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The Pharos/Winter 2008 3

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Officers and Directors at Large 

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Editorial 

The song goes on 

Robert Atnip, MD 

The author (AΩA, University of Alabama, 1976) 

is a member of the board of directors of Alpha 

Omega Alpha. 

am an academic vascular surgeon, a senior fac- 

I ulty member at a University Hospital, a mentor 

of medical students and residents, and a teacher 

of professionalism. My own lessons in professionalism 

came while in medical school, but 

not in any classroom or book. I don’t recall the 

word even being spoken during those four years 

(1974–78). No doubt some of those who modeled 

it for me were physicians, but in retrospect, the 

most influential person was no doctor, but a musician. 

That music has the power to pervade the human experience 

may be a mystery, but it is no secret. Music is as universal 

as the human senses, and as vital. As a form of human 

expression, music is at the same time both elemental and 

transcendent. It is one of humanity’s finest gifts to itself, a 

gift that to our lament cannot be as readily celebrated in The 

Pharos as the visual and literary arts. Music is not for speaking 

or writing. Music is ineffable emotion, a sequence of nameless 

swells and surges that defy the bounds of speech. Our voices 

are put to much better use making music than describing it 

and, in like manner, professionalism is much less a creed to 

be discerned and codified than it is a craft to be realized and 

enacted. Therein lies the basis for choral music to instruct me 

in the finer points of professionalism. 

Nowadays, professionalism is a paramount concern to the 

health care world, but it was not always so. “Professionalism” 

was irrelevant to academia prior to 1965. My search for “professionalism” 

as a key word in OLD_OVID (1947–65) returned 

only the red-lettered retort, “Unable to match with any subject 

heading.” In the fifteen years that followed, “professionalism” 

made its debut with 180 appearances, the majority in nursing 

journals or, oddly enough, in the dentistry literature. But only 

in the last thirty years has “professionalism” gained enough 

traction to merit the eight subject headings to which it now 

maps in OVID, the thousands of publications devoted to 

probing its obliquities, or the several awards and grants now 

bestowed in its name by prestigious societies such as ours. 

This logarithmic progression is extraordinary for a concept 

that acquired its name as long ago as the fourteenth 

century. Toward the end of the so-called Dark Ages, the word 

“profess” appeared among religious orders with the meaning 

“to take a vow,” or “to declare [a belief] publicly.” This definition 

and related word forms served adequately, perhaps even 

admirably, throughout all subsequent ages of history and into 

modern times. Only in the post-Modern era has the simplicity 

and sparse eloquence of these phrases come to be viewed as 

inadequate for today’s professionals. But I think what may be 

lacking is not the words, but the . . . music! 

And so in the mid-1970s, modern professionalism’s “early 

years,” I came upon my unwitting mentor-to-be while in medical 

school in Birmingham, Alabama. Having enjoyed music 

and singing as a youth, and wanting some activity 

beyond the confines of studying anatomy 

and physiology, I met JWS, the organist and 

choirmaster at a local church. The meeting 

was happenstance, but serendipity has never 

worked any better magic than this. I joined and 

sang in his choir, as much an amateur singer as 

I was a fledgling doctor. But the experience was 

profound, a turning point for me, and a revelation 

of new worlds. For the next three years this 

choir became as important to me as my medical 

education. Under the direction of JWS, or more 

properly, under his spell, I learned what it is to 

“profess” choral music: to blend many voices into one sound, 

the music built on every voice, but ever greater than any one 

alone; to tune each voice and phrase toward perfection; to purify 

many harmonies into one great and coherent beauty. The 

sounds and the music were exquisite, many of them recorded 

at that time, and still inspiring to me more than thirty years 

later. To listen to them is to understand the fruits of professionalism 

and, moreover, to discern therein a startling similarity 

to what we seek to do in the individual and corporate acts 

of medical practice. 

This connection of music to medicine may seem obscure to 

some, and self-evident to others. But I contend that the truths 

learned in the making of music are the same truths that we 

who profess medicine must teach our students, and re-affirm 

for ourselves: competence, discipline, determination, focus, 

artistry, the seeking of common goals, the drive to excel, the 

ability to lead and to follow, and one perhaps not as obvious: 

aesthetics—the presence of beauty and inner harmony in what 

we do. I do not equate humanism with professionalism, but 

they have much in common. They are separate yet inseparable, 

linked by a common need for each to nourish the other. I was 

most fortunate at a remarkable and formative time of my life to 

be in a milieu suffused with an abundance of each. To those who 

cleared this path for me, I owe an inexpressible debt. They knew 

that professionalism has not only a body, but a soul. 

It was never my destiny to become a professional musician, 

but I am delighted to be a musical professional. Music may not 

have made me a better medical scientist, but it has made me a 

better physician. Vita brevis, ars longa. To the extent that we 

are true to our identity as healers, then we must—in concert 

with advances in science and technology—remain centered on 

the collective humanity of patient and physician, which in all 

its forms is our common bond. 

JWS retired in 1998, and died in 2007 of Parkinson’s 

disease. He and Ted Harris were much alike. They were extraordinary 

persons who led others to perform beyond expectations, 

and showed all those around them that exceptional 

effort yields uncommon rewards. These two men were called 

into different professions, but each understood precisely what 

it meant to “take a vow.” and to “declare publicly.” It is to the 

betterment of humankind that each lived, and thus our own 

joyful duty to ensure that their song goes on. 

The Pharos/Winter 2011 1

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1 Editorial 

The song goes on 

Robert Atnip, MD 

35 

42 

46 

Health policy 

Our health care system is not 

broken—it’s obsolete! 

Jordan J. Cohen, MD 

The physician at the 

movies 

Peter E. Dans, MD 

Wall Street: Money Never 

Sleeps 

Conviction 

Reviews and reflections 

The Checklist Manifesto: How to 

Get Things Right 

Reviewed by David A. Bennahum, 

MD 

The Jump Artist 

Reviewed by Jeffrey L. Ponsky, 

MD 

Henry Kaplan and the Story of 

Hodgkin’s Disease 

Reviewed by William M. Rogoway, 

MD 

The National Institutes of Health: 

1991–2008 

Reviewed by Jack Coulehan, MD 

51 Letters 

AΩA NEWS 

38 2010 Alpha Omega 

Alpha Robert J. Glaser 

Distinguished Teacher 

Awards 

52 

DEPARTMENTS 

National and chapter news 

Instructions for Pharos Authors 

Leaders in American Medicine 

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ARTICLES 

Visionary art? 

Shamans, Charles Bonnet, and the cave 

paintings 

Henry N. Claman, MD 

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Going first 

Susie Morris, MD, MA 

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The monsters of medicine 

Political violence and the physician 

Amanda J. Redig, MD, PhD 

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Breaking bad news 

What poetry has to say about it 

Dean Gianakos, MD 

From rabbits to the 

League of Nations 

Early standardization of the insulin unit 

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Barry Fields, MD 

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On the cover 

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See page 4 

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The Pharos/Winter 2008 3 

11 Room K461 

Mary Krane Derr 

15 Musings on an Attic 

Tetradrach 

Alvin J. Cummins, MD 

23 Sestina on Limb- 

Lengthening Surgery 

Jenna Le 

27 Heartache 

John Allan, MD 

34 The Defendant 

H. Harvey Gass, MD 

36 Memento Mori 

Michael R. Milano, MD 

37 

40 

POETRY 

Reading a Review 

H. J. Van Peenen, MD 

Winning Poems of the 

2010 Write a Poem for 

This Photo Contest 

Benevolent Instructions 

David R. Downs, MD 

Commencement 

David F. Dozier, Jr., MD 

Adolescent Choices 


XX Ageless 

Thomas Atwater 

INSIDE 

BACK 

COVER


Shamans, Charles Bonnet, and the cave paintings 

Henry N. Claman, MD 

The author (AΩA, University of Colorado, 1979) is 

Distinguished Professor of Medicine and Associate Director 

of the Medical Humanities Program at the University of 

Colorado, Denver. He is a member of the editorial board of 

The Pharos. 

Paleolithic art, particularly the cave paintings of 

Southwestern Europe, is a source of amazement still. 

These images haunt many of us, not only because of 

their beauty and their great age, (stretching back over 30,000 

years), but because they are one of the few entrées we might 

have into the lives of our ancestors, who are among the great 

masters of artistic creativity, and about whom we know very 

little apart from this art. The study of this art continues to 

expand as art historians, anthropologists, archaeologists, and 

natural history scientists try to unravel the mystery of what 

the art “means” and why it was made. There is a wide divergence 

in opinions on this subject, and some experts have actually 

warned against further attempts to discover “the meaning” 

of paleolithic art. However, it is hard to abandon the quest, 

and this contribution attempts to call attention to another 

possible avenue of interpretation, relying on new neurophysiological 

concepts. 

The art was produced in profusion, and consists mainly 

of paintings and engravings, as well as sculpture in the round 

and in bas-relief. The early members of our genus and species, 

Homo sapiens sapiens, were hunter-gatherers. They lived in 

small nomadic bands of perhaps fifty to one hundred people, 

in a mostly egalitarian society. They made stone tools and had 

fire but made neither cloth nor pottery. Half of the art is in 

limestone caves and half is outside, mainly in shelters. Those 

in the caves are better preserved and have received the most 

attention. 

What was depicted? Many of the most prominent images 

are of animals, mainly large ones such as horses, bisons, bovids, 

lions, rhinoceri, reindeer, and so forth. Rarely seen is a 

small animal such as a rabbit or owl. The large animals are almost 

always shown in profile, in big or small images, complete 

or fragmentary. When I was lucky enough to be in the Great 

Hall of the “original” Lascaux cave (now closed to the public) 

I felt that I was engulfed in the midst of a huge stampede. It 

was an overwhelming experience of power and speed. In addition 

to all the animal depictions, however, there are a lesser 

number of human figures, or parts of humans, including positive 

and negative hand prints and images of (mainly female) 

genitalia. Intact humans are rare and almost always masked. 

There is a also very large number of enigmatic forms that are 

Man looking at prehistoric cave painting of animals. 

Photo by Ralph Morse//Time Life Pictures/Getty Images. 

4 The Pharos/Winter 2011



Bulls, horses, deer, Lascaux Cave, France, about 17,000 years ago. 

© The Bridgeman Art Library/Getty Images, Inc. 

difficult to describe, called abstract symbols, or designs, and 

so forth. These range from simple colored dots or strokes or 

carved shallow cupules in the stone to complex grid-like paintings 

or engravings. Some of these geometric designs have been 

termed “tectiforms” (roof-like) although there is no evidence 

that there were any roofs. 

These abstract forms, because of their refusal to give up 

their secrets, have been rather neglected by historians, at least 

in comparison with the more flamboyant animal images, to 

say nothing about the carved and decorative mostly female 

statuettes (misnamed “Venus” figurines). These abstract images 

can give us additional clues as to the production of the 

art in general. 

Deciphering the “meanings” of paleolithic art 

Analyzing the art is a formidable task, and the process continues, 

with various schema current at one time or another. 1,2 

Art for art’s sake—During the period when paleolithic art 

was known mainly from small carved and engraved bones and 

antlers, the genre was regarded as aesthetic and playful. This 

approach has been largely abandoned. 

Sympathetic magic—When the great cave paintings of 

Altamira and Lascaux were discovered, the depiction of large 

hunted animals, often with spears or arrows in them, led 

to the concept of “hunting magic” or “sympathetic magic.” 

According to this model, emphasized by Sir James Frazer in 

The Golden Bough, hunter-gatherer people made pictures of 

their prey to remember yesterday’s foray or to imagine and 

ensure the success of tomorrow’s venture. 3 This interpretation 

has its advocates today. 

In the structuralist approach, pioneered by André Leroi- 

Gourhan, the images were subjected to sophisticated measuring 

and counting techniques that led to interpretations of the 

arrangement of art in symbolic terms, emphasizing quantitative 

correspondences and dualistic contrasts, e.g., male versus 

female symbols, red versus black images and horses versus 

bison. 4 The ultimate rationale may have been to promote fertility 

in both human and animal worlds, which were, of course, 

extremely interwoven and interdependent in hunter-gatherer 

societies. Many find this approach arcane. 


Emphasis currently centers on what has been called the 

mystico/religious interpretation, in which spiritual concepts 

are invoked and shamans are considered to be closely involved 

in art production and corresponding ritual activities. This approach 

is largely influenced by David Lewis-Williams and his 

studies of the rock art of the San People of South Africa. He 

applies this interpretation to paleolithic and neolithic art. 5,6 

R. Dale Guthrie dismisses this concept in favor of a natural 

history/evolutionary schema, placing the art in the larger context 

of environmental influences and linking artistic behavior 

to our evolutionary past. 2 

None of these approaches has unanimous scholarly approval. 

Indeed, experts are beginning to doubt that we will 

ever uncover “the meanings.” Yet the desire to do so is irresistible, 

and so let us turn to a particular image. 

The shaman of Lascaux 

This astonishing figure, discovered when the cave itself 

was opened in 1940, should have brought the idea of shamans 

to the fore right away. It is unique, being the only complete 

“The Shaman of Lascaux,” about 17,000 years ago. A bird-headed and -handed ithyphallic stick man in front of a wounded bison, 

pierced by spears, with entrails spilling out. The Shaman has a bird-head staff. © Charles and Josette Lenars/CORBIS. 



Abstract “designs” (with perhaps a positive handprint)—a montage of items from caves in what is now France and Northern Spain, about 

17,000–10,000 years ago. Illustration by Jim M’Guinness. 

human image in the cave. It is far from the stampede of animals 

I mentioned above, and is placed on the wall at the bottom 

of an eighteen-foot “well” or “shaft”—curiously isolated 

and difficult to access. Considering the general profusion of 

animals on the walls and even the ceilings, the shaman is solitary 

and secluded. This stick-figure of a man, drawn poorly in 

outline, has a bird’s head and bird’s hands, with a bird-headed 

scepter at his side. He is obviously male, with a prominent 

erect penis (the “ithyphallic position”)—a symbol of power. 

He is either upright or leaning, depending on the angle of the 

photograph. He is next to a well-drawn bison that is looking 

over its shoulder at a gaping wound in his flank with his intestines 

falling out. There are two spears in his side. 

I agree with Joseph Campbell that he is a shaman, part 

human, part bird. 7 Including the bison, the ensemble must 

be the oldest narrative visual scene in human history. Yet it 

is profoundly ambiguous. What is the story? What is the shaman’s 

role vis-à-vis the bison?—a healer?—a hunter? Is he in a 

trance? Is he drugged? Why is he ithyphallic? 

Nevertheless, he is not the only masked magic man in the 

caves. There is the masked and antlered “sorcerer” man in the 

Trois Freres cave, and others as well. 


The abstract designs—providing clues? 

Returning to the abstract images, it is understandable 

that they have received less attention 

than those of animals and people. They are very 

numerous, but are often small and have proved 

opaque to interpretation. Perhaps the most attentive 

scholar has been S. Giedion, the Swiss 

historian. He believed that “symbolization is the 

key to all paleolithic art,” 8p79 and he points out 

that the “great abstract symbols which have no 

counterpart in the world of reality” are often 

“hidden away in the most inaccessible parts of the 

caverns.” 8p241 While the meanings of female pubic 

triangles and vulvas as well as penile images are 

easy to understand in terms of fertility and procreative 

symbolism, this is not true of the abstract 

designs. What then? 

Lewis-Williams thinks they are hallucinations, 

conjured up by shamans in trances, which 

provided powerful spiritual experiences of the 

San People’s three-tiered cosmos, and which 

were later displayed as rock art—petrographs and 

petroglyphs. 5 This is a concept worth considering. 

The hallucination approach 

This is a complicated subject indeed. The 

very long list of conditions associated with visual 

hallucinations includes ocular disorders, CNS 

disorders, toxic disturbances, psychiatric illnesses, 

and “normal” persons. 9 In the context of 

images hidden in large, dark caves, it is of interest 

that a number of the hallucinogenic scenarios 

in “normal” persons involve forms of sensory 

deprivations. These include dreams, hypnagogic 

and hypnotic states, sleep deprivation, and simply 

blindfolding. To this list should now be added a 

relatively new syndrome. 

The Charles Bonnet Syndrome 

This condition has a curious history. 10 Bonnet, 

born in 1720, was a Swiss/French naturalist and 

philosopher. (He deserves more recognition for 

his experiments in wood lice, establishing the phenomenon 

of parthenogenesis.) In 1760 he wrote a book in which he 

described how his eighty-seven-year-old grandfather lost his 

vision to cataracts and developed hallucinations “of men, of 

women, of birds, of carriages, of buildings.” Interestingly, the 

same later happened to Bonnet himself. 

The situation lay fallow until 1967 when George de Morsier 

proposed the term Charles Bonnet Syndrome (CBS) to describe 

the presence of recurrent visual hallucinations generally 

in persons with impaired vision but without clouded 

sensoria. Such persons are often elderly. Since then, the 

syndrome has been increasingly recognized and studied. 11 It 

is present in perhaps ten percent of the elderly with impaired 

vision. 

The hallucinations experienced are varied and often complex, 

in contrast to “unformed” hallucinations such as spots 

and flashes of light, which are termed “phosgenes.” They include 

animals, humans, geometric figures, and designs, similar 

to what is seen in the caves. They are in color or black and 

white, and are often brilliant and clear, contrasting with the 

poor “regular” vision of the subjects. They frequently fade or 

disappear as sight deteriorates further. The commonest cause 

of CBS in our society is age-related macular degeneration, 

but it has been reported in the young and also in association 

with pathological changes from the eye to the visual cortex. 

To diagnose CBS, there should be no evidence of delirium, 

dementia, psychosis, or intoxication. The visions are not felt 

to originate in the eye itself. 11 

It is well-known that hallucinations with a normal sensorium 

may be provoked or aggravated by a number of factors 

including sensory deprivation, the hypnagogic state, physical 

or auditory stimuli, extreme pain, etc. 9 The same is true of 

CBS. 

The pathophysiology of CBS—the release 

phenomenon 

The idea that hallucinations may be caused by “irritative” 

foci in the brain derives by analogy from John Hughlings 

Jackson’s analysis of focal epilepsy. This explanation for hallucinations 

has generally given way more recently to the 

work of David Cogan 12 (who also refers to Louis J. West 13 ) 

that suggests that hallucinations of various types are instead 

“release phenomena.” Interestingly, this concept also derives 

from Hughlings Jackson, who developed the general concept 

that higher functional layers of the CNS normally inhibit 

lower layers. When, however, the higher layers are themselves 

impaired, normally suppressed activities of the lower layers 

are released. (Consider the spasticity of the pithed frog or 

alcohol-induced misbehavior.) In the visual system, normal afferent 

stimuli dampen or block the spontaneous “endovision” 

activities. But when, in some people, blindness “deafferents” 

the visual pathways, the spontaneous endovisual activities take 

over, leading to hallucinations. In fact, fMRI studies support 

this concept. 14 

Hallucination manifestations 

Many studies of hallucination point out similarities in the 

images that are seemingly independent of the cause and the 

culture involved. Heinrich Klüver, with an extensive experience 

primarily associated with mescal studies, wrote of three 

stages of evolving hallucinations 15 : 

Type I—“Form constants,” namely geometric abstract designs 

described as gratings, lattices, fretwork; also tunnels, 

alleys, vessels; and spirals. 



Type II—Familiar objects such as people, faces, animals, 

landscapes. 

Type III—Fabulous landscapes and monstrous forms. 

Hallucinations in paleolithic art? 

The above outline of selected aspects of paleolithic imagery 

suggests that the abstract designs may not in fact be symbols. 

In fact, it was never clear what they might have symbolized. 

Instead they may be graphic representations of visual hallucinations—the 

“form constants” of Klüver’s Stage I. 

There are a number of circumstances that support this 

hypothesis, circumstances that reinforce each other: 

1. Many of the paintings and engravings are made in very 

deep caves, where the darkness (and difficulty of access) is 

daunting. Their very locations, even if dimly illuminated by 

the uncertain flickerings of oil lamps and flambeaux, would 

have been situations of considerable sensory deprivation. 

2. Any degree of partial visual impairment—from disease, 

CBS, trauma, etc.—would only heighten the deprivation. 

3. The possible (if not probable) use of psychedelic substances 

in trances or ceremonies would further the tendency 

to hallucinate. (What indeed was going on with the shaman 

of Lascaux?) 

4. The role of dreaming in gaining access to mental imagery 

should not be discounted. 

Conclusion 

Does the “hallucination approach” to the abstract designs 

give us any insight into the most intriguing problem of 

paleolithic art—the “meaning(s)” of the animal portrayals? 

Certainly, in a hunt-oriented culture dependent on animal 

protein for sustenance and perhaps also on animal skins for 

protection and disguise, it is not surprising to see those images. 

But it is not so simple. We are not seeing the mere paleolithic 

dinner menu, as many of the animal species portrayed 

were too dangerous to hunt and were, to judge from bony 

remains, not eaten. Nonetheless, the images of these animals 

demonstrate power, when one considers their numbers, their 

sizes, their detailed and imaginative depictions, their often 

secluded locations, and their artistic skill. The purposes were 

probably multiple, including messages such as “come here 

and nourish us” as well as “stay away—you’re dangerous” (the 

apotropaic or “warding off evil” strategy). 

The shaman of Lascaux confronting the wounded bison 

(risking being wounded himself in the process) would seem 

to provide a conceptual and possibly material link between 

the human/animal world and the realm of the spirits. It would 

be he who, via his trances (however induced), experienced 

that spiritual world and then “returned” to inspire the artists, 

perhaps including himself. In this context, these extraordinary 

portraits would reflect not only actual animals but thoughts, 

wishes, memories, or dreams or Type II Klüver hallucinations 

of them as well. 

E. H. Gombrich, the outstanding art historian, remarked 

that “the further back we go in history . . . the less sharp is 

the distinction between images and real things; in primitive 

societies, the thing and its image were simply two different . . . 

manifestations of the same energy or spirit.” 16p155 

Perhaps these artists perceived no differences at all! 

References 

1. Bahn PG, Vertut J. Journey Through the Ice Age. Berkeley 

(CA): University of California Press; 1997. 

2. Guthrie RD. The Nature of Paleolithic Art. Chicago: University 

of Chicago Press; 2005. 

3. Frazer JG. The Golden Bough: The Roots of Religion and 

Folklore. New York: Avenel Books; 1981. 

4. Leroi-Gourhan A. The Dawn of European Art: An Introduction 

to Palaeolithic Cave Painting. Cambridge: Cambridge University 

Press; 1982. 

5. Lewis-Williams D. The Mind in the Cave: Consciousness and 

the Origins of Art. London: Thames and Hudson; 2002. 

6. Clottes J, Lewis-Williams D. The Shamans of Prehistory: 

Trance and Magic in the Painted Caves. New York: Harry N. 

Abrams; 1998. 

7. Campbell J. The Masks of God: Primitive Mythology. New 

York: Penguin Books; 1976: 300–302. 

8. Giedion S. The Eternal Present: A Contribution on Constancy 

and Change. New York: Bollingen Foundation; 1962. 

9. Cummings JL, Mega MS. Chapter 13: Hallucinations. In: 

Cummings JL, Mega MS. Neuropsychiatry and Behavioral Neuroscience. 

Oxford: Oxford University Press; 2003: 187–99. 

10. Hedges TR Jr. Charles Bonnet, his life, and his syndrome. 

Surv Ophthalmol 2007; 52: 111–14. 

11. Menon GJ, Rahman I, Menon SJ, et al. Complex visual hallucinations 

in the visually impaired: The Charles Bonnet Syndrome. 

Surv Ophthalmol 2003; 48: 58–72. 

12. Cogan DG. Visual hallucinations as release phenomena. Albrecht 

v Graefes Arch klin exp Ophthal 1973; 188: 139–50. 

13. West LJ. Chapter 9: A Clinical and Theoretical Overview of 

Hallucinatory Phenomena. In: Siegel RK, West LJ, editors. Hallucinations: 

Behavior, Experience, and Theory. New York: John Wiley & 

Sons; 1975: 287–311. 

14. ffytche DH, Howard RJ, Brammer MJ, et al. The anatomy 

of conscious vision: an fMRI study of visual hallucinations. Nature 

Neurosci 1988; 1: 738–42. 

15. Klüver H. Mescal and Mechanisms of Hallucinations. Chicago: 

University of Chicago Press; 1966. 

16. Sontag S. On Photography. New York: Farrar, Straus and 

Giroux; 1977. 

The author’s address is: 

Allergy/Immunology B164 RC2 

12700 E. 19th Avenue, Room 10100 

Aurora, Colorado 80045 

E-mail: henry.claman@ucdenver.edu 


R O O M 

For Adrian Felix Carroll 

Tiny blue open-backed gown 

that never quite ties back up. 

Tiny blood pressure cuff, 

thermometer cuff. 

Tiny vital signs. 

Tiny primary color-coded IVs, 

tiny calibrated pumpings 

of opiate, anxiolytic, total 

parenteral nutrition with adjusted 

lipids to avert liver failure. 

Tiny blood transfusion. 

Tiny ostomy bag. 

Tiny liquid rolling crescents 

of bluegreen wake-eye. Tiny 

flickering visits with. 

Tiny answers 

from hall-snagged docs. 

So what is there here 

to miniaturize away 

this innards-clawing, hemorrhagic 

fever of grief? 

Mary Krane Derr 

Mary Krane Derr is a poet, writer, musician, 

chronic disease patient, and fourth-generation 

South Side Chicagoan. Her address is: 6105 South 

Woodlawn #3S. Chicago, Illinois 60637. E-mail: 

marykderr@aol.com. 

Illustration by Jim M’Guinness 


�� 

Susie Morris, MD, MA 

The author is a resident in Psychiatry 

at the University of Southern 

California. This essay won honorable 

mention in the 2010 Alpha Omega 

Alpha Helen H. Glaser Student Essay 

Competition. 

She has it so easy. 

I guess this shouldn’t be the 

first thing that comes to mind 

when I look at her. It’s about 12:30 in 

the afternoon. She is supine, dare I say 

resting? I feel uncomfortable calling 

her comfortable because I wonder if 

she’s already dead. I wonder if she died 

yesterday after she stopped speaking to 

us. I peel her eyelids back, and they are 

dilated. But she is propped here nonetheless, 

her heart still beating faintly 

through layers of fat under my stethoscope. 

At this point, it’s a stupid ritual. 

Her brother and niece are here looking 

on. 

“Kat went home for a shower,” her 

brother tells me. “Dr. Li talked her into 

it this morning. He needed to remind 

her it was okay to take care of herself.” 

Kat is Jenn’s partner. I can’t tell you 

how many lesbians I’ve known who 

went by Kat or Jenn. As her brother 

says her name, I wonder if she was a 

Katie or Kathy growing up and then 

switched to Kat later in life because it 

meshed better with her butch identity. 

I met the two of them four days ago. 

I found them, Jenn and Kat, sitting in 

this hospital room with a broad view 

of the city. Kat was perched anxiously 

on the fold-out couch, and Jenn was 

reclined confidently in the armchair 

next to her hospital bed, fully clothed in 

a short-sleeved button down and denim 

shorts. Both women had short unmistakably 

gay hair—the same haircut I 

once attempted during college when I 

was trying on my own identity. I was 

immediately drawn to them because 

something about them reminded me 

of home. 

Jenn told me that she’d been having 

hip pain, deep in her left side. She 

pointed to the region, and Kat watched 

her with cat-like eyes as if to make sure 

she described it in its full detail. Jenn 

starts a sentence with a slow, casual 

voice, one of those just-because-I-can 

smiles on her face. Kat finishes those 

sentences sharply with full medical detail, 

leaning forward into my face closer 

and closer each time. 

“I guess it started on like Friday, I 

think,” Jenn says, kind of looking out at 

the cityscape through the window. 

“Yes, it was Friday,” Kat states with 

some urgency. 

No fevers, no bowel symptoms, urinary 

symptoms, nothing. Just the pain. 

“And Kat says she saw a lymph node 

or something. That right, hon?” 

“Yes, she has a swollen inguinal 

lymph node. I first felt it on Friday, too, 

when she was in the shower.” Kat’s face 

is wrinkled now, with worry. Her eyes 

are dry but red and irritated. She uses 

the word “inguinal” to warn me that she 

too is medical. 

Jenn and Kat are nurses, home health 

nurses. This is actually how they met. 

“She was the leader of our team,” 

Kat tells me later with fresh pride as if 

it were yesterday, when in reality, Jenn’s 

illness has prevented her from working 

for months now. 

I think about this: the two of them 

making house visits together, surrounded 

by the death and sickness 

that provided the backdrop for their 

romance. Kat was smiling during the 

retelling, and her face was transparent 

with the old thrill of seducing her 

former boss. This was twelve years ago 

now. Four years ago, Jenn became suspiciously 

swollen. She was diagnosed with 

ovarian cancer. The intervening years 

are notable now for one large reductive 

surgery, the loss of Jenn’s uterus, 

ovaries, and omentum, and half a dozen 

chemotherapy trials. I pulled up her latest 

PET scan, and stable mets glowed 

back at me, a reminder that the chemotherapy 

had only delayed the inevitable 

for now. Luckily, she had remained 

physically quite strong and was looking 

forward to starting a new chemo regimen 

next week. 

It was Kat who kept her so fit. She 

administered meticulous, gentle care 

round the clock, but the past six months 

had proven increasingly difficult as Jenn 

suffered from intractable abdominal 

pain and several admissions for small 

bowel obstructions. Kat knew the landscape 

of Jenn’s body better than Jenn 

ever had. This is what one would expect 

of lovers of twelve years, except Kat’s 

knowledge was borne of something different. 

Kat’s eyes now combed the body 

of her life partner seeking suspicious 

changes, marks that portended the future, 

rather than pleasured in the right 


now. The numbers in her last CBC, her 

last bowel movement, its consistency, 

the color and volume of her urine. It was 

terror that prompted her daily searches 

and created, for them, a new connection 

between their bodies, a novel sort 

of lovemaking. 

It reminded me of years earlier when 

I totaled my car. My partner’s mother 

had sent us on our way that rainy morning. 

We called her later that day from 

the interstate, my car in pieces, to tell 

her what happened. She told me later 

that every time one of her girls left 

home, she always imagined the worst, 

thinking that if she thought of it first, 

it would never happen. That day, it 

seemed her pre-emptive imaginings 

had betrayed her. I wonder if Kat’s 

relentless surveying and bargaining 

came out of the same hope. 

“It was here-ish,” Kat said, her 

fingers plunged into Jenn’s groin, 

her gray pubic hair exposed while 

my resident and I stood by. Jenn 

was half listening, half aware of the 

low buzz of All My Children coming 

from the flat screen. “For some reason, 

I guess I can’t feel it now,” she said, bewildered 

and frustrated. 

“I never felt anything,” Jenn laughed. 

Kat scowled at the floor, seemingly pondering 

how her own fingers had somehow 

deceived her. 

I couldn’t feel anything either. 

Neither could my resident. At Kat’s urging 

though, in addition to increasing 

Jenn’s pain meds, we agreed to get some 

lab work and an abdominal CT. 

Kat and Jenn had spent the past 

two years or so preparing for the final 

moments. On the palliative service, I’d 

found this was actually kind of rare. 

Most people would delay and delay, 

throwing radioactivity and chemicals 

at tumors that laughed at their efforts, 

growing into organs and bone, hiding 

from x-rays and stealing moms away 

from babies, babies away from moms, 

lovers from lovers. Kat and Jenn, in addition 

to pursuing aggressive curative 

therapies, sought comfort in psychotherapy 

where they spoke freely about 

what was to come, what Jenn wanted it 

to look like, when and under what circumstances 

she wanted to stop. 

“Well, I’ve had four years since I was 

diagnosed.” Jenn is very frank with her 

words. “You know, I’d love four more. 

Shit, I’d like forty more, but we’re prepared 

either way.” I believed that Jenn 

was. Kat was another story. Kat’s movements 

were like Jenn’s words, decisive 

and exact. Wiping sweat from Jenn’s 

forehead, combing her hair from her 

face, positioning her arms about her 

body. However, sometimes I caught her, 

in between stoic statements, staring 

down at the floor like someone does 

whose eyes just flooded, waiting for the 

water to resorb, and then looking back 

up into the conversation. 

We really thought her pain sounded 

like a pulled muscle or something. 

Something really mild. She was pooping 

and peeing and without other systemic 

signs of something going wrong. 

Perhaps her pain was just related to 

her being almost sixty and overweight. 

Perhaps it had nothing to do with her 

cancer at all. It appeared to be a false 

alarm, and I figured we’d have her back 

home in no time. As I talked out my differential 

with the two of them, Kat nodded 

with some degree of relief, albeit 


Going first 

About the author 

I was born and raised 

in rural Utah. I attended 

Smith College and graduated 

with a degree in 

philosophy in 2004. I 

am a recent graduate 

of Northwestern 

University Feinberg School of 

Medicine where I earned my 

MD and my Masters in Medical 

Humanities and Bioethics. I am 

starting my residency in psychiatry 

this year at the University of 

Southern California. I hope to pursue 

a career in geriatric psychiatry. 

guarded. She accepted my explanation 

but called the family anyway. 

Jenn reminded me again: “Kat is my 

power of attorney.” 

“Yes, of course.” I was relieved they’d 

done the paperwork, aware of all the 

hospital horror stories that had befallen 

other gay couples, thinking also that 

it was premature to be worrying who 

would make decisions for her if she 

couldn’t do so herself. She looked just as 

healthy as I did. 

Radiology paged my attending the 

following afternoon. I pulled up Jenn’s 

CT. She had an abscess in her back muscle, 

on the left, just where her pain had 

originated. It was large enough for a med 

student to see it, meaning it was pretty 

damn big. It was a pillowed pocket of 

air and fluid, indicating either active 

bacteria or a fistula between her bowel 

and back or both. Either way, the recommendation 

was to stick a drain in it. I 

remember being surprised although not 

alarmed. We’d stick a central line in her 

neck and send her home with IV antibiotics 

and a drain coming out of her side. 

She continued to appear very well— 

moving around her room, her pain 

under better control. I was shocked 

to see an elevated white count on her 

CBC. She didn’t look sick! I scheduled 

her with interventional radiology the 

following afternoon. The drain was 

placed without incident. That evening, 

I dropped by her room to say hello. 

She and Kat had visitors: Jenn’s sisters, 

brother, and niece. Jenn seemed jovial. 

Kat appeared more at ease than before. 

She even smiled when I told her goodnight. 

“See you tomorrow,” Jenn said. Her 

sister hugged me. “See you tomorrow, 

girlfriend,” she said. 

Before heading to her room the next 

morning, I pulled her vitals up on the 

computer. Her heart rate was up, all 

night, into the hundreds. Her most recent 

blood pressure read 90/60: alarmingly 

low. Topped with a fever of 102 

degrees. All signs pointed to sepsis. I 

could feel my own heart bump around 

in my chest. I could feel my fingertips 

and groin get numb with the anxiety of 

heavy failure. How could I have not seen 

this coming? 

I waited for my attending before I 

went to the room. I was afraid of the 

picture that the vitals had painted for 

me, and I knew that if I actually looked 

at her, that would only make it real. I 

wasn’t ready to hit that on my own. 

“It appears that Jenn is septic,” my 

attending explained to the family. They 

didn’t know sepsis from a septic tank, 

none of them medical. But the connection 

between the two seemingly related 

entities conjured a fitting image of severity. 

I could see that. Kat knew best 

though, herself a nurse. The word softened 

her voice and cut deep lines in her 

weary face. She looked ruddy, almost 

hungover with sadness this morning. 

She knew it all along. She had been 

guarded, accepting our explanations and 

speculations throughout the admission. 

Carefully optimistic, but knew to call 

the family anyway. 

Looking at Jenn: she knew too. It 

wasn’t the pain that brought her in, I 

decided, looking back at it from where 

I was in time now. The pain had been a 

sign, and she knew. 

We asked the regular questions. 

“What’s your understanding of what’s 

going on, Jenn?” That’s my attending’s 

gentle voice, priming them for the 

events looming on the horizon. 

“Well, it looks like I may die.” Her 

frankness was killing me. I had to swallow 

hard and look away from her. Kat 

took her hand and moved to sit on her 

bed. She couldn’t get close enough to 

her. I remember feeling that way as a 

child, small spooning my mom in my 

parent’s bed at night, thinking that if I 

could just get closer and closer, I would 

be invincible. This is how Kat looked 

at Jenn now—like if she could just get 

close enough, maybe she could keep her, 

get away from the bad-news voices, and 

be invincible. 

Jenn was weak, intermittently trailing 

off, but lucid when she needed to 

be. In between cracking jokes about 

the doom in the room, she made her 

intentions very clear, careful always to 

speak in the first person, plural. Now, 

she was speaking for Kat, too. Jenn may 

have been dying, but it seemed Kat was 

surrendering. She asked us to stop the 

antibiotics. 

“I’m at peace, you know,” she huffed, 

showing her exhaustion. “Everyone is 

here. Kat’s here.” 

“She keeps twitching,” Kat said, 

watching Jenn’s legs worm around under 

the sheets. 

“Oh, that doesn’t bother me,” Jenn 

said. 

We ignored Jenn and started something 

to stop the twitching. Our focus 

had shifted from treating Jenn to protecting 

Kat. If Kat didn’t want to see 

twitching, then we would make it so. 

That was the one thing we could do for 

her. It made me feel a little more useful 

in my attempts to make up for the colossal 

failure I’d suffered against the natural 

forces that were claiming Jenn. 

Jenn didn’t really speak again after 

that. She fell into a kind of trance, 

sometimes restless. At those times, we 

gave her morphine, and she was quieted 

again. Her breathing was rough. 

We patched her with scopolamine and 

fentanyl. 


Kat claimed that she and the family 

were working shifts. This was a lie. The 

family wandered in and out through 

the day. Kat went nowhere, sitting on 

the bed, feeling Jenn’s skin, placing ice 

packs, requesting acetaminophen suppositories 

to bring down Jenn’s fever. 

My resident told her this morning 

to go home for a while, get a shower, a 

change of clothes. Eat something. “Don’t 

feel guilty,” he’d told her. And she left. 

During her absence, I thought I’d 

take a break, too. Jenn was clinging to 

the status quo. I thought she’d make it 

through the weekend. I went to the cafeteria 

to get a soda. My pager went off 

about that time. 

Jenn’s brother and niece were sitting 

next to the bed. The television was off, 

the sun beat down on the window. It 

made me think it was warm outside 

when really, it was just a cool 60 degrees 

with some incidental sunlight here and 

there. Jenn’s face was grey, her hands 

still warm. I placed my stethoscope 

over her chest and watched the clock. 

The silence in her chest was eerie. The 

Owl, symbol of Athens, reverse of 

a silver tetradrachm from Athens. © Corbis. 

sixty seconds were long and made me 

very aware of the pain in my back from 

bending over. Kat hadn’t made it back 

yet, but she had just called. It was one 

o’clock. 

“Is she gone?” She asked Jenn’s niece 

without being prompted. 

“She’s in heaven now,” her niece 

whispered as we performed our rituals. 

Maybe it brought her some comfort to 

say that. 

I Googled her name until her obituary 

was finally posted. It took the family 

over a week to put her in the ground. 

Until that time, I knew that Kat must 

have been surrounded by Jenn’s family 

coming in and out, strangers sending 

things like flowers and meat trays. I 

decided I would give her a call a couple 

days after the funeral. I know from 

my own experience that that’s when 

the mourning will start—when the 

crowds quiet down, and Kat is left to 

pick through Jenn’s closet, sleep in the 

sheets that smell like her, throw out 

the pill bottles that litter her cabinets, 

dispose of the relics that documented 

the presence of her and the life they’d 

built together. She’d be stuck wondering 

if she should dispose of everything that 

made the longing burn fresh or worry 

about whether it would make her forget 

something sacred about them. An old 

shirt, a matchbook, a used pencil, a half 

eaten sandwich. She’d want to reach out 

to someone to help her decide what to 

keep and realize that her habit for years 

now was to reach for Jenn. 

“I just wanted you to know that your 

relationship is really inspiring.” This was 

a couple hours before Jenn’s death when 

I found Kat in the room by herself. She 

cried. I think it was something that had 

built up for a while, and now she just 

couldn’t control it. 

“Twelve years is just not enough,” she 

said, sniffing and shaking her sore, red 

face, “but, you know, fifty wouldn’t have 

been enough.” 


4249 West Sarah Street 

Burbank, California 91505 

E-mail: susielisa@gmail.com 

Musings on an Attic Tetradrachm 

What hands are these that stamped wide-eyed 

Owls on rounds of Laurian silver, 

And whose knives are those who carved 

Humanity on blocks of solid stone? 

What artist’s brush has painted antic 

Nymphs on urns of reddened clay, 

And whose minds are they who plumbed 

So deep within the human soul? 

Whose book is this which tells such tales of 

Bloody death on ancient Trojan shores, 

What princely youth has led his men 

To trample vast miles of Asian soil? 

And which men with their lines and angles 

First measured the circumference of the Earth? 

Now seek ye out the Olympian gods, 

And as the Delphic Sybil nods, 

Athena’s owl will tell you Who 

Alvin J. Cummins, MD 

Dr. Cummins (AΩA, Johns Hopkins University, 1944) is retired as professor of Medicine at the 

University of Tennesseee Center for the Health Sciences in Memphis. His address is: 13114 Brooks 

Landing Place, Carmel, Indiana 46033. E-mail: nero6@aol.com. 


�� 

Victim testifies at the Nuremberg Trials. The Doctors Trial 

considered the fate of twenty-three German physicians who 

either participated in the Nazi program to euthanize persons 

or who conducted experiments on concentration camp prisoners 

without their consent. Sixteen of the doctors charged 

were found guilty. Seven were executed. 

16 The Pharos/Winter 2011 

© dpa/dpa/Corbis

�� 

Political violence and the physician 

Amanda J. Redig, MD, PhD 

The author (AΩA, Northwestern University, 2010) is a 

resident in the Department of Medicine at Brigham and 

Women’s Hospital in Boston. This essay won second prize 

in the 2010 Helen H. Glaser Student Essay Competition. 

Human health in the early days of a new millennium 

stands at the crossroads of a paradox: thanks to a vast 

increase in knowledge and technology, we are more 

effective than ever before in both the saving and the taking of 

lives. Indeed, the twentieth century is characterized by two 

incongruous realities. On the one hand, we have the hope and 

optimism generated by groundbreaking strides against the suffering 

caused by disease. Yet coupled to such progress is the 

dark legacy of genocide, war, and political violence on a scale 

previously unimaginable. What makes reconciling these two 

competing visions so difficult for the medical profession is the 

fact that physicians have been instrumental in advancing not 

only the achievements but also the atrocities. 

Decades after their deaths, physicians such as Jonas Salk 

or Alexander Fleming remain household names because of 

the effect their work has had on the advancement of medicine’s 

ability to heal. In contrast, there are also physicians 

whose names have become synonymous with the very worst 

of humanity, such as the “Angel of Death,” Dr. Josef Mengele. 

Fortunately, there are far more famous than infamous physicians, 

but no matter how much the medical profession may 

wish to think otherwise, the physician who chooses to embrace 

death over life is not an anomaly. 

The list of physicians who have participated in and furthered 

political violence is extensive. Nazi physicians directed 

the mass murder of the weak, the ill, and the disabled in 1930s 

Germany, as well as the horrific medical experiments of Nazi 

World War II concentration camps. Japan’s World War II 

Project 731, led by Dr. Shiro 

Ishii, killed thousands of POWs 

and Chinese and Soviet citizens 

in experiments on germ warfare 

and vivisection. Among other 

historic firsts, including leadership 

of the first organization 

to use hijacked airliners as a 

political tool, Palestinian pediatrician 

George Habash was also 

responsible for orchestrating a 

rocket attack on a bus full of 

children in which nine passen- 

Major Nidal Hasan 

HO/Reuters/Corbis 

gers died. Out of the violence that turned neighbor against 

neighbor in the former Yugoslavia, psychiatrist Radovan 

Karadzic is currently standing trial in the Hague for his role 

in the massacre of Bosnian Muslims at Srebenica and the 

Siege of Sarajevo. Al-Qaeda counts numerous physicians as 

operatives, from number two Ayman al-Zawahiri to the individuals 

responsible for the failed suicide bombing at Glasgow 

International Airport in 2007. Most recently, Fort Hood 

psychiatrist Major Nidal Hasan was responsible for the worst 

attack of terrorism on a domestic U.S. military installation in 

American history. 

Clearly, incongruity aside, physicians are not exempt from 

participation in the most chilling of crimes against humanity. 

Despite the repugnance with which most physicians view 

such actions on the part of their colleagues, the fact remains 

that politically-motivated violence perpetrated by physicians 

happens far too often, across all lines of politics, religion, 

and ethnicity. The questions to be asked are thus far more 

complex than whether or not a profession built on the best of 

intentions can exist side by side with great evil. Instead, the 



medical profession must face far more nuanced questions that 

are much more difficult to answer. Why do some physicians 

act as if some lives have no value? What do their actions mean 

for those choosing instead to live by primum non nocere? It 

is too simplistic to dismiss the Mengeles and al-Zawahiris 

among us as either terrorists or sociopaths. The medical profession 

needs to go through the potentially painful process 

of looking inward to recognize both its unique strengths and 

weaknesses. After all, we remember the names of medicine’s 

most infamous members not because of their heinous deeds 

but rather because such actions were carried out by doctors. 

Consequently, we must look more closely at the roots of terrorism 

and state-led violence to understand both the physicians 

who embrace them, as well as those who do not.* 

Internal pressure: surely they must be mad 

The first explanation often used to make sense of physician 

violence is mental illness. The gulf that divides what a physician 

is supposed to do and what some physicians have done is 

so vast that it is not surprising we question the sanity of those 

we cannot understand. The sociopathy defense provides society—and 

especially the medical community—with a mental 

escape from the possibility that a sane individual, someone 

who could be any of us, would willingly engage in such horrors. 

At a superficial level, this initial impression seems accurate 

as a way of explaining aspects of both barbarism that 

defies words and actions that are so contradictory they cannot 

be reconciled. The Holocaust and the campaign in the Pacific 

are among the most extensively analyzed and referenced topics 

in the historical literature, 

yet the details of the medical 

torture that took thousands of 

lives still remain in the shadows. 

The thought of physicians 

removing organs or limbs from 

live patients without anesthesia, 

spinning people in centrifuges 

until they died, or using prisoners 

tied to posts to test the efficacy 

of flame-throwing devices 

stand apart as too horrific to 

contemplate. And what could be 

more contradictory than an individual 

who chooses a career as a 

physician and then participates 

Dr. Josef Mengele 

© Bettmann/CORBIS 

in political violence? Several of 

the physicians implicated in the 

* In this paper “terrorism” refers to Paul Wilkinson’s definition of 

“violence or the threat of violence,” here used primarily in reference 

to non-state actors. 1 “State-led violence” is used for similar actions, 

specifically war crimes and genocide, orchestrated by state actors. 

The word “violence” is used exclusively to refer to actions that have 

an underlying political nature, regardless of the organizational level 

at which such goals are pursued. 

Glasgow International Airport suicide 

bombing plot were not only 

practicing medicine at the time 

but were also living among the 

very people they were attempting 

to destroy. The duality of treating 

one’s neighbors by day and plotting 

to blow them up at night makes no 

sense. Even though Major Nidal 

Hasan’s trial has not yet begun, it 

is assumed that he will use an insanity 

defense because his actions 

are so at odds with his professional 

career. The DSM-IV definition of 

antisocial personality disorder— 

the preferred way of referencing 

the sociopath of common usage— 

Dr. Ayman al-Zawahiri 

AFP/Getty Images 

includes at its core a lack of regard for the rights of others. 2 

In this sense, at least, the actions of such infamous physicians 

seem to fit. 

Yet, a closer examination of the actions of these physicians 

makes it clear that mental illness does not explain their atrocities. 

The DSM definition of antisocial personality disorder 

is far more complex than the superficial understanding of a 

person who does the unthinkable; it also includes several essential 

criteria, starting with a pervasive pattern of disregard 

for and violation of the rights of others occurring since the age 

of fifteen. 2 Patients with this disorder must also meet three (or 

more) of the following: 

1. failure to conform to social norms with respect to lawful 

behaviors as indicated by repeatedly performing acts that 

are grounds for arrest 

2. deceitfulness, as indicated by repeated lying, use of 

aliases, or conning others for personal profit or pleasure 

3. irritability and aggressiveness, as indicated by repeated 

physical fights or assaults 

4. reckless disregard for safety of self or others 

5. consistent irresponsibility, as indicated by repeated 

failure to sustain consistent work behavior or honor financial 

obligations 

6. lack of remorse, as indicated by being indifferent 

to or rationalizing having hurt, mistreated, or stolen from 

another. 2 

This more nuanced pattern does not entirely fit any of the 

physicians whose crimes the profession would like to forget. 

The very act of choosing a career in medicine and completing 

medical school makes psychopathology at a level that 

encompasses mass murder untenable. Medicine is a profession 

entered as an adult with extensive emphasis on social norms 

and regulated, responsible behavior, and for which consistency 

in meeting numerous obligations is essential. While it 

is clear that something is grievously wrong with physicians 

like Mengele and his ilk, attributing even the most despotic 


Dr. Karl Brandt at the Nuremberg trial. 

© dpa/Corbis 

of actions solely to psychiatric disease misses an essential, if 

unsettling, element of the dark side of physician behavior: they 

were once just like us. 

Nazi physician Karl Brandt was the director of the T-4 

euthanasia program that murdered thousands of Germans 

before it became the inspiration for the gas chambers of the 

death camps. At his trial at Nuremberg, Brandt said this: 

Would you believe that it was a pleasure to me to receive 

the order to start euthanasia? For fifteen years I had 

laboured at the sick-bed and every patient was to me like a 

brother, every sick child I worried about as if it had been my 

own. . . . With the deepest devotion I have tortured myself 

again and again, but no philosophy or other wisdom helped 

here. There was the decree and on it there was my name. 3 

Before his execution by hanging, Brandt offered himself as 

the subject for medical experimentation. 3 His offer was rejected, 

but both his words and actions speak to the guilt and 

conflicted emotions of an individual who is clearly tormented, 

yet hardly insane. A trial with similar charges is set to start 

in March 2010, as Radovan Karadzic will have to answer for 

his role in orchestrating the slaughter of Bosnia’s Muslims. 

Karadzic has thus far refused to cooperate in his own defense, 

but the details of his evasion from capture for over a decade 

speak volumes. After he was apprehended, a New York Times 

profile sought out those who knew Karadzic as New Age 

healer Dragan Dabic. 4 Although most acknowledged the eccentricity 

of their new neighbor, no one made the connection 

between the bearded alternative medicine guru and the man 

once known as the Beast of Bosnia. 

When daylight came, Goran Kojic, the Healthy Life 

editor, wanted to talk one more time. He seemed the most 

troubled by the unresolvable contradictions of his recent 

life. Was the pose of gentle spiritualist a complete fake and a 

cover for a soul darkly outed as hideous, violent and bestial? 

Or was there some truth to Dabic’s character? 

“There are two options,” said Kojic, cautiously, hesitantly, 

as if he were speaking for a nation. “Either we are all a bunch 

About the author 

I studied biochemistry and creative 

writing at the University of Arizona before 

enrolling in the medical scientist training 

program at Northwestern University. 

While in Chicago, I completed my PhD 

in cancer biology and graduated with the 

Feinberg School of Medicine Class of 2010. I am currently 

a resident in Internal Medicine at the Brigham 

and Women’s Hospital in Boston and plan to pursue a 

career as an oncologist. Interests include translational 

research but also medical humanities/narrative and 

health/science policy. I have been an online contributor 

to the Virginia Quarterly Review and have had medical 

narratives featured in the Journal of the American 

Medical Association and Health Affairs. 

of fools and madmen who believed 

in the existence of a nonexistent 

man.” Or, he said, there 

is the possibility of redemption. 4 

Those with personal knowledge of 

both Karadzic himself and the carnage 

he caused are unable to separate 

the threads of his identity. We 

do not have similar commentary 

from those who personally knew 

physician-suicide bombers, but 

these individuals did not live the 

life of the criminally insane. They 

worked as physicians; some had 

families. Clearly, physicians who 

participate in political violence 

Dr. Radovan Karadzic 

© dpa/Corbis 

share the undeniable trait of humanity gone horribly awry, but 

this truth provides neither a final answer nor an excuse for the 

medical profession to settle for such an oversimplification. 

External pressure: the genuine grievance theory 

Another common explanation rationalizing physician 

atrocities on behalf of state or non-state actors is terrorism. 

Recasting the actions of certain physicians as rank-and-file 

terrorists can mask the need to probe the healer/destroyer 

dichotomy. Physician. Terrorist. What more need be said? 

Even though physicians spearheaded the establishment of 

many of the most violent terrorist groups in the Middle East 

in the 1960s and ’70s, their paradoxical role is rarely examined. 

Physician George Habash graduated from the American 

University of Beirut before he started the Popular Front for 

the Liberation of Palestine. 5 His political colleague and former 

medical school classmate, Dr. Wadih Haddid, 5 is the mastermind 

behind the hijacking of commercial airliners even before 

the horrors of September 11, 2001. Islamic Jihad was founded 



Dr. George Habash 


Dr. Ikuo Hayashi 

AFP/Getty Images 

Dr. Wadih Haddid 


by yet another physician, 

Dr. Fathi Shiqaqi. 6 The Aum 

Shinrikyo sarin nerve gas attack 

on the Tokyo subway 

that made headlines around 

the globe probably would 

not have succeeded without 

the involvement of Dr. Ikuo 

Hayashi, a one-time rising 

star at the Japanese Ministry 

of Science and Technology. 7 

Even with the series of al- 

Qaeda-associated bombings 

perpetrated by physicians 

over the last five years from 

Glasgow in 2007 to Jordan 

in 2009, nearly all analyses of the attacks’ significance focus 

on the development and re-structuring of al-Qaeda tactics, 

not the startling (or so one would think) observation that 

physicians are so openly participating. The evidence is clear 

that the physician-terrorist is far from a unique construct, yet 

rather than explore this puzzling reality, in a leap of circular 

reasoning, the existence of such a duality has itself become a 

substitute explanation for it. 

Unfortunately, this approach also draws the medical community 

into acknowledging elements of the genuine grievance 

theory in an attempt to understand the unthinkable. While 

this perspective represents an important first step in any rootcause 

analysis, it may also legitimize terrorist acts. During a 

time in which the Palestinian cause was inextricably linked 

to violence targeting civilians, Yasser Arafat stood before the 

United Nations General Assembly and stated: “The difference 

between the revolutionary and the terrorist lies in the reason 

for which each fights. For whoever stands by a just cause . . . 

cannot possibly be called terrorist.” 8 His words are shocking, 

but they are also an uncanny echo of Menachem Begin, who 

wrote twenty years before: “the ideal is the important thing, 

not the man.” 9 

It is this seeming connection of the almost universally 

accepted ideal of freedom with terrorism that has led to the 

maxim: “Terrorism appears whenever people have genuine, 

legitimate grievances. Remove the grievances and terror will 

cease. Like all good lies, this statement cloaks itself in an 

almost-convincing mantle of truth. Indeed, an analysis of the 

personal lives of so-called physician-terrorists reveals more 

than one connection to some of the most turbulent events of 

recent history. George Habash and Wadih Haddid were young 

medical students when their families lost everything to the 

fledgling Israeli Army of 1948. 5 The desperation and suffering 

endured by generations of Palestinians living without hope or 

a future is a powerful stimulus for many elements of organized 

terror, both past and present. The same struggle for national 

independence can be seen at the root of the conflicts involving 

Algeria and the FLN, or Ireland and the IRA. Although not as 

direct a correlation, al-Qaeda propaganda uses the suffering of 

Muslim civilians in the Middle East as a powerful recruiting 

tool for many who have not themselves lived through the horrors, 

including physicians. 

But despite an accurate recognition of the value of justice 

and the unfortunate historical reality of injustice, the arguments 

forming the genuine grievance theory are based on a logic that 

is both unsound and a precept the medical profession should 

never accept as an explanation for the troubling existence of the 

physician-terrorist. Those who turn to terror undermine their 

own cause by denying the meaning and universality of the very 

principles to which they appeal. Even the most cherished ideals 

of freedom and self-determination cannot be used to legitimize 

a cause that only applies them in one direction. This is part of 

what makes the individual who wields a stethoscope in one hand 

and a bomb in the other so difficult to comprehend. Medicine 

as a profession is based on helping all those in need, a principle 

�� 

�� 

�� 

—Yasser Arafat 

�� 

� 

�� 

—Menachem Begin 

enshrined in one form or another in medical oaths spanning 

both geography and time. The Hippocratic Oath and its injunction 

to “first do no harm” is most familiar to the Western world, 


ut this concept is a universal one, paralleling the evolution of 

the physician as an individual with a unique and honored calling. 

The Charaka Samhita is an ancient Sanskrit text dating to 

the third century BCE which states, “Day and night, however 

thou mayest be engaged, thou shalt endeavor for the relief of 

patients with all thy heart and soul.” 10 What is thus so troubling 

for the medical profession is that one of its members could fully 

accept the responsibility of the physician but only as applied 

to a few select persons. Whatever the supposed grievance, the 

terrorist attempts to hide behind moral relativism even while 

claiming a monopoly on moral superiority, as in Yasser Arafat’s 

reference to Abu Nidal as “a real terrorist” after Nidal’s nearsuccessful 

assassination attempt against the PLO leader. 11 The 

hypocrisy of any attempt to cling to a moral code one has shown 

no compunction in violating underscores the vital role that ethics 

plays in any analysis of terrorism, especially that perpetrated 

by physicians. 

And this is the second point the medical profession must 

acknowledge as we attempt to first understand and then prevent 

the actions of those who claim our calling but reject our 

creed. The justification used by physicians who take life to advance 

political goals—whether acting on behalf of the state or 

non-state actors—is unmistakably a moral decision that must 

be recognized as such before it can ever be rejected. Both religious 

and secular terrorists, as well as those acting on behalf 

of the state in cases of genocide, provide moral justification for 

their actions in a way that clearly rejects the universal value 

of individual human life that is at the heart of medicine. The 

writings of Carlos Marighella have been translated into over 

a dozen languages and discovered in more than one hundred 

terrorist safe houses throughout the world; his Minimanual 

of the Urban Guerrilla states, “the urban guerrilla’s arms are 

inferior to the enemy’s, but from a moral point of view, the 

urban guerrilla has an undeniable superiority.” 12 The most 

important significance of this work for such a broad range of 

organizations lies in the conclusions that equate the legitimacy 

of a cause with the methods used to achieve it. This codified 

morality for the actions of a terrorist is one in which human 

life is not respected. His words horrify, yet it should not be 

surprising that upon learning his bomb destroyed German 

instead of Israeli tourists, the bombmaker responded, “Infidels 

are all the same.” 13 The difficulties in establishing a working 

definition of terrorism and even the use of the word as a 

descriptive label imply a moral judgment that can be used to 

wage a war of semantics against unwanted political behavior. 

But despite legitimate definitional challenges, the conscious 

choice to take life in defiance of the profession that stands 

for saving it is a moral decision framed by a rejection of the 

fundamental worth of the individual. It is only in recognizing 

this fact that the medical community can ask the difficult 

questions about itself that must be the first steps towards any 

attempt to combat such actions by physicians. 

Moving forward 

Reframing the infamous physicians as one who chooses to 

devalue human life—regardless of confounding psychiatric 

or political factors—raises two compelling questions for the 

medical profession with implications at the practical level. 

First, is there something about medical training that can 

lead to some physicians rejecting the value of human life? 

While the overarching values of the medical profession say 

absolutely not, a closer analysis of the day-to-day process of 

becoming a physician and practicing medicine suggests otherwise. 

From the very beginning of medical school, the training 

process demands would-be physicians put aside some of 

their most basic human instincts. As human beings, we draw 

away from death, from blood, from suffering, yet medical 

training demands that we embrace and sometimes even cause 

all of the above. What starts in the cadaver lab extends to the 

surgical theater, the chemotherapy clinic, and the radiation 

suite. The goal of practicing medicine is to support life, but 

in the process of doing so, physicians nonetheless act in a way 

that in any other setting would be unthinkable: we take knives 

to flesh, administer the deadliest of toxins, direct radiation to 

permanent harm. In other settings, each of these activities 

has been the basis for charges of crimes against humanity. In 

many settings, transplant surgery or experimental protocols 

among them, physicians can take on the role that throughout 

history has traditionally been granted only to God: determining 

who lives and who dies. The regulation of clinical trials 

and human experimentation has undergone dramatic development 

throughout the last decades, but even with the deep 

scrutiny of today’s IRB committees the role of directly experimenting 

on human subjects is an established part of modern 

medicine. No amount of preclinical development and testing 

can take away the fact that the goal of Phase I clinical trials is 

to identify toxicities in a human population. 

Clearly, most physicians complete their medical training 

without following the twisted path of one who uses it to 

destroy rather than heal. Yet the fact remains that a career in 

medicine forces one to confront questions of life, death, suffering, 

and healing at a level of intimacy that no other profession 

can match. Ironically, it is spiritual leaders who likely come the 

closest, and the relationship between organized religion and 

political violence needs no further elaboration here. In the setting 

of medical training, then, both the events of the past and 

the developments of today suggest that physicians—like those 

from any background of deep ideological convictions—may be 

vulnerable to radicalizing influences not in spite of their training 

but perhaps because of it. While this is a sobering reality 

to consider, it is also one that offers the promise of change. 

Medical training has undergone a remarkable transformation 

over the last decades, with an emphasis on ethics and professionalism 

in medical education as never before. We already 

have the tools to strengthen our commitment to respecting 

the humanity and dignity of all who cross our path—the challenge 

now before us is how best to utilize them. Just as an individual 

physician makes the choice about where her deepest 

allegiance lies, so too can the medical profession. 

This, in turn, raises a related point that can be all the more 



difficult to recognize for its subtlety. Any discussion of political 

violence, war crimes, and terrorism must emphasize the deep 

ideological fervor of participants that permits participation in 

atrocities. But convictions of even the most deeply-held principles 

are in themselves neutral entities; only in their application 

do we truly see what an individual has chosen to reject or 

embrace. For every physician who joins the medical profession 

with a deep faith in a given principle only to emerge a monster, 

there are far more who use their values to shape a commitment 

to medicine into something of profound inspiration. Most telling 

of all, the potential for making positive rather than negative 

contributions can be seen in medical organizations that cut 

across the spectrum of religious and secular beliefs. The stated 

mission of Physicians for Human Rights is to “[mobilize] health 

professionals to advance health, dignity, and justice.” 14 For the 

strength of this commitment and its real-world application, 

the organization shared the 1997 Nobel Peace Prize. Two years 

later, Doctors without Borders, an organization “based on the 

humanitarian principles of medical ethics and impartiality” 

was recognized with this same award. 15 Furthermore, deep 

spiritual convictions do not automatically translate to fundamentalist 

hate. In this context, consider the example of the mission 

statements of the Islamic Medical Association of North 

America (IMANA) and the Christian Medical and Dental 

Association (CMDA). Both acknowledge the fundamental role 

of the Islamic or Christian faith, respectively, in the lives of 

their members. Both incorporate spiritual beliefs that are only 

accepted by members of their distinct faiths. Yet it is the deep 

and abiding respect for life on spiritual grounds in conjunction 

with a professional calling to medicine that also brings both 

organizations to a conclusion utterly repudiating the actions of 

those who claim a spiritual heritage to legitimize acts of great 

evil. The IMANA mission statement concludes with this verse 

from the Qur’an: “If anyone has killed one person (except in 

lieu of murder or mischief on earth) it is as if he has killed the 

whole of mankind, and if he has saved one life it is as if he saved 

the whole of mankind.” 16 The CMDA mission statement indicates 

that the organization exists to equip Christian physicians 

to, “pursue professional competence and Christ-like compassion 

in their daily work.” 17 The inspiration for such compassion 

is this injunction from the gospel of Mathew: “You shall love 

your neighbor as yourself.” 18 

It is these words—and others like them—that represent the 

true challenge facing the medical profession as we continue 

to struggle with the paradox of physicians who both heal and 

destroy. As a profession, we must understand our heritage and 

walk the very fine line of respecting the personal differences 

among us while refusing to compromise on the moral integrity 

on which medicine is based. We must challenge ourselves to 

treat all equally. We must recognize that principle always has 

a place in argument even while acknowledging that principles 

themselves can be hijacked and used to justify heinous acts of 

violence. In short, we must be physicians, first and always, but 

we must also be physicians who live in the real world and never 

lose sight of any opportunity—from improving medical education 

to supporting humanitarian medical aid—to emphasize 

the uncompromising foundation of respect for humanity on 

which our profession is built. This approach will not remove 

every threat to the integrity of the physician posed by political 

violence, but it does provide a place to start from the only 

perspective that matters: one life at a time. 

References 

1. Wilkinson P. Terrorism and the Liberal State. Second edition. 

New York: New York University Press; 1986. 

2. American Psychiatric Association. DSM-IV-TR Diagnostic 

Criteria for Antisocial Personality Disorder (301.y). In: Diagnostic 

and Statistical Manual of Mental Disorders. Fourth edition. Washington 

(DC): American Psychiatric Association; 1994. 

3. Spartacus Educational web site. Karl Brandt. www.spartacus. 

schoolnet.co.uk/GERbrandtK.htm. 

4. Hitt J. Radovan Karadzic’s new-age adventure. New 

York Times 2009 Jul 22. www.nytimes.com/2009/07/26/ 

magazine/26karadzic-t.html. 

5. Habash G, Soueid M. Interview: Taking stock: An interview 

with George Habash. J Palestinian Stud 1998; 28: 86–101. 

6. Greenberg J. Islamic group vows revenge for slaying 

of its leader. New York Times 1995 Oct 30: A9. www.nytimes. 

com/1995/10/30/world/islamic-group-vows-revenge-for-slaying-ofits-leaders.html. 

7. Murakami H. Underground: The Tokyo Gas Attack and the 

Japanese Psyche. New York: Vintage; 2001. 

8. Richardson L. What Terrorists Want: Understanding the 

Enemy, Containing the Threat. New York: Random House; 2007. 

9. Laqueur W, editor. The Terrorism Reader: A Historical Anthology. 

New York: New American Library; 1978. 

10. Menon LA, Haberman HF. The medical students’ oath of 

ancient India. Med Hist 1970; 14: 295–99. 

11. Harmon C. Terrorism Today. London: Frank Cass; 2000: 191. 

12. Marighella C. Minimanual of the urban guerrilla. New World 

Liberation Front; 1970. 

13. Hoffman B. Inside Terrorism. New York: Columbia University 

Press; 1998: 168. 

14. Physicians for Human Rights web site. About PHR. physiciansforhumanrights.org/about/. 

15. Doctors Without Borders web site. About Us—History and 

Principles. www.doctorswithoutborders.org/aboutus/. 

16. Islamic Medical Association of North America web site. Mission 

and Vision. www.imana.org/index.php?option=com_content&v 

iew=article&id=196&Itemid=65. 

17. Christian Medical and Dental Association web site. Mission 

& Beliefs. www.cmda.org/WCM/CMDA/Navigation/About/MissionsBeliefs/Missions_Beliefs.aspx. 

18. The Holy Bible Containing the Old and New Testaments 

New King James Version. Nashville (TN): Thomas Nelson Publishers; 

1982: 873. 

The author’s e-mail is: aredig@partners.org 


Sestina on Limb-Lengthening 

Surgery 

John’s father was a famous novelist, 

his mom a musical sensation. In short, 

John was born with two silver spoons in mouth. 

A bright boy, he sailed through Harvard, then 

demonstrated 

valor in the Horn of Africa. A great 

career in politics awaited; the only 

obstacle was John’s stature: he was only 

five-foot-two, puny as a sapling that lists 

whichever way the wind blows. For a great 

price, John secured the services of a shortspoken 

but skilled cosmetic surgeon, who operated 

on John’s bones to make him taller, so his mouth 

could speechify from a loftier place. The mouth 

of conventional wisdom says that only 

females are vain, preening in front of crenellated 

mirror frames, making lengthy shopping lists 

of perfumes, lipsticks, skirts, and shorts; 

but masculine vanity is no less great. 

My friend Millie, whose voice is apt to grate, 

but who has pretty eyes and a sweet mouth, 

helped me see why this is the long-and-short 

of the matter. She tells me that she only 

dates boys who are at least five-foot-ten, lest 

their offspring’s height be too modest, too understated. 

Where prejudices of this kind are indurated, 

it’s no surprise that male vanity is great. 

The man I date, the man who tops the list 

of men in my life, with his honest mouth 

says that his brothers tower over him only 

because he is a twin: he has been short 

ever since he, together with his short 

sister, inhabited their mom’s trabeculated 

womb. He regrets his shortness, saying, “If only 

I were taller . . . ,” while the fire in the grate 

backlights the beauty of his face; his mouth, 

nose, eyes all vie for which is loveliest 

to me. My stammering mouth replies at last, 

“My patient, John, could have been great if only 

a complicated surgery hadn’t cut his life short.” 

Jenna Le 

Ms. Le is a member of the Class of 2010 at the Columbia University 

College of Physicians and Surgeons. This poem won first prize in the 2010 

Pharos Poetry Competition. Ms. Le’s e-mail address is: jenna.le@gmail.com. 



B�� 

What poetry has to say about it 

The author is the associate director of the Lynchburg Family 

Medicine Residency in Lynchburg, Virginia, and a member 

of the editorial board of The Pharos. 

Breaking bad news to patients is difficult. Even experienced 

physicians struggle to do it competently. Until 

recently, it’s a skill that has received little attention 

in medical schools, residencies, and fellowship training programs. 

1 There is scant evidence on how to do it well. 2,3 Most 

articles on the subject refer to certain steps that may be helpful: 

create a comfortable setting for patients and families; find 

out what patients know about their condition; ask them how 

much they desire to know; deliver the news in a clear, concise 

fashion; show empathy; be prepared to respond to various 

reactions to the news—sadness, denial, anger, or guilt; and, 

finally, summarize and outline a plan for the patient. 3–5 

Experience, frequent practice, coaching from mentors, 

and reviewing the medical literature are traditional ways to 

improve one’s ability to deliver bad news. I believe reading 

poetry is another way: reading poems with care and empathy 

fosters an appreciation of the importance of language, feelings, 

and nuance in communication and relationships. Raymond 

Carver’s poem, “What The Doctor Said,” offers insights into 

patient-physician relationships not found in other forms of 

instruction. In this poem, Carver shows how difficult, frightening, 

and awkward (for the patient and physician) delivering 

and receiving bad news can be: 

He said it doesn’t look good 

he said it looks bad in fact real bad 

he said I counted thirty-two of them on one lung before 

I quit counting them 

I said I’m glad I wouldn’t want to know 

about any more being there than that 

he said are you a religious man do you kneel down 

in forest groves and let yourself ask for help 

when you come to a waterfall 

mist blowing against your face and arms 

do you stop and ask for understanding at those moments 

I said not yet but I intend to start today 

he said I’m real sorry he said 

I wish I had some other kind of news to give you 

I said Amen and he said something else 

I didn’t catch and not knowing what else to do 

and not wanting him to have to repeat it 

and me to have to fully digest it 

I just looked at him 

for a minute and he looked back it was then 

I jumped up and shook hands with this man who’d just given 

me 

something no one else on earth had ever given me 

I may have even thanked him habit being so strong 6 

The doctor in the poem botches it—badly. 7 In his first 

attempt to deliver the news, he tries a detached, scientific approach: 

he counts. Not only does he count the nodules; he reports 

the number to the patient—the number before he stops 

counting. Ten, twenty, or thirty-two nodules—what clinical 

difference does it make? Then he resorts to quasi-religious, 

poetic imagery: “do you kneel down in forest groves and let 

yourself ask for help when you come to a waterfall, mist blowing 

against your face and arms.” I’m fine with asking patients 

if they are religious, but does anyone want this question after 

being told they have more than “thirty-two of them on one 

lung”? 


The truth is, most of us blunder from time to time, no 

matter how experienced we are in communicating serious 

news. We come prepared with the words that soothe—“this 

must be very difficult for you; I cannot imagine how you must 

feel”—only to utter stupid, insensitive things. And sometimes 

the patient saves us from ourselves. He feels the doctor’s discomfort 

in breaking the news, and works to ease the doctor’s 

pain, jumping up and even thanking him! 

Every time I read this poem, I feel uncomfortable. I squirm 

as the anxious physician who cannot find the right words 

Illustrations by Erica Aitken 

to communicate in an honest, sensitive way. I squirm as the 

patient who suffers through not only the news about a devastating 

diagnosis, but also the nonsense coming from the 

physician’s mouth. What could the physician in Carver’s poem 

have done differently? What can any of us do when we realize 

the conversation is going badly? After his first verbal blunder, 

maybe the physician should have said something like: “I’m not 

saying this very well; let me start over.” Maybe he should have 

started the conversation with “I wish I had some other kind 

of news to give you,” and then quietly waited for the patient’s 


Breaking bad news 

response after delivering the diagnosis. Things might have 

gone differently. Perhaps not. At many points in the dialogue, 

I simply want the physician to stop talking. And maybe that is 

one of the major lessons of the poem. 

Dr. John Stone’s poem “Talking to the Family” delivers 

other insights: 

My white coat waits in the corner 

like a father. 

I will wear it to meet the sister 

in her white shoes and organza dress 

in the live of winter, 

the milkless husband 

holding the baby. 

I will tell them. 

They will put it together 

and take it apart. 

Their voices will buzz. 

The cut ends of their nerves 

will curl. 

I will take off the coat, 

drive home, 

and replace the light bulb in the hall. 8 

The physician’s fear of doing his duty is palpable. Like a boy 

who dreads telling his father about an accident or other bad 

news, but knows he must, the physician reluctantly puts on 

his white coat of authority to inform the family of the patient’s 

death. As Kathryn Montgomery beautifully puts it, 

the secret of the poem, the reason its speaker is not the 

heartless bastard a first-year student every now and then 

will argue he must be, is that, except for the first line, it is 

written in the future tense. . . . The dreadful telling has not 

happened yet. The speaker is still elsewhere, off stage, in his 

office perhaps, and the dread—along with the acceptance of 

a physician’s duty—is his. 9 

Despite the tragedy, life goes on. The physician cannot 

dwell on the moment—he has other patients to see, and other 

patients to console. He also has other things to do. Doctoring 

is only one of his roles. The doctor slips on his white coat at 

work, and slips it off when his professional duty is done. He 

goes home and, like the rest of us, must perform mundane 

tasks such as changing light bulbs. 

The simple, mechanical task takes his mind off the terrible 

news. Changing the light bulb is an important step toward 

focusing on the present, renewing his energy, and healing 

his own pain. The light goes out in one life, but the doctor 

is climbing the ladder again, making physical and emotional 

adjustments so that he can bring new life and light to others. 

Life goes on. 

Physicians need to be intellectually and emotionally prepared 

to deliver bad news. Patients and families may have 

many questions about treatment and prognosis. They may 

react to the news in a variety of ways, including sadness, anger, 

or shock. And physicians themselves will have their own 

reactions to the telling of the news. But preparation for these 

things is not sufficient. Once they are in the middle of a conversation, 

physicians must be flexible, creative, and self-aware, 

ready if necessary to change the direction of the dialogue, offer 

a tissue, or simply be quiet. Like Stone’s poem, what’s left 

unsaid often has more power than what is said: Stone does not 

explicitly tell us about the husband’s grief—he uses a remarkable 

image, “the milkless husband holding the baby,” to convey 

the impending grief and loss. 

Reading the poems above is no substitute for preparation, 

practice, and clinical experience. Nevertheless, I believe 

physicians who read these poems with attention and empathy 

will enhance their understanding of language, feelings, and 

the communication of bad news. The poems also remind us 

how unpredictable these conversations can be, no matter how 

frequently we rehearse for them. Finally, we should not be surprised 

by our dread and reluctance to do our duty and deliver 

the message: a milkless husband is hard to bear. 

References 

1. Hebert HD, Butera JN, Castillo J, Mega AE. Are we training 

fellows adequately in delivering bad news to patients? A survey of 

hematology/oncology program directors. J Palliat Med 2009; 12: 

1119–24. 

2. Walsh RA, Girgis A, Sanson-Fisher RW. Breaking bad news. 

2: What evidence is available to guide clinicians? Behav Med 1998; 

24: 61–72. 

3. Barclay JS, Blackhall LJ, Tulsky JA. Communication strategies 

and cultural issues in the delivery of bad news. J Palliat Med 2007; 

10: 958–77. 

4. Back A, Arnold R, Tulsky J. Mastering Communication with 

Seriously Ill Patients: Balancing Honesty with Empathy and Hope. 

Cambridge: Cambridge University Press; 2009. 

5. Ptacek JT, Eberhardt, TL. Breaking bad news: A review of the 

literature. JAMA 1996; 276: 496–502. 

6. Carver R. All Of Us: The Collected Poems. New York: Vintage 

Books; 2000: 289. 

7. Gianakos D. What the Doctor Said: Commentary. Acad Med 

2008; 83: 420–21. 

8. Stone J. Music From Apartment 8. Baton Rouge (LA): Louisiana 

State University Press; 2004: 51. 

9. Montgomery K. A setback: In memory of John Stone, 1936– 

2008. Lit Med 2008 Fall; 27: 119–23. 


Lynchburg Family Medicine Residency 

2323 Memorial Avenue, #10 

Lynchburg, Virginia 24501 

E-mail: deangianakos@yahoo.com 


�� 

A heart aches 

Like the earth when it quakes 

A void left where ground once lay 

Impossible to heal 

A scar fills the space 

With memories that once were real 

John Allan, MD 

Dr. Allan (AΩA, Saint Louis University, 2009) 

is a PGY-2 in Internal Medicine at New York- 

Presbyterian Hospital Weill-Cornell Medical Center. 

His address is: 445 East 68th Street, Apartment 8G, 

New York, New York 10065. E-mail: allanj@slu.edu. 



�� 

�� 

�� 

�� 

Early standardization of the insulin unit 

Barry Fields, MD 


The author is chief resident in 

Internal Medicine at the Yale 

Primary Care Residency Program. 

From its advent in September 

2006 until its removal from the 

market in October 2007, inhaled 

insulin for diabetes mellitus 

represented the first effective alternative 

to subcutaneous injections in 

more than eighty years. Aside from 

its administration modality, Exubera 

(Insulin Human [rDNA origin]) also 

transformed dosage labeling from 

the traditional insulin “unit” into 

milligrams. While this conversion 

may have appeared novel, it actually 

harked back to a time early in insulin 

therapy’s history. Indeed, defining insulin 

quantity in terms of milligrams 

sits at the heart of post-World War I 

efforts to ensure the new product’s 

safety and reliability. These early attempts 

at its international standardization 

laid the foundation on which 

insulin dosage is still based today. 

Frederick Grant Banting. 

Courtesy of the National Library of Medicine. 

Producing an insulin extract 

In the autumn of 1920, Canadian 

surgeon Frederick Grant Banting 

scribbled, 

Diabetus 

Ligate pancreatic ducts of 

dog. Keep dogs alive till acini 

degenerate leaving Islets. 

Try to isolate the internal secretion 

of these to relieve glycosurea 

[sugar in the urine]. 1p50 

In this short note, Banting 

outlined how he would 

find the quintessentialtreatment 

for a disease he could not even spell. 

Over the next year, Banting worked 

in the University of Toronto physiology 

laboratory of Professor J. J. R. 

Macleod. With the help of graduate 

students Charles Best and Clark 

Noble, he purified his first insulin extract 

from the degenerating pancreases 

of canine subjects and showed it 

could transiently reduce the animals’ 

blood sugar. 

Banting presented his findings to 

the American Physiological Society 

conference in December 1921. Among 

attendees expressing interest in extract 

production was George H. A. 

Clowes, research director for the Eli 

Lilly Pharmaceutical Company of 

Indianapolis. Though his offer was 

initially turned down, it caused the 

researchers to patent their process 

to maintain their control over the 

integrity of the extract’s manufacture 

and purification. The University of 

Toronto’s Board of Governors subsequently 

licensed the process to Lilly’s 

laboratories. 1 American production 

supplemented the relatively meager 

yields at Toronto’s own Connaught 

Antitoxin Laboratories, supplying 

a burgeoning international market 

with insulin therapy. 

To oversee insulin’s future licensing 

and distribution, the Board 

of Governors organized Toronto’s 

Insulin Committee (IC) in 1922. One 

of its first actions was to offer patent 

rights to the British Medical Research 

Council (MRC), thus giving Europe 

its first access to insulin. The MRC 

sent Dr. Henry H. Dale, a department 

director at their National 

Institute for Medical Research, to 

Toronto. Dale quickly recognized the 

promise of insulin and suggested the 


From rabbits to the League of Nations 

MRC accept control of the British patent. 

At the same time, he and his traveling 

companion, biochemist Harold W. 

Dudley, expressed serious reservations 

regarding the IC’s earliest definition of 

the insulin unit. Dale wrote: 

The Toronto definition of a “unit” 

of the specific insulin activity, was 

the dose required, with intravenous 

injection, to throw 3 out of 5 rabbits 

into hypoglycaemic convulsions! I 

had made it no secret, from the first, 

. . . that I regarded such a definition 

as having so little claim to accuracy, 

as to be practically almost useless, 

and eventually misleading. 2p445 

Clowes from Lilly later echoed these 

misgivings when developing a reliable 

insulin unit became a matter of international 

concern. 

A rabbit-based unit 

Dale’s observation came months after 

the first insulin unit was defined. 

During the spring of 1922, Macleod, 

James B. Collip, Banting, and Best began 

calibrating insulin by its effects on animals. 

Using two-kilogram rabbits, they 

determined that hypoglycemic convusions 

usually appeared as the animals’ 

blood sugar component fell below 0.045 

percent. This observation served as a 

threshold on which to base the first 

“physiologic unit” or “rabbit unit” of insulin, 

about one cc. The authors wrote: 

As a tentative basis for the physiological 

assay of insulin we consider 

as one unit the number of 

cubic centimeters which causes the 

blood sugar of normal rabbits to fall 

to 0.045 per cent within 4 hours. 

This dose is decidedly active in lowering 

the blood sugar in diabetic 

patients. 3p175 

Their report also compared the effects 

of infused insulin solution on a 

two-kilogram normal rabbit with an 

eleven-kilogram depancreatized dog. 

The authors noted that, after taking 

into account the animals’ weight and 

dosage disparities, the dog still showed a 

much more dramatic reduction in blood 

sugar levels after having received only 

one third the dose that the rabbit had 

received. 3 The unit’s value would change 

later that year to reflect this observation. 

These early attempts to define an 

insulin unit coincided with the first 

diabetic human patients being treated 

with the pancreatic extract. Fifteenyear-old 

Elizabeth Hughes, the diabetic 

daughter of New York governor 

and future Chief Justice Charles Evans 

Hughes, began her injections in mid- 

August. Just one cc twice daily effectively 

cleared the sugar from her urine. 

However, by October her dosage had 

risen to five cc twice daily. In a letter to 

her mother, Hughes wrote: 



Charles H. Best. 


We only have a two cc. syringe you 

know and so Blanche [her nurse] 

fills that and gives it to me and then 

unscrews it from the needle which 

is left sticking in to me (I feel like a 

pincushion) fills it again, and gives 

me that (am left a pincushion once 

more), and then have the fifth cc. 

It really is quite a process, and altogether 

takes about twenty minutes 

for the whole performance. 1p155 

There is no indication that Elizabeth 

Hughes’s diabetes had worsened, nor 

that her sensitivity to insulin had decreased. 

Since she remained in Toronto 

for the first months of treatment, it is 

almost certain she received her insulin 

from the same source, Connaught 

Antitoxin Laboratories. A lack of consistency 

in production protocol and 

continued efforts to increase their yield 

resulted in wide fluctuation 

in the final product’s 

activity. Therefore, while 

Canadian researchers held 

the definition of an insulin 

unit constant in terms of 

its clinical effects on rabbits, 

the actual dosage fluctuated 

greatly. 1 

An ever-evolving unit 

Late in 1922, additional 

criticism of the definition 

of the insulin unit emerged 

from giants in American 

diabetology such as Dr. 

Frederik Madison Allen 

and Dr. Elliot P. Joslin. 

These physicians and their 

colleagues disliked the 

“physiologic unit” of insulin 

because its relative 

strength in humans forced 

some patients to receive 

fractions of a unit, creating 

confusion among patients 

and nurses alike. 4 Clowes 

at Lilly brought their 

concerns to the IC. On 

December 30, 1922, they 

announced: 

The Toronto Committee conferred 

with Drs Clowes, Allen and Joslin as 

to the adoption of a unit for Insulin 

required to lower the blood sugar 

and the following conclusions were 

arrived at: 

1) The unit adopted for Insulin 

shall be approximately one-fifth that 

of the original Toronto unit, which 

is the amount of Insulin required to 

lower the blood sugar of a 2 kg fed 

rabbit 0.045 per cent within four 

hours, and cause symptoms. 4 

This new unit was to be called the “clinical 

unit” of insulin as opposed to the 

original “physiological,” “Toronto,” or 

“rabbit” unit. In this manner, the IC 

had adjusted its calibration of insulin to 

accommodate the needs of clinicians, 

as represented by Lilly. Further col- 

laborations between the pharmaceutical 

company and the IC would not proceed 

as smoothly. 

As with Elizabeth Hughes’s insulin 

supply, clinicians in 1923 complained of 

potency discrepancies among batches 

supposedly of the same clinical strength. 

California physician W. D. Sansum and 

his research team provided unique insight 

into the unit’s evanescence. During 

early 1923, they helped establish the 

“sugar-metabolizing power” of a given 

lot of insulin—the amount of sugar metabolized 

by each insulin unit. They 

showed Lilly’s insulin to have 1.25 grams 

of sugar metabolizing power per unit. 5 

Unfortunately, clinicians and their patients 

remained vulnerable to continued 

unit modifications elsewhere. 

Beginning in May, the researchers 

noted that previously well-controlled 

diabetic patients had sugar reappearing 

in their urine. The new insulin 

units’ sugar metabolizing power had 

decreased by approximately one third 

compared to one month previously. The 

authors state: 

We then learned that the unit had 

been redefined as being one-third 

of the amount required to lower 

the blood sugar below 0.045% and 

cause convulsions in a two-kilogram 

rabbit which had been previously 

starved for twenty-four hours. This 

redefinition was based on the belief, 

supported by experimental evidence, 

that it requires four times as 

much insulin to cause a convulsion 

in a two kilogram rabbit as in a 

one kilogram rabbit. In using onethird 

instead of one-fourth the convulsion 

[dose] in the two kilogram 

rabbits, these workers believed that 

they were increasing the value of 

the unit. 5 

Their comments allude to discrepancies 

in rabbit size between Lilly’s laboratories 

and those of the IC. While Toronto 

had been using two-kilogram fed rabbits 

in its tests of potency, Lilly had 

been using one-kilogram fasting rabbits. 


From rabbits to the League of Nations 

To complicate matters further, Clowes 

never applied the IC’s new definition of 

the clinical unit to his product. Instead 

of dividing the physiologic unit by five 

per their directive, Clowes divided it 

by four and added twenty-five percent 

to account for product deterioration. 

He cited discrepancies in experimental 

results between Lilly and the IC and the 

tendencies of clinicians to desire a more 

potent unit to rationalize his decision. 4 

With an increasingly reliable extract 

provided by the IC and Lilly, attention 

could shift toward improving its international 

standardization. 

A weight-based standardization 

scheme 

A standardized drug is one that is 

always produced at equal potency in all 

manufactured lots. An international effort 

to standardize emerging treatments 

had been underway for decades before 

insulin was developed. Without knowing 

the chemical composition of these 

new biologic extracts, tests to determine 

potencies were relative; the substance’s 

effect on one group of animals (or “biological 

system”) would be compared to 

its effects on another reference or “standard” 

system. This procedure, however, 

assumed that the substance being tested 

and the animals in each test group were 

identical, an untenable assumption. 6,7 

As Lilly’s rabbits had demonstrated, 

standardization based solely on a reference 

biological system was fraught with 

dangerous inaccuracy. 

In 1897, German physician Paul 

Ehrlich described attempts at medical 

standardization based on activity 

of a certain weight of active ingredient. 

His task had been to ensure uniform 

potency of the newly-developed 

diphtheria antitoxin; due to the instability 

of the diphtheria toxin, he was 

consistently unsuccessful. Recognizing 

the fallibility of the biological system, 

he devised a standardization scheme 

based on weight of dried antitoxin. His 

institute in Germany kept samples of 

the sterile, dried product in vacuum at 

low temperature. Units of antisera were 

defined in terms of the weight of this 

standard. Laboratories and production 

plants around the world could periodically 

obtain samples and compare them 

to their new product to ensure the potency 

of its unit matched the standard 

in Germany. 

The MRC’s Henry Dale studied 

Ehrlich’s principles during a period in 

which he became increasingly frustrated 

with the international community’s attempt 

to standardize many medical 

breakthroughs. Efforts to institute unit 

standards consisted mostly of debates 

concerning the merits of one biological 

method over another. 8 With Dale’s 

encouragement, the League of Nations 

Health Committee sponsored a 1923 

Edinburgh Conference to discuss new 

methods of international standardization. 

In the months before the conference, 

Dale directed Dudley to prepare a 

solid form of insulin, resulting in insulin 

hydrochloride, a dried powder standard 

that companies and laboratories could 

compare their product against. 

The League of Nations weighs in 

When the International Congress 

met at Edinburgh in 1923, champions 

of biological systems proposed extending 

rodent hypoglycemia methods to 

international acceptance. Dale objected, 

citing the many drawbacks of such systems. 

He wrote: 

the definition, for permanent adoption 

and international transmission, 

of any unit of biological activity in 

terms of the reaction of a proportion 

of test animals, was inadmissible; 

and that the only safe basis for the 

definition of a unit of insulin, or of 

any other potent remedy, would be 

in terms of a precise weight of a 

standard, stable sample of the remedy 

in question, in the form of a 

completely dried powder. 2p448 

After displaying a vial containing the 

insulin hydrocholoride Dudley had developed, 

Dale proposed that interested 

parties work to correlate amounts of the 

powder with what they believed to be 

the experimental activity of one insulin 

unit. He also suggested they ask the 

League of Nations for another conference 

in two years, at which investigators 

taking part in the trials could present 

their findings. 

Reorganization within the League of 

Nations helped make that future conference 

a viable reality. In 1924, the League 

of Nations Health Committee became 

its Health Organization, one of several 

“technical agencies” that functioned 

semi-autonomously within the League. 9 

Its president, Thorvald Madsen, placed 

biological standardization near the top 

of his priority list for world health initiatives. 

7 These developments within the 

League, combined with ever-increasing 

numbers of new biological compounds, 

set the groundwork for a Second 

International Conference on Biological 

Standards at Geneva in 1925. 

In the interim, five institutions, including 

Connaught Laboratories and 

Lilly, contributed samples of their insulin 

product to a growing pool of extract 

at the MRC. Under Dale and Dudley’s 

supervision, the preparations were combined 

and then converted to a single 

batch of powdered insulin hydrochloride. 

The product was divided into 100mg 

ampules, dried, sealed, and sent to 

laboratories in England, Canada, and 

the United States. Those independent 

labs could determine the value of “solid” 

insulin in terms of their own units at 

the time. Their results were remarkably 

consistent, showing each milligram of 

powder to have a value of 8.4 to 8.8 

units. To avoid fractional units, the IC 

declared that the solid insulin standard 

contained 8 units per milligram. 10 

The Second International Conference 

met in late August and early September 

of 1925. Chaired by Henry Dale, it considered 

the standardization of several 

biological products, with insulin receiving 

particular attention. Their unanimous 

recommendation read: 

That the dry preparation of insulin 

hydrochloride, prepared by 

the Medical Research Council of 

Great Britain at the request of the 

Edinburgh Conference, should be 


accepted as the international standard 

preparation of insulin. That 1 

milligram of this standard contains 

8 units of insulin (or 1 unit = 0.125 

milligrams), as provisionally defined 

by the Insulin Committee of the 

University of Toronto. 8p61 

The League of Nations’ Permanent 

Commission on Biological Standards 

subsequently adopted this recommendation. 

In doing so, the insulin unit 

was transformed from being defined by 

rodent convulsions to one determined 

by comparison to an internationally 

recognized standard preparation, in 

milligrams. 

Over the next decade, decreases 

in the use of the standard preparation 

method and further advances 

in insulin purification led world authorities 

to seek a new standard insulin 

unit. 10 In 1935, the League of 

Nations Permanent Commission on 

Biological Standardisation “accepted 

the new standard for international 

use and redefined the unit of insulin 

as the specific insulin activity of one 

twenty-second (1/22) of a milligramme 

of the new standard.” 11p486 A Third and 

Fourth International Standard would 

be elucidated under the World Health 

Organization, United Nations’ equivalent 

to the League of Nations Health 

Organization. Remarkably similar to the 

1935 standard, the Fourth International 

Standard defines biologically extracted 

insulin as 24.0 insulin units per milligram. 

10 

Therefore, more than eighty years 

after a unit-milligram equivalency was 

first created to ensure international insulin 

standardization, this concept was 

resurrected to simplify inhaled insulin 

dosing and administration in a new 

form. Tables on Pfizer’s Exubera web 

site and in print aided clinicians and 

their patients in making this contemporary 

unit-to-milligram conversion 

(Pfizer’s web page for Exubera has been 

removed; a web page with similar information 

is referenced). 12 In doing so, 

they also brought to mind a historical 

definition—that of the insulin unit itself. 

Henry H. Dale. 

Courtesy of the National Library of Medicine. F. Netter, compliments Armour Laboratory, Chicago. 

Acknowledgment 

I thank my faculty advisors Stephanie 

Brown-Clark, MD, PhD, and Michael Green, 

MD, MSc, for their thoughtful comments, 

guidance, and support in preparation of this 

manuscript. 

References 

1. Bliss M. The Discovery of Insulin. 

Chicago: The University of Chicago Press; 

1982. 

2. Murnaghan JH, Talalay P. H. H. 

Dale’s account of the standardization of 

insulin. Bull Hist Med 1992; 66: 440–50. 

3. Banting FG, Best CH, Collip JB, et 

al. The effect of pancreatic extract (insulin) 

on normal rabbits. Am J Physiol 1922; 62: 

162–76. 

4. Sinding C. Making the unit of insulin: 

Standards, clinical work, and industry, 

1920–1925. Bull Hist Med 2002; 76: 231–70. 

5. Sansum WD, Blatherwick NR, Smith 

FH, et al. The treatment of diabetes with 

insulin. J Metab Res 1923; 3: 641–65. 

6. Miles AA. Biological standards and 

the measurement of therapeutic activity. Br 

Med Bull 1951; 7: 283–91. 

7. Cockburn WC. The international 

contribution to the standarization of biological 

substances. I. Biological standards 

and the League of Nations 1921–1946. Bio- 

logicals 1991; 19: 161–69. 

8. Knaffl-Lenz E, League of Nations 

Health Organisation Permanent Commission 

on Standardization of Sera, Serological 

Reactions and Biological Products. 

Memoranda on Cardiac Drugs, Thyroid 

Preparations, Ergot Preparations, Filix 

Mas, Suprarenal Preparations, Vitamins, 

Pituitary, Salvarsan, Oil of Chenopodium, 

Insulin. III. Health. 1928 III. 10. Geneva: 

Publications of the League of Nations; 1928. 

9. Aufricht H. Guide to League of Nations 

Publications: A Bibliographical Survey 

of the Work of the League, 1920–1947. New 

York: Columbia University Press; 1951. 

10. Lacey AH. The unit of insulin. Diabetes 

1967; 16: 198–200. 

11. Best CH, Dale HH. I. Insulin. 1. The 

new international insulin standard and the 

re-definition of the existing unit in terms 

therof. League of Nations Q Bull Health Org 

1936; 5: 584–658. 

12. Exubera (Insulin Human [rDNA origin]) 

Drug Information: Uses, Side Effect, 

Drug Interactions and Warnings at RxList. 

http://www.rxlist.com/exubera-drug.htm. 


5221 Town Walk Drive 

Hamden, Connecticut 06518 

E-mail: barry.fields@yale.edu 


� �� 

There in a royal box 

ordinary folks still as rocks 

posed as in a portrait 

decide another’s fate 

watching evidence passing by 

like shooting stars in the sky. 

At recess the courtroom a deserted camp. 

In one corner the flag hangs limp 

like a runner out of breath. 

The defendant alone, the last on earth. 

The clock points its moving finger 

distanced from slander and anger. 

Worry directs every thought 

about what legal tacks have wrought 

that may dissolve dreams to dust 

threatening future with rust. 

The decision, at last, is made 

by citizens returning in parade. 

His honor enters in his black gown. 

Suspense suppresses every sound. 

All wait for words cast in cement 

that will terminate this event. 

“No cause,” the verdict of the jury. 

Behold the plaintiff’s fury. 

From the defendant relief effervescent bubbles 

from a bottle of troubles. 

H. Harvey Gass, MD 

Dr. Gass (AΩA, University of Michigan, 1941) is retired from practice as a clinical 

professor of Neurosurgery at Wayne State Medical School. His address is: 6155 East 

Longview Drive, East Lansing, Michigan 48823. E-mail: sgass@msu.edu. 



Health policy 

Our health care system is not broken— 

it’s obsolete! 

Jordan J. Cohen, MD 

The author (AΩA, Tufts University, 1978) is professor 

of Medicine and Public Health at George Washington 

University and president emeritus of the Association of 

American Colleges. 

We often hear that our health care system is “broken.” 

Indeed, it’s become a pat refrain among 

policymakers and the media. But thinking the 

system is “broken” implies that it can be “fixed”—patched 

up to make it work like it used to. That’s what would-be 

health care reformers seem to think when they tinker with 

“fixes” like expanding insurance coverage with mandates and 

subsidies, guaranteeing insurance despite pre-conditions, 

crafting pay-for-performance incentives to change provider 

behavior, and expanding use of electronic medical records. 

All of these “fixes” would undoubtedly be helpful and should 

be implemented without delay. But unfortunately, even in the 

aggregate, these and other attempts to tinker with the current 

system cannot get at the fundamental problems we have to 

solve and, hence, are a far cry from true health care reform. 

Why? Because our health care system is not “broken.” 

Rather, it’s outmoded. It’s archaic. It’s a legacy system that is 

simply incapable —inherently incapable—of meeting today’s 

health care needs, no matter how much we tinker with it. 

Imagine trying to fix a Model T Ford so that it could fly. You 

could put in a more powerful engine, take off the fenders, 

strap on wings, and put on a pair of aviator goggles. But you 

still couldn’t get the darned thing off the ground! 

The hand-me-down system we’ve inherited is just like that 

old car, the product of a bygone era that was well designed for 

yesteryear but is no longer serviceable. Yesteryear was when 

the health care system needed to deal primarily with acute, 

often self-limited illness and injury; when medical technologies 

were much more limited in scope and much less complex; 

when we thought “the world’s best health care system” 

delivered uniformly high-quality care to everyone; and when 

the overall cost of health care was still in the single digits as a 

percentage of GDP. 

In times like those, our country could get along quite well 

with autonomous doctors working solo or in small groups. 

And we rather liked having our doctors in total control, 

with all other health care professionals playing supporting 

roles. We could tolerate independent hospitals 

competing with one another for patients. We had 

a fee-for-service payment system that was well 

designed to deal with isolated episodes of 

illness and discrete encounters with individual 

providers. And paper-based 

medical records kept separately by 

each of our providers worked 

well enough. 

Today, we face an entirely different set of realities, realities 

that our legacy system was never designed for, and can never 

be retrofitted to deal with satisfactorily. Chief among them are 

rising costs, an increasing burden of chronic, unrelenting disease 

and disability, way too many medical errors, inexplicable 

variations in the way medicine is practiced across the country, 

profound lapses in quality, and wide disparities in health and 

health care even among those with adequate insurance. 

The fragmented, uncoordinated, fee-for-service conglomeration 

we have inherited cannot hope to cope effectively with 

these twenty-first-century challenges. 

If policymakers would shift their mental model from “broken, 

let’s fix it” to “obsolete, let’s redesign it,” I doubt there 

would be much disagreement about the features a new system 

should have. We’d want “units of accountability” big enough 

to be held responsible for delivering comprehensive, high- 

quality, cost-effective care to large groups of people. These 

units of accountability would be required to develop systematic 

approaches to weeding out waste, to coordinating the care 

of the chronically ill, to avoiding redundant tests, to guaranteeing 

that preventive strategies were broadly implemented, 

and to fully utilizing the skills of all health care workers in 

high-performing teams. 

Moving from our dysfunctional, fragmented legacy system 

to an integrated, accountable system will not be easy and will 

not happen quickly. The barriers to achieving the fundamental 

transformation required are enormous. An entirely different 

financing scheme will be needed to release the system from 

the paralyzing constraints of our current fee-for-service arrangement, 

and a new cultural paradigm among providers will 

be needed to foster collaboration, teamwork, accountability, 

quality improvement, and patient safety. Even before clearing 

those barriers, however, a way must be found to overcome the 

resistance from entrenched stakeholders who are profiting 

handsomely from the current system and who have powerful 

political allies. 

But the risk of trying to preserve an obsolete system is 

simply too great to let these obstacles stand in the way of 

needed reforms. Fortunately, a window of opportunity has 

opened up. Buried in the myriad “fixes” included in the Patient 

Protection and Affordable Care Act is a call for CMS to promote 

demonstration projects to implement and evaluate innovative 

approaches to organizing and delivering health care. 

Such demonstrations could allow for the creation, on a large 

scale, of what Stephen Shortell and Lawrence Casalino have 

called accountable care systems, systems that are “capable of 

implementing organized processes for improving the quality 

and controlling the costs of care, and of being held accountable 

for the results.” 1 Being “accountable” would entail both 


Our health care system is not broken—it’s obsolete! 

demonstrating appropriate clinical outcomes and taking on 

significant financial risk. It’s hard to imagine how these expectations 

could be met in the absence of a fully integrated system 

of providers in which doctors, nurses, hospitals, public health 

professionals, nursing homes, pharmacists, home health 

agencies, etc. join forces to manage cost-effectively the care of 

individuals and to deal systematically with the known health 

needs of a region or population. 

As possible points of departure for developing such 

truly accountable care systems, Shortell and Casalino suggest 

several current organizational arrangements including 

multispecialty group practices, hospital staff organizations, 

physician-hospital organizations, independent practice organizations, 

and health plan-provider organizations or networks. 

I’m concerned that none of these existing organizational arrangements 

is likely to be sufficiently scalable to meet the real 

challenges. What has more potential of doing so, in my view, 

are well-organized academic health centers. 

Indeed, many academic health centers are uniquely poised 

to develop the kind of integrated health care systems that we 

need. Many already have organized faculty practice plans, a 

network of affiliated hospitals, community physician referral 

bases, a relatively robust IT infrastructure, a tradition of innovation, 

loyal patients, and the trust and respect of their communities. 

Modern information technologies could be used to 

stitch together the network of hospitals, doctors, home health 

agencies, pharmacies, and other community resources needed 

both to provide for the health and health care needs of a large 

population and to monitor the system’s fiscal performance 

and to identify opportunities for improvement. Given their 

existing capabilities—and their avowed mission to serve the 

public interest—academic health centers, either individually 

or preferably in partnership with others, should lead the way 

toward solving what is arguably the most urgent health problem 

facing our county. 

However we do it, if we want our health care system to fly 

in the twenty-first century, we’ve got to stop trying to repair 

a hodgepodge arrangement that is hopelessly antiquated and 

get on with the hard work of replacing it with a real system 

that can actually do the job. Now that Congress has provided 

CMS with substantial resources to fund more appropriate 

ways to structure and finance health care services, I believe 

academic health centers—as engines of innovation—should 

seize the opportunity to demonstrate what true health care 

reform might look like. 

References 

1. Shortell SM, Casalino LP. Health care reform requires accountable 

care systems. JAMA 2008; 300: 95–7. 

Memento Mori 

The first one caught me by surprise. 

I was doing my initial thoracentesis, 

a task less daunting than the word implies. 

A cheerful woman gasped from fluid in her chest, 

a pleural effusion caused by rampant cancer. 

There was no effusiveness in the somber needle 

I guided carefully through her chest wall. 

“I’m going to die now,” she calmly said, 

and, with nothing further, laid back dead. 

It was the moment doctors dread; 

full frontal with the enemy ahead 

And I midwife to the highest drama. 

This was no time for contemplation. 

Coding, CPR, intracardiac adrenaline; 

we were quick and forceful, but for naught. 

Relatives were notified, and in intense detail 

we probed each second, searching for a clue or cause. 

None came, and nothing from a later autopsy. 

We had no solution, no solace, and no one to blame. 

While preachers celebrate the rising soul, 

and mystics sense transfiguration, and 

loved ones clasp one another, casting 

hope against the loneliness of death, 

we found no answer in her body, 

no meaning in the metaphysics, 

and nothing in ourselves to talk about. 

Michael R. Milano, MD 


1177 22nd Street, NW 

Jim M’Guinness 

Washington, DC 20037 

E-mail: msdjjc@gwumc.edu 

Dr. Milano (AΩA, Albany Medical College, 1964) is a psychiatrist living 

36 and practicing in Teaneck, New Jersey. The His Pharos/Winter e-mail address is: milanovino- 2011 

nos@aol.com.

Reading a Review 

M. Esteller. Molecular Origins of Cancer: Epigenetics in Cancer. 

N Engl J Med 2008; 358: 1148. 

I have learned from this reading that I will die 

not by the agency of great gods of sea and sky, 

or of the lesser ones, the sprites of groves and wells, 

nor even by will of the many-breasted mother, 

Earth herself. 

I must kneel instead to bits of my own cells, 

those invisible smalls within, where methyls delve, 

and shortened ribbons of RNA 

plug phosphates to genes and capriciously play 

with my molecules making them epigenetic. 

This change in belief runs through me like a panic attack. 

Worship my genes? They are far too small 

for that. I am used to gods who are huge, and call 

on lightning’s power, or sometimes explode a sun 

over a cave in Palestine. 

Water from rock, pillars of fire define 

my life and beliefs. How can I live with the notion 

that these new gods of cancer, incapable of emotion, 

not even of guilt, have no concept of 

a high God’s mercy and unearthly love? 

Must I plead to my own, these bits of cell débris, 

even as they settle down to murder me? 


Dr. Van Peenen is retired from medical practice. His address is: 74 W. 29th 

Avenue, Apartment 1103, Eugene, Oregon 97405. E-mail: lkvanp@comcast.net. 



2010 Alpha 

Omega Alpha 

Robert J. Glaser 

Distinguished 

Teacher Awards 

Each year since 1988, Alpha 

Omega Alpha, in cooperation 

with the Association of American 

Medical Colleges, presents four AΩA 

Distinguished Teacher Awards to 

faculty members in American medical 

schools. Two awards are for ac- 

Gary L. Dunnington, MD (Clinical) 

J. Roland Folse Professor and Chair of 

Surgery, Southern Illinois University 

School of Medicine 

Dr. Dunnington (AΩA, University 

of Southern California, 1994) joined 

Southern Illinois University School of 

Medicine in 1979 as professor in the 

Department of Surgery. Since then, he 

has been director of the General Surgery 

Residency Program and professor and 

chair of the Department of Surgery. He 

was named the J. Roland Folse Professor 

and Chair of Surgery in 2009. 

Dr. J. Kevin Dorsey, dean of the 

complishments in teaching the basic 

sciences and two are for inspired 

teaching in the clinical sciences. 

In 1997, AΩA named the award to 

honor its retiring executive secretary 

Robert J. Glaser, MD. Nominations 

for the award are submitted to the 

AAMC each spring by the deans of 

medical schools. 

Nominations were reviewed by a 

committee chosen by AΩA and the 

AAMC. This year’s committee members 

were: Ronald Arky, MD; David 

A. Asch, MD, MBA; J. John Cohen, 

MD, PhD; Molly Cooke, MD; Eugene 

C. Corbett, MD, FACP; Linda S. 

Costanza, PhD; Arthur F. Dailey II, 

PhD; Erika Goldstein, MD; Aviad 

Distinguished teachers Gary L. Dunnington, MD; Duane E. Haines, PhD; John W. Pelley, 

PhD; and James R. Stallworth, MD. Deborah E. Powell, MD, immediate past chair of 

the AAMC board of directors and Associate Vice President for New Models of Medical 

Education is on the left. On the right are Richard L. Byyny, MD, Executive Director of Alpha 

Omega Alpha, and Darrell G. Kirch, MD, President and CEO of the AAMC. 

Photo credit: Richard Greenhouse Photography, Inc. Courtesy of the AAMC. 

SIU School of Medicine, writes: “Dr. 

Dunnington is a passionate advocate 

and practitioner of excellence in medical 

education. He has received nineteen 

teaching awards at three institutions, 

including the Outstanding Teacher of 

the Year award at SIU in 2010. With 

several colleagues, he developed and 

refined an academic incentive system 

that has been in use at SIU for more 

than ten years. Dr. Dunnington’s influence 

spreads far beyond the walls of 

SIU, however. He was one of the thought 

leaders involved in the ACGME’s Task 

Haramati, PhD; Bruce M. Koeppen, 

MD, PhD; Jeanette Norden, PhD; 

Paul L. Rogers, MD; James L. 

Sebastian, MD; Gabriel Virella, MD, 

PhD. 

Winners of the award receive 

$10,000, their schools receive 

$2,500, and active AΩA chapters 

at those schools receive $1,000. 

Schools nominating candidates for 

the award receive a plaque with the 

name of the nominee. 

Brief summaries of the accomplishments 

in medical education of 

the 2010 award recipients follow. 

Richard L. Byyny, MD 

Executive Director 

Force charged with developing the six 

competencies toward which all residencies 

in the United States now train. He 

and four other surgeons were founding 

members of the American College of 

Surgeon’s Surgeons as Educators course. 

He facilitated the development of a “surgery 

readiness” elective for senior medical 

students, which is among the highest 

rated electives in the school and has 

inspired other SIU clinical departments 

to create similar electives. The report of 

the program in the medical literature has 

spawned numerous clones. A comprehensive 

system for evaluating operating 

room performance was selected by the 

American Board of Surgery as a template 

for a national system for rating operative 

performance. It will be required for all 

applicants for board certification.” 

Dr. Dunnington says of teaching, “You 

have to teach from the learner’s agenda, 

not from scripts. A truly great teacher 

says, ‘What can I help you learn today?’ ” 

Duane E. Haines, PhD (Basic) 

Professor and Chairman, Department 

of Anatomy, University of Mississippi 

Medical Center School of Medicine 

Dr. Haines received his PhD in 

Anatomy-Physical Anthropology at 

Michigan State University. He joined 

the University of Mississippi in 1985 

as a professor of Anatomy. He has received 

the A. J. Ladman AAA/Wiley 

Exemplary Service Award and the Henry 

Gray/Elsevier Distinguished Educator 

Award from the American Association 

of Anatomists, and the Silver Hammer 

Award as Teacher of the Year from 


the Department of Neurology at the 

University of Mississippi Medical Center. 

Dr. LouAnn Woodward, dean of the 

University of Mississippi Medical Center 

School of Medicine writes of Dr. Haines: 

“Dr. Haines embodies the definition of 

“doctor” from the Latin “to teach.” He 

has consistently gone the extra mile to 

provide an excellent quality education 

program with a focus on clinically relevant 

information. 

“Dr. Haines is well recognized for his 

atlas of the human brain, Neuroanatomy: 

An Atlas of Structures, Sections, and 

Systems, now in its eighth edition. He 

is also the editor and co-author of 

Fundamental Neuroscience for Basic and 

Clinical Applications, currently in its 

third edition. 

“At every medical center where he 

has held a faculty position, Dr. Haines 

has been extensively involved in teaching 

programs of his department. His many 

teaching awards span both undergraduate 

and graduate education. 

“Dr. Haines is a model educator and 

true scholar with a great heart for students.” 

John W. Pelley, PhD (Basic) 

Associate Professor of Cell Biology 

and Biochemistry, Texas Tech Health 

Sciences Center School of Medicine 

Dr. Pelley received his PhD in Zoology 

from the University of North Carolina. 

He joined TTUHSC in 1972 as assistant 

professor in Biochemistry. 

Dr. Pelley has received the President’s 

Excellence in Teaching Award twice 

at TTUHSC. He has also received the 

School of Nursing Dean’s award for 

teaching pathophysiology. He has received 

the SGEA Medical Education 

Scholarship Award for the Outstanding 

Presentation and the Award for Merit 

for Applications in Healthcare Education 

by the International Associate for 

Psychological Type. 

Dr. Steven L. Berk, dean of the 

School of Medicine, writes: “Dr. Pelley 

has achieved significant recognition for 

his teaching contributions both within 

and outside of the TTUHSC School of 

Medicine due to his use of innovations in 

the classroom such as concept mapping, 

question analysis and ‘prefrontal pauses.’ 

These teaching strategies are designed 

to develop the student’s ability to learn 

as well as to improve delivery of content. 

He has authored a popular USMLE Step 

1 review book, now in its third edition, 

and a course companion biochemistry 

book that is part of an integrated series 

(second edition in preparation). 

“Dr. Pelley’s teaching extends well 

beyond biochemistry. He has developed 

an expertise in learning theory and strategies 

in medical education. He developed 

his metacognitive approach to learning 

during his ten-year tenure as associate 

dean for Academic Affairs, which he 

documented in the book SuccessTypes in 

Medical Education, freely available at the 

SuccessTypes Medical Education Page 

(www.ttuhsc.edu/som/success/default. 

htm). Dr. Pelley is an active member 

of the international medical education 

listserve, DR-ED, the Southern Group 

on Educational Affairs, International 

Association of Medical Science 

Educators, and Team Based Learning 

Collaborative.” 

James R. Stallworth, MD (Clinical) 

Associate Professor, Department 

of Pediatrics, University of South 

Carolina School of Medicine 

Dr. Stallworth (AΩA, University 

of South Carolina, 1987) joined the 

University of South Carolina in 1979 

as an instructor in Pediatrics. He is 

currently associate professor in the 

Department of Pediatrics, Vice Chair 

for Education and Faculty Development, 

the M-III Pediatrics Clerkship Director, 

and Director of Student Recruitment. 

Dr. Richard A. Hoppmann, dean of the 

School of Medicine, writes: “There is 

only a short list of names on the outstanding 

teachers list at the University 

of South Carolina School of Medicine. 

The name of Dr. James Stallworth is at 

the top of that list. A faculty member for 

over thirty years, he has become a legend 

among students, faculty, and alumni. 

Dr. Stallworth’s involvement in undergraduate 

education spans all four years 

of medical school, but he is best known 

for his role as M-III Pediatrics Clerkship 

Director, a position that he has held for 

twenty-seven years. The reason he remains 

clerkship director has nothing to 

do with lack of ambition, but everything 

to do with his passion for medical education 

and his desire to see every student 

reach their full potential and succeed as 

a physician. Over the years he has garnered 

tremendous respect from students 

for his straightforward, no-nonsense approach 

to pediatric clinical education, 

and for the high ethical and professional 

standards that he sets for himself and for 

students. 

“It is because of Dr. Stallworth that 

many of our students over the years have 

chosen to train as pediatricians. Former 

students would tell you about his caring 

and concern for his patients. They would 

also tell that Dr. Stallworth could be 

quite intimidating, but he never let any 

of them give any less than their best for 

their patients and themselves.” 

Distinguished teacher nominees 

Patricia Lipford Abbitt, MD, University of 

Florida College of Medicine 

Ezra Amsterdam, MD, University of California, 

Davis, School of Medicine 

Charles L. Bardes, MD, Weill Cornell Medical 

College 

John B. Bass, Jr., MD, University of South 

Alabama School of Medicine 

David M. Clive, MD, University of 

Massachusetts Medical School 

Joseph C. Fantone, MD, University of Michigan 

Medical School 

Mark Christian Flemmer, MD, Eastern Virginia 

Barbara Freeman, PhD, Case Western Reserve 

University School of Medicine 

Joshua I. Goldhaber, MD, David Geffen School 

of Medicine at UCLA 

Stephen B. Greenberg, MD, MACP, Baylor 

College of Medicine 

Richard Gunderman, MD, PhD, MPH, Indiana 

University School of Medicine 

Jesse B. Hall, MD, University of Chicago 

Pritzker School of Medicine 

Thomas Karl Hoskison, MD, University of 

Oklahoma College of Medicine 

David C. Kaufman, MD, FCCM, University of 

Rochester 

James P. Keating, MD, Washington University 

in St. Louis School of Medicine 

Gary L. Kolesari, MD, PhD, Medical College of 

Wisconsin 

Susan Lehmann, MD, Johns Hopkins University 


Ruth Levine, MD, University of Texas Medical 

Branch at Galveston 

Fred A. Lopez, MD, LSU Health Sciences 

Center School at of Medicine at New Orleans 

Salvatore Mangione, MD, Jefferson Medical 

College of Thomas Jefferson University 

Kathryn Montgomery, PhD, Northwestern 

University, The Feinberg School of Medicine 

David Muller, MD, Mount Sinai School of 

Medicine of New York University 

Dennis H. Novack, MD, Drexel University 


Mark T. O’Connell, MD, University of Miami 

Miller School of Medicine 

Noor A. Pirzada, MD, The University of Toledo 


Mark L. Savicakas, PhD, Northeastern Ohio 

University Colleges of Medicine and Pharmacy 

Maria C. Savoia, MD, University of California, 

San Diego, School of Medicine 

John S. Sergent, MD, Vanderbilt University 


Paul Shanley, MD, State University of New 

York Upstate Medical University College of 

Medicine 


The Write a Poem for This Photo Contest was the brainchild of 

Ted Harris, who loved the intersection of images and imagery. 

The charming photograph illustrating the poems was taken 

by Dr. Anthony Shaw (AΩA, University of Virginia, 1980) of 

Pasadena, California. 

The winning poems in this year’s contest are: 

First prize: “Benevolent Instructions” by David R. Downs, MD. 

Second prize: “Commencement” by David F. Dozier, Jr., MD. 

Third prize: “Adolescent Choices” by H. J. Van Peenen, MD. 

Benevolent Instructions 

If I’ve told you once, I’ve told you twice 

It’s this way, Junior, to the ice. 

David R. Downs, MD 

Dr. Downs was elected to AΩA at the University of 

Wisconsin in 1957. His address is: 411 West Merrimac Street, 

Dodgeville, WI 53533-1409. E-mail: dbdowns@mhtc.net. 

40 The Pharos/Winter 2011 

W

�� 

� 

�� 

� 

�� 

Commencement 

I see him with his friend, 

Describing sights he’s just discovered. 

I feel a father’s pride 

As he revels in his furry youth. 

This is no time to tell him 

Of the Orca, or the sea’s 

Potential rage and power. 

I’ll keep my distance, 

Keep him safe by nudge 

And praising, and let him feel 

The buoyant joy of entering the water. 

Soon enough he’ll grow and hunt for food, 

And huddle with the family 

When the winter blizzards blast us. 

For now, he rules his world, 

But I’ll be watching. 

David F. Dozier, Jr., MD 

Dr. Dozier received his MD from Stanford University 

in 1961. His address is 5168 Mississippi Bar Drive, 

Orangevale, California 95662. E-mail: david_dozier@ 

sbcglobal.net. 

Adolescent Choices 

Two friends are making up their minds. 

To stay or go? How compromise if 

Right wants out and Left wants stay? 

Which one of them for both decides? 

“That way,” Right points a furry wing, 

but Left is skeptical. He thinks 

Right too impulsive, immature, 

and leaving home so soon unwise. 

The next frame of the film will show 

them parting. Left will turn away, 

the good son going back to mother. 

(She’s at the photo’s edge, her head 

embroidered yellow, white, and red.) 

And Right the tempter, Right the other, 

will waddle to the right to seek 

whatever comes from being born 

with an impulsive stubborn streak. 

These two age mates, once hatched together, 

once childhood friends and now half-grown, 

part frostily to grow alone 

into a harsh maturity. 

One to warm eggs on frozen feet. 

One be eaten by a seal. 


Dr. Van Peenen’s address is 74 W. 29th Avenue, 

Apartment 1103, Eugene, Oregon 97405. E-mail: 

lkvanp@comcast.net. 


The physician at the movies 

Peter E. Dans, MD 

Wall Street: Money Never Sleeps 

Starring Michel Douglas, Shia La Beouf, Josh Brolin, Carey 

Mulligan, Eli Wallach. 

Directed by Oliver Stone. Rated PG-13. Running time 133 

minutes. 

It’s hard to believe that the original Wall Street was released 

twenty-three years ago. Like The Godfather, it has achieved 

iconic status with its memorable Oscar-winning performance 

by Michael Douglas as Gordon Gekko and its signature line 

“Greed is good.” Gekko accumulates billions by wedding his 

belief that “information is the most valuable commodity” with 

a philosophy based on the writings of the sixth-century-BC 

Chinese warlord Sun Tzu. As Gekko tells his protégé Bud 

Fox (Charlie Sheen), “I don’t just throw darts at a board. Read 

Sun Tzu’s The Art of War. Every battle is won before it is ever 

fought.” To Gekko, the game is “not about the money; it’s 

about the game between people.” In short, it’s about winning, 

or in the words of a popular phrase of the time, “the one 

who dies with the most toys wins.” 

Not surprisingly, the sales of The Art of War, 

which is still used in war colleges, skyrocketed after 

the film as Gekko wannabes tried to absorb 

some of its lessons. In the original movie, 

Shia La Beouf in Wall Street: Money Never Sleeps. 

20th Century-Fox/Photofest 

Gekko is brought down by Fox who, after he is caught doing 

insider trading, saves his hide by wearing a wire to incriminate 

Gekko. Before being sent to prison, Gekko sequesters $100 

million in a Swiss account in his children’s names. 

The sequel begins in October 2001 at Sing Sing, where 

Gekko is released after having served his eight-year sentence 

for insider trading and securities fraud. He reclaims his possessions, 

including an out-of-date cell phone and, when no 

one is there to meet him, he takes a cab back to “the city.” The 

scene shifts to 2008 with two Gen Xers in bed as the morning 

news comes on the television. The woman is Gekko’s estranged 

daughter Winnie, who angrily shuts off the TV upon 

hearing that Gekko is back in the limelight promoting his 

book Is Greed Good? Winnie used to visit her father regularly 

in prison until her brother died of a drug overdose that she 

blamed on her father. As seeming recompense for Gordon’s 

sins, she has become a blogger for an anti-corporate website, 

Frozen Truth. Her live-in boyfriend, Jake Moore (Shia La 

Beouf), insists that she ought to hear about him, but she wants 

none of it. Jake, it turns out, is an up-and-coming Wall Street 

trader whose “saving grace” is his championing of alternative 

energy technology to save the planet. He is employed by the 

firm Keller/Zabel (KZI), headed by a one-time powerful figure 

Louis Zabel (Frank Langella), to whom Jake is devoted. Zabel 


dodges Jake’s questions about rumors that KZI is on the brink 

of insolvency, saying, “Are we going under? That’s the wrong 

question. Who isn’t?” He ends the conversation by giving Jake 

a $1.45 million bonus, telling him to enjoy it. Jake uses part 

of it to buy Winnie an engagement ring (although he knows 

she’s against marriage) and to go out partying. He decides to 

plow the rest into KZI despite a friend’s warning that the firm, 

having kept subprime mortgage toxic debt off its books, is in 

danger of collapse. 

Enter Bretton James (Josh Brolin), the CEO of Churchill 

Schwartz, a fictional firm meant to represent a combination 

of Goldman Sachs and J.P. Morgan. By refusing to support a 

bailout for KZI, he engineers its destruction as a payback for 

Zabel’s not bailing out Churchill Schwartz eight years before 

under similar circumstances. There are ominous meetings of 

the Federal Reserve Commission in New York as Zabel unsuccessfully 

tries to trade on old loyalties and friendships by 

pleading his case before the group that holds his fate in their 

hands. There are a couple of great scenes on the Upper West 

Side in Central Park and the subway, involving a distraught 

Zabel and Jake. 

Re-enter Gekko as he goes on the lecture circuit to Fordham 

Business School to publicize his book. He tells the students 

that “money is a bitch that never sleeps and she is jealous.” He 

reiterates his old axiom that greed is good, but too much is 

not, and that greed is legal. He notes that forty percent of the 

nation’s profits come from financial services, not production 

of goods, principally involving what he calls “banks on steroids.” 

Jake goes up to him after the lecture and tells him that 

he is engaged to Winnie. They ride the subway together and 

forge a quid pro quo arrangement in which Gekko helps Jake 

unravel the steps leading to the destruction of KZI in return 

for trying to reconcile him with his daughter. This grafting 

of a love affair, such as it is, onto the picture’s main theme of 

the convoluted machinations of the Wall Street traders never 

really works. It seems like an attempt to reach a younger audience 

while showing that Gekko has some humanity (although 

not much). He is not averse to duping his daughter and Jake 

to get back his $100 million, which he promptly turns into $1 

billion, showing that he hasn’t lost his old touch. 

The film is filled with what might be called “inside baseball,” 

with references to the cutthroat side of the financial 

world with its own arcane language of credit default swaps, 

hedge funds, derivatives, bundling subprime mortgages, and 

toxic debt. At the time, these terms were totally unfamiliar to 

the majority of the public whose retirement funding depended 

on their effects on the markets. They were also ignored by the 

numerous public watchdogs at the Federal Reserve, the relevant 

Congressional committees, and the SEC until the crisis 

exploded into public consciousness in 2008. There are also 

the references to banks being “too big to fail” and their being 

given bailouts in which they are awarded 100 cents on the 

dollar while investors are short-changed. This illustrates the 

concept of “moral hazard”—someone takes your money and 

acts differently when insulated from risks than he would if he 

were fully responsible for losses. The comment in the film is 

that it is “unethical but not illegal.” 

Though long, the film held my interest throughout. What 

is particularly good about it is the acting, first by Douglas 

who looks as old, tired, and sick as he is in real life. Look for 

another Best Actor Oscar, possibly posthumously. Next is the 

outstanding supporting cast. Frank Langella is great as an old 

Lion being eaten alive by the unscrupulous young shark played 

by Josh Brolin. Eli Wallach is also great as Jules Steinhardt, another 

old Lion, who looks half-dead but is still in control, just 

as he was in The Godfather until he got bumped off by that 

cannoli. As he drops his little pearls, he emits a little whistle, 

one of the best touches in the film that I have to believe he improvised. 

Susan Sarandon is less effective as Jake’s mother, who 

is forever cadging money from her son for failed real estate 

schemes. Also look for Oliver Stone, who pulled a Hitchcock 

by appearing in both films as a trader. There are many shots 

of New York’s buildings and a little taste of sex, drugs, and 

materialistic excess as the young lions get outrageous bonuses. 

Oliver Stone is one of my bête noirs. His outlandish attempts 

to rewrite history, his admiration for Castro and Chavez, and 

his inane pronouncements characterizing Hitler as simply a 

“product of his time” and extolling the “good” side of Stalin, 

have discredited him in my view. Still, I must commend him 

for clearly being ahead of the curve with these two films. 

He was filming the first one in 1985 and released it in 1987, 

when the financial crash occurred. As for the second, he was 

promptly on the case of the 2008 debacle in that the film began 

shooting that year. He also has highlighted the fact that 

wealth in America was once based on the production of goods. 

That has changed in the computer age, when information 

can make or break individuals and companies and paper has 

replaced tangible goods as the currency of wealth. He presumably 

learned that lesson from his father, who was a broker at 

Shearson Lehman into the 1980s. Maybe he should give up 

making pictures and be “the canary in the coal mine” in the 

corner at those federal watchdog group meetings. 

Conviction 

Starring Hilary Swank, Sam Rockwell, Minnie Driver, Juliette 

Lewis and Peter Gallagher. 

Directed by Tony Goldwyn. Rated R. Running time 107 minutes. 

I 

’m conflicted about Conviction. I attended a screening with 

a friend and if I had driven my own car, I would have been 

gone after the first fifteen minutes. If I had been watching it 

at home, I certainly would have gonged it. Here’s why. The 

film opens in 1980 with a long handheld camera sequence 

panning over a grisly, blood-soaked murder scene in Ayer, 

Massachusetts, where a woman named Katharina Brow had 


The physician at the movies 

been stabbed over thirty times. This is followed by rapid 

clips of two children, Kenny and Betty Anne Waters, stealing 

from and trashing the lady’s house, getting punished by their 

mother who gave birth to nine children by seven fathers, and 

being sent to foster homes, intercut with scenes of them as 

adults. Kenny (Sam Rockwell) is clearly a certifiable sociopath, 

alternating between turning on the charm and acting out his 

violent temper. He is repeatedly taken into custody by policemen 

who profess to like him and excuse his behavior. The 

scene that really turned me off was where he is in a bar dancing 

with his little child in his arms at a family celebration. A 

person he accidentally knocks into questions his taking such 

a toddler into a bar and at that time of night. Kenny slowly 

puts his child down and goes over and punches out the guy’s 

lights. Then he turns on the charm by buying everyone a drink 

and does a full striptease to the amusement of his family and 

the patrons. I found this scene hard to believe as well as to 

stomach. 

After the woman is killed, Kenny is confronted by the police 

and detective Nancy Taylor (Melissa Leo) while sawing 

wood at his home next door to the murder scene. He fights 

being arrested and although he has an alibi, Taylor, whom he 

taunts, is seemingly out to get him. Two years later during the 

funeral for his grandfather in a Catholic Church, the police 

march down the aisle and interrupt the service to haul him off 

to jail in handcuffs. I’ve lived in Massachusetts and that just 

wouldn’t happen. I realize that this is a movie where the story 

is fictionalized, but this whole setup is ludicrous. 

I hung in for the rest of the story, which was fairly predictable 

but did raise some interesting issues. Kenny is brought 

to trial; the evidence consists of his having blood type O, the 

same as the perpetrator, and testimony that he had indeed 

been the killer by two ex-girl friends, one of whom he was 

living with at the time and with whom he had had a child. In 

1983, he is sentenced to life without parole. His sister Betty 

Anne (Hilary Swank) is sure he is innocent and devotes her life 

to exonerating him. A high school dropout, she gets her GED, 

a bachelor’s degree, and a law degree from Roger Williams 

Law School. With the help of law school classmate Abra Rice 

(Minnie Driver) and Barry Scheck (Peter Gallagher), cofounder 

of the Innocence Project, she uses DNA evidence to 

exonerate Kenny in 2001 after eighteen years of incarceration. 

During this period her devoted husband leaves her because 

of her obsession on behalf of her brother and all the time 

that her studies take away from the family. Her two children 

receive little attention, given her time at school and work as 

a waitress in a bar. The children ask to live with their father, 

although they appear to come back to her when he remarries. 

It’s particularly interesting that all the publicity and reviews 

refer to her doing this as a “single mom,” but she certainly 

didn’t start out that way. 

The film ends when Kenny is freed and reunited with his 

daughter, who had been estranged from him presumably 

because his weekly letters were intercepted by her mother 

and she believed that he was the killer. The filmmakers don’t 

mention that Kenny died six months after his release. The 

few write-ups that do mention his death say only that he died 

“tragically,” without giving the details. Actually, he died scaling 

a fifteen-foot fence taking a shortcut to a convenience 

store. He fell on his head and was later found dead. In 2009, 

the town of Ayer settled his estate’s civil rights suit for $3.4 

million. 

In addition to those cited earlier, there were other problems 

with this movie. First of all, I was puzzled by how little attention 

was paid to developing Taylor’s character to gain insights 

into her willingness to frame Kenny as well as at least one 

other person. The only reason posed is that it was tough being 

a female detective in those days. Really! Does that justify 

framing people? Would they have us believe that women who 

pioneered in those positions had to do that to gain awards? 

That’s an insult to them. In addition, she seemed to have suffered 

no consequences beyond being given a desk job. 

I was also struck by the lack of attention to solving the 

murder. The police spent two fruitless years investigating a 

murder that cried out for seeking someone who knew the 

victim and hated her with a passion. Given all the evidence 

at the crime scene, consisting of fingerprints, hair, and blood, 

they dawdled before nailing the wrong guy. There was also 

no mention of using the DNA database even though it was 

operational years later. The emphasis was on exoneration, not 

solving the murder. Not only that, but the producers never 

met with the victim’s children to tell them of the movie, which 

justly troubled them, another example of how negligent they 

were in touching base with the principals in the case except 

for Betty Anne Waters. 

Okay, what are the redeeming features? First, the acting. 

Hilary Swank, who is in almost every scene, although she 

never seems to age, gives an earnest if unexceptional performance. 

Still, I predict she will earn an Oscar nomination in 

this year’s Erin Brockovich secular saint category. Much better 

is Juliette Lewis in a small role as Roseanna Perry, a reclusive 

alcoholic girlfriend with rotten teeth and a loopy demeanor 

who is persuaded by Taylor to testify that Kenny was the killer. 

Interestingly, Lewis never met the actual person she plays and 

a blogger who knew the woman said neither she nor her teeth 

were anything like what was portrayed in the film, although 

Kenny did knock out two teeth which she got replaced. 

Getting the story right seems to take a back seat to an Oscar 

nominating performance. By contrast, Sam Rockwell gives a 

riveting pull-out-all-the-stops performance that doesn’t sugarcoat 

Kenny. He should win the Academy award for Best Actor, 

given that the Academy loves anti-heroes, especially those that 

are somewhat depraved. Rockwell drew from his hardscrabble 

youth as a rebel in a home broken by divorce when he was 

five and as someone who committed petty crimes, to create 

a character who alternates between Dr. Jekyll and Mr. Hyde. 


Hilary Swank and Sam Rockwell in Conviction. Photo by Ron Batzdorf. 

The film also shows how misleading evidence based on 

blood typing was in the days before DNA testing was available. 

The film credits Barry Schenk and the Innocence Project 

he co-founded in 1992 at Cardozo School of Law of Yeshiva 

University in 1992 for providing the guidance that got Kenny 

off. They receive thousands of requests per year and have been 

able to use DNA evidence, as of November 2, 2010, to exonerate 

261 convicted felons, some of whom had been on death 

row. This figure is impressive, and I couldn’t help but marvel 

at the fact that DNA evidence could be exculpatory but in the 

case of O.J. Simpson insufficient to obtain his conviction, in 

part because DNA testing was impugned by the defense. 

Finally, there is an interesting sidebar involving Martha 

Coakley, the attorney general of Massachusetts who lost the 

senatorial contest to Scott Brown in 2010. She is portrayed as 

a villain because she was presumably the Middlesex County 

District Attorney (DA) when Taylor framed Kenny, and who 

gave Taylor an award. She’s also shown stonewalling the performance 

of the DNA testing and then refusing to act on the 

results when the DNA evidence exonerated him. Actually, 

she didn’t become the Middlesex County DA until 1998. 

Furthermore, her office not only facilitated the testing and 

a second test to corroborate it but she moved to vacate the 

conviction three days after receiving the test results and he 

was freed within two weeks. After a screening, she graciously 

complimented Swank and ascribed the misrepresentation 

to the need to telescope events in movies. She cheerfully 

lamented that it hadn’t been a good year for her. 2 It’s hard 

to understand the motives of the director and screenwriter. 

I am not a litigious person but I would sue for defamation of 

character, especially since the film opened two weeks before 

she stood for re-election as Massachusetts Attorney General. 

References 

1. The Innocence Project—About Us: Mission Statement. www. 

innocenceproject.org/about/Mission-Statement.php. 

2. Gelzinis P. Martha Coakley: Movie’s “inaccurate” but a 

“delight.” news.bostonherald.com/news/columnists/view. 

bg?articleid=1288682. 

Dr. Dans (AΩA, Columbia University College of Physicians and 

Surgeons, 1960) is a member of The Pharos’s editorial board and 

has been its film critic since 1990. His address is: 

11 Hickory Hill Road 

Cockeysville, Maryland 21030 

E-mail: pdans@comcast.net 



David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors 

The Checklist Manifesto: How 

To Get Things Right 

Atul Gawande 

New York, Metropolitan Books, 2009 

Reviewed by David A. Bennahum, 

MD (AΩA, University of New Mexico, 

1984) 

In The Checklist Manifesto, his latest 

lucid and elegantly written analysis 

of how to improve health care, Atul 

Gawande addresses the idea that the 

simple introduction of checklists to patient 

care can reduce costs and save 

lives. In each of his books and essays 

Gawande has engaged the reader’s interest 

with stories that illustrate specific 

points and problems. Here he begins 

with a surgical case that had been 

recounted to him by a physician 

colleague about a patient who 

had almost exsanguinated 

from an abdominal stab 

wound so deep it had 

cut the aorta. 

There are a thousand ways that 

things can go wrong when you’ve 

got a patient with a stab wound. But 

everyone involved got almost every 

step right—the head-to-toe examination, 

the careful tracking of the 

patient’s blood pressure and pulse 

and rate of breathing, the monitoring 

of his consciousness, the fluids 

run in by IV, the call to the blood 

bank to have blood ready, the placement 

of a urinary catheter to make 

sure his urine was running clear, 

everything. Except no one remembered 

to ask the patient or the emergency 

medical technicians what the 

weapon was. 

“Your mind doesn’t think of a 

bayonet in San Francisco,” John 

could only say. p3 

The staff knew that the patient had 

been stabbed, but he was comfortable 

and talking so no one thought to ask 

with what and then consider the possible 

consequences of a deep stab wound. 

In the second case, a patient undergoing 

surgery to remove a cancer of the 

stomach suddenly went into cardiac 

arrest. Because the patient had a low 

potassium before surgery the anesthesiologist 

had given him corrective dose of 

potassium. Gawande in his understated 

but dramatic style quotes the surgeon. 

I was chagrined at having missed 

this. An abnormal level of potassium 

is a classic cause of asystole. 

It’s mentioned in every textbook. 

I couldn’t believe I overlooked it. 

Severely low potassium levels can 

stop the heart, in which case a cor- 

rective dose of potassium is the remedy. 

And too much potassium can 

stop the heart, as well—that’s how 

the states execute prisoners. 

The senior anesthesiologist 

asked to see the potassium bag that 

had been hanging. Someone fished 

it out of the trash and that was when 

they figured it out. The anesthesiologist 

had used the wrong concentration 

of potassium, a concentration 

one hundred times higher than he’d 

intended. He had, in other words, 

given the patient a lethal dose of 

potassium. p6 

The patient was lucky and survived, 

but Gawande uses these stories to argue 

for a simple method to prevent such 

errors, a checklist. In the first chapter 

he writes about problems of extreme 

complexity and how training and practice 

can achieve astonishing results; 

but he argues that in medicine we expect 

miracles such as that offered by 

penicillin. We have lost the discipline 

that a methodical approach requires. 

More than 50 million operations are 

performed annually in the United States 

and Americans undergo an average of 

seven operations in a lifetime. Yet we 

suffer 150,000 post-surgical deaths each 

year. Gawande writes: 

Moreover, research has consistently 

showed that at least half our deaths 

and major complications are avoidable. 

The knowledge exists. But 

however supremely specialized and 

trained we may have become, steps 

are still missed. Mistakes are still 

made. p31 


To better understand this idea 

Gawande turns to the introduction 

of checklists in 1935 by the U.S. Army 

Aircorps when it was flight-testing the 

aircraft that would become the B17 

bomber, the famous Flying Fortress. 

After a number of flight failures the 

aeronautical engineers realized that the 

complexity of the modern airplane required 

not better test pilots but rather 

a simple method to prevent mistakes, 

the checklist. He follows this by reminding 

the reader of the four vital signs to 

which a fifth sign, pain, has recently 

been added and asks whether these are 

not checklists that guide nurses. 

Gawande recounts the remarkable 

experience of Dr. Peter Pronovost at 

Johns Hopkins in 2001. Provonost identified 

five steps that a physician must 

take to place a central line and then 

asked the nurses to observe whether 

every physician unfailingly followed 

each step. In more than a third of the 

patients, doctors skipped at least one. 

Pronovost then persuaded the hospital 

administration to allow the nurses to 

stop any physician who had skipped a 

step. Over the next year “the ten-day 

line-infection rate went from 11 percent 

to zero.” p38 Only two line infections 

occurred over the next fifteen months! 

Pronovost had proven that checklists 

raised baseline performance. 

Gawande then goes on to explore the 

use of checklists in several industries 

and the literature on complexity. He 

reports that researchers have defined 

three categories of problems: simple, 

such as baking a cake; complicated, 

such as sending a rocket to the moon; 

and complex, such as raising a child. He 

notes the evidence in favor of checklists 

for simple and complicated problems, 

then asks whether checklists are also 

helpful in situations of great complexity. 

To address that question he cites 

data from the building industry about 

the construction of massive skyscrapers. 

And there again he found checklists 

at every level and “an annual avoidable 

failure rate of less than 0.00002 percent.” 

p71 

Gawande finds that checklists “are 

not comprehensive how-to guides, 

whether for building a skyscraper or 

getting a plane out of trouble. They 

are quick and simple tools aimed to 

buttress the skills of expert professionals.” 

p128 He writes that on January 14, 

2009 the World Health Organization 

came out with a “Safe Surgery” checklist. 

The very next day Captain Chesley 

B. Sullenberger III saved U.S. Airways 

Flight 1549 after a flock of Canada geese 

flew into and stalled his aircraft’s engines. 

While the cool demeanor, good 

judgment, and experience of the pilots 

and crew were crucial, no less so were 

the years of attention to detail and the 

relentless discipline of their aviation 

checklists. 

This is a marvelous and elegant 

book. It is an important if very simple— 

but not simplistic—contribution to the 

medical literature, as is almost everything 

that Gawande writes. While most 

of the book focuses on the application 

of checklists to technical practice, there 

is one point that I found very appealing. 

Gawande describes that as a surgeon 

introducing the checklist to his own 

surgical teams he now asks that they 

begin each operation by reintroducing 

themselves to each other, thereby leveling 

the distinctions between physicians, 

nurses, and technicians and creating 

a team of the moment for the benefit 

of the patient. Captain Sullenberger 

pointed out that he and his crew were 

also a team, each equally important to 

the final outcome. At the core of The 

Checklist Manifesto is a plea for an ethic 

of relationship between individuals who 

work together on any project and especially 

for those with a commitment to 

excellent patient care. 

Dr. Bennahum is a book review editor for 

The Pharos and a member of its editorial 

board. He is emeritus professor of Internal 

Medicine at the University of New Mexico 

School of Medicine. His address is: 

1707 Notre Dame Drive NE 

Albuquerque, New Mexico 87106 

E-mail: dbennahum@salud.unm.edu 

The Jump Artist 

Austin Ratner 

New York, Bellevue Literary Press, 2009 

Reviewed by Jeffrey L. Ponsky, 

MD (AΩA, Case Western Reserve 

University, 1971) 

I n the tradition of Chekhov, Somerset 

Maugham, and William Carlos 

Williams comes another MD who writes 

beautiful and compelling literary fiction. 

Austin Ratner, a graduate of Johns 

Hopkins Medical School, turned to fiction 

as a career after receiving his MD. 

His debut novel, The Jump Artist is a 

worthy addition to the ranks of literary 

historical fiction. 

The history that forms the basis for 

the novel is fascinating and largely unknown. 

Philippe Halsman was a young 

Latvian Jew hiking with his father in 

the Tyrolean Alps when his father 

fell to his death while walking behind 

Philippe on the hiking path. In an affair 

dubbed in Europe “The Austrian 

Dreyfuss Affair,” Philippe was arrested 

and convicted of his father’s murder 

and imprisoned in an Austrian jail for 

two years, despite only circumstantial 

evidence. The young, still adolescent 

Halsman was thrown into a world of 

horror and only released by a pardon, 

not an exoneration, after the tireless 

efforts of his sister Liouba and the assistance 

of human rights activists all 

over the world, including such notables 



as Albert Einstein, Thomas Mann, and 

Eleanor Roosevelt. After being released 

from prison, the young Halsman was 

expelled from Austria permanently and 

went to Paris, to try fulfill his father’s 

dream for him of becoming an engineer 

or doctor. After much struggle, Philippe 

became a well-known Parisian photographer, 

only to flee Paris as the Nazis invaded. 

Penniless and stateless, Philippe 

emigrated to the United States and rose 

to become one of the country’s most 

celebrated photographers of the 1950s 

and 1960s. His name may be unfamiliar, 

but his work we all know: the famous 

headshot of Albert Einstein, Marilyn 

Monroe in a white dress backed into a 

corner, Salvador Dali with the curling 

moustache, the Duke and Duchess of 

Windsor jumping in the air. Halsman 

had more Life magazine covers to his 

credit than any photographer in history. 

The story of The Jump Artist is 

compelling as an arc from despair to 

triumph, but it is not in the straightforward 

telling of the story that this strong 

debut novel succeeds. Rather, Ratner 

writes the inner life of a human being 

who has experienced a level of trauma 

beyond imagination. His vivid descriptions 

of prison, of helplessness, and of 

the unearned, but agonizingly felt, guilt 

of a victim and survivor are so richly 

imagined that the reader feels that he 

comes to know the interior Halsman. 

We feel his adolescent struggles with 

a father whom he loved and venerated 

but was irritated by, his haunting sense 

of loss, his shocked passivity in the face 

of victimization, and his self-loathing, 

so common in victims of trauma. As 

he tries to make sense of his surreal 

experience, he moves to art just as the 

surrealist movement is gaining sway in 

Europe, and his use of the camera begins 

to move him into the outside world. 

The camera captures the full range of 

human emotion, from the surreal to 

the playful to the beautiful. As Halsman 

slowly allows love and art into his life, 

he reclaims his life. Ratner’s use of language 

and his strong artistic storytelling 

draws the reader deep into Halsman’s 

world and, as the novel builds, we root 

for his success, hoping he will overcome 

the tragedy of his youth. It is not just the 

story that stays with you, it is Halsman 

the human being. 

As physicians we are always struggling 

to understand the human condition. 

This stunning novel does what all 

truly fine novels should do. It illuminates 

an understanding of the human 

condition through its moving exploration 

of trauma, suffering, and redemption. 

Dr. Ponsky is the Oliver H. Payne Professor 

and chairman of the Department of 

Surgery at Case Western Reserve University 

and the Surgeon-in-Chief of University 

Hospital at Case Medical Center in Cleveland. 

His address is: 

University Hospitals, Case Medical 

Center 

Department of Surgery 

11100 Euclid Avenue, LKS-5047 

Cleveland, Ohio 44106 

E-mail: jeffrey.ponsky@uhhospitals.org 

Henry Kaplan and the Story of 

Hodgkin’s Disease 

Charlotte De Croes Jacobs 

Stanford, California, Stanford University 

Press, 2010 

Reviewed by William M. Rogoway, 

MD 

The 1960s and early ’70s were times 

of significant change in the approach 

to cancer therapy in this country. 

As the hazards and potential benefits of 

radiation therapy became more widely 

appreciated, it became a powerful treatment 

tool. At the same time, drugs were 

developed that not only led to tumor 

shrinkage, but, in the case of childhood 

leukemia, could eradicate disease. 

Henry Kaplan was a towering figure in 

this heady time of oncologic creativity. 

Charlotte Jacobs traces Kaplan’s beginnings 

in Chicago as the older son 

of Russian immigrants, recounting the 

early death of his father and his determined 

mother’s struggles to keep the 

family afloat financially and to further 

her favorite child’s ambitious goals. This 

story is interwoven with the history of 

the gradual recognition of Hodgkin’s 

disease as an entity, from Thomas 

Hodgkin’s original cases to Dorothy 

Reed’s defining pathologic description, 

as well as the development of radiation 

therapy from a scientific curiosity to a 

therapeutic tool. By the time Dr. Kaplan 

graduated from Rush Medical College 

in 1941, a rudimentary understanding 

of the disease with which he became so 

identified existed and radiotherapy had 

been used as treatment. 

Dr. Jacobs outlines Henry Kaplan’s 

rapid professional trajectory from 

trainee to chairman of Radiology at 

Stanford Medical School at age twentynine; 

the remainder of the book is devoted 

to his diverse and impressive 

scientific and personal achievements. 

The over-riding theme is that of a brilliant 

physician driven to ever-more ambitious 

goals. 

Where does one begin? The Stanford 

linear accelerator that permitted higher 

energy and more targeted x-ray therapy, 

the willingness to deliver higher doses 

of radiation to wider fields in the quest 

for Hodgkin’s disease cure, the identification 

of the mouse leukemia virus and 

the search for a human viral etiology for 

malignancy, attempts to create antibodies 

to human tumors. Kaplan gained 


credit for all these, sometimes leaving 

the contributions other investigators 

played in these advances forgotten or 

little noted. While he played a pivotal 

role in the clinical development of the 

accelerator and aggressively pushed its 

use forward, other clinicians at other 

centers were moving in the same direction. 

Dose escalation and contiguous 

uninvolved field therapy built heavily on 

the work of the Canadian Vera Peters, 

and an understanding of the logical 

pattern of Hodgkin’s disease spread was 

very much a product of his colleague 

Saul Rosenberg. Kaplan never did identify 

the elusive human tumor virus and 

monoclonal antibody success was left 

to others. 

Kaplan’s lasting scientific achievement 

was the rigorous investigation of 

Hodgkin’s disease. He and his associates 

pioneered the randomized clinical trial, 

answering one question and proceeding 

to the next in single institution studies 

with the single-minded goal of curing 

the disease and lessening the complications 

of therapy. 

Concurrent with his science, HSK, as 

his associates knew him, attempted to 

reshape Stanford’s medical school in his 

image. From the time he became chairman 

of Radiology, he assumed a leadership 

role in creating a research-oriented 

school as the university moved its medical 

school campus from San Francisco 

to Palo Alto. He was instrumental in recruiting 

a sterling faculty that included 

three future Nobel Laureates. As his 

department grew, he envisioned a nationally 

sanctioned comprehensive cancer 

center, but as his dream threatened 

to dominate the school, close colleagues 

withdrew support and the center never 

happened. This was a devastating and 

embittering defeat. His struggles, sometimes 

very contentious, with deans and 

other faculty were legendary, his failures 

and successes are carefully chronicled. 

There were forays as well in the national 

scientific scene and HSK played 

a key role in refining the 1971 National 

Cancer Act that paved the way for a 

dramatic increase in funding for cancer 

research and NCI independence. 

Throughout his career, HSK developed 

a few close professional and 

personal relationships. These were significant 

scientists whose common characteristic 

seemed to be the same drive, 

ambition, and dismissiveness toward 

others less forceful. Perhaps most interesting 

is the thorough account of his 

evolving friendship with Dr. Vincent 

DeVita, who was key in developing curative 

combination drug therapy for 

Hodgkin’s disease that rivaled Stanford’s 

radiotherapy efforts and who ultimately 

became the director of the National 

Cancer Institute. In interviewing over 

one hundred of his colleagues, patients, 

friends, and family members, Dr. Jacobs 

was able to bring detail to HSK’s fascinating 

and multifaceted life and his 

impact on others. Particularly revealing 

are first-person recollections of confrontations 

with associates and friends 

whose views differed from his. His 

close, though imperfect, relationship 

with his children is tenderly presented. 

Dr. Jacobs has authored a loving account 

of a powerful figure. While the 

chronology is painstaking, I’m not sure 

that one comes away with a balanced 

picture of this giant of American medicine. 

As Dr. Jacobs writes toward the 

end of her book, “anonymity wasn’t 

Henry’s way. If you had the chance to 

reach your goal, you grabbed it.” p310 He 

began poor with a very visible physical 

deformity, a brilliant mind and a desire 

to achieve. He worked tirelessly and 

with tremendous self-assurance built 

a scientific career that was outstanding. 

While not detailed in the book, at 

a time when radiation oncology was a 

relatively new discipline, his early trainees 

became department chairs at half 

a dozen academic medical centers. He 

had talents and a drive beyond most, 

but alienated many associates and his 

own brother. While warm and compassionate 

toward patients, he could be dismissive 

to associates. While he was very 

public in much of what he did professionally, 

his humanitarian work was carried 

out with much less flourish. He was 

a complex and flawed man, but indeed 

a visionary who brought a scientific 

rigor to the practice of oncology and 

helped move Hodgkin’s disease from an 

untreatable malignancy to one for which 

cure is now the rule. Dr. Jacobs’ book is 

a riveting read, meticulously covering a 

time of dramatic creativity in American 

medicine while also revealing the personal 

infighting that took place behind 

the scenes. 

Dr. Rogoway is a member of the editorial 

board of The Pharos and emeritus adjunct 

clinical professor of Medicine at Stanford 

University. His address is: 

266 Old Spanish Trail 

Portola Valley, California 94028 

E-mail: rogoway@stanford.edu 

The National Institutes of 

Health: 1991–2008 

John Kastor 

New York, Oxford University Press, 

2010, 271 pages 

Reviewed by Jack Coulehan, MD 

(AΩA, University of Pittsburgh, 1969) 

W hen I did my internship at the 

Hospital of the University of 

Pennsylvania, John Kastor was a rising 

star in Penn’s Division of Cardiology. 

He was also one of my favorite attending 

physicians, partly because of excellent 

teaching and obvious commitment to 



patients, but also because of his compassion 

for students and house officers. At 

the end of my rotation with Dr. Kastor, 

he invited our whole team to his home 

for dinner. And a splendid evening it 

was! I remember that dinner as an island 

of warmth and conviviality in the 

often turbulent sea of internship. Since 

then, Kastor has become one of the nation’s 

most prominent cardiologists and 

a leading figure in American medical 

education. He is the author of several 

important books on academic medicine, 

including Governance of Teaching 

Hospitals (2003), Specialty Care in 

the Era of Managed Care (2005), and 

Selling Teaching Hospitals and Practice 

Plans (2008). These works focus, in particular, 

on issues of governance in large 

health care institutions. 

In his new book, The National 

Institutes of Health: 1991–2009, Kastor 

turns his attention to “the premier organization 

for performing and funding 

biomedical research in the United 

States.” pxi The book is primarily a description 

of the structure, function, mission, 

finances, and priorities of the NIH 

over nearly two decades, a period that 

spans the terms of three NIH directors: 

Bernadine Healy, Harold Varmus, and 

Elias Zerhouni. While the author presents 

plenty of “hard” historical facts, 

the real energy of his book arises from 

its human perspective: 222 interviews 

of present and past NIH administrators 

and scientists and other knowledgeable 

observers, conducted over a nearly 

two-year period. The text relies heavily—and 

appropriately—on quotations 

from these interviews, which provide 

the reader with a sense of living history. 

The NIH consists of twenty research 

Institutes and seven Centers, five of 

which serve as providers of infrastructure 

and support for the institutes. The 

NIH budget in 2008 was around $29 

billion, eighty-five percent of which 

supported extramural research, i.e., 

grants to universities, hospitals, and 

laboratories throughout the United 

States. Another ten percent funded the 

intramural research program, which 

employs over one thousand scientists 

at its Bethesda campus, as well as a 

large number of trainees. The final five 

percent of the budget was devoted to 

administration. The individual research 

Institutes range in size from the enormous 

National Cancer Institute (NCI, 

$4.8 billion budget) and National Heart, 

Lung and Blood Institute (NHLBI, $2.9 

billion) to the tiny National Institute for 

Nursing Research (NINR, $139 million). 

It requires over seventy separate administrative 

entities—and their acronyms— 

to fully characterize the structure and 

governance of the NIH. Fortunately, the 

reader need not internalize most of this 

alphabet soup to gain a basic understanding 

of the organization, although 

for the interested masochist Kastor provides 

an appendix listing every single 

acronym and its meaning. 

As an academic physician, I found 

some of the trends described in The 

National Institutes of Health especially 

interesting. First, although I was aware 

that the NIH budget had grown in 

the 1990s, I had no idea of how much. 

During the six-year period 1998 through 

2003, its budget more than doubled 

from $13.6 to $27.1 billion, an average 

increase of about fifteen percent per 

year. Even more amazing was the sustained 

average annual eight and a half 

percent increase over the preceding 

twenty-seven years (1971–1997). On the 

other hand, during most of the Bush era 

(2003 through 2008), the NIH budget, 

when corrected for inflation, suffered an 

annual decline. 

Another interesting point was the 

historical trend of the NIH’s intramural 

research training program. Kastor 

writes of the “yellow berets,” physicians 

commissioned in the United States 

Public Health Service and assigned to 

the NIH in the 1950s, ’60s and ’70s, 

who provided the nation with a large 

pool of budding physician scientists. In 

subsequent decades, as the doctor draft 

ended and NIH research training became 

less attractive to young physicians, 

the size of this pool decreased, resulting 

in the NIH having more difficulty 

recruiting physician investigators for its 

intramural programs. However, the NIH 

still provides the major source of financial 

support for the training of physician 

scientists through its Medical Scientist 

Training Program (MSTP), which supports 

MD/PhD students in medical 

schools throughout the country. 

Finally, I learned for the first rime 

about the “Roadmap for Medical 

Research,” a strategic plan developed 

in 2002 and 2003 by then-NIH director 

Elias Zerhouni. Zerhouni wrote, “It was 

clear to me that science had changed, but 

the NIH had not.” p179 A “convergence of 

concepts and methodologies” had made 

many of the traditional rigid distinctions 

between disciplinary Institutes outdated. 

Zerhouni initiated a process to answer 

such questions as “What are today’s 

scientific challenges?” and “What are 

the roadblocks to progress?” This led 

to a strategic plan, which, among other 

things, placed new emphasis on clinical 

research. Zerhouni also set aside funds 

for Roadmap projects, a practice later 

endorsed by Congress when it created 

the “Common Fund” as a separate pool 

of money to support the initiation of innovative 

interdisciplinary projects. 

In The National Institutes of Health: 

1991–2008, John Kastor has written a 

clear, concise, and highly informative 

book that will serve as a useful entrypoint 

for anyone interested in gaining 

a basic understanding of the structure 

and inner workings of the NIH. As a 

bonus, the book also presents a human 

perspective on the NIH’s recent history, 

with fascinating insights on the process, 

as well as examples of the content, of 

NIH intramural research. 

Dr. Coulehan is a book review editor for 

The Pharos and a member of its editorial 

board. His address is: 

Center for Medical Humanities, Compassionate 

Care, and Bioethics 

HSC L3-080 

State University of New York at Stony 

Brook 

Stony Brook, New York 11794-8335 

E-mail: jcoulehan@notes.cc.sunysb.edu 


Letters to the editor 

�� 

Edward D. Harris, M.D. 

1937 — 2010 

�� 

Poetry and Ted Harris 

I never met Ted Harris. Never spoke 

a single word to him. I only knew him 

as the editor of a journal I enjoyed 

reading. About ten years ago, I sent Dr. 

Harris a letter expressing my desire to 

serve on The Pharos editorial board. 

I practice and teach internal medicine 

in a small community in Central 

Virginia. Although I’ve been interested 

in the humanities since college, there 

was little in my CV to suggest I was 

qualified to serve. He did not grant 

me a position, but asked me to review 

submissions. I accepted. I was eager to 

review articles on history, philosophy, 

and literature. 

Every few months, Ted would send 

me a poem. I waited for essays to be 

sent; they never came. What did I 

know about poetry? Not much. As 

soon as a poem arrived, I analyzed the 

poem as best I could and immediately 

returned it. This went on for years. I 

began to study poetry, and read it 

every day. 

You know how the story 

ends. Ted (and Debbie 

Lancaster) gave me 

a position on the 

board in 2004. 

It’s been a wonderfully rewarding experience, 

and I’m forever grateful. 

Ted gave me something else: poetry. 

He also showed me how to open 

academic doors for others. 


Lynchburg Family Medicine Residency 

Lynchburg, Virginia 

Vicarious respect for Ted Harris 

I only met Dr. Harris briefly, and 

that was unrelated to medicine. I barely 

knew him personally, yet I think I had 

an insight many did not. Imagine my 

surprise when receiving this summer’s 

Pharos, and immediately recognizing 

him on the cover. Needless to say, I was 

a little stunned, as this to me was so 

unexpected. 

Let me backtrack a little to the early 

1960s. I had recently moved with my 

parents to a small bedroom community 

on the West Shore of Harrisburg, 

Pennsylvania. My Latin teacher that 

year was a stern taskmaster, the way it 

used to be—and perhaps should still 

be. No nonsense was tolerated, and total 

respect was demand by Mrs. Harris. 

Somehow I survived. By my senior 

year, I had enough seniority to get a 

coveted paper route. By chance, she 

became my customer. She lived alone 

in a modest home that had a large, flat 

front yard. More on that later. I eventually 

graduated from Camp Hill High 

School, some ten years after her son 

had. 

Fast forward to my general surgery 

residency in 1975 at the Dartmouth 

Affiliated Hospitals in Hanover, New 

Hampshire, and White River Junction, 

Vermont. In those days, residents 

were indeed residents. We leaped at 

any chance to do something “normal,” 

and the annual medical school tennis 

tournament was just that excuse. My 

doubles partner and I were soundly 

defeated in the first round by none 

other than Ted Harris, that being my 

only personal encounter. Soon after 

that, though, he brought his mother to 

live in Hanover. She would often visit 

and go shopping with my wife, also a 

Camp Hill alumna. Mrs. Harris proved 

to be hugely independent, intelligent, 

and quite friendly, all surprising attributes 

considering my opinion as an 

adolescent. By the way, she informed 

us, her front yard had been a grass tennis 

court, where her son had learned 

the game well, permitting our paths to 

eventually cross. 

Can it be just a coincidence how 

all our lives are intertwined in some 

way? The passing of Dr. Harris abruptly 

engendered in me a fear of my own 

mortality. Yet is only DNA immortal 

as it passes from one generation to the 

next? I think not. The human lives we 

as physicians and teachers touch and 

influence daily, no matter how briefly, 

in some intangible way create another 

pathway to gain a sense of immortality, 

through their achievements as well. We 

both came from a small town, yet Ted 

Harris rose from humble beginnings to 

achieve grander things, to change the 

lives of many. His revitalized Pharos 

became an extension of his personality 

that again influenced me later as a “senior” 

attending. Hopefully, it will survive 

his loss. The world will be a lesser 

place without him. 

Geoffrey G. Hallock, MD 

(AΩA, Jefferson Medical College, 1975) 

Allentown, Pennsylvania 


Instructions for Pharos authors 

We welcome material that addresses scholarly and nontechnical 

topics in medicine and public health such as history, 

biography, health services research, ethics, education, 

and social issues. Poetry is welcome, as well as photograph/ 

poetry combinations. Photography and art may also be 

submitted. Scholarly fiction is accepted. All submissions are 

subject to editorial board review. Contributors need not be 

members of Alpha Omega Alpha. Papers by medical students 

and residents are particularly welcome. 

Submissions must meet the following criteria: 

1. Submissions may not have been published elsewhere 

or be under review by another journal. 

2. Essays should have a maximum of 15 pages (approximately 

5000 words), and be submitted in 12-point 

type, double-spaced, with one-inch margins. They should 

be accompanied by a covering letter and a title page with 

the word count (or page count), return address, and e-mail 

address. Papers exceeding the page count noted will be 

returned to the author. References should not exceed 20 

unique items (see below). 

3. Poems or photograph/poetry combinations should be 

in 12-point type, with one-inch margins, with the author’s 

name, address, and e-mail address on the first page. 

4. Electronic submissions are preferred. Send them to 

info@alphaomegaalpha.org. Or send by mail to Richard L. 

Byyny, MD, Editor of The Pharos, 525 Middlefield Road, 

Suite 130, Menlo Park, California 94025. 

5. After peer review, comments on the manuscript will 

be sent to the author along with an editorial decision. Every 

attempt is made to complete preliminary reviews within six 

weeks. 

6. The editors of The Pharos will edit all manuscripts 

that are accepted for publication for style, usage, relevance, 

felicity, and grace of expression, and may provide appropriate 

illustrative material. Authors should not purchase illustrative 

material because the editors cannot guarantee that it 

will be used. 

7. In accordance with revised copyright laws, each contributor 

will need to sign an Author’s Agreement, which will 

be sent with the edited galleys. Information on copyright 

ownership and re- publication of articles is detailed in the 

Author’s Agreement. 

Reference information 

Authors are responsible for the accuracy of citations and 

quotations in their papers. Once a manuscript has been accepted 

for publication, therefore, the author will be required 

to provide photocopies of all direct quotations from the 

primary source material, indicating page numbers. (Please 

mark the quoted material on the photocopies with highlighter.) 

In addition, the editors will require photocopies of 

all references: the title page and copyright pages of all books 

cited, the first and last pages of book chapters cited, and the 

first and last pages of journal articles cited, as well as the 

Table of Contents of the particular issue of the journal in 

which the cited article appeared. The foregoing items will be 

used to verify the accuracy of the quotations in the text and 

the references cited, and to correct any errors or omissions. 

The photocopies will not be returned. 

References should be double-spaced, numbered consecutively 

in the text, and cited at the end in the following 

standard form: 

Journal: Zilm DH, Sellers EM, MacLeod SM, Degani N. 

Propranolol effect on tremor in alcoholic withdrawal. Ann 

Intern Med 1975; 83: 234–36. 

Book: Harris ED Jr. Rheumatoid Arthritis. Philadelphia: 

WB Saunders; 1997. 

Book chapter: Pelligrini CA . Postoperative 

Complications. In: Way LW, editor. Current Surgical 

Diagnosis and Treatment, Ninth Edition. Norwalk (CT): 

Appleton & Lange; 1991: pp 25–41. 

Each reference should be listed in the bibliography only 

once, with multiple uses of a single reference citing the same 

bibliography reference number. Examples are available at 

our web site: www.alphaomegaalpha.org. 

Citation of web sites as references is discouraged unless a 

site is the single source of the information in question or has 

official or academic credentials. Examples of such sites are 

official government web pages such as that of the National 

Institutes of Health. Encyclopedia sites such as britannica. 

com are not primary references. 

Leaders in American Medicine 

In 1967, as a result of a generous gift from Drs. David 

E. and Beatrice C. Seegal, Alpha Omega Alpha initiated a 

program of one-hour videotapes featuring interviews with 

distinguished American physicians and medical scientists. 

The collection has been donated to the National Library 

of Medicine, which will maintain it for permanent use by 

scholars visiting the library. A listing of tapes available 

for loan from AΩA can be found on our web site: www. 

alphaomegaalpha.org, or by contacting Debbie Lancaster at 

d.lancaster@ alphaomegaalpha.org or (650) 329-0291. Those 

wishing to purchase copies may do so by contacting Ms. 

Nancy Dosch, manager, Historical Audiovisuals, History 

of Medicine, Building 38, Room 1E-21, 8600 Rockville Pike, 

Bethesda, Maryland 20891. Telephone (301) 402-8818, e-mail 

nancy_dosch@nlm.nih.gov.

2 The Pharos/Winter 2008

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