louisville medicine - glms louisville medicine s a principal investigator for more than 400 clinical...

LouisviLLe MedicineGREATER LOUISVILLE MEDICAL SOCIETY VOL. 60 NO. 2 JULY 2012

JULY 2012 3

GLMS Board of GovernorSDavid E. Bybee, MD, board chairRussell A. Williams, MD, presidentJames Patrick Murphy, MD, president-electBruce A. Scott, MD, vice president and AMA delegateHeather L. Harmon, MD, treasurerRobert A. Zaring, MD, MMM, secretary and AMA alternate delegateRobert H. Couch, MD, at-largeRosemary Ouseph, MD, at-largeTracy L. Ragland, MD, at-largeJeffrey L. Reynolds, MD, at-largeJohn L. Roberts, MD, at-largeWayne B. Tuckson, MD, at-largeFred A. Williams Jr., MD, KMA vice presidentRandy Schrodt Jr., MD, KMA 5th district trusteeDavid R. Watkins, MD, KMA 5th district alternate trusteeK. Thomas Reichard, MD, GLMS Foundation president Stephen S. Kirzinger, MD, Medical Society Professional Services presidentToni M. Ganzel, MD, MBA, interim dean, U of L School of MedicineLaQuandra S. Nesbitt, MD, MPH, director, Louisville Metro Department of Public Health & WellnessJay P. Davidson, president and CEO, The Healing PlaceAdele Murphy, GLMS Alliance president

LouiSviLLe Medicine editoriaL BoardEditor: Mary G. Barry, MDElizabeth A. Amin, MDDeborah Ann Ballard, MDR. Caleb Buege, MDArun K. Gadre, MDStanley A. Gall, MDLarry P. Griffin, MDKenneth C. Henderson, MDJonathan E. Hodes, MD, MSTom James, MDTeresita Bacani-Oropilla, MDTracy L. Ragland, MDCharles B. Ross, MDM. Saleem Seyal, MDDave Langdon, Louisville Metro Department of Public Health & WellnessDavid E. Bybee, MD, board chairRussell A. Williams, MD, presidentJames Patrick Murphy, MD, president-electLelan K. Woodmansee, CAE, executive directorBert Guinn, MBA, chief communications officerEllen R. Hale, communications associateDonna Watts, communications designer

advertiSinG Cheri K. McGuire, director of marketing736.6336, [email protected]

LouisviLLe Medicine is published monthly by the Greater Louisville Medical Society, 101 W. Chestnut St. Louisville, Ky. 40202 (502) 589-2001, Fax 581-9022, www.glms.org. Articles to be submitted for publication in LM must be received on electronic file on the first day of the month, two months preceding publication. Opinions expressed herein are those of individual contributors and do not necessarily reflect the position of the Greater Louisville Medical Society. LM reminds readers this is not a peer reviewed scientific journal. LM reserves the right to make the final decision on all content and advertisements. Circulation: 4,000

on the cover: The Richard Spear, MD, Memorial Essay Contest. Story on page 20. Design by Donna Watts.

LoUisviLLe MedicineGreater LouiSviLLe MedicaL Society voL. 60 no. 2 JuLy 2012

f E A T U R E A R T I C L E S

D E p A R T M E N T Sfrom the Presidenttime to tee offRussell A. Williams, MD

We Welcome you

Physicians in Print

in remembranceedward Warrick Jr., MdF. Albert Olash Sr., MD

reflectionsto Be or not to Be?Teresita Bacani-Oropilla, MD

doctors’ LoungePossibly not deadlyMary G. Barry, MD

a fragment of Medical economic ephemeraMorris M. Weiss, MD

Letter to the editorMichael Needleman, MD

Letter to the editorGordon R. Tobin, MD

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Play Ball!Ellen R. Hale

i Was Wrong #6: Perfection and our fda auditHarold Bays, MD, FACP, FACE, FNLA

top Ways to Prevent Physician complaints and Malpractice issuesC. Kenneth Peters, MD

history of the university of Louisville School of Medicinev. a new Kentucky home for old Medical artsGordon R. Tobin, MD

the richard Spear, Md, Memorial essay contestit’s Worth it – Practicing/Life WinnerSohail Ikram, MD, FACC

hanging onto the coattails – in-training/Student WinnerSarah M. Fisher

total ankle arthroplasty: Where are We now?R. Todd Hockenbury, MD

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4 LoUisviLLe Medicine

JULY 2012 5

fROM ThE pRESIDENTRussell A. Williams, MDGLMS President

TIME TO TEE Off The Greater Louisville Medical Soci-ety exists to unify physicians around activities that are important to our profession. This month, I want to share two exciting opportunities for GLMS members to join together and make an impact in our community. First, we are forming a new Envi-ronmental Medicine Committee, and I’m looking for members who have expertise and interest in this area to serve. Preventive medicine is a major focus of our profession. As a surgeon, I find myself thinking beyond efforts to prevent chronic conditions like heart disease and diabetes. How can we, as physicians, create a healthier community by preventing injuries or other conditions that happen in the environments our patients live in, particularly workplaces? We recall the instrumental role that GLMS played in the adoption of our community’s comprehensive smoking ban, a huge achievement that is improving the health of Louisville residents. I have tapped Robert W. Powell, MD, the expert pulmonologist who serves as chair of the Louisville Metro Air Pollution

Control Board, to chair the Environ-mental Medicine Committee. My vision for the committee is to expand our efforts at enhancing the local environment, not only air quality but water quality, recycling, the reduc-tion of toxins and enhanced natural preservation. The committee will identify opportunities for GLMS and our members to work on areas where environmental factors are negatively affecting the health of our patients. As physicians, we should be a trusted voice in these matters that impact patients. Let me know if you have ideas for the work of this committee or would like to get involved. Second, we are gearing up for the second annual GLMS Foundation Scholarship Golf Outing on Mon-day, September 24, at Hurstbourne Country Club. This is our foundation’s fundraiser for medical student schol-arships. Numerous area businesses, led by tournament sponsor Stock Yards Bank & Trust, have stepped up as team sponsors and are generously contributing to the next generation of doctors. Physicians, residents and medical students all have the op-portunity to join in the fun of the

day. Thanks to our sponsors, there is no cost for GLMS members to play. Contributions to the scholarship fund will be appreciated, however. Last year’s inaugural Scholarship Golf Outing was enjoyed by all, despite golfers braving rainy weather out on the greens. (We’re rooting for great weather this year.) The event’s shamble format enabled golfers of all skill levels to engage in friendly competition with their colleagues. The top three teams received prizes. But most meaningful was seeing the gratitude of the five medical students who each received a $4,000 check from the GLMS Foundation. I encour-age you to reserve your spot now. I want you to get the most out of your GLMS membership, whether it’s through participating in our impor-tant committee work, enjoying our special events or taking advantage of other member benefits. GLMS values your time and expertise, which make our medical community strong and allow us to play an integral role in Louisville.

Note: Dr. Williams practices General Sur-gery with Associates in General Surgery.

LM

to register for the GLMS foundation Scholarship Golf outing, go to www.oldmedicalschool.org and click on “Scholarship initiative.” or, contact director terry todd at [email protected] or 502-736-6356.

JULY 2012 7

play Ball! AsoneofhisfirstactsasGLMSpresident,RussellA.Williams,MD,threwoutthefirstpitchbeforetheLouisvilleBatsplayedtheDurhamBullsonSaturday,June2.About350GLMSmembersandtheirfamiliesturnedoutforapicture-perfecteveningatLouisvilleSluggerFieldaspartofthisyear’sPresident’sSoiree.

Beforethegame,therewasapicnicdinnerbuffetandbriefprogram,whichfeaturedtheinstallationofDr.WilliamsbyoutgoingPresidentDavidE.Bybee,MD.LouisvilleMedicineEditorMaryG.Barry,MD,announcedthewinnersofthefifthannualRichardSpear,MD,MemorialEssayContest.

ThePresident’sSoireewassponsoredbyKentuckyOneHealth,theGLMSFoundationandMedicalSocietyProfessionalServices.

Note: Ellen R. Hale is the communications associate for the Greater Louisville Medical Society.

Ellen R. Hale

1. President-Elect James Patrick Murphy, MD, and GLMS Alliance President Adele Murphy.2. Essay contest winner Sohail Ikram, MD, (third from right) with wife Farah Ikram, MD, children Amani, Ameenah, Maliha and Salah, sister Rukhsana Rahman, MD, and brother-in-law Zaka Rahman, MD.3. David Rhoads, MD, Shiela Rhoads, MD, and family.4. Louisville Bats President Gary Ulmer, a GLMS Wear the White Coat graduate.5. Gerald Berman, MD, and Benita Berman.6. Ted Steffen, MD, and Pam Steffen.7. KMA 5th District Trustee Randy Schrodt Jr., MD, and Chrissy Schrodt.8. Andrew Dailey, MD, Stephanie Dailey, MD, Dianne Dupuy and family.9. Ferenc Nagy, MD, Mary Nagy and family.10. Jim Jewell, MD, with Debbie Benzick and her son.11. Virginia Keeney, MD, and Tom Chambers.12. Albert VanVooren, MD, and Ro VanVooren.13. GLMS Foundation President K. Thomas Reichard, MD, and Mary-Stuart Reichard.

14. (Left to right) Jane Schultz, MD, Judy Water-man, Norton Waterman, MD, and Stephen Winters, MD.15. Dr. Williams with Bob Hecht, private banking director for Stock Yards Bank, and Linda H. Gleis, MD.16. (Left to right) David Shanahan, Katie Hunt, Debra Shanahan and Patrick Shanahan, MD.17. Don Harmon, MD, and Donne O. DeMunb-run-Harmon, MD.18. Robert Tillett Sr., MD, and Jean Tillett.19. Albert Goldin, MD, (left) and Melvyn Koby, MD.20. James Tavelli, MD, and Carrie Crigger, DO.21. Christin Honaker, MD, (left) and Natalie Stephens, MD.22. Amy Garlove, MD, Lee Garlove and family.23. Kunnathu Geevarghese, MD, Chinnu Geevar-ghese and family.24. (Left to right) Sean Fizer, Laura Hayman, Mary Hayman, MD, and Ed Hayman.

LMDr. Williams throws out the first pitch.

The Williams family (left to right): Jared, Russ, Alex, Travis and Terrie.

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s a principal investigator for more than 400 clinical trials spanning more than 20 years,

after writing every letter of our initial and annually updated compliance policies, after speaking every word at our “off-site” biannual staff meeting presentations and after count-less internal and external audits, I just knew our research site was compliance perfect. After listening to hundreds of investigator meeting lectures on what to expect from an FDA audit, I knew we were mentally prepared.

I was wrong. Ultimately, our research site did well, having no ob-servational findings. However, through our FDA audit, we found areas we could improve. Most surprising was the emotional toll taken upon the staff and during the audit. I had previously undergone a routine tax audit from the government (yet again, with no substantive findings). But with a tax audit, I had backup accountants who were paid to ensure my compliance with tax codes and certified to protect my interest. So no worries here. Most importantly, if findings did arise during a tax audit, the most likely worst-case scenario would mean simply paying back money. (At least, that’s what happens with U.S. govern-ment employees, such as our current U.S. treasury secre-tary.) In contrast, FDA audit findings become part of the public record and have the potential to adversely affect future reputations, academic careers and employee jobs. I hope that a listing of some of my misperceptions

about our FDA audit might be useful to the many clinicians in this area participating in clinical research, who like us are at peren-nial risk for an FDA audit.

Misperception 1: Because our research site undergoes routine monitoring by the study sponsor (or its representatives), this means we are always “good-to-go” for any future FDA audit.

Reality: It is the study sponsor who pays the study monitors. It is therefore the job of study monitors to protect the interests of the study sponsor, not the research staff.

Misperception 2: If a study monitor reaches the point where the focus is on minor (i.e. ridiculous) issues such as instructing the research site to formally notify an Ethics Review Board when a study participant is late for an appointment, or demanding the staff sign and date stray pen marks, or insisting the investigators sign and date blank pieces of paper, then this must mean all major com-pliance issues are 100 percent covered. So again, if a study undergoes routine monitoring by the study sponsor, then

I W A S W R O N G # 6

perfection and Our fDA Audit

Continued on page 10

aHarold Bays, MD, FACP, FACE, FNLA

it is a waste of investigators’ valuable time to redundantly ensure the compliance of their research site.

Reality: Wrong ... so, so, so wrong ... I mean this is really wrong ... I’m not kidding ... definitely wrong.

Misperception 3: FDA audits are chosen solely “for cause” purposes.

Reality: While I suspect that many FDA audits are conducted “for cause” purposes, we were chosen for this FDA audit because we were the top enrolling site of what could potentially be the first novel lipid-altering drug approved in about a decade. I was the overall principal investigator of the study, presented the data at major international scientific conferences and was lead author on the publication of the study results. In retrospect, it was perfectly appropriate we were selected for an FDA audit for this study.

Misperception 4: If you have a highly qualified and highly trained staff with an unwavering dedication to study subject safety and quality research, then you will not lose sleep over an FDA audit.

Reality: If you and your staff care about your work and if you fear the government, then you should plan for no sleep during the days to weeks of an FDA audit. Post-ing a suicide hotline might be handy as well.

Misperception 5: FDA auditors are nitpickers who care more about process than what really matters to patients.

Reality: Our experience suggests that the FDA is pri-marily focused on protecting the safety and rights of study subjects, ensuring that study participants entering the trial reasonably reflected what was intended by protocol and that the data collected at the site was accurately commu-nicated to the FDA, as it applies to measured parameters of efficacy and safety. During the audit, documentation was also key, such as ensuring objective verification of research training, investigator oversight, drug account-ability, drug storage and that the study conduct was consistent with the protocol.

Misperception 6: I knew what to expect from an FDA audit.

Reality: I knew most of what to expect from an FDA audit. However, I did not anticipate everything, because many areas covered during the audit were not covered at study-sponsored investigator meetings, nor assessed dur-ing study-sponsored monitoring visits. Also, I absolutely

did not anticipate the degree of emotional and opera-tional disruption that occurred during the audit. As noted, we did fine. But we also learned some valuable lessons. As many might know, one of my hobbies is to collect, create and post quotes on our website. Through this experience, I have now posted two new “quotes:”

1. “The good thing about audits is they find things; the bad thing about audits is they find things.”

2. “Audits improve perfection.”

In summary, we “survived” our FDA audit. We emerged not only unscathed, but stronger. As noted in our Standard Operating Procedures: “We strive to be better today than yesterday, and better tomorrow than today.” Toward this end, just as with the countless other study sponsor audits we had previously undergone, we translated our FDA audit experience into a learning ex-perience. Due to the upgrades we implemented after our FDA audit, I am now more certain than ever our research site has finally achieved perfection.

At least until our next audit.

Or until I get to the office tomorrow.

Note: Dr. Bays is medical director and president of L-MARC Research Center.


Continued from page 8

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JULY 2012 11


“An ounce of prevention is worth a pound of cure.” I serve as a consultant for the Kentucky Board of Medical Licensure, reviewing com-plaints against physicians and malpractice cases to determine whether KBML should

take action against the physician. The following is a list of com-mon pitfalls for physicians, based on cases I have reviewed.

1. At every office visit, ask the patient if he has any drug aller-gies and what medications he is currently taking. Consider add-ing a reminder to this effect into your system. The patient may not remember to tell you about a drug allergy. He may be taking medication prescribed by multiple physicians. The best way to avoid allergic reactions or drug interactions is to ask the patient every time.

2. Always have an attendant with you when examining a pa-tient, particularly a patient of the opposite sex. This avoids a case becoming “he said-she said.”

3. Documentation is critical. If you don’t record what you said or did, it didn’t happen.

4. Address the needs of an irate patient immediately. Do not leave this to a staff member and do not wait. You must be involved. You can usually resolve the patient’s complaints by having a calm discussion and finding out how you can help.

5. Get involved when there is a billing conflict over copays or balances after insurance has paid. If the patient isn’t doing well or has lost a job, consider canceling the bill. It may not be worth losing the patient and having him criticize your practice to oth-ers.

6. Be careful when you are out of town. Physicians can be vulnerable when leaving town after performing surgery or when leaving town after admitting a patient to the hospital. Consider introducing the patient to the physician who will cover the case for you before you leave. Patients may react negatively to a new physician they have not met in advance and your not being available. If something goes wrong, the patient may blame you as well as your colleague. He holds you accountable.

7. Emergency physicians must take extra care when changing shifts. Both the physician who starts a workup and the physician who take over the case can be vulnerable if something goes wrong. You and the patient can best be served by starting over and working up the patient and not being biased by a colleague who may have hurriedly begun the workup.

8. When multiple physicians are on the same case, consult with each other and designate one physician to provide all the information to the entire family at the same time. With patients in critical care units who require multiple consultations, the fam-ily may give different interpretations of events, particularly when things aren’t going well. In life-threatening cases, sending mixed or conflicting messages to family members can lead to prob-lems.

9. Don’t write prescriptions for friends or family. Follow the AMA’s Code of Medical Ethics. If there is an emergency, you may participate in the treatment; however, document what you did and inform the individual’s regular physician.

10. Don’t socially date your patients or your staff.

11. As part of new state legislation, participating in KASPER is now mandatory. Be sure to follow the requirements regarding KASPER use when prescribing Schedule II controlled substances or Schedule III controlled substances containing hydrocodone. Physicians must be part of the solution to identify “doctor shop-ping.”

12. The information in a patient’s medical record belongs to the patient. Comply with state law and provide one copy of the medical record on request, free of charge. Problems may arise when physician groups split up, dissolving their association or partnerships. Patients must decide if they will stay with you or not. Staff members may have allegiance to particular physicians and fail to respond to a patient’s request for a medical record. There may be “bad blood” and legal counsel is often involved. Respect the patient’s choice as to whether he stays or goes, and don’t use the medical record as a “parting shot” toward another colleague. There is no substitute for civility.

13. Death certificates must be completed by the attending physician or the coroner under the timeline required by state law. If multiple physicians have seen the patient, consult with each other and designate one physician to sign the certificate in a timely manner. This is very important for survivors of the deceased.

Note: Dr. Peters is a retired family physician.

C. Kenneth Peters, MD

LM

Top Ways To prevenT physician complainTs and malpracTice issues

JULY 2012 13


Gordon R. Tobin, MD

hISTORY Of ThE UNIVERSITY Of LOUISVILLE SChOOL Of MEDICINE:V. A New KeNtucKy Home for old medicAl Arts

continued on page 16

Physicians and civic leaders worked under great time pressure 175 years ago this summer to found a new medi-cal school, the louisville medical insti-

tute, which would later become the university of louisville. the memorable events and consequences of that critical summer unfolded in intense and dramatic fashion, which typifies the u of l story. ’TWAS SUMMER, 1837 the sun shone brightly on Judge John rowan’s two Kentucky homes. At his Bardstown plantation, federal Hill, ’twas summer and spirits were likely gay, as corn tops rip-ened and meadows were in bloom. At his louisville home, however, gaiety was surely muted. Judge rowan was presi-dent of the newly authorized lmi, and he, city councilman James Guthrie and the initial faculty recruited from lex-ington’s transylvania university medical department were under enormous pressure to organize the school in time for opening that fall. As plantation crops ripened, these gentlemen were planning a much different crop – medi-cal students in hoped-for, good numbers. However, the summer offered a very short time frame for completing the faculty, organizing a full curriculum, arranging teaching facilities and recruiting those desired students in a highly competitive setting with the regional rivals.

hARD TIMES COME Gaiety throughout louisville was also much suppressed by the harsh depression afflicting the country (the panic of 1837), which was exceptionally severe locally. one po-tential bright spot was the new school, which might bring students and their spending. louisville’s Public Advertiser stated: “what a valuable addition to our population would four or five hundred respectable students form! – think of the mass of money they would expend here!” (opinions would later change, when that wish became reality.)

MEDICINE’S NEW KENTUCKY hOME, ThE ChESTNUT STREET CAMpUS the four acres between chestnut and magazine streets and between eighth and Ninth streets were designated col-lege square, which would become lmi’s home. louisville’s leading architect, Gideon shyrock, was commissioned to design an elegant new building, which would be sited on the southwest corner of chestnut and eighth streets. Just west on the property was the city workhouse, an inade-quate facility for teaching, where classes would be tempo-rarily housed while awaiting construction of the school.

ASSEMBLING ThE fACULTY of all tasks that summer, by far the most important was obtaining a complete and skilled faculty, on which all else depended. the respective expertise of relocated transylva-nia faculty provided a solid foundation. charles caldwell, md, was appointed chair of the institutes of medicine and clinical practice, and of medical jurisprudence. A few weeks later, John esten cooke, md, was made chair of the theory and practice of medicine, and lunsford Pitts yan-dell sr., md, was made chair of chemistry and of materia medica. However, additional faculty were needed for a complete curriculum. A chair of obstetrics and diseases of women and children was needed, and lmi was fortunate to have in louisville Henry miller, md, a highly skilled obstetrician-pediatrician, who was appointed early on. Anatomy and surgery chairs were also essential. Joshua Barker flint, md, was recruited from Boston for the chair of surgery, and Jedediah cobb, md, was recruited from cincinnati’s medical college of ohio for the chair of anat-omy. At transylvania, materia medica and medical Botany had been taught by charles wilkins short, md, but dr. short was undecided on moving and remained that year in lexington. dr. yandell worked intensely to bring dr. short to louisville and succeeded the following year. dr. yandell taught materia medica in dr. short’s absence. thus, a full

JUne 2012 15

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complement of faculty and medical skills was assembled for the opening session that fall.

ThE fIRST fACULTY charles caldwell, md, (1772-1853) (fig. 1) can truly be called father of u of l’s medical school, as his reputa-tion (dean at tmd and his national stature), seniority,

enthusiastic advocacy and public persuasiveness were essential in key early events. He trained in medi-cine at Philadelphia under Benjamin rush and came as dean to transylvania from the Philadelphia faculty. when appointed professor in louisville, he was 65 years old and at the height of his skills. He was su-premely self-confident and a skilled orator in the style of the times. His scholarly and authoritative manner projected a strong, effective

image. Among peers, however, his stature was diminished by rigid adherence to speculative philosophy (such as separate creation of the races), to odd medical theories (such as phrenology, the belief that shape of the skull determined one’s character and intellect) and to an eccen-tric theory on the function of blood. He failed to abandon these theories as they became discredited, and he would not accept chemistry, which was rapidly gaining cred-ibility. students found his attention to impractical theory far less attractive than the useful teachings of anatomy, surgery and materia medica. However, he was expert in medical jurisprudence and contributed solidly to the early field of neurology. dr. caldwell was afflicted with towering egotism. it was said, “if conceit could make a man great, dr. caldwell would stand on the highest pedestal.” for example, in lectures he claimed that there were only three perfect heads in America, naming Henry clay and dan-iel webster. He then stated “modesty prevents me from identifying the third,” as he tapped his own head. Although clearly the leader of the lmi faculty in the earliest years, his egotism and rigid embrace of discredited theories eroded his stature and would force a traumatic resignation in the late 1840s.

lunsford pitts yandell sr., md, (1805-1878) (fig. 2) also came from the transylvania faculty. Born in tennessee, he took his medical degree from transylvania before joining its faculty. He became lmi’s first dean and was expert in chemistry and paleontol-

ogy. He was appointed chair of chemistry and chair of materia medica (until dr. short was persuaded to accept the latter in 1838). He was broadly knowledgeable, was very popular with students, was a highly effective speaker and writer, and was an lmi pillar throughout the antebel-lum years. in the civil war, he served in the confederate Army and became pastor of the Presbyterian church in dansyville, tennessee, afterward. later, he returned to medical practice in louisville and was elected president of the Kentucky medical Association at the end of his life. His sons, david wendell yandell, md, and lunsford P. yandell Jr., md, would have distinguished careers at u of l, thus creating a remarkable medical family legacy.

John esten cook, md, (1830-1886) (fig. 3) also came from the transylvania faculty and was a Philadel-phia graduate. At lmi, he was again made chair of the

theory and practice of medicine. He was highly respected for his integrity and consci-entiousness. early in his career, he authored a respected textbook but, like caldwell, he was unable to abandon outmoded practices. A loyal pupil of Benjamin rush, he was a fierce promoter of rush’s theories, including heavy uses of bleeding to balance physiol-ogy and of calomel as the primary remedy

for nearly all disorders. calomel was mercurous chloride, a strong laxative and an insoluble compound that could convert to highly poisonous mercuric ion under certain conditions of digestion or accompanying medications. dr. rush had compounded his calomel pills from mercurous chloride and jalap. cooke became famous for “dr. cooke’s pills,” which were compounded of calomel, rhubarb and aloe. As calomel’s danger became recognized, dr. cooke’s staunch allegiance to the drug brought challenges from his colleagues, especially with the arrival of dr. daniel drake. this ultimately led to dr. cooke’s forced resignation in 1844.

henry miller, md, (1800-1874) (fig. 4) was the only physician practic-ing in louisville that dr. caldwell judged qualified for professorship, and he became chair of obstetrics and diseases of women and children. He graduated from tmd in 1822, where his

continued from page 14

continued on page 18fig. 4 henry Miller, MD

fig. 2 Lunsford pitts Yandell Sr., MD

fig. 1 Charles Caldwell, MD

fig. 3 John Esten Cooke, MD

JUne 2012 17

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thesis was so admired that his classmates funded its publi-cation, a remarkable compliment. He was a skillful medi-cal writer and was known to relish “disputation,” strong criticism of theories and practices of others, especially european professors. He was popular with students and his professional skills widely respected. later, he became president of the American medical Association and wrote a classic obstetrics textbook.

Joshua Barker Flint, md, (1801-1864) (fig. 5) was an 1825 Harvard medical school graduate and gained a high reputation for surgical skill in his Boston practice. He was scientifically well-in-formed and became a medi-cal journal editor. He was appointed to the lmi chair of surgery, and he then trav-eled to europe to select the bulk of lmi’s library and ap-paratus. dr. flint was a care-ful and skillful surgeon with conservative, good judg-ment. Although recruited on dr. caldwell’s recommenda-tion, his position was later undermined by caldwell. His teaching skills were called weak, and he resigned from the faculty in 1840. He remained important in louisville medicine, and he became instrumental in founding a rival institution to u of l. years later, he returned to the u of l faculty.

Jedediah cobb, md, (1800-1860) (fig. 6) was ap-pointed the chair of anatomy, which he fulfilled with great skill. He was a graduate of Bowdoin and had been profes-

sor of theory and practice of medicine at cincinnati’s medical college of ohio for more than a decade. An outstanding lecturer and an effective teacher, he was highly popular with students. He was later elected dean of the lmi faculty. However, he had an unexplained aversion to writing and left no scientific publica-tions whatsoever. in 1852, he resigned and returned to the medical college of ohio.

charles Wilkins short, md, (1794-1863) (fig. 7) did not come until 1838, but was much wanted by his col-leagues from the beginning. He earned his undergraduate from transylvania, before his md at Philadelphia in 1815. He practiced 10 years in lexington and Hopkinsville before appointment as chair of materia medica and botany at tmd. He was a founder and editor of the pioneering transylvania Journal of medicine and Associated sciences. He was tmd dean for 10 years and again became dean

of faculty at lmi. A highly regarded medi-cal botanist, he was also internationally renowned in tradition-al botany. He authored several botany texts and leading botani-cal scholars named several new species in his honor. dr. yandell valued his scholarship highly and worked relentlessly to recruit him. dr. short greatly disliked and avoided the intramural con-flicts of his peers at both tmd and lmi, and he much preferred the tranquility of horticulture, collecting specimens and classification. His great-grandson is louisville physician thomas courtenay, md. the courtenay family preserved dr. short’s volumi-nous correspondence, including the persuasive 1837 let-ters from dr. yandell, which today are at the filson club.

WEEp NO MORE there is no record of tears by civic leaders and faculty over the stresses of high responsibility, financial risks and urgency, but the trials of that summer likely evoked many colorful 19th-century expressions. there is, however, another significant dimension to the early u of l saga. A compelling motive from the beginning was to provide much-needed physician care for the poorhouse infirmary and public hospital at chestnut and floyd streets. severely injured, desperately ill and dying patients suffered terri-bly there, and these tragedies brought great weeping and anguish to their families and friends. the coming of faculty and students would serve these medical needs and bring relief of much suffering for many generations. the enormous efforts of the 1837 summer were reward-ed by the successful opening of lmi classes on october 31, with a complete faculty and full classes – all ready to begin a new chapter in Kentucky medical history. the sun shone brightly on medicine’s new Kentucky home. that fall, it would light the lecture amphitheaters, laboratories and dissection rooms, making American medicine endur-ingly brighter thereafter.

Note: Dr. Tobin is a professor at the University of Louisville School of Medicine, Department of Surgery, Division of Plastic and Re-constructive Surgery. He practices with University Surgical Associ-ates. Dr. Tobin is a member of the Innominate Society, Louisville’s medical history society.


continued from page 16

LM

fig. 5 Joshua Barker flint, MD

fig. 6 Jedediah Cobb, MD

fig. 7 Charles Wilkins Short, MD

JUne 2012 19GLMs

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PLAY IT FORWARD!

i went to bed that night at 2 a.m. i was determined to do my taxes early this year to avoid that disorganized last-minute scramble. I was

on call and was hoping for a quiet night. I dreamt that my pager was going off. Moments later, my cell phone started ringing and I realized that it was not a dream. It was the hospital operator calling for an emergency. The time was 5:30 a.m., and within 30 minutes I was in the cardiac catheterization laboratory. The patient was a young man who’d been brought in by EMS with a myocardial infarc-tion. He was also in cardiogenic shock. He had received a stent in his Left Anterior Descending (LAD) coronary artery six months ago. He was a heavy smoker and had been counseled to completely stop smoking and to take aspirin and Plavix without fail. He was uninsured and was given a follow-up appointment in an indigent clinic. His “fiancée” accompanied him to the hospital. She told us that the patient had resumed smoking one week after his stent and that a few weeks ago, he had also stopped tak-ing all his medications. He never showed up in the clinic for follow-ups. She said that he felt good and “they did not give him all his medications,” so he did not go to the clinic. He smoked three packs per day and that night the two “also smoked pot and did cocaine.” Coronary angiography showed total occlusion of his LAD with a large blood clot in the stent. After a successful thrombectomy, angioplasty and hemodynamic support with an intra-aortic balloon pump, the patient stabilized and was transferred to the coronary care unit. The time was 8 a.m. now and I was craving a cup of coffee. My clinic was starting in 30 minutes. The nurse informed me that the patient’s family wanted to talk to me. There were about 15 family members in the waiting room. Two women were crying, and the smell of smoke was strangling. The patient’s mother told me, “I don’t want my baby to die.” A brother wanted to know why the stent closed up so soon. A sister remarked that “If they had giv-en him his medications, this would not have happened.”

IT’S WORTh IT

Sohail Ikram, MD, FACC

pracTicing and liFe memBer caTegory Winner


JULY 2012 21

It was 8:40 a.m. and the clinic staff was paging me. Two patients had already arrived. One patient had another appointment and was demanding to be seen right away. I rushed to the clinic. This was a new patient; she had come for a second opinion. She had brought along 60 pages of medical records. A quick review revealed that she had already consulted four cardiologists but was “not happy” with any of them. I noticed that my regular medical assistant was not in the clinic. She had called in sick. I had 22 patients sched-uled and seven of them were new. I had barely finished evaluating the first patient when I was informed that three more patients were in their rooms waiting to be seen. Two were straightforward follow-ups. The fourth patient was also new, following a recent hospitalization in an outly-ing hospital. No records were available for review. He was unhappy to learn this. “They were supposed to send them to you,” he said. While seeing the patient, I received an urgent call from a fellow physician. It was not an emergen-cy, but he requested an echocardiogram on a patient he was seeing in his OB/GYN clinic. The echo technician told me that she was busy checking in patients because my assistant was off and that she would try to do the echocar-diogram when she had some time. It was 11 a.m. now. I had seen nine patients. The office manager reminded me that the office was transitioning to electronic health records and all notes had to be typed into the new system. Everybody was struggling with the new EHR, and it was taking three times longer than the usual dictations. The next two patients were also com-plex. One was a middle-aged lady who came in as a new patient with complaints of syncope. She said that she had “passed out” five times in the last month. Surprisingly, none of those spells was witnessed; she did not sustain any injuries and did not feel like going to the hospital for evaluation. The next was a gentleman whom I had seen merely one week ago but who’d still insisted on an earlier appointment today. He was obsessed with checking his blood pressure four times a day. He was concerned that his systolic BP had increased last night to “125 from his usual around 110.” Then came a cancer patient accompa-nied by her husband. The patient was doing fine, but her husband kept telling me that her previous doctors had “goofed up” and missed her diagnosis. Two more patients came for follow-ups after coronary stenting. They contin-ued to smoke. One told me that he had “cut down to half a pack from two packs,” and the other patient said that he “does not inhale.” Then came a patient with heart failure, diabetes, hypertension and sleep apnea with a body weight of 361 pounds. Despite counseling him and his family regarding the hazards of obesity and referring him to a dietitian, he was 12 pounds heavier than his previous clinic weight. The time was 1:30 p.m. and I had slept four hours out of the last 32. I had not had breakfast, lunch or even a cup of coffee. I started to wonder, “Was it worth doing what I was doing? Was I making any difference in the lives of my patients? Do they really appreciate what we doctors do? Should my children continue to grow up without seeing their dad? Should my wife wait for me every day to spend

some quality time with me?” I had one last patient to see before I headed off to the cath lab again. The patient was an 88-year-old black fe-male, a new patient in the clinic. I was tired and frustrated. I was sure that she would have some dementia, and I had no intention of listening to her whole life story. I wanted to spend the bare minimum amount of time necessary. I walked into the examination room and introduced myself to her in a businesslike manner. I did not make much eye contact with her. “Thank you so much for seeing me, doctor,” she said with a beautiful smile. “I would not have bothered you, but I am in pain.” I suddenly found myself looking into her eyes. She was a lovely, young-looking 88-year-old lady. She had come for a pre-op evaluation prior to a shoulder surgery. I put aside my notes and started talking to her. She was intelligent, articulate and completely coherent. She told me that she had lived a wonderful life. She had never smoked nor drank. She had been widowed twice. Each time she had been married for more than 30 years. Both of her husbands were “kind and loving,” and she had been so fortunate to have had them in her life. She had mothered 22 children. Sixteen of them were living and six were “gone.” While she missed her dead children, she was blessed to have had them and it was the Lord’s wish that they were with him now. Her 16 children were all very close to her and called her regu-larly. I kept listening to her, and she kept thanking all the people who came into her life. I felt a peace descending over me. That night when I came home, I told my wife how beau-tiful she is and how much I love her. I tucked my children in bed and read them the stories that I had been promis-ing that I would read. When I went to bed, I had no doubts that every day, every hour, every minute and every second that I spend as a doctor is worth it.

Note: Dr. Ikram is a professor and director of invasive and interven-tional cardiology at the University of Louisville School of Medicine, Department of Medicine, Division of Cardiovascular Medicine. He practices with University of Louisville Physicians.

LM

Louisville Medicine Editor Mary G. Barry, MD, presents Dr. Ikram with his award at the President’s Soiree.

the majority of my days as a first-year medical stu-dent precepting with a phy-sician were spent hanging onto the doctor’s coattails

– following him or her around endlessly and soaking in every word. From an early age, I was a curious girl, always asking too many questions. That is still true 20 years later in medical school. I ask my pre-ceptors about labs, X-rays, what exactly multiple sclerosis is and how you manage chronic pain without breeding addiction. During my spring break, I spent most of the week precepting in a family medicine office. My family medi-cine preceptor instructed me to think about what exactly brings the patient into the office and what his or her expectations from the visit are. As we discussed each patient before and after the visit, I was intrigued by the vast knowledge that he knew and appreciated about his patients. He would ask me, “So why do you think that patient came into the office?” After a moment of thought, I replied, “Because she was scared. Her sister died from a pulmonary embolism, and she is afraid she is going to die just like her.” After my preceptor managed a smile, I saw myself hanging onto his coattails. After precepting, I would go down to the gastroenter-ology office that I have worked at for the past 14 years and offer to help. Since I’m now a medical student, I was asked to see each patient with the physician and act as a chaperone with the female patients. As we were ushered from one room to the next, the physician would grill me on questions about medications, disease processes and intricate heart murmurs I’ve never heard. Some I knew, but others I didn’t. I was desperately trying to hang onto his coattails.

hANGING ONTO ThE COATTAILS

Sarah M. Fisher

in-Training and sTudenT memBer caTegory Winner

Continued on page 2422 LoUisviLLe Medicine

JUne 2012 23


With each patient, we would examine the patient together and talk about our findings. Once, I told my physician, “I think that she has a regular rate and rhythm, no extra heart sounds and no murmurs.” At that moment, I looked down to see the patient’s face white as snow with the same deer-in-the-headlights look that I’ve nar-rowly missed going down our country road. Immediately, I reassured the patient: “That is great news, ma’am. That means your heart is working just fine.” The relieved look on her face echoed onto my own nervous one, and I was suddenly at ease. After walking out of the room, the physi-cian turned to me and said: “She may have come in with problems with constipation, but now she is leaving even more satisfied because you took care of her. You made her feel at ease. Good job.” And then, I was hanging onto his coattails. After the office closed, the physician and I would drive over to the hospital to make evening rounds. It was in this setting that I was literally hanging onto his coattails. Since I was precepting and working in my small, rural hometown, the hospital was almost like a Wal-Mart – I saw everyone and their brother, and they all wanted to stay and talk when my physician was headed out the door. It’s awfully hard not to be rude to the lady who used to check you in at the eye doctor, now isn’t it? Learning grace and a sweet goodbye, I desperately tried to keep up with my physician as we sped from room to room, hall to hall. Even though I felt like we were moving quickly, it always seemed that we spent the right amount of time with the patients. We were never rushed and even sat down to talk with the scared family members crowding around the bed of their loved one. There, in a hospital room on the third floor where I stood next to the physician sitting in a chair as he explained what had happened to their loved one, I was hanging onto my physician’s coattails. Hanging onto the coattails – what an idea. It’s not just trying to keep up with a racing physician, power-walking down the tiled hallway (with rapid glimpses of the occa-sional hanging artwork) to see the next patient. It could be quite trying to keep up with physicians’ coattails intellec-tually, rather than physically. It seems that doctors know everything, and that can be daunting to a student. For me, it’s both scary and wonderful, riding on a physician’s coattails in that manner. It is hard to admit to mediocrity by not knowing something. However, it is reassuring to know that I will learn the material, just like the questioning physicians did, and know the information eventually so that I can benefit my own patients. Keeping up with physicians isn’t the only aspect of hanging onto their coattails. It also includes seeing your-self as a physician, grabbing onto the physician’s coattails and holding onto qualities that make him or her a great doctor. I keep a running list of one quality in each physi-cian I know or have worked with that I admire. I force myself to narrow what I love about my family doctor and admire in my dad and every other medical role model into one single trait that I aspire to resemble. Now that is hang-ing onto some pretty hefty coattails – living up to high expectations, a responsibility that I don’t take lightly.

Last, and perhaps most important, hanging onto the coattails of physicians is about caring – not just caring about your patients to treat them, but caring how you talk around them so that they can feel at ease to trust you as a physician and confide in you. Beyond that, chasing after coattails also includes caring about how a patient’s family will react to his or her illness and thinking about the family unit. Even outside of the patient realm, hanging onto coattails is about fostering medical students who are excited about medicine and want to envelop everything they can about the field. I have seen aging physicians who become cynical and unwelcoming to students. This, to me, is heartbreaking, because those older physicians are the ones whose coattails I want to cling to. They have lived through so much medical history, can show you things like “the poor man’s sinus X-ray” and can give you advice on interacting with patients. I hope that practicing physicians never forget the days when they were medical students, desperately hanging onto their attendings’ coat-tails for advice, guidance and teaching. A day in the life of a medical student is about living up to the expectations and standards that have been set before us by preceding and successful physicians. We will hang onto their white coattails, soaking in every last word and every piece of advice, aspiring to be as caring, intel-ligent and efficient as they are. Perhaps someday, if we are lucky enough, we too will be the ones who are having our coattails tugged at by eager medical students. And at that time, we will let them, so that we can teach them as we have been taught. Above all else, honor thy teacher.

Note: Sarah M. Fisher is a rising second-year medical student at the University of Louisville.

LM

On behalf of Dr. Barry, Communications Associate Ellen R. Hale presents Sarah Fisher with her award at The Old Medical School Building.


JULY 2012 25

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Ten years ago, I wrote a brief summary of total ankle arthroplasty in this journal. After performing more than 100 ankle replacement surgeries, I feel that I am able to speak with some authority about this pro-cedure. This relatively unknown procedure offers a viable alternative to ankle fusion in

some patients. In most patients over 50 years of age with a healthy body weight, total ankle arthroplasty is successful in relieving pain and maintaining motion for at least 10 years. Ankle arthritis is not as common as knee or hip arthritis, but physical and mental disability is equal to that experienced with hip arthritis.1 It is estimated that eight to nine times as many patients are evaluated with knee arthritis than ankle arthritis.2 Total knee replacement is performed about 24 times more frequently than ankle fusion and ankle replacement combined.3 Most ankle arthritis develops secondary to trauma following fracture or ligamentous injury.4 Primary ankle osteoarthritis is rare. The conservative care of ankle arthritis includes nonsteroidal anti-inflammatory medica-tions, shoe wear modifications, bracing, limited use of corticosteroid injection and activity modification. Viscosupplementation injections have not been shown to be effective in the ankle joint and are not FDA-approved for use in the ankle.5 The surgical treatment of early or localized ankle arthritis entails the open or arthroscopic removal of osteophytes, removal of loose bodies, synovectomy and shaving or drilling of cartilage defects. Distraction arthroplasty is a new technique involving the place-ment of articulated ankle external fixator, which holds the joint distracted 5 mm for three months, theoretically allowing cartilage to regenerate. Localized osteochondral grafts can also be delivered into cartilage and bony defects of the talus. A detailed discussion of these techniques is beyond the scope of this article.6

The recommended surgical treatment for end-stage ankle arthritis unresponsive to conservative management has been ankle fusion. Ankle fusion provides pain relief at the expense of loss of ankle motion. Studies have documented satisfactory pain relief with ankle fusion.7 The ankle joint contributes 50 percent to 70 percent of plan-tar flexion and dorsiflexion of the foot and ankle. This loss of ankle movement produces increased stress on adjacent joints resulting in increased rates of arthritis in the hindfoot and midfoot over time.8,9 Studies document that at an average of 20 years following fusion, 50 percent of patients were handicapped during activities of daily living. SF-36 values for physical function, emotional disturbance and bodily pain were also significantly lowered. Compared with normal individuals, patients with an ankle arthrodesis have slower walking velocity, slower cadence and a shorter stride, and they consume

more energy while walking.10-14 Poor long-term functional results following ankle fusion have fueled interest in procedures that preserve ankle motion while providing pain relief. A successful ankle joint replacement decreases pain while maintaining functional ankle motion needed for activities of daily living and also shielding adjacent foot joints from increased stress and arthritis. Normal walking requires 30 degrees of ankle mo-tion. Descending stairs requires 56 degrees of motion. Patients with ankle fusions report difficulty negotiating stairs, walking up inclines and walking on uneven ground. These functional deficits are less common following ankle replacement. The design of an ankle joint prosthesis is challenging for many reasons. The ankle has poor soft tissue coverage. The usual anterior surgical approach is adjacent to anterior neurovascular structures. The ankle joint is smaller than the knee and hip joints, which pro-vides less bone surface for component fixation. At 500N of load, the contact area of the ankle joint averages 350 mm2, compared with 1,120 mm2 for the knee and 1,100 mm2 for the hip. The smaller contact area causes higher peak contact stresses than in the knee or hip.15 Available bone for implant support is smaller and joint pressures are higher in the ankle than in the knee or hip, resulting in higher rates of prosthesis loosening and worse ankle arthroplasty longevity rates. Another difference between ankle replacement and hip or knee replacement is the need to address foot deformity during ankle replacement. A severely high arch (cavus foot) or low arch (planus foot) puts increased stress on the ankle collateral ligaments and may lead to early implant failure. Total ankle joint replacement procedures began in the 1970s and, due to design failures of highly constrained cemented components, subsequent results were poor, failure rates were high and the procedure was ultimately aban-doned. Unfortunately, a negative bias toward this procedure persists. In the 1980s, better designs were developed in Europe. In 1992, the Agility Total Ankle Joint Prosthesis was approved for use in the U.S., and

TOTAL ANKLE ARThROpLASTY: WhERE ARE WE NOW?

R. Todd Hockenbury, MD

JULY 2012 27

early results were encouraging. The third gen-eration of total ankle arthroplasty systems has now produced implants with better designs and potentially bet-ter long-term out-comes (Figs. 1-2). Third-generation TAA is characterized by minimal bone resection, use of ankle ligaments to maintain stability, large contact bone areas for implant fixation and no use of cement for fixation.6 The four current designs now available for use in the U.S. are the Salto Talaris (Tornier), InBone (Wright Medical), STAR (Small Bone Innovations) and Agility (Depuy). These designs have two common design features: all are porous-coated and non-cemented for bone ingrowth, and almost all components are made of titanium with a cobalt-chrome-polyethylene articulation.16 The only design that includes a mobile bearing polyethylene component is the STAR prosthesis, which allows both rotation and flexion-extension between the metal and plastic components. The advantages of a mobile bearing over a fixed bearing design have not yet been proved in long-term follow-up studies.

pROCEDURE Foot or ankle realignment with oste-otomy, midfoot or hindfoot fusion and tendon transfer may be needed to cor-rect the foot to a plantigrade position prior to embarking on ankle replace-ment. Ankle arthroplasty is performed through an anterior longitudinal incision (Fig. 3). The joint is resected utilizing cutting jigs, and the prosthesis is placed without cement. Soft tissue balancing is accomplished by releasing the deltoid ligament as needed. In varus ankles, the lateral ankle ligaments are tightened and a peroneus brevis tenodesis to the tibia corrects inversion laxity. Calcaneal osteotomies are utilized to address heel varus or valgus concurrently with ankle replacement. Postoperatively, the patient is admitted overnight. Range of motion exercises begin 10-14 days post-operatively. Weight bearing commences at six weeks postoperative.

INDICATIONS Ankle replacement surgery should be performed on patients with end-stage ankle arthritis. Contraindications for surgery include infec-

tion, neuropathy, poor ankle motor control, extensive talar avascular necrosis and severe osteoporosis. Relative contraindications are segmental tibial or talar bone loss, severe varus or valgus deformity, weight greater than 200 pounds and age less than 50. The ideal patient for total ankle replacement is older than 50, has low body weight, possesses good bone stock, has low physical demands and has a previous fusion of the hindfoot or midfoot.

OUTCOMES The question of which procedure to recommend to patients with end-stage ankle arthritis remains to be answered. No prospective blinded studies with long follow-up are available comparing ankle replacement to ankle fusion. A retrospective meta-analysis of 49 studies involving 682 TAA patients and 1,262 ankle fusion patients showed similar outcomes. Various different ankle implant designs were used. The mean AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale score was 78.2 points for patients treated with total ankle arthroplasty and 75.6 points for patients treated with ankle arthrodesis. Revision rate following total ankle arthroplasty was 7 percent, with the main reason being for loosen-ing and/or subsidence. The revision rate for ankle arthrodesis was 9 percent, with the main reason for revision being nonunion.17 Ten-year implant survival rate was 77 percent. In another review article, Easley et al report survivorship of total ankle arthroplasty implants ranging from 70 percent to 98 percent at three to six years and from 80 percent to 95 percent at eight to 12 years.18 A study of 84 STAR ankle replacements showed an implant survival of 96 percent at five years and 90 percent at 10 years. The

AOFAS score improved from 43 to 82. Fourteen additional surgical procedures were required.19

A retrospective study using joint registries in Europe investigated revision rates of knee, hip and ankle replacement surgeries. After a total ankle replacement, a mean of 3.29 revisions per 100 observed component years was seen, compared to 1.29 for the hip and 1.26 for the knee.20 Therefore, the risk of revision following TAA was 2.5 times greater than with the hip or knee. Studies are now showing better patient satisfaction and better functional outcomes following ankle replacement. A study of 138 patients undergoing ankle fusion or ankle replacement with average 4.1 year follow-up showed better patient outcomes and better pain relief with ankle replacement.21 Maintenance of ankle range of motion following TAA most likely improves function (Fig. 4). A temporal-spatial gait analysis study by Brodsky et al on 50 consecutive STAR TAA patients demonstrated improved ca-dence and stride length, increased knee and hip motion and significant increases in ankle power compared to previous studies on ankle arthrodesis patients at intermediate follow-up.22

COMpLICATIONS Both ankle fusion and ankle replacement have complications. Po-tential complications following fusion include nonunion, malunion, wound dehiscence, infection, screw penetration into adjacent joints and development of arthritis in adjacent joints over time. Morrey



and Wiedeman reported a 48 percent complication rate fol-lowing ankle fusion with delayed union rates of 7 percent and mal-union rates of 12 percent, and inadequate surgical alignment with early loss of position occur-ring in 15 percent of patients.23

Potential complications following ankle replacement are wound healing problems, malalignment, loosening of com-ponents, component subsidence, infection, bone cyst formation due to osteolysis and instability. A study of 114 ankle replace-ments compared to 47 ankle fusions, followed at a mean of 39 months, showed a 54 percent complication rate for ankle replacement and a 26 percent complication rate for ankle fu-sion. Outcomes for pain relief and function were similar for the two groups.24 A meta-analysis of 4,705 ankle fusions and 480 ankle replacements between 1995 and 2004 showed that the complica-tion rate was higher for ankle replacement patients. The rates of revision after ankle replacement were 9 percent at one year and 23 percent at five years compared to 5 percent and 11 percent for ankle fusion. Regression analysis confirmed a higher risk of revision sur-gery following ankle replacement but a lower rate of subtalar fusion compared to ankle fusion.25

COST An analysis of cost-effectiveness of ankle replacement using a Markov model evaluated expected costs and quality-adjusted life (QALF) years. Ankle replacement cost $20,200 more than ankle fu-sion and resulted in 1.7 additional quality-adjusted life years, with an incremental cost-effectiveness ratio of $11,800/QALF gained. TAA was found to be a cost-effective alternative to ankle fusion in a 60-year-old patient with end-stage ankle arthritis.26

CONCLUSION Ankle replacement surgery provides comparable pain relief and better functional outcomes than ankle fusion. However, ankle replacement is not for all patients. Ankle replacement has higher complication rates than fusion. The best candidates for ankle replacement are older than 50 years old, have low body weight and have low physical demand. For patients with preexisting midfoot or hindfoot arthritis or fusion, total ankle arthroplasty is preferred over fusion. Ankle fusion is still the best procedure for young patients, obese patients and people with high physical demands. As with knee or hip replacement, ankle replacement should not be done to allow high-impact physical activity. Ankle replacement longev-ity at 10 years ranges from 77 percent to 90 percent. We currently advise patients that a knee replacement should last approximately 15 years. We currently do not have the data to advise patients how long an ankle replacement will last. Long-term studies are ongoing to determine ankle replacement longevity and outcomes.

referenceS1. Glazebrook M, Daniels T, Younger A, Foote CJ, Penner M, Wing K, Lau J, Leighton R , Dunbar M: Comparison of health-related qual-ity of life between patients with end-stage ankle and hip arthrosis.

J Bone Joint Surg Am. 2008 Mar;90(3):499-505.

2. Thomas R, Daniels TR: Ankle arthritis. Current Concepts Review. J Bone Joint Surg Am. 2003;85(5):923-936.

3. Praemer A, Furner S, Rice DP, editors. Musculoskeletal conditions in the United States. 1st ed. Park Ridge, III: Ameri-can Academy of Orthopaedic Surgeons; 1992.

4. Saltzman CL, Salamon ML, Blanchard GM, et al: Epidemiol-ogy of ankle arthritis: Report of a consecutive series of 639 patients from a tertiary ortho-paedic center. Iowa Orthop J. 2005;25:44-46.

5. DeGroot H, Uzunishvili S, Weir R, Al-omari A, Gomes B: Intra-articular injection of

hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am. Jan 2012;94(1):2-8.

6. Chou LB, Coughlin MT, Hansen S, Haskell A, Lundeen G, Saltzman CL, Mann R: Osteoarthritis of the ankle: the role of arthroplasty. J Am Acad Orthop Surg. May 2008;16(5):249-259.

7. Hendrickx RP, Stufkens SA, de Bruijn EE, Sierevelt IN, van Dijk CN, Kerkhoffs GM: Medium- to long-term outcome of ankle arthrodesis. Foot Ankle Int. 2011 Oct;32(10):940-7.

8. Fuchs S, Sandmann C, Skwara A, Chylarecki C: Quality of life 20 years after arthrodesis of the ankle: A study of adjacent joints. J Bone Joint Surg Br. 2003;85:994-998.

9. Buchner M, Sabo D: Ankle fusion attributable to posttraumatic arthrosis: A long-term followup of 48 patients. Clin Orthop Relat Res. 2003;406:155-164.

10. Beyaert C, Sirveaux F, Paysant J, Molé D, André JM. The effect of

JULY 2012 29

tibio-talar arthrodesis on foot kinematics and ground reaction force progression during walking. Gait Posture. 2004;20:84-91.

11. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis. Long-term follow-up with gait analysis. J Bone Joint Surg Am. 1979;61:964-75.

12. Thomas R, Daniels TR, Parker K. Gait analysis and functional out-comes following ankle arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am. 2006;88:526-35.

13. Waters RL, Mulroy S. The energy expenditure of normal and pathologic gait. Gait Posture. 1999;9:207-31.

14. Wu WL, Su FC, Cheng YM, Huang PJ, Chou YL, Chou CK. Gait analysis after ankle arthrodesis. Gait Posture. 2000;11:54-61.

15. Kimizuka M, Kurosawa H, Fukubayashi T: Load-bearing pattern of the ankle joint. Arch Orthop Trauma Surg. 1980;96:45-49.

16. Cracchiolo Andrea III and DeOrio James K: Design Features of Current Total Ankle Replacements: Implants and Instrumentation. J Am Acad Orthop Surg. September 2008;16:530-540.

17. Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L: Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 2007 Sep;89(9):1899-905.

18. Easley ME, Adams SB Jr, Hembree WC, DeOrio JK: Results of total ankle arthroplasty. J Bone Joint Surg Am. 2011 Aug 3;93(15):1455-1468.

19. Mann JA, Mann RA, Horton E: STAR ankle: long-term results. Foot Ankle Int. 2011 May;32(5):S473-84.

20. Labek G, Thaler M, Janda W, Agreiter M, Stockl B: Revision rates

after total joint replacement: cumulative results from worldwide joint register datasets. J Bone Joint Surg Br. 2011 Jul;93(7):998.

21. Saltzman CL, Kadoko RG, Suh JS: Treatment of isolated ankle osteoarthritis with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clin Orthop Surg. 2010 Mar;2(1):1-7. Epub 2010 Feb 4.

22. Brodsky JW, Polo FE, Coleman SC, Bruck N: Changes in gait fol-lowing Scandanavian total ankle replacement. J Bone Joint Surg Am. Oct 2011;93(20):1890-1896.

23. Morrey BF and Wiedeman GP Jr: Complications and long-term results of ankle arthrodeses following trauma. J Bone Joint Surg Am. 1980 Jul;62(5):777-84.

24. Krause FG, Windolf M, Bora B, Penner MJ, Wing KJ, Younger AS: Impact of complications in total ankle replacement and ankle ar-throdesis analyzed with a validated outcome measurement. J Bone Joint Surg Am. 2011 May 4;93(9). Epub 2011 Apr 15.

25. SooHoo NF, Zingmond DS, Ko CY: Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg Am. 2007 Oct;89(10):2143-9.

26. Courville XF, Hecht PJ, Tosteson AN: Is total ankle arthroplasty a cost-effective alternative to ankle fusion? Clin Orthop Relat Res. 2011 Jun;469(6):1721-1727.

Note: Dr. Hockenbury practices Orthopaedic Surgery with Jewish Physician Group-South Louisville Orthopaedics. He is an assistant clinical professor at the University of Louisville School of Medi-cine, Department of Orthopaedic Surgery.

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W E W E L C O M E Y O UGLMS would like to welcome

and congratulate the fol-lowing physicians who

have been elected by Judicial Council as provisional members. During the next 30 days, GLMS mem-bers have the right to submit written comments perti-nent to these new

members. All com-ments received will be

forwarded to Judicial Council for review. Provi-

sional membership shall last for a period of two years or until the member’s first hospital reappoint-ment. Provisional members shall become full members upon comple-tion of this time period and favor-able review by Judicial Council. LM

candidateS eLected to ProviSionaL active MeMBerShiP

Derhake, Brian Matthew (18660)Lisa Derhake MD4402 Churchman Ave Ste 302 40215502-366-7317Pain Management Anesthesiology U of Louisville 05 Kasaraneni, Yamuna (31060)Suresh Kasaraneni10284 Shelbyville Rd 40223502-244-5827Family Medicine 06 Andhra Med College 85

Stacy, II Donnie Ray (3917)Mary Shannon Stacy3920 S Dupont Sq 40207502-721-0116Radiation Oncology 05 U of Louisville 99

Turbyville, Joseph C (30940)Rachel Turbyville9800 Shelbyville Rd Ste 220 40223502-429-8585Pediatrics 00,08 Allergy & Immunology 09 U of Tennessee 97

candidateS eLected to ProviSionaL in-traininG MeMBerShiP

Deveneau, Nicolette (31087)401 E Chestnut St Unit 410 40202502-271-5999Obstetrics Gynecology U of Texas 08

Attention all Internal Medicine, Family Practice and Endocrinology Physicians who treat Diabetes patients: The GLMS Physicians Take AIM at Diabetes Program invites YOU to participate in this exciting initiative.By attaining the NCQA DRP Recognition you: Demonstrate to your patients that you are providing excellence in diabetes care Earn increased respect from your peers

The GLMS AIM Program provides at no charge: DRP audit support DRP practice administrative and educational support services Patient and physician tools

Contact: Jessica Williams, Manager of Physician Education and Practice Support and AIM Program Director at 502-736-6368 or [email protected]

LM

P h y S i c i a n S i n P r i n tAlton TM, Brock GN, Yang D, Wilking DA, hertweck Sp, Loveless MB. Retrospective review of intrauterine device in adolescent and young women. J Pediatr Adolesc Gynecol. 2012 Jun;25(3):195-200. PubMed PMID: 22578480.

Dave LY, Caborn DN. Outside-in menis-cus repair: the last 25 years. Sports Med Arthrosc. 2012 Jun;20(2):77-85. PubMed PMID: 22555204.

El-Mallakh RS, Whiteley A, Wozniak T, Ash-by M, Brown S, Colbert-Trowel D, penning-ton T, Thompson M, Tasnin R, Terrell CL. Waiting room crowding and agitation in a dedicated psychiatric emergency service. Ann Clin Psychiatry. 2012 May;24(2):140-2. PubMed PMID: 22563569.

Giesen T, Acland RD, Thirkannad S, Elliot D. The vascularization of the median nerve in the distal forearm and its potential clinical importance. J Hand Surg Am. 2012 Jun;37(6):1200-7. PubMed PMID: 22624784.

haddy RI, Richmond BW, Trapse FM, fannin KZ, Ramirez JA. Septicemia in

patients with AIDS admitted to a university health system: a case series of eighty-three patients. J Am Board Fam Med. 2012 May;25(3):318-22. PubMed PMID: 22570395.

Hansen H, Manchikanti L, Simopoulos TT, Christo PJ, Gupta S, Smith HS, Hameed H, Cohen Sp. A systematic evaluation of the therapeutic effectiveness of sacro-iliac joint interventions. Pain Physician. 2012 May;15(3):E247-78. PubMed PMID: 22622913.

Miller KH, Ziegler C, Greenberg R, patel pD, Carter MB. Why Physicians Should Share PDA/Smartphone Findings With Their Patients: A Brief Report. J Health Commun. 2012 May 2;17 Suppl 1:54-61. PubMed PMID: 22548599.

Roman J. Nicotine-induced Fibronectin Expression Might Represent a Common Mechanism by which Tobacco Promotes Lung Cancer Progression and Obstructive Airway Disease. Proc Am Thorac Soc. 2012 May;9(2):85-6. PubMed PMID: 22550262.

Simopoulos TT, Manchikanti L, Singh V, Gupta S, Hameed H, Diwan S, Cohen Sp. A systematic evaluation of preva-lence and diagnostic accuracy of sacro-iliac joint interventions. Pain Physician. 2012 May;15(3):E305-44. PubMed PMID: 22622915.

Slater AD, Tatooles AJ, Coffey A, Pappas PS, Bresticker M, Greason K, Slaughter MS. Prospective clinical study of a novel left atrial appendage occlusion device. Ann Thorac Surg. 2012 Jun;93(6):2035-40. PubMed PMID: 22632497.

NOTE: GLMS members’ names appear in boldface type. Most of the referenc-es have been obtained through the use of a MEDLINE computer search which is provided by Norton health-care Medical Library. If you have a recent reference that did not appear and would like to have it published in our next issue, please send it to Alecia Miller by fax (736-6363) or email ([email protected]).

JULY 2012 31

• ForGLMSmembersonly• DownloadtoEHRsystem• Oneyearlicenseagreement• AccessselectGLMSmember information online 24/7• Reducesstafftime• Affordabletiered-pricingbasedon practice size

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IN REMEMBRANCEedWard Warrick Jr., md (1923-2012) dr. edward warrick was born in tennessee and raised in North carolina. His father was a high school principal and saw that ed did not shirk his educational responsibilities. ed graduated from Berea college playing basketball, with a degree in pre-med, then earned his medical degree from the university of louisville school of medicine in 1948. He served as a medical officer in the Korean war, where he was a surgeon on the uss salem. ed completed his surgical train-ing at the university of louisville and started a solo surgical practice in lou-isville. He married sherry Bunton on April 14, 1953, and they raised their two daughters, lynne wilson (don) and lark o’Neal, in louisville. ed’s practice was that of a general surgeon and was centered in the Bap-tist hospital system. He also continued his association with the university of louisville surgery department as an associate professor of surgery. He was always available for consultation, and i found his surgery meticulous. ed’s love for tennis and basket-ball was legendary. while in medical school, he played “semi-pro” basket-ball with a team called “doaks docs,” and the team gradually developed a

reputation as a contender. His tennis abilities were well-recognized, and his tennis highlight was a tennis match with Billie Jean King. His fishing skills were unparalleled and his trophies numerous. He was fishing in Kentucky lake the day of the 1974 tornado. when he returned to louisville be-cause of the storm, he discovered that he had lost his residence due to the tornado. After several trips to Hawaii, ed decided that his retirement should be in Hawaii, but things did not work out as planned and he spent his retire-ment in louisville. ed’s terminal ill-ness was of short duration and rather abrupt in onset. He leaves behind a legacy of excellent surgery combined with devotion to his wife and family. He was a great man and a fair and competitive sportsman.

– f. Albert olash sr., md

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JULY 2012 33

It is a safe bet that somewhere in the world, at any time of day or night, different rites are being performed in celebration of significant events in the lives of the people involved. In England in April, gun salutes were fired in honor of the queen’s 86th birthday. Feasting

and dancing accompanied the induction of adolescent boys into manhood by a tribe in Africa, a budding teenage lady carrying the Torah on her bat mitzvah in Maryland was cause for rejoicing and the ordination of three priests in the local cathedral was occasion for hope and renewal for the church people. The months of May and June are a popular time for families and friends to gather for graduations, a rite of pas-sage of our modern culture in the U.S. Little kindergartners for the first time pass in review in their miniature caps and gowns to prove to their doting admirers that they have mastered enough social skills to go through a ceremony meant for adults, to show off their thespian and musi-cal skills with aplomb and without too much squirming. Eighth-graders, beautiful budding ladies balancing them-selves in their first high heels, and handsome young men with beginning fuzz on their chins, chafing under tight collars and neckties, pass on the candles of knowledge to the seventh-graders. Further along, impressive and sometimes occupying athletic halls for the occasion, are the 17- and 18-year-olds graduating from high school. Along with their honors, distinctions and much advice, they are whistled, clapped and cheered as they are launched into, hopefully, a bright adult world. For some, this is the end of formal education. Equipped with such, they are ready to face the challenges of life. Others, however, who choose to do so and have the means will augment their knowledge in college to better prepare themselves for what they hope will be lifelong careers. Four or five years later, another graduation will punctuate the end of their college experience. Where do the medical graduates come in? These are a breed of students who subject themselves to another four years of study, tests and sleepless nights before they get that next diploma after college. Through perseverance,

financial and social sleights of hand and sheer will, they learn how to cure the ailments of mankind. They emerge with hopes but also worries, that they will not match with the right residency, to practice the knowledge they have learned. It is at this juncture that they seem to be at the acme of their life and able to begin to make a difference in the lives of others. In truth they are at a vulnerable stage. Oth-ers expect so much from them, yet they are just begin-ners. Their former colleagues have had a running start on them already. A nephew, soon to be a chief resident, asked, “Is it usual for medical residents to be at this age (30) and have no possessions to their name?” Maybe for the last time, they will need their elders, parents and practicing and retired physicians to support and encourage them. They need incentive, to prove to themselves that all they have gone through was not in vain. They need vindication, that their profession was meant not only to make money but also to gain self-sat-isfaction in being able to help others. They have so many questions and decisions to make. Where to work? What kind of work? Where to live? What kind of lifestyle? Find a suitable spouse? If already have one, where to raise the children? And, how and when to pay the loans? In retrospect, knowing how much effort it took for our medical graduates to come to this point in their lives, is it worth encouraging our children and those of others to follow their and our paths? Is it asking too much sacrifice from them? Will they find satisfaction from pursuing the art of medicine or has it changed so much that it is unrec-ognizable from what it used to be? Ultimately it will depend on them. Hopefully the rites they have been through will be stepping-stones from which to gauge where they have been and how high they still hope to go. Our task is but to inform and to wish them well.

Note: Dr. Oropilla is a retired psychiatrist.

Teresita Bacani-Oropilla, MD

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To Be or noT To Be?

R E f L E C T I O N S


possibly Not Deadly But definitely dangerous, are the seven cardinal sins

of medicine. I began to contemplate this when reading about the Vatican’s fear and criticism of Catholic nuns (sin and being Catholic are inextricably en-twined, maybe only more so if you’re a Holy Roller). Nuns were second only to my parents in developing any sense of right and wrong I possess, not to mention Latin and the classics, music, community organizing and sewing. My nuns are Sisters of Lo-retto from the activist ’60s who have never stopped protesting intoler-ance, urging justice, caring for others and teaching. As did our family, the sisters taught us to combine fair play with a sharp tongue and honed our sensitivity to the glories of ridicule and the faults of tin-pot dictators. Sloth was abhorred. I still fight a deep-seated prejudice against the lazy. Medical sloth is potentially deadly: too lazy to look it up, too lazy to learn it right, and worst of all, too lazy to go and see the patient. Lazy students need spurring and if they lack any sense of shame, a good failing grade is ideal. Consequences count (if you have a conscience). Yet in today’s medical training programs, failing people is nearly impossible, because the school can’t afford the subsequent lawsuit, not to mention

the resentful student-teacher evalua-tions that bring the wrath of accredit-ing organizations rapidly down on the program. Wrath – another one that put you in a major childhood doghouse – is the sure way to medical mistakes. It may clear the air to spout off, but in the throes of anger it is hard to see the other person, hard to think a step ahead and all too easy to judge somebody instead of to understand the issues. I was warned against being angry with patients by every great teacher I ever had the joy to know, and have given in to it only to my sorrow. Gluttony in the doctor field I think applies to all of us at times. We overuse tests instead of thought, we overschedule and we pay attention to digital data and amusements, instead of to human observation and needs. Doctors are often gluttons for punishment (a very Old Testa-ment notion) and we are definitely gluttons for guilt. I defy any one of you (there’s that wrath thing again) to deny that you have felt medically guilty in excess of what you deserve. Lust – hmm, nuns did not discuss that much at Loretto. Officially, we dealt with the If He Kisses You in the Backseat and Your Tongues Touch, Can You Get Still Pregnant? sort of issue, until we were seniors and the dreaded priest-delivered film on sex ed was mandatory. I think they hoped the film alone would be

enough to turn us off lust forever. As my sister Winnie memorably remarked, by the time he got to the orgasm part, the whole room con-vulsed, and not with passion. Medical lust at General Hospital we called “888-ing,” after the phone extension for the Burn unit tub room. I’m not privy to the current slang at U of L. Perhaps some nice young person could clue me in. Envy was the great subject of Rene Girard, the French philosopher. And why had I ever heard of him? Sister Emmanuel, of course. He introduced mimetic theory, which holds that we only want something that somebody else wants too, or already has, or has more and better of than we do. I recall this theory as her explanation of why currency is based on gold. “It’s shiny and hard to get, and the whole world speaks its same language – un-less you’re in a prison camp, where the currency was food, or shoes, or the place away from the window.” Mimetic theory was recently studied in France (the home of much lust, I would think) and found to be hard-wired into our brains. Dr. Mathias Pessiglione and colleagues, writing in the May 23 Journal of Neurosci-ence, found that brain MRIs showed that our centers for assigning value to objects are linked to our centers for envy. They hope this may help explain why autistic children, who do this connection much less, have

Mary G. Barry, MDLouisville Medicine [email protected]

SpEAK YOUR MIND The views expressed in Doctors’ Lounge or any other article in this publication are not those of the Greater Louisville Medical Society or Louisville Medicine. If you would like to respond to an article in this issue, please submit an article or letter to the editor. Contributions may be sent to [email protected] or may be submitted online at www.glms.org. The GLMS Editorial Board reserves the right to choose what will be published.


JULY 2012 35

A fragment of Medical Economic Ephemera The current monetary crisis in

American medicine is sucking us into a maelstrom and swirling the entire medical society into a vertiginous spiral, with no escape discernable, into a black hole. This Jewish Hospital bill for the week of June 8-15, 1930, for an un-complicated delivery and routine stay of one week was $21. The entire cost for the week, including delivery suite, was $43.20. (You note the mother and baby stayed in the hospital seven days – not seven hours.) The same charges in 2012 are, of course, thousands of dollars, but that is not my intention for presenting this bill. Regardless of the outcome of the Supreme Court decision on the constitutionality of the Affordable Health Care Law, the exorbitant cost of doing our “medical business” can no longer be sustained. The big play-ers (pharmacy, hospital companies, equipment companies; those who write regulations to promote tests

and not payment to doctors for intel-lectual ability; and the very real fear and anxiety of malpractice suits) are driving us toward a single-pay sys-tem working for many of our kin in the nations of Europe. Regardless of your phil-osophical and political persuasion, some form of a single-pay pro-gram will eventually be the law of the land. If a young physician might hap-pen to read this – just get ready and make your plans accord-ingly.

Note: Dr. Weiss practices Cardiovascular Diseases with Medical Center Cardiolo-gists. He is a member of the Innominate Society, Louisville’s medical history society.

Morris M. Weiss, MD

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trouble socializing and sharing toys and playing with non-autistic kids. Medical envy is apparent in any local hospital system, as is greed. Youall have an office near Oldham County? So do we. Youall have an office in Clarksville? We have three, thank you very much. Youall got a da Vinci robot? Ha! We got the newest one last week. I’ll have fun imagining the white-hot firing of the “envy” and “value” linkages in the Norton brass the next time Jewish or Baptist opens

up any new anything. That brings us to pride, or the sin of the Vatican, as I see it. Pride in medi-cine can breed slothfulness (why should I bother to read the NEJM?) or envy (jeez, their EMR is way easier than ours) or wrath (why do I have to be the one who calls 1-800-Insurance Renee every single time?!). Pride, unless it’s the parade, is only OK for other people. If you are self-proud you’ll get shot down eventually (see: Caesar, Murdoch, Newt Gingrich, etc.).

Sins don’t change. Humans may. That’s my hope, that we may change enough to withstand several millen-nia of human nature, just to the point to resist the seven medical sins. As for the personal ones – that might be a matter for the confessional, but only if nuns are on the other side.

Note: Dr. Barry practices Internal Medi-cine with Norton Community Medical Associates-Barret. She is a clinical associ-ate professor at the University of Louis-ville School of Medicine, Department of Medicine.


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JULY 2012 37

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Letter to the Editor Despite my great respect for our im-mediate past GLMS president, I must disagree with Dr.

David Bybee when he used my physi-cian group as an example of one “reacting with acquiescence, looking at their relationship with the health care system only with the eye of self-interest for what is most profitable” and abandoning our patients (“From

the President,” May 2012). On the contrary, our group changed employ-ers in the best interest of our practice and patients – a decision not at all based on financial considerations. We agonized how this change would interrupt the continuity of care and did our best to inform our patients of our move within the restriction of our contracts. It has been gratifying and humbling to see how our patients and staff followed us to our new locations – it is equally disheartening to experience how a hospital system

selfishly imposes obstacles for a rea-sonable, timely transfer of patients, jeopardizing care. Yes, these type of disruptions could be avoided if more physicians had the ability to remain independent – oh, how I miss those “golden years” of private practice. Nevertheless, the patient-physician relationship contin-ues to be strong.

Note: Dr. Needleman practices Family Medicine with Norton Community Medi-cal Associates.

Michael Needleman, MD

Letter to the Editor I wish to correct an error in my April article, “History of the University of Louisville School of

Medicine: II. The Transylvania Lega-cy.” The image on page 16, labeled “Benjamin W. Dudley, MD,” is actually that of William Hall Richardson. Dr. Dudley’s correct image is at the right (Fig. 1). Dudley and Richardson were linked by the legendary duel they fought in 1817. Reportedly, the challenge arose over Dudley’s repeated harsh criticism of Richardson’s holding the Transylvania Medical Department chair of obstetrics and diseases of women and children without having an MD degree (he was well-trained

and skillful). Dudley’s shot wounded Richardson, causing severe hemor-rhage from the groin, which Dudley helped repair. The event disgraced them both, as dueling was losing respectability. Daniel Drake arranged for Richardson to receive the MD de-gree the following year. Dudley and Richardson subsequently became friends and close faculty allies. Again, I hope readers identifying errors in these articles will offer cor-rections. Also, any additions to these interesting stories are most welcome.

Note: Dr. Tobin is a professor at the Uni-versity of Louisville School of Medicine, Department of Surgery, Division of Plastic and Reconstructive Surgery. He practices with University Surgical Associates. Dr. Tobin is a member of the Innominate So-ciety, Louisville’s medical history society.

Gordon R. Tobin, MD


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fig. 1 Benjamin W. dudley, Md, professor of anatomy and surgery at transylvania university Medical department

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JULY 2012 39

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Through the use of Twitter, GLMS has the ability to reach patients with health and wellness reminders. Please ask your patients to sign up! They can become a follower of @VitalSigns2Go on Twitter or text “follow VitalSigns2Go” to 40404 and receive the brief messages on their phone. The tweets are a free service connecting patients to reliable medical information.Standard message rates from their carrier may apply.

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