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AUTUMN 2007 



HarvarH Medical 



ALUMNI BULLETIN 




WHAT ARE DOCTORS FOR? 






LUMINARY 



Walter Bauer, MD, pictured here 
mid-twentieth century, greets a 
young patient— and Eleanor 
Roosevelt— at Massachusetts 
General Hospital. Bauer devoted 
himself to the study of skeletal-tis- 
sue diseases and published v/hat 
many consider the definitive work 
on rheumatoid arthritis. From 1 929 
to 1 958, he led the hospital's pro- 
gram for the study of rheumatiej 
diseases and, in 1951, became*... 
hospital's chief of medical services. 
At HMS, Bauer rose from reseaj 
fellow to become the Jackson Pro* 
fessor of Clinical Medicine. 



V 

\ 



V 




AUTUMN 2007 • VOLUME 81, NUMBER 1 



r.ONTF.NT.S 



DEPARTMENTS 



Letters 3 

Pulse 5 

The dean offers a new vision and welcomes 
a new class; Harvard physicians reach 
out to patients in rural Cambodia; 
Partners in Health commemorates its 
20th anniversary 

Bookshelf 9 

Bookmark 10 

A review by Elissa Ely of two physician- 
written children's books 

Benchmarks 12 

J Scientists rid murine brains of Alzheimer's 

5 plaques; family and friends influence per- 

5 sonal weight gain; a botanical may be an 

i anti-epileptic agent; research on women's 

^ health issues 

< 

i Alumna Profile 56 

t Pardis Sabeti excels in the laboratory 

X and on stage, hy Janice O'Leary 
< 

I Class Notes 58 

o 

I Obituaries 61 

1 Endnotes 64 

o 

^ The small hours of the morning provide 
g a ghmpse into the healing role of doctors. 
* hy Erica Scigucr Shcnoy 

o 
o 

E Cover photograph: Stephen Webster 

y 




SPECIAL REPORT: WHAT ARE DOCTORS FOR? 



What Are Doctors For? 16 

The most recent phase in the evolution of the physician's role may prove 
to be the most problematic. fc>'wiLLiAM ira bennett 

The Machine in the Garden 20 

An increasingly sticky bureaucracy often paralyzes doctors as they 
struggle to preserve their healing role, ly Christopher crenner 

Ritual Healing 26 

what can traditional healers teach Western physicians? 

fc)- timothy FERRIS 

In Good Company 32 

As stresses on the health care system grow, physicians are finding they 
dorit have to face them alone, hy mitchell t. rabkin 

Terminal Care 38 

The strictures in this futuristic fable lead one doctor to a decision at odds 
with her time. Ijj'William ira bennett 

The Dean Counter 42 

HMS alumni are making their mark as leaders of the nation's medical 

schools. fcyANN MARIE MENTING 

Fighting Chance 50 

A cancer diagnosis stirs a physician to consider her living time rather 
than her dying time, hy bernadine healy 






Harv^rrl Merlin;^1 



ALUMNI BULLETIN 




In This Issue 

IFTY YEARS AGO, SHORTLY BEFORE I BOARDED A PROPELLER AIRPLANE FOR 

the 24'hour trip from the West Coast to Cambridge and Harvard, I was 
warned that the University was a breeding ground for communists. 
This proved not to be true (and anyway I never really inhaled). In fact. Harvard 
Medical School seems to have instead become a breeding ground for medical 
school deans. As of last count, nine of the 126 medical schools in this country 
are being led by HMS graduates. Even though they have taken their work up 
in interesting times, their testimony in "The Dean Counter," our roundup that 
begins on page 42, indicates that they enjoy the challenges. 

The job of a medical school dean is, of course, to keep the show on the road: 
preserve the institution's strengths, improve its shortcomings, and see to it that 
the buildings don't leak and the bills are paid. That ought to be enough, but 
these responsibilities come at a time when the economics and politics of health 
care are as problematic and contested as they have ever been. Demand for 
health care is expected to rise in the near future both because the baby 
boomers are reaching the age at which their consumption of care is likely to 
increase (even as boomer physicians begin to retire) and because insurance 
coverage is likely to be extended to a larger proportion of the population. 

Do these projections mean that more physicians and medical schools will be 
needed? In some quarters the answer has been yes. After 20 years in which the 
number held steady, several new medical schools are opening or are in the 
planning stages. Will increasing the number of U.S. physicians actually meet 
the country's needs? Or will it distort the market by creating demand for a lux- 
ury product? It is possible, after all, that the population would be better 
served by non-physician practitioners who are trained, less expensively, to per- 
form part of the physician's traditional role — and to do it well. Who, actually, 
will decide? And what are the alternatives? Can we even imagine planning the 
economy of health care in the United States? The current generation of deans 
will not be able to avoid these questions. 

With this issue, we thank Janice O'Leary, our assistant editor for more than 
three years. Janice has left the Bulletin to work in the consumer publishing 
world. And, in a sweet symmetry, we welcome in her place Jessica Cerretani, - 
who left consumer publishing to join our magazine. We wish Janice well and 
look forward to working wdth Jessica. 



U.iL^ 



0UA\ l/U 



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EDITOR-IN-CHIEF 

William Ira Bennett '68 

EDITOR 

Paula Brewer Byron 

ASSOCIATE EDITOR 

Ann Marie Menting 

ASSISTANT EDITOR 

Jessica Cerretani 

EDITORIAL INTERN 

Rachel Nania 

BOOK REVIEW EDITOR 

EHssa Ely '88 



EDITORIAL BOARD 

JudyAnn Bigby '78 

Rafael Campo '92 

EHssa Ely '88 

Daniel D. Federman '53 

Timothy G. Ferris '92 

Alice Flaherty '94 

Atul Gawande '94 

Robert M. Goldwyn '56 

Petri Klass '86 

Victoria McEvoy '75 

James J. O'ConneU '82 

Nancy E. Oriel '79 

Anthony S. Pacton '58 

Mitchell T Rabkin '55 

Jason Sanders '08 

Eleanor Shore '55 



DESIGN DIRECTOR 

Laura McFadden 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



ASSOCIATION OFFICERS 

WiUiam W. Chin '72, president 

Steven E. Weinberger '73, president-elect 1 

JudyAnn Bigby '78, president-elect 2 

Ken Offit '81, vice president 

Rodney J. Taylor '95, secretary 

Douglas G. Kelhng '72, treasurer 

COUNCILLORS 

Rosa M. Crum '85 

Laurie Ghmcher '76 

Edward D. Harris, Jr. '62 

Jim Kim '86 

Triste N. Lieteau '98 

Christopher J. O'Donnell '87 

Michael Rosenblatt '73 

Rachel G. Rosovsky '00 

John D. Stoeckle '47 

DIRECTOR OF ALUMNI RELATIONS 

George E. Thibault '69 

EXECUTIVE DIRECTOR OF 
ALUMNI RELATIONS 

Mary Moran Perry 

REPRESENTATIVES TO THE 
HARVARD ALUMNI ASSOCIATION 

Joseph K. Kurd, Jr. '64 
John D. Stoeckle '47 

The Harvard Medical Alumni Bulletin is 

pubhshed quarterly at 25 Shattuck Street, 

Boston, MA 02n5 » by the Harvard 

Medical Alumni Association. 

Phone: (617) 384-8900 • Fax: (617) 384-8901 

Email: bulletin@hms.harvard.edu 

Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191-7757 • Printed in the U.S.A. 






SECOND OPINIONS FROM OUR READERS [ 



T.F.TTKRS 



ft 




%^MeclinpF 



CLOTHES MAKETH THE DOCTOR 

when I first saw your Fashion Issue, I ^ 

thought, This has nothing to do with md But 

when I opened the pages, I found myself 

pulled in. The issue is marvelous. The design is elegant and 

the articles insightful, especially the history of doctor fashion. 

Thanks for a wonderful issue! 

GEORGE RICHARDSON '46 
NAHANT, MASSACHUSETTS 



THf^fASHION 



Beyond the Looking Glass 

I enjoyed reading the article that Robert 
Goldwyn '56 wrote about plastic 
surgery in your Winter 2007 special 
report on fashion. In just a few para- 
graphs, Dr. Goldwyn encapsulated the 
history of the field as well as a sense of 
his own compassionate approach to 
his patients. His sly sense of humor 
emerged, too, just as I remember it from 
my encounters with him during my der- 
matology rotation at Massachusetts 
General Hospital 40 years ago. The only 
thing missing from the article was a 
glimpse of his sartorial elegance. 

I hesitate to disagree with my mentor, 
but I would like to offer an alternative 



perspective on the exchange he quoted 
between Pablo Picasso and Gertrude 
Stein. According to Stein in The Autobiog- 
raphy of Alice B. Toklas, Picasso said, 
"Everybody says that she does not look 
like it but that does not make any differ- 
ence, she will." I never imagined that 
Picasso was referring to Gertrude's 
aging when he said that she would look 
like the portrait. I interpreted his 
remark to mean that Stein would realize 
that he had captured the essential 
Gertrude in oil on canvas and would 
will her visage to mirror the portrait. 
Picasso was laying claim to having cap- 
tured Stein's inner soul after having her 
sit for him more than 80 times. His 
famous sitter came around to his view. 



saying in Steinese, "I was and stdl am 
satisfied with my portrait, for me it is I, 
and it is the only reproduction of me 
which is always I, for me." 



OILMAN D. GRAVE, MD 
BETHESDA, MARYLAND 



Meter Reader 



In "Girl, Interrupted" in the Winter 2007 
issue of the Bulletin, the author, Jerome 
Groopman, described the diagnostic 
approach that Myron Falchuk '67 takes. 
That description reminded me of one of 
the most important lessons I learned in 
my time at HMS. 

I was a hard- charging third-year 
student rotating through medicine at 
Massachusetts General Hospital when 
we had a guest professor, Robert Fred- 
erick Loeb, Class of 1919, of textbook 
fame. (Coincidentally his son was in my 
class.) We were on rounds when an 
impeccably turned out internal medi- 
cine resident presented a case of hepati- 
tis B to Dr. Loeb. The resident recited an 
exemplary "general" presentation with 
many facts and lab results. When he had 
finished. Dr. Loeb, who had been quiet- 
ly inspecting the patient in the bed, 
asked him, "Doctor, is the patient get- 
ting better?" 

The resident, who certainly thought 
he had covered any answer to that ques- 
tion with his erudite presentation, 
looked a little puzzled but then repeat- 
ed a pointed summary of data that made 
it obvious to the surrounding throng 
that the patient was better. Dr. Loeb 
again asked the resident if the patient 
was better. Again the resident, obvious- 
ly bevdldered, launched into a stellar, 
MGH-worthy presentation. 

Dr. Loeb smiled gently, turned to the 
patient and asked, "Are you hungry?" 
The patient answered, "I'm starved!" 
Dr. Loeb then turned to the assemblage 
and announced, "This patient is better! 
Next case." 

That little vignette about listening 
to the patient always came to my mind 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 






T.ETTERS 



I SECOND OPINIONS FROM OUR READERS 



Physicians wait 

an avcraoje of only 

~t 18 scconfls before 

•" ~1 * cutting short 

# -■ -B^ patients' recitations 

1 — ■- 1 1 of their symptoms. 


W 


Inter- 


rupted 

wen over the pist 15 years. She gues«d it was close to 10. 
Now, two days after Christmas 2004, on a surpnslngly 
mild morning, she was driving into Boston to see yer 
another physician, tier primary care doctor had opposed 
the trip, arguing that Anne's problems were so long- 
standing and so well defined thai this consultation would 
be useless. B^t her boyfriend had stubbornly insisted. 



If you cannot tell me what I just told you 

such that I recognize it as what I thought 
I told you, then we have not communicated." 



during my practice years when some 
new internist announced that he or she 
needed to acquire the "database" before 
entertaining a diagnosis for the patient. 

Fortunately my practice patient 
encounters were managed more along 
the style of Dr. Falchuk, occurring as 
they did before the explosion of man- 
aged care with its "covered lives" 
instead of patients and such immoral 
disincentive plans as full-risk capita- 
tion. When I entered an exam room in 
my practice I used to emphatically set 
the patient chart aside on a counter, sit 
comfortably in a chair, lean back, look 
directly into the patient's eyes, and try 
to produce an aura of empathy and infi- 
nite time to listen. I would then ask, 
"How can I help you?" 

I dorit know if HMS now has courses 
on how best to interact with patients, 
but, if it does, I'd be happy to impart a 
simple tip for use in such a course. It is 
a loosely structured technique from a 
communications concept called mean- 
ing theory: "If you cannot tell me what I 



— MICHAEL J. MCKEOWN '6l 

just told you such that I recognize it as 
what I thought I told you, then we have 
not communicated." 

Have young practitioners test this by 
asking a patient, "What did I just tell 
you?" I have found that asking this ques- 
tion is immensely helpful, especially when 
talking with a patient with a serious, 
life-threatening illness such as cancer. If 
I believe we have not communicated, I 
take full blame — most patients are 
somewhat in awe of physicians and usu- 
ally assume any lack of understanding is 
their fault. I then gently tell the patient 
this is something important and that 
I'm willing to take as much time as nec- 
essary to ensure both of us have an 
equivalent understanding of the subject. 
This cannot be done in a 15-minute visit! 

The basic pathophysiologic, whole- 
patient approach I learned at HMS 
stood me in good stead on the front lines 
of a rural practice in Oregon. Unfortu- 
nately, I was forced to retire from my 
active OB/GYN practice in 1977 because 
I had developed a rare form of limb- 



girdle muscular dystrophy. The full 
impact of managed care had by that time 
stripped away 30 to 40 percent of my 
routine office care. And because I 
refused to ramp up my practice volume, 
I only broke even in my last three 
months of practice, a fact that angered 
the aggressive new management of the 
group to which I belonged. 

It used to be Primum non noccrc, but it is 
now Primum non rcdundo! 

MICHAEL J. MCKEOWN '6l 
PORTLAND, OREGON 



Handyman Special 



Permit me to express my concern that 
the Winter 2007 book review of Next 
poorly served your readers and the 
book's author, Michael Crichton '69. It is 
a given that 'Next was written for the gen- 
eral pubhc, and for the reviewer, Ehssa 
Ely '88, to concentrate on its hterary 
aspects seems beside the point. 

Germane to your audience and the 
meat of the matter was in the book's final 
pages, entitled "Author's Note." Here the 
author describes five current, socially sig- 
nificant issues, including gene patenting, 
the use of human tissues, and the vanish- 
ing hnes between the medical "profession" 
and business. These issues call for action 
and change. All are within the purview of 
Harvard Medical School, yet the reviewer 
gave them only passing mention. 

An opportunity for continuing educa- 
tion was missed. Information and dis- 
cussion were ignored. Please don't rely 
on the scientifically illiterate general 
public to take responsibility for what 
those in science create. 

You break it, you fix it. 

LENORE FRAZIER 

(WIDOW OF HOWARD S. FRAZIER '53) 

WINCHESTER, MASSACHUSETTS 

The Bulletin welcomes letters to the editor 
Please send letters hy mail (Harvard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02115); fax (6J7-384-890J),- or 
email (hulletin@hms.harvard.edu). Letters may 
he edited for length or clarity. 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



MAKING THE ROUNDS AT HMS 



PTIT.SE 



The Unfolding Vision 



by Jeffrey S. Flier 




ARVARD MEDICAL SCHOOL IS 

the greatest medical school 
in the world by all objective 
criteria, from the competi- 
tiveness of our medical and graduate 
programs, to the success of our alumni 
as they assume leadership positions 
around the globe, to the accomplish- 
ments of our faculty, to the size and 
deserved reputations of our affiliated 
hospitals and institutes. 

When I became dean of HMS at the 
start of September, I faced an obvious 
dilemma: Should I follow the estab- 
lished course and maintain the excel- 
lence of this amazing institution, or 
should I consider a less conservative 
approach, one that would seek to iden- 
tify new opportunities, even if they 
might entail some institutional change? 
To resolve this for myself, I considered 
the real questions: Are we as good as we 
can be? If not, should we be satisfied to 
remain simply as we are? 

In answering such questions, we 
must remember why we are here in the 
first place. Our official mission is to cre- 
ate and nurture a diverse community of 
the best people committed to leadership 
in alleviating human suffering caused by 
disease. Although we are delighted that 
HMS is held in high regard throughout 
the world, we must remember that our 
goal is not to win a tournament of rank- 
ings. Our enemies are diseases and the 
suffering they cause, and there is no 
shortage of work to be done against these 
foes. Staying the course is not an option. 

How do we assess the changes neces- 
sary to meet these challenges? First, we 
must remind ourselves that at its core 
HMS is a medical school. Our principal 
responsibility is to train physicians to 
excel in medicine and to prepare them 
for leadership positions. To this end, 
HMS is now enacting a comprehensive 
medical curriculum reform that was 
developed over the past several years. I 




will continue to work with our educa- 
tional leaders to ensure the implementa- 
tion goes smoothly and to make any 
necessary adjustments. 

I also hope to initiate a reform recom- 
mendation that has yet to be acted upon: 
requiring HMS students to engage in a 
scholarly activity. Many of our students 
are already involved in such activities, 
often launching amazing careers in the 
process. But many more could be encour- 
aged to undertake an in-depth scholarly 
experience, which could involve wet lab- 
oratory research, clinical research, or any 
number of other endeavors. Such experi- 



ences would better position our gradu- 
ates for leadership roles in whatever 
career path they choose. 

At the same time, I am concerned 
about the indebtedness that many of our 
students face and the effect such debt 
has on their professional options. I am 
dedicated to finding ways to increase the 
financial aid to our students, to help 
them become the leaders they can — and 
should — be. 

In addition to being an educational 
institution, HMS is a research center of 
amazing size and breadth. It is my respon- 
sibility to keep our preclinical depart- 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



ptit.se 



MAKING THE ROUNDS AT HMS 



ments — ^both the basic science and social 
science departments — at the leading edge 
and to ensure they are well positioned to 
respond to scientific opportunities. 

I also need to be concerned, however, 
about Harvard faculty members who are 
based in the clinical departments of our 
affihated hospitals and institutes. They 
are extraordinary in their number, diversi- 
ty, and quahty. Yet they could be interact- 
ing vv4th one another far more often, a 
missed opportunity that raises several 
questions: Are we organized to capitalize 
on the most exciting aspects of modern 
science? To foster effective collaborations 
among faculty on the Quad and in our 
affihated institutions? To interact robust- 
ly with the other Harvard schools? To take 
full advantage of the School's physical and 
financial resources? And to mentor and 
develop our faculty effectively? 

I beheve the answer to these questions 
is no. We need to seize more opportuni- 
ties in the advancing fields of basic sci- 
ence, to collaborate more consistently 
across departments and institutions, and 
to use our substantial resources better. 
We need to augment the mentoring we 
provide our faculty and the leadership 
opportunities we afford them. 

Changes in the way research centers 
are funded may help us accomphsh those 
goals. In fact, a mandate from the National 



The Class of 201 1 



Institutes of Health (NIH) will consoh- 
date much of the clinical and translation- 
al research across our community. 

Currently each of Harvard's major 
teaching hospitals — Massachusetts Gen- 
eral Hospital, Brigham and Women's 
Hospital, Children's Hospital, and Beth 
Israel Deaconess Medical Center — has a 
General Clinical Research Center, or 
GCRC. For the past several decades, the 
NIH has funded the infrastructure for 
this type of hospital-based clinical 
research entity by offsetting the costs of 
the beds; nursing, nutritional, and admin- 
istrative support; and the physical struc- 
tures necessary for its endeavors. 

Several years ago, then NIH Director 
Elias Zerhouni announced that all fund- 
ing for these centers would end by 2010, 
with institutions housing the centers 
either closing them or rolUng them into a 
new kind of grant. This new grant is the 
Clinical and Translational Science 
Award, designed to transform clinical 
and translational research both as a 
practice and as a career path. The award 
will not only incorporate funding for 
existing GCRCs but will also add many 
other required elements related to edu- 
cation and career development for clini- 
cal-translational researchers, communi- 
ty outreach, and regulatory support. The 
centers funded by this award will be 



called Clinical and Translational Science 
Centers, or CTSCs. 

The catch, for Harvard, is that it can 
have only one such center. Harvard has 
apphed for a CTSC, and the grant would 
be awarded to the Medical School for 
distribution. With the exception of the 
Dana-Farber/Harvard Cancer Center, 
this would be our first cooperative, 
broad-ranging, clinical research initiative. 

This sole CTSC would act as a research 
hub, unifying aspects of the various chnical 
research centers by encouraging collab- 
orative use of resources. This consohda- 
tion would reduce redundancy across 
the centers, allowing the saved resources 
to be directed toward more infrastruc- 
ture, new technology development, sup- 
port for career development, and pilot 
grant programs. In addition, HMS, the 
affiliated hospitals, and the University's 
new Science and Engineering Commit- 
tee would each commit $16 million in 
new funds. The changes engendered by 
this grant would be transformative, and 
its impact on HMS would be profound. 

Another area in which I see tremen- 
dous opportunity is the broad and excit- 
ing field of bioengineering. Neither the 
Medical School nor the University has 
major identified efforts in this area. 
Although the hospitals have many impor- 
tant centers of bioengineering research. 



AT summer's end, HMS GREETED THE 165 MEMBERS OF 

the Class of 201 1 in the usual manner — with a presentation 
of their first white coats. HMS Dean Jeffrey Flier welcomed 
students and commented on their remarkable strengths and 
diversity. The class's 77 women and 88 men hail from 
63 colleges and universities in 34 states, as well as from 
schools in Bulgaria, Canada, China, Ghana, Jamaica, 
Japan, Lebanon, Nigeria, Thailand, and Zimbabwe. 
Thirty-three percent of the students are of Asian descent, 
1 3 percent are of African descent, and 8 percent are 
Latino. Native Americans make up less than 1 percent. ■ 




HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



these centers are not coordinated intellec- 
tually with one another. We have, there- 
fore, begun discussions with the new 
School of Engineering and Apphed Sci- 
ences and the Faculty of Arts and Sciences 
on developing a plan for a major invest- 
ment in bioengineering. 

Human genetics research presents us 
with another opportunity. Breakthroughs in 
this field will undoubtedly lead to better 
understanding, treatment, and preven- 
tion of disease. Although HMS currently 
has pockets of excellence in this research, 
the field is insufficiently represented. As a 
result, I am working closely with Chff Tabin, 
the chair of our Department of Genetics, and 
an executive committee to plan for a more 
coordinated and robust effort in human 
genetics, perhaps involving all of Harvard. 
I believe that with significant intellectual 
and financial investment, we can create an 
unparalleled program of human genetics 
research across the institution. 

I'm also dedicated to exploring oppor- 
tunities in pharmacology, therapeutics, 
toxicology, and chemical biology. The 
revolution in cellular and molecular biol- 
ogy has produced some spectacular sci- 
ence that will help accelerate the process 
for discovery and optimization of new 
therapeutics. Yet we lack a major pro- 
gram for researchers intent on these 
goals. This is an important intellectual 
discipline, one in which — ^with a few 
additions to our faculty and perhaps the 
involvement of the hospitals and the 
University — we can excel. 

Finally, we are implementing a strategic 
planning process that will engage the 
entire HMS community. We have great 
value to gain by talking openly and hon- 
estly about the issues we face. And I 
beheve our efforts in the coming years will 
accelerate our capacity to fulfill our core 
mission of creating and nurturing a diverse 
community of the best people committed 
to leadership in alleviating human suffer- 
ing caused by disease. ■ 

Jeffrey S. Flier, MD, is dean of Harvard Medical 
School. He offered these remarks in the first town 
forum of his tenure as dean. 




The Cambodian Connection 

RESIDENTS OF TWO REMOTE CAMBODIAN VILLAGES NOW HAVE ACCESS TO 

the expertise and experience of HMS-affiliated hospitals and physicians without 
the expense of airline tickets or visas. Clinicians in both countries are using 
technology to connect rural Cambodians with Boston physicians volunteering in 
the Partners HealthCare Center for Connected Health. 

The center — formerly Partners Telemedicine — enables hospitals to connect with 
patients outside the clinic using 
widely available technology 
such as digital cameras, cell 
phones, and the Internet. A 
high-risk cardiac patient, for 
example, can transmit vital 
signs to a nurse through an 
at-home monitoring device, 
enabling the nurse to help man- 
age the patient's care from a 
distance and to provide neces- 
sary treatment. 

In 2001 , the center began 
an initiative called Operation 
Village Health in partnership with the relief agency American Assistance for 
Cambodia to assist Cambodian health care workers in providing more sophisti- 
cated care. Monthly clinics are held in the villages of Rovieng and Banlung. 
There, a nurse interviews, examines, and digitally photographs patients and 
emails the information to Boston, where physicians respond with medical 
opinions and treatment suggestions. Care is coordinated with a hospital in 
Phnom Penh. 

"What has turned out to be really interesting is that it isn't infectious diseases 
we're seeing but mostly noncommunicable chronic conditions like hypertension 
and diabetes," says Paul Heinzelmann, an HMS clinical instructor in medicine 
at Massachusetts General Hospital and the project leader for Operation Village 
Health. While infectious diseases continue to be a problem, he says, Cambodi- 
ans are increasingly diagnosed with chronic diseases that need long-term man- 
agement, creating a "double burden." Nearly two-thirds of the patients visiting 
the Rovieng clinic are repeat customers. Each clinic attracts up to 20 patients a 
month, and more than 800 consultations have been performed since the pro- 
gram was started by volunteer physicians at Massachusetts General Hospital, 
Brigham and Women's Hospital, and Partners/Dana-Farber Cancer Care. 

Operation Village Health has attracted international acclaim. In 2006, it 
was chosen as the winner of the Stockholm Challenge in the health category. 
The Stockholm Challenge recognizes projects that use information and commu- 
nication technology to counteract social and economic disadvantages. 

In the future, Heinzelmann says, the initiative aims to bring clinics to addi- 
tional villages. The center is also working with Cambodian clinicians to explore 
the use of digital pen technology to standardize reports. Other nonprofit organi- 
zations are helping to restructure local hospitals' operations, including imple- 
menting the integration of telemedicine, which in turn will increase support for 
the clinics and their expansion. ■ 

Emily Lieberman is an editorial assistant for Focus. 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



ptit.se 



MAKING THE ROUNDS AT HMS 




When Words Fail 




N SEPTEMBER, PARTNERS IN HEALTH CELEBRATED THE 20TH 

anniversary of its founding with an exhibit of 100 
photographs depicting its work and the communities in 
which it has forged partnerships with patients and local 
health workers to combat epidemics of AIDS, tuberculosis, hunger, 
poverty, and injustice. 

The nonprofit organization, whose cofounders include Paul 
Farmer '90 and Jim Kim '91, collaborates with Harvard Medical 
School, the Harvard School of Pubhc Health, and Brigham and 
Women's Hospital to bring the benefits of modern medical science to 
the poor, sick, and needy in Africa, Haiti, Latin America, Russia, and 
the United States. 

"If a picture is worth a thousand words," says OpheHa Dahl, exec- 
utive director of Partners in Health, "these images are worth millions 
for what they have to say about human dignity in the face of intoler- 
able suffering and criminal indifference, about soUdarity, and ulti- 
mately about hope." 

The exhibit is currently on display at Harvard Medical School's 
Gordon Hall, and there are plans to take it on the road. For more 
information on Partners in Health and the exhibit, visit 
www.pih.org. ■ 



RECENT DEVELOPMENTS: A striking photography exhibit merles the 
20th anniversary of Partners in Health's founding. 



8 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



BOOKS BY OUR ALUMNI 



n O O K S H K 



II 



High 
Performance 

Health 




W'^ 


JAMESM.RIPPE.MB. 




Yanvan Jourtml 





UTERINE 
FIBROIDS 




Teaching and 
Assessing the 
ACGME Core 
Competencies 



M vkiNd; 



■'iMVfi 

BiiRIK8 



High Performance Health 

]0 Real Life Solutions to Redefine Your Health 
and Revolutionize Your Life, by James M. 
Rippe 79 (Thomas Mson, 2007) 

Rippe, a cardiologist, believes that health 
is a tool for achieving a joyous and 
meaningful life. He contends that health 
should become a core value and that 
"high performance thinking" can help 
readers achieve the kind of life they want. 
The book provides a practical, ten-step 
action plan for the mind, body, and spirit. 
These steps include eating to fuel perfor- 
mance, estabhshing a time for solitude, 
and embracing active rest principles. 

A Life in Academic Medicine 

by Philip J. Snodgrass '53 
(iUniverse, 2007) 



With a fondness for his mentors and 
without the gloss of nostalgia, Snodgrass 
chronicles his rise from junior resident to 
chief of gastroenterology at the Peter 
Bent Brigham Hospital to chief of the Vet- 
erans Administration medical service in 
Indianapolis. He revisits his struggle to 
support his family on a resident's salary 
while trying to juggle his clinical and 
research responsibilities. He also recalls 
the moments that bring life to memories. 

Yerevan Journal 

by A. Scott Earle '53 (Larkspur Books, 2007) 

This book recounts the author's experi- 
ences as a volunteer surgeon in Yerevan, 



t 



Armenia, in the years after an earth- 
quake devastated the country. He details, 
for example, the numerous burn patients 
he saw, as an extremely cold winter led 
to the lighting of dangerous petrol fires 
in attempts to gain warmth. Earle also 
chronicles his observations of the ten- 
sions in the small clinic and the larger 
political ones of that nation. 

Understanding Parkinson's Disease 

A Personal and Professional View, 
by Richard B. Rosenbaum '71 
(Prager Publishers, 2006) 

Rosenbaum, a neurologist whose father 
has Parkinson's disease, combines both 
his personal and professional experi- 
ences with Parkinson's to give his read- 
ers a comprehendible and comprehen- 
sive explanation of the disease, which 
affects nearly one million Americans. 
The topics Rosenbaum covers in his 
book include diagnosis of the disease, 
prognostic variations, investigations 
into the causes of the disease, the treat- 
ment options, and research efforts now 
under way. 

Uterine Fibroids 

The Complete Guide, by Elizabeth A. 
Stewart '85 (Johns Hopkins University 
Press, 2007) 

More than 25 percent of all women have 
uterine fibroids, the author says, and 
doctors often resort to hysterectomy 
to remove the noncancerous growths. 
Stewart explains the treatment options 



available to women, including hormonal 
therapies and the use of agonists. Help- 
ful diagrams illustrate the surgical pro- 
cedures described. 

A Practical Guide to Teaching and 
Assessing the ACGME Core Competencies 

by Elizabeth A. Rider '91, Ruth H. 
Nawotniak, and Gary Smith (HCPro, 2007) 



This book provides research, best prac- 
tices, models, and tools for teaching and 
assessing core medical education com- 
petencies required by the Accreditation 
Council for Graduate Medical Educa- 
tion for residency programs. The com- 
petencies include: patient care, medical 
knowledge, practice-based learning and 
improvement, interpersonal and com- 
munication skills, professionalism, and 
systems-based practice. 

From Making Bows to Fixing Babies 

by Orvar Swenson '37 
(PuhlishAmerica,2006) 



In this autobiography, Swenson docu- 
ments his journey from child entrepre- 
neur — making and seUing fire-by-friction 
sets and archery equipment — to pedi- 
atric surgeon. He reflects on the defining 
moments in his life, including his immi- 
gration to the United States from 
Sweden at the age of six, the early death 
of his mother, his acceptance into med- 
ical school, and his career in medicine. In 
recounting these stories, he offers subtle 
advice to younger generations seeking a 
similar path. 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



ROOKMARK 



I REVIEWING THE PRINTED WORD 



And Tango Makes Three 

by Justin Richardson '90 and Peter Parnell 

and illustrated by Henry Cole (Simon & Schuster, 2005) 




by Justin Ricliardson 

onJ Peter PomeK 

iftustroted by Henry Cofe 



ALL RIGHT, CHILDREN. GATHER AROUND. INDOOR VOICES, PLEASE. 

Recess is over; it's reading time. Amanda, you need a tissue. If 
anyone else wants one before we start, give a quiet wave. 

We have time for two books, and both are full of won- 
derful pictures. Be suspicious of the person who says he has 
never written a children's book, dears. If he doesn't have 
one hidden in a drawer, he has it hidden in a closet. Doctors 
are no different when they write such a book, though they 
tend to drop the "MD" after their names. Maybe this is so 
you won't mistake what lies inside their books for medical 
advice, and flee before opening them. 

One of the stories today will be for the youngsters, and the 
other is for those who can read to themselves. And Tango Makes 
Three is famous; perhaps your parents have heard of it. The 
author is Justin Richardson '90, a psychiatrist, along with the 
playwright Peter ParneU and the artist Henry Cole. The story 
is true. Two chinstrap penguins in the Central Park Zoo fall 
in love. They set up a nest together, "nice, but a little empty." 
They cannot lay eggs — though they try futilely to hatch a 
stone — because both of them are boys. 



The Luck of the Loch Ness Monster 

A Tale of Picky Eating, by A. W. Flaherty '94 

and illustrated by Scott Magoon (Houghton Mifflin, 2007) 




FOR THOSE OF YOU A GRADE OR TWO ALONG, HERE IS ANOTHER 

book. The Luck of the Loch Ness Monster is by A. W. Flaherty, 
better known to our readers as Alice Flaherty '94, a neu- 
rologist at Massachusetts General Hospital. But except for 
a few paragraphs on the last page about the science of 
picky eaters and taste buds, you would never know that. 
And unlike And Tango Makes Three, which was tenderly writ- 
ten v^dth a message in mind. The Luck is an irreverent story 
written apparently for joy. The wry asides are like trea- 
sures you win under twist-off drink tops. 

Flaherty conflated the names of her own twin girls to give 
this picky eater the moniker Katerina-Elizabeth. While trav- 
eling on a cruise ship without her parents, this plucky hero- 
ine sends her oatmeal flying out the porthole. This is a good 
thing for her, and also for a nearby sea worm, "no bigger 
around than a thread and no longer than your thumbnail." 
By the luck of its Me, it is lounging haphazardly under the 
ship. Did you know that oatmeal is the sea worm's number 
one nutrient? Don't quote me on that, though. 



10 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



Their keeper notices all this from his office and is 
inspired to offer them an egg in need of warmth. Months 
and pages later. Tango appears, "the very first penguin in 
the zoo to have two daddies." They raise her with all the 
right penguin values, loving her dearly. Visitors to the zoo 
enjoy watching the whole family. The last picture in the 
book shows Tango snuggling with her parents at day's 
end, preparing, like all families in the city around them, to 
fall asleep. 

Now children, the American Library Association has 
reported that And Tango Makes Three (which is targeted for 
children between four and eight years old) was the book 
most often challenged in 2006. Some school libraries even 
tried to have it removed. People spent a great deal of time 
protesting the idea that their young ones might be exposed 
to male penguins creating a family together. They might have 
spent that time protesting an unnecessary war with horrific 
death counts, or government corruption, or iatrogenically 
elevated air temperatures. But they were too busy 
protesting penguins. These are dire days indeed. 



One bowl leads to another, and 
next thing you know, we are in Loch 
Ness, Scotland, with a worm "as 
thick as an elephant's belly and as 
long as the main hall of an elementary 
school." Will it continue to grow? Will 
it ever see the founder of its feast again? 
Without oatmeal, will Katerina-Elizabeth, 
as her parents fear, become stunted for life? 

You're all too young for worldly worries. There's sun coming 
through the windows, and it's pleasant to read about loving, 
nontraditional families and high-spirited, ocean- crossing 
girls. But Amanda, I feel a cold coming on myself. Pass the 
tissues, please. Go home now, everyone, and kiss your mothers 
and fathers — who, one hopes, will let you follow your grow- 
ing, curious noses and read whatever you want. ■ 

Elissfl Ely '88 is a psychiatrist at the Massachusetts Mental 
Health Center 




BENCHMARKS 



DISCOVERY AT HMS 



Disappearing Plaques 




XPERIMENTS BY A TEAM OF 

scientists at Brigham and 
Women's and McLean hos- 
pitals have succeeded in 
ridding the brains of mice of the toxic 
plaques associated with Alzheimer's 
disease. The cleanup tool: genetically 
engineered cells. 

The scientists first induced the mice 
to develop Alzheimer's at an accelerat- 
ed rate, then implanted them with the 
doctored cells. The animals' brain- 
muddling plaques melted away. If the 
research translates to humans, a debil- 
itating disease that robs millions of 
elderly people of their memories could 
become history. 

The team was led by Dennis Selkoe, 
Vincent and Stella Coates Professor of 
Neurologic Diseases at HMS, and its 
findings were reported August 28, 
2007, in PLoS Medicine. 

Alzheimer's involves a protein 
known as amyloid-beta, which forms 
gooey clots or plaques in the brain. 
These toxic clumps, along with acces- 
sory-tangled fibers. Ml brain cells and 
interfere with memory and thinking. 

The gene modification and implan- 
tation technique employed by the 
researchers has been used in other tri- 
als with animals that model human 
diseases, including cancers. The proce- 
dure involves removing cells from 
patients, making genetic changes, and 
then reintroducing the modified cells, 
which should treat a disease or disabil- 
ity. So far, this approach has produced 
encouraging results for cancers, spinal 
cord injuries, stroke, Parkinson's and 
Huntington diseases, amyotrophic lat- 
eral sclerosis, and blood, muscle, and 
eye diseases. 

The Harvard team used fibroblasts 
from the animal's own body to intro- 
duce a gene for an amyloid-busting 
enzyme known as neprilysin. These skin 
cells were chosen because they do not 
form tumors, migrate from the implan- 
tation site, or cause any detectable 




adverse side effects, hi addition, "fail- 
safe" genes can be added to the fibro- 
blast-neprilysin combo; the genes act to 
eliminate the implants if something 
starts to go wrong. 

Transferable Skills 



"The experiment showed a robust 
clearance of plaques in the brains of 
the mice," says Selkoe. "Such results 
support — and encourage — further in- 
vestigation of gene therapy for treat- 
ment of this common and devastating 
disease in humans." 

Translating the successful technique 
to applications in humans, however, 
brings many hurdles. One such obstacle, 
Selkoe says, is the larger size of a human 
brain compared to that of a mouse. That 
difference wiU require the implanted 
genes to travel throughout a much larg- 
er space in order to affect the needed 
increase in amyloid-busting activity. 



The researchers are already devising 
ways to overcome difficulties. One sug- 
gestion involves implanting the genes 
and fibroblasts where they would have 
the best access to amyloid-beta — in the 
spinal fluid, for example — instead of try- 
ing to dehver the modified cells into a 
small target by injection. The amyloid- 
kiHin g combo might be put into capsules 
that would secrete neprilysin into the 
blood that circulates in the brain, elimi- 
nating the need to hit an exact spot. 

This or some other nonsurgical 
maneuver might eliminate the gooey 
plaques, but would that improve a per- 
son's memory? And would any change 
be long lasting? Further study is 
required, say the researchers, but there 
is a wealth of evidence suggesting that 
long-lasting improvements to memory 
would indeed be likely. ■ 

William]. Cromie is a former staff writer for 
the Harvard University Gazette. 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



WORD OF MOUTH 




HERE MAY BE THE LAWNMOWER CHALLENGE, 

the accent-color contest, and even the race to snare 
B^! a spot in the "best" school, but HMS researchers 
can now point to one area where neighbors are 
unlikely to keep up with the Joneses: body shape and size. 

According to research from a team of HMS scientists led 
by Nicholas Christakis '88, a professor in the School's 
Department of Health Care Policy, and their colleagues at 
the University of California, San Diego, the weight and 
shape of your neighbors have little influence on your dimen- 
sions. Instead, to unravel personal propensities to plump- 
ness and beyond, the researchers suggest looking to your 
brother, sister, friend, or spouse. Or even to the friends of 
your friends, siblings, and partner. 

In this country, approximately 66 percent of adults are 
now overweight, and the prevalence of obesity among this 
group has grown from 23 to 31 percent in nearly two 
decades. These changes occur throughout all socioeconomic 
groups and cannot, given the time period during which they 
occurred, be explained simply by genetics. 

In the July 26, 2007, issue of the New England Journal 
of Medicine, the researchers report how social and environ- 
mental factors contribute to this 
phenomenon. Weight gain, they 
found, can spread through social 
network ties, and the weight status 
of one person can be linked with 
that of another up to three degrees 
of separation away. 

"It's not that obese or non-obese 
people simply find other similar 
people to hang out with," says 
Christakis. "Rather, there is a 
direct, causal relationship." 

When one person gains weight, 
that gain increases by 57 percent 
the chance that the person's close 
friend will gain weight, by 40 per- 
cent the chance that her or his sib- 
ling will put on pounds, and by 37 
percent the chance that a spouse 
will add heft. 

The scientists also found that indi- 
viduals of the same sex influenced 
each other to a greater degree than 



did those of opposite sex. Among siblings, a man's chance of 
becoming obese increased 44 percent if his brother became 
obese, while a woman's risk increased 67 percent if her sis- 
ter became obese. And in same-sex friendships, individuals 
had a 71 percent increased risk for becoming obese if a 
friend of theirs became obese. 

"The social network effects arise not because friends 
and siblings adopt each other's lifestyles," says Christakis. 
"It's more subtle than that. What appears to be happening 
is that a person becoming obese triggers a change in 
norms about what counts as an appropriate body size. 
People come to think it's okay to be bigger, and that sensi- 
bility spreads." 

The study data were derived from records on 1 2,067 
people who participated in the Framingham Heart Study 
between 1971 and 2003. The researchers plumbed previ- 
ously unused records of participants' family changes — 
births, marriages, deaths, and divorces — as well as lists of 
their closest friends, many of whom had also been partici- 
pants in the Framingham study. Altogether, the researchers 
analyzed information on 38,61 1 social and family ties of 
5, 1 24 study participants. ■ 




HE AINT HEAVY, HE'S MY BROTHER: Researchers have found that weight gain con 
spread widely through one's network of family and friends. 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



13 



BENCHMARKS 



I DISCOVERY AT HMS 



Plant Cachet 




F A PAINTING'S WORTH WERE 

measured by the money it 
fetched, Vincent van Gogh's 
famous rendering of his 
friend and physician Paul Gachet would 
be among the most valuable in all of art. 
Portrait of Dr Gachet — ^which depicts a 
languid man holding a purple foxglove, 
the plant from which the drug digitahs 
is derived — ^was sold in 1990 for $82 
million. The great and famously tor- 
tured artist had his own reasons for 
valuing the portrait. He suffered from 
severe epilepsy and depended on 
Cachet's prescription of digitalis to 
treat his debilitating seizures. 



The ranks of epilepsy medications 
have expanded in the past hundred 
years, mostly owing to the addition of 
pharmaceutically derived compounds. 
Still, people with epilepsy, approximate- 
ly 2 percent of the population, may con- 
tinue to suffer from seizures or from sec- 
ondary effects hnked to their medicines. 

"About two out of three people with 
epilepsy do not achieve the goal of 
therapy, which is freedom from seizures 
without side effects," says Steven 
Schachter, associate director of chnical 
research at the HMS Osher Institute 
and an HMS professor of neurology at 
Beth Israel Deaconess Medical Center. 




Part of the problem is that epilepsy is 
a brain disorder that has several under- 
lying mechanisms. A drug that works in 
one patient may not work in another. 
Yet all epileptic seizures are character- 
ized by uncontrolled electrical activity. 
One way to control them would be to 
block substances in the brain, such as 
glutamate, that cause neurons to fire. 
Pharmaceutical companies, with limit- 
ed success, have been pressing to find 
glutamate-inhibiting compounds. 

Schachter has hit upon a compound 
that does just that. And he has done so 
by drawing upon the same centuries-old 
botanical tradition that yielded digitahs. 
He and colleagues have identified a com- 
pound derived from the spiky-looking 
Chinese club moss that, when tested in 
rodents, had the power to prevent 
seizures. The seizures are considered to 
be representative of the highly debihtat- 
ing grand mal, or tonic-clonic, episodes 
that many patients with epilepsy 
experience, and which are often refrac- 
tory to treatment. Schachter soon hopes 
to launch a small clinical trial of the com- 
pound, huperzine A. 

Hup, Hup, Hurray 

It will not be the substance's first foray 
into the medical arena. Chinese healers 
have long been using extracts of hup- 
erzine A to quell inflammation and fever 
and, recently, to treat schizophrenia. 
Clinical trials are under way in China and 
the United States to test huperzine A's 
power against Alzheimer's disease. And 
the compound is being marketed as an 
over-the-counter memory aid. But it has 
yet to be used as a treatment for epilepsy. 
In Alzheimer's disease, huperzine A 
is thought to work by blocking the 
enzyme that degrades acetylcholine, a 
neurotransmitter associated with mem- 
ory. But the compound also blocks glu- 
tamate, which suggested to Schachter 
that it might have potential as an anti- 
epileptic agent. Working with col- 



14 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



WOMEN'S HEALTH 



leagues at the National Institute of Neu- 
rological Disorders and Stroke and the 
University of Utah, Schachter tested 
huperzine A in a well-known rodent 
model of seizures. 

Brain Balm 



The researchers administered the com- 
pound to the animals and then exposed 
them to three levels of seizure-inducing 
electrical currents. Huperzine A pre- 
vented seizures on all three levels. More 
remarkably, the doses required at the 
highest and lowest currents differed 
httle. "All other drugs that are effective 
in this model require larger doses to 
stop seizures as the voltage goes up," 
Schachter says. 

What makes the compound ready for 
chnical tests is that pure preparations 
are already available as supplements, 
and apparently safely so. Schachter plans 
to give huperzine A to about 20 patients 
who have not responded to available 
anti-epileptic drugs or who are experi- 
encing side effects. "We'll see how well 
the patients tolerate different dosages 
of huperzine A, whether it's benefiting 
their seizures, and, perhaps, some indi- 
cation of any effects on their memory," 
he says. He and colleagues will also be 
looking at how the compound might 
interact with other seizure medications. 

Huperzine A is just the first of a 
promising pipeline of herbal extracts 
and extract-derived botanicals that 
Schachter hopes to test in humans. In 
some cases, he will try to improve upon 
nature. For example, although hup- 
erzine A worked well in rodents, it was 
most effective when given an hour 
before the rats received the seizure- 
inducing current. To produce a drug 
that is effective 24 hours a day could, 
Schachter says, require tinkering with 
huperzine As pharmacokinetics. ■ 

Misia Landau is the senior science writer 
for Focus. 




11^ RATE CHANGE 

Prescribing a commonly used anti-arrhythmia 
medication to women suffering from atrial fibrilla- 
tion may have a serious downside, say 
researchers at Beth Israel Deaconess Medical 
Center. A research team led by Peter Zimetbaum, 
an HMS associate professor of medicine, has 
reported that women using amiodarone were 
nearly five times more likely to require a pace- 
maker to correct for slow heartbeat than women who did not use the drug. The 
report, published in the August 1 3/27 issue of the Archives of internal Medicine, 
further cautions physicians to consider lowering doses prescribed for elderly 
women, since the potential need for a pacemaker increases with age. 



11^ ACCEPT NO SUBSTITUTES 

Researchers at Brigham and Women's Hospital have found that supplemental 
doses of vitamins C and E and beta<arotene do not help protect women 
against cardiovascular events. A team led by JoAnn Manson, the School's 
Elizabeth F. Brigham Professor of Women's Health, followed 8,171 women for 
an average of nine years. Participants in the randomized, controlled study 
were considered at high risk for heart disease. The findings, reported August 1 3 
in the Arcliives of Internal Medicine, show that antioxidant vitamins, used 
alone or in combination, neither increased nor decreased the chance of car- 
diovascular events among high-risk women over the age of 40. The scientists 
urge women to hew to proven prevention methods: exercise, a healthy diet, 
and control of weight, cholesterol, and blood pressure. 



111^ BON APPETIT 

According to a report in the August 1 3 issue of Cancer Cell, cells grown for 
tumorigenesis studies need good grub to reach their full potential. Tan Ince, an 
HMS instructor in pathology at Brigham and Women's Hospital, concocted a new 
growth medium for normal human breast epithelial cells, then grew a batch of 
these cells in it. When he exposed the cultivated cells to genes known to transform 
normal cells into malignant ones, the cultivated cells formed tumors that closely 
resembled human breast adenocarcinomas. The tumors also showed metastatic 
capabilities, something almost unheard of in laboratory-grown cells. The new 
medium, Ince believes, could help standardize the way researchers cultivate so- 
called tumor stem cells, providing better cross-laboratory comparisons of results. 



illi^ VEIN GLORIOUS 

Investigating whether vitamin E protects against deep vein thrombosis, researchers 
at Brigham and Women's Hospital analyzed data from 39,876 participants in the 
Women's Health Study who, for a decade, had taken a placebo or 600 interna- 
tional units of vitamin E every other day. When control and vitamin E groups were 
compared, the hazard for developing deep vein clots was reduced 2 1 percent 
among women with thrombosis risk factors, such as hormone therapy, and 27 per- 
cent among women without risk factors. Robert Glynn, an HMS associate professor 
of medicine at the hospital, reported the findings in Circulation on September 1 1 . 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 









EARLY ADOPTER: ^ 
^ Hesy-Ra, one of the first 
known physicians qnd 
dentists, served the 
Egyptian ruler Djoser i 
during the third dyne 



fW 




{special report} 



The most recent phase in the 

evolution of the physician's role may 
prove to be the most problematic. 

hy William Ira Bennett 




Doctors 



■^< 



:he most basic of the ancient Egyptian 



D 



jiv^s for doctor, perhaps analogous to the 
creasingly quaint term "general practitioner." 
^ Transliterated swnw, and nowadays pronounced 
to rhyine with "who knew," the word is surely 4,000 years old and like- 
ly to be much older. Other ancient languages also had words that are 
more or less comfortably translated with "physician" or "doctor," as 
distinct from shaman, faith-healer, priest, or magician. 

We must pause, though, and ask ourselves why this is so. What real 
hnk is there between the nephrologist of today and the swnw, who 
apparently had no knowledge of kidney function? Not to mention the 
radiologist, the endocrinologist, and the hematologist, whose disci- 
phnes had no counterparts much before the twentieth century? Indeed, 
apart from some fundamental surgical procedures, relatively httle in the 
theory and practice of medicine hnks contemporary physicians with 




AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 17 




ow remarkable it is that the social role has been 
.value of that role have mutated so thoroughly. 




18 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 





the people who bore that title two hun- 
dred years ago. How remarkable it is that 
the social role has been so durable, when 
the knowledge, activity, and value of that 
role have mutated so thoroughly. 

The common thread that runs through 
perhaps five millennia of doctoring is 
materialism, in the narrow sense that ih' 
ness has been assumed to have a physical 
reality, which could be addressed 
through material interventions, as dis- 
tinct from spiritual or magical ones. The 
latter are not necessarily excluded, to be 
sure. The swnw had prayers and incanta- 
tions to use, but his — or sometimes 
her — assertion of competence was in the 
claim to knowledge of substances or 
anatomical interventions that would pro- 
vide rehef or cure. 

A striking feature of the swnw's materi- 
alism was its modesty. The surviving 
papyri make it clear that the Egyptian 
physicians recognized conditions, such as 
cancers, that they could not treat and 
which they acknowledged as beyond 
their competence. (Priests and miracle 
workers have not heeded such limitations 
but have laid careful groundwork for 
assigning the blame for failure elsewhere.) 

To say that doctors were by nature 
materiahsts is not to say they were scien- 
tific. Their interventions, whether ani- 
mal, vegetable, or mineral, were more 
often than not unfounded in a real grasp 
of physiology until about five hundred 
years ago. But beginning with the giants 
of the sixteenth century, medicine has 
made breathtaking advances in science 
and, therefore, in the theory of treatment. 

If that were the end of the story, we 
could say that the doctor's role has 
passed through two stages. The first was 
the long, long epoch of faith in material 
interventions, unconstrained by system- 
atic knowledge of disease and governed 
more by practice than theory. This epoch 
extends from before the oldest medical 
papyri to around the time of Mohere's 
last play. The Imaginary Invalid. The second 
stage was a relatively brief and explosive 



era in which medicine came to be 
grounded in experimental knowledge. 
Tradition gave way to scientific theory. 

This scientific transformation had a 
profound effect on the physician's role. 
How to become a doctor and how to 
function as a doctor in society were 
altered by the emergence of scientific 
medicine. But we would do well to 
remember that in the long history of doc- 
tors, this change took effect only about a 
century ago, a transition marked in the 
United States by the Flexner Report, 
which in 1910 transformed the country's 
approach to medical education. Increas- 
ingly from that time forward medical 
interventions would be based on a 
knowledge of physiology and pathology. 

But sound pathophysiological research 
and carefully developed theory did not 
always serve patients as well as medical 
scientists would claim. Radical mastec- 
tomy, for example, was considered a sci- 
entifically valid intervention for breast 
cancer until evidence accrued showing 
other approaches could be as effective. 
Thus, the emergence of statistical or, as 
we now call it, evidence-based medicine 
comes as a third phase in the evolution of 
the physician's role, and it may become the 
most problematic. Unlike scientific medi- 
cine, which supported the doctor's claim 
to singular competence and even a kind 
of intellectual heroism, evidence-based 
medicine has the potential to diminish — 
or even end? — the physician's social role. 
To the extent that evidence governs 
medical interventions, the function of 
the doctor becomes difficult to distin- 
guish from that of a technician, whose 
work is guided by protocols. 

Asking what doctors are for may 
sound naive, Kke asking what lunch is 
for. The answer is less obvious, however, 
than several millermia of medical history 
might lead us to beUeve. ■ 

William Ira Bennett '68, a psychiatrist in 
Cambridge, Massachusetts, is editor-in-chief of 
the Harvard Medical Alumni Bulletin. 



I 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



{what are doctors for?} 



' "' ^^..i^-'^ 




An increasingly sticky bureaucracy often paralyzes 
doctors as they struggle to preserve their healing role. 

hy Christopher Crenner 




MIENT, KATHRYN SCOTT, WAS IN A PERSISTENT VEGETATIVE STATE WHEN I FIRST 



:t her. she looked peaceful but also terribly sick as she lay on a gurney in 
,. ^ e clinic hallway and breathed through a tracheotomy tube. An inhision 
'hirred beside her, and the humidifier on the oxygen line murmured. Yet 
^lathryn remained silent. It was her daughter, Patricia Scott, who spoke on her behalf 
and who, not incidentally, was managing to keep her alive at home, with occasional 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 21 



nstead of worrying about machines, we struggle with a 
to overwhelm the humane intentions of medical care. 



urgent episodes. Patricia was neither intimidated nor 
hampered by the complex medical machinery that she 
wheeled alongside her mother's gurney. It was the hos- 
pital's faceless bureaucracy that caused her frustration. 

My impression of the Scotts would doubtless have 
been different 30 years earlier, when physicians and the 
pubhc first began to worry about a new and imposing 
threat to humane medical care. Technological advance- 
ments had once seemed poised to overwhelm the per- 
sonal side of medicine. The image of the suffering patient 
caught in a tangle of monitor wires, intravenous tubing, 
and beeping sensors captured deep anxieties about the 
way we treated the sick. During this era of fearful 
machines, physicians seemed to be losing their compas- 
sion in an overeager pursuit of technical control and sci- 
entific exactitude. 

Today we no longer hear as much about the threat of 
impersonal technology. Yet our current anxieties wear a 
surprisingly similar guise. Instead of worrying about 
machines, we struggle v^dth a tangled bureaucratic and 
institutional system that threatens to overwhelm the 
humane intentions of medical care. In the place of a cool- 
ly ht monitor screen and a grid of data lines, we see a 
maze of billing forms, survey parameters, and auditing 
criteria. Where once we blanched beneath the steely 
gaze of science, we now duck from the scrutiny of 
bureaucrats and adjusters. The medical system seems to 
offer less accommodation for individual differences and 
less time for nurturing a humane response to sickness. 

Why are our struggles with bureaucracy and rou- 
tinization so similar to our earher anxieties? Have we 
banished our older demon of technological dehuman- 
ization, or has it simply returned in new attire? Such 
concerns came to a crisis for me through the dilemma 
facing Kathryn Scott's family. It afforded me an insight 
into the problems of both machines and bureaucracies — 
and how we choose to use them. 

Who Runs the Machines? 



By the time I was assigned as Kathryris primary care 
physician, she had been shuffled between the emer- 
gency department and the hospital wards countless 
times, at the mercy of an ever-changing series of physi- 
cians. Kathryn, it turned out, was both profoundly ill 
and easily stabilized. The physicians who saw her were 
able to correct her recurrent infections and respiratory 
flare-ups. But once they glimpsed the fundamental 
futihty of her case, they were equally ready to consign 
her to the next stage of decline. 



From her daughter's perspective, this sporadic med- 
ical attention took a great deal of time and yielded ht- 
tle benefit. Patricia spent her days in waiting rooms, on 
hold on the phone and retelling her story to a growing 
List of social workers, nurses, and insurance case man- 
agers, with little to show for her efforts. 

It did not take me long — though longer than I care 
to admit — to recognize both the temptations of this 
brushfire approach and its essential vacuity. I also 
became aware of the substantial tensions that were 
growing between Patricia and the physicians assigned 
to her mother's care. In a busy hospitalist system with 
a large residency program, Kathryn tended to see dff- 
ferent doctors on each admission. And occasionally 
the doctors became irritated when Patricia accused 
them of giving up on her mother when they talked 
about vegetative states. 

These debates — and the staff members' whispers 
that the daughter was keeping her mother ahve just to 
collect disabihty payments — alarmed me. So I request- 
ed an ethics consult the next time Kathryn entered the 
hospital. I had hoped to interrupt the hastening spiral 
of mistrust. But I learned that mistrust wasn't the only 
source of tension. 

Bearing Witness 

My sense of the ethics in Kathryris case had been 
shaped by that earlier era of fearful machines. I went in 
hoping to discover what Kathryn would have wanted 
for herself with respect to her dependence on medical 
technology. I would place at the Scotts' disposal con- 
cepts and regulations that could help them wriggle free 
of the technology that threatened to ensnarl them. 
Informed consent and Uving wills would permit for- 
mal, organized expression of individual freedoms and 
integrity and protect Kathryn from overly aggressive 
medical treatment. 

During our meeting I raised ethical questions to the 
group. Were we inappropriately extending Kathryris 
suffering and robbing her of dignity through a forced 
dependency on technology? Patricia responded poUte- 
ly but emphasized that these issues were not high on 
her list of concerns. She knew her mother wanted care, 
she said, and she could provide that care by managing 
the catheter bags, enteral nutrition, and humidified 
oxygen. She just needed better cooperation from her 
mother's doctors. 

This ethics consultation solved ffttle; it merely illu- 
minated more sharply the existing conflicts. The case 



22 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



mF' 











^r 













ii^ 










manager continued to push for early discharge, the 
staff continued to lobby for placement in long-term 
care, and Patricia continued to insist that she knew 
best what her mother would want. 

But I found something in my own perspective shift- 
ing fundamentally. I realized that Patricia felt over- 
whelmed not by technology or daunting medical 
authority, which she managed quite well, but by the 
web of different doctors, state agency officials, social 
workers, claims adjudicators, and case managers. All 
she really needed was a doctor, one charged with mak- 
ing this conglomerate focus on the task of healing. 

Soon after our ethics meeting, I noticed that we 
were approaching the first anniversary of the nearly 
fatal asthma attack that had put Kathryn in her vege- 
tative state. So I called Patricia to talk about her mother. 
After that call, I took small steps to keep better track 
of Kathryn in the system, checking in with Patricia 



rather than waiting for her to penetrate the phone tree 
and the shared paging coverage. I wanted to see how 
Patricia managed to take care of someone in a persis- 
tent vegetative state at home, so I arranged to substi- 
tute a home visit in place of their difficult journey to 
the clinic. 

Patricia welcomed me into her home, where I saw 
she had devoted a portion of the tiny room that served 
as living room, dining room, and teenager's bedroom to 
her mother's hospital bed. Through the small galley 
kitchen I could also glimpse a staging area equipped 
with pumps, a gurney, and oxygen equipment. 

I had arrived just as there was work to be done, so 
I lent a hand. Patricia and I set to the tasks, rolling 
Kathryn up on to her sides so we could sponge her off, 
smoothing out the linens, realigning all the connec- 
tions, and patting down the covers. Our ministrations 
took but a few moments, but they seemed to contain all 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 23 



^m^ 



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24 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 




e should remain alert to the ways that complex medical 



of healing. But our problems increasingly lie elsewhere. 



the ageless routines of caregiving for people who 
have lived and died in the shelter of their homes, 
with doctors there to attend, witness, and certify. 

As we finished and stepped back from the gurney, 
the world resumed its customary pace. But the respon- 
sibilities associated with being Kathryn's doctor had 
taken on a weightier and less hurried feel. My partici- 
pation in the routine tasks of caretaking seemed to 
have changed Patricia as well. Perhaps she had begun 
to realize that her mother would indeed die. 

Patricia gradually decided against the imposition of 
frequent hospital admissions. We continued to treat 
her mother attentively within the possibilities of home 
care. I encouraged Patricia to talk to an excellent hos- 
pice nurse, and she eventually enrolled her mother in 
home hospice. 

Several months later, at three o'clock in the morning, 
the hospice nurse paged me; Kathryn had died. I 
exchanged a few words with the nurse and talked 
briefly with Patricia as well. Ordinarily I would have 
struggled to regain sleep after being paged in the small 
hours of the morning. But that night I slipped easUy 
into slumber. When I spoke to Patricia again later, she 
had begun making plans of her own, resuming the life 
that her mother's final illness had put on hold. 

With a Human Face 



I wonder whether we are all like Patricia these days. 
We should remain alert to the ways that complex med- 
ical technologies can distract from the humane quali- 
ties of healing. But our problems increasingly lie else- 
where. In some ways, we might trace our dilemma to a 
common set of developments. The advance of medical 
technology has altered both what doctors can do and 
what we are asked to do. 

One of the lessons from the history of medicine is 
that new technologies lead to new and growing 
demands. As medicine continues to achieve more in a 
technical sense, doctors are asked to do more. What are 
doctors for? Well, a lot these days and always more. And 
the ethics developed in the days of the fearful machines 
provide only weak solutions to the challenges of these 
growing demands. 

The infusion pump in Patricia's living room had 
looked httle different from the toaster on the kitchen 
counter, and Patricia likely managed both with equal 
aplomb. Who had suffered at the mercy of high-tech 
medicine? Kathryn had been in a persistent vegetative 



state; what could we have known of her suffering? 
Would she have wanted to have been free of machines, 
or would she have wanted to have given her deter- 
mined and capable daughter more time to care for her 
and to part from her gradually? How could the tra- 
cheostomy her daughter suctioned or the gastrostomy 
tube her daughter connected up each night have dis- 
turbed her? 

Kathryn had not been dependent on machines. She 
had endured a gentler dependency, spending her wan- 
ing days under the care of her strong, eldest child who 
had loved her so powerfully. 

Helping Hands 



The reorganization of medical services into market struc- 
tures and pohtical economies has left physicians with 
less time for the humane aspects of medicine. Yet the shift 
of complex medical technology out of hospitals can put 
machines securely into the hands of patients and their 
famihes. With technology increasingly run by the people 
we know, the age and the ethics of fearful machines may 
be passing. And, if we are fortunate, perhaps our bureau- 
cracies can be amenable to a similar taming. 

One hundred years ago medicine was a disjointed 
cottage industry, under the proprietorship of individual 
physicians. But now corporations and goverimients are 
calling physicians to account. Medicine has simply 
become too costly to escape diligent, bureaucratic over- 
sight, and those of us in medicine increasingly find our- 
selves asked to justify the valuable services we dehver. 

What remains to be discovered is how to give indi- 
vidual patients and families a stronger voice in the 
bureaucracy. Would it help if the control of bureaucratic 
decisions and regulatory agencies moved closer to the 
people who are directly responsible for care? Perhaps 
it's time for case managers and medical directors to 
make house calls. ■ 

Christopher Crenncr '93, PhD, is the Hudson-Major Chair of 
the Department of History and Philosophy of Medicine at the 
University of Kansas School of Medicine, where he is also an 
associate professor of medicine. 

The names and minor details of the patient and her daughter have 
been changed to protect confidentiality. A more detailed discus- 
sion of the Scotts' predicament can he found in Crenner's essay in 
Cho in the Clinic: History in Medical Practice, edited by 
Jacalyn Duffin (Oxford University Press, 2005). 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 25 



{what are doctors for?} 



► m 




Lttle more than a place to stop 
at on the trail to the Langtang 
Valley in northcentral Nepal. I had 
just arrived as the new village health 
v\^orker, and I wanted to make a good 
impression. I was still unpacking my 
gear when a Nepalese man sporting a 
brightly colored scarf walked into the 
clinic. Years of exposure to the sun at 
an elevation of 12,000 feet had turned 
his face leathery. He smiled, revealing 
a mouth full of rotted teeth, and then 
complained that his knee hurt. 

Drawing on my training as an 
emergency medical technician, I 
examined his knee. I then explained 
in my rudimentary Nepali that I 
couldn't find anything wrong. He 
seemed delighted with my assess- 
ment, and he invited me to dinner. I 
soon learned that he was the villag 
shaman, and he had come to chec 
me out. 

The shaman's — or ritual healer's— ^ 
approach to illness and heahng pro 
vides a stark contrast to the practio 
of science-based medicine and thu 
offers a valuable lens through whicl 
to view the medical profession 
Inspired by undergraduate classes in 
medical anthropology, which were 
filled with stories about sudden deaths 
induced by aboriginal bone-pointing 
rituals and remarkable cures, I set off 




What can traditional healers 
teach Western physicians? 

hy Timothy Ferris 



26 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



had arrived in Nepal with the bookish notion 
for an obviously organic illness. 




to observe the work of these healers in 
the hills of Nepal and the rice fields of 
Bali. At the time, I was trying to decide 
whether I wanted to become a doctor, 
and I was curious. Could traditional 
healers actually cure people in ways 
unknown to Western medicine? How 
did their patients view the care they 
received? How could watching them 
help me decide whether to become a 
physician? And what could an aspiring 
doctor learn? I wanted to see for myself. 

I had arrived in Nepal with the book- 
ish notion that people would choose 
traditional medicine for psychosocial 
problems and Western medicine for an 
obviously organic Ulness. Having few 
patients to attend to in the Nepalese 
clinic, I spent my days wandering the 
stepped fields of dahl with my inter- 
preter. I interviewed everyone we 
encountered. After inquiring about their 
health, I would ask which kind of doc- 
tor they would consult first for which 
kind of health problem. The responses I 
received convinced me that the role of 
traditional healers was both simpler 
and more complex than my original 
theory had posited. 

As the Spirit Moves 

One evening the shaman invited me to 
a ceremony at the home of a woman 
dying of breast cancer. A bonfire illu- 
minated the exterior of the one -room 
hut. The interior was lit as well, by sev- 
eral lanterns and a blazing kitchen fire. 
People crowded the dirt-floored, smoke- 
filled home; the patient lay on a bed in 
one corner. 

The shaman was sitting and talking 
in a low voice to the patient and her 
family, intermittently tapping on his 
drum. Without any announcement, the 
drumming became more regular and 
insistent. His hushed voice gained vol- 
ume; the ceremony had begun. In what 
I came to recognize as a classic perfor- 
mance of Himalayan spirit possession. 



he described an imaginary stroll 
through the countryside that the assem- 
bled friends and family members knew 
so well. He beat his drum harder and 
faster, circling the room and shouting. 
He was, I learned, calUng his guardian 
spirit. He ran in and out of the hut and, 
after seeing his spirit in the distance, 
ran to catch it. 

The spirit, speaking through the 
shaman, described an old conflict 
between the dying woman and her 
father. The spirit told us how he had 
found the patient's father walking along 
a trail and had convinced him to return 
the "spleen" he had taken from his 
daughter. With a burst of drumming, the 
shaman rubbed the patient's abdomen, 
shaking her shghtly so as to return the 
spleen to the dying woman. 

In that crowded room, I saw a range 
of reactions to the performance. The 
children up front looked spellbound, 
while some of the young adults in the 



rear snickered. Most of those assembled, 
however, watched quietly with a pen- 
sive gaze. As the gathering dispersed, the 
patient's family seemed genuinely grate- 
ful for the evening's events, lingering in 
conversations by the bonfire coals under 
the brilliant starlight and repeatedly 
thanking everyone for coming. 

Part of the difficulty many Western- 
ers have with understanding ritual heal- 
ing stems from the word we use to 
describe it. The EngUsh word "heal" 
comes from the ancient Germanic word 
hailjan. Hailjan means cicatrix, the closing 
of a wound, as well as "to make whole" 
and "to repair." Cultures all over the 
world, including our ovwi, use the same 
word to describe both cicatrix and the 
resolution of a problem. 

That people throughout history 
would make an analogy between the 
physiologic closing of a cut and the reso- 
lution of any one of hundreds of human 
maladies should not be surprising. But 




THE HUNT FOR RED SNAPPERS: Robert Yancey '82, the author's mentor while in 
Golphu Banjang, examines a sputum sample for tuberculosis bacilli. 



28 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



A HILL OF BEANS: 

The vie>v south from 

Golphu Banjang 

tov/ard Kathmandu 

sho>vs stepped fields 

of dahl, or lentils. 




we shouldn't allow our language to mis- 
lead us. The use of "heal" to describe 
what occurred tempts us to focus on 
physiologic effects, yet the ceremony 
showed that healing also addresses sev- 
eral non-physiologic problems. 

What happened that starry Nepalese 
night? The evening was partly theater — a 
storytelling marked by sound and hght- 
ing effects. Like any good performance it 
removed the audience from their routine 
and provided them with a shared experi- 
ence. The evening was partly a rehgious 
ceremony, with an officiant articulating a 
specific local understanding of the mys- 
teries of human life and suffering. The 
vocabulary describing the Nepalese world 
order had been passed down through 
many generations, but also had slowly 
been modified to account for the chang- 
ing circumstances. The evening was 
partly a social services intervention. 



giving family members a respite from 
their deathbed vigil, and partly therapy 
for a woman who was suffering through 
the final days of her life. These sociocul- 
tural aspects of the ceremony were a 
much bigger part of the night than any 
particular focus on the specific illness of 
the dying woman. 

Nonetheless, the budding clinician in 
me could not escape the question: 
What, if any, help did the event provide 
the patient? Of course we could point to 
neurohumoral mechanisms by which 
the events that evening may have been 
therapeutic. Some pathways — such as 
the consolation of being surrounded by 
friends and loved ones and the comfort 
that a distraction from pain provides — 
are not a stretch. 

Other, less well- characterized effects 
include the possibility that the inclusion 
of an unresolved conflict between the 



patient and her father helped reUeve a 
deep-seated source of anxiety. And 
maybe the subsequent neurohumoral 
effects did alter the course of her illness. 
I would not be surprised if that ceremo- 
ny even increased the number of days 
she remained alive. Nothing miraculous 
or magic, just a small change in the 
course of a devastating disease. 

Importantly none of these effects 
seemed to depend on a belief in the real- 
ity of the events. The Nepalese walking 
home that night expressed a range of 
opinions about the literalness of the 
healing. Each had a different interpreta- 
tion of the performance, and few I spoke 
with seemed to take the evening's events 
at face value. 

During those months in Golphu 
Banjang, I realized that the people 
who attended my clinic and those who 
instead sought out the shaman could 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



29 




FLOWER POWER: 

Balinese healer Ketut 

:» Liyer concludes a 

healing ritual by 

sprinkling holy water 

with a lotus blossom. 



30 



not be easily categorized. My hypothesis 
was not panning out. People are not ide- 
ologues when it comes to pain and suf- 
fering; they tend to accept help wherev- 
er it might lie. "Behef" did not play a big 
role in the health-care-seeking behavior 
of the Nepalese I met. 

Nor did the shaman see our roles as 
conflicting. Crowds sometimes formed 
around me as I set up the microscope on 
a bench outside the clinic to take advan- 
tage of the sunlight. Those gathered 
seemed to enjoy the performance — ^which 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



usually consisted of my staining sputum 
and then hunching over the microscope 
to look for bright red tuberculosis bacil- 
h — but I carit imagine it was as satisfying 
as an evening with the shaman. Yet no 
one doubted the power of the medica- 
tions I distributed whenever I saw the red 
snappers. While I could not perform the 
meaningful stories or ceremonies of the 
shaman, he could not provide a pill that 
returned a tubercular child from lethargy 
and wasting to energy and activity. We 
each had something to offer. 



From Nepal to Bali 

Traditional healing on Bali is more 
structured than in Nepal. The elaborate 
religious festivals of this Indonesian 
island have generated a rich culture of 
traditional healing. In contrast to the 
shamans of Nepal, the healers of Bah, 
called balians, take an approach that 
more resembles that of Western doc- 
tors. Balians apprentice for several 
years, study from texts written in an 
ancient Javanese script, and issue pre- 




he shaman and the bahan remind us 
when the prescription is written. 



scrip tions for amulets. Like Western 
physicians, they often see their patients 
one at a time, and they even have their 
ovvTi version of a Hippocratic oath. In 
contrast, though, the interventions they 
offer resemble Balinese religious rituals: 
offerings to ancestral spirits, chanting in 
secret languages, and blessings with 
sanctified water splattered over the 
head and shoulder with a lotus blossom. 

I spent three months with Ketut Liyer, 
a bahan hving in a small village south of 
the town of Ubud. Ketut had worked 
with several anthropologists and, fortu- 
nately for me, spoke Enghsh fairly weU. Li 
between patients we discussed his train- 
ing and work. A baharis income was unde- 
pendable so, like many Balinese, Ketut 
painted pictures that incorporated classi- 
cal Balinese images. Ketut's two occupa- 
tions intersected: He used drawings as a 
source of magic for his patients. 

The balian can be viewed as part of 
the evolution of healers. The increased 
reliance on textual learning, the orga- 
nized entry into a field, and a greater 
focus on individuals with specific 
problems are similar to the constructs 
of Western medicine. The baharis set of 
interventions, however, are drawn from 
rehgion, not science. 

Before I left Bali, Ketut insisted that I 
become one of his patients. He had 
noticed that I had a significant problem: 
I was 24 years old yet unmarried. Ketut 
thought he understood the dilemma. 
The Balinese consider clear skin to be 
an important physical characteristic, and 
he suspected my freckles were hinder- 
ing my efforts to secure a wife. 

To address my predicament, Ketut 
copied a drawing from one of his texts, 
and together we followed the pre- 
scribed steps to infuse the drawing 
with power. We knelt facing the vol- 
cano and chanted, and he blessed me 
with water by tapping my head and 
shoulder with a wet lotus blossom. 
When we finished, he told me he was 
confident I would soon find a wife if I 



stayed in Bali. But he wasn't sure how 
powerful his magic would be back in 
the United States. 

Healers by Any Name 

Some have called traditional healers 
social parasites, aUeging that they profit 
from the misery of their fellow humans. 
Others tout the miraculous benefits of 
traditional medicine. Each characteriza- 
tion is wrong-headed and unfortunate. I 
suspect some traditional healers are out 
to cheat people, but this doesn't explain 
the institution as a whole. Instead of con- 
spiracies, in Nepal and Bah I witnessed a 
true caring for the suffering of people and 
a genuine apprehension about the essen- 
tial perplexities of life and death. The 
Nepalese shaman wasn't pretending to be 
possessed by a spirit, and Ketut wasn't 
empowering magical paintings with an 
eye toward profits. I didn't witness any 
miracles in the mountains of Nepal or 
the rice fields of Bali — unless you con- 
sider our daily struggle with illness, suf- 
fering, and death to be a miracle. 

What can a Western physician schooled 
in pathophysiology and molecular biol- 
ogy learn from a shaman? While the 
actions of physicians may contain a bit of 
theater (do we really need to hsten to the 
lungs of a patient who has no respiratory 
complaint?), I have never considered 
bringing a drum into my exam room. 
And while much of what I say to my 
patients may be unintelhgible to them, it 
would be a stretch to call my diagnostic 
explanations incantations. 

The traditional healer is a solo practi- 
tioner with the sole responsibility of 
attending to the many needs of sick indi- 
viduals and the communities in which 
they live. As Western-trained physicians 
living in developed societies, we are con- 
tinuously adopting new technologies to 
meet the physiologic needs of our 
patients. The complexity of these ever- 
evolving technologies requires our full 
attention if we are going to bring their 



power to the aid of our patients without 
hurting them. How, then, do we tackle 
all our patients' other needs? 

The shaman and the balian remind 
us that the work of caring does not end 
when the prescription is written. To 
me, as a primary care doctor, this work 
means joining with nurses and other 
allied health workers, specialists, social 
workers, and members of the clergy to 
fulfill my patients' other needs, the 
needs I am not so skilled at answering. 
I don't need a drum, but I need to know 
someone who has one. The capacity to 
identify and mollify the various aspects 
of suffering is what distinguishes a 
physician from a technician. 

Wordsworth pointed out that "sci- 
ence is ... a prop to our infirmity." It 
seems to me he was partly right. We 
should not undervalue the importance of 
the technical components of curative 
therapy. Watching those tubercular 
Nepalese children grow stronger because 
of their daily pills convinced me that 
medicine was the right path for me. 

Yet we should not be trapped into 
thinking that the physician's realm is 
limited to the technical. Healing is both 
the closing of a wound and the resolu- 
tion of more global problems. As a tech- 
nician I could close a wound, but as a 
doctor I must take greater responsibili- 
ty. Western doctors are healers only to 
the extent that they address both aspects 
of healing. ■ 

Timothy Ferris '92 is an associate professor of 
medicine and an assistant professor of pediatrics 
at Harvard Medical School, medical director of 
the Massachusetts General Physicians Organi- 
zation, and a senior scientist at the Institute for 
Health Policy at Massachusetts General Hospi- 
tal. He still has the magical drawing that Ketut 
Liyer created to help him mask his freckles and 
thus end his bachelorhood. It seems to have 
worked: When Fcrris's wife first met him, she 
reported to a friend that he was a redhead. But 
when her friend asked whether he had freckles, 
she had to admit she hadn't noticed. 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



As stresses on the health care system 
TAT /^^ r^r^T^ grow, physicians are finding they dorit 
UN VJ"V^/v^_L/ have to face them alone. 




32 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



{what are doctors for?} 





.BER IT AS A TYPICALLY BUSY DAY, FILLED 

lie conventional tasks associated with 
^ :ing a major teaching hospital. Then, wit^ 
one conversation, the day became remarkablel 

Robert Master, a physician at Boston Unl 
versity, approached me with a proposition for 
a different model of care. Would I be intereslj| 
ed in hearing about it? 1- 

I was. So Master began describing a care 
model that tapped the talents of a range of 
health care providers for home-to-hospital 
dehvery of primary care to patients who ofte 
lacked access to such care: the elderly, dij 
abled, chronically ill, homebound, institutior 
alized, and poor. 

That day in 1977 was a little more than on 
decade into my tenure as chief executive off] 
cer of what was then Beth Israel Hospita 
Since I had started at the hospital, I had bee 
working with administrators and top depart 
ment chairs to strengthen the institution 
vision of equal care for all. As part of thi 
reshaping, we had phased out the ward systei 



)y MITCHELL T. RABKIN 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 




ne result of this evolving landscape has been 
clinicians in the delivery of health care. 



and had instituted the nation's first 
patients' bill of rights. So when Master 
finished outlining his plan of quality 
care for all, my response was immediate; 
"You guys are welcome here. This idea 
makes a lot of sense." 

That decision 30 years ago helped 
catalyze the Urban Medical Group, a non- 
profit private medical practice that con- 
tinues to deliver effective primary care to 
patients across the economic spectrum. 
The organization could be considered a 
prototype for what is now known as the 
medical home model. This model inte- 
grates care along the institutional con- 
tinuum, places the focus on the primary 
care physician and the treatment of the 
whole patient, and uses an approach that 
teams physicians with non-physician 
clinicians. It also is a model that just 
might be part of an evolution that will 
determine how physicians reinvent their 
practices for the twenty-first century. 

Face in a Crowd 



Some numbers can help give size and shape 
to this evolution. At the start of the twenti- 
eth century, one in three health care work- 
ers was a physician. By the 1980s, that ratio 
had fallen to one in sixteen, where it has 
remained through at least 2004. 

This trend has been associated vvdth 
several interacting variables. One has 
been the emergence of managed care, 
which enabled aspects of primary care to 
be shifted from physicians as a means of 
tempering costs and improving efficien- 
cy. But other changes — particularly the 
drift in the burden of illness from acute 
to chronic conditions and the aging of 
the population — have contributed as 
much, perhaps more, to this trend. These 
changes have also triggered health and 
social problems that physicians have 
been largely unprepared, or perhaps 
somewhat disinclined, to address. Physi- 
cian involvement in primary care has 
been further tempered as many pursued 
more specialized practices. 



One result of this evolving landscape 
has been the greater participation of 
non-physician clinicians — a group that 
includes nurses, nurse practitioners, 
physician assistants, midwives, social 
workers, physical therapists, medical 
assistants, and psychologists, among oth- 
ers — in the dehvery of health care. A 2003 
analysis of data gathered at multiple insti- 
tutions between 1987 and 1997, for exam- 
ple, showed that the proportion of 
patients who saw non-physician clinicians 
rose from 30.6 percent to 36.1 percent. 
This demand, the analysts found, spurred 
a doubling in the number of graduates 
from non-physician clinician programs 
during that decade. It also coincided with 
new state laws that expanded the scope 
of practice for these professionals. 

Built to Scale 



Among the non-physician roles that have 
burgeoned is nursing. The profession has 
embraced diversification, expanding 
from the long-farmhar hcensed, practical 
nurse and registered nurse to include 
those who pursue additional education 
to master any of a range of specialty 
disciplines. Advanced-practice nurses — 
such as nurse practitioners, clinical 
nurse specialists, and nurse midwives — 
are often considered primary health care 
practitioners and work in collaboration 
with physicians. In some areas of the 
nation, specially trained nurse practi- 
tioners have taken on new responsibih- 
ties previously restricted to physicians, 
such as writing prescriptions. 

One offshoot of this expansion of nurses' 
responsibilities has been the "big box" 
store clinic. The "MinuteClinic" of the 
CVS pharmacy chain and similar kiosk- 
clinics within Wal-Marts, Targets, and 
other large, national, discount retailers 
are most often staffed with nurse prac- 
titioners who deal with the more rou- 
tine health complaints of visiting 
patients. The clinics, which offer low 
costs and a limited menu of services — 



vaccinations, screening tests, and treat- 
ments for simple conditions — are grow- 
ing in popularity. A 2005 poll that was 
recently reported in the New England Jour- 
nal of Medicine showed that while only 
7 percent of those surveyed had already 
used such a clinic, 41 percent said they 
would likely use one in the future. These 
in-store centers are unlike the pharma- 
cies domiciled in supermarkets, which 
function no differently from the corner 
drugstore. Instead, they resemble some 
European pharmacies in which a person 
may present a complaint to the pharma- 
cist and receive the pharmacist's remedy. 

Most advanced-practice nurses work 
with private physicians or are affiliated 
with hospitals. A 2007 survey by the 
American Academy of Nurse Practition- 
ers of members and non-members found 
the largest practice setting was private 
physician practices (32 percent) and the 
largest specialties were family and adult 
medicine (51 and 20 percent, respective- 
ly), with pediatrics and women's health 
following closely. 

A 2004 study by the same organiza- 
tion found a notable level of autonomy in 
the day-to-day operation of these non- 
physician clinicians: 35 percent have 
physicians on-site less than 60 percent of 
the time and, among that group, 20 per- 
cent have physicians on-site less than 
10 percent of the time. 

Model Home 



For the medical home model, the skills 
and autonomy of the nurse practitioner — 
and those of another key non-physician 
clinician, the physician assistant — are 
exceptionally useful in building 
its team-based approach to care. At its 
most fundamental, the medical home 
model is a strongly patient-centric 
approach, one in which a care plan is 
crafted for each patient. These plans 
consider patients' cultural traditions, 
personal preferences, lifestyles, and 
family situations in concert with their 



34 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 





specific diagnoses and treatments. 
Emphasis is placed on involving the 
patient and the family in clinical deci- 
sions and on giving the patient respon- 
sibility for important aspects of the 
plan's monitoring and execution. Vital 
to the success of the model are the tools 
and support that the primary care team 
provides, such as access, education, 
communication, and coordination. The 
model also capitalizes on the growing 
capabilities offered by health informa- 
tion technology, including electronic 
health records, to help patients manage 
chronic conditions, schedule same-day 
medical appointments, and securely use 
email to communicate with team mem- 
bers about personal medical issues. 

Building and maintaining a relation- 
ship with the patient is critical to this 
approach and is the very area in which 
nurse practitioners and physician assis- 
tants often contribute the most. Nurse 
practitioners take medical histories, field 
call-in inquiries, teach patients and their 
families how to manage illnesses or 
injuries, and provide basic preventive 
health care both in the clinic and in the 
home. Nurse practitioners, as well as 
physician assistants, can make calls to 
patients in their homes to assess living 



conditions and help monitor treatments, 
rehabilitation, and recovery. 

Physician assistants, like nurse practi- 
tioners, can help with in-home care and, 
in the clinic, by taking medical histories 
and call-in inquiries, examining and 
treating patients, ordering and interpret- 
ing laboratory tests and x-rays, and mak- 
ing diagnoses. This range of responsibih- 
ties — and likely the opportunity to work 
closely with physicians in planning and 
administering care to patients — has 
helped make the physician assistant 
profession one of the fastest growing in 
health care. 

Recent data from a survey by the 
American Academy of Physician Assis- 
tants show that these professionals, a 
cohort that numbered more than 75,000 
in 2007, work in more than 60 specialty 
fields, with most finding positions in 
family medicine. Forty-four percent are 
employed in single- or multi-specialty 
physician group practices while 13 per- 
cent work in single-physician offices; 39 
percent report earning a master's degree 
in the field. 

The continued expansion of the 
responsibilities and use of these profes- 
sionals has spurred legislatures and 
other governance groups to codify fur- 



ther their roles. In July 2007, for instance, 
the state of Pennsylvania enacted a law 
allowing "...certified registered nurse 
practitioners, chnical nurse specialists, 
physician assistants, nurse midwives, 
and independent dental hygienist practi- 
tioners to take medical histories, perform 
physical or mental examinations, and 
provide acute illness or minor injury care 
or management of chronic illness in the 
same manner as physicians and dentists, 
so long as those activities fall within the 
specialty certification and scope of prac- 
tice." Studies of the effectiveness and the 
economic Implications of these expand- 
ed roles wHl be important. 

Patient Voice 



Ensuring a smooth transition to the 
hospital may rely on the skills of anoth- 
er non-physician specialist: the office 
nurse practitioner. This member of the 
health care team can serve as the link 
between the medical and human history 
the patient has accumulated over years 
of contact with the primary physician 
and the technocracy of the hospital 
caregivers. Through daUy visits to the 
hospitalized patient, the office nurse 
practitioner can help ensure the person- 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



35 




GRUDGING A NURSE 




A few years ago, I happened 
upon the book From Novice to 
Experf (Prentice Hall, 2001) 
by a professor of nursing at the Uni- 
versity of California, San Francisco. 
It opened my eyes. Its descriptions of 
today's nursing professionals and its 
evidence of their clinical and academ- 
ic accomplishments left me shaking 
my head in wonder — and despair. 
How, I thought, could Harvard Univer- 
sity, an institution that cultivates critical 
thinking and research in so many dis- 
ciplines, neglect nursing? 

Like medicine, clinical nursing has 
become more specialized, and nurs- 
ing research has become more far- 
reaching. Funding for peer-reviewed 
research in nursing, in fact, is highly 
competitive and has led to advance- 
ments in many areas, including pal- 
liative care, patient safety, and inte- 
grative medicine. The contributions 
to the discipline even have earned it 
an NIH address: the National Insti- 
tute of Nursing Research. Yet at 
Harvard, applications for nursing 
scholarship get returned to sender. 

A nursing school at Massachusetts 
GeneraltHospital opened in 1 873 — 
and closed in 1981 . Similar pro- 
grams existed at Beth Israel, Brigham 



and Women's, Children's, and New 
England Deaconess hospitals, yet 
each has closed. Another MGH pro- 
gram, carried out in conjunction with 
Radcliffe College, allowed nurses to 
earn both a bachelor's degree and 
an RN degree. That seed blossomed 
into the MGH Institute of Health 
Professions, which offers programs in 
clinical investigation, medical imag- 
ing, physical therapy, and speech- 
language pathology, as well as a 
master's degree program in nursing. 
Among many of the top medical 
schools and their related universities, 
nursing education and scholarship 
are considered vital components — 
Columbia, Duke, Johns Hopkins, 
Pennsylvania, and Yale, for example, 
all have nursing schools. For many 
of us at HMS, that list has a notable 
omission. If clinical and translational 
research in the academic medical 
center are important, if patient care 
is important, and if specialized medi- 
cine is important, then the need for 
greater nursing scholarship and a 
continuing supply of well-educated 
and well-trained nurses — Harvard- 
educated and -trained nurses — «S 
cannot be denied. * ' 

—Mifchell T. Rabkin '55 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 




ou dorit need to be board certified to notice that 
many throw rugs on the floors of her home. 



alization of the patient's care while also 
keeping a careful eye on the patient's 
progress and providing critical feed- 
back to the primary physician. 

A hospital counterpart to the office 
nurse practitioner is the primary nurse. 
Primary nursing, implemented hospital- 
wide for the first time at Beth Israel near- 
ly 30 years ago, developed as a response 
to deficiencies such as discontinuous 
care, complex charmels of communica- 
tion, and gaps in shared responsibihty. In 
practice, primary nursing involves the 
development of nursing care strategies 
that coordinate physicians' diagnoses 
and treatment details for patients with 
direct bedside care. Such plans allow pri- 
mary nurses to integrate a patient's care 
for a 24-hour period, to brief the physi- 
cian responsible for that patient's care, 
and to help develop a program for the 
next 24 hours. The method makes for 
continuity of care and, with strong colle- 
giality between nurse and physician, 
leads to more shared knowledge, better 
patient care, and greater satisfaction on 
the parts of patient, physician, and nurse. 

Growing empowerment of nurses in 
both office and hospital is indeed wel- 
come. A confounding problem, however, 
relates to payments for diagnostic and 
therapeutic actions performed by these 
and other non-physician clinicians. In the 
typical fee-for-service arrangement, 
insurers might reimburse only when such 
actions are carried out by physicians, not 
when performed by non-physician pro- 
fessionals. This can place the office-based 
physician in a difficult spot, torn between 
allocating nursing time to appropriate 
patient care and restricting nurses to facil- 
itating the processing of patients by the 
physician to meet volume requirements 
that can keep a practice in the black. 

Group Health 

In contrast with primary care col- 
leagues, team care of patients in major 
hospitals may include a greater variety 



of physician and non-physician special- 
ists, each attentive to one aspect of a 
patient's problem. A team caring for 
someone with malignant melanoma, 
for example, might include a dermatolo- 
gist, a dermatologic surgeon, an oncologic 
surgeon, a plastic surgeon, an oncolo- 
gist, and a pathologist as well as a spe- 
cialty-trained nurse and a social worker, 
all working to forge the most appropri- 
ate care for the patient. 

In-hospital coordination of these 
teams may often be the responsibility 
of the hospitalist. Modeled on inpa- 
tient speciahsts in Canada and Great 
Britain, these physicians focus on the 
general medical care of hospitalized 
patients and can have roles that range 
from clinical care and teaching to 
research and hospital administration. 

According to the Society of Hospital 
Medicine, the nation's hospitahst census 
has been increasing since the 1990s 
when the concept first established itseff 
in this country, growing from less than 
1,000 to nearly 13,000 by 2004. A 
2003-2004 survey by the American 
Hospital Association found hospitalist 
programs in 59 percent of teaching hos- 
pitals, 63 percent of acute care hospitals 
with more than 200 beds, and a growing 
number of rural hospitals that operate 
with 50 beds or fewer. 

A former Beth Israel coUeague of mine, 
Steven Weinberger '73, who, as a senior 
vice president at the American College of 
Physicians, keeps an eye on such trends, 
hsts some reasons the hospitahst model 
has grown in popularity. "It's hard for 
ambulatory physicians to straddle both 
the in-patient and the ambulatory envi- 
ronments," he says. "To do so, they must 
find time for patient rounds, inpatient 
management, their growing patient pop- 
ulations, and the mounting knowledge 
base for ambulatory medicine." 

The news on hospitalists is not 
altogether rosy, though. Together with 
residents and emergency medicine 
physicians, hospitahsts are being affect- 



ed by work-hour and shift restrictions 
that can increase the risk for the frag- 
mentation of care and communication. 

Work-Life Balance 



As we move further into the twenty- 
first century, it is likely the role of non- 
physician clinicians will mushroom, 
fueled both by physician specialization 
and — something I believe would be 
desirable — a resurgence of the primary 
care physician. If I were starting a prac- 
tice today, I'd set up something along 
the lines of the medical home model- 
join with a couple of doctors; bring on 
some nurse practitioners, nurses, and 
probably a home visitor or medical assis- 
tant; ensure everyone is well educated, 
trained, and effective as a team; and set 
about meeting the needs of each patient. 
The point is to deliver quality medical 
care. You don't need to be a board-certi- 
fied speciahst to notice that an elderly 
woman with osteoporosis has too many 
throw rugs on the floors of her home. 

I have watched Urban Medical 
implement this home-to-hospital model 
for three decades and have seen it 
achieve results: fewer and shorter hos- 
pitalizations and healthier and more 
independent patients. Other medical 
home groups around the country are 
having similar success, in some cases 
even improving the bottom line for the 
practice, potentially good news for the 
often financially beleaguered primary 
care physician. But this all remains a 
work in progress. Ultimately, the capac- 
ity for coordinated teamwork among a 
mix of professionals and the resulting 
quality and cost of care will define the 
success of this evolution. ■ 

Mitchell T. Rabkin '55 is a professor of medicine 
at HMS, chief executive officer emeritus at Beth 
Israel Hospital and CareGroup, and an institute 
scholar at the Carl J. Shapiro Institute for Edu- 
cation and Research at HMS and Beth Israel 
Deaconess Medical Center 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



{what are doctors for?} 



ECAUSE SHE IS THE PHYSICIAN ON DUTY FOR THE 

the emergency departments of the northeastern United 
States, Rashida Warren, MD, PhD, is sitting in an on-call 
unit in Boston's Allston district, minutes by water taxi from 
her home in a nearby 20'Story tower. She likes being on call, 
but her husband is miffed that she has agreed to work on 
New Year's Eve. Her sweetly pedantic reassurance that they 
can celebrate the true arrival of the century next year — on 
December 31, 2100 — has not mollified him. She is about to 
make a professional misjudgment, and she will come to 
wonder whether their little fight was what led to it. 

She is cocooned in a room banked v^th computer displays 
that include antiquated plasma screens and a dilapidated 
holograph for virtual assessment of problem patients. 
Although the physical attendance of a doctor in any health 
care setting has become largely obsolete, decades- old feder- 
al legislation has mandated that an insurer- certified physi- 
cian be "remotely present" to provide real-time monitoring 
of clinical care. 

For the 12 hours she is on call, Rashida is isolated from 
both her personal life and the world outside the several 
hundred emergency facihties she oversees. She is subject to 




38 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



'%i^ 




ggg 



The strictures in this futuristic fable lead one doctor to a 
decision at odds ^vith her time, hy William Ira Bennett 



n the emergency departments of Rashida's | 
physician is unusual — and rarely reimbursed, i 



monitoring by the Joint Commission, 
either electronically or through unsched- 
uled site visits by agents who seek to ver- 
ify that she is present and alert, in the 
event that a protocol failure should 
require her direct intervention. 

Unidentified Object 

Like nearly all the few thousand fuUy 
trained physicians in the United States, 
Rashida spends most of her time review- 
ing and refining the computer algorithms 
that set standards of care and allocate 
resources. For her, being on call is a pleas- 
ant break from data analysis. She enjoys 
this sohtary clinical time. It is an oppor- 
tunity to carry on a medical tradition, 
and Rashida especially relishes the rare 
occasions in which she is called upon to 
intervene in individualized decisions. 

In this she is unlike many of her fel- 
low physicians, who grudgingly take 
a turn away from their laboratories or 
economic analysis centers to deliver this 
vestige of direct clinical care. They resent 
the intrusions of "wacko JCAHO" and 
the tedium of waiting for the infre- 
quent occasions when a multimodal 
alarm indicates that an algorithm gov- 
erning patient care has moved to the 
limit of its competence. They are 
uncomfortable when required to 
become arbiters of remote medical 
dilemmas. And they pay as little atten- 
tion as possible to the tedious wob- 
bling of indicators that reflect how 
closely each patient's care matches his 
or her clinical characteristics. 

More than many on- call physicians, 
Rashida devotes a good deal of screen- 
side time to the readouts of problematic 
patients. She does not depend solely on 
the alarms the triage algorithms gener- 
ate. Nor does she rely on the LED arrays 
that identify whether patients are emer- 
gent, urgent, expectant, or stable — 



40 HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



terms that have long since been replaced 
by alphanumeric codes. 

The pulsing diodes alert her to clini- 
cal situations that are approaching one 
of the boundaries of probabOity or poh- 
cy, beyond which the algorithms either 
do not function or, under prevaOing reg- 
ulations, are not allowed to set the 
course of clinical care. She will be noti- 
fied immediately, for example, if a child 
with one of the congressionally protect- 
ed cancers enters an emergency depart- 
ment. Clinical management of certain 
diseases — ones with effective lobbies 
supporting them — must follow care 
guidelines outside the standard system 
of prior authorization. 

Virtually everyone who enters any 
type of medical facility has a Halamka 
Identity Device implanted subcuta- 
neously. The HID immediately triggers 
the facility's computers to gather the 
patient's medical history, legal status, 
and insurance coverage from national 
databanks. By law, none of the informa- 
tion can be connected to data external 
to health care, such as a name or pass- 
port number, but Rashida doubts these 
protections will resist growing politi- 
cal pressure to make the codes avail- 
able to law enforcement and immigra- 
tion authorities. 

Rashida is so curious about the 
patients she monitors and so attentive to 
their data patterns that she recognizes 
many returning patients; she even 
invents names for them. (Later she will 
speculate that had she read fewer nov- 
els and spent less time imagining the 
hves of her patients, she would not have 
made her mistake.) 

Descended as she is from generations of 
physicians in New England and the Pun- 
jab, Rashida Warren feels driven to honor 
the medical tradition of patient contact — 
even though the "contact" is virtual. 
When an alarm does pulse, Rashida takes 



pleasure in making a voice connection 
with hospital technicians. She enjoys the 
intensity that comes when she must make 
decisions that are normally governed by 
the Cochrane Control System. The heart 
of the CCS is an enormous and complex 
program for integrating data from clinical 
trials with cost-benefit information from 
the Insurance Industry Registry of Risk, 
or IIRR, a privatized database designed 
to provide a measure of distributive equi- 
ty in health care while maintaining a 
profit margin for the consortium of 
insurers that replaced Medicare. 

Over time, the CCS has evolved into a 
program that allows for the cost-con- 
tained dehvery of evidence-based health 
care. Highly specialized and exquisitely 
skilled medical technicians are trained in 
courses derived from the now obsolete 
medical curriculum of the previous cen- 
tury. Guided by the CCS, they perform 
all the bedside and hands-on ministra- 
tions that were once carried out by 
physicians. In the emergency depart- 
ments of Rashida's catchment area, the 
physical presence of a physician is 
unusual^and rarely reimbursed. 

Human Error 



As Rashida scans the monitors around 
her, one profile gives her pause. This male 
has been highlighted for a while because 
he is frequently admitted to the same 
emergency department. Tonight he car- 
ries two high-risk, high-cost icons, one to 
indicate that his probabihty of leaving the 
emergency department ahve has dropped 
to around 15 percent, the other that he has 
reached the upper ratio of expenditure to 
prognosis, the E/P ratio, a formula devel- 
oped by the IIRR. Rashida notices that 
on the Glasgow/Appelbaum/Bursztajn 
assessment of Cognition, Capacity, and 
Judgment this patient is deemed to be 
fully aware and able to assess his own 




medical choices — ^within the authoriza- 
tion boundaries. 

Rashida knows the person behind the 
avatar, Koji Hemings. When in medical 
school together they had made a brief, 
tender, and sad attempt at a love affair. 
The first clue to his identity is his date of 
birth, two years to the day before hers. 
The second is his particular combination 
of diagnoses — bipolar disorder, HIV, and 
sickle- cell anemia. The third is the hospi- 
tal providing his care; classmates have 
told her that Koji receives treatment 
there. It also happens to be the hospital 
where she did her residency in statistical 
modeling of fluctuations in the regional 
need for emergency services. 

After a century and a half of research, 
Koji's diseases remain incurable, and the 
damage they inflict is at varying rates 
progressive. Now, following some years 



of stabihty, he is rapidly losing ground on 
two fronts. Chemotherapy has reduced, 
but not eliminated, the repeated infec- 
tions and sickling crises that have cor- 
roded his body, and his once agile mind 
has been sabotaged by a mood disorder 
he has been too proud to acknowledge. 
Recently, however, a prescribing psy- 
chologist has managed to engage Koji in 
therapy and place him on a mood-stabi- 
lization protocol. Rashida knows all this 
only through common friends. She also 
knows that Koji has married, and she is 
curious about the man who would com- 
mit himself to someone so ill. 

She pauses to consider Koji's E/P ratio. 
She knows that a technician, a social 
worker, and an ethicist will soon be pre- 
senting the situation to Koji and his hus- 
band. Using the Aetna QOL model as a 
basis, they will outline the limitations of 



further treatment and the probable tra- 
jectory for his dechning quahty of life. 
The technician will present the numbers. 
The ethicist will use coded — but chill- 
ingly familiar — language to impart the 
idea that the expense of any care to 
extend Koji's life would divert resources 
from others with better prognoses. No 
one wiU miss the point. The social work- 
er will linger afterward to help the cou- 
ple deal with their inevitably delayed 
reaction to this austere conversation. 

Nothing on the screen calls for Rashi- 
da's intervention. Everything that is hap- 
pening or that is scheduled to happen is 
falling well within the limits of the pro- 
tocol. The data and the models are not 
strained. The icons denote an acute case 
but not a problematic one. 

Rashida's obligation here is to do 
nothing. She knows if she intervenes and 
the Board of Registration in Medicine 
learns of her action, she will risk disci- 
pline and possibly her hcense. Indeed, 
the only intervention available to her 
requires deception. She knows the E/P 
model well, and she knows the code inti- 
mately, as part of her postdoctoral fel- 
lowship was devoted to debugging it. She 
also knows how to hack into the hospi- 
tal's computer system. It would not be 
difficult for her to shift Kojis E/P ratio 
and abort the conversation scheduled for 
the next hour or so. 

She realizes what she is considering 
has no support from her training or the 
current canon of medical ethics. She wiU 
be personalizing the care of someone 
who has received fuU algorithmic consid- 
eration. As she opens a new screen and 
begins to enter a series of security codes, 
tears fiU her eyes. ■ 

William Ira Bennett '68, a psychiatrist with a 
private practice in Cambridge, Massachusetts, 
is editor-in-chief of the Harvard Medical 
Alumni Bulletin. 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 




HMS alumni are making their mark as leaders of the 



-^DEAN 

counter 



It may not be easy being dean, but the nine hms aiumm 

who currently serve as such at medical schools across the United States do 
see the position as a privilege, a joy, and a challenge. 

At a time when medical education is being revamped to meet the needs 
of twenty- first century health care — and medical schools are under pressure 
to educate new physicians to fill rapidly thinning ranks — the School's alum- 
ni are accepting a degree of leadership well out of proportion to their num- 
ber. HMS graduates about 1 percent of the country's 16,000 medical students 
each year, yet approximately 7 percent of the nation's medical schools are 
led by Harvard-trained physicians. And, according to a recent roster from 
the Association of American Medical Colleges, HMS women are more than 
holding their own among that number: four of sixteen female deans are 
alumnae of the School. 

Several possible explanations likely exist for why so many HMS alumni 
find their way into these leadership positions. But one, posited by Carmen 
Puliafito 11, a member of this group, may simply be that this sort of 
responsibility is part of the culture — and the philosophy — of Harvard 
Medical School. 

"HMS is a place that values leadership in academic medicine," he says, 
"and, directly or indirectly, the School encourages that in its graduates." 





AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



43 



Carmen Puliafito 



Dean: Keck School of Medicine of the University of Southern California 
Appointment: November 2007 
Medical Specialty: Ophthalmology 




T 



HE COAST-TO-COAST ADDRESS 

swap will undoubtedly bring 
challenges, expected and not 
so expected. But the fun- 
damental challenge facing 
Carmen Puhafito '77 is one he is familiar — 
and comfortable — ^with; energizing and 
expanding a medical enterprise. Puliafito 
has moved from Miami's Bascom Palmer 
Eye Institute to take the top spot at the 
Keck School of Medicine of the Universi- 
ty of Southern California. To Puhafito, 
enhancing the stature of the Keck School 
is key to USC's future and, perhaps, even 
to the future of medicine. 

"All the ingredients are well posi- 
tioned at Keck: sohd philanthropic sup- 
port, a great research infrastructure, and 
lots of research space," Puhafito says. 
"My contribution, as I see it, is to bring a 
sense of leadership and direction. That 
involves promoting and identifying new 
leaders in medicine both at the school 
and outside the school." 

Puhafito also beheves that contribu- 
tion includes making sure that the edu- 
cation of the school's students combines 
the rigor and substance of traditional 



programs with the coUegiahty and "user 
friendliness" crucial to building tomor- 
row's physicians. "The forces driving 
medical education have changed," he 
says. "Students have a higher level of 
expectation about what the educational 
experience should be hke." 

"Today there is an emphasis on team- 
work and on creating a stimulating 
educational environment that lets stu- 
dents know they are valued," he adds, 
"one in which the students realize the 
school actually cares about what they 
think, worries about them, and is avail- 
able to help them." To this, Puhafito adds 
a layer of personal duty: "The dean's 
job— my responsibihty — also includes 
ensuring the students' safety, health, 
and happiness." 

A clinician, scientist, administrator, 
and inventor — he led the HMS team that 
developed optical coherence tomogra- 
phy, a technology used by eye doctors 
worldwide to diagnose retinal prob- 
lems — Puhafito may also be the first 
graduate of Pennsylvania's Wharton 
School to head up a medical school. This 
combination may, Puliafito believes, 
determine the shape of deans to come. 

"The nature of the medical enterprise 
is such that you want physicians running 
it," he says. "To do that, physicians need 
to understand the world of business." 



■( 



"We look for 
students," says 
Valerie Montgomery 
Rice, "who want 
their interests in 
research and clinical 
practice to reach 
from bench to bed- 
side to community" 



44 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 




Nancy Andrews 

Dean: Duke University School of Medicine 

Appointment: October 2007 

Medical Specialty: Pediatric Hematology/Oncology 



It's one thing to expect challenges as one moves from 
a position as dean for basic sciences and graduate 
studies at Harvard Medical School to one as dean of 
the Duke University School of Medicine. But to expect 
joy is quite another thing. 
"One of the joys for me throughout my tenure at HMS was 
watching students, residents, junior faculty, and even senior 
faculty, learn and grow and succeed," says Nancy Andrews 
'87. "I get great pleasure from knowing this will remain true 
for me as I go forward." 

That step forward has made a little history. Andrews has 
become the first woman to serve as dean of one of the 
nation's top ten medical schools for research. 

Andrews filled many roles at HMS — as a physician at Chil- 
dren's Hospital and Dana-Farber Cancer Institute, as a pedi- 
atric oncologist studying red blood cell disorders, as the lead 
administrator for research in the School's preclinical sciences 
departments, and as director of the School's MD-PhD Pro- 
gram — and so is well aware of the demands that can face 
medical students. 

"One of the biggest challenges to producing tomorrow's 
doctors," says Andrews, "is the amount of information that 
needs to be conveyed in a short time. Doctors today have far 
more pulls on their time because of the demands of a chang- 
ing health care system. For faculty, such demands take away 
from their efforts to teach. And how do you turn out people- 
oriented, compassionate doctors when the teachers have little 
time to teach or practice that themselves?" 




Valerie Montgomery Rice 

Dean: Mehcrry Medical College School of Medicine 

Appointment: March 2006 

Medical Specialty: Obstetrics/Gynecology 



MY TIME AT HARVARD V/AS 
great," says Valerie 
Montgomery Rice '87. 
"The wonderful men- 
toring during my 
high-school and undergraduate years 
solidified when I come to Harvard. My 
mentors there showed me how to accom- 
plish what I wanted to accomplish and 
gave me the security I needed to follow 
through on my decisions. That experi- 
ence taught me that anyone can be 



successful with the right nurturing, the 
right skills, and the right environment. 
This lesson is something I definitely put 
into practice at Meharry." 

Since being promoted to dean of the 
Meharry Medical College School of 
Medicine, Montgomery Rice has set about 
strengthening the Nashville institution's 
commitment to researching health care dis- 
parities and to serving the medically 
underserved. As a physician-scientist who 
specializes in reproductive endocrinology. 



she has enhanced the college's clinical 
research initiatives and re-established its 
residency program in obstetrics and gyne- 
cology. Under her leadership, the college 
also has been critically examining what 
type of student flourishes there. 

"One of the things we've made a 
commitment to at Meharry is to accept 
students who are diverse — not just racial- 
ly or ethnically, but also academically 
diverse," Montgomery Rice says. "We 
are very successful with students some 
would consider risky. We consider them 
diamonds in the rough." 

The jewels that Meharry mines tend to 
give bock: Nearly 70 percent of its grodu- 
ates do some service in underserved commu- 
nities. "We look for students," Montgomery 
Rice says, "who want their interests in 
research and clinical practice to reach 
from bench to bedside to community." 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



45 



Michael Rosenblatt 

Dean: Tufts University School of Medicine 
Appointment: November 2003 
Medical Specialty: Endocrinology 



IF A DEAN WANTS TO FUEL CONVERSATION 
with students, one way might be to 
take a well-tested and heartwarming 
concept and give it a contemporary 
twist. With a tip of the hat to Franklin 
Roosevelt, Michael Rosenblatt '73 has 
done just that: He holds fireside chats with 
each class at the Tufts University School of 
Medicine. The informal conversations allow 
him to get to know the students and to learn 
how things are going. The twist? Video fire. 
"We don't have an old building with a 
fireplace," says Rosenblatt, "so we wheel 
out a video console and play a 45-minute 
loop of a fireplace complete with a flick- 
ering fire. The tape actually begins with 
crackling sounds and, if you are alert 
enough to catch it, one log even shifts." 
That eye for detail has been useful to 
Rosenblatt in his career as head of Beth 
Israel Deaconess Medical Center; leader 
of the research team that developed the 
osteoporosis drug Fosamax; a founder of 
HMS-Beth Israel's Carl J. Shapiro Institute 
for Education and Research; a leader of 



the Harvard-MIT Health Sci- 
ences and Technology program; 
and a sabbatical researcher at 
the Whitehead Institute for Bio- 
medical Research. 

"I went from working with a 
giant Lego set to just thinking 
about a little mouse and the 
research I was doing on it," 
Rosenblatt says of his career 
arc. "So when I got a call from 
Tufts asking whether I'd be inter- 
ested in being dean and having 
responsibility for research, edu- 
cation, and a clinical enterprise, 
I was ready: ready to give back 
and ready to get involved in 
medical education." 

Rosenblatt's interactions with 
students include an open-door 
policy: "I tell everybody that if 
my door is open, you can stick your head 
in and tell me what's on your mind." This 
wide access jibes with what he believes is 
fundamental to the profession. "'Doctor' 




means 'teacher,'" he says, "so teaching is 
just hard-wired into what we doctors do. 
We train the members of the next genera- 
tion and then we pass them the baton." 




Deborah German 

Dean: University of Central Florida College of Medicine 

Appointment: January 2007 

Medical Specialties: Internal Medicine and Rheumatology 



SEVERAL HAD ENTERTAINED THE 
idea, some had even applied for 
the opportunity. Yet many, 
despite knowing they were 
finalists, had turned away, 
saying it couldn't be done. But when 
Deborah German 76 was asked whether 
she felt up to the task, all she could say 
was, "I'm more afraid of not trying to do 
this than I am of failing." And with that, 
she got her chance to build a medical 
school from scratch. 

Less than a year into her appointment 
as dean of the College of Medicine at the 
University of Central Florida, German is 
busy hiring faculty and staff, developing 



the curriculum, and preparing for the 
school's accreditation while also keeping 
an eye on contractors who are layering 
floors on the school's research building 
and architects who are designing the 
academics building. 

The school is scheduled to open in 
2009 on a 50-acre campus within the 
Lake Nona section of Orlando, which 
will also host a science and technology 
center. The Lake Nona development ■wdll 
be home to a new Veterans Administra' 
tion hospital, too, and to the East Coast 
branch of the Burnham Institute for 
Medical Research, a scientific enter- 
prise based in La JoUa, California. 



Paul G. Ramsey 



Dean: University of Washington School of Medicine 

Appointment: June 1 997 

Medical Specialties: Internal Medicine and Infectious Diseases 



BEING RESPONSIBLE FOR A FIVE'CAMPUS MEDICAL SCHOOL 
that serves approximately 5,000 students and 
trainees and supports the work of more than 6,000 
chnical and research facult)' in an array of hospi- 
tals, clinics, and biomedical research programs 
is no small feat. But it's something else entirely when each 
of those campuses is located in a different state — and one of 
those states is geographically separated from the other four 
by Canada. Yet for more than a decade, Paul G. Ramsey 75 has 
led the University of Washington School of Medicine, trax'el- 
ing regularly from the Seattle campus to the school's sites in 
Alaska, Idaho, Montana, and Wyoming. 

Many might consider the responsibility daunting. Ramsey, 
howe^'er, considers it a pleasure and a pri\Tlege. 

"I have wonderful colleagues who are world leaders in edu- 
cation, research, and clinical serxice," he says. "In 2006 alone 
the faculty garnered nearly $800 miUion in research funding." 
Ramsey and his colleagues also have been making curricu- 
lar strides; their comprehensi^'e analysis of the school's cur- 
riculum precipitated a renewed focus on core clinical skills 
and professionahsm. 

"We established a college system within the school of 
medicine," says Ramsey, "with each college haxlng a dedicat- 
ed faculty whose members are responsible for teaching 
professionahsm and clinical sldlls and for serving as mentors 
to students across all four years of medical school." The 
restructuring has been in effect for five years — one full cycle 
of medical students — and, thus far, is getting sohd re\dews. 




Despite the sparkling newness of the 
institution, German recognizes the role 
of tradition — and hopes to estabhsh one 
herself. "We would call it 'The Good Doc- 
tor: A Uni\'ersity of Central Florida tradi- 
tion,' " she says. "I would ask students to 
imagine that the person they lo\'e most is 
ill and ha^'e them describe the qualities 
they would hope to find in the physician 
who cared for that person. Then I would 
make a contract with them and work to 
help them become that doctor." 

German finds it difficult to condense 
her character in a few words. Yet when 
she describes how she does what she 
does, her answer is clear. "I truly enjoy 
working with wonderful people toward a 
meaningful goal. For me, part of ha\ing 
fun is doing something that's hard and 
doing it well. No one wants to do this 
kind of work unless they have an adven- 
turesome, pioneering spirit — and are a 
httle bit of a risk-taker. That combina- 
tion makes for great fun." 



When Deborah German 
was asked whether she felt 
up to building a medical 
school from scratch, all she 
could say was, "I'm more 
afraid of not trying to do 
this than I am of failing." 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



47 



Eve Higginbotham 

Dean: Morehouse School of Medicine 
Appointment: April 2004 
Medical Specialty: Ophthalmology 





THE PLACE LEAVES HER BKEATH- 
less. And that's saying a lot, 
since Eve Higginbotham 79 
has been part of some rather 
remarkable organizations. 
But the students and the faculty of 
Atlanta's Morehouse School of Medicine, 
Higginbotham says, take her breath away. 
"This is a people-oriented, humanity- 
centered organization," she says. "Our 
faculty are committed to the institution, 
many have been here more than 20 years, 
and our students are research-driven, 
community-focused — and accomphshed. 
Take, for example, the fact that 100 per- 
cent of the students In our current third- 
year class passed step one of the boards. 
Now, I remember step one of the boards 
when I was going through medical 
school, and I carit say that every person in 
our class passed. Yet at Morehouse, this is 
the second class we've had do that." 

Higginbotham arrived at Morehouse 
with an aim of preser\ang the humanism 
in medicine and has found the school to 
be fertile ground. The institution's com- 
munity focus, Higginbotham believes, 
fosters a spirit of humanism, a tradition 



of producing physicians who "keep the 
patient's interest in mind every step of 
the way." Also on her to-do hst; drive the 
school's research agenda. The organiza- 
tion's intellectual and cultural assets 
have eased that task, too. 

Morehouse recently garnered a 
National Center for Research Resources 
Clinical and Translational Science 
Award. Presented to a consortium of 
organizations that includes Morehouse, 
Emory University, and the Georgia 
Institute of Technology, the grant gives 
Morehouse responsibility for the health 
care disparities, training, and outreach 
aspects of the award. "We'll be the 
translators of the basic science discov- 
eries developed with the grant," Higgin- 
botham says. 

Her appointment marks another mile- 
stone for the institution: She is the first 
woman to be named dean on a perma- 
nent basis. This fact carries an interesting 
note, for the medical school is an inde- 
pendent entity of the all- male Morehouse 
College, a historically black institution 
founded shortly after the Ci\al War. 

"I imagine if you talked to every dean, 
each would have the same level of enthusi- 
asm about his or her school," says Higgin- 
botham. "But I'm particularly enthusiastic 
about this school. There are just so many 
wonderful treasures here." 



o< 

Ox 



"When 'Uncle 
Albert' gave his 
imprimatur to 
the school, we 
also embraced his 
humanitarism, 
compassion, and 
commitment to sci- 
entific excellence." 



48 




David Stern 



Dean: University of Cincinnati College of Medicine 
Appointment: August 2005 
Medical Specialty: Internal Medicine 



AS A YOUNGSTER, DAVID STERN '78 LEARNED TO COAX 
beautiful music from a rented metal clarinet that 
had survived a run-in v^ith a school bus. Imagine, 
then, v/hat the grown-up Stern, the physician, vas- 
cular pathobiologist, and musician, might pro- 
duce from the v/ell-tuned — and decidedly undamaged — Univer- 
sity of Cincinnati College of Medicine. 

Stern is organizing his school around centers of excellence 
in such areas as neuroscience, cardiovascular disease, can- 
cer, and metabolic disorders. The selection is not random: 
These are the major causes of morbidity and mortality in the 
Cincinnati region as well as in the United States. 

"I'm working to make this medical center very much a part 
of the fabric of Cincinnati," Stern says, "so the community will 
take ownership of it. We're focusing our resources in key areas 
that are important to the community we serve." 

The centers allow a blending of clinical and research 
expertise that Stern believes seamlessly embraces the college's 
educational mission. "I like to think that the way we do 
research and the way we see patients follows on integrated 
approach," he says. "We look at a clinical problem the way 
the patients see it. And the way the students want to see it, as 
a way to care for the whole patient." 

The Cincinnati appointment also seems to be allowing Stern 
to take care of the whole Stern. After a 30-year hiatus, he is 
again playing the clarinet: The musician who first played tunes 
in a marching band in Great Neck, New York, now makes 
music with friends in his university's music conservatory. 




Allen Spiegel 



Dean: Albert Einstein College of Medicine of Yeshivo University 
Appointment: June 2006 
Medical Specialty: Endocrinology 



ALLEN SPIEGEL '71 SPENT HIS FIRST 
four months as dean of the 
Albert Einstein College of 
Medicine of Yeshiva University 
on the 25th floor of a student 
high rise. It was a living — and learning — sit- 
uation that proved convenient as he made the 
transition from Bethesda, Maryland, to The 
Bronx. It also was an experience that allowed 
him to sketch a picture of Einstein students, 
one that time has shown to be accurate. 
"This is an academic medical center 
with a strong social mission," he says, 



"and the students gravitate here because 
of that identity." The school also offers an 
MD-PhD program, a blend, Spiegel says, 
of social mission and research that reflects 
inherited values. "When Uncle Albert, as 
he's affectionately called around here, 
gave his imprimatur to the school, we also 
embraced his humanitarianism and com- 
passion, coupled with a commitment to 
sustaining the area's scientific excellence." 

Spiegel's ability to manage both 
aspects of this mission grew from his 
own career, first as a clinical endocrinol- 



ogist and researcher, then as director of 
the intramural program at the National 
Institute of Diabetes and Digestive and 
Kidney Diseases, and finally as that insti- 
tute's director. This arc also inscribed the 
evolution of a personal view. 

"When I was at HMS, I interviewed for 
an internship at Massachusetts General 
Hospital. During that interview, Dan Feder- 
man ['53] asked me whether I saw myself 
becoming a chair of medicine one day. 
I was brash and insensitive and replied, 
'No! Why? That would be a waste of 
time!' I wanted to be a physician-scientist 
and had no intention of becoming involved 
in what I assumed were dry administrative 
matters. But since then, I have discovered 
how satisfying it con be to help others flour- 
ish OS researchers. And I relish the opportu- 
nity to engage with medical students." ■ 



Ann Marie Menting is associafe editor of 
the Harvard Medical Alumni Bulletin. 



49 



.^' 



rP 



m. \ 



^^^^ 



A CANCER 



NOSIS S 



SICIAN TO CONSIDER HER 






So this is how I die. 

These words ran through my mind as I lay in the 
emergency department of the Cleveland Clinic on 
Valentine's Day, 1999. Only a few hours earlier, my 
lusband, Fred, and I had been sitting in bed watching 
the Oscar De La Hoya fight. At some point I passec. 
out, only to awaken with paramedics standing by our 
3ed. I soon found myself strapped to a narrow gurney 
in an ambulance with flashing lights, hurtling along 
dark, deserted streets into midtown Clevelanc. 



LIVING TIMH^THER than HER DYING TIME, by Bernadine Healy 




AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN I 51 




Y BRIEF REVERIE WAS INTERRUPTED WHEN 
HOMEWORK— A LITERARY PASSAGE I WAS 



Patrick Sweeney, the attending neurol- 
ogist that evening, met us in the emer- 
gency department, ready to perform the 
usual neurological tests for what my hus- 
band believed had been a seizure. At the 
time, Fred, a renowned cardiac surgeon, 
was director of the Cleveland Chnic, but 
he was pure husband that night. He hs- 
tened attentively to Sweeney and acted as 
the best of spouses would, making sure 
I was comfortable, squeezing my hand, 
and calming my nerves with hghthearted 
jokes: "Hey, was this just your way of 
getting out of watching the prizefight?" 

But we soon learned that my blackout 
had not been an inconsequential seizure 
after all. The spell had resulted from a 
good-sized tumor growing in my brain. 
I asked Sweeney whether it was malig- 
nant. Leaning over the rail and peering 
into my eyes, he said simply, "Yes." 

All I could think was: So this is how I 
die. Not in a car accident or a plane crash, 
not felled by a heart attack in honor of 
my own medical specialty, but by my 
own cells, mutating and roaming inside 
my body — in my head, no less. I felt pow- 
erless and immobile. My life's work with 
the critically ill brought me no special 
strength or solace; if anything, I knew 
too much. This cancer was insidious, 
already having grown to a near-fatal 
state in my brain without ever tipping 
me off. Not one hint. 

Looking up into the sad, drawn face of 
my husband, I knew that all of our med- 
ical expertise combined would not help 
us cope with this numbing news. No 
matter who we are, from whatever back- 
ground, we aU feel the same chill upon 
hearing a cancer diagnosis. 

Away with Words 



My surgery took place several days later. 
The surgeon. Gene Barnett, speculated 
that my tumor was a grade III glioma. I 
pressed for a prognosis. His answer was 



sobering. With a full course of treat- 
ment — including surgery, radiation, and 
possibly chemotherapy — I might have 
one or two good years, maybe more; with 
surgery alone, it would be less. In either 
case, the outcome would be improved if 
he could remove the entire tumor. But 
the tumor was in an unlucky location: 
on the left side of my brain. 

Like most people, I'm left-brained. If I 
had to have a brain tumor, having it on 
my dominant side was not the best news. 
The situation was even dicier because 
the mass likely sat near my brain's speech 
center. If by some stroke of good fortune 
my speech center happened to be located 
on the right side of my brain, or present 
in both brain hemispheres, the risk that 
removing the tumor could damage my 
ability to speak would be eliminated. 
So, prior to surgery, I would undertake 
a Wada test to determine something 
most of us never need to know — exactly 
where all my chatter was coming from. 

The Wada test sorts out the activities 
of the right and left parts of the brain by 
selectively anesthetizing one or the other 
hemisphere. As my left brain feU asleep, I 
instantly went mute. I was alert, focused, 
and trying hard to answer the neuroradi- 
ologist's repeated questions. The words 
lined up in my head, wanting to be 
released, but instead just piled on top of 
one another. 

I flunked the test. My speech center 
was located near the tumor, making the 
operation that much more difficult. One 
thing was now clear in my mind: Howev- 
er much time I had ahead of me, I did not 
want to wake up from surgery unable to 
talk. My husband and I urged Barnett to 
err on the conservative side of how much 
he could remove safely. As Fred put it 
simply: "I want my wife back." 

Barnett gave me the option of being 
awake during the portion of the neuro- 
surgery in which the tumor was actually 
being removed. By speaking aloud on the 



operating table, I would assure Barnett 
that his cutting wasn't affecting my 
speech zone. I had done a great deal of 
public speaking in my time, but this 
recitation would become the most 
important speech of my life. 

Minding My Language 

The operation began hke all others, as 
the neuroanesthesiologist let me peace- 
fully doze off while trying to count to 
ten. This gentle sleep was abruptly bro- 
ken when he brought me back to full 
consciousness in the midst of the opera- 
tion. I felt no paui, mental or physical. 
Barnett had already numbed my scalp 
with a local anesthetic and opened a 
four- to five-inch window into the left 
side of my skuU to expose the tumor. 

My brief reverie was interrupted 
when a neurologist appeared over me 
holding my homework — a hterary pas- 
sage I was to read again and again during 
the operation. Like a third grader reading 
aloud in front of the class, I tried to pro- 
nounce each word perfectly, though the 
words seemed odd. I asked the neurolo- 
gist if this passage made sense to him, 
and he laughed. To me, it seemed out of 
context and very flowery, not at all a pas- 
sage I would have chosen for this critical 
moment in my life. But, hey, who was I to 
be choosy? Just as I was feeling comfort- 
able about my abiUty to handle this 
strange experience, Barnett told me he 
was finishing up and all was well. He 
had removed about half the tumor. 

My tumor turned out to be an oligo- 
dendroglioma, known for its unusual 
genetics. Yet studies at the University of 
Toronto had suggested that at least one 
subset of this tumor, when it carried a par- 
ticular genetic profile, was surprisingly 
responsive to therapy — including chemo. 

The standard treatment for most brain 
tumors is surgery followed by radiation. 
In the past, chemotherapy had been 



52 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



A NEUROLOGIST APPEARED OVER ME HOLDING MY 
TO READ AGAIN AND AGAIN DURING THE OPERATION, 




considered a bust because of the blood- 
brain barrier. This barrier, so important 
to isolating the brain from blood-borne 
disease, also shields brain malignancies 
from many chemotherapy drugs that 
might otherwise destroy them. Histori- 
cally, chemotherapy for brain tumors 
had been considered salvage therapy, 
when all other options had been 
exhausted. And sometimes, mysteri- 
ously, a tumor did respond. 

I told my medical team that radiother- 
apy wasn't for me. Although this treat- 



ment typically shrinks brain tumors and 
can lengthen life, long-term exposure 
to the radiation puts patients at risk for 
memory and cognitive difficulties. That 
was one risk I chose not to take. I want- 
ed to be me for as long as possible — with 
my children, with my husband, at home, 
at work. Plus, as a lifelong geek, I could 
not bear to threaten this brain of mine 
that had served me so well over the years. 
We now had a plan: chemo following 
the surgery, then patience. And with 
that plan came a certain relief. I quickly 



became a professional patient, guided by a 
daily schedule of chnic and hospital stops 
that left httle time for much else. During 
one appointment, I had my head staples 
removed; on another I had a post-op MRI. 
Then I twice visited the operating room 
to have special catheters installed through 
tiny incisions beneath my collarbones, 
one set to harvest bone marrow cells 
and then a port to administer chemo. 
Blood tests became regular events. My 
arms began to show the telltale needle 
marks and bruises of my patienthood. 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



53 



▼ 



HATEVER OUR STRUGGLES AND TRIUMPHS, 
SOON THEY BLEED INTO A WASH, JUST 




A few days later, I received my three- 
drug cocktail: procarbazine, lomustine, 
and vincristine. During the first week 
of treatment, my appetite plummeted, 
along with my weight. Food tastes 
changed — everything I put into my 
mouth tasted metallic — and my skin 
dried up like a broken twig. About half 
my hair fell out. Occasionally I donned 



my trusty wig, but I never did figure out 
how to keep it straight. 

My first blast of chemo toxicity hit 
hard during the second week of therapy 
when I started the procarbazine for a 
two-week daily stint and had my first 
dose of vincristine. These drugs didn't 
seem too bad — until later that night. Just 
past midnight, nausea, dry heaves, and 



vomiting hit suddenly, and they recurred 
like clockwork every 45 minutes, 
untouched by the standard antinausea 
medicine I'd been taking. Exhausted, I 
would fall asleep as each wave passed, 
but unfairly so, as my husband, who had 
a job to go to in the morning, was awake 
all night. This happened for several 
nights in a row as my body reacted, 
relentlessly and rhythmically trying to 
reject the toxic stuff seeping into it. 

I vowed to take the heavier antinausea 
medicine. After that, queasy was the 
worst of it — and I have never been so 
grateful for queasy. How awful chemo 
must have been before the discovery of 
these more powerful medicines. The 
newer but more expensive drugs gave me 
a semblance of normalcy during a long 
stretch of toxic treatment. 

Genes that Fit 



At about this time we received good 
news: A gene analysis showed my tumor 
matched the profile of those that had 
responded to chemotherapy in the 
Toronto study. It seemed as if a world of 
time had fiUed the eight weeks since my 
diagnosis. I was back at work as dean of 
the College of Medicine and Public 
Health at Ohio State University, and hfe 
at home had settled into its old rou- 
tines. I had successfully weathered one 
bout of bone marrow toxicity. 

But after my first cycle of chemother- 
apy it was time for an MRI scan, which 
brought me back to cancer's reahty. My 
doctors had warned me not to expect 
too much improvement after just one 
month of treatment. This scan, though, 
was still a kind of reckoning. There I lay, 
head rigid, arms fixed, eyes staring 
upward with nothing to see, encased in 
a sleek white sarcophagus. 

I promptly came to life as the noise 
ceased and I was motored out of the 
narrow tunnel. My neurologist, Patrick 



54 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 



Sweeney, was standing next to the com- 
puter console where the neuroradiolo- 
gist was studying the scan. Sweeney 
flashed a big smile and held both thumbs 
up. I had won a reprieve. The drugs were 
working sooner than expected. 

But early in my second cycle I hit a big 
speed bump, when I had another, more 
serious run of bone marrow toxicity. 
Although I felt well, I popped an antibi- 
otic to ward off infection, monitored my 
temperature, and gave in a bit more to 
the nagging fatigue of severe anemia. I 
was buoyed by an even better MRI after 
cycle two, which showed that the tumor 
was on the run. 

My marrow, though, refused to bounce 
back. Any more exposure to these drugs, 
and I ran the risk of turning my marrow- 
filled bones into barren cavities. Here I 
was with a chemosensitive tumor that 
was melting away, and I could no longer 
take the miracle medicine that was 
doing the trick. 

But by sheer luck, a new drug had just 
gained Food and Drug Administration 
approval for use in brain tumors that had 
failed to respond to other treatments. 
Temodar, or temozolomide, had a special 
knack for crossing the blood-brain barri- 
er. And, crucially for me, it dehvered less 
bone marrow toxicity than my original 
drug cocktail. I became one of its earhest 
users, and for the next year my scans 
steadily improved. Now this drug is rec- 
ognized as a breakthrough in brain tumor 
treatment and is the first drug to be 
used routinely early in the treatment of 
ghoblastoma multiforme, the most severe 
and common of the malignant brain 
tumors. For other, less common gliomas, 
like my own, it's now standard care. 

Great Transformations 



News of cancer close to home is always 
wrapped in sadness and anxiety for both 
the patient and the family. But like birth 



and death, cancer is one of the few life 
experiences you fundamentally face on 
your own, for however many loved ones 
surround you, the cancer journey is 
essentially a solitary one. 

Treasuring the moment is what lifts 
the spirit. To those threatened by a grave 
illness, every day of just being takes on 
a new light. You wonder how you could 
ever complain again — about a rainy day, 
a broken piece of china, or someone's 
unkind words. Although that feeling of 
equanimity salves the cancer shock, it 
can also linger in the consciousness and 
become a subtle yet permanent state of 
being. I stop myself when I get too caught 
up in some silly little thing; I remind 
myself how lucky I am to be here. 

I'm often asked how my experience 
with cancer transformed me, and I always 
say, "I'm still me." Some beheve that v\dth 
age you become more of who you are, and 
an illness can do this to you, too. The 
mask comes off, and your true self is laid 
bare. Yet we're always reaching beyond 
our limits. An iUness such as cancer can 
set us up to think about our own capaci- 
ty to enhance our strengths and make our 
days meaningful to ourselves and to those 
we care most about. This process is in 
essence a spiritual experience. 

Faith is central to the hves of many peo- 
ple. For them, reading the Bible or other 
religious writings, praying, and having 
others pray for them can be calming. 
Throughout the ages, people have also 
looked to the arts — a sublime piece of 
music, a timeless painting, a classic work 
of hterature — for inspiration, guidance, 
balm for an aihng spirit. Sometimes you 
just need a lovely diversion from the 
blood counts and treatment schedules, 
to allow you to think deeply and sooth- 
ingly for a while, and to remember that 
life goes on. 

I recall a serene moment early in my 
cancer journey. My outlook was uncer- 
tain, and my mood reflected it; I had been 



feeling vulnerable and weak, both phys- 
ically and emotionally. On that particu- 
lar day I had a platelet transfusion. Dur- 
ing the process I absorbed myseff in a 
book. Memoirs of a Geisha, which had 
blessedly transported me to another 
world. I was so sorry to turn the last 
page of this gorgeously written novel. A 
surprising euphoria came over me as I 
read and reread the last two lines of the 
book; "But now I know that our world 
is no more permanent than a wave ris- 
ing on the ocean. Whatever our strug- 
gles and triumphs, however we may 
suffer them, all too soon they bleed into 
a wash, just like watery ink on paper." 

Call it rehgion, call it spirituahty, call it 
grace. We are all beings in only one point 
in time. We are all ripples in the ocean. 
And thinking about that brought me a 
calm and an equanimity that tapped into 
the core of my soul. I came to better terms 
with my misbehaving clump of cells that 
day, and the effect has been enduring. 

If or when my cancer reappears, I will 
know what to expect. I will not see what- 
ever treatment there is for me as salvage 
but as round two or round three. And if I 
get knocked out in that round, I will have 
tried my best, with the behef that some- 
day my daughters and my sweet husband 
will look back and say, "You know, we 
could have cured Mom had she lived 
today." I hope so. I've already seen the 
glimmer that such a time is coming — the 
time when cancer has no riddles, presents 
few uncertainties, and brings no fear. ■ 

Bernadine Hcaly '69, the health editor for U.S. 
News &r World Report, has served as direc- 
tor of the hiational Institutes of Health and pres- 
ident and chief executive officer of the American 
Red Cross. This article was adapted from 
her hook Living Time; Faith and Facts to 
Transform Your Cancer Journey, copyright 
2007 by Bernadine Healy Reprinted by permis- 
sion of The Bantam Dell Publishing Group, a 
division of Random House, Inc. 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 



ATJTMNA PROFIT. F. 



PARDIS SABETI '06 



Doc of Rock 



LARK KENT HAD THE PERFECT GUISE FOR HIS ALTER 

identity — who could have guessed the nerdy reporter 
batded evil after just a change in costume? Pardis Sabeti '06 
is something of a quick- change artist herself, although no cape 
peeks from beneath her white lab coat. By day, the scientist toils 




at the HMS-affiliated Broad Institute, 
tracking genes involved in the coevolution 
of humans and their pathogens. By night, 
that scientist transforms into a musician, 
intent upon recording tracks for the next 
album with her alternative-rock band. 

Sabetis records are not made only in 
studios. At HMS, she became only the 
third woman to graduate summa cum 
laude since women were first admitted 
in 1945, a feat she accomplished while 
assembling her band. 

"Science will always be my main 
career," she says, "but I pursue music with 
equal intensity." And with equal passion, 
for whether tracking the genetic changes 
that affect human disease or honing her 
music to impart just the right energy and 
emotion, Sabeti is always striving to reach 
the next rung of discovery. 

Discovery sometimes comes in small 
doses. Sabeti views all of what she does 
as creative exercises in problem solving. 
"Often in music you dorit even know what 
you're trying to convey when you begin," 
she says. "At first you're working with aU 
the httle pieces, and then the whole song 
emerges. It's an amazing feeling." 

Research also grows through synthe- 
sis and assembly, a process Sabeti likens 
to finding your way in a dark room. 
"You might stumble over an idea," she 
says, "but not quite figure out what it is 
you tripped over. At other times, you 
immediately know what that idea will 
look like when the lights go on." Either 
way, she says, the result is euphoric. 

Not Just a Lark 



Sabeti's own genes never seemed to be 
encoded with any particular musical 



talent. No one in her family plays an 
instrument, at least so far as she 
knows; some distant relatives live in 
Iran. Sabeti did, too, until age two 
when her family emigrated to avoid 
that nation's revolution. 

Her father could carry a tune, howev- 
er, and would always sing in their home. 
Like him, Sabeti describes herself as 
"music obsessed," even though she'd 
never so much as strummed a guitar 
until her twenties, when she studied bio- 
logical anthropology as a Rhodes scholar 
at Oxford. Some friends in her doctoral 
program kept saying they wanted to 
start a band. She finally asked why they 
didn't just begin already. When told they 
had no rhythm section, Sabeti went out 
and purchased a bass guitar. 

"It turns out I had been training myself 
all along without knowing it," she says. 
"I've always thought about songs and 
cared about music deeply. Rather than 
just passively hstening, I would harmo- 
nize and make up my own lyrics. As soon 
as you care about something, the flood- 
gates open and it becomes easy." 

At Oxford, those gates opened wide. 
She quickly discovered she could sing 
and had a flair for writing lyrics and com- 
posing music. During medical school she 
took a poetry class to boost her song- 
writing skills and started to play with 
some local musicians. Together they 
formed a band, naming it Thousand Days, 
inspired by the title of the first song they 
wrote together. 

Sabeti finds material for songs from sci- 
ence and from books she's read. One song, 
"Turkana Boy," was inspired by the dis- 
covery of the fossilized skeleton of a boy 
who hved more than a milhon and a half 



years ago. She wrote another, "Crying to 
Breathe," after reading The Diving Bell and 
the Butterfly, a memoir written by a man 
who had become paralyzed by a stroke 
that affected his brainstem. He dictated 
the book by blinking his left eye to a 
colleague who translated the blinks into 
letters of the alphabet. 

"I was incredibly affected by his story," 
Sabeti said. "I envisioned that in order to 
scream, he would open wide that one eye. 
I had to put that into a song." 

These days Sabeti has the big screen in 
her sights. She recently paired up with a 
record producer to try to place one of her 
songs in a movie. 

The War on Bugs 

Although much of Sabeti's recent work 
has involved the human genome, she 
hopes to shift her focus to the evolution 
of infectious diseases, such as the changes 
that occur along the genome of the para- 
site that causes malaria. 

In her laboratory in Cambridge, in fact, 
Sabeti has a bead on the genome of the 
malaria- causing parasite. In addition to 
learning how the organism behaves bio- 
logically, Sabeti is investigating two of its 
more advantageous survival traits — 
immune invasion and drug resistance — 
and, together with colleagues, has identi- 
fied some genomic regions that may be 
responsible for the latter. 

Sabeti's study of malaria was prompted 
by her learning of a relatively "recent" — 
within the past 10,000 years — mutation 
on the human genome. She uncovered this 
information by using an algorithm of her 
own design to infer the first appearance 
of certain groups of genes. Those genes 
can, in specific situations, help protect a 
person from the malaria parasite. 

Her work could eventually lead to new 
medications that would attack the para- 
site's weaknesses, but Sabeti also hopes it 
wiU provide a greater understanding of 
the pathogen's evolution and, perhaps, 
guide tactics to prevent malaria. 



56 



HARVARD MEDICAL ALUMNI BULLETIN • AUTUMN 2007 




By night, the scientist transforms into a 
musician, intent upon recording tracks for the 
next album with her alternative-rock band. 



Sabeti likens such a holistic approach to 
warfare. "You look at wiping out the enemy 
from many angles," she says. "Not just how 
to win short term, but also how to stay 
the course. If you can understand what a 
pathogen is doing, you can see how it 
evolves over time in different populations." 

Sabeti hopes to impart her enthusiasm 
for genetics research to a roomful of 
undergraduates. She was recently named 



an assistant professor of organismic and 
evolutionary biology in Harvard's Faculty 
of Arts and Sciences. She enjoys the prob- 
lem solving involved in teaching a lecture 
class. "How do you get people excited 
about genetics?" she asks. "How do you 
keep students' attention?" 

Sabeti's own interest in her human 
genetics research remains high. A paper in 
the October 18, 2007, issue of Nature reports 



her team's findings about changes along 
the genomic pathway that drives the devel- 
opment of hair follicles. Their results indi- 
cate that the distribution of these foUicles 
may be changing, possibly decreasing, in 
humans — especially among certain indige- 
nous people of Latin America and among 
natives of Japan and China. A similar 
change, Sabeti says, has already been seen 
along the same pathway in the genomes of 
some species of fish. "It's well documented 
that freshwater fish have fewer scales than 
their saltwater counterparts," she says. 
"There's been a rapid evolution along this 
same genetic pathway in humans." 

Sabeti's laboratory found three human 
genes linked to changes in the develop- 
ment of hair follicles, a mutation that 
could result in fewer sweat glands and 
less body hair. Now she and her team are 
puzzling over why the mutation is 
increasing in frequency. 

Rock and Roll Forever 



Sabeti's band released its third album last 
summer. Her musical success, however, 
doesn't seem to detract — or distract — 
from her genetics research. To her, neither 
feels like work, so she easily finds time for 
both. And she doesn't mind the fact that 
she doesn't fit the traditional mold of the 
physician-musician. 

"Most doctors stop doing rock," she 
says. "After a while, it's more acceptable to 
do classical music. Playing classical piano 
still works with the doctor persona; play- 
ing in dive bars doesn't. Rock just doesn't 
fit into what people expect of doctors." 

Sabetis two worlds — studying molec- 
ular evolution and playing in a band — do 
indeed seem disparate. But for Sabeti, 
swdtching from one world to the other is 
seamless — and requires neither phone 
booth nor cape. 

After all, who needs a cape when 
you've got a guitar? ■ 

Janice O'Leary is a former assistant editor of the 
Harvard Medical Alumni Bulletin. 



AUTUMN 2007 • HARVARD MEDICAL ALUMNI BULLETIN 57 



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