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Louisville
GREATER LOUISVILLE MEDICAL SOCIETY
Medicine
VOL. 60 NO. 9 February 2013
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LOUISVILLE MEDICINE
GLMS Board of Governors
David E. Bybee, MD, board chair
Russell A. Williams, MD, president
James Patrick Murphy, MD, president-elect
Bruce A. Scott, MD, vice president and AMA delegate
Heather L. Harmon, MD, treasurer
Robert A. Zaring, MD, MMM, secretary
and AMA alternate delegate
Robert H. Couch, MD, at-large
Rosemary Ouseph, MD, at-large
Tracy L. Ragland, MD, at-large
Jeffrey L. Reynolds, MD, at-large
John L. Roberts, MD, at-large
Wayne B. Tuckson, MD, at-large
Fred A. Williams Jr., MD, KMA president-elect
Randy Schrodt Jr., MD, KMA 5th district trustee
David R. Watkins, MD, KMA 5th district
alternate trustee
K. Thomas Reichard, MD, GLMS Foundation president
Stephen S. Kirzinger, MD, Medical Society Professional Services president
Toni M. Ganzel, MD, MBA, interim dean,
U of L School of Medicine
LaQuandra S. Nesbitt, MD, MPH, director,
Louisville Metro Department of Public
Health & Wellness
Karyn Hascal, The Healing Place president
Adele Murphy, GLMS Alliance president
Louisville Medicine Editorial Board
Editor: Mary G. Barry, MD
Elizabeth A. Amin, MD
Waqar C. Aziz, MD
Deborah Ann Ballard, MD
R. Caleb Buege, MD
Arun K. Gadre, MD
Stanley A. Gall, MD
Larry P. Griffin, MD
Kenneth C. Henderson, MD
Jonathan E. Hodes, MD, MS
Teresita Bacani-Oropilla, MD
Tracy L. Ragland, MD
M. Saleem Seyal, MD
Dave Langdon, Louisville Metro Department
of Public Health & Wellness
David E. Bybee, MD, board chair
Russell A. Williams, MD, president
James Patrick Murphy, MD, president-elect
Lelan K. Woodmansee, CAE, executive director
Bert Guinn, MBA, chief communications officer
Ellen R. Hale, communications associate
Kate Allen, communications designer
Advertising
Cheri K. McGuire, director of marketing
736.6336, [email protected]
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Louisville Medicine is published monthly by the
Greater Louisville Medical Society, 101 W. Chestnut
St. Louisville, Ky. 40202 (502) 589-2001, Fax 581-9022,
www.glms.org.
Louisville
Greater Louisville Medical Society
Medicine
Vol. 60 No. 9 FEbruary 2013
feature articles
Integrative Medicine Can
All-Too-Short Visit into
11 How
16 An
Improve Patient Outcomes
Obstetrics in Tanzania
and Advance the Accountable
Care Organization Model
Deborah Ann Ballard,
MD, MPH
Can a Workplace History
12 What
Reveal?
Frank P. Vannier, MD
Kuric Comes to Louisville
15 Dr.
Ellen R. Hale
Divya Cantor, MD, MBA
Gigi Girard, MD
of Louisville National
19 History
Medical College and the
Red Cross Hospital: African
American Medicine in
Louisville, Kentucky - 18721976 - Part 2
Morris Weiss, MD, FACC, FAHA,
FACP
departments
5
From the President
Playing Defense
Russell A. Williams, MD
24 Reflections
Retreading the Retired
7
Alliance News
Adele Murphy
Lounge
27 Doctors’
Back to the Future
9
In Remembrance
Kenneth Holtzapple, MD
Steve Wheeler, MD
22 We Welcome You
Review
23 Book
The Long Walk
Teresita Bacani-Oropilla, MD
Mary G. Barry, MD
How We Got to
Where We Are
Kenneth C. Henderson, MD
30 Physicians in Print
by Judith C. Owens-Lalude
Elizabeth A. Amin, MD
Articles to be submitted for publication in LM must
be received on electronic file on the first day of the
month, two months preceding publication.
Opinions expressed herein are those of individual
contributors and do not necessarily reflect the position of the Greater Louisville Medical Society. LM reminds readers this is not a peer reviewed scientific
journal.
LM reserves the right to make the final decision on
all content and advertisements.
Circulation: 4,000
On the cover: The country of Tanzania and its flag.
Story on page 16.
February 2013
3
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LOUISVILLE MEDICINE
From the President
Russell A. Williams, MD
GLMS President
Playing Defense
S
ince the presidential election, we have
all become more familiar again with
Obamacare – especially with the numerous
newspaper spreads outlining its ramifications
for patients, insurance companies, hospitals
and physicians. Many organizations are gearing
up to develop methods to reduce the cost of
medical care in view of the fact that more of the
population will be covered with a fixed pool of
monies. We are seeing the development of ACOs,
essentially capitated plans, and preventative care
in order to have a healthy population, which
will likely save some money. As an aside, my
thought of preventative care is to slap a $5 tax
on a pack of cigarettes and use that money in
schools to teach healthy habits (i.e. eating well
and exercise). Back to my point, however – a
significant part of the fixed pool of money is
being wasted. We the physicians are also wasters.
I do not see any organizations (hospitals and
insurance companies) trying to come up with a
solution either. An occasional denial of service
by an insurance company may help save money
(i.e. when a breast MRI is denied in a patient I
have clinical concerns about), but then I may not
sleep as well because of the welfare of the patient
and risk exposure.
I’m talking about the practice of defensive
medicine. In a week’s time, as a general surgeon,
I’m sure I order several CT scans for abdominal
pain that, based on clinical findings, will be of
very low yield. It is what most patients expect
and it has become knee-jerk to order diagnostics
with little clinical basis to support them.
If we want to stop wasting billions of dollars
nationally, we need to have some effective
malpractice reform. I’m not sure how you can
have an effective ACO without it. If affiliated with
a particular entity, now is a good time to discuss
this with hospital administrators. Insurance
companies and hospital associations may also
be interested in the opinion of physicians on
these matters.
We should bring this topic back to the top
of our agenda in Frankfort and Washington
before we see a weeklong series of articles on how
physicians waste medical dollars. I was told that,
in Kentucky, malpractice reform would require a
constitutional amendment that can only happen
in even years. Regardless, we should apply a halfcourt press, steal the ball, and maybe next year
we can get an alley-oop and a slam dunk. Let’s
reopen that dialogue with our legislators, given
that you may already be communicating with
them regarding other issues.
I’m going to the AMA National Advocacy
Conference in Washington this month. National
malpractice reform seems to have been buried
during development of the new health care laws.
When I have the opportunity to meet with our
national legislators, this will be one of my chief
agenda items as the current captain of the GLMS
team. LM
Note: Dr. Williams practices General Surgery with
Associates in General Surgery.
February 2013
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LOUISVILLE MEDICINE
Alliance News
Adele Murphy
GLMSA President
“You can make more friends in two months by becoming interested in other people
than you can in two years by trying to get other people interested in you.”
–Dale Carnegie
“D
on’t criticize, condemn, or complain” is the first principle
in Dale Carnegie’s famous book How to Win Friends and
Influence People. In 2012, as Frankfort struggled to pass
prescription drug laws and then dealt with the aftershock, there was plenty
of criticism, condemnation and complaining to go around. These laws
are due to be revisited in 2013. While this year may prove to be no less
contentious, the GLMS Alliance is planning to take a positive approach.
The KMA “Day at the Capitol” is Tuesday, February 12. The KMA
and Alliance are teaming up this day to conduct “House Calls,” a health
fair designed to promote health education and community service
throughout the commonwealth. From 10 a.m. to 1 p.m., our dedicated
white lab-coated company will be greeting lawmakers and their staff in
the Capitol Annex building. We will be taking blood pressures, handing
out healthy snacks and offering educational materials in a caring,
friendly environment. This is a great opportunity to make new friends in
Frankfort and show our appreciation for the hard work they do. Please
try to attend and encourage as many of our members as possible to
join in. Afterward, plan to stick around for some great fellowship at a
group luncheon to follow our work at the Capitol.
Dining in Frankfort is not the only tasty treat on our upcoming
GLMS Alliance menu. Due to the popularity of last year’s lunch and
cooking demonstration by “Top Chef ” contestant Edward Lee at 610
Magnolia, we will once again be dining and learning in 2013. Mark
your calendars for 11 a.m. on Tuesday, Feb. 5, as we reprise our
(Left to right) Millicent Evans, Barbara Cox and Dean Furman at the GLMS Alliance
luncheon at the Science Hill Inn.; GLMS Alliance members learn about the Christopherson Gross Anatomy Lab in The Old Medical School Building during a tour.
gustatory adventure, this time at the exquisite Corbett’s restaurant,
5050 Norton Healthcare Blvd., in northeastern Jefferson County.
It might be an odd-numbered year, but we will keep an even
keel supporting our medical community’s mission. In 2013, the
GLMS Alliance will continue partnering with the Kentucky Science
Center, the Greater Louisville Medical Society and Jewish Hospital to
bring the highly acclaimed interactive educational program Pulse of
Surgery to middle and high school students from all around Kentucky.
The GLMS Alliance is also supporting the Center for Women and
Families in Louisville by collecting and donating gently used OR
scrubs, yoga pants and new men’s and ladies’ underwear. In addition,
the GLMS Alliance Doctors’ Day committee is busy planning our
lovely annual reception to honor our retired doctors. The luncheon
will be March 22, once again at the elegant Audubon Country Club.
January and February certainly come at a cold time of the year,
but with warm hearts, we have the opportunity to win many
friends. If you are interested in being interested in others, please
come join us! LM
Note: Contact Adele Murphy at [email protected] or 502-664-5925.
February 2013
7
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LOUISVILLE MEDICINE
In Remembrance
Kenneth Holtzapple, MD
(1931-2012)
isville for residency training, and ultimately
practice. In 1991, we were a special “couples
match,” with me considering a faculty position
and her a residency slot, when Dr. Pat asked Dr.
H what really was the decisive question, “Will
you still be chair while I’m training?” If he had
said “no,” we would have considered it a deal
breaker, because we found his leadership and
his personal strength so valuable.
K
enneth Eugene Holtzapple, MD, 81,
died on Sunday, September 23, 2012, in
Steilacoom, Washington, surrounded
by family.
He was born on August 30, 1931, in Dallastown, Pennsylvania, the son of Curvin and Olive
R. (Flinchbaugh) Holtzapple.
Dr. H was a graduate of Gettysburg College
and Temple University Medical School. After his
medical internship at Presbyterian Hospital in
Philadelphia, he entered the United States Army
Medical Corps and completed his Internal Medicine residency at Madigan Army Medical Center.
As a member of the Army Medical Corps
from 1960 to 1980, he served in Washington
state, Virginia, Germany, Washington, D.C. (in
the Surgeon General’s Office), and Georgia. He
was instrumental in starting the Army Medical
Corps’ Department of Family Medicine and was
chief of the first Family Medicine residency at
Fort Benning, Georgia. His last Army Medical
Corps assignment was chief of the Department
of Family Medicine at Madigan Army Medical
Center.
He continued his teaching and medical career
at the University of Louisville School of Medicine, where he was chairman of the Department
of Family Medicine, the William Ray Moore
Endowed Professor and, eventually, professor
emeritus. He continued teaching, seeing patients
and precepting in the department until age 79.
Dr. Holtzapple was board-certified in Internal
Medicine, Family Medicine and Geriatric Medicine.
My wife, Dr. Pat Wheeler, and I consider
Dr. H one of the key reasons we stayed in Lou-
We loved his laugh. He would squint his eyes,
rear back in his seat and laugh all over, so that
his whole body would shake. Two times that he
laughed like that were tied together. Jewish Hospital once gave a party at the Harley-Davidson
retail store, where those willing could have their
picture snapped dressed in leather astride a big
Harley bike. Dr. and Mrs. H were always players,
so they suited up and climbed on. The picture
was wonderful, so what better place to clandestinely use it than at his gala retirement party, a
few years later. Appropriately enlarged, mounted
and elegantly framed, it was unveiled as his final
gift of the celebration, with the Shangri-Las’ 1964
hit sounding over the loudspeakers, appropriately christening him “The Leader of the Pack!”
Based on his many lifetime achievements,
he was inducted into Alpha Omega Alpha, the
national honor medical society, in 1996. When
the School of Medicine needed to expose premed students every year to what it meant to be a
doctor in the finest tradition and meaning of the
word, we recruited Dr. H to come and interact
with them. When Admissions at the School of
Medicine needed someone who was respected,
thoughtful and insightful (but NOT “dry” ...
no, NEVER dry!) to help with interviews and
decisions, Dr. H agreed.
I’ve said many times, “Dr. H is who I want to
be when I grow up.” This is still true. I used to
claim that the high point of my career occurred
once as I was walking down the back hallway at
the Ambulatory Care Building while Dr. H was
seeing his patients. “Come here,” he said. I came.
“What would you do with this patient?” he asked.
I blushed with the honor, quickly scanned the
chart of a most difficult patient, looked up and
honestly answered, “I’d ask you.”
But then, what a privilege it was to be asked
to be his doctor. Daunting and yet, with his laidback attitude, he made it possible, even easy.
It was interesting to negotiate diagnostic and
therapeutic decisions with him; he always had
his opinion but respected mine as well.
It was daunting, even easy ... until ... the cancer. Then the things I’d seen him model, learned
from him about approaching hard issues and
having hard conversations with patients, had to
be applied to our relationship, to the heartfelt
conversations we had. The parts about paying
attention to the patient, not just to the disease,
became even more important and personal.
We loved Dr. H and miss him terribly. When
you teach and model patient care for others,
your knowledge, influence, ideas and approaches
reach far beyond those relatively few patients
you can personally touch. As a role model and
mentor to thousands of students at all levels, Dr.
Holtzapple’s life’s work and legacy will continue
gently to improve the care of patients across the
country for generations to come.
As usual, Dr. H summarized his life and
thoughts best in a September 2011 response to
his nomination for an “Optimal Aging” award:
“Why the hell does a grumpy grouchy old man
get nominated for ‘Optimal Aging?’ What’s going
on? At any rate, here are a few thoughts which
I believe describe my path to so-called ‘optimal
aging’ ... caring, supportive parents; good education; wonderful marriage, without question the
most important factor; loving caring children,
grandchildren and in-laws; very enjoyable fulfilling career in a profession I love; varied interests
in areas outside my professional field; no desire
to ever permanently retire; always looking ahead
to the future.”
Dr. Holtzapple is survived by his wife of 57
years, Patricia DeHoff Holtzapple; by his sisters,
Yvonne R. and Mary E. Holtzapple, and Betty
Amick (Allen); by his children, Ann Bender
(Mark), Sue Bender (Matthew) and Samuel Holtzapple; and by his beloved grandchildren, Grace
E. and Matthew A. Bender.
If desired, memorial contributions can be
made to:
The Kenneth E. Holtzapple Award for
Excellence in Humanistic Medicine
University of Louisville
Health Sciences Development Office
132 E. Gray St.
Louisville, KY 40202 LM
–Steve Wheeler, MD
February 2013
9
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Themes:
Practicing/life physician category:
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Physician-in-training/medical student category:
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Length:
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Format:
Do not put your name on your essay, but include a
separate cover letter with name, entry category, essay
title and contact information.
Medical Writing for the
Public Award:
In addition to the regular contest, GLMS offers a special
award, Medical Writing for the Public. You may enter an
article of any length, written on a medically related topic
for readers in the general public, that was published in a
printed newspaper, magazine or book anytime during 2012.
The submission may not be a self-published work. Include
a copy of the article along with a cover letter with the name
and date of the publication and your contact information.
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preferred, but if not possible, send entry by fax to
502-736-6339 or by mail to
101 W. Chestnut St., Louisville, KY 40202.
All entrants must be GLMS physician members or
GLMS in-training members or University of Louisville
medical students.
10
LOUISVILLE MEDICINE
Serving greater Louisville and southern Indiana with
a 60-year track record of quality and dedication. Call
Ludmilla Plenty, employment director, at
502-736-6342 or visit us at www.glms.org.
MedicaL
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Services
A Greater Louisville Medical Society Company
How Integrative Medicine Can Improve
Patient Outcomes and Advance the
Accountable Care Organization Model
Deborah Ann Ballard, MD, MPH
A
ccording to the
Consortium
of Academic
Health Centers for
Integrative Medicine
(this includes such highly
respected institutions
as Harvard, Yale, the
Cleveland Clinic, Boston
University, the University of California, San
Francisco, and Duke University):
“Integrative Medicine is the practice of
medicine that reaffirms the importance of
the relationship between practitioner and
patient, focuses on the whole person, is
informed by evidence, and makes use of
all appropriate therapeutic approaches,
healthcare professionals and disciplines to
achieve optimal health and healing.”
Thus integrative medicine can achieve
many of the objectives of an Accountable Care
Organization. When combined with traditional
medicine, it can complete the continuum of care
to improve patient outcomes and reduce overall
medical costs. Integrative medicine empowers
people with knowledge and skills they can apply
in their everyday lives to heal faster, control pain
and anxiety, and reverse diseases caused by an
unhealthy lifestyle.
Integrative medicine activates the human
body’s own natural healing mechanisms,
provides techniques for self-management of
pain and anxiety, and teaches coping skills that
empower people to overcome illness and injury.
It is a powerful means to reduce human suffering.
According to the Centers for Disease Control
and Prevention, 85 percent of chronic diseases
and 40 percent of all cancers are preventable
through proper diet, exercise and avoidance
of tobacco. Optimal nutrition, physical fitness
and stress management are the foundations of
integrative medicine and have immense potential
to prevent illness as well as treat conditions
already present. Furthermore, integrative
medicine is not an episodic approach to disease
or injury management. It provides a means to
change one’s lifestyle permanently and maintain
health after the illness or injury is treated.
The passage of House Bill 1 by the Kentucky
legislature last year has left physicians looking
for alternatives to narcotics and other controlled
substances to treat pain and anxiety. Integrative
medicine can offer evidence-based therapies
such as acupuncture and healing touch to meet
this acute need.
Integrative medicine includes therapies
formerly labeled as complementary and
alternative medicine. There is a growing body of
evidence on the effectiveness of many integrative
therapies. The Consortium of Academic Health
Centers for Integrative Medicine is dedicated
to applying the same rigorous evidence-based
standards to integrative therapies as have been
applied to traditional therapies. In February 2012,
the Bravewell Collaborative released a landmark
study, “Integrative Medicine in America: How
Integrative Medicine Is Being Practiced in
Clinical Centers Across the United States,” which
provides current data on the patient populations
and health conditions most commonly treated
with integrative strategies.
and knowledge as well as a professional
commitment to adhere to the American Board
of Physician Specialties (ABPS) Medical Code of
Ethics. The ABPS anticipates accepting ABOIM®
applications starting in July 2013. Certified
physicians can be located on the ABOIM website:
http://www.abihm.org/search-doctors.
The Kentucky Board of Medical Licensure has
authority over acupuncturists.
Integrative medicine is an evolving field. It is
important to make sure integrative physicians
and other practitioners have shown a dedication
to a high standard of evidence-based care and
professional ethics by training at a reputable
institution, obtaining board certification and
obtaining continuing medical education on the
specialty.
Integrative medicine’s time has come.
Integrative medicine does not replace traditional
evidence-based therapies. It provides a means
to assure their success, promote optimal
healing, reduce suffering and prevent future
illnesses. LM
Note: Dr. Ballard is with Holiwell Health
Consultation.
According to the CDC, in 2007, approximately
38 percent of adults aged >18 years reported
using complementary and alternative medicine
(CAM) during the preceding 12 months. Women
(43 percent) were more likely than men (34
percent) to use CAM. In 2007, adults in the
United States spent $33.9 billion out of pocket
on visits to CAM practitioners and purchases of
CAM products, classes and materials.
The Consortium of Academic Health
Centers for Integrative Medicine has training
opportunities for integrative physicians and
other practitioners. If an integrative practitioner
trained at one of the consortium members or
affiliates, he or she has completed an evidencebased curriculum.
Physicians completing the Integrative
Medicine board certification (ABOIM)
demonstrate mastery of the specialty experience
February 2013
11
What Can a
Workplace History Reveal?
Frank P. Vannier, MD
T
he
histor y
of a patient’s
workplace
activities is an obvious
and essential component
of the care provided in an
Occupational Medicine
practice. This workplace
history, however, at times
can play a role in delineating causes of symptoms
and clinical issues in the primary care practice.
Therefore, when the primary care physician
encounters patients it is helpful to consider a
workplace origin of the clinical problem. Taking
an occupational history can make the difference
between a complete versus an incomplete
diagnostic and treatment plan.
If you are caring for someone whose asthma
has proved difficult to manage, and may have
been associated with exacerbations at work, the
occupational history is meaningful. Someone
who works in the auto repair industry can be
exposed to the isocyanate compounds, which
are often a component in spray-on polyurethane
products. These compounds are a significant
irritant and also a potent sensitizing agent. This
can cause asthma that is difficult to treat without
addressing exposure in the workplace. At times,
smaller companies may not be aware of all the
characteristics of products that they employ and
may not provide the ideal personal protective
equipment for their workers. The primary
care physician can here play a valuable role in
identifying this etiology.
The isocyanate compounds are also used
in building-insulation materials. Spray-on
polyurethane chemicals have been used to
protect cement, fiberglass, steel and aluminum
products, so ask questions about what your
patient is working with and how he or she might
be exposed.
For example, a young man of 25 presented
to our office with a history of transferring to a
12
LOUISVILLE MEDICINE
work area where a coating was being applied
to manufactured product. He presented with
a non-productive cough associated with his
work station and a tendency to feel short of
breath. He did not have a previous history of
asthma or respiratory dysfunction. The fact
he had recently transferred to the area where
the industrial coating was applied appeared to
suggest the possibility of occupational asthma.
On physical examination, he had bilateral
scattered end expiratory wheezing. Exhalation
also tended to precipitate a cough. The chest
X-ray was clear. The pulmonary function testing
was consistent with mild obstructive disease.
The bronchodilator albuterol was prescribed
to use as needed. A call was made to the plant
requesting MSDS information (material safety
data sheets) for the polyurethane coating that
was being utilized. It then became clear that an
isocyanate component was used in this product,
and that a negative pressure respirator as
personal protective equipment was indicated for
this work process. After our patient began using
the negative pressure respirator, his shortness of
breath and cough resolved. If symptoms persist
in spite of personal protective equipment (e.g.
this respirator), transfer of the individual to an
area free of exposure to the specific entity is
recommended.
Cobalt is often combined with tungsten in the
workplace to form an alloy called carbide that
has significant resistance to wear. Cobalt can
serve as a sensitizing entity and can cause contact
dermatitis. Occupational asthma can also occur
with exposure to cobalt, and a pneumoconiosis
called “Hard Metal Lung Disease,” a chronic lung
disease developing over an extended period,
is associated with long-term cobalt exposure.
For patients with respiratory symptoms, the
occupational history should include questions
about cobalt exposure.
As doctors, we are aware of latex allergy
and realize that the existence of dermatologic,
respiratory and in certain circumstances even
anaphylactic reactions can occur with latex,
which is omnipresent in patient care. Ask food
service workers, transporters, and maintenance
and housekeeping workers about latex exposure,
not just nursing and pharmacy staff.
Pre-work shift and post-work shift pulmonary
function testing or peak expiratory flow testing
with an individual peak flow monitor can be
utilized to assist in the diagnosis of occupational
asthma. In addition, heat, cold, dust, co-workers’
cigarette smoke or perfumes, and environmental
allergens including molds and grasses all can play
a part. Think about what your patient faces in
his or her work day to help you make a diagnosis
and guide evaluation and treatment. As we can
see, determining the occupational history in
our patients can serve to aid the process of
determining the etiology of the symptoms
associated with the clinical problem for which
the patient has sought medical care. LM
Note: Dr. Vannier is a member of the new GLMS
Environmental Medicine Committee. He practices
Occupational Medicine with Occupational
Physician Services of Louisville.
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LOUISVILLE MEDICINE
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52218_B7_C1-1
06/06/12
RLX
Dr. Kuric
Comes to Louisville
Ellen R. Hale
K
atie Kuric was the goalkeeper for the University of Louisville soccer
team. Kyle Kuric was a star on the U of L basketball team that went
to the Final Four last year. Now, Steven and Judi Kuric, the proud
parents, have come to Louisville with their own special talents – treating
neurosurgery patients.
Steven Kuric, MD, joined Michael Doyle, MD, in practice last fall after
20 years practicing in Evansville, Indiana. Judi Kuric is an APRN. Though
Kyle graduated in 2012 and is currently playing professionally in Spain,
Katie remains in Louisville as a first-year dental
student at U of L. The Kurics decided to give up
the two-hour drives and embrace Louisville as
their new home.
Both Indiana natives, Steven was a medical
student at Indiana University and Judi was a
nursing student when the two met in anatomy
class. Dr. Kuric graduated from medical school in
1982 and completed his neurosurgery residency
at Wayne State University in Detroit. With her
husband working all the time, Judi said, she went
ahead and earned her master’s degree.
(Above left) Kyle Kuric in the “infrared” uniform worn during the Cardinals’
unexpected postseason run.; (above right) The Kuric family celebrates on the
court after Louisville’s victory over Florida to go to the Final Four: (left to right)
Judi, Kyle, Steven and Katie.
for the Asefa Estudiantes on a two-year contract. The Kurics visited for the
first time in late December.
“He likes playing basketball, and he’s getting paid to do it,” Dr. Kuric said.
The proposal story made its way to Spain,
where a magazine article billed Kyle as “El Ultimo
Romantico.” Fans have already requested Louisville
T-shirts. “It’s just incredible fan support,” Judi said.
The Kurics continue to marvel at Kyle’s fan
support in Louisville as well.
“Louisville adopted him,” Judi said. She recalls
how Kyle, before his senior year began, wanted to
find a way to give back to Louisville. He brought
children with cancer who attended Indian Summer
The Kurics on graduation day at the
Camp to a U of L scrimmage, then organized a
University of Louisville.
drive for Halloween costumes for children at the
Home of the Innocents. The charity was named Kyle’s Korner for Kids. At
Both of their children played sports from an early age and displayed a
Christmas, fans donated more than 2,000 toys that the Kurics distributed
competitive spirit. “We did not play board games in our household,” Judi
to several charities, including at Kosair Children’s Hospital on Christmas
said, laughing. “They do not like to lose.”
Day. Teammates Peyton Siva and Elisha Justice joined Kyle in visiting the
Fast-forward to 2010 and the Cardinals’ final game in Freedom Hall.
ICU and oncology unit. All patients were invited to the lobby to select a
Kyle, a sophomore who had been averaging just three points, scored 22 in
gift. “The people of Louisville made it happen,” Judi said.
the second half to lead Louisville over top-ranked Syracuse.
She recalled meeting a mother of five children, one of whom had been
“Still, to this day, I can’t believe it happened,” Dr. Kuric said.
readmitted to the hospital two days before Christmas due to chemotherapy
complications. “We were just getting ready to tell our kids we didn’t have any
Capping his career with a Big East championship and trip to the Final
Christmas for them,” the woman told Judi. “This is an answer to our prayers.”
Four “was almost like a dream – no one was expecting it,” Dr. Kuric added.
The Kurics were able to travel to Portland, Phoenix and New Orleans for
all the games during the Cards’ NCAA tournament run, returning to catch
up on work in Evansville between trips.
Even with its founder overseas, Kyle’s Korner for Kids held a second
Christmas toy drive at a home game this December.
Judi said she kept wondering if each game would be Kyle’s last for
U of L, particularly when the Cards were down late to Florida in the Elite
Eight. “When they pulled that out, we couldn’t believe it. We knew how
hard he and the team had worked for it,” Judi said. “It was something he
had wanted so badly. He wanted to do the Final Four.”
Note: Ellen R. Hale is the communications associate for the Greater
Louisville Medical Society.
“Certainly, we’re happy for what he’s accomplished on the court but also
for what he’s accomplished off the court,” Dr. Kuric said. LM
Kyle’s notoriety didn’t end with the basketball season, however. He
generated headlines when he proposed to his girlfriend, Taraneh, on stage
as she received her diploma from the U of L dental school in May. They’re
planning a July 2013 wedding from Madrid, Spain, where Kyle is playing
February 2013
15
An All-Too-Short Visit
into Obstetrics in Tanzania
Divya Cantor, MD, MBA,
Gigi Girard, MD
T
anzania is a
country known
for its rich culture,
spectacular landscape and
wildlife wonders. Despite
this great beauty, most
Tanzanians live with very
limited resources. On a
recent trip there, we wanted
to explore the obstetrical services available to women in this country and
also look at some of the cultural differences and practices in regards to
circumcision. We interviewed a private practice obstetrician in the city
of Arusha, and we also got to interview the Maasai about their traditions
as well.
Dr. Amal Nur is a solo OB-GYN who practices in her private, freestanding
birthing center. She is originally from Somalia and trained in Kiev, Ukraine.
Although this facility is relatively new, her clinic has the ability to provide
vaginal deliveries and postpartum care to those patients seeking her care.
She currently performs 10-15 deliveries per month; if her patient needs a
C-section, she will transport her in the clinic’s ambulance to the nearby
hospital. Indications for Dr. Nur’s C-sections are the same as U.S. OB
doctors are familiar with: breech, fetal distress and obstructed labor. Her
unofficial rate of “switch to section” is 25 percent.
When describing antepartum care, Dr. Nur states she will often see
patients after just one missed period. In these cases, patients will generally
be seen seven to eight times during the gestation of the pregnancy. She has
two ultrasound machines in the clinic, one located in the office and the other
in the L&D area (an ultrasound will cost $25 to the patient). Ultrasounds
are performed for dating on her patients, and she will draw a panel of blood
work at 13 weeks. She states she has approximately five HIV positive patients
per year. She is able to treat them with basic medications with PMTC and
ARV but if they are in need of further treatment, she refers them to the public
hospital that provides the treatment for free. At 20 weeks, a fetal survey US
will be performed and a two-hour GTT is standard at 28 weeks. Despite
carbohydrates being a dietary staple for Tanzanians, diabetes is not very
16
LOUISVILLE MEDICINE
(Clockwise from left) Dr. Divya Cantor (left) and Dr. Gigi Girard outside the clinic
entrance; The Mother Medical Care clinic’s private ambulance, which takes
patients with emergency needs to the hospital where additional care can be
provided; Dr. Amal Nur.
common, probably because their society does not appear to be sedentary.
Everyone walks as their primary mode of transportation.
Infants born after 28 weeks will have the greatest chance of survival
in Tanzania. If a patient of Dr. Nur is at risk for pre-term delivery, she
will hospitalize her and is able to augment labor with IV oxytocin. For
postpartum hemorrhage management, she has only oxytocin to help.
Patients in labor preparing for a vaginal delivery do not receive any
analgesics other than local anesthesia for episiotomy repair. On occasion,
a pudendal block will be administered during the second stage of labor.
Patients will stay 24 hours after an uncomplicated vaginal delivery. A routine
vaginal delivery costs approximately $250; many expatriates rely on her
service, as this cost can be prohibitive to the locals. In Tanzania, most nontribal males are circumcised at the hospital between the ages of 5 and 6.
Of note, Tanzania has approximately 1.8 million births per year, with
an infant mortality rate of 46 deaths per 1,000 live births, according to the
2012 estimate in the CIA World Factbook. The U.S. rate, for comparison,
is 6 per 1,000 live births. For mothers, Tanzania’s 2010 maternal mortality
rate was 460 per 100,000 deliveries, compared to the U.S. rate of 21
per 100,000. Using the CIA World Factbook definition, the maternal
mortality rate in Kentucky has dropped from 17 in 1995 to 7.6 in 2004.
The factbook defines MMR as the annual number of female deaths per
100,000 live births from any cause related to or aggravated by pregnancy
or its management (excluding accidental or incidental causes). The
MMR includes deaths during pregnancy, childbirth, or within 42 days
of termination of pregnancy, irrespective of the duration and site of the
pregnancy, for a specified year.
HIV remains a pandemic in the sub-Saharan countries such as Tanzania.
According to UNICEF, in 2010, the prevalence of the population living with
HIV is 5.9 percent for all ages; this is equal to 44 million people in Tanzania
living with HIV. Services for HIV/AIDS are available, especially in the urban
areas of the country. According to a 2011 United Nation AIDS report,
HIV prevalence has declined among pregnant women attending antenatal
clinics and young people ages 15-24. This is great news for a country where
almost one-half of the population is less than 15 years old. Dr. Nur spoke
very highly of the Benjamin William Mkapa HIV/AIDS Foundation. This
is a nonprofit organization established in 2006 to provide supplemental
support to the government of Tanzania. It promotes an equitable delivery
of treatment to those in need and includes a reproductive and child health
component. More information for those interested can be found online at
www.mkapahivfoundation.org.
The other part of our journey in Tanzania included a drive through
a Maasai village on the way to Tarangire National Park. We noticed an
adolescent male with his face painted white. He was also wearing the
traditional robe of brightly colored beautiful fabric in red, blue and purple.
We were able to learn that there is a group circumcision between the ages
of 15 and 18, without anesthesia, as part of the ritual for entering into
manhood. These young men are now known as the young warriors, maroni
in Swahili. They paint their faces white as evidence of the procedure having
been performed. Years ago, the tradition for the maroni was to fight a
lion while living in the desert for two months. With the numbers of lions
dwindling due to human impact, conservation groups over the past five
years have approached the Maasai elders to try and eliminate this aspect of
the tradition. These traditions have been slow to change, according to our
guide. However, one tradition that has changed is that female circumcisions
are rarely performed these days in Arusha, thankfully.
While in the Serengeti National Park, we had a Maasai guide who was
happy to share with us that both of his children had been born in a hospital,
despite the fact that he lives in a very remote community. The Maasai women
are encouraged to seek prenatal care and to deliver in a hospital. Some
Maasai have greater access due to their proximity to the hospital, but they
still may have to walk or, if lucky, get a motorbike to take them to the hospital
when in labor. Our guide told us what a wonderful celebration the village
had when his son returned home from the hospital, where all the women
came to sing to the baby, and a calf was slaughtered in honor of his son.
Lab on the premises that can perform many routine lab requests.
Despite the fact that 80 percent of the population lives in a rural area, 50
percent of pregnant women have a skilled attendant at birth and 50 percent
of pregnant women do an “institutional delivery,” according to UNICEF.
Geography, costs and cultural differences may have been barriers to health
care for people in Tanzania years ago. However, today there are increasing
resources with access to health care reaching into even the most remote
areas of this large nation. We enjoyed learning about different aspects of
obstetrical care and women’s health in this country. We would invite our
colleagues also to go and experience the richness of Tanzania! LM
Note: Dr. Cantor is senior physician consultant with Healthgrades and
Kentucky Section chair of the American Congress of Obstetricians and
Gynecologists. Dr. Girard practices Obstetrics and Gynecology with Associates
in Obstetrics and Gynecology, a part of Norton Women’s Care.
References
www.unicef.org
www.indexmundi.com
www.cia.gov/library/publications/the-world-factbook/geos/tz.html
www.mkapahivfoundation.org
The delivery suite with two birthing beds and screens for privacy.
February 2013
17
18
LOUISVILLE MEDICINE
History of Louisville National
Medical College and the
Red Cross Hospital: African
American Medicine in Louisville,
Kentucky – 1872 to 1976
Part 2
Morris M. Weiss, MD, FACC, FAHA, FACP
I
n the saga of Henry Fitzbutler and Louisville
National Medical College, other important
characters include Fitzbutler’s wife, Sarah Helen
McCurdy Fitzbutler (Fig. 1). Sarah Fitzbutler was a
supportive spouse and an intellectual force in her
own right. Clearly, she helped Henry succeed in all
his diverse endeavors. They married in 1866 and
after Sarah arrived in Louisville with three young
children, three more offspring were born. Three of
their children became physicians, and one died during childhood. After
the children grew up and began to leave home, Sarah entered her husband’s
Louisville National Medical College and became the first African American
female in Kentucky to receive a medical degree.
Sarah practiced medicine and treated people free of charge in the
tenements and back alleys of West Louisville for years after her husband’s
death in 1901. Obstetrics and pediatrics were her forte, and she enjoyed
a fine reputation. In addition, Sarah supervised the nursing program
at Louisville National Medical College, which at that time was the only
institution training African American girls for a career in medicine. Among
her other duties, she was superintendent of the Auxiliary Hospital in the
1000 block of Madison Street. In 1907, the 19th Bulletin of the medical
college lists her as one of the five directors. She continued to practice in
Louisville until her health deteriorated; eventually, she moved to Chicago
to be near a daughter, where she remained until her death in 1922. Sarah
deserves to be better known among Louisville’s famous citizens because of
her great courage, which her grandchildren remarked was her hallmark.
Prima, a daughter born in Canada in 1868, graduated from Central
High School in Louisville in 1885 and graduated from Louisville National
Medical College the year her father died, 1901.
Daughter Mary Fitzbutler Waring, born in Canada in 1871, graduated
from Central High School in Louisville in 1888 and LNMC in 1898 (Fig.
2). In 1919, during World War I, she was chairman of the Colonel Denison
Red Cross Auxiliary; she also was chairman of the Red Cross Colored
Women’s Club of the U.S. and president of the National Association of
Colored Women from 1933 to 1937.
The Fitzbutlers’ son, James H. (some references say “John H.”), was
Fig. 1 Dr. Sarah McCurdy Fitzbutler, wife
of Dr. William Henry Fitzbutler, a graduate of Louisville National Medical College
who supervised and directed the nurses
training program in addition to practicing medicine.
born in 1873 in Louisville, the year
after his parents arrived. He graduated
from Central High School in 1890 and
Louisville National Medical College
in 1893. He first practiced medicine
in the Philippine Islands and later in
Chicago, Illinois, where he married
Mae Hamilton on August 25, 1905.
James served for a short period as
secretary to the Louisville National Medical College and was professor of
surgery, demonstrator in anatomy and surgeon in the Auxiliary Hospital.
A daughter Sarah was born in Canada in 1872, just prior to the family’s
moving to Louisville, and Myra was born in 1874 in Louisville. Details of
their lives are not known.
The Caron 1911 City Directory of Louisville, Kentucky, lists Prima
Fitzbutler as a teacher at Central Colored School, living at 1027 W. Green,
and Sarah H., physician, also living at 1027 W. Green. This was in 1911, 10
years after the death of Henry Fitzbutler.
Although Henry Fitzbutler was the driving force behind the medical
school, two colleagues were of tremendous help and key role players for
him. The most important was Dr. W.A. Burney of New Albany, Indiana.
Dr. Burney, a remarkable man in his own right, was born May 11, 1846, in
Dublin, Indiana, the son of John Henderson Burney and Elizabeth Mitchell,
originally from Guilford County, North Carolina, but raised in Indiana. In
1864, in the Union Army at Indianapolis, he was listed in the 28th U.S.C.
Volunteers Co. F as a private. He continued in service until June 24, 1865,
and was honorably discharged.
Dr. Burney was present at Lee’s surrender to Grant at Appomattox. After
his discharge, he moved to Canada, where he worked in a grocery store
and continued his education. In 1867, he returned to New Albany and
practiced his trade as a plasterer. In early 1868, Burney moved to Kansas
(Continued on page 20)
February 2013
19
Appendix I
Church of Our Merciful Saviour (Fig. 3)
This is the Episcopal church at 473 S. 11th St., on the northeast corner of
Muhammad Ali Boulevard (Walnut Street).
The Fitzbutlers were one of four families that supported this church in its
early years. On the east wall is a bronze plaque with Drs. Henry and Sarah
Fitzbutler’s names, honoring their endowment of the church. There also is
a large stained glass window above the altar on the south wall. The original
window was donated by Dr. Prima Fitzbutler in honor of her parents at the
time of their deaths. The current window has replaced the original window.
When the Fitzbutlers moved to Louisville in 1872, construction had
begun on the church and they were early contributors. An endowment
fund given long ago by Prima and others honors the Doctors Fitzbutler
and still furnishes money for the church’s operating expenses.
Fig. 2 Mary Fitzbutler Waring (middle first row), Fitzbutler’s daughter. From
Scott’s Official History of American Negro in WWI, Emmet J. Scott, Chapter 28,
photo 13.
(Continued from page 19)
City to practice his trade and to further his education. Later that year, he
graduated from Central School in Buffalo, New York, only to return to
Indiana to study medicine with his preceptor, Dr. S.S. Boyd of Dublin,
Indiana, eventually graduating in 1879 from the Long Island Hospital
School of Medicine.
Appendix II
The Fitzbutler Humanitarian Award
at the University of Louisville
This is an annual award funded by the Student Government and the Dean’s
Office, whose recipient is decided by medical students. Dr. Bart Spurling, a
medical student in 2001, and Dr. Leah Dickstein, a retired medical school
professor, initiated the Fitzbutler award. The award honors a physician who
has contributed most to the humanitarian aspects of the medical profession.
Finally, following these sojourns, Dr. Burney returned to New Albany in
the fall of 1877 to begin a very large and profitable practice as a consultant
surgeon in the surrounding area. In 1880, he joined the Floyd County
Medical Society and was elected vice president in 1884 and became president
the same year due to the death of the elected president. In 1886, he was
elected a member of the New Albany City Board of Health. In addition to
all these duties, he and William Octah Vance published a newspaper, The
Weekly Review, for the local African American community from 1881 to
1883. He also was a contributor to the Ohio Falls Express, the newspaper
published by William Henry Fitzbutler across the Ohio River in Louisville.
Over the years, many awards and honors came his way. His office and
residence was at 111 E. Elm St. in New Albany until 1906, when he retired
and moved to San Diego, California, where he died in 1911. His offices in
the Louisville National Medical College included trustee, professor and
dean, 1901-1906 (after the death of Fitzbutler).
The other physician who worked with Drs. Burney and Fitzbutler was
Dr. Rufus Conrad, a Louisville osteopath who went with Drs. Burney and
Fitzbutler to petition the Kentucky State Legislature for the right to open
a medical school. No other biographical data is available on Dr. Conrad.
Fig. 3 Church of Our Merciful Savior, endowed by the Fitzbutler family,
473 S. 11th St.
20
LOUISVILLE MEDICINE
Appendix III
The Fitzbutler Jones Medical Society
Award, University of Michigan
The Fitzbutler Jones Society is an organization of African American
University of Michigan medical students. The group honors African
American students and raises scholarship funds. Sofia Bethena Jones was
the first female African American graduate of the University of Michigan
College of Medicine. She devoted her life to promoting the health of African
American women. After her graduation from UM College of Medicine in
1985, she joined the faculty at Spelman College in Atlanta and initiated a
nurse training course. She practiced medicine in St. Louis, Philadelphia
and Kansas City during her professional career.
Appendix IV
A Few Bits of Ephemera to Help
Better Refine Henry Fitzbutler’s
Extraordinary Vitality and Existence
In 1875, Fitzbutler backed two black men who attempted to buy theater
tickets to watch a play. They were blocked from purchasing tickets. Fitzbutler
said the Civil Rights Act gave them this right. This was possibly Louisville’s
earliest theater sit-in; a trolley car sit-in took place in 1871. Fitzbutler ran
for the school board and “other elected positions” over a 20-year period
– and lost. He formed the R.B. Elliott Club, a black political organization,
and was very active in all Louisville elections in the 1890s. But he never
was elected to any office – not even the school board.
The “Marse Henry” story: Fitzbutler took on the powerful patriarch
Henry Watterson, the owner, publisher and editor of The Courier-Journal
(Fig. 4). This episode occurred during Fitzbutler’s civil rights activities. In
an article in his (Fitzbutler’s) paper, he refers to a gentleman by the name of
“Marse Henry.” Fitzbutler wrote of him in a derogatory sense, presumably
because of Watterson’s racist attitude. Watterson filed suit against Fitzbutler
and his newspaper, the Ohio Falls Express, demanding $5,000. “Marse
Henry” is a derogatory term for a Southern plantation owner of slaves.
In his newspaper article, Fitzbutler never mentioned Henry Watterson by
name. In a rather clever court defense, Fitzbutler said, “If Henry Watterson
considers himself ‘Marse Henry,’ that’s his problem, not mine.” Fitzbutler
won the lawsuit. Unfortunately, there are no records in the courthouse or
in the newspaper of this event. Whether it was purged after the trial or
this is an apocryphal story is unknown. In any case, it beautifully defines
Fitzbutler’s personality and lifestyle.
Fig. 4 Henry Watterson, owner and publisher, The Courier-Journal, circa 1895.
Appendix V
Key Sites in the Fitzbutler Saga
1891: William Henry Fitzbutler’s home – 1110 W. Madison.
Other members of the Fitzbutler family in Louisville between 1891 and 1909:
• James H. Fitzbutler, son. Clerk at Post Office.
• Home: 1110 W. Madison.
• Marie H. Fitzbutler, daughter. Teacher, Eastern Colored High School.
• Home: 1110 W. Madison.
• Prima Fitzbutler, daughter. Teacher, Western Colored High School.
• Home: 1110 W. Madison.
• Sarah Fitzbutler, wife, MD.
• Home: 1110 W. Madison.
1891: William Henry Fitzbutler. 503 Center (apparently his office).
Church of Our Merciful Saviour, 11th and Muhammad Ali (formerly
Walnut Street).
The Fitzbutler family church, which they helped endow.
LM
Note: Dr. Weiss practices Cardiovascular Diseases with Medical Center
Cardiologists. He is a member of the Innominate Society, Louisville’s medical
history society.
February 2013
21
WE WELCOME YOU
GLMS
would like to welcome and congratulate the following physicians who have been elected
by Judicial Council as provisional members. During the next 30 days, GLMS members have
the right to submit written comments pertinent to these new members. All comments received will be forwarded
to Judicial Council for review. Provisional membership shall last for a period of two years or until the member’s
first hospital reappointment. Provisional members shall become full members upon completion of this time
period and favorable review by Judicial Council. LM
Candidates Elected
to Provisional Active
Membership
Honaker, Joshua Travis
(4233)
Michelle
1930 Bishop Ln Ste 1600
40218
272-5005
Pediatrics 01,09
U of Louisville 98
22
LOUISVILLE MEDICINE
Pratt, Jonathan William
(31368)
220 Abraham Flexner Way Ste
1100
40202
584-3377
Physical Med. & Rehab.
Pain Management
West Virginia U 07
Book review
The Long Walk: Slavery to
Freedom
Judith C. Owens-Lalude
Anike Press, Louisville, 2012
Reviewed by
Elizabeth A. Amin, MD
J
udith C. Owens-Lalude is a Kentuckian by birth
and grew up in Louisville. She is a nationally and
internationally recognized educator. She has
traveled widely, researching the impact of language
and writing on childhood development. She has
taught on the staff of the University of Louisville’s
Delphi Center, the JCPS Life Learning Program and
Bellarmine University’s Continuing and Professional
Studies Program. In 2002, she established the j.
camille cultural academy that primarily focuses on
encouraging women and girls to pursue their writing interests.
Ms. Owens-Lalude lives in Louisville with her physician husband, A.
O’tayo Lalude, MD, a longtime member of the Greater Louisville Medical
Society.
The Long Walk: Slavery to Freedom, Ms. Owens-Lalude’s first novel, is
the culmination of a very personal search for her ancestors in Kentucky.
The novel centers on Clarissa, a young enslaved woman, and her young son
George Henry. The novel opens as Clarissa and George Henry are being
loaded onto a dirty oxcart by their new owner, Ben Mullins. The date is stated
as January 16, 1846. Ben has just purchased the mother and young son at
the auction in the Jefferson County courtyard in downtown Louisville, and
he is now headed back to his farm in Spencer County along the turnpike.
The weather and the journey are miserable in the extreme, as is Clarissa’s
state of mind. Only briefly have we been told that Clarissa is thinking of her
man, Jake, her big boy Toby and her twin girls Mary and Molly, sold off to
different owners at that fateful auction. Not until chapter 15 will we learn
more about Clarissa’s family and her heritage. What we will have learned,
though, by reading about the author and the introductory notes, is that
George Henry – whose age is given as somewhere between 2 and 3 years old
at the time of the auction – is in fact Ms. Owens-Lalude’s great-grandfather
and Clarissa is her great-great-grandmother. Ben Mullins’ 600-acre farm
in Spencer County is where George Henry grew up.
Using this factual information, Ms. Owens-Lalude has created a work
of historical fiction set in the Kentucky of the mid-19th century. She has
peopled her novel with characters so finely drawn that one can see them
in the mind’s eye. Her visits to what was the Mullins property have allowed
her to recreate for the reader the farm and its buildings. The ruts and trails
are evidence of the to-ing and fro-ing of slaves and masters. Life on the
farm is minutely described, the smells, the sounds, the daily tasks, the
nightly woes. For most, escape seems like a dream. The idea of freedom is
pushed to the edges of minds and hearts too full of cares and too aware of
the high price it demands.
When Clarissa and her son arrive at the farm, they are delivered by Ben
to Effie’s cabin. Effie is the oldest female slave and raised Ben from infancy.
Ben maintains a measure of respect for Effie and during her lifetime there
is wood for her fire and adequate food. With Effie’s care, Clarissa and
George Henry slowly recover from their terrible journey. The two of them
are allowed to continue to live in Effie’s cabin along with Little Bo, the
young son of Ben Mullins’ blacksmith. Clarissa takes up her duties at the
big house with the other female slaves. George Henry thrives under Effie’s
care and learns the secrets of her healing potions as he observes the ways
of the menfolk and the duties he will be expected to perform as he grows
older. Life is hard, though everyone tries to stay out of trouble, and all
the hurts and travails flow through Effie’s cabin. It is the only place where
solace can be found – if any exists at all. With advancing age, Effie’s health
declines and Clarissa and George Henry become her caretakers. Effie has
no fears for herself and her one wish – to be buried under the big old red
oak behind her cabin – is known to everyone. Ben will guarantee it.
Clarissa aches to be free. For the 10 years she has been at the farm, she
has thought about it. She has to wait for George Henry to grow strong
enough and old enough to make the walk with her. She, too, needs time
to recover from a serious leg injury inflicted upon her by her mistress in
a fit of rage. During this time, Clarissa’s one possession, an old ragged,
bloodied and repeatedly mended quilt, has been her constant inspiration.
We are told that Clarissa inherited the quilt from her Grandma Alice who
took care of her as a child. Alice had inherited the quilt from her mother,
Mary, who, Alice understood, had been brought from Africa. On one side
are the remembrances of the many women who have added to the quilt
over the years. On the other side is the road to freedom. Clarissa knows by
heart the significance of the north star, the dipper, the drinking gourd, the
river that can only be crossed in winter and other signs to look for along
the way. Clarissa adds her own story to the quilt with scraps of fabric torn
from old clothes.
Effie understands Clarissa’s yearning and explains to her the significance
of the clanging of the blacksmith’s hammer — the sounds she must listen
for on those dark winter nights when the conditions, for those who are
prepared, might be such that escape can be risked. After Effie’s death,
Clarissa starts her preparations with a single-mindedness spurred on by
the fear that another January auction could see her separated from George
Henry and by the fact that George Henry is beginning to question where
(Continued on page 24)
February 2013
23
REFLECTIONS
Teresita Bacani-Oropilla, MD
RETREADING THE RETIRED
B
elonging to the generation of the “young old,” a still-youthful
psychiatrist retired to join her husband who had just been piped out
in style from active naval medical service. There followed three years
of R and R (rest and recreation), learning to dance the tango in Argentina,
visiting old civilizations like China in the East, making pilgrimages in
Europe, doing charity works for the church, helping to write a book and
enjoying what many envision as the ideal retired life. But, they were too
young.
There is so much unharnessed potential that is lost among our retirees.
Not only physicians, but nurses, social workers and other therapists who
have made helping people their line of work, miss their calling. They
would still like to use their talents but are hindered by too many rules and
bureaucracy if they attempt to use them at hours that suit their schedules.
So, at the peak of their experience and expertise, they are let go, or electively
leave because of set rules and regulations that individually are difficult to
surmount at their stage in life.
Her psychiatric clinic co-workers missed her. Besides, the powers-thatbe needed someone to organize a program to gather, treat and house the
chronically mentally ill. These poor souls roamed the streets, inhabited
cubbyholes under the bridge or any place that provided shelter from the
cold and rain, were non-compliant with treatment, and showed up like bad
coins at hospital emergency rooms, or the jail in times of crisis.
It was fortunate that this particular health department recognized the
talents and services that they could squeeze out of their retired doctor and
were personal and flexible enough to make arrangements to have these
accomplished for everyone’s benefit.
These powers-that-be lassoed her back with a grant, giving her a free
hand to run such a program. Two years later, 80 almost-hopeless cases were
permanently housed, being treated regularly at clinics or at home, being
helped by case managers to apply for benefits and some even capable of
holding jobs. Having a home base had turned these patients’ lives around.
It is hoped that some enterprising genius will have the patience to figure
out and make it simpler to retread the retired. They are unmined veins of
gold or just precious nuggets lying around for the picking. L
M
Note: Dr. Oropilla is a retired psychiatrist.
The program continues to hunt for more of these “lost” people, weeding
out the non-mentally ill incorrigibles who make their homes a den of drug
distribution or a fence for thieves. Having accomplished her mission, the
still youngish psychiatrist is back to being retired.
(Continued from page 23)
they are from. This awakens too many memories for Clarissa to ignore.
Mother and son do make their escape, but it is not a given that they
will succeed. The skill of the author and the realism of her storytelling are
such that until Clarissa and George Henry are washed up and rescued on
the Indiana shore of the Ohio River we are not sure what will happen to
24
LOUISVILLE MEDICINE
them. Ms. Owens-Lalude has painstakingly researched her material not
only locally but also spending time in Nigeria, her husband’s home country.
I found her novel to be a compelling read for many reasons. L
M
Note: Dr. Amin is a retired diagnostic radiologist.
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Back to the Future
Mary G. Barry, MD
T
Louisville Medicine Editor
[email protected]
he price of denial is failure. When
individuals do it, “I’ve got to smoke”
produces lung cancer, and “I don’t feel
like exercising” becomes diabetes. “It’s just
heartburn” turns angina into acute MI. “Just one
more” translates into bad news of all kinds, from
30 more pounds to 30 more vodkas to 30 more
days of desperately seeking drugs. Preventable
misery dogs the lives of those in daily denial.
When Congress does it, large parts of the
country suffer. On both sides of the aisle, senators
and representatives deny that they are choosing
power, partisan politics and lobbyist loot over
what we, their constituents, actually need. They
deny that their decisions will be harmful and
instead argue that what should properly be called
“loss of medical care” can be euphemized to
“fiscal responsibility.”
By March 1, the president and our Congress
must decide together if they can come up with
any agreement to target specific spending cuts
to multiple federal programs. If not, then a
mandatory 2 percent cut to these programs
will wreak havoc in many forms. We face this
second fiscal cliff because in August 2011 the
polarized Congress, facing an election year to
come, settled in the Budget Control Act for
pushing important decisions to 2013, when a
new Congress could be tasked. Both sides hoped
that they would win in November 2012 and that
some sort of electoral mandate would simplify
not only their choices, but also the logistics of
fighting such choices through the legislative
labyrinth. Wishful thinking remains a handy,
though equally destructive, form of denial.
By December 2012 nothing had changed.
Only the last-gasp intercession of Vice President
Joe Biden, after weeks of private negotiations
between the president and House Speaker John
Boehner, saved the nation from falling off the
fiscal cliff. The same talks delayed, for the 10th
year in a row, the automatic 27 percent cut in
Medicare’s pay to doctors, the cut mandated by
the hopelessly unfair, ill-designed and outdated
Sustainable Growth Rate formula. The SGR is
a classic case of government double-speak, in
which payments to physicians have been frozen
for a decade, while the cost of providing care to
patients has risen by more than 20 percent. If
there were no large hospital systems employing
doctors, the number of specialists and generalists
who accept Medicare would long ago have
dropped below 50 percent, and the citizens who
have served this country the longest would be the
ones most injured. As it now stands, the SGR cut
has been delayed again for a year, and the monies
to pay for it will come from cuts to hospitals’
inpatient service reimbursement, payments for
medical imaging, payments to dialysis providers
and payments to Medicare private plans.
But the March 1 cuts, called budget
sequestration (automatic cuts to meet the gap
between budgeted money and actual spending),
amount to annual cuts ranging from $10 billion to
$16 billion to Medicare. According to the AMA,
the American Hospital Association estimates
that would cause a net loss in 2013 alone of
almost 500,000 jobs. Defense spending would
fall by 10 percent, and more than 1,200 federal
accounts would face sudden drops, including
health care for the active duty military and for
the VA, research losses at the NIH and a $66
million loss for health insurance exchange grants.
Economic researcher Dr. Stephen Fuller, PhD at
George Mason University, said that the sequester
could cost the country overall 2.1 million jobs,
cut the GNP by more than $200 billion, and send
the country back into recession.
If that fails to worry you, think about Social
Security. In The New York Times of January 6,
professors Gary King and Samir Soneji dissected
the current database that Social Security uses to
estimate its costs and revenues, and our mortality.
You’d think the Three Stooges had made up the
formulae – they’re that bad. For instance, their
chart predicts that in 2028, everyone 55-58 years
old will up and die, while their relatives who
are over 95 will keep on living. Multiple errors
here pointed out would result in an additional
$801 billion of cost to Social Security by 2031,
a cost completely and utterly not anticipated or
budgeted for by our government. If these guys
are as much into denial as our Congress, then
there will be a rapidly shrinking safety net for
the old, the infirm and the disabled. We will
become a country of unpaid medical bills for the
vast majority, as opposed to merely a huge slice
of the population (although naturally members
of Congress will continue to vote themselves the
best health coverage in the land).
The only way through this minefield is straight
talk and stark honesty about why, how much
and which cuts our members of Congress will
inflict on us, because cuts seem inevitable in
the current climate. Doing the least amount of
medical damage is my priority, but who knows
theirs? If the members of the Congress of 2013
allow their denial to exceed both their courage
and their judgment, then patients, doctors,
hospitals, nurses, nursing homes, veterans, the
serving military and the patients who won’t be
helped by research will pay the initial price.
If we plunge back into recession, then the
whole country, in every business sector, will
pay the price. “Failure is not an option,” said
Sir Winston Churchill. “Leadership is solving
problems,” said General Colin Powell. “Failure
is not fatal, but failure to change might be,” said
Coach John Wooden. “It’s time Congress got its
priorities straight,” said Sen. Mitch McConnell. I
may be in denial, but I sure hope Congress can
change. LM
Note: Dr. Barry practices Internal Medicine with
Norton Community Medical Associates-Barret.
She is a clinical associate professor at the University
of Louisville School of Medicine, Department of
Medicine.
Speak Your Mind The views
expressed in Doctors’ Lounge or any
other article in this publication are not
those of the Greater Louisville Medical
Society or Louisville Medicine. If you
would like to respond to an article in
this issue, please submit an article or
letter to the editor. Contributions may
be sent to [email protected] or may be
submitted online at www.glms.org.
The GLMS Editorial Board reserves the
right to choose what will be published.
February 2013
27
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LOUISVILLE MEDICINE
Doctors’ Lounge
How We Got to Where We Are
Kenneth C. Henderson, MD
T
he changes that
have occurred
in the private
practice of medicine in
my lifetime have created
the future in which we
find ourselves. I would
like to briefly touch
on what I consider
the operative events.
In my view, these events include third-party
payment for medical services, the operation and
management of hospitals by non-physicians, the
subspecialization of medicine post-World War II,
Medicare and Medicaid, DRG reimbursement,
cost shifting of governmental programs to the
private sector and Obamacare. The best way to
approach this complex task may be to reduce
these multifaceted issues to their simplest form.
Form usually follows function in most complex
systems. It turns out that many form issues in
the private practice of medicine in this country
are financial, and therefore follow funding. In
my opinion, the end of the private practice in
this country began and continues to end with
third-party reimbursement.
In the 1930s, the reimbursement concept
arose in this country to separate the payment for
medical services from the person who receives
the services to another responsible party. The
third-party insurance company was placed at
primary financial risk instead of the patient or
the recipient of medical services. The consumer
of medical services was no longer obligated to
pay directly for the charges or the cost of medical
care. Unfortunately, this third-party system
of payment for health care did not produce a
responsible consumer or guarantee a responsible
physician or provider of services.
Physicians and surgeons in great numbers
volunteered or were drafted into military
service during WWII. In their absence, a new
group of providers of health care called hospital
administrators filled their vacant hospital
ownership and management roles. Public and
private hospitals became a business as opposed
to the previous charity provider of health care
services. Church denominational and physician
hospital ownership began to decline. All for-profit
and not-for-profit institutions were required
to make a profit margin to both support their
mission and to survive in this new marketplace.
All hospitals became fiscally the same except for
the form in which they distributed their earned
margins to their shareholders.
The demands for medical and surgical care
during WWII supported the development of
specialty practice. When the military doctors
came home to this new health care environment,
the available reimbursement opportunities
supported the growth of subspecialty care as
well. Subspecialty care and its reimbursement not
only insulated the patient from direct payment
for services rendered, but in some cases from
the provider as well. Based primarily on both
hospital and physician reimbursement issues,
hospital medical care later became separated
from private clinical office practice. The private
doctor-patient relationship no longer related
directly to the continuity of diagnosis, treatment
and follow-up. The growing complexities of
medical care in the office setting and the cost
of solo practice led to its decline and eventual
extinction in this country.
In 1965, Medicare and Medicaid became a
reality. This new concept of an infinite demand
placed upon a finite resource was now the law
of the land. Citizens for the first time became
entitled to health care based on age, means tested
economic status or disability. The full impact
of these two measures is yet to be determined.
Dual eligibility without the provider’s ability to
balance-bill Medicaid is the current health care
financing dilemma related to a growing number
of seniors and disabled persons. Patients, who
are entitled to health care related to age, financial
status or medical disability, may also currently
have a right to health care. Soon all of our patients,
citizens or not, may enjoy the right to health care.
The advent of Medicare and Medicaid changed
the business model of health care by reversing
the supply and demand relationship. There is
substantial evidence that the demand for health
care services is directly related to the supply of
physicians in that geographic location. Therefore,
it is no surprise that there is currently a demand
for more physician providers. I suggest that
the acquiescence of physicians to being called
“providers” has come full circle. In my opinion,
medical care providers have a much higher
medical-legal risk than do physicians who are
acquainted with their patients. Physicians who
blatantly advertise likely represent themselves
as providers.
The original objective of DRGs was to
develop a classification system that identified
the “product” that an inpatient received in
the hospital. DRGs also served to identify the
“products” that a hospital provides. Since 1983,
DRGs have been used to determine the amount
Medicare and later Medicaid would pay the
hospital for each “product.” The end game was
to replace the “cost-based” reimbursement of
hospitals that had been used up to that point in
time. Patients became products purchased by the
government from vendor providers.
The open-ended use plus under-funding of
Medicare and Medicaid created massive cost
shifting in hospitals and in private medical
practice billing. In the current environment,
hospitals do not bill charges but instead most
must rely on a negotiated percentage of cost.
All payers and providers strive to follow the lead
of the federal government by cost shifting in a
financial environment currently containing no
charge or cost payers. The end result is a loss of
revenue and increased debt for all concerned.
The cost and benefit of “The Patient Protection
and Affordable Care Act” is unknown and yet
to be determined. A preliminary study done in
the Northwest on small numbers of patients
indicates that there will be a 25 percent increase
in utilization of health care services when this
act is in force. However, recipients of Obamacare
did not utilize emergency services at a higher
rate than did individuals with other types of
insurance. Members with this new type of
financing system were less depressed in general
and were reported to be more satisfied with their
health care provision than were their controls.
This comprehensive law was passed in the same
grand tradition as Medicare and Medicaid
without knowing what the law really says, what
the provisions will mean when the regulations
are written, or what it may cost now, and in the
future. This massive new entitlement may be the
final governmental intrusion into health care
provision and financing before the more formal
program of single-payer is put into place. It is
clear that we are following the time-honored
practice of our European neighbors of socializing
medicine at a time when we can least afford it. It
seems to this observer that the private practice of
medicine has been essentially forced to ride the
(Continued on page 30)
February 2013
29
Doctors’ Lounge
(Continued from page 29)
governmental tiger’s back of reimbursement for almost 50 years, and as
a result has wound up in his stomach. Did private practicing physicians
really have, or do they presently have, any real choices? In my opinion,
the majority of practicing physicians may have simply followed, or gone
along with, the pervasive mood of the country that is based on taking
more and giving back less.
The current political and socioeconomic climate in America,
demonstrated by the reelection of President Obama, will create for the
first time a new middle class in this country that is dependent upon the
federal government. Physicians and their families have become the upper
middle class members of that rapidly developing group. LM
Note: Dr. Henderson is a clinical professor at the University of Louisville
School of Medicine, Department of Pediatrics.
Physicians in
Print
Downard CD, Renaud E, St Peter SD, Abdullah F, Islam S, Saito
JM, Blakely ML, Huang EY, Arca MJ, Cassidy L, Aspelund G; For
the 2012 American Pediatric Surgical Association Outcomes
Clinical Trials Committee. Treatment of necrotizing enterocolitis:
an American Pediatric Surgical Association Outcomes and
Clinical Trials Committee systematic review. J Pediatr Surg. 2012
Nov;47(11):2111-2122. PubMed PMID: 23164007.
Scheker LR, Martineau DW. Distal radioulnar joint constrained
arthroplasty. Hand Clin. 2013 Feb;29(1):113-21. PubMed PMID:
23168033.
Weaver JL, Bradley CT, Brasel KJ. Family engagement regarding the
critically ill patient. Surg Clin North Am. 2012 Dec;92(6):1637-47.
PubMed PMID: 23153887.
NOTE: GLMS members’ names appear in boldface type. Most of
the references have been obtained through the use of a MEDLINE
computer search which is provided by Norton Healthcare Medical
Library. If you have a recent reference that did not appear and
would like to have it published in our next issue, please send it to
Ellen Hale by fax (502-736-6339) or email ([email protected]). LM
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