Catherine D. DeAngelis, MD, Is Named New JAMA Editor

Chicago—Catherine D. DeAngelis, MD, was named the 15th editor of the Journal of the American Medical Association on October 8. The 59-year-old pediatrician will become the first woman editor in the 116-year history of JAMA.

DeAngelis begins her duties in early January, almost 1 year after the American Medical Association (AMA) fired former editor George D. Lundberg, MD, saying he had threatened JAMA's integrity by inappropriately interjecting the journal into the debate surrounding the Clinton impeachment trial. The AMA's actions were viewed by many in the academic, scientific, and medical communities as an infringement on the editorial freedom of JAMA (JAMA.1999;281:403). A governance plan guaranteeing editorial independence for JAMA was negotiated and approved by the JAMA Editor Search Committee, AMA senior management, and the AMA Board of Trustees in May (JAMA. 1999;281:2239-2242).

DeAngelis said that implementation of the plan was vital to her acceptance of the JAMA editorship. "I needed to make sure that everyone had signed on, that it was a secure position, and that editorial freedom was maintained," she said. "The key issue here is to guard what I think is the sacred trust to the medical science community—that their written work will be fairly reviewed by their peers and the publication of their work will be based on merit and nothing else."

DeAngelis said she doesn't plan any drastic changes for JAMA, although she does have some ideas for certain changes, but she wants to settle in and wait a few months before deciding if they're tenable.

The governance plan under which DeAngelis will serve creates a seven-member journal oversight committee that acts as a buffer between the JAMA editor and AMA management. Editorial matters will be dealt with through the oversight committee while the editor will report to the senior vice president for publishing and business services for financial and business operations only. Any proposal to dismiss the editor must be evaluated by the oversight committee, whose recommendations will be presented to the AMA Board of Trustees. A two-thirds vote by the AMA board will be required for dismissal (JAMA. 1999;281:2239-2242).

DeAngelis is currently vice dean for academic affairs and faculty and professor of pediatrics at Johns Hopkins University School of Medicine. Since 1993, she has been editor-in-chief of the AMA's Archives of Pediatrics & Adolescent Medicine (APAM). She is also a member of the JAMA Editorial Board.

Roger N. Rosenberg, MD, chair of the JAMA Editor Search Committee and editor-in-chief of the AMA's Archives of Neurology, said DeAngelis received the unanimous recommendation of the search committee, the AMA administration, and the AMA Board of Trustees.

"We are thrilled and excited to have Dr DeAngelis as our new editor," Rosenberg said. "She represents the very best in medicine. Her background includes all of the elements we were seeking."

E. Ratcliffe Anderson, Jr, MD, the AMA's Executive Vice President and Chief Executive Officer who fired Lundberg, said he was "delighted" by the DeAngelis decision.

"She is the perfect person to take JAMA into the new millennium and make it better than it already is," Anderson said. "I look forward to a new wonderful future for JAMA."

Perhaps ironically, Lundberg is in rough agreement with Anderson.

"Dr DeAngelis is widely regarded as one of the best academic pediatricians in this country and has risen to the top of most of the pediatric and medical specialty groups. I am, of course, biased since I hired her to be the editor of the Archives several years ago," said Lundberg, who is now editor of an online medical Web site. "But I believe she is a splendid choice. I wish her well, and I offer to help in any way I can."

As for the issue of editorial independence for JAMA, Lundberg said the DeAngelis appointment "is a wonderful signal on behalf of the American Medical Association to the academic, practice, and media communities. I cannot comment on whether the governance [plan] will or will not work since I am not privy to any of the final details."

DeAngelis has more than 30 years of experience in the peer review process as an author, reviewer, and editor. It is that experience that impresses Phil B. Fontanarosa, MD, interim coeditor of JAMA.

"We all know Dr DeAngelis from her excellent work as editor of the Archives of Pediatrics and Adolescent Medicine," Fontanarosa said. "It's clear that Dr DeAngelis brings strong academic credentials and a solid track record of academic achievement to JAMA and the Archives journals."

Richard M. Glass, MD, interim coeditor of JAMA, agrees. "Dr DeAngelis is a highly qualified editor," Glass said. "We look forward to continuing to improve the many ways JAMA fulfills its key objective, ‘to promote the science and art of medicine and the betterment of the public health,' after she arrives as the new editor in January."

Besides becoming editor of JAMA, DeAngelis becomes the editor-in-chief of the AMA's Division of Scientific Information and Multimedia, meaning she will provide leadership for the AMA's Archives journals and the Web site for the AMA journals.

DeAngelis was born in Scranton, Pa, and received an RN degree in 1960 from Scranton State General Hospital School of Nursing and an MD degree in 1969 from the University of Pittsburgh School of Medicine. In 1973, she received an MPH from the Harvard Graduate School of Public Health. She completed an internship in pediatrics at Children's Hospital in Pittsburgh and received her residency in pediatrics from Johns Hopkins Hospital. Since 1972, she has served in academia at Columbia University, the University of Wisconsin School of Medicine, and Johns Hopkins.

DeAngelis said she wasn't looking to leave Johns Hopkins or APAM but she couldn't pass up this opportunity.

"I'm on the JAMA editorial board. As such, I care very much about JAMA," she said. "I think it's an absolute jewel, and I was concerned about maintaining its excellence. I think this is going to be a lovely and fun experience for everyone. I've enjoyed working with the staff I've met, and I think we'll do great things for the medical community."

Los Angeles—It's one of the most difficult moments in aging: admitting the time has come to surrender the car keys.

While no one can turn back the hands of time or stop age-related vision loss, new studies are zeroing in on specific vision deficits that contribute to vehicular crashes among older drivers. Researchers hope the findings will help identify high-risk drivers and interventions to enhance driver safety.

"We need better methods to identify older drivers, and perhaps all drivers, who are at risk of being in crashes," said Gary Rubin, PhD, professor of ophthalmology at University College in London, during a recent seminar sponsored by Research to Prevent Blindness, a New York–based vision research foundation.

In a study of 2500 adults aged 65 to 84 in Salisbury, Md, Rubin and his former colleagues at the Wilmer Eye Institute of Johns Hopkins University School of Medicine measured vision changes over 2 years. They tested five components of eyesight—visual acuity, the most common eye test that measures the ability to see detail in high-contrast situations; stereoacuity, the ability to see depth with both eyes; visual field, which measures peripheral vision; contrast sensitivity; and glare sensitivity. Participants also took a brief cognition test.

When Rubin and his colleagues analyzed the vision test results and participants' crash histories from state records, only the visual field test was associated with crash risk. "The people who had restricted visual field were about 30% more likely to have been in a crash," Rubin said. Cognitive deficits increased crash risk by 50% to 60%.

Standard vision testing at motor vehicle bureaus usually measures only visual acuity, which doesn't consider such everyday driving conditions as fog and glare. John Brabyn, PhD, director of rehabilitation engineering research at Smith-Kettlewell Eye Research Institute in San Francisco, said his studies of 900 adults aged 65 and older found that the most dramatic age-related vision changes involved sensitivity to glare and the time it takes the eyes to readjust to normal light after exposure to glare.

Cynthia Owsley, PhD, and her colleagues at the University of Alabama at Birmingham (UAB) have focused on the impact of cataracts on crash risk. In a study comparing 281 patients aged 55 or older who had cataracts with 105 age-matched controls, Owsley found that those with cataracts were two and a half times more likely to have been in a crash during the previous 5 years than those without the condition.

"Glare, contrast sensitivity, and acuity are believed to be the three functions affected by cataracts," Owsley noted. Of those three, she said, older drivers with severe contrast sensitivity from cataracts were eight times more likely to be in a crash than those who did not have that particular deficit.

Subsequently, half of the patients with cataracts had surgery to remove them. Three years after surgery, their crash rates had leveled off, at a rate of about 4.9 crashes per million person-miles of travel. But among those who chose not to have surgery, crash rates increased from 4.8 to 8.3 in three years.

"This is one of the first demonstrations that you can actually do something about reducing crash rates," Owsley said, noting that cataract is the leading cause of vision impairment in older adults.

Melvin Shipp, OD, MPH, also of UAB, said it's been estimated that 17% of all licensed drivers in the United States will be aged 70 or older by 2020 and that 88% of older Americans rely on a car for their main source of transportation. Because independence is so closely linked with driving, suggestions of more restrictive vision tests for driver's license renewal prompt intense, emotional public policy debates.

However, in his analyses of state vision testing policies, Shipp has found that the fatality rate is 12% less among older drivers in states that require vision tests to obtain a driver's license than in states that do not require testing, although it's possible some factor other than vision testing may be responsible for the decreased fatality risk. His research also has found that vision testing doesn't reduce the proportion of older drivers.

Rubin said California and Maryland are examining whether more comprehensive vision testing should be implemented for driver's license renewal. But he also stressed that impaired vision affects all aspects of life: reading, walking, and seeing the faces of family and friends.

Even if medical treatment can't reverse many cases of age-related vision loss, Rubin said low-vision rehabilitation can help. Low-vision specialists recommend modifications that make homes and workplaces easier to navigate.

"Many patients who could benefit from low-vision rehabilitation do not get referred to it," he noted.

In addition to access and cost barriers, Rubin said "some physicians are not convinced that low-vision rehabilitation is effective. We need to do more research to show with hard numbers that this is effective."

The National Eye Institute (NEI) launched a Low Vision Education Program in October. According to the NEI, low vision is visual impairment that interferes with daily activities and cannot be corrected with eyeglasses, contact lenses, medicine, or sugery. The new program is intended to help the estimated 14 million Americans who have low vision learn about rehabilitation and adaptive devices that can help them lead independent, productive lives.

New York—The central character of Wit, the Pulitzer Prize–winning play by Margaret Edson currently on stage at Union Square Theatre in Manhattan, is a woman diagnosed with stage IV ovarian cancer. Hardly the stuff of light comedy, Wit nevertheless evokes laughter as well as tears in its deft portrayal of the issues faced by a patient with this malignancy.

The issues raised by the play—how a patient deals emotionally with cancer and how that patient is treated by medical professionals managing her care—have struck a chord with audiences, so much so that after every Tuesday night performance, theatergoers are invited to attend a "talk-back" discussion with the actors and a guest moderator.

The patient is Vivian Bearing, PhD, a 50-year-old professor of English and a renowned scholar of John Donne's Holy Sonnets. The most effective treatment for the aggressive tumor, says her oncologist, is an experimental combination of chemotherapeutic agents. To the satisfaction of the physicians overseeing her therapy, Bearing completes the grueling course of treatment. But despite her steadfast adherence to therapy, the cancer is not vanquished.

In Bearing's encounters with the physicians, nurses, and technicians involved in her care, much attention is focused on the brusqueness and insensitivity of a young clinical fellow, who sees the patient as a research subject rather than a fellow human deserving of compassionate regard. The only character who shows concern for Bearing's emotional well-being throughout her ordeal is an oncology nurse.

Leading the postperformance discussion on October 5 was Lewis Lipsey, MD, a clinical assistant professor of medical oncology at New York's Mount Sinai Medical Center. Lipsey said that the play, which he has seen twice, is adept at depicting the difficulties faced by a cancer patient and reflects many of his own experiences with patients.

Lipsey began the discussion by asking whether the wall between patient and physician depicted in the play must exist. Members of the audience responded by sharing both negative and positive experiences that they or friends or family had had with health care professionals in times of severe illness.

One woman recounted the compassion with which her mother, diagnosed with terminal cancer, was treated by her physician. He had assured her mother that this was a journey she would not make alone or in pain. This assurance, she said, gave great comfort to her mother, who seemed more concerned about the pain associated with dying than with death itself.

In contrast with this uplifting story, another woman related a disturbing tale of the insensitive treatment her mother (who was dying of lung cancer) received from a young resident. On first meeting the patient, the resident asked how many packs a day she had smoked. When she responded that she had never been a smoker, he accused her of lying.

Even after many years, the pain, hurt, and anger this thoughtless exchange caused the patient and her family was still palpable in her daughter's voice. Lipsey, who was obviously deeply troubled by the story, but not surprised, said such cavalier attitudes toward patients get played out all too often and need to be eliminated.

A child psychologist in the audience responded to this exchange by raising the issue of whether training prepares physicians for dealing with the emotional issues of their patients. She said systems need to be in place that help them become better at this task.

Lipsey pointed out in an interview that nurses in top-ranked cancer centers, who are "thoroughly attuned to the needs of these patients, are probably much better at teaching new physicians and new residents how to take care of the emotional needs of patients than [are] senior mentors."

In the play, the character of the nurse in particular is true to form, he said. "In my own training it was the nurses who taught us everything about how to deal with patients. They are the primary caretakers in cancer centers, the ones who get to know the patients and their families, their fears and hopes. They're also the ones who temper the enthusiasm of the doctors, keep expectations realistic, and make sure patients are protected."

Not only nurses but every member of the medical team treating the patient should show the same concern and the same responsibility toward dealing with the emotional needs of the patient, said Lipsey. While this can be draining, he said, it can also be meaningful to hear that you have made a difference in a patient's life.

Forums such as the Tuesday night discussion are one useful way of helping concerned individuals and medical professionals air their concerns and ideas about improving patient care. The play challenges the medical community not only to offer cancer patients cutting-edge therapies, but to do so with compassion and humanity.

After 6 years as director of the National Institutes of Health (NIH), Harold Varmus, MD, is leaving his post at the end of December to become the president of Memorial Sloan-Kettering Cancer Center in New York City.

Varmus's decision was not unexpected. Shortly after arriving at NIH in 1993, he said that he thought that 6 years serving as director would be "about right." He is credited with attracting talented biomedical researchers to the NIH and working successfully to convince the executive branch and members of Congress to increase the nation's investment in basic and clinical research. The NIH's overall budget grew from around $11 billion in 1993 to more than $15.6 billion in 1999.

However, some patient advocacy groups criticized the Nobel Prize–winning molecular biologist's emphasis on basic science. A 1998 Institute of Medicine report chided the NIH for not seeking input from patients and urged the agency to include a consideration of deaths and suffering caused by specific diseases when setting its research priorities. In response to this criticism, the NIH established a new advisory committee to the NIH director, the Council of Public Representatives, to facilitate interaction between the NIH and the public.

Although Varmus had no previous experience overseeing any enterprise larger than a research laboratory, he was widely regarded as a savvy administrator of NIH's 25 institutes and centers. In an October 7 letter to President Clinton, Varmus wrote, "I hope that the achievements of the past several years will encourage you and your successors to consider other active medical scientists to run this extraordinary agency."