Penn Medicine Magazine | Summer 2016

SUMMER 2016

FOCUS ON PRECISION MEDICINE

What Medical Students Can Learn from Chaplains Turning an Internship at HUP into Poetry

THE PREP

On the Way to Residency Photos by Daniel Burke

The surroundings were different this year for members of the graduating class – the Harrison Auditorium in the Penn Museum – but the anticipation and excitement were the same. It was Match Day, when the 140 members Class of 2016 would learn where they would be doing their residency training. One by one, they were called to receive the envelopes that would tell them. “We’re going to be disseminating knowledge and expertise throughout the United States of America,” said J. Larry Jameson, M.D., Ph.D., dean of the Perelman School of Medicine.

Several students, as it turned out, will not be moving far: 37 students will train at Penn, CHOP, and the Scheie Eye Institute. With families, friends, and faculty in attendance, all of the students celebrated.

A LOOK AT THE CLASS OF 2016:

140

graduates

18 States where students will train

37

Students will train at Penn, CHOP and Scheie Eye

8

Students pursuing careers in business

TOP THREE SPECIALTY CHOICES: Internal Medicine Pediatrics Emergency Medicine

56%

Students who completed certificates or advanced degrees

8

16 22 28

DEPARTMENTS

Left THE PREP On the Way to Residency 2 VITAL SIGNS Penn joins the Parker Institute for Cancer Immunotherapy 34 DEVELOPMENT MATTERS First Medical Alumni Weekend at the Jordan Center Is Picture Perfect 36 ALUMNI NEWS Progress Notes and Obituaries 40 EDITOR’S NOTE To Be Precise 41 ONE LAST THOUGHT Capturing Global Health in Photos

19 33 SUMMER 2016 / VOLUME XXVII NUMBER

One Size Doesn’t Fit All | By Mark Wolverton 8 Combine the wealth of health-related information now available to doctors and researchers

with the substantial advances in molecular biology, and the result is the remarkable growth of precision medicine. The goal: to provide the right treatment to each individual at the right time.

16 Dr. Coulehan’s Journeys |

By John Shea

An advocate of medical humanities believes that poetry can offer glimpses of the deeper meaning of a physician’s work. Any raw material can be used – in Jack Coulehan’s case, even his difficult time as an intern at HUP.

19

When Majors Act Like Minors |

By Karen Kreeger

A research team anchored at Penn has shown that the social behavior of ants can be modified using chemical epigenetic inhibitors. What might be the implications for other animals?

22 Learning from Chaplains |

By David Lewellen

By shadowing chaplains as they interact with patients, first-year medical students at Penn can see the impact of spirituality on patients in crisis situations. The experience can help students learn how to acknowledge patients’ beliefs as they treat their bodies.

28 A Man, A Hip, An MRI: Close Encounters with the World of Orthopaedics | By Rob Press STAFF John R. Shea, Ph.D. Editor Graham P. Perry/NCS Studios Design / Art Direction ADMINISTRATION Susan E. Phillips Senior Vice President for Public Affairs Holly Auer, M.B.E. Director of Communications

It’s one thing for a Penn Med employee to be aware of what patients go through in the Health System. But what happens when that employee becomes the patient? Here is a personal – and entertaining – perspective.

33 Maintaining a Masterpiece |

By Paul Foster

Benjamin West, born in Springfield, Pa., but a successful artist in England, painted his second version of Christ Healing the Sick in the Temple for Pennsylvania Hospital. In the early 1800s, the painting served as a fund-raiser for the hospital.

Penn Medicine is published for the alumni and friends of Penn Medicine by the Office of Public Affairs. © 2016 by the Trustees of the University of Pennsylvania. All rights reserved. Address all correspondence to John Shea, Penn Medicine, 3535 Market Street, Suite 60 Mezzanine, Philadelphia, PA 19104-3309, or call (215) 662-4802, or e-mail john.shea@uphs.upenn.edu.

Visit Penn Medicine’s web site: http://www.uphs.upenn.edu/news/publications/PENNMedicine/

VITAL SIGNS

Carl June, M.D., far left, the Penn director of the Parker Institute, joined other members on stage with news personality Katie Couric, far right.

Penn Joins First-of-its-Kind Research Collaboration to Fight Cancer

The University of Pennsylvania has joined an unprecedented cancer research effort, the Parker Institute for Cancer Immunotherapy. The institute brings together six of the nation’s top medical schools and cancer centers to work toward accelerating breakthrough immunotherapy research that will turn more cancers into curable diseases.

The venture is backed by a $250 million gift from the Parker Foundation, making it the largest single contribution ever made to the field of immunotherapy. The Parker Foundation was founded by Sean Parker – who cofounded Napster and was an early president of Facebook – with a $600 million gift intended to spur innovations in the life sciences, global public health, and civic engagement.

“We are tremendously excited to join this collaboration, which will allow us to investigate promising new immunotherapy avenues for the treatment of cancer outside of our institutional silos in very unique ways,” said the Parker Institute’s Penn director, Carl June, M.D., the Richard W. Vague Professor in Immunotherapy in the Department of Pathology and Laboratory Medicine and director of translational research in the Abramson Cancer Center. “Working together will enable us to make quicker progress as we work to translate our laboratory findings into clinical trials.”

Initial funding of $10 to $15 million has been awarded to set up the Parker Institute at Penn. This investment will con2

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tinue to grow on an annual basis via additional project grants, shared resources, and central funding. The funding will support laboratory studies and clinical trials, recruitment of faculty, and support for early-career investigators who will train at Penn. Robert Vonderheide, M.D., D.Phil., the Hanna Wise Professor in Cancer Research and associate director of translational research in the Abramson Cancer Center, and John Wherry, Ph.D., a professor of microbiology and director of Penn’s Institute for Immunology, will serve as co-directors of the Parker Institute at Penn.

The Parker Institute includes more than 40 laboratories and 300 researchers from Penn and five other leading centers: Memorial Sloan Kettering Cancer Center; Stanford Medicine; the University of California, Los Angeles; the University of California, San Francisco; and the University of Texas M. D. Anderson Cancer Center. In a unique agreement among the centers, the administration of intellectual property will be shared, enabling all researchers to have immediate access to a broad range of core discoveries.

The Parker Institute’s scientific advisors and site leaders have laid out a scientific roadmap which allows the Parker Institute scientists to make big bets on major cross-cutting collaborative research projects, as well as to fund individual research projects at its sites. At Penn, initial projects will cover a wide range of both basic science and clinical areas, including studies to test the ability of oncolytic adenoviruses to enhance T cell therapy efficacy, and cancer prevention vaccines.

N.I.H. Panel Cites Center’s Success

A new five-year N.I.H. grant to the Penn Center for Musculoskeletal Disorders will support research aimed at improving the prevention, diagnosis, and treatment of conditions such as osteoporosis, osteoarthritis, low back pain, and rotator cuff tears.

128 112

ABOUT THE CENTER:

$4

Million Grant

faculty members

from five Penn schools

A Rise in Opioid Prescriptions

A recent online study in JAMA by Penn researchers traced a steady rise in opioid painkiller prescriptions provided by physicians to surgical patients for relatively minor procedures. Across all four surgeries included in the study, the percentages of patients who obtained and filled opioid prescriptions sharply increased from 2004 to 2012, rising as much as 18 percent for patients undergoing knee arthroscopy. “These data show us a concerning trend,” said Mark Neuman, M.D., M.Sc., senior author of the study. Neuman, an assistant professor of anesthesiology and critical care and director of the Penn Center for Perioperative Outcomes Research and Transformation, said that additional work is needed “to define better strategies for treating postoperative pain safely and effectively in the future.”

They Said It

In The Top Five Again: Perelman Shines The Perelman School of Medicine was ranked the 3rd best research-oriented medical school in the United States in the annual medical school survey by U.S. News & World Report. This is the 19th year in a row the school has been ranked among the top five medical schools. The Perelman School also ranked among the nation’s top medical schools in three areas of specialty training: a first-place ranking in Pediatrics and honors in Women’s Health (#3) and Internal Medicine (#4). The School of Medicine is also #11 in the rankings of medical schools specializing in primary care.

The U.S. News rankings placed the Perelman School of Medicine in a three-way tie with Johns Hopkins University and University of California, San Francisco. Harvard University and Stanford University were ranked first and second.

The medical school rankings, released annually in the U.S. News & World Report “Best Graduate Schools” issue, are based on statistical indicators that measure the quality of a school’s faculty, research, and students. Information is obtained through surveys of program directors, academics, and other professionals. Criteria used include peer assessment surveys, research activity, MCAT scores, and NIH funding.

“Study after study shows that screening saves lives,” said Chyke A. Doubeni, M.D., M.P.H., chair and the Presidential Associate Professor of Family Medicine and Community Health, referring to colorectal cancer. It is the second highest cause of cancer death in the United States, expected to claim the lives of an estimated 49,190 people in 2016. As Doubeni notes as lead author of a commentary in Gastroenterology, “many of those in the group most affected by this deadly disease are unable to afford the screening they critically need. We must renew efforts to ensure equitable access to and use of disease prevention, detection, and treatment services for colorectal cancer.”

M.D. + J.D.

Cross-disciplinary study has been a longstanding hallmark of the curriculum in both the University’s Perelman School of Medicine and the Law School. They have just announced a joint J.D./M.D degree program for students pursuing careers at the intersection of law and medicine. The new program will begin accepting applications for the 2017-18 academic year.

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VITAL SIGNS Honors & Awards

Marisa Bartolomei, Ph.D., a professor in the Department of Cell & Developmental Biology and co-director of the Epigenetics Program, has been awarded the 2017 Genetics Society Medal. The award recognizes outstanding research contributions to genetics. She will deliver an accompanying lecture and receive the medal next year at the Society, which is based in London.

Bartolomei’s laboratory focuses on the study of genomic imprinting and X-inactivation in mice. In most cases, people inherit one copy of genes from each parent. But in genomic imprinting, just one of the two versions is activated. One imprinted gene that Bartolomei studies, H19, may help suppress tumors by preventing cancer cells from growing and dividing.

In X-inactivation, one of the two copies of the X chromosome in female mammals is inactivated.

Bartolomei joined Penn as an assistant professor in 1993. In 2011 she received a MERIT award from the National Institutes of Health, and she was elected a fellow of the American Association for the Advancement of Science in 2014. Bartolomei is a member of the editorial boards of Human Molecular Genetics and Molecular and Cellular Biology as well as associate editor for PLOS Genetics. She has published approximately 120 papers in peer-reviewed publications.

David F. Dinges, Ph.D., chief of the Division of Sleep and Chronobiology and director of the Unit for Experimental Psychiatry in the Perelman School, has received the 2016 Pioneer Award from the National Space Biomedical Research Institute. The award recognizes an individual each year whose efforts and accomplishments have blazed new trails on behalf of the Institute, its partnership with NASA, and the space biomedical community at large.

Dinges has conducted studies through peer-review grant funding from the Institute since its inception in 1997 and has conducted additional grant-funded research for NASA during this period. His recent research for NASA includes studies of sleep, alertness, and neurobehavioral responses of astronauts on the International Space Station and on people living in isolated, confined, and extreme space-analog environments. He is currently leading a group of scientists integrating a suite of validated “Behavioral Core Measures” for use by NASA in spaceflight, space analogs, and exploration missions.

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Dinges has more than 300 scholarly publications whose findings have influenced public policy, public health recommendations, and work schedules for professionals in safetysensitive occupations, such as astronauts, pilots, health care professionals, commercial drivers, and first responders.

Benjamin Aaron Garcia, Ph.D., a Presidential Professor of Biochemistry & Biophysics, was named the recipient of the 2016 Protein Science Young Investigator Award, given to a scientist who has made an important contribution to the study of proteins within the first eight years of an independent career. His pioneering research involves developing new mass spectrometry methods and bioinformatics computational tools to examine critical modifications in cellular proteins that alter and control their functions. Garcia, who earned a doctorate in chemistry from the University of Virginia, has received more than a dozen major awards, including a Presidential Early Career Award and a National Institutes of Health Director’s New Innovator Award.

Kiran Musunuru, M.D., Ph.D., M.P.H., an associate professor of cardiovascular medicine and genetics, has been honored with a Presidential Early Career Award for Scientists and Engineers.

The award recognizes Musunuru’s outstanding achievements in research on the genetic factors behind heart attack, sudden cardiac death, and other cardiovascular disorders. Musunuru officially joined Penn in March from Harvard University.

The Presidential Award Program was created to honor young scientists and engineers who, in their early research careers, exemplify exceptional potential in the field. Musunuru received up to a five-year research grant from the National Heart, Lung, and Blood Institute to support his focus of analyzing the genetics behind cardiovascular and metabolic diseases by using human models – genetically modified human pluripotent stem cells and stem-cell-derived tissues – and “humanized” mouse models to study genetic variations.

In tandem with his biomedical research, Musunuru is a practicing cardiologist and a teacher. He received his medical degree from Weill Cornell Medical College, his Ph.D. degree from The Rockefeller University, and his M.P.H. degree from Johns Hopkins.

Amita Sehgal, Ph.D., the John Herr Musser Professor of Neuroscience and director of the Chronobiology Program in the Perelman School of Medicine, has been elected to the National Academy of Sciences, considered one of the highest honors accorded a U.S. scientist or engineer. Sehgal studies the molecular and genetic components of sleep and circadian, or 24-hour, rhythms. Using the fruit fly, she and others have characterized a molecular clock present in flies and humans.

Her lab has also developed the fly as a model system for studying sleep, showing that the rest phase in flies is a sleeplike state, helping to answer important questions about the essential need for sleep. Sehgal received the Stanley Cohen Senior Faculty Research Award from Penn Medicine and is associate editor

of the Journal of Clinical Investigation and associate editor for the Journal of Neuroscience. She is also a Howard Hughes Medical Institute investigator.

Sehgal was selected along with two other Penn faculty members: Marsha Lester, Ph.D., the Edmund J. Kahn Distinguished Professor in the Department of Chemistry, and Andrea Liu, Ph.D., the Hepburn Professor of Physics in the Department of Physics and Astronomy, both in Penn’s School of Arts and Sciences.

Two Elected to Association of American Physicians

Two Penn Medicine physicians – Ebbing Lautenbach, M.D., M.P.H., M.S.C.E. ’01, chief of the division of infectious diseases and the Robert Austrian Professor in the Department of Medicine, and Ben Z. Stanger, M.D., Ph.D., an associate professor of medicine and associate investigator of the Abramson Family Cancer Research Institute – were elected to the Association of American Physicians.

Lautenbach, also a professor in the Department of Biostatistics and Epidemiology, has focused his work on the control of bacterial infections in both health care and community settings. His research has concentrated primarily on understanding and curtailing the emergence and further spread of antibiotic-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gram negative organisms. More recent work has focused on the role of biomarkers to inform the use of antibiotics.

Stanger and his lab study how cells acquire their specialized features and their ability to adapt to new roles when given exposure to new, different conditions. His work has focused on gastrointestinal cancer and tissue regeneration. Stanger received his medical degree and his doctorate from Harvard Medical School and came to the University of Pennsylvania in 2006.

Pathologists Honored

The American Society for Clinical Pathology (ASCP) has named two faculty members in the Perelman School of Medicine, Kevin Alby, Ph.D., and Roseann Wu, M.D., to the society’s 2016 “40 under Forty” list. Both are assistant professors in the Department of Pathology and Laboratory Medicine. The award honors the top 40 pathologists, residents, and laboratory professionals under the age of 40 who are making significant contributions to the profession. Nominees represent the achievements and qualities important to the pathology and laboratory sciences fields and stand out as future laboratory leaders.

Alby received his doctorate in pathobiology from Brown University and completed a fellowship in clinical microbiology at the University of North Carolina Hospitals. He is an assistant director of the Clinical Microbiology Laboratory at HUP, where he focuses on implementing new technology such as multiplex PCR assays and MALDI-TOF mass spectrometry. He is focused on identifying resistant bacteria sooner and developing molecular tests to detect viral illness. The ASCP cited Alby for his active role in professional organizations.

Wu received her medical degree and master’s degree in public health from the Icahn School of Medicine at Mount Sinai. She took her AP/CP residency at Massachusetts General Hospital, where she was chief resident and a Priscilla D. Taft Fellow in Cytopathology. Also specializing in cytopathology at HUP, she is a member of the Anatomic Pathology Division.

The ASCP cited Wu for her use of innovative methods for delivering education and involvement in adaptive e-learning initiatives. Penn is one of only six institutions with two or more honorees this year.

They Said It

“I don’t think there’s any doubt: Child maltreatment is our number one public health issue, and we need to do more about it, and Spotlight is just the beginning,” said Steven J. Berkowitz, M.D., an associate professor of clinical psychiatry and director of the Penn Center for Youth and Family Trauma Response and Recovery. Berkowitz was one of the panelists at a recent Levin Family Dean’s Forum, sponsored by the School of Arts & Sciences, which focused on this year’s Academy Award recipient for best picture and best original screenplay. Spotlight tells the story of the Boston Globe team that exposed the Roman Catholic Church’s cover-up of sexual abuse of children by priests. Child abuse, Berkowitz said, “happens in every institution that works with children in this country.”

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VITAL SIGNS to want to know how caring and comforting caregivers are in various departments of a hospital.”

In addition, two of the top five Yelp categories most strongly associated with negative Yelp review ratings – insurance and billing, and cost of hospital visit – are not covered by HCAHPS domains.

Citing previous research, the authors of the Health Affairs study note that formal surveys such as HCAHPS suffer from low response rates and typically entail significant delays between hospitalization and public reporting of results. While the researchers write that reviews on social media sites are not currently randomized, and are largely uncurated, unvalidated, and subject to gaming, they add that the reviews are free, continuously updated, and often reveal in precise detail what the

Yelp May Help

With 142 million unique monthly visitors, the online crowd-sourced Yelp wields a fair amount of influence when it comes to helping people chose where to dine, where to stay on vacation, and where to have their hair done. And where to go for their health care as well?

A recent study published in Health Affairs by researchers at the Perelman School of Medicine explored that very topic. On Yelp’s site, patients have been able to use the same rankings – from one to five stars – that people have used to evaluate other services and businesses. The Penn researchers compared approximately 17,000 Yelp reviews of 1,352 hospitals to reviews of the same institutions by the Hospital Consumer Assessment of Healthcare Providers and Systems. The HCAHPS Survey (pronounced “H-Caps”) is a standardized survey and data-collection tool that has been used since 2006 to measure patients’ perspectives of hospital care in 11 different categories.

But are those 11 categories sufficient to measure patients’s concerns? Raina M. Merchant, M.D., M.S.H. P., the study’s senior author, noted that 42 percent of U.S. Internet users in 2012 reported looking at social media for health-related consumer reviews. Merchant, an assistant professor of emergency medicine and director of the Penn Social Media and Health Innovation Lab, added that, “Meanwhile, only six percent of Americans had heard of the government website where the HCAHPS survey is reported, as of 2008.”

What’s Not Covered – and What Could Be

In fact, four of the top five Yelp topics most strongly associated with positive Yelp review ratings were not covered by HCAHPS domains. These included: caring doctors, nurses, and staff; comforting; surgery/procedure and peri-op; and labor and delivery. “These topics that are covered within the Yelp reviews are important because they relate to the interpersonal relationships of patients with physicians, nurses, and staff,” said the study’s lead author, Benjamin L. Ranard, a junior fellow at the Penn Social Media and Health Innovation Lab and a combined M.D./M.S. student in health policy research at the Perelman School. “Prospective patients are likely 6

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Reviews Negative and Positive

The negative Yelp hospital reviews are not for the faint of heart. A sampling of hospitals across the United States: “[This] ER is the absolute worse unless you have a gunshot wound or something weird growing out the side of your head!

Was there for hours with a friend. . . . But 8 hours in an ER and no conclusion to what happened is RIDICULOUS!!”

“The ER is horrible!!!!! My 18 year old daughter hurt her foot . . . went to the ER at 10:30 in the morning and got out at 6:30 at night. What did they do for her in all that time. . . . An X-Ray and a pair of crutches. . . . They did not even offer her a glass of water or something to eat in all that time!”

But in contrast: “I had surgery . . . and (almost) everyone was fabulous – surgeon, nurses, etc. . . . All test results, appointments, etc., get automatically uploaded and any doctor in their network can access the information. In-patient wards have family lounges with kitchenette and seating areas. The in-patient rooms are very quiet at night – the nurses close the doors but monitor through special windows out to the hallway.”

“Where do I begin. If I could’ve gave them six stars, I would’ve!! . . . I had a kidney transplant. . . . The staff who got me ready for surgery were really nice. They helped assure me everything is going to go fine when I got nervous.” problem or positive occurrence was that affected the patient’s or family member’s experience.

“In addition, patients’ perceptions of what matters most to them can change over time,” Merchant said. “HCAHPS may not be able to respond as agilely to these kinds of changes as social media.”

– Katie Delach

Two Named to Blue Ribbon Panel to Inform Cancer “Moonshot” Initiative

Chi Van Dang, M.D., Ph.D., director of the Abramson Cancer Center of the University of Pennsylvania, and Peter C. Adamson, M.D., G.M.E. ’87, professor of pediatrics and director of Experimental Therapeutics in Oncology at The Children’s Hospital of Philadelphia, have been named to the Blue Ribbon Panel that will help inform the scientific direction at the National Cancer Institute. Vice President Joe Biden launched the National Cancer Moonshot Initiative in January during a visit to the Abramson Center.

The panel — made up of clinical leaders, patient advocates, members of the pharmaceutical industry and experts in immunology, cancer prevention, bioinformatics, and genomics, among others — will serve as a working group of the presidentially appointed National Cancer Advisory Board and will provide scientific guidance from thought leaders in the cancer community. The effort aims to make greater headway in developing cancer vaccines, highly sensitive approaches to early detection, and enhanced data sharing.

“This Blue Ribbon Panel will ensure that, as the National Institutes of Health allocates new resources through the Moonshot, decisions will be grounded in the best science,” Biden said in a news release.

Among those also named to the Blue Ribbon Panel was Neal Kassell, M.D. ’72, professor of neurosurgery at the University of Virginia.

They Said It

“Less is more – less time in bed is better,” said Michael Perlis, Ph.D., an associate professor of psychiatry and director of the Behavioral Sleep Medicine Program. He commented on new guidelines from the American College of Physicians stating that cognitive behavioral therapy should be the first-line treatment for insomnia.

CBT has been shown to work for 50-70% of patients. “If you are awake, spend that time somewhere else,” Perlis told WHYY’s Newsworks. “That is the rule of thumb. There’s no pill on this planet that will give you sustainability of treatment gains after treatment is discontinued.”

As a Standard, BMI May Not Be A-OK

Packing on a few pounds may not be such a bad thing.

According to a recent study in JAMA involving more than 100,000 adults in Denmark, as a group, overweight people are living the longest nowadays. The new analysis fuels continuing debate about what’s a healthy body mass index — especially in light of rising obesity rates, improved heart health treatments, and other factors influencing health and longevity.

“This is a very carefully done study,” said Rexford S. Ahima, M.D., Ph.D., a professor of medicine and director of the obesity unit in the Institute for Diabetes, Obesity, and Metabolism. Commenting in Science News, he said that the findings strengthen the notion that “BMI as a number alone may not be sufficient to predict health and risk of death. It has to be taken within context.” Ahima was not involved in the research but has analyzed previous studies urging a rethinking of how BMI influences mortality.

Researchers screen for obesity by calculating BMI – a popular but fairly crude measurement of body fat reached by dividing a person’s weight in kilograms by the square of height in meters. People with BMIs between 18.5 and 24.9 are considered normal. A BMI between 25 and 29.9 is “overweight”; 30 and above is “obese.”

Many studies suggest that obese individuals face a higher risk of heart disease, stroke, and other ills. But a 2013 metaanalysis of 97 studies found that being overweight was associated with lower risk of death than having a normal BMI – a surprising finding that echoed a 2005 study by the same researchers.

From 1976 to 2013, BMI associated with lowest risk of death increased from 23.7 to 27. That falls squarely in the overweight category. Obese individuals also had the same mortality risk as people in the normal range, the analysis found. That trend held even when researchers took into account potentially confounding factors including age, sex, smoking, and a history of cardiovascular disease or cancer.

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By Mark Wolverton

Photos by Addison Geary

COVER STORY

With the recent creation of the Penn Center for Precision Medicine, the Center for Personalized Diagnostics, and the Institute for Biomedical Informatics, Penn is laying the groundwork to advance options for cancer patients and beyond.

F

or most of medical history, practitioners have faced a great dilemma. While in most ways, people are pretty much alike, they can still be very different on an individual and personal basis: not merely in superficial things such as skin color, hair color, height, weight, or even personality, but on a more profound genetic level. For physicians, that means that while the procedure for treating something like a broken arm is basically the same for every patient, dealing with a disease such as cancer is decidedly not. One is simple and straightforward; the other is infinitely more complex. Yet until very recently, given the tools and techniques available to doctors, a onesize-fits-all approach – aimed at the supposedly “average” patient, possibly with only minor, imperfectly understood variations – was the only option.

The Human Genome Project, the multibillion-dollar effort to map the entire human genetic blueprint, changed all that.

The wealth of information now available to doctors and researchers, along with new molecular biology techniques of unprecedented power, promises to supplement and perhaps even replace the coarse instruments of traditional medicine with new tools that can be wielded with exquisite precision and sensitivity.

The new term is precision medicine, one that few in the general population had ever heard until President Obama’s 2015 State of the Union address. During his address, he called for a national Precision Medicine Initiative. “What if figuring out the right dose of medicine was as simple as taking our temperature?” he asked. It may not be quite that simple yet, but Penn researchers are at the forefront of the effort to realize

the promise of this extremely new and still largely unexplored approach to medicine.

Even if the strategies and techniques now being developed are new, the idea itself really isn’t. Terms such as “personalized” or “individualized” medicine have been around for a while, representing the notion of approaching and treating each patient as an individual with a unique set of problems and issues. In that sense, of course, all medicine has more or less been “personalized” from its very beginnings: As Obama observed, “Doctors have always recognized that every patient is unique.”

But there’s a big difference between that and what’s now called precision medicine – a difference that’s, well, very precise.

“It’s a way to encompass personalized medicine without calling into question the fact that medicine has been personalized for a few thousand years,” says David B. Roth, M.D., Ph.D., chair of the Department of Pathology and Laboratory Medicine and director of Penn’s new Center for Precision Medicine (CPM). “It has to do with technological advances and being able to measure things very precisely and also to be able to make very highly targeted approaches to diseases like certain cancers, where we haven’t been able to do that before.”

The main reason we have not been able to do such things before is, in a word, information. Our ability to store, use, and disseminate it was limited. When the Human Genome Project completed its work, some observers – many of a more entrepreneurial than scientific outlook, hailed the achievement as

One of the new advances that are driving precision medicine is the development of next-generation, high-throughput sequencing technology that has sharply reduced the cost and increased the efficiency of genomic analysis. the dawn of a new age that would rapidly lead to definitive cures for cancer, heart disease, AIDS, and nearly every other scourge of humanity. After all, now armed with this new deep insight into the essentials of life, how could we not solve nearly every medical mystery?

Nature, as usual, turned out to be far more complex and stubborn than we’d hoped. Genes are indeed important, perhaps of primary importance in human health and some diseases, but it’s become increasingly clear that curing cancer, for SUMMER 2016

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David B. Roth, M.D., Ph.D., director of the new Penn Center for Precision Medicine, meets with Guannan Wang, Ph.D., a postdoctoral researcher in molecular and cellular biology.

example, is not simply a matter of turning the right genes on and off. A crucial insight of precision medicine is that more than just genetic information must be considered. It’s one reason that the earlier notions of “personalized medicine” using a person’s genome as the sole guide to curing his or her disease have evolved into far more sophisticated and broad-based

Penn’s Center for Personalized Diagnostics aims to deploy large-scale genetic testing to inform patient care.

According to Kojo Elenitoba-Johnson, M.D., its director, “We have more tools in the toolkit than we’ve had in the past, but clearly there remains a lot to be done.” concepts. The new medicine offers the prospect not just of treating existing disease but avoiding it altogether by identifying and flagging a person’s individual risk factors.

“Humans are not hardwired by their genomes,” noted an editorial in Science Translational Medicine last summer.

That’s why, said the authors, “a defining assertion of precision medicine is that genomics – no matter how powerful or economical – is far from sufficient to understand human physiology and pathophysiology. Myriad other components – molecular, 10

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developmental, physiological, social, and environmental – also must be monitored, aligned, and integrated in order to arrive at a meaningfully precise and actionable understanding of disease mechanisms and of an individual’s state of health and disease.”

But even if the initial hype over the sequencing of the human genome turned out to be overly optimistic, it has led to definite new advances that are now driving precision medicine. Of particular note is the development of next-generation, high-throughput sequencing technology that has sharply reduced the cost and increased the efficiency of genomic analysis. For that reason, the concepts of precision medicine are concentrated at present on a problem where they can do the most immediate good: fighting cancer.

As Francis Collins, M.D., Ph.D., director of the National Institutes of Health, and Harold Varmus, M.D., wrote recently in The New England Journal of Medicine, “Oncology is the clear choice for enhancing the near-term impact of precision medicine” (2/26/15). It’s an arena in which the more finessed approach of precision medicine can be a distinct advantage over the blunt force of more conventional treatment strategies.

“The way we traditionally have treated cancer is carpet bombing,” says Roth, using a self-consciously militaristic but apt metaphor. “There’s a lot of collateral damage. You’re basically napalming the jungle so you can get the bad guys. And that’s why with traditional chemotherapy, your hair falls out, you throw up, all the classic bad side effects.” But, he adds, “if you can find those little broken bits in the [genetic] machinery and target them, you’ll generally get a medication that doesn’t cause a whole lot of side effects.”

COVER STORY

Fighting Cancer, Still a Rapidly Moving Target

Compared to more systemically based disorders such as hypertension, “cancer is a relatively better understood paradigm to study,” says Kojo Elenitoba-Johnson, M.D., the Peter C. Nowell, M.D., Professor in the Department of Pathology and Laboratory Medicine and inaugural director of Penn’s Center for Personalized Diagnostics (CPD). Defining the genetic makeup of different cancers is a primary mission of the center. “We aim to deploy large-scale genetics testing in informing patient care,” he explains. Since the CPD opened its doors in 2013, more than 4,000 tumor samples have been sequenced. Because the specific genetic mutations driving certain types of cancers are now known, “there are directed therapies that can be deployed to arrest the growth of the cancer cells in a targeted and specific way without harming the normal cells.” And because genetic mutations are shared across a multitude of cancers, a therapy that targeted a mutation in one form of cancer may work against another form.

While cancer, genetically speaking, may be a relatively low-hanging fruit, it’s also a rapidly moving target. One patient’s lung cancer is not necessarily exactly the same as another’s, even if the same mutations initially sparked both tumors. Even in the same patient, cancer can mutate to evade the onslaught of targeted chemotherapy medications. That means the recurring tumor must be repeatedly sequenced. “It’s possible that in the recurrence there might be acquisition of mutations that are targetable,” says Elenitoba-Johnson. “Actually, we have examples of that, in which patients have responded famously well to the new medicine that was specified by the genetic testing.”

Dr. Elenitoba-Johnson inspects a flow cell, which typically contains 30 to 40 DNA samples at a time.

The center’s work, however, is only beginning. According to Elenitoba-Johnson, “The rate at which we’re able to identify mutations unfortunately is faster than the rate at which the drugs can be developed for specific mutations.” Still, he notes, “this is a new day. In the past, the armamentarium of drugs that could antagonize different mutations was a lot smaller than it is today. We have more tools in the toolkit than we’ve had in the past, but clearly there remains a lot to be done.”

Dealing with data is perhaps the main obstacle to the promise of precision medicine. More than simply collecting the vast amounts of information, the key to making it useful is understanding how one data point relates to others, and what it all means for treating disease.

Dr. Elenitoba-Johnson confers with David B. Lieberman, M.S., L.C.G.C, technical manager for the Center for Personalized Diagnostics.

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The “Engine” Behind Precision Medicine

Creating the CPD was an element of the Perelman School’s faculty-led “Shaping the Future of Medicine: Five-Year Strategic Plan, 2013-2017.” Another recommendation was establishing the Institute for Biomedical Informatics, which also opened in 2013. “Informatics permeates every aspect of precision medicine,” says Jason H. Moore, Ph.D., the institute’s director. “Every aspect of precision medicine benefits from informatics, from the clinical informatics side, the clinical databases, the patient resources that we can tap into to identify patients at high risk, and computational methodologies to extract the data, work with the data, and find the patterns. That requires informatics infrastructure to track the samples, make sure the samples are linked to the patient, and mine the patient data.” When the researchers have identified a subgroup of patients, they are then able to identify their samples and do specific testing on those samples.

It’s far more than simply genomics and knowing the roughly 25,000 protein-encoding genes of a human being. Again, it comes down to information, whether contained in the genome or the countless other environmental and experiential factors that shape the individual human being throughout a lifetime. For precision medicine to truly achieve its full potential, that information needs equal consideration with the genomic data. Ironically, measuring and understanding the unseen subtleties of the genome is currently far easier than understanding the effects of environment. Such effects involve not only air and water quality and toxic exposures, but the smaller-scale effects of an individual’s diet, lifestyle, activities, even psychology.

The medications a person takes can also be considered part of their individual “environment,” Moore explains. “You can think of drugs as environmental agents as well, because when you give a drug, you’re putting a chemical in the body, and there’s a whole cellular physiologic infrastructure for dealing with that. Each of us differs in our ability to process and metabolize drugs and in our response to those drugs. So we have to do the research to figure out how those multiple factors interact with each other to impact health and drug response.”

The environmental questions, Moore argues, need much more attention. “The tools and the technology just aren’t there yet. We’ve invested a lot of money in measuring the human genome and we can do that pretty well now, but we need a similar level of investment and commitment to measuring the environment and then being able to integrate all of that data using informatics into the genomic and clinical data.” In fact, Moore says, it’s not even that the research hasn’t been done yet. “We’re missing key pieces of information and data that we need to complete that research.”

One promising solution for collecting such data that’s just now becoming widespread consists of wearable or implantable personalized devices that can provide 24-hour real-time data on an individual’s various physical parameters. Many people already own devices like Fitbits, from which data could be collected and integrated into personal medical care. Specialized devices can also be designed and customized for specific studies. At Penn, Moore points out, “the Center for Excellence 12

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in Environmental Toxicology is talking about strapping on monitors that you wear throughout the day, just like an Apple watch, that measures what you’re exposed to and grabs all that data and feeds it into a database.” Such concepts are still in the very early stages, but they can be a practical means of gathering data for precision medicine.

In general, as far as patients are concerned, precision medicine is basically a behind-the-scenes matter. The CPM and CPD don’t treat patients directly: “Seeing patients and dealing with whatever advances we can help to enable will be done by the people who have always done it,” Roth says. Elenitoba-Johnson adds, “What we do is provide the clinicians and oncologists with information that basically specifies what kind of treatment their patients should get.” But there is a notable exception that makes precision medicine about as hands-on as it can get.

Knowing Better Where to Cut for Cancer

Cancer patients may have their tumors genetically sequenced and closely imaged with CT, MRI, and PET scanning. But when the time comes for a surgeon to actually remove the tumor from the body, the only tools he or she has available are the eyes and fingers. Cancer, however, is endlessly insidious and can hide in places that can’t be seen by the naked eye or palpated with the fingers.

“For the last 200 years, all you had was your hands and your eyes to decide where to cut,” says Sunil Singhal, M.D., an assistant professor of surgery. The director of the Penn Medicine Thoracic Surgery Research Laboratory, he was appointed director of the recently established Center for Precision Surgery.

But surgeons now have a new tool: fluorescent dyes that make cancer glow with color under infrared light.

“What happens is a patient comes in a hour or two before surgery, and we just inject a dye into their veins, and then you give it some time for the dye to go around their body. And then

On these two pages, Sunil Singhal, M.D., top right, leads a surgery with a new tool: fluorescent dyes that make cancer glow with color under infrared light.

once it gets taken up by the tumor, you go for surgery, and once the light in the room hits the tumor, it starts glowing.” That allows not only the margins of the tumor mass to be sharply delineated but can also reveal the presence of any satellite lesions in surrounding healthy tissues that might elude the naked eye.

“By having the dye, the tumor glowing, you can know better where to cut. We’ve been able to find smaller and smaller lesions that typically would have been missed.”

Over the past three years, Singhal and his colleagues have performed more than 300 surgeries on various types of cancer using the technique, known as intraoperative molecular imaging. “There are different surgeons doing different specialties.

There are some unifying themes, like finding tumors and making sure the margins are good. Each specialty has its own challenges. For example, breast cancer has a hard time with margins, and something called vector carcinoma in situ, VCIS. So we use it for that. With kidney cancer, we know where the exact margins of the kidney are, and instead of taking out the whole kidney, maybe we can just take out a chunk of the kidney, so kidney functions are not as affected. The future of cancer surgery is really transforming in front of our very eyes.” The Center for Precision Surgery is also embarking on clinical trials

and research to investigate techniques and establish the efficacy of precision surgery in different varieties of cancer.

The example of Singhal’s precision surgical techniques both demonstrates the breadth of disciplines encompassed by the “precision medicine” term and highlights why Penn is extremely well positioned to make great strides in the field. “I think Penn Medicine is ripe for this kind of work,” Roth says.

“We have the medical school and all the other schools such as Engineering, and we have strong computational people on campus. All the ingredients are at hand, but the scientists and clinicians are too busy doing their day jobs to really be able to make this happen.” On becoming director of the Center for Precision Medicine, Roth decided to bring all the pieces together. “I thought, let’s just add a little bit of extra power so they have the bandwidth to do it.”

With the various centers up and running, Roth believes that all of the pieces are now in place. “I’m hoping it’ll be especially useful for the research scientists, who are coming up with all these great ideas and technologies and systems but don’t have time to go to the clinical meetings where we talk about patient problems, so they’re often not aware of specific clinical problems that could be solved by their side. Even if they are aware that there’s a clinical need and have a great idea how to meet it, they don’t generally have the clinical context to even know where to start about making it happen in SUMMER 2016

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Jason Moore, Ph.D., director of the Institute for Biomedical Informatics, left, and Paul M. Kopec, M.S., its project director, sketch out ways to make “big data” useful to researchers and clinicians.

actual patient care. So our policy will be to provide people who know how to do that.”

That policy can lead to surprising partnerships, Roth points out. “The first project that we’ve had success with is to look at a very rare disease in humans, a very rare but lethal disease called angiosarcoma, cancer of the blood vessels. In collaboration with folks at the School of Veterinary Medicine, we realized that large breeds of dogs like German Shepherds and Golden Retrievers have these angiosarcomas very commonly.”

After doing genetic profiles on the dog angiosarcomas, they identified some potential candidates as molecular drivers of

David B. Roth, M.D., Ph.D., director of the Penn Center for Precision Medicine, intends to make it “especially useful for the research scientists, who are coming up with all these great ideas and technologies and systems but don’t have time to go to the clinical meetings, so they’re often not aware of specific clinical problems that could be solved by their side.” the cancer, which might lead to some clinical trials on dogs in the very near future. That could be good for the dogs, Roth continues, “but more broadly, we already know from our initial work that the human angiosarcomas and the dog angiosarcomas definitely have some similarity at the molecular level. If you identify an FDA-approved drug that has significant effect in the dog angiosarcoma setting and find that 14

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driving mutation in a human, you could potentially accelerate the rate of doing some trials in those people.”

Some Hurdles Ahead

Still, there are definite hurdles to overcome before “precision medicine” becomes simply “medicine.” One is a problem of public perception that crops up with nearly every other major medical advance: the hazards of making big promises too soon. “There is a lot of buzz about [precision medicine] in the commercial space,” Roth says. “You know that not all that stuff ’s going to last. I do think that there’s a danger of overhyping and in disappointing people.”

Roth believes that the answer is to “get practical” by moving precision medicine techniques from the lab into the clinical setting. “Many of our peer institutions are focusing on the research side, discovering more molecular drivers of this or that disease so we can find drugs or make better predictions about what’s going happen with an individual patient.” Penn Medicine is aiming in a different direction. “I thought, let’s come up with some wins and show that we can do this in the context of regular health care, not just some exotic trial where we need to control all the conditions very carefully. We can show some practical ways that we’re really changing the way we do this with fairly large numbers of people.”

Instead of being a “magic bullet” that will cure all human disease overnight, precision medicine is poised to develop and evolve into the general practice of health care. As Elenitoba-Johnson says, “it’s not unlikely that the whole concept of precision medicine itself will get refined as the individualized aspect becomes more prominent. As long as we are evaluating the patient within the context of the disease and their circumstances and treatment is administered in that regard, we’ll be making the right decision. For every disease, we can come up with uniform protocols within discrete population cohorts that will be appropriate to treat those patients – and then discern the appropriate treatment.”

COVER STORY whether the insurance company will reimburse for the enviViewing the question from his informatics perspective, Jaronmental testing, the genetic testing, and the other clinical son Moore is somewhat more cautious. “We’re in the early measures necessary to assemble the patient’s information. days. There’s a lot of research to do, a lot of infrastructure deThen that information would have to be fed into a computer velopment. It’s a fundamental change in the practice of medialgorithm, which would, Moore says, “predict what drug they cine, and it will require some time to sort out. I would say we should get or what prevention strategy you should implement. have at least another decade, maybe two decades, of research When insurance companies start reimbursing for these tests, to really get a handle on what the precision medicine stratethen I think it’ll become commonplace.” gies are that we should be using.”

Costs can also be expected to come down as precision In a recent “Sounding Board” piece in The New England medicine continues to become ever more precise. According Journal of Medicine, in fact, J. Larry Jameson, M.D., Ph.D., to Roth, “If you can really precisely identify who needs the indean of the Perelman School, and Dan Longo, M.D., tervention, you don’t have to give it to everybody, and I think suggested another impact of precision medicine: “Medical that’s going to be a great way to offset costs as we move away school curricula will need to focus even more on informafrom volume-based to value-based payment for delivering tion management” (5/27/15). medicine. Figuring out what’s wrong at the molecular level According to Gail Morrison, M.D., G.M.E. ’76, senior vice and having a great precise tool to treat it should lead to cost dean for education, precision medicine will require that docsavings in a number of areas.” tors classify individuals not by diseases but by subpopulations.

The subpopulations will be grouped by their susceptibility to a particular disease; by the biology and/or prognosis of the disease they develop; and by the individuals’ responses to a specific treatment. That is why molecular profiling for patients in routine clinical settings will be necessary for matching patients to their ideal treatment.

To prepare the medical students, the Perelman School has implemented a required curriculum block for all first-year students in cancer biology.

The new block integrates concepts important to understanding and practicing precision medicine by doing molecular genetic profiling for cancer, evidence-based medicine for making decisions, and epidemiology of various types of cancer. “We want to assure that our students will be prepared to treat patients with precision medicine as it becomes the norm in the clinical setting,” Morrison says.

Another issue that needs to be resolved is not scientific, but financial. Who pays for the tests and treatments based on precision medicine? No matter how advanced and sophisticated the techniques may be, they’re essentially irrelevant if they remain inaccessible and unaffordable to the patients who need them. “We see that with a lot of things,” says Elenitoba-Johnson. “The fee Jason Moore and Jing Li, a postdoctoral researcher, are interested in visualization methods that can greatly enhance the ability to make sense of data-mining results. schedules are just being worked out on a national level. Sometimes local negotiations with the payers also inform the way in which the testing gets reimbursed. So that’s in flux, and the extent or what However long it may take for precision medicine to shake proportion of the testing you can get back is also in flux.” free of its adjectival modifier, Roth and his colleagues are conAs Moore puts it, “At least in the short term, this is going fident that it’s the new paradigm for the future of medicine. “I to be a technology and a methodology that is available only think precision medicine is the next iteration in the evolution at the bigger, more well-funded institutions that can invest of health care,” he says. Despite its current heyday as “the next money on the front end. When we drop the ‘precision’ from big thing,” it seems clear that it’s not going away. “I promise ‘precision medicine,’ I think it’ll be a commodity that anybody you ‘the next big thing’ is going to come along, but I think can take advantage of just like any other medical technology.” we’ll make some really important advances with what we’re On a practical level for the patient, however, it depends on doing now.”

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By John Shea

Doctor Coulehan’s Journeys An advocate of medical humanities believes that poetry can offer glimpses of the deeper meaning of a physician’s work – exhausting hours and all.

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he poem, simply titled “Journey,” begins quietly: “Sixteen blocks to the hospital from home / at 47th and Pine.” As someone who has lived and worked in West Philadelphia – and who even had an apartment at 47th and Pine streets for a couple of years – I was immediately hooked. But no doubt there are other cities that have such numbered and named streets. A few lines later, however, another tip appeared: “44th and Spruce.” This was going to prove a journey within a city, then. When the narrator arrives at 34th Street, however, it is 16

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clear that Jack Coulehan, M.D., G.M.E. ’70, M.P.H., is writing about Philadelphia and his daily walk to HUP. And what a journey it is, full of surprising and sometimes amusing juxtapositions. In the poet’s imagination, yaks clang in the Himalayan mountains of Bhutan, while he dismisses from his mind a “Chevy Impala on concrete blocks.” The reader also encounters the rivers of exotic Sarawak, a Malaysian state thousands of miles away, as the walker does his best to ignore dog turds on the city street. Finally, he arrives at the “lair” of the “wolves of compassion,” apparently the HUP physicians. The narrator is not yet a full-fledged member of this pack but is, instead, “an adopted son.”

More than a touch of ambivalence and uncertainty on this early morning walk: “my mind blocks the reality of row houses, muffler shops, / and work.” At the same time, his imagination seems boundless.

“Journey” was published in the December 1, 2015, issue of JAMA. Coming upon it, I recognized the poet’s name at once.

In fact, I had covered a visit Coulehan made to the Penn campus many years after his time here as an intern (Penn Medicine,

FEATURE Summer 2006). He was part of a group of distinguished guests who spoke to medical students and faculty on the vital topic of professionalism. Back then, Coulehan was a professor of preventive medicine at the State University of New York at Stony Brook, where he served as director of the Institute for Medicine in Contemporary Society. At Stony Brook, he also directed the medical school’s required four-year curriculum in ethics and social issues in medicine. A co-author of The Medical Interview: Mastering Skills for Clinical Practice (5th edition, 2006), he had also received the Humanities Award of the American Academy of Hospice and Palliative Medicine.

At the Penn symposium, Coulehan noted that many students enter medical school determined to be activists and “complete physicians.” In the course of their four years of study, however, some become cynical as they recognize a disparity between the school’s explicit curriculum and what he called “the informal curriculum” and what others have called “the hidden curriculum,” the influences exerted by an organizational culture. Some students continue to believe that “the patient comes first,” but they remain somewhat detached from the patient. One of the ways to foster professionalism, Coulehan suggested, was for medical schools to include more role models in their clinical departments who would “demonstrate the qualities we want to inculcate.”

At that time, I did not realize that Coulehan was also a poet who often used his experiences as a physician in his writing.

Looking back, I find another of his suggestions for fostering professionalism especially relevant: to teach students to make use of “narrative,” not in the patients’ charts but “in our minds, in our relationships.” It seems a small step to a different kind of creative writing that can also be a way of making deeper personal connections – poetry.

In a lecture Coulehan gave at a plenary session of the American College of Physicians meeting in 2012, he summarized his beliefs about the connections between medicine and poetry. One of his patients many years earlier at a community health center in Pittsburgh was a “chronically dissatisfied” woman who made it clear that “I was too young to know what the hell I was doing.” But one day she – “Celia” – appeared at the office wearing a white lace dress and presented Coulehan with a potted plant, which she called “an act of Christian love.” Coulehan was stunned – and moved. Later, he wrote a poem called “The Act of Love,” using the language of poetry “as a lens through which to glimpse the deeper meaning of my work as a doctor and my relationship with Celia.” Somehow he felt himself become more connected to her.

As he put it, “So when I speak of the poetry of medicine, I’m not suggesting that all doctors should sit down and write poetry, or even read it; rather, I’m talking about paying close attention to those ‘aha!’ moments that are available to us and can sustain us, as well as making us better able to heal our patients, if we respond appropriately to them.”

It was this spring, when I got in touch with Coulehan, that I discovered he had trained in internal medicine at HUP. In addition, he has written several poems based on his time at Penn. Six appeared in his most recent collection, Bursting

with Danger and Music (Plain View Press, 2012). “Journey” and another poem inspired by his Penn internship, “The Secret of the Care,” will be included in his new book, The Wound Dresser (J. B. Stillwater), appearing this year. The “internship” poems are situated in a world of conflicting value systems, conflicting duties, and long, exhausting hours.

In “The Secret of the Care,” he describes himself as wearing “vestments to clinic – / pressed white pants, crisp shirt, and

To read Dr. Coulehan’s “Journey” in full, please access it at the JAMA site. http://jama.jamanetwork.com/article.aspx?articleID=2473496.

Copyright ©2015 American Medical Association. All rights reserved.

jacket, symbols of purity.” At the same time, however, he is “disguising the depth of my doubt” as he hoped to “grow in wisdom.”

Reviewing Bursting with Danger and Music, Martin Kohn, Ph.D., director of Medical Humanities at Cleveland Clinic, calls Coulehan “a giant in our field” as a clinician, teacher, and scholar. “Jack’s poetry brings us home – to deeper meaning, to compassion, to the struggle to remain human as one cares for suffering humanity” (Journal of Medical Humanities, 20 December 2012).

Given Coulehan’s artistically expressed concern and compassion for the patient, it is not surprising that he has also SUMMER 2016

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FEATURE tackled another topic that sometimes appears lacking in relationships between physician and patient: humility. In addressing the Perelman School’s Class of 2011 during its graduation ceremony, Arthur Rubenstein, M.B., B.Ch., quoted from an article Coulehan had published on the subject earlier that year in Perspectives in Biology and Medicine. It was the last Perelman class that Rubenstein would address before stepping down as dean. As the students prepared to advance to the next stage of their professional lives, he wanted to emphasize this often overlooked characteristic. Humility is essential, he said, especially when doctors today “often seem superconfident, assertive, and impatient” with those they are treating.

In his article, Coulehan does not mince words: “Nowadays, humility is hardly a valued ideal. The words ‘good physician’ call up an image of confidence, technical skill, and assertiveness, a cluster of characteristics that seems inconsistent with humility. . . . In today’s medical culture, humility appears weak, wishy-washy, counterproductive, or even deceptive (as in the case of ‘false modesty’).” In contrast, Coulehan associates humility with other traits he believes are necessary for the profession, such as an awareness of one’s limitations; avoidance of arrogance; honesty, especially about mistakes; and the ability to maintain inner balance and to modulate self-interest. It also seems to follow that being so open to patients, circumstances, and experiences would help a writer of poems or narratives.

Today, Coulehan is emeritus professor of preventive medicine and senior fellow of the Center for Medical Humanities, Compassionate Care, and Bioethics at Stony Brook University.

In 2012 he received the Nicholas E. Davies Memorial Scholar Award from the American College of Physicians for “outstanding contributions to humanism in medicine.”

Looking Back at “Journey”

Jack Coulehan, M.D., Puts His Poem in Context In late June 1969, I arrived to begin my internship at the Hospital of the University of Pennsylvania (HUP). Although intimidated by HUP’s high-powered reputation, I was also gratified that Penn’s internal medicine residency program had selected me. At Orientation the Chief assured us that we were the chosen few. Someday we would become leaders of American medicine. Meanwhile, we had to work our asses off. I soon discovered my duties were all-consuming to an extent that I hadn’t anticipated. The endless cycle of admissions, rounds, procedures, emergencies, and conferences allowed me to spend little time actually talking with patients. I seemed to be out of sync with the prevailing ethos, which was academic and research oriented. My body managed to keep up, but my enthusiasm lagged far behind. Is an intern supposed to be so ambivalent about his work? I asked myself. I must not be cut out for medicine.

Though in reality only sixteen city blocks, the distance from my wife and baby daughter at home on Pine Street to the wards at HUP seemed almost like crossing a continent. Each morning 18

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I’d make that journey by foot, keeping an eye on the pre-dawn city, but allowing my mind to roam through an exotic world of high adventure. My job was intense and highly focused. Evenings at home were consumed by the demands of a colicky baby and a wife grieving her father’s recent death. But on that trek, my troubles disappeared, anxieties dissolved.

For some inexplicable reason, the hospital library included a collection of brightly illustrated travel books. I’d often borrow one and fantasize about visiting Paraguay, Cambodia, or Mozambique, especially on my daily walk to HUP. In this particular “Journey,” imagination carries me to a high pass in the Himalayas and to a jungle in Sarawak. Mostly, it carries me to freedom. Ah, freedom!

As I approach HUP, the narrative (“voiceover”) changes from escapist fantasies to a fantastic version of the hospital itself, “where wolves of compassion roam.” Why wolves? Because they’re determined, aggressive, clannish animals, just as I perceived my colleagues and attending physicians, who were nonetheless dedicated to healing, the work of compassion. In the poem I feel out of place. I’m not born to this pack. My sensibilities are slower, softer, more personal. Yet I need to put away “geographies” and prepare to take out my “stacks of patterns” and “procedures” – in other words, to get to work.

Though not indigenous, I’ve been adopted into this wolf pack.

Perhaps “precious thimblefuls of love” will help me accomplish my hundreds of daily tasks.

In retrospect, internship was one of the great adventures of my life, certainly more meaningful than the exotic journeys that I daydreamed. The mystery of human illness, suffering, and healing confronted me every day. Ironically, the sidewalk in West Philly did, in fact, carry me to a new world, where, despite anger, ambivalence, and the numbing fatigue of working 80 or more hours per week, I learned to be a doctor.

But I wouldn’t want to do it again.

WHEN MAJORS ACT LIKE

MINORS

By Karen Kreeger

The Behavior of Ants Can Be Changed Through Epigenetic Chemicals – Would That Work for Other Animals As Well?

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xhibit 1: Shelley Berger, Ph.D., the Daniel S. Och University Professor with an appointment in Penn’s Department of Cell and Developmental Biology, is working in her office in the Smilow Center for Translational Research. If she turns slightly from the computer screen toward the wall within arm’s reach on her left, she sees a large framed photograph (about 15 inches high by 18 inches long) of a leaf-cutter ant.

Even the largest of that species would be no longer than 0.63 inches, so the magnification is startling.

Exhibit 2: Shelley Berger is approaching her office in the Smilow Center. As she draws nearer, she sees another framed photo just to the right of the door. This one shows – in more detail than some squeamish viewers might like – two ants. Its dimensions are about 21 inches high by 16 inches long.

It’s probably safe to conclude that Berger has a strong interest in ants and possibly some affection for them as well. But what role do these creatures play in her scientific research?

About ten years ago, before joining Penn Medicine, Berger made a trip with her family to Costa Rica. While there, she became fascinated by the fungus-eating leaf-cutter ants. Like all ants, they are social creatures and – despite having decidedly different castes – carry identical genes. What distinguished one ant from the other, if it was not their genes?

Ants, Berger realized, would be an ideal group for studying how epigenetics affects behavior and the overall development of individual ants. Epigenetics is the field that investigates inherited changes in gene activity, in which genes are turned on or off via molecular “tags.” The DNA sequence itself, however, does not change. In the case of ants, each colony comprises thousands of individual sisters – notably, the queen and all workers are female – with nearly identical genetic makeup, SUMMER 2016

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The majors are the “brawny” soldiers, with large heads and powerful mandibles that help to defeat enemies and process and transport large food items.

The minors – much smaller and “branier” – search for food. much like human twins. At the same time, these sisters possess stereotypically distinct physical traits and behaviors based on caste.

Back in the United States, Berger discussed her idea with Danny Reinberg, Ph.D., a professor of biochemistry at New York University and, like Berger, a pioneer in epigenetics. He, too, saw the possibilities in such an approach. When Berger left the Wistar Institute and joined Penn Medicine – also becoming director of the Penn Epigenetics Program – she continued her study of ants. Then, in 2008, with Juergen Liebig, Ph.D., a behavioral ecologist at Arizona State University who had studied the social behavior of ants, Berger and Reinberg received a Collaborative Innovation Award from the Howard Hughes Medical Institute. The interdisciplinary team’s initial goal was to sequence the genomes of two ant species: Jerdon’s 20

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jumping ant, which is found in India, and the Florida carpenter ant. Two years later, they published their results in Science.

The next step: to probe more deeply into the social behavior of the carpenter ants.

“Brawny” and “Brainy” Divide the Roles

In carpenter ant colonies in Florida, distinct worker castes called “minors” and “majors” exhibit pronounced differences in social behavior throughout their lives. But in a study published in January 2016 in Science, the multi-institutional team anchored at the University of Pennsylvania found that these caste-specific behaviors are not set in stone. Instead, the social behavior of these ants can be reprogrammed. The findings indicate that an individual’s epigenetic – not genetic – makeup determines behavior in ant colonies.

Epigenetic regulation influences a variety of distinct traits in animals, including body size, aging, and behavior. However, there is an enormous gap in knowledge about the epigenetic mechanisms that regulate social behavior.

In their 2010 study, Berger and her colleagues showed that epigenetic regulation is crucial to distinguishing two distinct castes of Florida carpenter ants. The majors are the “brawny” soldiers of carpenter ant colonies; the minors are their smaller, “brainier” sisters. Majors have large heads and powerful mandibles that help to defeat enemies and process and transport large food items. Minors are much smaller, outnumber majors

FEATURE two to one, and assume the important responsibility of searching for food and recruiting other ants to help with the harvest. Compared to majors, these foraging minors have genes involved in brain development and neurotransmission that are over-expressed.

“The results suggest that behavioral malleability in ants – and likely other animals – may be regulated in an epigenetic manner via histone modification,” says Daniel F. Simola, Ph.D., a postdoctoral researcher in Penn’s Department of Cell and Developmental Biology. Simola is co-lead author of the 2016 Science study with Riley Graham, a doctoral student in the Berger lab.

It’s All About the Histone

The seminal 2016 study shows that caste behaviors are regulated by epigenetic changes in the way chemical tags are added to or taken away from histone structural proteins in the nucleus. To reach that conclusion, the team used the fact that chromatin structure – the coiling of the DNA around histone proteins – can be altered by adding compounds that alter the epigenetic tags such as acetyl groups. That addition ultimately changes the compaction of the genome. As described in the Science paper, the team fed foraging minors a chemical inhibitor that prevents cells from removing acetyl groups from histones. This treatment enhanced foraging and scouting for food and, correspondingly, led to increased histone acetylation near genes that are involved in neuronal activity. Conversely, inhibiting the addition of acetyl groups led to decreased foraging activity.

In contrast to the dramatic boost in foraging seen in minors, feeding mature major workers these epigenetic inhibitors caused little to no increase in foraging. However, the team found that directly injecting the inhibitors into the brains of very young majors immediately increased foraging.

The treated majors reached foraging levels normally observed only in minors. In addition, a single treatment with these inhibitors was sufficient to induce and sustain foraging in the majors for up to 50 days. These results suggest that there is what can be described as an epigenetic window of vulnerability in young ant brains, which confers increased susceptibility to environmental manipulations, such as with histone-modifying inhibitors.

Broader Implications

Berger observes that all of the genes known to be major epigenetic regulators in mammals are also present in ants.

That, she continues, makes ants “a fantastic model for studying principles of epigenetic modulation of behavior and even longevity, because queens have a much longer lifespan compared to the major and minor workers. Because of the remarkable window we have uncovered, ants also provide an extraordinary opportunity to explore and understand the epigenetic processes that come into play to establish behavioral patterns at a young age.” Such a topic, she continues, is of increasing research interest in humans, “owing to the growing prevalence of behavioral disorders and diseases and the appreciation that diet may influence behavior.”

One important gene implicated in the ant study is CBP, which is an epigenetic “writer” enzyme that alters chromatin by adding acetyl groups to histones. “From mammalian studies, it’s clear this is an important protein involved in learning and memory,” Berger notes. “The finding that CBP plays a key role in establishing distinct social behaviors in ants strongly suggests that the discoveries made in ants may have broad implications for understanding social organization.”

The Berger team is now focused on precisely defining the epigenetic window of vulnerability and its crucial molecular features. She explains that “understanding the mechanisms of when and how this window is opened and how changes are

The research team found that directly injecting chemical epigenetic inhibitors into the brains of very young majors immediately increased foraging. The treated majors reached foraging levels normally observed only in the minors, the foraging caste. In addition, a single treatment was sufficient to sustain foraging in the majors for up to 50 days. sustained – and why the window closes as the major ant ages – may have profound implications for explaining human vulnerability to early life exposures.”

After the second study appeared in Science, Berger demonstrated a valuable talent: being able to communicate what she does not only to non-scientists but to young children as well.

She appeared on “Science Knocks,” a three-minute science podcast hosted by Sindya N. Bhanoo, the “Observatory” columnist for The New York Times. Bhanoo, who described the carpenter ant study in the Times, gave a simplified version to Naina, her four-year-old daughter. As Bhanoo explained offscreen and her daughter echoed her or asked questions, quickly drawn sketches appeared on the screen. The queen of the carpenter ants was distinguished by a tiny crown. One of the foragers gathering food apparently decided to bring back a slice of pizza. Naina wondered why there weren’t any “boy ants.” Berger’s voice: “All of them are girls. . . . There are very, very few boys.”

When Naina learned that the soldier ants began to act like forager ants, she asked, “Like, how did they make them act like that?” Berger replied: “There are special chemicals that change the way the brains work,” and the scientists injected these chemicals into the newborn ant brains. Naina grasped the concept: “because people give them a special chemical medicine!” Then, as the three minutes came to an end, the little girl added: “Thanks for your time, Dr. Berger.”

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By David Lewellen

LEARNING FROM The Role of Spirituality in Medical Education

Leah Zuroff, a first-year student, accompanies Dasha Saintremy, a chaplain resident, through the trauma department.

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CHAPLAINS:

Photographs by Tommy Leonardi

First-year medical students learn how to acknowledge patients’ beliefs as they treat their bodies.

T

he young woman in the ICU was dying; there was no medical reason at all to think she wasn’t. But her family was clinging to hope. “God is good,” they told the chaplain. “It’s in God’s hands. We know he will bring a speedy recovery.”

The chaplain listened sympathetically and said little. When she left the waiting room at HUP, Joey Bahng, then a first-year medical student who was shadowing her for the night, was surprised. “They’re delusional,” he told her. “We should say something. We should do something.” But she shook her head. “Nothing we can say now is going to make them change their minds,” she said gently.

Bahng was getting a lesson in the power of silence.

That recognition was helping him, and other students, learn how spirituality affects people’s lives and how to communicate effectively. First-year students who sign up for the chaplain shadowing program at Perelman School of Medicine, now in its fifth year, also get a chance to see practice in the trauma department (now at Penn Presbyterian Medical Center) and to observe how medical decisions affect human interactions.

As the evening went on, the chaplain and Bahng made several more visits to the ICU room, and the atmosphere began to change. An aunt and a cousin of the patient had a more realistic view of the situation, and the chaplain encouraged them to say what was on their minds. The family didn’t want advice so much as a chance to talk about the situation. When the chaplain left the room, Bahng listened and nodded, and that was enough.

“Doctors and nurses have a lot to learn from chaplaincy,” says Bahng, who served as the student co-coordinator of the

tion in recent years, so has the role of the chaplain, mandated to be a part of palliative care teams. Palliative medicine recognizes the role of “spirituality, ritual, meanings, and how families come to terms with the loss of a loved one,” DeLisser says. In addition to physical pain, patients face existential pain, and their families must cope with their own issues of grief and loss.

DeLisser is quick to invite chaplains to participate in the decision to transition to comfort care. When the patient is actively dying, it is often the chaplain who can make the time to sit by the bedside and wait. And they serve a valuable role as an independent mediator between doctors and families.

Perelman students work on communications skills and empathy in normal class work, and they also learn how specific beliefs may affect medical treatment. For example, a Jehovah’s Witness refuses blood transfusions, and a Muslims may be fasting during Ramadan. Students learn how to Horace DeLisser confers with Rhoda Toperzer, coordinator of clinical pastoral education at talk with people in crisis – which involves much Penn’s Health System. more listening than talking. “What people really need is someone who’s present and attentive, someone who program, a year after his memorable night. Even within the says I’m choosing to be here with you,” as DeLisser puts it. For confines of a patient consultation, Bahng has learned not to physicians, it is part of an overall maturation process from interrupt and to let patients tell their stories. And when he is self-centered to patient-centered. “Even if I have a radically rushed, he will remember that chaplains may have the time to different view of the meaning of life, I can join their celebrasit and let a situation unfold naturally. tion, their experience – not because I agree, but because I’m Students’ individual experiences vary – some nights are there for them, I’m supporting them.” busier than others – but all of them see the impact of spiritu Before his night with the trauma chaplain, Bahng says, “I ality on people’s lives and get a sense of how they can acexpected it to be all about Jesus, and that was barely menknowledge patients’ spirits even as they treat their bodies. tioned. It’s so not about evangelism. It’s about being empathetic and establishing a bond and treating people’s soul as “The reality is, the majority of people do have some condistinct from their body.” But even so, many students are surcept of spirituality that involves a being, an entity that they’re prised by the role faith plays in patients’ decisions. able to engage, through which they find meaning” says Horace DeLisser, M.D. ’85, G.M. ’91, the associate professor of medi That is exactly why DeLisser values the program and would cine who leads the shadowing program. Many students, he like it to expand. Watching a chaplain in action gives students points out, arrive at medical school with an “indifferent, dis“a little glimpse of how they themselves can do spiritual care,” missive, or even hostile attitude” toward religion or spiritualhe says. A first-year student shadowing a chaplain may be enity. DeLisser emphasizes that they must develop awareness of countering death for the first time and seeing its effects on their own issues and beliefs – and respect for those of other others in the room as well. According to DeLisser, “The first people. “Patients are very smart,” he says. “They can pick up order of business is to establish that they care. . . . I’m here to when you’re dismissive of them, even if you don’t say it.” listen, and I can wait.” The communication skills may be basic, DeLisser has studied spirituality in medicine for his entire but they are nonetheless necessary. career. As a pulmonologist, he often witnessed grief and loss A small example that DeLisser offers: When patients or in the ICU. He realized that the spiritual and emotional chalfamily members mention prayer, he will ask them to pray for lenges he witnessed were separate from, but related to, the him and for the medical team. It shows respect, affirms their medical problems he was trained to treat. “My spirituality inbelief, gives them a way to participate, and functions as care forms my work,” he says. “I see my work in engaging and helpfor the spirit. ing patients and their families in crisis as both a privilege and Should doctors lead prayer with patients? DeLisser’s answer calling from God. It also helps me cope with the burden and is “Yes, if.” If prayer feels authentic to the physician; if the pastress of dealing with suffering.” tient welcomes it; and if the goal is “comforting, consoling, af There are signs that the much of the medical world is comfirming,” never about influencing. At a secular institution such ing to share that view. As palliative care has gained recogni24

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FEATURE as HUP, he points out, meeting all of those conditions is relatively rare. On the other hand, “If they’re inviting you into their lives,” he continues, “I can’t see that as bad.”

As far as participating in prayer led by someone else, DeLisser says that he more often feels comfortable with it as he has become “a more culturally competent physician.” A doctor who feels uneasy in that situation should “respectfully step out of it.”

Margaret (Meggie) Kobb, M.Div., a staff chaplain at HUP, took five or six medical students around with her in a recent year, and she remembers the questions they asked afterward: How do you know what kind of prayer to offer? How do you learn to be comfortable sitting in silence? Were you intimidated when that family was so angry with you?

In her answers, she tells them that a chaplain has to learn to “dive deep quickly.” As she emphasizes, “There’s no time for small talk about where they’re from or the weather or how the Eagles are doing. In moments of crisis, people are so receptive to having that lifeline.”

The situation that Bahng saw, when the family is praying for a miracle, is one of the trickiest that a chaplain faces.

“Very often, I’m the bridge between the medical team and the family,” Kobb says. “I love family meetings. They’re incredibly stressful for everyone, but it’s also an opportunity for everyone to be heard.”

Kobb’s memorable case was the matriarch of a West African Catholic family who was on life support. The medical team was ready to remove it, the family wasn’t, and “they

As palliative care has gained recognition, so has the role of the chaplain, mandated to be part of palliative care teams. Palliative medicine recognizes the role of “spirituality, ritual, meanings, and how families come to terms with the loss of a loved one.” spent days avoiding each other.” When a meeting finally took place, everyone agreed that they did not want the patient to be hurt, and she was eventually discharged to long-term care.

“It didn’t feel like a win for either group,” Kobb reports, “which told me it was a good compromise.”

Based on her occasional contacts with the students who have shadowed her, Kobb believes that the program is having a lasting impact. “They carry that impression with them,” she says. Physicians are trained to make decisions quickly, and “knowing when to sit in silence is a skill. It’s counterintuitive to what doctors are about.”

Once students shed their misconceptions, they learn that spiritual care offers “a listening ear and presence, being attentive to the patients’ stories and concerns and fears,” DeLisser says. What the medical students may be surprised to learn is that one of the stops the chaplains make on their rounds is at

Joan Li, a first-year student, and Pauline Jennett, a chaplain resident, touch base with Alonzo Hugh, a security officer at Penn Presbyterian.

Leah Zuroff and Dasha Saintremy hear from Jeffrey Moon, M.D., M.P.H, a Health System Clinician in emergency medicine.

the department’s security desk. In fact, it is often the first stop, when they are informed of any delicate situations affecting the families of patients or any possible disruptions, which can happen when trauma is involved. Much of the chaplains’ work with families is spiritual – but a fair amount of it is administrative as well, easing the families’ stay at the hospital.

When patients and families are enduring the worst day of their lives, a chaplain can identify the resources they can make use of for coping — their own religious tradition, family and friends, music, nature, etc. — and may suggest other alternatives. But they also offer and share what DeLisser calls “their authentic selves.”

The shadowing program began in 2012, when student Andrew Perechocky, M.D. ’13, took notice of chaplains’ interpersonal skills during his palliative care elective. He arranged on his own to spend an evening with a chaplain and found it to be a great experience for his own education and career development. When other students then showed an interest, Perechocky helped set up the program’s first year. Subsequently, he was the lead author of a paper in Journal of Surgical Education (2014) on the program. (DeLisser and two HUP chaplains – including James Browning, M.Div., coordinator of clinical pastoral education for Penn’s Health System – are among the authors.) The article notes that spirituality typically receives little attention in the curricula of most medical schools. “Particularly lacking is formal instruction in effective communication with patients and families experiencing grief, loss, or death of a loved one.” Although the sample size was small, the medical students who took part in the shadowing and responded to the survey were overwhelmingly positive. All recommended that the experience be part of the medical school 26

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curriculum. According to the article: “Hospital-based trauma chaplains undergo extensive training in providing emotional and spiritual support for patients and their families in crisis, enabling them to be effective role models for medical students who wish to strengthen their interpersonal and communication skills.” For his part, Perechocky found that the providers of spiritual care are “experts in active listening, being a supportive presence, and navigating family dynamics.”

Even in a high-volume, high-pressure setting, “you can establish a rapport and form a connection in a short amount of time. It’s something you need to work on.” Even the simple act of sitting down helps calm the atmosphere.

Now an emergency medicine resident at Boston Medical Center, Perechocky says that even in a high-volume, high-pressure setting, “you can establish a rapport and form a connection in a short amount of time. It’s something you need to work on.” Even the simple act of sitting down helps calm the atmosphere. In general, he continues, such skills are better learned from watching other people than from reading a text.

“Patients can benefit from speaking with a chaplain in multiple situations,” Perechocky says, “even if it’s not life-threatening and the patient’s not religious.”

FEATURE “When I went to medical school, I didn’t know what a chaplain was,” says Amy Westcott, M.D., G.M.E. ’08, who was a mentor for Perechocky’s research and an author of the journal article. More than a decade after her own education and her work in palliative care and geriatrics, she now recognizes the importance of treating the whole person and paying attention to how each person copes. As a profession, Westcott says, medicine is “moving toward treating patients as whole persons.” Now an associate professor of medicine, geriatrics, and palliative medicine at Penn State Hershey Medical Center, she found spiritual care integrated throughout its system when she moved there in 2014.

Interprofessional work has always been one of Westcott’s interests, and now she is seeing wider acceptance of the team model. “Sometimes the physician leads, sometimes she’s a member of the team. It’s going to vary depending on the situation,” she says. “Sometimes it’s the chaplain running the family meeting, and my job is to listen. Or if I’m in the room, the certified nursing assistant is going to coach me on how to help turn the patient. They studied for that; I didn’t.”

Westcott praised Perechocky’s initiative in seeing a need and acting on it. As she puts it, “Things really come from the students these days. They know what’s missing better than we do.”

It’s usually 30 to 40 students, from a class of about 150, who have participated in the shadowing program during the fall.

The program is now expanding to spring, in order to accommodate word-of-mouth recommendations from students to their peers. The feedback has been so positive that DeLisser would like to see the program become mandatory. That, of course, might change the experience, and more logistical support would be needed, but he feels the benefits would be more widespread. Students who sign up now are probably self-selected for being open to the experience, and DeLisser hopes that those who skip it because of indifference might learn something.

The next step in formally recognizing the growing integration of medicine and spirituality will come this summer, when DeLisser enrolls the first cohort to receive a certificate in spirituality, similar to ones already offered in community health, women’s health, and global health. The six-week summer program, he believes, would push students “growing in their own spirituality, their sense of who they are, and empower them to be better doctors.”

As part of that program, fourth-year students may again shadow chaplains. But in addition, they will track patients and families over consecutive days and present verbatim accounts of their experiences to peers in order to evaluate their communication and the relationship with the patients. Group sessions will deal with common fears and desires, and participants will practice meditation and attend seminars on such topics as theology and medical ethics, 12-step spirituality, and near-death phenomena.

Watching chaplains at work has been a lesson in interpersonal skills to Adam Mayer, who had been a student coordinator

along with Bahng. “Even in five minutes, you can make people feel heard,” he says. “They’re not just a heart failure or a cancer – they’re a person, with hobbies and things they care about.”

Mayer knew something about chaplaincy going in, because he had volunteered at a nursing home. But that setting was almost all Jewish, and seeing patients of all faiths at the hospital has broadened his horizons. In his rotations now, he often suggests calling the chaplain into a conference with family members.

He recalls the experience of being at the bedside of a woman who was dying. Mayer held hands in a circle with family members as the chaplain prayed. The family was Christian, and Mayer was wearing his yarmulke, but, he says, “I felt a

Joan Li reflects on her experiences in a journal kept in the Penn Presbyterian trauma department.

connection with them, and they felt a connection with me.

They said thank you and that it helped them process things.”

Mayer has seen the role spirituality plays in patients’ lives – even nonreligious people frequently ask for a chaplain because “they just need someone to talk to.”

He was particularly moved when he witnessed his first patient death, a woman whose mother was still alive. Partly influenced by his memory of spiritual care in action, he called the mother afterward and told her he’d always remember her daughter, so “her memory is going to live on in my memory. It was a very special moment.”

For the lasting benefits involved, Mayer says, giving up a free evening to shadow a chaplain “is totally worth it.”

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A MAN, A HIP, AN MRI: CLOSE ENCOUNTERS WITH THE WORLD OF ORTHOPAEDICS Written and illustrated by Rob Press

O

ver on the Penn Medicine News Blog, we frequently write about what it’s like to work for or experience life at the University of Pennsylvania Health System. What we don’t get the chance to write about very often is what it’s like to see it from the other side: as a patient, just trying to figure out what’s wrong – and to get better. Fortunately (well, not really), I’ve now got one such story to relate.

Prologue (or: Five Years of Bad Decisions)

Winter, five years ago: I’m doing some weightlifting, putting in time at the squat rack, when I notice a mild, sharp pain on the outside of my left hip. I don’t think much of it, since squats are supposed to engage your hips and I’m pushing myself. The pain goes away by the end of the night.

It then returns and recedes repeatedly over the next four-and-a-half years. Sometimes there are months between recurrences. Sometimes it sticks around for a few days, sometimes it’s gone within seconds. I make a mental note of it each time, but it’s consistently either mild or brief enough for me to not bother getting it checked out.

Six months ago, I’m running on a treadmill when I notice the pain is back again. It’s mild, as always – but this time it doesn’t go away. In fact, it sticks around for the better part of a week, despite my taking it easy. It starts bothering me outside of exercise, too. Sitting too long? Hip starts to hurt.

Standing too long? Hip starts to hurt.

It “catches” a few times, too, which is a feeling both bizarre and difficult to describe. Imagine cracking your knuckles. You know how there’s that one moment, mid-crack, where you feel a ton of tension or stiffness in the joint and know it’s 28

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a millisecond away from popping? Now imagine that on a much larger scale, except in your hip. And when it finally releases, you aren’t left with a satisfyingly loose knuckle, you’re left with a mild tingling in and around the entire joint – as well as the unease of knowing something down there, to use a technical term, just ain’t right.

Two months ago, I made an appointment to see an orthopaedic physician here at Penn Medicine. “You’re twenty-nine,” I’m told as they’re finding me a physician, “that’s too young.”

I’m inclined to agree.

First Appointment (or: But That’s a Problem for Old Guys)

Waiting five years to get hip pain checked out is a big enough error on my part, but it’s made particularly bad by my history with orthopaedics. Before landing here at Penn Medicine, I wrote news and covered conferences within the orthopaedic field. I was able to coherently explain to my fiancé what was likely (but hopefully not) going on in my hip, but unwilling to do anything about it.

What was likely going on: The femoral head was doing all sorts of terrible things to the acetabular labrum, which is the cartilage rim that protects the socket from the ball (and vice versa) in the ball-and-socket joint that is the hip. It’s called a labral tear, and it’s the sort of thing that doesn’t tend to go away on its own.

“Maybe it’ll go away on its own,” Past Rob told himself.

Past Rob was kind of a moron, Present Rob thinks to himself while waiting to be brought in for a simple hip X-ray at Penn Medicine University City.

It’s uneventful, with two exceptions: One, I find out that I look pretty good in

FEATURE the nifty wraparound gowns they give patients going in for imaging. Two, when I’m on my back under the X-ray machine and I’m asked to bring my left knee up slightly while turning my leg outward, I’m rewarded with a catching sensation and a jolt of pain to the entire hip. I let out an “oh-ho-HO,” which to my ears lands somewhere on the spectrum between “a noise of pain and surprise” and “the noise my dad makes when he’s proven me wrong about something.”

“Maybe don’t move so quickly,” I’m told by the radiologist. Noted.

After the X-ray, I reluctantly exit the fashionable but weather-and-perhaps-work-inappropriate gown and make my way to an examination room, where I’m to sit and wait until my physician’s available to see me.

Something I learned while writing orthopaedic news (and had reaffirmed by my experience getting a broken ankle taken care of two years ago): These physicians and surgeons waste absolutely no time. Mine swoops into the room, white coat billowing behind him, introduces himself, and shakes my hand before sitting down and getting right to business.

“Five years of pain, huh?” he says. “You’re too young for that.”

I’m inclined to agree.

I’m told that nothing on the X-ray really stands out as being problematic. No obvious bone spurs, no trouble areas in the bone structure itself. The imaging report – which I look up on myPennMedicine a day or two after the appointment – refers to the hip as “grossly unremarkable,” which is one of those things you love to hear about your body in a doctor’s office but absolutely nowhere else.

Since the X-ray doesn’t reveal anything of note, I’m told that the next step is to get a contrast MRI. The MRI can inspect soft tissue, which means it’ll be able to pick up on abrasions or tears within the acetabular labrum – which, I’m informed, is what the physician thinks the problem might be.

The English language is versatile, but I don’t know if a word exists within it to express the feeling of being right precisely when you didn’t want to be.

Prep Work (or: “You’re Gonna Be More Full of It than Usual”)

I’ve always wondered if physicians sometimes feel like they have to walk a tightrope between two distinct patient experiences. On one hand, I imagine you want each patient to feel as if they are your only patient of the day. You want them to feel like they have your most undivided and meticulous attention to detail. On the other hand, I imagine you also want the

patient to know that this is not even remotely your first rodeo.

That’s crossing my mind again as I sit on a chair in an imaging suite at Penn Medicine University City, the well-fitting hospital gown doing its very best to keep me modest as I stare at the massive fluoroscope across the room. It looks like a big “C” wrapped perpendicularly around a long table, with a camera sort of thing on the end of the “C” dangling overhead.

There are several monitors attached to the whole contraption.

An X-ray tech walks in and asks me a few questions, including one I’m about to get very familiar with: “Do you have any sort of metal in your body? Implants, screws, rods, shunts, a pacemaker, anything?”

I’m able to confidently say no. He asks again, this time rattling off an even longer list of metal objects that could find their way surgically or otherwise into the human body. I say no again – but less confidently, because I’m thinking back on every dumb way I’ve ever hurt myself and wondering if maybe there’s any way I’ve forgotten, I don’t know, a stray bullet or something. The tech seems satisfied and jots something down on his clipboard.

He then walks me through what’s about to go down. I’ll get up onto the table under the fluoroscope, have a sterile drape placed over a significant chunk of my torso and legs (“You need to make sure not to touch that,” he says, which I don’t even think twice about until a little bit later . . . but we’ll get there), and receive a small injection of lidocaine.

Lidocaine is a numbing agent, which is of great importance because the step immediately following it involves a large needle being driven directly into the hip joint. Through that parSUMMER 2016

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ticularly invasive needle, I’m going to receive injections of radiographic and arthrographic contrast (two separate fluids).

I’m told all of the prep for the procedure is longer than the procedure itself.

They inject contrast fluid into the joint because more than a century of development and advancement of imaging technology still can’t really make up for the fact that joints like the hip and shoulder just don’t give up their secrets easily. Contrast fluid helps out by lighting up under a fluoroscope or MRI, making defects and whatnot far easier to spot.

“Your hip’s going to feel . . . full,” the tech says. “It’ll be a day or two before the fluid is absorbed by your body, and then you should be back to normal. Just don’t do any running or anything strenuous on it in the meantime.”

Just then, one of the technicians who will be performing my MRI in a few minutes swings by. “Really quick,” she says, “do you have any sort of metal in your body? Implants, screws, rods, shunts, a pacemaker, anything?”

Injections (or: I Guess We’re All Friends Here)

As a musculoskeletal imaging fellow and the attending radiologist enter the room, the latter grabs the clipboard and begins to ask me a few of the same questions, as well as some new ones. He jots down my answers quickly, then looks up at me and begins walking me through what’s about to go down. I realize the reason I’m being walked through this procedure several times is to make sure I don’t feel surprised by something and freak out while they’ve got a needle or two buried deep in my hip joint. Once again, I’m told the prep for the procedure is much longer than the procedure itself.

Next, I’m told to walk over to the table under that big “C” arm and lie down. I do so, and rest my folded hands on my stomach. I’m a little nervous, but the team is moving like clockwork and making every single step as clear as possible 30

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along the way. It’s calming, which is good, because the next step involves pulling my gown to the side so they can sterilize the entire area of the joint.

I consider myself an easygoing guy, but it’s hard to maintain one’s chill when you’re one small shift of a hospital gown away from three complete strangers seeing, like, everything. The sterile drape that’s going to be placed over me is brought out of its packaging, and I’m told I can’t let my hands rest on my stomach anymore because they’d be in direct contact with the drape. I adjust, and they go about their business while I awkwardly try to figure out what I’m going to do with my hands. I end up folding them behind my head – the ultimate position of repose, which strikes me as entertaining given my sudden and notable lack of modesty. I chuckle to myself, and the tech checks in to make sure I’m doing okay.

“You all right?” he asks. “Nervous about the needles or anything?”

I tell him I’m not. The fellow holds up the first needle. “Lidocaine,” he says, making sure I understand we’re about to get under way. I feel a slight pressure, and he pulls away with the needle before I even realize he’d pierced my skin. So far, so good.

“You’re numbed up, but you’re going to feel a bunch of pressure,” I’m told as the second needle comes into view. I guess there’s only so much we can expect lidocaine to do.

I don’t really feel it when the needle enters, but I absolutely feel it when the needle gets close to the joint itself. “Pressure” is a good way to put it. Take your pointer finger and push it hard – I mean hard – into your hip. It doesn’t hurt, but it certainly doesn’t feel good. That’s what it’s like.

The injection of the contrast fluids goes quickly. The team grabs some radiographic images of the joint, which I stare at on the monitors. I’ve always been fascinated by X-rays of my own bones. I think people have a tendency to forget that everyone’s really just a walking skeleton wearing a meat coat.

FEATURE I keep that particular thought to myself.

Just like that, the procedure’s over and I’m free to get up and walk over to a private waiting room while the MRI machine is readied. The hip does, in fact, feel “full.” It’s tough to explain.

Nothing feels like it’s going to burst, and nothing’s all that painful – especially since the lidocaine’s still doing its thing – but there’s absolutely a sense of pressure within the joint that wasn’t there before. My first few steps are extremely tentative, but after that I’m moving only slightly slower than usual.

MR Arthrogram (or: Sound and Fury)

Years and years ago (around 1994), I was sitting on my bed playing Aladdin for the Sega Genesis when I noticed I was having trouble seeing the screen. It was like a blind spot near the middle of my visual field, a distortion or void that my mind tried ineffectually to fill in with nearby colors.

I was experiencing my very first visual aura – a precursor to my very first migraine.

I get migraines to this day, with rather startling frequency.

I’ve seen I-don’t-even-know-how-many doctors about them over the years, and the very first thing they all do is order an MRI. That’s standard procedure, as far as I’m aware, but it also means my very first migraine was followed quite closely with my very first MRI. I’m going to nerd out about how an MRI works for a little bit, so if you don’t really care, just skip the next paragraph or two. MRI stands for “magnetic resonance imaging,” and, as the name implies, relies on the use of large magnets. Hydrogen makes up about three-quarters of all the mass in the universe, and about ten percent of your body mass. Each hydrogen atom has one proton – and therein lies their importance here, because a proton is essentially a very (very, very) tiny magnet. By running your body past a giant magnet, we can make all of those protons line up in the same direction. Hitting those protons with radio waves knocks them out of alignment, and their ensuing re-alignment creates radio signals.

One of the images the doctor uses to evaluate Rob’s hip.

Those radio signals get picked up by receivers in the machine, and suddenly we’ve got a detailed image of the inside of the human body.

Consider for a second how amazing it is that we, as a species, even figured out we could do that. The first transatlantic phone call happened in 1927. The first MRI was performed in 1977. In the span of just fifty years, we went from being amazed at the concept of ringing someone in London . . . all the way to figuring out we could play with the alignment of the body’s atomic building blocks to get a better picture of whatever’s going on in there.

So, anyway, MRIs: I’ve had a bunch of them. As I’m in a small room off to the side of the machine itself waiting for my turn, one of the techs comes over and talks to me a bit about the procedure.

“Do you have any sort of metal in your body? Implants, screws, rods, shunts, a pacemaker . . .?” she asks. I can’t help but snicker as I say no, no there is not. She asks again, because I guess snickering the first time made it look like I was trying to pull a fast one. I say no, this time with the straightest face I can muster.

It’s an important question. As you might imagine, metal and MRI machines are not great partners. Or, more accurately, they’re incredible partners that you can’t allow to occupy the same room. When the MRI is switched on, metal objects will fly at or into it with potentially deadly speed. A metal object in the patient’s body probably wouldn’t be ripped out, but the resulting damage and pain would nonetheless be something worth avoiding at all costs.

The tech goes through a few basics, then walks me over to the room with the MRI machine itself. The entrance of the room is guarded by two large, lit posts, one on either side.

There’s cautionary signage on the floor. The real feature, however, is the door. It’s huge – like, bank vault huge. It swings aside a little, and I’m able to view the 13-ton MRI machine in its full glory.

It’s basically a large, eggshell-white rectangle with a hole in the middle. Sticking out of the hole is a table, upon which the patient is placed and then wheeled inward. The whole contraption takes up a huge chunk of the room.

The tech ushers me onto the table and begins some basic setup, which mostly involves positioning me and my legs so the most useful images can be obtained.

“It’s going to be about 20, 25 minutes, times two because we need two different setups,” she tells me. “You need to stay completely still. You’ll probably feel a little warmth as the machine works. It’s also going to be really loud, so we’re going to give you earplugs.”

I’m offered music, but decline. The tech does one final pass to make sure I’m comfortable – an uncomfortable patient’s not going to be staying perfectly still for an hour – then hands me the earplugs and walks out of the room. The earplugs are maybe a little too effective, because once the tech is at her station and communicating with me through the intercom, I realize I’m only just barely able to hear her when she says they’re going to get started.

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FEATURE I feel the table start to move underneath me, and slowly I slide into the machine. When I was getting my very first MRI at the age of eight, this was terrifying. Now, though? Can’t say I’m terrified. More fascinated. Maybe a little itchy.

One thing they really can’t prepare you for is just how loud the machine actually is. It’s one of those things that you know is working if it sounds broken. Loud bangs, clangs, buzzes, and hums fill the air around me, and I’m grateful for my earplugs. After a while, a pattern starts to emerge. It feels a little like when you hear a car alarm for so long that you start attributing a voice to it.

The next 25 minutes pass quickly and uneventfully.

The warmth the tech said I’d notice is barely noticeable – especially in comparison to the oddly full feeling my newly injected hip is generating. The tech’s barely audible voice comes over the intercom to let me know they’re done with this set of images, and soon I’m repositioned for another set.

“You did great!” the tech says as I’m allowed to get off of the table, and for a second I’m filled with pride at my ability to stay perfectly still and do nothing whatsoever.

I get changed and make my way out to the front desk, where I set an appointment in a week’s time with the orthopaedic doctor.

Finally, Results (or: Ayup, that’s Your Problem Right There)

It’s a week later, and I’m waiting in the office of the doctor who first sent me down this road.

The images– X-ray and MRI alike – have been brought up onto the monitor for the doctor’s perusal. I’m looking at them and suddenly feeling self-conscious, because one thing the MRI shows very effectively is a nice layer of fat. I try to ignore that and pick out the troubled part of the joint. It feels good to know I’m about to get some answers.

There’s a quick knock at the door.

Just as he did the first time around, the doctor opens it quickly and sweeps into the room, white coat trailing him with just a little bit of majesty.

“Hello again,” he says cheerfully as he sits down. “How are you feeling?”

I tell him I’ve actually been feeling pretty okay – which I have – and he nods as he scrolls through the images on the screen.

He stops at one image that looks, to me, like just about every other image. I’m still trying to figure out which way the joint’s even facing when he gestures for me to move in closer and points to a small white-ish spot on the screen. He tells me that’s where the contrast fluid managed to make it through the labrum.

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I’m reminded of when I go to the mechanic and he brings me into the garage. Yeah, see that? You, uh, you got a busted flange there. You’re gonna need a new flange . . . and maybe a new gasket. We’ve got one in the back, but it’s not gonna be cheap.

The fluid leaking through the labrum, the doctor explains, indicates an injury. There are a few points of concern, in fact, and he scrolls through some of the images to show me how different cross-sections of my hip display different levels of tearing. Long story short: It’s pretty much exactly what we thought it was.

“Well, okay,” I say. “What’s the next step?”

Quick flashback: About three years into college, I managed to mess up my shoulder. It required an MRI – as these things are wont to do – and resulted in a conversation with my doctor at the time that went just about the same as the conversation I was about to have with the doctor in front of me.

See, the shoulder and the hip are similar in that neither gets particularly good blood flow.

Which means those areas aren’t all that great at healing themselves. I got away with not having my shoulder operated on, but my hip’s not likely to be so forgiving. Think of it like a hangnail: If you’re not pushing or hitting it against something, you might not notice it – but then you do, and it makes itself very noticeable.

“So,” I say, “I need to get it operated on?”

The doctor looks at the images, then looks at me. He folds his fingers in front of him and sits back in his chair. He then tells me that if this injury isn’t impacting my daily activities, isn’t causing me much pain, and isn’t keeping me from doing what I want to do, he doesn’t see it as necessary. There’s a certain lack of urgency, he says, because this isn’t something critical like cancer or appendicitis. It’s mostly a quality-of-life thing.

Ultimately, you do a cost-benefit analysis: Does this injury currently bother me enough to warrant going under the knife?

The answer then, as it is now, is no. I’m actually doing pretty well. I’ve still got a full range of motion. I don’t jog anymore, but there’s plenty of other cardio to be done and I always hated jogging anyway. Some days are worse than others, but most days are just fine with only a few minor aches and pains here and there. Like a bad roommate or a clingy friend, it’s one of those things that’s just going to be there until I finally decide I’ve had enough.

Sound anticlimactic? I’m inclined to agree. But one thing I’ve learned in my time around medicine and its practitioners is that an anticlimactic answer is not necessarily a bad thing. Thanks to Penn Medicine and my doctor, I can say with certainty I know what’s wrong with my hip. That’s enough for now.

MAINTAINING A MASTERPIECE Pennsylvania Hospital houses a work by a painter once referred to as “the American Raphael.”

T

he enormous painting is impossible to miss in Pennsylvania Hospital’s Gallery Pavilion. But how Benjamin West’s grand Christ Healing the Sick in the Temple found its way to the hospital is a story in itself.

West was born in 1738 in nearby Springfield, Pa., and began painting here before moving to Italy to master his craft.

He then established himself as one of the most successful painters in England and became George III’s painter of historical scenes. West completed Christ Healing the Sick in the Temple in 1811, intended as a gift for the hospital. But English royalty took a liking to it before it was shipped across the ocean. Needing the money after a long illness, West sold it to the Prince Regent for what was then a record sum for a work of art and promised Pennsylvania Hospital a second version of the original. (The original is now in the National Gallery, London.)

True to his word, West worked diligently and the second Christ Healing the Sick in the Temple was completed in

By Paul Foster 1815. It looks like the one that was sold to the Prince Regent, but with one addition. At the time, Pennsylvania Hospital was at the forefront in treating mental illness, so West added a mentally ill man (“a demoniac,” in his words) and his caretaker. When it arrived in Philadelphia in 1817, the painting was such a success that a new structure was built to house it, aptly named the Picture House. An estimated 30,000 visitors viewed it during the first 12 months, paying admission fees, and the painting is estimated to have raised $15,000 while housed there.

The painting now and hangs front and center in the Gallery Pavilion, between the historic Pine Building and the more modern parts of the hospital. After years on display, however, the painting is in need of another conservation treatment. Previous treatments dealt with a bulge in the left bottom of the painting, but those treatments have not solved the problem. Stacey Peeples, Pennsylvania Hospital’s curator and lead archivist, explains that the canvas

has been stretched several times, and a new work plan is now in need of implementation.

According to Peeples, the best option now is to “back” the painting, which means literally giving the hung canvas a hard backing to provide long-term support. Fundraising efforts have proved helpful, but they are still a little short of having enough to go through with the conservation, which includes the construction of a small room right inside the gallery area.

The painting has its own fire protection, a metal wall that can be lowered and raised manually in the case of disaster. Peeples says that it’s been lowered only twice in her 15 years at Pennsylvania Hospital.

In a letter that accompanied the painting on its voyage, West wrote that he bequeathed the painting to the hospital in the joint names of himself and his wife, noting “their patriotic affection for the State of Pennsylvania, in which they first inhaled the vital air.”

DEVELOPMENT MATTERS

First Medical Alumni Weekend at the Jordan Center Is Picture Perfect

Surrounded by beautiful views in the Jordan Center atrium, returning alumni were treated to a wonderful view of the next generation of medical leaders at “Lunch and Learn: Meet Our Future Leaders.” Moderated by Gail Morrison, M.D. ’71, G.M.E. ’76, current and graduating students Egen Atkinson, M.D. ’16, W.G. ’16, Phillip Cohen, M.D. ’17, Abimbola Dairo, M.D. ’16, Sarah Huepenbecker, C ’12, M.D. ’16, and Ted Kreider, C ’10, G ’10, Ph.D. ’18, M.D. ’18, shared their thoughts on the School as well as their future plans – including careers in academic medicine, drug discovery, serving underserved communities, and ultimately giving back to future students through scholarship support.

The Next Advances in Medicine

The future may not be ours to tell, but our faculty do have a read on where medical practice is heading. “The Future of Medicine: What’s in Store?” session featured Chief Scientific Officer Dr. Jonathan Epstein as moderator, with panelists Drs. Jill Baren, Lee Fleisher, C ’82, Frederic Bushman, and Amita Sehgal. Advances in biomedical technology, particularly wearable monitors and telemedicine, were hailed as new frontiers, along with microbiomics and Big Data.

With wit and wisdom – and for the fifth consecutive year – our 50th Reunion panel kicked off Medical Alumni Weekend. The panelists of the Class of 1966, including Samuel Adebonojo, Michael Aronoff, Jerry Gardner, David Mishalove, and Fred Sanford – guided by moderator Alan Wein, Chief of Urology, a key Penn Medicine leader, and fellow member of the Class of 1966 – shared in marveling at the tremendous advances made across medicine throughout their careers.

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Getting the weekend’s activities started in style – and with much gratitude – scholarship recipients and donors, along with Perelman School leaders, faculty, and staff, gathered on the Thursday evening before Medical Alumni Weekend. The power of collective support was on full display, with Dean J. Larry Jameson noting, as an example, that the Class of 1966’s scholarship fund has grown from a modest contribution to a value of more than $1.5 million today.

Mini Talks

“Ideas Worth Spreading.” The pithy TED Talk slogan certainly hits the nail on the head for Penn’s own “Mini Talks,” moderated

by Michael S. Parmacek, M.D., Chair of Medicine.

David Fajgenbaum, M.D. ’13, W.G. ’15, M.Sc., kicked off the morning with the powerful story of his diagnosis in medical school with the rare Castleman disease, which led to his life’s work: better understanding and curing the disease. Dr. Fajgenbaum and his colleagues each had eight minutes to cover their areas of expertise, which also included childhood trauma, sports medicine, and the U.S. health care system.

Other presenters included Kevin Volpp, M.D. ’98, G. ’97, Ph.D. ’98, Gary Dorshimer, M.D. ’81, Steven Berkowitz, M.D., Neha Vapiwala, M.D. ’01, and Julian Harris, M.D. ’08, M.B.A. ’08.

During an event-filled weekend, alumni took center stage at the awards presentation session opened by Dean J. Larry Jameson’s well-received annual State of the School message. William Bunney Jr., M.D. ’56, and Joseph Loscalzo, C ’72, Ph.D. ’76, M.D. ’78, were presented with Distinguished Graduate Awards. Class of 1966 members Joel Porter, M.D. ’66, and H. Linton Wray, M.D. ’66, were acknowledged with the Alumni Service Award. Roderick Wong, M.D. ’03, received the Young Alumni Award.

Center City was the impressive backdrop for the inaugural All Alumni Social, the casual Friday night get-together in the Jordan’s Center Atrium – a rare opportunity for the mix and mingling of graduates of all ages, along with many faculty, administrators, and current Perelman School students. As guests – including Walter Gamble, M.D. ’57 (center), with Maggi Apollon, M.D. ’96, Karen LaFace, M.D. ’96, and Tracy Cohen, M.D. ’96 – enjoyed cocktails and hors d’oeuvres, a jazz ensemble provided a mellow soundtrack. Judging from the convivial spirit of the evening, this first-ever event will hardly be the last.

For more Medical Alumni Weekend coverage, visit www.pennmedicine.org/alumni

Keynote from Nobel Award-winning Alum

Often the most surprising results hold the greatest scientific value.

So says Nobel laureate Michael S. Brown, C ’62, M.D. ’66, Hon ’86, who joined a keynote discussion with Dean Jameson. “If you just confirm your hypothesis, then you didn’t learn anything,” said Dr. Brown, here to celebrate his 50th reunion. His most notable discovery, with partner Joseph L. Goldstein, M.D., was how cells take up LDL cholesterol – which led to the development of cholesterol-lowering statins, helping millions reduce their risk of heart attack.

No Medical Alumni Weekend is complete without a night out on the town.

Pictured here are classes in their 20th and 30th Reunion years – just a sample of the classes celebrating reunion dinners in Center City hotspots, such as Hyatt at The Bellevue and R2L.

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PROGRESS NOTES Send your progress notes and photos to: Donor Relations Penn Medicine Development and Alumni Relations 3535 Market Street, Suite 750 Philadelphia, PA 19104-3309 PennMedicine@alumni.upenn.edu

1950s William E. Bunney, M.D. ’56, an international award-winning researcher, is one of this year’s two recipients of the Perelman School’s Distinguished Graduate Award. Bunney has provided invaluable evidence regarding the causes and treatment for major psychiatric disorders, including major depressive disorder, bipolar disorder, and schizophrenia.

He completed his residency in

psychiatry at Yale University School of Medicine, then was recruited to the Intramural Program of the National Institutes of Mental Health. Later, he served three years as director of its Division of Narcotic Addiction and Drug Abuse. During his tenure, the division established eight university-based research programs on substance abuse.

Currently at the School of Medicine at the University of California, Irvine, Bunney is a Distinguished Professor and the associate dean for research administration and development.

He is the senior author on a notable paper presenting the first direct evidence for clock gene abnormalities in major depressive disorder; the paper has been

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ranked in the top 98% of all downloaded papers published by the Proceedings of the National Academy of Sciences.

Bunney was elected to the National Academy of Medicine and subsequently designated a Lifetime National Associate of the National Academies. He is the author of more than 447 scientific publications, and his papers have been cited more than 34,000 times. Bunney’s honors include the Hofheimer Research Award of the American Psychiatric Association and the 2011 Rhoda and Bernard Sarnat International Prize in Mental Health from the National Academy of Medicine/ National Academy of Science.

1970s Joseph Loscalzo, Ph.D. ’76, M.D. ’78, is one of this year’s recipients of the Perelman School’s Distinguished Graduate Award. He is a cardiovascular specialist renowned for his work in vascular biology, thrombosis, atherosclerosis, and systems biology. His most recent work has established the field of network medicine, which uses systems biology and network science to redefine disease and therapeutics from an integrated perspective. Loscalzo has also written or co-written more than 800 scientific publications, has written or edited 40 books, and holds 31 patents for his work in the field of nitric oxide and redox biology.

The Hersey Professor of the Theory and Practice of Medicine

at Harvard Medical School, Loscalzo is also physician-in-chief at Brigham and Women’s Hospital and chair of its Department of Medicine. He has also been chair of the research committee of the American Heart Association and chair of the board of scientific counselors of the National Heart, Lung, and Blood Institute.

A recipient of the NIH MERIT Award, he is editor-in-chief of Circulation.

Among his numerous honors is membership in the National Academy of Medicine and the American Academy of Arts and Sciences. He has received the George W. Thorn Award for Excellence in Teaching at Brigham and Women’s Hospital.

The American Heart Association has recognized Loscalzo with its Distinguished Scientist Award and its Research Achievement Award.

Verdi J. DiSesa, M.D. ’76, G.M.E. ’83, was named president and chief executive officer of Temple University Hospital. He has been at Temple since 2011 and will remain chief operating officer of Temple’s health system and senior vice dean for clinical affairs in the Lewis Katz School of Medicine at Temple University. He is board certified in internal medicine, general surgery, and thoracic surgery.

Steven A. Fischkoff, M.D. ’76, has been appointed chief medical officer of Lion Biotechnologies, Inc., which is developing novel cancer immunotherapies based on tumor-infiltrating lymphocytes. With 25 years of biopharmaceutical experience, Fischkoff most recently served as vice president of clinical and medical affairs at Celgene Cellular Therapeutics, where his responsibilities included the development of cellbased products for treating malignant and non-malignant diseases. Previously, he was vice president of clinical development at Palatin Technologies. Before joining the industry, Fischkoff spent 15 years in academic positions at the National Cancer Institute and the medical schools of the University of Maryland and the University of Pennsylvania.

Raymond C. Roy, M.D., G.M.E ’78, former chair of the Department of Anesthesiology at Wake Forest School of Medicine, was named an emeritus professor of anesthesiology. After serving on the Wake Forest faculty from 1978 to 1992, he left to become chair of anesthesiology at the Medical University of South Carolina and at the University of Virginia. Returning to Wake Forest, he served as department chair 1998-2008 and 2014-15.

Under his leadership, the patient simulation laboratory was established. A director of the American Board of Anesthesiology from 1993 to 2005, he served also as its president. Roy continues as an editor for the journals Anesthesia and Analgesia and Journal of Anesthesia History.

1980s Jason S. Fisherman, M.D. ’82, was appointed chief executive officer and a member of the board of C4 Therapeutics. The new company, launched from DanaFarber Cancer Institute, will develop novel treatments in the field of targeted protein degradation using proprietary Degronimid technology. Fisherman was a venture investor at Synthesis Capital and Advent International, where his team led or managed more than 35 investments. Before joining Advent International, he conducted drug research and had clinical development experience in biopharmaceutical companies, in academia, and at the National Cancer Institute.

Diana F. Hausman, M.D. ’89, was appointed chief medical officer of Zymeworks, Inc., a company that develops bi-specific and multi-specific antibodies.

Hausman brings more than 15 years of clinical drug development experience to the management team at Zymeworks. Most recently, she was chief medical officer at Oncothyreon, where she oversaw its Phase 2 targeted anti-HER2 cancer therapy. She has also held positions at Zymogenetics, Berlex, and Immunex.

1990s Richard A. Feifer, M.D. ’92, has been named chief medical officer of Genesis Physician Services, which is part of Genesis HealthCare, one of the nation’s largest providers of post-acute rehabilitation. Before joining Genesis, Feifer served as Aetna’s chief medical officer of national accounts and was vice president of clinical program innovation and evaluation at Medco, where he was responsible for the organization’s portfolio of care-enhancement programs. He is currently an assistant clinical professor at the University of Connecticut.

T. Sloane Guy IV, M.D. ’94, was recruited to lead the new robotic cardiac surgery program at New York-Presbyterian/Weill Cornell Medical Center and Weill Cornell Medicine. He joins the institutions from Temple University, where he served as chief of the Division of Cardiothoracic Surgery, program director for the thoracic surgery residency, and chief of robotic surgery. Guy also served as an active-duty U.S. Army surgeon for nine years, completing three tours in Iraq and Afghanistan with the rank of lieutenant colonel.

2000s Joshua B. Resnick, M.D. ’01, has been appointed a partner of SV Life Sciences. He will be based in Boston and join the biotech investment team, which partners with entrepreneurs and management teams to develop innovative medicines, technologies, and diagnostics. Before joining SVLS, Resnick was president and managing partner at MRL Ventures Fund. Earlier, he was a venture partner with Atlas Venture.

During his tenure there, he was also the founder and CEO of two start-ups in the immuno-oncology and neuro fields. He is also an attending physician at Massachusetts General Hospital and Brigham and Women’s Hospital and an instructor in medicine at Harvard Medical School.

Andrew C. Krakowski, M.D. ’03, has joined DermOne, a Conshohocken network of comprehensive dermatology practices, as chief medical officer. Previously, he served as director of medical innovation for Rady Children’s Hospital in San Diego.

2010s Deborah Hemel, M.D. ’10, has joined Scarsdale Medical Group, a multi-specialty practice serving Westchester and Fairfield counties and the surrounding Hudson Valley area. She had been an academic hospitalist at Montefiore Medical Center and an instructor of medicine at Albert Einstein College of Medicine.

OBITUARIES

1940s Frank H. Rittenhouse, M.D. ’42, Crafton, Pa.; October 3, 2015. A veteran of World War II, serving as a captain in the U.S. Army and as a doctor in a Portable Surgical Hospital Unit, he also had his own medical practice in Crafton for many years.

Isidore Cohn Jr., M.D. ’45, G.M.E. ’52, Gr.M. ’55, emeritus chairman of the Department of Surgery at Louisiana State University; October 14, 2015. Raised in New Orleans and named for his father, who was also a prominent surgeon, Cohn returned to the city of his birth after his studies at Penn. Having joined the LSU School of Medicine faculty in 1952, he succeeded his predecessor, James D. Rives, M.D., as chair of the department in 1962 and held that position for 27 years. He served concurrently as surgeon-in-chief of the LSU Service at Charity Hospital and was responsible for introducing thousands of medical students to general surgery and directing the training of more than 300 surgical residents. In 1987, in recognition of his mentoring, a group of former surgical residents funded the Isidore Cohn Jr. Professorship of Surgery, the first million-dollar

chair at the LSU School of Medicine. In 2002, former surgical residents and The James D. Rives Surgical Society (subsequently renamed the Isidore Cohn Jr. – James D. Rives Surgical Society) were the major donors for the Isidore Cohn Jr., M.D., Student Learning Center, a surgical training facility at LSU. Cohn published 358 articles in peer-reviewed medical journals and served as editor of ten, including The American Surgeon, Cancer, and the American Journal of Surgery. He was president of the New Orleans Surgical Society and the Surgical Association of Louisiana, and was named 1st Vice President of the American College of Surgeons in 1993. From 1975 to 1984, he served as director of the National Pancreatic Cancer Project of the National Institutes of Health. He also served on many civic and artistic associations, and the Cohns’ Steuben glass collection was exhibited at the New Orleans Museum of Art in 2004.

Among his many honors are the Spirit of Charity award from the Medical Center of Louisiana and an honorary doctorate from the University of South Carolina.

Marvin H. Terry Grody, M.D. ’46, Philadelphia, a retired gynecologist; July 7, 2015. He served as an officer in the U.S. Army Medical Corps in occupied Germany after World War II. On his return, he began his career as an OB/GYN in private practice in Hartford, Conn. After many years of practice, in 1986 he was appointed to the OB/GYN faculty of the College of Physicians

and Surgeons of Columbia University and the associated position of director of gynecologic surgery at the Presbyterian Hospital Medical Center in New York. From 1990 to 2001, he was a professor of OB/GYN at the Temple University School of Medicine and the director of gynecology at the Temple University Hospital. Later, he worked as a professor of OB/GYN at the Robert Wood Johnson Medical School and as senior gynecologic consultant at the Cooper University Hospital-UMDNJ. Grody published dozens of scientific manuscripts and appeared as a guest speaker around the world. He was also a pioneer in producing videos that taught gynecological surgery procedures.

He was recognized as a Distinguished Surgeon of 2001 by the Society of Gynecologic Surgeons.

He received ACOG Presidential Medals in 1995 for outstanding continued educational activity and in 1997 for district educational audiovisual contributions.

He was honored by medical students as Best Clinical Teacher at Temple University School of Medicine in 1997. In 2000, he appeared on NBC’s Today show with Katie Couric to discuss pelvic organ prolapse. Grody also published two books: Benign Postoperative Gynecologic Surgery and Rx for Happiness: An OB/GYN’s Story.

Joseph K. Corson, M.D. ’47, G.M. ’50, Plymouth Meeting, Pa., a retired dermatologist who practiced in Chestnut Hill for half a century; May 10, 2015.

Corson came from a long line of Quaker physicians, one of whom was decorated for bravery while serving as an assistant surgeon in the Union Army during the Civil War in 1863. Corson had served as chief of dermatology at Chestnut Hill Hospital and as associate clinical professor of dermatology and cutaneous biology at Jefferson Medical College. According to his daughter, Anna F. Corson, M.D. ’82, Corson’s father, Dr. Edward F. Corson, had been a dermatology professor at Jefferson.

She also noted that her father was the 17th member of the Corson family in five generations to obtain a medical degree from

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Penn. Corson also followed the pattern of the Corson doctors of accepting 10 percent of his cases as charity care. A skilled cabinetmaker, he built many pieces of furniture for family and friends.

These included grandfather clocks, dressing tables, and pieces in the Chippendale style.

pital on Staten Island, N.Y. The military service interrupted his career with West Jersey Anesthesiology Associates, which began in the firm’s offices at West Jersey Hospital in 1952 and continued until he retired in 1983 from the firm’s office in Marlton. Goos was a member of the New Jersey Anesthesiology Society.

1950s

Ray G. Sarver, M.D. ’54, Latrobe, Pa., a retired pediatrician who had maintained a practice there for 47 years; January 16, 2015. He was a veteran of the Air Force, attaining the rank of major, and served in the Reserves as chief of pediatrics at the Amarillo Air Force Base Hospital in Amarillo, Texas. He had full pediatric privileges at the Latrobe Area Hospital, where he also served as associate medical director.

Theodore B. Cohen, M.D. ’51, Narberth, Pa., a psychoanalyst who had been associated with the Psychoanalytic Center of Philadelphia for more than 60 years; April 22, 2015. Known for his focus on what he called “the vulnerable child,” he was deeply committed to understanding children, how they learned, and how their mental health issues could be overcome. In 1976, he organized the first international meeting centered on children and adolescents, held in Philadelphia. For many years he led an important discussion and study group on the vulnerable child.

Later, along with his colleagues Hossein Etezady and Bernard Pacella, Cohen used the substance of the discussions to edit three volumes of studies, published in 1993, 1995, and 1999. The volumes dealt with such topics as developmental disabilities, young children and violence, prenatal cocaine exposure, and problems with foster and day care.

After majoring in psychology at Brooklyn College, Cohen was drafted into the U.S. Army and served during World War II. According to his family, because of his undergraduate training, he was chosen to lead surviving children from the Dachau concentration camp so they could be cared for by the Red Cross.

Cohen was an avid sportsman, playing tennis and also table tennis. He advised the U.S. Olympic table-tennis team at the Seoul Games in 1988.

Richard C. Goos, M.D., G.M.E. ’51, Whiting, N.J., a retired anesthesiologist; July 12, 2015. After earning his medical degree, from 1955 to 1957, he fulfilled his military obligation by working as a physician for the U.S. Public Health Service, at a military hos38

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David Babbott, M.D. ’55, Shelburne, Vt., an emeritus professor of medicine at the University of Vermont; August 23, 2015. In 1946, he was inducted into the U.S. Army and served at Fort Richardson, Alaska. After graduating cum laude from Amherst College, he entered Penn’s medical school. He completed his graduate medical education at Hartford Hospital in Hartford, Conn., and at New England Medical Center in Boston. Following three years spent practicing internal medicine, he served as assistant director of medical education at Hartford Hospital, beginning what would become a career-long focus on the art of teaching patient care. In 1967, Babbott was appointed assistant dean and assistant professor of medicine at the University of Vermont College of Medicine.

From 1971 to 1993 he was on the full-time faculty in the Department of Medicine and was director of medical education for 18 years. He served as a role model, mentor, and advocate for hundreds of medical students, residents, and junior colleagues. On the occasion of his retirement as emeritus professor in 1993, the Medical Residents’ Library was named and endowed in his honor.

Babbott was elected a fellow of the American College of Physicians and served as governor of its Vermont Chapter from 1991 to 1995. A volunteer at King

Street Youth Center, Babbott had also been a board member of the Lake Champlain Land Trust and of Patient Choices Vermont.

ter, designed to help children with problems that are difficult to diagnose. The center was named in his honor in 2009.

Harrison M. Dickson, M.D. ’58, Lancaster, Pa., a retired surgeon; February 1, 2015. After graduation from high school, he served in the U.S. Army during World War II with the medical battalion of the 84th Infantry. He survived the Battle of the Bulge, receiving three Bronze Stars during his tour. After earning his medical degree, he completed a surgical residency at the Mayo Clinic in Rochester, Minn. He practiced surgery with his cousin, James Dickson, for seven years in Chambersburg. He left to serve as a deputy chief surgeon for Project Hope while in Maceio, Brazil, aboard the U.S.S. Hope.

The vessel was refitted and equipped as a peacetime hospital ship to serve developing nations with training and teaching

Edward J. Zobian, M.D. ’66, Wyomissing, Pa.; November 18, 2015. He served as a battalion surgeon with the U.S. Army’s 19th Combat Engineer Battalion in Vietnam. There, he was decorated twice for heroism, and when he returned home in August 1968, he was promoted to major and appointed chief of the Department of Hospital Clinics at Kirk U.S. Army Health Clinic.

In 1973, he began practicing ophthalmology with West Reading Ophthalmic Associates (now Eye Consultants of Pennsylvania). Zobian’s specialty was cataract surgery. He was an innovator

1960s Patrick S. Pasquariello Jr., M.D., G.M.E. ’63, Bala Cynwyd, Pa., and Longport, N.J., a pediatrician who worked at the Children’s Hospital of Philadelphia for 54 years; August 29, 2015. He earned his bachelor’s degree from St. Joseph’s University before receiving his medical degree from Jefferson Medical College.

He also served as a lieutenant in the U.S. Navy. In 1961, he became an intern at CHOP and served as chief resident under C. Everett Koop, M.D., who later became Surgeon General of the United States. Pasquariello joined the Penn Med faculty in 1962.

Promoted to professor of pediatrics in 1990, he became emeritus professor in 2005.

Throughout his career at Children’s Hospital, he held many leadership roles, including director of the Office of Continuing Medical Education, interim chief of the Division of General Pediatrics, director of the spina bifida program, and general pediatric consultant for the “22q and you” center and the cranial-facial reconstruction clinic. In 1989, Pasquariello created CHOP’s diagnostic and complex care cen-

in intraocular lens implantation, small incision sutureless cataract surgery, and no-injection local anesthesia; he performed more than 20,000 cataract operations in his career. A fellow of the American College of Surgeons, he was certified by the American Board of Ophthalmology and served as an attending surgeon at several Pennsylvania hospitals.

He also volunteered in the Philippines, performing free eye surgeries on the country’s blind population.

1970s Arnold W. Klein, M.D. ’71, Palm Springs, Calif.; October 22, 2015.

He served as dermatologist to the late Michael Jackson, Eliza-

LEGACY GIVING beth Taylor, and several other Hollywood celebrities. After he opened a private practice in Beverly Hills, his career got an early boost when Merv Griffin invited him to appear on his television talk show. His medical specialty was the use of injectable drugs such as Botox and Restylane to ease wrinkles and sagging skin.

In fact, Vanity Fair described him as “the Father of Botox.” His expertise in lip augmentation was confirmed when a region of the upper lip – the Glogau-Klein point – was named for him and fellow dermatologist Richard Glogau. Klein was also an early advocate and fundraiser for AIDS research.

2000s Lisa Marino, D.O., G.M.E. ’07, Southampton County, N.J., a physician at the Rothman Institute; April 13, 2015. Born with cystic fibrosis, Marino had to undergo rigorous physical therapy every morning and evening. According to her husband, Sean Sanford, she had never been in serious condition until being hospitalized in January, 2015. From 1997 to 1999, she was a chemist at Rohm & Haas Co., then earned a doctorate at the Philadelphia College of Osteopathy in 2003. She was an intern at what is now the Frankford campus of Aria Health and then chief resident in physical medicine and rehabilitation at HUP. She also did a fellowship there in spinal intervention and spine pain management.

FACULTY Patrick S. Pasquariello Jr., M.D. See Class of 1963.

Elaine Catherine Pierson-Mastroianni, M.D., Bryn Mawr, Pa., emeritus clinical associate professor of obstetrics and gynecology and former head of student health at Penn; October 3, 2015.

She attended the University of Michigan on a full scholarship, earning her B.A. degree in zoology and then her medical degree.

In 1957, she joined the faculty at

Yale University as a resident in OB/GYN. In the mid-1960s, she moved to Philadelphia with her husband, Luigi Mastroianni Jr., M.D., who became chair of the Department of Obstetrics & Gynecology at Penn, and their three children. (Dr. Mastroianni died In November 2008.) In 1968, she joined Penn as a staff physician in OB/GYN for the student health clinic. A year later, she also joined the faculty as an instructor.

She had also begun to write articles for The Daily Pennsylvanian about sex and contraception, under a pseudonym. In 1971, she published Sex is Never an Emergency: A Candid Guide for College Students, which cost only $1 and was given to every incoming student at Penn. More than 200,000 copies were sold.

She also wrote Female and Male: Dimensions on Human Sexuality (1974) with sociologist William V. D’Antonio, Ph.D. In 1979, she was promoted to clinical associate professor. She was accorded emeritus status in 1992.

Francis H. Sterling, M.D., Havertown, Pa., emeritus professor of medicine; January 18, 2015. A graduate of Jefferson Medical College, he served in the Army Medical Corps and was honorably discharged with the rank of major. After an internship at Misericordia Hospital, in 1967 he was appointed assistant professor of medicine at Penn as well as chief of the endocrinology section – University of Pennsylvania Service at the VA Hospital.

His teaching abilities were legendary. Using a Socratic style that was both rigorous and endearing, he integrated clinical phenomena and basic science into his teaching of biochemistry and endocrinology to preclinical medical students. Among his teaching honors were the University’s Lindback Award for Distinguished Teaching and the Donna McCurdy Award for Distinguished Teaching of Medical Housestaff. In addition, the Philadelphia VA Medical Center created the Francis H. Sterling Award for Educational Excellence.

Win-Win: Thankful for Connecting a Passion for Medical Education and Philanthropy “There is a vibrancy I have witnessed on campus that I am delighted to support,” said cardiologist and instructor Donald LaVan, C ’55, M.D. ’59, G.M. ’63.

“Helping further the education of the very bright students there now, who often earn dual degrees, also means a great deal to me. I am constantly impressed that Penn Medicine continues to recruit the top students in the country and is able to foster the development of future leaders in medicine.”

Dr. LaVan practiced in Philadelphia throughout his career and retired in 2014. He was also a faculty member of the Perelman School of Medicine – most recently as a clinical associate professor of medicine – who was passionate about teaching medical students at Pennsylvania Hospital.

Dr. LaVan cherished the opportunity to heal patients as well as to nurture future caregivers and leaders in medicine.

So when he began to consider ways to support students and give back to his alma mater – as well as access some of the wealth held in his retirement accounts – he opted for a Charitable IRA Rollover. This option was originally enacted in 2006 but did not become a permanent part of the tax code until 2015. The Charitable IRA Rollover allows donors who are 70½ or older to support their charity of choice by directly rolling over from an IRA up to $100,000 each year. Donors do not receive a tax deduction for the rollover gift but the Charitable IRA Rollover does count toward yearly Required Minimum Distributions (RMD). The charity accepts the rollover gift tax free.

Dr. LaVan earmarked his Charitable IRA Rollover gift to the Perelman School, specifically the Class of 1959 Medical Scholarship Fund. “Supporting Penn Medicine in this way,” he explained, “allows me to both give back to the School that I cherish, by supporting its current and future students, and make a philanthropic contribution very efficiently – more so than a straight contribution – through taxes and satisfying part of my RMD each year. It’s really a win-win.”

Planned Giving has sometimes been described by our donors as the final piece of a puzzle. Figuring out how this important puzzle piece, such as the Charitable IRA Rollover, can work best for you, your family, and your philanthropic goals is what we do best. Speak with us to learn more about giving options, and we will help you find the missing piece of your puzzle. Contact Christine S. Ewan, J.D., executive director of Planned Giving, at 215-898-9486 or cewan@upenn.edu.

For more information, please visit the website at: www.plannedgiving.med.upenn.edu.

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EDITOR’S NOTE

To Be Precise Personalized? Or Individualized? Genomic, perhaps? Or Precision? What to name this new kind of medicine? As many longtime medical practitioners insist, the best medicine has always been “personalized,” focused on the patients they are treating. So perhaps “precision medicine” is more accurate for what is currently developing. This issue’s cover story recounts what’s been happening at Penn with precision medicine.

Precision has a nice sound to it. Years ago, the graduate students teaching Freshman English to Penn students held a Halloween party. Having come up for air after a long stretch of grading essays, I decided to attend as a new superhero: Captain Correcto. I wore borrowed plastic goggles and probably made do with a long blue towel for a cape. On my chest, I had affixed a cardboard crest with these words: CLARITY & PRECISION. Captain Correcto had a very short life, but I’ve continued to appreciate precision when it’s called for. So I observed with interest as what was then “personalized medicine” a dozen years ago is now almost universally recognized as “precision medicine.” Even the Federal government is on board, as shown when President Obama delivered his 2015 State of the Union Address and called for a national Precision Medicine Initiative. This is not the first time he has shown interest in this kind of medicine. In August 2006, as a U.S. Senator, he introduced the Genomics and Personalized Medicine Act, which he claimed would help scientists tap the power of genomics to find treatments for disease. The bill was not enacted.

This time, things are different, as the president’s initiative has added $215 million to the federal budget and more and more institutions are pursuing precision medicine.

A few days after the State of the Union Address, President Obama asserted that precision medicine “gives us one of the greatest opportunities for new medical breakthroughs that we have ever seen. . . . What if figuring out

the right dose of medicine was as simple as taking our temperature?” He clearly stated the basic premise – and promise – of precision medicine: “delivering the right treatments, at the right time, every time, to the right person.” His words have a familiar ring. On the home page of Penn’s new Center for Precision Medicine: “The practice of precision medicine is about providing the right treatment (or prevention) to each individual at the right time.”

The need for more precision seems very clear when medications are involved. In April 2015, Nature ran a fullpage infographic (“Imprecision Medicine”) showing that for every person that the ten highest-grossing drugs in the United States do help, they fail to improve the conditions of between 3 and 24 people. Even more frightening, the article noted that for some drugs, such as statins, it may be as few as 1 in 50 who benefits.

Although precision medicine seems to have won the field, there remain some wary observers. In 2007, Penn Medicine reported on a symposium organized by Penn’s Institute for Translational Medicine and Therapeutics. Its title: “Personalized Medicine: Boon or Pipe Dream?” Two years later, the Penn Genome Frontiers Institute was one of the hosts of another symposium on personalized medicine. The consensus: challenges still remained. More recently, a publication of Penn’s Leonard Davis Institute of Health Economics ran “Personalized Medicine: The Promise and Perils” (March 2013). Several Penn Med faculty members were quoted, including Jason Karlawish, M.D., a professor of medicine: “As a society, we’re going to need to start to think about the ethical, legal, and social implications of this. . . . It’s a new model that presents novel challenges.” Even Jason H. Moore, Ph.D., featured in the current issue, notes that precision medicine “is a fundamental change in the practice of medicine, and it will require some time to sort out.” To be precise, the future may be john.shea@uphs.upenn.edu closer, but it’s not here yet.

--------------PERSONALIZED ----------------INDIVIDUALIZED --------GENOMIC >>PRECISION<<

Keep in Touch:

In the Fall Issue: If the high cost of drugs has individuals reeling, imagine how a health system with 2,500 licensed beds must feel. Also, two of Penn Med’s Nobel Prize recipients share glimpses of how they succeeded and what they’re doing now.

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PENN MEDICINE

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ONE LAST THOUGHT

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Capturing Global Health in Photos Penn’s Center for Global Health was launched by the School of Medicine in 2004 in response to requests from Penn’s medical students who had formed an interest group in global health. It now coordinates the global activities of the school and supports the international aspects of its research, educational, and service programs.

This year, the center invited students, residents, and fellows to submit photographs illustrating domestic or global health experiences. The results of its first annual photo contest were announced on World Health Day, April 7.

First place went to Anastasia Vishnevetsky, a fourthyear medical student also working toward her master’s degree in bioethics. She was involved in a research project that took her to Cusco, Peru. The title: “Patient Abandonment.” The photograph, taken by Carla Zapata del Mar, the research collaborator/research assistant for the project, shows a nurse visiting an elderly woman in the villages outside Cusco. She had been abandoned by her family and did not have access to medical care.

Michael Chua, a third-year medical student, took second place with “Peace.” The photo was taken during a health-outreach trip with the Philippines’ Research Insti-

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tute of Tropical Medicine, during which Chua took part in offering health screenings and providing medications for underserved villages throughout the Leyte province. The village of the girl in the photo, Nina, had been devastated by a typhoon. “Fortunately, her father was able to find shelter for their family and their pigs.”

Third place went to Christopher Magoon, a second-year student, during a visit to China’s mountainous Yunnan Province. The title: “Man smoking with woman on farm.”

Tobacco is a major agricultural product of the region; cigarette sales provide important government revenue; and tobacco is tied to notions of manhood and friendship.

“These cultural and economic forces make smoking cessation campaigns especially challenging.”

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