LouisviLLe Medicine - Greater Louisville Medical Society

Louisville
GREATER LOUISVILLE MEDICAL SOCIETY
Medicine
VOL. 60 NO. 11 April 2013
National
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Prevention
Month
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April 2013
1
GLMS Board of Governors
David E. Bybee, MD, board chair
Russell A. Williams, MD, president
James Patrick Murphy, MD, president-elect
Bruce A. Scott, MD, vice president and AMA delegate
Heather L. Harmon, MD, treasurer
Robert A. Zaring, MD, MMM, secretary
and AMA alternate delegate
Robert H. Couch, MD, at-large
Rosemary Ouseph, MD, at-large
Tracy L. Ragland, MD, at-large
Jeffrey L. Reynolds, MD, at-large
John L. Roberts, MD, at-large
Wayne B. Tuckson, MD, at-large
Fred A. Williams Jr., MD, KMA president-elect
Randy Schrodt Jr., MD, KMA 5th district trustee
David R. Watkins, MD, KMA 5th district
alternate trustee
K. Thomas Reichard, MD, GLMS Foundation president
Stephen S. Kirzinger, MD, Medical Society Professional Services president
Toni M. Ganzel, MD, MBA, interim dean,
U of L School of Medicine
LaQuandra S. Nesbitt, MD, MPH, director,
Louisville Metro Department of Public
Health & Wellness
Karyn Hascal, The Healing Place president
Adele Murphy, GLMS Alliance president
Louisville Medicine Editorial Board
Editor: Mary G. Barry, MD
Elizabeth A. Amin, MD
Waqar C. Aziz, MD
Deborah Ann Ballard, MD
R. Caleb Buege, MD
Arun K. Gadre, MD
Stanley A. Gall, MD
Larry P. Griffin, MD
Kenneth C. Henderson, MD
Jonathan E. Hodes, MD, MS
Martin Huecker, MD
Teresita Bacani-Oropilla, MD
Tracy L. Ragland, MD
M. Saleem Seyal, MD
Dave Langdon, Louisville Metro Department
of Public Health & Wellness
David E. Bybee, MD, board chair
Russell A. Williams, MD, president
James Patrick Murphy, MD, president-elect
Lelan K. Woodmansee, CAE, executive director
Bert Guinn, MBA, CAE, chief communications officer
Ellen R. Hale, communications associate
Kate Allen, communications designer
Louisville
12
Reaching the
Underserved
Grateful Hearts
Ellen R. Hale
14
History of Louisville
National Medical
College and the Red
Cross Hospital: African
American Medicine in
Louisville, Kentucky 1872 to 1976 - Part 3
Morris M. Weiss, MD, FACC,
FAHA, FACP
18
20
23
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Articles to be submitted for publication in LM must
be received on electronic file on the first day of the
month, two months preceding publication.
Opinions expressed herein are those of individual
contributors and do not necessarily reflect the position of the Greater Louisville Medical Society. LM
reminds readers this is not a peer reviewed scientific
journal.
LM reserves the right to make the final decision on
all content and advertisements.
Vol. 60 No. 11 April 2013
feature articles departments
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Louisville Medicine is published monthly by the
Greater Louisville Medical Society, 101 W. Chestnut
St. Louisville, Ky. 40202 (502) 589-2001, Fax 581-9022,
www.glms.org.
Medicine
Greater Louisville Medical Society
Tai Chi – Healing for Mind
and Body
Deborah Ann Ballard,
MD, MPH
What Are You Afraid to
Miss?
Stephen Wright, MD, FAAP
Intensive Caring:
An Antidote to
Dehumanizing Health
Systems, Industrialized
Practice and Professional
Disenchantment
Gordon R. Tobin, MD
27
The Bridge to Where?
Elizabeth A. Amin, MD
29
Health Equity - A
Challenge and
Opportunity
Sandra E. Brooks, MD, MBA
32
Click, Tap, Sign, Submit!
Lisa R. Klein, MD, FAAP,
FACC
5
Caught in the Act
From the President
Russell A. Williams, MD
7
Alliance News
Adele Murphy
9
In Remembrance
W. Neville Caudill, MD
Fred W. Caudill, MD
10
In Remembrance
Calvin R. Harding Jr., MD
Todd G. Richardson, MD
30
31
35
Physicians in Print
We Welcome You
Doctors’ Lounge
Not Just March Madness
Mary G. Barry, MD
Perception
Martin Huecker, MD
Letter to the Editor
Philip T. Browne, MD
Letter to the Editor
Harold Blevins, MD,
Michael Cassaro, MD
Circulation: 4,000
On the cover: April is National Child Abuse
Prevention Month. Story on page 20.
GLMS Mission
Promote the science, art and profession of medicine; Protect the integrity of the
patient-physician relationship; Advocate for the health and well-being of the
April 2013
community; Unite physicians to achieve these ends.
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LOUISVILLE MEDICINE
From the President
Russell A. Williams, MD
GLMS President
Caught in the Act
In addition, you can review a list of
current service opportunities posted at
www.glms.org or you can find a project
to participate in through the official Give
A Day website, www.mygiveaday.com. To
report your hours to GLMS, follow the instructions posted at www.glms.org under
Physician Alerts. The GLMS staff will automatically compile our time volunteered at
medical society meetings and events April
13-21.
W
ith the Dalai Lama coming to
Louisville in May to discuss
engaging in compassion, you
may begin to see more dialogue about how
Louisville can be a compassionate city. Until
recently, I was not familiar with the “Compassionate Louisville” concept, save for what
the name naturally implies.
To give a little background, Mayor Greg
Fischer signed a resolution on 11/11/11
committing to a 10-year Compassionate
Louisville campaign. His driving thought
was that “Earning an international reputation as a city of compassion will help set
Louisville apart; identifying our community
as a place where people want to live, and
companies want to locate and grow their
business.”
Fast-forward a few months later. Louisville was selected as the world’s No. 1 city for
compassion by Compassionate Action Network International, which then facilitated
the adoption of a Charter for Compassion
in Louisville. Supported by leading thinkers from many traditions, the Charter for
Compassion is a document that transcends
religious, ideological and national differences to restore compassionate action, essentially activating the Golden Rule around
the world.
As part of Compassionate Louisville, the
mayor organized the first Give A Day Week
of Service last April. By reporting acts of
compassion and volunteerism that week,
Louisville was awarded the title of “most livable city” by the U.S. Conference of Mayors.
This year’s Give A Day observance is April
13-21. This is an excellent opportunity for
us as physicians to finally get caught in the
act of doing good.
Compassion is probably a sequence of
nucleic acids that is woven into all physi-
Visit www.glms.org to report volunteer hours
between April 13-21.
cians’ DNA. The deeds we do on a daily basis
that go without recognition or compensation are usually too numerous to count. It is
what we do so naturally that little thought is
ever given to it. The health and well-being of
our community are often in the forefront of
our minds; not surprisingly, that has been a
component of the GLMS mission statement
for many years.
GLMS would like to track and compile
all of the compassionate acts and volunteer
activities of our physician members in order to send a unified physician submission
toward the Give A Day Week of Service.
Activities may include:
•
Involvement in organized medicine
or nonprofit boards
•
Participation in associations and
societies
•
Hospital committee work (e.g. quality assurance, credentialing, pharmacy and therapeutics)
•
Teaching residents and medical
students as gratis faculty as well as
teaching physician assistants, nurse
practitioners and RNs
•
Pro bono patient care (including
uncompensated write-offs)
Armed with all this information, GLMS
can demonstrate what a significant asset our
community has in physicians and what an
integral part we play in Louisville being recognized as a compassionate city. While we
will only be documenting what physicians
do during this one week, we are well aware
that a similar level of compassion happens
during the other 51 weeks of the year. This
is what we do. We don’t simply give a day
or give a week to the service of others – we
give our lives.
Let’s collectively show Louisville what a
snapshot of that looks like. LM
GLMS Mission
• Promote the science, art and
profession of medicine;
• Protect the integrity of the
patient-physician relationship;
• Advocate for the health and wellbeing of the community;
• Unite physicians to achieve these
ends.
Note: Dr. Williams practices General Surgery with Associates in General Surgery.
April 2013
5
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Alliance News
Adele Murphy
GLMSA President
April prepares her
green traffic light
and the world
thinks “Go.”
- Christopher
Morley
A
pril is a very exciting time to be in Louisville, as the city prepares
for the Kentucky Derby Festival. It’s also “go time” for the Greater
Louisville Medical Society Alliance as we work hard and enjoy
our spring events. It is particularly bittersweet for me, since my term as
president comes to a close in May. It has been a great year so far, and the
coming weeks will be just as fantastic.
We recently enjoyed coming together on February 12 in Frankfort with
Alliance members across the state for “House Calls,” a legislative health fair
for KMA and Alliance Day at the Capitol. Our members greeted legislators
and staff while wearing white coats and stethoscopes. Blood pressures
were monitored (especially important for our legislators during the hectic
“short session” that just completed) and health education materials were
distributed along with our always-popular “healthy” snacks.
On March 22, the GLMS Alliance – with help from the GLMS Foundation
– once again honored retired physicians and guests at the annual Doctors’
Day luncheon held at Audubon Country Club. During the program, we
had the pleasure of recognizing Dr. David Dageforde for his service and
mission work.
On April 21 and April 22, members will be traveling to Northern
Kentucky for the spring meeting of the KMA Alliance. A fun “gangster”
(clockwise) Millicent Evans (left) and Fu-mei Tsai; (left to right) Mimi Prendergast,
Rhonda Rhodes and KMA Alliance President Don Swikert, MD; GLMS and KMA
Alliance members in Frankfort for a legislative health fair.
theme is being planned – a tongue-in-cheek nod to the “colorful” gambling
history of Newport, Kentucky.
As April comes to a close, Alliance members will once again gather at
Churchill Downs for the wildly popular “Night at the Races” on Saturday,
April 27. Besides being a great time of fellowship and fun, the program
raises money for health career scholarships. Tickets, which include tickets
to the Jockey Club Suites, dinner and a racing program, are going fast at
$75 per person and $600 per table of eight.
Finally, all are invited to join us for brunch Tuesday, May 7, for our Annual
Meeting and induction of officers. It will begin at 11 a.m. Past president
Betty Allen has graciously opened her home for this event.
Hope does spring eternal this spring! I am looking forward to seeing
you at our amazing events. LM
Note: Contact Adele Murphy at [email protected] or
502-664-5925.
April 2013
7
8
LOUISVILLE MEDICINE
In Remembrance
W. Neville Caudill, MD (1933-2013)
M
y father, Neville, died on November
25, 2012, a few days shy of his 79th
birthday. To me and to most who
knew him, before all else, he was a physician. It
was how he saw himself, how he defined himself,
and I suspect it was what he had always wanted
to be, ever since he was old enough to realize that
his father before him was a physician. I remember
asking him what he wanted my wife, Elizabeth, to
call him, Neville or “Dad.” His response, delivered
in his best physician voice, was: “Dr. Caudill. Dr.
Caudill will be fine.” Classic Neville.
Having trained in Louisville in the early ’90s
and having watched his generation approach their
retirement, I could see that this was the mindset
of most of his colleagues. It is admirable in many
ways since it allowed them, and specifically my
father, to set themselves apart so they could do
their jobs, without emotions and sentimentality
getting in the way. Of course, it robbed most of
them of some of their own humanity, the price
to be paid, I suppose, for being a detached and
effective physician. Some of them, including
Neville, reveled in this persona, building it up
to be armor against the pain of watching a patient
suffer or losing a patient; maybe it was also armor
that protected them against the loneliness of
being in that role and away from their loved ones.
might be in scrubs, but he’s wearing them while
out in the garden working. I don’t see him dressed
in a lab coat, but sitting at the piano playing
“Madame Jeannette” or strumming his beloved
ukulele. My father taught me many things, most
by example rather than direct instruction, and
not all of them good. I’m sure he is a big part of
why I became a physician and I hope that I share
his work ethic and his dedication to his patients.
But he is also a reason why I love music and
gardening, and why I don’t work late and never
on the weekends. Most of that time is spent with
my wife and sons and, occasionally, especially
since November, reminiscing about Granddaddy
whom we will all miss very much. LM
–Fred W. Caudill, MD
Neville definitely had chinks in that armor and
would occasionally acknowledge that there were
other elements to what made him tick beyond
being a physician. He had a lifelong love of music,
gardening, dogs and learning. It’s funny that when
I see the internalized version of my father, he
April 2013
9
In Remembrance
Calvin R. Harding Jr., MD (1936-2013)
D
r. Calvin R. Harding Jr. passed away
on January 25, 2013, at the age of 76.
Born and raised in Louisville, he grew
up assisting his father with running Harding’s
Pharmacy on Hikes Lane, where his father, Calvin
R. Harding Sr., also served as its pharmacist. His
mother, Marguerite Roehm Harding, was a nurse.
Together, his parents shaped his values of caring
deeply for the needs of others. The Harding family has been a significant part of the Louisville
community for more than 100 years.
A 1955 graduate of Louisville Male High
School and a 1959 graduate of the University of
Louisville, Dr. Harding then served briefly in the
U.S. Army before returning to the University of
Louisville to graduate from its School of Medicine
in 1965. He completed his internship at the University of Iowa and residencies at the University
of Florida and University of Louisville hospitals.
After finishing his training, Cal Ray joined
Dr. Paul Fleitz and the anesthesia group at
St. Anthony Hospital. During this period, he
practiced general anesthesia.
In 1976, he left St. Anthony Hospital and soon
joined Dr. Morton Kasdan, a hand and plastic surgeon, here in the city. The two had been
friends since high school, a relationship that
never wavered. Their surgery suite was not directly joined to a hospital complex. Like all areas
of medicine, anesthesia was undergoing change,
but it was considered unusual, if not revolutionary, that Cal Ray Harding, MD, joined Morton
Kasdan, MD, at an outlying surgical facility. As
time went on, their practice took on a character of
its own; the work schedule gradually gravitated to
a period later in the day. That was due to the fact
that the great portion of their work was a result
of traumatic injury, which generally occurred
later in the day. The end result was that they
often worked late into the night. In 1976, there
were only a few relationships like this scattered
around the country. Now there are anesthesiologists who specialize in specific areas of surgery,
such as pediatrics, open heart and cardiovascular
surgery, pain medicine, regionalists and others.
When Cal Ray and Morton split up in 1991, it
was due to other factors than professional. Their
time together had been unique, successful and,
10
LOUISVILLE MEDICINE
in many ways, trail-blazing. It should be noted
that during the 15-year period that the two men
worked together, a period that included thousands of operations, they never had one anesthesia complication. This was partly due to Cal Ray’s
style. He was a traditionalist in that he kept his
use of anesthetics and drugs in general to those
he had been trained to use early in his career.
His experience with that group of medicines increased their safety factor. It also helped that he
was a very careful, gentle and skilled practitioner.
Cal Ray was a highly respected and trusted physician, with his professional colleagues preferring
him to treat their family members.
To be Cal Ray’s friend was a gift, as he gave his
entire self to nurture and grow every personal
relationship. He will be remembered as “the kindest man of all.” It has been decades since Cal Ray
and I first met. We were soon close friends. As
the years passed, we studied together in college,
went to U of L medical school together, raised
our families together and weathered the storms
of life together.
He was preceded in death by his first wife
of 35 years, Linda Little Harding, and his son,
Calvin Raymond Harding III. He is survived
by his wife, Mary Kemp Harding, his daughter,
Jennifer (Jenny) Harding, his stepson, Nick (wife
Julie) Titus, and his granddaughter, Rosannah
Linda Moore. LM
–Todd G. Richardson, MD
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April 2013
11
Reaching the Underserved
Grateful Hearts
Ellen R. Hale
How are local physicians addressing the needs of the
uninsured? In this space, Louisville Medicine features
the good work being done to reach the underserved
and highlights ways that others can join in the effort.
I
t’s a busy Tuesday afternoon at Louisville Cardiology Group.
Michael J. Imburgia, MD, examines a man who presents with numbness
in his arms and legs, chest pain and shortness of breath that keeps him
from walking long distances. He’s already had a stent placed in his leg to
address a blockage. Dr. Imburgia has seen the patient before, about two
years ago. The man, who also has emphysema, admits he’s struggling with
the recent death of his mother and is still smoking.
Dr. Imburgia decides to schedule him for a
heart catheterization. What makes this patient
different from others in the waiting room? All of
his care is being provided free of charge, through
Dr. Imburgia’s Have a Heart Foundation.
Dr. Imburgia founded Have a Heart in 2008 as
a way to offer free indigent care out of his practice.
Currently, he sees patients – referred from free or low-cost primary care
clinics in Jefferson, Shelby and Spencer counties – one Saturday and one
Tuesday each month. Louisville Cardiology allows him to use its facilities
and equipment; Baptist Health Louisville often agrees to free inpatient care
if it is necessary. Dr. Imburgia averages about 12 to 20 patients per month.
He estimates that about 60 percent of the patients he evaluates do not need
heart treatment. The remainder is another story.
“The people I see who are sick – they’re horribly sick. And they don’t
have any avenue whatsoever,” Dr. Imburgia said. “I have people who would
have been dead by now because they desperately needed bypass surgery,
who had bad enough hearts that they needed defibrillators. These people
have nothing.”
might also receive blood pressure cuffs, transportation reimbursement
and free medication based on need. A number of companies – Boston
Scientific, Cardinal Health, Medtronic and Merit Health – have made inkind donations such as catheters, stents and defibrillators.
“People act like taking care of people with no insurance is costly. But it’s
really not,” Dr. Imburgia said. “People are willing to donate their resources,
their time, their equipment – you just have to ask. They’re all pretty generous
about doing it. It underscores how physicians, if left alone, could take care
of poor patients.” He believes this approach could be a successful model
for employed physicians and hospitals going forward.
Regular volunteers include his wife, Sandy, a nurse who tackles the
difficult task of scheduling patients who often don’t have reliable phone
numbers or addresses or who speak little English;
his medical assistant, Anita Keating; and Sue
Dillon, an ultrasound technician at Louisville
Cardiology. Other physicians who have given
free care include partners Jamie D. Kemp, MD,
and Rudolph F. Licandro, MD, and heart surgeon
Samuel B. Pollock Jr., MD.
“It just brings so much joy every Saturday when
we’re here, treating patients who don’t have the resources,” Dillon said.
“There are so many constraints to get them here, and Dr. Imburgia has
done just an enormous job. His generosity is contagious.”
Keating said she is motivated to serve because her 8-year-old son has a
congenital heart defect. “One day he may very well be in a similar situation
– not be able to get insurance and need to benefit from a service like this,”
she said. “There are a lot of people Dr. Imburgia has helped who wouldn’t
be able to get help otherwise, without having him as their advocate.”
The Have a Heart Foundation can be reached at 502-245-0002.
LM
Note: Ellen R. Hale is the communications associate for the Greater
Louisville Medical Society.
Have a Heart can provide office visits as well as echocardiography, nuclear
stress testing, cardiac catheterization, coronary artery stent placement,
pacemakers and defibrillators, and vascular screening and testing. Patients
Previously Featured Clinics
Cardinal Clinic-East Broadway
914 E. Broadway
Volunteer physicians needed Monday and
Wednesday evenings.
Contact: 502-727-3401 or
[email protected].
12
LOUISVILLE MEDICINE
For a current list of service opportunities for physicians, visit www.glms.org.
Cardinal Clinic-Iroquois
4100 Taylor Blvd.
Volunteer physicians needed Monday
evenings.
Contact: 859-588-1254 or
[email protected].
Family Community Clinic
1406 E. Washington St.
Volunteer physicians needed Saturday
mornings and Tuesday evenings.
Contact: 502-554-7248 or
www.famcomclinic.org.
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History of Louisville National
Medical College and the
Red Cross Hospital: African
American Medicine in Louisville,
Kentucky – 1872 to 1976
Part 3
Morris M. Weiss, MD, FACC, FAHA, FACP
Louisville National Medical
College
Louisville National Medical College was birthed
through the energy and vision of William Henry
Fitzbutler and the racial prejudice that barred
Dr. Fitzbutler and other African American
physicians from practicing in Louisville hospitals
or attending medical lectures at local colleges.1
Drs. Fitzbutler, W.A. Burney and Rufus Conrad
were appointed trustees of the school, and
the governor of Kentucky, on April 24, 1888,
signed the Kentucky State Legislature charter for
Louisville National Medical College.
Before delving into the details of the school,
a few words seem appropriate for medical
education in Kentucky in the 19th- and early-20th
century. Medical education in Kentucky begins
with the medical department of Transylvania
University and ends with the University of
Louisville and University of Kentucky medical
schools that now exist in the 21st century. In the
19th century, nearly all medical schools were
proprietary – that is, privately owned, with
nominal or no university affiliation. They were
run as commercial enterprises to pay the salaries
of the teachers and indebtedness from buildings
and equipment. Transylvania and the University
of Louisville had buildings and equipment paid
for by funds and public-spirited citizens. They
were established universities and owned their
property as well as other buildings, including
libraries and laboratories.
In 1799, Transylvania authorized a medical
school that was opened in 1817. At that time,
there were only four university medical schools
in America: Pennsylvania (1765), Columbia
(1768), Harvard (1782) and Dartmouth (1797).
With Transylvania’s success, others tried to open
medical schools in Kentucky – for example,
Anthony Humm in Danville, a short-lived
institution of approximately one year. In 1833,
Louisville Medical Institute was chartered to
provide care to Louisville’s Marine Hospital,
14
LOUISVILLE MEDICINE
which took care of injured and sick riverboat
workers. The Louisville Marine Hospital was
the progenitor of Louisville General Hospital
on Chestnut Street (now University Hospital)
and not the current Marine Hospital belonging
to the U.S. Public Health Service in Portland.
Throughout the 19th century, several other
medical schools were chartered in Kentucky,
primarily in Louisville, the state’s principal city.
This is a fascinating subject and a story in its
own right (told separately by Dr. Gordon Tobin).
During the last decades of the 19th century,
two African American medical institutions
existed. We know only of LNMC; the other,
of which nothing is known, was extremely
ephemeral.
In 1874, Louisville had 570 medical students,
only 30 fewer than the city of Philadelphia. In
the 1890s, there were 1,200 to 1,500 students
in Louisville. This far exceeded any other city
in America. This introduction sets the table
for Louisville National Medical College and
the environment in which Dr. Fitzbutler found
himself working.
“The Louisville schools were poorly equipped
and overcrowded.” –From Abraham Flexner’s
famous Carnegie report #1 of 1910
Very little is known about the black proprietary
medical schools in this part of the country (unlike
the missionary schools, which had affiliations
with universities or religious organizations).
LNMC and Chattanooga National African
American medical schools answered to no other
record-keeping organization. Official records of
these schools no longer appear to exist. If they
are lingering in attic boxes somewhere, they have
never reached the public domain. Much of the
information about Louisville National Medical
College has been gleaned from the Simmons
College (then University) archives (which can
be reviewed in the Ekstrom archives at the
University of Louisville), the Louisville Caron
Directories (which can be found at the Filson
Historical Society), and the Ekstrom Library,
Courier-Journal articles and a few extant catalogs
from the later years of Louisville National
Medical College that reside in the University of
Louisville Kornhauser Health Sciences Library.2
In 1888, when the college opened, the
generation of black physicians had trained
mainly at Howard University, Meharry Medical
College, and Leonard and Flint Universities.
Only Howard and Meharry medical schools
survive into the modern era. Their graduates
practiced around the country but remained
primarily in the South, where the majority of
blacks still lived. Several of these black physicians
followed a trend in the white medical world,
establishing proprietary medical schools. The
first was Louisville National Medical College
in 1888, and it was followed by several others
in Tennessee.
For details of the African American proprietary
colleges, 1888-1923, one need go no further than
the work of Todd L. Savitt. Dr. Savitt’s classic
article in the Journal of the History of Medicine
& Allied Sciences (Vol. 55, July 2000) and his
subsequent book Race & Medicine in Nineteenthand Early-Twentieth-Century America (Kent
State University Press, 2007) brilliantly and
thoroughly cover this subject.3
In 1888, LNMC’s first classes were conducted
at the United Brothers of Friendship, a black
national benevolent association that gave it
space in its building during the year (Fig. 1).
The next year, LNMC purchased the two-anda-half-story brick building at 104 W. Green St.
(Liberty Street), now the site of a hotel. The
school lasted in this building for 23 years. A
separate library or dormitory for students did
not exist. The building that Drs. Fitzbutler,
Conrad and Burney purchased was originally
the Louisville School of Pharmacy. Of the six
first-year graduates, William Octa Vance opened
his practice in New Albany, Indiana, and became
an LNMC professor. Degrees were conferred on
two older practitioners: H.P. Jacob from Natchez,
Mississippi, and B.F. Porter Jr. from Louisville,
who had been in practice twice as long as state
law required before lawful registration. Drs.
Jacob and Porter graduated in 1890.
Many of the students had parents and
grandparents recently freed from slavery.
Dr. Fitzbutler recognized early on that many
of his students had very inferior educations
prior to applying to medical school. In 1891,
a month before classes began, Dr. Fitzbutler
set up a preparatory class for review of Latin
and medical etymology, arranged through the
Baptist Collegiate Institute and the Black State
University. He was deliberate in not allowing
uneducated students into the school. This was
not always the case at proprietary schools, both
black and white, throughout the country.
In 1894, Louisville National Medical College
purchased and combined two houses: 1027 and
1029 W. Green St. (Liberty Street) to create an
auxiliary hospital for the college (Fig. 2). It later
was called Citizens National Hospital. It had 12
large rooms and most patients were not charged
for services performed at the hospital. Monies
to operate the school and hospital came from
private contributions, and many doctors taught
pro bono.
During this 23-year period, many graduates
stayed on to teach at LNMC (Fig. 3). Some
were paid, but all gained enough exposure to
enhance their reputations and ability to build
medical practices capable of producing enough
income to raise their families. Most of the
faculty members over the years (approximately
75 percent) were LNMC graduates. From the
available LNMC catalogs, four white physicians
have been identified. In 1889, the first graduating
class paid tuition and lab fees of $48. There were
free tickets to wards at the local hospitals and
scholarships for the needy for the lecture fee of
$30. The school waived the $4 matriculation fee
and the graduation fee of $15.
With Dr. Fitzbutler in command, LNMC
was always trying to improve, by demanding
proof of mental and educational qualifications
prior to admission. The students had to be 21
years old at the time of graduation and were
required to complete three years of study, dissect
at least two cadavers and pass a final exam. The
school year was expanded from five months to
six and students were encouraged to have an
understanding of Latin, German and physics as
taught in “common schools.”
Curricular Summary
• The first year: Proficiency and Practical
Anatomy, Chemistry and Physiology. The
lectures “must be punctually attended.”
• Second year: Students must
(left, fig 1.) Original building, Louisville National
Medical College. (right, fig 2.) Auxiliary hospital,
Louisville National Medical College.
preceptor and passage of a series of
examinations. Fourth year also included
Principles of Surgery, Ophthalmology,
Diseases of the Skin, Otolaryngology,
Rhinology, Clinical Medicine and
Surgery, Electrotherapeutics and Medical
Jurisprudence.
This was all coordinated with state and
national standards. The students were required
to spend additional time in laboratory courses:
Medical Chemistry, Bacteriology, Histology and
Anatomy with a cadaver. Staining and mounting
of slides and bacteriology were emphasized,
along with water examination. All these were
added gradually after the beginning of reforms
in 1891.
During the 1890s, LNMC established a free
medical and surgical dispensary and gave free
(continued on page 16)
pass the first-year examination.
Courses included Materia
Me d i c a ,
M i c r o s c o p y,
Dermatology,
Histology,
Pathology, Hygiene, Medical
Jurisprudence, Obstetrics and
Clinical Surgery.
• Third year: The Theory and
Practice of Medicine, Diagnosis,
Classification and Treatment of
Morbid Conditions, Bacteriology
and Surgery.
• The fourth year included a
preliminary course with a
(fig 3) Operating room, Louisville
National Medical College, circa 1905.
April 2013
15
(continued from page 15)
medicines to those who were unable to pay. The
clinic was at the auxiliary hospital in about the
1000 block of West Green Street (now Liberty
Street). It is important to note that LNMC met
all state requirements for an accredited medical
school, and even as the state requirements were
lightened in the 1890s, Dr. Fitzbutler struggled
to keep the medical school requirements at the
highest level – this in anticipation of the famous
Flexner report 12 to 15 years later.
In 1896, an auxiliary hospital was opened
next to the medical school; at that time, the
student body was between 25 and 30 annually
and averaged five MDs graduating each April.
By 1899, the school had 58 total MD graduates;
by 1908, greater than 100.
As an interesting sidebar, in April 1891, during
graduation exercises, 50 white students from
other medical schools in Louisville accepted an
LNMC invitation to attend the graduation of its
four senior students. The graduate theses were
read and well-received by the 50 guests. This
was reported in the Louisville Courier-Journal.4
The influence of the Association of American
Medical Colleges quickened in the 1890s, and
LNMC responded by increasing the entire school
curriculum from three years to four.
In 1901, Dr. Fitzbutler died and the fortunes of
the school began to decline. This was not all due
to his death, but more to the reform that was in
full bloom in America to upgrade the quality of
American medical science and education. The
United States was hopelessly behind European
countries, and Johns Hopkins University was
the first to embrace the European model and
curriculum.
In 1910, the medical reform tract (Carnegie
Report #1), written by Abraham Flexner and
sponsored by the Carnegie Institute, was
published. But before the Flexner report, schools
like Louisville National Medical College, with
no university land, buildings, endowment,
library and laboratory, were struggling. After
Dr. Fitzbutler’s death, the classrooms were
remodeled and dormitory rooms and a small
library were added. The school continued to
survive but in 1908 went into a profound decline,
and the last catalog was issued. The doors of the
medical school closed in 1912.
The costs of laboratory and library space
and classrooms were too much to sustain and,
with the loss of Dr. Fitzbutler, the energy and
inspiration to raise money and organize the
community was lost.
The proprietary colleges simply could not
keep up after the Flexner reforms, and all black
and white proprietary medical colleges soon
closed. Only two African American schools
16
LOUISVILLE MEDICINE
survived – and that was due to the contribution
of substantial funds from the Rockefeller
Foundation to Howard University (Abraham
Flexner was on the Board of Directors) and
Meharry Medical College.
Even as late as the 1890s, Louisville National
Medical College was trying to establish a
university affiliation. At the time, Simmons
College of Kentucky was an accredited university,
with schools of law, nursing, dentistry and
pharmacy, and an undergraduate program
where the classics were taught. Simmons College
currently is headed by Dr. Kevin Cosby, senior
pastor of St. Stephen Baptist Church. Simmons
University was established in 1879 by the
governing body of the American Association
of Baptists and Kentucky Board of Trustees.
Their predecessor was organized in 1865 when
12 black Baptist churches met at the Fifth Street
Baptist Church in Louisville and organized a
state convention of colored Baptist churches in
Kentucky, but this is another story.
And so, in 1912, LNMC ceased to exist, but
for 20 years it could boast that it was the only
successful African American medical college
100 percent owned, operated and controlled by
African Americans. Drs. Fitzbutler and Burney
had made every effort in the 1880s and 1890s
to keep up with the ever-changing science
requirements for their medical students and
school. The directors studied the latest state and
national recommendations, and implemented as
much as they possibly could afford.
But proprietary medical schools in America,
both white and black, could not survive the
scientific and educational reform movement
that swept through American medicine. Johns
Hopkins University adopted the European model
and this was embraced by the American Medical
Association. The Carnegie Institute funding
provided Abraham Flexner’s famous report,
which brought American medicine into the
20th century. Thus, the bell tolled for proprietary
schools, which could not afford the libraries,
laboratory space and debt of buildings and land.
Only university-affiliated medical schools had a
chance of survival.
Louisville Sites of
Louisville National Medical
College and William Henry
Fitzbutler
• Louisville National Medical College: 104
W. Green St. – now Liberty Street. Recently
the home of the Inn at Jewish Hospital and
now a motel.
• Auxiliary Hospital of Louisville National
Medical College: 1027-1029 W. Green St.
Now there is no street, but it is in the center
of Beecher Terrace housing project.
• Simmons College of Kentucky: 1811
Dumesnil St. Evolution of Simmons:
originally, in 1879, it was at Seventh and
Zane, on four acres. Louisville National
Medical College was joined with the State
University of Kentucky, which was an allAfrican American institution that then
was called Simmons University and now
is Simmons College of Kentucky.
• Louisville National Medical Hospital: 106107 W. Green St.
• Louisville National Medical College: 114
W. Green St. originally, became number
108 in 1909.
References
1.
Savitt, Todd L. Four African-American
Proprietary Medical Colleges, 1888-1923.
Journal of the History of Medicine, Volume 55,
July 2000, pages 203-255. (This article is the most
important tract on the subject – it was followed
by Savitt’s book-length discussion of this subject.)
Savitt, Todd L. Race and Medicine in Nineteenthand Early-Twentieth-Century America. Kent
State University Press, 2007, page 451, illustrated.
2.
3.
4.
The National Library of Medicine contains a
few catalogs issued over the years by Louisville
National Medical College. Much of this same
material can be found in the Kornhauser Health
Sciences Library, University of Louisville School
of Medicine.
The History of Simmons University. Lewiston,
New York, Edward Mellon Press, 1987.
See reference 1.
They Are Doctors Now. The Courier-Journal,
Friday 10-April-1891. In the 1890s, several other
articles appeared:
4-July-1893, Colored Commencement
11-April-1894, Colored Doctors Graduated
4-November-1894, Colored Doctors Graduated
9-April-1896, Colored Commencement
8-April-1898, Five New Colored Doctors
4-June-1898, 10th Commencement Louisville
National Medical College. LM
Note: Dr. Weiss practices Cardiovascular
Diseases with Medical Center Cardiologists.
He is a member of the Innominate Society,
Louisville’s medical history society.
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Tai Chi –
Healing for Mind and Body
Deborah Ann Ballard, MD, MPH
T
ai Chi originated in China thousands of
years ago as a martial art. Tai Chi is the
shortened version of T’ai Chi Ch’uan,
which literally translates as “supreme ultimate
fist.” Since the early 20th century, the health
benefits of Tai Chi have been discovered by
growing numbers of people who practice it less
as a martial art and more as a form of mind-body
exercise. According to Dr. Paul Lam, a family
physician and Tai Chi expert who created the
Tai Chi for Health program:
medical literature documenting the effectiveness
of Tai Chi in improving outcomes for patients
with many conditions.1-6 In February 2013, the
Centers for Disease Control and Prevention
issued a guideline promoting Tai Chi as an
exercise form to prevent falls among older adults.
The Sun-style Tai Chi program developed by Dr.
Lam is approved by the Arthritis Foundation
as effective and safe exercise for persons with
arthritis. You can learn more at www.arthritis.
org/resources/community-programs/tai-chi.
“The essential principles of Tai Chi are
based on the ancient Chinese philosophy of
Taoism, which stresses the natural balance in
all things and the need for living in spiritual
and physical accord with the patterns of
nature. According to this philosophy,
everything is composed of two opposite,
but entirely complementary, elements of yin
and yang, working in a relationship which
is in perpetual balance. Tai Chi consists
of exercises equally balanced between yin
and yang, which is why it is so remarkably
effective.”
As with any therapy, traditional or integrative,
it is important to make sure the instructor has
been trained by credible teachers. Persons trained
through Dr. Lam’s Tai Chi for Health Institute or
through the Taoist Tai Chi Society of the USA
have received training through credible sources.
Dr. Lam and his team have developed many
Tai Chi for Health programs designed to meet the
special needs of persons with arthritis, diabetes,
osteoporosis, back pain and high risk of falling.
Throughout the world, physicians are
recommending Tai Chi as an evidence-based
integrative therapy for everything from chronic
pain, to chronic obstructive pulmonary
disease, heart failure, hypertension, diabetes,
schizophrenia and depression, to name a few. A
search of Pub Med reveals an impressive body of
18
LOUISVILLE MEDICINE
Like other integrative therapies, Tai Chi
empowers people with a practice that promotes
optimal health for the rest of their lives. It is never
boring because the moves take on more meaning
and power the longer one practices.
There are five different styles of Tai Chi,
including Chen, Yang, Wu, Wu (or Hao)
and Sun style. Chen and Yang style are more
physically demanding, while Sun style is more
suited to persons with arthritis and chronic
disease. Tai Chi forms are a series of graceful
flowing movements performed in a specific
sequence combined with rhythmic controlled
breathing. The movements practiced in Tai Chi
mimic movements in the natural world. These
movements have very lyrical names such as
“white crane flashing wings,” “wave hands in
the clouds,” “bear swimming upstream,” “white
Tai Chi on the beach at sunrise in San Diego
snake spitting poison,” “leisurely tying a coat”
and “playing the lute.”
I first became intrigued with Tai Chi
while participating in a National Geographic
photography expedition to San Francisco in
2010. While in a park in Chinatown, I was
mesmerized by a solitary elderly man in a
state of total concentration, control and grace
practicing the Yang 24 form. I cannot adequately
put into words how beautiful this form is, so I
encourage you to view it on the Internet at www.
dailymotion.com/video/xfg4p_24-form-yangstyle-tai-chi_news.
I began practicing Tai Chi at the Lakeside Swim
Club about one year ago. I was recovering from
an anterior cervical diskectomy and fusion. I am
extremely grateful to the gifted neurosurgeon
who rid my body of the demon that I had allowed
to gnaw at my left neck and arm for years. He
performed a technically perfect operation and
removed the anatomical cause of my pain and
weakness. However, I still had much healing to
do. I had residual problems with limited range of
motion, weakness and poor balance on the left
side of my body. I faithfully attended physical
therapy. My therapists were very kind and
competent and helped me get through the first
few weeks, but the home exercises were painful
and, quite frankly, boring. Tai Chi allowed me
to calm my mind, to move again without pain
and to develop fellowship with my incredibly
wonderful teachers and classmates, many of
whom used Tai Chi to overcome various injuries
and illnesses of their own. I am very happy to
report that I can now balance again on my left
foot and have regained normal strength in my
left arm and hand. I share my story because
it is a perfect example of how the very best of
traditional Western medicine combined with an
integrative therapy can produce great outcomes
for patients healing from injury or illness.
Tai Chi is more than just physical exercise.
It requires very focused concentration and, as
Lao Tsu says, one must empty the mind and let
it become still. Tai Chi classes usually incorporate
Qigong, translated “life energy cultivation,” which
aligns breathing, movement and concentration
to cultivate and increase life energy in the body.
When I attended the Scripps Annual
Conference on Integrative and Holistic Medicine
in San Diego last year, Dr. Robert Bodaker, who
incorporates Tai Chi into his pain management
practice, led about 60 of us physicians in Tai
Chi on the beach at sunrise. At the end of class,
we all formed a circle and performed Qigong
exercises to share and increase our life energy. It
was the most beautiful, powerful and memorable
bonding experience I have ever shared with my
fellow physicians.
Rose Phillips is also a Tai
Chi instructor at Lakeside. She
emphasizes how wonderfully Tai
Chi reduces stress and refers to it
as “moving meditation.” She notes
how Tai Chi increases calmness
and mindfulness and provides
a wonderful opportunity for
socialization.
Classes at Lakeside are only
open to its members, but classes are
available to anyone in the Metro
Louisville area through the Taoist
Tai Chi Society.
You can learn more at
the Taoist Tai Chi Society’s
Kentucky Branch website
(http://kentucky.usa.taoist.org) or by
calling 502-614-6424.
References:
1.
Cliff Jones, my teacher, at 70 years old, has a
strong and agile mind and body. Cliff explained
how he became a Tai Chi teacher:
“I have arthritis in my neck, lower
back, knees, feet, elbows and hands. I was
becoming very stiff to the point that it was
difficult to put on my socks. I had heard that
practicing Tai Chi was good for balance and
flexibility. A trip to the library confirmed
that Tai Chi could be helpful to me.
I heard that Tai Chi classes were offered
at Lakeside Swim Club. This was the
opportunity to learn more, so I joined
the class. After a few months, it became
obvious that it was helping me. I was gaining
flexibility and had less arthritis pain. I could
put my socks on with very little effort and,
as a bonus, my golf handicap dropped eight
strokes.
I took courses to become a Tai Chi
instructor with Sheila Rae, an instructor
from Dr. Lam’s Tai Chi for Health Institute.
Recently I had knee replacement surgery.
In all the preoperative tests done in the
hospital preparing for the surgery, the
doctors told me my results were that of a
healthy 50-year-old. I am 70 years old.
During rehab, the therapists have told me
I am well ahead of average. I have to credit
a lot of this to Tai Chi.”
2.
3.
4.
5.
6.
Am J Health Promot. 2010
Jul-Aug;24(6):e1-e25.
doi:
10.4278/ajhp.081013-LIT-248. A
comprehensive review of health
benefits of qigong and tai chi.
Jahnke R, Larkey L, Rogers C,
Etnier J, Lin F. Source: Arizona
State University College of Nursing
and Healthcare Innovation, 500 N
3rd Street, Phoenix, AZ 85004,
USA.
Cochrane Database Syst Rev. 2012 Sep
12;9:CD007146. doi: 10.1002/14651858.
CD007146.pub3. Interventions for preventing
falls in older people living in the community.
Gillespie LD, Robertson MC, Gillespie WJ,
Sherrington C, Gates S, Clemson LM, Lamb
SE. Source: Department of Medicine, Dunedin
School of Medicine, University of Otago,
Dunedin, New Zealand. lesley.gillespie@otago.
ac.nz.
Evid Based Complement Alternat Med.
2012;2012:809653. doi: 10.1155/2012/809653.
Epub 2012 Aug 27. Complementary medicine,
exercise, meditation, diet, and lifestyle
modification for anxiety disorders: a review of
current evidence. Sarris J, Moylan S, Camfield
DA, Pase MP, Mischoulon D, Berk M, Jacka FN,
Schweitzer I. Source: Department of Psychiatry,
The University of Melbourne, Melbourne, VIC
3000, Australia.
Cochrane Database Syst Rev. 2012 Aug
15;8:CD007566. doi: 10.1002/14651858.
CD007566.pub2. Exercise interventions on
health-related quality of life for cancer survivors.
Mishra SI, Scherer RW, Geigle PM, Berlanstein
DR, Topaloglu O, Gotay CC, Snyder C. Source:
University of New Mexico, Albuquerque, NM,
USA. [email protected].
Eur Respir J. 2012 Aug 9. Short-form Sun-style
Tai Chi as an exercise training modality in people
with COPD. Leung RW, McKeough ZJ, Peters MJ,
Alison JA. Source: Concord Repatriation General
Hospital, Sydney, Australia.
Congest Heart Fail. 2012 Oct 12. doi: 10.1111/
chf.12005. Tai Chi in Patients with Heart Failure
with Preserved Ejection Fraction. Yeh GY, Wood
MJ, Wayne PM, Quilty MT, Stevenson LW, Davis
RB, Phillips RS, Forman DE. Source: From the
Osher Center for Integrative Medicine, Harvard
Medical School, Boston, MA Division of General
Medicine and Primary Care, Department
of Medicine, Beth Israel Deaconess Medical
Center, Brookline, MA Division of Cardiology,
Massachusetts General Hospital, Boston, MA
Division of Preventive Medicine, Brigham and
Women’s Hospital, Boston, MA Division of
Cardiovascular, Brigham and Women’s Hospital,
Boston, MA New England Geriatric Research,
Education, and Clinical Center, Veterans
Administration Boston Healthcare System,
Boston, MA. LM
Note: Dr. Ballard is with Holiwell Health
Consultation.
April 2013
19
What
Are
You
Afraid
to
Miss?
Stephen Wright, MD, FAAP
A
s a practicing pediatrician, there were a
few things I was always afraid I would
miss because I knew it could lead to tragic
consequences. I never wanted to miss meningitis,
an abdominal mass or congenital glaucoma. Each
specialty has its own list of “you don’t ever want
to miss” diagnoses.
Child abuse must be added to that list – no
matter what specialty we are in. We all interact with children in some
way whether we are parents, aunts, uncles, cousins or internists, surgeons
or other subspecialists.
Every year in Kentucky, 30-40 children die and another 30-60 are left
with permanent, devastating injuries due to abuse. Additionally, there are
more than 14,000 substantiated reports of abuse and neglect. Statistics
for Indiana are not much better.
The 2007-2009 Kentucky Child Fatality Review System reports that
more children 0-1 year of age die from abuse than from all other causes
of accidental injury. But child abuse is not accidental. It is preventable!
Dr. Melissa Currie, forensic pediatrician, rightly asks, “When considering
the pervasive public safety campaigns regarding car seats, booster seats,
smoke detectors and child-proof containers, it brings to question why we
20
20
LOUISVILLE MEDICINE
LOUISVILLE MEDICINE
aren’t doing more to raise awareness of the early warning signs of child
physical abuse ... especially abusive head trauma.”
The early warning signs are often very subtle. Almost half the children
with life-ending or devastating neurological injuries have had early signs
of abuse documented in their medical records. Unfortunately for these
children, the importance of these subtle findings was not recognized or
reported.
Child abuse is rarely a onetime event. Most children presenting with
fatal or permanent disabling injuries have had previous episodes of
maltreatment that have gone unrecognized.
At Kosair Children’s Hospital we see firsthand, on a far too regular basis,
the devastating effects of abuse on our children. Rarely does a week go by
that we don’t have at least one child in our intensive care unit. Recognition
and prevention of child abuse must become top priorities for all of us. By
banding together and educating ourselves, we can begin to reduce and
ultimately eliminate this horrible blight on our states.
As physicians, whatever our specialty, we have an obligation to educate
ourselves regarding early recognition of abuse. Kosair Children’s Hospital
and the Partnership to Eliminate Child Abuse stand ready to provide
the necessary education and training that will enable all of us to save the
next child’s life. Through the cooperation of the Greater Louisville Medical
Society, we hope to provide you with the necessary information and tools
to join in this fight to eliminate child abuse.
Sadly, a number of factors and pressures impact child abuse, including a
lack of understanding of how children develop, and caregivers’ expectations
of how a child should behave. Patterns of alcohol and substance abuse,
financial pressures, job loss and the inability to provide for the family can
cause a parent to feel overwhelmed, unable to cope, and more likely to
lose control of emotions and tempers when pressures become too great.
with; and recognizing the signs
and knowing how to report
incidents of abuse or suspected
abuse. LM
Note: Dr. Wright is medical
director of Kosair Children’s
Hospital. He is a professor and
academic advisory dean at the University of Louisville School of Medicine,
Department of Pediatrics.
The best way we can eliminate child abuse within our community is
through preventive education and resources focused on teaching parents
and other caregivers how to react when tensions run high to prevent
situations from getting out of control; helping parents understand the
importance of knowing and trusting the people they leave their children
What Not to Miss
First in a series from the
Partnership to Eliminate Child Abuse
Melissa L. Currie, MD
Case Report
A 4-month-old previously healthy male presents to the pediatrician for a
well-child exam. No concerns are expressed by parents, who both attend
the appointment. The child’s developmental milestones and growth are
on track. He has begun eating solid baby food from a spoon without
difficulty and is able to roll front-to-back and back-to-front. The child
lives at home with biological mother and father and 2-year-old sister,
who is also seen at the pediatrician’s office.
The physical exam is normal and unremarkable with the exception
of two dime-size bruises on the back of each thigh. When asked about
the bruises, the parents report that they have seen these once before
and assume it is the result of diaper changes – this child is significantly
more physically active than his sister was at this age.
There have been no social concerns or red flags with the family. The
parents usually attend appointments together, and there has been only
one prior missed appointment. Both parents work outside the home
on alternating shifts so that there is always one parent home with the
children.
The pediatrician documents the bruising, along with the parents’
explanation. She notes the absence of social concerns and instructs
the family to return at 6 months of age for another well-child exam.
One week later, the patient presents to the emergency department via
EMS in status epilepticus (continuous seizure activity). The seizure began
while he was at home with both parents. There is no history of trauma,
fever, ingestion of medication or other unusual substances, free water
administration or chemical exposure. Electrolytes are normal. Head
CT indicates acute bilateral subdural hematomas extending over both
convexities and the posterior interhemispheric fissure and early diffuse
cerebral edema. Once stabilized, the patient underwent a complete
skeletal survey that revealed a total of 13 fractures, both healing and new.
Fractures included posterior and lateral rib fractures, classic metaphyseal
fractures of both distal femurs and both proximal tibias, and a healing
midshaft humerus fracture.
Child protective services and police were notified. Father ultimately
admitted to causing the injuries. He reported that he began hurting the
baby on the day he came home from the hospital. Mother later reported
ongoing domestic violence in the home, which she had never previously
disclosed to anyone. A thorough evaluation revealed no alternative
diagnoses, and the diagnosis of abusive head trauma and inflicted child
physical abuse was made.
Discussion
Bruising in pre-mobile infants is not normal. Studies show that bruising
is present in less than 0.6 percent of infants under 6 months of age, and
until babies begin to cruise, they rarely bruise. Consequently, bruising in
babies should be evaluated immediately, including a thorough history
and physical exam and studies to screen for inflicted injury (head CT,
skeletal survey, trauma labs), bleeding diathesis (CBC, PT, PTT) and
neoplasm (CBC). Contrary to popular belief, inflicted injury is significantly
more common in infants presenting with even a single bruise than a
bleeding disorder. Consequently, evaluation for inflicted injury should
be a priority. LM
References
Kellogg et al. The American Academy of Pediatrics Policy Statement on the Evaluation
of Suspected Child Physical Abuse. Pediatrics, 2007. Reaffirmed Aug 1 2012.
Sugar et al. Those Who Don’t Cruise Rarely Bruise. Pediatrics, 1999.
Note: Dr. Currie, a board-certified child abuse pediatrician, is chief, medical
director and associate professor at the University of Louisville School of
Medicine, Department of Pediatrics, Kosair Charities Division of Pediatric
Forensic Medicine.
April 2013
April 2013
21
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Intensive Caring:
An Antidote to Dehumanizing Health Systems,
Industrialized Practice and Professional
Disenchantment
Gordon R.
Tobin, MD
I
ntensive caring may sound like practice in
an ICU, but the term describes intensity for
a very different and most important purpose.
Intensive caring is the fusion of compassion, skill,
unwavering commitment and undivided personal
focus given to patients at their time of need in
any setting. It is the pinnacle of the values and
ethics that guide physician endeavors. In 1887,
British artist Sir Luke Fildes captured intensive
caring in his powerful painting, “The Doctor” (Fig.
1). Fildes included symbols representing many
essential elements of care: the desperation of the
parents conveys the importance of mission, the
impoverished cottage represents providing care to
all, the medicine bottle symbolizes professional skills, the lamp still burning
as morning dawns shows priority of patient over physician convenience
and the piercing focus of his attention shows total commitment to the
child’s care. The elements visually portrayed in “The Doctor” capture the
spirit of intensive caring with an eloquence beyond words.
Physicians emotionally bond to principles of intensive caring, as nearly
all chose to enter medicine because of them. However, we find these values
most difficult to cast into words. In response to a 2009 call by Louisville
Medicine for essays on practice, I sought to describe these values and found
words barely adequate. I did write that we were given “the rare privilege
and great responsibility of visiting the most personal and private realms
of another person’s life, often in their moments of their greatest need,
which is a trust that must be held sacred, carefully nourished, and fiercely
preserved,” and that “allowing ourselves to become overbooked, rushed and
impersonal … [by] productivity pressures and delivery systems encumbered
by time-consuming inefficiencies” must be resisted. The American Medical
Association, Kentucky Medical Association and Greater Louisville Medical
Society (and other state and county societies) have consistently spoken in
advocacy of protecting the physician-patient relationship, realizing it to be
vital to both patients and physicians. It is in fact irreplaceable.
The Threat of “Industrialized”
Practice
The current environment threatens personal caring of patients greater
Fig. 1 “The Doctor” by Sir Luke Fildes exemplifies our legacy of intensive caring.
than at any time in memory, as system changes and economic forces recast
practices toward industrialized patterns and corporate values. The essence
of these changes is captured by another artistic masterpiece, the 1936 silent
film “Modern Times,” starring, written by and directed by Charlie Chaplin.
Chaplin used industrial symbols to represent dehumanizing forces and
their mechanical crushing of individuality (Fig. 2). Physicians are voicing
widespread dissatisfaction with such forces in health systems, as they
lead to overbooked schedules, rushed judgments in critical matters and
assembly-line patient processing that allow insufficient time for personal
attention and whole-patient care. These pressures come from all quarters,
including accommodation of inappropriate reimbursement hurdles from
government and private insurers, absorbing the burden of uninsured care
and a litigation-prone environment. Added to these is the recent widespread
movement from independent practice to employment, which has brought
aggressive productivity demands from employers, loss of independent
referral judgment and pressures in some settings to overutilize tests and
services of the employer by subtle or overt coercion.
Professional Disenchantment and
Burnout
Physicians, nurses and other health care workers enter their chosen
professions with humanitarian goals, which were rewarded and sustained
in past eras. Now, these goals are rapidly eroded by the deteriorating
(Continued on page 24)
April 2013
23
(Continued from page 23)
environment described above, and early idealism is replaced by disillusion,
chronic fatigue and career burnout. Studies show this erosion to now be at
unprecedented levels. The resultant harmful effect on patients adds even
more concern to this evolution.
A System That
Abandons
Patients
Patients report dehumanizing
experiences in encounters with
virtually all elements of the
health care system. Hospital
care is increasingly reported as
impersonal “processing” followed
by undecipherable bills having
enormous cost markups and reports
of unnecessary tests and services. Cover-ups
of product risks and regulatory manipulation
scandals by pharmaceutical and medical
device companies are repeatedly exposed,
and “polypharmacy” grows unchallenged.
Patient experiences with their insurers include
arbitrary denials of coverage, cancellations of
policies at times of greatest need and shrinking
percentages of premium payments going to
medical care as premium costs far outpace inflation.
Medical bankruptcies among patients who thought themselves wellinsured remain the most common of bankruptcies. Doctors are too often
detached, and patients are frustrated in attempts to communicate with
them. All of these factors leave patients feeling vulnerable and “abandoned”
by the system.
Intensive Care: A Step Toward
Solutions
Many changes are needed to address the myriad of dysfunctional elements in
our health system. However, the very first step should address the needs of
patients for advocacy, trust and protection in times of illness, and physicians
must be the “first responders” to those needs. Rehumanization of the health
care system begins with strengthening the physician-patient relationship
at the personal level, and that can only come from physician commitment
to intensive caring. Steps toward accomplishing these ends are simple in
concept but difficult in execution. For example, the time pressures of practice
today work against giving patients undivided attention and displaying every
verbal and nonverbal signal that nothing else is more important. As noted
in my 2009 article, the physician may have many encounters scheduled that
day, but for each patient the encounter “may be the most important event
of the day, and perhaps for many future days …Undivided attention must
focus on this one patient, as though no other obligations exist.”
Dr. Robin Youngson and Time to Care
Of the many who contemplate the problems described above, I know
of none who have engaged it as fully and sought formulation of
remedies more diligently than Dr. Robin Youngson, a New Zealand
anesthesiologist whose expertise in quality improvement and patientcentered care achieved international recognition. He is now devoting
full-time attention to rehumanizing the physician-patient relationship
(Fig. 3). His in-depth studies, contemplations and conclusions led to his
book, Time to Care, and to founding the organization Hearts in Healthcare
24
LOUISVILLE MEDICINE
(www.heartsinhealthcare.com). I find his book to be the best writing
on the subject.
It begins by describing and documenting the
enormous amount of stress and burnout afflicting
professionals. Next, he shows the exceptionally
negative consequences of this for the patients and
for the health care system that increasingly fails to
serve them. He then offers sensible and achievable
solutions that can be incorporated individually
and systemically. His recommendations come
from a broad array of studies and approaches,
including positive psychology, learned
optimism, appreciative inquiry
and the practice of mindfulness.
He shows how early investment
of time in personal attention to
patients by doctors and nurses,
no matter how busy, returns
far more time later. Moreover,
he cites evidence showing that
Fig 2a & 2b In “Modern Times,” Charlie
Chaplin needs only a white coat and
stethoscope to represent today’s
physicians.
the application of straightforward
care-enhancement practices has
revitalized health care professionals
and made their hospitals and institutions simultaneously more humane
and more productive. Summaries of his insights are available on YouTube at
www.youtube.com/user/DrRobinYoungson or on DVDs at the GLMS
offices.
Louisville physicians and health care workers will have an opportunity
to hear Dr. Youngson in mid-May. He will be the featured speaker at the
University of Louisville Gheens Lecture on Humanism in Medicine at noon
on Thursday, May 16, on the U of L medical campus. For information, check
http://louisville.edu/medschool/familymedicine. Other presentations and
workshops are being organized, and GLMS members will be informed
of these arrangements through Louisville Medicine and other GLMS
communications. I urge each of us to examine Dr. Youngson’s program
for revitalization of purpose and improvement of patient care, personal
satisfaction and career enjoyment.
“A Rose by Any Other Name …”
I have chosen the term “intensive caring” to describe enhancing the personal
physician-patient relationship and pushing aside barriers to total focus
on the patient. Other approaches to the same goals use terms such as
compassion, empathy, patient-centered care and similar descriptions.
Although these concepts are not precisely identical, they all have a
common core of compassion for patients and goals of better experiences
and outcomes. During activities this May, the term “compassion” will
likely be the term heard most, as a number of spectacular compassion
advocacy events will occur simultaneously. Highlighting these events
and drawing them to Louisville is the May 19-21 visit of His Holiness
the Dalai Lama, sponsored by the Drepung Gomang Institute. This will
draw international participants and visitors to hear the world’s leading
spokesperson for compassion and nonviolence. For information on this
eventful visit, go to www.dalailamalouisville.org. In the immediately
Fig 3. Time to Care by Robin Youngson, MD, is the best guide to
compassionately revitalizing today’s medical care.
preceding days, May 14-19, Louisville’s highly regarded Festival of
Faiths will give its 18th annual presentation, with the theme Sacred
Silence: Pathway to Compassion. This too will draw an international
audience to hear the assembly of highly respected speakers discuss
many dimensions of compassion and meditation. For information on
the Festival of Faiths, visit www.festivaloffaiths.org. Simultaneously, the
International Summit on Compassionate Organizations will meet here
for intensive workshops to strengthen a wide array of compassionate
organizations, which will draw another set of respected leaders working
in many international venues. For information on these workshops, visit
www.compassionorg.net. Louisville’s participation is represented by Mayor
Greg Fischer’s Compassionate City initiative led by Tom Williams, cohost for the Partnership for a Compassionate Louisville. The section for
compassion in health care is led by Stephanie Barnett, and a program
focused exclusively on health care is being planned. For further information,
visit www.louisvilleky.gov/compassionatecity. There will be several other
programs relevant to compassion in health care, in addition to Dr.
Youngson’s presentations and those described above. As schedules become
firm, Louisville Medicine and other GLMS communications will keep
members informed of opportunities to hear these compelling messages.
Our physician heritage of intensive caring must be revitalized. The
compassion-focused events of May in Louisville provide a perfect
opportunity to begin this rebuilding. LM
Note: Dr. Tobin is a professor at the University of Louisville School of Medicine,
Department of Surgery, Division of Plastic and Reconstructive Surgery. He
practices with U of L Physicians - Plastic & Reconstructive Surgery. Dr. Tobin
is a member of the Innominate Society, Louisville’s medical history society.
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The Bridge
to Where?
Elizabeth A. Amin, MD
F
rom the moment I knew that the Big
Four Bridge was going to be refurbished
and converted to a pedestrian walkway
across the Ohio, I desperately wanted to be
one of the first across. Unfortunately I could
not make it on opening day, but in the late
afternoon of Saturday, February 9, my husband
and I decided to drive down River Road and
see what the sunset would look like from the
center of the bridge.
We did not have too much trouble parking
and set off up the spiral ramp with several other
walkers. The ramp was wider than I expected,
with an easy incline that allowed for continued
chatter between couples and members of groups.
Everyone seemed animated and glad to be seeing
for themselves the final outcome of the bridge’s
rebirth. I thought about other bridges I had
walked on during my lifetime, some of them so
weighed down with history that the presence
of newcomers was completely inconsequential.
On that Saturday, though, it seemed we were all
playing a small part in this bridge’s future.
As we approached the center of the bridge, we
could hear music playing from the loudspeakers.
To our left, four young women had turned a
part of the guardrail into a ballet barre and
were delighting onlookers with their graceful
movements. Farther on, photographers were
setting up their tripods, anxious to get the shot
or shots that would have special meaning for
them on this chilly February Saturday. Most
people had bundled up for their stroll, but two
girls walked by, seemingly with great purpose,
in short shorts and flip-flops (reminding me
that once long ago I also was invincible or overly
optimistic or downright foolhardy – depending
on who was making the call).
Reaching the barricaded Indiana end of the
bridge, we all peered down at the soon-to-be
opened ramp’s infrastructure. The homes on
either side looked dignified and welcoming. I
hope the inhabitants won’t be inconvenienced by
the visiting hordes when we can finally make that
descent. As yet, there is no detectable Starbucks
or Panera Bread, but someone spotted a favorite
restaurant and a lively little conversation ensued:
value for dollar, fresh-cooked wholesome food, a
place to park – the sort of thing that one always
judges.
Then it was time to turn around and walk back
the way we came. It seems to me that one of the
enduring discoveries about bridges over rivers
is that the way back is never the same as the way
over. Looking upstream, we could see a barge
coming into view. It looked small compared with
the width of the Ohio, which stretched away
into the distance. Viewed from the shoreline,
barges always seem to dominate the river. Viewed
from the bridge, the river dominates. Looking
downstream, we were at eye level with the traffic
on the Kennedy and Clark Memorial bridges. The
sun was beginning to go down and we loitered,
not wanting to give up on our goal.
The sunset was a wintry one, as expected given
the time of year and the temperature. As we
looked west from the bridge, the surface of the
river, for just an instant, became a smooth, black
reflecting pool from which color slowly emerged.
The salmon pink and the turquoise mirrored
the colors of the sky. The Louisville skyline took
on a uniform, almost two-dimensional wintry
white/gray appearance that somehow allowed the
outlines of the buildings and the many church
steeples to stand out in stark relief. The wind
was starting to nip at our noses, and we walked
back to the spiral ramp – by now illuminated by
its modern, multicolored lights. As we looked
down to the surface of the water one last time,
we saw debris moving slowly with the current.
Yes, this is a salvaged bridge over an
industrialized river, and the first 100 years of its
existence saw numerous tragedies. The second
chapter in its history is starting to be written.
We will all be part of it. Some more than others
will help create the stories that attach to it. But
each one of us, whether we cross the bridge once,
twice or many times, will have significance in
the narrative. LM
Note: Dr. Amin is a retired diagnostic
radiologist.
April 2013
27
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Healthy Equity –
A Challenge and Opportunity
M
Sandra E. Brooks, MD, MBA
y focus on health disparities and
prevention began more than 15 years
ago through a series of “aha” and
“oh my” moments as a practicing gynecologic
oncologist at an academic medical center in
Baltimore. I saw the 45-year-old scrub tech
presenting with Stage IIIb cervical cancer who
had not had a Pap smear or seen a doctor in years,
and the 60-year-old woman with ovarian cancer
who, although she worked full time, did not have
insurance and sought care in the emergency
room when her abdomen began to swell. I cared
for the 55-year-old morbidly obese woman with
endometrial cancer who had to be hospitalized
before treatment due to unmanaged co-morbid
illness. Despite my individual efforts and those
of my health system, where I worked for more
than 10 years trying to provide the highest
standard of care, I accumulated hundreds of
similar case histories and began to seek answers
to the question, “How do we address these issues
in a lasting way?”
Nearly a decade has passed since the Institute
of Medicine report, “Unequal Treatment:
Confronting Racial and Ethnic Disparities in
Health Care.” Despite programmatic focus and
research, persistent disparities highlight the
complexity of unraveling the intersection of
race, ethnicity, place, poverty and education.
Given reports indicating the elimination of
disparities in preventable hospitalizations would
avoid potentially 1 million hospitalizations and
save $6.7 billion in health care costs each year,
examining these issues is vital using, among
other techniques, creative team strategies,
partnerships and emerging technology.1-4
The Affordable Care Act will directly
address the goal of reducing disparities in
health and health care by increasing access to
health coverage. However, it is acknowledged
that insurance coverage alone will not reduce
disparities in outcomes. The ACA also embraces
the notion that health happens both inside and
outside the doctor’s office, which gives us a
unique opportunity to examine how we integrate
high-quality health care and public health.5,6 Our
public health officials are playing key roles in
identifying disparities in our community and
addressing those disparities through capacity
building, policy change and evidence-based
initiatives.7,8 Communities have responded
through low-cost clinics and support centers.
Health systems and foundations have also used
these statistics and quality metrics to identify
and address gaps in care through the support of
programs such as Healthy Start and the extension
of services through patient navigator programs.
One such program based at our center came
to the aid of a woman who lost her insurance
when she was laid off from work. She had not
had a mammogram in several years and was
encouraged to be screened on a mobile health
unit. She was subsequently diagnosed with
cancer and, with the help of her patient navigator,
began treatment and received support services
immediately after diagnosis. Such programs
funded through private and public partnerships
are examples of how we might expand our teams
to provide critical understanding, promote
adherence, and reduce financial and other
barriers to care.
Additional opportunities exist to promote
health equity through collaboration with the
many faith-based and community organizations
that seek to incorporate health in their mission.
Our community outreach programs go beyond
episodic events and work with groups over time
to empower them to lead their own initiatives.
Such collaborations incorporate multiple views
and create a culture of equity.9 Organizations such
as the YMCA (farmer’s markets, school nutrition
and activity programs, Diabetes Prevention
Program) and Louisville Urban League (youth
training and obesity awareness) are but two
examples of organizations that are adept at
collaboration, are founded in empowering
communities and are incorporating health equity
into their platforms with success.10,11
In the very near future, technology and new
communication tools will allow us to tailor our
reach to the communities we serve, harness data
and demonstrate value.12 The growing availability
of digital health applications enabling access
to personal health data will radically change
how we deliver health care and serve as a great
tool for self-health management.13 Our patients
can now access their medical information
and communicate with their health team
electronically. We are also piloting “m-health” to
promote adherence and provide patient support.
There is a role for multiple perspectives in
advancing health equity. For those in health care,
we must commit to continue to use the data to
identify the issues, create collaborative teams
and apply new technology and evidence-based
frameworks in order that we may ensure optimal
outcomes for all patients.14,15
References
1.
Institute of Medicine of the National
Academies. 2003. Unequal Treatment:
Confronting Racial and Ethnic Disparities in
Health Care. Washington, D.C.: The National
Academies Press.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Centers for Disease Control and Prevention.
“CDC Health Disparities and Inequalities
Report – United States, 2011.” Morbidity and
Mortality Weekly Report, January 14, 2011;
60(Supplement): 1-116. Washington, D.C.: U.S.
Department of Health and Human Services.
Agency for Healthcare Research and Quality.
2011. 2010 National Healthcare Disparities
Report. AHRQ Publication No. 11-0005.
Rockville, Md.: U.S. Department of Health and
Human Services http://www.ahrq.gov/qual/
nhdr10/nhdr10.pdf (accessed October 2012).
The Behavioral Risk Factor Surveillance
System (BRFSS) is performed under the
auspices of the Centers for Disease Control
and Prevention. The version of the BRFSS
referenced was administered by the KY
Department of Public Health, and made
available by the CDC. 2009.
Davis, MM, Walter, JK. Equality-in-Quality
in the Era of the Affordable Care Act. JAMA,
August 24/31, 2011—Vol 306, No. 8,873.
http://www.solvingdisparities.org/tools/
roadmap, date accessed 2/12/13.
Louisville Metro Health Equity Report. Smith,
P, Pennington, M, Crabtree, L, Illback, R. 2011.
Institute of Medicine. Race, Ethnicity, and
Language Data: Standardization for Health
Care Quality Improvement. Washington,
D.C.: The National Academies Press, 2009.
http://www.ahrq.gov/research/iomracereport/
iomracereport.pdf (accessed 2/23/13).
http://www.solvingdisparities.org/tools/
roadmap, date accessed 2/12/13.
http://www.louisvilleky.gov/Health/equity/
HealthyinaHurry.htm 2/24/13.
Currie, D. Kentucky program brings produce
to some Louisville corner stores. The Nation’s
Health August 2011 41:13.
http://www.apha.org/NR/
rdonlyres/7A0DE1D1-2EC7-47E5-8D700DD1EEFE59D7/0/MYMProgram2012_feb11.
pdf. Date accessed 2/24/13.
http://www.wdrb.com/story/20275183/mobileapplications-are-revolutionising-healthcaresays-frost-sullivan.
Institute of Medicine Committee on Quality of
Health Care in America: Crossing the Quality
Chasm: A New Health System for the 1st
Century. Washington DC, National Academy
Press, 2001.
https://www.qualityforum.org/Topics/
Disparities.aspx. Date accessed 2/13/2013. L
M
Note: Dr. Brooks, a gynecologic oncologist, is
system vice president, research and prevention,
of Norton Healthcare.
April 2013
29
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LOUISVILLE MEDICINE
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LM
PubMed PMID: 23345019.
NOTE: GLMS members’ names appear in boldface type.
Most of the references have been obtained through the use
of a MEDLINE computer search which is provided by Norton
Healthcare Medical Library. If you have a recent reference that
did not appear and would like to have it published in our next
issue, please send it to Ellen Hale by fax (502-736-6339) or
email ([email protected]).
WE WELCOME YOU
GLMS
would like to welcome and congratulate the following physicians who have been elected by
Judicial Council as provisional members. During the next 30 days, GLMS members have the
right to submit written comments pertinent to these new members. All comments received will be forwarded to
Judicial Council for review. Provisional membership shall last for a period of two years or until the member’s first
hospital reappointment. Provisional members shall become full members upon completion of this time period
and favorable review by Judicial Council. LM
Candidates Elected to Provisional Active Membership
Webber, Audra (31409)
Ryan T. Hughes
Dept 5090 PO Box 740041
40201
Anesthesiology
U of Pittsburgh 07
We hate lawsuits. We loathe litigation. We help doctors head off
claims at the pass. We track new treatments and analyze medical
advances. We are the eyes in the back of your head. We make CME
easy, free, and online. We do extra homework. We protect good
medicine. We are your guardian angels. We are The Doctors Company.
The Doctors Company is devoted to helping doctors avoid potential lawsuits. For us, this starts with patient safety.
In fact, we have the largest Department of Patient Safety/Risk Management of any medical malpractice insurer. And,
local physician advisory boards across the country. Why do we go this far? Because sometimes the best way to look
out for the doctor is to start with the patient. Our medical professional liability program is exclusively endorsed by the
Kentucky Medical Association. To learn more about our benefits for KMA members, call Frank Buster or Gary Noel at
(800) 338-7148 or e-mail [email protected].
Exclusively Endorsed by
www.thedoctors.com
3774_KY_LouisvilleMedicine_Jul2012.indd 1
5/10/12 9:44 AM
April
2013
31
Medicine in Verse
Click, Tap, Sign, Submit!
Lisa R. Klein, MD, FAAP, FACC
Click, click, click---tap, tap, tap
The thrum of fingertips typing on a keyboard
The sound of a stylus making contact with a screen
Gaze is focused on the screen, not on the face of the patient
Eyes dart between faces and screen, a halfhearted attempt to make eye contact
Click, click, click---tap, tap
Enter the data, enter the facts
Make more eye contact, then quickly avert gaze
Click on boxes to select phrases with robotic precision
Phrases that scratch the surface of what you really want to say
Click, click, click---tap
Take the joy out of medicine
Seriously alter the art of medicine
Change the face of medicine
Change the fate of medicine LM
Note: Dr. Klein is an associate professor at the University
of Kentucky College of Medicine, Department of Pediatrics,
Division of Pediatric Cardiology.
32
LOUISVILLE MEDICINE
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Not Just March Madness
Mary G. Barry, MD
T
Louisville Medicine Editor
[email protected]
he health care industry in this country
makes sense only to those who profit
from it, not to those who need and use it.
Steven Brill, founder of Court TV and Lawyer
Advocate, has written in a February issue of TIME
magazine a masterful exposé of the cutthroat
greed that characterizes the way patients of
all financial means are billed, and treated, by
hospital systems, drug and medical device
manufacturers, medical supply companies and
most doctor-owned clinics. That includes all
non-profits, including all the major systems in
Louisville, university-owned hospitals, and small
community hospitals.
I always tell my patients that the only thing
worse than being in the hospital and getting stuck
all the time is going home and having to deal with
the bills. The bills make no sense to anyone who is
accustomed to knowing what things cost before
one buys them, because health care cost is a pig
in a poke, and the pig part is overwhelmingly
and deservedly accurate.
Mr. Brill dissects real patient bills from real
hospitalizations and itemizes the true market
cost of things for which patients are routinely
charged markups of 400 percent to 1,000 percent.
One generic Niacin cost someone $24 at Texas
Southwestern; its actual cost is 5 cents. One
generic Tylenol at MD Anderson was “only”
$1.50, but you can buy a hundred of them for
that on Amazon.com. MD Anderson charged a
man with a rapidly growing and symptomatic
chest lymphoma more than $13,000 for a dose of
Rituximab, which likely cost Biogen/Genentech
somewhere around $300 to make, though they
sold it to MD Anderson for a price likely to be
less than $3,500. (All these are estimates since
neither MD Anderson nor the drugmaker will
actually say. According to the partnership’s
stockholder annual reports, the cost of making
Rituximab is about 10 percent of its average sale
price, and knowledgeable hospital buyers helped
Mr. Brill with the MD Anderson estimate.) The
Biogen/Genentech partnership for Rituxan does
have a free drug program for people who need
Rituximab but can’t afford it. Since they averaged
$5.5 billion in sales last year, they can stand to
give some away. The CEO for Biogen Idec alone
made $11,331,111 – in salary – in 2011.
Mr. Brill also shoots down the always-claimed
defense of high charges from both for-profit and
non-profit hospital systems. In general they point
out the millions they provide in unreimbursed
care as the excuse for charging $283 for a chest
X-ray (Medicare reimburses about $20-25
depending where one lives). However, according
to the McKinsey & Co. consulting firm, which
has studied health care costs minutely, the total
expenditure of non-profits nationally on such
charity care averages only about 5 percent of
their revenue for 2010. And their revenues are
through the roof because of what is called the
Chargemaster.
The Chargemaster is the list of what hospitals,
clinics and the like claim that you must pay for
needed items and care given. The lymphoma
patient was charged more than $15,000 for
labwork for which Medicare would have paid
MD Anderson less than $500. He was charged
$7 for every little alcohol prep pad, though
he could have gotten his own online at 200
for $1.91. MD Anderson, which had refused
to treat our lymphoma man until he paid
$83,900 in advance (luckily he got his motherin-law to write an enormous check) had an
operating profit for the fiscal year 2010 of $531
million. That’s a profit margin of 26 percent on
revenues of $2.05 billion. MD Anderson is a
huge industry employing 19,000 people, and
enjoys a world-class reputation. Its president
got paid $1,845,000 last year, not including his
outside earnings from “financial ties to his three
principal pharmaceutical companies.” I like that
“principal” note; God only knows what he might
make on the side from some future gene-therapy
drug still in the un-principal startup mode.
Medicare computes a hospital’s costs by
looking at all kinds of data, overhead, equipment,
personnel, etc. etc. Medicare compares costs
regionally, and will by law only pay what it
decides the approximate actual cost is. Medicare
beneficiaries more than 90 percent of the time
also buy a supplement to cover “their” 20 percent
of the charges, meaning in general except for
drug costs, they have 100 percent coverage for
all hospital-based services. Hospitals charge
everyone the same; the people who get stuck
with the bills are the people who are insured but
with very low limits (the limit part will go away
under the ACA in 2014) and the working poor,
who do not qualify for Medicaid but nonetheless
fall down and hit their heads, resulting in $17,000
ER bills and $1,000 ambulance rides and $6,000
CT charges, which later result in bill collectors,
bankruptcies and loss of all financial security. The
Chargemasters (closely guarded proprietary data
for all) churn out prices that have no bearing to
reality. Most insurers negotiate steep discounts;
on average, hospitals receive from commercial
insurers about 35 percent of what was charged.
However, routine markups of 400 percent will
still yield a profit handsome enough to pay even
the midlevel administrators (all 14 of them, at
Sloane-Kettering alone) $500,000 apiece per
year. The uninsured or poorly insured have
no protection, and the hospital business and
its collection agencies have become enduringly
profitable.
We taxpayers have no protection against the
enormous costs of drugs, even with Medicare,
because in order to get the Affordable Care Act
passed, Medicare was forbidden to negotiate the
prices of drugs it pays for. Every other civilized
country in the world allows its government-run
insurer to bargain with drug suppliers. We are
supporting the huge bills of the drug research
industry for the entire world. We, and our
(Continued on page 40)
Speak Your Mind The views
expressed in Doctors’ Lounge or any
other article in this publication are not
those of the Greater Louisville Medical
Society or Louisville Medicine. If you
would like to respond to an article in
this issue, please submit an article or
letter to the editor. Contributions may
be sent to [email protected] or may be
submitted online at www.glms.org.
The GLMS Editorial Board reserves the
right to choose what will be published.
April 2013
35
Doctors’ Lounge
Perception
Martin Huecker, MD
M
any of us are now familiar with
the provision in the Affordable
Care Act of applying 1 percent of
Medicare spending (almost $1 billion) toward
institutional bonuses (Hospital Value-based
Purchasing Program, or HVBPP). Redistribution
of the dollars will be based on two factors:
quality clinical measures and results of patient
surveys. Below are the 12 quality measures for
anyone who has not encountered an accurate list
(www.healthcare.gov/news/factsheets/2011/04/
valuebasedpurchasing04292011b.html).
It is difficult to argue with these, though
focusing on some quality measures may not
alter outcomes. In Great Britain, a bonus system
rewarding normal blood pressure measurements
by primary care providers resulted in no change
in overall blood pressure control and no decrease
in MI, stroke or mortality, according to a 2004
study.
Medical:
Well-summarized by Dr. Mary Barry in
Louisville Medicine (“Have a Nice Bypass,”
January 2012), these surveys ask questions about
the patient experience that physicians may feel
are unrelated to the actual quality of care. Patrick
Conway, the CMO of the Centers for Medicare
and Medicaid Services, says that “Asking patients
directly is the best way to measure care.” Is the
perception of good care equivalent to good
care? I do not believe we should focus solely on
reimbursement strategies, but I want to inquire
philosophically into this paradigm.
•• Percent of MI patients receiving
fibrinolytics within 30 minutes
•• Percent of MI patients going to PCI
within 90 minutes
•• Percent of CHF patients sent home with
discharge instructions
•• Percent of pneumonia patients with
blood culture in ED prior to antibiotics
•• Proper antibiotic selection in community
acquired pneumonia patients
Surgical:
•• Prophylactic antibiotics within one hour
prior to procedure
•• Proph antibiotic selection
•• Proph antibiotics stopped within 24
hours postop
•• Cardiac surgery patients with “controlled
6 a.m. postop glucose”
•• Patients already on beta blockers who
receive BB perioperatively
•• Patients with proper venous
thromboembolism prophylaxis ordered
•• Patients who received proper VTE proph
24 hours preop to 24 hours postop
36
LOUISVILLE MEDICINE
Nevertheless, many physicians will likely
object more to the 30 percent of bonus money
determined by surveys.
The survey asks three questions related to
physicians’ care and also asks three questions
related to pain control. Does this mean that
in the eyes of CMS the weight of the complex
interaction of physicians and patients should
in retrospect be equivalent to the patient’s pain
control? Patients are asked if physicians treated
them with courtesy and respect, if we listened
carefully and if we explained things in language
they could understand. Put simply, these are
admirable goals and we can hardly be irritated to
be held to this standard. However, rewards will
go to hospitals whose surveys result in scores of
nine or 10 out of 10, nothing less.
Will House Bill 1 limit our ability to provide
analgesia? Or will we have more justification
when we fall short in our attempts to “do
everything we can” to alleviate the patient’s
pain? The ACA survey fortunately addresses
pain control while in the hospital and does not
ask the patient questions related to prescription
of analgesics for outpatient use. Perhaps this was
done intentionally. But when a patient fills out
the survey, his answers may be affected by the
pain pills he is currently taking at home.
We are increasingly asked to treat the patient
as a customer. Rather than an institute of
healing, the hospital will be like a restaurant or
department store. We can even follow ratings
on www.medicare.gov/hospitalcompare – like
Yelp for health care. Treasure Valley Hospital
in Idaho, owned by physicians, will receive
the largest bonus in the HVBPP. Each patient
receives handwritten thank-you notes.
We have to wonder if all of these measures
actually enhance quality. The Medicare test of 266
hospitals within the Premier Hospital Alliance
showed increased performance scores. But a later
study showed similar hospitals not motivated by
financial incentives fared just as well.
We can complain about these bonuses all we
want, but they are becoming more and more real.
At least 40 private insurers have already followed
Medicare’s lead instituting Pay for Performance
incentives. Medicare also plans to increase
this bonus to 2 percent of reimbursement.
Considerations for future additional quality
measures are hospital cost-efficiency, infection
frequency and emergency department wait times.
Why are we entering a system that rewards
and punishes physicians based essentially on
“courtesy” and “respect?” Are these words just
parameters now, incentives? Are the rising
MCAT and GPA requirements for medical school
admissions drawing less well-rounded applicants?
Are we evolving into a less humanitarian
profession and therefore have to create rules to
ensure we appear to care about people? Are the
demands for profuse documentation causing us
Doctors’ Lounge
to spend less time with patients? Will we simply
game the system – create a facade of care just to
enhance reimbursement?
One prominent physician has found a way to
appeal to dignity and professionalism without
creating a financial motive. Johns Hopkins
physician Peter Provonost developed a very
successful checklist that reduced catheter-related
infections. New York Times writer Bill Keller
points out that Dr. Provonost did this not with
pay incentives but by appealing to physicians’
pride.
Checklists in medicine are gaining popularity,
as we have adapted techniques used in other
high-risk specialties (airline industry, nuclear
power). Dr. Atul Gawande’s book The Checklist
Manifesto is a must-read. Perhaps we should
incorporate a checklist in our electronic medical
records, to include the three physician-related
survey questions and one for pain control. We
could input four boxes at the end of each chart
to ensure we have done our best to enhance
the patient’s perception that high-quality care
was delivered. Our charts could look like
kindergarten report cards – did we treat our
patients with courtesy and respect, or did we
steal their lunchboxes?
Or, we could just treat our patients with
compassion and be good doctors. LM
Note: Dr. Huecker practices Emergency
Medicine with Physicians in Emergency
Medicine. He serves as gratis faculty for the
University of Louisville School of Medicine,
Department of Emergency Medicine.
Letter to the Editor
Philip T. Browne, MD
D
r. Deborah Ballard’s article (“How
Integrative Medicine Can Improve
Patient Outcomes and Advance
the Accountable Care Organization Model,”
February 2013) was interesting from a number
of standpoints, some topical and others personal.
Her professional address, Holiwell Health
Consultation, is a new venture just incorporated
in December 2012. There is no information
available on her webpage about the nature of
this practice, but I assume it is distinct from her
previous Internal Medicine practice.
She espouses the current trend toward
including unproven techniques in standard
medical practice under the rubric of integrative
medicine. Her examples of acupuncture and
healing touch date back to the prescientific
era and rely on improbable concepts for their
acceptance. They are examples of placebo
medicine, which have long been utilized when
appropriate in standard medical care.
and anxiety, and reverse diseases caused by an
unhealthy lifestyle.”
Her definition of integrative medicine notes
it “makes use of all appropriate therapeutic
approaches, healthcare professionals and
disciplines to achieve optimal health and healing.”
Who can argue with that? The rub comes when
you enumerate WHAT therapeutic approaches,
and WHO these health care professionals are.
It is clearly obvious that nurse practitioners,
massage therapists, acupuncturists and the
various purveyors of so-called mind-body
medicine can more cheaply see and treat sick
people than medical and surgical physicians. It
also seems likely that, in the near future, many
patients will no longer have a say in who they
seek care from. LM
Ah, but the underlying secret is her plea to
Advance the Accountable Care Organization
Model. Various political and medical forecasters
have suggested that, in order to reduce costs,
much medical management will be done by nonphysicians. Decisions concerning eligibility for
care could be made by administrative advocates
that will, as Dr. Ballard states, “empower people
with knowledge and skills they can apply in
their everyday lives to heal faster, control pain
Note: Dr. Browne is a retired orthopedic
surgeon.
April 2013
37
Doctors’ Lounge
Letter to the Editor
W
e are writing to our colleagues
in the local medical community
asking you to join us in supporting
Grow Smart Louisville, a nonprofit organization
working to promote smart growth in Metro
Louisville. We have volunteered our time and
resources to Grow Smart Louisville’s efforts to
engage the United States Department of Veterans
Affairs in reconsidering a downtown location for
its new medical center.
Approximately nine months ago, the VA
purchased a tract of land at Brownsboro Road
and the Watterson Expressway with plans to build
a new state-of-the-art medical center to replace
its existing hospital located off Zorn Avenue.
The improvements made to the eastbound offramp from the Watterson to Brownsboro Road
were not connected to the construction of the
hospital. Construction on the actual hospital will
not begin on-site until mid-2014 at the earliest.
In other words, despite popular belief that this
land will be used by the government for a new
veterans’ medical center, it is NOT a “done deal.”
Our belief is that this facility should be built
downtown adjacent to University Hospital and
near other world-class health care facilities.
Grow Smart Louisville contends, and we agree,
that this is a better location for veterans and the
community as a whole. A downtown medical
center offers:
• Better care for veterans by being
conveniently located near our downtown
offices or where we are already performing
rounds
• Access for veterans to health care technology
already located in the downtown medical
campus
• Utilization of resident and student
38
LOUISVILLE MEDICINE
Harold Blevins, MD,
Michael Cassaro, MD
physicians already working downtown
• Occasions for hospitals and physicians to
work together in finding innovative ways
to improve health for patients
• Relief from duplication of services by the
VA in having to hire physicians or buy
equipment with tax dollars to fill voids
created by a hospital in the suburbs
• A safer experience for veterans with
greater vehicular access and connected and
reserved parking
• More convenience for veterans’ family
members with vehicular access, nearby
hotels and wide selection of restaurants
and attractions
• Opportunities for business development
through medical research grants, expansion
(hotels, restaurants, etc.) and tax income for
the community
We have also identified other uses for the
existing site selection that will serve veterans
with even greater needs. Grow Smart Louisville
is researching the feasibility of these options.
It’s NOT too late! NOW is the time to show
your support for the effort to build the VA’s new
medical center downtown where it belongs. More
than 90 percent of veterans’ medical centers are
located in downtown urban settings connected
to university hospitals. Our veterans deserve the
same level of care.
If you would like to support this project, there
are many ways you can help.
• Visit http://growsmartlouisville.org to add
your name to our list of supporters.
• Contribute $25, $50 or $100 to Grow
Smart Louisville’s legal, public relations
and administrative fees. Visit the website
for more information.
• Contact local Metro, state and congressional
representatives to express your support for
a DOWNTOWN veterans’ medical center.
• Spread the word about Grow Smart
Louisville to your colleagues, friends and
family.
Grow Smart Louisville is earning support
from veterans, physicians and other health care
professionals, community leaders and elected
officials wanting to make sure the VA does the
right thing for our local veterans and citizenry.
We hope you will join us. LM
Note: Dr. Blevins practices Otolaryngology with
ENT Associates. Dr. Cassaro practices Pain
Medicine in solo private practice.
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[email protected]
April 2013
39
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IBC
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39
State Volunteer Mutual Insurance Co
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Medical Protective
39
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www.painstopshere.org
KMA Insurance Agency
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OBC
www.republicbank.com
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Jewish Hospital St Mary’s HealthCare
The Pain Institute
www.pasmedicalbilling.com
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Humana CareSource
26
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Floyd Memorial Hospital-Home Health
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28
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The Doctors Company
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VanZandt Emrich & Cary
33
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Medical Society Employment Services
11
www.glms.org
(Continued from page 35)
economy, are slowly dropping into a sinkhole of
medical costs that greed has created and lobbyists
for the entire medical industry have successfully
maintained. Together, medical industry lobbyists
have spent $5.36 billion dollars in Washington
since 1998. The defense and aerospace industries
together have only managed $1.53 billion, and
the oil industry just over $1 billion.
We spend in the USA 20 percent of our
GDP on health care, twice as much as do other
developed countries. Said Mr. Brill, “We spend
more every year on artificial hips and knees than
what Hollywood collects at the box office. We
spend the $60 billion price tag for cleaning up
after Hurricane Sandy every week now.”
Mr. Brill argues that moving everyone to
Medicare now would save the country lots of
40
LOUISVILLE MEDICINE
money, because hospital systems could charge us
all day and have to eat their exorbitant fees. He
said theoretically (for politically it seems quite
impossible) that charging younger people the
sorts of premiums we pay now for commercial
insurance, that charging wealthier Medicare
recipients a bit more for outpatient care, all in
one single-payer system will save us trillions.
His presentation of the data is convincing. But
since that is so unlikely (we cannot even manage
a budget in our current government) he wants
to outlaw the Chargemaster. I wish him luck. No
one can afford American medical care, yet we
doctors continue to order it up, and families go
broke paying for it. I would love to see a singlepayer system where the bills mean what they
say, and people get what they need. But the day
that happens will be the day I start for Coach
Pitino. The madness will continue, and the U.S.
will slowly be buried by its cost. LM
Note: Dr. Barry practices Internal Medicine
with Norton Community Medical AssociatesBarret. She is a clinical associate professor at
the University of Louisville School of Medicine,
Department of Medicine.
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LOUISVILLE, KY 40202
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