UNIVERSiTY OF NORTH CAROLINA?
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HEALTH SCIENCES LiBRARY ^
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he Official Durnai of tiie ortli Carolina edical Society
J'''ferth Carolina Medical Journal
For Doctors and their Patients
New Views of a Debilitating Disease:
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SR?»!RS!&1
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GEOGRAPHIC ORIGINS OF SICKLE CELL GENES
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North Carolina Medical Journal
FOR DOCTORS AND THEIR PATIENTS
January/February 1997, Volume 58, Number 1
Cover: Geographic densities of sickle gene haplotypes in Africa anci Asia. (Adapted and redrawn, witfi permission, from: Embury SH, et al. Sickle Cell Disease: Basic Principles and Clinical Practice. Raven Press, Ltd., 1 996, p 355.) See article, page 62.
THE STATE OF OUR HEALTH
10 Conjoint Repon; To the NC Medical Society and the NC Commission for Health Services
Ronald H. Levine, MD. MPH
DIMENSIONS OF DOCTORING
14 Medicine as a Mission
18 Patient-Centered Care: A Collaborative Approach
Dan G. Blazer. MD, PhD Howard J. Eisenson, MD
ETHICS AT THE END OF LIFE
25 Physician-Assisted Suicide: Lessons From the Kevorkian Trials
30 Physician-Assisted Suicide: Current American Medical Association Initiatives
Bernard J. Carroll, MB, PhD John Glasson, MD
MODERN MEDICINE
32 Most Anesthesiologists No Longer Restrict Clear Ruids for Eight Hours Before Elective Surgery A. Colin McKinley, MD, Robert L. James, MS, and Grover R. Mints, III, MD
,^6 Perinatal Substance Abuse Within Central North Carolina
Pamela Cobb, MD, Katherine Hartmann, MD, John M. Thorp, Jr., MD,
Connie Renz, MSN, Deborah Stanford, BSN, CNMW, and Kathleen Rounds, PhD
HEALTH CARE ELSEWHERE
44 Opportunities for Cooperation: A Dialogue With the Saratov Medical University, Russia
Micliael Gill. PhD. MSIV. Michael Simmons MD, James W. Lea, PhD, and Gary D. Bos, MD
FICTION BY PHYSICIANS
Locked and Loaded: Roger Castle's Gulf War Syndrome
Dennis A. Greene, MD
PATIENT'S POINT OF VIEW
My Encounter With Cancer: One Woman's Battle With Cancer and Today's Health System
Teena Vaughn-D 'Annibale
CLINICAL PRACTICE
Interval to Cancer Diagnosis Following "Negative" Transthoracic Fine Needle Aspiration Biopsy
Warden L. Woodard, III, MD, Michael J Kelley, MD, William L. Betsill, Jr., MD, and Herman A. Godwin, Jr., MD
ORIGINS OF DISEASE
New Views of Sickle Cell Disease
TOXIC ENCOUNTERS
"All But Death, Can Be Adjusted": Ma Huang (Ephedrine) Adversities
Wendell F. Rosse, MD
Ronald B. Mack. MD
HEALTH WATCH
39 Wellness is Key for Diabetics: Don't Let Sick Days Get You Down
Cyril A. Allen, MD. MSPH
BULLETIN BOARD
5 Letters to the Editor 12 Instructions for Authors 60 Carolina Physician's Bookshelf
71 Classified Ads
72 CME Calendar
80 Aphorisms of the Month, Index to Advertisers
NCMJ January/February 1997, Volume 58 Number 1
NORTH CAROLINA
MEDICAL JOURNAL
For Doctors and their Patients
January/February 1997, Volume 58, Number 1
Published Bimonthly as the Official Organ of the North Carolina Medical Society (ISSN 0029-2559)
EDITOR
Francis A. Neelon, MD Durham
DEPUTY EDITOR
Edward C Halperin. MD Durham
CONSULTING EDITOR
Eugene A. Stead. Jr.. MD
ASSOCIATE EDITORS
Eben Alexander. Jr.. MD
Winsion-Salem Wilham B, Blythe, MD
Chapel Hill F. Maxton Mauney. Jr., MD
Asheville James P Weaver. MD
Durham
MANAGING EDITOR
Jeanne C, Yohn
Durham 919/286-6410 fax: 919/286-9219 e-mail: [email protected]
BUSINESS MANAGER
Donald R. Wall
SECTION EDITORS
Eugene W, Lintbrs. MD Daniel J. Sexton. MD
EDITORIAL BOARD
William B, Blythe. MD
Chapel Hill Johnson H. Kelly. MD
Shelby Patnck D. Kenan, MD
Durham Assad Meymandi, MD
Raleigh William G. Porter, MD
Charlotte Mary J. Raab, MD
Greenville C. Stewart Rogers. MD
Greensboro J. Dale Simmons. MD
Raleigh Thomas G. Stovall. MD
Winston-Salem
The Society is not to be considered as endorsing the views and opinions advanced by authors of papers delivered at the Annual Meeting or published in the official publication of the Society. — Constitution and BxUiws of the North Carolina Medical Society. Chap. IV, Section 3. pg. 4.
NORTH CAROLINA MEDICAL JOURNAL
Box 3910, Duke University Medical Center, Durham, NC 27710,
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Internet address: http://www.medicine.mc.duke.edu/ncmedj). is owned and pubHshed by The
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North Carolina Medical Society, Address manuscripts and communications regarding editonal
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Beginning this month...
Find the Journal on the Internet at:
http'J/www. medicine, mc. dul<e. edu/ncmedj
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With this issue, we officially launch the North Carolina Medical Journal's home page on the World Wide Web at the address above. Our site will include:
♦ general information about the Journal,
♦ author's guidelines and submission information,
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Our page remains "under construction" so that we may update it to coincide with print deadlines. We encourage readers to provide us with feedback on how we can improve our website. We welcome comments by mail (Box 3910, Duke University Medical Center, Durham, NC 27710) or via e-mail: [email protected] [
J
NCMJ January /February 1997, Volume 58 Number 1
Letters to the Editor
A
Doctors and Lawyers: An Uneasy Relationship
Editor's note; The next two letters were sent to Anne Duvoisin, the Durham attorney who wrote "Lions and Hyenas in Love: The Promise of the Medicolegal Guidelines" (NC Med J 1 996;57:296-7) which appeared in the September/October Journal. We publish them here, with permission from Dr. Au and Dr. Demas, accompa- nied by Ms. Duvoisin's responses.
To the Editor:
Ms. Duvoisin can surely answer the hypothetical questions she poses to herself in her article, "Lions and Hyenas in Love." I am a plastic surgeon who is sometimes called in to see patients in the emergency department. Afterward, I often receive an unpleasant surprise in the form of a subpoena to appear as a witness. The sheriff may even serve this on me in front of my waiting patients. Just once, it would be nice to receive some advance request from the participating lawyers to discuss the case, the fees involved, and so on. I know that lack of notifica- tion is part of the turf, but I didn't know it when I chose my professional direction in college. Had I known, I would prob- ably still be an engineer.
I don't choose who I see in the emergency department. But I can, and do, choose whom to see in the office. The nature of our court system is adversarial. Doctors can count on being subpoenaed and savaged by one side or the other. Conse- quently, I no longer see or evaluate new liability patients in consultation for their attorneys. Why would anyone in their right mind willingly do that? I don't blame attorneys entirely, because without the demand, there would be no suits. It's the system, a system that lawyers don't seem to want to change. You can't blame doctors for being reluctant to be drawn into an arena full of hyenas, where we feel more like lambs than lions.
Victor K. Au, MD
Southeastern Plastic Surgery Center, PA
2430 S. Church St., Suite B
Burlington, NC 27215
Ms. Duvoisin responds:
Dr. Au is right; Medical students should learn about the legal implications of their choice of profession. A desire to be involved with the judicial system is not what motivates one to enter medical school. Nonetheless, it is a virtually certain
component of most medical careers, particularly the surgical specialties. A short course on the professional obligations of medical witnesses to their patients and to the legal system would allow students to choose specialty areas more intelli- gently, even whether to pursue a medical career at all.
The Medicolegal Guidelines cannot solve this missing link in the medical educational system, but they do address and can resolve the problems Dr. Au describes. Physicians who feel that attorneys have abused the subpoena power, or been unfair in terms of notice or fee payment should complain to the Joint Committee of the NC Medical Society and the NC Bar Associa- tion, or their local Bar Association's medicolegal liaison com- mittee for dispute resolution. (Alamance, Buncombe, Durham, Forsyth, and Mecklenburg County Bar Associations have such committees.)
Most trial attorneys do accommodate physicians' sched- ules and honor their fees for expert services — but it only takes a few rotten apples to make the whole barrel look bad. Provi- sions of the Guidelines explicitly address Dr. Au's complaints:
Subpoenas. Part III(A) discusses subpoenas at length:
1 . Under NC law, physicians are required to be subpoenaed so that an expert witness fee may be awarded to them after they have testified.
2. Attorneys should accommodate patient scheduling needs of physicians and notify them early and often of when they might be needed as witnesses.
3. Physicians must understand that the business of the courts cannot be governed by the convenience of witnesses, whom- ever they may be.
Pretrial communication. Part 11(D) addresses pretrial dis- cussions between attorneys and treating physicians. I was surprised to learn when first chairing a medicolegal liaison committee that many physicians were angered by the failure of attorneys to consult them about their patients, their testimony, and fee issues prior to subpoenaing them. For years I had listened to lawyers gripe (and griped myself) about physicians who would not respond to letters or calls regarding their patients/clients or who refused to meet with attorneys prior to taking the witness stand. Because of those "rotten-apple" expe- riences, I did not (and many attorneys still do not) know that most physicians would appreciate communication from attor- neys planning to call them as witnesses. The rules vary depend-
NCMJ January/February 1997, Volume 58 Number 1
ing on whether the lawyers subpoenaing the doctor represent the patient or not.
The patient's lawyer. The Guidehnes encourage physi- cians to communicate frankly with their patients' lawyers "for the purpose of obtaining a complete understanding on the part of each as to the medical and legal issues involved. An exchange of facts and opinions in advance of such testimony minimizes confusion and time demands, encourages settlements, and enhances the understanding of the roles of the two professions."
Other lawyers. The Guidelines warn that doctors'should not communicate with any person without the patient's consent or a court order. Often the subpoenaing lawyer does not repre- sent the patient and is ethically and legally prohibited from consulting with the patient's physician. Nonetheless, that law- yer is entitled to and may be obligated to depose or subpoena the treating physician in order to fulfill his or her obligations to the clients. An example would be acase where a party adverse to the patient seeks to prove that claimed injuries are bogus, exagger- ated, or were not caused by their client.
To the Editor:
We have had medicolegal guidelines in Charlotte for more than 10 years, the result of planning between the medical and legal professions. I have been involved in a number of court cases, and most of them involved good relationships with the attorneys, but there have been exceptions.
I'm concerned that the guidelines sometimes seem to have no value for the physician. I have experienced this myself in a few instances. I have received a number of subpoenas, most without any preceding letter from the attorney involved. I keep these in a box, anticipating that I will probably never be called to court. Some attorneys do tell me when to expect a subpoena and whether I will be called to court. Then there are those instances in which it is clear that we will be going to court, and the attorney will want talk to me beforehand. Finally, I have, on occasion, been summoned to court at the last minute — on a case involving a patient that I may not have seen for several years — without the attorney ever having spoken to me.
I am particularly concerned with how physicians are reim- bursed for time spent in court and in preparation for a case. Until recently, the guidelines in Charlotte recommended that the physician charge up to $300 an hour for his or her time. New recommendations are now $400 an hour. About two years ago, I was involved in a case in which the attorney had not bothered to talk to me before subpoenaing me, and my testimony was, for the most part, detrimental to his case. The judge awarded me $50 an hour, which I protested. The guidelines state that the attorney should assist the judge in arranging adequate reim- bursement. But in this case, the attorney explained frankly that if I had helped him win the case then he could have been more sympathetic m providing truly adequate reimbursement. I dis- cussed this with the attorney in the next case that came up. I received the same blatantly unethical advice: If I expected appropriate reimbursement by the court, then I would have to
help the attorney who subpoenaed me win the case.
I would appreciate suggestions on how to deal with attor- neys who take such an unethical position. When I brought the issue to our liaison committee in Charlotte, they were sympa- thetic, saying that perhaps the attorney should not have taken this position. But I couldn't expect anything to be done about it or to change the format of how physicians are reimbursed for their time.
Of course, I am adamantly against going to court for the attorney's sake. I am there strictly to provide an honest ap- praisal of the patient's condition and to assist with an under- standing for the jury and involved participants. In some cases I find myself advocating strongly for the patient, primarily be- cause of the adversarial nature of the attorney who may deny fully acknowledging the patient's significant disorder.
Fortunately, most attorneys I have dealt with in court or at depositions have been honest and forthright. And they guaran- tee me, at the outset, that my testimony will be reimbursed at the going rate regardless of what I might have to say as long as I am honest and competent.
Ronald C. Demas, MD Demas Neurology and Medical Rehabilitation, PA
2219 E. Seventh St. Charlotte, NC 28204
Ms. Duvoisin responds:
It is imperative that physicians and attorneys understand their respective roles in litigation. The Guidelines distinguish them:
Fees. Fees are generally addressed in Guideline Part IV. A fee should never be contingent on the outcome of the physician' s testimony. Dr. Demas testified pursuant to subpoena and the court ordered a fee that was grossly inadequate. It was the duty of the attorneys "to assist the trial judge in determining a reasonable fee." The attorneys who called Dr. Demas as a witness ascribed their lack of vigor in performing this duty to his failure to provide favorable testimony. The conduct Dr. Demas describes is addressed by both the Rules of Professional Con- duct (RPC) governing attorneys and the Medicolegal Guide- lines.
Violations of the RPC. The NC State Bar licenses and disciplines NC attorneys. Possible disciplinary actions range from warnings to disbarment. Anyone can report a grievance to the State Bar by calling 9 1 9/828-4620. The behavior Dr. Demas mentions is addressed in RPC 7.9(B), which prohibits attorneys from paying, offering to pay, or acquiescing in the payment of compensation to witnesses contingent on the content of their testimony or the outcome of the case. RPC 7.9(C) prohibits lawyers from offering inducements to witnesses to testify falsely. The purpose of the Rule is obvious: "Witnesses should always testify truthfully and should be free from any financial inducements that might tempt them to do otherwise."
Violations of the Guidelines. The Joint Committee of the NC Medical Society and the NC Bar Association has a mandate
NCMJ January/February 1997, Volume 58 Number 1
to assist attorneys and physicians who "experience problems related to a failure of adherence to these Guidelines." Com- plaints about possible violations of the Guidelines should be addressed to: NCBA Medicolegal Liaison Committee, P.O. Box 3688, Gary 27519, 919/677-0561. Part IV of the Guide- lines disapproves conduct by a lawyer which suggests that payment of a physician's expert witness fees is wholly or partially contingent on the outcome of the matter in which medical testimony is offered.
What remedies exist for Dr. Demas for what has already happened? Complaints to the State Bar or to the Joint Commit- tee could lead to discipline and/or resolution of the past fee dispute. What can be done to prevent future occurrences? Physicians should address with the attorney the issue of hourly rates and who will pay for their time spent, whether for depo- sitions, consultations, or in-court testimony, before any ser- vices are rendered to any attorney.
Two rules restrict fee arrangement: Outcome-oriented fee agreements are prohibited and attorneys cannot pay their client's expert witness fees, although they can advance them. The Guidelines distinguish between treating and non-treating phy- sician witnesses but allow each to contract for the payment of the fees. Treating physicians are limited to reasonable compen- sation. Non-treating physicians providing expert assistance are entitled to fees "as negotiated between the physician and the contracting parties," whether reasonable or not.
An agreement between Dr. Demas and the contracting attorney, whether he was a treating or non-treating expert, obligates the attorney to pay in accordance with the agreement even if the court orders a lesser amount. The Guidelines provide that "all fees agreed to by an attorney for the physician's assistance in legal matters should be promptly paid by the attorney in accordance with the agreement."
Investigating NC's Medical History
To the Editor:
I recently received a copy of "^he November 1995, North Carolina Medical Journal, a special issue on the history of medicine in your state. The article on Confederate hospitals and Civil War medicine (NC Med J 1995;56:548-53) was espe- cially interesting because it helped me answer a visitor's specific question, and the sources cited in the article will enable this visitor to investigate these hospitals more fully.
I hope that the Journal devotes future issues to North Carolina's rich medical history.
James Ogden, III, Historian
US Department of the Interior, National Park Service
Chickamauga and Chattanooga National Military Park
P.O. Box 2128, Fort Oglethorpe, GA 30742
Celebrating the "Art" of Aging
To the Editor:
I thoroughly enjoyed Dr. Assad Meymandi's introductory remarks in the November/December special issue devoted to aspects of eldercare in North Carolina(NC Med J 1995:57:342). I was fascinated by his reference to the "art" of aging, which I am fearful that I will never develop! It would be interesting if that concept, along with "the art of loving," that is, loving others as a positive force in a life, could be developed for another issue of the Journal. I believe these subjects would interest a great majority of people — even doctors!
Carolyn R. Ferree, MD
President, North Carolina Medical Society
Professor, Department of Radiation Oncology
Bowman Gray School of Medicine
Medical Center Boulevard
Winston-Salem NC 27157
What's In a (Compound) Name?
To the Editor:
I enjoyed Dr. Meymandi's article, "The Art of Aging" (NC Med J 1995;57:342). I am a retired physician, age 81 , and have written quite a bit myself. I give Dr. Meymandi an "A*" for the effort, and I am glad that he is a member of the Journal's Editorial Board.
I am a stickler for keeping facts correct, and I did discover one mistake in the article. The beginning of the piece mentions Ehrlich's Salvarsan, a compound with which I am familiar. During medical school in Philadelphia from 1935-1939, 1 had the opportunity to give many shots of Salvarsan to the unfortu- nate people who came down with syphilis. Salvarsan was more commonly known as arsphenamine at that time, and we medical students composed a popular song by that name sung only in the confines of taverns.
Salvarsan was synthesized as Compound "606," not "666," as Dr. Meymandi wrote. It was the 606th compound tested and the first found to successfully kill spirochetes. Later on, Ehrlich came up with compound "914," which was even deadlier for spirochetes, but "606" was used more, since it was easier to produce. So much for "606."
Dr. Meymandi's remarks about his mother reminded me of my older brother. At 84, and a retired philosophy professor whose career spanned 50 years, he still calls me weekly from Boston to ask me what book I'm reading!
Abe L. Feuer, MD, FACS 1006 Fairfield Drive Gastonia, NC 28054
continued next page
Guidelines for Letters: Letters must be typed, double-spaced, and no longer than 500 words. We resen/e the right to abridge longer letters or consider them opinion pieces for potential publication elsewhere in the Journal. We may send original letters to Journa/authors for appropriate response. Send letters to: North Carolina MedlcalJournal, Box 391 0 DUMC, Durham, NC 27710; fax to: 919/286-9219, e-mail to: [email protected]
NCMJ January/February 1997, Volume 58 Number 1
Taking a Stand on Pain Management
To the Editor:
Drs. Grosshandler and Stratas did an excellent job in raising our level of awareness in their article, "Opiates for Chronic Nonmalignant Pain?" in the Septeinber/OctoberyoMr- nal (NC Med J 1996;57:288-90).
During his tenure as North Carolina Medical Board (NCMB) president, Dr. Stratas asked for a "pain policy." We have made one, with the aid of our staff (especially Dale Breaden) and in consultation with experts in the field of pain management (especially David Joranson, and Drs. David Haddox, June Dahl, and Gerald AronofO- The NCMB adopted a position statement on the "Management of Chronic Nonma- lignant Pain" on September 13, 1996, after studying this issue for two years. [An abbreviated version appears at right. — Eds.] The American Academy of Pain Medicine and the American Pain Society recently developed and approved a consensus statement on "The Use of Opioids for the Treat- ment of Chronic Pain." Our statement borrows from that document and from the pain policies of several other state medical boards across the nation. We will consult these sources again for our educational program.
Accumulated data suggest that chronic nonmalignant pain is often undertreated or, at best, poorly treated. The use of opioids is only one facet of treatment, yet it probably ranks as the most controversial. Some of this controversy was nicely outlined in the paper by Drs. Grosshandler and Stratas and it is specifically addressed in our position statement.
Our guidelines, intentionally kept brief in the policy statement, parallel and complement those of the authors. Our intent is to foster a statewide educational program, hopefully through the state's Area Health Education Centers (AHECs), that will allow physicians to learn more about this type of pain management. To help develop and implement this program, we hope to draw on the skills of pain management specialists like Dr. Grosshandler in Chapel Hill, Dr. Spanos in Raleigh, Dr. Aronoff in Charlotte, and others. If possible, we would also like to involve the North Carolina Medical Society, the Drug Enforcement Administration, and pharmacists across our state.
The Board is aware of the risks associated with the adoption of this position statement, some of which were suggested in the Journal paper. We are also concerned about such risks as diversion, iatrogenic problems, and misuse or misinterpretation of the statement by some physicians. We hope to minimize those risks by educating and distributing information to physicians in North Carolina.
We feel the ultimate beneficiaries of this position state- ment will be the citizens of North Carolina. We call on all North Carolina physicians to help us make this a successful endeavor.
Charles E. Trado, MD, Vice President
North Carolina Medical Board
P.O. Box 20007, 1203 Front St.
Raleigh, NC 27619
A Summary of the NCMB Position Statement:
Management of Chronic Nonmalignant Pain
Effective pain management is a low priority for our health care system. Little information on the subject is integrated in medical education and clinical practice. In addition, few practitioners are specifically trained to manage pain, and the fear of legal consequences — for physician and pa- tient— exists when controlled substances are used.
Pain can be categorized as acute, cancer-related, and chronic nonmalignant. Our statement focuses on chronic nonmalignant pain since it is often difficult to diagnose, intractable, and undertreated. The NCMB recognizes that many strategies exist for treating this type of pain. Because such pain may have many causes and perpetuating fac- tors, treatment varies from behavioral and rehabilitation approaches to the use of a number of medications, includ- ing opioids. Specialty groups point out that most chronic nonmalignant pain is best managed using a number of strategies simultaneously. Inadequate pain management is not uncommon, however, despite the availability of safe and effective treatments.
Some physicians avoid prescribing controlled sub- stances, such as opioids, in treating chronic nonmalignant pain. These physicians should not abandon their reserva- tions about using opioids in such situations. However, the Board recognizes that opioids can be an appropriate treat- ment for chronic pain.
Effective chronic pain management should consist of: / documenting all aspects of the patient's assessment
and care, / taking a history and physical examination, including a
drug and pain history, / conducting appropriate studies, / developing a working diagnosis and treatment plan, / establishing a rationale for the treatment selected, / educating patients and ensuring that they understand
their physician's treatment methods and goals, / formulating a mandatory follow-up protocol, / assessing treatment efficacy regularly, / consulting with specialists in pain medicine when war- ranted, and / using a multidisciplinary approach, when indicated.
The Board expects physicians using controlled sub- stances to manage chronic pain to be familiar with condi- tions such as: physical dependence, respiratory depres- sion and otherside effects, tolerance, addiction, and pseudo- addiction. Literature is abundant on these topics and on the effective management of pain. Physicians should regularly update their knowledge in these areas.
No physician need fear reprisals from the Board for appropriately prescribing, as described above, even large amounts of controlled substances indefinitely for chronic nonmalignant pain. Nothing in this statement should be construed as advocating the imprudent use of controlled substances.
8 NCMJ Januan'/Februan' 1997. Volume 58 Number 1
Because this is no place for a doctor to operate.
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THE STATE OF OUR HEALTH
Conjoint Report
To the North Carolina Medical Society and the North Carolina Commission for Health Services
Editor's note:Th\s report is an adaptation of State Health Director Dr. Ronald H. Levine's address to the North Carolina Medical Society during its Annual Meeting at Pinehurst on November 15, 1996.
I take this opportunity to present a summary of issues central to the heahh and well-being of the citizens of North Carolina.
Birth Outcomes
I am extremely happy to report that, in 1995, North Carolina's infant mortality rate declined to 9.2 deaths per 1,000 live births — the lowest rate in state history, and a 26% decline from 1988. The total number of infant deaths in the state dropped below 1,000 for the first time since records have been kept. Rates for both white and nonwhite infants were the lowest in state history. These good results are a testimony to the efforts of thousands of people across our state who are working to reduce infant morbidity and mortality.
The medical community has played a key role in improving birth outcomes. Efforts to provide more accessible care are reflected in the higher percentage of women who initiated prenatal care in the first trimester of pregnancy . The percentage of women who smoke during pregnancy fell, suggesting that the effort of providers to promote healthy behaviors is making a difference. More widespread use of effective treatments, such as corticosteroids and surfactant, improved the survival of severely preterm infants.
Although the trends are most encouraging, we must not lose sight of the fact that North Carolina's infant mortality rate is still well above the national average, and the rate for minority infants is twice as high as that of white infants. The rates of low and very low birth weights continue to be unacceptably high, particularly among minorities, indicating our relatively minor successes in coping with the fundamental problem of preterm birth. Much more to do here.
Child and Adolescent Health
Again on the positive side, our child fatality rate dropped to 89 deaths per 100,000 children, a 9% reduction from the previous year, and a 26% reduction since 1988. The number of deaths declined in all age categories except 1 6- to 1 7-year-olds, where motor vehicle-related deaths continue to rise. I am encouraged that local child fatality prevention teams are now active in each county. These teams review the deaths of resident children and seek to develop ways to prevent further such deaths. I encourage physicians to participate on the teams in their communities.
We are working hard to help adolescents gain access to preventive health care services through the development and use of school-based and school-linked adolescent health cen- ters. I am pleased to report that a network of more than 30 such centers is now in place. We recently received grants from the Robert Wood Johnson Foundation and the Duke Endowment to enhance and expand this initiative. Both foundations based their awards in part on the support of these centers by practicing physicians, and for this we are extremely grateful.
One effort that I am quite excited about is the "Healthy Child Care" campaign — a collaborative effort of our Depart- ment, the Department of Human Resources and the North Carolina Pediatric Society aimed at enhancing linkages be- tween health care providers and child day care providers to assure healthier and safer child care environments. Campaign components include the recruitment of physicians to act as consultants to child care centers; the development of programs to educate both physicians and child care operators about health and safety issues; the initiation of a hotline to respond to providers' questions; and a host of awareness activities to encourage both child care providers and parents to model preventive health behaviors for children.
The Rabies Epidemic
I am sorry to report that 58 of our 100 counties have now been visited by the current rabies epidemic. The number of animal
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NCMJ Januan-ZFebmaJS' 1997. Volume 58 Number 1
cases has more than doubled each year since 1990. Wild animals account for the vast majority of cases, but rabies has occurred in cats, dogs, horses, and cattle. We even had a rabid rabbit in Harnett County, a very rare event.
Our staff is engaged in multiple educational efforts about rabies, including education for medical professionals through the AHEC system. Consultants are available in the Department to respond to questions; we have produced a booklet titled "Management of Animal Bites." Call 919/733-3410 durmg working hours or 733-3419 after hours, on holidays or week- ends, for consultation or to request a copy of the booklet.
AIDS and HIV in North Carolina
More than 6,700 people have developed the acquired immuno- deficiency syndrome (AIDS) in North Carolina since 1983, when the disease was made reportable in our state. Since 1989, and every year thereafter, more AIDS cases have been reported among African Americans than among whites. The cumulative total of AIDS cases reported through the end of September, 1996, shows that 61% are African American, 2% are Hispanic, and 1% are American Indian.
Dealing with Human Immunodeficiency Virus (HIV) in- fection of pregnant women and interruption of transmission of the virus to their babies is an area where the health care system must be more proactive. The most recent Survey of Childb ear- ing Women indicates that, in 1994, three of every 2,000 women who gave birth in North Carolina was HIV-positive; among African- American women, the figure was 10 of every 2,000. In some counties the prevalence of HIV exceeded one per hundred African- American women giving birth. This distressing knowl- edge, in combination with the demonstrated success of zidovudine (AZT) treatment in reducing transmission of HIV from mother to fetus, prompted our Health Commission to pass a rule requiring HFV counseling, and strongly encouraging HIV testing as a part of routine prenatal care for all women. This is an area where the medical community can tremendously help the state's prevention efforts.
The State of the Public Health System
I close by sharing several concerns regarding the continued vitality of your public health system. I consider the system to be facing very substantial challenges, including the following:
1 . Our much-beloved North Carolina tradition of home rule and local autonomy has led to an unacceptably great range of scope and quality of public health programs and services. Recognizing that the state has no authority to compel our smallest counties to join together in multicounty districts (al- though that arrangement has proven to be highly effective), county commissioners all too often maintain very small health departments. These depend on a small tax base, pay low salaries, face overwhelming problems in recruiting and retain-
ing qualified staff, and are often unable to attract key health professionals such as nutritionists, health educators, and envi- ronmental health specialists. Rather than supporting the obvi- ous answer to this dilemma (grouping counties together into fewer but vastly stronger administrative units) local elected officials instead opt to combine weak county health programs with weak county welfare programs, a recipe sure to produce weak so-called "human service" programs, the abolition of professional oversight Boards, and the transfer of critical, often sensitive health decisions away from public health profession- als into the hands of county managers.
2. Our seriously fragmented state health structure tends to separate the state public health agency from its natural partners (Medicaid, Rural Health, Health Facility Licensure, HMO regulation, and so on). As a result it cannot bring to bear upon state health policy-making its experUse in disease prevention or its ability to advocate the use of health outcomes and health status as critical elements of health system reform.
3. Many of us have envisioned a system that provides universal access to high quality, cost-effective health care — with hands-on clinical care being provided mainly by the private sector. This would allow public health professionals to concentrate on their core mission of prevention and health promotion through communicable disease control, environ- mental health, community health assessment, and community health education activities. Alas, that vision has dimmed, if not vanished, leaving ever larger numbers of uninsured and underinsured citizens who look to the emergency room and the local health department (considered by many to be the residual guarantor of care) as their only options for health care services.
Does the public health system have the resources to serve those who have no funds and no third-party payor? Can they cost-shift as they have in the past, using a portion of their Medicaid receipts to cover such care (as well as a sizeable portion of their population-based services)? No, not at all! Because Medicaid patients are being redirected into managed care plans, depriving local health departments of a key source of financial support. Still unresolved are questions about how well patients like difficult-to-serve Medicaid moms and their babies will fare in the traditional HMO.
All is not gloom and doom, however. We have several examples (including Cleveland and Buncombe counties) of instances in which practicing physicians, hospitals, and a strong local health department have come together to develop an integrated system of care, each partner doing what it does best and each respecting the contributions of the others. I believe this cooperative approach is the best answer to the questions of quality, access, cost, and health status. It returns to health professionals themselves the responsibility to design, imple- ment and evaluate the health care system of the 21st century.
The doctors of North Carolina can help us today, as they have in the past, to preserve and strengthen our public health system at both state and local levels. This will allow us to condnue to be a reliable, credible, respected partner as together we tackle the daunting health care challenges ahead. Q
NCMJ Januan/February 1997, Volume 58 Number 1
11
Instructions for Authors
The North Carolina Medical Journal is a medium for communication with and by members of the medical com- munity of this state. The Journal pubhshes six times a year: in January, March, May, July, September, and November. The Journal will consider for publication articles relat- ing to and illuminating medical science, practice, and his- tory; editorials and opinion pieces; letters; personal ac- counts; poetry and whimsical musings; and photographs and drawings. Papers that relate to the present, past, or future practice of the health professions in North Carolina are especially pertinent, but manuscripts reflecting other perspectives or topics are welcomed. Prospective authors should feel free to discuss potential articles with the editors.
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NCMJ January/February 1997. Volume 58 Number 1 1 3
DIMENSIONS OF DOCTORING
Medicine As a Mission
Dan G. Blazer, MD, PhD
Editor's note: Dr. Blazer delivered this address to graduating medical students at the Hippocratic Oath Ceremony, Duke University School of Medicine, May 10, 1996.
"Give no drugs and perform no operation for a criminal purpose"
In a few moments each of you will repeat this phrase modified from the Hippocratic Oath. I suggest that these words have taken on a very different meaning in 1996 than they had 2,500 years ago. The literal translation reads "I will give no deadly medicine to any one if asked, nor suggest any such counsel; in like manner, I will not give to a woman a pessary to produce an abortion."' We have changed the words to make them relevant to 20th-century medicine, but I do not believe we have changed the intention of Hippocrates (or the Hippocratic physicians). These ancient physicians were, I believe, less concerned with the ethics of a particular medical procedure than with the potential to abuse power which resides in the role of the physician. Other portions of the Hippocratic writings recognize this authority and power:
Life is short, and art is long; the crises fleeting; experience perilous, and decision difficult. The physi- cian must not only be prepared to do what is right himself but also to make the patient, the attendants and externals cooperate}
Hippocratic physicians had significant authority and re- sponsibility over all the persons involved in the healing arts. I find it especially interesting that the Hippocratic physicians believed the physician must "be prepared" to make "the patient do right" and "the externals cooperate." In another place, however, we read:
Medicine is of all the arts the most noble; but, only to the ignorance of those who practice it. ..it is at present far behind all the other arts. Their mistake appears to me to arise principally from this, that in the cities there is no punishment connected with the practice of medi-
cine (and with it alone) except disgrace, and that does
not hurt those who are familiar with it.^
During Hippocrates' time, there was little control over the practice of medicine. Two major forces influenced health care during this period — the profession of medicine (that is doctors) and religion. But Greek religion was in turmoil with the emer- gence of secular philosophy, and the shrines were losing their influence. Therefore secular medicine was the dominant force. Hippocrates did not want that dominance destroyed. He be- lieved in the value of medical science unencumbered by reli- gious superstitions. Yet he feared that, if physicians gained too much power, they would neglect the responsibilities that ac- company the healing arts. A concern for the proper use of power in the practice of medicine pervades the Hippocratic writings.
The power of physicians has waxed and waned since the era of ancient Greece, but during the 19th century physicians again became the dominant force in health care. Hospitals were places where persons were taken "to die"; most health care was provided by doctors in the homes of patients. Doctors were reimbursed directly by patients for the service.
During the 20th century, two new forces began to exert a major influence on health care: hospitals and health care insur- ers. As we near the end of the century they have become the dominant players in the delivery of health care in this country. Indeed, it is sometimes difficult now to distinguish hospitals from insurance companies. For example, Columbia-HCA (a company that originally managed hospitals) is negotiating the purchase of Blue Cross/Blue Shield of Ohio. Insurance compa- nies have evolved into managed care companies and health maintenance organizations (like Kaiser Permanente) that buy hospitals. What has happened to physicians while these changes have been occurring?
Physicians, as a voice in health care, have faded to the
Dr. Blazer is J. P. Gibbons Professor of Psychiatry and Behavioral Sciences and Dean of Medical Education, Box 3005, Duke University Medical Center, Durham 27710.
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NCMJ January/February 1997, Volume 58 Number 1
background. Does this mean that the changes in our health care system are necessarily bad? Do physicians necessarily need to be "in control"? Few of us would say yes. Yet most physicians, perhaps for the first time in history, are trying to find their role in the delivery of health care. Why are we undergoing this identity crisis?
Not because of advances in technology. Physicians today have more tools available to them (and to them alone) than at any time in history. As a psychiatrist, I can do more today to treat psychiatric disorders than ever before in the history of humankind. The findings of molecular genetics have put us on the verge of truly remarkable therapeutic breakthroughs. Major new discoveries are reported weekly.
Not because physicians are not as bright, independent, or energetic as they were in the past. It is almost trite to say that medicine attracts the best and the brightest. One would search far and wide (and unsuccessfully) to find a profession with more talent, energy, and integrity than medicine. Knowing my col- leagues and knowing our students, I believe that the young generation is just as independent, perhaps more so, than my own was when I entered the profession.
Not because external factors render physicians impotent. I hear much talk about "the system," but there have been systems throughout history. Systems are shaped by people with inge- nious ideas and the energy and will to see those ideas through to reality. Only passive people are shaped by "the system."
Not because patients take responsibility for their own health. Persons, especially in modern Western society, are more informed today about their health than in the past. And they are taking increased responsibility for their health. Nevertheless, the gap between what doctors know and what the woman or man in the street knows is widening, not narrowing. Patients need guidance and consultation from their physicians more today than perhaps at any time in the past. Despite recommendations for self-examination for breast and skin cancer, despite blood pressure monitors in grocery stores, despite a plethora of dietary supplements and potent drugs now available in nonprescription form, the doctor is more essential to health care today than at any time in history.
In my opinion, the problems we confront at the end of the 20th century lie in the attitudes of physicians themselves. Hippocrates was concerned about the abuse of power by the physician; I am concerned with the impotence and passivity of the medical profession. We have become complacent.
Eugene Stead, the doctor's doctor of Duke University Medical Center said years ago, "What this patient needs is a doctor."" I believe what this society needs is for doctors to stand up and be doctors! Doctors must recognize their ability to influence — their power, if you will. They must use that influ- ence and power constructively to shape rather than be shaped by the forces that dominate health care today. Don't mistake me. When I say that physicians must be motivated to shape the system, I do not mean that they must be motivated to break the system. Medicine has changed. It will never be the same. The new health care system is a reality that will not disappear,
although it will evolve. But we, physicians, can force managed care organizations to deliver optimal health care for our pa- tients.
How can you and I do this? How can we make certain that we, to rephrase the Hippocratic statement, "Assure that we can give those drugs and perform those operations which benefit our patients"? Let me suggest two related attitudes which will ensure that we have our say in the arena of health care for the benefit of our patients:
1) We must view ourselves not only as professionals, but as missionaries. I worked as a medical missionary in Africa for two years and I can tell you that the attitude of a missionary is more focused than that of a professional. Missionaries, after all, have a mission, a role underlined by a sense of moral obligation. Now, I do believe that we have moral obligations when we practice medicine. This has not been better stated than in the "Patient-Physician Covenant" published in theyo«r«a/o//4men- can Medical Association:
Medicine is, at its center, a moral enterprise grounded in a covenant of trust... .[Physicians] are both intellec- tually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times. ...These traits mark physicians as members of a moral community dedicated to some- thing other than its own self-interest. ...Only by caring and advocating for the patient can the integrity of our profession be affirmed. Thus we honor our covenant of trust with patients.^
2) We physicians must take risks. The book. Becoming Doc- tors, includes an essay by Ernest Castro Lee of the University of Texas (Class of 1994) titled, "I'll Light a Candle Before I Curse the Dark." In it he discusses his experience while a medical student visiting his native homeland, the Philippines. "It was there where I rediscovered my dreams of 'saving the world,' or at least, 'saving my Philippines.'" Mr. Lee saw hunger, poverty, and desperation as he visited medical mission- ary sites. He responded,
// is my vision to return to my homeland on medical missions every summer to perform free surgery for the poor. I plan to move there permanently and to help offset the 'brain drain ' by teaching all that I have learned in the United States to high school, college, and medical students. ...Many who hear of my plans discourage me, telling me lam too idealistic. This only serves to strengthen my resolve to return home. But the majority of people feel that the situation in the Philip- pines is hopeless and thus do nothing to help the Filipinos, all the more reason for the few who are still able to dream for a better Philippines to return and inspire the hopeless. If only one innocent child is spared a terrible disease by my medical practice or teachings, then my goal to make a difference in my homeland will be accomplished.^ I, a middle-aged academic physician, find this statement a bit idealistic, perhaps even naive. But I hope Dr. Lee proves me
NCMJ January/February 1997, Volume 58 Number I
15
wrong. We need people in our profession who strongly believe in their mission, who dare to dream to the point that they defy odds, they take risks. Many will fail, perhaps return discour- aged, but some will succeed.
In the aftermath of the Korean War where he had served as a Navy doctor, Tom Dooley, MD, returned often to Southeast Asia. For most of his short life (he died at age 34) he served the needs of that impoverished, war-torn area. He wrote three books during the 1950s about his experiences, including De- liver Us From Evil.'' Dr. Dooley's books not only encouraged me to be a doctor, they encouraged me to be a medical mission- ary. Dr. Dooley's favorite poem was "Stopping By Woods on a Snowy Evening" by Robert Frost. The final verse reads:
The woods are lovely, dark and deep
But I have promises to keep
And miles to go before I sleep
And miles to go before I sleep.
I no longer serve as a medical missionary in Africa, but I view my role as a doctor today as much a mission as I did then. I hope you will do the same. Because of your talent, your education, and your choice of profession, you have promises to keep. As you take the Oath, I ask that you not only celebrate your entrance into the profession of medicine, but recognize your power and your responsibility. I also ask that, at some level and in some way, each of you take upon yourself a mission. Medicine, frankly, is just more fun when you have a mission. Q
References
1 Hippocrates: The Oath. In: The Great Books. Hippocratic writings. Frances Adams, translator. Chicago: Encyclopedia Britannica, 1 952, xiii.
2 Hippocrates: Aphorisms. In: The Great Books. Hippocratic writ- ings. Frances Adams, translator. Chicago: Encyclopedia Britannica, 1952, p 131.
3 Hippocrates: The Law. In: The Great Books. Hippocratic writings. Frances Adams, translator. Chicago: Encyclopedia Britannica, 1952, pl44.
4 Stead EA Jr. What This Patient Needs Is a Doctor. Wagner GS, Cebe
B, Rozear MP, eds. Durham, NC: CaroHna Academic Press, 1978,
viii.
Crawshaw R, Rogers DE, Pellegrino ED, et al. Patient-physician
covenant. JAMA 1995;273:1553.
Lee EC. I'll light a candle before 1 curse the dark. In: Becoming
Doctors: Essays, Poems and Stories by Medical Students. Bolina P,
ed. Chicago: Student Doctors Press, 1995, pp 341-2.
Dooley T. Deliver Us From Evil. New York: Fanar, Straus and
Cudahy, 1956.
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DIMENSIONS OF DOCTORING
Patient-Centered Care
A Collaborative Approach
Howard J. Eisenson, MD
Editor's note: This paper was presented in March 1995, at the Randolph County Public Library in Asheboro, as one of the Jared Haft Goldstein Memorial Lectures. Dr. Goldstein, a family physician and founder of the Randleman Family Health Center, died in 1991 after a brief illness. He was 39.
Dr. Goldstein was a dedicated physician who cared deeply about his patients and his community. His academic interests were broad, and he published several papers on the importance of a human connection between doctor and patient. Family and friends established the Goldstein Lectures to further the exploration of the role of humanities in medicine. The Lectures fund is administered by Duke's Department of Community and Family Medicine.
In this talk I will describe the challenges of providing compre- hensive medical care which attends to the "whole patient" — to that individual whose health and well-being are determined by so much more than biological processes — by social, emotional, psychological, spiritual, and family factors that inform who all of us are, how illness affects us, and how we respond to treatment. I will refer to this as patient-centered care. Second, I will discuss a model for collaboration between mental health practitioners and medical practitioners, designed to enhance our ability to provide patient-centered care, especially for our most challenging cases. I will illustrate this collaborative ap- proach with a case from my own practice.
Why Patient-Centered Care?
Even those who have practiced medicine for only a short time know that medication prescriptions or surgical interventions are often insufficient to achieve improved well-being for our patients. Indeed for many of them, especially those with chronic or incurable conditions and conditions with underlying psycho- logical, social, and emotional causes, the key to feeling better and functioning better, seems to reside in changed perceptions, attitudes, or behaviors.
Through the years, many of the most esteemed medical practitioners and teachers have advised that to accomplish the
Dr. Eisenson is a physician with Lakewood South Family Prac- tice, PA, 3713 University Drive, Suite B, Durham 27707, and Assistant Consulting Professor, Duke Family Medicine Center.
best results, with the most patients, it is important that we understand and attend to the "whole patient." Dr. Francis Peabody is often quoted for his observation that "one of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient."' The man we have gathered to honor. Dr. Jared Goldstein, knew well the importance of connecting with his patients on a human level. He and others have written eloquently about the successes possible when physicians move beyond a strictly biomedical model for explaining and treating illness.'
Patients too have told us how important it is to them for their physicians to learn about them as people, and having understood better who they are, to care for them, to respect them, and to treat them as partners in the search for better health. Norman Cousins, drawing on his own experiences as a patient, tells us that "the patient-physician relationship is a powerful, sometimes mysterious, frequently healing interaction between human beings. ..at the core of this interaction is communication. . .the right words can potentiate a patient, mo- bilize the will to live, and set the stage for heroic response. The wrong words can produce despair and defeat or impair the usefulness of whatever treatment is prescribed."' Research on patient satisfaction demonstrates the importance to patients of a physician who will take the time to listen to them, to elicit their concerns in a friendly, empathic, and nonjudgmental fashion, and who will try to get to know them as people.'*
Despite these awarenesses and attitudes on the part of patient and physician alike, all too often there is insufficient attention to the whole patient in modern medical practice. Commonly physicians know relatively little about their pa-
18
NCMJ January/February 1997, Volume 58 Number 1
tients — who they Uve with; what their upbringing was like; how they function on a day-to-day basis; what have been the joys and sorrows in their lives; what are their hopes, their dreams, their fears; how do they handle pain or suffering. Too often we physicians behave as if our only task is to make or to exclude a "biomedical" diagnosis, to select the appropriate drug, or to recommend the appropriate surgery. Often we overlook impor- tant psychiatric diagnoses or evidence of such dysfunction as substance abuse or family violence.''''
Of course there are many physicians who attempt to provide patient-centered care. However, it is important to recognize that, unfortunately, there are many obstacles to practicing medicine this way.
Challenges to Patient-Centered Care
Medical training is based primarily on the biomedical model. Courses in anatomy, microbiology, biochemistry, and pathol- ogy are accorded much more curricular time than doctor-patient communication, or medical ethics. This priority is important. Modern medicine has made extraordinary strides thanks to advances in our understanding of medical science. It is neces- sary and appropriate that the scientific bases of medicine should be given major emphasis in medical school curricula. But we have also learned a lot about the importance of a humanistic approach to medical care, about the relevance of a "biopsychosocial" model of health and illness.' Yet relatively little curricular time is devoted to teaching this. Regardless of the time allocated, students soon learn that much more empha- sis is placed on their mastery of the "hard" sciences than of the "soft" ones. Some students find this emphasis on scientific medicine over humanistic medicine to be demoralizing. They become confused as many of the instincts that led them to a career in medicine, many of the instincts that lead them to try to "connect" with patients on a "human" level, they are taught to see as inefficient, or counterproductive to the important work of making a biomedical diagnosis and implementing an efficient treatment plan. This confusion is resolved by many students losing some of their idealism and modifying their style of interaction. Some leave the profession or select areas of special- ization where patient contact is minimal. Fortunately, some find the strength to endure an uncomfortable experience yet come out on the other end with their caring intact.
With the rigors of medical school and residency training behind us, we still find it difficult to practice patient-centered medicine. Medical practice is typically organized so that as many patients as possible are seen as quickly as possible. The doctor's time is expensive and, accordingly, is allocated spar- ingly. Support pers'onnel are used to reduce unnecessary con- tact between doctor and patient. The doctor uses several exam rooms at a time, so he or she can move quickly from one to the other while patients are dressing or undressing. Schedules are kept full, and usually "overbooked" so that no gaps are created by the occurrence of "no-shows." Typically, there is little if any
time built in for handling phone calls — from patients, or from other caregivers — so interruptions are frequent. The atmo- sphere is busy and often hectic. This doesn't seem to be getting better with time.
Limited patient contact time is only one of the obstacles to physicians getting to know their patients. Fewer and fewer physicians today are in solo or small group practices. Most are in ever larger group settings." In these settings, and especially with the impetus to keep schedules full, it is difficult for patients to consistently see the same doctor. Doctors may be less invested in getting to know their patients well because contact will be inconsistent. In addition, ours is an increasingly mobile society. Not only do patients change doctors because they (or the doctor) are moving, but many patients, even long estab- lished ones, leave their doctors because of changes in their health insurance options. In managed care settings where medi- cal care providers are paid in advance (capitated) for each patient on the plan, incentives exist to keep each patient's utilization of care low, i.e. not only to keep visits brief, but to keep patients out of the office as much as possible.
In addition to demographic and practice organization fac- tors, physician attitudes tend to interfere with doctors knowing their patients well and attending to their psychosocial as well as physiological needs. Many physicians feel that they lack the time "to open Pandora's box" and explore their patients' psy- chosocial concerns. Often they feel that they lack the training to address the issues that may surface. ** Additionally, physicians may be uncomfortable dealing not only with their patients' emotions but also with their own, around personal and distress- ing issues. Probably some physicians avoid exploration of their patients' psychosocial concerns because of worries about "boundaries" issues; about becoming too involved with their patients or of promoting in their patients a dependency on them.
Many physicians may feel that while a patient-centered approach to care has theoretical importance, in practice its benefits are elusive. Although they understand the importance of not missing a biomedical diagnosis, it seems generally to be acceptable to fail to recognize, or to be imprecise about a psychosocial diagnosis. Often physicians (and even patients!) seem to have the attitude that suffering as a consequence of physical illness is more legitimate than suffering as a result of psychosocial factors.
Some primary care physicians feel that exploration of their patients' psychosocial concerns is not their responsibility, and is better left to mental health experts, yet many do acknowledge the importance of attending to these concerns, at least on a basic level. These physicians will attempt to learn about their patient ' s social "context" by asking routine questions about family and work environments. However, even physicians sympathetic to this view may not practice what they preach. In a small study last year in our own residency program's family practice center we learned that of 100 new patients presenting for a complete health assessment, only a small fraction had even basic data collected by the physician regarding the patients' family- marital status, whether they had any children, who lived in the
NCMJ January /February 1997, Volume 58 Number 1
19
household, etc. Other studies have demonstrated that even when family context is addressed, it is usually in terms of inquiry about the medical history of family members; seldom is there discussion about the opinions, expectations, or feelings of family members.'"
Patient attitudes also play a role in determining the extent of physician attention to their psychosocial concerns. Many patients are reluctant to hear that there may be an emotional or psychological component to their difficulties. Even when they acknowledge significant psychological trauma, as with victims of sexual abuse, they may resist discussing this. Commonly patients will not accept referrals for mental health services.
There are many potential adverse consequences when doctors are unwilling or unable to explore psychosocial issues with their patients. Important diagnoses may be missed. This often results in inappropriate treatment, often with multiple medications that fail to alleviate the patient's suffering. Simi- larly, when diagnosis proves difficult physicians may obtain multiple laboratory and radiologic studies unnecessarily. These carry the burden of unnecessary costs and discomfort, and sometimes yield abnormal but irrelevant findings which them- selves generate more unnecessary studies. Difficult-to-diag- nose or difficult-to-treat patients may also be subjected to unnecessary referrals. Doctors suffer too when diagnosis is elusive and treatment unsuccessful. They may be subject to "burnout" when they struggle with too many such patients.
Collaboration as a Means to Providing Patient-Centered Care
Given the difficulties in attending to patients' psychosocial needs, it is not surprising that caregivers are looking for new approaches. One such approach is "collaborative care," which has been described as a team effort between "biologically oriented" and "psychosocially oriented" professionals." This model accords equal importance to the mind and the body — the psychological and the biological — in diagnosis and treatment. In addition, it emphasizes consideration of the patient's social milieu, especially the family, in gaining an accurate under- standing of problems and in designing a treatment strategy that makes the best use of available resources. The model facilitates integration, on behalf of the patient, of the different, but complementary expertise and perspectives of the "biologi- cally" and "psychosocially" oriented caregivers. Perhaps the best way to illustrate some of the advantages of this model is to describe a case from my own practice.
For several years I had been seeing a patient I will call Mrs. G, a 57-year-old married woman whom I found increasingly frustrating to deal with. She suffered from a variety of chronic pains and also from illnesses including severe ulcer disease and chronic bronchitis. Our frequent visits always followed the same pattern. She would complain of a variety of symptoms for which I could find no clear cause, and the visits would invari- ably end with a prescription for pain medication. I came to dread
her visits as my inability to "make her better" or even to explain adequately what was causing her pain made me feel like a failure. Worse, I resented the fact that I felt like I had no recourse but to prescribe narcotic pain medication, and wondered if I were being manipulated. After a couple of years of this, think- ing that there must be a better way, I asked a therapist colleague, Joe Kertesz, to see Mrs. G with me.
I continued to have my regular "clinic" visits with Mrs. G, but in addition, Joe and I would meet with her together, for approximately 45 minutes every three or four weeks. Initially, most of the time was devoted to learning more about her as a person. With encouragement, she talked with us about her childhood. We learned that she was the second oldest child in a rural farm family of five children, and that her father was an alcoholic who was frequently abusive when he was drinking. We learned that her mother died when Mrs. G was in her early teens, and that she took on parenting responsibilities for her younger siblings. She married while still a teenager. During the early years of her marriage she and her husband both began drinking heavily. Her husband was frequently on the road with his work, but when home was often drunk and sometimes abusive. Though they lived in a small apartment, the G's continued to care for her two youngest brothers until they were old enough to leave home.
As this story unfolded over several visits, Mrs. G became a much more "real" person to me. I began to see her as a complex individual with admirable strength to have survived a difficult life, much of which was devoted to caring for others. It helped too that she so appreciated these sessions. Though she often cried in talking about her past, she said repeatedly that she appreciated this opportunity, and confided that she was telling us things that she had never felt she could talk about before. It became easier and much more satisfying to see Mrs. G as I developed an appreciation for her and as she seemed at last to be deriving benefit from our visits. I wish I could report that her physical complaints lessened; some of them actually did, though she continued to have problems with chronic pain. The main difference was that she and I were both coping better with the pain.
It was very important to have Joe there for these sessions, especially in the beginning. I still chuckle to recall how difficult it was for me to sit quietly and just let Mrs. G talk. I'd become particularly uncomfortable when she paused. I suspect that for many physicians, silences feel like an unacceptable waste of time. After five to 10 seconds of silence I'd be squirming in my chair, eager to ask another question or to make a remark. Joe taught me by example to sit quietly, to tolerate my patient's emotions, and her silences. He taught me to listen carefully to what she was saying, rather than to think so much about what I was going to say next. These are normal operating modes for the skilled mental health practitioner, but for me, a family doctor with 13 years of experience, it was unfamiliar stuff. But gradually I got better at it. As time went on, I did most of the interviewing, and conducted occasional counsehng sessions on my own. I
20 NCMJ Januan'/Febman,- 1997, Volume 58 Number 1
It was also very helpful to have a trusted colleague giving me feedback on my work. He helped me to accept that I could not bear responsibility for understanding and solving all my patient's problems. Even when understanding and solutions were not possible, he helped me to feel good about the empathy and support I could provide, and which seemed to be such a comfort to my patient.
"...when understanding and solutions
were not possible, (my colleague)
helped me to feel good about the
empathy and support I could provide,
and which seemed to be such a
comfort to my patient."
After several sessions, Joe suggested that we include Mrs. G's husband. I had seen him several times in the waiting room, and had spoken to him briefly once or twice when he picked up a prescription for his wife. But meeting him, and seeing the two of them together challenged my preconceptions. At one time a heavy drinker who was occasionally abusive, he was for many years now abstinent of alcohol. He had become a religious man, and was in fact a lay minister. His manner with his wife was warm and caring, and they often related with a gentle teasing humor.
As time went on, Mrs. G's ulcer disease became more serious, and she underwent a series of surgeries, followed by complications, which left her weakened, malnourished, and unable to work. This created strains on the couple's relation- ship. Joe helped me to recognize a recurring problem in their interactions, whereby Mr. G would try to encourage his wife to get out of the bed and busy herself with chores to take her mind off her worries and symptoms. His "cheerleading" approach to her feeling bad seemed to worsen his wife's symptoms, and to cause her to withdraw further. Over several sessions, we were able to help the couple see this recurring dysfunctional pattern and to suggest a different approach for both of them . We helped Mr. G to understand that while well-intentioned, his encourage- ments felt like criticism and a lack of empathy to his wife, which worsened her feelings of distress. We helped her to understand that her husband was trying to be helpful, but that he needed her to tell him how best to be of comfort to her. The couple accepted these and similar observations, and gradually improved their communication skills and the strengths of their relationship.
At a later point in our work together questions arose about the severity and prognosis of Mrs. G's medical problems. While she remained weakened, malnourished despite a feeding tube, and in considerable pain, her diagnosis was unclear. For a time my specialist consultants had felt it likely that she had a cancer of the gastrointestinal tract. Later, this diagnosis seemed less likely, but I was advised that her condition was nonetheless serious enough that "she might as well have cancer." Though
Mrs. G was starting to show more interest in understanding the details of her illness, and what she could expect in the future, I was unsure about how much to reveal. I was afraid to frighten her or to rob both of them of their hope. Joe reminded me to listen to the patient, and to trust her resources for taking care of herself. It was not my responsibility to "protect" her from the burden of what I knew, especially when she was asking for more information. Though it was Mr. G's coping style to "think positively" and to put his trust in God, he need help to accept that his wife's wish was to understand, as best she could, what dangers the future held. I was surprised to see how well she took the grim news about her prognosis, and how supportive her husband was able to be even in accompanying her to the funeral home to pick out her own casket. Those things done, we were able to return to the themes of how to live as well as possible in the face of life-threatening illness. Mrs. G was then better able to accept some of our self-care instructions such as avoiding all aspirin-containing products.
It is still humbling to me today, more than two years after I started this collaborative work, to realize how much more help I have been able to give this couple by virtue of seeing them with my partner. Had I continued to work alone, I would almost certainly not have developed with Mrs. G the kind of bond we now have. I probably would have never recognized the impor- tance of her husband or had the opportunity to coach them as a couple in ways to be more mutually supportive. I could have continued to be mired in worry and frustration that I was unsure of my patient's diagnosis, and to feel alone with my struggles over how best to alleviate her pain. My therapist colleague's awareness of how to uncover significant personal information and concerns, his ability to look at the whole system — patient, family, and doctor — and his skill at identifying opportunities for attitude and behavior change (the patient's, family's, and mine), and strategies to accomplish these, were invaluable to me
". . .my patient's trust, my intimate
familiarity with her medical history,
and my ability to communicate to her
and her husband what seemed to be
going on in her body were also
invaluable to what (my colleague
and I) could accomplish as a team."
In the same way, my patient's trust, my intimate familiar- ity with her medical history, and my ability to communicate to her and her husband what seemed to be going on in her body were also invaluable to what we could accomplish as a team. Had I not been an essential part of the process, it's a good chance that the G's would never have accepted a referral for counsel- ing. Had the counseling not been jointly conducted, my medical work with this patient, and the counselor' s work would not have
NCMJ Januan'/Februan' 1997, Volume 58 Number 1 21
been closely coordinated and, in my view, would have been much less effective.
This represents one example of a close physician-therapist collaboration, one that involved 45-50 minute sessions at inter- vals of every three to four weeks, most of them jointly con- ducted, and continuing after two years. There are many ways to conduct collaborative care, ranging from ongoing consultation about a case, to co-therapy sessions, to referral for intensive work by the mental health specialist, depending on the needs and preferences of the patient and the capabilities and interests of the caregivers. However, there are several principles to be met if collaborative care is to be successful. First there should be regular, easy communication between the physician and therapist. This is often best facilitated by having regular oppor- tunities for interaction, such as with a shared workspace, for at least part of the week. In our work on this case, Joe and I would meet for five to 10 minutes to discuss strategy prior to meeting with the family, and would debrief for another five minutes afterward. Occasionally we would break during a session to modify our strategy. Second, there should be agreement about the goals of treatment. In this case it was to help the patient (and physician!) cope better with pain that couldn't be cured. Third, it is important for the physician and therapist to share a family, or "system"-oriented approach to care — that is, a willingness to think about patients and their problems in the context of "family" or other important social system. This involves con- sideration of how the patient's problem affects the family and, especially, how the family affects the problem and can be mobilized to be part of the solution. Finally, there needs to be a trust and respect between the collaborating caregivers, with each understanding and valuing the perspective of the other. Such relationships take time to build, but are a worthwhile investment.
Collaborative care, certainly at the level of co-therapy, raises questions about billing for services and adequacy of
reimbursement. In the case described here, care was provided in an academic center, often with resident physicians behind an observation mirror. Part of our time was covered by funds allocated for teaching, which lessened the need to bill enough to compensate two professionals for their time. Only the phy- sician billed for the sessions, listing several diagnoses in addi- tion to depression. Those interested in further discussion of the logistics of collaborative care are referred to a recent text by Seaburn, et al.''^
We firmly believe that collaborative care has the potential to save money over the long term by increasing diagnostic accuracy and treatment effectiveness, and by reducing the utilization of unnecessary services. As other clinicians have experiences similar to our own, and as these experiences are documented in clinical studies, insurance coverage should become less of an issue.
Although there is a need for further research on the results of close collaboration between mental health and medical practitioners, many of us who have used this model are im- pressed by its value to patients and practitioners alike. We recognize that this approach is not necessary and may not be practical for many of our patients, but that those who suffer from severe, chronic, and poorly understood conditions that disrupt healthy functioning may particularly benefit. We be- lieve that the collaborative approach offers many of our most challenging patients the patient-centered care that doctors and patients have long advocated, and that doctors working alone are often unable to provide. □
Acknowledgment: The author thanks Joseph Kertesz. MA, of the Duke University Medical Center Department of Community and Family Medicine, for his skilled and generous collabora- tion in the care of this patient and others.
References
1 Peabody FW. The care of the patient. JAMA 1927;88;877-82. Reprinted in JAMA 1984;252:813-18,
2 Goldstein JH. Desperately seeking science; the creation of knowl- edge in family practice. Hastings Cent Rep 1990;20;26-32.
3 Cousins N. Physician as humanist. In; Reiser DE, Rosen DH. Medicine as a Human Experience. Baltimore; University Park Press, 1984:xi.
4 Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Prac 1991;32;175-81.
5 Coulehan JL, Zetder-Segal M, Block M, et al. Recognition of alcoholism and substance abuse in primary care patients. Arch Intern Med 1987;147;349-52.
6 Heimberger LK, Saunders DG, Hovey M. The prevalence of domestic violence in practice and rate of physician inquiry. Fam Med 1992;24;283-7.
7 Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196:129-36
22
NCMJ January/February 1997, Volume 58 Number 1
8 AMA Council on Long Range Planning and Development. The future of medical practice. Chicago: AMA, 1994.
9 North S. Marvel MK, Hendricks B, Morphew P, North D. Physi- cians' usefulness ratings of family-oriented clinical tools. J Fam Prac 1993;37:30-4.
10 Marvel MK, Schilling R, Doherty WJ, Baird MA. Levels of physician involvement with patients and their families: a model for teaching and research. J Fam Prac 1994;39:535-41,
1 1 McDaniel S, Campbell TL, Seaburn DB. Family-oriented primary care; a manual for medical providers. New York; Springer- Verlag, 1990.
1 2 Seaburn D, Lorenz A, Gunn WB, Gawinski B, Mauksch L. Models of Collaboration : A Guide for Mental Health Professionals Work- ing With Health Care Practitioners. New York; Basic Books, 1996.
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24 NCMJ Januan'/Febman' 1997. Volume 58 Number 1
ETHICS AT THE END OF LIFE
Physician-Assisted Suicide
Lessons From the Kevorkian Trials
Bernard J. Carroll, MB, PhD
In February and again in May 1996, Dr. Jack Kevorkian was tried in the Oakland County Circuit Court, Michigan. He was charged with violating first a state law, then the common law against physician-assisted suicide. At the request of Geoffrey Fieger, Dr. Kevorkian's pro bono attorney, I appeared as an expert witness in both trials. My testimony dealt primarily with psychiatric issues but inevitably also with the more general matters of professional ethics raised by these prosecutions. The experience reinforced my belief in two foundations of our plurahst society: the Golden Rule and the jury system.
Though the outcomes were hardly a foregone conclusion, both juries acquitted Dr. Kevorkian, so patients remain free to request and receive his help. During the period of these trials the Second and the Ninth United States Circuit Courts of Appeal, hearing independent cases concerning state laws prohibiting physician-assisted suicide, issued major decisions protecting the right of patients to end their suffering with medical assis- tance. Physicians have become more willing than ever to state publicly that they render such assistance. Witness the recent disclosure that 25% of doctors caring for patients with AIDS have actively assisted Mother Nature in the terminal stage of the disease. The current respite in criminal trials of Dr. Kevorkian gives us the chance coolly to discuss the main issues. In this article I will focus on the major lessons of the two trials for physicians, leaving it to others to discuss the legal nuances and the social implications of these events.
Why Were the Trials Held?
H. L. Mencken described a puritan as a person consumed by the fear that somebody, somewhere is having a good time. Today ' s puritans are beset by the fear that somebody, somewhere will escape the suffering of advanced disease by endii>g their own life, God forbid, with the help of a physician. Both the old and
Dr. Carroll Is Clinical Director, Geropsychiatry Institute, John Umstead Hospital, Director, Duke Mental Health Clinical Re- search Center for Depression in Late Life, and Professor, Department of Psychiatry and Behavioral Sciences, Box 3414, Duke University Medical Center, Durham 27710.
the new puritans say the source of their anxiety is concern for the "slippery slope" down which any moral laxity must take us. Both groups cast about intolerantly to police the private actions of total strangers in the conviction that deviance from their absolute standards will lead to social degeneracy. These new puritans are dangerous people, driven by the classically psycho- neurotic puritan dynamic of unconscious reaction formation. As the prosecutors of Oakland County, Michigan, demon- strated, the new puritans have a capacity for the sadistic dehu- manization of suffering patients and their relatives far worse than anything they accuse the other camp of possessing. Little wonder that the attack was ferocious, as I saw and felt when testifying in both trials. Despite the moralizing face the pros- ecutors tried to present to the courts, the neurotic puritan dynamic was only too obvious. Before both juries I character- ized the prosecutions as petty and vindictive. As a sad commen- tary on "the people's prosecutors," the relatives and friends of the patients refused to cooperate, even though given immunity, because they saw that the prosecutors were determined to trivialize the patients' suffering and to ridicule the patients' memories in their zeal to convict Dr. Kevorkian.
What Is Suicide?
Suicide is a term that people think they understand until they are forced to reflect on it. Within the Judeo-Christian tradition suicide is considered the unforgivable sin, an act of ultimate despair. In the puritan view, moreover, a suicide is a suicide is a suicide. That view ignores a variety of suicidal behaviors that span a wide spectrum of moral contexts. When physician- assisted suicide is viewed within that spectrum the bald term "suicide" loses its customarily negative connotations.
First, we are today more familiar than we would wish to be with the concept of religious suicide, often linked to a political objective. In these cases an individual seeks a greater good through self-immolation, bolstered by the promise of a paradise that the ayatollahs describe in lasciviously sensual terms.
In Western societies a more familiar — and culturally sanc- tioned— act is altruistic suicide. A famous example is Capt.
NCMJ January/February 1997, Volume 58 Number 1
25
Lawrence Gates, who walked away from Scott's South Pole expedition to his certain death in an Antarctic blizzard, hoping to improve his companions" chances of survival, as he believed his own debility threatened the entire team. This example was used to educate the juries about the issue of primary intention. In its context. Dates' behavior had the goal of saving others' lives. Though he did something that in another context could be judged morally reprehensible, he is viewed in this context as having acted with heroism, and he has become a cultural icon. The juries had no difficulty extrapolating this principle to the cases being tried.
A third culturally sanctioned category is preemptive sui- cide, performed as a means of avoiding inevitable pain and suffering. An outstanding historical example is that of the Jewish encampment at Masada. Knowing that they were about to be overrun by the 1 0th Roman Legion, the defenders of Masada committed group suicide in order to prevent the rape, torture, suffering, and death they knew would follow. More current examples are the widespread but seldom discussed suicides of Jews, Gypsies, and homosexuals to avoid degrada- tions and death in the concentration camps of the Nazi Third Reich. Nobody today calls those Holocaust suicides morally reprehensible. Even the government of the United States sanc- tions preemptive suicide, as when the Central Intelligence Agency provides cyanide capsules to its operatives so that they will have a choice for avoiding torture in the event of capture. Gnce again, the Kevorkian juries had no difficulty seeing the parallels between these examples of preemptive suicide and the cases being tried. They accepted our point that it makes no moral difference whether the pain and suffering being avoided through preemptive suicide result from incurable disease or from the malevolence of other people.
Finally, we have the category of clinical suicide, commit- ted under the judgment-distorting influence of a psychiatric disorder such as major depression, schizophrenia, alcoholism, and adjustment disorders. The major clinical correlate of these suicides is not the diagnosis perse but the cognitive symptom of hopelessness, sometimes delusional, sometimes not. Clini- cal suicides represent attempts to relieve intolerable psychic pain. Most are preventable, and therapeutic optimism is always in order, even in refractory cases.
When this spectrum of suicides was presented in court, the prosecutors were deprived of the rhetorical tactic of using the naked term "suicide" with its automatically pejorative over- tones. They were also prevented from focusing concretely on the suicidal acts without reference to the primary intent of both the patients and Dr. Kevorkian, which was to relieve pain and suffering.
What About Untreated Depression?
A significant issue in the trials was whether the cases repre- sented preemptive or clinical suicides. The diagnosis of clinical suicide requires the diagnosis of a psychiatric disorder. Fortu-
nately, Dr. Kevorkian had videotaped interviews with each patient. I spent considerable time reviewing the videotapes and they were seen in part by the juries as well. The taped sessions were not structured as formal mental status examinations but each covered a wide enough range of content that an experi- enced psychiatrist could form a reasonable judgment about the patient's clinical state. The videotapes also contained good samplings of the nonverbal behavior and communications of the patients.
I found none of the four patients in the two trials to be cognitively impaired or psychotic. None acted under the force of delusions about their disorders or their prognoses. All were competent to make decisions. All were in a state of emotional distress, to varying degrees, but none was in a state of clinical major depression. All had been successful, independent per- sons who had become overwhelmed by their medical condi- tions, yet they remained willing to try any reasonable treatment which was expected to help them. The medical conditions in question were formidable: two patients had a terminal, progres- sive neurologic disorder (amyotrophic lateral sclerosis [ALS], and multiple sclerosis), each with extensive involvement of the bulbar and respiratory muscles; one patient had terminal mul- tiple myeloma with severe pain and imminent spinal cord compression; and one patient had intractable vulvodynia and secondary central pain syndrome associated with genital scar- ring after radiation injury and vulvectomy. In this last case a prefrontal lobotomy had been seriously proposed as the only remaining treatment option.
Almost all symptoms of depression displayed by the pa- tients could be attributed to their medical conditions or to the treatments they were receiving. Their emotional state would be best characterized as grieving, which is not a pathologic re- sponse. We forcefully made the point before the juries that being emotionally upset, even having crying spells, is by no means equivalent to a major depression. The prosecutors did obtain the services of one psychiatrist who testified at the May 1 996, trial that both patients were depressed. The jurors did not find his testimony credible, however, when they learned that the prosecution's expert witness had not viewed the videotapes, that he had only the sketchiest of medical records on which to base his opinion, and that most symptoms of "depression" he cited were due to the primary medical conditions.
The videotapes were very persuasive to the jury: an aver- age person could see that the patients did not look, act or speak as though they were in the grip of a morbid depression. The jurors easily identified with the patients, who appeared as stunningly ordinary people discussing their situations on video- tape in simple, direct terms, without histrionics or self-pity. The jurors concluded that the patients had made rational decisions for preemptive suicide. They could empathize with the patients' situations and apply the simple Golden Rule, "Do for others as ; you would have them do for you." Aided by the videotapes, the j jurors could imagine themselves facing the same choices, making the same decisions, and hoping that somebody like Dr. Kevorkian would be there to deliver them from their suffering.
26
NCMJ Janitan,'/Febniar\ 1997, Volume 58 Number I
Not surprisingly, the prosecutors strove mightily but unsuc- cessfully to prevent the videotapes from being shown to the jurors.
The criteria for diagnosing major depression in patients
with serious medical illness are being actively researched. The
last word on the subject is a long way off. Two relevant
conclusions of the studies conducted to date are: 1) it is
extremely difficult to validate in the medically ill diagnoses of
major depression made by the usual psychiatric criteria; 2)
"depressed" medical patients have not been shown to respond
specifically to antidepressant drugs, that is, their responses to
drugs do not surpass their responses to placebo. There is no
{ basis in controlled clinical trials to mandate as the standard of
I care the treatment of such patients with drugs, psychotherapy,
j or anything other than treatment of the primary medical condi-
I tion. The reason, of course, is that many of the psychiatric
J "diagnoses" are invalid because medical symptoms (weight
change, lassitude, anorexia, fatigue, poor concentration, sleep
i| disturbance) are mistaken for psychiatric symptoms. The juries
I in both trials were persuaded by this perspective. They also
i discounted major depression as a factor after hearing that all the
I patients had received antidepressant treatments long in advance
of the decision to end their lives.
Parenthetically, one must acknowledge here the masterly work of Dr. Kevorkian to support the patients for months to years, encouraging them to seek other options for relief of their suffering, especially psychiatric help and pain clinic manage- ment. The conclusion that all practical options were exhausted was not Dr. Kevorkian's but was conveyed to the patients with varying degrees of forthrightness by their own physicians. Far from being the impulsive "Dr. Death" portrayed by the media, Dr. Kevorkian acted conservatively in his relationships with the patients until the final decision was reached.
But Should Doctors Help?
It is one thing to recognize that patients may choose pre- emptive suicide rationally and unaffected by psychiatric ill- ness, but quite another to say that doctors should help them do it. At least, it is quite another thing to say so out loud. Yet as Sherwin Nuland makes clear in his book. How We Die, doctors have a long tradition of quietly helping terminally ill patients die quickly and easily. This is an area of medical practice in which euphemism and obfuscation abound. It is a closely veiled practice of the guild, the more mysterious the better to avoid accountability, audit, or explanation to outsiders. When it is done well it is magical. The preferred technique is to narcotize the patient with excessive amounts of morphine to the point of respiratory arrest, all the while humbly declaring one's lack of skill in judging just how much pain the patient is enduring, and begging the forgiveness of the relatives for not more effectively relieving the patient's suffering. By the time it is over, usually not a long time, the grateful relatives have little awareness of what has happened, the hospital or hospice staff know better
than to say anything, the patient has been spared a few days to a few weeks of agonal suffering, and the physician has experi- enced a satisfying reinforcement of his or her sense of mastery of the art of medicine. What could be wrong with any of that? It was good enough for Edward VII and for Sigmund Freud on their way out wasn't it?
There are other scenarios but that is the classical model of autonomous and omnipotent decision-making by the physi- cian. In this scenario the physician is accountable only to professional peers and then only indirectly. In the view of many physicians, Jack Kevorkian's most egregious fault lies not in helping patients but in his openly defiant publicizing of his work. The guild did not appreciate having the screens removed from the doorway to the dying room. They fear that some of their freedom to help patients die quickly and easily, without publicity and with no questions asked, has been lost. They are right. And now that a societal searchlight is on the matter, there is a new focus on the questions how and when.
A Natural Death?
At the trial in February 1 996, it was stated that Merion Frederick, dying of ALS, unable to swallow, unable even to hold her head up, would have been permitted under Michigan law to end her suffering by starving herself to death, refusing feedings through her stomach tube. She was competent to make that decision and had she done so her case would never have been a topic of discussion in the Oakland County Circuit Court. Never mind that she would suffer pitiably in the drawn-out process of starving. Never mind that one would be prosecuted for doing the same thing to a dying animal. Never mind. It would be a natural death, that was the important thing, even more impor- tant than a humane death. It was put to her adult children that as law-abiding citizens they should have influenced her in that direction rather than support her in the course she took. Natu- rally, they rejected these sadistic suggestions in the most derisive terms. That was not a good moment for the hapless prosecutors.
The jurors likewise were not impressed by this argument for a natural death. They did accept our position that the duty of a physician is always to relieve suffering but not necessarily to prolong life at any cost to patient or society. The relief of suffering is not only a duty of the physician, it is at the same time a right of the patient. The competent patient can make a legitimate claim on society for this right. Once it has been determined that the patient's suffering should end, even if that entails ending the patient's life, the only remaining consider- ations are that the death be rapid, painless, and certain — a humane death. It is not important that the means adopted be a traditional "medical act" such as the narcotizing scenario de- scribed above. As a recent English commentary noted, "It is the issue of the patient's legitimate interests that concerns about euthanasia must address and not the narrow definition of whether or not the intervention is medical."' These arguments
NCMJ January/February 1997. Volume 58 Number 1 27
prevailed over the prosecution's theatrical rhetoric that the carbon monoxide canisters and potassium chloride solutions used by Dr. Kevorkian have no place in traditional medical therapeutics.
Still, use of such methods is a high hurdle for physicians, and even higher when the patient is not "terminal" in the usual sense of the final phase of illness. The ambivalence of physi- cians is easy to understand and will be hard to overcome until we remember that it is the patient who performs the final act. That principle of autonomy was affirmed by the Ninth and the Second US Circuit Courts of Appeal in the past nine months.
But People Will Abuse It
Of course they will. There is no development of culture or society that people will not abuse, human nature being what it is. But that is no reason to make the perfect the enemy of the good. Consider adoption. Could any activity better reflect the life-affirming virtues of charity and compassion than the adop- tion of a motherless child? Perhaps that was once true — until adoption became an industry, supporting the comfortable lifestyles of legions of professional "charity workers" and responding to the flows of supply and demand, with money changing hands, with black marketeering, and with trafficking in kidnaped infants. These are good reasons to make adoption a regulated social service but none is sufficient reason to make adoption itself a criminal offense. Similarly, puritans might better direct their energies to regulating the practice of physi- cian-assisted suicide than to criminalizing it. The juries under- stood these points.
Psychiatric Activism
All societies have a judicial process that permits the involuntary commitment of persons thought to be a danger to themselves, for example, at risk of clinical suicide. A matter of lively concern for the future is that puritanical psychiatrists will subvert and manipulate the involuntary commitment process to force the detention of patients known to be contemplating physician-assisted suicide. Using guerilla tactics if necessary, these psychiatric activists will fabricate psychiatric diagnoses to suit their purpose. We are all too familiar with such radical behavior in the Roe v Wade wars.
At the May 1996, trial of Dr. Kevorkian such tainted diagnoses were shamelessly proffered as evidence by the pros- ecution. An activist psychiatrist who had never met with the patient falsely described herself as the patient's "consultant psychiatrist" in Court papers requesting involuntary psychiat- ric commitment. A second psychiatrist who also did not meet with the patient completed the second section of the petition for commitment, claiming a diagnosis of major depression. The primary physician caring for the patient had not invited either of these activists into the case. They literally intruded as ethical
busybodies into a matter that was none of their professional business.
The patient was briefly detained at a state psychiatric hospital, then released after examination by the hospital-based psychiatrist, who rendered a diagnosis of pain disorder without a psychiatric diagnosis. The patient and her family experienced the coercive, manipulative, involuntary commitment as con- firming their fear that some physicians would go to any length to deny or trivialize her suffering. These activists conveyed the sadistically dehumanizing message, "I will feel better if I force you to remain alive, even though you will suffer more."
Adding insult to injury, the puritan prosecutors did not hesitate to misrepresent these activist shenanigans as valid psychiatric opinions. We were able to deflect these attempts to mislead the jury and to expose the prosecution's tactics for what they were. Just the same, it was a chilling experience to have to stare down a threatening public prosecutor, who used all the license permitted by the rules of courtroom cross-examination, knowing that he was trying to introduce tainted evidence. Observers saw in this episode a conspiracy of the puritan right to subvert the professions of medicine and the law in pursuit of their neurotic agenda. That is why I believe the neo-puritans are so dangerous: they do not respect professional boundaries and codes of conduct because they regard themselves as agents of a higher cause.
Epilogue
Medicine is a profession large enough and strong enough to accommodate diverse, conscientiously held positions on our role in the ending of life. But not guerrilla warfare. Physician- assisted suicide ought to be a much less divisive issue for the profession than abortion is, if for no other reason than that the dying patient asks the physician to act. There is no movement to coerce the radical right wing or any other members of the profession to participate in physician-assisted suicide. They are free to follow their consciences. The Golden Rule here requires that the rest of the profession be extended the same courtesy of noncoercion and noninterference.
Now that the trials have stopped, what next? That will depend a great deal on where medicine itself goes with the new models of "health care delivery." To the extent that these new models work against the formation of a confidential physician- patient relationship which is sustained over years and within which physicians can quietly help dying patients in the tradi- tional way, then patients will demand solutions that, to my taste, are less palatable. Solutions like Obitaria — organized places where just a few doctors specialize in physician-assisted sui- cides— which I think is one of Jack Kevorkian's nuttier ideas. But I can imagine worse. I can imagine the devolution of assisted suicide into a "health care benefit" administered by one of the transient functionaries in a "health care delivery system," perhaps an Employee Assistance Program gatekeeper, who arranges for the actual work to be done in the most cost-
28
NCMJ Januan/Februan; 1997. Volume 58 Number- 1
effective way by the physician extender of the day. After all, it' s not exactly rocket science, is it?
If we hope to prevent such an outcome, the lessons of the Kevorkian trials will be important. First, ordinary people as patients and as jurors accept that there can be valid claims for physician-assisted suicide; the pressures on physicians from this direction will only grow, and it is not too early for us to think of regulatory procedures, now that the phase of criminalization seems to be over. All schools of thought within the profession will rightly want to be heard in the process of establishing guidelines. Second, a spirit of reciprocal tolerance within the profession is called for rather than neurotically driven activism that subverts professional standards (to say nothing of profes-
sional etiquette) in the diagnosis and management of suicidal risk. Third, physicians cannot assist patients at the end of life in the customary ways if the health care delivery system destroys the tradition of enduring, confidential relationships between physicians and patients. We can thank Jack Kevorkian for what he has done to force us to pay attention to these issues, even as we curse him for upsetting the comfortable old system. But then, if the comfortable old system had been working right all those patients would not have found their way to Jack Kevorkian in the first place, would they? □
Reference
I Burn.s A, Hams J. Ethical issues in dementia. Psych Bull 1996;20:107-8.
Endnote
by Assad Meymandi, MD, Editorial Board member, and guest editor, "Aspects of Elder Care," Nov/Dec 1996 special issue
The topic of physician-assisted suicide deserves robust examination, debate, and public scrutiny. In 1994, Ore- gon voters passed a law legalizing physician-assisted suicide (it has been blocked by a challenge), and only recently has the Supreme Court shown willingness to hear this matter.
There is a real danger that the debate will become marred by emotionality, dogmatism, and polarization. The discussions must be conducted in a flexible but dispas- sionate, logical, and sober atmosphere. I was distressed
to observe a television broadcast of flamboyant behavior by Dr. Kevorkian's legal team after one court victory. This serves no purpose.
As physicians, we must remember that our role is to advocate for our patients, not serve as a mere doctrinaire system of beliefs. Dr. Carroll's seminal article forcefully furthers these arguments. I am happy to see it published.
(On the next two pages. Dr. John Glasson summa- rizes current American Medical Association initiatives on physician-assisted suicide. — Eds.)
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NCMJ January/February 1997, Volume 58 Number 1
29
Physician-Assisted Suicide: Current A (VIA Initiatives
by John Glasson. MD, Immediate Past Chair, AMA Council on Ethical and Judicial Affairs, and retired orthopedic surgeon, Durham
The American Medical Association and its Council on Ethical and Judicial Affairs have explicitly opposed physi- cian-assisted suicide since 1991 when the report "Deci- sions Near the End of Life" was issued to the House of Delegates at its Annual Meeting. Two years later an additional report explored many of the ethical concerns associated with the practice of physician-assisted sui- cide, and revealed problems with the proposed regulatory measures.
During the past year, the issue has returned to the spotlight, and remains debated by the public and the medical profession. In 1995, Michigan prosecutors at- tempted to apply a state law to convict Dr. Jack Kevorkian, a retired pathologist who had helped two patients commit suicide. The fact that he did assist was never in question, but he was acquitted of criminal involvement. Two further attempts to prosecute him failed, the latter under common law rather than statutory law. Amid these proceedings. Dr. Kevorkian filed a $1 0 million lawsuit against the AMA for libel. He also became an outspoken advocate for the right of patients to control their own deaths.
As the Kevorkian cases played out in the Michigan court system, two decisions of far greater legal signifi- cance were reached in the Ninth and Second Circuit Courts of Appeals. The Ninth Circuit Court ruled that controlling the time, manner, and circumstances of death are the constitutional right of each individual. Conse- quently, states cannot override that right without due process in accordance with the Fourteenth Amendment. Perhaps more significantly for physicians, citizens have grounds under this ruling to demand assistance in dying from the medical profession.
The Second Circuit Court reached a similar conclu- sion about physician-assisted suicide, but on different constitutional grounds. The court argued that physician- assisted suicide is covered by the equal protection clause of the Fourteenth Amendment; it found no appreciable difference between the withholding or withdrawing treat- ment and assisted suicide. Since the result (death of the patient) is the same in either case, the court stated that the acts themselves must carry equal moral status. And because patients on life support can end their lives merely by withdrawing such support, those not on life support who require active assistance to die cannot be denied that opportunity. Following the equal protection argument, if death is the desired end, the state cannot restrict one group from an opportunity to obtain that end while another group is not restricted.
Both these arguments significantly shift the debate and alter the context within which discourse about physi- cian-assisted suicide must be conducted. Offering consti- tutional protection to assisted suicide gives it status that
no other form of health care currently enjoys (with the possible exception of abortion, which is covered underthe broad heading of privacy). Perhaps more troubling is the fact that the Second Circuit decision blurs distinctions in end-of-life care that have been established over decades of legal action and ethical discourse. Both legally and ethically, we recognize a patient's right to stop unwanted care based on a perception of the harms associated with treatment. That right is upheld despite the possibility that exercising it leads to death. It is upheld as a means of avoiding the suffering caused by treatment, not because it affords patients the means to end their lives. That argument does not hold with assisted suicice. Further- more, lumping withdrawal of care with physician-assisted suicide, runs the risk that patients will be unable to refuse heroic measures because their decision will be seen as "suicide."
The court decisions make it difficult, perhaps impos- sible, to construct adequate safeguards limiting assisted suicide. By contending that assisted suicide is a matter of individual choice between a physician and a patient, the Ninth Circuit Court established a broad right that cannot be restricted only to the terminally ill or even to those suffering from illness of any kind. Under the court's ruling, the responsibility for establishing eligibility for death be- longs to the individual whose final judgments are not subject to review by the state. In short, patients can use any subjective criteria to determine their suitability for discontinuing life; there will be no real way to prevent them from acting upon their conclusions.
The Second Circuit Court argument also creates problems with regulation. Basing its opinion on the equal protection clause, the Court opened the door to leading from assisted suicide to overt euthanasia. Assuming physician-assisted suicide were made legal, under the Fourteenth Amendment physicians could not refuse to provide life-ending measures simply because a patient was incapable of self-administrating the lethal agent. Patients whose debilitating illness prevented them from committing suicide would be allowed to request and receive active euthanasia. The unspoken but inevitable endorsement of euthanasia is a tragic consequence that many jurists and policymakers have not considered.
Relevant Studies
Several pspers published in the Journal of the American Medical Association and the New England Journal of Medicine have fueled the flame of public debate. JAMA published the first of these studies (called SUPPORT) in November 1995. It documented the failure of an experi-
30 NCMJ Januaty/Februaiy 1997, Volume 58 Number 1
mental protocol, applied at five reputable teaching institu- tions, to bring patterns of care into accordance with patients' living wills. Patients haddocumentedtheirwishes for end-of-life care, but the percentage of physicians who upheld those wishes was low. The SUPPORT study strengthened the perception of patients that they have lost their autonomy and that regaining control of their own destiny through the use of advance directives is not a viable option. In short, SUPPORT brought into sharp focus the problems surrounding end-of-life care and set the stage for groups who maintain that the central issue in assisted suicide is respect for the autonomous decisions of competent patients.
In February 1996, the New England Journal of Medi- cine published two studies documenting the attitudes of physicians and the public in Michigan and Oregon regard- ing physician-assisted suicide. These studies show ap- parently strong support among the public and the profes- sion for assisted suicide, but the data should be inter- preted with caution. For instance, one of the questions depicted a scenario in which the patients were asked to imagine they had a "terminal illness that is certain to involve a great deal of pain and suffering." A large number of respondents said they would consider assisted suicide under these circumstances. It is important to note, how- ever, that the premise is not well-grounded in the medical realities of pain management. With appropriate palliative treatment, almost no patients should face certain pain and suffering; the implications of data gleaned from such a question are entirely unclear, but the surveys suggest that some segments of society do support assisted suicide.
In March 1996, JAMA published a study indicating that patient requests for assisted suicide are not rare, and that a number of physicians have, in fact, granted these requests. The New England Journal of Medicine pub- lished a survey in which several nurses indicated that they had participated in acts that contributed directly to the death of patients. The latter study drew heated criticism based on what many perceived to be poor methodology, but both studies point to a willingness of at least some health care providers to act outside of the law when they perceive need.
The AMA Response
• Perhaps the AMA's most important response is a recog- nition that physicians have not adequately met the needs of dying patients. Methods exist to provide comfort in virtually all terminal illnesses, but they are tragically underused. Consequently, the AMA's primary goal is to focus attention on the resources available to meet the psychological and physical needs of those facing the end of life. Fear of pain and loss of dignity — the cornerstone of public support for assisted suicide — needs to be ad- dressed. To achieve its goal, the AMA is planning a massive "train-the-trainer" project to educate physicians about advance directives and palliative care. The AMA has formed a coalition of health professionals to pool the resources of disparate groups in carrying out educational projects to improve the quality of care at the end of life.
• The US Supreme Court has agreed to hear cases on physician-assisted suicide early this year and is expected to render a decision in July. The AMA and 45 other medical and health professional groups joined forces in a friend-of-the-court brief urging the Court not to legalize physician-assisted suicide. The groups include the Ameri- can Nurses Association, the American Psychiatric Asso- ciation, and the North Carolina Medical Society. At least one medical group, the American Medical Students Asso- ciation, is expected to be among those filing briefs in support of legalizing physician-assisted suicide. In a re- lated research study at Duke University, Dr. Harold Koenig recently reported that elderly patients usually oppose physician-assisted suicide, although most of the younger members of their families support this option.
• The statement below on physician-assisted suicide from the 1996-97 AMA Code of Medical Ettiics summa- rizes the current AMA position. Its essential elements have been strongly and proactively supported by both the House of Delegates and the Board of Trustees in 1995 and 1996 in formal update reports:
Pfiysician-assisted suicide occurs wfien a phiysician facili- tates a patient's death by providing the necessary means and/or information to enable the patient to perform the life- ending act (for example, the physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide).
It is understandable, though tragic, that some patients in extreme duress — such as those suffering from_ a terminal, painful, debilitating illness — may come to decide that death is preferable to life. However, allowing physicians to partici- pate In assisted suicide would cause more harm than good. Physician-assisted suicide Is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks.
Instead of participating in assisted suicide, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is deter- mined that cure is impossible. Multidisciplinary interventions should be sought including specialty consultation, hospice care, pastoral support, family counseling, and other modali- ties. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.
Issued 1994 based on: "Decisions Near the End of Life, "issued June 1991, and "Physician-Assisted Suicide," issued December 1993 (JAf\/lA 1992:267:2229-33). Updated June 1996. Source: AfvlA. Code of Medical Ettiics: Current Opinions with Annotations, 1996- 1997 ed. Chicago: AMA, 1996, pp 56-7 sect. 2.21 1
NCMJ Januan/Februarv 1997, Volume 58 Number 1
31
MODERN MEDICINE
Most Anesthesiologists
No Longer Restrict Clear Fluids for
Eight Hours Before Elective Surgery
A. Colin McKinley, MD, Robert L. James, MS, and Grover R. Minns, III, MD
For many years an overnight fast has been standard practice before elective surgery. The rationale was that an empty stom- ach would prevent the aspirating of gastric contents, but the origin of the practice of withholding food and fluids after midnight is obscure. Not that there is no interest in the subject; an on-line literature search located more than 600 references published in the past 10 years dealing with fasting regimens to prevent aspiration. Recently, a number of articles' ' have ques- tioned whether clear fluids should be withheld as part of the overnight fast, and several have recommended short periods of fluid deprivation.
Standard physiology texts state that the stomach empties of clear fluids in 1 5-30 minutes, but in obstetric and trauma cases, where gastric emptying time is increased, it is often impossible to wait for the stomach to empty before surgery. The pediatric literature recommends brief fasts for infants and children since an overnight fast can cause dehydration and hypoglycemia, and a stormy, difficult induction of anesthesia. There has been much debate over the status of breast-fed infants, but the consensus seems to be that breast milk, being a semisolid food, should be restricted and only clear liquids given during the two to three hours before elective surgery.
Anesthetic Practice in the US and in NC
To determine whether the duration of fasting recommended by anesthesiologists has changed, we conducted a national survey'' and found that withholding clear fluids for eight hours before elective surgery is no longer common practice. Of the respon-
Dr. McKinley Is Assistant Professor, Mr. James is Statistician, and Dr. Mims is Associate Professor, Department of Anesthe- sia, Bowman Gray School of Medicine, Medical Center Boule- vard, Winston-Salem 27157.
dents to our survey, 94% were aware of recent recommenda- tions for shorter fasting times for clear fluids; 67% had changed their practice to allow clear fluids three to six hours before surgery and only 15% still required a seven- to eight-hour fast before elective surgery. Most considered coffee without cream a clear fluid and almost two-thirds allowed black coffee during the three to six hours before surgery. Less than 1% of anesthe- siologists restricted fluids for eight hours before elective sur- gery in children. Most of our respondents felt that surgeons were unaware of the recommendations regarding shorter fast- ing times, but less than half were trying to educate surgeons about this. A small number of anesthesiologists felt that allow- ing clear fluids during the eight hours before elective surgery made their practice more difficult, probably because these patients may not be able to be moved up in a busy schedule.
We followed the national survey with a survey of all North Carolina anesthesiologists, to find out whether they, too, were aware of the recent literature recommending shorter periods of fasting from clear fluids before elective surgery, and whether they had changed their practices as a result. The results of the NC survey (see sidebar, next page) mirror the national survey, except that more NC anesthesiologists use shorter fasting times before elective pediatric surgery. Both surveys indicate that shorter fasting times have become the norm.
Discussion
The first recorded anesthesia-related death may have been due to aspiration of gastric contents.' Later, Mendelson called attention to the possibility that gastric acid was aspirated during anesthesia in a number of obstetric cases,'' and for a time "Mendelson' s Syndrome" referred to the clinical consequences of aspiration. The fulminating pulmonary edema described by Mendelson was similar to that reported by Winternitz'' who
32
NCMJ January/February 1997, Volume 58 Number 1
instilled acid into rabbit tracheas as part of his study of gassing deaths after World War I. Subsequent review of Mendelson's work indicated that many of his cases may have been due to particulate rather than acid aspiration. It seems safe to say that the seriousness of particulate aspira- tion is related to the volume of aspirate in contrast to acid aspiration where a small quantity of acid gastric contents may be a potentially lethal event.
Restricting solids for eight hours before elective sur- gery remains a legitimate way of reducing the danger of particulate aspiration. A number of ideas for reducing the danger of acid aspiration have been proposed and dis- carded}'^-These include the use of oral antacids, H, blockers, and emetics. Oral antacids themselves can cause particulate aspiration, and the routine use of H^ blockers is not consid- ered a cost-effective intervention in such a rare event. Neither patients nor anesthesiologists would accept the routine use of emetics to guarantee an empty stomach. For patients at risk of aspiration, awakened intubation, cricoid pressure, and rapid sequence induction are recommended.
Much of the concern about the risks of acid aspiration center around the small volume of acid reportedly needed to put patients at risk (25 cc of stomach fluid with a pH less than 2.5). Unfortunately, the index paper" that defined pH and volume variables was never published in a peer re- viewed journal, and when the study was repeated,'"* it was found to be grossly in error. We now believe that patients can have larger gastric volumes of low pH without being at risk for acid aspiration. A number of papers report that shorter fasting times for clear fluids do not increase risk, and some even advocate giving water up to two hours before surgery to increase gastric emptying.'' A review of insur- ance claims indicates that acid aspiration during anesthesia is uncommon. Several authors-'^ suggest that we better define fasting status for clear fluids for elecdve surgery.
Most North Carolina anesthesiologists are aware of recent recommendations and no lorger restrict clear fluids for eight hours before elective surgery. The recommenda- tions for shorter fasting times for clear fluids have been made within the past 10 years and anesthetic practice is probably still changing because of this. Shorter fasting times for infants and children have been recommended for more than 20 years and are now accepted by almost all anesthesiologists. The advent of managed care means that increasing numbers of patients are being admitted to hospi- tals the morning of elective surgery. Anesthesiologists must often rely on others for the preoperad ve preparation of these pafients. An understanding of the new recommendations about fasting from clear fluids should help in preparing patients for elective surgery. Certain pafients (those who are diabetic, obese, or who have peptic ulcer disease or gastroe- sophageal reflux) are still at risk for acid aspiration ; primary care physicians should check with an anesthesiologist in preparing such patients for elective surgery. □
Survey of NC Anesthesiologists Regarding Nature of Fasting Before Elective Surgery
The North Carolina Society of Anesthesiologists supplied us with the names and addresses of all members. We mailed a one-page questionnaire to the 408 Society members, and followed this with a second mailing to nonrespondents; 356 (88%) of the anesthesiologists contacted returned a question- naire.
The survey sought information on current attitudes about duration of fasting, whether fasting orders differed between adult and pediatric patients, and whether shorter fasting orders do or might make practice more difficult (see Table 1, next page). Information about hospital type and size was also requested on the survey form.
The percentage of respondents giving each possible re- sponse to a survey question was calculated, and the 95% confidence intervals for these percentages were calculated using either exact methods or the normal approximation of a binomial where appropriate. Chi-square analyses and Fisher's exact tests were used to explore possible relationships be- tween demographic factors and fasting practice. Alpha levels of these tests were adjusted for multiple comparisons using the Bonferroni method.
The primary objective of our survey was to determine whether or not North Carolina anesthesiologists require eight- hour fasting from even clear fluids before elective surgery. The results of our survey are shown in Table 1 . Almost 94% of the respondents were aware of recent literature recommendations that fasting times be shorter than eight hours, and 67% had changed their practice to accommodate this. Only 1 5% still use seven- to eight-hour fasts before elective surgery; over two- thirds limit fasting to three to six hours. The majority of respon- dents consider coffee without cream to be a clear fluid, and almost two-thirds allow coffee up to three to six hours before surgery. Less than 1 % of the respondents restrict fluids for eight hours before elective surgery for pediatrics.
Eight percent of respondents thought that less than eight- hour fasts had made their practice more difficult. Allowing clear fluids the morning of surgery may make it difficult to move cases up in a busy surgical schedule, and some anesthesiologists feel that this makes their practice more difficult. Most of those surveyed felt that surgeons were not aware of current recom- mendations for shorter fasts, but less than half were trying to inform their surgeons of this trend.
No significant associations were found between survey responses and the demographic factors assessed (population base of the hospital; bed capacity of hospital; presence of a trauma center at the hospital; whether the hospital was a teaching institution; whetherthere was a teaching hospital in the city of practice).
The results from North Carolina agree with those from our recently published survey of anesthesiologists nationwide, al- though more NC anesthesiologists used shorter fasting times before pediatric surgery than the national average."
NCMJ Januaty/Februan- 1997, Volume 58 Number 1 33
Table 1. The practice of North Carolina
anesthesiologists regarding fastinc
before elective
surgery*
1) Are you aware of recent literature with respect to shorter fasting times before elective surgery?
Yes*
94% (93,95)
No
2.5% (1.9,3.1)
Missing 3.2% (1.9,4.5)
2) If yes, has this information changed your way of practice?
Yes
67% (65,68)
No
26% (24,27)
N/A
3.1% (2.4,3.7)
Missina
4.8% (4.0,5.6)
3) How many hours before elective surgery on adults do you allow clear fluids
7-8 hrs
15% (13,16)
5-6 hrs 44% (42,46)
3-4 hrs 2 hrs 32% (31,34) 3.9% (3.2,4.7)
1 hr 0.6% (0.3,0.8)
Missina
4.5%
(3.7,5.3)
4) How many hours before surgery do you allow coffee?
26% (25,29)
41% (39,43)
24% (23,26)
2.0% 1.5,2.5)
0.8% (0.5,1.2)
5.9% (5.0,6.8)
5) How many hours before pediatric 0.3% (0.1,0.5) elective surgery do you allow clear fluids?
10% (9,12)
57% (56,59)
23% (21,24)
2.2% (1,7,2.8)
7.3% (6.3,8,3)
6) Does/would these new procedures mal<e practice more difficult?
Yes
7.9% (6.9,8.9)
No
84% (83,86)
Missing 7.9% (6.9,8.9)
7) Are the surgeons aware of this fasting literature?
Yes
22% (21,24)
No
64% (62,65)
Missina 14% (13,16)
8) Have you tried to inform surgeons of this literature?
Yes
43% (41 ,45)
No
47% (45,49)
N/A
5.3% (4.5,6.2)
Missing 4.5% (3.7,5.3)
9) Is your practice:
Individual 12% (10,13)
Group 83% (82,85)
Missing 5.1% (4.2,5.9)
10) If group practice, has your group as a whole changed fasting times due to the literature?
Yes
38% (36,39)
No
43% (41,46)
N/A
10% (9.0,1 1.2)
Missing 9.6% (8.5,10.6)
* Table values show percentages of 356 respondents (to 408 mailed
sun/eys) with 95% confidence inten/als
in parentheses.
Acknowledgment: The authors wish to thank Marjorie A. Bowman, MD, Chair. Department of Family Medicine, Bowman Gray School of Medicine, for her help in reviewing this manuscript.
References
1 Stoelting RK. The 29th Rovenstine lecture: clinical challenges for the anesthesiologist. Anesthesiology 1991;74:1129-36.
2 Stoelting RK, Anesthesiology. JAMA 1991;265:3103-5.
3 Cote CJ. NPO after midnight for children: a reappraisal. Anesthesiology 1990;72:589-92,
4 McKinley AC, James RL, Mims OR III. NPO after midnight before elective surgery is no longer common practice for the majority of anesthe- siologists. Am J Anesthesiology 1995;March/April:88-92,
5 Vandam LD, Aspiration of gastric contents in the operative period, N Engl J Med 1965;273:1206-8,
6 Mendelson CL, The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-205.
7 Winternitz MC, Smith GH, McNamara FP, Effect of intrabronchial insuf- flation of acid, J Exp Med 1920;32:199-204,
8 Holdsworth JD, Furness RM, Roulston RG, A comparison of apomorphine and stomach tubes for emptying the stomach before general anaesthesia in
obstetrics. Br J Anaesth 1974;46:526-9, 9 Lahiri SK, Thomas TA, Hodgson RM, Single-dose antacid therapy for the prevention of Mendelson's syndrome, Br J Anaesth 1973;45:1 143-6,
10 Taylor G, Pryse-Davies J, The prophylactic use of antacids in the preven-
tion of the acid-pulmonary-aspiration syndrome (Mendelson's syndrome). Lancet 1966;1:288-91,
1 1 Dobb G, Jordan MJ, Williams JG, Cimetidine in the prevention of the
pulmonary acid aspiration (Mendelson's) syndrome, Br J Anaesth 1979;51:967-70,
12 Sellick BA, Cricoid pressure to control regurgitation of stomach contents
during induction of anaesthesia. Lancet 1961;2:404-6,
13 Roberts RB, Shirley MA, Reducing the risk of acid aspiration during
cesarean section, Anesth Analg 1974;53:859-68,
14 Raidoo DM. Marszaiek A, Brock-Utne JG, Acid aspiration in primates (a
surprising experimental result), Anaesth Intensive Care 1988;16:375-6,
34
NCMJ January/Februar\ 1997. Volume 58 Number 1
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Perinatal Substance Abuse Within Central North Carolina
A Suburban-Rural Perspective
Pamela Cobb, MD, Katherine Hartmann, MD, John M. Thorp, Jr, MD,
Connie Renz, MSN, Deborah Stanford, BSN, CNMW, and Kathleen Rounds, PhD
The use of intoxicating substances during pregnancy is a major cause of preventable perinatal morbidity and mortality. Urine toxicology screening studies show that 5%-20% of pregnant women use illicit drugs,'"' but most of the studies have been conducted in large urban areas with populations composed of minority, indigent women. ''■^ Since substance abuse is not confined to urban areas, we designed a study to look at the magnitude and duration of perinatal substance abuse problems (and important comorbid conditions) in a suburban-rural North Carolina population.
Screening for Perinatal Substance Abuse
The Horizons Perinatal Substance Abuse Program is operated by the Department of Obstetrics and Gynecology at the Univer- sity of North Carolina School of Medicine and funded by the North Carolina Department of Human Resources, Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. The program uses a public health model to provide substance abuse treatment and prenatal care at 1 4 sites in six suburban-rural counties in central North Carolina: Caswell, Alamance, Orange, Lee, Harnett, and Chatham. Every woman presenting for prenatal care is asked about substance use problems using a modification of the CAGE questions.'' Preg- nant women who respond positively to these questions, or who report current or past illicit substance use, or who have a history of substance abuse problems are evaluated by a certified sub- stance abuse counselor.' If the initial screen is found to be
The authors are affiliated with the Horizons Perinatal Substance Abuse Program, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, 214 MacNider Building, Chapel Hill 27599-7570. This work was funded by the North Carolina State Department of Human Resources, Division of Mental Health and Substance Abuse Services.
accurate, a formal evaluation is performed at the prenatal care site or at UNC's Substance Abuse Clinic.
The formal evaluation consists of a structured interview with six components: demographic information, financial his- tory, vocational history, trauma history, family support assess- ment, and drug and alcohol use assessment (the questionnaire is available upon request from the authors). The interviews are conducted in private by certified substance abuse counselors or social workers who have been formally trained to use the assessment instrument. Patients are reassured before the inter- view that all information is confidential and will not be shared without their permission.
Data from the interviews were stored in a computerized database. Means, ranges, and standard deviations were calcu- lated, but because of the diversity and small number of subjects, we made no statistical comparisons. Numbers of respondents vary by question because subjects could decline to answer any question.
The Scope of the Problem
Between July 1993, and November 1994, 123 women were evaluated. Maternal age ranged from 15 to 40 years (mean = 26.8+6.2 years); gestational age ranged from 6 to 41 weeks (mean = 27.3+9.5 weeks). The women identified their racial/ ethnic background as African-American/black (59%), white (40%) or Hispanic ( 1 %); all spoke English. Figure 1 , next page, shows counties of residence; 83% lived in the six-county service region. Patients were referred for evaluation because of current drug use (in 48% of respondents), past substance abuse (47%), positive responses to the CAGE questions (9%), addic- tion of the patient's domestic partner (8%), physical abuse by the partner (7%), or addiction of the women's parents.
Nine of 1 19 women said they were currently in school; 60 of 109 women had a high school diploma or equivalent; 23 had
36
NCMJ January/February 1997, Volume 58 Number 1
attended college or graduate school, and two were college graduates. Twenty-three of 1 09 said they were working full-time and six, part-time; 69 of 106 respondents said they had worked in the year preceding pregnancy. Social support services were highly used: 70% of the women were using Medicaid; 57%, Women, Infants, and Children's (WIC) nutritional services; 39%, the Baby Love program; 25% received help from the Aid to Families with Dependent Children program; and 7% each used food stamps or public housing assistance. All women used Medicaid or Baby Love pro- grams, or both.
Half the women were single; another 20% lived with a domestic partner, 14% were married, 13% separated or divorced, and 3% were widowed. Sixty-eight of 95 (71%) women reported that the fathers of their unborn children planned to be in- volved in care of the child. Fifty-two of 1 15 (45%) already had minor children living with them, and 20 said they were respon- sible for other adults living in their home. Twenty-five of 109 (23%) had minor children who did not live with them.
Seventy-five of 90 (83%) women said they felt safe in their current living situation, but 18 of 100 (18%) reported that they felt unsafe (unsafe feelings are those produced when a woman is pushed or hit, or is worried that she might be). In all 18 instances, the women reported actual physical violence. The individuals responsible for the violence were husbands in three cases, unmarried partners in six, a parent in one, and other family members in five; respondents declined to specify in three cases. Overall, 61 of 1 02 (51%) women reported that they had experienced physical violence. Thirty-nine of 97 (40%) reported a history of forced sexual activity at ages ranging from four to 35 years (mean = 16 years); in 20% of instances the perpetrator of forced sexual activity was a family member or the women's domestic partner. Two women reported more than one assailant.
Alcohol (in 72% of cases), marijuana (53%), and cocaine (51%) were the drugs of choice in this North Carolina popula- tion (fewer than 10% reported recent use of narcotics or hallucinogens). Twenty-seven (25%) abused one substance; 43 (40%), two; and 40 (36%), three or more substances (excluding nicotine). Six of 65 women (8%) reported intravenous use of cocaine or narcotics. One-half of the 63 cocaine users used alkaloidal cocaine ("crack") exclusively; 24 of the 63 (38%) reported binge use of cocaine. Of 90 women abusing alcohol, 2 1 (23%) reported tolerance, 11 (12%)reported withdrawal symp- toms, and 20 (3 1 %) reported "blackouts." Seventy-eight women said they had abstained from use of mood-altering substances for varying lengths of time (50% for one month or less, 37% for a year or less, 8% for up to five years, and 5% for more than five years).
Orange
24%
Alamance
28%
Caswell
5%
Others
10%
■ Alamance
■ Others D Caswell
■ Chatham D Durham
■ Lee
■ Orange
Fig 1 : Distribution of county of residence
Forty-one women (38%) had previously been treated for substance abuse, including 39 who had attended a meeting of a 12-step program. Sixty women (58%) thought that one or more first-degree relatives had a substance use problem, and 36 (34%) reported that parents or siblings had been treated for substance abuse. Seventy women (67%) said that their partners currently used drugs, and 35 (39%) felt the partner had a substance use problem.
There was a wide range in frequency of use of all intoxicat- ing substances, from daily use to once per month. Nearly 70% of women who abused alcohol did so three or more times per week, and more than 80% of those who used marijuana or cocaine did so three or more times per week. After becoming aware of their pregnancy, about 25% of women were able to discontinue use of alcohol or marijuana, but very few women were able to discontinue their use of cocaine.
Twenty women (21%) reported previous suicide attempts (four had made more than one attempt); 37 (40%) felt currently suicidal. Eighteen (14%) had undergone psychiatric treatment.
Fourteen women (13%) had been convicted for driving while intoxicated. Forty-two (46%) reported prior arrests. Thir- teen women (19%) said they were currently on probation or parole.
The Fallout From Intrapartum Substance Abuse
Our data show that severe substance abuse problems are not restricted to urban areas. Cocaine use appears to be ubiquitous and superimposed on chronic alcohol and marijuana use. Intra- venous use of narcotics or cocaine was rare in our population, but our data were gathered from self reports and not confirmed by toxicological assays.
NCMJ January/February 1997, Volume 58 Number 1 37
Substance use problems in this North CaroHna population were not limited to individuals, but extended throughout the family; like others," we found a high prevalence of intergen- erational addiction. We also found high prevalences of domes- tic violence, sexual assault, and psychological dysfunction. We are currently evaluating our population for posttraumatic stress disorder, hypothesizing that at least some of these women may be using mood-altering chemicals to medicate themselves for this disorder.
Almost half of our patients have minor children at home and another quarter have children in the custody of others.'' The presence of children greatly limits the ability of women to accept placement for residential treatment or to attend intensive outpatient treatment. If we want treatment to succeed, we must
find ways to care for these children. Most mothers will decline treatment if it requires separation from their children.-' The importance our patients place on meeting family responsibili- ties is demonstrated by the large number of women who are currently employed or have been employed within the past year. Our results demonstrate the chronic, relapsing nature of substance use problems: 37% of our respondents had received substance abuse treatment in the past and 40% had been able to abstain from drug use for a year or more. This emphasizes the need for long-term treatment that must extend beyond the duration of pregnancy. '" Programs that emphasize only that we have "drug-free babies" will, in the end, return these children to addicted mothers or dysfunctional families. □
References
1 Centers for Disease Control. Current trends: statewide prevalence of illicit drug use by pregnant women, Rhode Island. MMWR 1990:39:225.
2 Charkin W. Drug addition and pregnancy: policy crossroads. Am J Pub Health 1990:80:483.
3 Frank DA, McCarten K, Cabral H. et al. Cranial ultrasounds in term newborns: failure to replicate excess abnormalities in cocaine ex- posed. Pediatr Res 1992:31:2475.
4 Kulroth RH, Phillips B, Durand DJ. Perinatal outcomes of infants exposed to cocaine, and/or heroin in utero. Am J Dis Child 1989:143:905.
5 Little BB, Snell LM, Klein VR, et al. Cocaine abuse during pregnancy: maternal and fetal implications. Obstet Gynecol 1989:73:157.
6 Erving JA. Detecting alcoholism: the CAGE questionnaire. JAMA 1984:252:1905.
7 Cyr MG, Wartman SA. The effectiveness of routine screening ques- tions in the detection of alcoholism. JAMA 1988:259:51.
8 Finkelstein N, Treatment programming for alcohol and drug depen- dent pregnant women. Int Addict 1993:28:1775.
9 Neuspiel DR, Zingman TM, Templeton VN, et al. Custody of cocaine exposed newborns: determinants of discharge decisions. Am J Public Health 1993:83:1726.
10 Saffet F, Brothman R. A comprehensive care program for pregnant addicts: obstetrical, neonatal, and child development outcomes. Int J Addict 1994:19:199.
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38
NCMJ January/February 1997, Volume 58 Number 1
^V ^^ NORTH CAROLINA MEDICAL SOCIETY
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Health Watch
VOL. 58 - NO. 1 - JANUARY/FEBRUARY 1997
Wellness is Key For Diabetics
DON'T LET SICK DAYS GET YOU DOWN
by Cyril A. Allen, MD, MSPH
Along with the ills and chills of winter — comes the cold and flu season. People with diabetes get colds and flu just like others, but when illness strikes, they need to take special care to prevent complications. Illness can send diabetes out of control if precautions are not taken. Sick day management is an important issue for people with diabetes, especially during this time of year.
Common illnesses — such as colds or flu — can affect the control of diabetes. "Illness can make your blood sugar rise," says Mary Ann Simpson, certified diabetes educator at Rex Healthcare in Raleigh. "Your body is under stress during sickness and can easily become dehydrated, especially if it is a stomach virus with nausea and vomiting. With diabetes, the body has a hard time recovering once it is dehydrated."
Cyril A. Allen, MD, MSPH, is a Raleigh-based internist and hematologist. He is Chairman of the Diabetes Care WorkgroupofProjectD[RECT(DiabetesInter\'entionReach- ing and Educating Communities Together).
Monitoring Blood Sugar
According to Simpson, the three most important things to do to prevent problems before and during an illness are:
1. Test your blood sugar
2. Test your blood sugar
3. Test your blood sugar
"The best way to avoid complications during sickness is to monitor your blood sugar," Simpson advised, "not just when you are sick, but always so that you will be aware of any changes. If you have continual readings on your blood sugar, you can take a few extra steps to control your diabetes when you are sick. This can stop a minor problem — like colds or flu — from causing major problems with your diabetes control."
Control is the name of the game. Monitoring is an essential part of the management of diabetes, and it is even more important during an illness.
• Take your usual dose of medication whether you take insulin or pills. Even if you don't feel like eating, take your insulin.
NCMJ January I February 1997, Volume 58, Number I
39
Check your blood sugar more often than usual — every one to four hours while awake. Record the results and contact your healthcare provider if blood sugar is over 240.
Check your urine ketones every time you go to bathroom. Whenever a person with diabetes is ill, regardless of the symptoms or the blood sugar, urine ketones should be monitored. Ketones indicate that the body is "starving" itself and breaking down fats to get the energy it needs. Contact your physician if you have ketones in your urine.
If your blood sugar is higher than 240, check it during the night also. All people with diabetes should test blood sugar at home when ill, even if they do not monitor at home at other times.
Over-the-counter medications may also affect your diabe- tes. Check with your pharmacist or healthcare provider before taking any new medicine, including cough syrups, cough drops, and decongestants.
Maintaining energy: liquids are important
Fluids are an important part of managing diabetes during a sick day. Try to drink at least 1 /2 cup of water or other calorie- free, caffeine-free liquid every half hour. If you are sick to your stomach, take liquids in small sips to avoid vomiting. If you need to, space liquids out over the day by taking a sip every 15 minutes to avoid dehydration.
Free Liquids
Water Sugar-free tea or coffee
Broth Sugar-free soda
Bouillon Sugar-free flavored drink mix (Kool Aid, Crystal Light, etc.)
Foliow normal meal plan
It is also important to eat the same amount of high-energy carbohydrates that you usually eat. If you can, eat your regular diet. If you are sick to your stomach or vomiting, try to eat enough soft foods or liquids to equal the carbohydrates you would normally get from your diet. The main goal is to feed the body easy-to-eat foods and liquids to keep blood sugar under control.
If you use exchanges, eat 1 5 grams of carbohydrates for each starch, fruit, milk, or other carbohydrate exchange. If you
have a sore throat and have difficulty swallowing, eat soft foods in place of regular carbohydrates, like bread and fruits. Use the following list to make these exchanges. One serving from this list can replace each serving of bread or fruit in a normal meal plan.
Food
Amount
Fruit juice
1/3 to 1/2 cup
Soft drink (with sugar)
1/2 cup
Gelatin (with sugar)
1/2 cup
Hot cereal
1/2 cup (cooked)
Ice cream (vanilla)
1/2 cup
Broth-based soup
1 cup
(With noodles, rice, potatoes,
or beans)
Avoid foods that are very hot or very cold because they may increase nausea, vomiting or diarrhea. As nausea decreases, gradually return to a regular diet plan. Divide meals into small feedings at first. Continue to drink extra free liquids until you feel well again and have returned to a normal diet. Record weight changes and any breathing problems and share with your physician.
Even when you start feeling better, you will need to check your blood sugar more often than usual. Continue monitor- ing your blood sugar until it has returned to normal and ketones are no longer in your urine. Remember a cold or flu can send your diabetes way out of control. This is an important time to be extra careful about your diabetes care.
40
NCMJ January/February 1997, Volume 58, Number 1
Call Your Health Provider
It is imperative that people with diabetes and their family members find an experienced health care provider team to help during times of illness. Illnesses that might be relatively insignificant for the person without diabetes can develop into a major medical emergency in persons with diabetes, particu- larly with insulin-dependent diabetes. In addition, diabetes itself or its complications, can mimic other serious health problems.
When calling your provider, be prepared to report the fol- lowing:
• the amounts of food and kinds of fluids taken and when you last ate and drank
• the amount and type of insulin or diabetes pills you have taken and the time
• other medicines you have taken
• your temperature
• your blood sugar and urine ketone results
• how long you have been sick
• presence of vomiting or diarrhea
• any weight loss while sick (a sign of dehydration).
If you are having problems and cannot reach your doctor, go to the nearest emergency department. Call for help if you are alone and cannot take care of yourself.
Meet with your doctor or diabetes educator to work out a personal sick day plan before you become ill. The plan should include:
• name of relative or close friend to call for help
• emergency telephone numbers
• list of medications
• records of blood sugar levels and other monitoring records
• the names of sugar-free, non-alcoholic, over-the-counter medications such as cough medicines and pain relievers
• having the basics on hand such as scales, thermometers, and other supplies
\
Reminders for Sick Days
Call
your healthcare provider if any of the follow-
ingl
lappens to you:
•
You are ill and are not getting better, espe-
cially if more than one or two days
•
You feel too sick to eat normally and are
unable to keep down food for more than six
hours
•
You are having severe diarrhea
•
You have weight fluctuations
•
Your temperature is more than 100 degrees
for 24 hours
•
Your blood sugar is lower than 60 mg/dL
•
You take insulin and your blood sugar is over
240 mg/dL even after extra insulin
•
You take diabetes pills and your blood sugar
before meals is above 240 mg/dL
•
You have other unexplained symptoms
•
You have severe abdominal pain
•
You have a moderate or large amount of
ketones in your urine
•
You are having trouble breathing
•
You feel sleepy and can'tthink clearly (Have
someone call your health care provider or take
you to an emergency department.)
("Source: Taking Charge of Your Diabetes - A Guide for
Care,
p. 44, US Dept. of Health & Human Services,
Public Health Service, Centers for Disease Control &
Prevention)
NCMJ January/February 1997, Volume 58, Number 1 41
What is diabetes?
Almost every one of us knows someone who has diabetes. An estimated 16 million people in the United States have diabe- tes mellitus — a serious, lifelong condition. About half of these people do not know they have diabetes. Each year, about 650,000 people are diagnosed with diabetes.
Diabetes is a disorder of metabolism — the process by which our bodies use digested food for growth and energy. Most of the food we eat is changed into a simple sugar called glucose. Glucose is the main source of fuel for the body.
After digestion, the glucose passes into our bloodstream where it is available for body cells to use for growth and energy. For the glucose to get into the cells, insulin must be present. Insulin is a hormone produced by the pancreas, a large gland behind the stomach.
When we eat, the pancreas is supposed to automatically produce the right amount of insulin to move the glucose out of blood into our cells. In people with diabetes, however, the pancreas either produces little or no insulin, or the body cells do not respond to the insulin that is produced. As a result, glucose builds up in the blood, overflows into the urine, and passes out of the body. Thus, the body loses its main source of fuel, even though the blood contains large amounts of glucose.
(Source: Diabetes Overview, National Diabetes Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Disease, NIH) Q
Records for Sick Days
How often
Every day
Every evening
Every morning and every evening
Every 4 hours
or before every meal
Every 4 hours
or before every meal
Every 4 hours or each time you pass urine
Every 4 to 6 hours
Question
Answer
How much do you weigh today? How much did you drink today? What is your temperature?
. pounds
. glasses
.A.M. P.M.
How much diabetes medicine did you take? Time Dose
Time Dose
What is your blood sugar?
Time Blood sugar Time Blood sugar
What are your urine ketones?
How are you breathing?
Time Ketones
Time Ketones
Time Condition
Time Condition
CSource: Taking Charge of Your Diabetes - A Guide for Care, US Dept. of Health & Human Services, Public Health Service, Centers for Disease Control & Prevention)
42
NCMJ January/February 1997, Volume 58, Number 1
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HEALTH CARE ELSEWHERE
Opportunities for Cooperation
A Dialogue with the Saratov Medical University, Russia
Michael Gill, PhD, MSIV, Michael Simmons, MD, James W. Lea, PhD, and Gary D. Bos, MD
In the late 1980s the Sister Cities organization in Chapel Hill, in an effort to foster better relations between the peoples of the United States and the Soviet Union, began searching for a sister city in Russia. In 1990, the city of Saratov was identified, based on similarities between the universities in the two cities. The initial dialogue eventually led to the establishment of formal relations between the two cities in 1992. Since then, there have been a number of cultural and business exchanges under the aegis of the Sister Cities organization. Recently, these contacts have broadened to include the medical community.
The first medical connection between Saratov and the University of North Carolina (UNC) Medical Center occurred in summer 1994, when Ilya Bondurenko, a 14-year-old from Saratov, arrived in Chapel Hill. Several months earlier, Ilya had been diagnosed with osteosarcoma of the proximal fibula. Unfortunately, due to widespread shortages of chemotherapeu- tic agents in Russia, his long-term prognosis was poor, and he faced probable loss of his leg. Through the efforts of relatives in North Carolina, arrangements were made for chemotherapy and subsequent limb-sparing surgery at UNC Hospitals. During the months of treatment in Chapel Hill, the Sister Cities com- mittee actively rallied support for Ilya and his mother. The committee also stimulated the medical school to explore pos- sible relations with the medical school in Saratov.
Saratov and Its Medical School
Saratov is a city of approximately one million people located about 500 miles southeast of Moscow along the banks of the Volga River. Established over 400 years ago, this port town flourished as a major center of trade between Western Russia
The authors are affiliated with the University of North Carolina School of Medicine, Chapel Hill. Dr. Gill is a fourth-year medical student; Dr. Simmons is Professor, Department of Pediatrics; Dr. Lea is Professor, Family Medicine, and Director, Interna- tional Affairs; and Dr. Bos is Associate Professor, Department of Orthopaedics, CB# 7055, UNC, Chapel Hill 27599-7055.
and the Orient. In the late 19th century, an edict of Czar Nicholas II led to the simultaneous founding of a university and medical school; construction began in the early 1900s and the first medical students graduated just before the Bolshevik Revolution. From a single university clinic, the Saratov Medi- cal University (SMU) has now expanded to include an exten- sive series of clinics on the university campus, and teaching facilities at several major hospitals and specialty clinics through- out the city.
In October 1995, a delegation from UNC visited SMU and its affiliated hospitals and clinics for the purposes of establish- ing a medical student exchange program and exploring interin- stitutional research and cooperation. The following article is a brief description of the Russian medical system and of the opportunities for exchange that have already grown from the first visit.
The Russian Medical System
Most Americans have preconceptions about abysmal condi- tions, primitive equipment, and low standards of care in the provincial hospitals of post-communist Russia. The initial impression of the First City Hospital in Saratov would seem to confirm these stereotypes. Yet beyond the crumbling plaster and cold dark stairwells we found a medical system that functioned with a surprisingly high level of knowledge and expertise.
There were apparent contradictions in every hospital and clinic we visited. In the corridors, doctors and patients alike smoked cigarettes, but the surgical suites were spotless, with the smell of bleach lingering in the air. X-rays were taken with antiquated equipment and the films developed by hand, but were of diagnostic quality nevertheless. To our surprise, laparoscopic cholecystectomies were performed with the same instruments used in American surgical suites. But many instru- ments that we consider disposable are reused.
Throughout Russia, there is a terrible shortage of hospital beds. In Saratov, we saw 10 or more patients in one room and
44
NCMJ January/February 1997, Volume 58 Number 1
occasionally on beds in the corridors. There were usually many relatives present, often having come great distances from out- lying provinces. In addition to providing psychosocial support, families play an integral role in the daily care of their loved ones, changing bed pans, bandages, and linens. Because of the disproportionately low nurse-to-patient ratio, this practice is an unavoidable necessity. The lack of technology, often leading to long hospital stays, compounds the problem.
Chronically besieged by shortages of supplies and lack of funds, doctors in Russia have become highly innovative and cost-effective. Until five years ago, Saratov was a closed city, and there was little communication with the outside world. However, the ingenuity that once went into the production of Russian military apparatus was and is still being applied to health care. As a group, Russian physicians are very clever and intelligent, and strongly motivated to do more for their patients.
During the communist era, the Soviet health care system was touted as completely egalitarian, providing free compre- hensive health care for all citizens. In reality, the system deviated far from this ideal. It developed into a set of stratified and hierarchical institutions, with the best facilities reserved for the political elite. Significant variations in quality and accessi- bility existed on the basis of geography. In major cities, large polyclinics provided primary care, referring patients to local hospitals and specialists when necessary. In sharp contrast, provincial cities often had primitive hospitals. Rural health care was usually provided by poorly trained physician assistants in facilities that might lack even running water.
With the collapse of the Soviet system, much of the country's infrastructure underwent monumental changes. In a series of landmark reforms passed in 1993, the health care system was decentralized, and responsibility for the develop- ment of a health insurance system was placed on regional authorities. For the first time, patient rights were officially acknowledged, including the rights of patients to be informed about their condition, to accept or refuse treatment, and to participate in experimental protocols.'
The reforms of 1993 created an autonomous regulatory agency to establish contracts with clinics and hospitals for the primary care needs of the constituency. This agency is funded through compulsory insurance premiums paid by employers and contributions from the state for the unemployed. The reforms also encouraged the development of a parallel system of voluntary supplemental insurance offered by private compa- nies to foster efficiency through the forces of market competi- tion.^ There are already reports of self- financing polyclinics in progressive cities such as St. Petersburg. These offer superior quality services to a predominantly pay-out-of-pocket wealthy clientele.'
Change was apparent even in the regional hospitals of Saratov where revenues from private clinics have allowed the purchase of sophisticated new equipment to improve efficiency and increase output in some specialties. Physicians' salaries have also benefited from the reforms. During the communist regime, general practitioners earned about as much as a com-
mon laborer, but private clinics and the new insurance system are improving this situation.
Medical Education in Russia
Medical education in Russia lasts for six years and begins after completion of secondary school (about equivalent to our first year of college). For two years, the medical curriculum focuses on the natural sciences and basic humanities.
The third and fourth years correspond roughly to the first and second years of American medical schools, concentrating on basic sciences, medical ethics, and social medicine. The development of clinical skills begins in classes that focus on typical clinical problems encountered in surgery, internal medi- cine, and radiology. Each course is organized around a morning lecture, followed immediately by rounds on patients who illus- trate the particular problem discussed that day. On the day of our visit to a surgery class, a small group of students heard a lecture on hernias and then went to see patients with incisional, inguinal, and femoral hernias. On rounds, an attending made a brief presentation of the patient, then instructed students in techniques of physical examination. Students were challenged to ask focused questions that might confirm the diagnosis and were asked to present a reasonable differential diagnosis for each patient. Each case was discussed in relation to treatment options and subsequent follow-up.
The syllabus for this course covers a wide range of com- mon problems in each specialty area, and the staff was quick to point out that they have no problems locating at least one patient in the clinics to serve as a teaching case. The teaching system has a large inpatient population to draw from, and takes advan- tage of this to integrate traditional didactic lectures with case- based learning, reinforcing book knowledge with real life scenarios. This approach is now coming into favor in American medical schools.
The fifth- and sixth-year curricula in Russia closely re- semble the clinical years in American medical schools. Stu- dents are responsible for following patients on their service but also have lectures on selected topics each day. Students follow- ing patients with the sort of problems discussed in the day's lecture must read up on all aspects of the disease and present the patients on teaching rounds. Fifth-year students rotate through the various major medical disciplines, and sixth-year students rotate through several subspecialties. In general, students in Russia have fewer hands-on patient care activities, and receive more direct instruction from faculty rather than house staff
Development of a Relationship with SMU
The visit of the UNC delegation had two goals; 1) to invite a medical student from Saratov to take a rotation at UNC; and 2) to establish a dialogue between the two medical schools that would foster interinstitutional cooperation in research and
NCMJ January/February 1997, Volume 58 Number 1 45
clinical training. The enthusiasm we encountered at SMU was very encouraging and greatly facilitated discussion of future plans. Our short visit led to offers of collaboration from many of the faculty at SMU. We are working to arrange connections between faculty of the two institutions in clinical and research areas.
In April 1996, Victor Bogatov, a fifth-year medical student at SMU, began a two-month clerkship on the UNC orthopaedic service. His knowledge base was equal or superior to American counterparts at corresponding third-year level; he had less surgical and ward experience, but was able to catch up quickly. Victor found the vigorous pace of an American medical student a challenge, but fortunately, SMU has a strong program in foreign languages and Victor was able extend his knowledge of English to the medical setting.
UNC has committed to accepting one student a year from SMU for a two-month visit. SMU, in turn, has invited a UNC student to come to Saratov. SMU already has a strong program in medical Russian, since they receive students from many other countries. An American student with a basic knowledge of Russian could function well after a few weeks of intensive language training in Saratov.
The second goal of our trip was to foster joint research projects, seminars, and exchange of medical personnel between the two universities. One of the most exciting aspects of the visit was to discover the markedly different regional epidemiologies and the unique ways in which certain disorders are treated. As an example, for six months there has been an unusual outbreak of diphtheria in rural Saratov; plasmapheresis has been used with good success to treat this. Another example is the substan- tial number of patients with a wide array of problems attributed to radiation exposure from the Chernobyl nuclear plant acci- dent. Visits with clinicians and researchers from SMU can establish relationships that will permit information exchange by interested groups on both sides. The possibilities of applying our technology to disease processes which are rare in the US is exciting.
The process of exchange and collaboration was further aided by the visit of Rector Kirichuk and three SMU professors to UNC last February. They came to learn about medical education and health care financing in the US. They also visited various laboratories and physicians engaged in clinical and laboratory research to establish collaborative studies.
The Russian guests began a discussion about setting up a combined Russian-American hospital service in Saratov. Such a service is possible in Russia because the Rector has the ability to license physicians. A group of patients with diseases of interest to visiting clinicians could be brought to the facility for treatment by the combined faculties. Research opportunities could be arranged. If this venture is to succeed, funds would
need to be solicited from outside agencies to build a hospital wing or freestanding building to house the service. The discus- sions led to the signing of an agreement to work toward the establishment of such a service.
Further broadening contacts between the two universities, a nine-member delegation from UNC visited Saratov in Sep- tember to take part in a joint conference on health care reform. The delegation consisted of clinicians as well as representatives from the UNC School of Public Health and UNC Hospitals. Concepts such as managed care were new to the Russians, yet both sides shared similar problems including issues surround- ing primary care, rural health, and the costs and quality of medical education.
Following the conference, one of the delegates (Dr. Gill) remained in Saratov as the first UNC medical student to work in a Russian hospital. His month-long rotation in internal medicine and pediatric infectious disease afforded not only a better understanding of the Russian medical system, but a glimpse into pathologies not frequently encountered in the United States, such as diptheria and hemolytic uremic syn- drome.
Several other exchanges are currently being organized. In March, the medical school and the School of Public Health will host a conference on health care issues, with 20 doctors from Saratov attending. Early this year, UNC expects to receive multiple junior faculty from SMU on various clinical services and in research laboratories. A UNC family practice professor is expected to spend a month in Saratov helping to develop a primary care network that can be implemented in the Saratov region.
Continued exchanges with Saratov will require significant manpower. We hope that the effort will extend beyond UNC faculty, but wish to keep the service staffed with physicians from North Carolina. Faculty from any of the state's medical schools, as well as doctors in private practice who want to participate should contact Dr. Bos at 919/966-7130 (e-mail: [email protected]).
Conclusion
Our first contact with SMU was highly favorable. We are confident that it will be possible to establish clinical and research exchange. The fact that SMU is set in a recently opened city and has a knowledgeable medical faculty may explain the ease of developing a relationship without the request for funds that often hampers such efforts. We found the attitude refresh- ing, especially in the present milieu of declining health care budgets in the US. We believe that such an attitude is the key to establishing a long-term relationship with benefits for all. Q
References
1 Cassileth BR, Vlasssov VV, Chapman CC. Health care, medical prac- tice and medical ethics in Russia today. JAMA 1995;273:1569-73.
2 Sheiman I. Forming the system of health insurance in the Russian
Federation. Soc Sci & Med 1994:39:1425-32. 3 Curtis S, Petukhova N, Taket A. Health care reforms in Russia: the example of St. Petersburg. Soc Sci & Med 1995;40:755-65.
46
NCMJ January/February 1997, Volume 58 Number 1
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FICTION BY PHYSICIANS
Locked and Loaded
Roger Castle's Gulf War Syndrome
Dennis A. Greene, MD
Author's note: Nearly six years ago, my colleagues and I were preparing to leave the Arabian peninsula and return to our families, friends, and practices after fiaving given 180 days of service to Operation Desert Shield and Desert Storm. IVlost of the people in my group were reservists, like me. Many were North Carolinians.
I wrote this story about a somewhat reluctant physician-soldier, who found himself caught up in the events. It is fiction, but the events described might have happened. Memories fade. I dedicate this narrative to the many men and women who have served, and continue to serve, their country.
Gently shivering, he lay on his back, head resting on his blanket- roll, squeezed among his buddies on the hard tarmac, looking at the brilliant stars in the cloudless night sky. He tried to shield himself from the cold dry wind blowing across the desert to the sea. "We will board the plane at oh-dark-thirty," the colonel had announced at the evening formation. "Try to get some sleep; it' s gonna be a long night."
At one o'clock in the morning, they had been awakened and brought to the airstrip, passing for the last time the heavily fortified checkpoint that, for three months, had separated them from the outside world. Now, while medical equipment and personal gear were loaded onto the 747, the company had no place to sit. They lay down on the runway apron to keep warm, each with private thoughts and silent memories of the half-year - coming to its end.
The 41 1th Evacuation Hospital, from Buffalo, New York, was one of 10 Army Reserve hospitals that had been mobilized and sent to the Arabian peninsula in November 1990, three months after Saddam Hussein moved his Republican Guards and irregulars across the border and occupied the oil-rich sheikdom of Kuwait. The American President, himself a Texas oilman, was outraged. "This aggression will not stand!" he said on the evening news. He assembled a coalition of 30 American, Middle Eastern, and European nations to confront the stubborn Saddam. When Saddam would not budge, history was made in January 1991: a massive military operation that bombed the Iraqi Army for 38 days and nights, then moved tens of thou-
Dr. Greene is with the Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente, West Raleigh Medical of- fice, 3100 Duraleigh Road, Raleigh 27612.
Glossary of terms
LTC, MC,
USAR
Lieutenant Colonel, Medical Corps, US Army Reserve
NAAD:
National Army Medical Department Augmentation Detachment
SHAPE:
Supreme Headquarters, Allied Personnel, Europe
sands of soldiers, Bradley fighting vehicles, and tanks from Saudi Arabia, re-taking Kuwait in just four days. The clean-up took another month, then the troops were given orders to go home.
For Roger Castle, MD, LTC, MC, USAR, life had been routine until the President called up the Reserves. Roger, Chief of Radiology for the 4 1 1th, was not a weekend warrior, not one of those citizen-soldiers seen once a month driving convoys of olive-drab vehicles to fulfil their commitment to the Army Reserve or National Guard. Yes, he was in the Reserves, but as far-removed as possible. As a radiologist, one of the more underrepresented medical specialties in the Army, he had given his time, but no more than was required, and he had been allowed a good deal of flexibility in arranging his duty time, so that his personal life would not be disrupted. "Lucky to have me," he thought. The Armed Services needed Reserve medical personnel. There simply weren't enough doctors and nurses on active duty to support the far-flung military community, espe- cially in times of crisis.
He had been on active duty once before, in 1 973- 1 975. That was very different. He had been drafted out of high school, but
48
NCMJ January/February 1997. Volume 58 Number I
granted deferment through college, medical school, and radiol- ogy residency at Northwestern. Those were Vietnam War years, but the Army sent him to Germany, as radiologist at the hospital in Wiirzburg. He rose to major, but he hated Army bureaucracy, hated spinning his wheels. "Enough of this," he thought. "I'm going back to the world. I have a career to get started." He resigned his Reserve commission. He put his uniforms in a box in the attic. He moved to Carville, North Carolina, and started a radiology practice that expanded steadily as the hospital grew. The years went by. He almost forgot about his military tour.
Roger hadn't figured on a mid-life crisis. After 15 years in harness, he was a little bored. Everything seemed predictable. He practiced full-time at the hospital in Carville; he was active in the local and state medical societies; he was well- known in the community. The Radiology Department grew to accommodate two associates and even residents from the University in Chapel Hill. Maybe he was a little burned out. The hospital at Fort Bedford needed a part-time radiolo- ! gist. They were small and needed someone with experience to ' develop the department. It was just 30 minutes away. Why not go back into the Reserves? There might be some benefits, and besides, wasn't it time to "give something back" for his years of ; privilege? That was two years ago. They made him a lieutenant : colonel. If he stayed until he retired, he would be a full "bird" colonel. He had to go to Fort Bedford two afternoons a month, but he enjoyed the work with young soldiers, the bonding, the ! Army's emphasis on physical fitness, the teaching of the younger medical officers and staff.
He planned to spend his required two weeks of active duty at a different place every year, in Europe, if possible. In 1989, he went to the SHAPE hospital in Mons, Belgium; in 1990 he I went to Heidelberg, to US Army Headquarters; next year was to be Italy. The "fun" stopped two days before Thanksgiving 1 990, in his office in the radiology suite, at 2:45 in the afternoon. "Sir, this is Spec4 Hammer from the NAAD. We are mobiliz- ing, sir, and you are to report to your mobe site no later than oh- nine-hundred Saturday morning. That is an order from General Thomas. Sorry, sir, but all Evacuation Hospitals are getting called up."
"What? Wait a minute, Specialist Hammer, I can't just leave everything, are you sure about this?" Roger was begin- ning to sweat. He sat down hard.
"Sir, you've been assigned to the 41 1th Evacuation Hospi- tal out of Buffalo. HQ's pulled you from your parent unit because the 411th needs a radiologist. Their guy is nondeployable. Bad heart or something. We're doing a lot of mixing and matching down here, getting these units up to strength. It's been a real Charlie Foxtrot, if you get my drift. Oh, by the way, you need to go to Bragg."
Fort Bragg was three hours away. Roger had been there before, to the big Womack Army Hospital for conferences, to teach radiology residents, to read an x-ray or two. It was a small part of his Reserve duty, but not a part he particularly liked, being too close to what he did all day at home. All the same, he
enjoyed watching the maneuvers of the 82nd Airborne and the Special Forces, who had made Fort Bragg famous.
"What are we going to do, fill in at Womack until the regular Army guys get back from Saudi?" Roger muttered. "Don't know, sir. Just get there and you'll get orders." The soldier from NAAD clicked off. The National Army Medical Department Augmentation Detachment, located at Fort Gillem in suburban Atlanta, was Roger's administrative headquarters. To Roger it was just an "800 number;" he called them; they called him, usually about trivial things, like retirement points, courses, forms to fill out. He had never seen the place, nor they him. He wondered if the soldiers he spoke to looked the way they sounded, or vice versa, like Specialist Fourth Class Ham- mer, the NAAD clerk. "Who the hell is Spec4 Hammer? Jesus, wake up! What the hell am I going to tell Laura?"
Two days before Thanksgiving! He had until Saturday, Friday really, to rearrange his life. "Can they really do this to me?" Well, Vijay and Ken, his two partners, would just have to handle the practice for a while. They were all pumped up over Desert Shield anyway. The media had really got their attention. To Roger it had always been odd how often people who had never been in the military were much more hawkish than he, much more willing to send in the troops. Ken, six years younger, had been a flower child in Berkeley during Vietnam. Vijay was probably sfill in medical school in India back then. Well, it's not the '60s anymore.
Roger got on the phone to Laura: "I can't believe this, but I've been activated! I don't know how long, maybe a few months, maybe six months, I don't know! Look, I'll be home early and we'll talk this out, but I've got to find Vee and Ken!" Christ! There won't be any money coming in; what about the mortgage, the insurance?
Vijay and Ken were in the back office, having coffee, when Roger reached them. They sat for a while, silent, stunned. Vijay spoke first. "Rog, this is bloody awful, you know. But, by golly, what did you expect, anyway? Hey, I think I speak for both Ken and me. We'll hold down the fort. Don't worry about us. Just stay as safe as you can. Hell, you'll probably be a general by the time you get back!" Ken nodded, then softly and slowly added, "We'll make sure Laura and the kids are okay. Are you going to be all right as far as money is concerned? Your accounts receivable are only going to last a few months, you know. Maybe we can take out a loan or something." Ken's calculator mind was kicking into high gear, as usual in times of crisis.
"Look," Roger said, "I really don' t have much time to deal with this, so I'll just have to see what they're going to do with me and play it by ear for a while."
A dozen phone calls later, he was at home. He had talked to the bank, the accountant, the hospital staff secretary, the medical school liaison, and left a message for the Rotary Club co-chair: "Won ' t be at the meeting next week, or the next. Carry on without me." Everyone seemed supportive and understand- ing. Hope it lasts. Damn! What a mess! What a shock!
He remembered the next few days as a blur. Laura's brave smile, her eyes betraying worry — or was it anger? Timmy and
NCMJ January/February 1997, Volume 58 Number 1
49
Terry, the twins, just starting out in the new school, trying to make new friends, having a tough time. "Bye, Daddy, we love you," they waved as he turned and slowly walked down the jetway for the flight to Texas. Not to Fort Bragg. He had been reassigned to a training unit at Fort Sam Houston. He was one of the older ones this time around, his gray hairs earned. "I'm a father figure," he thought. "That's all I need."
"Modified boot camp. Learn tlie tasks.
Go or no go, simple as tinat. Qualify
witin pistol, with rifle..,. All of this seemed
to be happening to someone else. He
was a radiologist, for Pete's sake."
The schedule: up before six, work all day at military and medical tasks, fall into bed at night. Hours and hours of filling out forms: for pay, life insurance, power of attorney, medical records, personnel records. Standing in lines, lots of lines. Lots of marching. Basic soldiering, they call it. Modified boot camp. Learn the tasks. Go or no go, simple as that. Qualify with pistol, with rifle. Qualify with chemical protective suit. It can save your life. All of this seemed to be happening to someone else. He was a radiologist, for Pete's sake.
Roger felt isolated, cut off from his life. He knew he would be transferred after three weeks, but not where he was going. Laura and the boys flew to San Antonio for a day, but he had only a few hours with them, at dinner. The trainmg group was called for a late briefing. "How thin you look," Laura said as they parted.
Message from Specialist Hammer: "Report at once to Aberdeen Proving Ground, Maryland. The 4 1 1 th Evac Hospital is mobilizing and will be ordered to Saudi Arabia."
They were housed in ancient barracks that had been hastily reconditioned to make them habitable, at least by Army stan- dards. Roger bunked with 30 men, enlisted and officer alike, in one long, narrow room. He had a bed, a locker, a little desk. The only telephone was a pay phone on a pole between two of the buildings. By standing in line for an hour, he could call home.
Because of security issues and training schedules, they were not allowed to leave the post, to have visitors, or to disclose their location to anyone, although it was no secret where they were. "They're out there. This is real," said the colonel, a stumpy urologist with a slight limp, warning of a perceived threat to their safety. They could use the gym and track, but not the Officers' Club. They would march in forma- tion to the mess hall. Alcohol was forbidden, by order of the general staff. They were going to war. They were going to be ready. "Locked and loaded, leaning forward in the foxhole," was how the trainer put it, "good to go."
In Aberdeen that winter, it either rained or it snowed. Cold and wet, they continued their training. Roger was miserable. He felt imprisoned. His barracks-mate, an ambulance driver named
Mario, said, "Geez, Doc, this is worse than jail. I've been in jail ! We had our own cell, three meals a day, TV; our wives could visit; we had a telephone. It was much better than this!"
How could the Army, he wondered, send him to a hostile area? Weren't there plenty of regular Army full-timers to take overseas duty? Weren't the reservists supposed to backfill at places like Walter Reed and Womack? Are we sending a message to Saddam? Is that it? Watch out, Saddam! Roger Castle is coming! I bet he's quaking in his boots.
Christmas, and a few days off, finally. He went home, but nearly wished he hadn't. Laura was exhausted. The boys were acting out, obviously unhappy. On their last night together they sat close and tried to dedicate themselves to making the best of the situation. "After all, think of all the single moms and dads, the students pulled away from a whole year's work, who are so much worse off than we are. We'll get through this, that's all."
On New Year's Day, the colonel called a formation. "We've received our orders to deploy overseas. We will leave in 48 hours. You will be given our destination later. Dismissed." The 411th spent the next day and night preparing. "Finally, something to do," Roger thought. Pack up a hospital. Equip- ment, vehicles, bandages, solutions, tables, chairs, you-name- it. Beans, bullets, and bandages, they said. Most of it would go right on the plane with them. The rest would arrive later. But where, exactly?
When the buses came, it was snowing hard. Oh-dark-thirty, once again. Everything happens at the "dismal time." It was a long slow trip to McGuire AFB, in New Jersey. The bus convoy was directed to an empty terminal building. Air Force personnel materialized, and within an hour the company was being out- processed and readied for the next stage of their journey. They were in full battle dress, the 400 personnel of an Evacuation Hospital company. Doctors, nurses, technicians, clerks, driv- ers, cooks, repair personnel, security, communications, supply. In the darkness, they could have resembled any of the thousands of soldiers who had already passed through.
"Roger could sleep almost anywhere, even amid the constant noise and activity of his bunk-room
mates. He dreamed about weapons under seats."
As they boarded the airplane, they carried their M- 16s; the officers strapped on their .45s. Their knapsacks weighed 60 pounds, including the sleeping bag. Attached to their web-gear were a flashlight, first-aid kit, and two canteens. They marched in formation to the plane. "Hey, you guys look tough," said one of the Air Force noncoms helping them load. "No shit. We're a hospital," someone replied. Roger scribbled a note to Laura: "We're leaving. I love you more than you know." He gave it to one of the attendants. "Don't worry, I'll send it to her," she promised.
50
NCMJ Januan'/Febi-iian- 1997, Volume 58 Number I
"Welcome to Tower Air Flight 999, Boeing 747 Service to Saudi Arabia. Please stow your weapons under your seats, muzzles pointed toward the aisles," said the intercom. They tool< off into the dark sky . Roger fell asleep almost immediately . He had learned to cover his eyes with one of those black eyeshades he used to see in old movies and plug his ears with Army-issue earplugs. He could sleep almost anywhere, even amid the constant noise and activity of his bunk-room mates. He dreamed about weapons under seats.
Four hundred soldiers traveling together did not take long to eat up all the food and fill up all the toilets. It was hard to move about the airplane. The aisles were filled with gear or sleeping bodies. Roger amused himself listening to Arabic language tapes and playing pinochle with his mates. He fell into the sleep- wake pattern of boredom and fatigue.
"Doc, sir, wake up! You gotta see this, sir!" A corpsman was snapping pictures through the porthole on Roger's left. It must have been late afternoon, local time, because from 38,000 feet he could clearly see the long shadows pointing eastward from the Great Pyramids of Cheops and Chefren, as they flew directly over Giza. Was that the Sphinx down there? It was one of the most beautiful things Roger had ever seen. The Nile stretched north and south, with its great bulge near the ancient j cataracts, like a page from one of his childhood storybooks. Then they were over the desert and the Red Sea. As the sun set they began their descent somewhere over Saudi Arabia.
The camp lay at the north end of a runway. The engineers had bulldozed the sand flat and then spread gravel over a one- fourth square mile area surrounded by a chain-link fence and razor- wire. There were a few collapsible modular buildings and l| a lot of tents occupied by Air Force personnel who flew aerial ■ refueling missions over the Persian Gulf. Some of the crews came from North Carolina's Pope Air Force Base. "Small world," Roger thought.
The hospital was going to be a hybrid. The Air Force was bringing in its own staff, essentially matching the 4 11 th. The Air Force commander, a tall, good-looking general surgeon, stood on a table. Our colonel hopped up next to him. "We're going to be the first combined Army and Air Force hospital. We want you to ignore the insignia on your uniforms. From now on, you , are one service. No rivalry, no competition, no rank. We're here to do a job and we are going to cooperate with each other fully." Actually, mused Roger, lying with a stiff back on the cold asphalt, it had worked pretty well, except for softball and touch football games.
When completed, the hospital had a capacity of 1 ,000 beds. They were far enough from the battlefield to be safe from SCUD missiles, but close enough to provide rapidly accessible medical care. The modular buildings and tents connected side-to-side or end-to end, included four modular operating rooms, all well- equipped. And excellent anesthesia. The x-ray equipment was a little outdated, and Roger would have loved a CT scanner, but he was confident that this evacuation hospital could fulfill its mission, and then some.
That was three months ago. It was hard to remember all that they had done since. They trained for what they hoped would never happen: mass casualties; planeloads of wounded, nerve- gassed soldiers, landing on the runway and taxiing right up to the hospital's open door. Boy, the luck! The most serious casualty was a young woman soldier with a ruptured ectopic. Friendly fire, they called it. A few troopers with vague nausea and vomiting, aches and pains, rashes that no-one could ex- plain. "Lots of stories; so many people dislocated just like me. Someday I'll have to write about it."
"Three months ago," Roger thought, "we landed in a dark spot in a desert with nothing but an airstrip. We built a hospital out of tents and containers. And the best thing is that we never needed it. We trained and trained, but never filled our beds. We saw war on CNN. I think we were ready, but I guess we' 11 never really know. Now we are leaving and all this will disappear. The hospital will go back in its box and the airstrip will be left to the sand. Six months from now, if you flew over this place, you would see no tents, no razor wire, nothing but desert."
"Okay, we're ready to go," the colonel announced. "The pilot said to get a move on or it'll get too warm for us to take off with this load." "No problem-o," said Roger, as he wearily got to his feet, stretched, picked up his gear and walked to the stairway, his boots crunching on the sand. Q
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NCMJ January/February 1997, Volume 58 Number 1
51
PATIENT'S POINT OF VIEW
My Encounter With Cancer
One Woman's Battle with Cancer and Today's Health System
Teena Vaughn-D'Annibale
She touched me, and I knew.
Cancer!
Her name was Diane, I think. A sonographer. I lay there with my head tipped uncomfortably back so my neck was exposed to the gooey slime and the cold instrument. I knew the sonogram did not look good. Every time she touched my arm I felt- Cancer.
A shy smile —
Cancer.
A brush of my hair —
Cancer.
A quiet, "Everything looks good. You're all done. Here let me get that goo off of your neck." —
Cancer!
She glanced down, then back to me; our eyes met and I knew —
Cancer.
She said, "Have a great day," and then I was sure. —
Cancer.
The doctors kept saying: "It's growing too fast to be cancer." "You're too young. Your age is working for you." "The chances of cancer in cases like this are 1 in 100." Yet, I knew when I looked in Diane's caring eyes —
Cancer!
I walked out to the car, where the world went on as if nothing was different at all. I watched a little girl and her mom waiting for a city bus. The girl was fussing with a beautiful green, potted plant, picking the leaves off behind her mother's back. The mother chatted with an older man on a cane about the buses always running late. "What do they think? That we have all the time in the world?" she asked in a hostile tone.
I turned away. "All the time in the world" —
Cancer.
The steps to the parking lot were the awkward sort where two steps are two long and one too short. You have to take giant steps or baby steps. I wonder what sadistic person designed steps like this and why they were everywhere. Baby steps or giant steps? —
Cancer.
At the car I just sat in the heat, sweat running down the back of my neck, gripping the steering wheel, knowing —
Cancer!
Thinking, "What am I doing? The doctors all say it is not cancer. Why am I being so negative and melodramatic? It's not cancer." A horn blew. Was I moving or staying? They want my parking space — MY SPACE —
CANCER!
On the drive home I began to cry: scared; mad at being selfish and stupid; hurt that this was happening to me; wonder- ing what I was supposed to learn from this life-lesson God had so graciously dropped in my lap. Yet, despite all the uncer- tainty, I felt a strength that I knew would get me through to the end. At the red light tears streamed down my face, but when somehow I got home, into the driveway, I decided not tell Peter. In my heart, though, I knew I eventually would. We share everything. We are soulmates. He would know the minute he looked in my heart. I told Peter.
The days became a week. I thought — Cancer — every minute. I tried to forget but I wanted someone, someone official, to back me up, to tell me, I was right — or even better — wrong! But those words never came. Instead, it was doctors, doctors, doctors. The doctors all said I did not fit the pattern for cancer, so not to worry. But "Go see the endocrinologist." Scary, painful tests, with no anesthetic. The doctors said there
Ms. Vaughn-D'Annibale lives in Shippensburg, PA. At the time of this writing, she was a Wilmington resident.
52
NCMJ January/February 1997, Volume 58 Number I
were not enough cells to be conclusive. They sent the cells to someone who is even more of an expert. Well, now, there are not enough cells but... I'm leaning toward being "concerned." That's a nice way of saying — Cancer! — in my book.
On to the surgeon. Huge waiting room, curt receptionist, cool, calculating explanations and options.
"Just take it out, doc. I want it all out," I say. He agrees.
I go home and tell Pete and the kids, "It's nothing to worry about. The doctor says it's cut and dried," that "the likelihood of cancer is 1 in 100."They all breathe a sigh of relief. I think —
Cancer.
Nothing to eat. Be there at 5 a.m. for preps. The alarm goes off. We dress. I put my hair up on top of my head, thinking, "It'll be out of the way." No makeup so they can see if you look pale — which you do because you are scared to death, but surprisingly calm because it's all about to be over — finally.
I cannot look at Peter. He looks so worried, so scared. I know he is wondering — "Cancer?" — but never says a word.
"Come on let's go," he says, "I love you, ya know." I know. I know that more than anything else I know in life. I' m so scared to lose him. I cling to his shirt and wish I could fuse my body right inside him so we were all one person. But it's too much pain to handle right now. I push him away —
Cancer.
It's dark and the headlights illuminate only the world in fi-ont of our car. That's good because that's about all I can handle right now. How has this all happened? I cannot believe it. I have never been sick my whole life.
"Fat and healthy," that's what Doc Frank and I always say. "Lose some weight and you'll be sickening." Yet, six months ago his face was strangely serious when he found a pea-sized nodule on my neck during a routine exam.
"Nothing to be that concerned about, but we need to address it." Doctor talk for —
Cancer?
The parking lot has a yellow-blue hue from the street lights. On the funny, sadistic stairway I choose to take baby steps today. Inside, paperwork and bracelets, intravenous feeding tubes, and "this will make you sleepy" medicine. But Peter's there so I'm pretty calm.
"It's time, Mrs. D' Annibale," and off we go —
Cancer?
We will soon know.
Peter kisses me at the door. I assure him I'll be okay. We part physically, but mentally he's right here with me, waiting in that cold, cold room. Waiting for the surgeon to drink his coffee (have two doc, I want you awake) and eat his doughnut, laugh with some nurses about a joke he heard the night before. —
Cancer.
Soon I'm whisked around 100 machines. I swear you have to be an Indy car driver to maneuver those stretchers around all the machines and the ashen-faced old men waiting for prostate
surgery. But we make it, and the anesthesiologist says, "Good morning. How are you today?"
I want to say, "How the hell do you think I am?" —
CANCER!
but instead I smile and say, "Hangin' in there." Which is a smart choice since this guy will have my life in his hands for the next five hours. Good night. Canczzzzzzzzz!
"Honey, are you awake?" I say nothing. My mouth feels dry and there is a searing pain in my neck. People talk around my head, bustling. Intravenous bottles clank on poles, a chart is thrown on my legs. Someone shakes my arm, "Teena? Teena?" I look up and see a blurry, black-headed figure. "Hi, sweetie. It's Jeanie from Mary Kay . You did great ! " I close my eyes without saying a word. My mouth is thick with cotton and the smell of anesthesia. I realize there is a tube in my nose. We move quickly down the hall, lights overhead a blur.
"Hey girl, how you been?" the person pushing me says to a woman waiting for the elevator.
Bump ! Ow ! Bump ! Ow ! The wheels click over the elevator entrance. I feel like I'm on a bungee cord that has been mistakenly tied around my neck. More lights and more race car- driver skills as we maneuver around food carts, people — some walking, others ashen-faced, like I, too, must be at this point.
We come to a room and everyone leaves except one nurse who arranges the IV on a pole and takes my vital signs. "Is there anything you need?"
I say, "No," because I cannot think of all the things / do need right now. Aren't they supposed to know what I need?
A squeeze on my hand and I open my eyes to see Peter. Oh, Peter. It hurts so much, I think, but all I can say is, "I love you."
"I love you, too," he says with a hard and long squeeze of my hand. I know I'm okay now. I sleep.
My eyes open to someone yelling for a bedpan. Peter is there and I feel a lot of pain.
"Peter, please tell them I need some pain medication. And my mouth is so dry." I whisper. He slips ice chips into my mouth and a tiny drop of water slides down my throat. I am sure this ice is laced with razor blades. Soon the nurse arrives with Demerol and 15 seconds after they inject it, I'm asleep. This sequence goes on for most of the day, and the immediate need for relief from pain has erased the word Cancer from my brain.
At one point Peter does tell me that they only took out half of my thyroid because the frozen section was clean, and with no goiter they did not feel the need to take the other half. He has a big smile on his face and a look of relief.
It was good to hear. . .but. . .in my heart I was rocked. I had been wrong. It wasn 't cancer. It shook my very belief in myself. Yes, I was glad for the news, but I had been so sure it was cancer and now, it seemed, I could not even trust my feelings. I was confused; I felt as if had been dealt a blow almost as bad as cancer itself. My instincts have always been right. My intuition was one thing I could always count on. God had given me this
NCMJ January/February 1997, Volume 58 Number 1 53
gift of knowing and He had never failed me before — good or bad. I felt abandoned and happy at the same time.
This time I did not tell Peter. I was shaken and embarrassed to have had such negative, melodramatic feelings, to be so cocky and sure that it was cancer. And now it was not. I was wrong, wrong] Hurray!
The other shoe soon came crashing down. I was sent home after a little more than 24 hours because of our HMO's rules. I endured the ride home, and tried to cope with my recovery amid all the "help" from my four wonderful children. They greeted me at the door. Hugs and kisses, except from Jamie who is a little scared about it all, so he kisses my hand. Smiles on their scared faces. I smile to reassure them, but I really need to lie down. I love them all so much. Amber, 13, does a lot of housework and tries to keep the need for me to scream at a minimum. But she is only a kid and so are the three younger ones; Kaitlyn, 8, James, 7, and his twin brother Christian. Just four days after my surgery, I drive them to see the whale movie, "Free Willy II." With a pillow propped behind my head, I am actually able to enjoy doing something normal for the first time in a long, long while. No cancer! What do ya think of that?!
Monday I wake to a ring- ing phone and Dr. T's nurse telling me he had to cancel my follow-up appointment due to emergency surgery. Well great! I had taken the day off from my at-home day care for
the appointment. This was a
pain in the neck (a phrase I use a lot lately, metaphorically and otherwise). Butljustsay toher, "I understand. Let my husband call and make the new appointment since he'll have to take off work to cover my day care while I go."
"Well, all we have is Wednesday at 2:30," she tells me in a miffed voice, obviously pissed that she has to reschedule Dr. T's whole day of appointments and wishing no one had a life outside of doctor's appointments so she could just whip through the whole list and then have the rest of the day off. But, I insist she call my husband. They decide on the following Monday, two weeks after my surgery.
Tuesday, my day care kids come back and I am thrilled to have something to do, to feel their hugs and kisses, to know I am truly missed by all. But as the week goes on the "C word" creeps back into my brain. The doc had sent my thyroid — the "speci- men"— off to a lab to double check the hospital's findings of "not cancerous." "It must have been okay or they would've insisted I come in," I think to myself. No one calls. "Of course, it was okay or they would have called." By Friday I call, to ask that my records be sent to Doc Frank. On the phone I hear the nurse say, "The tests that we sent away do show cancer cells. . ." She keeps talking but I' m not listening anymore — Cancer cells ! Cancer cells!
"We... posture for some position of
power so we con face the battle: Us
Against tine Doctor. (It) is supposed to
be the Doc-as-General, on our side
against the illness as enemy."
My whole being was rocked for a second time. I had doubted myself. I believed in modern medicine and it was wrong! A feeling of strength began to grow in me like I have never felt before. Like a rush of water from a fire hose, washing my whole body clean, renewing my faith in myself and my God. Isn't it strange that a negative result could have such a positive effect on me? But it was more important to me to be tuned into my soul and my God than not have a physical disease I knew I had the strength to fight. All of this knowledge flooded over me in a period of about five seconds. I heard a voice saying, "Monday at 2:00." I stood there for a long, long time after we hung up, wondering and knowing, all at the same time — why? Monday's visit was a dichotomy. This time an angry Peter came, and we sat in the empty exam room saying things like: "They screwed up big time," and "We'll call lawyers when we get through with all of this" (which is a joke, because we're not the suing kind), and "Are you sure we should come back to this doctor? He did mess up the first time." But Doc Frank says he's the best and I trust Doc Frank because he's the one who's listened and believed in us. "I trust Doc Frank, not this guy." We say all of these things, hyperbolizing and posturing for
some position of power so we can face the battle : Us Against the Doctor. I cannot help think it is supposed to be the Doc- as-General, on our side against the illness as enemy. But this has all turned into a Vietnam, a place where we do not know
■ the good guys from the bad
and the only people we can trust are the fellow soldiers in our own platoon — me and Pete against the world of big, scary, all- powerful, all-knowing people who literally hold my life in their hands. They have the knowledge, authority, egotism, wealth, and an army of colleagues on their side. We, we have each other. So, the surgeon comes in and goes over the pictures of my thyroid (their "specimen ") and the cancer. He shows us little red dots on a Polaroid, which I assume has been taken through the lens of a microscope. It is so obvious to me and to Peter that I see the cancer on that picture even before he points it out. I wonder to myself, "How did the pathologist miss that\" If the pathologist had seen that, Dr. T would have taken my whole thyroid right there on the operating table, and I wouldn't be in this pickle. But how is a pathologist whose specialty is not thyroids suppose to see that] (I found out, accidentally, that the pathologist who inspected or read or diagnosed my "frozen section" while I lay open on the operating table was not a thyroid pathologist. Maybe he was in charge of brain tumors or something and did not know thyroid cancer from a piece of meat. The thyroid pathologist at the lab they sent it to saw the cancer and said, "It's spreading right on the specimen.") I, mother, writer, day care-provider, wife, look at the picture with the big red dots, and I, me, lowly me, see it in three seconds. So,
54
NCMJ January/February 1997, Volume 58 Number 1
what' s with this pathology guy? Did he drink enough coffee to- day or what?!
Peter asks questions about the operation; I continue to stare at the picture in disbehef. The doctor rephes, "It's cut and dried." Peter seethes, ''That is what you said the first time." The doctor does not say any- thing. What can he say? He is sorry, truly sorry. I am unmis- takably sure about that. But if he internalizes every patient, how could he do his job effi- ciently? I understand that, too.
We ask to stay in the hos- pital longer than one day this time, explaining, "Last time was pretty hard, what with the four kids and no one to help." He looks surprised and says, "You have /our kids?"
I say, "Yes, and no help. So, what do ya say? Can I stay more than one day?"
He agrees to let me stay. Meanwhile, I'm thinking that I know that this man has a wife and a daughter in her 20s who is to be married soon. I bothered to find this out about Dr. T who is going to slice open my neck. But he did not even know I had kids, much less four of them. In my book that is something a doctor should know before he
sends you home with a neck full of stitches and a prescription for Percocet. It's no secret; there are ways to find out, without my having to volunteer the information. Maybe in casual conversa- tion, the way Doc Frank learns about his patients. Doc Frank probably knows more about us than he needs to, but that lets him make medical decisions that are real-istic and humanistic. Why isn't Doctor T like that? I feel cheated.
The second, "total," thyroidectomy is pretty much the same as the first, except that I really do not have any thyroid left this time. The second specimen was not cancerous (my intuition and I concur, not that anyone asked). The surgery hurt a lot more, but I did get to stay in the hospital three days. There. is radiation treatment in the month ahead. But the worst is over.
In retrospect, even with all the mixed signals, I have to
' marvel at the expertise and genius my doctors used to heal me.
I thank God for them every day, and hope they are thanking God
for me, too. Finally, I dedicate this journal to Dr. Frank Snyder —
a wonderful doctor but, more importantly, a wonderful friend. □
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NCMJ Janiiaiy/Febritarv 1997. Vohtme 58 Number I
55
CLINICAL PRACTICE
Interval to Cancer Diagnosis Following "Negative" Transthoracic Fine Needle Aspiration Biopsy
Warden L. Woodard, III, MD, Michael J. Kelley, MD, William L Betsill, Jr., MD, and Herman A. Godwin, Jr., MD
Transthoracic fine needle aspiration bi- opsy (TFNAB) under fluoroscopic or computed tomographic (CT) guidance can be used to evaluate suspected malig- nant lesions of the lung parenchyma, hi- lum, or mediastinum. As with any test, it is possible to determine the operating characteristics of TFNAB. These test characteristics include sensitivity (the true-positive rate or percentage of pa- tients with the condition who have a posi- tive test), specificity (the true-negative rate or percentage of patients without the condition who have a negative test), the false-positive rate (the percentage of pa- tients with a positive test who do not have the condition) and Xhe, false-negative rate (the percentage of patients with a nega- tive test who eventually turn out to have the condition).'
TFNAB has a sensitivity of 64%- 98%'" and a specificity of 92%- 1 00%.''- False-positive results are usually
8.11,12,15
less than 1 %
2,4-8,10-12,16
False-negative as-
pirations average about 11%," but there are reports of false-negative rates over 30% 8,11,12,15,17 -j-jjyg^ .^^j^jjg positive pre- dictive value is very high (>98% of pa- tients with a positive aspiration do have
The authors are affiliated with the Caroli- nas Medical Center, 1000 BIythe Blvd., Charlotte 28203. Drs. Woodard and Godwin are with the Blumenthal Cancer Center, Dr. Kelly is with the Department of Radiology, and Dr. Betsill is with the De- partment of Pathology.
cancer),^*" the predictive value of a nega- tive test is in the range of 50%-85%.''"" Accuracy may be diminished when le- sions are small and centrally located.- '" Best results are obtained when both the radiologist doing the procedure and the pathologist interpreting the biopsy are experienced.-'*'"' The general rule re- garding needle aspiration biopsies is that negative results do not exclude malig- nancy and that suspicious lesions should be evaluated further.
Accuracy and technical aspects of TFNAB have been extensively discussed, but little information exists about the length of time from a "negative" TFNAB to the diagnosis of malignancy in those cases where the TFNAB result was a false-negative. Since we perform many TFNABs at our large community teach- ing hospital, we have reviewed clinical outcomes of patients who had "negative" TFNABs. In addition to assessing the false-negative rate for diagnosis of ma- lignancy, we determined the time inter- val from TFNAB to diagnosis in these patients.
Methods
We obtained from the Departments of Radiology and Pathology a list of pa- tients who had negative TFNAB per- formed between October 1986, and De- cember 1990. All aspirations were per-
formed at Carolinas Medical Center in Charlotte using standard fine needle tech- nique under fluoroscopic or CT guid- ance. Samples obtained by aspiration were stained using rapid Papanicolaou tech- nique, and smears were reviewed imme- diately by a cytopathologist and radiolo- gist. If no diagnosis could be made, aspi- ration was repeated unless there was a clinical contraindication (a second TFNAB at the same sitting was not con- sidered a separate procedure). Cell blocks were reviewed on the day after the proce- dure and results were correlated with initial smears. The ordering physician was notified of the final diagnosis and, if negative, provided information concern- ing adequacy of sample. Bacterial, fun- gal, and mycobacterial cultures were per- formed when appropriate.
A total of 735 TFNABs were per- formed during the time period studied; 173 (23.5%) TFNABs in 173 patients were reported as negative for cancer. The 173 names were matched against names in the hospital's Tumor Registry, a can- cerregistry maintained according to stan- dards of the American College of Sur- geons. After review of abstracts of regis- try cases and available medical records, 27 of the 173 patients were found to have been diagnosed subsequently with pri- mary or metastatic intrathoracic cancer. A search of the state Central Cancer Reg- istry produced no additional cases. Ten of these 27 cases were excluded because
56
NCMJ January/February 1997, Volume 58 Number I
records were inadequate for confirma- tion of cancer diagnosis in four, biopsies had been made by technique other than TFNAB (they were on the list by mis- take) in three, there was a specific benign (not mahgnant) diagnosis in one, the TFNAB was actually positive (on the list by mistake) in one, and both a malignant and benign result were recorded on same day in one. Seventeen cases remained in whom cancer had been documented fol- lowing "negative" TFNAB.
The cancer diagnosis was established cytologically or histologically in Meases: via repeat TFNAB in four; repeat TFNAB and thoracotomy in three; thoracotomy in one; bronchoscopy in four; and biopsy/ aspiration from a nonpulmonary source in two cases. A clinical diagnosis of in- trathoracic cancer (based on histologic proof, antedating TFNAB, of cancer at another site, and enlarging bilateral pul- monary masses considered by attending physicians to be metastases) was accepted in the three remaining cases.
Results
In general, the diagnostic performance of TFNAB was quite good. As shown in Table 1 (below), 562 of 735 (76%) biop- sies confirmed the presence of cancer. In 173 (24%), the TFNAB result was not indicative of malignancy. In 31 (4%) of these cases, it was possible to make a specific benign diagnosis such as granu- loma, hamartoma, abscess, tuberculosis, etc. In no instance where such a specific diagnosis was made was there subse- quent revision to a malignant diagnosis. On the other hand, in 142 (19%) of the cases, cytopathology was not sufficient
to make a specific diagnosis, either be- nign or malignant.
In 17 cases (12% of the 142), the original diagnosis was subsequently re- vised to a malignant one. Table 2 (next page) shows details of the TFNAB re- sults in these 17 false-negative cases, the subsequent studies used to establish a diagnosis, and the interval to and nature of the final diagnosis. A diagnosis of intrathoracic malignancy was established within two weeks in nine patients; in the other eight, the interval to correct diagno- sis was five months or longer. Twelve patients had primary pulmonary neo- plasms and five, metastatic. In seven cases, TFNAB samples were cellular but nondiagnostic ; in 1 0, the cytologic sample was hypocellular or acellular (Table 3, page 59).
Of the eight patients whose interval to diagnosis was five months or longer, four had primary pulmonary neoplasms and four had recurrent or metastatic dis- ease. Delays to diagnosis in patients with primary lung tumors were five months, five months, 12 months, and 24 months. Two patients of the four with metastatic disease underwent major nonthoracic cancer operations (total glossectomy, partial hepatectomy), which could have been avoided had pulmonary metastases been proven by TFNAB.
Discussion
Our false-negative rate of 9.8% is consis- tent with the average from the literature. ' ' The causes of false-negative TFNAB have been well documented. Adequacy of sample depends on proper placement of needle and sufficient cellularity of speci-
Table 1. Transthoracic fine need aspiration biopsies (TFNAB) in 735 patients
Initial TFNAB diagnosis Number
Positive for cancer 562
Negative for cancer 1 73
specific benign diagnosis 31
indeterminate diagnosis 142
Final diagnosis of cancer
*
17
0
17
The 562 patients intially diagnosed with cancer by TFNAB were not systematically followed to determine whether any diagnosis was false-positive.
men. Areas of necrosis, inflammation, or fibrosis in a tumor increase the chance of a negative result.'"' In addition, some tumors yield mucoid or hemorrhagic material, possibly decreasing accuracy.^ Malignancy can be confidently ex- cluded if a specific benign diagnosis (hamartoma, granuloma, infarct, or in- fection) is made.''^" Such specific be- nign diagnoses can be made in 12%-70% of nonmalignant aspirates (the lower fig- ure is generally felt to be more accu- rate)5,6,i4,i6.i8
False- negative results are more likely when the pretest probability of malig- nancy is high." Factors increasing the probability of malignancy include older age, a history of smoking, and absence of the lesion on prior radiographs. Younger patients, nonsmokers, travelers to areas of endemic infections, and immunosup- pressed padents are more likely to have nonmalignant diagnoses such as infec- tions or other inflammatory processes.
Certain strategies can help decrease the chance for false-negative results and the delayed diagnosis of malignancy. A cytopathologist should be available to perform immediate cytologic analysis. "'■" If the cellularity of the sample is inad- equate, TFNAB should be repeated im- mediately. It may be helpful to repeat TFNAB at a subsequent setting if the initial procedure is nondiagnostic since 35%-65% of repeat procedures report- edly lead to a correct diagnosis.^'" Re- peat TFNAB was successful in seven of our patients; in four of these cases the interval was one week or less.
If repeat TFNAB is nondiagnostic and the clinical suspicion of malignancy is low, a conservative approach seems appropriate, especially in patients with impaired functional status who are poor surgical candidates. Patients should be monitored closely forradiographic change or worsening clinical status. Repeat ra- diographic evaluation two to three months after negative TFNAB has been sug- gested.^'^'-'* Of course, clinical and ra- diographic surveillance depend on pa- tient compliance, which is not always achieved.
The incidence and causes of false- negative TFNAB are well known, but
NCMJ January/February 1997, Volume 58 Number 1 57
Table 2
. False-negative TFNAB: Initial result, eventual diagnostic method, interval to diagnosis, and final diagnosis
Case
1
TFNAB result
Macrophages, consistent with granuloma or pneumonitis
Diagnostic method
Repeat TFNAB
Interval
2 days
Final diagnosis
Consistent with adenocarcinoma
2
Intense inflammation and suspicious atypical cells
Repeat TFNAB
3 days
Squamous cell carcinoma
3
Intense acute inflammation
Thoracotomy
1 week
Bronchial adenoma, carcinoid type
4
Atypical cells, probably reactive
Bronchoscopy
1 week
Poorly differentiated adenocarcinoma
5
Numerous macrophages and a few atypical cells
Lumbar puncture
1 week
Metastatic adenocarcinoma, unknown primary; multiple pulmonary/brain metastases, carcinomatous meningitis
6
Few hemosiderin laden macrophages, cell block acellular
Repeat TFNAB and thoracotomy
1 week
Bronchioloalveolar carcinoma
7
Amorphous necrotic debris, mucus, and a few lymphocytes
Repeat TFNAB
1 week
Consistent with large cell undifferentiated carcinoma
8
Blood and macrophages, sample not representative
Bronchoscopy
1 week
Adenocarcinoma consistent with lung primary
9
Few atypical bronchial cells
Bronchoscopy
2 weeks
Atypical cells consistent with non-small cell carcinoma
10
Blood, fibrin, acellular
Repeat TFNAB and thoracotomy
5 months
Poorly differentiated adenocarcinoma consistent with lung origin
11
Muscle, fat, few inflammatory cells; inadequate
Repeat TFNAB and thoracotomy
5 months
Large cell undifferentiated carcinoma
12
Inflammatory cells
Clinical*
6 months
Pulmonary metastases from squamous cell carcinoma of oropharynx. Radical surgery after "negative" TFNAB.
13
Benign connective tissue and lung; cell block blood only
Clinical*
8 months
Lung/liver metastases from colon cancer. Right liver lobectomy after negative TFNAB.
14
Few reactive and degenerated cells; hypocellular
FNA supra- clavicular mass
1 year
Metastatic adenocarcinoma \ with squamous features
15
Few macrophages and benign respiratory cells, scanty sample
Clinical*
13 months
Recurrent bronchioloalveolar ; carcinoma
16
Benign changes consistent with granuloma or hamartoma
Repeat TFNAB
2 years
Adenocarcinoma
17
Blood; few clusters of atypical cells, insufficient for diagnosis
Bronchoscopy
4 years
Metastatic renal cell carcinoma
*These patients had bilateral enlarging pulmonary lesions clinically previous histologic diagnosis of malignancy.
consistent with recurrent or metastatic cancer. Each had a
58
NCMJ January/Februaty 1997. Volume 58 Number 1
-
Table 3. Summary of 17 false-negative TFNAB
Interval to positive diagnosis
< 2 weeks 9
> 5 months 8
Type of neoplasm
Primary bronchogenic cancer 12 Metastatic cancer 5
Nature of "negative" sample
Cellular/nondiagnostic 7
Hypocellular/acellular 10
there is sparse documentation of the ac- tual interval to subsequent correct diag- nosis. A number of series have docu- mented false-negative TFNAB without reporting the delay in diagnosis.'*"""" Others give scanty information: Todd and colleagues stated that, of 36 false- negative cases, five had delay in treat- ment of longer than four months (three eventually were diagnosed at thoracotomy and two developed nodal metastases de- tected on subsequentmediastinoscopy).'"
Wescott reported five false-negatives in his series of over 400 TFNAB; in two cases correct diagnosis was made "months" after the procedure, and in an- other, repeat TFNAB two years later re- vealed adenocarcinoma.'' To our knowl- edge our report is the first to fully detail the interval to diagnosis in patients with false-negative TFNAB. Delayed diagno- sis may compromise the outcome of treat- ment and increase malpractice liability.'" In addition, failure to establish the pres- ence of pulmonary metastases from head and neck, colon, or other cancers may lead to unnecessary operations, as in two of our patients.
What should physicians do when they receive a "negative" (nondiagnos- tic) TFNAB report? Calhoun and col- leagues, in a review of 38 false-negative TFNAB, found no clinical, cytologic, or radiologic criteria that could define pa- tients with insignificant risk for cancer.''' Therefore, a negative TFNAB should be followed by second attempt at diagnosis using repeat TFNAB, bronchoscopy, or surgery. Eight of our 17 patients had the
diagnosis established within two weeks by one of these interventions.
Perhaps a change in wording on TFNAB reports could decrease the chance of a delay in diagnosis. It has been sug- gested that "negative" be used only for specimens with adequate cellularity . "In- sufficient for diagnosis" would be se- mantically more appropriate for speci- mens with inadequate cellularity. Fur- thermore, the report of a nondiagnostic cellular sample could say "cells present are not diagnostic of a specific lesion."" Such changes in terminology might help the physicians who order TFNAB, par- ticularly primary care physicians. Radi- ologists and pathologists should advise clinicians about the need to carefully monitor patients with "negative" aspir- ations. Q
Acknowledgments: The authors thank Alicia Whitener, RN, BSN, and Anne Lowdermilk, ART, for their assistance in data management, and William G. Por- ter, MD, for helpful comments.
References
1 Wong JG, Feussner JR. Screening for asymptomatic diseases in your patients. NC Med J 1993;54:218-21.
2 Weisbrod GL. Transthoracic percutane- ous lung biopsy. Radiol Clin North Am 1990;28:647-55.
3 Wescott JL. Percutaneous transthoracic needle biopsy. Radiology 1988;169:593- 601.
4 Cristallini EG, Ascani S, Farabi T, et al. Fine needle aspiration biopsy in the di- agnosis of intrathoracic masses. Acta Cytologica 1992;36:416-22.
5 Stanley JH, Fish GD, Andriole JG, et al. Lung lesions: cytologic diagnosis by fine- needle biopsy. Radiology 1987:162:389- 91.
6 Khouri NF, Stitik FP, Erozan YS, et al. Transthoracic needle aspiration biopsy of benign and malignant lung lesions. AJR 1985;144:281-8.
7 Crosby JH, Hager B, Hieg K. Transtho- racic fine-needle aspiration: experience in a cancer center. Cancer 1 985 ;56:2504- 7.
8 Caya JG, Clowry LJ, Wollenberg NJ, Tieu TM. Transthoracic fine-needle aspi-
ration cytology: analysis of 82 patients with detailed verification criteria and evaluation of false-negative cases. Am J Chn Pathol 1984;82:100-3. 9 Westcott JL. Direct percutaneous needle aspiration of localized pulmonary lesions: results in 422 patients. Radiology 1980;137:31-5.
10 Todd TRJ, Weisbrod G, Tao LC, et al. Aspiration needle biopsy of thoracic le- sions. Ann Thorac Surg 1 98 1 ;32: 1 54-6 1 .
1 1 Veale D, Gilmartin JJ, Sumerling MD, Wadehra V, Gibson GJ. Prospective evaluation of fine needle aspiration in the diagnosis of lung cancer. Thorax 1988;43:540-4.
12 Winning AJ, McI vor J, Seed WA, Husain OAN, Metaxas N. Interpretation of nega- five results in fine needle aspiration of discreet pulmonary lesions. Thorax 1986^41:875-9.
1 3 Cagle PT, Kovach M, Ramzy I. Causes of false results in transthoracic fine needle lung aspirates. Acta Cytologica 1993;37:16-9.
14 Calhoun P, Feldman PS, Armstrong P, et al. The clinical outcome of needle aspira-
tions of the lung when cancer is not diag- nosed. Ann Thorac Surg 1986;41:592-6.
15 Charig MJ, Stutley JE, Padley SPG, Hansen DM. The value of negative needle biopsy in suspected operable lung cancer. Clinical Radiology 1991;44:147-9.
16 Salazar AM, Westcott JL. The role of transthoracic needle biopsy for the diag- nosis and staging of lung cancer. Clinics m Chest Medicine 1993;14:99-110.
17 ZakowskiMK,GatschaRM,ZamanMB. Negative predictive value of pulmonary fine needle aspirates. Acta Cytologica 1992;36:283-6.
18 Fraser RS. Transthoracic needle aspira- tion: the benign diagnosis. Arch Pathol Lab Med 1991;115:751-61.
19 Austin JHM, Cohen MB. Value of having a cytopathologist present during percuta- neous fine needle aspiration biopsy of lung: report of 55 cancer patients and meta-analysis of the literature. AJR 1993;160:175-7.
20 Osuch JR, Bonham VL. The timely diag- nosis of breast cancer: principles of risk management for primary care providers and surgeons. Cancer 1994;74:271-8.
NCMJ January/February 1997, Volume 58 Number 1
59
Carolina Physician's Bookshelf
Book review editor: Edward C. Halperin, MD, Professor and Cliair,
Department of Radiation Oncology, Box 3085, Duke University l\/ledical Center, Durham 27710
The Rough Riders
By Theodore Roosevelt, originally published in 1899, available on audiocassette narrated by John Randolph Jones, Recorded Books, Inc., 1993, ISBN 1-55690-914-4
Has the North Carolina Medical Journal gone completely off the deep end? Here we are reviewing a book published in 1899! I suppose everyone has heard the joke about the old magazines m the doctor's waiting room, but this is ridiculous!
My encounter with this 1 899 book began innocently enough. Part of my responsibilities at Duke include serving as a radiation oncologist at a variety of off-site hospitals. This sometimes involves a 1 1/2- to 2-hour drive in the morning to the hospital and an equal amount of time for the return trip. I know that there are some people who can deal ^^_i^^^^^^^_
with trips of this sort by listen- ing to music and others who become fans of public radio. I don't have enough patience, or the ability to "zone out," to deal with the long drive with either of these techniques. I have tried listening to continuing medical education tapes but this requires a fair amount of concentration. Therefore, if you have to
swerve, change lanes, or come
to a stop, you have to put the tape on hold and reverse it to be sure you didn't miss something.
A reasonable alternative to the continuing medical educa- tion tapes are recorded books. These are available from a variety of companies. I rent them by the month. The book arrives in the mail, consisting of four to 10 cassettes and narrated by an actor. I try to pick things that don' t require too much concentration and they help to while away the time during long drives.
It was through this means that I encountered Theodore Roosevelt's 1 899 book, The Rough Riders. The story of Theodore Roosevelt is, of course, known to most schoolchildren. Roosevelt was the product of an upper middle-class family of Dutch origin in New York. He was a weak and sickly child who, through a program of vigorous physical exercise, built himself up. Roosevelt ultimately graduated from Harvard. Following the simultaneous death of his first wife and his mother, Roosevelt moved to the
"Several interesting aspects of Roosevelt's narrative of the Spanish- American War intrigued this physician- iistener. For example, I never knew that
Theodore Roosevelt was not the
commander of the Rough Riders. The
commanding officer was, in fact, a
physician— Dr. Leonard Wood,"
American West where he worked, for several years, as a deputy sheriff, cowboy, and horseman. He was a profoundly intellec- tually curious individual and wrote prolifically. He produced a variety of serious books of history including A History of the War of 1812, travel books describing his experiences in the western United States, books devoted to conservation, descrip- tions of big game hunting in Africa, collections of letters, and various political tomes.
Ultimately, Roosevelt returned to New York state where he threw himself into politics. He served in the New York State Assembly, as a civil service commissioner, and as a police commissioner. Eventually he ended up in the Navy Department in the McKinley administration where he, along with others, agitated for war with Spain.
The war with Spain was the result of prompting by a warmongering "yellow press" which took considerable lib- erties with the truth to build up allegations of "Spanish atrocities" in Cuba. A grow- ing sense of American impe- rialism lead to an interest in "driving the Spaniards out of the Western Hemisphere." When the USS Maine blew up in Havana Harbor under mys- terious circumstances, the dye was cast and war was declared. What does any of this have to do with medicine? Several interesting aspects of Roosevelt's narrative of the Spanish- American War intrigued this physician-listener. For example, I never knew that Theodore Roosevelt was not the commander of the Rough Riders. The commanding officer was, in fact, a physician — Dr. Leonard Wood.
Wood was, by all accounts, a remarkable man — a fact Roosevelt drives home at every opportunity. After graduating from Harvard Medical School in 1 884, Wood worked briefly as a chief surgeon for the Southern Pacific Railway. He subse- quently entered the Army Medical Corps. He was assigned to the cavalry units pursuing Geronimo and was present at the capture of the Apache leader. Wood had a natural affinity both for medicine and for persevering in the marches through the hot desert and rugged mountains. He was ultimately awarded the
60
NCMJ January/February 1997, Volume 58 Number 1
Congressional Medal of Honor and given command of an
infantry unit. Wood later served as personal physician to
Presidents Cleveland and McKinley.
I While in Washington, Wood became a close friend of
' President McKinley's young assistant secretary of the Navy,
j Roosevelt. Both men strongly favored military intervention in
I Cuba against Spain. When the Maine exploded in Havana
Harbor and war was declared in April 1 898, Wood was named
j colonel and commander of an all-volunteer Cavalry regiment,
officially called the First United States Volunteer Cavalry, but
j known to every schoolchild as the "Rough Riders." Roosevelt
was named a lieutenant colonel and second in command.
The Rough Riders contained an assortment of cow punch- ers, sheriffs and marshals, miners, and hunters, as well as j portions of the Harvard, Yale, and Princeton football teams — all in search of combat and adventure. The short-lived cam- paign included a landing on the southeastern coast of Cuba, a brief skirmish with the Spanish, a march on the city of Santiago, the battle of San Juan and Ketde Hills, a short siege of Santiago, and the eventual capitulation of the city when the Spanish fleet was decimated by the US Navy — thus cutting off possibilities of reinforcement. The Philippines were taken by sea by Admiral Dewey (in fact Dewey was victorious so quickly that he had to stall until troops could land to occupy the city). Puerto Rico was taken in a brief campaign.
After the brief and bloody Santiago campaign, Wood went on to become military governor of Cuba, military governor of the Philippines, chief of staff of the US Army, and a candidate for the Republican nomination for president in 1920. Wood lost out, at the convention, to Warren G. Harding who eventually was elected president. Wood had been offered, but declined, the nomination of vice president. When Harding died in office, Calvin Coolidge, the taciturn governor of Massachusetts who ultimately took the vice presidential job, became president. Thus, Wood was almost our first physician-president. Wood I died in 1927 of a meningioma, having been operated on by Dr. Harvey Cushing.
In addition to encountering Leonard Wood, Roosevelt intrigued this physician-listener with a dramatic accounting of ballistic injuries suffered by his troops. The Spanish Army used German weapons and many Americans were killed or wounded by these Mauser bullets. Roosevelt graphically describes the wounds wrought by these weapons and the pitiful state of medical care and sanitary conditions during the war.
Roosevelt is unstinting of his criticism of US military . incompetence. Inefficient transportation, inadequate food, bun- gling bureaucratic organizations, and the inability of his mili- tary superiors to recognize the decimation wrought on US troops by tropical disease all draw his wrath. After the war was won, epidemics in the Army camps eventually forced com- manders in the field to publicly call for an evacuation of troops from Cuba.
Roosevelt's personality emerges in his narrative — without equivocation. The future president's language sounds like the dialogue you'd expect in an inspirational grade school history
book. Roosevelt describes how some of his troops were, before their military service, territorial marshals who had chased "white desperadoes." When he praises his troops we hear language like: "duty . . . virtue . . .vigor. . .manliness. . . gallantry . . . fearlessness... coolness under fire... anxious to see action." Roosevelt vividly describes the conduct of the "colored troops" charging up San Juan and Kettle Hills — occasionally using racist language and images, although not as often as I might have expected.
Roosevelt and Dr. Wood made enjoyable company on my commutes. I recommend them to you. Q
On Doctoring: Stories, Poems, Essays
Reynolds R, Stone J, editors. New York:
Simon and Schuster, 1995, ISBN 0-684-80255-4, $30
My wife and children presented me with this anthology last year. The flyleaf promised "this new, larger edition of On Doctoring is an extraordinary collection of stories, poems, and essays written by physicians and nonphysicians alike — works that record what it is like to be sick, to be cured, to lose, or to triumph.... At a time when medicine is becoming more and more technical and institutionalized, the book captures the breadth and wonder of the medical profession, reminding us of what it is really all about." Wow, an ambitious undertaking for only 448 pages!
What On Doctoring provides is a collection of short stories, poems, excerpts from books, and essays. After a few selections from The Bible, Keats, and Donne we leapfrog to the late 19th century for a half-dozen authors. The next approxi- mately 60 writers are 20th-century writers. I would have thought that more selections could have been found outside our own time.
I wish I could tell you that this is a great book, perfect for the physician on your gift list, and appropriate for your own nightstand. Sorry. Frankly, a lot of the selections are not about doctoring at all — they are about death, aging, and illness. I, for one, don't think that the subjects are interchangeable. 1 also didn't enjoy most of the poetry — although I'm prepared to admit that this may be my fault. I think that the appreciation of poetry is an energy-requiring process. I haven't expended the energy.
The book is redeemed by some notable descriptions of the practice of medicine: Elspeth Cameron Ritchie's "Hospital Sketchbook: Life on the Ward through an Intern's Eyes," David Hilfiker's exceptional essay on errors in medicine, a selection from Abraham Verghese's book My Own Country, and Joseph Hardison's "The House Officer's Changing World."
On Doctoring will reward the selective reader. If a third edition is planned, I'd suggest that the editors substitute some selections from pre-20th century English literature and en- deavor to be truer to their title — the book is supposed to be about doctoring, not about being ill. □
NCMJ January/February 1997. Volume 58 Number 1 61
ORIGINS OF DISEASE
New Views of Sickle Cell Disease
Wendell F. Rosse, MD
Sickle cell disease was first recognized more than 85 years ago, and the exact nature of the molecular defect that causes has been known for at least 40 years. Despite the historical position of sickle cell disease as the first described "mo- lecular" disease, a great deal of research in the past few years has led to some new and interesting insights.
The Geographic Origins of Sickle Cell Disease
The defect in sickle cell disease consists of an inherited abnormality in the hemo- globin molecule. In all affected patients, the 6th amino acid from the beginning (the amino terminus) of the B chain is changed from glutamine to valine, chang- ing hemoglobin A (HbA) to hemoglobin S (HbS). The change in protein structure is always due to a change in the gene in which a thymidine molecule is substi- tuted for an adenine. Examination of the genetic material surrounding that encodes for the B chain (using a process known as detection of restriction fragment length polymorphisms or RFLPs) shows that the substitution of thymidine for adenine occurred in only five original individu- als, each of whose descendants are char- acterized by a specific RFLP pattern or
Dr. Rosse is Florence McAlister Profes- sor of Medicine, Division of Hematology and Medical Oncology, Department of Immunology, Box 3934, Duke University Medical Center, Durham 27710.
haplotype. All patients with sickle cell disease or sickle cell trait ("trait" means having a HbS gene from one parent, and a HbA gene from the other parent) are descended from these five founders.'
By ascertaining the geographic den- sity of the occurrence of each specific haplotype, we can deduce where the ab- normal gene originated and how far it has spread from its site of origin (Figure 1, next page). The most widely spread sickle cell gene haplotype began in what is now Nigeria; it is called the Benin type. This gene found its way to the Mediterranean region (either through trans-Sahara trade or through the importation of slaves in late Roman times) and is the gene seen in patients of Greek or Italian ancestry. Another widespread gene originated in the area just north of the mouth of the Congo River (the Central African Re- public, or CAR haplotype). The Senegal haplotype originated in western Africa, near modern Liberia, and a fourth Afri- can haplotype originated very recently in Cameroon where it is found only in mem- bers of a single tribe. The fifth sickle gene originated outside of Africa, in the Indus valley of India, probably during the Harappa civilization that flourished there about 4,000 years ago. It is found in descendants of the aboriginals of India now called the Hill Tribes. This gene and the African gene from Benin have spread to the Arabian peninsula.
From analysis of the sickle genes of African-Americans, the pattern of im- portation of slaves into America can be deduced. The two major sites of importa- tion were Charleston, South Carolina,
and the Chesapeake Bay area of Virginia. Most of the slaves brought into Charles- ton came from West Africa. As a result, the Senegal haplotype is present in higher percentage in upland South Carolina than elsewhere. After the importation of slaves was made illegal, there was still illicit importation to the Sea Islands off Geor- gia and South Carolina from the only remaining entrepots in Africa (in Portu- guese Angola); these individuals prima- rily had the CAR sickle gene. In Virginia, the predominant importations came from English and Dutch entrepots on the "Slave Coast" (modern Ghana, Benin, and Nige- ria) so that most of these individuals had genes of the Benin type, which still pre- dominates in the Mid-Atlantic area.
What Is the Effect of the Sickle Cell Defect?
Why did the mutations that led to HbS in five individuals prosper so well? For some time it has been thought from epidemio- logical data that the gene conferred a resistance to malaria. This has now been confirmed by demonstrating that the red cells of individuals with sickle trait resist invasion by the malarial organism, thus making those individuals less likely to infected. This (and several other abnor- malities of the red cells) allowed African slaves to remain in malarious lowlands of the Carolinas during the summer when their European-descended owners fled to the uplands. The relatively recent appear- ance of the sickle gene probably corre- sponds to the relatively recent emergence
62
NCMJ Januan'/Febman' 1997. Volume 58 Number 1
ARAB-INDIA
SENEGAL
Fig 1 : Distribution of the different sickle gene haplotypes in Africa and Asia. (Adapted and redrawn, with permission, from: Embury SH, Hebbel RP, Mohandas N, et al. Sickle Cell Disease: Basic Principles and Clinical Practice. Raven Press, Ltd., 1996, p355.)
of malaria. Human malaria requires a criti- cal concentration of individuals for its continued propagation, a concentration probably only achieved when early hu- mans began to live settled, communal lives. The single amino acid change in the 6 globin gene has far-reaching consequences. It alters the external surface of the mol- ecule so that, upon deoxygenation, it can bind to another like molecule and become part of a long string of pairs of molecules called a paracrystal (Figure 2, next page). Each paracrystal associates with some 13 other similar chains to form a rod inside the red cell. Rod formation leads to a number of effects:
1. It distorts the cell into a sickle shape, reducing its ability to circulate and caus- ing some hemolysis.
2. It alters the membrane so that the cell more readily sticks to endothelial sur-
faces and also becomes leaky to ions. 3. It increases the internal viscosity of
the cell, which in turn may increase
the viscosity of the blood. Figure 3, next page, shows the sequential effects of these changes. All lead to per- manent or functional vascular occlusion and the impaired perfusion of organs that causes most of the clinical problems in sickle cell disease.
When and Why Do People Die of Sickle Cell Disease?
For many years, it was thought that sickle cell disease was an illness of childhood, and that most patients died before early adulthood. The Cooperative Study of Sickle Cell Disease recently found other- wise.- There is an early peak of mortality
during the first three years of life, due primarily to acute infection (treatment can limit this — see below). There follows a period during which few patients die from the disease itself, but beginning in the middle 20s, patients again begin to die. The mean age at death for patients who receive HbS genes from both parents (that is, who are homozygous for HbS) is 44 years for men and 46 for women. Longev- ity is markedly improved in patients who, for any of a number of reasons, have high levels of fetal hemoglobin (HbF) in their red cells. Other abnormal hemoglobin molecules may alter survival. For example, patients who have one gene for HbS and one for hemoglobin C (SC disease, the next most common sickling disorder) have high levels of HbF and live about 15-20 years longer than patients with SS disease. Patients die of a variety of problems,
NCMJ January/Februar-y 1997, Volume 58 Number 1
63
• • •
• • •
Unpoly- merized
Nucleation
Random Rods
Parallel Rods
Fig 2: Formation of the paracrystal from sickle hemoglobin molecules upon deoxygenation.
Precipitation of Hemoglobin on Membrane
Paracrystal Formation
Membrane Alteration
Cellular Deformation
Hemolysis
Increased
Intracellular
Viscosity
\
Increased
Blood
Viscosity
VASCULAR OCCLUSION
Endothelial Adhesion
Fig 3: The effects of paracrystal formation on the red cell in sickle cell disease.
but we are often left uncertain about the exact cause (Figure 4, next page). In at least a 20% of cases, no cause can be specified; in about 15%, death is due to chronic organ damage, usually renal or cardiac; in over 30%, it is due to pulmo- nary problems which are lumped together as "acute chest syndrome."
The acute chest syndrome. This syn- drome, now recognized as the major cause of death, is second only to the painful episode in frequency and is unrivaled in
the severity of its consequences.' It prob- ably begins with the accumulation of sickled cells in the pulmonary arterioles. Normally, these cells unsickle when they take up oxygen, but if there is interfer- ence with the transfer of oxygen or with the perfusion of the area, sickled cells accumulate. This further impairs blood flow and widens the area of poor perfu- sion, which may show on the chest x-ray as a pulmonary infiltrate. The affected area is ideal for bacterial growth so that, even if not infected originally, it becomes
infected. This process may spread very rapidly to involve large areas of lung, leading to poor ventilation and arterial oxygen desaturation (Figure 5, next page). The ultimate result may be systemic hypoxemia and the "multi-organ damage syndrome" or "sludge" syndrome described below.
Several things predispose pa- tients to the acute chest syndrome. In children, it is usually precipitated by a chest infection; in adults, it commonly accompanies painful epi- sodes and is more common in pa- tients with relatively high hemat- ocrit (such as patients with SC dis- ease or sickle B thalassemia). It is the leading cause of postoperative mor- bidity, particularly in operations near the diaphragm and in patients who have not been prophylactically trans- fused.
There are several steps in the care of the "acute chest syndrome." All adults with chest infiltrates must be closely observed; this often means that the patient must be admitted to the hospital. If fever is present, anti- biotics should be given empirically. Oxygen should be given by nasal catheter. If the infiltrate worsens or if the arterial oxygen saturation can- not be maintained, immediate and complete exchange transfusion should be carried out. It is important to recognize how lethal this syn- drome can be and to give maximal attention to the care of the patient.
The "acute multi-organ damage" syndrome. This life-threatening syn- drome occurs when blood becomes too viscous to perfuse tissues. "* Whole blood viscosity is determined by several factors: the viscosity of the plasma (not a concern in this setting), the internal vis- cosity of the red cells (increased in sickle cell disease because of the formation of paracrystals of hemoglobin), and the pro- portion of red cells in the blood (the hematocrit). Whole blood viscosity will be elevated when the sickle hemoglobin is deoxygenated (because this increases the internal viscosity of the red cells) andy or when the hematocrit is increased. When
64
NCMJ Jamtarx/February 1997. Volume 58 Number 1
iilie \
111
these conditions occur on the arterial side of the circulation, organ perfusion be- comes difficult and tissue hypoxia may result. This leads to loss of organ function (coma if the CNS is involved, acute renal failure if the kidneys are, etc.) and some necrosis. Hypoxia usually affects more than one organ at one time and, unless recognized and treated promptly, results in permanent loss of function and even death. Nasal oxygen should be given and hyperbaric oxygen may be of help if available. Most importantly, immediate and complete exchange transfusion should be done; if this is cannot be done locally, the patient should be trans- ferred quickly to a facility that can doit.
Pain in Sickle Cell Disease
The most common complication of sickle cell disease is the painful epi- sode.' The pain is due to tissue hy- poxia but we are not entirely sure what goes into causing the hypoxia. The typical painful episode has a discrete beginning, lasts five to 10 days, and has a gradual resolution. Between episodes, the patient is nearly asymptomatic. During the painful episode, there is evidence of intravascular clotting, suggesting obstruction to flow caused by an agglomeration of sickle cells which then activate clotting within the ag- glomeration. The pain presumably doesn't resolve until the fibrin clot is fully digested and the agglomera- tion disassembled. The initial causes of these episodes and the reasons why pain may occur in several sites at the same time are not at all clear. In some patients, particularly those with a hematocrit higher than 32%, pain may be chronic. The epi- sodes are not discrete and do not seem to resolve satisfactorily, leav- ing the patient with some pain on imostdays. This pain may result from difficulty in perfusion on a more moderate scale than in the "sludge" syndrome. There is no evidence of
increased coagulation; since no aggrega- tions of cells occur, no clot surrounds them.
The possible differences in origin of pain have implications for treatment. Occlusion pain can be treated vigorously with maximal narcotics, avoiding mep- eridine (Demerol) because it has limited duration of action and presumably causes more hypoxia. Increasing the arterial oxy- gen concentration (even hyperbaric oxy- gen) does not help because the occlusions are set in place by surrounding clot. On the other hand, perfusion pain is more
Sudden Death Peri-Operative
chronic and access to narcotic medica- tions needs to be somewhat limited so that patients do not become addicted. In theory, chronic pain symptoms should be relieved by reducing the hematocrit to allow better perfusion, but this idea has not yet been tested. Perfusion pain may be helped by increasing arterial oxygen concentration since there is no fixed ob- struction. The nature and treatment of pain in sickle cell disease need further research, but at least we have a frame- work with which to think about this most vexing problem.
Chest
in and Chest
Pain
Renal Failure
Missing and Unknown
Heart Failure
Chronic CVA
Trauma
Other
Cancer
Fig 4: The causes of death in sickle cell disease.
Multi-Organ Damage
Sludging on Pulmonary Arteriolar Side
\
Hypoxemia
Consolidation
Perfusion-Ventilation Mismatch
Pneumonia
Fig 5. The "vicious cycle" that results in acute chest syndrome in sickle cell disease.
NCMJ January/February 1997, Volume 58 Number 1
65
Treatment Advances
Prophylaxis with penicillin. A major cause of death in children with sickle cell disease is sepsis caused by gram-positive organisms, particularly S. pneumoniae. The susceptibility occurs because the spleen, which becomes filled with sick- led cells almost as soon as HbS begins to be produced instead of HbF, is essentially disabled. It no longer filters bacteria from the bloodstream to process them for a primary immune response. Hence, bacte- remia readily turns to septicemia. Pro- phylactic penicillin can prevent this,'' re- ducing the death rate from 15%-20% during the first five years to almost noth- ing. For this reason, most states screen newborns to identify those at risk and have a system to ensure that these infants get their penicillin.
The downside of prophylaxis is the development of penicillin-resistant or- ganisms; this appears to happening at an alarming rate in some areas. One possible answer is the development of vaccines against the antigens of the pneumococ- cus. Presently available vaccines are not effective until recipients are more than two years old, which is much too late to be very useful. Improved vaccines, in- cluding those in which the pneumococcal polysaccharides are conjugated to pro- teins, are being developed and tested.
Hydroxyurea. When fetal hemoglobin is present in the cells of the patient with sickle cell disease, the clinical effects of the disease are ameliorated. This was first suggested by studies of patients in east- ern Saudi Arabia, where a gene that per-
mits the continued production of HbF is often inherited along with the sickle cell gene. Most patients with homozygous sickle cell disease are asymptomatic when they have persistent production of HbF. The Cooperative Study of Sickle Cell Disease showed that increased levels of HbF reduced the likelihood of painful episodes'" and lengthened life expectancy. -
"Recently, bone morrow
transplantation has
been used in sickle cell
disease in children who
hove already had
complications. The
mortality rate of
transplantation was
about 10% and the
success rate was
about 70%."
Several drugs cause the body to con- tinue to make HbF. Of these, the safest discovered to date is hydroxyurea (HU), which has been used as achemotherapeu- tic agent in myeloproliferative diseases for a number of years. In a double-blind study of patients with homozygous sickle cell disease, HU was found to reduce by over 50% the incidence of painful crisis and of acute chest syndrome.' The dose of HU must be carefully tailored to each patient and requires a careful dosing schedule since overdose causes danger- ous marrow suppression. The drug can be
given only under strict medical supervi- sion, but it is the first successful specific treatment for sickle cell disease. It has made an enormous difference in the lives of many patients.
Bone marrow transplantation. The de- velopment of bone marrow transplanta- tion over the past several years has made it safer to replace diseased marrow with a normal marrow. Transplantation between HLA-identical siblings has been used with great success in thalassemia, where the clinical consequences of the disease are more predictable than in sickle cell dis- ease." Recently, bone marrow transplan- tation has been used in sickle cell disease, particularly in children who have already had complications. In this group, the mortality rate of transplantation was about 1 0% and the success rate was about 70%. These results make it reasonable to con- sider bone marrow transplantation at an early age for all children who have appro- priate donors.
Gene therapy. The hope of modern medi- ; cal science is to replace or modify the ; abnormal genes of patients with genetic disease. In the case of sickle cell disease, the replacing gene must have a very high production rate to make enough hemo- globin to fill the cell; this has not yet been achieved . Other scientists are concentrat- ing on understanding and modifying the ' steps that govern the change from fetal to [ adult hemoglobin production. Genei therapy has great promise, but for the foreseeable future it remains only a prom- ise in the treatment of sickle cell disease. Q
I
References
1 Nagel RL. Origin and dispersion of the sickle gene. In; Embury SH, Hebbel RP, Mohandas N, et al. Sickle Cell Disease: Basic Priniciples and Clinical Practice. New York: Raven Press, Ltd., 1996, pp 353-80.
2 Piatt OS, Brambilla DJ, Rosse WF, et al. Mortality in sickle cell disease: life expect- ancy and risk factors for early death. N Engl J Med 1994;330:1639-44.
3 Castro O, Brambilla DJ, Thorington B, et al. The acute chest syndrome in sickle cell
disease: incidence and risk factors. Blood 1994;84:643-9.
4 Hassell KL, Eckman JR, Lane PA. Acute multiorgan failure syndrome: a potentially catastrophic complication of severe sickle cell pain episodes. Am J Med 1 994;96: 1 55- 62.
5 Piatt OS, Thorington BD, Brambilla DJ, et al. Pain in sickle cell disease: rates and risk factors. N Engl J Med 1991;325:11-6.
6 Gaston MH, Verier JI, Woods G, et al.
Prophylaxis with oral penicillin in children with sickle cell anemia: a randomized trial. N Engl J Med 1986;314:1593-9.
7 Charache S, Terrin ML, Moore RD, et al Effect of hydroxyurea on the frequency of painful crises in sickle cell anemia. N Engl J Med 1995;332:1317-22.
8 Giardini C, Galimberti M, Lucarelli G. Bone marrow transplantation in thalas- semia. Annu Rev Med 1995;46:319-30.
66
NCMJ January/February 1997, Volume 58 Number 1
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TOXIC ENCOUNTERS
''All But Death, Can Be Adjusted''
Ma Huang (Ephedrine) Adversities
Ronald B. Mack, MD
The poet, Emily Dickinson, spent her adult life writing verse that dealt with the universal themes of love, death, and im- mortality. She became a recluse in her early 20s, allegedly because of a disap- pointing affaire de coeur, and thereafter communicated with her friends solely through letters to them.'' Probably the "Belle of Amherst" would have been happier if she had had access to ephe- drine. But then, artificially happy, she might not have written that profound po- etry, revealing her spectacular insights into the deep emotions encountered by all human beings able to experience "feel- ing."
In this age of modern medicine, amid daily reports of diagnostic and therapeu- tic advances, many Americans express an interest in alternative forms of health care — including nutritional supplements and herbal remedies — to assuage real or imagined ailments. Most of these nos- trums are available at health food stores, convenience stores, and exercise facili- ties. Of course, they do not require a prescription. One of the more popular products in current use has been available in China for the past 5,000 years.''' It is ma huang, an herbal remedy that contains ephedra.
Dr. Mack is Associate Professor, Depart- ment of Pediatrics, Bowman Gray School of Medicine, Medical Center Boulevard, Winston-Salem 27157.
Five millennia ago, ma huang was used to combat the common cold, asthma, allergies, cough, headache, and fever.'' Today, it is widely used in products that are alleged to boost energy, control weight, and heighten sensations, but is still promoted to relieve cold symptoms and improve respiratory function. "* In some cases ephedra is touted as an "herbal high" (not surprisingly, those who be- lieve this are primarily the young of our species searching for better health or a better "high"). Ephedra is known by many common names in addition to ma huang: miner's tea, Mexican tea, sea grape, yel- low horse, teamster's tea, and popotillo. Mormon tea and squaw tea are beverages made from alkaloid-free species of this herb.'* The problem with listing ephedra as a so-called "food supplement" is that the Food and Drug Administration has linked it to 1 7 deaths.' And more than 800 people have been treated for disorders traced directly to "health food" prepara- tions sold to reduce weight, build muscle, and improve stamina.''
Ephedra's Family Tree
At least 40 species of evergreen plants are members of the genus ephedra. The vari- ous species have worldwide distribution and appear as erect, evergreen plants re- sembling small shrubs. They have a thick woody base and many slim, jointed branches covered with thin, scale-like leaves. All of these plants have a distinc-
tive pine odor and an astringent taste,' but not all produce alkaloids. In those species that do, the highest concentration is found in the green branches. A number of alka- loids possessing sympathomimetic prop- erties may be present, including pseu- doephedrine, norephedrine, and nor- pseudoephredrine, but principally ephe- drine. Ephedrine was first isolated from ephedra in 1887 by the Japanese,' but Western medicine did not see any thera- peutic value in it until 1930 when Chen and Schmidt published a comprehensive document recommending it for treatment of asthma.'
Ephedrine stimulates both alpha and beta-adrenergic receptors.''' For readers who went to medical school as long ago as I did, a short review may be in order. The pharmacology teachers who in- structed us were noble men and women for sure, but still obsessed with turning base metals into gold. In any case, what I now know is that stimulation of alpha- 1- receptors produces contraction of both vascular smooth muscle and genitouri- nary smooth muscle, as well as increased contractile force of the heart and arrhyth- mias, as well as glycogenolysis, gluco- neogenesis, and hyperpolarization and relaxation of intestinal smooth muscle. Stimulation of alpha-2-receptors de- creases insulin secretion, platelet aggre- gation, and the release of norepinephrine from the nerve terminals, but causes con- traction of vascular smooth muscle (like alpha- 1 -receptor stimulation).
If you stimulate beta- 1 -receptors you
I
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68
NCMJ January/February 1997, Volume 58 Number 1
get increased force and rate of contrac- tion of the heart, increased velocity of conduction through the atrioventricular node, and increased renin secretion. If you stimulate beta-2-receptors you get relaxation of smooth muscle (of blood vessels, bronchi, the gastrointestinal and genitourinary tracts) as well as glyco- genolysis, uptake of potassium, and glu- coneogenesis. Finally, stimulation of beta- 3-receptors causes lipolysis. Lest I for- get, in addition to its direct sympathomi- metic effects, ephedrine can release nore- pinephrine from its storage sites.' This type of science differs from what I learned as a young doctor — things like giving mercury compounds to produce a diuretic effect on the kidneys. I cannot believe I ever did such things, but I did as an intern at Chicago' s Cook County Hospital, God forgive me!
The Pharmacologic Perspective
m
Putting these pharmacologic data in per- spective, ephedrine in therapeutic dosage eads to cardiac stimulation and elevated systolic and diastolic blood pressure. Giv- ng ephedrine frequently or for a pro- onged period can produce tachyphylaxis' 'a progressive decrease in response after epetitive administration of a pharmaco- ogically active substance) to its effects )n blood vessel and bronchial smooth nuscle. Depletion of norepinephrine tores by ephedrine is believed to be one
,i5(j.;ause of tachyphylaxis.
[,, || Ephedrine is completely and rapidly ibsorbedafteroral, intramuscular, or sub-
. :utaneous administration.' The drug is listributed throughout the body and rosses the blood-brain barrier. It is pri- narily metabolized by N-demethylation 0 norephedrine.'" Its half-life ranges be- ween 2.7 hours to 7.5 hours. Within 48
. : lOurs, 70%-80% of a given dose is elimi-
^ ■; lated unchanged in the urine where it can le detected by a number of tests.' The ntemational Olympic Committee did not Tohibit ephedrine consumption by com- ■etitors but did rule that urine levels over ' 00 ng/mL indicate abuse and are grounds ar disqualification.' At least one author-
ity considers this level is too low because a recent study found that healthy volun- teers given realistic doses of an ephe- drine-containing nasal spray (approxi- mately 14 mg) had urine levels of 0.09- 1.65ug/mL."
It is not surprising that the toxic effects of ephedra-containing products are primarily due to ephedrine, and to a much lesser degree, pseudoephedrine. Both of these alkaloids stimulate the adr- energic system, and toxicity can occur after doses that are only two or three times the therapeutic dose. Recall that absorption of these compounds is rapid and effects can be evident one hour after ingestion. The good news is that the dura- tion of the evil effects is usually short- lived and resolution of clinical adversi- ties usually occurs within six hours be- cause of the short half-life (unless the patient ingested a sustained- release prod- uct'-).
The toxic effects of ephedra occur primarily in the cardiovascular and cen- tral nervous systems. Major adverse car- diovascular events include hypertension, cardiomyopathy , dysrhythmias, and myo- cardial infarction.*"' Severe CNS prob- lems include seizures, psychosis, and stroke. There are many other troubling effects such as headaches, dizziness, trem- ors, anxiety, and auditory and visual hal- lucinations. Death is a real possibility. Speaking of death, as grave as a subject as there is. People magazine ' s May 20, 1 996, issue" related the sad story of a group of young men who purchased some Ulti- mate Xphoria, an over-the-counter di- etary supplement containing caffeine and ephedra. Only a few hours later one was dead, allegedly from a fatal cardiac ar- rhythmia induced by the "dietary supple- ment." On August 28, 1996,' the Associ- ated Press reported that the FDA, headed by Dr. David Kessler, was concerned about the safety of these products and an FDA advisory panel was formed to con- sider their use. Even before that the FDA had warned of a link between ephedra and health risks "ranging from dizziness to seizures." '■' In 1992, a product called Herbal Ecstacy was introduced and has produced an estimated $300 million for the entrepreneurs who promote this "eu-
phoria" producer." It is even alleged that sales rose 25% after the FDA's warning, which supposedly implied that the chemi- cal causes a big jolt. Herbal Ecstacy is not the same as the illicit drug "Ecstacy" (3,4-methylenedeoxymethamphetamine, a.k.a. MDMA'). However, the manufac- turers tout their product as increasing energy and enhancing sexual sensation, just as "Ecstacy" is supposed to do. The FDA has proposed removing oral ephe- drine products from the open market be- cause they are used in the production of illicit drugs, and they are misused as stimulants and for weight loss.*"
The treatment of ephedra (ephedrine) overdose is not very satisfying. The drug is absorbed so rapidly that ipecac syrup is not a wise maneuver. If the patient is seen early, giving activated charcoal seems like a good idea to prevent further absorp- tion of ephedrine. As usual, supportive care is paramount: Treat the patient, not the poison. It is essential to maintain an open airway and assist ventilation if nec- essary. Seizures should be treated with diazepam or lorazepam; if this fails, phe- nobarbital or phenytoin may be used.' Hypertension could be treated with va- sodilators such as nitroprusside, hydrala- zine, phentolamine, or nifedipine. Lidocaine, low-dose propranolol, or esmolol are usually successful in treating tachyarrhythmias." Toxic doses of ephe- dra produce a risk of rhabdomyolysis, so take heed and do not acidify the urine (this could, in theory, enhance the secre- tion of ephedrine but at the risk of in- creasing cardiac irritability and precipi- tating myoglobin in the renal tubules, leading to acute renal failure). After read- ing about this drug, which would you rather have: ma huang or a plate of lobster fra diavolol
A Fatal "Quick Fix"
The remainder of Emily Dickinson's poem, whose first line is quoted in the title of this article, reminds us that:
"All but death, can be Adjusted —
Dynasties repaired —
Systems — settled in their Sockets —
Citadels — dissolved —
NCMJ January/February 1997, Volume 58 Number 1
69
Wastes of Lives — resown with Colors By Succeeding Springs — Death — unto itself — Exception — Is exempt from Change — "'
It is very difficult to explain to citizens searching for a quick fix that getting "high" on life should be the summum
bonum. When you are dead it is for a very long time and cannot be adjusted. Q
References
1 TH Johnson (ed). Final Harvest Emily Dickinson' s Poems. Boston: Little, Brown and Co., 1961, p 186.
2 Dickinson, Emily. Microsoft® Encarta Encyclopedia. 1993- 1995 Microsoft Corp. Funk and Wagnalls Corp.
3 Tang DH. Ephedra ("ma huang"). Clin Toxicology Rev 1996; 18:1.
4 Olin BR (ed). The ephedras. In: The Lawrence Review of Natural Products. St. Louis, MO: Facts and Comparisons, 1995.
5 Associated Press, reported in the Win- ston-Salem Journal, August 28, 1996, p 12.
6 Adverse events associated with ephedrine- containing products, Texas, December 1993-September 1995. MMWR 1996; 45:689-93.
7 Karch S. Pathology of Drug Abuse. Boca Raton, FL: CRC Press, 1996, pp 194-8.
8 HardmanJG.LimbirdLE. Goodman and Oilman' s Pharmacological Basis of Thera- peutics, 9th ed. New York: McGraw-Hill, 1996, pp 125-212,221,300.
9 Sympathomimetics, oral. Poisindex ®, Micromedex Inc., Vol. 88, 1996.
10 Leikin JB, Paloucek FP. Ephedrine sul- fate. In: Poisoning and Toxicology Hand- book, 2nd ed. Lexi-Comp Inc., 1995, pp 316-7.
1 1 Lefebvre R, Sunmont F, Moerman E. Uri- nary excretion of ephedrine after nasal application. J Pharm Pharmacol 1995;44:672-75.
12 Benowitz NL. Phenylpropanolamine and Related Decongestants in Poisoning and Drug Overdose, 2nd ed. Norwalk, CT: Appleton-Lange, 1994, pp 253-4.
13 Rogers P, Eftimiades M, Aunapu R, et al. Legal but legal. People Magazine, May 20, 1996, p 105.
14 Recent Safety Information on FDA-Regu- lated Products. FDA Medical Bulletin 1996;26.
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NCMJ January/February 1997, Volume 58 Number 1
Classified Ads
BC-BE INTERNIST: Sought by well-established practice in beautiful mountains of western North Carolina. Competitive salary, one in three call, buy-in option, low managed care penetration. Share rewarding career in rural community with good patients and fine colleagues. Mail CV to: Physician Recruiter, Murphy Medical Center, 2002 US Highway 64 East, Murphy, NC 28906.
EXPANDING INTERNAL MEDICINE/GERIATRIC part- nership opportunity in Winston-Salem, NC. Inpatient and consultative position with excellent income potential. Con- tact Susan Chatman, 910/724-1900.
FOR SALE: three laboratory microscopes, binocular, three objectives, A&O, great condition: $700-$900 each; three stereoscopic dissecting scopes, B&L: $ 1 50 each; one medi- cal exam table, metal, with stirrups: $900. Call Dr. Hoyle at 910/229-1444, 10a.m.-5p.m.
FOR SALE: HP Sonos 100 CF color flow echo— includes: Sony color printer UP300, super VHS VCR Panasonic AG7350, 2.5 mhz transducer, 1.9 mhz continuous Doppler probe. Excellent condition. $34,900. 910/452-9910.
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MEN'S SPECIALTY CLINIC: is searching for a physician in the following Carolina areas: Greenville/Spartanburg, Raleigh/Durham, Greensboro, and Charlotte. IM, FP, or general medicine background with office experience pre- ferred. 8-5, M-F, no call, no evenings, no weekends required. 1 5-20 patients per day. Need to be an excellent communica- tor and able to relate to patients extremely well. Generous compensation and benefits package. No J- 1 locations avail- able. Send CV to Chuck Branson, IMR, 10311 Maple Drive, Overland Park, KS 66207, or fax to 9 1 3/649-2552. Call 800/ 772-8168, ext. 543.
PRIMARY CARE/FAMILY PRACTICE PHYSICLVNS WANTED: BC/BE Family Practice Physicians or Urgent Care Physicians. Immediate opening to join multispecialty group in the Triad metro area of North Carolina. Excellent financial package with minimum guarantee and perfor- mance based above minimum. Excellent area to live and raise a family. J-1 or HIB visa acceptable. Send resume to: rila Barnes, 507 Lindsay St., High Point, NC 27262, call 910/883-4453, ext. 168, or fax 910/883-0002.
Classified rates and info: $35 for the first 25 words, 35 cents for each additional word; $10 discount for North Carolina Medical Society members. Do not send advance payment; billing sent separately. Mail ad copy and billing information, including phone number, to: NC Medical Jour- nal, Box 3910, Duke University Medical Center, Durham, NC 27710, 919/286-6410. fax: 919/286-9219, e-mail: [email protected] (deadline for next issue, March/ April, is February 7).
NCMJ January/February 1997, Volume 58 Number 1
71
CME Calendar
January 6-7
ACLS Renewal Course
Place: Rex Healthcare, Raleigh
Credit: 8 hours, AAFP
Fee: $100
Info: Iris Ahlheit, RN, ACLS Course Coordinator, Educa- tional Services Dept., Rex Healthcare, 4420 Lake Boone Trail, Raleigh 27607, 919/783-3161
January 9-10
Challenges in Geriatric Practice
Place: Friday Center, UNC Chapel Hill
Credit: 13.5 hours Category 1, AM A
Fee: $185
Info: Dail White, UNC Office of CME and Alumni Affairs,
UNC School of Medicine, 919/962-21 18,
fax: 919/962-1664
January 21
First Senior Physician Meeting
Place: University Club, Durham
Info: open to physicians who are retired, semi-retired, and 65 and older from Durham, Granville, and Person counties, and their spouses. Sponsored by the North Carolina Medical Society Foundation. Contact Nell Agee, Director, NCMS Foundation, P.O. Box 27167, Raleigh 276 11, 800/722- 1350 or 9 1 9/833-3836
January 21-23
NIH Consensus Development Conference:
Breast Cancer Screening in Women Ages 40-49
Place: Natcher Conference Center, NIH, Bethesda, MD Info: Conference Registrar, Technical Resources Interna- tional, Inc., 3202 Tower Oaks Blvd., Rockville, MD 20852, 301/770-0610, fax: 301/468-2245. e-mail: [email protected]
February 7-9
4th Annual Physicians for a Violence-Free Society Conference: Alcohol — Fuel for Family Violence?
Place: Hyatt at Fisherman's Wharf, San Francisco, CA Info: JoAn Dwyer, Associate Executive Director, Physicians for a Violence-Free Society, P.O. Box 35528, Dallas, TX 75235-0528, 214/590-8807, fax: 214/590-4079
February 8
8th Annual Triangle Update in Cardiology Symposium
Place; North Raleigh Hilton
Info: sponsored by the American Heart Association, Wake Division; UNC School of Medicine; and Wake Area Health Education Center. Call 919/783-7853
February 8
Urology State of the Art 1997
Place: Winston-Salem
Credit: 6.5 hours Category 1, AMA
Info: Office ofContinuing Education, Bowman Gray School
of Medicine, 9 1 0/7 1 6-4450, or Physician Access Line
(PAL) 800/277-7654
February 11-13
NIH Consensus Development Conference:
Interventions to Prevent HIV Risk Behaviors
Place: Natcher Confrerence Center, NIH, Bethesda, MD j Info: Conference Registrar, Technical Resources Interna- tional, Inc., 3202 Tower Oaks Blvd., Rockville, MD 20852, 301/770-0610, fax: 301/468-2245, e-mail: [email protected]
February 24-26
4th Annual Cancer Conference:
Advances in Thoracic Oncology
Place: The Breakers, Palm Beach, FL
Info: jointly sponsored by Duke Comprehensive Cancer Center and The Cancer Institute and Good Samaritan Medical Center, West Palm Beach, FL. For info, contact: Duke Oncology Consortium, Box 3326, Duke University Medical Center, Durham 27710, or call 919/419-5500
March 12-15
21st Annual Internal Medicine Conference
Place: Friday Center, UNC-Chapel Hill
Credit: 24 hours Category 1, AMA
Fee: $400
Info: Dail White, UNC Office of CME and Alumni Affairs,
UNC School of Medicine, 919/962-2118,
fax: 919/962-1664 i
fi!;e i:
(rili(
Si
72
NCMJ January/February 1997, Volume 58 Number 1
March 12-16
North Carolina Medical Society's Spring Conference:
"Turning Adversity Into Advantage"
Place: Washington Duke Inn & Golf Club, Durham Info: Alan Skipper, NCMS, 800/722- 1 350 or 919/833-3836
March 14-15
Neurology for the Primary Care Provider
Place: Winston-Salem
Credit: 1 1 hours Category 1 , AMA
Info: Office of Continuing Education, Bowman Gray School
of Medicine, 910/71 6-4450, or Physician Access Line
(PAL) 800/277-7654
April 4-5 Practical Pediatrics
Place: Winston-Salem
Credit: 9 hours Category 1 , AMA
Info: Office ofContinuing Education, Bowman Gray School
of Medicine, 910/71 6-4450, or Physician Access Line
(PAL) 800/277-7654
April 11-12
10th Annual Surgical Symposium and Hightower Lecture
Place: Winston-Salem
Credit: 9 hours Category 1, AMA
Info: Office ofContinuing Education, Bowman Gray School
ofMedicine,910/716-4450, or Physician Access Line
(PAL) 800/277-7654
April 30-May 1
21st Annual Symposium of the UNC Lineberger Comprehensive Cancer Center: Innovative Approaches to Cancer Treatment
Place: UNC Chapel Hill
Info: Sarah Rimmer, 919/966-2997
April 30-May 4
Critical Care '97: 11th Annual Review and Update
Place: Hyatt Regency, Washington, DC
Credit: 41.25 hours. Category 1, AMA, and AAFP
Fee: $795 (by March 21 ) for physicians; $575 for
physicians-in-training and other allied professionals Info: Center for Bio-Medical Communications, Inc.,
201/385-8080, fax: 201/385-5650,
e-mail: [email protected]
May 2 ^j5 Building Partnerships for Healthier Hearts
Place: Winston-Salem redit: 1 1 hours Category 1, AMA [nfo: Office ofContinuing Education, Bowman Gray School
of Medicine, 910/71 6-4450, or Physician Access Line
(PAL) 800/277-7654
May 2-6
Council of Biology Editors Annual Meeting
Place: Adam's Mark Hotel, Philadelphia Info: CBE, 60 Revere Drive, Suite 500, Northbrook, IL 60062, 847/480-6349, fax: 847/480-9282
May 9-16
56th Annual American Occupational Health Conference
Place: Orange County Convention Center, Orlando, FL Info: Kay Coyne, American College of Occupational and Environmental Medicine, 847/228-6850, ext. 152
May 14-16
Carolinas Medical Center Spring Symposium 1997
Place: Charlotte Convention Center
Info: Mary Anne Cox, CHS/Charlotte AHEC Office of
CME, 1366 E. Morehead St., Charlotte 28204,
704/355-8631 or 800/562-7314,
e-mail: [email protected]
June 6-9
Comprehensive Internal Medicine Board Review Course
Place: Winston-Salem
Credit: 32 hours Category 1, AMA
Info: Office ofContinuing Education, Bowman Gray School
of Medicine, 910/71 6-4450, or Physician Access Line
(PAL) 800/277-7654
June 10-14
6th Annual Advanced Cardiovascular
Interventions Symposium
Place: Westin Resort, Hilton Head, SC
Credit: up to 18 hours Category 1, AMA
Fee: $750
Info: Mary Anne Cox, CHS/Charlotte AHEC Office of
CME, 1366 E. Morehead St., Charlotte 28204,
704/355-8631 or 800/562-7314
July 4-6
North Carolina Medical Society's
Sports Medicine Symposium
Place: Sheraton Hotel, Atlantic Beach Info: Alan Skipper, NCMS, 800/722-1350 or 919/833-3836
CME guidelines: Listings are free for approved courses, workshops, and events as space allows. Include date, location, fees, credit hours, and address of contact person or sponsoring institution or organization. Send typewritten information to: North Carolina MedicalJournal, Box 391 0, DUMC, Durham, NC 27710; fax to: 919/286-9219, or e-mail to: yohnOOOl @mc. duke.edu Deadline for next issue is February 7.
NCMJ January/Februarv 1997. Volume 58 Number 1
73
New Members
John Louis Adami (CD), Eastern Carolina Car- diovascular, PA. 1 1 1 -B Medical Drive, Eliza- beth City 27909
Karen Halaburt Albritton (RES). 19 S. Circle Drive, Chapel Hill 27514
Joseph Michael Alvarez (U), 1 134 N. Road St., Elizabeth City 27909
Philip Elias Asmar (RES), 816 Crowne Oaks Circle, Winston-Salem 27106
Brian Jack Bartholmai (RES), 550 Haven Ridge Road, #8, Winston-Salem 27104
Brian Anthony Bates, 2305 Chatham Drive, Greensboro 27408
David Edward Bouska (FP), Urgent Medical Care Ctr., PA, 102 Pomona Drive, Greens- boro 27407
Alan Hayden Brader (GS), 3396 Six Forks Road, Raleigh 27609
Donald Michael Brescia (RES), 601 Channel Drive, Winterville 28590
Alexis Ann Buzuma, 3055-D Pisgah Place, Greensboro 27455
Margaret Ferriter Campbell, 23 1 9 Regents Park Lane, Greensboro 27455
Jaime Andres Cardenas (RES), 410-V Park Ridge Lane. Winston-Salem 27104
Sandra MicheleCarr (RES), FAHECFam. Med. Res. Prog, 1601 Owen Drive, Fayetteville 28304
Fred Anthony Caruso, 7694 Heriot Drive, Fayetteville 28311
Christopher Michael Cerjan (RES), 8306 Kapplewood Court, Charlotte 28226
George Maurice Charron, 7208 Manor Oaks Drive, Raleigh 27615
Firas Chazli (RES), 2642 Mulberry Lane, Greenville 27858
Eric James Christopher (RES), 4600 University Drive. #1615. Durham 27707
Kathleen Maria Clarke-Pearson (PD). 105 Por- ter Place. Chapel Hill 27514
David Harry Cook, 4207 Lake Boone Trail, Ste. 200, Raleigh 27609
Carey Gordon Cottle. Jr.. 600 Greenvalley Road. Ste. 204. Greensboro 27408
Henry David Cremisi (NEP). 2321 West- moreland St., Charlotte 2820S
Paul Miller Crum, Jr. (RES). 423 Brent St., Winston-Salem 27103
Peter Gerald D' Amour, Mecklenburg Radiol- ogy Assoc. P.O. Box 22 1 249. Charlotte 28222
Leon Entea Dantzler. Jr. (IM). 1262 Oliver St., Fayetteville 28304
Steven Alan Daub (FP), Urgent Medical Care Center, 1 02 Pomona Drive, Greensboro 27407
Nitinchandra D. Desai (M), 124 Bryce Creek
Lane, Fayetteville 28303 Vandana Prakash Devalapalli, 108 Elsmore
Court, Raleigh 27607 JillBurnettDickerson(RES),51 1 1 Copper Ridge
Drive, #204. Durham 27707 Karen Diane Dunn. Carolina Allergy/Asthma
Cons., 4301 Lake Boone Trail, #309, Raleigh
27607 Peter Robert Ennever (HEM), 4520 Jamesford
Drive, Jamestown 27282 Nurum Filiz Erdem (RES), 5 1 27 Copper Ridge
Drive, #202, Durham 27707 Ifeanyichukwu M. Eruchalu. C.W. Williams
Health Ctr., 3333 Wilkinson Blvd.. Charlotte
28266 Augustine Richard Eze (VS), Metrolina Sur- gery, 1928 Randolph Road, Charlotte 28207 Brian Keith Fleming (FP), Fayetteville Fam.
Med. Care, 1 307 Avon St.. Fayetteville 28304 Kelly Ann Flynn (RES), 430-V Park Ridge
Lane, Winston-Salem 27104 Virginia Rutledge Forney (RES), 2324 Duke
University Road, Durham 27706 Ann Selser Forshag, 3501 Foxridge Road, Char- lotte 28226 Ernest Ronald Foster (PHYS ASST), 5452
Ramsey St., #7, Fayetteville 28311 David Jonathan Framm (CD), Mecklenburg
Medical Group, 3535 Randolph Road, Ste.
300. Charlotte 28211 Sarise B. Freiman, 7018 Seton House Lane,
Charlotte 28277 Michael Joseph Gale (STU), 621 Corona St..
Winston-Salem 27103 Susan Renee Garwood, 20905 Torrence Chapel
Road, Suite 203 Davidson 28036 Kathleen Gibson (RES), 1 608 Edgewood Drive,
Chapel Hill 27514 Steven Charles Gilbert (RES), 115-5 Crowne
Chase Drive, Winston-Salem 27104 Paula Elisa Gizzie (OBG), 3404 Wake Forest
Road, Ste. 100, Raleigh 27609 Mark Allen Goodson (RES), 104 Huckleberry
Lane, Winterville 28590 Maria Soffia Gottfredsdottir (RES), 174
Kingsbrook Ave., Ann Arbor, Ml 48103 Tracy Hamill (RES), FAHEC Fam. Med. Res.
Prog.. 1601 Owen Drive. Fayetteville 28304 Cameron Blair Harkness (RES). 1680 Hender-
sonville Road, #H-15. Asheville 28803 Kimberly Nichols Heiselman (FP). P.O. Box
909, Mars Hill 28754 Allison Lewis Jacokes (OBG), Kaiser Ob/Gyn,
2500 Blue Ridge Road, Ste. 300, Raleigh
27612 Michael James, Rex Ridge Internal Medicine,
2800 Blue Ridge Blvd., Ste. 205, Raleigh
27607 John Richard Jones, 1728 Metromedical Drive,
Fayetteville 28304 Michael Josilevich (IM), Internal Medicine/Pri- mary Care, 1701 Country Club Road, Jack- sonville 28546 Leila Catherine Kahwati (RES), FAHEC Fam.
Med. Res. Prog, 1601 Owen Drive, Fay- etteville 28304 Sabine A. Kelischek, Box 40, Brasstown 28902 William Stewart Ketcham, Raleigh Internal |
Medicine, 3320 Wake Forest Road, Raleigh
27609 Mark Henry Knelson, Raleigh Radiology Assoc,
Inc.. P.O. Box 19907. Raleigh 27619 Jan Ellen Kohl. 4426 Mill Village Road, Ra- leigh 27612 Todd Michael Kopczynski, 1408 E. Franklin
St., Monroe 281 12 Steven Paul Kubicki (PD), Capitol Ped/Adoles-
cent Center, PA, 3803-A Computer Drive, lb
Raleigh 27609 Lynn Kristen Lecas (RES), 4005 In wood Drive,
Durham 27705 Philip Lincoln Levin, 1805 Northbay Drive,
Browns Summit 27214 Walter Dickinson Liebkemann (RES), 441
Hearthside Drive, Winston-Salem 27104 Steven Marc Liebowitz. 2800 Blue Ridge Blvd.,
Ste. 205, Raleigh 27607 Esther Eugene Lyons (P). Chowan Psychiatric
Service, P.O. Box 629. Edenton 27932 j Nancy Marie Major (R), 108 Lakeshore Drive,;
Durham 27713 !
Howard Mandell (N), 10620 Park Road, Ste.;
230. Charlotte 28210 \
John Hendren Migliaccio (OBG). P.O. Box
620081, Oklahoma City, OK 73162 Arlene Nichols Miller (RES), 2135 W. Front
St., Burlington 27215 Shama Ravi Mittal (RES), T-1 Doctors Pari
Apts., Greenville 27834 Stephen Irwin Moore, 111 (FP), 4010 Barrel
Drive, Ste. 104. Raleigh 27609 Ravi Munver (RES), 3611 University Drive
Apt. 3P. Durham 27707 Michele Duval Nacouzi, 7433 Tynewind, Waki
Forest 27587 Larsen Alan Norman (RES), 5317 Quailwooi
Road, #D, Winston-Salem 27104 Jerome Henry Nymberg, III, 9111 Covey Hoi
low, Charlotte 28210 U-j^.,
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NCMJ Januaiy/Febniary 1997. Volume 58 Number I
Kevin PatrickO'Reilly (RES), 20Thorne Ridge
Drive, Durham 27713 Emest John Oddono. Jr., Guilford Anesthesia,
1834 Pembrook Road, Greensboro 27408 Kathryn Burnett Page (RES), 7817 Quail HiH
Road, Charlotte 28210 Michel Camille Pare, 3314 Melrose Road, Ste.
104, Fayetteville 28304 Prerana Patel (STU), 14-F Post Oak Road,
Durham 27705 Ann Thimsen Pflugrath, 1804 Knox Road, Ra- leigh 27608 Jane Ann Quinn, 101 W.T. Harris Blvd., #3301 ,
Charlotte 28262 Michael Anthony Rave, 416 Kingsford Road,
Fayetteville 28314 Walter Jones Revell, Jr., 10620 Park Road. Ste.
206, Charlotte 28210 Bennie Dwayne Roberts (AN), 415 N. Center
St., Ste. 103, Hickory 28601 Eugene Leonard Roberts, Jr.. 501 Billingsley
Road, Charlotte 28211 Rebecca Lynn Roberts (PHYS ASST), 2800
Blue Ridge Road, Ste. 402, Raleigh 27607 Glenn Lewis Robertson (RES), FAHEC Fam. Med. Res. Prog., 1601 Owen Drive, Fay- etteville 28304 Ion Scott Rosnes (OBG), Bowman Gray School of Medicine, Medical Center Blvd., Win- ston-Salem 27157 iussell Lawrence Rothman (RES), 1 4 Winthrop Court. Durham 27707 tiiilMlan S. Ryder-Cook (N). 10620 Park Road,
Ste. 230, Charlotte 28210 lii«(3arolyn Marie Sampson, 1307 Avon St.,
Fayetteville 28304 teflanine Anita Scott (RES), FAHEC Fam. Med. Res. Prog., 1601 Owen Drive, Fayetteville 28304 iapnaRamesh Shah (RES), 1601 Owen Drive,
Fayetteville 28304 3elia Lauren Morse Spillmann, 805 Blanton
Place, Greensboro 27408 icott Joseph Spillmann, 805 Blanton Place,
Greensboro 27408 ane Laura Steiner (P), 620 N. Elm St., Greens- boro 27401 4ary Coleen Wassell Stowe (IM), 3535
Randolph Road, Ste. 300. Charlotte 2821 1 i/Iichael Sue (GE). 110 Medical Drive, Ste. #7,
Elizabeth City 27909 ames Michael Sutherland (GS), 109 Schooner
Point. Belhaven 27810 Varren Douglas Taylor (RES), 800 Snowcrest
Trail, Durham 27707 :hris M. Thomson (RES), 7604 Waterford Lakes
Drive, #1928, Charlotte 28210 "atricia Fowler Triplett, 520 N. Elam Ave., j Greensboro 27403
Lusai Ali Umran (RES), 3461 Westgate Drive, i Greenville 27834
::heryl Vallon (RES), 7224 DeloachCourt, Char- j lotte 28270 jlreg E. Viehman (RES). Box 3822. DUMC,
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Durham 27710
Brian Douglas Weiss, 2501 Hinton St., Raleigh 27612
Daniel Baxter Whitesides, The Nalle Clinic, 1918 Randolph Road, Charlotte 28207
Robert Lee Wooten (PHYS ASST), 612 Ken- neth Road, Greensboro 27455
Arthur David Zacco (FP), Apex Medical Cen- ter, 410 E. William St., Apex 27502
Thomas Nelson Zweng, 2300 Randolph Road, Charlotte 28207
Alamance-Caswell
Robert Taylor Elliott (GE), Kernodle Clinic, 1234 Huffman Mill Road, Burlington 27215
Scott Cooper Stoioff (U), 827 Heatner Road, Burlington 27215
Avery
Gary Evan Welliver (ORS). P. O. Box 1526, Route #1. Banner Elk 28604
Bertie-Gates-Hertford
Senthil NayaganSundaram(lM), Gates County Primary Care, P.O. Box 8, Gatesville 27938
Joseph Everett Swanton (GYN). Bertie County Health Dept.. 502 Barringer St., Windsor 27983
Bladen
Pearly Berlette Graham-Hoskins(IM), P.O. Box 517, 300-A E. McKay St., Elizabethtown
28337
Brunswick
Howard Mason Johnson (FP), P.O. Box 2646,
Southport 28461 Richard Matthew Leighton (ORS), 25 Union
School Road, Ste. #3, Shallotte 28470
Buncombe
Brian Kent England (NEP), 10 McDowell St.,
Asheville 28801 Robert Andrew Errico (PD). 77 McDowell St.,
Asheville 28801 Michael Joseph Messino (IM), 445 Biltmore
Ave., Ste. G-102, Asheville 28801 Robert J. Pritchard (IM), Asheville Pul/Critical
Care, 205 Asheville Hwy. Ste. 601, Sylva
28779 Helen Hyman Wiest (R), 534 Biltmore Ave.,
Asheville 28804 Robin Diane Wright (GE), Ste. W-18 Doctors
Bldg., Doctor's Drive, Asheville 28801
Burke
Anthony Maglione (C), 210 Mulberry St. SW,
Lenoir 28645 Ryan Vern Miller (C), Western Piedmont Heart
Ctr.. 350 E. Parker Road. Morganton 28655
Cabarrus
James Wiley Dickerson. Ill (P), 920 Church St. N, Concord 28025
Mark E. Ellis (AN), 920 Church St. N, Concord
28025 Ruppert Augustus Hawes (FP). 543 Jackson
Park Road. Kannapolis 28083 Carla D. Jones (FP), 3008-C High Glen Drive,
Charlotte 28269 Jennifer Alice Lane (OBG), 1388 Chalmers
Court NW, Concord 28027 Robert Gerard Moser (IM), 140 Lecline Drive
NE, Concord 28025 Stephen Joseph O' Brien (PD), 506 Worthington
Court NE, Concord 28025 Anthony Curtis Patterson, 1 44 Overbrook Drive
NE, Concord 28025
Caldwell
Russell Clyde Collins (FP), Hudson Familycare
Center, 589 Main St., P.O. Box 519, Hudson
28638 Susan Mane Kuzmyk (FP), Caldwell Family
Physicians. 912 Connelly Springs Road,
Lenoir 28645 Anthony Maglione (C), Western Piedmont
Hearth Ctr., 210 Mulberry St. SW, Lenoir
28645 Ryan Vern Miller (C), 350 E. Parker Road,
Morganton 28655
Carteret
Joseph Franz Nutz, Jr. (FP), Crystal Coast Fam- ily Practice. 3610 Medical Park Court, Morehead City 28557
Catawba
Daniel Leo Collins (PMR), 1 877 N. Center St., Hickory 28601
William Doheny (FP), Claremont Family Prac- tice, 101 E. Main St.. Claremont 28610
Anthony Maglione (C), 210 Mulberry St. SW, Lenoir 28645
Ryan Vern Miller (C), 350 E. Parker Road, Morganton 28655
Thomas More Ray (PMR), 1877 N. Center St., Hickory 28601
Cleveland
Barbara Van Hoy Clifton (IM). Shelby Medical Assocs., PA, 808 Schenck St., Shelby 28150
Brett Alison Koder (OTO), Carolina ENT, 802 N. Lafayette St., Shelby 28150
Paramjit Shergill (IM), 103 S. Watterson St., Kings Mountain 28086
Surendrapal Singh Sidhu (FP), 201 Grover St., Shelby 28150
Michael Douglas Wehmueller (R), 805 N. Mor- gan St., Shelby 28150
Craven-Pamlico-Jones
Elizabeth Bolter Perry (AN), New Bern Anes- thesia Assocs., 2719 B & C, Neuse Blvd., New Bern 28562
Cumberland
Warren Frank Bowland (GS). 437 Summerplea.
NCMJ January/February 1997, Volume 58 Number 1
75
Fayetteville28311 Laurel Evans Broadhurst (Gpm), 5647 Dobson
Drive, Fayetteville 28311 Odette Veronica Callender (OPH), Carolina Eye
Associates, 1289 Oliver St., Fayetteville
28304 James Michael Geiger, Jr. (OPH), 3505 Birkdale
Court, Fayetteville 27303 RhondaV.SandersonLowry (RES), 1601 Owen
Drive, Fayetteville 28304 Ezra Lee McConnell, III (IM), 1319 Avon St.,
Fayetteville C2830 James Francis Nolan (U), Fayetteville Urology
Assocs, 1786 Metromedical Drive, Fay- etteville 28304 Syed Asif Raza Rizvi (IM), Valley Medical
Associates, 1641 Owen Drive, Fayetteville
28304 Richard E. Roux, 2919 Hybart St., Fayetteville
28303 Nancy Elaine Thompson (PD), 121 1 -A Ireland
Drive, Fayetteville 28314
Davidson
Frank Edward Reedy, Jr. (PD), 200 Arthur Drive,
Thomasville 27360 Donald Bryant Winters (PD), 200 Arthur Drive,
Thomasville 27360
Durham-Orange
James Robert Alexander (STU), 1000 Smith
Level Road, Apt. F18, Carrboro 27510 Robin Renee Ali (STU), 3604 Manford Drive,
Durham 27707 Brandy M. Allen (STU), 311 S. LaSalle St.,
#51-R, Durham 27705 Pamela Kaye Alston (STU), 104 Timber Hol- low Court, #238, Chapel Hill 27514 Ankie-Marie Amos (STU), 1406 Remington
Circle, Durham 27705 Cory Lyn Annis (IM), 4904 Reigalwood Road,
Durham 27712 Anuja Kandanatt Antony (STU), Merritt Apts.,
Apt. #4, 5 Howell St., Chapel Hill 27514 Anne Bond Archie (STU), 403-A Smith Ave.,
Chapel Hill 27514 Carlos A. Bagley (STU), 1801 Williamsburg
Road, Apt. 48-C, Durham 27707 Cecil Orm Borel, III (AN), Box 3094, DUMC,
Durham 27710 Joseph Anthony Bosco, III (ORS), 2609 N.
Duke St., Ste. 900, Durham 27704 Beth Ann Brubaker (STU), 8226 Morrow Mill
Road, Chapel Hill 27516 Suzanne Bruch (STU), 3325 Coachman's Way,
Durham 27705 Gregory Michael Buchold (STU), 400
Westwood Drive, Chapel Hill 27516 Janine Elizabeth BuUard (STU), 3 1 7 McCauley
St., Apt. #2, Chapel Hill 27516 Troy Augustus Bunting (STU), 105-U Misty- wood Circle, Shadowood Apts., Chapel Hill
27514 Michael Capps (STU), 3 Holland Drive, Chapel
Hill 27514 Alicia Carter (STU), 6110 Chesden Drive,
Durham 27713 Abigail Suzanne Caudle (STU), 2701 Home- stead Road, #412, Chapel Hill 27516 Sung Kyu Chang (STU), 902-A6 Park Ridge
Road, Durham 27713 Deborah Eva Citrin (STU), 910 Constitution
Drive, Apt. 811, Durham 27705 Kimberley Renette Clemons (STU), 409
Parkside Circle, Chapel Hill 27516 Patricia Ashley Coppage (STU), 200 Hwy. 54
Bypass, Apt. 303-E, Carrboro 27510 Francine Jo D'Ercole (AN), Box 3094, DUMC,
Durham 27710 Susan E. Davenport (STU), 910 Constitution
Drive, Apt. 811, Durham 27705 Jesse A. Davidson (STU), 4800 University Drive,
Apt. 22K, Durham 27707 Barnaby Todd Dedmond (STU), 306 N, Estes
Drive Ext., Apt. 18-H, Carrboro 27510 David Rodolph Dixon (STU), 421 Lawndale
Drive, Winston-Salem 27104 Karen Dixon (STU), 40 1 Hwy. 54 Bypass, Apt.
F-1, Carrboro 275 10 Cescili Aurelia Drake (STU), 501 Jones Ferry
Road, #Q7, Carrboro 27510 Leslie Renee Ellis (STU), 401 Hwy. 54 Bypass
West, F-1, Carrboro 27510 Corey Dean Fogleman (STU), 500 Umstead
Drive, 207-D, Chapel Hill 27516 Tara Anne Forcier (STU), 50 1 Jones Ferry Road,
Apt. Y-9, Carrboro 27510 William J. Foster (STU), 710 S. LaSalle St.,
Apt. G, Durham 27705 Daniel Benjamin Fried (STU), 502 W. Poplar
Ave., E-4, Carrboro 27510 Katina Geiger (STU), 200 54 Bypass, #F103,
Carrboro 27510 Jenny Leigh Graham (STU), 700 Bolinwood
Drive, Apt. 34-G, Chapel Hill 27514 Tina R. Griffin (STU), 209 Conner Drive, Apt.
#5, Chapel Hill 27514 Brett Gurkin (STU), 60 1 Jones Ferry Road, Apt.
J-10, Carrboro 27510 David M. Harrild (STU), 4615-A Byrd Road,
Durham 27705 Janet E. Harris (STU), 9510 N. Hwy. 15-501,
#8, Chapel Hill 27514 Steven Brett Heavner (STU), 302 Cedarwood
Lane, Carrboro 27510 Carolyn L. Hess (STU), 11 00 Hwy. 54 Bypass,
Apt. 50, Chapel Hill 27516 Janie Angela Ho (STU), 8 Saint James Place,
Chapel Hill 27514 Albert Hamilton Holt, Jr. (STU), 105 Fidelity
St., Apt. B-23, Carrboro 27510 Sarah Louise Irons (STU), 213 McCauley St.,
Chapel Hill 27516 David Lawrence Isaacs (STU), 902 E. Franklin
St., #2, Chapel Hill 27514 Jeffrey Paul Kaiser (STU), 1 17 Mallard Court,
Chapel Hill 27514 Rohini Kanniganti (STU), 5304 Hideaway
Drive, Chapel Hill 27516
Andrew L. Kaplan (STU), 1315 Morreene Road,
#5-A, Durham 27705 Jason Neil Katz (STU), 5 1 3 Craige Dorm, UNC,
Chapel Hill 27514 Frank Howard Kern (AN). Box 3094, DUMC,
Durham 27710 EunKim(STU), 1 1 -J River Birch Road, Durham
27705 Jimmy Larry Kontos (STU), 710 Airport Road,
Apt. F-1 5, Chapel Hill 27514 Dennis John Kubinski (STU), 316-B Cedar- wood Lane, Carrboro 27510 Zane Ian Lapinskes (STU), 254 Butler Court,
Chapel Hill 27514 Jennifer E. Larson (STU), 1200 N. Greensboro
St., Carrboro 27510 Catherine Tung-Ling Lee (STU), 1426 Gray
Bluff Trail, Chapel Hill 27514 Bruce James Leone (AN), Box 3094, DUMC,
Durham 27710 Kimberly S. Levin (STU), 1 10 Cameron Court,
Chapel Hill 27516 Leslie Nicole Levine (STU), 1100 Hwy. 54
Bypass, Apt. #50, Chapel Hill 27516 Paula Lightfoot (STU), 2315 Snowcrest Trail,
Durham 27707 Bartholomew J. Lopina (STU), 501 Hwy. 54
Bypass, #1-M, Carrboro 27510 David Alan Lubarsky (AN), Box 3094, DUMC,
Durham 27710 Susan Lee Marcelli (STU), 140 BPW Club
Road, Apt. B- 1 , Carrboro 275 1 0 Stacy Marcus (STU), 2314 Nation Ave., #2
Durham 27707 Alycia M. McFarland (STU), P.O. Box 60,
Bethel 27812 Andrew Craig McGregor (STU), 108-V
Shadowood Drive, Chapel Hill 27514 Peter H. McHugh (STU), 1 12 Hwy. 54 Bypass,
Apt. D-8, Carrboro 27510 Jason Derek Merker (STU), P.O. Box 69, Chapel
Hill 27514 Russell Raymond Miller, III (STU), 3 Holland
Drive, Chapel Hill 27514 Christopher Bmet Mizelle (STU), 101 Rock
Haven Road, Apt. 100-A, Carrboro 27510 Kathryn Mlinar (STU), 130 E. Longview St.J
Unit N, Chapel Hill 27516 Joseph Albert Molitiemo, Jr. (STU), 705-F W
Main St., Carrboro 27510 Justin A. Mutch (STU), 400 Westwood Drive
Chapel Hill 27516 Michael Gerald Mythen (AN), Box 3094|feiii
DUMC, Durham 27710 Scott David Nash (STU), 700 Bolinwood Drive(
Apt. 22-D, Chapel Hill 27514 Mark Franklin Newman (AN), Box 3094l|(()1'oti|
DUMC, Durham 27710 I &*,,
Stephen A. Oljeski (STU), 201 Westbrook Drive liif
Apt. B-6, Carrboro 27510 Jeffrey Scott Overcash (STU), 404 Wildwoo)|llC.|J;
Drive, Salisbury 28144 Wendy Gail Owen (STU), 424 Summerwall
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76
NCMJ January/February 1997, Volume 58 Number 1
Circle, Chapel Hill 27514 Vikas Patel (STU), 910 Constitution Drive,
Apt. 121, Durham 27705 Deepa Perumallu (STU), 401 Hwy. 54 Bypass,
Apt. G-l,CarTboro 27510 Kyle K. Pond (STU), 3611 University Drive,
Apt. 16-J, Durham 27707 Katherine E. Posther (STU), 2314 Snowcrest
Trail, Durham 27707 Ashutosh A. Pradhan (STU), 4800 University
Drive, Apt. 30J, Durham 27707 Nerissa Marge Price (STU), D-4 Fenway Court,
Carrboro 27510 Tiffany Quick (STU), 8501 Peeles Chapel Road,
Laurel Hill 28351 Lisa Rahangdale (STU), 2701 Homestead Road,
Apt. 412, Chapel Hill 27516 Nadeem Ur Rahman (STU), 910 Constitution
Drive, Apt. 406, Durham 27705 Adam Gates Ravin (STU), 910 Constitution
Drive, Apt. 210, Durham 27705 Susan Diane Rich (STU), 6321-4 Hwy. 86 S.,
Chapel Hill 27514 Douglas David Rockacy (STU), 309-B Laurel
Ave., Carrboro 27510 Jonathan Ramirez Saluta (STU), 20 1 Westbrook
Drive, B-6, Carrboro 27510 Shannon Sawin (STU), 63 Fearrington Post,
Pittsboro 27312 William D. Schell (STU), 902 E. Franklin St.,
Apt. #2, Chapel Hill 27514 George Lee Shih (STU), 361 1 University Drive,
Apt. 14-Y, Durham 27707 Linmarie Sikich (P), UNC, Dept. of Psy., CB
#7160, Chapel Hill 27599 Tamara Danielle Simon (STU), 119-A E.
Longview St., Chapel Hill 27516 Eric Smith (STU), Box 2804, DUMC, Durham
27710 jVIaurice A. Smith (STU), 200 Hwy. Bypass 54,
D-304, Carrboro 27510 David Victor Smullen (STU), 436 Summerwalk
Circle, Chapel Hill 27514 Ij^aurie Snyder (STU), 400 Alexander Ave., 3-
D, Durham 27705 ?usan Marie Steele (AN), Box 3094, DUMC, 1151) ; Durham 27710 J, St 3ryant Walter Stolp (AN), 341 3 Duke Hospital
North, Durham 27710 )j.f»l»lichael D. Sullivan (STU), 31 1 S. LaSalle St., ' Apt. 31 -G, Durham 27705 pliver Shu-On Tai (STU), 4800 University
Drive, Apt. 22-K, Durham 27707 |.lelanie Lynn Tew (STU), 2701 Homestead
Road, Apt. 211, Chapel Hill 27516 .pjJIonja K. Trojak (STU), 1 100 Hwy. 54, Bypass,
Apt. 67, Chapel Hill 27516 'ony Potung Tsai (STU), 1 14 Marlowe Court,
Carrboro 27510 'ania F. Upchurch (STU), 1600 Sturdivant
Drive, #5, Wilmington 28403 :yan C. Wanamaker (STU), 73 1 Raleigh Road,
Chapel Hill 27514
tephen Lifan Wang (STU), 910 Constitution
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Drive, Apt. 315, Durham 27705 Heather Robertson White (STU), 4661-1 Hope
Valley Road, Durham 27707 Dana N. Wiener (AN), Box 3094, DUMC,
Durham 27710 Mark Wayne Williams (STU), 1 000 Smith Level
Road, Apt. F18, Carrboro 27510 Stephen Wong (STU), 502 Mayfield Circle,
Durham 27705 Matthew Donald Young (STU), 32 Hamilton
Road, Chapel Hill 27514 Charles W. Yowell (STU), 131 Forest Oaks
Drive, Durham 27705 Jeffrey Zaref (STU), 702 Gatehouse Lane,
Durham 27707 Peter Anton Zeman (STU), 400 Westwood
Drive, Chapel Hill 27516 Ming Zhang (STU), 1315 Morreene Road, #2-
C, Durham 27705 Hui Zhu (STU), 2724 Campus Walk #2A,
Durham 27705
Edgecombe
Scott Chester Stone, Jr. (PMR), 1 1 1 Hospital Drive, Tarboro 27886
Forsyth-Stokes-Davie
Stewart G. Allen (STU), 2038 Queen St., Win- ston-Salem 27103
Ross Blackmon Armour (IM), 4805 Century Oaks Lane, Winston-Salem 27106
Ricky Lee Bare (U), Bowman Gray, Dept. of Urology, Medical Center Blvd. Winston-Sa- lem 27157
Cynthia Anne Bums (STU), 2200 Westfield Ave., Winston-Salem 27103
Lisa Caporossi (STU), 1810 Elizabeth Ave., Winston-Salem 27103
Randall Lewis Carpenter (AN), Bowman Gray School of Medicine, Medical Center Blvd., Winston-Salem 27157
John Jeffrey Carr (DR), Bowman Gray School of Med., Medical Center Blvd., Winston- Salem 27157
Jeff Constantine (STU), 1018 S. Hawthorne Road, Winston-Salem 27103
Edward Nicholas B. Digges (STU), Bowman Gray, MS Box 2743, Medical Center Blvd., Winston-Salem 27103
Jeffrey J. Drees (STU), 2399 Jefferson Ave., Winston-Salem 27103
Campbell Edwin Enarson (AN), Bowman Gray School of Medicine, Medical Center Blvd., Winston-Salem 27157
John C. Flanagan (STU), 500-V Park Ridge Court, Winston-Salem 27104
Robert W. Gardner (STU), 260-A S. Sunset Drive, Winston-Salem 27103
T. Adam Ginn (STU), 2320-D Ardmore Ter- race, Winston-Salem 27103
Evan Daniel Gross (STU), 175 Crowne Chase Drive, Apt. #4, Winston-Salem 27104
Kerry L. Hammond (STU), 235 Corona St., Apt. 301, Winston-Salem 27103
Kelly Harris (STU), 912 Kingston Drive, High
Point 27262 Melissa A. Helman (OBG), Winston-Salem
Woman Care, 755 Highland Oaks Drive,
#201, Winston-Salem 27103 Scott Thomas Hines (STU), 4860 Thales Road,
Apt. J, Winston-Salem 27104 Hampton A. Howell (STU), 236-C Melrose St.,
Winston-Salem 27103 Lyell Keen Jones, Jr. (STU), 225 Lockland
Ave., Winston-Salem 27103 Laurence Michael Kish (RES), 3520-D Beacon
Hill Drive, Winston-Salem 27106 William T. Kuo (STU), Bowman Gray School
of Medicine, MS Box 2772, Medical Center
Blvd., Winston-Salem 27157 James M. Lai (STU), 210 Oakwood Square,
Winston-Salem 27103 Ivan Mac (STU), 100 Riley Forest Court, Win- ston-Salem 27127 Daniel D. Munn (STU), 225 Lockland Ave.,
Winston-Salem 27103 Amie E. Myers (STU), 23 1 9-C Queen St., Win- ston-Salem 27103 Roger J. Narayan (STU), 243-C Magnolia St.,
Winston-Salem 27103 Christy Neale (STU), 3501 -B Trafalgar Square.
Winston-Salem 27106 Brett C. Niblack (STU), 170 Jones Road, #66,
Winston-Salem 27107 Michael Nielsen (STU), 390-E Glendare Drive,
Winston-Salem 27104 Nikesh Patel (STU), 497 1-L Thales Road, Wm-
ston-Salem 27104 James Earl Radford, Jr. (ON), Bowman Gray
School of Medicine, Medical Center Blvd.,
Winston-Salem 27157 Mary M. Ransom (STU), 210 Oakwood Court,
Winston-Salem 27103 Eric M. Rotert (STU), 807 West End Blvd., Apt.
C-2, Winston-Salem 27101 James R. Scharff (STU), 1819 Grace St., Win- ston-Salem 27103 Hatai Jan Sinthusek (STU), 1200 Tartan Court,
Winston-Salem 27106 Carl J. Szczesniak (STU), 3022 Polo Road,
Winston-Salem 27106 Alexander Urioste (STU), 2038 Queen St., Win- ston-Salem 27103 David Joseph Vining (R), Bowman Gray, Dept.
of Radiology, Medical Center Blvd., Win- ston-Salem 27157 Ronald Patten Waterer (AN), 1900 S.
Hawthorne, Ste. 408, Winston-Salem 27103 Kari L. Wilson (STU), 1832 Stonewood Drive,
Winston-Salem 27103 Catherine York (STU), 1100 Hickory Trace
Drive, Greensboro 27407
Gaston
Walter Harry Caulfield (PS), Southeastern Plas- tic Surgery, PC, 760 N. New Hope Road, Gastonia 28054 I Brett Standard Cleveland (AN), Gaston Anes-
NCMJ January/February 1997, Volume 58 Number 1 77
thesia Associates, 1760 Country Club Road,
Gastonia 28054 Paul Michael Peindl (EM), 1013 Cheviot Lane,
Gastonia 28054 Myron Jay Petruska (FT), 1264 Fenwick Hall
Court, Gastonia 28056 Donna Robin Scanlan (ID), 1034 X-ray Drive,
Gastonia 28054
Granville
Thomas Frank Koinis(FP), 101 -A Professional Park Drive, Oxford 27565
Greater Greensboro Society of Medicine
Christopher Scott Dickson (VS), 1317 N. Elm St., Ste. #1, Greensboro 27401
Stephen William Downing (TS), 1317 N. Elm St., Ste. #1, Greensboro 27401
James William John (IM), 520 N. Elam Ave., Greensboro 27403
Stephen Alexander Olson (GS), Bethany Medi- cal Center, 507 Lindsay St., High Point 27262
Aleksei V. Plotnikov (IM), 520 N. Elam Ave.. Greensboro 27408
Gerald Irvmg Plovsky (P), 522 N. Elam Ave., Greensboro 27403
Donald R. Pulitzer (PTH), Greensboro Pathol- ogy Assocs., PA, 1200 N. Elm St., Greens- boro 27401
Michael Dennis Redman (OTO), 1309 N. Elm Ave., Greensboro 27401
Walter Lee Schmalstieg, Jr., 700 Walter Reed Drive, Greensboro 27403
Patricia Ann Shevlin (FP), 520 N. Elam Ave., Greensboro 27408
Bruce Henry Swords (IM), 520 N. Elam Ave., Greensboro 27403
John David Symanski (C), 520 N. Elam Ave., Greensboro 27403
Richard Joseph Taavon (OBG), 301 E. Wendover Ave., Greensboro 27401
William Burt Veazey (R), Moses H. Cone Mem. Hosp., Hosp-Radiology, 1200 N. Elm St., Greensboro 27401
Henderson
William Leonard Overstreet, 111 (PS), 735 Sixth
Ave. W, Hendersonville 28739 Allen Simon Steinhardt (PD), 107 Nob Hill
Road, Hendersonville 28791
High Point
Wayne Beauford (PUD), 3900 Wesseck Drive,
High Point 27265 Gary John Desalvo, 901 N. Lindsay St., High
Point 27262 Richard Timothy Escajeda (FP), 3 1 2 N. Elm St.,
High Point 27262
Iredell
Gregory B. Hall (GS), 642 Carpenter Ave.,
Mooresville28115 Joseph Edward Moran (IM), 2603 Davie Ave.,
P.O. Box 1845, Statesville 28687
Lee
Frederica Jo Nanni (FP), Behaven Medical Cen- ter, Rt. #6, Box 360- 1 A, Sanford 27330
Miles Warren Whitaker (OPH), Route #6, Box 1137, Sanford 27330
Lenoir-Greene
John Wallace Galbreath(IM), 109 Airport Road,
Kinston 28501 Lewis Bailey Gilpin (DR), 1214 Sweetbriar
Circle, Kinston 28501
Lincoln
Gerald T. Ahigian (FP), 9816 Sam Furr Road, #101, Huntersville 28078
Susane Habashi Ahigian (FP), 9816 Sam Fun- Road, #101, Huntersville 28078
Francis Joseph Milewski, Jr. (OTO), 1402 E. Gaston St. Ext., Lincolnton 28092
Macon-Clay
Paul W. Black (PS), Center For Plastic Surgery, Fifth & South Sts., Ste. #1 , Highlands 28741
Mecklenburg
John Brooks Armitage (PTH), American Red
Cross, 2425 Park Road, Charlotte 28236 Kenneth T. Ashkin (N), 1900 Randolph Road,
Ste. 1010, Charlotte 28207 Werner Michael Blocs (CD), 2330 Randolph
Road, Charlotte 28207 Mindy Beth Cetel (N), 101 W.T. Hams Blvd.,
Ste. 4106, Charlotte 28262 Barry B. K. Chan (TS), 301 Hawthorne Lane,
Charlotte 28211 John Daniel Clark (PHYS ASST), Miller Or- thopaedic Clinic, Inc., 1001 Blythe Blvd.,
Ste. 200, Charlotte 28203 Abelard K. Cofie (PD), 6708 Albemarle Road.
Charlotte 28212 Todd Douglas Cohen (U), 1 333 Romany Road,
Charlotte 28204 Charles Michael Gotten, Carolinas Med. Ctr.,
Critical Care/Neonatology, P.O. Box 32861,
Charlotte 28232 Giles Cowan Floyd (ORS), 2233 Sutton Springs
Road, Charlotte 28226 Derek Claver Gardner (U), Metrolina Urology
Clinic, PA, 1900 Randolph Road, Ste. 310,
Charlotte 28207 Dennis Michael Gettelfinger (N), 10610 Park
Road, Ste. 230, Charlotte 28210 Stanley B. Getz, Jr. (PS), 1 0 1 W.T. Harris Blvd.,
Ste. 1213, Charlotte 28262 MichaelTiffany Gillette ( AN), 1620Scott Ave.,
Charlotte 28203 Howard Milton Guthmann, II (FP), Waxhaw
Family Physicians, P.O. Box 10, Waxhaw
28173 William Donald Heisel, Jr. (PHYS ASST), Miller
Orthopaedic Clinic, Inc., 1001 Blythe Blvd.,
Ste. 200, Charlotte 28203 Michael William Kendall (IM), 7810 Provi- dence Road, Ste. 103, Charlotte 28226
Clifford Scott Kramer (PHYS ASST), Miller Orthopaedic Clinic, Inc., 1001 Blythe Blvd., Ste. 200, Charlotte 28203
Jay Berry Levy (PDU), 1 7 1 8 E. 4th St., Ste. 805, Charlotte 28204
Bradley Todd McCall (RO), 425-D S. Sharon Amity Road, Charlotte 28232
Alan Micklin (CD), 2330Randolph Road, Char- lotte 28207
Terrence DeWitt Morton, Jr. (EM), 1 92 1 E. 8th St., Charlotte 28204
Irvin Hart Naylor. Jr. (IM), 1001 Blythe Blvd. Ste.300, Charlotte 28203
Teresita Yap Nelson (CHN), 1001 BlytheBlvd., Ste. 601, Charlotte 28203
Dennis Michael O'Neil (PHYS ASST), Miller Orthopaedic Clinic, Inc., 1001 Blythe Blvd., Ste. 200, Charlotte 28203
Augustine Nnana Onwukwe (FP), 4200 Fox- moor Drive, Charlotte 28226
Lois Kathleen Osier (ORS), 1915 Randolph Road, Charlotte 28207
Ronald Hubert Peeler (EM), 12616 Tucker Crossing Lane, Charlotte 28273
Mark Kevin Reames, The Sanger Clinic, PA, 1 001 Blythe Blvd., Ste. 300, Charlotte 28203
John Gardiner Richards Roddey (GE), 3535 Randolph Road, Charlotte 2821 1
Louise Cree Rogers (OBS), 2801 Randolph Road, Charlotte 28211
Lisa Rohde (IM), 7 1 08 Pineville Matthews Road, Charlotte 28226
Gary Charles Rolband (END), Mecklenburg Medical Group, 3535 Randolph Road, Char- lotte 28211
Geoffrey Andrew Rose (IM), 1001 BlytheBlvd., Ste. 300, Charlotte 28203
Agustin Francisco Sanchez, 9533 Fairway Ridge Road, Charlotte 28262
Douglas Kevin Smith (R), Mecklenburg Radi- ology Assoc, 200 Hawthorne Lane, Char- lotte 28204
Gary Samuel Stein (P), 7800 Waterford Lakes Drive, #1734, Charlotte 28210
SorayaToosi(FP), 910N. Alexander St., Char- lotte 28206 :
Julianne Weidner (IM), 4501 Cameron Valley' Pkwy., Charlotte 28211
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Peter Louis Duffy (C), Pinehurst Cardiology!
Consults., P.O. Box 1502, Pinehurst 28374 Luke Stephan Erdoes (VS), Pinehurst Surgica'
Clinic, PA, One Memorial Drive, Pinehurs
28374 jiniioj
Peter Joseph Vassallo (C), Pinehurst Cardiol fern
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28374
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Kevin Patrick Galvin (AN),
Assocs., PA, 3709 Westridge Circle Drive
Rocky Mount 27801 Michael Joseph Landolf (IM), Carolina Urgei
«ley
78
NCMJ January/February 1997, Volume 58 Number 1
i\
Care,621 Tiffany Blvd., Rocky Mount27804 Jeffrey Charles Livingston (OBG), Nash Ob- Gyn Assocs., PA, 200 Medical Arts Mall, Rocky Mount 27803
New Hanover-Pender
Anna Peacock Bettendorf (PM), 1776 Wel- lington Ave., Ste. #2, Wilmington 28403
William James Brennan,Jr. (R). 8809 Whaley Circle, Wilmington 28412
Alan Wesley Brown (OPH), 1960 S. 17th St., Wilmington 28401
Birgit A. Kaeslingk (IM), Hanover Med. Spe- cialists, PA, 1515 Doctors Circle, Wilmington 28401
Robert Dennis McArtor (NPM), Coastal AHEC, P.O. Box 9025, Wilmington 28402
Brian Richard Webster (IM), Wilmington Health Asscoiates, 1202 Medical Center Drive, Wilmington 28401
Pasquotank-Camden-Currituck-Dare
Harold Eugene Crow (FP), 2604 Bridge Lane,
Nags Head 27959 Karl Winsor Hubbard (ORS), 1 1 40 N. Road St.,
Elizabeth City 27909 Jasvinder Pal Singh (PUD), 2006 Cedar Point
Circle, Elizabeth City 27909
Pitt
George Liell Adams (STU), 1632 Treybrooke Circle, Greenville 27834
Anne Beam (STU), 2315 Oleander Drive, Wilmington 28403
Amy Lee Blumenthal (STU), 1929 White Hol- low Drive, Greenville 27858
Tammy Bone (STU), 27 1 8 Meridian Dnve, #2, Greenville 27834
Timothy Brent Chafin (STU), 1521 Treybrooke Circle, Greenville 27834
Steven Boyce Coker, 3808 Sheffield Court, Greenville 27834
David A. Crumble, Jr. (STU), 2926 West Hills Drive, Apt. B, Greenville 27834
rason Richard Dameron (STU), 1446 Trey- brooke Circle, Greenville 27834
Bmily L. Davis (STU), 1020 W. Rock Spring Road, Greenville 27858
(oseph D. Deveau (STU), 2913 Cedar Creek Road, Apt. #6, Greenville 27834
scott Fairbrother (STU), 1202-E Allen Road. Greenville 27834
Troy Treanor Fiesinger (RES ) , 1 3 1 5 Westpointe Drive, #4, Greenville 27834 hristopher Grubb (STU), 3317 Dortches Court, Greenville 27834 |j*herry Lene Hall (IM), Physicians East, 408 Old Tow Road, Winterville 28590 ennifer B. Helderraan (STU), 1608 W. Arling- ton Blvd., Apt. 4, Greenville 27834 enny Hinson (STU), Apt. A3, Doctor's Park, Beasley Drive, Greenville 27834 Christine Marie Hoffman (FP), ECU Family
"3:
iitki
Practice Ctr., Moye Blvd., Greenville 27858 Amy Virginia Isenberg (STU), 1 345 Treybrooke
Circle, Greenville 27834 Laurie H. Johnson (STU), Doctors Park Apts.
#P5, Beasley Drive, Greenville 27834 Martha Johnston (STU), 1288 Park West Drive,
Apt. 10, Park West Apts., Greenville 27834 Joseph Christopher Jordan (FP), 620 S. Memo- rial Drive, Greenville 27834 Janine L. Keever (STU), I530-M Bridle Circle,
Greenville 27834 Gwendolyn Knuckles (OBG), 704-B W. H.
Smith Blvd., Greenville 27834 Heather M. Lancaster (STU), 2507-A Dickinson
Ave., Greenville 27834 Cynthia Lee Robinson Lopez (N), 4101 Hard- wick Court, Greenville 27834 Douglas Scott Love (STU), 2647 MacGregor
Downs Road, Apt. L, Greenville 27834 Michael Vincent Lurie (STU), 802-22
Treybrooke Circle, Greenville 27834 Dillard Massey (STU), 400-C Paladin Drive,
Greenville 27834 Michael D. Milligan (STU), 404-22 Treybrooke
Circle, Greenville 27834 David Wayne Overby (STU), 1305 E. First St.,
Greenville 27858 Shetal H. Padia (STU), 406-33 Treybrooke
Circle, Greenville 27834 Sujan Patel (STU), 3304 S. Memorial Drive,
Greenville 27834 Eduardo A. Piqueras (STU), 1216 Treybrooke
Circle, Greenville 27834 Shannon R. Prevette (STU), 2818 Edwards St.,
Greenville 27858 Elizabeth Quick (STU), A-3 Doctors Park Apts.,
Beasley Drive, Greenville 27834 Scot Eric Reeg (ORS), 622 Medical Drive,
Greenville 27834 Willie Richardson (STU), 1647 Mandy Drive,
Greenville 27834 Jerome Edward Schulz (FP), 708 Bremerton
Drive, Greenville 27858 L. Karenna Senors (STU), 408-B Paladin Drive,
Greenville 27834 Brent Sharpe (STU), 1 1 1 1 -Fl Grovemont Drive,
Greenville 27834 Rajesh B. Solanki (STU), 3812 Steriing Point
Drive, Unit F-7, Greenville 27834 Ingrid M. Spruill (STU), 1288 Park West Drive,
Apt. #6, Greenville 27834 Karen Elizabeth Stewart (STU), 406-13
Treybrooke Circle, Greenville 27834 Jane M. Stubbs (STU), 406-22 Treybrooke
Circle, Greenville 27834 Chris R. Va'illancourt (STU), 406-34 Treybrooke
Circle, Greenville 27834 Grantham D. Warren (STU), 1 3 Colindale Court,
Greenville 27858 Jana Watts (STU), P-6 Doctors Park Apts.,
Beasley Drive, Greenville 27834 Wendy L. Worsley (STU), 3470 Westgate Drive,
Greenville 27834
Rockingham
Matthew Thomas Desena (PD), 1303 Town Creek Road, Eden 27288
Rowan
Thomas Edwin Brown (ORS), 400 Mocksville
Ave., Salisbury 28144 Lisa Marguerite Grana (OBG), 3 1 5 Mocksville
Ave., Salisbury 28144
Stanly
Harold Sudhir Samuel (IM), HI Penny St., Albemarie 28001
Transylvania
Tamela Powell Booker (FP), 1 2 Kingfisher Road, Brevard 28712
Wake
Maureen Leahy Aarons (D), 3809 Computer Drive, Ste. 200, Raleigh 27609
Brian Charles Bennett (U), 4301 Lake Boone Trail, Ste. 300, Raleigh 27607
Ward Emerson Bennett (FP), 991 Jones Wynd, Wake Forest 27587
Mahlon Alan Dickens (OPH), 3900 Wake For- est Road, Ste. 104, Raleigh 27609
Vivian Denise Everett, Wake Med. Education Inst., 3024 New Bern Ave., Raleigh 27610
JamesTodd Harris (PD), 2800Blue Ridge Blvd., Ste 501, Raleigh 27607
Rhett Charies High (PS), Raleigh Plastic Sur- gery, 1112 Dresser Court, Raleigh 276 1 5
Jillyn Ann Kratochvil (PD), North Raleigh Pe- diatrics, 7205 Stonehenge Drive, Raleigh 27613
Mina Lea Levin (IM), Cary Medical Group, 2 1 6 Ashville Ave., Ste. 20, Cary 275 11
Naseem J. Masood (IM), 193 Dixon Ave., Dumont, NJ 07628
Syed A. Masood (IM), 1 93 Dixon Ave., Dumont, NJ 07628
Gordon K. Middleton, Jr. (PD), 1321 Obedin Road, Raleigh 27608
Vicki Morgan Morris (ID), 2500 Blue Ridge Road, Ste. 219, Raleigh 27607
Ednan Mushtaq (OTO), Mann Ear, Nose, and Throat, PA, 226 Ashville Ave., Ste. 40, Cary 27511
Stephen Samuel Rotholz (OBG), 2500 Blue Ridge Road, #300, Raleigh 27607
Tobe Lynn Rubin (OPH), Wake Ophthalmol- ogy Assocs., 3141 John Humphries Wynd, #290, Raleigh 27612
Paul OskarSchricker (ORS), 10717Cahill Road, Raleigh 27614
Gregory Vladimir Solovieff (EM), 6800 Jean Drive, Raleigh 27612
Wayne
Ravinder Kumar Kurl (IM), 105 Ridge Runner Drive, Goldsboro 27530
NCMJ January/February 1997, Volume 58 Number 1 79
Aphorisms of the Month
Daniel J. Sexton, MD, Section Editor
"More Thoughts from Big Ed's Calendar*"
We think in generalities; we live in details.
— Alfred North Whitehead
I wonder that a soothsayer doesn't laugh when he sees another soothsayer. — Cicero
An ounce of mother is worth a pound of priest.
— Pope John Paul U
Being popular is important. Otherwise people might not like you. — Oscar Wilde
Nobody is so irritating as somebody with less intelli- gence and more sense than we have. — Don Herold
Ninety percent of the politicians give the other 10% a bad reputation. — Henry Kissinger
It's a characteristic of all movements and crusades that the psychopathic element rises to the top.
— Robert Lidner
We're all of us sentenced to solitary confinement inside our skins. — Tennessee Williams
Sports is the toy department of life. — Howard Cosell
Realism is the art of depicting nature as it is seen by toads. — Ambrose Pierce
Television has made dictatorship impossible but democracy unbearable. — Shimon Peres
* Big Ed's Calendar is a monthly feature in Briefcase, a publication of the Oklahoma County Bar Association, provided to the editor by John M. Perry, III.
Fax aphorisms to Dr. Sexton at 919/684-8358, or send them via e-mail: [email protected]
80
NCMJ January/February 1997, Volume 58 Number 1
Index to Advertisers
BB&T MasterCard
70
Carolina Center for Clinical Information
17
Carolinas Physicians Network
67
Century American Insurance Co. inside front
cover
Children's Emergency Relief Teams
55
CompuSystems, Inc.
back
cover
CSC Corp.
1
Healthcare Consulting Group
47
Interim Physicians
51
Jeremy Cay/The Hammocks, SC
2
MAG Mutual Insurance
12-13
Medical Billing Practice, Inc.
35
Medical Mutual Insurance Co. inside back
cover
Medical Protective Co.
9
Medstaff, Inc.
38
Mountain Area Health Education Center
67
NCMS Endorsed Programs
43
NC Primary Care Network, Inc. :
29
Shared Services Healthcare, Inc.
16
Transcribe
47
Triad Radiographic Imaging
.
US Air Force
23
US Air Force Reserve ^
55
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