Professional Documents
Culture Documents
P H A R O S
OF ALPHA OMEGA ALPHA HONOR MEDICAL SOCIETY Winter 2009
T H E
P H A R O S
of Alpha Omega Alpha honor medical society Winter 2009
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Alpha Omega Alpha Honor Medical Society “Worthy to Serve the Suffering”
Founded by William W. Root in 1902
Robert G. Atnip, MD
Editorial Board Hersey, Pennsylvania
N. Joseph Espat, MD
Jeremiah A. Barondess, MD Lawrence L. Faltz, MD Eric Pfeiffer, MD Providence, Rhode Island
New York, New York Sleepy Hollow, New York Tampa, Florida
David A. Bennahum, MD Faith T. Fitzgerald, MD Richard C. Reynolds, MD Ruth-Marie Fincher, MD
Albuquerque, New Mexico Sacramento, California Gainesville, Florida Augusta, Georgia
John A. Benson, Jr., MD Daniel Foster, MD William M. Rogoway, MD Douglas S. Paauw, MD
Omaha, Nebraska Dallas, Texas Stanford, California
Seattle, Washington
Gert H. Brieger, MD James G. Gamble, MD, PhD Shaun V. Ruddy, MD
Baltimore, Maryland Stanford, California Richmond, Virginia Don W. Powell, MD
Richard Bronson, MD Dean G. Gianakos, MD Bonnie Salomon, MD Galveston, Texas
Stony Brook, New York Lynchburg, Virginia Deerfield, Illinois
John C.M. Brust, MD Jean D. Gray, MD John S. Sergent, MD Joseph W. Stubbs, MD
New York, New York Halifax, Nova Scotia Nashville, Tennessee Albany, Georgia
Charles S. Bryan, MD David B. Hellmann, MD Audrey Shafer, MD
Stanford, California Medical Organization Director
Columbia, South Carolina Baltimore, MD
Robert A. Chase, MD Marjorie S. Sirridge, MD John Tooker, MD, MBA
Pascal James Imperato, MD
Stanford, California, and Kansas City, Missouri
Brooklyn, New York American College of Physicians
Jaffrey, New Hampshire Clement B. Sledge, MD
Elizabeth B. Lamont, MD
Henry M. Claman, MD Chicago, Illinois
Marblehead, Massachussetts Councilor Directors
Denver, Colorado Jan van Eys, Ph.D., MD
Kenneth M. Ludmerer, MD Nashville, Tennessee Eric P. Gall, MD, MACP, MACR
Fredric L. Coe, MD St. Louis, Missouri
Chicago, Illinois Abraham Verghese, MD, DSc Chicago Medical School at Rosalind
James B.D. Mark, MD (Hon.) Franklin University of Medicine
Jack Coulehan, MD Stanford, California Stanford, California and Science
Stony Brook, New York J.Joseph Marr , MD Steven A. Wartman, MD, PhD Chicago, Illinois
Ralph Crawshaw, MD Broomfield, Colorado Washington, DC
Portland, Oregon Stephen J. McPhee, MD Amy Goldberg, MD
Gerald Weissmann, MD
Peter E. Dans, MD San Francisco, California New York, New York Temple University School of Medicine
Baltimore, Maryland Robert H. Moser, MD David Watts, MD Philadelphia, Pennsylvania
Scott K. Epstein, MD Madera Reserve, Arizona Mill Valley, California
Boston, Massachussetts Edmund D. Pellegrino, MD Anne Mancino, MD
Washington, DC University of Arkansas School of Medicine
Little Rock, Arkansas
Student Directors
Natalia Berry
Dartmouth Medical School
Manuscripts being prepared for The Pharos should be typed double-spaced, submitted in triplicate, and conform to the format
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Suite 130, Menlo Park, California 94025.
Cason Pierce
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University of Texas Southwestern Medical
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Editorial
The dreaded burnout
Da
Two words: poverty and depression. They are personal What causes the despair that can lead to full depression
disasters. Poverty is easier to recognize and treat than is de- and suicidal ideation or suicide among medical students? One
pression. Recall the agonizing account of George Hurstwood study published in the Annals of Internal Medicine in
in Theodore Dreiser’s novel, Sister Carrie, whose descent by Liselotte Dyrbe and her colleagues attempts to relate the
from manager to tramp defines poverty with incisive detail. prevalence of suicidal ideation in medical students and its re-
Alleviating poverty usually entails providing resources, such lationship to burnout, demographic characteristics, and qual-
as money. Depression, in contrast, is a black hole separating ity of life.2 Using the evidence that suicidal ideation is a direct
one from life. John le Carré, in A Most Wanted Man, describes precursor of a suicide attempt, they found a direct relationship
the feelings of a man standing in the Ernst Barlach museum, between suicidality and burnout, and a strong dose-response
viewing sculptures of mythic figures not easy to view: “each relationship between burnout and suicidal ideation during the
figure was as alone as he was, and . . . each was communicat- subsequent year.
ing something; but nobody was listening, each was searching But what is “burnout”? The investigators defined the do-
for a solace that was not available.” That is depression. mains of burnout as:
Do you remember your years as a medical student? Oh sure, t FNPUJPOBMFYIBVTUJPO
there was stress—the oral exam in biochemistry, falling asleep t EFQFSTPOBMJ[BUJPO
trying to really understand renal clearance, suffering the arro- t MPXTFOTFPGQFSTPOBMBDDPNQMJTINFOU
gance of residents. But balancing and trumping those traumatic Within the group of students meeting the criteria for
times were the camaraderie of your classmates, the pizza and burnout, twenty-seven percent were no longer burned out at
beer that appeared late Friday afternoons, and the glimmering one year follow-up. They had recovered! This group of “recov-
crescendo of certainty that when these trials were behind you, ereds” were less likely than students with “chronic burnout”
a career in the most respected of professions would be yours. to report suicidal ideation in the subsequent year (. versus
There was idealism, too, although cynicism eroded away much .). Burnout among medical students, then, can be revers-
of what you had brought to medical school. ible! The authors make logical recommendations:
Is it not confounding and perplexing, then, to read that . Require medical schools to have systems in place to
among medical students, depression occurs in fifteen to thirty identify currently suicidal students
percent, three times higher than the rate of depression in ei- . Identify students with burnout—those at high risk for
ther the general population or in age-matched peers? What is suicidal ideation
medical education doing wrong? Or does this imply a link of a . Implement “student support and wellness programs [to]
depressive trait to aptitude for science and a caring nature? optimize the learning environment, the organization of clini-
Heather Finlay-Morreale was, as you were, in a bedeviled cal rotations, and the diversity of clinical experiences.” 2p340
but balanced and accepting state of mind before her classmate, Could AΩA chapters help with these interventions? On
Mike, in the first year of medical school, committed suicide. one hand, our students are not equipped to help with therapy
This was not an impulsive act on his part in the midst of a self- of students with suicidal ideation, nor can we expect AΩA to
limited crisis. He chose to die by carbon monoxide inhalation, have a significant impact upon curricular reform. What AΩA
a method that requires step-by-step planning. Ms. Finlay- can do is to organize mentoring programs for fellow students.
Morreale wrote about the impact of his death upon her in Mentoring is contact of one to another that is not teaching,
her essay, “And then there were eight,” for which she received not therapy, not role modeling. It is taking the hand of and
second prize in the AΩA Helen H. Glaser Student Essay guiding someone through the treacherous waters that the
Competition. Her essay was published in the Winter mentor has already navigated successfully. AΩA is the national
issue (pp. –). Her review of the literature found that only honor medical society recognizing scholarly achievement, but
forty-two percent of medical students with suicidal ideation providing service to others can be a greater reward than the
asked for help. Reasons for not seeking help included fears of AΩA key and certificate.
documentation on academic records, of unwanted interven-
tion, and of lack of confidentiality. She found encouragement References
in recent efforts, including a consensus statement published . Center C, Davis M, Detre T, et al. Contronting depression and
in JAMA, to set up systems that recommend specific inter- suicide in physicians: A consensus statement. JAMA ; : .
ventions to reduce physician suicide.1 These steps to cure, . Dyrbe LN, Thomas MR, Massie FS, et al. Burnout and sui-
however, do not address causality. For Heather, the question cidal ideation among U.S. medical students. Ann Int Med ;
remains: Why? Why? Why? : –.
1 Editorial
The dreaded burnout
Edward D. Harris, Jr., MD
4
42 The physician at the
movies
Peter E. Dans, MD
Stagecoach
The Horse Soldiers Be still, my (irregularly) beating heart
AΩA NEWS
14
52 2008 Alpha Omega
Alpha Robert J. Glaser
Distinguished Teacher Page 14
Awards
Page 10
Issue
Illustration of a removal of
a breast tumor by Seishu
Hanaoka from Geka Kihai
(1851) a treatrise by one of
Hanaoka’s students, Keishu
Kamata.
Image courtesy of Wellcome Images, London.
See page 35
Isabella
James Reilly, MD
18 POETRY
9 Extracorporeal Membrane
Oxygenation (ECMO)
Sarah Cross, MD
21 41 Bridge
Radhika Sreeraman
Don K. Nakayama, MD
63 Welcome to AΩA
Daniel V. Schidlow, MD
35 72 Palliatives
Virginia Aronson
00
Inside
Back My Eye Doctor
Cover Jenna Le
0
Back Breaking Good News
Cover Dean Gianakos, MD
Page 35
Page 18
Photo courtesy of the authors.
4 The Pharos/Winter 2009
Judah Folkman, MD
1933–2008
Dr. Nathan is President Emeritus of the Dana-Farber At Ohio State University, Folkman came to the attention
Cancer Institute, Physician-in-Chief Emeritus of Children’s of Dr. Robert M. Zollinger, Sr., a pioneering surgeon who
Hospital in Boston, and the Robert A. Stranahan became his early mentor. That relationship profoundly influ-
Distinguished Professor of Pediatrics and Professor of enced Folkman’s career, further forging his nascent interest
Medicine at Harvard Medical School. His recent book, The in surgery and inspiring him to take his medical education at
Cancer Treatment Revolution, was reviewed in the Summer Harvard, Zollinger’s alma mater. That decision conferred a
2008 issue. huge benefit on Harvard Medical School, Boston Children’s
Dr. Gimbrone is the Ramzi S. Cotran Professor of Hospital, and the entire field of cancer research.
Pathology at Harvard Medical School and the Chairman of
the Department of Pathology and Director of the Center for
Excellence in Vascular Biology at Brigham and Women’s
Hospital in Boston. He was the first postdoctoral fellow in From the dog lab to
the Folkman laboratory at the Children’s Hospital, Boston,
from 1971 to 1972, and remained a lifelong colleague and
medical school
friend of Judah Folkman.
T
he sudden catastrophe that stopped the heart of Folkman was a precocious medical student who im-
Judah Folkman on January , , robbed his fam- mediately caught the eye of Dr. Robert Gross, the master
ily of a loving husband, father, and grandfather, and pediatric surgeon at Children’s Hospital and a man armed
prematurely terminated the career of one of the world’s most with a sure taste for talent. Gross invited him into his dog
productive physician-scientists and leaders in modern aca- surgery laboratory where incredibly daring and creative new
demic medicine. surgical procedures to correct congenital heart defects were
Moses Judah Folkman was indeed a remarkable man. being devised. Folkman thrived in that environment, gradu-
Gifted with a keen intellect, engaging personality, and ated magna cum laude from Harvard Medical School in
genuine humanity, his creativity and energy were seemingly the class of (and was elected to AΩA in the same year),
boundless. Brought up in a highly religious Jewish family, he and went on to become an intern and resident in Surgery at
was a source of intellectual ferment from early childhood. the Massachusetts General Hospital. The surgical service at
Like the elephant child in Kipling’s Just So Stories, Judah MGH was then a fabled place. It was dominated by surgeons
Folkman had “ ’satiable curiosity.” He combined his bound- of the quality of Richard and William Sweet, Oliver Cope,
less determination to find answers to difficult questions with Edward Churchill, Robert Linton, Claude Welch, Arthur
a devotion to the betterment of the human condition. The Allen, Marshall Bartlett, John Burke, and many others. In
result was his early decision to become a physician and sur- that rarified environment, Folkman performed exceptionally
geon. well, but in , after his senior residency, he was forced to
interrupt his training to answer the call to compulsory mili- diseases, and point the way to novel strategies for their treat-
tary service. ment. Intrigued by the apparent abundance of blood vessels
Before he took up his Navy commission, Folkman made he encountered during his attempts at surgical resection of
the smartest decision of his entire life. He proposed to Paula tumors in the operating room, he became fascinated by the
Prial, a Wellesley graduate with a beautiful character, vis- basic question of how tumor blood vessels grow, a problem
age, and voice. Paula was accustomed to the medical life to which he productively devote his creative energies for the
because she was the daughter of a physician in Fall River, rest of his life.
Massachusetts. They were married for less than a month Though Folkman was content with his clinical and re-
before they loaded a small trailer with their possessions and search activities at Boston City Hospital, a seismic event
headed for basic training and then Folkman’s assignment at was about to occur across town at the Children’s Hospital.
the National Naval Medical Center in Bethesda. Robert Gross, Folkman’s medical student mentor, decided
The salutary role of the major military hospitals and the to retire, and an ad hoc committee to select a successor to
National Institutes of Health intramural program in the that giant of pediatric surgery was established. To the aston-
development of modern academic medicine cannot be over- ishment of many, the committee, vociferously urged on by
stated. The Korean and Vietnam wars had many unintended cancer researcher Sidney Farber, selected Judah Folkman.
consequences, most of them very negative, but the “doctor After a six-month special fellowship in pediatric surgery un-
draft” that gave the opportunity for some of the very best der the watchful eye of Dr. C. Everett Koop at the Children’s
young physicians and surgeons to be awarded Public Health Hospital of Philadelphia, Folkman returned to the Boston
Service commissions and work in those excellent and well Children’s Hospital to assume his new leadership position as
equipped institutions provided a level of scientific training its surgeon-in-chief in at the remarkably young age of
that for three decades fostered the careers of a new breed thirty-five.
of physician-scientists. Many of the advances in academic Soon after the wunderkind arrived, those who were
medicine in the United States are owed to that draft. amazed at the selection began to understand its wisdom.
Indeed, Folkman’s posting to the National Naval Folkman was a competent and careful surgeon, but his clini-
Medical Center at Bethesda laid the foundation of his fu- cal forte was differential diagnosis and, above all, teaching.
ture career. There he joined a cadre of like-minded young Crowds of students and residents surrounded him on rounds
physician-scientists and began initial studies of the behavior because he could combine modern biology with clinical
of tumor cells outside of the body, in the novel context of practice in a fashion equaled by none. His choice of descrip-
isolated perfused organs. Along the way, he investigated the tive words was unique. He invented the term “chronophage”
semipermeable characteristics of silastic tubing, an inquiry on one of those rounds to describe administrators and rule
that directly led to an efficient contraceptive device for use in makers who find countless ways to consume the time of
the underdeveloped world. clinical investigators and rob them of the moments they need
with their patients and in the lab. His devotion to patients
and families was exemplary, and his respect for the opinions
Constantly of colleagues palpable. Despite the considerable burden of
his new leadership role, he remained devoted to his mission
imagining, creating, as a physician-scientist and redoubled his research efforts in
coalescing thoughts the laboratory focusing on the phenomenon of tumor blood
vessel growth.
Learning to be a surgeon,
the senior resident, in his cowboy
boots and sea-foam scrubs, tries to explain ECMO
in his Texas Spanish, impatient for the interpreter,
in the neonatal intensive care unit.
Only a few days old, the solid red mound of liver,
had slipped up months ago in the dark.
See, said the surgeon, up in the apex
of the chest, her lung.
I could only see a grey-blue fleck,
like the still wing of the tiniest butterfly.
We push the liver back in place, lash
the diaphragm—would-be mighty muscle
of respiration—shut, and invade artery & vein to
stream oxygen into the blood
ourselves to buy time.
Her chest filled with blood, she is opened
again. Then I am allowed to sew
the wound closed, between two ribs
as soft as green twigs in spring,
perhaps because it was futile,
or perhaps small things heal well.
Sarah Cross, MD
Mark D. Lo, MD
The author (AΩA, University of sounds of an arrhythmia, probably atrial the right place, as it was the only ECG
Vermont College of Medicine, 2005) is fibrillation. available. I explained the problem in the
an instructor in pediatrics at the Duke- “Damn,” I said out loud. Afib isn’t an appropriate medical lingo.
NUS Graduate School of Medicine in immediately fatal disease, but certainly “Palpitations? Shortness of breath
Singapore. is serious, even for younger people. I without syncope? Fill out these forms
had heard enough of these arrhythmias and we’ll see you right away!” she ex-
I
t was barely the end of my clerkship in older patients to recognize that I claimed. Three minutes later I was
year. I had just driven home to visit now needed a hospital visit. I knew having a nurse confirm my irregular
my parents for the weekend during just enough to know that I needed to heartbeat and take my blood pres-
a call-free elective month in medical start with an ECG, and the only place sure, which was dramatically elevated.
school. They were already going to bed, open during the weekend was the lo- “White coat syndrome,” she murmured.
so I said goodnight to them before cal hospital emergency department. I “Happens all the time.” I say that to my
flipping open my laptop to check my wrote my folks a note to tell them I hypertensive patients, too, I thought.
e-mail. would be in the ED, trying to use the And I’m usually the one wearing the
Ka-chung. My heart suddenly ac- most benign language I could think of. white coat.
celerated, like I had just finished a run. Stupidly, I then drove myself to the hos- Ten minutes later, I was wearing a
It didn’t slow down in the next five pital, not realizing how risky that could flimsy hospital gown for the first time
minutes, so I figured it was just some be. I was secretly hoping that I would be in my life. It kept slipping off my shoul-
random adrenaline in my twenty-eight- wrong, that the ED would think I was a ders. I had the ECG leads on, and the
year-old system, or maybe the coffee I paranoid medical student and send me printout confirmed atrial fibrillation.
had just drained. It would be fine after away with a lecture on not adding to “Nice pickup,” said the nurse, but I was
a good night’s sleep. But I couldn’t sleep the burgeoning costs of overcrowded already running through the treatment
more than four hours that night, and EDs. And I was somehow fantasizing options in my head.
I woke with the weird heartbeat still that I only needed an ECG, as my basic I knew I wouldn’t be leaving anytime
there. coverage student health insurance plan soon, and the treatment might be more
I puttered around the house, noticing + emergency room visit = much poorer invasive than I wanted. Coming to the
that I didn’t feel my normal energy level. student. Maybe I could sneak off with ED meant the full workup automati-
No lightheadedness, but my breaths just “the basics.” cally, and I couldn’t get away with my à
were rushed, even at rest. I’m sure it will I had never been to the ED for any- la carte request. Labs were drawn, IVs
go away in a little bit, I told myself as I thing more serious than a sprained were inserted, chest X-rays were taken. I
threw myself into bed. I’m just tired, and ankle. Walking in, I felt slightly embar- was stunned at how painful the IV could
I can sleep this off. After a short nap, rassed as I spoke with the desk clerk. be, jammed against a valve in my vein.
there was no relief from my symptoms. “I don’t think this is emergent or I felt like a sham, as I squirmed in pain
I finally took my quickened pulse, and it anything, but, uh, I was wondering when the nurse tried to flush it. I was
felt “irregularly irregular,” an unwelcome where I could get an ECG this time of ashamed at my reaction to this ubiqui-
indicator of what my problem might be. day. Is there an after-hours clinic (read: tous procedure that I myself had sub-
Closing my eyes, I slipped on my stetho- cheaper)?” jected so many patients to. Suddenly I
scope and heard the confirmatory heart She assured me that I had come to was cognizant of the fact that although
we medical students practiced insert- the hospital. blurred. The last sounds I heard were
ing IVs on each other, we never stayed Cardioversion is the process of pass- the irregular beeping of the C-R moni-
hooked up to them for very long, and no ing a couple hundred joules of energy tor fading away . . .
medicine ever passed through the lines. through the heart, effectively obliter- Zap.
A paper funnel was handed to me. ating any irregular rhythm. It is then
“Urine sample!” chimed a different assumed that the natural pacemaking I awoke and immediately knew I
nurse. I was getting confused between ability of the heart will take over and a was in sinus rhythm. I also immedi-
the different people taking care of me, regular heartbeat will be re-established. ately wished I had just chosen hospital-
each with the greeting “I’m [insert dif- In essence, cardioversion is just like on ization. Since cardioversion, I’ve been
ferent name] and I’ll be your nurse.” TV when the medics break out the pad- cleared of any cardiovascular issues. It
Why didn’t they ask me for the urine dles and yell “Clear!” before delivering is thought that caffeine or the stress of
before I was hooked up to the IV?” I the electric shock to reboot the heart. medical school triggered an episode of
grumbled. Giving the sample with IV Risks include the arrhythmia persist- lone atrial fibrillation. The experience
lines and monitoring wires all tangled ing even after the shock, or the heart of being a patient in the emergency
up, I suddenly appreciated the fact that stopping and not remembering to start room brought home the reality of what
it’s hard to move—much less undo a beating again. The cardiologist wanted we do every day. I was struck again by
zipper—without free hands. to sedate me and do this to me. In my our effect on our patients, and how very
The patient in the bed next to me head, I knew that this was the normal quickly even our own health can change.
began moaning in pain, and I wondered protocol and perfectly safe. In my heart My many years of youthful invincibility
what was wrong with her. Her moans of hearts (pun intended!) I thought this were all taken away in a literal heart-
turned into yelps of pain, and through was nuts. I was now on the wrong end beat, with no warning whatsoever. For
the curtain I could hear her family try- of a code situation. the first time in my life I felt betrayed
ing to comfort her. They could also hear It might have been the first time in by my body, and for months afterwards
what my care providers were telling me my life that I truly had to trust doctors I wondered if every tiny chest pain or
about my newly diagnosed arrhythmia. completely. In the end it came down to tachycardia or quickened breath meant
Being roommates with somebody else my unwillingness to be hospitalized and that something more serious was about
pretty much obliterates any kind of pri- wait longer, with the potential of weeks to occur. I can still live my life happily
vacy, I discovered. of anticoagulation ahead. I made sure in the moment, but in the back of my
Almost two hours went by as I waited that I talked to my loved ones before mind there is a shadow lurking. The
for the cardiologist to come see me. I going under sedation, and even drafted shadow is the uncertainty of health, and
thought about how I always ended up a quick living will. I wanted to clarify understanding the tremendous speed
making patients wait on me as well. The my future medical wishes should I be with which illness may come.
nurses started me on an IV medicine incapacitated, and from the corner of As physicians, we do our best to safe-
in an attempt to convert me back to my eye I thought I saw the cardiologist guard our patients’ health, and to fight
my normal heart rhythm. I lay back on roll his eyes. But if my brief foray into for them when the illness does come.
my pillow, watching the monitor as the medicine taught me anything, it was Atul Gawande writes of the doctor’s
medicine dripped in for an hour, pray- that you never knew how things were profession, “We are for the moment the
ing to see P waves. It didn’t work—I still going to turn out. healthy few who live among the sick.” 1
was in arrhythmia and I could feel it. My eyes widened as they broke the My new insight to the experience of be-
Argh. I knew what was coming next. plastic lock to the code cart. The oxy- ing both healthy and sick has convinced
On cue, the cardiologist came bus- gen mask went on, and they tore open me once again that being a doctor is the
tling in, looking every bit the profes- the silver bag containing the adhesive most meaningful profession I could hope
sional one could hope for. I wondered if paddles. The sticky gel was cold, and I for. As long as we are still healthy few,
I looked like this when I saw patients as felt a slight tingle as they pushed mor- ours is the privilege to help the sick.
a student doctor—with me it was always phine and midazolam. The cardiologist
partly competence and partly me con- switched on the defibrillator. Reference
vincing myself I really was competent. “Hang on, hang on,” I choked out. . Gawande A. Nine Thousand Sur-
We chatted for a few minutes about “I’m still here, I’m still totally awake.” geons. In: Gawande A. Complications: A
my history and presentation, and how More midazolam. Surgeon’s Notes on an Imperfect Science.
the medicine hadn’t worked. He then “Nope, still here, I think I need some, New York: Picador; : –.
told me what I had been expecting, that uh, uh, m-more . . .”
cardioversion was the next option if I My eyelids were closing of their The author’s e-mail address is: mark.lo@
wanted to avoid staying overnight in own accord and the edges of my vision duke-nus.edu.sg
h e dreams of riding
down a canopied highway
on his monster Harley
to the beach the beach
a woman waits for him
with food and drink
the Florida sun
exploding in his head
pelicans diving and diving
and skimmers skimming
Eric Pfeiffer, MD
I
pushed Isabella Montez’s gurney into the operating room “Good morning, Mrs. Montez,” I lead the group as we
at first light. She shivered, “I’m cold.” crowd around her thin hidden form on the hospital bed. Her
“We’ll give you a warm sheet in a minute,” I replied. roommate seems asleep behind the curtain that separates
She sees no reassuring smiles, no bright teeth here; we’re the two patients, but she could easily hear every word. The
all face-covered with paper masks and drug company-logoed two women have talked about their kids, their spouses, their
disease, their fears. They talk about the nurses and, especially, it won’t come back, reassure her that she’ll live. Sometimes I
about their doctors. meet these expectations, but too often I just bring more bad
“May I see your incision?” I ask and begin stripping the news. The tumor has spread, chemotherapy and radiation are
tape and gauze from her abdominal skin. “Looks good. Diet next. And no promises for a future.
as tolerated, staples out on POD , please.” The young sur- Under these circumstances, Isabella and I can’t get too
geons scribble notes. Then I notice. Isabella has put on a face, attached. So we focus on the task, on my craft, the opening,
used some make-up, a bit of blush on her cheeks, and lipstick. probing, taking-out, rearranging, sewing up. But no commit-
She’s back from her trip in Charon’s boat, her visit to Hades. ment to the future, just the here and now.
“The lipstick sign,” I intone. “Usually seen on POD . Ms. Other doctors do commit. The pediatrician expects to
Montez, you’re ahead of schedule. You’ll be just fine.” see a child from birth through adolescence, to be witness to
growth spurts, runny noses and fevers, first day at school,
maybe a broken bone or bad appendix. Internists watch their
Outcome: Back to normal, a lifelong patients for years, to detect the blood pressure or glucose or
scar . . . or worse cholesterol misbehavior, to counsel against those bad choices
we all make and seek absolution for, and to witness and hold
at bay the slow breakdown of form and function we all suffer
Surgeons do terrible things to patients. In a cold harshly-lit as we age. Even an obstetrician gets nine months with his pa-
operating theatre, we render them helpless, unconscious, tients, and a singular joyful new person as a reward.
and mercifully unfeeling. We strip them naked, and cut them Not so for surgeons. Our patients don’t want to get to
open, looking, grasping, moving things about, removing know us. Mostly our failures keep coming back, and they’re
parts, replacing them, putting them back together. We give often angry or sad at the predicament that keeps us together.
them immediate suffering in exchange for a better future, an My patients want nothing more than to hear me say, “You’re
almost religious bargain. And we know there’s no going back. done with surgery for now. Let’s get you back to your doctor.”
Once I start working, Isabella Montez will never be the same. Or to the next specialist in chemotherapy or radiation therapy
She’ll most likely be better, I think, but different, for sure. or rehabilitation. Just not more surgery, or surgeons.
She’ll wear my incision’s scar all her life and, if things don’t
work out the way we both hope for, she’ll take it with her to
a perhaps premature grave. That realization of irreversibility
Introducing a patient to the
haunts every surgeon’s decision. beginning of more living
Surgeons need some protection from this awful real- . . . or death
ity, and our defense mechanisms have to be robust, if not
impenetrable. We erect some walls of separation. We some-
Isabella and her daughter came to my clinic two weeks
times depersonalize our patients, transform them from flesh
after surgery. She admitted to being fatigued, but was eating
and blood people, like us, with parents, loved ones, hopes,
good familiar food, enjoying visits from attentive family mem-
dreams, a future, into a body part, specifically, the one that’s
bers, and described in singular detail her bowel habits. She
acting up, misbehaving, the part that needs dealing with, to
knew I’d want to know. I had some good news.
come out and be done with. The nagging hernia, the stone-
“I have your pathology report. We got the whole tumor,
filled gallbladder, the ulcerated stomach, the inflamed or
and the lymph nodes were all negative. No tumor in the
cancer-burdened colon.
nodes. That’s good news.”
Surgeons experience surgery with shocking intensity.
She began to weep, but then thought better of it, wiped
During an operation, every sense, tactile, auditory, and espe-
her eyes, and murmured, “Thank you, doctor.” Her daughter
cially visual, is acutely energized, laser-focused on the task,
hugged her. Isabella put on her coat, gathered her bag, and
every tissue probed and cut, every bleeding surface, every
left arm in arm with her daughter. They’d be back in a few
structure we disturb, and those we leave be. For days to
months for a check-up.
months after an operation, I can recall the details of the pro-
A few moments later, my resident introduced me to my
cedure with singular clarity, a mental videotape that reruns
next patient, a forty-three-year-old woman with a stone-hard
when I encounter Isabella recovering, and even in my dreams.
breast mass, and a lump in her armpit. “May I examine you?”
This remembrance gives Isabella a new and singular dimen-
I asked. Her eyes filled with tears; she knew I would break her
sion that is our shared secret. No one has seen Isabella as I
heart. I handed her a tissue, and we began to get acquainted.
have, explored her in this frighteningly intimate way. And so,
when I refer to her as “the colectomy,” I’m describing her in a
The author’s address is:
dimension uniquely known between patient and surgeon.
21 E. 87th Street #9A
Isabella, while she’s stripped and vulnerable, lying abed in
New York, New York 10128-0506
pain, nevertheless has high hopes for me. She prays I’ll bring
E-mail: jjreilly@prodigy.net
her good news, tell her that the tumor is gone, promise her
Stagecoach, 1939, directed by John Ford (left), starring John Wayne and
Claire Trevor.
UA/Photofest ©United Artists
the credit. When he expresses dismay that the reporters won’t (The Grapes of Wrath [], How Green Was My Valley [],
print the truth, one replies, “This is the West. When the legend and The Quiet Man []), oddly enough was never honored
becomes the fact, print the legend.” for his quintessential westerns. Nonetheless, his influence is
indelible, no more so than in High Noon.
Stagecoach (1939) This film is noteworthy for being the first Ford film shot on
location in isolated Monument Valley, at the time miles
Starring John Wayne, Claire Trevor, Thomas Mitchell, and
from Flagstaff over rough roads, and for making John Wayne,
John Carradine.
in his eightieth film, a star. Born Marion Michael Morrison,
Directed by John Ford. Not rated. Black and white. Running
Wayne was a pre-law student at USC on a football scholarship,
time 96 minutes.
but when he injured his knee he could not afford to continue.
One needs to get past the hokey scene involving their coming school’s older reverend are pressed into service to delay the
upon a mansion inhabited by a Southern belle named Hannah Union soldiers until Nathan Bedford Forrest’s cavalry can reach
Hunter of Greenbriar (Constance Towers) and her black maid them. To Marlowe’s credit he refuses to fight them and turns
Lukey, played by Althea Gibson, a tennis star between tail and runs, leaving the cadets ecstatic. They recruit Deacon
and who was called the Jackie Robinson of tennis (again Clump (Hank Worden), who was part of the Underground
check out her bio). Although the accents and the dialogue at Railroad, to help them escape from Forrest’s men. Kendall
dinner are cringe-producing, stay with it because there is a nice stays behind to care for the wounded, knowing that he will be
duplicitous twist at the end such that the two women are forced imprisoned. As he says, “Medicine is where you find it, even at
to join the patrol on its march to prevent them from letting the Andersonville.” The latter is one of the film’s anachronisms, in
Confederates know of their presence. Hunter adds some spice to that the prison had not been built in . Still, all in all, this
the movie, as she reinforces the doctor’s dislike for the Colonel. is a picture worthy of putting on your rental list, if only to see
You also have to overlook Hunter being generally all made- a favorable portrayal of a doctor in the era before we got to be
up and well-coiffed except in the field hospital scenes, when “the bad guys.”
Kendall operates without anesthetics and with little laudanum
and copious whiskey. The benefits of a tree moss poultice that Addendum
Kendall learned from a Cheyenne are extolled. According to Wikipedia and other sources, The Horse
After the confrontation at Newton Station, the Colonel is Soldiers is based on the April raid led by Colonel
upset at all the casualties and starts drinking, and reveals to Benjamin Grierson, who, with men, traveled several
Hunter why he has been so harsh on doctors. He says they hundred miles from Northern Mississippi to disrupt the rail-
say, “Medicine is the most noble profession. Banners held on road from Newton Station to Vicksburg. The successful raid,
high—so high they won’t admit they’re groping.” He then tells which prevented troop reinforcements by General John C.
how he trusted the doctors when they told him that his wife Pemberton, was said to have been “remarkably bloodless.”
had a tumor. They operated and found nothing. “They said
they were sorry; they made a mistake. They had something to Dr. Dans (AΩA, Columbia University College of Physicians and
talk about before their next experiment.” Surgeons, 1960) is a member of The Pharos’s editorial board and
Although the mission is accomplished, Marlowe refuses to has been its film critic since 1990. His address is:
retreat and pushes on to Baton Rouge. Along the way they pass 11 Hickory Hill Road
a black church where they are saluted. The cadets at Jefferson Cockeysville, Maryland 21030
Military Academy, none of whom are over sixteen, and the E-mail: pdans@comcast.net
John Ford and John Wayne on the set of The Horse Soldiers, 1959. UA/Photofest ©United Artists
re-imagine the terrible experiences all was kind of like using my high school Henderson’s Equation
humans face better than anything writ- French
Jerome Lowenstein
ten in any medical textbook. I would when I went to Paris.
Gadd & Company Publishers, Great
cite Auden’s “Musée des Beaux Artes” Let me put it this way.
Barrington, Massachusetts, 2008, 304
and Hopkins’s “To a Young Child.” Some doctors would encourage me,
pages
Where can you find a better evocation help me along.
of loss and grief than in these two short I felt they were open to my questions Reviewed by Jay Baruch, MD
poems? because when they used words I didn’t
I
. Most importantly for physicians, understand, must start with a confession: I dreaded
we encounter powerful stories; hear I would say, “Well, what’s that?” acid-base balance in medical school.
amazing things from our patients. We and they would explain. Comprehending the dissociation and
carry those images and stories around Then there were other people movement of ions, the creation of buf-
with us for days. Writing them down who could tell, of course, fers, the arrows darting into and out of
in a journal, or perhaps in a poem, that I didn’t know much and they would blood, kidneys, and lungs led directly and
helps us unburden ourselves, a form be like immediately, I believe, to my hair loss.
of healing. I remember the time a almost insulted that I would even try. Late at night, nauseated from too much
patient, who had once experienced It was as if they were saying, caffeine, jittery with self-doubt, I’d torture
shock therapy for recurrent depression, “Leave that to me. myself even further by considering the
told me, “It took away the memory Leave that kind of talk to me. truth of my predicament. I wasn’t intel-
of my children’s childhood.” I carried You just had swollen ankles. ligent enough to grasp fully the intimate
that statement around for days until I You didn’t have edema. details intuited and refined by Lawrence
thought to write it down. Or the time Let me talk about edema.” J. Henderson. Unlike me, he didn’t need
an eighty-five-year-old woman told That’s the way it was to check the answers at the back of the
me, “I’ve been sinking.” And when I when I used medical language.p98 textbook. I’d get depressed, then I’d eat
responded as if this were a metaphor, a pint of Ben & Jerry’s. Dr. Henderson
she corrected me: “I swim half a mile Sekou Sundiata died in and was known to us only as a surname, a
three times a week, and last Friday Herwaldt dedicates her book to that tag attached to some seminal equations
when I swam, I sank. I couldn’t float brave person who had the courage to that described how the body used buf-
any more” Once we discovered the speak medicalese like someone attempt- fer systems to maintain neutrality with
pleural effusion that had taken away ing high school French in Paris. It is a changing acid concentration in blood.
her buoyancy, we were on the track to fitting tribute in a fine book. Now he appears in the flesh as a central
effective understanding and treatment. character in Dr. Jerome Lowenstein’s
I had to write that one down too. Dr. Platt is a general internist in private novel Henderson’s Equation.
So I heartily recommend this book practice and clinical professor of Medicine I wish I’d had Dr. Lowenstein to
to physicians, would-be- physicians, at the University of Colorado. A leading explain the beauty of Dr. Henderson’s
physicians-in-training, and other clini- authority on communication skills in med- intricate and provocative thoughts.
cians. (That’s a whole lot of us.) I rec- icine, Dr. Platt is the author of Conversa- The specific details by which the body
ommend it because it offers a wealth of tion Failure, Conversation Repair and Field regulates itself and maintains dynamic
unexpected poems to read and savor Guide to the Difficult Patient Interview. His equilibrium through elegant buffering
and because it opens a door for all of address is: systems comes alive in this novel, partly
us, a route into literary unburdening 396 Steele Street because the ideas of “fitness” and the
that will be comforting and joyous. I Denver, Colorado 80206 relationship of the organism to his or her
invite you all, do open that door. If you E-mail: plattf@hotmail.com surroundings, and Henderson’s later ap-
are lucky, you will end up with a piece plication of his physiological principles
like Sekou Sundiata’s story, transmitted to sociological systems, takes on meta-
through Loreen Herwaldt’s abridge- phorical resonance.
ment to: I don’t know how best to categorize
this work: novel, creative nonfiction,
Speaking Their Language memoir? Maybe all three genres were
I didn’t learn medical language recruited to construct a story that feels
only to communicate with doctors. innately personal and intellectually am-
It gave me a sense of power too. bitious. The story centers around Aaron
Using medical language with doctors Weiss, a young Jewish medical student
tory and teaching include leadership following his undergraduate and medi- Distinguished teacher nominees
and bioethics, civil rights, and religion, cal school experience at Harvard, where Murray Altose, MD, Case Western Reserve
which culminated in his being named to he was elected to AΩA in , his University School of Medicine
William Anderson, PhD, University of New
the President’s Council on Bioethics in residency in medicine at the Beth Israel Mexico School of Medicine
. He is the host on “Daniel Foster, Hospital, research training at UCSF, Ronald Arky, MD, Harvard Medical School
MD,” a weekly television series on PBS and chief residency and early faculty David A. Asch, MD, University of
and the BBC. appointments at Stanford University Pennsylvania School of Medicine
Except for two years as a clinical School of Medicine. Chantal Brazeau, MD, UMDNJ-New Jersey
Medical School
associate at the NIH, Dr. Foster has Patrick Carr, MD, University of North
spent his entire life in Texas. He earned Paul L. Rogers, MD Dakota School of Medicine and Health
his MD at UT Southwestern, graduat- Professor, Critical Care Medicine, Sciences
ing first in his class and being elected University of Pittsburgh School of Francis Counselman, MD, Eastern Virginia
to AΩA in , and he stayed on for Medicine Medical School
Craig Wilson Davis, PhD, University of
his residency in Internal Medicine un- Dr. Rogers has seven Golden Apple South Carolina School of Medicine
der the direction of Donald Seldin. He awards for Excellence in Clinical Thomas M. De Fer, MD, Washington
serves on the editorial board of The Education sitting on his desk, and six University in St. Louis School of Medicine
Pharos. awards as the Critical Care Medicine Donna Elliot MD, Keck School of Medicine
Faculty member of the year. Rounding of the University of Southern California
Glen Gabbard, MD, Baylor College of
David W. Nierenberg, MD out these recognitions are the University Medicine
Edward Tulloh Krumm Professor of Pittsburgh Chancellor’s Distinguished Bertha Garcia, MD, University of Western
of Medicine and Pharmacology/ Teaching Award () and the Society Ontario Faculty of Medicine and Dentistry
Toxicology and Senior Associate of Critical Care Medicine Presidential Erika Goldstein, MD, University of
Dean for Medical Education, Citation Award (). His dean calls Washington School of Medicine
Joel A. Gordon, MD, University of Iowa Roy
Dartmouth Medical School him “the most highly regarded educator J. and Lucille A. Carver College of Medicine
Since arriving at Dartmouth on the at our school, both by students and by Jesse B. Hall, MD, University of Chicago
faculty in , Dr. Nierenberg has peers.” Dr. Rogers has been a pioneer Divison of the Biological Sciences Pritzker
been known as an “educational star” in the use of human patient simulation School of Medicine
at DMS. He founded what remains as a teaching modality for medical stu- Thomas S. King, PhD, University of Texas
Medical School at San Antonio
the best course at Dartmouth, Clinical dents. At the University of Pittsburgh, Arno Kumagai, MD, University of Michigan
Pharmacology and Therapeutics, given his innovations set in motion an institu- Medical School
to the entire senior class. In addition to tional decision to embrace high-fidelity Albert Kuperman, PhD, Albert Einstein
a sound foundation in therapeutics, he simulation as an essential education College of Medicine of Yeshiva University
has modeled for students how to be free modality. His excellent curricular devel- Linda Mottow Lippa, MD, University of
California, Irvine, School of Medicine
from influence from the pharmaceutical opments facilitated a decision to require Fred A. Lopez, MD, Louisiana State
industry. Since Dr. Nierenberg has critical care medicine as a component University School of Medicine in New
directed the Scientific Basis of Medicine of the internal medicine clerkship. Dr. Orleans
course correlating organ system physi- Rogers conducts daily teaching sessions Bennett Lorber, MD, Temple University
ology, pathology, and clinical disease. with medical students before leading School of Medicine
Susan Masters, PhD, University of
Recently, he has worked on curricular bedside rounds in the ICU. He has re- California, San Francisco, School of
renewal, the New Directions plan uti- ceived substantial research funding for Medicine
lizing problem-based learning to de- his work in experimental therapeutics Gary D. Plotnick, MD, University of
velop competency-based physicians. His in critical illness. Maryland School of Medicine
longevity as a teacher is reflected by After receiving his BS at Century David A. Rogers, MD, Southern Illinois
University School of Medicine
his having received from the graduat- College and his MD degree at the Monica Shaw, MD, University of Louisville
ing class in the Clinical Sciences University of Arkansas, where he was School of Medicine
Teaching Award, with repeated awards elected to AΩA in , Dr. Rogers Myles Sheehan, MD, Loyola University
in and . In and he was an Internal Medicine resident at Chicago Stritch School of Medicine
was given the Best Educator prize in the the University of Virginia and Critical Jack T. Stern, Jr., MD, Stony Brook
University Medical Center School of
Department of Medicine. Second-year Care fellow at the NIH. He joined the Medicine
students in and voted him University of Pittsburgh faculty in . John Tarpley, MD, Vanderbilt University
their best lecturer, small group leader, School of Medicine
and overall educator. Patricia Thomas, MD, Johns Hopkins
Dr. Nierenberg arrived at Dartmouth University School of Medicine
Re “Wrongful death” and they want to operate on her.” I told was coming to see her. “Okay”—shortly
I read your recent editorial (Summer him I would check on things. When I the husband called our office and can-
, p. ) with the greatest interest: it came back to see him, I told him I had celed the house call. I went anyway and
recalled a score of patients throughout checked things out and she needed knocked on the door, was treated cour-
my nearly fifty-year career as a hema- surgery. He said, “Yes, I want her oper- teously and shown to her bedside.
tologist and oncologist. ated on but I can’t sign for it because I found a young woman lying on
You struck a marvelous balance I’m a Christian Scientist, as you know.” I her side with a contracture of her hip
without being stridently censorious . . . felt a chill go down my spine. Mr. Kyser due to a ruptured appendiceal abcess
and it shined a light on homeopathy then said, “Georgia is not a Christian presenting in her groin. The husband
which celebrates the dictum of “pri- Scientist. She could sign but she’s visit- would carry her to the bathroom. Her
mum non nocere.” ing her mother in California.” Another temp was and she was quite pale.
Thanks for your successful efforts. spinal chill. After relaxing a few sec- She had been bedridden for three
onds, I said, “Do you have her phone weeks.
George H. Porter, MD
number?” We had the hospital phone The husband agreed to hospitaliza-
(AΩA, Duke University, )
operator call the number and got Mrs. tion, and there I got consultation from
President Emeritus, Ochsner Clinic
Kyser. I told her what was necessary, my wonderful surgeon friend, who was
Foundation
she said, “Yes,” as the phone operater a gentle, quiet guy, not threatening in
New Orleans, Louisiana
and another resident listened in. any way. Together we took her to the
I just read your editorial in the Years later, the other daughter de- OR, drained the abcess, and started
recent issue of The Pharos. Do you veloped ovarian cancer, said goodbye antibiotics. Later, she walked out of the
remember the band leader Kay Kyser, to her friends, and went off somewhere hospital.
who had radio shows on NBC in the to die. Some months later I got a letter
s? I have never understood Christian from the patient, thanking me, and
Some time in the mid s he Science. I wish when I was a student at saying that she was wrestling with her
converted to Christian Science to help UNC School of Medicine they had Mr. belief in Christian Science and had not
his “arthritis.” During his active days, Kyser come to a class or Grand Rounds come to a conclusion yet.
he married late to a young singer in and discuss it. So thank you for teaching me what
his band, Georgia Carroll. He moved I didn’t know about the background of
Duncan S. Owen, Jr., MD, FACP
to Chapel Hill in . They had two Mary Baker Eddy and Phineas Parker
(AΩA, Virginia Commonwealth
girls. As a freshman in , I remem- Quimby.
University, )
ber the Kysers rolling the children in a
Richmond, Virginia William W. Johnson, MD
baby carriage. We became friends. My
(AΩA, Northwestern University, )
late physician father had known Mr. My general practice was in Los
Medford, Oregon
Kyser when they were in undergraduate Gatos, California. I had an estimated
school. , patient encounters in forty
I was a medical resident at the hos- years. Medical illiteracy
pital in . One night, when I was One day out of the blue came a The summer issue was superb. Every
on call, I stopped by the ER to see phone call from San Francisco, the pro- article sparkled with elegant writing
what was going on. Mr. Kyser was ducer of an excellent medical TV show. and pertinent new information (to
standing against a wall. I said, I don’t know how he got my name. me). But several of the essays left me
“Mr. Kyser, can I help you “I have a niece who is a Christian with a forlorn sense of angst. In my
with anything? He said, Scientist, who is very ill in your simple-minded view, the historical and
“Duncan, one of my area. Would you see her? She’s only contemporary popularity of alterna-
daughters is sick twenty-eight and can’t get out of bed at tive medicine (CAM is an unfortunate
with appendicitis home.” I phoned the home and said I euphemism) is primarily related to the
on our house staff salaries in . Lou Kent Brooks, MD, a graduate of Maladies des Poumons et du Coeur,”
played an anesthesiologist in an OR the University of Kansas School of published in . Laennec found direct
scene (note it was Lorne who ultimately Medicine, played the role of the inef- auscultation of the thorax to be less
became the anesthesiologist) and fectual Dr. John Spivey in One Flew than ideal under many circumstances.
Lorne, if my memory is correct, had Over the Cuckoo’s Nest. Dr. Brooks Stimulated by his observation of chil-
speaking scenes! Part of my vivid was Superintendent of Oregon State dren playing near the Louvre listening
memory of these details comes from Hospital, where the film was shot, and to the end of a long piece of wood that
envy. You see, both Lou and Loren were he gave co-producer Michael Douglas transmitted the sounds of a pin scratch-
my interns then when I was a first-year access to a vacant ward and the hospital ing, the following day Laennec rolled a
resident (now called an R) and grounds in . Dr. Brooks came under piece of paper into a tube, tied it with a
got the parts and I didn’t. Envy is espe- fire for allowing Cuckoo’s Nest to be string and listened to his patient’s chest.
cially green when others get the green. filmed at Oregon State Hospital and for Being a carpenter, Laennec fashioned
tacitly portraying psychiatric treatment his listening device from wood, con-
Gerald Charles, MD
in a harsh and technically incorrect structing a cylinder centimeters long
(AΩA, University of Colorado, )
light for the time period (for example, and . centimeters in diameter. Thus
University of California, San Francisco
anesthetics and muscle relaxants were the stethoscope was born. Laennec died
The summer issue of The Pharos is in common use in even though the of pulmonary tuberculosis. His nephew,
splendid, from cover to your thought- film shows Jack Nicholson’s character Meriadec, listened to his uncle’s chest
ful and informative film reviews. The receiving ECT without such benefit). and heard the fateful sounds of pulmo-
question of doctors as film actors was In fact, in the wake of a long history of nary tuberculosis. He used his uncle’s
intriguing. documented patient abuses, Oregon stethoscope to make the diagnosis.
Do bit parts count? While I was in State Hospital is being torn down and Laennec returned to Brittany from
my four years of training for Pathology rebuilt. Dr. Brooks, who retired from Paris following the diagnosis, which
(–) at what was then the U.S. practice in , is now ninety-one was a harbinger of certain death at that
Public Health Service Hospital on years old. time. While in Brittany, he wrote his
Staten Island, New York, the head of will, in which he bequeathed his stetho-
Arthur Lazarus, MD, MBA
the OB/Gyn division was a Dr. Robert scope to his nephew.
(AΩA, Temple University School of
B. Dorsen, an excellent obstetrician in Recently I had a routine appoint-
Medicine, )
the old style, who eventually delivered ment with my doctor. A few days later
Chadds Ford, Pennsylvania
three of our six children. Bob delivered I accompanied my wife to a follow-up
our son Douglas () by the normal Regarding physicians who were appointment with her oncologist.
route, despite a forecoming hand, with cast in feature films, I submit Bruce Thankfully both encounters resulted in
no harm to mother or baby. He was Gewertz, who was a year or two behind good news. At each of the two visits the
justifiably proud of avoiding a C-section me at Jefferson. Bruce, a surgical de- patient was examined first by a fellow
by careful maneuvering during the birth partment chairman in Chicago, played and then by the attending physician.
process. the department chairman at Richard On all four examinations of the thorax,
Bob was also proud of having had Kimball’s (Harrison Ford) hospital in the physician listened through the pa-
a bit part as a public health officer in the movie version of The Fugitive. You tient’s shirt or gown, never raising the
Panic in the Streets. It has been so long will recall that movie also featured clothing to listen to the lung fields or,
since I viewed that film that I cannot mountains and a very large dam in the for that matter, to percuss the thorax. I
recall whether Bob had any spoken plains of Illinois. cannot say that I was shocked by these
lines. At any rate, Bob will always have observations, rather I was surprised
James E. Barone, MD
a special place in our hearts. I doubt and disappointed. Having examined the
(AΩA, Jefferson Medical College, )
that he is still alive, but wherever he is, chests of thousands of patients during
Stamford, Connecticut
he deserves respect as a fine doctor . . . the past fifty-five years in the specialty
and actor! of Thoracic Surgery, I learned that, at
Calling Dr. Laennec! least for my hearing process, applica-
John L. Meyer II, MD
René-Théophile-Hyacinthe Laennec tion of the stethoscope directly to the
(AΩA, SUNY Downstate, )
was born on February , , and died skin yields the most dependable audi-
Rockland, Maine
on August , . He invented the tory transmission.
I am aware of at least one “real doc- stethoscope in and reported its use Like others of my vintage (MD )
tor” who had a somewhat memorable in a paper entitled “De l’Auscultation I decry the decline and misuse of the
role in a very substantial movie. Dean Médiate ou Traité du Diagnostic des History and Physical Examination,
Minneapolis Children’s Hospital. I am Iranian and mar- to the author(s) of original nonfiction manuscripts pub-
ried to a lovely Irish-American woman. We have two lished in The Pharos. Authors need not be members of
wonderful children. My life is rooted in a culture rich ΑΩΑ, but must be forty-five years old or younger as of
with storytelling. My parents are well established au- December of the calendar year in which the paper is sub-
thors, and reading and writing has been a cornerstone mitted. To be competitive for a prize, the paper submit-
of my life. Living and studying in different cultures has ted must be in the standard format of The Pharos (see
strengthened this foundation. Medicine provides unique Instructions for Pharos Authors immediately following),
and ample opportunities for sharing stories. By sharing and not published previously in any form. Content should
stories from my work I hope to convey the wide spec- be in the areas emphasized by The Pharos—medical
trum of human behavior in times of stress, and the ideals history and biography, ethics, professional issues, and
common to all. personal essays. Essays submitted to the ΑΩΑ Helen H.
Ms. Leong tells us: I am half-Chinese, half-Jewish and Glaser Student Essay competition are not eligible for this
grew up in New Mexico. When I was seven, my mother prize, nor are previous winners of the Editor’s Prize eli-
made me keep a journal, and each entry had to be four sen- gible to compete. All manuscripts are subject to review of
tences long. I complied as long as “Hi” and “Bye” counted Pharos editorial board members. Judging will be on the
as sentences. Then I started writing. It took me a long time basis of style and composition, originality, scholarship,
to find what stories matter, which ones bring you outside and interest and relevance to medicine.
yourself. When I wrote “First Month,” I felt overwhelmed
by my first experiences in the hospital. And yet, the kind- Instructions for Pharos authors
ness I saw in patients and doctors alike comforted me. We welcome material that addresses scholarly and non-
Looking back, I think how lucky I was. technical topics in medicine and public health such as his-
tory, biography, health services research, ethics, education,
Announcing the 2009 Pharos Editor’s Prize and social issues. Poetry is welcome, as well as photograph/
For the twelfth year, Alpha Omega Alpha is pleased poetry combinations. Photography and art may also be
to offer up to four prizes of , , , and submitted. Scholarly fiction is accepted. All submissions
are subject to editorial board review. Contributors need be used to verify the accuracy of the quotations in the text
not be members of Alpha Omega Alpha. Papers by medical and the references cited, and to correct any errors or omis-
students and residents are particularly welcome. sions. The photocopies will not be returned.
Submissions must meet the following criteria: References should be double-spaced, numbered con-
. Submissions may not have been published elsewhere secutively in the text, and cited at the end in the following
or be under review by another journal. standard form:
. Essays should have a maximum of pages (approxi-
mately words), and be submitted in -point type, Journal
double-spaced, with one-inch margins. They should be Zilm DH, Sellers EM, MacLeod SM, Degani N.
accompanied by a covering letter, a -word abstract, and Propranolol effect on tremor in alcoholic withdrawal. Ann
a title page with the word count (or page count), return ad- Intern Med ; : –.
dress, and e-mail address. Papers exceeding the page count
noted will be returned to the author. References should not Book
exceed unique items (see below). Harris ED Jr. Rheumatoid Arthritis. Philadelphia: WB
. Poems or photograph/poetry combinations should be Saunders; .
in -point type, with one-inch margins, with the author’s
name, address, and e-mail address on the first page. Book Chapter
. Send your submissions to Edward D. Harris, Jr. M.D., Pelligrini CA. Postoperative Complications. In: Way LW,
Editor of The Pharos, Middlefield Road, Suite , editor. Current Surgical Diagnosis and Treatment, Ninth
Menlo Park, California . You may also e-mail them to: Edition. Norwalk (CT): Appleton & Lange; : pp –.
postmaster@alphaomegaalpha.org.
. After peer review, comments on the manuscript will Each reference should be listed in the bibliography only
be sent to the author along with an editorial decision. Every once, with multiple uses of a single reference citing the same
attempt is made to complete preliminary reviews within bibliography reference number. Examples are available at
six weeks. our web site: www.alphaomegaalpha.org.
. The editors of The Pharos will edit all manuscripts Citation of web sites as references is discouraged unless a
that are accepted for publication for style, usage, relevance, site is the single source of the information in question or has
felicity, and grace of expression, and may provide appro- official or academic credentials. Examples of such sites are
priate illustrative material. Authors should not purchase official government web pages such as that of the National
illustrative material because the editors cannot guarantee Institutes of Health. Encyclopedia sites such as britannica.
that it will be used. com are not primary references.
. In accordance with revised copyright laws, each con-
tributor will need to sign an Author’s Agreement, which will Leaders in American Medicine
be sent with the edited galleys. Information on copyright In , as a result of a generous gift from Drs. David
ownership and re-publication of articles is detailed in the E. and Beatrice C. Seegal, Alpha Omega Alpha initiated a
Author’s Agreement. program of one-hour videotapes featuring interviews with
distinguished American physicians and medical scientists.
Reference information The collection has been donated to the National
Authors are responsible for the accuracy of citations and Library of Medicine, which will maintain it for permanent
quotations in their papers. Once a manuscript has been ac- use by scholars visiting the library. Videotapes continue to
cepted for publication, therefore, the author will be required be available for loan from AΩA. A listing of available tapes
to provide photocopies of all direct quotations from the can be found on our web site: www.alphaomegaalpha.org,
primary source material, indicating page numbers. (Please or by contacting Ms. Debbie Lancaster at d.lancaster@
mark the quoted material on the photocopies with high- alphaomegaalpha.org or () -. Please also con-
lighter.) In addition, the editors will require photocopies of tact Ms. Lancaster to borrow tapes. Those wishing to pur-
all references: the title page and copyright pages of all books chase copies may do so by contacting Ms. Nancy Dosch,
cited, the first and last pages of book chapters cited, and the manager, Historical Audiovisuals, History of Medicine,
first and last pages of journal articles cited, as well as the Building , Room E-, Rockville Pike, Bethesda,
Table of Contents of the particular issue of the journal in Maryland . Telephone () -, e-mail nancy_
which the cited article appeared. The foregoing items will dosch@nlm.nih.gov.
Verse II
Soon you will graduate
And likely relocate
And start to activate
A license to medicate
Remember your identity
With joy and humility
Work with tenacity
And keep your virtuosity
You are now AΩA
To you a big hooray
And let us all say…
Drink Chardonnay
Aha, aha, drink Chardonnay
Ah . . . to AΩA!!
Daniel V. Schidlow, MD
Elizabeth Lee, Amanda Rachel Lerman, Katie Kupfer Lockwood, Theresa Madaline, Alumni: Joxel Garcia
Rebecca Matro, Alexander Francis Mericli, Leslie Moroz, Jennifer Neuman, Laila Faculty: Jesus Cruz Correa, Juan B Fernandez-Perez
Nurmohamed, Nicholas J Petruzzi, Joseph Portale, Karl Martin Schweitzer, Laura Universidad Central del Caribe School of Medicine—Gamma Puerto Rico
Ann Snyder, Kristina Stransky, Marguerite Thomer, Scott Howard Troob, Sarah Mary Students: Michelle M Arrieta Gonzalez, Gustavo Bauza Almonte, Gabriel Mariano
Wallett, Jason David Walls, Melissa Ann Wilson Covarrubias, Eduardo J Cruz-Colon, Teresa Garcia, Jordan Michael Glaser, Jeanne
Faculty: Katherine Berg, Edward Jaeger Gissele Guevara, Jesus I Hernandez Rivera, Mireily Rivera-Rosado
House staff: Alexander Arriaga, Geoffrey Bowers, Eric Hager Alumni: Carlos A Blanco Ramos, Francisco R de Torres
University of Pennsylvania School of Medicine—Beta Pennsylvania Faculty: Ohel Soto-Raices
Students: Cynthia Marie Adams, Kiona Yasmin Allen, Daria Babushok, Andrew House staff: Jose Antonio Rivera-Valles
Richard Bond, Robert Scott Fenning, Boris Gershman, Laurie Beth Gray, James
RHODE ISLAND
Matthew Gregory, Amma Hewitt, Lillias Christine Holmes, Daniel Edward
Houseman, Andre Michel Ilbawi, Deborah Jones, Autumn Michelle Kieber-Emmons, The Warren Alpert Medical School of Brown University—Alpha Rhode
John Nicholas Lukens, Landi Marie Parish, Ross Hamilton Parker, Rebecca Frances Island
Rabin-Bloomberg, Alexander Tuukka Ruutiainen, Patricia Marie Salmon, Ilana Students: David Lloyd Ain, Sophia Califano, Christina M Cinelli, Apara Dave, Juliann
Michelle Sherer, Peter Bernard Veldman, Jonathan Wanderer Gaydos-Gabriel, Jonathan Greer, Silvia Hartmann, Elizabeth Naylor, Christina Ronai,
Faculty: Gregg Y Lipschik Justin Routhier, Joshua Spaete, Gita Suneja
Alumni: Griffin P Rodgers
University of Pittsburgh School of Medicine—Gamma Pennsylvania
Faculty: Brian Alverson, Anthony A Caldaone
Students: Jonathan Bortinger, Shawna Teresa Bouwers, Patrick Joseph Brown,
House staff: Brenda Ijeoma Anosike, Samielle Brancato, Elizabeth Dufort
Amanda Banks Christini, Jessica Ellerman, Jesse Fisk, Paul Joseph Hoffman, Douglas
Jason Hsu, John Robert Klune, Yinchong Erica Mak, Sami Paul Makaroun, Nidhi SOUTH CAROLINA
Mehta, Christopher Andrew Rippel, Arun Sharma, Gennedy Shiferman, Eveline H Medical University of South Carolina School of Medicine—Alpha South
Shue, Nicholas T Spina, Paul G Tarasi, Joyce Tawfik, Nicole Francesca Velez, Emily K Carolina
Weber, Alik Widge, Richard Wiley Williamson Students: David Arrington, Joshua Stephen Black, Devon Eileen Bork, Jason B Coker,
Faculty: Gregory Matthew Bump, Asher Arthur Tulsky Jason Andrew Curry, Virginia Culyer Daughtery, Matthew Garin, Bradley S Kalinsky,
House staff: Niladri Das, Paulraj Samuel, Linwah Yip Ian D Kane, Amy Ketcham, Peter Jennings King, Carlotta Jenkins Lalich, Andrew
Drexel University College of Medicine—Delta-Zeta Pennsylvania Roper Lewis, Meredith Cates Northam, Clarice Marie Seifert, Todd Nathanial Senn,
Students: Mark Robert Anderson, Farah Awadalla, Katherine Rotondo Baker, Ryan Katherine Culp Silver, Barclay Thompson Stewart, Julie Miller Swick, Benjamin John
Callahan, Maria Syl de la Cruz, Ryan Duffy, Elysia Marie Engelage, Abbey Fingeret, Thomas, Zeke Jonathan Walton, John Weathers, Caroline Felder Wooten, MaryShell
Adam Benjamin Fleit, Rebecca Anne Fox, Sandi-Jo Galati, Lisa Kay Gibson, Israel Zaffino
Green-Hopkins, Zachary Scott Hoffer, Adam Holleran, Rebecca Jackson Howell, Amy Faculty: Paul Ray Lambert, Stuart Marc Leon
Hyun Kyung Hwang, Kiana Kashef, Linda Keele, Stephanie Keller, Steven Hyungmin House staff: John R Barbour, Thomas Slade Dozier, Corey Michael Hatfield
Kim, Jessica Hope Klausmeier, Jodi Dara Langer, David Ansley Lawrence, Annette University of South Carolin School of Medicine—Beta South Carolina
Meliza Lopez, Marcelo Malakooti, Abhijith Dev Mally, Ajay Mahesh Manchandia, Students: Sarah Bailey, Kevin Budman, Franklin Gettys, Bevin Elizabeth Hearn,
Jacob Christian Miss, Nikhil Mull, Mona Patel, Steve Pugliese, James Eric Roth, Christopher James Huffman, Christopher James Huffman, Philip Ross Mason,
Inderpreet Singh Saini, Pooja Sharma, Kimberly Ann Slininger, Dennis Michael Rebecca Suzanne Napier, Courtney Riley, Patrick Ware, Krystal Southerlin White,
Sopka, Ksenia Stafeeva, Amaal Jilani Starling, Michael Charles Tressler, Byron Jesse Woodard
Vaughn, Sarah Wood Alumni: Ralph N Riley
Alumni: Mary Ann Adler Cohen, Christopher Todd Olivia Faculty: Donald J DiPette
Faculty: Edward Gracely, Nancy Dollase Spector House staff: Jeremy Michael Byrd, Shanna Bradley Holcomb
House staff: Jeffrey Morgan Denney, Jose N Nativi Nicolau, Amy Elizabeth Pattishall
Temple University School of Medicine—Epsilon Pennsylvania SOUTH DAKOTA
Students: Behrad Ben Aynehchi, Roya Azadarmaki, Brian Christopher Barrett, Sanford School of Medicine of the University of South Dakota—Alpha South
Katharine Theresa Criner, Racher Elaine Davis, Jayanth R Doss, Jonathan B Ford, Dakota
Michael Joseph Franco, Joshua S Gluck, Janelle Marie Hesse, Janice Elizabeth Hobbs, Students: Nathan Bradley, Sam Joseph Chelmo, Andrew John Gunn, Kassy Arnette
Shraddha Devendra Jani, Sarah Ann Johnson, Robert James Katzer, Matthew T Hegge, Emily J Horner, Nathan James Miller, Tara Nikole Miller, Jenny Nelson,
Kleiner, Aiham Chaher Korbage, Kevin John Krauland, Daniel Jeffrey Landsburg, Annette L Siewert
Christine Agnes Martin, Katie Lynn Miro, Melissa Ann Mroz, Michael Joseph Alumni: Juliann Reiland-Smith
O’Malley, Alexander Pantelyat, Utpal Patel, Jason Joseph Redon, Katherine Nicole Faculty: Joseph J Fanciullo
Rinaldi, Jonathan C Roberts, Michael Thomas Schweizer, Scott Simonson Short, House staff: Deshandra M Raidoo
Timothy P Smith, Stephanie Lynn Tessing TENNESSEE
Faculty: Susan Gersh, Nikitas J Zervanos Vanderbilt University School of Medicine—Alpha Tennessee
Pennsylvania State University College of Medicine—Eta Pennsylvania Students: Jeffrey Martin Albert, India Fox Bayley, Ryan Patrick Bayley, Mihaela
Students: Justin B Bigger, Erik James Elwood, Christopher David Hanks, Jessica Lynn Hristova Bazalakova, Christopher Bunick, Kevin Meyer Elias, Kirsten Inglee Gibbs,
Holzman, Leah Marie Kinlaw, Katherine Louise Maietta, Bradley William Moatz, Erin Roxanne Horn, Kathryn Lynn Jongeward, Jonathan Andrew Kropski, Diana
Maribeth Ruth Morral, David Thomas O’Gurek, William Michael Peterson, Nicholas Catharine Lemly, Jason Richard Mann, Carrie Campbell McCoy Menser, Mary Alice
Stephen Pierson, Nicole Marie Saddic, Sara Jane Heilig Wasong, Douglas Matthew Nading, William Michael Oldham, Rebecca Anne Snyder
Wisner, Joselyn Lee Wozney Alumni: Kevin B Churchwell, Wonder P Drake
PUERTO RICO Faculty: Derek A Riebau, Charlie B Rush
University of Puerto Rico School of Medicine—Alpha Puerto Rico House staff: Nicole S Carroll, Peter F Crossno, Michele R Henson
Students: Juan Carlos Almodovar Mercado, Ana M Montanez Concepcion, Omar University of Tennessee Health Science Center, College of Medicine—Beta
Corujo Vazquez, Eneida Maria De La Torre Lugo, Lilliam Diaz Velez, Hermes Gabriel Tennessee
Garcia, Arlene E Garcia Soto, Rafael S Garcia-Cortes, Maria C Gonzalez Mayda, Students: William David Algea, Kevin Todd Arnold, Reem S Awwad, Joshua Bryant
Jahzel M Gonzalez Pagan, Tania Maria Gonzalez-Santiago, Luis J Haddock Morales, Byrd, Tyler Austin Cannon, Lauren Roberts Cooper, Evan James Dunn, Kristen Lynn
Nicole Rassi Stella, Carlos Felipe Sanchez-Glanville, Sheila Garcia Santana, Rafael A Heins Fernandez, Daniel Peter Mazei Fowler, Allison Leigh Gratzer, Jessica Hammett,
Vicens-Rodriguez Jonathan Paul Hayes, Rose Lee Hiner, Julia Amanda Jackson, Emily Hicks Jones,
Alumni: Marcia Roxana Cruz-Correa, Maria Isabel Herran Jack William Lambert, Kerry Allison Lavigne, Michael Paul Lazarowicz, Van Karlyle
Faculty: Fernando Luis Joglar, Nerian Ortiz Morris, Amir Paydar, Matthew Whitby Roberts, William Bradley Rogers, Bryan
House staff: Jose Guillermo Cabanas Rivera, Hilton Franqui - Rivera, Carlos J Romero MIchael Sabbe, Bighnesh Satpathy, John Patrick Selph, Paul Albert Tennant, Mridula
Marrero Bagrodia Watt, Jonathan Taylor Whaley
Ponce School of Medicine—Beta Puerto Rico Faculty: Jerome Walter Thompson
Students: Yamilka Abreu, Amelia Karen Adcock, Jesse R Aleman Ortiz, Tracy Catlin, House staff: Christopher James DiBlasio, Paxton Vandiver Dickson, Kathryn Azelia
Alejandra Matilde del Toro, Cynthia Gonzalez Gonzalez, Tareq Ali Khedir Al-Tiae, Providence
Peter Anthony Mennie, Neha Morparia, Cumara O’Carroll, Maria Cristina Rueda Meharry Medical College School of Medicine—Gamma Tennessee
Rueda Gonzalez, Jennifer Rullan, Taina Aracelis Trevino Students: Ronald Clinton Atwater, Jeremy Michael Bennett, Irma Fleming, Nam Le,
Katrina Andrea Mattingly, Jeremy McDuffie, Kenya Chantel Miles, Natu Mmbaga,
North, Andrew P Pace, Callie Nicole Riggin, David Shearer, Ian Slade, Dawn Stanek, DeLong, Zobeida Margarita Diaz, Milad Hakimbashi, Aric Cameron Hall, Kathryn
Sundrayah N Stoller, Kathryn Treit, Mark P Van Tighem, Jason Van Winkle, Sadie Anne Hammes, Benjamin Joseph Heinzen, Jaime L Hook, Adam Owens Kadlec,
West Marcie Ann Navratil, Emily Diana Kerins Ruedinger, Neil Sandhu, William Robert
Faculty: Richard William Arnold, Roger Perry Tatum Schmitt, Shannon Marie Straszewski, Kim Mary Strupp, Kathryn Therese Sullivan
House staff: Massimo Arcerito, Basak Coruh, Dinah Thyerlei Dillie, Kyle Ian Swanson, Ryan H Sydnor, Abigail Marie Tokheim
WEST VIRGINIA Medical College of Wisconsin—Beta Wisconsin
Students: Jill Marie Arganbright, Mark Richard Beahm, Lisa M Benz, Carmen Renee
West Virginia University School of Medicine—Alpha West Virginia
Bergom, Timothy John Berkseth, Kyle Matthew Blake, Michael Blair Bradshaw, Beret
Students: Melissa Ann Alleman, Anthony Louis Cacco, Jonathan Michael Christy,
Ann Casey, Jeff Chang, Maria Anna Delgado, Mary Patricia Eldridge, Colby Scott
Grant Michael Clark, Anna K Donovan, Evan A Dougherty, Gregory Alan Hickey,
Engar, Benjamin Lange Garvey, Gwen Marie Grimsby, Ethan Benjamin Handler,
Natalie P Kreitzer, Lindsay A Kruska, Adam Joseph Lorenzetti, Thomas Christopher
Genevieve A Henry, Andrew George Keenan, Jessica Layne Lambert, Joyce Ying Lin,
Marshall, Barbara Jean Meade, Elliot Isaac Palmer, Elizabeth Gail Roberts, Sarah
Gregory Leo McHugh, Anne Catherine Melzer, Donna Mae Bartyzal Miller, Donald
Helen Sofka
Alan Neff, Christine M Palmer, Payal S Potnis, Benjamin Carl Ringger, Stephanie
Faculty: Hassan H Ramadan
Leigh Siehr, Takashi Takahashi, Norman Earl Taylor, Matthew Raymond Vernon,
House staff: Tanya Fancy, Nicholas Ryan Young
Christopher Edward Weber
Joan C Edwards School of Medicine at Marshall University—Beta West Faculty: Julian H Lombard, James J Nocton
Virginia House staff: Jill M Bader, Prem Anand Kandiah
Students: Paul David Fletcher Bailey, Janelle Marie King, Robert Martin Ore, Aaron
R Parry, Susan K Saunders, Andrew Phillip Stack, Preeti Subhedar, William David
Terrell Students
Faculty: Patricia Jean Kelly, Dilip Nair Alumni
House staff: Hany H Guirgis, Benjamin Lee Moosavi, Matthew Earl Simpson Faculty
WISCONSIN House staff
University of Wisconsin School of Medicine and Public Health—Alpha
Wisconsin Total new members
Students: Bamidele Oyebamiji Adeyemo, Jonathan David Barlow, Laura Ann
Bonneau, Sara Anne Buckman, Elizabeth Nicole Chapman, Bridget Stephanie
Palliatives
this is what you feel you must
when the minutes open up like crackled skin,
blank spaces to fill, the rows of doors
down the long gray halls of hospital wings
spread sheetlike across your days, your future
and you resist reality with all you’ve got
left, which is nothing perfect
nothing is perfect, never was
you’re leaning now in that direction
when you stop nibbling off plastic trays
turn off the IVs, spit pill after pill
scowl at all in white, blue scrubs
soft-sole shoes that squeak in the night
the dimming drone of respirators and tvs
Spanish soap operas, courtroom catfights
the blare of emergency room melodramas
with sutured endings, benign little plot twists
where others’ stories unfold as scripts
everyone swallows and enjoys but you
refuse to abide by the popular soundtrack
suckling your Saltines between gum sores
aspirating your way down the road less taken,
cluttered with the bones of your ancestors
this is how you fade away
your filament shivers, quivering out
Erica Aitken