org.

8. Hallstrand TS, Moody MW, Wurfel MM, Schwartz LB, Henderson, Jr.WR, Aitken ML. Inflammatory Basis of Exercise-inducedBronchoconstriction Am J Respir Crit Care Med 2005. Vol 172. pp 679–686.

9. Beuther DA, Weiss ST, Sutherland ER. Obesity and Asthma Am J RespirCrit Care Med 2006. Vol 174. pp 112–119.

10. Juniper EF, Guyatt GH, Cox FM, Ferrie PJ, King DR. Development andvalidation of the Mini Asthma Quality of Life Questionnaire. Eur Respir J1999; 14:32-38.

Note: Dr. Morton is an associate professor in the University of LouisvilleSchool of Medicine’s Department of Pediatrics, Division of PulmonaryMedicine. Dr. Eid is professor and chief of the Division of PulmonaryMedicine. Dr. Morton, Dr. Eid and Tammy Pasko practice with PediatricPulmonary Medicine PSC. Marcelline Coots is Passport Health Plan’s programmanager for Healthy Hoops Kentucky.


LM

AUGUST 2010 23

24 LOUISVILLE MEDICINE

BOOk REVIEw

LM

Waking Up Blind is the account of apreeminent eye surgeon whose actionsresulted in horrifying medical problemsfor his patients. It is the detailed chronol-ogy of the practice and ultimately disas-trous choices and consequences of aphysician, no less the chairman of the

Department of Ophthalmology at Emory University, who out ofgreed, avarice and a total disregard for his patients’ welfarestepped way over the line of ethics, professionalism, morals andthe law.

The book factually describes the period from 1982 to 1986and how a nationally respected medical institution sought tocover up the events, even falsely accusing and withdrawingsupport from some of those who were quite vocal about thetravesty that was occurring in plain view.

Dr. Tom Harbin’s book chronicles the subsequent lawsuitsfrom their origins to their outcomes. Dr. Harbin relies on courtpapers, tape-recorded conversations, interviews and personalobservations to shine a light on a truly shocking story about theprofession of medicine.

Dr. Harbin certainly put himself on the line insofar as accu-racy of the events is concerned. He really had to in order not toincur a libel suit against himself. One must admire such an indi-vidual for his boldness in detail. The author of this review spoketo Dr. Harbin at some length and received the impression thathis outrage was, and still is, great concerning the apathy andlack of “stomach” on the part of the university to address andget rid of one of the largest moneymakers in the Emory system.

Although the title of the book catches one’s eye and imagi-nation, the book is not about an aberrant ophthalmologistoperating on the wrong eye and causing blindness. It is not justabout greed, egocentrism, lying and working outside of the

standard of care. It is about a failed systemwith all of its checks and safeguards. In short, “Who guards theguards?”

The purpose in reviewing the book is to bring to the fore-front the main intent of the author. In order to give this somerelevance, the last two paragraphs of the last page are herequoted:

“These events happened over twenty years ago at an institution that has changed significantly. Emory is an excellent and well-respected center. Then why write this book? I wanted to document in full detail what happens when leadership fails to respond to people bringing credible warnings about existing problems. The events described here could happen at any university or in any company, public or private. The current headlines bear witness to the many consequences of other leaders ignoring warnings of problems similar to those in this book.So what should be done? How can a leader winnow out the significant problems from the many issues he or she hears about every day? How should investigations of such problems proceed? How do you balance lapses of judg-ment and character with the many positive attributes of a person? When do you decide that the bad outweighs the good and someone has to go? What if you are low on the pecking order and see problems? How do you report wrongdoing?”A physician, albeit the chairman of a department at a major

teaching program, is described. However, the same scenario isrepeated daily not only in academia but in non-academic prac-tice as well. We all have seen it. We all abhor it. Are we to con-tinue to bury our heads in the sand? Are we to stand by asrighteous accusers are admonished, punished and evenexpelled?

This book is of consequence to all of us who attempt topractice medicine in an ethical and professional manner, withthe creed that “Patient welfare comes first.” This review and thisbook should serve as a warning to those who transgress.

Note: Dr. Florman is an assistant professor in the University of Louisville School ofMedicine’s Department of Surgery. He practices Plastic Surgery and Otolaryngology-Head and Neck Surgery with University Surgical Associates PSC.

Reviewed byLarry D. Florman, MD

BY toM HARBin, MdPublisher: Langdon Street Press, 2009

waking Up Blind:Lawsuits Over Eye Surgery


In REmEmBRAncE

Joseph Michael Dew, MD. April 16, 1932-January 16, 2010.University of Louisville: A&S 1958; Medical School 1962. He issurvived by Betty Dew, his wife of 58 1/2 years, his son, KevinDew, MD, his daughter, Michele Dew Hottinger, 10 grandchil-dren and five great-grandchildren. He is preceded in death byhis son, Michael Eric Dew. These are the facts he would wantstated, nothing more. I, however, was asked to flesh out thestory.

I had to ask myself which J.M. Dew should be remembered.The one who lost his father at age 4 and spent his early years inand out of St. Joseph’s home at the height of the Depression?He grew up to serve on the foster care board for the LincolnTrail region in Kentucky.

There was the teenager who creatively recalculated his agein order to join the Army. He retired as lieutenant colonel after37 years of active and Reserve service.

How about the young man who worked multiple jobsduring college and medical school to pay tuition and supporthis growing family? He slept in his car because a drive homewould take too long. This man was the scoutmaster who disap-peared from campouts to make rounds yet seemed to alwaysmake it back for the evening campfire, skits and sing-a-longs.How can I forget his off-key tenor?

I would be remiss to forget the one who would spend anhour with a patient if needed or who would attend a sick childor sew up a leg in the middle of the night. And I also couldn’tforget the guy who would make bunny ears on the Band-Aidsof children or draw funny faces on tongue depressors. ManySaturdays he and I traveled the then-gravel roads of HardinCounty while he made house calls. He’d toss me a medicaljournal and tell me to read something and report back to him

when I was finished. It was quite a game to see if I could pro-nounce the words correctly, let alone understand anything ofthe article!

And how can I forget the fellow who loved reading andinstilled that love in his family? He taught us early on to learn asmuch as we could about as many things as possible. He comesto mind when some arcane piece of trivia helps me make adiagnosis or recognize a problem with a patient – or an auto-mobile for that matter. Dad embodied the Latin meaning ofdoctor: teacher. He never missed an opportunity to impartknowledge to anyone who would listen.

The phrase “bittersweet” certainly applies to memories ofmy father. There was my youthful intolerance of the man whohad no father of his own and flew by the seat of his pants whendealing with me. His attempts to impart knowledge and experi-ence were viewed by me to be examples of how I could neverbe good enough for him. Far too late in life I realized that thesemessages were admonishments to always strive to be better –that there is always room for improvement. He was being afather in the truest sense: sharing experience, strength andhope with his son. I find myself behaving in a similar mannerwith my own children.

Every patient I encounter, each moment with my children,every book I read or fishing knot I tie and all things Irish serve asreminders of my dad.

Then there was the man who deeply loved his Lord and hisChurch. He was ordained Permanent Deacon in the CatholicChurch in 1978. Recent events in the Church merely served toreinforce in him that we should love and honor the principlesand attempt to forgive the humans that failed to live up tothem. “They crucified the only perfect human there was!” washis frequent statement.

Then there was the man who proudly donned cap andgown and walked with me at my medical school graduation. Iremember this one well. I also remember the man lying in hisdeathbed whose last words to me, and to anyone, were “I loveyou too, buddy.”

I especially remember that man.

_ Kevin Dew, MD

LM

JoSEPH M. dEW, Md (1932-2010)

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AUGUST 2010 29

Baker AA, nauta H, Hodes, J. Endoscope-only surgical resec-tion of a large bi-hemispheric supratentorial epidermoid tumorthrough an 18mm trephination. Journal of the KMA. 2010 Jul;108(7):207-211.

Bower M, Jones w, Vessels B, Scoggins c, martin R. Role ofesophageal stents in the nutrition support of patients withesophageal malignancy. Nutr Clin Pract. 2010 Jun;25(3):244-9.PubMed PMID: 20581317.

Bowling JT, Reuter NP, martin Rc, mcmasters km, Tatum c,Scoggins cR. Prior biliary tree instrumentation does not pre-clude hepatic arterial therapy for malignancy. Am Surg. 2010Jun;76(6):618-21. PubMed PMID: 20583518.

dashti SR, Spetzler RF, Park MS, Stiefel MF, Baharvahdat H,McDougall CG. Multimodality treatment of a complex cervico-cerebral arteriovenous shunt in a patient with CHARGE syn-drome: case report. Neurosurgery. 2010 Jul;67(1):208-9; discus-sion 209. PubMed PMID: 20559068.

Dickinson A, Qadan M, Polk Hc Jr. Optimizing surgical care: acontemporary assessment of temperature, oxygen, andglucose. Am Surg. 2010 Jun;76(6):571-7. PubMed PMID:20583510.

Duerinckx J, wolff Tw. A new concept for thumb basal jointarthrodesis: the V-shaped osteotomy. Tech Hand Up ExtremSurg. 2010 Jun;14(2):73-6. PubMed PMID: 20526158.

Franklin GA, Santos AP, Smith Jw, Galbraith S, Harbrecht BG,Garrison Rn. Optimization of donor management goals yieldsincreased organ use. Am Surg. 2010 Jun;76(6):587-94. PubMedPMID: 20583513.

Harbrecht BG, Smith Jw, Franklin GA, miller FB, RichardsonJd. Decreasing regional neurosurgical workforce-a blueprint fordisaster. J Trauma. 2010 Jun;68(6):1367-72; discussion 1372-4.PubMed PMID: 20539182.

Lesch DC, yerasimides JG, Brosky JA Jr. Rehabilitation followinganterior approach total hip arthroplasty in a 49-year-old female:a case report. Physiother Theory Pract. 2010 Jul;26(5):334-41.PubMed PMID: 20557264.

mcmasters km. Honor, duty, and purpose in surgery. Am Surg.2010 Jun;76(6):555-62. PubMed PMID: 20583508.

Roman J. The Southern Society for Clinical Investigation 2010President's Address: Is it time for evolution? Am J Med Sci. 2010Jul;340(1):3-4. PubMed PMID: 20610955.

NOTE: GLMS members’ names appear in boldface type. Most ofthe references have been obtained through the use of aMEDLINE computer search which is provided by nortonHealthcare medical Library. If you have a recent referencethat did not appear and would like to have it published in ournext issue, please send it to Alecia Miller by fax (736-6363) or e-mail ([email protected]). LM

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Sotiropoulos, George Peter (21364)Christina M. SotiropoulosUL Pediatrics 571 S Floyd St Ste 300 40202629-7212Pediatrics 87 Saint Louis U 82

van Berkel, Victor Henry (21444)Robin201 Abraham Flexner Way Ste 1200 40202561-2180Thoracic Surgery Washington U 03

Virshni, Kingal (21387)Kusum Yadav231 E Chestnut St 40202Grant Medical College 99

Warren, Jamie A (21335)Jennifer (Jen)225 Abraham Flexner Way Ste 30240202587-7874U of Louisville 04

Kelly, Thomas (21272)Kenita3118 E 10th St Jeffersonville IN47130812-285-4585U of Cincinnati 04

Krueger, Michael Robert (21497)Michelle Krueger1113 Woodland Dr ElizabethtownKY 42701270-737-4343Medical College of Wisconsin 04

Haulk, Ryan Lee (21339)Vanessa6400 Dutchmans Pkwy Ste 25040205587-9660Nephrology Internal Medicine 08 U of Louisville 05

Hooker, Robert L (21230)Patricia Hooker5129 Dixie Hwy Ste 100 40216447-8786Radiology 09 Medical U of South Carolina 04

Morris, Marvin Elston (21437)Venus401 E Chestnut St Unit 71040202583-8303Boston U 00

Pendleton, Amber Lynette (21346)Michael Eli PendletonUL Pediatrics 571 S Floyd St40202629-8901Pediatrics 08 U of Kentucky 05

Ramsey, III Christian Norman(21485)April Ramsey3900 Kresge Way Ste 41 40207899-3623U of Kentucky 01

Rueff, Daniel E (21317)Leslie13151 Magisterial Dr Ste 20040223587-1236U of Louisville 04

Smith, Clarence Edwin (21248)Brooke Smith5129 Dixie Hwy Ste 100 40216447-8786Radiology 09 Vanderbilt U 04

Biscette, Shan M (21395)401 E Chestnut St 40202271-5999U of Texas 99

Fasheh, Rami George (21389)3950 Kresge Way Ste 203 40207895-8911Family Practice 09 U of Dublin/Trinity College 04

Fraig, Mostafa M (21466)Lamia M. Elsayed530 S Jackson St 40202852-1648Cytopathology 99 Pathology 98 Cairo U 90

Garner, Kamara E (21332)Trent A. Garner6801 Dixie Hwy Ste 133 40258937-3864Family Practice 06 U of Kentucky 02

Guillory, Robin Kelly (21377)Victor van BerkelUL Anesthesiology 530 S JacksonSt Rm C2A01 40202852-5851Washington U 02

Gump, William C (21275)Paige Raabe Gump210 E Gray St Ste 1105 40202583-1697Neurological Surgery U of Louisville 01

Halton, Lori (21284)Charles234 E Gray St Ste 850 40202585-1735U of Louisville 04

GLMS would like to welcome and congratulate the following physicianswho have been elected by Judicial Council as provisional members.During the next 30 days, GLMS members have the right to submit writ-ten comments pertinent to these new members. All comments received

will be forwarded to Judicial Council for review. Provisional membershipshall last for a period of two years or until the member’s first hospitalreappointment. Provisional members shall become full members uponcompletion of this time period and favorable review by Judicial Council.

Candidates Elected to Provisional Active Membership

wE wELcOmE yOU

Candidates Elected toProvisional AssociateMembership

Mem

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ip

AUGUST 2010 31

Burke, Anna Marie (30015)UL Medicine 530 S Jackson St40292852-7041Internal Medicine Midwestern U 10

Case, Jennifer R (30020)Obstetrics Gynecology U of Louisville 10

Chism, Amanda Beth (30042)John Chism550 S Jackson St 40202852-4277Pediatrics U of Louisville 10

Chojecka, Pola Alida (30028)401 E Chestnut St Ste 580 40202813-6801Neurological Surgery Jagiellonian U 10

Cothron, Kyle Jordan (30002)Internal Medicine U of Louisville 10

Creeden, Catherine P (30055)Michael CreedenInternal Medicine U of Cincinnati 09

Samonte, Francis Ravago (18026)Maria SamonteChildren Hospital Boston HarvardMed School Pediatrics De La Salle U 95

St. Hill, Charles Randolph (21390)Andrea M. St. Hill401 E Chestnut St Unit 710 40202583-8303U of Southern California 05

Attum, Basem Abdulla (30098)General Surgery U of Louisville

Auer, Ronald Thomas (30074)Jennifer Auer210 E Gray St 40202Orthopaedic Surgery U of Cincinnati 10

Bavle, Abhishek Amar (30027)Aishwarya KulkarniPediatrics Kempegowda Institute of MedSciences 09

Bickel, Scott Graham (30099)Katherine BickelPediatrics U of Louisville 10

Bitar, Maya (30025)301 E Muhammad Ali Blvd 40202Ophthalmology Saint Joseph U 06

Brown, Deanna Gardenhire(30033)Stephen BrownInternal Medicine U of Tennessee 10

Brown, Jordan Taylor (30004)NicoleEmergency Medicine

Brunett, David Wesley (30032)Melanie BrunettUL Emergency Medicine 530 SJackson St 40292ER U of Texas Med School 10

Livesay, Jr Kenneth Wayne (17897)Meg Livesay, DMD300 Middletown Park Pl Ste B40243254-3818Oral Maxillo.Surgery 04 U of Louisville 98

Stephens, Kendal Kay (16810)Charles Austin Stephens207 Sparks Ave Ste 301Jeffersonville IN 47130812-280-7063Obstetrics Gynecology 09 U of Louisville 03

Abreu, Cristy (30070)305-773-7881Family Medicine Ross U

Akintola, Kemisola Omoseye(30089)571 S Floyd St Ste 412 40202629-8828Pediatrics Semmelweis U 09

Ali, Muhammad K.S. (30048)Aniqa201 Abraham Flexner Way 40202Family Medical Dow Med College 90

Alnabki, Ziad (30076)Nour Aborchid267-241-2460Internal Medicine Damascus U 09

Asad, Ismat Ara (30007)Asad I. QuasemFamily Medicine

Mem

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Candidates Elected toProvisional In-TrainingMembership

Mem

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ip


he long lazy days ofsummer are sooncoming to an end. Themornings are begin-

ning to cool with a hint ofautumn dew. Colorful and fra-grant gardens and flower bedswill send out their last bloomsbefore the coolness of fall stillstheir beauty. For those of youwho have children, there is adefinite hustle and bustle ofpreparing for the beginning ofschool with the purchase ofnew school supplies andschool clothing. Children onceagain must get into theroutine of going to bed earlyand getting up early. We asparents take a deep breathand express a sigh of reliefknowing that our children willfind other words in theirextensive vocabularies besidesthe dreaded “I am bored.”

Excitement builds with the beginning ofeach new school year as our children stepinto the world of the unknown with a newgrade, new teacher and new friends. Oldfriendships, which have become dormantover the summer break, will becomerenewed. While we were once those excitedchildren, the concept of a new beginning is

not foreign to us as adults. For those of uswho belong to the Greater LouisvilleMedical Society Alliance, this is a year ofnew beginnings as well as a time to renewdormant friendships. We want to reach outto our dear faithful members and invite newmembers in hopes that we will fulfill oneaspect of our mission statement – toencourage support among doctors’ families.We want to support our families by extend-ing a “Helping Hand.” This service commit-tee reaches out to our medical familiesduring their time of need or special help. Asimple card, a gentle phone call or food pro-vided for loved ones is always appreciated.For our new residents’ spouses, the GLMSAlliance is hoping to provide support andguidance from those who have experiencedthe many facets of transition from studentto resident to attending physician. It is fre-quently a time of uncertainty and if one isnew to the area, we want to provide anexciting transition into the great city ofLouisville. For our seasoned veterans of theGLMS Alliance, we look forward to yoursupport and continued vigor in the directionwe are headed.

With the dawn of a new school year, theGLMS Alliance hopes to promote healtheducation among our area schoolchildren.We are seeking ways to educate our childrenin the area of science and safety. Underthe new leadership and direction of Dr.Kimberly Alumbaugh, the GreaterLouisville Medical Society is reachingout to our children to promote a newprogram in conjunction with theLouisville Science Center called Pulse ofSurgery. The GLMS Alliance hopes toencourage our community “as a familyof medicine” to promote this wonderfuleducational opportunity by supportingGLMS and this endeavor to encourageinterest in the sciences.

We also want to serve our communi-ty through our various programs. Wewill continue to support The HealingPlace and Gilda’s Club of Louisvillewhile looking at other avenues to reachout. I believe we should bond togetherin an effort to grow in ways we haven’timagined until now. Help us to growand live up to our title “Alliance” and

our mission statement: to encouragesupport among doctors’ families and topromote health education and communityservice.

My vision and goal for the 2010-2011GLMS Alliance is to purposefully and mean-ingfully strengthen the bond of support weserve for GLMS members and families whilealso joining in the efforts of GLMS topromote the science, art and profession ofmedicine to the community.

I am encouraging each and every one ofyou to provide your own unique support bycreating at least one idea for a new yearlyprogram to the GLMSA on how we cansupport our physician spouses by support-ing GLMS. Please submit your ideas to meby e-mail at [email protected]. Eachidea will be carefully reviewed and consid-ered.

The long lazy days of summer are comingto an end. However, for GLMS and the GLMSAlliance, it will be an exciting new year withnew friends, renewed friendships and newleadership. I believe that we, as members ofboth organizations, will breathe our ownsigh of relief and state, “We are not bored!”

Note: Lisa Sosnin is a registered nurse and is thepractice manager for her husband’s solo practice,Bluegrass Community Family Practice, inBardstown.

Lisa Sosnin, RNGLMSA President

ALLIAncE nEwS

TLM

AUGUST 2010 33

See-thru is not Alwaysobscene

But “transparency” is the new buzz-word in health reform, and if you’re ahealth insurance exec trying to hide hiscompany’s profit margins in every waypossible, it’s practically pornographic.Three U.S. House bills would attempt totackle the problem of comparing costs ofcare among various plans and amonghospitals and doctors, but it’s likely they’llnever get out of the House Energy andCommerce’s Subcommittee on Health. Itschair, Rep. Frank Pallone (D-N.J.), held asingle hearing on these bills on May 6,but said he’s “afraid that patients wouldfail to follow their doctors’ advice, insteadchoosing the cheaper treatment.” He’salso worried that publishing what healthcare actually costs will lead to standardi-zation of prices and stifle competition, sohe refused to allow a vote.

One of the intended benefits ofhealth care reform was to make the com-parison of hundreds of various insuranceplans web-based, rapid, comprehensiveand user-friendly. Companies that partici-pate in the national insurance exchangepool must by 2014 post the extent ofpatients’ cost-sharing, includingdeductibles, co-pays and effect of coin-surances. But current talk in Washingtonhas focused on what else would beextremely handy for the consumer toknow, if the intent is to compare oneinsurance company with another. If Imade policy, I would require eachcompany to post its rate of denials for

coverage of each brand-name medicationand to disclose the number of formsrequired of the physician even to ask forsuch coverage. I want to know how oftenpatients’ health coverage has beenabruptly dropped and how often rateshave been raised in response to a newdiagnosis, for instance of breast or ofprostate cancer. I want to know howoften each company denies claims forimaging, for procedures and for officevisits. I want data on its speed of payingclaims and on how easy it is to submitclaims that are rapidly paid, i.e. its “hasslefactor” rating from its local medicalsociety. Finally, I want to know how well itpays me compared to other companiesand to Medicare, for the same services.

Price is the focus of the bills nowstalled in the House subcommittee. Rep.Steve Kagen, MD (D-Wis.), along with 54Democratic co-sponsors, wants everyprice posted for every single health caretransaction. That way, he says, we canfind out what we are paying and whatthe person next to us is paying. This ideaso far has made health care executives onboth the provider and the insurer sideclutch their throats in horror. How manytimes did we read in The Courier-Journallast summer that Anthem and Nortonutterly refused to disclose the actualdollar amounts of anything? No, no. “Thatwould affect our contracts with otherentities,” said both sides. Information ispower. I have no idea how much my ownoffice overhead truly is in relation to theoverall Norton overhead and whether mypay is proportionate to what I contributein patient care, or not. It’s a black box formost employed physicians, and thedreaded “proprietary information” policyof all commercial health insurers pre-cludes open discussion in any forum.

Quality, not price, matters most of allin taking care of patients. Most measures

of quality are arcane and inherently com-plicated by how sick patients are to startwith, how early or late they present, howmotivated they are and whether theylead healthy lives, how experienced theirdoctors and nurses are, the degree ofexcellence vs. decay of available technol-ogy, and how well the medical andnursing staffs are supported by adminis-trators. Quality is something that evenilliterate patients can usually recognize atthe moment of care, but understandingMortality and Morbidity comparisons forcardiac bypass reports from variousdoctors and hospitals requires more effortand education. Everybody can read adollar sign, however, and if all we have tocompare plans and doctors and hospitalswith are dollar signs, that’s still a lot moreempowering than total ignorance.

Posting universal prices will no doubtlead to a lot of uncomfortable officeencounters, until everyone is used to it.Honesty is the best policy, and just as noone expects Kentucky Bison burgers tocost less than White Castles, no oneexpects a good doctor to cost less than aKroger clinic. Without accessible andunderstandable measures of quality, priceis a very valid measure to begin with.Patients would soon learn what freedomof choice they could afford. Knowing thetrue cost of bad health habits is often astrong influence on improving them.

Right now the emperor has clothes,in fact the cloak of invisibility. I’d like toshred that cloak and use actual financialdata to support the buyers and users ofhealth insurance. I’m pretty sure the cut-throat competitive spirit of the Americanmarketplace would eventually benefit theconsumer, if only he knew what, and howmuch, he was paying for.

Note: Dr. Barry practices Internal Medicine withNorton Community Medical Associates-Barret.

Mary G. Barry, MDLouisville [email protected]

LM


The views expressed in doctors’ Lounge or any other article in this publication are notthose 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 [email protected] or maybe submitted online at www.glms.org. The GLmS Editorial Board reserves the right to choose what will be published.

SPEAk yOUR mInd


Health Reform andindependence

We are nowblessed or cursed,depending on yourviewpoint, with a new

health care law. Independent of the costsin terms of taxes, choice, etc., there aresome things that are rather clear. Thepractice of medicine will by necessitychange, whether for the better or for theworse. Pilot programs based on the ideaof integrated health care systems andcombined payments for hospital andphysician services will put the clearadvantage to those physicians andgroups of physicians who are aligned in afashion to communicate regardingpatients, testing, evaluation of patientrisk, medical quality and outcomes oftreatment and preventive measures.

In fact, Medicare has toyed for anumber of years with the idea of payingfor so-called episodes of care, rather thanfor individual services, much as there areglobal fees for surgical procedures. Theexpansion of that concept to its extremewould mean that if a patient has a diag-nosis, the system responsible for thatpatient would receive payment for his orher care calculated in some manner torepresent so-called “best practices,” inde-pendent of the types of services providedin an individual case.

Obviously, such a transition can’thappen overnight, but it is clear that agradual transition to such a system ofpayment would encompass a number ofsequential changes in the manner inwhich medical and surgical services arepaid.

One first step is to give preferentialpayment or treatment to a system thatintegrates information such as patienttesting and diagnostic information inorder to avoid duplication. Another stepis to pay both the facility and the physi-cian in a single payment and let the twoparties sort out the division of thepayment. It seems clear to me where thebulk of such payment will go, given thecurrent imbalance of power betweenphysician and hospital.

For many years, Louisville wasblessed with a medical practice environ-ment that could easily be described asfriendly and competitive, in that those ofus in practice obviously were competitivewith one another, each trying to best theothers in our specialty in attracting and

keeping patients, staying current withmedical science and technology, andgenerally staying ahead of the field, so tospeak. However, the competition wasfriendly, we were all on the same levelplaying field, and when one of us was inneed, the remainder came in to supportthat person, whether it was illness, acci-dent or simply a bad turn of events. I canrecall a number of physicians staffing acompetitor’s office when he was criticallyill for a period of time, making sure he didnot lose his patients and making sure theincome stayed in that office.

Others have already written aboutthe Balkanization of medicine in Louisvilleand elsewhere, so I need not repeat that.The friendliness goes out of competitionwhen the playing field is no longer level,so that some are given advantage overothers. That is clearly the case inLouisville at the present. The largeplayers, hospitals and hospital systems,so-called “not-for-profits” (clearly a mis-nomer), now employ physicians innumbers previously only seen in hugemultispecialty clinics. Those employedphysicians are given significant advan-tage in terms of payment, coverage,expenses, etc., in comparison to inde-pendent (non-hospital-employed) physi-cians, a situation made even more egre-gious when independent physiciansrealize that it is their own tax dollars thatsupport their competition. Medical staffleadership, theoretically independentfrom administration, is largely, if notentirely, made up of employed or con-tracted physicians, obviously beholden tothe same administration that signs theirpaychecks: so long to the independenceof the medical staff.

It is clear that the hospitals andsystems that employ such large numbersof physicians still rely on the independentphysicians to make their bottom lineprofitable. They simply do not employenough physicians to make the systemwork based on those admissions andservices alone. Yet those independentphysician voices are rarely heard, andeven more rarely heeded. Additionally,when payment systems change as sug-gested above, physicians will be left tothe decisions made by hospitals when itcomes to payment for their services.

We now have an opportunity asindependent physicians to both strength-en our position at hospitals and, just asimportantly, an obligation to our futureas physicians to realign ourselves in themanner of an integrated system if we areto survive in the new health care era.

Independent physicians must bandtogether into integrated organizations to

develop the types of quality systems,disease management systems, practiceeconomic systems and integrated healthdelivery systems required by both thenew health care arena and evolving con-cepts of medical practice. Many of youmay think that I am suggesting reinvent-ing TPA … a good idea at the time, but afailure eventually for a number of reasonsindependent of the goals and talents ofthe individuals who spent so much timeand effort toward that organization. Anew structure and paradigm is needed …one that draws on the strengths of theindependent physician practice but com-bines the power of numbers and infor-mation technology to both improvepatient care in a more economical systemof delivery of health care and provideassurance of the high quality our patientshave come to rightly expect from theirindependent physician. It is no longernecessary simply to band together to beable to share information regardinginsurance contract offerings and advice, itis necessary to be able to legally negoti-ate with not only insurance carriers, butpotentially hospitals and hospital systemsas well. The only way this can be done isthrough a true integration of practiceswith one another in a manner that is notseen as simply protective of the physi-cian’s ability to charge a higher fee for aservice. Such integration can and shouldlead to better care, better integration ofcare, less duplication of effort, greaterefficiency and easier availability topatients. It will mean a radical change inthe manner in which we as physiciansinteract and, by necessity, will meanmore interdependence with one another.

I propose a series of meetings overthe next few months to discuss these andrelated issues and the development of atleast one independent physician practiceintegrated system of health care … avirtual multi-specialty clinic if you will, tostand toe to toe with the largest systemof employed physicians in the area and toprotect our patients’ access to highquality and cost-efficient care whileensuring the survivability of the inde-pendent physician practice in this com-munity.

Without such an effort, it is clear tome that the present generation will bethe last one that involves independentphysicians in this community to anyextent. If this is a good idea, then theresult will be positive. In my opinion, thiswould be a disaster for physicians and,more importantly, their patients to betotally reliant on the decisions of a corpo-rate entity to decide on the location,types of services, medications available,

Larry P. Griffin, MD


AUGUST 2010 35

Moving from thecurative and thePalliative Model ofMedical care to anew universal Health care Model

The prevailing overemphasis on thecurative model of medical care may bepresently viewed by many in governmentas the shortcoming of our uniquelydisease-oriented American health andmedical care system. Present fundingsources have suggested that more end-of-life education and training is requiredand that our health care system is inade-quately prepared to care for dyingpatients based on the prevailing curativemodel of medical care in our health caresystem. A brief and nostalgic farewell visitto the curative and palliative models ofhealth care may be in order before begin-ning our consideration and speculationon the new universal model of healthcare that I believe will surely result in agovernmental single-payer system forour country.

The curative model of health carehas as its primary and somewhat narrowfocus the noble goal of cure regardless ofthe cost to the patient or to the financialimpact on the present health caresystem. There is no disagreement that inthis model the eradication of the cause ofillness or disease and the reversal of thenatural history of disorders are appropri-ate goals and objectives for Americanmedicine. Medicine, of course, has manyother important goals that include pro-moting health, preventing illness andinjury, restoring functional capacity,avoiding premature death, relieving suf-fering and caring for those terminally illwho cannot currently be cured.

The curative model of health care inthis country has characteristics thatinclude an inherent set of assumptions,attitudes and values. Analytic and ratio-

nalistic thinking are certainly central tothis model. Clinical concerns in thismodel are often approached as puzzlesto be solved or occasions for scientificinquiry. The object of analysis is often thedisease process and not necessarily thepatient. Symptoms at times are treated asclues to diagnosis and therefore notworthy of medical treatment. The cura-tive model values scientific data over allother types of information. Laboratoryresults and imaging are valued over thepatient’s perceptions, and anything sub-jective, immeasurable or unverifiable isgenerally devalued. Treatments aredirected toward the underlying cause ofillness in the curative model rather thanto the outward manifestations of diseaseas expressed by the patient. The patient’sperceived quality of life may be viewed assubjective in the curative model. Whilebrain physiology has not been elucidatedin great detail to date, the curative modelseems to belittle any phenomena notexplainable by science. Psychologicalfactors may be regarded as trivial or evenspurious. When facts are differentiatedfrom feelings in the curative model, thebody may potentially become dissociatedfrom the mind. In an effort to curepatients, the curative model tends to per-ceive patients in terms of their compo-nent parts in the hard science of mole-cules, cells and organ systems. Dopatients then become repositories fordisease instead of whole persons? Domedical ailments become all but separat-ed from the persons who serve as theirhosts?

A hierarchical structure usually if notalways accompanies the curative model.The physician who commands the mostbiomedical knowledge commands themost authority and therefore determinesto what degree other staff members canquestion decisions and the course oftherapeutic action. The curative modelassumptions are that clinical investiga-tions can never be complete until patho-physiology is understood, diagnoseddisease is treated, and that diagnosis andtreatment are always possible, necessaryand desired.

Does our death-averse society valuea good death? The curative model con-flicts with the notion of a good death.Cure, then, must be the ultimate goal,and death is the ultimate failure in thecurative model. Therefore, patientswhose disease cannot be treated,stopped or slowed are untreatable andbeyond medical help. This unfortunatelymay place the care of such patientsoutside the purview of medical care.

The palliative care model supports avariety of goals including the relief of suf-fering, the control of symptoms and therestoration of functional capacity. Thismodel supports neither the exclusivegoal of cure nor the hastening or pro-longing of death. The treatment of painthat cannot be verified or even explainedis still a legitimate goal of palliative medi-cine and of good health care.

The palliative care approach isaccepting of and embraces the limita-tions of medical care. In this model, treat-ment is regarded as worthwhile onlyfrom the patient’s perspective. Death isnot equated with defeat, but rather deathis accepted as the natural conclusion oflife. Therefore, the response to death bythe health care system can now becomfort rather than isolation and with-drawal. This model of health care acceptsthe patient’s personal values and prefer-ences, and appropriate treatment is notconsidered a scientific question bestdecided only by the physician. The careplan is tailored to the individual patient,and the comprehensive care of the wholepatient involves psychological, social, cul-tural, ethical and clearly spiritual con-cerns. The power and authority of thehierarchy of the curative system givesway to the necessary interdisciplinaryteamwork of the palliative system. Thereverence for technology that is usually ahallmark of the curative model is notrequired by the palliative model.

The palliative model requires com-munication and relationship-building,and it stresses humanistic qualities andinterpersonal skills. The efficiency-driven

Kenneth C. Henderson,MD, FACPE

LMoptions for therapy and diagnosis thatpatients will receive. The ability of aphysician to choose the optimum rangeof choices for the benefit of his or herpatient should not be limited by contrac-tual obligations to a corporate entity. Just

as we fought successfully to eliminategag clauses in managed care contracts anumber of years ago, we should work justas hard to ensure that a “virtual gag” isn’tplaced on physicians because of suchobligations. The best way to ensure that,

in my view, is to ensure that independentphysician practice remains viable.

Note: Dr. Griffin practices Obstetrics andGynecology with Women’s Care Physicians ofLouisville.



and time-limited setting of the acute careprocess of medical care reinforces thecurative model and is incompatible withthe palliative model.

The health care question has neverbeen which of these two models is supe-rior or better. The most suitable modelalways reflects the individual patient’sgoals, objectives and care needs. Curehas always been the goal of health carewhen medical care is capable of restoringhealth. The palliative care model is oftenthe best fit for patients in the final phaseof a terminal illness. Relatively fewpatients present to the health caresystem with curable conditions alone, butthey have chronic and disabling condi-tions as well. The new universal healthcare approach will have more characteris-tics of the palliative model but will liesomewhere between the two caremodels. Hopefully the palliative approachwill support all the legitimate goals ofhealth care, medical care and physicianswhile possibly reserving the right to with-hold or limit care for the good of thepatient, the system and all concerned.

After months of debate, Congresshas finally passed the health care act of2010, perhaps the most far-reaching leg-islation in more than a generation. It isdesigned to fundamentally reform theentire U.S. health care system. Once thislegislation is fully implemented, it willhave a major impact on virtually everybusiness and individual by requiring thatthe majority of U.S. residents not coveredby Medicaid or Medicare obtain healthcare coverage either individually orthrough his or her employer. However, itwill take several years for this legislationto become fully operational because theeffective dates for the various provisionsare phased in over several years.Although the centerpiece of this massivehealth care reform legislation is a require-ment that the majority of U.S. residentsobtain health insurance, this requirementgenerally does not become effective until2014. It is predicted that 50 percent ofthe 32 million presently uninsuredAmericans that will be affected by thenew health care act of 2010 will qualifyfor Medicaid under this new universalhealth care model that will be federallyfunded until 2014. That year, the stateswill assume their usual responsibility forMedicaid funding. This means there willbe approximately 300,000 new Medicaidrecipients in Kentucky that will require

state funding at the 30 percent level.In my opinion the new universal

health care model, while bearing aresemblance to the present palliative caresystem, will move the power of control ofthe provision of health care away frompatients and providers to a federally man-dated health care system. It should beclear that choice will be more limited forpatients and providers in the new univer-sal health care model, particularly relatedto the expensive issues associated withthe beginning and end of life. This will beaccomplished by shifting the cost benefitcurve away from patients, providers andsuppliers of care toward the preventivegoals and objectives of the new universalhealth care or governmental single-payersystem.

In my view, clinical decision makingin the new universal health care para-digm will likely be shared equally amongthe payer, the patient and the provider.Quality measures will also be a similarlyshared responsibility. Physicians andother providers of health care will nolonger dominate clinical decision making.Clinical decision making will necessarilyreflect the broader view of the good ofthe individual as it is related to the goodof the system and all concerned. Theprocess and substance of health care willbe equal as determined by the percep-tion of individuals who have the right tohealth care services.

I would like to suggest that medicallegal clinical decision making and theentire malpractice industry could beresolved and disappear in the new uni-versal health care model. This will be arequirement in this model in order thatthese funds may be reallocated to moreproductive areas of health care. Thissingle-payer system will represent theultimate clinical decision maker andtherefore should bear the clinical proto-col responsibility that directs all medicalcare in the new universal health caremodel. As a result, the new universalhealth care model may possibly enjoylegal immunity.

As predicted in Paul Starr’s book, TheSocial Transformation of AmericanMedicine, the movement of the physi-cian’s role from one of cultural authorityto a social authority role is occurring or infact has occurred. Physician providers willcontinue to be key players in the newuniversal health care model, and theirstrength and power will continue tostream from the patients they are privi-leged to treat and care for with skill and

compassion. The migration of the physi-cian from the independent, learned andlicensed professional with clear culturalauthority to a team member employeewith social and positional authority willoccur. In this movement, there is a risk tophysicians that both cultural and socialauthority will be lost, leaving only posi-tional power in the new universal healthcare model.

It is clear to me that American healthcare has and is rapidly moving from the55-year-old entitlement era to the newuniversal health care model in which theindividual right to care is paramount.Providing health care in this new environ-ment will require physician providerswith both curative and palliative clinicalskills. Curative health care will be nega-tively viewed as not as cost effective aspalliative health care. The required transi-tion to a more palliative health caresystem will free up the necessary fundingfor wellness and prevention.

To be successful in the new universalhealth care model, I believe that physi-cians will need to become expert system-directed providers of limited resourcesbased on both controlled availability ofcare and predetermined medical necessi-ty. Physicians as team members will beselected as much for their interpersonalskills as their clinical knowledge andwisdom. Who a physician is will becomeas important in the new universal healthcare model as what the physician is as amedical professional. Criteria and science-based clinical decision making will shareequal importance. Financially chargedend-of-life decisions may be made inadvance, requiring only the application ofthe appropriate protocols based in parton the good of the patient but primarilybased on the good of the system and allits concerns. Priorities for end-of-lifeissues will shift to wellness and preven-tion as cost benefit analysis demands. It ismy fear and apprehension that the addi-tional thousands of newly trained physi-cians that will be required to staff theFederal Community Health Clinicsrequired for the new universal health caresingle-payer system will be viewed andvalued as health care social engineers.

Note: Dr. Henderson, a pediatrician, is leadKentucky Medicaid medical director with SHPSInc.

LM


AUGUST 2010 37

derby PartyA warm

magical evening, andit’s party time again.The Derby Museumhas been restored:the flood as an histor-

ical event is forgotten. The weather hasturned toward the warmth of Louisvillesummer. “Now dear,” the lady ahead ofme in line asserted to her husband, “youcan stop for drinks. I’m headed for thegiant shrimps.” And she giggled in herjust-a-little-too-tight evening dress. It’sthe annual night before the Oaks NortonDerby party. The crowd was channeledinto chutes like guests getting on a cruiseship and then directed to a table withname tags. Sadly, I had not rememberedto RSVP so I had to wait at anotherstation for someone to letter my first andlast name onto a tag for me to stick onmy jacket. I always discard these, notreally wanting to get on a first-namebasis with people I do not know. Whenyou get to be of a certain age (around 50probably), you do not expect clerks at thebank to use your first name. As a matterof fact, the only person I felt comfortableabout calling me by my first name wasmy mother. The name tags had changed.It used to be Dr. Jones and Mrs. SallyJones, but now it was just plain JohnJones and Sally Jones: the Dr. before orMD after were for the most part gone.

So I waited again in the receivingqueue to pass by the Norton dignitaries. I was almost lifted off my feet as I gotwhisked by with a substantial if perfunc-tory handshake. Inside, not much hadchanged. There were doctors and doctorsand doctors’ wives. There were foodtables, there were drink stands, therewere desserts, and there may have beenshrimp. What was different was a notice-able absence of the community from theother side of Chestnut Street and the uni-versity. Where in the past the youngNorton vice presidents of this and thatcould be found behind poles inconspicu-ously eying the greats of Medicine andSurgery, they were now in conspicuousevidence as were judges, councilmen,state senators, representatives – an entirearray of public functionaries. Indeed, thiswas no longer a party for doctors; it hadmorphed into an employer-employeeevent with invited functionaries. Nomatter. If someone throws a party andyou are invited, get dressed up, go, smile,eat and have a good time. I did noticeWade Mountz off by himself between

two pillars eying the assembled guestslike the Queen Mother at the Coronation.

How did we get to where we aretoday? As the best and the brightest wewent into Medicine and Surgery for avariety of reasons. The science of healingis expansive, exciting, changing: wedetected that with the unraveling of thegenetic code and the promise of newtherapies for important afflictions. Welabored over The Genetic Basis ofInherited Disease, mostly carrying theheavy book from place to place withoutever understanding or remembering itscontents. We went into Medicinebecause of personal experience withillness: we wanted to be able to carebetter for ourselves and our relatives. Yetfate is a powerful force. Despite the bestintentions, sometimes we do not learnand we repeat the misadventures of thepast and fail in the struggle againstdisease. We elected to be healers to makethe world a better place, and yet it is notreally better: great catastrophes continuearound the globe and misery of our ownmaking is everywhere from Haiti, to theVatican, to Eastern Europe, to Asia andbeyond.

We struggle today with a practicemired in regulation and dissatisfaction.Each piece of paper we are obligated tosign in too small a space contains areminder that we could be imprisoned,fined, punished or worse. To my view, thedecline of medicine has its origins inthree major sea changes that have takenplace in the past 10 years. These are ourloss of control over medical records, theimposition of marketplace rules in clinicalpractice and a loss of respect for theprivacy of person normal in our society.

In the beginning, the medical recordconsisted of physician notes with someadministrative identifiers, laboratoryreports and the like. It was terse. Notewriting recorded only sentinel events andwas only done by the most seniormedical doctors. I recall a record at theMayo Clinic in which the only entry was“Appendectomy” Ch. Mayo and the date.This was two centuries ago. Gradually,the concept evolved to a pertinentcapsule of facts or questions aboutpatient care. Half a century ago, we wrotedown our “differential diagnosis” in themedical record. In teaching hospitals,house staff working literally more than ahundred hours a week and totallyresponsible for patient care left extensive“on-“ and “off-service” notes detailingtheir treatment of the sick. Studentswrote even longer notes and oftenincluded references to collateral reading,as what was a record (narrative) became

more an editorial.The sentinel change was when

others began writing in the notes. First itwas the physical and respiratory thera-pists, but soon it became the dietitians,the social workers, the ostomy nurses andreally anyone at the bedside including,but not limited to, the chaplain.

Today the medical record servesmany purposes. It is the basis for “qualitycontrol,” for billing, for lawsuits, forfederal audits. We are not only told whatto write, but how to write it. Certain time-honored notations like “qd” are forbiddeneven if they are used to prescribe a med-ication that is never taken more frequent-ly than a daily vitamin. I am to be “contin-uously available” for my cases and thatvery phrase shall be in the record, like“presente” inscribed on the graves ofheroes in South America. So I intend that“continuously available” – not awake,keenly interested or prescient – beinscribed on my tomb, dedicated to yearsof useless activity supervising perfectlycompetent house staff in the perform-ance of minor tasks well within theircapabilities. It is no longer enough towrite “healthy football player” for ayoung patient to have knee arthroscopy.Not only do we have to include enoughsystems to get paid, but also today’s hos-pital by-laws demand that we ask aboutreligious or ethical beliefs that mighthave a bearing on the intended opera-tion. What happens to medical recordscrowded out with daily physical therapynotes, respiratory therapy encounters, X-ray reports and awkwardly writtennursing notes remains to be seen.

The second sea change in Medicinewas the introduction of advertising andsubsequently market forces into healthcare. Those educated in the ’70s learnedthat marketing had no place in whatphysicians were supposed to do. Indeed,promotion of self, promotion of proce-dures and promotion of nostrums wereconsidered unethical. Various legalrulings undid this principle. Control ofadvertising was restraint of trade and freespeech. It began innocently enough withforums, lectures and information piecesbut has since expanded to newsprint, tel-evision and the Internet. With hospitalmanagers in the mix, there is today nolimit to the promotion of procedures andpeople for the intention of improving thebalance sheet. My attractive young col-leagues, now practitioners, are shownbouncing babies on their shoulders alleg-ing family values and bigger-than-life-sizevideo images of an already large enoughand handsome young man expressing his

David Seligson, MD


concern for people. Would that the publicunderstand that his special interest isextirpating en bloc entire sections of thehuman skeleton. They are now all eitherworld class, world renowned or worldfamous – whatever that means (althoughnot all of them have passed the nationalspecialty exams and not all of them havecompleted advanced fellowship training).Does this kind of advertising conform tothe spirit of Kentucky law that enjoinsphysicians from making claims of uniqueabilities (201 KAR 9:018)? Or is this a testi-monial by someone else and thereforenot advertising by but advertising aboutthe doctor?

Hospital managers now select high-profile technology to promote their insti-tutions as “at the cutting edge” of healthscience. In a world where thousands offingers, hands and/or heads are loppedoff daily, we sew them back. In a worldwhere basic needs for food, water,latrines and simple medicines are unavail-able, we provide “robot” surgery. In anage where the threat of pandemic strikesterror into entire nations leading to themassacre of millions of domestic animals,we transport, for the publicity value,single cases over oceans for a criticalhumanitarian operation and then cannotget the blood typed correctly. The ration-ale that the allocation of resources tohigh-profile medical adventures is justi-fied because the financial health of theenterprise is improved is a specious one.As we neglect daily to perform humdrumhealth care tasks expertly, our impliedsocial contract is voided. The doctor as anemployee on hours and salary, the doctoras just another “health care provider,” thedoctor who considers that advancedtraining is an MBA, or the doctor who nolonger lays on even a gloved hand butrather is a committee animal erases thespecial esteem in which the public heldits healers.

Third, we have begun to apply differ-ent standards to the modesty customaryin our society when we are in the hospi-tal. I remember visiting a distinguishedsurgeon in France. In the locker room, theattendant, a woman, instructed me toundress and then passed the surgicalgarb from underclothes to pajamas over

to the top of the locker for me to wearinto the operating room. I figured thiswas France where a lot more goes onthan it does in the U.S. A recent advicecolumn in the local newspaper suggestedthat the fellow scantily clad at the annualcouples cabin party be told to getdressed or get out. The watershed inhealth care began, in my opinion, whenfemale nurses and assistants in the oper-ating room began catheterizing malepatients. When I trained, this was all doneby male orderlies dressed in white uni-forms or by the male students and juniorresidents. Our male students stand casu-ally by and chat while the female circulat-ing nurse uncovers the patient and placesthe Foley catheter. Today it is not unusualeven for a male worker in the operatingroom to bladder-catheterize a femalepatient. Lack of respect for privacy andimmodest acts like making personsremain naked for extended periods aretechniques used in prisons and concen-tration camps to minimize the humanityof victims.

Where is it all going? In my opinion,we have not yet reached the bottom. Asphysicians, we continue to chase increas-ingly arcane and unreasonable require-ments for everything from credentialingto writing in themedical record. Iam expected nowto add an “elec-tronic signature”to each chart inthe operatingroom to provideauthorization fororders or medica-tions I have nevergiven. We contin-ue to sit for pub-licity pictures, andwe dance at theirparties. It will endsurely when thepublic discoversthat medical carehas been hope-lessly mired inineffective regula-tion and thatneeded servicesare unavailable.

The people will discover that to chaselegal redress through lawsuits and tighterregulations will not rescue a single oil-soaked brown pelican from the Gulf ofMexico. People will demand good healthcare, and they will be willing to pay for it.It won’t be over until the fat lady sings.

Note: Dr. Seligson is professor and vice chair ofthe University of Louisville School of Medicine’sDepartment of Orthopaedic Surgery and practiceswith Orthopaedic Trauma Associates PSC.


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LM

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U.S. POSTAGE PAID

LOUISVILLE, KY

PERMIT NO. 6

Greater Louisville Medical Society

101 WEST CHESTNUT STREET

LOUISVILLE, KY 40202

August 2010 - NEW - Greater Louisville Medical … Public Health & Wellness Lynn T. Simon, MD, board...

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Transcript of August 2010 - NEW - Greater Louisville Medical … Public Health & Wellness Lynn T. Simon, MD, board...