A Publication of the
Program on Prevention
In Education & Practice
November
2001 - Volume 1, Number 10
We dedicate this edition
to the memory of Dr. Floyd Denny who,
among many marvelous works,
established the Program on Health Promotion Disease Prevention (now Program
on Prevention).
A great
doctor, teacher and humanitarian.
We miss him and we honor him.
First, a little history... Dr. Denny received his medical degree at Vanderbilt University where he also did his internship and residency. Following this, as a member of the U.S. Army Medical Corps, he was assigned to the Department of Preventive Medicine at Case Western Reserve. He worked with Drs. Charles Rammelkamp and John Dingle in Cheyenne, Wyoming on landmark studies of streptococcal infections that lead to the prevention of rheumatic fever (Denny F, Wannamaker L, Brink W, Rammelkamp C and Custer E. Prevention of Rheumatic Fever: Treatment of the Preceding Streptococcic Infection. JAMA. 1950;143:151-153.) This work has saved countless lives throughout the world and has spared millions the debilitating effects of acquired heart disease.
Following his time with the Army, Dr. Denny joined the Department of Pediatrics at the University of Minnesota, then moved back to Vanderbilt and then back to Case Western Reserve before joining the UNC faculty as Chairman of the Department of Pediatrics in 1960.
His many contributions to UNC... "The stage was set for the fantastically exciting days in academic medicine in the 1960s and '70s... we were limited at that time only by our imaginations and how hard we were willing to work." ~(Dr. Denny from Berryhill Lecture, 1987)
Some of Dr. Denny's many contributions to the School of Medicine and the Department of Pediatrics are the following:
increasing the number of pediatric faculty (from 7 in 1960 to 75 in 1987.) "...start
with young faculty who give the signs of a promising career, protect them as
much as possible so that they can develop, and then hold them accountable for
what they do"; ~(Dr. Denny from Berryhill Lecture, 1987)
integral involvement in developing a combined medicine-pediatric program. "...
forerunner of its kind in the country and generally considered to be the best";~(Dr.
Denny from Berryhill Lecture, 1987)
nurturing and developing a competitive state-of-the-art pediatric residency
program (from 7 applicants in 1960 to over 300 in 1987);
developed the UNC Pediatric Rheumatology Clinic and
the joint UNC-Duke Pediatric Rheumatology Research Center;
initial involvement in pediatric part of AHEC that allowed pediatric teaching
to spread beyond the walls of UNC;
developed the Program on Health Promotion and Disease Prevention to provide
prevention education for the medical school. "Through his efforts, HPDP
has been identified as one of the four major themes for the school's long-range
planning process";~(Thomas
Boat, Louis Underwood and Judson Van Wyk from the "Nomination of Floyd
Denny for the Howland Award")
fostered extensive collaboration among faculty in medicine and public health
on a project to define the contribution of cigarette smoke exposure to the incidence
and severity of respiratory tract infections in infants and to develop intervention
strategies;
extensive research in three areas: 1) streptococcal infections and their consequences;
2) the role of Mycoplasma pneumoniae as a respiratory pathogen; and 3)
the epidemiology of respiratory infections in children;
became a worldwide spokesperson and consultant on the debilitating effects of
acute respiratory infections to improve the health of children in other countries;
recipient of numerous teaching awards including the
Professor Award (UNC Medical School Class of 1965), Distinguished Faculty Award
(UNC School of Medicine, 1987), Resident Award for Excellence in Teaching (Pediatric
House Staff, 1979-80), and the O. Max Gardner Award of the UNC 16-campus system
(1988). Residents established the Floyd Denny Pediatric Society which is dedicated
to the educational enrichment of the current housestaff;
well respected spokesman for pediatric issues in national and international
forums as President of both the Society for Pediatric Research (1968-69) and
American Pediatric Society (1980-81); and
member of the Institute of Medicine of the National Academy of Sciences.
What his colleagues
and students have said...
Many
resident have described Dr. Denny as having great humility, "If he doesn't
know something he will say so."~(Thomas
Boat, Louis Underwood and Judson Van Wyk from the "Nomination of Floyd
Denny for the Howland Award")
Another commonly cited attribute is Dr. Denny's integrity,
"He is rigid in believing that kindness and consideration is mandatory
in caring for ill children and their patients."~(Thomas
Boat, Louis Underwood and Judson Van Wyk from the "Nomination of Floyd
Denny for the Howland Award")
Three former residents dedicated their pediatric practice
to Dr. Denny. A plaque in the waiting room reads "Floyd W. Denny, MD, Professor
and Chairman of the Department of Pediatrics at the University of North Carolina
School of Medicine, has been a profound influence on our professional careers.
More than any other individual he has molded our approach to the health care
of children. We aspire to have... Pediatric Associates reflect the principles
of scholarship, intellectual honesty and love of children that he taught us
by precept and example. To this end, in appreciation, we dedicate this practice
to him."~(Thomas
Boat, Louis Underwood and Judson Van Wyk from the "Nomination of Floyd
Denny for the Howland Award")
I first met Dr. Denny in December of 1978 when I
came to UNC for my Clinical Scholars' interview. Dr. Denny "preached" the importance
of epidemiology to me and told me that I should come to Carolina for the epidemiology
department even if I wasn't accepted into the Clinical Scholars program. I remember
that he talked slow and he was my only exposure on that trip to a faculty member
with a southern accent. However, it was clear immediately that there was no
relationship between the speed of his speech and the lightning speed of his
mind. He was gracious and enthusiastic and I was ready to enlist. As a scholar,
I was urged to take a look at a position in the Department of Social Medicine.
This seemed like a diversion from my expected career direction and potentially
away from pediatrics and clinical care. I consulted with Floyd about applying;
he counseled that I should take the position and told me about his own early
career in preventive medicine at Case and about the development of Alan Cross's
career. By the time I joined the Social Medicine faculty, he had stepped down
as chair of Pediatrics. He continued to support my dual role as a social medicine
faculty member and as a pediatrician. Floyd had an office in Social Medicine
and he and Alan Cross were known as "Batman and Robin" as they together pushed
the development of the HPDP Center and program in the School of Medicine. They
worked with Carol Runyan; Floyd, looking at my chaotic and overextended work
patterns, once asked Carol how she put up with me. Floyd was irreverent and
funny. I sought him out again as an experienced voice when I had issues related
to assuming the Chair of Social Medicine. He provided a few inside secrets such
as never asking the faculty for their opinions at faculty meetings. Floyd taught
me what is warmly referred to in our family as the "Denny Salute" in which one's
glasses are pushed up the nose with the middle finger as a means of demonstrating
displeasure with a concept or person. Floyd demonstrated brilliance, commitment,
integrity and enthusiasm in all that he undertook. He made UNC a richer place
by infusing it with his gentleness, collaboration and enthusiasm. We will all
miss him. ~ (Desmond Runyan, MD, DrPH)
"Dr. Denny has been a model
clinician, a wise and revered teacher, an imaginative and productive investigator,
a highly successful department chairman, an inspirational leader of American
Pediatrics and Infectious Disease Medicine, and a shaper of health planning
and policy for children everywhere."~(Thomas
Boat, Louis Underwood and Judson Van Wyk from the "Nomination of Floyd
Denny for the Howland Award")
"A Day that will Live in Infamy"
When we woke up, it was just another day, like any other day. In the early morning, two planes crashed into the World Trade Towers and another into the Pentagon killing thousands and leaving mounds of devastation all around us. When we went to bed that night it was a changed world. September 11, 2001 is now a day like the days President Kennedy or Martin Luther King were assassinated, the day the Challenger exploded or when Pearl Harbor was bombed. We remember exactly where we were and what we were doing... and always will.
In the wake of September 11th, many things have changed, our country is no longer a safe haven from outside forces and there is cause for fear in our everyday activities. Anthrax is the latest fear of many. The following articles examine some of the fallout of the September 11th tragedy as it applies to medical education.
AAMC President Calls for Medicine-Public Health Collaboration
"Everything in American changed September 11th," says AAMC President, Jordan Cohen, MD.
In the aftermath of September 11, widespread fear of anthrax and other threats of bioterrorism call on physicians to provide some authoritative words and answers for the country. In the November edition of the Reporter, AAMC's monthly newsletter, Dr. Cohen says the changes call for "new priorities, new responsibilities and new opportunities for leadership [in academic medicine]." He says that September 11 provides an "opportunity for all of us to recognize that clinical medicine is powerless to deal effectively with bioterrorism without a solid and seamless partnership with public health." Unfortunately, this system has not received the attention it needed in the past. This provides an opportunity for academic medicine to join forces with the public health community to "lead the charge for a rapid build up of our country's public health capacity."
In this new America, Dr. Cohen also suggests it is also important to begin preparing students to deal with bioterrorist threats. He says "equipping medical students and residents, as well as practitioners, with the knowledge and skills required for early detection of biological and chemical attacks has suddenly become a permanent part of our curricular offerings." He also mentions the need for training in post-traumatic stress and working in collaboration with other clinicians and public health workers.
This has prompted the AAMC to implement a plan of action, "First Contact, First Response." As part of this plan, the AAMC will bring together a panel of experts in bioterrorism to provide guidance to medical schools on adding curriculum content. Goals include developing learning objectives appropriate for the education of medical students and recommending educational strategies to achieve the stated objectives. In addition, the AAMC will be building on a cooperative agreement with the Centers for Disease Control and Prevention (CDC) to improve existing partnerships between public health and medicine. Go to "First Contact, First Response" for more information.
A quick search of our medical school online syllabus offers very few opportunities for students to learn about bioterrorism. Perhaps the AAMC initiative will provide an opportunity to build a bridge across Columbia Street, between the Schools of Medicine and Public Health here on our own campus.
Influenza Vaccine Update- The Anthrax Connection
Many are eager to get their influenza vaccine as quickly as possible as a means of preventing a complicated anthrax infection. The thinking is... if a person gets flu-like symptoms and has had the flu shot, an anthrax-related illness will be detected and treated earlier. The problem lies in the fact that there is a limited amount of influenza vaccine again this year and high-risk individuals need to receive their vaccine first. Additional vaccine supply is being produced and will be available mid-November or December. At this point, the CDC and ACIP (Advisory Committee on Immunization Practice) have identified these populations as "high-risk" and in need of initial vaccination-
persons 65 years and older
persons under 65 years with high-risk medical conditions
pregnant women
health care workers
The CDC does NOT recommend that you get a flu shot so you can tell if you have the flu or an anthrax-related illness. Many viruses and bacteria besides influenza (including anthrax) can begin with flu-like symptoms, which include fever, body aches, tiredness, and headaches. In fact, most illnesses with flu-like symptoms are not caused by influenza or anthrax. The flu shot can prevent 70-90 percent of the flu illnesses, but it will not prevent illnesses with flu-like symptoms caused by anything other than the influenza virus.
See http://www.cdc.gov/nip/Flu/qa-public.htm#anthrax for more information.
Psychological
Debriefing for Survivors of September 11
By Jeffrey Sonis, MD ~ Department of Social Medicine
The tragic events of September 11 caused more than 4,000 deaths in the course of hours. In addition, thousands upon thousands of people in New York City and Washington, D.C. areas were directly exposed to the traumatic events, and are at increased risk of developing post-traumatic stress disorder (PTSD) and other mental health problems, such as depression. People who were in or near the World Trade Centers or the Pentagon during the attack, rescue workers of all stripes, journalists, and families of the missing or dead are all at increased risk.
PTSD is a syndrome in which people who are directly exposed to extreme trauma develop psychological symptoms in the following three areas: 1) re-experiencing the event, such as nightmares, or flashbacks; 2) emotional numbing and avoidance of situations and thoughts that are reminders of the event; 3) increased arousal, such as difficulty sleeping or hypervigilance. An estimated 10% to 20% of people exposed to extreme trauma such as natural disasters develop PTSD at some point in their lives.
Since so many people were exposed to the trauma of September 11, and since 10% to 20% of them can be expected to develop a disabling psychiatric condition, why not intervene to try to prevent PTSD? Psychological debriefing is an intervention designed to do just that. Debriefing is designed to minimize the adverse immediate consequences of psychological trauma and reduce the risk of development of PTSD. It is a group intervention, in which persons who were exposed to the trauma, but are not reporting symptoms, have the opportunity to discuss their thoughts and feelings. The group leader emphasizes the normality of extreme emotions, and discusses specific coping and support strategies for the future. Debriefing is a one time intervention which lasts several hours.
Despite the unassailable logic of prevention, and the strong theoretical models from which debriefing is derived, there is little empirical evidence to support its effectiveness, and some evidence to suggest that it may in fact be harmful. A meta-analysis of eleven randomized trials of debriefing (from a variety of different types of trauma) showed that the short-term risk of PTSD was equal in the debriefing and control groups (odds ratio 1.0, 95% confidence interval 0.6 to 1.8). The one year risk of PTSD, in the two trials employing long term follow-up, was actually greater in those randomized to debriefing (odds ratio 2.0, 95% confidence interval 0.9 to 4.5). Debriefing does not appear to reduce general psychological morbidity, depression, or generalized anxiety, but the confidence intervals for those estimates are wider and do not exclude either a beneficial or adverse effect of debriefing. There is good evidence, however, that persons who participate in debriefing are satisfied with it immediately after they participate.
A number of non-randomized studies have reported that debriefing resulted in improvements in a variety of outcomes among participants including anxiety, depression, re-experiencing symptoms, and job turnover. However, because the people who chose to participate in debriefing were almost certainly different from those who did not, the differences in outcomes may simply reflect baseline differences.
Why debriefing does not work is unclear. Perhaps the debriefing intervention is too short. Perhaps one session allows serious issues to be raised but not resolved. Perhaps it is inappropriate to apply debriefing to all exposed persons rather than just those with symptoms. Perhaps some people need time to process the trauma by themselves before discussing it with others. Perhaps awareness of PTSD leads to increased self-reporting of symptoms. Or perhaps debriefing is a great idea that just doesn't work.
The clinical implications for survivors of the September 11 tragedy are clear: debriefing should not be provided routinely to any group of asymptomatic survivors, no matter how severe the exposure to trauma. It is possible that future research may lead to fine-tuning of debriefing that will improve its effectiveness, but it cannot be recommended at the current time. There is, however, strong evidence from dozens of observational studies that social support can help attenuate the adverse impact of severe trauma, and health care providers who work with survivors should encourage them to utilize their existing support networks. In addition, there is strong evidence from high quality randomized trials that cognitive-behavior therapy and pharmacotherapy can reduce the severity, and duration of PTSD. Clinicians should be attuned to the symptoms of PTSD among survivors and treat and/or refer them for appropriate therapy.
It is completely natural for people to want to reach out and help others who were exposed to extreme trauma like the events of September 11. Debriefing is an intervention developed out of that compassion. But to be effective, compassion must be leavened with evidence. Only then can our humane impulses really help those in need.
Around the World Wide Web...
People have more access to health care information than ever before. Not only do they hear about health news in the media but more and more individuals are looking to the WWW for information. Directing your patients to credible and reliable information is key. The Web can be a valuable resource for educational material for patients and providers alike if it is used wisely.
This CDC site offers parents anthrax information and tips on how to talk to
their children about bioterrorism.
http://www.bt.cdc.gov/DocumentsApp/Anthrax/11072001/parents.asp
Look for our next edition
of "An
Ounce of Prevention" in January,
2002.
If you have comments or questions
about this newsletter or its contents, please e-mail alward@med.unc.edu.
Program Co-Directors:
Russ Harris, MD, MPH and Linda Kinsinger, MD, MPH
Education Coordinator
& Editor: Amy L. Ward
Go to the Program on Prevention Homepage