Robert Wachter, Champion of Quality and Patient Safety What Drew Them to Medicine? Members of the Class of 2019 Explain
Principles, Service, and Satisfaction
Photo by Daniel Burke Each year at the White Coat Ceremony, a faculty member who exemplifies the humanistic physician is selected to speak to the incoming class. This year, it was Jack Ludmir, M.D., G.M.E. ’87. Ludmir is chair of Obstetrics and Gynecology at Pennsylvania Hospital. An expert in maternal-fetal medicine, he has been honored for his strong advocacy for assuring that the underserved and uninsured receive maternal care. He is one of the founders of Puentes de Salud and Latina Clinic Health Services. Ludmir began his talk by noting that medicine “is the greatest profession and career choice in the world.” He proceeded to share the principles that helped him to have a more fulfilling career. His first principle: To be a doctor is to have a privilege – use it well. Talk to your patients, get their stories. Always keep in mind the way you would want to be treated if you were a patient. 2. This profession is not about us but about our patients. It is important to find a niche and to promote yourself through research and scholarship. But remember you’re starting this journey not to fulfill your professional
3. Intellectual curiosity and pursuit of new knowledge. Don’t take dogma and repetition as the only truth. Ludmir gave an example from his own career. For many years, he prescribed absolute bed rest to pregnant patients to decrease the risk of premature birth. But recent randomized clinical trials have shown that bed rest actually increases the risk. 4. Fight health inequalities and advocate for your patients. Lack of access to health care and mental care continues to be a problem, even in Philadelphia. Try to understand the important role that the social determinants of health play. You can fight for the just thing – health for all regardless of the ability to pay or legal status. 5. You are human and you will make mistakes. You are here to learn and accept that medicine is not a perfect science; sometimes adverse outcomes will occur even with the best treatments. Don’t shy away from them; instead learn, discuss, disclose. 6. Finally, resilience and perseverance. Find your own way to constantly reinvigorate yourself, whether it’s family,
development but to make a difference in the well-being of another person.
sports, arts, hobbies, etc. Remember that you can make a difference in the life of a human being.
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Left THE PREP Principles, Service, and Satisfaction 2 VITAL SIGNS The Physics of Cancer 36 DEVELOPMENT MATTERS Honoring One of the Nation’s Greatest Cancer Pioneers 38 ALUMNI NEWS Progress Notes and Obituaries 44 EDITOR’S NOTE CTE and Fracking: Back in the News 45 ONE LAST THOUGHT Zion Harvey Tests His Hands
STAFF John R. Shea, Ph.D. Editor Graham P. Perry/NCS Studios Design / Art Direction ADMINISTRATION Susan E. Phillips Senior Vice President for Public Affairs Holly Auer, M.B.E. Director of Communications
17 33 FALL 2015 / VOLUME XXVI NUMBER 3
Fracking and Public Health: Finding the Best Balance 8 By Mark Wolverton
The experts in Penn’s Center of Excellence in Environmental Toxicology seek the facts that are essential for decisions that affect our environment. The center’s role is all the more important when there is controversy.
14 An Illuminated Mind Offers “Mind Illuminated” By John Shea
Greg Dunn, a Penn Med Ph.D., combines his neuroscience training with his creativity and skill to create distinctive works of art. And he continues to experiment, taking his art in new directions.
Restoring Function . . . and Quality of Life 17 By Sally Sapega and John Shea
American cancer survivors now number 14 million. Mously Le Blanc, M.D. ’06, has found a niche providing care for the late side effects of the therapies that cured them.
20 Welcome to Wachter’s World |
By Marshall Ledger
Bob Wachter, a recent recipient of the Distinguished Graduate Award, is a professor, a hospitalist, an author, a blogger, a ruminator, an occasional performer . . . but his constant causes are quality and patient safety.
26 The Path to Penn Medicine |
By John Shea
Another class of exceptional students has entered the medical school. Their experiences, college majors, and interests can vary greatly, despite their common urge to join the health professions. Here’s a look at some of these highly motivated young people.
33 In Equal Parts: Physician and Poet |
By John Shea
William Carlos Williams, who distinguished himself in two very different fields, can be an inspiration for experienced physicians and medical students alike. His advice for both doctors and writers: deal in particulars.
Penn Medicine is published for the alumni and friends of Penn Medicine by the Office of Public Affairs. © 2015 by the Trustees of the University of Pennsylvania. All rights reserved. Address all correspondence to John Shea, Penn Medicine, 3535 Market Street, Suite 60 Mezzanine, Philadelphia, PA 19104-3309, or call (215) 662-4802, or e-mail email@example.com.
Visit Penn Medicine’s web site: http://www.uphs.upenn.edu/news/publications/PENNMedicine/
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New Penn Center Will Investigate the Physics of Cancer
A five-year, $10 million grant award from the National Institutes of Health is supporting the creation of the Physical Sciences Oncology Center at Penn (PSOC@Penn). It is one of four centers the National Cancer Institute is funding across the country as part of its Physical Sciences in Oncology Network. The network was started in 2009 in recognition of the fact that perspectives rooted in physics, mathematics, chemistry, and engineering can all contribute to cancer research. Members of the Penn team will make fundamental physical measurements as they clarify mechanisms of how tumors become palpably distinct masses and also how such physical changes contribute to tumor growth. Their research will focus on liver cancer. More than 30,000 people in the United States
Lancaster General Health Joins Penn Medicine
Effective August 1, Lancaster General Health, Lancaster County’s largest health system, officially became part of Penn Medicine. The state and federal agencies concluded their review of the proposed deal. The combination joins one of the nation’s top academic medical centers with a health system that is nationally ranked for its clinical quality. Both are among the top five systems in Pennsylvania, as ranked by U.S. News & World Report. “Joining the University of Pennsylvania Health System strengthens our region’s access to cost-effective, high-quality 2
are diagnosed each year with liver cancer, according to the American Cancer Society, and the five-year survival rate is less than 15 percent. New methods to improve early detection and treatment of the disease are needed. The Penn team is drawn from three University schools: the Perelman School of Medicine; the School of Engineering and Applied Science; and the School of Arts and Sciences. Heading the center is Dennis E. Discher, Ph.D., the Robert D. Bent Professor in SEAS. According to Discher, “A key challenge facing cancer research in this age of precision medicine is to deeply comprehend the molecular causes and consequences of tissue changes that are often first measured by clinicians in physical exams of tumors.” Investigators representing the Perelman School are Rebecca G. Wells, M.D. (Medicine), Paul A. Janmey, Ph.D. (Physiology), Emma E. Furth, M.D. (Pathology), David E. Kaplan, M.D., MSc. ’07, (Gastroenterology & Immunology), Roger A. Greenberg, M.D., Ph.D. (Cancer Biology), and Mark A. Lemmon, Ph.D. (Biochemistry and Biophysics). “Many tumors are first detected as hard lumps of stiff tissue,” Wells said. “In some cases such as breast cancer, increased tissue stiffness appears to be a risk factor for cancer. Our research will focus on liver cancer because current clinical evidence suggests that liver stiffening may work in the same way, as a high-risk factor for developing that disease.” The Center also aims to understand how the shape of the cell’s nucleus changes as part of a response to altered microenvironments. Whether and why such processes might also lead to damage of the DNA contained therein will be important to quantify, because DNA damage is a likely cause of mutations that drive cancer.
care, will improve our communities’ health and well-being, and will strengthen our complementary teaching and research missions,” said Thomas E. Beeman, then serving as the president and CEO of LG Health. Penn Medicine will provide for the health care needs of the LG Health community for as long as the system is affiliated with Penn Medicine. LG Health’s assets will continue to be used to advance the health and well-being of the LG Health community. Two of LGH’s 14 trustees will be selected by Penn Medicine and three LG Health trustees will join Penn Medicine’s board.
Transitions Thomas E. Beeman, Ph.D., formerly president and CEO of Lancaster General Health, was named the chief operating officer of regional operations for Penn’s Health System. Jan Bergen succeeded him in both roles. In his new role, Beeman will work closely with senior leaders of UPHS to guide its regional market and ambulatory strategy; facilitate system-wide integration across entities, starting with LG Health; and coordinate relationships with important partners across market regions. He will oversee LG Health and The Chester County Hospital and work closely with Garry Scheib, the chief operating officer for Philadelphia operations. Beeman has more than 35 years of experience in health care and served as
HUP’s senior vice president for hospital operations and executive director in the late 1990s. Bergen has more than 30 years of experience in health care, including management of hospitals, ambulatory centers, and rehabilitation centers. In her 15 years as a leader at LG Health, she has been executive vice president and COO, as well as chief mission officer. Frederic D. Bushman, Ph.D., a widely recognized leader in the fields of microbiology and gene therapy, was appointed chair of the Department of Microbiology. He holds a secondary appointment as a professor of pediatrics. Bushman was instrumental in the formation of the Microbiome Program of Penn
and Children’s Hospital and serves as the program’s co-director. His early pioneering work in understanding how HIV reproduces by inserting its genetic material into the DNA of a host cell led to crucial advances in antiretroviral therapy and gene-transfer technology. Today, many research projects in his lab utilize deep-sequencing methods to investigate genetic mechanisms and DNA integration in human gene therapy. A fellow of both the American Academy of Microbiology and the American Association for the Advancement of Science, Bushman received a Pioneer Award from Human Gene Therapy in 2014. James M. Metz, M.D., G.M.E. ’00, the Morton M. Kligerman Professor of Radiation Oncology, was named chair of the Department of Radiation Oncology. Metz, who has served as interim chair since November 2014, has held a series of administrative positions in the department, beginning in 2005 when he was appointed director of clinical operations. Metz led the development of the Roberts Proton Therapy Center and helped to establish it as one of the premier such centers in the world. He has been a pioneer in the use of online cancer survivorship plans and web-based cancer education and information. Metz was also the longtime editor-in-chief of OncoLink, the nationally recognized online source for cancer information, and now serves as its executive director.
Abramson Cancer Center Shines
The Abramson Cancer Center has received an “exceptional” rating from the National Cancer Institute during an extensive peer-review process for its five-year competitive research support grant. It is the highest rating possible for an NCI cancer center. The rating also signifies that Abramson’s status as a “comprehensive” center has been renewed. The designation means that the center demonstrates an added depth and breadth of multidisciplinary laboratory, clinical, and population-based research, as well as substantial transdisciplinary research that bridges these scientific areas. “This is an exceptional cancer center and, importantly, one with a ‘soul’ and unmatched esprit de corps,” said Chi Van Dang, M.D., Ph.D., director of the center. Since the last competitive renewal process in 2010, faculty physicians and researchers have amassed more than 5,000 cancer-related publications, and the center’s research initiatives have been buoyed by an increase in peer-reviewed funding from the NCI. FALL 2015
VITAL SIGNS Grading High
In the annual U.S. News & World Report survey of hospitals, the combined enterprise of HUP and Penn Presbyterian Medical Center was ranked as the 9th best hospital in the United States and #1 in the region. According to the magazine’s editors, this distinction “signals both rare breadth and rare depth of medical excellence.” Pennsylvania Hospital and Chester County Hospital were part of a four-way tie for #8 in the Philadelphia metro area. In all, Penn Medicine hospitals were recognized for their excellence in 13 specialties. This year, U.S. News analyzed nearly 5,000 hospitals in the nation. In addition, the University of Pennsylvania Health System has been ranked as one of the top academic medical centers by the Ambulatory Care Quality and Accountability Ranking
“Wellcome” Support for Launching Biomedical Research Careers
Five researchers early in their careers have received funding for five years from the Burroughs Wellcome Fund (BWF) for their excellence in biomedical research. Three are in the Perelman School: Rajan Jain, M.D., an instructor in the Department of Medicine; Matthew Stern Kayser, M.D. ’07, Ph.D., an assistant professor of psychiatry and neuroscience; and Rahul Manu Kohli, M.D., an assistant professor of infectious diseases in the Department of Medicine. Jain studies the mechanisms of genome organization and how that influences cardiac cell development and maturation in order to better understand heart disease. Specifically, he studies the protein network that surrounds the nucleus and how that is emerging as an important scaffold to organize large pieces of DNA that affect gene expression. Jain will receive $700,000 over five years. Kayser studies the mechanisms by which sleep, a critical and highly conserved biological process, controls brain development. He aims to examine whether abnormal sleep early in life increases susceptibility to neurodevelopmental disorders and how sleep itself might be harnessed as a novel therapeutic modality. Kayser will receive $700,000. Kohli studies new approaches to antibiotic-resistant bacteria. There is some evidence that when bacteria experience stress, they can mutate at higher rates, which would facilitate their escape from antibiotics. Kohli plans to evaluate this possibility by generating bacteria strains to directly tune stress responses and determine how evolutionary dynamics are altered when the bacteria are challenged with antibiotics. Kohli will receive $500,000. The other Penn researchers are Ann M. Hermundstad, Ph.D. a postdoctoral researcher in physics and astronomy in the School of Arts and Science, and Igor E. Brodsky, Ph.D., an assistant professor of pathobiology in the School of Veterinary Medicine. 4
of the University Health System Consortium. In this new ranking by the consortium, Penn’s system ranked #3 out of 46 academic medical centers that took part in the inaugural study. The new award honors AMCs that demonstrated excellence in five areas: access to care, capacity management and throughput, quality and efficiency, continuum of care, and equity. Pennsylvania Hospital’s Emergency Department was one of four hospitals to receive this year’s Lantern Award. Only 58 of the more than 5,000 EDs in the country hold that distinction. The award recognizes emergency departments that exemplify exceptional practice and innovative performance in the core areas of leadership, practice, education, advocacy, and research.
Penn Medicine and Virtua Health have formed a strategic alliance to jointly develop and coordinate programs to benefit both organizations across their respective mission areas. Particular emphasis will be on coordinating patient management and delivering high-quality and cost-effective patient-care services. Both organizations will continue to function independently but expect to form expanded partnerships on certain initiatives, particularly in strengthening clinical programs in Virtua’s local market and improving access to tertiary and quaternary care provided by Penn Medicine. Located in Southern New Jersey, Virtua is an integrated delivery system comprising three acute-care hospital, surgical centers, group-practice physician offices, urgent-care clinics, and rehabilitation centers. It has received Leapfrog “A” grades for all hospitals and a Press Ganey Award for Patient Satisfaction. Virtua is also listed on Information Week’s 500 list of technology innovators, manages an accountable care organization, and has earned #1 Place to Work recognition. At the start, the patient-care delivery areas for the strategic alliance will focus on cancer and neuroscience programs. Penn Medicine’s radiation oncology patient quality and safety program will be followed in all Virtua hospital sites. The organizations will collaborate for the surgical and medical management of neurological diseases. Beginning in January, Penn Medicine surgeons will perform surgery at Virtua’s hospitals. These programs will be branded jointly in the Southern New Jersey market.
Honors & Awards Peter C. Adamson, M.D., G.M.E. ’87, professor of pediatrics and pharmacology and leading scientist at the Children’s Hospital of Philadelphia, had been appointed by President Obama to the National Cancer Advisory Board. He is the only pediatric oncologist currently on the board. In this role, Adamson will advise the U.S. Secretary of Health and Human Services, the director of the National Cancer Institute, and the president on a wide range of issues relating to the national cancer program. A recognized leader in drug development to combat pediatric cancer, Adamson has served as chair of the Children’s Oncology Group, the world’s largest organization devoted exclusively to childhood and adolescent cancer research. From 1999 to 2014, he was chief of the Division of Clinical Pharmacology and Therapeutics as CHOP. Rinad Beidas, Ph.D., assistant professor of psychology in the Department of Psychiatry and a senior fellow in the Leonard Davis Institute of Health Economics, was honored by the Association for Behavioral and Cognitive Therapies. The President’s New Researcher Award recognizes her robust body of early research on the dissemination and implementation of evidence-based practices – those practices proven to be most successful through clinical expertise, scientific research, and patient preference – in the treatment of youth with psychiatric disorders in community settings. Beidas also has clinical expertise in the cognitive-behavioral treatment of child and adolescent anxiety. Steven Douglas, M.D., professor of pediatrics in the Perelman School and chief of immunology at the Children’s Hospital of Philadelphia, received the 2015 Paradigm Builder Lectureship award, presented by the International Society for NeuroVirology. He is recognized for his seminal and continuous contributions to the field of leukocyte biology, with emphasis on monocyte/macrophage biology in HIV infection. David Fajgenbaum, M.D. ’13, M.B.A. ’15, a research assistant professor in the Department of Medicine’s hematology/ oncology division, has received the RARE Champion of Hope award for science. The honor recognizes his efforts in advancing meaningful research for Castleman’s disease as a researcher and for co-founding and serving as executive director of the Castleman Disease Collaborative Network, a global network of physicians, researchers, patients, and loved ones dedicated to accelerating research and treatment for the disease. The award was presented by Global Genes, a patient
advocacy organization for the patients of rare diseases. The disease involves the body’s immune system becoming activated and releasing inflammatory proteins that can shut down the liver, kidneys, and bone marrow. Fajgenbaum himself was diagnosed with idiopathic multicentric Castleman’s disease (iMCD) in 2010. He and his associates published a new model of pathogenesis for iMCD in Blood. The network is now focused on identifying what triggers the immune activation, which immune cells are activated, and what existing or novel therapies may be effective for patients that do not respond to the only therapy approved by the Food and Drug Administration. For his efforts, Fajgenbaum was also recognized in Forbes magazine’s “30 Under 30” list for health care. He has also recently accepted a position as associate director of patient impact for the Penn Orphan Disease Cent Edna Foa, Ph.D., received the 2015 Distinguished Scientific Contributions Award from the American Psychological Association. A professor of clinical psychology in the Department of Psychiatry and director of the Center for the Treatment and Study of Anxiety, Foa was recognized for her contribution to the theory and practice of psychology, specifically for the research and treatment of anxiety disorders. She is widely recognized for her major contributions to the study of psychological trauma and post-traumatic stress disorder (PTSD). Foa developed prolonged exposure therapy, a treatment for PTSD in which patients revisit the traumatic event in order to achieve long-term healing. She has also contributed to the understanding of the psychopathology and treatment of anxiety disorders, with a focus on obsessive-compulsive disorder, panic disorder, social anxiety disorder. Emily Kramer-Golinkoff, M.B.E. ’13, manager of strategic initiatives and operations at the Penn Medicine Social Media and Health Innovation Lab, was one of nine “Champions of Change” honored at the White House in July for making a difference in health treatment. A 30-year-old with advanced-stage cystic fibrosis, she cofounded Emily’s Entourage to raise funds and awareness for new treatments and a cure for the rare form of her disease. Since its founding in 2011, Emily’s Entourage has raised more than $1.5 million and led worldwide efforts to fast-track research on rare “nonsense” cystic fibrosis mutations. Caryn Lerman, Ph.D., a professor of psychology in the Department of Psychiatry, received the Outstanding Investigator Award of the National Cancer Institute, a new grant bestowed upon influential cancer researchers to provide long-term supFALL 2015
VITAL SIGNS Honors & Awards Continued port for cancer research that has a beneficial impact. Lerman, whose research focuses on the interface between neuroscience and cancer prevention, will receive $6.5 million over a seven-year period. She is senior director of Penn’s Abramson Cancer Center and co-director of the Penn Medicine Neuroscience Center. Tobacco use and obesity account for more than 45 percent of preventable cancer deaths, yet the cancer-risk behaviors are resistant to long-term change despite widespread knowledge of the risks. The new grant will support the premise of Lerman’s research: that it is possible to enhance the brain’s capacity to override behavioral habits that contribute to obesity and cigarette smoking – and ultimately to cancer. Harvey L. Nisenbaum, M.D., associate professor of radiology in the Perelman School and chair of the Department of Medical Imaging at Penn Presbyterian Medical Center, was elected president of the World Federation for Ultrasound in Medicine and Biology. The Federation has more than 50,000 members and involves more than 50 countries. One important mission is to help bring sustainable ultrasound programs to all the underserved areas of the world to help improve their health care. At the graduation ceremonies of the Perelman School of Medicine in May, Nisenbaum was presented with a Special Dean’s Award. The honor recognizes outstanding achievements in medical education by the Perelman School’s faculty members, particularly in the development of new, innovative educational programs. With the support of the school’s leaders and a generous grant, Nisenbaum was able to help develop and implement the school’s ultrasound curriculum. He believes the appropriate use of ultrasound has become a necessary skill for all future physicians. Nancy A. Speck, Ph.D., a professor of cell and developmental biology, was honored with the 2015 Henry M. Stratton Medal for Basic Science for her seminal contributions in the area of hematology research. The award is presented by the American Society of Hematology. Speck, who is associate director of Penn’s Institute for Regenerative Medicine, co-leads 6
the hematological malignancies program at the Abramson Cancer Center and is an investigator at the Abramson Family Cancer Institute. She is recognized for her important contributions to the understanding of developmental hematopoiesis as well as the translation of those findings into the study of leukemia. John Q. Trojanowski, M.D., Ph.D., G.M.E. ’80, received the Award for Meritorious Contributions to Neuropathology from the American Association of Neuropathologists. He is a professor of pathology and laboratory medicine and serves as director of the Institute on Aging. He was recognized for his long career as a leader and pioneer in the research and treatment of neurodegenerative diseases. The association described his work as a steady contribution “that spans many diseases, disciplines, genes, and domains.” Trojanowski’s aptitude for collaboration was also cited, and his most significant collaborator has been his wife, Virginia Lee, Ph.D., the John H. Ware 3rd Professor in Alzheimer’s Research. They are among the most widely cited researchers studying Alzheimer’s disease. In addition to pursuing their own research, they founded Penn’s Center for Neurodegenerative Disease Research. Kevin Volpp, M.D. ’98, Ph.D. ’98, professor of medicine and health-care management in the Perelman School and the Wharton School, was honored with the Association for Clinical and Translational Science’s 2015 Distinguished Investigator Award for Career Achievement. He also received the 2025 Matilda White Riley Award from the Office of Behavioral and Social Sciences of the National Institutes of Health. Volpp, whose research focuses on the impact of financial and organizational incentives on health outcomes, is the founding director of the Center for Health Incentives and Behavioral Economics and vice chair of health policy in the Department of Medical Ethics and Health Policy. Jeremy Wilusz, Ph.D., assistant professor of biochemistry and biophysics, was awarded a $500,000 grant from the Rita Allen Foundation. He will receive $100,000 a year for five years as a 2015 Rita Allen Foundation Scholar. Wilusz studies circular RNAs, a recently discovered version of ribonucleic acid. He and his team seek to describe and understand how circular RNAs are generated and regulated and how they function. They also investigate whether circular RNAs are misregulated in various diseases, such as cancer, and if they can be therapeutically targeted against the diseases in which they may play a role.
Penn Medicine’s Preparations for Pope Francis Our three Philadelphia hospitals stocked up and staffed up in preparation for the crowds and road closures that came with the pontiff’s historic visit to the City of Brotherly Love. Here’s a snapshot of what it took to be ready.
DURING THE VISIT, WE HAD…
AND WE STOCKED UP ON….
staff sleeping at the hospital
babies born organ transplant surgeries
Statistics of Note
pounds of sheets, towels and blankets
million worth of medication
1,830 units of blood products
Two researchers from the Center for Clinical Epidemiology and Biostatistics were part of a team honored with the 2015 Outstanding Statistical Application Award from the American Statistical Association. The Penn authors of the recognized paper are Wensheng Guo, Ph.D., professor of biostatistics, and Anne R. Cappola, M.D. ’94, Sc.M., associate professor of
pounds of chicken fingers
translation phones for non-Englishspeaking patients
endocrinology in the Department of Medicine and an associate scholar at the center. Their paper, titled “Modeling Bivariate Longitudinal Hormone Profiles by Hierarchical State Space Models,” was published in the Journal of the American Statistical Association. Guo and Cappola are the first faculty members from the Perelman School to receive this award. Guo’s research interest is broad, including functional data analysis, time series analysis, and joint modeling of longitudinal and time-to-event data. Cappola’s research focuses on the hormonal alterations that occur with aging and the clinical impact of these changes. Mary D. Sammel, Sc.D., a professor of professor of biostatistics and epidemiology at Penn, was also recently elected as a Fellow of the America Statistical Association. She was recognized for her outstanding contributions in introducing and establishing statistical science as a core aspect of the field of women’s health and reproduction research; for achieving a relevant and important body of work in women’s health; for outstanding mentoring of women and junior researchers; and for major contributions in the development of statistical methodology. FALL 2015
FRACKING AND PUBLIC HEALTH: FINDING THE BEST BALANCE
© Amy Sussman/Corbis
By Mark Wolverton
The experts in Penn’s Center of Excellence in Environmental Toxicology seek the facts that are essential for decisions that affect our environment.
ust a few years ago, the term fracking might have drawn a perplexed stare from most of the general population. But today, particularly in large parts of the United States such as rural Pennsylvania, the word isn’t just a figure of speech but a real and immediate curse word. Although fracking in common parlance has come to represent the entire range of unconventional gas and oil drilling activities, technically it refers only to 8
the technique of hydraulic fracturing or hydrofracturing: extracting natural gas from deep within the Earth by cracking open rock layers with high pressure liquids. It’s become one of the most contentious political and environmental issues of the past decade. It is a focus of bitter controversy, from the national news all the way down to the grassroots community level, as the lives and perhaps the health of residents in previously sleepy rural communities are disrupted and threatened. Meanwhile, gas well drilling in states such as Pennsylvania and North Dakota continues to expand and accelerate at so fast a pace that the concerns of residents, environmentalists, and other involved parties seem almost an afterthought. That’s certainly true from a scientific and public health standpoint, particularly in Pennsylvania, where the proliferation of well drilling seems to be inversely proportional to the available data on its environmental and health effects. At Penn Medicine, studying those effects falls under the aegis of the Center of Excellence in Environmental Toxicology (CEET). Part of the Perelman School of Medicine, CEET is also one of only twenty Environmental Health Sciences Core Centers
COVER STORY (EHSCCs) in the United States, as designated by the National Institute of Environmental Health Sciences (NIEHS). In collabMA oration with the Mailman School of Public Health at Columbia NEW YORK CONN University, Penn’s center recently published a major study MICHIGAN identifying an association between fracking and increased hospitalization rates. Their work is already having a major PENNSYLVANIA NJ impact on the fracking controversy, introducing some sorely needed facts into an issue too often muddied by passionate OHIO MD but ill-informed rhetoric on all sides. As the only EHSCC in the Environmental Protection Agency’s WEST Region III (Pennsylvania, Delaware, Maryland, Washington SHALE FORMATIONS VIRGINIA VIRGINIA DC, Virginia, and West Virginia), Penn’s center could be exKENTUCKY pected to take a particular interest in the fracking controversy. Most of those states lie firmly atop the Marcellus Shale formation, one of the major sources of natural gas to be developed and explored in recent decades. Half of Pennsylvania’s land and professor of medicine. The study, “Unconventional Gas mass, in fact, rests under Marcellus Shale. At a 2012 meeting and Oil Drilling is Associated with Increased Hospital Utilizaof all the EHSCCs, Trevor Penning, Ph.D., a professor in the tion Rates,” he notes, was rated among the journal’s top six Department of Systems Pharmacology and Translational Therviewed publications online, garnering about 14,000 views in apeutics and director of CEET, only a month and a half. “So it’s gave a presentation on potential obviously a passionate area.” Trevor Penning doubts that banning public health impacts of hydraulic Although the commotion and fracturing in Pennsylvania. “I made controversy over hydraulic frachydraulic fracturing on a national the point that this was such a comturing might be fairly recent, the plex issue that no single environscale is practical. The best we can practice itself is not. It was first mental sciences center could tackle used in Kansas in 1947. As mendo is identify the potential risks and tioned, it’s only one part of an this by itself. What we needed was to pool our resources so we could elaborate process that includes manage them by having the industry the selection of the well site, pad work collaboratively together. That led to the establishment of an inconstruction, drilling, and encasadopt safe practices. ter-center working group on hying the borehole in concrete. A draulic fracturing.” mile or more deep, the drilling And led as well to the recent study, published in the journal changes to a horizontal direction, into and along the shale layPLOS One in the summer of 2015. The lead author was Reynold ers. Then the actual hydraulic fracturing process begins, in A. Panettieri Jr., M.D. ’83, G.M.E. ’90, deputy director of CEET which the horizontal borehole is perforated by holes at various spots and millions of gallons of fracturing fluids are pumped through them at high pressures. That forces the rock layers to crack and fractures to open, releasing their coveted stores of natural gas, to be recovered and stored back on the surface.
Photos by Tommy Leonardi
Why Fracking, Why Now?
Trevor Penning: striving for scrupulous scientific objectivity.
If fracking is nothing new, why is everyone suddenly so concerned about it? The main reason is that in the past, hydraulic fracturing tended to be done in places where oil and gas drilling were already well established. But in recent years, the economics of energy production and demand, dwindling supplies of more “conventionally” obtained gas, the desire to reduce our reliance on dirtier carbon-based fuels such as coal, and the development of improved drilling techniques that make accessing formations such as the Marcellus Shale cheaper and more practical have all come together to spur a burgeoning new enterprise. That means that drilling is now being done in FALL 2015
HYDRAULIC FRACTURING PROCESS A. A perforating gun is used to make fractures in the shale and fracturing fluid is pumped into the well at high pressures forcing the fractures to crack open.
B. Fractures release the natural gas trapped in the rocks so it can rise to the surface.
These maps illustrate the growth of gas producing wells in Pennsylvania between 2008 and 2014.
thousands of locations that have never before seen anything more industrial than a passing diesel truck. Now these communities are being invaded by hundreds of trucks, heavy equipment, and noisy and smelly activities that used to happen hundreds or thousands of miles away. All these developments have literally brought home the oil and gas industry to many people who previously would encounter it only at their local gas stations. “While hydraulic fracturing is not new,” Panettieri explains, “the magnitude of the drilling is certainly different. So we have to take that into account and the proximity to populations which didn’t necessarily exist before. The other part of the equation obviously is, well, if we don’t use this fuel, we would simply continue to do coal burning. Isn’t this better than coal burning? That becomes a societal issue.” Engineers and geologists prefer to use the term fracking (with a “k”) to mean the overall drilling process and the word fracing (or frac’ing) to refer solely to the hydraulic fracturing technique. They make that distinction because some phenomena that have been blamed on fracking, such as recent earthquakes in Oklahoma, are not actually the result of hydraulic fracturing but other processes, such as the injection of waste water into deep underground wells. Whatever one’s preferred terminology, it’s the possible release of toxic materials into air or water that’s of prime concern, especially for the people living near well sites. A 2013 Wall Street Journal report esti10
Marcellus Shale Layer
mated that more than 15 million Americans live within one mile of a well drilled since the year 2000. In the rush to find and develop resources to satisfy America’s ever-increasing thirst for energy, the people most directly affected by it have more and more questions – but definitive answers remain frustratingly elusive. “How do we have no data on an enterprise of this magnitude?” asks Aubrey K. Miller, M.D., M.P.H., a senior medical advisor at National Institute of Environmental Health Sciences. “How do we have 15 million people living within one mile of a well, and we can’t answer their questions?” The reassurances from the oil and gas industry that well operators are scrupulously observing best practices often ring hollow to mothers whose children have developed mysterious rashes and other ailments or homeowners who have found their drinking water wells contaminated by unknown substances. Anecdotes and horror stories abound, as do confident proclamations of safety, but with a dearth of hard data, it’s virtually impossible to sift out truth from the rhetoric.
Assessing the Risks
“There are different ways to approach the problem,” Penning says. “One is a classical risk-assessment approach,” with four components. “Risk identification, meaning what are the hazards that we have to be concerned about as it relates to human health? I think we have a good handle on what the
What’s Real and What Isn’t Real?
The CEET/Columbia study looked at two counties in northeastern Pennsylvania where unconventional oil and gas drilling has blossomed and is continuing (Bradford and Susquehanna) and one in which no active wells are located (Wayne). Researchers looked for any correlation between the density of wells in each area and the inpatient admission rates from 2007 to 2011. “Our whole approach is an unbiased examination of the data,” says Panettieri. “What’s most important is that we look at this with glasses off, what’s real and what isn’t real.” Penning, Panettieri, and their collaborators were startled by what they found. Using data from 25 specific medical categories (e.g., cardiology, dermatology, gynecology, gastroenterology, neurology), they examined hospitalization rates within each category and county, noting any association with well activity. They expected to find fairly stable rates, considering that they were working with a time span that was relatively short, in epidemiological terms. Instead, the study found significant associations between inpatient admissions and fracking activity in a number of
medical categories, particularly for cardiology and neurology. Seeing such a strong statistical signal over such a short time is considered fairly remarkable. Says Panettieri, “It was shocking to us that we saw a signal after five years. Many epidemiological studies of toxic exposure take decades. This was fast and really speaks to maybe some major issues that need to be addressed.” But just as with any other controversial public issue, people tend to hear what they want to hear, and nowhere is that more prevalent than with fracking. “Obviously when the data came out, we were embraced quickly by all of the pundits who were against fracking, while we made no friends in the oil industry,” says Panettieri with a laugh. Careful scientists that they are, however, Panettieri and his colleagues emphasize the study’s limitations and caution against drawing premature and unfounded conclusions. The study states that “the precise cause for the increase in inpatient prevalence rates . . . remains unknown” and that “the clinical significance of the association remains to be shown.” As Penning puts it, “This is just a drop in the ocean in terms of where we could go with this approach.” He points out that there are subcategories that need to be mined to see whether certain subsets of disease show up. In addition, he says, “so far we’ve only looked at hospitalization rates. We need to look at outpatient data as well.”
Weighing the Impact on Wells and Springs
Aside from the CEET study, another draft report released in 2015 has caused a mighty stir: a study by the U.S. Environmental Protection Agency that examines the potential impact of hydraulic fracturing on drinking water sources. It focused specifically on Bradford and Susquehanna Counties in Pennsylvania, the same counties studied by CEET. Analyzing more than 225 water samples taken over a year and a half from about 40 different locations, the EPA found no evidence of any “widespread” impact on homeowner wells or springs from hydraulic fracturing, although it did find some evidence of fracking-associated methane and ethane in several wells.
Unconventional Gas Drilling in the Marcellus Shale of Pennsylvania Solid Waste Produced Annually 2,000,000
SOLID WASTE (TONS)
possible air pollutants might be. We don’t have a strong handle on the pollutants that might contaminate the water supply.” Although the hydraulic fracturing fluid used by well operators is about 99% water, the remainder is a mixture of other chemicals that varies among different companies, and the specific formulation of a company’s “fracking fluid” is considered proprietary information – a trade secret to be protected and guarded. “Therefore,” notes Penning, “we don’t know what we’re looking at.” A second component of risk assessment is to establish a solid baseline of data to identify what’s normal and what’s not. “Because of the lack of baseline data both in air and water quality, it’s tough to attribute contamination or air pollution to the process itself, because there could be other sources,” Penning explains. That, of course, provides a convenient out for industry representatives to discount the complaints and concerns of local residents. Once a particular hazard has been identified, it needs to be characterized. What are its effects? How much exposure is needed to induce what kind of responses? Again, in the fracking debate, answers to these questions are few and far between. As Penning observes, “Most things follow a dose response curve, and you need to know what the margin of safety is between the exposure and the levels that would cause a health effect. And that’s also obviously very difficult when you can’t do the hazard identification in the first place.” The final piece of risk assessment is figuring out how to mitigate risks and how to communicate information effectively both to policy makers and to residents. “So it’s a four-part approach, but it’s also sequential,” Penning says. “And we’re stuck on one and two right now. That’s what led us to actually think about designing the PLOS One study. We felt we needed some kind of broad-stroke approach to determine whether there was a signal worth looking at.”
YEAR FALL 2015
Photos by Tommy Leonardi
tive study on drinking water throughout the life of a nearby well. Water quality may significantly yet transiently change.” Howarth asserts that there is no data to determine if these changes are occurring and, if they are, what are the impacts on people’s health. Still, Penning emphasizes that the best way to resolve such contentious issues is to strive for a scrupulous scientific objectivity, which means taking biases into account, both conscious and unconscious. Many studies are not adequately designed, or their results are exaggerated or misrepresented by the press or overzealous advocates on both sides. “We get these one-liners, but you have to look at the details,” he observes. “One thing that made the PLOS One study so powerful is it’s unbiased. We didn’t have any preconception of what we should be measuring. Some of the other health studies have been focused on one or more particular health point that’s been pre-selected, so you don’t know if, based on that pre-selection, other things could have been missed.”
What Remains to Be Done?
Reynold Panettieri, here conferring with Christie Ojiaku, led the CEET study.
It was predictable that the EPA study (which remains to be finalized after review and public comment) was interpreted differently by pro- and anti-fracking camps. While those in industry saw themselves vindicated, fracking opponents criticized the EPA for pandering to oil and gas companies. The EPA has acknowledged some definite limitations in the study, and scientists such as Penning have criticized it on that score. As he explains, “we sent in a 22-page commentary that was actually not too pleasant.” The CEET experts identified what they considered serious gaps in knowledge that should have been taken into account in the agency’s executive summary. Even more emphatic is Marilyn V. Howarth, M.D., an adjunct associate professor of emergency medicine and pharmacology at the Perelman School who also serves as director of CEET’s Community Outreach and Engagement Core. “The EPA’s conclusions are premature,” she says. “Their retrospective studies found impacts on drinking water such as increased sediment and problems with clarity. No one should be expected to drink water that contains debris whether or not the debris is toxic. In addition, there has been no prospec12
Because so much remains unknown and uncertain, there’s much more work to be done. While many researchers are focusing on toxicological effects of air and water pollution from hydraulic fracturing, little attention has been given as yet to the psychosocial aspects, which may be even more important in the long run. Says Penning, “If you look at the PLOS One study, you’ll see there was a trend but not a specific association between psychological disorders as well, but specifically issues of depression, anxiety, and so on. I think psychosocial stress is a very important component of this, along with sleep deprivation.” As Panettieri points out, “These areas are pretty bucolic, they’re rural. And in comes a lot of industry very quickly setting up camp, disrupting that lifestyle, and it engenders a lot of stress. We know that chronic stress can cause cardiovascular disease and impair the immune system. We believe that with this short observation period and the rapidity and robustness of the data, there’s a stress response from noise, disruption of lifestyle, uncertainty, and air pollution from diesel truck exhaust. Our hypothesis is that a combination of chronic stress on top of air pollution rather than water pollution might be responsible for our findings.” What should be done now, while we continue to debate and study and assess and define the risks of hydraulic fracturing? It’s a question that depends heavily upon the political climate, which in Pennsylvania is undergoing a shift from the unabashedly pro-industry stance of the administration of the former governor, Tom Corbett, to the apparently more cautious administration of Governor Tom Wolf. One measure that CEET and other scientific and public health experts recommend is estab-
COVER STORY lishing a health registry to track and monitor the health of residents living near fracking sites. But while the current Wolf budget has set aside funding for a registry, it’s not nearly enough. “It was only funded to a level of $100,000 a year, which is basically one person at a computer,” Penning notes, adding, “a registry is not really a valuable tool unless there is appropriate exposure data to go with it.” That data, he says, should be based on a particular ill effect or symptom as diagnosed by a physician trained in taking exposure history. “Unfortunately, what we have in Pennsylvania – which is not unusual for the U.S. as a whole – is a lack of physicians that are actually trained in occupational environmental medicine.”
The Consensus: More Information Is Desperately Needed
Although the fervent advocates on both sides of the fracking controversy might consider the essential questions already settled, the only real scientific and public health consensus at the moment is that far more information is desperately needed. To the researchers at CEET and the other EHSCCs, it’s clear that something is going on. Says Panettieri, whose expertise includes asthma and pulmonary disease, “I’m confident that as time goes by, you’re going to see more and more studies showing health consequences rather than safety.” But at this stage, specifics are hard to come by. As Panettieri noted at a 2014 CEET symposium on fracking and public health: “We can only get the right answers with the right questions and right tool set. We don’t have the tool set. We don’t know necessarily what we’re looking for. Mixed toxigen exposure is wildly complex. It’s multiple doses from a long period of time – air and water pollution together – that we’re seeing in hydrofracking. It could be synergistic, and we need to understand that.”
The Funding Dilemma
Striving for scientific objectivity in a public health issue as volatile and polarized as fracking is a continuing problem. “We’ve been very careful in terms of accepting any money for our research,” says Trevor Penning, Ph.D., director of Penn’s Center of Excellence in Environmental and Toxicology. “We have been approached by the American Petroleum Institute, and we did not take money from them or from public advocacy groups. We don’t want to have our work pilloried because people feel it’s biased in some way.” One way to avoid accusations of bias and undue influence is to keep funding sources independent. “We would love to be able to do a lot more,” Penning emphasizes. “We’ve been doing it on a shoestring, really, and when we think about what needs to be done, it means a large investment of dollars.” Penn alumni who wish to contribute to the efforts of CEET to study not only hydraulic fracturing but also other pressing questions in environmental health and toxicology should contact Torren Blair, in Penn Medicine Development, at firstname.lastname@example.org or 215-898-7680 for more information.
Marilyn Howarth points out that even when dealing with individual communities and patients who may be affected, doctors are often working in the dark. “The secrecy that has been codified into law that prevents doctors from quickly learning the chemicals that ill patients may have been exposed to is unprecedented.” She explains that although technically a pathway exists for obtaining information about exposure to
Anecdotes and horror stories about the impact of fracking abound, as do confident proclamations of safety, but with a dearth of hard data, it’s virtually impossible to sift out truth from the rhetoric. chemicals, the delay involved precludes its usefulness in making a diagnosis. “Exemptions to environmental laws are generally reserved for processes that have been thoroughly researched and found to be safe. Hydraulic fracturing enjoys the exemption from major environmental laws without being thoroughly researched or having very many restrictions.” With natural gas and oil drilling currently part of the U.S. energy picture, Penning is doubtful that banning hydraulic fracturing on a national scale is practical, even if individual communities and states such as New York choose to do so. “The best we can do is identify the potential risks and manage them by having the industry adopt safe practices. I also believe that some in the industry would like to make sure that there are useful best practices, because they do not want the industry to become overregulated because of some bad actors. There’s a middle ground, and I think by trying to reach that middle ground we end up being no one’s friend.” In the meantime, Panettieri notes, “there has to be a concerted effort and resource allocation to further research.” That includes facilities to better monitor air and water near fracking sites and more prospective studies that compare data before and after drilling. “If oil companies have found sites that are going to be initiated for drilling, it would be very important for a third party to do an assessment of health six months or a year before drilling, and then follow the health care consequence afterwards.” “There are severe gaps in knowledge,” says Penning. “And the question becomes, who is best positioned to fill those gaps in knowledge? Is it the industry? Is it environmental advocacy groups? Or is it trusted academic institutions?” Perhaps Aubrey Miller of the National Institute of Environmental Health Sciences best sums up the attitudes of science and public health professionals: “Let’s not assume health and safety – let’s establish health and safety.” FALL 2015
AN ILLUMINATED MIND OFFERS “MIND ILLUMINATED” By John Shea
Greg Dunn combines his neuroscience training with his creativity and skill to create distinctive works of art. And he continues to experiment, taking his art in new directions.
reg Dunn has entered the third dimension. Or, to be precise, his art has, as can be seen in an exhibition at the Mütter Museum at the College of Physicians of Philadelphia. A rare combination of artist and neuroscientist, Dunn began showing his Asian-style paintings of neurons while enrolled in the Perelman School’s Biomedical Graduate Studies program. One of his early shows was at the Burrison Gallery, in Penn’s Faculty Club, shortly before he earned his doctorate in neuroscience in 2011. The show was called, very appropriately, “Neurons and Nature,” displaying his work in enamel, gold and copper leaf, and ink. On display were elegant, colorful, but seemingly straightforward paintings. One depicted autumn branches; another showed stark, leafless trees with a reddish background that evoked sunset. But in the same show, you could see paintings of pyramidal neurons, with their long dendritic trees looking uncannily similar to the “real” trees in the other works. Also included were 14
paintings on scrolls, in the style of the scroll and screen painting done in medieval Japan. As Dunn has said, “it was a fine day when two of my passions came together” – Asian art and neuroscience. But it was certainly not by chance, given his keen interest in both. Dunn realized that the elegant forms of neurons could be painted expressively in the Asian sumi-e style. “Neurons may be tiny in scale, but they possess the same beauty seen in traditional forms of the medium (trees, flowers, and animals).”
A New Process to Illustrate the Brain’s Complexity
At the time of that show, Dunn explained his attraction to gold leaf and copper leaf. Metal leaf “is a complicated medium to master,” but at the same time, “it brings the painting to life.” The effects of light on metal leaf, he pointed out, can change the painting in interesting ways. More recently, Dunn has taken another step, developing a new process – microetching – that makes his two-dimensional pieces of art appear to have depth. In many of his newer works, he has moved away from the simplicity he treasures in the Asian art in an attempt to suggest the brain’s immense complexity and constant activity. “Microetchings allow the viewer to clearly perceive complex images in a way that is impossible through two-dimensional renderings,” he says in connection with the current show. Now several of the artworks on display seem to be more alive – indeed, more “interesting,” to use Dunn’s deliberately understated adjective. For example, as viewers move past Chaotic Connectome (2013), they perceive different parts of the image. In general, a connectome depicts the mapping of all neural connections within an organism’s nervous system, akin to a wiring diagram. It is no surprise that such an image looks busy, even chaotic. As viewers pass, what may have appeared first in gorgeous browns, pale yellows, and golds now takes on blues and reds. Different neurons seem to appear and disappear. As Dunn explains on his web site: Chaotic Connectome is illumi-
FEATURE skrit, prana is the life force and pranayama means the extension of the life force. Dunn and Edwards seek to suggest the movement of energy through the body, the inhaling and exhaling. This piece is different from many of the ones on display because it shows the entire human body, a man sitting as if in meditation – but without the covering of skin that would normally obscure the patterns of energy within the body. Depending on which way viewers move, they see the density of energy entering the body as breath does or leaving the body. From a distance, this meditating man with the pale gold currents swirling within and outside his body would not be out of place in a Marvel superhero comic book! Dunn notes that the microetchings are designed to evolve based on the moving perspective of the viewer. As engaging as the still images are, they cannot capture the full experience of the microetchings.
A Very Tall Building and a Giant Brain
Only about half the works on exhibit are microetchings. An earlier painting is One Liberty, depicting the familiar skyscraper in Philadelphia. Done with gold, dye, and enamel on copper and aluminized panel, it’s an imposing six feet high. No neurons are visible, but Dunn explores the patterns of the different floors and windows, with golden clouds in the back-
Spiny Stellate (2015). Ink on 21K moon gold.
nated by three colors of light embedded within a custom shadowbox of dark wood. The shadowbox includes a fader to control the intensity of the illumination. In Dunn’s career as an artist, Chaotic Connectome has a special place. It was his first microetching, which involves etching neurons on metal plates, making microscopic ridges at specific angles to catch light from different sources, then covering the surface with gold leaf. He developed the process with Brian Edwards, an artist and research scientist at Penn who earned his Ph.D. degree in electrical and systems engineering from the School of Engineering and Applied Sciences in 2009. As Dunn notes on a video on his web site, the microetchings “are likely the first of their kind in the world,” and Edwards shares the credit on those works. Like Dunn, Edwards has a practical side as well. As he puts it, “I have had the privilege of being one of the few experimentalists in a mostly theory-based group. It’s exciting to try to design, simulate, and build nuts-and-bolts realizations of my colleagues theories.” Edwards even has some experience as a carpenter. Another of the very eye-catching works on display at the Mutter Museum is a microetching called Pranayama. In San-
The Artist at Work
Neural Migration (2015). 21K and 12K gold, ink, and dye on stainless steel.
Pranayama (2014). 22K gilded microetching. Greg Dunn and Brian Edwards.
ground. And the sides of the building, with all their straight lines, seem to be reflecting something more free, something less controlled. As the exhibition note puts it, One Liberty contrasts “the sleek angularity of this iconic building . . . with the chaotic connections and evolutions of the human mind that designed it.” Here Dunn clearly demonstrates that he can handle buildings as well as trees and neurons – and invest it with subtle meaning as well. Dunn and Edwards are also recipients of a grant from the National Science Foundation. Their project: to produce a giant (eight feet by 12 feet) reflective microetching of a sagittal section of the human brain. With the collaboration of neuroscientists, artists, and engineers, they expect to complete it in 2016, and its ultimate home will be the Franklin Institute. According to the artist-scientists: “This project will almost certainly be the most complex and detailed artistic depiction of the brain ever created.” They have two primary goals, which seem characteristic of their dual interests. First, to use “the unique power of art” to inspire a new generation of neuroscientists and to encourage the lay public to view the brain in a different light. Second, to provide a piece of art aimed at professional neuroscientists that is as close as possible to complete anatomical and functional correctness. Since his show at the Burrison Gallery, Dunn has had his art on exhibit at the New York Hall of Science, had a detail of 16
one of his microetchings as the cover of American Scientist, been covered in Wired, The New York Times, and The Huffington Post, and appeared on Studio 360, a weekly public radio program about the arts and culture produced by Public Radio International and WNYC in New York City. The jaunty title of that segment: “A Neuroscientist Throws Science Overboard for Art.” Viewers may beg to differ. Instead, it seems the very combination of neuroscience and art that makes the work of Greg Dunn stand out. Dunn’s exhibition, “Mind Illuminated,” will run at the Mütter Museum through January 7, 2016. On the back cover: Brainbow Hippocampus (2014), by Greg Dunn and Brian Edwards. This is a microetching of the cellular structure of the rodent hippocampus, a region of the brain involved in learning, memory, and sensory integration.
Mously Le Blanc, M.D., examines cancer patient Sarah Happy.
Restoring Function . . . and Quality of Life With American cancer survivors now numbering 14 million, Mously Le Blanc fills an emerging niche, providing care for the late side effects of the therapies that cured them.
ously Le Blanc, M.D. ’06, is a detective of sorts. As a cancer rehabilitation specialist – one of only a few in the country – she uses her knowledge of nerves, muscles, and bones to connect the dots between patients’ mysterious symptoms and the cancer treatments they received, often years before. Take, for example, the 35-year-old patient with a weakness in his right shoulder. He came to see her two months after receiving a Botox injection for neck pain. “He couldn’t raise his
By Sally Sapega and John Shea Photos by Daniel Burke arm more than 90 degrees and thought it was connected to the injection,” Le Blanc says. “But the location of the injection site and where he had weakness didn’t add up.” When the patient removed his shirt for examination, Le Blanc immediately knew the problem. “I asked him if he had been treated for cancer, and he told me he had both surgery and radiation for bilateral tonsillar cancer 13 years earlier.” How did she know? The muscle tissue in that area had shrunk and looked contracted, tight from the radiation. And the shoulder blade was winging out, as opposed to lying flat as it normally does. “During head and neck surgery or radiation treatment, the spinal accessory nerve – a small nerve that lies near the surface – can be injured,” she explains. “This nerve stimulates the trapezoid muscle, which is a major shoulder stabilizer. Without the working nerve, the shoulder blade doesn’t move correctly and prevents the arm from moving the full range of motion.” Le Blanc prescribed a rehab program aimed at restoring muscular balance. “We worked on strengthening the compensatory muscles, like the rhomboids and levator scapular, and FALL 2015
MORE PEOPLE SURVIVE CANCER
SITES OF POSSIBLE LATE EFFECTS CARDIOVASCULAR SYSTEM
HEAD AND NECK
MILLION PEOPLE HAVE CANCER IN THE U.S.
MILLION MAY DEVELOP SOME LATE EFFECTS
also stretching out the pectoral muscles,” she says. “After eight weeks, the patient had a full range of motion back on that side.” Women who undergo treatment for breast cancer can experience similar problems from radiation, which changes the structure of the muscles. “The muscles are no longer soft and tensile. They’re still and fibrotic,” Le Blanc says. “These women can become hunched over due to overactive pectoral muscles from the radiation. They’re scared to move their arms and avoid using that side.” As a result, they lose much of their range of motion. Six months after one patient had a mastectomy, she couldn’t dress herself and was in significant pain. Anti-inflammatory drugs did not work; neither did physical therapy using just heat and massage. Le Blanc gave her a steroid joint injection and then put her on an aggressive physical therapy plan. As a result, the woman regained her full range of motion and is without pain. “Radiation can affect all the muscles, bones, nerves, and lymphatics in the irradiated area, but the effects can occur years later,” she said. And when they do present, she explains, it is so long since the cancer that primary-care physicians do not consider any connection to the cancer treatment. “We are now seeing what happened from the 1990s,” Le Blanc says, referring to the cancer treatments of the time. But more recently, as physicians have learned more about the effects of radiation, treatments are changing. Doses have to be low enough to limit the possible side effects. She cites proton therapy as an example; it has the potential to minimize damage to healthy tissue that surrounds tumors. Because of more successful therapies for cancer, a greater number of people are surviving the disease. There are an estimated 14 million in the United States alone. But as oncolo18
gists, reproductive endocrinologists, and cancer rehabilitation specialists now understand, cancer treatments are not without consequences. In the past, survivors have often been left to deal with these long-term effects with little or no guidance. In 2005, however, the Institute of Medicine published a detailed report on the state of cancer survivorship, calling attention to the need cancer survivors have for care plans beyond their immediate treatment – a summary of the treatments they received and the potential for late effects that may take years to manifest, plus tips on follow-up tests and screenings they may need. Subsequently the Commission on Cancer, an organization that accredits cancer centers, responded by requiring all accredited centers to provide such plans to their survivors. “Survivorship care is ongoing and indefinite,” Le Blanc says. “It may require multiple decades.” At Penn Medicine, the Abramson Cancer Center developed the first adult cancer survivorship program in the nation in 2001. It provides specialized care, addressing the wide array of physical and mental health problems that cancer survivors and their families experience. About two-thirds of cancer survivors will experience a late effect, either physical or psychosocial, of chemotherapy or radiation that persists or develops more than five years from the time of diagnosis. In addition, OncoLink, Penn Medicine’s award-winning cancer website, developed the first online program, OncoLife, to help patients with their physicians to chart out their health-care future after cancer. According to James M. Metz, M.D., G.M.E. 2000, executive director of OncoLink and chair of the Department of Radiation Oncology, “This is the most comprehensive survivorship plan tailored to the individual that’s out there. There’s a lot of available data, but patients are
FEATURE not always getting it from their physicians.” Oncolife, he says, empowers patients to be active participants in their health care. To date, there have been more than 50,000 care plans created using OncoLink’s programs and products. As progress of this sort continues, Le Blanc will likely treat fewer and fewer patients whose symptoms appear mysterious. But in the meantime, she does not lack for patients. Le Blanc practices at Penn Medicine Rittenhouse, Penn Medicine Radnor, and the Perelman Center for Advanced Medicine, where she is part of the Rena Rowan Breast Center. She is also director of cancer rehabilitation services within Penn Medicine’s Department of Physical Medicine and Rehabilitation. According to Timothy Dillingham, M.D, chair of the department, “she has done a wonderful job at growing the awareness of the importance of exercise and rehabilitation for persons with cancer. As cancer becomes more and more a chronic disease, the holistic approach to survivorship and optimal function takes on greater importance.” Le Blanc’s first mentor at Penn’s medical school was Andrea L. Cheville, M.D., then a professor of rehab medicine. (She is now at Mayo Clinic’s Cancer Center.) Cheville, says Le Blanc, “had an amazing bedside manner with patients.” Her specialty was lymphedema, a painful swelling of the arm that often results from breast cancer surgery or radiation. Even though Le Blanc fell in love with the specialty very early on, she paid attention to Cheville’s advice to learn all of rehab medicine. “In order to be a great cancer rehab doctor,” Le Blanc explains, “you have to be a great rehab doctor.” What drew her to the field? Dealing with the patients. “Every day, I just left clinical feeling really good.” She did not find rehab a grim setting. Despite the difficult situations the patients had been through, when they were with Le Blanc in rehab, “their defenses were down.” They were able to relax. “They’re so grateful for anything you can do for them.” For her training, Le Blanc entered a combined program of Columbia University and Cornell University, rotating through several major hospitals. Along the way, she met Michael D. Stubblefield, M.D., then at Memorial Sloan Kettering Cancer Center, whom she considers another of her mentors. He is one of the authors of Cancer Rehabilitation: Principles and Practice (2009). Stubblefield “helped forge the field in physiatry,” Le Blanc says. “I’ve trained with two leaders in the field with different focuses.” Last year, she was one of the co-authors with Stubblefield for a chapter on cancer rehabilitation in Current Diagnosis and Treatment: Physical Medicine & Rehabilitation. After such training, she believes, you often know “as soon as you walk in the room what the patient’s problem is.” One of the complications from cancer treatment that Le Blanc sees is post-mastectomy pain syndrome. It is frequently misdiagnosed and, as a result, mistreated. This chronic pain can occur after breast cancer surgeries – most prevalent after a lumpectomy – and removal of axillary lymph nodes. Both radiation and direct injury to the sensory nerves in the underarm can cause the symptoms. As Le Blanc explains, “It’s like a stabbing, burning, squeezing that shoots across the chest in a band-like distribution.”
One of her patients, a young breast cancer survivor, was on high-dose narcotics but still was in pain and unable to have anything touch her chest area without severe discomfort. Le Blanc started her on a medication that specifically addressed the nerve pain. “After three weeks, the patient identified her pain as ‘level 2’ and was able to wear a bra and shirt.” But, more important, the patient was finally able to hold her baby close. Le Blanc can also help patients before treatment, through “a prehabilitation program” to help minimize the risk that the patients will develop some of these complications. “If a patient is not tolerating treatment, it may need to be stopped,” she says. “If it’s better managed, the patient will stay on it.” Aromatase inhibitors – which are estrogen blockers given to women with hormone responsive cancer to reduce the risk of recurrence – can also cause programs. At least one-third and possibly more of these patients develop symptoms very
An ultrasound machine can visualize the tendons, ligaments, nerves, and bones that make up the shoulder joint.
similar to fibromyalgia, such as diffuse pain, fatigue, and “a foggy brain.” Joint pain associated with these drugs can be especially crippling. Daily activities, like walking, going down stairs, cooking, and cleaning, are now impossible without significant pain. “These women are often in their 30s or 40s but feel like they aged 20 to 30 years overnight. I hear that all the time,” Le Blanc says. “They go through physical therapy and pain medication, but nothing helps.” To relieve these symptoms, Le Blanc prescribes a neuropathic pain medication and an anti-inflammatory as needed, in combination with a specific program in physical therapy and occupational therapy. Often, when the women return for a follow-up visit three weeks later, “the difference is amazing.” As Le Blanc emphasizes, aromatase inhibitors decrease the risk of that the cancer will recur, so it’s very important to stay on the medication. “Creating a plan to help them manage potential side effects can be lifesaving.” “Oncologists save lives,” she says. “I help facilitate a return to a better quality of life.” FALL 2015
Welcome to Wachter’s World By Marshall A. Ledger
Bob Wachter is a professor, a hospitalist, an author, a blogger, a ruminator, an occasional performer . . . but his constant causes are quality and patient safety. Photographs by Susan Merrell
obert M. Wachter, M.D. ’83, an internist and hospitalist, thinks he doesn’t take himself too seriously. Some self-deprecating presentations bear him out. At the national convention of the Society of Hospitalist Medicine last year, he donned a costume and wig, sat at a piano, and belted out his own words to the tune of Elton John’s “Your Song.” (“Sometime in the ’90s, / A new field was born, / Docs lived in the building / From nighttime ’til morn. / They called themselves ‘hospitalists’ — / Oh god, what a name! / But once they took over, / Nothing was the same.”) The audience of some 3,600 gave him a standing ovation. When he received the Perelman School of Medicine’s Distinguished Graduate Award in June, he spoke about how his own medical students gave him a comeuppance last year when he thought he’d shake them up a bit. “You folks,” he intoned to them, “are entering a profession that will be profoundly different from when I entered medical school because you will be under relentless, unremitting pressure to deliver care of the highest quality, the highest safety, the highest patient satisfaction, and the lowest cost.” Whereupon one of his charges raised his hand and said, “What exactly were you trying to do?” He also recalled, three months into his own medical school career, meeting his first patient, at the Veterans Administration 20
Hospital: “So I said to the patient, ‘Why are you here?’ and he said, ‘I have gout,’ and I said, ‘What’s that?’” His alumni audience roared at both stories. In his blog, Wachter’s World, he summed himself up by recalling his undergraduate stint (B.A. ’79) as the Penn Quaker, mascot of the University of Pennsylvania: “I needed to be funny, quirky, ungraceful, and utterly without shame,” he wrote, adding, “These skills have served me well through my subsequent career.”
The other side
Wachter does, however, take medicine seriously — “our sacred charge,” he called it when receiving the alumni award. He is one of the creators of the term hospitalist, giving impetus to a nascent movement that has been hailed as the fastest-growing specialty in medical history. He edits two web sites for the Agency for Healthcare Research and Quality — AHRQ WebM&M, on confidentially reported medical errors, with commentary, and AHRQ PSNet, on patient safety. He is a professor of medicine at the University of California at San Francisco, where he holds the Marc and Lynne Benioff Chair in Hospital Medicine, serves as associate department chair (and interim chair, as of July), and heads both the medical
The empowerment of patients and the questioning of scientific expertise will be part of the sociological landscape for the 1990s, and not only in AIDS. Having our patients and our research subjects ask, or demand, to have an active voice in what we do and how we do it may be challenging, time-consuming, and even unpleasant. It is also undeniably right. The Fragile Coalition (1991) service at the UCSF Medical Center and the 60-plus-member Division of Hospital Medicine. He was the first elected president of the Society of Hospital Medicine (1999-2000) and chaired the American Board of Internal Medicine from 2012 to 2013. For these efforts, most others take his work – and him – seriously as well. He has won the nation’s top honor in patient safety, the John M. Eisenberg Award, from the National Quality Forum, which serves to improve health care, and the Joint Commission, the U.S. accrediting organization for health care. For seven years, Modern Healthcare magazine included him among the 50 most influential physician-executives in United States. In 2015, the magazine named him number one. A web site for health-care executives called him one of the “10 healthcare bloggers we’re thankful for.” In retrospect, Wachter’s career looks coherent, but it took him a while to discover how to integrate his interests in patients,
Bob Wachter as the Penn Quaker
their care, health policy, systems thinking, and informatics. Happenstance often led him. Even he laughs and apologizes when interviewing job candidates and asking about their fiveyear plans. He never had one.
Doctor and systems
Growing up on Long Island, N.Y., Wachter knew his parents would be proud if he became a physician, but he worried about that motivation. And despite volunteering at a local hospital, he felt he hardly knew what it was to be a doctor. His parents, who socialized with doctors, admired them but also saw through them: “My dad would get dressed up for a cocktail party, and he’d look perfectly normal and about to go out, but he’d have his garage-door opener on his belt” — fitting in with, yet laughing at, the doctors, who had beepers. As an undergraduate, Wachter took the science courses that medical schools required, but his intellectual heart was in his major, political science. He was drawn to “politics and the way systems worked and people thought and organizations did their thing.” He credits John Eisenberg, M.D., G.M.E. ’77, for showing him how to weave these interests together. Eisenberg taught and practiced at Penn Med from 1975 to 1992, founded and led the Division of General Internal Medicine, and later headed AHRQ. In his work on physician practice patterns, patient safety, and health-care effectiveness, Wachter explains, he saw a way “to being a really good doctor and thinking about the way the system works.” Even so, Wachter’s career started in a routine way. He visited UCSF for a residency on a whim (Eastern Airlines had a $600 fly-anywhere-in-the-U.S.-for-a-month promotion); liked the more casual style of the West Coast; resisted the pull from his mother, “who thought even Philly was a little far”; and, in his fellowship period as a Robert Wood Johnson Clinical Scholar, began to think of fundable research projects and publications. With a résumé that included peer-reviewed articles on the treatment of AIDS patients, he was appointed program director of the Sixth International Conference on AIDS, which UCSF hosted in 1990. Senior faculty members told him he’d learn “how the world works and how policy and politics work.” He did learn that, but not because his advisers were prescient. AIDS activists, moved in part by the social advocate Larry Kramer’s “Call to Riot,” descended upon the conference with “die-in” street protests. They heckled speakers and challenged the sedate expectations of the scientists and clinicians in attendance. The activists sought to change both attitudes about and government regulations against people with AIDS – and demanded to be included in the discovery processes toward treatment. During the conference, Wachter kept notes, which he organized into the 1991 book Fragile Coalition: Scientists, Activists, and AIDS. Looking back, he calls it “an amazing and ultimately important story about this tension between experts and science and the community that’s affected by it and their efforts essentially to morph into one.” FALL 2015
Decades of research, mostly from outside health care, have confirmed our own medical experience: Most errors are made by good but fallible people working in dysfunctional systems, which means that making care safer depends on buttressing the system to prevent or catch the inevitable lapses of mortals. This logical approach is common in other complex, high-tech industries, but it has been woefully ignored in medicine. Instead, we have steadfastly clung to the view that an error is a moral failure by an individual, a posture that has left patients feeling angry and ready to blame, and providers feeling guilty and demoralized. Most importantly, it hasn’t done a damn thing to make health care safer. Internal Bleeding (2005)
Reviewers credited Wachter for forging a relationship, however tenuous, among the groups and pointing the way to non-adversarial health policy that includes patients. Meanwhile, he turned his back on the standard research track, “the job you’re supposed to want,” he says. Ironically, it helped that a major proposal of his was turned down. It helped, too, that he felt “too social” to isolate himself while generating fundable ideas; he also realized he had organizational skills. In 1992, he was made director of the residency program, yet he was feeling, in his words, “a little bit adrift.”
The hospitalist “thing”
“Then the hospitalist thing happened,” he says. In 1995, his new department chairman, Lee Goldman, M.D., M.P.H. (now head of the Columbia University Medical Center), appointed him to run the inpatient service at UCSF’s medical center and in particular to figure out how to re-organize it. Goldman’s rationale: It hadn’t changed since he had been a resident there 20 years earlier, a sure sign of stagnancy. In calls and conferences and visits to hospitals across the country, Wachter found an emerging model — an in-house doctor was taking over patient care. He thought it made sense, a generalist who was a specialist in care at one place. When a UCSF colleague left to become a “hospital manager” across town, Wachter, struck by the odd title, interviewed him, then wrote about it and his other findings for the house-staff newsletter. Encouraged to redo the piece for a journal, he engaged Goldman as a co-author, and their seminal article, “The Emerging Role of ‘Hospitalists’ in the American Health Care System,” appeared in The New England Journal of Medicine in 1996. The response was immediate – and sharply divided. Hospital CEOs asked how to develop such a program. Doctors called, saying they had been doing the work for many years and thought they were the only ones. A group of family physicians in 22
Florida frankly didn’t want to manage their hospitalized patients and had just hired a young internist for that responsibility. Among critics, primary-care doctors feared that patients would not want to be cared for by a physician they’d never seen, or the physicians simply wanted to continue caring for their hospitalized patients as in the past. Critical-care physicians saw a threat to their turf. Specialists feared fewer consultations. Others worried that, without providing inpatient care, internists would be indistinguishable from family physicians and nurse practitioners. Some suggested that hospitalists would become insular and miss advances emerging in medical specialties. Some worried about the continuity of care when patients left the hospital. Wachter’s father happened to sum up the opposition’s bitterness. As Wachter told Modern HealthCare, his proud father phoned to tell him excitedly about his tennis partner, a doctor: “He’d heard of you!” The senior Wachter paused, then added, “He hates you.” “The article just gave voice to the idea that a trend was happening,” says Bob Wachter. Primary-care doctors had little time to tend to their hospitalized patients; the worry about patients’ preferences “turned out not to be a big deal,” he says, although it’s still argued. Hospital administrators were trying to reduce length-of-stays and costs. Residents were less available because their hours were being cut.
But health care’s path to computerization has been strewn with land mines, large and small. Medicine, our most intimately human profession, is being dehumanized by the entry of the computer into the exam room. While computers are preventing many medical errors, they are also causing new kinds of mistakes, some of them whoppers. Sensors and monitors are throwing off mountains of data, often leading to more confusion than clarity. Patients are now in the loop – many of them get to see their laboratory and pathology results before their physician does; some are even reading their doctor’s notes – yet they remain woefully unprepared to handle their hard-fought empowerment. While someday the computerization of medicine will surely be that long-awaited “disruptive innovation,” today it’s often just plain disruptive: of the doctor-patient relationship, of clinicians’ professional interactions and work flow, and of the way we measure and try to improve things. . . . Before I go any further, it’s important that you understand that I am all for the wiring of health care. The Digital Doctor (2015)
A professor of medicine at UCSF, Wachter also heads the medical service at its Medical Center.
In early 1997, Wachter and others sketched out a specialty, with its own organization, journal, training programs, textbooks, and conferences. “It just grew. I knew it would,” he says. But the field had to offer physicians something more lofty and inspiring than saving money. “I really worried quite deeply about that.” The answer came when the Institute of Medicine, in 1999, issued To Err is Human: Building a Safer Health Care System. The report estimated that medical errors cause as many as 98,000 deaths in the United States annually. “We need to own this,” Wachter recalls thinking. “We have the opportunity: a brand-new field — in hospitals, which are going to be the epicenters of improving quality and safety and where the hazards are the greatest. We have the opportunity to brand our field as being about improvement.” The mantra became: “We have two sick patients: the person you take care of in the building and the system you’re in.” As Wachter observes, “That turned out to be a good call.” When he was doing his study, there were an estimated 500 hospitalists. Today, according to the American Hospital Association, the number now approaches 50,000, defined in Wachter’s words as “physicians whose main professional focus is inpatient care.”
When I was a medical resident in the 1980s my colleagues and I performed a daily ritual that we called “checking the shoebox.” All of our patients’ blood test results came back on flimsy slips that were filed, in rough alphabetical order, in a shoebox on a small card table outside the clinical laboratory. This system, like so many others in medicine, was wildly error-prone. Moreover, all the things you’d want your physician to be able to do with laboratory results — trend them over time; communicate them to other doctors, patients, or families; be reminded to adjust doses of relevant medications — were pipe dreams. . . . For those of us whose formative years were spent rummaging through shoeboxes, how could we help but greet health care’s reluctant, subsidized entry into the computer age with unalloyed enthusiasm? The Digital Doctor (2015)
When I was a medical student in the 1980s, the beating heart of the Hospital of the University of Pennsylvania was not the hospital’s mahogany-lined executive suite, nor the dazzling operating room of L. Henry Edmunds Jr., HUP’s most famed cardiac surgeon. No, it was in the decidedly unglamorous, dimly lit Chest Reading Room, where all the x-rays were hung on a moving contraption called an alternator that resembled the one on which the clothes hang at your local dry cleaner. Controlled by a seated radiologist operating a foot pedal, the machine would cycle through panel after panel until it arrived at your films. The radiologist took his foot off the pedal, the machine ground to a halt, and the dark x-ray sheets were brought to life by intense backlighting. Saying that HUP’s epicenter was the Chest Reading Room is a bit unspecific. It really was in the seat of the late
Some are well-placed, such as Patrick Conway, M.D., the chief medical officer of the Centers for Medicare & Medicaid Services (who earned an M.Sc. degree in health services research from Penn In 2007); and the U.S. Surgeon General, Vice Admiral Vivek H. Murthy, M.D. “And,” Wachter points out, “this is a pretty young field.” According to Wachter, there is substantial evidence that care has become safer in the past several years, demonstrated by fewer adverse events; falling mortality rates in hospitals; and marked improvements in certain safety targets such as central line infections, sepsis, and falls. “I don’t know how much of that is due to hospitalists,” he adds, “but I think they have had a role — and they increasingly are taking on leadership roles in safety and quality because of their work in these areas.” At UCSF, for example, the chief quality officer, the chief patient-experience officer, the chief medical officer for adult care, and the chief medical information officer – four of the senior physician leaders in quality/safety/IT – are hospitalists. Yet the field hasn’t finished evolving and most likely won’t. For instance, Wachter still hears criticism that hospitalists create a “discontinuity” between patients and their primary-care doctors. Wachter’s response: “You have to figure out how to make the communication work – but people who criticize it, I’m always fine with that, because it’s not perfect.” “To me,” he says, “the touchstone is value. I’m relatively agnostic on whether it’s hospitalists or something else. It’s what system delivers the best care at the lowest cost. And that should win. Right now, hospitalists do that better than the old system. Will it be that way forever? Who knows?”
Becoming a better writer
Since then, Wachter has mined the essentials of the specialty. He served as lead editor of the text Hospital Medicine 24
Wallace Miller Sr., a crusty but endearing professor of radiology and one of the best teachers I’ve ever known. . . . At Penn in the 1980s, everybody – and I mean everybody, from the lowliest student to the loftiest transplant surgeon – brought films to “The Wal” to decipher. For students like me, time spent with him was at once exhilarating and terrifying. “What’s this opacity?” he asked me once, the memory burned into my hippocampus by that cognitive curing process known as overwhelming anxiety. “A . . . a pneumonia?” I stammered. “Mooiaaa,” retorted The Oracle, an unforgettable signature sound that was uttered as Miller smartly turned his head away in mock disgust. I loved it. We all did. The Digital Doctor (2015)
in 2005; wrote Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes (2005; with Kaveh G. Shojania, M.D.); and wrote both the primer Understanding Patient Safety (2007, 2012) and The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age (2015). His topics are urgent, but even more, his writing is compelling (the word Terrifying was supplied by publisher). He draws from many fields, writes directly, and has an eye for everyday examples and an ear for humor and irony. He generalizes convincingly. He understands sentence rhythms and plays them sharply or lyrically (or ornately, in a self-mocking way). He has a brawny ego yet is upfront about his shortcomings. An insider, he doesn’t write like one. He assumes that the physician reader appreciates good prose and the lay reader is intelligent – and both audiences respond. He’s also open to advice. In 2002, The New York Times wrote about “The Wrong Patient,” a series on medical mistakes that he edited for the Annals of Internal Medicine. A publisher called Wachter to propose a book on the subject. Wachter wrote three chapters in what he felt was honest and flowing prose on interesting cases. The publisher replied in an e-mail with “I hope you’re sitting down” in the subject line. Over three pages, he faulted Wachter’s lack of candor. He found the text “dripping with caution.” He figured that Wachter didn’t want to annoy doctors or nurses or administrative leaders and concluded, “Either do this right or get out of my face.” Wachter winced. “I haven’t been talked to that way very often,” he says. Colleagues were only partly consoling. “He’s an ass,” they told him, “and he’s completely right.” Wachter dropped the caution. The result was Internal Bleeding, which readers praised for its style, warmth, and frankness (the authors described their own mistakes), as well as its message.
FEATURE For The Digital Doctor, Wachter received sage guidance from his wife, Katie Hafner, who has written even more books than he (six) and who writes on health care for The New York Times. When he told her his idea, she replied, “The only way you’re going to get this story right, the only way it’s going to be interesting, is to go out and talk to people.” “As soon as I started doing that,” he acknowledges, “it was immediately obvious that she was right.” He interviewed 94 people (listed in the book), quarried his own experience, consulted history (tracing patient notes from their Greek origin to the present), and visited computer and other companies, physician practices, and hospitals, including his own, where the book’s centerpiece patient error occurred because of, not despite, the latest technology. Computers, Wachter concludes in The Digital Doctor, prevent some mistakes of the past but create new ones. The error he explores was the result of bad software and a glut of false alerts to patients’ situations, which lulled hospital personnel from paying proper attention to genuine crises. Computers have
also distanced doctors from patients as well as from each other. He argues for “a thoughtful use of technology.” For instance, better communication with software engineers for “user-centered design.” Most people are good people trying to do the right thing, he says, but things can go wrong when those involved see only through their own lens. Another recommendation: doctors should get their heads out of their computer screens and back to facing their patients. Enabling him to investigate and discuss a near-fatal error was “an act of incredible organizational bravery” on UCSF’s part, he says, and the feedback “has been universally good. It was the right thing to do.” “On the other hand,” he adds, “we got a letter from the Joint Commission saying, ‘Can you tell us a little more about it?’ — as if UCSF’s actions and standards were problematic. The Commission’s response “is a little disappointing,” Wachter says. “I would hope that the incentive system out there would be one in which this kind of thing is praised, because that’s the way we’re going to get better.”
A physician and a blogger, Wachter encourages “a thoughtful use of technology.”
Photos by Peggy Peterson
THE PATH TO PENN MEDICINE
By John Shea
Members of the incoming class share the goals of advancing health care and biomedical research, but their backgrounds and experiences vary greatly.
he went to Egypt to become fluent in Arabic – then had to flee the country when a revolution broke out. He was a peer tutor in physics at Penn – and a disk jockey at the student-run radio station. She led a group of high-school girls to South Africa, where they interviewed people who had lived through the nation’s grim apartheid period. She was a cellist in her university’s orchestra. He was a member of the Yale Climbing Team. She was a co-captain of Fordham University’s varsity soccer team. 26
Today, they are all members of the Perelman School’s Class of 2019. Not your typical background for aspiring physicians? Each year at the White Coat Ceremony that officially welcomes the new students into the medical profession, Gail Morrison, M.D. ’71, G.M.E. ’76, provides an overview of the entering class. This year’s class of 156 students is composed of slightly more men than women, ranging in age from 20 to 36 years old. About 15 percent plan to pursue a combined degree (M.D.-Ph.D.). Students come from 65 different undergraduate colleges and universities across 25 states. About 68 percent declared science as their college majors. Among the incoming students are campus leaders in government, political organizations, and community groups. Many were varsity athletes, in sports ranging from soccer, football, and lacrosse to saber and gymnastics. Many have shown talent in diverse artistic and musical fields. Continuing a recent trend, many in the class took a year or more off from their formal studies after college. Some spent that time working at the National Institutes of Health or at top academic health centers; others worked in pharmaceutical and biotech industries. Significantly, most of the students, as Morrison put it, “have been extensively involved in community service both in the U.S. and abroad . . . to help the underserved populations of the world.”
FEATURE Here are brief accounts of how some members of the Class of 2019 found their way to the field of medicine and to Penn Medicine. For Amanda Labora, who grew up in Miami, the desire to practice medicine was greatly influenced by her travels to some very different places. As a high-school student, she had taken part in an exchange program in Turkey because of her broad interest in the Middle East. Then, in 2011, as an undergraduate majoring in history at Brown University, she went abroad again – and got much more than she expected. At first, she was in Egypt, which she chose because she wanted to become fluent in colloquial Arabic. She was enrolled in an immersion-style course where the students were not allowed to speak any English. But when the revolution against the regime of President Hosni Mubarak began, there were violent clashes between protesters and government forces; police stations were burned. Labora tried to continue her education in Syria, but civil war was breaking out there as well, between President Bashar al-Assad’s government and several opposition groups. Today, she says, she could not return to the Da-
Traveler to the Middle East
mascus that she knew – parts of the city where she had been were destroyed. Back in the United States, Labora worked as a scribe at Rhode Island Hospital, the main teaching hospital for Brown University’s Warren Alpert Medical School. Medical scribes help with billing and discharge and document the procedures. That allows the physicians to be more focused on the patients and less concerned with charting. Labora found the experience very useful: she learned some “medical lingo” and observed how the physicians could rule out certain underlying causes swiftly and why they would order certain tests. But she also had what she calls “the unfiltered view of what’s going
on.” Some patients had no insurance coverage, some were homeless, some fought drug and alcohol addictions. Labora found parallels between what had happened to the people in Egypt and Syria and what she saw with the people who came to the hospital’s emergency department. In particular, she was inspired by the physicians’ ability “to bear witness to suffering and provide compassion despite the chaos around them.” As a dual citizen of Mexico and the United States, Labora appreciated the talk Jack Ludmir, M.D., G.M.E. ’87, gave at this year’s White Coat Ceremony: he spoke about giving back to the Latino community and trying to overcome the barriers to health care that many still face in our nation.
She had an “unfiltered view of what’s going on.” Some patients had no insurance coverage, some were homeless, some fought drug and alcohol addictions.
Sabrina Layne, originally from New York, came to Penn from Stanford University, where she majored in human biology. For her, medicine has always been a presence – both of her parents are physicians. She grew up in that environment and used to go on rounds with them. She found she loved science and explored plant biology and epigenetics for a while
nity members. Interviews of community members and health workers provided the basis of Layne’s honor thesis, which focused on access to health care. During her busy undergraduate career, Layne played club tennis, volunteered at the Pacific Free Clinic, and was an advisor for Human Biology students, among other pursuits. Another item on her list of accomplishments: she served as an intern for a state senator in New York, analyzing health policy. While at Stanford, she was a teaching assistant for a course called Critical Issues in Child Health. After graduation, she remained there as a course associate, teaching Human Biology.
Health Policy Analyst
Michael Stephens, who majored in biology at Thomas More College in Kentucky, didn’t have a particular experience that set him on a path to medicine. In college, he had taken more analytical classes, like math, but he felt an innate desire to be able to help others, to be “more service-oriented.” Going into medicine seemed, he says, “a perfect intersection” of what he was good at and what he felt gave him a purpose. In addition to going to Guatemala to distribute donated clothing and tutor students, he was a research intern at Cincinnati Children’s Hospital. There he studied protein purification and shadowed some of its physicians, and he has an author’s credit for a subsequent article in PLOS One. Stephens earned a perfect score on the national American Chemistry Society exams. What did he do when he was not studying or volunteering? He was president of the Thomas More College Student Government Association – and played NCAA Division III tennis. One of the perks of going to a small liberal arts college, he
but discovered she was more of a “people person.” As an undergraduate, she says, “I was all over the map” and considered history as a major, but she was ultimately drawn to health care through her experience volunteering at a student-run health clinic. In high school, she heard a documentary filmmaker talk about her work on obstetric fistula, a hole in the birth canal that affects from 50,000 to 100,000 women worldwide. Layne felt what she called “an initial spark,” and she began to think beyond one-to-one patient interactions to broader global and public health issues. Some of the issues involved in global health, she has come to understand, are present “in our own backyard.” After her sophomore year at Stanford, she and a friend created their own qualitative research project, investigating public health services in Cape Town, South Africa. Coming face to face with the consequences of violence and abject poverty, they were inspired by the resilience of commu-
Student Government President
FEATURE points out, is that he had many opportunities to try different things. And he apparently was very accomplished in several: he was a peer tutor in math, chemistry, physics – and, in a very different field, Latin as well. When Claire Hirschmann says she took “a pretty nontraditional route” to medical school, she’s not exaggerating. Originally from Washington, she was an English major at Yale University. In addition to being captain of the Yale women’s Ultimate Frisbee
Wilderness First Responder
team, she became leader of Yale’s Freshman Outdoor Orientation Trip program and taught sections on preventing substance abuse as a Yale community health educator. “I totally fell in love with teaching,” she says, particularly history and literature. But it was not precisely the kind of teaching familiar to most of us, where the class meets in a room. Hirschmann preferred a full immersion. With The Traveling School, a study-abroad program for high-school girls, she led students to South America and to South Africa, where the educational process involved interviewing people who had lived through South Africa’s apartheid and even restaging battles to further engage the students. Back in the United States, she earned a master’s degree at Harvard’s Graduate School of Education, focusing on school leadership and development. The next step was founding – with two other visionary women – The Field Academy, a traveling high-school program in Portland, Maine, that combines academics and place-based education. To explore what it means to be an American citizen, for example, Hirschmann brought students to Appalachia to see what it means to be a coal miner, what it means to be in a union, what happens when the top of a mountain is blown off to expose seams of coal. What may have been only cerebral to students, Hirschmann says, suddenly became real to them. Hirschmann’s decision to apply to medical school, however, did not come out of the blue. Her father is a physician, her mother a former nurse practitioner. Hirschmann was a volunteer with the Portland Trauma Intervention Program, on call with the police and fire departments and local emergency
room. Sometimes she dealt with the patients themselves, more often with their families. She learned how to ask supportive questions and serve as a go-between for the families. In many cases, she says, “there was no way to make it better, but you could make it potentially less bad.” When she enrolled in a post-baccalaureate program at Goucher College, she was also a volunteer with the University of Maryland Shock Trauma Center. She is certified as a Wilderness First Responder as well, which has led her to think about the fields of disaster relief medicine and adolescent medicine, which would also make use of her teaching experience. The cello has played a major role in the life of Jee Yoon (“Gina”) Chang. She began lessons in second grade; performed during orchestra tours of Europe; gave private lessons on the instrument to underserved students; and became principal cellist for the orchestra at Washington University in St. Louis. Cello and Chang seemed a very natural fit, but it could have been much different! When she was first presented with a choice between violin and cello, she remembered that a friend of hers who played violin had to stand – and Chang thought playing sitting down made more sense. Despite all the demands during college, she learned how to budget her time and balance responsibilities, and she says playing the cello was calming and steadying. At Washington University, Chang’s major was biology. She especially enjoyed a lab in neurophysiology, very hands-on,
CLASS OF 2019 STATISTICS
Non PA Residents
Underrepresented in Medicine
Including: Black, Mexican American, Puerto Rican, American Indian, Native Hawaiian, Other Hispanic
For Combined Degree
Post-Baccalaureate Studies FALL 2015
Peru and Argentina. In Argentina, she spent six weeks shadowing pediatric general surgeons. In Peru, she served as an interpreter, instructed children how to brush their teeth correctly, and translated for a physical therapist. In the United States, she has taken part in the Clinton Global Initiative University, where college students meet to talk about world challenges and possible solutions. With her background, Chang is interested in earning a master’s degree in public health.
“ Principal Cellist
with animal models. She was also a teaching assistant her junior year for a sophomore biology course called “Physiological Control Systems.” One of her responsibilities was doing the problems with the students – “one of my favorite parts,” she says, getting feedback from them and becoming more comfortable with public speaking. Chang also worked in the lab of a neurologist, Beau Ances, M.D. ’01, Ph.D. ’00, who was particularly interested in the damaging neurological effects of HIV. But at the same time, she took many courses outside science and minored in Ancient Studies, studying Greek and Roman history. One of her courses was “Magicians, Healers, and Holy Men.” Like many of the new students in the Perelman School, Chang has had experience as a volunteer abroad. She was in
As a volunteer with an intervention program, on call with the police, she learned how to ask supportive questions and serve as a go-between for the families.
Originally from Connecticut, David Steinmetz was a Biological Basis of Behavior (BBB) student at Penn – and in fact he did research on the 8th floor of the Smilow Center for Translational Research. He had some sense of medicine from very early on. His father, an internist, “planted some seeds.” From him, the young Steinmetz learned, much to his relief, that doctors “aren’t there just to make people cry and give shots.” But his father died when Steinmetz was four years old. His mother became a role model, demonstrating positive spirituality throughout those difficult times. Then his mother was diagnosed with breast cancer when he was going to college,
FEATURE and Steinmetz appreciated all the more that having good health and being “an agent of good health” was more important than seeking money and power. As a Penn undergraduate, Steinmetz was a member of a Medical Emergency Response Team, a peer tutor in physics and statistics, and a research assistant in radiation oncology. Part of the research involved looking for new assays that would contribute to better prediction of risk and clinical management of cancers. He was also named a Benjamin Franklin Scholar. According to the program’s site, the Scholars “are selected based on their interest in, and demonstrated capacity for, a deep engagement in the liberal arts and sciences, both as ends in themselves and as engines of change in the world.”
Varsity Soccer Co-Captain
Peer Tutor in Physics
He appreciated the BBB major because it allowed students to range and try out different classes. One example he notes was a history of the American South, which intrigued him. But Steinmetz also made time for non-academic pursuits. He played Club Ultimate Frisbee and was a disk jockey for Penn’s student-run radio station, WQHS. His specialty? Live recordings of the Grateful Dead. Katherine – Katie – McDermott comes to the Perelman School from Arizona, by way of Fordham University. Her father and both of her grandfathers were doctors. As an undergraduate, she was captivated by psychology and she became interested in studying racial and socio-economic disparities, especially as they affected adolescents. She also was skilled enough to be a co-captain on the women’s varsity soccer team. Her early clinical experience came as a counselor at Planned Parenthood. McDermott provided women and girls the results of their urine pregnancy tests and counseled them on their options: continue the pregnancy and parent the baby, terminate the pregnancy, put the baby up for adoption, etc. “It was really jarring to see so many women without access to health care,” she says. Often, they were underprivileged, with no other place to go. McDermott notes that the experience
helped her learn how to talk to people who did not have a medical background. In addition, she gained experience as a summer research assistant at the National Institutes of Mental Health. There she trained and accompanied research subjects in MRI scanning, recruited volunteers, acquired consent forms, and initiated a small genetic analysis. At Massachusetts General Hospital, she helped coordinate research trials investigating new treatments for autism spectrum disorders, bipolar disorder, and ADHD. She also handled correspondence with the hospital’s institutional review board as well as the FDA and the NIH. McDermott herself became a voting member of the IRB: she presented research protocols, assessed studies for safety and ethics, and voted if the research should be continued. When she was convinced of her career direction, McDermott enrolled in the pre-med program at Bryn Mawr College. Penn Med named her a Harrison Surgical Scholar; the program was established to expose post-baccalaureate students to all aspects of clinical surgical research. Her experience working with Penn cardiac surgeons as a Harrison Scholar was a major factor in her decision to come to Perelman. Matthew Kubicki was raised in Kentucky. His parents came to the United States from Poland in the 1980s and both became mathematics professors at the University of Louisville. Kubicki was drawn to “hard sciences” and was a Molecular Biophysics and Biochemistry major at Yale. But it was not all serious work: he was on the Yale Climbing Team and helped coordinate various intramural sports. Kubicki was interested in service as well: he took part in a hypertension awareness and prevention program while at Yale, doing blood-pressure screenings and getting involved in community education. He also was an academic associate at the Yale Eye Center, where he helped with clinical studies and shadowed physicians. He vividly recalls one of his own experiences shadowing an ophthalmologist – on this occasion, the anesthesia used in the surgical procedure didn’t work. “That was really scary!” he says. Fortunately, the patient FALL 2015
Member of the Yale Climbing Team
recovered. While shadowing a pediatric surgeon, Kubicki says, “I understood the God complex for the first time.” Surrounded by music of his choice, indulging in some dark humor, the surgeon was operating on the five-year-old child’s spinal cord, “100 percent convinced” that the child would be walking fine in just a few weeks. But the experience helped inspire a personal realization for Kubicki: science is great, math is great, research can help people in the long run – but this surgeon was changing someone’s life in a very short time. Increasingly, Kubicki was drawn to “the more human side of medicine.” He recalls doing patient screenings in New Haven, working with the poor and the uninsured, “who sometimes didn’t want to have anything to do with us.” At a soup kitchen, he was impressed when a worker was able to calm an alcoholic visitor and listen to her troubles. Kubicki comes to Perelman with a solid background in research. He started doing research after his first year at Yale and continued throughout his time there. After graduation, he studied the effects of mutation on protein function as an Intramural Research Training Associate at the NIH. Another member of the Class of 2019 who went through the pre-med program at Bryn Mawr College is Mariah OwusuAgyei. While she was there, she was also volunteering at Bryn Mawr Hospital. “I love the way you get to help people,” she says. And like David Steinmetz, she already was familiar with the University of Pennsylvania, having majored here in economics. But she did have farther to travel to medical school than most of her classmates: she was born in Ghana, in West Africa. How did she come to the United States? “My family won the lottery!” she says, then explains about the Diversity Immigrant Visa Program, administered annually by the Department of State. It provides a maximum of 55,000 Diversity Visas each fiscal year to be made available to persons from countries with low rates of immigration to the United States. Her mother was interviewed by the American authorities. She must have been persuasive, because the family received the visas. Owusu-Agyei 32
was seven years old when she left Ghana and arrived in the South Bronx. It was drastic change, but, she says, “I thought it was heaven.” She was raised a Seventh-Day Adventist, and her family found a Ghanaian church of that denomination in the Bronx. She took part as a child, then, when she was older, became a leader. When she entered Penn as an undergraduate, she joined a similar church in Philadelphia and volunteered with the children. Among the activities, they produced a play based on the biblical story of the Good Samaritan. Owusu-Agyei did the writing – sticking to the Bible’s outline but dramatizing the story. The lesson, she says, was to underscore that people should help anybody in need, no matter what apparent differences there may be. Owusu-Agyei always wanted to be a doctor, she says. Her parents wanted that, too, and an older brother who came to the U.S. is now a doctor as well. But the financial crisis of
2007-08, when she was in high school, got her to thinking. She also took part in the High School Fed Challenge, a program of the Federal Reserve Bank of New York, in which students competed to offer ideas on financial actions that should be enacted. After her freshman year at Penn, she was an intern at the New York Stock Exchange. As a research assistant at Penn’s Leonard Davis Institute of Health Economics, she studied the Affordable Care Act, collecting data.. The experience, she says, was eye-opening, but it gave her a fuller sense of the impact of economics on health. Even after graduating from Penn, she was a financial analyst with Citigroup. But she came to realize “that’s not really what I wanted to do.” What she did want to do is pursue medicine. In fact, her dream is her family’s dream as well. “My entire family is involved in health care in some way,” she says. One sister is a nurse practitioner. Another brother is an architect, and the family’s vision is to have him design a clinic in Ghana. There, the other siblings would provide services to those in need. In short, inform and empower the people and help them to heal.
In Equal Parts: Physician and Poet By John Shea
William Carlos Williams distinguished himself in two very different fields. His example can be an inspiration for experienced physicians and medical students alike. His advice for both doctors and writers: deal in particulars.
n the 250 years since its founding as the first medical school in America, the Perelman School of Medicine has produced many alumni and trainees who have gone on to gain the highest honors in a variety of medical fields. So far, however, there has been only one to achieve eminence in the field of literature. A seemingly tireless writer who produced many volumes of poetry, prose, drama, and autobiography, William Carlos Williams, M.D. 1906, was posthumously awarded the Pulitzer Prize for Poetry in 1963 for Pictures from Brueghel and Other Poems. Along the way, he also received the Gold Medal for Poetry from the National Institute of Arts and Letters and the National Book Award for Poetry. And all the while, Williams maintained a long practice in pediatrics and general medicine and was for many years chief of pediatrics as what was then known as Passaic General Hospital in New Jersey. In many ways, Williams, born in Rutherford, N.J., remained a Jersey boy. He entered Penn’s medical school in 1902, after a special examination, when he was only 18. After earning his Excerpts by Williams from The Collected Poems of William Carlos Williams, Vol. 1, 1909-1939. Copyright New Directions Publishing Corp.
M.D. degree, he did internships at hospitals in New York City and traveled to the University of Leipzig for advanced study of pediatrics. But New Jersey drew him back and was his base for the rest of his life. For nearly 40 years, he served as chief of pediatrics at what was then Passaic General Hospital. Although Williams had written some poems before entering medical school, it was at Penn that he met one of the people who had the most influence on his writing. Ezra Pound, whose brilliant career as a poet was eventually overwhelmed by his fascist sympathies, was then an undergraduate. But the young Pound’s outspoken ambition and ideas on poetry and literature proved attractive to the young medical student. Williams began to look beyond traditional verse of rhyme and meter and to try different forms. Despite Pound’s championing of things European, Williams sought to develop a more “American” style, full of concrete images and details, sometimes using a more common American speech. He acknowledged the significance of a modernist poem such as T. S. Eliot’s FALL 2015
The Waste Land, but Williams was determined to write poems that did not require, for example, knowledge of mythology. As he later phrased it: “No ideas but in things.”
What Is the Writer’s Business?
It’s likely that Williams’s career as a physician had something to do with his artistic credo. An article on him in The New York Herald Tribune (January 18, 1932) began this way: “Medicine and literature make the best possible combination in a man’s life, according to Dr. William Carlos Williams.” Later in the piece, Williams is quoted: “It seems to me that writing complements the doctor’s life so well. When you are tormented by people’s illnesses, it is a relief to be able to write your emotions down. Even surgery has its poetic side.” The Herald Tribune also noted that he would sometimes jot down his poetic ideas on prescription pads between calls. Later, Williams said that he wanted to write about the people who were close to him, not in the abstract. “That is the poet’s business. Not to talk in vague categories but to write particularly, as a physician works, upon a patient, upon the things before him, in the particular to discover the universal.” This does not mean that all of Williams’s work is crystal clear. Even Pound, in fact, criticized one of his books as “incoherent.” Williams would also mix genres, which could throw some readers off. One of his more daunting works may be Paterson, eventually consisting of five volumes, all about the people, geography, and history of the New Jersey city. It even includes letters from another New Jersey poet who attained fame, Allen Ginsberg. One of Williams’s poems that is often anthologized demonstrates his urge to avoid the grandiose and obscure, to speak more directly but artistically. “This Is Just to Say” could very well have been dashed off on a pad (not necessarily one for prescriptions) and stuck on a refrigerator: I have eaten the plums that were in the icebox and which you were probably saving for breakfast Forgive me they were delicious so sweet and so cold A poem that seems to allude to his other profession appears in an early collection called Spring and All (1923). It begins “By the road to the contagious hospital.” Williams then evokes a rather bleak landscape, with cold winds, dried weeds, trees “with dead, brown leaves under them.” Then in the short poem comes the turn: “Lifeless in appearance, sluggish / dazed 34
spring approaches –” Spring is not yet an obvious powerful force, but there is a growing sense that things are starting to change. The last lines: One by one objects are defined -It quickens: clarity, outline of leaf But now the stark dignity of entrance -- Still, the profound change has come upon them: rooted they grip down and begin to awaken Here the lack of a period at the end of the poem seems quite functional!
A Legacy Lives On
The University of Pennsylvania did not overlook Williams’s achievements in his chosen fields. In 1952, he received an honorary degree. More recently, the poetry prize for the best original poems by a Penn graduate student (in any school) was named the William Carlos Williams Prize, presented jointly with the Academy of American Poets. The spirit of Williams lives on at Penn Medicine in a different way as well. A fourth volume of Stylus, which describes itself as “a medical humanities literary and art journal,” has recently been posted. Most of the contributors in the new issue are medical students and Ph.D. candidates here. The editors have connections with the University and with medicine. The founding editor, Yun Rose Li, is a fifth-year M.D.-Ph.D. candidate at the Perelman School. She is finishing her clinical training after having completed her doctoral dissertation in genomics and computational biology. There are also pieces by an assistant professor of clinical neurology at HUP and a staff chaplain at HUP. The faculty advisors are Horace DeLisser, M.D. ’85, associate professor of Medicine and head of Penn Med’s Spirituality, Religion, and Medicine program, and Zachary Meisel, M.D., M.P.H., assistant professor of Emergency Medicine and a frequent columnist for Slate and for Time.com. The form and topics of the new Stylus vary widely, and many catch your attention. One of the prose pieces that touches most directly on the practice of medicine is “Grey Zone of the White Coat,” by Avi Baehr, a medical student at the Perelman School who is completing a fellowship in health policy in Washington, D.C. Here she grapples with one of the inevitable responsibilities of the physician, being able to pick yourself up when a patient’s condition worsens and to prepare to face your next patient with full attention: This was my first real taste of what it can mean to don the white coat and have the privilege of practicing medicine. It means seeing a horrible thing happen to a grandfather with a kind face. It means walking across the hall and plastering on a smile because I’ve committed not only to do-no-harm but to do good by that other patient, too. And he needs to have that reassurance that my mind isn’t elsewhere. It means sitting down with a wife while her husband is in surgery and saying, “I’m so sorry this happened to you,” knowing she isn’t hearing a word
medicine ◆ art ◆ literature Penn Medicine | Vol. IV ◆ 2015
has found the creative process to be therapeutic: “Putting experiences and emotions onto paper enabled me to contend with challenges I didn’t realize I was facing.”
How Did Williams Do It?
“Plastic Bags,” a poem by Ayoosh Pareek, makes use of a ubiquitous and perhaps overly familiar object of contemporary life: There is something fascinating about plastic bags, Floating in the stratosphere, symbols of plastic love, discardable affection.
For a look at the most recent issue of Stylus, go to: http://www.themedicalstylus.com that’s coming out of my mouth but hoping that she derives some small comfort from my stopping by in a crisp white coat with a stethoscope around my neck. Dr. Williams would no doubt sympathize. Putting her piece in context, Baehr says, “While I’ve seen a lot of really difficult things throughout my time in medical training, there have been a handful of experiences that have really stuck with me. I have found it incredibly cathartic to write about the experience. It’s something I do on the side in my free time, and mostly just for myself. However, I have submitted these essays for publication a couple of times, when I think that the experience might resonate with others as well.” Daniel Child is the author of “Blood,” which surprisingly combines some fairly precise medical terminology (isopropyl alcohol, the polypropylene parasite, clotting factor V) with allusions to medieval heresies (that fiend Cathar, auto-da-fé, inquisition). The youthful narrator expresses confidence that there is no trace in his blood of “the heretic / that infiltrated my family generations ago”; but then recalls that complacency “allowed the dissident’s influence to send my genetic predecessors to the hospital for their last time.” Child is now in the Ph.D. phase of his M.D.-Ph.D. training, with an interest in genetics and gene regulation. “Most of my writing efforts over the past year have been directed to a scientific end,” he says. “Fortunately, I enjoy the process just as much as I enjoy writing creatively.” He has read and enjoyed many of Williams’s poems and short stories. “His works have taught me a deeper understanding of empathy and compassion, the magic of genuine human relationships, and the sacredness of the individual.” These themes, Child acknowledges, are not unique to medicine, “but they are attributes that seem to define the caring physician.” For himself, Child
So begins the poem, which hints at dislocation, attempts to escape a reality, “drowning yourself,” “the inability to breathe.” One startling image that is both matter-of-fact and somewhat surreal: “Nothing resembles us more than a recently used ashtray.” Pareek reports that “The Red Wheelbarrow,” one of William Carlos Williams’s most anthologized poems, was one of the first poems Pareek ever read. He enjoyed creative writing in high school and at Brown University, where he took a course taught by the poet laureate of Rhode Island. He also joined WORD!, a spoken word group at Brown, “because I thought I needed to explore other creative venues and expand my horizons.” Even in medical school, he has been typically writing a poem every week. On the other hand, he’s not sure whether he will be able to continue writing while he pursues a career in orthopaedic surgery. “It’s hard for me to imagine how Williams did it,” Pareek notes, “especially being the prolific author that he was.” But, like Williams, he hopes to be in it for the long haul. Sara Rendell is a medical students as well as a Ph.D. candidate in cultural anthropology. For her, Williams has been “a huge inspiration,” and she marvels about his ability to write in the midst of a busy career. Rendell wrote her poem “Brush Strokes” while taking a break from studying histology slides as a first-year medical student. She was, she says, “both entranced by the complexity and beauty of what I was learning and overwhelmed by how quickly my tenuous grasp of any chunk of information could evaporate.” We do not memorize, we sweep details -- dust trapped in cobwebs, nestled between floor planks, abandoned in the cabinet’s shadow. . . . Perhaps even more frightening for the writer are these lines from later in the poem: “Words we once saw fade from the facts / we know . . .” Rendell writes fragments every day. “When my schedule is lighter, I write 1-2 pages in my journal each night.” And she hopes to continue writing as she pursues a medical career: “I think I would dry up and disintegrate if I could not write.” Cover image: Brachial Graft, by Eo Trueblood, lead medical illustrator with Stream Studios at The Children’s Hospital of Philadelphia. FALL 2015
Honoring One of the Nation’s An Endowed Professorship Named for Peter C. Nowell, M.D.
n a long-anticipated honor for Peter C. Nowell, M.D. ’52, the Lasker Award-winning Penn luminary who co-discovered the Philadelphia chromosome, an endowed professorship has been established in his name. Kojo S. ElenitobaJohnson, M.D., will be the first to hold the Nowell chair. The chair was made possible through a collaborative effort by faculty, some of whom trained with Dr. Nowell, and myriad donors coming together from a broad swath of the Penn community. Many donors are, in fact, long-time supporters of the Abramson Cancer Center, for which Dr. Nowell served as its first director beginning in 1973. “I am deeply gratified that such stalwart supporters in our fight against cancer have chosen to honor the groundbreaking work that Dr. Nowell has contributed to oncology, innovations that shifted the cancer paradigm decades ago and that reverberate now in cancer immunotherapy,” says Chi V. Dang, M.D., Ph.D., the John H. Glick, M.D., Abramson Cancer Center Director’s Professor and director of the Abramson Cancer Center.
A professorship honoring Peter Nowell is one of many deserved plaudits for a genuine giant in Penn history and cancer discovery. –D r. David B. Roth
Simon Flexner Professor of Pathology and Laboratory Medicine Chair, Department of Pathology and Laboratory Medicine
The 87-year-old Dr. Peter Nowell – who holds the Gaylord P. and Mary Louise Harnwell Emeritus Professorship of Pathology and Laboratory Medicine – along with his research partner, the late David Hungerford, Ph.D., discovered the Philadelphia chromosome in 1960. This finding, an abnormally small chromosome in the cancerous white blood cells of patients with chronic myeloid leukemia (CML), was considered a watershed moment in cancer research, demonstrating the genetic basis for cancer, which ran counter to prevailing thought at the time. Their revolutionary work also formed the foundation for the clinical trials for Gleevec®, the Novartis Pharmaceuticals drug that received FDA approval in 2001 and has since stabilized 36
disease in 95% of treated CML patients and which has been approved to treat 10 different kinds of cancer. In 1998, Dr. Nowell shared the Albert Lasker Clinical Medical Research Award, the nation’s highest honor for biomedical research, with the University of Pennsylvania’s Dr. Alfred G. Knudson Jr. Dr. Nowell was first to show that bone marrow transplantation was effective in irradiated animals, and his work also helped to pave the way for the current revolutionary advancements in CAR T cancer immunotherapy that we are seeing today: He observed that a plant protein, known as PHA, was capable of stimulating mitosis. This knowledge later proved essential for culturing white blood cells – results arguably as important as the Philadelphia chromosome discovery. Later in his career, he developed the clonal evolution model of cancer: cancer cells incessantly accumulate mutations that yield a survival advantage and thus are regulated by natural selection. In addition to his service as the first cancer center director at Penn, Dr. Nowell was chair of the Department of Pathology from 1967 to 1973. He championed scientific and medical education: achievements in which, as he has often said, he takes the greatest pride. He provided time in the lab, and held lab picnics for elementary and high school students – particularly those with less direct access to educational resources. He mentored several prominent faculty members and was known for turning every question or interaction into a learning experience – enlightening rather than intimidating – and, in the process, modeling how to be a complete physician-researcher and mentor to peers, fellows, and students. The inaugural Nowell chair-holder, Dr. Kojo ElenitobaJohnson, is an international leader in the field of hematopathology, molecular pathology, and mass spectrometry- driven proteomics. He is also the founding director of Penn Medicine’s Center for Personalized Diagnostics and chief of the Division of Molecular and Genomic Pathology. His laboratory at the University of Michigan is credited with having identified several recurrent genetic abnormalities linked to the development and progression of a number of lymphoma subtypes. Kojo S. Elenitoba-Johnson, M.D.
Greatest Cancer Pioneers: “Dr. Elenitoba-Johnson is an outstanding investigator whose research has already had significant impact, and I am excited by the prospect of future innovations – as transformative as Dr. Nowell’s – arising from his work,” said J. Larry Jameson, M.D., Ph.D., executive vice president for the Health System and dean of the Perelman School of Medicine.
Dr. Elenitoba-Johnson is an inspired and ideal choice as the inaugural Peter C. Nowell, M.D., Professor. – Dean Jameson
He has received several awards, including the Outstanding Teaching Award in Anatomic Pathology from the University of Utah (1999 and 2003), the Ramzi Cotran Young Investigator Award from the United States and Canadian Academy of Pathology, and the American Society for Investigative Pathology Outstanding Investigator Award. He was recognized in Best Doctors in America from 2003 to 2014 and is a member of the American Society for Clinical Investigation. Dr. Elenitoba-Johnson earned his M.D. degree from the College of Medicine, University of Lagos, in Lagos, Nigeria. Subsequently,
THE PRESIDENT’S DISTINGUISHED PROFESSORSHIPS
Endowed chairs support the lifeblood of any great university: its eminent faculty. Providing the resources to recruit and retain the finest minds, funds from these chairs also protect vital clinical, research, and education endeavors in times of financial uncertainty. Today, there is a new opportunity to establish a fully endowed chair with a gift of only $2.25 million – rather than the usual full $3 million commitment. In early 2014, Penn President Amy Gutmann announced an ambitious plan, as part of her Penn Compact 2020 Presidential Initiative, to establish 50 new endowed chairs. The goal of the President’s Distinguished Professorship Fund is to recruit and retain eminent multidisciplinary faculty. Penn Medicine Trustee partners George Weiss, W’65, HON’14, and Richard Vague joined President Gutmann’s effort: to encourage new endowed chairs, they pledged $10 million to match gifts to create new distinguished professorships. The challenge contributes $750,000 to the endowment for each new chair, so donors can establish a Presidential Distinguished Professorship with a gift of $2.25 million. We invite you to join President Gutmann, George Weiss, and Richard Vague in helping fuel Penn Medicine’s drive from excellence to eminence. To learn more, contact Penn Medicine Development and Alumni Relations at (215) 898-0578.
Peter Nowell with David Hungerford (c. 1960).
he went to the Brown University School of Medicine for his residency in anatomic and clinical pathology and served as chief resident. He then moved on to the National Cancer Institute to complete a fellowship in hematopathology, as well as the Leadership Development for Physicians in Academic Health Centers program at the Harvard School of Public Health. Before arriving at Penn, he held the Henry C. Bryant Professorship at the University of Michigan and served as director of the Molecular Diagnostics Laboratory there. “Endowed chairs are a critical part of a thriving academic medical center,” explained Dean Jameson. “I am particularly delighted that the Nowell Chair has allowed us to attract a clinician-scientist of the caliber of Dr. Elenitoba-Johnson – who brings a natural continuation of Peter’s work – as well as honor Dr. Peter Nowell: the first face of cancer research at Penn, who ushered in the modern era of cancer research.”
Peter Nowell received the Benjamin Franklin Medal from the Franklin Institute in 2010.
PROGRESS NOTES Send your progress notes and photos to: Donor Relations Penn Medicine Development and Alumni Relations 3535 Market Street, Suite 750 Philadelphia, PA 19104-3309 PennMedicine@alumni.upenn.edu
1960s Patricia A. Gabow, M.D. ’69, was elected to the board of trustees of Seton Hill University, where she earned her B.A. degree in biology. A national leader in hospital reform and the delivery of public health care, Gabow also serves on the board of trustees of the Robert Wood Johnson Foundation. Listed as one of Modern Healthcare’s “50 Most Powerful Physician Executives in Health Care,” she currently serves on the federal Medicaid and CHIP Payment and Access Commission and the Health Advisory Board of the National Governors Association. A nephrologist by training, Gabow retired in 2012 after 20 years as chief executive officer of Denver Health and Hospital Authority.
1970s Barry J. Gertz, M.D. ’79, has joined Nuvelution Pharma Inc. as chief physician scientist. He is a venture partner at Clarus Ventures and chief medical advisor for Relay Pharmaceuticals Inc. Before joining Clarus, he was senior vice president of global clinical development at Merck. He was instrumental in the development and approval of more than 25 new drugs and vaccines, including six new approvals in 2014, and is an author of more than a hundred scientific publications and articles.
1980s Alan F. List, M.D. ’80, was appointed chair of the scientific advisory board of Cellular Biomedicine Group Inc. He previously served as president and chief ex-
ecutive officer of Moffitt Cancer Center and Research Institute. Earlier, he was executive vice president and physician-in-chief, vice deputy physician-in-chief, and chief of the malignant hematology division at Moffitt, where he holds the Morsani Endowed Chair. Before joining Moffitt in 2003, he was a professor of medicine at the University of Arizona, where he also served as director of the leukemia and blood and marrow transplant program and the translational/ clinical research program. Stephen Ostroff, M.D. ’81, is the acting commissioner of the Food and Drug Administration. Before being named to the position, Ostroff served as the FDA’s chief scientist. He led and coordinated its scientific and public health efforts, providing support for its regulatory science and innovation initiatives. Ostroff joined the FDA in 2013 as chief medical officer in the Center for Food Safety and Applied Nutrition and as senior public health advisor to its Office of Foods and Veterinary Medicine. Earlier, he had been deputy director of the National Center for Infectious Diseases at the Centers for Disease Control and Prevention, where he was also acting director of the CDC’s Select Agent Program. While at the CDC, he focused on emerging infectious diseases, food safety, and coordination of
as the director of the Bureau of Epidemiology and acting physician general for the Commonwealth of Pennsylvania. Randall Patkin, M.D. ’85, G.M.E. ’89, is a comprehensive ophthalmologist specializing in cataract surgery, glaucoma, diabetes, and routine eye care, based at the Eye Center of the Northshore in Salem, Mass. He received the Dr. Bennett I. Solomon Community Leadership Award at Cohen Hillel Academy’s 27th Annual Gala. Patkin has served on numerous committees and is a board member of the North Shore Cataract and Laser Center.
1990s Bruce A. Monaghan, M.D. ’90, G.M.E. ’95, an orthopaedic surgeon, was named vice president of the 550-member medical staff of Inspira Medical Center Woodbury, in New Jersey. He joined its medical staff in 1996 after completing a fellowship in hand and microvascular surgery at the Indiana Hand Center in Indianapolis. A former vice president of the South Jersey Surgical Center in Mount Laurel, he currently serves as the chairman of the board of Gloucester County Surgical Center in Mullica Hill, a joint venture between physicians and Inspira Health Network. He is also president elect of the New Jersey Orthopaedic Society. Steven Jay Perch, M.D. ’91, G.M.E. ’95, has joined the radiation oncology physician team at the Dale and Frances Hughes Cancer Center at Pocono Medical Center.
responses to complex outbreaks. He retired from the Commissioned Corps of the U.S. Public Health Service at the rank of Rear Admiral (Assistant Surgeon General). Ostroff has also served
Christina M. Coughlin, M.D. ’99, Ph.D. ’99, has been appointed chief medical officer of Immunocore Limited, a biotechnology company based in Oxfordshire, U.K., that seeks to develop novel drugs to treat cancer, viral infections, and autoimmune diseases. She will oversee the company’s pre-clinical and clinical programs. Coughlin has led multiple programs across the full spectrum of drug development.
Most recently, she supervised two early-development programs at Novartis, leading the program’s teams in pre-clinical pharmacology, toxicology, clinical pharmacology, clinical development, biomarker development, and regulatory work. Previously, Coughlin had studied patient responses to tumor antigens at Penn Medicine under the direction of Carl June, M.D.
2000s Rajiv J. Shah, M.D. ’02, Ph.D., was named to the board of directors of Omeros Corporation, a Seattle-based biopharmaceutical company. From 2010 to 2015,
Shah served as administrator of the United States Agency for International Development. Before that, he was Under Secretary for Research, Education, and Economics and chief scientist at the U.S. Department of Agriculture. He has also worked in senior roles at the Bill & Melinda Gates Foundation. He is currently a distinguished fellow at Georgetown University’s School of Foreign Service, where his work focuses on international development. He also sits on the board of directors of Arcadia Biosciences Inc. and the board of trustees of the Rockefeller Foundation. Jay R. Venkatesan, M.D. ’02, has become managing partner at Alpine BioVentures, a venture-capital firm based in Seattle. Most recently, he was executive vice president and general manager of
Oncothyreon Inc., which he joined after it was acquired by Alpine Biosciences. Previously, he was founder, portfolio manager, and managing director of Ayer Capital Management. He serves on the boards of Lion Biotechnologies and AuraSense Therapeutics.
Michael E. Burczynski, Ph.D. ’99, who earned his doctorate in pharmacology, is the author of The Ripper Gene, a medical thriller recently issued by Tor/ Forge. A biomedical scientist and adjunct professor in the Perelman School’s Department of Systems Pharmacology and Translational Therapeutics, Burczynski is also an executive director and head of biomarker technologies for a major pharmaceutical firm. He wrote The Ripper Gene under the pen name Michael Ransom. The novel tells the story of a neuroscientist turned F.B.I. profiler, Dr. Lucas Madden, who sequences the DNA of the world’s most notorious serial killers and proposes a controversial “damnation algorithm” that could predict the behavior of a serial killer using DNA alone. Then a new murderer begins terrorizing women in the Mississippi Delta, and Madden’s former fiancée is kidnapped. Only by “entering” the killer’s mind will Madden have a chance of understanding the killer’s twisted rationale and ending his reign of terror. Part of Burczynski’s real-life research involves scanning the 3.2 billion nucleotides of the human body to identify tiny alterations that influence an individual’s susceptibility to disease. He is also the editor of two scientific textbooks: An Introduction to Toxicogenomics (2003) and Surrogate Tissue Analysis: Genomic, Proteomic, and Metabolomic Approaches (2005). He uses his background in modern molecular biology to bring cutting-edge science into his fiction. Early in The Ripper Gene, Madden explains his research to
a colleague, noting that “I’d studied the works of neurobiologists at Penn and other institutions, who’d insisted there was a biological basis for violence, no matter if people didn’t want to admit it. . . . “We eventually showed that ripper encoded a dopamine transporter that localized to the amygdala region of the brain. It was a perfect culprit. Most people carry normal copies and as a result have normal transmission in the amygdala. . . . But in a small set of unfortunate individuals carrying two dysfunctional copies of the ripper gene, dopamine transporters are turned on like crazy, depleting the available dopamine in their brains and causing a signaling defect in their amygdala. They respond no differently whether they’re looking at a rabbit in a garden or a torture victim in a basement. . . . Anyway, my thesis showed that deficits in ripper gene function were present in more than seventy percent of the serial killers I tested. The prevalence in the normal, non-incarcerated human population is around two percent.” For readers interested in what he calls “the controversial and intriguing scientific premise” of his novel, Burczynski in his acknowledgments recommends The Anatomy of Violence (2013), by Adrian Raine, Ph.D. Raine is the Richard Perry University Professor of Criminology & Psychiatry at Penn. Burczynski/Ransom is scheduled to read at the Penn Bookstore on November 16, at 6:00 p.m.
Douglas C. Fisher, M.D. ’03, M.B.A., has resigned from his position as a director on the board of Sera Prognostics, a women’s health-care company based in Salt Lake City that is in the final stages of developing a novel proteomic predictor for pre-term birth risk. Fisher has now joined the company’s management team as chief business officer. He is also an executive-in-residence at InterWest Partners, a venture capital firm in Menlo Park, Calif. Throughout his career, Fisher has focused on biopharmaceutical, diagnostic, and medical device investments, working in venture capital, consulting, and pharmaceutical industries.
1930s Frank R. Braden Jr., M.D ’33, Coraopolis, Pa., a retired physician; May 19, 2014. He was attending physician in both the medical and surgical clinics of Allegheny General Hospital 1935-1941. In World War II, he served in the Medical Corps of the U.S. Army, rising from 1st Lt. to Lt. Col. The public schools of Coraopolis, Neville Island, and Moon Township employed him as medical examiner from 1945 to 1978. He served as president of the medical staff of Sewickley Valley Hospital and was on the board of directors for the Allegheny County Medical Society.
1940s Edward S. McCabe, M.D. ’42, Merion, Pa., a retired physician who was on staff at the old Presbyterian Hospital for 35 years; June 1, 2014. He was an associate
professor of medicine at Temple University. During World War II, he served as a surgeon with the U.S Army in Europe. George R. Wade, M.D. ’43, McKinney, Tex., a retired pediatrician who had been chief of pediatrics at Paoli Memorial Hospital from 1968 to 1981; February 11, 2014. He was president of its medical staff 1970-1972. The hospital’s nursery was named in his honor. During World War II, Wade served as a psychiatrist in the U.S. Navy, serving in the Pacific theater. James Hickman Jr., M.D. ’45, Knoxville, Tenn., a retired physician; August 31, 2015. He served in the U.S. Army as a medical officer during World War II, leaving with a rank of captain. He was the medical director of BASF, the chemical company, in Morristown, Tennessee, retiring in 1986. Ralph A. Jessar, M.D. ’46, G.M. ’50, a retired assistant clinical professor at the Perelman School of Medicine; April 15, 2015. He earned his B.A. degree in 1943 from Penn’s College of Arts & Sciences. He served in the U.S. Navy as a lieutenant, j.g. Jessar returned to Penn in 1953 as a research fellow in rheumatology and joined the teaching staff as an instructor the following year. As a rheumatologist, he was a member of the research team that developed the use of corticosteroid injections for the treatment of rheumatoid arthritis. He also served as chief of rheumatology at Graduate Hospital before retiring from Penn in 1986. John M. Stevens Jr., M.D. ’46, Cornwall, Pa., a retired psychiatrist and psychoanalyst who had maintained a practice in Philadelphia for many years; October 7, 2014. During World War II, he served as a medical officer in the U.S. Army. He had helped set up psychiatric counseling at Penn’s Student Health Center. Robert P. Brundage, M.D. ’47, G.M. ’51, Archbald, Pa., a retired family physician; September 5, 2014. As an undergraduate at Penn, he was a member of the
football team. He served in the U.S. Navy during World War II and the Korean War and received the Bronze Star for his service as a surgeon on the front lines in Korea. Samuel Mickle Fox III, M.D. ’47, Bar Harbor, Maine, a retired cardiologist and former chief of the Heart Disease Control Program of the U.S. Public Health Service; April 22, 2015. His
photographic memory and knowledge of ships, as shown by an essay published in Naval Proceedings, attracted the U.S. Navy’s attention. He became a commissioned ensign of the U.S. Naval Reserve in 1942, later advancing to Commander, Medical Corps, U.S. Navy. He graduated from Haverford College in 1944. In medical school, he met Mary Alice Vann, also a student. They wed in 1949 and had four children. Fox was acting chief of gastroenterology at the National Naval Medical Center, Bethesda, 195051, where he translated knowledge of heart rhythms obtained during endoscopy into an interest in cardiology. He then served at the Office of Naval Research in London for the Naval Forces in Europe, the Atlantic, and the Mediterranean; there, he became interested in physical activity and the prevention of heart disease. He became chief of the cardiology service at the Naval Medical Center and then head of the Department of Clinical Investigation at the U.S. Naval Medical Research Unit in Cairo, 1954-56. His other positions included chief of cardiology at the U.S. Naval Hospital in Portsmouth, Va., and senior staff of the Cardi40
odynamics Section at the National Heart Institute of NIH, Bethesda Naval Hospital, 19571962, where he developed an in-patient cardiac rehabilitation program. Fox also served as physician for America’s first astronauts in NASA’s Project Mercury (1960-64) and monitored the first manned space mission from a tracking station in Zanzibar. During this time, he worked at the U.S. Public Health Service’s Heart Disease Control Program, where he soon became chief. After setting up Georgetown University Hospital’s Cardiac Rehabilitation Lab, he became professor and director of the Preventive Cardiology Program. A longstanding member of the American College of Sports Medicine and eventually vice president, he edited Coronary Heart Disease: Prevention, Detection, Rehabilitation, with Emphasis on Exercise Testing (1974), a landmark reference on cardiac disease and prevention. Fox was president of the American College of Cardiology and was named a Distinguished Fellow of the college. He received the 1974 Eleanor Naylor Dana Award for Preventive Medicine, presented by American Health Foundation. G. Clayton Kyle, M.D. ’47, G.M.E. ’51, an endocrinologist who specialized in diabetes; December 24, 2014. He served with the C.I.A. in Munich from 1951 through 1953. A clinical associate professor when he retired from medicine, he spent his entire career at the Hospital of the University of Pennsylvania and served as the chairman of its medical board from 1977 to 1979. Kyle resisted established norms and instead pioneered and taught innovative methods that reduced complications and extended the lives of hundreds of patients. In the early 1960s, he concluded that lowering blood glucose reduced the risk of complications, and he also made the observation that part of the underlying pathogenesis of type 2 diabetes included failure of the beta cell to produce adequate insulin. Because of this discovery, he was one of the first clinicians in the world to aggressively treat hyperglycemia; he also intro-
duced insulin in the early stages of type 2 diabetes, to the great benefit of his patients. Kyle published original research and review articles on the effects of diabetes in pregnancy and pioneered tight control of blood sugar in pregnancy before it became standard practice. Through the generosity of grateful patients, friends, and colleagues, Kyle founded the Penn Rodebaugh Diabetes Center, which aims to treat diabetes and prevent its complications in a manner consistent with his exacting standards and brings together diabetes specialists, nurses, podiatrists, nutritionists, and others skilled in managing various aspects of the illness. An associate professorship at HUP was established in Kyle’s name. Mary Alice V. Fox, M.D. ’48, G.M.E. ’52, Bar Harbor, Maine, a retired physician; April 25, 2011. She graduated from the Women’s College of North Carolina, Greensboro, in 1944, and attended the University of North Carolina, Chapel Hill. At Penn’s School of Medicine, she met her future husband, Samuel M. Fox III, M.D. ’47. She interned at the Hospital of the Medical College of Virginia and completed a residency at the Children’s Hospital of Philadelphia. After accompanying her husband to London and Cairo, she established a private practice in Bethesda, Md., and also served in the Health Department of Montgomery County, Md. She later was Chief of Crippled Children’s Control for the State of Maryland and then went on to hold a similar position in Montgomery County. She retired in 1979. George Henry Miller Jr., M.D. ’48, Livermore, Maine, a retired professor of urology; July 28, 2015. He served in the U.S. Navy briefly in World War II as a hospital corpsman and re-enlisted in 1951 as a lieutenant j.g. assigned to Great Lakes Naval Hospital. He served on the U.S.S. Consolation hospital ship in 1952, and was dispatched to Korea and Japan for active duty. He entered the Naval Reserve in 1954. He was an instructor and assistant professor at the University of
Chicago and the College of Medicine at the University of Florida, where he founded its Division of Urology. He was promoted to assistant dean and full professor in 1968. From 1968 to 1976, he served as chief of staff at the VA Hospital in Gainesville, Fla. In 1976, he became chief of staff at the VA Hospital in Togus, Maine, where he remained until his retirement in 1990. David P. Morris Jr., M.D. ’48, Matthews, N.C., a retired director of the U.S. Navy’s Aerospace Medical Research Development Facility; July 16, 2014. He had earlier served as head of launchsite medical operations at the NASA Manned Spacecraft Center, Cape Canaveral. Following his career in the Navy, he worked to treat alcoholism and chemical dependency at several treatment centers.
1950s Jaime Asch, M.D., G.M. ’51, Mexico City, an otolaryngologist; March 3, 2014. Stanley Masters, M.D., G.M. ’51, Floral Park, N.Y., a retired ophthalmologist; July 24, 2014. He had been associated with the Long Island College Hospital. Melvin J. Chisum Jr., M.D. ’52, Philadelphia, a retired general practitioner who later became associate medical director for the old Bell Telephone Company of Philadelphia; October 22, 2014. During World War II, he served with the U.S. Army in the Pacific as a chief warrant officer. Chisum had been a member of the board of overseers of the Penn Libraries. Abraham L. Cohen, M.D., G.M.E. ’52, Upper Gwynedd, Pa., a retired physician; June 18, 2014. During World War II, he served in the U.S. Army Medical Corps. James P. Geiger, M.D. ’52, San Rafael, Calif., retired chief of cardiothoracic surgery at the Walter Reed Army Medical Center; April 16, 2015. He served 23 years with the Medical Corps of the U.S. Army, receiving several awards and decorations, includ-
ing the Legion of Merit twice. His Army career included service in Europe, the Philippines, Korea, Vietnam, and postings across the United States from West Point, N.Y., to San Francisco. After retiring from the military, Geiger continued his medical practice for 27 more years as a cardiothoracic surgeon in San Francisco at St. Mary’s Medical Center and at Marin General Hospital. Alexander Daniel Kovacs, M.D. ’52, Philadelphia, a retired physician; August 30, 2015. He served in both the U.S. Navy and Army. He had lived in New Jersey, where he practiced as an obstetrician-gynecologist. In the early 1980s, he was president of the New Jersey AMA. Buel S. Smith, M.D. ’52, Akron, Ohio., a retired surgeon; January 15, 2015. He served in the U.S. Army Medical Corps, European Command, at the U.S. Army Hospital in Versailles, France. He practiced orthopaedic surgery in Akron for more than 35 years. He had been chairman and director of the residency training program in the Department of Orthopaedic Surgery at Akron General Medical Center. In addition, he served as president of the hospital’s staff and at Barberton Citizens Hospital, and he had been a professor and chairman of orthopaedic surgery at Northeast Ohio University College of Medicine. The Buel S. Smith Orthopaedic Surgery In-Patient Center at Akron General Medical Center was dedicated in 2010. He was elected to the Society of Distinguished Physicians at Akron General Medical Center and received the President’s Award. A. Peter Batson, M.D. ’53, G.M.E. ’60, Norwich, Vt., a retired ophthalmologist who had maintained a practice there for 22 years; May 15, 2014. After his internship at Philadelphia General Hospital, Batson joined the U.S. Air Force as a first lieutenant. He served for 23 years, as flight surgeon, ophthalmologist, chief of hospital services, and hospital commander, and was promoted to colonel in 1970. He received the Meritorious Service
Medal, among many awards. When he retired from the Air Force in August 1976, Batson moved to Vermont and opened an ophthalmology office in Lebanon. Frank Christian Greiss Jr., M.D. ’53, Lake Norman, N.C., a retired physician; July 23, 2015. He served as a U.S. Navy lieutenant at the dependents’ hospital of the Charleston Navy Yard. In 1960, he joined the Department of Obstetrics and Gynecology at Bowman Gray, where he served as chairman. He received the Foundation Prize of the American Association of Obstetricians and Gynecologists as well as the Distinguished Service Award from the North Carolina Obstetrical and Gynecological Society. Paul G. McKelvey Jr., M.D. ’53, Greensburg, Pa., a retired family physician; October 25, 2014. He served in the military during World War II as a member of the 159th Engineer Combat Battalion, which played a prominent role in the Battle of the Bulge. For his service, he was awarded the American Campaign Medal and the European-African-Middle Eastern Campaign Medal, with five Bronze Stars and the World War II Victory Medal. In Greensburg, he maintained a private practice for 25 years. He then joined the staff of Latrobe Area Hospital as a teaching faculty member in the Family Medicine Residency Program, in which he trained recent medical school graduates in the nuances of running a successful family practice. He also served as plant physician for the former ITE Corp., makers of circuit breakers, for 25 years. C. Burns Roehrig, M.D., G.M. ’53, a retired internist and endocrinologist, Hilton Head Island, S.C.; January 17, 2015. He received his medical degree from the University of Maryland and completed his residency in internal medicine at the University of Pennsylvania. During the Korean War, he served as a flight surgeon and captain in the U.S. Air Force. Roehrig had been chief of the general medical staff and
president of the medical administrative board at New England Deaconess Hospital. He was also a member of the physician advisory group for the Health Care Financing Administration (now known as Centers for Medicare and Medicaid Services). He was former president of the New England Diabetes Association, had served on the board of directors of the Greater Boston YMCA, and had been president of the Massachusetts Society for Internal Medicine. A former president of the American Society of Internal Medicine, Roehrig also served for 12 years as editor of the organization’s monthly magazine, The Internist. He was elected a Master of the American College of Physicians.
his great-uncle Isaac J. Wistar in 1892. Rhoads had also been a vice president of the board of directors of Friends Hospital. One of his daughters is Caroline S. Rhoads, M.D. ’89.
Donald Vail Rhoads, M.D. ’54, a retired physician who had maintained a family practice in Chestnut Hill for many years; January 27, 2015. He completed a threeyear fellowship in internal medicine at the Mayo Clinic in Rochester, Minn. A conscientious objector during the Korean War, Rhoads served his alternative
William S. Vaun, M.D. ’55, Norfolk, Conn., a retired physician; December 1, 2014. From 1957 to 1959, he served as a captain in the U.S. Air Force, with concurrent assignments at the Pentagon and at Andrews and Bolling Air Force bases in Washington, D.C. In 1965, he became director of medical education at Monmouth Medical Center. He oversaw a residency program that grew from 30 residents to more than 100 physicians-in-training and from four accredited residency programs to 10 upon his retirement. He was a fellow of the American College of Physicians, where he served on the committee on hospitals, and of the Association of Hospital Directors of Medical Education, where he had been vice president and chairman of the program committee. Vaun also served on the legislative council of the American Hospital Association. In 1987 he became a consultant at the Continuing Medical Education complex at the University of Medicine and Dentistry of New Jersey.
service at Rochester State Hospital. He was also an assistant clinical professor of medicine at Penn, where he taught senior medical students in the outpatient clinic. He had been a member of the staff of Northwestern Institute of Psychiatry and worked as a medical adviser to the American Friends Service Committee. He served for 31 years on the board of the Wistar Institute of Anatomy and Biology, which had been founded by
Jay A. Desjardins, M.D. ’55, West Chester, Pa., a retired internist; November 23, 2014. From 1956 to 1962, he served as a lieutenant commander in the U.S. Navy Medical Corps. He practiced internal medicine for 35 years in Havertown, Pa., and was an attending physician at Fitzgerald Mercy, Riddle Memorial, and Delaware County Memorial hospitals. He was honored in 2012 by Mercy Catholic Medical Center for 50 years of devoted service.
Matthew A. Asbornsen, M.D. ’57, Stuyvesant, N.Y., a retired physician; August 21, 2011. After graduating from Rutgers University, he worked for Brown Brothers Harriman, the banking firm, until drafted into the U.S. Army during the Korean War. He served his two years in a research
OBITUARIES laboratory at the Army Chemical Center. After earning his medical degree, he completed his training at the University Hospitals of Cleveland. He then joined the Rip Van Winkle Clinic in Columbia County, N.Y., before establishing his own practice in Kinderhook, where he practiced for 26 years. He was a former supervisor and councilman of Stuyvesant and worked to initiate recycling throughout the county. Asbornsen was also instrumental in the preservation of five miles of Stuyvesant’s shoreland.
for the Supreme Headquarters of the Allied Powers in Europe at Versailles, France. He joined the Navy Reserve and was honorably discharged with the rank of captain in 1959, then joined the staff at Nazareth Hospital in Northeast Philadelphia. In 1982, he resigned as chairman of obstetrics and gynecology at Nazareth to help train doctors at Mercy Catholic Medical Center in Darby Borough and at the Medical College of Pennsylvania in East Falls.
William L. Clovis, M.D. ’57, Philadelphia, a retired psychiatrist; July 31, 2014.
Wayne C. A. Hurtubise Jr., M.D. ’57, Haverford, Pa., a retired physician; November 10, 2014. He practiced medicine for 37 years, treating patients at the former Haverford State Hospital and Bryn Mawr Hospital. He was doctor and team physician at the Episcopal Academy and Agnes Irwin School. Thomas Mair Wilson Jr., M.D. ’57, Minneapolis, a retired neurologist; September 5, 2015. He served two years in the U.S. Air Force as a medical doctor and was stationed in the Philippines. He then moved to Minneapolis to join Midwestern Neurologic and Psychiatric Consultants and Abbott Northwestern Hospital. Frederick F. Paustian, M.D., G.M.E. ’58, Omaha, emeritus professor of gastroenterology at the University of Nebraska; November 2, 2014. He served as president of the Metropolitan Omaha Medical Society and of the Nebraska Medical Association. He had also been governor of Nebraska for the American College of Physicians, which in 1993 designated him a master. In 2006, he was named one of the first five “Legends of Medicine” at the University of Nebraska Medical Center. James Schaller, M.D. ’58, West Chester, Pa., a retired obstetrician-gynecologist; August 8, 2015. He served for five years in the U.S. Army Medical Corps and was a general medical officer
William P. Calvert, M.D. ’60, Miami, a retired radiologist; January 26, 2014. He served as a flight surgeon at Clark Air Force Base in the Philippines for two years during the Vietnam War. He practiced radiology for more than 25 years in Miami. During that time, he was chief of radiology at Larkin Hospital and the Community Health Center; spent time on the faculty of the University of Miami School of Medicine; and served as locum tenens radiologist at Mariners, Fishermen’s, and Keys Community hospitals in the Florida Keys. Calvert was also active in the Dade County Medical Association and the South Miami Medical Forum. Aaron M. Rosenthal, M.D., G.M. ’61, St. Louis, a retired physician; November 29, 2013. Karl D. Nolph, M.D. ’63, G.M.E. ’67, Columbia, Mo., the Board of Curators’ Emeritus Professor of Medicine at the University of Missouri; June 16, 2014. He had been chief medical resident at Bryn Mawr Hospital. A pioneer in the field of dialysis, he had been chief of nephrology at the school. The Chair of Nephrology at Missouri is named in his honor. Earlier, he served as a major in the U.S. Medical Corps for two years, as a research internist and renal consultant at Walter Reed General Hospital. John N. Thurman, M.D. ’67, former clinical associate professor of medicine in the Perelman School of Medicine; November
6, 2014. He completed his post-graduate work at Geisinger Medical Center and served on Penn’s clinical faculty intermittently from 1981 until 2010. He was an internist at Penncare Internal Medical Associates of Delaware County, from which he retired in 2011. At Riddle Memorial Hospital, he was on its active staff 1973-2011 and had served as chair of its subdivision of endocrinology.
1970s John L. Currie, M.D., G.M.E. ’72, Asheville, N.C., former chair of the Department of Obstetrics-Gynecology at Dartmouth-Hitchcock Medical Center; April 22, 2015. He earned his M.D. degree in 1967 at the University of North Carolina at Chapel Hill. After his training at Penn, he served in the U.S. Air Force for two years, then returned to join Chapel Hill OBGYN. He later joined the medical faculty at the UNC-CH. Currie also served as chief of the division of gynecological oncology at Johns Hopkins before moving to Dartmouth-Hitchcock. He concluded his medical career by establishing a gyn-oncology practice at the John B. Amos Cancer Center in Columbus, Ga. In 2001, Curie graduated from Vermont Law School and entered the New Hampshire Bar.
sity for four years. Lev-Toaff returned to Penn in 2008 as a professor of radiology and a member of the Clinical Practices of the University of Pennsylvania. She taught and practiced at Penn until 2014. Joseph L. Mallon Jr., M.D. ’89, Philadelphia; September 9, 2015. He worked for 12 years as a general internist at Abington Memorial Hospital and for two years as a hospitalist physician at McLeod Hospital in Florence, S.C. He moved to the Lehigh Valley in 2007, working as a hospitalist physician at Lehigh Valley Hospital in Allentown.
FACULTY Stella Y. Botelho, M.D., emeritus professor of physiology, Blue Bell, Pa.; March 11, 2015. After earning a medical degree from the Woman’s Medical College, she became an instructor at Penn’s School of Medicine in 1949. She was promoted to professor in 1969 and retired in 1981. She taught courses in applied and medical physiology. In her research lab, she studied re-
1980s Richard A. Browning, M.D., G.M.E. ’85, Barrington, R.I., former chief of anesthesia at Rhode Island Hospital and the Miriam Hospital; November 13, 2012. He also had been a clinical professor of anesthesia at Brown University. Anna S. Lev-Toaff, M.D., G.M.E. ’86, professor of radiology at Penn; April 3, 2015. She earned her medical degree in 1979 from New York University. Early in her career, she was an instructor in radiology at the Perelman School of Medicine.. She was also on the faculty at Thomas Jefferson University for 18 years and at Temple Univer-
spiratory physiology, neuromuscular physiology, the spinal cord, and secretions of exocrine glands. She was the principal investigator on many scientific grants, and her research was funded by the Muscular Dystrophy Association and the National Council to Combat Blindness. Botelho also sat on scientific review panels for the National Science Foundation, the
LEGACY GIVING National Research Council, and the National Institutes of Health. In 1968, she received the Alumnae Award of Merit from Penn, where she had earned her undergraduate degree in chemistry in 1940. Howard Holtzer, Ph.D., Philadelphia, emeritus professor of cell and developmental biology; November 5, 2014. After serving in the Army in the Pacific during World War II, he graduated from
ments at universities and institutes in Tokyo, Beijing, London, Rome, Heidelberg, and Berlin. He won a Fulbright Scholarship and was a Guggenheim Fellow at Carlsberg Laboratories in Copenhagen. Holtzer remained active in his research at Penn until a few years before his death. He is survived by his wife and research collaborator of 64 years, Sybil Holtzer. Ralph A. Jessar, M.D. See Class of 1946. Anna S. Lev-Toaff, M.D. See Class of 1986. Donald Vail Rhoads, M.D. See Class of 1954.
the University of Chicago, where he also earned his doctorate in 1952. In 1953, he joined what was then called Penn’s Department of Anatomy, continuing his research that provided the foundation of much of the molecular work on inductive signals between tissues and how cells communicate during development. At Penn, he applied a new technique, fluorescent labeling of antibodies, to the study of myogenesis. According to Jonathan Epstein, M.D., executive vice dean and chief scientific officer of the Perelman School, “From this new ability to examine much earlier stages of development came such creative ideas as cell lineages giving rise to more and more restricted options until a terminally differentiated cell is produced (progressive lineage restriction).” Among his other discoveries: the existence of a new class of filaments, the intermediate filaments (including keratins, lamins, and neurofilaments). Holtzer was also known as a great colleague who trained many scientists. Holtzer’s research took him across the globe, to appoint-
Doing Her Part for Medical Research and Care
John L. Sbarbaro Jr., M.D., St. Augustine, Fla., a retired assistant professor of orthopaedic surgery at Penn who had also been chief of orthopaedic surgery at the old Medical College of Pennsylvania; September 2, 2014. He was a veteran of the U.S. Navy. He developed and patented the Sbarbaro Total Hip Prosthesis. Heinz Schleyer, M.D., Havertown, Pa., emeritus assistant professor of surgery in the Perelman School of Medicine; November 10, 2014. He joined Penn as a postdoctoral fellow in medical physics in 1961 and was appointed an assistant professor of biophysics in 1970; emeritus status was conferred in 2004. He was known for his work on Cytochrome P-450, enzymes involved in drug metabolism. John N. Thurman, M.D.. See Class of 1967. Camillus L. Witzleben, M.D., Swarthmore, Pa., an emeritus professor of pathology and laboratory medicine; October 1, 2014. He joined the faculty in 1964 and was appointed emeritus in 1996. During his time at Penn, he also held a secondary appointment in pediatrics and was pathologist-in-chief at Children’s Hospital of Philadelphia for 25 years. An expert on pediatric liver disease, Witzleben was a former president of the Pediatric Pathology Society.
“Make the world a better place” is the personal philosophy of Janet Shapiro, who has lived a lifetime of volunteering – from working in a hospital snack shop in high school to knitting shawls for cancer patients in retirement – and who has added Penn Medicine to the list of charitable organizations she supports. Mrs. Shapiro inherited her desire to help others from her parents, who held a strong personal belief in the importance of giving to charitable organizations, particularly in the field of medicine. She grew up sharing their tradition of charity. When she came to Penn as an undergraduate, she volunteered at the Hospital of the University of Pennsylvania. “There’s always a need for help,” she said, “and I always thought a hospital should use their funds to focus on patient care.” “Penn Medicine is a place that makes such a positive difference in health. I want to support the great work being done here.” Mrs. Shapiro worked with the development office to set up a Charitable Gift Annuity, which allows her to make a gift in exchange for life-long, guaranteed annuity payments and an income tax deduction. By designating her Charitable Gift Annuity to the Penn Medicine Friends Fund Endowment, Mrs. Shapiro will continue her lifetime tradition of annual, unrestricted giving to Penn Medicine for all time. “Now, every time I read about the research being
done at the Penn, I know I’m making a difference now and into the future,” she said. “I’m glad I can do my part, and I hope it inspires others to do the same.” Janet Shapiro chose one of a multitude of creative gift opportunities. As you plan your philanthropic future, the Office of Planned Giving is ready to assist in developing an appropriate strategy to incorporate your charitable objectives. Contact Christine S. Ewan, J.D., executive director of Planned Giving, at 215-898-9486 or email@example.com. For more information, please visit the website at: www.plannedgiving.med.upenn.edu. FALL 2015
Concussion and Fracking: Examining the Controversies This summer, one of the National Football League’s most honored linebackers, Junior Seau, was inducted into the league’s Hall of Fame – posthumously. But only Seau’s family attended the induction: the retired player had killed himself in 2012. Nine months later, the National Institutes of Health reported that he had a degenerative brain disease consistent with chronic traumatic encephalopathy (CTE), making him the most prominent player to be associated with the disease. This year’s induction brought renewed attention to the disease. The Fall 2014 issue of Penn Medicine looked at concussion and the growing recognition of the danger of CTE among football players. Unlike traumatic brain injury, which can result from one or two very hard hits to the head, CTE seems to emerge after countless smaller shocks. As H. Branch Coslett, M.D. 1977, a professor of neurology, pointed out, it is not yet clear why some people who have received blows to the head get CTE while others do not. The article also noted
that the first positive diagnosis of CTE in a football player was published in 2005 by Bennet Omalu, M.D. The NFL, whose annual revenues are now about $10 billion, was slow to deal with CTE or concussions. In fact, when Omalu published his first article on his discovery in the journal Neurosurgery, the league demanded that it be retracted. For several years, its own doctors continually dismissed Omalu’s findings as seriously flawed and purely speculative. Now there are rumors that the NFL has again stirred itself, in response to a movie set to open on
December 25: Concussion, starring Philadelphia’s own Will Smith as Dr. Omalu. Last month, The New York Times reported that the movie had been altered to avoid antagonizing the NFL. The director of the new film, Peter Landesman, disputed the report. “Anyone who sees the movie will know that it never once compromises the integrity and the power of the real story,” he said. The viewers, of course, will judge. The cover story of this issue of Penn Medicine looks at another controversial topic, fracking. It has been hailed as a cure for the nation’s economic woes and assailed as a health hazard. Penn experts have been studying the effects of fracking in recent years. In 2014, Penn’s Center of Excellence in Environmental Toxicology (CEET) sponsored a conference that brought together scientists, physicians, corporate representatives, and citizens to examine the matter. Earlier this year, members of CEET and researchers from Columbia University’s Mailman School of Public Health published a major study in PLOS One. It identified an association between fracking and increased hospitalization rates in counties where “unconventional gas and oil drilling,” as the study puts it, has taken place. The article argues that rigorous science is all the more necessary when tension is high and divisions are wide. Science will establish whether fracking is the cause of the various illnesses and other negatives effects. If the studies point to fracking, policy makers and industry leaders will likely be called upon to compensate inhabitants of the affected regions – and the findings could halt the entire drilling process until safer procedures can be firstname.lastname@example.org developed and proven.
In the Winter Issue: More Penn Med students are recognizing the
role of spirituality in the care of patients and learning how to listen better to patients and their families. A program in which the students shadow hospital chaplains is becoming more popular. Also, an alumna at Dana-Farber Cancer Institute has been instrumental in efforts to introduce newborn screening for sickle cell disease in Liberia and to offer treatment for affected children. 44
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ONE LAST THOUGHT
Zion Tests His Hands
Photos by Rob Press
One of the most heartwarming news stories of the year concerned an eight-year-old boy named Zion Harvey. At the age of two, Zion suffered a life-threatening infection that forced doctors to amputate both his hands and feet. In July, Zion became the first pediatric patient ever to receive a bilateral hand transplant. The operation, which lasted 10 hours, involved nearly two dozen people from Penn Medicine and the Children’s Hospital of Philadelphia, drawn from orthopaedic surgery, transplant, and plastic surgery. Leading the procedure was L. Scott Levin, M.D., chair of Penn’s Department of Orthopaedic Surgery. To prevent rejection, patients who undergo this kind of operation must take immune-suppressing drugs for the rest of their lives. Zion was a suitable candidate because he received a kidney from his mother when he was two and was already taking the anti-rejection drugs. Six weeks after he made history, Zion was finally ready to leave the hospital and complete his recovery back in his home city of Baltimore – but not before one last visit with Levin. He led Zion through a string of dexterity tests to see just how his new hands were coming along. Zion told Levin all about his plans for the future, which included doing what
he can to help out others in similar situations and writing to the parents of the child whose hands he received. As we posted on the Penn Medicine Facebook page, along with a gallery of these images on the day Zion went home from the hospital: “He’s a wonderful, brilliant child, and we are privileged to have been a part of his story.”
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This colorful image is a microetching designed to illustrate a region of the brain. But whose brain? Find out more on page 16.
Published on Nov 17, 2015
Published on Nov 17, 2015
The experts in Penn’s Center of Excellence in Environmental Toxicology seek the facts that are essential for decisions that affect our envir...