Age-related macular degeneration (AMD) is a very common condition that can result in profound central vision loss. As the name implies, AMD affects older individuals typically over the age of 50 and is a leading cause of central vision loss in the elderly. AMD is divided into two major categories: non-neovascular (dry) and neovascular (wet). Approximately 80 percent of total AMD cases are dry; however, wet disease accounts for roughly 90 percent of severe central vision loss in patients with AMD. Therefore, it is essential to promptly diagnose and treat wet AMD before scar tissue forms to avoid permanent vision loss. I am often asked by patients, “Which form of AMD is worse, wet or dry?” To answer this question, it is more appropriate to think about AMD in terms of stages: early, intermediate and late (advanced), as opposed to simply dry or wet. The disease starts in the dry form, and remains dry through the early and intermediate stages. Late stages can be either advanced dry or wet, both of which can cause significant vision loss. However, progression of dry AMD is often insidious, whereas wet AMD can present with sudden central vision loss.
Hepatitis C at 30: Targeted efforts to increase awareness and facilitate treatment of those most impacted
Hepatitis C has reached a high level of awareness among the public in the past several years. It is hard to imagine that only 30 years ago this year, the virus was first identified and the name “non-A, non-B hepatitis” was replaced with “hepatitis C.”
I’m sitting alone at a gate at the Detroit airport as I write this, on the way to Shanghai for an educational adventure. I’ve been flying internationally since before I could remember flying at all. My first flight was at the tender age of 3 months, and I started flying alone overseas (shepherded by flight attendants as an unaccompanied minor) around the age of 5 or 6. This raises a few eyebrows when told today, but you have to take into account that it was a different era. Pan Am still ruled the skies; pilots and flight attendants lead glamorous lives, and the Internet had not yet corralled the wild unknown romance of the far-flung corners of the Earth into the tidy little package that we know today. As a 6-year-old child, life was already a grand adventure. To travel alone as a 6-year-old child made that adventure the stuff of legend.
The space between
Deval (Reshma) Paranjpe, MD, FACS
Kiss me and make me better
John Kokales, MD
Perspective ........................... 70
What’s in a name and other first
Andrea G. Witlin, DO, PhD
Perspective ........................... 72
Age-related macular degeneration in 2019
Jared Knickelbein, MD, PhD
As part of the 2019 Medicare annual inpatient prospective payment system (PPS) fee schedule update, CMS has added a “rule” requiring hospitals to publish a list of standard charges beginning January 2019. CMS announced this initiative as follows:
Dr. Towers was introduced to the medical profession at a young age. Her father passed away when she was 14 years old, and the physicians and nurses that took care of him when he was ill had a lasting impact on her.
After completing an engineering degree at Cornell University, Dr. Towers entered the University of Connecticut, where she earned her medical degree. Her interest in internal medicine and geriatrics stemmed from her childhood, growing up around a lot of older adults as a result of her grandmother, aunt and uncle each having personal care facilities in their own homes. “I enjoyed hearing their stories and was interested in their medical issues,” Dr. Towers said. “It made sense to pursue internal medicine and transition into geriatrics.” She also was influenced by several professors of geriatrics during her medical training. They became more like mentors and helped to steer Dr. Towers toward the specialty of geriatric medicine.
As a medical student, Dr. Towers had the opportunity to travel to Sri Lanka for six weeks, which was a memorable and eye-opening experience. Describing it as very primitive and observing undesirable care of the elderly, Dr. Towers recalls seeing patients with rabies, tuberculosis and other diseases that were not prominent in the states. The experience was life-changing, and she would encourage all medical students to participate in an overseas mission trip if the opportunity presents itself.
Dr. Towers has been on the faculty at the University of Pittsburgh since 1992 and is currently an associate professor of Medicine and Psychiatry in the Division of Geriatric Medicine. Her prior roles include medical director, Primary Care, at Western Psychiatric Institute and Clinic; vice chair of Quality Improvement and Patient Safety for the Department of Medicine; medical director of UPMC Health Information Management; and medical director of UPMC Home Health. She also served as president, Medical Staff, UPMC Presbyterian.
As medical director of UPMC Health Information Management for nearly seven years, Dr. Towers oversaw medical records at every UPMC hospital. The position required her to attend all the hospitals’ medical staff meetings, which enabled her to meet physicians throughout the health system and learn about the issues at each hospital. “Fulfilling that position made me aware of the need for physicians to communicate with each other and to be connected. We shared a lot of the same issues, and a lot of the same solutions could be applied at each hospital.”
During her tenure, the department developed two computer-assisted coding (CAC) tools that became quite successful. In 2013, Dr. Towers was invited to join the staff at UPMC Enterprises, which is dedicated to technology development for medical providers and insurance companies. She currently serves as senior clinical advisor and director of Risk Adjustment.
“I have been very fortunate to work with several of the start-up companies that UPMC has supported or initiated,” Dr. Towers said. “My primary focus is with a company called Health Fidelity. It is dedicated to helping providers and health plans succeed in utilizing new value-based models of care.” Dr. Towers welcomes individuals who have innovative ideas to improve healthcare to reach out to her.
In addition to her position at UPMC Enterprises and traveling throughout the country to educate providers about value-based models of care, Dr. Towers still sees patients at Benedum Geriatric Center at Montefiore Hospital. “I told them [UPMC Enterprises] that I could not talk the talk if I could not walk the walk,” describing her desire and need to stay connected to patient care.
Staying connected to patient care is one reason why Dr. Towers thinks active membership within the medical society is so important for physicians. “Right now, physicians feel like their authority has been removed in terms of provision of care or oversight of care for their patients,” she said. “Therefore, we need to be united in our efforts to retain that role as the leader in our patients’ care. It is important for us to keep our position at the table as the patient advocate.”
As ACMS president, Dr. Towers’ vision is one of unity, inclusion and support. This year is the first year where more than 50 percent of medical school enrollees are women, and Dr. Towers believes more work still needs to be done to support women who want to pursue medicine as a career, balanced with having a family.
Physician wellness and support of those experiencing burnout also are issues that she would like to address during her presidency. “Due to EMR, many things have been placed in the physician’s lap. We need to become more efficient with our healthcare teams, which means working with nurse practitioners and physician assistants collaboratively and not separately.”
Dr. Towers believes the medical society needs to continue to attract and retain members, which means finding out what issues affect physician well-being and figure out what resources it can provide to help the physician community to make them stronger and more unified.
In her spare time, Dr. Towers enjoys dancing, especially Argentine tango and ballroom. “I strongly encourage physicians to take up dancing as a hobby because it exercises both the body and mind.”
Dr. Towers also is an avid beekeeper, a hobby that she picked up five years ago as a result of her pumpkin plants not producing any pumpkins. Taking the advice of a wise onlooker, Dr. Towers obtained bees to help pollinate her plants. A year later, her plants produced 96 pumpkins, which she shared with everyone. Dr. Towers’ beekeeping hobby even helped her neighbors harvest plentiful pear trees and bountiful raspberry bushes.
Dr. Towers is the mother of three and resides in Wilkinsburg.
“Does your Mommy know you’re here?” asks the patient as he enters my clinic. The 76-year-old man has put me in an impossible situation. He may or may not know my age, but he knows full well that he’s put the young woman in her place, leaving little room for us to graciously acknowledge our differences or his surprise at seeing a young woman in charge. He sidesteps me and sits down in the chair I offer, saying nothing more in the silence that follows.
For the record, my mother is indeed aware that I am there. Admittedly, my efforts to become an academic gastroenterologist also have bewildered her alongside my other life choices: to obtain more than a bachelor’s degree, to marry only in my 30s, to delay having children. Although matriculation rates in medical schools have been higher for women than men for the past two years, and young female doctors populate training programs and junior faculty positions across the country, patients are still getting used to us.1 There has been increasing attention focused on the systematic ways women face discrimination within medical institutions and from peers, but we have so far paid relatively little attention to the experience of female physicians upsetting the expectations of our patients.2 Studies have consistently suggested that female physicians lower mortality rates for patients in areas from myocardial infarction to elderly care.3,4 In addition to closer adherence to evidence- based guidelines and higher standardized test scores, the authors of one these studies partially attributed this difference to female internists offering “more patient-centered care.”4 Women are supposed to be more emotionally skilled and more inclined to communicate with and connect with their patients. What is not discussed, however, is the difficulty that gender bias on the part of our patients adds to our everyday practice. I suspect that my experiences are not rare. We may do better for patients, and are certainly just as skilled as our male counterparts, but it doesn’t feel that way when we walk into a room.
During a recent week on call as an attending gastroenterologist, I noted that seven days out of seven, someone – usually a patient or family member – commented directly to me on how young I looked. Not all took the form of inquiring about my parents, but remarks along these lines were uttered multiples times every day. One patient, after his colonoscopy and a conversation in which I delivered a diagnosis of colon cancer, told me that he “felt comfortable with me [telling him this news], even though I was so young.” The crow’s feet at the corner of my eyes and the fatigue in my face during a week on call do not enhance my youthfulness, of this I am sure. Neither does the fact that I have spent nearly a decade in specialty training after medical school. I suspect instead that seeing a young woman in my position is somewhat disconcerting. The septuagenarian mother of another patient put it best when she exclaimed, “Why, if I saw you on the street, I’d never believe you were a doctor!”
Historians and sociologists of medicine have noted for decades how reforms in medicine also have changed the nature of the doctor-patient relationship, but as a profession we haven’t sufficiently discussed the jarring questioning of female authority, in part because it’s largely invisible. When male colleagues join me in an examination room with a patient, the comments aren’t made. Nevertheless, over the next decades we will face a profound change as the profession becomes increasingly more diverse, even as our patients will, in some cases, have had decades of experience without regular contact with female physicians. Medical schools and training programs will need to find ways to address this reality directly, because it affects nearly every aspect of being a physician, from how we respond to questions about our competence to how we choose to physically present ourselves.
In some regards, I have sympathy for my patients’ confusion: Female physicians have indeed become normalized in a relatively short time. Most of us don’t have mothers who also went into medicine, and the examples we have of pioneering female physicians are by presumption never about ordinary experiences. Female physician narratives almost universally highlight the great odds that women have overcome in order to enter the profession. Dr. Helen Brooke Taussig succeeded as a female cardiologist, becoming the first female president of the American Heart Association in addition to overcoming adult-onset hearing loss. Dr. Elizabeth Blackwell was rejected multiple times from medical schools and then ridiculed when she was admitted as a joke. Dr. Rebecca Lee Crumpler overcame racial discrimination as she became the first female African American to earn a medical degree. Despite these high-profile successes, change came slowly, and as recently as 1970, only 7.1 percent of physicians were female, and those were concentrated in pediatrics and psychiatry.5 Barriers are nowhere near this high for women to enter medicine in 2018: This reality represents the triumph of these earlier pioneers, for which I am incredibly grateful. It has never been a better time than now for women in medicine, but its normalcy presents precisely the conundrum. In 2018, it is not Dr. Taussig or Dr. Crumpler who walks into the room: Odds are that it is an ordinary physician who does.
I count myself incredibly fortunate despite these challenges. The opportunity I have been given to take the Hippocratic Oath, to improve my patients’ health and well-being, is one I would trade for no other.
But I am no Helen Brooke Taussig. And neither are my female colleagues. That’s not a problem. Equality will be achieved not when exceptional women succeed, but when ordinary women are treated no differently than ordinary men. At best, I am a highly qualified and dedicated physician, one who consciously strives each day to improve. For now, when a patient enters the room with that misguided question, I embrace the opportunity to challenge existing biases. I consider my options, and then I smile broadly and say, “Why yes, sir. Yes, she does.” And then we carry on.
This was truly surreal. I had seen these phenomenally talented young women and men on the stage many times, but to be sharing pizza with them during their off hours? And yet there we all were – what a privilege. I listened, fascinated, as they exchanged stories and gossip and wolfed down meatballs – these incredibly disciplined and talented professionals at the peak of their craft were still kids at heart. Two ex-dancers who had risen to great heights and then gone on to reach the pinnacle of the teaching and management sides sat down. The tone of the conversation instantly changed, and the younger dancers stiffened up a little the way medical students might if two respected professors suddenly sat down in the student lounge.
A conversation I’d had earlier in the day was still on my mind. A medical student had wondered aloud how and when the confidence to operate alone – and make management decisions alone – arises in the process of becoming an attending. I thought back to the first time I operated completely alone – it was a lonely, scary, adrenaline rush of an experience to realize that no mentor or colleague was there at my side to offer tips or jump in if I ran into difficulties. I asked my father (also a surgeon) for advice, and he said: “Pray at the scrub sink, leave all other thoughts at the OR door as you walk through, and remember: If not you, then who? You’re the only one there. You have to fix it. Your patient is depending on you.” That last bit is what he told himself as a surgery intern in New York City in the 1960s – long before the Libby Zion case, 80-hour work week rules and all the tight regulations regarding precepting and supervision that we have now. The interns in those days really knew fear, and exhaustion, with nearly continuous q2 call. If that was the mantra my father and his generation of physicians swore by, I would certainly use it. It’s the best advice I’ve ever heard in that regard.
During a lull in the dancers’ conversation, I asked a question of the entire group: “How did you get over stage fright?” I bet myself that not only would there be common ground between professional ballet performers and physicians, but also teaching points that physicians could take away. The answers I got were these:
One of the principal male dancers answered first: “Complete preparation. If you’ve practiced nonstop, you have muscle memory and you know you’ll be able to perform whenever it’s asked of you. And repetition. You know what your body can do, because you’ve trained over and over again, and that gives you confidence.” This is the rote memorization, the knot-tying, the repetition of procedures until we attain mastery.
His fiancée agreed, and added: “And practicing with your partner, so you know exactly what the other will do or is thinking.” This is the teamwork to which we aspire in our medical and surgical teams – making processes look and feel effortless because everyone knows their role and plays it smoothly.
Another engaged pair of dancers had wildly different personalities. His perspective was this: “Sometimes I have to remember what a privilege it is to be on stage doing what I love. When I look at all the people in the audience, I have to remember that they have made an effort to dress up and be there, and that I get to make them happy as part of my work. The audience is either already happy and looking to celebrate, or needs an escape from their everyday life, and what a privilege it is to be able to provide that joy through my art.” What better reminder is there for us? Isn’t it a privilege for us to be able to do what we love, and to often make people healthier and happier through our efforts? When we can’t do that, isn’t it a privilege to share in the lives of our patients, to earn their trust, and to ease their pain where we can?
Her perspective is what impressed me the most that evening – and it was seconded heartily by her friend and colleague who cited her as inspiration. “My mantra is: ‘No *bleeping* hesitation.’ I trained with a dancer who had performed with Cirque du Soleil, and they perform hundreds of feet in the air without nets. If you hesitate in that situation, you die. And I don’t want to die. So, no *bleeping* hesitation.”
In the heat of battle, in a trauma, in a code; in surgery, in the clinic, and in necessary patient and family discussions; isn’t that our mantra, too? Physicians don’t hesitate to put themselves in difficult situations: If not you, then who? If we hesitate, our patient might die. No *bleeping* hesitation. (Having the preparation and practice to back up that lack of hesitation is key, as in any high-wire act.)
Finally, it was the turn of the two retired professionals. The teacher, who had danced on stage all over Europe, told of her experience of stage fright in dancing before one of the most famous ballerinas of her day; in the taxi on the way to the theatre, she realized that if she was too nervous to get on stage, she needed to find a new line of work. As she loved ballet too much to consider quitting, she went ahead and danced. Just as for us, at some point, it’s too late to turn back now. We can branch out but never really turn back, for our experiences have shaped us.
The dancer who had transitioned into the upper echelons of management said he had never had stage fright, at which everyone laughed. “No, really!” he protested. “I can still dance in front of anyone, anywhere, without getting nervous. But I am deathly afraid of public speaking. I use that old trick of imagining that everyone in the audience is in their underwear to make myself laugh and relax.” Which proves that everyone is afraid of something – even the most seasoned performers have an Achilles heel. No different for us – my theory is that whatever appeals to you and does not scare you as a medical student determines your eventual specialty.
So, remember, if you have anxious trainees on your watch, or whether you yourself need bucking up now and then in your career:
• Prepare until it’s second nature.
• If not you, then who?
• It is a privilege to make people better and bring joy.
• And lastly, no *bleeping* hesitation.
Editorial ................................. 37
Deval (Reshma) Paranjpe, MD, FACS
Editorial ................................. 39
A young woman in medicine: Facing challenges of patient-level bias
Anna Evans Phillips, MD, MS
Editorial ................................. 41
Richard H. Daffner, MD, FACR
Perspective ........................... 44
The handicapped police
Andrea G. Witlin, DO, PhD
Perspective ........................... 45
‘Black lung’ and the history of occupational pulmonary medicine
Kristen Ann Ehrenberger, MD, PhD
I’m a fan of bumper stickers and car window decals. My favorite is not the Coexist, nor is it the Jesus Fish, nor is it the Darwinian Jesus Fish with feet, although I love all of these. It is not the Stick-Figure family; nor is it the My T-Rex Ate Your Stick Figure Family; nor is it the Zombie Stick Figure Family, complete with Zombie cat. (I really don’t understand why zombies are a “thing.”) My favorite is a simple saying: “Wag More, Bark Less.” And so, here are a list of New Year’s resolutions.