Even as all the traditional trappings of reunion—the Friday evening clambake, the Saturday morning symposium and the dean’s welcoming reception—remained in place, change was in the air this year. At the traditional Friday afternoon welcome in the Starr Atrium of the Anlyan Center, the medical school’s new dean made his first appearance before alumni.
“This is my fourth day as dean here,” said Robert J. Alpern, M.D., who arrived from his post as dean of the University of Texas Southwestern Medical Center on June 1. Alpern lauded the alumni for their support of the school and said that he views serving as dean as “an incredible opportunity.”
For those willing to come to New Haven a day early, a reinvigorated Yale Surgical Society offered a Thursday afternoon roundtable, “The Surgeon as Writer,” by three of its veterans. And this year’s reunion included not one, but two scientific symposia, starting with a Friday afternoon panel on cardiovascular disease. The traditional Saturday morning panel discussed ethical issues facing physicians.
At the annual Saturday morning meeting of the Association of Yale Alumni in Medicine (AYAM), two appointments were made to the executive committee. Richard D. Kayne, M.D. ’76, HS ’79, was appointed to his first two-year term. Irving G. Raphael, M.D. ’71, was elected to a second two-year term. In addition, Ercem S. Atillasoy, M.D. ’91, and Frank L. Gruskay, M.D. ’54, HS ’56, were named representatives to the Association of Yale Alumni.
Arthur C. Crovatto, M.D. ’54, HS ’61, and Joseph F.J. Curi, M.D. ’64, each received the Distinguished Alumni Service Award. Of Crovatto, a classmate wrote, “It is reported that when you cut yourself shaving, you bleed Yale blue. We thank you for your energy and your dedication to the Yale School of Medicine.” To Curi, said Donald E. Moore, M.D. ’81, M.P.H. ’81, president of the AYAM, “You have been a tireless worker and loyal alumnus.”
Over lunch, talk about obesity
On Friday, at the New Haven Lawn Club, the topic at the School of Public Health’s Alumni Day was obesity. During a panel discussion, a keynote speech by Kelly D. Brownell, Ph.D., professor and chair of psychology and director of the Yale Center for Eating and Weight Disorders, and a luncheon talk by J. Michael McGinnis, M.D., Yale faculty and alumni discussed the implications of the national epidemic of obesity and its related health problems.
Elaine P. Anderson, M.P.H. ’76, director of alumni and community affairs, joked that organizing a conference on obesity presented a new problem. “This year,” she said, “the challenge was lunch. We had some food fights and we had some disagreements. The entrees will meet the requirements of Atkins, the South Beach diet and Carboholics Anonymous.”
“I was planning to stay for lunch until I heard what it was going to be,” Brownell quipped. “If it meets all those criteria it’s going to be awful.”
In a more serious vein, Brownell said that the nation’s obesity crisis has many roots. “Interwoven are complex social issues, political beliefs, large-scale economic forces and, of course, science,” he said. “What we are finding with the approach our government is taking, as well as the food industry’s, is that science is becoming almost irrelevant. That approach is driven by money and it leads to a focus on personal responsibility instead of the global environmental causes that are creating this problem in the first place.”
Following Brownell’s keynote talk, a panel discussed various aspects of the obesity crisis. Participants included Loretta DiPietro, M.P.H. ’85, Ph.D. ’88, associate professor of epidemiology (environmental health); Susan T. Mayne, Ph.D., associate professor of epidemiology and public health; Marlene B. Schwartz, Ph.D. ’96, co-director of the Yale Center for Eating and Weight Disorders; and Derek Yach, M.P.H., representative of the director-general of the World Health Organization.
Luncheon speaker McGinnis of the Robert Wood Johnson Foundation (RWJF) said that the current focus on counting carbs may help mitigate obesity, but it diverts attention from the key issues. “There’s no point arguing whether it’s fat or carbs that matter,” he said. “It’s both.”
McGinnis laid part of the blame for America’s sugar- and starch-laden diet at his own doorstep. In addition to being the principal architect of the Healthy People process that elevated nutrition on the national agenda, he was a key contributor to the Dietary Guidelines for Americans. The Guide-lines lay out central nutritional concepts that still pertain, but when the United States Department of Agriculture (USDA) developed the accompanying food pyramid many people looking at recommendations for six to 11 daily servings of bread, cereal, rice and pasta failed to distinguish between simple and complex carbohydrates.
“We in public health were so happy to have buy-in from the USDA, with its sizable food-industry constituency, that the potential for misunderstanding when it came to carbohydrates didn’t receive the emphasis it deserved. We meant clearly to focus on high-fiber carbs, and the fact is I didn��t pay enough attention to how the graphic might be misrepresented or to the appropriateness of the number of servings,” McGinnis said. But he added: “The good news is we have the opportunity now to get it right.”
Getting it right is important, given that Americans consume 150 pounds of sugar a year (compared to 7.5 pounds 200 years ago), McGinnis said, adding that diet and activity patterns are now responsible for more than 500,000 premature deaths each year in the United States, ranking at the top of the list of preventable causes of death. Because of the stakes involved, the RWJF has made childhood obesity its top priority. “The vision,” he said, “is not for everyone to be slim. Instead, we want society’s signals to promote a healthy diet and healthy living.”
At lunch the Distinguished Alumni Service Award was presented to James M. Malloy, M.P.H. ’67, president of Malloy Associates, a health care management consulting firm in Mississippi. James Rawlings, M.P.H. ’80, and Patti Harvey Rose, M.P.H. ’85, Ed.D., were inducted into the Alumni Public Service Honor Roll.
Finding the genes that cause disease
From the two photographs, it seemed obvious who would live longer. One showed a jogger, looking fit at 5’10” and 150 pounds. The other showed a seated man with a double chin, 5’8” and 270 pounds—a cigar smoker.
Ironically, the jogger fared far worse than did his counterpart, reported Richard P. Lifton, M.D., Ph.D., chair and Sterling Professor of Genetics, speaking at the symposium titled “Cardiovascular Disease: From Bedside to Bench and Back Again.” The first man, running guru James F. Fixx, died of a heart attack at 52. The other, Winston Churchill, lived to be 90. The probable cause for the difference—genes—is increasingly the subject of research at Yale into the leading cause of death in the United States, said Lifton.
Lifton’s research has led him to “scour the globe” for families with extreme phenotypes, such as severe hypertension, which develops as early as adolescence. Lifton and his team identify the genetic mutations affecting the families and show, on the molecular level, how the mutations cause disease. Understanding these mechanisms could suggest ways to manipulate gene products and pathways to fight diseases in the general population.
Other speakers included Jeffrey R. Bender, M.D., HS ’83, the Robert I. Levy Professor of Preventive Cardiology, who discussed the effects of hormone replacement therapy on vascular inflammation; William C. Sessa, Ph.D., professor of pharmacology, who described his research on improving peripheral circulation; and Stuart D. Katz, M.D., associate professor of medicine, who discussed his hypothesis that lower serum iron levels reduce the risk of endothelial disease.
The ethics of modern medicine
At the Saturday morning symposium four panelists described ethical issues facing physicians and society. Thomas P. Duffy, M.D., explored “how it is that we live our daily lives as physicians.” Rupali Gandhi, J.D. ’00, M.D. ’04, discussed rules that protect children in clinical trials. Patricia T. Powell, M.D. ’87, described the Japanese practice of physicians informing families, rather than individuals, of bad news. Philip R. Reilly, M.D. ’81, J.D., discussed the impact of the genomic revolution.
For Duffy, the image of the physician has taken a beating. The New York Times, he said, was having a field day with articles about alcoholic practitioners, Botox queens of Park Avenue and “boutique” doctors catering to the elite. On top of depictions of physicians as something less than selfless healers, the demands of practice compete with those of family, and physicians find themselves involuntary partners with insurance companies that want a say in medical decisions. “Our profession is a house divided, almost a house conquered. It is time to come together to reflect on our moral dilemmas,” Duffy said.
Gandhi reviewed the issues concerning children as research subjects. In 1789, she noted, Edward Jenner made the questionable decision to test the worth of cowpox as a smallpox vaccination by inoculating his son. “Children,” Gandhi said, “lack the maturity and the information base to make a truly informed decision. The regulations [governing clinical trials] provide children with additional protections because they are a vulnerable group. Nevertheless, although regulations limit the participation of children in research trials, problems—such as ambiguous and inconsistent terminology—persist.”
During the four years she lived in Japan, Powell was at first appalled by physicians’ reluctance to share bad news with a patient. “I could not imagine any principled reason for not revealing to patients their diagnoses,” she said. Yet in Japan physicians are more likely to relay the information to a family member and, with the patient’s family, invent a fiction about the illness and find a way to continue treatment. However, a shift is under way and disclosure has become acceptable if the patient is psychologically stable and capable of making a decision regarding treatment; there are good relations between the doctor, patient and family; and the patient has a strong support network.
Family relations are also of concern to Reilly, CEO and chair of the board of Interleukin Genetics. If a patient has a genetic disorder, does the physician have an obligation to inform family members who might also be vulnerable? And how can a physician inform others without violating patient confidentiality? Pharmacogenetics, he added, “will change everything about patient care.”
Reilly also worries about genetic testing of fetuses. A survey of pregnant American women conducted in the mid-1990s found that many considered gene variants that predispose to obesity as serious as genetic mutations that cause cystic fibrosis. “I worry about a culture that is more interested in perfection,” Reilly said.
The surgeon as writer
Richard A. Selzer, M.D., HS ’61, gave up surgery, but he cannot give up writing. “Once you have become an artist and that third eye of the artist is open, it can never be closed,” he said.
At the ninth annual spring reunion of the Yale Surgical Society, Selzer and fellow writers and surgeons Sherwin B. Nuland, M.D. ’55, HS ’61, and Bernie S. Siegel, M.D., HS ’61, discussed the paths that led them away from surgery, even while drawing heavily on their experiences as physicians.
For Siegel, the act of writing was self-preservation as he struggled emotionally with death and dying. “The training we don’t have is: How do you deal with loss?” he explained. He coped by keeping a journal. Impressions grew in complexity and Siegel found himself writing books. He divided his calendar between medicine and writing until he noticed that he had colored all his days in surgery black—he had come to prefer writing.
Nuland’s entry into literature was less deliberate. A literary agent asked him to write a book called How We Die. Nuland declined until it dawned on him that the book would be an opportunity “to write about my entire career, indeed my entire life.”
How We Die was not what the agent envisioned. It was also a surprise to the author, who uncovered, “an entire philosophy about death and dying that I didn’t know I had.”
Like Selzer, who teaches creative writing to Yale medical and nursing students, Nuland believes medicine provides rich material for literature. “Please do write,” Nuland told his colleagues in the audience, before adding, to laughter, “but whatever you write, don’t send it to me.”