Alpha Omega Alpha Honor Medical Society Winter 2014 the PHAROS of Alpha Omega Alpha Honor Medical Society Winter 2014

Alpha Omega Alpha Honor Medical Society Winter 2014 THE PHAROS of Alpha Omega Alpha honor medical society Winter 2014

“Be Worthy to Serve the Suffering” Alpha Omega Alpha Honor Medical Society Founded by William W. Root in 1902 Ofﬁcers and Directors at Large Editor Richard L. Byyny, MD John Tooker, MD, MBA President Philadelphia, Pennsylvania Editor Emeritus (in memoriam) Robert J. Glaser, MD C. Bruce Alexander, MD Immediate Past President Associate Editor and Helen H. Glaser, MD Birmingham, Alabama Managing Editor Douglas S. Paauw, MD (in memoriam) President-Elect Seattle, Washington Managing Editor Debbie Lancaster Joseph W. Stubbs, MD Secretary-Treasurer Art Director and Illustrator Albany, Georgia Robert G. Atnip, MD Designer Erica Aitken Hershey, Pennsylvania Eve J. Higginbotham, SM, MD Editorial Board Philadelphia, Pennsylvania Richard B. Gunderman, MD, PhD Indianapolis, Indiana Jeremiah A. Barondess, MD Faith T. Fitzgerald, MD Eric Pfeiffer, MD Sheryl Pfeil, MD New York, New York Sacramento, California Tampa, Florida Columbus, Ohio David A. Bennahum, MD Daniel Foster, MD William M. Rogoway, MD Albuquerque, New Mexico Dallas, Texas Stanford, California Alan G. Robinson, MD John A. Benson, Jr., MD James G. Gamble, MD, PhD Shaun V. Ruddy, MD Los Angeles, California Portland, Oregon Stanford, California Richmond, Virginia Wiley Souba, MD, DSc, MBA Richard Bronson, MD Dean G. Gianakos, MD Bonnie Salomon, MD Hanover, New Hampshire Stony Brook, New York Lynchburg, Virginia Steven A. Wartman, MD, PhD John C.M. Brust, MD John S. Sergent, MD Jean D. Gray, MD Washington, DC New York, New York Halifax, Nova Scotia Nashville, Tennessee Charles S. Bryan, MD David B. Hellmann, MD Marjorie S. Sirridge, MD Columbia, South Carolina Baltimore, Maryland Kansas City, Missouri Medical Organization Director Robert A. Chase, MD Pascal James Imperato, MD Clement B. Sledge, MD Carol A. Aschenbrener, MD Stanford, California, and Brooklyn, New York Marblehead, Massachussetts Association of American Medical Colleges Jaffrey, New Hampshire John A. Kastor, MD Jan van Eys, Ph.D., MD Washington, DC Henry N. Claman, MD Baltimore, Maryland Nashville, Tennessee Denver, Colorado Michael D. Lockshin, MD Abraham Verghese, MD, DSc Councilor Directors Fredric L. Coe, MD New York, New York (Hon.) Stanford, California Lynn M. Cleary, MD Chicago, Illinois Kenneth M. Ludmerer, MD Steven A. Wartman, MD, PhD State University of New York Upstate Medical Jack Coulehan, MD St. Louis, Missouri Washington, DC University Stony Brook, New York J.Joseph Marr, MD Gerald Weissmann, MD Mark J. Mendelsohn, MD Ralph Crawshaw, MD New York, New York University of Virginia School of Medicine Portland, Oregon Stephen J. McPhee, MD David Watts, MD San Francisco, California Alan G. Wasserman, MD Peter E. Dans, MD Mill Valley, California Baltimore, Maryland Francis A. Neelon, MD George Washington University School of Lawrence L. Faltz, MD Durham, North Carolina Medicine and Health Sciences Sleepy Hollow, New York Coordinator, Residency Initiatives Suzann Pershing, MD Stanford University

Student Directors www.alphaomegaalpha.org Christopher Clark, MD University of Mississippi Medical School Tonya Cramer, MD Manuscripts being prepared for The Pharos should be typed double-spaced, submitted in triplicate, and conform to the format Chicago Medical School at Rosalind Franklin outlined in the manuscript submission guidelines appearing on our website: www.alphaomegaalpha.org. They are also available University of Medicine & Science from The Pharos office. Editorial material should be sent to Richard L. Byyny, MD, Editor, The Pharos, 525 Middlefield Road, Suite Laura Tisch 130, Menlo Park, California 94025. Medical College of Wisconsin Requests for reprints of individual articles should be forwarded directly to the authors. The Pharos of Alpha Omega Alpha Honor Medical Society (ISSN 0031-7179) is published quarterly by Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, Menlo Park, California 94025, and printed by The Ovid Bell Press, Inc., Fulton, Administrative Ofﬁce Missouri 65251. Periodicals postage paid at the post office at Menlo Park, California, and at additional mailing offices. Copyright Richard L. Byyny, MD © 2012, by Alpha Omega Alpha Honor Medical Society. The contents of The Pharos can only be reproduced with the written Executive Director permission of the editor. (ISSN 0031-7179) Menlo Park, California Circulation information: The Pharos is sent to all dues-paying members of Alpha Omega Alpha at no additional cost. All correspondence relating to circulation should be directed to Ms. Debbie Lancaster, 525 Middlefield Road, Suite 130, Menlo Park, California 94025. E-mail: [email protected] Menlo Park, California 94025 Telephone: (650) 329-0291 POSTMASTER: Change service requested: Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, Fax: (650) 329-1618 Menlo Park, CA 94025. E-mail: [email protected] The Pharos • Volume 77 Number 1 • Winter 2014 In This Issue

DEPARTMENTS On the cover

Alpha Omega Alpha Honor Medical Society Winter 2014 Editorial See page 11. 2 Teaching and learning in medicine Alan G. Robinson, MD Richard L. Byyny, MD 2013 Robert J. Glaser 31 Distinguished Teacher Awards

The physician at the movies 34 Peter E. Dans, MD Blue Jasmine Enough Said Call Northside 777 (1948)

Reviews and reflections ARTICLES 39 I Wasn’t Strong Like This When I Started Out: True Stories of Fall from grace Becoming a Nurse 8 Reviewed by Judy Schaefer, RN, MA J. Joseph Marr, MD Forgive and Remember: Managing Medical Failure Reviewed by Jack Coulehan, MD Plagiarism of ideas Guidebook for Clerkship Directors, 14 Benjamin Rush and Charles Caldwell— 4th edition Reviewed by Deepti Rao, MD a student–mentor dispute What Doctors Feel: How Emotions Charles T. Ambrose, MD Affect the Practice of Medicine Reviewed by Johanna Shapiro, PhD Last days National and chapter news 44 25 Richard C. Reynolds, MD

INSIDE New program POETRY BACK COVER So Long AΩA Fellow in Leadership Award 24 Thomas J. Balkany, MD, FACS, FAAP Negatives 30 Alexander Fortenko O.E.D. 38 Henry N. Claman, MD

49 49

Editorial Teaching and learning in medicine

Alan G. Robinson, MD Dr. Robinson (AΩA, University of Pittsburgh, 1988) is How People Learn: Brain, Mind, Experience, and School.1 The the Distinguished Professor, Associate Vice Chancellor, report’s major points were: and Senior Associate Dean at the David Geffen School of • Individual learning is built on one’s own prior knowledge Medicine at UCLA. He is a member of the board of direc- from instruction and experience. tors of Alpha Omega Alpha. • Learners differ in styles of learning, prior instruction, previous experience, and other factors. Introduction • Learning is facilitated by formative evaluation with feed- Richard L. Byyny, MD back for understanding of concepts. Executive Director, Alpha Omega Alpha • Learning requires reflection, awareness, and self- I recently had a discussion with close friend Dr. Alan questioning of one’s understanding and learning process. Robinson about the importance of teaching and learning in • Learning is enhanced for those who value the knowledge medicine. We shared our ideas and worries, including the learned. problems of not having adequate funding for teaching in • Active learning results in better understanding and re- medicine and the dearth of medical teachers with a full un- tention of knowledge and information. derstanding of educational research in pedagogy and learning. • Learning is a continuum from novice to expert, where I subsequently asked Al to write an editorial for The Pharos knowledge and information can be effectively retrieved, un- on the topic. derstood, and applied. Like many teachers in medicine I learned to teach by ob- The most effective medical teaching requires not only serving my teachers and adopting or rejecting their teaching medical and scientific knowledge, but also the knowledge of methods and style. I also used the “see one, do one, teach one” education science and the ability to apply these educational pedagogy described by Al and others. I spent one summer principles. Most basic science courses in medical school could with Dr. Kelley Skeff at the Stanford Faculty Development utilize the principles of education science to organize their Center for Medical Teachers to learn how to become a bet- courses, or could apply the principles of education science to ter bedside teacher and worked hard to become an excellent course organization. This involves changing the perspective physician, teacher, and scholar. I was surprised and flattered to from what is often instructor-centered teaching to student- receive some teaching awards and excellent evaluations from centered learning. Incorporating instruction around student medical students, residents, and patients. engagement with a case or problem early in medical education However, it wasn’t until I served as the Chancellor of the and then pursuing this during the clinical education experi- University of Colorado at Boulder that I really learned about ences enhances learning and motivation. This shifts learning the science of teaching and learning. There, distinguished from the model of teaching of facts followed by application to research faculty applied what has been called “scientific teach- one of inductive teaching that begins with a case or clinical ing” in their courses for undergraduate students, using the problem and students learning the relevant concepts and facts principles set forth in the National Research Council’s report, in the process of understanding and solving the problem. The

2 The Pharos/Winter 2014 An instructor demonstrates the surgical procedure for amputation, circa 1903. Courtesy of the National Library of Medicine.

shift takes advantage of the ability of technology to facilitate make them better servants of the people they care for. just-in-time learning. Among AΩA’s core values is “to improve care for all by Reflection is another important learning strategy. I was encouraging the development of leaders in academia and always surprised when I asked a group of students or residents the community.” At its annual meeting this year, AΩA’s to tell me one thing they had learned during rounds or the Board of Directors approved an AΩA Leadership Award and session and found that most couldn’t do it. Repetition of the Development Program. I hope that some of the applicants request taught them to reflect on lessons learned. The chal- will seek to develop their leadership skills in the science and lenge for us in medical education is not so much in what we programs described in Dr. Robinson’s editorial. teach medical students, but more in how we teach them to develop as expert physicians. Teaching and learning in medicine Medical schools are placing increasing emphasis on profes- Alan G. Robinson, MD sionalism, one aspect of which is the willingness and ability to It was my first meeting with the Senior Associate Dean work within a team—including those in medical education, for Medical Education in my new position as Executive where a member of the team might be an education special- Associate Dean at the UCLA School of Medicine. Sitting ist skilled in the science of education. Faculty members who across my desk was a petite woman who is a big player on devote themselves to medical education are by the nature of the national stage of medical education, LuAnn Wilkerson. the work dedicated to what is termed servant leadership. Their I immediately exposed my unconscious ignorance about commitment is to serving the medical students in an effort to medical education by indicating that I thought the major

The Pharos/Winter 2014 3 Teaching and learning in medicine

educational problem facing academic medical centers was to educate the public about the benefits of our wonderful research and clinical care . . . and, “oh yes, training future physicians.” Over the next few weeks I rapidly became consciously ignorant of my understanding of medical education. My direct reports were the deans responsible for research and for education, while finance, department chairs, and the clinical system reported directly to the dean. My unconscious to conscious ignorance of medical education was further brought to my attention in a discussion with the Senior Associate Dean for Faculty Affairs. He noted that I had an outstanding record in medical research, continuous NIH funding, and administrative experience by running a large division and serving as Vice Chair of Medicine at the University of Pittsburgh. However, he observed that I hadn’t done much specifically related to medical education and wondered aloud how I would handle the oversight of that area. In the few minutes that I absorbed his comments I made a life-changing decision when I responded, “I’ll do what I’ve always done; I’ll start a journal club.” I went back to LuAnn Wilkerson to ask her help in setting up a medical education journal club. She embraced the idea as a wonderful venue in which people interested in medical education could exchange information about recent publications and discuss research opportunities in our school. What embrace the science of education when it is considered within I wanted was for the journal club to educate me. the neurosciences and how the brain functions. Now, however, I came from the “see one, do one, teach one” generation there is also a growing broader acceptance of the science be- that believed that any competent and good physician was hind the psychological approach to learning. The book How a good teacher. Academic medicine has built a marvelous Learning Works2 is directed to college teachers, but is equally system of training physicians to become experts in a broad useful to medical school educators and stresses the science range of specialty disciplines. Rigorous standards define the behind the authors’ Seven Researched-based Principles for experience necessary to be considered an expert. But for the Smart Teaching. most part less or little attention has been given to the method There are two areas in which the science of education of the pedagogy. could make an enduring contribution to medical education: Especially in the last decade medicine has begun to accept 1. Making every graduating physician a better teacher the concept that there is a “science” of education, just as there 2. Growing a cadre of medical faculty whose expertise, is a science that underlies each of our specialty disciplines. research, and faculty commitment is based on applying the In 2001, experts from the Institute of Medicine joined mem- science of education to medical education. bers of the National Academy of Sciences and the National When we think about community practitioners as teachers, Academy of Engineering to publish a book by the National we usually think of the important contribution they make as Research Council titled How People Learn.1 Physicians readily volunteer faculty teaching our medical students. However, an

4 The Pharos/Winter 2014 even more important role of teaching is the interaction with teach back improved insulin therapy in diabetics.3 patients. Virtually every patient contact with a physician re- One day I was talking with a medical student about his quires communication between the physician and the patient plans for a career. The conversation was rather laborious until that “teaches” the importance and timing of an appropriate I asked him about his experience as a volunteer mentor help- medical therapy. The science of education, the science of how ing students in lower classes who were having difficulty. He people learn, can inform the teaching of patients as well as the brightened immediately and told me how he first evaluated teaching of students. Many of the principles of smart teach- the student’s type of learning: visual, aural, or written; then he ing are immediately recognized as principles of good medical evaluated how the student organized his or her course mate- care: rial for study. I was so impressed with this scientific approach • What is the patient’s prior understanding of their disor- to teaching that I asked if he had had a course in education in der (correct or incorrect)? medical school (not UCLA). He responded, “Oh, no. I learned • What is their motivation to adhere to therapy? that in training to become a skiing instructor.” • How might their ethnic and intellectual status affect their So some of these approaches to education may find as adherence to therapy? ready application in the business and religious communities • Etcetera. as in schools of medicine. These are all things that we know as physicians and hope- A new technique for classroom teaching that is receiving fully gain as practice skills as we learn to take care of patients. attention is the flipped classroom, in which students listen to But the science of patient care and education is not generally the lecture material and/or read the material before the sched- considered equally important to, for example, the science of uled classroom time. Time in the classroom is then spent with clinical pharmacology. We all accept that there is not one question/answer or a more interactive workshop approach. dosage of one drug that fits every patient, so we think of phar- This was reported in an article in Science to increase retention macology science in administering a drug, but do we think of in an introductory physics course.4 I tried this for a lecture education science in our conversations with patients? I give in the endocrinology block for second-year students. A new technique used in teaching patients is the “teach The week before the lecture I gave the students information back” at the end of the clinic visit. After the physician explains that I was going to use this approach and provided a video the recommendations to the patient, the patient is asked to lecture and written material before the classroom teaching. tell the physician what the patient was asked to do. I was The students seemed engaged during the class, but the evalu- impressed with the value of teach back in a recent experience ations were not good, with most students preferring a straight taking my ten-year-old grandson fly fishing with a guide in lecture. I now think such a novel approach can’t be introduced Utah. The young adult guide asked my grandson if he would as a single event. I ignored one of the Seven Research-based like to learn how to tie the hook on the end of the line. When Principles for Smart Teaching. I did something that was not my grandson eagerly answered in the affirmative, the guide consistent with the overall intellectual climate of the endocri- said, “Here’s what I’m going to do. I’ll describe every move of nology block. my fingers while you watch me tie the hook onto the line; then These examples indicate that science is being used to I will do it again with you telling me every move my fingers evaluate outcomes of some new pedagogic techniques. We should make while I tie the hook onto the line; finally you will propose that scientifically evaluating teaching of medicine repeat the directions to yourself as you tie the hook on the should continue and increase. In the September 2, 2013, issue line.” I thought, “Wow, this guy is a good teacher! No wonder of the New York Times, science writer Gina Kolata described he’s the person that was suggested by the marina when we re- work being done in the Institute of Education Sciences to quested a guide who was good with children.” I don’t have any support randomized controlled trials in education similar data that my grandson knows how to tie the hook on the end to randomized clinical trials for new drugs.5 A new cadre of a fishing line better than if he had been asked to try it after of scientifically trained medical education specialists might showing him once. I don’t have a controlled trial. I do know by regularly perform randomized trials to determine what works his response that he understood the directions and I believe he in medical education. learned it better because of the teach back. Interestingly, the It is readily understood and accepted in academic medi- guide learned this technique when he was in training for his cine that to gain expertise in a specialty requires an immer- Mormon mission. It is encouraging that in a scientifically con- sion educational experience devoted entirely to the science trolled study reported from UCSF titled, “Closing the Loop,” of the specialty. Yet, those few medical faculty members who

The Pharos/Winter 2014 5 Teaching and learning in medicine

choose to become experts in the science of education often schools with a cadre of these specialists, that would increase have to fit this additional training into their multiple com- the quality of teaching and learning in our medical schools. mitments for clinical care and research. Fortunately, there is This increase in quality of education would help make all some evidence that this is changing. In the September 2013 medical school graduates and ACGME trainees better teach- issue of Academic Medicine the AM Last Page describes the ers of patients as well as students. Training medical disciplin- increase in master’s degree programs in health professions ary specialists to also become education specialists requires a education, noting that fifteen years ago there were fewer than significant commitment of time: the school must first have a ten programs and today there are 121.6 In a 2006 article in division or center with faculty who are specialists in the sci- Academic Medicine, Larry Gruppen and coworkers reviewed ence of education, then the medical trainees must commit the nine fellowship programs in medical education and described time for specialty training in education. Academic medical some of the common elements among the programs.7 They centers will have to support the education expert faculty in noted that the Accreditation Council for Graduate Medical the division or center and additionally support the physi- Education (ACGME) was then changing the requirement that cians who want to obtain degrees or fellowship training in something be taught, to requiring that a specific competency the science of medical education. Here at UCLA during my actually be accomplished. They further noted that the skill set sixteen years as Executive Associate Dean in the School of required to develop tools to reliably measure competencies Medicine we hired six PhD professors with expertise in the is one firmly based on the science of education. The master’s science of education (a couple of whom have gone on to other degree programs in health professions education are described schools). Dr. Wilkerson has trained more than 140 faculty in the AM Last Page as being “very prescriptive with many members who were supported by their departments to take required courses and very few electives,” while the fellowship her fellowship in medical education (many of whom have programs described by Gruppen and coauthors usually involve taken leadership positions in medical student and/or resi- a scholarly research component leading to publications or dent education). Five members of the Center for Educational presentations. Development and Research or the division of Student Affairs How do we better train clinicians as teachers and develop have obtained a doctorate in education. UCLA now has a medical faculty devoted to the science of education? If we cadre of faculty who are consciously competent in the science produced more education specialists and populated medical of medical education. They have, as described in How People

6 The Pharos/Winter 2014 Learn, “pedagogical content knowledge.” This was not cheap. physician communication with diabetic patients who have low It required intellectual and financial commitment from the health literacy. Arch Int Med 2003; 163: 83–90. departments and from the Dean’s office, but considered as a 4. Deslauriers L, Schelew E, Wieman C. Improved learning in a return on investment the expense is often less than supporting large-enrollment physics class. Science 2011; 332: 862–64. new research or recruiting new faculty, while the payback to 5. Kolata G. Guesses and hype give way to data in study of the medical school in the education of its students is real and education. New York Times 2013 Sep 2. http://www.nytimes. lasting, equivalent to or exceeding other investments. com/2013/09/03/science/applying-new-rigor-in-studying-educa- P.S. The journal club at UCLA is ongoing and strong and tion.html. has outgrown Dr. Robinson’s apartment as a meeting space. 6. Tekian A, Artino AR Jr. AM Last Page: master’s degree in Anyone interested in Dr. Robinson’s ten rules for a successful health professions education programs. Acad Med 2013; 88: 1399. journal club can request them by e-mailing Dr. Robinson. 7. Gruppen LD, Simpson D, Searle NS, et al. Educational fellowship programs: common themes and overarching issues. Acad Med References: 2006; 81: 990–94. 1. Committee on Developments in the Science of Learning, Bransford JD, Brown AL, Cocking RR, editors. How People Learn: Dr. Robinson’s address is: Brain, Mind, Experience, and School. Washington, DC: National David Geffen School of Medicine at UCLA Academy Press; 1999. 10833 Le Conte Avenue, 12-238 CHS 2. Ambrose SA, Bridges MW, DiPietro M, et al. How Learning Los Angeles, California 90095-1722 Works: Seven Research-Based Principles for Smart Teaching. San E-mail: [email protected] Francisco: Jossey-Bass; 2010. E-mail Dr. Byyny at: [email protected]. 3. Schillinger D, Piette J, Grumbach K, et al. Closing the loop:

The Pharos/Winter 2014 7 Fall from grace J. Joseph Marr, MD

The author (AΩA, Johns Hopkins as there a certain time when Whenever it occurred, the transforma- University, 1964) is a retired academic it happened? If so, probably tion of the physician during the sec- physician and business executive. He is the inflection point occurred ond half of the twentieth century from a member of the editorial board of The inW the nineties when business took over shaman to skilled labor was inexorable Pharos. formally. That was a watershed series and, in my opinion, will prove to be of events, surely, but the full process irreversible. Illustrations by Jim M’Guinness. seems to have been more like death from All of us who were active in medicine a thousand cuts, some self-inflicted. and medical science during these years

8 The Pharos/Winter 2014 played a role in its transformation. We Two things happened in 1961, when I their time to patient care and paid little were troubled—and then horrified— was a sophomore in medical school, that attention to the institutions in which observers, yet often more than a little were to some degree prophetic. I recog- the care was delivered unless there were complicit. Hubris had much to do with nized both of them as being significant, obvious issues of neglect or mismanage- it, and all of us were culpable to varying but did not see that they were harbingers ment. They also paid little attention to degrees. Is medicine today better, worse, of the future. An article in the Journal patients themselves beyond the office or just different? Does it matter? Perhaps of the American Medical Association or hospital visits. The problem of health not so much to people born in the late chronicled a study of the interpretation care delivery to the medically indigent twentieth century, but it matters much of chest x-rays read both by radiologists was left to municipal hospitals, chari- to those of us who practiced medicine and by a computer. The two methods table clinics, and the free care provided and loved it during the last half of the were about equally accurate. The con- by many medical practitioners. The fact last century. clusion was that computers were no that these municipal hospitals served To answer this question with any better than radiologists. My conclusion sometimes as superb training facili- hope of perspective, it may be valuable was that the radiologists were doing the ties abetted the situation. Management to consider the issue as having two com- best they could and the computer was and planning of indigent care largely ponents: the evolution of medicine itself learning and would do better as time was left to those who tried to respond and the effects of that evolution on the went on. The other event was a conver- to medical-social issues from a back- physician practitioner. The changes in sation with some physicians about the ground of social work, law, or politics. the institutions through which medicine management of hospitals. I wondered These are general statements—there is practiced, important as they are to if physicians should not be managing were physicians and physician groups our current situation, will be treated hospitals themselves since they knew that recognized the problem of delivery as a concomitant and parallel sideline. more about patient care. The response of care—but the emphasis remained on Permit me to be an observer and guide was that physicians could hire people fee-for-service with some charity care here and use some of my own history to do this; the medical staff actually ran done. to illustrate. I do not think of myself as the hospitals anyway. Yes, I thought, but The “threat” of Medicare and Virgil, but rather as a fellow traveler. The actually we work for the administrative Medicaid in the 1960s caused much of comments and illustrative experiences organization. For years afterwards, phy- organized medicine to react strongly I use are, within broad limits, common sicians who recognized this disconnect against governmental intrusion into to us all. and went into administrative medicine medical practice. In particular, the were considered, quite unfairly, as sim- American Medical Association (pre- A brief case history ply unfit for practice and their real im- sumed to be the spokesperson for phy- Those of us born in the late 1930s or portance not credited. Where did that sicians generally) lobbied against any very early 1940s entered medical school lead? Look around. changes in the fee-for-service practitio- in the later 1950s or early 1960s. It was ner model of medical care. The specter a time that I have heard described as “a Hubris of socialized medicine was raised when- Golden Age of Medicine.” A golden age, There was considerable hubris ever any governmental changes were of course, is relative to the observer. We among physicians in this time. We had proposed, but no alternative solution to were at the top of a revered profession social status, financial rewards, and the the problem of the uninsured and under- dedicated to the care of others and al- gratification of playing an important served was put forward. When Lyndon most solely responsible for the manage- role in our society. Did this play a role Johnson brought Medicare and Medicaid ment and delivery of that care; on the in the changes in medicine? I believe into law in 1965, two things happened other hand, that care was very unevenly so. A “cottage industry,” as medicine of among physicians: first, outrage—there distributed and closely related to abil- the time rightly has been called, had was much talk of “socialized medicine” ity to pay. The physician was priest and no incentive to look at the larger social and the downfall of the private practice seer; his opinions were respected, given picture, nor the mechanism to introduce model. Practice nevertheless went on great credence, and sought in areas out- change had it wished to do so. The revo- as usual, although with the realization side of medicine. He was a scholar in lution of biotechnology and biomedical that a major event had occurred, the the broad, liberal-arts sense of the term. engineering as applied to the physician consequences of which were yet to de- He was the alchemist who understood practitioner could be compared to the velop. Second, the slow realization that science, and he knew the workings of industrial revolution and the cottage in- the medical care physicians had been the human body and psyche as well. He dustries that it eliminated. No one saw it providing gratis now would be reim- was a shaman at the end of the age of coming: a computer reading a chest film bursed by the government. Predictably, shamans. It was like that. caused no alarm. Physicians devoted opposition softened. We gradually came

The Pharos/Winter 2014 9 Fall from grace

to tolerate, and then love, the beast. The in the civilian world (start IV fluid or not. I began my slow, yet steady, appre- words from Alexander Pope’s Essay on blood infusions; some surgery to prevent ciation of changing medical economics Man, intended for other situations, were or mitigate larger surgery later), they and the disparity of medical care in our never truer: also made the decisions to do so. Slowly society. it became clear that nonphysicians who Later, in the early 1980s, I was Chief Vice is a monster of so frightful mien, had some training could make these de- of Medicine at the same metropolitan As, to be hated, needs but to be seen; cisions. This had started with the corps- hospital and needed to conserve the Yet seen too oft, familiar with her face, men in World War II, and expanded time and energies of my medical resi- We first endure, then pity, then rapidly in the Korean War, but it came dents. They could not manage seriously embrace.1 into full flower in Viet Nam. And un- ill inpatients and a large outpatient clinic like the situations after the former wars, population without loss of quality of Expansion of the medical care these people came back home to a social care and exhausting themselves in the system milieu needing ways to lower costs while process. Those of us new to medicine in 1965 providing more care to the underserved The solution was to staff the diabetic paid scant attention to these changes or ignored. They began to fit into medi- and hypertension clinics with nurse in the payment system, as there were cine and alter its practice. The expansion practitioners and a single supervising internships and residencies to deal with. of the medical care delivery system and medical resident. This freed about five The familiar operational chain remained the dilution of the physician’s role had house staff from each clinic to man- solidly in place: physician, nurse, and begun in earnest. A very few years later, age in-patients. The nurse practitioners patient. Physician extenders had yet to the paramedic appeared, as early studies were knowledgeable, anxious to prove make a significant appearance. There of firefighters in several metropolitan themselves, and very popular with the were technical personnel in hospitals areas showed that such a rapid response patients, since they spent more time and clinics to be sure, but they provided system could save lives. The delegation with them than the house staff was able ancillary services in laboratories and of immediate care outside of hospitals to do. It was surprisingly popular for all radiology and not direct patient care. and physicians’ offices had begun. concerned, and bitterly opposed by the Surgical technicians were new, and, by My time in the military gave me a medical staff. and large, registered nurses filled these grudging and then wholehearted ap- There was an additional, time- positions. preciation of the skills and enthusiasm consuming issue: a medical resident was Then there was Viet Nam. For those of corpsmen. Diagnosticians they were expected to read all the EKGs for the of us who became part of the military, a not, but they were doers and rather hospital. This was not a teaching exer- world opened with a life-changing array good at it. This was not new, but it cise, it was a billing exercise for the hos- of new experiences and considerations. was to me and started a line of thought pital. The solution came in the form of a Among these were physician extend- about medical care extension and a re- new EKG machine that read the results ers of many sorts (I use this term a bit examination of my reference frame that itself. It eliminated all normal readings; loosely to make the point of the various would become useful several years later. the abnormal tracings still were avail- forces that would come to bear on the Later, as a medical resident, I wrote a able for teaching purposes. This was the delivery of medical care after that war): prescription for a new antihypertensive information technology equivalent of medical corpsmen who, though nar- medication for a lady in the clinic at a the computer-read chest films of fifteen rowly trained, were many times quite city hospital. Because of military service years earlier. The time saved for the good at what they did and often took and graduate school interludes, it had house staff was considerable. This time, serious risks to do their jobs; techni- been a few years since I had been an in- the obvious was clear to me. cians who performed a variety of tasks tern, and new medications had appeared These small but important changes, that simplified the work of physicians that I wanted to try. She thanked me and instituted to provide good medical care (some of these positions existed in civil- went away. About an hour later, she re- in an overused and understaffed envi- ian medicine, but not to the degree that appeared and dropped the prescription ronment, were harbingers of changes in they were employed in the military); he- on my desk with the comment “I can’t medical care to come. licopter medevac pilots greatly improved afford this.” This, of course, destroyed survival of the wounded and would ap- my plan of treatment and waved a large Changes in diagnostic methods ply their skills to air ambulances back flag in my face. We reworked the plan At about the same time, the auto home. using some older and quite generic med- analyzer appeared in clinical laborato- One thing about these workers was ications that cost very little. I managed ries and began to turn out reports with overlooked: not only did they do proce- her for a long time using those generics; twelve and then twenty-five biochemical dures generally reserved for physicians drugs had changed but physiology had tests on small amounts of blood. It was

10 The Pharos/Winter 2014 a wonderful advance and was the lead- medical diagnosis by making it more in cost, the strength of the physician- ing edge of the entry of technology into accurate and efficient. At the same time, patient relationship, and the effect on medical care. Many advances followed it has raised the cost of care, probably our national economy. The physician’s and were woven into the standard of has decreased clinical acumen, and has arcane diagnostic knowledge gave way to care. The unanticipated concomitant made medical care a bit more like that in technology based on science. We slowly was significant overuse and overreliance Star Trek—impersonal, yet efficient and became recipients of technical informa- on these in lieu of clinical judgment. effective—and less like that provided tion and were on the road to becoming They also were used increasingly as de- by the beloved family doctor. Patients skilled labor. fensive medicine and raised the cost of received more time, sympathy, and care not insignificantly. The device ar- personal care from the latter but who The entry of business into medical mamentarium, now much broader, more would go there again? These improve- practice accurate, and more rapid, has improved ments carried a price and that price was As the cost of care became an

The Pharos/Winter 2014 11 Fall from grace

increasingly visible issue, there was agi- A little more case history are termed good business practices. tation to “do something about it.” The It was 1986 when DRGs appeared at Although a “cottage industry” could not practice model was essentially the same our hospital and the sky began to darken. change the system, a business organi- as it had been for hundreds of years, Raising fees for extra work was no longer zation with its hierarchical structure even though group practices had begun permitted. In response, it was decided certainly could, and did. This led to our to deliver care with more efficiency. that if a patient was in an academic current situation, in which physicians Within medicine, there was unrest be- medical center, then, by definition, he who once tried to remain independent cause the ability to pass a device of some or she had a complex problem and we are rushing into the waiting arms of vari- type into the body garnered significantly were to bill accordingly. Hospital rounds ous health care provider organizations. more income. This led not only to spe- were no longer just about patient care Each stage of the weakening of the cialization but also to increasing num- but also about spending time to be sure physician-patient relationship came bers of physicians migrating to more the chart reflected the weighty thinking about gradually, as physicians were re- lucrative specialties and the proliferation that justified the top level of billing for quired to increase patient visits per unit of sub-specialties. This became a par- the visit. I did this for a while and then time, accept lower reimbursement for ticular issue within academic medicine, realized that the flow of teaching rounds these visits, vie with insurance claims where some divisions tended to operate had been completely subverted by the adjustors for compensation or the right at a loss while others had comfortable documentation process. The chart had to carry out diagnostic testing, immerse profits and often did not care to share been well documented before, but now themselves in relative value arcana to them. The pressures to increase clinical the quantity of words became as im- maximize the earned reimbursement, revenue burgeoned for those specialties portant as their quality. Consequently, and, in general, devote more and more that did not have a financial gimmick I made two sets of rounds. The first time and psychic energy to defending (forgive the word, but is appropriate in was teaching and therapeutic rounds the citadel of traditional medical prac- this context). with students and house officers and tice against an onslaught of accountants, Into this, in the early- to mid-1980s, fellows; then, a second set alone to do middle managers, directors, and execu- came two major events that would the additional notes and form checking tives. Individual practitioners or small change medicine forever: first, payment that justified the billing. This, of course group practices now are less and less according to Diagnostic Related Groups took more time—it probably cost me an able to withstand the pressure to sell (DRGs), the lynchpin of various payment additional hour or more each day when their practices to local or regional health changes to come from both the govern- on service—but it led to better teaching. care for-profit organizations. The entre- ment and the insurance industry. The As a physician in academic medicine, preneur increasingly becomes the em- major tool for the savings that would the pressures of time were not those of ployee. We have come to this: the selling come from this was to be the more ef- physicians in private practice, but they of our patrimony to philistines because ficient management of physicians and still led to longer days and a definite there is no other choice. The world does their methods of practice.2 The second feeling of being disingenuous regard- end with a whimper. change was the business management ing the billing situation. I felt I could people who appeared with the promise not justify billing at the highest level all The remains of the day of instituting efficient “business prac- the time and backed down the charges If one looks at the cost in the United tices” that would lower the cost of care. as patients recovered—I heard about it States to deliver health care relative to The increasingly incestuous relation- more than once from those concerned the rest of the world’s countries, we are ship between the insurance industry with revenue flow. in trouble. We know that. If one com- and business conglomerates that man- There came an afternoon in the clinic pares this cost with life expectancy, the aged ever larger and increasingly vora- when I was talking with an older clini- picture is even worse. We know that as cious “health care delivery” systems was cian. He looked upset and finally looked well. The United States spends about the vehicle that ejected medicine from at me and said: “Dammit, Joe, I am not 4500 per capita for a life expectancy its delusional world where the doctor- a Health Care Provider, I am a Doctor.” of about seventy-seven years; Cuba, to patient relationship still was paramount We talked about that and the directions pick only one of many countries, spends and hurled it into the arena where quar- of things for a while and then we both about eleven percent of that for the same terly earnings increases were the only returned to providing health care. life expectancy.3 Our delivery structure thing that seemed to matter. These al- is inordinately large, cumbersome, laden tered forever the nature of medical care Barbarians at the gates and with a variety of profit centers, and bur- and made it health care delivery. The everywhere else dened with regulations for both provider physician now was definitely a mere It was during the 1990s that medicine and patient alike. employee of a system. fell increasingly under the sway of what The shift, in our lifetimes, from

12 The Pharos/Winter 2014 individual and small group practice to will provide more health care, the care physician is only one of these. The phy- institutional medicine was not necessar- will be more affordable to people indi- sician will become—has become—de- ily bad. There are many instances of im- vidually, there will be more preventive creasingly the guide and guardian of proved efficiency and better patient care. medicine, and, probably more emphasis the system and more of a supervisor Kaiser Permanente, one of many not- on behavioral change to bring about in the mosaic of provision of care. I for-profit health care delivery groups, healthier living. While it will not be the feel that we have lost something very has done well in caring for patients at type of care that many of us recall, ulti- important; physicians younger than I a reasonable cost. Size is not necessar- mately it will be a system that provides are not so sure. Perhaps we are looked ily a negative factor. Coupling medical care to people who now cannot afford it. upon in the same way we looked upon care to the profit motives of health care Spend some time talking with the family doctor of another era. He companies and insurance organizations, younger people who know little or noth- was beloved, honored, respected, and he however, has altered the focus of medi- ing about medicine of thirty or forty gave of his time and energy unsparingly. cal practice from patient care to patient years ago. They are quite willing to ac- But he did not cure as many people as care at the lowest possible cost to the cept governmental intrusion if it allows we did. Those who have come after us caregiver organizations and payers. The them to save for their children’s educa- are just as intelligent and competent but intrusion of these companies into the tion. They understand that visits for care have more knowledge and tools and are practice of medicine to bring costs to an are brief and the physician is harried, but curing more people than we did. Good optimum level certainly is appropriate; it is the system they know. The other medicine persists. It is our model that is demanding some discipline from physi- thing they know is that they can afford gone; another has taken its place. cians to be as efficient as possible and to it. The public is indifferent to how the The physician remains; he or she conserve resources also is a reasonable physician feels; it just wants a system practices differently. We still play an request. Interfering with good medical that provides affordable care. important and essential role but it will care simply to cut costs is not. be increasingly supervisory. Can you I remain convinced that until the Coda imagine a physician supervising a cadre profit motive is purged from medicine— Let us set aside the monster of the of physician assistants or nurse practi- read quarterly earnings increases and delivery and payment systems and look tioners in lieu of individual family physi- insurance profits—all talk and action at the resultant of these fifty years with cians? How about a surgeon managing to improve our health care system will respect to medicine itself and physicians. several operations performed by skilled be of little or no benefit. One need only Having reviewed some specific examples technicians or robots? I can imagine look at health care systems around the expanded into the general, we can see all of these. In our own minds, we have world, each with its own inefficien- the changes that have occurred. The been marginalized; in the minds of pa- cies and abuses, and note that the gen- result is a complex body of knowledge tients, we still are here. We remain very eral opinion of consumers is that their that has given patients access to an ever- much in the game. Our problem is with country’s system is good and benefits better level of scientific medicine: earlier the intangibles; we lost the spotlight. all. All of these health care systems are diagnosis and treatment, fewer and less essentially not-for-profit models oper- invasive procedures, telemedicine, the References ated by governments with physicians as tailoring of therapy to genome structure, 1. Pope A. The Poetical Works of Alex- employees.4 use of genomics to manage probabilities ander Pope. New York: Thomas Y. Crowell; But look at the system from another of diseases, better prenatal diagnosis 1896. perspective. Set aside for the moment and therapy, new applications of ro- 2. Eastaugh SR. Managing risk in a the ineptness of the creation of the botic surgery. Regenerative medicine risky world. J Health Care Finance 1999; Affordable Care Act (ACA), its fault- will provide new tissues and, ultimately, 25: 10–16. ridden introduction, and the new bur- new organs. Medicine is unquestionably 3. University of California, Santa Cruz. den on our economy. These are not far better than when we began. We do Health: Global Inequalities in Health. http:// small issues, but they are temporary and, things now as a matter of course that ucatlas.ucsc.edu/health.php. with some difficulty, will be overcome were undreamed of then. Patients are 4. Reid TR. The Healing of America: in the short term. The Supreme Court much better off now. What else would A Global Quest for Better, Cheaper, and decision to uphold the ACA, the failure one expect after half a century? Fairer Health Care. New York: Penguin of the government shutdown in October On the other hand, the straight line Press; 2010. 2013 to alter or rescind the ACA, and of physician-nurse-patient is gone and the general acceptance of the ACA by will not recur. An increasingly complex The author’s e-mail address is: marrj@ much of the public, all ensure that it is therapeutic system requires an increas- mho.com here to stay in one form or another. It ingly complex variety of providers. The

The Pharos/Winter 2014 13 Benjamin Rush. Courtesy of the National Library of Medicine. Plagiarism of ideas Benjamin Rush and Charles Caldwell— a student-mentor dispute

Charles T. Ambrose, MD

Charles Caldwell. Courtesy of the National Library of Medicine. Plagiarism of ideas

The author was elected to AΩA as a faculty member at the University of Kentucky in 1980. He is a professor in the Department of Microbiology and Immunology at the University of Kentucky in Lexington. Besides teaching pathogenic microbiology, he is a longtime instructor in the history of medicine and the history of microbiology.

lagiarism has likely been a vexing concern in all literate cultures. Even before writing first appeared, bards of old probably complained of rival fabulists having filched Ptheir best tales. Today plagiarism is of two types—stealing written words or pirating a novel idea/concept. Text plagiarism involves assuming authorship of a passage written by someone else; we are not concerned with it here. Concept plagiarism concerns claiming the origin of an idea/concept conceived and generally published earlier by someone else. While similar or even identical ideas may occur independently to several inves- tigators,1 appropriating another’s novel concept without due attribution is a serious offense in the sciences, since this may later raise the thorny issue of priority of discovery. Much of research today is highly competitive; the primacy of discovery often determines not only favorable recognition but also income, advancement, and tenure in academia and industry. Research universities occasionally have had to confront troubling instances of concept plagiarism involving students and mentors. A notable example occurred at Rutgers University in 1943. Professor Selman A. Waksman claimed priority for the discovery of streptomycin, which had been originally isolated and studied independently by his graduate student, Albert Schatz. Even though Schatz was senior author on the first two papers describing the new antibiotic, Waksman deprecated Schatz’s contribution to its discovery and development into a potent drug, and became the sole recipient of the Nobel Prize in 1952. Schatz had received a legal settlement from Waksman and Rutgers in 1950.2 A much earlier and little known case of purported plagiarism involved Dr. Benjamin Rush, the foremost physician of colonial America, and a young student, Charles Caldwell. During the defense of his medical dissertation in 1796, Caldwell clashed with Rush over who stole certain of its ideas from whom. While Rush is quite well known, Caldwell is far less so, although during the early nineteenth century he became a significant medical educator in Kentucky.

Pennsylvania Hospital. Courtesy of the National Library of Medicine.

16 The Pharos/Winter 2014 Pennsylvania Hospital. Courtesy of the National Library of Medicine.

The Pharos/Winter 2014 17 Plagiarism of ideas

The University of Pennsylvania School of Medicine. Courtesy of the National Library of Medicine.

Benjamin Rush (1745?–1813) Indian physician who employed “stimulants—bark [quinine], Benjamin Rush is remembered today as a minor patriot wine, spirits” instead of Rush’s “heroic” approach.5pp75–6 during the American Revolution who later became the most During the second yellow fever epidemic of 1797, Rush’s influential physician of his time. He represented the interests medical reputation came under fire from a radical journalist of Pennsylvania in the Continental Congress between 1774 and and English political refugee, William Cobbett. In spite of his 1789, and was one of five physicians to sign the Declaration of “disdain for the Colonials,” Cobbett had settled in Philadelphia Independence (just above Benjamin Franklin). Rush influenced and soon came to hate Rush “because of his republicanism.” 6p97 Thomas Paine’s political ideas and even provided the title for He published scathing articles in his royalist newspaper, his famous work, Common Sense (1776). During the war, from Porcupine’s Gazette, under the pen name Peter Porcupine. 1777 through 1778, he served as a military physician inspecting When others merely questioned Rush’s copious bloodlet- army hospitals. ting and vigorous purging, Cobbett published invective-filled Rush’s medical fame arose mainly during the last two de- articles disparaging this treatment and denouncing Rush for cades of his life, beginning with Philadelphia’s 1793 yellow fever promoting it in his frequent letters to newspapers. Cobbett’s epidemic, which killed ten percent of the city’s forty to fifty ridicule was successful in reducing the number of new patients thousand residents. Only during the course of this outbreak seeking Rush’s medical care and prompted him to consider did he come to believe that yellow fever was not contagious. He moving his practice to New York City. But his overtures later wrote, “For the change of my opinion upon this subject, I for an appointment to the medical faculty of King’s College am indebted to Dr. Caldwell’s and Mr. [Noah] Webster’s publi- (now Columbia University) were rebuffed by the influence of cations upon pestilential diseases.” 3pp280–81 Alexander Hamilton (a Federalist), who considered Rush (a During the epidemic, Rush was noted for his harsh treat- Democrat like Jefferson) too radical. With his medical income ment of patients, bleeding them copiously and purging them greatly reduced, Rush prevailed on President John Adams to frequently with large doses of calomel (HgCl) and jalap (a appoint him treasurer of the mint. In 1800 Rush sued Cobbett strong cathartic made from the root of a Mexican plant). for slander and won a settlement of 5000 at the libel trial in a Though he sought to convert other physicians to his approach, New York court. Rush also regained his remunerative medical many strenuously rejected it. Thomas Jefferson wrote to a practice in Philadelphia.7 friend that Rush “in his theory of bleeding and mercury . . . During Rush’s lifetime, medical practice was roiled by dif- has done much harm, in the sincerest persuasion that he was fering belief systems about the causes of diseases. Spirited preserving life and happiness to all around him.” 4p200 Alexander debates over medical theory threatened the fraternity of physi- Hamilton and his wife became ill in New York with yellow fe- cians, while confused patients questioned the various treat- ver in 1793, but both survived under the gentle care of a West ments offered by rival doctors. Infectious diseases were given

18 The Pharos/Winter 2014 Linnaean-type names based on particular signs or symptoms, action and country air.” 9p205 He achieved it through a short- resulting in medical dictionaries with a bewildering nosology. term enlistment as surgeon in a federal military expedition sent The humoral notions of Hippocrates and Galen were rejected to stamp out the Whiskey Rebellion in western Pennsylvania. by some British doctors who instead speculated that diseases The Whiskey Rebellion arose in response for a 1791 tax were due to the tonicity of various parts of the body. The Congress had levied on distilleries to help pay state war claims. Scottish physicians William Cullen and John Brown attributed Whiskey made from surplus corn was used instead of rarer illnesses to tensions in the brain and nerves (sthenic and as- metal or paper currency since kegs were more easily trans- thenic forces). In contrast, Parisian François Broussais taught ported than whole corn. To many settlers in the Appalachians that the basis of all pathology was gastroenteritis. and beyond this tax was considered unjust and reminiscent Meanwhile, in Philadelphia Benjamin Rush focused on the of the infamous British Stamp Act. For several years federal flushed skin of febrile patients with infections or those who de- agents had attempted to collect the new whiskey tax, but veloped them secondarily during their illnesses. He interpreted many were thwarted and even assaulted—several being tarred, this physical sign as due to “excess excitability in the blood feathered, and carried out of town on a rail. Some irate farm- vessels,” 6pp93–94 and developed a theory of the unity of diseases ers of the Monongahela Valley vowed never to pay the tax and based on the commonality of fever present in most patients. threatened to secede from the Union, hence the name of the According to Rush, mankind suffered from one significant dis- conflict. On August 7, 1794, President Washington called up ease, arterial wall hyperexcitability, which could be relieved by the four-state militia of 12,000 men, a force larger than any bleeding, purges, and salivation induced by calomel. one group he had commanded during the Revolutionary war. Rush’s aggressive approach with lancet and mercury re- He left Philadelphia (then the country’s temporary capital) on flected his rejection of a major Hippocratic belief—the healing October 1, and accompanied the army as far west as Bedford. power of nature (vis medicatrix naturae). He “had no confi- The insurrection collapsed upon the approach of such an over- dence in Mother Nature, and insisted that she be driven from whelming federal force.10 the sick room as one would a stray dog or cat.” 8p718 In his de- One morning in early October, just weeks before the peace, fense, however, he is credited with two valuable medical ideas: the newly commissioned Caldwell had set out on foot to the the notion of focal infections and the enlightened care of the first encampment of his brigade at Downington, thirty-two insane. Rush suggested, for example, that decayed teeth might miles west of Philadelphia. His personal baggage, camp equip- be the source of much general pathology. He wrote the first ment, and newly purchased medical and surgical supplies had American book on mental diseases—Medical Inquiries and preceded him by several hours in a light wagon he had hired. Observations upon the Disease of the Mind (1812)—and is now In an effort to catch up with it, he and a companion proceeded regarded as the father of American psychiatry. But many were at a strenuous walking pace, leaving both of them fatigued on skeptical of his medical system and writings. Elisha Bartlett arrival that night. When Caldwell awoke the next morning he declared that “There is more utter nonsense and unqualified felt slightly feverish and was lent a horse to continue westward. absurdity in Rush’s works than in the whole vast compass of Later during his ride “a copious shower of rain” drenched him medical literature.” 7p81 thoroughly and to his surprise “entirely extinguished” the slight fever he labored under.9p213 In a day or so he reached the next Charles Caldwell (1772–1853) encampment in Lancaster, where his brigade remained for a In 1792, at the age of twenty, Charles Caldwell traveled from week. During this pause he penned a letter to Rush, describ- North Carolina to Philadelphia to begin medical studies at the ing the “perfect hydropathic cure” of the fever he had just University of Pennsylvania. There he immediately came under experienced.9p213 Caldwell ignored the fact that his equally the influence of Dr. Benjamin Rush, Professor of the Institutes fatigued companion went by cart to Lancaster and was found of Medicine and Clinical Practice. When the horrendous yel- there with “his soreness and fever . . . considerably abated,” low fever epidemic engulfed Philadelphia in the fall of 1793, a presumably without the aid of any hydropathic therapy.9p213 pest house was established in an empty mansion on the out- He gave no further details of his military service, which ended skirts of the city. At Rush’s recommendation Caldwell lived and within a few weeks after it had begun and allowed his return worked as an unpaid medical attendant there. His close contact to Philadelphia. with patients during the plague led him to be among the first Once back at school, Caldwell learned that Rush had dis- to become convinced and to declare that yellow fever was not cussed in his course of lectures “the curability of fever by a spread from person to person—a view Rush later adopted. thorough wetting in rain, or by immersion in water.” 9pp214This At Rush’s suggestion, Caldwell spent much of 1794 translat- “cure” was also mentioned by Rush in the following year. His ing Johann Friedrich Blumenbach’s Institutiones physiologicae failure to acknowledge in either lecture that Caldwell had writ- (1786) into English. The “genuine, knotty, German Latin” 9p197 ten to him about his experience led to a breach in their early was difficult and so taxing that by the fall Caldwell was “men- friendship and the subsequent charge of plagiarism leveled by tally fatigued and . . . debilitated” and felt the need of “muscular the disillusioned student against his mentor.

The Pharos/Winter 2014 19 Plagiarism of ideas

Caldwell’s case Caldwell defends his thesis During the late winter of 1794/1795 Caldwell read a paper In his autobiography, published posthumously in 1855, before a Philadelphia medical group titled, “Use of Cold Water Caldwell wrote that he “had passed, not without some éclat, in the Treatment of Fever.” 9p232 Several members in the audi- [his] examination for the doctorate” 9p236 but had delayed for ence knew of Caldwell’s letter on the subject to Rush and an- a time defending his dissertation. Finally in 1796 he submit- ticipated beforehand that Caldwell would voice his well-known ted it for examination. He was fearful “that somewhat of an disappointment in not having been given due credit by the explosion between Dr. Rush and [himself] was likely to occur,” Professor of Theory and Practice of Medicine. Rush was not for his thesis “already printed, contained sundry opinions in attendance. But, reluctant to accuse his mentor publicly of earnestly supported, which [Rush] as earnestly opposed and plagiarism, Caldwell expressed the belief that Rush would be condemned.” 9p236 Like his medical talk a year before on cold able to establish that he had “observed, in his own practice, the water treatment of fever, the pending public defense attracted cure of fever by a fall of rain . . . [or] that he had found cures a large audience anticipating a lively interchange. of the kind recorded in some book . . . [and] had forgotten to The thesis was titled, “An Attempt to Establish the Original make the reference when he mentioned the fact.” 9p233* Such Sameness of Three Phenomena of Fever (principally confined an admission would relieve Rush of the stigma of “deriving to infants and children) . . . Hydrocephalus Internus, Cynanche knowledge from a pupil, and silently using it as his own.” 9p233 Trachealis, and Diarrhoea Infantum.” 9p239 Caldwell chose One of Rush’s students attending the lecture asked Caldwell these three diseases, “of which so little was known,” because whether he “thought himself justified in throwing . . . suspicion they allowed him to express his own views about their fevers on the conduct and character of the distinguished Professor.” and not fall “under the suspicion of being a borrower . . . Caldwell rose to his feet and stated that he always felt “justi- [of] a single fact or thought derived from the press.” 9p240 His fied in stating the truth,” and concluded by suggesting that two main examiners were Dr. Rush and Dr. Caspar Wistar, his interlocutor “deems it possible for Dr. Rush to be guilty of Professor of Anatomy. Caldwell had previously criticized Dr. plagiarism; I deem it impossible.” 9pp234–35 Caldwell implied that Wistar’s lecture on “the uses of the cellular membrane” 9p241 had Rush been present, he could have satisfactorily clarified in the development of general anasarca.9p241 But according to the matter. Caldwell’s recollections a half century later, the professor had He later learned that Rush had sensed the damning insinu- recognized the correctness of his student’s view and treated ation and felt “that suspicion was irrevocably fixed on his own him with “great courtesy and politeness” thereafter and, pre- conduct.” 9p235 And so in a subsequent lecture Rush explained sumably, also during the thesis examination.9p242 However, the that he had omitted any reference to Caldwell’s contribution oral examination by Dr. Rush became the “explosion” Caldwell because he had intended to acknowledge it “in a work he was had expected.9p236 then preparing for the press.” 9p235 (This work was never pub- Caldwell had initially inserted into his thesis “a brief ac- lished.) And so the issue Caldwell implied in his talk simmered count [of his army letter of 1794], respecting the cure of fever in the minds of some over the ensuing months. by a shower of rain, and the purpose to which Dr. Rush had All during this time Caldwell had taken copious notes on applied it.” 9p243 But after the initial printing and at the sugges- his professors’ lectures and published occasional newspaper tion of the Dean of the Faculty, Caldwell requested the printer reviews of them under the pen name of “a Medical Student.” to omit this insertion and deliver to Rush a revised, expunged Because some articles were critical of the medical ideas and version. Caldwell wrote that at the public defense Dr. Rush “re- practices then, they attracted attention and made the author ferred to [the army letter] with great virulence and blame.” 9p243 easily identified and locally famous.9pp120,190 In several articles Caldwell rose, addressed the presiding professor, and “said with Caldwell challenged one of Rush’s favorite notions—the unity great calmness, and in a suppressed tone, ‘I was summoned of disease. This added to the continued cool relationship be- here . . . to defend only what is contained in my thesis; not what tween them. I have stricken out of it.’ ” 9p243 The provost ruled that “Dr. Rush has no right to refer to [the expunged passage]. In doing so, he is out of order.” 9p243 Rush vehemently asserted that he had a right and called on Caldwell to defend his account. A heated exchange between the provost and the two disputants led Caldwell to take the * The practice of cooling the febrile body with cold water probably pamphlet “unceremoniously” out of Rush’s hand and to identify dates to Hippocrates’ time, but it gained prominence near the end of the passage at issue being present in it. But copies held by other the eighteenth century when James Currie of Liverpool prescribed this treatment for cases of typhus/typhoid fever. Currie believed that members of the examining board were devoid of the passage. the heat of a fever was due to a “ ‘morbid stricture’ of the capillaries Caldwell exclaimed “in a tone of cutting sarcasm: ‘This is a spu- of the skin and internal organs,” 11p489 an idea similar to Rush’s. In rious copy of my thesis, procured by what device I know not, modern times in Boston cold water-drenched sheets were among the 9p244 12 and brought here for what purpose I care not.’ ” After some measures used to treat patients with fevers above °F. further histrionics, Caldwell added, “The printer of my thesis

20 The Pharos/Winter 2014 informed you yesterday that the passage [in question] was Shortly before he died, Rush compiled a list of medical students erased by my order.” 9p245 Rush declared that the printer “did who had received individual training under him. It began with not tell me that the passage was stricken out; but only that it students who registered in 1812 and continued in reverse or- was to be stricken out. But finding it here . . . , I felt authorized der to those in 1770, the first year of Rush’s medical practice. to suppose the order to be withdrawn.” 9p245 Caldwell concluded Caldwell’s name is not included among the 135 students listed.14 the incendiary interchange by declaring, “Had you looked into the copy which, by my direction, [the printer] sent to you this Caldwell’s later life morning . . . you would have perceived that my order to him After the fracas at his thesis defense, Caldwell established a had been faithfully executed.” 9p245 private practice in Philadelphia, joined various societies there, Caldwell wrote that Dr. Rush, “almost hysterical with rage,” gave numerous invited public discourses, and charged students said to him, “Sir, do you know . . . who I am . . . when you for freelance lectures on various medical subjects such as phys- presume thus arrogantly to address me?” 9p244–45 The provost iology and medical jurisprudence. Caldwell regarded himself as requested calmness and decorum so that the “business of the the cynosure of the academic life in Philadelphia. All the while day should go on.” 9p246 Caldwell ultimately passed his disserta- he coveted Rush’s professorial chair and waited.9 tion defense, but Rush refused to sign his name to the diploma In 1815 the University of Pennsylvania established a Faculty alongside those of the other professors unless Caldwell would of Physical Sciences, where Caldwell gave three courses of lec- retract some “expressions, and apologize for having used tures in 1816 and 1819. According to his autobiography, he was them.” 9pp246 Only several years later did mutual friends of the appointed Professor of Geology and the Philosophy of Natural two arranged a polite truce at which time Rush finally signed History.9 But R. A. Glock, in his 1959 master’s thesis, deter- the diploma.* mined that Caldwell never received an official appointment.15 Rush died in 1813 but not before arranging that his chair in Rush’s afterthoughts the Faculty of Medicine be occupied by someone other than In May 1796 Rush forwarded to John Redman Coxe, Caldwell. Within two years the chair again fell vacant and the Professor of Chemistry at the University in Philadelphia, sev- person appointed was someone of whom Caldwell naturally eral student theses, including that of Caldwell. Rush wrote, held a low opinion. “Dr. Caldwell’s [thesis] you will perceive is stolen from my Recognizing that his academic prospects in Philadelphia publications and lectures. I convicted him of plagiarism at the were dim, Caldwell accepted an offer for a medical profes- public examination of his thesis.” 13p777 In Caldwell’s later rec- sorship at the fledgling Transylvania University in Lexington, ollection of his dissertation defense he focused exclusively on Kentucky. This university, the first west of the Alleghenies, had his rain cure for fever and mentioned nothing about the unity been founded by the General Assembly of Virginia in 1780. The of the three diseases discussed in his thesis. Rush, on the other trustees established a Medical Department in 1799, making it hand, did not allude to the rain cure of fever but only to what then the fifth medical school in the country. Caldwell had contested in Rush’s “publications and lectures”— In the fall of 1819 Caldwell moved to Lexington and found that is, the idea of the unity of disease. thirty-seven students and a “most miserable” 9p354 faculty wait- In December 1809 Rush wrote, “Dr. Caldwell’s opposi- ing for him at Transylvania University. He termed three of the tion and hostility to me have met with a severe check.” Rush professors “little else than medical ciphers” 9p354 and regarded reported that Caldwell had complained that “students would the surgeon Benjamin Winslow Dudley as “the only one that attend his lectures, were they not afraid of old Rush black- was qualified and resolutely determined to work.” 9p355 Yet dur- balling them when they were examined for degrees.” But ac- ing Caldwell’s first decade at Transylvania University, its medi- cording to Rush, the class expressed their indignation against cal department grew to rival that of Pennsylvania in the rising Caldwell and passed a vote in favor of Rush. Caldwell “was reputation of its faculty and its growing library of imported publicly hissed in Dr. Coxe’s lecturing room” and later “was European medical books and scientific instruments. refused admittance into the lecturing room by the janitor of Caldwell taught in Lexington for nearly two decades and in the University.” 13p1030 In February 1810 Rush remarked about his autobiography claimed (incorrectly) to have established the Caldwell, “His name is never mentioned by the students but Medical Department there.9 In point of fact, he was respon- with contempt and detestation.” 13p1036 sible for replacing its preceptorship-type training with formal And in April 1810 Rush wrote that “Dr. Caldwell finished his courses, regular lectures, and examinations. He gave lectures lectures with a most intemperate phillipic against my system on physiology, pathology, and hygiene, and occasionally thera- of medicine. . . . I have refused all intercourse with him.” 13p1040 peutics or medical jurisprudence. He opposed including chemistry in the medical curriculum and later became enamored of mesmerism, phrenology, and spiritualism.15 * The diploma is not in the archives of three universities where In the late 1830s inland Lexington was becoming eclipsed Caldwell taught—the University of Pennsylvania, Transylvania economically by the growing river cities of Louisville and University, or the University of Louisville. Cincinnati. Important political leaders and doctors in Louisville

The Pharos/Winter 2014 21 Plagiarism of ideas

Transylvania University, 1847, where Charles Caldwell taught from 1819 to 1837. Credit: www.granger.com.

funded a new medical school there, to which Caldwell and Plagiarism of ideas today several Transylvania professors moved in 1837. A chair at Their conflict shows both Rush and Caldwell in an unfavor- the Louisville Medical Institute was established specifically able light. Lost in their several petty disputes was the seminal for him. He continued publishing articles on phrenology and observation about the non-contagion of yellow fever—first medical jurisprudence but never contributed to the fertile made by Caldwell and quickly adopted by Rush. Instead, they field of gross pathology. According to Caldwell’s colleague, brooded on the presumed plagiarism of several ideas of little Louisville medical professor Lundsford P. Yandell, Sr., Caldwell relevance in medicine today. Since Rush never published any “slept through” the advances being made in physiology.9pxx As of the ideas presumably purloined from Caldwell, he could be he had in Philadelphia and Lexington, he so antagonized col- absolved of plagiarism in print—but not during his lectures. leagues in Louisville by his superior attitude that in 1849 he Instances of concept plagiarism in the scientific literature was asked to step down, ostensibly because of his approaching seem to have exploded in recent years, reflecting perhaps the the age of seventy. In retaliation, Caldwell sought to estab- exponential rise in publications and the burgeoning number lish a rival medical school in Nashville but was unsuccessful. of stressed scientists competing for limited research support. Instead, he spent his final years penning a caustic autobiog- The news pages of Nature and Science regularly report mis- raphy, reviewing “what [he had] done and suffered.” 9p301 In it appropriation of scientific ideas. In one example in 1999 at he omitted any mention of his two wives, the famous cholera Columbia University, a graduate student accused members of epidemic in Lexington of 1832, and many medically relevant her thesis committee of incorporating ideas from her disserta- events of the period in which he lived. Typical of his focus of tion without her consent when they applied for a departmental the autobiography was page 192, which contains the pronoun research grant.16 Another lawsuit at Columbia University in “I” twenty times. the same year involved competing claims by a student and his

22 The Pharos/Winter 2014 professor-mentor over which had devised a new mathemati- 2. Waller J. Rank Hath Its Privileges: Selman A. Waksman cal proof.16 As in the Rush/Caldwell case, what might seem of (1888–1973). In: Leaps in the Dark: The Making of Scientific Reputa- minor importance to an independent observer was regarded as tions. Oxford: Oxford University Press; 2004: 244–66. serious intellectual theft by the aggrieved students at Columbia. 3. Rush B. Medical Inquiries and Observations. Philadelphia: A similar threat to the integrity of scientific research are Hopkins and Earle et al.; 1809. reviewers who misuse information they read in manuscripts 4. Jefferson T. The Writings of Thomas Jefferson. Washington submitted to journals or in research grant proposals. An (DC): Thomas Jefferson Memorial Association; 1903. example widely discussed in 1989 concerned a reviewer who 5. Neilson W, Neilson F. The Verdict for the Doctor: The Case published as original some observations presumably from his of Benjamin Rush. New York: Hastings House; 1958. experiments that paralleled those he had read in a paper by an 6. Flexner JT. Doctors on Horseback: Pioneers of American investigator in the same field. The similar data were recognized Medicine. New York: Dover Publications; 1937. by the original investigator and led to an investigation by NIH, 7. Blain D. Benjamin Rush, M.D.—1970. Trans Stud Coll Physi- which later debarred the reviewer from applying for future cians Philadelphia 1970; 38: 61–98. federal grants.17 8. Shryock RH. The advent of modern medicine in Philadel- Stephen Jay Gould, the famous evolutionary biologist, phia, 1800–1850. J Biol Med; 1941; 13: 715–38. secure in his tenure at Harvard University, could write that 9. Caldwell C. Autobiography of Charles Caldwell, M.D. New “Debates about the priority of ideas are usually the most mis- York: Da Capo Press; 1968. directed in the history of science,” 18p35 but the noted American 10. Callahan N. Thanks, Mr. President: The Trail-Blazing Sec- sociologist of science Robert Merton emphasized “that compe- ond Term of George Washington. New York: Cornwall Books; 1991. tition and concern over priority and credit are not to be depre- 11. McTavish JR. Antipyretic treatment and typhoid fever: cated but are central to the scientific enterprise.” 19p76 Concern 1960–1900. J Hist Med Allied Sci 1987; 42: 486–506. over gaining the rewards of priority may lead to egregious 12. Weinstein L. The Practice of Infectious Disease. New York: actions. Jennifer Crocker, a social psychologist at Ohio State Landsberger Medical Books; 1958. University, in her paper, “The road to fraud starts with a single 13. Rush B. Letters of Benjamin Rush. Volume II: 1793–1813. But- step,” discusses the justifications offered by researchers who terfield LH, editor. Princeton (NJ): American Philosophical Society commit fraud, including the plagiarism of ideas.20 by Princeton University Press; 1951. It is indisputable that plagiarism can occur unconsciously, 14. Gibson J. Benjamin Rush’s apprenticed students. Trans Coll since ideas remain in the memory long after they are first Physicians (Philadelphia) 1946–47; 14: 127–32. encountered.21 Scientists, no less than poets and writers of 15. Glock RA. Charles Caldwell, M.D.: The Rejection of Chem- fiction, are sometimes beholden for inspiration to memories istry in America. Abstract. Master’s Thesis Mss. 540.973.G51. Phila- of conversations perhaps only vaguely recalled. This human delphia: University of Pennsylvania; 1959. propensity was inferred long ago when Johann Wolfgang von 16. Marshall E. Two former grad students sue over alleged mis- Goethe asked, “Who can say he has discovered this or that? It use of ideas. Science 1999: 284: 562–63. is frank foolishness to boast about priority and an unconscious 17. Culliton BJ. NIH sees plagiarism in vision paper. Science conceit not to admit oneself a plagiarist.” 22p239* Exploiting 1989; 245: 120–22. such an inspiration should not be decried—an idea residing 18. Gould SJ. Ontogeny and Phylogeny. Cambridge (MA): in memory might not have come there fully formed but may Belknap Press of Harvard University Press; 1977. profit from a new interpretation filtered through a new mind. 19. Davis BD. The scientists’ bookshelf: The Double Helix. Am Scientist 1982; 70: 76–77. Acknowledgment 20. Crocker J. The road to fraud starts with a single step. Nature I am grateful for the literary research assistance of Mrs. Amanda 2011; 479: 151. Williams, Librarian at the College of Medicine, University of 21. Jackson CI. Honor in Science. Research Triangle Park (SC): Kentucky, Lexington, Kentucky, and the continued support of the Sigma Xi, the Scientific Research Society; 2000. late Ch. Tray. 22. Goethe JW von. Maximen und Reflexionen. Weimar: Goethe-Gesellschaft; 1907. References 1. Merton RK. Singletons and multiples in scientific discovery: A chap- The author’s address is: ter in the sociology of science. Proc Am Philos Soc 1961; 105: 470–75. Department of Microbiology, Immunology, and Molecular Genetics College of Medicine * The translation in the text is by the author: “wer kann sagen, dass er University of Kentucky diess oder jenes erfunden habe? Wie es denn überhaupt, auf Priorität Lexington, Kentucky 40536 zu pochen, wahre Narrheit ist; denn es ist nur bewusstlower Dünkel, wenn man sich nicht redlich als Plagiarier bekennen will.” 22p239 E-mail: [email protected]

The Pharos/Winter 2014 23 a fashion no longer fit removed for the last time gently but finally obscene. Do I alone remember our song when you squeezed my thumb tightly as we climbed hopeful

I spring from the pages into your arms— into the high stands of the glaring decease calls me forth. afternoon —Walt Whitman, “So Long!” You sense that I have withered or died or met sweetly and often Sundays or ceased to be whatever it was on your breaking bed? since you have come to me in the night you wished me to be, heated and empty, or in the afternoon Thomas J. Balkany, MD, FACS, FAAP with need in your mouth for passion or eroded, irradiated Dr. Balkany (AΩA, University of Miami, 1972) comfort, cut sharply away with cold steel, is Hotchkiss Professor and Chair Emeritus of the reduced anyway until Department of Otolaryngology at the University a lifetime since you have wanted of Miami Miller School of Medicine. His address the small flakes of my life that I could pulling myself up with great effort is: Department of Otolaryngology, 358 N. Ocean Boulevard, Delray Beach, Florida 33483. E-mail: tbal- 24spare from my dream of you in the late night [email protected] Pharos/Winter 2014 few enough though willingly. or in the afternoon, of wearing on you Illustration by Laura Aitken Richard C. Reynolds, MD The author (AΩA, Johns Hopkins, 1953) is retired. He was during and shortly after her last five-day hospitalization. She founding chair of the Department of Community Health died on November 5, 2011. My wife’s name was Mary Jane, and Family Medicine at the University of Florida College of but everyone knew her as MJ. Medicine, dean of Robert Wood Johnson Medical School MJ and I first met in Baltimore when I was a fourth-year from 1978 through 1987, and the executive vice president medical student and she was a second-year student nurse. I of the Robert Wood Johnson Foundation. Dr. Reynolds also was doing an elective in obstetrics and MJ was earning extra served on the editorial board of The Pharos for many years. money working overtime. I was preparing to deliver a baby Photographs are courtesy of the author. when I noticed that the nurse assigned to assist me had a lock of the reddest hair I have ever seen peeking from be- am an eighty-three-year-old physician living in a retire- neath her hood. ment community. I had been married to the patient de- Our first date was to a nightclub, our only visit to such an Iscribed below for fifty-eight years. During the final two establishment. years I served as her full-time caregiver. I wrote what follows We tried dating others after that first date, but it was soon

The Pharos/Winter 2014 25 Last days

plain that we had become inseparable. Even though I had multiple surgeries on her hands and feet. There have been planned to leave Baltimore for residency training, I applied bouts of sepsis and pneumonias, exacerbated by the aggres- at the last minute to Johns Hopkins and was accepted as a sive therapies to relieve discomfort and deter progression of medical intern at Johns Hopkins Hospital. We married after her disease. Chronic anemia persists. Osteoarthritis, osteo- MJ’s graduation one year later, and stayed in Baltimore while porosis, and several decades of steroid therapy have contrib- she worked, supporting us during my payless residency. uted to spontaneous fractures in her pelvis and spine. She What was MJ like? Many things come to mind—loyalty, has lost six inches of stature. In spite of all this, MJ remained love, humor, exciting, challenging—but, above all, MJ always physically active until three years ago when her back pain remained her own person while giving me unlimited love became persistent and severely painful. Pain management and friendship. She could be feisty: In the 1970s while we specialists recommended low back surgery and para spinal were in Florida, there was a spate of divorces among medical injections. None of these treatments worked. She began us- school faculty. Arrangements were made to provide counsel ing long-acting narcotics supplemented by additional opiates to the faculty wives. At the meeting, the counselor asked MJ, for breakthrough pain, but the therapy was only modestly “What is it like to be married to someone smarter than you?” successful. During episodes of severe pain, I would rub her MJ’s response: “And what makes you think my husband is back to soothe and comfort. To our surprise, this did help smarter than I am?” ease the pain. Before this hospitalization, pain was becoming During her last few years I could see her failing; her death refractory to increased doses of narcotics, and sometimes was not a surprise. It provided the family relief that we could I would do back rubs twelve times a day to offer MJ some not deny to a long tenure of pain and discomfort. But her relief. death, its finality, has left me with a void that I doubt will The day before the hospital admission, we were up as ever ease completely. I am thankful for every day we were usual at 5 AM. I had made coffee and prepared breakfast. The together, a message I conveyed to her many times. morning newspaper was already at our doorstep and, as was our custom, we read it, kibitzing about items of interest. MJ November 2011 went back to bed. Later on, after lunch, we drove to a big I sit on a sofa, eight feet from my seventy-nine-year-old box store. I would usually push MJ in a wheelchair, though wife in the Medical Intensive Care Unit (MICU). MJ was at times she was able to get behind the wheelchair and walk admitted to the MICU four days earlier in acute pulmonary short distances. Her walking capability had declined the past insufficiency, following abrupt onset of aspiration pneu- six months. Even a few steps would often precipitate back monia. She has the accoutrements of many patients in the pain. We replaced our afternoon walks with drives through MICU—an oxygen mask covers her face, there are IVs in the rural countryside. These were pleasant interludes. MJ both arms, a urinary catheter is in place, as well as a loosely was beginning to spend more of her daytime hours in bed. fastened abdominal restraint applied during an earlier period When awake, she was annoyed by her increasing memory of restlessness. She is attached to a monitor that graphically problems. She could not remember what she had eaten at a portrays her vital signs and beeps annoyingly when it records previous meal, or recall a recent conversation. This evening, abnormal values. MJ was more tired than usual, ate little supper, and retired I walk to the bedside and brush the hair from her brow. It early. This change worried me as it mimicked episodes that is still naturally red and still beautiful, the hair that first at- were preambles to earlier hospitalizations. Her most recent tracted me to her some sixty years ago. With my mouth close stay had been two months ago. to her ear, I try talking to her. There will be no response, but I awoke about 4:00 AM, and reached over to touch her— I try anyway. Events from the past life cascade through my she felt warm. I roused her with difficulty; though awake, she memory. I walk about the room. I peer out the door, looking was obviously confused. She had trouble holding a thermom- at nothing. A nurse walks by and asks if I need anything. Am eter in her mouth, but it registered 101 degrees. Transferring I all right? How do you describe that you feel like someone her from the toilet to the wheelchair took twenty minutes has a hand in your gut, and is trying to pull something from with encouragement and assistance. I knew she needed hos- you? pitalization. I called our daughter Karen, who lives in the same rural community that we do. Karen works as a nurse Twenty-five years ago, MJ began to have severe joint in the hospital where her mother had been admitted several pains. Because we were living in New Jersey, Lyme disease times. I told her I had to take her mom to the hospital. Karen was first considered as the cause. A consulting rheumatolo- was already preparing to go to work and said she would meet gist subsequently diagnosed rheumatoid arthritis. A quarter us there. The trip from home to hospital required an ambu- of a century later, the disease remains active, causing my wife lance. Our small community has excellent service, and within to experience the full gamut of its manifestations and treat- minutes after calling 911 an ambulance arrived. ment complications. Progressive joint arthropathy required I drove to the hospital, arriving a few minutes before the

26 The Pharos/Winter 2014 ambulance. MJ was taken immediately into the ER. I could When I entered my wife’s room, there were two pairs of not join her until the ER personnel had placed her in a room clean, used trousers lying on a chair. Both were size 36. The and begun their assessment. My protestations to the staff reason for the earlier question was now clear—the nurse had that controlled visitors to the ER that my wife was obtunded provided two pairs of trousers of different lengths, hoping and would not be able to answer questions were deflected. one would be satisfactory. I have spent a lifetime in hospitals I was told that the professional staff was most capable, and as a clinician, teacher, administrator, and a visitor. Never be- I would be permitted to be with my wife as soon as they fore had I experienced such unique thoughtfulness. I did not thought it was reasonable. The wait was not long, but it was discover the nurse’s name to say thank you. frustrating. I knew the strange setting with unfamiliar people On the second day, the hospitalist who served as MJ’s pri- questioning and examining MJ would add to her confusion. mary physician during this admission wanted to discuss what When I was finally allowed to see her, she was in bed. An IV treatment strategy the family wished the professional staff to had been started and people were in and out of her room take. He said that the hospital record indicated we favored drawing blood, doing an EKG, and taking her for x-rays. aggressive therapy including a full code for resuscitation. They also asked questions and examined her, trying to as- I was surprised to hear this. MJ and I had prepared living sess her condition. Once the data were gathered, she was wills with explicit directions that neither of us favored heroic promptly seen by the ER physician, the hospital admitting measures that might prolong life but had little chance of im- physician, and pulmonary and infectious disease consults. I proving the quality of life. was able to help them review her complex and lengthy medi- Later in the day, the pain management physician and the cal history and recount her present illness. During the early pulmonologist (both of whom had treated MJ during her hours in the ER, MJ was awake, cooperative, and able to an- previous hospitalization) and I met at her bedside. She was swer some simple questions. Overall, her mental acuity was unresponsive but restless, and had obviously deteriorated sluggish and dull. The assessment was thorough and done since admission. Unspoken was the realization by all three of quickly and efficiently. us that recovery was unlikely. A treatment plan emerged that The plan was to admit her to the pulmonary unit but no we all supported; antibiotics for her pneumonia would be bed was available. Her condition worsened. She had become continued, she would receive IV fluids to maintain hydration more obtunded and, at times, was difficult to arouse. She and kidney output, she would be sedated enough to control required oxygen by face mask to maintain proper saturation. agitation, she would be given analgesia if deemed necessary She remained in the ER until early evening when a bed be- for back pain. The consensus was that this regimen would came available in the MICU. give her a chance to recover, though this was unlikely. The During her long stay in the ER, the staff was attentive, plan would be reassessed regularly. I thought this approach supportive, and comforting. Nurses were appropriately ag- would meet MJ’s approval, a conclusion based on many con- gressive in contacting doctors responsible for her care, espe- versations during the past several years. It also had the sup- cially to obtain orders for analgesics to ease her back pain. port of our three children. The first day, I stayed with MJ, taking only a brief lunch Over the next forty-eight hours, MJ’s restlessness eased, break. I was able to answer questions for the administrative she became afebrile, and the need for sedation and analge- and professional staff as they readied her for admission. But sia lessened. But she still remained insensate. I spent most time hangs heavy waiting in the ER for a room to become of each day in her room. I paced and stood at her bedside. available. I brushed her hair from her forehead. This last gesture that During a conversation with one of the physicians treating was focused on her red hair somehow comprehended our life my wife, I had the urge to urinate. There are no bathrooms in together. It never failed to bring me to tears. the patients’ rooms in the ER. Scattered along the corridors As a physician I knew my wife was dying. It would not are unisex bathrooms to accommodate visitors one at a time. be long. I had agreed to the care plan. But there were mo- I spotted two bathrooms, both occupied and each with a ments of doubt. Should I have opted for a more aggressive person waiting outside the closed door. I kept looking. Being approach? Had I been premature in backing away? I was older, and with all the symptoms of prostatism, my sense of certain, at least intellectually, that “we”—the family and the urgency was not to be denied. I finally found an unoccupied physicians—had chosen the right course. I was doing what bathroom, but it was too late. My khaki pants had a notice- MJ wanted, what she would tell us to do if she could. Even so, able wet stain down the inner side of my left trouser leg. All weeks later, I have my moments of doubt. I could do to minimize my embarrassment was to walk with My daughter Karen has worked for fifteen years as a nurse my head held high and hope that passersby would not notice. in this hospital. She had fallen in love with nursing and had As I passed a nurses station, a nurse leaning against its sur- gone to nursing school in midlife. Karen tried to ease her rounding counter fell in stride with me. She asked me what distress by working. It was not successful. Her colleagues size pants I wore. Surprised, I muttered, “36.” She left at once. encouraged her to return to her mother’s bedside, where she

The Pharos/Winter 2014 27 Last days

Richard and Mary Jane Reynolds in the late 60s.

was also support for me. We sat silently on the sofa. When major teaching hospital so that it could become part of an one of us said something, it was usually an anecdote, often academic health center. After five years, MJ decided she humorous, from times past. We smiled and wept at the same wanted to be closer to family. Our children Wayne, Karen, time. and Stephanie lived in California, Ohio, and England, re- MJ and I had moved to Ohio two years earlier. spectively. We decided to move to Ohio where Karen and Throughout my working life I had changed jobs several her son were. times, living ten or more years in Maryland, Florida, and During MJ’s third day in the MICU, a member of the hos- New Jersey. We had retired to Florida, but I continued to pital’s palliative care team met with me. Her task was to pre- teach and serve on committees at the medical school where pare me for conclusions to the admission other than death. I had been a faculty member twenty years before. Seven I was prepared for MJ to die, but suppose she didn’t? What years later we moved to south Florida, where I tried unsuc- were my thoughts and plans? Previous hospitalizations had cessfully to help a community hospital transform into a been serious enough to raise similar questions. During those

28 The Pharos/Winter 2014 episodes, I had been confident that she would recover. Each of the beginning and end of our journey together. I imagined time I brought her home and together we would try to cap- her saying: “Dick, it’s all right. I don’t hurt anymore. It was ture a semblance of a quality life. This time I did not feel that my time. I love you.” Our children and I hugged, wept. This way. Now my fear was that any improvement that postponed was goodbye. death might leave her bedridden, obtunded, or even coma- I want this essay to be a celebration of life, love, marriage, tose, which would require a level of care that no one person and MJ. It is our story. I grieve, I am sad, but I’m doing fine. could manage at home. I remember Lou Gehrig, famed Yankee player, who said as I remembered an earlier life-threatening illness at another he addressed the fans at Yankee Stadium shortly before his hospital that required a week in the MICU. Our daughter death: “I consider myself the luckiest man on the face of this Stephanie, an Anglican nun in a convent in Oxford, England, earth.” I think I can tell Lou Gehrig to move over. was visiting us at that time. “Dad”, she counseled me, “there comes a time when you must let Mom go.” Intellectually, Coda clinically as a physician, I understood. But “letting go” is an I have shared this story with family and colleagues. Many emotional challenge. This time I thought I was ready. have said they are deeply moved or touched by it. Some are The palliative care attendee had a nursing background. uneasy about its frankness and its rawness. Why are you She put together a list of nearby facilities to care for MJ if she writing this, they ask, and for whom? I am not sure I have should live but remain unresponsive. I was at the stage where an answer. Throughout my professional life I have recorded I wanted her to die and was afraid she would not. We had observations, ruminations, and wonderments about daily discussed this dilemma and had prepared living wills cau- events. I have filled notebooks with these musings. So the tioning against heroic, aggressive treatment in a dire terminal habit of writing about events may represent the hidden dia- state akin to MJ’s current condition. MJ had even threatened rist that is part of me. But it was different this time. me that if I disavowed her wishes she would return to haunt As a clinician I have helped—or tried to—many patients me. But all that preparation is not enough to erase all doubt and families through similar situations. During my first years or reassure that you are making the right decision. of practice in a small western Maryland city, I recognized The palliative care professional nudged me toward my that despite my excellent clinical training, I came up short wife’s bedside as she left. She said I should give MJ a hug and in providing them with comfort and wisdom. Later on as a kiss. She added that I probably would like to comfort her a department chair, I established a division of humanities. by crawling alongside and entwining our legs. These are not I never could set aside Thomas Mann’s phrase: “Medicine, her exact words but they relaxed my face into a faint smile. that subdivision of humanities.” I would have liked to discuss My God, I thought, is the love and lust of an eighty-two- with him his interpretation of this comment in The Magic year-old man for his wife in the throes of a terminal illness so Mountain. obvious? I was not naive when caring for my wife during the early MJ died on the fifth hospital day. She had remained un- and late stages of her illness. I had witnessed similar situa- conscious since the first day. tions in other patients and friends as they were dying. This The last days were a continuation of the preamble. MJ was different. I began to doubt my clinical judgment. I was never responded. She developed a cardiac arrhythmia with uncertain about previous decisions my wife and I had made tachycardia that was not treated. Respirations become more to cope with death’s intimacy. I could see how even mea- labored, and it was now definite that death was the only ger hope could push patients and families toward unwise conclusion. There were no abrupt changes. On the final day I therapies. went home to shower and change clothes—I needed a break I was not depressed or troubled with guilt. I did not real- in the vigil. As I entered our home, a forty-five-minute drive ize, however, the degree of sadness or emptiness I would from the hospital, the phone was ringing. It was Karen, who experience. Even now, I weep as I reread these lines. If there had remained with her mother, telling me MJ had just died. is any take-away message from my story, it is that no matter I returned at once to the hospital. Karen was still with how knowledgeable, how prepared an individual is for situ- her mother. The staff had closed the door to the room and ations like this, it is still likely that the doctors, the health pulled the curtains together that covered the window facing professionals in attendance will underestimate the hurt (I the inside corridor. Karen and I hugged and said little. We wish I could find a better word) that is occurring among the were alone in the room. After awhile, without words spoken, patients and their families. we left. After MJ’s death I went to the funeral home for the re- The author’s address is: quired identification prior to cremation. Karen and Wayne 5790 Denlinger Road, Apartment 4311 were with me. MJ was laid out in a room by herself. She Dayton, Ohio 45426 looked comfortable. Her hair, still naturally red, spoke to me E-mail: [email protected]

The Pharos/Winter 2014 29 “There’s no such thing as death, really,” she said. “Just a lack of life.” Her limbs hung loosely. Body defined by what wasn’t there. She dragged through the streets, Accompanied by two lonely letters: M. S. Which always seemed to buzz around her head. A halo of desperation. Leaving her few moments of peace. To reminisce on better days. Negatives Alexander Fortenko Mr. Fortenko is a member of the Class of 2015 at George Washington University School of Medicine and Health Sciences. This poem won Honorable Mention in the 2013 Pharos Poetry Competition. Mr. Fortenko’s e-mail address is: [email protected]

Illustration by Erica Aitken

30 The Pharos/Date The 2013 Robert J. Glaser Distinguished Teachers. From left to right: AAMC Immediate Past Chair Valerie N. Williams, PhD, MPA; Roy Ziegelstein, MD; Cynthia Lance-Jones, PhD; Stuart Slavin, MD, MEd; AΩA Executive Director Richard L. Byyny, MD, FACP; AAMC President and CEO Darrell G. Kirch, MD. Missing is Mikel H. Snow, PhD.

2013 Robert J. Glaser Distinguished Teacher Awards

ach year since 1988, Alpha Omega Alpha, in coopera- Winners of the award receive 10,000, their schools receive tion with the Association of American Medical Colleges, 2,500, and active AΩA chapters at those schools receive presentsE four AΩA Distinguished Teacher Awards to faculty 1,000. Schools nominating candidates for the award receive members in American medical schools. Two awards are for a plaque with the name of the nominee. accomplishments in teaching the basic sciences and two are Brief summaries of the accomplishments in medical educa- for inspired teaching in the clinical sciences. In 1997, AΩA tion of the 2013 award recipients follow. named the award to honor its retiring executive secretary Richard L. Byyny, MD Robert J. Glaser, MD. Nominations for the award are submit- Executive Director ted to the AAMC each spring by the deans of medical schools. Nominations were reviewed by a committee chosen by AΩA and the AAMC. This year’s committee members were Cynthia Lance-Jones, MA, PhD (Basic) prior award recipients J. John Cohen, MD, PhD; Ruth-Marie Assistant Dean for Medical Student Research, Associate Fincher, MD; William H. Frishman, MD; Bruce F. Giffin, PhD; Professor, Department of Neurobiology, University of Richard B. Gunderman, MD, PhD; Brian Hodges, MD, PhD; Pittsburgh School of Medicine John (Jack) Nolte, PhD; LuAnn Wilkerson, EdD; Amy Leigh Dr. Lance-Jones received her PhD at the University of Wilson-Delfosse, PhD. Massachusetts at Amherst in 1977, and completed a fellowship

The Pharos/Winter 2014 31 2013 Robert J. Glaser Distinguished Teacher Awards

in neuroscience at Yale University in 1980. She joined the Stuart Slavin, MD, MEd (Clinical) University of Pittsburgh School of Medicine in 1983 as an as- (AΩA, Saint Louis University, 1984) sistant professor in the Department of Neurology and is now Associate Dean for Curriculum and Professor, Department Assistant Dean for Medical Student Research. of Pediatrics, Saint Louis University School of Medicine Dr. Lance-Jones has received many of the University Dr. Slavin received his MD at Saint Louis University in 1983 of Pittsburgh’s awards for outstanding educator, including and completed his residency in Pediatrics at UCLA in 1986. He the Excellence in Education Award as a Preclinical Course received his MEd at the University of Southern California 1992. Educator in 1997, the Dean’s Award for Master Educator, He joined Saint Louis University as a professor of Pediatrics in Kenneth E. Schuit Award in 2004, the Academy of Master 2004. He is currently the Associate Dean for Curriculum and Educators in 2005, the Excellence in Education Award as Small chairs the Curriculum Management Committee. Group Facilitator in 2009, and the Sheldon Adler Award for Dr. Slavin received the Saint Louis University School of Innovation in Medical Education in 2011. Medicine Distinguished Teaching Award for Humanism in Dr. Lance-Jones is coordinator for the first-year basic sci- 2009, 2011, and 2012, and the Father James Tobin award in ence block, and oversees implementation of the core anatomy, 2008. He received numerous awards while a faculty member biochemistry, genetics, cell biology, and pathology courses. at UCLA, including the Golden Apple Award for Excellence She was a major designer of the combined course in cell in Teaching from the UCLA School of Medicine Class of 1999 biology and pathology, has designed a computer module on and the Robert C. Neerhout Teaching Award from the UCLA vascular structure, atherosclerosis, and the potential use of Pediatric Residents in 2004. noninvasive biomarkers, has created and implemented a team- During his tenure at UCLA, Dr. Slavin was cofounder of based learning exercise on wound healing, and introduced the the Doctoring curriculum, which has since become a national use of virtual microscopy material for histology workshops model for curricula addressing underrepresented topics at and laboratories. medical schools in the United States. He was the primary ar- As Assistant Dean for Medical Student Research, Dr. chitect for the Colleges system, which focused on enhancing Lance-Jones is responsible for helping student design and the educational experience for fourth-year medical students, implement Scholarly Projects, longitudinal research experi- was pediatric clerkship director, and led the development of a ences required of all medical students. She has been asked core curriculum based on the COMSEP educational guideline. to speak at other medical schools interested in establishing At Saint Louis University, Dr. Slavin directed an effort to similar programs. improve the mental health of medical students, and spear- Dean Arthur S. Levine says of Dr. Lance-Jones, “She ap- headed a comprehensive restructuring plan for the four-year proaches . . . tasks with creativity and insight into student undergraduate medical curriculum. concerns and learning styles because she also serves as a lec- Dr. Slavin is a popular teacher, as evidenced by the com- turer, a small group facilitator, and/or a laboratory instructor ments of students: “Dr. Slavin just gets it. I think it’s pretty rare in multiple courses. Her ability to clearly present and synthe- for professors to be able to remember what it was like to be a size [information] . . . and to make topics relate organically to student and the fact that he remembers and is able to relate to several different courses is recognized by the students not only us is greatly appreciated. Fantastic.” “Dr. Slavin is an excellent with outstanding evaluations and attendance at her lectures teacher because he takes complex subjects and makes them but also by the fact that she is one of only three faculty mem- simple to understand. I appreciate that instead of focusing on bers who are asked each year to provide review sessions for excessive detail, Dr. Slavin taught overarching principles that USMLE step 1 exams. Dr. Lance-Jones has served for several can then be used to remember why certain diseases present in years as one of three faculty advisors to the Medical Student a particular fashion.” Honor Council. This working group of elected student rep- Dean Philip Alderson writes of Dr. Slavin, “He is being resentatives advises students on issues relating to our honor nominated because of the long track record of leadership and code and professionalism. This role, coupled with her teaching innovation that he has accrued during his career in medical and Scholarly Project work, positions her as one of our most education, his significant creative work in the field, and his committed preclinical educators.” outstanding record in teaching of medical students.”

32 The Pharos/Winter 2014 Mikel Snow, PhD (Basic) Roy Ziegelstein, MD, MACP (Clinical) (AΩA, University of Southern California, 1988) (AΩA, Boston University, 1986) Director of Medical Education and Professor and Chair, Vice Dean for Education, Sarah Miller Coulson and Frank Department of Cell and Neurobiology, Keck School of L. Coulson, Jr., Professor of Medicine, and Executive Vice Medicine of the University of Southern California Chairman, Department of Medicine, the Johns Hopkins Dr. Snow received his PhD in Anatomy at the University University School of Medicine of Michigan in 1971 and his doctorate in Molecular Biology Dr. Ziegelstein received his MD from Boston University in at the University of Washington in 1989. He joined USC in 1986 and completed his residency in Internal Medicine at Johns 1975 as assistant professor in the Department of Anatomy Hopkins in 1989. He subsequently completed a Cardiology and Cell Biology. He is currently Professor and Chairman Fellowship at Johns Hopkins in 1993. Dr. Ziegelstein joined of the Department of Cell and Neurobiology and Director the faculty of Johns Hopkins University School of Medicine of Medical Education at the Keck School of Medicine at the in 1993 as an assistant professor. He is currently Vice Dean for University of Southern California. Education and professor and Executive Vice Chairman of the Dr. Snow is the director of Anatomy at the medical school, Department of Medicine. known for his dynamic and comprehensive lectures as well as Dr. Ziegelstein directed the Internal Medicine residency his original student materials. Dr. Snow played a pivotal role program at Johns Hopkins Bayview Medical Center from 1997 in the revision of the basic science curriculum, one of the to 2006, and also coordinated the Internal Medicine rotation greatest curriculum advances at USC in the past ten years. He for third-year medical students. He redesigned that program serves as an advisor on the Student Ethics Committee. to emphasize not just the didactic and technical aspects of Dr. Snow’s awards at USC are many: he received the medical education and clinical medicine, but also humanism Master Teacher of Distinction Award at the Keck School and professionalism. Dr. Ziegelstein developed the fourth- of Medicine in 2009, the Outstanding Teaching Award and year course “Transitions to Residency and Internship and Outstanding Mentor Award in numerous years, as well as the Preparation for Life (TRIPLE),” which has become one of the Excellence in Teaching and Lecturing Awards in several years. highlights of the required medical school curriculum. He was also given the Gender Equity Award for “Promoting At Hopkins, Dr. Ziegelstein has won the George J. Stewart a fair environment for the education and training of women Award for outstanding clinical teacher five times and was physicians,” by the American Women’s Association in 1996 awarded the Professor’s Award for Distinction and Teaching and the Dean’s Teaching Award in 2002 at the University of in the Clinical Sciences in 2003. The Maryland chapter of the Wisconsin School of Medicine. American College of Physicians awarded him the C. Lockard Dean Carmen Puliafito writes of Dr. Snow, “As an educa- Conley Award for contributions to resident education and tor, administrator, and mentor, Dr. Mikel Snow is nothing research in 2004 and the Theodore W. Woodward Award for short of exemplary. Through his directorship of the gross medical education in 2007. His clinical skills were recognized anatomy course, his chairmanship of the musculoskeletal by the Miller Coulson Academy for Clinical Excellence in system section, and his involvement in ethics and curricular 2009. committees, Dr. Snow is a pillar of the medical school and in- Dean Landon S. King says that “Dr. Ziegelstein has been tegral to students’ success. This truth may be most evidenced an outstanding teacher of medical students (and all levels of by the students who ‘vote with their feet’ and fill his lectures learners) since he came to Johns Hopkins as a member of the to 100 capacity, despite their opportunity to webcast lec- Osler House Staff program in 1987. . . . As a reflection of the tures comfortably from home. . . . With his gifts Dr. Snow has commitment and excellence that define Dr. Ziegelstein’s ap- helped thousands of students learn the difficult concepts in- proach to teaching, he was recently named as the Vice Dean herent to physiology and anatomy. Simply put by one student, for Education in the Johns Hopkins School of Medicine. In this ‘Every time Dr. Snow speaks, I learn something useful.’ . . . critical role, he will oversee the medical school’s undergradu- We believe Dr. Snow is exactly the type of medical educator ate, graduate, residency, postdoctoral, and continuing medical worthy of AΩA recognition.” education programs.”

The Pharos/Winter 2014 33 The physician at the movies Peter E. Dans, MD

Cate Blanchett in Blue Jasmine, directed by Woody Allen. © Sony Pictures Classics

Blue Jasmine The latest shoo-in is Cate Blanchet for her extraordinary Starring Cate Blanchett, Alec Baldwin, Andrew Dice Clay, and performance as a really mixed up and downright nasty woman Sally Hawkins. in Allen’s forty-eighth and latest film. Jasmine (née Jeannette) Directed by Woody Allen. Running time 98 minutes. Rated is married to slick businessman Hal (Alec Baldwin). They live PG-13. in an elegant Upper East Side Manhattan apartment, summer in the Hamptons, attend charity galas, and otherwise enjoy the oody Allen, who doesn’t attend the Oscars, has created lifestyle of the New York rich and famous who don’t produce roles that have garnered eleven Best Actress and Best anything but make money off deal-making. WSupporting Actress nominations with five Academy Award Jasmine appears to be the only one who doesn’t know that winners.1 The most memorable is Diane Keaton’s quirky but Hal is a world-class womanizer; she is apparently blinded by lovable Annie Hall. Other nominees portray decidedly less the diamond necklaces and bracelets he showers upon her. lovable women bordering on the despicable. The other win- When Hal’s business crashes down and he is indicted and ners were actresses who played against type: Dianne Wiest put in jail for creating a Ponzi scheme, Jasmine is devastated. (Hannah and Her Sisters, Bullets Over Broadway), Mia Unable to bear the ignominy and having lost millions, Hal Sorvino (Mighty Aphrodite), and Penelope Cruz commits suicide, leaving Jasmine untethered and bereft of (Vicki Cristina Barcelona). By contrast, male her apartment and possessions, which are garnished. Popping roles have received four nominations with only Xanax, which she washes down with martinis (one of her Michael Caine winning for best actor in more memorable lines is, “Who do I have to sleep with to get Hannah and Her Sisters.2 a Stoli martini?” 3), she moves in with her sister Ginger (Sally

34 The Pharos/Winter 2014 Hawkins) in a really downscale apartment in San Francisco. Enough Said Emotionally fragile but still haughty and superior, she disap- Starring James Gandolfini, Julia Louis-Dreyfus, Toni Collette, proves of Ginger’s boyfriend Chili (Bobby Cannavale), who has and Catherine Keener. to move out of the apartment to accommodate Jasmine. He Directed by Nicole Holofcener. Running time 93 minutes. turns out to be a very violent guy who rips up the store where Rated PG-13. Ginger works as a checkout clerk. Jasmine tells Ginger that Chili is another loser like Ginger’s ex-husband Augie, played by Andrew Dice Clay. (I had never seen any performances by was glad to get the notice of this screening. It had been a Clay who according to Don Steinberg “calls himself ‘the most trying period and I needed some laughs. The film didn’t dis- vile comic ever to walk on a stage.’ He became a rock star of appoint,I especially in the first half. The very witty dialogue in stand-up comedy in the late 1980s as a filthy-mouthed brag- the mode of When Harry Met Sally is enhanced by a talented gart, selling out Madison Square Garden telling vulgar ver- pair of actors, Julia Louis-Dreyfus and James Gandolfini, who sions of nursery rhymes. He was vilified by women’s groups honed their skills on television. Gandolfini (Albert) the star of and gay groups for his material.” 4) Playing against type, he is The Sopranos is so natural, it’s hard to believe he’s acting. His the most sympathetic of the film’s characters. It turns out that performance is so good that it magnifies the regret about his Ginger and Augie won the lottery. Jasmine suggested they recent death of a heart attack at fifty-one. Louis-Dreyfus (Eva) invest the money with Hal, and they lost everything, which who played the role of Elaine on Seinfeld has perfected the art led to their breakup. of using facial expressions that are just as funny as the lines Accepting Jasmine’s advice, Ginger takes up with Al (Louis themselves. Unfortunately, some of the lines were drowned C.K.), a sound engineer who seems to be a step up from Chili. out by a person guffawing in the almost packed audience. He turns out to be another loser, married and unwilling to Dreyfus plays a divorced masseuse or massage therapist divorce his wife. Jasmine, who has never worked a day in her who is invited to a party that seems like another dead end life, starts taking a course in interior design while working as for meeting Mr. Right. She tells the couple who brought her a receptionist in a dentist’s office and doing a pretty bad job of that no one appeals to her. Albert, a divorced curator of a Los it. The dentist hits on her and she quits. Then the seemingly Angeles television history museum, makes the same com- perfect match appears, Dwight (Peter Sargaardt), a wealthy ment. But their words are belied by their well-matched senses diplomat who is enamored with her. He has money, standing, of humor and easy repartee. Days later, Albert invites Eva out and connections; she has the beauty and sophistication to be on a date. Despite her misgivings about this self-confessed a good consort. She will design his new house and they will portly slob, she agrees, and begins to take a liking to him. After marry. Then he finds out that her background story is com- their first date, they shake hands. On the second date, they pletely false and dumps her. Reeling, she learns that her son begin a series of awkward, and to my mind too many filmed is working in San Francisco and seeks him out only to find that he hates her and wants nothing to do with her because of something that she did that is not revealed until the end. You get the picture: this is one mixed up lady and ninety minutes in her company is almost enough to make one reach for that antidepressant bottle that she carries around with her. I’m ready to give her the Academy Award and be rid of her. I wish Allen would use his great talent to create warm-hearted and inspiring characters. Annie Hall 2, anyone?

References 1. McGrath C. How Woody Allen sees it. WSJ, the Wall Street J Mag 2013 Jul/Aug: 70–75. 2. Podhoretz J. Feminine mistake: The high cost, and sweet rewards, of Woody Allen’s vision of women. Weekly Standard 2013 Aug 12: 39. 3. Morgenstern J. Jasmine’s: Woody, Cate in bloom. Wall Street J 2013 Jul 26: D3. 4. Steinberg D. The Dice gets the role. Wall Street J 2013 Jul 19: D5.

Catherine Keener in Enough Said. © Fox Searchlight Pictures

The Pharos/Winter 2014 35 James Gandolfini, Julia Louis-Dreyfus star in Enough Said. © Fox Searchlight Pictures sleepovers. In short, the story focuses on two divorced people praises her. At the end of the film the girl’s mother tells Eva coming together and the difficulty in navigating a relationship that she is the girl’s mother, not her, and angrily berates her for the second time around. Those who have been divorced might the advice she has given her. be able to relate better to the film than I, who was fortunate to During the second half Eva becomes creepy, using what have been married to a wonderful woman for over thirty-eight she heard about Albert’s bad points to alienate and embarrass years before she died of breast cancer in 2004.1 him. Later when we meet her ex, one senses that she was the Another audience connector involves both of them hav- principal party causing the divorce. Played by Toby Huss who ing daughters who are going off to college, and being parents was in the Wiz episode on Seinfeld, he seems to be very level- who are facing the empty nest like the friend who joined me headed and caring. He has re-married to a widow, which Eva at the screening. The parting scene at the airport is well done. doesn’t learn until she unleashes a wisecrack about them. As Albert’s daughter Tess (Eve Hewson), who is off to Parsons for Albert and the loopy poet, if one wants to pin the tail on School of Design, seems to have inherited the disposition the donkey, she seems to be the reason their marriage failed. of her mother, self-absorbed published poet Marianne (ex- Her judgmental and self-referential manner contrasts with quisitely played by Catherine Keener). She puts down Eva’s his sweeter, more humble, and lighthearted disposition. The daughter Ellen (Tracey Fairaway), who is going to Sarah second half drags as Albert realizes what Eva has been doing Lawrence, which Tess proclaims isn’t what it used to be. I’m and they separate. Still it ends on an up note with a few more not sure what Sarah Lawrence alums think about this, but I laughs. Despite my reservations, I would recommend the film. guess any mention is useful, especially since Eva sports a Sarah Lawrence sweatshirt which might otherwise be considered a Reference product placement like the Taittinger champagne she pours 1. Dans PE Colette’s Story. Self-published; 2011. out at their brunch. The second half of the film introduces a major plot twist in Call Northside 777 (1948) which Marianne becomes a client of Eva and rags on her ex, Starring James Stewart, Lee J. Cobb, and Richard Conte. with neither knowing the connection. When Eva sees Albert’s Directed by Henry Hathaway. Black and white. Running time daughter, she gets the picture. The second part seems like it 111 minutes. Not rated. was written by another screenwriter, with Eva exclaiming in potty-mouth language to her friend Sarah (Toni Collette), will be reviewing some old films that I think you might not something that was absent before and is dropped just as have heard of and which you might enjoy. This one is based quickly. She becomes less appealing when her daughter’s onI a true story adapted from Chicago Times articles by James friend Chloe (Tavi Gevenson), who likes their house better P. Maguire. It is set in a grittier Chicago of the late 1930s and than her own, asks whether she should let her boyfriend go 1940s picturing the Merchandise Mart, the Holy Trinity Polish all the way. Eva confirms that Tess is a virgin and tells her to Mission, the Wrigley Building, and the neighborhood around do what feels good to do. When she tells her they did it, Eva the stockyards with a bar on every corner. The characters are

36 The Pharos/Winter 2014 Top, Call Northside 777 movie poster, 1948. Right, James Stewart, star of Call Northside 777. © 20th Century-Fox

believable. The cast is stellar. Told in the documentary style of Naked City, it opens with a Times ad offering 5000 for information in connection with the murder of a policeman, for which Frank Wiecek (Richard model prisoner who works in the hospital and may be that one Conte), who claims innocence, is serving a ninety-nine-year who is really innocent. McNeal begins a series of interviews sentence. It’s the heyday of newspapers, signified by the news- and learns that everyone except the prosecutor and the jury papers coming hot off the presses and being bundled to go thought he was innocent, including the judge, who has since into the delivery truck. The Times managing editor Brian Kelly died. The interviews lead to a series of front page articles. (Lee J. Cobb) calls in reporter P. J. McNeal (James Stewart) to Ciecek submits to a polygraph or lie detector test even though follow up. He begins his investigation in a municipal building he is told if that if he fails he is “cooked” but if he passes, it where the ad-placer, a Polish cleaning woman, is scrubbing would be inadmissible in court. Leonarde Keeler, the inventor floors and steps. That struck a responsive chord with me of the polygraph, administers the test in the movie. In one of because when I was a boy I lived in a cold-water flat with my the articles, McNeal reveals the story of Ciecek’s wife, who extended family,2 I used to join my Italian grandmother when was faithful to him but divorced him at his insistence so that she worked the 4:00 to 12:00 shift as a cleaning woman in she could marry a man who promised to care for her and Brooklyn’s Borough Hall. their son. The story is accompanied by a photo that infuriates McNeal learns that Mrs. Ciecek (Kasia Orzazewski) worked Ciecek by compromising their anonymity and he tells McNeal eleven years to get 5000, a lot of money in those days, that to call off the search. McNeal, who is becoming unsure of might tempt someone to step forward with new evidence to Ciecek’s innocence, makes one more effort to find someone in clear her son, who was apparently framed. In 1932, the year of the bars who knows something. There is an interesting twist the murder during Prohibition, there was a close relationship at the end. It’s an enjoyable travel back in time. between corrupt policemen, organized crime members, and speakeasy owners. All sides are anxious to get a quick convic- Reference tion. The film is filled with nice little touches such as when 1. Dans PE, Wasserman S. Life on the Lower East Side: Photo- McNeal goes home and after dinner, sits down with his wife graphs by Rebecca Lepkoff 1937–1950. New York: Princeton Archi- to do a jigsaw puzzle as he tells her about the case he is work- tectural Press; 2006. ing on. This also resonated with me in that it was our family’s favorite after-dinner pastime as attested to by the many com- Dr. Dans (AΩA, Columbia University College of Physicians and pleted puzzles around ours and my daughter’s house where Surgeons, 1960) is a member of The Pharos’s editorial board and our prized 2000-piece Casablanca puzzle resides. has been its film critic since 1990. His address is: McNeal visits Ciecek in the penitentiary. There are inter- 11 Hickory Hill Road esting posted rules governing where inmates may meet and Cockeysville, Maryland 21030 kiss relatives. McNeal, the typical cynical journalist who has E-mail: [email protected] seen and heard it all—including the fact that all prisoners are innocent—questions the warden, who says that Ciecek is a

The Pharos/Winter 2014 37 O.E.D. Don’t you just love it when suddenly one of your off-track words occurs by luck in conversation or better, when you can float the word itself into the stream saying why that’s so apotropaic! Henry N. Claman, MD

Dr. Claman (AΩA, University of Colorado, 1979) is Distinguished Professor of Medicine and Associate Director of the Medical Humanities Program at the University of Colorado, Denver. He is a member of the editorial board of The Pharos. His address: Mail Stop B164, Research 2, 12700 E. 19th Avenue, Room 10100, Aurora, Colorado 80045. E-mail: [email protected].

38 The Pharos/Winter 2014 Reviews and reflections

David A. Bennahum, MD, and Jack Coulehan, MD, Book Review Editors

but chuckle as the cover blurbs reflect and nursing students, but nope—nope— the trite and out-of-fashion tradition no desk for retreat. Nurses learn to The book review editors request of physician approval. The cover of the turn on a dime in the fishbowls of their that books for potential review be book suggests that nurses, the nursing wards, trailing a computer; or in the pa- approved by the editors before profession, still seeks primarily—pri- tient’s home trailing a phone. Graceful the reviews are written. Reader marily—the praise of physicians. and elegant. Swift and bold. interest and space are always Ironically this collection illustrates All of these stories have both strong considerations in this section and nursing autonomy. We can remain “telling” voices and strong interior, unsolicited reviews may be re- seated when doctors walk into the room self-deprecating, voices loaded with jected. Contact Dr. Bennahum at and we “implement prescriptions”; we good humor. In fact, humor is one of [email protected] and don’t take orders. Some of us with ad- the strongest tools for these nurses. I Dr. Coulehan at john.coulehan@ vanced degrees write prescriptions. We laughed reading Eddie Lueken’s “Hitting stonybrookmedicine.edu. nurses “consult” with each other and the Bone.” Demonstrating the good stu- with our multidisciplined colleagues. dent’s desire to learn and experience We provide peer review and peer sup- hands-on skills, she writes, “I was pay- port. A nurse is not a handmaiden to ing the college to teach me how to keep the physician but works with the doctor people alive; I already possessed the as colleague in the best interest of the skills to let someone die.” p27 The interior patient. dialogue of this essay is priceless. Oh, Perhaps the book is intended for I wish I would have read this one as a doctors? Every doctor should indeed student. read this book. The narratives are such a I wanted to cry when I read Kimberly good source of information for doctors, A. Condon’s “Approaching Death.” In the public, and nurses, and especially the first paragraph she writes, “There is nursing and medical students. What a terrifying, soul-piercing scream that would Flo* say? a mother makes when she loses a child. The narratives in this book are bold, This scream is so universal that every- funny, scary, and true to the bone. one, in every corner of the emergency Twenty-one nurses tell compelling sto- department, knows what has just hap- ries of their training and subsequent pened when they hear it.” p247 I Wasn’t Strong Like This When growth in the nursing profession. Their I sympathized and felt a chill when I I Started Out: True Stories of stories can be the basis for learning as read Thomas Schwarz’s “The Haunting.” Becoming a Nurse well as for entertainment. I wish I could While a story of the loss of innocence, have read and discussed these stories it is also a soul-searching story of scar- Lee Gutkind, editor when I was a nursing student. They are ring and redemption. He writes, about Pittsburgh, In Fact Books, 2013 powerful. himself and his patients, that not all Reviewed by Judy Schaefer, RN, MA As the nurses in this collection de- injuries can be seen and judged with the scribe, nurses make decisions on the human eye or reasoned with the human spot and on the run, without recourse to mind. “Nor do all illnesses have scien- et me say this before I say anything contemplation at a desk. A family mem- tific, rational roots. Some surround the else: I LOVE these stories. Yet, had ber once brought this to my attention heart like barbed wire, never admitting IL not been asked to write this review, when she asked, “Where is the nurse’s peace or happiness, never allowing the I would have unwittingly left this book desk?” I had never thought of it before. release of residual, unspoken, or mis- to gather dust on the shelf. Why? The These ward warriors make life-and- placed guilt.” p41 This is a superb story cover has four lovely blurbs written by death decisions on the go, in soft shoes, for both new and experienced nurses. doctors. The early praise for this book with grace and good humor—as these I wanted to jump and shout when of creative nonfiction by nurses stories attest. There may be a break I read Tilda Shalof’s “I See You.” Her came from a total of nine doc- room or cubicle where coffee is dosed superb writing inspires the title of the tors. All nice and knowledge- out in between patients and family, at- collection. She writes, “Most of all, you able people, surely, but tendings, interns, and residents, medical need moral courage because nursing is what do nursing leaders about the pursuit of justice. It requires think of this book? you stand up to bullies, to do things I can’t help * Florence Nightingale. that are right but difficult, and to speak

The Pharos/Winter 2014 39 Reviews and reflections

your mind even when you are afraid. I sion. Well done! types of error and the consequences of wasn’t strong like this when I started And—one more thing—and write each for surgical residents. In techni- out. Nursing made me strong.” p150 Does this on your cover: Flo would like this cal errors the surgeon performs “his Shalof remind us that nurses are like book! No, that’s wrong. Flo would LOVE task conscientiously, but his skills fall hired-guns and are certainly paid ob- this book! short of what the task requires.” p37 servers? I laughed and I cheered as I Errors of judgment occur “when an read her description of the nurse as Judy Schaefer, RN, MA, edited the first incorrect strategy of treatment is cho- angel, “In addition to holding the pa- biographical/autobiographical work of sen.” p45 When a resident makes a tech- tient’s hand, that nurse had analyzed English speaking nurse-poets, The Poetry nical or judgmental mistake in patient her twelve-lead electrocardiogram and of Nursing: Poems and Commentaries of care, his superiors’ response is gener- monitored her for arrhythmias. She Leading Nurse-Poets (The Kent State Uni- ally supportive, despite scrutiny at the had drawn serum troponin levels and versity Press, 2006), and co-edited the first Morbidity and Mortality Conference, ensured that electrolyte levels were nor- international anthology of creative writing and the resident is forgiven, as long malized. She had given information, by nurses, Between the Heartbeats (Univer- as his mistakes are infrequent, and he oxygenation, anticoagulation, and pain sity of Iowa Press, 1995). Her address is: learns from them. Hence, the book’s relief.” p151 Not just another angel! These 4423 Carrington Court title, Forgive and Remember. angels have strong wings. Harrisburg, Pennsylvania 17112 The third type, normative error, oc- The implications and challenges E-mail: [email protected] curs when a surgeon fails “to discharge of diverse cultures are inherently ad- his role obligations conscientiously.” p51 dressed in all of these narratives and In other words, the surgeon neglects his specifically addressed in “Healing duty to a patient or to his colleagues on Wang Jie’s Bottom” by L. Darby-Zhao, the surgical team because of laziness, “Docking in Togo” by Jennifer Binger, inattention, lack of respect, or irrespon- as told to Ann Swindell, “Listening and sibility. Quasi-normative errors repre- Other Lifesaving Measures” by Karla sent a failure to discharge an obligation Theilen, and “Messiah, Not Otherwise specific to a given hospital or surgical Specified” by Janet Gool. These are su- service, i.e., a regimen the Chief in- perb essays for discussion by students sists upon, although other approaches of nursing and medicine who are in- might be equally valid. Normative and terested in global as well as domestic quasi-normative errors are considered health care pursuits. moral failings, rather than evidence Pamela Baker’s “Individually of insufficient skill. Accordingly, they Identifiable” touches on the need for evoke a more negative response from stories in spite of the HIPAA climate. attending surgeons. A resident guilty She addresses issues of policy and proof normative error can expect dire con- cedure that could be the ground work Forgive and Remember: sequences, e.g., failure to advance, or for policy research. And importantly Managing Medical Failure even immediate dismissal. she touches on the reasons nurses do Charles L. Bosk This second edition of Forgive and not write. What an essay to facilitate Chicago, University of Chicago Press, Remember deserves our attention be- discussion for nurses in their English 2003 cause it sheds new light on Professor requirement courses! Bosk’s study. He now confesses to The narratives could be read one Reviewed by Jack Coulehan, MD having made his own errors of judg- at a time or in one setting from front ment in writing the original book. In to back. Each one stands alone. Read n the late 1970s, sociologist Charles a remarkable Appendix entitled, “An them as you will. Now having said this, I Bosk spent eighteen months as a par- ethnographer’s apology, a bioethicist’s thought the book ended poignantly with ticipant-observerI in the surgical resi- lament—The surgeon and the sociolo- “The Nurses Whispered” by Patricia dency program at a major West Coast gist revisited,” Bosk describes two omis- A. Nugent and “Becoming” by Lori teaching hospital. His report, Forgive sions that he once considered trivial, Mulvihill. “The Nurses Whispered” is and Remember: Managing Medical but he now realizes were important. subtle truth telling and “Becoming” is a Failure, which became a classic of The first omission relates to his dis- loving summary. They bring the book to medical sociology, investigated power cussion of the process by which resi- a satisfying closure with a respectful and relationships and decision-making in dents were chosen for advancement knowing salute to the nursing profes- academic surgery. Bosk described four to the next level, or dropped from the

40 The Pharos/Winter 2014 program. At the promotion meeting, anesthesiologist, and asks an African- Dr. Coulehan is a book review editor for only one resident failed to make the American scrub nurse, ”Do you know The Pharos and a member of its editorial grade. Every one of the senior sur- how many times I had to practice this board. His address is: geons considered that person guilty of operation on blacks before they let me Center for Medical Humanities, Com- normative errors, i.e., unprofessional do it on whites?” pp226–27 Tellingly, the passionate Care, and Bioethics behavior. In fact, attendings applied author has to reconstruct this scene Stony Brook University words like “sick” and “crazy” to the from memory because he failed to in- Stony Brook, New York 11794-8335 resident. Following standard practice, clude it as important in his field notes. E-mail: john.coulehan@stonybrook- Bosk preserved the confidentiality of Why did the author choose after all medicine.edu his subjects by altering names and other these years to reveal his omissions? He distinguishing features—including gen- considers several reasons, ranging from der. Thus, the failed resident, always personal catharsis to demonstrating referred to as “he” in the book, was the difficulty of using supposedly de- actually a woman; in fact, she was the tached and objective ethnographic data only female resident. to draw inferences about professional There were no precedents for a fe- morality. It is obvious to today’s reader male surgical resident in that program. that the female resident’s failure can- While the male sociologist blended not possibly be understood in isolation in with the surgical “gang,” the female from gender discrimination and sexual resident never did. She remained an harassment. It is also obvious that any outsider. How much did this alienation resident’s response to intimidation and affect her performance? How much humiliation by superiors must have did her attendings’ bias affect their influenced how normative and quasi- evaluations? Was she considered “sick” normative errors were perceived and Guidebook for Clerkship or “crazy” simply because she aspired evaluated. Directors, 4th edition to become a surgeon? Whatever the This raises another question: Why answers, there can be no question that recommend a decades old ethnographic Alliance for Clinical Education, Bruce Z. her gender was an important datum study recently revealed as flawed from Morgenstern, editor omitted in the original edition. the outset? In my opinion this new edi- Gegensatz Press, 2013 The second omission Bosk reveals is tion of Forgive and Remember is doubly Reviewed by Deepti Rao, MD (AΩA, “the hectoring, often abusive behavior relevant. First, it remains a richly de- University of New Mexico, 2013) of senior surgeons.” p223 He originally tailed investigation of surgical training chose not to tell his readers that “verbal that still applies in many ways to clinical harassment was a rather routine event education today. This is especially true s clerkship directors, we love for all residents,” p223 at least in part with regard to the classification of error teaching and working with medi- because he wanted his work “to read and the relative valuation of technical calA students. To that end, we tend to be differently than other sociological ac- and moral competence. Second, the a busy group of people with a number counts of this time which seemed to author’s revelations provide the reader of academic projects. We also generally engage routinely and somewhat unre- with an altered lens through which to realize the limits of our knowledge and flectively in doctor-bashing.” p228 The view his original ethnographic narra- seek counsel when necessary. So finding author believed that if he gave a full active. The temptation to delete messy a practical educational reference that is count of this harassment, it would dis- details that don’t “fit” with a preferred well written by notable medical educa- tract the reader from his major theme, diagnosis is always present in medicine. tors is invaluable. I found the Alliance an analysis of decision making in the The new Forgive and Remember is a for Clinical Education’s Guidebook for strict, authoritarian social system of a “retrospect-o-scope” that teaches how Clerkship Directors to be such a book. surgical residency. He didn’t want to important such details can sometimes I have to admit, when I was be just another doctor-basher. In the be. It also shows how much the mores handed the Alliance for Clinical new Appendix, he describes a typical of clinical education have changed in Education’s Guidebook for Clerkship example of harassment. In the operat- the last thirty years. Unfortunately, Directors several months ago, I planned ing room, a senior surgeon verbally gender discrimination and trainee ha- to read the tome from cover to cover. “trashes” both Bosk and a resident, rassment still occur, although now con- Indeed, I started out that way, reading makes derogatory comments about sidered aberrant, rather than routine. the initial information packed chap- “slopes, gooks, and dinks” to an Asian ters with gusto. However, soon life

The Pharos/Winter 2014 41 Reviews and reflections

interrupted and I lost my way in that intended to be a reasonably complete too emotionally involved with their noble pursuit. Instead I began to read manual for clerkship directors as well as patients.” p4 But what does this really single chapters as questions came up other members of the medical student mean? Medical education rarely ad- for which I needed answers. And to my teaching team.” That makes it very valu- dresses the emotions of learners, al- surprise, I found that in following my able not only for clerkship directors, though research has documented an own academic pursuits, over the course but also for any clinician who teaches intense panoply of positive and negative of several months, I had the chance to students of medicine and the health sci- emotions. Even outstanding physician read most of the chapters in this book. ences. I recommend the book as a truly role models rarely discuss their feelings, For instance, I am working on a clini- unique and helpful guide. leaving medical students to attempt to cal reasoning elective for fourth-year deduce appropriately professional emo- medical students, so I read the chapters Dr. Rao is an assistant professor of tional responses from indirect verbal, on clinical reasoning and working with Internal Medicine at the University of nonverbal, and behavioral cues. The students who had experienced difficul- New Mexico Health Sciences Center. Her medical literature as a whole is surpris- ties. I am in the process of revising a address is: ingly silent on this topic. behavior-based PRIME grading form University of New Mexico School of Thankfully, Ofri has stepped forward that I helped develop, so I read a very Medicine to tackle this sensitive issue. Through a helpful chapter on evaluation of stu- MSC10 5550 series of examples derived from her dents (authored among others by Louis Albuquerque, New Mexico 87131 own clinical encounters and those of Pangaro). I am currently working on E-mail: [email protected] other physicians, as well as regular ci- a simulation-based training for clini- tation of relevant literature, she makes cal procedures, so I read the chapter the argument (using a metaphor bor- on simulation in medical student edu- rowed from the neuroscientist Antonio cation. The book mirrored the infor- Damasio) that the physicians’ feelings mation I needed to gain not just as a are the “underlying bass line” p3 exert- clerkship director but also as a medical ing a profound effect on their actions student educator. regarding patients. In a bold and for- With respect to the book itself, I ward-looking move, Ofri calls for care- found the chapters very thorough, well ful attention to, understanding of, and organized, and easy to understand. I skill to work with personal emotions presented a few of the chapters above in the interests of patient well-being. but there are several other topics in- Although she rarely uses this term, in cluding but not limited to chapters effect she suggests that physicians need on the management of a clerkship, to develop emotional intelligence. the clerkship orientation, longitudinal Following in the footsteps of Jodi clerkships, and career development. Halpern, Jack Coulehan, William I found the chapters presented new What Doctors Feel: How Branch, and countless other physician- knowledge that often gave me some Emotions Affect the Practice scholars, Ofri reminds us of the key role new insight or helped me structure the of Medicine of empathy as the gateway to managing thoughts I had about the subject. For Danielle Ofri, MD one’s emotional reactions and achieving instance, the chapter on clinical reason- Boston, Beacon Press, 2013 the goal of compassionate care. She rec- ing had a very thorough and organized ognizes that it is easiest to feel empathy summary table outlining teaching strat- Reviewed by Johanna Shapiro, PhD when the patients’ suffering “makes egies and tools. Also the chapters were sense,” p10 and much harder when it organized so that if I wished to read a motions in medicine are both a does not. Yet empathy (which of course good review of a subject I could, or if I neglected and problematic subject. is not the same as enabling or indulging wanted to skip to a very specific topic I EAs internist and author Danielle Ofri the patient’s every claim) is essential in could do that as well. observes in her new book What Doctors all clinical encounters, not simply those As a busy clinician with a family it is Feel, the model of detached concern is involving likeable and grateful patients. definitely hard to find time to research still prevalent in clinical practice and in Yet how to cultivate empathy under and read on every topic. This book has training. As she writes, “the often un- challenging, time-pressured circum- a wealth of information in a very ac- spoken (and sometimes spoken) mes- stances is rarely included in the cur- cessible format. As stated at the end sage in the real-life trenches of medical riculum. Reflecting on her own training of the first chapter, ”This guidebook is training is that doctors shouldn’t get (mostly by older white male physicians)

42 The Pharos/Winter 2014 she identifies the quality of respectful course of their career are surrounded by reverberation of anguish and self-doubt curiosity, “the . . . act of taking a patient chronic suffering, progressive incapac- is lengthy and profound. In her words, and her story seriously,” p54 as going ity, and death. How—and when!—do they are “soul-corroding events,” p190 of- a long way toward yielding positive physicians mourn these losses? How— ten because the physician had a strong doctor-patient relationships. and when!—do they appropriately give emotional connection with the patient. The chapter “Can We Build a Better vent to their grief? All too often, as What Doctors Feel is written in ac- Doctor” skillfully dissects the multiple Ofri and others have observed, grief is cessible, personal style, easily absorbed pressures on medical students to de- simply buried. The team moves on to by lay persons, medical students, and identify with the patient and instead the next patient and there seems to be physicians alike. One of the most cathect to the residents and medical no time and no inclination to mourn. touching aspects of the book is the team. This often means prioritizing Ofri points out that sadness, like fear, narrative of Julia, a longtime patient efficiency and productivity over com- is unavoidable, and further, that neither and undocumented immigrant with passion, laughing at or making fun of emotion is without value (the alertness two children about whom Ofri wrote the patient, and not protesting the use that results from a certain level of anxi- in Lost in Translation. Charting the of derogatory terms such as “gomer” ety can keep the physician on her toes; ups and downs of Julia’s progressively (an elderly, demented nursing home grieving for a patient can bring some worsening struggle with genetically in- patient) or a racially charged term such measure of peace to the physician), duced CHF while she is in her thir- as “status Hispanicus” to refer to a vo- but the key is to learn how to navigate ties and forties is a moving example of cal patient in labor. This and similar these emotions so that they do not de- relationship-centered care. Ofri does chapters on medical malpractice point stroy the physician, but rather serve the not shy away from documenting the to some of the systemic underpinnings larger goals of patient (and physician) joys and heartbreak she experiences of physician disillusionment and resul- well-being. in caring for Julia. She does not expect tant “bad behavior,” and suggest that Ofri also discusses shame, and its that she—or other physicians—should solutions focused only on the individual disabling properties. Whether her dis- feel such emotional connection with all level are doomed to failure. tinction between guilt (about a specific patients. But she does fearlessly exca- Ofri does the medical community a behavior) and shame (a more global vate all that it can mean to step within favor by naming some of the most dif- experience) is accurate, her larger point the orbit of a patient’s suffering, yet not ficult emotions that physicians experi- is that the toxic blaming and shaming be pulled so closely that she implodes. ence, starting with fear. There are small that still occurs in medical school and The result is a portrait of the doctor we fears (looking or actually being incom- residency training has persistent nega- would all long to have as we embark on petent in a given situation) and large tive effects that paradoxically make it our final journey. fears (is this really the right profession more difficult to accept responsibility What Doctors Feel takes a crucial for me?) in medicine, all culminating for mistakes and apologize to patients. step into the murky waters of emotion, in the oppressive fear of doing irrepa- The tendency to hide and cover-up long a taboo subject among both acade- rable harm, or even killing a patient. incidents perceived to be shameful, and micians and practitioners. It points the Ofri points out the paralyzing nature of the resultant quest for perfectionism, way toward systematic research, teach- some fears, and consequent suboptimal is both unrealistic and detrimental to ing, and clinical practice that acknowl- (or terrible) care to patients, as well as good patient care. edges the humanity of the physician, as great suffering to the physician. This Burn-out, stress, and disillusion- well as of the patient, in the service of is a heavy burden to bear, but it can- ment with the profession of medicine better patient care. not be addressed by silence. Ofri rec- are also considered in What Doctors ommends stress management, support Feel. Ofri pinpoints many causes, from Dr. Shapiro is Director of the Program in groups, and mindfulness meditation, paperwork, time pressures, financial Medical Humanities & Arts and Professor all of which have been demonstrated to demands, family strains. None of these of Family Medicine at the University of improve physician well-being. But until insights is new—much research and California, Irvine, School of Medicine. Her the culture of medicine shifts so that it anecdotal reports already exist sup- address is: can acknowledge these fears, medical porting the deleterious consequences University of California, Irvine students and their role models will have of these conflicts. But Ofri brings these Rm 835, Bldg 200, Rt 81 to struggle along in relative isolation. experiences to life. She is particularly 101 The City Drive South Another emotion to which Ofri de- eloquent on the emotional toll malprac- Mail Code 2975 servedly gives much attention is loss tice suits extract, citing evidence that Orange, California 92868 and grief. Medical students at an early concludes that, whether the physician E-mail: [email protected] age and physicians throughout the is found liable or not, the emotional

The Pharos/Winter 2014 43 AΩA Board of Directors and national office staff, left to right: Mark J. Mendelsohn, MD; Eve J. Higginbotham, SM, MD; Alan G. Wasserman, MD; Sheryl Pfeil, MD; N. Joseph Espat, MD; Tonya Cramer, MD; C. Bruce Alexander, MD; Ruth-Marie Fincher, MD; Barbara Prince; Richard L. Byyny, MD; John Tooker, MD, MBA; Lynn M. Cleary, MD; Alicia Alcamo, MD; Robert G. Atnip, MD; Steven A. Wartman, MD, PhD; Laura Tisch, MSIV; Christopher Clark, MD; Wiley Souba, MD, DSc, MBA; William F. Nichols; Richard B. Gunderman, MD, PhD; Suzann Pershing, MD; and Alan G. Robinson, MD.

2013 meeting of the AΩA board of directors Programs Administrator Candice Cutler; Membership The annual meeting of the board of directors of Alpha Administrator Jane Kimball; Managing Editor Debbie Omega Alpha was held in Denver, Colorado, on October Lancaster; Controller Barbara Prince. 5, 2013. Present were: Absent: Secretary-Treasurer Joseph W. Stubbs, Officers: President C. Bruce Alexander, MD; President MD; Member at Large Douglas S. Paauw, MD; Medical Elect John Tooker, MD, MBA; Immediate Past President Organization Director Carol A. Aschenbrener, MD, Ruth-Marie Fincher, MD. Association of American Medical Colleges. Members at large: Robert G. Atnip, MD; N. Joseph New to the board are: Mark J. Mendelsohn, MD, rep- Espat, MD; Eve J. Higginbotham, SM, MD; Sheryl Pfeil, resenting the University of Virginia School of Medicine, MD; Alan G. Robinson, MD; Wiley Souba, MD, DSc, elected to a three-year term as Councilor Director; Wiley MBA; Steven A. Wartman, MD, PhD. Souba, MD, DSc, MBA, elected to a three-year term as Councilor directors: Lynn M. Cleary, MD, State member at large; Laura Tisch, MSIV, representing the University of New York Upstate Medical University; Medical College of Wisconsin, elected to a three-year Richard B. Gunderman, MD, PhD, Indiana University term as student director; Steven A. Wartman, MD, School of Medicine; Mark J. Mendelsohn, MD, PhD, elected to a three-year term as member at large. University of Virginia School of Medicine; Alan G. Councilor director Richard Gunderman, MD, PhD, was Wasserman, MD, George Washington University School elected to a three-year term as member at large. of Medicine. The board of directors recognized the retiring board Student directors: Alicia Alcamo, MD, the Ohio State members, and expressed thanks for their service to University College of Medicine; Christopher Clark, MD, Alicia Alcamo, MD; N. Joseph Espat, MD; and Ruth- University of Mississippi School of Medicine; Tonya Marie Fincher, MD. Cramer, MD, Chicago Medical School at Rosalind Thanks were also expressed for the exemplary service Franklin University of Medicine and Science; Laura of retiring President C. Bruce Alexander, MD, who be- Tisch, MSIV, Medical College of Wisconsin. comes immediate past president. Coordinator, Residency Initiatives: Suzann Pershing, MD. Elections National office staff: Executive Director Richard L. The following members of the board were elected as Byyny, MD; Assistant Treasurer William F. Nichols; officers for a one-year term:

44 The Pharos/Winter 2014 National and chapter news

1. John Tooker, MD, MBA—President unanimous consent. 2. Douglas S. Paauw, MD—President Elect A report on The Pharos was presented by Managing 3. C. Bruce Alexander, MD—Immediate Past Editor Debbie Lancaster. President Dr. Pershing presented a report on the Residents Five honorary members were proposed this year and Initiative project and the results of the Postgraduate were elected to honorary membership for their distin- Award. guished contributions to medicine. Profiles of these honorary members will appear in a future issue of The Miscellaneous Pharos: The minutes of the 2012 board meeting were ap- 1. Shotai Kobayashi, MD, PhD—President, Shimane proved. A final budget was also approved. University Respectfully submitted 2. Mats Lundström, MD, PhD—Professor Emeritus, Executive Director Richard L. Byyny, MD Lund University, Sweden 3. Boris Malyugin, MD, PhD—Deputy Director General, S. Fyodorov Eye Microsurgery State Institution Alpha Omega Alpha elects new officers and 4. John H. Pearn, MD, PhD, MPhil, AO, RFD— directors Professor Emeritus, University of Queensland, Brisbane, Alpha Omega Alpha Honor Medical Society is pleased Australia to announce the election of its officers and directors for 5. A. G. Prentice, MBChB—President, the Royal the 2013/2014 year. College of Pathologists, London Officers Reports President—John Tooker, MD, MBA, MACP (AΩA, Dr. Alexander and Dr. Byyny presented their reports University of Colorado, 1970), is Emeritus Executive Vice for the year, summarizing the year for AΩA programs, President and CEO of the American College of Physicians new medical school chapters, chapter visits, fundraising, and Adjunct Professor of Medicine at the Perelman the membership directory and database, and communi- School of Medicine at the University of Pennsylvania. cations and public relations. Dr. Tooker served as Executive Vice President and Chief The financial review was presented by Mr. Nichols Executive Officer of ACP from 2002 through 2010 . He and Ms. Prince. A presentation on AΩA’s invest- served as Medical Organization Member on the AΩA ment program was given by Jennifer Ellison and Diana Board of Directors from 2009 through 2011, and was Lieberman of Bingham Osborn & Scarborough. elected a member at large in 2011. Mr. Nichols presented a proposal for regular small Immediate Past President—C. Bruce Alexander, MD dues increases, subject to approval each year by the (AΩA, University of Virginia, 1970), Professor and Vice Executive Committee. The proposal was passed by unan- Chair of the Department of Pathology at the University of imous consent. Alabama at Birmingham. Dr. Alexander was elected to the Dr. Gunderman reported on the councilor meeting board of directors of AΩA in 2002 as a councilor direc- that immediately preceded the board meeting. A final tor, and subsequently elected as member at large in 2005. report on the councilor meeting from the committee He became secretary-treasurer of the society in 2007 and chairs (Dr. Gunderman, Dr. Gabriel Virella, and Dr. Elma president of the society in 2013. LeDoux) follows. President-Elect—Douglas S. Paauw, MD, MACP Dr. Fincher reported on the status of new chapter (AΩA, University of Michigan, 1983), Director, Medicine chartering. Student Programs, Professor of Medicine, Rathmann A report on the Professionalism Award and the Family Foundation Endowed Chair in Patient-Centered Professionalism Meeting in July was presented by Dr. Clinical Education at the University of Washington School Paauw by teleconference. of Medicine in Seattle, Washington. Dr. Paauw was elected A report on the work of the committee for the to the board of directors of AΩA in 2005 as a councilor Leadership Award was presented by Dr. Higginbotham. director and was elected as member at large in 2007. He A motion was made to approve the Leadership Award was awarded the AΩA Robert J. Glaser Distinguished and Development Program to promote the development Teacher Award in 2001. of leaders in academia, medical and health organizations, and the community. The motion was passed by

The Pharos/Winter 2014 45 National and chapter news

Alpha Omega Alpha elects new officers and directors

C. Bruce Alexander, MD Richard B. Gunderman, MD

Mark J. Mendelsohn, MD Douglas S. Paauw, MD, MACP Wiley “Chip” W. Souba, MD, DSc, MBA

Laura Tisch, MSIV John Tooker, MD MBA, MACP Steven A. Wartman, MD, PhD, MACP

46 The Pharos/Winter 2014 National and chapter news

Directors University and Johns Hopkins. Member at Large—Richard B. Gunderman, MD, PhD, A complete list of the members of the AΩA Board of MPH (AΩA, University of Chicago, 1992), Professor of Directors is on the inside front cover. Radiology, Pediatrics, Medical Education, Philosophy, Liberal Arts, and Philanthropy, and Vice Chair of 2013 AΩA Councilor Meeting Radiology, Indiana University School of Medicine. Dr. The 2013 AΩA councilor meeting was held in Denver, Gunderman was elected to the board of directors of AΩA Colorado, on October 3 and 4. Approximately one-third as a councilor director in 2010. He was awarded the AΩA of chapter councilors attended, as well as several national Robert J. Glaser Distinguished Teacher Award in 2012. Dr. officers and staff members from the national office. The Gunderman was elected to a three-year term as member program for the meeting was organized by a committee at large. including Richard Gunderman, Elma LeDoux, and Gabriel Councilor Director—Mark J. Mendelsohn, MD (AΩA, Virella, and members of the AΩA staff. Experience of University of Virginia, 2007), Associate Professor of participating councilors varied widely: several had served Clinical Pediatrics at the University of Virginia School of as councilor for more than two decades, while others had Medicine was elected to a three-year term as councilor been appointed to the post only a month or two before director. Dr. Mendelsohn has been the AΩA councilor the meeting. at the University of Virginia since 2008 and is regularly Executive Director Richard Byyny opened the meet- recognized as one of the university’s oustanding teachers. ing with a discussion of the importance of the leadership Dr. Mendelsohn serves on the medical school Admissions opportunity that every councilor enjoys, particularly with Committee, is the long-time chair of the Pediatric Intern regard to promoting both AΩA and its mission to stu- Selection Committee, and co-directs the university’s dents, faculty, and alumni. There is ample evidence that International Adoption Clinic. many contemporary physicians are discouraged about the Member at Large—Wiley “Chip” W. Souba, MD, DSc, future of medicine, and AΩA can make a big difference in MBA (AΩA, University of Texas at Houston, 1978), Vice redressing this situation by fostering local discussions of President for Health Affairs and Dean of the Geisel medicine’s core aspirations and the practical steps all phy- School at Medicine at Dartmouth College, was elected to sicians can take to help promote them. a three-year term as member at large. Dr. Souba is widely At each medical school, the AΩA councilor can serve recognized for his innovative approaches to developing as a node in the nexus of important networks in medi- leaders and leadership, having published more than forty cine, including different medical specialties, academic articles on health care leadership challenges, personal and and nonacademic physicians, and different generations organizational transformation, leading oneself, barriers to of physicians, from the most senior to the most junior. effective leadership, and the language of leadership. An effective councilor can act as a catalyst, helping the Student Director—Laura Tisch, MSIV, at the Medical chapter and its members do a better job of serving physi- College of Wisconsin, was elected to a three-year term as cians at all levels, as well as schools of medicine, hospitals student director. Ms. Tisch is the AΩA chapter president and health systems, and the communities they serve. at MCW and was elected to AΩA in 2013. Ms. Tisch has Councilors can provide critical leadership and help all been active in her chapter’s volunteer activities, including parties regain a focus on medicine’s most defining and es- the MCW Saturday Clinic for the Uninsured, the USMLE sential missions. Step 1 Board Review Tutoring program, and the MCW The meeting featured the debut of the first chapter Department of Admissions Applicant Liaison and Student handbook for councilors and chapter AΩA personnel Interviewer program. She has participated in research in developed by the staff in the national office. Dr. Byyny early breast feeding rates and Kaposi Sarcoma. stressed that the handbook remains a work in progress, Member at Large—Steven A. Wartman, MD, PhD, but it represents by far the most useful resource chapters MACP (AΩA, Johns Hopkins University, 1970), President have ever enjoyed. The handbook’s purpose is not to tell and CEO of the Association of Academic Health Centers councilors how to do their jobs, but to provide an orga- and member of the editorial board of The Pharos since nizing framework and range of options for the activities of 1996, was elected to a three-year term as member at large. each chapter. Dr. Wartman is recognized internationally for his work The handbook addresses a variety of core topics of in the organization and management of academic health concern to every councilor and chapter, including AΩA’s centers. He is currently a Distinguished Professor in the constitution, information about the roles of officers and Department of Medicine at Georgetown University and the board of directors, and eligibility and nomination pro- an Adjunct Professor of Medicine at George Washington cedures for different categories of members, including

The Pharos/Winter 2014 47 National and chapter news

Photo: Councilor meeting co-chairs Richard Gunderman, MD, PhD; Elma LeDoux, MD; and Gabriel Virella, MD, PhD; with Executive Director Richard L. Byyny, MD.

students, residents, faculty, alumni, and honorary mem- years and then graduate in the same academic year. This bers. It also covers AΩA’s many award programs, which makes it difficult to achieve the level of engagement and support a variety of chapter-based and national oppor- continuity in student leadership found in chapters that tunities in service, creativity, and leadership. Other help- nominate third-year students, who stay on as fourth ful sections address chapter organization, staffing, and years. It is not difficult to identify the top three or four finance. students to be nominated late in the third year, and ear- It is worth stressing that, in many respects, there is no lier selection of a few student leaders can provide impor- “correct” way to run a chapter. Every chapter must oper- tant continuity with student involvement in the chapter. ate in accordance with AΩA’s constitution, but doing so Another important point regarding new members is still provides considerable latitude to adapt to local chal- the fact that the organization’s constitution was revised lenges and capitalize on local strengths and opportuni- in 2012 to allow many AΩA chapters to nominate more ties. The councilors meeting provides an opportunity for candidates in non-student categories for membership, in participants to share new ideas and best practices. Many proportion to the size of the size of each student class. councilors commented on the many ideas they had en- This change was enacted without reducing the number of countered at the meeting, which they intended to share such candidates any chapter can nominate. Many coun- with members back home. cilors report that new members in the alumni and faculty A perennial point of great interest among councilors categories often demonstrate a particularly high level of are the different procedures chapters have adopted for enthusiasm for AΩA, so chapters should consider taking nominating new members, which should include crite- full advantage of this opportunity. ria beyond just grades and board examination scores. Chapters should also take steps to ensure that their Chapters at schools with pass/fail grading policies often school’s students, including incoming first-year students, find it difficult to nominate students in their third year, are well-informed about AΩA’s mission, history, and the which means that student members are elected as fourth nomination criteria for membership, so that students

48 The Pharos/Winter 2014 National and chapter news

John Tooker, MD, MBA, president of the AΩA Board of Executive Director Richard Byyny and Clarence Joe, DMD, Directors, with Jim Sebastian, MD, councilor at the Medical MD, councilor at the Medical College of Georgia. College of Wisconsin.

know how new members are selected. As previously councilors is the Administrative Recognition Award, indicated, different chapters assign different weights to which provides a certificate of appreciation and a modest such factors as scholarship, leadership, service, profes- honorarium to the chapter staff person who assists the sionalism, and research. Though it happens infrequently, councilor in day-to-day operations. These administrators it is always a shame when a nominated student elects not often contribute a great deal, and in many cases, doing to join, in part because it usually takes a spot away from so is not a part of their formal job description. The board another student who might be eager to do so. and national office encourage councilors to nominate Some chapters are inviting all students whose class worthy administrators, many of whom find the recogni- standing makes them eligible for membership to submit tion one of the most meaningful they have received. brief reflective essays setting forth their understand- Another program that merits more chapter participa- ing of AΩA’s mission and describing the ways in which tion is the Visiting Professorship program, which brings they would help to advance this mission if they were to distinguished physicians and scientists to medical school become members. This helps to prime newly elected campuses, where they address both AΩA members and members to hit the ground running and play an active broader medical school communities. One particularly role in the life of AΩA. It also provides additional useful appropriate occasion for such visits is each chapter’s an- information that chapters can use in determining which nual induction banquet, at which visiting professors often students to nominate for membership. serve as featured speakers. The national office supports It is especially important that all chapters engage new each visiting professor’s travel and lodging expenses and members as active participants in the work of the orga- provides an honorarium, making it a no-cost opportunity nization. The probability that members will get involved for chapters. seems to be highest near the time they first join. Many of The induction dinner can play several important roles. AΩA’s most vibrant chapters have developed programs Some chapters use the occasion as an opportunity to that give new members in all categories an opportunity to recognize faculty members who have been nominated support the organization’s missions with their time, tal- by students as models of teaching excellence or profes- ent, and treasure. Going forward, the plan is to dissemi- sionalism. Many charge a sufficiently high price for pay- nate examples of such best practices through both the ing attendees that inductees can be subsidized to attend website and upcoming issues of The Pharos. at no charge. Others use the occasion as an opportunity AΩA’s award programs are too numerous to detail for fundraising, sending out a request for donations here, but one that deserves more participation by many with invitations. Some also hold silent auctions at which

The Pharos/Winter 2014 49 National and chapter news

attendees can bid on items that have been produced by informative and energizing for those who attended, and members or donated by local organizations. provided participants with an opportunity to get to know Debbie Lancaster, managing editor of The Pharos and one another and exchange helpful tips and perspectives. webmaster, reviewed the national organization’s website, It is primarily at the level of each individual chapter that which continues to improve. The website now features a AΩA comes fully to life, and the extent to which each Chapter Resources page with information specifically for does so hinges in large part on the imagination and dedi- chapter personnel. cation of its councilor. Serving as a councilor is an ef- A session at the councilors meeting led by residency fective and rewarding way to make a difference not only initiatives coordinator Suzanne Pershing focused on for AΩA but also for the profession and the suffering keeping newly elected members engaged throughout their patients whom we strive to be worthy to serve. residency training, which often takes place at an institu- Respectfully submitted, tion different from the medical school where they were Richard B. Gunderman, MD, PhD elected. An informal poll of participants revealed that at Elma LeDoux, MD most institutions, resident members tend to have little Gabriel T. Virella, MD, PhD role in chapter life. Residents can be involved in many ways, including participating in the new member nomination process, contributing to service projects, and helping Instructions for Pharos authors to educate students about residency training in different We welcome material that addresses scholarly and fields. nontechnical topics in medicine and public health such as One key in engaging resident members is determining history, biography, health services research, ethics, educa- which residents at an institution are AΩA members and tion, and social issues, as well as philosophy, literature, then encouraging them to become involved in their lo- the arts, professionalism, leadership, and humor. Poetry cal chapter’s activities. It is generally helpful to identify a is welcome, as well as photograph/poetry combinations. resident or two who will serve as a local champion of resi- Photography and art may also be submitted. Scholarly fic- dent engagement. The new Postgraduate Research Award tion is accepted. All submissions are subject to editorial program also provides another opportunity to engage board review. Contributors need not be members of Alpha residents. Of course, it is always important to query resi- Omega Alpha. Papers by medical students and residents dents themselves about how they would like to become are particularly welcome. involved. Submissions must meet the following criteria: In conclusion, the 2013 councilor meeting was highly 1. Submissions may not have been published elsewhere

Lesley Motheral, MD, councilor at the Texas Tech University Lynn Cleary, MD, councilor at the State University of Health Sciences Center School of Medicine, and John Brust, New York Upstate Medical University and councilor MD, councilor at Columbia University College of Physicians and director on the AΩA Board of Directors, and Melvin Surgeons. Lopata, MD, councilor at the University of Illinois College of Medicine.

50 The Pharos/Winter 2014 National and chapter news

Regina Gandour-Edwards, MD, councilor at Gregory Strayhorn, MD, PhD, councilor at Morehouse School of Medicine, the University of California, Davis, School of and Amelia Drake, MD, councilor at the University of North Carolina at Medicine, and Kathleen Ryan, MD, councilor Chapel Hill. at Drexel University College of Medicine.

or be under review by another journal. double-spaced, with one-inch margins. They should be 2. Essays should have a maximum of 15 pages (approxi- accompanied by a covering letter and a title page with the mately 5000 words), and be submitted in 12-point type, word count (or page count), return address, and e-mail address. References should not exceed 20 unique items (see below). 3. Poems or photograph/poetry combinations should be in 12-point type, with one-inch margins, with the author’s name, address, and e-mail address on the first page. 4. Electronic submissions are preferred. Send them to [email protected]. Or send by mail to Richard L. Byyny, MD, Editor of The Pharos, 525 Middlefield Road, Suite 130, Menlo Park, California 94025. 5. After peer review, comments on the manuscript will be sent to the author along with an editorial decision. Every attempt is made to complete preliminary reviews within six weeks. 6. The editors of The Pharos will edit all manuscripts that are accepted for publication for style, usage, relevance, and grace of expression, and may provide appropriate illustrative material. Authors should not purchase illustrative material because the editors cannot guarantee that it will be used. 7. In accordance with revised copyright laws, each contributor will need to sign an Author’s Agreement, Dan Blunk, MD, councilor at the Texas Tech University which will be sent with the edited galleys. Information on Health Science Center Paul L. Foster School of Medicine. copyright ownership and re- publication of articles is de- tailed in the Author’s Agreement.

The Pharos/Winter 2014 51 National and chapter news

Participants meet in small groups to discuss chapter participation by residents.

Appleton & Lange; 1991: pp 25–41. Reference information Each reference should be listed in the bibliography only Authors are responsible for the accuracy of citations and once, with multiple uses of a single reference citing the same quotations in their papers. Once a manuscript has been bibliography reference number. Examples are available at our accepted for publication, therefore, the author will be re- web site: www.alphaomegaalpha.org. quired to provide photocopies of all direct quotations from Citation of web sites as references is discouraged unless a the primary source material, indicating page numbers. site is the single source of the information in question or has (Please mark the quoted material on the photocopies with official or academic credentials. Examples of such sites are highlighter.) In addition, the editors will require photocop- official government web pages such as that of the National ies of all references: the title page and copyright pages of Institutes of Health. Encyclopedia sites such as britannica. all books cited, the first and last pages of book chapters com are not primary references. cited, and the first and last pages of journal articles cited, as well as the Table of Contents of the particular issue of Leaders in American Medicine the journal in which the cited article appeared. PubMed or In 1967, as a result of a generous gift from Drs. David MedLine citations are also acceptable. The foregoing items E. and Beatrice C. Seegal, Alpha Omega Alpha initiated a will be used to verify the accuracy of the quotations in the program of one-hour videotapes featuring interviews with text and the references cited, and to correct any errors or distinguished American physicians and medical scientists. omissions. The photocopies will not be returned. The collection has been donated to the National Library References should be double-spaced, numbered con- of Medicine, which will maintain it for permanent use by secutively in the text, and cited at the end in the following scholars visiting the library. A listing of videos available for standard form: loan, as well as streaming videos of some of the collection, Journal: Zilm DH, Sellers EM, MacLeod SM, Degani N. can be found here: www.alphaomegaalpha.org, or by con- Propranolol effect on tremor in alcoholic withdrawal. Ann tacting Debbie Lancaster at d.lancaster@alphaomegaalpha. Intern Med 1975; 83: 234–36. org or (650) 329-0291. Those wishing to purchase copies Book: Harris ED Jr. Rheumatoid Arthritis. Philadelphia: from the National Library of Medicine may do so by con- WB Saunders; 1997. tacting Ms. Nancy Dosch, manager, Historical Audiovisuals, Book chapter: Pelligrini CA. Postoperative History of Medicine, Building 38, Room 1E-21, 8600 Complications. In: Way LW, editor. Current Surgical Rockville Pike, Bethesda, Maryland 20891. Telephone (301) Diagnosis and Treatment, Ninth Edition. Norwalk (CT): 402-8818, e-mail [email protected].

52 The Pharos/Winter 2014 New program AΩA Fellow in Leadership Award

t its annual meeting in October 2013, the AΩA Board of Directors approved an AΩA leadership awardA and development program to be implemented in 2014. Leadership has long been a core value of Alpha Omega Alpha Honor Medical Society, and is one of the criteria for membership. Unfortunately, many AΩA members with leadership potential or leadership experience at mid-level positions may find themselves without the resources to advance their careers. We believe this is a lost opportunity for medicine. How can AΩA as an interdisciplinary honor medical society best support and contribute to leadership promotion and development as part of our mission and one of our core values—“to improve care for all by encouraging the development of leaders in academia and the community”? The AΩA Fellow in Leadership Award will recognize and support further development of outstanding leaders exemplifying the qualities of leading from within, the society’s professional values, and the concepts of servant leadership. The five essential components of the program are: 1) Self-examination, the “inward journey,” leading from within; 2) a structured curriculum focused on topics related to leadership, including an understanding of the relationship between leadership and management; 3) mentors and mentoring; 4) experiential learning to broaden the perspective and understanding of leadership as it relates to medicine and health care; 5) team-based learning and developing communities of practice. Mid-career physicians providing outstanding leadership in organizations in medicine and health care, including schools of medicine, academic health centers, community hospitals, clinics, agencies, or organizations, with a high promise for future success and contribution are eligible to apply. The proposed nominees must be members of AΩA. For information about the AΩA Fellow in Leadership Award, please see our web site: http://alphaomegaalpha. org/leadership.html. A proud

AΩA’s new scarf highlights the society’s insignia, based on the shape of the manubrium sterni. Te center medallion feature the Pharos lighthouse of Alexandria, one of the seven wonders of the ancient world, for which AΩA’s journal is named. Te borders are stylized DNA strands.

Alpha Omega Alpha neckties or freestyle bowties are fashioned from ﬁne silk by Vineyard Vines of Martha’s Vineyard, Massachusetts.

Scarves are 35 x 35 inches, of 12 m/m silk twill with handrolled hems. Four colorways are available as shown: red/black, turquoise/ purple, peach/mint, and navy/lavender. Scarf design by J&J Designs of San Francisco (jnjdesigns.biz). To order, send a check for the appropriate amount to: Alpha Omega Alpha, 525 Middleﬁeld Road, Suite 130, Menlo Park, CA 94025. Or order online at www.alphaomegaalpha.org/store. Price includes shipping and handling.