WCPM April 2015

Do you know which major physician and community leader built this home in downtown Raleigh in the later part of the 19th Century? Answer on page 14 inside.

contents

6

4 Abraham Lincoln:

A Book Review and Essay on Mental Health

By Assad Meymandi, MD, PhD, DLFAPA

7

Medicaid, Population Health and Accountable Care

By Elizabeth Cuervo Tilson, MD, MPH

The Pope House: celebrating a prominent Raleighite, an African-American life, and an era

By Ilina Ewen

14

Image from N&O archives and City of Raleigh Museum

Why the North Carolina Medical Society? By Robert W. Seligson, M.B.A.; M.A.

8

Madness in Shakespearian Tragedy Fast Forwarded to the 21st CenturyBy L. Jarrett Barnhill, MD

Publisher

Editor

Wake County Medical Society

Officers and Executive

Council

Council Members

WCMS Alliance

Co- Presidents

Wake County Medical Society

Paul Harrison

2015 President | Andrew Wu, MD Secretary | Robert Munt, MDTreasurer | Robert Munt, MD Past President | Patty Pearce, MD Founding Editor | Assad Meymandi, MD, PhD, DLFAPA

Terry Brenneman, MDMaggie Burkhead, MDWarner L. Hall, MDKen Holt, MDAssad Meymandi, MD, PhD, DLFAPARobert Munt, MDPatricia Pearce, MDDerek Schroder, MDMichael Thomas, MD Brad Wasserman, MDAndrew Wu, MD

Barb SavageKaren Albright

WCPM

Wake County Medical Society2500 Blue Ridge Road, Suite 330

Raleigh, NC 27607 Phone: 919.792.3644

Fax: 919.510.9162 [email protected]

www.wakedocs.org

“The Wake County Physician Magazine is an instrument of the Wake County Medical Society; however, the views expressed are not necessarily the opinion of the Editorial Board or the Society.”

April 2015

contributors

L. Jarrett Barnhill, MD is a professor of Psychiatry at the UNC School of Medicine and the director of the Developmental Neuropharmacology Clinic within the Department of Psychiatry. He is a Distinguished Fellow in the American Psychiatric Association and Fellow in the American Academy of Child and Adolescent Psychiatry.

2 | APRIL 2015

Elizabeth Cuervo Tilson, MD, MPH, graduated John Hopkins University School of Medicine and is Board Certified in Preventive and Pediatrics. She currently provides primary care in the Wake County Human Service Child Health Clinic and is the Medical Director of Community Care of Wake/Johnston Counties.

Assad Meymandi, MD, PhD, DLFAPA is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

Robert W. SeligsonFor the last 20 years, Robert W. Seligson has served as Executive Vice President, CEO of the North Carolina Medical Society, the oldest professional association in the state, representing nearly 13,000 physicians and physician assistants throughout North Carolina. He also serves as CEO of the North Carolina Medical Society Foundation, the philanthropic arm of the Medical Society.

Wake County Physician Magazine (WCPM) is a publication for and by the members of the Wake County Medical Society. WCPM is a quarterly publication and is digitately published January, July, April, and October.

All submissions including ads, bio’s, photo’s and camera ready art work for the WCPM should be directed to:

Tina FrostGraphic Editor [email protected] 919.671.3963

Photographs or illustrations:Submit as high resolution 5” x 7” or 8” x 10” glossy prints or a digital JPEG or TIF file at 300 DPI no larger than 2” x 3” unless the artwork is for the cover. Please include names of individuals or subject matter for each image submitted.

Contributing author bio’s and photo requirements: Submit a recent 3” x 5” or 5” x 7” black and white or color photo (snapshots are suitable) along with your submission for publication or a digital JPEG or TIF file at 300 DPI no larger than 2” x 3”. All photos will be returned to the author. Include a brief bio along with your practice name, specialty, special honors or any positions on boards, etc. Please limit the length of your bio to 3 or 4 lines.

Ad Rates and Specifications:Full Page $800 1/2 Page $400 1/4 Page $200

WAKE COUNTY PHYSICIAN | 3

The Wake County Medical Society is inviting its members to write articles for upcoming issues of the Wake County Physician Magazine. Wake County

Medical Society members wishing to write an article for publication are asked to submit a brief five sentence proposal. Proposed article summaries could focus on your first person accounts of the personal side of practicing medicine (e.g., a patient overcoming all odds and achieving a positive outcome, experience with grief/ overcoming grief, your best day practicing medicine, or care management success stories, etc.) or any other human interest story that might appeal to our readership- keeping in mind that anything resembling promotion of a current practice or practitioner, or taking a political stance would not be useable, with the final say on such matters resting with the editorial board. Please email your brief proposal to Paul Harrison, editor, by June 1, 2015 at [email protected]. The plan is to begin publishing member articles in the July 2015 issue, which will be posted on our website. Thanks!”

February 12 was Lincoln’s birthday. It is somewhat of an irony that George Washington, the grand patriarch of our

beloved nation, was born on February 16. This Book Review and Essay on Mental Health is devoted to the 16th US President, Abraham Lincoln, whose decisions saved our country from splitting in half. In observance of the occasion, I am offering the review of the book “Lincoln’s Melancholy” by Joshua Wolf Shenk, publisher Houghton Mifflin Company.

When a publisher sends a book for review, I routinely cast an editorial “screening” glance to separate substance from fluff by noting the book’s proportion of text to notes, bibliography, and index. A scholarly and substantial book usually carries an extensive set of notes and references for almost every line of the book. A high volume of notes and an extensive bibliography assure the reader that the book is not fluff. Such is Shenk’s remarkable book on Lincoln. The title is misleading. Although the book deals with Lincoln’s depression and melancholia, it is really a psychobiography of Lincoln a la Freud’s work on Leonard da Vinci, Michelangelo, and Dostoevsky. Part of the book reads very much like Maynard Solomon’s biography of Mozart the review of which the faithful readers of this space recall from an earlier day.

But there is something unique about this book.

It is a book that seduces the reader. I fell in love with the book, not with the subject, not with the author’s erudition and intellectual prowess, not

4 | APRIL 2015

AbrAhAm LincoLn: A book review And essAy on mentAL

heALthBy Assad Meymandi, MD, PhD, DLFAPA*

[continued on page 10]

[Article republished with permission.]

6 | APRIL 2015

Greeks added music to their drama in order to facilitate catharsis and release the power of Dionysius. Shakespeare used a different mode- the power of his words to evoke insights into the darker corners of his tragic characters. Yet neither the Greek tragedians nor Shakespeare shared our pre-occupation with developing personality during childhood. Shakespeare focused instead on how character influenced individual reactions to events and circumstances.

Throughout this series we overlooked several of Shakespeare’s most troubled characters. In Twelfth Night a narcissistic Malvolio is duped by those he devalued into making a fool of himself pursuing his imagined-lover and boss, Olivia. These same underlings declare him mad and send him to the “dark house”. Malvolio is subject to the same ridicule usually heaped upon the mentally ill in Shakespeare’s England. Malvolio is not mad, but he is a vain, condescending and moralizing steward, yet successfully manages the estate of Countess Olivia. Our sympathies shift when the cruelty of his coworkers outweigh his malevolence. Yet Malvolio cannot forgive this humiliation. His wounded pride becomes destructive, further alienating him from this society. We

never know the origins of his narcissism, just the destructiveness of his character once ridiculed and when humiliated.

In A Winter’s Tale we face pathological jealousy of King Leonidas. For no clearly stated reason Leonidas becomes quasi-delusional about his very pregnant wife. He is convinced that she “cuckholding” him with his best friend from childhood. His suspicions turn very destructive when his

wife apparently dies; he orders his faithful servant abandons his infant daughter in the wilderness, the stress of his machinations contribute to his son’ death from shock and grieving. It takes the artistry of Shakespeare to restore the Elizabethan sense of order and atonement for Leonidas’ long years of self-imposed isolation and penitence through psychological flagellation. We are given no clues about the source of his malignant transformation from

love to pathological jealousy and rage. The most glaring omission was Othello.

In this tragedy the coldly malevolent Iago psychologically deconstructs Othello. Othello’s subsequent fall leaves us with two unanswerable questions. Who is mad, Iago or Othello? Why does Iago destroy Othello? Even Iago has no solid explanation for his

Madness in Shakespearian Tragedy Fast Forwarded to the 21st Century.

By L. Jarrett Barnhill, MD

The



Consider the North Carolina Medical SocietyIn representing physicians for over 34 years, I

am constantly reminded by physicians why they are not members of the North Carolina Medical Society (NCMS). Why would I start an article off on such a negative note? Because it is easy, from my perspective, to respond with the many reasons the NCMS is so vital to the practice and, more importantly, the professionalism of medicine.

The NCMS became essential to the medical community over 160 years ago. In 1849, a group of concerned physicians met in Raleigh with legislators in the old capitol building to express their concerns about people disguising themselves as physicians and ultimately doing harm to their patients. This brought about the creation of a licensing agency for physicians. Since that time, the NCMS has been involved with the key issues of the day -- public health, licensing, clinical standards, health care regulation at the state and national level -- always speaking as one voice for the practice of medicine. One aspect I am most proud of is our illustrious history in advocating for strong public health and access to health care for the citizens of our wonderful state, and this is something I routinely describe in speeches I make throughout North Carolina.

Physician Advocacy- NC MedicaidToday, the NCMS is at the forefront of Medicaid

reform, and advancing value-based medicine/accountable care organizations through our advocacy in the North Carolina General Assembly and the US Congress.

The NCMS has long been a strong and convincing voice at the legislature, especially now in dealing with Medicaid reform. We have been at the table in all Medicaid reform discussions since Governor McCrory first submitted his plan for reform back in April 2013. Before the Governor announced his proposal, the NCMS had already submitted a request for information (RFI) that focused on reforming the system through value-based medicine/ACOs. This is the current direction taken by the Department of Health and Human Services (DHHS) and the Governor. The Governor’s recent budget includes 22 additional full-time positions in the Department of Medical Assistance dedicated to implementing an ACO-

based Medicaid reform program that is physician driven.

The NCMS has invested over $1 million in researching and promoting value-based medicine as a means to reform Medicaid, but also as a basis for developing meaningful health care reform. The NCMS has compiled numerous resources for doctors through our Toward Accountable Care Consortium and Initiative (TAC), which is comprised of over 40 health organizations. TAC has produced over two dozen tool-kits for physicians covering a variety of specialties and how they fit into the value-based environment. TAC also has guides to shared savings and bundled payments.

Physician Advocacy- support physician led Accountable Care Organizations, repeal of SRG at the Federal level

The NCMS also leads the NC ACO Collaborative, which brings together existing and fledgling ACO’s throughout the state as well as supporting organizations in order to share ideas and experiences.

On the national level, just last week NCMS President Robert E. Schaaf, M.D. met at the White House with key health policy advisors to President Obama to discuss issues including reform of the RAC audit process, repealing the SGR, extending the meaningful use timetables, implementation of ICD-10 and ensuring any increase in compliance or reporting burdens on physicians are accompanied by commensurate payment increases and not penalties. NCMS leadership also met with the congressional delegation on these issues. The NCMS holds executive committee roles with national organizations including The Physicians Foundation and the Physicians Advocacy Institute to represent your professional interests at the federal level.

Protect and promote the well-being of patients and physicians

The NCMS has had to be smart and agile to survive 166 years, and continues to position the profession to be at the forefront of positive change. Founded in 1849 to protect patient safety and promote public health, we are the oldest nonprofit professional society in North Carolina. We are still positioned squarely in the middle of the debate over how best to protect and promote the well-being of patients and doctors in our state, and will continue to be the voice of medicine for the physicians of North Carolina. §

Why the North Carolina Medical Society?By Robert W. Seligson, M.B.A.; M.A.

Executive Vice President/CEO North Carolina Medical Society

8 | APRIL 2015

Medicaid, Population Health, and Accountable

CareBy Elizabeth Cuervo Tilson, MD, MPH

The total cost for North Carolina’s Medicaid program in SFY 2014 was just over $13 billion. Medicaid is a shared

federal and state program and is supported by three major funding streams. For SFY 2014, federal funding totaled $8.2 billion (63%), state appropriations totaled $3.5 Billion (26%) and several other funding streams including drug rebates, bed taxes, fraud recovery and cost settlement totaled an additional $1.4 Billion (11%).

Several factors determine overall Medicaid costs: Eligibility (who you cover); Benefits (what services you cover); Fees (how much you pay for services); and Utilization (how many services you pay for). Currently, the first three factors are determined by the General Assembly and the Department of Health and Human Services. The last factor is the one most influenced by care management.

Our current care management strategy for Medicaid is not comprehensive. While 1.4 out of the 1.8 million NC Medicaid recipients are enrolled in Care Management (i.e. Community Care of North Carolina), 400,000 patients are not, primarily due to the nature of their specific Medicaid eligibility category. These are often some of the most high cost, high risk patients (e.g. patients in Skilled Nursing Facilities). In addition, utilization of all Medicaid services are not managed under the same program. Community Care of North

Carolina (CCNC) is the most comprehensive Care Management program, but only has influence over about 45% of total Medicaid claims spending (primary care, hospital visits, and medications). Personal Care Services, Diagnostic Testing, Durable Medical Equipment, Behavioral Health Services, Nursing Homes and Long Term Care settings are managed by different entities and agencies or not managed.

However, despite the complexity of the finances and the fragmentation of our current system, NC Medicaid spending has been quite stable in recent years and, in fact, North Carolina Medicaid claims spending has grown at a lower rate than any other state in the country (2.3% average rate of growth). In addition, while Medicaid enrollment has grown, primarily due to the down turn in the economy (18.5% increase from 2008-2012), the average spending per Medicaid beneficiary has decreased (5% decrease from 2008-2012).

So why do we hear that Medicaid is “over budget?” Some of this is likely due to the complexity of budgeting and forecasting applied to such a large spend. The funding streams are fairly consistent year to year, but there can be some small variations in the proportion of the funding streams. These small variations can result in large budgetary shifts. For example, even with the same total spend of $12.6 billion, a 3% shift from federal and other funding streams to state funding

can result in an almost $400 million dollar increase spend by the State. In addition, the year to year small shift in relative funding sources was exaggerated by the temporary enhanced federal match that states received as part of the American Recovery and Reinvestment Act. In 2009 and 2010, the federal government paid 90% of NC Medicaid costs. Once the enhanced match stopped, even with stable Medicaid costs, there was a large increase (back up to 26%) in the states’ portion of Medicaid costs. This large swing in the state’s portion was difficult to account for during the budgeting process and contributed to the state budget “over runs.”

In summary, overall total NC Medicaid costs have been stable. However, budgeting for the state portion of Medicaid costs has been challenging. In addition, while stable, Medicaid costs are large and therefore there are opportunities for cost reductions. This is where concepts of Population Health, comprehensive care management, and accountable care can play a role.

Population Health can be defined as improving the health of a whole population for whom one is responsible, in addition to improving the health of an individual. It requires looking at the holistic needs, health care patterns, providers, and total costs of patients

and populations. Patients with the most complex health conditions and social circumstances often have a wide range of needs beyond acute physical health. In addition, as evidenced by the weighting system of the Robert Wood Johnson (RWJ) Foundation’s County Health Rankings, social determinants of health can have a great influence of the health outcomes of populations. In determining the health of a population, RWJ weighs Physical Environment as 10%, Clinical Care as 20%, Health Behaviors as 30%, and Social and Economic factors (education, income, employment, family and social support, and community safety) most heavily at 40%. Addressing the needs of a population requires the inclusion of prevention, behavioral health, long-term care services, community resources, public health, and socio-economic supports along with physical health care services. Finally, Populations Health includes key strategies of risk stratification, tailored interventions, and deploying resources to fit the needs of patients in different risk strata in a population.

One Population Health strategy to improve the care and health of the Medicaid population is to move towards a comprehensive care management system that can efficiently coordinate the complex needs of

patients. Integrating physical health and behavioral health care management is crucial due to the high prevalence of chronic physical and behavioral health needs in the high cost Medicaid population. Incorporating long term supports (e.g. Personal Care Services and Durable Medical Equipment) under the same umbrella of care coordination is a great opportunity for efficiently tailoring resources to the needs of a patient. One team could assess the global and diverse needs of a patient and facilitate the delivery of and coordination of the right level of services to enhance the patient’s health outcomes. Extending care management to include Long Term Care Facilities and Skilled Nursing Facilities could result in large cost savings and improved care for a vulnerable and high cost population.

Another element within Population Health is the concept of Accountable Care in which a set of providers are associated with a defined set of patients for whom they are accountable for the quality of care. Key elements of Accountable Care include: 1) Practice Transformation and Quality Improvement; 2) Medical and Health Neighborhoods; 3) Health Information Technology (IT); and 4) Effective Care Management.

Strategies to achieve Practice Transformation and Quality Improvement



10 | APRIL 2015

with the brilliant syntax and craftsmanship of the composition, but with the book itself. For me, an objective book reviewer engaged in this pursuit for more than 50 years, it is a rare phenomenon that the book itself becomes the object of love. Well, the book has a prelude, and introduction and three parts with subsections dealing chronologically with Lincoln’s birth, growth, development, political maturation, education, religion, social interaction and finally death. But first a word about the author.

Joshua Wolf Shenk is neither an academic historian nor a Lincoln specialist. He is not of stature of famed Douglas Wilson, author of “Lincoln’s Sword” or Allen Guezlo, the internationally renowned leading Lincoln scholar. Readers might recognize Joshua from the pages of New Yorker, Harper, and Atlantic Monthly. He is referred to as an “independent scholar.” In this book, he shows command of psychopathology of depression, a good understanding of DSM IV (Diagnostic statistical Manuel IV) and a keen insight into human nature. He seems to understand the comprehensive model of bio-psycho-social dynamics in the genesis and evolution

of mental illness. But none of these explains why the book had a mesmeric effect on me. I guess as a psychiatrist in my practice dealing with psychic trauma and life tragedies, it is comforting to see the story of a man like Lincoln, with incredible childhood depravity, adverse upbringing, having lived a life of domestic slavery, constant beating and emotional denigration and put down, pull himself out of psychological sewer, literally clean up, educate himself, and ultimately become the 16th President of the United States of America. It is this subtle message reflective of Pauline theology of redemption, hope, love, faith, and possibilities that generated the uncommon mesmeric effect on me.

The book starts with a startling chapter on Lincoln’s family history of mental illness. His Uncle Tom Lincoln, according to court records had a “deranged mind”. So did his parents. Lincoln’s parents were born in Virginia and crossed the Appalachian Mountains and came to Kentucky in the late 18th century. They married in 1806 and had three children, Sarah, born Feb 19, 1807; Abraham, born February 12, 1809; and his brother Thomas born in 1811. They were all prone to deep depression. Lincoln’s mother Nancy died on October 5, 1818. She was

about 35 years old. Lincoln was nine. Along the way, in addition to Lincoln’s mother, Lincoln lost his uncle and aunt. His care was left to a twenty-year-old cousin, during the absence of Abe’s father who returned to Kentucky to court his second bride. Lincoln was beaten, mistreated and abused during those years. There are a lot of well documented accounts that Lincoln was self-taught. As a child he read all the books he could find. Tom Lincoln, Abe’s father, at some point started to oppose his son’s reading and education. The relationship between father and son was conflicted and abusive; Tom Lincoln would beat young Abe mercilessly. However, Lincoln continued to read and memorize and became very popular with his friends and fellow workers. It is recorded that he was not sad and depressed during his teen years because he had many friends and knew more than all of his friends put together. He did not attend a university to learn law. “I studied with nobody,” he said. A lawyer named Lynn McNutty Greene wrote that “Abraham Lincoln was extremely ambitious.” Greene remembered Lincoln telling him that all the folks seem to have good sense but none of them become distinguished, and he believed it was for him to become so.

Tracing the mental status

[Abraham Lincoln continued from page 4]


of Mr. Lincoln, one discovers that he was suicide prone. At one time, a neighbor, Mentor Graham, related that “Lincoln told me that he felt like committing suicide often.” The neighbors and friends were compelled to keep watch and ward over him. This was even more pronounced when Lincoln’s first love, a bright, pretty young woman, Anna Mayes Rutledge, with flowing blond hair and blue eyes became ill. She died August, 1835. Lincoln was desperately in love with Anna. He suffered his first bout of major depression after her death. He had a second and more devastating bout of major depression in 1841. The repeat episode of major depression was precipitated by many causes among them breaking his engagement with his wife to be, Mary Todd, possibly “because of his affection for another woman.” Again, his friends and relatives were fearful that Lincoln might commit suicide. They removed guns and knives from his environ.

There is another set of assumptions that relates Lincoln’s depression to Marfan Syndrome. Marfan is an inherited genetic disorder that diminishes the strength of connective tissue from tendons to heart valves. Persons afflicted with Marfan are tall, gangly, with hyper flexion of joints. Marfan along with other connective tissue disorders such as Ehler-Danlos Syndrome

are often associated with depression. An aside: the famed magician virtuoso violinist Paganini who could produce those fabulous high notes on his instrument, by hperflexing his arm and fingers had Ehler-Danlos Syndrome and for most of his life suffered from depression. Robert Schumann who wished his fingers were like Paganini’s to do acrobatics on the keyboard, suffered from Bipolar Disorder. He would put his fingers through painful stretch exercises to make them longer and more limber....

Back to Lincoln, I do know of several sources who have

studied Lincoln’s connective tissue disease including the eminent researcher, Victor A. McKusick, Professor of Medical Genetics at Johns Hopkins. He along with other Lincoln scholars, including Gabor Borritt, Adam Borritt, Douglas Wilson and Allan Guelzo, collectively state that Lincoln did not have Marfan Syndrome.

The second part of the book deals with the dynamics of Lincoln as a self-made man. He won elections, made friends, and with his eloquence mesmerized his audience. Lincoln continued to be [continued on page 18]

include implementation of protocols and decision supports to foster best practices, the ability to track quality metrics, utilization of formal Quality Improvement processes (e.g. Model for Improvement), ensuring access for and communication with patients, and multi-disciplinary care management of high risk patients. Working on these elements also helps practices achieve national standards (e.g. Patient Centered Medical Home recognition) which can have additional benefits to practices.

Creating connected medical and health neighborhoods includes having efficient referral networks and communication between providers such as primary care, specialists, hospitals, radiology, behavioral health, preventive services. Linkages between care sites (e.g hospitals and long term care facilities) help to improve care transitions. Multi-disciplinary care teams (e.g. including pharmacists, paramedics, dieticians) that include community-based professionals can enhance the effectiveness and efficiency of practice-based care. Connecting with the resources of public health, social services, housing, transportation, etc can help address some of the social determinants of health.

Health IT facilitates data sharing across providers within the medical neighborhood and can combine information from separate healthcare sites to create a single virtual patient health record. On the individual patient level, it can also identify and prompt clinicians to address care gaps for that patient during point of care. On the population level, Health IT can incorporate data into a comprehensive view of evidence-based population health dashboards to facilitate a systematic approach to improving care. Chronic disease registries (e.g. diabetes, asthma) help improve chronic care of populations. Reporting on clinical quality measures informs quality improvement processes and helps practices meet requirements of national recognition programs.

Effective care management is informed by Health IT analytics that performs population risk stratification, identifies patients potentially impactable by care management, and guides tailored and targeted outreach to different strata within a population. Prioritizing high yield care management activities (e.g. Transitional Care) can create quick and demonstrable cost savings. Utilizing patient-centered health

education strategies such as Red Flag Education with Teach Back, Motivational Interviewing, Shared Decision Making, and Shared Care Plans can engage and empower patients and foster sustainable health behavior change. Connecting patients to community resources can help to address the holistic needs of patients.

Aligning financing with other aspects of Accountable Care can further support Population Health activities. Payment reform options include models such as Quality-based Tiered Payments and Bundled Payments for Episodes of Care. A more robust alignment of financial and quality elements are Accountable Care Organizations (ACOs) in which a set of providers are accountable for the quality and the cost of care for a defined population. Within ACOs, there are different financial models including a Shared Savings model, in which the ACO and the payor share in whatever savings are achieved. In a Fully Capitated model, the ACO is given a set amount of funding to care for a population. The ACO is “at risk” for any increase in costs, but is able to keep and re-invest all the savings achieved through their efforts, as long as they meet quality metrics.

12 | APRIL 2015

[Medicaid continued from page 9]

Three local examples of Accountable Care

Comprehensive Asthma Management Program – Partnership of Community Care of Wake and Johnston County (CCWJC), Wake County Human Services, Wake County Environmental Services, and Primary Care Providers. Multi-disciplinary, multi-component program including home visits by a Registered Nurse and Registered Sanitarian addressing asthma education, medication and device training, identification and reduction of environmental asthma triggers, and feedback to the Provider. Asthma-related ED visits have decreased by 56%, asthma-related hospitalizations by 77%, and an average cost savings of $703 per patient over the time period of the program.

Child Health Accountable Care Collaborative – Partnership of CCNC/CCWJC, Public Health, Hospitals, Specialists, Primary Care Providers, and long term care services to wrap coordinated health neighborhoods around medically complex children. Specialty RN Care Managers are embedded at WakeMed and work with hospitalists, sub-specialists and Hilltop Home – an Intermediate Care Facility for children with severe and profound

WAKE COUNTY PHYSICIAN | 13[continued on page 20]

14 | APRIL 2015

Pope House, a two- story brick home nestled on a narrow plot that was once in the center of Raleigh’s historic black Main Street, now stands alone, a stalwart reminder of an era passed.

After Reconstruction, this neighborhood was known as the Third Ward, a thriving African-American enclave. The neighborhood boasted residences of black professionals and business owners. Shaw University already stood nearby, as did several as churches and a small private hospital. The old brick structures that remain today provide a stark contrast to the steel of Raleigh’s growing skyline. This juxtaposition of old and new is epitomized at Stronachs Alley, between South Wilmington and South Blount Streets. Dr. Manassa Thomas Pope started building his home here in 1900, hugging the borders of a racially segregated Raleigh. Born free in 1858 as the son of literate landowners in Rich Square, North Carolina and educated at Shaw, Pope was a prominent citizen and one of North Carolina’s first licensed black physicians. Revered at a time when most blacks were persecuted, Pope set the stage to challenge voting laws by registering to vote in 1902. He then made a run for Raleigh mayor in 1919, becoming the only African American to run for mayor of a capital city in the South

The Pope House: celebrating a prominent Raleighite, an African-

American life, and an era

By Ilina Ewen

images from N&O archives and City of Raleigh Museumarticle adapted from Life & Style, My Town printed 1/30/2015

The


during the days of Jim Crow.He also proved to be a savvy

businessman, establishing the successful Queen City Drug Company in Charlotte. He served as an officer and surgeon in the Spanish-American War, and later practiced medicine in an office on Hargett Street and in an exam room he added to back of his house.

Pope’s home “is a national treasure and should be appreciated as such,” said Dr. John Hope Franklin, the esteemed author and historian who died in 2009. “The home’s treasures are a bounty of riches that tell our city’s history. There are myriad trappings of family life that show us what times were like for the affluent African-American class.”

Indeed, the Pope House is North Carolina’s only historic house museum of an African American family. Remarkably, only the Pope family has ever lived here.

Living museum: One of the most remarkable artifacts in the home is a wartime photo of Dr. Manassa T. Pope carrying his 1898 medical kit. That kit is still intact with its original contents and on display.

To visit the home is to step back in time. An upright piano, original tufted sofas, scraps of original wallpaper, wide plank hardwood floors, and everything from etiquette books to medical instruments to children’s storybooks, porcelain dolls, and lace dresses owned by Evelyn and Ruth, Dr. Pope’s daughters fill its rooms.

A petal-shaped stained glass window in the entry is a hallmark feature. The house also boasts original copper-plated hardware and hinges, intricately carved moldings, and newel posts and stair rails carved from a single block of wood. Original fixtures including gas and electricity hook-ups, running water, a full bathroom, telephone, and a servant call bell system all indicate the family’s wealth.

The home was placed on the National Register of Historic Places in 1999 and is now owned and managed by the City of Raleigh, which opened the home as a museum a year ago. Staff and volunteers

are currently cataloging and archiving items in order to curate exhibits and outreach programs. The aim is for the home to be not only a house museum and a restored building, but a robust education center showcasing the roots, contributions, and cultural heritage of the people who once called the Third Ward home.

An exhibit of photographs from the family’s history at the City of Raleigh Museum runs Feb. 3-28.

Dr. M.T. PopeThe Pope House, at 511 S. Wilmington Street, offers free, guided tours on Saturdays, 10-3.

The City of Raleigh Museum: 220 Fayetteville St. cityofraleighmuseum.org.

Read more here: http://www.waltermagazine.com/the-pope-house/#storylink=cpy

CURRENT PROGRAMSProject Access - A physician-led volunteer medical specialty service program for the poor, uninsured men, women, and children of Wake County.

Community Care of Wake and Johnston Counties CCWJC has created private and public partnerships to improve performance with disease management initiatives such as asthma and diabetes for ACCESS Medicaid recipients.

CapitalCare Collaborative - The CCC program is a membership of safety net providers working corroboratively to develop initiatives to improve the health of the region’s medically underserved such as asthma and diabetes for Medicaid and Medicare recipients.

The Wake County Medical Society (WCMS) is a 501 (c) 6 nonprofit organization that serves the licensed physicians and physician assistants of Wake County. Chartered in 1903 by the North Carolina Medical Society.

Membership in the Wake County Medical Society is one of the most important and effective ways for physicians, collectively, to be part of the solution to our many health care challenges. A strong, vibrant Society will always have the ear of legislators because they respect the fact that doctors are uniquely qualified to help form health policies that work as intended. It’s heartening to know the vast majority of Wake County physicians, more than 700 to date, have chosen to become members of the Wake County Medical Society.

JOIN TODAY!

Become a Member of Wake County Medical Society and help support the indigent care and community service

programs of the Society.

WHY JOIN

To serve and represent the interests of our physicians; to promote the health of all people in Wake County; and to uphold the highest ethical practice of medicine.

WCMS MISSION

Service Programs - The spirit of volunteerism is strong in Wake County. Hundreds of local physicians volunteer to help our indigent. The Society coordinates several programs that allow low income individuals access to volunteer doctors and to special case management services for children with diabetes, sickle cell anemia or asthma.

Publications - Members receive the peer-reviewed The Wake County Physician Magazine four times a year, and we keep you informed regularly via pertinent emails. The magazine focuses on local health care issues in Wake County, the Wake County Medical Society and the WCMS Alliance, a companion organization composed of physician spouses and significant others.

Socializing with your physician colleagues - Many physicians feel too busy to do anything except work long hours caring for patients. But, the WCMS provides an opportunity for physicians to nourish relationships through social interaction with one another at our dinner meetings featuring prominent speakers and at other events.

Finally, joining the WCMS is plain and simple the right thing to do - Physicians and the community benefit from our membership and our leadership in local affairs.

BENEFITS OF MEMBERSHIP

To become a member of the Wake County Medical Society contact Deborah Earp, Membership Manager at [email protected] or by phone at 919.792.3644

HOW TO JOIN

A portion of your dues supports to the volunteer and service programs of WCMS. Membership is also available for PA’s. There is even an opportunity for your spouse to get involved by joining the Wake County Medical Society Alliance.

18 | APRIL 2015

ambitious, determined, and industrious. He was a devoted Christian with flavors of “old school of Calvinism”, and “hard shell Baptism” running through his speeches. However, Lincoln was a pragmatist and had a keen sense of reality.

According to Allen Guelzo, the leading Lincoln scholar, Lincoln was a serious philosophical thinker who kept abreast of leading ideas of his time. An indication of his pragmatism, as an example, in 1846 he wrote “What I understand is called ‘the Doctrine of Necessity’, that is the human mind is impelled to action, or held in rest by some power, over which the mind itself has no control.” It was John Stuart Mill who first used the phrase “Philosophical Necessity.” The author quotes Herman Melville, Lincoln’s contemporary and fellow melancholic who suffered deep depression, “The in tensest light of reason and revelation combined cannot shed such blazing light upon deeper truths in man, as well sometimes proceed from his own profoundest gloom. Utter darkness then is his light, and cat-like he instinctively sees all objects through a medium which is mere blindness to common vision.

Part Three of the book deals with Lincoln’s Presidency and the fierce civil war which he fought with conviction and courage. He was absolutely against the notion of the United States splitting into two nations. He married Mary Todd, and they had four boys, only one of who lived to maturity. In 1858 Lincoln ran against Stephen A. Douglas for US Senate. He lost the election, but in debating with Douglas he gained a national reputation that won him the Republican Party nomination for President in 1860. As President, he built the Republican Party into a strong national organization. On January 1, 1863, he issued The Emancipation Proclamation that declared forever free those slaves within the Confederacy. On Good Friday, April 14, 1865 Lincoln was assassinated at Ford’s Theater in Washington by John Wilkes Booth,

an actor, who somehow thought he was helping the South.

In his epilogue, the author states that he went to spend a weekend with the Association of Lincoln Presenters at their annual convention in Beckley, West Virginia. Seeing all these men in black suits and stovepipe hats and beards shaved above the chin was an instructive experience. However, he concludes that “it is a generic and inherent flaw of biography that in order to wrestle a figure, in this instance the formidable figure of Lincoln, onto the page, three dimensions get turned into two.” However, I believe that the young scholar, Joshua Wolf Schenk has done an excellent job of painting a three- dimensional picture of Lincoln. Bravo!

Lastly, this book has one perhaps unintended but welcome social and political implication. Here we have a politician, Lincoln, with depression genes atavistically skulking his psychic space. He had several major depressive episodes (nervous breakdowns in 19th century parlance) well known to the public. Yet he rose to become President of this country. I was thinking of the late Thomas Eagleton, the former US Senator from Missouri, and George McGovern’s VP nominee on the 1972 Democratic ticket who had to withdraw because of controversy over history of depression. It seems the public tolerance of mental illness has drastically decreased since 1841, Lincoln’s last episode of major Depression, to 1972, when it was discovered that Eagleton had treatment for depression. Are we turning backward? §

*The writer is Adjunct Professor of Psychiatry, University of North Carolina School of Medicine at Chapel Hill, Distinguished Life fellow American Psychiatric Association, and Founding Editor and Editor-in-Chief, Wake County Physician Magazine (1995-2012). He serves as a Visiting Scholar and lecturer on Medicine, the Arts and Humanities at his alma mater the George Washington University School of Medicine and Health.

[Abraham Lincoln continued from page 11]

malevolent obsession. Our sense is that Iago is Reason run amok, Will without conscience or Evil incarnate. Othello as a middle-aged heroic, warrior desperately in love with a very young Desdemona but no match for Iago. Iago plays upon Desdemona’s rebellion against her father’s wishes by marrying Othello. He builds a case in Othello’s mind through innuendo while conjuring evidence such as the scarf lost by Desdemona, yet converted to damning evidence by Iago. There is no developmental history but the play is set on the island of Venus where sexual passion and violent destruction are conjoined (Eros and Thanatos). In Act 5, when Othello learns of Iago duplicity he looks at Iago’s feet cloven hooves as evidence for the devil. There is nothing that obvious. Othello then suicides. The answer “whence cometh this evil?” still eludes us but we are reminded of the veneer of self-control that dissolves into psychological chaos.

We explored Hamlet, Macbeth/Lady Macbeth and several characters in King Lear. Each suffered for errors but none fit Aristotle’s convention of a tragic hero. Perhaps to understand these plays we need not focus on developmental psychology but instead look at the consequences these bad choices birthed. As noted at the beginning of this series, there were no attempts to diagnose.

After all playwrights are poets are not clinicians. The

Bard is disinclined towards psychological development, listing categories of clinical symptoms or developing elaborate theories of causality. Tragedies are about people in the midst of challenges that require actions. They make wrong decisions (hamartia) and pay for them dearly. Many are no more flawed than we are. They are trapped in inconceivably bad situations.

Perhaps Sophocles had it right when he rendered his tragic heroes as isolated, immutable and willful individuals. These articles neglected our conceptual models of mental illness, not to argue that mental illness that mental illness is a social construct, but that our modern categorical, statistical and neurobiological models of psychiatric disorders do not add to our understanding of madness in tragedy.

The rise of philosophy and the Age of Enlightenment helped construct our veneer of civilization. We tried to construct reason, rationalism, and materialism as barriers to the terror of our history and repress the timeless gods of violence, brutality and the destructive expressions of forces of nature and human passions (Eros). Some social historians transformations in nation states towards growing secular, scientific rationalism helped unleash the horrors of WWI and WWII and subsequent genocides. As metaphor,

Oppenheimer correctly linked nuclear power to the Hindu creator-destroyer god. Nuclear energy was a gift and a danger. It took threat of annihilation by nuclear warfare to create a 20th century version of the early medieval Peace and Truce of God. It is ironic that MAD (Mutually Assured Destruction) kept our veneer of civilization intact. Without it things are less restrained and more uncertain.

Nietzsche in the Birth of Tragedy discussed the Dionysian and Apollonian forces at play in Greek drama. Shakespeare took this to a new level of complexity. Sigmund Freud in Civilization and Its Discontents alluded to analogous forces within the individual. Perhaps the unstable balance between Apollonian world of reason, art and civilization protect us from the terror of history at the cost of stagnation. Opening to the Dionysian world of creativity exposes the darker sides of human emotions. These examples of madness in tragedy may remind us of the “dark side of the force”. Throughout, we’ve stuck with Nietzsche’s metaphor of Apollonian versus Dionysian forces. This was a conscious decision designed to remind us that psychiatric diagnosis and literary/historical forms of madness are not identical. In closing, reading or seeing a performance of Hamlet or Oedipus the King are far more exciting than reading from the DSM-5. §

[Madness continued from page 6]


20 | APRIL 2015

The discussion about Medicaid reform in NC has included the concept of the ACO model. The infrastructure of NC could lend itself well to this model. There are already existing ACOs created for other populations (e.g. Medicare). These include ACOs that have been formed by hospital-systems, Federally-Qualified Health Centers, independent physicians, and partnerships of hospitals and independent physicians. These existing ACOs could expand to include Medicaid in their covered populations. In addition, Community Physicians of North Carolina, which is a developing, state-wide clinically-integrated network (CIN) is another avenue of ACO involvement for independent providers. Through this framework, independent providers could work together to improve the quality of care they deliver, create efficiencies in their operations, and partner with hospitals and other key players in the local health care system in the context of an ACO. There could be many different relationships and opportunities within NC for providers of all types to participate in the evolving health care and population health landscape. §

developmental disabilities and medical fragility. The Care Managers coordinate care between specialists and primary care, foster the smooth transition from in-patient to out-patient care, and provide support and education for families and care givers. For the children at Hilltop, total hospitalizations have decreased 66%, total hospital days have decreased by 76%, and ED visits have decreased by 69% since the initiation of the activities.

Chronic Pain Initiative/Project Lazarus – Community wide partnership of CCNC/CCWJC, Public Health, Pain Clinics, Behavioral Health Providers, Addiction Specialists, Hematology, Emergency Medical Services - Advanced Practice Paramedics, Emergency Departments, and Primary Care to: 1) address the epidemic of uncoordinated and excessive use of prescription pain medications; 2) change systems of care and prescribing patterns to promote consistent, quality, and safe care for patients with chronic pain; and 3) avert unintended deaths and over-utilization of health care services. Since launch of the program in 2010, deaths due to unintended poisonings by prescription narcotics has decreased by 40% in Wake County and by 50% in Johnston County.

[Three local examples of Accountable Care continued from page 13]

Are you interested in becoming a Wake County Medical Society member? Simply visit our website at www.wakedocs.org and complete the online application or contact us by phone at 919.792.3644.

A portion of your dues contributes to the volunteer and service programs of WCMS. Membership is also available for PA’s. There is even an opportunity for your spouse to get involved by

joining the Wake County Medical Society Alliance.

JOIN TODAY!

Documents

WCPM April 2015