January 2011 - Greater Louisville Medical Society
Transcription
January 2011 - Greater Louisville Medical Society
LOUISVILLE GREATER LOUISVILLE mEdIcAL SOcIETy MEDICINE VOL. 58 nO. 8 jAnUARy 2011 T H E O R I G I N A L H O M E C A R E P E O P L E When it’s time for home care, refer to VNA Nazareth Home Care. Our goal is to give your patients the same great care you provide, in the home. With our innovative services and specialty programs, we can help your patients regain their independence and quality of life. Want to find out more about our specialty programs such as Safe Sight, Diabetes Management, Falls Prevention and many more? Visit www.vnanazareth.org or call 1-800-346-4577. HomeCare Elite TM 2006 t 2007 t 2008 t 2009 Physician Priority Line: 502-585-7699 Referral Fax: 502-581-8682 General Information: 1-800-346-4577 www.vnanazareth.org Attention all Internal Medicine, Family Practice and Endocrinology Physicians who treat Diabetes patients: The GLmS Physicians Take AIm at diabetes Program invites YOU to participate in this exciting initiative. By attaining the NCQA DRP Recognition you: • Demonstrate to your patients that you are providing excellence in diabetes care • Earn increased respect from your peers The GLMS AIM Program provides at no charge: • DRP audit support • DRP practice administrative and educational support services • Patient and physician tools The GLMS AIM Program is excited to announce: • PQRI Reporting audit services at no charge offered when applying for new DRP services to qualifying physicians. • Physicians can earn an incentive payment of up to 2 percent of their total allowed charges for all Medicare services billed in 2010. Contact: Dottie Hargett, Director of Professional Relations and AIM Program Director at 502-736-6348 or [email protected] I don’t just have insurance. I own the company. Katrina Hood, M.D., F.A.A.P. Pediatrician PEDIATRIC & ADOLESCENT ASSOCIATES, LEXINGTON, KY Medical Professional Liability Insurance “Like me, you’ve probably noticed some professional liability insurance providers recently offering physicians what seem to be lower rates. But when I took a closer look at what they had to offer, I realized they simply couldn’t match SVMIC in terms of value and service. And SVMIC gives me the peace of mind that comes when you’re covered by a company with more than 30 years of service and the financial stability of an “A” (Excellent) rating. At SVMIC, I know it’s not just one person I rely on… there are 165 professionals who work for me. That’s because SVMIC is owned by you, me, and over 15,000 other physicians across the Southeast. So we know our best interests will always come first.” Mutual Interests. Mutually Insured. Contact Susan Decareaux or Jesse Lawler at [email protected] or call 1-800-342-2239. svmic.com GLMS Board of Governors Lynn T. Simon, MD, board chair Kimberly A. Alumbaugh, MD, president David E. Bybee, MD, president-elect Robert A. Zaring, MD, vice president and AMA alternate delegate Heather L. Harmon, MD, treasurer James Patrick Murphy, MD, secretary Robert H. Couch, MD, at-large Elmer Dunbar, MD, at-large John M. Gormley, MD, at-large Daniel W. Varga, MD, at-large Jonathan W. Wilding, MD, at-large Russell Williams, MD, at-large Bruce Scott, MD, AMA delegate Gordon R. Tobin, MD, KMA president Fred A. Williams, Jr., MD, KMA 5th district trustee David R. Watkins, MD, KMA 5th district trustee alternate K. Thomas Reichard, MD, GLMS Foundation president Stephen S. Kirzinger, MD, Medical Society Professional Services president Edward C. Halperin, MD, MA, dean, UofL School of Medicine Matthew M. Zahn, MD, interim director, Louisville Metro Dept. of Public Health & Wellness Jay P. Davidson, president and CEO, The Healing Place Lisa Sosnin, GLMSA president Louisville Medicine Editorial Board Editor: Mary G. Barry, MD Elizabeth A. Amin, MD Deborah A. Ballard, MD Arun Gadre, MD Stanley A. Gall, MD Larry P. Griffin, MD Darin Harden, MD Kenneth C. Henderson, MD Jonathan E. Hodes, MD Thomas James III, MD Michael T. Macfarlane, MD Joe Maurer, MD Teresita Bacani-Oropilla, MD Danielle Pigneri Tracy Ragland, MD Charles B. Ross, MD M. Saleem Seyal, MD Dave Langdon, Louisville Metro Department of Public Health & Wellness Lynn T. Simon, MD, board chair Kimberly A. Alumbaugh, MD, president David E. Bybee, MD, president-elect Lelan K. Woodmansee, CAE, executive director Bert Guinn, MBA, communications & membership director Ellen R. Hale, communications associate Donna Watts, communications designer Advertising Cheri K. McGuire, director of marketing 736.6336, [email protected] LouiSviLLE MEdicinE is published monthly by the Greater Louisville Medical Society, 101 W. Chestnut St. Louisville, Ky. 40202 (502) 589-2001, Fax 581-9022, www.glms.org. Articles to be submitted for publication in LM must be received on electronic file on the first day of the month, two months preceding publication. Opinions expressed herein are those of individual contributors and do not necessarily reflect the position of the Greater Louisville Medical Society. LM reminds readers this is not a peer reviewed scientific journal. LM reserves the right to make the final decision on all content and advertisements. Circulation: 3,800 LOUISVILLE MEDICINE GREATER LOUISVILLE mEdIcAL SOcIETy VOL. 58 nO. 8 jAnUARy 2011 FEATURE ARTICLES 9 12 18 20 32 39 A Brief Look at the Birth and Growth of neurosurgery Andy Dzenitis, MD Behind closed doors Christi Bradshaw The Richard Spear, Md, Memorial Essay contest: 2011 Mary G. Barry, MD issues in Public Health and Preventive care: Something to Build on Deborah Ann Ballard, MD The Gawandes of Athens, ohio M. Saleem Seyal, MD, FACP, FACC An unforgettable Patient Elsa M. Haddad, MD DEPARTMENTS 5 11 14 From the President Kimberly A. Alumbaugh, MD Physicians in Print Book Review: Start-up Nation: The Story of Israel’s Economic Miracle by Dan Senor and Saul Singer Reviewed by Arun K. Gadre, MD, FACS 22 Book Review: 26 28 30 31 35 Reflections The Checklist Manifesto - How To Get Things Right by Atul Gawande Reviewed by M. Saleem Seyal, MD, FACP, FACC Say Thank You Teresita Bacani-Oropilla, MD Alliance news Lisa Sosnin, RN We Welcome You in Remembrance Robert Pfeiffer Kraft Jr., Md Carolyn Kraft doctors’ Lounge The Ville Is Not Vegas Mary G. Barry, MD Stroke Prevention Breakthrough in Patients with AF Kerri S. Remmel, MD, PhD JANUARY 2011 3 FROm THE PRESIdEnT Kimberly A. Alumbaugh, MD GLMS President Meeting with the soon-to-be most part, all of our practices, hos- us a reprieve from the bottom of mayor, Greg Fischer, last month, I pitals and health systems could be every good list? was reminded how similar driven improved. Couldn’t they? The trick is individuals are, no matter what their knowing who your audience is, vocation. A good mind, a good knowing what matters him “close the gap” heart and a good work ethic are to them and caring from where we find truly the tools of any successful enough to do something our city to where individual, no matter his or her pro- about it. Intuiting the our city should be. fession. The mayor, a businessman, problems of the system Our meeting deliv- has an enthusiasm for his new job is not difficult, you ered to him the that is palpable, and through his simply need to slow message that we connection to medicine, with a wife down your personal rat are a physician who is a pediatric pathologist, he race long enough to work force ready to understands how linked the health really take a look. meet any chal- of our community is to its future. Mayor Fischer is looking for a few good men and women to help As you reassess what lenge. His message Folks who hang out with physicians you did well last year, in return is that he often get that perspective a little what you hope to do is going to ask us better than the average business- better this year and to help. He is going man or businesswoman. where you totally missed to emphasize what the mark, try to lend a is right with our If you read Mayor Fischer’s bio online, it is interesting that his few minutes to the company, SerVend, was a Baldrige problems of our city as a quality award finalist. Hospitals and health desert. Our medical society is to move forward together as a com- progressive companies alike can loaded with 3,800 physicians who munity, compassionately. Gosh, it receive these. The Baldrige awards are oases of ability and who among sounds like he has spent some time are given in multiple fields for them must have a bazillion neurons hanging out with a physician ... LM mayor Greg Fischer improving competitiveness and per- that could create a web of thought formance. What a treat it will be to so prodigious that we could fix our watch Mayor Fischer apply best hometown’s barriers for adequate practice principles to Metro govern- health care. We could help find ment. Not that the local govern- ways that every child could eat ment doesn’t run fairly well, it does, good food and exercise. Couldn’t but almost every situation can be we? We could make sure no child made better with intentional intu- missed out on health care, couldn’t ition. we? If how we treat the least among Now, sometimes it is true, espe- city, change what is wrong and urge us Note: Dr. Alumbaugh practices Obstetrics and Gynecology with Total Woman PLLC. E-mail her at [email protected]. us is how we ourselves will be cially in surgery, that great is the treated, shouldn’t we at least try? I enemy of good. You know that last know we all do our small parts every little snip that leads to 10 extra day, but isn’t it time for a grand sutures that you would have liked to effort to remove Kentucky from the have done without? But, for the No. 1 spot on every bad list and give JANUARY 2011 5 JANUARY 2011 7 A Brief Look at the Birth and Growth of neurosurgery Andy Dzenitis, MD E vident from bone healing in scores of excavated skulls, attempts at primitive brain surgery date back to the Neolithic period. Though lacking in therapeutic value, these findings are more likely a credit to the skill of the operator and hardiness of the “patient.” first pharmacist and operative surgeon, designed instruments to avoid dural tears during trephination! He also ligated the temporal artery for headaches and placed opium-laced cloth over the mouth and nose as intraoperative sedation. He published Kitab al-Tasrif (a medical encyclopedia), Continued on page 10 Edwin Smith’s discovery of Egyptian papyri gave us a record of the cunning and clinical judgment of Imhotep’s selection of treatable ailments and wounds (circa 28 to 26 centuries B.C.). Hippocrates (circa 460 to 377 B.C.) and Galen (circa A.D. 130 to 210) did appreciate that injuries to the head led to incapacity or death of the victim. During the Medieval period, besides the observations of Lefrank (1250-1306) and de Chauliac (13001368), there were no pertinent advances in science or care of the injured brain. However, 10th and 11th century Middle Eastern physicians showed a remarkable understanding of human anatomy and surgical skills. Two Arabs, Albucasis and Avicenna, studied writings of Hippocrates and Galen and corrected and recorded their misconceptions. Rhazes (A.D. 864) was first to describe cerebral concussion and showed remarkably accurate understanding of the spine and nerve roots. Albucasis (A.D. 936-1013), considered the JANUARY 2011 9 Continued from page 9 writing on spinal anatomy, management of trauma, cranial fractures, CSF drainage for hydrocephalus, migraine, back pain and facial palsy. Avicenna (A.D. 980-1037) bridged Eastern and Western cultures and was decreed the “Prince of Physicians.” Ambroise Paré (1510-1590), known as the father of military surgery and skilled in traumatic wound care treatment (“I dressed him and God healed him” and “Cure occasionally, relieve often, console always”), lifted bone fragments and debris from head wounds. He also reasoned that phantom limb sense occurred in the brain. But as late as 1874, London surgeon John Erichsen wrote: “The abdomen, chest, and brain will forever be closed to operations by a wise and humane surgeon.” Frenchman Jean Louis Petit, inventor of the tourniquet, and Percival Pott (John Hunter’s mentor) had some successes treating cranial trauma and suppuration in the 17th and 18th centuries. However, it was the genius, courage and skill of the likes of W.W. Keen, Ernst von Bergmann, William Macewen, Victor Horsley and Harvey Cushing that initiated neurosurgery as a specialty of its own. Philadelphian William Williams Keen (18371932) was the first American brain surgeon who succeeded in removing a meningioma. During his long career, he treated Civil War troops, operated on President Grover Cleveland’s tumor in the neck, diagnosed polio in President Franklin D. Roosevelt and later lectured on surgical pathology. Among the contributions of Russian-born German von Bergmann (1836-1907) to neurosurgery are aseptic surgical technique, steam sterilization of instruments and follow-up records on patients. Glaswegian William Macewen (1848-1924) was the first to perform a brain operation for tumor based on clinical findings, thus showing his understanding of cerebral localization (1879). This predated Britain’s Rickham Godley’s extirpation of a meningioma in 1884. Sir Victor Horsley (1857-1916) was first to confine his practice to Neurosurgery and in 1890 published an article on surgical treatment of hematoma, hydrocephalus, skull fractures and abscess. He introduced the use of beeswax for control of bleeding diploic bone. Trained in Halstedian tradition, Harvey Williams Cushing (1869-1939) found Horsley’s surgical techniques coarse and mortalities unacceptable. With 10 LOUISVILLE MEDICINE Cushing’s meticulous surgical skills, operative mortalities dropped from 90 percent to 8, thus setting new standards in Neurosurgery. He was recognized worldwide as a teacher, scientist and author. Cushing was a contributor in endocrinology and CSF pressure dynamics, utilized Röntgens’ X-rays in diagnostics and refined Riva-Rocci’s sphygmomanometry in tracking vital signs during surgery. Additionally, he authored 14 books, 300 articles and won a Pulitzer Prize for Osler’s biography. Walter Edward Dandy (1886-1946), a precocious Missourian, Johns Hopkins-trained, intellectually gifted and technically skilled, was nominated for a Nobel Prize owing to his work in neurodiagnostics (pneumoencephalography, 1919). He established the principles of CSF circulation and was first to clip an intracranial aneurysm (PCA), although Norman Dott had successfully treated an aneurysm by wrapping it with a muscle pledget. Dandy completed the removal of acoustic neuroma, operated and described the surgery for ruptured lumbar disc in 1929 (five years ahead of Mixter and Barr), and is considered by many as the most gifted American neurosurgeon of his time. Prior to the discovery of X-rays, diagnostic judgment in neurology and surgery was largely based on clinical findings. This often led to missed diagnosis and negative surgical exploration. In 1895, engineering genius Wilhelm Conrad Röntgen found that his wife’s hand left different shadows for bone and flesh when interposed between cathode rays and a photographic plate. Roentgenology was born and the Nobel Prize went to its discoverer in 1901. The last four decades witnessed development of radioisotope scanning, computed tomography (Godfrey Hounsfield, 1967, Nobel Prize in 1979), magnetic resonance imaging in 1975 and 3-D image reconstruction. Positron emission tomography scanning was introduced in 1988 by Steven Petersen and Marcus Raichle and showed brain function in “real time.” Today minimally invasive surgery, endoscopic and intraoperative guided imaging and the endovascular approach to inaccessible lesions are commonly employed. Robotics in Neurosurgery may be “just around the corner.” LM Note: Dr. Dzenitis is a retired neurological surgeon. He is also clinical professor emeritus in the University of Louisville School of Medicine’s Department of Neurosurgery. PHySIcIAnS In PRInT Arthur JM, Klein jB. Proteomics in CKD. Adv Chronic Kidney Dis. 2010 Nov;17(6):453-4. PubMed PMID: 21044767. Bays HE, Maki KC, Schmitz K. Colesevelam HCl Powder for Oral Suspension versus Cholestyramine Powder for Oral Suspension: Comparison of Acceptability and Tolerability. Endocr Pract. 2010 Nov 1:1-23. PubMed PMID: 21041163. dimar jR, Carreon LY, Riina J, Schwartz DG, Harris MB. Early versus late stabilization of the spine in the polytrauma patient. Spine (Phila Pa 1976). 2010 Oct 1;35(21 Suppl):S187-92. PubMed PMID: 20881461. Mowlavi A, Pham S, Wilhelmi Bj, Masouem S, Guyuron B. Anatomical characteristics of the conchal cartilage with suggested clinical applications in rhinoplasty surgery. Aesthet Surg J. 2010 Jul-Aug; 30(4):522-6. Funke AA, Kulp-Shorten cL, callen jP. Subacute cutaneous lupus erythematosus exacerbated or induced by chemotherapy. Arch Dermatol. 2010 Oct;146(10):1113-6. PubMed PMID: 20956642. Peitzman AB, Richardson jd. Surgical treatment of injuries to the solid abdominal organs: a 50year perspective from the journal of trauma. J Trauma. 2010 Nov;69(5):1011-21. PubMed PMID: 21068605. Casperson BK, Anaya-Baez V, Kirzinger SS, Sattenberg R, Heidenreich JO. Coexisting MS and Lehmitte-Duclos Disease. Radiology Case. 2010 Aug; 4(8):1-6. Hazani R, Elston, J, Whitney RD, Redstone J, Chowdhry S, Wilhelmi Bj. Safe treatment of trigger thumb with longitudinal anatomic landmarks. Eplasty. 2010 Sep 15; 10. pii: e57. Chinnapongse R, Pappert EJ, Evatt M, Freeman A, Birmingham W. An open-label, sequential doseescalation, safety, and tolerability study of rimabotulinumtoxinb in subjects with cervical dystonia. Int J Neurosci. 2010 Nov;120(11):703-10. PubMed PMID: 20942584. Kapoor N, Fahsah I, Karim R, Jevans AJ, Leesar MA. Physiological assessment of renal artery stenosis: comparisons of resting with hyperemic renal pressure measurements. Catheter Cardiovasc Interv. 2010 Nov 1;76(5):726-32. PubMed PMID: 20931666. Chowdhry S, Hazani R, Collis P, Wilhelmi Bj. Anatomical landmarks for safe elevation of the deep inferior epigastric perforator flap: a cadaveric study. Eplasty. 2010 May 28;10:e41. Mays CJ, Steeg KV, Chowdhry S, Seligson d, Wilhelmi Bj. Wrist joint reconstruction with a vascularized fibula free flap following giant cell tumor excision in the distal radius. Eplasty. 2010 May 22;10:e38. Chowdhry S, Yoder EM, Cooperman RD, Yoder VR, Wilhelmi Bj. Locating the cervical motor branch of the facial nerve: anatomy and clinical application. Plast Recontr Surg. 2010 Sep; 126(3):875-9. Merchant ML, Klein jB. Proteomic discovery of diabetic nephropathy biomarkers. Adv Chronic Kidney Dis. 2010 Nov;17(6):480-6. PubMed PMID: 21044770. Pham S, Wilhelmi Bj, Mowlavi A. Eyebrow peak position redefined. Aesthet Surg J. 2010 May;30(3):297-300. Van Berkel V, Kuo E, Meyers BF. Pneumothorax, bullous disease, and emphysema. Surg Clin North Am. 2010 Oct;90(5):935-53. Review. PubMed PMID: 20955876. Banerjee T. A Day in Neurosurgery: Brain + Spine and a Lot More. PublishAmerica, December 2010. NOTE: GLMS members’ names appear in boldface type. Most of the references have been obtained through the use of a MEDLINE computer search which is provided by norton Healthcare medical Library. If you have a recent reference that did not appear and would like to have it published in our next issue, please send it to Alecia Miller by fax (736-6363) or e-mail ([email protected]). LM “The SBA 504 loan program is just what the doctor ordered!” SYMPTOM: PRESCRIPTION: PROGNOSIS: RESULT: Financing for fixed asset needs. Take one SBA 504 loan and rest Saving $$$$$$ Long term loan with fixed rate of interest As little as 10% equity injection required Better cash flow Financial stress relief Contact Capital Access Corporation-Kentucky today and see what benefits you can realize by discussing your fixed asset loan requirements with the #1 SBA lender in Kentuckiana. Servicing Kentucky and Southern Indiana CAPITAL ACCESS CORPORATION-KENTUCKY 401 W Main Street, Suite 2010 • Louisville, KY 40202 502.584.2175 www.cac-ky.org JANUARY 2011 11 Behind closed doors Christi Bradshaw It’s 7:30 a.m. on a Monday morning. My keys rattle as I pull them out of the debris in the pocket of my white coat and place them in the lock. I unlock the imposing wooden door and step across the threshold that separates the outside world of sanity and propriety, albeit tenuous at times, from the world where aberration and misfiring neurons reign supreme. In other words, I step onto the floor of an inpatient psychiatry unit, about to begin yet another day of my third-year psychiatry clerkship, to be confronted with all the bizarreness that such an experience often entails. Going into my psychiatry rotation, I expected a number of things from my time on the inpatient unit, all of which happened: the accumulation of outlandish stories, encounters with eccentric patients, and of course, medical insight into the subtleties of mental illness. What I didn’t expect, however, was the degree to which I became attached to some of the patients, one in particular. In the midst of manic individuals speaking illogically at high velocities, schizophrenics throwing medication at nurses in order to rebel against “the conspiracy,” and severely depressed patients who hibernated in bed, there was Mrs. V. Unbeknownst to her, my interactions with Mrs. V defined the tone of my psychiatry clerkship and provided me with the most compelling sense of reward that I had experienced thus far in my clinical rotations. A middle-aged woman admitted to the unit for profound depression and suicidal thoughts, Mrs. V’s story seemed at first indistinguishable from those of her depressed peers. What began as a nuts-and-bolts investigation into yet another case of major depressive disorder, though, quickly morphed into one of emotional investment and reciprocal awe and respect. The first step in this progression occurred during my first meeting with Mrs. V in which she shared her story with the physicians and me. Vulnerable and sincere, Mrs. V tearfully relayed the tale of the death of her 13-month-old son 17 years ago and the unrelenting guilt and grief that had plagued her ever since. Her friends’ and family’s incessant and at times callous comments to “take it to the Lord” and “leave it all up to God” did little to console her, and the pressure of raising seven other children along with adjusting to her recent diagnosis of myasthenia gravis only hastened her downward spiral. Thoughts of overdose and an emergency therapy visit later, she sat before me, morose and fatigued yet eager to embark on the long road to recovery. “I am willing to do whatever it takes to get better,” she stated with as much fervor as she could muster, and with that one statement and a look around at the apathetic group of folks populating the stale beige corridors of the unit, I knew I had stumbled upon someone special. 12 LOUISVILLE MEDICINE It didn’t take much time before I found myself looking forward to my morning dialogues with Mrs. V. Whereas most patients would grunt responses to my early morning questions, she would willingly expand upon the topics of inquiry and then end the conversation with “Thank you so much for your help.” Her compliance was made even more outstanding when juxtaposed with some of the other majorly depressed patients on the unit, who only emerged from their rooms for meals, if then. Now, although the politeness and cooperation that characterized Mrs. V were a rare find during my six weeks on inpatient psychiatry, the qualities were not unheard of. To be fair, I encountered a handful of patients who possessed the faculty and insight that allowed them to recognize the value of the staff’s actions and to subsequently engage willingly in therapeutic activities. What separated Mrs. V from these similarly afflicted people, however, was how effectively and positively she was able to deal with her discomfort, whether it was mental, emotional or physical. During her hospital stay, it was rare to hear her complain about her struggles with myasthenia gravis. When one day I entered her room, found her huddled on her bed with her hand over her eye and asked her what was wrong, it was only then that she revealed that she had been experiencing double vision, a common finding in myasthenia gravis sufferers. The dosage of the appropriate medication was quickly adjusted, an action that would have been missed since she hadn’t let her debilitating condition prevent her from doing all that was necessary to achieve recovery from her grief. She’d gotten out of her room to attend group therapy even with double vision, and also had engaged in extensive individual psychotherapy with her attending physician. In short, she hadn’t used her illness as an excuse to wallow in her depression, a convenient behavior that might appeal to most of us human beings in our times of melancholy. Aside from her unwavering dedication to improve her mental health, perhaps the most impressive aspect of Mrs. V’s two weeks on the unit was how she interacted with her peers on the floor. For anyone who maintains a relatively accurate grasp on reality and has stepped onto an inpatient psychiatric floor, it is overwhelming at the best of times. Witnessing psychosis in action can be assaulting to the senses, whether it’s one’s first time encountering such a scene or 20th year in practice. Therefore, it is not surprising that many of the solely depressed patients on the unit appeared frightened, amused or even repulsed by their more “unbalanced” roommates or neighbors. Here again, however, Mrs. V distinguished herself, for she dealt with everyone, from hostile schizophrenics to irritable bipolar patients to the generally disgruntled with a kindness and ingenuousness that one seldom sees in daily life outside the hospital walls. When I inquired as to how she was handling the color on the floor, she said, “I enjoy talking to everyone here. They’ve really helped me see that we ALL have problems and that we can use our different experiences to help one another through hard times.” In the month after she was discharged, I never heard another patient capture the value of such encounters more profoundly, and that same insight is something I certainly hope she will never forget either. As influential as Mrs. V’s two-week hospitalization was toward her recovery from grief, so was her impact on my desire to continue pursuing my career in medicine. At one time or another, I’m sure every one of us who has embarked on the long and arduous road to physician-hood has questioned whether or not the sacrifice, the commitment and the 64 ounces of caffeine daily are worth it. Even as a mere medical student, it is all too easy to become jaded and to let doubt creep in. Fortunately, though, there are moments in medicine that poignantly capture the true essence of what it means to care for a fellow human being, and as I walked away from my time in psychiatry, the door to the unit locked behind me, it is those moments that I most look forward to. LM Note: Christi Bradshaw is a fourth-year student at the University of Louisville School of Medicine. Did You Know? National Insurance Agency offers GLMS Physicians unique insurance products not available in the ordinary Insurance marketplace. GLMS Individual Own Occupation Disability Income Plan. New Issue and Participation limits make the GLMS Disability Plan a valuable addition for both small and large practice physicians seeking additional protection. Call, visit us at NIAI.com, or have your agent call us to learn more about these special plans. NIA GROUP NATIONAL INSURANCE AGENCY Inc. Professional Association & Affinity Insurance Services www.niai.com • Phone: 502 425-3232 • Contact Woody Long Directly: [email protected] BOOK REVIEW Start-up nation: The Story of Israel’s Economic miracle BY dAn SEnoR And SAuL SinGER Twelve, Grand central Publishing, november 2009 Reviewed by Arun K. Gadre, MD, FACS Israel appears to be perpetually in the news – most of it bad. On what seems like a daily basis, the newswires crackle with the actions of human kamikaze bombers. Newscasts show the saber-rattling of an apparently crazed leader of the once-great Persian nation, with threatened nuclear annihilation of the Jewish state. These vie for headlines with news of violence on board a “peace flotilla” from Turkey headed for Gaza. In the face of the violence and an existential threat, coupled with a nadir in U.S.Israeli relations, this book describes the curiously paradoxical phenomenon of an ascendancy of the economy of a tiny sliver of land at the eastern edge of the Mediterranean. As the authors succinctly put it, “This is a book about innovation and entrepreneurship,” and is undoubtedly one of the most thought-provoking books I have ever read. Tuesday evening on March 9, 2010, was yet another gray winter day in Louisville, and relations between Washington and Jerusalem were at their soggy best. An expectant crowd of perhaps 150 people gathered in an off-the-foyer room within the clubhouse at the Standard Country Club. They 14 LOUISVILLE MEDICINE came from every walk of life, some having driven in from as far away as Lexington and Bowling Green. A few sat stiffly in their chairs, their anticipation palpable, but most made pleasant conversation among themselves, milling about and nibbling on pastries, and partaking of soft drinks from tables that lined a side of that large hall. The snacks were a handsome diversion but were clearly not a huge attraction for those gathered. The 6:30 hour came and passed, and the crowd was restless. Was his flight delayed as someone had suggested? Soon one of the organizers took the podium, and the guests began taking their seats. At the back of the hall, leaning quietly against the wall, water bottle in hand, stood an unassuming but distinguished gentleman. His was the arrival that was eagerly anticipated. He appeared perhaps not quite 40 years old. Boyish features contrasted with a determined square jawline, and scholarly yet wistful spectacled eyes drew one’s attention away from a broad forehead and a disarming smile. He wore well-pressed trousers and a suit jacket over an open-collar shirt. He sipped from a water bottle that graced his long fingers. His manner was disarming, and there was nothing pompous or haughty about one who had, despite his youth, left an indelible mark on the newly democratic post-Saddam Iraqi nation. His casual style belied a tremendous depth of knowledge that became evident as he began to speak. He Continued on page 16 Continued from page 14 paced back and forth while connecting with the audience, who listened in rapt attention, mesmerized as it were, hanging on to his every word. The hour passed by too quickly. Dan Senor, from appearances on television, had been the face of the Coalition Provisional Authority in Iraq and was one of the earliest civilians to follow our military after the fall of Baghdad in 2003. For a while, he had disappeared from the glare of the public spotlight but then, quite by accident, I saw him again, on Book TV C-SPAN2, discussing his first book. It had little if anything to do with Iraq. I was not about to pass up the opportunity to hear a person with such distinguished credentials speaking in our fair city. Start-up Nation is the product of the labor of two authors, Dan Senor from New York and Saul Singer, who lives in Jerusalem. The book has 340 pages, 242 of narrative with the rest including notes, a well-annotated bibliography and an index. It belongs to the realm of business and economics rather than history. The project congealed when Mr. Senor, who is a product of the vaunted Harvard Business School, took a bunch of students to Israel. These students were not all Jewish; indeed it was a most international and diverse group. They were all there to personally witness and study the great boom in the Israeli economy, despite the backdrop of violence and war. All determined to answer the same question … why? Out of their deliberations and interactions with formidable political and business leaders in the field was conceived Start-up Nation. The authors debunk the myth that this success is solely the result of wealthy Jews of the Diaspora. Indeed, most multinational companies investing in Israel do so because they see the value of it, and most are run by non-Jews. They ascribe the success to a few well-defined attributes. In their opinion, the military experience of every child after high school imbues individuals with maturity, so that when they enter higher education they get more out of that educational experience than their counterparts in other countries. Military experience also teaches the concept of leadership and team spirit and the need, indeed the imperative, to depend on each other, thereby making them resilient and cooperative. The ability of Israelis to take a critical look at their mistakes and discuss and argue with each other irrespective of rank or status in society and then come up with a solution, is refreshing. In the workplace, solutions are ordinarily not ordained from above but come from within the ranks. In the opinion of the authors this, coupled with favorable government policies toward immigration and business, is what makes the nation and its economy tick. Each of these attributes individually may not be unique to the country and yet the entire package is uniquely Israeli. Each chapter is laced with true stories that are as inspirational as they are educational. For those who are not fortunate enough (or do not have the time) to read the book, here are a few snippets. Israel welcomes Jewish immigrants from very disparate cultures. A Jew from Russia has almost nothing in common with one from Ethiopia or India (perhaps 16 LOUISVILLE MEDICINE the belief in one God being the exception) and yet instead of marginalizing those less privileged, no effort is spared to uplift and integrate. This provides a source of manpower not only to defend the country but a motivated work force that is the lifeblood of its economy. The book is not a chronological historical document either, but is a mosaic of stories and examples that in their totality make the case for Israel’s industrial and technological ascendancy. Without giving it all away, here are a few things that I did not know and hope to share. I was surprised to learn that this small country boasts the highest density of start-ups and has more companies on NASDAQ than all of Europe. It is Israeli ingenuity and perseverance, for example, that took the wind out of the sails of the famous Santa Clara company’s concept of increasing clock speeds of computer chips, a process that resulted in increased power consumption and heat. Smarter chip architecture resulted in the production of the Core 2 Duo chips (which are more efficient and consume less power) for Intel. There is the story of Iscar, an Israeli company that was bought by the legendary investor, Mr. Warren Buffet. The factory is located less than eight miles from the Lebanese border and was the target of rocket attacks. Eitan Wertheimer, the chairman of Iscar, told his new boss that that despite the damage, he would make certain that “all the customers would get their orders on time or even earlier.” He kept his word. No country this small has as big a Military-Industrial Complex. The book theorizes that it was the French betrayal in 1969 that catalyzed this reality. Georges Pompidou diverted tanks to Libya and Mirage jets to Syria. As an offshoot of an imperative for independence from other countries, and in attempting to ensure her own survival through self-reliance, have come discoveries that have even revolutionized medical care. Among the several interesting anecdotes in the book, there were two that captured my imagination. A gifted rocket scientist modified and miniaturized a light source with a camera, its power source and transmitter into a capsule that could be swallowed. It was able to transmit pictures from inside the gastrointestinal tract. The PillCam was born. It is astounding that technology housed in the nose of a lethal missile can also be used to send 18 pictures per hour for several hours from the gut of a human being. Moreover these can be accessed and viewed from across the room or anywhere in the world. Another story speaks about a subcutaneous implant that combines oxygen-producing algae from Yellowstone National Park’s famous geysers, along with fiber optics and beta cells, to be used for the treatment of diabetes. The authors describe a “mashup” of multidisciplinary ideas in combination with human experiences both civilian and military, which result in creative solutions that are unique. The authors then contrast the economic miracle of Dubai with that of Israel. They also compare and contrast it with several other smaller countries that may or may not have threats at their borders such as Singapore, Finland and South Korea. They underscore the fact that almost all the large multinational companies have a presence in all of the word is out. INTRODUCING THE AREA’S MOST ADVANCED NAME IN COMPREHENSIVE ENT AND ALLERGY CARE FOR YOUR PATIENTS. Formerly Commonwealth Ear, Nose and Throat Keith D. Forwith, M.D., Ph.D. John R. Morris, M.D. Andrew R. Gould, M.D. Steven D. Shotts, M.D. Kenneth M. Hodge, M.D. Donald V. Welsh, M.D. Gorden T. McMurry, M.D. Formerly Ohio Valley ENT & Allergy Daniel P. Akin, M.D., Ph.D. Eric S. Carter, M.D. V. Vasu Kakarlapudi, M.D. Thomas E. Sonne, M.D. Formerly Louisville ENT Associates Gregory M. Abbas, M.D. Wes A. Allison, M.D. Kenneth H. Richmond, M.D. La Grange 1023 New Moody Lane, Suite 202 La Grange, Kentucky 40031 Phone: 502-222-4589 Dixie - Caritas Medical Mall 6801 Dixie Highway, Suite 128 Louisville, Kentucky 40258 Phone: 502-995-5525 Dupont 4004 Dupont Circle, Suite 220 Louisville, Kentucky 40207 Phone: 502-893-0159 For a detailed listing of capabilities, or to learn more about what Advanced ENT and Allergy can do for your patients, visit AdvancedENTandAllergy.com today. Bardstown 118 Patriot Drive, Suite 106 Bardstown, Kentucky 40004 Phone: 800-561-2122 New Albany 2125 State Street, Suite 6 New Albany, Indiana 47150 Phone: 812-945-3557 Jeffersonville 301 Gordon Gutmann Blvd., Suite 402 Jeffersonville, Indiana 47130 Phone: 812-206-1910 Shelbyville 731 Hospital Drive, Suite 1 Shelbyville, Kentucky 40065 Phone: 800-561-2122 AdvancedENTandAllergy.com these countries; most utilize their presence there for servicing their regional customers. Israel remains one of the few places where critical research and development is carried out. In my opinion a fact that hasn’t, but could have received more attention, is the presence of superb institutions of higher learning such as the Weizmann Institute of Science, the Technion, the Jerusalem Hebrew University and Tel Aviv University. These among others have created a ferment of unparalleled intellectual excellence. A critical mass of highly educated and creative human capital, along with favorable economic policy, helped rocket creativity. This is nothing short of enviable. A highly educated and creative work force is arguably a crucial element that is lacking in surrounding countries. With investment of petro-dollars it is inevitable that this gap will close over time, and yet how one is able to change tradition in hidebound cultures is anyone’s guess. Another factor that is neglected in the book is that if immigration from the erstwhile Soviet Union was the impetus for creativity, what happens when this source eventually dries up? Israel’s friends and enemies can both learn much from the book. As our nation prepares for the winding down of military operations in Iraq and Afghanistan, and as we welcome our troops home, we need to ponder how this highly trained and disciplined group can help rebuild our economy. Progress can be made through discipline, educa- Poplar Level 3515 Poplar Level Road Louisville, Kentucky 40213 Phone: 502-459-3760 tion, innovation and the ability to question authority. Intellectual cross-fertilization through immigration, an immigration based on national need and individual aptitude, appears to have helped Israel just as it did the United States in the ’60s and ’70s. At a time which is economically about as bad as any in human memory, and when the natural tendency is to turn protectionist, the book may be a source of inspiration for planners to think outside the box. Cities and states that have suffered job losses from, say, a problem within the manufacturing sector could use the principles of creative destruction to spawn industries as yet unknown. This is a book I will undoubtedly read again. I have even made my teenage children read it. It is an uplifting, inspirational and intellectually satisfying book, written in language that is easy to understand, about a part of the world that is for the most part portrayed by the media in the bleakest of terms. I look forward to other books by these authors. I recommend the book most highly to anyone who has had the fortitude to read this review. LM Note: Dr. Gadre is the Heuser Hearing Institute Endowed Professor in Otology and Neurotology in the Department of Surgery and Division of Otolaryngology-Head and Neck Surgery at the University of Louisville School of Medicine. JANUARY 2011 17 The Richard Spear, md, memorial Essay contest: 2011 W Mary G. Barry, MD Louisville Medicine Editor 18 hy did you choose to be a doctor? Louisville Medicine wants to hear your story about the people, places, events and experiences that led to your career in medicine. We’re inviting all Greater Louisville Medical Society physicians and medical students to submit an essay for the fourth annual Richard Spear, MD, Memorial Essay Contest. Dr. Spear was a beloved Louisville surgeon who left GLMS a generous bequest for an annual essay contest. He wished to promote good writing among the physicians in our community. The first three years of the essay contest have generated numerous insightful and well-crafted pieces that have been published in Louisville Medicine. We look forward to reading what we’ll receive this year. The all-volunteer judges will consider excellence in expression, creativity, readability and clarity. We judge by category and reward accordingly: $1,500 to the practicing/life physician winner and $500 to the physician in training/medical student winner. An honorable mention gift card may also be awarded. LOUISVILLE MEDICINE Please review the guidelines below and submit your essay by April 1. Good luck! Guidelines You must be a GLMS physician or medical student to participate. All entries must be original, unpublished writing intended solely for publication in Louisville Medicine. Length: 800 to 2,000 words. Format: Do NOT put your name on your manuscript! Our judges are blinded to authors. Instead, include a separate cover letter with name, entry category, essay title, contact information and, if applicable, your year in medical school. Deadline: April 1. Submission: Send via e-mail to Alecia Miller, at [email protected]. Electronic versions are preferred, but if not possible, send essay by mail to 101 W. Chestnut St., Louisville, KY 40202. LM Looking for a Bank That Understands Your Special Needs? C ha + Bu si + Co ness Acc o mm ercia unts + Li lL ne + Eq s of Cre oans dit ui + Pe pment L rson al C easing +M heck ortg in age Loan g s i r ma n an d CE O- Repu blic Ban k We’ve W e’ve Been Ser SServing erving the Medical Medical Community Over Years. C ommunity for Ov er 25 Y ears. Please P lease contact any of our medical finance specialists for yyour our banking needs: #BSC$VUUFSt #BSC$VUUFSt "TIMFZ3PCFSUTt " TIMFZ3PCFSUTt .JTTZ,BJTFSt . JTTZ,BJTFSt We W e wer were e her here e for you yester yesterday. day. W We e ar are e here here for you today today.. W We e will be her here e for you tomorrow. tomorrow.® JANUARY 2011 19 tenth in a series Something to Build On Deborah Ann Ballard, MD I In the book, The Blue Zones: Lessons for Living Longer From the People Who’ve Lived the Longest , Dan Buettner explores the characteristics of the world’s healthiest people. He defines a Blue Zone as a place where people typically live to be more than 90 years old, have very low rates of chronic disease and have almost no dementia. Blue Zones include places like Sardinia, Italy, Okinawa, Japan, and Loma Linda, California (Seventh-day Adventists). It is no surprise that the healthiest people engage in regular physical activity, eat a plant-based diet and drink red wine. However, their good health comes from within as much as from without. Buettner found that the healthiest people in the world also have: 1. 2. 3. 4. 5. A purpose in life Low stress A healthy social network A belief system Strong family lives. Unfortunately, the American lifestyle is often one of fractured families, social isolation, harried schedules, insatiable consumerism and shallow for-show spirituality. An axiom of public health practitioners is that knowledge alone is insufficient to produce behavior change. Indeed, when I ask most patients why they do not exercise or follow their diet, it not because they do not believe they should do it or have not been given There is a growing consensus among sociologists, political scientists and spiritual leaders that strengthening our sense of community is the key to building a better world in every way. Robin Dunbar, a professor of psychology from the University of Liverpool, states, “The lack of social contact, the lack of sense of community, may be the most pressing social problem of the new millennium.” Americans are losing their sense of being one community. We are so divided along political, ideological, racial and ethnic lines that we cannot seem to work for the common good anymore, with the result that our communities are hollow and sometimes even hostile places to live. As the Dalai Lama observed: “Tibetans are shocked to hear of situations where the information. Rather they say they are under too much people are living in close proximity, have neighbors, stress, have no support system and lack the money (even and they may have been your neighbors for months though they can afford cigarettes, cell phones, cable TV and or even years, but you hardly have any contact with elaborate manicures). They feel too depressed to make the them … There is no real connection, no sense of community … If this sense of community is lacking, effort. 20 LOUISVILLE MEDICINE then when you feel lonely, and when you have pain, Mother Teresa wrote, “For all kinds of diseases there are there is no one to really share it with. I think this kind medicines and cures. But for the disease of being unwanted, of loneliness is probably a major problem in today’s except where there are willing hands to serve and there is a world, and can certainly affect an individual’s day-to- loving heart to love, I don’t think this terrible disease can ever day happiness.” be cured.” It can also have a profound effect on health and even survival. I remember a particularly tragic patient I cared for as an intern. She was in her early 60s, single, disabled and poor. After having been “found down” in her apartment by her landlord, she was brought into the emergency room comatose and hypothermic. An EMS survey of her medicine cabinet revealed medicines for all the obesityrelated illnesses – diabetes, hypertension and hyperlipidemia. She had decubiti on her back and buttocks from being on the floor so long. No one came to the hospital to check on her. She had no family, no power of attorney, no friends and no community. She never regained consciousness, but she was kept “alive” for three weeks in the ICU before she ceased to have measurable vital signs and we decided she was dead. Her hospitalization probably cost taxpayers more than a million dollars. This tragedy would never have happened had she lived in a Blue Zone where at 60, she still would have most likely been vibrant and healthy, and if she had been ill, her family or community would have checked on her every day. Over and over again, I hear patients tell of being alone with no family or community support. They graze on junk food all day because there is no one to share a meal with. They can’t keep appointments for procedures like a colonoscopy because they have no one to drive them home. They can’t stay out of the hospital because they have no help at home and fall; can’t get to doctor or therapy appointments; can’t get their medications. On a population level, a lack of community support makes it extremely difficult to deliver effective prevention and wellness programs. It also makes it very difficult to deliver accountable medical care – a new and needed mandate from health care reform. Sorry, libertarians, but rugged individualism just does not work in the realm of public health. John Michael Talbott, author of The Lessons of St. Francis, writes, “Independence is a pervasive and popular myth. But the truth is that nothing in our universe is truly independent. Nature is an interdependent network. The cosmos is communitarian.” Going forward, Louisville needs to invest in its neighborhoods to build up their capacity to provide effective programs to prevent disease and to care better for those already ill. Dr. Adewale Troutman, former director of Louisville Metro Public Health and Wellness, effectively advocated for many structural changes toward this end. He will be greatly missed. He started the process of building a healthier environment, and now we have to advocate for the process to continue. Many physicians already volunteer countless hours for various community and faith-based organizations. As community builders, we can create Blue Zones right here in Louisville. We can also rally others to join in the effort. Talk to your patients about community building. Some of them will take up the cause – and we hope that gradually our neighborhoods will become happier, healthier places to live, and our jobs as physicians will get a lot easier. LM Note: Dr. Ballard is the director of community outreach for the Norton Cancer Institute’s Prevention and Early Detection Program. JANUARY 2011 21 BOOK REVIEW The checklist manifesto – How To Get Things Right BY ATuL GAWAndE Metropolitan Books, new York, december 2009 Reviewed by M. Saleem Seyal, MD, FACP, FACC The fact is that no one likes checklists, and most of us actually abhor checklists irrespective of our vocations. They are boring, time-consuming and seemingly plain silly. After all, if you have been practicing medicine, doing procedures and surgeries for several years and have been working with experienced nurses and other ancillary personnel in the hospital, you really have no desire to start your day with niggling checklists. But that is precisely what Atul Gawande, MD, tries to convince you to do in his latest book. And, you must do it daily, on a regular basis, without fail: because adhering to these ostensibly annoying and bureaucratic checklists will improve outcomes and save lives. Period! Dr. Gawande’s article “The Checklist” was published in the December 10, 2007, issue of The New Yorker, and the book that grew out of that article was published in 2010. The Checklist Manifesto is the third book by Dr. Gawande, another New York Times best seller after his blockbuster first two books – Complications and Better. All his books and articles as a staff writer in The New Yorker have earned him high accolades and fame. This book starts out with a familiar theme of patient stories that the author is swapping with a colleague, the first one when a stab victim is brought to the Emergency Department with an innocuous-looking wound in the abdomen and overall stable vital signs. The patient promptly crashes, however, with a precipitous drop in his blood pressure and cardio-respiratory arrest. Immediate resuscitative measures are instituted, and the patient is wheeled emergently to the operating room. There he is found to have a tear in his aorta due to a bayonet stab injury, which is repaired, and the patient eventually survives. The second case involves an inadvertent infusion of an inordinately high dose of potassium during a surgical procedure, resulting in asystole. But the mistake is quickly Continued on page 24 Feel F eel better. better. because providing leading cardiac specialists is at the heart of what we do. Baptist Health welcomes Louisville Cardiology Group and Baptist Cardiac Surgery. Terrific news for heart patients: Two of the region’s most advanced cardiac care practices are joining Baptist Health. The highly experienced and respected cardiology physicians of Louisville Cardiology Group and the cardiothoracic surgery specialists of Baptist Cardiac Surgery are known for fast, lifesaving, and minimally-invasive procedures and advanced heart therapies. Their long-standing commitment to personal relationships with patients and their families matches well with Baptist Health’s focus on a positive patient experience. The addition of Louisville Cardiology Group and Baptist Cardiac Surgery to the Baptist Health team of heart-care specialists can mean only one thing: a whole lot of hearts will be feeling a whole lot better. Learn more at baptistmedicalassociates.com or call (502) 897-8131 for a physician referral. CARDIAC CARE baptisthealthky.com BAPTIST HOSPITAL EAST | BAPTIST HOSPITAL NORTHEAST | BAPTIST EASTPOINT | BAPTIST URGENT CARE | BAPTIST MEDICAL ASSOCIATES Continued from page 22 discovered, resuscitation continues while various means to reduce the potassium level are carried out pronto, and the patient recovers. Dr. Gawande stresses the point that, despite all the technological advances and an unprecedented proliferation of knowledge and science, physicians are neither omniscient nor all-powerful but, in fact, remain and will continue to remain constrained by the limitations of human fallibility. The practice of medicine is never going to be perfect. Our failures, he points out, are either due to ignorance (mistakes committed because of poor knowledge) or ineptitude (mistakes made because of our inability to apply what we do know), and it turns out that the failures are mostly because of the latter. He describes the everincreasing complexity of our daily lives in the first chapter of the book, particularly the sheer number of decisions we as physicians have to make for our patients who present daily with a myriad of clinical challenges. In critical care areas of the hospital including surgical suites, procedure rooms of all types, intensive care units and emergency departments, where stakes are quite high and the lives and well-being of patients are on the line, it is incumbent to have a structured checklist to do things right, and decrease the oft-quoted errors in medicine that result in close to 100,000 deaths annually in the United States alone. In the aftermath of the tragic crash of a Boeing 299 in Dayton, Ohio, during a flight competition for the U.S. Army in 1935, a pilot checklist was devised for every pilot no matter how experienced the pilot was, and that revolutionized the way airplanes have been flown. In hospitals, vital signs that include blood pressure, pulse rate, respiratory rate and temperature have been the ubiquitous checklist components for a long time, and nurses have recently 24 LOUISVILLE MEDICINE added pain rating, medication timing charts and written care plans. In 2001, Peter Pronovost, MD, PhD, an intensivist at The Johns Hopkins Hospital, initiated a simple five-point checklist for preventing central line infections, which when followed scrupulously produced a remarkable drop in infection rates. Another similar project was initiated on a larger scale in Michigan’s ICUs, and the study was published in 2006 in The New England Journal of Medicine reporting savings of $175 million in cost to the hospital and more than 1,500 lives saved – all because of a simple checklist! Checklists are everywhere! Dr. Gawande found them in the building industry, in his favorite Boston restaurant, at The Boeing Company and in David Lee Roth’s band, to name a few. He conducted site visits and interviewed key personnel at various places. He eventually conducted a worldwide study of preventing surgical errors by implementing a pre-surgery checklist, and the results were uniformly positive in saving money and lives by incorporating the checklist as a requirement. The “time out” checklist has become the norm now prior to any invasive procedure (despite initial resistance by physicians). The patient’s name, date of birth, the name of the procedure, the preparation and reaffirmation of the correct site/side, the results of important and pertinent labs, the availability of blood and blood components – all are loudly recited by a nurse in a matter of few minutes. Clinical judgment, of course, plays an important and sentinel role in taking care of patients. The checklist is simple and straightforward, easy to implement – despite some physicians’ consternation – and much more effective in saving lives than taking things for granted. LM Note: Dr. Seyal practices Cardiovascular Diseases with River Cities Cardiology MPC. /2&$/6(59,&(1$7,21$/35(6(1&(*/2%$/32:(5 / 2 & $ / 6 ( 5 9 , & ( 1 $7 , 2 1 $ / 3 5 ( 6 ( 1 & ( * / 2 % $ / 3 2 : ( 5 State of the art Practice Management System Qualify for up to $44,000 per physician EHR is guaranteed to meet meaningful use criteria for ARRA stimulus money Complimentaryy ROI on EHR & Practice Management Complimentar for your business Free EHR Readiness Assessment (limited time only) by certified Medical Practice Executive REFLEcTIOnS Teresita Bacani-Oropilla, MD o n a Sunday’s homily, a priest commented on an observation, namely, that to receive is innate in human beings. A newborn baby does not have to be taught to suckle when put to the breast. He/she is comfortable being nurtured and cared for without asking or having to give back. Conversely, giving thanks for services rendered freely does not come naturally. It has to be taught. “Thank you” is among the phrases parents teach their children from an early age. Presuming the premise is so, do we have proper training in the art of expressing gratitude? Does saying thanks follow a scale similar to that of describing pain, i.e. from zero to 10? Are there benefits in giving thanks? Are there drawbacks? Can it be mistaken for facetiousness or as a ploy to cull more favors? Some common occurrences here mentioned touch on the relevance or irrelevance of saying thanks. A godfather spent hours looking for just the right tennis racquet that his godson needed. It was mailed with the anticipation that the latter would be delighted with the gift, but the godfather waited in vain for feedback. Although the racquet was received, it was never acknowledged. Did the godson just feel entitled or did he not know any better? A group of students excitedly giggled while putting up a sign to greet their teacher, “Happy Birthday.” When the latter went on with business as usual, the children’s faces fell with disappointment. Did the teacher think it inappropriate to recognize the honor or had she never had happy surprises in her life and was clueless on what to say? A patient being presented during rounds answered questions repeatedly, was examined in front of all to show his pathology, and discussions were conducted in his presence. Would that these were done with the utmost delicacy and sincere respect, and would that the rounding doctors thanked him for his cooperation. Physicians learn something from every patient they see, and the latter have to have 26 LOUISVILLE MEDICINE their due, or should patients be beholden to their doctors and give thanks instead? When children and grandchildren try to shield their elders from what they deem might upset them and try their wings at flying solo, concerned experienced relatives admonish them for their own safety. But when they make efforts to fulfill expectations, do we encourage and thank them? When at a doctors’ gathering the tables are set with flowers, the snacks or dinners are ready, the programs are present at each place setting, and the mike is working, had Girl Scouts come and gone incognito? Most likely not. Some ever faithful and thoughtful staff had planned and executed these to perfection for the comfort of their honored guests. Are they hovering discreetly around? Do they know that we know what they did? When a mother/wife sleepily folds the laundry after a challenging day at the clinic and puts the clothing in stacks for family members to take to their rooms, nobody takes notice. Is this just a routine ending of the daily job she voluntarily chose? And when a dad takes a little extra time to prepare a special meal and efforts to cook it just so, he takes pleasure in seeing others gobble down his masterpiece. However, the likelihood increases that this treat will be repeated if a few verbal compliments or satisfied grunts come from the consumers’ side. A smile, a small gesture, a passing word of acknowledgement, a thumbs-up: all work wonders. They banish the monotony and dreariness of everyday work. Sagging shoulders visibly perk up like flowers after a shower. Words of thanks relieve the stress of not knowing whether expectations are being met or not. They enhance the joy of pleasing others and making them happy. As my observant padre pointed out, saying thank you has to be taught. Long past the time of parental urging, it can also be selftaught. Then it has to be practiced until it becomes second nature. At every turn in life, if we look and make ourselves aware, the opportunities are myriad in finding things to be thankful for. Even the gifts of life and health cannot be taken for granted. Recognizing and rediscovering these things, acknowledging them, and giving thanks make the brand new year before us brighter and something to look forward to. LM Note: Dr. Oropilla is a retired psychiatrist. Medical Society Professional Services is pleased to announce a new locum tenens program for GLMS member physicians, offering Long Term Physician Placements Short Term Physician Placements Direct Hire of Physicians We now are seeking board certified physicians in family practice and internal medicine for early 2011 placements. We welcome your listing of physician openings in your practice Hourly rates competitive with national placement firms Professional Liability Insurance Provided Work with local people you know and trust For details and a confidential consultation contact Ludmilla Plenty, Director Medical Society Employment Services 502.589.2006 [email protected] ALLIAncE nEWS Lisa Sosnin, RN GLMSA President Happy new year! We of the Greater Louisville Medical Society Alliance hope that you and your family had a wonderful holiday season. What would the New Year be without making our list of New Year’s resolutions? Of course, after gorging ourselves on fine cuisine and spending quite a bit of money on gifts for our loved ones, some of the traditional resolutions may include eating healthier, losing weight and spending less money. My challenge to you is that part of your New Year’s resolution would be to join the GLMSA. I can’t promise you that our members will always eat healthier, lose weight or manage our money better. However, I can assure you that we will provide learning opportunities on how to have a healthier and less stressful you. Part of this opportunity would come through the many friendships that you make being part of such a wonderfully unique group of individuals who understand what it is to be part of the family of medicine. In November, after having a catered lunch from the Bristol, the GLMSA toured the Louisville Science Center and watched the IMAX program, The Light Before Christmas. Bert Guinn, GLMS communications and membership director, spoke to our group about the exciting Pulse of Surgery program and encouraged all GLMSA members to be involved. In December, the GLMSA participated in a candlelight tour of Historic Locust Grove for the holidays. We offered this evening event so that it would be a family affair to enjoy the holiday festivities. A New Year’s resolution for the GLMSA would be to reach out to as many spouses of our physicians as possible and offer the gift of love and friendship. We are resolved in our belief that we can contribute to our community and schools by serving others. We hope to offer opportunities to our members to participate in providing support for our physicians by learning about legislative issues and calling our representatives in Frankfort. 2010 may have come and gone. However, we can start anew in 2011. Let’s resolve to not only take better care of ourselves in these stressful times but be proactive and support each other by bringing new thoughts and ideas to our group. We would love to hear from you! LM Note: Lisa Sosnin is a registered nurse and is the practice manager for her husband’s solo practice, Bluegrass Community Family Practice, in Bardstown. E-mail her at [email protected]. GLmS Alliance members gather outside the exhibit Sesame Street Presents: The Body. (clockwise from top left) Lisa Sosnin, michelle Feger, Fu mei Tsai, jeanne Kral, Betty Allen, millicent Evans and Barbara cox. The GLmS Alliance toured the Louisville Science center in november, including the BodyWatch exhibit. Betty Allen (left) and jeanne Kral check out the exhibit. Barbara cox (left) talks with Louisville Science center tour guide Ally Sauer. Ilene Booscher (left) and Adele murphy listen to a presentation on Pulse of Surgery by Bert Guinn, GLmS communications and membership director. 28 LOUISVILLE MEDICINE • Full Time IM or FP Board Eligible or Certified • Well Established Private Practice • 5 Days a Week, 1 Call Per Week Confidential responses to: Hospital Internal Medicine Associates, PLLC 201 Abraham Flexner Way Suite 1003 Louisville, KY 40202 Attn: Tina 502.584.4479 [email protected] • Inpatient Care Salary and Benefits combined $150K JANUARY 2011 29 WE WELcOmE yOU GLMS would like to welcome and congratulate the following physicians who have been elected by Judicial Council as provisional members. During the next 30 days, GLMS members have the right to submit written comments pertinent to these new members. All comments received will be forwarded to Judicial Council for review. Provisional membership shall last for a period of two years or until the member’s first hospital reappointment. Provisional members shall become full members upon completion of this time period and favorable review by Judicial Council. Candidates Elected to Provisional Active Membership 30 Erickson, Kavita K. (30297) Craig K. Erickson, MD 2444 Lakeridge Dr Newburgh IN 47630 812-618-5221 Radiology/ Neuroradiology Louisiana State U Miller, Glenn Alan (312) Nita 9342 Cedar Center Way 40291 239-3228 Family Practice 78, 95, 02 U of Louisville 74 Scheker, Luis Roman (606) Aurora 225 Abraham Flexner Way Ste 700 40202 561-4263 Hand Surgery U de Santo Domingo 76 Ferraz, Francisco Marconi (30229) Audrey R. Ferraz 3900 Kresge Way Ste 41 40207 899-3623 Neurological Surgery 87 Universidade Federal Pernambuco 75 Nord, Kristi Mahaffey (30314) Jonathan Nord 3991 Dutchmans Ln Ste 200 40207 899-6782 Neurology The Pennsylvania State U Sulkowski, Gregory Michael (21480) 1169 Eastern Pkwy Ste 3334 40217 458-9004 Ophthalmology Harvard Med School 04 Johnson, Michael William (30163) Lisa Marie Stoll 810 Barrett Rd Fl 7 40204 852-5587 Anatomic Pathology/ Neuropathology/ Forensic Path Northwestern U Ramirez, Allan M (21401) Yvette M. Cua 401 E Chestnut St Ste 310 40202 813-6500 Pulmonary Diseases 00 Critical Care Medicine 02 Internal Medicine 98 Northwestern U 95 LOUISVILLE MEDICINE Candidates Elected to Provisional Associate Membership Conrad, Brandon Nelson (30293) Tiffany Sammons U of Kentucky Membership • Promote your business in a publication read cover to cover by some of the more sophisticated, well-educated, affluent and influential people in the metropolitan Louisville area. • Readership includes 85% of physicians in Louisville. • Mailed to physicians’ homes. In REmEmBRAncE RoBERT PFEiFFER KRAFT JR., Md (1949-2010) Robert Pfeiffer Kraft Jr., MD, passed away October 7, people in ways that helped to reduce anxiety and increase 2010. He was 60 years old and is survived by his wife, Betty understanding. Among the adjectives most frequently Price Kraft, two sisters, two stepchildren, a stepgrandson used to describe him as a professional were “kind,” and a nephew. “caring,” “skillful” and “dedicated.” He loved being a physi- He was graduated in 1971 from Indiana University with a double major in zoology and chemistry and received his Doctor of Medicine degree from the cian, and that showed in his performance, infectious smile and upbeat manner. Additional words that describe him in his personal life University of Louisville in 1975. After completing his resi- include “fun-loving,” “multifaceted” and “family-oriented.” dency in Internal Medicine at the U of L-affiliated hospitals He was a voracious reader and an avid and talented golfer and serving as the chief resident in Medicine during the and photographer. He also thoroughly enjoyed music of final year of that training, he completed his fellowship in all kinds, movies, socializing with colleagues, theater, Gastroenterology at the University of Iowa in 1981. He was cooking, college football and basketball, computers and board certified in both Internal Medicine and electronics, landscaping projects and traveling, especially Gastroenterology. He began a private gastroenterology to Hawaii. Family, friends and home were infinitely impor- practice that was later named Gastro East Physicians and tant to him and were always at the center of his life from practiced until his retirement in 2004. childhood until his death. Bob, as everyone called him, was a native of Louisville So many more things could be written about Bob, but and was devoted to his hometown. He always said that one gentleman who had been his patient for years Louisville was a wonderful place to pursue a medical summed it all up eloquently when he attended the funeral career because of the high caliber of physicians in the home visitation. He simply said, “Dr. Kraft was the best community and the strong culture of commitment to doctor I’ve ever had and the best man I’ve ever known.” LM learning, research and innovation in so many different areas of medicine. The genuine concern that underscored Bob’s desire to _ Carolyn Kraft, Dr. Kraft’s sister help individuals to deal with sometimes complex and frightening information was very much a reflection of his personality. He was a natural teacher, and patients and medical personnel alike often commented that he had a real knack for explaining diagnoses and procedures to JANUARY 2011 31 The Gawandes of Athens, Ohio M. Saleem Seyal, MD, FACP, FACC On a visit to Athens, Ohio , in 2009 where our son John was a senior at the time at Ohio University, I picked up the phone and dialed the office number of a local urologist, Dr. Atmaram Gawande. Instead of an answering machine or a secretary, Dr. Gawande himself answered the phone. After introducing myself, I pointed out that I was an admirer of the writings of his son, Atul Gawande, and have a strong interest in the history of immigrant physicians in the United States and their children. “Ram” immediately invited my wife, Sally, and I to come over to his home, which happened to be only a few blocks from our hotel. We were greeted warmly at his beautiful yet modest home and sat down for a chat in their living room. The following account is a distillation of my conversation with Dr. Gawande and his wife. 32 LOUISVILLE MEDICINE Ram hails from a rural area of Nagpur that lies precisely in the center of India and is part of Maharashtra, where the Marathi language is spoken. He earned his medical degree in 1962 and started his Surgery residency there. Like most new medical graduates in the Indian subcontinent, he wanted to go to England for postgraduate education, earn the FRCS (Fellow of the Royal College of Surgeons) designation and return to India. Coming to America for foreign physicians was a new phenomenon at that time. After he passed his requisite ECFMG (Educational Council for Foreign Medical Graduates) examination, obtained his passport (which took six months) and secured a visa from the United States Consulate through the help of the Ventnor Foundation of New Jersey, he landed in New York with $8 in his pocket. He started his internship at St. Mary’s Hospital in Brooklyn and came to work with residents from multiple nationalities. His foray into Pathology residency was boring, and he switched to residency in Urology at the Martland Medical Center, affiliated with the New Jersey College of Medicine. During his residency, he met his wife, Sushila, who came to America from Ahmedabad, India, and was pursuing a Pediatrics residency. Sushila Gawande (she likes to be called “Sushi”) followed her physician sister to the United States. Ram was smitten by her and, after initial resistance (her mother had told her to beware of Indian men who might be married with a wife back in India), she relented and started the courtship. They were united in marriage by an employee from the Indian Embassy who officiated the ceremony, since he knew the marriage rituals. There were no Hindu temples in New York in the 1960s. The Gawandes were ready to come back to India in 1970 with their two children, Atul and Sumeeta, when they discovered that Atul was allergic to the smallpox vaccine. The plan of returning to India was scrapped since they did not want to take a chance on exposing Atul to smallpox. They moved from New York to a sleepy little town called Athens in Ohio (population close to 20,000), located along the Hocking River in the southeastern portion of the state. Ohio University is one of the oldest universities in the United States (chartered in 1804). Ram was the first urologist in town and worked as a solo practitioner with privileges at the local O’Bleness Memorial Hospital. Sushila started her pediatrics practice, which steadily grew, and the couple has been at the same place for 40 years. Ram informed me that the day I talked to him was the last day of his private practice at age 73; Sushi had retired three years earlier. The Gawandes have given back generously to the community both in Athens and in India. Sushi ensured that she took care of the poorest children in Athens during her years in practice, and both Ram and Sushi are involved in numerous charity initiatives. Ram has been a regular member of the local Rotary Club and currently serves as the district governor. Twenty-five years ago, the Gawandes gave seed money to establish a college in Ram’s hometown in Nanded, Maharashtra, India, named in memory of his mother. Dr. Atul Gawande was graduated from Stanford University and obtained his MA in politics, philosophy and economics from Oxford University, and his MD and MPH from Harvard. He completed his surgical residency at Brigham and Women’s Hospital in Boston and joined the faculty as a general surgeon with special interest in Endocrine surgery. He was a Rhodes scholar and also won the MacArthur Award in 2006 for his research and writing. He is an author of three New York Times best seller books and is a staff writer at The New Yorker. His sibling, Sumeeta Gawande, is academically quite accomplished as well. She completed her premedical studies but switched to women’s studies and obtained her BA from Cornell and JD from Rutgers School of Law. She practices law in Newark. It was indeed a delight to spend time with Drs. Ram and Sushila Gawande in Athens, Ohio. They are an unassuming, simple, down-to-earth Indian American couple who are extremely content in achieving their own version of the American dream. Dedication to work and family, the Gandhian principle of simple living and help for their fellow human beings appear to be the components of their guiding philosophy. LM Note: Dr. Seyal practices Cardiovascular Diseases with River Cities Cardiology MPC. dr. Seyal and his wife, Sally, at the home of drs. Atmaram and Sushila Gawande drs. Atmaram and Sushila Gawande JANUARY 2011 33 Electronic Health Record Consulting Health Care Excel can help you PDNHWKHWUDQVLWLRQZLWKFRQ¿GHQFH W e specialize in: We $VVHVVLQJSUDFWLFHVDQGVWDIIIRU $VVHVVLQJSUDFWLFHVDQGVWDIIIRU (+5UHDGLQHVV ,GHQWLI\LQJDQGWDUJHWLQJ improvement opportunities, such DVRI¿FHZRUNÀRZDQGSURFHVV UHGHVLJQ *XLGLQJSUDFWLFHVWKURXJK(+5 implementation Assisting practices using an EHR WRLWVIXOOHVWSRWHQWLDO Special Discounts for GLMS Members! %LVKRS/DQH6XLWH/RXLVYLOOH.<ZZZKFHRUJ %LVKRS/DQH6XLWH/RXLVYLOOH.< %LVKRS/DQH6XLWH/RXLVYLOOH.<ZZZ ZZZKFHRUJ 502-454-5112, For more information, call 502-454-51 12, extension 2201 34 LOUISVILLE MEDICINE SPEAK yOUR mInd The views expressed in doctors’ Lounge or any other article in this publication are not those of the Greater Louisville medical Society or Louisville medicine. If you would like to respond to an article in this issue, please submit an article or letter to the editor. contributions may be sent to [email protected] or may be submitted online at www.glms.org. The GLmS Editorial Board reserves the right to choose what will be published. Mary G. Barry, MD Louisville Medicine Editor [email protected] The ville is not vegas The chief executives of Passport Health Plan have been livin’ Las Vegas, roaring off in their limos and leaving the poor and disabled with facefuls of exhaust and handfuls of denials: business as usual when you think of yourself as Mr. Big. Not for you the stop and wheeze of the Broadway bus, or the grime and garbage of the night-cleaning staff, or the long lines at the food stamp office; no, you are in the VIP room, cruising past the velvet rope straight to the Chateauneuf du Pape. Thanks to Sen. Tim Shaughnessy, state Auditor Crit Luallen and veteran Courier-Journal reporter Tom Loftus, we have been treated to the true vision of our community leaders tasked to serve the poor, and it’s not one of duty, honor and courage. It’s “Lodgings were often luxury spas and resorts,” and “The executives used limousine services and dined at expensive restaurants.” After all, health care is big business, they reason, and aren’t they just like the owners of Humana and Anthem and United? Aren’t they entitled to the good life too? They administer the state’s largest contract of $793 million. They must need all the help they can get from our state legislators, for instance, for they spent a million dollars on lobbying and public relations, to get language inserted in a bill to prevent funding cuts (Gov. Steve Beshear later vetoed that wording). It sure is hard work to lobby – all that talk about staying on message, and who knows whom – one must surely eat well to survive. They have face to maintain, too. They have to throw a bone to the working class from time to time (why else would they spend $10,000 to sponsor a blow-up doll for the Pegasus Parade) and they have to sweet-talk the rich, with donations to the Kentucky Opera, political receptions and campaign contributions. They showered their own pockets and those of their friends at AmeriHealth Mercy with more than $200,000 in bonuses. All told they gave away more than $423,000 dollars in gifts and scholarships. To whom? And why? And where was the board? The board was at work, that’s where, at the helm of every downtown hospital and at U of L. What they knew about it, and if they knew, are subjects that The Courier-Journal has had to go to court to find out. In keeping with the privileged way they view themselves, Passport staff members have maintained that the exact records of expenditures and the minutes of board meetings are private, and not subject to the state Open Records Act. Ms. Luallen, backed by Attorney General Jack Conway, has argued that since Passport is 100 percent publicly funded, such meetings must be open to public inspection. We therefore have no data on the board’s proceedings or deliberations. On the other hand, Passport paid all of the entities it represents handsome sums – multimillion dollar transfers – because they were investment partners in the creation of Continued on page 36 JANUARY 2011 35 Continued from page 35 Passport in 1997. Such millions were not designated solely for indigent care, however. Such millions (and from what part of patient care delivery or denial did these funds come?) went to the general funds of these institutions, in proportion to their investments. Was that the intent of the taxpayers? All of us pay for the care of those with no means. Did we intend those monies for the individual needs of Norton or Jewish or U of L, for example, or did we intend to pay only for the prevention of illness and the care of the sick and disabled, which these institutions do very well? If well-managed care results in large savings, should all of those savings go back into direct patient services only? Passport patients help to educate future doctors and nurses and techs. Should these monies be directed to pay for medical education? Should doctors’ and nurse practitioners’ payments be increased, clinics expanded, and eligibility requirements and formularies relaxed? Who decides? Secrecy around the use of public monies always makes the citizenry uneasy. As taxpayers and as physicians who help to deliver this care, we should Kerri S. Remmel, MD, PhD Stroke Prevention Breakthrough in Patients with AF As a stroke neurologist, I am not only interested in the treatment of stroke but also in the prevention of stroke. While I treat patients at 36 LOUISVILLE MEDICINE have free and open access to all of this financial decision making, without having to force the issue in Jefferson Circuit Court. Passport has maintained that its managed-care policies save taxpayers money, and that its current medical cost increase of only 4.5 percent compares very favorably with the regional increase of 9.3 percent and the national one of 7.1 percent. However, no true cost comparison of Passport with the surrounding 16-county Medicaid region has been done, and the audit by Ms. Luallen found that it was impossible to conclude that overall moneysaving has been accomplished. A separate study by an outside consultant will be commissioned by the Cabinet for Health and Family Services. Like all doctors of the modern era, I have written countless letters to the self-ordained VIPs of this world begging for better or different or even barely minimal care for my patients. I can’t wait to demand that my patient whose Lyrica has been twice denied by Passport should have her coverage restored at least to the tune of the $3,996 spent on limos alone. Dr. Walter Badenhausen University of Louisville Hospital, my hope is that the number I see decreases each year. The problem is that strokes are difficult to prevent. It’s up to each individual person to commit to a lifestyle of healthy behaviors and to comply with medical treatments to reduce stroke risk when necessary. However, with the Food and Drug Administration’s approval of dabigatran (Pradaxa) for patients with atrial fibrillation, there is hope that more strokes will be avoided in the future. AF patients suffer from cardiac arrhythmia, which ultimately puts has spent decades caring for injured and disabled children and having his requests for adaptive devices turned down. Why can’t they now have the high-tech brace that fits better, or the lightest wheelchair that rolls better, in place of the standard-issue Yugo model, with some of that $70,000-plus hotel money? The ICUs of all three downtown hospitals should get to split the million spent on lobbying – it won’t cover more than one indigent patient outlier with major burns, trauma or sepsis, but it might buy some really nice respirator tubing. What these executives have done is to raid the public trough for bonuses and parties. They have identified themselves as creatures of the red carpet instead of guardians of the public health. The best solution to this travesty is the establishment of absolute financial transparency plus the appointment of a strong leader who believes in service, not entitlement. LM Note: Dr. Barry practices Internal Medicine as an employed physician with Norton Community Medical Associates-Barret. She is a clinical associate professor in the Department of Medicine at the University of Louisville School of Medicine. them at an increased risk for blood clots and ischemic stroke. According to the American Heart Association, 15 percent of strokes occur in people with AF. The FDA approved dabigatran as a result of the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY), a noninferiority, randomized trial that compared two fixed doses of dabigatran with warfarin (Coumadin) in more than 18,000 patients with AF. The primary outcomes were stroke or systemic embolism. Continued on page 38 We Provide: S erving greater • Direct placement • Temporary placement • Temp to hire southern Indiana with a We Guarantee: 60-year track record of • • • • • quality and dedication. Criminal background checks Reference checks Credit checks Drug screening Skills testing Louisville and Call Ludmilla Plenty, employment director, at 502-736-6342 or visit us at www.glms.org. Continued from page 36 Dabigatran 110 mg twice daily was found to be comparable to warfarin for the primary outcome of stroke or systemic embolism. This dose was not FDA-approved. Dabigatran 150 mg twice daily was found to be superior to warfarin in terms of the primary endpoints of stroke or systemic embolism (1.11 percent per year for dabigatran versus 1.69 percent per year for warfarin [p<0.001]). The rate of hemorrhagic stroke was 0.38 percent in the warfarin group compared to 0.10 percent in the dabigatran group at 150 mg twice daily (p<0.001). All major bleeding was comparable for the two groups. Dabigatran 150 mg twice daily was approved by the FDA for prevention of stroke and systemic embolism in patients with AF. The decreased stroke rates shown in the RE-LY trial bring good news for those with AF, because strokes caused by AF are particularly devastating. They are large vessel cardioembolic strokes and can affect 38 LOUISVILLE MEDICINE the cortex and one’s ability to think and communicate. The way to prevent them is through pharmaceutical means. Blood thinners such as warfarin have been the mainstay to thin blood and keep clots from forming in the heart’s chambers, then traveling to the brain through blood vessels in the neck. Warfarin reduces the risk of stroke by 60-70 percent, so it can be an effective stroke prevention modality for qualified patients with AF, but it is being underutilized. Only half of the people with AF who are appropriate candidates for warfarin receive the drug. The problem is that many physicians and consumers are not comfortable using it because it can lead to life-threatening bleeding, and there are many food and drug interactions that affect the drug levels in the bloodstream. There have also been concerns with the appropriate dosing of warfarin. If the level is too high, patients could experience severe bleeding; if the level is too low, blood clots could form. For those reasons, the FDA’s approval of dabigatran is a significant breakthrough in the treatment of patients with AF. There are no Vitamin K interactions and no need for blood work to check drug levels. The primary outcome showed a lower incidence of both ischemic and hemorrhagic strokes, which makes dabigatran an excellent alternative to warfarin. A downside to dabigatran is that people may develop gastrointestinal bleeding, so individuals with a history of GI bleeding may not be appropriate candidates for blood thinners such as dabigatran. Dabigatran’s introduction is a big step toward stroke prevention for one subset of people. If the risk of stroke can be reduced for anyone, we all move closer to establishing an improved system of stroke care. LM Note: Dr. Remmel is director of the University of Louisville Hospital’s Stroke Center. Disclosure: Dr. Remmel will serve as a member of a speakers bureau for Boehringer Ingelheim Pharmaceuticals Inc., the company that manufactures dabigatran. An Unforgettable Patient Elsa M. Haddad, MD It was about 10 years ago. My boys were 6 and 7 at the time, and I had a fulltime solo pediatric practice, which meant my kids did not always come first. We had just finished eating dinner when I was paged by one of the local hospitals to let me know that a child I had sent over earlier for routine rehydration was taking a turn for the worse. The tone of the nurse’s voice simultaneously alarmed me and made me skeptical. After all, what kind of a “turn for the worse” could a kid with mild vomiting and diarrhea take in such a short time? I left the house and drove the 10 minutes to the hospital, going straight to the Pediatric floor. As I walked in the room, I knew it was bad. They had called the ED physician who was attempting to intubate the child. We completed the intubation; however, this was not a pediatric hospital and its crash cart was not equipped to handle the needs of a 10-year-old crashing. The rest of the details are not relevant because the child did not survive. Looking down at that little boy, so much like my own, I sat on his bed and could not begin to consider the possibility of going to tell his father what had happened. I didn’t know what had happened. It never occurred to me that when I had talked to that dad just a few hours earlier and reassured him that just as a “precaution” he should take his son to the hospital to get some IV fluids, I would be telling him that his child was dead – his only child, whose mom had died two years earlier. Why are some people given such horrific challenges in life? Why did I have to break this man’s heart in such a way that it will never heal? Why am I the one who gets to keep her two sons while he has lost his one? I am not sure how I did it, but my words and tears conveyed a reality that was beyond my comprehension. I don’t really remember driving home that night or what time it was when I finally entered my children’s room. But I do remember sitting on the bottom bunk bed listening to the steady rhythm of their breathing, feeling grateful and guilty while making a vow to always make these two boys my first priority. Then I cried myself to sleep. The autopsy report showed no relevant findings, and the cause of death was listed as respiratory failure. For the next two years, I carried this child’s autopsy report with me and would ask as many pediatricians who would listen if they had any idea what precipitating events could have led to this child’s outcome. I continually replayed the conversation I had had with the dad – the symptoms he had described, the advice I had given him – and wondered just what I had missed. Because surely kids this healthy with this mild form of an illness just don’t die, this meant that I must have missed something. I had always believed that I was really good at the job that I always referred to as my passion, but after this occurrence, I started to believe I had just been lucky. Although I eventually stopped carrying the report, I continued to carry the memory. It led me to voice my concerns to the hospital administration and work on improving the pediatric facility. Though it was never explicitly said that even the most well-equipped pediatric trauma room could have saved that child’s life, the remote possibility was a concrete entity where I could affect change. However, the greatest change took place inside of me. I began to realize that the limitations I have as a physician go well beyond limitations in knowledge. They are limitations based solely on my humanity. I once read a quote by Gandhi that said “It is for us to make the effort, the result is always in God’s hand.” I am not sure why this concept was so hard for me to comprehend. Maybe it was arrogance and youth combined with a first-rate medical education and training where the objective was always to save, heal, sew, set, replace – not necessarily to “allow.” My practice of medicine changed, subtly at first and then in a more pronounced way. These were not changes that would be noted by an outside observer, for it was an internal shift in what I felt to be my responsibility toward my patients. Realizing that my knowledge was far from all-encompassing and my ways not the only ways, I became much more flexible in the doctor-patient relationship. I saw my job as one of providing the latest and best medical information and giving guidance. Instead of dictating treatment in non-life-threatening situations, I allowed parents to be more involved in the decision-making process, respecting their opinions and concerns. I began to rely on a more holistic approach, and I think I connected on a much deeper level with the parents and the children. It was a wonderful time, and I once again began to believe that I was a pretty good pediatrician. The greatest changes and possibly the most lasting have been in my own personal life. I committed myself from that night on to be a better mom and wife, yet I know that those for whom that commitment was made may not always have seen it that way. But when I look at my motives and intentions in the naked, raw light of self-inspection, I know it’s the truth. And that is all I could change. LM Note: Dr. Haddad works in Pediatrics at Kosair Children’s Hospital and Baptist Hospital East. 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