Alpha Omega Alpha Honor Medical Society Autumn 2013 the PHAROS of Alpha Omega Alpha Honor Medical Society Autumn 2013

Alpha Omega Alpha Honor Medical Society Autumn 2013 THE PHAROS of Alpha Omega Alpha honor medical society Autumn 2013

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

Student Directors www.alphaomegaalpha.org Christopher Clark, MD University of Mississippi Medical School Tonya Cramer, MD Manuscripts being prepared for The Pharos should be typed double-spaced, submitted in triplicate, and conform to the format Chicago Medical School at Rosalind Franklin outlined in the manuscript submission guidelines appearing on our website: www.alphaomegaalpha.org. They are also available University of Medicine & Science from The Pharos office. Editorial material should be sent to Richard L. Byyny, MD, Editor, The Pharos, 525 Middlefield Road, Suite Laura Tisch 130, Menlo Park, California 94025. Medical College of Wisconsin Requests for reprints of individual articles should be forwarded directly to the authors. The Pharos of Alpha Omega Alpha Honor Medical Society (ISSN 0031-7179) is published quarterly by Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, Menlo Park, California 94025, and printed by The Ovid Bell Press, Inc., Fulton, Administrative Ofﬁce Missouri 65251. Periodicals postage paid at the post office at Menlo Park, California, and at additional mailing offices. Copyright Richard L. Byyny, MD © 2012, by Alpha Omega Alpha Honor Medical Society. The contents of The Pharos can only be reproduced with the written Executive Director permission of the editor. (ISSN 0031-7179) Menlo Park, California Circulation information: The Pharos is sent to all dues-paying members of Alpha Omega Alpha at no additional cost. All correspondence relating to circulation should be directed to Ms. Debbie Lancaster, 525 Middlefield Road, Suite 130, Menlo Park, California 94025. E-mail: [email protected] Menlo Park, California 94025 Telephone: (650) 329-0291 POSTMASTER: Change service requested: Alpha Omega Alpha Honor Medical Society, 525 Middlefield Road, Suite 130, Fax: (650) 329-1618 Menlo Park, CA 94025. E-mail: [email protected] The Pharos • Volume 76 Number 4 • Autumn 2013 In This Issue

DEPARTMENTS On the cover

Alpha Omega Alpha Honor Medical Society Autumn 2013 Editorial See page 28. 2 Alpha Omega Alpha and scholarship Richard L. Byyny, MD, editor 2013 Alpha Omega Alpha 36 Professionalism Meeting

Reviews and reflections 39 Enhancing the Professional Culture of Academic Health Science Centers: Creating and Sustaining Research Communities Reviewed by Jack Coulehan, MD Hippocrates Cried: The Decline of American Psychiatry ARTICLES Reviewed by Michael Schwartz, MD Wet dust Robert H. Moser, MD, MACP 8 Peter Daniel 42 1923 – 2013

2013 Visiting Professorships Yes, I can 43 14 Learning to cope with death 2013 Administrative 45 Recognition Awards YunZu Michele Wang, MD

2013 Volunteer Clinical Food fight 46 Faculty Awards 20 Matthew Molloy

POETRY Running toward the fire Dignity 28 Empathy and ethics in medical education 34 Rachel A. Davis, MD Noah M. Rosenberg, MD The 3:10 38 Dennis F. Devereux, MD On Finding a Slim Volume 32 Who killed lab rounds? 47 Henry N. Claman, MD Thomas Fekete, MD INSIDE Habeas Corpus BACK 49COVER Adam Possner, MD

Hippocrates The conversion of Galen Avicenna Anton Van Leeuwenhoek Images courtesy of the National Library of Medicine.

Editorial Alpha Omega Alpha and scholarship

Richard L. Byyny, MD

cholarship has long been and continues to be an important medical and scientific literature to learn about their patient’s and vital responsibility for physicians. Doctor, from Latin illness and other diagnostic possibilities and to find current Sdocere, means “to teach.” Physicians have a responsibility diagnostic and therapeutic best practices. They implement to use observation and reasoned thought to expand human a clinical plan, inform and teach the patient and staff, and knowledge and ameliorate suffering. All physicians are teach- then record the information in the medical record. Physicians ers and are called on to teach. Throughout history physicians observe, discover, study, interpret, and teach. This is scholarly have endeavored to learn and understand from their work activity by every physician. with the sick and injured and taught about the science and art Here is one contemporary example of a physician scholar. of medicine. It has been said that the researcher at the bench, In the s, Dr. Joel Weisman, an osteopathic family practi- the clinician in the ward or office, and the epidemiologist in tioner practicing in Southern California, began to see young the field are all making “experiments.” We are, therefore, all men with shingles, Kaposi sarcoma, and lymphoma-like scholars in medicine and health. illnesses. In , he cared for a number of gay men with a Research may be defined as careful or diligent search, studious puzzling constellation of symptoms, including weight loss, inquiry or examination, or the collecting of information about lymphadenopathy, fever, rashes, low WBCs, and fungal infec- a particular subject. Many physicians equate scholarship with tions that appeared to be immunological in origin. Some of biomedical research, even though it has been estimated that only the patients also had pneumonia. Weisman consulted with about two percent of physicians are directly involved in basic Dr. Michael Gottlieb, who diagnosed these and other similar research. Medicine and patient care have been dramatically im- patients as having biopsy-proven pneumocystis pneumonia. proved by these physicians through their scholarship in biomedi- Weisman then took the next step in scholarship. He published cal research, its applications and translations, and publications. a description of five cases, a case series, in the Centers for I believe that all physicians do research every day in the Disease Control June , , Morbidity and Mortality Weekly care of patients, and that we also have an obligation to par- Report.1 This case series report is recognized as the first ticipate in active scholarship. Clinicians carefully evaluate the scholarly publication describing AIDS. Dr. Weisman’s clinical patient’s history, perform a thorough examination, develop a observations, reflection, and clinical reasoning in the care of hypothesis based on the clinical findings, and then gather data his patients was followed up with a crucial step: publication and information to support or reject their hypotheses. They of his case series. This starting point led to the application of then make informed decisions and act to make a dianosis, pre- epidemiologic, social, and biomedical research that has taught dict prognosis, and determine treatment. They often study the us much about HIV and AIDS.

2 The Pharos/Autumn 2013 Ignaz Semmelweis Edward Jenner John Snow Robert Koch

Scholarship in medicine invention of the printing press and movable type in  led to Scholarship and experimentation in medicine has a long the rapid rise of science and medicine. history. Plato defined science as “ the discovery of things as Many other medical scholars followed and contributed by they really are” based on observation and reasoned thought. In cataloging their observations and experiences. William Harvey Babylon in the second millennium BCE, the concepts of symp- in seventeenth century described the circulatory system, by toms, physical examination, diagnosis, etiology, prognosis, deducing that the presence of valves in veins and their absence treatments, and traditional herbal practices based on empirical in arteries determined the direction of blood flow, as well as observations and the use of logic were taught. The literature the necessity for pulmonary circulation to oxygenate the blood in medical compendia defined the purpose of medicine to and the heart as the pump to maintain circulation. cure diseases of the sick, protect the healthy, and prolong life. Developments in pharmacology and technology led to other Although their concepts were based on the preconceived no- important medical discoveries. In  using the new technol- tion of the imbalance of body elements and humours, among ogy of the microscope Anton van Leeuwenhoek first observed the achievements of medicine of the time were the isolation bacteria and microorganisms. In  anesthesia, both nitrous of some patients with infectious diseases, performance of oxide and ether, was used for dental extractions and surger- surgical interventions, food prohibitions, and the treatment ies. In  Ignaz Semmelweis dramatically reduced the death of patients with herbal medicine, acupuncture, massage, and rate of mothers by requiring physicians to clean their hands other remedies. before assisting in childbirth. Joseph Lister in  proved the Hippocrates observed and described the clubbing of the fin- principles of antisepsis in the treatment of wounds by using gers in lung and cyanotic heart disease, the Hippocratic facies, phenol/carbolic acid to sterilize surfaces before surgery and and other physical manifestations of diseases. He categorized promoted handwashing and wearing gloves to further maintain illness as acute, chronic, endemic, and epidemic. He was the asepsis. Louis Pasteur linked microorganisms with disease and first chest surgeon to operate for thoracic empyema. developed the process of pasteurization. Galen was a great surgeon performing many complex sur- During the  cholera outbreak in London, John Snow geries who wrote extensively on anatomy based on his human documented the location of each of his cases with a “dot map” dissections. that showed a definite cluster around Broad Street. After learn- Avicenna wrote The Canon of Medicine () and The ing through interviews that most of his patients drank water Book of Healing (). At this time books, mostly religious and from the Broad Street pump, he caused the pump handle to some medical texts, were hand written and copied. Gutenberg’s be removed, ending the outbreak. Snow is now considered the

The Pharos/Autumn 2013 3 William Osler. Courtesy of the National Library of Medicine.

founder of the science of epidemiology. He published his find- the scientific basis of medicine and he worked to disseminate ings in a letter to the editor of the Medical Times and Gazette.2 the research and discoveries of others. Osler’s clinical practice, In , Dr. Edward Jenner, after learning that milkmaids keen observations, teaching, lecturing, and writing made ma- were usually immune to smallpox, hypothesized that previous jor contributions to medical education. Osler’s The Principles exposure to cowpox protected them from the more severe and Practice of Medicine, published in  was for decades disease. Jenner tested the hypothesis by inoculating an eight- the seminal textbook of modern medical practice. Osler made year-old boy with pus from a cowpox blister. After the boy many other contributions to medical education and practice, recovered from the mild case of cowpox he acquired, Jenner including requiring that medical students participate in bed- inoculated him repeatedly with pus from smallpox blisters; the side teaching with direct care of patients, establishing the first child never developed smallpox. Jenner continued his research residency training program for physicians, creating one of and finally published his findings on  cases.3 The results the first organized educational journal clubs, founding of the spread through Europe and beyond; vaccination became widely Association of American Physicians, and establishing the Johns accepted as a safe means to prevent smallpox. Hopkins University School of Medicine. He emphasized and Dr. Robert Koch is considered the founder of modern bacte- taught students and physicians to, “listen to your patient, he is riology. He identified the causative bacterial agents for anthrax, telling you the diagnosis.” His participation in the creation and cholera, and tuberculosis, successfully culturing organisms development of the Johns Hopkins School of Medicine was obtained from patients treated in the examination room next pivotal in the  Flexner Carnegie Foundation Report that to his laboratory, staining the cultured organisms, and observ- revolutionized medical schools and medical education in the ing them under the microscope. While many authorities of United States.4 the time believed that tuberculosis was a hereditary disease, The twentieth century produced amazing research and Koch believed it was an infection caused by a bacteria. He con- scholarship in medicine, science, engineering, technology, firmed the crucial stepwise tests: mycobacterium was present health, and patient care, fueled by research in many areas of in all cases of tuberculosis, the organism could be isolated and science and engineering. The National Institutes of Health grown in healthy guinea pigs, the isolated and cultured organ- (NIH) was established in ; its subsequent research role be- ism caused tuberculosis when inoculated into healthy guinea gan in . In , the NIH became the engine for biomedi- pigs, and the recovered organism from the diseased guinea pigs cal research with government support and funding. While not was the same as the organism cultured from the original dis- all of the discoveries related to medical science and medicine eased patient. These are now referred to as Koch’s postulates. were made by physicians, physicians adapted and applied the He published papers on each of these infectious diseases and discoveries to patient care and actively taught about the new won the Nobel Prize in Medicine in . discoveries and their clinical applications. The following table Sir William Osler is an example of a great clinician scholar. summarizes some of the highlights of progress, discovery, and He was not a research scientist, but his scholarly work at the application of advances in the science of medicine and health turn of the nineteenth to twentieth centuries transformed clini- in the twentieth century. cal medicine and medical education. Osler firmly believed in Standing out from among the many advances in scholarship

4 The Pharos/Autumn 2013 Twentieth-Century Research and in medicine during the twentieth century is the development Scholarship in Medicine of the Randomized Controlled Trial (RCT), now accepted as Aspirin !"#" the “gold standard” for acquiring scientific evidence to evaluate therapeutics in medicine. Another pivotal research project was Clean water, safe food, electricity, education !$%%–!$&% an observational study, the Framingham Heart Study, begun Discovery of blood groups !$%! in .5 It had been established by then that cardiovascular Endoscopy !$%!–!$#' disease, including heart attacks and stokes, was a rising epi- X-Rays !$%# demic. The debate about high blood pressure ranged between two positions: One group hypothesized that the aging vascular Flexner Report on Medical Education !$!% system became stiff and required a higher blood pressure to Vitamins A, B, C, D, E, K (vital nutrients not made !$!' on adequately provide circulation. Another group believed that endogenously by humans) hypertension contributed to heart disease and stroke by expos- Electrocardiogram !$!( ing the vessels to increased vascular pressure. Vaccines The National Heart Institute at NIH in collaboration with DPT !$#%s Boston University advanced a hypothesis that the develop- Influenza !$(& ment of cardiac disease was influenced by lifestyle and family Yellow fever !$') Polio !$&& history. The group devised a long-term observational study to Measles, mumps, rubella !$)! identify potential factors for heart disease in a large cohort of Hepatitis A and B !$"%s–!$$%s people originally without evident heart disease in Framingham, Pneumonia !$)) Massachusetts. They enrolled , men and women between Eradication of smallpox !$"% thirty and sixty-two years of age and observed them over many Discovery of insulin !$## years to elucidate the differences between those who devel- Control of infectious diseases oped heart disease and those who did not. Participants were Discovery of sulfa !$'%s given extensive physical examinations and lifestyle interviews, Discovery of penicillin !$#" with follow-up every two years for a medical history, physical Other antibiotics examination, and laboratory tests. There have now been more Flame photometer (electrolyte measurements) !$'* than a , publications on this population. The Framingham Cardiac catheterization !$(! Study demonstrated the association of cigarette smoking as Modern randomized controlled trial !$(" a cardiovascular risk factor in the s. Subsequently other major cardiovascular risk factors were identified, including Framington Heart Study !$("–present high blood pressure, elevated cholesterol, physical inactivity, Radioimmunoassay to measure peptides !$&%s and others. Open heart surgery !$&# Perhaps the next most significant achievement of twentieth- DNA structure !$&' century research has been the Human Genome Project, which Diagnostic ultrasound !$&( was initiated in  by the Department of Energy and NIH to sequence the human genome. Three non-physician scientists Kidney transplant !$&* led the projects to sequence the human genome, James Watson Contraception !$*%s and Francis Collins at the NIH and J. Craig Venter at the pri- Computer assisted tomography (CT) !$)%s vate company Celera. The human genome was sequenced and Magnetic resonance imaging (MRI) !$)! the results published in  and  and has now greatly 6 Angioplasty !$)( advanced our understanding of human biology and medicine. AIDS epidemic !$"! “Scholarship Reconsidered” Reduction in mortality from heart attacks and !$*$– In , Ernest Boyer from the Carnegie Foundation for strokes the Advancement of Teaching published his seminal report,

The Pharos/Autumn 2013 5 Alpha Omega Alpha and scholarship

Scholarship Reconsidered: Priorities of the Professoriate, in is scholarship that is interdisciplinary, interpretive, and inte- which he advocated for expansion of the traditional and widely grative. It naturally leads to the next category, scholarship of accepted definition of scholarship and research.7 He focused application and engagement. primarily on scholarship for faculty of traditional colleges and universities, particularly their roles and responsibilities in a mi- The Scholarship of Application and Engagement lieu in which scholarship was equated with traditional research This gets at the question, “How can knowledge be respon- and the scholarship of discovery. Boyer’s model of scholarship sibly applied to consequential problems? How can knowledge has subsequently been widely adopted in many academic insti- be useful and helpful to physicians, patients, and society?” 7p21 tutions and medical schools. I believe it is directly applicable How to connect knowledge and theory to practice? It is the to the scholarly and scholarship responsibilities of physicians scholarship of service. Scholarly service both applies and con- in their multiple professional roles and functions, including the tributes to human knowledge, resulting in the application of care of patients. It also directly relates to the physician’s fun- knowledge and skills in medical practice, including diagnosis, damental responsibility for continued learning. Boyer’s model serving patients, shaping public or institutional policy, pro- is also based on the concept that “Theory surely leads to prac- viding leadership, demonstrating professionalism, and serv- tice. But practice also leads to theory.” 7p16 He noted, “Surely, ing society. Scholarly service often involves presentations at scholarship means engaging in original research. But the work professional or community meetings, case reports, case series of the scholar also means stepping back from one’s investiga- articles, and sharing information in diverse ways. tion, looking for connections, building bridges between theory and practice, and communicating one’s knowledge effectively The Scholarship of Teaching to students.” 7p16 He then presented his concepts of the types We in medicine have an obligation to teach what we know. of scholarship. As Aristotle said, “Teaching is the highest form of understanding.” Most of us can attest that we also learn from having to The Scholarship of Discovery teach and from the process of teaching. Teaching contributes For many, scholarship means engaging in original research to the continuity of knowledge and stimulates creativity and in biomedical sciences, humanities, social sciences, epidemiol- curiosity. It actively promotes and contributes to scholarship. ogy, and translational research that advances knowledge. Physicians have many opportunities to teach, from bedside He quoted William Bowen, former president of Princeton or clinic rounds, to patient consultations, to journal clubs, to University, who said that scholarly research “reflects our organized teaching conferences, to mentoring of other physi- pressing, irrepressible need as human beings to confront the cians and students. Teaching promotes a spirit of inquiry and unknown and to see understanding for its own sake. It is tied scholarship. inextricably to the freedom to think freshly, to see proposi- tions of every kind in ever-changing light. And it celebrates Scholarship in medicine today the special exhilaration that comes from a new idea.” 7p17 And Many medical schools have developed a Mentored Scholarly a quote from Lewis Thomas on major medical breakthroughs Activity requirement for medical students. The term “schol- in the twentieth century: “It was basic science of a very high arly” is used purposefully, recognizing that some students will order, storing up a great mass of interesting knowledge for its choose to do bench or clinical research for their project, but own sake, creating, so to speak, a bank of information, ready many are more interested in scholarship in the humanities, for drawing on when the time for intelligent use arrived.” 7p18 arts, social sciences, epidemiology, public policy, and other Scholarship of Discovery is usually documented in peer-review areas. publications of original research. The Accreditation Council for Graduate Medical Education (ACGME) established a requirement for each resident to dem- The Scholarship of Integration onstrate acceptable scholarly activity to complete his or her This represents scholars who give meaning to isolated training.8 They explain that for residents to pursue scholarly facts, putting them in perspective and context by integration. activities, they not only need to work and learn in a culture It involves the synthesis of information and the making of that values and nurtures scholarship, but also need to learn connections across disciplines, across topics within a disci- specific skills, such as transforming an idea into a research pline, or across time, illuminating data in a revealing way to question (experimental, descriptive or observational), choosing bring new insights. It means interpretation into larger intel- an appropriate study design, determining what instrumenta- lectual patterns to learn “What do the findings mean?” 7p19 It tion to use, preparing for data collection, management and

6 The Pharos/Autumn 2013 analysis, ethical conduct of research, and the rules and regula- of a million dollars per year for programs and awards that are tions governing human subjects research. ACGME and their mostly to support scholarship. These include: Four Robert J. RRCs have adopted the Boyer concepts of scholarly activity. Glaser AΩA Distinguished Teacher Awards; about  AΩA The responsibility for establishing and maintaining an envi- Medical Student Research Fellowship Awards; Edward D. ronment of inquiry and scholarship rests with the faculty, and Harris AΩA Professionalism Awards and support of na- an active research component must be included within each tional meetings on medical professionalism; AΩA Medical program. Both faculty and residents must participate actively Student Service Leadership Awards; about sixty AΩA Visiting in scholarly activity. Scholarly activity is a common program Professors; AΩA Clinical Faculty Awards; AΩA Postgraduate requirement for accreditation by the Accreditation Councilor Awards for resident and fellow scholarly projects; and AΩA for Graduate Medical Education.9 Scholarship is defined as one medical student awards for essays and poetry. AΩA also pub- of the following: lishes the society’s journal, The Pharos, a peer-reviewed means to publish articles other than biomedical research and related • The scholarship of discovery, as evidenced by peer- to health and medicine. reviewed funding or publication of original research in peer- I encourage all of us in medicine to rethink scholarship and reviewed journals. I urge all of us to more actively pursue scholarly work in our • The scholarship of dissemination, as evidenced by re- practices, communities, and societies. I also hope to promote a view articles or chapters in textbooks. keen “spirit of inquiry and scholarship” in our profession. • The scholarship of application, as evidenced by the publication or presentation a local, regional, or national pro- References fessional and scientific meetings, for example, case reports . Gottlieb MD, Schanker HM, Fan PT, Saxon A, Weisman JD, or clinical series. Pozalski I. Pneumocystis pneumonia—Los Angeles. Morbidity and • Active participation of the teaching staff (including Mortality Weekly Report;  Jun . residents) in clinical discussions, rounds, journal club, and . Johnson S. The Ghost Map: The Story of London’s Most research conferences in a manner that promotes a spirit of Terrifying Epidemic —and Hos It Changed Science, Cities, and the inquiry and scholarship; offering of guidance and techni- Modern World. New York: Riverside Books; . cal support, e.g., research design, statistical analysis, for . Riedel S. Edward Jenner and the history of small pox and vac- residents involved in research; and provision of support for cination. Proc (Bayl Univ Med Cent) ; : –. resident participation as appropriate in scholarly activities.10 . Flexner A. Medical Education in the United States and Can- ada. Carnegie Foundation for the Advancement of Teaching; . All physicians need to pursue scholarship that “promotes Available at: http://www.carnegiefoundation.org/sites/default/files/ a spirit of inquiry and scholarship.” I encourage physicians to elibrary/Carnegie_Flexner_Report.pdf. write about their observations and experiences and submit . Kannel WB, Dawber TR, Kagan A, Revotskie N, Stokes J rd. their work for publication. While many physicians are not good Factors of risk in the development of coronary heart disease—six writers, all have some experience writing personal statements year follow-up experience. The Framingham Study. Ann Intern Med and essays, as well as clinical histories. Unfortunately, many ; : –. of us have developed nonclinical “writing apraxia,” a common . Collins FS, Green ED Guttmacher AE, Guyer MS. A Vision for condition in which the physician has no problem talking about the future of genomics research. nature ; : –. complex topics, but can’t write cogently about them. It is a . Boyer EL. Scholarship Reconsidered: Priorities of the Profes- poorly understood but common condition. The idea that your soriate. Princeton (NJ): Princeton University Press; . writing must be perfect results in not writing at all. But writing . Schultz HF. Research during internal medicine residency train- well can be learned, and we all need to learn to do it, and do it ing: meeting the challenge of the Residency Review Committee. Ann better. It is an important part of scholarship. We need to over- Intern Med ; : –. come writing apraxia because we need to share our observa- . Accreditation Council for Graduate Medical Education. tions and experiences with the medical profession. Remember Residency program training requirements. http://www.acgme. Dr. Weisman’s five cases and the difference his observations org/acgmeweb/Portals//PFAssets/-PR-FAQ-PIF/_inter- and publication made in the recognition of a new disease, HIV nal_medicine_.pdf. and AIDS. . Grady EC, Roise A, Barr D, et al. Defining scholarly activity Alpha Omega Alpha ( AΩA) has long been an advocate and in graduate medical education. J Grad Med Ed : –. supporter of scholarship. We provide more than three-quarters

The Pharos/Autumn 2013 7 Wet dust

Photo credit Getty Images/Niko Guido

8 The Pharos/Autumn 2013 Peter Daniel The author (AΩA, Medical College of Georgia, 2013) is day. How much is enough? How much of my time, energy, a member of the Class of 2014 at the Medical College of resources, and voice is enough? I’ll admit I don’t know the Georgia of Georgia Regents University in Augusta, Georgia. answer, but I intend to respond. I would like to participate This essay won honorable mention in the 2013 Helen H. in the tension and potential framed by the question, which Wet dust Glaser Student Essay Competition. brings us to faces—words come alive when punctuated with person. When you find something in a human face that calls out to I remember many faces. The first that come to mind are you, not just for help but in some sense for yourself, how those I’ve drawn. As a visual artist, I felt a transition ap- far do you go in answering that call, how far can you go, proaching when I moved to Bayonnais, Haiti, but I wasn’t seeing that you have your own life to get on with as much sure how it would look. Faces of my new Haitian commu- as he has his? nity inspired me, and my acrylic abstractions gave way to —Frederick Buechner1p27 representational graphite portraits. Because I prefer not to work from photographs, each person would sit for one to uechner’s question haunts and impels me. It led me two hours in exchange for a protein shake and the undivided to live in rural Haiti before guiding me to medical attention of the resident blan, Creole for “foreigner.” The Bschool, and it continues to inform my decisions each children enjoyed it so much that I made a waiting list, which

The Pharos/Autumn 2013 9 Wet dust

above my right eye hangs lower than that above my left. As in art so in life—and in medicine. You can focus more on a document than a patient, perhaps allowing conventions and stereotypes to dictate “how things look” to you more than the person in front of you. Before you know it, you’ve unwittingly missed the pertinent diagnosis, just as you missed my eyes. Claude Monet once said that “he wished he had been born blind and then had suddenly gained his sight so that he could have begun to paint . . . without knowing what the objects were that he saw before him.” 3p1 He wanted a tabula rasa void of associations; he wanted to truly see light and how it touches form. Our art, both visual and medical, will be limited if we are not willing to use truth instead of conventions. Monet’s comment reminds me of the small dark eyes of my future godson as they opened for the first time. In a mud hut room filled with too many people, I assisted the delivery of Ti-helas, who had barely survived his mother’s weakness. I saw poverty framed in his face, a connecting of the dots between his fa- ther’s financial insecurity, his mother’s malnutrition, and the seemingly eternal five minutes during which she was too weak to push. An experienced midwife shared a guarded prognosis as family and friends nearly prayed the tin roof off the house. A few years Peter Daniel. later in that same room, I listened to the story of his mother’s death during the cholera epidemic. I remember the dimly lit face of his grandmother in the corner of the room, tears shining in the light of a kerosene was good for my artistic discipline. These drawings were very lamp. Looking through projector flare into the eyes of challenging, and the models would often become fatigued as my first-year medical school colleagues, I shared the story I was completing half the face. I found these “half portraits” one morning between lectures; the family photograph be- intriguing, both in composition and meaning. I started call- hind me brought cholera home more effectively than a GM ing them the “Incomplete Series” because something in each ganglioside. work suggested that we need community to see ourselves I remember the faces of two eight-year-old boys who asked whole; as Chaim Potok’s character, Asher Lev, would say, “I me for food one evening. I could tell they were genuinely did not know. But I sensed it as truth.” 2p324 hungry, as they hadn’t eaten since the previous day. But I had Truth can be hard to receive. Conventions, or stereotypes learned to say no; I had a finite supply of Cliff bars to con- if you will, are what render faces difficult, for the greatest serve for “emergencies.” It is unfortunately normal not to eat challenge in art is seeing the subject. The first day of art class for a day in Bayonnais. I hear a medical school interviewer in Haiti, I asked my students what they wanted to learn. Their asking me why he just put me through a rigorous ethics sce- response: “To draw things as they look.” The lesson is actually nario. “It addresses the value of a human life,” I responded. quite simple, though it may take a lifetime to master. All you “Yes, and as a physician, you will have to make difficult deci- must do is learn to see light (which as a budding ophthalmol- sions with limited resources, and we want to know if you can ogist makes me smile) but to do so you must let go of your handle the consequences of those decisions,” he added. conventional ways of seeing. If I ask you to draw my portrait, I remember the face of Isaac, one of my students, humbly you may find some predetermined shapes in your mind com- asking in rehearsed French whether I could spare some food peting with what is actually there. I may observe you focusing for his family, as they hadn’t eaten in three days. Yes. A couple more on your paper than me, and in the final product, your of boxes of protein bars for a family of eight are not much, bias toward symmetry may cause you to have missed the but they are something. A few weeks later he invited me to fact that my left and right eyes do not look the same: the line visit his house, and as we shared time together, his family

10 The Pharos/Autumn 2013 prepared their meal of the day. When Isaac offered me an equal portion, my polite refusal was met with insistence, to which I whispered, “But your family needs this.” I will never forget Isaac’s expression, for without words he said with perfect clarity, “Peter, you don’t understand how important it is that you share this meal with us.” How far do you go? How far can you go as a well-developed, well-nourished American who has already enjoyed breakfast and for whom lunch waits? That day Isaac pushed a wealthy American into poverty, and he taught me that sometimes you serve others by allowing yourself to be served. I later learned that there are limits. I visited the home of Noncilien, a student who lives an hour and a half into the mountains. In this area, people may go a week without eating more than a sweet potato or an ear of corn during the dry season. Old women may work in the field because their social security died of malaria or other illness. Four of Noncilien’s siblings had died at ages eight, nine, eleven, and twelve. When we arrived at the house, his mother had prepared a meal, which I received graciously—and artfully, for there is an art to how far you go, how much you eat. You honor the gift and the dignity of the host by eating, while acknowledging the hunger in the eyes of the child peeping Above, Eslilim Jannoe. Below, Gustave Fabienne. through the window; whatever is left behind will certainly not go to waste. As I said my goodbyes, Noncilien’s mother offered me a large sack of shelled beans. Fortunately I was leaving the country the following day—permission for another polite refusal with the justification that Customs would not allow my return with agricultural products. In Haiti, I learned to say yes to receiving from people with next to nothing, as well as no to hungry children, among many other difficult things. My friends’ generosity taught me that there are limits to how far I could go and introduced me to the art of receiving. I learned to see my subjects well, or at least better—the silent faces as well as the complexity of poverty. But of all the faces I drew, the most challenging was my own. It was a showdown of sorts to stare into that mirror for two hours, trying to see something in too-familiar a human face. It provoked the question: What makes me important? My response has been: “It is ‘relevance’ 4p27 that makes me important. Thus, I must prove my worth by accumulating accomplishments and affirmation.” That’s fine if you’re a successful people-pleasing, performance-driven perfectionist, which probably describes many medical students. But this foundation has two critical flaws: value is conditional and inherently insecure—conditional because you’re only important as long as you can earn it, insecure because your relevance depends on others being less important. According to C.S. Lewis,

Pride gets no pleasure out of having something, only out of having more of it than the next man. . . . It is the comparison that makes you proud: the pleasure of being above the rest. Once the element of competition has gone, pride has gone.5p122

The Pharos/Autumn 2013 Wet dust

François Alcima and Charles Saintissile.

Of course, there is nothing intrinsically wrong with ac- Those of us who seek originality to justify our relevance, complishments, affirmation, relevance, and pride in good who need our names to live forever, might want to turn to work, but should they support the weight of our identities? If Lewis for another lesson from the arts: that’s all we are, we can become scavengers for our egos, and often at the expense of others, including our patients. We’ll Even in literature and art, no man who bothers about origi- travel samsāra’s wheel of expectation and disappointment6p77 nality will ever be original: whereas if you simply try to tell until we ground ourselves elsewhere. the truth (without caring twopence how often it has been Elsewhere is a place where meaning and worth are not told before) you will, nine times out of ten, become original earned but given—a place of grace. Grace is inherently un- without ever having noticed it.5p226 conditional, undeserved, value freely given. It can support you when accomplishments and pride cannot. Nevertheless, A beautiful irony: we may become most relevant when we own Flannery O’Connor rightly observed, “All human nature vig- the truth that our worth is not earned or proven, but rather orously resists grace because grace changes us and the change given. is painful.” 7p307 We like earning our worth because it gives Also given is the last part of Buechner’s question, which us the illusion of control. Pride fears grace because it strips concerns the lives we have “to get on with”—but who’s to say away this illusion, which I saw in my mirror, and it does so for how long? My cadaver in anatomy lab offered one of my less like an old Band-Aid than that super-sticky tape used for most profound lessons on not taking life for granted. Hers is IV lines. My self-portrait taught me about seeing my subject; another face I’ll never forget. Thinking about neural circuits it portrayed my incompleteness. I’m working on trading con- responsible for various muscle contractions and cognitive ventions for truth, pride for grace, because I want to go that processes, I remember looking at her one day and thinking, far, and I believe the art of my life and medicine will be better “This is just something we ride around in.” In her frail form I for it. found myself to be more than my body . . . I recalled thoughts

12 The Pharos/Autumn 2013 About Peter Daniel I grew up in Savannah, Georgia before studing visual art and French at Davidson College in Davidson, North Carolina. I plan to pursue ophthalmology and look forward to continued work in Haiti. For more information about my experiences in Haiti, please visit peterbdaniel. wordpress.com. Illustrations by Peter Daniel.

marrow. I agreed. I’m simply borrowing these atoms for a time, after all. How do we measure all of these lives, the ones we have to get on with as well as the ones we decide to help? If our eyes are open, and if we’re willing to see beyond what is conve- nient, it’s not hard to find that there are always faces calling out for help and for our selves. The faces may be those of our Sylvestre Yvolene. patients or families. I learned from Haiti and from medical school that we must make difficult decisions with limited resources and finite time. We must learn to say the difficult yes and the painful no. We must decide each day when and where to show up. I struggle with how far to go, how to help without from my journal about Jean Jonel’s baptism in a mud-brown encouraging dependence. We’re going to make mistakes, but Bayonnais river: if we’re grounded in grace, we’ll be much more likely to offer it to ourselves and to each other. We’ll live from confident His coffee skin disappears in the river. We are but wet peace instead of polished fear, and we’ll ironically become dust, “for a stream would rise from the earth, and water the more relevant and original than we could have otherwise whole face of the ground—then the Lord God formed man hoped. By asking how much is enough? what is mine to do? from the dust of the ground, and breathed into his nostrils we’ll find that we’ve come further than we realize. We’ll come the breath of life; and the man became a living being.” 8pp1–2 to own a simple truth uniting our faces together, that being But breath must yield to waters, that body becoming for mo- wet dust is indeed one of the highest callings. ments an inanimate image of God: wet dust returned to the river, its density mingling with the world. These long seconds References are pregnant with resurrection. It is time. It is his time. His . Buechner F. Now and Then. New York: HarperCollins; . body rises, dripping. Lungs open like sails to carry his heart . Potok C. My Name Is Asher Lev. New York; Random House; along a new horizon. Inflated with a name still warm and . humid, Jean Jonel is as he was not. . House J. Monet: Nature into Art. New Haven (CT): Yale Uni- versity Press; . The Genesis narrative gives us the image of an all-powerful . Nouwen HJM. In the Name of Jesus: Reflections on Christian God bent over on His knees, responding to the “face of the Leadership: New York: Crossroad Publishing; . ground,” our wet dust that must have called out to Him in some . Lewis CS. Mere Christianity. New York: HarperCollins; . sense for Himself. My cadaver reminded me that I am wet dust . Kulananda. Principles of Buddhism. Birmingham (UK): Wind- animated with the breath of life. horse; . As with claiming grace over pride, this knowledge also has . O’Connor F, Fitzgerald S. The Habit of Being: Letters of Flan- profound implications on my showing up in others’ lives. Last nery O’Connor. New York: Farrar, Straus and Giroux; . year a thirty-two-year-old woman with acute myelogenous . Holy Bible with the Apocrypha: New Revised Standard Ver- leukemia asked for some of my dust. Suddenly, what I had sion. Peabody (MA): Hendrickson Publishers; . casually signed up for following a first-year medical lecture became a request not just for help, but for my self—my bone The author’s e-mail address is: [email protected].

The Pharos/Autumn 2013 13 Yes, I can Learning to cope with death

YunZu Michele Wang, MD The author is an intern in Pediatrics at the University of investigating the pathways involved in hematopoietic stem cell California at San Diego. This essay won third prize in the emergence, I became fascinated by the concept of bone mar- 2013 Helen H. Glaser Student Essay Competition. row transplantation. But before committing myself to a career in pediatric hematology/oncology, I wanted to deal with my ut it’s so sad!” Every time I mention that I am inter- lingering fear of being unable to cope with death. ested in pediatric hematology/oncology, this is what I In the foreword of Bernice Harper’s Death: The Coping hear. Sparked by an undergraduate research experience Mechanism of the Health Professional, Dr. Jesse Steinfeld writes B that many health professionals “unfortunately will contribute to their patient’s anxiety” because they are “unable to cope with [their] own discomfort about death.” 1pvii I was afraid I would be one of them. The seminal On Death and Dying by Elizabeth Kübler-Ross helped me understand why I was so uncomfortable with death. In our society,

children are excluded [from coping with death] with the presumption and pretext that it would be “too much” for them . . . we ship the children off to protect them from the anxiety and turmoil.2p6–7

I was one of those children. Relatives who passed away did so on an island  miles away. I did not attend a funeral until college. My first experience witnessing the death of a stranger was during a premedical shad- owing program. A young man was brought in after committing suicide by jumping off a building. My memories of the exact series of events are hazy; I was too excited, too scared, too horrified. Throughout the entire resuscitation, I kept thinking, “He’s too young to die,” and simultaneously, “But he wanted to die. We’re trying to give life back to someone who no longer wanted it.” Finally, the code was called, and as our team trudged back to Denial 14 Illlustrations by Erica Aitken The Pharos/Autumn 2013 our floor, a third-year medical student turned back to me and asked if I was okay. It was her second experience with death, she admitted, and no less difficult than her first time. “I’m okay,” I assured her. My muscles, each and every one tense in the ED, gradually relaxed. I was walking and talking, my heart was still beating, my vision still clear—physiologically, I was okay. Mentally, though, I was still dazed. We returned to rounds, and the topic was not brought up again. More recently, during my third year of medical school, I was part of the surgical team responding to a pediatric trauma event. I felt the same flood of emotions, the same tightening of my entire body, but with more anger. There was more I could not process, especially the nagging “Why?” and the unanswerable “How could this happen?”—unhelpful questions that made me uselessly rail at the world and its injustice. Before I left for the day, I sought out the pediatric trauma nurse who had been with us and asked her how she could deal with seeing cases every day. “It doesn’t ever get easier,” she told me, “but given all of her injuries, she is in a better place now.” For her, the cases were also a constant reminder to value the relationships she had with the people around her. This was the most satisfying, most helpful response I could have received at that moment. Her words forced me to accept that what had already happened to the patient had happened and that what could have been done for her in the emergency department had been done. They redirected my attention from my own mountain of unmanageable emotions Anger to the patient—and left me at peace. Those were my experiences with traumatic death. While situations in the emergency department quickly declared themselves as black or white, oncology has all shades of gray. How do health professionals face patients and their families every day with the uncertainty they carry? How do they bear this emotional weight? While there were certainly times when variations in the blips I spent a month reading the literature on coping with death and beeps of the monitors caused momentary panic, I learned and end-of-life care, hoping to resolve my own nagging fears that more reliable indicators of how kids felt were their crossed about death. I hope that what I learned will work for me in the arms or their pouting lips. Likewise, when my stethoscope on future, and I am sure more experience will help me develop bare skin caused a grimace, I knew it was not the time to wean coping strategies. For now, I believe that a foundation of clear pain medication. By watching and listening, we give the patient and honest communication with our patients, particularly a voice in the direction of care. about death, allows us to concentrate on realistic goals for both To Cicely Saunders, founder of the palliative care move- ourselves and them. While doing this, we must also be mindful ment, it was important to have someone, such as the bedside of our own reactions and practice self-care. nurse, there When caring for patients, communication is key. Kübler- Ross emphasizes the need to communicate early and often to explain what a doctor had said and to listen endlessly to in the course of the illness. She highlights the importance of fears . . . [since] so many crippling emotions are less powerful interpreting body language, noting that caretakers often focus to hurt once they have been expressed to another person.3

on the equipment rather than on the facial expressions of As the third-year medical student, officially the lowest the patient, which can tell us more important things than the ranking (and in my case also shortest) member of the team, most efficient machine.2p18 I considered myself the least intimidating person. As the one

The Pharos/Autumn 2013 15 Yes, I can

ask I believe they should be told.” She does advocate for some degree of knowing and understanding the patient first, since sometimes “we judge the patient to be unready as yet to face the full knowledge. But then we must return, for this may need a whole series of exchanges.” 4 Avoiding the topic of death will not prepare the patient for this news; rather, honest communication and unhurried exploration of his or her understanding of the condition and beliefs about death are excellent starting points. If and when patients reach the final Kübler-Ross stage of acceptance,

the family needs usually more help, understanding, and support than the patient himself. While the dying patient has found some peace and acceptance, his circle of interest diminishes. He wishes to be left alone or at least not stirred up by news and problems of the outside world.2p100

And after death, especially for pediatric death, our role is not silence. It is, in the words of Joan Arnold and Penelope Gamma,

To listen and to speak of child death, recognizing it for all that it is—an unparalleled human tragedy. To ensure that families will be respected and admired for their ability to deal with the vastness of their loss, we need to legitimize their loss, to talk openly about the dead child. To continue the silence is somehow to deny the child’s very existence.5p130

Several resources are available to help us find just the right Bargaining words, especially in difficult situations with their own nuances, such as death in the delivery room and in the ED.6 For both health professionals and parents, the United Kingdom’s Child Bereavement Trust website (www.childbereavement.org.uk) with the most time, I felt that I spent the most time with my specifically addresses what to say to the bereaved about the patients and that that time, together with my approachability, death of a child. Although a few choice words may suffice to made it obvious to me that I should be their confidante. But as start that difficult discussion, one may also turn to those who much time as I thought I spent with them, I quickly realized are experienced to learn how to sustain such a conversation. In that their nurses spent more. More times than I can remember, The Anatomy of Hope, Dr. Jerome Groopman writes that nurses raised concerns that parents or patients were hesitant to bring to the attention of the medical team. learning how to care for patients was still very much like When death is possible or probable, it must be addressed. being an apprentice in a medieval guild. You closely and re- As Kübler-Ross puts it, death is often “a frightening, horrible, peatedly observed master craftsmen at their work and then, taboo topic,” 2p28 our real-life Voldemort. To the superstitious, largely on your own, tried your hand at it.7p32 and sometimes even the usually-nonsuperstitious, talking about death will cause it to happen. That fear seizes our hearts I have always learned by modeling my teachers, whether it was and evicts reason. We do not need to talk about death in every crossing out units in dimensional analysis or using a suction pi- conversation with the family; we do not need to bludgeon it pette. But opportunities to observe my medical school teachers into them until they accept. But we must be open to discus- engaging in serious discussions with their patients were neither sion and brave enough to initiate that first discussion, and open nor plentiful. Our Practice of Medicine course supple- afterwards, continue our support of the patient and family mented discussions about the art of medicine with role-playing throughout the entire process. To the uncomfortable question sessions, but all of the role-playing sessions in the world could of “Should a patient know . . . ?” Saunders argues that the an- not reassure me that I would be competent in the delivery of swer is, undoubtedly, yes. It is our duty to patients—“If they do bad news. As an MS and MS I seized every opportunity to go

16 The Pharos/Autumn 2013 with my team to any serious discussions. Unlike the traditional About YunZu Michele Wang, MD see one, do one, teach one, I knew I needed more than one ex- I grew up in Arcadia, California, read- perience, and even now, I know I need to observe more master ing all the time. I continued to do so while clinicians at their compassionate best. With their guidance, obtaining my degree in biochemistry at and most importantly, with more practice of my own fledgling UCLA, albeit less for personal enjoyment skills, I hope to develop a level of mastery in the art of deliver- and more to pass my classes. My child- ing and discussing bad news that will allow me to be a source hood was full of the outdoors, bargain shopping, deli- of comfort to patients and families in distress. cious Taiwanese food, and my parents’ emphasis on the One communication pitfall I have been guilty of is that of value of education. I am incredibly grateful for the sup- telling patients and their families only what they want to hear. port of my family, friends, and all of my twenty-one years I am an inherently optimistic person, but as the bearer of news of teachers from the Arcadia Unified School District, and the interpreter of test results, I felt pressure to set a good UCLA, and Washington University School of Medicine. Currently, I am a Pediatrics intern at the University of California in San Diego.

mood for the day. Knowing that both content and delivery matter, I always tried to emphasize the good things or the progress they achieved. Even if it was not what they wanted to hear, I tried to balance unwanted news with something positive. But when I was asked a tough question or when the answer was bleaker than having to stay in the hospital for a few extra days, I faltered. Unable to depict the situation positively, and still inept at delivering bad news, I dodged the question and desperately emphasized the few things that were going well. Unconsciously, I was probably in the Kübler-Ross stage of denial; I wanted to protect the family from my own despair. As Groopman tellingly describes it,

The evasions, the elliptical answers, the parsed phrases were all supposed to be in the service of sustaining hope. But that hope was hollow.7p53

Not only was I starting down a slippery slope of half-truths, where my integrity could be questioned, but I was also a textbook example of a health professional contributing to her patients’ anxiety by avoiding their questions. Worse, my attempts to protect the family were also weakening their basis for hope, as I denied them the knowledge of what they could even hope for. Laying out the risks and benefits of treatment, talking about what a sixty percent chance of survival really means, and distinguishing between curative and palliative treatment are not easy. But this is what patients have the right to expect of us, and what we must do. Only with understanding of the facts, probabilities, and options available to them can patients have true hope. Furthermore, for patients to believe that there is a way to a better future, the medical team must have hope, too. My attempts to dodge the patient’s and family’s questions betrayed Depression my own hopelessness, and they probably saw through it.

The Pharos/Autumn 2013 17 Yes, I can

According to Harper, “To consider a disease or patient hope- transferred without words. It can do so much to lift the feel- less is often to render them so,” 1p18 which Groopman reiter- ing of helplessness from a patient as well as from ourselves.3 ates: “for a physician to effectively impart real hope, he has to believe in it himself.” 7p209 As a medical student, the opportunity to do something, This is more than the so-called power of positive think- anything, to be helpful—as opposed to hopelessly helpless— ing. Neither physician nor—especially—patient may consider was especially significant in emergency situations. I can imag- alternatives or take risks if they feel that nothing will make any ine that the satisfaction of being able to medically manage and difference. Our only option is to use our knowledge and expe- ease a patient’s long-term suffering and death must be magni- rience to guide our patients. Groopman relates the thoughts fied manifold. of Richard Davidson, PhD, Director of the Laboratory for In addition to reframing our own mindsets, helping the Affective Neuroscience at the University of Wisconsin, patient and family reframe theirs may bring further satisfaction.Instead of hope as a single entity, “alluring but vague, Hope does not cast a veil over perception and thought. In this way, it is different from blind optimism: It brings reality into sharp focus. In the setting of illness, hope helps us weigh highly charged and often frightening information about the malady and its therapies. Hope incorporates fear into the Acceptance process of rational deliberation and tempers it so we can think and choose without panic.7p199

How do I find hope in seemingly hopeless situations? By reframing—looking beyond the ominous circum- stances to see that there is much I can do for the patient in front of me. By ceasing my own useless and unsatisfying “why?” questions and, above all, by making it about my patients and not about me. Unconsciously, or perhaps sometimes deliber- ately, as August M. Kasper writes,

The dying are thus not neglected, but they are very rarely approached with hope or even interest, because, I suppose, they simply will not feed the doctor’s narcissism by responding and getting well. Their care is demanding, frustrating, and far from helpful to the medical magician’s self-esteem.8p5–6

Things do not feel so awful when we focus on our patients instead of ourselves, and give instead of looking to gain. The advice I received following my own experience in pediatric trauma exemplified such an attitude. It was a reminder to focus on doing what I could for the patient, instead of allowing myself to be overwhelmed by my negative emotions. With her experience as both a nurse and physician, Saunder stresses that

Much can be done to control pain, nausea and vomiting, to relieve dyspnoea and confusion, both so frightening to any patient. Skill at this stage helps us come to a patient with ever renewed interest and that positive feeling which is

18 revered but ineffable, aloof from daily life and mostly inac- views and goals and what we can help them achieve will give us tionable,” identifying “smaller, salient, and steadying” hopes hope. And practicing consistent self-care and promoting a sup- brings to light more achievable, and perhaps more meaningful, portive work environment will allow us to endure and carry on. goals.9 Recognizing “hope as a force that helps to carry the Death, and pediatric death in particular, is a terrible tragedy unbearable,” patients can be asked about their “hopes for the but as one social worker put it, “I cannot stop that, or make it future and the good things that inspired [them] to continue to go away by running away from it, so I must turn around and live.” 10 In the same way that we need to refocus our attention help.” 1p60 And so I will. on matters within our control, we should also help our patients acquire some measure of control over their own conditions. Acknowledgments Beyond doing the best for our patients in the hospital or Thanks to Dr. Elliot Gellman and Elaine Khoong for editing, and to office, we also need to deal with our thoughts and emotions. Mary Alice McCubbins, PNP, for inspiration. Burnout and compassion fatigue are common in physicians caring for patients with end-stage illness; they need not be References inevitable, however, as several self-care and self-awareness . Harper BC. Death: The Coping Mechanism of the Health methods to prevent burnout can help.11 A very delicate balance Professional. Greenville (SC): Southeastern University Press; . in the physician-patient relationship needs to be maintained. . Kübler-Ross E. On Death and Dying. London: MacMillan; Acceptance As oncologist Dr. David Steensma writes, . . Saunders C. The management of fatal illness in childhood. If I get too close to my patients and allow myself to become Proc R Soc Med ; : –. emotionally entangled in their suffering, every death feels . Saunders C. Care of the dying—. Should a patient know…? like the loss of a family member. I risk becoming paralyzed Nursing Times ; : –. in grief. But if I don’t allow my patients’ agony to hurt me . Arnold JH, Gemma PB. A Child Dies: A Portrait of Family at all—if I attempt to preserve myself by making myself Grief. Rockville (MD): Aspen Systems Corporation; . untouchable, emotional Gore-Tex—then, like old Tithonus, . Levetown M. Communicating with children and families: who was granted immortality but not eternal youth, I am from everyday interactions to skill in conveying distressing informa- condemned to shrivel up into a grasshopper, abandoned by tion. Pediatrics ; : e–. the voice needed to give comfort to my patients.12 . Groopman JE. The Anatomy of Hope: How People Prevail in the Face of Illness. New York: Random House; . Recognizing risk factors related to closeness of the physi- . Kaspar A. The Doctor and Death. In: The Meaning of Death. cian-patient relationship may help one avoid both compromis- New York: McGraw-Hill; : –. ing clinical judgment and physician burnout.13 . Feudtner C. The breadth of hopes. N Engl J Med ; : In addition to self-awareness, a supportive environment at –. work is championed in almost every work I have read. It is a . van Laarhoven HWM, Leget CJW, van der Graaf WTA. very special bond formed by shared experience. Already, in my When hope is all there is left. Oncologist ; : –. brief years of clinical experience, residents, nurses, and attend- . Kearney MK, Weininger RB, Vachon ML, et al. Self-care of ings have provided the necessary “listening ear with simple physicians caring for patients at the end of life: “Being connected . . . support and encouragement,” 14 and I know I will value their a key to my survival.” JAMA  Mar ; : –. help even more in my future. While studies show that an of- . Steensma DP. The narrow path. J Clin Oncol ; : – . ficial debriefing following a traumatic event carries both risks . Wolpin BM, Chabner BA, Lynch TJ Jr, Penson RT. Learning to and benefits,15,16 I believe that the health professionals involved cope: how far is too close? Oncologist ; : –. in such an event should not be expected to mute their grief any . Reynolds F. How doctors cope with death. Arch Dis Child more than the family should. ; : . I know this is not the end of my learning. I wanted a how-to . Baverstock A, Finlay F. Specialist registrars’ emotional re- guide, an instruction manual, but this is not that kind of expe- sponses to a patient’s death. Arch Dis Child ; : –. rience. I wanted to cross off “confront fear of death” from my . Rose SC, Bisson J, Churchill R, Wessely S. Psychological to-do list, and then run away and get as far as I could from it debriefing for preventing post traumatic stress disorder (PTSD) (Re- until having to confront it again. What I have learned, however, view). Cochrane Database of Systematic Reviews ; : CD. is that it is really not so fearsome. Developing the courage and confidence to approach patients about the possibility of their The author’s e-mail address is: [email protected]. deaths will certainly take more observation and experience, just as it will take more experience to learn to manage the clinical aspects of end-of-life care. But understanding our patients’

The Pharos/Autumn 2013 19 FO!" F#$Ht

Matthew Molloy

The author is a member of the Class One can only wonder what color we college. In fact, I remember finding of 2014 at Johns Hopkins University will use for states that tip the scales many premed students off-putting. I School of Medicine. This essay won with greater than thirty-five percent studied biology and chemistry because honorable mention in the 2013 Helen obesity. Perhaps black. As the months of a passion for understanding how the H. Glaser Student Essay Competition. rolled by, the maps lost their comic world worked. Every pathway, every relief and turned into annoyance. It reaction, every explanation taught me besity. America’s epidemic. I seemed as though every tenth lecturer more. I was fascinated by research and remember the first time we felt the need to remind us about the the opportunity to contribute to the Owere shown the CDC National trend. We were about to be thrown collective knowledge of the scientific Obesity Trends maps in medical into the trenches of medicine’s war community. I conducted assays and school. Beginning in  with light on food. I remember looking around Western blots to elucidate the aber- blue and lighter blue, we watched as the room and wondering if there were rant signaling in cystic fibrosis cells. I the years progressed and new colors any new recruits to the war. Me? I was performed microarray analysis of the were added. Dark blue. Yellow. Orange. a veteran. I’d been fighting the Food African malaria vector to ascertain Now twelve red states in . It Fight for years. differing responses to stress. It was seemed almost comical in a way, the all well and good, but something was colors resembling political party des- My decision to enter medicine was missing. ignations. The colors changed as the a roundabout one. I haven’t wanted I also found passion in politics. average waist size expanded. Democrat, to be a doctor since I was born. It A card-carrying liberal, I joined then Independent, now Republican. wasn’t even on my radar when I started the College Democrats and began

Illustrations by Jim M’Guinness

20 The Pharos/Autumn 2013 working on local campaigns in north- met Carlos on my ambulatory clerk- know what it feels like, I wanted to tell ern Indiana. I even worked as an intern ship during my first year of medical him. But I didn’t. Carlos needed a plan. on Capitol Hill for a summer. I craved ! school. He was twelve years old, five- Where to start? Fast food? Soda? After the rush that comes with a heated pol- foot-one, and  pounds. Clinically school snacks? I decided to put the ball icy debate and the satisfaction of enact- obese. Looking at his growth curve, it in his court. ing something into law. I treasured my was a diagnosis that he had carried for “I see that the doctor has talked to time working in the political realm, but many years. I was asked to counsel him you about what you eat before. Have knew it wasn’t for me. on weight control and diet modification. you tried anything in the last year to As a cradle Catholic, I sought to I sat down with him and his mother, a change your eating habits?” infuse my education and career with caring woman struggling with her own “We don’t eat out as much. And I meaning. I was enthralled by ethics weight. I began by asking Carlos what stopped drinking a lot of soda.” and perused philosophical and theo- he thought about his weight. “That’s great!” logical literature. I fervently argued “I’m big. I’ve always been big. It’s His mom interjected, “Yeah, we got my opinions and developed a strong hard sometimes at school. Kids can be him to stop drinking so much soda by foundation for my own ethical con- mean to me, but it doesn’t really bother getting him to drink fruit juice. And science. Yet the theory of it all seemed me.” I’ve been trying to cook more at home.” so dry at times—I wanted to act, not “Kids can be mean sometimes. I’m Fruit juice. My mind jumped to philosophize. sorry about that. I’m glad you don’t let the sugary, calorie-dense juices I used There was no epiphany, no thun- it bother you too much.” I glanced back to drink as a kid. “What kind of fruit derbolt moment. I realized eventually at his growth curve. It was true. He juice?” I asked. that medicine could let me combine had always been big. My eyes drifted It wasn’t diet. It was full-sugar fruit the things I was most passionate about. to another area of the chart: family juice. Full-calorie fruit juice. And he Science for the betterment of human- history. Diabetes. Cardiovascular dis- sure was drinking it. A lot of it. I asked ity. Political debate and policy wran- ease. Hyperlipidemia. MI. My stomach Carlos and his mom if they knew gling at every level. Morality and ethics dropped. Suddenly, getting this kid to how many calories were in a serving. in practice. realize the importance of the situation They didn’t. To be fair, I rarely used to Only one problem: I was obese. You seemed more real. I caught the twinge know what I was putting into my body. can’t be a doctor if you’re obese. of pain he had in discussing the issue. I Carlos seemed interested in the answer,

The Pharos/Autumn 2013 21 Food fight

so I got onto the Internet and we fig- Maybe he did what we decided and cut have very few instances of bullying be- ured out together that he was drinking out the fruit juice. Maybe he decided cause of my weight. I was never really over  calories a day in juice. The that he wanted to make a change. Or teased, but I always struggled. I grew number sunk in. maybe his mom decided for him. Or up in Arizona, where swimming dur- “Wow. I had no idea. I thought I maybe he’s still drinking five servings ing the summer is a way of life. All fun was giving him something healthy,” his of fruit juice a day and continuing to and games, unless you’re a twelve year mom said. A dangerous and common tip the scales, barreling down a road old with noticeable gynecomastia. Or, misconception. I could tell that I had that will lead to his genetic gifts of car- as the skinny kids like to call it, “man convinced mom, but I needed to con- diovascular disease and diabetes. boobs.” Nobody had to say the words vince Carlos. I left clinic that day wondering how aloud, I said them in my own head. “Well, Carlos, if you’re on board, I I could reach out to my patients. How Every year during our “Health Safari” I think that this is something that you all could I tell them that I understood watched the number climb higher and can target. Drinking water instead of their plight and seem genuine? How higher. Into the three digits. As puberty juice every day would eliminate a huge could I tell them that we were fighting hit, my other chubby friends sprouted amount of calories and will definitely the Food Fight together? That I wasn’t up and lost their baby fat. I grew, too, help you manage your weight. I think just another skinny doctor wanting but in both directions. that would be a great first step.” them to lose weight? Tell them, “It gets I tried my hand at my first diet as I Carlos seemed to be pondering the better.” Or rather, “It can get better.” approached the dangerous  mark situation. “It’s going to be hard. I like at age thirteen. My mom and I joined juice,” he said. I’ve been overweight for as long as a weight loss program, and I stayed Hard, I thought. That’s an under- I can remember. Looking at old pic- motivated all summer, dropping almost statement. “You can have juice from tures, it appears that I started to look twenty pounds. My parents and I were time to time,” I pointed out. “Maybe chubby at the age of eight. Being the very proud. I finally seemed to be mov- you and your mom can go to the store fat kid affected me in more ways than ing in the right direction! My eighth- and look for some drink options that I think I will ever realize. I went to grade year started with excitement would still taste good and have a lot Catholic school and always had to wear as I prepared for high school life. We fewer calories.” uniforms. They came in three sizes: bought new uniforms and registered at “Yeah. That sounds good,” he said. slim, normal, and husky. I was always my new school. Then the celebrations I never saw Carlos again, so I’ll “husky,” a terrible term. Like a nice hit: holidays, end-of-year parties, grad- never know if I got through to him. way of calling you fat. I was lucky to uation, summer sleepovers. And with

22 The Pharos/Autumn 2013 them the pounds came back. When I possibility of needing an extra seat- About Matthew tried to get into my new high school belt to fly home on an airplane. My Molloy uniform, it didn’t fit. Not even close. I weight fluctuated from time to time as I am a fourth year remember crying when I brought the I slipped in and out of “health eating” medical student at shorts out to my mom. I didn’t need and coped with a modest student sti- the Johns Hopkins one size up. I needed two sizes up. I pend. I hovered just below  through University School of overheard my dad saying, “Did he re- most of college, always staying below Medicine and am cur- ally gain that much weight?” I guess I that magical number that seemed rently pursuing a Master of Public had. I guess I was always going to be to portend something truly wrong. I Health degree from the Johns the fat kid. didn’t like how I looked, but I seemed Hopkins Bloomberg School of My biggest enemy in my Food Fight to avoid the worst consequences of be- Public Health. I am originally from was body image. I had great friends. ing obese. I was the biggest “normal” Gilbert, Arizona, and attended the I was relatively popular. I had dates weight that you could be; at least in University of Notre Dame, where I to the dances and even a girlfriend at my mind. My BMI was misleading, I studied Biological Sciences. I now times. I was successful in the class- thought. live in Baltimore, Maryland, with room. In fact, I was at the top of my And there I stayed. my wife, Molly. I intend to pursue class in grade school and high school. a career in Pediatrics and Public Summa cum laude at a prestigious I sat in a small group room re- Health. I hope that my own strug- university. I was constantly busy with hearsing motivational counseling. gle will make me a more compas- outside activities. I traveled and stud- Convincing people to change their sionate and effective physician. ied abroad. I had a happy, stable family. habits for the better. We all practiced But none of that could get rid of the on a standardized patient who was internal struggle I had when I looked trying to quit smoking, artificially fast- in the mirror every morning. I hated forwarding from clinic visit to clinic “I felt like you didn’t understand the wearing the baggy jeans and hunting visit as our fake patient struggled with fact that deep down I wanted to quit, for the largest sizes at the store, dread- modifying her lifestyle. My group was but couldn’t find a way to make it work ing the day when I might have to shop not very successful at moving the ac- for me.” in the “Big and Tall” section. I feared tress to her goal. She broke character We had failed her. We had failed not fitting into the safety harness on to give our group feedback at the end to understand her struggle. She didn’t the roller coaster. I was ashamed at the of the session. need convincing, she needed guidance

The Pharos/Autumn 2013 23 Food fight

and support. She needed someone to realize how much you had eaten. The Shortly before embarking upon fight with her. promise you make to yourself when my own weight-loss journey, my older One of the tools in our tool bag you hear the statistics about heart dis- cousin achieved what I never before as medical-professionals-to-be is the ease. The inspiration you feel when, thought possible. Growing up, we Stages of Change model. People move here and there, a victor emerges in the were always the big kids in the family. through these stages: precontempla- Food Fight. We were both plagued with thinner tion, contemplation, preparation, ac- Preparation. The plan. How am siblings and a love of calorie-packed tion, and maintenance. Oh, and relapse. I going to do this? What didn’t work foods. But she was much bigger than I Don’t forget about relapse. about the diet last year? I’m about to was. In fact, in my own way, I was able Our actress-patient modeled the start interviewing at medical schools to make myself believe that my own various stages of change in smoking and I need to start acting the part, weight wasn’t that bad because it was cessation. Despite the make-believe practicing what I preach. I guess I nowhere near as bad as hers. environment and timeline, it was use- should look up the gym hours. Then everything changed. She made ful and instructive to see her progress Action. Only two pieces of pizza. a decision to change her life and lost through the stages from visit to visit. I know the cake looks good, but veg- nearly  pounds. I don’t know what In her struggle with cigarettes, I saw etables and hummus are just as tasty. clicked for her this time. I’m not sure my own struggle with weight loss. The Right? Finding a way to fit in time for if she does, either. I have rarely been same struggle that so many people go the gym every day, even if it means more proud of anybody in my entire through as they try to conquer their scurrying across the parking lot in the life and was overjoyed to see her suc- own BMIs. snow. cess. The only downside: now I was the Precontemplation. The days before I Maintenance. What? I can’t go back only fat one. I had no more excuses. realized that I was more than just “big- to my old ways? I guess that’s what they By this time, I was an adult. I had no boned,” when I convinced myself things mean by changing your lifestyle. one to answer to but myself. Nobody to were fine. Food was delicious, life was As I reflected more, I felt a more blame for my habits but myself. short, my weight had plateaued. I had appropriate term would be “Cycle of With my cousin’s victory as the final no time to exercise. Change.” Action isn’t the end. Not even catalyst, I waded into the trenches. Contemplation. Looking at pictures maintenance. Change is a vicious cycle The most epic fight of my life thus far. tagged on Facebook and not liking and relapse is the enemy. The Food Fight I decided, once again, that it was time what I saw. The sense of disgust when rages on with no cease-fire in sight. for a change. I began my final year of you feel too full to move and only then college, submitted my medical school

24 The Pharos/Autumn 2013 applications, and made a promise to about the moral weakness of a patient can’t run around outside because it’s myself that this time I was really going who can’t quit smoking. Can’t put not safe. Lawyers who barely have time to lose weight. down the gin and tonic. Can’t stop to grab a bite to eat, let alone cook. shooting heroin. Can’t shed those last Frustrated hypertensive patients who I waited in line at the Subway in few pounds. It’s almost easier for us really have tried their best for years. the hospital cafeteria. An obese man that way. We remove ourselves from The thirty-two year old who was teased verbally constructed his sandwich a the puzzle. It’s their failure, not our in grade school. The sixty-eight year couple of spots in front of me in line. A failure. I wonder if either of those old for whom this just became an issue. hospital visitor, his wristband told me. employees ever had to worry about We are their allies. Here not to Presumably here to visit a sick friend. their own weight. I wondered if either judge, but to offer assistance. To not Or family member. Or child. He had of them ever had to counsel patients roll our eyes. To not throw the food ordered a foot-long steak and cheese. It about changing the way they eat. back in their faces. To stand with them looked delicious. Maybe he was going My Food Fight is a personal one. on the front lines if they are willing to split it. Maybe he was going to gob- The war against obesity that our coun- to fight. To trudge with them through ble it all down himself. Maybe it wasn’t try and our profession is waging is boot camp. I remember the doctor even for him and he had a healthy really a series of personal struggles. visits of my past, standing on the scale, lunch packed back in the room. Stories of people who hate what they watching the nurse push the weight Between us were two hospital work- look like. People who love food and higher and higher. Sometimes there ers in green scrubs. After the man don’t care about the supposed risks. was no acknowledgment of the obvi- paid for his meal and departed, one of Former athletes whose metabolism has ous. Moving to the “” part of the them commented, “I think he could played a dirty trick on them. Mothers scale was enough. Sometimes there was have used half a sandwich. Or maybe a who can’t afford healthy food. Hard- the half-hearted banter about trying salad, instead.” working individuals who have already to lose weight. What I needed was an “It surprises me that they even of- lost the weight—three times. Sons and ally who recognized the difficulty, who fer food like that in the cafeteria. Not daughters cursed by the genetics of would congratulate me on past success, exactly staving off obesity,” the other ancestors they never knew. Patients who could reaffirm my desire to lose added. They laughed. I didn’t. dealing with more pressing health con- weight, who would simply ask, “How It’s so easy to fall into the trap of cerns. Addicts struggling with more do you think I can help you?” moral superiority. Assumptions made difficult life changes. Teenagers who

The Pharos/Autumn 2013 25 Food fight

They say each journey begins with discouraging, but the number slowly was walking down a busy street in a single step. Mine began with a single came down. Every new low was an- Baltimore to my first day of medical lap. After doing some soul searching, I other victory. It was slow going, school. Still obese, but more deter- realized that the one thing I had never though. After all, I was still in college! mined than ever to reach the end of my really tried in the past when trying Plus, I was interviewing for medical journey. I slaved through anatomy, bio- to lose weight was exercising. I knew school. Traveling back and forth across chemistry, and genetics, all the while that if I was going to be successful this the country every other weekend and continuing my clash with the scale. I time, I needed to incorporate exercise eating the delicious pastries they put remember getting stares from strangers into my life. And the only way was to out in the morning—not taking one as I read a dissector on the treadmill, do what I’d never done before: run. I would be rude. Coping with the stress but it was worth it. It was working. I started a “couch to k” program that I of uncertainties that plagues seniors even had to buy a whole new profes- found online one afternoon. The first about to enter the real world. sional wardrobe for my clinical skills couple of weeks were horrible. I simply Then, finally, the magic happened: class. It was an expensive trip to the could not understand how people ran people began to notice. Friends, fam- mall. It was the best trip to the mall I a full mile, let alone . miles or . ily, and even strangers started making had ever made. miles. But eventually I was able to run comments about how good I looked. One cold December morning, I half a mile. Then two. Then three. I It was invigorating and kept me go- stepped on the scale and the three-digit stopped making excuses and fit exer- ing. After an unforgettable senior year, number I saw began with a one. I can’t cise into my day instead of only going I stood on the scale one day in May even describe what that felt like. By to the gym when I had free time. before graduation and moved the scale the end of that first semester, my BMI I changed the way I ate, too. I tried balance to the “” mark.  pounds. dipped below . I had made it: no lon- to forgo the desserts. Cut back on the Another victory. ger obese. alcohol. Paid attention to portions. I graduated, celebrated, and drove Didn’t go back for thirds. Packed my across the country with my girlfriend. I went to see my new primary care own lunch. Drank lots and lots of Back in Arizona that summer, I sweat physician. I was a victor, I thought. A water. off another dozen or so pounds conqueror of obesity. I had won my Most importantly, I stepped on with the help of a particularly pushy fight with food and was proud to step the scale every day. At first, it was personal trainer. Before I knew it, I on that scale in a fresh environment

26 The Pharos/Autumn 2013 and not have the label of “obese.” commit yourself to it. And I don’t know over two years now, but I suspect some It was a standard history and physi- what was different for me this time sort of relapse is inevitable. The fear cal. She did everything right. Personal than the previous dozens of times that grips me every time I see the numbers medical history, family history, review of I tried. This time it worked.” creep back up on the scale. Working systems. When we finished, one of the Driving home, I was bothered by exercise into my schedule becomes first sentences out of my doctor’s mouth my answer. I didn’t just have trouble more difficult with every passing was, “Your BMI is .. We like it to be explaining to someone else why I was month, and I see my old eating habits below . Have you ever thought about able to lose weight, I had trouble ex- slowly inching their way back into my trying to lose a few pounds?” plaining it to myself. I had dieted many life. I’m proud of what I’ve done and I I flushed. What she was saying times before, reached many points in truly believe I have made some perma- was true—I was still overweight. In my life when I had said “now or never.” nent lifestyle modifications, but only my Food Fight, I guess I had forgot- I guess this time I had the motivation time will tell the story of my success. ten about the other categories below of seeing someone close to me achieve I may have won a decisive victory, but a BMI of . I had come so far only to weight loss success. This time I had the the war, the Food Fight, continues. fall short. My “ideal” weight was still motivation of becoming a healthy role Soon I will be a doctor. I will enter twenty plus pounds away. My thoughts model for my future patients. This time the trenches of medicine’s war on food, raced as I stammered, “Actually . . . um I had the motivation of being in a seri- on infection. The battles we wage are . . . I’ve lost about  pounds in the ous relationship with my now-wife. But many. And the map continues to turn a last year.” I don’t even know if that is the whole deeper shade of red. She looked at me for a moment. answer. There were always motivat- I don’t know what the answer is. We I knew what must have been going ing factors in previous attempts. This can’t legislate the problem away. We through her head. It had gone through time I pushed through and something probably won’t find a pill that melts the mine a hundred times before as I stum- clicked. I finally moved past the Action pounds, or a gene that explains why we bled through my patient interviews point of my cycle into that place be- can’t put down the cupcakes. We can as a medical student: I said the wrong tween Action and Maintenance that try to incentivize good behavior, but— thing. How do I recover? we never talk about: Success. I made a really—we need to rethink how we live “Oh. Wow! You lost this weight on lasting change. our lives. But that will take years, or purpose?” I don’t think there is a secret. No generations. “Yeah. I exercise about five days a trump card that I can dish out to my In the meantime, we can be there for week and I try to watch what I eat.” patients. No battle-ending move. No our patients. Every patient is fighting “That’s amazing. Congratulations! checkmate. No motivational speech his or her own war. For some, that war You should be very proud.” that could turn that CDC map blue. It is with food. We can join them in the I am proud. It’s a weird sense of was a combination of motivation, luck, Food Fight. Every patient’s battle means pride. To be proud of yourself for doing and timing. something different—for me, for Carlos, things that you know you should be do- I think I finally realized a message for the man at Subway, or the frustrated ing anyway. To be proud of taking care that I could share with patients: Losing patient sitting across from you in clinic. of your body. To be proud of finally weight is hard. It’s probably the hardest We know the different battles of many starting to look like most of your peers thing I’ve ever done. It’s something that individuals, every day. We can learn have looked their entire lives. is still very much a part of my life after the art of war and pass on the hope of At the end of the visit, my doctor three years, and that will probably al- victory. We can ask how we can help. asked one last question. “I have to ask. ways be a part of my life, like cigarettes Patients are on different parts of their I have so many patients that struggle for a former smoker. But victory is pos- journeys through life and we have the with their weight. If I may, how did you sible if you persevere. If you commit. privilege of being invited to walk with lose all the weight?” You might fail or relapse, despite your them, if only for a few steps, a mile, a Fair question. I’ve been asked that best effort, but you can regroup, tweak marathon, or a spin on the elliptical. a thousand times by family, friends, your strategy, and attack from a differ- If there’s one thing I’ve learned on my and strangers. I’m still not sure how to ent angle. Someday, you just might win. own journey, it’s that food fights are answer. messy, but so is being a doctor. “I lost weight by dieting and exer- Relapse. The word still sends shivers cising. Mostly exercise, I would say,” through my spine every time I think The author’s e-mail address is: mmolloy4@ I replied. “But there isn’t really a se- back to the Stages of Change. I’ve been jhmi.edu cret. You have to want it. You have to able to maintain my new weight for

The Pharos/Autumn 2013 27 28 The Pharos/Autumn 2013 Illustrations by Laura Aitken Running toward the fire Empathy and ethics in medical education

Noah M. Rosenberg, MD The author (AΩA, University of Massachusetts Medical alone compassion—have all been proposed as possible reasons School, 2012) is a resident in the Department of Family for this decrease in empathy. Medicine and Community Health at the University of Perhaps the best way to understand the causes behind this Massachusetts Medical School, and president of the AΩA decreased empathy is to listen to medical students’ own sto- chapter there. ries. Rather than focusing on data and numeric measures of empathy, one fascinating study simply interviewed a group of he senior family physician seated before me offered medical students throughout the years of medical school. One just one piece of advice: for the next three years of fourth-year female participant, for example, argued that medi- residency training, my job was “to run toward the cal students become less empathic because they treat patients fire.”T I should consider every crisis a learning experience and as “intellectual cases rather than people.” 3p11 A fifth-year male a personal responsibility to help where I could. When a “Code participant said, “When starting off, you will let the empathy Blue” was called on the overhead public announcement sys- affect the way that you are, whereas that happens less as you tem, I should rush to the patient’s bedside to gain experience go through medical school.” 3p11 attempting to resuscitate someone. I sensed that he also felt Not all students felt that empathy declined during the that physicians have an overarching ethical responsibility to years of medical school. Some believed that gaining experi- respond to crisis situations. While it seems that ethical choices ence allowed them to develop strategies for enhancing their should come naturally to practitioners of an empathy-rich art empathic response. A fourth-year female student explained, “I like medicine, recent studies of medical students and residents understand a bit more about the conditions and I know how demonstrate a complex link between ethics and empathy. they affect patients.” 3p11 Another fourth-year female student Whether one agrees or disagrees that physicians have extraor- summed up what many also expressed: “I felt very emotional dinary responsibilities in times of crisis, maintaining this sense a lot of the time dealing with breaking bad news, watching of duty relies on training medical students to become doctors people die . . . watching people get sick . . . That used to affect who will run toward the fire. This may not be so easy. me and it affects me less now, but it’s not because I don’t feel Much has been made of recent data that show that medi- it, it’s because I don’t let it affect my emotions as much.” 3p11 cal student empathy declines successively with each year of The study’s authors found that medical students had contrast- medical school. Indeed, pooled data from nine separate studing experiences with respect to the decline or enhancement of ies demonstrated a significant decrease in empathy during empathy, and concluded that students experience a more af- medical school.1 One study, frighteningly titled “The Devil Is fective or emotional type of empathy at the beginning of their in the Third Year,” followed  medical students throughout studies, with their focus shifting toward a more intellectual or medical school, and observed that while empathy scores were cognitive version of empathy as training progresses.3 relatively consistent during the first two years, by the end of Unfortunately, medical students are not the only ones the third year students showed a significant decline in empa- affected by decreased empathy. At least five studies have thy that persisted until graduation.2 The third year of medical shown a continuing decrease in empathy during residency.1 school marks a great transition for medical students: the move One study of resident and attending physician views found from the lecture hall to the patient’s bedside. Increased stress, that “derogatory and cynical humor directed at patients is a longer hours, and the difficulty of learning medicine—let well-documented and ubiquitous phenomenon in medical

The Pharos/Autumn 2013 29 Running toward the fire

education.” 4p38 The two most common locations for deroga- school, the students surveyed became more likely to have tory humor were hallways outside patient rooms during engaged in unprofessional behavior, the rates rising from . rounds and in conference settings where residents congregate. percent in the first year to . percent in the fourth year.6 In Attending physicians and residents agreed that the “rules” of addition, increasing student debt is correlated with increases the game dictated that the persons within the group with the in unprofessional behavior: In one study, . percent of stu- least authority, particularly medical students, almost never dents with debt less than , engaged in unprofessional initiated derogatory humor.4 The objects of such derogatory behavior, compared to . percent of students with debt comments most often included alcohol- and drug-abusing greater than ,.6 patients, obese patients, and a “large category of ‘difficult’ It is interesting to note that declines in empathy among patients.” 4p37 medical students are not universal. A study of Portuguese One internist called this behavior a coping mechanism, medical students found that students in their final year were saying, “Sometimes we spill over into derogatory humor and more empathic than those in their first year.7 A number of that’s wrong and we try to catch ourselves . . . [yet if we] took studies have shown that female students are less likely than everything we saw seriously every day we wouldn’t make it male students to experience as large a decline in empathy through the day emotionally.” 4p39 These unprofessional be- during medical school.8 And medical students who choose haviors can continue beyond the training period. In a study person-focused fields of medicine are likewise less likely to ex- published in Medical Education in , Brigitte Maheux perience a decline in empathy compared to students who enter and colleagues found that forty percent of fourth-year and technology-oriented fields.8 These studies, as well as many twenty-five percent of second-year medical students believed others, were performed using the independently validated that their teachers did not behave as humanistic caregivers student version of the Jefferson Scale of Physician Empathy, a or were not good role models in teaching the doctor-patient common questionnaire for measuring the empathy of medical relationship.5 Perhaps unsurprisingly, this study’s authors and students. others emphasize that medical students make assessments of Further research has shown that doctors may actually derogatory humor that are remarkably similar to those made experience an “empathy bump” in their first few years of by residents and attending physicians. This finding highlights fully licensed practice, bringing their empathy levels close to the degree to which medical students look to more senior where they were before the declines in medical school and clinicians as role models of professionalism. residency.9 In response to the recently recognized problems While empathy may be a strong driver for running toward of declining empathy and increased unprofessional behavior, the fire or responding to a crisis, the decision to do so—or medical schools are experimenting with structured methods not—is ultimately an ethical one. This raises the question: to combat these problems. does a decline in ethical behavior parallel the decline in At the Indiana University School of Medicine, the tenets of empathy in medical school? A recent study examining both appreciative inquiry (AI) and complex responsive processes medical student empathy and professional conduct found (CRP) are used in the medical student curriculum, in which a surprising answer. In a survey of students at seven U.S. students reflect on emotionally challenging patient cases.10 AI medical schools, fewer than ten percent of students reported is a method adapted from management science that focuses engaging in cheating/dishonest academic behaviors, compared on amplifying what an organization does well rather than to an astonishing forty-three percent of the , students eliminating what it does badly. In comparison, CRP is a way who reported unprofessional conduct related to patient care to structure group communication that emphasizes conversa- (including reporting a result as normal that had been inadver- tion and encourages each group member to reflect on how tently omitted from the physical exam, and affirming that a individual ideas can unpredictably combine and produce novel test had been ordered when it actually had not). This seems to outcomes. Many other medical schools employ required writ- suggest that students hold unprofessional conduct in patient ten assignments, though student perception of these predict- care to a different standard than similar conduct in a strictly ably varies from the enthusiastic to the burned out. Whatever academic setting. the perception of such assignments, many medical schools are Importantly, students’ emotional and psychological states actively trying to teach empathy and professionalism. strongly related to their professionalism. Students with burn- The issue of professionalism in medicine is hardly a new out—those who experienced long-term exhaustion and dimin- phenomenon—the Hippocratic Oath of circa  BCE may ished interest—were almost twice as likely as those without to be considered medicine’s first code of professionalism, one report engaging in unprofessional behaviors.6 They were also that has grown more relevant as recent research demonstrates less likely to report holding altruistic views regarding physi- the scope of the problem with respect to medical education. cians’ responsibilities to society; for instance, they were barely The pioneering  paper by Richard and Sylvia Cruess, half as likely as students without burnout to want to provide “Teaching Medicine as a Profession in the Service of Healing,” care to the medically underserved.6 With each year of medical brought to light the crisis in medicine, fomenting since the

30 The Pharos/Autumn 2013 that this is the case, recognition of the problem has allowed medical schools to reshape their curricula toward helping medical students maintain the empathy and professionalism with which they enter their medical training. “Whenever you see people running one way,” the senior family physician advised, “you run the opposite direction—toward where they came from.” Let us hope the next generation of doctors agrees and shoulders its responsibility to serve the suffering.

References . Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med ; : –. . Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med ; : –. . Tavakol S, Dennick R, Tavakol M. Medical stu- s, “not of competence or skill but of moral standing and dents’ understanding of empathy: a phenomenological study. Med authority.” 11p942 The Cruesses nevertheless emphasized the Educ ; : –. idealism and commitment of incoming medical students and . Wear D, Aultman J, Zarconi J, Varley JD. Derogatory and outlined a proposed program that they felt should be taught cynical humour directed towards patients: views of residents and by all institutions of medical training, including: the concept attending doctors. Med Educ ; : –. that being a medical professional is not a right but a privilege, . Maheux B, Beaudoin C, Berkson L, et al. Medical faculty and the foundation of altruism inherent to the moral value of as humanistic physicians and teachers: the perceptions of students professionalism.11 at innovative and traditional medical schools. Med Educ ; : The  Flexner Report revolutionized medical educa- –. tion and led to unparalleled strength in the national system of . Dyrbye LN, Massie FS Jr, Eacker A, et al. Relationship be- physician licensing. Meanwhile, empathy and ethics received tween burnout and professional conduct and attitudes among US comparatively less attention. Programs such as those outlined medical students. JAMA. ; : –. by the Cruesses and established by Indiana University School . Magalhães E, Salgueira AP, Costa P, Costa MJ. Empathy in of Medicine demonstrate a sea change in medicine’s approach senior year and first year medical students: a cross-sectional study. to professionalism. These days, the Oath of Maimonides, BMC Med Educ ; : . which is commonly used before the start of the third years, has . Tavakol S, Dennick R, Tavakol M. Empathy in UK medical largely replaced the Hippocratic Oath in medical schools. One students: differences by gender, medical year and specialty interest. line in particular speaks to medicine’s professional tenets of Educ Prim Care ; : –. ethics and empathy: “May I never see in the patient anything . DiLalla LF, Hull SK, Dorsey JK. Effect of gender, age, and rel- but a fellow creature in pain.” evant course work on attitudes toward empathy, patient spirituality, Many would argue that doctors bear a special responsibility and physician wellness. Teach Learn Med ; : –. to respond to crisis situations. Some hospitals include clauses . Cottingham AH, Suchman AL, Litzelman DK, et al. Enhanc- in their contracts with doctors and other members of the ing the informal curriculum of a medical school: a case study in health care team stipulating that they must report to work in organizational culture change. J Gen Intern Med ; : –. the event of natural disasters or infectious outbreaks. Thus, . Cruess RL, Cruess SR. Teaching medicine as a profession in like other first responders, physicians and health care teams the service of healing. Acad Med ; : –. are likely to be exposed to risks greater than those for the general population. The actions of all first responders are in- The author’s address is: formed by a sense of altruism and ethical duty. But what if that UMass Memorial Medical Center sense of ethics and altruism in physicians—that cornerstone Department of Family Medicine and Community Health of not just caring for patients, but caring about patients—is 119 Belmont Street diminishing in medical students and, as a logical consequence, Worcester, Massachusetts 01605 in the doctors they become? While recent data demonstrate E-mail: [email protected]

The Pharos/Autumn 2013 31 Who killed lab rounds?

Thomas Fekete, MD

The author (AΩA, Temple University, the chilling news of a cluster of cases of microbiology lab rounds was the equiv- 1998) is Executive Vice Chair of Pneumocystis infection in five gay men alent of lighting a single candle instead Medicine, Section Chief for Infectious in Los Angeles. In short order I learned of cursing the darkness. Diseases, and professor of Medicine about infections and tumors that I could When I arrived at my current job at Temple University School of barely pronounce. Unsurprisingly, my in , I tried to replicate micro lab Medicine. existing microbiology expertise was in- rounds, which I convened three days sufficient to deal with these unprec- a week in my new institution. Fellows, did not know in  when I ap- edented new problems. I was lucky residents, and students would join me plied for Infectious Diseases fellow- that my training included regular daily in the microbiology laboratory, and we ship training that the most dramatic rounds in a state-of-the-art clinical mi- would review the interesting cultures Ipandemic of my lifetime had started. crobiology laboratory where myster- and stains with the laboratory techni- On June , , less than four weeks ies were peeled away and techniques cians, supervisors, and the laboratory before I started my fellowship, I read were clarified. The slow immersion in directors. We would discuss what was

32 The Pharos/Autumn 2013 happening to hospital flora and talk patient-focused results to an incorpo- actually counterintuitive since modern about the triumphs and limits of clini- ration of the wonder and poetry of the patients who have complex problems, cal microbiology. Over the years I ran microbial world as seen from the clini- emerging new diseases, and changing over  lab rounds, which shrank cal laboratory perspective. In , there patterns of resistance are more likely to two sessions per week and grew to was scant knowledge of phenomena to depend on the lab than patients with cover nutritional and environmental such as biofilms, quorum sensing, bac- yesterday’s more common problems. In quirks of microbes, newer techniques terial persisters, or the human microbi- fact, this deemphasis of microbiology to improve and hasten species deter- ome. Back then only a genius or a fool is just one of the results of the general mination and susceptibility, challenges would have suggested that bacteria have minimizing of the importance of basic of microbial naming, microbial physi- any bearing on obesity, heart disease, or science in the clinical years of medical ology and genetics, and the evolving cancer. Even now, this knowledge has no school and during residency. I have role for molecular techniques. Because direct clinical application and few prac- never heard anyone say this, but the of a change in my job duties, I was no ticing doctors or trainees keep up with competition in laboratory governance longer able to sustain lab rounds and no this burgeoning field of research. Thirty between clinicians and microbiologists one offered to take over. So lab rounds years ago we had great, if naive, confi- on one side and pathologists on the expired on December , . Time of dence that the discovery of new chemi- other could also be playing a role. The death : . cal agents to control bacterial infection laboratory territorial battle has been I may have pulled the trigger, but was would be never-ending. In hindsight, ceded to others; infectious diseases cli- I the person who killed lab rounds? we also had a surprising nonchalance nicians are perceived as just another I learned early that students study- about the potential toxicity that these interested party. ing microbiology in Year II of medical drugs can cause directly or via ecologi- Nostalgia is a false friend. Lab school acquire some limited expertise, cal disturbance. rounds evolved with the times and such as looking at Gram stains and an- I have also observed that the labora- provided practical information such as swering multiple choice questions, but tory staff is less interested in lab rounds how long it takes for a blood culture that knowledge is offloaded somewhere than they were three decades ago. This to be detected as positive, along with between Step  of the USMLE exam and is, as best I can tell, an adaptive state more abstract concepts such as when to the beginning of Year IV. Some students brought on by a combination of a highly question susceptibility data. Changes in retain more facts than others, but most regulated work environment and a medical practice and technology result cannot explain even the basic aspects of strong emphasis on efficiency. When I from observations and breakthroughs concepts such as gene regulation, tran- started my training, the laboratory was that emerge from medical research. scription, translation, or mechanisms of a revenue center with billing oppor- Although some research leads to an ex- resistance. Very few students delve into tunities. Now the hospital laboratory pansion of medical knowledge, the pay- new discoveries because they are usually has become just another cost center off in better patient outcomes may not not directly applicable to clinical medi- competing with other hospital entities be immediate. We face the challenge of cine. The practical understanding of the for a share of a global payment. This weighing risks and benefits to apply the laboratory (such as it is) is conveyed by marginalization has resulted in the dis- incomplete or ambiguous experience residents who, as it turns out, have an appearance (or at least partial outsourc- of clinical research to the real world of equally limited grasp of microbiology. ing) of many hospital labs and lab tests. patient care. Even when the knowledge And, unsurprisingly, beginning infec- While this approach can save costs, the pool is incomplete, new developments tious diseases fellows continue to lack opportunity to inquire about results, occupy “mindshare” and we may find microbiology competence. Lab rounds double check unusual reports, or ask for our brains filled with scraps of incom- mitigated this, but most learners were clarification is diminished when the lab plete information until the moment comfortable with the limits of their lives far from the patient. we resolve the ambiguity and validate knowledge, and even the most intensive Another factor that seems surprising actionable approaches. cheerleading for microbiology did not to those who trained in the twentieth In the meantime, regulatory changes created a demand for this information. century is the reduced emphasis on lab- in medical education have irrevers- Lab rounds, while enjoyable for stu- oratory medicine knowledge in accredit- ibly altered the rhythm and content dents and residents, ranked lower than ing exams such as the Internal Medicine of teaching. Daily workflow has been other teaching activities and in a time- and Infectious Diseases Boards. While it adjusted to meet the curricular needs constrained setting was clearly makes sense for question writers to ac- of residents. The need to get the same expendable. commodate “newer” areas such as HIV amount of work finished in less time Over the years, lab rounds evolved and transplant medicine, the decreased has been a challenge to many training from a more detailed review of role of clinical microbiology expertise is programs. Sessions such as laboratory

The Pharos/Autumn 2013 33 Who killed lab rounds?

rounds are often a low priority for busy residents and fellows who need to finish time-sensitive patient care tasks. How can we live in a golden age of microbiology yet find lab rounds dispensable? One hour per week can scratch the surface of the marvelous discoveries that animate contemporary microbiology, it can review and clarify Di!ni"# It’s midnight for me “pearls” of knowledge that can improve and midnight for her the practical utility of the lab, and it means time of death can give real time awareness about our is coming soon. patients. But time, the principal cur- rency of modern medicine, is spent to She knows. complete the myriad tasks required of I see it in her eyes. doctors, and there is precious little left I feel her terror over. We have come to wait patiently her aloneness for the laboratory to tell us what is im- her grief. portant. When radiographic images are Her daughter cries viewed anywhere in the hospital within as she lies in vomit minutes of the procedure and lab results in the bathroom are copied from the LCD screen to the fallen off the progress note, discussion of advanced toilet. molecular techniques that result in the reclassification of a bacterium or how Out of dignity new diagnostic tests can be faster and she dies. more precise than standard techniques Rachel A. Davis, MD seems inefficient and possibly indul- gent. Time spent discussing the nuances Dr. Davis (AΩA, University of Colorado, of microbial resistance is pleasurable !""#) is a psychiatrist in private practice but does not necessarily lead to direct and attending psychiatrist in Psychiatric changes in patient care. Learning why Emergency Services at Denver Health Medical Center. Her address is: $%#$ E. #th Avenue, cocci are round and rods are usually but Suite !"", Denver, Colorado $"!&". E-mail: not always sausage-shaped and why we [email protected]. are covered with thousands of species of Illustration by Laura Aitken. microbes very few of which have even been grown in a laboratory—well, when do we find the time for that? Perhaps the new discoveries in the human mi- crobiome that are getting traction in real-world medical problems will spark a renewed interest in our microbial friends and nemeses. I know how and why lab rounds died, but I am not too worried about microbiology—it has plenty of life left in it.

The author’s address is Temple University School of Medicine 3401 N. Broad Street Philadelphia, Pennsylvania 19140 E-mail: [email protected]

34 The Pharos/Autumn 2013 The Pharos/Autumn 2013 35 Richard L. Byyny, MD, opening remarks.

2013 Alpha Omega Alpha Professionalism Meeting

n July  and , , Alpha Omega Alpha, with support from a President’s Grant from the Josiah Macy Jr. OFoundation, sponsored a meeting in New York City on medical professionalism. The host of the meeting for Alpha Omega Alpha was Richard L. Byyny, MD, Executive Director of the society. The focus of the meeting on July  was Use of Systems to Enhance Professionalism. July  centered on Best Practices for the Remediation of Lapses in Professionalism. Moderating the meeting were: • Douglas S. Paauw, MD, Professor of Medicine, Rathmann Family Foundation Endowed Chair for Patient-Centered Clinical Education, and Head of the Section of General Internal Medicine, University of Washington School of Medicine • Maxine Papadakis, MD, Professor of Medicine and Associate Dean for Student Affairs, University of California, San Francisco, School of Medicine Presenting were: • Catherine Lucey, MD, Vice Dean for Education, University of California, San Francisco, School of Medicine, “st Century Professionalism: New Thinking about an Old George E. Thibault, MD Topic”

36 The Pharos/Autumn 2013 Deborah Ziring, MD

• Rebecca Saavedra, MD, Vice President for Strategic “How Do Medical Schools Identify and Remediate Students Management, University of Texas Medical Branch, with Professionalism Lapses?” “Interprofessional Systems to Enhance Professionalism” Other attendees: Gerald B. Hickson, MD, Joseph C. Ross Chair of Medical • C. Bruce Alexander, MD, Professor and Vice Chair, Education and Administration, Professor of Pediatrics, and and Residency Program Director, Department of Pathology, Associate Professor of Family and Health Systems Nursing, University of Alabama School of Medicine; President, AΩA Vanderbilt University School of Medicine, “Pursuing Board of Directors Professionalism (But Not without a System)” • Carol Aschenbrener, MD, Executive Vice President and • Jo Shapiro, MD, Chief, Division of Otolaryngology in Chief Strategy Officer, Association of American Medical the Department of Surgery and Director of the Center for Colleges Professionalism and Peer Support at Brigham and Women’s • William T. Branch, Jr., MD, Director, Division of General Hospital, “Cultural Transformation in Professionalism” Medicine and Vice Chairman for Primary Care, Emory • Richard M. Frankel, PhD, Professor of Medicine and University School of Medicine Geriatrics, Indiana University School of Medicine, Director • Holly J. Humphrey, MD, MACP, the Ralph W. Gerard of the Mary Margaret Walther Center for Palliative Care Professor in Medicine and Dean for Medical Education at the at the Simon Cancer Center, and Associate Director of the University of Chicago Division of the Biological Sciences, The VA Center of Excellence in Implementing Evidence Based Pritzker School of Medicine. Practice at the Richard L. Roudebush VAMC, “Remediating • Gail Morrison, MD, Professor of Medicine, Vice Dean for Unprofessional Behavior in Medical Students: Each School Education, and Director of the Office of Academic Programs, an Island?” Raymond and Ruth Perelman School of Medicine at the • Anna Chang, MD, Associate Professor of Medicine and University of Pennsylvania Director, Foundations of Patient Care Course, University of • Maria Savoia, MD, Dean of Medical Education, University California, San Francisco, School of Medicine, “Clinical Skills of California, San Diego School of Medicine Remediation: Strategies for Intervention of Professionalism • George E. Thibault, MD, President, Josiah Macy Jr. Lapses” Foundation • Dennis H. Novack, MD, Professor of Medicine and • Geoffrey H. Young, PhD, Senior Director of Student Associate Dean of Medical Education, Drexel University Affairs and Student Programs, Association of American College of Medicine; and Deborah Ziring, MD, Assistant Medical Colleges Professor of Medicine, Drexel University College of Medicine,

The Pharos/Autumn 2013 37 She has become an intruder in my household. Possessed by an intruder of her own, visible only in its invisibility, recognized by all. She prowls in the dark of night preceded by uriniferous scent and clicking teeth. The creaking floor betrays her presence. Looking up, I see her glaring at me. “ Where did you hide my bras . . . I know you hid them.” Frequent vitriolic eruptions and foul language never before heard from a once religious woman. Now incontinent of faculties and functions, to remain ever so. Sadly, loss of tangible reconciliation partners with dark appeal. Dennis F. Devereux, MD

Dr. Devereux (AΩA, Robert Wood Johnson Medical School, "#$%) is a member of Albemarle Surgical Associates in Albemarle, North Carolina. His address is: Albemarle Surgical Associates, "&' Yadkin Street, Albemarle, North Carolina ($&&". E-mail: [email protected].

Illustration by Jim M’Guinness 38The Pharos/Autumn 2013 The Pharos/Date38 Reviews and reflections

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

The book review editors request research, a multidisciplinary commu- Translational Science Laboratory in that books for potential review be nity of scientists “sharing our dreams, Indiana through the development of approved by the editors before the exchanging our inspirations, listening a network of institutional relation- reviews are written. Reader interest intently to our young, and setting out ships and a successful application for and space are always considerations daily in new directions on the journey an NIH Clinical and Translational in this section and unsolicited re- we have chosen.” p194 Science Award (CTSA). The chapter views may be rejected. Contact Dr. It’s an inspiring vision, but hardly on Seattle’s Group Health experi- Bennahum at [email protected]. the state of affairs in today’s cut- ence is another example. Eric Larson, edu and Dr. Coulehan at john.coule- throat world of biomedical research. Christine Tachibana, and Edward [email protected]. Neither sharing dreams nor listen- Wagner recount the development of ing to students ranks high among the the Group Health Research Institute priorities of America’s major research (GHRI) and list a number of its myriad institutions. Yet, the genius of Inui and contributions to translational research. Frankel’s book—subtitled “Creating and One important clinical example of syn- Sustaining Research Communities”—is ergy between Group Health’s clinical to show that a number of such multi- practice and GHRI is the team-based, disciplinary, relationship-based com- patient-centered care model for pa- munities do, in fact, exist and at least tients with chronic illness, which arose some thoughtful scientists consider from the findings of a number of GHRI human relationships to be of funda- studies. mental importance in their research. Other chapters focus more specifi- The editors describe the process of ap- cally on interpersonal process. “The preciative inquiry, during which they Relationship-Centered Care Research conducted open-ended one-on-one Network” by Richard Frankel and col- interviews with twelve researchers of leagues tells the story of the network’s varied backgrounds and specialties, creation and maturation during a asking each individual to tell the story series of informal meetings of eleven of one incident or situation “in which researchers that took place over four you have felt your best as a scientist.” p3 years, mostly at participants’ homes, Enhancing the Professional Most of the book consists of these sto- with the help of an external facilitator. Culture of Academic Health ries, supplemented by each narrator’s Network members attribute much of Science Centers: Creating reflections on his or her institutional the group’s success to this context of and Sustaining Research program and personal experience. freedom from “the ordinary constraints Communities Appreciative inquiry is a technique of ‘doing science’, ” and being able “to Thomas S. Inui (AΩA, Johns Hopkins that locates the energy or spirit of an relate to others personally as well as University, 1988) and Richard M. institution in participants’ stories about professionally.” p138 Frankel, editors their best work experiences; in this “Carrying a Center of Excellence New York, Radcliffe Publishing, 2013 case, investigators and administrators through a Critical Transition in relate stories of professional fulfillment. Leadership” explores interpersonal Reviewed by Jack Coulehan, MD The reported incidents vary widely, but process at a different level, in this case (AΩA, University of Pittsburgh, 1969) they cluster around a small number of an effective collaboration by senior themes: successful mentoring of train- investigators to steer a Department n the final chapter of Enhancing the ees, persevering after initial failure, of Veterans Affairs Health Services Professional Culture of Academic building trusting relationships with Research and Development Center IHealth Science Centers, Richard colleagues, using skills to help others, through an unexpected transition in Frankel and Thomas Inui write, and convening or participating in a leadership. The most significant les- “We are encouraged by the team “who loved to learn together.” p5 son from this process was that “a generosity of spirit that fills Several chapters are devoted to flesh- successful center is built from strong these pages.” p190 They ing out the “multidisciplinary com- relationships.” p183 then conclude the book munity of researchers” concept. For Richard Gunderman’s story is one with their vision of example, in “Breaking out of the Silos of the most engaging in the book. For a new culture for in the Heartland,” Anantha Shekhar nine years Gunderman helped care biomedical describes the creation of a statewide for a young man who suffered from

The Pharos/Autumn 2013 39 Reviews and reflections

severe and progressive neurological Culture of Academic Health Science disease. Many at the hospital criti- Centers are about sharing and dream- cized the team for investing so much ing. Inui and Frankel’s appreciative time and effort prolonging the life of inquiry represents out-of-the-box a patient who was “barely there” and thinking about scientific progress terminally ill. When the young man because it puts a premium on the died, his parents asked Gunderman lived experience of research and takes to make some comments at the fu- community seriously. Their book neral. In reflecting on his own feelings, is the third volume of a series from Gunderman realized that “there is Radcliffe that has the overall title, something precious in a fragile, brittle Culture, Context and Quality in life,” p110 no matter how limited. This Health Sciences Research, Education, realization gave Gunderman a feeling Leadership and Patient Care. If the of immense gratitude, when he “felt at others are similarly enlightened, the [his] best as a scientist.” In the rest of series should be a significant contribu- the chapter, with the help of the Book tion to conceptualizing tomorrow’s of Genesis, Gunderman explores the academic health sciences center. DSM-, as well as a series of horrifying role of dreams in science. Yes, you read mass murders and attacks by mentally correctly: dreams. The author is not Dr. Coulehan is a book review editor for imbalanced individuals has kept psy- referring here to random eye move- The Pharos and a member of its editorial chiatry and the mentally ill in the spot- ments during sleep, but rather to the board. His address is: light. The medical profession and the remembered content of dreams, as Center for Medical Humanities, Com- larger society tend to view psychiatrists well as the generic use of that word passionate Care, and Bioethics and their patients with ambivalence for visions, ideals, and aspirations. Stony Brook University and suspicion. The broad range of con- The chapter’s title is “Cultivating the Stony Brook, New York 11794-8335 ditions that psychiatrists must consider, ‘Research Mind’—Reason, Dreams, E-mail: john.coulehan@stonybrook- the lack of laboratory-based diagnostic Discovery.” Gunderman’s point is that medicine.edu assistance, the shame, stigma, and dis- creative imagination is just as essential crimination associated with a psychiat- to the “research mind” as is reason and Hippocrates Cried: The ric diagnosis and treatment, along with it must be cultivated—not suppressed, Decline of American the micromanagement of practice and as is often the case in academic Psychiatry payments by third parties, challenge environments. psychiatric clinicians and researchers In their epilogue Frankel and Michael Alan Taylor on a day-to-day basis. Inui evoke another dimension of the New York: Oxford 2013 Freud’s explication of the dynamic creative life: sharing one’s dreams. Reviewed by Michael Schwartz, MD unconscious and the principles of They explain that in some Australian psychoanalysis (along with its myriad Aboriginal traditions people gather derivatives) in the early twentieth around the fire each morning to share ippocrates Cried: The Decline of century, coupled with the discovery memories of their dreams to assist American Psychiatry by Michael and development of modern psycho- them in communal decision making. HAlan Taylor, is a trenchant commen- pharmacology in the mid-twentieth “It is thought that the dreams of chil- tary on the current state of American century have been the driving forces in dren are most important . . . [because psychiatry. Dr. Taylor is with the modern psychiatry. Despite advances children] have fresher imagination, University of Michigan, and prior to in neurochemistry, brain imaging, less confusion about the reality of their that he had been the Chairman of the and psychiatric genetics, psychiatrists dreams, and are a more secure source Department of Psychiatry at Chicago remain stymied in their ability to un- of creative thought.” p193 Application Medical School. Dr. Taylor is extremely derstand psychopathology at its most to biomedical research? Imagination, critical of what he considers to be psy- basic level, i.e., at the level of the brain communication, trusting relation- chiatry’s overreaching with regard to mechanisms that are responsible for ships, and willingness to learn from our areas of claimed expertise and conse- psychiatric disorders. students. quent ineffective and unethical meth- Psychiatry’s status and power is seen It is remarkable that the final ods of practice. as suspect because of its shaky scien- thoughts of Enhancing the Professional In the past year, the publication of tific underpinnings and this has opened

40 The Pharos/Autumn 2013 the door to a cottage industry of critics psychiatrists interested in less “severe” conditions. Besides being great cases to of psychiatry and psychiatrists. Some (i.e., neurotic) conditions. Although learn from, they remind us that it is all critics espouse radical change while many of these conditions are now too easy to become intellectually lazy others see the necessity for incremental understood to be the result of neuro- in the day-to-day practice of psychiatry change. The best known contemporary logically based differences in tempera- and fail to consider medical and neuro- critic espousing radical change was ment, influenced and shaped by critical logical conditions as part of the differ- the late Thomas Szasz, who was of the experiences during development, and ential diagnosis of patients who do not opinion that mental illness is a myth, ultimately manifested as maladaptive respond as expected. and that psychiatrists do not concern personality traits, Taylor believes that Dr. Taylor is a little more on target themselves with true illnesses; rather, these conditions have no place in mod- with his criticisms of the embrace of they deal with personal, social, and ern psychiatric practice. Moreover, he newer psychopharmacological agents. ethical problems in living. condemns the gold standard treatment He contends that the newer medica- More conservative, politically en- for these conditions, psychoanalysis, as tions have not delivered on the promise trenched psychiatrists have tended to completely ineffective. of either being more efficacious or worry about the erosion of psychiatric Taylor worries that psychiatrists do safer than older medications. In fact, authority and the declining public trust not commonly think about including the older medications may be more ef- in the field. They believe that there neurological conditions, particularly fective. Furthermore the marketing of needs to be some sort of overarching seizure disorders, in their differential these medications as safer than older officially sanctioned scientific paradigm diagnosis. He is angered that the phar- medications has led to widespread us- that guides psychiatry and psychiatrists maceutical industry has had undue age of psychotropic drugs and broaden- in their work; they just disagree on influence on the way that psychiatry is ing of diagnostic categories to the point what that paradigm should be. practiced, effectively promoting expen- of meaninglessness in order to justify Into this fray jumps Dr. Taylor, sive drugs that are not as effective as their use. He sees this process as driven whose philosophy appears to put him older medications. Finally, he accuses by the pharmaceutical industry and in the camp of the radical critics. It is the field of having been seduced by a influential academic psychiatrists who Dr. Taylor’s opinion that psychiatry is research paradigm mentality, while giv- have colluded with them over the years. beset by many problems, including the ing only lip service to the goal of clini- Dr. Taylor asks whether psychiatrists outsize influence of psychoanalytically cal excellence. will still be needed by the end of this oriented psychiatrists and pharmaceu- Many of these criticisms will not century. Already most mental condi- tical companies, a scope of practice too be new to longtime practitioners and tions are treated by nonpsychiatrists who broad to allow the specialty to put its observers of psychiatry. Nevertheless, are viewed by many as less expensive efforts where needed, and diagnostic they demand thoughtful rebuttal. and equally effective. If psychiatry is to laziness and imprecision by its prac- Unfortunately the tone of Dr. Taylor’s survive, he thinks that its salvation lies titioners. Taylor directs his contempt criticism contains a degree of hostility in the embrace of neuropsychiatry, a at psychoanalysis, the modern edi- and contempt for psychiatry and his subspecialty that avoids the fuzziness of tions of the Diagnostic and Statistical fellow psychiatrists that I found off- thinking that he obviously detests. While Manual (DSM), the current practice putting. Successful psychiatrists learn Dr. Taylor is clearly opinionated, he has of psychopharmacology, the influence early on that the key to facing the daily earned the right to these opinions, and of Big Pharma, residency training in challenges of psychiatric practice is to readers who can get past his cantanker- psychiatry, child psychiatry, and even maintain a positive and supportive at- ousness will find much food for thought. the anti-psychiatry movement. Taylor titude, in spite of the many challenges believes that psychiatry should focus that face us and our patients. Dr. Schwartz is Associate Professor of Psy- only on neuropsychiatric syndromes The book is generously sprinkled chiatry and Director of Psychiatry Training that have a clear basis in brain dys- with cases histories of patients who at Stony Brook University School of Medi- function. By this he means classical presented with complaints that proved cine. His address is: neuropsychiatric syndromes associated resistant to standard psychiatric thera- Department of Psychiatry with seizure disorders, brain injuries, pies and who were then referred to HSC Level 10, Rm 20 dementia, delirium, and other condi- the tertiary centers that Dr. Taylor Stony Brook University Medical Center tions like schizophrenia, manic depres- was associated with. When Dr. Taylor Stony Brook, New York 11794 sive illness, melancholia, and certain consulted, he often uncovered a neu- E-mail: michael.schwartz.1@stony- anxiety disorders. He is dismissive of rologically based explanation for these brookmedicine.edu

The Pharos/Autumn 2013 41 Robert H. Moser, MD, MACP 1923 – 2013

AΩA, Georgetown University, 1969 (Summer ), “My Romance with Space” (Autumn ), and “Mene, Mene, Tekel, Upharsin Comes to Medicine— got to know Bob Moser in  when he became the book Redux” (Autumn ). review editor for The Pharos. For the next three years, Bob was not one to sit back and relax in his retire- weI talked on the phone every couple of weeks, discussing ment—one year he volunteered to read and review all the books and reviews and all the things he was doing in his life. essays submitted to the AΩA Student Essay Competition. He told me about his spinal stenosis and the high-tech sur- He raced through the more than fifty essays and wrote de- gery he had for it, his bike accident (this in his s), his wife tailed reviews for each. From that year until this, he contin- Linda’s cat rescue operations, the sale of his home in New ued to read and review them all in a marathon session each Mexico, his travels, his son’s death. February and March. Bob was interested in almost everything and everyone. After Bob retired as the book review editor we kept in He wanted to know all about the AΩA office, my cats, The touch and he stayed involved in The Pharos, writing reviews, Pharos, and my childhood in Hawaii, where he had also letters, and commentaries. In June the word came: pancreatic lived and worked. Bob was witty, opinionated, and fun. As cancer. When I asked him if he would like to write one last we continued our chats, it gradually dawned on me that he article for The Pharos, a final laying-down-of-the-law for the had had quite a life: service and decorations in the Korean profession, he said he was too tired. I knew the end must be War, medical flight controller for the NASA Mercury and near. Apollo programs, chief of Medicine at Walter Reed, editor- Bob died in hospice care in early August. I miss him in-chief of JAMA, executive vice president of the American dearly, but I know that the profession of medicine is richer College of Physicians. More of his background emerged in for his life. the articles he wrote for The Pharos: “Mene, Mene, Tekel, Debbie Lancaster Upharsin Comes to Medicine” (Fall ), “The Korean Managing Editor, The Pharos Experience: Vignettes from Cloister to Chaos and Back”

42 The Pharos/Autumn 2013 2013 Visiting Professorships

eginning in , Alpha Omega Alpha’s board of directors University of Chicago Division of the Biological Sciences The Pritzker School of Medicine Boffered every chapter and association the opportunity to David Ansell, MD, MPH, Rush Medical College of Rush host a visiting professor. Sixty-seven chapters took advantage University Medical Center of the opportunity during the / academic year to INDIANA invite eminent persons in American medicine to share their Indiana University School of Medicine varied perspectives on medicine and its practice. Richard Lofgren, MD, MPH, FACP, Indiana University School of Following are the participating chapters and their visitors. Medicine IOWA ALABAMA University of Iowa Roy J. and Lucille A. Carver College of Medicine University of Alabama School of Medicine David Bloom, MD, University of Michigan Medical School James Madara, MD, University of Chicago Division of the KANSAS Biological Sciences The Pritzker School of Medicine and the University of Kansas School of Medicine American Medical Association Gerald Kerby, MD, MACP, University of Kansas School of ARIZONA Medicine University of Arizona College of Medicine LOUISIANA David Alan Fox, MD, University of Michigan Medical School Louisiana State University School of Medicine in New Orleans ARKANSAS C. Bruce Alexander, MD, University of Alabama School of University of Arkansas for Medical Sciences College of Medicine Medicine and President, AΩA Board of Directors Wesley Burks, MD, University of North Carolina Children’s Louisiana State University School of Medicine in Shreveport Hospital Ruth Parker, BS, MD, Emory University School of Medicine CALIFORNIA Tulane University School of Medicine Loma Linda University School of Medicine Stephen Katz, MD, National Institutes of Health Timothy Brigham, MD, Association of American Medical MARYLAND Colleges Johns Hopkins University School of Medicine University of California, Davis, School of Medicine Daniel Sulmasy MD, PhD, University of Chicago Division of Anthony Iton, MD, JD, MPH Biological Sciences The Pritzker School of Medicine DISTRICT OF COLUMBIA Uniformed Services University of the Health Sciences F. Edward George Washington University School of Medicine and Health Hébert School of Medicine Sciences Colonel Todd Rasmussen, MD, Uniformed Services University of Mitchell Krucoff, MD, Duke University School of Medicine the Health Sciences F. Edward Hébert School of Medicine University of Maryland School of Medicine FLORIDA Florida State University College of Medicine Fitzhugh Mullan, MD, George Washington University School of Medicine and Health Sciences Steven Kanter, MD, University of Pittsburgh School of Medicine University of Florida College of Medicine MASSACHUSETTS Richard Gunderman, MD, PhD, Indiana University School of Boston University School of Medicine Medicine and AΩA Board of Directors Richard Gunderman, MD, PhD, Indiana University School of University of Miami Leonard M. Miller School of Medicine Medicine and AΩA Board of Directors Faith Fitzgerald, MD, University of California, Davis, School of Tufts University School of Medicine Medicine T. R. Reid USF Health Morsani College of Medicine MICHIGAN Douglas Barrett, MD, University of Florida College of Medicine Michigan State University College of Human Medicine GEORGIA John Penner, MD, Michigan State University College of Human Medical College of Georgia at Georgia Regents University Medicine Joseph Stubbs, MD, Albany Internal Medicine and AΩA Board of University of Michigan Medical School Directors Ben Carson, MD, Johns Hopkins University School of Medicine Mercer University School of Medicine Wayne State University School of Medicine Randolph Canterbury, MD, University of Virginia School of Richard Gunderman, MD, PhD, Indiana University School of Medicine Medicine and AΩA Board of Directors Morehouse School of Medicine MINNESOTA Erich Jarvis, PhD, Duke University School of Medicine University of Minnesota Medical School ILLINOIS Robert Baron, MD, MS, University of California, San Francisco, Chicago Medical School at Rosalind Franklin University of Medicine School of Medicine & Science MISSISSIPPI Kevin Weiss, MD, MPH, Accreditation Council for Graduate University of Mississippi School of Medicine Medical Education Gene Hoyme, MD, Sanford School of Medicine of the University Loyola University Chicago Stritch School of Medicine of South Dakota Hope Haefner, MD, University of Michigan Medical School

The Pharos/Autumn 2013 43 2013 Visiting Professorships

MISSOURI PENNSYLVANIA Saint Louis University School of Medicine Jefferson Medical College of Thomas Jefferson University Stefan Friedrichsdorf, MD, University of Minnesota Medical Steven Larson, MD, Hospital of the University of Pennsylvania School Pennsylvania State University College of Medicine University of Missouri—Kansas City School of Medicine Richard Gunderman, MD, PhD, Indiana University School of Judith Bowen, MD, Portland Veteran’s Affairs Medical Center Medicine and AΩA Board of Directors NEBRASKA Temple University School of Medicine University of Nebraska College of Medicine Paul Farmer, MD, Harvard College and Harvard Medical School Samuel Benson, MD, PhD, Registry of Physician Specialists PUERTO RICO NEVADA Ponce School of Medicine and Health Sciences University of Nevada School of Medicine Ana Puga, MD, Ponce School of Medicine and Health Sciences John Pelley, PhD, Texas Tech University Health Sciences Center Universidad Central del Caribe School of Medicine School of Medicine John Prescott, MD, Association of American Medical Colleges NEW JERSEY University of Puerto Rico School of Medicine Rutgers, Robert Wood Johnson Medical School Chaim Colen, MD, PhD, Oakland University William Beaumont Norman Edelman, MD, Stony Brook University School of School of Medicine Medicine SOUTH CAROLINA NEW MEXICO Medical University of South Carolina College of Medicine University of New Mexico School of Medicine Paul Goepfert, MD, University of Alabama School of Medicine David Grimes, MD, University of North Carolina at Chapel Hill University of South Carolina School of Medicine School of Medicine John Prescott, MD, Association of American Medical Colleges NEW YORK SOUTH DAKOTA Albany Medical College Sanford School of Medicine The University of South Dakota Kimberly Davis, MD, MBA, FACS, Yale University School of Keith Lillemoe, MD, Massachusetts General Hospital and Medicine Harvard Medical School Columbia University College of Physicians and Surgeons TENNESSEE Daniel Lowenstein, MD, University of California, San Francisco, University of Tennessee Health Science Center College of Medicine School of Medicine Layton Rikkers, MD, University of Wisconsin School of Medicine Icahn School of Medicine at Mount Sinai and Public Health Karen DeSalvo, MD, MPH, MSc, Tulane University School of Vanderbilt University School of Medicine Medicine Martin Kohn, MD, Massachusetts Institute of Technology New York Medical College TEXAS Joseph Fins, MD, Weill Cormell Medical College University of Texas Medical Branch School of Medicine State University of New York Downstate Medical Center College of Ronald Rapini, MD, University of Texas Medical School at Medicine Houston Robert Nussenblatt, MD, MPH, National Institutes of Health/ University of Texas Medical School at Houston National Eye Institute Thomas Force, MD, Temple University School of Medicine State University of New York Upstate Medical University VERMONT Patrick Basile, MD, LCDR, MC, USN, Walter Reed National University of Vermont College of Medicine Military Medical Center Richard Gunderman, MD, PhD Indiana University School of University of Rochester School of Medicine and Dentistry Medicine and AΩA Board of Directors Holly Atkinson, MD, Icahn School of Medicine at Mount Sinai VIRGINIA NORTH CAROLINA University of Virginia School of Medicine Wake Forest School of Medicine of Wake Forest Baptist Medical Aaron Vinik, MD, PhD, Eastern Virginia Medical School Center Virginia Commonwealth University School of Medicine John Tarpley, MD, Vanderbilt University School of Medicine Doris Trauner, MD, University of California, San Diego, School OHIO of Medicine Case Western Reserve University School of Medicine WEST VIRGINIA Richard Gunderman, MD, PhD, Indiana University School of Marshall University Joan C. Edwards School of Medicine Medicine and AΩA Board of Directors Jeanette Norden, BA, PhD, Vanderbilt University School of Northeast Ohio Medical University Medicine John Pelley, PhD, Texas Tech University Health Sciences Center West Virginia University School of Medicine School of Medicine Catherine DeAngelis, MD, MPH, Johns Hopkins University Ohio State University College of Medicine School of Medicine Richard Schwartzstein, MD, Harvard Medical School

44 The Pharos/Autumn 2013 2013 Administrative Recognition Awards

his award recognizes the AΩA chapter administrators who are so important to the functioning of the chapter or association.T The nomination is made by the councilor or other officer of the chapter. A gift check is awarded to the individual, as well as a framed Certificate of Appreciation. The following awards were made in /:

CALIFORNIA University of California, Davis, School of Medicine Lao Thao INDIANA Indiana University School of Medicine Ruth Patterson MICHIGAN University of Michigan Medical School Charlotte Pierson NEBRASKA University of Nebraska College of Medicine Vicki Hamm TEXAS Texas Tech University Health Sciences Center School of Medicine Charlotte Pierson flanked by AΩA President Hasan Siddiqi and Kim Johnson AΩA Vice-President Megan Beems.

Lao Thao, Kim Johnson , Vicki Hamm, and Ruth Patterson.

The Pharos/Autumn 2013 45 2013 Volunteer Clinical Faculty Awards

NEBRASKA he Alpha Omega Alpha Volunteer Clinical Faculty Award University of Nebraska College of Medicine is presented annually by local chapters or associations to Jerry Seiler, MD T NEW JERSEY recognize community physicians who have contributed with University of Medicine and Dentistry of New Jersey—New Jersey Medical distinction to the education and training of medical students. School AΩA provides a permanent plaque for each chapter’s dean’s Ravi Munver, MD office; a plate with the name of each year’s honoree may be NEW YORK Icahn School of Medicine at Mount Sinai added each year that the award is given. Honorees receive Gaines Mimms, MD framed certificates and engraved key rings. The recipients of New York Medical College this award in the / academic year are listed below. Benjamin Dodoo, MD New York University School of Medicine CALIFORNIA Paula Prezioso, MD University of California, Davis, School of Medicine State University of New York Downstate Medical Center College of James Wiedeman, MD Medicine Pierre G. Zalzal, MD DISTRICT OF COLUMBIA George Washington University School of Medicine and Health Sciences State University of New York Upstate Medical University Hrant Semerjian, MD George Stanley, MD Howard University College of Medicine University of Rochester School of Medicine and Dentistry Juanita Archer, MD Daniel Yawman, MD Weill Cornell Medical College GEORGIA Morton Bogdonoff, MD Medical College of Georgia at Georgia Regents University Timothy Kinsey, MD NORTH DAKOTA University of North Dakota School of Medicine and Health Sciences HAWAII Rhonda Schafer McLean, MD University of Hawaii, John A. Burns School of Medicine David Waters, MD OHIO Ohio State University College of Medicine ILLINOIS John O’Handley, MD Chicago Medical School at Rosalind Franklin University of Medicine & Science University of Cincinnati College of Medicine Gail Bryant, MD Marianna Vardaka, MD University of Chicago Division of the Biological Sciences The Pritzker PENNSYLVANIA School of Medicine Drexel University College of Medicine Michael Hughey, Jr., MD Bruce Fisher, MD, FACP, FIDSA INDIANA Jefferson Medical College of Thomas Jefferson University Indiana University School of Medicine Gerald Fendrick, MD Chad Davis, MD University of Pittsburgh School of Medicine William Lamb, Jr., MD IOWA University of Iowa Roy J. and Lucille A. Carver College of Medicine SOUTH CAROLINA Shawn Jones, MD University of South Carolina School of Medicine Michelle Tucker, MD KANSAS University of Kansas School of Medicine TENNESSEE Greg Thomas, MD Vanderbilt University School of Medicine Bradley Bullock, MD KENTUCKY University of Louisville School of Medicine TEXAS Jon Miller, MD University of Texas Southwestern Medical Center at Dallas Southwestern Medical School LOUISIANA Bruce Faust, MD Tulane University School of Medicine Raj Warrier, MD VERMONT University of Vermont College of Medicine MARYLAND Francis Cook, MD Johns Hopkins University School of Medicine Catherine Parrish, MD VIRGINIA University of Maryland School of Medicine Virginia Commonwealth University School of Medicine Julio Menocal, MD Kara Somers, MD, FAAP MICHIGAN WEST VIRGINIA University of Michigan Medical School West Virginia University School of Medicine Etienne Dehoorne, MD Charles Bradley Franz, MD

46 The Pharos/Autumn 2013 On Finding a Slim Volume

(For John Conger, PhD)

I’ve done it again, John, failing to pay attention to what seemed a side issue. Who knew the Dean wrote poetry, And if he did— while managing a medical campus— how important it might be? I found out . . . too late, that you were a close observer of the silence of snow, a lover of the sudden red, who could discover the shape of your life laid bare. I imagine the conversations we might have had, Forgive me. Henry N. Claman, MD

Dr. Claman (AΩA, University of Colorado, !"#") is Distinguished Professor of Medicine and Associate Director of the Medical Humanities Program at the University of Colorado, Denver. He is a member of the editorial board of The Pharos. His address: Mail Stop B!$%, Research &, !&#'' E. !"th Avenue, Room !'!'', Aurora, Colorado (''%). E-mail: henry.claman@ ucdenver.edu. 2013 Postgraduate Award winners

Peter Stanich, MD (AΩA, University of Toledo, ) n , the board of directors of Alpha Omega Alpha estab- The Ohio State University College of Medicine lished the Postgraduate Award to encourage and support Project category: Research AIΩA residents or fellows from programs or institutions with Video capsule endoscopy completion and association with physical activity Marty M. Meyer, MD, mentor an active AΩA chapter or association to pursue a project in Talia Swartz, MD (AΩA, Mount Sinai, ) the spirit of the AΩA mission statement. Project applications Icahn School of Medicine at Mount Sinai were accepted in the categories of: Project category: Research HIV infection and inflammasome activation . Research: Support for clinical investigation, basic labora- Benjamin Chen, MD, mentor tory research, epidemiology, or social science/health services Kija Weldon, MD (AΩA, University of Iowa, ) research. University of Iowa Roy J. and Lucille A. Carver College of Medicine Research category: Research . Service: Local or international service work, focusing Late-Life Cognitive Outcomes in Schizophrenia: Does Treatment with on underprivileged or immigrant populations or those in the Antipsychotic Medicines Protect from Alzheimer’s Disease developing world, as well as patient and population education Susan Schultz, MD, mentor projects. . Teaching and education: Research, development, or implementation of education academic curricula, with the focus on postgraduate education. Are you a multi-AΩA . Leadership: Leadership development. family? . Humanism and professionalism: Projects designed to encourage understanding, development, and retention of Executive Director Richard Byyny and his son traits of humanism and professionalism among physicians, Richard are both AΩA members. How many AΩA directed to physicians in postgraduate training. members are in your family? Send us an e-mail at Nine applicants received  awards to support their [email protected]. List all the AΩA work. The recipients of the  awards are: members in your family and include the names of the schools at which they received their memberships and N. Teresa Bleakly, MD (AΩA, University of Washington, ) the years of induction. Include a photo if you have one. Stanford University School of Medicine Project category: Research We’ll be publishing a list on our web site and in a future Cardiac function in malnourished children: an observational study in an issue of The Pharos. urban hospital in Bangladesh Yvonne Maldonado, MD, mentor Christine Dinh, MD (AΩA, University of Miami, ) University of Miami Leonard M. Miller School of Medicine Project category: Research Effects of dexamethasone on cisplatin ototoxicity in vitro Thomas Van De Water, PhD, mentor Adam Gepner, MD (AΩA, University of Wisconsin, ) University of Wisconsin School of Medicine and Public Health Project category: Research Ultrasound Assessment of Carotid Arterial Stiffness with Speckle Tracking: A New Use of a Novel Imaging Technique for Predicting Cardiovascular Disease Risk James H. Stein, MD, mentor Rachel Issaka, MD (AΩA, Northwestern University, ) Northwestern University The Feinberg School of Medicine Project category: Service Developing and implementing a community based program to increase colorectal cancer screening Rajesh Keswani, MD, mentor Brenessa Lindeman, MD (AΩA, Vanderbilt University, ) Johns Hopkins University School of Medicine Project category: Teaching and education Cognitive Task Analysis to Identify and Assess Development of Competency in Decision-Making and Error Avoidance in Surgical Trainees Pamela Lipsett, MD, MHPE, mentor Victoria Mui, MD (AΩA, Jefferson Medical College, ) George Washington University School of Medicine and Health Sciences Project category: Service Implementation of a Teaching Program for Midwives in Rural Guatemala and Its Impact on Postgraduate Global Health Education Dr. Richard Byyny ( , University of Southern Amr Madkour, MD, mentor AΩA California, 2000) and Executive Director Richard L. Byyny (AΩA, University of Southern California, 1964).

48 The Pharos/Autumn 2013 Habeas Corpus

In this city of lawyers he finds himself held without charge, a prisoner of a totalitarian state of debilitating and unexplained signs and symptoms. I don’t know how much longer I can hold on, he confides at our initial meeting from the confines of his chair, solitary through illness, an aide standing by the door. Part of the torture comes from not having a name for this. And so, wearing my white coat like a barrister’s white wig I begin to assemble his case for scientific review—subpoena outside records, consult with colleagues, perform warranted searches of his body and his blood, translate his deposition of pertinent positives and pertinent negatives into a differential— all the while aware his day of justice may never come. Adam Possner, MD

Dr. Possner (AΩA, University of Michigan, !""#) is assistant professor in General Internal Medicine at Medical Faculty Associates, George Washington University. His address is: Medical Faculty Associates, George Washington University, !$%" Pennsylvania Avenue, NW, Suite %-&$# North, Washington, DC !""'(. E-mail: [email protected]. edu. A proud

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

Alpha Omega Alpha neckties, $45, or freestyle bowties, $38, are fashioned from ﬁne silk by Vineyard Vines of Martha’s Vineyard, Massachusetts.

Scarves are 35 x 35 inches, of 12 m/m silk twill with handrolled hems. Four colorways are available as shown: red/black, turquoise/ purple, peach/mint, and navy/lavender, $65 each. Scarf design by J&J Designs of San Francisco (jnjdesigns.biz). To order, send a check for the appropriate amount to: Alpha Omega Alpha, 525 Middleﬁeld Road, Suite 130, Menlo Park, CA 94025. Or order online at www.alphaomegaalpha.org/store. Price includes shipping and handling.