October 2014 - Wake County Medical Society

contents
Pictured Louise Wilson
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wcms annual tara farms picnic
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project acces of wake county update
7
wcms call for articles
8
omnipotence or ominous impotence of humans and humanity
10 accountable care organization begins in wake county
14 king lear and madness
WAKE COUNTY PHYSICIAN | 1
contributors
WCPM
October 2014
Publisher Wake County Medical Society
Editor Paul Harrison
Wake
County
Medical
Society
Officers and
Executive
Council
2014 President | Patty Pearce MD
Secretary | Robert Munt, MD
Treasurer | Robert Munt, MD
President Elect | Andrew Wu, MD
Past President | Dick McKay, MD
Founding Editor |
Assad Meymandi, MD, PhD, DLFAPA
Council Terry Brenneman, MD
Members Maggie Burkhead, MD
Warner L. Hall, MD
Ken Holt, MD
M. Dixon McKay, MD
Assad Meymandi, MD, PhD, DLFAPA
Robert Munt, MD
Patricia Pearce, MD
Derek Schroder, MD
Michael Thomas, MD
Brad Wasserman, MD
Andrew Wu, MD
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.
Robert H. Bilbro, MD, FACP
was one of the cofounders of
Raleigh Medical Group where he
practiced for 35 years. He now
works as associate medical director
for Community Care of Wake and
Johnston Counties.
Assad Meymandi
WCMS Barb Savage
Alliance Karen Albright
Co-Presidents
Wake County Medical Society
2500 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.”
2 | OCTOBER 2014
is Adjunct Professor of Psychiatry,
University of North Carolina
School of Medicine at Chapel
Hill, Distinguished Life fellow
American Psychiatric Association;
Life member, American Medical
Association; Life member, Southern
Medical Association, and Founding
Editor and Editor-in-Chief, Wake
County Physician Magazine (19952012).
Pam Carpenter
is Program Manager of Project
Access of Wake County
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 Frost
Graphic Editor WCPM
[email protected]
919.671.3963
Dear WCMS Executive Council Members,
Please note the following Executive Council meeting.
Date: Tuesday, Nov. 11, 2014
Time:
6:00 pm
Where: 2500 Blue Ridge Rd. #330 | Raleigh NC 27607
A light dinner will be served at the meeting.
On behalf of Susan Davis, Executive Director of Community
Health Foundation and myself, we have enjoyed working
with you throughout 2014.
Thank you,
Paul Harrison
Executive Director
Wake County Medical Society
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
See page 6 for legend.
By Pam Carpenter
Since Project Access started in 2001, more
than 20,000 uninsured, low-income adults have
received medical and surgical treatment or
a diagnosis that ruled out disease from Wake
County doctors donating their time and skills.
Since 2008 over $15 million per year has been
donated in care.
Before Project Access, the safety net clinics
had informal arrangements that allowed
limited referrals to private physicians, hospitals
and medication assistance programs, but
referrals were labor-intensive. Many physicians
donated care for their patients who could
not afford to pay, but efforts were thwarted
by a “patchwork” system of care that was
ineffective and frustrating. If patients needed
services they could not afford - whether
medications, lab work, x-rays, specialty
services or hospital care – physicians and other
healthcare workers would spend time and
effort searching for resources, asking for favors,
and dealing with paperwork. The coordinated
care system Project Access provides is the
reason physicians have continued to pledge
support each year.
Project Access began recruiting dentists in
2013. The goal is to increase the network of
oral health professionals who have a desire
to treat those with few resources. Dentists are
asked to either donate services in private
offices or volunteer at the new Wake Smiles
Dental Clinic at the Salvation Army Building.
Project Access has also increased the
collaboration with local healthcare systems,
namely the Open Door Clinic, Alliance
Medical Ministry, Wake Health Service
clinics, Southlight Healthcare, the Mariam
Clinic, Shepherd’s Care Medical Clinic and
People’s Medical Care. This partnership has
helped to achieve the goals of the program
by 1) facilitating the development of a
more integrated local healthcare system
for Wake County residents; 2) decreasing
the use of emergency room facilities by the
target population; 3) increasing primary care
capacity in Wake County; and 4) increasing
volunteerism among physicians and other
community partners.
“Thank you” doesn’t really seem like
enough. Hats off to all Wake County
physicians AND dentists who are actively
demonstrating their commitment to promoting
the health of all people in this community. §
Who’s Who at the WCMS 2014 Tara Farms Picnic
(pictured left to right)
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Deb Meehan and Louise Wilson
Ken and Kristin Stone and family
Mini the Clown
Barb Savage, Anna Hattaway, Marilu
Thordsen and Deb Meehan
5 | Murthy and Bharathi Manne
6 | Paul Harrison and Susan Davis
7 | Kirk and Shonette Charles & family
8 | Warner Hall
9 | Bindi and Anvitha Ravipati
10 | Marilu Thordsen-Velez and daughter
11 | Jamila Fletcher, Rasheeda Monroe,
6 | OCTOBER 2014
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15
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and Murthe Manne
Patricia Pearce and Jamila Fletcher
Russell and Louise Wilson
Hetal Wasudev
Hetal Wasudev, Louise Wilson, Barb
Savage, Deb Meehan and Marilu
Thordsen
Louise Wilson
Susan Denny, Hetal Wasudev and
Louise Wilson
Walter and Frances Pugh
Patricia Pearce and Susan Davis
T
he 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 readershipkeeping 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 October 24th
at [email protected]. The plan
is to begin publishing member articles
in the January 2015 issue, which will be
posted on our website. Thanks!”
WAKE COUNTY PHYSICIAN | 7
Omnipotence or Ominous Impotence
Of Humans and Humanity
By Assad Meymandi, MD, PhD, DLFAPA*
L
ooking over the annals of human history,
it is undeniable that we have made
progress in industry, mechanization,
discoveries, and advancement in health,
technology, arts, sciences and finance.
After all, we put men on the moon with
their safe return to earth more than 41 years
ago. But one wonders if we have made any
progress in civility, humanity and assertion
of the necessity of love and charity in
human relations. One wonders if we have
succeeded in overcoming greed, if we have
learned to stop manipulating, exploiting and
using our fellow humans for our selfish gain.
1770 BC, a fellow by the name of
Hammurabi, in Khuzestan, a part of Susa,
Persian Empire, wrote a set of 282 rules or
law, each of which dealing with the rights of
8 | OCTOBER 2014
individual and the ultimate respect for one
another. Over 50 of the 282 codes deal with
equality of humans and specifically with the
dignity and rights of women.
Cyrus the Great, the Persian Emperor,
to whom the Bible has more than 100
references, over 2500 years ago, rule his
kingdom with dignity and beneficence. One
of the Biblical references, for example, Isaiah
45, calls Cyrus the Great, King of Persia,
the Messiah. Cyrus emancipated the Jews
and established equal rights for men and
women. In managing his vast empire, to be
in touch with his emissary/rulers in distant
parts of the kingdom, developed a formal
service charged with sending and receiving
communiqués to and from his lieutenants,
thus the birth of the postal service which he
called “Peyk”. The cabinet
of Cyrus the Great consisted
of twelve viziers (ministers or
secretaries) a few of whom
were women. The first person
in charge of the Royal mail
service was a woman. Her
name was Mithra (which
in Zoroastrian parlance
means, dignity). The
father of the United States
Postal Service (USPS), the
polymath Benjamin Franklin,
referred to Mithra in both
official language, as well
as amorous terms. After all,
the gentleman was a lady’s
man! No wonder he had
special regards for Mithra…
In 2010, in the same county,
Persia, they are stoning
women for an insignificant
offense of showing their hair,
or ankles or holding hands
with a male in public. Is this
progress in civility, humanity
and human dignity?
Fast forward the clock
of history. Count Giovanni
Pico della Mirandola
(24 February 1463 – 17
November 1494), the Italian
Renaissance philosopher,
at the age of 23, in 1483,
in his equivalent to today’s
PhD thesis proposed to
defend 900 theses on
religion, philosophy, natural
philosophy and magic
against all comers. The result
was the famous Oration on
the Dignity of Man. It has
been called the “Manifesto
of the Renaissance”, and
a key text of Renaissance
humanism. In this essay,
Pico invokes the writings and
thoughts of all ancient wise
men, going back to Moses,
Zoroaster, Zerubbabel,
Pythagoras, Aristotle,
Platonic philosophers and
neo-platonic philosophers
such as Plotinus to conclude:
“At last, the Supreme Maker
spoke: we have made you a
creature neither of heaven
nor of earth, neither mortal
nor immortal, in order that
you may, as the free and
proud shaper of your own
being, fashion yourself in the
form you may prefer. It will
be in your power to descend
to the lower, brutish forms of
life; you will be able, through
your own decision, to rise
again to the superior orders
whose life is divine.’’
So, where are we? Why
we are not rising to the
superior orders in advancing
the cause of humanity,
human dignity and enhance
connectedness in human
family?
Saadi of Shiraz, the
eloquent Persian poet (born
1210, died 1290) has a
poem, the rough translation
is Bani Adam, the progenies
of Adam. That is to say,
we humans are organs of
one body…If an organ of
Humanity is in pain, other
organs thereof cannot
stay restfully, loosing their
function…So, we humans
without one another cannot
function…” He goes on to
say, “If one organ of the
body is ill and aches, the
rest of the body experiences
pain and become restless…”
I do not know of any more
eloquent and descriptive
simile that illustrates human
being’s connectedness and
brotherhood. Yet we have
constant war, constant
destruction and constant
killing. In America we have
a population of 300 million,
or about 4.5 to 5% of the
world’s roughly six billion, yet
we consumed over 25% of
the world reservoir of energy.
We have over 2.5 million
people in prison, more than
any other developed nation.
Reliable sources report that
up to 80% of our prison
and jail population have
a diagnosable psychiatric
illness and should be treated
rather than imprisoned.
Certainly what International
Affairs Committee is doing
and has done since its
inception in 1995 is helpful
to bring these matters to the
forefront of consciousness,
and bring people together.
Congratulations the NADE’s
Board of Director and to host
Jeffrey Price.
The title I have chosen
for my MM today
“Omnipotence or Ominous
Impotence” draws on
these historical facts. The
life of Neolithic man on this
earth is short, about ten
thousand years. Looking
back 8000 years ago with
the emergence of Sumerians
and invention of writing
in Lydia, the world has
witnessed rise and fall of
many dynasties, empires and
powerful nations. There was
Mesopotamian kingdom,
Accadians, Egyptians, and
the mighty Roman Empire,
Pax Romana, which was
destroyed by Rome’s preoccupation with the affairs
of the Middle East. There
were the Persian Empire
now in shambles, and in
modern day, the empires
emerging in the developed
world, British Empire and now
America... Pax Americana…
They have all experienced
omnipotence, yet the
ignominious ending has been
nothing but impotence,
destruction and reduction to
a vague memory forgotten
in the dustbin of human
history. In England, there
was Lady Matilda Maud
(1102-1167) who first wrote
[continued on page 12]
WAKE COUNTY PHYSICIAN | 9
Acccountable Care
Organization Begins
in Wake County
By Robert H. Bilbro, M.D., FACP
W
akeMed Key Community Care is an
Accountable Care Organization
(ACO) formed in the fall of 2013
to enhance the quality and coordination
of health care, and to reduce the costs of
care by providing more value for patients.
ACOs facilitate medical providers’ working
more closely together to create healthier
communities and to help patients better
manage their health. Doctors, hospitals
and insurers participate voluntarily in
accountable care programs to deliver
enhanced coordination of care and provide
resources to help reduce costs and improve
quality of care for patients. These efforts can
benefit patients in a variety of ways across
their health care experience, including
routine check-ups, ongoing disease
management, necessary procedures,
and unforeseen trips to the emergency
department.
The ACO is a collaboration between
WakeMed Health & Hospitals and Key
Physicians. The partnership is designed
to ensure that patients, especially the
chronically ill, get the right care at the
right time at the right level, while avoiding
10 | OCTOBER 2014
unnecessary duplication of services and
preventing medical errors.
Key Physicians is a network of 225
independent, primary care physicians which
includes pediatricians, family practice
physicians, and internal medicine physicians.
It is an independent practice association
(IPA) in Wake County in existence for 20
years. It is the largest such IPA in North
Carolina. Additionally 65 nurse practitioners
and physician assistants are a part of this
IPA.
WakeMed is a well-established hospital
system initiated and owned by Wake
County, first opening its doors in 1961.
Governance was changed in 1997 to a
private, not-for-profit organization. At that
time the name was changed from Wake
Medical Center to WakeMed. Its ownership
and governance remain entirely in Wake
County. It retains a strong commitment to be
a community based health care institution
with a mission to serve the health and wellbeing of the people of Wake County. Its
hospitals are on New Bern Avenue in Raleigh
and on Tryon Road in Cary. In recent years,
emergency departments, clinics, and
surgical centers have been established at
other locations in Wake County. In addition,
WakeMed Health and Hospitals brings 25
primary physicians and over 200 specialty
care providers to be a part of this ACO.
WakeMed Key Community Care is a
nonprofit organization led by a 10 member
board of directors which includes four
physicians from Key Physicians, four
physicians from WakeMed, a community
representative who is a former board chair
of WakeMed, and a Medicare beneficiary
who is a physician retired from Key Physicians
IPA.
The activation of this ACO occurred first
with a shared savings contract with the
Center for Medicare/Medicaid Services
(CMS) to serve Medicare patients beginning
January 1, 2014. Under that contract are
more than 30,000 attributed lives.
In early August an agreement was signed
by this ACO and Blue Cross Blue Shield of
North Carolina. This contract will enhance
quality and provide greater value to
BCBSNC patients who receive care from
WakeMed Health and Hospitals, WakeMed
physician practices, or Key Physicians.
Through this agreement WKCC and BCBSNC
will work closely together to help patients
better manage their health. Financial
structures are in place to encourage
payment for value of healthcare, including
quality and efficiency. BCBSNC and WKCC
are establishing a Joint Quality Committee,
responsible for achieving high quality
measures that focus on prevention, chronic
disease management, inpatient quality, and
patient satisfaction. This plan will enhance
doctors’ ability to provide exceptional care
both in and out of the office setting while
controlling medical costs.
Benefits to patients with this new care
model include:
• Proactive services that help patients
achieve wellness and receive preventive
care such as immunizations and screenings.
• Tools, materials and outreach that
help patients better manage their chronic
diseases.
• Secure online access to personal
health information so patients can actively
participate in their care.
• Staff to help patients navigate care at
the right level, at the right time, in the right
setting.
• Safer, more effective care as a result
of shared knowledge and best practices
among health care providers.
• More information about the quality and
costs of care.
Patients do not need to enroll or sign
up. Current and new BCBSNC customers
who are patients of WakeMed Health &
Hospitals, WakeMed Physician Practices and
Key Physicians will automatically benefit
from enhanced coordination of their care
through the ACO. Insurance benefits stay the
same whether or not a patient’s physician
participates in an ACO.
Recognizing the potential enhancement
in quality and efficiency of healthcare,
WakeMed is using this same infrastructure of
the ACO for some 29,000 uninsured patients
whom WakeMed has identified as using
their facilities and staff for their healthcare
whether it be in-patient, outpatient, or too
often through the emergency department.
WakeMed already absorbs the costs for this
patient population. It expects to improve
clinical outcomes and save expenses in the
healthcare of these uninsured patients by
utilizing systems developed by this ACO for
Medicare patients and commercially insured
patients.
WakeMed/Key Community Care is a new
accountable care organization, now less
than a year-old, committed to enhancing
quality and improving value in healthcare. It
is already taking effective steps to improve
collaboration and coordination among
the various elements of the health care
system. §
WAKE COUNTY PHYSICIAN | 11
Omnipotence or Ominous continued from page 9]
a manifesto of human and
women rights. Her activities
led to emergence and
development of King John’s
Magna Carta in 1215. In
America, Susan B Anthony
(1820-1906) fashioned her
activities after Lady Maud. In
1920, the 19th amendment
to the Constitution signed by
President Woodrow Wilson
gave women right to vote.
With the historical decline
and retrogression of human
values and the humanities, I
am offering some thoughts
and suggestions. The history
of humanity has offered us
some brilliant role models
who forcefully invite us to
espouse the kind of altruism
that promises the salvation of
humanity.
I want to invoke the names
of three brilliant stars in
the intellectual firmament
whose teachings have
influenced human behaviour
the most. The first is Saint
Augustine of Hippo, born
345, died 430 AD. He was
born a pagan, converted
to Christianity at age 32, in
386, was baptized Easter
Sunday April 4, 387. He wrote
49 volumes in theology,
philosophy and other topics
related to humanities, a total
of 25 million words. Saint
Augustine’s autobiography,
13 books of Confessions
bravely talks about his
stealing from his parents,
fathering a son out of
wedlock, stealing pears
form neighbor’s yard, lying
to his mother and finally
sneaking off to Carthage,
thence to Rome where he
became a Manichean and
finally met his intellectual
superior in the person of
St. Ambrose in Milan. St.
Ambrose, one of four Latin
12 | OCTOBER 2014
Doctors (beside Augustine,
Saint Jerome, and Pope
Gregory) was instrumental in
setting Augustine’s course to
conversion and ultimately to
priesthood and Sainthood.
Saint Augustine’s writing is
replete with man’s dalliance
with false omnipotence.
He wrote extensively about
narcissism, self indulgence
and greed. As a matter of
fact, he called a newborn
baby not a bundle of joy
and innocence, but a
bundle of sin, because the
baby is wrapped up in self
and survival and removed
from consideration of others.
This is what in psychoanalytic
jargon is called “primary
infantile autism” or “primary
infantile narcissism”. As
the child grows and the
central nervous system
matures, reality testing
skills and learning to have
consideration for and,
deference to, others are
developed. The opportunity
to grow and become more
altruistic, more giving, and
less selfish and self centered
is the gift of life. Saint
Augustine was a proponent
of the concept of grace
and salvation. He espoused
Pauline theology of grace
which briefly is described
as “an unearned and
undeserved free gift”. He
wrote more than a million
words on grace.
The second brightest star
of the intellectual firmament
we are exploring is Moses
Maimonides of Cordoba,
born 1135, died 1204, a
Jewish physician, colleague,
theologian, philosopher,
clinician and practitioner.
He too wrote about 20
million words in his lifetime.
He also was concerned
about the issue of grace and
salvation. Moses, in spite of
being the Caliph’s personal
physician in Cordoba, was
pressed by anti-Semitic
forces to flee to Egypt. There
is a small statue of Moses
(Rambam) in Cordoba. Emily
and I take a single long
stem rose and place it at his
statue every time we are in
Cordoba. We do the same
when we visit the tomb of
Claudio Monteverdi, father
of Western Opera (Orpheo
et Euridice 1607) in Iglesia
de Santa María Gloriosa dei
Frari, Venice, Veneto Region,
Italy
The third brightest star of
the intellectual constellation
is Ibn Khaldoun, born 1336,
died 1420, an Arab/Muslim
theologian, economist,
philosopher, music lover and
advocate and writer. He too
wrote about 20 million words
in his lifetime. Ibn Khaldoun
was the father of trickledown
economics which was
adopted by the late
President Reagan in 1981.
He appointed Columbia
Professor Robert Mundel, as
Chair of the White House
Economic Council. Emily
and I had lunch with him
at his villa near Florence in
1993. And our conversation
was around Ibn Khaldoun
whose books and writings
surrounded Robert’s study.
He won the Nobel Prize for
Economics in 1999, after
fathering the birth of Euro as
a unit of currency for Europe.
He is now busy developing
a unit of currency for the
Middle East. Incidentally,
Ibn Khaldoun’s advocacy
of music was ingenious. A
word of history of the world
of music in Islam is in order:
Mohammad, the founder of
Islam was born 580 AD. At
age 40, 620 AD, he started
Islam and two years later, the
Islamic Holy Book, Quoran,
was completed. In early
Islam, music and paintings
were prohibited by Islamic
canon and Fatwa. Ibn
Khaldoun, a lover of music
noted that it is permissible
to sing the passages from
Quoran as the Muezzins sing
their invitation to prayer from
minarets five times a day.
He suggested to the ruling
grand Ayatollah of the day
to organize a competition
and invite the best readers
of various Islamic nations
to come to a place and
compete, picking the
best singers of the Quoran
passages. It is called Talavat
Quran Majeed. It started
in 1365 and continues
to this day. It is like the
Olympics of signing. He
later introduced percussion
(tablah) and strings to
enhance the majesty of
Quoranic passages. The
Talavat competition has
gone on uninterruptedly
since 1365. The only other
continuous musical event
regardless of war, depression
and uncertainties is Handle’s
Messiah, since 1742. The first
performance was attended
by George I. He was so
moved by the Alleluia chorus
that he stood up, handing
down the custom of standing
ovation to this day.
These three writers’
advice against hubris,
omnipotence, appearance
and glitz, repeatedly warn
us not to mistake ominous
impotence for power and
omnipotence. The distilled
message of almost 60 million
words written by these
three sages is—and I am
offering it as a take home
treat-- “The road to grace,
salvation is to know what is
good inside of you, that is
intellect love, compassion,
altruism, empathy, access
to the rich array of so many
other feelings; and knowing
what is good outside of
you, family, connectedness,
friendship, music, nature,
flowers, dance, and poetry;
And to be thankful for them
by giving something back
and making a difference
in the lives of others.” The
issue of awareness is very
important. It takes discipline
to be aware. The heightened
form of awareness in Sufi
is called “Zekr”, that is to
be constantly aware of
all good things inside and
outside. Mowlana Rumi said
“Blessed are those who are
in Zekr; they are in constant
prayer…” What do we do
with all this doom and gloom
and pessimism? I think there
is hope. There is possibility,
there is redemption.
I believe that ultimately for
those who believe in God
that God wants us humans,
His children or Her children,
to succeed and progress.
From time to time, one is
chosen to become a role
model. He sent Buddha
to teach us patience,
wisdom and awareness.
He sent Zoroaster to give
us the concept of good
and evil, epistemological
dualism. He sent Moses
to exemplify discipline,
devotion and yes, the gift
of doubt. He sent Jesus of
Nazareth to demonstrate
the power of love. He sent
Mohammad to offer us Islam
total submission to the will
of God. He sent Mozart to
illustrate the power of music.
This every day common
man with multiple organ
system failure, including
kidneys and liver ravaged
by alcohol, mourning the
death of his mother and his
little daughter, in the summer
1786 wrote Symphony in G
minor, topping the trio with
Jupiter Symphony in C major.
No mere human can do
this. Finally he sent America,
our Founding Fathers,
Thomas Jefferson, George
Washington, James Madison,
Benjamin Franklin and
others to give us a system of
government, a republic, that
cherishes the supremacy
of rule of law, and not
the whims of kings, shahs
and Ayatollahs. America
is a decent and generous
nation. America is there in
case of natural disaster, in
Tahiti, in Pakistan, in Nepal
and Myanmar. America is a
land that allows its citizens
to reach their maximum
potential. I am very optimistic
about the future of the world
because the world has
America. §
*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.
WAKE COUNTY PHYSICIAN | 13
I
n For those of us past
60, Shakespeare’s King
Lear animates some of
our worst nightmares about
ageing and our “crawl towards
death”. In this tragedy, Lear
initiates the action by dividing
his kingdom, abdicating his
throne, and trying to maintain
the trappings of his kingship.
Perhaps he hoped to avoid
civil war after his death,
but his “do-you-love-me
most” trial failed miserably.
Like Oedipus, Lear makes
14 | OCTOBER 2014
wrong choices and in doing
so, inadvertently releases a
“plague” upon his kingdom.
He further complicates
the situation by ignoring
any contradictory advice
from his closest supporters.
But this tragic hero is from
Shakespeare’ imagination, not
from Sophocles’, and what a
difference that makes.
There are 3 old men in King
Lear- the king and his two
advisors, Glocester and Kent.
Each will endure a fall. Lear
falls farthest as a consequence
of misjudging his three
daughters. His descent begins
with a rigged flattery contest
to determine which daughter
who loves him most. In fairy
tale fashion, Cordelia, his
youngest and favorite, refuses
to play the game. Lear disowns
her. Her two older sisters,
Goneril and Regan, appease
Lear and receive their rewards.
Almost immediately they set
about brutally deconstructing
their father by stripping the
King Lear and Madness
By L. Jarrett Barnhill, MD
king of the trappings of
kingship. Shakespeare makes
it abundantly clear - this is
not your mother’s fairy tale.
Gloucester makes a similar
misjudgment. He is fooled
by an Iago-like bastard
son, Edmond. Accepting
Edmond’s false evidence of
treachery by his legitimate
son, Edgar, Gloucester
disowns, then attempts to
destroy him. Gloucester’s
eventual punishment for
his mistake is straight from
Dante’s Inferno- because
he couldn’t see the truth,
his eyes are torn out. Kent
on the other hand directly
lambasts the fallacy of Lear’s
trial by love and is banished
only to return, disguised in
order to protect his king and
friend. This play is not a safe
place for old men.
There are three trials in
King Lear. The first involves
Lear’s trial-by-love-profession.
The second trial involves
Glocester. In it, the cruel
but rational Regan, her
husband, Cornwall, and
Edmond convict Glocester
as a traitor. Cornwall, with
Regan’s urging, gouges
out the old man’s eyes
and leaves him to “smell
his way to Dover”. The mad
Lear presides over the third
trial as both the judge and
prosecutor. Joining him
on the tribunal are his Fool
and Edgar (disguised as a
madman). The defendants,
[continued on page 16]
WAKE COUNTY PHYSICIAN | 15
King Lear continued from pag 15]
Regan and
Goneril,
are stools
in this
surreal
courtroom.
There
are 3
species of
madmen.
The Fool is mad but displays
the greatest insight into
Lear’s folly. The Fool’s antics,
songs, satire and wit refocus
Lear on his decisions as
the cause of his undoing.
The Fool functions as a
psychotherapist but he
is eventually hanged for
supporting the disjointed king.
Edgar escapes Gloucester’s
plan to execute him by
feigning madness as “Tom
o’ Bedlam”. But, it is the
king’s madness that takes
center stage. Enraged, he
commands a deconstruction
of creation. Shakespeare’s
use of the storm to animate
Lear’s madness creates the
central metaphor of this playthe disintegration of Lear, his
kingdom and Elizabethan
ideal of universe accreted by
love. Without Love, there is
primordial chaos.
There are 3 examples of
uncharacteristic altruism
and compassion- as it might
appear in Lear’s world. Lear’s
confrontation with Poor Tom
as the “unaccommodated
Man” reminds the king of
his neglected subjects.
Rather than revenge his
father’s treatment, Edgar
as Mad Tom leads the blind
Gloucester to Dover and
aborts Gloucester’s suicide
16 | OCTOBER 2014
by staging a feigned leap
from the cliffs. Gloucester
miraculously survives, his
depression temporarily
cured. Cordelia returns
from France to temporarily
restore Lear’s sanity, but
her invasion plans fail and
she is hanged. The greatest
act of altruism comes from
Cornwall’s unnamed servant
who dies trying to prevent
the Gloucester’s blinding. But
none of these actions undo
the evil running amok in this
play. There is no good deed
that goes unpunished.
The forces of Machiavellian
reason (Edmond, Regan,
Goneril and Cornwall) win
a battle, but lose the war.
Cornwall is already dead;
Edgar kills Edmond, while
Reagan and Goneril destroy
each other. Only Edgar, the
unaccommodated man, and
Albany survive. This course
of action was so unsettling
that 150 years after the play
was written, Samuel Johnson
acknowledged that he could
never reread its ending.
Several 18th and early 19th
century presentations rewrote
Shakespeare’s endingCordelia survives, marries
Edgar and both rule England.
So what possessed the
poet who “wrote for all the
ages” to expose the dark
horror lurking within the
human condition? Why does
Shakespeare end this tragedy
without reconstructing a
new universe as he might
in a comedy? His “good”
characters face the same
cruelty, horror and brutal
victimization as his villains.
Suffering does not purify
nor sanctify. Lear comes to
realize that he is just another
unaccommodated madman.
He suffers as Citizen Louis
Bourbon in the French
and Comrade Romanov
in the Russian revolutions.
In those worlds, what is
madness? Is it a collapse, a
fall, or a post-apocalyptic
survival mechanism? Lear
acknowledges the cruel
reality of his disintegrating
world when he notes that
wailing is our first action on
earth. Yet love, compassion,
morality and kindness still
emerge in the actions of a
few.
Both Lear and Oedipus
endured a world where
insight and blindness seem
intertwined? Oedipus blinds
himself when he sees his wife/
mother’s dangling body.
Lear regresses further when
he confronts Edgar disguised
as Tom O’Bedlam. Both strip
themselves of titles, earthly
power, responsibilities and
duties. Yet unlike Job, they
also have no answer for
their suffering other than a
voice from the whirlwind.
Lear remains “blind” until
his last scene in which
he looks into Cordelia’s
face and sees something
that offers hope. Is this a
hallucination of a “foolish,
fond old man” or does he
finally understand why the
people that he harmed still
love him? Are such insights
the transcendent or are they
madness made manifest? §
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.
CURRENT PROGRAMS
Project 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.
Become a Member of Wake County Medical Society
and help support the indigent care and community service
programs of the Society.
WHY JOIN
BENEFITS OF MEMBERSHIP
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.
HOW TO JOIN
To become a member of the Wake County Medical Society
contact Deborah Earp, Membership Manager at dearp@
wakedocs.org or by phone at 919.792.3644
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.
WCMS MISSION
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.
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 peerreviewed 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.
JOIN TODAY!
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
joining the Wake County
contributes to the volunteer Medical Society Alliance.
and service programs of
WCMS. Membership
is also available for
PA’s. There is even an
opportunity for your
spouse to get involved by
JOIN
TODAY!

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