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an online version of the magazine Spring/Summer 2005
Irrepressible Dr. De
  The blue-collar kid who grew up to be a School of Medicine dean is now one of the most powerful and persistent critics of American health care as editor in chief of JAMA.

Here comes Dr. De, hustling down the hall on the 10th floor of the American Medical Association building in downtown Chicago. She's about 5 feet 4 inches tall in those comfortable, low-heeled pumps and black pants. Where'd those chalky fingerprints come from? She's asking herself, brushing at her legs furiously. She's missing an earring. It's 8 a.m., and the editor of Journal of the American Medical Association, one of the most influential publications in the world, looks like she's already gone into battle.

She likes to be at her desk by 7. On days when she feels a little sluggish (or she senses her staff does), she blasts the “William Tell Overture” from her corner office to rally her troops. Today, there's no need. She's moving so fast to her office, it's hard to keep up.

Catherine DeAngelis—she prefers Dr. De—is the first woman to be editor in chief of JAMA. A professor of pediatrics at Johns Hopkins, she was born and raised in Old Forge, Pa. , the granddaughter of Italian immigrants. You can hear that heritage in her accent, the way she punctuates her sentences with “You're outta your mind!”—her version of fuggedaboutit.

You can hear it when she calls out to each of her 80 employees, offering a friendly wave while passing his or her desk, or pausing to talk for a moment before burrowing on through the maze of cubicles to her back corner office, rubbing her hands together the whole time as if warming them before a fire.

She passes a wall of framed, mostly black and white 8 x 10 photographs—displaying the mugs of all the men who have held her position since JAMA published its first issue 121 years ago. Bearded and expressionless, they seem like an intimidating bunch. She gives them an appraising look. The boys, she calls them. The last boy on the wall is George D. Lundberg. The physician editor was fired in 1999 for publishing a study on how adolescents define sex, which the AMA said inappropriately brought JAMA into the controversy surrounding President Clinton's impeachment.

At the time, DeAngelis was the vice dean for academic affairs and faculty at the School of Medicine and the editor of the Archives of Pediatrics & Adolescent Medicine, one of JAMA's nine specialized publications. She and the other eight archives editors were infuriated by Lundberg's firing, which they saw as a violation of JAMA's editorial freedom. While the administration searched for Lundberg's replacement, she championed a proposal that said JAMA's future editor would report to a 17-member journal oversight committee, not the AMA managers. She took it upon herself to rally the other editors:

“I said, guys—'cause they're all guys—let's get them to sign this, or we'll all resign.”

The editors agreed, and to her surprise, so did the AMA. Then—surprise again—the AMA administration asked DeAngelis to be JAMA's new editor in chief. She accepted.

Today, in her regular editorials, she has become one of the loudest and most persistent critics of the health care and pharmaceutical industries. She's also increased the journal's influence. Its “impact factor,” or the number of times JAMA articles are cited, has doubled in the last five years.

In 2004, she led the International Committee of Medical Journal Editors' efforts to stop pharmaceutical companies from suppressing scientific studies that reveal the negative effects of their products. Drug companies rely on the major medical journals to make the results of their studies public, so DeAngelis says the best way to get them to do the right thing is to refuse to publish any study unless the results of all related clinical trials performed on humans are published on a public registry, such as www.clinicaltrials.gov.

Last summer, in what seemed like a step in the right direction, GlaxoSmithKline settled a lawsuit by New York State 's attorney general that accused the pharmaceutical giant of misrepresenting the data on Paxil, an antidepressant often prescribed for children. GSK paid $2.5 million to the state of New York and promised to make the results of its studies available on its own Web site.

But DeAngelis didn't see this as much of a victory. “Proportionally, Glaxo is paying about as much as I'd pay for a parking ticket,” she says. She told the Associated Press that relying on drug companies to post results of clinical trials on their own Web sites was like trusting a fox to run the hen house.

She thinks journal editors working together can “keep the drug companies honest.” Back in 2002, she proved just how much influence the major medical journals can have on drug sales when she published a ground-breaking study by the Women's Health Initiative revealing that combined estrogen-progestin hormone replacement therapy increased risks of invasive coronary heart disease, stroke and pulmonary embolism. The study was widely cited in the media, and by July 2002, the price of shares in Wyeth, the pharmaceutical company that manufactures the most commonly prescribed form of estrogen-progestin, had dropped by roughly half.

“If I were a pharmaceutical company, I'd be pretty mad at me,” she says, shrugging her shoulders. But she's not willing to risk public health for advertising dollars—and yes, JAMA, like the other major journals, depends on pharmaceutical ads for revenue, a potentially major conflict of interest. Yet advertising dollars have probably never influenced editorial content at JAMA, and they won't under DeAngelis either. (JAMA's policy is that firms selling ads don't know the articles that will be in an issue until it is published.)

Phil Fontanarosa, JAMA's executive deputy editor, has been impressed by how DeAngelis encouraged editors to band together to change the way drug companies report their findings. He notes that in the last five years, the ICMJE has become more collegial and that DeAngelis has a lot to do with the more cooperative spirit.


Of her tendency to speak freely and passionately about her opinions on the state of health care and to tackle everything from the pharmaceutical companies to the FDA in her frank editorials and media interviews, she says, “Some people might say I've reached a point in my life where I'm not afraid.” (DeAngelis turned 65 in January.) “But I've never been afraid. Everything that I value has very little monetary worth,” she explains. “They can't take my family. They can't take my knowledge. What are they gonna take—my job?” She laughs.

“Take it! I'll get another one.”




Cathy DeAngelis certainly never dreamed she'd end up a spokesperson for American medicine. The humility, social concern and openness to divine providence that have distinguished her career, she says, grow from strong Roman Catholic roots. And, in fact, she still attends Mass every Sunday, even when she's at a JAMA meeting in a far-flung corner of the world. (Her husband, James Harris, a Hopkins professor of psychiatry and pediatrics, usually helps her find the nearest church.)

It's because DeAngelis' earthy roots are so evident, plus her tendencies to respond to just about any compliment or insult with that same dismissive You're outta your mind! and to make sure that you've eaten something if you're in her office for more than 20 minutes, that you can feel like you're sitting at the knee of an old-fashioned Italian mama. You'll be inclined to forgive her when she gets your name wrong, no matter how many times you correct her. You'll learn to go through her executive assistant, Marla Hall, if you want attention to those small details.

“I should probably be on Ritalin,” DeAngelis shrugs, apologizing.

And until she eyes your lunch plate with concern and reminds you that you shouldn't eat so much red meat, you might forget that you're eating a medium-rare hamburger in front of one of the most powerful people in health care.

Still, this woman who has been breaking barriers in her profession for most of her life started out wanting simply to be a medical missionary and a surgeon. “Somebody who didn't know what they were talking about,” she says, told her women became doctors by studying nursing first. So DeAngelis got her R.N. with the intention of joining the Maryknoll Missioners, an order of Catholic nuns who devote their lives to service overseas. Then, in 1965, instead of taking all those religion classes, she decided to enroll at nearby Wilkes College (now Wilkes University ), a small liberal arts school in Wilkes Barre, Pa. , as a pre-med student. She'd still minister to the sick, she figured, but not exactly according to plan. “You make plans, and God laughs,” she says.

And so, by the time DeAngelis enrolled in medical school at the University of Pittsburgh , she already held a degree in nursing and had a year of work experience at Columbia Presbyterian Medical Center . She'd also spent three years plus a summer working at Pitt's School of Public Health . “I knew my way around a lab,” she says. She was therefore shocked when her first research paper came back marked zero.

“Remember that this was the '60s,” DeAngelis points out: She was one of nine women in a class of 124, and the medical profession in general was skeptical about whether any woman was able to be a competent physician. That night, she contemplated giving it all up—her dream of being a doctor, even her life. She decided instead to return the paper to the teacher unrevised and demand that he grade it again.

“Either you give me the proper grade on that, which is—at a minimum—a B, or let's go down to the dean's office right now,” she told the faculty member. “Because I want you to pick any five papers from our class plus mine, unmarked, hand them around to a group of people, and I want them to grade them all. Are you willing to do that?” She got an A.

“I swear to you,” she says, leaning in close as she finishes the story, narrowing her eyes. “I wanted to punch him.”

During her third year at Pitt, DeAngelis spent three months in a bush hospital in West Africa . Later, she organized immunization programs and taught nurse practitioners in Peru and in the West Indies . Despite her childhood dream—she used to cut open her rag dolls and stitch them back together—she decided she wouldn't be a surgeon. She could do more to improve the overall health care of the young and the poor by specializing in general pediatrics and researching ways to improve medical education.

Journal of the American Medical Association


In 1970, with her M.D. in hand, DeAngelis moved to Baltimore to do a pediatric residency at Johns Hopkins. Two years later, she was awarded an NIH fellowship to study health law and economics at Harvard's School of Public Health, where she began writing a curriculum and a textbook to teach M.D.'s and R.N.'s how to work together to improve critical care. R.N.'s were undervalued and underused, she insisted. They may not have the same knowledge and skills as doctors, but they were capable of contributing more than they had been. They could triage patients and care for less-urgent needs. She'd seen them do just that in the African bush.




Nursing school had taught DeAngelis things about relating to patients she didn't learn in medical school: how to talk to sick people, how to comfort a child, how to touch patients and look them in the eye. Even when she became an M.D., her own patients sometimes refused to believe she was a doctor—not just because she was a woman, but because of the way she treated them.

Could compassion be learned? she wondered. She believed it could. When she joined the pediatrics faculty at Johns Hopkins in the late '70s, she finally found herself in a position to test that theory. In DeAngelis' mind, Hopkins had always symbolized “the epitome of good medicine: scholarly, compassionate and profound.” She even remembers thinking, as a girl, that Johns Hopkins was the only medical school in the country. “For a long time, I didn't realize you could become a doctor without going to Hopkins ,” she says.

She therefore found it hard to believe that medical students here could graduate without logging any time inside a doctor's office. “You can be the best medical mechanic in the world,” she says, “have all the book knowledge available, but if you can't relate to the patients in their environment, you're useless.”

Rising quickly through the ranks, DeAngelis was named the School of Medicine 's associate dean for academic affairs in 1991. One of her first projects in that job was to begin shaping a curriculum that would train medical students in what she called “compassionate care. It's not enough to be on the arrow pointing the way,” she told this magazine then. She wanted Hopkins to be “at the point.”

Propelled by $2.5 million in funding from the Robert Wood Johnson Foundation, DeAngelis set out to introduce a whole different way of teaching and practicing medicine from the one she'd learned two decades before. Working with a key group of faculty clinicians and researchers here, she developed a program that ramped up clinical work and introduced medical students to patients right away. Beginning in the first year, they would be expected to spend time with community physicians, linking their real-world experiences with traditional basic science classes.

Today, “compassionate care” and “care of the whole patient” may be catch phrases in medical education. But they weren't in her day, DeAngelis reminds. Johns Hopkins Curriculum for Medical Education in the 21st Century, the book she wrote about the overhaul of the teaching program here that made these concepts basic to a Hopkins ' medical education, is now a model for schools nationwide.

But, it is as a champion of women in academic medicine that DeAngelis is perhaps best known at Hopkins . She'd never forgotten the biases she'd encountered as a young woman setting out to become a doctor, and she wanted to make certain that faculty women at the School of Medicine didn't face similar obstacles. In 1991, she initiated the School's Report on the Status of Women, an anual listing of faculty salaries and promotions, and by 1994, she was able to show that no department had a significant gender discrepancy. That same year, she established the Women's Leadership Council, a network that was part support group and part watchdog for the 19 women full professors.

Cathy DeAngelis, who last year was named one of Chicago's 20 most influential women, reigns over her JAMA empire from the 10th floor of the American Medical Association's headquarters.  
> Cathy DeAngelis, who last year was named one of Chicago's 20 most influential women, reigns over her JAMA empire from the 10th floor of the American Medical Association's headquarters.

In 2000, when DeAngelis left the School of Medicine for JAMA, she was the longest-serving senior member of the dean's office. The job she once held is now two jobs: vice dean of the faculty and vice dean of education. And although she now lives most of the year in Chicago , she still considers Baltimore home. Once a month or so, she heads back to the English-looking home she and her husband own near Hopkins ' Homewood campus. Her husband—Jimbo! she greets him joyfully each time throughout the day he calls her cell phone—is currently on leave of absence, commuting from Chicago to run his mental health clinic at Hopkins and teach a once-monthly class.

DeAngelis also remains on the Hopkins pediatrics faculty and is still officially a general pediatrician. Some of her patients may be nearing 35 years old, but they remain unwilling to make the transition to another doctor.

It's easy to see why you'd never want to leave her when she lays a warm, soft hand on your arm to beg your pardon. She's got to answer her phone, which has been ringing constantly. She'd let it go, but she's got a sick relative, and she doesn't want to miss his father's call. And it's easy to see why when, as she's walking you out at the end of the day, she sees the child of an employee and quickly makes herself so small that she and the boy are eye to eye. He kicks at the ground shyly before he smiles at her.

And DeAngelis still considers herself a missionary, whether she's serving in the African bush or an office tower in downtown Chicago . Even when she accepts appointments at the most prestigious universities in the world, she requests that she be allowed to visit patients in poor communities.




But it is in her position as editor in chief of JAMA that Cathy DeAngelis has been able to exercise the most direct and far-reaching impact on patient care. The journal is published in 14 languages and 120 countries. Under her direction, issues have focused international attention on many of the causes she holds dear: global health, depression in children and gender-based health care (since a recent trend that says diseases and treatments affect men and women differently, DeAngelis will only publish research data broken down by sex). She has also continued the journal's tradition of publishing poetry, and on its covers, fine art reproductions. “Doctors should know about art,” she says. “They should be well-rounded people.”

On Mondays and Thursdays DeAngelis runs manuscript meetings in the 10th floor conference room, where she sits at the foot of the table—she'd never call it the head—and discusses the most promising of the 5,000 manuscripts the journal receives every year. Only about 50 percent get sent out to one of JAMA's 20,000 readers. About 350 will be published, most only after extensive revision.

This job can be stressful, combining the fast pace and constant deadlines of a weekly journal with the rigor of a professional publication and the high stakes of medicine. So, whenever she can, Dr. De tries to keep things light. She throws food at people when they get too serious. Usually Gummi Bears.

And even though she's no longer in her beloved Baltimore clinic, she does feel she's doing her part by making sure this influential journal is scholarly, compassionate, profound, even amusing. She's proud that doctors can look to it for advice on patient-care decisions, and that the media and the public can look to it for accurate, honest information about medical issues. She's also proud that it's a pretty cool place to work.

Still, when this second five-year contract is up in 2010, DeAngelis says she'll be looking for a new challenge. “Ten years at any job is long enough.”

Is she nervous about what's next?

What's there to be nervous about?” she asks. “You're not getting out of this life alive, and if you have a soul, you shouldn't care.”


 Change of Heart
 Irrepressible Dr. De
 The Heat Is On
 Circling the Dome
 Medical Rounds
 Annals of Hopkins
 Learning Curve
Johns Hopkins Medicine

© The Johns Hopkins University 2005