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LOUISVILLE
GREATER LOUISVILLE MEDICAL SOCIETY
MEDICINE
VOL. 62 NO. 6 NOVEMBER 2014
UNINTENDED
CONSEQUENCES
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GLMS BOARD OF GOVERNORS
BOARD CHAIR James Patrick Murphy, MD, MMM
PRESIDENT AND AMA DELEGATE
Bruce A. Scott, MD
PRESIDENT-ELECT Robert H. Couch, MD, MBA
VICE PRESIDENT Heather L. Harmon, MD
TREASURER John L. Roberts, MD
SECRETARY Tracy L. Ragland, MD
AT-LARGE Frank R. Burns, MD
AT-LARGE John D. Kolter, MD
AT-LARGE Jeffrey L. Reynolds, MD
AT-LARGE Neal J. Richmond, MD
AT-LARGE Wayne Tuckson, MD
AT-LARGE Regi Varghese, MD
AMA ALTERNATE DELEGATE
Robert A. Zaring, MD, MMM
KMA 5TH DISTRICT TRUSTEE
Randy Schrodt Jr., MD
KMA 5TH DISTRICT ALTERNATE TRUSTEE
David R. Watkins, MD
GLMS FOUNDATION PRESIDENT
K. Thomas Reichard, MD
DEAN, U OF L SCHOOL OF MEDICINE
Toni M. Ganzel, MD, MBA
DIRECTOR, LOUISVILLE METRO DEPARTMENT
OF PUBLIC HEALTH & WELLNESS
LaQuandra S. Nesbitt, MD, MPH
THE HEALING PLACE PRESIDENT Karyn Hascal
GLMS ALLIANCE CO-PRESIDENTS
Michelle Feger & Rhonda Rhodes
LOUISVILLE
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CONSEQUENCES OF THE
KENTUCKY KASPER DRUG LAW
OF APRIL 2012
Stanley A. Gall, MD, FACOG
Alfred B. Jensen, MD
DEPARTMENTS
5 FROM THE PRESIDENT
FEATURES
6 4TH ANNUAL
Bruce Scott, MD
Aaron Burch
- DO YOU HEAR THE
DRUMBEAT? IT’S GETTING
LOUDER EVERY DAY . . .
9 IN REMEMBRANCE CONDICT MOORE, MD
Norton G. Waterman, MD, FACS
10 IN REMEMBRANCE
- FRED E. COY JR., MD
Owen K. Hitt, MD
12
REFLECTIONS
- CROSSROADS
Teresita Bacani-Oropilla, MD
19 ALLIANCE NEWS
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
VOL. 62 NO. 6 NOVEMBER 2014
20 UNINTENDED
LOUISVILLE MEDICINE EDITORIAL BOARD
EDITOR Mary G. Barry, MD
Elizabeth A. Amin, MD
Waqar C. Aziz, MD
Deborah Ann Ballard, MD, MPH
R. Caleb Buege, MD
Arun K. Gadre, MD
Stanley A. Gall, MD
Larry P. Griffin, MD
Jonathan E. Hodes, MD, MS
Martin Huecker, MD
Thomas James, III, MD
Sarah Khayat
Teresita Bacani-Oropilla, MD
Tracy L. Ragland, MD
Ben Rogers, MD
M. Saleem Seyal, MD
Dave Langdon, Louisville Metro Department of
Public Health & Wellness
James Patrick Murphy, MD, MMM, board chair
Bruce A. Scott, MD, president
Robert H. Couch, MD, MBA, president-elect
Lelan K. Woodmansee, CAE, executive director
Bert Guinn, MBA, CAE, associate executive
director
Kate Williams, communications designer
Aaron Burch, communications specialist
MEDICINE
GREATER LOUISVILLE MEDICAL SOCIETY
Rhonda Rhodes
30 WE WELCOME YOU
31 PHYSICIANS IN PRINT
33 MEMBER SPOTLIGHT
- PETER G. DEVEAUX, MD
Aaron Burch
37 DOCTORS’ LOUNGE
- HYPOCRISY
Mary G. Barry, MD
FOUNDATION GOLF
TOURNAMENT AWARDS
SCHOLARSHIPS
14
WILL TREATMENT
OF HEPATITIS C CAUSE
CONFLICT AMONG
PHYSICIANS?
Thomas James III, MD
25 THE DRUNK TANK
Stephen Love
28
NEW WEBSITE
TO TRACK SUCCESS IN
ACHIEVING COMMUNITY
HEALTH GOALS
LaQuandra Nesbitt, MD, MPH
GLMS MISSION
Promote the science, art and
profession of medicine; Protect the
integrity of the patient-physician
relationship; Advocate for the
health and well-being of the
community; Unite physicians
regardless of practice setting to
achieve these ends.
NOVEMBER 2014
3
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From the
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BRUCE A. SCOTT, MD
GLMS President | [email protected]
DO YOU HEAR THE DRUMBEAT?
IT’S GETTING LOUDER EVERY DAY . . .
A
bout 20 years ago I heard a similar
but less sinister cadence as hospital
medical staffs one by one amended
their bylaws to require board certification.
This mandate was theoretically in response
to “public demand” – presumably patient
demand. Back then some physicians pointed
out that there was no evidence to prove
that performance on a written standardized
exam equated to high-quality patient care.
Established physicians already on the medical staff were “grandfathered” so there was
little resistance to the amendments to “protect our patients” and “ensure quality care.”
Many physicians in the past have supported board certification as an indication
of expertise within a specialty, but as the 24
member boards of the American Board of
Medical Specialties (ABMS) have over time
greatly expanded their requirements for recertification physicians are complaining that
the process, now known as Maintenance of
Certification (MOC), has become intrusive,
difficult to comply with and financially burdensome. Physicians particularly object to
the requirement for a secure standardized
written examination. Although, there continues to be no compelling evidence that
ABMS Certified physicians who enroll in
MOC provide better patient care, this expanded certification is said to ensure quality
- all of this again, in response to that “public
demand.” Personally, I have not heard the
public outcry. In my experience many patients remain confused about board certification, and I have never had a patient ask
if I participate in MOC or have recertified.
Now we learn that the Federation of State
Medical Licensure Boards is encouraging
state medical licensing boards to mandate
“Maintenance of Certification” as a condition of “Maintenance of Licensure” (MOL).
The self-regulated ABMS strongly supports
this requirement. Of course, this is the same
group that profits from the standardized
tests and required reporting that are the
basis of MOC.
The concern many physicians have expressed is whether the MOC process and
the reliance upon a standardized written
examination truly measures the quality of
physician-provided patient care. It seems
hypocritical that the ABMS which certifies the credentials of physicians remains
unable or unwilling to scientifically validate the MOC process, much less written examinations, which they recommend
mandating for physicians. Cynics suggest
that the ABMS is motivated by the greatly
expanded revenues generated by the MOC
requirements.
The Kentucky Board of Medical Licensure
(KBML) already requires that physicians
participate in CME to maintain their license.
I don’t necessarily agree with some of the
specific CME courses required by random
legislative actions over the last number of
years, but I believe it is our professional
responsibility to keep our knowledge base
current and strive for continuous improvement in the quality of care we provide our
patients. Hearing the drum beat, the KBML
is considering adding MOC to our licensure
requirements. Given the physician shortage
in Kentucky, which has led to expansion
of the scope of non-physician providers,
perhaps one should ask, “If a board certified
internal medicine physician elects not to
take an MOC examination can they still
work as a nurse practitioner?”
Sensing the drums getting louder in Kentucky, a number of GLMS members expressed concern to GLMS. Our Policy & Advocacy Committee responded by initiating a
resolution, which was carried by your elected GLMS delegates to the recent Kentucky
Medical Association Annual Meeting and
was ultimately passed by the KMA House
of Delegates. The resolution calls upon the
KMA to join the American Medical Association in advocating for an impact study
that addresses the effect of maintenance of
certification and maintenance of licensure
requirements on physician workforce, cost
to physicians, access to care, and most importantly quality improvement in patient
care. In addition, it asks the KMA to urge
the Kentucky Board of Medical Licensure
to reject any action that would implement
any requirement of maintenance of certification or the Federation of State Medical
Boards maintenance of licensure program
as a condition of licensure until results of
an impact study are known.
While we await the results of the impact
study, the KMA will work with the AMA
and other organizations to make hospitals, employers, and payers aware of the
potentially onerous impact on Kentucky’s
physician workforce that may result from
mandating maintenance of certification as
a condition of employment or of inclusion
in health plans’ provider panels.
Furthermore the KMA will study potential legislation which prohibits the state
from requiring any form of the Federation
of State Medical Boards’ proprietary Maintenance of Licensure program, including
any Maintenance of Licensure program tied
to Maintenance of Certification, as a condition of medical licensure, and additionally
prohibits the state from requiring specialty
medical board certification and MOC.
Meanwhile, the GLMS and the KMA will
continue to encourage physicians to strive to
constantly improve their care of patients by
the means they find most effective, within
the standards of accepted and prevailing
medical practices.
Just because someone is beating a drum
doesn’t mean everyone should automatically
fall in line, sometimes it is appropriate to
listen to a different drummer.
Dr. Scott, board certified in OtolaryngologyHead & Neck Surgery, is the president of
Kentuckiana Ear, Nose, and Throat, PSC.
NOVEMBER 2014
5
GLMS FOUNDATION
4TH ANNUAL GOLF TOURNAMENT
AWARDS SCHOLARSHIPS
Aaron Burch
F
our University of Louisville medical students were awarded $20,000 in scholarships thanks to the combined efforts
of the medical and business communities who gathered at
Hurstbourne Country Club on September 23. The GLMS Foundation’s fourth annual Scholarship Golf Tournament welcomed
more than 70 physicians and sponsors to the event to raise money
for promising young adults pursuing medicine. The all-tourney
sponsor was Stock Yards Bank & Trust.
their endless possibilities. “We are so proud of who our students
are, what they do and what they’ll become,” Dr. Ganzel said. “Our
future is bright with young people like these.”
The weather was cool and beautiful for 18 teams to enjoy a day
of golf. The event concluded with an awards reception and scholarship presentation where each of the four winners, selected on
excellent academic work and community engagement, received a
check for $5,000.
In the golf outing, teams of physicians and businesspeople followed a shamble format for the competition, in which all team
members tee off and then play out the hole at stroke play from the
location of the best ball. The championship team was sponsored
by Stock Yards bank and included Rick Tobe, Tony Simms, Ryan
Blas and Bart Brown.
“This is a wonderful opportunity for the medical community
and the community at large to come together for something great,
supporting our physicians of the future,” said Denise Puthuff,
MD, GLMS Foundation Medical Missions Committee Chair. Golf
Committee Chair David R. Watkins, MD, explained the day’s purpose was to help maintain the pipeline of well-trained medical students to lead in health care.
In second place came a team sponsored by Dr. David Watkins
which included Dr. Watkins, Russell Williams, MD, Danny Watkins and Ron Daniel. Third place went to a second team sponsored
by Stock Yards Bank which included Bob Hecht, Chris Ochsner,
Ron Ferro and Patrick Schmidt. A special “Worst Putter Award”
– sponsored by Mary G. Barry, MD, in memory of her father, journalist Mike Barry – was given to Tony Simms.
This year’s medical student scholars were Andrea Breaux, Kelsey
Gregory, Virginia Haselden and Meagan Holtgrave. Three of the
recipient scholarships were funded by the GLMS Foundation and
the fourth was funded by Jewish Hospital and St. Mary’s Foundation Healthcare Horizons Award.
During the Scholarship Golf Tournament, players were treated
to brunch, luncheon baskets and a cocktail reception. There was
also a live auction and a raffle to raise money for the scholarship
fund.
Helping to present the awards, U of L School of Medicine Dean
Toni Ganzel, MD, praised the recipients for their hard work and
6
Photos: (left) Mark Ihnen, MD, teeing off for a hole-in-one to win a car from Bob
Hook Chevrolet (middle top) Tommy Thompson, MD, Robert Caudill, MD, Mark
Ihnen, MD and Neil Patil, MD (middle bottom) Russ Williams, MD, David Watkins,
MD, Ron Daniel and Danny Watkins (right) Craig Deweese, MD
LOUISVILLE MEDICINE
Note: Aaron Burch is the communications specialist for the Greater
Louisville Medical Society.
MEETING THE SCHOLARSHIP RECIPIENTS
SPONSORS
ALL TOURNEY SPONSOR:
Stock Yards Bank & Trust
$5,000 SCHOLARSHIP
SPONSOR:
Jewish Hospital & St. Mary’s
Foundation,
Healthcare Horizons Award
Andrea Breaux, Linda Gleis, MD, Toni Ganzel, MD, Meagan Holtgrave, ???, Kelsey Gregory and David Watkins, MD, posed after the
scholarship ceremony.
ANDREA C. BREAUX
VIRGINIA N. HASELDEN
Hometown: Ashland, Kentucky
Undergraduate: University of Louisville
Activities: Received the Letitia KimseyTaylor Award for Excellence in Medical
Microbiology; Elected to the Pathology
Honor Society; Elected to Alpha Omega
Alpha Honor Medical Society; Served
as a course representative, tutor and
mentor; Served as an Orientation
Committee member for incoming
students; Served as a unit lab advocate;
Participated in a medical mission trip to
Ecuador.
Hometown: Louisville
Undergraduate: College of Charleston,
South Carolina
Activities: Received the Drs. Herbert
Wald & Armond Gordon Phi Delta
Epsilon Scholarship Award; Elected to
Alpha Omega Alpha Honor Medical
Society; Participated in a post-operative
emergence delirium investigative project
at Kosair Children’s Hospital; Served as
director and physician coordinator at the
Cardinal Clinic; Volunteered in Walking
Works program; Camp counselor at
Flying Horse Farms summer camp for
children with hematologic/oncologic
diseases.
KELSEY A. GREGORY
Hometown: Henderson, Kentucky
Undergraduate: Georgetown College
Activities: Elected to Alpha Omega
Alpha Honor Medical Society;
Participated in Medals4Mettle
program where medical students run
in KY Derby Mini or Full Marathon
supporting pediatric cancer patients;
Participated in Dress for Success women
empowerment program; Participated
in the Walking Works program; Serves
as class representative in the Honor
and Professionalism Advocacy Council;
Participated in a medical mission trip
to Ecuador and served as the group
Pharmacy Coordinator.
MEAGAN M. HOLTGRAVE
Hometown: Louisville
Undergraduate: University of Louisville
Activities: President of the
Medals4Mettle program where medical
students run in KY Derby Mini or Full
Marathon supporting pediatric cancer
patients; Participated in a medical
mission trip to Ecuador; Received the
McGraw-Hill/Lange Medical Student
Award; Elected to Alpha Omega Alpha
Honor Medical Society.
Joe Thompson, MD, Michael McCall Sr., MD, Michael McCall Jr., MD, and Tim Brown, MD, posed Linda Gleis, MD, presented
Tony Simms with the Worst
at the 18th hole of the Hurstbourne Country
Putter Award donated by
Club golf course.
Mary G. Barry, MD.
The championship golf team for 2014 was
(from left to right) Bart Brown, Ryan Blas,
Rick Tobe and Tony Simms in a team sponsored by Stock Yards Bank & Trust.
TEAM SPONSORS:
Robert H. Clarkson Insurance
Agency
Timothy S. Brown, MD
Drs. Gregory & Linda Gleis
Family Allergy & Asthma
Greater Louisville Medical
Society
Merrill Lynch
Mountjoy Chilton Medley LLP
Norton Healthcare
Professionals’ Insurance
Agency, Inc.
University of Louisville
Dr. & Mrs. David Watkins
(Sharon)
ASSOCIATE SPONSORS:
Kleinert Kutz Hand Care PLLC
Norton Neuroscience Institute
Passport Health Plan
Republic Bank & Trust
Company
Stites & Harbison PLLC,
Attorneys
HOLE-IN-ONE SPONSORS:
Stock Yards Bank & Trust
Bob Hook Chevrolet
HOLE SPONSORS:
Passport Health Plan
Denise Puthuff, MD & Janice
Yusk, MD
Tracy Ragland, MD
Stifel Financial Corporation
Van Zandt, Enrich & Cary
Insurance
Welenken CPA
OTHER DONORS:
Brunch – The Door Store &
Windowss
Lunch – Hosparus
Awards Reception – BrownForman Corporation
Auction/Raffle Items –
Brown-Forman (Gift Basket),
Northwestern Mutual
(Souvenir Section of UofL 2013
Championship Game Floor),
Texas Roadhouse (Gift Basket)
Worst Putter Award – Mary G.
Barry, MD
NOVEMBER 2014
7
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IN REMEMBRANCE
CONDICT MOORE, MD 1916-2014
I
t is worth noting the death of Dr. Condict Moore, Professor of Surgery at the University of Louisville School of Medicine. His many
accomplishments included teaching, research and the publication of 68 research papers and three books. He has been recognized by
his peers for what he accomplished by being the first cancer surgeon and member of the Department of Surgery in 1958. He was not
well-treated then due to the opposition of the faculty as cancer surgery was not recognized as a specialty and chemotherapy was in its
infancy. Surgery was done by the general surgeons and chemotherapy by the internists. Dr. Moore persisted in promoting the need for a
cancer center for the University and for Louisville.
With his face to the wind, he persevered and ultimately with others established the J. Graham Brown Cancer Center. Dr. Moore’s efforts
will pass into history. I thought that it is important for those outside his immediate circle of doctors and friends to recognize his contribution
to Louisville. His work and the work of others will benefit generations of medical students by providing them with a better education.
- Norton G. Waterman, MD, FACS
NOVEMBER 2014
9
IN REMEMBRANCE
FRED E. COY JR., MD 1923-2014
I
n 1974, I was fortunate to join the orthopedic surgery practice of Drs. Costigan, Riley and Coy, PSC. Over the ensuing years, I came to
know Fred Coy as a true renaissance man as well as a talented and compassionate surgeon.
Fred graduated from Fern Creek High School in 1942 and subsequently enlisted in the United States Army Air Corps in 1943. Although he rarely talked about it until later years, he was a P-47 pilot and squadron leader in WWII flying 130 missions in France and
Germany. Only last year did I find out he received the Distinguished Flying Cross and Air Medal with twenty Oak Leaf Clusters. He was
a very modest man indeed.
After his military service, Fred received his medical degree and completed his orthopedic residency at the University of Louisville. He
then joined Dan Costigan, MD, and James Riley, MD, in the practice of orthopedic surgery. He particularly enjoyed spending time with
patients at Kosair Crippled Children’s Hospital (as it was then known).
When not practicing medicine, Fred was an expert on Kentucky’s Native American petroglyphs and was passionate about their preservation and documentation. In fact, he was the co-author of “Rock Art of Kentucky” which was published in 1997. He was a founding
member of the George Rogers Clark Press, amateur archaeologist and historian, a member of the Eastern States Rock Art Research Association, the American Heritage Council, the Old Mill Association, and the Red River Historical Society.
He was an expert photographer as well, using this art to become an authority and frequent lecturer on Kentucky wildflowers.
When Fred died we lost a most interesting person and a wonderful colleague and friend.
- Owen K. Hitt, MD
10
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11
REFLECTIONS
CROSSROADS
Teresita Bacani-Oropilla, MD
A
t the latest white coat ceremony for
entering freshmen, Class of 2018, we
watched a select group of young men
and women once more commit themselves to
the path of being healers of men’s ills. Their
enthusiasm, their young faces mirrored hope
for the future. Their loved ones in the audience
wished them well and prayed they will finish
and realize their dreams strong and unscarred.
Every person faces crossroads in life. The decision to take one
road versus the other determines what happens to the rest of one’s
life. Some can afford to meander thru the forest of life and take
little side roads to explore the possibilities that it may offer. Some
resolutely decide on one path and pursue it to its end. Still others
hesitate and are suspended in indecision while precious time passes
by. Time then becomes the limiting factor and pushes one to decide,
else one is in limbo forever.
The path towards being a fulfilled physician has changed through
the years. It used to seem so much simpler. Two generations ago, in
the 1950’s, if one had enough brains, the desire to “help humanity”
and the will to persevere, one set a goal and went after it.
After medical school and the proper specialty training, one expected a life of service to others. All presumed there would be personal
sacrifices which would involve one’s family as well. In return, one
looked forward to self satisfaction, respect, the freedom to exercise
one’s wisdom and skills, and maybe being one of the pillars of one’s
community. If one knew how to manage finances well, one could
even become well off. Many made use of their vision, creative skills
and resources to delve into and advance the cause of Medicine in
all fields. Thus we now live in an era of unprecedented knowledge
and technology.
We sometimes wonder if the plethora of knowledge and online aid
has somehow shifted the balance of focus from our patients to the
wonders that the former can do. Have machines, new discoveries,
12
LOUISVILLE MEDICINE
and important tests taken over the diagnosis and the treatment of
our patients? And has greed taken over in the exploitation of these
aids and taken advantage of the doctors’ skills too? Have too many
entities come between patient and doctor?
Can patients still rely on their overburdened doctors to soothe
their anxieties, explain in understandable terms what is happening
to their bodies, tell them what is the prognosis of a beloved relative,
and guide them in decisions about their health and if appropriate,
their death? Or have some outside entities now dictate what should
be done else these very learned doctors won’t meet certain standards set up by these same entities? Have doctors been somehow
trapped into doing useless things against their good judgments?
Are they being interfered with? Have our patients become the
biblical sheep that are unable to hear their shepherd’s voice amidst
the melee of the merged herds, as in “I know mine, and mine know
me.” Indeed, do patients know who their doctors are and can the
latter be reached when they are needed? If not, we are indeed in a
very sad state of affairs.
We hear there will not be enough physicians for the future. We
see a great pool of eager young graduates with a wide selection of
careers to choose from. We see a cadre of parents, and well-wishers, ardent supporters of these young ones, willing to buoy them
in their lean years. Seeing the state of the medical profession now,
will our bright youth continue to be enticed to join us? Is it still
worthwhile to encourage them to follow our footsteps? Will it still
be a good choice for a lifetime career, or has it lost its luster, nay,
its substance, and is it now an unrecognizable facsimile of what it
used to be? Would we have made the same choice if the practice of
medicine were like this when we started?
The latest generation will give us our answers. Surely they will
forge their way to the next frontiers and reassure us that our fears
were baseless.
Note: Dr. Oropilla is a retired psychiatrist.
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WILL TREATMENT OF HEPATITIS
C CAUSE CONFLICT AMONG
PHYSICIANS?
Thomas James III, MD
T
here is dissension in the ranks of practicing physicians. Treatment of one
disease—Hepatitis C—threatens to
take resources from the management of other
medical and surgical conditions. That sounds
like a very brash statement, but it is one being
openly discussed inside the beltway. Hepatitis
C is the most common chronic blood borne
infection in this country. CDC estimates that
3 ½ to 4 million Americans have chronic infection with this virus.
But this estimate may be an underestimation. The US Preventive
Services Task Force (USPSTF) in 2013 issued recommendations
based upon Level B evidence that all adults born between 1945 and
1965 have a one-time screening for Hepatitis C (HCV), along with
a screen for HIV. The USPSTF apparently feels that Baby Boomers
lived an especially more hedonistic life style in their youth, to create
greater risk than other age group segments. Right upon the heels
of the USPSTF’s pronouncement, CMS issued coverage guidelines
allowing coverage of a one-time screen for Hepatitis C in Medicare
beneficiaries who meet one of these conditions (1.):
14
•
Those at high risk because they have a current or past history
of illicit injection drug use
•
Those who had a blood transfusion before 1992, or
•
Those born between 1945 and 1965
LOUISVILLE MEDICINE
With greater screening the numbers of individuals identified
as infected with HCV is likely to rise. At the same time that mass
screening is occurring, treatments are being more effective, easier
to administer, and associated with a more benign side-effect profile.
The days of Pegylated interferon and ribavirin with 30-40 percent
sustained viral remission (SVR) have become supplanted by all
oral drug regiments with relatively higher tolerance and SVR rates
reported at 96%. Nirvana is here! Finally there is discussion of the
possible eradication of Hepatitis C by aggressive treatment of all
patients with Hepatitis C.
Aye, there’s the rub. The costs of successful treatment of Hepatitis
C in this country are estimated to be between $100,000 and $130,000.
This is expensive stuff. Sure the early treatment regiments for AIDS
were relatively expensive—maybe not on this order of magnitude,
but expensive enough that they were shunned by insurers and
physicians on “risk contracts.” Ultimately the costs of drugs for
AIDS have come down and AIDS can be managed as a chronic
condition at a reasonable cost. This is not the case with Hepatitis
C. The manufacturers appear to believe that the market will accept
a treatment at the $100,000 level.
So if at the $100,000 price all 3.5 million Americans with the infection were treated in an effort to eradicate the disease, the country
would be looking at expenditures for drug therapy of $3.5 X1011th
or more than one-third of a trillion dollars. That is the estimated
amount spent for all drugs currently! If we doubled pharmacy
costs in an elastic economic environment, we would just shrug
our shoulders and say that is the price of saving lives. But we don’t
have an elastic medical economy, and we would be treating large
numbers of people who will not receive any benefit from treatment.
Unlike HIV where failure to treat will rapidly lead to high rates
of morbidity and mortality; HCV is a slow growing virus. Eighty
percent of infected individuals never have symptoms. Of those
twenty percent who do develop liver disease three-fourths (i.e.15%
of the total infected population) will develop significant liver disease
but not die from the virus. It is an estimated 3 to 5% of all infected
individuals who will die from their disease. But even if we look at
the number needed to treat to prevent any significant disease, it
would take half a million dollars of treatment to prevent one person
from developing significant liver pathology; and nearly two million
dollars per life potentially saved.
Doctors are usually not comfortable talking like this, i.e. putting
a price tag on potentially life-saving treatment. But if physicians
look to see where the dollars might have to come from to provide
the funding to “knock out Hep C,” we would be looking at significant cutbacks to essential services such as law enforcement, our
military, and public education. Alternatively, Hepatitis C funding
could come from cannibalizing dollars directed toward treatment
of other diseases.
Such a scenario might pit breast cancer against Hepatitis C. It
could be that funding for diabetes, Crohn’s disease, hypertension,
and newborn care could all suffer if society values eradication of
Hepatitis C more than these other conditions. And it is not just
“society” in a general sense making these judgments. Living now
in Philadelphia, I have had discussions with gastroenterologists
and infectious disease specialists who are advocating so hard for
their patients to receive treatment (even in the face of continued IV
illicit drug use), that some have literally told me that it is not their
concern where the money comes from, they just want to see their
patients treated. In my view, this breaches the AMA standards for
the medical ethical principles of Justice.
The discussions on the distribution of financial resources are
not commonly couched in ethical terms. The issues around the
new treatments for a chronic disease that affects more than 1%
of the US population would evoke both the ethical principles of
the provision of competent, compassionate care for individual
patients, the use of advanced scientific knowledge in the care of
patients, and regarding the care of individuals as paramount. But
with the cost impact of these drugs causing potential disruption of
resources for society and/or for other diseases, the treatment runs
afoul of the ethical principles improvement of community health
and of supporting access to medical care. The Washington Post
article, “New hepatitis C drugs’ price prompts an ethical debate:
Who deserves to get them” (May 2, 2014) quotes Dr. Gary Davis,
the co-chairman of the American Association for the Study of Liver
Disease—Infectious Diseases Society of America (AASLD-IDSA).
He is reported to have said, “We just put down the best regimen for
the individual. We recognize cost issues are really important, but
we are clinicians, not the people who should be addressing that.” If
expert clinicians make recommendations based upon science and
what is possible without considering the ramifications of resource
allocation, then how can they be surprised if they have little to say
about the final decisions? In order to assume true leadership in the
health care arena, physicians must balance the ethical decisions on
population health with those for individual patient care. To do less
physicians are speaking with only a portion of their ethical and moral
authority. Assumption of leadership puts doctors in often difficult
decisions. But most doctors make difficult clinical decisions on a
daily basis. The profession demands that physicians become more
engaged in public policy decisions.
The ethical discussions need to be taken to a more granular
level. I have had the privilege of sitting on the National Quality
Forum’s Cardiovascular Disease Work Group, where both patients
and doctors have openly worried that resources for heart disease
will suffer as money is re-routed to treatment of Hepatitis C. The
National Quality Strategy has had reduction of heart disease as the
key element for improving the overall health of the nation. Now
the cardiologists and others concerned about heart disease are
worried. This tension between specialties has always been there,
but has been exacerbated by having such expensive cures. Will
physicians continue to enjoy cordial professional relations or will
the economic pressures of curative treatments drive the wedge
between specialties even deeper? Will physicians hold only to the
ethical principles around individual patient care or will they also
embrace the principles of social justice? ….and finally, will we as
a profession adopt the leadership role in balancing individual and
societal health needs. The new ultra-expensive treatments of a single,
prevalent disease will force our profession to assume a leadership
role or to become technical advisors.
REFERENCES:
1.) Your Medicare Coverage: Is my test, item or service covered?
Hepatitis C screening test. http://www.medicare.gov/coverage/
hepatitis-c-screening-test.html (last accessed Sept. 12, 2014)
2.) Recommendations for testing, managing and treating hepatitis
C. American Association for the Study of Liver Diseases—
Infectious Diseases Society of America, Revised August 11,
2014. http://www.hcvguidelines.org/fullreport (last accessed
Sept. 17, 2014)
3.) The comparative clinical effectiveness and value of simeprevir
and sofosbuvir in the treatment of chronic hepatitis c infection. California Technology Assessment Forum—Institute for
Clinical and Economic Review (ICER), April 15, 2014. http://
(continued on page 16)
NOVEMBER 2014
15
(continued from page 15)
www.ctaf.org/sites/default/files/assessments/CTAF_Hep_C_
Apr14_final.pdf (last accessed Sept. 17, 2014)
4.) Leof A, Gerrity M, Thielke A, King V. Sofosbuvir for the treatment of hepatitis C and evaluation of the 2014 American Association for the Study of Liver Disease treatment guidelines.
Portland, OR; Center for Evidence-based Policy, Oregon Health
and Science University. http://www.ohsu.edu/xd/research/
centers-institutes/evidence-based-policy-center/med/upload/
Sofosbuvir_for_HepatitisC_FINAL_5_19_2014.pdf (last accessed Sept. 17,2014)
5.) Appleby J. New hepatitis C drugs’ price prompts an ethical
debate: Who deserves to get them? Washington Post, May 2,
2014. http://www.washingtonpost.com/business/new-hepatitisc-drugs-price-prompts-an-ethical-debate-who-deserves-to-getthem/2014/05/01/73582abc-cfac-11e3-937f-d3026234b51c_
story.html (last accessed Sept. 26, 2014)
Note: Dr. James is the Corporate Medical Director of Clinical Policy
at The AmeriHealth Caritas Family of Companies in Philadelphia. He
has a part-time practice within Main Line Healthcare in Philadelphia.
AMA PRINCIPLES OF MEDICAL ETHICS
PREAMBLE
The medical profession has long subscribed to a body of ethical statements developed
primarily for the benefit of the patient. As a member of this profession, a physician must
recognize responsibility to patients first and foremost, as well as to society, to other health
professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable
behavior for the physician.
PRINCIPLES OF MEDICAL ETHICS
I. A physician shall be dedicated to providing competent medical care, with compassion
and respect for human dignity and rights.
II. A physician shall uphold the standards of professionalism, be honest in all professional
interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
III. A physician shall respect the law and also recognize a responsibility to seek changes in
those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
V. A physician shall continue to study, apply, and advance scientific knowledge, maintain a
commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be
free to choose whom to serve, with whom to associate, and the environment in which to
provide medical care.
VII. A physician shall recognize a responsibility to participate in activities contributing to
the improvement of the community and the betterment of public health.
VIII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
IX. A physician shall support access to medical care for all people.
Adopted June 1957; revised June 1980; revised June 2001.
16
LOUISVILLE MEDICINE
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ALLIANCE NEWS
“AND THEY’RE OFF”
Rhonda Rhodes
T
he Alliance got off to a great start. We
began our year with a luncheon at Michelle Feger’s house in September. We
saw several familiar faces as well as some new
ones. Everyone enjoyed catching up from our
summer fun with food and friends. It’s always
great to reconnect and plan the year.
September 27, 2014, John and I hosted a KPPAC reception called
“Pumpkins and Politics” for multiple legislators and physicians. It
was a beautiful evening for all of us to talk about important legislation coming up this session. We noted that our medical community
has been variously assaulted by mandates from government and
insurance companies, and we must work hard to make our voices
heard.
On September 2nd, we joined the Extell
Team to Walk for Alzheimer’s. My Mom lost her battle in June
of 2012 and many of our members have a family member who is
battling this disease.
With the holiday season coming fast, we will gather at Audrey
Carter’s house to enjoy each other’s company – details to be emailed.
Congratulations to Ilene Bosscher for becoming the KMAA
Secretary for 2014-2015. She was installed at the annual meeting
September 15, 2014. The installation was held at Doc Crow’s during
our luncheon. Sarah Sanders, AMAA President introduced the
new officers (by the way using Cheerios to illustrate duties and
relationships).
Stay tuned as we ring in 2015 for more Alliance fun to continue
and more opportunities for philanthropy as well.
Note: Rhonda Rhodes is the co-president of the GLMS Alliance
with Michelle Feger.
NOVEMBER 2014
19
UNINTENDED CONSEQUENCES
OF THE KENTUCKY KASPER DRUG
LAW OF APRIL 2012
Stanley A. Gall, MD, FACOG
Alfred B. Jensen, MD
T
he Kentucky Maternal Mortality Committee is charged by the State of Kentucky to investigate maternal deaths
in the state of Kentucky, report the results to
the Kentucky Department of Public Health,
Mother – Child Division and the Kentucky
Medical Association (KMA). The results are
published in the KMA Journal and the committee makes recommendations to address
the causes of maternal deaths. The Kentucky Death Certificate
addresses maternal death in box 38 and is signed by the attending
physician or medical examiner.
•
Not pregnant within the past year.
•
Not pregnant, but pregnant within 42 days of death.
•
Not pregnant, but pregnant within 43 days to 1 year before
death.
•
Pregnant at the time of death.
•
Unknown if pregnant within the past year.
In an attempt to identify maternal deaths, the death certificates
of all females aged 13-50 years who die in the State of Kentucky are
sent to the chairman of the Kentucky Maternal Mortality Commit20
LOUISVILLE MEDICINE
tee for review. The death certificates for the years 2013, 2012 and
portions of 2011 were reviewed and fewer than 10 maternal deaths
were identified for each year. However, in reviewing all the death
certificates it became glaringly obvious that drug overdoses were
the most frequent cause of death.
In females aged 13-50 years, however box 38 indicated, no pregnant females died of a drug overdose. The purpose of this report
is to determine whether the passage of the KASPER Drug Law of
April 2012 [House Bill 1] had an impact on the number of females
aged 13-50 years who died from drug overdoses, and the types of
drugs they used. The information regarding the cause of death
was taken from the death certificate. Drugs were either listed by
name or simply stated as multiple narcotics or multiple opiates.
The pregnancy status of each patient, as well as marital status race,
place of death, manner of death and county of death were reviewed.
The period of May 2012 through 2013 (Post KASPER) with 1316
death certificates was compared to the pre-KASPER Drug Law
(2011 to April 2012) of 510 death certificates. The pre-KASPER
sample is incomplete as portions of the death certificate from 2011
had been discarded.
The first striking result is the significant increase in heroin deaths
after passage of the KASPER law (table 1). On the pre-KASPER
period 3/97 (3.1%, P=<0.001, 95% CI .063-9.12) heroin deaths were
reported and were significantly lower when compared to 61/280
(21.8%, 95%CI 17-27) in the post –KASPER period. Non-heroin
deaths were significantly greater in the pre-KASPER period 94/97
(94%)(95% CI =90.88-99.38) P=<0.001 than in the post-KASPER
period 219/280 (78.21%) (95% CI =82.68-94). The percentage of
fatal overdose deaths in the two time periods did not change significantly. Post-KASPER overdose deaths 280/1316 (21.3%) 95%
CI 19-23 vs 97/510 (19.2%) 95% CI = 16-22% of pre-KASPER
overdose deaths (table 1).
The top 10 causes of death in the entire sample are seen in table
1a. Drug O.D. deaths were the most frequently listed cause of death
followed by myocardial infarction. Motor vehicle accident deaths,
cancer and suicide deaths completed the top five causes of death in
the post-KASPER period. Respiratory failure deaths did not make
the top 10 list of causes of death in the pre-KASPER period; this was
the seventh leading cause of death in the post KASPER period. The
increase in respiratory deaths can be explained by the increase in the
use of heroin and its effects on respiration. It became clear to death
certificate signers of the dramatic effect of heroin on respiration.
The top 10 counties with the most drug overdosed deaths are listed
in tables 2 and 2a (on page 22). Heroin deaths were led by Jefferson,
Fayette, Kenton, Boone and Campbell. Jefferson and Fayette counties
showed the greatest increase in heroin deaths when compared to the
pre and post KASPER periods. Jefferson increased from 9/97 (9.2%;
3-15%) to 48/280 (17.1%; 13-22%) P=0.07. Fayette increased from
1/97 (1.01%; 0-3%) to 22/97 (7.8%; 14-31%) P= 0.013.
The place of death also showed significant differences when com-
paring pre and post KASPER periods (Table 3 on page 23). There
was a significant increase in emergency room deaths in the postKASPER period: 38/280 (13.57% 95% CI = 10.01-18.12) compared
to the pre-KASPER period 4/97 (4.1%) 95% CI 1.24-10.05 P=0.009.
This was accompanied by a significant decrease of deaths at a residence. Pre-KASPER 85/97 (87.6% 95%CI 79.4-92.99) compared to
post-KASPER 203/280 (72.5%)95% CI 66.97-77.43 P=0.002. This
indicates an increased awareness of personal distress and of making
attempts to reach a medical care/medical facility. It also indicates
the possibility that acute drug treatment may have been initiated.
The marital status of females aged 13-50 years dying from a drug
overdose is noted in table 4 (page 23). There was an increase in
married females and a decrease in never married females dying of
a drug overdose: married, post KASPER 88/280(31.4%; 26-37%),
increased from 28/97 (18.6%; 20-38% P=0.7) - but neither change
is statistically significant.
Table 5 (page 23) lists the manner of death in females dying from
a drug overdose. There is no difference in the reporting from the
pre-KASPER to post-KASPER period. It is of interest that all of
the seven heroin deaths from Bell county were signed out as “not
determined.”
Table 6 lists the racial differences in drug overdose deaths. In both
periods of study, white patients overwhelmingly predominated,
270/280 (96.4%; 95% CI; 94-98%) post KASER and 93/97 (96%;
95% CI, 92-99%) pre-KASPER; there was no significant difference
between the time periods.
(continued on page 22)
Table 1: Heroin Overdose Deaths among Drug Overdose Deaths in Females
Aged 13-50 Years in Two Periods of Time in (n1=280, n2=97).
Post KASPER (N=280)
Pre KASPER (N=97)
Death Overdose Type
N
%
95% Lower
95% Upper
N
%
95% Lower
95% Upper
P
Non Heroin
219
78.21
72.98
82.68
94
96.91
90.88
99.37
<0.001
Heroin
61
21.79
17.32
27.02
3
3.09
0.63
9.12
<0.001
Table 1a: Top 10 Causes of Death in Females aged 13-50 Years in Two Periods of Time (n1=1316, n2=510).
Post KASPER (N=1316)
Pre KASPER (N=510)
Cause of Death
N
%
95% Lower
95% Upper
N
%
95% Lower
95% Upper
P
Drug Overdose
280
21.28
19.15
23.57
97
19.02
15.84
22.67
0.303
M.I.
118
8.97
7.53
10.64
25
4.9
3.31
7.17
0.003
Motor Vehicle
101
7.67
6.35
9.25
51
10
7.67
12.93
0.109
Lung Cancer
67
5.09
4.02
6.42
20
3.92
2.52
6.02
0.329
Suicide
55
4.18
3.22
5.41
29
5.69
3.96
8.08
0.172
A.H.D
53
4.03
3.08
5.24
21
4.12
2.67
6.25
0.896
R.F.
53
4.03
3.08
5.24
12
2.35
1.3
4.12
0.092
Breast Cancer
45
3.42
2.56
4.55
25
4.9
3.31
7.17
0.138
C.O.P.D
44
3.04
2.23
4.12
21
2.55
1.45
4.36
0.644
Bacterial Sepsis
40
2.13
1.46
3.07
13
3.92
2.52
6.02
0.049
Liver Disease
28
21.28
19.15
23.57
20
19.02
15.84
22.67
0.303
NOVEMBER 2014
21
(continued from page 21)
Table 2: Drug Overdose Deaths in Females Aged 13-50 Years in Two Periods of Time in 10 Counties (n1=280, n2=97).
Post KASPER (N=280)
Pre KASPER (N=97)
County of Death
N
%
95% Lower
95% Upper
N
%
95% Lower
95% Upper
P
Jefferson
48
17.14
13.14
22.03
9
9.28
4.71
16.95
0.071
Fayette
22
7.86
5.18
11.67
1
1.03
0.00
6.2
0.013
Kenton
18
6.43
4.04
10
8
8.25
3.97
15.71
0.642
Boone
10
3.57
1.86
6.54
4
4.12
1.24
10.5
0.761
Campbell
9
3.21
1.6
6.09
2
2.06
0.08
7.7
0.736
Bullitt
7
2.5
1.11
5.18
1
1.03
0.00
6.2
0.686
Bell
7
2.5
1.11
5.18
1
1.03
0.00
6.2
0.686
Pulaski
7
2.5
1.11
5.18
4
4.12
1.24
10.5
0.484
Harlan
6
2.14
0.87
4.71
2
2.06
0.08
7.7
1
Anderson
3
1.07
0.21
3.26
0
0
0.00
4.6
0.572
Table 2a: Heroin Death in Top 10 counties in post KASPER group and Heroin Deaths in Females Aged 13-50 Years in
Two Periods of Time in 10 Counties (n1=61, n2=3)
Post KASPER (N=61)
County of Heroin Death
N
%
95% Lower
95% Upper
N
%
95% Lower
95% Upper
P
Jefferson
13
21.31
12.61
33.41
0
0
0.00
67.62
1
Fayette
7
11.48
5.25
22.27
0
0
0.00
67.62
1
Kenton
5
8.2
3.05
18.3
2
66.67
13.78
100.00
0.03
Boone
4
6.56
2.02
16.25
1
33.33
0.00
86.22
0.22
Campbell
4
6.56
2.02
16.25
0
0
0.00
67.62
1
Bullitt
2
3.28
0.16
11.93
0
0
0.00
67.62
1
Bell
1
1.64
0.00
9.63
0
0
0.00
67.62
1
Pulaski
1
1.64
0.00
9.63
0
0
0.00
67.62
1
Harlan
1
1.64
0.00
9.63
0
0
0.00
67.62
1
Anderson
2
3.28
0.16
11.93
0
0
0.00
67.62
1
The intended benefits of the 2012 KASPER Drug Law were to
decrease the street use of prescription opioids, shut down “pill mills,”
and introduce more responsibility in drug prescribing. The unintended consequences of this drug law were to significantly increase
the use of street heroin, increase respiratory failure as a cause of
death, increase the place of death to emergency departments and
increase the overdose deaths in married women.
The overall number of females aged 13-50 years dying from a
narcotic overdose has not changed, but the KASPER Drug Law
increased the deaths from heroin. No pregnant woman was a drug
overdose death, as reported by death certificates.
The KASPER law decreased the availability of prescription narcotic drugs by shutting down “pill mills” by greater supervision of
large dispensers of narcotic drugs. The mandate to use the statewide
narcotic date base “KASPER” when narcotics are prescribed was a
welcome step forward. However, the marketplace does not always
function as lawmakers desire, so as prescription narcotics and opi-
22
Pre KASPER (N=3)
LOUISVILLE MEDICINE
oids become more difficult to obtain and the costs increased, cheaper
heroin became the drug of choice. The percentage of overdose drugs
did not change when comparing pre and post KASPER periods but
the deaths due to heroin significantly increased.
STATISTICAL METHODS:
Chart records were reviewed. Descriptive measures, such as frequency and percentages, were produced for entire cohorts and also
within subsets of the cohort (Agresti 2002). The 95% confidence
intervals for proportions are produced using a precise method
(Yuan and Rai 2011; Agresti and Coull1998). Results are declared
statistically significant at alpha=5%. The statistical analyses are
performed using R (R 2006).
Statistical expertise by Shesh Rai, PhD
STATISTICAL REFERENCES:
Agresti A. Categorical data analysis, 2nd ed. New York: Wiley and
Sons, 2002.
Table 3: Place of Death Dying from Drug Overdose in Females
Aged 13-50 Years in post and pre KASPER groups (n1=280, n2=97)
Post KASPER (N=280)
Pre KASPER (N=97)
Place of Death
N
%
95% Lower
95% Upper
N
%
Residence
203
72.5
66.97
77.43
85
Motel
6
2.14
0.87
4.71
2
In-Patient
18
6.43
4.04
10
ER
38
13.57
10.01
Road/Parking Lot
15
5.36
3.2
95% Lower
95% Upper
P
87.63
79.4
92.99
0.002
2.06
0.08
7.7
1
4
4.12
1.24
10.5
0.615
18.12
4
4.12
1.24
10.5
0.009
8.72
7
7.22
3.25
14.44
0.463
Table 4: Marital Status in Drug Overdose Deaths in Females
Aged 13-50 Years in post and pre KASPER groups (n1=280, n2=97)
Post KASPER (N=280)
Pre KASPER (N=97)
Marital Status
N
%
95% Lower
95% Upper
N
%
95% Lower
95% Upper
P
Married
88
31.43
26.25
37.11
28
28.87
20.67
38.67
0.702
Never Married
73
26.07
21.25
31.54
34
35.05
26.19
45.06
0.116
Divorced
91
32.5
27.26
38.21
27
27.84
19.77
37.59
0.447
Widowed
11
3.93
2.12
6.99
5
5.15
1.88
11.84
0.569
Separated
17
6.07
3.75
9.58
3
3.09
0.63
9.12
0.307
Agresti A and Coull BA. Approximate if better than “exaxt” for
interval estimation of binomial proportions. American Statistician,
52:119-126, 1998.
Yuan X and Rai SN. Confidence Intervals for Survival Probabilities:
A Comparison Study. Communications in Statistics – Simulation
and Computation, 40(7): 978-991, 2011.
R Development Core Team (2006). R: A language and environment
for statistical computing. R Foundation for Statistical Computing,
Vienna, Austria. ISBN 3-900051-07-0, URL www.R-project.org.
Note: Dr. Gall is a professor at the University of Louisville School
of Medicine, Department of Obstetrics, Gynecology and Women’s
Health, Division of Maternal-Fetal Medicine. He practices with UofL
Physicians-Maternal-Fetal Medicine.
Table 5: Manner of Death in Drug Overdose Deaths in Females
Aged 13-50 Years in post and pre KASPER groups (n1=280, n2=97)
Post KASPER (N=280)
Pre KASPER (N=97)
Manner of Death
N
%
95% Lower
95% Upper
N
%
Accident
229
81.79
76.81
85.9
77
79.38
70.14
86.39
0.652
Natural
17
6.07
3.75
9.58
7
7.22
3.25
14.44
0.638
Suicide
15
5.36
3.2
8.72
7
7.22
3.25
14.44
0.463
Not Determined
23
8.21
5.48
12.08
5
5.15
1.88
11.84
0.377
95% Lower 95% Upper
P
Table 6: Race in Drug Overdose Deaths in Females
Aged 13-50 Years in post and pre KASPER groups (n1=280, n2=97)
Post KASPER (N=280)
Pre KASPER (N=97)
Race
N
%
95% Lower
95% Upper
N
%
95% Lower
95% Upper
P
White
270
96.43
93.46
98.14
93
95.88
89.5
98.76
0.761
Black
8
2.86
1.35
5.64
2
2.06
0.08
7.7
1
Hispanic
2
0.71
0.02
2.74
1
1.03
0.00
6.2
1
Unknown
0
0
0.00
1.63
1
1.03
0.00
6.2
0.257
NOVEMBER 2014
23
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THE DRUNK TANK
Stephen Love
B
efore I started medical school, all of six
months ago as I write this, I worked
in the emergency department at University Hospital for a few months. I was one
of those millennials who took a clichéd “gap
year” to travel and “find myself ” before beginning the rest of my life. I started the job in the
ED at the tail end of my year off to make sure
that I still wanted to go to medical school, I
still wanted to become a doctor. I figured that if I immersed myself
in a clinical environment and didn’t want to run away, I would be
able to give myself one final affirmation that I was making the right
decision before leaping into the Asculepian black hole that has since
consumed my life.
I saw everything on my imagined spectrum during the short time
working there, from assault rifle wounds to the common cold. The
major trauma came at an unexpectedly high frequency as the weather
warmed up, but the commotion of “Room 9” was often an enlivening
change of pace from the banality that can be a lazy afternoon in an
emergency department for a lowly medical scribe trying to figure
out what he wants to do with his life. It showed me, in no uncertain
terms, that being a physician means saving lives. However, what I
took away from my experiences in the ED ultimately had very little
to do with the grand actions of acute lifesaving interventions, and
very much to do with the more mundane and, in my opinion, still
often overlooked aspects of medicine. Nothing that I saw in those
dramatic encounters stuck with me more than the daily deluge of
victims of poverty, mental illness, and substance abuse did. The
tragedy of trauma was ghastly, and each adverse outcome was as
devastating and personally upsetting as the next, but the despair of
the endless procession of the souls who were seemingly resistant
to the efforts of the system, relentlessly gnawed at the remnants of
my battle-weary idealism.
“The regulars” are the men and women who show up in the ED
nearly every day - maybe because they passed out on a bench;
maybe because they were talking to their hallucinations in public;
maybe because it’s cold and wet outside. I felt like some of them
were already old friends of mine by my third week on the job, and
I had never even talked to them. I knew their histories by heart.
When I first started working, all I was concerned with was doing
my job. Once I got that under control, I busied myself by seeking
out all of the procedures, complex cases, and otherwise interesting
interventions that occurred in my little corner of the health care
system. Once that novelty wore off, however, the personal stories
of all of the patients that I saw became my primary focus. I enjoyed
writing the summary of a patient’s history at the beginning of the
chart when the physician with whom I was working had been given
an extensive one, especially in regard to social history. It was like I
had met a new person, and I was commissioned to write a miniature
biography of them: the more extensive the social history, the more
interesting the story. Sure, the medical history was usually more
important, given my job, but it was the myriad little stories about
(continued on page 26)
NOVEMBER 2014
25
(continued from page 25)
patients’ personal lives that captured my interest on a daily basis.
And it was these same stories that unsettled me deeply as I spent
more and more time in the “drunk tank” in the back of the ED.
Intoxication. Hearing voices. Intoxicated. Found wandering. ETOH.
Hallucinations. Heroin OD. Took “a bunch of pills.” SI. Intoxication.
“No place to go.” SI. Too drunk for jail. OD. “Hearing voices.” Heroin.
ETOH. SI. Heroin OD. Found down. ETOH. SI. Intoxicated. OD.
ETOH. “Doesn’t want to live.” ETOH.
The very existence of a place like an emergency department with
doors that are never closed, fully staffed with doctors, nurses, and
social workers, is an unbelievable blessing for society in more ways
that I can even count. It has essentially become the solution to every
problem having to do with medical emergencies in everyday life,
and it is often taken for granted in a world where everything from
hamburgers and TV shows to appendectomies and cardiac catheterizations is expected to be drive-through and on-demand. Emergency
departments are the safety net of and for our health care system, but
should they also be the safety net for social responsibility?
No generalization can encapsulate the range of circumstances
surrounding each individual’s odyssey toward becoming a “regular”
in the ED, and surely there would be great variation in the degree of
sympathy with which those men and women would be viewed by
many, in accord with the degree to which personal choice, rather
than situational misfortune or socioeconomic disadvantage, played
a role in forming his or her current self. Nevertheless, the plight of
these individuals - these patients - refuses to leave my mind.
It is clear that many of these individuals either should be or already
are patients of psychiatry, and it is only natural that some of them
may occasionally slip through the cracks of the system and land in
the ED, as is the case for patients in all other areas of medicine. But
to label and group all of these men and women into that category
and dismiss their collective affliction by writing it off as “just the
way it is” would be a disservice to all of humanity. Additionally, it
should not be the responsibility of inner-city emergency departments
around the country to shoulder the burden of taking care of all of
these individuals. The patience and compassion that I witnessed in
so many physicians and nurses, not to mention the oft-overlooked
and under-appreciated techs, in their dealings with these men and
women was encouraging, if not inspiring.
These patients taught me that they are not the products of a defective health care system, but of a defective society. They taught
me that it is not health care workers who need to do more for them,
but their communities that do. They taught me that they did not
slip through the cracks, but were born in the abyss.
They taught me that we, as fellow human beings, are not doing
enough.
Note: Stephen Love is a second year medical student at the University
of Louisville with an interest in psychiatry.
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NOVEMBER 2014
27
NEW WEBSITE TO TRACK
SUCCESS IN ACHIEVING
COMMUNITY HEALTH GOALS
LaQuandra Nesbitt, MD, MPH
L
ast month the Metro Department of
Public Health and Wellness launched
HealthyLouisvilleMetro.org, yet another tool in our ongoing campaign to improve
health in Louisville. The new website tracks
progress toward achieving the goals laid out
in Healthy Louisville 2020, our city’s plan for
improving population health over the next
six years.
Published earlier this year, Healthy Louisville 2020 sets goals and
28
LOUISVILLE MEDICINE
makes policy recommendations for 13 key focus areas as a way to
improve our community’s health. The report also presents data
targets for each focus area.
HealthyLouisvilleMetro.org is organized around these 13 focus
areas - Access to Healthcare, Cancer Prevention and Screening, Chronic
Disease Prevention and Screening, Healthy Homes and Healthy Neighborhoods, Healthy Mothers and Healthy Babies, HIV Prevention and
Screening, Safe and Healthy Neighborhoods, Mental and Behavioral
Health, Obesity Prevention, Oral Health, Public Health Infrastructure,
Social Determinants of Health and Substance Abuse.
The website also brings other data, local resources and a wealth of
information to one, accessible, user-friendly location. It posts best
practices, news articles and information about community events.
It gives Louisville residents and policymakers the information they
need to participate in the work of building a healthier Louisville.
•
The Healthy People 2020 Tracker compares Louisville’s
health to the national objectives set out in Healthy People
2020 and whether or not we have met the objectives. Healthy
People 2020 provides science-based, 10-year national objectives for improving the health of all Americans.
A Collaboration Center invites community members to post
events, initiatives and ideas to improve the health of the community. The Collaboration Center fosters dialogue on best practices
and funding opportunities as well as ongoing programs here in
Louisville.
•
Promising Practice citations identify strategies from across
the country and around the world to improve overall health
in Louisville without having to reinvent the wheel. HealthyLouisvilleMetro.org makes distinctions between practices
that have been thoroughly and scientifically reviewed (Evidence Based) from those that have undergone less rigorous
(Effective Practice), or perhaps no evaluation (Good Idea).
The site includes:
•
More than 100 Health and Quality of Life Indicators
Researchers and other users will find several report tools useful.
•
Healthy People 2020 and Healthy Louisville 2020 Trackers
•
•
Performance Tracking
•
Database of Proven Programs
The Report Assistant can be used to run a customized
report that will contain content from this site that can be
either saved or shared with others based on keywords or
topics of interest.
•
Collaboration Center
•
•
Report Assistant (to help Present Data)
Indicator Comparison Report allows users to view multiple
indicators at a time. This can be useful in focusing on a particular topic area and in viewing various indicators related
to that particular topic area side by side. This tool can also
be used to view a single indicator across multiple locations
such as county, census tract and zip code
Each indicator on HealthyLouisvilleMetro.org is accompanied
by icons that denote how well Louisville is doing on that particular
indicator.
•
The Regional Comparison Indicators provide a visual
representation of how Louisville is doing compared to other
communities. •
Average Comparison Indicators show how Louisville compares with the median or mean U.S. value.
•
The Time Comparison Indicator shows how the current
value compares to the previous measurement period.
•
Compare to Target Indicators show whether or not the
Healthy Louisville 2020 goal has been met. The site has several other features.
•
The Community Dashboard allows users to view all available indicators for a particular region and view them by topic
or by status (red / yellow / green). Users are able to explore
what data is available by selecting an option from ‘Location
Type’ and a corresponding ‘Location.’
•
The Disparities Dashboard allows users to view indicator
information broken down by age, gender, or race/ethnicity.
The disparities dashboard is organized by primary category
(health, education, public safety) and then sub-categories
(cancer, diabetes, school environment, crime).
•
The Demographics Page includes such information as population size, age, racial and ethnic composition, population
growth, and density.
The website also features a Report Center – a repository of published reports, web content, fact sheets, planning documents, and
other materials maintained by the Department of Public Health
and Wellness.
HealthyLouisvilleMetro.org should prove useful for anyone who
wants to improve the health of our city. Certainly hospital health
systems, health coalitions, nonprofit organizations, planners, grant
writers, health care providers, students and businesses committed
to worksite wellness programs should find the site a valuable tool.
The site will also prove useful for those seeking to get involved in
health initiatives but don’t know where to begin. The easy to use red/
yellow/green system for indicator tracking can help the population
health novice easily identify areas of opportunity in our community
where we need more help “moving the needle!”
HealthyLouisvilleMetro.org is operated by the Louisville Metro
Department of Public Health and Wellness in partnership with
the Healthy Communities Institute, a non-profit organization that
works with cities across the nation and internationally to facilitate
community change through information technology solutions
and services for health departments, hospitals and community
coalitions. The institute provides a customizable template and data
for health indicators as well as news of funding opportunities and
information on best practices.
Note: Dr. Nesbitt, a family physician, is the director of the Louisville
Metro Department of Public Health and Wellness.
NOVEMBER 2014
29
WE WELCOME YOU
GLMS
would like to welcome and congratulate the following physicians who have been elected by
Judicial Council as provisional members. During the next 30 days, GLMS members have the
right to submit written comments pertinent to these new members. All comments received will be forwarded
to Judicial Council for review. Provisional membership shall last for a period of two years or until the member’s
first hospital reappointment. Provisional members shall become full members upon completion of this time
period and favorable review by Judicial Council.
Candidates Elected to Provisional Active Membership
Gaunt, William Trevor (34374)
Tina C. Gaunt, M.D.
10109 Colonel Hancock Dr
40291
606-424-5445
General Surgery 13
U of Louisville 94
Guess, Karla Denise (1213)
3101 Breckenridge Ln Ste 1F
40220
502-458-7400
Anesthesiology 95
U of Louisville 89
Ryan, Maureen A (3431)
Robert D. Bridges
8442 Dixie Hwy 40258
502-295-3994
Internal Medicine 96,10
Pediatrics 97
Medical College of Georgia 90
Semder, Christopher (34032)
Whitney Jordan Semder
3900 Kresge Way Ste 60 40207
893-7710
Cardiovascular Diseases 13
Internal Medicine 10
Marshall U 07
NEW ISSUE AVAILABLE NOW!
Vital Signs
THE GLMS
PUBLICATION FOR
PATIENTS
Subscriptions to Vital Signs are available as a benefit to all active and
associate members at NO COST.
To receive Vital Signs at your practice contact Membership Coordinator Jennifer Howard
at [email protected] or 502-736-6362.
30
LOUISVILLE MEDICINE
PHYSICIANS IN PRINT
Ghelani SJ, Glatz AC, David S, Leahy R, Hirsch R, Armsby LB,
Trucco SM, Holzer RJ, Bergersen L. Radiation dose benchmarks
during cardiac catheterization for congenital heart disease in
the United States. JACC Cardiovasc Interv. 2014 Sep;7(9):10609. PubMed PMID: 25234681.
Jacobson TA, Ito MK, Maki KC, Orringer CE, Bays HE, Jones PH,
McKenney JM, Grundy SM, Gill EA, Wild RA, Wilson DP, Brown
WV. National Lipid Association recommendations for patientcentered management of dyslipidemia: Part 1 - executive
summary. J Clin Lipidol. 2014 Sep-Oct;8(5):473-88. Epub 2014
Jul 15. PubMed PMID: 25234560.
Kimbrough CW, McMasters KM, Davis EG. Principles of
Surgical Treatment of Malignant Melanoma. Surg Clin North
Am. 2014 Oct;94(5):973-988. PubMed PMID: 25245962.
Kwon D, McFarland K, Velanovich V, Martin RC 2nd. Borderline
and locally advanced pancreatic adenocarcinoma margin
accentuation with intraoperative irreversible electroporation.
Surgery. 2014 Oct;156(4):910-22. PubMed PMID: 25239345.
Milano C, Pagani FD, Slaughter MS, Pham DT, Hathaway DR,
Jacoski MV, Najarian KB, Aaronson KD; ADVANCE Investigators.
Clinical outcomes after implantation of a centrifugal flow
left ventricular assist device and concurrent cardiac valve
procedures. Circulation. 2014 Sep 9;130(11 Suppl 1):S3-S11.
PubMed PMID: 25200052.
Zhang Z, Zhang YP, Shields LB, Shields CB. Technical
comments on rodent spinal cord injuries models. Neural Regen
Res. 2014 Mar 1;9(5):453-5. PubMed PMID: 25206835.
NOTE: GLMS members’ names appear in boldface type. Most of
the references have been obtained through the use of a MEDLINE computer search which is provided by Norton Healthcare
Medical Library. If you have a recent reference that did not
appear and would like to have it published in our next issue,
please send it to Jennifer Howard by fax (502-736-6363) or email
([email protected]).
Mackowski MJ, Barnett RE, Harbrecht BG, Miller KR, Franklin
GA, Smith JW, Richardson JD, Benns MV. Damage control
for thoracic trauma. Am Surg. 2014 Sep;80(9):910-3. PubMed
PMID: 25197880.
GLMS Marketing Opportunities
It’s your
for any healthy media plan
Market Your Practice Directly
to Your Colleagues
Louisville Medicine
GLMS News
GLMS Annual Pictorial Roster
www.glms.org
GLMS Sponsorship Opportunities
GLMS Mobile App
Mailing Labels available for purchase
Contact Cheri K McGuire
Director of Marketing
502-736-6336
[email protected]
NOVEMBER 2014
31
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MEMBER SPOTLIGHT
PETER G. DEVEAUX, MD
Aaron Burch
Editor’s Note: Welcome to Louisville Medicine’s Member Spotlight
section. We’ll be highlighting interesting and exceptional GLMS
physicians on a regular basis beginning this month with Dr. Peter
Deveaux.
B
efore arriving in Louisville last September, Peter G. Deveaux, MD, had been all over the world. Now he’s settled
down in Derby City with his wife, Lynn, and four sons for
what must be one of the more relaxing periods of his career.
He’s served 14 years in the military and been deployed six times
to some of the most tumultuous places on earth, including Afghanistan, Iraq, Pakistan, Kyrgyzstan, Uzbekistan and more.
Once you’ve been shot at while attempting and succeeding at
lifesaving trauma surgery, the University of Louisville becomes a
drastic change of pace. Though he hangs his hat in this new place,
Dr. Deveaux’s sense of duty to his fellow man hasn’t changed.
Born in Boston, Dr. Deveaux moved to Dubuque County, Iowa,
the setting of Kevin Costner’s famous Field of Dreams, where he
grew up with two younger sisters before finishing high school and
heading to the University of Iowa.
The pursuit of a surgical career led Dr. Deveaux to Chicago
Medical School, now known as Rosalind Franklin University of
Medicine and Science. In addition to his ambition to become a
surgeon, Dr. Deveaux also pursued a Master’s Degree in Pathology.
“I thought it would make me a better doctor if I understood pathology,” said Dr. Deveaux, who went on to Loyola University for
his General Surgery residency, where he married Lynn, his wife
of 18 years, in Oak Park, Illinois. “Things were so kinetic then.
We got married, had a week to honeymoon, and I went back to
residency.”
Throwing himself into his medical career, Dr. Deveaux accepted
a U.S. Army scholarship to pay for his time in college. When he
graduated from Loyola University, he began his three-year obligation as an army general surgeon. However, three years was just
the beginning.
“Medicine is really the only thing I ever wanted to do. You get to
hang around smart people and help others, learn new things and
understand the human body; there’s nothing better,” he said.
“I went up to Fort Wainwright, Alaska, where I was a general surgeon,” said Dr. Deveaux. “I loved my time in Alaska. There
were only two of us, two surgeons. And it was so physically beauti-
ful. I could see
Mt. McKinley
from my office.
I had moose in
my backyard.
I could see
the Northern
Lights
every
night.”
A turn of fate would soon exchange the snow and cold of Alaska
for the desert sands of Afghanistan. When planes hit the World
Trade Center and the war in Afghanistan began, Dr. Deveaux was
part of the second forward surgical team deployed. For six months,
from July to December 2002, Dr. Deveaux lived in Kandahar, the
second largest city in Afghanistan, and took care of a wide variety
of traumatic injuries and general surgeries.
“I think those experiences made me a lot more confident. When
you’re deployed and you see really devastating trauma, and you
see a lot of it, you don’t become numb to it but you begin to process it differently,” said Dr. Deveaux. “I try to turn everything into
a technical problem. ‘Okay, this guy has no legs. How am I going to
stop the bleeding and establish priorities?’ I didn’t become numb
but I was able to step back and say ‘This is a technical problem.’ ”
Despite the responsibilities of the work he was doing, Dr. Deveaux enjoyed his time in the country. “I liked Afghanistan better
than other places. I thought the people were beautiful and dignified. The landscape was amazing, rugged and austere,” he said.
During his experience, he worked closely with local national physicians and spent time caring for both coalition forces and locals.
There were a few small moments of combat nearby, but Dr. Deveaux explained these as minimal compared to his later deployments. “We really didn’t move around much. We were rocketed a
couple times, mortared once. Not a big deal.”
When his first deployment came to an end, Dr. Deveaux visited
Louisville for the first time where he was accepted to U of L for a
Colorectal Fellowship in 2003-04. However, it wasn’t long before
he was headed back overseas.
(continued on page 34)
NOVEMBER 2014
33
(continued from page 33)
more fun, but it was a lot more scary.”
“Getting on a helicopter with two guns strapped to you, landing and going out on a target… It’s the same feeling I get before a
big operation. I’m not scared, but certain things concern me,” said
Dr. Deveaux, emphasizing an attention to detail and a continued
thought process of how to be good at his job as essential to keeping
a level head.
“If there were hostilities… the phrase is, ‘if the environment
turned kinetic,’ I didn’t get scared. I got very focused. Like, ‘Okay,
this is very serious. I know what I need to do. I need to do it to the
best of my abilities.’ And it always worked out,” he said.
Even in the face of imminent danger, Dr. Deveaux focused on
the lives of his teammates over his own. “One time, we were getting rocketed and I was operating on someone. We had to make
the decision to stay or go. And I just said ‘Screw it. We’re going to
stay, and hopefully this will go…’ You know. I have pictures of me
afterwards in body armor, and I’m completely soaked in sweat. I
have this look like I can’t believe I just did that.”
“That told me a lot about myself. You always want to know
how you’d react in that situation,” he said. “Making money, gaining rank, those don’t mean anything. The intangible stuff is what
counts.”
“I went back into the Army, because I had incurred more obligated time, and because I liked it,” he said. “I deployed a total of six
times to Afghanistan, Iraq and the Horn of Africa.”
Throughout his service to the military, Dr. Deveaux built up a
considerable amount of experience with distinct military training.
In addition to surgery, he attended several rare and specialized
combat and command trainings. In Alaska, Dr. Deveaux spent
time in cold weather survival school, camping out in minus 40
degree weather, building snow shelters and catching rabbits. He
also completed SERE (Survival, Evasion, Resistance and Escape)
school.
Dr. Deveaux’s favorite post was the Command and General
Staff College at Fort Belvoir, Virginia. “It was wonderful, a class
of about 150. We went to the State Department, the White House,
the Treasury, the USAID, FBI Academy and the National Security
Agency,” he said. “Once each week, we’d get briefed by the State
Department, by writers of books and policy makers. George Casey, Army Chief of Staff came to speak with us. Hillary Clinton
was going to but had a last minute State Department emergency.
It was awesome.”
On his third deployment, Dr. Deveaux went for the first time as
a part of Special Operations. This time, his work would take him
behind enemy lines and much closer to combat. “Their mission
was completely different. We were always moving, every night, flying in helicopters and going out on targets,” he said. “It was a lot
34
LOUISVILLE MEDICINE
When he wasn’t spending time on dangerous assignments, Dr.
Deveaux was stationed at Fort Bragg, North Carolina where he
moved up the ranks as a senior Army surgeon. “I liked Fort Bragg
because it was the center of the universe,” he said.
As one of only seven colorectal surgeons in the army at that
time, and the only one at Fort Bragg, Dr. Deveaux had an almost
exclusive practice. “For 12 months at a time, I’d be a colorectal
surgeon. Then I’d go away for 4-6 months to another country to do
a lot of trauma surgery. I had a perfect balance. Whenever I was
bored, I was picking up and leaving and going to do something
else.”
In his time at Fort Bragg, Dr. Deveaux eventually became the
General Surgeon Residency Program Director, teaching residents
from other army bases how to operate. It was here where he may
have left his most lasting impact from his time in service: a lasting
structured residency program for incoming surgeons.
“We had people with the title of Program Director, but they
didn’t do anything. They just used the residents to do grunt work.
So we created a Morbidity and Mortality Conference, basically an
academic day with structured academic activities. And we tried to
be more professional about how we taught residents in the operating room, at the bedside and in the clinic,” he explained.
Once Dr. Deveaux and his colleagues built the foundations of
the residency program, other programs joined and expanded the
potential education. Soon Fort Bragg was seeing Family Medicine
and even Oral Maxillofacial residents as part of an increased focus
on continued medical education.
“Where there was nothing before, now there was structure and
function and a way to evaluate residents more effectively. We
weren’t just giving them a thumbs up or a thumbs down but we
were actually drilling down into their weaknesses and strengths,
providing a mechanism for feedback so they really got something
out of a rotation.”
Combat deployments for Dr. Deveaux regularly interrupted the
residency program build-up, which took three years to effectively put in place. But it remains to this day. “I wanted to leave my
mark and build something of value. This program didn’t exist and
I thought it was worth something.”
It was just last year when Dr. Deveaux was led back to Louisville, prompted in part by his wife. “After six deployments, she
said, “You have to make a decision. Are you going to stay in the
Army forever?’”
It was then Dr. Deveaux contacted U of L Surgeon Dr. Susan
Galandiuk, his mentor during his fellowship nearly ten years earlier. She offered him a job and Dr. Deveaux moved to Louisville
with his wife and four boys, two of which are adopted.
“I’d like to adopt two girls as well, but we’re stretched thin at the
moment,” he explained. “Over the arch of my life, I kept jumping
around. But that doesn’t happen anymore. I’ve got family. I want to
put down roots and really build something of value here.”
time we got multiple casualties in Afghanistan, there were only
three surgeons. You’re kind of looking at each other saying, Well,
now what do we do? ” he explained.
For right now though, the military life is a distant rumble. “My
wife says I have no friends, no hobbies and no vices, but when you
think about it, I have a great job and I have a great family,” said Dr.
Deveaux.
When he isn’t working, Dr. Deveaux spends time with his wife
and raises his sons. With one in Boy Scouts, one in marching band
and one in football, there is little time to rest. Despite his other
commitments, Dr. Deveaux is reaching out to other organizations
including the Crohn’s Colitis Foundation, and he’s interested in
starting a military medical student interest group for students following a path similar to his.
“I’d really like to build something of value,” he said. “Whether
it’s a Crohn’s clinic or an anal dysplasia clinic, just to have it up and
running as a magnet for people throughout the state to say, I want
to see that guy Deveaux - he’s the best in this area- for them to
know they’re going to be taken care of with respect. That’s it. That’s
what I want to do.”
Note: Aaron Burch is the communications specialist for the Greater
Louisville Medical Society.
Dr. Deveaux’s first day of work in Louisville was Sept. 4, 2013.
He practices as a general colorectal surgeon and much of his
work the past year has involved inflammatory bowel disease and
anal-rectal disease, primarily among HIV positive men.
“There’s a stigma attached. Anytime you have butt problems,
people giggle,” said Dr. Deveaux. “But for these people, it’s really
serious. Being able to look someone in the face and say you understand their problem and they know you aren’t making a judgment
about how they got the disease, it’s really important. I enjoy treating people with dignity.”
Soon Dr. Deveaux will be working with the University of Louisville undergraduate program pursuing outreach in medical assistance. He’s also working with the head of the WINGS HIV clinic
to concentrate on this portion of the Louisville population. “It’s off
to a good start so far. The bottom line is that I like to talk to these
people who are suffering and don’t have anywhere else to go, and
say ‘I can help you.’”
While he makes strides in helping the less privileged in Louisville, Dr. Deveaux still thinks about the military. He had 14 years
of active duty and plans to stay in the Army reserves until the 20
year mark.
“I’ve got a lot of experience I think could be helpful to young
surgeons. I’ve been with the Big Army. I’ve been with the Small
Army. I’ve been in combat. I’ve taken care of sick people with minimal resources, and I think it’s helpful when you deploy to have
someone say, ‘Hey, I got this. Here’s what we did last time.’ The first
NOVEMBER 2014
35
Register today
18th annual
Internal Medicine Update
A continuing medical education opportunity for physicians and nurses
Population Health
Management for the
Primary Care Provider
Dec. 12 and 13, 2014
8 a.m. to 5:30 p.m.
Louisville Marriott Downtown
280 W. Jefferson St., Louisville, Ky.
For a symposium brochure,visit
NortonHealthcare.com/
CMELiveEvents. To register, call
(502) 629-1234, option 2.
SPEAK YOUR MIND 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. Please note that 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.
HYPOCRISY
Mary G. Barry, MD
Louisville Medicine Editor
[email protected]
I am surrounded by priests who repeat incessantly that their kingdom is not of this
world, and yet they lay hands on everything
they can get. - Napoleon, 1814
C
urrently Big Tobacco is licking its
chops over the prospect of controlling the electronic cigarette
market as totally as it controls all other tobacco product sales. As of this spring e-cig
and “vaping” mods sales in the US had already surpassed $1.5 billion, and that was
with smaller producers pushing their wares
onto the shelves. Special vaping parlors have
sprung up all over the country, where lovers
of nicotine can try, for instance, Chocolate Martini flavored liquid nicotine, and
commune with others of their ilk. As of
this month there are an estimated 35,000
of these independent nicotine retailers, and
their customers are devoted to them – if
they can survive the impending FDA regulation, and all of its attendant costs.
Fake cigarettes like the mass marketed Blu
as originally devised are battery powered.
Each cartridge is single use only, and flavor
choices are limited (experts say that the
traditional tobacco industry has planned
ahead for regulation, and if the 2009 provisions hold up, many kinds of flavorings
won’t be allowed). The vaping devices are
very different. They feature an “open system”
or cartridge that holds liquid capsules of
myriad flavors and strengths of inhalable
tobacco. The Chinese dominate the liquid
capsule market. A whole culture has sprung
up around them, with vaping houses, gear
and accessory sales, and thousands of online
merchants – there are pages of choices on
Amazon.com alone. My patients who have
switched to e –cigs from real cigarettes sneer
at certain devices and extol others, but tell
me that they like to try new ones too, just
in case. They like how portable they are, the
lack of odor, the sweet or spicy taste, and the
virtuous feeling they get from having given
up their Camels. At least half of the 40 million U.S. smokers have at least tried e-cigarettes once, according to industry estimates.
Many smokers of course use both real and
e-cigs, depending on their surroundings,
and when trying to quit the real ones.
Huge sums of money are potentially involved. The World Health Organization says
as of August there are 446 e-cig types on
the market and that global spending for
them reached $3 billion in 2013. A Wells
Fargo analyst has estimated a market of
$10 billion by 2017. Lorillard bought the
Blu e-cig brand for $135 million and now
has pushed it to over 80,000 retail outlets
(though CVS recently bowed out of that
market). R. J. Reynolds has launched the
Vuse “Digital Vapor Cigarette,” trumpeting
its “smart technology” and its rechargeable
battery that give the smoker “A Perfect Puff.
First Time, Every Time.” Its website says,
“Designed and assembled in the U.S. by
tobacco experts R. J. Reynolds tobacco company, Vuse brings 100 years of tobacco expertise to the future of vapor.” Altria Group,
the other giant player in the market, owns
two brands of e- cigs and plans to expand.
The world market for vapor devices may
eventually be even bigger than that of the
$80 billion one for tobacco. Sales of vapor
devices grew by more than70 percent over
the past 15 months, especially in Britain
and the U.S, where indoor smoking bans
are common.
Even if the Vuse brand offers consistency,
it does not offer the huge variety of flavors
that the vapers want. Just this summer,
sales of e-cigs have declined at convenience
stores, where over 70 percent are sold, although for the whole year they are only
slightly behind the 2013 benchmark of $722
million. Therefore Big Tobacco, as it has lost
some ground, has now piously and cynically
started to tout the hazards of using vaporized-device tobacco. Tobacco companies
have argued for both the ban of and the FDA
regulation of vapor device nicotine, citing
how dangerous these devices are. The warning labels for the Altria Group’s Mark Ten
e-cigs are more detailed than they are for
their Marlboros, and in part say, “Nicotine
is addictive and habit-forming and is very
toxic by inhalation, in contact with the skin,
or if swallowed.” Other e-cig warnings say
smoking is dangerous for children, and for
those with diabetes or high blood pressure.
As reported by Richard Craver in the
Winston-Salem Journal, Reynolds American Inc. has recommended in a 119 page
comment to the FDA that it ban the use of
(continued on page 38)
NOVEMBER 2014
37
DOCTORS’ LOUNGE
(continued from page 37 )
vapor electronic cigarettes. The FDA, per
the 2009 tobacco law, cannot ban tobacco.
Already, children have been poisoned by
e-cigs (just as US farm laborers have had
tobacco poisoning from picking tobacco).
Already, sales to teens have soared, as e-cigs
are viewed as handy pick-me-ups, like energy drinks, that also help keep one’s weight
down. Already, arguments rage about how
cancer-causing they are – and we will not
know for many many years, as right now so
many smokers of both e- and combustible
cigarettes pollute any such data. Already,
9:41 AM
however, smokers who use them are quitting
real cigarettes at higher rates than with any
other nicotine replacement.
If the FDA’s regulations as proposed go
into effect, it will cost hundreds of thousands of dollars – potentially a few million
– to get the FDA stamp of approval for sale
and advertising. Who has the deepest pockets? Well, not your corner vaping parlor –
the little guys, who say they are traditional
American red-blooded family businesses.
On the other hand, what money the Chinese
100%
may somehow throw at the FDA remains
to be seen. Big Tobacco, by pushing for
regulation of these “dangerous” products,
may ultimately shoot itself in the foot, if
the Chinese take them on. But – as with all
hypocrisy – they’re not about to admit it.
Note: Dr. Barry practices Internal Medicine
with Norton Community Medical Associates-Barret. She is a clinical associate professor at the University of Louisville School of
Medicine, Department of Medicine.
THE GLMS
NEWSLETTER
IS GOING ALL
DIGITAL!
Beginning in January 2015, your Greater Louisville Medical Society Newsletter
will be moving to an exclusively digital format.
This green initiative will drastically reduce paper usage while bringing new and exciting physician info to
your fingertips each month via the GLMS App and www.glms.org.
GLMS is always looking for fresh and efficient strategies to maximize membership funds while maintaining
our outstanding quality of service to you, our members, in every way possible.
So that GLMS may more accurately keep you informed, please make sure we have your current
e-mail address. You can update your e-mail with us via www.glms.org or by contacting GLMS
Membership Coordinator Jennifer Howard at 736-6362 or [email protected].
*Louisville Medicine Magazine remains committed to a print edition.
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