Why did three good men-all prominent Johns Hopkins physicians, all in their prime, all ostensibly healthy-die suddenly while engaging in the one activity they no doubt thought would help them live longer: exercise?
It's a question that gripped the medical campus last November when 47-year-old Rick Montz, an expert in gynecological malignancies, collapsed and died while jogging (see page 40) only six months after neurosurgeon Jeffery Williams, 50, a preeminent interventional radiologist, died while exercising in the Cooley Center. Just five weeks before that, another obstetrician/gynecologist, David Nagey, 51, who specialized in high-risk pregnancies, died while running in a 5K race to support his son's school.
The deaths are stunning losses for Hopkins. And while each case is different, all seem to highlight the exigency of understanding more thoroughly the risks of sudden cardiac death
The tragedies spurred Roger Blumenthal, director of the Cicarrone Preventive Cardiology Center, to circulate a letter to the entire Hopkins community explaining the causes of sudden cardiac death and outlining ways to thwart its chief culprit, coronary artery disease.
Realistically, though, warnings about the dangers of smoking and the potential benefit of taking small amounts of aspirin regularly wouldn't have been news to the three doctors. And presumably, they would have paid attention to the classic symptoms of coronary artery disease. That is precisely what makes these three deaths so confounding.
One key to the puzzle is family history. Nagey's father died while jogging when he was 56. His paternal grandfather died of a heart attack at 59. And while Montz, reportedly, had no sign of coronary artery disease and no evidence of a heart attack, he's known to have had a family history of heart disease.
But the conundrum persists that the first and only symptom of coronary artery disease, particularly in young men like these, may be sudden cardiac death. And the hardest part about preventing such an event, says cardiologist Hugh Calkins, director of the arrhythmia service, is knowing how to pinpoint those at highest risk.
Experts say that before embarking on a vigorous exercise program, people with family histories of heart disease should probably take extra precautions, including exercise stress tests and other diagnostic studies. Calkins adds that some might want to consider an implantable defibrillator, a device that can help prevent sudden cardiac death.
Developed at Hopkins 20 years ago, defibrillators typically are implanted in patients who have survived a cardiac arrest. But Calkins says that they are also being used in patients who have never had an arrest but who are at high risk for sudden cardiac death because of certain inherited conditions. He admits, though, that it is unlikely that any of the three doctors would have been considered at high enough risk to warrant a defibrillator.
Whether or not anything could have averted these tragedies, no one knows. As the Hopkins community ponders such questions, department heads have begun the long process of trying to find replacements for three star physicians.
Anne Bennett Swingle
Heather Whitestone McCallum could handle not being able to hear her friends' voices as she grew up. She took it in her stride when she couldn't hear her own name announced as the winner of the 1995 Miss America contest. But last year when one of her sons fell while playing in the backyard of her Atlanta home and she failed to pick up his cries for help, she knew it was time to do something. At age 29, McCallum, who had been profoundly deaf since she had meningitis at 18 months, no longer was satisfied with a hearing aid that only let her distinguish muted words and muffled sounds. She wanted a cochlear implant.
More than 60,000 people in the United States (most of them children) have received cochlear implants since the technology was first introduced in 1954. An electronic device that works with a microphone and speech processor, the implant offers even profoundly deaf people the ability to hear. Made up of a miniature receiver coil and an array of stimulating rings that translate sound to an electrical signal, the device is surgically implanted in the mastoid bone and inner ear through an incision behind the ear. It works by sending the electrical signal along a wire to the electrodes in the inner ear where it stimulates the auditory nerve connecting the ear to the brain. The brain then interprets the sensory input into understandable information. So dramatically have cochlear implants improved over the last few years that most people who receive one now hear well enough to use a telephone.
At Johns Hopkins, which has the largest cochlear implant program in the nation, otolaryngologist John Niparko has led the program for the past decade. And it was Niparko to whom Heather McCallum came for her implant. Her case was particularly challenging. McCallum had been deaf for so long that Niparko was uncertain how responsive she would be to the electrical signals transmitted by the device. "Of all the patients who have received an implant here, she had one of the most profound levels of hearing loss," he says.
But the former Miss Alabama-and first beauty queen with a disability ever to be named Miss America-had a lot going for her. She'd mastered ballet, which taught her to understand rhythm, and as a child she'd been rigorously schooled in speech therapy by her mother. And that, says Niparko, "was a very important piece of the puzzle, because she had continually searched for ways to understand the messages conveyed by sound."
Niparko and his team surgically implanted Heather McCallum's device late last summer. They activated it six weeks later. The first sound McCallum heard on that rainy fall morning when her appliance was turned on was a high-pitched "beep, beep, beep," like a truck backing up. She opened and closed her hands to the rhythm of the noise. Then her Hopkins audiologist Jennifer Yeagle clapped once, and a stunned McCallum put her hand to her mouth. A second clap, and Miss America of 1995 bent her head and wept. "I heard that," she whispered.
Later, at her downtown hotel, McCallum heard the spritz of her hair spray, the slam of a car door, and found herself turning her head in the direction of voices.
It will take months, even a few years, for McCallum to fully understand the sounds of her young sons, ages 3 1/2 and 22 months. Such are the effects of long-term deafness. But her ability to absorb and dissect noises and voices will increase daily as she incorporates her implant into her life. Niparko likens her present status to an English-speaking person plopped down in the middle of Red Square. "You can hear the voices, but speech sounds are very complex. In someone like Heather, sounds are now competing for the space that other senses have controlled for years."
Still, as last year came to an end, Niparko was able to report one more step forward by McCallum. She'd called to say that a few nights before she had been reading "Goodnight Moon" to her sons. As the boys repeated the words in the familiar children's book, for the first time ever, their mother heard their voices. And all at once, the phrase "Goodnight Moon" took on a whole new meaning.
- Seana Coffin
The case brought a pause to the panel of Johns Hopkins scientists, ethicists and lawyers gathered in the sterile-looking meeting room. A School of Medicine researcher was ready to begin a clinical trial of a surgical device he had invented, but the researcher had significant financial interest in the privately held company that was producing the invention. Under Hopkins' new conflict-of-interest policy, considered among the most comprehensive in the country, the researcher's involvement in the study was prohibited. The committee voted to put the
trial on hold and ask the researcher why this case shouldn't follow standard policy.
The conundrum may sound complicated, but it's not unique. Universities nationwide are attempting to strike a balance between supporting faculty whose research receives financial backing from industry and protecting people who volunteer as test subjects.
The stage was set for such debates in September 1999 at the University of Pennsylvania when 18-year-old Jesse Gelsinger, a liver-disorder patient, died after participating in an experimental gene therapy trial. It turned out that both the university and the inventor of the therapy (who headed the Penn institute that directed the study) had stood to profit from a positive outcome of the trial.
In December 2001, the Association of American Medical Colleges recommended that medical schools limit to $10,000 annually the amount of income a researcher could earn from a company with a vested interest in the outcome of a clinical trial.
Meanwhile, Hopkins already had begun re-examining its own policy. "It wasn't an easy process," says Chi Dang, vice dean for research. "We considered the fact that a $10,000 limit for someone pulling in $200,000 a year has quite a different impact from the same limit imposed on an investigator pulling in $60,000. It's all so arbitrary."
Last summer, though, Hopkins finally decided to prohibit researchers from participating in human-subject research if their financial income (or their spouses' or dependent children's) exceeded $25,000 annually from the sponsor or manufacturer of the treatment under trial.
The financial umbilical cord linking academic medical centers and the industry is strong. At Hopkins, corporate-sponsored research amounts to some $50 million annually. Royalty distributions from licensed discoveries for the first half of fiscal year 2002 alone brought in approximately $2.5 million, $427,000 of which went to faculty and $181,000 to their laboratories.
Since Hopkins' new policy took effect, the Committee on Conflict of Interest, led by cancer researcher Curt Civin, has reviewed 47 trials with potential conflicts of interest. Several were eventually approved with varying degrees of limitations placed on the investigator, but a number were rejected until the researcher lowered his financial interest or limited his role in the study.
And still, several national groups argue that researchers should have no financial interest in products under testing. Even at Hopkins, opinion was divided over whether the financial limit should be $10,000 or $25,000.
But Dang asks, "Does it really matter whether the researcher's interest is $24,900 or $9,900? The important thing," he says, "is to make certain regardless of the amount of compensation that we review and strictly manage every [scientist's] financial involvement in an approved clinical trial."
- Patrick Gilbert
Four internal medicine specialists are the first members of a new group of physicians at The Johns Hopkins Hospital-academic hospitalists. Started last fall by three members of the Department of Medicine: Director Myron Weisfeldt, Residency Program Director Charlie Wiener and Director of General Internal Medicine John Flynn, the hospitalists program is meant to solve a complex set of problems.
First proposed in a 1996 article in the New England Journal of Medicine by physicians from the University of California San Francisco, the rationale for the new medical specialty went this way: With hospital costs rising, patients becoming sicker and managed care requiring shorter hospital stays, why not hire physicians who just work on hospital wards? They could be expertly trained to care for patients with severe and complicated illnesses, and they would understand from the get-go how hospitals operate.
Since then, the number of doctors working as hospitalists has skyrocketed, first among non-academic medical institutions and then within private physician practice groups. Today, the National Association of Inpatient Physicians estimates there are more than 5,000 practicing hospitalists. Hopkins' own Bayview Medical Center, in fact, began its hospitalists program more than six years ago. "It's been a huge help in allowing us to manage an increasing patient load and in easing the burden on our house staff," says Steven Kravet, who directs the service.
By last year, Weisfeldt was certain it was time for a program at Hopkins Hospital. With baby-boomers aging rapidly, the Hospital census would be increasing. At the same time, the Department of Medicine faced the burden of keeping its resident duty hours within regulations. Meanwhile, the Hospital needs to fund its portion for two new clinical buildings, making it more necessary than ever to keep every bed filled. For all of these reasons, having a ready supply of physicians to care for inpatients became a priority.
"I can't see a more cost-effective solution," says Weisfeldt, who had experience with a hospitalists program as chair of medicine at Columbia University. Indeed, his contention is backed by a report showing that nationally the new specialists reduced hospital stays by 16.6 percent and costs by 13.4 percent without sacrificing quality of care.
Weisfeldt is certain the modest size of his department's initial group of hospitalists will be short-lived. Within a year, he's planning to double the number. Flynn says the program will differ from many other medical centers' in that "we looked for recruits who had an interest in doing research and teaching, and serving in tenure-track positions. We're committed to giving them the time, the support and the mentoring to get promoted up the academic ladder."
Wiener, who put together the operational plans for the program, says the initial cadre will create a curriculum that defines how future hospitalists function. Plans call for them to be active in teaching residents, medical students and nurse practitioners.
Weisfeldt, meanwhile, feels quite certain that within 10 years, this new breed of doctor will encompass 20 to 30 percent of the internal medicine workforce.
- Patrick Gilbert
For two decades, Paul White has managed the process of admitting students, first at Yale University, then at Hamilton College and Colgate University in New York. In 1994, he signed on as director of undergraduate admissions at The Johns Hopkins University; in 2000, he moved to the School of Medicine, where more than 6,400 hopefuls annually apply for a class that will number 120 members. This year, White became the first School of Medicine admissions dean to also oversee financial aid.
You have a bachelor's degree in American Studies from Yale, a law
degree from Georgetown, and you've made your entire career in admissions.
How did that happen?
I wanted to help society change. Growing up, I wanted to be a judge. I was very impressed by a profile I read of Constance Baker Motley, the first black woman named to a federal bench. I saw judges as making decisions, hearing people out, hearing their issues. I always thought that was the greatest thing.
Then at Yale, I fell into working in the admissions office. I loved it. I did that for three years, then decided to get on with my career and go to law school.
After my first year at Georgetown Law, I realized how much I'd enjoyed working for a college. Whenever people asked me what I did prior to law school, they said my whole face would light up when I talked about admissions work.
So, in a sense, you did become a judge after all.
Yes! I have the opportunity to help bring together a class, to shape the institution. The students I'm trying to get to Hopkins are the best. This job gives me an opportunity to influence what the entire class looks like.
With so many applications coming in every year, are there some you
automatically toss in a rejection pile?
No. Every single one is reviewed. There are about 10 of us-me, Dr. James Weiss, who's the associate dean for admissions, and six to eight faculty members-who meet for about four hours every Wednesday from mid-August to mid-February, reviewing each application and selecting the students who are invited to interview. Many people assume medical schools only look at grade point averages and MCAT [Medical College Admission Test] scores. But you can have great scores and be as flat as this piece of paper. Numbers alone don't make you a good physician.
What does catch your eye?
Leadership, enthusiastic support from the student's home institution, a long-time interest in medicine and follow-through on that interest, community involvement. We look for quality that's all over the map, for students who've had enriching experiences, who are entrepreneurial, who are self-starters. These are the people who light up a school with their energy. And it's not just the 22-year-olds. The thing is to recognize excellence in all its forms, then bring that excellence here.
Is part of your job convincing students to accept an offer of admission?
To a certain extent, it is, but it isn't just the job of the admissions office. There's a perception that faculty don't care about students at Hopkins. To overcome this, we asked members of the Committee on Admission to contact students they'd interviewed who were later admitted. We wanted them to reach out and let prospective students know we're interested in them.
Another perception is that Hopkins is incredibly competitive-prospective students mistake competition to get in with competition once you're here, which is not the case at all.
Then there's our location, but the perception isn't what you think, that the neighborhood is unsafe. Instead, it's that Baltimore itself isn't as hot a town as Boston or New York or San Francisco. So now we make sure admitted students get a bus tour of the city, so they see there's more to it than just the Inner Harbor.
There's also the perception that our financial aid is inadequate.
We don't run out of aid here. We are need-blind when it comes to admissions decisions. But sometimes we need to be more flexible with financial aid to meet our objectives.
Is that why you're now wearing two hats, admissions and financial aid?
I think the decision was based in part on my interest-in 20 years you have to pick up something!-and because it seemed logical to combine these two related functions. Financial aid isn't just to help students afford the cost after they have been admitted, but to counsel them on how to manage once they're here.
What's the most challenging part of your job?
Having to turn away really wonderful students. There are very few who apply to Hopkins who simply are not qualified. We could fill the class many times just with people we do not even have room to invite to interview. What's difficult is when some of these students (or their family members) call and ask, What happened? I have to let them know that there was nothing they did that was wrong, but that we're fortunate to be able to choose from a deep pool of talented students. These are tough calls to take.
- Mary Ann Ayd