Arthur K. Asbury, MD, FCPP

By David Woods, PhD, FCPP

Following a stellar career of faculty and hospital appointments and a lengthy list of awards, honors and honorary memberships, multiple publishing positions including that of chief editor of the Annals of neurology, and numerous publications and administrative positions, Art Asbury is what is known in thoroughbred racing circles as a stayer: at 85, he still shows up daily at the University of Pennsylvania as part of a research project exploring genetic factors in diabetes.

Actually, the racing metaphor is quite an appropriate one. His father, a surgeon, bred racehorses in Kentucky, one of which, a colt named Determine, won the Kentucky Derby in 1954. Art recalled that he was so excited he threw his hat in the air and never retrieved it. Later, he too got into breeding thoroughbreds. And, to compound the metaphor, he lived for 20 years in a converted horse barn in Center City before  moving some months ago to a condominium at Naval Square, from where he walks the six blocks to Penn; or, if weather precludes that, he’ll drive there in his trusty ten year old Honda.

Actually, Art is something of a thoroughbred himself, having attended the upscale Phillips Academy in Andover and completing his internship and residency in medicine, neurology and pathology at prestigious Mass General and a teaching fellowship at Harvard. He was chair of the University of Pennsylvania’s Department of Neurology… and served as vice dean for research, vice dean for faculty affairs , and for three years as interim dean of that Ivy League University. He also became in 2002 a Fellow of the Royal College of Physicians of London, which required passing a stringent exam. He did manage to get to the races while in the UK, though.

So why did he choose neurology as a specialty? By chance, a friend at the University of Cincinnati, where Art acquired his MD, in 1958, was a classmate who had worked as an EEG  technician When he left that position, took it on full-time for two summers. The research that he did then confirmed his interest in neurology… and getting published in the Annals of Neurology, of which he later became chief editor between 1985 and 1992, cemented that interest. Neurology has changed dramatically during his career, he says. It used to be “in the backyard – a subset of medicine or psychiatry; now it’s a specialty in its own right.”

Among his more than 130 visiting professorships and invited lectureships were the Eric Kukelberg keynote lecture in clinical neurophysiology in Israel and honorary professorships at the teaching hospital at Shijiazhuang and the Hebei medical college in China.

Between 1951 and 1953, Pfc. Asbury saw active service in the US Army reserve at Fort Miley, Texas, where he was an instructor in the Guided Missiles Group.

 Not surprisingly, his biography has appeared in Who's Who in America, Who's Who in Medicine and Healthcare, and Who's Who in Education… and the Arthur K. Asbury award for outstanding faculty mentoring is given to a senior faculty member at Penn Medical School annually.

His involvement in the College of Physicians of Philadelphia dates back to 1974. He became president twice––in 1981 and in 2004; he also served as interim CEO while the College was searching for a full-time executive director, eventually appointing Dr George Wohlreich to that position, which Art believes was a very good move, given the poor track record  of a couple of the previous incumbents.

Asked about some current policy issues in healthcare, Art shows his diplomatic skill. Of the Affordable Care Act he believes that it will be okay––if it works. Similarly, of the prospect of a single-payer healthcare delivery system, he says the same thing… but believes it would not be easy to put in place.

Art had three children through his first marriage, which ended in divorce; and in 1980 he married Carolyn Holstein, a Wharton PhD, who commutes daily to the Dana Foundation in New York where she is an adviser on clinical neuroscience research proposals. She leaves by train at  6:45 am and returns in time for dinner at 8. The pair met at a medical conference in New Orleans and, says Art,”I bypassed all the lectures and spent time talking and talking with Carolyn.” Both of them are trustees of the College of Physicians of Philadelphia… and both enjoy the Philadelphia Orchestra, and Phillies baseball, where they have enjoyed season tickets for 30 years. The couple spend two weeks in Maine in the summer.

Asked what he has learned in some 8 decades on this planet, he says that the most important thing is successful interpersonal relationships. “I work at making friends,” he says.

You can reach David Woods at HMI 3000@Comcast.net or on his website at www.Davidwoods.info

Who’s for Tennyson? The case for language and literature in medical school

By David Woods, PhD, FCPP

In his impious 1911 glossary The Devil’s Dictionary Ambrose Bierce defined a physician as “one upon whom we set our hopes when ill and our dogs when well.”

But in today’s medicine, our hopes are more likely to rest with an array of sophisticated technologies and gadgetry, rather than with a human being. Dr. Jerry Vannatta, former dean of the University of Oklahoma College of Medicine, says: “This technology has become a religion within the medical community.  It is easy to lose sight of the fact that still, in the 21st century ... 80 to 85 percent of the diagnosis is in the patient’s story.”

Yet many physicians today lack either the skill, the time or the inclination to listen to that story – a talent that used to be called bedside manner. This is a shame because of the four elements in communication – speaking, reading, writing and listening – listening is learned first, is used most through life and is taught least through all the years of schooling. Yet deficiencies in listening and the ensuing failures of communication are a major source of wasted time, ineffective operation, miscarried plans and frustrated decisions. In medicine, they can also be a source of error and litigation.

But according to the New York Times “It is this lost art of listening to the patient that has been the inspiration behind a burgeoning movement in medical schools throughout the country: Narrative Medicine.” This is part of a growing trend towards exposing medical students to the humanities in much the same way as Drexel provides such courses to first year engineering students.

Narrative Medicine’s founder, Dr Rita Charon, teaches such a course at Columbia University’s medical school. In the 19th century, she says, doctors carefully and humbly visited with patients – listened to them; and not just with a stethoscope. Parenthetically, the inventor of that instrument, R.T. Laennec, required his medical students to take exhaustive notes after seeing a patient. Dr. Charon believes that medicine has been struggling to come close to the patient ever since that time. “Medicine,” she says, “is beholden to the singular experience of individual patients; we’ve always known this. But it’s been eclipsed by a heady optimism that because we understand organ systems and molecular biology we understand the patient.”

If you listen to patients’ lament, she says, “It’s not that ‘my doctor can’t open my stent;’ it’s that ‘my doctor doesn’t listen to me.’” Not that Dr Charon has much time for bland exhortations to create a more caring and empathic medical profession. “What’s needed,” she says, “is the prescription; the How.”

And that’s what Narrative Medicine is about: reading, writing, perceiving – paying attention. Since 1982, Dr Charon’s students have been analyzing in literary terms that which they hear and read. It has to do with eliciting nuance and subtlety.

She emphasizes that this is no soft option course. Not only are Columbia med students required to take graduate level humanities courses, the material itself is presented in a highly rigorous and disciplined manner. Says Dr Charon, who is an internal medicine physician who also has a doctorate in English: “When I teach Henry James here, I do so as I would in the English Department.”            

Dr Charon’s group also produces a seminannual journal, Literature and Medicine, which is published by Johns Hopkins University Press. And Oxford University Press  published her book Narrative Medicine: Honoring the Source of Illness.

Another well-known exponent of communication skills for medical students was the late Norman Cousins. Cousins, who wrote Anatomy of an Illness, the story of his diagnosis and treatment for ankylosing spondylitis, was an eminent journalist who went on to teach medical students at UCLA. In an interview with him some years ago, he told me that he’d developed a survey of 500 patients. One of the questions was: ‘If you’ve ever changed doctors – why?’ “That really got the attention of the students,” he recalled.

Cousins went on to say that “What is required {of a doctor} is the deepest possible understanding of what the patient is talking about. Respect for the patient” His survey yielded such responses as ‘He was a very competent physician but he really didn’t know what my problem was;’ or ‘I admired him as a doctor but I had no confidence in him as a human being.’ Cousins’ conclusion: It’s the style of the physician, not the competence of the physician, that is the yardstick people use for keeping or changing their doctors.

Cousins further believed that “medicine begins with science but treatment of human beings involves artistry. Physicians need to marry art to science.” Moreover – shades of Narrative Medicine – Cousins told me that “novelists portray the physician not just as a prescriber of medicaments but as a symbol of all that is transferable from one human being to another.”

All of this is not simply to create a new layer of kinder, gentler doctors ... or to graft some Gray’s Elegy onto Gray’s Anatomy. It’s to rediscover a fundamental part of the diagnostic and therapeutic process, one that will make the patient’s medical encounter more productive and less frightening. ‘Doctorspeak’ too often means jargon that’s incomprehensible to patients, who may not be at their receptive or emotional best. And the impersonal “put the emphysema in the other ward and bring the prostate biopsy in here” doesn’t help. Nor does the absolving “We” -- also favored by royalty and editorial writers -- as in “How are we, today?” or “We see a lot of that.”

Novelist and psychologist Liam Hudson says there’s a “crisis of intelligibility” among scientists, and notes that the truth can best be grasped by prose that is itself vigorous, disciplined, and plain. Noting that scientists are barely able to utter a sentence that does not include the key words situation, interaction and role, Hudson says that by contrast the business of writing a novel or a poem is one of highly-wrought discipline. What lies between scientists and their subject matter, he says, is an inadequate grasp of the English language. Their grasp can be tightened by reading, interpreting – and understanding -- the great writers.

Tennyson, anyone?

You can reach David Woods at hmi3000@comcast.net or at www.davidwoods.info

Walter Tsou, MD, MPH

By David Woods, PhD, FCPP

 
Despite the high-profile positions he's held as Health Commissioner of Philadelphia and as President of the American Public Health Association, Dr Walter Tsou is a pretty unassuming guy. An adjunct professor of family medicine and community health at Penn, he wears his erudition and his accomplishments lightly.

But that doesn't mean he isn't a passionate proponent of public health and a stalwart advocate for a single-payer healthcare system, serving on both the National Board of Public Health Examiners and national Board advisor to Physicians for a National Health Program (PNHP).

At 60, he now focuses mainly on family life with his wife Jean Lee, a nephrologist, and his 13-year-old daughter, Casey, who definitely won't go into medicine, she says, because she hates the sight of blood. Coming relatively late to family life Walter notes wryly that he gets to read Modern Maturity and Parent magazine

Asked what’s given him the most professional satisfaction he unhesitatingly points to the hands-on practice of public health. A particular joy was when he served as deputy director for personal health services and medical director of the Montgomery County Health Department and helped to stamp out hepatitis B among  local schoolchildren. He also appreciated the autonomy that that job gave him, in contrast to his role as Philadelphia Health Commissioner where he came up against Mayor John Street’s bureaucracy.

Walter’s medical degree is from the University of Pennsylvania and his MPH from Johns Hopkins School of Hygiene and Public Health. He started out in internal medicine, but wound up working in a public health clinic, and the rest, as they say, is history.

As for the Affordable Care Act, while he acknowledges that its introduction has been far from stellar, it's also not a simple matter to launch such a convoluted software program. In fact, he says, a single-payer system would not only be more streamlined but would encourage doctors to join organized medicine.

Of his rather low-key manner, he says that if you preen too much you can become a target. People like to shoot at targets, he says, and this is especially true for public health physicians who are highly visible. If they’re seen munching on hamburgers, drinking, or lighting cigarettes someone’s sure to jump on them.

One public health issue that could find Walter in the cross hairs is fracking. He believes that the current methodology which involves millions of gallons of water  creates a health risk. “We have to be careful,” he says, “and look to less dangerous ways of extracting shale.”

If the government has difficulty in introducing so-called Obamacare, is there any hope that it could run a national health program? Well, PNHP has some 18,000 members, and thinks it can. And Walter Tsou agrees, noting that the US is the only advanced country that doesn’t have such a program. The barriers, he believes, are the strong and well-heeled lobby groups in the pharmaceutical and private insurance industries.

Both Walter and his wife are of Chinese extraction and he serves on the board of the Asian Pacific Islander American Health Forum. Among his many accolades is the Public Health Recognition Award from the College of Physicians of Philadelphia, where he is a trustee. He believes that the College is a wonderful source of both social and educational activity. And you may see him at either. Just don't expect him to preen. He's better at asking questions than answering them … noting that his Myers-Briggs score suggests he would have made an  excellent journalist.

Since he and Jean enjoy the theater, ballet, and movies maybe Walter’s next career will be as an arts reporter or movie critic.

But he won’t tell everyone.

You can reach David Woods at hmi3000@comcast.net or at www.davidwoods.info

The Future of Medical Publishing

By David Woods, PhD, FCPP

(excerpted from a speech to students at Jefferson's College of Graduate Studies.)

Commenting on the future of anything is a mixed blessing. On the one hand, for an editorialist it offers an irresistible combination of temptation and opportunity; on the other hand, one is mindful of the many who have upended themselves memorably on the banana peel of prediction.

For instance, in 1800, Thomas Malthus, a practitioner of what later became known as "the dismal science" of economics, famously foretold of a world population imminently to be extinguished by its inability to feed itself. Today, a senior fellow of the Hoover Institute claims that "the entire population of the world could be housed in the state of Texas, in single-story houses -- four people to a house -- and with a typical yard around each home."

This assumes, of course, that you could persuade them all to move to Texas.

In 1943, Thomas Watson, then-chairman of IBM, stated confidently that there was a world market for about five computers. And C.P. Scott, crusty editor of the (then Manchester) Guardian is said to have snorted: “Television? The word’s half Greek and half Latin: no good can possibly come of it.”

No wonder Yogi Berra vowed that he would predict anything except the future.

Since Thomas Wakley published the first issue of the Lancet in 1823 – as he put it “to put an end to mystery and concealment” in the world of medicine -- the sum total of medical knowledge has increased explosively (today there are some 25,000 biomedical journals) and the speed at which communication is achieved has been even more dramatic. In Wakley's time, the speed of communication was no faster than a human or a horse could carry it. Today's communication is about two-thirds of a billion miles per hour. The good news is that that's as fast as it can go.

Unless, of course, Einstein was wrong.

The bad news is that costs have no such limitations. While Wakley’s Lancet sold for sixpence, average annual subscription prices for medical periodicals surged from $51 in 1977 to a whopping average four-digit price in many instances today. No wonder Cornell University  decided to review and severely prune the $1.7 million a year it was paying mega- medical publisher Elsevier for some 930 science journals.

In his book 'The Inarticulate Society', Tom Shachtman says that Americans today watch 1,500 hours of television a year, which means about 50 days a year; or, if we extrapolate a bit, roughly nine years by the time they reach 65 if they haven’t expired earlier from boredom. By contrast, they spend a combined total of only 290 hours reading newspapers and magazines. Part of this decline in literacy, says Shachtman, is the chasm between the literate-based and oral languages. He refers to a computerized scale of comprehension skill in which a "level of difficulty" of an article in a scientific journal, Nature, rates 58.6 units, compared with a sample of Time magazine at 6.8 and of The National Enquirer at minus 10.3. He then goes on to note that "knowledge derived from {print} tends to remain more detailed, to stay with us longer, and to be more broadly based than what we receive from television." Perhaps that's why the three principal medical television companies have ceased to exist in the past couple of years.

Neil Postman, professor of communications at New York University, points out that the process of reading encourages rationality. Postman -- surely a felicitous eponym for the bearer of such an epistle -- says that a printed page containing a narrative or argument that unfolds line by line encourages a more coherent view of the world than does a slambang broadcast of quickly changing, high-impact images.

In any event, there's a wonderful invention known as the Box Of Organized Knowledge. It has no electrical circuits or wires or mechanical parts, can be used anywhere, and consists of a number of sheets of paper bound together. The symbols on each sheet are absorbed optically and registered on the brain. This phenomenon is known by its acronym B.O.O.K.

The Economist, in a special report on the future of medicine, noted that doctors are finding it hard to absorb ever more information, and that American doctors typically spend no more than three hours a week educating themselves. And for most of them, the report says, applying the knowledge gained from reading journals has become as much an art as a science. The information can often be conflicting and few doctors have any idea how to resolve such conflicts. Not that this is a new phenomenon. More than a century ago Sir William Osler noted: "It is astonishing with how little reading a doctor may practice medicine, but it is not astonishing how badly he may do it."

What does this mean for publishing? It means a whole new set of opportunities. Healthcare professionals are avid for management information, and  customer service and legal and ethical issues are all assuming new significance; new technologies need to be explained; information technology has to be demystified. It’s hardly surprising that an estimated 2% of our $2.5 trillion a year healthcare system is now spent on consultants trying to figure out, and explain, what’s happening! For medical writers the opportunities are huge. Not only in interpreting the enormous and complex advances in medical science, but also in exploring and clarifying the healthcare delivery issues that affect all of us: Affordability is perhaps the main one. But also the need for ‘wiring’ healthcare; the aging population; increasingly sophisticated (and expensive) technology; malpractice and medical error; consumer power; quality and consistency of care; the 44 million or so uninsured Americans; the threats posed by biologic, chemical and radiologic weapons; re- thinking the way we train health professionals  and the continuing, nagging issue of what former Penn professor of medicine the late Dr. Bill Kissick called “Infinite needs versus finite resources.”

So with paper costs rising, journal advertising declining, subscription prices forcing libraries -- and individuals -- to cut back on purchases but still to demand the best and most current information, is the way to do it an electronic way. A superhighway?

Well, radio existed for 38 years before it had 50 million listeners; television took 13 years to reach that number; the Internet got there in just 4 years. Today, the overwhelming majority of US physicians access the Internet… with medical libraries and publishers' sites ranked highest among doctors who use the web for professional reasons.

To be sure, the Internet is more quirky and less linear than print. Whoever said that freedom of the press is greatest for those who own one was unwittingly prescient. Traditional publishing is an ex-cathedra affair, top-down, hierarchical. Electronic publishing is essentially egalitarian. Not only that, but in the electronic age, publishers may not be the only ones doing the publishing. Universities  may be the sleeping giants of publishing with the World Wide Web having turned every university into a publisher and every faculty member into an author; after all, the University's business is knowledge creation, transmission, and management.

And incidentally, anyone who enters chat rooms on the Internet will readily see that it's only a matter of time before we return to grunts and hieroglyphics. In medicine, where clarity and simplicity in communication are vital, there is a crisis. Illegible handwriting is one thing; unintelligible speech and prose are quite another.

 In sum, I see a synergistic broadcasting of information through a variety of media… with quality and relevance and credibility of the material being the principal factors governing the user's choice of medium. In fact, the British medical Journal suggests an amalgam of short print articles hitched to a more detailed version of the same thing online. The Journal also whimsically leans on the Simpsons to illustrate changes in medical publishing. After noting that such publishing is changing dramatically because of many forces, the editors posit four possible futures: In the wise (Marge) world, academics innovate and publish primarily on the web, not in journals; publishers must publish large numbers to succeed. In the lazy (Homer) world, publishers adapt to the electronic world and continue to publish research. In the well-informed (Lisa) world publishers have largely disappeared and communication takes place mainly through global electronic conversations.  And in the streetwise (Bart) world, publishers have largely disappeared, and large organizations have become the main purveyors of research.

As the Association of American publishers puts it: " there are some who will rightly conclude that the changes in medical publishing are so enormous, and the sociological  adaptability lacks so far behind, the business of print-based publishers will continue to be robust way into the 21st century.