wcpm oct 2014

contents

6 project acces of wake county update

8

7

10

wcms call for articles

omnipotence or ominous impotence of humans and humanity

accountable care organization begins in wake county

4 wcms annual tara farms picnic

14 king lear and madness

Pictured Louise Wilson

WAKE COUNTY PHYSICIAN | 1

Publisher

Editor

Wake County Medical Society

Officers and Executive

Council

Council Members

WCMS Alliance

Co-Presidents

Wake County Medical Society

Paul Harrison

2014 President | Patty Pearce MD Secretary | Robert Munt, MDTreasurer | Robert Munt, MD President Elect | Andrew Wu, MDPast President | Dick McKay, MD Founding Editor | Assad Meymandi, MD, PhD, DLFAPA

Terry Brenneman, MDMaggie Burkhead, MDWarner L. Hall, MDKen Holt, MDM. Dixon McKay, MDAssad Meymandi, MD, PhD, DLFAPARobert Munt, MDPatricia Pearce, MDDerek Schroder, MDMichael Thomas, MD Brad Wasserman, MDAndrew Wu, MD

Barb SavageKaren Albright

WCPM

Wake County Medical Society2500 Blue Ridge Road, Suite 330

Raleigh, NC 27607 Phone: 919.792.3644

Fax: 919.510.9162 [email protected]

www.wakedocs.org

“The Wake County Physician Magazine is an instrument of the Wake County Medical Society; however, the views expressed are not necessarily the opinion of the Editorial Board or the Society.”

October 2014

contributors

L. Jarrett Barnhill, MD is a professor of Psychiatry at the UNC School of Medicine and the director of the Developmental Neuropharmacology Clinic within the Department of Psychiatry. He is a Distinguished Fellow in the American Psychiatric Association and Fellow in the American Academy of Child and Adolescent Psychiatry.

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Robert H. Bilbro, MD, FACP was one of the cofounders of Raleigh Medical Group where he practiced for 35 years. He now works as associate medical director for Community Care of Wake and Johnston Counties.

Pam Carpenteris Program Manager of Project Access of Wake County

Assad Meymandiis Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association; Life member, American Medical Association; Life member, Southern Medical Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012).

Wake County Physician Magazine (WCPM) is a publication for and by the members of the Wake County Medical Society. WCPM is a quarterly publication and is digitately published January, July, April, and October.

All submissions including ads, bio’s, photo’s and camera ready art work for the WCPM should be directed to:

Tina FrostGraphic Editor [email protected] 919.671.3963

Photographs or illustrations:Submit as high resolution 5” x 7” or 8” x 10” glossy prints or a digital JPEG or TIF file at 300 DPI no larger than 2” x 3” unless the artwork is for the cover. Please include names of individuals or subject matter for each image submitted.

Contributing author bio’s and photo requirements: Submit a recent 3” x 5” or 5” x 7” black and white or color photo (snapshots are suitable) along with your submission for publication or a digital JPEG or TIF file at 300 DPI no larger than 2” x 3”. All photos will be returned to the author. Include a brief bio along with your practice name, specialty, special honors or any positions on boards, etc. Please limit the length of your bio to 3 or 4 lines.

Ad Rates and Specifications:Full Page $800 1/2 Page $400 1/4 Page $200


Dear WCMS Executive Council Members,

Please note the following Executive Council meeting. Date: Tuesday, Nov. 11, 2014

Time: 6:00 pm

Where: 2500 Blue Ridge Rd. #330 | Raleigh NC 27607 A light dinner will be served at the meeting.

On behalf of Susan Davis, Executive Director of Community Health Foundation and myself, we have enjoyed working with you throughout 2014.

Thank you,Paul HarrisonExecutive DirectorWake County Medical Society

See page 6 for legend.

Since Project Access started in 2001, more than 20,000 uninsured, low-income adults have received medical and surgical treatment or a diagnosis that ruled out disease from Wake County doctors donating their time and skills. Since 2008 over $15 million per year has been donated in care.

Before Project Access, the safety net clinics had informal arrangements that allowed limited referrals to private physicians, hospitals and medication assistance programs, but referrals were labor-intensive. Many physicians donated care for their patients who could not afford to pay, but efforts were thwarted by a “patchwork” system of care that was ineffective and frustrating. If patients needed services they could not afford - whether medications, lab work, x-rays, specialty services or hospital care – physicians and other healthcare workers would spend time and effort searching for resources, asking for favors,

and dealing with paperwork. The coordinated care system Project Access provides is the reason physicians have continued to pledge support each year.

Project Access began recruiting dentists in 2013. The goal is to increase the network of oral health professionals who have a desire to treat those with few resources. Dentists are asked to either donate services in private offices or volunteer at the new Wake Smiles Dental Clinic at the Salvation Army Building.

Project Access has also increased the collaboration with local healthcare systems, namely the Open Door Clinic, Alliance Medical Ministry, Wake Health Service clinics, Southlight Healthcare, the Mariam Clinic, Shepherd’s Care Medical Clinic and People’s Medical Care. This partnership has helped to achieve the goals of the program by 1) facilitating the development of a more integrated local healthcare system for Wake County residents; 2) decreasing the use of emergency room facilities by the target population; 3) increasing primary care capacity in Wake County; and 4) increasing volunteerism among physicians and other community partners.

“Thank you” doesn’t really seem like enough. Hats off to all Wake County physicians AND dentists who are actively demonstrating their commitment to promoting the health of all people in this community. §

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Who’s Who at the WCMS 2014 Tara Farms Picnic (pictured left to right)

1 | Deb Meehan and Louise Wilson2 | Ken and Kristin Stone and family3 | Mini the Clown4 | Barb Savage, Anna Hattaway, Marilu Thordsen and Deb Meehan 5 | Murthy and Bharathi Manne6 | Paul Harrison and Susan Davis7 | Kirk and Shonette Charles & family8 | Warner Hall9 | Bindi and Anvitha Ravipati10 | Marilu Thordsen-Velez and daughter11 | Jamila Fletcher, Rasheeda Monroe,

and Murthe Manne12 | Patricia Pearce and Jamila Fletcher13 | Russell and Louise Wilson14 | Hetal Wasudev15 | Hetal Wasudev, Louise Wilson, Barb Savage, Deb Meehan and Marilu Thordsen16 | Louise Wilson 17 | Susan Denny, Hetal Wasudev and Louise Wilson18 | Walter and Frances Pugh19 | Patricia Pearce and Susan Davis

By Pam Carpenter

The Wake County Medical Society is inviting its members to write articles for upcoming issues of the Wake

County Physician Magazine. Wake County Medical Society members wishing to write an article for publication are asked to submit a brief five sentence proposal. Proposed article summaries could focus on your first person accounts of the

personal side of practicing medicine (e.g., a patient overcoming all odds and achieving a positive outcome, experience with grief/ overcoming grief, your best day practicing medicine, or care management success stories, etc.) or any other human interest story that might appeal to our readership- keeping in mind that anything resembling promotion of a current practice or practitioner, or taking a political stance would not be useable, with the final say on such matters resting with the editorial board. Please email your brief proposal to Paul Harrison, editor, by October 24th at [email protected]. The plan is to begin publishing member articles in the January 2015 issue, which will be posted on our website. Thanks!”


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Looking over the annals of human history, it is undeniable that we have made progress in industry, mechanization,

discoveries, and advancement in health, technology, arts, sciences and finance. After all, we put men on the moon with their safe return to earth more than 41 years ago. But one wonders if we have made any progress in civility, humanity and assertion of the necessity of love and charity in human relations. One wonders if we have succeeded in overcoming greed, if we have learned to stop manipulating, exploiting and using our fellow humans for our selfish gain.

1770 BC, a fellow by the name of Hammurabi, in Khuzestan, a part of Susa, Persian Empire, wrote a set of 282 rules or law, each of which dealing with the rights of

individual and the ultimate respect for one another. Over 50 of the 282 codes deal with equality of humans and specifically with the dignity and rights of women.

Cyrus the Great, the Persian Emperor, to whom the Bible has more than 100 references, over 2500 years ago, rule his kingdom with dignity and beneficence. One of the Biblical references, for example, Isaiah 45, calls Cyrus the Great, King of Persia, the Messiah. Cyrus emancipated the Jews and established equal rights for men and women. In managing his vast empire, to be in touch with his emissary/rulers in distant parts of the kingdom, developed a formal service charged with sending and receiving communiqués to and from his lieutenants, thus the birth of the postal service which he

Omnipotence or Ominous ImpotenceOf Humans and Humanity

By Assad Meymandi, MD, PhD, DLFAPA*


called “Peyk”. The cabinet of Cyrus the Great consisted of twelve viziers (ministers or secretaries) a few of whom were women. The first person in charge of the Royal mail service was a woman. Her name was Mithra (which in Zoroastrian parlance means, dignity). The father of the United States Postal Service (USPS), the polymath Benjamin Franklin, referred to Mithra in both official language, as well as amorous terms. After all, the gentleman was a lady’s man! No wonder he had special regards for Mithra…In 2010, in the same county, Persia, they are stoning women for an insignificant offense of showing their hair, or ankles or holding hands with a male in public. Is this progress in civility, humanity and human dignity?

Fast forward the clock of history. Count Giovanni Pico della Mirandola (24 February 1463 – 17 November 1494), the Italian Renaissance philosopher, at the age of 23, in 1483, in his equivalent to today’s PhD thesis proposed to defend 900 theses on religion, philosophy, natural philosophy and magic against all comers. The result was the famous Oration on the Dignity of Man. It has been called the “Manifesto of the Renaissance”, and a key text of Renaissance humanism. In this essay, Pico invokes the writings and thoughts of all ancient wise men, going back to Moses, Zoroaster, Zerubbabel, Pythagoras, Aristotle, Platonic philosophers and neo-platonic philosophers such as Plotinus to conclude: “At last, the Supreme Maker

spoke: we have made you a creature neither of heaven nor of earth, neither mortal nor immortal, in order that you may, as the free and proud shaper of your own being, fashion yourself in the form you may prefer. It will be in your power to descend to the lower, brutish forms of life; you will be able, through your own decision, to rise again to the superior orders whose life is divine.’’

So, where are we? Why we are not rising to the superior orders in advancing the cause of humanity, human dignity and enhance connectedness in human family?

Saadi of Shiraz, the eloquent Persian poet (born 1210, died 1290) has a poem, the rough translation is Bani Adam, the progenies of Adam. That is to say, we humans are organs of one body…If an organ of Humanity is in pain, other organs thereof cannot stay restfully, loosing their function…So, we humans without one another cannot function…” He goes on to say, “If one organ of the body is ill and aches, the rest of the body experiences pain and become restless…” I do not know of any more eloquent and descriptive simile that illustrates human being’s connectedness and brotherhood. Yet we have constant war, constant destruction and constant killing. In America we have a population of 300 million, or about 4.5 to 5% of the world’s roughly six billion, yet we consumed over 25% of the world reservoir of energy. We have over 2.5 million people in prison, more than any other developed nation.

Reliable sources report that up to 80% of our prison and jail population have a diagnosable psychiatric illness and should be treated rather than imprisoned. Certainly what International Affairs Committee is doing and has done since its inception in 1995 is helpful to bring these matters to the forefront of consciousness, and bring people together. Congratulations the NADE’s Board of Director and to host Jeffrey Price.

The title I have chosen for my MM today “Omnipotence or Ominous Impotence” draws on these historical facts. The life of Neolithic man on this earth is short, about ten thousand years. Looking back 8000 years ago with the emergence of Sumerians and invention of writing in Lydia, the world has witnessed rise and fall of many dynasties, empires and powerful nations. There was Mesopotamian kingdom, Accadians, Egyptians, and the mighty Roman Empire, Pax Romana, which was destroyed by Rome’s pre-occupation with the affairs of the Middle East. There were the Persian Empire now in shambles, and in modern day, the empires emerging in the developed world, British Empire and now America... Pax Americana…They have all experienced omnipotence, yet the ignominious ending has been nothing but impotence, destruction and reduction to a vague memory forgotten in the dustbin of human history. In England, there was Lady Matilda Maud (1102-1167) who first wrote [continued on page 12]

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WakeMed Key Community Care is an Accountable Care Organization (ACO) formed in the fall of 2013

to enhance the quality and coordination of health care, and to reduce the costs of care by providing more value for patients. ACOs facilitate medical providers’ working more closely together to create healthier communities and to help patients better manage their health. Doctors, hospitals and insurers participate voluntarily in accountable care programs to deliver enhanced coordination of care and provide resources to help reduce costs and improve quality of care for patients. These efforts can benefit patients in a variety of ways across their health care experience, including routine check-ups, ongoing disease management, necessary procedures, and unforeseen trips to the emergency department.

The ACO is a collaboration between WakeMed Health & Hospitals and Key Physicians. The partnership is designed to ensure that patients, especially the chronically ill, get the right care at the right time at the right level, while avoiding

unnecessary duplication of services and preventing medical errors.

Key Physicians is a network of 225 independent, primary care physicians which includes pediatricians, family practice physicians, and internal medicine physicians. It is an independent practice association (IPA) in Wake County in existence for 20 years. It is the largest such IPA in North Carolina. Additionally 65 nurse practitioners and physician assistants are a part of this IPA.

WakeMed is a well-established hospital system initiated and owned by Wake County, first opening its doors in 1961. Governance was changed in 1997 to a private, not-for-profit organization. At that time the name was changed from Wake Medical Center to WakeMed. Its ownership and governance remain entirely in Wake County. It retains a strong commitment to be a community based health care institution with a mission to serve the health and well-being of the people of Wake County. Its hospitals are on New Bern Avenue in Raleigh and on Tryon Road in Cary. In recent years, emergency departments, clinics, and

Acccountable Care Organization Begins in Wake CountyBy Robert H. Bilbro, M.D., FACP


surgical centers have been established at other locations in Wake County. In addition, WakeMed Health and Hospitals brings 25 primary physicians and over 200 specialty care providers to be a part of this ACO.

WakeMed Key Community Care is a nonprofit organization led by a 10 member board of directors which includes four physicians from Key Physicians, four physicians from WakeMed, a community representative who is a former board chair of WakeMed, and a Medicare beneficiary who is a physician retired from Key Physicians IPA.

The activation of this ACO occurred first with a shared savings contract with the Center for Medicare/Medicaid Services (CMS) to serve Medicare patients beginning January 1, 2014. Under that contract are more than 30,000 attributed lives.

In early August an agreement was signed by this ACO and Blue Cross Blue Shield of North Carolina. This contract will enhance quality and provide greater value to BCBSNC patients who receive care from WakeMed Health and Hospitals, WakeMed physician practices, or Key Physicians. Through this agreement WKCC and BCBSNC will work closely together to help patients better manage their health. Financial structures are in place to encourage payment for value of healthcare, including quality and efficiency. BCBSNC and WKCC are establishing a Joint Quality Committee, responsible for achieving high quality measures that focus on prevention, chronic disease management, inpatient quality, and patient satisfaction. This plan will enhance doctors’ ability to provide exceptional care both in and out of the office setting while controlling medical costs.

Benefits to patients with this new care model include:

• Proactive services that help patients achieve wellness and receive preventive care such as immunizations and screenings.

• Tools, materials and outreach that help patients better manage their chronic

diseases. • Secure online access to personal

health information so patients can actively participate in their care.

• Staff to help patients navigate care at the right level, at the right time, in the right setting.

• Safer, more effective care as a result of shared knowledge and best practices among health care providers.

• More information about the quality and costs of care.

Patients do not need to enroll or sign up. Current and new BCBSNC customers who are patients of WakeMed Health & Hospitals, WakeMed Physician Practices and Key Physicians will automatically benefit from enhanced coordination of their care through the ACO. Insurance benefits stay the same whether or not a patient’s physician participates in an ACO.

Recognizing the potential enhancement in quality and efficiency of healthcare, WakeMed is using this same infrastructure of the ACO for some 29,000 uninsured patients whom WakeMed has identified as using their facilities and staff for their healthcare whether it be in-patient, outpatient, or too often through the emergency department. WakeMed already absorbs the costs for this patient population. It expects to improve clinical outcomes and save expenses in the healthcare of these uninsured patients by utilizing systems developed by this ACO for Medicare patients and commercially insured patients.

WakeMed/Key Community Care is a new accountable care organization, now less than a year-old, committed to enhancing quality and improving value in healthcare. It is already taking effective steps to improve collaboration and coordination among the various elements of the health care system. §

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a manifesto of human and women rights. Her activities led to emergence and development of King John’s Magna Carta in 1215. In America, Susan B Anthony (1820-1906) fashioned her activities after Lady Maud. In 1920, the 19th amendment to the Constitution signed by President Woodrow Wilson gave women right to vote.

With the historical decline and retrogression of human values and the humanities, I am offering some thoughts and suggestions. The history of humanity has offered us some brilliant role models who forcefully invite us to espouse the kind of altruism that promises the salvation of humanity.

I want to invoke the names of three brilliant stars in the intellectual firmament whose teachings have influenced human behaviour the most. The first is Saint Augustine of Hippo, born 345, died 430 AD. He was born a pagan, converted to Christianity at age 32, in 386, was baptized Easter Sunday April 4, 387. He wrote 49 volumes in theology, philosophy and other topics related to humanities, a total of 25 million words. Saint Augustine’s autobiography, 13 books of Confessions bravely talks about his stealing from his parents, fathering a son out of wedlock, stealing pears form neighbor’s yard, lying to his mother and finally sneaking off to Carthage, thence to Rome where he became a Manichean and finally met his intellectual superior in the person of St. Ambrose in Milan. St. Ambrose, one of four Latin

Doctors (beside Augustine, Saint Jerome, and Pope Gregory) was instrumental in setting Augustine’s course to conversion and ultimately to priesthood and Sainthood.

Saint Augustine’s writing is replete with man’s dalliance with false omnipotence. He wrote extensively about narcissism, self indulgence and greed. As a matter of fact, he called a newborn baby not a bundle of joy and innocence, but a bundle of sin, because the baby is wrapped up in self and survival and removed from consideration of others. This is what in psychoanalytic jargon is called “primary infantile autism” or “primary infantile narcissism”. As the child grows and the central nervous system matures, reality testing skills and learning to have consideration for and, deference to, others are developed. The opportunity to grow and become more altruistic, more giving, and less selfish and self centered is the gift of life. Saint Augustine was a proponent of the concept of grace and salvation. He espoused Pauline theology of grace which briefly is described as “an unearned and undeserved free gift”. He wrote more than a million words on grace.

The second brightest star of the intellectual firmament we are exploring is Moses Maimonides of Cordoba, born 1135, died 1204, a Jewish physician, colleague, theologian, philosopher, clinician and practitioner. He too wrote about 20 million words in his lifetime. He also was concerned

about the issue of grace and salvation. Moses, in spite of being the Caliph’s personal physician in Cordoba, was pressed by anti-Semitic forces to flee to Egypt. There is a small statue of Moses (Rambam) in Cordoba. Emily and I take a single long stem rose and place it at his statue every time we are in Cordoba. We do the same when we visit the tomb of Claudio Monteverdi, father of Western Opera (Orpheo et Euridice 1607) in Iglesia de Santa María Gloriosa dei Frari, Venice, Veneto Region, Italy

The third brightest star of the intellectual constellation is Ibn Khaldoun, born 1336, died 1420, an Arab/Muslim theologian, economist, philosopher, music lover and advocate and writer. He too wrote about 20 million words in his lifetime. Ibn Khaldoun was the father of trickledown economics which was adopted by the late President Reagan in 1981. He appointed Columbia Professor Robert Mundel, as Chair of the White House Economic Council. Emily and I had lunch with him at his villa near Florence in 1993. And our conversation was around Ibn Khaldoun whose books and writings surrounded Robert’s study. He won the Nobel Prize for Economics in 1999, after fathering the birth of Euro as a unit of currency for Europe. He is now busy developing a unit of currency for the Middle East. Incidentally, Ibn Khaldoun’s advocacy of music was ingenious. A word of history of the world of music in Islam is in order: Mohammad, the founder of

Omnipotence or Ominous continued from page 9]


Islam was born 580 AD. At age 40, 620 AD, he started Islam and two years later, the Islamic Holy Book, Quoran, was completed. In early Islam, music and paintings were prohibited by Islamic canon and Fatwa. Ibn Khaldoun, a lover of music noted that it is permissible to sing the passages from Quoran as the Muezzins sing their invitation to prayer from minarets five times a day. He suggested to the ruling grand Ayatollah of the day to organize a competition and invite the best readers of various Islamic nations to come to a place and compete, picking the best singers of the Quoran passages. It is called Talavat Quran Majeed. It started in 1365 and continues to this day. It is like the Olympics of signing. He later introduced percussion (tablah) and strings to enhance the majesty of Quoranic passages. The Talavat competition has gone on uninterruptedly since 1365. The only other continuous musical event regardless of war, depression and uncertainties is Handle’s Messiah, since 1742. The first performance was attended by George I. He was so moved by the Alleluia chorus that he stood up, handing down the custom of standing ovation to this day.

These three writers’ advice against hubris, omnipotence, appearance and glitz, repeatedly warn us not to mistake ominous impotence for power and omnipotence. The distilled message of almost 60 million words written by these three sages is—and I am offering it as a take home

treat-- “The road to grace, salvation is to know what is good inside of you, that is intellect love, compassion, altruism, empathy, access to the rich array of so many other feelings; and knowing what is good outside of you, family, connectedness, friendship, music, nature, flowers, dance, and poetry; And to be thankful for them by giving something back and making a difference in the lives of others.” The issue of awareness is very important. It takes discipline to be aware. The heightened form of awareness in Sufi is called “Zekr”, that is to be constantly aware of all good things inside and outside. Mowlana Rumi said “Blessed are those who are in Zekr; they are in constant prayer…” What do we do with all this doom and gloom and pessimism? I think there is hope. There is possibility, there is redemption.

I believe that ultimately for those who believe in God that God wants us humans, His children or Her children, to succeed and progress. From time to time, one is chosen to become a role model. He sent Buddha to teach us patience, wisdom and awareness. He sent Zoroaster to give us the concept of good and evil, epistemological dualism. He sent Moses to exemplify discipline, devotion and yes, the gift of doubt. He sent Jesus of Nazareth to demonstrate the power of love. He sent Mohammad to offer us Islam total submission to the will of God. He sent Mozart to illustrate the power of music. This every day common man with multiple organ

system failure, including kidneys and liver ravaged by alcohol, mourning the death of his mother and his little daughter, in the summer 1786 wrote Symphony in G minor, topping the trio with Jupiter Symphony in C major. No mere human can do this. Finally he sent America, our Founding Fathers, Thomas Jefferson, George Washington, James Madison, Benjamin Franklin and others to give us a system of government, a republic, that cherishes the supremacy of rule of law, and not the whims of kings, shahs and Ayatollahs. America is a decent and generous nation. America is there in case of natural disaster, in Tahiti, in Pakistan, in Nepal and Myanmar. America is a land that allows its citizens to reach their maximum potential. I am very optimistic about the future of the world because the world has America. §

*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

In For those of us past 60, Shakespeare’s King Lear animates some of

our worst nightmares about ageing and our “crawl towards death”. In this tragedy, Lear initiates the action by dividing his kingdom, abdicating his throne, and trying to maintain the trappings of his kingship. Perhaps he hoped to avoid civil war after his death, but his “do-you-love-me most” trial failed miserably. Like Oedipus, Lear makes

wrong choices and in doing so, inadvertently releases a “plague” upon his kingdom. He further complicates the situation by ignoring any contradictory advice from his closest supporters. But this tragic hero is from Shakespeare’ imagination, not from Sophocles’, and what a difference that makes.

There are 3 old men in King Lear- the king and his two advisors, Glocester and Kent. Each will endure a fall. Lear

falls farthest as a consequence of misjudging his three daughters. His descent begins with a rigged flattery contest to determine which daughter who loves him most. In fairy tale fashion, Cordelia, his youngest and favorite, refuses to play the game. Lear disowns her. Her two older sisters, Goneril and Regan, appease Lear and receive their rewards. Almost immediately they set about brutally deconstructing their father by stripping the

14 | OCTOBER 2014


king of the trappings of kingship. Shakespeare makes it abundantly clear - this is not your mother’s fairy tale.

Gloucester makes a similar misjudgment. He is fooled by an Iago-like bastard son, Edmond. Accepting Edmond’s false evidence of treachery by his legitimate son, Edgar, Gloucester disowns, then attempts to destroy him. Gloucester’s eventual punishment for his mistake is straight from

Dante’s Inferno- because he couldn’t see the truth, his eyes are torn out. Kent on the other hand directly lambasts the fallacy of Lear’s trial by love and is banished only to return, disguised in order to protect his king and friend. This play is not a safe place for old men.

There are three trials in King Lear. The first involves Lear’s trial-by-love-profession. The second trial involves Glocester. In it, the cruel

but rational Regan, her husband, Cornwall, and Edmond convict Glocester as a traitor. Cornwall, with Regan’s urging, gouges out the old man’s eyes and leaves him to “smell his way to Dover”. The mad Lear presides over the third trial as both the judge and prosecutor. Joining him on the tribunal are his Fool and Edgar (disguised as a madman). The defendants,

By L. Jarrett Barnhill, MD

King Lear and Madness

[continued on page 16]

Regan and Goneril, are stools in this surreal courtroom.

There are 3 species of madmen.

The Fool is mad but displays the greatest insight into Lear’s folly. The Fool’s antics, songs, satire and wit refocus Lear on his decisions as the cause of his undoing. The Fool functions as a psychotherapist but he is eventually hanged for supporting the disjointed king. Edgar escapes Gloucester’s plan to execute him by feigning madness as “Tom o’ Bedlam”. But, it is the king’s madness that takes center stage. Enraged, he commands a deconstruction of creation. Shakespeare’s use of the storm to animate Lear’s madness creates the central metaphor of this play- the disintegration of Lear, his kingdom and Elizabethan ideal of universe accreted by love. Without Love, there is primordial chaos.

There are 3 examples of uncharacteristic altruism and compassion- as it might appear in Lear’s world. Lear’s confrontation with Poor Tom as the “unaccommodated Man” reminds the king of his neglected subjects. Rather than revenge his father’s treatment, Edgar as Mad Tom leads the blind Gloucester to Dover and aborts Gloucester’s suicide

by staging a feigned leap from the cliffs. Gloucester miraculously survives, his depression temporarily cured. Cordelia returns from France to temporarily restore Lear’s sanity, but her invasion plans fail and she is hanged. The greatest act of altruism comes from Cornwall’s unnamed servant who dies trying to prevent the Gloucester’s blinding. But none of these actions undo the evil running amok in this play. There is no good deed that goes unpunished.

The forces of Machiavellian reason (Edmond, Regan, Goneril and Cornwall) win a battle, but lose the war. Cornwall is already dead; Edgar kills Edmond, while Reagan and Goneril destroy each other. Only Edgar, the unaccommodated man, and Albany survive. This course of action was so unsettling that 150 years after the play was written, Samuel Johnson acknowledged that he could never reread its ending. Several 18th and early 19th century presentations rewrote Shakespeare’s ending- Cordelia survives, marries Edgar and both rule England.

So what possessed the poet who “wrote for all the ages” to expose the dark horror lurking within the human condition? Why does Shakespeare end this tragedy without reconstructing a new universe as he might in a comedy? His “good” characters face the same cruelty, horror and brutal victimization as his villains.

Suffering does not purify nor sanctify. Lear comes to realize that he is just another unaccommodated madman. He suffers as Citizen Louis Bourbon in the French and Comrade Romanov in the Russian revolutions. In those worlds, what is madness? Is it a collapse, a fall, or a post-apocalyptic survival mechanism? Lear acknowledges the cruel reality of his disintegrating world when he notes that wailing is our first action on earth. Yet love, compassion, morality and kindness still emerge in the actions of a few.

Both Lear and Oedipus endured a world where insight and blindness seem intertwined? Oedipus blinds himself when he sees his wife/mother’s dangling body. Lear regresses further when he confronts Edgar disguised as Tom O’Bedlam. Both strip themselves of titles, earthly power, responsibilities and duties. Yet unlike Job, they also have no answer for their suffering other than a voice from the whirlwind. Lear remains “blind” until his last scene in which he looks into Cordelia’s face and sees something that offers hope. Is this a hallucination of a “foolish, fond old man” or does he finally understand why the people that he harmed still love him? Are such insights the transcendent or are they madness made manifest? §

16 | OCTOBER 2014

King Lear continued from pag 15]

CURRENT PROGRAMSProject Access - A physician-led volunteer medical specialty service program for the poor, uninsured men, women, and children of Wake County.

Community Care of Wake and Johnston Counties CCWJC has created private and public partnerships to improve performance with disease management initiatives such as asthma and diabetes for ACCESS Medicaid recipients.

CapitalCare Collaborative - The CCC program is a membership of safety net providers working corroboratively to develop initiatives to improve the health of the region’s medically underserved such as asthma and diabetes for Medicaid and Medicare recipients.

The Wake County Medical Society (WCMS) is a 501 (c) 6 nonprofit organization that serves the licensed physicians and physician assistants of Wake County. Chartered in 1903 by the North Carolina Medical Society.

Membership in the Wake County Medical Society is one of the most important and effective ways for physicians, collectively, to be part of the solution to our many health care challenges. A strong, vibrant Society will always have the ear of legislators because they respect the fact that doctors are uniquely qualified to help form health policies that work as intended. It’s heartening to know the vast majority of Wake County physicians, more than 700 to date, have chosen to become members of the Wake County Medical Society.

JOIN TODAY!

Become a Member of Wake County Medical Society and help support the indigent care and community service

programs of the Society.

WHY JOIN

To serve and represent the interests of our physicians; to promote the health of all people in Wake County; and to uphold the highest ethical practice of medicine.

WCMS MISSION

Service Programs - The spirit of volunteerism is strong in Wake County. Hundreds of local physicians volunteer to help our indigent. The Society coordinates several programs that allow low income individuals access to volunteer doctors and to special case management services for children with diabetes, sickle cell anemia or asthma.

Publications - Members receive the peer-reviewed The Wake County Physician Magazine four times a year, and we keep you informed regularly via pertinent emails. The magazine focuses on local health care issues in Wake County, the Wake County Medical Society and the WCMS Alliance, a companion organization composed of physician spouses and significant others.

Socializing with your physician colleagues - Many physicians feel too busy to do anything except work long hours caring for patients. But, the WCMS provides an opportunity for physicians to nourish relationships through social interaction with one another at our dinner meetings featuring prominent speakers and at other events.

Finally, joining the WCMS is plain and simple the right thing to do - Physicians and the community benefit from our membership and our leadership in local affairs.

BENEFITS OF MEMBERSHIP

To become a member of the Wake County Medical Society contact Deborah Earp, Membership Manager at [email protected] or by phone at 919.792.3644

HOW TO JOIN

A portion of your dues supports to the volunteer and service programs of WCMS. Membership is also available for PA’s. There is even an opportunity for your spouse to get involved by joining the Wake County Medical Society Alliance.

Are you interested in becoming a Wake County Medical Society member? Simply visit our website at www.wakedocs.org and complete the online application or contact us by phone at 919.792.3644.

A portion of your dues contributes to the volunteer and service programs of WCMS. Membership is also available for PA’s. There is even an opportunity for your spouse to get involved by

joining the Wake County Medical Society Alliance.

JOIN TODAY!

wcpm oct 2014

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