LOUISVILLE MEDICINE Medicine/LM... · sseepptteemmbbeerr 22000088 33 louisville greater louisville medical society 24 medicine vol. 56 no. 4 september 2008 see page 24 for cover story

MEDICINELOUISVILLEGREATER LOUISVILLE MEDICAL SOCIETY VOL. 56 NO. 4 SEPTEMBER 2008

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SSEEPPTTEEMMBBEERR 22000088 33

LOUISVILLEGGRREEAATTEERR LLOOUUIISSVVIILLLLEE MMEEDDIICCAALL SSOOCCIIEETTYY

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MEDICINEVVOOLL.. 5566 NNOO.. 44 SSEEPPTTEEMMBBEERR 22000088

See page 24 for cover story.

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On Call - Winner Practicing and Life Member CategoryKenneth Henderson, MD

A Chance Encounter - Winner Resident CategoryGena L. Napier, MD

Clyde Cohen - Winner Student CategoryClint Morehead

White Coat - Honorable Mention (from Student Category)Danielle Pigneri

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

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13

D E P A R T M E N T S

5 From The PresidentMichael McCall, MD

CommentaryNot Enough BolshieMary G. Barry, MD

Guest CommentaryKentucky Nurses Make Contribution to State BudgetSherri Allen, BSN, RN

Letter to the EditorJohn N. Lewis, MD, MPH

We Welcome You

In RemembranceJohn E. Ryan Sr., MDTribute by Arthur T. Daus, MD, and John Edward Ryan Jr.

10

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Departments continued on page 4

In preparing my remarks for lastmonth’s White Coat Ceremony fornew medical students, I found myselfmulling over the direction the speechwould go, attempting to determinewhat I could say that would encour-age medical students to take advan-tage of the opportunities GLMS offersthem, and also prevent them fromnodding off in their seats. Whilst con-sidering these issues, I kept circlingback to the fact that each of these stu-dents is entering into a remarkablystrong community of leaders. For thisis what we are, at the core of it:Leaders. As physicians, we havechosen the huge burden and privilegeof caring and treating for all membersof our community, without regard totheir age, race, or creed. In makingthis choice, we have stepped to theplate, willing or unwilling, as leadersof this community.

A physician must treat to the bestof his or her ability. There are timeswhen this common sense statement isdifficult to meet. Sometimes, I findthat “choice” of treatment is often anillusion, with the reality somewherebetween what insurance will coverand what is best for the patient. Iknow that I am not alone when I saythat this ever forceful illusion is alwaysfrustrating, and never simple.

A leader must lead to the best ofhis or her ability. This statement is notfraught with the illusions we navigatein our daily quest to be physicians.Instead, it is as straightforward as itseems. Leading is not always simple,but a leader must lead. Thankfully, weare not alone. We have an entirenetwork of fellow physicians. We can

all lead in our separate ways, in ourseparate practices, in our separatespecialties. Or, we can choose tocombine our strengths, and lead thiscommunity together.

I often hear my fellow physiciansvoice concerns about the strength ofthe pharmaceutical and insurancelobbies. I too have raised similar con-cerns over the years. Most of you areprobably well aware of the recentveto of the 10.6 percent Medicarecuts. However, you may not be awarethat it was the voices of doctors—leaders—raised together that assistedin preventing these cuts. While otherlobbies certainly added their weight,physicians played a significant role.

As you navigate your daily prac-tice, remember that you have a com-munity of physicians working withyou, and a community of patientswaiting for you to make your voiceheard. The Greater Louisville MedicalSociety has a KMA Delegation & QuickAction Team Subcommittee thatworks closely with the KentuckyMedical Association, and is willing tohelp promote your concerns to yourstate legislators. As physicians, we willcontinue to face pressures fromvarious realms in our quest to besttreat our patients.

As leaders, we must determinehow to face these pressures, keepingin mind that how we respond deter-mines our strength as a community ofleaders. I sincerely believe that wehave one of the strongest communi-ties in the nation. I hope that each ofyou will join me in making our voicesheard.

D E P A R T M E N T S

41

LLOOUUIISSVVIILLLLEE MMEEDDIICCIINNEE44

AllianceMimi PrendergastGLMS Alliance President

Book Review: Kill as Few Patients as PossibleReviewed by Arun Gadre, MD

Reflections: On Hospital Ministry volunteeringTeresita Bacani Oropilla, MD

Physicians in Print44

4243

LOuISvILLE MEDICInE is published monthlyby the Greater Louisville Medical Society, 101 W.Chestnut St. Louisville, Ky. 40202 (502) 589-2001,Fax 581-9022, www.glms.org.

Articles to be submitted for publication in LLMMmust be received by the first day of the month,two months preceding publication.

Opinions expressed herein are those of individ-ual contributors and do not necessarily reflect theposition of the Greater Louisville Medical Society.LLMM reminds readers this is not a peer reviewed scientific journal.

LLMM reserves the right to make the final decisionon all content and advertisements.

Circulation: 3,800

GLMS Board of GovernorsG. Randolph Shrodt Jr., MD, board chairMichael W. McCall, MD, presidentLynn T. Simon, MD, president-electKimberly A. Alumbaugh, MD, vice presidentBernard L. Speevack, MD, secretaryRussell A. Williams, MD, treasurerKerry Short, MD, at-large Heather L. Harmon, MD, at-large Christopher K. Peters, MD, at-largeDeborah A. Ballard, MD, at-large Charles B. Shane, MD, at-large Lewis Hargett, MD, at-largeRobert R. Goodin, MD, AMA delegate Bruce A. Scott, MD, AMA alternateLinda H. Gleis, MD, KMA ranking officerGordon R. Tobin, MD, 5th District trusteeRobert A. Zaring, MD, 5th District alternate ..............

delegateTimothy S. Brown, MD, GLMS Foundation ...................

presidentStephen S. Kirzinger, MD, Medical Society

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

UofL School of Medicine Adewale Troutman, MD, MPH, director,

Louisville Metro Department of Public Health & Wellness

Mimi Prendergast, GLMS Alliance presidentLouisville Medicine Editorial BoardEditor: Mary G. Barry, MDDeborah Ann Ballard, MDLaurie Ballew, EdD, DOWilliam A. Blodgett, MDEugene H. Conner, MDFrank DeLand, MDArun Gadre, MDJeremy Gerwe, MDTracy Ragland, MDStanley A. Gall, MDLarry P. Griffin, MDDarin Harden, MDJonathan E. Hodes, MDThomas James III, MDLouanda M. Kynhoff, MDMichael T. Macfarlane, MDTeresita Bacani-Oropilla, MDM. Saleem Seyal, MDBernard L. Speevack, MDDave Langdon, Louisville Metro Department

of Public Health & WellnessG. Randolph Schrodt Jr., MD, board chairMichael W. McCall, MD, presidentLynn T. Simon, MD, president-electLelan K. Woodmansee, CAE, executive directorBert Guinn, MBA, communications & membership

directorMatthew Ralph, communications associateDonna Watts, communications designer Advertising Cheri K. McGuire, director of marketing736.6336, [email protected]

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Departments continued from page 3

In preparing my remarks for lastmonth’s White Coat Ceremony fornew medical students, I found myselfmulling over the direction the speechwould go, attempting to determinewhat I could say that would encour-age medical students to take advan-tage of the opportunities GLMS offersthem, and also prevent them fromnodding off in their seats. Whilst con-sidering these issues, I kept circlingback to the fact that each of these stu-dents is entering into a remarkablystrong community of leaders. For thisis what we are, at the core of it:Leaders. As physicians, we havechosen the huge burden and privilegeof caring and treating for all membersof our community, without regard totheir age, race, or creed. In makingthis choice, we have stepped to theplate, willing or unwilling, as leadersof this community.

A physician must treat to the bestof his or her ability. There are timeswhen this common sense statement isdifficult to meet. Sometimes, I findthat “choice” of treatment is often anillusion, with the reality somewherebetween what insurance will coverand what is best for the patient. Iknow that I am not alone when I saythat this ever forceful illusion is alwaysfrustrating, and never simple.

A leader must lead to the best ofhis or her ability. This statement is notfraught with the illusions we navigatein our daily quest to be physicians.Instead, it is as straightforward as itseems. Leading is not always simple,but a leader must lead. Thankfully, weare not alone. We have an entirenetwork of fellow physicians. We can

all lead in our separate ways, in ourseparate practices, in our separatespecialties. Or, we can choose tocombine our strengths, and lead thiscommunity together.

I often hear my fellow physiciansvoice concerns about the strength ofthe pharmaceutical and insurancelobbies. I too have raised similar con-cerns over the years. Most of you areprobably well aware of the recentveto of the 10.6 percent Medicarecuts. However, you may not be awarethat it was the voices of doctors—leaders—raised together that assistedin preventing these cuts. While otherlobbies certainly added their weight,physicians played a significant role.

As you navigate your daily prac-tice, remember that you have a com-munity of physicians working withyou, and a community of patientswaiting for you to make your voiceheard. The Greater Louisville MedicalSociety has a KMA Delegation & QuickAction Team Subcommittee thatworks closely with the KentuckyMedical Association, and is willing tohelp promote your concerns to yourstate legislators. As physicians, we willcontinue to face pressures fromvarious realms in our quest to besttreat our patients.

As leaders, we must determinehow to face these pressures, keepingin mind that how we respond deter-mines our strength as a community ofleaders. I sincerely believe that wehave one of the strongest communi-ties in the nation. I hope that each ofyou will join me in making our voicesheard.

From The PresidentMichael McCall, MDGLMS President



n O T E n O u G H B O L S H I E

As the housing crisis continues,parents forego their medications tobuy their children milk, the job marketplummets and gas prices soar, theCEOs at the top of the food chain con-tinue to rake it in. The median valuefor their pay packages in 2007 was$8.4 million dollars per year(Associated Press). Note that is the“median,” not the average. At the topend is Mr. John Thain of Merrill Lynch,who signed for $83 million lastDecember despite the fact that Merriillhad one of its worst-ever losses thatyear. Mr. Richard Wagoner of GeneralMotors heads a company that closedfour plants and lost $39 billion dollarsin 2007, but guess what? He got a 64percent raise, to $15.7 million (not inMr. Thain’s league, but enough to buyat least a timeshare in a Learjet, or abauble or two at Tiffany’s).

As reported in June by RachelBeck and Matthew Fordahl, the 10best-paid CEOs “made more than halfa billion dollars last year, even thoughhalf of them were leading companieswhose profits had shrunk dramatical-ly.” They found that “CEO pay rose andfell regardless of the direction of acompany’s stock price or profits,” foran average pay increase across theboard of 3.5 percent.

Imagine the outcry if you camehome at the age of 17 and told yourdad you had just lost all of yourcollege savings at the racetrack. “Itwas a bad day in a bad year, Daddy,and the market was against us,” youmight say, tearfully. I somehow doubtthat in response he would give you abigger allowance, a cost-of-livingincrease, extra perks in auto use,above-market interest on deferred

pay, and a signing bonus for your newafter-school job. Yet three-fifths ofthese executives of the Standard &Poor’s 500 companies got all thosethings, and more.

How divorced from the reality ofeveryday American life are these guys?If ex-President Bush’s famed inabilityto recognize a bar code is any indica-tor, they are totally out-of-touch.Many of them may have come upthrough the ranks, hustled all theirlives, baled hay or shucked oysters tomake it through B-school, so they mayonce have had some idea of how theworking classes live. But if they thinkof that much salary as somehow fair,they have lost their souls for sure.Indubitably they support charities, andare universally thus praised (I can’tcomment on whether they actuallypay taxes, or just know nifty account-ants in the Caymans). But, for instance,do they personally peel off $20s topay the cabbie? No – they haveflunkies for that sort of thing. Ask abillionaire CEO what it costs a cabdriver per weekend just to fill the tank,and I bet 85 percent of them wouldguess wrong, whereas the averageguy on the GM line would get it inone.

They have stresses of their own,but I can’t believe that even teak-paneled boardroom warriors deservethat much money. They go to meet-ings, right? They make expensive deci-sions, right? They stay up late, get upearly, talk endlessly on the phone, goto work at the crack of dawn, arebesieged with problems of every con-ceivable nature, trail reams of paper-work behind them, and work pasttheir emotional limits sometimes; allthat, right? Big deal. So do we, and notfor any $18 million, either.

This leads us to our second groupof interestingly-salaried people: ourUniversity leaders. Looking at the June’07 to June ’08 year, our indomitableCoach Pitino topped all U of L salariesat $2.25 million. Coach Kragthorpe(referred to in many circles by othernames, including “Slagheap”) made amere $1.1 mill. Who is the highest-paid U of L doctor? According to theCourier’s Web site, it’s not Dr. DanDanzl or Dr. Bill Smock of the ER, eventhough they have many years ofincomparable in-the-trenches experi-ence, not to mention responsibility formass casualty crises. They’re not evenon the first five pages. It’s not Dr.Hiram C. Polk, who built the programthat Dr. Kelly McMasters now leads,and it’s not Dr. McMasters. It’s not Dr.Don Miller or Dr. William Spanos of theCancer Center, or Dr. Gerard Rabalais,the chair of Pediatrics, or Dr. SuzanneIldstad, the famous researcher, either.Nobody in the Department of OB-GYNis even close.

The top pay goes to Dr. LarryCook, vice president of Health Affairs,whose salary is listed at $878,383,which is $400,000 dollars more thanPresident Ramsey’s and more than$300,000 more than Dean Halperin’s,who sits at fourth overall.

Dr. Cook must go to meetingsnonstop and make very expensive,one might say exorbitant decisions, Iguess. I don’t think he spends muchtime in Room 9 anymore.

Only three women made it overthe $300,000 barrier. Thankfully, foronce the Department of FamilyMedicine did not finish last; its chair,Dr. James G. O’Brien, has been betterrewarded than a couple of othermedical department chairs. The dean


Commentary Mary G. Barry, MDLouisville [email protected]

Continued on page 8


Guest Commentary

of the Law School at $260, 000 makes$100,000 less than the dean of theCollege of Business, who is only$20,000 behind Tom Jurich, whodeserves more! He has helped everysingle sport at U of L. Every bench-warming softball player and lacrossemidfielder is in his debt, as are allCardinal fans.

Dr. Kerri Remmel makes less thanthe baseball coach, Dan McDonnell,but more than that ex-professor ofeducation, Robert Felner. (The moralof that story is that if you get beaned

at home plate at least you will get agood neurological opinion, but if youhave to go to court, do what Mr.Felner did and get the very best, ScottCox).

Who’s at the very bottom, thelanterne rouge of the salary list? Notsurprisingly, it’s the poor Departmentof Social Work, which never gets anyrespect. Yet they devote themselves toteaching the selfless people who aredesperately needed to help the mostvulnerable of us, the people that allthose CEOs never see.

Perhaps our own highest-salarieddoctors will manage to avoid the fate

of the elite, and keep some awarenessof, “From each according to his abili-ties, to each according to his needs.”Right now, I’d say the czars are far toopowerful. Onward the Bolshies!

The views expressed in this commentary or any otherarticle in this publication are not necessarily those ofthe Greater Louisville Medical Society or LouisvilleMedicine.

If you would like to respond to an article or commen-tary in this issue, please submit your response in theform of a Letter to the Editor. You may submit lettersto the Editor online @ www.glms.org or by emailingour editor directly at [email protected]. The GLMSEditorial Board reserves the right to choose whichletters will be published.

LM

Continued from page 7

The State Budget Bill that waspassed during the 2008 LegislativeSession calls for $1.7 million to betransferred from the Kentucky Boardof Nursing to the General StateBudget Fund in 2008. This is moremoney than is being transferred fromthe Kentucky Board of Dentistry andthe Kentucky Board of MedicalLicensure combined (House Bill 406).

With the state already facing anursing shortage, the decision by leg-islators to double-tax nurses will defi-nitely not encourage others to join theprofession. Furthermore, the morethan 7,000 out-of-state nurses withKentucky nursing licensure maydecide to quit practicing in Kentucky ifannual licensing renewal fees are sub-

stantially increased in order for theKBN to meet its operating expenses.

The $1.7 million dollar removalfrom the KBN will also have a signifi-cant impact on its ability to continueto provide scholarship funds to nurseswho are continuing their education.The KBN already turns down morethan 500 applicants each year forscholarship money due to a lack ofresources. This is occurring at thesame time that the Best in Careprogram is experiencing major federalgovernment funding cuts. The Best inCare program is a loan providedthrough the Student Loan PeopleCorporation that allowed nurses totake out loans for education with anannual 15 percent to 20 percent for-

giveness rate. As of June, no newapplications will be available for thisprogram.

It is amazing to me that Kentuckylegislators didn’t have the backboneto increase a tobacco tax that wouldhave generated an additional $292million in revenue but they had noproblem double-taxing the 65,000-plus nurses who provide care to thecitizens of the commonwealth. Placingincreased burdens on the professionof nursing will have a negative impacton all citizens of Kentucky. Increasedlicensing fees and decreased fundingfor education will only worsen thecurrent nursing shortage in our state. LM

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Dear Dr. Barry,

Thank you for your very thoughtful editorial, “Punishing the Sick,” in the July Louisville Medicine. I am also critical of the way theCenters for Medicare & Medicaid Services (CMS) pays bills, but for somewhat different reasons.

The following are complications for which CMS will not pay hospitals, as of 10/1/08, if they were acquired in the hospital.• Catheter-associated UTIs• Vascular catheter-associated infections• Mediastinitis after CABG surgery• Pressure (decubitus) ulcers• Fractures, dislocations, or other hospital-acquired injuries• Serious preventable events (“Never Events”)

� Objects left in during surgery� Air embolisms� Blood incompatibilities

Additional hospital acquired conditions (HACs) are under consideration as CMS candidates in 2009, pending expert and public response.• Surgical site infections following elective surgery

� Total knee replacement� Laparoscopic gastric bypass and gastroenterostomy� Ligation and stripping of varicose veins

• Legionnaires’disease• Glycemic control

� Diabetic ketoacidosis� Nonketotic hyperosmolar coma

• Diabetic coma• Hypoglycemic coma• Iatrogenic pneumothorax• Delirium• Ventilator-associated pneumonia (VAP)• Deep vein thrombosis (DVT)/ pulmonary embolism (PE)• Staphylococcus aureus septicemia• Clostridium difficile-associated disease As indicated by your comments, some of these HAC draft rules will probably not withstand intense scrutiny (e.g. Legionnaires’ and

delirium). Others are either clear-cut preventable medical errors or are “reasonably preventable through the application of evidence-basedguidelines.” The measures are based on strong, published, evidence-based criteria, most are in agreement with National Quality Forummeasures, and they are supported by the American Hospital Association, CDC, and most infectious disease experts. They are all intended tolimit payment to hospitals, not payment to physicians.

Physicians generally accept the premise that we should first do no harm. Is it reasonable to assume CMS will always pay for complica-tions for which physicians and hospitals are at least partly responsible? Whatever the intent of CMS, I believe there are large opportunitiesfor CMS to improve on their methods.

• Payment should not be withdrawn as a punishment• CMS should, rather, take a proactive, positive approach with a timely, increased payment for services that follow best practices• Incentives should be based on better practices of physicians (such as practices that could prevent a UTI) rather than outcomes (UTI)CMS frequently uses disincentive policies (such as the recently proposed 10.6 percent payment cut to physicians) rather than positive,

timely incentives. The current Physician Quality Reporting Initiative could be a step in the right direction, but it pays too little and much toolate, a year after the activities being rewarded.

Just as CMS and Congress should be more positive and proactive in their approach to the broken Medicare payment system, physi-cians will need to take positive and proactive approaches to the system to get what they and their patients need. Congress has before it amixed bag of legislation affecting CMS payments and oversight. Kentucky happens to have members in very influential positions. SenatorBunning is on the key Senate Finance Committee, Senator McConnell is the minority leader, and Rep. Yarmuth may soon sit on the HouseCommerce Committee. The mood in Congress is against rewarding physicians if we don’t take positive positions and actions on qualityimprovement, cost containment, use of best practices and transparency. The recent popular Kentucky legislation which was championedby Dr. DeWeese is a good example of a positive legislative approach with a better public image for physicians. This is a good time for us allto be more active in our own interests.

Sincerely,

John N. Lewis, MD, MPH

(Note: The views expressed in this letter are mine, not necessarily those of my employer, and certainly not of CMS.)

Letter to the Editor

1111SSEEPPTTEEMMBBEERR 22000088

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MONDAY• Opening House of Delegates Session• Reference Committees• KEMPAC Dinner

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WEDNESDAY• General Session• Specialty Group Meetings• Exhibit Hall• Final House of Delegates Session

For additional information on the 2008 KMA Annual Meetingvisit www.kyma.org

MONDAY, SEPTEMBER 15 - WEDNESDAY, SEPTEMBER 17New Location - The Galt House, Louisville, Kentucky


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Candidates Elected to Provisional Active MembershipMohsin, Shehnaz (20000)1505 South 7th Street 40208637-1077Family Practice Dow Medical College 1999

Nixdorf-Miller, AllisonShepherd (19938)Travis L. Miller530 South Jackson Street40202852-5534Pathology West Virginia University 2003

Rai, Amit (19806)Rupinder Kaur6400 Dutchmans Parkway Suite 250 40205 587-9660Nephrology; Internal Medicine2006 Government Medical College2000

Sepich, Jody Tucker (19985)Christopher201 Abraham Flexner Way Suite 905 40202502-569-7983Internal Medicine 2006 East Carolina University 2003

Silberberg, Phillip J (19899)231 E Chestnut St 40202629-7661Diagnostic Radiology; PediatricRadiology; Radiology 1993 University of the WitwatersrandMedical School

Smith, J Steve (19983)Jennifer Alexander Smith4130 Dutchmans Ln Suite 300 40207897-1794Orthopaedic Surgery; SportsMedicine University of Kentucky 2001

Smith, Jason Wayne (19960)Heather Ann Smith550 S Jackson St 2nd Fl ACB40202852-1729General Surgery The Ohio State University 2002

Goodwin, C Jeffery (19921)Kristie101 Hospital BoulevardJeffersonville IN 47130812-282-3899Urological Surgery University of Louisville 2002

Hasselbacher, David A (19046)Lauren1169 Eastern Parkway Suite 3310 40217 459-9127Pulmonary Diseases; CriticalCare Medicine; InternalMedicine University of Louisville 2001

King, Jeffrey Charles (19999)Ruth Anne King601 South Floyd Street Suite 300 40202271-5999Maternal/Fetal Medicine 1988;Obstetrics Gynecology 1982 Rush University 1975

Lowe, Dawn Christine (19996)130 Hunter Station Way Suite 202 Sellersburg IN 47172812-248-0800Pediatrics; Internal Medicine University of Louisville 2004

McDowell, Roddy (19836)Carolyn McDowell916 Dupont Rd 40207454-7107Pediatric Cardiology; Pediatric2005 University of Louisville 2002

Mehta, Jinesh P (17464)Hemangini Mehta4003 Kresge Way Ste 31240207 899-7377Internal Medicine 2004;Pulmonary Diseases 2007 Seth G.S. Medical College 1999

Meredith, Shirley Jean (19915)201 Abraham Flexner Way Suite 904 40202585-2226Internal Medicine University of Louisville 1995

Alsorogi, Mohammad S(19898) Dina M. Emara250 East Liberty Street Suite 202 40202589-6177Neuropsychiatry; Neurology Ain-Shams University 1996

Arndt, Frederick V (19807)Amy Hunt6400 Dutchmans Pkwy Ste 250 40205 587-9660Nephrology; Internal Medicine2006 Albany Medical College 2003

Attallah, Nizar Mousa (19805)Lina Yassine, MD6400 Dutchmans Parkway Suite 250 40205587-9660Nephrology 2005 University of Jordan 1998

Ayyanar, Kanyalakshmi(19289)Manirajan Mahalingam601 South Floyd Street Suite 403 40202 629-7750Pediatric Hematology-Oncology2006; Pediatrics 2003 Madurai Medical College 1995

Christensen, Rebecca Lyn(19837)Charles J. Christensen2307 Green Way 40220736-4356Pathology 2003 University of Louisville 1996

Chubindize, Omari (19476)Michelle Chubinidze2355 Poplar Level Rd Ste 20040217636-7444Family Practice Tbilisi State Medical Institute1994

Ferreira Lopez, Ricardo Daniel(10596)Svetlana Nakatis, MDJewish Hospital Health Services534 Fairway Dr BrandenburgKY 40108 270-422-5000Family Practice 2004 National University of Asuncion1996

W E W E L C O M E Y O UGLMS would like to welcome and congratulate the followingphysicians who have been elected by Judicial Council as provision-al members. During the next 30 days, GLMS members have theright to submit written comments pertinent to these new mem-bers. All comments received will be forwarded to Judicial Council

for review. Provisional membership shall last for a period of twoyears or until the member’s first hospital reappointment.Provisional members shall become full members upon completionof this time period and favorable review by Judicial Council.


W E W E L C O M E Y O UBurns, Candice Marie (20140)Troy BurnsUL Pediatrics 530 S Jackson St 40202Indiana University 2008

Byers, Matthew William(20152)UL Pediatrics 530 South Jackson Street 40202Ohio State University 2008

Chady, Laura Anne (20118)UL Medicine/Pediatrics 530South Jackson Street 40202University of Louisville 2008

Chang, Chih Cheng (20095)Yen-Dih ChangUL Internal Medicine 530 South Jackson Street 40202University of Louisville 2002

Cochran, Angela Rose (20101)CoryUL Medicine 530 South Jackson Street 40202University of Texas 2008

Davis, Hunter W (20186)201 Abraham Flexner Way Suite 690 40202University of Louisville

Dayyat, Ehab (20126)UL Pediatrics 530 South Jackson Street 40202Damascus University 1999

DeHaven, Benjamin Aaron(20085)Jessica DeHavenUL Emergency Medicine 530 South Jackson Street 40202West Virginia University 2008

Al Dammad, Tarek (20166)Salameh Tavassoli550 South Jackson Street RoomA3 40202852-5841University of Aleppo

Alhaddad, Mohsin T (20128)Zainab Sabin AlhaddadUL Cardiology 550 South Jackson Street 40202Moi University 2000

Ali, Aisha (20151)Raza AuUL Pediatrics 530 South Jackson Street 40202King Edward Medical College

Armstrong, Jared Troy (20074)JennyUL Orthopaedics 530 South Jackson Street 40202University of Louisville 2008

Bell, Tricia Courtney (20129)Brendan BellUL Pediatrics 530 South Jackson Street 40202Loyola University 2008

Booth, Rebekah Elise (20150)Justin EslingerUL Pediatrics 530 South Jackson Street 40202University of Louisville 2008

Bourgeois Mire, Danielle M(20137)Rick MireUL Psychiatry 530 South Jackson Street 40202Louisiana State University 2004

Breland, Ryan Baker (20084)UL Orthopaedics 530 South Jackson Street 40202University of Alabama 2008

Aburomeh, Ibrahim Saleh(20133)Shereen AlsabohUL Internal Medicine 530 South Jackson Street 40202University of Jordan 2002

Adams, Sarah Tatjana Maria(20139)Lance AdamsUL Pediatrics 530 South Jackson Street 40202Oxford University 2007

Kennedy, Stephen Douglas(18913)Valorie1034 Spring Street JeffersonvilleIN 47130812-218-8840Family Practice 2004 Indiana University 1994

Sohi, Sameet Singh (19959)Star6420 Dutchmans Parkway Suite 380 40205894-8441Otolaryngology University of Louisville 2003

Sokol, Jason Aaron (20021)Eva Jenny Lipner8801 North Meridian StreetSuite 207 Indianapolis IN 46260317-573-1000Ophthalmology New York University 2004

Weeks, Jonathan W (2496)Brenda K. WeeksBHE Fetal Testing Center 3rdFloor 4000 Kresge Way 40207Obstetrics Gynecology 1991,2001, 2002, 2003, 2004, 2005;Maternal/Fetal Medicine 1995,2001, 2002, 2003, 2004, 2005 University of Kentucky 1984

Candidates Elected toProvisional AssociateMembership

Candidates Elected ToProvisional In-TrainingMembership





We love our doctors.

Why not share the love?WE WORK HARD TO HELP ALL OUR PHYSICIANS PROVIDE exceptional care to patients throughout southern Indiana. And it shows up in the high scores that doctors — and their patients — give us.

How do we do it? We listen. We communicate clearly. And we care for every patient as if he or she was a member of our own family.

If you care for southern Indiana patients — or if you’d like to — we invite you to join the growing number of physicians who see patients at Clark Memorial Hospital. Healing begins here.

(812) 282-6631 | www.clarkmemorial.org | 1220 Missouri Ave., Jeffersonville, IN

Healing Begins Here.

W E W E L C O M E Y O UHendren, Sara Jane (20006)Bradley T. Hendren1 Audubon Plaza Drive 40217636-8123Emergency Medicine University of Louisville 2006

Houser, Philip Thomas (20088)Ranelle HouseUL Anesthesiology 530 South Jackson Street 40202University of Texas 2008

Hu, Jane B (20079)Gerald L. KeeneUL Psychiatry 530 South Jackson Street 40202Shanghai Medical College/FudanUniversity 1989

Hunley Dyer, Brandi Jo (20082)Adam DyerUL Internal Medicine 530 South Jackson Street 40202University of Louisville 2008

Hussain, Afzal Syed (20148)571 South Floyd Street Suite 300 40202629-8828Deccan College of MedicalSciences 2005

Jeffy, Brooke Grant (20099)Benjamin Jeffy310 East Broadway 40202University of Louisville 2004

Johnson, Crystal D (20120)UL Medicine/Pediatrics 530 South Jackson Street 40202Medical University of theAmericas 2008

Johnson, Joshua Ryan (20109)Kelly JohnsonUL Physical Medicine and Rehab530 South Jackson Street 40202University of Kentucky 2008

Galanopoulos, Panagiotis(20136)UL Family and GeriatricMedicine 530 South Jackson Street 40202Ross University 2007

Gentner, Jennifer Elizabeth(19935)1261 Goss Avenue 40217635-6937Allergy and Immunology;Internal Medicine 2006 University of Louisville 2003

George, Michael Robert (20070)UL Ophthalmology 530 South Jackson Street 40202Louisiana State University 2007

Godbout, Jennifer Miller(20102)Eric C. GodboutUL OB/GYN 530 South Jackson Street 40202Eastern Virginia Medical School2008

Goodman, Jason Edward(20149)UL OB/GYN 550 South Jackson Street 40202University of Louisville 2008

Haji Abdollahi, Sara (20146)UL Internal Medicine 530 South Jackson Street 40202University of Texas 2008

Harandi, Mietra Sadegh (20092)Amir Harandi, MDUL Internal Medicine 530 South Jackson Street 40202852-7041Pikeville College of OsteopathicMedicine 2008

Hargett, James L (20086)Elizabeth HargettUL Anesthesiology 530 South Jackson Street 40202852-1732University of Louisville 2008

Dickinson, Lindsay Ashbrook(20131)571 South Floyd Street Suite 300 40202629-8828University of Louisville 2008

Donovan, Kristina Janssen(20124)Chris DonovanUL Physical Medicine and Rehab 530 South Jackson Street 40202West Virginia School ofOsteopathic Medicine 2008

Durbin, Kaci Lyne (20083)Michael T. DurbinUL OB/GYN 530 South JacksonStreet 40202University of Illinois 2008

Elmaadawi, Ahmed Z (20115)Shiva Elmaadawi501 East Broadway Street40202Mansoura University 2003

Espinosa, Martin A (20125)Silvia PotenziawiUL Internal Medicine 530 South Jackson Street 40202Escuela Luis Razetti MedicoCirujano 2005

Faber, Kelly L (20114)UL Pediatrics 530 South Jackson Street 40202University of Louisville 2008

Fichandler, Craig Evan (20093)UL Otolaryngology 530 South Jackson Street 40202Eastern Virginia Medical School2007

Forster, Derek Walter (20090)Laura ForsterUL Internal Medicine 530 South Jackson Street 40202University of Louisville



We love our doctors.

Why not share the love?WE WORK HARD TO HELP ALL OUR PHYSICIANS PROVIDE exceptional care to patients throughout southern Indiana. And it shows up in the high scores that doctors — and their patients — give us.

How do we do it? We listen. We communicate clearly. And we care for every patient as if he or she was a member of our own family.

If you care for southern Indiana patients — or if you’d like to — we invite you to join the growing number of physicians who see patients at Clark Memorial Hospital. Healing begins here.

(812) 282-6631 | www.clarkmemorial.org | 1220 Missouri Ave., Jeffersonville, IN

Healing Begins Here.


W E W E L C O M E Y O UMilam, Kristan A (20104)Michael SchisslerUL Internal Medicine 530 South Jackson Street 40202University of Louisville 2007

Milliner, Beth A (20106)UL Emergency Medicine 530 South Jackson Street 40202852-5681University of Louisville 2008

Minix, Amy Lynn (20122)UL Emergency Medicine 530 South Jackson Street 40202University of Kentucky

Morehead, Robert Clinton(20130)UL Internal Medicine 530 South Jackson Street 40202852-7041University of Louisville 2008

Neamtu, Daniela (20147)Aurel NeamtuUL Internal Medicine 530 South Jackson Street 40202University of Medicine andPharmacy 1982

Noplis, II Charles R (20077)UL Psychiatry 530 S Jackson St 40202University of Louisville 2008

O'Bannon, Ashley Brooke(20081)Darko LatinovicUL Pathology 530 South Jackson Street 40202University of Louisville 2003

O'Neill, Edward Francis (20091)Missy O'NeillUL Pediatrics 530 South Jackson Street 40202University of South Florida 2005

Ladner, Emily Watson (20097)Benjamin Ladner, MDUL Pediatrics 530 South Jackson Street 40202Creighton University 2008

Liu, Jonathan Chinhua (20141)Sharon Kim425 South Hubbards Lane40207949-812-2704Saint George's University 2002

Lloyd, Margie Nicole (20096)UL Pediatrics 530 South Jackson Street 40202University of Louisville 2008

Mallory, Brad Morris (20117)879 Haywood Cedar Grove RoadGlasgow KY 42141439-8833University of Louisville 2008

Masden, Troy Andrew (20182)Heather Masden201 Abraham Flexner Way Suite 690 40202852-0132Ross University

Meade, Michael Daniel (20112)Carmela MeadeUL Internal Medicine 530 South Jackson Street 40202University of Louisville 2008

Merkwan, Courtney Elizabeth(20073)Carson MerkwanUL Emergency Medicine 530 South Jackson Street 40202University of South Dakota 2008

Mian, Haroon Afzal (20183)Alia Mian201 Abraham Flexner Way Suite 690 40202American University of theCaribbean

Johnson, Karen Lynn (20116)UL Surgery 530 South Jackson Street 40202University of Alabama 2008

Kalajian, Andrew H (19883)Andrea Deborah Booth Kalajian301 East Broadway Suite 200 40202583-1749Dermatology University of South Florida 2003

Kemp, Jamie Dawn (20080)UL Cardiology 550 South Jackson Street 3rdFloor ACB 40202Washington University 2004

Kenner, Emily Sue (20111)Jared KennerUL Internal Medicine 530 South Jackson Street 40202University of Louisville 2008

Kershner, Nicole Allison (20113)UL Internal Medicine 530 South Jackson Street 40202Eastern Virginia Medical School2008

Khan, Rehan Ahmad (20145)Wahida F. KhanUL Gastroenterology/Hepatology530 South Jackson Street 40202Dow Medical College 1993

Knight, James C (20071)530 South Jackson Street 40202852-7041Saba 2008

Ladner, Benjamin W (20098)Emily Ladner, MDUL Anesthesiology 530 South Jackson Street 40202Creighton University 2008




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W E W E L C O M E Y O UStaley, Tyler Jay (20068)UL Physical Medicine and Rehab530 South Jackson Street 40202Saint George's University 2007

Stocker, Abigail Melissa (20100)UL Internal Medicine 530 South Jackson Street 40202University of Louisville 2008

Tipton, Jr James Davis (20078)Rachel Tipton571 South Floyd Street Suite 300 40202University of Louisville 2008

Troyer, Sara Ann (20143)Jeffery D. MazurekUL Pediatrics 530 South Jackson Street 40202Ohio State University 2008

Turney, Emily Hope (20103)UL OB/GYN 530 South Jackson Street 40202University of South Alabama 2008

Warren, Joel M (20087)Ashley WarrenUL Internal Medicine 530 South Jackson Street 40202University of Louisville 2008

Wesley, Caresse Lynnette (20185)Clayton Wesley201 Abraham Flexner Way40202852-6684Nova Southeastern University

Wiles, Jason Roy (20142)BrandyUL Pediatrics 530 South Jackson Street 40202University of Louisville

Roberts, Tadd Nicholas (20108)UL Emergency Medicine 530South Jackson Street 40202852-5689University of Louisville 2008

Ruth, Erika Jaclyn (20107)UL Psychiatry 530 South Jackson Street 40202University of South Carolina 2007

Sawyer, Robert D (20110)Ashton Smythe SawyerUL Internal Medicine 530 South Jackson Street 40202University of Kentucky 2008

Sepich, Christopher Michael(20072)Jody Sepich, MDUL Medicine/Pediatrics 530 South Jackson Street 40202Brody School of Medicine 2008

Sigford, Douglas Kenneth(20135)UL Internal Medicine 530 South Jackson Street 40202University of Minnesota 2008

Smallwood, Jordan Christopher(20127)UL Pediatrics 530 South Jackson Street 40202University of Kentucky 2008

Smith, John Wesley (20069)Blythe SmithUL Medicine/Pediatrics 530 South Jackson Street 40202Louisiana State University 2008

Smotherman, David Scott(20138)Kristen SmothermanUL Internal Medicine 530 South Jackson Street 40202University of Louisville 2008

Parker, Joel L (20123)UL Emergency Medicine 530 South Jackson Street 40202Meharry Medical College 2008

Perry, April Marie (20119)UL Emergency Medicine 530 South Jackson Street 40202University of Louisville 2008

Phelps, Gregory L (20132)GayleUL Internal Medicine 530 South Jackson Street 40202Medical University of SouthCarolina 1979

Pierce, Andrew Denton (20105)UL Emergency Medicine 530 South Jackson Street 40202Indiana University 2008

Pridemore, Ronnie Dale (20134)Kelly PridemoreUL Emergency Medicine 530 South Jackson Street 40202University of Louisville 2008

Reiland, Alison Marie (20121)UL Emergency Medicine 530 South Jackson Street 40202University of Alabama 2008

Rey, Jonathan "Juan" M (20153)UL Family and GeriatricMedicine 530 South Jackson Street 40202Ross University 2008

Reynolds, David Nowell (20076)Kristen K. ReynoldsUL Internal Medicine 530 South Jackson Street 40202University of Louisville 2008



KENTUCKIANAALLERGY,P.S.C.(Allergy, Asthma and Immunology)

is proud to announce and welcomea new associate to their practice

Jeremy D. Jones, M.D.

JohnG.Riehm,M.D. Daniel P.Garcia,M.D.StuartW.White,M.D. DerekA.Damin,M.D.

Adriana S.McCubbin,M.D.

AngelaD.Thomas,M.S.N., A.R.N.P TiffanyL. Simpson,M.S.N., A.R.N.P.

9113 Leesgate RdLouisville, KY 40222

502.426.1621 phone502.426.7906 fax

Toll Free 800.548.6543

www.kyaai.com

JeremyD. Jones,M.D.Doctor Jeremy D. Jones grew up inNashville, Tennessee and graduated asvaledictorian from Greenbrier HighSchool in 1994. Soon thereafter, he beganhis collegiate tenure at Western KentuckyUniversity, where he graduated with aBachelor of Science degree in chemistryand biology in 1998. The same year beganhis medical school training at the Univer-sity of Louisville School of Medicinewhere he graduated summa cum laude in2002. Doctor Jones remained at the Uni-versity of Louisville for his residencytraining in Internal Medicine during whichtime he received honors in professionalismand being the outstanding senior residentof his class. Upon completion of his resi-dency in 2005, he served as Chief MedicalResident for the Department of Medicine,before relocating back to Nashville for hisfellowship training in Allergy and Im-munology at Vanderbilt University.

Currently Doctor Jones is active in theAmerican Academy of Allergy, Asthma,and Immunology, the American Collegeof Allergy, Asthma and Immunology andthe American College of Physicians. He iscertified by the American Board of Inter-nal Medicine and will sit for the AmericanBoard of Allergy and Immunology in Oc-tober 2008.

Doctor Jones and his wife, Doctor LoriHaycraft, have been married since 2001and have many hobbies including travel,music and church activities.


LM

W E W E L C O M EY O U

Williams, Susan R (20089)UL Pathology 530 South Jackson Street 40202University of Louisville 2008

Xiang, Dong (20187)Wencheng Zhu529 South Jackson Street 40202852-4121First Military Medical University

Zhang, Wenqing (20144)UL Hematology/Oncology 529 South Jackson Street 40202Xinxiang Medical College 1988


Need a second opinion?

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Laurie Dobbins [email protected]

215 Breckenridge Lane • P.O. Box 7669 • Louisville, KY 40207 502.893.2020 • Fax 502.897.1533

Dr. Gentner is a Louisville native, having graduated fromSacred Heart Academy as a National Merit CommendedStudent in 1994. She received her Bachelor of Arts degree inBiology Summa Cum Laude from Bellarmine University in1998, followed by her Doctor of Medicine from the UniversityOf Louisville School Of Medicine in 2003. Dr. Gentner completed her Internal Medicine Residency at the University ofCincinnati in 2006, after which she moved to Missouri for herfellowship training in Allergy and Immunology at the St LouisUniversity School of Medicine.

Dr. Gentner is a member of the American Academy of AllergyAsthma and Immunology and the American College of AllergyAsthma and Immunology. She is certified by the AmericanBoard of Internal Medicine and will sit for the AmericanBoard of Allergy and Immunology in October 2008.

Allergy Care is proud to announce and welcomea new associate to their practice

Jennifer E. Gentner, M.D.

John M. Karibo, M.D. Dwight E. Lindsay, M.D.Mark L. Corbett, M.D. Thomas A. Glass, M.D.

Allergy Care has happily been serving thecommunity for 34 years and has offices in

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and Brandenburg.

A stroke in progress demands immediate and expert attention to help prevent lasting brain damageand disability. Fortunately, the people in this community have access to the certified stroke centerthat provides the most advanced care available anywhere in the country.

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For more information on stroke or the remarkable care available at University Hospital StrokeCenter, please call 562-8009.

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LLOOUUIISSVVIILLLLEE MMEEDDII--

Kenneth Henderson, MD

Heaven help me, I am having the Gulliver’s Travels nightmare again. While it hasbeen a recurrent dream of mine, it seems to come more often now since my micro-premie infant son was born. We had lost the fetal heart tones about 24 hours prior tohis delivery. He was estimated to be extremely early at about 21 weeks gestational age.He was born with no heart rate or respirations, an apgar score of zero. I had to be there,but offered him no treatment. I did baptize him with the available IV solution. Hismother felt guilty in that she did not want to be pregnant for the third time. I felt guiltythat in spite of my training and experience as a newborn baby specialist, I was helplessto save my only son. We buried baby boy Henderson in the children’s section of thecemetery next to the freeway so he could feel and hear the motor noise. He came froma long line of good men who loved cars. While he never saw any of them, I believe hehas seen and is with God. Life is short, no matter how long a person lives. I believe pre-mature babies toil in the vineyard of the Lord, through labor and delivery, struggling tobe born. It is a life lived long enough to reap the reward of heaven from an all-lovingand merciful God. His death provided me with the empathy to last my entire lifetime.

In the dream, true to Jonathan Swift, they have me staked out again like a frog on adissecting board in general biology class. I was held securely by No. 5-0 black silk sutureand a million pins. All of my old patients, alive and dead, were busy performing the pro-cedures on me that I had once performed on them. The disadvantaged were gleefullyassisting their more fortunate classmates. I recognized many of them and could recalltheir names. They continuously assured me it would not hurt. It, for sure, hurt me muchmore than it did them. I can never be absolutely sure if my dream is in retribution forthe pain that I have caused or if I am the one in need and in fact the patient. Maybe thelittle babies, my patients, are there to treat me and make me well. Are they now able toshow their gratitude by making me whole?

The phone rang again and again. I was not sure if I was at home or in the hospital. Islept in scrubs when on call at home and had a rule that if called back to the hospitalafter midnight I would sleep the remainder of the night there, if I could. I was not sure ifit was Saturday or Sunday. On Saturday, I had promised my oldest daughter Amy that Iwould let her make rounds with me once again in the intensive care nursery. If it wasSunday, I would meet my wife and family at St. Joe’s for 11 a.m. Mass, then go to thecountry club for brunch. It turned out to be neither.

I tried the coffee in the sleeping quarters but it was not drinkable. I made my wayacross the hall to the intensive care nursery. It was the sixth intensive care nursery I haddeveloped, in three different states, over a 20-year period. I believe that I had finallygotten it right this time. It was designed with 36 critical care beds for assisted ventila-tion arranged in four pods. All laboratory work was done stat and the results came backas soon as available to the correct pod via computer. We had our own portable X-raymachine in an effort to avoid infection issues and a huge 36-space rotational viewingbox. All of our X-rays were photocopied and displayed by bed number, available forpatient care and teaching. Only respiratory therapists especially trained and certified towork in our nursery could attend patients. No heel stick could be done except by labo-ratory technicians trained to work in the unit. Respiratory therapists could draw arterialblood gases and registered nurses could draw routine lab from catheters. Attending

On Call


physicians intubated patients and managed assisted ventila-tion, placed arterial and venous catheters, did lumbar punc-tures and occasionally placed chest tubes. Of course, indreams, my premature Lilliputians can do all these proce-dures having been carefully taught by our time-honoredmethod of “See one, do one and teach one.”

The architect of the intensive care nursery had beeninstructed to give special attention to issues of light sobabies and staff would know day from night. Physicians andnurses may become disorientated working long hours withno perception of day or night. Graduates of the nursery alsoneed to begin to learn day from night, especially afterhaving been there for several months. We had a color con-sultant pick the wall and cabinet paint colors and the floorcovering design and color. We had paid special attention tomusic and sound issues, as well, for the benefit of all con-cerned. After multiple phone conversations, I had traveledto northern Georgia during the construction phase andarranged for a total of 39 original, one-of-a-kind stuffedanimals, most of which were life-sized, to be donated fromthe Cabbage Patch factory. This gave the intensive carenursery a warmer and friendlier look, a place of hospitality,for the purpose of reducing the anxiety level of parents,family, staff and visitors. I was able to take my daughterAbby along with me for her sixth birthday. We adopted aspecial baby for her.

I got the head nurse’s attention coming through thelast barrier door into the unit. She had just started changingthe watch with the nurses leaving and coming on shift. Sheimmediately came over to remind me I had interrupted theirrounds just last week and I could not start my rounds untilthey were finished. I also could not come along and makecomments that would slow them down. She next told me togo to the cafeteria and eat breakfast. I was already muchtoo thin. This is the same nurse I had trained several yearsago to work in the unit when she was just out on nursingschool. She told me I should go to the nesting room andtake an hour nap after I had eaten. This meant the room wasclean and empty. It was a special room we had designed formothers to spend the night with their high risk infantbefore taking them home. It was a way for them to performtheir mother craft, give medications and learn to managethe required equipment under the supervision of the inten-sive care nurses. The mothers were allowed to stay untilthey had the confidence and experience needed to take thebaby home. Only cocaine-addicted mothers had thecourage to refuse this free service. I was given the localcredit for inventing this concept. No one ever invents any-thing. I had adapted the concept from the various parts ofsimilar units that I had seen and developed during my manytravels.

We lost the micropremie newborn baby boy whom Ihad come in to treat a few hours earlier. We always say babyboy or baby girl to give the patient proper identificationbecause most are born too soon for the parents to have aname in mind. In fact, we had about one death each week. Ihad become all too experienced with death and dying. I lec-

tured on the subject as well as on how to process grief. Ithad occurred to me while walking to the obstetrics floorthat I may still have some anger over the loss of my micro-premie son. Again, I thought if we could only meet theparents, prior to the death, of the babies who died withinthe first 24-36 hours after admission, we could do a muchbetter job supporting them. Nearly 50 percent of our babieswere born in referring hospitals and transferred, by us, toour unit. About 80 percent of our inborn babies came fromyoung single mothers with little or no social or financialsupport systems. High-risk babies come from high-riskparents. I smiled when I recalled meeting a very attractivegreat-grandmother last week who was 45 years old. Maybeit is time for me to stop this line of work when the physicianis older than the great-grandmothers, much too skinny andhas had three eye surgeries.

I went to visit the parents of the micropremie baby boythat had died. I located a sleepy ward attendant who gaveme the room number. On entering the room I was surprisedto see two middle-aged parents that were awake and veryhappy. I should have realized that I was in the wrong roombut I suppose my exhaustion clouded my perception. Whileit may be spiritually enlightening to learn that micropremieshave little or no skin pigment, making their race difficult todetermine, it is not a mistake a person with my experienceshould be expected to make. I slowly introduced myself in amuch protected way since I was there to tell them of theirson’s death and I had not met them. They listened intentlyas I explained my role in their child’s care and the workingof the intensive care nursery. I had developed the skill overthe years to have two meetings, during one first visit, in thissituation. The second meeting was to provide the bad news.As my conversation grew dark the father unexpectedlycame over to me and put his hand, or God’s, on my shoul-der. “We know who you are,” he said. “We have seen you ontelevision several times. You are Dr. Henderson, the directorof the intensive care nursery. I am sure it has been a longnight for you and you look tired. Boy, are we glad you are inthe wrong room. I have just visited our healthy baby boy.We sure feel so sorry for the parents that are waiting foryour visit.” It was amazing and quite reassuring to me thatthis kind man, unknown to me, chose to save all three of usfrom further embarrassment in this unique real-time situa-tion. I believe he did not want me to say something thatwould later require their forgiveness.

I stood in the cool dark hall for a few seconds in orderto regain my composure. Maybe I should have waited a bitlonger after the death of the patient to resolve my own feel-ings before trying to console the parents. Could it be I wasjust trying to rationalize my error? Later, I would have thetime to reflect on the implications of this night. What doesit mean that very early in gestation we are all the same? Welook more like each other then than we will later look likeour siblings. Sex can usually be determined but not gender,race or color. We are all created in the image and likeness ofGod but also created from the slime of the earth as well.



Could it be possible to develop a spirituality in the world toenable mankind, in spite of this dichotomy, to maximize oursameness for the benefit of ourselves, of all other speciesand of the earth? Could this sameness be the new basis forworld peace? Peace at least for Jews, Christians and Muslimswho are all the descendants of Abraham? Will we beallowed to live, at all, if we all can not live together?

I visited the nursing station again. This time the nurseescorted me to the correct room and departed. The youngmother was watching television after finishing her too latedelivered post-partum meal. Still shaken from my recentexperience, I slowly began the first of the two meetings. Atthe end of the first meeting, I told the teenage mother,about the issues we were having with her micropremiebaby boy’s heart and lungs. She had not stopped watchingtelevision during the first meeting, a very bad sign. She sud-denly said to transfer the baby to a hospital that doesheart/lung transplants on tiny babies and went back towatching television. After I told her of the death of her son,she said I had waited too long to transfer the baby and thatI would be hearing from her. I explained that she would bereceiving a call from my secretary in about two weeks toarrange a one-hour post-death conference. This meetingwould occur in about 90 days, would be without charge andwould be helpful to help resolve some of the many issuesconcerning the loss of her child. She said fine, but may notkeep the appointment. I have not heard from her or herlawyer, yet. In fact, my medical malpractice concerns relatedto a lifetime of critical care medicine, thankfully, have neverbeen realized.

While eating cold eggs and hot grits, I recalled a recentconversation on parenting with my older brother Don whowas dying with lung cancer. He concluded that in order toreproduce, parents essentially had to be both trained andcertified adults. Don had not yet heard my working defini-tion of an adult as a person able to love and work. I told himan adult person is able to love himself and as a result havethe capacity to love others as well. Adults should be able dowork for their own benefit and for the benefit of others.We agreed our prodigal father had taught us the uncondi-tional love parents can have for their children and ourmaternal grandfather and our mother had given us ourfaith, and had taught us the unconditional love God has forsinners. We agreed that our own mother’s love was condi-tional and required performance above all things. Iexplained that my life’s work required unconditional lovefor totally dependent little patients. We talked of my longexperience with teenage pregnancy. He was amazed tolearn that if a young girl’s male sexual partner is significant-ly older, or physically abusive, she will very likely have asecond child and that child, along with the loss of what self-hood she may have had, will be directly related to her notfinishing high school. In my opinion, this continues thepoverty cycle that is the root cause of many feminist issues.He and his second wife had raised six children together. He

believed bad parents should go to jail. We did not alwaysagree.

Don had recently had a very personal experience withdeath, having lost his youngest son to AIDS. He pointed outhow unnatural and unbelievably sad it was for parents tohave to bury their children. He was curious how parentsgrieve for the loss of a tiny baby that in his view had neverreally lived. I tried to explain by saying premature babiesjust do not die in the intensive care nursery. They die in thehearts of their mothers, fathers, siblings, extended families,towns and communities. Grandparents sometimes think ofthem as replaceable, in a misguided effort to reduce theirown child’s grief, but parents never do. No matter howsmall a baby is to us, that baby is still the mother’s idealchild. No baby is replaceable to the mother. Most mothersgrieve for the loss of that child for the rest of their lives andare tearful when recalling the loss for any reason.

On my way back to the nursery I wondered how I hadgotten into this neonatal intensive care business anyway.Why would any physician choose this career path? I camefrom a family of eight children and loved babies. I learnedunconditional parental love from my father. He loved andprotected all newborn animals. I loved my teachers who hadtaught me pediatrics. I grew to love emergency room workand critical care medicine. I loved the thrill, excitement andresponsibility for life and death issues. I did not like to treatpatients that were old and the majority of their healthissues were lifestyle related. I have a well-developed rever-ence for technology. I helped develop the first time-cycled,pressure limited ventilator for babies. I loved patients whosecritical condition came through no fault of their own. I, likedad, was in love with God’s most vulnerable creatures.Through my grandparents, parents, eight siblings, myfamily, my mentors, the death of my infant son, and mymany patients, I had developed my present transcendentalrelationship with God. I believe, as Karl Rahner, that God isaccessible to all ordinary human experience, and all humandevelopment depends primarily on love and being loved.Punishment for my past and present sins and the finalacceptance of God in my daily life, were no longer myprimary spiritual issues.

Entering the intensive care nursery, I put on my armor,located my weapons and prepared myself for mortalcombat. As I enter the coliseum, based on their need tobelieve I am the emperor, I perceive my 36 patients as tinylittle anonymous gladiators ready to say, “We who are aboutto die salute you.” Thumbs up, I am not the emperor.Rejoice, life and death is not up to me. I too am a gladiatorand like you are in the pit. While I gladly seek combat, myrole is not to cause wounds, but to bind them up. It hadtaken me many years of medical practice to learn I was notin charge of the divine mercy of life and death. God hadspared me from that decision-making process in order toprotect me from decisions I would never be capable of, orbe prepared, to make. However, much of what we knewabout babies with a birth weight of less than 650 grams

On Call Continued from page 25


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came from what we had done to them, not from the care wehad proven scientifically, and in advance, knew they wouldbenefit from receiving. Each tiny micropremie’s individualcare was a well-designed experiment, although not neces-sarily enrolled in a study group with double-blind control.How small is too small? Have we oversold what we can dofor our tiny patients? Does care provided with no reasonableexpectation of success violate the patient, nature, or God?Have we reached an ecological impasse, a collision course,in terms of human expectations on the ability of medicalscience to deliver care? Cowboys are said to trust in Godand luck. Fighter pilots may choose to have God as their co-pilot. I believe my life’s work is my daily prayer. I do notexpect to have all my questions answered in this lifetime.My survival and the survival of those patients on my watchis dependent on me doing one right thing at a time. There isno save what you can, or triage, permitted in this unit. Ourdeath-adverse cultural pathology aside, the death of ourpatients must not rob us of our joy, the joy we need to com-municate to the living that will hopefully help insure theirsurvival.

At any rate, my congregation waits. I am here to preachthe gospel of modern neonatal medical science. I know thehomily well. Social justice, in this applied science setting, ismore than taking care of patients that cannot pay. It is alsotreating all patients equally. I have spent my professional

life in the quest of converting knowledge into wisdom. Theart of medicine requires much more practice than thescience of medicine. I believe wisdom is much more thanintellectual love. Wisdom has many traditions and requiressages. Much work is required.

I walked over to stand between the giraffe and the ele-phant to watch my nurses finish their rounds. This unit is somuch more than a monument to its builders. Such adescription is far too inadequate. This facility is a cathedral,complete with icons, pipe organ, rose window and flyingbuttress. The decor is flooded with sound, color and themystic feminine of the Middle Ages. It is a sacred placeflowing with the mysticism of everyday life. Only vocationscan be practiced here. I believe this is a healing place ofGod’s grace of unity and reconciliation. It is filled with theHoly Spirit. Miracles are expected and do happen here withsome frequency. Again, just like the first time, I realized thatby placing myself in the hands of God, I could accept theparental unconditional love, and responsibility for these 36lives. I trust with the grace supplied to me from the HolySpirit that I can do this thing called healing. I have beengiven many gifts, and therefore, I have many obligationsand responsibilities. I have God’s work to do today. I wasborn, with the gift of faith, into God’s hands. May He workthrough mine this day, for the good of the least of us, whoare the hope of the future.

On Call Continued from page 26


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Gena L. Napier, MD

At four o’clock on a Friday afternoon, my intern and I were called to the emergencydepartment to evaluate an open call patient. Open call patients are those who do nothave a designated primary care provider or whose primary provider does not have privi-leges to admit to this particular hospital. The patient awaiting our care typified theformer group; in fact, she had only two encounters with organized health care in thepast 60 years.

Ms. M presented to us as an 82-year-old woman with abdominal pain. The pain, morediscomfort really, had been bothering Ms. M for several weeks. She waited until Fridayafternoon to come to the ER because she first wanted to finish her work week. Thischarming 82-year-old worked as a cashier at a small grocery store, and she did not likemissing days. Ten years prior to our encounter, she had undergone a total left hipreplacement, and five years prior to that, her husband died in a hospital. Otherwise, Ms.M got along quite well away from doctors and health care in general.

As an upper level resident, I sent the intern in first to perform a history and physicalexam. Over the next 10 to15 minutes, I reviewed the vital signs, lab work and imagingstudies already completed by the ER physician. Before I even saw her, I knew that Ms. Mwas very sick. Based on the data in her chart, her stomach discomfort was due to anunknown primary carcinoma, which had multiple widespread metastases to her liver andcolon. Her prognosis was poor.

Friday afternoon is a busy time in a hospital. I knew that things would have to movequickly in order to get a fine needle biopsy or my patient would have to wait untilMonday. I immediately discussed the necessary orders with the charge nurse and madea call to interventional radiology to ask about their queue. I then politely pulled theintern away from the bedside and met my new patient.

Ms. M’s story never grew more complex. She simply had abdominal discomfort. Theintern and I could elicit no other signs, no other symptoms and no other complaints. Shewas planning to return to work the following Monday, as the grocery store stayed busyand had little help. Her son would be in shortly. She joked and laughed, and her faceheld an easy smile.

If Ms. M was going to undergo a biopsy within the hour, she would have to know theresults of her imaging. The intern and I pulled two plastic chairs to her bedside, and in aloud, chaotic ER, I held Ms. M’s hand. I told her that she likely had cancer. I sensed thatshe was a lady of great strength when I first saw her, and now I was convinced of it. Hersparkling eyes watered in the following silence, and she stared at me. Then as quick asthe pain came to her eyes, it was gone. She smiled and asked about the “next steps.” Asthe astute intern proceeded with a thorough exam including evaluation for breastmasses and lymphadenopathy, I told the patient everything I knew about her health andall the things that I did not know: the things we would have to find out together. Sheagreed with my plan with one caveat: she wanted to be back at work by Monday.

I was unable to get Ms. M her biopsy on that Friday afternoon. She spent the night inthe hospital with us and was “very ready!” to leave the following morning. Her son was

A ChanceEncounter



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NOTE TO READERS: The names and identifying characteristics of patients have all beenchanged to preserve confidentiality. Names of physicians and staff have also beenchanged to protect anonymity.

Clint Morehead

Imagine for a moment that you are hiking through a forest. Against a thin layer ofrubber, plastic and Gore-Tex, you feel the consistency of the forest floor, a trail packedsolidly by unknown hikers. The trees rise like cathedrals above your head before thebranches begin. Then everything goes dark. The leaves act like filters, altering thedimming light, turning your skin green — green and yellow — until your eyes muststrain to make out any color at all. You hear the jostle of leaves high above. As youround a bend, a slit of sky comes into view. It is heavy with clouds — gray and black. Thewind has picked up. You find shelter against a nearby rock wall and you watch the stormunfurl.

The thunder moves you. Your heart grows anxious. Fear occupies the space betweenyour heart and your sternum as you tuck yourself into a ball. The trees within your viewbend in positions you never thought possible, positions your own body made oncebefore, at a time you cannot remember. Here, in your sylvan asylum, you pray that youwill not be found.

The storm now sounds of Howitzers retreating. You return to your trail. It’s different.One of the giants has fallen, a casualty of the belligerent wind. Its roots are thrust intothe air; its trunk parallels the trail as if a hand had set it down with thoughtful precisionso that you may easily navigate around it. Up ahead, its branches are flayed in a half-circle of disarray, defeated, crushed and snarled against the puddled ground.

* * * * *Clyde Cohen held his 6-foot-5-inch stature rigidly, towering over the other patients

in the psychiatric ward at Norton Hospital. On the morning after his admission in mid-August, his face, expressionless, gave us no indication whether he understood the sever-ity of his illness or the fact that he was ill at all. Frozen in position, muscles at rest, hisface resembled a concrete bust, unresponsive to the flurry of movement in the day-room where other patients clipped hurriedly around him, awakening, rubbing their eyesand yawning, orienting themselves as the hospital staff sorted and distributed breakfast.Clyde gazed simply into the air and said nothing. When he walked, he assumed thenature of a machine. He picked up his right foot, held it an inch or so above the floor,and with his knee locked, he moved the entire right side of his body forward, pivotingaround the left leg, then the right. With his spine and neck aligned in perfect militarystature, I was inclined to imagine him as a tree. Had he extended his arms straightoutward, perpendicular to his body, we would have had no trouble passing underneaththem.

Clyde was 35 years old. At 19, he was diagnosed with schizophrenia. “Before it allbroke loose,” his mother said, referring to his first psychotic break, Clyde had beenstudying engineering at Western Kentucky University. He was an athlete and a musician,participating in his school’s cross country team and playing the guitar with his friends.Now, 16 years later, he has retreated into a dismal state of solitude, most days lockinghimself inside his apartment, allowing only his mother to enter. The day before we metClyde, his mother had filed a Mental Inquest Warrant, or MIW, which would hold him in


Clyde Cohen


an inpatient psychiatric facility until it could be proven thathe’s no longer a threat to himself or anyone else. His mothertold the social worker that Clyde had been on a slow, steadydecline over the past several months, regressing finally to apoint in which, she believed, he could no longer take care ofhimself. She reported that his thinking had grown increas-ingly disorganized, that he had begun talking excessivelyabout religious themes, and that he had quit showering. Shedescribed how clutter and trash had accumulated in all therooms of his apartment, making it impossible for anyone tomove around without tripping. She also noted that he hadpositioned the few pieces of furniture he owned in bewil-dering orientations: feng shui, schizophrenia style. Thekitchen was a story in itself: “Canned goods are piling up,”she said, “and he has six cartons of eggs in the refrigeratorand some in the freezer. I’m worried that he’s going to makehimself sick.”

Dr. Shield, our attending, assigned me to Clyde shortlyafter we first spoke with him. “This should be a good casefor you,” he said. “Mr. Cohen is an excellent example of dis-organized schizophrenia. Hopefully you’ll get to see himimprove while you’re here.”

So I followed Clyde for a little over a month. Everymorning after the team completed its rounds, I headed tohis room, knocked on the door, walked him to an unoccu-pied table in the day-room, and asked him some questions.Dr. Shield instructed me to ask the same questions everyday: How had he slept the night before? Did he have a goodappetite? Had he noticed any side effects from his medica-tions? Was he in a good mood? Did he have an inclination tokill himself? Psychiatrists routinely ask their patients thesequestions to assess the ways their minds are working. Clydenever was suicidal. He always reported sleeping and eatingwell. And when asked his mood, he invariably replieddespondently, “Fine, I suppose.”

Through this standardized set of questions I made infer-ences about Clyde’s progress by observing how heanswered them. Over the course of that month, his respons-es varied. Before the medications had kicked in, eachmorning he faithfully led me down a solitary, dizzying loopof nonsense, what psychiatrists call circumstantiality. Hismind surfed to a place that only he knew, but with the relia-bility of a boomerang, he would eventually make his wayback to my original question, even if, by then, I had forgot-ten what it was.

After the first two or three days, I started paying atten-tion to Clyde’s tangents, which nearly always gravitatedtoward the subjects of clarity and nature. They made nosense to me. But these thoughts contained such concreteimagery that it would not have been a stretch to believethat he could have been a great writer or a poet had he thecapacity to integrate. Every morning, for example, when Iasked him how he had slept the night before, he wouldbegin by answering as anyone else would. “I slept fairlywell,” he often said. I would begin to think that we were

finally making some progress. But he didn’t stop at that.Before I could move on to the next question, he woulddescribe the act of waking up. He would say that he rosewith the sun, watching its rays engulf the narrow hospitalwindow and strike the wall across from his bed. “The lightstarted in stripes,” he said one morning, and described ittaking on geometrical shapes: horizontal lines that spread,widened, and blurred against a wall that caught and heldthem like an artist’s canvas. He said he watched the stripesmove across his bed, and he resolved not to start his dayuntil they reached his eyes. This was the reason he was lateto group therapy that morning. The light in the hospitalreminded Clyde of his apartment, which I later learned, hemissed dearly. He would describe the light entering hiskitchen, striking a chair and crossing its carved woodwork,throwing its shadow onto a yellow wall, and making its wayto the living room. Only then, once the light had covered allthree walls and disappeared, would Clyde stop reading hisnewspaper, lace his shoes and leave the apartment for a six-mile run. What a way to live.

* * * * *

Regardless of Clyde’s farraginous intellect, I envied himfor his awareness of the world. Even though I knew that allthese images filtered through a psychotic mind, I wishedthat I were more like him, that I paid more attention to myworld the way he did his. He remembered everything hesaw as if it were for the last time.

Sometimes as a medical student, you come across apatient who enters the thickest layers of your skin and findshis or her way into some of the deepest, most vulnerableplaces. Clyde became one of those patients. As time passed,I realized that he and I were not all that different. We bothplayed the guitar and loved music. We both took long runsoutdoors and had belonged to our high schools’ cross-country teams. We both found solitude in nature. I washappy to spend time with him, to try to understand hisillness and to watch him respond to the medications. Butlater I found myself worried that I may have become tooinvolved, paying more attention to him than to the otherpatients I was following. I wondered whether, in principle, Iwas giving him better care simply by showing interest andtrying to engage him in conversation. Therapists call thisnatural drive to identify with a patient countertransference.Almost automatically, we find aspects in our patients thatremind us of ourselves. In the first and second years ofmedical school, I was taught that countertransference hadits advantages and disadvantages, but the overriding themeof these lectures, I remember, was that it can be a curse, andthat for now, to keep things simple, we were to avoid at allcosts. If it somehow crept into that doctor-patient relation-ship (or in my case, student-patient) I was expected to iden-tify it, target it, and annihilate it, for it has the strength, I was told, to break down walls, taking the caregiver downperilous paths of emotional and personal involvement that



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could be detrimental to everyone. There are always stories circulating the wards of how a

young doctor, seemingly stable, had completely lost it oneday. It was an unexpected complication, an order leftunwritten, a patient who died. Any of these could havepushed them over the edge. Then they would leave thehospital sobbing, blaming themselves for what had hap-pened, mourning excessively, and then later, spendinghours of sleepless anxiety reevaluating their lives, question-ing their competence, wondering if they had chosen theright career. To avoid such reactions, I was told, we mustkeep that nasty countertransference at bay. We must dis-connect. We must stay in control.

I saw an oncology fellow once who, apparently, hadtaken those words to heart, intent on not losing it, thoughhe may not have even known what he was doing. He wassitting at the nurses’ station on the cancer ward atUniversity Hospital dictating a discharge summary. Awoman was wheeled onto the floor in obvious pain, herscreams we could hear before she even came into view.Awaiting a clean room, the transporter locked her stretcherin place directly in front of that fellow who continued dic-tating into a phone, never looking up, never offering help,completely oblivious to her screams. All I knew just thenwas that I didn’t want that to be me, untouched anddistant. I later described the incident to a palliative caredoctor. “That fellow,” she said, “put up a wall and wouldn’tlet the patient touch him … Here, in this place, it’s just youand the patient and your soul. You have to look inside. Youhave to listen to your soul and just let go. It’s like writing aprescription for yourself — one of the hardest things adoctor can do.”

In some ways I can understand why those preclinicaleducators said what they did. We deal with life-and-deathsituations every day. There’s bound to be a complication,something that no one had expected to happen, and wemust try to remain composed. Furthermore, when we meeta patient who vexes us to no end, we are naturally inclinedto avoid them. This reaction in particular we must watch outfor. But is it truly possible to give the best care to ourpatients if we must also maintain strict indifference towardthem? Such a cold view surely would level the playing field,removing the purging of emotion or the favoritism orneglect that countertransference may bring, but at thesame time, it would prevent us from caring. Compassionwould disappear.

We, doctors and students, are people too. Fear, confi-dence, desire, anger, sadness and pity are welded into us bynature. To completely detach ourselves from one another isa sad prospect. Unless we want to view our patients as bagsof organs and conduits of fluid rather than as persons, asreal as you and me, we must allow room for attachment.Determining where the line that separates attachment fromdetachment and setting it down every time I meet a newpatient, for a young medical student like myself, is wherethe trouble is. I do not claim to know how to connect with a

patient, how to feel without feeling too much. I just knowthat I need to come up off the bench, get in there, do it andlearn: for me and for them. Thoreau knew the frustrationinvolved in wrestling with our identities. In a light passagefrom his journals written when he was only 23 years old, hewrites, “I think if I had had the disposal of this soul of man, Ishould have bestowed it sooner on some antelope of theplains than upon this sickly and sluggish body.”

I am flawed, I know it. I dance clumsily with these heavymatters of the soul each time I encounter a patient. I’m notsure whether my questions dig too deep, whether theycause their recipients to shuffle nervously in their chairs.I’ve stationed myself in unfamiliar territory. I feel locked-in,watching from above with a discerning eye, seeing my mis-takes as I make them. I must grow into this skin. I must learnhow to be both a care-giver and a companion, a role I’venever known. I must look inside. I must write that prescrip-tion every day.

* * * * *

On the last day of my psychiatry rotation, the unitreceived word that one of the patients who had been dis-charged a few days earlier had committed suicide. A heavycurtain of sadness fell as the news spread. I had not beenassigned to follow him as I did Clyde, but I had seen himeach morning on rounds during his two-week stay with us.He had been admitted for an acute depressive episode. Hewas bipolar. I observed how the unit responded to the newsof his suicide at our team’s meeting that morning. Silencedrew around us all as the nurses and doctors gathered theirthoughts. Then Dr. Shield put forth his hand. Trying ineffec-tively to hold back his tears, he blamed the insurance com-panies for restricting doctors from caring for their patientsthe way the doctors see fit. I was astonished to see thisaged man so affected. Silently, I hoped that one day I wouldrespond the same way. There is no glamour in grief, but it isreal, and to feel it shows that we are real.

I felt for those around me, but I was unable to conjure avisceral reaction myself. But that’s the place of the student,all this time sitting in the periphery, observing, learninghow to feel. For the student, this is a unique position. Wehave here the opportunity to spend time with the patientswithout the pressure of efficiency, without endless admis-sions and discharges, without issues of billing and fightswith insurance companies. Those, for now, are the jobs ofothers. The student reads the patient’s history, studies thechart, researches the diagnoses and therapies and sees theillness as it presents in a person rather than in a textbook.The student also learns how to interact with that person,experimenting with diction and tone, with schemes andtropes, with how to express concern and compassion.

With Clyde Cohen, I tried all this. Although his reactionto my words was difficult to interpret at first, I eventuallyfound him sharing his thoughts with me, thoughts that hedidn’t want to discuss with his doctors. He looked at me



LLOOUUIISSVVIILLLLEE MMEEDDIICCIINNEE

Danielle Pigneri

White coat. Put it on. Take it off. An utter transformation, there and back, in 30seconds. I had never stopped to think about the significance of a white coat until I wasadmitted to medical school and found myself at my own white coat ceremony. Itsmeaning was so well-ingrained in my mind from such an early age that an understand-ing of its worth felt natural, almost innate, something that did not need to be ques-tioned, pondered or even brought into my conscious awareness. I see a doctor, man orwoman, young or old, of whatever shade and whatever size, and the white coat looksnatural on them, as if they were born to wear one and have been wearing it theirwhole lives.

I pull my white coat around my shoulders and the effect is so incongruent with myprevious image that it causes me to pause. I am not a doctor. I am an ordinary person,one with fears and imperfections, one who makes mistakes and tries to learn, butsometimes falls again. I ask myself why I deserve to wear a white coat. I am a first-yearmedical student, after all, and I was given this coat before I had attended even onelecture, let alone studied for my first exam. I have seen no patients and I have assumedno responsibility for anyone other than myself.

I tell myself that I have plenty of time. That by the beginning of my rotations thirdyear I will feel comfortable in my white coat, and if not by that time, then certainly bymy graduation.

As the fall months of my first semester come and go, it becomes clear that mywhite coat looks less fake to others than it does to me. The first time I wear my whitecoat outside of campus is for my emergency room preceptorship. It is mid-Septemberand a friend and I stop by the Idea Festival in downtown Louisville beforehand to heara talk about one man’s perspective on the mechanics of the human mind. The time-frame is tight, so I wear my scrubs and white coat to the talk to make sure I will be atmy preceptorship on time. I will never forget the expression I see next. An elderly manlooks at me and my white coat in a way I have never been looked at before by astranger. I half expect him to look for a few seconds longer and then realize hismistake. I am not a real doctor, not yet. In fact, I am barely on my way. I have donenearly nothing yet to earn the respect of future patients, let alone strangers. But theman’s expression remains unchanged, and his particular blend of admiration and trustbegins to feel less unsettling. At least in his mind, I do belong.

Although I keep this experience to myself, somewhat embarrassed that I don’t feelcompletely worthy of the white coat my fellow classmates seem to wear withoutconcern, other people begin sharing stories of coat-induced experiences. Most of thestories involve being mistaken for a doctor during preceptorships in the psychiatryclinic or ER, but the story that strikes me most profoundly did not take place in amedical setting of any kind. Rather, a classmate was seen in a Panera Bread restaurantby a small boy, whose reaction has affected me.

As this little boy stood in line with his mother, he turned to see a classmate ofmine in her white coat, and he became scared. At first the boy hid behind his motherand when she did not reach down to protect him, he began to cry. As insignificant andas commonplace as this might seem to seasoned physicians, it is this encounter that isresponsible for my fuller understanding of the meaning of the white coat. It is notsimply a statement of position, a decoration which you must earn through hard workand dedication. It is also a dynamic symbol that we are constantly defining, one with apurity and authority we must strive to protect. My actions while wearing such a coatwill shape the perception my patients have of all others who bear similar coats. Even

White Coat


LM

at the bedside when our team rounded on Saturday. He wasa tall man with dirt under his fingernails, a sharp eye andthe good fortune to inherit his mother’s smile. Ms. M waswalking the halls, eating well and her lab work was relative-ly normal other than a mildly symptomatic urinary tractinfection. We arranged the biopsy as an outpatient and dis-charged her home with antibiotics.

The following day Ms. M’s son returned to the hospitalwith his mother. He had found her down in her home, unre-sponsive. He also brought with him her living will, whichshe had completed 15 years ago after the death of herhusband. According to her wishes, we were to do nothing“extraordinary.” No intensive care, no drips, only antibiotics.Beyond that our hands were tied. The resident on call talkedto the son and provided comfort measures through theafternoon. Ms. M died later that evening.

Over the past 20 years physicians and other health careworkers have broken fantastic new ground in end-of-lifecare. Instruction and encouragement to initiate discussionsregarding living wills and dying wishes are incorporatedinto our learning curriculum. These sensitive interactionsmay always be challenging, but my education facilitated the

conversation that memorable day in the emergency depart-ment. I wonder if Ms. M’s husband had experienced apeaceful end, one that prompted her to delineate her endof life wishes, or if they together suffered through a fright-ening death 15 years ago. Tragic events can unfold quickly,and physicians must remember the importance of foresightand planning as we counsel our patients.

Ms. M spoke with the strength of one who is at peacewith the world. I know I felt great relief upon seeing Ms. M’swishes on paper when she was unable to verbally communi-cate them. Relieved of demanding decisions, her son alsoseemed comfortable and free to grieve. As I reflect on theevents from Friday through Sunday, I am thankful thateverything went so smoothly, and I fervently hope she andher son agree. I can imagine that those who knew her wellwere deeply saddened by her passing but that they also cel-ebrated her life as a blessing to all of those she touched.

A Chance Encounter Continued from page 30

now, before I have become a practicing physician, it is myresponsibility to protect the reputation of medicine and ofother doctors.

Soon spring break rolls around and I realize that I amnearly finished with my first year of medical school. Before Ileave for break, I perform a full physical exam for one classand prepare a differential diagnosis for another of a manwith toe pain that we eventually diagnose as acute gout. Onthe car ride up to Des Moines, Iowa, I explain to my familyhow taking infrequent stops while traveling promotes deepvein thrombosis and why it is that preventing urination forlong periods can foster the beginnings of urinary tract infec-tions among prone individuals. When we get to my grand-parents’ house, my grandmother shows me the splint fromher carpal tunnel surgery and I explain to her ways toprevent needing the surgery in her other wrist, which hasalso been causing her pain. Over lunch my grandfather and Idiscuss the implications of the recent methicillin-resistantStaphylococcus aureus outbreaks in hospitals across thecountry. Next we visit my great aunt, who has unfortunatelybeen afflicted with multiple sclerosis since she was hardlyolder than I am, and I recall what I have learned of neu-roanatomy and the symptomatic disease pathway of neu-ronal demyelination. I race through it all silently as I askmyself over and over how it is that we have no way ofhelping her. I lose sleep wondering if there isn’t some wayto prevent or slow autoimmune diseases with gene therapy,transplantation, or drugs, something obvious we just

haven’t figured out yet. Then four of my cousins appear, allyounger than I am, all healthy and excited about every tinyaspect of life. To me it seems so precious, so incredible thatthey are all healthy, happy, and safe.

When I get home, my white coat hangs in my closet,waiting for its next outing. I put it on and I take it off andthis time it doesn’t seem like a transformation at all. I nolonger feel like an imposter as I wear my white coat, but Ialso don’t feel less like a medical professional with it off. Iam the same person either way. I am going to worry aboutthe health and happiness of others regardless of how Iappear on the outside. Disease and decline are just asupsetting and good health is just as amazing with orwithout my white coat. Although I have much farther to gobefore I’ve earned the right to practice medicine, I havegrown into my coat, just a little, and I am going to workhard to protect the image of that coat as I continue to grow.After all, what good can we do as physicians if people donot know that we can be trusted, that they can share inti-mate details of their health with us, and that we will trulywork as hard as possible to make certain that they are safeand cared for? The white coat ensures patients of thesethings, and I am honored to wear mine. LM


I N R E M E M B R A N C E

John E. Ryan Sr., MD, was born April 30, 1925, onhumble Date Street, west Louisville, where he deliverednewspapers by bicycle and worked at a family grocery at30th and Greenwood. He became champion at mathematicsat St. Xavier High School in 1943. Informing the Navy andMarines he wanted to become a medical doctor, he attend-ed the Berea College Officer Training School, then trans-ferred to study at Notre Dame and Harvard. As an ensign inthe Navy, he became communications officer toCommodore O. O. Kessling in postwar Japan in 1945-1946.Later, an avid musician like his mother, Clara, he joined theArt Jarrett Band of Cleveland as bass player and toured thenation. His mother’s telegram – “Come home now, son, youare accepted to medical school, University of Louisville” –led to his return. He made a difficult choice to leave musicbriefly, to become a serious student from 1946 to 1950.

Dr. Ryan interned at Great Lakes Naval Hospital inChicago, treated the wounded of the Korean War and in1951 was one of the first U.S. doctors to carry an emergencyradio-telephone beeper. Returning home to enter familypractice, he served patients primarily at the Saints Mary andElizabeth Hospital for 40 years. He married TheolaFranzman, a surgical nurse at St Mary’s, in 1950. He was alsoon the active staffs of Norton, St. Anthony, and SouthwestJefferson Hospitals. He practiced at 3308 West Broadway inwest Louisville, at 4500 Churchman Ave. and at SouthernParkway Medical Center of south Louisville. Most significantamong the accomplishments of his dedicated family prac-tice, he delivered an unsurpassed record of 6,000 babiesduring the 1950-1990 period. Dr. Ryan earned the title

“Diplomate of the American Academy of Family Practice” in1984. He also served as president of the Louisville Society ofPhysicians and Surgeons, as Lt.Governor of the Kentucky-West Virginia Optimist International, the “friend of youth.”

As he neared retirement, from 1995-2007 he was thebass player in the Docs of Louisville Band. He was a devoutCatholic, and a leader in St. Thomas More Church of southLouisville. He was the devoted father of six children: JohnJr., Rebecca, Kathleen, Chris, Kevin and Melissa, and heencouraged all of them to continue their educations, andbecome leaders in their fields. Dr. Ryan served on the volun-teer faculty at University of Louisville School of Medicine,where young medical students rotated with him throughfamily medical practice, pediatrics, obstetrics, gynecology,“teamwork” referrals to psychiatry or surgery, and the“lumps and bumps” excisions. Dr. Ryan also performedsome surgical procedures like D&C’s and numerous tonsil-lectomies as a part of his family practice. He also served assports medicine doctor for the DeSales High School, FlagetHigh School and Shawnee High School football teams.

This consummate family physician was extremely dedi-cated to his patients, family, friends and medical associates.His involvement in all aspects of Louisville life will begreatly missed, both professionally and personally.

-Arthur T. Daus, MD, and John Edward Ryan Jr.

JOHn E. RYAn SR., MD(1925-2008)

LM


A L L I A N C E

Calling all history enthusiastsMimi PrendergastGLMS Alliance President

f Louisville history with a medical twistinterests you, we have the perfect dayfor you. Alliance members, retired

physicians and practicing physicians areinvited to join us for a morning in Portland on Monday, Oct. 27 at 10 a.m.

We will be meeting at the U.S. Marine Hospital for a tour ofthe historic facility, followed by a tour of Portland “Proper.”Rick Bell, executivedirector of the MarineHospital, will lead thetour.

Please contact Mimiat 894-0977 or 500-9696 for moreinformation.

II

LM

one day, nearly four weeks after his admission, his thoughtsclearer now, and said with some frustration that was diffi-cult to tease from his expressionless face: “I have an openmind, and I’d accept whatever they have to tell me. I justwant to know why I’m here.” I tried to imagine what it mustfeel like to be exquisitely ill but not to have the slightestidea that you are sick at all. Unimaginable, I thought.

Before my time with Clyde, I had never known that apatient with schizophrenia could have such a distinctivepersonality, just as we all have. It just takes work and timeto find it. “Indeed, the innermost core of the patient’s per-sonality is not even touched by a psychosis,” says ViktorFrankl. “An incurably psychotic individual may lose his use-fulness but yet retain the dignity of a human being.”

It is sad to look at the history of a schizophrenic likeClyde and to trace his regression. Clyde’s case is typical. Ayoung man a few weeks into college, away from home for

the first time in his life, suddenly recoils, loses interest in hisclasses and his friends, starts to think that people arecoming to get him, to steal his neurons and such, andalmost as quickly as a strike of lightning, he is gone, and forthe rest of his life, no one except his family and his doctorsknows he exists.

No one really knows what triggers someone to fall sud-denly into a mental illness as precipitously as Clyde did. Itmight be genes that cause some of us to lose control andothers to remain unscathed, but there are probably manyother factors. Who knows the ones among us who mighthave a slightly weaker psyche than the rest? Everything’sfine, then it all breaks loose. From there, like death, it drivesthem down an irreversible course deep through the mudand the mantle of society, shunned and forgotten, lostforever. All it takes is a little stress, a blow of wind. What anincredibly thin line it is, almost invisible, that separatesthem from us.


LM

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Our minds were made up. We wereleaving Houston and moving toLouisville. My wife and I had justbroken the news to our two childrenand were rewarded by great protests.Dr. George Schroth was a senior col-

league and friend whom I spoke to next. A cardiologist bytraining, a hyphenated citizen (Canadian-American), a wiseman with enlivening insight in the ways of the world, hespoke English, French and German. Moreover, he was neverafraid to speak his mind. Generous with his time and wit, henever hesitated to share his wisdom with me. When asked,there was no more frank person who spoke his mind. Istopped by his office on the top floor of a prominentdoctor’s building on Fannin Street and gave my friend thenews. He gave me a hug as we said our good byes. Then hereached for an unread book on his desk. He had just boughtthe copy for himself, and in a moment of customary gen-erosity, he signed it and said, “You will enjoy this one, keepit, it’s yours.”

Life in Louisville was a series of two humdrum unpack-ing events; once at the apartment and finally at our home.As I unpacked, the book caught my eye. For over a year thatbook had languished in one of those brown boxes one cannever seem to complete unpacking after a move. I pulled itout, the pages still crisp as the day I packed it. In it I sawGeorge’s inscription. I thumbed through the paperback, andcould not help chuckling at the first rule in the book. It readRule 1 Be Jewish. The unpacking soon took second place tothe pleasure of reading. I could not set it down. It isabsolutely hilarious and very little contained in the bookhas anything to do with Judaism.

I researched the author, Oscar London, whose realname is Dr. Arlan Cohn, a septuagenarian internist in ElCerrito, California. He decided to change his decidedlyethical name, into a decidedly non-ethical nom de plumeOscar London, MD, WBD. The book is a series of 56 shortessays that exude wit, albeit dry, and sometimes subtle,while at other times bordering on the slapstick. The 109-page book can easily be read in a few hours, and each essay

can be read independ-ent of the other. Inplaces it reminded meof the writings of thatprolific humorist P.G.Wodehouse. In others there is an air ofself-importance (who else would follow his MD with WBD-world’s best doctor) which in its own special way I foundamusing and even sometimes annoying. A sampling of hiswritings is included in this brief review, in the hopes of pro-viding the reader of Louisville Medicine with a flavor of thebook.

For example, Rule 6 tells an addict to take a walk. Hereis a sentence from the chapter. “For years I tried to rehabili-tate a wealthy married couple who were hooked on vodka.At breakfast they tinged their vodka with orange juice; atlunch, they pinkened their vodka with tomato juice; atdinner, they sweetened their vodka with vodka.” In anotherchapter he has words of wisdom and admonishes that hedoes not keep addictive drugs in his office or doctor’s bagbecause, “they tempt the burglar latent in the junkie; theytempt the junkie latent in the doctor.” Rule 14 deals withhonoring the aged. “Her arthritically hand-knit sweater iscomposed of 75 percent wool, 15 percent loose cat hairs,and 10 percent Dacron, but to my eyes it’s pure ermine.”

Being as it is a compilation of essays, the set of rules aredisjointed and for the average person impossible to remem-ber. Indeed it may perhaps be by design that they not beremembered. This then does not qualify for a self-helpbook. It is a book that must be enjoyed in the moment, andperhaps reread, but never assimilated. Clearly it is notmeant to be taken too seriously. It is hard not to seepatients and doctors you may know reflected in thosestories.

This book is a great way to add myrrh to an otherwiseboring day and it most certainly beats unpacking. You mayhave to sustain the wrath of the spouse to whom you madea promise you would. At the rate I am progressing ourunopened boxes will continue staying the way they are fora long, long time….Thank you, George!

B O O K R E V I E W

Book reviewed by Arun Gadre, MD

by Oscar London, MD, WBD (Ten Speed Press, 1987)

LM

Kill as Few Patients as Possible and Fifty-Six Other Essays on How to be the World’s Best Doctor


Ministering to the soul. It sounds so presumptuous. Howcan one minister to someone or something that one cannotsee, feel or touch? Yet there is such a ministry in hospitals,on the fields of battle, in nursinghomes, in the homes of the des-titute and dying and placeswhere hope is essential.

This ministry encompasses awide field that formally involvesprofessionals such as ordainedchaplains, priests, rabbis andspiritual counselors of otherdenominations. It also includesordinary lay people who are del-egated jobs specific to their indi-vidual training. Among theselatter are some volunteers whobelieve that to be a ministereven in the least way is a privilege, furthermore, that theyreceive more than they give.

It is not so much what they do, for many of their worksare neither tangible nor quantifiable. It is, rather, the avail-ing of the opportunity to be an agent of peace and reconcil-iation for the patient towards his God, himself, and thosearound him.

In the face of illness and death, which often happens inhospitals, facades fall and pretenses are abandoned.Although very careful not to intrude, hospital ministers

nevertheless become privy to a person’s inner sanctum andperchance also to the ones who love him. It is not unusualto observe, encounter or participate in events that are verymeaningful to the persons concerned. By doing so, a hospi-tal minister’s life is touched as well. Snippets of life areencountered on rounds.

One early morning, an elderly family physician died inhis hospital room. His daughter who had been on vigil allnight was bereft at the sight of this once confident andbenevolent father who in his heyday had decided thecourse of treatment of countless patients of his own.Although death had been expected, his daughter wasmomentarily stunned at what to do next. Referred to a min-ister, no words needed to be spoken. It was enough thatsomeone held her hands as she collected her thoughts, real-ized the finality of her loss and her tears flowed.

Three siblings were watching their veteran fatherquietly slipping away. He was past communicating hiswishes. A greeting to break the painful silence, a briefprayer acknowledging the inevitable and commending theirbeloved to his eternal home helped in some way to verbal-ize their grief and provide some relief.

A wife holding her husband’s hand before he waswheeled to surgery was edifying. It was an unspokenreminder of their relationship, affirming that love doesendure. On the other hand, watching the faces of a group ofreturned veterans discussing the loss of their friends andthe horrors of war was very sad. Their frustrations at tryingto reintegrate into a peaceful society that is oblivious totheir experiences revealed the pain and bewilderment that

they were going through. Wouldthat they continue to get thelong term care they need!

A recovering substanceabuser proudly displayed hislatest token of sobriety. Of whatuse is success without someoneto share it with? Or someone toencourage him further? Theimpatience of a person who hadno time to talk or tarry wasalmost comical. He was prepar-ing to be discharged with hisdiabetic foot intact. “Look! Stillgot my foot!” He was out of

there before anyone changed their minds about amputa-tion. The expressed gratitude of countless patients and staffmembers for the availability of the sacraments of the faiththat sustains them gives a lot of satisfaction and joy to theministers that bring them. Devoid of time constraints andthe responsibility for the patient’s lives or health on theirhands, hospital ministers hope that their presence and whatthey offer by means of spiritual comfort will make a differ-ence. Is that what ministering to the soul means?

Reflections:On HospitalMinistryvolunteering

Teresita Bacani-Oropilla, MD

R E F L E C T I O N S

LM


Radtke ND, Aramant RB, Pety HM, Green PT, Pidwell DJ, Seiler MJ.Vision improvement in retinal degeneration patients by impantation of retina together with retinal pigment epithelium.AJO 2008, 146:172-182.

Abbasi S, Stewart DL, Radmacher P, Adamkin D.Natural course of cholestasis in neonates on extracorporealmembrane oxygenation (ECMO): 10-year experience at a singleinstitution.ASAIO J. 2008 Jul-Aug;54(4):436-8.

Djurasovic M, Bratcher KR, Glassman SD, Dimar JR, Carreon LY.The effect of obesity on clinical outcomes after lumbar fusion.Spine. 2008 Jul 15;33(16):1789-92.

Federico AC, Chagpar AB, Ross MI, Martin RC, Noyes RD,Goydos JS, Beitsch PD, Urist MM, Ariyan S, Sussman JJ,McMasters KM, Scoggins CR; Sunbelt MelanomaTrial.Effect of multiple-nodal basin drainage on cutaneousmelanoma.Arch Surg. 2008 Jul;143(7):632-7; discussion 637-8.

Fowler JF Jr, Perryman JH, Quinlan B.Positive patch-test reactions to platinum are rare.Dermatitis. 2008 May-Jun;19(3):146-7.

Gall SA.Vaccines for pertussis and influenza: recommendations for usein pregnancy.Clin Obstet Gynecol. 2008 Sep;51(3):486-97.

Hazani R, Engineer NJ, Mowlavi A, Neumeister M, Lee WP,Wilhelmi BJ.Anatomic landmarks for the radial tunnel.Eplasty. 2008 Jun 22;8:e37.

Landry CS, Woodall C, Scoggins CR, McMasters KM, Martin RC2nd.Analysis of 900 appendiceal carcinoid tumors for a proposedpredictive staging system.Arch Surg. 2008 Jul;143(7):664-70; discussion 670.

Lenz AM, Fairweather M, Cheadle WG.Resistance profiles in surgical-site infection.Future Microbiol. 2008 Aug;3:453-62.

Martin RC, Woodall C, Duvall R, Scoggins CR.The use of self-expanding silicone stents in esophagectomystrictures: less cost and more efficiency.Ann Thorac Surg. 2008 Aug;86(2):436-40.

Nakashima S, Arnold SA, Mahoney ET, Sithu SD, Zhang YP,D'Souza SE, Shields CB, Hagg T.Small-molecule protein tyrosine phosphatase inhibition as aneuroprotective treatment after spinal cord injury in adult rats.J Neurosci. 2008 Jul 16;28(29):7293-303.

Nichols KK, Foulks GN, Schaumberg DA, Smith JA.The changing times in dry eye research.Optom Vis Sci. 2008 Aug;85(8):613-4.

Risner B, Nyland J, Crawford C, Roberts CS, Johnson JR.Orthopaedic In-Training Examination Performance: A Nine-YearReview of a Residency Program Database.South Med J. 2008 Jul 9.

van Balken I, Litvan I.Current and future therapeutic approaches in progressivesupranuclear palsy.Handb Clin Neurol. 2008;89:493-508.

Weeks JW.Antepartum testing for women with previous stillbirth.Semin Perinatol. 2008 Aug;32(4):301-6.

NOTE: GLMS members’ names appear in boldface type. Most of theabove references have been obtained through the use of a MEDLINEcomputer search which is provided by Norton Healthcare MedicalLibrary. If you have a recent reference that did not appear and wouldlike to have it published in our next issue, please send it to Alecia Millerby fax (736-6363) or email ([email protected]). LM

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LOUISVILLE MEDICINE Medicine/LM... · sseepptteemmbbeerr 22000088 33 louisville greater louisville medical society 24 medicine vol. 56 no. 4 september 2008 see page 24 for cover story