Officers and Directors at Large Editorial Board Medical Organization Director Councilor Directors Coordinator, Residency Initiatives Student Directors Administrative Office 525 Middle!eld Road, Suite 130 Editorial Mentoring and coaching in medicine
Richard L. Byyny, MD
he concept of mentor was first described by Homer in the negotiation for my first faculty position, my chairman of Odyssey, personified in the character Mentor, the “wise Medicine asked me, “If you could do anything, what would you andT trusted counselor.” Physicians can be excellent mentors do?” I had never been asked that before—I never even asked because of their motivation to serve, to share knowledge and myself that question—but I quickly formulated my answer, a experience, and their commitment to caring. Mentoring as different one than what we had negotiated. His response was, defined by the Study Committee on Postgraduate Medical “Why don’t you do that and I will help.” and Dental Education is “a process whereby an experienced, I followed my passion, with his help and guidance, along a highly regarded, empathetic mentor guides another individual different professional path. in the development and re-examination of their own ideas, Later, one of my patients, the president of the university, learning and personal and professional development. The asked me during his office visit with me, “What are you going mentor achieves this by listening or talking in confidence to to do next in your career and professional life?” I answered, “I the mentee.” have been wondering about that and I have no idea.” Mentors have wisdom and experience worth seeking His next question was: “What did you want to do before out. They are people who are willing to spend their time to you were professionalized?” I reflected back and explained guarantee a protégé’s success. Mentors are especially helpful that I had been a history major and had thought I would be a when they share personal knowledge, advice, and experi- history professor. Although I had no clear idea what it meant, ence, provide feedback about performance, and help mentees I said I thought maybe I would become the president of a small understand professional culture, traditions, networks and college. He asked, “Why don’t you do that?” My response was, opportunities. “Because I have been professionalized.” Then he said, “You are My career attests to the need for good mentors. There were better prepared than you think, and if you want to pursue that no physicians in my family, but I was fortunate to find men- path I will help.” He helped, and again I changed my profes- tors who used their professional networks to introduce me sional trajectory. to medical school faculty and to distinguished and successful I tell these stories to emphasize how important teaching, professionals in the community. coaching, and mentoring can be in our personal and profes- During medical school, many of my teachers taught me sional development, and to illustrate the importance of men- well and served as exceptional role models. The best were tors, mentoring, and coaching. smart, tough, fair, demanding, and supportive. They were also Although we intuitively know the definitions of each of kind, humane, compassionate physicians caring for the poor, these important roles and functions, let’s look at them again: and always treating the sick and suffering with respect and • Teaching is “to cause one to know something, to know dignity. how, to guide the studies, to impart knowledge, to instruct by During residency, the faculty and more senior residents precept, example, or experience.” expected far more work and set a higher expectation for me • A coach is “a private tutor who instructs and/or trains than before. But they set the same high standard for everyone. players, athletes, musicians in the fundamentals, skills and My mentor during my endocrine fellowship was not a warm intricacies to improve performance.” and communicative person, but he demanded curiosity, pur- • A mentor is “a trusted counselor guiding the professional suit of excellence, hard work, critical thinking, and excellent development of an individual.” communication skills. There is much overlap in these functions, and it is impor- I have been fortunate to have had many excellent tant to recognize that good mentors are all of these things, mentors during my academic career who helped and that they change their techniques and functions over time me through many important experiences and based on the needs of those they mentor. gave me much wise advice, but it is the wise We recently surveyed small numbers of AΩA members questions they asked me at critical points about what they would most like to contribute to medicine. that I remember most. The great majority responded, “to mentor undergraduate When I was concluding my students, medical students, and/or young, less experienced
The Pharos/Winter 2012 1 Mentoring and coaching in medicine
physicians.” If that describes you, I encourage you to seek out Table !: Tips for Good Mentoring mentors for your professional development, and to serve as Self-Assessment Mentor mentors to others. The process of professional development is complex. Commit to mentoring Offer guidance and direction regarding professional goals and Professionals must first acquire knowledge and the skills of Have a clear understanding of your motivation to mentor issues their profession through study and experiential learning. Provide timely, clear, and But true professional expertise comes through practice and Mentor based on a realistic assessment of your skills and comprehensive feedback to constant feedback, often from a mentoring relationship with leadership abilities questions a senior colleague. The mentee learns and internalizes the Recognize barriers to good Set goals, objectives, and timetables profession’s attitudes and values, most often with a mentor. mentoring that often relate Explore, teach, and illustrate Mentoring is an iterative process analogous in many ways to to time and be realistic about Discuss professional and preparing for and embarking on an expedition. your time commitment unprofessional behaviors Each mentor/mentee relationship must be based on the Ensure a noncompetitive Discuss the importance of self- common goal of advancing the educational, personal, and relationship regulation as a professional professional growth of the mentee. Although there is no single Set the Principles Teach how to set priorities and how successful mentoring model, there are identified character- Develop mutual respect to politely say no istics of good mentors and mentees. Five basic elements for Develop good Emphasize the importance of successful mentoring relationships have been described as: communications and problem teamwork for a professional • The relationship focuses on achievement or acquisition solving strategies Offer wise counsel and answer of knowledge Emphasize ethics and questions clearly • It consists of emotional and psychological support, direct professional values Offer to serve as a confidante, if assistance with career and professional development, and role Be direct and honest appropriate modeling Commit to confidentiality Model continuous learning • Both mentor and mentee derive tangible benefits Listen carefully to understand Build a professional network • The relationship involves direct interaction, and is per- Clearly communicate your Promote reflection and learning sonal in nature expectations Anticipate misunderstandings • It emphasizes the mentor’s greater experiences, influ- Be flexible and adaptable Promote greater initiative, ences, and achievements in the profession or organization. Be fair and just independence, and self-reliance Good mentors inspire others to be like them because of Be nonjudgmental in the Address fears, anxieties, low self- aspects of their character, ethics, and expertise, and their ac- relationship esteem, worries, and pressure cessibility and approachability. They respect and are respected Communicate hope and Ask questions: by their peers. optimism • What are you passionate about? Some general principles for mentoring are set out in the • What gives you the most joy? Advise, don’t dictate or be • What are you good or best at tables following. Hopefully, they will help guide mentors and autocratic doing? mentees in this complex and developmental professional rela- Give constructive criticism Explain the criteria for advancement tionship of mentoring. Celebrate success in the organization When I reflect on the people who had the greatest influ- Be reliable Encourage development of skills and ence on me, I think of my coaches. From my first competitive Nurture self-sufficiency knowledge swimming coach at the YMCA, to my swimming and water Share yourself Encourage original thinking and polo coaches in high school, junior college, and at the univer- appropriate risk taking Use common sense sity, coaches were the most influential people in my life and Share stories Remember career early development. Each one coached me for many hours each development is an Stimulate periodic reflection about day and over long periods, effectively coaching the required evolutionary process the path and encourage continuous skills, and teaching me how to train and persevere, set high learning goals and aspirations, and improve through practice and rep- etition. They taught me how to compete and to understand the value of competition. I experienced the joy of improv- in the New Yorker magazine, “Personal Best: Top Athletes and ing, succeeding, and winning. They were also mentors who Singers Have Coaches, Should You?” In the article, he points helped me to develop good values, to reflect and change, and out that in our traditional educational and professional pro- to work as a team member for a common goal. I also learned cess there is a perception that after a defined amount of time about quantitative data, that the final time or score was not a student no longer needs instruction. It is presumed that negotiable. after a certain point you go the rest of the way on your own by Recently, Dr. Atul Gawande published an interesting article practicing what you have learned.
2 The Pharos/Winter 2012 Table !: Working with Your Mentee Table ": Tips for Mentees Find joy in your mentee’s Acknowledge contributions of Self-Assessment Learn improvement and successes your mentee Have a clear understanding of Actively listen and contribute to Have a clear understanding of the Help your mentee develop your motivation to be mentored the conversations expectations and goals of your humility Select a mentor based on your Do your homework mentee Help your mentee develop self- short-term goals and career Use other resources to look up Encourage your mentee’s ideas esteem interests useful information and work Be aware of biases and don’t let Have a clear understanding Demonstrate the ability to set Provide constructive and useful assumptions interfere of your expectations of your agendas critique of your mentee’s work mentor Encourage your mentee to take Ask what knowledge, skills, and Challenge your mentee to on leadership roles Be proactive to find mentors expertise you need to develop expand and improve his abilities Observe your mentee at her Be realistic about time further Respect the uniqueness and professional work commitments Discuss what you believe to be the contributions of your mentee Ensure a noncompetitive strengths you already have relationship Be aware when the relationship Determine your areas of need has run its course In contrast, coaching holds that no matter how well pre- Determine the help needed to Say “thank you” pared people are after their education and training, few can reach your potential and goals Celebrate accomplishments achieve and maintain their best performance on their own. Decide what you hope to gain Give back to the profession by Most people continue to practice what they are already good from mentoring mentoring others at, but need an outside perspective to learn how to continue Set the Principles to improve. Communicate your expectations Accept criticism Good coaches or mentors can observe a performance and Be reliable Continually reassess performance break it down into crucial individual components, then make Be honest Be respectful suggestions about how to improve. A good coach makes you aware of where you are falling short. Then, with the coach’s Follow through Act on your own initiative feedback and suggestions and your own self-effacement and personal practice, you can move forward. There are currently no recognized coaches in medicine. development and in medicine, the effects of mentoring are The practice of medicine is largely unwitnessed by anyone. difficult to measure and the literature is limited. Among the After a number of years of “practice,” a doctor is considered an perceived benefits of mentoring include greater satisfaction expert forever. But this is clearly not true. Gawande writes: “As in the profession, help with and a widening of career choices, I went along, I compared my results against national data, and improved coping skills, increased social support, improved I began beating the averages. My rates of complications moved professional development, improved bedside and learning steadily lower and lower. And then, a couple of years ago, they skills, better ability to monitor personal development, im- didn’t. It started to seem that the only direction things could proved professional behavior, broader educational experience, go from here was the wrong one.” Recalling an afternoon spent and increased networking. with a tennis coach improving his serve, Gawande decided Our profession requires us to be continual students and what he needed was a surgical coach. He enlisted a former learners and show continual improvement as physicians. All mentor who observed him in practice and made many help- of us can use good teachers, mentors, and coaches. ful suggestions for improvement in his operations. With that Physicians have always been teachers. We often think about coaching, he was successful in improving performance, and teaching medicine in the traditional sense of lectures, case hopefully patient outcomes. presentations, ward rounds, surgery, and other learning expe- Gawande concludes, “Coaching done well may be the most riences. I believe we should view mentoring as a professional effective intervention designed for human performance.” He obligation and seek opportunities to mentor others. writes, “In the past year, I’ve thought nothing of asking my I hope you will read and reflect on mentors, mentoring, hospital to spend some hundred thousand dollars to upgrade and coaching and pursue opportunities to give back to oth- the surgical equipment I use, in the vague hope of giving me ers what you have learned and experienced preparing for and finer precision and reducing complications. . . But the three or practicing in medicine. four hours I’ve spent with [my coach] each month have almost Richard L. Byyny, MD, FACP certainly added more to my capabilities than any of this.” Executive Director, Alpha Omega Alpha While many of us empirically know the value and impor- Editor, The Pharos tance of teaching, mentoring, and coaching in professional
The Pharos/Winter 2012 3
DEPARTMENTS ARTICLES
Editorial 1 Mentoring and coaching in “My life, my soul, my body I owe to you medicine and God” Richard L. Byyny, MD, editor Harvey Cushing and the patient-physician relationship seen through correspondence 2011 Robert J. Glaser 42 Distinguished Teacher Courtney Pendleton Awards
Reviews and reflections Choosing a medical specialty 44 Exploring Happiness: From Aristotle to Brain Science Epiphany, where are you? Reviewed by Stephen G. Post, PhD Jenna L. Thomason, BS Match Day: One Day and One Dramatic Year in the Lives of Three New Doctors Reviewed by R. MacDonell- Carlos Finlay, Walter Reed, and the politics Yilmaz, MPH of imperialism in early tropical medicine We’re NOT Leaving: 9/11 Daniel Liebowitz Responders Tell Their Stories of Courage, Sacrifice, and Renewal Reviewed by Richard Bronson, MD 50 Letters
Harvey
University,
Library.
Yale
MD,
Medical
Boyd,
Whitney
Willard
Hay
Walter
by
Photo Cushing/John On the cover Dr. Harvey Cushing closing 2000th verified brain tumor, April 15, 1931. Photo by Walter Willard Boyd, MD. Yale University, Harvey Cushing/John Hay Whitney Medical Library. See page 6
AΩA NEWS
2011 Robert J. Glaser The AMA and health care reform 42 Distinguished Teacher Allison Hinko, MD Awards N a t i o n a l and Chapter news 48 2011 meeting of the AΩA board Competencies as the basis for reformed of directors Instructions for authors premedical education Leaders in American Medicine The case for an unrestricted liberal arts collegiate education Nathan Kase, MD, and David Muller, MD POETRY
Breaking Bad News 23 Sarah Leeper A Reminder 31 Allison Jiang Mechanical Man 41 Henry Langhorne, MD Graduatin, We Pack 52 Sarah Buckley, MD INSIDE Adagio Ma Non Troppo BACK 39COVER Richard Bronson, MD
!"
Courtney Pendleton The author is a member of the Class of 2012 at the Johns reviewed and analyzed. Unless otherwise noted, all quotations Hopkins University School of Medicine. This essay won are taken from the unpublished surgical records.3 first prize in the 2011 Helen H. Glaser Student Essay These files contain the tremendous volume of written cor- Competition. respondence between Cushing and his patients and colleagues across the globe. The many facets of the patient-physician he need for written documentation in the medical relationship are illuminated through the lens of the written profession has grown over the past century, in re- correspondence between Cushing and his patients. sponse to the increasing complexity of medico-legal regulations.T Yet, for all the written notes charting phone calls, Post-operative follow-up lab reports, clinic visits, and follow-up, the contemporary At the turn of the twentieth century, Cushing had estab- clinician meets the classic definition of a cynic, “A man who lished a nationwide referral base, operating on patients from knows the price of everything, and the value of nothing.” 1p116 as far west as California and as far north as Canada.3,4 With In the era of e-mail, social networking, and electronic patient travel still a time-consuming endeavor of long locomotive records, written correspondence has arguably become less a journeys, it was often impossible for patients to return to the necessity and more a quaint pastime, and the immense value Hopkins clinic for post-operative observation and care. Many of the letter as a tool for patient-physician communication has patients were lost to follow-up, presumably obtaining further been forgotten. care closer to home from specialists or primary care physi- Through IRB approval and courtesy of the medical records cians. Cushing regularly wrote to these former patients, ask- office and the Alan Mason Chesney Archives of the Johns ing for information regarding their health and post-operative Hopkins Medical Institutions, the surgical files from the Johns course. Most of them offered straightforward descriptions of Hopkins Hospital from to were accessed. The cases their health conditions, as in the letter written by a thirty-six- attended by Harvey Cushing, an inveterate letter writer,2 were year-old sailor whom Cushing treated for epilepsy:
I am very glad to let you now of my condition as it is over ninety days since I had a convulsion and I am very hopeful Left, Harvey Cushing at the bedside of a child. Photo by T. W. Dixon. Yale University, Harvey Cushing/John Hay Whitney Medical Library. of getting well again. My physical condition is fairly good Above, Harvey Cushing in a straw hat, 1903. but I still retain those periods of quiet not caring to converse Yale University, Harvey Cushing/John Hay Whitney Medical Library. with anyone.
The Pharos/Winter 2012 7 “My life, my soul, my body I owe to you and God”
A handwritten letter from the first patient Cushing operated on through the omega incision for a sellar lesion. He wrote: “I hope there is something that you can send that will lessen the pain. The least amount of urine in twenty four hrs was a bout three pts—& the most—about four pts—it varies as some days I drink more water than others. Thanking you for past favors I remain as ever” Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions.
Cushing’s intraoperative illustration of a surgical inter- vention for epilepsy in a seventeen-year-old female patient. Stimulation of the cortex was done to map the motor area, and Cushing labeled the areas “hand,” “face,” [illegible], “tongue” from top to bottom. The patient’s mother later wrote that there had been no improvement in her daughter’s condition.
Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions.
Not all follow-up reports were positive, however. The medications and supplies, including large batteries for the mother of a seventeen-year-old girl who had also undergone electrical stimulation he prescribed for patients who had operative intervention for epilepsy wrote to Cushing almost undergone peripheral nerve operations. One such patient three years post-operatively: was the first patient Cushing operated upon for a presumed sellar lesion using the so-called omega incision. This patient In regards to your letter about my daughter I don’t see diligently catalogued his symptoms in letters to Cushing, pre- that she is any better now she has that bad feeling in hur sumably in response to instructions from the neurosurgeon: head like she had when she went there and the attacks ar the same her helth is very good only once a month she has I can’t see that there is an increase in the amount of hur bad attacks drawing in hur lages and arms and pain in urine within the last year but will try t measure it . . . my hur back and head. She had a bad spell after she came home kidneys act from two to four + sometimes five times during from the hospital she was taken the of june with a sleepy the night. feeling in hur hands and feat and lost the use of hur self and stade so till the next spring Clearly the patient tried to follow Cushing’s instructions to the letter, going so far as to redact his words to show that he would Although the operation was not successful in treating the not merely attempt to perform a task, he would complete it. patient’s epilepsy, the mother’s letter contains no trace of bit- Probably unbeknownst to him, he was using these epistles terness, and she closed with a request to Cushing to “let us to describe the presence or absence of symptoms of diabetes heair from you a gain.” inspidus, a syndrome Cushing knew occurred after sellar op- erations.4 Later, the patient wrote to Cushing:
Patients often faced a difficult conundrum: they were I do not feel able to go to Baltimore. Why can you not not well enough to travel to Baltimore, but were unable to doctor me here by sending the treatment here so I can re- obtain specialized medical care or pharmaceuticals close to main at home. home. Many patients wrote to Cushing asking that he send
8 The Pharos/Winter 2012 Cushing must have responded in the affirmative, because the Patients’ families used these notifications of death to search next letter, dated nearly four months later, says: for answers as much as to give information. The family of a twenty-four-year-old woman on whom Cushing performed Dear Dr. surgery for a brain tumor wrote to him upon her death: I have finished taking the tablets but am feeling a bout the same as I did before taking them. Writing to you today is with a different feeling than the one over a month ago, I would not dare think our darling would not recover, however without pain and in so terrible Death notification condition we try to be reconciled though now as I study and Contemporary physicians customarily use Internet searches wonder it would be so comforting to know, where did you and national databases such as the Social Security Death Index locate the pressure . . . and what was the immediate cause to find information about patient deaths. In Cushing’s era, in- of her going? formation traveled more slowly, with no central repository to access for this information. The majority of Cushing’s patients treated at the Johns Hopkins Hospital lived and died without Gratitude having a Social Security number (the program was instituted Patients most frequently wrote to Cushing to express their in ), making their fates difficult to ascertain even with all gratitude for his interventions, almost regardless of his suc- the resources of modern technology. cess. Some of the most effusive letters were written by patients Families often sent letters to simultaneously inform who underwent surgical treatment for trigeminal neuralgia, a Cushing of the death of a former patient and to express grati- paroxysmal pain syndrome dubbed the “suicide disease” be- tude for his operative services and continued interest. cause of the intractable pain it causes those suffering from it. The mother of a five-year-old child who was operated on This point is certainly emphasized by the chief complaint of for a brain tumor wrote a little less than three weeks following “misery in the head” documented for a patient diagnosed with the end of their hospital stay: the disease. One fifty-seven-year-old patient, treated in , wrote that he experienced: Dr. Cushing, Dear Friend, never a twinge from the nerve! A world of thanks and praise Just a few lines to let you know that my dear little girl to you, my dear sir. May your hand never lose its wonderful died last week July . She died without a struggle just as cunning! though she were asleep. I only wish she would have been where you could have A young man whose epilepsy made him incapable of work- tapped that place as it was very full . . . ing was able to return to light work in the family business after Thanking you for all your many kindnesses shown us. Cushing operated. The patient wrote:
Cushing was clearly viewed as a healer in the truest sense by I am surely thankful I became aquainted with Dr Harvey this family. That the mother offered her thanks to the sur- Cushing for I feel sure my Lord hath blessed me in this way geon who failed to save her daughter’s life is a testament to and through you has enabled me to reash my highest aspira- Cushing’s skill at the bedside as well as within the operating tions and also fulfilled an anxious mothers hope theater.
The Pharos/Winter 2012 9 “My life, my soul, my body I owe to you and God”
Cushing’s original intraoperative drawing of cortical softening in a thirty-eight-year-old man treated for thrombosis of the middle cerebral artery. Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions. The closing of the final letter to Cushing from the above patient. He wrote to Cushing on many occasions, expressing his gratitude. Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions.
Despite Cushing’s best efforts, the patient had continued to He wrote again in December : have seizures during his post-operative stay in the hospital, but his letter reflects no frustration or disappointment. Again I want to thank you with all my heart that you have This profuse gratitude in the face of less than ideal results saved me, of course nature is trying to heal in the brains but is not unique—multiple letters echo these sentiments. At the never-the-less it was you who saved me. There is no doubt turn of the twentieth century, neurosurgery was still consid- about it. ered by many to be a fool’s errand at worst, and a desperate last resort at best. These patients may have recognized that Five years later, the patient’s last letter to Cushing reads: Cushing had shepherded them through the no-man’s-land of an intracranial operation and brought them out unscathed, So in a way, I am happy because for the last three years it possibly even improved. One thirty-eight-year-old patient is a beautiful world. . . . even now I cannot express myself with symptoms consistent with a left-sided lesion underwent the way I want to but I go where I please now. I was in Los surgery. Cushing expected a brain tumor, but a second op- Angeles and San Diego last spring myself and that is proof eration revealed a thrombosed middle cerebral artery and that I go where I please by myself and for a good many years softening of the surrounding brain parenchyma. The patient I could not do it. It was certainly a wonderful operation in was discharged in “improved” condition, but his right-sided Baltimore. weakness and aphasia remained. He wrote nearly three years later, stating: Overall, the letters of thanks from Cushing’s patients ap- pear to value increased independence over complete cure of First of all, My life, my soul, my body I owe to you and their ailments. God. I am gaining nicely and it is the first time for pretty near three years that I thought I would write to you to-day.
10 The Pharos/Winter 2012 Other requests appears that Cushing himself attempted to avoid responding The written correspondence filed in the surgical records is in either way. by no means confined to clinical outcomes and medical ques- tions; many of the letters reflect the complexities and conun- Dr. Cushing, drums of the patient-physician relationship that Cushing must Why don’t you write. You did not answer my last letter. have struggled with throughout his career. . . . I would like to see you and tell you all and I want you to see K . . . ever time she gets sick she says she wants to see Dr. Cushing.
There is no record that K and her mother ever re- turned to Hopkins, or that Cushing proffered a re- sponse. The last letter from the family was dated March :
I know you will be surprised to hear from me. Guess you remember me and little K who you oper- ated on for spasms, I am glad to say she is so much better and doing fine you certainly did help her some times she goes for months and don’t have one. And I think she will get entirely over them. I wish you could see her she looks fine. And thinking of getting married this summer what do you think about it let me have your opinion. I told her I was going to ask you about it first. She sends her love to you and said tell you she would love to see you.
One of the delights of the written letter is the poten- A handwritten from the mother of a girl Cushing had operated on tial of inferring what the author might have implied. In for idiopathic epilepsy when the patient was sixteen years old. this case, it may be that the mother merely sought Cushing’s in- The mother wrote multiple letters attempting to set up a meeting between her daughter and Cushing, with unknown intentions. person evaluation of her daughter, but the persistence of these Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of efforts, coupled with the request that Cushing weigh in on her Johns Hopkins Institutions. daughter’s impending marriage, offer a titillating alternate pos- sibility—she may have attempted to play matchmaker for her In the spring of , Cushing operated on a sixteen-year- daughter and the young, albeit newly married, neurosurgeon. old girl for the treatment of “idiopathic epilepsy.” She had an While such a scenario may seem unlikely, Cushing had a uneventful recovery, and was sent home in improved condi- fair share of ardent admirers among his female patients. In tion. Her mother began a correspondence with Cushing that April Cushing operated upon a twenty-three-year-old spanned the next three years; the letters begin innocuously woman for a “cerebellar pontine tumor.” The operation met enough, with the mother writing: with success and she was discharged in “improved” condition. In November , two months after leaving the hospital, the Enclosed is record of K’s attacks during month of September, patient wrote a very flattering letter to Cushing: her condition generally is about the same . . . Please let me hear from you soon, what do you think of her now? Dear Dr. Cushing, I suppose you wonder who in the world this is, so I’ll tell The postscript to that letter begins to develop shades of you it is none other than M who so often thinks and talks of strangeness: you, her favorite Dr...... If you were near enough I’d give you some of the nice PS. things I get to eat. I would like for you to see K I can bring her to see you if Dr. Cushing, would it be asking too much to ask you to you want to see her. Let me know. I want you to see her and send me your picture? I’m sure if you knew how much I want then I can explain all to you. She looks so well. it you would grant my request. I declare, Dr., I want it worse than any thing I know of. Within the hundreds of letters contained in the surgical re- Please write, in your own hand, your name and date under cords, most contain patients’ regrets at being unable to travel the picture. . . . to Baltimore to see Cushing; this mother’s letters are the only If you practice your profession forty thousand years you written correspondence that so steadily pursues an appoint- will never have a patient who loves you like ment with Cushing. From the next letter, dated early , it M
The Pharos/Winter 2012 11 “My life, my soul, my body I owe to you and God”
Dr. Harvey Cushing, the 2000th verified brain tumor operation, April 15, 1931. Photo by Walter Willard Boyd, MD. Yale University, Harvey Cushing/John Hay Whitney Medical Library.
Though Cushing regularly corresponded with his patients, Cushing continued this correspondence, although his letters and may have written to M and her family, he appears to have are not preserved in the surgical files. The last handwritten avoided responding to this particular request, much as he did note is dated March , and describes M’s continued interest with K’s mother. M was not to be dissuaded, however, and in in seeing Cushing again: March she wrote Cushing again: we are hoping that business or pleasure may sometime bring Dear Dr. Cushing, you to this part of the U.S. and that we may have the very I’m writing this note to find out if the extremely cold great pleasure of entertaining you here. Don’t you think that winter has frozen your memory— Do you know that you said might be a possibility. you would sometime send me a picture of yourself— ? Have you not yet been the victim of a photographer?” This letter includes a glimpse at the general fondness she had for all her attendings at the hospital:
Was I to infer from your last letter that Dr. Goetsch is now a Bostonian . . . I certainly would like to see him if he wouldn’t shave my head again.
The chart contains a final letter, dated July , which was excerpted and typed into the surgical record. The excerpts contain entirely clinically relevant descriptions of the patient’s condition at that time, without a hint of the more personal communication she had held in earlier letters.
The handwritten letter from a former patient, who was operated on for a suspected brain tumor in 1911. Courtesy of the Medical Records Office and the Alan Mason Chesney Medical Archives of Johns Hopkins Institutions.
12 The Pharos/Winter 2012 Referrals As an up-and-coming young neurosurgeon, Cushing certainly strove to develop his practice beyond the confines About Courtney Pendleton of Baltimore. By the early s, he had expanded his prac- I studied studio art and English tice to include patients traveling great distances to visit the literature at New York University, Johns Hopkins Hospital. Many of his former patients wrote graduating in , and am currently describing cases of friends and loved ones that they hoped a fourth-year student at the Johns would fall within the purview of Cushing’s practice. Hopkins School of Medicine. I plan In addition to advocating for personal care for her daughter, to pursue a career in neurosurgery, and I thank Dr. K’s mother sought a consult from Cushing for a family friend: Alfredo Quiñones-Hinojosa for supporting this work.
Now Dr. Cushing, I have a friend here, and he has a brother that is insane caused from kick in the head over years go. The poor man has large family and not much money for he has been sick so long. What would you operate on him for? How cheap could you do it. Please let me know by return Hospital, from African-Americans born in the South before the mail. He is not wild very quiet and his brother will bring him Civil War to urban socialites with charts full of documentation to you. Please let me know at once. from European specialists. The letters written by these patients are equally varied, including well-written genteel epistles and No patient chart matching this description can be found in the harried notes full of misspellings. Unlike the documentation surgical records. It is uncertain if Cushing declined to see the that fills contemporary medical records, which often provide patient, or if the patient came to the Johns Hopkins Hospital only abstracted clinical data, these letters offer insights into under the care of another attending. the lives of the patients who painstakingly wrote them, as well Another rich source of referrals was Cushing’s growing as the surgeon bound to receive them. The handwriting often group of satisfied former patients. While the surgical records chronicles the decline of patients suffering from incurable do not indicate whether patients were referred by friends or brain tumors; the laboriously written, misspelled letters show acquaintances who had been treated by Cushing, many letters us the perseverance of patients with limited education who indicate that patients translated gratitude into referrals. In desired nothing more than to communicate their gratitude; particular, Cushing’s success at treating trigeminal neuralgia and the detailed descriptions of symptoms and signs over time earned him much admiration among his patients. One sixty- demonstrate patients’ efforts to provide a trusted physician three-year-old man who underwent avulsion of the sensory with adequate information to treat them from afar. Through root of the trigeminal nerve wrote expressing his gratitude: each letter we see Cushing not as the curmudgeonly taskmaster often portrayed in biographies,2,5 but as a young neurosurgeon Now my dear doctor, how to express my gratitude to you with enough humanity to inspire this volume of earnest letter for what you have done for me, I am at a loss to know. I shall writing. ever regard you as my greatest benefactor in this world, and pray the good Lord to shower upon you His heavenly bless- References ings, and make you instrumental in giving relief to many . Wilde O. Lady Windermere’s Fan. London: A.R. Keller; . more such afflicted mortals as I was. . Bliss M. Harvey Cushing: a Life in Surgery. New York: Oxford University Press; . He was not content to leave matters entirely in the hands of . The Johns Hopkins Hospital Surgical Records to . “the good Lord,” and later wrote: Courtesy of the Alan Mason Chesney Archives of the Johns Hopkins Medical Institutions. Several parties afflicted as I was have either written to me or . Cushing H. The Pituitary Body and Its Disorders: Clinical called on me personally and I have recommended you as a States Produced by Disorders of the Hypophysis Cerebri. Philadel- specialist, who can certainly give them relief. phia: J.B. Lippincott; . . Fulton JF. Harvey Cushing: a Biography. Springfield (IL): Charles C. Thomas; . Conclusions The surgical records reveal the truly diverse patient popula- The author’s e-mail address is: [email protected]. tion treated by Cushing during his time at the Johns Hopkins
The Pharos/Winter 2012 13 14 The Pharos/Winter 2012 Choosing a medical specialty Epiphany, where are you?
Jenna L. Thomason, BS The author is an MD/MPH candi- family physician. I tested each reflex seeing mostly sick patients, skin versus date in the Class of 2012 at Emory and every nerve during my neurology bones versus eyes . . . and it’s more University School of Medicine and clerkship. At the side of a radiologist, I complicated than those aforemen- the Rollins School of Public Health at learned anatomy that Arnold couldn’t tioned molecular, biochemical, and cel- Emory University. teach me. I cared for many minds on lular mechanisms ever were. psychiatry and many tiny bodies on So, dear Epiphany, why are you so epiph·a·ny noun \i-΄pi-fә-nē\: () : pediatrics. I have witnessed the full late? You were supposed to make this a usually sudden manifestation or range of disease etiologies, including an easy decision. Is this punishment perception of the essential nature or genetic, developmental, toxic, infec- for all of those days during first year of meaning of something () : an intui- tious, traumatic, metabolic, chemical, medical school when I snuck into tive grasp of reality through some- neoplastic, and degenerative. I have lecture when the minute hand was a few thing (as an event) usually simple studied the vast spectrum of treatment degrees past ? I thought for sure that and striking () : an illuminating options, including behavioral, pharma- you would be here by now. I was count- discovery, realization, or disclosure. cologic, and surgical, and I understand ing on you. I’m starting to think you’re —Merriam-Webster Online the rationale and application of each not coming. Maybe you never were. to the above disease etiologies. All this Contrary to my idealistic expecta- h Epiphany, where are you? has led me to the most difficult profes- tions, many medical students—if not I attended a year and a half sional crossroads of my life: Where do I most—end up marking you down as a Oof lectures and absorbed as go from here? “no show” in our appointment books. much information as possible about The decision to pursue medical The truth is, there may not be one every molecular, biochemical, and school was the easiest decision that single specialty that’s right for any of cellular mechanism imperative to I have ever made. I’ve never known us. If we are having trouble deciding maintaining the body’s homeostasis. a stronger desire than the one that I between two or three, any one is likely I spent countless hours in the base- felt (and still feel) to become a doc- to fit roughly equally as well as the oth- ment of the medical school learning tor. I wanted to make the commitment ers. After spending many months ago- anatomy from my cadaver (whom we to caring for people and possess the nizing over this decision, I have finally fondly named “Ar nold”). I have studied knowledge to do so. I hardly knew what found that Jenna the pediatrician is not every organ system—integumentary, I was getting myself into, but I couldn’t so different from Jenna the dermatolo- musculoskeletal, respiratory, lymphatic, wait to get started. gist or Jenna the geriatrician—because cardiovascular, endocrine, genitouri- So how did the simplest decision I will not be defined by the type of pa- nary, gastrointestinal, nervous, repro- turn into the hardest one? And when tient I see, but how I see them. ductive—as well as the hundreds of did life become a multiple choice test? Stress over what divides us is tem- disease processes that cause these sys- All of sudden I have to chose between: porary, but preserving what unites tems to go awry. (a) kids; (b) adult males and females; us—commitment to lifelong learning, I wielded a blade like a surgeon. (c) females only; or (d) both (a) and medical ethics, and our patients—is I walked the halls of Grady like an (c). I have to decide whether I want to unceasing, and is what earns all of us internist. I delivered a baby like an interact with patients or examine their the extra letters that follow our last obstetrician. I held the hand of a dying pictures or inspect their pieces (in the names. patient as a palliative care provider. I form of pathological specimens). Do Epiphany, we meet at last. distinguished macules from papules I want to know a little about a lot or a and patches from plaques on my der- lot about a little bit? I have to factor in The author’s address is: matology rotation. I treated everyone lifestyle, inpatient versus outpatient, 2210 Westchester Ridge NE from tiny babies to pregnant ladies academics versus private practice, Atlanta, Georgia 30329 to the elderly as the understudy of a seeing mostly healthy patients versus E-mail: [email protected]
The Pharos/Winter 2012 15 Yellow fever epidemic in Philadelphia, 1793. Carriages rumbled through the streets to pick up the dying and the dead. Woodcut shows Stephen Girard on errand of mercy. © Bettmann/CORBIS.
Daniel Liebowitz The author is a member of the Class of 2015 at the Major General William Shafter on August , , Lieutenant University of Vermont College of Medicine. This essay won Colonel Theodore Roosevelt wrote honorable mention in the 2011 Helen H. Glaser Student Essay Competition. There is no possible reason for not shipping practically the entire command North at once. . . . If we are kept here it n a warm September day in , American and will in all human possibility mean an appalling disaster, for Cuban scientists and dignitaries convened in the surgeons here estimate that over half the army, if kept Philadelphia at Jefferson Medical College, the alma here during the sickly season, will die.1 Omater of Dr. Carlos Juan Finlay, to celebrate the centennial of Finlay’s graduation from that institution. Finlay, who became a pioneer in the field of tropical medicine when he introduced the theory of mosquito transmission of yellow fever in , might have been surprised by this bi-national recognition. At the time of his discovery, when nationalist spirits were strong and scientific views were often dictated by political climates, Finlay had been widely ridiculed or dismissed for his proposal of a theory that contradicted established scientific knowledge. What gave rise to this belated celebration of his life’s work? Finlay’s research was largely ignored until the United States realized that it had a stake in Cuba and the rest of the mosquito-infested tropical world. In April the United States government declared war on Spain. The first U.S. sol- diers landed on Cuba in June. The island was infamous for its deadly yellow fever climate, and the men who came to fight knew that they had two enemies: Spain and disease. In the July campaign at Santiago de Cuba, the United States defeated Lieutenant Colonel Roosevelt and Colonel the Spanish, but not before yellow fever struck. In a letter to Leonard Wood. Courtesy of The National Library of Medicine.
16 The Pharos/Winter 2012 Aedes aegypti. Right, Dr. Carlos J. Finlay Courtesy of the National Library of Medicine.
The Pharos/Winter 2012 17 Carlos Finlay, Walter Reed, and the politics of imperialism in early tropical medicine
The Prado in Havana in 1899. Courtesy of the Historical Collections & Services, Claude Moore Health Services Library, University of Virginia.
Roosevelt’s plea came too late; nearly , men contracted the South, where yellow fever was most likely to strike again, yellow fever in that camp. The disease’s devastation to the and apathy from the rest of the country, where yellow fever U.S. Army spurred the creation in June of the U.S. Army was not a direct problem, meant scientific research on the Yellow Fever Commission, presided over by Major Walter disease gained very little support. The prevailing scientific Reed. The Commission eventually was successful in confirm- theories on the contagion of infectious diseases attributed yel- ing the theory of mosquito transmission of yellow fever and low fever to either miasma (a filth in the atmosphere) or fomi- used this knowledge to eradicate the disease first from Havana tes (disease-infected clothing and material). Americans were and then from other newly acquired American territorial confident that sanitary reform that removed these sources of possessions. But the studies on yellow fever at the turn of the disease and isolated the sick from the healthy would stave off twentieth century were inseparably intertwined with the poli- further epidemics or at least protect the wealthy and powerful tics of nationalism and imperialism. from the sickly and “morally depraved” poor.2p61 When Finlay began his research on yellow fever in the Unlike in the United States where yellow fever was an s, very little was known about this mysterious disease. intermittent unwelcome visitor, in Cuba the disease was a Endemic in Cuba, it caused great morbidity in the native-born constant presence. Most Cubans acquired the disease in infected in childhood and great mortality in immigrants who childhood, leaving survivors with protective immunity. Yellow lacked immunity. In the United States, where the climate was fever was less kind to foreign visitors or immigrants. As a cooler, yellow fever struck in waves of periodic epidemics. In Spanish colony, Cuba attracted many Spaniards both civilian a widespread epidemic hit more than U.S. cities from and military. Yellow fever killed enough Spaniards to earn the the Deep South to as far north as Ohio. An estimated , nickname the “undaunted plague of foreign visitors” and the cases of yellow fever and , deaths crippled commerce “greatest enemy of Spanish soldiers.” 3p78 It was in this disease and had enormous financial costs. The disease struck people climate that Carlos Finlay began his research. of all races, ages, and social backgrounds, and traditional ef- Finlay, born in in Camagüey, Cuba, to a Scottish fa- forts of quarantine and sanitation were fruitless. When the ther and a French mother, completed his medical training in epidemic subsided as winter approached, the nation blamed Philadelphia at Jefferson Medical College and returned to his the yellow fever epidemic on poor sanitation in the South and native Cuba to practice and study yellow fever. He initially ac- recommended isolating the epidemic states to punish them for cepted the existing climate-miasma theory, which attributed their so-called “filthy living.” 2p60 the yellow fever climate in Cuba to chemicals in the air that Despite the terror and devastation that the outbreak created an alkaline atmosphere, but by the s he began caused throughout the southern United States, after the epi- to notice compelling correlations between the prevalence demic subsided the U.S. government and public were largely of mosquitoes and the severity of yellow fever epidemics. satisfied to get on with business as usual and accept that peri- In addition to making epidemiological and meteorological odic epidemics were a way of life. Lack of adequate funding in observations, he devised a method of inoculating humans
18 The Pharos/Winter 2012 About Daniel Liebowitz I graduated from Vassar College in with a major in history and a minor in chemistry. I am currently a second- year medical student at the University of Vermont College of Medicine. I am inter- ested in internal medicine and infectious disease, but continue to explore my interest in the history of medicine to help me understand how the profession has progressed to its modern manifesta- tion. I also enjoy running, cycling, and exploring the outdoors in my spare time.
before the generality of my colleagues accept a theory so entirely at variance with the ideas which have until now prevailed about yellow-fever.4p42 Political cartoon of 1878, “Shall We Let Him In? Mr. Mayor and gentlemen of the Board of Aldermen, the He asked that his colleagues observe his epidemiological and answer rests with you.” © Bettman/CORBIS experimental evidence and consider its merits. Since the exist- ing theories had proven to be useless, the mosquito-transmis- with infected mosquitoes to test his theory. In he pre- sion theory could lead to control of the disease. sented his first paper on the subject to the Royal Academy From to the end of the century Finlay proceeded with of Medical, Physical and Natural Sciences in Havana and the his mosquito inoculation experiments, continuing to publish International Sanitary Conference in Washington, D.C., titled, and present his mounting evidence of the correctness of his “The Mosquito Hypothetically Considered as the Agent of theory. Unfortunately, because his inoculations had limited Transmission of Yellow Fever.” He began by stating success (of individuals inoculated by , he had only a few positive results), the scientific community in Cuba and I feel convinced that any theory which attributes the origin abroad understandably continued to be skeptical. Despite and propagation of yellow fever to atmospheric influences, shortcomings in his research, Finlay’s astute observations on to miasmatic or meteorological conditions, to filth or to the the habits of mosquitoes and the spatial and temporal distri- neglect of general hygienic precautions, must be considered bution of yellow fever resulted in his identification of the sole as utterly indefensible.4p27 carrier, the mosquito, and the primary species, Culex fasciatus (now called Aedes aegypti). Finlay argued that Finlay did not give up on supporting his theory, nor did he neglect to devise public health solutions based on his the meteorological conditions which are most favorable to research. As early as he proposed practical methods to the development of yellow fever are those which contribute eradicate yellow fever that ultimately were used by the U.S. to increase the number of mosquitoes.4p40 Army sanitarian Major William Crawford Gorgas after . Finlay wrote, At this early stage in his research he had only made five at- tempted inoculations, which had resulted in one mild case of Why should not the houses in yellow fever countries be yellow fever, two abortive cases in which yellow fever was not provided with mosquito blinds, such as are used in the apparent but immunity seemed to result, and two cases of a United States as a mere matter of comfort, whereas it might nondescript, or as he called it, ephemeral fever. He concluded be a question of life or death? The mosquito larvae might be destroyed in swamps, pools, privies, sinks, street-sewers and These experiments are certainly favorable to my theory, but other stagnant waters, where they are bred, by a methodical I do not wish to exaggerate their value in considering them use of permanganate of potassium. . . . But the most essen- final . . . I understand but too well that nothing less than an tial point must be to prevent those insects from reaching absolutely incontrovertible demonstration will be required yellow fever patients.5p354
The Pharos/Winter 2012 19 Carlos Finlay, Walter Reed, and the politics of imperialism in early tropical medicine
Finlay had, in the twenty years before the U.S. Army Yellow Fever Commission was established, observed or tested most of the “discoveries” the commission touted as its own. To under- stand the historical progression from the dismissal of Finlay’s work to U.S. Army scientists gaining world recognition for continuing what Finlay had started, it is important to trace the scientific and political interests of the United States in Cuba. In , when Finlay first proposed his theory, the concept of insect vectors of disease was still very new. In Patrick Manson of England observed that mosquitoes were the inter- mediate host of the filarial worm of the disease elephantiasis, but even then did not claim that disease could be passed directly from the mosquito to the human host. It was not until and Ronald Ross’s work on malaria that the theory of direct mosquito-human transmission began to be widely accepted.6 The political climate in Cuba and the country’s tenuous relationship with both Spain and the United States no doubt negatively affected Finlay’s research and his legitimacy. Social and political strife defined Cuban affairs, penetrating even to the disruption of academic and scientific research. After the unsuccessful bid for independence from Spain in the Ten Years War of to , the Cuban economy and the value of sugar crashed together as Spain attempted to make Cuba pay for the war debt. Unemployment was high and large ur- ban migrations led to dangerous overcrowding in the cities. Walter Reed. Courtesy of the National Library of Medicine. Many white middle-class creoles like Finlay had their property confiscated and jobs replaced by the hundreds of thousands of Spanish immigrants who flooded into Cuba, seeking a bet- ter life in the New World. Many disgruntled creole Cubans inevitability of annexation. As early as John Quincy became adamant supporters of separation from Spain and Adams suggested that it was only natural for Cuba to become turned to the United States for both economic and politi- a part of the United States because its connection to Spain cal support. Cuban planters became increasingly reliant on was bound to fail and Cubans were inherently incapable of the United States as U.S. capital penetrated deeper into the supporting the nation themselves.8 The majority of Cubans, Cuban economy, and many even became advocates of U.S. however, were ardent believers in national sovereignty and intervention.7 complete independence. The opposition to annexation by As U.S. financial interests in Cuba grew and Spanish control Cuban nationalists made the nation a “burden and annoyance,” over the island declined, the United States began to recognize according to U.S. Secretary of War Elihu Root, but the United that it needed to exercise more influence over the future of States was not about to relinquish all claims and leave its in- Cuba. The Second Cuban War of Independence of to terests unsecured. Here the Platt Amendment loomed large. offered the United States the chance to flex its imperial Attached as a rider to the Army Appropriations Act of , muscles. Debate within the United States between imperial- the Platt Amendment limited Cuban independence with the ists and anti-imperialists took many forms, but ultimately U.S. aim of protecting U.S. interests and secured the right of the public officials and policy makers became convinced that the United States to intervene if the Cuban government proved United States had a duty to protect its southern neighbors from incapable of maintaining stability and protecting property, Old World tyranny and to bring them into the modern world. including that owned by American citizens.7 After the United States aided Cuban revolutionaries in Throughout the U.S. involvement in the Spanish-Cuban- ejecting the Spaniards, it established an occupation govern- American War and during the occupation period, U.S. inter- ment to aid in Cuba’s transition to democracy. Under the ests were threatened by another more sinister enemy—the military occupation government headed by General Leonard scourge of yellow fever. During the brief U.S. involvement Wood from to , the United States grappled with in the war, more American soldiers died from yellow fever the fate of the island. Much of U.S. policy towards Cuba in than from combat. The disease challenged U.S. strength the nineteenth century had been based on the presumed and proved once again the powerlessness of U.S. medicine
20 The Pharos/Winter 2012 Above, Reed (second from left) with volunteers and other at Camp Lazear, 1901. Right, Part of Camp Lazear, showing buildings 1 and 2. Courtesy of the Historical Collections & Services, Claude Moore Health Services Library, University of Virginia. against the mysterious fever. The Yellow Fever Commission under the leadership of Major Walter Reed was entrusted with the task of finding a cure and protecting American he- gemony over Cuba. The Commission began its research along the same lines as before, continuing to search for the causative microbial agent with no suc- cess. Aware of Ronald Ross’s recent mosquito theory and an observation made by American scientist Henry Rose Carter on the incubation period of yel- campaign led by Major William Crawford Gorgas to eradicate low fever, Reed and his men, with much hesitation and doubt, the disease by removing the mosquito vector. By drying up turned to Finlay for help. Finlay supplied the U.S. Commission mosquito breeding grounds and destroying mosquito larvae with the eggs of Aedes aegypti that would prove once and for in human dwellings, the Army Commission quickly eradicated all that yellow fever was transmitted by the mosquito vector. yellow fever in Cuba, and Reed and Gorgas were celebrated Although the Commission was still convinced that the disease as heroes and innovators in the realms of tropical medicine was most likely spread by fomites, they decided to test Finlay’s and public health. The supremacy of American medicine was theory. They isolated healthy individuals and exposed them to secured and sanitary reform entered the rhetoric of American either mosquitoes (Building ) or fomites (Building ) that had occupation. The Platt Amendment included a clause requiring been in contact with yellow fever patients and then observed the maintenance of the sanitation measures instituted by the whether or not the healthy subjects developed disease. It U.S. Commission and prevention of epidemics of infectious quickly became apparent that yellow fever was in fact spread diseases, a logical addition to the many other restrictions on by mosquitoes and not by fomites.9 Cuban independence.10 With the theory supported, the U.S. Army mounted a Considering the U.S. climate of animosity towards Cuban
The Pharos/Winter 2012 21 Carlos Finlay, Walter Reed, and the politics of imperialism in early tropical medicine
medicine? In Fulgencio Batista staged a coup and seized power in Cuba. Shortly after his rise to power, the United States government recognized his regime. Batista protected American interests in Cuba and was anti-Communist in an era of Communist fear in the United States. Finlay’s contribution had been denied by Americans when American interests were threatened by Cuban nationalists in . In , when U.S. interests were protected by the Cuban government, Finlay was honored. In both instances, the public perception of scientific discoveries was greatly influenced by the political climate. The events that transpired over years ago can also provide insight into our modern world where new and diver- gent scientific theories are emerging every day and science and medicine are constantly politicized. We must, of course, remain open to divergent theories that go against existing knowledge, but we must also be wary of the political manipu- lations of science and medicine.
References Major General William Crawford Gorgas. . Roosevelt T. The Rough Riders. Williamstown (MA): Corner Courtesy of the National Library of Medicine. House Publishers; : –. . Ellis JH. Yellow Fever and Public Health in the New South. Lexington (KY): The University Press of Kentucky; . resistance to American annexation, it is not surprising that . Danielson R. Cuban Medicine. New Brunswick (NJ): Trans- Finlay’s contribution to Reed’s confirmatory experiments was action Books; . largely diminished or entirely denied. In the process of turn- . Finlay CJ. The Mosquito Hypothetically Considered as an ing over the rule of law to the Cuban government, Finlay was Agent of Transmission of Yellow Fever. Read before the Royal Acad- granted a leading role in the public health movement because emy of Medical, Physical and Natural Sciences. In: Trabajos Selectos of his closeness to the Americans, but this was much different del Dr. Carlos J. Finlay. Havana: Republic of Cuba, Secretaria de from giving him credit for a theory that had such far-reaching Sanidad y Beneficencia; . Available online at http://www.archive. consequences in global health and imperialism. org/stream/trabajosselectosfinlpage/n/mode/up. The credit for confirming the mosquito vector of yellow . Finlay CJ. Mosquitoes considered as Transmitters of Yel- fever was hotly contested because of its symbolic power in a low Fever and Malaria: In: Trabajos Selectos del Dr. Carlos J. modernizing world. The American role in the discovery and Finlay. Havana: Republic of Cuba, Secretaria de Sanidad y Be- eradication of the yellow fever vector served as justification neficencia; . Available online at http://www.archive.org/stream/ for U.S. intervention and proved to the American public that it trabajosselectosfinlpage/n/mode/up. was a civilizer and bringer of modernity to the Cuban people. . Delaporte F. The History of Yellow Fever: An Essay on the Cuban nationalists, upset by the American intervention that Birth of Tropical Medicine. Cambridge (MA): The MIT Press; . seemed to be a mere replacement of Spanish domination, saw . Pérez LA Jr. Cuba Between Reform and Revolution. Third Finlay’s pivotal role in the American Commission’s efforts as edition. New York: Oxford University Press; . proof of Cuban capability and justification for their national . Pérez, LA Jr. Cuba and the United States: Ties of Singular independence. Intimacy. Athens (GA): University of Georgia Press; . Cuban-American relations remained shaky for many years . Reed W, Carroll J, Agramonte A, Lazear JW. The etiology after the successes of the Yellow Fever Commission. The Platt of yellow fever—a preliminary Note. Reprinted from the Proceed- Amendment remained an ever-present reminder of American ings of the Twenty-eighth Annual Meeting of the American Public influence, and American economic interests remained a politi- Health Association, Indianapolis, Indiana; Oct . cal force. The United States maintained and still maintains a . The Platt Amendment. Available online at http://www.our- military presence in Cuba at Guantánamo Bay. Strident de- documents.gov/doc.php?flash=true&doc=. bates over the roles of Finlay and Reed in the discovery of the mosquito vector of yellow fever continued as long as Cuban The author’s address is: independence and American interests remained threatened. 161 Austin Drive #76 Why then in did Americans and Cubans come to- Burlington, Vermont 05401 gether in Philadelphia to celebrate Finlay as a hero of tropical E-mail: [email protected]
22 The Pharos/Winter 2012 Breaking Bad News
We practice all afternoon, telling each other, “I have some bad news. Your mother has died.” Sometimes it’s a sister, a son. We say, “We did everything, everything we could” and “I’m so sorry” and “Do you want to see her now?” Our teacher is an emergency physician. She does this all the time. We ask, “What if the family gets angry?” She says, “That’s why you always stand near the door.” We ask, “What if we start to cry?” She says, “If you can help it, don’t cry. But it probably won’t make things worse.” We ask, “Do you always say the word dead?” She says, “I try to say it twice. Usually, even then, they’ll ask— ‘So you mean he’s dead?’ ‘Yes,’ I say, ‘He’s dead.’ “ We ask, “What if they want to know if he was in pain?” She says, “Say no.” She pauses. “Although,” she says, “I believe the feat of dying is not un-painful. The brain must panic, even if the body doesn’t. But,” she continues, “Say no. Always just say no.” Sarah Leeper
Ms. Leeper is a member of the Class of !"#! at the Warren Alpert Medical School of Brown University. This poem won first prize in the !"## Pharos Poetry Competition. Ms. Leeper’s e-mail address: [email protected]. Illustration by Jim M’Guinness. Allison Hinko, MD The author is a resident at the St. Joseph Hospital in Chicago. This essay won second prize in the 2011 Helen H. Glaser Student Essay Competition.
ealth care issues facing America today revolve around the core health care system outcomes of access, qual- ity and cost. Millions of people remain uninsured, the perception of quality care continues to hinge on the develop- ment and utilization of new technologies, and these medi- cal advancements contribute to escalating costs. Much like the health care system itself, public opinion on how to best “fix” this broken entity is fragmented, with discordant view- points influenced by many factors. Led by President Obama, Congress in passed into law a contentious health care re- form bill after laborious negotiations and partisan rancor. The Republican-led House of Representatives has since passed leg- islation repealing the law, although the Democratic-controlled Senate has not acted on the repeal measure. Various states are challenging in federal courts the plan’s central mandate for all Americans to carry health insurance, a constitutional fight that will most likely end up on the docket of the U.S. Supreme Court.1 Many different public interest groups, industries, and politicians hold large stakes in the outcome of the health care debate. Health care spending amounted to . percent of GDP in and its annual rise is expected to accelerate.2 Legislation not only allocates vast sums of money and re- sources but also regulates the influence of private industry and government in the lives of Americans. Physicians are a specific subset of stakeholders that are represented in Washington by various groups having varying levels of political influence. The American Medical Association (AMA) is the most prominent physician organization that lobbies to develop and advocate for policy in the interest of its members and their patients. Important questions for physicians to consider are: Does the AMA speak for all physicians in America? Do the AMA’s lob- bying efforts influence government actions? Illustration by Erica Aitken
24 The Pharos/Winter 2012 The Pharos/Winter 2012 25 The AMA and health care reform
Physicians understand the health care system and its pitfalls aimed at informing and empowering citizens regarding money better than the average citizen (or, arguably, government of- in politics, classifies and analyzes lobbying reports. According ficial). Because of this informed vantage point, physicians also to the center’s data analysis, total health care lobbying expen- are in a position to exert influence in matters of health care leg- ditures reached a peak in of million, not surpris- islation. The spectrum of lobbying in Washington ranges from ingly coinciding with the drafting of the health care legislation. individual physicians to associations representing nurses, doc- Within the health sector, pharmaceutical and health care tors, or hospitals. A study published in the Archives of Internal product industries spent the most in (. million), Medicine in examined how individual physicians lobby followed by hospitals and nursing homes ( million), health their members of Congress. The investigators interviewed care professionals ( million) and health services organiza- the legislative assistants of randomly selected members of tions and HMOs ( million).6 both the House and Senate. These assistants, who work The Pharmaceutical Research and Manufacturers of on health care legislation America (PhRMA) not and meet with lobbyists only ranks first in expen- on behalf of their employ- ditures within its umbrella ers, answered questions industry but also places regarding the frequency of fourth among all organiza- meetings with physicians, tions in spending on lob- the issues discussed, and bying (years –).7 the perceived effective- Pfizer and Amgen also put ness of physician lobbying. forth strong lobbying ef- Meetings occurred with an forts. Overall, the pharma- average of ten (Senate) and ceutical industry supports four (House) physicians patent reform and research per month, suggesting ap- funding, while favoring re- proximately , such strictions on generic drug meetings occur annually. use and opposing gov- Medicare reimbursement ernment-run health care. was the issue most frequently discussed, followed by managed The American Hospital Association constitutes the biggest care reform. Legislative assistants generally assessed physi- spender among hospitals and nursing homes and also ranks cians as effective or somewhat effective lobbyists; however, the sixth overall in lobbying expenditures. The hospital and nurs- assistants commonly suggested that physician lobbying should ing home industry advocates for rural and teaching hospital focus less on reimbursement and more on a broader range of protection, increases in health coverage, and preservation health care issues.3 While this study has various limitations of Medicare and physician pay. Aetna Inc. and Blue Cross/ and presents dated information, it provides insight into the Blue Shield are examples of powerful players within the process of individual physician lobbying, as well as perspec- health service and HMO industry, a sector that also opposes tive on what issues remain relevant ten years later. Financial Medicare payment cuts and a public insurance plan. The concerns involving reimbursement remain at the core of much category of health care professionals encompasses relatively physician lobbying today, and, as the authors noted similarly small specialty societies, such as the American College of at the time of the study, this focus on compensation remains Rheumatology and the Society of Thoracic Surgeons, as well at odds with the social and insurance problems that continue as broad consortiums like the American Dental Association to concern the general public. and the American Nurses Association. Among these diverse Hundreds of physician groups, hospital and nursing home entities, the American Medical Association (AMA) remains associations, insurance and managed care companies, disease the largest and most influential trade group within the health advocacy and public health organizations, and pharmaceutical care professional industry.6 and health product companies comprise the opposite end of The AMA, founded in by Dr. Nathan Smith Davis, the lobbying spectrum. These groups wield greater resources functions to unite physicians across the nation to work on and thus exert more powerful influences than the individual professional and public health issues. The mission of the as- lobbyist, and they can use their expertise and influence to aid sociation is “to promote the art and science of medicine and members of Congress in drafting complex medical legisla- the betterment of public health.” 8 This goal is not so different tion.4 The Lobbying Disclosure Act requires lobbyists to from the objectives laid out by the delegates at the found- submit biannual reports describing their parent organizations ing meeting of the AMA: to improve public health, launch a and the amounts spent on lobbying activities.5 The Center for medical ethics program, and promote scientific advancement Responsive Politics, a nonpartisan, nonprofit research group and medical education standards.8 AMA membership is open
26 The Pharos/Winter 2012 to physicians, residents and fellows, and medical students. Dues range from a annual physi- cian fee to for a one year student membership. About Allison Hinko A twenty-one-person board of trustees guides the I graduated from Northwestern University AMA as it pursues its mission statement, and seven in with a BA in English and a con- councils focus on specific matters such as ethics and centration in American Literature. During medical education, and make policy recommenda- medical school I completed the Summer tions. The primary policy-making body of the AMA Fellowship Program at Henry Ford Hospital is its House of Delegates. The AMA includes many in Detroit and received the Professor Daniel member organizations, each of which is entitled to at least one A. Koechel Scholarship for academic excellence. I plan delegate, with representation proportional to the number of to pursue a career in academic medicine. Since graduat- AMA members in each society. House of Delegates represen- ing from the University of Toledo College of Medicine tation includes delegates from all fifty states, federal services in June , I have begun my Transitional Year resi- (e.g., the U.S. Army, the U.S. Navy), national medical specialty dency at St. Joseph Hospital in Chicago. Upon comple- societies (e.g., the American Academy of Family Physicians, tion, I will begin my ophthalmology residency at The the American College of Cardiology), and professional inter- Ohio State University. I thank my parents for their great est medical associations (e.g., the American Medical Women’s support and encouragement as I’ve pursued my interests Association, the Medical Student Section). This body develops in both writing and medicine. policy positions about the organization and function of the health care system that drive the lobbying efforts and the sub- stantial monetary expenditure of the AMA.8 The positions that the AMA takes on the organization and function of the American health care system have helped to for medical services, the AMA works to promote and im- shape health care financing, payment, insurance, and delivery. plement policies that protect the interests of patients and For example, in , the AMA published the first edition physicians. The AMA believes in universal health insur- of the Current Procedural Terminology (CPT), a medical ance coverage. It launched a national awareness initiative, procedure documentation system. Today, the AMA Board of “Covering the Uninsured,” in . It considers expanded Trustees authorizes a CPT Editorial Panel, which develops, affordable coverage choice and the elimination of denials for owns, and maintains the CPT codes. Once the panel assigns a pre-existing conditions to be critical elements of health system medical procedure a code, the AMA-authorized Relative Value reform. The association also has advocated for comprehen- Update Committee (RUC) calculates a recommended value sive Patients’ Bill of Rights legislation in Congress. In terms for the new code. Under the resource-based relative value of provider interests, the AMA seeks to implement medical scale (RBRVS) implemented in , a formula divides physi- liability reforms, modify antitrust enforcement policies, and cian payments into physician work, practical expense, and repeal the Medicare physician payment formula. The AMA malpractice expense. Each independent component is then strives to advance its positions in a variety of ways, but one of expressed in relative value units (RVUs). After factoring in its most influential methods remains the lobbying of Congress geographic practice cost indices, the total RVUs are multiplied and federal agencies.10 by a conversion factor that determines the monetary payment The AMA lobbies to advocate for its agenda, most recently for a service. Advisory committees, drawn from among House and publicly voicing its opinion on President Obama’s plan of Delegates subspecialty society physician representatives, for national health care reform. In terms of all organizations’ exert significant influence over both the CPT Editorial Panel lobbying expenditures—not just those of the health sector and the RUC. The government-run Centers for Medicare and industries—the AMA ranks second only to the U.S. Chamber Medicaid Services (CMS) ultimately reviews the RUC value of Commerce. The AMA spent ,, in alone. recommendations and publishes a Medicare Physician Fees By comparison, the lobbying expenditures for the sec- Schedule (MPFS) that is open to revision during its first year. ond leading spender in the health professionals industry, the After that year, the values become final, though the value units American Academy of Family Physicians (AAFP), totaled a assigned to each CPT code undergo review every five years. mere ,,.6 With that level of financial heft and the Through the CPT Editorial Panel, the RUC and the advisory widely held belief that it represents America’s physicians, the committees composed of representatives from the House of AMA holds a high profile position in the national debate on Delegates, the AMA occupies a central role in the determina- health care reform. Consequently, when the organization in tion of billable services (and thus what services are available July reversed its opposition to the health care plan pro- to patients), as well as reimbursement.9 posed by the House of Representatives and endorsed it, that In addition to helping determine delivery of and payment decision received heightened media attention.
The Pharos/Winter 2012 27 The AMA and health care reform
What were the AMA’s original positions on the overhaul sustain practices that care for Medicare patients. For years the of the health care system? By February of , the AMA had AMA has successfully lobbied against these cuts, resulting in outlined clear reform objectives. It affirmed that every person the passage of regular temporary fixes that postpone the pay must own a personal health insurance policy and that individ- reductions.13 The prospect of finally securing a permanent ual tax credits inversely related to income constituted the best repeal of the reimbursement formula no doubt influenced the method for expanding coverage. The association supported AMA’s decision to support H.R. , despite the inclusion in requiring people earning greater the bill of the public option. than percent of the federal However, a procedural vote poverty level to obtain at mini- in the Senate on October , mum a basic health care policy. , to bring swift debate and In terms of insurance reform, the passage of the bill to repeal the AMA advocated changes to the Medicare SGR formula failed on existing private market system, a vote of to . While not op- including expanding choice and posed to the principle of the bill, eliminating denials for pre-exist- Republicans refused to endorse ing conditions. Other elements the measure on grounds that of the AMA’s plan included it would cost billion over modifications to antitrust laws ten years, a cost not paid for or and medical liability reform (for example, implementing a offset. Republicans asserted that Democrats were essentially , cap on noneconomic damages). increasing Medicare payments to buy physician support for While certain AMA proposals aligned with those of health care reform and that the bill violated President Obama’s Congress, such as the requirement that all those who could vow that new legislation would not increase the budget deficit. afford insurance coverage should be required to obtain it, In response, the Senate Democratic whip, Richard Durbin, the two entities fundamentally disagreed on other signifi- offered his own opinion that “Republicans believe they can cant points. In June of , the AMA publicly voiced its derail health care reform by defeating the doctor fix. That’s opposition to the elements that President Obama and many what this is all about.” 14 The failure to pass forced the AMA Democrats believed essential to reform legislation: the cre- to resume its all-too-familiar position of fighting for the repeal ation of a public, government-sponsored insurance plan and a of the SGR formula. mandate that all doctors that care for Medicare patients must On December , , Senate majority leader Harry Reid participate in it. The AMA issued comments to the Senate of Nevada announced an agreement among liberal and cen- Finance Committee, stating its belief that “The introduction of trist Democrats to remove the government-run public insur- a new public plan threatens to restrict patient choice by driv- ance option from the bill. This concession seemed necessary ing out private insurers . . . [and] the corresponding surge in to garner the votes of more moderate Senate Democrats public plan participation would likely lead to an explosion of needed to pass the legislation.15 It also aligned with the AMA’s costs that would need to be absorbed by taxpayers.” 12 original stance of opposition to the public option. Despite these disagreements, the AMA on July , , On March , , President Obama signed the legisla- issued a statement urging the House committees of jurisdic- tion—H.R. , the “Patient Protection and Affordable Care tion to pass H.R. , “America’s Affordable Health Choices Act”—into law.16 The AMA refers to this law, in conjunction Act of ,” for consideration by the full House. This bill with H.R. , the “Health Care and Education Affordability included the public insurance option the AMA opposed, as Reconciliation Act” (signed into law on March ), as the well as a measure the association fights to pass year after year: Affordable Care Act (ACA). The association ultimately gave the permanent repeal of the Medicare physician payment its approval of the act, having publicly announced its quali- formula that perpetually threatens to cut Medicare payments fied support on March , .17 It endorsed the elements of to physicians by twenty-one percent. The formula, established extended coverage to the majority of the uninsured, increased in the early s, determines payment amounts for medical competition and choice in the insurance marketplace, and the services based on the calculated relative value of the services promotion of preventive care. The provisions for preventing multiplied by a conversion factor. Under this formula, pay- denials of coverage for pre-existing conditions and requiring ments may not exceed a “sustainable growth rate” (SGR). The individuals to hold minimum health insurance or pay a penalty SGR provides the basis for calculations that yield spending tar- were among those that also garnered AMA support. gets, which then dictate the conversion factor value. The CMS Despite these positive outcomes from the AMA’s point annually updates the conversion factor, thus controlling and of view, the final ACA failed to include key provisions for limiting payments to physicians.9 However, the formula results which the association had strongly advocated. It amended in such large cuts in payments that most physicians cannot some aspects of medical liability but did not specify a cap for
28 The Pharos/Winter 2012 malpractice reform. He be- lieved that the AMA’s early support for the reform legis- lation hampered his efforts, adding, “It was the chair- man [of the House Energy and Commerce Committee, Rep. Henry Waxman] telling me my amendments are not necessary because my AMA has already signed off on this bill.” 19 The AMA ostensibly speaks for America’s physi- cians, so while its lack of sup- port in all probability would not have changed the bill’s outcome, the association’s public endorsement repre- sented a coup for President Obama and the backers of President Obama signs the Patient Protection and Affordable Care Act into law, March 2010 his reform legislation. It is © Pete Souza/White House/Handout/Corbis. virtually impossible, how- ever, for an organization non-economic damages. Antitrust reform to remove legal and that counts fewer than one- regulatory barriers to physician collaboration was excluded third of physicians as members to represent doctors across from the law. Perhaps most significantly, the act did not in- the United States. In contrast to the AMA’s position, a clude a repeal of the SGR-based Medicare physician payment September survey published in the New England Journal formula. Instead, another temporary fix manifested as sepa- of Medicine, showed that almost three-quarters of the sur- rate legislation when, on December , , President Obama veyed doctors supported some type of public option. Out of signed into law a one-year delay of the impending twenty-five a randomized sample of , physicians, sixty-three percent percent Medicare physician payment cut. This law simply of physicians favored both private and public insurance op- postpones the arrival of an enduring resolution. The AMA tions. Twenty-seven percent wanted private insurance only, must again work with Congress in and aggressively lobby to repeal and replace the formula.18 Though the AMA constitutes the country’s largest physi- cian organization and places second out of all lobbying organi- zations in terms of spending, the association’s advocacy efforts and official endorsement of the health care bill seem to have had little effect on the law’s final outcome. The AMA opposed the public option, and this component was eventually removed from the bill. However, the AMA endorsed the bill prior to the exclusion of the public option, which Democrats sacrificed to secure the necessary votes to pass the legislation—not to cater to the AMA. The Senate voted against the repeal of the Medicare SGR formula (after the AMA had approved the overall health care bill), a provision that for years has stayed at the forefront of the association’s agenda. Questions subsequently arose regarding the AMA’s clout and lobbying strategy. Republican Representative Michael Burgess, a physi- cian and AMA member, asserted, “As a member of Congress, it was very difficult for me to get votes on my amend- ments,” referring to proposals for the SGR formula repeal and Congressman Michael Burgess. AP Photo.
The Pharos/Winter 2012 29 The AMA and health care reform
while ten percent believed in a public-only option.20 An . The Center for Responsive Politics. http://www.opensecrets. earlier January investigation, published in the Journal org. of General Internal Medicine, found that a substantial pro- . Steinbrook R. Lobbying, campaign contributions, and health portion of physicians support single payer national health care reform. N Engl J Med ; : e()–(). http://www.nejm. insurance (NHI). Out of , doctors who received a six- org/doi/pdf/./NEJMp. item survey on insurance coverage expansion options, , . About the American Medical Association. http://www.ama- responded. Nearly eighty-nine percent of responders agreed assn.org/ama/pub/about-ama.page?. that all Americans, regardless of ability to pay, should receive . Beyer DC, Mohideen N. The role of physicians and medical necessary medical care, in accord with AMA policy. About organizations in the development, analysis, and implementation of fifty percent supported the current employer-based insurance health care policy. Semin Radiat Oncol ; : –. system with the addition of tax credits or penalties, whereas . The American Medical Association. http://www.ama-assn. forty-two percent believed in a government-run, single-payer org/ama/pub/health-system-reform/about-us.shtml. Accessed Janu- NHI program. In this report, a slight majority of polled physi- ary . cians backed financial incentive-based reform.21 Both surveys . Plested WG III. The American Medical Association stake in were flawed in that they lacked specificity regarding the pub- the future of US health care: The American Medical Association lic and private reform approaches. Nevertheless, the results plan for reform of the US health care system. Urol Clin N Am ; demonstrate that doctors as a whole, in contrast to the AMA’s :–. public position, are far from reaching a consensus on the issue . Pear R. Doctors’ group opposes public insurance plan. New of government-run health care. York Times Jun . ttp://www.nytimes.com////us/ Physicians hold a large stake in the outcome of the health politics/health.html?_r=. care reform debate. Changes to the health care system directly . Mayer LR. Health professionals stand divided—OpenSecrets affect how they practice medicine and how they are reim- Blog. OpenSecrets.org. Center for Responsive Politics. http://www. bursed. Doctors must consider not only what most benefits opensecrets.org/news///health-professionals-stand-div.html their livelihoods but also, in keeping with their sworn duty, . Pear R. Senate Democrats hit snag with doctor payment bill. the best interests of their patients. Regardless of whether it ac- New York Times Oct . http://www.nytimes.com//// curately represents the beliefs of all physicians, the American health/policy/health.html?sq=pear. Medical Association represents physicians’ greatest lobby- . Dems make deal to drop public option. CBS News ing power and public voice. As the battle over the future of Dec . http://www.cbsnews.com/stories////politics/ America’s health care system continues, doctors face a choice. main.shtml. They can air their concerns about the actions of the AMA and . Stolberg SG, Pear R. Obama signs health care overhaul bill, the government behind the closed doors of their private prac- with a flourish. New York Times Mar . http://www.nytimes. tices or hospital offices, or they can recognize their unique com////health/policy/health.html?scp=. vantage point in the health care debate and make their voices . Herszenhorn DM. A.M.A. offers “qualified support” for heard. health bill. New York Times Mar , . http://prescriptions. blogs.nytimes.com////a-m-a-offers-qualified-support-for- References health-bill/. . Herszenhorn DM, Pear R. House votes for repeal of health . The American Medical Association. http://www.ama-assn. law in symbolic act. New York Times Jan . http://www.ny- org/resources/doc/washington/aca-advocating-for-improvements. times.com////health/policy/cong.html?_r=. pdf. . Norman J. National health expenditures now grab . . Haberkorn J, Kliff S. Doctors’ lobby losing clout on hill. Po- percent of GDP, study projects. The Commonwealth Fund litico Jul . http://www.politico.com/news/stories//. Feb . http://www.commonwealthfund.org/Content/Newsletters/ html. Washington-Health-Policy-in-Review//Feb/February--/ . Shapiro J. Poll finds most doctors support public op- National-Health-Expenditures-Now-Grab--Percent-of-GDP- tion. NPR Sep . http://www.npr.org/templates/story/story. Study-Projects.aspx php?storyId=. . Landers SH, Sehgal AR. How do physicians lobby their . McCormick D, Wooldhandler S, Bose-Kolanu A, et al. U.S. members of congress? Arch Intern Med ; : –. physicians’ views on financing options to expand health insurance . Glabman M. Lobbyists that the founders just never dreamed coverage: A national survey. J Gen Intern Med ; : –. of. Managed Care . http://www.managedcaremag.com/ar- chives//.lobbying.html. The author’s e-mail address is: [email protected]. . Landers SH, Sehgal AR. Health care lobbying in the United States. Am J Med ; : –.
30 The Pharos/Winter 2012 A Reminder
An intellectual is someone whose mind watches itself. I entered into this profession, this art— It is easy to slip into a selfish thirst to prove myself, Amidst all the memorization of complex body parts. I entered into this profession, this art. But I sometimes forget the patients whom I am working for, amidst all the memorization of complex body parts. (Biochemical pathways, reactions, and science galore.) I sometimes forget the patients whom I am working for, We were all so idealistic—bright-eyed and bushy-tailed at the inception. In spite of biochemical pathways, reactions, and science galore, It is crucial to keep clear and undimmed our perception. We were all so idealistic—bright-eyed and bushy-tailed at the inception; More difficult is now to stay the course and remain consistent. It is crucial to keep clear and undimmed our perception: Integrity, honesty, communication—to these we must be persistent. More difficult is now to stay the course and remaining consistent— It is easy to slip into a selfish thirst to prove myself. Integrity, honesty, communication—to these we must be persistent. Recall—an intellectual is someone whose mind watches itself. Angela Jiang
Ms. Jiang is a member of the Class of !"#$ at the Ohio State University College of Medicine. This poem won third prize in the !"## Pharos Poetry Competition. Ms. Jiang’s address is: #"%! Pennsylvania Avenue, Columbus, Ohio $&!"#. E-mail: angela. [email protected]. Illustration by Erica Aitken The Pharos/Autumn 2011 31 Illustration by Erica Aitken. The case for an unrestricted liberal arts collegiate education
Nathan Kase, MD, and David Muller, MD
Dr. Kase (AΩA, Yale University, 1968) is Dean Emeritus, The case for SCIENCE competencies: professor of Obstetrics/Gynecology and Reproductive The HHMI-AAMC Report Science, and professor of Medicine in the Division of The AAMC and HHMI convened a diverse group of sci- Endocrinology, Diabetes, and Bone Disease at the entists, physicians, and science educators drawn from small Mount Sinai School of Medicine. Dr. Muller (AΩA, Mount colleges, large universities, and medical schools to address the Sinai School of Medicine, 1965) is the Dean for Medical following paradox: while the scientific knowledge essential Education at Mount Sinai. for acquiring and successfully applying the skills necessary for the expert practice of clinical medicine has changed “dramati- ne hundred years ago Abraham Flexner changed the cally,” the medical prerequisites and admission requirements paradigm by which physicians are trained in this have remained “essentially unchanged.” The group was asked country.1,2 Among his many contributions was the to address the inherent tension between “teaching scientific principle that successful performance in universal, standard- facts” and “preparing physicians to actually use scientific ized, and demanding premedical basic science courses be knowledge.” It set out to identify “the most important scien- required of undergraduates applying for admission to U.S. tific competencies in the natural sciences required of students medical schools. By these requirements were fully en- graduating from college prior to matriculating into medical trenched, requiring two semesters each of chemistry, biology, school.” 9ExecSum and physics, and one semester of organic chemistry. Eighty In keeping with the National Academies’ BIO conclu- years later, despite continued and mounting opposition, these sions that premedical course requirements and the MCAT premed requirements continue to be enforced. content constrain undergraduate science education,11 the Calls for change of this status quo have persisted and, in HHMI/AAMC group defined eleven knowledge principles recent years, intensified.3–8 While the displeasure is uniform, and eight scientific competencies that reflect acquisition and the ways in which baccalaureate preparation for medical effective application of those principles. Proficiency in each school and medical school admissions policies might be determines readiness for medical school admission. amended reflect differing and sometimes even opposing per- In the view of the committee, the shift from testing facts to spectives. Most representative of this polarity are two major achieving competencies will allow greater flexibility for col- advocacy statements: on the one hand the report of the legiate faculty and curriculum planners to exploit the talents AAMC-HHMI Committee, “Scientific Foundations for Future and resources of their institutions when revising course con- Physicians,” 9 and on the other the now decades old but still tent. Ultimately, such changes will help to engage and person- pertinent “Physicians for the Twenty-First Century” report of alize the curricula of their science/premedicine students and the AAMC Project Panel on General Professional Education their science faculties. of the Physician and College Preparation for Medicine (GPEP) The report acknowledged that these recommendations which appeared in the early s.10 Both the AAMC-HHMI were a “first step” in a continuing “conversation” about the and GPEP expert panels were commissioned to examine, appropriate skills, knowledge, values, and attitudes future among other elements of medical education, the aims and physicians should possess. In this regard the AAMC has also content of the premedical curriculum. Their vastly different convened a separate panel to examine the behavioral and conclusions are emblematic of the major themes that charac- social science (our emphasis) competencies for future physi- terize diverging objectives of premedical education reforms. cians, which will be released at a later date.
The Pharos/Winter 2012 33 Competencies as the basis for reformed premedical education
Table ! HHMI: Scientific Foundations for Future Physicians Eight Expectations of Entering Medical Students !. Apply quantitative reasoning and appropriate mathematics to ". Demonstrate knowledge of how biomolecules contribute to the describe and explain phenomena in the natural world. structure and function of cells. • Interpret data sets and • Apply algorithmic approaches • Structure, biosynthesis, and • Biochemical processes that communicate those and principles of logic (including degradation of biological carry out transfer of biological interpretations using visual and the distinction between cause/ macromolecules information from DNA, and other tools effect and association) to • Principles of chemical how these processes are • Demonstrate quantitative problem solving thermodynamics and kinetics regulated numeracy and facility with the • Extract relevant information that drive biological processes • Principles of genetics and language of mathematics from large data sets in the context of space (i.e., epigenetics to explain heritable • Make statistical inferences from compartmentation) and time: traits in a variety of organisms data sets enzyme-catalyzed reactions and metabolic pathways, regulation, integration, and the chemical logic of sequential reaction steps #. Demonstrate understanding of the process of scientific inquiry, and $. Apply understanding of the principles of how molecular and cell explain how scientific knowledge is discovered and validated. assemblies, organs, and organisms develop structure and carry out function. • Develop observational and • Articulate (in guided inquiry • General components of • Mechanisms governing cell interpretive skills through or in project-based research) prokaryotic and eukaryotic cells, division and development of hands-on laboratory or field scientific questions and such as molecular, microscopic, the embryos experiences hypotheses, design experiments, macroscopic, and three- • Principles of biomechanics • Demonstrate the ability to acquire data, perform data dimensional structure, to explain and explain structural and measure with precision, analysis, and present results how different components functional properties of tissues accuracy, and safety • Demonstrate the ability to contribute to cellular and and organisms • Operate basic laboratory search effectively, to evaluate organismal function instrumentation for scientific critically, and to communicate • How cell-cell junctions and the measurement and analyze the scientific extracellular matrix interact to literature form tissues with specialized functions %. Demonstrate knowledge of basic physical principles and their &. How organisms sense and control their internal environment and application to the understanding of living systems. how they respond to external change. Explain: • Mechanics as applied to human • Thermodynamics and fluid • Maintenance of homeostasis • How living organisms use and diagnostic systems motion in living organisms by using internal and external defense • Electricity and magnetism (e.g., • Quantum mechanics, such as principles of mass transport, heat and avoidance mechanisms charge, current flow, resistance, atomic and molecular energy transfer, energy balance, and to protect themselves from capacitance, electrical potential, levels, spin, and ionizing feedback and control systems threats, spanning the spectrum and magnetic fields) radiation • Physical and chemical from behavioral to structural • Wave generation and • Systems behavior, including mechanisms used for and immunologic responses propagation to the production input-output relationships and transduction and information and transmission of radiation positive and negative feedback processing in the sensing and integration of internal and environmental signals '. Demonstrate knowledge of basic principles of chemistry and some (. Demonstrate an understanding of how the organizing principle of of their applications to the understanding of living systems. evolution by natural selection explains the diversity of life on earth. How: • Atomic structure • Principles of chemical reactivity • Genomic variability and mutation • Evolutionary mechanisms • Molecular structure to explain chemical kinetics contribute to the success of contribute to change in gene • Molecular interaction and derive possible reaction populations frequencies in populations and • Thermodynamic criteria mechanicms to reproductive isolation for spontaneity of physical • Chemistry of carbon containing processes and chemical compounds relevant to their actions and the relationship of behavior in an aqueous thermodynamics to chemical environment equilibrium Source: Reference !.
34 The Pharos/Winter 2012 The case for ATTITUDES AND VALUES competencies: The GPEP Report Assembled three decades ago, the GPEP committee in- cluded college presidents, medical school deans, chairmen, professors, practitioners, and nonmedical members. Its charge was an ambitious, all-encompassing review of the entire landscape of American medical education: collegiate, medical school, graduate medical education, and faculty development. In particular, the panel was commissioned to assess the ad- equacy of medical education and admissions policies and the nature of premedical undergraduate preparation to “meet the challenges of medical care in the twenty-first century.” 10pxiii The report’s recommendations reflected the panel’s per- ception of a widening disconnect between () increasing medical specialization fueled by the accelerating expansion of medical science, technology, and information services, and () the individual patient’s—indeed the general public’s—con- cerns about quality and access to health care. With respect to premedical education, their major recom- mendations were as follows: • Broaden the baccalaureate preparation in the social sci- ences and the humanities. • Modify medical school admissions requirements to In the panel’s view, the tendency of college students to accommodate broader and more diverse baccalaureate shape their education prematurely towards the narrow objec- preparation. tive of admission to medical school generates an unbalanced • Require an undergraduate scholarly endeavor. college experience resulting in exclusion of a broad liberal arts • Final admissions decisions should incorporate an appli- education. The panel predicted a further reinforcement of cant’s ability “to learn independently, acquire critical analyti- these adverse tendencies if medical school admissions policies cal skills, [and] develop the values and attitudes essential for continued to emphasize high MCAT scores and exceptional members of a caring profession.” 10p9 science grade point averages. The fundamental position un- derlying the panel’s conclusion was the conviction that all Table ! physicians, regardless of specialty, should not only acquire General Professional Education of the Physician and College and sustain clinical expertise, skills, and knowledge, but also Preparation for Medicine in the Twenty-First Century retain, hone, and apply humanistic values and attitudes nur- Recommendations: Baccalaureate Education tured and expanded in college and inherent to a profession !. Broaden “….to achieve an education that encompasses dedicated to caring and healing.10pp18–19 In support of this preparation broad study in the natural and social sciences and conclusion, the panel recommended that evidence of strong of every in the humanities.” First to publicly define and decry student existence of “a Premed Syndrome.” rhetorical skills be included in medical school admissions criteria and given greater weight in their selection processes. ". Modify “Medical school admissions committees’ practice admissions of recommending additional courses beyond These skills were defined as cogent, effective writing demon- those required for admission should cease. Some strating originality, thorough research, sound analysis, and institutions may wish to experiment by not persuasive argument that was developed and sharpened in a recommending any specific course requirements.” variety of liberal arts disciplines. #. Requiring “College faculties should make the pursuit of GPEP also suggested that “medical school admissions com- scholarly scholarly endeavor and the development of mittees’ practice of recommending additional courses beyond endeavor effective writing skills” a requirement. those required for admission should cease” and that “some $. Making “Medical school admissions committees should institutions may wish to experiment by not recommending selection make final decisions using criteria that appraise any specific course requirements.” 10p20 decisions students’ abilities to learn independently, to In conclusion, both HHMI and GPEP, albeit with very acquire critical analytic skills, to develop attitudes essential for members of a caring profession and to different approaches and reasoning, seek to distinguish and contribute to the society of which they are a part.” nurture the self-initiating, self-directed, independent student Source: Reference !%. from the equally intelligent, well prepared, but passive recipi- ent of current knowledge.
The Pharos/Winter 2012 35 Competencies as the basis for reformed premedical education
Efforts to meld these principles are ongoing. For example, the Accreditation Council for Graduate Medical Education (ACGME) introduced the “General Competencies” for gradu- ate medical education in .12 This broad set of general skills and attitudes (including competence in patient care, medi- cal knowledge, and interpersonal and communication skills, among others) was meant to serve as a framework for resident training and development. To sustain ACGME accreditation, each training program, regardless of specialty, is now respon- sible for documenting its trainees’ performance and progress within each competency element. In the AAMC, with broad input from national lead- ers in medical education, published the “Learning Objectives for Medical Student Education” as part of its Medical School Objectives Project (MSOP).13 This aimed to define the essen- tial attributes physicians need to fulfill their “duty to society” (including requiring physicians to be altruistic, knowledge- able, skillful, and dutiful).13 Two elements of the proposals by GPEP, ACGME, and the AAMC (MSOP) are strikingly similar: the inextricable connec- tion between competency in communication skills and effec- tive patient care, and the fact that altruism and accountability (performing in a “dutiful” manner) are essential elements inherent to the behavioral attributes we call “professionalism.”
How will medical schools respond? Applicants to the HuMed program are college sophomores While both the HHMI and GPEP positions are appealing, (and rarely juniors). Therefore admission decisions are based it seems that meaningful reform can only be achieved by a on high school and initial college freshman and partial sopho- combination of () individual colleges developing competency more grades and SAT scores. As important, however, are based curricula, () the AAMC altering the MCAT to assess two personal essays, three letters of recommendation, and a the acquisition of competencies, and () medical schools mod- listing of extracurricular (school and community) activities. ifying the philosophies governing their admissions criteria. Approximately fifteen percent of the applicant pool is invited That degree of change is daunting on many levels, not the least for personal interviews at Mount Sinai. of which is medical schools’ apparent collective reluctance to The assessment process therefore involves two major fix something they believe isn’t broken. elements. What is missing is formal, persuasive evidence defining . In addition to excellent GPA performance, high SAT how well students perform if admitted to medical school with scores are admittedly crucial. Although the stipulated mini- radically different post-Flexnerian baccalaureate backgrounds, mum score for each element is , in recent years the pool foregoing the MCAT and allowing them to undertake a diverse of applicants chosen for interview generally exceed on and flexible array of undergraduate coursework. average and those chosen for final admission to the program score over . The Humanities and Medicine Program at Mount . In the personal essays, interviews, and extracurricular Sinai School of Medicine evidence of personal interests and involvement, we seek evi- In partial answer to this challenge, a recent detailed re- dence of rhetorical “skills defined by cogent, effective writing port of the Mount Sinai School of Medicine Humanities in displaying originality, thorough research, sound analysis, and Medicine (HuMed) Program is worthy of consideration.14 The persuasive argument developed and sharpened” in a variety HuMed Program, founded in the late s, sought to embody of activities. In the interviews we seek cogent, lucid, thought- the essence of the GPEP principles. A portion of the medical ful responses—evidence of “competency in communication” school entering class applicants who were exclusively liberal to challenging questions.10 Finally personal activities should arts majors were exempted from all the standard premed cur- demonstrate depth of involvement and conclusive impact on riculum courses and omitted the MCAT examination. In this some aspect of human welfare. day of evidence-based decision making, it must be noted that Accordingly, the HuMed selection process seeks to dis- this major decision was based on expert opinion alone. tinguish the self-initiating, self-directed, and independent
36 The Pharos/Winter 2012 student from the equally intelligent, well prepared, but passive • Science is not presented as the portal of entry through recipient of current knowledge. which the wonders of biomedicine can be engaged. Rather it Once accepted, students must maintain a college GPA of is distorted into a set of obstacles to be surmounted and func- .. Although they forego the full traditional requirements and tions solely as a filter through which medical school admission MCAT, they are required to take and achieve a minimum grade committees select applicants.6,7 of B in biology and general chemistry (two semesters each). But more important than simply enriching the applicant After completing their junior year in college, students pool, HuMed was founded on the principle that a broad liberal are required to spend an eight-week summer term at Mount arts education might supply the values, skills, and attitudes Sinai. This experience includes clinical service rotations in GPEP espoused. As such, a liberal arts education might en- all specialties, seminars in medical topics (e.g., bioethics, hance student appreciation and understanding of the range of health policy, palliative care), and an abbreviated course in characteristics describing the human condition, the context the Principles of Organic Chemistry and Physics Related to in which dysfunction, disability, and disease intrudes and dis- Medicine (six credit hours for organic chemistry; two credit torts. It was felt that this benefit might be accrued from three hours for physics). Students complete weekly examinations elements of a challenging liberal arts background: amplifica- that are graded pass/fail. tion, self-discovery, and the development of professionalism. During the summer prior to matriculation, HuMed stu- • Amplification—Fiction at its best can depict in several dents may attend an optional Summer Enrichment Program hours of reading and reflection more about the nature of the (SEP) that serves to acclimate incoming HuMed students to the human condition (that brew of joy, sadness, fright, relief, be- medical school curriculum and environment. Approximately wilderment, confusion, and pain) than the untutored, intuitive seventy-five percent of the matriculating HuMed cohort observations derived through the single, often imperfect lens participates each year. The SEP curriculum includes over- of a maturing adolescent. Reading the best fiction as part of views of biochemistry, anatomy, embryology, cell biology, and a colloquium led by an experienced preceptor/facilitator in a histology. Examinations are the self-assessment type and are small group of able, interactive classmates identifies and am- reviewed in class. Students do not receive grades. plifies elements that may be ephemeral in life, often unseen or The first-year medical school curriculum is not altered to unremarked. Focused insight through reading, discussion, and accommodate the HuMed students. interpretation replaces and completes the surmised and the unexperienced. It gives meaning to a life-altering event and Aims of the HuMed program the needs of the individual(s) involved. This new program sought to encourage a group of appli- • Self-discovery—Not only does a liberal arts education cants with an interest in the humanistic elements of medicine prepare the student for what to look for in others, it also to consider pursuing a career in the profession. At a minimum, informs the sensitized and guided student of his or her own the program would result in a more diverse and enriched pool diverse reactions and sensitivities. It induces and expands of potential applicants. Mount Sinai believed that these poli- personal scrutiny of one’s own preferences, prejudices, miscal- cies would eliminate the initial reluctance of these applicants culations, and ignorance. Under the best circumstances it ex- to pursue medicine, typically based on an uncertain interest in pands the individual’s sense of self: what talents and resources science, concern over their ability to meet the high scholastic one possesses and which need development, strengthening, expectations of medical school admissions committees, and/ and correction, all in preparation for a career dedicated to or their unwillingness to divert the time and effort required to healing others. meet standard medical school requirements. • Professionalism—A liberal arts collegiate education, so The keen awareness premed students have of the com- often undertaken in a small-group faculty-facilitated format, petitive nature of the admissions process and the need for reinforces awareness of the importance and benefits of pro- outstanding performance in science GPA and MCAT scores ductive interaction with others. These benefits are twofold. might induce them to cram for grades without appreciation The best students will endeavor to hone the skills that maxi- of the science being studied. As a result, their retention of the mize effective written and oral communication: conciseness, information might only be transitory. Educators have turned cogency, lucidity, and fluency. They discover and emulate “what should be a comprehensive meritocracy into a narrow those virtues in their most effective classmates, and they de- minded and mean spirited ‘testocracy.’ ” 15 velop a personal style of interactive conduct of their own that This narrow focus fosters other negative results: leads to more successful subsequent interactions. Moreover • Cultivation of true scientific curiosity is diminished as the benefit of interdependence induces positive socializing the satisfactions of scientific discovery are lost. behavior, personal control, ethical interactions, civility, and • The process of assessing student performance by “objec- courtesy. tive” validating memorized current knowledge ignores the fact These are the essential elements of all human interactions, that science is not static. be they with patients or peers. Over time, students successful
The Pharos/Winter 2012 37 Competencies as the basis for reformed premedical education
in these encounters appreciate language and the methodolo- • Honors grades in clerkship (except Psychiatry, where gies and the targets of precise communication. They become significantly more HuMed students received honors grades) as aware of the needs of others as they are of their own. In • School leadership sum, the defining philosophy of HuMed posits that the result • Gold Humanism Honor Society awards of such an education will be a receptive, interactive, communi- • Rank in the top twenty-five percent of the class cative, and sensitive prospective medical professional. • Nomination to AΩA HuMed students were significantly more likely (thirty-two Outcomes percent versus twelve percent) to do a scholarly year dedicated The HuMed Program has been in place for over twenty to research and be awarded Doris Duke Clinical Research years. A recent report in Academic Medicine reviewed out- Fellowships (twelve percent versus three percent) There was come data for six graduating classes.14 The report compares a nonsignificant trend among the HuMed students (eleven medical school performance outcomes of undergraduate percent versus seven percent) to graduate with Distinction in humanities and social science majors who specifically omit- Research (first-author peer-reviewed publication). Notably, ted all standard premed requirements and the MCAT with HuMed students were also more likely to require nonschol- classmates who pursued the traditional premed science-based arly leaves of absence, typically for academic or personal preparation. Using a Medical Student Performance Evaluation difficulties. (MSPE) grid, the report compares academic data reflecting ba- Finally, although difficult to quantify, a trend was identi- sic science knowledge, clinical performance, leadership, com- fied among HuMed students versus non-HuMed students to- munity service, humanism and professionalism, and research/ wards residency choices in Primary Care (fifty percent versus scholarship of the two groups of students. No statistically forty-two percent) and Psychiatry (thirteen percent versus six significant differences were identified between HuMed and percent), and away from surgical subspecialties (five percent non-HuMed students for the following academic outcomes: versus twelve percent) and Anesthesiology (seven percent • USMLE Step failures versus eleven percent). • Exceptional performance on the end of third-year The results provide evidence that for these HuMed stu- Comprehensive Clinical Assessment dents a significant reduction of standard premed requirements did not result in a limited ability to assimilate the basic science knowledge necessary for promotion to the clinical clerkship years, nor did it limit success in the clinical years either in clerkships, electives, clinical skills exams, research endeavors, or residency selection.
Discussion The HuMed Program at Mount Sinai School of Medicine was designed to encourage application from students who were interested in the altruistic and humanistic elements of a medical career but were deterred by the rigid academic requirements. Directly or indirectly, intentionally or not, the traditional requirements appear to be very effective barriers that limit the diversity of applicant premed preparation. Humanities and social science majors matriculating in U.S. medical schools in comprised less than eighteen percent of the total.16 We believe however, these prerequisites need not be a bar- rier to dual-major collegiate education, provided the medical school has known policies that welcome, not exclude, such applicants. This has certainly been the case at Mount Sinai, where from the first entering classes in and thereafter the school has welcomed dual majors.17 In , the proportion of these dual majors among the entering class was twenty- five percent, excluding the HuMed students, and almost half (forty-three percent) when HuMed was included. These nontraditional students had pursued a wide range of liberal
38 The Pharos/Winter 2012 arts majors—music, history, theology, economics, and fine arts, among others. The number one student in the class of was a Religious Studies major, one of the top graduates in (AΩA and currently a PGY in Medicine at Mount Sinai) a Dramatic Arts major, and the number one graduate in the class of a Music major. Finally, a member of the class of spent his entire collegiate career in the extremely competitive combined Columbia-Juilliard Performing Arts program studying and performing as a cellist. This story does not always apply. Many students accepted to Mount Sinai via the HuMed program decide to pur- sue other, nonmedical careers. Case in point: one accepted HuMed student continued his interest in creative writing and is now a New York Times best-selling novelist! As an experiment in educational philosophy defining the ingredients necessary for a career in medicine, the HuMed pro- gram clarifies the extent to which traditional courses in organic chemistry, physics, and mathematics are necessary for success- ful completion of a medical school curriculum. For example, we compared the USMLE Step scores, Step failure rates, and serious academic difficulty (defined as three course failures or two course failures and two marginal grades in the first or sec- ond year of medical school) for the HuMed and non-HuMed cohorts. These outcomes were respectively, Step scores addition, they have performed as well, and in some instances versus , Step failure four percent versus two percent, and better, than their premed classmates in the clinical years. serious academic difficulty . percent versus . percent. Only The success of HuMed over the years has had an unantici- the Step score difference was statistically significant. pated but gratifying impact on our medical school community. More troubling is the higher rate for HuMed students of It has broadened the spectrum of criteria for admission for nonscholarly leave of absence (eleven percent versus three the entire pool of applicants. In addition, it has encouraged percent, P=.).14 This may indicate that a very small num- initiation and expansion of required and elective humanism ber of students are troubled as they struggle academically in medicine courses within the medical school curriculum. with unfamiliar material (but do not fail) and require a pause Finally and yet to be determined is whether the expanded before returning to school. Still others find they are unsure liberal arts background obtained in a variety of experiences of their career choice. Mount Sinai addresses these concerns such as electives, community service, additional degrees, and in a variety of ways: admission standards attempt to identify personal avocations will lead these HuMed students to pur- students with very high academic potential and intellectual sue successful, fruitful lifetime careers in the profession. Can “flexibility,” students who attend SEP learn studying and test- follow-up ever accurately measure fulfillment and satisfaction? taking skills for the sciences, prospective students are strongly Will burn-out frequencies or incidents of unprofessional be- encouraged to take at least one year off before matriculating. havior be reduced? We believe this does allow ample time for most to reflect on Alas, incidents of immoral behavior occur in all elements their career choice. Happily, HuMed students in this category of society. Those of us in medicine—as practitioners, educa- return to school and graduate at a rate no different from their tors, or investigators—are painfully aware of the egregious non-HuMed classmates. examples of criminality, addiction, mendacity, abuse, plagia- HuMed outcomes suggest that no essential preparatory rism, and bribery that have tarnished our profession. We have ingredient was missing by having had an extensive liberal arts assumed, and continue to rely on, our ability to identify and college education at the expense of the traditional require- weed out those with such tendencies as they emerge, however ments and outstanding performance on MCATs. It is clear subtly, during the challenging and stressful years of medical that a significant reduction of the traditional requirements did school and residency training. Clearly, this process is an im- not result in either significant failure or significant inability to perfect and deficient filter. assimilate and apply the predoctoral basic science material in We invite the Pharos readership to suggest applicable mea- years and , nor did it limit success in the clinical years either sures we might employ to judge the long-term impact, if any, in clerkships or clinical skills exams. The HuMed students did of the HuMed program on these students. not significantly fail the challenges of the basic sciences. In What can be said with certainty, however, is that such a
The Pharos/Winter 2012 39 google.com. . Dalen JE, Alpert JS. Premed requirements: The time for change is long overdue! Am J Med ; : –. . Dienstag JL. Relevance and rigor in premedical education. N Engl J Med ; : –. . Emmanuel EJ. Changing premed requirements and the medical curriculum. JAMA ; : –. . Kanter SL. Toward a sound philosophy of premedical educa- tion. Acad Med ; : –. . Gross JP, Mommaerts CD, Earl D, DeVries RG. After a cen- tury of criticizing premedical education, are we missing the point? Acad Med ; : –. . Thomas L. How to fix the premedical curriculum. N Engl J Med ; : –. . AAMC-HHMI Committee. Scientific Foundations for Fu- ture Physicians. Washington (DC): Association of American Medi- cal Colleges; . . Project Panel on the General Professional Education of the Physician and College Preparation for Medicine. Physicians for the Twenty-First Century. Washington (DC): Association of American Medical Colleges; . . Committee on Undergraduate Biology Education to Prepare Research Scientists for the st Century, Board on Life Sciences, change in requirements does not adversely influence success- Division on Earth and Life Studies, National Research Council of the ful performance in a demanding and highly competitive medi- National Academies. Bio : Transforming Undergraduate Educa- cal school environment. tion for Future Research Biologists. Washington (DC): The National Academies Press; . Summary . ACGME Outcome Project. General Competencies. http:// As the HHMI-AAMC declared, their report should be www.acgme.org/outcome/comp/compmin.asp. Accessed October taken as a “first step in a continuing conversation about the . appropriate skills and knowledge,” and, echoing the ACGME . Medical School Objectives Project—Initiatives—AAMC. and GPEP, “values and attitudes that future physicians should Medical School Objectives Project (MSOP). https: www.aamc.org/ possess.” 9pExecSum As a new formulation evolves, the pre- initiatives/msop. Accessed October . medical curriculum must foster “scholastic vigor, analytic . Muller D, Kase N. Challenging traditional premedical re- thinking, quantitative assessment and analysis of complex quirements as predictors of success in medical school: The Mount systems.” 9pExecSum Based on the Mount Sinai experience, these Sinai School of Medicine Humanities and Medicine Program. Acad qualities are not engendered solely nor confined to engage- Med ; : –. ment in natural sciences. Students involved in a variety of . Gunderman RB, Kanter SL. “How to fix the premedical cur- baccalaureate liberal arts endeavors appear to acquire similar riculum” revisited. Acad Med ; : –. intellectual competencies. Furthermore, when performed suc- . Association of American Medical Colleges. Table : MCAT cessfully in challenging collegiate environments, a thorough and GPAs for Applicants and Matriculants to U.S. Medical Schools liberal arts education may yield precisely the same values, by Primary Undergraduate Major, . https://www.aamc.org/ attitudes, and behavioral characteristics all agree are essential download//data/. Accessed October . to the medical profession and preparing physicians for the . Rifkin MR, Smith KD, Stimmel BD, Stagnaro-Green A, Kase twenty-first century. NG. The Mount Sinai Humanities and Medicine Program: An al- ternative pathway to medical school. Acad Med ; : S–. References . Beck AH. The Flexner Report and the standardization of Address correspondence to: American medical education. JAMA ; : –. Nathan Kase, MD . Flexner A. Medical education in the United States and Mount Sinai School of Medicine Canada: A Report to the Carnegie Foundation for the Advancement One Gustave L. Levy Place, Box 1025 of Teaching. Bulletin Number Four. New York: Carnegie Foundation New York, New York 10029 for the Advancement of Teaching; . Available online at books. E-mail: [email protected]
40 The Pharos/Winter 2012 Mechanical Man
pread-eagled in full restraints, SDonald Bates glares at me, a plastic tube in his throat connecting with a Bennett respirator whose dials dictate his breathing. The lump under the skin of his chest, a Medtronic pacemaker since his November heart attack, clicks its seventy beats a minute. Each night they debate their total control as he struggles to sleep— the respirator, heaving and sighing in a whish thump voice challenging him to live without it, the electronic genius inside his chest boasting its control of pump and flow to every organ needed to survive. This morning he scribbles on a clipboard like a third-grade child, “Why are you doing this to me?” Outside the CCU his family waits for my morning report. I avoid the clichés—they see in my eyes the news they expect to hear. I go home to fix a doorknob in the kitchen. Henry Langhorne, MD
Dr. Langhorne (AΩA, Tulane Medical School, !"#$) is in private practice in cardiology at Cardiology Consultants in Pensacola, Florida. His address is: !"!% Seville Drive, Pensacola, Florida &'#%&. E-mail: [email protected]. Illustration by Jim M’Guinness. The Pharos/Winter 2012 41 2011 Robert J. Glaser Distinguished Teacher Awards
The 2011 AΩA Robert J. Glaser Distinguished Teachers. Left to right: Dr. Thomas Lawley, immediate past-chair of the AAMC, Dr. Richard L. Byyny, Executive Director of Alpha Omega Alpha, Dr. Mark T. O'Connell, Dr. LuAnn Wilkerson, Dr. Dennis H. Novack, Dr. Gerald D. Abrams, and Dr. Darrell Kirch, President of the AAMC.
ach year since , Alpha (Jack) Nolte, PhD; Jeanette Norden, Gerald D. Abrams, MD Omega Alpha, in cooperation PhD; James L. Sebastian, MD; Professor Emeritus of Pathology, withE the Association of American Kelley M. Skeff, MD; Jeffrey G. University of Michigan Medical Medical Colleges, presents four Wiese, MD. School AΩA Distinguished Teacher Winners of the award receive In his more than five-decade ca- Awards to faculty members in ,, their schools receive reer, Dr. Abrams (AΩA, University of American medical schools. Two ,, and active AΩA chapters Michigan, ) has educated nearly awards are for accomplishments at those schools receive ,. , students on the intricacies of in teaching the basic sciences and Schools nominating candidates for pathology, and has been consistently two are for inspired teaching in the award receive a plaque with the rated the highest performing basic sci- the clinical sciences. In , AΩA name of the nominee. ence faculty teacher at the University of named the award to honor its retir- Brief summaries of the accom- Michigan Medical School. For much of ing executive secretary Robert J. plishments in medical education his career, Dr. Abrams has contributed Glaser, MD. Nominations for the of the award recipients follow. to the oversight, design, and modifica- award are submitted to the AAMC tion of the medical school curriculum. Richard L. Byyny, MD each spring by the deans of medical In the s, he developed a series of Executive Director schools. lectures in general pathology that in Nominations were reviewed by the s was made an independent, a committee chosen by AΩA and permanent part of the first-year cur- the AAMC. This year’s committee riculum. Over the years, Dr. Abrams members were: Helen C. Davies, has adapted his teaching methods to PhD; Joel M. Felner, MD; William incorporate advances in information H. Frishman, MD; Aviad Haramati, technology. He developed an interactive PhD; Robert M. Klein, MD; John CD-ROM to accompany a histopathol- ogy course he developed and later digi- tized the slides from the course to create a “virtual microscope” format to be used in teaching labs and on the Internet. 42 The Pharos/Winter 2012 Dennis H. Novack, MD Mark T. O’Connell, MD LuAnn Wilkerson, EdD Professor of Medicine, Associate Senior Associate Dean for Professor of Medicine, Senior Dean for Medical Education, Drexel Educational Development, Senior Associate Dean for Medical University College of Medicine Advisor to the Dean, Bernard J. Education, University of California, Dr. Novack (AΩA, Drexel University, Fogel, M.D., Endowed Chair in Los Angeles David Geffen School of ) has made significant contribu- Medical Education, and Associate Medicine tions to the way in which academic Professor of Medicine, University of Dr. Wilkerson’s vision for medi- medicine teaches and assesses Miami Leonard M. Miller School of cal education is one in which engaged physician-patient communications. Medicine learners and passionate teachers imple- He was integral to the development of For more than a quarter-century, Dr. ment a coordinated and ever-evolving an Internet-based clinical skills cur- O’Connell (AΩA, University of Miami, curriculum. For more than three de- riculum and more recently developed ) has made numerous contributions cades, she has pursued this goal through a complementary Internet-based as- in the areas of information technol- the design of medical school curricula sessment tool. In partnership with the ogy, curriculum design, program de- and enhanced faculty development. To American Academy on Communication velopment, and student initiatives. He ensure that UCLA’s students possess the in Healthcare and Drexel University, established the Office of Biomedical competencies needed for modern medi- Dr. Novack led the creation of doc. Computing, one of the first microcom- cal practice, Dr. Wilkerson helped pio- com. Using text and video, doc.com puter labs at a medical school, which neer the Doctoring program. She also demonstrates basic and advanced in- allowed Miller School students to be oversaw the creation of fourth-year “col- terviewing skills through more than among the first trained on MEDLINE. leges”—learning communities that pair forty modules tailored to various learner He pioneered the use of a controlled students and faculty to enhance career developmental stages. Dr. Novack also vocabulary to index the Miller School’s mentoring. Dr. Wilkerson directs the helped develop WebOSCE, which en- curriculum and then worked with Center for Educational Development ables students to interview standardized the AAMC to develop the curricular and Research, which helps faculty im- patient-actors through videoconference database that was the forerunner of prove curriculum and fosters teaching and provides both immediate feedback CurrMIT. Described as a consummate skills and the use of technology. She from the patient-actor and a video of the program builder, Dr. O’Connell was is dedicated to faculty development, interaction for further review, as well instrumental in creating a two-year particularly as it relates to ambulatory as links to doc.com and other sites that satellite program at Florida Atlantic teaching and problem-based learning. help learners enhance their skills. At University. When the program expanded Dr. Wilkerson has been described as “a Drexel, Dr. Novack created and directs to four years, he helped develop the cur- teacher of teachers,” whose “accomplish- the Physician and Patient course, which riculum and oversaw all aspects of the ments and contributions to the field provides fundamental skills to first-year accreditation process. His influence is of medical education are colossal and students, and also directs and teaches felt throughout the Miller School, hav- profound.” the doctoring curriculum for internal ing been responsible for establishing the medicine residents. Department of Community Service, a student-run nonprofit that consistently achieves nearly one hundred percent participation, the Office of Professional Development and Career Guidance to mentor students, and the Physicianship and Professionalism Advocacy Program.
The Pharos/Winter 2012 43 Reviews and reflections
David A. Bennhaum, MD, and Jack Coulehan, MD, Book Review Editors
making real conceptual progress on an ability to make the connections be- carefully selected topics that beg to be tween domains of knowledge that would addressed across many sectors of so- otherwise remain apart in separate ac- ciety. But this newest book, Exploring ademic silos, making real progress un- Happiness, is Bok’s best ever. Why? likely. She provides what is, in my view, Methodologically, Bok has now po- the best example of integrative scholar- sitioned herself at the new interface be- ship on happiness to date. This is there- tween moral thought and the sciences, fore a book that any neo- Aristotelian, both social and biological. Here she utilitarian, or Kantian philosopher will glides with astonishing clarity through have to grapple with, and that any sci- the works of philosophical, and even entist interested in a deeper concep- some theological, luminaries, picking tual understanding of the “happiness” and choosing her key figures with in- that they are investigating will have to novative diligence. But she is equally read before focusing on methodological Exploring Happiness: From adept in her familiarity with key sci- technocracies. Both the philosophy and Aristotle to Brain Science entific findings on happiness as she the science are presented in a way that Sissela Bok engages with national and international most lay readers will easily handle, and Yale University Press, New Haven, CT, happiness surveys, the genetics of “set in her skillful, almost pastoral, style, 2010 point” happiness, evolutionary psychol- Bok is able to make all this relevant to ogy, economic investigations of money the reader on an existential level. It is Reviewed by Stephen G. Post, PhD in relation to happiness, game theory, possible to read this book and be trans- neuroscience, pro-social behavior, so- formed to some degree. n while I was at the University cial capital theory, positive psychology, Bok is always an innovative thinker of Chicago, Martin E. Marty placed a and so forth. Those of us who believe by virtue of her ability to pick important Ihardback copy of Sissela Bok’s then new that meaningful progress can best be and timely topics, often ones that have book, Lying, in my hand and said, “Read made on big topics such as happiness not been handled before with much it!” Fortunately, his intention was non- only at such a dialogical interface with clarity. What do we mean by happi- remedial. In reading Lying, I discovered the sciences are of course delighted to ness? How much of it can be had in what it means to write masterful philo- see an eminent philosopher like Bok this life? How can it be measured? Is sophical history for a wide audience turning in this direction. our happiness something for which we while articulating a clear normative The astonishing thing about are responsible as individuals at some position that is balanced, not Exploring Happiness is that the clear level, despite genetically shaped predis- overbearing, and of value for and probing exegesis of the great phi- positions and personality types? How the wider culture. Many losophers is matched in quality by the can we nurture it? Can happiness ever remarkable books from penetrating analysis of major scientific be lasting, or is it always fleeting and Sissela Bok have fol- investigations. Bok weaves these two unstable? Do we always fear its loss? lowed, all of them strands together with precision and Is there any one view of happiness that
44 The Pharos/Winter 2012 trumps others, or should we be very of purpose? The neo-Aristotelians and cautious about such assertions? How eudaemonists will no doubt engage in does my “pursuit” of happiness pertain some critique of Exploring Happiness morally to your pursuit? Whose happi- because it clearly constitutes the finest ness are we ultimately responsible for, or liberal (minimally prescriptive) analy- can we be responsible for? sis of happiness to date, and as such Exploring Happiness is great expo- deserves very high praise indeed. It is sitional writing. Bok warns that the normative not in asserting what hap- topic is extremely complex, and that piness is, but in articulating procedural we should not seek premature closure. and minimalist contractarian moral re- She is clear in her conclusion that the straints on its pursuit. Perhaps this is pursuit of happiness needs to be mor- enough, for as they say, “hard lessons ally circumscribed. After all, there are are learned hard,” and perhaps we can those who, like the al-Qaeda pilots who only teach ourselves how to pursue hap- flew into the World Trade Towers, do piness well in all our idiosyncratic error. great damage while pursuing their own This book is highly recommended as visions of a promised eternal bliss. In the best liberal contractarian statement other words, at some level, we do need to date. But the neo-Aristotelians who had grown more intense and antici- to relate our individual pursuits of hap- are coming into dominance in many pated than graduation itself,” as expe- piness to the notion of a shared or a American universities will wish for a rienced by three young women—Eule’s common humanity rather than to some treatment of happiness that is in fact girlfriend Stephanie, and friends Rakhi small fragment thereof, and we must be a little more prescriptive than what and Michele—I anticipated that it careful of arrogance. Bok offers. Perhaps they have met their might offer a glimpse into our own fast- In humility, Bok does not wish to match. approaching futures. prescribe any one vision of happiness, The prologue depicts the tension or to set out a method for achieving it. Dr. Post is the director of the Center for of Match Day morning, leading up to As she writes, Medical Humanities, Compassionate Care the moment when envelopes across the and Bioethics at Stony Brook University country will be opened. It then leaves us I have argued for the greatest pos- Medical School. His address is: hanging, stepping back to orient readers sible freedom and leeway in the pur- Center for Medical Humanities, to the Match, complete with its origins suit of happiness, subject to moral Compassionate Care, and Bioethics and modifications. This history is truly limits. There is no one view of hap- Health Sciences Center enlightening; I had no idea that the piness that should exclude all oth- Stony Brook University Match computer resides in Washington, ers, much less be imposed on the Stony Brook, New York 11794-8335 DC, and runs its annual algorithm to recalcitrant. But the pursuit cannot E-mail: [email protected] completion in less than ten minutes. merely involve “choosing happiness” Subsequent chapters examine the ap- as many advice manuals propose. plication process and the nuances of ap- Pursuits of happiness that abide by Match Day: One Day and One plying to specific residencies, especially fundamental moral values differ cru- Dramatic Year in the Lives of those offering more flexible lifestyles cially from those that call for deceit, Three New Doctors without a sacrifice in pay: the “R.O.A.D. violence, betrayal.p176 (radiology, ophthalmology, anesthesiol- Brian Eule ogy, dermatology) to Happiness.” It also One wonders, though, if this retreat St. Martin’s Griffin, New York, 2010, 272 provides an honest look at what influ- from much objectivity in the pursuit of pages ences applicants’ decisions about where happiness really suffices. It is of course Reviewed by R. MacDonell-Yilmaz, to apply and how to rank programs. One important that our pursuits of happiness MPH particularly compelling scene depicts be limited by some foundational and Rakhi’s struggle to finalize her rank list minimalist moral restraints. But are we hours before the deadline. She must not rightly tempted to encourage a view hen I approached Brian Eule’s weigh the program she has dreamed of of happiness comprised by some set Match Day, I imagined it might for years against one at another univer- of goods pursued over the course of a Wmake an apt birthday gift for a good sity where her husband—who moved lifetime, such as contributing to the lives friend, a fellow third-year medical stu- across the country, worked unfulfilling of others, moral integrity, and nobility dent. Given its focus on “a ritual that jobs, and weathered rejections from
The Pharos/Winter 2012 45 Reviews and reflections
graduate schools while she studied med- if Eule is trying to convince us that his icine—has just gained admission. This subjects are likeable and their stories glimpse of a couple sorting through moving, but the details are often forced complex if-this-then-that scenarios, at- and generic rather than unique and tempting to reconcile disparate per- defining. He notes, for example, that sonal goals with an entwined future, Michele’s “keen awareness of fashion poignantly illustrates how this profes- often led her to opt for a trendy hat, sion’s training taxes many lives beyond knit scarf, or big sunglasses” p32 and that that of the trainee. an end-of-year party is “sure to include We arrive back at Match Day to learn drinking and celebrations.” p234 the contents of the women’s envelopes This tendency is especially frustrat- and then set out with the newly-minted ing in his depictions of the women’s physicians as they navigate the chal- medical experiences. For a practitioner, lenges of internship. Along the way, Eule the incidents he highlights and his de- explains the controversies surrounding scriptions of them are neither earth- legal work-hour restrictions. shattering nor revelatory—a medical He also explores the difficulties of student nervous about practicing blood “finding time for a life,” especially for draws with classmates, a surgeon snap- We’re NOT Leaving: 9/11 Stephanie, a surgical intern. In a rare ping at an intern, a cancer patient refus- Responders Tell Their Stories moment of expressing his own feelings, ing further treatment. I wanted to pull of Courage, Sacrifice, and Eule confesses how the strain of interns’ him aside and whisper, You think this is Renewal lives extends to their loved ones: bad? You don’t know the half of it. Benjamin J. Luft, MD Admittedly, my irritation at his Greenport Press, New York, 2011 The problem with Stephanie’s wordiness might simply stem from my schedule, in addition to the long own impatience, a trait Stephanie also Reviewed by Richard Bronson, MD hours, was the lack of predictability. possesses: “Af ter hours of moving fast, (AΩA, New York University, 1965) . . . I could never tell what time she of talking quickly and efficiently, she would get home from the hospital. sometimes expected the same at home. Williamsburg Bridge, sun hits the And she never knew the four indi- If I answered a question in a round- train vidual days she would get off in a about way, I could see aggravation in As it rises over the city again. month until that month’s rotation her eyes.” p210 Slower sections of writing Nobody speaks, everyone stares began. . . . inspired similar aggravation as I waded Remembering all that used to be It was impossible to make plans along, eager to reach the next example there. to see friends or family. . . . My re- of his journalistic prowess. sentment grew.pp135–36 Overall, Match Day offers a fasci- “Brooklyn Train,” Lucy Kaplansky nating history and fresh perspective Happily, we learn, she does find at least on medical training from an author y waiting room had a television a smidgeon of free time—enough for who, though neither practitioner nor attached to the wall. In the middle their wedding at year’s end. patient, finds his life deeply affected Mof morning hours, a nurse cried, “Come, Throughout the book, Eule’s tone var- by the process. Just as House of God look at this.” Against a blue, cloudless ies between journalistic and narrative. serves as an unofficial handbook for sky, I saw the tail of an airplane sticking Using the former, he explains the Match medical students and residents, Match out of the upper stories of one of the and its permutations, including the Day is an excellent guide for family and Twin Towers, surrounded by flames! Couple’s Match and the transitional year. friends. Ultimately, I bought my friend a Then the second jet, the realization that His account of the infamous Zion case bouquet of flowers and passed the book this was not an accident, the unexpected and the resulting Bell Commission are along to my mother. collapse of both towers, the horror and excellent as well; his words flow smoothly fear as the day went on and the magni- and authoritatively, easily capturing and Ms. MacDonell-Yilmaz is a member of the tude of the attack became clear. It was a maintaining the reader’s attention. Class of 2012 at the School of Medicine at time of candlelight vigils, firemen and Much of the actual storytelling, how- Stony Brook University Medical Center. policemen marching to bagpipes at fu- ever, is not handled as deftly. His narra- Her e-mail address is: beckymacd28@ nerals, and photos of missing husbands, tion of the women’s experiences lacks gmail.com. wives, sons, and daughters stapled to the spark of his journalism. It feels as telegraph poles. Twin searchlights rose
46 The Pharos/Winter 2012 into the night for months, a reminder language is simple, frank, and descrip- to any one person who responded. of what had been there. But the inva- tive . . . Although they speak of sorrow . . . sion of Baghdad, two lengthy wars, the and pain, to me they are a source of . . . There were fires, there were economic crisis, and a major reces- celebration of the human spirit’s ability explosions, there were tons of steel sion intervened. We largely lost track to transcend unimaginable hardships, and debris falling. There were jump- of the responders who were imprinted and still maintain its humanity.” p8 There ers, there were bodies falling. . . . with the trauma of those days and have is no better way of conveying what he It’s etched in their brains, in their continued to lead their lives, altered by means than to quote a few representa- minds, in their memory and their that experience. We’re NOT Leaving tive stories: spirit.pp317–21 restores our emotional connection with that event, and the people who played a I was actually inside the building, heroic role in the initial response to the near the escalators, when the Tower I am very proud that in time of attack and the subsequent clean up and collapsed. . . . And I was able to hold crisis, /, that our church showed reclamation. This is their oral history. onto the doorway with my left arm. up and we stood there . . . We were Created by Dr. Benjamin Luft, the People blew by me and under me there every day, /, for eight and a Edward D. Pellegrino Professor of and through me. Only with one arm, half months. We served over half a Medicine at Stony Brook University did I hold on. . . . there was utter million meals . . . . Medical Center and Director of the terror...... and many days I would do Long Island Medical Monitoring . . . As we crawled out we saw blessings and last rites on body bags, and Treatment Program, We’re NOT people and we tried to help them and it meant the world to the work- Leaving contains a selection of first- and they were dead. . . . ers to have the clergy in the site with person narratives from more than . . . Our radios didn’t work. . . . them . . . videotaped interviews. Many of these I couldn’t call my command.pp24–27 . . . They wore respirators instead men and women are still recovering of neckties and Kevlar suits instead from the disaster. As Dr. Luft notes, of Brooks Brothers suits. So this was “They suffer from post-traumatic stress In the beginning, the first few a community that was brought to- disorder, nightmares, sleep apnea, anxi- days, it was very hard to get around. gether out of love, through love and ety, asthma, persistent cough, and in There were makeshift morgues compassion and service. I like to de- many cases, anger and disillusionment around the place, and you could see scribe it as a season of love.pp380–82 about how they were treated by a soci- people picking up body parts and ety that dragged its feet in responding putting them in bags and people When I started to read We’re NOT to their needs when they became ill crying. It was very sad and scary, I Leaving, I was concerned that much as a result of responding to the disas- actually felt like I was in a war zone. might be lost in transcription. This was ter.” p14 He has recognized the necessity . . . We were working twenty- not the case. There were times when I of remembering. four hours a day, seven days a week. could not continue reading. It was too The book consists of thirty-two chap- We were sleeping on the floor at emotionally difficult, and I had to put ters (each an individual’s personal narra- Hudson Street. We just take a nap, the book down. There is a deep truth in tive), divided into five sections, and an get up, and . . . It was taking its toll. these voices of people who placed their epilogue. These sections, titled “Caught A couple days without showering, duty above their own personal health in the Collapse,” “Looking for Survivors,” everyone smelling, stinking.pp39–41 and gave everything they could give at “Recover, Recovery, Recovery,” “The a time when our country was attacked. Responders Need Help,” and “Renewal,” take us from the initial moments of the I’m a psychiatrist . . . volunteer Dr. Bronson is Professor of Obstetrics & attack, before and following the collapse responder. . . . Gynecology and Pathology at Stony Brook of the Towers, the experiences of early . . . We’re learning about all these University Medical Center and a member responders, the realization that there physiological interactions between of the editorial board of The Pharos. His were few survivors, the search for bod- stress, depression, PTSD and heart address is: ies or portions of bodies, the work of disease and the immune system and Stony Brook University Medical Center, dismantling the wreckage, and, finally, other things that shorten lives . . . . T9-080 efforts to support those who worked on . . . I think the press and the pub- Stony Brook, New York 11794-8091 “The Pile” and minister to their needs. lic look at it as though it was one E-mail: [email protected] Dr. Luft best describes these testimo- event . . . . nies. “The stories are powerful . . . Their . . . But it was hundreds of events
The Pharos/Winter 2012 47 2011 meeting of the AΩA board of directors MD, elected to a three-year term as Medical Organization The annual meeting of the board of directors of Alpha Director. Omega Alpha was held in Chicago, Illinois, on September Retiring from the board are: Cason Pierce, MD; Anne , . Present were: Mancino, MD; Donald E. Wilson, MD. Officers: President Rae-Ellen W. Kavey, MD, MPH; Renewed for three-year terms are: C. Bruce Alexander, Vice President Donald E. Wilson, MD, MACP; Secretary- MD; Robert Atnip, MD; Joseph Stubbs, MD. Treasurer C. Bruce Alexander, MD. Members at large: Robert G. Atnip, MD; N. Joseph Constitutional changes Espat, MD; Ruth-Marie Fincher, MD, MACP; Eve J. The board voted to approve the following constitutional Higginbotham, MD; Douglas S. Paauw, MD; Don W. changes: Powell, MD; Joseph W. Stubbs, MD, FACP. . Eliminate the office of Vice President Councilor directors: Richard B. Gunderman, MD, PhD, . Add the office of President-Elect Indiana University School of Medicine; Sheryl Pfeil, MD, . Add the office of Immediate Past President the Ohio State University College of Medicine; Alan G. The relevant changes to the constitution may be seen on Wasserman, MD, George Washington University School of AΩA’s web site: www.alphaomegaalpha.org/constitution. Medicine and Health Sciences. html, Article V. Organization and Central Administration. Student directors: Alicia Alcamo, MD, the Ohio State Dr. Tooker will chair a committee to explore further University College of Medicine; William E. Bynum IV, constitutional changes. MD, University of South Carolina School of Medicine; Tonya Cramer, MSIV, Chicago Medical School at Rosalind Elections Franklin University of Medicine and Science; Cason Pierce, The following members of the board were elected as MD, University of Texas Southwestern Medical School. officers: Medical Organization Director: John Tooker, MD, . Ruth-Marie Fincher, MD, MACP, President MBA, American College of Physicians. . Rae-Ellen W. Kavey, MD, MPH, Immediate Past Coordinator, Residency Initiatives: Suzann Pershing, President MD. . C. Bruce Alexander, MD, President-Elect National office staff: Executive Director Richard L. Byyny, . Joseph W. Stubbs, MD, FACP, Secretary-Treasurer MD; Assistant Treasurer William F. Nichols; Managing Two honorary members were proposed this year. Both Editor Debbie Lancaster; Programs Administrator Judy were elected to honorary membership for their distin- Yee; Membership Administrator Lena Beavers; Controller guished contributions to medicine. Profiles of these honor- Barbara Prince. ary members will appear in a future issue of The Pharos: Absent were: Anne Mancino, MD, councilor director for . Thomas R. Cech, PhD the University of Arkansas School of Medicine, and Carol . Martin George Tauber, MD A. Aschenbrener, MD, of the Association of American Medical Colleges. Reports New to the board are: Eve J. Higginbotham, MD, Dr. Kavey and Dr. Byyny presented their reports for elected to a three-year term as member at large; Alan G. the year, summarizing the year for AΩA programs, new Wasserman, MD, elected to a three-year term as councilor medical school chapters, chapter visits, fundraising, the director; Tonya Cramer, MSIV, elected to a three-year membership directory and database, communications and term as student director; and Carol A. Aschenbrener, public relations, and staffing.
The Pharos/Winter 2012 48 National and chapter news
The financial review was presented by Mr. Nichols and . Essays should have a maximum of pages (ap- Dr. Alexander. A presentation on AΩA’s investment pro- proximately words), and be submitted in -point gram was given by Jennifer Ellison and Diana Lieberman type, double-spaced, with one-inch margins. They should of Bingham Osborne & Scarborough. be accompanied by a covering letter and a title page with A report on The Pharos was presented by Debbie the word count (or page count), return address, and e- Lancaster. mail address. References should not exceed unique Dr. Gunderman and former councilor director Dr. items (see below). Gabriel Virella reported on the AΩA Councilors . Poems or photograph/poetry combinations should Meeting, held on September and , just before the be in -point type, with one-inch margins, with the au- board of directors meeting. Drs. Gunderman and Virella thor’s name, address, and e-mail address on the first page. chaired the meeting. A report on the meeting will appear . Electronic submissions are preferred. Send them to in a future issue of The Pharos. [email protected]. Or send by mail to Richard L. Dr. Pershing presented a report on the Residents Byyny, MD, Editor of The Pharos, Middlefield Road, Initiative project, which has resulted in the AΩA Suite , Menlo Park, California . Postgraduate Award (see our web site for more details: . After peer review, comments on the manuscript www.alphaomegaalpha.org/postgrad_award.html). will be sent to the author along with an editorial decision. Every attempt is made to complete preliminary reviews New business within six weeks. Dr. Byyny discussed the possibility of AΩA support for . The editors of The Pharos will edit all manuscripts a leadership development program. A committee chaired that are accepted for publication for style, usage, rel- by Dr. Tooker will investigate the proposal and possible evance, and grace of expression, and may provide appro- ways for AΩA to contribute to leadership in medicine. priate illustrative material. Authors should not purchase Dr. Byyny led discussion on communication strategies illustrative material because the editors cannot guarantee and public relations outreach to members and the public. that it will be used. A Communications committee was formed, chaired by Dr. . In accordance with revised copyright laws, each Atnip. A PR Committee chaired by Dr. Higginbotham was contributor will need to sign an Author’s Agreement, established. which will be sent with the edited galleys. Information on copyright ownership and re- publication of articles is Miscellaneous detailed in the Author’s Agreement. The minutes of the board meeting were approved. A final budget was also approved. The board meeting Reference information will be held in San Francisco in October . Authors are responsible for the accuracy of citations and quotations in their papers. Once a manuscript has Instructions for Pharos authors been accepted for publication, therefore, the author We welcome material that addresses scholarly and will be required to provide photocopies of all direct nontechnical topics in medicine and public health such as quotations from the primary source material, indicating history, biography, health services research, ethics, educa- page numbers. (Please mark the quoted material on the tion, and social issues, as well as philosophy, literature, photocopies with highlighter.) In addition, the editors the arts, professionalism, leadership, and humor. Poetry will require photocopies of all references: the title page is welcome, as well as photograph/poetry combinations. and copyright pages of all books cited, the first and last Photography and art may also be submitted. Scholarly fic- pages of book chapters cited, and the first and last pages tion is accepted. All submissions are subject to editorial of journal articles cited, as well as the Table of Contents board review. Contributors need not be members of Alpha of the particular issue of the journal in which the cited Omega Alpha. Papers by medical students and residents article appeared. PubMed or MedLine citations are also are particularly welcome. acceptable. The foregoing items will be used to verify the Submissions must meet the following criteria: accuracy of the quotations in the text and the references . Submissions may not have been published elsewhere cited, and to correct any errors or omissions. The photo- or be under review by another journal. copies will not be returned.
49 The Pharos/Winter 2012 National and chapter news
References should be double-spaced, numbered con- as britannica.com are not primary references. Do not use secutively in the text, and cited at the end in the following Wikipedia as a reference. standard form: Journal: Zilm DH, Sellers EM, MacLeod SM, Degani N. Leaders in American Medicine Propranolol effect on tremor in alcoholic withdrawal. Ann In , as a result of a generous gift from Drs. David Intern Med ; : –. E. and Beatrice C. Seegal, Alpha Omega Alpha initiated a Book: Harris ED Jr. Rheumatoid Arthritis. Philadelphia: program of one-hour videotapes featuring interviews with WB Saunders; . distinguished American physicians and medical scientists. Book chapter: Pelligrini CA. Postoperative The collection has been donated to the National Library Complications. In: Way LW, editor. Current Surgical of Medicine, which will maintain it for permanent use by Diagnosis and Treatment, Ninth Edition. Norwalk (CT): scholars visiting the library. The collection has been digi- Appleton & Lange; : pp –. tized and excerpts will be featured on AΩA’s web site in the Each reference should be listed in the bibliography only future. A listing of videos available for loan as DVD or VHS once, with multiple uses of a single reference citing the tape can be found on our web site: www. alphaomegaalpha. same bibliography reference number. Examples are avail- org, or by contacting Debbie Lancaster at d.lancaster@ able at our web site: www.alphaomegaalpha.org. alphaomegaalpha.org or () -. Those wishing to Citation of web sites as references is discouraged unless purchase copies may do so by contacting Ms. Nancy Dosch, a site is the single source of the information in question manager, Historical Audiovisuals, History of Medicine, or has official or academic credentials. Examples of such Building , Room E-, Rockville Pike, Bethesda, sites are official government web pages such as that of Maryland . Telephone () -, e-mail nancy_ the National Institutes of Health. Encyclopedia sites such [email protected].
Letters to the editor
Re “AΩA and Professionalism in teachers by “osmosis.” My sources were Medicine” William L. Bradford, MD, and William Your editorial in the Summer is- S. McCann, MD. sue of The Pharos is very well done Russell M. Lane, MD (Summer , pp. –). (AΩA, University of Rochester, ) Here is a brief passage from my Sunderland, Massachusetts file—to me it is a like expression of some of the points of your essay: Re “The Light Switch,” Summer a voice that medicine can ill afford 2011, pp. 30–32 to lose—one of clearheadedness, un- Thank you for sharing your sentimental idealism, and the great unfortunate experience on the wisdom of affectionate optimism. obstetric anesthesia service —Hans Zinsser commenting on in The Pharos. That same Francis Weld Peabody, thing happened to me circa on my last call night in anesthesiology I am , a retired G.P.—in my medi- residency six- cal school days, we talked about learn- teen years ing “professionalism” from our revered ago. I was
The Pharos/Winter 2012 50 on overnight with one of the cardiac My wife and I really enjoyed reading Re “The History of Tracheotomy” anesthesia attendings. Lucky, because your article, “The Light Switch.” It was I enjoyed reading the article of it quickly turned into a cardiac case. an extremely well-written account of Drs. Choby and Goldenberg on “The Mother and one of the twins did not an incident that every physician fears History of Tracheotomy” (Summer make it, the other twin survived. After and dreads facing in their professional , pp. –). Their exposé of three hours of resuscitation and open career. One can only imagine your the evolution of the procedure from cardiac massage, we rolled the patient thoughts and reactions at the time, but prehistoric times until today is com- down the hall to the ICU on fem-fem your telling of your experience serves prehensive and very interesting. I do bypass. The look of the husband’s sob- as an example of the compassion that take issue with their assertion concern- bing, anguished face is still seared into all physicians should have towards their ing the death of George Washington my memory. Then when Dr. Sheila patients and families, as well as part of which perpetuates the misconception Cohn, Chief of Obstetric Anesthesia at the process of catharsis that must come that “the first President of the United Stanford, came in at and looked sooner or later if one is to continue to States died of an acute upper airway down at me with her wise, sympathetic be an effective physician. Thank you so obstruction secondary to a peritonsillar eyes while I was writing my note, I just much for sharing what must have been abscess.” p36 A review of the historical lost it. The diagnosis at the time was a most difficult process for you and all accounts of George Washington’s de- fairly obvious looking at the bloated, others involved, including the family of mise and the chronology of his symp- quivering right ventricle and studies your patient. toms suggests that his final illness was later confirmed it: amniotic fluid em- most likely adult acute epiglottitis. The Roger A. Meyer, MD, DDS, FACS bolism. But that didn’t make it any eas- clinical picture of a rapidly escalating (AΩA, Creighton University, ) ier . . . my first intra-operative death, sore throat, hoarseness, and respiratory Greensboro, Georgia and my career had not even begun. obstruction is most consistent with this E-mail: [email protected] And then the feelings of doubt and diagnosis. Even though a peritonsillar guilt. Of thinking over and over, was Thank you for your article. I am a abscess causes sore throat and fever, there something I did to cause this or practicing anesthesiologist in suburban it rarely results in significant airway could have done to prevent it? Maybe Chicago. We graduated medical school compromise, especially in an adult, and there was something more I could have the same year and I can tell our careers is even more rarely a cause of death. done to save her? It had a huge impact have much in common. A peritonsillar abscess in its natural on me as I purposefully chose a job I recently cut back to part time history will usually rupture and self- that did not have obstetric anesthesia practice, but OB anesthesia remains drain prior to causing upper airway service despite really enjoying OB an- my most treasured work environment. obstruction. As an otolaryngologist, I esthesia during my residency. You clearly captured the joy and po- have seen many patients return to the Reading the beautifully written ac- tential agony of OB anesthesia and I Emergency Room in extremis a few count of your experience on that fate- empathize with you and your patient’s hours after being diagnosed with acute ful night eight years ago helped me family. pharyngitis and sent home on oral an- remember and reprocess my event. A bad outcome in anesthesia is very tibiotics, to undergo emergency treat- Thanks. I, too, still think about that painful for experienced practitioners ment for acute epiglottitis. lonesome father and his daughter, now like ourselves to accept, but is some- I thank Drs. Choby and Goldenberg age sixteen, and grieve. thing we all must learn to live with. for their interesting presentation. Your caring and open response to the Jeffrey Clayton, MD Elias Hilal, MD family and situation provides a model (AΩA, Medical College of Wisconsin, (AΩA, American University of Beirut, for our profession. ) ) I plan to share your most thoughtful Department of Anesthesiology Chief, Division of Otolaryngology— article with my colleagues. Sutter Medical Center Head &Neck Surgery Thank you again for your contribu- Sacramento, California UPMC Mercy tion and best regards. E-mail: [email protected] Pittsburgh, Pennsylvania Ed Matthew, MD E-mail: [email protected] (AΩA, University of Illinois, ) E-mail: [email protected]
51 The Pharos/Winter 2012
We sold all the furniture (of course lamps went first) And are left sifting through dim rooms of inventory • Old Halloween costumes (and all of my clothes and all of his clothes) • Harrison’s, Bates’, Sapira, Nuland, non-medical books • Piles of dirty scrubs, piles of clean scrubs, all other piles • Business cards for various restaurants we have loved in the city Evening: we sort by the light of laptop screens. Our apartment collapses into discrete shippable units. Our French press, bread maker, fruit parer become Kitchen Box Our two-person tent, camping stove, hiking boots become Activities Box Our African masks, Brooklyn Bridge print, Quechua tapestry become Art Box A photograph of our life is filtered, pointillized, The finer points brushed into smudges, mere suggestions of our world These last four years. Sarah Buckley, MD
Dr. Buckley is an Internal Medicine resident at the University of Washington Medical Center. Her e-mail address is: [email protected]. Illustration by Laura Aitken
“the last master of resounding song, the gracious mouth by which music spoke has ceased to be.” —Vienna, March , Beethoven knew too well these tappings only palliative. physician to the Maestro in his last illness? “You are dying. Whom should I call for?” Next day, he was gone. into the depths of the man. notes fading into darkness. Richard Bronson, MD Had he only followed them! Then, the apologies. I knew it all.
Dr. Bronson (AΩA, New York University, !"##) is Professor of Obstetrics & Gynecology and Pathology at Stony Brook University Medical Center and a member of the editorial board of The Pharos. His address is: Stony Brook University Medical Center, T"-$%$, Stony Brook, New York !!&"'-%$"!. E-mail: [email protected]. Presenting the AΩA scarf Presenting the AΩA scarf AΩA's new scarf highlights the society's insignia, based on the shape of the manubrium sterni. The center medallion features the Pharos lighthouse of Alexandria, one of the seven wonders of the ancient world, for which AΩA's journal is named. The borders are stylized DNA strands.
Scarves are x inches, of 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.
To order, send a check for to: Alpha Omega Alpha, Middlefield Road, Suite , Menlo Park, CA Or order online at www.alphaomegaalpha.org/store.html (Price includes shipping and handling)