jan 2004 senior bulletin - the american academy of … · luck or fate? — a personal ... the...

Senior BulletinAAP Section for Senior Members

Report From The ChairDavid Annunziato, MD, FAAP

We hope that you are enjoying good health.

Your executive committee met in New Orleans at the NCE meeting. We could not complete ouragenda in the short time alloted us. We also hadseveral presentations from Academy representatives.

Jeff Mahony updated us as to the events plannedfor the 75th anniversary of the AAP in 2005. Heurged the cooperation of the senior section indeveloping the “Coffee Table” book to be pub-lished describing, in 200-500 words, outstandinglandmark changes which have occurred over thepast 75 years. These anecdotal accounts willdescribe how we practiced, the diseases wetreated and conquered, AAP changes, landmarklegislation or anything else, which we may thinkis an important event. Sit and think for a fewminutes and I’m certain you will think of a fittingevent. Write it down and send it to Jeff Mahonyat AAP headquarters. There was a deadline ofDecember 31, 2003 but I’m certain any good arti-cle received after that date will be considered forpublication.

John Chamberlain, MD member of the Councilon Sections Management Committee joined usand reviewed with us our annual report andactivities. We urged him to aid us in our efforts towaive the NCE registration fees for local seniorsand help us to convince chapters to develop sen-ior activities. Cosman continues to urge all sec-tions to have liaison with all chapters. A recent

survey tells us that most chapters do not have asenior group or committee. We are developingmeans to help us in this endeavor.

We discussed developing liaisons with othergroups with similar interests. It was suggestedthat we investigate a relationship withGenerations United. Are you a member of thatorganization? If yes, please let Jackie Burke orme know.

What’s Inside?Report From The Chair . . . . . . . . . . . . . . . . . . . 1Executive Committee/Subcommittee Chairs . . . 2Technology Intersects Age. . . . . . . . . . . . . . . . 2Section on Senior . . . . . . . . . . . . . . . . . . . . . . . 3Editors’ Note: . . . . . . . . . . . . . . . . . . . . . . . . . . 4Presidential Candidates Statements . . . . . . . . . 5Special Editors’ Note:. . . . . . . . . . . . . . . . . . . . 6Errata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Letters To The Editor . . . . . . . . . . . . . . . . . . . . 7Grandparents Can Make A Difference . . . . . . . 9Cultural Effects/Practice at Shirati Hospital . . 10Dr. Janeway and the Cameroon Project . . . . . 11Evolution of Newborn Care . . . . . . . . . . . . . . 14The “Second” Exchange Transfusion . . . . . . . 15Doctor Joe. . . . . . . . . . . . . . . . . . . . . . . . . . . 16First Surgery for Tetrology of Fallot . . . . . . . . 18HIPPA for Dummies . . . . . . . . . . . . . . . . . . . 19Probiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Herbs/Dietary Supplemtns, Risks/Benfits. . . . 23Person to Person - Helpful Stories . . . . . . . . . 24Luck or Fate? — A Personal Assessment . . . . 25Hidden Expenses/Searching Mutual Funds . . 27Pediatricians Who Volunteer? . . . . . . . . . . . . 28Physician Wellness - Join SIG . . . . . . . . . . . . 29The New English Language . . . . . . . . . . . . . . 30

Copyright© 2004 American Academy of Pediatrics Section for Senior Members

Continued on Page 2

Acting Co-Editor: Avrum L. Katcher, MD, FAAPActing Co-Editor: Joan Hodgman, MD, FAAPAssociate Editor: Donald Schiff, MD, FAAPAssociate Editor: Benjamin Silverman, MD, FAAPContributing Editor: Read Boles, MD, FAAPContributing Editor: Sol Browdy, MD, FAAPContributing Editor: Solomon Cohen, MD, FAAPContributing Editor: Joseph Girone, MD, FAAPContributing Editor: Eugene Wynsen, MD, FAAP

Volume 13 No. 1 – January 2004

The first timers breakfast went well again in New Orleans. About280+ attended. We again were lacking a host at every table. In aneffort to remedy this, we will ask the Young Physicians section toco-host this event with us.

Jackie Noonan, MD provided us with a wonderful program withoutstanding speakers. I was still somewhat disappointed in thenumber of people who attended. We plan to have another section,like the young physicians, co-sponsor a program with us.

Toni Eaton, MD, our new nominating committee chairman alongwith Jim Holroyd, MD have developed a magnificent slate of poten-tial officers for the senior section. Please vote and thank you Toniand Jim.

We have 12 nominees for this year’s senior Advocacy award. We willreview and choose one at our spring meeting.

Our senior bulletin continues in its high quality with new editorsAvrum Katcher and Joan Hodgman. We thank them for their hardwork and efforts on our behalf. Both have requested feedback. Youwill be receiving a feedback letter from them. Please respond.

As usual, we have great need for your input into what you wouldlike us to be doing. Send us your thoughts.

May you be well and enjoying whatever you do.

Cordially yours,

David Anunziato, MDChairman, Senior Section

2 Senior Bulletin - AAP Section for Senior Members - January 2004

Chairman’s Report Continued from Page 1 _________________________

Executive Committee

David Annunziato, MD ChairEast Meadow, NY

Avrum L. Katcher, MDFlemington, NJ

Jacqueline Noonan, MDLexington, KY

James L. Reynolds, MDNew Orleans, LA

Donald W. Schiff, MDLittleton, CO

Benjamin Silverman, MDSeal Beach, CA

Herbert Winograd, MDPast Chair, Scottsdale, AZ

Subcommittee Chairs

ProgramJacqueline Noonan, MD

Legislative AdvocacyDonald Schiff, MD

Financial PlanningJames Reynolds, MD

Membership/BudgetAvrum Katcher, MD

History Center/ArchivesDavid Annunziato, MD

StaffJackie Burke,Sections Manager800/434-9016, ext. [email protected]

Roxanne Shannon,Sections Coordinator800/434-9016, ext. [email protected]

TECHNOLOGYINTERSECTS AGE

Due to advances in modern infertility technology a63 year old woman has a baby. Several friends cometo see this miraculous child. The mother tells themthe baby is sleeping and seats them to wait. Aftersome little time, the guests become restless and askto see the baby while sleeping. The motherresponds, “You will have to wait until she wakes upand cries. I’ve forgotten where I put her.”

Senior Bulletin - AAP Section for Senior Members - January 2004 3

Executive Committee Meeting Summary Monday, November 3, 2003 10:00 am-1:30 pmAs part of the AAP National Conference andExhibition (NCE)New Orleans, LA

Members Present:David Annunziato, MD, ChairpersonJoan Hodgman, MDAvrum Katcher, MDJackie Noonan, MDJames Reynolds, MDDon Schiff, MDBenjamin Silverman, MDHerbert Winograd, MD

Guest Present:John Chamberlain, MD (p/t)Antoinette Eaton, MD (p/t)Robert Grayson, MDArthur Maron, MD

Staff Present:Jackie Burke, Sections ManagerRoxanne Shannon, Sections Coordinator Jeff Mahony, Manager of Project

Development (p/t)

The Chairperson convened the meeting at 10:00AM on November 3rd and welcomed the mem-bers of the Executive Committee.

A plaque was bestowed to Dr. Avrum Katcher foroutstanding service to the section as executivecommittee member. Dr. Katcher will continue asnewsletter co-editor.

The minutes from the April 12-13, 2003 meetingswere reviewed and approved.

Staff reviewed the action items from the April,2003 meeting.The following issues were discussed in detail:

1. Emeritus Recruitment: The section will con-tinue efforts to recruit 2,700 emeritus mem-bers who do not belong to the section.

Generations UnitedIt was suggested that an educational programbe developed that focuses on senior and young

pediatricians working together to advocate forchildren. Dr. Grayson suggested that the execu-tive committee use the Generations Unitedorganization as a model for such a program.

Annual ReportDr. Chamberlain reviewed the section annualreport with the executive committee. TheExecutive Committee discussed the followingissues with Dr. Chamberlain and requestedCOSMAN’s assistance with:

1. Waiving NCE registration fees for local seniors

2. Helping the section convince AAP Chaptersto encourage local seniors to help fulfill theChapters goals/initiatives.

First Timer’s BreakfastDr. Annunziato noted that 280 attended this yearFirst Timer’s Breakfast. There were roughly 18hosts. The idea of having Young Physicians tohelp host the First Timers Breakfast was broughtforth to the section. It was agreed that YoungPhysicians could work in teams with seniors tohost the breakfast. Also staff will recruit any reg-istered attendee age 55+. It was suggested thatVice President’s speech be shortened to allowmore time for the hosts to mingle with theirguests.

Cosman continues to request that the sectionshave liaisons to all chapters. The section hasalready challenged AAP Chapters to use seniorsat the local level.

Staff reviewed the budget. The section finishedthe fiscal year with a positive variance in the coreand noncore budgets.

Senior GuideThe section would like to produce a senior guidefor the Chapters.

Educational Programming ’04 NCE ProgramThe program for the NCE was reviewed. It wassuggested that the award presentation be builtinto the advertised schedule.

Continued on Page 4

SECTION ON SENIOR This is privileged information. Contents have not been reviewed for accuracy and may not represent AAP policy


’05 NCE ProgramPossible topics for the NCE program are, childadvocacy, history of pediatrics.

Child Advocacy AwardThere were 12 nominations for next years award,which will be reviewed in detail at the April 2004Executive Committee Meeting.

ElectionsDr. Eaton noted that she and Jim Holroyd, MDwould serve as the nomination committee forthe 2004 Section Elections. There are three posi-tions that will be open on the ExecutiveCommittee including the chairperson and twoexecutive committee member positions.

Senior Bulletin NewsletterJoan Hodgman, MD, and Av Katcher, MD willcontinue to serve as the co-editors. The section

discussed the frequency of the Bulletin’s distribu-tion and re-confirmed their decision to have four(4) bulletins per year, if possible.The editors would like to get feedback from themembership to see how they can improve theBulletin for the members.

75th Anniversary of AAPJeff Mahony presented the AAP’s plan for a “cof-fee-table” style, illustrated book to commemo-rate the 75th anniversary of the Academy. TheAcademy requests contributions from its mem-bers about what pediatricians have accom-plished to improve the health and welfare ofchildren over the past century. The deadline forcontributions is December 31, 2003. It was sug-gested that many issues of the Bulletin containuseful historical material, although withoutgraphic illustrations. It was recommended thatMahony and his staff review past issues.

SECTION ON SENIORS Continued from Page 3 _____________________________________________________

Editors’ Note:

The Editors welcome contributions from any reader. Please prepare your article on a stan-dard typewriter or word processing program. Send, preferably as an e-mail attachment, , toRoxanne Shannon at [email protected] or, if you do not have access to e-mail, via the PostalService to Roxanne Shannon, c/o American Academy of Pediatrics, 141 Northwest Point Blvd,Elk Grove Village, IL, 60007-10019. Articles should emphasize material of potential value toother Seniors. Topics may include novel activities others might care to adopt, work in caringfor or advocating for children, with lessons to be learned from your experience, planning foryour future financially, professionally, psychologically or personally, navigating changes ornegotiating balances between your work and personal life, health maintenance or improve-ment, or other pertinent thoughts. If you would care to comment on articles appearing inthis issue of the Bulletin, send a letter to the editors, also at one of the above addresses. If youprefer, there is a Senior Listserv for more casual communications and thoughts.

The Editors


Eileen M. Ouellette, MD, JD, FAAPNewton Center, MA

We must address the issues of concern to pedi-atricians and children and convince our mem-bers that their becoming involved will make adifference. We must actively reach out to pedia-tricians at all stages of their professional andpersonal lives. Each group has different inter-ests and needs.

Residents: In collaboration with training pro-grams, we must enroll residents into the AAP.Chapter leaders can provide residents with childadvocacy education. They can invite and sup-port residents’ attendance at chapter meetings,describe chapter initiatives, section member-ship opportunities in the surgical, medical sub-specialty and special interest groups at grandrounds, and assist residents to apply for CATCHgrants. We can provide bulletin boards for med-ical students and residents to network andexchange information.

Young Physicians: We can provide new mem-bers with written information that explains themission of the AAP, and describes its committees,sections, chapters and programs. Leaders shouldcontact members to match their interests andexpertise with local and national opportunities.We must provide leadership training to thesepediatricians, and make childcare available atmeetings. AAP web sites can provide special sec-tions devoted to the interests and needs of youngphysicians.

Mid-career Physicians: Pediatricians in theirmiddle years are struggling with all the issuesaffecting medicine today: access, quality, reim-bursement, medical liability, medication pre-approval and other regulations. We mustcontinue to inform them regularly of AAP effortson their behalf at the national, state and commu-nity level and convince them that their partici-pation is vital to achieve our goals. We can teachthem to contact and effectively influence theirelected officials.

Seasoned Physicians: These pediatricians have

WHAT DO YOU VIEW AS THE KEY TO ENERGIZING AND INVOLVING THE GRASSROOTS MEMBERSHIP?

Robert P. Schwartz, MD, FAAPWinston Salem, NC

The first step in energizing the grassroots is tofind out the concerns of our members.

How do we find out the concerns of our members?

• Provide AAP support for chapters to develop amember survey to aid in the identification andprioritization of issues. This would help chap-ters in formulating resolutions for the AnnualChapter Forum. The survey could also includea list of committees available for members tojoin.

• Encourage chapter officers to hold “townmeetings” in various regions of their state toget feedback on issues from members.

• Schedule a time at the National Conferenceand Exhibition for members to ask questionsand voice concerns to the Board of Directors.

• Create a place on the AAP members’ only web-site to ask questions, with a mechanism fordelivering a response in a timely manner.

How do we get members involved in the Academy?

• Focus on issues of importance to the mem-bership such as fair reimbursement for physi-cian services, contracting with managed care,malpractice, etc.

• Provide AAP support to chapters to enhancetheir newsletters and websites.

• Reduce chapter dues/meeting registration feefor members in their first years of practice.

• Reconfigure chapter committee activities sothat the members can participate more easilyby listserv rather than travel to meetings.

• Provide perks to established members forbringing new members to meetings.

• Involve residents in the AAP at an early stage oftheir career through the advocacy curriculumnow required by the Residency Review

PRESIDENTIAL CANDIDATES STATEMENTS

Continued on Page 8 Continued on Page 8


Special Editors’ Note:Pediatricians who have considered volunteer work for a governmental or non-profit agency,as a pediatrician, have often found this was not practical because, if they have retired, andceased to carry malpractice insurance, it is either unavailable or comes only at a burdensomecost.

The Senior Section Executive Committee has repeatedly discussed this issue but has beenunable to contrive a solution of wide usefulness. The free journal, Pediatric News, for December2003, page 40, carries a review article of the current status of this problem in several states. Afew have arrangements for steeply discounted insurance at relatively minor cost. Most havedone little to make this practical.

Are any of our readers aware of other solutions to this problem? If so, please send a Letter tothe Editor so that we made distribute the information to others. If any of our readers wouldlike to work on this problem, we would be glad to facilitate getting something done. Please writeto:

Editors, Senior Section Bulletinc/o Jackie Burke or Roxanne ShannonAmerican Academy of Pediatrics141 Northwest Point BlvdElk Grove Village, IL, 60007-0927Phone 1-800-433-9016E-mail [email protected] or [email protected].

Errata . . .The Editors of the Senior Bulletin regret that the following was not included with the articleby Mamta Gautam, MD and Rhona MacDonald, HELPING PHYSICIANS COPE WITH THEIROWN CHRONIC ILLNESSES, and we are indebted to the publishers of the originating journalfor permission to reproduce this article and apologize for the omission.

West J. Med, 2001:175:336-338, Helping Physicians Cope with Their own Chronic Illnesses,Gautam, M., MacDonald, R.

The BMJ Publishing Group grants permission for the above article to be reproduced in theSenior Section Bulletin of the American Academy of Pediatrics, a not-for-profit organizationof the pediatricians in the United States and Americas, with non exclusive world rights in printand electronic formats for this and all future editions of this Work.


To the Editors:

Readers of Karl Hess’ article onHunger and means to combatit might be interested in arecent editorial in the New YorkTimes: Banking for the World’sPoor. It begins: “Microcredit—tiny business loans extended topoor people in developingcountries—is a proven devel-opment strategy…But theworld’s poor desperately needaccess to a broader range offinancial services—microfi-nance is the more apt term…”The editorial goes on to praisethe work of the type of agencyDr. Hess describes, and to pointout that for-profit organiza-tions are now entering thisfield, primarily because it hasbeen found that default rateson microfinance loans are onlya minute fraction of those onlarge corporate loans in manyunderdeveloped areas.

Constant Reader

To the Editors:

My opinion is that the AAP hasneglected, and still does neg-lect, practicing pediatricians,the backbone of the Academy.The AAP neglects the problemsof those in practice: over-regu-lation by government, govern-m e n t a l re i m b u r s e m e n t ,government paperwork—thedustup re: HIPAA is a goodexample, recertification sub-mission, managed care auton-omy, etc.

The AAP in its zeal to advocatefor children, to appear un-tainted by professional con-cerns or lucre, has become

professionally unconcerned.So many pediatricians in myarea think the AAP not onlydoesn’t represent them andtheir interest, but doesn’t careabout them at all. They feel thatthe AAP is responsive only topediatricians in academia, andDemocrats in government, andthat academic pediatricianscompletely run the Academyshow. Practitioners feel that theAAP uses practitioners to boastof its numbers and to appeal tothe public by citing practi-tioner membership, but inpractice the AAP pays them noheed.

If you are arguing that the AAP’sreach has progressively broad-ened and because of that thewell being of children is nolonger as focused as it was pre-viously, that would seem to betrue, but I don’t see what thathas to do with your final point,i.e., asking senior pediatricianswhat the Academy can do foryou—a phraseology reminis-cent of John Kennedy that sug-gests instead that seniors dosomething for the AAP.

James Louis Reynolds, MDMetairie, Louisiana

To the Editors:

I would like to counter thequestion raised by the editorsof The Senior Bulletin (Sep-tember 2003): “What wouldyou like the AAP and the SeniorSection to do for you and whatcan individual pediatricians doto help the AAP and the SeniorSection accomplish its goals?”I would propose the AcidQuestion: Would you advise

your children/grandchildren tobecome pediatricians?

Personally, in all honesty, I havedifficulty in advising my chil-dren/grandchildren to becomepediatricians. True, I enjoyedworking with little citizens (andsometimes with their moth-ers). I frequently catch myselfwatching toddlers as theymarch into gyms with theirmothers—and I have to smileto myself—each doing it intheir own way. But I also countmyself among those disgrun-tled pediatricians, who couldn’twait to leave practice. Call itimpatience, stress and lowincome for starters. Today, addthe mixed blessings of practic-ing in or in competition withHMOs, the poor economy andthe continuing liability climate.

Do I have any suggestions tooffer? I believe all medical spe-cialties are affected to someextent by present conditions.For awhile I thought if I had achance to do it over, I stillwould choose the medical pro-fession but I would selectanother specialty, and at thesame time I would like to pur-sue a parallel career, like writ-ing. Because each providessufficient time to do both, Iwould consider radiology,emergency medicine or der-matology. Dissenters may wellsay that the grass always looksgreener on the other side of thestreet, and they could be right.

Finally, I realize that countriesproviding universal health cov-erage (England, Canada andIsrael) have their own prob-

Continued on Page 8

L E T T E R S T O T H E E D I T O R


lems. Perhaps what is needed isa special blend of all three: uni-versal, private practice andH.M.O.’s.

Sol Browdy, Park City, Utah

To the Editors:

In a recent issue Sol Browdywrote about his experiencewhen his driver’s license waslifted after two severe one-car

collisions. For readers who maybe having difficulty, we wish tocall attention to efforts byAARP, described in several pub-lications, on ways in whichstates are aiding older drivers.These are primarily risk reduc-tion ventures, such as im-proved medical screeningmethods, alterations in licens-ing requirements and changesto highways at intersections,

road signs, more rumble strips,markers and so forth. AARP inall areas conducts Driver SafetyPrograms (full disclosure: wehave taken these programs;t h e y a r e c l a s s r o o m a n d didactic; they did change ourdriving behaviors) consistingof two sessions of four hourseach.

Constant Reader

LETTERS TO THE EDITOR Continued from Page 7_____________________________________________________

the experience and wisdom that are so vital toimpart to our medical students, residents andyoung physicians. We can collaborate with pedi-atric training programs to develop pediatric pre-ceptorship and mentoring programs. Seniorpediatricians command respect from legislatorsand make excellent advocates.

Finally, we must collaborate with minority med-ical associations to identify pediatricians ofdiverse backgrounds and assist chapters and sec-tions to mentor them into leadership positions.Involving all our membership will make ourAcademy stronger and more effective in advocat-ing for children and pediatricians.

Committee.

The key issue is the perception of the value ofAAP membership. We should make it easier foryoung pediatricians, who increasingly arewomen, to have meaningful participation in theAAP. We must help them understand that weneed their input, and even a limited amount oftime can make a significant contribution.Personal contact from members in leadershippositions will further stimulate efforts to increasegrassroots involvement in the Academy.

PRESIDENTIAL CANDIDATES STATEMENTS Continued from Page 5______________________________

Eileen M. Ouellette, MD, JD, FAAPNewton Center, MA

Robert P. Schwartz, MD, FAAPWinston Salem, NC


The American Academy ofPediatrics continues itsproud history of leadershipin childhood advocacy withthe inauguration statementof its new president, CardenJohnston, and the introduc-tion of the two candidatesfor Vice President onN o v e m b e r 4 : E i l e e nOuellette and Robert P.Schwartz. These three lead-ers, as well as outgoingPresident Steve Edwards,forcefully reviewed ourefforts to progress towarduniversal health insurancefor all of our nation’s chil-dren and pledged a vigorousmove to achieve that goal,though our nation’s sputter-ing economy, paired withthe tragic war in Iraq, are for-midable obstacles to any sig-n i f i c a n t a d v a n c e s i nreaching our goal.

As most readers of thisnewsletter are seniors, weare familiar with the majorhealth issues which we face,including the very high costsof needed medications. AAct has been passed whichmay help many seniors payfor their medications withina confusing set of guidelines.This Act has become part ofa political battle between thetwo major parties basedupon a longstanding effortby the majority party to pri-vatize the entire Medicareand Social Security program.The Act has become law, buteffective dates are years intothe future, and absent writ-

ing of regulations it is tooearly to know what its finalform will look like.

In the background, anotherseries of important trends inhealth care is intermittentlyreported. The total numberof Americans without healthinsurance has risen to 43million. Over 11 million chil-dren are uninsured at anysingle moment, and almosttwice that number at sometime during the past year.More employers are reduc-ing their health insurancebenefits for families, forcingbreadwinners to pay anincreasing share of theirinsurance premiums, if theycan keep their coverage.

State governments facingunprecedented budgetdeficits are cutting Medicaidand S-CHIP programs, aswell as child care and schoolsupport.

Enormous economic forcesneed to turn in a positivedirection. Clearly this isbeyond any of us as individ-uals. However, each of us canmake a contribution in ourown communities which willbenefit children.

In addition to being in-formed as to whether our taxdollars are being spentwisely on our children, wecan volunteer in schools toh e l p o u t o u r s e v e r e l ystressed education systems,use our grandparentingexperience in day care cen-ters, and wherever possible,make life for children better.

I know that many readers are actively engaged in helping children on a weeklybasis in many venues. I hopethat you will share with us what you are doing. You can e-mail me at [email protected].

GRANDPARENTS CAN MAKE A DIFFERENCEBy Donald Schiff, MD FAAP

Editors’ Note: Readers interested in intergenerational collab-oration on public policy and local programs to improve thelives of children, youth and the elderly might wish to joinGenerations United, a not-for-profit voluntary organizationoperating many programs for this purpose.

Postal Address: Generations United122 C Street, NW, Suite 820Washington, DC 20001

Electronic: [email protected]

Telephone: 202-638-1263

In addition, there is a National Mentoring Partnership whichhas encouraged development of many programs at state levelto enable interested seniors to connect with young people inneed of a mentor.


As you suggested, I am writingdown some of my observationsabout the cultural effects uponmedical care and medical prac-tice at Shirati Hospital, Shirati,Tanzania. Susan, my spouse,and I spent five years in threeunequal terms between 1978and 1996 and have visited ourfriends there annually from1998 through 2003.

1) Fatalism

This world view is so en-trenched into the East Africanmind, especially the Luo tribeliving along the eastern shoresof Lake Victoria, that the peo-ple find it difficult to absorb theidea of cause-and-effect. Infact, the Swahili language hasbuilt into it language thatexcludes causality. For exam-ple, when a bottle of bloodcrashed on the floor of the sur-gical supply room, I went intothe-room and asked (inEnglish), “Who broke it?” Myquestion was met with .achuckle and silence! It turnsout that my question cannot betranslated into Swahili. I waslater told that people do notbreak things, but that “thingsjust break!” “Imeharibika” isthe Swahili word for “It broke(itself ).” Or “it just happenedby fate.”

One night at 3:00 AM I was

called to the hospital in theusual way: a hospital guardbrought a note written by anurse-on-duty. The note read,“Please come. The patient inbed 2 women’s ward. Her con-dition has changed.” This usu-ally meant that the patient wasdying or was already dead. Sureenough, this was a 70 year-oldwoman who was twelve hourspost-op. She had died of post-operative. abdominal bleeding.I reviewed the vital signs writ-ten on the chart by her bed:

According to the recordings ofthe student nurse, there hadbeen no change in the vitalsigns during the entire post-opcourse until the moment ofdeath. I tried to tell the nursethat this was not likely and thatmore careful recording may

have alerted us to the problemand perhaps we would havebeen able to prevent thepatient’s death. To this day I amsure that she saw no cause-and-effect between her negli-gence and the patient’s death.Why? Fatalism.

I believe that fatalism and thelack of cause-and-effect think-ing derives from centuries ofexperiences in the fields. In theNorth Mara Region of Tanzaniaone-third of the years the cropsare good, one-third of the yearsthe crops fail and one-third ofthe years the crops are border-line. Every year the farmers doexactly the same work and theresults have no relationship totheir efforts.

2) Myths

“I learned from a trusted med-ical assistant on one of myrecent trips that when a childunder the age of one year dies,everyone in the community-including the mother-knowsthat the child’s father has beenunfaithful to his wife! Thatexplains some of the additionalmisery and sadness that ayoung mother suffers as shecarries her dead baby from thepediatric ward.

There are many myths about

CULTURAL EFFECTS UPON MEDICAL CARE AND MEDICAL PRACTICE AT SHIRATI HOSPITAL, SHIRATI, TANZANIA

By Stanley Godshall, MD

Editors’ Note: Dr. Stanley Godshall, who contributed the following article, is a family physician whotrained at Hunterdon Medical Center in Flemington, NJ. Although he writes as much about adults aschildren, his comments are generic, and may be applied, in principle, to any ethnic group.We have heardfrom the AAP and other sources of the importance of ethnic awareness in health care. The literatureincreasingly documents the relationship between quality of achieved care and ethnic and other formsof awareness.

Continued on Page 12

TIME BP PULSE

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We are delighted to reproduce a shortened version of an article by Robert Haggerty and RobertChamberlin, originally appearing in The Pharos for Autumn, 2000, p11 to 16, with permission fromthe journal and from Dr. Haggerty. Readers are suggested to take note both of the difficulties and theaccomplishments of the dedicated group Dr. Charles Janeway headed. Those who might be interestedin work in developing countries would do well to read the original article, as well as the one by Dr.Godshall in this issue. In addition, attention is called to the article on The Hunger Project forPediatricians, by Karl Hess, appearing in our September issue, this year. Hess describes a way of improv-ing health via improving annual income through local efforts. Readers interested in pursuing work indeveloping countries will find Dr. Haggerty happy to make suggestions.

Charles Janeway, son ofTheodore Janeway MD, whowas the first full-time profes-sor of medicine in the UnitedStates at the Johns Hopkins,graduated from Yale Universityand the Johns HopkinsUniversity School of Medicine.He trained in internal medicineat Hopkins and Harvard, andwas recruited to the Peter BrentBrigham Hospital in Boston.His interest in infectious dis-ease in children took him to theChildren’s Hospital where in1946 he was appointed asProfessor and Chief of thePediatric service. This in-ternist-turned-pediatriciandeveloped one of the leadingpediatric research and trainingprograms.

In 1973, Janeway was asked by the US Agency for In-ternational Development(USAID) to organize a projectin the Cameroon. From 1973-75 a Harvard team was estab-lished in Yaoundé, the capital.The program was designed toeducate local professionals tomaintain a permanent healthcare team in place after thewithdrawal of the Harvard fac-ulty in 1979. The main featureof the project was to preparepersonnel to meet the healthneeds of a largely rural popula-tion rather than copy schools

focused on specialty medicine.Janeway was the coordinator,responsible for the recruitmentof staff.

Nine health professionals wererecruited who would work withCamaroonian counterparts.The team included a pediatri-cian, an obstetrician, a midwifeand a pediatric public healthnurse from Harvard, all ofwhom would work with localcounterparts. From the begin-ning, the project was plannedfor continuity rather than ashort-term task. Janeway andhis colleagues felt they coulddevelop a model that could bereplicated in other developingcountries.

Cameroon was, as now, anagrarian, equatorial countrythe size of California with ayoung population and very fewphysicians. Diseases of equa-torial Africa were prevalent.Population growth and infantmortality were both high. In1963, the World Health Or-ganization was asked todevelop a medical school. Itbegan in 1969 with 40 medicalstudents and 7 faculty! By 1972,there were 61 faculty, 44 ofwhom were Camaroonian. Thecentral hospital in Yaoundéhad a skeleton staff and stu-dents were often left with min-

imal supervision and muchresponsibility. In the pediatricarea as many as a dozen criti-cally ill infants, most with pre-ventable diseases, would arrivedaily. Early in the project,Harvard faculty assisted withthe hospital care but wereimpatient to develop the pre-ventive programs which werethe goal of the project. In thehospital there was strict sepa-ration of inpatient and outpa-tient staff, making it almostimpossible to develop an inte-grated service program.Janeway found it difficult toimplement the plan for care ofthe whole community and forprevention, but 2 of his per-sonal characteristics were per-sistence and patience.

By 1974, 2 Harvard physicians,in collaboration with 2 fromCamaroon University hospital,began a special Maternal andChild health program. In spiteof heavy pressure to servicemore patients, the programwas restricted to 20-30 preg-nant patients during eachmorning session, attended by6-12 medical students. Theintent was to provide studentswith clinical skills in preventivemedicine and demonstrate thecost effectiveness of a well-runprogram.

DR. JANEWAY AND THE CAMEROON PROJECTBy Robert J. Haggerty, MD and Robert W. Chamberlin, MD



AIDS, such as, if a manbecomes HIV positive heshould undergo sexual cleans-ing by having sex with a virgin!Or, condoms cause AIDS!

3) Denial

Most people who die of AIDSare said to have died of chronicsomething else-like chronicmalaria, chronic typhoid,chronic tuberculosis ratherthan from AIDS. The AIDSdiagnosis carries with itextreme shame in Africa.Fortunately, community edu-cation is starting to change allof this. There is more openness.

One pastor who is HIV positivehas been telling others abouthis condition.

4) Common choices of therapeutic options

Fractures were usually treatedby local “bone setters.” One daya 25-year-old man was broughtto our hospital with a mid-femoral fracture from a LandRover accident. By good for-tune an orthopedic surgeonwas scheduled to fly to our hos-pital the next day. Since theaccident happened on a polit-ical campaign the patient hadmedical insurance to cover all

his expenses. I placed him inskeletal traction using ropesand sandbags. The next day thefamily took him out of the hos-pital to be treated by a bone-setter in their village. I sawmany persons with crookedlimbs walking around the vil-lage due to poorly treated frac-tures.

Mental illness was alwaystreated by the local medicineman.

Jaundice was also treated bythe local medicine man.

CULTURAL EFFECTS UPON MEDICAL CARE . . . Continued from Page 10 ________________________

Teaching primary care con-sisted of making ward rounds,giving lectures and workingwith students in a rural pri-mary care clinic. The studentsbeing familiar with British pro-nunciation had difficulty atfirst with American English.There were no screens onwhich to project slides, nor cur-tains to shut out the light. Thefaculty projected slides on thewall and hoped for a cloudyday so they could be seen. Wardrounds were another challengeA ward often contained a childwith meningitis next to a childwith diarrhea and malnutritionbedded down next to one withpneumonia. There were noseparating curtains. The sinkswere often plugged so thathandwashing was impossible.Surprisingly, most patients gotwell in spite of the conditions.Family members did much ofthe bedside care. In the centerof each room was a table on

which lumbar punctures andother procedures were carriedout. A shortage of incubatorsled to the necessity of puttingseveral infants in one. The hos-pital was unable to stock manymedicines, and when a childwas admitted the parents weregiven prescriptions and sent tothe nearest pharmacy.

The number of surgical abor-tions, often performed underunsanitary conditions with dis-astrous results, was recognizedas well as the poor condition ofpregnant women who hadclosely spaced pregnancies.Family planning was thereforea high priority for a new clinic.In the first 9 months more than1000 patients were served andthe child-spacing clinic be-came one of the most appreci-ated parts of the project. In theYaoundé region the averagewoman had 5 children by 26.6years. This group was an espe-

cially high risk population, butwith 11,000 deliveries yearly onthe obstetric service, manyhigh risk patients arrived atdelivery with no prenatal care.Efforts were initiated in 1975 toorganize a high risk pregnancyprogram.

Conflicts between overworkedclinicians and administratorsand a lack of interest in localfaculty in serving in the lessattractive rural areas plaguedthe project. The same reluc-tance to serve the underservedand isolated communitiesexists in most developingcountries. Faculty believed“that their personal involve-ment would remove them fromopportunities that might welldetermine their fate in theinstitution”. These factorsfavored an urban centralizedoperation rather than a morerelevant rural operation. The

DR. JANEWAY AND THE CAMEROON PROJECT Continued from Page 11 ______________________



difficulties outlined by Janewayare common to such enter-prises and should be expected.He mentioned lack of inven-tory control, difficulty in get-ting parts for Americanequipment, inadequate tele-phone facilities and difficultyin finding jobs for trained localCamaroonians. Even by theend of the project, equipmentfrom abroad was being held upin spite of written agreementsto allow duty-free import.Travel within the country washazardous and frequentlyunpleasant. Other practicalproblems arose.Benches forpeople to sit on while waitingwere needed but the hospitaldid not have the money to buythem. A hurried call to Janewayproduced several thousanddollars to buy them and otherneeded equipment The fundsprobably came from Janeway’sown pocket, an act typical ofhim.

A rural family health clinicfinally was established. There,all members of the Harvardteam worked collaborativelyand demonstrated simpleassessment techniques. It wasthe only place where studentscould participate in an inte-grated multi-disciplinary pro-gram. The clinic was firmlyestablished with local profes-sionals by the end of the proj-ect and was well attended bypatients. Those who partici-pated were enthusiastic aboutthe on-the-job training withthe Harvard faculty. Althoughwe know that medicine is not aspectator sport, the studentshad been previously taughtlargely by lectures.Learningclinical skills is especially

important in countries wherea diploma from abroad is con-sidered more important thandeveloping clinical skills. TheHarvard group wanted to havethe clinical training ofCamaroonians continued afterthey left. Two Harvard nursesand 2 Camaroon nurses co-authored a community ori-ented nursing textbook, “TheNurse and Community Healthin Africa”. The nurses sent sev-eral letters to Janeway askingfor financial assistance andhelp with Harvard copyrights.Again, Janeway’s persistenceand patience were required toget the book published.

What lessons can be learnedfrom this small and focusedproject in a developing coun-try? Most emerging countriesin the tropics with low percapita income have similarhigh morbidity and mortality,predominately from preventa-ble infectious diseases, espe-cially among children underfive. Contaminated water, lackof sanitation and protein-defi-cient nutrition are other majorcontributors to high childhooddeath rates, as well as a lack ofchild spacing. Female literacycan overcome these environ-mental problems, perhapsbecause women with even amodicum of education under-stand household hygiene andhave a greater desire to prac-tice family planning. Somewould argue that a model pri-mary care and preventive med-icine program is not what adeveloped country should beproviding to a developingcountry. Rather, they shouldconcentrate on environmentalhealth and fertility control.

However, studies have shownthat mothers are not sympa-thetic to family planning untilthey believe that most of theirc h i l d r e n w i l l s u r v i v e childhood. Governmentalcommitment to expensive en-vironmental programs requiresa supportive population. Anintegrated maternal and childhealth program will increasechildhood survival and buildcommunity support forbroader health measures.Physicians have much prestigein developing countries. Ifphysicians are educated to thetwin needs of dedicated clini-cal care and public healthmeasures, they can be power-ful advocates for change intheir countries.

In his final report, Janewaygave tribute to the talentedgroup of Harvard health pro-fessionals who contributed tothe project. “For us it has beena very instructive and enlight-ening experience throughwhich our horizons havebroadened and we have madenew friends.” How typicallygenerous of him to ignore thefrustrations and to emphasizethe positive and the contribu-tions of others. Janeway’sexample continues to be a bea-con to all of us who are com-mitted to help others in thedeveloping world to have bet-ter health and with it, a betterchance for peace.

Original by Robert Haggartyand Robert Chamberlin, Jr. forThe Pharos, autumn 2000

Edited for The Senior Bulletinby Joan Hodgman

DR. JANEWAY AND THE CAMEROON PROJECT Continued from Page 12 ______________________


When I was a medical student and in pedi-atric training, newborn infants were notgiven medical care. They were given nursingcare. Newborns were handed to the nursewho washed them, wrapped them and putthem in their bassinets where they made it ornot. We did not provide IV fluids, we did notdo chemistries or x-rays. Microchemistrieswere not available and a potassium took 5cc’s of blood. With a patient blood volume of80-100cc’s, blood chemistries were well nighimpossible. Everyone knew that x-rays wereuseless as the machines of the time couldnot stop the breathing at 60-80/min.ofinfants with respiratory distress. Infantsweighing less than 1000 grams were consid-ered non-viable and no effort was made tosave them.

As a student at University of California SanFrancisco during 1943-46 I saw one newborninfant, the one I delivered on the obstetricalservice. Students were not allowed in thenurseries because of the fear of infectiousepidemics, particularly diarrhea. It was laterlearned that these were due to a particularstrain of E. coli and of course there were noantibiotics yet.

On my first night on call as a straight pedi-atric intern at UC Hospital, I had to relievethe house officer assigned to the nursery.When I told him that I had never been in thenursery, he offered to show me around. Weentered the anteroom, he waved at theadjoining two rooms and said, “That’s thenormal nursery and that is the prematurenursery. Good luck.” Then he vanished downthe hall, leaving me with my heart in mymouth. As it turned out, I did not need to beso apprehensive as the experienced nightnurses knew exactly what to do with the lim-ited options available.

For my pediatric residency from 1948-50, Icame home to the Los Angeles CountyGeneral Hospital (now called the

LAC+University of Southern CaliforniaMedical Center). The hospital had a largedelivery service of 15,000 to 18,000 deliveriesper year, no special care nursery for terminfants, but a premature center. The hospitalwas ahead of its time in admitting outsideborn premature infants, but because of thepersisting fear of infection, these were care-fully quarantined. The premature nurseriescontained no ventilators, no monitoringequipment, no availability of blood gases.Gordon Armstrong incubators were used forthe smaller infants. In order to access theinfant, the lid needed to be raised allowingthe heat and oxygen to escape. Standard rec-tal temperatures were taken with a ther-mometer that registered to 94 degrees F. Theroutine admitting temperature was NRstanding for not registered. The thinking atthe time was that the level of the temperaturedid not matter as long as it was stable. Infantswere routinely not fed immediately, and thesmaller infants were kept npo for as long as72 hours under the misplaced apprehensionthat they would vomit and aspirate. Some ofthe smaller infants actually died of starva-tion and dehydration. The large service wascovered by a pediatric resident half time and2 rotating interns. My major responsibilityeach morning as a resident was to sign outthe stack of charts of half a dozen or soinfants who had died during the night.

Interest in newborn care intensified startingin the middle 1950’s. Infant mortality haddecreased dramatically except for the neona-tal period focusing attention on neonatalmortality, and important strides were madein technology leading to the introduction ofmore sophisticated care into the nursery. In1968, an increase in space allotted to thenursery service allowed us to open a neona-tal intensive care unit with the ability to mon-itor vital signs and provide assistedventilation. Neonatal mortality continued tofall and the rest is history.

EVOLUTION OF NEWBORN CAREBy Joan E. Hodgman, MD

Director Emerita, Division of NeonatologyLAC+USC Medical Center and USC Keck School of Medicine


The year was 1947, and babieswere still dying from Erythro-blastosis Fetalis. This was theterminology given by Dia-mond, Baty and Blackfan to thebundled group of four diseases,which previously were calledcongenital hemolytic anemiaof the newborn, icterus gravis,fetal hydrops or stillbirth witherythroblastoses in the tissues.These conditions affected oneof about every 200 births. In1940, Landsteiner and Weinerhad described the existence of“another human blood anti-gen” which they termed “Rh,”because the antigen was origi-nally discovered in Rhesusmonkey blood. The Britishcalled it CDE factor.

The usual treatment of thisproblem had been multipletransfusions with “Rh” negativeblood. The mortality rateremained at about 30%,accounting for some 3% of all newborn deaths. Many survivors suffered from ker-nicterus and other com-plications. Weiner, in 1944,postulated that exsanguina-tions with subsequent replace-ment of the baby’s blood(Exchange Transfusion) shouldbe helpful. I was told that somehad tried this with disastrousresults. Most experts agreedthat babies, already in distress,could not handle the shock ornear-shock of the procedure.

Alexander.Weiner, the out-standing hemopathologist whowith Landsteiner firstdescribed the Rh blood groupsystem was continuing his ded-icated quest for a successfultreatment of the Rh problem.

Weiner was working with thewell known Benjamin Kramerof the Brooklyn Jewish Hos-pital. Now, in Brooklyn, at thattime, there was a not sofriendly competition for pedi-atric recognition by twogroups, those at the LongIsland College of Medicine,chaired by Charles Weymullerand Kramer’s group.

In 1946, Harry Wallerstein pub-lished his famous article in“Science”, describing the firstexchange transfusion. Heaccomplished this by the“simultaneous withdrawal ofthe Rh+ blood from the sagittalsinus, and the administrationof Rh negative blood through acannulated vein.” The race wason to see who would be the firstto do this in Brooklyn. I recallthe preparation. There werealmost daily planning meet-ings. We experimented withknown concentrations of salineor glucose solutions using dou-ble ended bell jars with rubber

diaphragms. We removed 20 ccfrom one end and injected 20cc at the other. We consistentlyfound that we accomplishedan 80 percent dilution of theoriginal solution. This was inaccord with the then currentand future estimates of the pro-cedure in vivo.

Suddenly and unexpectedly,the first case in Brooklynappeared. Jimmy White wasborn prematurely weighingabout four and one-halfpounds. His mother was a first,too. She had sickle cell disease,was in her early thirtys and wasRh negative. She had hadnumerous transfusions andwas hailed as the oldest patientwith sickle cell disease to givebirth.

We were ready. Bill Doyle, ourvery bright chief resident at theLong Island College hospitaland I did, what I was told wasthe second exchange transfu-

THE “SECOND” EXCHANGE TRANSFUSIONBy David Annunziato, MD, FAAP



DOCTOR JOEBy David Annunziato, MD, FAAP

As you know, the HistoricalArchives Advisory Committeewith the help of many, is accu-mulating the living histories ofthe giants in Pediatrics, theinnovators, the researchers, thegreat and renowned teachersand diagnosticians. I wasthinking recently about thenot-so-well-known pediatri-cians who have had an indeli-ble impact on our lives. I amcertain that each of us canthink of one or two or more.Those who, while perhapslocally out standing, will neverbe remembered with a livinghistory, but will never be for-gotten by those whose livesthey touched. Let me tell youabout one whom I revered.

He was a short man about fivefeet six inches tall. He worethick horn rimmed glasses andsported a bushy crop of black hair, cut in the crew fashion. Hismustache was full and squaredat the ends. He had a stockybuild and always wore a blacksuit. His ties were unremark-able at best. He had hadSmallpox as a youngster in Italyand his face was notably pock-marked. This made it difficultfor him to achieve a really cleanshave. There usually were smallstubbles of hair in some pock-marks. In other words, he wasnot handsome, indeed hiscountenance had much to bedesired. But, he was Beautiful.

I got to know Dr. Joe, as he wasfondly called, as a student atKings County Hospital (KCH)in Brooklyn where he was theChairman of Pediatrics on theclosed division. (There were

two pediatric training pro-grams at KCH. The open divi-sion, not affiliated with themedical school, and the closeddivision, which was a medicalschool program.) His knowl-edge of pediatrics was trulyremarkable. Frequently, afterhearing a history he would dis-cuss a differential diagnosis,but always ended by saying,“This child has”—always a cor-rect and eventually provendiagnosis. When he arrived tomake rounds, an entouragedeveloped and followed himaround the ward, listeningintently. One of his dicta was:“Take a good history and youwill know the diagnosis beforeyou touch the patient in eightout of ten cases”. With him, Ibelieve it was ten of ten.

In part, I chose my internshipat the private hospital where healso chaired the pediatricdepartment in order to learnfrom him. Indeed many of thevoluntary attendings at KCHused that hospital for their pri-vate patients. Dr. Joe maderounds there daily exceptSaturday. Residents from otherhospitals came to make roundswith him every Sunday morn-ing. I rarely missed thoserounds even when I was onanother service.

Some people called him thepied piper because when heentered the pediatric corridor,almost always with a disarm-ing smile, the children flockedto him, not only his patientsbut many who had never seenhim before. Invariably hescooped up one or two of them,

hugged them and he deliveredmany kisses. Remember, hewas not a very attractive manbut his love for children wasimmediately visible.

The following story serves todemonstrate his wisdom, pedi-atric knowledge and diagnosticability.

One morning he called me at7:00 a.m. and said he was send-ing in an eight-month old withfever for two days and who hadvomited twice. She had nodiarrhea. At about nine a.m. heappeared at the ward and said,“Well, what does the childhave”? The residents and I hadfound nothing. The lab workwas not back yet. Her X-ray’swere normal. When I said wehad found nothing, he glancedat the chief resident, walked tothe nurses’ desk, and wrote ona piece of paper. Then, puttingit into his pocket, he proceededto examine the child, thenasked “what did you find onrectal”? We had not done a rec-tal. He donned a glove, did aquick rectal and, by-passingthe residents, said to me “nowyou do a rectal”. I did and to mysurprise found a walnut sizedmass on the right side. Whenhe left that morning, heremoved the paper from hispocket and tossed it on thenurses’ desk. After he enteredthe elevator we all ran to look atthe paper. It read “AppendicealAbscess”. Later that day I askedthe mother if he had done arectal exam at home. Shereplied, “I just spoke to him onthe phone this morning and he



told me to go directly to thehospital. He did not see her tillshe was here”. There were someunhappy, embarrassed faceson the ward that day.

After he completed rounds thenext day, I approached him andasked, “How did you know thatbaby had an abscess?” Hesmiled and said, “I’ve beenwaiting for someone to ask”. Heproceeded to explain that heasked the mother if the childcried on voiding and she saidyes. He then noted that in aninfant, the appendix is a pelvicstructure which lies close to thebladder. When the appendix isinfected, the child cries onvoiding because the contrac-tion of the bladder pulls on thepainful appendix, especially ifit has ruptured. He added thatwe should remember that ininfants the thin walled appen-dix ruptures quickly. When Isuggested that cystitis wouldbe a more likely diagnosis fromthe history, he smiled and said,“except that the mother saidthat the baby cried more whenheld over her right shoulderthan when held over her leftshoulder”. This lesson has heldme in good stead over theyears. I have made the diagno-sis four times since then by his-tory alone.

As an example of his kindness,sensitivity, understanding andgentility, I suggest the follow-ing: I was an intern onPediatrics for only two weekswhen one night we admitted afour-month old with obviouspneumonia which we verifiedby X-Ray done shortly afteradmission. Being quite ill, Istayed with the baby most of

the night. The baby died earlythe next morning in spite of ourtherapy. At autopsy we found astaphylococcal pyopneumoth-orax. At rounds the next morn-ing we discussed the case atlength. When Dr. Joe was leav-ing he asked me to walk withhim to the elevator. While mystethoscope visibly hung frommy neck, he asked “Do youhave a stethoscope”? As Ilooked down and felt for mystethoscope, he softly said,“Use it more often” and hedeparted.

As the New Year approached, Ihad not been home for severaldays. My one year old was illwith vomiting and diarrhea.Upon speaking to my wife atabout eleven one night, Ibecame worried about hishydration. I called Dr. Joe, toldhim the story and asked if Icould be allowed to go off acouple of hours to evaluate myson. I had no car and wouldhave had to take the LongIsland railroad since I lived adistance from the hospital inanother county. He softly said,“no, you stay there, I will go andsee your child”. At about onea.m., he called me from myapartment and told me not toworry, that my son would befine. He improved and becamewell very shortly after that visit.

I could go on and tell anotherhundred stories about thiswonderful man. Permit me justone more. Dr. Joe had no chil-dren but his love for childrenwas obvious. Suddenly at aboutage fifty, we learned that he hadre-married. No one knew howhis first marriage ended. Overthe next four years, he fathered

four children including a set oftwins. Wanting to spend moretime with his family he leftBrooklyn and started a newsmaller practice on LongIsland. Though still a distanceaway, we again brought ourchildren to him for care. WhileI was a resident, he resigned hisposition as chairman at KCHfive times. His resignation wasrefused each time and he con-tinued.

One morning in 1960 he calledme on the phone and asked if Iwould sponsor him for mem-bership in the AmericanAcademy of Pediatrics.Flattered, I agreed.

Dr. Joe was a very private man.He died suddenly at age sixty orso of acute fulminating hepati-tis. We went to his wake and forthe first time met his wife.When we introduced our-selves, she said he had oftentalked about me. In my heart Iknew that he had adopted mesoon after I began my intern-ship. I had many wonderfuland bright teachers over theyears but no one approachesthe respect and love I had forDr. Joe. He was truly a giant ofPediatrics.

Joseph Battaglia was born inItaly in 1901. All of his school-ing was in the United States. Hereceived his medical degreefrom the Long Island Collegeof Medicine in 1924 and wascertified by the AmericanBoard of Pediatrics in 1937.

Who was your hero?

DOCTOR JOE Continued from Page 16 ____________________________________________________________________


sion ever done in this country.Following Wallerstein’s tech-nique, I extracted 20 C.c. ofblood from the superior sagit-tal sinus vein, and he injected20 C.c. of compatible, fresh,Type 0 Rh-negative blood via acutdown in the sap

Incidentally, drawing bloodfrom the sagittal sinus was aneasy procedure, since wehenous vein at the ankle. Wethen did this 20 times achiev-ing what we had calculated tobe an 80 percent exchange ofthis four-pound baby’s blood.Jimmy White did well. routinelydid our blood work on all newadmissions using blood drawnfrom there. The next day a pic-ture of Jimmy, held by a nurseand myself appeared on the

front page of the now-defunctBrooklyn Eagle newspaper.

The procedure was done in theclean treatment room in theneonatal unit. Everyone wasproperly, sterilely capped,gowned and gloved. We used20 sterile syringes and needles.The blood given was warmedto body temperature and hungfrom an I. V. pole with threehot-water bottles surroundingthe bottle. It required threehours to complete. We gave IV.calcium gluconate twice dur-ing the procedure. We did notuse heparin. With all of ourcareful preparation there wasstill blood all over the placeincluding the ceiling. After thatfirst, we never used the sagittalsinus again but rather we cut

the radial artery at the left wristand allowed the blood toescape into measuring cups.The problem with this proce-dure was that some babies laterhad a radial nerve palsy belowthe site. When Diamond in1948 described the method ofcatheterizing the umbilicalvein with plastic tubing andusing a three-way stopcock, wefollowed that procedure.

Now, more than a half-centurylater, we can prevent almost allcases of erythroblastosis. It isgratifying to know that in mylifetime in medicine we haveidentified the cause, developeda treatment and a means toprevent a condition, which wascommonplace and often life-threatening.

FIRST SURGERY FOR TETROLOGY OF FALLOTBy Avrum Katcher, MD, FAAP

In 1944, when I was a first year medical student at Hopkins, one day there was an air of greatexcitement about the place. Members of my class tipped me off to get over to Hurd Hall, thehospital auditorium. Dr. Alfred Blalock, Professor and Chairman of the Department of Surgery,was to present his first three patients who had had subclavian-pulmonary anastomoses forTetralogy of Fallot. One at a time, each patient was described to the packed room. All three,in order, were asked to enter the room, all pink. After the presentations, Dr. Helen Taussig, thepediatric cardiologist, and Dr. Arnold Rice Rich, Professor and Chairman of Pathology, wereasked to comment.

Originally, Rich had been interested to learn why the pulmonary artery did not show the samedegree of arteriosclerosis as did the aorta, particularly in hypertensive patients. He wonderedwhat would happen if the pulmonary artery were subjected to the same blood pressures asthe aorta. Blalock was experienced in vascular surgery; Rich asked him if he could create asuitable anastomosis. Working with his remarkable assistant, Vivian, Blalock anastomosed thesubclavian to the pulmonary artery successfully in the dog.

When Taussig heard about this, she discussed the idea of human surgery to improve oxygena-tion in patients with Tetralogy of Fallot with Blalock and Rich. Blalock agreed to try it in thehuman. No IRB in existence in 1943-1944. And away they went. At the presentation of thosefirst three patients, when Rich was asked to speak, he said, “I feel like Adam being asked tocomment on the creation.” Never forgot that moment.

THE “SECOND” EXCHANGE TRANSFUSION Continued from Page 15 ______________________


As a health care provider(formerly known as a physi-cian) and/ or client (for-merly called patient) you areaffected by the HIPAA pri-vacy regulations. This is thefeds latest attempt to set aGuinness record for numberof words describing a com-mon sense situation. HIPPAstands for Health andInsurance Portability andAccountability Act of 1996.The vagueness and confus-ing words of the name itselfis the first clue to its over-stated purpose.

Good doctors and healthcare facilities (formerlyknown as hospitals) havebeen following many of thepatient privacy rights volun-tarily that are included in theHIPAA regs. Let’s look at afew:

• Facilities are kept securefrom intruders with locks,alarms etc.

• When a person no longerworks at a facility, keys andID badges are returned.

• “Quiet areas” are used forsensit ive informatione x c h a n g e s w h e n e v e r possible.

• Only the patient’s name iscalled out in waitingrooms or on paging sys-tems.

• Patient information is notleft in public areas.

HIPAA requires all practicesneed to appoint a “Privacy

Officer”. This person istrained to handle all mattersthat are HIPAA related forthat practice. This involvestime and money for thepractice to initiate and sus-tain this position. As ap a t i e n t , you ma y ha venoticed your registration atthe desk takes more timeand involves you acknowl-e d g i n g t h a t y o u h a v er e c e i v e d t h e “ P r i v a c yPractices” information. Thisprinted information willinvolve more cleanup as thebrochures may end up onthe floor of the waiting roomor the parking lot. God blessrecycling. Even the “sign in”sheets should not revealthose who have previouslysigned in. The practice needsto purchase a shredder orobtain a shredding service todispose of personal medicalinformation.

Admittedly, computers,email, fax and answeringmachines need to be dis-cussed with those who usethem regarding patient pri-vacy. Possibly privacy guide-lines could be circulated byhospital or physician asso-ciations. Is an Act withpenalties and an Office ofCivil Rights necessary?

But all of this patient privacymaterial is the tip of the ice-berg for what arrived in theFall 2003 and what is tocome. To determine whatthe Federal governmentreally wants to accomplish,

look at the Act itself. PublicLaw 104-191 is an Act “toamend the InternalRevenue Code of 1986 toimprove portability and con-tinuity of health insurancecoverage in the group andindividual markets, to com-bat waste, fraud, and abusein health insurance andhealth care delivery, to pro-mote the use of medical sav-ings accounts, to improveaccess to long-term careservices and coverage, tosimplify the administrationof health insurance, and forother purposes.”

It turns out what they reallywant to do is to developstandards for certain elec-tronic health transactions,including claims, enroll-ment, eligibility, paymentand coordination of bene-f i t s . T h e Ho n . D a v i d L .Hobson in the House ofRepresentatives on October22, 1997 in a clarificationstatement said, “the intentof the law is that all elec-tronic transactions for whichstandards are specific mustbe conducted according tothe standards.”

The Privacy section of theAct was the first to be putinto effect. The next rule andstandard of the Act wasimplemented on October 16,2 0 0 3 : Mo d i f i c a t i o n s t oElectronic Data TransactionStandards and Code Sets.This is a 62-page document

HIPPA FOR DUMMIESBy Joseph A.C. Girone, MD, FAAP


(Federal Register, August 17,2000) that addresses combat-ing waste, fraud and abuse inthe health care delivery system.This part of the Act standard-izes the format for submissionsto Medicare and Medicaid.Wrong format, no pay and can’tresubmit. No penalty for incor-rect private insurer submis-sions. This appears to be thereal reason for the Act.

The next rule (49 pages, FederalRegister, February 20, 2003) willgo into effect April 21, 2005.This is the Security andElectronic Signature Standards.The summary states: “The useof the security standards willimprove the Medicare andMedicaid programs and otherFederal health programs andprivate health programs, andthe effectiveness and efficiencyof the health care industry ingeneral by establishing a levelof protection for certain elec-tronic health information.”This rule sets standards for thesecurity of individual healthinformation and electronic sig-nature use by health plans,health care clearinghouses andhealth care providers. Enforce-ment is accomplished byHIPAA granting HHS theauthority to impose civil mon-etary penalties against entitiesfor non-compliance; in otherwords, fines and imprison-ment.

Is HIPAA helping in any way?

Dr. David Kibbe, director ofhealth information technologyat the American Academy ofFamily Physicians thinks so. Hefeels HIPAA has raised the con-sciousness level among all thevarious stakeholders withregard to how information

technology can improve thequality of patient care, lead togreater efficiencies and givepatients better service. Dr.Richard Sacks-Wilner, aninternist in private practice dis-agrees. His view is that HIPAAfails utterly. It gives federalbureaucracy access to yourmedical records at will, with-out your permission. Forenforcement, there are 34“HIPAA police” for the entirecountry. The trial lawyers hitthe jackpot again since they arethe ones who will be the realenforcers. HIPAA is expensive.Dr. Sacks-Wilmer estimates$40,000 for a solo practice andabout $100,000 for a seven per-

son practice. In his opinion, theonly good part is that HIPAAmakes the transactionsbetween physician and theinsurance companies stan-dard.

As a health care provider andalso potential or actual client,prepare for the rules that gointo effect on April 21, 2005.Your tax dollars never stop giving: the US Postal Service,the IRS and now HIPAA. If you ever have a problem get-ting to sleep, just type inwww.hhs.gov/ocr/hipaa/ onyour computer browser andstart to read. You will be asleepin minutes.


HIPPA FOR DUMMIES Continued from Page 19 ___________________________________________________

Editor’s Note: I wish to raise another consequence of the HIPAA rulesnot covered by Dr. Girone in his interesting article on the subject. Theadvent of HIPAA has seriously interfered with my ability to performclinical research. I work in a large medical center with an active andbusy NICU.We have over 10 years of the clinical information of allour very low birth weight infants on a computer file. This is anexcellent source to answer clinical questions about the character-istics, complications and response to treatment of our most fragilepatients. The patients’ records are filed by name and hospital num-ber. During the course of an investigation, they are not identified inany personal way. The patient’s are selected by clinical criteria suchas birth weight and gestation. The results are presented as meansand ranges of the various factors studied. Since the advent of HIPAA,because the patients are filed by name, we are required to obtainparental consent to use the information in the file. This is well nighimpossible especially at a county hospital. Both our medical stu-dents and our fellows are required to complete research projects. Thecomputer data base has been a productive resource especially for themedical students. The adherence of our IRB to the new law hasseriously interfered with our ability to evaluate our NICU care andwith the education of our trainees.

Joan Hodgman MDCo-editor Senior Bulletin

EDITORS’ POSTSCRIPT:

AAP News for November, 2003, p225 and 230, reports that after theAAP and over 70 other medical associations and health care com-



Editors’ Note: The following article by Eugene Wynsen was prepared to encourage further considera-tion and investigation of the usefulness of micro-organisms felt to be harmless in order to prevent ortreat disease. We make no case for or against his thoughts, but present them for your interest. Weencourage responses from interested readers.We also might remind you of the book Microbe Huntersby Paul de Kruif, published at least 50 or 60 years ago. This volume on distinguished researchers in the19th century, included a chapter on Elié Metchnikoff, who enthusiastically encouraged use of theorganisms mentioned, found in buttermilk and other soured dairy products, for health maintenanceand treatment of disease. Readers also might check comments on Probiotics in the summary of the talkat the NCE by Dr. Fugh-Berman

Probiotics are live micro-organisms which whenadministered in adequate amounts confer ahealth benefit on the host.(1) I have read aboutProbiotics, but I have little clinical experiencewith them. A variety of articles in lay publica-tions, the pediatric literature and other scien-tific sources suggest that Probiotics are useful inmany situations. Hospitalized children withrotavirus infection, for example (2) have theduration of symptoms shortened by up to 1.5days, with decreased severity. Probiotics havealso seemed useful in chronic bowel problemslike irritable bowel syndrome, with suggestivebenefits.

The literature contains many articles on the mer-its of different species of bacteria, in particularfrom the lactobacilli group.(3) Among these areLactobacillus acidophilus GG, Lactobacillusrhamosus, and Lactobacillus reuteri. Theseorganisms secrete substances that seem to beable to protect the bowel wall. They have beenidentified in other animals such as goats, rats,and of course, in humans. Breast milk seems toencourage growth of the lactobacilli, includingthe Lactobacillus acidophilus, rhamosus, andbifidum groups. As you all know from observingbreast fed infants, their stools are distinctly dif-ferent than formula fed infants.

I am not especially up to date on my bacteriol-ogy these days, but it is intriguing to contem-plate the fact that these organisms could be usedin the treatment and prevention of disease inchildren and adults. Children with diarrhea ofvarious types, not limited to rotavirus, have beentreated with Probiotics. Probiotics have beenused in irritable bowel syndrome and also ininflammatory bowel disease Testimonials are theworst type of clinical data to use in evaluating

any treatment, but they may be a useful clue. Arelative in northern California told me of explo-sive diarrhea appearing at inopportune times. Isuggested that my relative try both L. reuteri andL. Acidophilus GG; she found L. reuteri moreeffective. She was able to obtain it over thecounter, but now it is difficult to find. I wasunable to locate any at all in my area.

I wondered why it was not available. Apparentlyfew or no physicians in this area recommendthis product; and I thought that I am either thesmartest of all...or the dumbest. Since theseorganisms are generally tolerated very well, Iwonder why they are not used more often. Withthe great number of admissions for rotavirus, itwould seem that even one day shorter hospitalstay would result in significant decrease in dis-comfort and would be economically a great ben-efit. I checked with many pharmacies, and wasgenerally greeted with “oh yes, we have it”, butwas given Lactobacillus acidophilus. Not one ofthem was familiar with the difference in speciesand varieties and the resultant different activitiesthey possess. McNeil was producing L. reuteri,but discontinued it for marketing reasons, mean-ing that they were not making a profit since theydid not sell enough. Another company, Biogaia(a Swedish company) makes a similar product,but it is not available in stores, and must beobtained through dealers, who will want to sellyou all sorts of products that you likely do notwant. Another company sells Culterelle, a prod-uct that contains L acidophilus GG. A number ofproducts contain L rhamosus.

There is a considerable literature on organismsfound in various species; they have found use ina number of areas, including infants, preemies,

PROBIOTICSBy Eugene Wynsen, MD, FAAP



panies have signed letters requesting flexibility with noncompliant physicians and billing services,a TEMPORARY reprieve from federal standards regulating electronic communication between physi-cians and insurance companies has been offered. Centers for Medicare and Medicaid Services, theAmerican Association of Health Plans, the Health Insurance Association of America, and the BlueCrossBlueShield Association have all agreed temporarily to accept existing claim formats. The AMA hasreported that barely a third of physicians feel they understand the new HIPAA transaction require-ments; less than a quarter believe their office managers or staff understand.

We also thought you might be amused by the following true anecdote, with fictional identification,from Ben Silverman:

The Assistant Athletic Director of the University and I were watching an NCAA tournament lacrossgame. Near the end of the first half, a local attachman, his knee already in a brace, was checked,knocked down, writhed in pain, and had to be helped from the field by teammates and the trainer.

After the half-time break, the team returned to the field without the injured player. My companionleaned over the rail and hollered to the trainer, “Tom, how’s Watson? Did he hurt his knee again?”

The trainer responded by waving his arms across his body to denote a negative response, while shout-ing, “HIPAA, HIPAA,” The AAD turned to me and said, “Uh, oh, it’s more serious; he got his hip thistime.” Seniors who are out of the practice loop should be aware that HIPAA is the acronym for thenew pervasive medical privacy regulations; university team trainers are bound by these regulations.


adults and animals.(4) Rats grow better with L.reuteri and zinc. There are a number of productsthat contain these organisms, for example inyogurt. Ross laboratories has done someresearch on the safety of L. reuteri, and foundthem safe for children, infants and adults.(4,5,6,7)] Are we missing the boat, or is this justa lot of hype?

References:1. Sanders, M.E., Probiotics: Definition, impor-

tance to microbiology and health, and opti-mal standards for human use. AmericanSociety for Microbiology, May 18-23,Washington DC.

2. Shornidova A.V. et. al. Bacteriotherapy withLactobacillus reuteri in rotavirus gastroen-teritis. Pedatr. Infect Dis. J. 1997 Dec: 16(2):1103-7.

3. Biogaia References relevant to probiotic use of

Lactobacillus reuteri List revised April 2001.115 references

4. Ruiz-Palicio G., et al, Tolerance and fecal col-onization with Lactobacillus reuteri in chil-dren fed a beverage with a mixture oflactobacillus spp. 1996” Pediatr Res. 39(4) part2: 18A abstract 1090

5. Vesikari T.,Karovonen A-V., (2001) Safety andfeasibility study of lactobacillus reuteriadministration to neonates. Study report

6. Wolf B.W.., Et al. Safety and tolerance of lacto-bacillus reuteri in healthy adult male subjects.Microb. Ecol. Health Dis. 8:41-507.

7. Wolf B.W.et al. Safety and tolerance of lacto-bacillus reuteri supplementation to a popula-tion infected with the HumanImmunodeficiency Virus. Food Chem. Toxicol.36:1085-1094



HERBS AND DIETARY SUPPLEMENTSRISKS AND BENEFITS

A presentation by

ADRIANE FUGH-BERMAN, MDGEORGETOWN UNIVERSITY SCHOOL OF MEDICINE

Senior Section Pharmacy Section Joint Program at AAP NCE

November 3, 2003

This is a report based on syllabus provided by speaker and notes taken by Avrum L.Katcher, MD. Any errors are the responsibility of Dr. Katcher. Information provided shouldbe verified by a professional with knowledge of the field.

Pediatric use of Complementary and Alternative Medications (CAM) in multiple surveysvaries from 9% to 70%. Multiple disorders are so treated; examples include ADHD, depres-sion, asthma, irritable bowel syndrome, malignant tumors. A 1998 survey found thatmore than half of AAP respondents in Michigan chapter would use or refer patients inselected situations for CAM therapies.

Harmless herbs for children include catnip, other mints, (but may worsen GERD) fennel,ginger or chamomile, always excepting relatively rare allergic reactions. In contrast, thereare many hepatotoxic plants including Chaparral, Kava, Heliotrope, Senecio, borage andmany others. Other toxic plants include coltsfoot, comphrey, Jamaican bush tea, senna (GItoxicity with bleeding). A number of herbals used for GI upsets may contain lead or mer-cury. Topical garlic produces rash, burns, ulcers. Many topical herbal creams were foundto contain steroid (unlabelled) in up to five times higher concentrations than in creamsfor adults.

Echinacea is commonly used to treat URIs. Several studies find no evidence of a preven-tive effect; there is some suggestive evidence it may decrease symptoms and duration.However it may increase atopy and asthma. St. John’s wort has been said to lighten depres-sion, but it induces cytochrome 450, thereby interacting with many drugs by increasingtheir metabolism and lowering blood levels. Chamomile cream for treatment of eczema,marketed as Kamilosan, produced no difference. Aloe vera juice promotes superficialepithelialization and is widely used for topical healing of injuries that are not deep. Theleaf extract contains anthroquinones and is a potent laxative. Oral probiotics, such asLactobacillus GG or Bifidobacterium lactis Bb12, in infants, (see related article by EugeneWynsen, MD, in this issue of the Bulletin) have been said to reduce the risk of atopy orimprove atopic dermatitis.

Pediatricians will do well to become familiar with cultural diagnoses and treatments in thearea where they practice. Most, but far from all, folk beliefs and practices are not harm-ful. It is wise carefully to ask parents what they are using, encourage them to share fullytheir beliefs and practices, and avoid discouraging or disparaging remarks for those localcustoms which are not harmful. On the other hand, those which are dangerous should bediscouraged, and the difference explained.


Two books have come to myattention, one quite re-cently; the first brought theother, published some 50years ago, to mind. Thiscame about when the Editorof Pediatrics published ashort quote as filler not longago. It was so thoughtful Ihad to investigate further.For those of you who missedthis, a part of the quote was:

“Doctors…in their willing-ness to visit patients’ homes,had agreed to expose them-selves to the context ofpatients’ lives…Those doc-tors never indulged in falseconsolation, but the depthof understanding that theygained by submitting them-selves to the lives of theirpatients—as opposed todemanding that theirpatients come to them, how-ever painfully—gave them afar better chance of meetingthe sick as their equals…”

The author, essayist andpoet, Reynolds Price, fromNorth Carolina, was an earlysuccess as a writer, andbecame a full Professor ofEnglish at Duke. He has pub-lished novels, plays, poems,translations from the Bible,and radio and televisionmaterial. Price becameaware in 1984 of pain andmotor weakness then dis-

covered to be due to a neo-plasm entwined in his uppercord. He had multiple sur-geries, became paraplegic,and never recovered use ofhis limbs, at least up to thetime of a memoir he pub-lished in 1994: A Whole NewLife, published throughAtheneum, New York.

Much of this volume con-cerns details of the effect ofhis disease on his mentaland physical functioning.But features of his experi-ences are important for any-one who must deal with themedical establishment, orwho may be forced to learnto live with some conditionthat will not go away, or thatwill get progressively worse.

Price is clear, unmistakableeloquent in his descriptionof the many physicians withwhom he interacted. Hedescribes warmth andinsensitivity, understandingand callousness, helpful andheedless behavior. It is worthreading through just in orderto ask yourself the question,under other times, other sit-uations, could I have actedlike that towards my patientsor their families? As anexample:

“The…radiologist withwhom I spoke, a man from

Texas, assured me that in mycase they were ‘burning thatsucker out of there.’ Hebeamed as if we were smok-ing a badger out of its denwith certain success. My pre-siding oncologist saw me asseldom as he could manage.He plainly turned aside…Heseemed to know literally noword or look of mild encour-agement or comradeship.”

On the opposite side, Pricerelates how friends whocalled or wrote, with theirassurances that somehow hewould not die of his cancer,that he would manage to goon, gave him energy anddetermination, and thewherewithal to combat bothhis depression and his dis-ease. And most important,he describes what he feels iscrucial for anyone else whomust go and grow through agrievous illness:

“You’re in your presentcalamity alone, as far as thislife goes. If you want a wayout, then dig it yourself, ifthere turns out to be anytrace of a way. Nobody—least of all a doctor, can res-cue you now, not from thedeeps of your own mind, notonce they’ve stitched yourgaping wound.

PERSON TO PERSON

HELPFUL STORIES ABOUTCHRONIC OR HANDICAPPING CONDITIONS

By Avrum L. Katcher, MD, FAAP



LUCK OR FATE? — A PERSONAL ASSESSMENTBy Sol Browdy

Luck is chance, a producer of good or bad for-tune; the events, favorable or unfavorable, that itbrings. Fate is the power, thought to control allevents and impossible to resist; a person’s pre-destination.

In chapter ten of my memoir Life the SecondTime Around, entitled “Where Do I Go fromHere? A Potpourri of Thoughts,” I track a series ofthe life events important for me, for which I ammost thankful. Were they instances of luck orfate is an intriguing question? Does it matter?Not really. You be the judge, while I offer myassessment. “L” stands for luck; “F” stands forfate; and “COMBO” stands for a combination.

1. My immigrant parents: mother from Odessa,the Ukraine; father from Nizhan, Russia hadthe gumption to pick up and leave Europeand settle in America. COMBO. Ed. Note: Alsoincludes personal choice, free will—not justfate!

2. The Army for drafting me in 1941 after gradu-ating pre-med at Temple University,Philadelphia and having no medical schoolto attend. Fate decreed stateside service as anenlisted man. COMBO.

3. My dad owned a delicatessen and confec-tionery store, frequented by a busy obstetri-cian who loved mother’s home-made gefiltefish. It was he who informed me that WakeForest College had become a four year med-ical school under the name of Bowman GraySchool of Medicine (now Wake ForestUniversity School of Medicine). While still inthe Army I applied, was interviewed, andaccepted. COMBO.

4. World War II depleted the supply of physiciansand dentists. As a result the federal govern-ment set up Army Specialized TrainingPrograms (ASTP) to train doctors and den-tists. I was released “at the convenience of thegovernment” to be trained as a medical offi-cer. We studied through the summer, so Icaught up one of the two years served as anenlisted man. On completion of the medical

training I would pay back the government twoyears’ service as a medical officer. L.

5. If I were not stationed at Camp Stoneman,California, I never would have met my futurewife’s brother a dentist from Chicago also inASTP. After my military service I intended tolook for a pediatric residency in Chicago. Allhe had to say was, “Why-don’t-you stop byand visit my parents in Chicago I have twinsisters?” COMBO.

6. I courted the younger and prettier of the twinsWe married while I was stationed overseas in Germany and honeymooned inBerchtesgarden. Our housing was located inNuremberg; we were assigned a maid. We hada ball, visiting many countries includingSwitzerland and cities like Paris. COMBO.

7. While visiting Garmisch, Germany we wentfor a hike up rather steep mountainous ter-rain. On reaching the crest, we spied a bobsledsurrounded by a group of Germans. We soonlearned that this was the famous Olympicbobsled run; the only way to get down was forus to sit on a sled between two of the Germansand negotiate the course! It was a memorableharrowing and foolhardy experience; I partic-ularly remember the thrill of riding the ninety-degree turns! COMBO.

8. Naturally we could not escape having any illfortune. Our first living male infant had a con-genital inherited disease intimately known topediatricians: cystic fibrosis. He survived fourmonths. Because of the one in four chance ofrecurrence, we were advised to forego havingany other children. But mainly on Elaine’sinsistence we bucked the odds and subse-quently had two loving unaffected children!COMBO. Ed. Note: Free will again.

9. Even though I had my first heart attack at theage of 62 and a quadruple bypass at 65—notto mention chronic pulmonary disease—Iremain alive and reasonably active at 80.COMBO.



“Generous people—true prac-tical saints, some of them bor-ing as root canals—are waitingto give you everything on Earthbut your main want, which issimply the person you used tobe.

“But you’re not that personnow. Who’ll you be tomorrow?And who do you propose to befrom here to the grave, whichmay be hours or decades downthe road?

“Have one hard cry, if the tearswill come. Then stanch thegrief, by whatever legal means.Next find your way to be some-

body else, the next viable you—a stripped-down whole otherclear-eyed person, realistic as asawed-off shotgun and thank-ful for air, not to speak of thehuman kindness you’ll meet ifyou get normal luck.”

I can not comment. I’ve notbeen there. Just at 78, I do notknow what portends. But if andwhen, I hope I can do that.

Now the other book. In 1952the Editors of Lancet publisheda slim volume, Disabilities:How to Live with Them. Theepigraph, attributed to one G.R. Girdlestone, said “It isn’t

what happens to you that mat-ters. It’s how you take it.” Insideare 47 first person singular sto-ries, most by non-medical per-sons, some by physicians,about what happened to them.Loss of limbs, sight, hearing,congenital deformities, dis-eases of uncertain cause, thelist is as long as a person’s life.All are characterized by exactlythe courage shown by ReynoldsPrice. All should be read by anyphysician. Probably unobtain-able except via an old or usedbook store. Try Alibris. But soworth while, so very worthwhile.

PERSON TO PERSON Continued from Page 24 __________________________________________________________

10. I survived a cardiac arrest on an indoor ten-nis court, overcoming odds where only 4% ofout-of-hospital arrests survive unscathed,which I credit for sending me into my secondlife. COMBO.

11. When my 10-year old pacemaker waschecked, it was registering a steady decline inbattery charge. A replacement would beneeded within six months. A highly reputablesurgeon at the University of Utah Hospitaldid not mince his words, recommendingearly surgery. When I asked whether the sur-gery could be postponed until my returnfrom a week’s vacation in Hawaii, he thun-dered back: “In no way!” Then he proceededto add insult to injury by telling me thatthough I wouldn’t feel “too bad” postopera-tively, I should not expect to return to mynormal activities for three weeks. That againwas bad news. At surgery, when the surgeonused the cautery for the first time, it becameobvious that the pacemaker no longer was

functioning. The battery, literally, had diedon the operating table. But quick as a bunny,the surgeon implanted a temporary pace-maker via the femoral route and proceededwith the implanting of a dual device, whichfunctions both as a pacemaker and defibril-lator. I had dodged a bullet; the surgeon livedup to his reputation. COMBO.

12. In July 2002 two motor vehicle accidents hap-pened to me, which could have maimed orkilled me, but which should be included inthis compendium of Luck or Fate. That storywas published in an earlier edition of theBulletin. They were instances of COMBO.

In summary, according to my tally, almost all ofthese events were instances resulting from mul-tiple factors: luck, predestination and free will. Ihave a hunch that for many of us who considerourselves lucky, the same is true, we really haveour destiny and our personal qualities as well tothank!

LUCK OR FATE? — A PERSONAL ASSESSMENT Continued from Page 25 _______________________________


With the most devastatingbear market performancesince the great depressionstill weighing heavily oninvestors’ minds, many arenow looking more closely atthe expenses that havebecome part of the drag ontheir investment returns.Stock and bond investors areclosely analyzing tradingcommissions and purchasemarkups in order to deter-mine if they have received afair value in return for theexpenses incurred. Thosewho feel they have receivedan unfair value are turningto professionally managedmutual funds. More in-vestors than ever before areincorporating mutual fundsin their overall portfolio, andalong with this increasedinterest comes a greater vari-ety of funds to choose from.While there are many vari-ables to evaluate whenselecting a fund, perhaps themost misunderstood is totalfund costs and their impacton fund returns.

The first expense of a mutualfund deals directly with itspurchase. Load mutualfunds offered through stockbrokers and other financialadvisors have a built-inupfront or contingent de-ferred sales charge thatranges from 2% to 5.75%.Discounts are available forlarger purchases, typically

beginning at the $50,000level. A portion of this “load”or sales charge is passed onto the broker to compensatehim or her for their dealingswith the client. In this case,the broker provides theresearch and assists theclient in selecting the spe-cific load fund that meetstheir objectives.

The alternative to brokerassisted “load” funds wouldbe “no-load” mutual funds.These funds, also known as“no help” funds, do not havea built-in sales chargebecause the investor buysthe fund directly from thefund company withoutgoing through a broker. Theinvestor does his or her ownresearch, places the tradesand monitors the invest-ment. The fund companycan provide historical infor-mation to review but gener-ally will not provide overallfinancial planning advice.(Editors’ Note: A number offund companies, such asVanguard, TIAA-CREF, T.Rowe Price, USAA and oth-ers do provide extensiveservices, including opportu-nity to speak with a repre-sentative broker, financialplanning tools, and exten-sive records. In addition rat-ing and evaluation services,such as Morningstar orLipper, also provide detailedmeans of comparison

among funds. Each readershould consider for herselfor himself whether to makeuse of a financial advisor, orindividually investigate andcompare different funds,preferably with the aid ofone of the rating and evalu-ation services.)

With either type of mutualfund it is important to realizethat you do not get some-thing for nothing. There areinternal costs with allmutual funds that are dis-closed in the requiredprospectus. This summaryof expense disclosure willbreak out internal fund coststhat are being assessed to allshareholders. Other thansales charges, the primaryexpense will be manage-ment fees. This is the cost ofresearch, salaries, and thetransaction costs associatedwith the fund portfolio.Another category is termed“other expenses”. This wouldinclude shareholder services(processing and mailing ofstatements and customerservice personnel), legal,transfer agent, and custo-dian expenses.

Often times marketingexpenses such as advertisingand brochures will also beincluded in this category.When comparing expensesbetween load and no-load

HIDDEN EXPENSES ARE NO TREASUREWHEN SEARCHING FOR MUTUAL FUNDS

By Joel M. Blau, CFPMEDIQUS Asset Advisors



funds, you may begin to noticea greater no-load expense ratio.This is due to the fact that no-load funds generally havehigher marketing expensessince they are sold directly tothe public. That is why you maynotice more print and televi-sion ads for no-load funds.These added costs are sharedby all shareholders within thefunds. Some funds also chargea 12b-1 fee, which is a market-

ing-related expense for no-loadas well as load funds. In thecase of load funds, some of the12b-l expense is paid to thebroker as compensation formaintaining the client relation-ship.

As you evaluate different funds,you will realize that annualtotal fund expenses will rangefrom .25% to over 2.5%, with anaverage of about 1%. Keep in

mind that there are many fac-tors to investigate before youinvest in a fund, such as man-agement style and historicalreturns over varying time peri-ods. Consider fund expenses asyet another factor that shouldnot be ignored.

Mr. Blau welcomes readers’questions. He can be reachedat 800-883-8555 or [email protected].

HIDDEN EXPENSES ARE NO TREASURE . . . Continued from Page 27 _____________________________

PEDIATRICIANS WHO VOLUNTEER!

Pediatricians who have considered volunteer work for a governmental ornon-profit agency, as a pediatrician, have often found this was not practicalbecause, if they have retired, and ceased to carry malpractice insurance, it iseither unavailable or comes only at a burdensome cost.

• The Senior Section Executive Committee has discussed this issue severaltimes, but has been unable to contrive a solution of wide usefulness.

• The free journal, Pediatric News, for December, 2003, page 40, carries areview article of the current status of this problem in several states.

• A few of them have arrangements for steeply discounted insurance at relatively minor cost.

• Most have done little to make this practical.

Are there any of our readers who areaware of other solutions to this problem?

If so, please send a Letter to the Editor so that we made distribute the information to others.

If any of our readers would like to work on this problem, we would be glad tofacilitate getting something done.


PHYSICIAN WELLNESS

ARE YOU INTERESTED IN:

• Your own emotional, psychological, physical and spiritual well-being?

• The balance between personal and professional needs and responsibilities?

• Sustaining the meaning in practicing pediatrics?

• Exploring core values and beliefs that underlie our roles as healers?

• Enhancing your sense of control over your work environment and life choices?

• Brining more well-being into your practice?

If so, we suggest you join the

Special Interest Group (SIG) on Physician Wellness!

The SIG is open to all AAP members. There are no dues and no required attendanceat meetings. Your interest, input and support are welcome to whatever extent you areable to provide them. We welcome your participation. We will soon be releasing anextensive report of an AAP survey of members on this topic.

If you would like to join, fill out this form and send to

Bob Sebring, c/o AAP 141 Northwest Point Blvd.Elk Grove Village, IL 60007

or via e-mail [email protected], or via fax, 847/434-4996:

— — — PLEASE PRINT — — —

Name: ______________________________________________________________________

Address: _____________________________________________________________________

___________________________________________________________________

Phone: ____________________________________________________________________

E-mail: ____________________________________________________________________


THE NEW ENGLISH LANGUAGEOBTAINED FROM THE INTERNET

By Sol Browdy, MD

The European Commission has just announced an agreementwhereby English will be the official language of the EuropeanUnion rather than German, which is the other possibility. As partof the negotiations, Her Majesty’s Government conceded thatEnglish spelling had some room for improvement and hasaccepted a five-year phase-in plan that would become known as“Euro English”. In the first year, “s” will replace the soft “c”.Sertainly, this will make the sivil servants jump with joy. The hard“c” will be dropped in favour of the “k”. This should klear up kon-fusion, and keyboards kan have one less letter. There will begrowing publik enthusiasm in the sekond year when the trouble-some “ph” will be replaced with the “f”. This will make words likefotograf 20% shorter. In the 3rd year, publik akseptanse of the newspelling kan be expekted to reach the stage where more komp-likated changes are possible. Governments will enkourage theremoval of double letters which have always ben a deterent toakurate speling. Also, al wil agre that the horibl mes of the silent“e” in the languag is disgrasful and it should go away. By the 4thyer peopl wil be reseptiv to steps such as replasing “th” with “z”and “w” with “v”. During ze fifz yer, ze unesesary “o” kan be dropdfrom vords kontaining “ou”. After zis fifz yer, ve vil have a reil sen-sibl riten styl. Zer vil be no mor trubl or difikultis and evrivun vilfind it ezi tu understand ech oza. Ze drem of a united urop vil finalikum tru. If zis mad yu smil, pleas pas on to oza pepl. Zen ve vilrul ze vorld!!

Editors’ Note: Perhaps the author of this suggestion,and Dr. Browdy, may recall the efforts of playwright andessayist George Bernard Shaw to bring about the adop-tion of phonetic spelling in Great Britain in the early1900s. He failed completely.

jan 2004 senior bulletin - the american academy of … · luck or fate? — a personal ... the...

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