Residents Ashwin Balagopal, Dan Negoianu and Karen Kelley cheer as they score a point in the Quiz Bowl that pitted them against alumni at the first-ever reunion of internal medicine house staff.

Samuel Kushlan moderated the match between residents and alumni.

Nothing trivial about house staff reunion

More than 225 former residents in medicine return to New Haven for program’s first reunion.

What is the name of the dog on the Cracker Jack box? How many movies did Tracy and Hepburn make together? Who was the first TV sitcom couple to share a double bed? How many points did Kareem Abdul-Jabbar score during his NBA career?

In the intellectually rigorous world of medical scholarship, you might not think this information would matter to the well-trained resident in Yale’s Department of Internal Medicine. But these facts proved vital at the first alumni reunion of house staff and fellows, held on campus October 25 and 26.

Free of the stress and exhaustion that dogged them during their residency years, more than 225 alumni—spanning the decades since 1935—showed up to reconnect with classmates and faculty and revisit the place where they launched their careers. “It’s very sentimental,” said Sanjivini G. Wadhwa, HS ’00. “When I talk to [fellows from other programs] they describe horrendous, nightmarish times. I don’t remember it that way. I remember a faculty that really got to know us and made us feel we could achieve something.”

Robert H. Gifford, M.D., HS ’67, had a similar experience. “It was like a big family,” he said. “It was a very enriching and supportive place.”

Welcoming the alumni gathered in the Fitkin Amphitheatre, Dean David A. Kessler, M.D., noted the dual role residents played. “You were students learning medicine and—whether it was as colleagues teaching fellow students, or residents teaching medical students or faculty teaching everybody—you were our teachers at the medical school. You are all part of the Yale family,” he said.

Ralph I. Horwitz, M.D., then-chair of the Department of Internal Medicine (See Faculty), praised Yale’s residency program, saying, “The house staff program has helped to shape American medicine through the contributions of its students, its residents, its fellows and its faculty.” He also expressed concern for what he sees as an erosion of the doctor-patient relationship. When he needs to seek out a resident, he said, the last place he looks is the patient’s room. “We must unburden doctors from their clerical duties and return them to the bedside,” he said.

But the seriousness was leavened by many lighter moments, most notably Quiz Bowl, a Trivial Pursuit-type contest between two teams of alumni and one composed of current house staff. Questions ran the gamut from popular music (In what year was “Duke of Earl” released?) and sports (What’s the width of a football field?) to geography (After Toronto, what’s the largest city in Canada?) and popular culture (In Gone with the Wind, how many months passed during Melanie’s pregnancy?) Questions about the medical school (What year was it founded?) stumped current house staff and alumni, while queries about the human body (How many permanent teeth does an adult human have?) were easily answered.

Who won? The house staff team’s correct answer to the question—How many states border Florida?—put them over the top. But it didn’t seem to matter, thus confirming what one returning alumnus said about the place: “There was very little one-upmanship. You were always made to feel you were part of the team.”

—Jennifer Kaylin

The answers to the trivia questions are as follows: Bingo; nine; Lily and Herman Munster; 38,387; 1962; 53 1/3 yards; Montreal; 22; 1810; 32; two. Although during the Quiz Bowl the Munsters were credited with being the first sitcom couple to sleep in the same bed, according to the Morty’s Fun Facts and Useless Information website, that distinction properly belongs to Darrin and Samantha Stephens in Bewitched.

In regions where resources are scarce, a gap between patients and treatment

The approximately 400 New Haven-area residents who stepped into a 48-foot tractor-trailer parked outside the School of Public Health for three days last October entered a world where treatable infectious diseases go unchecked because lifesaving medications are unavailable.

The trailer was home to AccessEXPO, a traveling exhibit that is part of the Access to Essential Medicines Campaign launched in 1999 by the international humanitarian aid group Doctors Without Borders. After almost a year in Western Europe, AccessEXPO attracted nearly 15,000 visitors in the United States between March and November 2002.

Through photographs, text, video, sound, and interaction with medical field volunteers and staff, the exhibit personalizes the crisis in access to essential medicines. Visitors spin a “Wheel of Misfortune” to be “stricken” with one of five diseases—sleeping sickness, kala azar (visceral leishmaniasis), HIV/AIDS, tuberculosis or malaria. A card titled “Your Situation” describes symptoms and concerns, family health history, obstacles to obtaining treatment, and other personal circumstances, such as living and working conditions. Visitors continue through the exhibit, learning about the history and nature of these diseases, their death rates, available treatments, the state of research and development for medicines and a host of other information. A ticking clock underscores the death rates for these diseases: every eight minutes someone dies from sleeping sickness; every 10 minutes someone dies from kala azar; and every minute five people die from AIDS, four die from TB and two children die from malaria. Visitors finish the tour with a “consultation” with a Doctors Without Borders volunteer about “their” disease and prognosis. Before leaving, visitors may sign a petition urging the U.S. government and the Pharmaceutical Research and Manufacturers of America (PHRMA) to make research and development of medicines for neglected diseases a priority.

The World Health Organization estimates that more than 14 million people die each year from infectious diseases, 90 percent of them in developing countries. For people in poor countries, the medicines they require either are too expensive or have gone out of production, often because they’re not considered profitable for sale to poor countries.

Mario Garcia, M.D., M.P.H. ’02, who worked with Doctors Without Borders from 1990 to 1995, assisted with the exhibit at EPH in October. Garcia, who served as a medical coordinator and country manager for health programs in Brazil, Bosnia, Nicaragua and Belize, said the exhibit conveys the gap between research and patients’ needs. He characterized the issue as one of “access vs. excess.” “Pharmaceutical research in Europe and the United States creates prosperity,” he said. “But with this prosperity comes responsibility. You cannot develop products only for the people who can pay.”

The pharmaceutical industry does provide assistance to those in developing countries, according to Jeff Prewhitt, a PHRMA spokesperson, including $1.5 billion in medicines to sub-Saharan Africa in 2001. “We take our charitable responsibilities around the world seriously, and we are heavily involved in a number of philanthropic programs,” Prewhitt said.

AccessEXPO’s tour of nearly 30 U.S. cities included stops at the American Public Health Association annual meeting in Philadelphia, Pa., and the American Medical Students Association convention in Washington, D.C., in March. It will conclude its tour in Washington in May, when the petitions will be delivered.

Commenting on the impact the exhibit may have on public health students at Yale and elsewhere, Garcia said it “shows that there are other needs, other ways to make a difference as a public health practitioner.”

—Anne Sommer

With an eye on outcomes, doctors work on perfecting the art of the interview

Robert C. Smith, M.D., Sc.M., told the 45 physicians at a workshop on interviewing skills last fall that he was about to demonstrate either an unskilled patient interview or an artful one. Afterward, he would ask the audience at the Yale faculty development workshop to judge which type he’d done.

Smith then interviewed a doctor posing as a patient with debilitating back pain. Smith extended his hand to the patient but did not introduce himself or greet the patient by name. When the patient began telling his story, Smith launched into a series of yes-or-no questions about the back pain but asked nothing about three other problems the patient mentioned: insomnia, worries about work and marital friction. Smith asked the audience: “Which sort of interview was that?”

“The regular one,” replied one physician in the audience in Hope 216—and everyone laughed.

Smith, a professor of medicine and psychiatry at Michigan State University, specializes in helping physicians improve upon that “regular” interview, the one in which, according to studies, physicians interrupt patients after a mean time of 18 seconds and miss 94 percent of problems linked to psychosocial distress. Smith argues that it is unscientific to focus solely on problems that are biomedical in nature. By largely ignoring psychosocial problems, physicians collect biased and incomplete data. The study of the interview, Smith said, “has brought the scientific method to the doctor-patient relationship.”

Smith taught the group how to conduct a more balanced interview, one that allows doctors to elicit and absorb the patient’s story while still meeting the doctor’s need for concrete information about the patient’s history of disease. Smith reported that research has shown that when physicians conduct skilled interviews, patients are more satisfied, compliant and knowledgeable; less likely to introduce last-minute “doorknob” complaints; and less likely to sue or to “doctor-shop.” Smith said skillful interviewing also improves outcomes: cancer patients live longer, blood pressures drop, surgery patients recover more quickly and perinatal outcomes are better.

Auguste H. Fortin VI, M.D., who directs the psychosocial curriculum for Yale’s primary care residency program, said that learning Smith’s technique for patient-centered interviewing “revolutionized my practice of internal medicine.” He said patients began telling him they felt better simply because they’d seen him. Interviewing is central to the physician’s work, said Frederick D. Haeseler, M.D., FW ’76, who directs the primary care clerkship and established an interview skills program at Yale in 1993. Haeseler said the average primary care physician conducts at least 100 patient interviews each week and more than 150,000 in a career, underscoring the need for students to learn how to communicate with patients both efficiently and effectively. “You really need to make connections with patients quickly,” he said.

Smith advised the group to begin by making the patient feel welcome, stating how much time is available (generally 15 minutes) and negotiating an agenda for using that time. (“When it’s crushing pressure on the chest radiating to the jaw, you say ‘We’ll deal with that first, not the discolored fingernail,’ ” Smith said with a laugh.)

He told the physicians to listen to the patient’s story during the patient-centered portion of the interview, by asking “focusing” questions. Next, when the patient has told his or her story, the physician should ask “emotion-seeking” questions and express respect and support. As Fortin put it, “Get an emotion on the table and handle it with empathy.” The doctor should inform the patient when it’s time to shift to the doctor-centered part of the interview, in which the doctor controls the conversation.

Smith’s approach saves time, according to Haeseler, because patients tell more coherent stories and make connections between physical symptoms, psychosocial factors and their experience of the illness, connections that might otherwise be collected piecemeal. Studies have proven the efficiency of including a patient-centered segment in the interview, according to Smith.

After Smith’s talk, workshop participants practiced interviewing each other, as well as actors trained to portray patients. Margaret J. Bia, M.D., FW ’78, said she was delighted that so many physicians had taken time off to learn how to build relationships with patients. “It’s getting harder and harder to do in the toxic atmosphere of the business model in which we’re all practicing medicine,” she said.

The purpose of the workshop was to train physicians to teach interviewing skills when they mentor Yale medical students in the “Doctor-Patient Encounter” course and in clinical clerkships. Smith said Yale was one of the few medical schools in the nation to teach interviewing skills to medical students not only in the first year but also in the third and fourth years, when students work with patients.

—Cathy Shufro

At Yale conference, calls for a “Marshall Plan” to fight HIV and AIDS

Children growing up in Massachusetts can expect to live almost 100 years; a child in southern Africa is likely to die by 35. Alex de Waal, D.Phil., co-director of Justice Africa, a nonprofit human rights group, said this difference between his own children’s prospects and those of African children is symptomatic of “an inequality in the right to life … that we have never witnessed before.” de Waal was one of 14 speakers from four continents at a November conference held at Yale, “HIV/AIDS as a Threat to Global Security.” The conference was organized by Yale College seniors Genevieve Tremblay and Ziad Haider with sponsorship from several interdisciplinary research groups at Yale. About 70 people attended.

A central theme of the conference was that AIDS imperils global stability by destroying families, disrupting economies and cutting short the lives of teachers, health care workers, farmers and political leaders. Although major epidemics are poised to erupt in India, China, Central Asia and Eastern Europe, nowhere is the possibility of destabilization more threatening than in Africa.

The “secondary impact” of AIDS in Africa, de Waal said, may be even more devastating than “the terrible figures” showing that HIV has infected up to 30 percent of the population in some countries. A wave of social and economic disruptions is “just beginning to crash over southern Africa,” he said. People won’t live long enough to pay off mortgages. Women who know how to survive by foraging during famine will grow too sick to transmit that knowledge. University-educated young people will die a decade into their careers. He compared Africa under these circumstances with a university led by student leaders instead of seasoned academics.

The world needs a “Marshall Plan” to respond to the “catastrophe,” said Paulo Roberto Teixeira, M.D., an AIDS program director in Brazil, which distributes its own generic anti-retroviral drugs gratis. The burden of the epidemic “is a global responsibility,” said Teixeira. “It’s very clear that rich countries will have to pay the bill. Rich countries are rich because they drain the majority of resources from the rest of the world.”

Indeed, Western countries are not paying their share, said Stephen Lewis, United Nations Special Envoy for HIV/AIDS. UN Secretary-General Kofi Annan’s campaign for an annual AIDS budget of $10 billion has brought in only 5 percent of that during three years of trying. Lewis said the United States has contributed less than $1 billion of its $2.5 to $3 billion share, based on its gross national product. [In his State of the Union address in late January, President Bush announced a commitment of $15 billion to fight global AIDS over the next five years, including $1 billion for the UN fund, a portion critics called inadequate.]

Women with AIDS, children in tow, ask Lewis, “Why can’t we have the drugs that you have?” He has no answer. “I don’t understand what in God’s name is happening. … We talk about [AIDS] endlessly, and we are losing millions of lives every year that we don’t have to lose. That’s what’s so astonishing: we’re just losing lives and we don’t care. … And I’ll never understand—to my dying day—I’ll never understand it.”

—Cathy Shufro

Et Cetera

When Pfizer comes to town

Nearly two decades ago, vacant land on Frontage Road was designated a potential site for private ventures in biotechnology and the health sciences. In February, that vision bore its first fruit with the announcement of plans for a $35 million clinical research unit by Pfizer Inc., the world’s largest pharmaceutical company. During a ceremony in the Medical Historical Library attended by the governor, the mayor and Yale’s president, Pfizer CEO Hank McKinnell, Ph.D., unveiled plans for a 60,000-square-foot facility that would employ more than 40 staff and provide 50 inpatient beds for Phase I clinical trials. Pending approvals, construction is to begin in the fall. The proximity to Yale, its research capabilities and its scientists made New Haven the company’s first choice. “The informality of that interaction,” McKinnell said, “is going to spawn ideas that neither of us may have had.”

—Michael Fitzsousa

Tobacco funds up in smoke

The $246 billion tobacco settlement was supposed to help fund anti-smoking programs, but most states are using little or none of their windfalls for that purpose and aren’t making up the deficit with other monies either, a Yale researcher has found. The study, authored by Cary P. Gross, M.D., assistant professor of medicine, found that in 2001 states received an average of $28.40 per person from the settlement funds, but dedicated only $3.49 per person to tobacco control programs. Published last fall in The New England Journal of Medicine, the study also found that tobacco control spending was lowest in states with the highest rates of tobacco use. Gross said research has shown that tobacco control programs are highly effective at reducing smoking rates. “What people need to realize is that the decision to use tobacco settlement money for other purposes comes at the cost of human life.”

—Jennifer Kaylin


			Originally published in Yale Medicine, Spring 2003. Copyright © 2003 Yale University School of Medicine. All rights reserved.